BPAP Flops, Fails to Shorten Duration of Continuous Albuterol Therapy in Children With Acute Asthma: JAMA
USA: Researchers have found in a randomized trial that bilevel positive airway pressure (BPAP) did not reduce the duration of continuous albuterol therapy compared with sham BPAP in children with acute asthma exacerbations. Because prolonged beta-agonist therapy can cause tachycardia, diastolic hypotension, and lactatemia, the study was stopped early for futility after no meaningful treatment benefit was observed.
The study, published in JAMA Network Open, was led by Patrick T. Wilson, Department of Pediatrics, University of Colorado Anschutz School of Medicine, Aurora, and colleagues. The investigators evaluated whether introducing BPAP early in the emergency department (ED) could shorten the time children required continuous inhaled albuterol and potentially reduce critical care management.
The double-blind randomized clinical trial included 66 children aged 5 to 17 years presenting to a quaternary pediatric ED with acute asthma exacerbations. Participants had a Pediatric Respiratory Assessment Measure (PRAM) score of at least 4, indicating moderate disease, and required continuous albuterol therapy. Between June 2023 and May 2025, participants were randomly assigned to receive either BPAP or sham BPAP delivering minimal pressure for 4 hours. Both patients and healthcare professionals were blinded to treatment allocation.
The trial revealed the following findings:
- Children receiving BPAP required a mean of 8.3 hours of continuous albuterol therapy, compared with 8.7 hours with sham BPAP.
- The mean difference was −0.5 hours, showing no statistically or clinically significant reduction with BPAP.
- The trial was stopped early after meeting the predefined futility criteria at the 50% interim analysis.
- No deaths, invasive mechanical ventilation, air-leak syndromes, or aspiration pneumonia were reported in either treatment group.
The findings may partly reflect the moderate asthma severity of the study population, as most children did not require PICU admission and the mean PRAM score was 5.2. Earlier data used for sample-size calculations involved children with much longer continuous albuterol use. The researchers therefore recommended that future studies define clinically meaningful treatment differences in populations more representative of the intended study group.
The study had several limitations. Duration of continuous albuterol therapy is not a commonly used primary outcome in asthma trials, while hospitalization, PICU admission, and hospital length of stay lacked standardized institutional criteria. BPAP was administered for only 4 hours, limiting applicability to children who require prolonged noninvasive respiratory support. Use of sham BPAP enabled blinding but prevented albuterol delivery through the aerosol face-mask method commonly used in clinical practice.
The authors concluded that early BPAP did not significantly reduce continuous albuterol duration in children with moderate acute asthma exacerbations. They recommended further open-label studies in children with more severe asthma and investigation of heated and humidified albuterol delivery.
Reference:
Wilson PT, Tanverdi M, Brinton JT, Ambroggio L, Szefler SJ. Bilevel Positive Airway Pressure and Continuous Albuterol for Pediatric Asthma Exacerbations: A Randomized Clinical Trial. JAMA Netw Open. 2026;9(8):e2630627. doi:10.1001/jamanetworkopen.2026.30627
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