Anesthesia in a Patient with a Large Mediastinal Mass: NEJM
Large mediastinal masses increase the risks associated with GA. The most feared complication is airway collapse, which precludes ventilation despite intubation. There is limited understanding of the dynamic behavior of extrinsically compressed airways during anesthesia. Prevailing recommendations are to avoid the use of GA. If GA is required, maintenance of spontaneous ventilation and avoidance of paralytic agents are emphasized.

The authors report a single case in which videos of bronchoscopic evaluation of the carina were recorded during a staged anesthetic induction in a 69-year-old man with stage III squamous-cell carcinoma of the mediastinum. CTrevealed a large anterior mediastinal mass with compression of the distal trachea, carina, mainstem bronchi, and superior vena cava (Figure 1A and Video 1).

The patient was intubated while he was awake, and he was subsequently brought to the operating room for resection of the mass. Video recordings were made while the patient was in the semi-Fowler position, at the carinal level (Video 2), during various phases of the anesthetic induction.

As shown in Figure 1B through 1D, there was little change in airway patency with the different phases of anesthesia. Airway calibers were diminished after induction (Video 2), consistent with known effects of anesthesia on thoracic volumes.5 Positive-pressure ventilation and paralysis were associated with a slight increase in the airway area. Following paralysis, the respiratory excursions in the airway area associated with positive-pressure ventilation were no longer visible.

These observations cannot independently overturn decades-old recommendations against the use of positive-pressure ventilation and paralytic agents in such patients. However, the notion that spontaneous ventilation per se is superior to positive-pressure ventilation for preventing airway collapse is challenged by this evidence.

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