237 - Delivery of L-Epinephrine by Metered-Dose Inhaler for the Treatment of Croup: How Does it Compare?

Poster Number: 237
Publication Number: 237.2925

Background: Croup is a common pediatric presentation in the emergency department (ED). Patients with moderate or severe croup receive nebulized epinephrine, either racemic or L-isomer. To prevent the aerosolization of the SARS-CoV-2 virus, many institutions have replaced nebulized medications with a metered-dose inhaler (MDI). Primatene® MIST (PM) (Armstrong Pharmaceuticals) is an over-the-counter L-epinephrine MDI, which is FDA approved for the treatment of mild intermittent asthma in patients > 12 years old. In February 2021, the Pharmacy and Therapeutics (P&T) Committee of Northwell Health System approved PM in children > 1 year of age in the treatment of croup.

Objective: We aim to demonstrate that L-epinephrine administered by MDI is effective and non-inferior to nebulized racemic epinephrine in children presenting with moderate to severe croup.

Design/Methods: We conducted a single-center retrospective cohort review of children 1-10 years of age who presented to the ED at Cohen Children’s Medical Center and received either Primatene® MIST (PM) or nebulized racemic epinephrine (RE) for the management of croup from January 2021 to July 2023. We excluded patients that received corticosteroids or RE prior to ED arrival, and any patient with a congenital upper airway condition or prior airway procedure. Data collected included demographics, medications administered, heart rates, adverse events, disposition, and return within 48 hours. As part of the surveillance process by the P&T Committee, data for PM was collected prospectively with the addition of the Westley Croup Score. During the initial rollout of PM, eligible patients were administered 4 puffs through an attached spacer. Following safety review, the dose was increased to 6 puffs. The primary outcome measure was the need for additional epinephrine doses.

Results: A total of 351 pediatric encounters for croup were included, of which 39 received PM. The mean age was 3.3 years (SD:2.1) and 75% were male. Of the 216 patients that had respiratory viral testing, 14% were positive for SARS –CoV-2. Compared to RE, patients that received PM did not significantly differ in requirement of additional doses of epinephrine, 48 hour return to the ED, and admission (See Table 1).

Conclusion(s): L-epinephrine administered by MDI is effective and non-inferior to nebulized racemic epinephrine in children presenting with croup and should be considered as an alternative to racemic epinephrine when concerns for infectious aerosolization exists.