ACE Inhibitor Induced Angioedema

[NPO]

Who has ever seen or treated ACE Inhibitor Induced Angioedema, sometimes abbreviated ACEI-AAG.

For those unfamiliar, since I'm speaking to all audiences, ACEI-AAG is a reaction to ACE inhibitors that is often mistaken for an allergic reaction, and presents with swelling of the face and mouth. Unlike an allergic reaction, this reaction is not mediated by histamine but by bradykinin, which means treatment with Epi, antihistamines and steroids will produce no results.

I've seen it once for sure, but possibly twice, I can't remember the specifics of the second call. The first was an ICU transfer. The patient had suffered an anoxic brain injury because he had come into the ED and was sent home with Lisinopril. He had a reaction and came back several hours later. Unfortunately, the pathology went unrecognized and he was mistakenly treated for a histamine mediated allergic reaction, which will not treat this.

I was intrigued, not only because of the devestating effects, but I like obscure conditions like this. After completing the transfer I read up on this all I could to make sure I was never caught off guard by this. As a prehospital provider, there is very little I can realistically do to treat these patients, other than recognition. I probably wouldn't forego standard treatment with Epi just in case, but I wouldn't continue using it once it obviously didn't work.

I'm curious how prevalent this is, and how quickly this progresses. My understanding is that it progresses much slower than an allergic reaction, but how slow? Slow enough that an easy monitored ride to the ED is sufficient? Or is there a real need for airway control?

 

[VentMonkey]

I have, I gave them Benadryl and it actually worked. It’s fairly prevalent (common), and I want to say more so in the African-American population, but have no sources to currently cite.

It’s basically localized angioedema. I find/ found it intriguing as well. Seen, and treated it twice, one time (as stated above) the Benadryl worked, the other it had not.

Also, if you’re intrigued by the localized angioedema types, give Ludwig’s angina a search.

 

[VentMonkey]

So FFP seems to be the “go to” once diagnosis has been confirmed, or at least according to this publication in 2015:
https://emcrit.org/pulmcrit/treatment-of-acei-induced-angioedema/

 

[NPO]

So FFP seems to be the “go to” once diagnosis has been confirmed, or at least according to this publication in 2015:
https://emcrit.org/pulmcrit/treatment-of-acei-induced-angioedema/

Yes FPP, is the "obvious" choice. There are other options, which cost quite a bit more than is very reasonable. Some people debate if using blood products is worth it, but most people say yes. The FPP contains enzymes which help break down the excess Bradykinin.

Curious that you noted improvement with Benadryl. I wonder if they also had an allergic reaction occuring.

 

[VentMonkey]

Curious that you noted improvement with Benadryl. I wonder if they also had an allergic reaction occuring.

//shrugging// could be. The one I remember most would obviously be the most recent, which was also years ago in metro.

An Afro-American patient on ACE-I’s who couldn’t put their tongue back in their mouth, or talk, but who was sluggishly coherent with notably less swelling, and had the ability to put their tongue back in their mouth after a 50 mg slug of diphenhydramine IVP. I may have asked the doc about it, but if so I don’t remember their response.

I remember walking away thinking that it had a questionable effect on this population, but remember also feeling happy it worked almost as instantaneously as a diabetic, or narcotic reversal.

 

[E tank]

An Afro-American patient on ACE-I’s who couldn’t put their tongue back in their mouth, or talk, but who was sluggishly coherent with notably less swelling, and had the ability to put their tongue back in their mouth after a 50 mg slug of diphenhydramine IVP. I may have asked the doc about it, but if so I don’t remember their response.

Excellent discussion...There are two explanations for benadryl working here. One is that it was truly an allergic reaction to some med the patient was taking, ACEI or not. It may have also been a reaction to the ACEI, just not the one that was assumed. Trandolapril (generic for Mavik) is an ACEI that can cause EPS, mimicking an angioedema event (grossly protruding tongue), which, as you know, will respond to antihistimines like benadryl.

