Anterior Mediastinal Mass

[Crash cart]

On call recently, called to the unit emergently to intubate a 70 yo male (0300, only me and an ED attending in the house). Upon arrival, he's guppy breathing, SpO2 100% with BVM assistance, BP slightly elevated but not bad. He's very sedated - unresponsive really. Come to find out he's an oncology patient receiving XRT for a moderate sized anterior mediastinal mass with mets to his larynx (has had several rounds of XRT on both). RN says "the pulmonologist told us to call anesthesia if he got into trouble because he's a difficult airway." Chest CT shows a 3 x 4 cm AMM, overlying the distal trachea, about 1 cm above the carina. He's obese with an obese neck, full beard, skin over neck looks red and tight.

Turns out they overstated him with haldol, etc... but they said his respiratory status was marginal to begin with (stridor, increased effort). I try to convince myself that he's gonna fly on NIPPV, but there's no way. Decision is made to intubate.

How do you proceed?

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[Arch Guillotti]

Fiberoptically.

 

[Planktonmd]

It sounds that the sedation was already done for you so do some topical anesthesia of the mouth and a trans tracheal block, then do whatever you are best at:
Videoscope or Fiberoptic.

 

[Mman]

spray some topical in his mouth, put a glidescope in and place a tube through the cords. Then ask RT to keep him spontaneously breathing with maybe a little pressure support. I'll also casually suggest that if they have further problems that their next call is to the cardiac surgeon to go on bypass, because I've done as much as I can to help with the airway.

 

[chfo]

Prop, sux, tube, priest x2

 

[Robotic Wis-Hipple]

As has already been stated, you're trying to maintain spontaneous breathing so topicalize then glide with FOB backup, though if you have time I'd argue for FOB, just to confirm no distal tracheal stenosis/malacia and the placement of the tube distal to this if present. This could've been much much worse based on their heavy handed sedation in a pt who would've gotten nothing but topicalization from me.

 

[Consigliere]

Easy scenario for me - fiberoptic then back to bed.

 

[CardiacIntensivist]

Take pt down to OR if possible, if not, make sure there is an OR ready to take him. Maintain spontaneous ventilation. Have someone topicalize as much as possible and as soon as possible. Have surgeon around to do cric with equipment available. No further sedation. Fiberoptic with a reinforced ETT; may need someone with a C-MAC to help with the fiberoptic insertion. Be prepared to mainstem if needed given location of the ETT. Avoid paralysis if possible, always attempt to maintain spontaneous breathing, even with airway "secure."

 

[vector2]

Just curious...what was the reason he was altered and being sedated? Obviously no one wants to give him more sedation, but I'm not so sure a guy getting haldol is going to be compliant enough for FOI only with topicalization. If he's truly being a wild man, you need to be down in the OR, surgeon at bedside, and use a little glyco, ketamine, spontaneous sevo, head up 30 degrees

 

[GravelRider]

Topical fiberoptic then chew out the pulmonologist for not consulting someone from your group earlier. There should already be an anesthesia consult for a patient like this and well known amongst everyone in the group (especially the call person). Waiting until the patient decompensates to consult anesthesia is inappropriate and that has to be made known.

 

[itwasalladream]

Take pt down to OR if possible, if not, make sure there is an OR ready to take him. Maintain spontaneous ventilation. Have someone topicalize as much as possible and as soon as possible. Have surgeon around to do cric with equipment available. No further sedation. Fiberoptic with a reinforced ETT; may need someone with a C-MAC to help with the fiberoptic insertion. Be prepared to mainstem if needed given location of the ETT. Avoid paralysis if possible, always attempt to maintain spontaneous breathing, even with airway "secure."

I agree with your post, but one point about the bolded part. It's worth keeping in mind that if you lose the airway due to the AMM, a cric is still above the problem area, and your time might be better spent getting the patient onto ECMO, as someone earlier mentioned. Given that he had stridor and increased WOB even before the excess sedation, I'd be pretty concerned about collapse.

Anyone ever lose the distal airway and turn them to their side for intubation? Could be a last resort.

 

[Ronin786]

As above, but I'd make sure to fiberoptic with the patient sitting up rather than laying in bed.

