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Background and Objective: Bronchial thermoplasty (BT) has been consistently shown to reduce symptoms, exacerbations and the need for reliever medication in patients with severe asthma. Paradoxically, no consistent improvement in spirometry has been demonstrated. It has been suggested that this is due to a reduction in peripheral resistance in small airways, not captured by spirometry. Therefore, in this study, we evaluate the response to BT using oscillometry., Methods: A total of 43 patients with severe asthma from two centres were evaluated at baseline, 6 weeks and 6 months post BT, using spirometry, plethysmography and oscillometry, in addition to medication usage, exacerbation frequency and the Asthma Control Questionnaire (5-item version) (ACQ-5)., Results: The mean age was 58.4 ± 11.2 years, forced expiratory volume in 1 s (FEV 1 ) 55.5 ± 20.1% predicted, forced expiratory ratio 53.0 ± 14.5% and FEV 1 response to salbutamol was 14.0 ± 14.5%. Following BT, the group responded to treatment with an improvement in ACQ-5 from 2.9 ± 0.9 at baseline to 1.7 ± 1.1 at 6 months (P < 0.005). There was an 81% reduction in exacerbation frequency (P < 0.001) and 50% of patients were weaned completely from maintenance oral corticosteroids. No changes after treatment were observed in spirometry but the residual volume reduced from 147 ± 38% to 139 ± 39% predicted (P < 0.01). Baseline oscillometry demonstrated high levels of resistance at 5 Hz with normal resistance at 20 Hz, indicating resistance in the small airways was elevated, but no changes were observed in any oscillometry parameter after BT treatment., Conclusion: Lung impedance measured with oscillometry did not change following BT despite marked clinical improvements in patients with severe asthma., (© 2018 Asian Pacific Society of Respirology.)

Background: Bronchial thermoplasty (BT) is a novel bronchoscopic therapy for severe uncontrolled asthma unresponsive to standard pharmacological treatments, including inhaled corticosteroids and long-acting beta-2 agonists. Although several studies have shown that BT improves asthma control, the optimal predictors of BT response remain unknown., Patients and Methods: We reviewed 10 consecutive asthma patients treated with BT at Kanazawa University Hospital between January 2016 and March 2018 and attempted to identify factors that correlated with a positive BT response., Results: All patients had the most severe persistent asthma according to the 2017 Japanese guidelines for adult asthma and were uncontrolled despite adequate treatments including high-dose inhaled corticosteroids and long-acting beta-2 agonists. Six patients had significant improvement in asthma control evaluated with the Asthma Control Questionnaire-6. Eight patients showed a significant improvement in asthma-specific health-related quality of life evaluated with the Asthma Quality of Life Questionnaire. The number of severe asthma exacerbations decreased in 6 patients. The maintenance dose of oral corticosteroids decreased in 1 patient. There were no severe adverse events related to the procedure. Six patients showed a positive BT response, and all 4 patients with increased cough receptor sensitivity to capsaicin responded to BT. No other factors, including age, smoking status, body mass index, age of asthma onset, disease duration, blood eosinophil count, total serum immunoglobulin E, prebronchodilator forced expiratory volume in 1 second, reversibility to beta-2 agonist, or fractional exhaled nitric oxide, were associated with a positive BT response., Conclusion: Increased cough receptor sensitivity to capsaicin may predict a positive BT response.

Bronchial thermoplasty is an advanced therapy for severe asthma. It is a bronchoscopic procedure in which radiofrequency energy is applied to the airway wall, resulting in decreased airway smooth muscle burden. Human trials have shown that bronchial thermoplasty may reduce asthma exacerbations and improve quality of life in patients with severe uncontrolled asthma. It has been demonstrated to be a safe procedure, with most adverse events being early and mild. More studies are required to understand the precise effects of bronchial thermoplasty on the asthmatic airway and optimal parameters to appropriately select patients for this novel procedure., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To determine asthma outcomes in children undergoing adenotonsillectomy (T&A) for treatment of sleep-disordered breathing (SDB)., Hypothesis: Asthmatic children will demonstrate improvement in asthma control after T&A compared to asthmatic children not undergoing surgical treatment., Study Design: Prospective cohort., Patient-Subject Selection: 80 children with diagnosed asthma, aged 4-11, undergoing T&A and 62 controls matched to the T&A subjects by age, sex, and asthma severity classification., Methodology: Parents and children completed the Childhood Asthma Control Test (C-ACT) and the Pediatric Sleep Questionnaire (PSQ). Parents were queried regarding the number of asthma exacerbations, the frequency of the use of systemic steroids, the number of emergency room visits and the number of hospitalizations in the prior 6 months. The identical questionnaires and interviews were completed 6 months after entry., Results: The adjusted mean (95% CI) C-ACT score was 21.86 (20.94-22.68) at entry and 25.15 (24.55-25.71) at follow-up for the T&A group compared with 22.42 (21.46-23.28) and 23.59 (22.77-24.33) for the control group. There was a significant group by time interaction (P < 0.001). Simple effects analysis showed that group means did not differ at entry (P = 1.00) but did differ at follow-up (P = 0.006). Baseline PSQ was a significant predictor of improvement in C-ACT scores. Statistical modeling did not demonstrate significant group by time interactions for any of the asthma clinical outcomes, although these outcomes were very infrequent in both groups., Conclusion: Treatment of SDB improves asthma outcomes as measured by the C-ACT., (© 2018 Wiley Periodicals, Inc.)

