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(Chest. 2006;129:1114-1115.)
© 2006 American College of Chest Physicians

Use of Racemic Epinephrine in Bronchiolitis

What Is the Emergency Physician’s Perspective?

Muhammad Waseem, MD

Lincoln Hospital, Bronx, NY

Correspondence to: Muhammad Waseem, Lincoln Hospital, Department of Emergency Medicine, 234 East 149th St, Bronx, NY 10451; e-mail: waseemm2001{at}hotmail.com

To the Editor:

Bronchiolitis is the most common lower respiratory tract infection in infants. Many aspects of its treatment are controversial. Therapy with inhaled racemic epinephrine relieves airway obstruction in patients with respiratory syncytial virus bronchiolitis. We conducted a study to find out about the current usage of racemic epinephrine in patients with bronchiolitis.

One hundred emergency departments (EDs) were sent a four-part questionnaire by mail. The questionnaires were mailed to the director of the ED at each facility and inquired about their practice regarding the use of racemic epinephrine using the following four questions:

  1. Do you use nebulized racemic epinephrine as a first-line agent in bronchiolitis?
  2. In which patients do you choose to use nebulized racemic epinephrine?
  3. Do you admit all children with bronchiolitis who have received nebulized racemic epinephrine?
  4. What do you prescribe at the time of discharge?

The response rate was 78%. Over 85% of the physicians who responded do not use racemic epinephrine as a first-line agent. More than two thirds of physicians (84.6%) reserved this agent for treating patients with moderate-to-severe illness. Sixty-two percent of those who responded admit to the hospital those children who have received racemic epinephrine. Fifty-two percent of physicians prescribed albuterol in a metered-dose inhaler, 22% prescribed normal saline solution, and 26% prescribed nothing at the time of hospital discharge.

Several studies1 have shown that nebulized racemic epinephrine, which stimulates both {alpha}-adrenergic and ß-adrenergic receptors, is as effective or superior to albuterol in relieving airway obstruction in patients with viral bronchiolitis. Some studies23 have shown no significant difference in the effectiveness of nebulized therapy with epinephrine and albuterol in a hospital setting. But short-term benefits in respiratory rate, oxygen saturation, and clinical score have been observed with the use of epinephrine. A single outpatient, placebo-controlled trial4 noted a statistically insignificant but potentially clinically meaningful 12% decrease in the hospitalization rate in the epinephrine group. One study5 in an ED showed that patients treated with epinephrine were discharged significantly earlier than patients who had been treated with albuterol.

There is no standardized outpatient regimen for the management of bronchiolitis. Racemic epinephrine is not the first agent of choice of most ED physicians for the treatment of bronchiolitis. Emergency physicians use nebulized epinephrine as a potential rescue medication for children who are to be admitted to the hospital.

References

  1. Reijonen, T, Korppi, M, Pitkakangas, S, et al (1995) The clinical efficacy of nebulized racemic epinephrine and albuterol in acute bronchiolitis. Arch Pediatr Adolesc Med 149,686-692[Abstract]
  2. Patel, H, Platt, RW, Pekeles, GS, et al A randomized, controlled trial of the effectiveness of nebulized therapy with epinephrine compared with albuterol and saline in infants hospitalized for acute viral bronchiolitis. J Pediatr 2002;141,818-824[CrossRef][ISI][Medline]
  3. Wainwright, C, Altamirano, L, Cheney, M, et al A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med 2003;349,27-35[Abstract/Free Full Text]
  4. Hariprakash, S, Alexander, J, Ramesh, CW, et al Randomized controlled trial of nebulized adrenaline in acute bronchiolitis. Pediatr Allergy Immunol 2003;14,134-139[CrossRef][ISI][Medline]
  5. Mull, CC A randomized trial of nebulized epinephrine vs. albuterol in the emergency department treatment of bronchiolitis. Arch Pediatr Adolesc Med 2004;158,113-118




This Article
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Right arrow Articles by Waseem, M.

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