Racemic Epinephrine for RSV in Infants
Racemic epinephrine is NOT recommended for routine treatment of RSV bronchiolitis in infants, as current AAP guidelines emphasize supportive care only and do not endorse bronchodilators, epinephrine, or other pharmacologic interventions for typical cases. 1, 2
Why Racemic Epinephrine Is Not Recommended
The American Academy of Pediatrics explicitly states that treatment modalities such as bronchodilators, epinephrine, corticosteroids, hypertonic saline, and antibiotics are generally not useful for RSV bronchiolitis. 2 The evidence-based approach prioritizes supportive care as the mainstay of treatment, with pharmacologic interventions showing no meaningful impact on morbidity, mortality, or quality of life outcomes. 1, 3
Evidence Against Routine Use
While older research showed racemic epinephrine could provide temporary relief of respiratory distress symptoms (particularly wheezing), it does not:
- Reduce length of hospital stay 4
- Decrease mortality 1
- Improve long-term outcomes 1
- Prevent progression to severe disease 2
A randomized controlled trial demonstrated that racemic epinephrine improved wheezing scores on day 2 of hospitalization but failed to shorten hospital length of stay (2.6 days vs 3.4 days, p > 0.05). 4 This transient symptomatic improvement without meaningful clinical benefit explains why guidelines do not recommend its routine use.
Mechanism and Limited Context
Racemic epinephrine works primarily through alpha-adrenergic receptor stimulation, causing vasoconstriction and reducing airway edema, rather than through beta-agonist bronchodilation. 5 This mechanism may explain why it provides modest short-term relief in some cases but does not address the underlying viral pathophysiology of RSV infection.
The American Thoracic Society mentions racemic epinephrine only in the context of subglottic stenosis with superimposed upper respiratory infections—a completely different clinical scenario from typical RSV bronchiolitis. 6 This highlights that any potential role for racemic epinephrine is limited to specific airway structural problems, not viral lower respiratory tract infections.
What TO Do Instead: Evidence-Based Supportive Care
Supplemental oxygen should be provided if oxygen saturation falls persistently below 90% in previously healthy infants. 1
Adequate hydration through intravenous or nasogastric fluids for infants unable to maintain oral intake is essential. 1, 2
Monitoring for signs of respiratory distress, with escalation to intensive care if the infant fails to maintain SpO2 >92% in FiO2 >60%, develops apnea, or shows severe respiratory distress with rising PaCO2. 1
Infection control through hand hygiene is the single most important measure to prevent transmission to others and nosocomial spread. 1
Common Pitfalls to Avoid
Do not continue bronchodilator or epinephrine therapy without documented clinical improvement—the AAP explicitly warns against this practice. 1
Do not use antibiotics unless there are specific indications of bacterial co-infection, as they are ineffective for viral illness. 1, 7
Do not use palivizumab for treatment—it has no therapeutic benefit for established RSV infection and is only approved for prevention in high-risk infants before infection occurs. 1, 8
Prevention Is Key
For high-risk infants (born <29 weeks gestation, chronic lung disease, hemodynamically significant congenital heart disease), palivizumab prophylaxis during RSV season reduces hospitalization by 45-55%. 8, 2 This preventive strategy is far more effective than any treatment intervention once infection is established.