Anterior mediastinal masses: an anaesthetic challenge

A patient with a large anterior mediastinal mass with minimal respiratory s ymptoms presented for a diagnostic biopsy of the mass. A pre-operative thor acic computed tomographic scan demonstrated narrowing of the distal trachea , and right and left main stem bronchi. An awake intubation was done. Thiop entone and muscle relaxant were given and surgery commenced. High airway pr essure developed and ventilation became difficult, although oxygenation rem ained satisfactory throughout. Anaesthetic implications are discussed. We r ecommend that patients with more than 50% obstruction of the airway at the level of the lower trachea and main bronchi have their femoral vessels cann ulated in readiness for cardiopulmonary bypass.