Background: Despite an improved understanding of the pathophysiology of asthma, severe asthma sufferers continue to experience a poor quality of life (QOL). Bronchial thermoplasty (BT) utilizes thermal energy to reduce airway smooth muscle. In industry-sponsored trials, BT improves QOL and reduces severe exacerbations; however, the impact of BT on asthma-related QOL and medication use in non-industry-sponsored trials is less clear., Objective: The aim of this study was to determine the impact of BT on asthma QOL measures (mini-AQLQ) and asthma controller medication use during the year following treatment with BT., Methods: We performed a prospective study of the impact of BT in 25 patients with severe persistent asthma. Our primary outcome was change in asthma-related QOL score (mini-AQLQ) 1 year after BT treatment. Our secondary outcome was change in asthma medication use 1 year after BT., Results: BT led to an improvement in mini-AQLQ score from a baseline of 3.6 ± 0.3 before therapy to 5.6 ± 0.3 1 year after the final BT procedure. Overall, 88% percent of patients showed a clinically significant improvement in mini-AQLQ at 1 year. Patients treated with BT showed a reduction in the use of montelukast and omalizumab 1 year after BT., Conclusion: In patients with severe persistent asthma and low asthma-related QOL scores, BT leads to an improvement in asthma-related QOL and a decrease in asthma medication use when measured 1 year after the final BT treatment., (© 2019 S. Karger AG, Basel.)

Objectives: Although excitements related to stem cell therapeutic outcomes have been highlighted enormously in asthma, the vast majority of works were conducted by researchers in animal models. Elucidating the mechanisms underlying the therapeutic effects of MSCs in asthmatic rats will provide a rational basis for assuring maximal safety of future clinical application of stem cells. In the current study, we sought to investigate the possible paracrine mechanism by which direct injection of MSCs and/or CM attenuate efficiently Th2-mediated inflammation in asthmatic lung tissues with the focus on ICAM-1 and VCAM-1 expression., Methods: Male rats were divided into four experimental groups (n = 6); healthy rats received PBS intratracheally (group C), sensitized rats received PBS intratracheally (group S), sensitized rats received CM intratracheally (group S + CM), and sensitized rats received PBS intratracheally containing 2 × 10 6 rBMMSCs (group S + MSCs). Two weeks post-transplantation, the expression of interleukin (IL)-5, -12 and INF-γ, ICAM-1 and VCAM-1 were assessed along with pathological injuries and the homing of MSCs into the lung tissues., Results: Our results showed CM, and notably rBMMSCs, returned the expression of IL-5, IL-12, INF-γ, ICAM-1, and VCAM-1 (p < 0.001 to p < 0.05) to the normal levels. Based on data, pathological injuries in pulmonary specimens of asthmatic rats were significantly attenuated (p < 0.001 to p < 0.05). Moreover, rBMMSCs had potential to successfully home to an asthmatic niche in cell-administrated rats., Conclusions: Our data noted the potency of CM and especially MSCs in ameliorating pathological changes via intra-tracheal route presumably by targeting ICAM-1 and VCAM-1 in lung tissues in rat asthma model., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Asthma is not a single disease, but recently, it is considered as a syndrome characterized through various clinical presentations and different etiopathologies. Large degree of the disease heterogeneity manifests in distinct characteristics that translate into variability of properties at single cell and molecular levels. Here, we conducted measurements of mechanical properties of bronchial tissue samples collected from patients suffering from asthma. The results obtained from different applied protocols for sample preparation may indicate that deep freezing and storage in liquid nitrogen, followed by consecutive unfreezing of tissue samples, preserve tissue mechanical properties as indicated by a parameter referred here as a tissue relative stiffness index. Tissue relative stiffness index quantifies both the degree of heterogeneity and deformability of tissue samples regarding healthy one. These studies demonstrate that the freezing protocol, optimized towards asthma tissue, can facilitate atomic force microscopy use what, together with recent findings on standardization of elasticity measurements, enables the measurements of large group of samples with minimized influence of errors stemming from the applied methodology of tissue stiffness determination., (© 2018 John Wiley & Sons, Ltd.)

