Virtual bronchoscopy-guided airway management in a case of a massive thoracic mass causing a mediastinal shift in an infant

Dear Editor, Infants with massive mass in the thorax that displace the trachea and bronchi and cause mediastinal shift present unique challenges to the attending anesthesiologists. Here, we describe a case where virtual bronchoscopy (VB) proved to be more informative than computed tomography (CT) scan, as it revealed contrasting results regarding tumor compression. While the CT scan suggested compression, VB revealed a near normal diameter of lumen, indicating no luminal narrowing or obstruction. This discrepancy between the two imaging techniques highlights the importance of incorporating VB to obtain a true intraluminal view of the trachea and bronchus, allowing for more accurate airway management and planning. A 7-month-old male infant presented with respiratory distress, cough, and chest retractions, requiring oxygen support of 3–4 L/min (to maintain >94% peripheral saturation). His chest radiograph suggested a large homogenous opacity in left hemithorax, causing mediastinal shift and tracheal deviation to the right side. A CT chest showed a sizable, multiloculated, solid cystic mass measuring 6.2 × 9.7 × 8.3 cm. The mass nearly occupied the entire left hemithorax and extended into the anterior mediastinum. It was closely abutting and compressing the main pulmonary artery and left pulmonary artery (LPA), leading to a reduced caliber of LPA [Figure 1a]. Also, there was compression of right bronchus, with external luminal diameter measuring 3.8 mm at its narrowest point [Figure 1b]. In light of these findings, the patient was referred to the pediatric surgical unit for removal of thoracic mass. CT-guided VB was performed preoperatively to evaluate the luminal diameter of trachea and bronchus, which revealed near normal diameter [Figure 1c]. Based on VB findings, an airway management plan included right endobronchial intubation using a 4-mm endotracheal tube. Tracheal intubation was considered a backup plan. During anesthesia induction, the infant was placed in a semi-sitting position, preoxygenated, and induced with sevoflurane–oxygen mixture, fentanyl, and ketamine. The right endobronchial intubation was successfully performed without ventilation issues, surgery was uneventful, and the child was extubated and transferred to pediatric ICU for further management.Figure 1: (a) CT image reveals a large, multi-loculated, solid cystic mass measuring 6.2 × 9.7 × 8.3 cm, almost completely occupying the left hemi-thorax and extending into anterior mediastinum, closely abutting and compressing the main pulmonary and left pulmonary arteries with reduced caliber. (b) Airway CT shows the narrowest part of right bronchus to be 3.83 mm. (c) Virtual bronchoscopy of the trachea and right bronchus at various positions. CT - computed tomographyAnesthesia for patients with large thoracic masses and mediastinal extension carries the risk of fatal or near-fatal complications.[1] Anesthesiologists must be familiar with the pathophysiology of compression effects on the mediastinum and vasculature, evaluate the mass's location in relation to critical structures, consult with the surgeon, and be well prepared for surgery. The primary objective of preoperative investigation is to determine the size, location of mass and its relationship of the tracheobronchial tree and vital vascular structures. CT scans and X-rays are the gold standard for this purpose. In children, a VB is non-invasive[2] and provides a visual insight into luminal diameter of the trachea and bronchus despite external compression observed in the CT scan. This information guided our decision to perform endobronchial intubation, avoiding airway obstruction and potential lung soiling. In conclusion, when dealing with massive thoracic masses, it is important to consider both CT imaging and VB for comprehensive airway evaluation. The intraluminal view provided by VB can offer valuable insights that may differ from the extrinsic compression observed on CT scans. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.