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Bogart J, Otteson T. Substance Use Disorder as Risk Factor for Intubation in Angioedema: A Nationwide Cohort Study. Laryngoscope 2024. [PMID: 39007365 DOI: 10.1002/lary.31644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/24/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVES Individuals with angioedema (AE) are at high risk for airway compromise and often require endotracheal intubation. Patient factors predisposing one to airway compromise are not well described. The objective of this study is to examine whether substance use disorder (SUD) in patients with AE is associated with need for airway intervention. METHODS This population-based retrospective cohort study compared AE patients with SUD versus propensity-matched control groups. Outcomes were hospitalization, intubation, and tracheotomy. Using the TriNetX National Database, this study included 28,931 patients with SUD and 117,509 patients without SUD who presented with AE. RESULTS Among patients with AE, those with each subtype of SUD (alcohol, cannabis, cocaine, tobacco, and opioids) were found to have higher risk of severe AE compared to propensity-matched non-SUD cohorts. Rate of hospitalization after cohort matching ranged from 20.4% for tobacco use disorder to 30.4% for cocaine use disorder, all significantly higher than the 8.0% in a population without SUD. Each SUD subtype was associated with a higher rate of intubation compared with matched non-SUD groups, with cannabis use disorder having the highest relative risk (RR) of 3.67 (95% CI: 2.69-5.02). Tobacco (RR = 2.45, 95% CI: 1.79-3.34) and alcohol (RR = 2.82, 95% CI: 1.73-4.58) use disorders were both associated with significantly higher risk of tracheotomy. CONCLUSION These data suggest that patients with SUD, regardless of subtype, and after propensity matching for demographics and comorbidities are at higher risk for adverse outcomes when presenting with AE. This study highlights clinically relevant predictors of airway compromise. LEVEL OF EVIDENCE Level 3 Laryngoscope, 2024.
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Affiliation(s)
- Joseph Bogart
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
| | - Todd Otteson
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
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Bacak BJ, Castle MS, Barbot C, Srikantha L, Stern NA, Vandjelovic ND. Airway Involvement and Intervention in Non-ACE-Inhibitor-Induced Angioedema. Laryngoscope 2024; 134:2282-2287. [PMID: 37902118 DOI: 10.1002/lary.31127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/29/2023] [Accepted: 10/10/2023] [Indexed: 10/31/2023]
Abstract
OBJECTIVES Characterize the presentation of patients with non-angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema and determine risk factors associated with patient disposition and possible need for airway intervention. METHODS The medical records of adult patients in the Emergency Department (ED) and diagnosed with non-ACEI-induced angioedema over 4.5 years were included. Demographics, vital signs, etiology, timeline, presenting symptoms, physical exam including flexible laryngoscopy, medical management, and disposition were examined. Statistical analyses were conducted using SPSS V 23.0 software calculating and comparing means, standard deviations, medians, and correlation of categorical and ordinate variables. RESULTS A total of 181 patients with non-ACEI-induced angioedema were evaluated with flexible laryngoscopy by otolaryngology. Notably, 11 patients (6.1%) required airway intervention and were successfully intubated. Statistically significant factors (p ≤ 0.05) associated with airway intervention included the diastolic blood pressure (DBP) and mean arterial pressure (MAP) (p = 0.006 and 0.01 respectively), symptoms of dysphonia (p = 0.018), the presence of oropharyngeal, supraglottic, and hypopharyngeal edema (p ≤ 0.001 for each site), and the number of edematous anatomic subsites documented on physical exam (p < 0.001). Other patient demographics, prior history of angioedema, heart rate, systolic blood pressure, symptom onset, number of symptoms at presentation, and medication administered in the ED did not correlate with airway intervention. CONCLUSION Dysphonia, DBP, MAP, anatomic location of edema and edema in multiple sites are associated with airway intervention and a higher level of care in non-ACEI-induced angioedema and can be useful in risk assessment in patient management. LEVEL OF EVIDENCE 4 Laryngoscope, 134:2282-2287, 2024.