Objectives: Bronchial thermoplasty (BT) can be considered in the treatment of severe asthma to reduce airway smooth muscle mass and bronchoconstriction. We hypothesized that BT may thus have long-term effects on airway dimensions and air-trapping detectable by quantitative computed tomography (QCT)., Methods: Paired in- and expiratory CT and inspiratory CT were acquired in 17 patients with severe asthma before and up to two years after bronchial thermoplasty and in 11 additional conservatively treated patients with serve asthma, respectively. A fully automatic software calculated the airways metrics for wall thickness (WT), wall percentage (WP), lumen area (LA) and total diameter (TD). Furthermore, lung air-trapping was quantified by determining the quotient of mean lung attenuation in expiration vs. inspiration (E/I MLA) and relative volume change in the Hounsfield interval -950 to -856 in expiration to inspiration (RVC 856-950 ) in a generation- and lobe-based approach, respectively., Results: BT reduced WT for the combined analysis of the 2nd-7th airway generation significantly by 0.06 mm (p = 0.026) and WP by 2.05% (p < 0.001), whereas LA and TD did not change significantly (p = 0.147, p = 0.706). No significant changes were found in the control group. Furthermore, E/I MLA and RVC 856-950 decreased significantly after BT by 12.65% and 1.77% (p < 0.001), respectively., Conclusion: BT significantly reduced airway narrowing and air-trapping in patients with severe asthma. This can be interpreted as direct therapeutic effects caused by a reduction in airway-smooth muscle mass and changes in innervation. A reduction in air-trapping indicates an influence on more peripheral airways not directly treated by the BT procedure., (Copyright © 2018 Elsevier B.V. All rights reserved.)

New asthma therapies such as omalizumab, mepolizumab and reslizumab are used according to the inflammatory phenotype, but there are many patients with asthma which are not suitable for these therapies or do not improve with these therapies. Bronchial thermoplasty (BT) was approved by FDA for the treatmet of adults with severe asthma and uncontrolled symptoms despite treatment with inhaler corticosteroids (ICS) and long-acting bronchodilators in 2010. BT is a minimally invasive bronhoscopic intervention based on radiofrequency energy delivery to the larger airways to reduce excessive airway smooth muscle mass. BT has been shown to be effective at reducing asthma exacerbations and improving asthma control for patients with severe asthma. BT is safe for 5 years after BT in patients with severe refractory asthma. BT may be primarily preferred for patients with nonallergic, non-eosinophilic (non-TH 2 ) severe asthma not improving with standart treatments. Unfortunately, the mechanism of action of BT is incompletely understood. Uncertainty remains how to identify patients who will responde to this intervention. Several studies are underway that may show the place of BT in severe asthma and identify responders. There is also a need for studies comparing BT with other treatment options. This review will provide an overwiew of BT. We will discuss the latest evidence on the use of BT in asthma, patient selection criteria and performing the procedure will be reviewed.

Background The prevalence of both allergic rhinitis and bronchial asthma is high throughout the world; their mutual influence on each other has been documented in many studies. However, studies regarding surgical intervention are limited. Objective To evaluate the clinical significance of endoscopic vidian neurectomy on bronchial asthma outcomes in patients with coexisting refractory allergic rhinitis and asthma. Methods A total of 109 patients with moderate to severe persistent intractable allergic rhinitis and mild/moderate asthma were allocated to the bilateral endoscopic vidian neurectomy group (group 1) or conservative medication group (group 2) according to the patients' self-selection. The Rhinoconjunctivitis Quality of Life Questionnaire, Visual Analog Scale, Asthma Quality of Life Questionnaire, Total Asthma Symptom Score, and medication scores were evaluated at six months, one year, and three years after undergoing the initial treatments. Multivariate analysis was performed to determine which triggers of asthma attacks were associated with improved asthma outcomes in patients. Results Ninety-five patients were followed up for at least three years. Postoperative scores of Rhinoconjunctivitis Quality of Life Questionnaire and Visual Analog Scale were significantly lower than preoperative scores during follow-up in group 1 and were significantly lower than those of group 2. Postoperative scores of Asthma Quality of Life Questionnaire at the three follow-up time points were higher than the preoperative scores in group 1. The Total Asthma Symptom Score was not significantly decreased in group 1. The medication scores for allergic rhinitis and asthma were gradually reduced after surgery. At the end of the follow-up, the improvement rates for allergic rhinitis and asthma were 90.6% and 45.3%, respectively. Asthma outcomes were significantly improved by controlling rhinitis symptoms in patients whose asthma attacks were induced by "rhinitis onset" or "weather change." Conclusion Controlling allergic rhinitis symptoms by bilateral endoscopic vidian neurectomy can significantly improve asthma outcomes in patients whose asthma attacks are induced by rhinitis onset and/or cold air.

