SCARF: A Study of Early Continuous Positive Airways Pressure in Acute Respiratory Failure
Background
Mild breathing difficulties are common in children with impaired immunity. If a child develops severe breathing difficulties, this can result in acute respiratory failure (where the lungs no longer function properly). This is characterised by pulmonary oedema, reduced lung compliance and hypoxaemia. Currently, when a child develops severe breathing difficulties, they will be treated on the ward with oxygen, antibiotics and fluids. If, despite treatment, their breathing difficulties worsen, they will usually be admitted to the paediatric intensive care unit (PICU) for further treatment. This often involves the child receiving a general anaesthetic to allow them to be attached to a mechanical ventilator which helps them breathe.
Recent research studies in adults with severe breathing difficulties have found that it might be better to admit patients to the critical care unit early for a treatment called continuous positive airway pressure (CPAP) which can reduce the need for a mechanical ventilator. The SCARF research study aimed to find out which treatment results in more children recovering from severe breathing difficulties, without needing a mechanical ventilator.
Design
In three UK children’s hospitals we undertook a, open, parallel-group randomised trial of children with impaired immunity who developed acute respiratory failure. Children were randomly assigned to early PICU admission for CPAP or to standard care with supplemental oxygen. The primary outcome was need for treatment using a mechanical ventilator by 30 days.
Results
In total, 42 children were enrolled into the study between January 2013 and January 2016. There was no significant difference in the need for treatment using a mechanical ventilator by 30 days with early CPAP (48%) compared with standard care (24%), odds ratio (OR) 2.9 (0.8-10.9) p=0.11. However, 30-day mortality was significantly higher with early CPAP (33%) compared to standard care (5%) OR 10.0 (1.1-90.6) p=0.041. Mortality at 90 days was: early CPAP (52%) versus standard care (19%), OR 4.7 (1.2-18.6) p=0.029 while mortality at one year was similar early CPAP (61.9%) versus standard care (42.7%), OR 2.2 (0.6-7.4), p=0.22. There were two serious adverse events reported, both in the early CPAP group.
Conclusion
The SCARF study provided no evidence to support early PICU admission for CPAP in children with acute respiratory failure and impaired immunity. There was a trend towards increased use of mechanical ventilation and increased early mortality in the early CPAP group.
Who led the study?
Professor Mark Peters, Great Ormond Street Hospital for Children NHS Foundation Trust
This study was funded by the Great Ormond Street Hospital Children’s Charity (Project: 10AR31)
Publications
Peters MJ, Agbeko R, Davis P, Klein N, Zenasi Z, Jones A, Mackerness C, George S, Veys P, Ray S, Mouncey PR, Harrison DA, Rowan K. Randomized Study of Early Continuous Positive Airways Pressure in Acute Respiratory Failure in Children With Impaired Immunity (SCARF) ISRCTN82853500. Pediatr Crit Care Med 2018; . http://dx.doi.org/10.1097/pcc.0000000000001683
