Use of Racemic Epinephrine in Bronchiolitis: What Is the Emergency Physician's Perspective?

Abstract

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: 1Do you use nebulized racemic epinephrine as a first-line agent in bronchiolitis?2In which patients do you choose to use nebulized racemic epinephrine?3Do you admit all children with bronchiolitis who have received nebulized racemic epinephrine?4What 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 studies1Reijonen T Korppi M Pitkakangas S et al.The clinical efficacy of nebulized racemic epinephrine and albuterol in acute bronchiolitis.Arch Pediatr Adolesc Med. 1995; 149: 686-692Crossref PubMed Scopus (99) Google Scholar have shown that nebulized racemic epinephrine, which stimulates both A-adrenergic and β-adrenergic receptors, is as effective or superior to albuterol in relieving airway obstruction in patients with viral bronchiolitis. Some studies2Patel 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: 818-824Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar3Wainwright 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: 27-35Crossref PubMed Scopus (205) Google Scholar 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 trial4Hariprakash S Alexander J Ramesh CW et al.Randomized controlled trial of nebulized adrenaline in acute bronchiolitis.Pediatr Allergy Immunol. 2003; 14: 134-139Crossref PubMed Scopus (38) Google Scholar noted a statistically insignificant but potentially clinically meaningful 12% decrease in the hospitalization rate in the epinephrine group. One study5Mull CC A randomized trial of nebulized epinephrine vs.albuterol in the emergency department treatment of bronchiolitis. Arch Pediatr Adolesc Med. 2004; 158: 113-118Crossref PubMed Scopus (46) Google Scholar 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.