Anaesthesia and mediastinal masses. A case report and review of the literature

Current Practices Supporting Rigid Bronchoscopy-An International Survey

BACKGROUND

There are no guidelines for anesthesia or staff support needed during rigid bronchoscopy (RB). Identifying current practice patterns for RB pertinent to anesthesia, multidisciplinary teams, and algorithms of intra and post-procedural care may inform best practice recommendations.

METHODS

Thirty-three-question survey created obtaining practice patterns for RB, disseminated via email to the members of the American Association of Bronchology and Interventional Pulmonology and the American College of Chest Physicians Interventional Chest Diagnostic Procedures Network.

RESULTS

One hundred seventy-five clinicians participated. Presence of a dedicated interventional pulmonology (IP) suite correlated with having a dedicated multidisciplinary RB team ( P =0.0001) and predicted higher likelihood of implementing team-based algorithms for managing complications (39.4% vs. 23.5%, P =0.024). A dedicated anesthesiology team was associated with the increased use of high-frequency jet ventilation ( P =0.0033), higher likelihood of laryngeal mask airway use post-RB extubation ( P =0.0249), and perceived lower rates of postprocedural anesthesia adverse effects ( P =0.0170). Although total intravenous anesthesia was the most used technique during RB (94.29%), significant variability in the modes of ventilation and administration of muscle relaxants was reported. Higher comfort levels in performing RB are reported for both anesthesiologists ( P =0.0074) and interventional pulmonologists ( P =0.05) with the presence of dedicated anesthesia and RB supportive teams, respectively.

CONCLUSION

Interventional bronchoscopists value dedicated services supporting RB. Multidisciplinary dedicated RB teams are more likely to implement protocols guiding management of intraprocedural complications. There are no preferred modes of ventilation during RB. These findings may guide future research on RB practices.

[Risky confirmation of a diagnosis: case series of three female patients with mediastinal mass syndrome]

Mediastinal mass syndrome (MMS) is a life-threatening complication of anesthesia for which prevention and treatment are a complication-prone interdisciplinary task. Clinical symptoms vary from asymptomatic patients up to life-threatening cardiorespiratory impairments, depending on the extent and size of a mediastinal tumor as well as the involvement of corresponding anatomical structures. Especially in the context of sedation or general anesthesia, there is a considerable risk of acute cardiopulmonary or respiratory decompensation related to tumor-induced compression of central blood vessels or even the large airways, which may result in severe complications, including death. In this case series three female patients are presented, who were each referred to this hospital with a mediastinal tumor for interventional or surgical confirmation of the diagnosis. Based on the case histories, characteristic complications are demonstrated and strategies to avoid possible adverse events of MMS are discussed. The specific anesthesiological requirements for MMS, the safety aspects of the choice of surgical and anesthesia procedures, circulatory and airway management for the required single-lung ventilation, and various aspects of the selection of the anesthetic agents are discussed in this case series.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

A Comparison of the Required Bronchial Cuff Volume Obtained by 2 Cuff Inflation Methods, Capnogram Waveform-Guided Versus Pressure-Guided: A Prospective Randomized Controlled Study

BACKGROUND

Double-lumen endobronchial tubes (DLTs) are used for one-lung ventilation (OLV) during thoracic surgery. Overinflation into the bronchial cuff causes damage to the tracheobronchial mucosa, whereas underinflation leads to an incomplete collapse of the nonventilated lung or incomplete ventilation of the ventilated lung. However, how to determine the appropriate bronchial cuff volume and pressure during OLV is unclear. The objective of this study is to compare the required bronchial cuff volume for lung separation obtained by 2 different cuff inflation methods under closed- and open-chest conditions.

