Acute Respiratory Failure
Conditions
Brief summary
The purpose of the study is to determine the efficacy and safety of dexmedetomidine during Non-invasive positive pressure ventilation (NPPV) for patients with acute respiratory failure compared to standard analgesic/sedation practices
Detailed description
Non-invasive positive-pressure ventilation (NPPV) is increasingly being used to manage patients with acute respiratory failure (ARF) in an effort to avoid the numerous negative sequelae associated with intubation and mechanical ventilation. In the USA, it is estimated that 20-30% of all patients placed on mechanical ventilation are treated with NPPV. Indications for NPPV include but are not limited to acute or acute-on-chronic hypercapnic respiratory failure, pulmonary edema, respiratory failure in immunocompromised patients or that due to chest wall deformity or neuromuscular disease. For NPPV to be successful, it is critical that the patient be cooperative and comfortable (i.e. no pain) as agitation and discomfort interfere with the success of NPPV. Despite the importance of patient comfort during NPPV, physicians infrequently use sedation or analgesic therapy during NPPV, primarily due to concerns about the respiratory depressant effects of most of the sedatives (e.g., benzodiazepines) and analgesics (e.g., opioids) that are currently available. In addition, neither the benzodiazepines nor opioids are easily titratable, can easily accumulate and can be associated with both the development of delirium and a withdrawal effect. Dexmedetomidine is an intravenous rapid-onset, short acting ά 2-receptor agonist that is approved for short-term sedation in post-operative and critically ill patients. It has been stated that this drug produces a state of cooperative sedation allowing the patient to interact with health care providers. Dexmedetomidine has been used for its ability to cause sympatholysis and, because of analgesic properties, to decrease the need for opioids. Potential advantages include its short half life and intravenous route of administration, permitting rapid titration to achieve sedation targets and, in patients with respiratory failure; it can provide both sedation and analgesia without inducing respiratory depression. Despite these advantages, it is currently used by less than 5% of pulmonologists/ intensivists as the primary sedative option during NPPV and has not been studied in a controlled fashion in this population. Therefore, dexmedetomidine may prove to be more efficacious and safe compared to standard sedation/analgesic therapy during NPPV.
Interventions
DRUGDexmedetomidine
Dexmedetomidine will be started at a rate of 0.2mcg/kg/hr and titrated by 0.1 mcg/kg/hr every 30 minutes to a maximum of 0.7 mcg/kg/hr to maintain a Riker-SAS 3-4.
DRUGPlacebo
Placebo infusion will be started at a rate of 0.2mcg/kg/hr and titrated by 0.1 mcg/kg/hr every 30 minutes to a maximum of 0.7 mcg/kg/hr to maintain a Riker-SAS 3-4.
Sponsors
Tufts Medical Center
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to 85 Years
Healthy volunteers
No
Inclusion criteria
* Age ≥ 18 years * Acute respiratory failure requiring the initiation of NPPV * Admission to the medical ICU service at Tufts Medical Center or Winchester Hospital
Exclusion criteria
* Patients with delirium (intensive care delirium screening checklist score ≥ 4) or disorientation (not oriented to person or place) * Receiving NPPV for ≥ 8 hours (includes treatment with NPPV at an outside hospital) * Intubation and mechanical ventilation in the past month based on hospital admission note * Age ≥ 85 years * Inability of the potential subject to give informed consent * Current treatment with antipsychotic agent based on hospital admission note * Heart rate ≤ 50 bpm * Systolic blood pressure ≤ 90 mmHg * History of heart block without pacemaker use or severe ventricular dysfunction (EF ≤25%) based on hospital admission note * Acute alcohol withdrawal based on hospital admission note * History of end stage liver failure (based on presence of ≥ 1 or more of the following: AST/ALT ≥ 2 times ULN, INR ≥ 2, total bilirubin ≥ 1.5 * Irreversible brain disease consistent with severe dementia based on hospital admission note * Pregnancy (all women of child-bearing age will undergo a pregnancy test prior to study enrollment) * Treatment with clonidine or dexmedetomidine in the past 30 days based on hospital admission note * Known allergy or sensitivity to clonidine or dexmedetomidine
