Emerging understanding of the mechanism of action of Bronchial Thermoplasty in asthma

d'Hooghe, Julia N S; Hacken, N.H.T. ten; Weersink, Els J.M.; Sterk, Peter J.; Annema, Jouke T.; Bonta, Peter I.

doi:10.1016/j.pharmthera.2017.07.015

Cited by 41 publications

(35 citation statements)

References 80 publications

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“…The clinical efficacy of BT was studied in three randomized controlled trials (RCTs) 2007-2010 (Table 1) and their 5-year long-term follow-up studies 2011-2013 (Table 2) [2]. The first RCT was the AIR trial, which was an unblinded trial in 112 patients with moderate-tosevere asthma [3].…”

Section: Clinical Efficacy Of Btmentioning

confidence: 99%

“…BT may be considered for patients with severe asthma with predominant chronic airflow obstruction and patients with an unsatisfactory response to anti-IgE, anti-IL-5, or macrolides. 2 Whether certain inflammatory phenotypes or responsiveness to specific asthma medication use correlates to the presence of irreversible airway obstruction and/or BT response is not clear and needs further investigation.…”

Section: Patient Selectionmentioning

confidence: 99%

“…1). During bronchoscopy, RF energy "activations" are delivered using the basket catheter in airways 2 mm or larger, and each activation heats the exposed airway section to approximately 65 ° C. Although the mechanism of action of BT is incompletely understood, there is evidence that BT mainly acts through intervening in airway remodeling by reducing airway smooth muscle (ASM) and potentially by modulating the composition of the extracellular matrix [2]. As such, BT is considered the first asthma treatment that targets airway remodeling instead of mainly modulating airway inflammation and bronchomotor tone.…”

Section: Introductionmentioning

confidence: 99%

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Bronchial Thermoplasty in Severe Asthma: Best Practice Recommendations from an Expert Panel

et al. 2018

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Bronchial thermoplasty (BT) is a bronchoscopic treatment for patients with severe asthma who remain symptomatic despite optimal medical therapy. In this “expert best practice” paper, the background and practical aspects of BT are highlighted. Randomized, controlled clinical trials have shown BT to be safe and effective in reducing severe exacerbations, improving quality of life, and decreasing emergency department visits. Five-year follow-up studies have provided evidence of the functional stability of BT-treated patients with persistence of a clinical benefit. The Global Initiative for Asthma (GINA) guidelines state that BT can be considered as a treatment option for adult asthma patients at step 5. Patient selection for BT requires close collaboration between interventional pulmonologists and severe asthma specialists. Key patient selection criteria for BT will be reviewed. BT therapy is delivered in 3 separate bronchoscopy sessions at least 3 weeks apart, covering different regions of the lung separately. Patients are treated with 50 mg/day of prednisolone or equivalent for 5 days, starting treatment 3 days prior to the procedure. The procedure is performed under moderate-to-deep sedation or general anesthesia. At bronchoscopy a single-use catheter with a basket design is inserted through the instrument channel and the energy is delivered by a radiofrequency (RF) generator (Alair^TM Bronchial Thermoplasty System). BT uses temperature-controlled RF energy to impact airway remodeling, including a reduction of excessive airway smooth muscle within the airway wall, which has been recognized as a predominant feature of asthma. The treatment should be performed in a systemic manner, starting at the most distal part of the (sub)segmental airway, then moving proximally to the main bronchi, ensuring that the majority of the airways are treated. In general, 40–70 RF activations are provided in the lower lobes, and between 50 and 100 activations in the upper lobes combined. The main periprocedural adverse events are exacerbation of asthma symptoms and increased cough and sputum production. Occasionally, atelectasis has been observed following the procedure. The long-term safety of BT is excellent. An optimized BT responder profile – i.e., which specific asthma phenotype benefits most – is a topic of current research.

