- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03126968
Prophylactic Topical Epinephrine to Reduce Bleeding in Transbronchial Lung Biopsies (PROPHET)
Prophylactic Topical Epinephrine to Reduce Transbronchial Lung Biopsy-related Hemorrhage in Lung Transplant Recipients: a Prospective Double-blind Placebo-controlled Trial (PROPHylactic Epinephrine in Transbronchial Biopsy [PROPHET] Trial)
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
The role of prophylactic topical epinephrine in improving hemostasis and prevention of clinically-significant pulmonary hemorrhage has never been studied formally in the past, despite its common use by pulmonologists performing bronchoscopic TBLB. Lung transplant recipients undergo multiple bronchoscopies and TBLBs for surveillance and evaluation of ACR as well as lung infection, especially during the first year post-transplantation. This population may have a predilection to TBLB-related bleeding and may benefit from measures to reduce the frequency and magnitude of this relatively common complication.
In the PROPHET trial, the investigators intend to assess the degree of biopsy-related bleeding, measures taken to control bleeding, and potential effects of bleeding on completion of the intended procedure in 50 bronchoscopy procedures performed on single and double lung transplant recipients, randomized to prophylactic topical epinephrine versus placebo (normal saline). The study participant, physician performing the TBLB, and independent observer reviewing the procedure recording will all be blinded to the randomization. Further use of measures to control bleeding that occurs during the procedure as well as the decision to complete the procedure as planned or to abort it prematurely will be left to the discretion of the performer. In this way, the investigators aim to elucidate a potential role of topical epinephrine in the prevention of TBLB-related airway bleeding in lung transplant recipients and assess whether the dose and volume of instillation used in the investigators' institution comprises an effective means to prevent hemorrhagic complications of TBLB.
HYPOTHESIS
The investigators hypothesize that prophylactic instillation of topical epinephrine prior to performance of TBLB will decrease the frequency and extent of biopsy-related hemorrhage as well as result in fewer procedures being aborted earlier than intended due to bleeding complications as well as shorter overall procedure time due to the preventive effect on bleeding. Concomitantly, the investigators hypothesize that the instillation of topical epinephrine will not be associated with a serious adverse event profile in comparison to placebo.
SPECIFIC AIMS
In this randomized-controlled double blind placebo controlled clinical trial post-lung transplant patients scheduled to receive bronchoscopy with TBLB as part of their routine standard of care will be randomized to receive a fixed dose and volume of topical endobronchial epinephrine versus matching volume of placebo which will be instilled into the target biopsy airway prior to performance of TBLB. This study will specifically aim at providing the following information:
Aim 1: Demonstrate the feasibility of assessments of bleeding related to TBLB, including:
- The degree of TBLB-related bleeding using a standardized grading scale used by the physician performing the procedure to quantify the degree of procedure-related bleeding.
- The degree of TBLB-related bleeding using a standardized grading scale used by two independent observers blinded to patient data and study drug assignment who will review a video recording of the procedure to quantify the degree of procedure-related bleeding.
- The magnitude of inter-observer variability in grading TBLB-related hemorrhage based on review of video recording of the procedure.
Aim 2: Evaluate the hypothesis that prophylactic administration of topical epinephrine results in reductions in TBLB-related hemorrhage in lung transplant recipients, including:
- The frequency of active measures taken to control pulmonary hemorrhage once it occurred.
- The proportion of procedures completed as planned in terms of obtaining a predefined target number of biopsy specimens.
- Comparison between single- and double-lung transplant recipients in terms of prevalence and degree of TBLB-related hemorrhage.
- Identification of clinical factors associated with an increased or decreased risk of procedure-related hemorrhage.
Aim 3: Evaluate the hypothesis that prophylactic administration of topical epinephrine affects the overall efficiency of bronchoscopy with TBLB performance, including:
- Overall duration of the bronchoscopic procedure.
- The proportion of procedures completed as planned in terms of number of adequate biopsies obtained as assessed by the physician performing the bronchoscopy.
- The proportion of procedures resulting in acquisition of adequate biopsy samples that allows proper pathologic evaluation of assignment of a pathologic diagnosis.
Aim 4: Explore the hypothesis that instillation of our prespecified dose and volume of topical epinephrine into the target biopsy airway is not associated with an adverse event profile that is significantly different from placebo, including:
- The prevalence of clinically significant hemodynamic changes.
- The prevalence of cardiac adverse events, including conduction abnormalities, arrhythmia, and myocardial ischemia.
- The prevalence of other vascular adverse events, including stroke, mesenteric ischemia, and critical limb ischemia.
- Identification of clinical factors associated with an increased or decreased risk of drug-related adverse events.
