Tommorrow's case......mediastinal mass

[s204367]

61 yr old 245 lb woman with a one month history of SOB, previous history sig for hashimoto's, workup revealed a 6x7cm mass in the superior mediastinum at level of aortic arch compressing the trachea to the level just a hair above carina. looks cystic, but also adhered to subclabian vein.

surgeons plans for right thoraotomy, and excision of lesion....

she has no present stridor, on the ct there is a impressive looking mass compressing the trachea, but it remains open to about one cm, and both mainstems look clear..

thanks..........

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[Planktonmd]

61 yr old 245 lb woman with a one month history of SOB, previous history sig for hashimoto's, workup revealed a 6x7cm mass in the superior mediastinum at level of aortic arch compressing the trachea to the level just a hair above carina. looks cystic, but also adhered to subclabian vein.

surgeons plans for right thoraotomy, and excision of lesion....

she has no present stridor, on the ct there is a impressive looking mass compressing the trachea, but it remains open to about one cm, and both mainstems look clear..

thanks..........

The fear of anterior mediastinal masses is frequently exaggerated and if the patient is able to maintain her airway awake most likely you will be able to ventilate with mask under GA.
So I would just induce GA and ventilate with mask prior to intubation in this case.
The other issue here is obviously the size of the trachea (1 cm) which makes a double lumen tube difficult if not impossible.
One lung ventilation here is a relative indication and done only for better surgical access.
So if they want one lung ventilation you will need to put a bronchial blocker of some sort or use a Univent.
You need to consider using a reinforced tube in case there is some tracheomalacia although unlikely considering the fast progress of the mass (1 month).
Good luck.

 

[UTSouthwestern]

I wouldn't recommend a combivent for this case. A small diameter univent tube perhaps.

This is a big lady and likely a baseline OSA patient. Most times, I would simply induce and intubate, but you already have a patient with a proven constricted airway and inducing will likely collapse what little lumen she has left, if you are stating that her trachea is 1 cm in diameter at the level of the compression, although how she would be without stridor with such a small lumen in this size lady is very impressive.

I'd advise an awake FOI for this likely short, morbidly obese, already compromised patient with likely little cardiopulmonary reserve.

I would also have the surgeon on standby for a trach as needed.

 

[Noyac]

Awake FOI with precedex and a rigid tube using a bronchial blocker for lung isolation. Have bypass ready if things go bad (may need to prep the femorals b/4 induction just in case). With all due respect UT, I don't think a surgeon with a trach set will help you at all if this airway collapses b/c the trach will still be above the collapsed trachea and therefore ineffective. Bypass is all that will help in this scenario. With that being said total airway collapse is rare IMHO.

 

[numbmd]

Have to agree with noyac on this one. We had one a few years back, and it sucked a big d*** for the guy passing gas. Airway collapsed and almost lost the pt. No muscle relaxant helps. It takes much longer to mask an adult (ie: it's always longer than you think).

 

[Planktonmd]

I wouldn't recommend a combivent for this case. A small diameter univent tube perhaps.

.

I actually meant univent

 

[Planktonmd]

Awake FOI with precedex and a rigid tube using a bronchial blocker for lung isolation. Have bypass ready if things go bad (may need to prep the femorals b/4 induction just in case). With all due respect UT, I don't think a surgeon with a trach set will help you at all if this airway collapses b/c the trach will still be above the collapsed trachea and therefore ineffective. Bypass is all that will help in this scenario. With that being said total airway collapse is rare IMHO.

Nothing wrong with this plan, but I still think that you can ventilate these people with positive pressure unless the mass has been there for a long time and caused tracheomalacia (not the case here).
If she looks like a difficult intubation then awake FOI seems reasonable.

 

[Noyac]

Nothing wrong with this plan, but I still think that you can ventilate these people with positive pressure unless the mass has been there for a long time and caused tracheomalacia (not the case here).
If she looks like a difficult intubation then awake FOI seems reasonable.

So what is a long time in this scenario, Plank?

And I know were you are going with this but for the sake of discussion for the newbys why does time have any impact of this case (ie: more time equals more tracheomalacia). How does one know if the tumor has caused tracheomalacia, if and when to do a FOI vs a mask etc? If you are going to induce this pt, are you going to paralyze? Are you going to prepare for bypass?

