Asthma: Phenotyping Exacerbations 3
Conditions: Asthma Attack
Sponsor: University of Nottingham

 
 
Page 1 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
 
 
 
 
 
 
 
 
 
 
Asthma: Phenotyping Exacerbations 3 
 
10TH November 2021 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
Page 2 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
 
 
Final version 1.0 
10TH November 2021 
 
 
 
Short title:  
 
Asthma: Phenotyping EXacerbations 3 
 
 
Acronym:   
 
APEX 3 
 
 
Trial Registration: 
www.clinicaltrials.gov 
 
 
ISRCTN:   
 
Not Applicable 
 
 
IRAS Project ID: 
304615 
 
 
Trial Sponsor: 
 
University of Nottingham 
 
 
Sponsor reference: 
21066 
 
Funding Source: 
Internal Funds 
 
 
Asthma: Phenotyping Exacerbations 3 

 
 
Page 3 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
STUDY PERSONNEL AND CONTACT DETAILS 
 
Sponsor: 
University of Nottingham 
Contact name 
Ms Angela Shone 
Research and Innovation  
University of Nottingham 
East Atrium  
Jubilee Conference Centre  
Triumph Road  
Nottingham  
NG8 1DH 
Email: sponsor@nottingham.ac.uk  
 
Chief investigator:  
Dr Matthew Martin 
 
Clinical lecturer and Registrar 
 
The Division of Respiratory Medicine 
 
The University of Nottingham 
Clinical Sciences Building 
Nottingham City Hospital 
Hucknall Road, Nottingham 
NG5 1PB 
Email: matthew.martin@nottingham.ac.uk 
 
Co-investigators:    
        Professor Tim Harrison  
Professor and Honorary Consultant 
The Division of Respiratory Medicine 
The University of Nottingham 
Clinical Sciences Building 
Nottingham City Hospital 
Hucknall Road, Nottingham 
NG5 1PB 
Telephone: 0115 823 1714 
 
 
Email: tim.harrison@nottingham.ac.uk  
 
 
 
 
 
 
        Mouaid Aljehani 
 
 
 
 
        PhD student 
        The Division of Respiratory Medicine 
The University of Nottingham 
Clinical Sciences Building 
Nottingham City Hospital 
Hucknall Road, Nottingham 
NG5 1PB 
Email: Mouaid.Aljehani@nottingham.ac.uk 
 
 
 
 
 
 
 
 
         

 
 
Page 4 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
Study Statistician: 
Professor Tricia McKeever 
 
Professor of Epidemiology and Medical Statistics 
 
The Division of Epidemiology and Public Health 
The University of Nottingham 
Clinical Sciences Building 
Nottingham City Hospital 
Hucknall Road, Nottingham 
NG5 1PB 
Telephone: 0115 823 1721 
Email: tricia.mckeever@nottingham.ac.uk 
 
 
 
 
 
 
 
Study Coordinating Centre:  The Nottingham Asthma Centre 
 
The Nottingham Respiratory Research Unit, 
 
The University of Nottingham, 
 
The division of Respiratory Medicine,  
 
Clinical Sciences Building, 
 
Nottingham City Hospital, 
 
Hucknall Road, Nottingham, NG5 1PB 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
Page 5 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
Title 
Asthma: Phenotyping Exacerbations 3 
Acronym 
APEX 3 
Short title 
Asthma: Phenotyping Exacerbations 3 
Chief 
Investigator 
Dr Matthew Martin 
Objectives 
Primary Objective 
 
To describe the symptom burden, lung function, inflammatory profile, and 
infection status in patients admitted to hospital with suspected asthma 
attacks. 
Secondary Objectives 
 
Determine the proportion of patients hospitalised with suspected asthma 
attacks likely due to non-asthma pathology. 
 
Describe and assess the incidence of extra-pulmonary co-morbidities in 
patients hospitalised with asthma attacks. 
 
Assess incidence of risk factors for attacks based on patients’ previous 
history. 
 
Assess patients’ adherence with asthma medications. 
 
Compare the use of Forced Oscillation Technique (FOT) as a non-effort 
dependent measure of airway obstruction in suspected severe asthma 
attacks to a standard measure of airway obstruction Peak Expiratory Flow 
Rate (PEFR). 
 
Compare the use of Fractional Exhaled Nitric Oxide (FeNO) as a measure 
of airway inflammation against sputum and blood eosinophils. 
 
Describe objective and symptomatic treatment response and recovery 
from severe asthma attacks following hospital discharge. 
 
Trial 
Configuration 
A Single-Centre, Longitudinal, Observational Study 
Setting 
Secondary Care. 
Sample size 
estimate 
This is an observational, hypothesis-generating study, and due to the lack of 
previous data on this subject, a meaningful sample size calculation cannot be 
performed. 
Number of 
participants 
100 
 
 
 
 
 
 
 
SYNOPSIS 

 
 
Page 6 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
Eligibility criteria 
Inclusion Criteria:  
 
The ability to give fully informed consent 
 
Male or female aged ≥ 18 years of age. 
 
Admission with a suspected acute asthma attack. 
 
Able (in the investigator’s opinion) and willing to comply with clinical 
investigation requirements.  
Exclusion Criteria 
 
Other clinically significant respiratory diseases including predominant 
Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis. 
 
Any other clinically significant medical disease or uncontrolled 
concomitant disease that is likely, in the investigator’s opinion, to impact 
the ability to participate in the study or the study results.  
 
Pregnant women, lactating women or women who are planning to 
become pregnant. 
 
Investigator determined apparent other cause for admission. 
 
Acute COVID infection. 
 
Non-English-speaking participants who are unable to comprehend the 
reasons for the study due to limitations in understanding the English 
language. 
Description of 
interventions 
 
The collection of medical history, demographic data, and concomitant 
medications. 
 
The incidence of upper airway symptoms will be assessed using the 
Sino-nasal Outcome Test (SNOT). 
 
The assessment of the incidence of Gastroesophageal Reflux Disease 
using the GERDQ questionnaire. 
 
The assessment of the incidence of vocal cord dysfunction using the 
Pittsburgh Vocal Cord Dysfunction (VCD) Index. 
 
The assessment of the incidence of dysfunctional breathing using the 
Nijmegen dysfunctional questionnaire. 
 
The assessment of the incidence of anxiety and depression using the 
Hospital Anxiety and Depression Scale (HADS). 
 
The assessment of the quality of life using the Acute Asthma Quality of 
Life Questionnaire. 
 
The assessment of medication adherence using the Medication 
Adherence Report Scale. 
 
The assessment of lung function by performing Fractional Exhaled Nitric 
Oxide (FeNO), Forced Oscillation Technique (FOT), Peak Expiratory 
Flow Rate (PEFR) and Spirometry. 
 
The collection of blood samples for laboratory analysis and storage for 
future research. 
 
The collection of sputum samples for sputum differential cell count, 
bacterial culture and sensitivity and storage for future research. 
 
The collection of nasal absorption samples for future cytokine profiling.  
 
The collection of samples via nasal lavage and throat swabs for viral 
identification. 
 
The collection of optional nasal brushing samples for RNA and DNA 
extraction. 
Duration of study Study duration: from January 2022 to July 2023.  

 
 
Page 7 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
Randomisation 
and blinding 
Not Applicable 
 
 
 
 
 
Outcome 
measures 
 
Assessment of cytokine levels in nasal lining fluid at attack and recovery 
visits. 
 
