Nebulised epinephrine in paediatric acute asthma
Date First Published:
February 7, 2007
Last Updated:
March 16, 2007
Report by:
Jon Lewin, SpR Emergency Medicine (St. Mary's hospital, London)
Search checked by:
Naeem Toosy, St. Mary's hospital, London
Three-Part Question:
In [children with acute asthma] does [nebulised epinephrine as opposed to nebulised beta-two agonists] [improve respiratory function and decrease hospitalisation].
Clinical Scenario:
A child presents with acute asthma. You start standard treatment with salbutamol, ipratropium and steroids. Your medical student points out that nebulised epinephrine is used for children with acute severe bronchiolitis, and wonders why you do not use the same treatment in asthma.
Search Strategy:
Ovid Medline(R) 1950 - Feb Week 1 2007
NCBI PubMed
NCBI PubMed
Search Details:
For Medline(R):
1 tAsthma/
2 tEpinephrine/ad, tu, th [Administration & Dosage, Therapeutic Use, Therapy] tt
3 t1 and 2 t
4 tlimit 3 to (humans and english language) t
For PubMed:
Epinephrine and Asthma
1 tAsthma/
2 tEpinephrine/ad, tu, th [Administration & Dosage, Therapeutic Use, Therapy] tt
3 t1 and 2 t
4 tlimit 3 to (humans and english language) t
For PubMed:
Epinephrine and Asthma
Outcome:
276 potential papers from Medline(R) and 48 from PubMed, of which 6 were considered suitable on reviewing the abstracts. When the full text was read, 3 studied adults only while one was in French. 2 papers were suitable for further analysis on reading the full text.
There was also a meta-analysis found (AJEM 2006 Vol 24 217-222), but this analysed only one paper in children. Since this paper is reviewed here, it was not added to the BET.
There was also a meta-analysis found (AJEM 2006 Vol 24 217-222), but this analysed only one paper in children. Since this paper is reviewed here, it was not added to the BET.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The Efficacy of Nebulised Racemic Epinephrine in Children with Acute Asthma: A Randomised, Double-blind Trial Amy C. Plint, Martin H. Osmond, Terry P. Klassen Oct-00 Canada | All children (1-18 years old) admitted to ED of a childrens hospital in Eastern Ontario between March-May and October-December with an acute asthma attack. | A prospective randomised double-blind study of children treated with oral steroids and either nebulised salbutamol or nebulised racaemic epinephrine for acute asthma. | Pulmonary index scores (similar to FEV1). | No significant difference | Excluded children with severe asthma, those with respiritoy distress and those needing intensive medical intervention. Uses pulmonary index scoring rather than peak flow to measure respiritory function. |
| Requirement for supplemental oxygen | No significant difference | ||||
| Length of stay in the ED | No significant difference | ||||
| Number of patients admitted to hospital | No significant difference | ||||
| Length of Hospital stay for those admitted | No significant difference | ||||
| Inhalation of Racemic Epinephrine in Children with Asthma B. Kjellman, H. Tollig and G. Wettrell 1980 Sweden | Ten children (7-16) with stable subacute asthma (FEV1 <70% predicited), 2 days post admission for acute asthma. | 10 children, each acting as their own controll. FEV1 measured pre-and post either salbutamol nebuliser (2 administrations per day) or epinephrine nebuliser (2 administrations per day). | Change in FEV1 | No difference between nebulised salbutamol and nebulised epinephrine | Small number of patients. Not acute asthma Only looked at FEV1, not the clinical effect on the child. |
Author Commentary:
In acute bronchiolitis, the alpha agonist effect of epinephrine is thought to reduce mucosal oedema in the bronchioles, whilst the beta agonist effect reduces smooth muscle spasm. It was postulated that this dual effect may be beneficial in acute asthma. Although this dual effect can be shown in vitro, it does not seem to be significant clinically. Inhaled salbutamol was introduced to replace subcutaneous epinephrine in acute asthma and was shown to be as effective. It seems that there is no additional benefit from inhaling epinephrine.
Bottom Line:
There is no evidence that nebulised epinephrine is superior to nebulised salbutamol in childhood acute asthma.
References:
- Amy C. Plint, Martin H. Osmond, Terry P. Klassen. The Efficacy of Nebulised Racemic Epinephrine in Children with Acute Asthma: A Randomised, Double-blind Trial
- B. Kjellman, H. Tollig and G. Wettrell. Inhalation of Racemic Epinephrine in Children with Asthma