slinger, peter, md, frcpc anterior mediastinal masses and ... · anterior mediastinal masses and...

2/3/2015

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Anterior Mediastinal Masses and Lower Airway Problems

Peter Slinger MD, FRCPC

25 y.o. Female Ant. Mediastinal MassCervical Mediastinoscopy + Biopsy

Most Important History?

A) DysphagiaB) FeverC) OrthopneaD) Chest pain

Anterior Mediastinal Mass 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 MassMost Important Investigation?

A) SpirometryB) Chest CT scanC) Trans-

Esophageal Echocardiogram

D) DLCO

Flow

Volume

Inspiration

Expiration

RVTLC

PEFR

Flow-Volume Loop Flow

Volume

Variable Extra-thoracic Airway Obstruction

Slinger, Peter, MD, FRCPC Anterior Mediastinal Masses and Lower Airway Problems

2/3/2015

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Flow

Volume

Variable Intra-thoracic Airway Obstruction

Before Rx After Rx

Vol.

Neuman et al. Anesthesiology 60: 144, 1984

Abnormal Flow-Volume Loops in Patients with Intra-thoracic Hodgkins Disease

Flow-Vol. Loopn=25

CT Trach.0-mild

CT Trach.Mod.

CT Trach.Severe

Normal11

8 3 0

Fixed Obstr. 7

3 1 3

Variable Extra-Thor 7* 5 2 0

( * No CT evidence of Extra-Thor. Trach. Obstuct. )(Vander Els, et al. Chest 2000; 117: 1256-61)

Abnormal Flow-Volume Loops in Patients with Intra-thoracic Hodgkins Disease

Flow-Vol. Loopn=25

CT Trach.0-mild

CT Trach.Mod.

CT Trach.Severe

Normal11

8 3 0

Fixed Obstr. 7

3 1 3

Variable Extra-Thor 7* 5 2 0Variab. Intra-Thor.0

0 0 0

( * No CT evidence of Extra-Thor. Trach. Obstuct. )(Vander Els, et al. Chest 2000; 117: 1256-61)

Intra-Thoracic Goiter

Mid-Tracheal Compression

Lymphoma

Carinal Compression


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25 y.o. Female Ant. Mediastinal Mass, 40% Distal Tracheal CompressionOptimal Anesthetic Management?

A) Propofol/Rocuronium Intubation

B) Awake FOB intubation, +Roc.

C) Inhalational Spontaneous Ventilation

D) Ketamine/Succinylcholine

Anterior Mediastinal Mass Concepts:

NPIC Anesthesia(Noli Pontes Ignii Consumere)


NPIC Anesthesia Procedure: Diagnostic vs. TheraputicChildren vs. AdultsSymptoms: mild/moderate/severe


Symptoms: dyspnea/cough (airway) vs. syncope (cardiovascular)

Symptoms: mild: supine no problemmoderate: supine some problemsevere: cannot lie supine


NPIC Anesthesia Procedure: Diagnostic vs. TheraputicChildren vs. AdultsSymptoms: mild/moderate/severePatients: safe/unsafe/uncertain for

NPIC

Anterior Mediastinal Mass NPIC Anesthesia:

Safe: Asymptomatic adult no tracheal compression

Unsafe:Severely symptomatic adult/child, child CT trach. compress. > 50%

Uncertain: all others


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20 y.o. Female , Diagnostic BiopsyAnterior Mediastinal Mass

? 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 LimbB) HeliumC) Rigid Bronchoscope

+SurgeonD) Cardiopulmonary Bypass

Pump in OR

Management for Uncertain Patients for “NPIC” Anesthesia:

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

Cardiopulmonary Bypass on “Standby”?

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


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Anterior Mediastinal Mass 25 y.o. Female

Post-op. Mediastinoscopy/ Biopsy

Severe dyspnea post-op. inRecovery Room? Diagnosis

25 y.o. Female Ant. Mediastinal MassSevere Stridor in PACU Management?

A) Propofol/Sux. IntubationB) FOB intubation in PACUC) MidazolamD) Spontaneous Ventilation

Induction in OR

Silastic Airway Stent

Perioperative Complications in Adults with Mediastinal MassBechard P, et al. Anesthesiology 100: 826-34, 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, pneumoniapredictors: 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. MaleGerm cell tumorL thoracotomy


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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: 970-8

Lower Airway Problems:Tracheal Stenosis

38 y.o. obese, Male

# L1, Laminectomy, +Fixation, Prone

Remote tracheal resection for stenosis

Mid-trach stenosis 3cm length, 5x15 mm

Isono S, et al. Anesthesiology 2010, 112: 970-8

Perioperative Management of a Patient with Tracheal Stenosis

A) Spinal

B) LMA

C) Fiberoptic intubation

D) Other

Your Management ?

Perioperative Management of a Patient with Tracheal Stenosis

Rigid Bronchoscopy Tracheal Dilation 7 mm armoured

(wire reinforced) ET Tube distal to stenosis

Turn Prone

My Management: One episode of coughing/cyanosis in ER, uncooperative

✦ Proceed/delay ?✦ Other investigations?✦ Anesthetic

management ?

30 y.o. Male following bar fight, for Rigid Bronch. Removal of FOB


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Rigid Bronchoscopy Anesthetic Management Considerations

? Spontaneous Ventilation vs. Paralysis

Rigid Bronchoscopy Ventilation Management Options:

Intermittent Ventilation

Apneic Oxygenation Jet Ventilation

(Saunders, Monsoon, etc.)

Ventilating Bronchoscope

Jet

Vent. Bronch.

Rigid Bronchoscopy Anesthetic Management Considerations

? Laser (Nd-YAG vs. CO2)? FiO2? Monitoring CO2

40

Anesthetic Management of a Patient with Tracheal Pathology

Start and End of Case

LMA

igel

Anterior Mediastinal Masses 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, 2007


slinger, peter, md, frcpc anterior mediastinal masses and ... · anterior mediastinal masses and...

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