From the Guidelines
In cases of acute airway obstruction, administer racemic epinephrine first, followed by budesonide, as this sequence provides immediate relief and addresses underlying inflammation, ultimately reducing morbidity and mortality. Racemic epinephrine provides immediate relief through rapid vasoconstriction and bronchodilation, typically given as 0.5 mL of 2.25% solution in 3 mL saline via nebulizer 1. This quickly reduces mucosal edema and improves airflow within minutes. After this initial treatment, administer budesonide (typically 0.5-1 mg via nebulizer for children or 1-2 mg for adults) to address the underlying inflammation. While epinephrine works quickly to open the airway in emergency situations, its effects are short-lived (2-4 hours) 1. Budesonide takes longer to work (hours to days) but provides sustained anti-inflammatory effects that help prevent rebound symptoms.
Some key points to consider in the management of acute airway obstruction include:
- The importance of early administration of systemic corticosteroids, such as budesonide, to reduce the inflammatory component of the condition 1
- The need for close monitoring of the patient after epinephrine administration for potential side effects, such as tachycardia, and the readiness to repeat the epinephrine dose if symptoms recur before the corticosteroid takes effect
- The potential benefits of combining epinephrine with other treatments, such as inhaled β-agonists or antihistamines, to achieve optimal outcomes in patients with acute airway obstruction 1
Overall, the sequential administration of racemic epinephrine and budesonide is a recommended approach in the management of acute airway obstruction, as it combines immediate symptom relief with longer-term inflammation control, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Administration of Racemic Epinephrine or Budesonide in Acute Airway Obstruction
- The decision to administer racemic epinephrine or budesonide first in cases of acute airway obstruction depends on the severity of the condition and the specific circumstances of the patient 2, 3.
- In patients with moderate to severe croup, the addition of nebulized epinephrine to corticosteroid treatment has been shown to improve symptoms and reduce the length of hospitalization 3.
- However, for patients with mild croup, a single dose of oral dexamethasone or nebulized budesonide may be sufficient to reduce the severity of symptoms and the need for additional medical attention 2, 4.
- The use of nebulized budesonide has been shown to be as effective as nebulized adrenaline in the treatment of moderately severe croup, with no significant difference in efficacy and safety between the two treatments 5.
- In general, the treatment of acute airway obstruction should be tailored to the individual patient's needs and circumstances, taking into account the severity of the condition, the presence of any underlying medical conditions, and the patient's response to initial treatment 6.
Key Considerations
- The diagnosis of croup is mainly clinical, and diagnostic studies are usually not necessary 2, 3.
- The management of croup has altered dramatically in the past decade, with good evidence existing to support the routine use of corticosteroids in all children with croup 2.
- Nebulized epinephrine should be reserved for patients with moderate to severe croup, while corticosteroids such as dexamethasone or budesonide may be used in patients with mild to moderate croup 2, 3.
- Simultaneous administration of corticosteroid and epinephrine may reduce the rate of intubation in patients with severe croup and impending respiratory failure 2.