Airway management in a child with anterior mediastinal mass complicated by cardiac tamponade - Role of spontaneous ventilation

Rudingwa, Priya; Panneerselvam, Sakthirajan; Arasu, Meenupriya; Arikrishnan, Thirumurugan

doi:10.4103/aca.aca_244_18

Cited by 2 publications

(1 citation statement)

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“…Most predate readily available fiberoptic bronchoscopes and lack objective confirmation of central airway collapse. While some appear to support an apparent temporal association between ventilatory crises and induction, transition to positive pressure ventilation, or paralysis (or resolution with emergence and return of spontaneous ventilation), 1,21–24 that association is poor or reversed in others, 1,25–27 and often the precise timing of events is difficult to determine. More compressible, small diameter pediatric airways likely behave differently than those of the adult.…”

Section: Discussionmentioning

confidence: 99%

Mediastinal Masses, Anesthetic Interventions, and Airway Compression in Adults: A Prospective Observational Study

et al. 2021

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Background Central airway occlusion is a feared complication of general anesthesia in patients with mediastinal masses. Maintenance of spontaneous ventilation and avoiding neuromuscular blockade are recommended to reduce this risk. Physiologic arguments supporting these recommendations are controversial and direct evidence is lacking. The authors hypothesized that, in adult patients with moderate to severe mediastinal mass–mediated tracheobronchial compression, anesthetic interventions including positive pressure ventilation and neuromuscular blockade could be instituted without compromising central airway patency. Methods Seventeen adult patients with large mediastinal masses requiring general anesthesia underwent awake intubation followed by continuous video bronchoscopy recordings of the compromised portion of the airway during staged induction. Assessments of changes in anterior–posterior airway diameter relative to baseline (awake, spontaneous ventilation) were performed using the following patency scores: unchanged = 0; 25 to 50% larger = +1; more than 50% larger = +2; 25 to 50% smaller = −1; more than 50% smaller = −2. Assessments were made by seven experienced bronchoscopists in side-by-side blinded and scrambled comparisons between (1) baseline awake, spontaneous breathing; (2) anesthetized with spontaneous ventilation; (3) anesthetized with positive pressure ventilation; and (4) anesthetized with positive pressure ventilation and neuromuscular blockade. Tidal volumes, respiratory rate, and inspiratory/expiratory ratio were similar between phases. Results No significant change from baseline was observed in the mean airway patency scores after the induction of general anesthesia (0 [95% CI, 0 to 0]; P = 0.953). The mean airway patency score increased with the addition of positive pressure ventilation (0 [95% CI, 0 to 1]; P = 0.024) and neuromuscular blockade (1 [95% CI, 0 to 1]; P < 0.001). No patient suffered airway collapse or difficult ventilation during any anesthetic phase. Conclusions These observations suggest a need to reassess prevailing assumptions regarding positive pressure ventilation and/or paralysis and mediastinal mass–mediated airway collapse, but do not prove that conventional (nonstaged) inductions are safe for such patients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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