Bilevel Positive Airway Pressure (BPAP) for Severe Asthma

Bilevel Positive Airway Pressure (BPAP) for Severe Asthma Exacerbations: A Randomized Controlled Trial

The goal of this clinical trial is to assess the feasibility of early initiation of bilevel positive airway pressure (BPAP) in the emergency department (ED) for children with severe asthma exacerbations. It will also collect preliminary data on the safety and potential effectiveness of this approach.

The main questions it aims to answer are:

1. Can eligible patients be successfully enrolled and complete study procedures across multiple sites?
2. What safety events occur with early BPAP use in this population?
3. How do clinical outcomes (such as symptom improvement and need for intensive care) compare between early BPAP and standard care?

Researchers will compare early initiation of BPAP plus standard asthma therapy to standard asthma therapy alone to determine whether early BPAP is a feasible and potentially beneficial treatment strategy.

Participants will 1) receive standard asthma therapy with or without early BPAP in the ED, 2) be monitored closely during the ED visit and hospitalization, and 3) have clinical data collected from routine care, including asthma severity scores, treatments, and outcomes.

The study will enroll approximately 36 participants (about 12 per site) across three sites over one year to inform a future multicenter randomized controlled trial.

Study Overview

• Status: Not yet recruiting
• Conditions: Acute Asthma; Pediatric Asthma; Non-invasive Positive Pressure Ventilation; BiPAP
• Intervention / Treatment: Device: Bilevel positive airway pressure ventilation

Detailed Description

Severe asthma exacerbations are a common reason for pediatric emergency department (ED) visits, hospital admissions, and pediatric intensive care unit (PICU) use. Although first-line therapies such as inhaled beta-agonists, anticholinergics, and systemic corticosteroids are well established, the optimal second-line treatment for children who remain in moderate to severe respiratory distress is unclear.

Bilevel positive airway pressure (BPAP) is a form of non-invasive positive pressure ventilation that may improve airway patency, reduce work of breathing, improve ventilation-perfusion matching, and enhance delivery of inhaled bronchodilator therapy. Prior pediatric studies suggest potential physiologic and clinical benefit, but available randomized trials have been small and have generally evaluated BPAP after PICU admission rather than early in the ED course. Therefore, the feasibility, safety, and potential clinical impact of early ED initiation of BPAP remain uncertain.

This multicenter, randomized, unblinded feasibility trial will enroll approximately 36 children across three sites. Participants will be children with severe asthma exacerbations who remain symptomatic after completion of standard first-line therapy and continue to require continuous albuterol. Patients will be randomized to receive either BPAP plus continuous albuterol or continuous albuterol alone during an approximately 2-hour intervention period. BPAP will be delivered using FDA-cleared devices, with mask interface and pressure settings managed according to routine clinical practice. After the intervention period, all further asthma treatment and respiratory support will be determined by the treating clinical team.

The primary purpose of this study is to assess feasibility of conducting a future definitive multicenter randomized trial. Feasibility domains include patient identification, consent and assent processes, timely randomization, BPAP initiation and adherence, completion of asthma severity assessments, and collection of clinical and safety data. Clinical outcomes, including asthma severity, duration of continuous albuterol, BPAP use, ED disposition, PICU and hospital admission, length of stay, and readmission, will be summarized descriptively. Safety monitoring will include adverse events potentially related to BPAP or continuous albuterol, including air leak syndrome, vomiting, aspiration, hypotension, skin breakdown, tachycardia, and tremor.

This feasibility trial is not powered to detect treatment efficacy. Results will be used to refine trial procedures, assess protocol adherence, estimate enrollment and data completion rates, and inform the design of a future multicenter randomized trial evaluating whether early ED initiation of BPAP reduces critical care resource use and improves outcomes in children with severe asthma exacerbations.

• Study Type: Interventional
• Enrollment (Estimated): 36
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Maria Kwok, MD, MPH; Phone Number: 917-375-2647; Email: myk2102@cumc.columbia.edu

Study Locations

• United States
  • New York
    • New York, New York, United States, 10032
      • Columbia University Irving Medical Center
      • Contact: Maria Kwok, MD, MPH; Phone Number: 917-375-2647; Email: myk2102@cumc.columbia.edu
  • Ohio
    • Columbus, Ohio, United States, 43205
      • Nationwide Children's Hospital
      • Contact: Adjoa Andoh, MD; Phone Number: 614-355-3713; Email: adjoa.andoh@nationwidechildrens.org
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19104
      • Children's Hospital of Philadelphia
      • Contact: Joe Zorc, MD, MSCE; Phone Number: 215-590-5237; Email: zorc@chop.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. 5 to 17 years of age (inclusive) presenting to the ED with an asthma exacerbation.
2. Demonstrate moderate-severe asthma exacerbation at triage (i.e., receive an institutional asthma score equivalent to moderate-severe asthma exacerbation or a Pediatric Respiratory Assessment Measure (PRAM) score of 6 or above).

