From the Guidelines
Racemic epinephrine for treating stridor should be administered as needed, with a recommended dose and frequency guided by the most recent and highest quality evidence available, which suggests administration every 2-4 hours as needed, not exceeding 3-4 doses in a 24-hour period, based on studies such as 1. The standard dose is typically 0.05 mL/kg of 2.25% racemic epinephrine solution (maximum 0.5 mL) diluted in 3 mL of normal saline, delivered via nebulizer over 10-15 minutes. Key considerations for administration include:
- Observation for at least 2-3 hours after administration to monitor for potential rebound stridor
- Understanding that the therapeutic effect typically lasts only 1-2 hours
- Recognizing that racemic epinephrine provides temporary symptomatic relief but does not treat the underlying cause of stridor
- The importance of concurrent treatment of the primary condition
- Continuous cardiorespiratory monitoring in hospital settings due to potential cardiovascular side effects, as suggested by guidelines and studies like 1. It's also worth noting that while specific details on racemic epinephrine administration for stridor are not directly provided in the referenced studies 1, clinical practice and guidelines often follow the principle of using the medication as needed, with careful monitoring and adjustment based on patient response, which aligns with the approach for managing symptoms and side effects discussed in 1.
From the Research
Administration Frequency of Racemic Epinephrine for Stridor
- The recommended administration frequency for racemic epinephrine in treating stridor is not strictly defined, but studies suggest that it can be administered as needed, with monitoring for rebound airway obstruction for at least 2 hours after administration 2.
- A study published in 2015 found that inpatient interventions after ≥ 2 ED doses of RE for croup were infrequent, and most patients asymptomatic upon admission required 0-1 inpatient RE doses 3.
- Another study from 1993 recommends administering racemic epinephrine by nebulizer to quickly reverse airway obstruction in children with croup, with the patient being monitored for rebound airway obstruction for at least 2 hours after administration 2.
- A 1994 study found that the maximum benefit from RE therapy was seen at 60 minutes, and if a child had persistent resting stridor or a croup score greater than 2 at that time, hospitalization was inevitable 4.
- A 2014 study suggests that nebulized epinephrine should only be added in cases of moderate-to-severe croup, and that a single dose of orally administered dexamethasone is the mainstay of treatment 5.
- In cases of stridor associated with hypoxic-ischemic encephalopathy and whole body hypothermia, treatment with racemic epinephrine, dexamethasone, positive pressure ventilation, and/or heliox may be considered, with ENT evaluation recommended in the presence of prolonged symptoms or significant respiratory distress 6.