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(‘opyright
I 994 by Tin Jourittil
of !Io,,t’
t,,,d
Joint
Sur,t,’err,
Incorporated
Upper-Airway
Obstruction
and Perioperative
Management
of the Airway in Patients
Managed
with Posterior
Operations
on the Cervical
Spine for Rheumatoid
Arthritis*
BY
IAN
WATTENMAKER.
M.D.t.
AND
In vestigation
ABSTRACT:
toid
pc’rformned
We reviewed
who had a total
on the cervical
arthritis.
the
Our
purpose
was
LIPSON.
at Brig/iammi
records
of 128 consecutive
spine for problems
MERCEDES
STEPHEN
CONCEPCION.
MDI.
amid Womemi
of 128 patients
posterior
related
periopera-
groups
had
similar
characteristics
with
age, sex, severity
of the myelopathy,
matology
Association
classification,
of Anesthesiologists
physical
status
rette
use,
duration
of the
arthritis,
regard
American
American
classification,
use
to
RheuSociety
ciga-
of preoperative
traction,
use of steroids
(both preoperatively
and intraoperatively),
size of the endotracheal
tube, duration
of
the operation,
total duration
of the anesthesia,
intraoperative
fluid balance,
and type of immediate
immobilization
of the neck. The only significant
difference
between
the groups was the time to extubation,
which
averaged
17.9 hours in the fiberoptic
group and 10.6
hours in the non-fiberoptic
group (p = 0.02). Logistic
regression
analysis
showed
that
non-fiberoptic
intuba-
tion was the significant
risk factor, even when allowance was made for the difference
in the lengths of time
to extubation.
We concluded
that this life-threatening
complication
agement
can
be
minimized
with
fiberoptic
v IIos/)ital
the
tive complications
related
to the airway. The patients
were divided
into two groups for analysis
on the basis
of the technique
of intubation
that had been used.
An upper-airway
obstruction
developed
after extubation
in eight (14 per cent) of the fifty-eight
patients
who had been intubated
without
fiberoptic
assistance
compared
with one (1 per cent) of the seventy
patients
who had been intubated
fiberoptically
(p = 0.02). The
two
man-
have
management
rheumatoid
of the
arthritis
airway
is difficult,
in patients
and
it is par-
head
torted
difficult
benefits
in any
form
have
been
received
or will
subject
360
of Orthopaedic
Surgery,
Boston,
Massachusetts
Beth
0221S.
Israel
Hospital,
330
and
neck,
in the
upper
MDI.
Sc/iool.
Boston
limited
an
airway,
fixation
operation
position
mouth-opening,
as important
Patients
who
motion
of the
poromandibularjoints
of
a decreased
of tissues,
and
factors
contributing
have rheumatoid
dis-
to a
arthritis
optimum
Aggressive
injury,
neck’4.
mouth-opening.
position
of the head
and
positioning
of the head
even in a patient
who has
Arthritic
involvement
of the temand micrognathia
result
in limited
Acquired
laryngeal
deviation’,
laryn-
geal mucosal
abnormalities”,
and the frequent
existence
of cricoarytenoid
and cricothyroid
arthritis’
also distort
the anatomy
of the airway
in patients
who have rheumatoid arthritis.
Finally,
axial impaction
may
the upper
airway’.
Although
many
the shortened
neck from
contribute
to the decreased
optic
intubation
a difficult
have
rheumatoid
trauma’3’72’,
authors
of
are
aware
posterior
who have
This study was designed
was to examine
the
complications
related
erations
on the cervical
arthritis.
airway.
lessen
of
The
improve
to avoid
any
of this
related
operations
rheumatoid
who
excessive
study
that
practice
to the
on the
arthritis.
with two
characteristics
to the
spine
fiber-
in patients
in order
not
atlantospace
in
recommended
airway
any clinical
benefit
the complications
that occur
during
spine
in patients
would
have
arthritis,
we
demonstrated
has examined
that
Wepartment
of Anesthesiology,
Brigham
and Women’s
Hospital. 75 Francis
Street.
Boston,
Massachusetts
0211S.
§Department
of Infectious
Diseases
and
Epidemiology.
Massachusetts
General
Hospital.
