Near-Fatal Angioedema Compromising the Airway in a Patient Following Angiotensin Converting Enzyme Inhibitor Formulary Substitution

We present an unusual case of life-threatening angioedema (AE) with airway compromise that occurred after a formulary substitution of one angiotensin converting enzyme inhibitor (ACEI) for another. AE is a known side effect of ACEI therapy. We report a rare case in which a patient who had tolerated years of therapy with enalapril, developed life-threatening AE shortly after being switched to another ACEI: ramipril. AE is of particular importance in airway management as it may present at any point in the emergency ward or hospital stay and it may rapidly become life-threatening if it involves airway compromise. Patient was an 81-year-old female with a past history including peripheral vascular disease, hypertension, and congestive heart failure. Patient was in the status of post femoral artery endarterectomy which subsequently became infected and required an incision and drainage, and subsequent flap closure. The patient was extubated post-operatively. The two main etiologies of AE are mast cell-mediated or kinin-related, although there are less frequent types as well. About 0.1-2.2% of patients treated with ACEI develop recurrent AE, often facial or lip swelling or edema of the tongue and/or larynx. The degree of swelling can be severe: cases of death by asphyxiation following closure of the upper airways have been reported. The interval between starting the ACEI and the appearance of the first AE can be months or even several years, so that making the linkage between the AE and the triggering ACEIs is sometimes unrecognized or recognized late. Because of the very common use of ACEIs, cases of AE are not rare. AE is a medical emergency and requires close monitoring as is routinely provided in an intensive care unit. It is important for practitioners to recognize that AE patients likely have altered airway anatomy and will be difficult intubations. It is crucial to then choose to not sedate or induce unconsciousness prior to securing the airway in these patients. Anticipating difficulty in one’s ability to readily secure an airway requires the presence of experienced airway professionals and the ready availability of specialized equipment. J Med Cases. 2015;6(1):24-26 doi: https://doi.org/10.14740/jmc2019w

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