 

[Doctor4Life1769]

Prop, sux, tube, priest x2

And a good attorney

 

[Crash cart]

Great responses and this case actually turned out to be very straight forward (to my utter relief). He was sedated enough that he could tolerate a glidescope just as he was (I gave 50 of fent total). Grade 1 view of cords. I lubed up an armored tube and easily passed it as he inhaled and his cords opened. Went smooth as silk.

But I did have the flexible FOB ready in the event I needed it. I really didn't have a strong plan B as the hospital I was at does not have CT surgery so no ECMO or CPB. I hate not having a plan B but that's just how it went. Of utmost importance was keeping him spontaneous and avoiding relaxant.

I got lucky but to the residents out there:

1) Sick folks are everywhere, even in small community hospitals. Pay attention in training b/c soon you'll be like me - alone in a hospital at night with a sick patient and no back up.

2) Read and understand why this case required more than prop, sux, tube. AMM are no joke. The RT in the room was harassing me "why don't you just put the tube in..." That's why you're an RT and not an MD, lady...

3) Never be afraid to ask questions. It's about patient safety and good patient care - never ego.


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[sevoflurane]

Anyone ever lose the distal airway and turn them to their side for intubation? Could be a last resort.

Yes except we went prone. And it required quick thinking of all possible causes.
We went prone as a last resort with jelly bumps over the R and L thorax so the mediastinal mass could freely hang. Sats came up rather quickly after this maneuver.
Pedi patient. Near miss of a zebra case.

 

[sevoflurane]

 

[anes121508]

Haven't personally done the topical awake glidescope approach, but have seen videos (emcrit has two residents doing it to each other)....any tips on this technique as compared to the afoi? What have your experiences been?

 

[Planktonmd]

Just curious...what was the reason he was altered and being sedated? Obviously no one wants to give him more sedation, but I'm not so sure a guy getting haldol is going to be compliant enough for FOI only with topicalization. If he's truly being a wild man, you need to be down in the OR, surgeon at bedside, and use a little glyco, ketamine, spontaneous sevo, head up 30 degrees

Neuroleptics are excellent for awake intubation, actually in the old days I did many awake intubations with Droperidol + Fentanyl. That was before Droperidol turned out to be so evil!

 

[Mman]

Haven't personally done the topical awake glidescope approach, but have seen videos (emcrit has two residents doing it to each other)....any tips on this technique as compared to the afoi? What have your experiences been?

actually pretty easy depending on why you are doing it. I give them similar meds to what I use for awake FOI (maybe some combo of midaz, precedex, ketamine) while spraying some local in their mouth. Ask them to close their eyes and open their mouth and stick out their tongue and that I've got a metal tongue depressor I'm going to look with. Before you know it you are staring at cords on the screen.

 

[Monty Python]

Neuroleptics are excellent for awake intubation, actually in the old days I did many awake intubations with Droperidol + Fentanyl. That was before Droperidol turned out to be so evil!

Innovar was great in the right patients. Can't remember the last time I saw it; late 1990s?

 

[Chloroform4Life]

View attachment 203816

So noone knew this kid had that big ass mediastinal mass prior to surgery?

 

[Arch Guillotti]

I agree with your post, but one point about the bolded part. It's worth keeping in mind that if you lose the airway due to the AMM, a cric is still above the problem area, and your time might be better spent getting the patient onto ECMO, as someone earlier mentioned. Given that he had stridor and increased WOB even before the excess sedation, I'd be pretty concerned about collapse.

Anyone ever lose the distal airway and turn them to their side for intubation? Could be a last resort.

Why in the world would you even think about putting this guy on ECMO? He needs a celestial discharge before he needs ECMO. The majority of us don't have access to ECMO anyway so it is a moot point.

The AMM is concerning for sure but even if you don't know about it, there is real concern for a no holds barred airway debacle in this guy. He is halfway gorked already so just numb him up however you need to (if he even needs it) and either use a fiberscope or a glidescope to intubate him. Use an armored tube if you really want to go all out. If you get his trachea numb then his tube tolerance will be excellent and he can just keep breathing on his own with whatever assistance he needs.

 

[pgg]

Neuroleptics are excellent for awake intubation, actually in the old days I did many awake intubations with Droperidol + Fentanyl. That was before Droperidol turned out to be so evil!

