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Inpatient Racemic Epinephrine

Bronchiolitis team recommendation: The AAP guideline recommends against the routine use of inhaled racemic epinephrine to treat acute bronchiolitis in both the inpatient and outpatient settings (Ralston et al., 2014). However, the Bronchiolitis CPG Team concludes the evidence is insufficient at this time to make a recommendation for against using racemic epinephrine.

Literature (See Appendix D) supporting this recommendation: The meta-analysis by Hartling et al., (2011) was analyzed using GRADEprofiler (GRADEpro). The evidence is GRADED as Moderate to Low quality. Risk of bias, specifically poorly reported allocation concealment and blinding were detected in the included studies. Studies were also inconsistent, which decreases confidence in the pooled results. However for the following outcomes there was no difference in the following outcomes

  • Length of stay: (N= 292) Mean difference = 0.35 days, (0.35 hours shorter to 0.17 hours longer)

  • Admission at from first outpatient encounter to within 24 hours: (N= 995) RR= 0.67, 95% CI [0.5, 0.89]

  • Admission overall, up to 7 days: (N= 835) RR= 0.81, 95% CI [0.63, 1.03]

Hartling et al., (2011) conclude that the evidence shows some reduction in hospital admission when children with bronchiolitis are treated with epinephrine. However, the short term of medication effect and the differences in timing of outcome measurements limit the quality of the evidence. There is no evidence to support the use of racemic epinephrine in the inpatient setting.

In a series of studies (Skjerven et al., 2013, 2015) report on the same group of subjects who received either inhaled racemic epinephrine versus normal saline for acute bronchiolitis in the inpatient setting. In the first study, (Skjerven et al., 2013) LOS was not significantly between the two groups. In the second study (Skjerven et al., 2015), the same subjects were evaluated approximately 2 years later. For those who received racemic epinephrine at the acute bronchiolitis visit, a comparison was made between and went on to develop either recurrent bronchial obstruction, atopic eczema, or allergic sensitization and those who did not develop these conditions. The outcome was the LOS at the acute bronchiolitis visit. There was no difference in LOS between those who went on to develop atopic symptoms and those who did not. 

Critically Appraised Topic (CAT): Inhaled Racemic Epinephrine

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.