Journal: Eur J Anaesthesiol 25(10):800-804, 2008.
Reprint: Department of Anaesthesiology, School of Medicine, Mustafa Kemal University, Bagriyanik Mahallesi, Hatay 31100, Turkey (B Cagla Ozbakis Akkurt, MD)
Faculty Disclosure: Abstracted by L. Easley, who has nothing to disclose.
Rheumatoid arthritis (RA) is a systemic autoimmune, inflammatory disease that is primarily manifested in the synovium. Any joint with a synovium can be affected in the course of the disease. It is expected to see difficult intubation in these patients, and managing intubation in patients with rheumatoid diseases is a special challenge because chronic inflammatory activity leads to multiple pathological alterations. This study aimed to examine the correlation between the activity and duration of the disease and the commonly used predictors of difficult intubation.
A total of 66 patients who were admitted to the physical therapy department with the diagnosis of RA and 60 control patients were included in the study. Body mass index (BMI) was calculated by dividing weight in kilograms by the square of the height in meters. Patients were asked to complete the Stanford Health Assessment Questionnaire (HAQ) to measure their functional capacity. Disease activity was assessed according to disease activity score in 28 joints (DAS 28). In order to predict difficult intubation, the Mallampati classification, sternomental distance (SMD), thyromental distance (TMD), inter-incisor distance and atlanto-occipital joint (AO) extension were measured.
No correlation was observed between the DAS 28 and Mallampati score, SMD, TMD, inter-incisor distance, angle I and angle II. There was no correlation between the duration of the disease and the Mallampati score, SMD, TMD, inter-incisor distance, angle I, and angle II. The authors also were not able to find a correlation between the HAQ score and the Mallampati score, SMD, TMD, inter-incisor distance, angle I, and angle II.
Although there have been significant advances in therapy, there is still no curative method of treatment. Current treatment strategies aim to achieve clinical remission in order to prevent the long-term consequences of RA. The simplicity of the disease activity score as a mere joint count or in the context of DAS has led to acceptance in several contemporary trials. Respiratory events are the most common anesthetic-related injuries, following dental damage. Difficult tracheal intubation accounts for 17% of the respiratory-related injuries and results in significant morbidity and mortality.
Managing intubation in patients with rheumatic diseases is a special challenge because chronic inflammatory activity leads to multiple pathological alterations. If regional anesthesia techniques are not possible, intubation of the trachea by direct laryngoscopy may be difficult or impossible. To avoid these complications, fiber-optic intubation should be performed. Several tests predicting difficult intubation have been proposed. TMD, SMD, horizontal length of mandible, inter-incisor gap and Mallampati scores are the most commonly used, reliable and easy tests in this area. It was found that Mallampati scores were higher, SMD and inter-incisor distance were shorter and occlusal surface-upper teeth angle and mouth corner-tragus line angle were smaller in the RA group compared with controls.
The authors found several studies concerning difficult intubation in different patient groups or nations but they did not observe a study concerning difficult intubation in specific disease groups. Relying only on these tests of disease activity and not performing the predictive tests for difficult intubation, especially in patients with very low scores, might result in missing the important joint involvements and cause unexpected difficult intubation.
In conclusion, the authors believe that predictive tests of difficult intubation should be performed in every patient with RA, even if the disease activity scores are low or the disease is newly diagnosed. |
