RACEMIC EPINEPHRINE VS. NORMAL SALINE NEBULIZATION FOR THE TREATMENT OF ACUTE
BRONCHIOLITIS IN INFANTS
Kristin Richter, Debora Allan, Jacqueline NonWeiler-Parr, Morhaf Al Achkar
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Background1,2
Viral Bronchiolitis is a common
medical condition affecting
infants and children
It results in inflammation of the
bronchioles and bronchial tree,
Typically in children less than two
years old
The majority of cases occur in
infants 3-6 months
It present with acute shortness of
breath, increased work of breathing, nasal flaring, accessory
muscle use, wheezing, and cough in infants
The length of hospital stay of patients is determined mostly
by the need for oxygen and IV fluids
The treatment is usually symptomatic and include IV fluids,
nasal suctioning, and oxygen as needed.
Epinephrine vs. Saline2
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Multi-center, prospective, randomized, double-blind, placebo-controlled trial
194 Infants (<12mo) with a diagnosis of acute bronchiolitis
Interventions included nebulized epinephrine or normal saline
The primary outcomes were length of hospital stay and time until patient was
ready for discharge
Infants in the epinephrine group had a mean LOS of 58.8 hours (95% CI 49.4
to 70.0)
Infants in the saline group had a mean LOS of 69.5 hours (95% CI 59.3 to
81.4)
There was no significant overall difference between treatment groups in the
length of stay or time until ready for discharge. (CI overlapping)
Treatment Guidelines4
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Conclusion
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Epinephrine vs. Albuterol vs.
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The Clinical Inquiry Question
Which one is better, nebulized racemic epinephrine or nebulized saline for the
treatment of infants with acute bronchiolitis?
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P:
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C:
O:
Infants with acute bronchiolitis
Nebulized racemic epinephrine
Nebulized saline
Length of acute bronchiolitis exacerbation (length of stay), time until
discharge from the hospital, clinical improvement.
The American Academy of Pediatrics recommended a single administration of
trial epinephrine inhalation in select patients
Repeated or continued use only if respiratory improvement is noted
Continued supportive treatment while hospitalized with acute bronchiolitis
exacerbation
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Prospective, double-blinded,
randomized placebo-controlled,
parallel-group trial
Infants up to 12 months old with
acute bronchiolitis presenting to the
ER Treatment interventions included
racemic epinephrine, albuterol, or
normal saline
The primary outcome were length
of stay (LOS) and time until discharge
from the hospital
Infants in the epinephrine group had
a mean LOS of 59.8 hours
(95% CI 42.3 to 77.3)
Infants in the albuterol group had a
mean LOS of 61.4 hours
(95% CI 46.3 to 76.5)
Infants in the saline group had a
mean LOS of 63.3 hours
Therefore there was no clinically
significant difference in effect
between each of the three treatment
groups (CI overlapping).
Saline3
The use of nebulized racemic
epinephrine, did not decrease the
length of hospital stay or the time
until discharge from the hospital
compared to saline or albuterol
Supportive care in infants with acute
bronchiolitis remains the mainstay
of treatment until the underlying
viral process runs its course,
regardless of type of bronchodilator
intervention used
The supportive measures include:
- Oxygen therapy
- Nasal suctioning
- Monitoring of clinical status
- Parental education
Reference
1. Walsh B, Czervinske M et al. Perinatal and Pediatric Respiratory Care. 3rd ed.
St Louis, Missouri: Elsevier; 2010.
2. Wainwright , Claire, et al. A multicenter, randomized, double-blind,
controlled trial of nebulized epinephrine in infants with acute bronchiolitis.
NEJM. 2003; 349: 27-35.
3. Patel, Hema 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. The Journal of Pediatrics.
2002; 141: 818-824.
4. The American Academy of Pediatrics. Diagnosis and management of
bronchiolitis. Pediatrics. 2006:118:1774-93.