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Sukhan VS. PULMONARY DISEASE DIAGNOSTIC AND REHABILITATION TREATMENT FOR PATIENTS WITH OVERLAP ASTHMA AND CHRONIC OBSTRUCTIVE PULMONARY DISEASES. POLSKI MERKURIUSZ LEKARSKI : ORGAN POLSKIEGO TOWARZYSTWA LEKARSKIEGO 2023; 51:314-320. [PMID: 37756449 DOI: 10.36740/merkur202304103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Aim: To analyze the effectiveness of rehabilitation treatment in the conditions of halo aerosol therapy and when using different groups of fixed-dose aerosol inhalers in patients with asthma, chronic obstructive pulmonary diseases and asthma-chronic obstructive pulmonary diseases overlap. PATIENTS AND METHODS Materials and Methods: A total 112 patients with asthma, chronic obstructive pulmonary diseases and asthma-chronic obstructive pulmonary diseases overlap. All patients carefully collected allergic history, anamnesis of life, and disease. The study includes assessment of resting anthropometric data, physical activity habits, blood pressure, structure and quality of nutrition, family and economic data. RESULTS Result: After a course of rehabilitation treatment, lung ventilation improved in all groups of patients compared to controls. The dynamics of FER indicators after the rehabilitation treatment had some differences for each group of patients in relation to the control groups. If in all A groups (control) the increase in FER indicators was insignificant, then in all B groups of patients it was significant, and differed from 14,6% up to 36%. CONCLUSION Conclusions: Thus, a differentiated approach to the use of fixed-dose aerosol inhalers increases the effectiveness of rehabilitation treatment under conditions of halo aerosol therapy in patients with various genesis of bronchi-obstructive syndrome.
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Li A, Lee P. Which Endoscopic Procedure to Use and in What Patient? Valves, Coils, Foam, and Heat in COPD and Asthma. Pulm Ther 2022; 9:49-69. [PMID: 36534323 PMCID: PMC9931990 DOI: 10.1007/s41030-022-00208-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022] Open
Abstract
Despite the latest developments in therapeutic agents targeting airway endotypes, a significant proportion of patients with asthma and chronic obstructive pulmonary disease (COPD) remain symptomatic. Endoscopic therapies have a complementary role in the management of these airway diseases. The sustained efficacy of bronchial thermoplasty (BT) among patients with asthma over 10 years has been encouraging, as it has been shown to improve symptom control and reduce hospital admissions and exacerbations. Studies suggest that BT helps ameliorate airway inflammation and reduce airway smooth muscle thickness. While studies suggest that it is as effective as biologic agents, its role in the management of severe asthma has yet to be clearly defined and GINA 2022 still suggests limiting its use to patients with characteristics of the various populations studied. Conversely, bronchoscopic lung volume reduction has shown promise among patients with advanced COPD. Rigorous patient selection is important. Patients with minimal collateral ventilation (CV) and higher heterogeneity index have shown to benefit the most from endobronchial valve (EBV) therapy. For those with ongoing CV, endobronchial coils would be more appropriate. Both therapeutic modalities have demonstrated improved quality of life, effort tolerance, and lung function indices among appropriately selected patients. The emerging evidence suggests that endoscopic procedures among airway disease still have a substantial role to play despite the development of new therapeutic options.
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Affiliation(s)
- Andrew Li
- Respiratory and Critical Care Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Respiratory Service, Department of Medicine, Woodlands Health, Singapore, Singapore.
