Anti-inflammatory Effect of Nocturnal NIPPV on Acute Asthma
Condition: Asthma Acute
MeSH terms: Asthma
Study type: Interventional

Summary: 
      INTRODUCTION: Asthma is a disease characterized by inflammation of the airway and secondary
      contraction of smooth muscle. Treatment for the crisis consist in the use of local and / or
      systemic bronchodilators and anti-inflammatories, and it has been shown that mechanical
      ventilation to the airway through non-invasive positive pressure ventilation (NIPPV)
      decreases bronchial hyperreactivity and contractility of smooth muscle.

      OBJECTIVES: To assess the effect of nocturnal NIPPV on local inflammation, systemic
      inflammation and the state of hypersensitivity in patients with asthma attack.

      MATERIALS AND METHODS: We will include patients with severe asthma attacks requiring
      hospitalization, without indication for acute NIPPV, and will be randomized to receive NIPPV
      with an spontaneous (S) bilevel or continuous positive airway pressure (CPAP, control group),
      all patients will receive standard treatment; gasometric exchange, local inflammation (FEV1
      and Exhaled fraction of nitric oxide), systemic inflammation (C reactive protein, IL-4, IL-5,
      IL-13 and IL-17 in peripheral blood) and the hypersensitivity state (eosinophilia and IgE)
      between both groups will be compared after 4 days of treatment.
    

Detailed description: 
      RESEARCH QUESTION What is the effect of non invasive positive pressure ventilation (NIPPV) on
      systemic inflammation in patients with asthma attacks?

      JUSTIFICATION Asthma is a global public health problem and one of the primary causes of care
      at the National Institute of Respiratory Diseases in Mexico; when presented as a crisis is a
      serious condition that puts the life of the patient at risk; in vitro and in vivo studies
      have shown that the application of chronic airway distention using non-invasive mechanical
      ventilation produces a reduction in bronchial hyperreactivity in patients with asthma and may
      have a positive effect on the treatment of this condition independent of its effects on
      ventilation in the presence of acute respiratory failure.

      HYPOTHESIS The use of NIPPV will improve systemic inflammation assessed by C reactive protein
      (CRP) in patients with severe asthmatic crisis.

      OBJECTIVES

      Main Objective:

      To assess the effect of NIPPV on systemic inflammation measure through C reactive protein in
      acute asthma

      Secondary objectives:

        1. - To assess the effect of NIPPV on the days of hospital stay in patients with asthma
           attacks.

        2. - To evaluate adherence to NIPPV in patients with asthma attacks.

        3. - To evaluate the effect of NIPPV on PaO2, PaCO2 and SpO2 in patients with asthma
           attacks.

        4. - To evaluate the effect of NIPPV on FEV1 and Exhaled fraction of nitric oxide in
           patients with asthma attacks.

        5. - To evaluate the effect of NIPPV on serum levels of interleukin (IL)-4, IL-5, IL-13 and
           IL-17 in patients with asthma attacks.

        6. - To assess the effect of NIPPV on total eosinophil count and Immunoglobulin (Ig) E
           level in patients with asthma attacks.

      MATERIALS AND METHODS

        1. Design: A prospective, longitudinal, comparative, parallel group study will be
           conducted; it was approved by the Science and Bioethics Committees of the National
           Institute of Respiratory Diseases Mexico with the code C34-14. In all cases, informed
           consent will be requested.

        2. Place: It will be carried out in the emergency and hospitalization service of the
           National Institute of Respiratory Diseases "Ismael Cosío Villegas" at Mexico city.

        3. - Procedures:

             -  Clinical history.

             -  Chest X-ray.

             -  Berlin Questionnaire. The Berlin questionnaire is a self-administered questionnaire
                validated in Spanish to establish the risk of obstructive sleep apnea.

             -  Arterial gasometry.

             -  Blood cell count.

             -  Ultrasensitive C-reactive protein.

             -  Determination of IgE.

             -  Spirometry and Exhaled fraction of nitric oxide according to international
                guidelines.

        4. - Intervention: Patients included will be randomized to receive, 4 nights of noninvasive
           nocturnal positive pressure ventilation with an S Bilevel device with a 12 cmH2O
           inspiratory pressure and a 4 cmH2O expiratory pressure or a 4 cmH2O Continuous Positive
           Airway Pressure (CPAP), as a control group.

           The equipment will be placed at night ad libitum and retired the following day in the
           morning, in all cases a VPAP ST S8 RESMED will be used. If the patient needs to increase
           inspired oxygen fraction it will be performed with nasal tips during the day and a
           distal oxygen connector at night. In all cases a nasal mask will be used.

           Blood gasometry, blood cell count, CRP, serum IL-4, IL-5, IL-13, IL-17 and IgE,
           Spirometry and Exhaled fraction of nitric oxide will be repeated at day 4.

        5. - Data Analysis A convenience sample of 20 patients was established. A balanced
           randomization will be performed. The variables were summarized according to their type
           and distribution. The comparison of dichotomous variables will be performed using
           Fisher's Exact test. The comparison of independent continuous variables will be carried
           out with U of Mann Whitney and the related variables will be analyzed with Wilcoxon
           Related Ranks Test.
    

Intervention name(s): NIPPV; CPAP
Intervention type(s): Device; Device
Intervention description(s): Application of chronic distension of the airway through NIPPV to produce a reduction in bronchial hyperreactivity.; 4 cmH2O CPAP as the minimum pressure necessary to mobilize the air flow and avoid the space death with no effect on the ventilation.
Other intervention name(s): bilevel
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Experimental, prospective, longitudinal, comparative, parallel group study
Masking: Double (Participant, Investigator)
Primary purpose: Treatment