Feedback in the Clinical Setting with Jamie Rubin, MD

The two primary anesthetic considerations with mediastinal masses include the possibility of airway collapse and the potential for vascular compression. Preoperative signs and symptoms of bronchiolar or tracheal collapse may include cough, dyspnea, orthopnea, or stridor. Preoperative symptoms of vascular compression include lightheadedness, visual disturbances, or syncope. Asymptomatic compression may be recognized as tracheal deviation on a chest radiograph or bronchial, tracheal, or vascular compression on computed tomography. Evidence of superior vena cava syndrome on physical exam may be associated with severe airway obstruction and cardiovascular collapse on induction of general anesthesia. Premedication should be avoided, adequate intravenous access should be obtained, and standard monitors including an arterial line should be placed. The anesthetic plan should take into consideration the possibility of difficulties with ventilation and intubation. After preoxygenation, a smooth induction maintaining spontaneous ventilation and hemodynamic stability should be performed. Awake intubation may be optimal in a cooperative patient, but straining or coughing may lead to increased positive pleural pressure and worsen tracheal compression, as it did in this question. Thus, adequate local anesthesia is paramount. In uncooperative patients, a slow inhalation induction or intravenous ketamine should be considered. If contraindications exist, incremental doses of propofol or etomidate may need to be used. Regardless, paralysis should be avoided during induction. Loss of spontaneous ventilation can precipitate complete airway obstruction.