Nebulized Epinephrine Dosing
For acute airway obstruction in children (croup, bronchiolitis, post-extubation stridor), use 0.5 mL of racemic epinephrine 2.25% solution (equivalent to approximately 5 mg of L-epinephrine or 3-5 mL of 1:1000 L-epinephrine solution) nebulized every 20 minutes for up to 3 doses, then reassess. 1
Standard Dosing by Indication
Acute Severe Asthma
- Subcutaneous route is preferred over nebulization for epinephrine in severe asthma: 0.01 mg/kg of 1:1000 solution (maximum 0.3 mg per dose), repeated every 20 minutes for up to 3 doses 1
- Nebulized selective β2-agonists (albuterol) are superior to nebulized epinephrine for asthma and should be used instead 1
- There is no evidence that nebulized epinephrine provides advantages over inhaled β2-agonists in asthma 1
Croup and Acute Airway Obstruction in Children
- Standard dose: 3-5 mL of 1:1000 L-epinephrine (3-5 mg) nebulized as a single treatment 2
- Alternative: 0.5 mL of racemic epinephrine 2.25% solution nebulized 1
- Repeat dosing: Can be administered every 20 minutes if needed, though typically given only once due to prolonged onset of action 1
- Evidence demonstrates this dosing range (3-5 mL of 1:1000) is safe with only minor side effects: transient heart rate increases of 7-21 beats per minute and occasional pallor 2
Post-Extubation Stridor
- Doses ranging from 0.5 mL to 5 mL of L-epinephrine showed no significant dose-response relationship in clinical trials 3
- Recommended approach: Start with 0.5-2.5 mL to minimize cardiovascular side effects (higher doses cause significant blood pressure elevation without additional clinical benefit) 3
Over-the-Counter Inhalation Products (FDA-Approved)
- Adult and children ≥4 years: 0.5 mL (contents of one vial) of 1% epinephrine solution added to hand-held rubber bulb nebulizer, administered as 1-3 inhalations every 3 hours (maximum 12 inhalations per 24 hours) 4
- Children <4 years: Consult physician before use 4
Administration Technique
- Dilution: Add epinephrine dose to nebulizer with minimum 2-3 mL normal saline for adequate nebulization 1
- Oxygen source: Use oxygen as the driving gas for nebulization when possible; supplement with additional oxygen if using compressed air to maintain adequate saturation 1
- Duration: Typical nebulization time is 15-20 minutes until solution is completely aerosolized 1
Safety Profile and Monitoring
Expected Side Effects
- Transient tachycardia (increase of 7-21 bpm lasting up to 60 minutes) 2
- Pallor in up to 48% of patients (self-limited, resolving within 30 minutes) 2
- Mild systolic blood pressure elevation (5-10 mmHg) with doses ≥5 mL 3, 5
- Temporary sore throat 5
Monitoring Requirements
- Heart rate and blood pressure before treatment and at 20,40, and 60 minutes post-nebulization 3
- Oxygen saturation continuously during treatment 6
- Clinical stridor score or respiratory distress assessment 3
Critical Pitfalls to Avoid
Do not confuse routes and concentrations:
- Nebulized epinephrine uses 1:1000 concentration (1 mg/mL)
- IV/subcutaneous epinephrine for anaphylaxis uses different dosing (0.01 mg/kg IM of 1:1000, maximum 0.5 mg) 7
- Never use 1:10,000 concentration for nebulization 7
Do not use nebulized epinephrine as first-line for asthma: Selective β2-agonists (albuterol) are more effective and have fewer systemic side effects 1
Do not exceed recommended doses in children: Doses >5 mL provide no additional clinical benefit and significantly increase cardiovascular side effects without improving outcomes 3
Do not use in smoke inhalation injury without specialist consultation: While research shows potential benefit with 4 mg every 4 hours in animal models, this is not yet standard clinical practice 8
Special Populations
Pediatric Considerations
- Safety established for 3-5 mL doses in children with acute inflammatory airway obstruction 2
- Lower doses (0.5-2.5 mL) may be preferable for post-extubation stridor to minimize side effects 3
- Supervision by an adult is required for children using OTC nebulized epinephrine products 4