Fruit
Street,
Boston,
Massachusetts
02114.
‘IlDepartment
Brookline
Avenue,
Medical
to compromise
the
neck for intubation.
may cause
neurological
that
be received
from
a commercial
party
related
directly
or indirectly
to the
of this article.
No funds
were
received
in support
of this study.
tl830
Town
Center
Drive,
Reston.
Virginia
22090.
harvard
anatomy
airway”.
matoid
*No
HIBBERD.
that affects
the cervical
spine have many of these
limitations. The frequent
findings
of head tilt and of instability
and stiffness
of the rheumatoid
cervical
spine
combine
of the airway.
Perioperative
and
space
first
who
PATRICIA
MASSACHUSETTS
ticularly
problematic
for those
who need
for involvement
of the cervical
spine.
Ovassapian
identified
a compromised
operations
to rheuma-
to examine
M.D4.
BOSTON.
primary
and
has
or that
airway
cervical
goals. The
causes
of
airway
after posterior
in patients
who have
second
was
to establish
perioperative
oprheu-
guidelines
management
of the
It is our hope
that these
recommendations
or eliminate
the life-threatening
complications
will
we observed.
Materials
The
records
erations
on
and Women’s
regarding
the
cervical
Hospital
THE
JOURNAL
and
Methods
128 consecutive
spine
between
OF
performed
1979 and
BONE
AND
posterior
op-
at Brigham
1990 on 128
JOINT
SURGERY
UPPER-AIRWAY
OBSTRUCTION
AND
PERIOPERATIVE
TABLE
DATA
ON
THE
MANAGEMENT
OF
THE
361
AIRWAY
I
PATIENTS
Patients
Fiberoptic
(N=70)
Age*
Sex
(yrs.)
rheumatoid
ofarthritis*
Cigarette
use
1/8
57
9
22 (5-54)
17
11
41
33
Preoperative
67
52
33
Intraoperative
67
52
Size
(per
use (per
cent)
cent)
of endotracheal
tube*
Duration
ofoperation8
Duration
of anesthesia*
Fluid
balance*
Time
to extubation*1
(lirs.)
(lirs.)
halo
(per
cent)
2.5
(1.5-4.5)
2.9
(2.0-4.6)
3.7
3.5
(2.0-5.5)
4.0
(3.0-6.0)
values
are
given
as the
mean,
values
are
given
as the
number
iThe
difference
was
had
(2.0-6.0)
(0-+6150)
+2600
significant
with
the
All
senior
of
one
the
the
arthritis
fiberoptic
group
or juvenile
and
the
were
vertebra,
had
from
thirteen
only an arthrodesis.
the occiput
to the
were
subaxial
cervical
vertebra,
axial,
eleven
were
subaxial
had
ond
both
an arthrodesis
cervical
vertebra
sis. Twenty-nine
arthrodesis.
with
from
five
of the
deses
from
with
the
subaxial
occiput
pression
or
of the
decompression;
foramen
and
non-fiberoptic)
of preoperative
VOL.
76.A.
NO.
method
3, MARCH
vertebra,
from
had
traction,
1994
the
subaxial
three
cervical
one
One
patient
dysesthesia:
and
IIIB,
The
of
been
two
groups
intubation
only
duration
the
of the
Age,
had
sex,
arthritis,
an
to perform
or self-care:
to a bed
American
classifi-
on
the
the
each
systemic
limited
I
noran ad-
Class
of the
Class
Society
III,
patient’s
an
usual
IV, incapacitation
of Anesthesiologists
patient
was
routine
preoperative
i indicated
a healthy
disease;
activity
Class
or
or wheelchair.
of the
Class
of the
develop-
airway.
physical
status
classification
of operatively
managed
was used
as a measure
of co-morbidity.
The
as part
Class
severity
activities:
duties
and
and
ability
to perform
restriction,
but
normal
most
defiand
of weakness
to walk;
to walk.
to
to
no neural
hyperreflexia
if the
related
(halo
of the airway.
to the classifica-
influence
restriction
of the
Class
II, moderate
to perform
neck
Association
arthritis
duuse
examined
findings
Rheumatology
to determine
ability
The
objective
complications
occupation
tion.
