Pilot RCT of Therapeutic Hypothermia Plus Neuromuscular Blockade in ARDS Patients
Acute Respiratory Distress Syndrome (ARDS) is a serious condition that occurs as a complication of medical and surgical diseases, has a mortality of ~40%, and has no known treatment other than optimization of support. Data from basic research, animal models, and retrospective studies, case series, and small prospective studies suggest that therapeutic hypothermia (TH) similar to that used for cardiac arrest may be lung protective in patients with ARDS; however, shivering and its metabolic impact is a major complication of TH, often requiring neuromuscular blockade (NMB) to control. Since the recently completed NHLBI PETAL ROSE trial showed that NMB caused conferred neither benefit nor harm in patients with moderate to severe ARDS, the investigators seek to bundle TH with NMB to reduce shivering. The investigators have completed an open label pilot study of TH+NMB in 8 ARDS patients that showed feasibility of the approach and improved clinical outcomes compared with historical controls who just received NMB. To test and refine protocols for recruitment and treatment prior to a large multisite Phase IIb RCT, the investigators are performing a small pilot single center RCT of TH (core temperature 34-35°C) + NMB for 48h vs. standard of care in patients with ARDS and P/F < 200. Primary outcome will be 28 day ventilator-free days and secondary outcomes will include physiologic measures, mortality, hospital and ICU length of stay, and serum biomarkers collected on days 0, 1, 2, 3, 4, and 7.
- Respiratory Distress Syndrome, Adult
- Eligible Ages
- Between 18 Years and 80 Years
- Eligible Genders
- Accepts Healthy Volunteers
1. Men and women
2. Any race and ethnicity
3. 18-80 years old
4. Endotracheally intubated or have a tracheostomy in place, and mechanically ventilated
5. Admitted to a participating ICU
6. have a P/F ratio <200 with PEEP ≥5 cm H2O
7. have radiologic evidence of bilateral pulmonary infiltrates
8. Respiratory process has occurred within one week of a condition known to be associated with ARDS
9. Respiratory process cannot be fully explained by hydrostatic pulmonary edema.
10. ARDS criteria must have been initially met within 48h of enrollment
11. have a Legally authorized representative (LAR) to provide consent
Additional inclusion criteria required for randomization:
1. receiving deep sedation and NMB for ≤12h by time of randomization and who will remain on NMB for an additional ≥48h
2. have a P/F ratio <200 with PEEP ≥5 cm H2O
- Missed ARDS window (>48hrs)
- Missed NMB window: (>12 hrs)
- Missed mechanical ventilation window (>7 days)
- Refractory hypotension ( > 0.2 mcg/kg/min of norepinephrine or equivalent dose for a minimum of 6 h)
- Core temperature <35.5°C while not receiving CRRT
- No Legally authorized representative
- Significant, active bleeding (>3u blood products and/or surgical or IR intervention)
- Platelets <10K (uncorrected)
- Active hematologic malignancy
- Skin process precludes cooling device
- Moribund, not likely to survive 72h
- Pre-morbid condition makes it unlikely that patient will survive 28 days
- Do Not Resuscitate status
- Not likely to remain intubated for ≥48h
- Physician unwilling to participate
- Severe underlying lung disease
- On home O2
- On BIPAP (except for OSA)
- prior lung transplantation
- BMI >45
- Known NYHA class IV heart disease
- Acute Coronary Syndrome (MI, unstable angina)
- Cardiac arrest within 30 days of enrollment 21 Previously randomized in CHILL study
- Phase 2
- Study Type
- Intervention Model
- Parallel Assignment
- Intervention Model Description
- Randomized (1:1) control (non-blinded) trial
- Primary Purpose
- None (Open Label)
- Masking Description
- Since it will be obvious to observers of the subjects whether they are in the treatment (TH+NMB) or control groups, the study is not masked but all treatments that determine outcome are protocolized.
