Can epinephrine (adrenaline) 1:1000 (intravenous) be used as a nebulizer in a pediatric patient with stridor?

Use of Epinephrine 1:1000 as a Nebulizer for Pediatric Stridor

Yes, epinephrine 1:1000 solution can be used as a nebulizer treatment for pediatric stridor, with a recommended dosage of 0.5 mL/kg up to a maximum of 5 mL. 1

Dosing and Administration

• Nebulized epinephrine (adrenaline) 1:1000 solution is administered at a dose of 0.5 mL/kg with a maximum dose of 5 mL for treating stridor in children 1
• For children 4 years and older, the FDA recommends 1 to 3 inhalations not more often than every 3 hours, not exceeding 12 inhalations in 24 hours 2
• For children under 4 years of age, administration should be supervised by a healthcare provider 2

Clinical Efficacy

• Nebulized epinephrine produces significant improvement in croup scores at 10 and 30 minutes post-treatment compared to placebo 3, 4
• The effect is transient, typically lasting 1-2 hours, requiring close monitoring for symptom rebound 1
• Both racemic epinephrine and L-epinephrine (isomer) are effective, with no significant clinical difference between the two formulations at 30 minutes post-treatment 4

Indications and Clinical Context

• Primarily indicated for moderate to severe croup with stridor at rest 1, 5
• Used to avoid intubation and stabilize children prior to transfer to intensive care 1
• Also effective for post-extubation stridor, showing significant reduction in stridor scores comparable to budesonide 6

Important Precautions

• The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring for symptom rebound 1, 5
• Should not be used in children who are shortly to be discharged or on an outpatient basis due to the risk of rebound symptoms 1, 5
• Patients should be observed for at least 2-3 hours after the last dose of nebulized epinephrine 5, 7

Combination Therapy

• Nebulized epinephrine should be used in conjunction with systemic corticosteroids for optimal management of croup 5, 7
• Oral dexamethasone (0.6 mg/kg) is typically administered alongside nebulized epinephrine 7

Common Pitfalls to Avoid

• Using IV epinephrine 1:1000 solution for intravenous administration - this concentration should only be used for nebulization or intramuscular injection, never IV 1
• Discharging patients too early after nebulized epinephrine (before the 2-hour observation period) 5
• Failing to administer corticosteroids in conjunction with nebulized epinephrine 5
• Not monitoring for tachycardia, hypertension, or other side effects of epinephrine 6

Discharge Considerations

• Consider hospital admission if three or more doses of nebulized epinephrine are required 5
• Patients may be safely discharged after 3 hours of observation if they show sustained response to treatment with nebulized epinephrine plus oral corticosteroids 7