Nebulized racemic epinephrine for extubation of newborn infants

Mark W Davies, Peter G Davis

Following a period of mechanical ventilation, post-extubation upper airway obstruction can occur in newborn infants, especially after prolonged, traumatic or multiple intubations. The subsequent increase in upper airway resistance may lead to respiratory insufficiency and failure of extubation. The vasoconstrictive properties of epinephrine, and its proven efficacy in the treatment of croup in infants, has led to the routine use of inhaled nebulized epinephrine immediately post-extubation in some neonatal units. It is also recommended for neonates with post-extubation tracheal obstruction and stridor in neonatal and respiratory textbooks and reviews. The primary objective was to assess whether nebulized epinephrine administered immediately after extubation in neonates weaned from IPPV decreases the need for subsequent additional respiratory support. Searches were of: MEDLINE from 1966 to September 2000; CINAHL from 1982 to September 2000; Current Contents from 1994 to September 2000; and the Cochrane Controlled Trials Register (Cochrane Library Issue 3, 2000). These searches were updated to September 2001 for this review update. Previous searches up to March 1999 included the Oxford Database of Perinatal Trials, expert informants and journal hand searching mainly in the English language, previous reviews including cross references, abstracts, and conference and symposia proceedings. All randomised and quasi-randomised control trials in which nebulized epinephrine was compared with placebo immediately post-extubation in newborn infants who have been weaned from IPPV and extubated, with regard to clinically important outcomes (i.e. need for additional respiratory support, increase in oxygen requirement, respiratory distress, stridor or the occurrence of side effects). No studies met our criteria for inclusion in this review. No studies were identified which looked at the effect of inhaled nebulized epinephrine on clinically important outcomes in infants being extubated. There is no evidence either supporting or refuting the use of inhaled nebulized racemic epinephrine in newborn infants. randomised controlled trials are needed comparing inhaled nebulized racemic epinephrine with placebo in neonates post-extubation. This should be looked at both as a routine treatment post-extubation and as specific treatment for post-extubation upper airway obstruction. Study populations should include the group of infants at highest risk for upper airway obstruction from mucosal swelling because of their small glottic and sub-glottic diameters (ie those infants with birthweights less than 1000 grams).