[Difficult airway management during emergency tracheostomy in a patient with severe rheumatoid arthritis]

We experienced difficult airway management in a 65-year-old woman with acute dyspnea due to bilateral recurrent nerve palsy suffering from severe rheumatoid arthritis for fifty years. Her cervical spine was ankylosed and could not be extended at all. Tracheostomy was planned under local anesthesia because of difficulty of endotracheal intubation, possibility of airway obstruction and laryngeal edema. In this condition, the surgical area was narrow and difficult to approach. The surgical bleeding and blood-aspiration into the tracheostomy site occurred followed by airway obstruction. A rigid tracheal tube could not be inserted through the tracheal incision and SpO2 decreased to 81%. We inserted a percutaneous cricothyroidotomy cannula through the tracheal incision and superimposed HFJV on her spontaneous ventilation. Assisting the ventilation in this way finally, a spiral endtracheal tube was inserted and her oxygenation became stable.