A Difficult Intubation: Ankylosing Spondylitis
In this article the authors interview Andrew Bowman, MSN, RN, ACNP-BC, an acute care nurse practitioner and paramedic in Indiana. Andrew recently faced a difficult intubation situation with a patient with CHF complicated by severe kyphosis secondary to ankylosing spondylitis. Patients with ankylosing spondylitis present extremely difficult intubation challenges. Andrew discusses his approach and how he was able to successfully intubate this patient.
Gene: Jason, what is ankylosing spondylitis and what are the difficulties faced when you have to intubate a patient with this condition?
Jason: Ankylosing spondylitis (AS) is one of a group of disorders that are related to rheumatoid arthritis. We have discovered genes that give you a predisposition to it, but it’s not a truly hereditary disease—it seems to be more of a body’s overreaction to an infection.
AS chronically inflames the tendons and joints of the axial skeleton. For whatever reason, it likes to go after the sacroiliac joint first and the spine second. Like other rheumatoid diseases, patients can get flare-ups of AS, and have a greater or lesser degree of symptoms in between flares. Having AS also puts patients at increased risk for stroke.
As the tendons get inflamed, they develop bony growths that make the AS patient’s spine very stiff and painful, making airway positioning difficult. The bones can become weakened and develop compression fractures, to the point where the patients will develop a severe kyphosis, as we will see with Andrew’s patient. The bones are so weak that if this happens even a neck manipulation as innocuous as putting a cervical collar on these patients can be quite dangerous. There is actually a case report of a 59-year-old man’s spine being fractured by application of a rigid cervical collar, which led to spinal cord injury and his eventual death.
In other words, you have to intubate these patients with their necks in the position you find, not the position you want.