The measurement of vitamin D levels in the blood on admission to the 
hospital. 
 
Assessment of evidence of infection: Throat swab/nasal lavage for viral 
PCR, sputum for bacterial culture and sensitivity, CRP. 
 
Assessment 
of 
incidence 
of 
extra-pulmonary 
co-morbidities: 
Questionnaires (SNOT, GERDQ, Pittsburgh VCD index, Nijmegen, 
HADS) and BMI. 
 
A specific asthma history (polypharmacy, previous asthma attacks, 
triggers, Personalised Asthma Action Plan) for the assessment of risk 
factor for attack. 
 
Assessment of adherence to medications (MARS, prescription records, 
inhaler technique) for the assessment of behavioural attack traits. 
 
Assessment of airway obstruction at attack and recovery visits using 
peak expiratory flow rate (PEFR), spirometry, physician recorded 
expiratory wheeze and Forced Oscillation Technique (FOT). 
 
Assessment of airway inflammation at attack and recovery visits using 
Fractional Exhaled Nitric Oxide (FeNO), sputum inflammatory cell count 
and blood eosinophil count. 
 
Assessment of symptom burden at attack and recovery visits using the 
Acute AQLQ questionnaire. 
Statistical 
methods 
The main outcomes of the exacerbation are descriptive in nature, and no 
statistical tests are planned. We will, however, compare key findings at 
exacerbation visits with those undertaken at the follow-up visits, including: Paired 
tests (paired t-test or McNemar) will be used to examine changes in fractional 
exhaled nitric oxide (FeNO), parameters derived from Forced Oscillation 
Technique (FOT), the Acute Asthma Quality of Life Questionnaire (Acute AQLQ), 
sputum differential cell count, nasal absorption, haematology, and clinical 
chemistry values. 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
Page 8 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
Acute AQLQ  
 
Acute Asthma Quality of Life Questionnaire 
 
AE 
 
 
 
Adverse Event 
 
 
CI 
 
 
 
Chief Investigator overall 
 
COPD  
 
 
Chronic Obstructive Pulmonary Disease 
 
 
CRF 
 
 
 
Case Report Form 
 
CRP 
 
 
 
C-Reactive Protein 
 
 
DMC  
 
 
Data Monitoring Committee 
FeNO   
 
 
Fractional Exhaled Nitric Oxide 
FEV1  
 
 
Forced Expiratory Volume in 1 Second 
FOT   
 
 
Forced Oscillation Technique 
GCP 
 
 
 
Good Clinical Practice 
 
GERDQ 
 
 
Gastroesophageal Reflux Disease Questionnaire 
 
HADS  
 
 
Hospital Anxiety and Depression Scale 
 
 
 
 
ICF 
 
 
 
Informed Consent Form 
 
MARS  
 
 
Medicines Adherence Report Scale 
 
MCS  
 
 
Microscopy Culture Sensitivities 
 
 
NHS 
 
 
 
National Health Service 
 
PI 
 
 
 
Principal Investigator at a local centre 
 
Pittsburgh (VCD) Index 
Pittsburgh Vocal Cord Dysfunction (VCD) Index 
 
PEFR  
 
 
Peak Expiratory Flow Rate 
 
 
PIS 
 
 
 
Participant Information Sheet 
 
PCR 
 
 
 
polymerase chain reaction 
 
 
REC 
 
 
 
Research Ethics Committee 
 
R&D 
 
 
 
Research and Development department 
 
 
SAE 
 
 
 
Serious Adverse Event 
ABBREVIATIONS  

 
 
Page 9 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
SNOT  
 
 
Sino-nasal Outcome Test 
 
T2 
 
 
 
Type 2 
 
WCC  
 
 
White Cell Count 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
Page 10 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
 
STUDY PERSONNEL AND CONTACT DETAILS ............................................................ 3 
SYNOPSIS ................................................................................................................................. 5 
ABBREVIATIONS ................................................................................................................... 8 
STUDY BACKGROUND INFORMATION AND RATIONALE ..................................... 12 
STUDY OBJECTIVES AND PURPOSE ............................................................................. 13 
PURPOSE 
13 
PRIMARY OBJECTIVE 
13 
SECONDARY OBJECTIVES 
13 
DETAILS OF PRODUCT(S) ................................................................................................ 14 
DESCRIPTION OF PRODUCTS 
14 
PACKAGING AND LABELLING 
14 
STORAGE, DISPENSING AND RETURN 
14 
PLACEBO 
14 
KNOWN SIDE EFFECTS 
14 
STUDY DESIGN .................................................................................................................... 15 
STUDY CONFIGURATION 
15 
Primary endpoint 
15 
Safety endpoints 
16 
Stopping rules and discontinuation 
16 
RANDOMIZATION AND BLINDING 
16 
STUDY MANAGEMENT 
16 
DURATION OF THE STUDY AND PARTICIPANT INVOLVEMENT 
16 
End of the Trial 
16 
SELECTION AND WITHDRAWAL OF PARTICIPANTS 
16 
Recruitment 
16 
Eligibility criteria 
17 
Inclusion Criteria 
17 
Exclusion Criteria 
17 
Expected duration of participant participation 
17 
Removal of participants from therapy or assessments/Participant Withdrawal 17 
Informed consent 
18 
STUDY TREATMENT AND REGIMEN ............................................................................ 18 
STUDY ASSESSMENTS ALGORITHM. 
18 
SCHEDULE OF STUDY ASSESSMENTS. 
20 
STUDY ASSESSMENTS 
21 
Compliance and adherence 
23 
Criteria for terminating trial 
23 
TRANSPORT AND STORAGE OF THE TISSUES 
23 
LABORATORY ANALYSES 
24 
TABLE OF CONTENTS 

 
 
Page 11 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
STATISTICS ........................................................................................................................... 24 
METHODS 
24 
SAMPLE SIZE AND JUSTIFICATION 
24 
ASSESSMENT OF SAFETY 
25 
PROCEDURES FOR MISSING, UNUSED AND SPURIOUS DATA 
25 
ADVERSE EVENTS .............................................................................................................. 25 
Definitions 
25 
Causality 
26 
Reporting of adverse events 
27 
TRIAL INVESTIGATION RELATED SAES 
27 
Participant removal from the study due to adverse events 
27 
ETHICAL AND REGULATORY ASPECTS ..................................................................... 27 
ETHICS COMMITTEE AND REGULATORY APPROVALS 
27 
INFORMED CONSENT AND PARTICIPANT INFORMATION 
28 
RECORDS 
28 
Case Report Forms 
28 
Sample Labelling 
29 
Source documents 
29 
Direct access to source data / documents 
29 
DATA PROTECTION 
29 
QUALITY ASSURANCE & AUDIT .................................................................................... 30 
INSURANCE AND INDEMNITY 
30 
TRIAL CONDUCT 
30 
TRIAL DATA 
30 
RECORD RETENTION AND ARCHIVING 
31 
DISCONTINUATION OF THE TRIAL BY THE SPONSOR 
31 
STATEMENT OF CONFIDENTIALITY 
31 
PUBLICATION AND DISSEMINATION POLICY .......................................................... 31 
USER AND PUBLIC INVOLVEMENT .............................................................................. 31 
STUDY FINANCES ............................................................................................................... 32 
Funding source 
32 
Participant stipends and payments 
32 
SIGNATURE PAGES ............................................................................................................ 33 
REFERENCES ....................................................................................................................... 35 
 
 
 
 
 
 
 

 
 
Page 12 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
Asthma is a common condition affecting 9.8 million people in the United Kingdom1. Asthma 
attacks cause nearly 1500 deaths per year in the UK2 and account for over 90,000 hospital 
admissions and 1800 intensive care admissions costing at least 1 billion pounds a year3. 
 
