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Intubating Angioedema – What Works?

October 18, 2021

Written by Vivian Lei

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Emergency intubation in patients with angioedema is managed with an array of advanced airway techniques and has an overall first-pass success rate of 81% in this descriptive analysis of airway registry data.

Why does this matter?
Angioedema is a true airway emergency, and preparing for first-attempt intubation success is important to minimize peri-intubation complications and further airway compromise from mechanical trauma. To provide the best care, ED clinicians should be competent in a range of advanced airway techniques, including use of flexible endoscopes and video laryngoscopy as well as RSI and “awake” intubation techniques.

A look at NEAR from afar
This was an analysis of the prospective multicenter National Emergency Airway Registry (NEAR) of ED intubations performed for angioedema. Of the 98 cases identified, the vast majority of first attempts at intubation were performed by emergency physicians (94%), either by an orotracheal route (58%) or nasotracheal route (42%). Flexible endoscopes were the most commonly used initial device (49%), followed by standard geometry video laryngoscopes (22%) and hyperangulated video laryngoscopes (19%). Overall first attempt success was 81%, with higher success rates in nasotracheal intubations (95%) compared to orotracheal intubation (70%). First attempt success with topical anesthesia-only intubation techniques (n=13) was 100%, while first attempt success with RSI using combination sedative and paralytic (n=60) was 82%. Patient-related factors such as clinical stability as well as provider comfort and proficiency likely confound interpretation of these numbers, however. Hypotension (13%) and hypoxia (12%) were the most common adverse events, and 2 patients underwent cricothyrotomy after an unsuccessful first intubation attempt. There were no recorded airway-related deaths.

The number of angioedema patients in this registry was small (only 0.5% of ED intubations) and drawing conclusions on what intubation technique is superior in a given setting is impossible from this data alone. However, it is important to be facile with a range of airway techniques to manage these patients given the unique anatomic challenges and diverse clinical presentations.

Emergency Department Intubations in Patients With Angioedema: A Report from the National Emergency Airway Registry. J Emerg Med. 2021 Aug 31;S0736-4679(21)00549-7. doi: 10.1016/j.jemermed.2021.07.012. Online ahead of print.

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