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Affiliation(s)
- Bartholomew J Bacak
- Department of Otolaryngology - Head and Neck Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Michael S Castle
- Department of Otolaryngology - Head and Neck Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Chantal Barbot
- Department of Otolaryngology - Head and Neck Surgery, Detroit Medical Center, Detroit, Michigan, U.S.A
| | - Luxman Srikantha
- Department of Otolaryngology - Head and Neck Surgery, Detroit Medical Center, Detroit, Michigan, U.S.A
| | - Noah A Stern
- Department of Otolaryngology - Head and Neck Surgery, Detroit Medical Center, Detroit, Michigan, U.S.A
| | - Nathan D Vandjelovic
- Department of Otolaryngology - Head and Neck Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
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Landry L, Witten T, Anwar AI, Jackson CN, Talbot NC, Ahmadzadeh S, Varrassi G, Shekoohi S, Kaye AD. Angiotensin-Converting Enzyme Inhibitors and Other Medications Associated With Angioedema. Cureus 2023; 15:e49306. [PMID: 38957198 PMCID: PMC11218608 DOI: 10.7759/cureus.49306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/23/2023] [Indexed: 07/04/2024] Open
Abstract
Angioedema is a localized swelling of the dermis, subcutaneous tissues, and/or submucosal tissues caused by fluid extravasation into these tissues. Angioedema is associated with certain vasoactive molecules and is typically mediated by histamine or bradykinin. It manifests clinically as facial edema, swelling of the extremities and urogenital area, and potential involvement of the larynx, leading to dyspnea and inspiratory stridor, which can become life-threatening. Histamine-mediated angioedema is associated with urticaria and pruritus and will show classic signs of allergic (type 1 hypersensitivity) reactions. Bradykinin-mediated angioedema is often familial (hereditary angioedema) and is more often associated with gastrointestinal symptoms (abdominal pain, nausea, vomiting, diarrhea), edema of the extremities and trunk, and a lack of urticaria and pruritus. Angiotensin-converting enzyme inhibitors (ACEIs) are a class of medications commonly prescribed for hypertension, heart failure, and diabetic nephropathy. ACEIs are associated with an increased risk of angioedema, which can range from a mild reaction to severe and life-threatening. ACEI-induced angioedema is a bradykinin-mediated reaction that can occur in individuals with a genetic predisposition. Other medications, such as angiotensin receptor blockers, nonsteroidal anti-inflammatory drugs, and certain antibiotics, most notably those in the beta-lactam class, can also cause drug-induced angioedema. The present investigation describes current knowledge of the pathophysiology, epidemiology, clinical manifestations, predisposing factors, and management of drug-induced angioedema.
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Affiliation(s)
- Layne Landry
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Taylor Witten
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Corrie N Jackson
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Norris C Talbot
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Wilkerson RG, Winters ME. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. Immunol Allergy Clin North Am 2023; 43:513-532. [PMID: 37394257 DOI: 10.1016/j.iac.2022.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Michael E Winters
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/critcareguys
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Wilkerson RG, Dakessian A, Moellman JJ, Bernstein JA. Clinical trial of C1-INH for treatment of ACEi-induced angioedema. Am J Emerg Med 2023; 68:196-197. [PMID: 37061431 DOI: 10.1016/j.ajem.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/08/2023] [Indexed: 04/17/2023] Open
Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Alik Dakessian
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Jonathan A Bernstein
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
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Arthur J, Caro D, Topp S, Chadwick S, Driver B, Henson M, Norse A, Spencer H, Godwin SA, Guirgis F. Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema. Am J Emerg Med 2023; 63:44-49. [PMID: 36327748 PMCID: PMC10015633 DOI: 10.1016/j.ajem.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 12/07/2022] Open
Abstract
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.
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Affiliation(s)
- Jason Arthur
- Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David Caro
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Stephen Topp
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Steven Chadwick
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Brian Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Morgan Henson
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Ashley Norse
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Horace Spencer
- Department of Biostatistics, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Steven A Godwin
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Faheem Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA.
