Anterior mediastinal masses make even seasoned anesthesiologists pause, and for good reason: a stable, upright patient can decompensate with a single change in position or a single dose of the wrong drug. We walk through a clear, stepwise approach that starts with anatomy and symptom red flags, then translates imaging, echocardiography, and pulmonary function testing into real-world decisions at the bedside. The focus stays practical: how to pick the safest setting, when to avoid general anesthesia, and what to prepare before anyone touches the airway.
We break down adult and pediatric risk criteria, including mass-to-chest ratio, degree of tracheal compression, SVC obstruction, pericardial effusion, and standardized tumor volume in children. From there, we outline sedation-first strategies using ketamine, dexmedetomidine, and carefully titrated remifentanil to preserve spontaneous ventilation and avoid precipitous loss of tone. For patients who truly need general anesthesia, we share an OR playbook: lower-extremity access when SVC flow is threatened, semi-upright preoxygenation, slow induction while maintaining spontaneous ventilation, awake intubation options, and selective use of short-acting agents to test tolerance of positive pressure.
Ventilation choices can make or break the case. We explain why long expiratory times and low respiratory rates reduce air trapping and auto-PEEP, and how fiberoptic bronchoscopy can guide tube position, predict extubation risk, and inform postoperative support. Rescue pathways are explicit: repositioning and CPAP, mechanical stenting with an endotracheal tube or rigid bronchoscope, rapid escalation to airway stents, and ECMO when distal collapse or cardiovascular compromise persists. We also spell out who needs ICU monitoring after surgery and why the safest path often means doing less.
If this topic raises your heart rate, you’re not alone. Tune in to sharpen your plan, align your team, and build a safer pathway from preop to postop for both adults and kids. Subscribe, share with your OR team, and leave a review with your best tip for managing high-risk mediastinal masses.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/283-how-to-plan-induce-and-recover-patients-with-anterior-mediastinal-mass-without-triggering-collapse/

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