The burden of angioedema on United States emergency departments: 2006-2010

Acute angioedema in Cape Town emergency centres and a suggested algorithm to simplify and improve management

BACKGROUND

Angioedema is the most common acute allergic presentation to emergency centres (EC), with hospitalisation rates increasing in high-income countries. Angioedema can complicate with life-threatening laryngeal obstruction. There are no local data; therefore, we aimed to characterise acute angioedema cases presenting to ECs and develop a simple management algorithm.

OBJECTIVE

To characterise the clinical presentation, management and outcomes of acute angioedema cases presenting to ECs. Based on these findings, we developed a management algorithm for acute angioedema to improve the care of acute angioedema in South Africa (SA).

METHODS

We conducted a retrospective folder review of all patients admitted to Groote Schuur Hospital (tertiary) and Mitchells Plain District Hospital (secondary) ECs from 1  June 2018 to 31  June 2020. Using ICD-10 coding, folders of adults ≥18 years with possible angioedema presenting to the ECs were screened. An allergist extracted demographics, medical history, management and outcome data for each angioedema event.

RESULTS

A total of 142 acute angioedema episodes were included, with a median (interquartile range) age of 42 (28 - 58) years, and 62% of patients were female. The majority (124/142, 87%) of acute angioedema EC presentations involved swelling above the shoulders, with airway involvement in 20 (14%) patients, with two patients requiring intubation. Nineteen (13%) patients required admission, with five (26%) admitted to high care/intensive care. Drug-induced angioedema was the most common cause, with 64/142 (45%) linked to a known offending drug, 42/64 (65.6%) being angiotensin-converting enzyme inhibitor (ACE-I). Critical information to guide angioedema management, including past personal/family allergy history, and duration of angioedema prior to EC visit, was not recorded in 64.7% and 37.8% of EC records, respectively. Unnecessary treatment with corticosteroids or antihistamines occurred in 19/53 (36%) and 16/53 (30%) cases with bradykinin-mediated angioedema ACE-I angioedema and hereditary angioedema). Overall, only 36/142 (25%) of angioedema patients were connected to allergy care.

CONCLUSION

Angioedema is the most common allergy presentation to two ECs in Cape Town, SA. Bradykinin-mediated angioedema secondary to ACE-I therapy is the single most common offender, and was not appropriately managed in more than a third of cases. Based on these findings, we have developed a management algorithm that easily stratifies patients into bradykinin or mast cell-mediated angioedema with a step-by-step management approach that is applicable to the SA context. Ongoing awareness and education on allergy emergencies are required to ensure accurate diagnosis of less common causes of angioedema (particularly bradykinin-mediated angioedema) and linkage to allergy specialist care.

Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema

OBJECTIVES

The objective of this study is to identify predictors of airway compromise among patients presenting to the emergency department with angioedema in order to develop and validate a risk score to augment clinician gestalt regarding need for intubation.

METHODS

Retrospective chart review of emergency department patients with a diagnosis of angioedema. After data extraction they were randomly divided into a training and test set. The training set was used to identify factors associated with intubation and to develop a model and risk score to predict intubation. The model and risk score were then applied to the test set.

RESULTS

A total of 594 patients were included. Past medical history of hypertension, presence of shortness of breath, drooling, and anterior tongue or pharyngeal swelling were independent predictors included in our final model and risk score. The Area Under the Curve for the Receiver Operator Characteristic curve was 87.55% (83.42%-91.69%) for the training set and 86.1% (77.62%-94.60%) for the test set.

CONCLUSIONS

A simple scoring algorithm may aid in predicting angioedema patients at high and low risk for intubation. External validation of this score is necessary before wide-spread adoption of this decision aid.

Role of Submandibular Ultrasound in Airway Management of a Patient With Angioedema

Angioedema is one of several life-threatening clinical scenarios that lacks clarity on when a patient requires intubation. We present a case of angiotensin-converting enzyme-inhibitor-induced angioedema with peri-oral swelling and normal airway measurements on ultrasound, who was intubated with an abundance of caution and extubated successfully. Current tests for intubation and extubation, such as traditional bedside assessments and the cuff leak test, vary in reliability for angioedema and similar urgent situations. Submandibular ultrasound is a quick, low-cost, non-invasive method for determining quantitative criteria for and assessing when intubation and extubation is indicated, which may lead to improved quality of care and patient safety.