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Angioedema Caused by Drugs That Prevent the Degradation of Vasoactive Peptides: A Pharmacovigilance Database Study. J Clin Med 2021; 10:jcm10235507. [PMID: 34884209 PMCID: PMC8658484 DOI: 10.3390/jcm10235507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/20/2021] [Accepted: 11/24/2021] [Indexed: 01/03/2023] Open
Abstract
Angioedema results from the decreased degradation of vasoactive peptides such as substance P and bradykinin. In this study, we sought to clarify whether dipeptidyl peptidase-4 (DPP-4) and angiotensin-converting enzyme (ACE) inhibitors that suppress the degradation of substance P and bradykinin are involved in angioedema onset. We calculated information coefficients (ICs) by performing a disproportionality analysis to evaluate DPP-4/ACE inhibitor-induced angioedema using the Japanese Adverse Drug Event Report (JADER) database. No angioedema signals were detected for DPP-4 inhibitors; however, a signal was detected for ACE inhibitors (IC: 2.42, 95% confidence interval (CI): 2.19 to 2.65). Of the patients treated with DPP-4 inhibitors, four developed drug-induced angioedema in combination with ACE inhibitors, and all were taking vildagliptin. Signals were detected for enalapril (IC: 2.39, 95% CI: 2.06 to 2.71), imidapril (IC: 2.83, 95% CI: 2.38 to 3.27), lisinopril (IC: 2.28, 95% CI: 1.55 to 3.00), temocapril (IC: 1.35, 95% CI: 0.29 to 2.40), and trandolapril (IC: 1.57, 95% CI: 0.19 to 2.95). Both inhibitors inhibited the degradation of substance P and bradykinin and were thus expected to cause angioedema. However, no signal of angioedema was detected with the DPP-4 inhibitors, in contrast to some ACE inhibitors. This study found that ACE inhibitors and DPP-4 inhibitors, which inhibit the degradation of substance P and bradykinin, tended to have different effects on the onset of angioedema in clinical practice.
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Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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9
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Sandefur BJ, Liu XW, Kaji AH, Campbell RL, Driver BE, Walls RM, Carlson JN, Brown CA. Emergency Department Intubations in Patients With Angioedema: A Report from the National Emergency Airway Registry. J Emerg Med 2021; 61:481-488. [PMID: 34479750 DOI: 10.1016/j.jemermed.2021.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/03/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Angioedema, a localized swelling of subcutaneous and submucosal tissues, may involve the upper airway. A subset of patients presenting for emergent evaluation of angioedema will require intubation. Little is known about airway management practices in patients with angioedema requiring intubation in the emergency department (ED). OBJECTIVE To describe airway management practices in patients intubated for angioedema in the ED. METHODS We analyzed data from the National Emergency Airway Registry. All patients with an intubation attempt for angioedema between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals. RESULTS Of 19,071 patient encounters, intubation was performed for angioedema in 98 (0.5%). First-attempt success was achieved in 81%, with emergency physicians performing the procedure in 94% of encounters. The most common device used was a flexible endoscope (49%), and 42% of attempts were via a nasal route. Pharmacologic methods included sedation with paralysis (61%), topical anesthesia with or without sedation (13% and 13%, respectively), and sedation only (10%). Among 19 (19%) patients requiring additional attempts, intubation was achieved on second attempt in 10 (53%). The most common adverse events were hypotension (13%) and hypoxemia (12%). Cricothyrotomy occurred in 2 patients (2%). No deaths were observed. CONCLUSIONS Angioedema was a rare indication for intubation in the ED setting. Emergency physicians achieved first-attempt success in 81% of encounters and used a broad range of intubation devices and methods, including flexible endoscopic techniques. Cricothyrotomy was rare, and no ED deaths were reported. © 2021 Elsevier Inc.
