Bilevel Positive Airway Pressure (BiPAP) for the Treatment of Moderate to Severe Acute Asthma Exacerbations
Bilevel Positive Airway Pressure (BiPAP) for the Treatment of Moderate to Severe Acute Asthma Exacerbations
Bilevel Positive Airway Pressure (BiPAP) is increasingly being reported as an effective and
 safe method of respiratory support for children with severe asthma exacerbations unresponsive
 to standard therapies and with impending respiratory failure. Much of the evidence base
 supporting its use comes from retrospective observational studies, and there is currently a
 lack of data from randomized controlled trials to inform this practice.

 The investigators hypothesize that the use of BiPAP in children with moderate to severe
 asthma exacerbations could reduce the length of hospital stay, need for invasive ventilation,
 and use of intravenous bronchodilators. The investigators aim to test this hypothesis by
 randomizing children attending the Emergency Department with a moderate to severe clinical
 severity score refractory to inhaled bronchodilators to receive either BiPAP in addition to
 standard asthma care, or standard care alone.
Children aged 2 - 18 years presenting to the Emergency Department (ED) with a moderate or
 severe asthma exacerbation (Pediatric Respiratory Assessment Measure (PRAM) of > 3) who fail
 to improve clinically with standard ED management with inhaled salbutamol and ipratropium
 will be randomized to receive either standard asthma management according to our local severe
 asthma guideline or management with BiPAP in addition to standard care. Both groups will
 receive a comparable dose of systemic steroid and hourly salbutamol inhalers with subsequent
 weaning according to PRAM score. Patients randomized to receive BiPAP will be admitted to the
 Pediatric Intensive Care Unit (PICU) and those randomized to the control group will be
 admitted to the medical ward. Both groups will be monitored with 3-hourly PRAM scoring
 through the duration of their admission.
Inclusion Criteria:

 -  2-18 years old

 -  Admitted to BC Children's Hospital with a clinical diagnosis of an acute asthma
 exacerbation

 -  PRAM score of >3 following initial treatment with three rounds of inhaled salbutamol
 and ipratropium bromide, and one dose of systemic steroid

 -  Parents willing and able to sign consent

 -  Children over the age of 6 willing to provide assent

 Exclusion Criteria:

 -  Clinical suspicion of co-existing bacterial pneumonia: focal crackles or bronchial
 breathing, and/or major chest x-ray findings

 -  Impending respiratory failure at presentation requiring direct PICU admission

 -  Receiving maintenance dose of oral steroid at time of hospital admission

 -  Any contraindication to BiPAP use including altered mental status, recent bowel
 surgery, intractable vomiting, or inability to protect airway

 -  Current tracheostomy, home ventilation (IPPV or NIPPV) or home oxygen requirement

 -  History of congenital heart disease or chronic respiratory disease (including
 bronchopulmonary dysplasia, cystic fibrosis, pulmonary hypertension)

 -  Craniofacial abnormality precluding the use of a tight fitting facial mask