Use of Pathological Phenotype to Determine Optimal Management for Moderate to Severe Preschool Wheeze
Phase: PHASE2
Conditions: Asthma
Sponsor: Imperial College London

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Preschool wheeze: Inflammation/Infection Guided Management (PrIGMa) 
 
Use of pathological phenotype to determine optimal management for 
moderate to severe preschool wheeze 
 
NCT number: 02517099 
 
Document date: 30/08/2016 
 

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Preschool wheeze: Inflammation/Infection Guided Management 
(PrIGMa) 
 
Use of pathological phenotype to determine optimal management for 
moderate to severe preschool wheeze 
 
Version 
5 
30 
August 
2016 
4 
23 
September 
2015
 
 
Main Sponsor: Imperial College London 
Funder: National Institute of Health Research (NIHR) 
Study Coordination Centre: Royal Brompton Hospital NHS Foundation Trust 
 
REC Reference: 15/LO/0050 IRAS project ID: 165460 
 
 

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Study Management Group 
Chief Investigator: Dr Sejal Saglani 
Co-Investigators: Prof Andrew Bush, Dr Louise Fleming 
Statistician: Mr Winston Banya, Dr Mark Rosenthal 
Trial 
Management: 
Research 
nurse 
– 
Yvie 
Bingham/Laura 
Baynton 
and 
Dr 
Saglani 
 
Study Coordination Centre 
For general queries, supply of trial documentation, and collection of data, please contact: 
Study Coordinator: - Research nurse – Yvie Bingham/Laura Baynton 
Address: Dept of Respiratory Paediatrics, 4th Floor Chelsea Wing, Royal Brompton Hospital 
NHS Foundation Trust, Sydney Street, London SW3 6NP 
 
 
 
 
 
Tel: 0207 352 8121 ext 8233 Bleep 1287 
 
 
Randomisations: 
Fax: 0207 351 8763 
 
 
 
Email: y.bingham@imperial.ac.uk  
 
 
 
 
 
 
Web address: http://prigma.myfreesites.net  
Clinical queries 
Clinical queries should be directed to “Research nurse” (Yvie Bingham/Laura Baynton
) who will direct the query to the appropriate person 
 
Sponsor 
Imperial College London is the main research Sponsor for this study. For further information 
regarding the sponsorship conditions, please contact the Head of Regulatory Compliance at: 
Joint Research Compliance Office 
5L10C, 5th Floor Lab Block 
Charing Cross Hospital 
Fulham Palace Road 
 London, W6 8RF 
Tel: 0203 311 0204 
Fax: 0203 311 0203 
 
Funder 

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National Institute of Health Research (NIHR) – Career Development Fellowship to Dr Saglani 
 
Table of Contents  
 
 
 
 
 
 
 
1. 
INTRODUCTION 
1.1 
Background 
2.  
STUDY OBJECTIVES 
3.  
STUDY DESIGN 
3.1 
Study Outcome Measures 
4. 
PARTICIPANT ENTRY 
4.1 
Pre-randomisation Evaluations 
4.2 
Inclusion Criteria 
4.3 
Exclusion Criteria 
4.4 
Withdrawal Criteria 
5. 
RANDOMISATION AND ENROLMENT PROCEDURE 
5.1 
Randomisation or Registration Practicalities 
5.2 
Unblinding 
6. 
TREATMENTS 
6.1 
Treatment Arms 
7.1 
Definitions 
7.2 
Causality 
7.3 
Reporting Procedures 
8. 
ASSESSMENT AND FOLLOW-UP 
 
8.1 
Lost to Follow-up 
8.2 
Trial Closure 
9. 
STATISTICS AND DATA ANALYSIS 
10. 
MONITORING 
10.1 
Risk Assessment 
10.2 
Monitoring at Study Coordination Centre 
10.3 
Monitoring at local site 
11. 
REGULATORY ISSUES 
11.1 
CTA 
11.2 
Ethics Approval 
11.3 
Consent 
11.4 
Confidentiality 
11.5 
Indemnity 
11.6 
Sponsor 
11.7 
Funding 
11.8 
Audits and Inspections 
12. 
TRIAL MANAGEMENT 
13. 
PUBLICATION POLICY 

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14. 
REFERENCES 
EXAMPLE APPENDICES 
APPENDIX 1.  
GLOSSARY OF ABBREVIATIONS 
AE 
Adverse Event 
AR 
Adverse Reaction 
ASR 
Annual Safety Report 
CA 
Competent Authority 
CI 
Chief Investigator 
CRF 
Case Report Form 
CRO 
Contract Research Organisation 
CTA 
Clinical Trial Authorisation 
DMC 
Data Monitoring Committee 
GAfREC 
Governance Arrangements for NHS Research Ethics 
GCP 
Good Clinical Practice 
ICF 
Informed Consent Form 
Main REC 
Main Research Ethics Committee 
NHS R&D 
National Health Service Research & Development   
PI 
Principal Investigator 
PIS 
Patient Information Sheet 
QA 
Quality Assurance 
QC 
Quality Control 
RCT 
Randomised Control Trial 
REC 
Research Ethics Committee 
SAR 
Serious Adverse Reaction 
SAE 
Serious Adverse Event 
SDV 
Source Document Verification 
SOP 
Standard Operating Procedure  
TMG 
Trial Management Group 
 
 
KEYWORDS 
Inflammation, infection, preschool wheeze, phenotype, inhaled steroids, antibiotics, 
eosinophils, clinical guidelines 
 
 
 
 
 
 
 
 