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Affiliation(s)
| | - Xiao-Wei Liu
- Department of Emergency Medicine, The First Affiliated Hospital of China Medical University, Liaoning, Shenyang, China
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Ron M Walls
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jestin N Carlson
- Department of Emergency Medicine, Allegheny Health Network, Erie, Pennsylvania
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Mohorn PL, Roebuck LD, Raybon-Rojas E, Duncan C. C1 esterase inhibitor for angiotensin-converting enzyme inhibitor-induced angioedema at a community teaching health system: A brief retrospective propensity-matched cohort study. Am J Emerg Med 2021; 49:6-9. [PMID: 34029784 DOI: 10.1016/j.ajem.2021.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/07/2021] [Accepted: 05/13/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Angiotensin-converting enzyme inhibitor (ACEi)-induced angioedema is a serious emergency that can cause life-threatening symptoms and death if not treated promptly. Potential treatment options for ACEi-induced angioedema include medications with limited evidence for use in this patient population. The purpose of this study was to evaluate the use, clinical efficacy, and angioedema-related medication costs of C1 esterase inhibitor (C1EI) for ACEi-induced angioedema. METHODS This was a retrospective, propensity-matched cohort study comparing patients who received C1EI to those who did not receive C1EI for ACEi-induced angioedema. The primary outcome of interest was comparing the proportion of patients who required intubation secondary to ACEi-induced angioedema. Secondary endpoints of interest were also included. RESULTS After propensity score matching, 22 patients were stratified into both the non-C1EI group and C1EI group, respectively. There was no difference between the groups with respect to the proportion of intubation (13.6% in the C1EI group vs. 9.1% in the non-C1EI group, p > 0.999). Mean cost of angioedema-related medication therapy was higher in the C1EI group compared to the non-C1EI group [$8758.95 (± $2959.30) vs. $15.91 (± $7.32), p < 0.001]. CONCLUSIONS In this retrospective cohort study, the use of C1EI for ACEi-induced angioedema did not demonstrate improved outcomes with respect to intubation and resulted in increased costs. Larger, multicenter, prospective studies are needed to further validate the results of this study and to provide more clarity on the role of C1EI therapy in ACEi-induced angioedema.
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Affiliation(s)
- Phillip L Mohorn
- Department of Pharmacy, Northeast Georgia Health System, Gainesville, GA, USA.
| | - Leslie D Roebuck
- Department of Pharmacy, Northeast Georgia Health System, Gainesville, GA, USA
| | - Erine Raybon-Rojas
- Division of Critical Care and Pulmonology, Northeast Georgia Health System, Gainesville, GA, USA
| | - Cory Duncan
- Georgia Emergency Department Services, Department of Emergency Medicine, Northeast Georgia Health System, Gainesville, GA, USA
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Dass C, Mahaffa M, Dang E, Campbell R, Ballas Z, Lee S. Evaluation of staging criteria for disposition and airway intervention in emergency department angioedema patients. Acute Med Surg 2021; 8:e704. [PMID: 34729186 PMCID: PMC8548721 DOI: 10.1002/ams2.704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/13/2021] [Accepted: 10/07/2021] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Conor Dass
- Department of Emergency MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Maggie Mahaffa
- Department of Emergency MedicineState University of New York at BuffaloBuffaloNew YorkUSA
| | | | - Ronna Campbell
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - Zuhair Ballas
- Department of Internal MedicineDivision of ImmunologyUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
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Emergency department evaluation of patients with angiotensin converting enzyme inhibitor associated angioedema. Am J Emerg Med 2020; 38:2596-2601. [DOI: 10.1016/j.ajem.2019.12.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/30/2019] [Accepted: 12/31/2019] [Indexed: 11/19/2022] Open
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Adeyeni TA, Domack A, Britt C. What Is the Role of Laryngoscopy in Angioedema Isolated to the Lips, Without Laryngeal Symptoms? Laryngoscope 2020; 130:2740-2741. [PMID: 32246776 DOI: 10.1002/lary.28664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/18/2020] [Accepted: 03/16/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Temitope A Adeyeni
