2/3/2015 1 Anterior Mediastinal Masses and Lower Airway Problems Peter Slinger MD, FRCPC 25 y.o. Female Ant. Mediastinal Mass Cervical Mediastinoscopy + Biopsy Most Important History? A) Dysphagia B) Fever C) Orthopnea D) Chest pain Anterior Mediastinal Mass 25 y.o. Female, Diagnostic Biopsy Hx: c/o cough + supine dyspnea x 2 months Physical exam: Other nodes to biopsy SVC Syndrome 25 y.o. Female Ant. Mediastinal Mass Most Important Investigation? A) Spirometry B) Chest CT scan C) Trans- Esophageal Echocardiogram D) DLCO Flow Volume Inspiration Expiration RV TLC PEFR Flow-Volume Loop Flow Volume Variable Extra-thoracic Airway Obstruction Slinger, Peter, MD, FRCPC Anterior Mediastinal Masses and Lower Airway Problems
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2/3/2015
1
Anterior Mediastinal Masses and Lower Airway Problems
Peter Slinger MD, FRCPC
25 y.o. Female Ant. Mediastinal MassCervical Mediastinoscopy + Biopsy
Most Important History?
A) DysphagiaB) FeverC) OrthopneaD) Chest pain
Anterior Mediastinal Mass 25 y.o. Female, Diagnostic Biopsy
Hx: c/o cough + supine dyspnea x 2 months
Physical exam:
Other nodes to biopsy
SVC Syndrome
25 y.o. Female Ant. Mediastinal MassMost Important Investigation?
A) SpirometryB) Chest CT scanC) Trans-
Esophageal Echocardiogram
D) DLCO
Flow
Volume
Inspiration
Expiration
RVTLC
PEFR
Flow-Volume Loop Flow
Volume
Variable Extra-thoracic Airway Obstruction
Slinger, Peter, MD, FRCPC Anterior Mediastinal Masses and Lower Airway Problems
2/3/2015
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Flow
Volume
Variable Intra-thoracic Airway Obstruction
Before Rx After Rx
Vol.
Neuman et al. Anesthesiology 60: 144, 1984
Abnormal Flow-Volume Loops in Patients with Intra-thoracic Hodgkins Disease
Flow-Vol. Loopn=25
CT Trach.0-mild
CT Trach.Mod.
CT Trach.Severe
Normal11
8 3 0
Fixed Obstr. 7
3 1 3
Variable Extra-Thor 7* 5 2 0
( * No CT evidence of Extra-Thor. Trach. Obstuct. )(Vander Els, et al. Chest 2000; 117: 1256-61)
Abnormal Flow-Volume Loops in Patients with Intra-thoracic Hodgkins Disease
Flow-Vol. Loopn=25
CT Trach.0-mild
CT Trach.Mod.
CT Trach.Severe
Normal11
8 3 0
Fixed Obstr. 7
3 1 3
Variable Extra-Thor 7* 5 2 0Variab. Intra-Thor.0
0 0 0
( * No CT evidence of Extra-Thor. Trach. Obstuct. )(Vander Els, et al. Chest 2000; 117: 1256-61)
Intra-Thoracic Goiter
Mid-Tracheal Compression
Lymphoma
Carinal Compression
Slinger, Peter, MD, FRCPC Anterior Mediastinal Masses and Lower Airway Problems
2/3/2015
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25 y.o. Female Ant. Mediastinal Mass, 40% Distal Tracheal CompressionOptimal Anesthetic Management?
A) Propofol/Rocuronium Intubation
B) Awake FOB intubation, +Roc.
C) Inhalational Spontaneous Ventilation
D) Ketamine/Succinylcholine
Anterior Mediastinal Mass Concepts:
NPIC Anesthesia(Noli Pontes Ignii Consumere)
Anterior Mediastinal Mass Concepts:
NPIC Anesthesia Procedure: Diagnostic vs. TheraputicChildren vs. AdultsSymptoms: mild/moderate/severe
Anterior Mediastinal Mass Concepts:
Symptoms: dyspnea/cough (airway) vs. syncope (cardiovascular)
Symptoms: mild: supine no problemmoderate: supine some problemsevere: cannot lie supine
Anterior Mediastinal Mass Concepts:
NPIC Anesthesia Procedure: Diagnostic vs. TheraputicChildren vs. AdultsSymptoms: mild/moderate/severePatients: safe/unsafe/uncertain for
NPIC
Anterior Mediastinal Mass NPIC Anesthesia:
Safe: Asymptomatic adult no tracheal compression
Unsafe:Severely symptomatic adult/child, child CT trach. compress. > 50%
Uncertain: all others
Slinger, Peter, MD, FRCPC Anterior Mediastinal Masses and Lower Airway Problems
2/3/2015
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20 y.o. Female , Diagnostic BiopsyAnterior Mediastinal Mass
? Management: Safe vs. Unsafe vs. Uncertain
25 y.o. Female Ant. Mediastinal Mass, 40% Distal Tracheal Compression
Most Important Pre-Induction Preparation?
