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Dr Sangeetha Pradeep, Paediatric registrar
Structured Clinical Question: In a patient with bronchiolitis, is nebulised adrenaline effective in
reducing their length of stay?
Scenario: We see a lot of children with bronchiolitis in the emergency department. The majority of
them have mild to moderate respiratory symptoms, are managing to feed, but still get admitted
because of mild respiratory distress. This literature search is to find out if adrenaline is useful in
these children in reducing their length of stay.
Methods: Medline and Embase were searched using the words epinephrine or adrenaline and
combined with the word bronchiolitis. The search was done both with and without thesaurus mapping,
the search was limited to human, English language and children between 0-23 months in Medline and
children up to 6 years of age in Embase. 73 studies were found in Medline, 58 studies were found in
Embase, among which 18 were found to be suitable. 7 randomised controlled trials were about the
use of adrenaline in emergency department, combination treatment were not included.
Commentary: Bronchiolitis is one of the most common reason for admission to paediatric wards.
Most patients require hospital admission for one or two days. Every possible action should be taken to
reduce these hospital admissions. At the same time, patients should get better.
2 other searches have been done on this same subject, one done by Hartling et al (3), published in 2003 and 2004. They concluded that there was insufficient evidence for the use of epinephrine among in-patients and they called for large, multi-centre trials to evaluate the use of adrenaline in an out-patient settings. The search was updated in 2011, (2) which found that adrenaline was superior in providing short term outcome for out-patients and called for more research to confirm the benefits of combined gluco corticoids and adrenaline treatment. The second search was done by Maud Meates in 2002 (1). According to her publication, nebulised adrenaline is safe, effective in controlling symptoms and it reduces hospital admissions. Results of this literature search: There are discrepancies in the results. A large multicentre trial (8)
found less successful discharges in the epinephrine group, although many other randomised
controlled trials showed that adrenaline gives short term clinical improvement and also it aids early
discharges, and some of these results are not statistically significant (Table 1). Further large, multi
centred trials are needed to evaluate this further.
Clinical bottom line: There is insufficient evidence to justify the use of adrenaline in bronchiolitis at
the moment.
epinephrine) or albuterol (0.15mg/kg of 0.5% ) nebuliser References:
1.Archives of Disease in Childhood, December 2002, vol./is. 87/6(548-50),
0003-9888; 1468-2044 (2002 Dec)
Author(s): Meates M
2. Epinephrine for bronchiolitis.
Cochrane Database of Systematic Reviews, 2011, vol./is. /6(CD003123),
1361-6137;1469-493X (2011)
Author(s): Hartling L; Bialy LM; Vandermeer B; Tjosvold L; Johnson DW; Plint AC; Klassen TP;
Patel H; Fernandes RM
3. A meta-analysis of randomized controlled trials evaluating the efficacy of epinephrine for the
treatment of acute
viral bronchiolitis.
Archives of Pediatrics & Adolescent Medicine, October 2003, vol./is. 157/10(957-64),
1072-4710;1072-4710 (2003 Oct)
Author(s): Hartling L; Wiebe N; Russell K; Patel H; Klassen TP
4. Emergency room management of acute bronchiolitis: a randomized trial of nebulized
Turkish Journal of Pediatrics, November 2011, vol./is. 53/6(651-60),
0041-4301;0041-4301 (2011 Nov-Dec)
Author(s): Simsek-Kiper PO; Kiper N; Hascelik G; Dolgun A; Yalcin E; Dogru-Ersoz D; Ozcelik U
5. Randomized controlled trial of nebulized adrenaline in acute bronchiolitis.
Pediatric Allergy & Immunology, April 2003, vol./is. 14/2(134-9), 0905-6157;0905-6157
(2003 Apr)
Author(s): Hariprakash S; Alexander J; Carroll W; Ramesh P; Randell T; Turnbull F; Lenney W
6. A Randomized Trial of Nebulized Epinephrine vs Albuterol in the Emergency Department
Treatment of
Archives of Pediatrics and Adolescent Medicine, February 2004, vol./is. 158/2(113-118),
1072-4710 (February 2004)
Author(s): Mull C.C.; Scarfone R.J.; Ferri L.R.; Carlin T.; Salvaggio C.; Bechtel K.A.; Hanes
Trephan M.A.; Rissman R.L.; Gracely E.J.

7. The clinical efficacy of nebulized racemic epinephrine and albuterol in acute bronchiolitis
Archives of Pediatrics and Adolescent Medicine, 1995, vol./is. 149/6(686-692),
1072-4710 (1995)
Author(s): Reijonen T.; Korppi M.; Pitkakangas S.; Tenhola S.; Remes K
8. Comparison of nebulized epinephrine to albuterol in bronchiolitis.
Academic Emergency Medicine, April 2008, vol./is. 15/4(305-13), 1069-6563;1553-2712
(2008 Apr)
Author(s): Walsh P; Caldwell J; McQuillan KK; Friese S; Robbins D; Rothenberg SJ
Institution: Department of Emergency Medicine, Kern Medical Center, Bakersfield, CA, USA
9. Comparison of nebulized adrenaline versus salbutamol in wheeze associated respiratory tract
infection in infants.
Indian Pediatrics, January 2002, vol./is. 39/1(12-22), 0019-6061;0019-6061 (2002 Jan)
Author(s): Ray MS; Singh V
10. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of
acute bronchiolitis.

Citation: Journal of Pediatrics, June 1995, vol./is. 126/6(1004-7), 0022-3476;0022-3476 (1995 Jun)
Author(s): Menon K; Sutcliffe T; Klassen TP


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