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STUDY SUMMARY 
 
TITLE: Use of pathological phenotype to determine optimal management for moderate to 
severe preschool wheeze 
SHORT TITLE: Preschool wheeze: Inflammation/Infection Guided Management (PrIGMa) 
RATIONALE: At least one-third of all children under 5 years suffer from wheezing and 
breathlessness, but despite the high incidence(1), there are few effective therapies(2). Current 
guidelines recommend the management of preschool wheezing should be determined by 
clinical phenotype(3). However, this is based predominantly on expert consensus with little 
evidence. The current guidelines have not been compared to other strategies. Current 
management does not take account of objective evidence of underlying inflammation or 
infection, however there is evidence to support that preschool wheezers have pathologically 
distinct phenotypes. This study will therefore determine the efficacy of treating preschool 
wheeze based on objective biomarkers of inflammation and presence of bacterial infection, 
and compare this to current clinical guidelines based management. This is a novel approach 
to managing preschool wheeze, which if effective, will have a significant impact on changing 
current clinical practice, and can be instituted within 5 years. 
AIMS:  To compare management of preschool wheeze using current clinical guidelines to 
management determined by eosinophilic inflammation in sputum or blood, and infection in 
sputum or oropharyngeal swabs 
To determine numbers that would be needed to perform a large, multi-centre randomised 
trial comparing management according pathological phenotype to current clinical guidelines 
 
DESIGN: Randomised, single blind, controlled trial comparing management of preschool 
wheeze based on inflammation and infection profile to current standard of care – the 
intervention will be over a 4 month period. This is a proof of concept study to determine 
feasibility of this approach and to obtain data to allow an assessment of numbers that would 
be needed for a larger randomised trial. 
 
Subjects will be recruited from out-patient clinics and attend for a screening / research visit 
during which assessments of pathological phenotype (bacterial infection and inflammation) 
will be made from induced sputum and blood. Their clinical phenotype will be determined by 
the Consultant. Subsequently, patients will be randomised to one of two arms: 
i) 
current clinical care (as directed by their Consultant) 
ii) 
pathological phenotype based management – presence of eosinophilia in blood 
(>32%) or induced sputum (>2.4%) – will receive twice daily inhaled steroids 
(beclomethasone 200mcg bd) for 4 months, presence of bacterial infection in 

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induced sputum or oropharyngeal swab – will receive 4 weeks of antibiotics 
targeted to the isolate, IF BOTH eosinophilic inflammation AND infection are 
present, then inflammation alone will be treated for 4 months. 
 
All patients will continue on as required bronchodilator therapy, and any other anti-
inflammatory therapy (other than inhaled steroids) e.g. montelukast. 
 
OUTCOME MEASURES:  
Primary outcome – number of unscheduled healthcare visits (UHCV) during the 4 month 
intervention period 
Secondary outcomes – health related quality of life, number of hospital admissions, number 
of days of oral steroids during the 4 month intervention period, and up to 1 year later 
 
POPULATION: Preschool children, aged 1-5 years attending out-patient clinic for recurrent 
wheezing 
 
ELIGIBILITY:  
Age 1-5 years 
> 2 courses of oral steroids (steroid bursts) OR hospital admissions in the last 12 months for 
acute wheezing, at least one of which is in the last 6 months 
 
TREATMENT:  
1. Inflammation / infection based management (pathological phenotype based 
management): 
 – use induced sputum and blood eosinophil count to determine whether regular inhaled 
steroids are prescribed for 4 months, or antibiotics are prescribed for 4 weeks (if sputum has 
a positive bacterial growth), if BOTH eosinophilic inflammation and bacterial infection are 
present, then treat the inflammation alone for 4 months 
2. Current standard of care: 
- Treat for 4 months as directed by the child’s clinician – according to current clinical 
guidelines 
 
DURATION: 
Duration of intervention: 4 months 
Duration of follow-up: after 4 months, then 6 monthly until the end of the trial.  
 
 
 
 
 

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REFERENCE DIAGRAM OF TRIAL DESIGN: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Children aged 1-5 years with moderate 
wheezing (> 2 oral steroid bursts OR 
hospital admissions in last 12 months) – 
seen in out-patient clinic 
Primary endpoint: Number of UHCV 
Secondary endpoints: 
Health related quality of life 
Number of hospital admissions 
Days of oral steroids 
Exhaled nitric oxide 
Induced sputum: inflammation, infection 
Oropharyngeal swab: infection 
Blood: eosinophilic inflammation  
Clinical characterisation   
 
Screening visit 
 
Pathological phenotype 
Clinical phenotype (multiple trigger or episodic wheeze) 
Symptoms and video questionnaire 
Health related quality of life 
Lung function: lung clearance index  
Management according to 
clinical phenotype (current 
standard of care) 
Randomise 
Management according to 
pathological phenotype 
(presence of inflammation / 
infection) 
4 months 
No acute exacerbation within 2 weeks of the screening visit, any children on regular inhaled 
steroids will be asked to stop these for 2 weeks prior to the screening visit (with their 
Consultant’s permission) 