METHODS

A total of 64 patients scheduled to undergo elective thoracic surgery requiring OLV were recruited. Left DLTs were used for both right- and left-sided surgery. The patients were randomly assigned to 1 of 2 inflation-type groups to estimate the bronchial cuff volume. In the capnogram waveform-guided bronchial cuff inflation group (capno group, n = 27), the bronchial cuff was inflated until a capnometer sampling gas containing CO2 from the nonventilated lung displayed a flat line. The corresponding bronchial cuff volume and pressure were then recorded. In the pressure-guided bronchial cuff inflation group (pressure group, n = 29), the bronchial cuff was inflated by a cuff inflator to a pressure of 20 cm H2O. Lung separation was confirmed when a flat line of a capnometer was observed after gas sampling from the nonventilated lung.

RESULTS

Under closed-chest conditions, the bronchial cuff sealing volume for the capno group was significantly lower than that for the pressure group (mean [standard deviation {SD}], 1.00 [0.65] mL vs 1.44 [0.59] mL, mean difference, -0.44; 97.5% confidence interval [CI], -0.78 to -0.11; P = .010). Under open-chest conditions, the bronchial cuff sealing volume for the capno group was also significantly lower than that for the pressure group (mean [SD], 0.65 [0.66] mL vs 1.22 [0.45] mL, mean difference, -0.58; 97.5% CI, -0.88 to -0.27; P < .001).

CONCLUSIONS

The lowest cuff volume providing an air-tight bronchial seal was obtained by the capnogram waveform-guided bronchial cuff inflation method. Since the cuff volume required to achieve an air-tight seal decreases after opening the chest, readjustment of the bronchial cuff volume to prevent bronchial cuff damage to the tracheobronchial mucosa after opening the chest may be advisable.

Performance and safety of diagnostic procedures in superior vena cava syndrome

Superior vena cava syndrome (SVCS) is an uncommon condition resulting from extrinsic compression or intraluminal blockade of the superior vena cava. The increased upper body venous pressure results in distended subcutaneous vessels and oedema of the head, neck and arms. SVCS can be a medical emergency if associated with laryngeal or cerebral oedema. The most common SVCS aetiologies are intrathoracic malignancies, accounting for 60 to 86% of cases [1–3].

Standard bronchoscopy and EBUS-TBNA have good diagnostic yield and are relatively safe procedures in the setting of SVCS. However, complications may arise from the underlying malignancy and its proximity to central vital structures.https://bit.ly/37HXFUY

Anesthetic considerations for bronchoscopic procedures: a narrative review based on the Cleveland Clinic experience

The advent of advanced diagnostic bronchoscopy has shown an increased demand for anesthesiologists to administer anesthesia in the bronchoscopy suite. Procedures such as navigational bronchoscopy, airway stenting and advanced therapeutic procedures often require the presence of an anesthesiologist to manage these more complex patients and procedures. In this review we describe the various bronchoscopic procedures and anesthetic management and complications of these procedures at our institution The Cleveland Clinic, Cleveland Ohio.

Airway obstruction after biopsy by cervical mediastinoscopy in a patient with a mediastinal mass -A case report-

Biopsy, using mediastinoscopy is commonly employed for accurate histologic diagnosis of a mediastinal mass. However, since the mass is not removed during the procedure, it may cause compression of vital structures such as major airways, the heart, the pulmonary artery, and the superior vena cava after surgery. We observed a case of a 66-year-old man with a mediastinal mass that caused severe airway obstruction during recovery from anesthesia following mediastinoscopic biopsy, probably caused by upper airway edema which seemed to originate from compression of the superior vena cava. Therefore, we suggest that unexpected airway obstruction in a patient with a mediastinal mass can be due to superior vena cava compression.

Rigid bronchoscopy for malignant central airway obstruction from small cell lung cancer complicated by SVC syndrome

Central airway obstruction (CAO) and superior vena cava (SVC) syndrome are potentially life-threatening complications in locally advanced lung cancer. Therapeutic rigid bronchoscopy has become an critical component in the treatment of the lung cancer patients with CAO who are not surgical candidates. However, the technique may pose significant risks in patients with coexisting SVC syndrome, especially, and even more so perhaps in patients over the age of eighty. In this case report, we address the potential risks and known benefits of therapeutic bronchoscopic intervention in an 85-year-old man with small cell lung cancer who presented with acute dyspnea secondary to advanced SVC syndrome and CAO involving the lower trachea and right main bronchus. Emergent therapeutic rigid bronchoscopy resulted in a marked improvement, in dyspnea, atelectasis, and postobstructive pneumonia, allowing rapid administration of systemic chemotherapy.

