Erdös G et al. Perioperative anaesthetic management of mediastinal mass in adults. Eur J Anaesthesiol. 2009 Aug;26(8):627-32.

The authors of this review have developed a methodology to guide management of the adult with a mediastinal mass. The preoperative protocol recommends detailed interdisciplinary team consultation and possible preoperative irradiation/chemotherapy. Concerning features on symptom review include respiratory distress in the supine position and superior vena cava syndrome. Correlation of the clinical and radiological findings (CT) +/-echocardiography and dynamic testing (pneumotachgraphs) should enable risk stratification. A cross-sectional tracheal area less than 50% of normal can predict frequent perioperative respiratory complications. Consideration must be given regarding safe transport to theatre, positioning, haemodynamic monitoring and lower extremity intravenous access. The authors prefer to secure the airway awake with a reinforced ETT and avoid all muscle relaxants if possible. Should complications arise, attempts should be made for rapid surgical decompression and/or repositioning and it is possible that a rigid bronchoscope or extracorporeal circulation may be required. HDU/ICU should be available and rapid extubation is preferred by the authors. Their recommendations are based both on available literature and their own clinical experiences and thus are limited to the level of expert opinion.