Study Type
Enrollment (Actual)
Phase
- Phase 2
- Phase 3
Contacts and Locations
Study Locations
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Maryland
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Baltimore, Maryland, United States, 21201
- University of Maryland Medical Center
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Baltimore, Maryland, United States, 21201
- University of Maryland Medical Center - Midtown Campus
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Male and female subjects, ≥18 years of age.
- Single- or double-lung transplant recipients scheduled for bronchoscopy with TBLB.
- Willingness to sign an informed consent for study participation.
Exclusion Criteria:
- Age <18 years.
- Pregnancy.
- Inability to understand and provide a written informed consent.
Exclusion criteria for TBLB:
- Platelet count <50 K/microL.
- International normalized ratio (INR) >1.5.
- Known bleeding diathesis.
- Use of prophylactic or therapeutic dose of unfractionated heparin within 6 hours of the procedure.
- Use of prophylactic dose of low molecular weight heparin within 12 hours of the procedure.
- Use of therapeutic dose of low molecular weight heparin within 24 hours of the procedure.
- Use of oral direct thrombin inhibitors or oral factor 10a inhibitors within 48 hours of the procedure.
- Use of clopidogrel, ticlopidine, ticagrelor, or prasugrel within 5 days of the procedure.
- Uremia, defined as estimated glomerular filtration rate (eGFR) ≤30 mL/min.
- Moderate to severe pulmonary hypertension as defined by a mean pulmonary artery pressure of >40 mm Hg on right heart catheterization or an estimated pulmonary artery systolic pressure of >62 mm Hg on transthoracic echocardiography, both performed within 1 year of the procedure.
- An additional synchronous procedure with possible bleeding (bronchoalveolar lavage and endobronchial biopsy allowed).
- Decompensated liver cirrhosis, defined as the presence of clinically significant ascites, clinical evidence of esophageal or gastric varices, or history of bleeding from gastric or esophageal varices.
- Prior history of TBLB-related airway bleeding requiring admission to the hospital or advanced measures to achieve hemostasis, including endotracheal intubation, bronchial blocker application, bronchial artery embolization, or surgical intervention.
Exclusion criteria for application of topical epinephrine:
- Systolic heart failure with an ejection fraction (EF) of <35% as assess by echocardiography performed within one year prior to the procedure.
- Myocardial infarction, acute coronary syndrome, percutaneous coronary intervention, or coronary artery bypass surgery within 6 months prior to the procedure.
- Symptoms and/or ECG findings suggestive of ongoing cardiac ischemia on the day of the procedure.
- Moderate- to severe-grade cardiac valvulopathy as assessed by echocardiography performed within one year prior to the procedure.
- Inadequately controlled supraventricular arrhythmia, including atrial fibrillation, atrial flutter, and atrio-ventricular node re-entrant tachycardia (AVNRT) as revealed by ECG or cardiac monitoring at the time of the procedure.
- Presence of an internal cardioverter/defibrillator.
- History of second or third degree (complete) heart block or sick sinus syndrome.
- Baseline ECG or cardiac monitoring revealing frequent occurrence (≥10 events per minute) of atrial or ventricular ectopy documented prior to or at the time of the procedure.
- History of ventricular arrhythmias requiring pharmacologic or electrical cardioversion within the 2 years preceding the procedure.
- Serum potassium of <3.0 mmol/L within the week prior to the procedure.
- Serum glucose level of ≥300 mg/dL within the week prior to the procedure.
- Any history of critical ischemia related to peripheral arterial disease.
- Persistent resting heart rate (HR) measurement of ≥120 beats per minute prior to or at the time of the procedure.
- Persistent resting systolic blood pressure (SBP) measurement of ≥180 mm Hg prior to or at the time of the procedure.
- Persistent resting diastolic blood pressure (DBP) measurement of ≥110 mm Hg prior to or at the time of the procedure.
- History of acute closed-angle glaucoma within one year of the procedure.
- Diagnosis of pheochromocytoma requiring pharmacologic therapy with an alpha adrenoreceptor blocker at the time of the procedure.
- Diagnosis of thyrotoxicosis requiring pharmacologic therapy with an anti-thyroid agent at the time of the procedure.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Prevention
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Quadruple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
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Experimental: Prophylactic topical epinephrine
Study participants who meet inclusion and exclusion criteria and allocated to this arm will be randomized to receive prophylactic endobronchial topical epinephrine in a blinded manner prior to performance of transbronchial lung biopsy.
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Prophylactic topical epinephrine
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Placebo Comparator: Placebo
Study participants who meet inclusion and exclusion criteria and allocated to this arm will be randomized to receive prophylactic endobronchial topical placebo in the form of normal saline in a blinded manner prior to performance of transbronchial lung biopsy.
