Brief Summary
Severe pediatric acute respiratory distress syndrome (PARDS) is a life-threatening and frequent problem experienced by thousands of children each year. Little evidence supports current supportive practices during their critical illness. The overall objective of this study is to identify the best positional and/or ventilation practice that leads to improved patient outcomes in these critically ill children. We hypothesize that children with high moderate-severe PARDS treated with either prone positioning or high-frequency oscillatory ventilation (HFOV) will demonstrate more days off the ventilator when compared to children treated with supine positioning or conventional mechanical ventilation (CMV).
Brief Title
PROSpect: Prone and Oscillation Pediatric Clinical Trial
Detailed Description
PROSpect is a two-by-two factorial, response-adaptive, randomized controlled clinical trial of supine/prone positioning and conventional mechanical ventilation (CMV)/high-frequency oscillatory ventilation (HFOV). About 60 pediatric intensive care units (PICUs), two thirds U.S. and one third international, with at least 5 years of experience with prone positioning and HFOV in the care of pediatric patients with severe Pediatric Acute Respiratory Distress Syndrome (PARDS), that can provide back-up extracorporeal membrane oxygenation (ECMO) support, are participating. Eligible consecutive subjects with high moderate-severe PARDS will be randomized to one of four groups: supine/CMV, prone/CMV, supine/HFOV, prone/HFOV. Subjects who fail their assigned positional and/or ventilation therapy for either persistent hypoxia or hypercapnia may receive the reciprocal therapy while being considered for ECMO cannulation. Our primary outcome is ventilator-free days (VFD) through day 28, where non-survivors receive zero VFD. We hypothesize that children with severe PARDS treated with either prone positioning or HFOV will demonstrate ≥ 2 more VFD. Our secondary outcome is nonpulmonary organ failure-free days. We will also explore the interaction effects of prone positioning with HFOV on VFDs and also investigate the impact of these interventions on 90-day in-hospital mortality and, among survivors, the duration of mechanical ventilation, PICU and hospital length of stay, and the trajectory of post-PICU functional status and health-related quality of life (HRQL). Up to 600 subjects with severe PARDS will be randomized, stratified by age group and direct/indirect lung injury. Adaptive randomization will first occur after 300 patients are randomized and have been followed for 28 days, and every 100 patients thereafter. At these randomization update analyses, new allocation probabilities will be computed based on ongoing intention-to-treat trial results, increasing allocation to well performing arms and decreasing allocation to poorly performing arms. Data will be analyzed per intention-to-treat for the primary analyses and per-protocol received for primary, secondary and exploratory analyses.
Categories
Completion Date
Completion Date Type
Estimated
Conditions
Acute Respiratory Distress Syndrome in Children
Eligibility Criteria
Inclusion criteria:
Intubated and mechanically ventilated with high moderate-severe PARDS for \<48 hours per PALICC guidelines (chest imaging consistent with acute pulmonary parenchymal disease and OI ≥12 or OSI ≥10). We require two blood gases meeting moderate-severe PARDS criteria (separated by at least 4 ± 2 hours during which time the clinical team is actively working to recruit lung volume and optimize the patient's hemodynamic status per PALICC guidelines; specifically, incremental and decremental PEEP changes to optimize lung volume). A second blood gas is not required for OI ≥16.
Exclusion criteria:
* Perinatal related lung disease
* Unrepaired congenital diaphragmatic hernia or congenital/acquired diaphragm paralysis
* Respiratory failure explained by cardiac failure or fluid overload
* Cyanotic heart disease
* Cardiomyopathy
* Unilateral lung disease
* Primary pulmonary hypertension
* Intubated for status asthmaticus
* Obstructive airway disease (e.g., Severe airways disease without parenchymal involvement or disease characterized by hypercapnia with FiO2 \<0.30 and/or evidence of increased resistance visible on the flow - time scalar and/or presence of intrinsic PEEP)
* Active air leak
* Bronchiolitis obliterans
* Post hematopoietic stem cell transplant; specifically, patients receiving continuous supplemental oxygen for three or more days prior to intubation; receiving noninvasive ventilation for more than 24 hours prior to intubation; receiving more than one vasoactive medication at time of meeting inclusion criteria; spending more than four days in the PICU prior to intubation; supported on or with immediate plans for renal replacement therapies; with two or more allogeneic transplants; who relapsed after the transplant; or with diffuse alveolar hemorrhage
* Post lung transplant
* Home ventilator dependent with baseline Oxygen Saturation Index (OSI) \>6
* Neuromuscular respiratory failure
* Critical airway (e.g., post laryngotracheal surgery or new tracheostomy) or anatomical obstruction of the lower airway (e.g., mediastinal mass)
* Facial surgery or trauma in previous 2 weeks
* Head trauma (managed with hyperventilation)
* Intracranial bleeding
* Unstable spine, femur or pelvic fractures
* Open abdomen
* Currently receiving more than 6 consecutive hours of either prone positioning or HFOV
* Supported on ECMO during the current admission
* Family/medical team not providing full support (patient treatment considered futile)
* Previously enrolled in current study
* Enrolled in any other interventional clinical trial not approved for co-enrollment
* Known pregnancy
Intubated and mechanically ventilated with high moderate-severe PARDS for \<48 hours per PALICC guidelines (chest imaging consistent with acute pulmonary parenchymal disease and OI ≥12 or OSI ≥10). We require two blood gases meeting moderate-severe PARDS criteria (separated by at least 4 ± 2 hours during which time the clinical team is actively working to recruit lung volume and optimize the patient's hemodynamic status per PALICC guidelines; specifically, incremental and decremental PEEP changes to optimize lung volume). A second blood gas is not required for OI ≥16.