Intraoperative strategy in patients with extended involvement of mediastinal structures

The mediastinum is a virtual space containing several vital organs and structures. Biopsy and resection of lesions located within this region often require several considerations that bear on intraoperative strategy. To optimize outcome, clinicians must be able to predict which patients are at highest risk of anesthetic complications. Superior vena cava involvement, extensive compression of the airway, and pericardial effusion have a clear impact on the decision-making of the anesthetist and surgeon, who should plan together when forming the surgical strategy.

Anästhesiologisches Management bei mediastinaler Raumforderung

The perioperative management of patients with mediastinal masses is a special clinical challenge in our field. Even though regional anaesthesia is normally the first choice, in some cases it is not feasible due to the method of operation. In these cases general anaesthesia is the second option but can lead to respiratory and haemodynamic decompensation due to tumor-associated compression syndrome (mediastinal mass syndrome). The appropriate treatment begins with the preoperative risk classification on the basis of clinical and radiological findings. In addition to anamnesis, chest radiograph, and CT, dynamical methods (e.g. pneumotachography and echocardiography) should be applied to verify possible intraoperative compression syndromes. The induction of general anaesthesia is to be realized in awake-fiberoptic intubation with introduction of the tube via nasal route while maintaining the spontaneous breathing of the patient. The anaesthesia continues with short effective agents applied inhalative or iv. If possible from the point of operation, agents of muscle relaxation are not to be applied. If the anaesthesia risk is classified as uncertain or unsafe, depending on the location of tumor compression (tracheobronchial tree, pulmonary artery, superior vena cava), alternative techniques of securing the respiratory tract (different tubes, rigid bronchoscope) and cardiopulmonary bypass with extracorporal oxygen supply are prepared. For patients with severe clinical symptoms and extensive mediastinal mass, the preoperative cannulation of femoral vessels is also recommended. In addition to fulfilling technical and personnel requirements, an interdisciplinary cooperation of participating fields is the most important prerequisite for the optimal treatment of patients.

Anesthesia for pericardial window in a pregnant patient with cardiac tamponade and mediastinal mass

PURPOSE

To present a case report of anesthesia for pericardial window surgery for acute cardiac tamponade in a patient with an anterior mediastinal mass in late pregnancy.

CLINICAL FEATURES

A 34-yr-old gravida 2, para 1 patient presented at 29 weeks gestation with dyspnea, orthopnea, chest pain, and cough. Investigations showed an anterior mediastinal mass due to Hodgkin's disease. A course of vinblastine at 31 weeks gestation resulted in symptomatic improvement but at 34 weeks gestation she developed an acute cardiac tamponade for which pericardial window drainage was required. Additional help and equipment were assembled in case of cardiopulmonary deterioration. Intra-arterial pressure and continuous fetal monitoring were established and iv access was secured in both arms and the left foot. After awake fibreoptic intubation, spontaneous ventilation was maintained. Anesthesia consisted of local anesthetic infiltration of the anterior chest wall, supplemented with fentanyl, midazolam, and ketamine. The patient remained stable, was extubated fully awake, and then monitored in an intensive care area.

CONCLUSION

This patient presented with acute cardiac tamponade and an anterior mediastinal mass in late pregnancy, an unusual combination of challenges that requires a careful approach to anesthetic management.

Perioperative issues in patients with cancer

The perioperative care of patients with cancer can be an exciting challenge. The physician must consider many factors, including the cancer diagnosis, the extent of disease, treatment received, the presence of comorbid conditions, and the patient's prognosis and must understand the impact of these factors on the planned surgical procedure. In this setting, the physician has the opportunity to perform an essential role in the perioperative management of patients with cancer.