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1. INTRODUCTION 
1.1 BACKGROUND 
At least one-third of all children under 5years suffer from wheezing and breathlessness, but 
despite the high incidence(1), there are few effective therapies(2). Current guidelines 
recommend the management of preschool wheezing should be determined by clinical 
phenotype(3). However, this is based predominantly on expert consensus with little evidence. 
The two clinical phenotypes are episodic wheeze, in which wheeze occurs during discrete 
episodes, usually in association with an upper respiratory tract infection, with no symptoms 
in between, and multiple trigger wheezing, with discrete episodes and symptoms in 
between(3). The current approach has several limitations: i) It relies on accurate parental 
reporting of symptom pattern, which may not always be clearly distinguishable as episodic or 
multiple trigger. ii) Clinical phenotypes may switch within patients in a short period, such as 
only 3 months(4). iii) The underlying infectious cause of acute episodes is not considered. 
Although it was previously thought that most episodes are precipitated by viral infections, it 
is now recognised that an equal number are also caused by bacterial infection(5). The current 
guidelines have not been compared to other strategies. It is essential that the correct 
approach is adopted since therapeutic options include steroids(2), which if administered 
incorrectly result in adverse effects, the most worrying in the preschool age-group being 
reduced growth(6).  
Evidence to support pathologically distinct preschool wheeze phenotypes 
The pathology of allergic asthma in adults and school-aged children is characterised by airway 
eosinophilic inflammation and structural airway wall changes, termed airway remodelling(7). 
Eosinophilia is usually steroid sensitive and thus the mainstay of therapy includes regular 
inhaled steroids. It is assumed that the preschool multiple trigger wheeze phenotype 
resembles allergic asthma and therefore is responsive to steroid therapy, whilst episodic 
wheeze is pathologically distinct and so is steroid unresponsive. Preschool wheezers have 
been shown to have bronchial eosinophilia(8;9). Furthermore, we have shown that most 
episodic wheezers do not have eosinophilia, and pathologically resemble non-wheezing 
controls. Levels of exhaled nitric oxide (a non-invasive marker of airway inflammation) are 
more likely to be elevated in multiple trigger wheezers(10). Lung function assessments also 
suggest multiple trigger wheezers have increased airway resistance and are distinct to 
episodic wheezers who have relatively normal lung function similar to controls(10). Despite 
this evidence supporting pathophysiologically distinct phenotypes, preschool wheeze is still 
treated using clinical symptom patterns, without the additional use of inflammatory 
biomarkers to guide therapy. Importantly, data from adults with moderate asthma suggests 
use of inflammation guided therapy is superior in reducing exacerbations compared to clinical 
guidelines based therapy(11). But, in children with severe asthma, the same approach was not 

PrIGMa – Trial Protocol v12 27 OctJan 20154 
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beneficial(12), suggesting the benefits of inflammation guided therapy may be influenced by 
disease severity.  
The lower airway is not sterile and its microbial composition is altered in children with 
asthma(13), but this can only be detected using molecular biology techniques such as 16SPCR. 
Airway microbial composition in preschool children is unknown. However, it is established 
that a significant proportion of recurrent preschool wheezers have airway bacterial infection 
identified using traditional culture techniques(14). An important unanswered question is the 
relevance of the microbial flora in determining recurrent wheezing in preschool children. 
1.2 Rationale for Current study 
Clinical Impact and Relevance 
Wheezing and breathlessness in preschool children is common, but difficult to treat, and 
results in exacerbations requiring frequent healthcare visits. Of all UK admissions for children 
aged 1-16 years with acute wheeze or asthma between 1998-2005, approximately 75% of 
admissions each year were for children under 5 years old (median age 3 years), and the rate 
did not change over the seven year period(15). In addition, caring for preschool children with 
wheeze cost the healthcare service an estimated £53 million in 1998/99, with the majority of 
costs being attributable to inpatient stays(16). The costs to families caring for an unwell child 
at home or in hospital was between £10-40 per day, this was in addition to the costs of taking 
unforeseen time off work(16). Current management of preschool wheeze is based on clinical 
phenotype alone and does not take account of objective evidence of underlying inflammation 
or infection. Given the drawbacks of parental recall bias, clinical phenotype switching and 
adverse effects of steroid therapy if used inappropriately, and the available evidence for 
pathologically distinct phenotypes in preschool wheezers, this study will determine the 
efficacy of treating preschool wheeze based on objective biomarkers of inflammation and 
presence of bacterial infection, and compare this to current clinical guidelines based 
management. This is a novel approach to managing preschool wheeze, which if effective, will 
have a significant impact on changing current clinical practice, and can be instituted within 5 
years. 
Since preschool wheezing is predominantly characterised by frequent exacerbations(2) and a 
sub-group of wheezers have evidence of eosinophilia (elevated exhaled nitric oxide, increased 
airway eosinophils), while others are likely to have evidence of airway bacterial 
infection(5;17;18), management based on objective evidence of inflammatory and infectious 
phenotype, rather than symptom pattern and clinical phenotype is an approach that warrants 
investigation. Importantly, the impact of disease severity and the optimal samples upon 
which to guide therapy also need investigation. 
Hypothesis 

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Targeted treatment of preschool wheeze determined by airway inflammation and infection 
will result in better outcomes including fewer unscheduled healthcare visits, improved health 
related quality of life (HRQOL) for the child and family, and fewer days of oral steroid therapy 
compared to using current clinical guidelines. 
2. STUDY OBJECTIVES 
1. Compare treatment of recurrent wheezing in preschool children aged 1-5years with >2 
courses of oral steroids for acute wheeze in the previous 12 months (at least 1 course in the 
previous 6 months) based on evidence of eosinophilic inflammation (blood or sputum 
eosinophils) and bacterial infection (oropharyngeal swabs) to current clinical guidelines. 
2. Compare treatment efficacy of this approach in recurrent severe wheezers (those 
undergoing a clinically indicated bronchoscopy for severe symptoms) to moderate wheezers 
(those not undergoing bronchoscopy). 
 
3. STUDY DESIGN 
This is a single blind, randomised, controlled trial comparing management of moderate to 
severe preschool wheeze according to current clinical guidelines to management determined 
by inflammation and infection profile (pathological phenotype). 
 