Background: The most common adverse effect of bronchial thermoplasty (BT) is short-term aggravation of asthma immediately following the procedure. However, the magnitude and duration of this deterioration, and its predisposing factors are yet to be quantitated. This information will be particularly important as BT is extended to include more severely obstructed patients., Methods: In this prospective, observational study of 20 consecutive patients with very severe asthma undergoing BT, post bronchodilator FEV 1 was measured in the 30 min prior to surgery, and then 24 h following the 60 procedures. In half the patients, further spirometry was conducted on day 3 and day 7 post procedure., Results: This study enrolled 12 males and 8 females, mean age 59.7 ± 12.8 years, with mean prebronchodilator FEV 1 of 52.3 ± 15.2% predicted, mean forced expiratory ratio of 51.4 ± 12.6%, and mean improvement in FEV 1 post salbutamol of 19.5 ± 15.3%. All patients were taking inhaled corticosteroids, mean beclomethasone equivalent dose 1950 ± 857 mcg, and 7 patients required maintenance oral corticosteroids for control of their asthma. Twenty four hours after BT, the mean deterioration in post bronchodilator FEV 1 was 166 ± 237 mls (CI 102-224, p < 0.001) or 9.1 ± 15.2% of baseline. This deterioration was significantly greater after upper lobe procedures (p < 0.01, ANOVA repeated measures), where a mean fall in FEV 1 of 17.1 ± 12.6% was observed. The change in FEV 1 post procedure was significantly correlated with the number of radiofrequency activations applied, r = -0.376, p < 0.005. By multivariate analysis, the only factor other than activations predictive of the change in FEV 1 was age, which was protective. When the lower lobes were treated, the postbronchodilator FEV 1 had returned to baseline values by day 3, but patients took 7 days to recover after upper lobe treatments. Despite the severity of asthma in these patients, and the measured deterioration post treatment, there was only one instance of readmission in the 60 procedures., Conclusions: The deterioration in lung function after BT is transient and well tolerated, but is greatest after upper lobe treatment, and is significantly related to the number of radiofrequency activations applied., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Asthma is a common condition and there remains a subset of patients who are poorly controlled on maximal therapy. Bronchial thermoplasty (BT) is a bronchoscopic therapy using radiofrequency energy to reduce airway smooth muscle, which has been shown to improve asthma control although further evidence regarding long-term efficacy and safety is required., Aim: We aimed to demonstrate safety and efficacy of BT on extended follow-up. Our initial experience with this group was previously reported in 2016, where patients were shown to have a significant improvement in asthma control test (ACT) scores 1-year post-treatment., Design: We carried out a retrospective observational study of seven patients who underwent BT between 2012 and 2013 in an Irish severe asthma centre. The primary endpoint was change in ACT scores from baseline to present., Methods: Seven patients underwent BT at a tertiary referral centre in Ireland. ACT scores and data on hospital admissions, exacerbations, maintenance corticosteroid requirements, rescue bronchodilator use and forced expiratory volume for 1 s (FEV1) prior to the procedure and on extended follow-up were collected. Mean follow-up was 49.42 months., Results: A trend towards improvement was seen in median hospitalisations (respective values for median over 12 months 3, 1 P = 0.059) and ACT scores, from 9 to 13 (P = 0.249). Mean FEV1 was 1.68 l prior to treatment and 1.46 l 4 years post-treatment (P = 0.237). There was no mortality among the group., Conclusions: These data support the safety of BT and suggest extended efficacy., (© The Author 2017. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Background: Bronchial thermoplasty (BT) is a non-pharmacological intervention for severe asthma whose mechanism of action is not completely explained by a reduction of airway smooth muscle (ASM). In this study we analyzed the effect of BT on nerve fibers and inflammatory components in the bronchial mucosa at 1 year., Methods: Endobronchial biopsies were obtained from 12 subjects (mean age 47 ± 11.3 years, 50% male) with severe asthma. Biopsies were performed at baseline (T0) and after 1 (T1), 2 (T2) and 12 (T12) months post-BT, and studied with immunocytochemistry and microscopy methods. Clinical data including Asthma Quality of Life Questionnaire (AQLQ) and Asthma Control Questionnaire (ACQ) scores, exacerbations, hospitalizations, oral corticosteroids use were also collected at the same time points., Results: A statistically significant reduction at T1, T2 and T12 of nerve fibers was observed in the submucosa and in ASM compared to T0. Among inflammatory cells, only CD68 showed significant changes at all time points. Improvement of all clinical outcomes was documented and persisted at the end of follow up., Conclusions: A reduction of nerve fibers in epithelium and in ASM occurs earlier and persists at one year after BT. We propose that nerve ablation may contribute to mediate the beneficial effects of BT in severe asthma., Trial Registration: Registered on April 2, 2013 at ClinicalTrials.gov Identifier: NCT01839591 .

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., (© 2018 The Author(s) Published by S. Karger AG, Basel.)

Bronchial thermoplasty is a novel procedure for patients with severe asthma showing a stable lung function. We herein report two cases with a deteriorating lung function. The lung function tended to improve in one case, while the other case discontinued mepolizumab medication after the procedure. Treatment was performed safely under general anesthesia in both cases. The use of bronchial thermoplasty may therefore be useful for the treatment of patients with a deteriorating lung function.

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 bronchos-copy a single-use catheter with a basket design is inserted through the instrument channel and the energy is delivered by a radiofrequency (RF) generator (AlairTM 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., (© 2018 S. Karger AG, Basel.)

