Indian J.

PG
344 ISSUE2005;
Anaesth. : AIRWAY
49 (4) : MANAGEMENT
344 - 352 INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
344

AIRWAY MANAGEMENT IN PATIENTS

WITH MEDIASTINAL MASSES
Dr. Vishnu Datt1 Dr. Deepak K. Tempe 2

Introduction Anotomy masses

Mediastinal masses can compress the major
airways, so these patients should be carefully evaluated
before subjecting them to anaesthesia.1 However, even large
mediastinal masses can present without any clinical
symptoms of airway compression.2 These large mediastinal
tumours with apparently normal airways preoperatively
may develop an obstructed airway after induction of
general anaesthesia (GA).2 Sometimes, a life threatening
airway compression can occur even after an uneventful
endotracheal intubation, and performing an emergency
tracheostomy to relieve obstruction may prove futile, as
the obstruction may be distal to the tube (lower airway
obstruction).3 In the presence of severe symptoms of
cardiorespiratory compression such as, positional
dyspnoea, orthopnoea, stridor, syncope, and superior
venacava syndrome (SVCS), administration of GA may
be fatal.4,5,6 The profound hypoxia may also be due to
compression of great vessels in the presence of patent
airway.1,7,8 In high risk patients with mediastinal mass,
irreversible cardiorespiratory collapse can occur with the
use of sedative premedication, induction of anaesthesia,
with the use of muscle relaxants,2 initiation of intermittent
positive pressure ventilation (IPPV),9 simply by making
the patient supine,1 change of posture,7 and tumour
resection or manipulation.1,10 It is also possible that
tracheobronchomalacia i.e., softening of tracheal wall,
due to prolonged compression by mediastinal mass,
may potentiate the airway collapse, with the onset of
relaxation produced by anaesthesia or commonly after
tracheal extubation or emergence.2,11 Therefore, airway
management in patients with large mediastinal masses
with or without the evidence of airway obstruction poses
a difficult challenge to the anaesthesiologists. This review
presents an overview of mediastinal masses, preoperative
evaluation and risk assessment, anaesthetic management,
and various measures utilized for airway management in
these patients.
1. D.A., DNB, MNAMS,
2. M.D., Director-Professor and Head
Department of Anaesthesiology and Intensive Care
G.B. Pant Hospital, New Delhi - 110002
Correspond to :
Dr. Deepak K. Tempe
E-mail : tempedeepak@hotmail.com
Boundaries of the mediastinum were proposed by
Shields in 1972. It extends superiorly to the thoracic inlet
and root of the neck, inferiorly to the diaphargm and
bounded laterally by the adjacent mediastinal parietal
pleura.12 It is divided into superior and inferior mediastina
by an imaginary plane passing from the sternal angle
anteriorly to the lower border of the body of fourth thoracic
vertebra posteriorly (fig. 1). Inferior mediastinum is further
divided into anterior, middle and posterior mediastina.
As the anterior mediastinum is in continuity with superior
mediastinum, it is also known as antero-superior
Fig. 1 : Schematic illustration of anatomical subdivisions of the
mediastinum. (for details refer to the text)
mediastinum.13 It is a space between the pleural cavities,
extending from the thoracic inlet to the diaphragm and from
the under surface of sternum to the anterior surface of the
pericardium and great vessels.14 Therefore, it is also known
as prevascular compartment. It contains, thymus, trachea,
oesophagus, large veins, large arteries, thoracic duct,
sympathetic trunk, lymph nodes, ectopic thyroid gland and
parathyroid tissues. Therefore, masses occupying this
compartment can compress these structures and frequently
present with tracheobronchial compression, dysphagia and
SVCS. Middle mediastinum is an anatomical compartment
between the anterior mediastinum and the anterior border
of the vertebral bodies. It is also known as visceral
compartment. It consists of heart and pericardium, great
vessels, oesophagus, and vagus and phrenic nerves. Masses
DATT, TEMPE : AIRWAY MANAGEMENT IN PATIENTS WITH MEDIASTINAL MASSES
occupying the middle mediastinum may also cause airway
obstruction due to compression or deviation of the airway
and often produce cardiac tamponade. The posterior
mediastinum or paravertebral sulci present posterior to the
middle mediastinum. It is a bilateral compartment and
projects on either side of the vertebral column. It contains,
intercostal nerves, thoracic spinal ganglion and sympathetic
chain. Posterior mediastinal masses rarely cause airway
problems. They predominantly produce effects on the spinal
cord. Thus, the anatomical location of the mass explains
some of its typical symptoms due to compression, deviation
or invasion of the adjacent mediastinal structures.
Mediastinal masses
The natural history of mediastinal masses varies
from those that are asymptomatic (benign) to that with
aggressive symptoms (invasive neoplasm) resulting in death.
The incidence of various mediastinal masses varies in infants,
children and adults. In a series of 196 infants and children,15
it was found that the most common lesions were, lymphomas
(45%), neurogenic tumour (34%), and germ cell tumor
(11%). Other series have also reported an incidence more
or less similar to this.10,16,17,18 In adults, neurogenic tumours
(neurilemmoma and neurofibroma) have been reported to be
the most common mediastinal masses.16 These occur in
posterior mediastinum and therefore do not cause airway
obstruction. The incidence of malignancy varies with age
with the lesions more likely to be benign in the first decade
of life (73%) and malignant from 2nd to 4th decade.19 The
classification of the common mediastinal masses by location
is shown in table 1.20
Table - 1 : Showing classification of mediastinal
tumours and masses by location.20
Anterior mediastinum Middle mediastinum Posterior mediastinum
• Thymoma • Foregut cyst • Neurilemmoma
• Lymphoma duplication • Neurofibroma
• Germ cell tumour • Lymphoma • Malignant
• Other mesenchymal • Pleuropericardial cysts • Schawannoma
tumour • Granulomatous diseases • Ganglio-neuroma
• Thymic cysts • Mesenchymal cyst • Neuroblastoma
• Endocrine tumour • Mesenchymal tumour
Patients with benign tumours are more often
asymptomatic (54%) than patients with malignant tumours
(15%). Lesions in the anterio-superior mediastinum
frequently produce symptoms (75%) related to the
compression or invasion of the airway and generally
present with cough, stridor, and dyspnoea. Symptoms of
Horner’s syndrome (ptosis, miosis, anhydrosis, apparent
345
enopthalmos, absence of pupillary dilatation on shading
the eye and abolition of ciliospinal reflex), hoarseness
and severe pain are often indications of malignant
pathology.15,18,21 The commonly encountered mediastinal
masses by the anaesthesiologist are the lesions located in
the anterio- superior mediastinum. These are lymphomas
(Hodgkin’s and non-Hodgkin’s), teratomas, lymphoblastic
leukemias or benign lesions like cystic hygroma,
bronchogenic cyst, etc.
Preoperative evaluation and risk assessment
It includes clinical presentation, radiological
examination, pulmonary function studies, awake fibreoptic
bronchoscopy and echocardiography.
Clinical presentation
Presenting features in a patient with mediastinal
mass depend upon the pressure effects on the surrounding
structures. Amongst the structures that can be compressed,
compression of the airway viz., trachea, main bronchi is
of primary concern to the anaesthesiologist. Therefore, while
evaluating a patient with mediastinal mass, he should
always try to know the symptoms related to the airway
obstruction. These could be cough, stridor, dyspnoea,
orthopnoea, postural dyspnoea, or cyanosis. Sometimes, the
symptoms may be very subtle, especially the ones related
to the postural changes may be ignored by the patient. The
anaesthesiologist should therefore, talk to the relatives in
detail to explore all the relevant symptoms in a given
patient. The presence of even the subtle symptoms should
warn him of the possibility of airway compression.
Sometimes, compression of the heart and its big vessels
may lead to cyanosis, syncope, and dysrhythmias. In extreme
cases, SVCS characterized by engorgement of the veins of
the neck, right upper arm, chest wall and oedema of neck,
head and upper arm and mental obtundation may be
present.22,23 These pressure effects by the anterior
mediastinal mass on airway, heart and its big vessels are
described as “superior mediastinal syndrome”23 and identify
these patients at higher risk.1,7,14,23-25 Therefore, these signs
and symptoms of airway and cardiovascular compression
are predictors of anaesthetic problems and are considered
as clear warning to avoid surgery other than lymph node
biopsy under local anaesthesia (LA).2,18,26 It has been advised
to establish the diagnosis from alternate sources
