How should an adult patient with ankylosing spondylitis and limited cervical spine mobility be intubated?

How to Intubate a Patient with Ankylosing Spondylitis

Use videolaryngoscopy as your primary intubation technique, with the anterior portion of any cervical collar removed and manual in-line stabilization applied, while having a stylet or bougie immediately available as an adjunct. 1

Primary Intubation Strategy

Equipment Selection

• Videolaryngoscopy is the preferred technique (Grade A recommendation) over direct laryngoscopy, as it provides superior first-pass success rates when cervical spine mobility is restricted 1
• Use whichever videolaryngoscope you are most familiar with—no specific device has proven superiority 1
• Have a stylet or bougie ready as an adjunct, as these significantly improve first-pass success when cervical spine is immobilized 1

Cervical Spine Management

• Remove the anterior portion of any cervical collar before intubation attempts to improve mouth opening and glottic visualization while minimizing cervical movement 1
• Apply manual in-line stabilization (MILS) during the procedure 1
• Use jaw thrust rather than head tilt-chin lift for airway maneuvers 1

Pre-oxygenation and Positioning

• Minimize cervical spine movement during pre-oxygenation and facemask ventilation 1
• Consider sitting the patient upright if their fixed spinal deformity makes supine positioning impossible—allow self-positioning to a comfortable posture 2

When to Consider Awake Fiberoptic Intubation

The decision between awake versus asleep intubation should be made case-by-case 1. Consider awake fiberoptic intubation (AFI) when:

• Severe cervical spine ankylosis with fixed flexion deformity prevents adequate positioning for videolaryngoscopy 2, 3, 4
• Extremely limited mouth opening from temporomandibular joint involvement 3, 4
• Large anterior cervical osteophytes at the level of the epiglottis 4
• High risk of neurological deterioration requiring continuous neurological monitoring during intubation 2, 5

Important caveat: There is no evidence that awake intubation is superior to asleep techniques in preventing secondary spinal cord injury 1. The overall neurological complication rate from intubation is only 0.34% 1.

Awake Intubation Technique Details

• Use dexmedetomidine for sedation to maintain cooperation while allowing self-positioning 2
• Consider nasal route if mouth opening is severely limited 3, 4
• Modified nasopharyngeal airways can facilitate nasal fiberoptic intubation while maintaining oxygenation through the contralateral naris 4
• Maintain spontaneous ventilation throughout 3

Backup Strategy

If videolaryngoscopy fails despite adjuncts:

1. Consider a combined approach: Use videolaryngoscope to visualize the airway while guiding a lighted stylet for tube placement 6
2. Switch to fiberoptic bronchoscopy if initial technique unsuccessful 1
3. Have emergency front-of-neck airway access prepared per Difficult Airway Society guidelines 1

Critical Pitfalls to Avoid

• Do not use head tilt-chin lift maneuvers—these increase cervical spine movement 1
• Do not leave rigid cervical collars fully in place—they significantly worsen mouth opening and intubation success 1
• Do not assume awake intubation is mandatory—it has comparable neurological safety to asleep techniques with videolaryngoscopy 1
• Do not attempt intubation without multidisciplinary planning when dealing with severe deformity 1

Pre-Procedure Planning

• Assess for extraspinal manifestations: cardiac conduction abnormalities, restrictive lung disease, renal impairment from chronic NSAID use 5, 7
• Evaluate airway anatomy for temporomandibular joint involvement and degree of cervical ankylosis 5
• Consider neurophysiological monitoring (somatosensory and motor evoked potentials) for patients with severe cervical deformity 5, 7
• Ultrasound identification and marking of the cricothyroid membrane before induction may be prudent if failed intubation is anticipated 1

The key principle: Videolaryngoscopy with cervical spine precautions provides the optimal balance of first-pass success and neurological safety for most ankylosing spondylitis patients, reserving awake fiberoptic techniques for anatomically extreme cases.