Bronchial thermoplasty is a treatment for severe persistent asthma that involves delivering controlled radiofrequency energy to heat and reduce airway smooth muscle. It has been shown to improve quality of life and reduce exacerbations, ER visits, and hospitalizations according to clinical studies. However, it carries risks of worsening respiratory symptoms that may require hospitalization during the treatment period when the bronchoscopies are performed. Further research is still needed to identify which patients are most likely to benefit from this treatment.

1. BRONCHIAL THERMOPLASTY
INTRODUCTION.
Asthma is a complex inflammatory disorder of the airways characterized by
airway hyperresponsiveness (AHR) and variable airflow obstruction. Although
advances in clinical and basic research over the past few decades have led to the
development of effective treatments and dissemination of detailed disease
management guidelines, [2, 3] difficult-to-treat asthma continues to affect 5-10%
of adults with this disorder
BRONCHIAL THERMOPLASTY:
 Bronchial thermoplasty (BT) is a modality for treating asthma approved by
the FDA in 2010 involving the delivery of controlled, therapeutic
radiofrequency energy to the airway wall, thus heating the tissue and
reducing the amount of smooth muscle present in the airway wall and is
thought to prevent the chronic structural changes that occur in airway smooth
muscle (ASM) in individuals with asthma.
 BT targets ASM via the delivery of a controlled specific amount of
radiofrequency (RF) energy (RF ablation [RFA]) to the airway wall through
a dedicated catheter.
 This reduces the capacity of the immune system to cause bronchoconstriction
through nitric oxide signalling, which is the main root cause of asthma
symptoms.
 Bronchial thermoplasty is normally used in severe persistent asthmatics who
do not respond well to typical pharmacotherapy regimens.
 Through a standard bronchoscopy procedure, a small flexible tube is
advanced into the airway, via mouth or nose, to mildly heat the airway halls.
 This treatment has been shown to result in acute epithelial destruction with
regeneration observed in the epithelium, blood vessels, mucosa and nerves.
 However, airway smooth muscle has demonstrated almost no capacity for
regeneration, instead being replaced by connective tissue.

2.  The treatment has been shown to be safe and effective in prospective studies
with duration up to five years.
 Bronchial Thermoplasty is indicated for the treatment of severe persistent
asthma in patients 18 years and older whose asthma is not well controlled
with inhaled corticosteroids and long acting beta agonists as per GINA
guidelines.
The goals of the treatment are:
 Fewer asthma attacks
 Fewer emergency room and hospital visits
 Fewer days lost from work, school, and other activities
 Better symptoms for up to 5 years after treatment.
Indications:
This treatment is only for people with severe asthma, doctor may recommend it if
the patient is,
 Have asthma attacks that aren't controlled by inhalers or asthma medicines
called beta-agonists
 Are ages 18 to 65
 Have not smoked for the past year
 You need oral steroids to help control your asthma.
 Brief Statement of Relevant Indications for Use, Contraindications,
Warnings, and Adverse Events:
 The Alair™ Bronchial ThermoplastySystem is indicated for the
treatment of severe persistent asthma in patients 18 years and older
whose asthma is not well controlled with inhaled corticosteroids and
long-acting beta-agonists.
 The Alair System is not for use in patients with an active
implantable electronic device or known sensitivity to medications
used in bronchoscopy.
 Previously treated airways of the lung should not be retreated with
the Alair System.

3.  Patients should be stable and suitable to undergo bronchoscopy.
 The most common side effect of BT is an expected transient
increase in the frequency and worsening of respiratory-related
symptoms.
 ENDO-551804-AA As with any procedure, there are risks, and
individual results may vary.
 The most common adverse event of BT is a temporary worsening of
respiratory-related symptoms.
 These events typically occur within one day of the BT procedure
and usually resolve within a week with standard care.
 There is a small risk (3.4% per procedure) that symptoms may
require hospitalization.
Procedure
A full course of bronchial thermoplasty treatment includes three separate
bronchoscopic procedures:
o One for the each lower lobe of the lung and
o Another for both upper lobes.
Each outpatient procedure is performed approximately three weeks apart.
 Under sedation, a catheter inside a bronchoscope—a thin, flexible tube-like
instrument introduced through the patient’s nose or mouth, and into their
lungs—delivers thermal energy into the airways.
 The patient is monitored after the procedure and usually returns home that
day or early the next day.
 The catheter delivers a series of 10-second temperature controlled bursts of
radio frequency energy which heat the lining of the lungs to 65 degrees
Celsius.
 It is this heat that destroys some of the muscle tissue which constricts during
an asthma attack, reducing the number and severity of exacerbations.

