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Regarding the use of L-epinephrine:
 
Plain L-epinephrine is considered by many the treatment of choice for
patients requiring an inhaled vasoconstrictor and is the only epinephrine
used in our department.  Racemic epinephrine is a 50:50 mixture of the d
and l isomers of epinephrine, although only the l isomer is active.  In
effect then a 2.25% solution of racemic epinephrine is physiologically a
1.125% solution of L-epinephrine.
 
The dose of 1:1000 epi used to treat the child in this report seems a
little low.  The 1:1000 solution is a 0.1% solution (1mg/1ml).  In our
nebulization treatments we use 2-4 cc of undiluted 1:1000 epi, which is the
equivilent of 0.2-0.4 cc of racemic epinephrine diluted with NSS.
 
The most recent articles on this subject might include the following:
 
1.  "Klassen TP: Recent advances in the treatment of bronchiolitis and
laryngitis. Pediatr Clin North Am, 1997; 44:249-6"
2.  "Waisman, Y, Klein BL, Boenning DA, et. al.: Prospective randomized
double blind study comparing L-epinephrine and racemic epinephrine aerosols
in the treatment of laryngo-tracheitis (Croup).  Pediatrics 1992; 89:302-6"
3.  "Nutman J , Brooks LJ , Deakins KM  et.al.: Racemic versus
L-epinephrine aerosol in the treatment of postextubation laryngeal edema:
Results from a prospective, randomized, double-blind study.  Critical Care
Medicine. 1994; 22:1591-4"
4.  "Fitzgerald D , Mellis C , Johnson M et. al.: Nebulized budesonide is
as effective as nebulized adrenaline in moderately severe croup.
Pediatrics 1996; 97:722-5"
 
Hope this helps.
 
Al Sacchetti
Our Lady of Lourdes Medical Center
Camden, NJ
 
Alfred Sacchetti
 
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