Asthma is a common chronic inflammatory condition of the airways. Conventional therapy comprises inhaled corticosteroid and bronchodilators as well as trigger avoidance and management of comorbid conditions. A small group remain symptomatic despite these strategies and novel therapies have been developed. Bronchial thermoplasty is a nonpharmacological therapy which targets airway smooth muscle to improve asthma control. Clinical trials to date have shown the efficacy and safety of bronchial thermoplasty with a persistent effect on extended follow up. Questions remain regarding the exact mechanism of action of bronchial thermoplasty, the cost effectiveness of the procedure and the ideal criteria for patient selection.

Background: The objective of this work was to evaluate the impact of asthma on the cost-effectiveness profile of endoscopic sinus surgery (ESS) compared to medical therapy for patients with chronic rhinosinusitis with nasal polyps (CRSwNP)., Methods: The study design consisted of a cohort-style Markov decision-tree cost utility analysis with a 35-year time horizon. Matched cohorts of CRSwNP patients with (n = 95) and without (n = 95) asthma who underwent ESS were compared with cohorts of patients from the national Medical Expenditures Survey Panel (MEPS) database who underwent medical management for chronic rhinosinusitis (CRS). Baseline, 1-year, and 2-year health utility values were calculated from responses to the EuroQol-5 Dimension (EQ-5D) instrument in both cohorts. The primary outcome measure was the incremental cost effectiveness ratio (ICER) for each cohort., Results: The reference cases for CRSwNP patients with and without asthma yielded ICERs for ESS vs medical therapy alone of $12,066 per quality-adjusted life year (QALY) and $7,369 per QALY, respectively. At a willingness-to-pay threshold of $50,000/QALY, the ICER scatter plots demonstrated 86% and 99% certainty that the ESS strategy was the most cost-effective option for CRSwNP patients with and without asthma, respectively. ESS was not significantly more cost effective for CRSwNP patients without asthma (p = 0.494)., Conclusion: ESS remains cost effective compared to medical therapy for patients both with and without asthma. While the comorbidity of asthma results in an inferior ICER result, it does not result in a statistically significant negative impact on the overall cost effectiveness of ESS., (© 2017 ARS-AAOA, LLC.)

Objective: The purpose of this study was to evaluate the use of MDCT to assess response to bronchial thermoplasty treatment for severe persistent asthma., Materials and Methods: MDCT data from 26 patients with severe persistent asthma who underwent imaging before and after bronchial thermoplasty were analyzed retrospectively. Changes in the following parameters were assessed: total lung volume, mean lung density, airway wall thickness, CT air trapping index (attenuation < -856 HU), and expiratory-inspiratory ratio of mean lung density (E/I index). Asthma Quality of Life Questionnaire score changes were also assessed., Results: Median total lung volumes before and after bronchial thermoplasty were 2668 mL (range, 2226-3096 mL) and 2399 mL (range, 1964-2802 mL; p = 0.08), respectively. Patients also showed a pattern of obstruction improvement in air trapping values (median before thermoplasty, 14.25%; median after thermoplasty, 3.65%; p < 0.001] and in mean lung density values ± SD (before thermoplasty, -702 ± 72 HU; after thermoplasty, -655 ± 66 HU; p < 0.01). Median airway wall thickness also decreased after bronchial thermoplasty (before thermoplasty, 1.5 mm; after thermoplasty, 1.1 mm; p < 0.05). There was a mean Asthma Quality of Life Questionnaire overall score change of 1.00 ± 1.35 (p < 0.001), indicating asthma clinical improvement., Conclusion: Our study showed improvement in CT measurements after bronchial thermoplasty, along with Asthma Quality of Life Questionnaire score changes. Thus, MDCT could be useful for imaging evaluation of patients undergoing this treatment.

Objective: Bronchial thermoplasty (BT) is a novel treatment for severe asthma. Its mode of action and ideal target patient group remain poorly defined, though clinical trials provided some evidence on efficacy and safety. This study presents procedural and short-term safety evidence from routine UK clinical practice., Methods: Patient characteristics and safety outcomes (procedural complications, 30-day readmission and accident and emergency (A&E) attendance, length of stay) were assessed using two independent data sources, the British Thoracic Society UK Difficult Asthma Registry (DAR) and Hospital Episodes Statistics (HES) database. A matched cohort (with records in both) was used to estimate safety outcome event rates and compare them with clinical trials., Results: Between June 2011 and January 2015, 215 procedure records (83 patients; 68 treated in England) were available from DAR and 203 (85 patients) from HES. 152 procedures matched (59 patients; 6 centres), and of these, 11.2% reported a procedural complication, 11.8% resulted in emergency respiratory readmission, 0.7% in respiratory A&E attendance within 30 days (20.4% had at least one event) and 46.1% involved a post-procedure stay. Compared with published clinical trials which found lower hospitalisation rates, BT patients in routine clinical practice were, on average, older, had worse baseline lung function and asthma quality of life., Conclusions: A higher proportion of patients experienced adverse events compared with clinical trials. The greater severity of disease amongst patients treated in clinical practice may explain the observed rate of post-procedural stay and readmission. Study of long-term safety and efficacy requires continuing data collection.

