Woo Jong Shin,
Jong Hoon Yeom, Woo Jae Jeon, Jae Hang Shim, Min Jae Cho, Sang Yun Cho*
Department
of Anesthesiology and Pain Medicine, Hanyang University Guri Hospital, Republic
of Korea
*Corresponding author: Sang Yun Cho, Department of
Anesthesiology and Pain Medicine, Hanyang University Guri Hospital, Republic of
Korea. Tel: +82315602400; Fax: +82315631731; Email: chosy@hanyang.ac.kr
Received Date:
16 April, 2018; Accepted Date: 25 April,
2018; Published Date: 02 May, 2018
1.
Abstract
Tracheal intubation in patients with cervical arthroplasty with
occlusion of the upper airway frequently poses great difficulty. The purpose of
this case study was to discuss lightwand tracheal intubation in patients with ankylosing
spondylitis (AS) through exploring a successful lightwand-guided intubation
case of a patient with AS. The patient was a 61-year-old male suffering from a
fixed extension-flexion deformity that affected mobility in his entire spine. Any
methods including GlideScope, I-gel were failed. Tracheal intubation using
lightwand was only successful. Based on this case, we would like to suggest
that using a lightwand in cases of AS may be appropriate.
2.
Keywords: Ankylosing Spondylitis; Lightwand
1. Introduction
Ankylosing Spondylitis (AS) is a chronic, progressive, and
autoimmune spondyloarthropathy. AS is a disease that starts with the sacroiliac
joint and the spine, causes inflammation of the entire spine, ultimately resulting
in the fusion of all vertebral bodies (bamboo spine). [1] The stiffness of the cervical spine and atlantooccipital,
temporomandibular, and cricoarytenoid joints caused by AS can cause great
difficulty during intubation. Patients who have had chronic AS for a long time
may have severe whole spine kyphosis, which makes it impossible for the patient
to be positioned properly for normal intubation, because the patient cannot
adequately extend their neck [2].
In many studies, a lightwand has proven to be useful for
intubation in patients who are unable to extend their neck. [3-5] The purpose of this study was to
investigate a case of a successful intubation using a lightwand in an AS
patient. Written consent was obtained from patient.
2.
Case
Report
A 61-year-old male patient who was 142 cm tall and weighed 45 kg was referred
to our clinic for both phacoemulsification and aspiration of cataracts. There
were no underlying diseases other than AS, which the patient was diagnosed with
at 30 years old. No abnormalities were found in laboratory tests, such as
general blood tests, clinical chemistry tests, and coagulation tests. The
patient's mouth opening was relatively good, with Mallampati score of class II,
and his tooth state was intact, but any neck extension was impossible (Figure 1). To evaluate the position and patency of the airway, whole spine
x-ray and MRI were performed. The results were as follows: (1) thoracic kyphosis
(2) ankyloses of the atlantoaxial joint, all apophyseal joints of the cervical
spine bilaterally, the first three costovertebral joints and (3) diffuse
marginal syndesmophytosis and arthritis of both facet joints of the lumbar spine
(Figure 2). As an otorhinolaryngology’s confirmed,
it was demonstrated that the upper airway patency was good, and it was recommended
that a fiber optic bronchoscope should be prepared for intubation. According to
the orthopedic consult, it was impossible for the patient to maintain supine
position during the expected operation time. The anesthesia team decided to use
a semi-sitting position with a pillow under the neck and back and proceeded
with surgery. In addition to the fiber optic bronchoscope, video laryngoscopes,
including the Glide Scope, LMA, and lightwand, and the equipment for a cricothyrotomy
were prepared. Sugammadex was also prepared for the reversal of the muscle
relaxant, due to anticipated difficulty of the intubation. Large pillows on the
neck and back were needed to maintain the semi-sitting position. (Figure 1), and led to the following heights: the bed-head
height was 32 cm, the bed-shoulder height was 14 cm, and the bed-nipple height
was 5 cm. After preoxygenation for more than three minutes with 100% O2 at 8 L/min, pentothal sodium was administered
at 4 mg/kg and rocuronium at 0.6 mg/kg. After the BIS was kept below 60, the
degree of muscle relaxation was checked with a nerve stimulator to confirm that
the TOF was 0, and intubation was attempted after confirming that the vital
signs of the patient were stable. I-gel supraglottic airway #3 and #4 insertion
were attempted. However, insertion of both I-gel #3 and #4 failed even though
neck manipulation was tried several times. Afterwards, tracheal intubation using
a GlideScope was attempted, but it failed because there was a grade IV
laryngeal view and the advancement of the endotracheal tube was not possible. At
that time, mask ventilation was still possible, and the pulse oximetry showed
that the SpO2 remained above 95%,
indicating that the patient’s airway was not in a state of “CICO” (cannot intubate
cannot oxygenate). Therefore, lightwand guided intubation was attempted. A
lightwand railroaded with an endotracheal tube was bent 90° at 5 cm the distal end. Lightwand intubation was successful in less than 10
seconds without any stimulation.