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Topical placebo (normal saline)
Other Names:
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Major hemorrhage as defined by two independent reviewers.
Time Frame: Primary outcome is defined as hemorrhage occurring up to 30 minutes after withdrawal of the bronchoscope and deemed related to transbronchial lung biopsy.
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The primary efficacy outcome of the PROPHET Study is the prevalence of major hemorrhage during bronchoscopy as defined by two independent reviewers who will review the procedure video while blinded to the individual patient information, study drug assignment, and any procedure related data not recorded on video. Hemorrhage will be graded according to the following grading system:
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Primary outcome is defined as hemorrhage occurring up to 30 minutes after withdrawal of the bronchoscope and deemed related to transbronchial lung biopsy.
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Occurrence of no, minor, or intermediate bleeding as defined by the independent reviewer.
Time Frame: This outcome is defined as hemorrhage occurring during the bronchoscopic procedure and deemed related to transbronchial lung biopsy and up to 30 minutes following withdrawal of the bronchoscope.
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Prevalence of no-, minor, or intermediate hemorrhage during bronchoscopy as defined by two independent reviewers who will review the procedure video while blinded to the individual patient information, study drug assignment, and any procedure related data not recorded on video.
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This outcome is defined as hemorrhage occurring during the bronchoscopic procedure and deemed related to transbronchial lung biopsy and up to 30 minutes following withdrawal of the bronchoscope.
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Intra-procedural hemorrhage grading by the performing bronchoscopist
Time Frame: This outcome will be analyzed at the time of procedure performance and up to 48 hours following the procedure.
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Intra-procedural hemorrhage will be graded by the performing bronchoscopist according to the following scale:
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This outcome will be analyzed at the time of procedure performance and up to 48 hours following the procedure.
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Number of forceps passes performed
Time Frame: This outcome will be analyzed at the time of procedure performance.
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Number of biopsy forceps passes performed during bronchoscopy.
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This outcome will be analyzed at the time of procedure performance.
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Number of adequate tissue samples obtained
Time Frame: This outcome will be analyzed at the time of procedure performance.
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Number of adequate tissue samples obtained during bronchoscopy as assessed by the performing bronchoscopist.
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This outcome will be analyzed at the time of procedure performance.
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Early termination of the procedure
Time Frame: This outcome will be analyzed at the time of procedure performance.
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Early termination of the procedure due to bleeding complication, defined as non-achievement of the target number of tissue samples as designated by the performing bronchoscopist prior to the procedure related to hemorrhage.
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This outcome will be analyzed at the time of procedure performance.
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Duration of the procedure
Time Frame: Duration of the procedure from first bronchoscope insertion to last bronchoscope withdrawal.
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Duration of the procedure from first bronchoscope insertion to last bronchoscope withdrawal.
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Duration of the procedure from first bronchoscope insertion to last bronchoscope withdrawal.
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Total volume of iced saline used
Time Frame: This outcome will be analyzed at the time of procedure performance.
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Total volume (mL) of iced saline used during the procedure.
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This outcome will be analyzed at the time of procedure performance.
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Total dose of unblended topical epinephrine used
Time Frame: This outcome will be analyzed at the time of procedure performance.
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Total dose (mg) of unblended topical epinephrine used during the procedure.
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This outcome will be analyzed at the time of procedure performance.
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Any use of hemostatic measures
Time Frame: This outcome will be analyzed at the time of procedure performance.
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Any use of hemostatic procedures including balloon tamponade, endobronchial blocker, bronchial artery embolization, emergency surgery.
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This outcome will be analyzed at the time of procedure performance.
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Any use of devices or procedures with intention of securing the airway
Time Frame: This outcome will be analyzed at the time of procedure performance.
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Any use of devices or procedures with intention of securing the airway including oral airway, nasal airway, laryngeal mask, endotracheal intubation, emergency cricothyroidotomy, and emergency tracheostomy.
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This outcome will be analyzed at the time of procedure performance.
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Unplanned admission to the hospital.
Time Frame: This outcome will be analyzed at the time of procedure performance and up to 48 hours following the procedure.
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Unplanned admission to the hospital.
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This outcome will be analyzed at the time of procedure performance and up to 48 hours following the procedure.
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Pathologic diagnosis achieved.
Time Frame: Up to 30 days post-procedure.
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Biopsy resulting in acquisition of a specimen which allows a viable pathologic diagnosis.
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Up to 30 days post-procedure.
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All-cause mortality
Time Frame: Within 3 hours on instillation of study drug.
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All-cause mortality
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Within 3 hours on instillation of study drug.