| | - Pyng Lee
- Respiratory and Critical Care Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228 Singapore ,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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3
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Hassoun D, Rose L, Blanc FX, Magnan A, Loirand G, Sauzeau V. Bronchial smooth muscle cell in asthma: where does it fit? BMJ Open Respir Res 2022; 9:9/1/e001351. [PMID: 36109087 PMCID: PMC9478857 DOI: 10.1136/bmjresp-2022-001351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/04/2022] [Indexed: 11/04/2022] Open
Abstract
Asthma is a frequent respiratory condition whose pathophysiology relies on altered interactions between bronchial epithelium, smooth muscle cells (SMC) and immune responses. Those leads to classical hallmarks of asthma: airway hyper-responsiveness, bronchial remodelling and chronic inflammation. Airway smooth muscle biology and pathophysiological implication in asthma are now better understood. Precise deciphering of intracellular signalling pathways regulating smooth muscle contraction highlighted the critical roles played by small GTPases of Rho superfamily. Beyond contractile considerations, active involvement of airway smooth muscle in bronchial remodelling mechanisms is now established. Not only cytokines and growth factors, such as fibroblats growth factor or transforming growth factor-β, but also extracellular matrix composition have been demonstrated as potent phenotype modifiers for airway SMC. Although basic science knowledge has grown significantly, little of it has translated into improvement in asthma clinical practice. Evaluation of airway smooth muscle function is still limited to its contractile activity. Moreover, it relies on tools, such as spirometry, that give only an overall assessment and not a specific one. Interesting technics such as forced oscillometry or specific imagery (CT and MRI) give new perspectives to evaluate other aspects of airway muscle such as bronchial remodelling. Finally, except for the refinement of conventional bronchodilators, no new drug therapy directly targeting airway smooth muscle proved its efficacy. Bronchial thermoplasty is an innovative and efficient therapeutic strategy but is only restricted to a small proportion of severe asthmatic patients. New diagnostic and therapeutic strategies specifically oriented toward airway smooth muscle are needed to improve global asthma care.
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Affiliation(s)
- Dorian Hassoun
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Lindsay Rose
- Nantes Université, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, Pays de la Loire, France
| | - François-Xavier Blanc
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Antoine Magnan
- INRAe, UMR 0892, Hôpital Foch, Suresnes, France.,Université Versailles-Saint-Quentin-en-Yvelines Paris-Saclay, Versailles, France
| | - Gervaise Loirand
- Nantes Université, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, Pays de la Loire, France
| | - Vincent Sauzeau
- Nantes Université, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, Pays de la Loire, France
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4
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Rajan A, Bennetts K, Langton D. Plethysmography Derived Gas Trapping Lacks Utility in Predicting Response to Bronchial Thermoplasty. ERJ Open Res 2022; 8:00690-2021. [PMID: 35539441 PMCID: PMC9081540 DOI: 10.1183/23120541.00690-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/04/2022] [Indexed: 12/03/2022] Open
Abstract
There is a paucity of literature on measurable baseline parameters predicting response and guiding selection for bronchial thermoplasty. This study examines whether baseline gas trapping, as assessed by plethysmography, is associated with a response to bronchial thermoplasty at 12 months. 43 consecutive patients with severe asthma (mean±sd age 57.6±13.3 years) were evaluated at baseline and 12 months post bronchial thermoplasty. Data collected at both time points included spirometry, body plethysmography and four clinical outcome measures, namely Asthma Control Questionnaire (ACQ) score, annual exacerbation frequency, maintenance oral corticosteroid requirement and short-acting β-agonist use. At baseline, participants had severe airflow obstruction (forced expiratory volume in 1 s 49.1±15.8%) with marked gas trapping (residual volume (RV) 150.3±40.8%, RV/total lung capacity (TLC) 51.3±10.5%), poor symptom control (ACQ 3.3±1.0) and frequent exacerbations (median 4, interquartile range 8). 12 months after bronchial thermoplasty, significant improvements were observed in all four clinical outcome measures. However, baseline RV and RV/TLC were not significantly associated with changes in ACQ nor any other clinical outcome measure, and changes in RV and RV/TLC did not significantly correlate with a change in any clinical outcome measure. Plethysmography-derived gas trapping does not demonstrate utility in predicting response and guiding selection for bronchial thermoplasty. An improvement in gas trapping was not associated with positive clinical outcomes, suggesting that this may not be the dominant mode of action of bronchial thermoplasty in generating clinical improvement. This study examined whether measuring gas trapping by plethysmography could be used to predict response to bronchial thermoplasty; no association was foundhttps://bit.ly/3tJN1X8
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5
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Asthma with Fixed Airflow Obstruction: From Fixed to Personalized Approach. J Pers Med 2022; 12:jpm12030333. [PMID: 35330333 PMCID: PMC8953236 DOI: 10.3390/jpm12030333] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/14/2022] [Accepted: 02/22/2022] [Indexed: 02/01/2023] Open
Abstract
Asthma is generally characterized by variable symptoms such as dyspnea and wheezing and variable airflow obstruction. This review focuses on a subset of patients suffering from asthma with persistent airflow limitation that is not fully reversible (asthma with fixed airflow obstruction, FAO). The pathophysiology, the risk factors and the clinical outcomes associated with FAO are presented, as well as the distinct clinical entity of severe asthma and its inflammatory subtypes (T2 and non-T2). The current strategies for the treatment of these endotypes and treatment of the distinct Asthma/COPD overlap (ACO) phenotype are described. Management and medical interventions in FAO and/or ACO patients demand a holistic approach, which is not yet clearly established in guidelines worldwide. Finally, a treatment algorithm that includes FAO/ACO management based on pharmacological and non-pharmacological treatment, guideline-based management for specific co-morbidities, and modification of the risk factors is proposed.
