airway obstruction associated with induction of general anesthesia in a patient with mediastinal...

Airway Obstruction Associated withInduction of General Anesthesia

in a Patient with Mediastinal TumorRyosuke ISHII, Ryoichiro MOTEGI,

Reiju SHIMIZU and Satoshi AKAZAWA

(Key words: airway obstruction, mediastinal tumor, head tilt-jaw thrust maneuver)

Large mediastinal tumors may causeobstruction of the trachea and mainbronchi. The following case emphasizesthe anesthetic hazards of administeringanesthesia to patients with mediastinaltumors.

Report of a Case

A 26-y~ar-old female at 27 weeks'gestation was admitted complaining ofsevere cough and her edematous face. Chestroentgenogram revealed a mass in theanterior mediastinum extending to the rightlung (fig. 1).

Cough was dry and increased markedlywhen supine, so she slept in the sittingor lateral position. On physical examinationshe had moderate facial edema, and breathsounds were clear but mildly decreased overthe right upper thorax.

Computerized tomography of the me­diastinum in the supine position showedthe mass compressing the trachea andbilateral main bronchi as shown infigure 2-A and B. Bronchoscopy couldnot be performed for her severe cough.The superior vena cava syndrome wasconfirmed by venography (fig. 3). And thebiopsy under local anesthesia revealed themalignant lymphoma.

Department of Anesthesiology, Jichi MedicalSchool, Tochigi, Japan

Address reprint requests to Dr. Ishii: Departmentof Anesthesiology, Jichi Medical School, Minami­kawachi-machi, Kawachi-gun, Tochigi-ken, 329-04

Japan

J Anesth 1: 209-211, 1987

Radiotherapy was intended, but notperformed considering the influence on thefetus, until the patient was scheduled toundergo cesarean section at 30 weeks'gestation.

Atropine, 0.5 mg, was given intramus­cularly in 30 min prior to the inductionof anesthesia. After enough preoxygenation,300 mg of thiopental and 60 mg ofsuccinylcholine chloride were given intra­venously. Immediately after unconciousnessand apnea developed, the trachea wasintubated under cricoid pressure withoutassisted ventilation (crash induction). Assoon as the patient was intubated witha 7.5 mm internal diameter cuffed tube,surgeons started operation. At that time,breath sounds were diminished over theright lung at first, and controlled ven­tilation became almost impossible about1 min later. The cuff was deflated,but no air entry was obtained. Theendotracheal tube was removed immediatelybut it had no abnormality, and ventilationvia a mask was also unsuccessful. Afteradditoional administration of 40 mg of thesuccinylcholine, the trachea was reintubatedwith 7.0 mm internal diameter tube. Thetube did not advance farther than 23 emfrom incisors with the firm resistance.

The patient became extremely cyanoticand premature ventricular contraction wasseen frequently on ECG monitor. A 1410gfemale infant was delivered about 5 minafter the onset of the airway obstructionwith Apgar scores of 6 and 9 at one andfive minites, respectively.

210 Ishii et aI J Anesth 1987

Fig. 1. Chest roentgenogram showing a

large mediastinal tumor.

About 15 min after the onset ofthe airway obstruction, air entry wasobtained somewhat in an attempt to liftup the intubated patient's jaw and tokeep her neck extremely extended. Airwayobstruction was diminished furthermoreafter spontaneous ventilation returned.Fiberoptic bronchoscopy was performed.Immediately above the carina, the tracheawas compressed anteroposteriorly and slit­like. The compression was more severe inthe supine position than in the left lateralposition. The patient was extubated in theleft lateral position after the operation wasover. No airway difficulty was encounteredafterward unless supine.

She was underwent radiation for 4 weeks.The mass had decreased in size on chestroentgenogram and she has been able tokeep the supine position without cough,having lost her facial edema. Neurologicaldefect was found neither in her nor in herinfant.