4. Risks
In the period immediately following the bronchial thermoplasty procedure, there
was an expected transient increase in the frequency and worsening of respiratory-
related symptoms. Bronchial Thermoplasty is not right for patients:
 Under 18 years old
 With a pacemaker, internal defibrillator, or other implantable electronic device
 Known sensitivity to medications required to perform bronchoscopy, including
lidocaine, atropine and benzodiazepines
 Previously been treated with Bronchial Thermoplasty
It should be noted that bronchial thermoplasty is irreversible: the smooth muscle
tissue which is destroyed cannot be recovered.
Side Effects
 It's common to feel sleepy right after thr treatment.
 Patient may also cough or wheeze some, or be short of breath.
 These symptoms usually go away in a week.
 In rare cases, may need hospital care for the symptoms.
 There is a risk that the treatment will trigger a bad asthma attack that may
even cause person to be hospitalized.
Procedure Availability
Bronchial thermoplasty was first approved by FDA in April 2010. Bronchial
thermoplasty is now being used as a treatment in many countries which include
United Kingdom, India, and United States.

5. ABSTRACTS
Bronchial Thermoplasty for Severe Asthma: A Review of the Clinical and Cost-
Effectiveness of BT:
Last updated: August 27, 2015
Three randomized clinical trials, two that demonstrated evidence of performance
bias, provided the evidence basis for the systematic review, two health technology
assessments, two economic studies and four guidelines on bronchial thermoplasty
identified and reviewed in this report. For patients with poorly controlled, severe
asthma limited evidence suggested a marginal improvement in quality of life for
some patients who received bronchial thermoplasty. One randomized controlled
trial reported decreased emergency department visits following the bronchial
thermoplasty treatment period as compared to a sham control. During the bronchial
thermoplasty treatment period, consistent evidence was identified for an increased
incidence of respiratory related adverse events requiring hospitalization in the
treatment group. This increase did not extend past the treatment period or in
five years of follow-up of treated patients. Other outcomes, including asthma
control, respiratory related hospitalizations, frequency of severe exacerbations, and
pulmonary function outcomes were either not improved or the evidence was
mixed. One economic analysis found that when decreased emergency department
visits and hospitalizations followed bronchial thermoplasty an increase in cost-
effectivene
ss was realized, while another found that this decreased resource use may provide
savings within five years when introduced into an asthmatic cohort of patients. No
clear recommendations on which patient populations would benefit most from
bronchial thermoplasty were provided, however three of the four identified
guidelines conditionally recommended bronchial thermoplasty as a potential
treatment option for poorly controlled, severely asthmatic patients already on
optimal pharmacological therapy.
2.In a double-blind, randomized, sham-controlled clinical study of bronchial
thermoplasty adults with severe asthma that were treated with bronchial

6. thermoplasty had improved asthma-related quality of life out to a year compared to
the control (sham-treated) patients. Additionally, when compared to control
patients, patients treated with bronchial thermoplasty also experienced the
following benefits, however none reached statistical significance:
 32% reduction in asthma attacks
 84% reduction in emergency room visits for respiratory symptoms
 66% reduction in days lost from work, school, or other daily activities due to
asthma symptoms
 73% reduction in hospitalizations for respiratory symptoms
In a clinical study, BT has been proven to provide long-term reduction in asthma
induced breathing difficulty to at least 5 years, and improve the quality of life for
severe persistent asthma patients. Reduction in asthma attacks, ER visits, and
hospitalizations for respiratory symptoms are maintained to at least 5 years. These
benefits were observed during clinical studies where patients continued to take
their standard maintenance asthma medications which included combinations of
inhaled corticosteroids and long-acting bronchodilators.
Bronchial thermoplasty
The Indian journal of tuberculosis 58(4):155-9 · October2011 with 187
Reads,Prince James
o Christian Medical College Vellore
Abstract
Even with the use of maximum pharmacological treatment, asthma still remains
uncontrolled in some cases. For such cases of uncontrolled asthma, a novel
therapy--Bronchial Thermoplasty (BT)--has shown some promising results over
the past few years. BT is application of controlled radiofrequency heat via catheter
inserted through a flexible bronchoscope, to the bronchial walls. It reduces the
smooth muscle mass in bronchial wall and thus results in decreased contractility.
Three major trials of BT show that it does not cause any improvement in FEV1.
However, BT causes improvement the quality of life and decreases the future

