What signs predict the need for airway interventions in patients with angiodema?

Bottom line: Studies found that patients with laryngeal or hypopharyngeal edema, rapidly worsening swelling of the floor of the mouth, and drooling were more likely to require intubation compared with patients with facial, tongue, or anterior lip swelling.

Summary of evidence:

Grant, Nazaneen N, Ziad EDeeb, and Stanley HChia. “Clinical experience with angiotensin-converting enzyme inhibitor-induced angioedema.” Otolaryngology – head and neck surgery 137.6 (2007):931-935.
In this retrospective chart review of 228 patients, “the location of airway swelling was divided into three categories…Type 1 showed lip or anterior tongue swelling; type 2 included floor of mouth, palatal, or oropharyngeal edema; and type 3 displayed laryngeal or hypopharyngeal edema. Patients with type 1 angioedema were discharged (71.3%) from the emergency room more frequently than those with type 3 angioedema (2.3%, P < 0.0001). Patients with type 3 were more likely to be intubated (34.1%) compared with type 1 (0%, P < 0.0001)….a patient with rapidly worsening floor of mouth swelling was likely to be intubated….A greater proportion of patients who presented with drooling required intubation (42.1%) than those without drooling (4.2%) using the Fisher exact test (P < 0.001).”

Ishoo, E, et al. “Predicting airway risk in angioedema: staging system based on presentation.” Otolaryngology – head and neck surgery 121.3 (1999):263-268.
“Angiotensin-converting enzyme inhibitor use in 36 cases (39%) was associated with intensive care unit (ICU) admission (P = 0.05). ICU stay correlated significantly with presentation with voice change, hoarseness, dyspnea, and rash (P < 0.05). On the basis of our data, we propose a staging system by which airway risk may be predicted from the anatomic site of presentation. Patients with facial rash, facial edema, lip edema (stage I), and soft palate edema (stage II) were treated as outpatients and on the hospital ward. Patients with lingual edema (stage III) usually required ICU admission. All patients with laryngeal edema (stage IV) were admitted to the ICU. Airway intervention was necessary in 7% of stage III patients and in 24% of stage IV cases.” The criteria have not been validated.

Brook, Christopher, et al. “Angioedema of the upper aerodigestive tract: risk factors associated with airway intervention and management algorithm.” International forum of allergy & rhinology 4.3 (2014):239-245.
In a retrospective study of 177 patients, patients with angiodema in the pharynx were signification more likely to be intubated than those with angioedema in the lip and face. “Patients who required intubation after progression between serial evaluations were statistically more likely to have edema that involved deeper portions of the aerodigestive tract.”

Zirkle, M, and NBhattacharyya. “Predictors of airway intervention in angioedema of the head and neck.” Otolaryngology – head and neck surgery 123.3 (2000):240-245.
Review of 138 charts of patients with angioedema as an admitting diagnosis found that involvement of the oral cavity/oropharynx predicted the need for airway intervention.

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About Lisa

I have been a Clinical Informationist (aka Medical Librarian) for Emory University since September 2013. Prior to that, I was a Medical Librarian for Lincoln Memorial University (LMU) from March 2007 to August 2013 and served its DeBusk College of Osteopathic Medicine, Caylor School of Nursing, and allied health programs. From January 2002 - March 2007, I served the Medical Assisting (MA), Occupational Therapy Assistant, Physical Therapy Assistant, Radiologic Technologist, and Nursing programs at South College in Knoxville, Tennessee. I graduated from The University of Tennessee School of Information Sciences with a Master of Science degree in December 2000.
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