Rev. Bras. Anestesiol. vol.66 número2

RevBrasAnestesiol.2016;66(2):215---218

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Anesthetic

management

of

a

large

mediastinal

mass

for

tracheal

stent

placement

Suman

Rajagopalan

,

Mark

Harbott

,

Jaime

Ortiz

,

Venkata

Bandi

a_{DepartmentofAnesthesiology,BaylorCollegeofMedicine,Houston,UnitedStates}

b_{DepartmentofPulmonologyandMedicine,BaylorCollegeofMedicine,Houston,UnitedStates}

Received23December2013;accepted15January2014 Availableonline20February2014

KEYWORDS

Anesthetic management; Mediastinalmass; Laryngealmask airway; Trachealstent

Abstract Theanestheticmanagementofpatientswithlargemediastinalmassescanbe com-plicatedduetothepressureeffectsofthemassontheairwayormajorvessels.Wepresent thesuccessfulanestheticmanagementofa64-year-oldfemalewithalargemediastinalmass thatencroachedonthegreatvesselsandcompressedthetrachea.Atrachealstentwasplaced to relieve thetracheal compression undergeneral anesthesia.Spontaneous ventilationwas maintainedduringtheperioperativeperiodwiththeuseofaclassiclaryngealmaskairway.We discusstheutilityoflaryngealmaskairwayforanestheticmanagementoftrachealstentingin patientswithmediastinalmasses.

© 2014SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.

PALAVRAS-CHAVE

Anestesia; Doenc¸asdo Mediastino; Máscaraslaríngeas;

Stents

Manejoanestésicodegrandemassamediastinalparaacolocac¸ãodestent_traqueal

Resumo Omanejoanestésicodepacientescomgrandesmassassituadasnomediastinopode sercomplicadoporcausadosefeitosdapressãodamassasobreasviasaéreasougrandesvasos. Relatamos omanejoanestésicobem-sucedido deuma pacientede64anoscomumagrande massamediastinalqueinvadiuosgrandesvasosecomprimiuatraqueia.Umstenttraquealfoi colocadoparaaliviaracompressãodatraqueia,sobanestesiageral.Aventilac¸ãoespontânea foi mantidaduranteoperíodo perioperatório comousode umamáscara laríngeaclássica. Discutimosautilidadedamáscaralaríngeaparaomanejodacolocac¸ãodestenttraquealem pacientescommassassituadasnomediastino.

©2014SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

∗_{Correspondingauthor.}

E-mail:[email protected](S.Rajagopalan).

Introduction

Mediastinaltumorsthatarelargeenoughtocause compres-sionof airway or major vesselspose a significant risk for

216 S.Rajagopalanetal.

Figure1 (A) ChestX-rayshowing alargemediastinalmasswith markeddeviation ofthetrachea tothe rightwith tracheal compression,(B)bronchoscopicviewofthetracheashowingthenarrowing,(C)chestX-rayafterthestentplacementshowingthe stentinthetrachea,and(D)bronchoscopicviewofthetrachealstent.

cardiopulmonarycomplications.Catastrophichypoxia, vas-cular complications and cardiac arrest can occur during the perioperative periodand have been reported in both theadult1 _{andpediatricpopulations.}2,3_{Further,theuseof} muscle relaxants and positive pressure ventilation during generalanesthesiahas been associatedwith an increased riskof airwaycollapse.4_{We reportthegeneralanesthetic} managementofapatientwhounderwenttrachealstenting foralargemediastinaltumorwhilemaintainingspontaneous ventilationwithalaryngealmaskairway(LMA).

Clinical

report

A 64-year-old female with a medical history remarkable for hypertension and asthma was diagnosed with a sar-comatoid carcinoma of the lung. This tumor measuring 9.3cm×9.0cm×11.7cmencroachedontheanterior

medi-astinum. Due to the advanced stage of the cancer, she was considered a poor surgical candidate. She received chemotherapy with adriamycin, ifosfamide and mesna in conjunction with radiotherapy. She remained relatively asymptomatic after therapy for a periodof 5 yearsafter whichshepresented touswithworseningdyspnea,cough andhoarseness of voice of one month duration.The dys-pnea wasworst onlying flat than in the semi-recumbent position.ThechestX-rayrevealedalargemediastinalmass

withmarkeddeviationofthetracheatotherightwith tra-chealcompression(Fig.1A).TheCTscanconfirmedthatthe mediastinalmasshadincreasedinsizeand,nowmeasured 10.3cm×10.4cm×12.7cm.Itencroachedonthegreat

ves-sels andtrachea, causing significant trachealcompression and deviation (Fig. 2). As the predominant symptom was

Figure2 CTscanshowing thelargemediastinalmass mea-suring 10.3cm×10.4cm×12.7cm encroaching on the great

Mediastinalmassfortrachealstentplacement 217

dyspnea due to the obstruction of the trachea, she was scheduled for theplacementof atracheal stentasa pal-liativemeasuretorelievetheairwayobstruction.