(thoracocentesis) to avoid complications in these symptomatic
patients.10,25
Radiological evaluation
Detailed radiological examination by way of
chest X-ray, computed tomography (CT) scan and
magnetic resonance imaging (MRI) scan is generally
346 PG ISSUE : AIRWAY MANAGEMENT
available in most of these patients. However, these are
normally performed with the objective of evaluation of the
tumour and not the airway. While the airway is clearly
visible in CT and MRI scans, it may not be so in the plain
chest X-ray. The anaesthesiologist should evaluate the
airway and if in doubt, a penetrated view (60-70 KB) of the
neck (anterio-posterior and lateral view) should be obtained,
which clearly delineates the airway (fig. 2). Since, airway
obstruction can be present in asymptomatic patients, this
should be done even in the presence of a slightest doubt.
Fig. 2 : X- ray neck (penetrated view) shows clearly visible shadow of
normal trachea (single arrow). Note : There is a mass on the right side and
the left bronchus is visible, (double arrow) and right one is not, suggesting
right bronchial compression.
Postero-anterior and lateral views of the chest X-ray provide
important information about the location of the mass and its
relation to the tracheobronchial tree, compression and
deviation of the airway and lung collapse.27 It also helps in
confirming the density of the mass (cystic, solid or calcified).
In 55% of patients with Hodgkin’s lymphoma involving
the mediastinum, tracheobronchial compression can be
detected by plain radiograph of the chest.28 Airway
compression can be very clearly appreciated in some patients
(fig. 3) and therefore, forms an important investigation.
Fig. 3 : Chest radiograph (postero –anterior view), showing a large mediastinal
mass occupying the right side with tracheal deviation and compression of the
distal trachea and carina.
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
CT and MR scans of the chest provide more accurate
information about the relation of mediastinal mass and its
effects on the tracheobronchial tree by compression or
invasion. CT scan quantifies the degree of airway
compression, which is not always obvious on the plain
X–ray of the chest (fig. 4). It is especially useful for the
evaluation of lower airway (main bronchi). The measurement
of the diameter, cross-sectional area, mediastinal thoracic
ratio (MTR) and mediastinal mass ratio (MMR) can be
used to identify patients at risk.
Fig. 4 : CT scan chest showing transverse section at the level of tracheal
bifurcation. Note the large mass occupying the entire right hemithorax and
compressing the trachea (arrow).
Tracheal diameter : The degree of tracheobronchial
compression confirmed on CT scan predicts airway
difficulty under GA. A 35% decrease in the diameter of
tracheobronchial lumen is associated with respiratory
symptoms, while a greater than 50% decrease may be
associated with complete airway obstruction during
induction or emergence from GA.25 King et al22 have also
reported a higher risk for developing respiratory
complications with the use of GA in patients with anterior
mediastinal mass with more than 50% compression of
the trachea. However, they have reported that degree of
tracheal compression on CT scan cannot be regarded
as a good predictor of respiratory complications, as 8%
patients with more than 50% diameter also had respiratory
complications under GA.22
Tracheal cross-sectional area : It can be used
to predict airway obstruction. Griscom and Wohl29 have
measured tracheal cross sectional area in 130 normal
children and described a formula to calculate the tracheal
area, tracheal area = age in years / 9, plus 0.35 cm2 for
boys and girls up to the age of 14 years. The tracheal area,
relative to the predicted tracheal area can be calculated
as % tracheal area = measured area / predicted area x
100. They have reported that patients with less than 50%
of the predicted area have higher risk of respiratory
DATT, TEMPE : AIRWAY MANAGEMENT IN PATIENTS WITH MEDIASTINAL MASSES
complications and recommended that these patients should
not receive GA. Shamberger et al30 have measured the
tracheal cross-sectional area in 42 patients with anterior
mediastinal masses. They reported orthopnoea in only two
patients and each had a tracheal cross sectional area of
less than 40%. They have also suggested that a less than
50% of the normal predicted tracheal cross sectional area
is associated with significant anaesthetic complications and
demonstrated a reduction in airway complications by avoiding
the use of general endotracheal anaesthesia in patients with
greater than 50% tracheal narrowing. It has been
recommended that patients with 50% or more reduction of
tracheal cross sectional area should have their femoral
vessels cannulated under LA, prior to induction of GA in
readiness for cardiopulmonary bypass (CPB).25,26 ,30
Mediastinal thoracic ratio (MTR) and
mediastinal mass ratio (MMR) : MTR is calculated
by comparing the size of the mediastinal mass with the
thoracic diameter. A patient with a MTR of more than
50% has higher risk of perioperative respiratory
complications.31,32 King et al.22 have described the “Mediastinal
mass ratio” (MMR) as a maximum width of the mediastinal
mass relative to the maximum width of the mediastinum,
measured by the CT scan. They have described mediastinal
masses as small, if MMR is less than 30%, medium if
MMR is equal to 31% to 41%, and large, if MMR of
more than 45%. Further, they observed that children with
small masses have no risk of anaesthetic complications,
whereas patients with MMR of more than 56% are
associated with respiratory complications. However, they
do not regard MMR as a true predictor of respiratory
complications as 3 patients with MMR of more than 56%,
underwent anaesthesia without difficulty.22
Pulmonary function study
These are quantitative and should be performed in
upright and supine position. These provide more objective
data in identifying the high risk patients.
Peak expiratory flow rate (PEFR) : It reflects
central airway diameter. A less than 50% of the predicted
PEFR in supine position has been associated with significant
anaesthetic complications.26,30 Shamberger et al30 have plotted
PEFR (% of the predicted) versus tracheal area (% of the
predicted) in 31 patients with anterior mediastinal mass
undergoing preoperative evaluation and developed a
“Shamberger risk assessment box” to select the appropriate
anaesthetic technique in these patients. The box is divided
into 4 sections (A,B,C, and D). Patients in sections “A”
(tracheal area less than 50% and PEFR more than 50% of
the predicted values) and “D” (tracheal area more than
50%, and PEFR less than 50% of the predicted values)
347
have moderate risk and therefore should receive LA, if
possible. If GA is necessary, it is safe to use spontaneous
inhalational anaesthesia and avoid the use of muscle
relaxants. Whereas, patients in section “B” (tracheal area
as well as PEFR more than 50% of the predicted) have
“low risk” and can receive GA without any complications.
But, patients in section “C” (tracheal area and PEFR,
both less than 50% of the predicted) have “high risk’ and
should receive LA only.
Flow volume loop - It graphically relates the
instantaneous airflow rate to the lung volume. It helps to
differentiate between the extrathoracic and the intrathoracic
airway obstruction.33 It is a dynamic, minimally invasive,
and most sensitive test,34 to reveal airway obstruction.35
Therefore, in some patients with a normal CT scan study,
it may reveal a significant reduction in peak flow rates.34,36
The patients with intrathoracic airway obstruction will
present with reduced expiratory flow rate, demonstrated
by appearance of expiratory flow truncation (expiratory limb
plateau), (Fig-5) whereas, those with extrathoracic airway
obstruction have diminished flow in the inspiratory phase
(inspiratory plateau).34,35 Patients with anterior mediastinal
masses causing airway obstruction demonstrated by severe
expiratory plateau in supine position can develop significant
airway obstruction under GA. Therefore, GA should be
avoided in these patients and biopsy should be performed
under LA, whenever possible or he should undergo
pretreatment e.g. radiotherapy or chemotherapy, before
biopsy is performed.10, 34
Fig. 5 : Flow volume loop showing reduced vital capacity and expiratory flow
rate. Note the expiratory limb plateauing (arrow) indicative of an intrathoracic
airway obstruction.
Awake fibreoptic bronchoscopy
It should be performed in symptomatic older children
or adult patients with anterior mediastinal masses to assess
the degree of obstruction due to extrinsic compression or
invasion by the mass. It has important advantages,7,9,11,34
such as, it allows direct visual assessment of the obstruction
348 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