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Chupp G, Kline JN, Khatri SB, McEvoy C, Silvestri GA, Shifren A, Castro M, Bansal S, McClelland M, Dransfield M, Trevor J, Kahlstrom N, Simoff M, Wahidi MM, Lamb CR, Ferguson JS, Haas A, Hogarth DK, Tejedor R, Toth J, Hey J, Majid A, LaCamera P, FitzGerald JM, Enfield K, Grubb GM, McMullen EA, Olson JL, Laviolette M. Bronchial Thermoplasty in Severe Asthmatics At 5 Years: The PAS2 Study. Chest 2021; 161:614-628. [PMID: 34774528 DOI: 10.1016/j.chest.2021.10.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Bronchial thermoplasty is a device-based treatment for subjects ≥18 years with severe asthma poorly controlled with inhaled corticosteroids and long-acting beta-agonists. The Post-FDA Approval Clinical Trial Evaluating Bronchial Thermoplasty in Severe Persistent Asthma (PAS2) study collected data on severe asthmatics undergoing this procedure. RESEARCH QUESTION What are the 5-year efficacy and safety results in severe asthmatics who have undergone bronchial thermoplasty? STUDY DESIGN AND METHODS This was a prospective, open-label, observational, multi-center study conducted in the United States and Canada. Subjects aged 18-65, taking inhaled corticosteroids ≥1000μg/day (beclomethasone or equivalent) and long-acting β-agonists ≥80μg/day (salmeterol or equivalent) were included. Severe exacerbations, hospitalization, emergency department visits, and medication usage were evaluated for the 12 months prior to and at years 1-5 post-treatment. Spirometry was evaluated at baseline and at years 1-5 post-treatment. RESULTS 284 subjects were enrolled at 27 centers; 227 subjects (80%) completed 5 years of follow-up. By year 5 post-treatment, the proportion of subjects with severe exacerbations, emergency department visits, and hospitalizations was 42.7%, 7.9%, and 4.8%, respectively, compared to 77.8%, 29.4%, and 16.1% in the 12 months prior to treatment. The proportion of subjects on maintenance oral corticosteroids decreased from 19.4% at baseline to 9.7% at 5 years. Analyses of subgroups based on baseline clinical and biomarker characteristics revealed a statistically significant clinical improvement among all subgroups. INTERPRETATION Five years after treatment, subjects experienced decreases in severe exacerbations, hospitalizations, emergency department visits and corticosteroid exposure. All subgroups demonstrated clinically significant improvement, suggesting that bronchial thermoplasty improves asthma control in different asthma phenotypes.