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Acute cardiovascular event
Time Frame: Within 30 minutes of instillation of the study drug.
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Acute cardiovascular event, including cardiac arrest, new onset chest pain, acute myocardial ischemia, pulmonary edema, acute ischemic stroke, critical limb ischemia, acute mesenteric ischemia.
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Within 30 minutes of instillation of the study drug.
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Acute closed angle glaucoma
Time Frame: Within 30 minutes of instillation of the study drug.
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Acute closed angle glaucoma
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Within 30 minutes of instillation of the study drug.
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New onset ECG changes suggestive of myocardial ischemia
Time Frame: Within 30 minutes of instillation of the study drug.
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New onset ECG changes suggestive of myocardial ischemia, including ST segment changes (defined: ≥1 mm ST segment elevation or ≥3 mm ST segment depression in ≥2 precordial or limb ECG leads that correspond together to one of the cardiac walls), new onset ventricular tachycardia, significant increase (≥10 per minute) in occurrence of ventricular ectopic beats, new onset supraventricular arrhythmia, new onset bundle branch block, and new onset 2nd or 3rd degree atrioventricular block.
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Within 30 minutes of instillation of the study drug.
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Significant change in heart rate
Time Frame: Within 30 minutes of instillation of the study drug.
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Significant change in heart rate, defined as heart rate of >120 bpm and/or increase by ≥30 bpm above the baseline or heart rate <60 bpm and/or ≥30 bpm below the baseline.
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Within 30 minutes of instillation of the study drug.
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Significant change in systolic blood pressure
Time Frame: Within 30 minutes of instillation of the study drug.
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Significant change in systolic blood pressure, defined as increase in systolic blood pressure >180 mm Hg and/or ≥40 mm Hg above the baseline; increase in diastolic blood pressure >110 mm Hg and/or ≥20 mm Hg above the baseline; or fall in systolic blood pressure <90 mm Hg and/or ≥20 mm Hg below the baseline.
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Within 30 minutes of instillation of the study drug.
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Collaborators and Investigators
Investigators
- Principal Investigator: Robert M Reed, MD, University of Maryland School of Medicine
Publications and helpful links
General Publications
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- Paret G, Vaknin Z, Ezra D, Peleg E, Rosenthal T, Vardi A, Mayan H, Barzilay Z. Epinephrine pharmacokinetics and pharmacodynamics following endotracheal administration in dogs: the role of volume of diluent. Resuscitation. 1997 Aug;35(1):77-82. doi: 10.1016/s0300-9572(96)01091-x.
- Diette GB, Wiener CM, White P Jr. The higher risk of bleeding in lung transplant recipients from bronchoscopy is independent of traditional bleeding risks: results of a prospective cohort study. Chest. 1999 Feb;115(2):397-402. doi: 10.1378/chest.115.2.397.
- Hopkins PM, Aboyoun CL, Chhajed PN, Malouf MA, Plit ML, Rainer SP, Glanville AR. Prospective analysis of 1,235 transbronchial lung biopsies in lung transplant recipients. J Heart Lung Transplant. 2002 Oct;21(10):1062-7. doi: 10.1016/s1053-2498(02)00442-4.
- Baz MA, Layish DT, Govert JA, Howell DN, Lawrence CM, Davis RD, Tapson VF. Diagnostic yield of bronchoscopies after isolated lung transplantation. Chest. 1996 Jul;110(1):84-8. doi: 10.1378/chest.110.1.84.
- Kalchiem-Dekel O, Iacono A, Pickering EM, Sachdeva A, Shah NG, Sperry M, Tran BC, Reed RM. Prophylactic epinephrine for the prevention of transbronchial lung biopsy-related bleeding in lung transplant recipients (PROPHET) study: a protocol for a multicentre randomised, double-blind, placebo-controlled trial. BMJ Open. 2019 Mar 23;9(3):e024521. doi: 10.1136/bmjopen-2018-024521.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Pathologic Processes
- Respiratory Tract Diseases
- Lung Diseases
- Signs and Symptoms, Respiratory
- Hemorrhage
- Hemoptysis
- Physiological Effects of Drugs
- Adrenergic Agents
- Neurotransmitter Agents
- Molecular Mechanisms of Pharmacological Action
- Autonomic Agents
- Peripheral Nervous System Agents
- Adrenergic alpha-Agonists
- Adrenergic Agonists
- Bronchodilator Agents
- Anti-Asthmatic Agents
- Respiratory System Agents
- Adrenergic beta-Agonists
- Sympathomimetics
- Vasoconstrictor Agents
- Mydriatics
- Epinephrine
Other Study ID Numbers
- HP-00070208
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
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