Evaluation of staging criteria for disposition and airway intervention in emergency department angioedema patients

Abstract

Aim Angioedema is a nonpitting edema that can lead to death secondary to airway obstruction. Previously, a staging system based on localization of the angioedema was proposed for risk stratification of likelihood of need for admission or airway intervention. This study aims to evaluate a staging system based on angioedema localization as a method of predicting need for admission or airway intervention. Methods This was a retrospective chart review of angioedema cases that presented to an academic emergency department (ED) from August 1, 2006, to January 31, 2018. Data were collected on location of swelling, treatment setting, and medical and procedural interventions. Cases were categorized by modified Ishoo criteria, defined as follows: 1, lips, face, periorbital, extremities, total body/diffuse swelling; 2, soft palate, posterior pharynx; 3, tongue; 4, larynx. Predictive probability of disposition by stage was then compared. Results A total of 320 patients were included in this study (median age, 44 years; 54.4% female). Stage 4 was more likely to require intensive care unit care without (probability 17%) and with (67%) airway intervention compared with stage 1 without (2.5%) and with (0.1%) airway intervention. Conversely, stage 1 was more likely to be treated in ED and discharged (85%) compared with stage 4 (0%). Stage 4 was also more likely to require airway intervention (67%) compared with other stages (1, 0.1%; 2, 8.6%; 3, 16%). Conclusion Higher‐stage patients were more likely to require higher levels of care and airway intervention. Thus, the staging system appears to be a valid method of predicting risk among ED angioedema patients.

Role of Submandibular Ultrasound in Airway Management of a Patient With Angioedema

“…A few different approaches for deciding whether to intubate include identifying locations of angioedema and presenting symptoms strongly associated with resulting intubation, as well as determining staging criteria [6,8,13]. However, the proposed staging criteria for angioedema have been based on visual assessment of the upper airway [13].…”

“…According to one staging criteria, our patient would be categorized as stage 2 angioedema due to edema of the soft palate, a stage where none of the patients were intubated in this study [12]. Even for more severe stages, less than a quarter of stage 3 and less than half of stage 4 patients required an airway intervention [13]. As such, it is possible that quantitative measurements, like those offered by submandibular ultrasound [10][11][12], could help elucidate clearer thresholds for intubation.…”

“…Generally, it is difficult to assess the necessity to intubate patients with angioedema, given that not all patients with angioedema have airway compromise and require intubation. A few different approaches for deciding whether to intubate include identifying locations of angioedema and presenting symptoms strongly associated with resulting intubation, as well as determining staging criteria [ 6 , 8 , 13 ]. However, the proposed staging criteria for angioedema have been based on visual assessment of the upper airway [ 13 ].…”

“…A few different approaches for deciding whether to intubate include identifying locations of angioedema and presenting symptoms strongly associated with resulting intubation, as well as determining staging criteria [ 6 , 8 , 13 ]. However, the proposed staging criteria for angioedema have been based on visual assessment of the upper airway [ 13 ]. According to one staging criteria, our patient would be categorized as stage 2 angioedema due to edema of the soft palate, a stage where none of the patients were intubated in this study [ 12 ].…”

“…Oral cavity height (cm) 5.54 3.65 (0.54) [10] Distance between lingual arteries (cm) 2.88 2.89 (0.56) [11], 3.04 (0.28) [12] Tongue thickness (cm) 4.76 3.04 (0.48) [10], 4.43 (0.63) [13], 6.39 (0.51) [11] Tongue width (cm) 5.21 4.82 (0.50) [12] Tongue cross-sectional area (cm 2 ) 19…”