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EDITORIAL
Year : 2011  |  Volume : 5  |  Issue : 3  |  Page : 241-243

Management of the patient with a central airway obstruction


Department of Anesthesia, University of Toronto, Toronto General Hospital, Canada

Correspondence Address:
Peter Slinger
Department of Anesthesia, University of Toronto, Toronto General Hospital
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.84094

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Date of Web Publication22-Aug-2011
 


How to cite this article:
Slinger P. Management of the patient with a central airway obstruction. Saudi J Anaesth 2011;5:241-3

How to cite this URL:
Slinger P. Management of the patient with a central airway obstruction. Saudi J Anaesth [serial online] 2011 [cited 2017 Nov 19];5:241-3. Available from: http://www.saudija.org/text.asp?2011/5/3/241/84094

The risk of life-threatening or fatal airway obstruction or cardio-vascular collapse during induction of anesthesia in patients with central airway obstruction has been recognized since the 1970s. [1] Over the subsequent 30+ years, anesthesiologists have become very aware of the high risk associated with general anesthesia in these patients. It seems that the perioperative management of these patients has improved, judging by the rarity of recent case reports of intraoperative fatalities and by the low morbidity reported in current retrospective surveys. The case report by El-Dawlatly et al. in this issue of the Journal is an excellent example of management of these cases. [2]

The anesthetic considerations for patients with a central airway obstruction vary according to the individual anatomy, pathology and the proposed surgical procedure. Thus, although there are general principles of safe anesthesia for these patients, there is the need to individualize management on a case-by-case basis. Masses may be benign or malignant tumors or cysts or aneurysms and may arise from the airway, lung, pleura or any of the components of the anterior mediastinum. The commonest diagnoses in adults are: Lymphoma (Hodgkin's or non-Hodgkin's), thymoma, germ cell tumor, granuloma, bronchogenic carcinoma, thyroid tumors, bronchogenic cyst and cystic hygroma [3] (the commonest diagnoses in children are essentially the same and vary only in order of frequency). Possible diagnostic or therapeutic surgical procedures include bronchoscopy, sternotomy, thoracotomy, cervical mediastinoscopy, anterior para-sternal mediastinoscopy, video-assisted thoracoscopic biopsy or biopsy of an extrathoracic mass. Occasionally, a patient with a central airway obstruction will present for anesthesia for another related or non-related emergent surgical indication such as ascending aortic aneurysm [4] or cesarean section. [5]

Patients may present with signs or symptoms which include dyspnea, chest pain or fullness, cough, sweats, Superior vena cava (SVC) obstruction, hoarseness, syncope or dysphagia. Or patients may be asymptomatic and have a mass diagnosed on a screening chest X-ray or computed tomography (CT) scan. Among the signs and symptoms which should alert the anesthesiologist to an increased perioperative risk are increased dyspnea (orthopnea) or cough when supine (increased risk of airway complications) and syncopal symptoms or pericardial effusion (increased risk of cardiovascular complications). Symptoms are graded mild, moderate or severe according to the patient's tolerance of the supine position. Patients with severe symptoms will not voluntarily lie supine even for a short duration.

All patients with a central airway obstruction should have a chest X-ray and a CT scan prior to any surgical procedure and the anesthesiologist must look at the imaging him/herself to plan the airway management. The CT scan will show the site, the severity, and the extent of the airway compromise. With modern fast CT scanners, this can be accomplished with scan times <20 sec. In addition, the patient's head and chest can be elevated to 30° without affecting the scan quality. Alternatively, the scan can be done in the lateral or even prone position if necessary. Patients with cardiovascular symptoms or those who are unable to give an adequate history should also have transthoracic echocardiography to assess for cardiac, systemic or pulmonary vascular compression.

There are important differences in the management of children versus adults. Anesthetic deaths have mainly been reported in children. [6] The deaths may be the result of the more compressible cartilaginous structure of the airway in children and/or because of underestimation of the severity of the airway compression in children due to the difficulty in obtaining a clear history of positional symptoms. Even with proper management, children with tracheo-bronchial compression greater than 50% cannot safely be given general anesthesia. [7] Securing the distal airway with awake fiberoptic intubation and placement of an endotracheal tube distal to a tracheal obstruction, which is an option for some adults with masses compressing the mid-trachea, is not an option in most children. While it is possible to induce and maintain anesthesia with a volatile agent and spontaneous ventilation to a depth sufficient to perform rigid bronchoscopy in a child, this is very difficult in an adult. In an adult, such as the one presented in this case, after induction with spontaneous ventilation and assuring the ability to manually ventilate the patient, a short-acting muscle relaxant and intravenous anesthesia will usually be given for the rigid bronchoscopy.

