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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 35-38

Airway management in a ‘rigid man’ with severe ankylosing spondylitis

Department of Anesthesiology, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Date of Submission06-Nov-2019
Date of Acceptance03-Jan-2020
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Joseph N Monteiro
Department of Anesthesiology, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ARWY.ARWY_32_19

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Fibreoptic-guided intubation is the gold standard in managing both the anticipated and unanticipated difficult airway. We report a 34-year-old male, a case of severe ankylosing spondylitis for 10 years which was progressive in nature, posted for elective left-sided hip replacement followed a week later by right-sided hip replacement. The patient had a fixed spine with absent lumbar and thoracic curvatures and had a mouth opening of <1 cm. The neck was fixed in flexion and rotated slightly towards the right as a result of the deformity. Our plan of anaesthetic management was to secure the airway by awake nasal intubation using fibreoptic bronchoscope followed by general anaesthesia. The ultimate challenge was to secure the airway using the fibreoptic bronchoscope in this patient with a flexed and stiff neck. We successfully managed this case using a Portex® north-polar tube placed nasotracheally in the awake state following topical anaesthesia. Based on our experience, we believe that such a procedure should be considered in other similar situations.

Keywords: Ankylosing spondylitis, difficult airway, fibreoptic intubation

How to cite this article:
Rawlani SS, Monteiro JN, Saksena SG. Airway management in a ‘rigid man’ with severe ankylosing spondylitis. Airway 2020;3:35-8

How to cite this URL:
Rawlani SS, Monteiro JN, Saksena SG. Airway management in a ‘rigid man’ with severe ankylosing spondylitis. Airway [serial online] 2020 [cited 2020 Jul 12];3:35-8. Available from: http://www.arwy.org/text.asp?2020/3/1/35/285429

  Introduction Top

Ankylosing spondylitis (AS) is a complex, potentially debilitating disease that is insidious in onset, progressing towards involvement of multiple joints leading to decrease in flexibility over several years.[1] AS can present significant challenges to the anaesthesiologist as a consequence of the potential difficult airway, cardiovascular and respiratory compromise. Awake fibreoptic intubation is the safest option in these patients with a potentially difficult airway as it allows continuous monitoring and preserves spontaneous respiration until a definitive airway is established.[2]

  Case Report Top

A 34-year-old male, known case of AS, was posted for elective left-sided total hip replacement with complex three-dimensional reconstruction. The patient was unable to walk for 2 years with bilateral hip stiffness and also complained of seasonal breathlessness. He was severely malnourished with a body weight of approximately 40 kg and had a stiff posture with neck fixed in flexion and slightly rotated towards the right. There was a loss of normal thoracic and lumbar spinal curvatures.

On general examination, the patient was afebrile with a pulse rate of 110/min, blood pressure of 120/68 mm Hg and respiratory rate of 18/min with restricted chest expansion. On airway examination, it was found that the patient had a mouth opening of <1 cm with absolutely no neck movements [Figure 1]. Preoperative routine laboratory investigations revealed a haemoglobin level of 9.9 g/dL and total protein level of 4 g/dL reflecting severe malnourishment. Chest X-ray was suggestive of bilateral upper lobe fibrotic shadows attributed to prior pulmonary tuberculosis. High-resolution computed tomography could not be carried out due to the patient's unique fixed posture. Electrocardiogram showed sinus rhythm with normal R-wave progression, and two-dimensional ECHO revealed an ejection fraction of 55%. Our plan of securing the airway was awake nasal intubation using a fibreoptic bronchoscope. The procedure was explained to the patient in detail, and written informed consent was obtained.
Figure 1: Patient's mouth opening less than one centimetre

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Standard monitoring in the form of electrocardiogram, noninvasive blood pressure and pulse oximeter were established, and intravenous access was obtained on the right forearm with an 18 SWG cannula. The patient was administered intravenous glycopyrrolate 0.004 mg/kg and ondansetron 0.1 mg/kg. We decided not to administer any opioid or sedative premedication to avoid apnoea, hypoventilation and possible desaturation.

The patient was preoxygenated using a Hudson mask with 6 L/min of oxygen [Figure 2]. Once preoxygenation was ascertained to be adequate, nasal preparation was begun. Nasal decongestion was done with oxymetazoline spray 1 mg/mL followed by 2% lignocaine jelly in both the nostrils. Under aseptic precautions, transtracheal block through the cricothyroid membrane with 4% lignocaine was performed despite difficult access due to the flexed and rotated neck of the patient.
Figure 2: Adequate preoxygenation using Hudson mask

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Nasal patency was checked by passing a 12 French gauge red rubber catheter through both the nostrils. We chose a 7.0 mm Portex® north-polar endotracheal tube which was cut at the point of its curvature and then loaded onto the bronchoscope. After application of 2% lignocaine jelly over the right nostril which was found to be more patent, the fibreoptic bronchoscope was introduced into the right nostril of the patient.

The stiff neck of the patient restricted the alignment of oral, pharyngeal and laryngeal axes due to inability to extend the neck. The procedure was performed with the operator standing on the left side facing the patient. The tip of the scope was then advanced beyond the base of the tongue and directed towards the glottic opening. The bronchoscope was then held by an assistant till the primary anaesthesiologist moved from the left to the right side of the patient. This was to enable advancing the bronchoscope while still facing the patient. Our patient was very cooperative, and with successful airway block, we advanced the bronchoscope until the verge of the glottis. On visualisation of the cords, 4% lignocaine was sprayed through the working channel of the bronchoscope using the spray-as-you-go technique. It was challenging to manoeuvre the bronchoscope beyond the cords due to the rotated neck of the patient. Once the fibrescope tip was advanced up to the carina, the endotracheal tube was slid over the bronchoscope and the circuit was connected.

