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Angioedema – Who Needs Intubation?

February 10, 2023

Written by Aaron Lacy

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In patients presenting with angioedema, history of hypertension, shortness of breath, drooling, and anterior tongue or pharyngeal swelling were risk factors predicting eventual need for intubation.

Why does this matter?
The decision to intubate in angioedema can be challenging: Providers want to avoid intubating patients, but if intubation is eventually needed and delayed, the procedure can become more challenging secondary to worsening swelling. If there was a way to predict who was high or low risk for intubation, it could help us decided when proceed with airway management.

Watch and wait or intubate?
This was a retrospective chart review of 594 adult patients diagnosed with angioedema. 446 patients were randomly placed into a ‘training’ group in which statistical analysis identified variables in patients that were highly correlated with eventual intubation (81 patients). Beta-coefficients on highly correlated risk factors were used to develop a scoring system. This scoring system was applied to the remaining 148 patients to test for validity. The 0-15 scoring scale was divided into low (0-4), moderate (5-7), and high-risk (>7) categories. Those in the low-risk category required intubation in less than ~5% of cases, while those in the high-risk category required intubation in ~79% of cases (table below). The AUC of the ROC for the test group was 86.1% (95%CI 77.62-94.60%).

Table adapted from cited article

This is a retrospective, single center study, and the scoring system needs external validation. However, it currently seems that the decision to intubate is based entirely off provider experience and gestalt. If validated, this could be a useful tool to employ going forward.

Editor’s note: Until we have an externally validated score, this study adds value in proactively managing patients who have several of these clinical variables rather than waiting to intubate, especially if interfacility transfer is needed. ~Clay Smith

Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema. Am J Emerg Med. 2023 Jan;63:44-49. doi: 10.1016/j.ajem.2022.10.017. Epub 2022 Oct 19.

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