Code 3 Workshop

Paramedic Education
Home/All lessons/Airway & Breathing/Angioedema and the Airway
Lesson

Angioedema and the Airway

12 min Airway & Breathing Skip to quiz

Objective: Treat swelling of the lip, tongue, or floor of the mouth as a closing airway. Give oxygen. Do not take repeated failed looks. Go to an emergency department that can do a surgical airway.

Why this matters

The patient can still talk, so the crew stays and watches. Swelling of the lip, tongue, or floor of the mouth can close the airway while you wait.

Angioedema from an angiotensin-converting enzyme (ACE) inhibitor, such as lisinopril, can keep swelling after the last dose. Allergic swelling may need epinephrine. ACE-inhibitor swelling and hereditary swelling often do not shrink with epinephrine.

This is a predicted difficult airway. The common miss is three looks while the mouth swells shut.

Key points
  • Sit the patient up. Give high-flow oxygen. Have suction ready. Do not lay a swelling tongue flat unless the patient loses a pulse.
  • Give intramuscular epinephrine for anaphylaxis: hives, wheeze, or shock. Tongue swelling from an ACE inhibitor alone may not respond to epinephrine. If the anaphylaxis picture is there, still treat it.
  • Go to an emergency department that can do a surgical airway. Do not wait at the door to see if the swelling stops.

Clinical sequence

  1. As you walk in, check the airway, breathing, and circulation. Listen to the voice. Look for drool, floor-of-mouth swelling, and stridor. Check the oxygen saturation (sat).
  2. Sit the patient up and put oxygen on. Start an intravenous line or intraosseous access only if it does not delay the exit. Put the patient on the monitor.
  3. If you see hives, wheeze, or shock, give intramuscular epinephrine per protocol. Do not withhold it because you are not sure about an ACE inhibitor. See the anaphylaxis lesson.
  4. Do not take a look just to see the swelling. If the patient is still oxygenating, move. If not, use a supraglottic airway or trained front-of-neck access per protocol. Do not take a fourth direct-laryngoscopy look.
  5. Go to an emergency department with difficult-airway and surgical backup. Call ahead early.

Teaching points

  • Allergic swelling often responds to epinephrine. ACE-inhibitor swelling often has no hives. Hereditary C1-inhibitor swelling can run in families and can also cause abdominal pain. You may not be able to tell these apart on scene.
  • Voice change, drooling, a firm floor of the mouth, and stridor mean the airway is closing now. A photo of the tongue does not treat the swelling.
  • Swelling hides landmarks. Repeated looks make the swelling worse. A supraglottic airway may buy time. Front-of-neck access is the rescue if you reach cannot-intubate-cannot-oxygenate.
  • Epinephrine does not reliably reverse ACE-inhibitor angioedema. Do not stay on scene waiting for the tongue to shrink.
  • Continuous positive airway pressure is not the first move for a swelling tongue. The problem is the upper airway, not fluid in the lungs.
Verbalize
  • This is a swelling airway. I am sitting the patient up and putting oxygen on.
  • I see hives, wheeze, or shock. I am giving intramuscular epinephrine per protocol, even if an ACE inhibitor is on the medication list.
  • This tongue swelling looks like ACE-inhibitor angioedema alone. I am not waiting for it to shrink. I am going to an emergency department that can do a surgical airway.
  • I am not taking repeated looks while the mouth swells shut.

Common errors

  • Waiting in the driveway because the patient can still speak in full sentences.
  • Taking three direct-laryngoscopy attempts “before it gets worse.”
  • Skipping intramuscular epinephrine because the bottle says lisinopril and you assume this cannot be anaphylaxis.

Practice

One-minute check

Partner: a 62-year-old on lisinopril has a tongue filling the mouth, a sat of 94% while sitting, and no hives. Say the first three actions and where you are going. Then the same patient has stridor and a sat of 86%. Say the airway plan in one sentence.

Related: Anaphylaxis Recognition, Front-of-Neck Access.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. A patient on an ACE inhibitor with a rapidly swelling tongue and no hives:
2. IM epinephrine is most clearly indicated when:
3. The worst plan for a disappearing oropharynx is:
4. Voice change plus floor-of-mouth swelling means:
← Airway Attempt Limits Ramping the Obese Airway →