A High-Risk Rigid Bronchoscopy for a Patient With a Mediastinal Mass Causing Superior Vena Cava Syndrome, Lobar Collapse, and Pulmonary Artery Compression: A Case Report

TL;DR

This case report details the anesthetic challenges and management of a high-risk bronchoscopy in a patient with a complex mediastinal mass.

Contribution

The paper presents a novel case highlighting anesthetic strategies for managing patients with multiple complications from mediastinal masses.

Findings

The patient required immediate jet ventilation after experiencing hypoxemic bradycardia during the procedure.

Post-extubation airway edema led to severe respiratory acidosis and reintubation.

A structured perioperative plan is critical for optimizing outcomes in high-risk patients with mediastinal masses.

Abstract

Mediastinal masses present significant anesthetic challenges due to potential airway collapse and cardiovascular instability. We describe a case of a 68-year-old man with a locally advanced right hilar mass with extension into the mediastinum complicated by superior vena cava (SVC) syndrome, right pulmonary artery obliteration, and right upper lobe collapse who underwent rigid bronchoscopy and biopsy after failed stenting of the SVC. Careful anesthetic planning included a multidisciplinary discussion, maintenance of spontaneous ventilation, and a standby extracorporeal membrane oxygenation team. Despite initial stability, the patient experienced hypoxemic bradycardia following paralysis, requiring immediate jet ventilation via rigid bronchoscopy. Post-extubation, airway edema led to severe respiratory acidosis and necessitated reintubation. This case highlights essential principles in the anesthetic management of mediastinal masses, including patient-specific risk stratification, preparation for emergent airway interventions, and having a back-up plan in place. A structured and comprehensive perioperative plan is critical to optimize outcomes in these high-risk patients.

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