Acute Airway Management of Anterior Mediastinal Mass in the Setting of Opioid-Induced Acute Respiratory Failure

Benjamin Brueske MD¹, Gebhard Wagener MD¹
¹Columbia University Irving Medical Center, Department of Anesthesiology, New York, NY, USA

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Introduction

• Anterior mediastinal masses (AMM) conventionally have been managed with awake fiberoptic bronchoscopic intubation, and preservation of spontaneous ventilation.¹,² Recent data demonstrates that application of positive pressure ventilation, and administration of paralyzing agents do not reduce tracheal diameter in this population.³,⁴

• We present a 62-year-old female with a large AMM requiring intubation, share our experiences using high-flow nasal cannula to provide oxygenation and ventilation throughout awake fiberoptic bronchoscopy, and review emerging data that is relevant to the management of this high-risk patient population.

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History of Present Illness

62-year-old female with high-grade metastatic leiomyosarcoma, large AMM (15.5×2.3×14 cm), and anterior neck mass (10×6.8×8.5 cm) presented to outside hospital for back pain. Found to be hypotensive, tachycardic, and pancytopenic. Transferred to Columbia University Irving Medical Center (CUIMC) 3/16 for oncologic management and arrived with altered mental status and in severe pain.

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Timeline 

March 16

1700 – SpO₂ 93% on 5 L NC. A&O×2 (baseline) in significant pain. Extended-release morphine 60 mg continued from OSH.

March 17

0700 – 13.6 mg hydromorphone total

March 18
0100–0800 – 8mg Morphine bolus ×3
0800 – Patient unresponsive, shallow respirations. ABG, Narcan.
0900 – ABG: 7.13 / >105 / 119. Rapid Response, started NRB, 0.4 mg Narcan.
Anesthesia consulted for difficult airway.
1025 – HFNC started. 85% FiO₂, 60 Lpm.
1055 – Transfer to OR for HFNFC. ENT on standby.

In Operating Room

1100: HFNC continued. Awake fiberoptic bronchoscope advanced through oropharynx. Topicalized with 2% lidocaine. Initial visualization challenging due to anterior mass. Fiberoscope passed over cords on third attempt. 6.0 reinforced ETT placed.

1130 – ABG: 7.37 / 70 / 85
1215 – Patient transferred to ICU on full monitors.

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Learning Points

• Patients with AMM are at risk for airway compromise during induction of anesthesia.

• Those in the “unsafe or uncertain” category should have two anesthesiologists and a perfusionist ptrdrny on induction, with CPB available.

• Preservation of spontaneous ventilation during awake fiberoptic bronchoscopy and armored ETT sized to trachea at the area of compression is best.

• Positive pressure ventilation and neuromuscular blockade may be safely employed if needed. Watch for lung hyperinflation.

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Discussion

Conventional Management⁵

• ETT sized based on tracheal diameter at level of obstruction per imaging.

• Mediastinal Mass Syndrome risk classification:

  • Safe: asymptomatic adults

  • Unsafe: symptomatic adults

  • Uncertain: adults with moderate symptoms, asymptomatic adults with obstruction (<50% normal), abnormal diagnostic evaluation, or without the possibility of diagnostic evaluation.

• Second anesthesiologist and perfusionist present for uncertain/unsafe cases.

• Avoid sedatives or muscle relaxants.

• Venous access in lower extremity. Reserve one lower extremity for possible CPB cannulation. Fully-prepared CPB machine for “unsafe” patients.

• Establish a “rescue” position prior to induction:

  • Position patient and see how it affects comfort/obstruction.

• Maintain normal muscle tone and spontaneous breathing, use short-acting agents for anxiolysis.

• Awake fiberoptic intubation with visualization of ETT tip bypassing obstruction prior to induction of anesthesia.

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Emerging Evidence⁴

• New evidence suggests no significant decrease in anterior–posterior tracheal diameter after induction of general anesthesia, positive pressure ventilation, or neuromuscular blockade compared with awake states.

• Positive pressure ventilation increases risk of air trapping. Ventilator settings should be adjusted to match patient’s spontaneous volume, rate, and I:E ratio.

• Spontaneous ventilation remains the preferred form of ventilation, but primarily to prevent hyperinflation. Positive pressure ventilation and neuromuscular blockade appear safe if they are required during induction, provided the anesthesiologist carefully observes for lung hyperinflation and allows for adequate expiration.

   

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