What are the indications for racemic epinephrine (adrenaline) inhalation?

From the Guidelines

Racemic epinephrine inhalation is indicated for the treatment of bronchiolitis in selected infants who show improvement in clinical condition after administration, particularly in the emergency department and hospitalized patients. The evidence from the study by Wainwright et al 1 suggests that epinephrine may have some potential for being efficacious, although the differences in clinical score, oxygen saturation, and respiratory rate were small and may not be clinically significant.

Key Points to Consider

• The Cochrane report concluded that there is insufficient evidence to support the use of epinephrine for the treatment of bronchiolitis among inpatients, but some evidence suggests that epinephrine may be favorable to salbutamol (albuterol) and placebo among outpatients 1.
• Racemic epinephrine has demonstrated slightly better clinical effect than albuterol, and it may be reasonable to administer a nebulized bronchodilator and evaluate clinical response 1.
• Individuals and institutions should assess the patient and document pretherapy and posttherapy changes using an objective means of evaluation, and continue the nebulized bronchodilator treatments only if there is documented clinical improvement 1.
• Due to the lack of studies, short duration of action, and potential adverse effects, epinephrine is usually not used in the home setting, and albuterol/salbutamol may be preferred for bronchodilator trials in the office or clinic setting 1.

Administration and Monitoring

• The typical dose and administration of racemic epinephrine for bronchiolitis are not specified in the study, but it is essential to monitor patients for rebound symptoms as the medication wears off, typically within 2-4 hours.
• Side effects may include tachycardia, hypertension, tremors, and nervousness due to systemic absorption, and patients should be closely monitored for these adverse effects 1.

From the FDA Drug Label

Warnings Asthma alert Because asthma may be life threatening, see a doctor if you: Are not better in 20 minutes Get worse Need more than 12 inhalations in 24 hours Use more than 9 inhalations in 24 hours for 3 or more days a week Have more than 2 asthma attacks in a week These may be signs that your asthma is getting worse Do not use: Unless a doctor said you have asthma

The indications for racemic epinephrine inhaled are for asthma, specifically for patients who have been diagnosed with asthma by a doctor.

From the Research

Indications for Racemic Epinephrine in Inhaled Form

• Racemic epinephrine is used in the treatment of croup, a common childhood illness characterized by barky cough, stridor, hoarseness, and respiratory distress 2.
• The indications for racemic epinephrine in inhaled form include moderate to severe croup, where it is used to reduce symptoms and hasten recovery 3.
• Racemic epinephrine can be used in conjunction with dexamethasone, a potent corticosteroid, to treat croup 3.
• The use of racemic epinephrine in inhaled form is also supported by studies that show its effectiveness in reducing croup scores and shortening hospital stays 2.
• However, the effect of racemic epinephrine is less remarkable in patients treated with dexamethasone, suggesting that dexamethasone may be a more effective treatment for croup 3.

Comparison with Other Treatments

• Racemic epinephrine has been compared to L-epinephrine, and no difference in croup score was found after 30 minutes 2.
• However, after two hours, L-epinephrine showed significant reduction compared with racemic epinephrine 2.
• Racemic epinephrine has also been compared to nebulized epinephrine administered via intermittent positive pressure breathing (IPPB), and no significant difference in croup score was found 2.

Clinical Guidelines

• The use of racemic epinephrine in inhaled form is supported by clinical guidelines, which recommend its use in patients with moderate to severe croup 4, 5.
• However, the guidelines also note that the effect of racemic epinephrine is transient, and that other treatments, such as dexamethasone, may be more effective in reducing symptoms and hastening recovery 4, 5.