Is it recommended to administer medication every 15 (q15) minutes for 3 doses for the treatment of croup?

Racemic Epinephrine Dosing Every 15 Minutes for Croup

Yes, you can administer racemic epinephrine every 15 minutes for up to 3 doses in moderate-to-severe croup, but you must observe the patient for at least 2 hours after the final dose before making any disposition decision. 1, 2

Dosing Protocol

• Standard dose: 0.05 mL/kg (maximum 0.5 mL) of 2.25% racemic epinephrine solution diluted in 2 mL normal saline, administered by nebulization 3
• Alternative if racemic epinephrine unavailable: L-epinephrine 1:1000 concentration at 0.5 mL/kg (maximum 5 mL) by nebulizer 3
• Simplified institutional approach: Many centers use a standard 0.5 mL dose for all patients regardless of weight, which is safe and simplifies administration 3

Treatment Algorithm

For all patients with croup:

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as first-line therapy regardless of severity 1, 2

For moderate-to-severe croup (stridor at rest, respiratory distress):

• Add nebulized epinephrine to corticosteroid therapy 1, 2
• Doses can be given every 15-20 minutes as clinically indicated 1
• The effect is short-lived, lasting only 1-2 hours 1, 2

Critical Observation Period

You must observe for at least 2 hours after the last epinephrine dose before discharge or transfer decisions, as rebound symptoms are common when the medication wears off 1, 2

Hospitalization Decision After 3 Doses

Recent evidence supports a "3 is the new 2" approach:

• Consider admission only after 3 total doses of racemic epinephrine are needed, not the traditional 2 doses 4, 1, 2
• This approach reduces hospitalization rates by 37% without increasing revisits or readmissions 4, 1
• Approximately 80% of admitted patients require no further airway interventions after admission 4, 3

Additional Hospitalization Criteria

Beyond needing ≥3 epinephrine doses, also consider admission for:

• Oxygen saturation <92% 1, 2
• Age <18 months 1, 2
• Respiratory rate >70 breaths/min 1, 2
• Persistent difficulty breathing despite treatment 1, 2

Critical Pitfalls to Avoid

• Never discharge within 2 hours of the last epinephrine dose due to rebound risk 1, 2
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2
• Do not confuse racemic epinephrine 2.25% solution with standard epinephrine 1:1000 or 1:10,000 concentrations—these are entirely different formulations 3
• Always give corticosteroids first, even in mild cases—nebulized epinephrine is reserved for moderate-to-severe presentations 1, 2, 5

Supportive Care During Treatment

• Maintain oxygen saturation ≥94% with supplemental oxygen as needed 1, 2
• Minimize handling to reduce metabolic demands 1
• Use antipyretics for comfort 1
• Avoid chest physiotherapy, which provides no benefit 1