An important part of the anesthetic assessment for these patients is to consider whether the proposed procedure is diagnostic or therapeutic. To obtain tissue for diagnosis in children or adults who are unsafe for general anesthesia, a common procedure is an awake CT-guided needle biopsy. This can be done with local anesthesia and sedation as required, with a diagnostic accuracy of >90%. [8] In adults, other useful options are awake fiberoptic bronchoscopy or anterior mediastinoscopy with local anesthesia. Cytometric and immunocytochemical studies of pleural fluid can also be used to secure a diagnosis. [9] This is particularly useful in lymphoblastic lymphoma which is associated with a high incidence of pleural effusions. Like needle biopsy, diagnostic thoracentesis can be done with ultrasound guidance in the sitting position with minimal or no sedation. However, once the diagnosis has been confirmed and if the surgery is for therapeutic excision of a central airway obstruction, then a management plan of safe anesthesia needs to be developed.

Patients with a central airway obstruction, who require general anesthesia, need a step-by-step induction of anesthesia with continuous monitoring of gas exchange and hemodynamics. Maintaining spontaneous ventilation until either the airway is definitively secured or the procedure is completed is a safe and popular strategy. [10] Anesthetic induction can be inhalational with a volatile agent such as sevoflurane (as in the presented case), or by intravenous titration of propofol, with or without ketamine. Awake intubation of the trachea before induction is a possibility in some patients if the CT scan shows an area of non-compromised distal trachea to which the endotracheal tube can be advanced before induction. If muscle relaxants are required, assisted ventilation should first be gradually taken over manually to assure that positive-pressure ventilation is possible and only then can a short-acting muscle relaxant be administered. Development of airway or vascular compression requires that the patient be awakened as rapidly as possible and then other options for surgery can be explored. Intraoperative life-threatening airway compression has usually responded to one of two therapies: Either repositioning of the patient (it should be determined before induction if there is one side or position that causes less symptomatic compression) or rigid bronchoscopy and ventilation distal to the obstruction. This means that an experienced bronchoscopist and rigid bronchoscopy equipment must always be available in the operating room at induction and throughout in these cases (as was done in the presented case).

Flow-volume loops are commonly ordered as part of the preoperative assessment for patients with a central airway obstruction. Specifically, an increased mid-expiratory plateau when changing from the upright to the supine position is thought to be pathognomonic for a variable intrathoracic airway obstruction and an indicator of patients who are at risk for airway collapse during induction of anesthesia. [11] Apart from sporadic case reports, studies of flow-volume loops have shown a poor correlation with the degree of airway obstruction [12] and have not demonstrated usefulness in managing these patients. [13] One study of 25 patients with intrathoracic masses due to Hodgkin's Disease found that no patient showed the pathognomonic pattern of variable intrathoracic obstruction on flow-volume loop even though 9/25 patients had moderate or severe intrathoracic tracheal compression on CT scan. [14] Also of note in this study, 7/25 patients showed an inspiratory plateau on flow-volume loop typical for an extrathoracic airway obstruction in spite of the fact that none of the patients actually had an extrathoracic obstruction on imaging. The myth of the usefulness of flow-volume loops in the assessment of patients with a central airway obstruction is well established in standard anesthesia texts and on anesthesia specialty exams. However, in clinical practice, flow-volume loops do not add any useful information beyond that which is obtained from the chest imaging.

Another myth which exists in the standard texts and reviews of management of patients with a central airway obstruction is the usefulness of cardiopulmonary bypass as a "standby" during induction of anesthesia. [15] The establishment of cardiopulmonary bypass by femoral cannulations prior to induction of anesthesia has been safely performed in adult patients. [16] However, once airway or cardiovascular collapse has occurred, it will require at least 5-10 min to cannulate and establish adequate circulation and oxygenation, [17] even with a primed pump and a prepared team. In such a scenario, it is probable that a young patient can be resuscitated but will suffer neurological injury. [18] Patients with extremely severe positional symptoms due to airway or cardiovascular compression cannot be safely given induction of general anesthesia, even with maintenance of spontaneous ventilation, unless an alternative technique to maintain oxygenation and/or circulation (extracorporeal membrane oxygenation or cardiopulmonary bypass) has been established.