Non-asthma conditions such as Vocal Cord Dysfunction4 and Dysfunctional Breathing Pattern5 
can mimic severe asthma and lead to hospital admission and inappropriate asthma treatment 
with potentially harmful high dose corticosteroids. However, the proportion of patients admitted 
with these asthma mimics is unclear. 
 
The use of biomarkers to guide treatment in stable asthma is now commonplace, but this 
prospect has not been fully explored in acute asthma attacks. Determining the type of 
inflammation underlying an attack can, however be tricky because many patients receive oral 
corticosteroid prior to, or soon after admission,  which promptly and markedly affects the most 
accessible type 2 asthma (T2) biomarkers7, the blood eosinophil count. Measurement of 
another T2 biomarker, fractional exhaled nitric oxide (FENO), during an attack may prove a 
useful measure of ongoing T2 airway inflammation, but this strategy requires assessment.  
 
Airway obstruction in asthma attacks is assessed and confirmed by measuring peak expiratory 
flow and/or forced expiratory volumes. These measures are effort-dependent and can, 
therefore, be unreliable and misleading if improperly performed. We aim to evaluate the 
potential feasibility and utility of alternative diagnostic methods of assessing airway obstruction 
and measuring T2 biomarkers to see if these allow the distinction between actual asthma 
attacks and asthma attack mimics and also if they can distinguish different types of asthma 
attacks. 
 
The pattern of recovery following asthma attacks is also not fully understood. Studies have 
reported varying recovery times8 and inconsistencies in the response of airway obstruction9 
and T2 biomarkers10 to corticosteroid treatment in acute asthma. 
 
We hypothesise that a significant proportion of patients admitted to hospital with suspected 
asthma attacks have an alternate cause for their clinical presentation. To further explore this, 
we propose an observational study to describe and investigate the characteristics of patients 
admitted with suspected severe asthma. We will assess the utility of point of care, non-invasive 
biomarker measurements in identifying pulmonary and extrapulmonary traits in patients 
hospitalised due to presumed asthma attack. A variety of study assessments will be performed 
at the baseline visit (exacerbation visit), and two follow up visits following hospital discharge. 
Results of study assessments obtained during each study visit will be compared and analysed. 
This is the first study to prospectively investigate acute asthma both during and following 
exacerbation episodes. This will allow a comprehensive understanding and description of 
pulmonary and extrapulmonary traits as well as the pattern of recovery following asthma 
attacks. 
 
 
 
 
 
 
STUDY BACKGROUND INFORMATION AND RATIONALE 

 
 
Page 13 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
PURPOSE 
 
The purpose of this study is to describe the biological and physiological changes (pulmonary 
traits) and physical and psychological comorbidities (extrapulmonary traits) seen in patients 
requiring hospitalisation for presumed asthma attacks. The recovery and response to standard 
treatment for asthma attacks following discharge from the hospital will also be described.  
 
The feasibility and utility of measuring non-invasive point of care biomarkers as a means of 
confirming and quantifying airway obstruction and detecting T2 airway inflammation will be 
assessed. Blood and sputum samples will be obtained for biomarker profiling. 
 
This will enable the most comprehensive description of asthma attack phenotypes requiring 
hospitalisation and recovery from these events to date. 
 
PRIMARY OBJECTIVE 
 
 
To describe the symptom burden, lung function, inflammatory profile, and infection 
status in patients admitted to hospital with suspected asthma attacks. 
 
SECONDARY OBJECTIVES 
 
 
Determine the proportion of patients hospitalised with suspected asthma attacks likely 
due to non-asthma pathology. 
 
Describe and assess the incidence of extra-pulmonary co-morbidities in patients 
hospitalised with asthma attacks. 
 
Assess incidence of risk factors for attacks based on patients’ previous history. 
 
Assess patients’ adherence with asthma medications. 
 
Compare the use of Forced Oscillation Technique (FOT) as a non-effort dependent 
measure of airway obstruction in suspected severe asthma attacks to a standard 
measure of airway obstruction Peak Expiratory Flow Rate (PEFR). 
 
Compare the use of Fractional Exhaled Nitric Oxide (FeNO) as a measure of airway 
inflammation against sputum and blood eosinophils. 
 
Describe objective and symptomatic treatment response and recovery from severe 
asthma attacks following hospital discharge. 
 
 
 
 
 
 
 
 
 
 
 
 
 
STUDY OBJECTIVES AND PURPOSE 

 
 
Page 14 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
Description of Products 
 
Saline 
 
Sterile saline solution of varying concentrations will be used in the sputum induction and nasal 
lavage procedures. This will be prepared from a commercially available 7% solution. 
 
Salbutamol 
An inhaled short-acting beta2agonist, Salbutamol, will be administered. This will be given 
prior to the sputum induction. All participants will have salbutamol prescribed to them as part 
of their routine care. 
Packaging and labelling 
 
All products described above are those used in standard NHS practice. 
 
Storage, dispensing and return 
 
All products described above are routinely stored in the Nottingham Respiratory Research 
Unit (NRRU) Clinical Trials Unit (CTU) at the City Hospital campus. 
 
Placebo 
No Placebo is being used. 
 
Known Side Effects 
 
Sputum induction in patients with asthma can cause a small fall in lung function (FEV1). This 
risk will be minimised with pre-treatment with Salbutamol. 
 
Known side effects of beta2agonists, such as Salbutamol, include fine tremor, headaches, 
palpitations and tachycardia. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DETAILS OF PRODUCT(S) 

 
 
Page 15 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
 
STUDY CONFIGURATION 
 
This is a single centre observational, longitudinal study. The study will aim to recruit 100 
patients hospitalised due to a suspected asthma attack. They will be identified from the 
Respiratory admission units or inpatient wards at the Nottingham City Hospital or the 
emergency department at Queens Medical Centre. 
 
The initial assessment will take place at the earliest timepoint possible following hospital 
admission with a suspected asthma attack. A range of investigations, including lung function 
tests, blood tests, and questionnaires, will be performed. A follow-up visit will be arranged, 
which will take place approximately two weeks after hospital discharge at the Nottingham 
Respiratory Research Unit, at which further lung function tests, blood tests and questionaries 
will be performed.  
 
A subsequent telephone follow-up visit will be scheduled at around four weeks after hospital 
discharge, at which additional questionnaires will be performed to determine the degree of 
symptomatic recovery. A PhD student will perform the majority of study recruitment and study 
interventions under the fellow’s direct supervision. 
 
 
Primary endpoint 
 
As this is an observational study with a primary objective that is descriptive in nature, there are 
no endpoints, and all outcome measures are equally essential in describing the primary 
objective; outcome measures include: 
 
 
Assessment of cytokine levels in nasal lining fluid at attack and recovery visits. 
 
The measurement of vitamin D levels in the blood on admission to the hospital. 
 
Assessment of evidence of infection: Throat swab/nasal lavage for viral PCR, sputum 
for bacterial culture and sensitivity, CRP. 
 
Assessment of incidence of extra-pulmonary co-morbidities: Questionnaires (SNOT, 
GERDQ, Pittsburgh VCD index, Nijmegen, HADS) and BMI. 
 
