Laryngeal angioedema: do we need a new treatment algorithm in the ER?

Introduction

Laryngeal angioedema (AE) could be life-threatening and is frequently due to allergic reactions. Other causes, that is bradykinin-mediated conditions, have to be taken into account. The aim of our survey is to provide information on the incidence, diagnosis and potentially new treatment options for laryngeal AE.

Methods

The data for 102 patients who were treated for swelling of the larynx at the Department of Otorhinolaryngology of Ludwig-Maximilians-University of Munich from 2004 to 2008 were evaluated in a retrospective survey.

Results

Causes of laryngeal AE were in 26 patients an allergic reaction, in 33 cases were due to radiotherapy after cancer, 32 patients took an angiotensin-converting enzyme inhibitor (ACEI), one patient had a hereditary angioedema (HAE) and in 10 patients are unknown. All patients independent from the underlying cause were treated with high-dose intravenous steroids, 69 patients with antihistamines, 33 with epinephrine (inhalation or i.m.), two patients with ACEI-induced AE were successfully treated with icatibant. Ten patients needed an intubation, 11 a tracheotomy, one patient an emergency coniotomy to preserve the airway. All 11 tracheotomy patients suffered from cancer. Nine out of 10 intubated patients took an ACEI and were extubated on the ICU after 2 to 7 days.

Conclusions

According to our experience 80% of the patients with laryngeal swelling and upper airway obstruction react well to the standard therapy with steroids, epinephrine and antihistamines, indicating that the AE is histamine induced. In contrast these drugs have almost no effect on bradykinin-induced angioedema; that is, AE induced by ACEI. There is preliminary evidence that the bradykinin B₂ receptor antagonist icatibant that is approved for treatment of HAE type I and II may also be effective in ACEI-induced edema.

Figure 1

Effect of 30 mg icatibant s.c. on a laryngeal edema due to ACEI.