Study duration: The intervention phase of the study will last for 4 months, with follow-up 
immediately after the intervention period and 6 monthly thereafter until the end of the trial. 
The minimum follow-up is at the end of the 4 month intervention period, maximum follow-
up will be for 3 years. During the 4 month intervention period, families will be contacted 
weekly by phone call for an update on unscheduled healthcare visits and symptoms. 
 
Type of subjects to be recruited: All subjects will be aged between 1 and 5 years old. All 
subjects will have moderate to severe preschool wheeze, defined as >2 oral steroid bursts OR 
hospital admissions for acute wheeze in the last 12 months, with at least one oral steroid 
burst OR hospital admission in the last 6 months.  
 
Number of subjects:  
Based on published data for children with moderate preschool wheeze it is apparent that 
approximately five healthcare attendances occur per child per year(16). In the current study, 
we wish to reduce the proportion of healthcare contacts by at least one-third per year. In 
order to achieve this with 80% power, and accepting statistical significance at the 5% level, 
we require a minimum of 36 evaluable patients with moderate wheeze per group. Evaluable 
patients are those from whom at least a blood sample to assess inflammation and an 
ororpharyngeal swab to determine infection can be obtained prior to randomisation. 

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A total of at least 72 children will therefore be recruited. However, this is the minimum 
number, and we aim to recruit 100 children (50 per group) if possible. 
 
The number of subjects is not based on a precise power calculation as this is a proof of concept 
study to determine the feasibility of this approach, and to inform a future power calculation 
for a large multi-centre trial addressing the same question.  
 
3.1 Study Outcome Measures: Primary outcome – number of unscheduled healthcare visits 
in the 4 month intervention period. Secondary outcomes – health related quality of life for 
the child and family, number of hospitalisations, days of oral steroids. 
 
4. PARTICIPANT ENTRY 
Patient recruitment at a site will only commence once the trial team has ensured that the 
following approval/essential documents are in place:  
1. The main REC, and Clinical Trial Authorization (CTA) approval,  
2. Final sponsorship and/or R&D approval (NHS Permission), 
3. Sponsor has conducted the trial initiation procedure 
 
Patient identification will take place at up to 5 sites (Royal Brompton Hospital, Kings College 
Hospital, Chelsea & Westminster Hospital, St Mary`s Hospital and Hillingdon Hospital, London
), all research visits, screening assessments, randomisation and drugs will be 
dispensed from the Brompton Hospital only. Kings College Hospital,Chelsea & 
Westminster Hospital, St Mary`s Hospital and Hillingdon Hospital will be used as patient 
identification (PIC) sites. 
All sites participating in the trial will also be asked to provide a copy of the following:  
1. Host site (R&D approval) and/or NHS Permission 
All subjects who wish to enter the study will be fully screened and consented by the Chief 
Investigator, or one of the qualified clinicians involved in the study as Clinical Co-investigator.   
4.1 Pre-randomisation Evaluations 
All participants will undergo an initial research / screening visit which will involve the 
following tests: 
Full blood count and Vitamin D 
Total serum IgE and RASTs to house dust mite, grass pollen, tree pollen, cat, dog, aspergillus, 
milk, egg, peanut 

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Assessment of lung function by incentive spirometry and lung clearance index (LCI) using the 
multiple breath washout technique 
Exhaled nitric oxide – using the offline tidal breathing technique 
Sputum induction using nebulised hypertonic saline 
Oro-pharyngeal swab 
Symptom questionnaire  
Health related quality of life questionnaire 
Urine sample for cotinine levels (and for storage if parents consent)/salivary cotinine 
 
4.2 Inclusion criteria 
Age > 1 years, < 6 years 
Reported recurrent wheeze, needing at least 2 admissions +/- oral steroids in the last 12 
months, 
at 
least 
one 
admission 
+/- 
oral 
steroids 
in 
the 
last 
6 
months
 
Past wheeze confirmed by a clinician 
 
4.3 Exclusion criteria 
Any known cardiac disease 
Any chronic respiratory condition (other than preschool wheeze) diagnosed by a physician 
Any chronic condition that increases susceptibility to respiratory tract infections such as 
severe developmental delay and feeding difficulty / unsafe swallow 
Prematurity <34 weeks, or requirement of ventilation in the newborn period 
History of neonatal chronic lung disease 
Family not contactable by telephone 
 
4.4 Withdrawal criteria 
The trial will be analysed using an intention to treat approach.  
The intervention arm or taking part in the trial will not affect the acute management of the 
child in any way, should the child become ill or develop symptoms, they should be taken to 
be seen by a healthcare professional in the usual way. Management of any acute episodes 
will not be influenced by the study or study team in any way. If during the 4 month 
intervention period the child’s clinicians / healthcare workers suggest a change in the 
maintenance therapy is needed, then this will be undertaken without any negotiation. The 
study team will request that they are informed of the change, and the child will still be 
included in the analysis because of the intention to treat design. 
If the participants wish to withdraw consent to take part in the study, the data obtained until 
the time of withdrawal will be used – as it is an intention to treat analysis – providing the 
participants agree. If however they do not wish for any of the data to be used or analysed, 
then all data will be destroyed. Parents / families will be free to withdraw at any stage, and 
that will not impact in any way on their child’s routine clinical management. 

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5. RANDOMISATION AND ENROLMENT PROCEDURE 
5.1 Randomisation practicalities 
All randomisation and enrolment will occur during routine working hours – as all research 
visits will take place in the Biomedical Research Unit during the week between 9am and 5pm. 
Children will be recruited when they are clinically well, not during an acute attack. 
 
We will use the Imperial INFORM database Unit to undertake randomisation 
 
We wish to stratify randomisation according to sex and age, to achieve similar numbers of 
boys and girls in each group, and to have a similar average age for each group. 
 
