Silent Swelling: A Case of Angiotensin Converting Enzyme Inhibitor Induced Upper Airway Angioedema

Background: ACE inhibitor (ACEi) – induced angioedema is rare but potentially life-threatening and may occur after years of uneventful use.

Case:A 66 year old woman on chronic lisinopril developed acute inspiratory stridor and respiratory distress 15 minutes post extubation after an uneventful outpatient D&C under general anesthesia. Initial albuterol was ineffective. Fiberoptic laryngoscopy showed isolated epiglottic and vallecular edema with normal cords/arytenoids. She received nebulized racemic epinephrine ×3, dexamethasone, tranexamic acid (1 g), and was observed for 23 h. Repeat airway exam showed resolution and she was discharged next day. Lisinopril was discontinued with counseling on ACEi-induced angioedema.

Conclusion:Consider ACEi-induced angioedema in postoperative respiratory decompensation. Early bedside fiberoptic evaluation and stopping the ACEi are key to prevent airway compromise.