In summary, this case report is a good example of the anesthetic management of patients with central airway obstruction. The most useful information for the anesthesiologist to guide management of these patients comes from the patient's history and examining the chest imaging. A rigid bronchoscope and thoracic surgeon should be available at induction. In patients at risk of central airway obstruction, spontaneous ventilation should be maintained as long as possible during and after induction of anesthesia. Also, these patients should be monitored closely for the development of airway obstruction postoperatively. [19]

 
  References Top

1.Slinger P, Karsli C. Management of the patienst with a large anterior mediastinal mass: Recurring myths. Curr Opin Anaesthesiol 2007;20:1-3.  Back to cited text no. 1
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2.El-Dawlatly A, Alnassar A, Abodonya A, Almutlaq N, Hajjar W. Anesthetic considerations of central airway obstruction. Saudi J Anaesth 2011;5:323-25.  Back to cited text no. 2
    
3.Ferguson MK, Lee E, Skinner DB, Little AG. Selective operative approach for diagnosis and treatment of anterior mediastinal masses. Ann Thorac Surg 1987;44:583-6.  Back to cited text no. 3
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4.Tominaga R, Tanaka J, Kawachi Y, Yoshitoshi M, Kohno H, Shiki K, et al. Surgical treatment of respiratory insufficiency due to tracheo-bronchial compression by aneurysms of the ascending aorta and innominate artery. J Cardiovasc Surg (Torino)1988;29:413-7.  Back to cited text no. 4
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5.Dasan J, Littleford J, McRae K, Farine D, Winton T. Mediastinal tumour in a pregnant patient presenting as acute cardiorespiratory compromise. Int J Obstet Anesth 2002:11:52-6.  Back to cited text no. 5
    
6.Victory RA, Casey W, Doherty P, Breatnach F. Cardiac and respiratory complications of mediastinal lymphomas. Anaesth Intensive Care 1993;21:366-9.  Back to cited text no. 6
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7.Hack HA, Wright NB, Wynn RF. The anesthetic management of children with anterior mediactinal masses. Anaesthesia 2008;63:837-46.  Back to cited text no. 7
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8.Chait P, Rico L, Amaral J, Ultrasound guided core biopsy of mediastinal masses in children. Pediatr Radiol 2005;35:s76.  Back to cited text no. 8
    
9.Chaignuad BE, Bosnal TA, Kozakewich HP, Shamberger RC. Pleural effusions in lymphoblastic lymphoma: A diagnostic alternative. J Pediatr Surg 1998;33:1355-7.  Back to cited text no. 9
    
10.Frawley G, Low J, Brown TC. Anaesthesia for an anterior mediastinal mass with ketamine and midazolam infusion. Anaesth Intensive Care 1995;23:610-2.  Back to cited text no. 10
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11.Neuman GG, Weingarten AE, Abramowitz RM, Kushins LG, Abramson AL, Ladner W. The anesthetic management of a patient with an anterior mediastinal mass. Anesthesiology 1984;60:144-7.  Back to cited text no. 11
    
12.Torchio R, Gulotta C, Perbondi A, Ciacco C, Guglielmo M, Orlandi F, et al. Orthopnea and tidal expiratory flow limitation in patients with euthyroid goiter. Chest 2003;124:133-40.  Back to cited text no. 12
    
13.Hnatiuk OW, Corcoran PC, Sierra A. Spirometry in surgery for anterior mediastinal masses. Chest 2001;120:1152-6.  Back to cited text no. 13
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14.Vander Els NJ, Sorhage F, Bach AM, Straus DJ, White DA. Abnormal flow volume loops in patients with intrathoracic Hodgkin's Disease. Chest 2000;117:1256-61.   Back to cited text no. 14
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15.Pullerits J, Holzman R. Anaesthesia for patients with mediastinal masses. Can J Anaesth 1989;36:681-8.  Back to cited text no. 15
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16.Tempe DK, Arya R, Dubey S, Khanna S, Tomar AS, Grover V, et al. Mediastinal mass resection: Femoro-femoral cardiopulmonary bypass before induction of anesthesia in the management of airway obstruction. J Cardiothorac Vasc Anesth 2001;15:233-6.  Back to cited text no. 16
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17.Takeda S, Miyoshi S, Omori K, Okumura M, Matsuda H. Surgical rescue for life-threatening hypoxemia caused by a mediastinal tumor. Ann Thorac Surg 1999;68:2324-6.  Back to cited text no. 17
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18.Turkoz A, Gulcan O, Tercan F, Koçum T, Türköz R. Hemodynamic collapse caused by a large unruptured aneurysm of the ascending aorta in an 18 year old. Anesth Analg 2006;102:1040-2.  Back to cited text no. 18
    
19.Bechard P, Letourneau L, Lacasse Y, Cote D, Bussieres JS. Perioperative cardiorespiratory complications in adults with mediastinal mass: Incidence and risk factors. Anesthesiology 2004;100:826-34.  Back to cited text no. 19
    



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