and of the proximal and distal airways, and anaesthesia can
be safely induced by passing a bronchoscope jacketed with
an armoured endotracheal tube through the obstructed portion
of the airway and thus having control of distal portion.37
Echocardiography
In addition to the tracheobronchial compression, the
patient with anterior mediastinal mass can have cardiac
tamponade and SVCS.6,8,14 Tumour enveloping the heart and
infiltrating the pericardium can develop refractory
cardiovascular collapse under the effects of GA.6,14
Therefore, preoperative cardiac assessment by ECG and
echocardiography is recommended in the symptomatic
Therefore, the anaesthesiologist must work out an
appropriate anaesthetic plan that will avoid the airway
obstruction and if it does occur, he should be ready with an
alternative that will quickly establish the airway patency or
restore the oxygenation. Often, such a plan is prepared in
consultation with the surgeon. In working out any plan, it
must be ensured that safety of the patient comes first.
Preserving the spontaneous ventilation during induction of
anaesthesia appears to be an important component of such
a plan. A schematic plan in dealing with such patients is
shown in fig. 6.
Mediastinal Masses

patients and femoro-femoral CPB should be available before

induction of GA in these patients.38,39 Symptomatic patient with
definite evidence of airway
Symptomatic on change of
posture only, with no Asymptomatic patient
with no evidence of
evidence of airway
obstruction on CT / MRI / obstruction airway obstruction
Bronchoscopy

