A 42-year-old male patient with 161 cm height was admitted for ankylosing spondylitis and atlantoaxial dislocation. The patient presented pain and restricted movement in the lower back 15 years ago. He was definitely diagnosed with ankylosing spondylitis. Because of no specific and effective treatment, his sign of hunchback developed worse and worse. Three years ago, he presented neck stiffness with limited movement and pain in the occipital and nape region; meanwhile, his head leaned and fixed rightward. Because of the progressive condition, his trunk deformity developed into a more curve magnitude company with physical pain, which led to reduced quality of life and social and psychological distress. Therefore, he was admitted for spinal fusion and instrumentation surgery to restore the spine without neurological deficit.
The patient's previous medical history was negative. He did not smoke and had no pets at home. There was no family history of any congenital, lung, or infectious conditions. After admission, he accepted a detailed assessment of neuromuscular spinal deformity, including clinical examination, cardiac and respiratory evaluation, and digestive and urinary assessment. Although there was thoracic deformity and motor disorder caused by ankylosing spondylitis, he did not present an obvious reduction in respiration and cardiac function. Also, there were no other apparent signs, for instance, abnormal chest auscultation. The preoperative thoracic computer tomography (CT) of the patient demonstrated multiple subpleural pulmonary bullae on the upper lobes of bilateral pulmonary.
Preoperative spirometry showed a forced expiratory volume in 1 s (FEV1) of 2.46 L (67.55% predicted), forced vital capacity (FVC) of 2.60 L (59.02% predicted), FEV1/FVC ratio of 113.07%, and a peak expiratory flow rate of 7.85 L/s (88.87% predicted).
After 1 month halo traction treatment, the patient was sent to the operating room for osteotomy orthopedics. Because his head was fixed rightward in the anterior flexion position, there was difficulty in rapid sequential induction; thus, awake nasotracheal intubation was implemented according to the preoperative anesthesia plan. After the standard monitoring was utilized and venous access was secured with an 18G cannula, the patient was administrated with 1 mg of midazolam and 5 microg of sufentanil, followed by ephedrine contracting vessel of the nasal mucosa and tetracaine nasopharynx mucosa surface anesthesia. During the process, the patient breathed with 5 L/min 100% oxygen under a mask covering his mouth and nose slightly. Meanwhile, he was administrated cricothyroid puncture with 5 ml of 1% tetracaine. After perfect surface anesthesia, a 6.0-size endotracheal tube (ETT) was inserted into the main trachea smoothly by a fiber bronchoscope guidance at 28 cm scale from the tip of the nose. Inflating cuff of ETT and connecting with breathing circuits. After the wave of end expiratory carbon dioxide was confirmed, the patient was administrated with 2 mg of midazolam, 20 microg of sufentanil, 100 mg of propofol, and 50 mg of rocuronium. When mechanism ventilation was used instead of spontaneous breathing completely, significant peritubular leakage happened accompanied by a sonorous sound from his mouth. At the same time, there was no distinct movement of the chest. An adequate seal was unable to achieve around the ETT cuff despite inflation with an increasing amount of air. Mechanism ventilation was quickly switched to manual ventilation to increase the volume of ventilation. There was still a sonorous sound of air leakage, but the movement of the chest and saturated pulse oxygen could be maintained. Bilateral respiration sounds were acquired by chest auscultation when manual ventilation. The ETT cuff was checked and injected with more air to stiff intensity. Fibrobronchoscope examination demonstrated the ETT located in the main airway again. Because of continuous air leakage and inability to maintain ventilation, the previous 6.0-size ETT was replaced by a 6.5-size ETT, and the cuff was inflated to stiff intensity. The situation made everyone disappointed due to uncorrected serious peri-cuff leakage. The patient's preoperative chest digital radiography image and CT had to be reviewed further. His chest digital radiography image showed that a part of the main trachea was seemingly wider than normal (Figure 1). However, the widened main trachea was unable to be confirmed by chest CT because the images were not the standard due to his scoliosis profile. Meanwhile, fibrobronchoscopy examination had to be done again, and it demonstrated the tip of ETT close to the carina of the trachea; thus, the ETT was withdrawn 3 cm distance. The air leakage was corrected suddenly whenever manual or mechanical ventilation. Finally, the ETT was fixed at 25 cm from the tip of the nose, and the ETT cuff pressure was regulated suitably. There was no peri-cuff leakage until the end of the operation. After recovery from the operation, the patient accepted a thoracic CT scan again and a three-dimensional airway reconstruction. Meanwhile, the result of the postoperative X-ray tracheomalacia test was negative. TBM was considered by these standard radiological images (Figures 2, 3).