A specific asthma history (polypharmacy, previous asthma attacks, triggers, 
Personalised Asthma Action Plan) for the assessment of risk factor for attack. 
 
Assessment of adherence to medications (MARS, prescription records, inhaler 
technique) for the assessment of behavioural attack traits. 
 
Assessment of airway obstruction at attack and recovery visits using peak expiratory 
flow rate (PEFR), spirometry, physician recorded expiratory wheeze and Forced 
Oscillation Technique (FOT). 
 
Assessment of airway inflammation at attack and recovery visits using Fractional 
Exhaled Nitric Oxide (FeNO), sputum inflammatory cell count and blood eosinophil 
count. 
 
Assessment of symptom burden at attack and recovery visits using the Acute AQLQ 
questionnaire. 
 
 
 
STUDY DESIGN 

 
 
Page 16 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
Safety endpoints 
 
As this is an observational study, there are no defined safety endpoints, although investigations 
at the time of exacerbation will not be performed if there are safety concerns. 
 
Stopping rules and discontinuation 
 
As this is an observational study, there are no planned stopping criteria other than for individual 
participants who wish to stop, or who cannot be contacted. 
 
RANDOMIZATION AND BLINDING 
 
There is no randomisation in this cohort study. 
 
STUDY MANAGEMENT 
 
The study will be managed by a Clinical Management Group, who will meet at least monthly 
to monitor the progress of the study. This will consist of the Chief Investigator, the Co- 
Investigator (s), the Asthma Research Development Manager, the Database Manager and the 
Research Nursing Team.  
 
The Chief Investigator has overall responsibility for the study and shall oversee all study 
management. The data custodian will be the Chief Investigator. 
 
 
DURATION OF THE STUDY AND PARTICIPANT INVOLVEMENT 
 
Study Duration:  
 
We plan to recruit approximately 100 patients over a period of 18 months. The total duration 
of the study will be approximately 2.5 years. The study will begin in January 2022 and finish in 
July 2023. 
 
Participant Duration:  
 
The baseline (Attack) visit will take place at the earliest timepoint possible following hospital 
admission. A follow up visit will be arranged, approximately 2 weeks after hospital discharge. 
A third telephone follow up visit will be arranged approximately 4 weeks after hospital 
discharge.  
 
Study participants will be participating in the study from the time of consent (earliest timepoint 
possible following hospital admission) up to approximately four weeks following hospital 
discharge. This could be from 4-12 weeks depending on the length of hospital stay. The 
maximum length of participation in the study is 12 weeks per participant. 
 
 
End of the Trial 
 
The end of the study will be the last visit of the last participant. 
 
SELECTION AND WITHDRAWAL OF PARTICIPANTS 
 
Recruitment 

 
 
Page 17 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
Participants will be identified and recruited from admission units or inpatient wards at the 
Nottingham City Hospital, or the emergency department at Queens Medical Centre. The initial 
approach will be from a member of the patient’s usual care team (which may include the 
investigator). 
 
The investigator or their nominee, e.g., from the research team or a member of the participant’s 
usual care team, will inform the participant or their nominated representative (other individual 
or other body with appropriate jurisdiction), of all aspects pertaining to participation in the study.  
 
It will be explained to the potential participant that entry into the trial is entirely voluntary and 
that their treatment and care will not be affected by their decision. It will also be explained that 
they can withdraw at any time, but attempts will be made to avoid this occurrence. In the event 
of their withdrawal, it will be explained that their data collected so far cannot be erased and we 
will seek consent to use the data in the final analyses where appropriate. 
 
Eligibility criteria 
 
Inclusion Criteria  
 
 
The ability to give fully informed consent 
 
Male or female aged ≥ 18 years of age. 
 
Admission with a suspected acute asthma attack. 
 
Able (in the investigator’s opinion) and willing to comply with clinical investigation 
requirements.  
 
Exclusion Criteria 
 
 
Other clinically significant respiratory diseases including predominant Chronic 
Obstructive Pulmonary Disease (COPD) and bronchiectasis. 
 
Any other clinically significant medical disease or uncontrolled concomitant disease 
that is likely, in the investigator’s opinion, to impact the ability to participate in the study 
or the study results.  
 
Pregnant women, lactating women or women who are planning to become pregnant. 
 
Investigator determined apparent other cause for admission. 
 
Acute COVID infection. 
 
Non-English-speaking participants who are unable to comprehend the reasons for the 
study due to limitations in understanding the English language. 
 
Expected duration of participant participation 
 
Study participants will be participating in the study for 4-12 weeks depending on the length of 
hospital stay. The maximum length of participation in the study is 12 weeks per participant. 
 
Removal of participants from therapy or assessments/Participant Withdrawal 
 
There are no plans to specifically withdraw participants from the study, unless they withdraw 
consent or cannot be contacted by the research team, despite several attempts. 
 
Participants may be withdrawn from the trial either at their own request or at the discretion of 
the Investigator. The participants will be made aware that this will not affect their future care. 
Participants will be made aware (via the information sheet and consent form) that should they 
withdraw the data collected to date cannot be erased and may still be used in the final analysis. 

 
 
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Protocol: Final Version 1.0 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
Informed consent 
 
All participants will provide written informed consent. The Informed Consent Form will be 
signed and dated by the participant before they enter the trial. The Investigator will explain the 
details of the trial and provide a Participant Information Sheet, ensuring that the participant has 
sufficient time to consider participating or not. The Investigator will answer any questions that 
the participant has concerning study participation.  
 
Informed consent will be collected from each participant before they undergo any interventions 
(including physical examination and history taking) related to the study. One copy of this will 
be kept by the participant, one will be kept by the Investigator, and a third will be retained in 
the patient’s hospital records. 
 
Should there be any subsequent amendment to the final protocol, which might affect a 
participant’s participation in the trial, continuing consent will be obtained using an amended 
Consent form which will be signed by the participant. 
 
Loss of capacity to consent during the course of the study will be managed as detailed on page 
27 of this protocol. 
 
 
The study will consist of a Baseline (attack) Visit, and two follow up visits. The baseline visit, 
which will take place at the earliest timepoint possible following hospital admission at the 
Nottingham City Hospital, will include a range of investigations, including lung function tests, 
blood tests and questionnaires. 
 
The second visit will take place approximately two weeks after hospital discharge at the 
Nottingham Respiratory Research Unit, at which further lung function tests, blood tests and 
questionnaires will be performed.  
 
The third visit (telephone follow up) will be arranged approximately four weeks after hospital 
discharge and will consist of questionnaires to determine the degree of symptomatic recovery. 
 
Investigations included in the baseline visit, second visit and third visit (telephone follow up) 
are listed in figure 1 and table 1. Patients admitted on more than one occasion with an attack 
will undergo attack visit investigation on each occasion if they consent to this.  
 
 
 
 
 
 
 
 
 
 
Study Assessments Algorithm. 
 
 
STUDY TREATMENT AND REGIMEN 

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
 
 
 
Figure 1: Study assessments algorithm.  
      
 
 
 
 
           
Definition of abbreviations: WCC = white cell count; FeNO = fractional exhaled nitric oxide; FOT = 
forced oscillation technique; PCR = polymerase chain reaction; MC+S = microscopy culture + 
sensitivity; SNOT = Sino-nasal outcome test; GERDQ = gastroesophageal reflux disease 
questionnaire; VCD = vocal cord dysfunction; HADS = hospital anxiety and depression scale; BMI = 
body mass index; CRP = c-reactive protein; PAAP = Personalised Asthma Action Plan; MARS = 
medication adherence report scale; AQLQ = asthma quality of life questionnaire. 
 
