Apnoeic oxygenation with high-flow nasal oxygen in adult patients undergoing endoscopic pharyngolaryngeal surgery: a clinical review.

Endoscopic pharyngolaryngeal surgery requires access to the base of tongue, pharynx, larynx, trachea and/or upper oesophagus using a rigid or flexible endoscope for diagnostic or therapeutic surgical management of benign or malignant disease. The anaesthetist must deliver a safe and effective shared airway management strategy. This strategy is aimed at optimising the surgical view and access to pathology, whilst avoiding airway obstruction, maintaining oxygenation, facilitating carbon dioxide clearance, and minimising the risk of airway fire. Various strategies exist to achieve this depending on the location, size and nature of the pathology, patient anatomy and comorbidities, and operating team experience. One such approach is apnoeic oxygenation using high-flow nasal oxygen. Over the last decade, this has become a widely adopted 'tubeless' anaesthetic technique; nevertheless, it cannot be used in all patients, for all pathologies, by all operating teams. Though our understanding of the physiological principles continues to evolve, it is clear that to deliver this technique optimally, there are several important considerations that the surgical, nursing and anaesthetic teams must be aware of. A collaborative team-based approach to case selection and planning is essential. This must be paired with an appreciation of the limitations of the technique and the need to have an immediately deliverable rescue oxygenation strategy in place. This article provides an overview of the likely physiological mechanisms, the benefits, the limitations, the alternatives and the important considerations involved in the safe and effective use of apnoeic oxygenation with high-flow nasal oxygen to facilitate endoscopic pharyngolaryngeal surgery.