The age stratification will be as follows: >1- <3 years and >3 - <5 years 
 
As wheezing in preschool children is a seasonal disorder (majority of symptoms and 
exacerbations occur between September – April each year), the baseline assessments and 
pre-randomisation visits will be arranged between late August – December each year, so that 
randomisation and intervention take place between September – January each year, to allow 
the 4 month intervention period to fall within the main season. 
 
All patients will be given a study specific 24hrs emergency contact card immediately after 
being randomized. The card includes details of the study: Study title, patient trial number, 
CI/PI’s contact details along with out of hours contact details in case of emergency.  
 
5.2 Unblinding 
The trial is a single blind trial. The parents of the children taking part and the physicians that 
decide the clinical management will be unaware of the arm the child has been randomised 
to, but the researcher will know – since the researcher will have to instruct the family on 
which treatment should be initiated once randomisation has occurred. 
 
We do not foresee a need to unblind as there are no new treatments being trialled, we are 
using licenced treatments but with a novel indication. All doses to be used are also within 
licenced indications. 
 
6. TREATMENTS 
6.1 Treatment arms 
 
The drugs to be used in the pathological phenotype arm include: 

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Beclometasone diproprionate metred dose inhaler with spacer – 100mcg per dose – 2 puffs 
twice a day  
or 
Antibiotics – augmentin duo (0.3ml/kg bd) or azithromycin (10mg/kg od) – therapeutic dose 
calculated according to the child’s weight – for 4 weeks. The actual antibiotic used will be 
determined by the sensitivities of the organisms identified on bacterial culture. For children 
that are allergic to penicillin, azithromycin will be used instead of augmentin duo. 
 
The drugs will be dispensed from the pharmacy at The Royal Brompton Hospital. If antibiotics 
are needed, a 4 week supply will be dispensed, and all children will be prescribed 4 weeks of 
therapy. 
If the beclometasone inhaler is needed, sufficient doses for 4 months will be dispensed. 
 
Management in the pathological phenotype arm: 
1. Eosinophilic inflammation, no bacterial infection: 
Children with sputum eosinophils >2.4% or blood eosinophils >3% will be defined as 
eosinophilic and management will be as follows: 
i) Regular inhaled steroids (beclometasone 200 mcg bd) for 4 months in those previously not 
on any regular therapy.  
ii) Of children who have already been prescribed inhaled steroid therapy, those with an 
eosinophilic phenotype will continue for a further 4 months.  
iii) Children who have already been prescribed a regular leukotriene receptor antagonist will 
continue this and regular inhaled steroids (beclometasone 200mcg bd) will be added to their 
maintenance therapy for 4 months. 
iv) Use of as required bronchodilator therapy will continue  
 
2. Non-eosinophilic, no inflammation, no infection: Children with either sputum eosinophils 
<2.4% or blood esoinophils <3% will be defined as non-eosinophilic and management will be 
as follows: 
i) Use of as required bronchodilators for acute symptoms 
ii) Non-eosinophilic children that have already been prescribed regular inhaled steroids will 
be asked to stop them for 4 months 
Children with no bacterial growth from oropharyngeal swab or induced sputum, and without 
eosinophilic inflammation will continue management according to the non-eosinophilic, no 
inflammation, no infection profile. 

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3. Bacterial infection, no eosinophilic inflammation: Children with a positive bacterial 
culture result from oropharyngeal swab or induced sputum will be treated with a 4 week 
course of antibiotics. Four weeks of antibiotic therapy will be used as this has been shown 
to be beneficial in a previous study of severe preschool wheeze(16). If these children have 
already been prescribed regular inhaled steroids, they will be stopped for 4 months. 
 
4. Eosinophilic inflammation AND bacterial infection: Children with raised eosinophils in 
induced sputum or blood AND positive bacterial culture will be managed according to the 
eosinophilic inflammation alone  guideline. They will only be given inhaled steroids for 4 
months, and no antibiotics. This is to assess only one intervention at a time. However, we 
do not anticipate many children will be in this group as our previous data shows those 
with positive bacterial cultures are very unlikely to have eosinophilia. 
 
Management in the clinical guidelines arm: 
The children will be treated as directed by their Consultant Paediatrician. The prescription for 
the drugs to be used will be dispensed from the pharmacy department at the Royal Brompton 
Hospital – as directed by the clinician. Usually only 2 weeks of medication is prescribed by the 
pharmacy, but for this trial 4 months’ supply will be given. 
 
6.2 Dose modifications for toxicity 
All drugs to be used in the trial are already licenced for use in children of this age and in the 
doses to be used. Drug induced toxicity is therefore not a concern. 
 
6.3 Premedication 
There are no additional drugs that will be used before randomisation. 
 
Concomitant treatment  
The following medication will be allowed to continue during the intervention period in both 
study arms. 
1. Use of rescue medication with bronchodilators for acute symptoms – salbutamol 
and/or ipratropium bromide 
2. Use of  leukotriene receptor anatagonist – montelukast – can continue regardless of 
whether it is being taken regularly or as required for acute symptoms 
 
 
6.4 Interaction with other drugs 

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All drugs to be used are already licenced for use in children of this age. There are no other 
drugs that the child should not receive while they are in the trial and having the drug 
interventions for the trial.  
 
