Angioedema in

ICU Dr Sananta Dash

• Angioedema is a medical emergency.
• Based on the mechanism, Angioedema may be classified as -

Histamine related Angioedema

Bradykinin related angioedema
• Histamine related Angioedema
 Similar to the spectrum of full-blown anaphylaxis
 Treatment is much similar to anaphylaxis

• Bradykinin related angioedoema

 Differs from the above by its mechanism and the appropriate treatment
 There are various types of Bradykinin mediated Angioedema
 Classification and abnormalities..

Disease Hereditary Hereditary Hereditary Angioedema with Acquired Angioedema

Angioedema-1 Angioedema-2 normal C1-INH
Pathology Low C1-INH Defective C1-INH Factor XII defective  Type 1: Associated Lymphoproliferative
disorders (CLL, NHL, Waldestrom’s
macroglobinemia etc)
 Type 2: Associated autoantibody against C1-
INH
C4 level Low Low Normal Low
C1-INH Low Normal Normal Low
antigen
C1-INH Low Low Normal Low
Function
C1q Normal Normal Normal Low
History & Clinical
presentation:
Histamine related
Angioedema/Allergic
Angioedema
Trigger? Allergens- Food, bites,
medications etc
Bradykinin mediated
Angioedema/Non-
allergic angioedema
Drugs- ACEi, ARBs
Minor trauma etc

Distribution Symmetric, all-over the body Localized, asymmetric

Tongue+ Larynx= 36% Tongue+ Larynx= 59%

 Prior personal history and positive family history

Onset Rapid Slow

Associated skin Rash, pruritus, flushing No pruritus. Hereditary

may point strongly towards Hereditary manifestations angioedema- Erythema
Angioedema marginatum

Other organs Hypotension May cause diarrhoea, vomiting

 Medications history i.e ACE-I inhibitor may Wheeze
Nausea, vomiting, diarrhoea
but usually non-systemic

suggest alternative diagnosis. Response to Adrenaline, Steroid Non-responsive to

drugs antihistamine, steroids,
adrenaline
 Infection (e.g. deep neck space infection)
Differential 

 Functional or factitious stridor

Diagnosis &  Foreign body
Superior vena cava syndrome
Lab values 

 Macroglossia (e.g. due to acromegaly, amyloid,

or hypothyroidism)

• Lab values sent:

 Complement level
 C1-Inhibitor (C1-INH) level
Management:-

Indication for intubation

- Stridor, dyspnoea, muffled or hoarse voice.
- Drooling and inability to handle secretions.
- Progressive deterioration of oedema to cause any of the above
- Nasolaryngoscopy shows significant laryngeal oedema or impending closure of the
posterior pharynx

Role of Nasolaryngoscopy:
- Delineate whether there is significant laryngeal edema.
- Rule out other causes of airway obstruction or edema
Pathophysiology and site of action of drugs

Tranexemic Acid

Ecallantide- Kallkrein inhibitor

• Pathophysiology and site of action of drugs

Icatibant- Bradykinin Antagonist
Mechanism of action

Tranexamic acid:

- Inhibits the conversion of plasminogen into plasmin (critical step involved in amplification of kallikrein activation)

- Effective in of bradykinin-mediated angioedema

C1-inhibitor concentrate:

- Inhibits XIIa and kallikrein (two most important enzymes involved in bradykinin generation)

Fresh Frozen Plasma:

• FFP replaces:

 Angiotensin converting enzyme (ACE) [ACEi-induced angioedema]

 C1-inhibitor [hereditary angioedema has deficient C1-inhibitor activity]

Bradykinin Antagonist (Icatibant) and Kallkrein inhibitor (Ecallantide)

- No robust evidence for use of the above

- Not widely available and very expensive (they are often even harder to obtain than C1-esterase inhibitor concentrate)

- For Subcutaneous administration which may not be useful in an acute setting

- Icatibant- Found to be ineffective in ACE inhibitor induced angioedema

- Ecallantide also was not found to be very effective and caries a 3% risk on anaphylaxis.
 Intubation
Extubation
Airway •

•
Anticipate difficult airway.
The swelling may get worse with airway
• Consideration: -
management •
manipulation.
If there is laryngeal edma, laryngeal mask
airway may become ineffective.
• Severity of swelling to start
with
• May need surgical airway in the first go as
orotracheal intubation may be impossible
• External features- visible
Procedure:
swelling, tongue swelling
• Awake fibreoptic intubation Vs Awake • Videolaryngoscopic view vs
cricothyroidectomy nasal endoscopy prior to
• Non-respiratory depressant agents for attempt for extubation
induction: Ketamine, Dexmedetomidine
• Preoxygenation • Cuff leak test
• Backup for front of neck approach • Extubation in operating
• Experienced operator theatre Vs in ICU
• Surgical expertise- (ENT) as back up
• Extubation over an
exchange catheter