Background: Bronchial thermoplasty (BT) is an emerging bronchoscopic intervention for the treatment of severe asthma. The predictive factors for clinical response to BT are unknown. We examined the relationship between the number of radiofrequency activations applied and the treatment response observed., Methods: Data were collected from 24 consecutive cases treated at three Australian centres from June 2014 to March 2016. The baseline characteristics were collated along with the activations delivered. The primary response measure was change in the Asthma Control Questionnaire-5 (ACQ-5) score measured at 6 months post BT. The relationship between change in outcome parameters and the number of activations delivered was explored., Results: All patients met the ERS/ATS definition for severe asthma. At 6 months post treatment, mean ACQ-5 improved from 3.3 ± 1.1 to 1.5 ± 1.1, p < 0.001. The minimal clinically significant improvement in ACQ-5 of ≥0.5 was observed in 21 out of 24 patients. The only significant variable that differed between the 21 responders and the three non-responders was the number of activations delivered, with 139 ± 11 activations in the non-responders, compared to 221 ± 45 activations in the responders (p < 0.01). A significant inverse correlation was found between change in ACQ-5 score and the number of activations, r = -0.43 (p < 0.05)., Conclusions: The number of activations delivered during BT has a role in determining clinical response to treatment.

Background: Bronchial thermoplasty (BT) is an approved bronchoscopic intervention for the treatment of severe asthma. However, limited published experience exists outside of clinical trials regarding patient selection and outcomes achieved., Aims: To evaluate the effectiveness and safety of BT in patients with severe asthma encountered in clinical practice., Methods: This is a retrospective analysis of the first 'real world' data from Australia. The following outcomes were measured prior to, and 6 months following BT: spirometry, Asthma Control Questionnaire-5 (ACQ-5) score, reliever and preventer medication use and exacerbation history., Results: Twenty patients were treated from June 2014 to December 2015 at three university teaching hospitals. All subjects met the European Respiratory Society/American Thoracic Society definition of severe asthma. Mean pre-bronchodilator forced expiratory volume in 1 s was 62.8 ± 16.6% predicted (range: 33-95%). All patients were being treated with high dose inhaled corticosteroids, long-acting beta 2 agonists and long-acting muscarinic antagonists. Ten patients (50%) were taking maintenance oral prednisolone. Most subjects also required at least one of montelukast (65%), omalizumab (30%) and methotrexate (20%). ACQ-5 improved from 3.6 ± 1.1 at baseline to 1.6 ± 1.2 at 6 months, P < 0.001. Short-acting reliever use decreased from a median of 8.0-0.25 puffs/day, P < 0.001, and exacerbations requiring corticosteroids also significantly reduced. Five of 10 patients completely discontinued maintenance oral corticosteroids. Ten patients with a baseline forced expiratory volume in 1 s of <60% predicted significantly improved from 49.2 ± 9.6% to 61.8 ± 17.6%, P < 0.05. Only two procedures required hospitalisation beyond the planned overnight admission., Conclusion: BT is a safe procedure which can achieve clinical improvement in those with uncontrolled symptoms and severe airflow obstruction., (© 2017 Royal Australasian College of Physicians.)

Purpose of Review: The inflammatory makeup of severe asthma is heterogeneous. Identification of the predominant cellular endotype via biomarkers can aid in the selection of more advanced therapies. This review is clinically focused on how to use these biomarkers to help select between biologic agents and/or bronchial thermoplasty., Recent Findings: Several Th2 biomarkers exist for the detection of eosinophilic disease; however, the best biomarker for clinical practice is debatable depending upon local resources. Currently, there are three federal drug agency-approved biologic agents (omalizumab, mepolizumab and reslizumab) to treat severe asthma with frequent exacerbations despite standard medical therapy. Several others are either in clinical trials or in the development phase for the treatment of eosinophilic asthma. To date, agents targeting neutrophilic inflammation have been largely unsuccessful. Bronchial thermoplasty has emerged as an option for the treatment of severe asthma., Summary: The appropriate selection of patients through the use of eosinophilic biomarkers has led to significant reductions in exacerbations with the use of mAb therapy. Bronchial thermoplasty has also shown reductions in asthma exacerbations and improved quality of life; however, it is unclear which patients may respond best to this intervention.

Bronchial thermoplasty (BT) is a recent, promising and well-tolerated technique for the treatment of severe asthma. By delivering thermal energy to the airway wall, this procedure can induce early pulmonary opacities seen on computed tomography (CT). We aimed to examine early CT modifications induced by BT and to determine their association with respiratory symptoms.Unenhanced chest CT was performed the day after each BT session in 13 patients with severe asthma, leading to the examination of 38 treated lobes. A total of 15 BT-treated lobes were evaluated in 11 patients at 1 month. The first two patients also underwent CT at 1 week.No symptoms suggestive of pulmonary infection were noted following BT in any patient. Peribronchial consolidations and ground-glass opacities were observed in all treated lobes on day 1, with three lower lobes showing complete collapse. Mild involvement of an adjacent untreated lobe was observed in 12 out of 38 (32%) cases. Opacities had decreased in 5 out of 15 (33%) and disappeared in 10 out of 15 (67%) at 1 month.BT induced early pulmonary peribronchial hyperdensities in all treated lobes. These alterations were unrelated to clinical symptoms and spontaneously decreased or disappeared after 1 month., (Copyright ©ERS 2017.)

