Airway management in angiotensin converting enzyme inhibitor related angioedema

Abstract

To the Editor: In their review of the anaesthetic implications of angiotensin converting enzyme inhibitors (ACEI) and angioedema,1 Sarkar et al. review a limited variety of airway management techniques. Rai et al. describe five patients with ACEI related angioedema, all requiring emergency airway control.2 Four patients had a tracheostomy, and three of these were performed following awake fibreoptic intubation. Tracheal intubation in these cases may be difficult. In one series, two of 14 cases required emergency cricothyroidotomy following failed endotracheal intubation. The authors produced an airway management algorithm, which suggested fibreoptic intubation with emergency cricothyroidotomy or tracheostomy if trans-oral intubation fails.3 Our own experience of three patients with ACEI angioedema suggests that early pre-emptive cannula cricothyroidotomy is useful in this setting. We use the Ravussin cannula-over-needle technique (VBM, Sulz, Germany). Pre-emptive, precautionary cricothyroidotomy has been shown to be an effective “insurance policy” in a variety of airway pathologies.4 This allows immediate oxygenation and ventilation if the airway becomes further compromised, and provides an effective bridge to definitive management. If the patient can be oxygenated via a cannula cricothyroidotomy, then the airway can be secured by either an awake fibreoptic technique, direct laryngoscopy under general anesthesia, or by tracheostomy depending on the operator’s expertise. Once the airway has been secured, however, there is little to be gained in performing a tracheostomy, as airway edema from ACEI usually resolves within 48 hr.3