The anterior medial mass patient continues to offer great challenges for the anesthesiologist. As such, newer and safer methods of providing anesthetic care are continually being sought. To this end, there is a growing body of evidence that may suggest that higher than Food and Drug Administration approved dosages of dexmedetomidine may offer another option in the arsenal of the anesthesiologist in this patient population. We recently cared for a middle aged male who presented with a large mediastinal mass, extrinsic compression critical tracheal stenosis, superior vena cava syndrome, and massive supraclavicular lymphadenopathy, scheduled for tracheal stent placement, biopsy, and diagnostic evaluation of the esophagus. After reviewing anesthetic options, we deemed the safest technique available to us to be the use of a high dose dexmedetomidine based technique with continuous infusion rate of 2mcg/kg/hr. Spontaneous respirations were maintained throughout the case, with a stable heart rate and blood pressure, and our patient tolerated the procedure without complications.

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The difficult airway has been defined as a “clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation of the upper airway, tracheal intubation, or both.” Given the potentially lifethreatening consequences, the American Society of Anesthesiology has developed an airway algorithm that focuses on establishing an airway, generally for the induction of anesthesia. However, there is no algorithm on how to safely transition from an established airway back to the normal, natural airway. Up to 0.19 percent of patients can require reintubation in the post anesthesia recovery unit, with the known difficult airway at greater risk in these settings for failed reintubation. Because of this, there has been recognition of the need for guidelines in the form of an algorithm to deal with extubation in these patients. To fill this current need, we propose the following difficult to intubate patient extubation algorithm for use in the operating room setting.