Managing Chronic Urticaria and Recurrent Angioedema Differently with Advancing Age

Angioedema and urticaria affect people of all ages. Accurate diagnosis and optimum management is essential for healthy aging. Older people continue to experience mast cell-mediated urticaria and angioedema, with a higher prevalence of autoimmune and a lower prevalence of autoallergic disease. Bradykinin-mediated angioedemas are more common in the elderly because of their association with angiotensin-converting enzyme inhibitor (ACEI) treatment. Acquired C1-inhibitor deficiency, another bradykinin-mediated angioedema, occurs predominantly in older people, whereas hereditary angioedema due to C1-inhibitor deficiency continues to cause symptoms, even in old age. Drug-induced angioedemas disproportionately affect older people, the most frequent users of ACEIs, aspirin, and nonsteroidal anti-inflammatory drugs. Accurate diagnosis and targeted treatment prevent unnecessary morbidity and mortality. Second-generation antihistamines with omalizumab if required are effective and well tolerated in older people with mast cell-mediated urticaria. For bradykinin-mediated angioedemas, these drugs are ineffective. C1-inhibitor replacement or blockade of kallikrein or the bradykinin B2 receptor of the contact pathway is required to treat hereditary angioedema and may be considered in other bradykinin-mediated angioedemas, if supportive treatment is insufficient. For aspirin-related angioedema and urticaria, alternative medications or, exceptionally, desensitization may be required.

Recurrent angioedema: Experience at a tertiary care urban medical center

OBJECTIVE

To determine the demographics, presentation, management, and outcomes of patients with recurrent angioedema. To compare the findings to patients with ACE inhibitor related angioedema.

METHODS

Retrospective case series with chart review of patients who presented to a tertiary-care hospital between January 2010 and December 2017 with two or more episodes of angioedema. Excluded were patients with anaphylactic reaction, medication induced angioedema, or angioedema secondary to an infectious etiology. A group of 88 patients who presented during the same time period with ACE inhibitor related angioedema was used as a control. Statistical analysis was conducted using a two-tailed Fisher exact test and a multivariate logistical regression model to determine significant associations.

RESULTS

Ninety-one patients were identified; 61 met the selection criteria and had 217 total episodes of angioedema episodes presenting to the emergency department. Fifty percent were Caucasian or Hispanic. The average number of episodes was 3.5 (range: 2-23). The lips and tongue were the most commonly affected sites (37% and 39%). The larynx and floor of mouth were least likely to be involved (7% and 6%). Only 1 patient was found to have C1 esterase inhibitor deficiency. Twenty-eight percent of patients had asthma, allergic rhinitis, food allergies, or atopic dermatitis. Only 11% of episodes required airway intervention. No patients required airway intervention after admission.

CONCLUSION

Recurrent angioedema was primarily idiopathic, was less severe than ACE inhibitor angioedema, and was associated with an atopic history. There was less frequent worsening of symptoms after admission, and recurrences occurred more frequently are at the same anatomic subsite.

LEVEL OF EVIDENCE

IV.

Evaluation of staging criteria for disposition and airway intervention in emergency department angioedema patients

AIM

Angioedema is a nonpitting edema that can lead to death secondary to airway obstruction. Previously, a staging system based on localization of the angioedema was proposed for risk stratification of likelihood of need for admission or airway intervention. This study aims to evaluate a staging system based on angioedema localization as a method of predicting need for admission or airway intervention.

METHODS

This was a retrospective chart review of angioedema cases that presented to an academic emergency department (ED) from August 1, 2006, to January 31, 2018. Data were collected on location of swelling, treatment setting, and medical and procedural interventions. Cases were categorized by modified Ishoo criteria, defined as follows: 1, lips, face, periorbital, extremities, total body/diffuse swelling; 2, soft palate, posterior pharynx; 3, tongue; 4, larynx. Predictive probability of disposition by stage was then compared.

RESULTS

A total of 320 patients were included in this study (median age, 44 years; 54.4% female). Stage 4 was more likely to require intensive care unit care without (probability 17%) and with (67%) airway intervention compared with stage 1 without (2.5%) and with (0.1%) airway intervention. Conversely, stage 1 was more likely to be treated in ED and discharged (85%) compared with stage 4 (0%). Stage 4 was also more likely to require airway intervention (67%) compared with other stages (1, 0.1%; 2, 8.6%; 3, 16%).

CONCLUSION

Higher-stage patients were more likely to require higher levels of care and airway intervention. Thus, the staging system appears to be a valid method of predicting risk among ED angioedema patients.

Clinical Features and Outcomes Associated with Angioedema in the Emergency Department

Introduction

Angioedema represents self-limited, localized swelling of submucosal or subcutaneous tissues. While the underlying etiology may be undeterminable in the emergent setting, nonhistaminergic and histaminergic angioedema respond differently to therapeutic interventions, with implications for empiric treatment. Clinical features and outcome differences among nonhistaminergic vs histaminergic angioedema patients in the emergency department (ED) are poorly characterized. We aim to describe the clinical characteristics and outcomes among ED patients with angioedema by suspected etiology.

