What is the recommended approach for adrenaline (epinephrine) nebulisation in a neonate presenting with stridor?

Adrenaline Nebulisation for Neonatal Stridor

Direct Recommendation

Nebulised adrenaline (epinephrine) at 0.5 ml/kg of a 1:1000 solution should be used in neonates with stridor to avoid intubation and stabilize prior to transfer to intensive care, but the effect is short-lived (1-2 hours) and requires continuous monitoring in a facility capable of definitive airway management. 1, 2

Clinical Context and Indications

When to Use Nebulised Adrenaline

• Severe stridor with respiratory distress requiring stabilization before intubation or transfer to intensive care 1, 2
• Post-extubation stridor in neonates who have been intubated 1
• Acute inflammatory airway obstruction (such as croup) where immediate relief is needed 2

Critical Contraindications

• Do not use nebulised adrenaline in neonates who are shortly to be discharged or on an outpatient basis due to its transient effect 1, 2
• The short duration of action (1-2 hours) means rebound worsening can occur after the medication wears off 1, 2

Dosing Protocol

Standard Dose

• 0.5 ml/kg of 1:1000 (1 mg/ml) adrenaline solution nebulised 1, 2
• For a 3 kg neonate, this would be 1.5 ml of 1:1000 solution
• Can be repeated as needed, but each dose only provides 1-2 hours of relief 1, 2

Administration Details

• Deliver via nebuliser with oxygen or compressed air 1
• Effect begins within 30 minutes and peaks quickly 2
• Duration of action is 1-2 hours, requiring ongoing monitoring 1, 2

Essential Monitoring Requirements

Immediate Observation

• All neonates receiving nebulised adrenaline must be observed in a facility capable of performing intubation or tracheostomy 2
• Monitor for signs of impending airway closure: change in voice/cry, loss of ability to swallow, increasing work of breathing 2
• Apply pulse oximetry and consider end-tidal CO2 monitoring 2

Post-Treatment Protocol

• Observe for at least 3 hours after administration to ensure no rebound worsening 3
• If stridor recurs after the adrenaline effect wears off, the neonate requires admission and likely intubation 1

Adjunctive Therapy

Corticosteroids

• Nebulised budesonide 500 µg may reduce symptoms in croup within the first 2 hours 1
• Systemic corticosteroids (dexamethasone 0.5-1.0 mg/kg) should be administered alongside adrenaline for inflammatory causes 2, 4
• Steroids take 6-12 hours to work, so adrenaline provides the immediate bridge 4

Positioning and Oxygen

• Keep the neonate upright 2
• Administer high-flow humidified oxygen 2
• Avoid agitation which can worsen airway obstruction 2

Diagnostic Considerations

Underlying Causes in Neonates

• Laryngomalacia is the most common cause of chronic stridor in neonates 5
• Acute laryngotracheitis (croup) is the most common cause of acute stridor 6
• Post-extubation edema in previously intubated neonates 1
• Up to 10% of infants have lesions in more than one anatomical site 6

When Endoscopy is Required

• Flexible fiberoptic laryngoscopy is the diagnostic procedure of choice for persistent or severe stridor 2
• Direct visualization under general anesthesia is the gold standard when diagnosis is unclear 6
• Both upper and lower airways should be inspected, as anomalies below the epiglottis occur in up to 68% of cases 2

Critical Pitfalls to Avoid

Common Errors

• Never discharge a neonate home after nebulised adrenaline without extended observation (minimum 3 hours), as rebound obstruction is common 1, 3
• Do not assume adrenaline will definitively treat the underlying problem—it only provides temporary relief while preparing for definitive management 1
• Do not delay intubation in a deteriorating neonate hoping for adrenaline to work—early intubation is safer than emergency intubation in a fully obstructed airway 2

Ineffective Treatments

• Standard antihistamines and corticosteroids are ineffective for certain types of angioedema (ACE inhibitor-induced, hereditary angioedema) 7
• Single-dose steroids given immediately before extubation are ineffective for preventing post-extubation stridor 4

Disposition Algorithm

After Nebulised Adrenaline Administration

If stridor resolves and remains absent for 3+ hours:

• Consider admission for observation rather than discharge 1, 3
• Ensure follow-up within 24-48 hours 3

If stridor recurs or persists:

• Prepare for intubation 1, 2
• Transfer to intensive care unit 1, 2
• Consider ENT consultation for endoscopy 2

If stridor worsens despite adrenaline:

• Proceed immediately to intubation or tracheostomy 2
• Do not give repeated doses hoping for improvement 1