Angiotensin-converting Enzyme Inhibitor–mediated Angioedema
Bibliographic record
Abstract
Angiotensin-converting enzyme inhibitor–mediated angioedema is the most common cause of angioedema and accounts for one-third of emergency department visits for angioedema. Nonpitting edema of the face, lips, tongue, and supraglottic/glottic structures may be present, with 9.5 to 15% of patients requiring emergency airway management.1,2 When respiratory difficulties are present, mortality rate is 11%.3 Angiotensin-converting enzyme inhibitor–mediated angioedema can be unprovoked or triggered by trauma, including dental and head and neck procedures, by endotracheal intubation,3 or after a mildly traumatic laryngeal mask airway insertion for a short procedure (presenting in our case as slurred speech and tongue swelling [panel A] 5 h after laryngeal mask airway removal). Local accumulation of bradykinin attributable in part to inhibition of degradation by angiotensin-converting enzyme (panel B) leads to tissue swelling. Unlike allergy-histamine-mediated angioedema, angiotensin-converting enzyme inhibitor–mediated angioedema is not associated with pruritis, rash, hypotension, and bronchospasm. As such, antihistamines, steroids, and epinephrine are unlikely to be effective. Plasma transfusion, C1-inhibitor replacement protein, antifibrinolytics, and icatibant, a selective bradykinin β2-receptor antagonist, have shown promising efficacy. Angiotensin-converting enzyme inhibitor–mediated angioedema risk factors include ethnicity (people of African descent and Hispanics have a higher incidence than Caucasians), women, smoking, elderly, history of drug rash, seasonal allergies, and use of immunosuppressants. Recurrence rates are high with increasing severity, thus angiotensin-converting enzyme inhibitor use must be discontinued. Attacks are self-limiting, lasting 48 to 72 h.When respiratory distress is present/imminent, orotracheal intubation may be difficult because of tongue swelling (panel A). Preparation for front-of-neck airway, including marking of the cricothyroid membrane (panel C) and calling for otolaryngologic support, should be made while an emergency nasotracheal intubation is carried out. In our case, the epiglottis and larynx were not swollen.The authors acknowledge Emily Cook, M.D., and Joanna Dion, M.D., F.R.C.P.C., Department of Anesthesiology and Perioperative Medicine, and Jason A. Beyea, M.D., Ph.D., F.R.C.S.C., Division of Otolaryngology-Head and Neck Surgery, Queen’s University, Kingston, Ontario, Canada, for their assistance with the figure and patient care.The authors declare no competing interests.
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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 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.016 | 0.004 |
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".