One-lung Ventilation Clinical Trial
Official title:
Clamping the Double Lumen Tube : A Novel Technique to Optimize One-Lung Ventilation
Nowadays, lung isolation techniques are an essential part of thoracic anesthesia. The two
principal devices used in order to achieve one-lung ventilation (OLV) are the double lumen
tube (DLT) and the bronchial blocker (BB). Even though DLT and BB have always been considered
equally effective in lung isolation, a study recently published by Bussières et al.
demonstrated the clear superiority of BB over DLT in terms of rapidity and quality of lung
collapse. In order to explain this result, a physiologic study was recently conducted. During
this project, some interesting discoveries were made. In fact, during lung isolation, while
the chest is closed, there is a buildup of negative pressure in the NVL until pleural
opening. Moreover, an absorption of ambient air through the lumen of the DLT or through the
internal channel of the BB is observed. Putting all these elements together, a possible
explanation for the superiority of BB over DLT was obtained. Indeed, in the first study of
Bussières, the internal channel of BB was occluded. By doing so, there were no possible
aspiration of ambient air in the NVL. This condition may have accelerated the absorption
atelectasis of the NVL that occurs during lung collapse by reducing NVL volume and by
conserving a higher alveolar partial pressure of oxygen in it.
The hypothesis is that when using a DLT in OLV, occluding the non-ventilated lung (NVL) lumen
will reproduce the BB physiology by accelerating the second phase of lung deflation and
giving a better quality of lung collapse compared to usual practice of keeping the
non-ventilated lung opened to ambient air.
The main objective is to compare the speed and quality of complete lung deflation occurring
during OLV with a DLT when the non-ventilated DLT lumen is occluded vs not occluded.
This randomized study will include a total of 30 patients scheduled for lung resection using
video-assisted thoracoscopic surgery (VATS). Fifteen patients will compose the experimental
group (NVL lumen occluded) and 15 other patients will be part of the control group (NVL lumen
opened to ambient air).
One-lung ventilation (OLV) is a major consideration in thoracic anesthesia. Lung isolation,
through the use of double-lumen tube (DLT) or bronchial blocker (BB), offers to the surgeon
the intra-thoracic access he needs for the surgery. With the use of a DLT, the non-ventilated
lung is isolated by disconnecting its specific lumen from the ventilator and keeping it
opened to ambient air. With a BB, the BB cuff is inflated in the bronchus after a brief apnea
period. Thereafter, only the dependent lung is ventilated.
Until recently, studies evaluating the quality of lung collapse with the use of DLT versus BB
showed contradicting results and were not conclusive. However, in 2016, Bussières' research
group obtained a faster lung collapse with the use of a BB with its internal channel occluded
and a second period of apnea at pleural opening.
A review of the literature could not explain in details these results. In the 2000s, lung
collapse during OLV was described as undergoing two distinct phases; the first phase occuring
at the opening of the pleural cavity and corresponding to a quick but partial collapse
secondary to the elastic recoil of the lung. The second phase, a slower one, being the
reabsorption, by the vascular capillary bed, of the gas contained into the alveoli; the speed
of this second phase being directly proportional to the solubility coefficient of the gas.
Since no previous studies had explanation for Bussières' unexpected results, they conducted a
physiologic study to extensively determine the physiology of the non-ventilated lung (NVL)
during OLV with the use of DLT and BB. Their results demonstrated that during lung isolation,
while the chest is closed, there is a buildup of negative pressure in the NVL until pleural
opening, when the lumen of the DLT or the internal channel of the BB are occluded. This
phenomenon was observed for both lung isolation devices (BB and DLT). They also observed an
absorption of ambient air through the lumen of the DLT and the internal channel of the BB
when the lumen of both device was open to ambient air. These results probably explain why
Bussières obtained a faster lung collapse with BB in their study. By occluding the internal
channel of the BB they prevented the aspiration of ambient air in the NVL. This condition may
have accelerated the absorption atelectasis of the NVL that occurs during the second phase of
lung collapse by obtaining an initial lower lung volume containing a higher alveolar partial
pressure of oxygen (PAO2) in the BB group.
Since these recent findings demonstrate that both lung isolation devices cause negative
pressure and an aspiration of ambient air, it is possible that the occlusion of the specific
lumen of the NVL of a DLT could reproduce the physiology of the lung isolation obtained with
a BB with its internal channel occluded.
The hypothesis is that by withholding gas exchange between the NVL and ambient air from the
beginning of OLV to the pleural opening, the resorption atelectasis will be facilitated.
Consequently, lung collapse of the NVL will occur faster when clamping its specific lumen on
the DLT instead of letting it communicate with ambient air like anesthesiologists usually do.
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