ACE Inhibitor Induced Angioedema

[E tank]

@E tank, do you guys use NTI in the hospital at all?

Very frequently, yes. Most routinely for dental procedures under general anesthesia but for a lot of oral/jaw procedures. On occasion for carotid endarterectomies where the surgeon needs the mouth completely closed for exposure. That isn't very often.

But the difference for us is most often a paralyzed patient where we do a DL and advance the tube with Magill's forceps into the glottis. Very different than a breathing patient where the tube is advanced into the airway blindly.

 

[EpiEMS]

But the difference for us is most often a paralyzed patient where we do a DL and advance the tube with Magill's forceps into the glottis. Very different than a breathing patient where the tube is advanced into the airway blindly.

This certainly makes a difference. Though I believe blind success rates are not awful?

 

[E tank]

This certainly makes a difference. Though I believe blind success rates are not awful?

eh...a 25% failure rate isn't so great. But so much depends on the circumstances. Attempting nasal intubation in the field means something very unusual and difficult is going on. All the more reason not to make it worse. Like anything, experience usually carries the day.

 

[Carlos Danger]

The thing about angioedema is this: only a small percent of cases proceed to life-threatening airway obstruction, and the airways are friable and can be worsened by manipulation. But the ones that DO progress can be exceedingly difficult or impossible intubations.

So......assuming they have a fair amount of edema but are breathing fine.......do you mess with their airway and take the risk of making it worse, on the small chance that they will eventually need intubation, or do you simply transport, with the understanding that this would likely be a very difficult airway that you will only make worse, and probably won’t progress to requireing intubation anyway?

My opinion is if they are breathing fine, transport emergent with supplemental oxygen, because chances are that is all the airway care they will need. If they start to crash, go straight to a cric.

Edit: The thing about nasally intubating these patients is that 1) if they are not yet in extremis, you may well make things much worse because the tissues can be quite friable, since they are so swollen, and 2) if they are in extremis, chances of success are low because the glottis is at least partially obstructed by swollen tissue - hence the extremis. Cricothyrotomy time.

 

[Tigger]

I think most medics would say the same, no? NTI has kinda fallen by the wayside in EMS, I had thought.

It was removed from the scope for city medics but kept in the county because outrage. Can't remember the last time it was done though. And now with Ketamine/Roc RSI as an option its use is even less likely as the contraindications for succs no longer need to come into play.