Airway obstruction due to late-onset angioneurotic edema from angiotensin-converting enzyme inhibition

Purpose: Angioneurotic edema is a well-documented complication of angiotens in-converting enzyme inhibitors (ACEI), We report a case of acute airway ob struction from a late-onset, probable ACEI-related angioneurotic edema and its subsequent management. Clinical features: A 48-yr-old obese man presented for transurethral resect ion of a bladder tumour (TURBT), His past medical history included hyperten sion controlled with hydrochlorothiazide and quinapril which had been start ed 13 mo earlier, Previous surgery was uncomplicated, Midazolam was used fo r premedication and for intraoperative sedation together with fentanyl and propofol, After uneventful spinal anesthesia with bupivacaine, operation an d recovery, he was transferred to the floor. Five hours later he developed severe edema of his face, tongue and neck, with drooling, that progressed i nto airway obstruction and respiratory arrest, Ventilation was restored via immediate cricothyroidotomy, and a subsequent tracheotomy was completed un eventfully in the operating room, His serum CI esterase inhibitor levels at 1, 5 and 23 days later were normal, The angioneurotic edema was attributed to the ACEI treatment, The edema resolved after 48 hr, and further follow- up was unremarkable. Conclusion: This observation is consistent with other reports that angioneu rotic edema from ACEI can occur many months after the initiation of treatme nt, This can involve the airway and may produce life-threatening respirator y compromise, Physicians should be aware of this association and the possib le need for immediate surgical intervention for the establishment of an air way in case of worsening edema or respiratory arrest.