Nebulized Racemic Epinephrine for Moderate‑to‑Severe Viral Croup

Dosing and Administration

Standard dose: Nebulized racemic epinephrine 2.25 % solution at 0.05 mL kg⁻¹ (maximum 0.5 mL) diluted in 2 mL normal saline. [6][7]
Weight‑independent practice: Many institutions give a fixed 0.5 mL dose to all children regardless of weight. [6][7]
Alternative agent: When racemic epinephrine is unavailable, L‑epinephrine 1:1000 can be used at 0.5 mL kg⁻¹ (maximum 5 mL). [6][7]

Avoidance of intubation: Nebulized racemic epinephrine is indicated to prevent progression to intubation and to stabilize children before transfer to intensive care. [8][9]
Post‑intubation stridor: The medication is effective for treating stridor that occurs after extubation. [8][9]

Duration of effect: The therapeutic effect lasts only 1–2 hours, necessitating mandatory observation after each dose. [8][9][10][11]12
Monitoring parameters: After administration, clinicians should record respiratory rate, work of breathing, oxygen saturation, and the degree of stridor. 13
Second‑dose protocol: If a second dose is required, the child should be observed for up to 2 hours after that dose to decide whether a third dose is needed. 14

Multiple‑dose rule: Children who need more than two doses of racemic epinephrine generally require hospital admission. 14
Outpatient restriction: Racemic epinephrine must not be used for children who are being discharged home or treated in an outpatient setting without observation. [8][9][10][11]12
Home‑use caution: Because of its brief duration and potential adverse effects, epinephrine is typically avoided in the home environment. 13