Anaesthetic management
Inhalational induction + IV induction in

comfortable posture
The incidence of complications related to airway Obstruction in
trachea
Lower airway
obstruction

Assess airway by bag and mask
ventilation

obstruction with the use of GA in patients with mediastinal

Use short acting muscle relaxant

Intubation

masses has been reported to be 7% to 18%.10 Patients with Biopsy under LA

large mediastinal masses present unique problems to the

Pretreatment in chemosensitive and
anaesthesiologist. There are numerous reports of sudden

radiosensitive tumours
Cystic aspiration in cystic lesions

refractory cardio-respiratory collapse on induction of GA in

symptomatic2,5,8,32 as well as asymptomatic patients.14,34,40
Reassess

The patients present to the anaesthesiologist for performing

the biopsy or definitive resection via sternotomy or No/Partial improvement Improvement-yes

thoracotomy. The anaesthesiologist should always be

prepared to deal with an emergency even in patients who Trachea Lower airway Lower airway Tracheal obstruction

have no symptoms or evidence of airway obstruction. GA
Awake fibreoptic bronchoscopy

under LA
Make arrangements for oxygenation by Treat like Asymptomatic

exacerbates extrinsic airway compression by various
Intubate beyond obstruction with alternate means such as but consider alternative
reinforced tube • Femoro – femoral CPB means such as, femoro-

If bronchoscope is not available before induction femoral CPB and others in

mechanisms; 1) By reducing functional residual capacity • Use spontaneous ventilation

for induction


•
•
Standby femoro – femoral CPB
Helium – Oxygen mixture
Use long endotracheal tube in adults and
lower airway obstruction

• Give short acting muscle

(FRC), as the lung volume is reduced by about 500 ml – relaxant with care microlaryngeal tube in child

1500 ml under GA due to increased abdominal muscle tone
and decreased inspiratory muscle tone.41 2) Loss of
For all patients


Always be prepared to perform tracheostomy & thoracotomy to debulk the tumor.