(fiberoptic
attempted.
of
inability
from
on
were
but an ability
and an inability
recorded
confinement
decom-
Asso-
of the
extubation
lilA,
signs
American
was
equate
of
into
to
influence
on complications
was graded
according
Class
cation2”
ment
occi-
had
time
long-tract
quadriparesis
indicated
no
mal activities;
vertebra
with
immobilization
and
rheumatoid
cervical
arthro-
arthrodesis
vertebra
magnum.
that
use
cervical
decompression.
were
divided
initial
cervical
Rheumatology
American
Society
of Anesthesiolclassification7’t,
cigarette
use, size
of postoperative
collar),
determine
their
Myelopathy
ar-
arthrovertebra
arthrodesis
to a subaxial
to a subaxial
the
first
an
cervical
vertebra
and
decompression;
occiput
of the
of
one
cervical
subaxial
a subaxial
cervical
The patients
second
American
classification2’,
physical
status
tion of Ranawat
et al. Class
I indicated
cit; Class II, subjective
weakness
with
the 5ccarthrode-
cervical
seven
a
atlantopatient
and
subaxial
or
of the first cervical
vertebra
and one with decompression
magnum;
second
with
a decompression
to the
decompression
to
0.02).
=
of the endotracheal
tube. duration
of the operation,
ration
of the anesthesia,
intraoperative
fluid balance,
of steroids
(both
preoperatively
and intraoperatively),
Fortysecond
to
(p
of myelopathy,
ciation
ogists
the
occiput
were
and one
decompression;
occiput
foramen
the
occiput
cervical
seventeen
with
decompression
the foramen
magnum,
put to the
arthrodesis
basis
had
subaxial
the
with
from
the
a subaxial
and
were
from
twenty-five
cervical,
patients
There
throdeses
deses
by
group
severity
rheu-
performed
non-fiberoptic
type
patients
were
0
in parentheses.
of us (S. L.).
Ninety-eight
eight
arthrodeses
cervical
operations
(+1 1(X)-+3850)
1 1.4 (0-24)
10
matoid
arthritis
were reviewed.
The study was approved
by the human
rights
committee
at the hospital.
Anterior
procedures
were excluded
to eliminate
the effect
of direct operative
trauma
to the airway
or its surrounding
tissues.
(0-60)
(5.5-8.0)
of patients.
between
rheumatoid
range
+2583
(-150-+4500)
10.6
(0-120)
1.5
tThe
who
2.6 (1.5-4.6)
(5.5-8.0)
17.9
tThe
patients
6.9
+2100
(/ir.s)
22
6.7 (5.5-7.5)
6.5
(mum)
(nil)
Postoperative
the
19 (10-35)
13
cent)
traction
Steroid
one
and
0
1
47
(per
Preoperative
-
66 (52-78)
63
22 (1-50)
Had
Obstruction
(N =9)
8/50
7
(vrs.)
Who
61 (20-82)
arthritist
Duration
Upper-Airway
13/57
arthritist
Juvenile
Group
61 (41-78)
(MIF)
Rheumatoid
Non-Fiberoptic
(N=58)
Group
classified
by
the
patients7’9
condition
anesthesiologist
anesthesia
patient:
Class
3, severe
systemic
but was not incapacitating:
evalua-
Class
disease
Class
2, mild
that
4. in-
362
IAN
TABLE
SEVERITY
OF
Class
II
MYELOPATHY
CLASSIFICATION
WATTENMAKER
RANAWAT
TO
ET
THE
AL.*
100
used
Patients
Who
Upper-Airway
Obstruction
(N = 9)
9 (13)
21 (36)
3 (33)
was
less
was
used
33 (47)
17 (29)
1 (11)
lIlA
13 (19)
10 (17)
2 (22)
IIIB
15(21)
values
given
as the
groups.
number
of patients,
with
the
The
time
the
to extubation
the time
that are
considered
than
0.05.
to more
test3
to extubation
not
test
is more
while
appropri-
regression
associated
to the airway
variables.
analysis
with
complica-
adjusting
for
possible
Results
in parentheses.
capacitating
systemic
disease
to life; Class
5, a moribund
that was a constant
patient
who
was
pected
to survive
operation.
