Airway Compromise Due to Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema

Brief review: Angiotensin converting enzyme inhibitors and angioedema: anesthetic implications

“…Angioedema, characterised by an acute onset nonpitting edema of the skin, mucosa and sc tissues, is a well-documented side effect of ACEIs, and it has been included in Food and Drug Administration-approved package inserts since the mid -1980s as a complication of ACEI therapy. However, the problem of ACEIinduced angioedema remains under-recognized [1][2][3][4][5][6] despite the fact that the association between ACEI and angioedema is well documented in the literature, and it is now considered to be one of the commonest causes of non-hereditary angioedema. 7,8 The problem of ACEI-induced angioedema is particularly relevant to anesthesiologists and emergency medicine physicians, as angioedema can cause rapid and progressive airway compromise which may be life-threatening.…”

“…Hereditary angioedema is a rare autosomal dominant disorder which is characterized by recurrent attacks of angioedema resulting from a deficiency of C1 esterase inhibitor enzyme (C1-INH). 6 The complement system consists of about 20 proteins, most of which circulate as inactive precursors. Activation of the system via one of two pathways -classical or alternative, results in opsonization, lysis, chemotaxis, histamine release and immune complex clearance.…”

“…3,6,15,83,84 It has been suggested that patients with pre-existing narrowing of the airway due to trauma, airway intervention, obesity, or head and neck surgery may be at increased risk. 4,14,69,72 In a recent study, a history of smoking and ACEI-induced cough were shown to be significant risk factors for developing angioedema.…”

“…In a more recent retrospective study, 64% cases of angioedema were thought to be related to ACEI therapy. 6 Hence, from a practical point of view, a thorough review must be conducted of all medications to exclude angioedema caused by ACEI treatment.…”

Late-onset angioedema due to an angiotensin-converting enzyme inhibitor

“…It is more likely to occur in black patients, those older than 65 years of age and in those with a history of drug-related rash or seasonal allergies (1). Although the onset typically occurs within the first weeks of ACEI therapy (3), cases with latencies ranging from several months to several years have been reported (4). In patients with such an atypical course, the diagnosis may be missed.…”