7. exacerbations and emergency hospital visits due to asthma. But the benefit
observed was too small to be clinically significant. Follow up (two to five years)
results of these BT trials did not show any significant long-term adverse event
related to BT. However, further independent large randomized controlled trials and
results of application of BT in real hospital settings are needed to define its role in
asthma management.
BRONCHIAL THERMOPLASTY
Prince James* and Richa Gupta*
* Even with the use of maximum pharmacological treatment, asthma still
remains uncontrolled in some
Bronchial thermoplasty for people with asthma
Cochrane data base study,
Background
Asthma is a chronic condition in which people experience symptoms of
breathlessness, wheezing, coughing and chest tightness due to airway inflammation
and airway muscle contraction. With inhaled treatments, including bronchodilators
(drugs that relax airway muscle and so open up the airways) and steroids (which
treat underlying inflammation in the lungs), symptoms usually can be controlled.
However, for some people, asthma cannot be adequately controlled with these
drugs, either because they are truly resistant or because they do not take them.
Bronchial thermoplasty is a relatively new procedure that reduces the amount
of muscle bulk in the airways of the lungs. A long flexible tube, called a
bronchoscope, is passed down into the lung under direct observation, and the walls
of specific areas of the lungs are heated to 65 degrees Celsius. This causes some of
the muscle to break up, making it harder for the muscles to tighten.
Generally, three sessions of treatment are given.
Study characteristics

8. Researcher found three trials comparing groups of adults treated with bronchial
thermoplasty versus adults who received standard medical treatment or a "sham"
(simulated) bronchial thermoplasty treatment.
Key results
These studies showed moderate improvement only in quality of life of patients
treated with bronchial thermoplasty and in the number of asthma attacks
(exacerbations) that they experienced. In addition, patients treated with this
procedure had more respiratory problems than patients who received the
alternative intervention during the period when they were undergoing treatment,
resulting in increased risk of hospitalisation due to a respiratory symptom during
this phase, but not afterward.
Quality of evidence
Confidence in the results of this review is moderate because two of the studies had
no sham intervention and there were differences regarding the characteristics of
patients and the comparisons performed. More studies should be conducted to
determine whether the observed effect and safety of bronchial thermoplasty are
durable over the long term, and to identify whether particular patients can be
identified who could benefit most.
Main results:
Researcher included three trials (429 participants) with differences regarding their
design (two trials compared bronchial thermoplasty vs medical management and
the other compared bronchial thermoplasty vs a sham intervention) and participant
characteristics; one of the studies included participants with more symptomatic
asthma compared with the others.
The pooled analysis showed improvement in quality of life at 12 months in
participants who received bronchial thermoplasty that did not reach the threshold
for clinical significance (3 trials, 429 participants; mean difference (MD) in
Asthma Quality of Life Questionnaire (AQLQ) scores 0.28, 95% confidence
interval (CI) 0.07 to 0.50; moderate-quality evidence). Measures of symptom