Methods

This was a 10-year retrospective study of adult ED patients with angioedema, using data abstracted from the electronic health record. We evaluated univariable associations of select clinical features with etiology and used them to develop a multivariable logistic regression model for nonhistaminergic vs histaminergic angioedema.

Results

Among 450 adult angioedema patients, the mean +/− standard deviation age was 57 +/− 18 years, and 264 (59%) were female. Among patients, 30% had suspected nonhistaminergic angioedema, 30% had suspected histaminergic angioedema, and 40% were of unknown etiology. As compared to histaminergic angioedema, nonhistaminergic angioedema was associated with angiotensin-converting enzyme inhibitors (ACEI) or use of angiotensin II receptor blockers (ARB) (odds ratio [OR] [60.9]; 95% confidence interval [CI], 23.16–160.14) and time of onset one hour or more prior to ED arrival (OR [5.91]; 95% CI,1.87–18.70) and was inversely associated with urticaria (OR [0.05]; 95% CI, 0.02–0.15), dyspnea (OR [0.23]; 95% CI, 0.08–0.67), and periorbital or lip edema (OR [0.25]; 95% CI, 0.08–0.79 and OR [0.32]; 95% CI, 0.13–0.79, respectively).

Conclusion

As compared to histaminergic angioedema, patients with nonhistaminergic angioedema were more likely to present one hour or more after symptom onset and take ACEI or ARB medications, and were less likely to have urticaria, dyspnea, or periorbital or lip angioedema. Identification of characteristics associated with the etiology of angioedema may assist providers in more rapidly initiating targeted therapies.

Management of difficult airway among patients with oropharyngeal angioedema

OBJECTIVE

The objective of our study was to assess the impact of a multidisciplinary difficult airway response team (DART), a quality improvement program, in the management of patients with difficult airway associated with oropharyngeal angioedema patients.

METHODS

Individual retrospective cohort study. Retrospective review of patient charts from July 2003 to June 2008 (pre-DART) and retrospective review of prospectively collected data from July 2008 to June 2013 (post-DART). Patients with angioedema were identified using International Classification of Disease codes 995.1 and 277.6. Patients were included in the study if an otolaryngologist was consulted for airway management. Patients were excluded if they had a history of angioedema but no active issues. Patient characteristics, airway evaluation, and interventions (intubation/surgical airway) were compared between the pre-DART and post-DART cohort.

RESULTS

The DART team attended to 27 patients with advanced oropharyngeal angioedema. Response time averaged 3.36 minutes. Preintubation fiberoptic airway evaluations were performed in 81% of the post-DART cohort and 56% of the pre-DART cohort. The incidence of patients requiring intubation was higher in the post-DART cohort (18 out of 27 [67%]) than the pre-DART (14 out of 36 [39%]) cohort. One emergency cricothyroidotomy was performed in each of the post-DART and pre-DART cohorts.

CONCLUSION

Angioedema of the larynx is a predictor of intubation or cricothyroidotomy. Fiberoptic-guided intubation is primarily used for establishing airway in angioedema patients. A multidisciplinary standardized approach such as the DART program offers adequate time and resources for airway evaluation prior to intervention and allows fewer number of attempts to secure an airway.

LEVEL OF EVIDENCE

3 Laryngoscope, 129:1360-1367, 2019.

Identification of Inpatient Allergic Drug Reactions Using ICD-9-CM Codes

BACKGROUND

The study of allergic drug reactions has been limited because of challenges in identifying and confirming cases.

OBJECTIVE

To determine the utility of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for identifying inpatient allergic drug reactions and to compare findings with previous data in the emergency department.

METHODS

By reviewing medical records of inpatients with ICD-9-CM codes and E codes suggestive of allergic drug reactions at a large urban academic medical center, we determined codes that yielded the most drug allergy cases and identified culprit drugs.

RESULTS

In 2005 and 2010, 3337 and 5282 possible allergic drug reactions during hospitalization were identified and 1367 were reviewed. Allergic drug reactions were found in 409 (30.1%) of the reviewed charts, with 172 (29.7%) in 2005 and 237 (30.5%) in 2010. The codes that identified the highest percentage of true allergic drug reactions were dermatitis due to drug (693.0), allergic urticaria (708), angioneurotic edema (995.1), and anaphylaxis (995.0). Antibiotics were the most common cause (44.4%); however, multiple drug classes were often identified as likely culprit drugs.

CONCLUSION

Specific ICD-9-CM codes can identify patients with allergic drug reactions, with antibiotics accounting for almost half of true reactions. Most patients with codes 693.0, 995.1, 708, and 995.0 had allergic drug reactions, with 693.0 as the highest yield code. An aggregate of multiple specific codes consistently identifies a cohort of patients with confirmed allergic drug reactions.