Hypothermia + Neuromuscular blockade
|Deep sedation and Neuromuscular blockade (NMB) and surface temperature management to maintain core temperature between 34 and 35°C for 48h, then rewarm to 36°C at 0.33°C per h and NMB discontinued when core temp reaches 35.5°C.||
Standard of care
|Acetaminophen and surface temperature management to maintain core temperature between 37°C and 38°C. Rewarming to 37°C for hypothermia ≤36°C with continuous renal replacement therapy.||
- NCT ID
- University of Maryland, Baltimore
Study ContactJeffrey D Hasday, MD
Despite recent advances in supportive care for patients with acute respiratory distress syndrome (ARDS), mortality remains >40%. Fever worsens and hypothermia mitigates animal models of ALI. A small non-randomized controlled trial of therapeutic hypothermia (TH) in moribund patients with septic shock and ARDS showed improved survival (3 of 9 vs. 0 of 10) in the TH group. However, the study preceded modern ARDS definition and management and mortality in both groups was much higher than current experience. Since oxygen utilization decreases ~10% per 1°C reduction in core temperature, TH may reduce injury in part by allowing lower levels of assisted ventilation. TH likely exerts additional lung protective effects by directly modifying temperature-dependent cellular processes in endothelium, epithelium, and leukocytes. However, cooling in critically ill patients is complicated by shivering and its adverse metabolic consequences. Neuromuscular blockade (NMB) is the ultimate treatment to block shivering and it is increasingly used in patients with ARDS to facilitate low tidal volume ventilation and prone positioning. Since the recently completed NHLBI PETAL ROSE trial showed that NMB caused conferred neither benefit nor harm in patients with moderate to severe ARDS, the investigators planned to bundle TH with NMB to reduce shivering. An open-label study of 8 ARDS patients showed that studying TH + NMB in patients with moderate to severe ARDS was feasible. Moreover, the patients treated with TH +NMB had more 28-day ventilator-free days (VFDs), ICU-free days (ICU-FDs) and greater hospital survival (75% vs. 25%; p = 0.027) than historical controls with ARDS and NMB but without TH. Within the limits of historical comparisons, these results support further study of TH in ARDS.
Focus of Study: The focus of the Cooling to Help Injured Lungs (CHILL) program is to test the central hypothesis that TH + NMB reduces mortality and morbidity in patients with ARDS in a Phase III randomized control trial (RCT). CHILL-RCT-pilot, a single-site Phase IIb RCT of TH vs usual temperature management in NMB-treated ARDS patients is the next step toward achieving this objective. CHILL-RCT-pilot has been started as a self-funded pilot with plans to transition to a DoD-funded phase contingent on grant funding. The data from the single-center study will allow refinement of study protocols and provide additional data to support and plan a larger, more definitive multicenter Phase IIb trial.
Primary and secondary objectives: The primary objective is to assess in an RCT whether mild TH + NMB is beneficial in patients with ARDS. The single-center pilot will provide information for planning a multicenter Phase IIb RCT TH + NMB vs. usual temperature management in patients with moderate to severe ARDS (PaO2:FIO2 (P/F) ratio<150).
Study design: The CHILL trial is a single center RCT.
Intervention: The study intervention is TH to core temperature 34°-35°C + NMB for 48h using surface cooling devices. Patients in the TH+NMB arm will receive deep sedation, continuous infusion of cisatracurium and mechanical ventilation for at least 48h. Decisions about transition to unassisted breathing, extubation, and transfer from ICU will be based on criteria in the CHILL study protocol.
TH arm: Once sedation and NMB are confirmed, TH to 34°-35°C will be initiated using either cooling blankets or Arctic Sun Device based on availability. Temperature will be measured from a central probe. Once target temperature is reached, TH will be maintained for 48h. Patients will then be rewarmed to 35.5°C by 0.3°C/h and the cooling devices removed. Post-TH fever suppression is not part of the CHILL protocol. Following ~54h treatment period, patients will receive antipyretics and surface cooling or warming at the discretion of the primary ICU team. Early stopping rules for TH and NMB include: persistent severe bradycardia, uncontrolled bleeding, and intractable arrhythmias.
Usual temperature management arm: Patients will receive light sedation (RASS 0 to -1). During the 54h post-randomizationtreatment period, acetaminophen will be given for core temperature >38°C and surface cooling will be initiated if core temperature remains >38°C within ≥45 minutes of receiving acetaminophen and adjusted to maintain core temperature ≤38°C. Patients in the usual temperature management arm with core temperature ≤36°C will receive surface warming to restore core temperature to 37°C. Following the 54h treatment period, patients will receive antipyretics and surface cooling or warming at the discretion of the primary ICU team.