What do you think about Haldol for this?

I've never tried it or seen it used in this manner. Just curious.

 

[Planktonmd]

What do you think about Haldol for this?

I've never tried it or seen it used in this manner. Just curious.

It should work as well or even better than Droperidol IMHO.

 

[deleted171991]

It should work as well or even better than Droperidol IMHO.

Agree. Both are great drugs, demonized for their rare (but serious) side effects. My best AFOI ever was with droperidol, back when I was a resident. The entire prep took 5 minutes, beyond giving glycopyrrolate early. I am not even sure whether we had him breathe nebulized lido preop. It was just beautiful, how easy it was. And I can't tell how many delirious ICU patients I have fixed with haloperidol.

 

[BLADEMDA]

I've done two cases like this in my career urgently. I brought them to the OR and performed a sevoflurane induction. I never lost spont respirations and sprayed the cords with lidocaine prior to the intubation.

These days we have precedex, low dose ketamine, etc to accomplish the same goal.

 

[itwasalladream]

Why in the world would you even think about putting this guy on ECMO? He needs a celestial discharge before he needs ECMO. The majority of us don't have access to ECMO anyway so it is a moot point.

More of a point in principle of what you can do when you lose the airway of an AMM. Cric will not necessarily help. In a kid, absolutely ECMO is an option. For this particular patient? You have a point but they're still treating with XRT, he's not DNR/DNI, and it's not really my call to withhold a possible therapy in that moment.

Another thing: In this guy, theoretically if you lost the airway and got him on ECMO in time (difficult, yes), he'd be on ECMO for like an hour while you establish an airway. Not exactly the usual ECMO mess.

 

[Robotic Wis-Hipple]

For those that have used haldol or droperidol what's the dose response curve like? I'd imagine it's like versed where one could go from not quite enough to inadvertent airway relaxation in 1/2 mg. Just curious, always looking for additional tools.

Agree with all additional points above, including sitting intubation position. This is exactly the reason I think as residents we need to practice driving the FOB from both positions, when you really need an awake fob you'll kick yourself if you feel uncomfortable doing it from in front of your sitting patient.

 

[Ronin786]

For those that have used haldol or droperidol what's the dose response curve like? I'd imagine it's like versed where one could go from not quite enough to inadvertent airway relaxation in 1/2 mg. Just curious, always looking for additional tools.

Agree with all additional points above, including sitting intubation position. This is exactly the reason I think as residents we need to practice driving the FOB from both positions, when you really need an awake fob you'll kick yourself if you feel uncomfortable doing it from in front of your sitting patient.

You know what will really make you feel uncomfortable? Trying an AFOI on a delirious/semi-sedated patient from the side of the bed when they punch you in the nuts. Not a fun experience.

 

[fakin' the funk]

What do you think about Haldol for this?

I've never tried it or seen it used in this manner. Just curious.

Current ICU dogma = anything other than antipsychotics and opioids cause delirium and are bad, m'kay? I.e., neuroleptanesthesia is back!

 

[fakin' the funk]

Nice work, OP. A testament to the fact that a lot of ICU/compensated patients don't need much, if anything, to achieve good intubation conditions.

As for this dude, how did the ICU get so far down the rabbit hole without him being DNR/DNI??? You can't radiate a frickin AMM with an endotracheal tube there. It's game over now.

 

[anes121508]

interesting case post thanks for sharing and discussing...

anybody willing to share experience where regular ett didnt cut it and armored tube was necessary? or lost airway/hemodynamic collapse requiring emergent ECMO?

I have only seen a handful of these in residency and have always prepared to the max, but have never seen anything bad happen.

 

[Noyac]

Sevo beat me to the punch here as usual but I was thinking all along while reading the first couple posts, just turn the pt over on his side (hopefully the mass is mor to one side then the other and you want that side down) and see if he breathes better. Then look at the RT and say, "he's all yours now and go back to bed."
The ICU can make him DNR/DNI in the morning.

 

[Twiggidy]

2) Read and understand why this case required more than prop, sux, tube. AMM are no joke. The RT in the room was harassing me "why don't you just put the tube in..." That's why you're an RT and not an MD, lady...