twenty-four
Cigarette
use
smoking
cigarettes.
meant
that
used
for the
The
tion
technique
determined
assigned.
of the
that
the
Our
patients
had
our
hypothesis
sented
a risk
that
because
Therefore,
in order
esis, we
fiberoptic
bated
the
with
basis
which
of the
in the
the
patient
intubation
to avoid
a bias
assigned
patients
in whom
intubation
had failed,
without
was
course
It was
intubation
to the
toward
an initial
and who
fiberoptic
repreairway.
this
hypoth-
attempt
at
were
intu-
visualization
patients
were
assigned
to the fiberoptic
fifty-eight,
to the non-fiberoptic
group.
Of the
in the non-fiberoptic
group,
forty-nine
had
nasotracheal
or oral
airway,
intubation
and
fiberoptic
scope
is often
necessary
airway
intubation
a laryngoscope
in the remaining
is used,
visualization
of
was
nine
used
to assist
patients.
Unless
in
a
intubation
for
is difficult.
without
without
patients
All
visualization
in whom
patients
in
access
both
of
sia of the nasal
was administered
passage,
before
benzodiazepam
tinely
intravenously.
and
tubation
the
is not
pressure
passed
into
fentanyl
If performed
the
is felt
nares.
was used
anesthe-
was
administered
well, this type
for the
when
The
the
patient,
except
benzodiazepam
has
fourteen
for four in the fiberoptic
cluded
the fluid balance
of the
Yates
arthritis
continuity
proportions
to the
group.
Other
in one patient
in one patient.
correction
of patients
airway
in the
had
groups.
TABLE
AMERICAN
RHEUMATOLOGY
Fiberoptic
Group
(N=70)
Class
I
a complication
Because
with
the
related
there
was
such
CLASSIFICATION2O*
Patients
Who
Upper-Airway
Obstruction
(N =9)
Non-Fiberoptic
Group
(N=58)
0
fourteen
the first
the occiput
subaxial
bination
to the
cervical
vertebra,
cervical
vertebra,
cervical
vertebra
patient
had
arthrodeses,
arthrodesis.
done
with
compression
from
Of
the
cervical
decompression
cervical
first
cervical
Had
vertebra,
twelve
combination
0
second
desis.
cervical
Of these
vertebra
fifty-eight
and
three,
and
were
with a detwo, with a
there
were
to the second
to the second
to a subaxial
arthrodeses,
from
the
a subaxial
arthrodeses,
and
one
to the
cervical
arthroten were
done
19 (27)
20 (34)
2 (22)
with
46 (66)
33 (57)
3 (33)
pression
of the first cervical
vertebra.
An initial
attempt
at fiberoptic
intubation
failed
in seven
patients
who
were
then
intubated
with
a
non-fiberoptic
technique.
These
patients
remained
in
in parentheses.
are
4(44)
5(9)
4(6)
values
given
as the
number
of patients,
with
the
percent-
THE
JOURNAL
and
occiput
twentycervical
cervical
cervical
III
*The
decompression
an
eleven
vertebra.
cervical
arthrodesis
One
without
II
IV
a subaxial
subaxial
of an
comsecond
arthrodesis.
arthrodeses,
decompression;
foramen
magnum;
of the
one
to the
decompression
sixty-nine
a subaxial
of the
and
the occiput
and a subaxial
a subaxial
arverte-
second
of an arthrodesis
cervical
the
to a subaxial
In the
non-fiberoptic
group,
six arthrodeses
from the occiput
vertebra,
fourteen
from the first
vertebra,
five from
the occiput
III
ASSOCIATION
1(1)
data induration
The chi-square
test
was used
to compare
who
two
missing
and the
from
from
is
an amne-
curred
noted.
corded
eleven
for
tube
sic effect
so that
most
patients
do not remember
intubation.
In the fiberoptic
group,
there
were
twenty-nine
throdeses
from the occiput
to the second
cervical
bra,
rouof in-
endotracheal
the airway,
to the fiberoptic
group.
It was anticipated
that if the hypothesis
was valid,
this method
of assignment
would
have
made
the differences
between
the
groups
less significant.