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Affiliation(s)
| | - Joel N Kline
- University of Iowa Hospitals and Clinics - Iowa City, IA/US
| | | | | | | | - Adrian Shifren
- Washington University School of Medicine - St. Louis, MO/US
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, KS
| | | | | | | | | | | | | | | | - Carla R Lamb
- Lahey Hospital and Medical Center - Burlington, MA/US
| | | | - Andrew Haas
- University of Pennsylvania - Philadelphia, PA/US
| | | | | | | | - Jamie Hey
- Pulmonary Associates of Richmond - Richmond, VA/US
| | - Adnan Majid
- Beth Israel Deaconess Medical Center - Boston, MA/US
| | - Peter LaCamera
- St. Elizabeth's Medical Center of Boston, Inc. - Boston, MA/US
| | | | - Kyle Enfield
- University of Virginia Health System - Charlottesville, VA/US
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7
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Postigo M, Hall CS, Castro M. Predicting the Response to Bronchial Thermoplasty: The Needier, the Better. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:1261-1262. [PMID: 32276691 DOI: 10.1016/j.jaip.2020.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/14/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Maykol Postigo
- University of Kansas School of Medicine, Kansas City, Kan
| | - Chase S Hall
- University of Kansas School of Medicine, Kansas City, Kan
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Kan.
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8
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Steinfort DP, Herth FJF. Bronchoscopic treatments for early-stage peripheral lung cancer: Are we ready for prime time? Respirology 2020; 25:944-952. [PMID: 32643221 DOI: 10.1111/resp.13903] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/29/2020] [Accepted: 06/10/2020] [Indexed: 12/13/2022]
Abstract
Lung cancer is the leading cause of cancer-related death worldwide and surgical lobectomy remains the preferred therapy for patients with early-stage NSCLC. Medical comorbidities and advanced age preclude resection in many patients and minimally invasive ablative therapies are needed for treatment. Stereotactic ablative radiation is established as an effective modality in this patient group, although may be contraindicated in some patients with prior radiation exposure, comorbidities or centrally positioned tumours. Percutaneous ablative methods are available, although are frequently associated with significant complications. Numerous endoscopic ablative techniques are under evaluation. With a more favourable safety profile and the ability to provide diagnosis and staging information potentially within a single procedure, there is a strong rationale for development of bronchoscopic ablative modalities. In the following article, the authors aim to explore the role bronchoscopic ablation may play in treatment of peripheral lung tumours, and to describe a pathway to establishing these modalities as part of routine care. The current status of several bronchoscopic ablative options is discussed in detail.
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Affiliation(s)
- Daniel P Steinfort
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Felix J F Herth
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research, Heidelberg, Germany
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9
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Wark PAB. Contemporary Concise Review 2019: Asthma. Respirology 2020; 25:651-656. [PMID: 32133761 DOI: 10.1111/resp.13794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 02/20/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Peter A B Wark
- Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia
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10
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Thomson NC. Recent Developments In Bronchial Thermoplasty For Severe Asthma. J Asthma Allergy 2019; 12:375-387. [PMID: 31819539 PMCID: PMC6875488 DOI: 10.2147/jaa.s200912] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/30/2019] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Bronchial thermoplasty is approved in many countries worldwide as a non-pharmacological treatment for severe asthma. This review summarizes recent publications on the selection of patients with severe asthma for bronchial thermoplasty, predictors of a beneficial response and developments in the procedure and discusses specific issues about bronchial thermoplasty including effectiveness in clinical practice, mechanism of action, cost-effectiveness, and place in management. RESULTS Bronchial thermoplasty is a treatment option for patients with severe asthma after assessment and management of causes of difficult-to-control asthma, such as nonadherence, poor inhaler technique, comorbidities, under treatment, and other behavioral factors. Patients treated with bronchial thermoplasty in clinical practice have worse baseline characteristics and comparable clinical outcomes to clinical trial data. Bronchial thermoplasty causes a reduction in airway smooth muscle mass although it is uncertain whether this effect explains its efficacy since other mechanisms of action may be relevant, such as alterations in airway epithelial, gland, and/or nerve function; improvements in small airway function; or a placebo effect. The cost-effectiveness of bronchial thermoplasty is greater in countries where the costs of hospitalization and emergency department are high. The place of bronchial thermoplasty in the management of severe asthma is not certain, although some experts propose that bronchial thermoplasty should be considered for patients with severe asthma associated with non-type 2 inflammation or who fail to respond favorably to biologic therapies targeting type 2 inflammation. CONCLUSION Bronchial thermoplasty is a modestly effective treatment for severe asthma after assessment and management of causes of difficult-to-control asthma. Asthma morbidity increases during and shortly after treatment. Follow-up studies provide reassurance on the long-term safety of the procedure. Uncertainties remain about predictors of response, mechanism(s) of action, and place in management of severe asthma.