Discussion

Airway obstruction associated withinduction of general anesthesia in pa­tients with mediastinal masses is wellrecognized1-5. The mechanism of theobstruction in these cases is considered

Fig. 2-A, B. Computerized tomography of the

mediastinum in the supine position showing the

mass compressing the trachea (A) and bilateral main

bronchi (8).

compression of the trachea by the tumormass.

Our patient had many conditions incommon with these cases. First, shehad had some predictive symptoms.Keon" suggested that dyspnea and in­tolerance of the supine position isa hazardous symptom. Mackie et alldescribed airway obstruction in patientswith mediastinal masses diagnosed superiorvena cava syndrome. Second, the airwayobstruction may be diminished in acertain position. Either right or leftlateral position may succeedv", Finally,airway obstraction was diminished afterspontaneous ventilation returned'':". Itis conceivable the compromised airwayin these patients remained patent onlyduring spontaneous ventilation. Once theskeletal muscles were paralyzed and the

Vol 1, No 2 Airway obstruction due to mediastinal tumor 211

Fig. 3. Venography of the superior vena cava.

Retention of contrast media indicating superior

vena cava syndrome is demonstrated.

smooth muscles were relaxed during generalanesthesia, airway obstruction occured",

In this case, improvement of airwayobstruction in the intubated patient wasobtained by extension of the head andanterior displacement of the mandible. Thismaneuver known as the head tilt-jaw thrustmethod might pull indirectly the tumorand open the compressed trachea and mainbronchi.

Prior to general anesthesia of thepatients with anterior mediastinal masses,the condition of their airway shouldbe evaluate in an organized waythat emphsizes the dynamic nature ofthe disease process". Some authors1,4- 6

emphasize the importance of maintainingspontaneous ventilation during inductionof anesthesia. Bittar" and Piro et al.7

recommend radiation to mediastinal tumorsin patients' with Hodgkin's disease priorto endotracheal anesthesia to preventlife-threatening airway complications.

In this case, however, preoperativeradiotherapy was avoided because of hergestation. To make the matter worse,inhalated anesthesia and neuroleptanesthe­sia suitable for maintaining spontaneous

ventilation are undesirable for the cesareansection because of relaxation of the smoothmuscle of the uterus and drug depression ofthe fetus.

We should have chosen spinal anesthesiaor epidural anesthesia in the left lateralposition, in spite of the possibility of theunexpected complication by her persistentcough.

Summary

The case of airway obstruction associatedwith induction of general anesthesia in apatient with mediastinal tumor is reported.This case emphasizes that the headtilt-jaw thrust method may improve airwayobstruction due to mediastinal tumor evenin the intubated patient.

(Received Nov. 28, 1986, accepted for pub­lication May 29, 1987)

References

1. Mackie AM, Watson CB: Anaesthesia andmediastinal masses. Anaesthesia 39:899-903,1984

2. Bray RJ, Fernandes FJ: Mediastinal tumorcausing airway obstruction in anaesthetizedchildren. Anaesthesia 37:571-575, 1982

3. O'Leary HT, Tracey JA: Mediastinal tumorscausing airway obstruction; A case in anadult. Anaesthesia 38:67, 1983

4. Bittar D: Respiratory obstruction associatedwith induction of general anesthesia in apatient with mediastinal Hodgkin's disease.Anesth Analg 54:399-403, 1975

5. Neuman GG, Weingarten AE, AbramowitzRM, Kushins LG, Abramson AL, LadnerW: The anesthetic management of thepatient with an anterior mediastinal mass.Anesthesiology 60:144-147, 1984

6. Keon TP: Death on induction of anesthesiafor cervical node biopsy. Anesthesiology55:471-472, 1981

7. Piro AH, Weiss DR, Hellman S: MediastinalHodgkin's disease; a possible danger forintubation anesthesia. lnt J Radiat OnealBioI Phys 1:415-419, 1976

8. Amaha K, Okutsu Y, Nakamura Y: Majorairway obstruction by mediastinal tumour; acase report. Brit J Anaesth 45:1082-1084,1973