ANTERIOR MEDIASTINAL MASS

Syllabus for Case Conference SCA Thoracic Symposium April, 2012

Philip Hartigan, M.D.

INTRODUCTION:

Few topics in our specialty have inspired such dogmatic teaching, based on so little evidence, as
the subject of anesthetic management of patients with an anterior mediastinal mass. There is no
question that general anesthesia exacerbates mass effects within the chest (Table 1), but the
precise mechanism(s) by which that occurs are less certain.

The landmark paper by Neuman, et al, based on case reports and logic (all that was available at
the time), provided a management algorithm which has persisted for nearly 3 decades with little
modification. This case conference shall strive to (1) concisely review the conventional teaching
on this topic, (2) summarize the evidence basis, and (3) provoke a reevaluation of those
recommendations, with an appreciation of the level of uncertainty and of the unanswered
questions which remain.

Table 1. Anesthetic Risks Associated with Large Anterior Mediastinal Mass

Obstruction of Major Airway

Cardiac Compression (Tamponade effect)
Compression of Pulmonary Artery or RVOT
SVC Compression (SVC Syndrome)

MECHANISMS:

Induction of general anesthesia is often treated as a single event, when in fact it often involves
several transitions:

1. Upright posture to supine position

2. Awake state to anesthetized state
3. Spontaneous negative pressure ventilation to positive pressure mechanical ventilation
4. Unparalyzed to paralyzed muscular tone

Mechanistically, each transition may be considered individually, and each bridge crossed
sequentially in a so-called staged induction. While # 1 and #2 clearly reduce FRC, the
mechanisms by which #3 and #4 exacerbate airway compression are less well defined.
INDUCTION OPTIONS:

Options for anesthetic induction depend on perceived risk, and include the following:
No Induction (Local)
Awake F.O.B / Intubate Distal to Stenosis before Induction
Staged IV or Inhalational Induction
Standard IV Induction

RISK ASSESSMENT:

Conventional teaching directs the clinician to judge risk based on data from the sources in Table
2, with the greatest emphasis on the presence of postural symptoms and radiographic evidence of
a large AMM with encroachment on vital structures. Limited guidance is available for
delineating levels of perceived risk.

Table 2. Risk Assessment for Patients with Anterior Mediastinal Mass

Symptoms / Signs
Radiographic Data (esp. CT Scan)
Spirometry (esp. PEFR)
Echocardiography (if suspected cardiac / vascular compression)

Acknowledging the uncertainties of risk stratification, one can generally identify patients as low,
intermediate, or high risk (Table 3). It is appropriate for less experienced practitioners to err on
the conservative. When general anesthesia cannot be avoided, the following modified algorithm
is proposed based on perceived risk.
Legend: Proposed algorithm for the anesthetic approach to the patient with an AMM and threatened airway.
Dashed red lines indicate response to a nonreassuring finding (such as difficulty ventilating, or worrisome finding on
bronchoscopy). Green solid lines indicate response to reassuring findings. Staged induction implies the stepwise
progression through each potentially exacerbating transition. Imprecision in risk assessment is acknowledged.
Therefore, rescue maneuvers (Table 4) should be readily available. From Hartigan PM (Editor). Practical
Handbook of Thoracic Anesthesia. Springer, 2012.
Table 3. Potential High Risk Criteria

Significantly symptomatic (esp. orthopnea)

Large mass by CT scan (esp. midline, distal tracheal)
Tracheal compression to < 50% of predicted cross sectional area (children)
PEFR < 50% predicted (children)
SVC syndrome
Pericardial effusion

Table 4. Rescue Options for Airway Compression from AMM

Advance ETT to stent open the stenotic portion of airway

Revert to prior stage (resume spont ventilation, upright posture, lighten anesthetic, etc.)
Reposition lateral or semiprone
Rigid bronchoscopy beyond stenosis (jet or sideport ventilation)
CPB / ECMO if preemptively cannulated

EVIDENCE BASIS

Case reports and series constitute the principal primary literature on this topic. By their nature,
they rely on recollections from stressful moments. The vast majority are pediatric patients.
Complications do not invariably occur with induction, and have been reported late in the course
of anesthetics, during emergence, and in the recovery period. Complications have been reported
in patients who were asymptomatic, and in patients maintaining spontaneous respiration and
without muscle relaxation. A limited number of studies in children have attempted to provide
guidance for risk stratification based on criteria such as tracheal cross sectional area, but are of
questionable applicability to adult patients.

CARDIOVASCULAR COMPRESSION

When the principle threat is to venous return and cardiac output (compression of heart, RVOT,
PA, SVC), induction (if necessary) should be performed with augmentation of preload, and
positioning to minimize compression of heart/vessels. Lower extremity IV access is needed if
SVC compression is a risk. Spontaneous ventilation augments venous return and should be
preserved in high risk patients.

Coexisting pericardial effusion clearly increases risk. Logically, any other impediment to venous
return (hypovolemia, large pleural effusion, etc.) would be expected to increase induction risk.
Cardiovascular compression may coexist with airway compression with a large AMM.

Should CV collapse occur, repositioning lateral may help to off-load the heart/vessels, as will
emergent sternotomy. Preemptive awake, femoral cannulation for CPB is a very conservative
approach, but reliance on emergent cannulation as a rescue maneuver is not recommended.
Selected References

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and pediatric populations. J Thorac Cardiovasc Surg 1993;106:67-72.
2. Azizkhan RH, Dudgeon DL, Buck JR, et al. Life threatening airway obstruction as a
complication of the management of mediastinal masses in children. J Pediatr Surg
1985;20:816-22.
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complications in adults with mediastinal mas. Anesthesiotoy 2004; 100; 826-34
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with mediastinal Hodgkins disease. Anesth Analg 1975;54:399-403.
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mass: Continuing professional development. Can J Anaesth 2011; Published online by
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anesthetic management of the patient with an anterior mediastinal mass. Anesthesiology
1984;60:144-7.
9. Ng J, Hartigan PM. Anterior Mediastinal Mass. Chapter 20 in Hartigan PM (editor), Practical
Handbook of Thoracic Anesthesia. Springer 2012.
10. Perger L, Lee E, Shamberger R. Management of children and adolescents with a critical
airway due to compression by an anterior mediastinal mass. J Pediatr Surg 2008;43:1990-97.
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intubation anesthesia. Int J Radiat Onc Biol Phys 1976;1:415-9.
12. Shamberger RC, Holzman RS, Griscom NT, et al. CT quantification of tracheal cross-
sectional area as a guide to the surgical and anesthetic management of children with anterior
mediastinal masses. J Pediatr Surg 1991;26:138-42.
13. Shamberger RC, Holzman RS, Griscom NT, Tarbell NJ, Weinstein HJ, Wohl ME.
Prospective evaluation by computed tomography and pulmonary function tests of children
with mediastinal masses. Surgery. 1995;118:468-71.
14. Sibert KS, Biondi J, Hirsch N. Spontaneous respiration during thoracotomy in a patient with
a mediastinal mass. Anesth Analg 1987;66:904-7.