6.5 Dispensing and Accountability 
The following drugs will be sourced from routine hospital stock and their handling and 
management will be subject to standard procedures of the pharmacy. 
Beclometasone diproprionate metred dose inhaler with spacer – 100mcg per dose 
Augmentin duo syrup 
Azithromycin syrup 
The Pharmacy hospital department will be responsible for maintaining & updating the trial 
Accountability Log, filed in the hospital pharmacy file.  
Route of administration, dosage, dosage regimen, and treatment period(s) of the 
medications 
Beclometasone diproprionate – inhaled, 100 mcg – 2 puffs  twice daily  via mdi and spacer, 
for 4 months 
Augmentin duo – oral, 0.3ml/kg twice daily for 4 weeks 
Azithromycin – oral 10mg/kg once daily for 4 weeks 
 
Assessment of compliance 
All beclometasone inhalers will be fitted with an electronic monitoring device (Smartinhaler) 
in order to ensure the medication has been taken according to the regimen prescribed 
The antibiotic for the full 4 week period will be dispensed from the hospital to help 
compliance 
Parents will be phoned weekly to remind them of the importance of giving the child’s 
treatment – whether that is the inhaler or antibiotics.  
 
7. PHARMACOVIGILANCE 
7.1 Definitions:  
Adverse Reaction (AR): all untoward and unintended responses to a medication related to 
any dose administered. All AEs judged by either the reporting investigator or the sponsor as 
having reasonable causal relationship to a medicinal product qualify as adverse reactions.  
 
Unexpected Adverse Reaction: an AR, the nature or severity of which is not consistent with 
the applicable product information (eg investigator’s brochure for an unapproved 
investigational product or summary of product characteristics (SmPC) for an authorised 
product).  
Serious Adverse Event (SAE) or Serious Adverse Reaction: any untoward medical occurrence 
or effect that at any dose:  

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Results in death  
Is life-threatening – refers to an event in which the subject was at risk of death at the time of 
the event; it does not refer to an event which hypothetically might have caused death if it were 
more severe  
Requires hospitalisation, or prolongation of existing inpatients’ hospitalisation  
Results in persistent or significant disability or incapacity  
Is a congenital anomaly or birth defect  
 
An Unexpected Adverse Reaction is an Adverse Reaction, when both the nature and severity 
of the event is not consistent with the information about the medicinal product in question,  
(a) in the case of a product with a marketing authorization, in the Summary of Product 
Characteristics (SmPC) for that product. 
 
Terminology for classification of SAEs 
1. Severity will be described using the following categories: 
▪ Mild—the adverse event does not interfere with the volunteer’s daily routine, and 
does not require intervention; it causes slight discomfort. 
▪ Moderate—the adverse event interferes with some aspects of the volunteer’s routine, 
or requires intervention, but is not damaging to health; it causes moderate discomfort. 
▪ Severe—the adverse event results in alteration, discomfort or disability which is clearly 
damaging to health. 
3. Expectedness will be described using following categories: 
▪ Expected—an AE that is classed in nature as serious and which is consistent with the 
information about the drug listed in the SmPC. 
▪ Unexpected—an AE that is classed in nature as serious and which is not consistent 
with the information about the drug listed in the SmPC. 
Recording of Safety Information 
Collection, recording and reporting of AEs (including serious and non-serious events and 
reactions) to the Sponsor will be done according to the Sponsor’s Pharmacovigilance SOP.  
 Adverse Events (AEs) 
All Adverse Events will be recorded in the hospital notes in the first instance.   
A record of all AEs, whether related or unrelated to the treatment will also be kept in the CRF 
and the Sponsor’s AE Log. 

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All drugs used in this trial are licensed in the UK and used within their marketing authorization.  
The most up-to-date version of the SmPC will be used during the trial. 
Contact details for reporting SAEs and SUSARs: 
Fax: 0207 351 8763, attention Dr Sejal Saglani 
Please send SAE forms to: Dr Sejal Saglani 
Tel: 0207 352 8121 ext 8509 
 
Annual Progress Reports (APRs) 
The Chief Investigator will prepare the APR. It will be reviewed by the JRO and sent to the 
main REC within 30 days of the anniversary date on which the favourable opinion was given 
by the Ethics committee, and annually until the trial is declared ended. 
Notification of Serious Breaches of GCP and/or the protocol 
Any Protocol Deviations, Violations, Potential Serious Breaches and Urgent Safety Measures 
will be recorded using the Sponsor’s Log issued during the Sponsor’s Trial/Site Initiation 
meeting/visit.  
Regulation 29A of the Medicines for Human Use (Clinical Trials) Regulations2004 [Statutory 
Instrument 2004/1031], as amended by Statutory Instrument2006/1928, contains a 
requirement for the notification of “serious breaches” of GCP or the trial protocol: 
(1) The Sponsor of a clinical trial shall notify the licensing authority in writing of any serious 
breach of: 
(a) The conditions and principles of GCP in connection with that trial; or  
(b) the protocol relating to that trial, as amended from time to time in accordance with 
regulations 22 to 25, within 7 days of becoming aware of that breach. 
(2) For the purposes of this regulation, a “serious breach” is a breach which is likely to effect 
to a significant degree: 
(a) The safety or physical or mental integrity of the subjects of the trial; or 
(b) The scientific value of the trial. 
The Sponsor will be notified immediately of any case where the above definition applies 
during the trial conduct phase. The Sponsor’s SOP on the Protocol Violation/Deviations and 
Serious Breaches will be followed.  
 

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8. ASSESSMENT AND FOLLOW-UP 
 
8.1 SCREENING ASSESSMENTS 
All children aged between 1 and 5 years attending the out-patient clinic for reported recurrent 
wheeze will be eligible. No additional initial screening assessments will be made other than 
to ensure the child meets the inclusion and exclusion criteria outlined in Section 4.2 and 4.3 
above. 
 
 
8.2 BASELINE ASSESSMENTS 
At the clinic appointment parents of eligible children will be approached and will be verbally 
informed about the study and given a written information sheet. Parents’ contact details will 
be taken and after a few days will be telephoned to ask whether they would like to take part 
in the study. Once parents have agreed, they will be invited for a research visit for baseline 
assessments prior to randomisation.  
 