Not being an ass here. From your posts, you can anesthetize me any time.

 

[Planktonmd]

So what is a long time in this scenario, Plank?

And I know were you are going with this but for the sake of discussion for the newbys why does time have any impact of this case (ie: more time equals more tracheomalacia). How does one know if the tumor has caused tracheomalacia, if and when to do a FOI vs a mask etc? If you are going to induce this pt, are you going to paralyze? Are you going to prepare for bypass?

Not being an ass here. From your posts, you can anesthetize me any time.

From the initial post I understood that the mass had developed over a period of 1 month, not long enough to cause tracheomalacia in my opinion and what is keeping the airway open is still the cartilage not the muscle tone.
If the airway was only maintained by muscle tone(Tracheomalacia is present) the patient would have symptoms of obstruction which does not seem to be the case.
"Long enough" is hard to define but at least several months.
If I am going to induce anesthesia I would give a hypnotic agent IV with nothing else and gradually deepen the anesthetic with a vapor then intubate without muscle relaxants.
Again it remains a question of personal comfort level and no body can blame you for doing it by the book.

Here is a little study about the subject:
http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=15550183&cmd=showdetailview&indexed=google

 

[UTSouthwestern]

Noy, you are correct. I missed the location of the mass.

 

[urge]

s204367,

How did the case go? What did you do?

 

[s204367]

At a 300 bed community hospital......

Prepped for an awake FBO....to OR with 4 of versed on board, masked her down so she was still breathing spontaneously, slipped a scope in her mouth, squrt on the cords with some lido through the scope...slipped past the obstruction to the carina which looked good, slid an 8.0 tube over the scope keeping her spon breathing...Had to do an 8 as the surgeon wanted to bronch her, then an esophagoscopy...

changed to a 35 DL ETT over a tube exchanger(small, but the 8 had a hard time passing through the tracheal obstruction...rings were intact),. Proceeded with case with a gen and a T5 epidural

Surgeon removed a baseball size bronchogenic cyst compressing the trachea, gus, and innominate....had big access and a couple of units in the room....


My initial concern was....No bypass available in the hospital....brought it up with the surgeon, and of course, he did not think it was going to be a problem......Kept her SV just in case I could not intubate, and in that case we would have shipped her off to a tertiary center with CPB capability....

fortunately things went very well, extubated in OR and off to ICU....

 

[Noyac]

At a 300 bed community hospital......

Prepped for an awake FBO....to OR with 4 of versed on board, masked her down so she was still breathing spontaneously, slipped a scope in her mouth, squrt on the cords with some lido through the scope...slipped past the obstruction to the carina which looked good, slid an 8.0 tube over the scope keeping her spon breathing...Had to do an 8 as the surgeon wanted to bronch her, then an esophagoscopy...

changed to a 35 DL ETT over a tube exchanger(small, but the 8 had a hard time passing through the tracheal obstruction...rings were intact),. Proceeded with case with a gen and a T5 epidural

Surgeon removed a baseball size bronchogenic cyst compressing the trachea, gus, and innominate....had big access and a couple of units in the room....


My initial concern was....No bypass available in the hospital....brought it up with the surgeon, and of course, he did not think it was going to be a problem......Kept her SV just in case I could not intubate, and in that case we would have shipped her off to a tertiary center with CPB capability....

fortunately things went very well, extubated in OR and off to ICU....

Well done. Great case and I like the "of course, he did not think it was going to be a problem". They never do until it is too late.

Where was your IV access?

Personally, I think these pts are not informed very well by their surgeons. I would not have had this case performed on me or any of my loved ones at a community hospital. I would be at a hospital with CPB capabilities for sure. Many times surgeons are not the best advocates for the pt. It is very unfortunate and it puts us in a bad position.

 

[gasnewby]

I don't think a surgeon with a trach set will help you at all if this airway collapses b/c the trach will still be above the collapsed trachea and therefore ineffective.

this might be a dumb question- but let's say the airway collapses and you can't intubate/ventilate. surgeon intervenes- why can't he do a cric and stick an ETT in there? that would be long enough to get past the obstruction. and that's what you do in a cric anyway- use a 6.0 or something small.

 

[Noyac]

this might be a dumb question- but let's say the airway collapses and you can't intubate/ventilate. surgeon intervenes- why can't he do a cric and stick an ETT in there? that would be long enough to get past the obstruction. and that's what you do in a cric anyway- use a 6.0 or something small.