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Affiliation(s)
- Neil C Thomson
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
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11
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Langton D, Wang W, Sha J, Ing A, Fielding D, Hersch N, Plummer V, Thien F. Predicting the Response to Bronchial Thermoplasty. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:1253-1260.e2. [PMID: 31712191 DOI: 10.1016/j.jaip.2019.10.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 10/06/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although it is established that not all patients respond to bronchial thermoplasty (BT), the factors that predict response/nonresponse are largely unknown. OBJECTIVES To identify baseline factors that predict clinical response. METHODS The records of 77 consecutive patients entered into the Australian Bronchial Thermoplasty Registry were examined for baseline clinical characteristics, and outcomes measured at 6 and 12 months after BT, such as change in the Asthma Control Questionnaire (ACQ) score, exacerbation frequency, the requirement for short-acting beta-2 agonist (SABA) medication and oral corticosteroids, and improvement in spirometry. RESULTS This was a cohort of patients with severe asthma: aged 57.7 ± 11.4 years, 57.1% females, 53.2% of patients taking maintenance oral steroids, 43% having been treated with an mAb, mean FEV1 of 55.8% ± 19.8% predicted. RESULTS BT resulted in an improvement in the ACQ score from 3.2 ± 1.0 at baseline to 1.6 ± 1.1 at 6 months (P < .001). Exacerbation frequency in the previous 6 months reduced from 3.7 ± 3.3 to 0.7 ± 1.2 (P < .001). SABA requirement reduced from 9.3 ± 7.1 puffs/d to 3.5 ± 6.0 (P < .001), and 48.8% of patients were weaned completely off oral steroids. A significant improvement in FEV1 was observed. Using multiple linear regression models, baseline ACQ score strongly predicted improvement in ACQ score (P < .001). Patients with an exacerbation frequency greater than twice in the previous 6 months showed the greatest reduction in exacerbations (-5.3 ± 2.8; P < .001). Patients using more than 10 puffs/d of SABA experienced the greatest reduction in SABA requirement (-12.4 ± 10.5 puffs, P < .001). CONCLUSIONS The most severely afflicted patients had the greatest improvements in ACQ score, exacerbation frequency, and medication requirement.
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Affiliation(s)
- David Langton
- Department of Thoracic Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia.
| | - Wei Wang
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Joy Sha
- Department of Thoracic Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia
| | - Alvin Ing
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - David Fielding
- Department of Thoracic Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Nicole Hersch
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Virginia Plummer
- Department of Thoracic Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Francis Thien
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia; Department of Respiratory Medicine, Eastern Health, Box Hill, VIC, Australia
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Abstract
Current management of severe asthma relying either on guidelines (bulk approach) or on disease phenotypes (stratified approach) did not improve the burden of the disease. Several severe phenotypes are described: clinical, functional, morphological, inflammatory, molecular and microbiome-related. However, phenotypes do not necessarily relate to or give insights into the underlying pathogenetic mechanisms which are described by the disease endotypes. Based on the major immune-inflammatory pathway involved type-2 high, type-2 low and mixed endotypes are described for severe asthma, with several shared pathogenetic pathways such as genetic and epigenetic, metabolic, neurogenic and remodelling subtypes. The concept of multidimensional endotyping as un unbiased approach to severe asthma is discussed, together with new tools and targets facilitating the shift from the stratified to the precision medicine approach.