Fibreoptic bronchoscope / rigid bronchoscope should be available

Endobronchial intubation with double lumen tube

spontaneous diaphragmatic movement under GA with the

Induction in suitable position
Ability to change position to lateral or prone

use of muscle relaxants eliminates the normal transpleural

pressure gradient as compared with the spontaneous
inhalational anaesthesia. 3) Relaxation of the
tracheobronchial smooth muscles enhances extrinsic
compressibility of the airways,34,42 4) The supine position
causes an increase in central blood volume, which may
increase tumour blood volume and its size. A rapid tumour
enlargement is also reported due to haemorrhage or
congestion within the tumour, and with the change of its
position under anaesthesia, exacerbates the airway
compression.2
The spontaneous ventilation preserves diaphragmatic
movements in a caudal direction so that a normal transpleural
pressure gradient is maintained. This keeps the airway
dilated and thus minimizes the airway collapsibility from
the extrinsic compression by the mediastinal mass.27,38
Fig. 6 : Showing simplified algorithm for anaesthetic management in a
patient with mediastinal mass causing airway obstruction. (CT: computed
tomography, MRI: magnetic resonance imaging, IV: intravenous, LA: local
anaesthesia, CPB: cardiopulmonary bypass)
Sedative premedication should be avoided in the
symptomatic patients. Opoids and benzodiazepines delay
the awakening and are dose dependent respiratory depressants.
Benzodiazepines also have muscle relaxation properties and
therefore, exacerbate airway compression by increasing the
tracheobronchial collapsibility by the large mediastinal
masses.10 Intramuscular atropine or glycopyrrolate are used
as antisialogogue agents.2 The optimal anaesthetic
management of a patient with anterior mediastinal mass is
guided by the presence of symptoms of airway obstruction,
reduction in tracheobronchial lumen assessed on CT scan,
reduction in the flow rates determined by expiratory plateau
DATT, TEMPE : AIRWAY MANAGEMENT IN PATIENTS WITH MEDIASTINAL MASSES
of the flow volume study in supine position and the nature
of surgical procedure to be performed.
Anaesthesia for biopsy
Tissue biopsy should be performed under LA or
regional anaesthesia in a symptomatic patient with large
mediastinal mass with definite evidence of airway
obstruction. Application of EMLA (eutetic mixture of local
anaesthetics) cream locally, improves the cooperation in a
very young symptomatic child for obtaining superficial lymph
node biopsy.10 Lymph node / tissue biopsy can be performed
safely with the use of ketamine sedation or anaesthesia
(0.5–1 mgkg-1, i.v.). Usually antisialogogue agents are used
before administration of ketamine to decrease the salivation.
Spontaneous ventilation under ketamine anaesthesia preserves
a normal transpleural pressure gradient and so, airway
patency. It is also recommended in patients with anterior
mediastinal masses causing cardiovascular compression, as,
its sympathomimetic properties help in maintaining the
haemodynamics in these patients.43 Tissue biopsy can also
be performed under general inhalational anaesthesia, in
high risk patients with severe airway compression, when
the procedure cannot be performed under LA.27
Anaesthesia for definitive surgery
The optimal anaesthetic plan for definitive surgery
via sternotomy or thoracotomy should be decided on the
evidence of airway obstruction, based on symptoms,
reduction in tracheobroncheal lumen revealed on CT scan
examination, severity of expiratory plateau shown on supine
flow volume loop study and abnormal echocardiography. If
there is no evidence of airway obstruction, inhalational
induction with a volatile anaesthetic agent such as,
sevoflurane / halothane or titrating dose of IV propofol or
ketamine is preferred. After documentation of the airway
patency by bag and mask ventilation, a short acting muscle
relaxant (suxamethonium) can be used to facilitate
endotracheal intubation. If IPPV can be achieved without
any problems, a long acting muscle relaxant can be
administered, till the procedure is completed.1,34 But, always
be ready to deal with any eventuality because, use of muscle
relaxants and positive pressure ventilation may result in
catastrophic airway obstruction, as the increased gas flow
across the stenosis decreases intraluminal pressure leading
to further tendency to collapse.37
If the patient has evidence of airway obstruction, a
more careful approach is required. If the obstruction is
severe as evidenced by stridor, orthopnoea, supine dysponea,
tracheal cross sectional area less than 50% of the predicted,
PEFR less than 50% of the predicted and supine flow
volume loop study shows severe expiratory plateau,10,26,30,34,44
the anaesthesiologists have utilized various methods to deal
349
with the obstructed airway. In all such patients, fibreoptic
bronchoscope, rigid bronchoscope, emergency tracheostomy
sets, double lumen tubes etc. should be readily available.
In addition, the surgeon should be ready to intervene, if the
need be.
Preoperatively, radiotherapy and chemotherapy have
been used in a sensitive group of patients (e.g. lymphoblastic
lymphomas)13 to reduce the tumour size and its encroachment
on the airways, prior to their receiving GA in an attempt
to decrease the risk of airway obstruction.5,14,27,32 Even a
single dose can shrink many tumours markedly and prevent
airway obstruction.45 Tempe et al46 have described cystic
aspiration, as a technique to relieve lower airway obstruction
in a patient with large cystic anterior mediastinal mass
causing severe airway obstruction and SVSC. An inhalational
anaesthetic technique was used for cystic aspiration and
definitive surgery was performed 2 days later under GA
with the use of muscle relaxants and IPPV. One basic
precaution that should be practiced in such patients is to
induce anaesthesia in the position in which symptoms of
airway compression are not present, e.g. right lateral position
in a tumour that is pressing the left main bronchus.
Awake fibreoptic intubation can be performed under
topical, surface anaesthesia to advance the tip of the
endotracheal tube in the non compressed area before
induction of anaesthesia. If awake intubation is not possible,
anaesthetic induction and endotracheal intubation can be
performed under deep inhalational anaesthesia. A short acting
muscle relaxant can be administered with all
precautions.2,4,5,7,34,40 If there is no airway obstruction on
IPPV, a longer acting muscle relaxant can be administered
to complete the procedure.
Patients with airway compression of the trachea and
distal main bronchi pose difficult challenge. This is so, as
the rigid bronchoscope or endotracheal intubation cannot be
performed beyond the obstructed segment of the airway.
Likewise, tracheostomy will also not be helpful. In such a
patient, it is obligatory to have some standby measures
such as CPB, to overcome the fatal complications that may
occur as a result of total airway obstruction. This should
include cannulation of vessels and keeping CPB circuit
primed and ready for instituting emergency CPB. Such an
approach provides absolute safety to the patient.
Management of acute airway obstruction
Airway obstruction is the most common and feared
complication in patients with anterior mediastinal mass
under anaesthesia. Loss of control of the airway can occur
at any stage of anaesthesia and consequences may be fatal.
Its management poses special problems due to frequent
involvement of the lower airways, therefore, possibility
350 PG ISSUE : AIRWAY MANAGEMENT
exists that emergency tracheostomy would not relieve the
airway obstruction in these patients. The first response
should be to minimize or reverse the deleterious effects of
GA (IPPV) and change the patient’s position.
Change of patient’s position : Sometimes,
turning the patient lateral, semiprone or prone position may
prove life saving under anaesthesia. It relieves the refractory
airway obstruction by taking some weight of the tumor off
the tracheobronchial tree.2
Emergency thoracotomy / median sternotomy
and tumor debulking: A rapid emergency thoracotomy
and tumor debulking can be performed in a patient with
refractory airway obstruction under anaesthesia, in an
attempt to decrease the extrinsic compression on the airway
by the anterior mediastinal mass.33
Various other measures described in the literature are
as follows :
Splinting the trachea and main bronchus
Airway obstruction can be overcome by splinting
the trachea with a long endotracheal tube or armoured
tube47,48 or by passing a rigid bronchoscope2,7,49 through the
affected region up to the level of carina or bronchus, when
normal endotracheal tube fails to relieve the airway
obstruction. Double lumen endobronchial tubes50 can cross
the tracheal obstruction and splinting of the main bronchi
can maintain the airway patency by ventilating each lung
independently, but paediatric sizes are not available.
Obstruction of the airway, extending to the main bronchi
may require a placement of “inverted Y stents”51 or
“covered stents.”52 Rarely, a bilateral bronchial obstruction
is treated by endobronchial placement of a conventional
single lumen endobronchial tube,53 thereby necessarily
sacrificing ventilation to the other lung with resultant
shunt. Harte et al53 have used a modified single lumen
endobronchial tube (by cutting a 5x3 mm oval fenestration,
11 mm below the tracheal cuff) to ventilate the right lung
positioned with the help of a fibreoptic bronchoscope in a
patient with severe tracheal and left bronchial compression
by mediastinal mass. Todres et al3 have used a coupled
endotracheal and endobronchial tube system that
independently ventilated each lung beyond the site of
obstruction in a child with critical obstruction of the distal
trachea and the left main bronchus. The compression of