Concomitant Treatment: Since prone positioning independently improves survival in ARDS, starting and stopping rules for prone positioning have been protocolized.
Primary and Secondary Endpoints:
Primary endpoint: 28-day VFDs. Decisions about transition to unassisted breathing will be made based on criteria in the CHILL protocol. The 28-day VFDs will be calculated at day 28.
Intermediate endpoint: The low and high core temperatures in each 2-hour period will be recorded and the mean core temperature for each of the first four study days will be calculated.
Clinical: (a) 28-day ICU-FDs: Decisions about transfer out of the ICU will be made based on criteria in the CHILL protocol. The 28-day ICU-FDs will be calculated at day 28 and recorded on the Day 28 case report form (CRF); (b) day 0, 1, 2, 3, 4, and 7 non-neurologic SOFA score; (c) Glasgow coma score at hospital discharge; (d) 60- and 90-day survival; (e) 60- and 90-day functional status. The Montreal Cognitive Assessment Tool (MOCA) will be administered at ICU and hospital discharge.
Physiologic: (a) day-3 and day-7 driving pressure and change vs baseline; (b) day-3 and day-7 oxygen saturation index (OSI) and change vs. baseline OSI. These measurements will be performed at the same time of day as the baseline values.
Plasma Biomarker: Day 0, 1, 2, 3, 4, and 7 plasma IL-1ß, IL-6, IL-8, IL-18, soluble-RAGE, surfactant protein-D, soluble ICAM-1, MMP8, and soluble TNFRI.
1. For the first 54h: (a) continuous cardiac monitoring for bradycardia with associated hypotension requiring i.v. fluid or vasopressors; (b) every 6h blood glucose measurement; (c) every 12 h potassium, magnesium and phosphate; (d) significant bleeding event (requiring 2u packed red blood cells or surgical or interventional radiologic intervention)
2. First 7 days: (a) Ventilator-associated pneumonia (VAP); (b) other secondary infections; (c) monitor for SAEs
Schedule of Clinical and Laboratory Evaluations:
1. Day 0: day of enrollment
2. Comprehensive metabolic panel (CMP): includes basic electrolytes, BUN, creatinine, ALT, AST, alkaline phosphatase, bilirubin, calcium, magnesium, and phosphate
3. CBC: complete blood count
4. Driving Pressure = Plateau Pressure - PEEP with patient NOT making inspiratory effort (on NMB or post-NMB and observed RR at set ventilator rate)
5. OSI = Mean airway pressure x 100 x FIO2/SpO2
2. Clinical and Research laboratory testing: One purple top (EDTA; 7 ml blood) tube will be collected for biomarker analysis at enrollment and on study days 1, 2, 3, 4, and 7 within 4h of randomization and at 8:00-10:00 on study days 1, 2, 3, 4, and 7. Clinical laboratory testing required for secondary clinical outcomes at enrollment and on study days 1, 2, 3, 4, and will be performed as part of usual clinical care whenever possible) at 6:00-10:00 AM and 6:00-10:00 PM
3. Day -2 to 0 (Screening and enrollment): To facilitate randomization within the inclusion window, we will consent and enroll based on partial fulfillment of randomization criteria and randomize once all criteria are met. Patients who have been receiving mechanical ventilation for up to 7 days and have bilateral pulmonary opacities not fully explained by pleural effusions, atelectasis, or hydrostatic pulmonary edema for <48h will be offered enrollment but will not be randomized until P/F ratio is <200. In patients without arterial blood gas values, the P/F ratio will be inferred from SpO2 readings using table e2 from Brown et al. (Chest 150:307; 2016) as long as the following conditions are met: 1) SpO2 values are 80-96%; (2) SpO2 is measured ≥10 min after any change in FIO2; (3) PEEP is ≥ 8 cm H2O; (4) the pulse oximeter waveform tracing is adequate; and (5) the qualifying inferred P/F ratio is confirmed 1-6 hrs after the initial determination.
