What is the recommended dose and interval for nebulized epinephrine (adrenaline) in managing mucosal edema?

Nebulized Epinephrine for Mucosal Edema: Dosing and Interval

For mucosal edema causing upper airway obstruction, administer nebulized L-epinephrine (1:1000 solution) at a dose of 0.5 mL/kg (maximum 5 mL) via nebulizer, which can be repeated as necessary based on clinical response. 1

Standard Dosing Protocol

Pediatric Dosing

• L-epinephrine (1:1000 solution): 0.5 mL/kg up to a maximum of 5 mL administered by nebulizer 1
• This translates to 0.5 mg/kg of epinephrine, with a maximum single dose of 5 mg 1

Adult Dosing

• 1 mg of epinephrine (1:1000 solution) in 5 mL of normal saline, repeated as necessary based on clinical response 2
• The FDA-approved formulation for hand-held nebulizers uses 0.5 mL (contents of one vial) of 1% epinephrine solution 3

Alternative: Racemic Epinephrine

• 2.25% racemic epinephrine solution: 0.05 mL/kg (maximum 0.5 mL) diluted in 2 mL of normal saline 1
• Many institutions use a standard 0.5 mL dose of racemic epinephrine for all patients regardless of weight 1
• If racemic epinephrine is unavailable, L-epinephrine (1:1000) can be substituted at 0.5 mL/kg up to 5 mL 1

Dosing Interval

Repeat Administration

• Repeat doses as necessary based on clinical response—there is no fixed mandatory interval 1, 2
• For FDA-approved inhalation products in adults and children ≥4 years: 1-3 inhalations not more often than every 3 hours, with a maximum of 12 inhalations in 24 hours 3
• In clinical practice for acute airway edema, doses have been successfully repeated more frequently when clinically indicated 2

Clinical Response Monitoring

• Immediate benefits are typically seen within minutes of administration 2
• The decision to redose should be based on persistence or recurrence of stridor, respiratory distress, or other signs of airway obstruction 2

Clinical Context and Indications

This dosing applies specifically to:

• Laryngotracheobronchitis (croup) 1
• Acute airway edema 1
• Postintubation/postextubation laryngeal edema 1
• Upper airway obstruction of various etiologies 2

Important Safety Considerations

Cardiovascular Monitoring

• Nebulized epinephrine in these doses produces few cardiovascular sequelae in most patients 2
• Monitor for tachycardia, hypertension, and arrhythmias, particularly with repeated dosing 2

Critical Pitfall to Avoid

• Do not confuse concentrations: Use 1:1000 (1 mg/mL) for nebulization, not 1:10,000 1
• The 1:10,000 concentration is reserved for intravenous use only 1

Preparation Method

• No dilution is needed if using pre-measured doses 1
• When preparing manually, draw the calculated dose of 1:1000 epinephrine and place directly in nebulizer chamber 1, 2
• For adult dosing, 1 mg can be diluted in 5 mL normal saline for easier nebulization 2

Limitations of Evidence

• While widely used and recommended in pediatric guidelines for croup, one randomized controlled trial found that L-epinephrine did not reduce clinical progression of postextubation laryngeal edema 4
• However, case series in adults demonstrate immediate clinical benefits for upper airway obstruction 2
• The discrepancy likely reflects differences in etiology of airway edema (inflammatory croup vs. mechanical postextubation injury) 4