 
 
 
 

 
 
Page 20 of 35 
 
Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
 
 
 
Schedule of study assessments. 
 
Visit 
Baseline visit 
Second visit 
Telephone visit 
Time 
Attack 
Day 14 +/-2 
Day 28 +/-2 
Investigations Performed 
 
 
 
Informed Consent 
X 
 
 
Medical History 
X 
 
 
Concomitant Medications 
X 
 
 
Demographic Data 
X 
 
 
Sino-nasal Outcome Test 
X 
 
 
Gastroesophageal Reflux Disease 
Questionnaire 
X 
 
 
Pittsburgh Vocal Cord Dysfunction Index 
X 
 
 
Nijmegen 
X 
 
 
Hospital Anxiety and Depression Scale 
X 
 
 
Medication Adherence Report Scale 
X 
 
 
Inhaler Technique check 
X 
 
 
Acute Asthma Quality of Life Questionnaire 
X 
X 
X 
Spirometry and PEFR 
X 
X 
 
Fractional Exhaled Nitric Oxide (FeNO) 
X 
X 
 
Forced Oscillation Technique (FOT) 
X 
X 
 
Clinical Chemistry (C- Reactive Protein) 
X 
X 
 
Sputum (induced or spontaneous) for 
differential cell count, supernatant storage and 
microbiological assessment 
X 
X 
 
Blood White Cell Count Differential 
X 
X 
 
Vitamin D 
X 
 
 
Viral PCR: Throat swab.  
X 
 
 
Nasal lavage 
X 
 
 
Nasosorption Sample 
X 
X 
 
Nasal Epithelium Samples for Genetic Analysis 
(optional) 
X 
X 
 
Table 1: Schedule of study assessments. 
 
 
 
 

 
 
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Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
 
 
Study Assessments 
Medical History, Demographics and Concomitant Medications 
Medical history will include clinically significant diseases and prior surgeries and smoking 
history. A specific respiratory history will also be recorded. Demographic data will include age, 
sex and self- reported race/ethnicity. Medication use will also be collected.  
Height, Weight and Blood Pressure 
Height, weight and blood pressure measurements will be obtained from medical record. 
Sino-nasal Outcome Test 
The incidence of upper airway symptoms will be assessed using Sino-nasal Outcome Test 
(SNOT). 
 
Gastroesophageal Reflux Disease questionnaire. 
 
The incidence of Gastroesophageal Reflux Disease will be assessed using GERDQ 
questionnaire. 
 
Pittsburgh Vocal Cord Dysfunction Index 
 
The incidence of vocal cord dysfunction will be assessed using Pittsburgh Vocal Cord 
Dysfunction (VCD) Index 
 
Nijmegen Questionnaire. 
 
The incidence of dysfunctional breathing will be assessed using Nijmegen dysfunctional 
questionnaire. 
 
Hospital Anxiety and Depression Scale 
 
The incidence of anxiety and depression will be assessed using Hospital Anxiety and 
Depression Scale (HADS). 
 
Medication Adherence Report Scale 
 
Participants’ adherence to medication will be assessed using the Medication Adherence 
Report Scale (MARS). 
 
Acute Asthma Quality of Life Questionnaire 
 

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
The impact of acute asthma on quality of life will be assessed using Acute Asthma Quality of 
Life Questionnaire at baseline and follow up. 
Fractional Exhaled Nitric Oxide (FeNO) 
FeNO will be measured using a standard device (NIOXX Vero®) in accordance with the 
manufacturer’s guidelines. The same type of device will be used at each visit. FeNO should 
be performed prior to any other respiratory assessment if possible.  
Forced Oscillation Technique (FOT)  
FOT is a non-invasive method that evaluates resistance and reactance in the respiratory 
system during tidal breathing. It should be performed after FeNO, but prior to Spirometry and 
will be conducted according to a study SOP.  
Spirometry 
Spirometry will be conducted according to a study SOP. The Global Lung Function (GLI) 2012 
equations will be used. Reversibility testing will not be routinely performed. Thus, asthma 
medications will not normally be withheld for study visits and patients should take their inhalers 
as usual. The same type of device will be used at each visit. 
Induced and Spontaneous Sputum  
Sputum induction will be performed according to an SOP, which includes measures to protect 
the safety of participants. These consist of pre-treatment with Salbutamol, a short acting 
bronchodilator, stipulated levels of lung function in order to perform the test and stopping 
criteria. If the participant is unable to undergo the procedure, due to safety reasons, they will 
be asked to produce a spontaneous sputum sample. Sputum samples will be collected for a 
differential cell count, bacterial culture and sensitivity and storage for future research. 
Procedures for sampling and processing will be detailed in a study SOP. 
Laboratory Assessments 
Blood will be collected for laboratory analysis, including Vitamin D, Haematology, WCC 
differential, C-Reactive protein. Sputum will be collected for microbiological assessment. 
These samples will be analysed at the local NHS laboratory. 
Blood Samples for Biomarkers 
Serum blood samples for biobanking will be collected at baseline (attack) and at second visits 
and stored for future research. 
Nasal Absorption 
Nasal absorption will be used to collect mucosal lining fluid from the respiratory tract for 
cytokines profiling at baseline (attack) and at second visits. 
Nasal Lavage  
Nasal lavage samples will be taken at the baseline (attack) visit. Samples will be obtained by 
injecting 5ml of sterile normal saline into the participant’s nostrils via a nasal adaptor and then 

 
 
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Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
immediately aspirated. These will be placed in a sterile container and transported to the 
laboratory for viral identification. This procedure will be detailed in a study SOP.  
 
Nasal Epithelium Sample 
Nasal brushings samples may be taken at baseline (attack) and at second visits for RNA and 
DNA extraction. This will be optional and specific consent from participants will be sought. 
Procedures for sampling and processing will be detailed in a study SOP. 
Throat Swab 
A throat swab will be taken at the baseline (attack) visit for viral identification.  
Compliance and adherence 
In order to assess adherence as a factor in exacerbations, a participant’s beliefs and attitudes 
towards medicines will be explored using the Medicines Adherence Report Scale (MARS) 
questionnaire. Non-intentional non-compliance with usual treatment will be assessed by 
checking inhaler technique; poor inhaler technique will be reported to the participant’s clinical 
team. Also, GP records will be reviewed for information on medications prescribed in the last 
12 months. 
Participants who do not attend study visits and then unable to be contacted despite several 
attempts may be withdrawn from the study.  
Criteria for terminating trial 
There are no planned criteria for terminating the trial, as we do not anticipate obtaining data or 
identifying circumstances that would necessitate closing the study early. For individual 
participants, discontinuation will be considered on a case-by-case basis.  
TRANSPORT AND STORAGE OF THE TISSUES  
Samples will be labelled in the same format, using study reference, unique patient identifier, 
time and date taken, and participant visit number.  
All biological (blood, sputum, nasal absorption samples and nasal lavage, nasal brushes and 
throat swabs) samples will be stored in a linked, anonymised format and labelled using a 
combination of study reference, unique study identifier and cross referenced with location code 
numbers to permit accurate linkage to study data and the consent form. The master database 
will be held by the NRRU Database Manager or delegate, in a password encrypted file. 
The analysis of samples will either take place in Nottingham, including University of Nottingham 
premises at Queens Medical Centre and also at the University of Nottingham itself, or in the 
laboratories of third party national and international partners, following appropriate Tissue 
Transfer Agreements.  
Samples for NHS laboratory analysis (blood samples for haematology, clinical chemistry and 
sputum for microbiological assessment) will be labelled and analysed in accordance with local 
NHS procedures.  

