Nebulised Adrenaline Dosing
For laryngotracheobronchitis (croup) and acute airway edema in children, administer 0.5 mL/kg of 1:1000 L-epinephrine solution (maximum 5 mL = 5 mg) via nebulizer. 1
Pediatric Dosing (Primary Indication: Croup/Airway Edema)
The American Academy of Pediatrics guidelines provide clear dosing for nebulised epinephrine:
- L-epinephrine (1:1000 solution): 0.5 mL/kg up to maximum 5 mL 1
- Racemic epinephrine (2.25% solution): 0.05 mL/kg (maximum 0.5 mL) diluted in 2 mL normal saline 1
Many institutions use a standard 0.5 mL dose of racemic epinephrine for all pediatric patients regardless of weight. If racemic epinephrine is unavailable, L-epinephrine (1:1000) can be substituted at the higher dose of 0.5 mL/kg up to 5 mL 1.
Adult Dosing (Upper Airway Obstruction)
For adults with upper airway obstruction, administer 1 mg of adrenaline (1:1000) in 5 mL normal saline via nebulizer, repeated as necessary 2. This approach has been shown safe and effective with few cardiovascular sequelae in selected cases.
Safety Considerations
Research evidence demonstrates that nebulisation with 3-5 mL of adrenaline (1:1000) is safe in children, with only minor side effects 3. A systematic review of 238 pediatric patients showed:
- Mean heart rate increases of 7-21 beats per minute (clinically insignificant)
- Transient pallor in some patients
- No significant blood pressure changes with doses up to 5 mL
Critical caveat: A dose-response study found no additional clinical benefit from higher doses (5 mL vs 0.5 mL) for post-extubation stridor, but did show modest increases in blood pressure at the 5 mL dose 4. This suggests starting with lower doses (0.5 mL/kg) and repeating if needed rather than immediately using maximum doses.
Key Pitfalls to Avoid
- Concentration confusion: Ensure you're using 1:1000 (1 mg/mL) solution for nebulisation, NOT 1:10,000 solution which is for IV/IO use
- Route confusion: Nebulised dosing is completely different from IM dosing for anaphylaxis (0.01 mg/kg of 1:1000, max 0.3-0.5 mg) 1
- Indication specificity: These nebulised doses are for croup/airway edema, not for anaphylaxis or asthma (where IM or SC routes are preferred)
Administration Technique
Administer via standard nebulizer with oxygen flow at appropriate rate. The treatment can be repeated as necessary based on clinical response, though specific repeat intervals are not rigidly defined in guidelines for airway obstruction (unlike the 20-minute intervals specified for SC administration in severe asthma) 1.