A reply

Abstract

We would like to thank Dr Bhatia et al. for their interest in our case reports. We thank them for their insight based on their experience of a solitary case and would like to point out that our reports clearly show that two of our patients received nebulised epinephrine with no demonstrable effect. There is no paucity of literature pertaining to the use of nebulised and inhaled epinephrine in this group of patients [1, 2]. We note that their patient had a Mallampati score of 4, which is impressive when one takes into account the fact that the swollen tongue in all our cases made it impossible to do a Mallampati score. Our experience with this form of treatment was not as fortunate. In the past, we have had a fatality in just such a case, which could have been avoided by securing the airway early. Life-threatening complications and fatalities have been reported from a failure to recognise the potential for rapid progression to fatal airway obstruction [3]. We would also like to re-emphasise that the course of ACE inhibitor-related angioedema is unpredictable and immediate management depends on the severity of the episode. Epinephrine, antihistamines, and regular corticosteroids have all been used with variable effects, hence they are recommended although their efficacy is yet unproven, and so far, no controlled studies have demonstrated their efficacy. As our patients did not respond to medical management, we felt it was unwise to persist. Medical therapy of progressive angioedema should be aggressive. Failing a rapid response, mechanical methods to secure an airway should be undertaken before massive oedema complicates intubation or a surgical airway. We highlight the need for early intubation/surgical airway and caution against relying on medications to reverse the pathology.