As wheezing in preschool children is a seasonal disorder (main symptoms between September 
– April each year), the baseline assessments and pre-randomisation visits will be arranged 
between late August – December each year, so that randomisation and intervention take 
place between September – January each year, to allow the 4 month intervention period to 
fall in the main season. 
 
All baseline assessments will be made providing the child has not had any acute wheezing 
episodes within the last 2 weeks. Also, with their Consultant’s permission, parents will be 
asked to stop administering any regular inhaled steroids (if they have been taking them) for 
2 weeks prior to the research visit. 
 
The baseline assessments to be made at the research visit include: 
Symptom questionnaire 
Parents of all patients will complete a written questionnaire to obtain details of symptom 
duration, onset and severity, including history of medications, allergies, family history. All 
parents will also be shown a validated video questionnaire to obtain objective confirmation 
of wheeze(31). Health related quality of life (HRQOL) for the child and family will be 
determined using the validated Child Health Questionnaire(32-34). 
 
Sample collection – all parents will be asked for consent for the child to undertake FeNO 
measurement, have a blood sample taken, undergo sputum induction and have an 
oropharyngeal swab taken. 

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1. Blood will be taken for a peripheral eosinophil count, total IgE and specific IgE to common 
aero and food allergens. 
2. Sputum induction will be performed using nebulised hypertonic saline (3.5%), chest 
physiotherapy and oropharyngeal suction using previously described techniques for 
preschool children. We have now established a protocol for sputum induction in preschool 
children with various airways diseases, including wheezing, and have shown the procedure 
can be performed safely and with up to 95% success. Sputum will be processed for bacterial 
culture and cytology. 
 
3. Lung function will be performed using the multiple breath washout technique to obtain a 
measurement of lung clearance index (LCI) as previously described, and according to recent 
American Thoracic Society recommendations. This technique does not require voluntary 
manoeuvres and needs minimal patient cooperation and is therefore suited to preschool 
children. We have recently performed a pilot feasibility study in preschool children attending 
the outpatient clinic, and demonstrated only 27% were able to perform LCI, but if the index 
was reduced to gas clearance in half the time (LCI0.5), the success rate increased to 77%. 
Importantly, it has been shown that LCI measurements can be reliably shortened in children 
to improve the feasibility of obtaining data. We will therefore perform LCI and LCI0.5 in this 
study, and will be able to use the data for more formal assessments of feasibility in preschool 
children with wheeze. This has not been reported to date. Incentive spirometry using 
computer aided incentive devices will also be performed, but the success of this is anticipated 
to be lower than that for LCI. 
 
3. Exhaled nitric oxide will be measured using the offline tidal breathing technique, with 
samples assessed using the NiOX chemiluminescence analyser. The recently published 
reference values for preschool children will be used to define elevated values. 
4. 5. Urine will be obtained and stored if parents consent to this. 
 
8.3 TREATMENT PROCEDURE 
The treatments to be used and each arm has been described in Section 6.1 above 
 
8.4 SUBSEQUENT ASSESSMENTS 
Children will not routinely be brought back for follow-up during the 4 month intervention 
period. 
Their compliance with the treatment prescribed will be monitored using electronic 
monitoring devices for the inhaled treatment, and by weekly telephone calls by the research 
nurse to remind the family of the importance of making sure the treatment is given daily for 
the period prescribed.  
A symptoms diary will not be kept by the parents during the intervention period, but an 
automated text will be sent to the parents daily asking whether or not their child had any 
Formatted: Font: 12 pt

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symptoms of wheeze in the last 24 hours – the answer to the text will be a simple “yes” or 
“no” response. 
 
Immediate follow-up assessment: 
After the 4 month intervention period, all children will be asked to return for a follow-up visit 
during which the following assessments will be made: 
Symptoms – using symptom questionnaire 
Health related quality of life questionnaire 
Number of unscheduled healthcare visits in the 4 month period (these will also have been 
recorded during the weekly telephone calls) 
Lung function assessment (using multiple breath wash-out technique as described in Section 
8.2 above) 
Exhaled nitric oxide measurement (using the offline tidal breathing technique as described in 
Section 8.2 above) 
Sputum induction – to assess inflammation and infection 
Urine- for storage if parents consent 
 
Long-term follow-up assessments: 
After the first follow-up visit at 4 months, parents of children will be contacted at 6 months 
by phone call to assess symptoms, unscheduled healthcare visits, courses of steroids and 
medication. They will also be asked to attend annually for a follow-up visit when all of the 
above plus lung function, exhaled nitric oxide and sputum induction will be performed. Urine 
samples will also be collected and stored if parents consent.These assessments will continue 
until the end of the trial period, or until the child reaches the age of 6 years, whichever is 
sooner. 
 
8.5 LOSS TO FOLLOW-UP 
All attempts will be made to stay in touch with families, initially weekly phonecalls will be 
undertaken during the intervention period to stay in touch, and subsequently, even if they do 
not wish to attend the hospital for follow-up visits, information will be obtained by phone call 
about symptoms, medication and unscheduled healthcare visits. If a family cannot be 
contacted, the GP and local hospital will be contacted to determine any change of address.  
 
8.6 TRIAL CLOSURE 
The minimum number of children to be recruited into each arm is 36, however, as this is a 
proof of concept study, an accurate power calculation cannot be performed, indeed part of 
the reason for this study is to determine the size of a larger trial that would be needed to 
definitively answer whether pathological phenotype based management is superior to 
current clinical guidelines. Therefore, recruitment of patients will continue until the end of 
the trial funding period, December 2018.  