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Tolerability of NIV as Assessed by an NIV Tolerance Score | Completed at time 0min, 30min, 60min, 3hr, 6hr, 12hr, and then every 12 hours after the start of NPPV therapy up to 72 hours | NIV tolerance (NIV intolerance score =1 out of 4) A score of 1 for a comfortable and relaxed patient tolerating NIV; a score of 2 for mild intolerance with some discomfort and occasionally grabbing at the NIV mask; a score of 3 for moderate intolerance and discomfort with the NIV mask most of the time but more frequent grabbing at the mask, sometimes pulling it off; and a score of 4 for severe NIV intolerance with agitation and the inability to leave the NIV mask in place. The outcome measure description of the time frame is reported as the average of the NIV tolerance scores reported at the various time frames (0min, 30min, 60 min, 3hr, 6hr, 12hr, and then every 12hr after the start of NIV therapy up to 72 hours) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Percent of Study Time Spent With a Riker-SAS Score Between 3 and 4 Inclusive | Completed at baseline and every 4 hours after the start of NPPV therapy for the duration of the study | Percentage of time spent at desired sedation goal |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Dexmedetomidine Dexmedetomidine: Dexmedetomidine will be started at a rate of 0.2mcg/kg/hr and titrated by 0.1 mcg/kg/hr every 30 minutes to a maximum of 0.7 mcg/kg/hr to maintain a Riker-SAS 3-4. | 18 |
| Placebo Placebo: Placebo infusion will be started at a rate of 0.2mcg/kg/hr and titrated by 0.1 mcg/kg/hr every 30 minutes to a maximum of 0.7 mcg/kg/hr to maintain a Riker-SAS 3-4. | 18 |
| Total | 36 |
Baseline characteristics
| Characteristic | Dexmedetomidine | Placebo | Total |
|---|---|---|---|
| Age, Continuous | 68 years STANDARD_DEVIATION 6 | 62 years STANDARD_DEVIATION 17 | 65 years STANDARD_DEVIATION 12 |
| Region of Enrollment United States | 18 participants | 18 participants | 36 participants |
| Sex: Female, Male Female | 6 Participants | 11 Participants | 17 Participants |
| Sex: Female, Male Male | 12 Participants | 7 Participants | 19 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 18 | 0 / 18 |
| serious Total, serious adverse events | 0 / 18 | 0 / 18 |
Outcome results
Primary
Tolerability of NIV as Assessed by an NIV Tolerance Score
NIV tolerance (NIV intolerance score =1 out of 4) A score of 1 for a comfortable and relaxed patient tolerating NIV; a score of 2 for mild intolerance with some discomfort and occasionally grabbing at the NIV mask; a score of 3 for moderate intolerance and discomfort with the NIV mask most of the time but more frequent grabbing at the mask, sometimes pulling it off; and a score of 4 for severe NIV intolerance with agitation and the inability to leave the NIV mask in place. The outcome measure description of the time frame is reported as the average of the NIV tolerance scores reported at the various time frames (0min, 30min, 60 min, 3hr, 6hr, 12hr, and then every 12hr after the start of NIV therapy up to 72 hours)
Time frame: Completed at time 0min, 30min, 60min, 3hr, 6hr, 12hr, and then every 12 hours after the start of NPPV therapy up to 72 hours
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Dexmedetomidine | Tolerability of NIV as Assessed by an NIV Tolerance Score | 99 percentage of time spent tolerant to NIV |
| Placebo | Tolerability of NIV as Assessed by an NIV Tolerance Score | 67 percentage of time spent tolerant to NIV |
p-value: 0.5495% CI: [0.44, 4.7]Chi-squared
Secondary
Percent of Study Time Spent With a Riker-SAS Score Between 3 and 4 Inclusive
Percentage of time spent at desired sedation goal
Time frame: Completed at baseline and every 4 hours after the start of NPPV therapy for the duration of the study
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Dexmedetomidine | Percent of Study Time Spent With a Riker-SAS Score Between 3 and 4 Inclusive | 100 percentage of time |
| Placebo | Percent of Study Time Spent With a Riker-SAS Score Between 3 and 4 Inclusive | 100 percentage of time |
p-value: 0.3Chi-squared