left main bronchus was splinted with an endotracheal tube
passed through a tracheostomy, and the right lung (where
the bronchus was not effected by the tumour) was ventilated
by a conventionally placed tracheal tube.
The microlaryngeal bronchial tube has a small
diameter (5 mm) and a longer length (31 cm) with a high
volume low pressure cuff. It is commonly used to maintain
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
airway during microsurgical procedures on the larynx to
avoid obscuring the surgeon’s view.54,55 It can be placed
into each main stem bronchi beyond the airway obstruction
caused by mediastinal mass.56
Femoro-femoral cardiopulmonary bypass
Successful use of femoro-femoral CPB has been
described in patients with mediastinal masses to restore the
oxygenation in the event of severe life threatening hypoxia
due to severe airway obstruction or by compression of the
pulmonary artery.4,57,58 Some authors have used femoral
CPB as a standby only, in patients with tracheal mass
causing airway obstruction, but have preferred to keep the
femoral vessels exposed under LA without cannulation.59,60
Tempe et al39 have recommended femoral vessel
cannulation under LA, CPB circuit primed and kept ready
before induction of GA in symptomatic patients with
mediastinal mass causing severe tracheal compression and
SVCS so that oxygenation can be maintained by initiation
of CPB without wasting any time. Whereas, others have
recommended the initiation of femoro-femoral CPB at the
time of induction of GA, in a patient with signs and
symptoms of airway compression, cardiac compression and
SVCS demonstrated on CT scan, echocardiography and
supine flow volume loop study.34
Helium-oxygen mixture
If extreme difficulty in maintaining oxygenation is
encountered in a patient with severe airway compression
under spontaneous inhalational anaesthesia, a helium–
oxygen mixture can reduce the resistance to the airflow
through the compressed airway, and thus help in maintaining
the oxygenation.61,62 However, helium is not readily
available in India.
Direct laryngoscopy
Direct laryngoscopy is also among the manoeuvres
used to relieve the airway obstruction under anaesthesia,
when conventional endotracheal intubation fails to control
the airway. It might apply tension to the tracheal wall
tending to straighten it out somewhat and make it taut to
relieve the airway obstruction due to extrinsic compression
by the mediastinal mass.63
Conclusion
Airway obstruction is the most common and feared
complication in patients with anterior mediastinal mass
under anaesthesia with the use of muscle relaxants and
IPPV.34 These symptomatic as well as asymptomatic patients
can develop fatal airway obstruction. Therefore, patients at
risk of airway obstruction should be identified by the presence
of the respiratory symptoms (cough, stridor, orthopnoea,
and positional dyspnoea), pulmonary function study (PEFR,
DATT, TEMPE : AIRWAY MANAGEMENT IN PATIENTS WITH MEDIASTINAL MASSES
pulmonary flow-volume loops) performed in upright and supine
position, and by radiological evaluation, e.g. X-ray chest,
CT scan, MRI scan and by bronchoscopy.
A subset of patients should undergo pretreatment
with chemotherapy/ radiotherapy and cystic aspiration in an
attempt to shrink the tumour size and relieve airway
compression.39,45 GA can be administered with minimum
risk in patients with airway obstruction under the guidance
of a simplified algorithmic approach (Fig. 6). In essence,
spontaneous ventilation should be preferred during the
induction of anaesthesia and preparedness to restore airway
and oxygenation is the key to success.
Reference
1. Ferrari LR, Bedford RF. General anesthesia prior to treatment of anterior
mediastinal masses in pediatric cancer patients. Anesthesiology 1990;
72: 991-995.
2. Bray RJ, Fernandes FJ. Mediastinal tumors causing airway obstruction
in anaesthetized children. Anaesthesia 1982; 32: 571-575.
3. Todres ID, Reppert SM, Walker PF, Grillo HC. Management of critical
airway obstruction in a child with a mediastinum tumor. Anesthesiology
1976; 45: 100-102.
4. Hall KD, Friedman M. Extracorporeal oxygenation for induction of
anaesthesia in a patient with an intrathoracic tumor. Anesthesiology
1975; 42: 493-495.
5. Levin H, Rursztein S, Heifetz M. Cardiac arrest in a child with an
anterior mediastinal mass. Anesth Analg 1985; 64: 1129-1130.
6. Tonneson AS, Davis FG. Superior vena cava and bronchial obstruction
during anesthesia. Anesthesiology 1976; 45: 91-92.
7. Mackie AM, Watson CB. Anaesthesia and mediastinal masses, a case
report and review of the literature. Anaesthesia 1984; 39: 899-903.
8. Northrip DN, Bohman BK, Tsueda K. Total airway occlusion and SVC
syndrome in a child with an anterior mediastinal tumor. Anesth Analg
1986; 65: 1079-1082.
9. Pulleritis J, Holzman R. Anaesthesia for patient with mediastinal masses.
Can J anaesth 1989; 36: 681-688.
10. Robie DK, Gursoy MH, Pokorny WJ. Mediastinal tumours -Airway
obstruction and management. Semin Pedia. Surg 1994; 3: 259-266.
11. Benumof JL. Respiratory physiology and respiratory function during
anesthesia, In: Anesthesia. Miller RD (ed), 4 th edition, New York.
Churchill Livingstone 1981; 712-713.
12. Pokorny WJ. Mediastinal tumours, In: Holder, Ashcraft (eds): Pediatric
surgery, 2nd edition, Philadelphia. WB Saunders 1993; 218-227.
13. Ricketts RR. Clinical management of anterior mediastinal tumours in
children. Semin Pediatr Surg 2001; 10: 161-168.
14. Keon TP. Death on induction of anesthesia for cervical node biopsy.
Anesthesiology 1981; 55: 471-72.
15. Grosfeld JL, Skinner MA, Rescorla FJ et al. Mediastinal tumours in
children: Experience with 196 cases. Ann Surg Oncol 1994; 1: 121-127.
16. Davis RD jr, Sabiston DC jr. The mediastinum, In: Sabiston DC jr,
Text book of surgery- The biological bases of modern surgical practice,
15th edition, New York,. W B Saunders 1997; 1906-1942.
17. Mullen B, Richardson JD. Primary anterior mediastinal tumours in
children and adults. Ann Thorac Surg 1986; 42: 338-345.
18 King RM, Telander L, Smithson WA et al. Primary mediastinal tumours
in children. J Pediatr Surg 1982; 17: 512-520.
19. Davis RD, Oldhan HN, Sabiston DC. Primary cysts and neoplasms of
the mediastinum: Recent changes in clinical presentation, methods of
diagnosis, management and results. Ann Thorac Surg. 1987; 44: 229.
351
20. Nyhus LM, Baker RJ, Ficher JE. (eds), Master of Surgery, 3rd edition,
Boston, Little Brown and Company, 1997; 608.
21. Glick RD, LA Quaglia MP. Lymphomas of the anterior mediastinum.
Semin Pediatr Surg 1999; 8: 69-77.
22. King DR, Patrick LE, Ginn-pease ME et al. Pulmonary function is
compromised in children with mediastinal lymphoma. J Pediatr Surg
1997; 32: 294-300.
23. Halpern S, Chatten J, Meadows AT et al. Anesthesia hazards and other
problems. J Pediatr 1983; 102: 407-410.
24 Lang SA, Shephard DAE. Surgey for mediastinal masses. Can J Anaesth
1991; 38: 255.
25. Azizkhan RG, Dudgeon DL, Buck JR, Colombani PM et al. Life
threatening airway obstruction as a complication to the management of
mediastinal masses in children. J Ped Surg 1985; 20: 816-822.
26. Shamberger RC. Preanesthetic evaluation of children with anterior
mediastinal masses. Semin Pediatr Surg 1999; 8: 61-68.
27. Sibert KS, Biondi JW, Hirsh NP et al. Spontaneous respiration during
thoracotomy in a patient with a mediastinal mass. Anesth Analg 1987;
66: 904-907.
28. Mandell GA, Lantieri R, Goodman LR. Tracheobronchial compression
in Hodgkin,s lymphoma in children. Am J Radiol 1982; 139: 1167-
1170.
29. Griscom NT, Wohl MB. Dimensions of the growing trachea related to
the age and gender. Am J Radiol 1986; 146: 233-237.
30. Shamberger RC, Holzman RS, Griscom NT et al. CT quantitation of
tracheal cross-sectional area as a guide to the surgical and anesthetic
management of children with anterior mediastinal masses. J Pediat Surg
1991; 26: 138-142.
31. Turoff RD, Gomez GA, Berjian R et al. Postoperative respiratory
complications in patients with Hodgkin’s disease: Relationship to the
size of the mediastinal tumor. J Cancer Clin Oncol 1985; 21: 1043-1046.
32. Piro AJ, weiss DR, Hellman S. Mediastinal Hodgkins disease. A
possible danger for intubation anesthesia. Int J Radiat Oncol Biol Phys
1976; 1: 415-419.
33. Prakash UB, Abel MD, Hubmayr RD. Mediastinal mass and tracheal
obstruction during the general anesthesia. Mayo Clin Pro 1988; 63:
1004-1011.
34. Neuman GG, Weingarten AE, Abramowitz RM et al. The anaesthetic
management of the patient with an anterior mediastinal mass.
Anesthesiology 1984; 60: 144-147.
35. Abermson AL, Goldstein M, Skenzler A, Steele A. The use of the tidal
breathing flow volume loop in laryngotracheal disease of neonates and
infants. Laryngoscope 1982; 92: 922-926.
36. Miller RD, Hyatt RE. Evaluation of obstructing lesions of the trachea
and larynx by flow-volume loops. Am Rev of Respir Dis 1973; 108:
475-481.
37. Lewer BM, Torrance JM. Anaesthesia for patient with mediastinal mass
presenting with acute stridor. Anaesth Intens Care 1996; 24: 605-608.
38. Goh MH, Liu XY, Goh YS. Anterior mediastinal masses: an anaesthetic
challenge. Anaesthesia 1999; 54: 670-682.
39. Tempe DK, Arya R, Dubey S, Khanna S et al. Mediastinal mass
resection: Femoro-femoral cardiopulmonary bypass before induction of
anesthesia in the management of airway obstruction. J Cardiothorac Vasc.
Anesth 2001; 15: 233-236.
40. Bittar D. Respiratory obstruction associated with induction of general
anesthesia in a patient with mediastinal Hodgkin,s disease. Anesth Analg
1975; 54: 399-403.
41. Bergman NA. Reduction in resting and expiratory position of the
respiratory system with induction of anesthesia and neuromuscular
paralysis. Anesthesiology 1982; 57: 14-17.
42. Degraff AC, Bouhays A. Mechanism of airflow in airway obstruction. Ann
Rev Med 1973; 24: 111-134.
352 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