Objective: To analyze the short-term (3 weeks) adverse respiratory events after bronchial thermoplasty(BT) in patients with severe asthma. Methods: The China-Japan Friendship Hospital recruited 62 patients with severe asthma for BT treatment from March 2014 to July 2016, with a total of 183 BT procedures. The data of adverse respiratory events within 3 weeks after procedure were collected to analyze the factors that might potentially influence the occurrence of adverse events. Results: Forty-three patients (69.4%) experienced adverse respiratory events within 3 weeks after treatment. Totally 153 adverse respiratory events occurred after 87 procedures(47.5%). The main adverse events were cough (15 events, 8.20%), sputum production (37 events, 20.22%), temporary PEF reduction (37 events, 20.22%), chest distress (12 events, 6.56%), blood in sputum (11 events, 6.01%), asthma exacerbation (10 events, 5.46%), and pneumonia(6 events, 3.28%). Most events were relieved or resolved with standard therapy in 1 week. No severe adverse events including tracheal intubation, malignant arrhythmias or death occurred within 3 weeks after procedure. The baseline eosinophil percentage in induced sputum and blood, operation times, and preoperative FEV(1) (% predicted) might influence the occurrence of adverse events after treatment. Patients with preoperative FEV(1) (% predicted) ≥60% had lower risk of adverse events. Conclusion: BT showed a good security profile in treating patients with severe asthma within 3 weeks after procedure.

Bronchial thermoplasty(BT) is a novel therapeutic modality for adult patients with severe asthma. BT is a procedure of applying radio frequency thermal energy to the airways with the goal of ablating the airway smooth muscle and ameliorating airway hypersensitivity. BT improves asthma related quality of life and reduces the rate of asthma exacerbations compared with standard therapy. These benefits are reported to..persist for at least 5 years. BT was introduced in Japan on April 2015, and the number of treated asthma patients is increasing. In this article, we describe the methods, effectiveness, safety and the current status of BT in Japan.

The objective of the study was to compare the effect of sinonasal surgery vs. medical treatment on asthma in patients with chronic rhinosinusitis with or without nasal polyps. We executed a PRISMA guidelines-based systematic search of the following databases: PubMed, CENTRAL, Embase, Scopus and CINAHL. The search ran from database inception until 26 Feb 2014. We included controlled clinical trials comparing surgical intervention with medical intervention in patients with chronic rhinosinusitis with or without nasal polyps. We included only English papers. We used a pre-defined data collection form. Two authors independently assessed study quality. We assessed directness of evidence and risk of bias using pre-defined criteria. Our search yielded 2004 original articles, six of which satisfied our inclusion criteria. One article was excluded from further review because no comparison could be made of the subgroup of operated asthmatic patients versus the non-surgical control group. Only one study used objective pulmonary function measurements in asthmatics undergoing sinonasal surgery and therefore had the highest directness of evidence. Also it had a low risk of bias. Patient characteristics, treatments and outcome measures varied across studies, as did the observed effect. Risk of bias was high in most studies. Patient characteristics, treatment and outcome measurement differed across studies, making a comparison of the effects difficult. There is a risk of publication language bias. There is insufficient evidence either for or against sinonasal surgery for asthma control as compared to medical treatment.

Bronchial thermoplasty (BT) is a therapeutic intervention that delivers targeted thermal energy to the airway walls with the goal of ablating the smooth muscle in patients with severe persistent asthma. Since the publication of the original preclinical studies, three large randomized clinical trials evaluating its impact on asthma control have been performed. These trials have shown improvements in asthma-related quality of life and a reduction in asthma exacerbations following treatment with BT. However, there remains significant controversy regarding the true efficacy of BT and the interpretation of these studies, particularly the Asthma Intervention Research 2 trial. In this article, we will discuss these controversies and present the latest evidence on the use of BT in asthma, specifically the 5-year longitudinal evaluation of patients. In addition, we will discuss new insights into the histopathologic changes that occur in the airways following BT, as well as the feasibility of performing the procedure in patients with very severe asthma. We also will discuss the ongoing translational and clinical investigations regarding the underlying mechanism of action and methods to improve patient selection for this procedure., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: This article provides the reader with recent findings on the pathophysiology of comorbidities in the obese, as well as evidence-based treatment options to deal with perioperative respiratory challenges., Recent Findings: Our understanding of obesity-associated asthma, obstructive sleep apnea, and obesity hypoventilation syndrome is still expanding. Routine screening for obstructive sleep apnea using the STOP-Bang score might identify high-risk patients that benefit from perioperative continuous positive airway pressure and close postoperative monitoring. Measures to most effectively support respiratory function during induction of and emergence from anesthesia include optimal patient positioning and use of noninvasive positive pressure ventilation. Appropriate mechanical ventilation settings are under investigation, so that only the use of protective low tidal volumes could be currently recommended. A multimodal approach consisting of adjuvants, as well as regional anesthesia/analgesia techniques reduces the need for systemic opioids and related respiratory complications., Summary: Anesthesia of obese patients for nonbariatric surgical procedures requires knowledge of typical comorbidities and their respective treatment options. Apart from cardiovascular diseases associated with the metabolic syndrome, awareness of any pulmonary dysfunction is of paramount. A multimodal analgesia approach may be useful to reduce postoperative pulmonary complications.

