Sarkiss Mona, Jimenez Carlos A
Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Mediastinum. 2023 Mar 6;7:16. doi: 10.21037/med-22-37. eCollection 2023.
Anesthesia management of patients with mediastinal mass compressing the central airway is considered challenging. It is widely believed that general anesthesia induction in patients with mediastinal mass is associated with airway collapse, difficulty in ventilation and hemodynamic compromise. Additionally, several case reports and case series described patients demise after induction of general anesthesia. This has led to the strong recommendations to use inhalation induction, avoid the use of muscle relaxant and maintenance of spontaneous ventilation. Recent studies shed new light on our understanding of airway changes associated with mediastinal mass by directly visualizing and measuring the actual changes of the airway caliber and the variation in the peak inspiratory flow (PIF) and peak expiratory flow (PEF) in patients with mediastinal mass. These studies describe the changes in airway mechanics in different states e.g., awake and anesthetized, spontaneous and positive pressure ventilated with or without muscle relaxation. Interesting new findings in these recent publications show that general anesthesia with and without muscle relaxation does not worsen a pre-existing narrowing of the airway compressed by mediastinal mass. Moreover, it was discovered that the addition of positive pressure ventilation, positive end-expiratory pressure (PEEP) and muscle relaxation in an anesthetized patient were associated with improvement in the airway caliber and airflow in these patient's population. This new understanding of the mechanics of airway obstruction and the effects of anesthesia and mechanical ventilation on patients with mediastinal mass challenges our current anesthesia practices and leads us to consider a new approach to anesthetize and ventilate these patients. This article will review the past literature that led to the widely practiced current anesthesia techniques and how it is challenged with the new research. The author will also provide a new perspective and anesthesia technique that align with the new research findings for safe induction and maintenance of general anesthesia in patients with mediastinal mass.
对于患有纵隔肿物压迫中央气道的患者，麻醉管理被认为具有挑战性。人们普遍认为，纵隔肿物患者的全身麻醉诱导与气道塌陷、通气困难和血流动力学不稳定有关。此外，一些病例报告和病例系列描述了患者在全身麻醉诱导后死亡。这导致了强烈建议采用吸入诱导、避免使用肌肉松弛剂并维持自主通气。最近的研究通过直接可视化和测量纵隔肿物患者气道口径的实际变化以及吸气峰流速（PIF）和呼气峰流速（PEF）的变化，为我们对与纵隔肿物相关的气道变化的理解提供了新的视角。这些研究描述了不同状态下的气道力学变化，例如清醒和麻醉状态、自主呼吸和正压通气（有无肌肉松弛）。这些最新出版物中的有趣新发现表明，无论有无肌肉松弛的全身麻醉都不会使已存在的由纵隔肿物压迫导致的气道狭窄恶化。此外，还发现对麻醉患者增加正压通气、呼气末正压（PEEP）和肌肉松弛与这些患者群体的气道口径和气流改善有关。对气道梗阻机制以及麻醉和机械通气对纵隔肿物患者影响的这种新认识挑战了我们当前的麻醉实践，并促使我们考虑一种新的方法来麻醉和通气这些患者。本文将回顾导致目前广泛应用的麻醉技术的既往文献，以及它如何受到新研究的挑战。作者还将提供一种与新研究结果一致的新观点和麻醉技术，用于纵隔肿物患者全身麻醉的安全诱导和维持。
