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Peer-reviewedCC BY-NC-ND 4.0The journal of allergy and clinical immunology. In practice

Anaphylaxis Clinical Care Pathway: Incorporating Intranasal Epinephrine (Adrenaline)

  • Timothy E. Dribin1,2
  • Brad Sobolewski1,2
  • Ronna L. Campbell3
  • Paul J. Turner4
  • Lene H. Garvey5,6
  • Jasmeet Soar7
  • Julie Wang8,9
  • Marcus S. Shaker10,11
  • Adam T. Fox12
  • Sarayna S. McGuire3
  • Kenneth A. Michelson13
  • David Schnadower1,2
21 more authors
  • Graham Roberts14,15,16
  • Waleed Alqurashi17,18
  • Moshe Ben-Shoshan19
  • David C. Brousseau20,21
  • Dianne E. Campbell22,23
  • Andrew T. Clark24
  • Antoine Deschildre25,26
  • Katie Frith27,28
  • Mattia Giovannini29,30
  • Gideon Lack31,32
  • Antonella Muraro33
  • Mark I. Neuman34
  • Nandinee Patel4
  • Guillaume Pouessel35,36,37
  • Kristina Rueter38,39,40
  • Nicholas Sargant
  • Peter Smith
  • Susan Waserman
  • Gary Wing-Kin Wong
  • Margitta Worm
  • Hugh A. Sampson8,9
40 affiliations
  1. 1Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  2. 2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
  3. 3Department of Emergency Medicine, Mayo Clinic, Rochester, Minn
  4. 4National Heart & Lung Institute, Imperial College London, London, United Kingdom
  5. 5Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital—Herlev and Gentofte, Gentofte, Denmark
  6. 6Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
  7. 7Southmead Hospital, Bristol, United Kingdom
  8. 8Elliot and Roslyn Jaffe Food Allergy Institute, Kravis Children’s Hospital, New York, NY
  9. 9Serena and John Liew Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
  10. 10Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, Lebanon, NH
  11. 11Departments of Medicine and of Pediatrics, Dartmouth Geisel School of Medicine, Hanover, NH
  12. 12Department of Paediatric Allergy, Evelina London Children’s Hospital & King’s College, London, United Kingdom
  13. 13Division of Emergency Medicine, Ann & Robert Lurie Children’s Hospital, Chicago, Ill
  14. 14Faculty of Medicine, University of Southampton, David Hide Asthma and Allergy Centre, Southampton, United Kingdom
  15. 15St Mary’s Hospital, Isle of Wight, United Kingdom
  16. 16NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
  17. 17Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
  18. 18Departments of Pediatrics and Emergency Medicine, Faculty of Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
  19. 19Division of Allergy, Immunology, and Dermatology, Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montreal, Quebec, Canada
  20. 20Department of Pediatrics, Nemours Children’s Health, Wilmington, Del
  21. 21Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, Del
  22. 22The University of Sydney Medical School, the University of Sydney, Sydney, New South Wales, Australia
  23. 23National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
  24. 24Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
  25. 25Univ. Lille, CHU de Lille, Lille, France
  26. 26Service de Pneumologie et d’Allergologie Pédiatrique, Hôpital Jeanne de Flandre, CHU de Lille, Lille, France
  27. 27Department of Immunology, Sydney Children’s Hospital, Randwick, New South Wales, Australia
  28. 28School of Clinical Medicine, University of NSW, Sydney, New South Wales, Australia
  29. 29Allergy Unit, Meyer Children’s Hospital IRCCS, Florence, Italy
  30. 30Department of Health Sciences, University of Florence, Florence, Italy
  31. 31Department of Women and Children’s Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
  32. 32Children’s Allergy Service, Evelina London Children’s Hospital, Guy’s and St Thomas’ Hospital, London, United Kingdom
  33. 33Food Allergy Referral Centre, Padua University Hospital, Padua, Italy
  34. 34Division of Emergency Medicine, Boston Children’s Hospital, Boston, Mass
  35. 35Department of Pediatrics, Children’s Hospital, CH Roubaix, Roubaix, France
  36. 36Pediatric Pulmonology and Allergy Department, Pôle Enfant, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
  37. 37University of Lille, ULR 2694: METRICS, Lille, France
  38. 38Departments of Immunology and Emergency Medicine, Perth Children’s Hospital, Perth, Western Australia, Australia
  39. 39UWA Medical School, Institute for Perioperative Excellence, The University of Western Australia, Perth, Western Australia, Australia
  40. 40UWA Medical School, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
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Abstract