Any
complications
related
to the airway
that
ocduring
hospitalization
and after extubation
were
The size of the endotracheal
tube
was not refor six patients
in the non-fiberoptic
group
and
the
were
pharynx,
larynx,
and trachea
the procedure.
Sedation
with
uncomfortable
that
to
groups
awake
during
the intubation;
an antisialagogue
to reduce
oral secretions,
and adequate
topical
technique
plan.
Seventy
group
and
fifty-eight
the
the
currently
the clinical
trauma
an
at intuba-
preoperative
non-fiberoptic
it caused
nasotracheally
was
attempt
to study
threat
not ex-
or without
patient
initial
to
was
on the
chosen
hours,
group
objective
been
age
was
the two
normally.
Differwhen
a probability
logistic
factors
percent-
between
distributed
significant
Multiple
to identify
tions related
confounding
(zero
Kolmogorov-Smirnov
Kolmogorov-Smirnov
ate for data
ences
were
3(33)
10(17)
are
Had
in the
hours),
to compare
Non-Fiberoptic
Group
(N = 58)
II
age
range
than
Fiberoptic
Group
(N = 70)
I
*The
AL.
a wide
ACCORDING
OF
ET
OF
BONE
three,
AND
with
JOINT
a decom-
SURGERY
UPPER-AIRWAY
OBSTRUCTION
TABLE
AMERICAN
SOCIEn’
PHYSICAL
STATUS
Fiberoptic
Group
Class
OF
16 (23)
44 (63)
4
*The
of the ability
to inspire.
Five
non-fiberoptic
group
in whom
became
obstructed
required
Patients
Who
Upper-Airway
Obstruction
values
are
number
of patients,
proved
fatality.
bated
1 (11)
fiberoptic
in whom
1 (11)
structed
with
the
dotracheal
percent-
had
failed.
non-fiberoptic
This
group.
airway
developed
Except
for the
patient
No
(Table
I).
significantly
(10.6
The
longer
compared
with
hours)
(p
elopathy’t
sociation
(Table
II),
classification2”
the
the
to
the
the
in both
to
the
American
(Table
III),
hours
group
groups
were
severity
the
of my-
was
the
of the
technique
with-
airway
with
in the
became
ob-
an 8.0-millimeter
single
largest
anesthesia
in whom
no striking
the airway
not (Tables
records
the
en-
tube
used
indicated
airway
became
without
any difficulty,
the second
try, and two
attempts
at intubation.
differences
between
the pabecame
obstructed
and those
I through
IV). Upper-airway
Stnidor
patients
tubated
classifica-
developed
in the one patient
the airway
became
who
were
tubated
at an average
to ninety-six
hours)
respiratory
distress
Rheumatology
Asand the American
status
upper
with
patients
in another.
extubation
in whom
hours)
non-fibenoptic
and
intu-
obstruction
developed
within
minutes
after the extubation in six patients,
after two hours in one, and after four
was
(17.9
which
Review
There
were
tients
in whom
in whom
it did
no sig-
extubation
group
physical
obstruction,
after extubation
patients
in the
one
cent)
of the
considered
characterized
before
death
seventy
patients
stnidor
to be
an
ON
THE
Level
of
Fusion
in the
NINE
twelve
from the
obstructed
hours
after
fiberoptic
(Table
reintubated,
four
group
V). Of
were
re-ex-
of forty-nine
hours
(range,
twelve
and one patient,
in whom
adult
syndrome
developed,
was not ex(Table
V).
patients
V
WHO
HAD
Time
to
Extubation
(Hrs.)
Nasotracheal
19.2
Nasotracheal
17.3
had
ofthe
considerable
by hypoventilation
to reintubation
either
patient.
TABLE
PATIENTS
Complications
ties caused
impair-
Intubation
Technique
Airway
respiratory
after
in one. The cause
was not
Both
patients
had severe
UPPER-AIRWAY
Time
to
UpperAirway
Obstruction
2 hrs.
difficul-
extubation,
leading
identified
myelopathy
OBSTRUCtiON
Time
to
Reintubation
Time
to
Re-Extubation
(Hrs.)