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9.0 STATISTICS AND DATA ANALYSIS 
 
Categorical data will be presented as number and percentage and comparisons between 
groups done using the chi squared or Fishers exact test. All numerical data will be tested for 
normality and normally distributed data will be presented as mean ± SD and comparisons 
between groups done using the 2 sample independent t test. For the data that are not 
normally distributed the median (IQR) will be presented and comparisons between groups 
done using the Mann-Whitney test. Poisson regression will be done to determine the factors 
the affect the primary endpoint, the number on unplanned hospital visits.  
 
 
10.0 MONITORING 
The trial will be monitored according to the monitoring plan agreed and written by the 
Sponsor, based on the internal risk assessment procedure. Where appropriate the CI will be 
asked to complete a copy of the Sponsor’s self-monitoring template. It is the responsibility of 
the CI to ensure this is completed and submitted to the RO every on request (see Study 
Monitoring Plan). It is the responsibility of the RO to determine the monitoring risk 
assessment and explain the rationale. 
Any urgent safety measures at either the CI or a PI site must be reported by that site 
Investigator within 3 days, as per UK Regulations.   
 
11.0 REGULATORY ISSUES 
 
11.1 ETHICS APPROVAL 
The Study Coordination Centre has obtained approval from the London- Hampstead 
Research Ethics Committee. The Study will be conducted in accordance with the 
recommendations for physicians involved in research on human subjects adopted by the 19th 
World Medical Assembly, Helsinki 1964 and later revisions. 
The Sponsor will ensure that the trial protocol, Patient Information Sheet (PIS), Informed 
Consent Form (ICF), GP letter and submitted supporting documents have been approved by 
the MHRA and a main Research Ethics Committee (REC), prior to any patient recruitment 
taking place. The protocol and all agreed substantial protocol amendments, will be 
documented and submitted for ethical and regulatory approval prior to implementation. 

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Before site(s) can enrol patients into the trial, the Principal Investigator must apply for Site 
Specific Assessment from the Trust Research & Development (R&D) and be granted written 
NHS R&D approval.  It is the responsibility of the Principal Investigator at each site to ensure 
that all subsequent amendments gain the necessary approval. This does not affect the 
individual clinician’s responsibility to take immediate action if thought necessary to protect 
the health and interest of individual patients (see section 12 for details of reporting 
procedures/requirements). 
 
11.3 INFORMED CONSENT 
Informed consent will be obtained by the Chief Investigator or a nominated deputy as 
recorded on Sponsor’s Delegation of Responsibilities Log. All individuals taking informed 
consent will have received training in Good Clinical Practice (GCP). 
Consent to enter this study will be obtained after a full account has been provided of its 
nature, purpose, risks, burdens and potential benefits, and the patient’s parent/guardian has 
had the opportunity to deliberate. The patient will be allowed to specify the time they wish 
to spend deliberating, usually at least 24 hours, but up to several days.  
The Investigator or designee will explain that the patients are under no obligation to enter 
the trial and that they can withdraw at any time during the trial, without having to give a 
reason and without prejudicing further treatment. 
After the participant has entered the trial any clinician that is responsible for the participant 
(GP, local paediatrician or Consultant from the study centre) remains free to give alternative 
treatment to that specified in the protocol at any stage if he/she feels it is in the participant’s 
best interest, but the reasons for doing so should be recorded. In these cases the participant 
remains within the study for the purposes of follow-up and data analysis.  
A copy of the signed Informed Consent Form (ICF) along with a copy of the most recent 
approved Patient Information Sheet (PIS) will be given to the participant’s parent/guardian.  
The original signed consent form will be retained at the study site (one filed in the medical 
notes).  
11.4 CONFIDENTIALITY 
Participants’ identification will be required for the registration process. The study 
coordination centre will preserve the confidentiality of participants taking part in the study. 
All data will be handled in accordance with the Data Protection Act 1998. 
11.5 INDEMNITY 

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Imperial College London holds negligent harm and non-negligent harm insurance policies 
which apply to this study. NHS bodies are liable for clinical negligence and other negligent 
harm to individuals covered by their duty of care.  
11.6 SPONSOR 
Imperial College London will act as the main Sponsor for this study. Delegated responsibilities 
will be assigned to the NHS Trusts taking part in this study. 
 
11.7 FUNDING 
The trial has been funded by the NIHR as part of a Career Development Fellowship awarded 
to the CI (Dr Sejal Saglani). 
 
11.8 AUIDITS AND INSPECTIONS 
The study may be subject to inspection and audit by Imperial College London under their 
remit as Sponsor, the Study Coordination Centre and other regulatory bodies to ensure 
adherence to GCP. 
 
12.0 TRIAL MANAGEMENT 
A Trial Management Group (TMG) will be appointed and will be responsible for overseeing 
the progress of the trial. The day-to-day management of the trial will be coordinated through 
the Royal Brompton Hospital Study Coordination Centre. The TMG will be made up of the CI 
(Dr Saglani), the trial statistician, and Coordinator (Yvie Bingham/Laura Baynton
). 
 
13.0 PUBLICATION POLICY 
All publications and presentations relating to the study will be authorised by the Trial 
Management Group. The first publication of the trial results will be in the name of the TMG, 
if this does not conflict with the journal’s policy. If there are named authors, these will include 
at least the trial’s Chief Investigator, Statistician and Trial Coordinator. Authorship of parallel 
studies initiated outside of the TMG will be according to the individuals involved in the 
project, but must acknowledge the contribution of the Trial Management Group in the Study 
Coordination Centre. 
 
14.0 REFERENCES 
 
References 
 

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