Is racemic epinephrine (adrenaline) used in the treatment of epiglottitis?

Racemic Epinephrine is NOT Used for Epiglottitis

Racemic epinephrine is ineffective for epiglottitis and should not be used. The primary pathology in epiglottitis is infectious/inflammatory edema of supraglottic structures (epiglottis and aryepiglottic folds), not the subglottic edema that responds to nebulized epinephrine 1.

Why Racemic Epinephrine Doesn't Work

• Historical evidence demonstrates failure: A 5-year study of 28 pediatric epiglottitis cases attempted treatment with IPPB and nebulized racemic epinephrine, expecting relief similar to that seen in laryngotracheobronchitis (croup), but "this did not materialize" - the obstruction from edematous aryepiglottic folds and hypopharyngeal structures was not relieved 1.

• Wrong anatomical target: Racemic epinephrine works for croup (laryngotracheobronchitis) where subglottic edema is the problem 2. In epiglottitis, the obstruction is supraglottic - involving the epiglottis and surrounding structures 3, 4.

Correct Management of Epiglottitis

Immediate Priorities

Airway management is the only life-saving intervention - this is a medical emergency where sudden complete airway obstruction can occur 3, 4.

• Maintain high index of suspicion: The supposedly typical sign of stridor occurs in only 42% of adult cases 3.
• Avoid oral examination if epiglottitis suspected: 44% of patients have normal oropharyngeal findings; diagnosis requires visualization via fiberoptic laryngoscopy 3.
• Prepare for emergency airway intervention: Have tracheostomy equipment immediately available - one patient died when intubation was attempted without a tracheostomy set at bedside 3.

Definitive Treatment

Medical management consists of:

• Antibiotics (primary treatment for the infection) 3, 4
• NSAIDs for symptom control 3
• Corticosteroids (methylprednisolone 20-40 mg IV every 4-6 hours) for inflammatory airway edema 5
• Possible nebulized epinephrine (1 mg) only if upper respiratory obstruction or stridor develops, though this provides only transient relief (30 minutes onset, 2 hours duration) and requires continued monitoring 5

Airway Intervention Rates

• Current airway intervention rate is approximately 10% (decreased from 20% in 1980s) 6
• Tracheal intubation has a 4.2% failure rate (1 in 25) 6
• 15 patients (14 immediate, 1 delayed) required intubation in one series of 43 adults 4

Critical Pitfall

Do not confuse epiglottitis with croup (laryngotracheobronchitis) - they are completely different diseases requiring different management 2, 1:

• Croup: Subglottic viral infection, responds to racemic epinephrine 0.5 mL/kg of 1:1000 solution (max 5 mL) by nebulizer 2
• Epiglottitis: Supraglottic bacterial infection, requires antibiotics and airway protection, does NOT respond to racemic epinephrine 3, 1