Result
Resolved
2 hrs.
in
-
Resolved
I hr.
in
-
Resolved
24 hrs.
in
-
1
Occ.-C2
-
2
C1-C2
-
3
0cc-CS
-
7.5
Laryngoscope,
oral
0.0
4
C1-C2
-
7.5
Nasotracheal
4.0
Mins.
Resuscitation
41
5
Occ.-C2
-
7.5
Laryngoscope,
oral
0.0
Mins.
30 mins.
No sequela
12
6
Occ.-C7
C3-C5
6.5
Nasotracheal
18.0
Mins.
2 hrs.
Resuscitation
48
7
Occ.-C2
-
6.5
Nasotracheal
24.0
5
mins.
5 mins.
No
96
8
C2-C7
C4-C5
6.0
Nasotracheal
21.2
1
mm.
2 mins.
Death
9
C3-C6
C4-C5
8.Ot
Fiberoptic,
VOL.
*Patient
died
tLargest
endotracheal
76.A,
NO.
after
5.5
Two
of the
and in
fiberoptic
audible
Size of
Endotracheal
Tube
Level
of
Decompression
Non-Obstructive
by stnidor,
in eight (14 per cent)
non-fiberoptic
group
DATA
Case
was
to
series.
near-fatalities
been
six had
IV).
developed
fifty-eight
We
to
patients
according
Upper-airway
group.
in
The
Anesthesiologists
tion7”9 (Table
(1 per
time
fiberoptic
time
0.02).
similarly
of
average
the
distributed
Society
related
the fiberoptic
group and the
regard
to the measured
van-
in the
=
assigned
in these
eight
patients.
time to extubation,
there
nificant
difference
between
non-fiberoptic
group with
ables
was
tube,
the
intubated
airway
had oral intubation
The one patient
obstructed
had been
intubated
one had been
intubated
on
patients
had needed
multiple
had
a successful
non-fiberoptic
at-
complications
been
six of the
that
tempt
group
had
patients
upper
reintubation.
use of a nasotracheal
7 (78)
in this
One
patient
after
an initial
with
the
with two
patients,
and two had
a laryngoscope.
age in parentheses.
the
fiberoptic
group.
fiberoptic
intubation
very difficult,
Of these
eight
initially
of the eight
emergency
out visualization
visualization
by
0
8 (14)
as the
This
one
(N =9)
7 (12)
given
Had
363
AIRWAY
in the
43 (74)
10 (14)
THE
ment
0
3
OF
IV
(N=58)
0
MANAGEMENT
ANESThESIOLOGISTS
Non-Fiberoptic
Group
2
PERIOPERATIVE
CLASSIFICATION7.I9*
(N=70)
I
AND
Not
development
3. MARCH
tube-size
1994
recorded
of adult
used
respiratory
in study.
distress
nasal
syndrome.
0.0
1
mm.
4 hrs.
12 hrs.
-
-
-
1.5 hrs.
-
sequela
Resolved
36hrs.
Death*
in
-
in
364
IAN
(class
may
lilA’8
have
in one
and
contributed
Statistical
class
IIIB
to the
in the
WATTENMAKER
other),
which
with
hypoventilation.
the non-fiberoptic
group.
p = 0.02. Interpretation
showed
obstruction
a sigin
value was 5.65,
was complicated
The chi-square
of this data
by a significant
difference
in the time
to extubation
between
the two groups
(Kolmogorov-Smirnov
testing,
p = 0.01).
In an effort
to determine
the relative
con-
ment
of
the
coexistent
of obstruction
of the
analysis
was performed.
The
analysis
were
the technique
verity
of myelopathy,
cigarette
tive traction,
Rheumatology
roids
size of the
Association
intraoperatively,
extubation,
be
and
noted
variables
to
airway,
logistic
duration
operation,
fluid
balance.
in this
statistical
fully
independent,
seventeen
because
they represented
individual
operation.
This
possibility
of a few
to obstruction
on
the
of the
variables.
patients
or, in one
done
to eliminate
was
patients,
of the
who
airway,
the interpretation
logistic
regression
of the
analysis
data.
was
peat
risk
to
all
operations
second
opera-
patient,
the
been
The
that
conclusion
non-fiberoptic
an increased
As
far
as we know,
complication
this
is the
first
tubation
in patients
who
vical
spine
for rheumatoid
prevalence.