 

[sevoflurane]

So noone knew this kid had that big ass mediastinal mass prior to surgery?

Nope.
Trauma case (both parents were fatally injured). It was discovered later. Made the diagnosis that much harder as there were a lot of distracting factors. Going prone was a last resort measure.

 

[Noyac]

Nope.
Trauma case (both parents were fatally injured). It was discovered later. Made the diagnosis that much harder as there were a lot of distracting factors. Going prone was a last resort measure.

Oh damn. I could have gone forever without knowing that. Kids really get to me sometimes. My worst ever case was a 13yo. Nice job figuring this out.

 

[BigRedBeta]

But I did have the flexible FOB ready in the event I needed it. I really didn't have a strong plan B as the hospital I was at does not have CT surgery so no ECMO or CPB. I hate not having a plan B but that's just how it went.

Why in the world would you even think about putting this guy on ECMO? He needs a celestial discharge before he needs ECMO. The majority of us don't have access to ECMO anyway so it is a moot point.

Great points about how you'll never know what will walk through the door out in the community.

Scariest call I ever got as a PICU fellow was from a small ED. Incidentally they had found an AAM in a 4 year old kid who for some other reason (I don't remember the specifics - maybe a wound dehiscence from a recent surgery, couple weeks prior? not really sure...) was going to the OR that night. On his way out of the ED, radiology finally got around to taking the CXR ordered a hour prior, but no one looked at it until the NightHawk service called. By the time they called me for assistance and I got a hold of the anesthesiologist, kid was intubated and case underway, with the anesthesiologist completely unaware of the CXR findings. The guy told me intubation was a little difficult but seemed within the realm of normal peds airway stuff in his mind, but then I think it dawned on him how terribly things might have gone.

For sure in most children's hospitals, an AMM puts the ECMO team on alert. The math is obviously different in pediatric patients, but that would be my preferred plan B...with plan A being position of comfort and BVM until you can transfer to an ECMO center.

 

[nimbus]

Great points about how you'll never know what will walk through the door out in the community.

Scariest call I ever got as a PICU fellow was from a small ED. Incidentally they had found an AAM in a 4 year old kid who for some other reason (I don't remember the specifics - maybe a wound dehiscence from a recent surgery, couple weeks prior? not really sure...) was going to the OR that night. On his way out of the ED, radiology finally got around to taking the CXR ordered a hour prior, but no one looked at it until the NightHawk service called. By the time they called me for assistance and I got a hold of the anesthesiologist, kid was intubated and case underway, with the anesthesiologist completely unaware of the CXR findings. The guy told me intubation was a little difficult but seemed within the realm of normal peds airway stuff in his mind, but then I think it dawned on him how terribly things might have gone.

For sure in most children's hospitals, an AMM puts the ECMO team on alert. The math is obviously different in pediatric patients, but that would be my preferred plan B...with plan A being position of comfort and BVM until you can transfer to an ECMO center.

It was probably reassuring to the anesthesiologist that the kid had recent surgery without an anesthetic mishap. The AMM was missed twice. What we get away with on a daily basis.....

 

[deleted171991]

It was probably reassuring to the anesthesiologist that the kid had recent surgery without an anesthetic mishap. The AMM was missed twice. What we get away with on a daily basis.....

That's why the CRNAs are making inroads. It takes a lot to kill a patient nowadays.

 

[sevoflurane]

Oh damn. I could have gone forever without knowing that. Kids really get to me sometimes. My worst ever case was a 13yo. Nice job figuring this out.

I think I know the case you are referring to. Tough case.

 

[Noyac]

I think I know the case you are referring to. Tough case.

Yes you do. Career changing. I'm sure I told you about it. Haunted me daily for over a year. And I don't even know why.

 

[deleted162650]

Yes you do. Career changing. I'm sure I told you about it. Haunted me daily for over a year. And I don't even know why.

Would love to hear about/learn from that one if you can bring yourself to share it one of these days.

 

[Noyac]

Would love to hear about/learn from that one if you can bring yourself to share it one of these days.

Nah, nothing to share. It was just a bad trauma that we couldn't save. That's all.

 

[deleted162650]

Nah, nothing to share. It was just a bad trauma that we couldn't save. That's all.

Gotcha. That would eat at me too.