Awake Tracheostomy in the Sitting Position for a Predicted Difficult Airway in Ankylosing Spondylitis With Inhalation Injury: A Case Report.

BACKGROUND: Airway management in patients with inhalation injury is particularly challenging because of rapidly progressive airway edema. This difficulty is further compounded in patients with ankylosing spondylitis, in whom cervical spine rigidity and deformity severely restrict neck mobility and may prevent standard positioning for airway interventions. In such situations, conventional airway management techniques may fail, necessitating alternative strategies. CASE PRESENTATION: We report the case of a 48-year-old man with inhalation injury following a flame burn who also had long-standing ankylosing spondylitis with marked cervicothoracic deformity. The patient developed progressive respiratory failure with impending airway obstruction. Emergency endotracheal intubation was attempted twice using a conventional Macintosh direct laryngoscope but was unsuccessful because of severe positional limitations, restricted cervical mobility, and progressive airway edema. MANAGEMENT AND OUTCOME: An emergency awake tracheostomy was performed in the sitting position at approximately 90° under local anesthesia with light sedation while spontaneous ventilation was maintained. Despite significant challenges related to anatomical deformity and soft-tissue edema, the procedure was successfully completed within approximately 10 min. Oxygen saturation improved immediately from approximately 85% to 99%-100%, and no immediate procedure-related complications were observed. Bronchoscopy performed after airway stabilization demonstrated Grade II inhalation injury according to the abbreviated injury score. The patient subsequently remained mechanically ventilated through the tracheostomy for 22 days and underwent two burn wound excision and autologous skin grafting procedures. He later developed sepsis progressing to septic shock and multiple-organ failure and died on Day 22 after tracheostomy. CONCLUSION: Emergency awake tracheostomy in the sitting position may be an effective option for securing the airway when conventional airway techniques are unsuccessful and supine positioning is not feasible. This case highlights the importance of individualized airway management, preservation of spontaneous ventilation, and readiness to transition promptly to a surgical airway in patients with severe anatomical and acute airway challenges.