43. Frawley G, Low J, Brown TCK. Anaesthesia for an anterior mediastinal
mass with ketamine and midazolam infusion. Anaesth Intens Care 1995;
23: 610-612.
44. Victory RA, Casey W, Doherty P, Breatnach F. Cardiac and respiratory
complications of mediastinal lymphomas. Anaesth Interns Care 1993;
21: 366-369.
45. Janin Y, Becker J, Wise I, Schneider K, Schwartz D et al. Superior vena
cava syndrome in childhood and adolescence: A review of the literature
and report of three cases. J Ped Surg 1982; 17: 290-295.
46. Tempe DK, Datt V, Virmani S, Tomar AS et al. Aspiration of a cystic
mediastinal mass as a method of relieving airway compression before
definitive surgery. J Cardiothorac Vasc Anesth 2005 (in press).
47. Pelton JJ, Ratner IA. A technique of airway management in children with
obstructed airway due to tumor. Ann Thorac Surg 1989; 48: 301-302.
48. Monrigal JP, Grawry JC, Rezzadori G et al. Preanesthetic management
in children with tracheal compression due to mediastinal tumours.
Anesthesiology 1992; 77: A-1202.
49. Amaha K, OjutsuY, Nakamura Y. Major airway obstruction by mediastinal
tumor – A case report. Br J Anaesth 1973; 45: 1082-1084.
50. Narang S, Harte BH, Body SC. Anesthesia for patient with a mediastinal
mass. Anesthesiol Clin North Am 2001; 19: 559-580.
51. Shiraishi T, Kawahara K, Shirakura T, Inada K et al. Stenting for airway
obstruction in the carinal region. Ann Thorac Surg 1998; 66: 1925-1929.
52. Schmidt B, Massenkele G, Jhon M, Arnold R et al. Temporary
tracheobronchial stenting in malignant lymphoma. Ann Thorac Surg
1999; 67: 448-1450.
53 Harte BH, Jakitsch MT, Mckenna SS, Body SC. Use of a modified
single lumen endobronchial tube in severe tracheo-bronchial compression.
Anesthesiology 2002; 96: 510-511.
54. Morrison JD, Mirakhur RK, Craig HJL. The larynx. In:Anaesthesia for
eye, ear, nose and throat surgery, (2nd edition), Churchill Livingstone,
Edinburgh 1985; 21.
55. Keon RI, Kotak PK, Ramsden RT. Anaesthesia for microsurgery of the
larynx. Ann R Coll Surg Engl 1982; 64: 111-113.
56. John RE, Narang VPS. A boy with an anterior mediastinal mass.
Anaesthesia 1988; 43: 864-866.
57. Woods FM, Neptune WB, Palatchi A. Resection of the carina and
mainstem bronchi with the use of extracorporeal circulation. N Engl J
Med 1961; 264: 492-494.
58. Jensen V, Milne B, Salerno T. Femoral–femoral cardiopulmonary bypass
prior to induction of anaesthesia in the management of upper airway
obstruction. Can Anaesth Soc J 1983; 30: 270-272.
59. Dodge TL, Mahaffey JE, Thomas JD. The anesthetic management of a
patient with an obstructing intratracheal mass-A case report. Anesth
Analg 1977; 56: 295-298.
60. Adkins PC, Izawa EM. Resection of tracheal cylindroma using
cardiopulmonary bypass. Arch surg 1964; 88: 405-409.
61. Riley RH, Raper GD, Newman MAJ. Helium-oxygen and cardiopulmonary
bypass standby in anaesthesia for tracheal stenosis. Anaesth Intensive
Care 1994; 22: 710-713.
62. Satoh M, Hirabayashi Y, Seo N. Spontaneous breathing combined with
high frequency ventilation during bronchoscopic resection of a large
tracheal tumour. Br J Anaeth 2002; 89: 641-643.
63. Desoto H. Direct laryngoscopy as an aid to relieve airway obstruction
in a patient with a mediastinal mass. Anesthesiology 1987; 67:
116-117.