Health care providers across settings must be trained to manage anaphylaxis by (1) removing the offending allergen if still present; (2) positioning the patient with legs elevated, and if respiratory distress is present, allow the patient to sit upright with legs extended and elevated; (3) immediately administering epinephrine (adrenaline) intramuscularly (IM) or intranasally (IN) every 5 to 15 minutes for persistent anaphylaxis; and (4) optimizing airway, breathing, and cardiovascular (ABC) resuscitation. This may include supplemental oxygen, noninvasive or invasive positive-pressure ventilation, and intravenous fluid resuscitation. For life-threatening or refractory presentations, (5) IM/IN epinephrine should be administered every 5 minutes while addressing ABC derangements; this includes aggressive intravenous fluid resuscitation for patients in anaphylactic shock. Providers may continue IM or IN epinephrine or switch to the other, as both routes are considered equally efficacious based on pharmacokinetic data. An intravenous epinephrine infusion should be prepared for patients with persistent anaphylaxis after 2 doses of IM/IN epinephrine and initiated after the third dose, or earlier at the provider’s discretion. In settings without epinephrine infusions, repeat IM/IN epinephrine should be administered every 5 minutes, along with other ABC interventions, and the patient should be transferred quickly to a setting equipped to provide advanced resuscitative care.

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Cite

BibTeXRIS
BibTeX
@article{dribin2026anaphylaxis,
  title = {{Anaphylaxis Clinical Care Pathway: Incorporating Intranasal Epinephrine (Adrenaline)}},
  author = {Timothy E. Dribin and Brad Sobolewski and Ronna L. Campbell and Paul J. Turner and Lene H. Garvey and Jasmeet Soar and Julie Wang and Marcus S. Shaker and Adam T. Fox and Sarayna S. McGuire and Kenneth A. Michelson and David Schnadower and Graham Roberts and Waleed Alqurashi and Moshe Ben-Shoshan and David C. Brousseau and Dianne E. Campbell and Andrew T. Clark and Antoine Deschildre and Katie Frith and Mattia Giovannini and Gideon Lack and Antonella Muraro and Mark I. Neuman and Nandinee Patel and Guillaume Pouessel and Kristina Rueter and Nicholas Sargant and Peter Smith and Susan Waserman and Gary Wing-Kin Wong and Margitta Worm and Hugh A. Sampson},
  journal = {The journal of allergy and clinical immunology. In practice},
  year = {2026},
  month = jul,
  doi = {10.1016/j.jaip.2026.07.004},
  url = {https://doi.org/10.1016/j.jaip.2026.07.004},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Anaphylaxis Clinical Care Pathway: Incorporating Intranasal Epinephrine (Adrenaline)
AU  - Timothy E. Dribin
AU  - Brad Sobolewski
AU  - Ronna L. Campbell
AU  - Paul J. Turner
AU  - Lene H. Garvey
AU  - Jasmeet Soar
AU  - Julie Wang
AU  - Marcus S. Shaker
AU  - Adam T. Fox
AU  - Sarayna S. McGuire
AU  - Kenneth A. Michelson
AU  - David Schnadower
AU  - Graham Roberts
AU  - Waleed Alqurashi
AU  - Moshe Ben-Shoshan
AU  - David C. Brousseau
AU  - Dianne E. Campbell
AU  - Andrew T. Clark
AU  - Antoine Deschildre
AU  - Katie Frith
AU  - Mattia Giovannini
AU  - Gideon Lack
AU  - Antonella Muraro
AU  - Mark I. Neuman
AU  - Nandinee Patel
AU  - Guillaume Pouessel
AU  - Kristina Rueter
AU  - Nicholas Sargant
AU  - Peter Smith
AU  - Susan Waserman
AU  - Gary Wing-Kin Wong
AU  - Margitta Worm
AU  - Hugh A. Sampson
PY  - 2026
DA  - 2026/07/14
JO  - The journal of allergy and clinical immunology. In practice
DO  - 10.1016/j.jaip.2026.07.004
UR  - https://doi.org/10.1016/j.jaip.2026.07.004
AB  - Health care providers across settings must be trained to manage anaphylaxis by (1) removing the offending allergen if still present; (2) positioning the patient with legs elevated, and if respiratory distress is present, allow the patient to sit upright with legs extended and elevated; (3) immediately administering epinephrine (adrenaline) intramuscularly (IM) or intranasally (IN) every 5 to 15 minutes for persistent anaphylaxis; and (4) optimizing airway, breathing, and cardiovascular (ABC) resuscitation. This may include supplemental oxygen, noninvasive or invasive positive-pressure ventilation, and intravenous fluid resuscitation. For life-threatening or refractory presentations, (5) IM/IN epinephrine should be administered every 5 minutes while addressing ABC derangements; this includes aggressive intravenous fluid resuscitation for patients in anaphylactic shock. Providers may continue IM or IN epinephrine or switch to the other, as both routes are considered equally efficacious based on pharmacokinetic data. An intravenous epinephrine infusion should be prepared for patients with persistent anaphylaxis after 2 doses of IM/IN epinephrine and initiated after the third dose, or earlier at the provider’s discretion. In settings without epinephrine infusions, repeat IM/IN epinephrine should be administered every 5 minutes, along with other ABC interventions, and the patient should be transferred quickly to a setting equipped to provide advanced resuscitative care.
SN  - 2213-2198
SN  - 2213-2201
ER  -