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, U.S.A
| | - Aaron Domack
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, U.S.A
| | - Christopher Britt
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, U.S.A
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C1 Esterase Inhibitor for Ace-Inhibitor Angioedema: A Case Series and Literature Review. J Emerg Med 2020; 58:e121-e127. [DOI: 10.1016/j.jemermed.2019.10.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/18/2019] [Accepted: 10/27/2019] [Indexed: 11/22/2022]
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15
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Affiliation(s)
- Antoine Eskander
- From the Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology (A.E., J.R.A., J.C.I.) and the Institute for Health Policy Management and Evaluation (A.E., J.R.A.), University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital (A.E.), the Institute for Clinical Evaluative Sciences (A.E.), and Princess Margaret Cancer Centre (J.R.A., J.C.I.) - all in Toronto
| | - John R de Almeida
- From the Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology (A.E., J.R.A., J.C.I.) and the Institute for Health Policy Management and Evaluation (A.E., J.R.A.), University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital (A.E.), the Institute for Clinical Evaluative Sciences (A.E.), and Princess Margaret Cancer Centre (J.R.A., J.C.I.) - all in Toronto
| | - Jonathan C Irish
- From the Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology (A.E., J.R.A., J.C.I.) and the Institute for Health Policy Management and Evaluation (A.E., J.R.A.), University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital (A.E.), the Institute for Clinical Evaluative Sciences (A.E.), and Princess Margaret Cancer Centre (J.R.A., J.C.I.) - all in Toronto
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Pandian V, Zhen G, Stanley S, Oldsman M, Haut E, Mark L, Miller C, Hillel A. Management of difficult airway among patients with oropharyngeal angioedema. Laryngoscope 2018; 129:1360-1367. [PMID: 30588625 DOI: 10.1002/lary.27622] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Vinciya Pandian
- Johns Hopkins School of Nursing, Baltimore, Maryland.,Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland
| | - Gooi Zhen
- University of Chicago Medicine, Chicago, Illinois, U.S.A
| | - Stanola Stanley
- Johns Hopkins School of Nursing, Baltimore, Maryland.,Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland
| | - Marco Oldsman
- Johns Hopkins School of Nursing, Baltimore, Maryland.,Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland
| | - Elliott Haut
- The Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine, Baltimore, Maryland.,The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.,The Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lynette Mark
- The Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
| | - Christina Miller
- The Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
| | - Alexander Hillel
- The Department of Otolaryngology Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Stone C, Brown NJ. Angiotensin-converting Enzyme Inhibitor and Other Drug-associated Angioedema. Immunol Allergy Clin North Am 2018; 37:483-495. [PMID: 28687104 DOI: 10.1016/j.iac.2017.04.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nonsteroidal antiinflammatory agents, β-lactam antibiotics, non-β lactam antibiotics, and angiotensin-converting enzyme inhibitors are the most common classes of drugs that cause angioedema. Drug-induced angioedema is known to occur via mechanisms mediated by histamine, bradykinin, or leukotriene, and an understanding of these mechanisms is crucial in guiding therapeutic decisions. Nonallergic angioedema occurs in patients with genetic variants that affect metabolism or synthesis of bradykinin, substance P, prostaglandins, or leukotrienes, or when patients are taking drugs that have synergistic mechanisms. The mainstay in treatment of nonallergic drug-induced angioedema is cessation of the offending agents.
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Affiliation(s)
- Cosby Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South T-1218, Medical Center North, Nashville, TN 37232-2650, USA
| | - Nancy J Brown
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South D-3100, Medical Center North, Nashville, TN 37232, USA.