Upper airway diseases and airway management: a synopsis

This article summarizes some of the more important upper airway conditions likely to affect airway management. A number of upper airway conditions may present difficult challenges to the anesthesiologist. For instance, infected airway structures may lead to partial airway obstruction, stridor, or even complete airway obstruction. Partial airway obstruction may be mild, as in snoring or nasal congestion, or may be more severe, perhaps requiring the use of airway adjuncts, such as a nasopharyngeal airway. Complete airway obstruction is usually managed by prompt intubation, but surgical airways are sometimes needed as a last resort.

Treatment of severe carinal stenosis with overlapping metallic endoprosthesis

A 50-year-old man presented with respiratory distress from central airway compression secondary to malignant mediastinal adenopathy. The stenosis involved the carinal triangle and created residual luminal diameters of 6 mm, 6 mm, and pinhole in the distal trachea and right and left mainstem bronchi, respectively. Airway patency at the carina was restored successfully with a stenting method that uses two overlapping Wall stents.

Benign symptomatic thymic tumors

Benign tumors of the thymic gland are relatively rare. Although most of these lesions are asymptomatic in nature, they may result in respiratory distress. This report describes 2 cases of benign thymic tumors presenting with respiratory symptoms that resolved after operative excision.

Anaesthetic management of an infant with anterior mediastinal mass

A substantial mediastinal mass in a small infant can create a dilemma regarding the safest mode of airway management. To ensure safety at all times, we adopted one lung ventilation for fear of compression of the carina and/or both main bronchi. Anaesthesia was maintained at a very light plane by the use of local nerve blocks to secure the airway and epidural analgesia for surgery until the tumour was mobilized.

Awake fibreoptic intubation, airway compression and lung collapse in a parturient: anaesthetic and intensive care management

A 28-year-old primigravida at 35 weeks gestation with acute onset of dyspnoea and stridor due to an intrathoracic neoplasm required semi-urgent caesarean section to allow diagnosis and treatment. Her inability to lie supine precluded regional anaesthesia. She underwent awake fibreoptic oral intubation followed by general anaesthesia. This was complicated by desaturation, high airway pressures, unilateral lung collapse, venous congestion and unexpected blood loss due to an undiagnosed placenta praevia.

Management of pleural effusions in children with malignant lymphoma

PURPOSE

The aim of this study was to determine potential problems in the diagnosis and management of children with pleural effusions and malignant lymphoma as well as the efficacy of thoracentesis.

METHODS

The case histories of six children with malignant lymphoma who presented with pleural effusions were reviewed. Thoracentesis was performed using the Seldinger technique.

RESULTS

Four of the children presented with symptoms and chest radiograph findings similar to pneumonia. A large mediastinal mass was present in two children. Pleural fluid analysis resulted in a definitive diagnosis of lymphoma in five of the six children. Two of the children had symptoms of reexpansion pulmonary edema after removal of pleural fluid. An empyema developed in one child after thoracotomy and chest tube placement. Reaccumulation of pleural fluid was common before initiating chemotherapy.

CONCLUSIONS

Malignant pleural effusions frequently are present in children with non-Hodgkin's lymphoma. They may present with respiratory distress because of the size of the effusion, the mediastinal mass, or both. Management of these pleural effusions is associated with potential complications, some of which are life threatening. Thoracentesis is the initial diagnostic and therapeutic procedure of choice. The use of a Seldinger technique for thoracentesis has proved useful and safe. In patients with large effusions, aggressive removal of the pleural fluid may be followed by reexpansion pulmonary edema.

Airway troubles related to the double-lumen endobronchial tube in thoracic surgery

PURPOSE

Several case reports indicate critical respiratory complications in relation to the double-lumen endobronchial tube (DLT). A prospective survey for the airway problems in using the DLT is presented.

