Rheumatoid Arthritis

Created on Wed, 12/23/2015 - 21:32
Last updated on Sat, 12/26/2015 - 16:52

Thus far, rheumatoid arthritis questions in the CICM Fellowship Exam have been mainly interested in the airway problems associated with having temporomandibular joint involvement and cervical spine instability. Alternatively, the examiners would show the candidates a series of photographs, depicting rheumatoid arthritis of the hands; the question then demanded a list of "hand signs" associated with the disease.

Questions about rheumatoid arthritis have included the following:

  • Question 12 from the first  paper of 2014 (intubation issues and general ICU management)
  • Question 10.3 from the second paper of 2013 (rheumatoid hands and chest Xray abnormalities)
  • Question 30.1 from the first paper of 2008 (rheumatoid hands and intubation issues)
  • Question 9 from the first paper of 2001 (general ICU management)

The ensuing summary and discussion takes into account the fact that RA is a massive topic. If the candidate has little else to do, they may review the UpToDate articles on RA, which will satisfy their lust for minute detail. The aim of this chapter is - rather than to act as a definitive resource on the subject - to bring together all the RA-related stuff which has previously appeared in the exam, and to limit revision to this discrete bundle.

Other excellent external sources include clinicalexam.com, which has an excellent entry on RA, with extensive lists of signs and examination techniques. The clinical features of RA are also  discussed in an excellent article from the European Journal of Radiology (Grassi et al, 1998). Pulmonary involvement in rheumatoid arthritis is well covered by Chanin et al (2001). An article on anaesthetic considerations in RA has a nice table (Table 2) of extra-articular manifestations of rheumatoid arthritis.

Features of rheumatoid arthritis

Hand signs

  • Ulnar deviation
  • Z deformity of the thumb
  • Swan neck deformities
  • Swelling of metacarpo-phalangeal joints
  • Wasting of small muscles of the hand
  • Boutonnieres deformity

General clinical features

  • Symmetric joint swelling, MCP > DIP
  • Morning stiffness  lasting at least 1 h before maximal improvement 
  • Extra-articular synovitis (tenosynovitis, bursitis)
  • General symptoms (malaise, fatigue, weight loss, fever)

Pulmonary involvement and chest Xray  features

  • Pleurisy/pleural effusion 
  • Pneumothorax 
  • Rheumatoid nodulosis 
  • Interstitial pulmonary fibrosis
  • Caplan's syndrome is the combination of rheumatoid nodules and pneumoconiosis
  • Bronchiectasis
  • Pulmonary vasculitis
  • Methotrexate-induced interstitial pulmonary fibrosis

Other extra-articular features of rheumatoid arthritis

  • Pericarditis
  • Valvular incompetence
  • Cardiac conduction abnormalities
  • Granulomatous myocardial disease
  • Restrictive cardiomyopathy (amyloidosis)
  • Respiratory myopathy
  • Glomerulonephritis
  • Osteoporosis
  • Carpal tunnel syndrome
  • Anaemia of chronic disease
  • Peptic ulceration
  • Thrombocytopenia (Felty's syndrome)
  • Hepatic fibrosis or hepatomegaly
  • Sicca (Sjogren’s); episcleritis.
  •  Scleromalacia perforans and pyoderma gangrenosum

Features which may complicate the intubation of a rheumatoid arthritis patient

  • Poor neck extension due to C-spine arthritis
  • Risk of spinal cord injury due to atltantoaxial subluxation
  • Poor mouth opening due to TMJ arthritis
  • Poor vocal cord opening due to laryngeal arthritis or crico-arytenitis
  • Poor respiratory reserve due to pulmonary fibrosis

Issues affecting the ICU management of a patient with rheumatoid arthritis

  1.  Difficult intubation, as caused by the abovementioned 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

​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.