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Kuperstock JE, Pritchard N, Horný M, Xiao CC, Brook CD, Platt MP. Inhalant allergen sensitization is an independent risk factor for the development of angioedema. Am J Otolaryngol 2018; 39:111-115. [PMID: 29310846 DOI: 10.1016/j.amjoto.2017.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVE The etiology and risk factors for angioedema remain poorly understood with causative triggers often going undiagnosed despite repeated reactions. The purpose of this study was to determine the relationship between inhalant allergen sensitization and angioedema. METHODS A retrospective review of patients who had in vitro inhalant allergy testing from 2006 to 2010 was performed. Patients with a diagnosis of angioedema who underwent inhalant allergy testing were identified. Analyses for co-morbidities, class of sensitization, seasonal timing of angioedema, and concurrent use of known hypertensive medications that can cause angioedema were performed. RESULTS There were 1000 patients who underwent inhalant allergy testing and qualified for the study. 37/1000 had at least one episode of angioedema and of these patients, 34 had positive inhalant sensitization testing results. Multivariate regression models showed overall sensitization status, seasonal allergen and epidermal/mite sensitization as independent risk factors (p<0.001, p=0.005, p=0.025 respectively) when controlling for ACE inhibitor use and other covariates. Tree, and epidermal/mite sensitizations were independent risk factors for angioedema in mono-sensitized subject analysis (p=0.028, p=0.029, respectively). CONCLUSION Both seasonal and perennial allergen sensitizations are independent risk factors for the development of angioedema. In patients with angioedema and an unknown trigger, inhalant allergen sensitization should be considered as a potential contributing factor to the development of angioedema.
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Duplin E, Mangé A, McCambridge C, Gérard S, Cestac P, Didier A, Rolland Y. What are the usual causes of angioedema? Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Driver BE, McGill JW. Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations. Ann Emerg Med 2017; 69:635-639. [PMID: 28110989 DOI: 10.1016/j.annemergmed.2016.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/29/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE Angioedema is an uncommon but important cause of airway obstruction. Emergency airway management of angioedema is difficult. We seek to describe the course and outcomes of emergency airway management for severe angioedema in our institution. METHODS We performed a retrospective, observational study of all intubations for angioedema performed in an urban academic emergency department (ED) between November 2007 and June 2015. We performed a structured review of video recordings of each intubation. We identified the methods of airway management, the success of each method, and the outcomes and complications of the effort. RESULTS We identified 52 patients with angioedema who were intubated in the ED; 7 were excluded because of missing videos, leaving 45 patients in the analysis. Median time from arrival to the ED to the first intubation attempt was 33 minutes (interquartile range 17 to 79 minutes). Nasotracheal intubation was the most common first method (33/45; 73%), followed by video laryngoscopy (7/45; 16%). Two patients required attempts at more invasive airway procedures (retrograde intubation and cricothyrotomy). The intubating laryngeal mask airway was used as a rescue method 5 times after failure of multiple methods, with successful oxygenation, ventilation, and intubation through the laryngeal mask airway in all 5 patients. All patients were successfully intubated. CONCLUSION In this series of ED patients who were intubated because of angioedema, emergency physicians used a range of methods to successfully manage the airway. These observations provide key lessons for the emergency airway management of these critical patients.
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Affiliation(s)
- Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | - John W McGill
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
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22
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Laccourreye O, Rubin F, Delort J, Bonfils P. Diagnostic approach to sudden onset of diffuse isolated oedema of the lips. Eur Ann Otorhinolaryngol Head Neck Dis 2017; 134:357-359. [PMID: 28082136 DOI: 10.1016/j.anorl.2016.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In the light of a case of sudden onset of diffuse, isolated oedema of the lips, the authors describe the key points of the diagnostic approach and the main epidemiological and clinical data.
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Affiliation(s)
- O Laccourreye
- Service d'Oto-rhino-laryngologie et de chirurgie cervico-faciale, Université Paris Descartes Sorbonne Paris Cité, HEGP, AP-HP, 20-40, rue Leblanc, 75015 Paris, France.
| | - F Rubin
- Service d'Oto-rhino-laryngologie et de chirurgie cervico-faciale, Université Paris Descartes Sorbonne Paris Cité, HEGP, AP-HP, 20-40, rue Leblanc, 75015 Paris, France
| | - J Delort
- Service d'Anesthésie, Université Paris Descartes Sorbonne Paris Cité, HEGP, AP-HP, 20-40, rue Leblanc, 75015 Paris, France
| | - P Bonfils
- Service d'Oto-rhino-laryngologie et de chirurgie cervico-faciale, Université Paris Descartes Sorbonne Paris Cité, HEGP, AP-HP, 20-40, rue Leblanc, 75015 Paris, France
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23
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Angioedema Due to ACE Inhibitors. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0099-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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