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13
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Kang J, Cho YS, Choi DK, Lee JS, Oh YM, Lee SD, Lee SW. Bronchial Thermoplasty in Patients with Severe Uncontrolled Asthma: First Korean Cases. J Korean Med Sci 2019; 34:e120. [PMID: 31001937 PMCID: PMC6473094 DOI: 10.3346/jkms.2019.34.e120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/20/2019] [Indexed: 11/20/2022] Open
Abstract
Bronchial thermoplasty is a nonpharmacological treatment for severe asthma that delivers thermal energy to the bronchial walls and reduces hypertrophied smooth muscle mass. Previous studies have shown its efficacy and safety, resulting in approval from the Food and Drug Administration in 2010. In Korea, the first bronchial thermoplasty was carried out in 2014; 4 patients have undergone the procedure so far. This case series presents the medical history and treatment outcomes of these 4 patients. All patients presented with uncontrolled asthma despite optimal medical treatment. Bronchial thermoplasty was performed at the right lower lobe, left lower lobe, and both upper lobes in order at 3-week intervals. All procedures were performed under general anesthesia. Two patients had significant decreases in exacerbations and required a lower dose of inhaled corticosteroids after the procedure. One patient had slightly fewer exacerbations but failed to reduce the use of systemic corticosteroids. One patient had no change in symptoms. One limitation of bronchial thermoplasty is the difficulty of predicting clinical responders. However, since more therapeutic options are needed in the management of severe asthma, especially T2-low asthma, discussion with experts about the feasibility and necessity of bronchial thermoplasty will ensure the best possible care.
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Affiliation(s)
- Jieun Kang
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - You Sook Cho
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Kee Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Do Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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14
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Donovan GM, Elliot JG, Boser SR, Green FHY, James AL, Noble PB. Patient-specific targeted bronchial thermoplasty: predictions of improved outcomes with structure-guided treatment. J Appl Physiol (1985) 2019; 126:599-606. [PMID: 30676870 DOI: 10.1152/japplphysiol.00951.2018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Bronchial thermoplasty is a recent treatment for asthma in which ablative thermal energy is delivered to specific large airways according to clinical guidelines. Therefore, current practice is effectively "blind," as it is not informed by patient-specific data. The present study seeks to establish whether a patient-specific approach based on structural or functional patient data can improve outcomes and/or reduce the number of procedures required for clinical efficacy. We employed a combination of extensive human lung specimens and novel computational methods to predict bronchial thermoplasty outcomes guided by structural or functional data compared with current clinical practice. Response to bronchial thermoplasty was determined from changes in airway responses to strong bronchoconstrictor simulations and flow heterogeneity after one or three simulated thermoplasty procedures. Structure-guided treatment showed significant improvement over current unguided clinical practice, with a single session of structure-guided treatment producing improvements comparable with three sessions of unguided treatment. In comparison, function-guided treatment did not produce a significant improvement over current practice. Structure-guided targeting of bronchial thermoplasty is a promising avenue for improving therapy and reinforces the need for advanced imaging technologies. The functional imaging-guided approach is predicted to be less effective presently, and we make recommendations on how this approach could be improved. NEW & NOTEWORTHY Bronchial thermoplasty is a recent treatment for asthma in which thermal energy is delivered via bronchoscope to specific airways in an effort to directly target airway smooth muscle. Current practice involves the treatment of a standard set of airways, unguided by patient-specific data. We consider the potential for guided treatments, either by functional or structural data from the lung, and show that treatment guided by structural data has the potential to improve clinical practice.
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Affiliation(s)
- Graham M Donovan
- Department of Mathematics, University of Auckland , Auckland , New Zealand
| | - John G Elliot
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital , Nedlands, Western Australia , Australia
| | | | - Francis H Y Green
- Cumming School of Medicine, University of Calgary , Calgary, Alberta , Canada
| | - Alan L James
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, School of Medicine and Pharmacology, University of Western Australia , Australia
| | - Peter B Noble
- School of Human Sciences, University of Western Australia , Crawley, Western Australia , Australia
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15
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Hall CS, Castro M. Predicting response to bronchial thermoplasty in patients with severe uncontrolled asthma: An elusive goal. Respirology 2018; 24:11-12. [PMID: 30324712 DOI: 10.1111/resp.13424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 09/19/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Chase S Hall
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Mario Castro
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO, USA
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