Your not going to get past the obstruction blindly like this. The best way around it is under visualization like with the fiberoptic scope. You can guide the smaller scope past the obstruction and then hopefully past the tube over the scope. The cric is not going to be reliably successful to use as your backup plan.

 

[urge]

this might be a dumb question- but let's say the airway collapses and you can't intubate/ventilate. surgeon intervenes- why can't he do a cric and stick an ETT in there? that would be long enough to get past the obstruction. and that's what you do in a cric anyway- use a 6.0 or something small.

The problem is not getting into the trachea (unless there is difficult intubation). It is that once inside the trachea you cannot ventilate past the obstruction. A cric will not change anything. I vote for ramming the tube past the obstruction. You can also sit the pt or turn them prone, which might alleviate the obstruction.

 

[gasnewby]

gotcha.

 

[Planktonmd]

At a 300 bed community hospital......

Prepped for an awake FBO....to OR with 4 of versed on board, masked her down so she was still breathing spontaneously, slipped a scope in her mouth, squrt on the cords with some lido through the scope...slipped past the obstruction to the carina which looked good, slid an 8.0 tube over the scope keeping her spon breathing...Had to do an 8 as the surgeon wanted to bronch her, then an esophagoscopy...

changed to a 35 DL ETT over a tube exchanger(small, but the 8 had a hard time passing through the tracheal obstruction...rings were intact),. Proceeded with case with a gen and a T5 epidural

Surgeon removed a baseball size bronchogenic cyst compressing the trachea, gus, and innominate....had big access and a couple of units in the room....


My initial concern was....No bypass available in the hospital....brought it up with the surgeon, and of course, he did not think it was going to be a problem......Kept her SV just in case I could not intubate, and in that case we would have shipped her off to a tertiary center with CPB capability....

fortunately things went very well, extubated in OR and off to ICU....

I am not sure I understand why you needed to do a fiberoptic intubation?
Did you feel she was going to be a difficult intubation?
You induced GA and maintained spontaneous ventilation which is great, why not just do a DL and intubate?

 

[UTSouthwestern]

At a 300 bed community hospital......

Prepped for an awake FBO....to OR with 4 of versed on board, masked her down so she was still breathing spontaneously, slipped a scope in her mouth, squrt on the cords with some lido through the scope...slipped past the obstruction to the carina which looked good, slid an 8.0 tube over the scope keeping her spon breathing...Had to do an 8 as the surgeon wanted to bronch her, then an esophagoscopy...

changed to a 35 DL ETT over a tube exchanger(small, but the 8 had a hard time passing through the tracheal obstruction...rings were intact),. Proceeded with case with a gen and a T5 epidural

Surgeon removed a baseball size bronchogenic cyst compressing the trachea, gus, and innominate....had big access and a couple of units in the room....


My initial concern was....No bypass available in the hospital....brought it up with the surgeon, and of course, he did not think it was going to be a problem......Kept her SV just in case I could not intubate, and in that case we would have shipped her off to a tertiary center with CPB capability....

fortunately things went very well, extubated in OR and off to ICU....

So the obstruction was proximal to the carina, and not compressing the carina directly? Confused me with the first post.

Great job. Not having CPB capacity would have made me force him to move the case to another facility. Tear any of the major vessels and she's likely dead on the table, especially with poor or difficult access through the thoracotomy and likely no equipment for a quick emergent sternotomy.

 

[Noyac]

Where was your IV access? And what was it, 18g, 14g, cordis?
Can anyone besides the attendings here tell me why this matters?

 

[dhb]

Well if the surgery is taking place in the mediastinum you're in the vicinity of all the big vessels so you want big caliber iv access that drains to the inferior as well as the superior vena cava in case they need to clamp one you can still give drugs/volume to the patient.
So i'd go for a 14 in the arm and in the IJ and an 18 or bigger in the legs.

 

[IceDoc]

The problem is not getting into the trachea (unless there is difficult intubation). It is that once inside the trachea you cannot ventilate past the obstruction. A cric will not change anything. I vote for ramming the tube past the obstruction. You can also sit the pt or turn them prone, which might alleviate the obstruction.

And failing the elegant ramming technique, a rigid bronch (and someone who can do it) is most useful.