Exclusion Criteria:

1. Prior participation in the study.
2. Use of BPAP at any time within approximately 12 hours for this acute asthma exacerbation, including in prehospital, ED, or inpatient settings, prior to randomization.
3. Receipt of continuous albuterol for over 150 minutes prior to being approached for consent.

4. If a blood gas is obtained, PaCO2 greater than 60 mmHg on the most recent blood gas prior to being approached for consent.

   Note: Blood gas values are not required for eligibility confirmation.

5. Anticipated immediate need (i.e., within approximately an hour after completion of first-line therapy) for invasive mechanical ventilation (e.g., endotracheal tube or laryngeal mask airway) or non-invasive mechanical ventilation (e.g., continuous positive airway pressure (CPAP) or BPAP), as determined by the treating physician.
6. Presence of a tracheostomy or a baseline requirement for noninvasive ventilation.
7. Wheezing due to non-asthma causes (e.g., foreign body, tracheomalacia, vocal cord dysfunction, pulmonary edema, uncorrected congenital heart disease, cystic fibrosis, or anaphylaxis).

8. Absolute or relative contraindication to BPAP, defined as any of the following:

   1. Facial trauma within the area where the face mask would be applied for BPAP (excluding minor abrasion or cuts on forehead or skull).
   2. Uncontrollable vomiting (i.e., > 3 episodes within approximately 1 hour prior to being approached for consent).
   3. Hypotension for age, defined as systolic blood pressure (SBP) less than 70 plus twice the patient's age in years (i.e., SBP < 70 + [2 x age in years]).
   4. Glasgow Coma Score of 8 or less.
   5. Known or clinical suspicion for air leak syndrome (e.g., pneumothorax, pneumomediastinum, pneumopericardium, or subcutaneous emphysema).
9. Weight < 20 kg.
10. Presence of an intra-abdominal mass compressing the stomach (e.g., due to tumor or large volume ascites) through EMR or medical history.
11. Known or suspected pregnancy by history or if pregnancy test completed by clinical team.
12. Any medical condition that, in the opinion of a site investigator, could 1) lead to difficulty complying with protocol procedures, 2) interfere with the safe completion of the study, or 3) affect the validity of the endpoint assessments.

13. PRAM score less than 7 or greater than 10 based on concurrent clinical assessment by a healthcare provider after completion of standard first-line therapies, which is defined as receiving all of the following prior to ED arrival or during the ED encounter for this acute asthma exacerbation:

    1. Albuterol with or without ipratropium bromide, either at least 3 albuterol doses via inhalation method (e.g., metered-dose inhaler (MDI) or nebulized) or at least one hour of continuous albuterol (i.e., continuous nebulized albuterol or three consecutive intermittent nebulized albuterol treatments as bridging therapy).
    2. Corticosteroids (e.g., Prednisolone, Prednisone, Dexamethasone/Decadron, or Methylprednisolone) via enteral, intravenous, or intramuscular methods.

    Note: Oxygen is not a required first-line therapy.

14. Do not require continuous albuterol or a second round of albuterol treatments (e.g., three back-to-back treatments or one hour of burst albuterol treatment) following completion of standard first-line therapies.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: BPAP plus continuous albuterol; Participants randomized to this arm will receive BPAP plus continuous albuterol administered via FDA-approved delivery systems according to routine clinical practice. BPAP will be delivered using an appropriately sized nasal or face mask and managed by trained respiratory therapists and/or nursing staff per standard care. Continuous albuterol will be administered through the BPAP circuit per manufacturer recommendations or site-specific practice. BPAP settings may be adjusted at the discretion of the treating clinician. Participants will remain on BPAP for approximately 2 hours or until continuous albuterol is discontinued, whichever occurs first. After the intervention period, continuation of BPAP will be at the treating clinical team's discretion.	Device: Bilevel positive airway pressure ventilation; This study involves non-invasive positive pressure ventilation (NIPPV) delivered as bilevel positive airway pressure (BPAP) in children aged 5-17 years presenting to the pediatric emergency department with severe asthma exacerbations. BPAP will be administered using FDA-cleared devices according to their intended use and standard clinical practice. Therapy will be delivered via an appropriately fitted nasal or face mask and managed by trained clinical staff. Ventilator settings will be adjusted at the discretion of the treating clinician, and continuous bronchodilator therapy may be delivered through the BPAP circuit per manufacturer recommendations or site practice.
No Intervention: Continuous albuterol alone; Participants randomized to this arm will receive continuous albuterol administered via FDA-approved delivery systems according to routine clinical practice. Non-invasive ventilation (including BPAP or CPAP) will not be initiated during the first approximately 2 hours after randomization unless clinically indicated; if initiated, the reason will be documented. All other aspects of care, including oxygen and adjunctive therapies, will be provided at the discretion of the treating clinical team per standard practice. After the intervention period, escalation of care, including initiation of BPAP or other respiratory support, will be determined by the treating clinician.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of eligible patients who consent	Proportion of approached, eligible patients who provide consent.	From screening through randomization, up to 2 hours
Proportion of participants who adhere to the BPAP protocol among all those assigned to the BPAP arm	Proportion of participants in the intervention arm who receive > 1 hour & 45 minutes of BPAP during the planned 2-hour intervention period without unplanned interruption (> 15 consecutive minutes), unless weaned off continuous albuterol.	From randomization through end of 2-hour intervention

