What are the best practices in bronchial thermoplasty (BT) performance?

Updated: Mar 30, 2021
  • Author: Said A Chaaban, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Answer

The National Asthma and Education and Prevention Program (NAEPP) Expert Panel Report 3 recommended add-on therapy with long-acting beta agonists, leukotriene modifiers, theophylline, and omalizumab in patients with difficult-to-treat asthma who take inhaled corticosteroids. [16]

Many of these add-on medications are expensive, have substantial side effects, and require adherence to daily administration or monthly or biweekly injections. These agents reduce inflammation or decrease airway narrowing by relaxing ASM but do not prevent the chronic structural changes that occur in ASM in individuals with asthma. Therefore, an alternative therapy is needed for this population. BT has been advanced as a potential solution for this unmet need.

In 2014, a European Respiratory Society (ERS)/American Thoracic Society (ATS) task force strongly recommended consideration of BT for adults with severe asthma in the context of an institutional review board (IRB)-approved systematic registry or as part of a clinical study. [4]  The quality of evidence behind this recommendation was labeled as very low, in that BT was considered as an add-on resource without a firm understanding of adverse effects, appropriate patient selection, or the degree of improvement in symptoms and quality of life to be expected.

In the 2020 focused updates [23]  to their 2007 asthma management guidelines, [16]  the Expert Panel Working Group of the National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC) made a conditional recommendation against BT in individuals aged 18 years or older who have persistent asthma. The Expert Panel noted, however, that BT might be considered in these individuals if they place a low importance on harms (short-term exacerbation of symptoms, unknown long-term side effects) and a high importance on potential benefits (improved quality of life, slightly reduced exacerbations).

Although the benefits of BT may be large, the potential harm may be large as well, and the long-term side effects are unknown. Further study is needed to assess exacerbation rates and long-term effects on lung function. It remains to be determined which phenotypes will respond best to BT, what the effects may be on obstructed patients with an FEV1 higher than 60%, and what the applicability of the procedure may be in patients receiving systemic steroid therapy.


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