METHODS

One hundred adult patients undergoing thoracotomy for lung cancer were investigated. Tube malposition and airway obstruction were searched using a fiber-optic scope. The endobronchial cuff was positioned just below the trachcal carina while the trachea was intubated with a DLT (Rüsch). The distances of displacement, from the tracheal carina to the bronchial cuff, were measured during anesthesia using an epidural catheter, which had marks every 5 mm. The distances for correcting the tube position were measured at both the bronchial cuff and the level of the teethPaO₂,PaCO₂ andSPO₂ were also measured.

RESULTS

Malposition (displacement over 5 mm from the correct position) was found in 42 patients, and 40 of them were in a withdrawal direction, occurring at the postural change and during one-lung ventilation, especially during manipulation of the lung hilum. Correcting distances at the level of the teeth were 15.3-3-times longer than those at the bronchial cuff. Airway deformities and gradual withdrawal of the bronchial cuff were found in association with surgical manipulation. Obstruction occurred at the tips of the tracheal tube in four patients and the bronchial tube in six patients, and at the tip of both in two patients. Hypoxemia (PaO₂<60 mmHg) occurred in four patients and hypercapnea (PaCO₂>60 mm Hg) in two patients.

CONCLUSION

Most of the DLT obstructions were associated with withdrawal malposition. Great attention to DLT displacement and airway deformity is advised.

A review of open biopsy for mediastinal masses

OBJECTIVE

To review the recent experience with biopsied mediastinal lesions in children and to assess the impact of recent advances in imaging and surgical techniques on diagnosis.

METHODOLOGY

The clinical and radiological features of 55 patients who had mediastinal biopsies at The Royal Alexandra Hospital For Children (RAHC) over 15 years were reviewed.

RESULTS

Fifty-five patients presented to RAHC between 1978 and 1993 with lesions of the mediastinum requiring biopsy of that site. Thirty-one of the 55 (56%) lesions were malignant. Neurogenic tumours were the most common (40%). In order of frequency the following lesions were found: neuroblastoma (15), teratoma (eight), non-Hodgkin's lymphoma (NHL; eight), enteric cyst/duplication (five), ganglioneuroma (five), bronchogenic cyst (three), ganglioneuroblastoma (two), lymphangioma (two), abscess (two), Hodgkin's lymphoma (HL; two), oesophageal granuloma (one), Langerhan's cell histiocytosis (one), congenital fibromatosis (one). Eighty-two per cent of neurogenic tumours were located in the posterior mediastinum, while 75% of teratomas and 100% lymphoid tumours were located anteriorly. Symptoms were generally unhelpful in establishing a specific diagnosis and in 27% of cases the lesions were discovered incidentally. Physical signs, such as thoracic inlet obstruction and neurological findings, were helpful clinically in localizing lesions within the mediastinum. Chest radiography enabled lesions to be subdivided within the mediastinum. This localization, in combination with the age at presentation, predicted the tissue diagnosis. Computerized tomography (CT) and magnetic resonance imaging (MRI) further defined the lesion and demonstrated involvement of adjacent structures. Histology, however, was essential to distinguish benign from malignant lesions.

CONCLUSIONS

The clinical presentation of mediastinal masses is often non-specific or incidental. Despite recent advances in imaging technology and biopsy techniques, full histological examination is required to exclude malignancy.

Cesarean section in a pregnant patient with an anterior mediastinal mass and failed supradiaphragmatic irradiation

Nodular sclerosing Hodgkin's disease stages IA and IIA are the most common presentation of this disease during pregnancy. Patients presenting with late Hodgkin's disease with failed irradiation for cesarean section present a unique challenge. When this presentation occurs, a voluntary interruption of pregnancy is recommended. Upper body irradiation during the second trimester of pregnancy is recommended as well. We report a case involving a pregnant patient at 34 weeks' gestation presenting for cesarean section with a symptomatic anterior mediastinal mass occupying over 50% of the thoracic diameter. The anesthetic management was performed using continuous spinal.

