Near-Fatal Angioedema Compromising the Airway in a Patient Following Angiotensin Converting Enzyme Inhibitor Formulary Substitution
Bibliographic record
Abstract
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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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.003 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.004 | 0.003 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".