A) IV Access Lower LimbB) HeliumC) Rigid Bronchoscope
+SurgeonD) Cardiopulmonary Bypass
Pump in OR
Management for Uncertain Patients for “NPIC” Anesthesia:
ALL Patients: Determine Optimal
Positioning Secure Airway Beyond
Stenosis if Possible Rigid Bronchoscope
Immediately Available
Selected Patients: Helium/O2 Prep. Chest for
Sternotomy, Elevate Mass
Cardiopulmonary Bypass on “Standby”?
Peripheral Cardiopulmonary Bypass Assisted Thymoma Resection
52 y.o. Female Fem-Fem Veno-Art
partial CPB Sevoflurane spont.
Vent. Induction and intubation
PPV after sternotomy
Soon J-L, et al. J Cardiothorac Vasc Anesth 21: 867-9, 2007 Mediastinal Sarcoma
Slinger, Peter, MD, FRCPC Anterior Mediastinal Masses and Lower Airway Problems
2/3/2015
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Anterior Mediastinal Mass 25 y.o. Female
Post-op. Mediastinoscopy/ Biopsy
Severe dyspnea post-op. inRecovery Room? Diagnosis
25 y.o. Female Ant. Mediastinal MassSevere Stridor in PACU Management?
A) Propofol/Sux. IntubationB) FOB intubation in PACUC) MidazolamD) Spontaneous Ventilation
Induction in OR
Silastic Airway Stent
Perioperative Complications in Adults with Mediastinal MassBechard P, et al. Anesthesiology 100: 826-34, 2004
N= 105; M’scope, sternotomy, VATS, thoracotomy, other
Intraop. 4/105: hypotension/ AF/ hypox.predictors: pericardial effusion.
Postop. 11/105 (7 life-threat.): resp. fail., aletectasis, pneumoniapredictors: preop. s/s,trach compress. >50%,
Silastic Stents: Rigid Bronchoscopy
(GA) Unstable Temporary Easily Removable
Flexo-Metallic Stents: Rigid or Flexible
Bronchoscopy Fairly Stable Difficult to remove Tend to stenose
17 y.o. MaleGerm cell tumorL thoracotomy
Slinger, Peter, MD, FRCPC Anterior Mediastinal Masses and Lower Airway Problems
2/3/2015
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Lower Airway Problems:Tracheal Stenosis
38 y.o. obese, Male
# L1, Laminectomy + Fixation, Prone
Remote tracheal resection for stenosis
Inspiratory & Expiratory Stridor
? Management
Isono S, et al. Anesthesiology 2010, 112: 970-8
Lower Airway Problems:Tracheal Stenosis
38 y.o. obese, Male
# L1, Laminectomy, +Fixation, Prone
Remote tracheal resection for stenosis
Mid-trach stenosis 3cm length, 5x15 mm
Isono S, et al. Anesthesiology 2010, 112: 970-8
Perioperative Management of a Patient with Tracheal Stenosis
A) Spinal
B) LMA
C) Fiberoptic intubation
D) Other
Your Management ?
Perioperative Management of a Patient with Tracheal Stenosis
Rigid Bronchoscopy Tracheal Dilation 7 mm armoured
(wire reinforced) ET Tube distal to stenosis
Turn Prone
My Management: One episode of coughing/cyanosis in ER, uncooperative
✦ Proceed/delay ?✦ Other investigations?✦ Anesthetic
management ?
30 y.o. Male following bar fight, for Rigid Bronch. Removal of FOB
Slinger, Peter, MD, FRCPC Anterior Mediastinal Masses and Lower Airway Problems
2/3/2015
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Rigid Bronchoscopy Anesthetic Management Considerations
? Spontaneous Ventilation vs. Paralysis
Rigid Bronchoscopy Ventilation Management Options:
Intermittent Ventilation
Apneic Oxygenation Jet Ventilation
(Saunders, Monsoon, etc.)
Ventilating Bronchoscope
Jet
Vent. Bronch.
Rigid Bronchoscopy Anesthetic Management Considerations
? Laser (Nd-YAG vs. CO2)? FiO2? Monitoring CO2
40
Anesthetic Management of a Patient with Tracheal Pathology
Start and End of Case
LMA
igel
Anterior Mediastinal Masses and Lower Airway Problems
History: dyspnea/cough, syncope
Investig.: CT (+/- Echo) Path: GA: Collapse/No Management: NPIC
safe/unsafe/uncertain Myths: Flow/vol. loop,
CPB standby Postop. Mgmt.
Slinger P, Karsli G. Curr Opinion Anaesthesiology 20: 1-3, 2007
Slinger, Peter, MD, FRCPC Anterior Mediastinal Masses and Lower Airway Problems
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