On visualisation of the first capnographic trace, propofol 2 mg/kg was administered intravenously followed by atracurium 0.5 mg/kg. Bilateral air entry was checked and the tube was fixed with the 26 cm mark at the nostril. Anaesthesia was continued with oxygen, nitrous oxide and sevoflurane. At the end of surgery, after the return of spontaneous respiration, residual neuromuscular blockade was antagonised with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. Thorough suctioning was done and the patient was extubated after he was completely awake and was generating adequate tidal volume. He was then transferred to the recovery unit for observation. The patient was shifted to the ward 4 h after surgery without any complications. After 1 week, this similar plan was followed for the right-sided hip replacement.

  Discussion Top

Patients with AS present tremendous challenges to the anaesthesiologist due to fusion of the cervical and thoracic spine and stiffness of the temporomandibular joint.[3] As the cervical spine involvement progresses, neck extension also decreases progressively, ultimately leading to a ‘chin-on-chest’ deformity [Figure 3].[4] This was seen in our patient. Many methods have been described to predict difficult airway among which neck extension, interincisor distance, sternomental distance and modified Mallampati class were found to be significant predictors of difficult intubation in patients suffering from AS.[5]
Figure 3: Classical ‘chin-on-chest’ deformity

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Difficult airway represents a complex interaction between patient factors, the clinical setting and the skills of the practitioner.[6] Maintenance of technical as well as psychological skill to handle a difficult airway is critically important for all anaesthesiologists.[7] Awake fibreoptic intubation under topical anaesthesia in an anticipated difficult airway is regarded as the safest approach and also the method of choice in patients with severe AS.[8],[9]

Our patient presented with a classical rigid posture as the result of the deformity with no movement (extension, flexion or rotation) at the level of the neck. Patients with AS are prone to spinal fractures even with minor movements, especially extension, resulting in neurological deficit and even death. Careful manipulation of the neck during transtracheal block and tracheal intubation is mandatory. We performed transtracheal block very carefully to avoid such fractures in our patient.

Our plan of airway management was awake fibreoptic intubation as spinal anaesthesia was not an option due to complete ossification and calcification of the lumbar spine (as evidenced and documented by preoperative anteroposterior and lateral X-rays of the lumbar spine as well as ultrasonographic screening of the lumbar spine). Our other concern was if the patient would have had respiratory compromise as a result of spinal anaesthesia, then an emergent airway management would have been nearly impossible in our patient. We performed awake fibreoptic intubation with a modification. We chose a 7.0 mm Portex® north-polar tube for intubation. Nasal bleeding is one of the major concerns with fibreoptic nasal intubation which may prevent fibreoptic view and also contribute to airway obstruction. The Portex® north-polar tube is made from velvet-soft polyvinyl chloride material, making it less likely to produce mucosal injury. The soft tip has been demonstrated to reduce trauma in the nasopharynx and oropharyngeal wall.[10] The non-traumatic nature of the Portex® north-polar tube not only made the fibreoptic visualisation less complicated but also facilitated easier sliding of the tube over the bronchoscope which proved to be of great advantage in our patient. Other methods routinely used to achieve the above advantages are to warm the conventional endotracheal tube by immersing it in sterile warm water before loading it on the bronchoscope. However, various studies have reported that the temperature of the liquid used for the heating of the tube may need to be controlled, as overheating may result in an obstruction due to kinking or distortion.[11] In our case, we preferred the Portex® north-polar tube because it was non-traumatic due to the soft material used in its construction, making it easier to insert.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: An overview. Ann Rheum Dis 2002;61 Suppl 3:iii8-18.  Back to cited text no. 1
Woodward LJ, Kam PC. Ankylosing spondylitis: Recent developments and anaesthetic implications. Anaesthesia 2009;64:540-8.  Back to cited text no. 2
Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting difficult intubation. Br J Anaesth 1988;61:211-6.  Back to cited text no. 3
Talikoti AT, Dinesh K, Kumar A, Goolappa. Ankylosing spondylitis: A challenge to anaesthesiologists due to difficulties in airway management and systemic involvement of disease. Indian J Anaesth 2010;54:70-1.  Back to cited text no. 4
[PUBMED]  [Full text]  
Üstun N, Tok F, Davarci I, Yagiz E, Guler H, Turhanoglu S, et al. Predictors of difficult intubation in patients with ankylosing spondylitis: Do disease activity and spinal mobility indices matter? Arch Rheumatol 2014;29:155-9.  Back to cited text no. 5
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251-70.  Back to cited text no. 6
Xu Z, Ma W, Hester DL, Jiang Y. Anticipated and unanticipated difficult airway management. Curr Opin Anaesthesiol 2018;31:96-103.  Back to cited text no. 7
Xue FS, Luo MP, Xu YC, Liao X. Airway anesthesia for awake fiberoptic intubation in management of pediatric difficult airways. Paediatr Anaesth 2008;18:1264-5.  Back to cited text no. 8
Crosby ET, Grahovac S. Diffuse idiopathic skeletal hyperostosis: An unusual cause of difficult intubation. Can J Anaesth 1993;40:54-8.  Back to cited text no. 9
Özkan AS, Akbas S, Toy E, Durmus M. North polar tube reduces the risk of epistaxis during nasotracheal intubation: A prospective, randomized clinical trial. Curr Ther Res Clin Exp 2019;90:21-6.  Back to cited text no. 10
Lee YW, Lee TS, Chan KC, Sun WZ, Lu CW. Intratracheal kinking of endotracheal tube. Can J Anaesth 2003;50:311-2.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3]


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