Asymptomatic undetected mediastinal mass: a death during ambulatory anesthesia

T-cell lymphoma is the fastest growing non-Hodgkin's lymphoma occurring in children. Its clinical presentation is frequently abrupt, and total tumor mass can double every few days. At the same time, the number of ambulatory anesthesia procedures for children is increasing at a rapid rate. Anesthesiologists are constantly faced with decisions regarding the adequacy of available preoperative information. What information do we need, and how recent should it be? This case shows that recent diagnostic imaging studies not showing the presence of a mediastinal lymphoma can be misleading. It provides a strong warning to all anesthesiogists involved in ambulatory anesthesia.

Difficult intubation following thoracic trauma

A previously fit 20-year-old man presented with a large haemothorax following a stab wound to the left chest. Pre-operative airway assessment indicated that tracheal intubation would be routine. On induction of anaesthesia, visualisation of the larynx proved impossible because of soft tissue swelling. Successful intubation was eventually achieved with the aid of a gum elastic bougie. At operation, the patient's common carotid artery was found to have been perforated close to its origin on the aorta. The patient made an uneventful recovery.

Massive thymic hyperplasia

Massive thymic hyperplasia is an extremely rare form of true thymic hyperplasia most often described in infants and children. Hyperplasia of this order is not known to occur in any other organ, and its etiology and prognostic significance remain unknown. As there is no accurate way of preoperatively differentiating massive thymic hyperplasia from other tumors of the thymus and anterior mediastinum, we advise excision in all cases for histological analysis and relief of mediastinal compression. This description of 4 cases updates the 30 previously reported cases, and includes a literature review.

Anterior mediastinal mass in a patient susceptible to malignant hyperthermia

We report a malignant hyperthermia-susceptible patient who required investigation for a large, symptomatic anterior mediastinal mass. Multiple attempts at tissue diagnosis under local anaesthesia were unsuccessful. Following awake fibreoptic tracheal intubation, general anaesthesia was administered using ketamine, midazolam, and nitrous oxide, maintaining spontaneous ventilation. Prophylactic dantrolene was not used, to avoid potential muscle weakness and respiratory compromise. Diagnostic mediastinotomy was performed without incident. We conclude that ketamine anaesthesia is appropriate for patients with anterior mediastinal masses, and is considered safe in malignant hyperthermia-susceptible patients.

Life-threatening airway obstruction at the presentation of Hodgkin's disease

Mediastinal involvement from Hodgkin's disease is common. Significant symptoms resulting from disease at this site are less common and only rarely does severe airway obstruction occur. The authors report six cases of Hodgkin's disease in which life-threatening airway obstruction was a major feature of the clinical presentation and early clinical course. The literature describing this complication is reviewed. General anesthesia with endobronchial intubation should be avoided if at all possible in patients with airway obstruction and alternative methods of diagnosis and management are discussed.

Sudden fatal cardiac arrest in a child with an unrecognized anterior mediastinal mass

We report a case of sudden fatal cardiac arrest in a 3-year-old boy. The arrest occurred when he was placed in the supine position by force for a venipuncture. Autopsy revealed a large anterior mediastinal mass. The death was attributed to the airway obstruction and cardiac compression by the mass. Postural change to supine position by force was believed to have triggered compression of the cardiopulmonary system by an unrecognized anterior mediastinal mass, resulting in cardiac arrest.

Anesthetic considerations in the pediatric cancer patient

Cancer is second only to trauma as the leading cause of death in children 1-15 years of age. Pediatric cancer patients have unique physiologic, pharmacologic, and psychologic considerations that present a unique challenge to plan anesthesiologist. A thorough understanding of pediatric tumors, along with chemotherapeutics and their complications, is necessary to plan anesthetic management properly. Special attention is directed to the psychologic needs and preparation of both the patient and parents. Close cooperation and coordination among the pediatric oncologist, surgeon, and anesthesiologist are necessary for safe and expeditious operative care.