Compression of the trachea, carina and main bronchi by mediastinal masses of benign or malignant pathologies may present as catastrophic airway obstruction. The situation may be inadvertently aggravated by conventional maneuvers intended to secure airway such as supine positioning of the patient and the use of paralytic agents during endobronchial intubation. We review the presentation, management and outcome of this group of patients in our institution. Various techniques to alleviate acute airway obstruction are discussed and an algorithm for the management of this life-threatening situation is proposed.
Retrospective review of the medical records of all patients who presented to our institution with life-threatening airway obstruction due to mediastinal masses, requiring urgent intervention and management in the Intensive Care Unit between March 1996 and December 2003.
8 patients with varied pathologies were identified (1 bronchogenic cyst, 3 lymphomas, 1 retrosternal goitre, 3 metastatic lymphadenopathies). The mean age was 37 years and 5 were females. 4 patients underwent successful endobronchial stenting; 1 patient failed stenting and required Extra-Corporeal Membrane Oxygenation(ECMO) whilst undergoing chemotherapy; 1 patient was supported with Continuous Positive Airway Pressure(CPAP) via facemask whilst undergoing chemotherapy; 2 patients went for curative surgery. All the patients were successfully weaned off the ventilator and transferred out of Intensive Care Unit.
The following recommendations are made:1)Avoidance of airway manipulation, muscle paralysis and general anesthesia. 2)Immediate maneuvers include repositioning the patient in the lateral, prone or sitting position; application of positive pressure support via facemask; administration of intravenous steroids if appropriate. 3)Awake fibreoptic bronchoscopic intubation is recommended if endobronchial intubation necessary. 4)Rigid bronchoscopy for endobronchial stenting should be accessible for immediate application if airway patency is not restored. 5)Standby ECMO as a temporizing life-saving measure. 6)Diagnosis should be established urgently so that specific therapy can be instituted, which includes surgery, chemotherapy, radiotherapy and palliative endobronchial stenting.
A multidisciplinary approach using a flexible algorithm combining various modalities is required to optimize patient outcomes in this situation. Table 1
Clinical Characteristics and InterventionsPatient/Age(yr)/SexEtiologyInterventionComment1/21/FLymphomaFailed endobronchial stenting via rigid bronchoscopy. Put on ECMO for 4 days while on chemotherapy.Airway obstruction precipitated by general anesthesia during open biopsy.2/20/MLymphomaEndobronchial stenting via rigid bronchoscopy.3/22/MLymphomaCPAP via facemask whilst steroids and chemotherapy given.4/60/FMetastatic lymphadenopathyWall stenting via rigid bronchoscopy.5/51/F 6/50/M 7/13/FMetastatic lymphadenopathy Metastatic lymphadenopathy Bronchogenic cystWall stenting via rigid bronchoscopy. Wall stenting via rigid bronchoscopy. Surgical resection.8/50/MRetrosternal goiterSurgical resection.
* Etiologies of all cases except 4, 5, and 6 were undiagnosed at presentation with acute respiratory obstruction.
G. Phua, None.