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Potential efficacy outcome: Duration of continuous albuterol use	Duration of continuous albuterol therapy	From randomization through hospital discharge beyond the intervention period, up to 120 hours.
Potential efficacy outcome: Duration of BPAP use	Duration of BPAP use	From randomization through hospital discharge beyond the intervention period, up to 120 hours
Potential efficacy outcome: PICU admission	Proportion of participants requiring admissions to the pediatric intensive care unit during the index ED visit	Disposition determined 2 hours after completion of the intervention period
Potential efficacy outcome: Hospital admission	Proportion of participants requiring hospital admission during the index ED visit	Disposition determined 2 hours after completion of the intervention period
Potential efficacy outcome: PICU length of stay	Length of stay in the PICU (hours) among participants admitted to the PICU.	From PICU admission to PICU discharge, up to 120 hours
Potential efficacy outcome: Hospital length of stay	Total hospital length of stay (hours) among admitted participants.	From hospital admission to hospital discharge, up to 120 hours
Safety outcome: Air Leak Syndrome	Proportion of participants with air leak complications (e.g., pneumothorax, pneumomediastinum, pneumopericardium, or subcutaneous emphysema).	From randomization until 4 hours post-randomization or until ED discharge, whichever occurs first.
Safety outcome: Vomiting	Proportion of participants experiencing vomiting.	From randomization until 4 hours post-randomization or until ED discharge, whichever occurs first.
Safety outcome: Pulmonary aspiration	Proportion of participants with suspected aspiration, defined as emesis followed by new findings on chest radiograph.	From randomization until 4 hours post-randomization or until ED discharge, whichever occurs first.
Safety outcome: Systolic hypotension	Proportion of participants with systolic blood pressure below the 5th percentile for age (defined as <70 mmHg + [2 × age in years]).	From randomization until 4 hours post-randomization or until ED discharge, whichever occurs first.
Safety outcome: Facial skin breakdown	Proportion of participants with facial pressure injury of Stage 2 or higher per National Pressure Injury Advisory Panel (NPIAP) criteria.	From randomization until 4 hours post-randomization or until ED discharge, whichever occurs first.
Potential efficacy outcome: Change in Pediatric Respiratory Assessment Measure (PRAM) score	Change in Pediatric Respiratory Assessment Measure (PRAM) score from the pre-intervention to post-intervention assessment. The PRAM score ranges from 0 to 12, with higher scores indicating greater acute asthma exacerbation severity. Scores are categorized as mild (0-3), moderate (4-7), and severe (8-12).	Pre-intervention to end of intervention, approximately 3 hours total

Collaborators and Investigators

• Sponsor: Columbia University
• Collaborators: Children's Hospital of Philadelphia; National Heart, Lung, and Blood Institute (NHLBI); Nationwide Children's Hospital; University of Utah

Study record dates

Study Major Dates

• Study Start (Estimated): June 1, 2026
• Primary Completion (Estimated): June 1, 2027
• Study Completion (Estimated): August 1, 2027

Study Registration Dates

• First Submitted: May 6, 2026
• First Submitted That Met QC Criteria: May 6, 2026
• First Posted (Actual): May 12, 2026

Study Record Updates

• Last Update Posted (Actual): May 15, 2026
• Last Update Submitted That Met QC Criteria: May 13, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Other Study ID Numbers: ACYY1620; 1R34HL173384-01A1 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes
• product manufactured in and exported from the U.S.: Yes