#EMconf #FlyEaglesFly: FFP for ACE-I induced angioedema

Clinical Question: Does fresh frozen plasma (FFP) reduce intubation risk or time to recovery in patients with ace-inhibitor (ACE-I) angioedema with airway threat?

The Bottom Line: There is little evidence supporting the use of FFP for ACE-I angioedema. Its use, however, seems low risk and in at least one retrospective study was associated with decreased intensive care unit length of stay.  A randomized, double blind, placebo controlled trial is needed.


Study 1: Saeb 2016 -

  • Retrospective cohort study of 128 patients with ACE-I angioedema admitted to the ICU at a single center in Detroit during 2007-2012
  • 20/128 patients received FFP - 35% of those receiving FFP were intubated (versus 60%, p=0.05)
  • ICU LOS was 1.5 days for those receiving FFP (versus 3.5 days, p<0.001)


  • As with any retrospective, unblinded, non-randomized study, these results are susceptible to bias. For example: patients with severe angioedema may have been intubated immediately, while those with less severe angioedema may have been deemed more appropriate for FFP therapy. Thus, severity of disease may have explained the difference in intubation rates rather than FFP therapy.

Study 2: Riha 2017

  • Systemic review including 9 articles describing 16 cases of angioedema treated with FFP in addition to other therapies
  • In 13/16 cases swelling was halted or improved within 4 hours of FFP administration


  • Similar to the first study, a systematic review of case reports or case series is often plagued with bias. Publication bias is often the culprit here:  cases where FFP is effective are more likely to be submitted for publication than cases where FFP failed to demonstrate improvement



1. Saeb A et al. Using fresh frozen plasma for acute airway angioedema to prevent intubation in the emergency department: A retrospective cohort study. Emergency Medicine International 2016; http://dx.doi.org/10.1155/2016/6091510.

2. Riha MH et al. Novel therapies for angiotensin-converting enzyme inhibitor-induced angioedema: A systematic review of current evidence. Journal of Emergency Medicine 2017; 54 (5): 662-679.