Thoracic Surgery Clinical Trial
Official title:
Physiology of Lung Collapse Under One-Lung Ventilation: Underlying Mechanisms
Lung isolation technique and one-lung ventilation (OLV) are the mainstays of thoracic anesthesia. Two principal lung isolation techniques are mainly use by clinicians, the double lumen tubes (DLT) and the bronchial blockers (BB). The physiology of lung collapse during OLV is not well described in the literature. Few publications characterized scant aspects of lung collapse, only with the use of DLT and sometime in experimental animals. Two phases of lung collapse have been described. The first phase is a quick and partial secondary to the intrinsic recoil of the lung. The second phase is the reabsorption of gas contained in the alveoli by the capillary bed. The investigators plan to describe the physiology of the second phase of lung deflation using of DLT or BB, in a human clinical context.
Lung isolation and one-lung ventilation (OLV) have been used for more than 60 years,
principally via double lumen endotracheal tubes (DLT). Since the beginning of the 21st
century, modernisation of bronchial blockers (BB) has favoured their more frequent use.
Meanwhile, video assisted thoracoscopic surgery (VATS) has increased, becoming the standard
for the majority of intra-thoracic pulmonary surgeries.
Lung collapse during OLV undergoes two distinct phases. The first phase occurs at the opening
of the pleural cavity and corresponds to a quick but partial collapse of the lung due to its
intrinsic recoil. This phase probably ends when small airways are closed. Thereafter, the
second phase, a slower one, corresponds to the reabsorption, by the capillary bed, of gas
contained into the alveoli. The speed of this reabsorption depends on the solubility of the
gas contained in the alveoli.
Intriguingly, the physiology of lung collapse under OLV remains poorly understood, especially
with the use of BB. Theoretically, many aspects of lung isolation may influence lung
collapse, including the ventilation strategy before OLV, the timing and the lung isolation
devices being used. While oxygen at 100% is widely used for ventilation before OLV, the
timing of initiation of lung isolation varies from centers to centers. Indeed, the most
conservative will begin the lung isolation just before the opening of the pleural space,
whereas others begin the lung isolation following the appropriate positioning of the patient
and confirmation that the lung isolation device is properly positioned by fiberoptic
bronchoscopy (FOB) examination. Therefore, the period between initiation of lung isolation
and pleural opening may vary from a few minutes to >30 minutes. The mechanic of lung
isolation differs between DLT and BB and consequently the physiology of lung deflation may be
different. When using DLT, the lumen that corresponds to the collapsed lung is disconnected
from the ventilator and is continuously in communication with the ambient air. When using BB
a bronchial cuff is inflated within the main bronchus following a 30 seconds apnea period,
allowing the initial lung deflation to be mediated by elastic lung recoil. After this initial
phase, the only communication with ambient air is through the small (2 mm) and long internal
(67 mm) channel, which is completely different from the larger lumen of the DLT.
Rapid and complete lung collapse is essential during lung isolation for VATS otherwise; there
is no alternative available for the surgeon to get proper view of the pulmonary hilum.
Previous studies suggested that BB allow a less effective lung collapse than the one obtained
with DLT. However, the authors recently documented that the use of BB with its internal
channel occluded creates a statistically significant shorter time to complete lung collapse
during VATS compared to DLT (36.6 ± 29.1 vs 7.5 ± 3.8 min; p<0.001). In contrast to the
previous studies, the authors used off-line review videos recorded during the surgery to
obtain a more objective evaluation of the complete lung collapse time which probably
reflected the second phase of lung deflation. Although, our definition of lung collapse was
very strict, meaning complete collapse of all the lung areas, graded using a standardized
visual scale and chart. However, authors do not have any data to explain why this internal
channel occlusion may have some positive impact. The authors hypothesized that their results
could be explained by the optimisation of the reabsorption phases following enhanced
atelectasis by gas reabsorption (phase 2) after bronchial blockade. This latter hypothesis is
supported by a pilot observation that ambient air (FiO2 at 0.21) was "sucked up" within the
collapsing lung when using DLT to a greater extent than with the use of BB (unpublished
data). The presence of ambient air (21%) in the alveolar space may likely slowing subsequent
gas reabsorption compared to intra-alveolar 100% O2 . However, these hypotheses remain to be
confirmed.
The investigators proposed this study to update the knowledge about lung collapse with the
actual lung isolation devices: DLT and BB. This protocol will describe the lung collapse
physiology and allows getting data for the elaboration of further studies.
Thus the present hypothesis is that during the second phase of lung collapse, the inflow of
air through the lumen of the non-ventilated lung of the DLT is greater than through the
internal channel of the BB, in the course of lung isolation for OLV.
The main objective of this study is the gas volume quantification (GVQ) coming from ambient
air towards the alveoli space of the non-ventilated lung during OLV with the use of DLT and
BB. These measurements will be performed from the beginning of OLV until 60 minutes after,
meaning approximatively 45 minutes after the opening of the pleura by the surgeon. The
secondary objective is the intra-pulmonary pressure measurement (IPM) in the non-ventilated
lung with the use of DLT and BB during the same period.
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