Currently the standard of care for acute asthma exacerbations in children involves immediate administration of an inhaled short acting beta agonist (SABA), most commonly Albuterol, paired with parasympatholytic (Ipratropium) both of which are administered via continuous nebulizer. Additionally, a course of oral or intravenous systemic corticosteroid such as methylprednisolone or decadron are also given to combat acute airway inflammation. Medical providers may also initiate the use of a respiratory support device that can range from supplemental oxygen delivered via nasal cannula (NC) and escalate to the use of Bi-level Positive Airway Pressure (BiPAP) or endotracheal intubation in order to increase delivery of medication to distal airways. Because asthma is the most common chronic disease of childhood, there have been ongoing studies on many fronts which are being undertaken to minimize morbidity, shorten hospitalization duration and more rapidly reduce a patient's level of respiratory distress.

When nebulized medication is delivered to a patient with active bronchospasm it might not be immediately delivered to the smallest bronchioles and terminal airways which are most affected by bronchospasm causing air trapping and poor gas exchange. Current modalities rely on dilation of larger airways first thus allowing medication to diffuse passively to the smaller airways as dilation occurs down the bronchial tree. Medication delivery is passive and dependent upon the progressive relaxation of these larger airways before reaching the smaller airways which is the ultimate goal of nebulized therapies. The critical pressure required for medication to reach these obstructed airways and keep them stented open is higher than in an otherwise healthy individual due to the natural consequences of airway remodeling seen in asthmatics which includes narrowing of the diameter of the airways, increased atelectasis of hypoventilated areas, and overall increased ventilation-perfusion (V/Q) mismatch. The concomitant processes of mucous plugging also commonly seen in asthma further complicates the efficient distribution of these medications in a thoracic cross section. However, application of positive pressure in patients with obstructive airways diseases such as asthma has potential to increase air-trapping, dynamic hyperinflation, and auto-peep and, in turn, aggravate ventilation-perfusion mismatch, all of which has potential to delay clinical improvement. With these considerations, we seek to determine if the physiologic benefit of proposed improved bronchodilator delivery by using added positive airway pressure (ie, active delivery of medication) is of sufficient magnitude to provide overall benefit to patients with acute asthma exacerbation.

The investigators propose to test this hypothesis through the following aim: To conduct a single-blinded (clinical team), randomized clinical trial to determine the efficacy of the AccuPAP device in comparison with the standard nebulizer to decrease acute exacerbation severity measured with the Acute Asthma Intensity Research Score (AAIRS), an objective and validated asthma scoring system, at 0, 1 and 2 hours after initiation of treatment. Secondary outcomes will include Emergency Department (ED) length-of-stay (LOS), general pediatrics floor hospitalization rate, Pediatric Intensive Care Unit (PICU) admission rate, number of patients who do not improve with AccuPAP, and rate of relapse within 24 hours of discharge from the ED. The investigators propose that outcome of the study findings have potential to not only shorten hospital stay duration which is cost efficient but also decrease the burden of the disease process on patient by implementing improved medication delivery strategies.