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Intubation for patients diagnosed with angioedema is a complex and critical medical procedure due to the nature of the condition and its potential for rapid deterioration [7]. Characterized by sudden swelling of the deeper layers of the skin and mucous membranes, angioedema poses a significant risk to life when it affects the airway [7]. This swelling can obstruct the upper respiratory tract, leading to breathing difficulties or complete obstruction [7]. Consequently, timely and proficient airway management, including intubation, is essential for patient survival [7].
Angioedema may be precipitated by various factors, including allergic reactions, medications (such as ACE inhibitors), hereditary conditions, and idiopathic causes [7]. The underlying pathophysiological mechanism involves the release of mediators, such as histamine or bradykinin, which increase vascular permeability and result in fluid accumulation in the interstitial tissues [7]. Histamine-mediated angioedema, often caused by allergic reactions, can be treated with corticosteroids, antihistamines, and epinephrine, while bradykinin-mediated angioedema (e.g., hereditary or ACE inhibitor-induced) typically requires more specific treatments [8].
The decision a whether a patient with angioedema needs intubation is based primarily on clinical presentation and the severity of airway obstruction [2]. Early indicators of airway compromise include stridor, hoarseness, and difficulty swallowing [2]. As the condition advances, patients may exhibit signs of respiratory distress, such as tachypnea, use of accessory muscles, and cyanosis [3, 4]. In such situations, securing the airway becomes paramount to prevent asphyxiation and ensure adequate oxygenation [3]. Intubation in the context of angioedema presents several challenges. Swollen tissues can obscure anatomical landmarks, making visualization of the vocal cords difficult. Moreover, the edema can render the airway more prone to bleeding [13]. These factors necessitate meticulous planning and the use of advanced airway management techniques. Fiberoptic bronchoscopy is frequently employed to guide intubation in these patients, allowing for enhanced visualization of the airway and more accurate placement of the endotracheal tube [1].
Other strategies can also enhance the success rate and safety of intubation in patients with angioedema. Pre-oxygenation—administering 100% oxygen for a few minutes before intubation—helps to maximize the patient’s oxygen reserves and mitigate the risk of hypoxia during intubation attempts [5]. Rapid sequence intubation (RSI) using sedatives and paralytics can be performed to facilitate the process while minimizing airway trauma [11]. A skilled team including an anesthesiologist and a respiratory therapist is invaluable in managing these complex cases.
Despite the inherent challenges, successful intubation significantly improves the prognosis for patients with angioedema [13]. Securing the airway stabilizes the patient’s condition, allowing time to treat the underlying cause [10]. This may involve the administration of corticosteroids, antihistamines, and epinephrine for allergic reactions or the use of specific treatments for hereditary angioedema, such as C1 inhibitor concentrates, bradykinin receptor antagonists, or fresh frozen plasma in resource-limited settings [9].
Transitioning from the intubation phase to ongoing management necessitates continuous monitoring and supportive care. Patients with severe angioedema often require admission to an intensive care unit (ICU) for close observation and management of potential complications [9]. The duration of intubation varies depending on the patient’s response to treatment and the resolution of airway swelling [10]. Extubation should be considered only when there is definitive evidence, such as with a cuff leak test, that the airway edema has resolved and the patient can maintain adequate oxygenation and ventilation without assistance [12].
Long-term management of patients with angioedema involves identifying and addressing triggers to prevent recurrence; for individuals with medication-induced angioedema, discontinuation and substitution of the offending drug are necessary [4]. In cases of hereditary angioedema, prophylactic therapy and patient education on recognizing early symptoms and seeking prompt medical attention are crucial components of care [6].
References
1. Alvarado AC, Panakos P. Endotracheal Tube Intubation Techniques. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560730/
2. Arthur, J., Caro, D., Topp, S., Chadwick, S., Driver, B., Henson, M., Norse, A., Spencer, H., Godwin, S. A., & Guirgis, F. (2023). Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema. The American journal of emergency medicine, 63, 44–49. https://doi.org/10.1016/j.ajem.2022.10.017
3. Bernstein, J. A., & Moellman, J. (2012). Emerging concepts in the diagnosis and treatment of patients with undifferentiated angioedema. International journal of emergency medicine, 5(1), 39. https://doi.org/10.1186/1865-1380-5-39
4. Bernstein, J.A., Cremonesi, P., Hoffmann, T.K. et al. Angioedema in the emergency department: a practical guide to differential diagnosis and management. Int J Emerg Med 10, 15 (2017). https://doi.org/10.1186/s12245-017-0141-z
5. Cabrini, L., Pallanch, O., Pieri, M., & Zangrillo, A. (2019). Preoxygenation for tracheal intubation in critically ill patients: one technique does not fit all. Journal of thoracic disease, 11(Suppl 9), S1299–S1303. https://doi.org/10.21037/jtd.2019.04.67
6. Craig, T., Aygören-Pürsün, E., Bork, K., Bowen, T., Boysen, H., Farkas, H., Grumach, A., Katelaris, C. H., Lockey, R., Longhurst, H., Lumry, W., Magerl, M., Martinez-Saguer, I., Ritchie, B., Nast, A., Pawankar, R., Zuraw, B., & Maurer, M. (2012). WAO Guideline for the Management of Hereditary Angioedema. The World Allergy Organization journal, 5(12), 182–199. https://doi.org/10.1097/WOX.0b013e318279affa
7. Holguín-Gómez, L., Vásquez-Ochoa, L. A., & Cardona, R. (2016). Angioedema [Angioedema]. Revista alergia Mexico (Tecamachalco, Puebla, Mexico : 1993), 63(4), 373–384. https://doi.org/10.29262/ram.v63i4.220
8. Lima, H., Zheng, J., Wong, D., Waserman, S., & Sussman, G. L. (2023). Pathophysiology of bradykinin and histamine mediated angioedema. Frontiers in allergy, 4, 1263432. https://doi.org/10.3389/falgy.2023.1263432
9. Long, B. J., Koyfman, A., & Gottlieb, M. (2019). Evaluation and Management of Angioedema in the Emergency Department. The western journal of emergency medicine, 20(4), 587–600. https://doi.org/10.5811/westjem.2019.5.42650
10. Misra, L., Khurmi, N., & Trentman, T. L. (2016). Angioedema: Classification, management and emerging therapies for the perioperative physician. Indian journal of anaesthesia, 60(8), 534–541. https://doi.org/10.4103/0019-5049.187776
11. Pieter F. Fouche, Christopher Stein, Paul Simpson, Jestin N. Carlson, Suhail A. Doi, Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis, Annals of Emergency Medicine, Volume 70, Issue 4, 2017, Pages 449-459.e20, ISSN 0196-0644, https://doi.org/10.1016/j.annemergmed.2017.03.026. (https://www.sciencedirect.com/science/article/pii/S0196064417303220)
12. Wittekamp, B. H., van Mook, W. N., Tjan, D. H., Zwaveling, J. H., & Bergmans, D. C. (2009). Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Critical care (London, England), 13(6), 233. https://doi.org/10.1186/cc8142
13. Wood, A., Choromanski, D., & Orlewicz, M. (2013). Intubation of patients with angioedema: A retrospective study of different methods over three year period. International journal of critical illness and injury science, 3(2), 108–112. https://doi.org/10.4103/2229-5151.114267
