Recommendations for the use of bronchial thermoplasty in the management of severe asthma

Abstract

There are approximately 3 million asthma sufferers in South Africa, and the national death rate is ranked as one of the highest in the world. Approximately 5% have severe asthma (uncontrolled despite being adherent on maximal and optimised therapy). Such uncontrolled asthma is associated with high healthcare expenditure and may require treatment with anti-IgE and/or systemic corticosteroids, in addition to inhaler therapy and oral agents. These treatments may be costly, and those such as oral corticosteroids may have potential serious adverse events. There is therefore a need for more effective, affordable and safe therapies for asthma. A new modality of treatment, bronchial thermoplasty (BT), has recently been developed and approved for the treatment of severe asthma. BT involves delivering radio frequency-generated thermal energy to the airways, with the goal of reducing airway-specific smooth-muscle mass. Several clinical studies have confirmed that BT is effective and safe, that it improves control and quality of life in patients whose asthma remains severe despite optimal medical therapy, and that the beneficial effects are sustained for at least 5 years. We provide recommendations for the management of severe asthma, with an emphasis on the role of BT, and endorse the use of BT in patients with severe persistent asthma who remain uncontrolled despite optimal medical therapy as outlined in steps 4 and 5 of the British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN), UK National Institute of Clinical Excellence (NICE) and Global Initiative for Asthma (GINA) guidelines. We outline the context in which BT should be used, how it works, its associated potential adverse events and contraindications, and unanswered questions and controversies. Med J 2015;105(9):726-732. S Afr

Guidelines for the management of asthma in adults and adolescents: Position statement of the South African Thoracic Society – 2021 update

“…Recommendation for the use of BT in SA have been published. [46] The lowest possible dose is ideally <10 mg prednisone equivalent per day. Table 7 outlines the recommended stepwise approach to asthma therapy with options for treatment choices at each step.…”

“…¶ The use of bronchial thermoplasty should be restricted to specialist centres and is detailed in a separate SATS document. [46] …”

Editor's Choice

“…[2] In addition, we publish recommendations for the use of bronchial thermoplasty in the management of severe asthma. [3] It is recommended that all endoscopic bronchothermoplasty procedures for severe asthma should be performed in the context of a local and/or international registry. The Assembly on Interventional Pulmonology of the South African Thoracic Society is willing to assist potential centres wishing to establish a thermoplasty and endoscopic lung volume reduction service in terms of training and accreditation.…”

Indications for the use of bronchial thermoplasty in severe asthma

“…A more comprehensive outline of the procedure, indications and contraindications, adverse events, evidence for long-term efficacy and safety, recommendations about using BT in South Africa, and international guidelines and agencies that have endorsed the procedure was provided in a more detailed article in last month' s SAMJ. [4] What is bronchial thermoplasty and how does it work?…”