9. control showed no significant differences (3 trials, 429 participants; MD in Asthma
Control Questionnaire (ACQ) scores -0.15, 95% CI -0.40 to 0.10; moderate-quality
evidence). The risk of bias for these outcomes was high because two of the studies
did not have a sham intervention for the control group.
The results from two trials showed a lower rate of exacerbation after 12
months of treatment for participants who underwent bronchial thermoplasty. The
trial with sham intervention showed a significant reduction in the proportion of
participants visiting the emergency department for respiratory symptoms, from
15.3% on sham treatment to 8.4% over 12 months following thermoplasty. The
trials showed no significant improvement in pulmonary function parameters (with
the exception of a greater increase in morning peak expiratory flow (PEF) in one
trial). Treated participants who underwent bronchial thermoplasty had a greater
risk of hospitalisation for respiratory adverse events during the treatment period (3
trials, 429 participants; risk ratio 3.50, 95% CI 1.26 to 9.68; high-quality
evidence), which represents an absolute increase from 2% to 8% (95% CI 3% to
23%) over the treatment period. This means that six of 100 participants treated
with thermoplasty (95% CI 1 to 21) would require an additional hospitalisation
over the treatment period. No significant difference in the risk of hospitalisation
was noted at the end of the treatment period.
Bronchial thermoplasty was associated with an increase in respiratory
adverse events, mainly during the treatment period. Most of these events were mild
or moderate, appeared in the 24-hour post-treatment period, and were resolved
within a week.
Authors' conclusions:
Bronchial thermoplasty for patients with moderate to severe asthma provides
a modest clinical benefit in quality of life and lower rates of asthma exacerbation,
but no significant difference in asthma control scores. The quality of life findings
are at risk of bias, as the main benefits were seen in the two studies that did not
include a sham treatment arm. This procedure increases the risk of adverse events
during treatment but has a reasonable safety profile after completion of the
bronchoscopies. The overall quality of evidence regarding this procedure is
moderate. For clinical practice, it would be advisable to collect data from patients

10. systematically in independent clinical registries. Further research should provide
better understanding of the mechanisms of action of bronchial thermoplasty, as
well as its effect in different asthma phenotypes or in patients with worse lung
function.
Recent Updates in Bronchial Asthma Treatment : Review of Guidelines and
New treatment Modalities
Dr. Nainesh Patel E-mail : drnaineshp@gmail.com
ABSTRACT
Asthma management is conventionally based on the guidelines provided by
various prominent bodies on the disease with GINA (Global Initiative For Asthma)
guidelines being most popular. In spite of these guidelines a significant proportion
of patients fail to achieve good control of their symptoms or prevent severe
exacerbations. For this reason new therapeutic strategies need to be explored.
Recently GINA has introduced the control based asthma management cycle
wherein pharmacological and non-pharmacological treatment is adjusted in a
continuous cycle that involves assessment, treatment and review leading to better
asthma outcomes. There are quite a few new therapeutic option in horizon which
target cytokines (anti IgE-omalizumab, anti IL-13-Lebrikizumab, anti-IL4Rá-
Dupilumab), neutrophilic inflammation (CXCR2 inhibitors), PGD2 receptor
(CRTH2 antagonist). Optimal use of these agents will probably require identifying
particular responsive phenotype .Novel therapy in the form of Bronchial
thermoplasty has been recently approved. It involves use of radio frequency
thermal energy to reduce the airway smooth muscle mass. Studies have
demonstrated improvements in asthma-related quality of life and a reduction in the
number of exacerbations following Bronchial thermoplasty

11. Bronchial Thermoplasty:A Decade ofExperience:State of the Art (journal of
allergy and clinical immunology)
Laren D.TanMDa
Ken Y.YonedaMDb
,et,al
Bronchial thermoplasty (BT) delivers targeted radiofrequency energy to bronchial
airway walls and results in the partial ablation of the airway smooth muscle that is
responsible for bronchoconstriction. It is approved for the treatment of severe
persistent asthma. Multiple, large clinical trials including a recent “real-world”
study demonstrate significant improvements in asthma-related quality of life,
reduction in asthma exacerbations, emergency department visits, and
hospitalizations after BT that is sustained out to 5 years. In this article, we review
the state of the art of BT treatment in severe persistent asthma and share a decade
of BT research and clinical experience. We share our personal experience and
introduce the three “I”s (identification, implementation, and intense follow-up) that
we believe promote successful patient outcomes and help build a successful BT
program.
Use of Multi-DetectorComputed Tomographyto Assess the
Results of Bronchial Thermoplasty
Aims and objectives
The objective of this study was to evaluate the role of MDCT findings in the
assessment of the efficacy of BT, what could help to provide a more effective
imaging-guided treatment for severe asthma.
Methods and materials
MDCT data from 26 patients with severe persistent asthma who underwent
imaging before and after BT were analysed retrospectively. Changes in the
following parameters were assessed:
 total lung volume (TLV),
 mean lung density (MLD),
 airway wall thickness (AWT),

