Abstract Background Large anterior mediastinal masses pose unique challenges for airway and hemodynamic management, particularly during intubation. Induction of anesthesia and neuromuscular blockade can precipitate airway collapse and cardiovascular compromise, a phenomenon known as mediastinal mass syndrome. Evidence-based guidelines remain limited, making individualized planning and multidisciplinary coordination essential. Case Presentation A 60-year-old woman with no significant cardiopulmonary history presented with three hours of acute shortness of breath following several weeks of dry cough. On arrival, she was tachycardic to 190 bpm with an irregular rhythm and hypoxic to 87%, requiring 10 L/min via facemask. Point-of-care ultrasound demonstrated diffuse B-lines consistent with pulmonary congestion. Despite noninvasive ventilation, her respiratory distress worsened, and an arterial blood gas revealed hypercapnia (pH 7.24, PaCO2 55.6 mmHg), prompting emergent airway stabilization. Chest imaging revealed a large anterior mediastinal mass compressing the left atrium and left mainstem bronchus, later confirmed as diffuse large B-cell lymphoma. Given the high risk of hemodynamic compromise with induction, the ICU team performed awake fiberoptic intubation using topical lidocaine to maintain spontaneous ventilation. The patient remained hemodynamically stable, with successful placement of a 6.5 mm endotracheal tube confirmed by capnography. She was stabilized on mechanical ventilation and initiated on chemotherapy. Discussion This case illustrates the importance of airway planning in patients with large mediastinal masses, where conventional induction may precipitate catastrophic airway obstruction or circulatory collapse. Awake fiberoptic intubation under local anesthesia maintained spontaneous respiration and provided a safe alternative for airway control. Mediastinal masses can also produce tamponade physiology from pericardial involvement or direct cardiac compression, leading to hypotension, elevated jugular venous pressure, and reduced cardiac output. Superior vena cava (SVC) syndrome may develop from impaired venous return, presenting with facial swelling and upper extremity edema. In rarer cases, neurologic complications may occur from compression of the recurrent laryngeal, phrenic, or sympathetic nerves, resulting in hoarseness, diaphragmatic paralysis, or Horner’s syndrome. Recognizing these potential complications is essential in critical care and perioperative settings. Early collaboration among anesthesiology, critical care, and oncology teams is pivotal to optimize outcomes. Conclusion Awake intubation under topical anesthesia should be considered in patients with mediastinal masses at high risk of cardiorespiratory compromise. This case highlights the need for continued research to establish evidence-based airway management guidelines for this complex population. This abstract is funded by: None
Siliezar et al. (Fri,) studied this question.