a) List the reasons why an underlying diagnosis of rheumatoid arthritis may make intubation difficult in a critically ill patient.
b) Briefly outline how rheumatoid arthritis may influence intensive care management of the patient following intubation.

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College Answer

a)
Musculoskeletal
 Limited neck mobility
 Cervical spine instability
 Limited mouth opening (TMJ)
 Cricoarytenoid arthritis
 Chest/spinal deformity
Pulmonary
 Underlying lung disease – e.g. ILD – further reducing her respiratory reserve
Cardiac
 Underlying cardiac disease – cardiac failure, IHD, valvular disease.
 May influence choice of induction agent(s).
Metabolic
 Impaired renal, hepatic function – more likely from medications for RA.
 May influence choice of induction/paralysing agents.

b) 
Related to the RA itself 
 RA can be a multisystem disease. 
 Respiratory – pulmonary fibrosis, pleural effusion, reduced chest wall compliance. 
 Cardiac – increased risk of IHD, pericardial disease, valvular insufficiency, cardiac failure. 
 Renal – insufficiency directly related to the RA is rare, although does occur (GN, IN, amyloid). 
 Haematological – e.g. anaemia (chronic disease), thrombocytopenia (Felty’s). 
 Amyloidosis – cardiac, renal, hepatic. 
 Skin / pressure sores. 
 Difficult venous / arterial access – limb deformity. 
 Analgesia requirement. 
 Secondary amyloidosis affecting liver spleen and kidneys. 
 Decisions re-extubation if difficult intubation. 
 Post-extubation – difficulties with chest physiotherapy, mobilisation. 
 Psychosocial aspects of patient with chronic illness.

Related to the treatment for RA 
 Immunosuppression – infectious complications. 
 Other cytopaenias – anaemia, thrombocytopenia. 
 Need for adequate steroid replacement if long-term use. 
 Pulmonary – e.g. ILD from MTX, gold. 
 Renal – more likely related to medications that RA itself – e.g. NSAIDS, cyclosporine, penicillamine, gold. 
 Hepatic – e.g. MTX, Azathioprine. 
 Upper GI bleeding – NSAID, SSZ use. 
 Myopathy, skin breakdown, hyperglycaemia – steroids. 
 Drug interactions.

Examiners' comments: Candidates did not think broadly enough, e.g. in part (a) confined their answer to issues relating to C-spine disease.

Discussion

  1. Difficult intubation, as caused by the belowmentioned issues:
    1. Poor neck extension due to C-spine arthritis
    2. Risk of spinal cord injury due to atltantoaxial subluxation
    3. Poor mouth opening due to TMJ arthritis
    4. Poor vocal cord opening due to laryngeal arthritis or crico-arytenitis
    5. Poor respiratory reserve due to pulmonary fibrosis
    6. Difficulty assessing all of these issues in the context of an ICU intubation - you are not seeing this person in the pre-admission clinic; likely they are trying to die in some sort of advanced life support scenario.
  2. Difficult mechanical ventilation:
    1. Oxygenation pproblems:
      1. Pulmonary fibrosis, diffusion defect
      2. Pulmonary hypertension
    2. Ventilation problems
      1. Pleural effusions
      2. Restrictive lung disease with poor complicance
    3. Weaning problems:
      1. Poor muscle strength due to steroid myopathy
      2. Delayed extubation if the intubation was difficult
  3. Cardiac and vascular problems:
    1. Propensity to arrhythmias
    2. Increased risk of ischaemic heart disease
    3. Diastolic failure due to restrictive cardiomyopathy and pericardial disease make fluid resuscitation challenging
    4. Cardiac weirdopathy (eg. failure due to amyloid deposition needs to be considered in the differential diagnosis of an otherwise unexplained heart failure when the patient also has RA)
    5. Difficult vascular access (limb deformities)
    6. Poor mobility and deformity promotes the development of pressure areas
  4. Neuropsychiatric problems:
    1. Steroid-induced psychosis - extubation may be interesting
    2. Psychological problems of chronic disease
    3. Increased analgesic requirements (chronic opiate/NSAID use)
  5. Electrolyte and endocrine abnormalities associated less with RA than with its treatment:
    1. Chronic steroid use may promote hypoadrenalism
    2. Electrolyte derangement due to chronic steroid use
  6. Renal problems:
    1. RA-associated (eg. glomerulonephritis, amyloidosis)
    2. Treatment-associated (eg. NSAID-induced damage)
    3. Does one commit to long term dialysis in this setting?
  7. Gastrointestinal and nutritional problems:
    1. "Rheumatoid cachexia" due to cytokine-driven hypermetabolism promotes the need for more protein and calories (Roubenoff et al, 1994) - but it is unclear whether they benefit from "overfeeding", as they tend to become cachexic in spite of a theoretically adequate dietary intake.
    2. Gastic erosion/ulceration due to chronic steroid and NSAID use suggests that this group should get PPIs routinely
  8. Haematological disturbances
    1. Anaemia of chronic disease: will you transfuse them?
    2. Thrombocytopenia (Felty's) - increased risk from neuraxial procedures and vascular access
  9. Immune and infectious issues
    1. Increased risk of infection
    2. Increased propensity to be often seen in hospitals tends to result in increased risk of MRO colonisation
    3. Weird antiRA drugs may interact with antibiotics

References

References

​Talley and O'Connor is a good source for the clinical features of RA.

Arnett, Frank C., et al. "The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis." Arthritis & Rheumatism31.3 (1988): 315-324.

Chanin, Katia, et al. "Pulmonary manifestations of rheumatoid arthritis." Hospital Physician 37.7 (2001): 2328.

Grassi, Walter, et al. "The clinical features of rheumatoid arthritis." European Journal of Radiology 27 (1998): S18-S24.

Krane, S. M., and L. S. Simon. "Rheumatoid arthritis: clinical features and pathogenetic mechanisms." The Medical clinics of North America 70.2 (1986): 263-284.

Canelli, Robert, John P. Weaver, and Elifce Cosar. "Anesthetic Considerations for Cervical Fusion Surgery in Advanced Rheumatoid Arthritis and Severe Pulmonary Hypertension." (2012).

Roubenoff, Ronenn, et al. "Rheumatoid cachexia: cytokine-driven hypermetabolism accompanying reduced body cell mass in chronic inflammation." Journal of Clinical Investigation 93.6 (1994): 2379.

McInnes, Iain B., and Georg Schett. "The pathogenesis of rheumatoid arthritis." New England Journal of Medicine 365.23 (2011): 2205-2219.

Samanta, R., K. Shoukrey, and R. Griffiths. "Rheumatoid arthritis and anaesthesia."Anaesthesia 66.12 (2011): 1146-1159.