P043: ACE-I RELATED ANGIOEDEMA LEADING TO EMERGENT TRACHEOSTOMY: A CASE REPORT
Douglas K Rausch, DO; Alden B Daniels, MD; Jacob S Topfer, DO; Gisele Wakim, MD; University of Miami/Jackson Health System Anesthesiology Residency Program
Introduction: Angiotensin Converting Enzyme Inhibitors (ACEIs) are prescribed ubiquitously for the treatment of a variety of cardiovascular and renal diseases. However, their use has also been associated with the risk of life-threatening angioedema caused by a reduction in bradykinin degradation. The presentation of ACE-I related angioedema varies widely, with the most severe presentation resulting in difficulty breathing and obstruction of the airway requiring emergent intubation or tracheostomy. Several retrospective reviews have demonstrated that surgical airway intervention is needed in just 0.3%-1.2% of cases 1-2. We will discuss a case of ACE-I related angioedema that required emergent tracheostomy.
Case Presentation: A 51-year-old, Nicaraguan male with past medical history of hypertension and chronic hearing loss presented to the hospital for elective resection of an acoustic neuroma. He underwent retro-sigmoid craniotomy and was admitted to the neurological intensive care unit post-operatively. On post-operative day (POD) 1, the patient resumed taking his home medication; lisinopril 10 mg daily. Approximately six hours later, he developed rapid onset swelling of his neck and tongue with difficulty breathing.
On examination, the otolaryngologist noted firm edema of the tongue, inability to visualize the soft palate, and stridor with respirations. The neck also had firm edema extending to the submental region. Nasal flexible fiberoptic examination demonstrated copious secretions that the patient was unable to clear with swallowing or coughing. Deep oral suctioning was performed, then the scope was inserted again and demonstrated an edematous epiglottis, obstructing the view of the glottis. After some difficulty, the camera was passed inferior to epiglottis and the endo-larynx was viewed, revealing diffuse edema of the false vocal folds and arytenoid cartilages, without adequate view of the glottis prompting paging of the airway team.
Upon evaluation by anesthesia, the patient began to desaturate to the 80s and bag-mask-ventilation was performed. The decision was made to proceed to the operating room (OR) for attempted intubation with surgical team present for possible tracheostomy. In the OR, the decision was made for awake tracheostomy to be performed, as an intubation trial was deemed too high-risk. The airway was secured via open tracheostomy and the patient’s vital signs stabilized after placement of a tracheostomy tube.
Discussion: ACE-I induced angioedema is a potentially life-threatening emergency. Immediate recognition and management are instrumental for optimal patient outcomes. Medical management with epinephrine, antihistamines, and steroids are uncertain. If patients are stable for transfer, airway interventions are best performed in controlled environments such as the OR. Our patient was successfully decannulated on POD 9 and subsequently discharged home after one week of inpatient rehabilitation.
1. Chiu AG, Newkirk KA, Davidson BJ, Burningham AR, Krowiak EJ, Deeb ZE. Angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter review and an algorithm for airway management. Ann Otol Rhinol Laryngol. 2001 Sep;110(9):834-40. doi: 10.1177/000348940111000906. PMID: 11558759.
2. Patel S, Mathew R, Bhoi S. Caution in diagnosing angioedema as anaphylaxis. BMJ Case Rep. 2019;12(9):e230329. Published 2019 Sep 4. doi:10.1136/bcr-2019-230329