Exclusion criteria:
* Perinatal related lung disease
* Unrepaired congenital diaphragmatic hernia or congenital/acquired diaphragm paralysis
* Respiratory failure explained by cardiac failure or fluid overload
* Cyanotic heart disease
* Cardiomyopathy
* Unilateral lung disease
* Primary pulmonary hypertension
* Intubated for status asthmaticus
* Obstructive airway disease (e.g., Severe airways disease without parenchymal involvement or disease characterized by hypercapnia with FiO2 \<0.30 and/or evidence of increased resistance visible on the flow - time scalar and/or presence of intrinsic PEEP)
* Active air leak
* Bronchiolitis obliterans
* Post hematopoietic stem cell transplant; specifically, patients receiving continuous supplemental oxygen for three or more days prior to intubation; receiving noninvasive ventilation for more than 24 hours prior to intubation; receiving more than one vasoactive medication at time of meeting inclusion criteria; spending more than four days in the PICU prior to intubation; supported on or with immediate plans for renal replacement therapies; with two or more allogeneic transplants; who relapsed after the transplant; or with diffuse alveolar hemorrhage
* Post lung transplant
* Home ventilator dependent with baseline Oxygen Saturation Index (OSI) \>6
* Neuromuscular respiratory failure
* Critical airway (e.g., post laryngotracheal surgery or new tracheostomy) or anatomical obstruction of the lower airway (e.g., mediastinal mass)
* Facial surgery or trauma in previous 2 weeks
* Head trauma (managed with hyperventilation)
* Intracranial bleeding
* Unstable spine, femur or pelvic fractures
* Open abdomen
* Currently receiving more than 6 consecutive hours of either prone positioning or HFOV
* Supported on ECMO during the current admission
* Family/medical team not providing full support (patient treatment considered futile)
* Previously enrolled in current study
* Enrolled in any other interventional clinical trial not approved for co-enrollment
* Known pregnancy
Inclusion Criteria
Inclusion criteria:
Intubated and mechanically ventilated with high moderate-severe PARDS for \<48 hours per PALICC guidelines (chest imaging consistent with acute pulmonary parenchymal disease and OI ≥12 or OSI ≥10). We require two blood gases meeting moderate-severe PARDS criteria (separated by at least 4 ± 2 hours during which time the clinical team is actively working to recruit lung volume and optimize the patient's hemodynamic status per PALICC guidelines; specifically, incremental and decremental PEEP changes to optimize lung volume). A second blood gas is not required for OI ≥16.
Intubated and mechanically ventilated with high moderate-severe PARDS for \<48 hours per PALICC guidelines (chest imaging consistent with acute pulmonary parenchymal disease and OI ≥12 or OSI ≥10). We require two blood gases meeting moderate-severe PARDS criteria (separated by at least 4 ± 2 hours during which time the clinical team is actively working to recruit lung volume and optimize the patient's hemodynamic status per PALICC guidelines; specifically, incremental and decremental PEEP changes to optimize lung volume). A second blood gas is not required for OI ≥16.
Gender
All
Gender Based
false
Keywords
Pediatric Acute Respiratory Distress Syndrome (PARDS)
Acute Respiratory Distress Syndrome (ARDS)
acute respiratory failure
child
pediatric intensive care unit
Healthy Volunteers
No
Last Update Post Date
Last Update Post Date Type
Actual
Last Update Submit Date
Maximum Age
20 Years
Minimum Age
2 Weeks
NCT Id
NCT03896763
Org Class
Other
Org Full Name
University of Pennsylvania
Org Study Id
831295
Overall Status
Enrolling by invitation
Phases
Not Applicable
Primary Completion Date
Primary Completion Date Type
Estimated
Official Title
PROSpect: Prone and Oscillation Pediatric Clinical Trial
Primary Outcomes
Outcome Description
Our primary research hypothesis is that children with severe PARDS randomized to either prone positioning or HFOV will demonstrate more ventilator-free days. We hypothesize that a superior treatment would improve VFD by at least 2 days, a clinically meaningful difference. VFD is the number of days within 28 days that a patient is alive and free of mechanical ventilation. Improvement in VFD will be considered within the context of patient safety; specifically, patients must also exhibit a similar safety profile.
Outcome Measure
Ventilator-free Days (VFD)
Outcome Time Frame
28 days
Secondary Ids
Secondary Id
5UH3HL141736-03
Secondary Outcomes
Outcome Description
Our secondary research hypothesis is that children with severe PARDS randomized to either prone positioning or HFOV will demonstrate more more nonpulmonary organ failure-free days. OFFD is the number of days within 28 days that a patient is alive and free of clinically significant non-pulmonary organ failure. Nonpulmonary organ failure-free days will be calculated based on the clinically important nonpulmonary organ systems (neurologic, cardiovascular, renal and hematologic) using nonpulmonary PEdiatric Logistic Organ Dysfunction-2 (PELOD-20 scores.
Outcome Time Frame
28 days
Outcome Measure
Nonpulmonary organ failure-free days (OFFD)
See Also Links
Url
Start Date
Start Date Type
Actual
Status Verified Date
First Post Date
First Post Date Type
Actual
First Submit Date
First Submit QC Date
Std Ages
Child
Adult
Maximum Age Number (converted to Years and rounded down)
20
Minimum Age Number (converted to Years and rounded down)
0
Investigators
Investigator Type
Principal Investigator
Investigator Name
Sara Soshnick
Investigator Email
ssoshnic@montefiore.org
Investigator Phone