When to Intubate ACEi Angioedema

Written by Sam Parnell

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Rapid progression of symptoms within the first 6 hours of angioedema onset, anterior tongue swelling, vocal changes, drooling, and dyspnea were all high-risk features associated with need for intubation in patients with ACE inhibitor (ACEi) associated angioedema. Patients with isolated lip swelling were significantly less likely to require intubation.

Why does this matter?
ACE inhibitors are associated with 30-40% of all ED presentations for angioedema. ACEi associated angioedema most commonly affects the lips, tongue, and face, but the most feared complication is acute airway obstruction which can occur in up to 10% of cases. The mainstay of treatment is discontinuing the offending agent as well as supportive care with close airway monitoring. However, the real challenge is determining when patients require intervention to secure their airway.

Man, that face is swole!
This was a retrospective study of 190 patient encounters of ACEi associated angioedema over a 3-year period at a large, urban, tertiary referral emergency department. Overall, 18 patients (9.5%) required intubation. No patients required a surgical airway or other airway rescue device. Risk factors associated with need for intubation were rapid progression of symptoms within the first 6 hours of angioedema onset, anterior tongue swelling, vocal changes, drooling, and dyspnea. Isolated lip swelling occurred in 54% of cases, and patients with isolated lip swelling were significantly less likely to require intubation. These risk factors combined with your clinical gestalt can be used to risk stratify patients with ACEi associated angioedema in order to determine the best plan for management and disposition.

Source
Emergency department evaluation of patients with angiotensin converting enzyme inhibitor associated angioedema. Am J Emerg Med. 2020 Dec;38(12):2596-2601. doi: 10.1016/j.ajem.2019.12.058. Epub 2020 Jan 7.

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