We
believe
document
a clear
have
that
benefit
the
airway
in this patient
The data suggest
that
of non-fiberoptic
intubation
study
to focus
of fiberoptic
to
of
population.
edema
caused
by the trauma
is a prime
cause
of the ob-
struction
rapraxia
of the airway.
It is possible
of the recurrent
laryngeal
that bilateral
nerves
may
occurred
in an occasional
contributed
patient
and
neuhave
to the
upper-airway
obstruction:
this has been
described
as a
cause
of transient
upper-airway
obstruction
following
traumatic
intubations56.
The one patient
in the fiberoptic
group
may
in whom
have
had
the
upper
a traumatic
airway
intubation.
became
She
obstructed
was
on
the
intubated
intubations
airway
had
that
that,
in the
became
been
ob-
noted
to be traumatic.
This indicates
airway
often
is not recognized
also
indicate
not
the
that
time
it is the
to
by
that
at the
method
extubation
obstructions
for all patients
cervical
both
the
spine
of in-
that
is cniti-
in
of
who
Most
of
arthritis
fiberoptic
in the fiberoptic
had
there
have been
numerous
struction
after
a variety
neck28’2’522.
rheumatoid
to
intubation
to extubation
occurred
in the
there
was an over-all
increased
all anterior
patients
occurring,
it
had an Open-
This was an attempt
to alto resolve
before
extubation.
use
time
study.
to extubation
spine
for
increased
the increased
years
of this
group.
procedures
on the
rheumatoid
arthritis
reports
of anterior
these
cervical
since
of upper-airway
procedures
airway
presumably
caused
by operatively
to the recurrent
laryngeal
nerves,
obthe
on
complications
were
induced
edema,
or postoperative
toma. The patients
in the current
study
to trauma
to the airway
by the operative
injury
hema-
were not exposed
procedure
itself,
Many factors
contribute
to the difficult
the airway
in these
patients.
Keenan
cerits
management
two
remain
intubated
overnight.
low edema
in the airway
on the
define
study
airway
that
were
who had
in a review
of patients
first
the
upper
subsize
the upper-airway
became
standard
fifteen
it is also
to the
It is of note
the
of the
with
large
of
over
the twelve
years
Second,
in reaction
to
on
to
trauma
in whom
and
ex-
an operation
arthritis
and
caused
the
use
intubation.
data
after
obstruction
was
the
ingly
more
accepted
and used
spanned
by our clinical
study.
of
of upper-airway
which
Since
unlike
patients
in reports
that concerned
obstruction
the airway
after an operation
on the neck2’’2’522.
Discussion
the
have
We excluded
predictor
of upperThe increased
risk
was 3.2, with 95
to demonstrate
group
(p = 0.02).
only
of the
time
of
study.
cal for the airway.
The increased
time to extubation
in
the fiberoptic
group
is explained
by two considerations.
First, fiberoptic
intubation
techniques
became
increas-
impact
limits
of i.04 to 10.34
(p = 0.04).
analysis
of the non-fiberoptic
and
after
elimination
of the seventeen
re-
operations
continued
in the non-fiberoptic
time
and
later
prone
may
anesthesiologist
trauma
to the
Since
third
theoretical
have
structed,
the
the
tube,
in this
tubes
has been
associated
it is possible
that the unusually
patients
ation
method
make
a misleading
intubation
was the only independent
airway
obstruction
after
extubation.
imposed
by non-fiberoptic
intubation
per cent confidence
Repeat
chi-square
fiberoptic
groups
To
the
may
having
time
the
observations
were
removed
on
one
nine
used
this complication.
tubation
It should
evaluation,
is now
tube
The
regression
of the
endotracheal
injuries’,
of this
endotracheal
tube
precipitated
develop-
endotracheal
tube,
American
classification2’,
use of ste-
intraoperative
that,
the
variables
included
in this
of the intubation,
age, Seuse, sex, use of preopera-
of intubation
tions
largest
large
glottic
Chi-square
analysis
of the two groups
nificantly
increased
risk of upper-airway
AL.
an 8.0-millimeter
single
Analysis
tributions
ET
patients
identified
who
of 710
who had
shortening
had
acquired
rheumatoid
of the
arthritis.
neck
Keenan
ening
of the neck
in the hypopharynx
Junk
and
coarytenoid
rheumatoid
laryngeal
from
micrognathia
or
THE
deviation
intubations
arthritis.