1. Pregnancy testing in women of child-bearing years
2. Obtain informed consent from patient or Legally Authorized Representative (LAR) depending on capacity
3. Complete Screening Worksheet and Screening and Enrollment CRFs
4. If patient meets randomization criteria, proceed to randomization, otherwise follow until randomization criteria are met or patient exits the 48 hr ARDS inclusion window or the 7 day mechanical ventilation window.
3. Day 0 (Randomization day): Pt. identified in screen:
2. If patient does not have a central temperature probe, place esophageal probe.
3. If patient is randomized to the TH arm, confirm adequate sedation (RASS -4) and NMB (Train of four ≤2 twitch) and initiate TH protocol.
e. Obtain baseline plasma for research testing. If >8h since last CBC and CMP, send.
h. Complete Randomization Worksheet and Randomization and Baseline Data CRFs i. Note time cooling initiated and time patient first reached target temperature on Baseline Data CRF
a. Fill out Daily Data CRFs b. Collect plasma for research testing (aliquot and store at -80°C). c. Measure Driving Pressure and OSI d. Make sure CBC and CMP sent every 12h e. Rewarming starts after 48h cooling on day 3 f. Complete Unassisted Breathing Checklist form if applicable
5. Days 5-6:
a. Follow for ventilator status, ICU status, survival, SAEs b. Complete Unassisted Breathing Checklist form if applicable
6. Day 7:
1. Fill out Daily Data - Day 7 CRF
2. Collect plasma for research testing.
3. Measure Driving Pressure and OSI
4. Make sure CBC and CMP sent
5. Complete Unassisted Breathing Checklist form if applicable
7. Day 8-27:
a. Follow for ventilator status, ICU status, survival, SAEs b. Complete Unassisted Breathing Checklist form if applicable
8. Day 28:
1. Complete Day 28 CRF
2. Calculate 28 day VFDs and ICU-FDs
9. When patient is discharged from the ICU, complete ICU discharge CRF
10. When patient is discharged from the hospital, complete Hospital discharge CRF (make sure to obtain contact information for follow up)
11. Day 60 and 90: Follow up about patient status. Complete phone follow-up CRF.
Study population: Adult patients with moderate to severe ARDS based on Berlin criteria (P/F < 200 while on PEEP ≥8 cm H2O) <48h in duration.
Data Analysis: This is a pilot trial to refine study protocols for the subsequent multisite Phase IIb trial (should grant funding materialize). Since this pilot trial will use the same protocols as the larger follow-up study, we plan on merging data from the pilot with the subsequent study and analyze as follows. The group difference on the primary outcome variable, 28-day, will be tested with a permutation test for the difference in group means with alpha = 0.05 (two-tailed). For secondary clinical outcomes, t-tests, Wilcoxon, or chi-square tests for the comparison of two proportions will be used as appropriate. Mean differences will be estimated using 95% confidence intervals for all outcomes to further inform the decision whether to recommend proceeding to as well as to plan for a multicenter Phase III trial.
Data Management: Data for this pilot RCT will be recorded on paper CRFs by Drs. Hasday, Shanholtz, or their designees. Completion of all fields will be checked in real-time by Drs. Hasday and Shanholtz. The forms have been designed to allow smooth transition to electronic data management once funding is approved.
Randomization Plan: The investigators will use a randomization protocol stratified for proning status using pre-generated random assignment lists. Assignments will be made using an in-house Excel-based assignment tool, which blinds the observer to the assignment list.
Subject Participation Duration: The duration of intervention, TH + NMB vs. usual temperature management, is 48h, followed by rewarming for 3-6h in the TH group. NMB will be discontinued and sedation reduced when subjects are rewarmed to core temperature ≥35.5°C. In the control group fever and hypothermia during continuous renal replacement therapy (CRRT) will be treated by protocol for 54h post-randomization. Physiologic and clinical parameters will be collected through study day 7. In hospital follow-up up to 90 days will include determination of 28-day VFDs and ICU-FDs, and day of hospital discharge. When the patient regains competence, consent for continued participation will be obtained
Study Duration: Completion of enrollment is anticipated within 2 years.