Navigating the challenges of asthma exacerbation in the presence of a mediastinal mass

Abstract

Mediastinal masses can mimic asthma by compressing the airway and causing wheezing, making emergency differentiation between true asthma and pseudo-asthma challenging. Airway management in such cases is critical, as intubation may precipitate severe airway or cardiovascular collapse. This case highlights a 14-year-old boy with a known history of asthma who presented with respiratory distress. Despite standard asthma treatments including nebulization, IV hydrocortisone, and magnesium sulfate, his condition deteriorated. Chest imaging revealed a widened mediastinum and opacities in the right lower lung zone.

Following intubation and paralysis, ventilation became nearly impossible and required manual bagging. Bronchoscopy revealed no airway obstruction up to the carina, and multiple attempts to bypass the mass—including ETT repositioning, unilateral intubation, and administration of sugammadex—were unsuccessful. The patient eventually succumbed despite resuscitative efforts. This case underscores the importance of suspecting mediastinal pathology in asthma-like presentations. Standard emergency protocols may not be appropriate, and alternative airway strategies, such as awake fiberoptic intubation, avoiding paralytic agents, and utilising extracorporeal membrane oxygenation (ECMO) or distal jet ventilation, should be considered. Early recognition and individualised airway management are crucial to avoid fatal outcomes.