Intubating a patient with Ankylosing Spondylitis could be dangerous

By SWA

COVID-19 pandemic has indeed seen a significant number of patients requiring mechanical ventilation due to severe respiratory complications.

Limited Understanding and Treatment Options: In the early stages of the pandemic, there was limited understanding of the best treatment protocols for severe COVID-19, which may have impacted patient outcomes.
Some patients with severe COVID-19 have been intubated. Unfortunately, some have not survived.
Were they checked for ankylosing spondylitis?

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease that primarily affects the spine and sacroiliac joints, leading to eventual fusion of the spine and a decreased range of motion. This fusion can create a fixed, rigid cervical spine, which is a significant consideration for intubation. Here are some of the challenges and considerations for intubation in patients with ankylosing spondylitis:

  1. Restricted Neck Mobility: Due to the fusion of cervical vertebrae, patients with advanced AS may have very limited ability to extend their neck, which is usually necessary for direct laryngoscopy.

  2. Atlantoaxial Subluxation: AS can lead to instability of the cervical spine, particularly at the atlantoaxial joint, which can increase the risk of spinal cord injury during neck manipulation.

  3. Fragile Bones: Long-term inflammation can make the bones more brittle and prone to fractures. Excessive force during intubation can cause fractures or other traumatic injuries.

  4. Difficult Airway Management: Due to the altered anatomy, standard intubation techniques might not be feasible, and advanced airway management techniques or tools (such as video laryngoscopy or fiber-optic bronchoscopy) may be required.

  5. Temporomandibular Joint Involvement: AS can also affect other joints, including the jaw, making mouth opening difficult and further complicating intubation.

  6. Pulmonary Complications: In advanced stages, AS can involve the lungs, causing a restrictive lung disease pattern, which may alter the approach to ventilation.

Because of these considerations, careful planning and the use of specialized equipment and techniques are often necessary. Anesthesia professionals should conduct a thorough preoperative assessment, including a detailed history and physical examination focused on the airway. In some cases, awake fiber-optic intubation may be considered to maintain spontaneous breathing and minimize neck manipulation.

It is essential to have a well-thought-out plan and a backup strategy when intubating a patient with ankylosing spondylitis. Multidisciplinary teamwork involving rheumatologists, anesthesiologists, and possibly otolaryngologists or other airway specialists may be beneficial to ensure the safest approach for these patients.

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