ISACON 2005
53 Annual National Conference Indian Society Of Anaesthesiologists
rd

Kolkata, 26th – 30th Dec, 2005 (Org. by West Bengal State Branch)
REGISTRATION CHARGES
CATEGORY UPTO UPTO FROM
30.9.2005 30.11.2005 1.12.2005 • Payment is only to be made by DD or Cash, in favour
(REGULAR) (DELAYED) (INCL. SPOT) of ‘ISACON 2005’ Payable at Kolkata.
ISA Members • Registration is compulsory for all participants, and
Conference Rs. 2000 Rs. 2400 Rs. 3200 accompanying persons (including children above 5 years)
C.M.E Rs. 500 Rs. 600 Rs. 700
Conf + C.M.E Rs. 2400 Rs. 2900 Rs. 3800 • Certificate from Principal or H.O.D. must accompany
the filled up registration forms of Post Graduate
PG Students students.
Conference Rs. 1500 Rs. 1900 Rs. 2300
C.M.E Rs. 500 Rs. 600 Rs. 700 Prof. Syamal Kr. Ray
Conf + C.M.E Rs. 1900 Rs. 2900 Rs. 2900 Organising chairperson
HOD, NRS Medical College, Kolkata
Non-ISA Members Housing Estate, Salt Lake, Kolkata – 97
Conference Rs. 2400 Rs. 2800 Rs. 3500 Tel – 033-23354583, 23354123
C.M.E Rs. 600 Rs. 700 Rs. 800 Mob – 9830383466
Conf + C.M.E Rs. 2900 Rs. 3400 Rs. 4200

Accompanying person Dr. Arabinda Ray

(Children above 5 yrs) Rs. 950 Rs. 1050 Rs. 1150 Organising secretary
20/9, S.E.Railway officers’ colony,
Overseas Delegates US$ 140 US$ 160 US$ 180 garden reach road, Kolkata - 700043
Tel – 033-24395796, Mob - 9831639236
Overseas US$ 90 US$ 110 US$ 130 e-mail : balai1@rediffmail.com
Accompanying Person