AS occurs in 1% of the male population and 0.5% of the female
population (in Caucasians). In males, it is the most common at the age of 20-30
and invades the spine and pelvic joints more often than in females [5]. The cause of the
disease is not known, and environmental factors (bacterial or viral agents) are
thought to be susceptible to diseases (HLA-B27) and gender, age, and ethnicity [2].
The formation of ectopic bone due to a persistent inflammatory response and
inflammation of the vertebral ligaments produce syndesmophytosis, which are
vulnerable to injury due to fractures. Through this process, fractures associated
with bamboo spines are formed. Cervical fracture is common in C5-6, which may
occur with impact or hyperextension. For this reason, there is a risk of
causing cervical spine and spinal cord injury by neck extension during
intubation, and neck movement (extension & flexion) should be evaluated
radiographically before intubation [3-5].
The GlideScope is useful for visualization of the larynx in patients with
difficult airways, such as patients [6]. The Glide Scope provides a better glottic view than that of
direct laryngoscopy, and endotracheal intubation using a GlideScope may be a
suitable alternative in AS patients. Indirect awake fiber optic intubation is
the safest option in patients with poor larynx structure, and laryngeal mask
insertion is an alternative when the patient refuses the former procedure or
for other reasons [7-9]. Also, lightwand-guided
intubation, which allows intubation without larynx visualization, can be
considered. Previous studies have shown that lightwand-guided intubation in
difficult intubation cases is useful [10-12]. However, it is difficult to directly study which intubation
tools are most useful in some situations, due to various limitations
(especially due to ethical issues).
In this case, we attempted intubation after induction of general
anesthesia rather than awake intubation because patient refused awake fiber
optic intubation and wanted general anesthesia. Because face mask ventilation
during preoxygenation was well maintained, the patient’s situation was not a CICO
situation, and other intubation tools could be used after the first failed
attempt without waking the patient.
Airway management in AS patients poses many difficulties for
anesthesiologists. The rigidity of the joints due to the arthroplasty of the
cervical vertebrae and the resulting limited neck extension is not only a great
threat to intubation but also increases the risk of cervical fracture during
neck manipulation for intubation. According to these limitations, the safest
method for intubation is awake fiber optic intubation, but in this case the
position of the patient is fixed to the supine (the circuit does not need to
move unstably). I-gel supraglottic airway #3 insertion was first attempted
because the patient’s mouth opening and the patency of the airway were good. After
this attempt failed, the view of the glottis through the GlideScope did not
show any possibility for intubation at all, and the lightwand, a tool for
intubation regardless of mouth opening or glottis view, was used.
Figure
1: Supine positon of
patient. Large pillows under the head and neck were placed to support a neutral
position.
Figure
2: Radiological
findings with diffuse marginal syndesmophytosis and arthritis
of both facet joints of the lumbar spine.
1.
Oliveira CR (2007) Ankylosing spondylitis
and anaesthesia. Rev Bras Anestesiol 57: 214-222.
2.
Woodward LJ, Kam PC (2009) Ankylosing
spondylitis: recent developments and anaesthetic implications. Anaesthesia 64:
540-548.
3. Shaikh SA (2007) Ankylosing spondylitis: recent
breakthroughs in diagnosis and treatment. J Can Chiropr Assoc 51: 249-260.
4. Jacobs WB, Fehlings MG
(2008) Ankylosing spondylitis and spinal cord injury: origin, incidence,
management and avoidance. Neurosurg Focus 24: E12.
5. Tico N, Ramon S,
Garcia-Ortun F, Ramirez L, Castelló T, et al. (1998) Traumatic spinal cord injury,
complicating ankylosing spondylitis. Spinal Cord 36: 349-352.
6.
Lai HY, Chen IH, Chen
A, Hwang FY, Lee Y (2006) The use of the GlideScope for tracheal intubation in
patients with Ankylosing Spondylitis. British Journal of Anesthesia 97: 419-422.
7. Lu PPL, Brimacombe J,
Ho ACY, Shyr MH, Liu HP (2001) The intubating laryngeal mask airway in severe
ankylosing spondylitis. Canadian Journal of Anaesthesia 48: 1015-1019.
8. Asai T, Wagle AU,
Stacey M (1999) Placement of the intubating laryngeal mask is easier than the
laryngeal mask during manual in-line neck stabilization. British Journal of
Anesthesia 82: 712-714.
9. Lucas DN, Yentis SM (200) A comparison of the intubating
laryngeal mask tracheal tube with a standard tracheal tube for fibreoptic
intubation. Anaesthesia 55: 358-361.
10. (1993) American Society of
Anesthesiologists Task Force on Management of the Difficult Airway. Practice
guidelines for management of the difficult airway. Anesthesiology 78: 597-602.
11. Weis FR (1992) Light-wand intubation for cervical spine
injuries. Anest Analg 74: 622.
12. Asai T, Shingu K (2000) Blind intubation
using the Endotrol tube and a light wand. Can J Anaesth 47: 478-479.