 

[EpiEMS]

I hadn't ever seen this until I saw this video, so, FWIW, here's Larry Mellick:

@VentMonkey, isn't Ludwig's angina caused by an infection? If so, I guess it's a DDx for angioedema caused by ACE inhibitors?

 

[VentMonkey]

@VentMonkey, isn't Ludwig's angina caused by an infection? If so, I guess it's a DDx for angioedema caused by ACE inhibitors?

TMK, yes typically oral infections like tooth abscesses. The swelling that can result though could make for somewhat of an airway nightmare.

 

[EpiEMS]

The swelling that can result though could make for somewhat of an airway nightmare.

Mallimpati V I don't know there is too much stuff in the way time to crike?

 

[NPO]

Mallimpati V I don't know there is too much stuff in the way time to crike?

Would you consider nasal intubation?
We carry Endotrol ETT and Bam Devices for nasal intubation to make it "easier".

 

[EpiEMS]

Would you consider nasal intubation?
We carry Endotrol ETT and Bam Devices for nasal intubation to make it "easier".

#NotAMedic but I would consider NTI if it were in my scope - my regional protocols permit NTI for medics, so I don't see why not, seems to be an acceptable (less invasive) alternative.

Would video laryngoscopy be worth trying?

 

[NPO]

Would video laryngoscopy be worth trying?

You could certainly attempt it, and it is our standard of care. However you would be wise not to mess around too long if you don't get a good view of the cords.

 

[VFlutter]

I have seen a few in the ICU . Most were intubated by Anesthesia or ENT with a fiberoptic scope. A couple were nasally intubated prior to arrival in the ICU. I think awake fiberoptic is the go to for bad cases or early video laryngoscopy. A quick google search suggests that they both have a similar success rate but video is quicker then fiberoptic which may result in less desaturations.

I have also been a part of a few bad Ludwig's Angina intubations. Similar type of airway

Could be wrong but I would assume the superficial swelling would happen first, i.e tongue and lips, before the actual airway so once you get passed the tongue you may have a good shot with video if early on.

 

[Tigger]

#NotAMedic but I would consider NTI if it were in my scope - my regional protocols permit NTI for medics, so I don't see why not, seems to be an acceptable (less invasive) alternative.

Would video laryngoscopy be worth trying?

I am not sure you could fit some of the video devices in that space and still have a view (King Vision and that type of device). We have NTI but I would be lying if I said I felt competent with it.

 

[harold1981]

I have seen a few cases. I can remember three cases of Quincke´s edema of the lips and tongue, related to the use of ACE-inhibitors, and one that involved swelling of the penis, without a clear reason. A collegue of mine described a case last year, in which her patient had isolated but significant swelling of the uvula, complete with drooling,stridor and hypoxia after using an NSAID. It is my understanding that the process does not involve just one mechanism. There is an inflammatory immune response that leads to vasodilation and extracellular leakage, in which certain hormones, bradykinins and serotonine have a role, but sometimes also histamine. In our system, we do treat aggressively as we would in an anaphylactic reaction, with the administration of oxygen, epi 0.5mg IM and airway management. Enroute we´d also give hydrocortison 200mg and clemastine 2mg. I´ve seen immediate results with this treatment protocol, although I can imagine that the role of clemastine would be ineffective in a group of patients and therefore variable.

 

[EpiEMS]

We have NTI but I would be lying if I said I felt competent with it.

I think most medics would say the same, no? NTI has kinda fallen by the wayside in EMS, I had thought.

 

[E tank]

I think most medics would say the same, no? NTI has kinda fallen by the wayside in EMS, I had thought.

So many people are taking one type of blood thinner or another these days, you really have to weigh the down side of not being able to get a nasal tube and bloodying up the airway and creating a worse scenario. But for an awake and/or spontaneously breathing patient, it isn't that difficult when the conditions are not awful.

 

[EpiEMS]

@E tank, do you guys use NTI in the hospital at all?

 

[VentMonkey]

https://airwayjedi.com/tag/intubation-in-ludwigs-angina/

 

[EpiEMS]

https://airwayjedi.com/tag/intubation-in-ludwigs-angina/

Cool site!