Asthma in Children
Conditions
Keywords
Pediatric Asthma, Asthma, Bi-level Positive Airway Pressure, BiPAP, Beta-Agonist
Brief summary
The goal of this clinical trial is to study if starting bi-level positive airway pressure (BiPAP), a mask that gives pressure to the lungs, works well for children in the emergency department with moderate to severe asthma attacks. The main questions it aims to answer are: 1. Whether initiation of BiPAP at the same time as continuous beta-agonist therapy (e.g., nebulized albuterol) will decrease how long children with moderate to severe asthma attacks need to receive continuous beta-agonist therapy. 2. Whether early BiPAP changes how the lungs function in children with asthma attacks. 3. Whether children receiving early BiPAP experience more issues or side effects than those children who do not. All children will receive the usual treatment for asthma attacks; if they are still experiencing moderate to severe symptoms after the initial treatment, they will be asked to participate in the study. Participants will then wear a mask while they are receiving the continuous beta-agonist therapy. Some patients will receive BiPAP where pressure is given to the lungs and others will have a sham BiPAP mask where no pressure is given to the lungs. Study participants will wear the mask for 4 hours or until their treatment team feels they are ready to come off of the continuous beta-agonist therapy. Participants will receive more medications and decisions on going home or being admitted to the hospital will be decided as usual by their treatment team. Researchers will compare BiPAP versus Control (Sham BiPAP) groups to see if there is a difference in how long continuous beta-agonist therapy is needed, how the lungs are functioning, and number or type of side effects.
Interventions
An appropriately sized vented BiPAP face mask with a good seal will be applied and monitored by trained respiratory therapists. Patients will be started on an inspiratory peak airway pressure (IPAP) of 10 cm of water and expiratory positive airway pressure (EPAP) of 5 cm of water per Children's Hospital Colorado (CHCO) clinical pathway. BiPAP pressures will be titrated to effect per the treating physician, using assessment of physical examination, vitals, and asthma score per institutional clinical pathway. Study participants will remain on BiPAP for four hours or until weaned off continuous beta-agonist therapy by the treating clinician. After the four-hour intervention period, it is at the discretion of the treating clinician regarding the ongoing use of BiPAP or not.
DEVICESham Bi-level Positive Airway Pressure
The sham BiPAP will have pressure attenuated using an orifice restrictor as described in previous double blinded studies using sham non-invasive ventilation. With this set-up pressures no greater than 2 cm of water have been documented at the location of the face mask. This will ensure that the patient is not receiving positive pressure with any effectiveness or deleterious effects. Study participants will remain on sham BiPAP for four hours or until weaned off continuous beta-agonist therapy by the treating clinician. After the four-hour intervention period, it is at the discretion of the treating clinician regarding the use of BiPAP or not.
Sponsors
National Heart, Lung, and Blood Institute (NHLBI)
University of Colorado, Denver
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Caregiver)
Eligibility
Sex/Gender
ALL
Age
5 Years to 17 Years
Healthy volunteers
No
Inclusion criteria
* 5 to 17 years of age (inclusive) presenting to the ED with an asthma exacerbation * Prior diagnosis of asthma by a physician who prescribed asthma medications (beta-agonist and/or inhaled or oral steroids) * PRAM score of 4 or greater after administration of first-line therapy (albuterol/ipratropium back to backs, corticosteroids, +/- oxygen) and need for continuous beta-agonist therapy after first-line therapy
Exclusion criteria
* Prior participation in the study * Hypercapnic (PaCO2 \> 60 mmHg) respiratory failure or need for invasive mechanical ventilation as determined by the treating physician * Hypoxemic respiratory failure (SaO2 \< 90% with fraction of inspired oxygen inspired oxygen fraction (FiO2) \> 0.35) * Presence of a tracheostomy or baseline noninvasive ventilation requirement * Non-asthma causes of wheezing: foreign body, tracheomalacia, vocal cord dysfunction, pulmonary edema, uncorrected congenital heart disease, cystic fibrosis, anaphylaxis * Absolute or relative contraindication to BiPAP: facial trauma, uncontrollable vomiting, hypotension for age, Glasgow Coma Score of 8 or less, drowsiness or confusion, known or clinical suspicion for pneumothorax, pneumomediastinum, or subcutaneous emphysema, pregnancy
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Duration of Continuous Beta-Agonist Therapy | Through study completion, an average of 24 hours | Number of hours until discontinuation of continuous beta-agonist therapy |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Respiratory Rate | At two and four hours after starting the intervention | Change in respiratory rate in breaths per minute from baseline to two and four hours |
| Invasive Mechanical Ventilation | Four-hour study intervention | Rate of participants requiring endotracheal intubation for invasive mechanical ventilation |
| Admission to Pediatric Intensive Care Unit (PICU) | Through entire hospitalization, an average of 72 hours | Rate of admissions to the Pediatric Intensive Care Unit (PICU) |
| Total Length of Stay in Hospital | Through entire hospitalization, an average of 72 hours | Total length of stay in hours in the Emergency Department (ED), Pediatric Intensive Care Unit (PICU), and hospital floor |
| Change in Pediatric Respiratory Assessment Measure (PRAM) | At two and four hours after starting the intervention | Change in Pediatric Respiratory Assessment Measure (PRAM) from baseline to two and four hours, minimum score of 0 and maximum score of 12, the higher the score the more severe the disease |
| Duration of Bilevel Positive Airway Pressure (BiPAP) | Through entire hospitalization, an average of 72 hours | Duration in hours of BiPAP administration |
| Adverse Events | Four-hour study intervention | Pneumothorax, pneumomediastinum, sub-cutaneous emphysema, hypotension, vomiting, aspiration, skin breakdown |
| Change in Pulse Oxygen Saturation | At 2 hour and 4 hours after starting the intervention | Change in pulse oxygen saturation (range from 0 to 100%) from baseline to two and four hours |
| Change in Heart Rate | At 2 hour and 4 hours after starting the intervention | Change in heart rate in beats per minute from baseline to two and four hours |
| Hospital Readmissions | 7 days from hospital discharge date | Rate of hospital readmission within 7 days |
Countries
United States
Outcome results
None listed