12.  CT air trapping index (density < -856HU),
 and expiratory/inspiratory ratio of MLD (E/I index).
Asthma Quality of Life Questionnaire (AQLQ) scorechanges were also
assessed. An AQLQ change in scoreof 0.5 was the minimal variation that
indicated asthma clinical improvement [5]. The four domains used to composethe
AQLQ overall score(symptoms, activity limitation, emotional function and
environmental stimuli) were also analysed individually and changes from
baseline to 12 months after BT were registered. Secondary outcomes included
changes in forced expiratory volume in the first second of expiration (FEV1) and
forced vital capacity (FVC).
Results
Median pre- and post-BT TLVs were 2668 (range, 2226-3096) ml and 2399
(range,1964-2802; p=0.08) ml, respectively. Patients also showed a pattern of
obstruction improvement, in air trapping values (median pre-treatment,
14.25%; median post-treatment, 3.65%; p<0.001] and in MLD values (pre-
procedure,-702 ± 72 HU; post-procedure,-655 ± 66 HU; p<0.01). Median AWT
also decreased after BT (pre-treatment,1.5 mm; post-treatment, 1.1 mm; p<0.05).
There was a mean AQLQ overall scorechange of 1.00 ± 1.35 (p<0.001), indicating
asthma clinical improvement, whereas 65.38% of subjects achieved minimal
important difference, i.e., an AQLQ scorechange of 0.5 or greater. Using the
Pearson's correlation test to evaluate associations between AQLQscorechanges
and imaging parameters variations, a moderate correlation coefficient was
observed between differences for the E/I index compared to the AQLQ symptoms,
environmental stimuli and overall scores (-0.41, -0.50 and -0.43, respectively). For
other associations, correlation coefficients were weak or very weak and were not
statistically significant. Although there was an improvement in FEV1 and FVC,
changes were not statistically significant (p=0.12, p=0.35, respectively).
Conclusion
This study showed that MDCT could demonstrate an improved respiratory pattern
after BT, a treatment for severe asthma that improves quality of life and reduces
healthcare need in many patients. Although further studies with greater sample

13. powers are needed, CT appears to be an option for the assessmentof BT results
that is considerably more accessible and less expensive than previously reported
imaging methods.
Reference:
1. ^ http://www.btforasthma.com/home.html
2. ^ Cox G., M. D., McWilliams A., FitzGerald J.M., and Lam S. (2006).
"Bronchial Thermoplasty for Asthma." American Journal of Respiratory
and Critical Care Medicine 173: 965 - 969.
3. ^ "Global Strategy for Asthma Management and Prevention". Global
Initiative for Asthma: 48. 2018. Retrieved 2018-05-21.
4. ^ Mitzner, W. (2006). "Bronchial Thermoplasty in Asthma." Allergology
International 55(3): 225 - 234.
5. ^ Jump up to: a b "DEFINE_ME_WA". jacionline.org.
6. ^ http://ginasthma.org/2018-gina-report-global-strategy-for-asthma-
management-and-prevention/
7. ^ "Clinical Pearls for Bronchial Thermoplasty : Journal of Bronchology &
Interventional Pulmonology". LWW.
8. ^ "American Journal of Respiratory and Critical Care Medicine".
9. ^ Thomson, N. C; Rubin, A. S; Niven, R. M; Corris, P. A; Siersted, H. C;
Olivenstein, R; Pavord, I. D; McCormack, D; Laviolette, M; Shargill, N. S;
Cox, G; AIR Trial Study Group (2011). "Long-term (5 year) safety of
bronchial thermoplasty: Asthma Intervention Research (AIR) trial". BMC
PulmonaryMedicine. 11: 8. doi:10.1186/1471-2466-11-8. PMC 3045390.
PMID 21314924.