title: Beta-Agonist Lung injury TrIal-2 (BALTI-2): a multicentre, randomised, double-blind, placebo-controlled trial and economic evaluation of intravenous infusion of salbutamol versus placebo in patients with acute respiratory distress syndrome.
abstract: BACKGROUND
  Acute respiratory distress syndrome (ARDS) is a major cause of mortality in intensive care patients and lacks effective treatments. A previous randomised controlled Phase II trial suggested that an intravenous (i.v.) infusion of salbutamol may be beneficial, as it reduced extravascular lung water and plateau airway pressure. The Beta-Agonist Lung injury TrIal-2 (BALTI-2) was initiated to evaluate the effects of this intervention on mortality in patients with ARDS.
  
  
  OBJECTIVE
  To evaluate whether or not, in patients with ARDS, an i.v. infusion of salbutamol given at 15 μg/kg ideal body weight (IBW)/hour for up to 7 days, compared with a placebo (0.9% sodium chloride) infusion, reduces 28-day all-cause mortality and other clinical outcomes. To evaluate salbutamol's clinical effectiveness and its cost-effectiveness in subgroups of patients.
  
  
  METHODS
  A multicentre, randomised, placebo-controlled trial.
  
  
  METHODS
  Forty-six intensive care units (ICUs) in the UK.
  
  
  METHODS
  Patients were eligible if they (1) were intubated and mechanically ventilated patients in participating ICUs; (2) were within 72 hours of onset of ARDS; (3) fulfilled American-European Consensus Conference definition for ARDS {acute-onset, severe hypoxaemic respiratory failure [partial pressure of oxygen in arterial blood/fraction of inspired oxygen ≤ 26.7 kPa (200 mmHg)] and bilateral infiltrates on the chest radiograph in the absence of clinical evidence of left atrial hypertension}; and (4) were aged ≥ 16 years.
  
  
  METHODS
  Intravenous infusion of salbutamol (15 μg/kg IBW/hour) or placebo (0.9% saline) for up to 7 days.
  
  
  METHODS
  All-cause mortality 28 days after randomisation, mortality at (first) discharge from ICU, mortality at (first) discharge from hospital, number of ventilator-free days, number of organ failure-free days, mortality at 12 months post randomisation, side effects (tachycardia/new arrhythmia/lactic acidosis) sufficient to stop treatment with trial drug, health-related quality of life (European Quality of Life-5 Dimensions and Short Form questionnaire-12 items at 6 and 12 months after randomisation), length of stay in critical care unit and length of stay in hospital.
  
  
  RESULTS
  Forty-six ICUs recruited patients to the trial. A total of 326 patients were randomised; 162 were allocated to salbutamol and 164 to placebo. One patient in each group withdrew consent. Recruitment was stopped after the second interim analysis because of safety concerns. Salbutamol increased 28-day mortality: 55 (34%) of 161 patients died in the salbutamol group compared with 38 (23%) of 163 in the placebo group (risk ratio 1.47, 95% confidence interval 1.03 to 2.08).
  
  
  CONCLUSIONS
  Treatment with i.v. salbutamol early in the course of ARDS was poorly tolerated, is unlikely to be beneficial and could worsen outcomes. Further trials of β-agonists in patients with ARDS are unlikely to be conducted. Some questions remain, such as whether or not there may be benefit at a different dose or in specific populations, but any studies investigating these would require a very strong rationale.
  
  
  BACKGROUND
  Current Controlled Trials ISRCTN38366450.
  
  
  BACKGROUND
  The National Institute for Health Research Health Technology Assessment programme.
authors.affiliation: Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Warwick, UK.
authors.forename: S
authors.initials: S
authors.lastname: Gates
authors.forename: G D
authors.initials: GD
authors.lastname: Perkins
authors.forename: S E
authors.initials: SE
authors.lastname: Lamb
authors.forename: C
authors.initials: C
authors.lastname: Kelly
authors.forename: D R
authors.initials: DR
authors.lastname: Thickett
authors.forename: J D
authors.initials: JD
authors.lastname: Young
authors.forename: D F
authors.initials: DF
authors.lastname: McAuley
authors.forename: C
authors.initials: C
authors.lastname: Snaith
authors.forename: C
authors.initials: C
authors.lastname: McCabe
authors.forename: C T
authors.initials: CT
authors.lastname: Hulme
authors.forename: F
authors.initials: F
authors.lastname: Gao Smith
mesh_terms: D018806:APACHE; D000293:Adolescent; D058666:Adrenergic beta-2 Receptor Agonists / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000420:Albuterol / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D004311:Double-Blind Method; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007262:Infusions, Intravenous; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000188:drug therapy* / Q000401:mortality; D006113:United Kingdom; D055815:Young Adult
chemical_list: D058666:Adrenergic beta-2 Receptor Agonists; D000420:Albuterol