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
Once analysis has taken place, blood and sputum samples will be stored at University of 
Nottingham premises at Respiratory Medicine, The Clinical Sciences Building, Nottingham City 
Hospital, Hucknall Road, Nottingham, NG5 1PB for future research (DI William Dunn – Licence 
Number 12265), if participants are agreeable and sign the optional clause on the consent form.  
Where participants do not agree to the future use of the samples, they will be destroyed in 
accordance with the Human Tissue Act, 2004.  
LABORATORY ANALYSES  
Sputum samples will be analyzed at NUH pathology labs for microscopy, culture and 
sensitivity, following a structured protocol. 
Sputum supernatant will be stored in aliquots at -80 degrees centrigrade, in monitored and 
alarmed freezers for future cytokine analysis. Cytospin slides for the differential cell count, will 
be fixed, stained and counted, before being stored. 
Nasal absorption samples will be analyzed in the laboratories of the University of Nottingham. 
Samples from nasal lavage and the throat swabs will be analysed in Nottingham, including 
University of Nottingham premises at Queens Medical Centre and also at the University of 
Nottingham itself, or in the laboratories of third-party partners, following appropriate Tissue 
Transfer Agreements. 
Samples from nasal brushings will be collected for RNA and DNA extraction and genetic 
analysis. This will be optional and specific consent from participants will be sought. Sample 
analysis will take place on University of Nottingham premises. Results of genetic testing will 
not be shared with participants, however, participants’ GP/Consultants will be informed of any 
incidental findings. 
Laboratory analyses will be detailed in a study laboratory manual.  
 
 
Methods  
Data analysis will be performed by a PhD student, Mouaid Aljehani, under the supervision of 
Professor Tricia McKeever, Professor Tim Harrison and Dr Matthew Martin. 
The main outcomes of the exacerbation are descriptive in nature, and no statistical tests are 
planned. We will, however, compare key findings at exacerbation visits with those undertaken 
at the follow-up visits, including: Paired tests (paired t-test or McNemar) will be used to 
examine changes in fractional exhaled nitric oxide (FeNO), parameters derived from Forced 
Oscillation Technique (FOT), the Acute Asthma Quality of Life Questionnaire (Acute AQLQ), 
sputum differential cell count, nasal absorption, haematology, and clinical chemistry values. 
Sample size and justification 
 
This is an observational, hypothesis-generating study, and due to the lack of previous data on 
this subject, a meaningful sample size calculation cannot be performed. 
STATISTICS 

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
Assessment of safety 
 
An assessment of safety to conduct study procedures will be carried out for each patient prior 
to recruitment in study and again prior to potential sputum induction. Participants will 
specifically be asked about the need for further urgent or emergency assessments or treatment 
for acute asthma at their follow up visit. 
 
Procedures for missing, unused and spurious data 
Values outside the accepted range will be investigated for accuracy. As the focus of this 
study is descriptive, complete cases analyses will be the primary method for data analysis.  
 
 
As this is an observational study, only unexpected AE’s and all SAE’s related directly to the 
trial investigations will be collected and reported. 
 
Definitions 
 
Adverse Events 
 
An adverse event is any unfavourable and unintended sign, symptom, syndrome or illness 
that develops or worsens during the period of observation in the study.  
 
An AE does include a / an: 
 
1. An exacerbation of a pre-existing illness. 
 
2. An increase in frequency or intensity of a pre-existing episodic event or condition. 
 
3. A condition detected or diagnosed after medicinal product administration even though it may 
have been present prior to the start of the study. 
 
4. A continuous persistent disease or symptoms present at baseline that worsen following the 
start of the study. 
 
An AE does not include a / an: 
 
1. A medical or surgical procedure (e.g., surgery, endoscopy, tooth extraction, transfusion); 
but the condition that lead to the procedure is an AE. 
 
2. A pre-existing disease or conditions present or detected at the start of the study that did not 
worsen. 
 
3. Situations where an untoward medical occurrence has not occurred (e.g., hospitalisations 
for cosmetic elective surgery, social and / or convenience admissions). 
 
4. A disease or disorder being studied or sign or symptom associated with the disease or 
disorder unless more severe than expected for the participant’s condition. 
 
ADVERSE EVENTS 
 
 
 
 
 
 
 
 

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
5. An overdose of concurrent medication without any signs or symptoms. 
 
Serious Adverse Events 
 
A Serious Adverse Event (SAE) is any adverse event occurring following study mandated 
procedures, having received the intervention that results in any of the following outcomes: 
 
1. Death 
 
2. A life-threatening adverse event 
 
3. Inpatient hospitalisation or prolongation of existing hospitalisation 
 
4. A disability / incapacity 
 
5. A congenital anomaly in the offspring of a participant 
 
Important medical events that may not result in death, be life-threatening, or require 
hospitalisation may be considered a serious adverse event when, based upon appropriate 
medical judgment, they may jeopardize the patient or participant and may require medical or 
surgical intervention to prevent one of the outcomes listed in this definition 
 
All adverse events will be assessed for seriousness, expectedness and causality. 
 
A distinction is drawn between serious and severe AEs. Severity is a measure of intensity 
whereas seriousness is defined using the criteria above. Hence, a severe AE need not 
necessarily be serious.  
 
Causality 
 
Not related or improbable: a clinical event including laboratory test abnormality with temporal 
relationship to trial intervention administration which makes a causal relationship incompatible 
or for which other treatments, chemicals or disease provide a plausible explanation. This will 
be counted as “unrelated” for notification purposes. 
 
Possible: a clinical event, including laboratory test abnormality, with temporal relationship to 
trial intervention administration which makes a causal relationship a reasonable possibility, but 
which could also be explained by other interventions, chemicals or concurrent disease. This 
will be counted as “related” for notification purposes. 
 
Probable: a clinical event, including laboratory test abnormality, with temporal relationship to 
trial intervention administration which makes a causal relationship a reasonable possibility, and 
is unlikely to be due to other interventions, chemicals or concurrent disease. This will be 
counted as “related” for notification purposes. 
 
Definite: a clinical event, including laboratory test abnormality, with temporal relationship to 
trial intervention administration which makes a causal relationship a reasonable possibility, and 
which can definitely not be attributed to other causes. This will be counted as “related” for 
notification purposes. 
 
With regard to the criteria above, medical and scientific judgment shall be used in deciding 
whether prompt reporting is appropriate in that situation. 
 

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
Reporting of adverse events 
 
Participants will be asked to contact the study site immediately in the event of any serious 
adverse event. All adverse events will be recorded and closely monitored until resolution, 
stabilisation, or until it has been shown that the study intervention is not the cause. The Chief 
Investigator shall be informed immediately of any serious adverse events and shall determine 
seriousness and causality in conjunction with any treating medical practitioners. 
 
All trial investigation related serious adverse events will be recorded and reported to the REC 
as part of the annual reports. Unexpected serious adverse events will be reported within the 
timeframes to the REC as stated below. The Chief Investigator shall be responsible for all 
adverse event reporting. 
 
Trial Investigation Related SAEs 
 
A serious adverse event that is unexpected in its severity and seriousness and deemed directly 
related to or suspected to be related to the trial investigation shall be reported to the ethics 
committee that gave a favourable opinion as stated below. 
 
