S015: RIGID BRONCHOSCOPY INTUBATION IN A PATIENT WITH DIFFICULT AIRWAY AND MEDIASTINAL MASS
Camila Gonzalez, DO1; Paul Campbell, MD2
1University of Florida College of Medicine; 2Malcolm Randall VA Medical Center
Introduction: Anterior mediastinal masses with tracheal and major vascular compression pose significant anesthetic and airway-management risks, including dynamic airway collapse and cardiovascular compromise. We present a case of a 58 year old male with grade 3 malignant thymoma refractory to chemo/radiation. He was evaluated by cardiothoracic surgeons at several institutions, and his tumor was deemed nonsurgical. At the time of this case his care was largely palliative. Progressive tumor growth produced significant SVC compression with hemodynamic impact, and midtracheal narrowing with tracheal shift and collapse of the right upper lobe secondary to compression of the right upper lobe bronchus. The tumor was also invading the SVC, right atrium, and aortic arch, compressing the brachiocephalic trunk and left carotid artery. Imaging showed mid-lower tracheal luminal diameter of 8x6cm and the patient reported severe dyspnea with a sensation of suffocation. ENT was consulted to discuss tracheostomy but considered it unfeasible due to low intrathoracic narrowing. Pulmonology planned rigid bronchoscopy for debulking and possible stent placement. Given the high risk of respiratory or cardiovascular collapse with neuromuscular blockade and positive-pressure ventilation, maintaining spontaneous ventilation was essential for this patient.
Methods: Multidisciplinary planning emphasized preservation of spontaneous respiration and optimizing conditions for rigid bronchoscope insertion. Preparations included arterial line placement, two large-bore IVs, glycopyrrolate and small-dose midazolam premedication, and ICU postprocedure care. Regional and topical anesthesia techniques were used to improve tolerance. We performed bilateral anterior tonsillar pillar injections under direct vision to block the glossopharyngeal nerve, ultrasound-guided superior laryngeal nerve blocks, and topical tracheal anesthesia via fiberoptic bronchoscope after the upper airway had been anesthetized. Induction employed careful titration of volatile anesthetic, low-dose propofol infusion, boluses of ketamine, and a background ultra-low dose remifentanil infusion to blunt reflexes without suppressing spontaneous ventilation.
Results: Airway management was technically challenging due to small mouth opening, Mallampati 4, poor neck mobility, prominent teeth, copious secretions, and a strong bite reflex. The pulmonologist required three attempts to place the rigid bronchoscope and the patient maintained spontaneous ventilation throughout. Adjustments included incremental ketamine and volatile anesthetic dosing and brief coordinated pauses during instrumentation. Bronchoscopic debulking removed a thick fibrous layer of the inner tracheal lumen from prior radiation while avoiding tumor. Airway caliber was significantly widened, but anatomy was deemed unsuitable for stent placement. Hemodynamics remained stable without vasoactive support. Postprocedure the patient was transferred to ICU for monitoring; on recovery he reported marked subjective improvement in dyspnea and decreased work of breathing.
Discussion: This case highlights the critical importance of multidisciplinary planning, preservation of spontaneous ventilation (paramount in these patients), and targeted regional/topical anesthesia for airway procedures in patients with critical central airway obstruction and mediastinal compression. Careful anesthetic titration and preparation for rapid conversion to definitive airway or cardiopulmonary support are essential to mitigate catastrophic respiratory or cardiovascular collapse.