They
atlanto-axial
erosions
laryngeal
in patients
et al. reported
may cause
redundancy
and further
complicate
Pedersen
arthritis
arthritis,
matic.
The authors
arytenoid
arthritis
obstruction
and
management
et a!. noted
consecutive
fiberoptic
erosive
polyarticular
paction
and
asymmetrical
osseous
ative
factors
and
noted
that
the
contributed
to difficult
intubations
of
im-
as causdeviation
who had
that
short-
of soft tissue
intubation.
noted
an over-all
prevalence
of 55 per cent in patients
many
of whom
were
of cniwho had
asympto-
emphasized
the importance
of cnicoas a possible
cause
of upper-airway
difficult
intubation.
The
presence
of
arthritis
of
the
JOURNAL
OF
BONE
temporomandibular
AND
JOINT
SURGERY
UPPER-AIRWAY
OBSTRUCTION
joints
limits
opening
of the mouth.
less than
3.5 centimeters
contributes
It is important
way’.
AND
to recognize
that
the
airway
airway.
A final
spine
of many
complicating
patients
who
traumatic
way or
and
expressed
is that the
rheumatoid
is limited.
Ovassapian
of fiberoptic
spondylitis
intubation
and who
the cervical
spine.
relationship
in a patient
who
needed
an extension
Messeter
between
respiratory
and
during
in patients
who had
unable
to demonstrate
of complications
related
In
and
operations
on the
airway
a difficult
authors
before
the
airhave
present
spine
upper-airway
obstruction
after
a posterior
operation
in a patient
who
has
awake.
All patients,
fiberoptic
cervi-
and
rheumatoid
intubation,
fiberoptic
that
while
especially
should
evidence
of stnidor
after
prepared
for emergency
The difficulties
involving
but
rate
is a freon the
arthritis
fiberoptic
assistance.
This
with fiberoptic
manage-
ment
of the airway.
We recommend
intubation
of such patients
be done
so-called
in the
but,
and who is intubated
without
complication
can be minimized
of
arthritis,
in the
opinions”4’7
conclusion,
complication
cervical
the
technique
365
AIRWAY
in patients
who had
cervical
spine.
Many
similar
quent
use
evaluated
rheumatoid
a reduction
to the
the
had ankylosing
osteotomy
Pettersson
intubation
insufficiency
cal spine
they were
et al.’7 advocated
alternative
unstable
an
THE
issue.
arthritis
is unstable,
and manipulation
of the head
and
neck for intubation
risks neurological
injury’4.
The literature
on management
of the airway
in these
patients
OF
study,
no one
had
demonstrated
a benefit
of fiberoptic
management
of the airway
in patients
who had
polyarticular
arthritis,
and few have even addressed
this
patients
in
an already
factor
have
MANAGEMENT
of
air-
Mouth-opening
to a difficult
facial
edema
caused
by placement
of these
the prone
position
can further
compromise
tenuous
cervical
PERIOPERATIVE
the fiberoptic
the patient
those
who
be monitored
extubation
re-establishment
the airway
have
is
non-
carefully
for
in a setting
that is
of the airway.
that developed
in
group.
Problems
with their study included
a small patient
population,
failure
to evaluate
other
possible
contnibuting factors
to complications
related
to the airway,
and
our patients
usually
did so soon
after
extubation,
but
since
one patient
did not exhibit
stridor
until
twelve
hours
after
extubation,
it may be necessary
to provide
failure
pretation
intensive
monitoring
hours.
While
it has
to define
of this
inclusion
the nature
of the complications.
paper
is further
compromised
of patients
who
had
Stiles
et al., in an early
optic
laryngoscope,
stated
an anterior
report
on the
that the device
Interby the
patients
of
been
procedure.
these
use of a fiberoffered
a less
the results
of this study
protect
against
upper-airway
intubated
patients
for at least
our recent
practice
until
the
do
first
to
twelve
keep
postoperative
not show
obstruction.
this
day,
practice
to
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