2/3/2015. Anterior Mediastinal Masses and Lower Airway Problems
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1 es and Lower Airway Problems es and Lower Airway Problems 25 y.o. Female Ant. Mediastinal Mass Cervical Mediastinoscopy + Biopsy Most Important History? A) Dysphagia B) Fever C) Orthopnea D) Chest pain Peter Slinger MD, FRCPC 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 PEFR Flow-Volume Loop Expiration Flow TLC RV Volume Volume Inspiration Variable Extra-thoracic Airway Obstruction 1
2 es and Lower Airway Problems Flow Volume Vol. Before Rx After Rx Variable Intra-thoracic Airway Obstruction Neuman et al. Anesthesiology 60: 144, 1984 Abnormal Flow-Volume Loops in Patients with Intra-thoracic Hodgkins Disease Flow-Vol. Loop n=25 0-mild Mod. Severe Normal Fixed Obstr Variable Extra-Thor 7* Abnormal Flow-Volume Loops in Patients with Intra-thoracic Hodgkins Disease Flow-Vol. Loop n=25 0-mild Mod. Severe Normal Fixed Obstr Variable Extra-Thor 7* Variab. Intra-Thor ( * No CT evidence of Extra-Thor. Trach. Obstuct. ) (Vander Els, et al. Chest 2000; 117: ) ( * No CT evidence of Extra-Thor. Trach. Obstuct. ) (Vander Els, et al. Chest 2000; 117: ) Intra-Thoracic Goiter Mid-Tracheal Compression Lymphoma Carinal Compression 2
3 es and Lower Airway Problems 25 y.o. Female Ant. Mediastinal Mass, 40% Distal Tracheal Compression Optimal Anesthetic Management? A) Propofol/Rocuronium Intubation B) Awake FOB intubation, +Roc. C) Inhalational Spontaneous Ventilation D) Ketamine/Succinylcholine NPIC Anesthesia (Noli Pontes Ignii Consumere) NPIC Anesthesia Procedure: Diagnostic vs. Theraputic Children vs. Adults Symptoms: mild/moderate/severe Symptoms: dyspnea/cough (airway) vs. syncope (cardiovascular) Symptoms: mild: supine no problem moderate: supine some problem severe: cannot lie supine NPIC Anesthesia Procedure: Diagnostic vs. Theraputic Children vs. Adults Symptoms: mild/moderate/severe Patients: safe/unsafe/uncertain for NPIC NPIC Anesthesia: Safe: Asymptomatic adult no tracheal compression Unsafe: Severely symptomatic adult/child, child CT trach. compress. > 50% Uncertain: all others 3
4 es and Lower Airway Problems 20 y.o. Female, Diagnostic Biopsy? 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 Limb B) Helium C) Rigid Bronchoscope +Surgeon D) Cardiopulmonary Bypass Pump in OR Management for Uncertain Patients for NPIC Anesthesia: Cardiopulmonary Bypass on Standby? 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 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 4
5 es and Lower Airway Problems 25 y.o. Female Post-op. Mediastinoscopy/ Biopsy Severe dyspnea post-op. in Recovery Room? Diagnosis 25 y.o. Female Ant. Mediastinal Mass Severe Stridor in PACU Management? A) Propofol/Sux. Intubation B) FOB intubation in PACU C) Midazolam D) Spontaneous Ventilation Induction in OR Silastic Airway Stent Perioperative Complications in Adults with Mediastinal Mass Bechard P, et al. Anesthesiology 100: , 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, pneumonia predictors: 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. Male Germ cell tumor L thoracotomy 5
6 es and Lower Airway Problems 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: Lower Airway Problems: Tracheal Stenosis Perioperative Management of a Patient with Tracheal Stenosis Your Management? 38 y.o. obese, Male # L1, Laminectomy, +Fixation, Prone Remote tracheal resection for stenosis Mid-trach stenosis 3cm length, 5x15 mm A) Spinal B) LMA C) Fiberoptic intubation D) Other Isono S, et al. Anesthesiology 2010, 112: Perioperative Management of a Patient with Tracheal Stenosis My Management: Rigid Bronchoscopy Tracheal Dilation 7 mm armoured (wire reinforced) ET Tube distal to stenosis Turn Prone 30 y.o. Male following bar fight, for Rigid Bronch. Removal of FOB One episode of coughing/cyanosis in ER, uncooperative Proceed/delay? Other investigations? Anesthetic management? 6
7 es and Lower Airway Problems Rigid Bronchoscopy Anesthetic Management Considerations Rigid Bronchoscopy Ventilation Management Options:? Spontaneous Ventilation vs. Paralysis Intermittent Ventilation Apneic Oxygenation Jet Ventilation (Saunders, Monsoon, etc.) Ventilating Bronchoscope Jet Vent. Bronch. Rigid Bronchoscopy Anesthetic Management Considerations Anesthetic Management of a Patient with Tracheal Pathology Start and End of Case? Laser (Nd-YAG vs. CO2)? FiO2? Monitoring CO2 LMA igel 40 es 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,
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