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Section: Clinical Efficacy Of Btmentioning

confidence: 99%

Section: Patient Selectionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Bronchial Thermoplasty in Severe Asthma: Best Practice Recommendations from an Expert Panel

et al. 2018

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“…Moderate and severe bronchiectasis, very high sputum production, and fixed airflow obstruction with FEV1 levels below 50% predicted are important contraindications for BT. The mechanisms underlying the potential effects of BT are unclear, and may involve effects on the neural innervation of the airways, or on the immune response, as well as the direct effect on airway smooth muscles [130]. Importantly, here is an urgent need for studies that clarify the effect of BT in specific phenotypes of severe asthma, in order to inform clinicians on how to identify patients that will benefit from BT.

c. Management of co-morbidities

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Section: Management Of Severe Asthmamentioning

confidence: 99%

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

Porsbjerg

Ulrik

Skjold

et al. 2018

European Clinical Respiratory Journal

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Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted patients. In some patients, symptoms are driven by other factors than asthma, and all patients with suspected severe asthma (‘difficult asthma’) should undergo systematic assessment, in order to differentiate between true severe asthma, and ‘difficult-to-treat’ patients, in whom poor control is related to factors such as poor adherence or co-morbidities. The Nordic Consensus Statement on severe asthma was developed by the Nordic Severe Asthma Network, consisting of members from Norway, Sweden, Finland, Denmark, Iceland and Estonia, including representatives from the respective national respiratory scientific societies with the aim to provide an overview and recommendations regarding the diagnosis, systematic assessment and management of severe asthma. Furthermore, the Consensus Statement proposes recommendations for the organization of severe asthma management in primary, secondary, and tertiary care.

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“…Bronchial Thermoplasty 15 patients were treated with BT by using the Alair System (Boston Scientific, USA) according to the current standard [19][20][21] and sedated using remifentanil/propofol [22]. Patients were treated with 50 mg of prednisolone 3 days before treatment, on the day of the procedure itself and 1 day thereafter.…”

Section: Design and Subjectsmentioning

confidence: 99%

Bronchial Thermoplasty-Induced Acute Airway Effects Assessed with Optical Coherence Tomography in Severe Asthma

et al. 2018

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Background: Bronchial thermoplasty (BT) is an endoscopic treatment for severe asthma targeting airway smooth muscle (ASM) with radiofrequent energy. Although implemented worldwide, the effect of BT treatment on the airways is unclear. Optical coherence tomography (OCT) is a novel imaging technique, based on near-infrared light, that generates high-resolution cross-sectional airway wall images. Objective: To assess the safety and feasibility of OCT in severe asthma patients and determine acute airway effects of BT by OCT and compare these to the untreated right middle lobe (RML). Methods: Severe asthma patients were treated with BT (TASMA trial). During the third BT procedure, OCT imaging was performed immediately following BT in the airways of the upper lobes, the right lower lobe treated 6 weeks prior, and the untreated RML. Results: 57 airways were imaged in 15 patients. No adverse events occurred. Three distinct OCT patterns were discriminated: low-intensity scattering pattern of (1) bronchial and (2) peribronchial edema and (3) high-intensity scattering pattern of epithelial sloughing. (Peri)bronchial edema was seen in all BT-treated airways, and less pronounced in only 1/3 of the RML airways. These effects extended beyond the ASM layer and more distal than the directly BT-treated areas and were reduced, but not resolved, after 6 weeks. Epithelial sloughing occurred in 11/14 of the BT-treated airways and was absent in untreated RML airways. Conclusions: Acute BT effects can be safely assessed with OCT and 3 distinct patterns were identified. The acute effects extended beyond the targeted ASM layer and distal of directly BT-treated airway areas, suggesting that BT might also target smaller distal airways.

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Emerging understanding of the mechanism of action of Bronchial Thermoplasty in asthma

Cited by 41 publications

References 80 publications

Bronchial Thermoplasty in Severe Asthma: Best Practice Recommendations from an Expert Panel

Bronchial Thermoplasty in Severe Asthma: Best Practice Recommendations from an Expert Panel

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

Bronchial Thermoplasty-Induced Acute Airway Effects Assessed with Optical Coherence Tomography in Severe Asthma

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