On the day of the procedure, a large bore peripheral intravenous line and a right radial arterial access were established.General anesthesiawhile maintaining sponta-neousventilationwithaLMAwasplanned.Rigidfiberoptic bronchoscopesweremadeavailableasaback-up interven-tionin the event of tracheal collapseduring induction of anesthesia. The cardiopulmonary bypassteamwas placed onstand-byinthe eventthatsignificant cardiorespiratory decompensationwastooccurandwe wereunableto res-cue with the rigid bronchoscopes. In the semi-recumbent position,generalanesthesiawasinduced with70% nitrous oxideinoxygenandsevoflurane.Oninductionofanesthesia, nitrous oxide wasdiscontinued and anesthesia was main-tained withsevoflurane in 100% oxygen. Withthe patient breathing spontaneously, bronchoscopy was performed to assess the feasibility of placing a self-expanding metallic trachealstent.Asize5classicLMAwasplacedtomaintain spontaneous respiration. Neuromuscular blocking agents andpositivepressureventilation wereavoided.Therewas largeairleakwiththepassageofbronchoscopesthroughthe LMAandwewereunabletomaintaingoodsevoflurane con-centrationsnecessaryfortheprocedure.Hence,wedecided tosupplementitwithpropofolinfusionatsedativedoseof 25---50mcg/kg/min. With this small dose of propofol, we could maintain spontaneous respiration and achieve ade-quate depth of anesthesia required for stent placement. An 18mm×60mm self-expanding metallic tracheal stent

was deployed through the LMA (Fig. 1D) with immediate improvement in the tidalvolumes. The LMA was success-fullyremovedattheendoftheprocedureandthepatient recoveredinthepostanesthesiacareunituneventfully.

Discussion

Mediastinalmassesareknowntobeassociatedwith signifi-cantmorbidityandmortalityduetotheanatomicalrelation of the mass with important structures within the thorax. Thecardiorespiratorycompromiseresultingfromthemass collapsing on the trachea, cardiac chambers, pulmonary veins or the superior vena cava could have devastating outcomes.Patientspresentingwithsymptomsof dyspnea, cough, hoarseness, stridor, postural symptoms, superior vena cava syndrome or evidence of tracheal compression ofmorethan50%asassessedbyCTscans,areatahigher riskforcardiopulmonarycollapse.4_{Thepresenceof} pericar-dialeffusionwasfoundtobeanindependentriskfactorfor complications.2_{Anindividualizedanestheticplanshouldbe} formulatedfor eachpatientpresentingwithamediastinal massbasedontheclinicalandradiological features. Gen-eral anesthesia is best avoided in such high-risk patients when possible. If general anesthesia is absolutely neces-sary, maintaining spontaneous respiration would preserve the normal transpulmonary pressuregradient that aidsin keepingtheairwaydistendedandpatent,thus preventing airwaycollapse.5

Patientswithintrathoracictumorsarefrequentlyseenin theperioperativeperiodforavarietyofprocedures requir-inganesthesia. Theuse ofmetallicself-expandablestents

as a palliative measure for relieving airway obstruction due to compression by tumors has increased significantly in the recent past. Anesthesia for tracheal stent place-menthasbeenwelldescribedbyBrodsky.6_{Trachealstents} arepreferablyplaced under general anesthesiaasit pro-vides an immobile patient with good visualization of the airway for stent placement. Airway management can be achieved with an endotracheal tube, rigid bronchoscopy withjetventilationoraLMA.7,8_{Sarkissetal.describethe} successfuluseoftheLMAinpatientspresentingfor interven-tionalpulmonology.9_{Evenpatientswithmassivemediastinal} masses have undergone successful procedures with LMA placement.10

Inourcase,thepatientwasnotonlysymptomatic,but alsodemonstrated tracheal narrowing starting just below thelarynxontheCTscan. Duringtheanestheticplanning ofourpatient,thepossibilityof cardiorespiratory decom-pensation could not be underestimated. Our patient had subglotticcompressionofthetracheaandthestent place-mentthroughanendotrachealtubeorarigidbronchoscope would have been difficult.7 _{Hence, a LMA was preferred} fortheplacementoftrachealstentfromthesurgicalstand point.The largeinternal diameteroftheLMA allowseasy passageof the stent loader withthe stent without inter-ruptionof ventilation.A classic LMAwas chosenas ithas aperture bars instead of theepiglottic elevator bars that alloweasypassageofbronchoscopeandstents.Ourmajor concernwiththe use of LMA in this patientwasthat the airway was not secure and there wasstill the possibility of tracheal compression by the tumor which could result insignificantdifficultywithventilation.Intheeventof air-waycollapse,theplanwastostenttheairwayopenwitha rigidbronchoscope.Thecardiopulmonarybypassteamwas onstandby asa last resort in case of emergentsituation althoughitwouldhavebeendifficulttogainfemoralaccess andgoonpumpinatimelymanner.11

Conclusion

Inconclusion,LMAcouldbeusedtoprovidesufficient anes-theticdepthfortrachealstentplacementinpatientswith massive mediastinal mass while maintaining spontaneous ventilation. However in these patients, a backup plan to rescue the airwayshould be made available in the event ofairwaycompromise.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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