The event shall be reported immediately of knowledge of its occurrence to the Chief 
Investigator. 
 
The Chief Investigator will: 
 
 
Assess the event for seriousness, expectedness and relatedness to the trial 
investigation. 
 
Take appropriate medical action, which may include halting the trial and inform the 
Sponsor of such action. 
 
If the event is deemed related to the trial investigation or device shall inform the REC 
using the reporting form found on the NRES web page within 7 days of knowledge of 
the event. 
 
Shall, within a further eight days send any follow-up information and reports to the REC. 
 
Make any amendments as required to the study protocol and inform the REC as 
required 
 
Participant removal from the study due to adverse events 
 
Any participant who experiences an adverse event may be withdrawn from the study at the 
discretion of the Investigator. 
 
ETHICS COMMITTEE AND REGULATORY APPROVALS 
 
The trial will not be initiated before the protocol, informed consent forms and participant and 
GP information sheets have received approval / favourable opinion from the Research Ethics 
Committee (REC), the respective National Health Service (NHS) or other healthcare provider’s 
Research & Development (R&D) department, and the Health Research Authority (HRA) if 
required. Should a protocol amendment be made that requires REC approval, the changes in 
the protocol will not be instituted until the amendment and revised informed consent forms and 
participant and GP information sheets (if appropriate) have been reviewed and received 
approval / favourable opinion from the REC and R&D departments. A protocol amendment 
ETHICAL AND REGULATORY ASPECTS 

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
intended to eliminate an apparent immediate hazard to participants may be implemented 
immediately providing that the REC are notified as soon as possible and an approval is 
requested. Minor protocol amendments only for logistical or administrative changes may be 
implemented immediately; and the REC will be informed. 
 
The trial will be conducted in accordance with the ethical principles that have their origin in the 
Declaration of Helsinki, 1996; the principles of Good Clinical Practice, and the UK Department 
of Health Policy Framework for Health and Social Care, 2017. 
 
INFORMED CONSENT AND PARTICIPANT INFORMATION 
 
The process for obtaining participant informed consent will be in accordance with the REC 
guidance, and Good Clinical Practice (GCP) and any other regulatory requirements that might 
be introduced. The investigator or their nominee and the participant shall both sign and date 
the Informed Consent Form before the person can participate in the study. 
 
The participant will receive a copy of the signed and dated forms and the original will be 
retained in the Trial Master File. A second copy will be filed in the participant’s medical notes 
and a signed and dated note made in the notes that informed consent was obtained for the 
trial.  
 
The decision regarding participation in the study is entirely voluntary. The investigator or their 
nominee shall emphasize to potential participant, that consent regarding study participation 
may be withdrawn at any time without penalty or affecting the quality or quantity of their future 
medical care, or loss of benefits to which the participant is otherwise entitled. No trial-specific 
interventions will be done before informed consent has been obtained. 
 
The investigator will inform the participant of any relevant information that becomes available 
during the course of the study, and will discuss with them, whether they wish to continue with 
the study. If applicable they will be asked to sign revised consent forms. 
 
If the Informed Consent Form is amended during the study, the investigator shall follow all 
applicable regulatory requirements pertaining to approval of the amended Informed Consent 
Form by the REC and use of the amended form (including for ongoing participants). 
 
There will be no official form of capacity assessment during the study. Where the research 
team perceive, that there are changes to a participant’s well-being, likely to impact on capacity 
to consent, the participant will be withdrawn from the study. 
 
 
RECORDS  
 
Case Report Forms  
 
Each participant will be assigned a trial identity code number, for use on CRFs other trial 
documents and the electronic database. The documents and database will also use their 
initials (of first and last names separated by a hyphen or a middle name initial when available) 
and date of birth (dd/mm/yy) and the visit. 
 
CRFs will be treated as confidential documents and held securely in accordance with 
regulations. The investigator will make a separate confidential record of the participant’s name, 
date of birth, local hospital number or NHS number, and Participant Trial Number (the Trial 

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
Recruitment Log), to permit identification of all participants enrolled in the trial, in accordance 
with regulatory requirements and for follow-up as required 
CRFs shall be restricted to those personnel approved by the Chief or local Principal 
Investigator and recorded on the ‘Trial Delegation Log.’ 
 
All paper forms shall be filled in using black ballpoint pen. Errors shall be lined out but not 
obliterated by using correction fluid and the correction inserted, initialled and dated. 
The Chief or local Principal Investigator shall sign a declaration ensuring accuracy of data 
recorded in the CRF. 
 
Sample Labelling  
 
Each participant will be assigned a trial identity code number for use on the samples, 
consent forms and other study documents and the electronic database. The documents and 
database will also use their initials (of first and last names separated by a hyphen or a middle 
name initial when available) and date of birth (dd/mm/yy) and visit. 
 
Samples for NHS pathology analysis will be labelled in accordance with local NHS 
procedures.  
 
Source documents  
 
Source documents shall be filed at the investigator’s site and may include but are not limited 
to, consent forms, current medical records, laboratory results and records. A CRF may also 
completely serve as its own source data. Only trial staff as listed on the Delegation Log shall 
have access to trial documentation other than the regulatory requirements listed below. 
 
Direct access to source data / documents 
 
The CRF and all source documents, including progress notes and copies of laboratory and 
medical test results shall made be available at all times for review by the Chief Investigator,  
Sponsor’s designee and inspection by relevant regulatory authorities (e.g. DH, Human Tissue 
Authority). 
 
DATA PROTECTION  
 
All trial staff and investigators will endeavour to protect the rights of the trial’s participants to 
privacy and informed consent, and will adhere to the Data Protection Act, 2018. The CRF will 
only collect the minimum required information for the purposes of the trial. CRFs will be held 
securely, in a locked room, or locked cupboard or cabinet. Access to the information will be 
limited to the trial staff and investigators and relevant regulatory authorities (see above). 
Computer held data including the trial database will be held securely and password protected. 
All data will be stored on a secure dedicated web server. Access will be restricted by user 
identifiers and passwords (encrypted using a one way encryption method). 
 
Information about the trial in the participant’s medical records / hospital notes will be treated 
confidentially in the same way as all other confidential medical information. 
 
Electronic data will be backed up every 24 hours to both local and remote media in encrypted 
format. 
 
 
 

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
 
 
 
 
 
INSURANCE AND INDEMNITY 
 
Insurance and indemnity for trial participants and trial staff is covered within the NHS Indemnity 
Arrangements for clinical negligence claims in the NHS, issued under cover of HSG (96)48. 
There are no special compensation arrangements, but trial participants may have recourse 
through the NHS complaints procedures. 
 
The University of Nottingham as research Sponsor indemnifies its staff, research participants 
and research protocols with both public liability insurance and clinical trials insurance. These 
policies include provision for indemnity in the event of a successful litigious claim for proven 
non-negligent harm. 
 
TRIAL CONDUCT 
 
Trial conduct may be subject to systems audit of the Trial Master File for inclusion of essential 
documents; permissions to conduct the trial; Trial Delegation Log; CVs of trial staff and training 
received; local document control procedures; consent procedures and recruitment logs; 
adherence to procedures defined in the protocol (e.g. inclusion / exclusion criteria, correct 
randomisation, timeliness of visits); adverse event recording and reporting; accountability of 
trial materials and equipment calibration logs. 
 
