anterior mediastinal mass

[anbuitachi]

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Obviously we are taught the what to do and what not to do stuff about AMMs in adults but anyone know of any good evidence for any of this? A lot of it seems theoretical in adults. I remember seeing a video on NEJM showing video of bronchus before and after paralysis, with no difference.

Also all the articles recommend maintaining spontaneous ventilation as opposed to mechanical ventilation. assuming we arent talking about a 100kg AMM, how many of you actually had unable to ventilate scenarios in general anesthesia after intubation?

Wondering about this because we do the occasional thyroidectomies with large substernal growth with significant compression and we dont have bypass or ecmo service. We obviously dont use long paralytics since its thyoidectomy, but all of them get heavy doses of narcotics to decrease bucking...

Also which guidelines are you using for CT images of tracheobronchial tree in terms of whether to go down AFOI route vs others?
Some sources it is safe if adult is asymptomatic and < 50% tracheobronchial tree compression. how exactly are you measurinfg this compression level? Our radiologists use mild/mod/severe, not percentage..

 

[Mikkel]

Like a lot of things in anesthesia, dogma teaches one thing, life experience teaches something different.

I'd feel comfortable putting the patient to sleep and using a paralytic. It's not like the airway will suddenly collapse because somatic muscle fibers get paralyzed, cartilage does most of the heavy lifting anyway and they're unaffected by paralytics.

 

[somedumbDO]

In a kid, had a vascular (didn’t know it at the time) ant med tumor, sv induction, progressively hard to bag, went down quick couldn’t pass an armored tube, tried l/r lat position. Cardiac guys at the ready went on bypass. It can happen but I am sure it is rare.

 

[anbuitachi]

I hear it happening in kids but in adults I never hear of it..

 

[deleted171991]

Obviously we are taught the what to do and what not to do stuff about AMMs in adults but anyone know of any good evidence for any of this? A lot of it seems theoretical in adults. I remember seeing a video on NEJM showing video of bronchus before and after paralysis, with no difference.

Ask them to show you the video with the tracheo-/bronchomalacia, too. 😉

Also all the articles recommend maintaining spontaneous ventilation as opposed to mechanical ventilation. assuming we arent talking about a 100kg AMM, how many of you actually had unable to ventilate scenarios in general anesthesia after intubation?

The whole point of good anesthesiology care is to prevent stuff like that, don't you think? A tube may not bypass the area of tracheomalacia/tumor completely. And I assume you meant controlled ventilation, when you said "mechanical".

Wondering about this because we do the occasional thyroidectomies with large substernal growth with significant compression and we dont have bypass or ecmo service. We obviously dont use long paralytics since its thyoidectomy, but all of them get heavy doses of narcotics to decrease bucking...

If I don't want to muscle relax a patient and I want to decrease bucking, I run remi.

The problem with AMM is that, when complications happen, the patient can die. Hence it's just not worth the risk. Btw, the ones that scare me the most are the ones with SVC syndrome.

 

[anbuitachi]

Ask them to show you the video with the tracheo-/bronchomalacia, too. 😉

The whole point of good anesthesiology care is to prevent stuff like that, don't you think? A tube may not bypass the area of tracheomalacia/tumor completely. And I assume you meant controlled ventilation, when you said "mechanical".

If I don't want to muscle relax a patient and I want to decrease bucking, I run remi.

The problem with AMM is that, when complications happen, the patient can die. Hence it's just not worth the risk. Btw, the ones that scare me the most are the ones with SVC syndrome.

I agree but at the same time, teaching things as if they are facts to all residents without strong evidence prevent further research..