The Trial Coordinator, or where required, a nominated designee of the Sponsor, shall carry out 
a site systems audit at least yearly and an audit report shall be made to the Clinical 
Management Group. 
 
TRIAL DATA  
 
Monitoring of trial data shall include confirmation of informed consent; source data verification; 
data storage and data transfer procedures; local quality control checks and procedures, back-
up and disaster recovery of any local databases and validation of data manipulation. The Trial 
Coordinator or where required, a nominated designee of the Sponsor, shall carry out 
monitoring of trial data as an ongoing activity.  
 
Entries on CRFs will be verified by inspection against the source data. A sample of CRFs (10% 
or as per the study risk assessment) will be checked on a regular basis for verification of all 
entries made. In addition the subsequent capture of the data on the trial database will be 
checked. Where corrections are required these will carry a full audit trail and justification. 
 
Trial data and evidence of monitoring and systems audits will be made available for inspection 
by REC as required. 
 
 
QUALITY ASSURANCE & AUDIT  

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
RECORD RETENTION AND ARCHIVING 
 
In compliance with the ICH/GCP guidelines, regulations and in accordance with the University 
of Nottingham Research Code of Conduct and Research Ethics, the Chief or local Principal 
Investigator will maintain all records and documents regarding the conduct of the study. These 
will be retained for at least 7 years or for longer if required. If the responsible investigator is no 
longer able to maintain the study records, a second person will be nominated to take over this 
responsibility.  
 
The Trial Master File and trial documents held by the Chief Investigator on behalf of the 
Sponsor shall be finally archived at secure archive facilities at the University of Nottingham.  
This archive shall include all trial databases and associated meta-data encryption codes. 
 
 
DISCONTINUATION OF THE TRIAL BY THE SPONSOR  
 
The Sponsor reserves the right to discontinue this trial at any time for failure to meet expected 
enrolment goals, for safety or any other administrative reasons.  The Sponsor shall take advice 
from the Trial Steering Committee and Data Monitoring Committee as appropriate in making 
this decision. 
 
STATEMENT OF CONFIDENTIALITY  
 
Individual participant medical information obtained as a result of this study are considered 
confidential and disclosure to third parties is prohibited with the exceptions noted above. 
Participant confidentiality will be further ensured by utilising identification code numbers to 
correspond to treatment data in the computer files. 
 
Such medical information may be given to the participant’s medical team and all appropriate 
medical personnel responsible for the participant’s welfare.  
 
If information is disclosed during the study that could pose a risk of harm to the participant or 
others, the researcher will discuss this with the CI and where appropriate report accordingly. 
 
Data generated as a result of this trial will be available for inspection on request by the 
participating physicians, the University of Nottingham representatives, the REC, local R&D 
Departments and the regulatory authorities. 
 
 
Throughout the study, the NRRU and BRC websites will carry stories and information will be 
provided to participants via newsletters, telephone, and social media at regular intervals, if they 
give permission to be contacted. Our results will initially be shared with our PPI members and 
those who participated in this study. We anticipate many outputs from this study, much of which 
will be included in a PhD thesis, presented at scientific meetings, and prepared for publication 
in peer-reviewed journals and through relevant organisations, such as Asthma UK. 
 
 
PUBLICATION AND DISSEMINATION POLICY 
USER AND PUBLIC INVOLVEMENT 

 
 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
A specific Patient and Public Involvement (PPI) group has been formed which consists of 
patients with asthma. Initial meetings with the research team have been held and it is planned 
that these will take place at least 3 times per year, throughout the study. This group were 
consulted on the priority and importance of this research and have advised on the study design 
and the participant recruitment and retention strategy. 
 
They have also been involved in the development of participant information and will advise on 
engagement activities, the dissemination of results and ongoing study conduct and 
management. 
 
 
Funding source  
 
Internal Funds 
 
Participant stipends and payments 
 
Participants will not be paid to participate in the trial. Travel expenses will be offered for any 
hospital visits in excess of usual care. 
 
 
 
STUDY FINANCES 

 
 
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Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
Signatories to Protocol: 
 
Chief Investigator: (name) Matthew Martin 
 
 
Signature:____ 
 ____ 
 
 
Date: 22/2/22 
 
 
 
 
Co- investigator: 
(name) __________________________________ 
 
 
Signature:__________________________________ 
 
 
Date: ___________ 
 
 
 
 
Co- investigator: 
(name) Mouaid Aljehani 
 
 
Signature: 
 
 
 
Date: 22/2/22 
 
 
 
Trial Statistician:  
(name)__Tricia McKeever________________________________ 
 
 
Signature:__
________________________________ 
 
 
Date: __23/02/22_________ 
 
 
SIGNATURE PAGES 

 
 
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Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
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This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
 
 
 
 
 

 
 
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Phenotyping Asthma Exacerbations: A Longitudinal Cohort Study 3 (APEX 3) 
Protocol: Final Version 1.0 
10.11.2021          IRAS: 304615 
 
This protocol is confidential and the property of the University of Nottingham. No part of it may be 
transmitted, reproduced, published, or used by others persons without prior written authorisation 
from the University of Nottingham 
  
 
 
1. 
Mukherjee M, Stoddart A, Gupta RP, et al. The epidemiology, healthcare and societal 
burden and costs of asthma in the UK and its member nations: analyses of standalone and 
linked national databases. BMC Med. Aug 29 2016;14(1):113. doi:10.1186/s12916-016-0657-
8 
2. 
Office for National Statistics (ONS). All data related to national deaths and 
populations . 2017.  
3. 
The British Lung Foundation. Asthma statistics. Available from: 
https://statistics.blf.org.uk/asthma [cited 2020 24 December].  
4. 
Kann K, Long B, Koyfman A. Clinical Mimics: An Emergency Medicine-Focused 
Review of Asthma Mimics. J Emerg Med. Aug 2017;53(2):195-201. 
doi:10.1016/j.jemermed.2017.01.005 
5. 
Global Initiative for Asthma. Global Strategy for Asthma Management and 
Prevention, 2020. Available from: www.ginasthma.org.  
6. 
Agusti A, Bel E, Thomas M, et al. Treatable traits: toward precision medicine of 
chronic airway diseases. Eur Respir J. Feb 2016;47(2):410-9. doi:10.1183/13993003.01359-
2015 
7. 
Saunders RH, Jr., Adams E. Changes in circulating leukocytes following the 
administration of adrenal cortex extract (ACE) and adrenocorticotropic hormone (ACTH) in 
infectious mononucleosis and chronic lymphatic leukemia. Blood. Aug 1950;5(8):732-41.  
8. 
Kim HJ, Lee J, Kim JH, et al. Factors Affecting Recovery Time of Pulmonary 
Function in Hospitalized Patients With Acute Asthma Exacerbations. Allergy Asthma 
Immunol Res. Nov 2016;8(6):499-504. doi:10.4168/aair.2016.8.6.499 
9. 
ten Brinke A, Zwinderman AH, Sterk PJ, Rabe KF, Bel EH. "Refractory" eosinophilic 
airway inflammation in severe asthma: effect of parenteral corticosteroids. Am J Respir Crit 
Care Med. Sep 15 2004;170(6):601-5. doi:10.1164/rccm.200404-440OC 
10. 
Oishi K, Hirano T, Suetake R, et al. A trial of oral corticosteroids for persistent 
systemic and airway inflammation in severe asthma. Immun Inflamm Dis. Sep 2017;5(3):261-
264. doi:10.1002/iid3.166 
 
REFERENCES