Bronchial thermoplasty has been found to be a safe and effective therapy for severe asthma. We report the case of a mediastinal hematoma and hemothorax developing in a 66-year-old woman several days after an uneventful bronchial thermoplasty of the right lower lobe. Evaluation revealed a bleeding right bronchial artery pseudoaneurysm. Pseudoaneuryms have been reported in association with other procedures involving the therapeutic application of thermal energy, and a single case of hemoptysis requiring bronchial artery embolization occurred in a clinical trial of bronchial thermoplasty. However, bronchial artery pseudoaneurysm with hemomediastinum and hemothorax has not previously been reported after bronchial thermoplasty., (Published by Elsevier Inc.)

Context: Surgical and pathologic handling of lung physically affects lung tissue. This leads to artifacts that alter the morphologic appearance of pulmonary parenchyma., Objective: To describe and illustrate mechanisms of ex vivo artifacts that may lead to diagnostic pitfalls., Design: In this study 4 mechanisms of ex vivo artifacts and corresponding diagnostic pitfalls are described and illustrated., Results: The 4 patterns of artifacts are: (1) surgical collapse, due to the removal of air and blood from pulmonary resections; (2) ex vivo contraction of bronchial and bronchiolar smooth muscle; (3) clamping edema of open lung biopsies; and (4) spreading of tissue fragments and individual cells through a knife surface. Morphologic pitfalls include diagnostic patterns of adenocarcinoma, asthma, constrictive bronchiolitis, and lymphedema., Conclusion: Four patterns of pulmonary ex vivo artifacts are important to recognize in order to avoid morphologic misinterpretations.

Background: Functional endoscopic sinus surgery (FESS) is considered to be the standard procedure for chronic rhinosinusitis with nasal polyps (CRSwNP). However, for CRSwNP that accompanies asthma, the results are not satisfying. Extensive endoscopic sinus surgery (EESS) aimed at reducing the inflammatory load has been indicated as a viable option for refractory chronic rhinosinusitis., Objective: To evaluate the clinical outcomes and safety of EESS (middle turbinate and superior turbinate resection and total ethmoidectomy) for patients with CRSwNP and with asthma., Methods: This was a prospective, single-institute cohort study conducted in a tertiary teaching hospital. Patients with CRSwNP and with asthma who were proceeding to surgery were enrolled. There were 23 patients in the EESS group and 24 patients in the FESS group. The preoperative disease severity was evaluated by the visual analog scale (VAS), Lund-Kennedy (L-K) endoscopy score, computed tomography Lund-Mackay score, asthma control test (ACT), and pulmonary function test. Clinical outcomes were comparatively evaluated between the two groups after a 1-year follow-up by using the VAS score, the postoperative endoscopic score (E score), L-K score, ACT score, and pulmonary function test., Results: The disease severity (general VAS score, endoscopic L-K score, computed tomography score, ACT score) showed no significant differences between the two groups before surgery (p > 0.05). One year after surgery, both groups achieved significant improvement in the VAS score and endoscopic L-K score. The EESS group showed better improvement in the olfactory VAS score and E score compared with the FESS group (mean [standard deviation] change of olfactory VAS, 6.00 ± 3.67 versus 3.30 ± 3.44, p = 0.015; mean [standard deviation] E score, 0.31 ± 0.18 versus 0.66 ± 0.26, p < 0.001). No significant differences were found in the change of general nasal symptom VAS score, other individual VAS scores (nasal congestion, discharge, headache and/or facial pain), L-K score, ACT score, and pulmonary function between the two groups (p > 0.05)., Conclusion: EESS for patients with CRSwNP and with asthma may help to improve the subjective olfaction and endoscopic appearance.

Background: Montelukast is used in the treatment of allergic rhinitis and asthma. It has been used as adjuvant therapy in patients with chronic rhinosinusitis (CRS), but its effectiveness has not been evaluated. This study evaluates the efficacy of adjuvant leukotriene receptor antagonism in CRS and subtypes., Methods: Retrospective review of collected data at a tertiary-referral institution. We identified all patients who were prescribed montelukast postoperatively and had a lapse in therapy for at least 1 month (n = 50), so that the patients themselves serve as their own control group. Twenty-item Sino-Nasal Outcomes Test (SNOT-20) scores and Lund-Kennedy endoscopy scores were obtained for each patient. Scores were compared with and without montelukast using Wilcoxon signed rank test. The analysis was controlled for changes in other medications., Results: Fifty-two therapy lapses were identified in 50 patients. Twenty-seven patients had eosinophilic CRS with polyps (eCRSwNP), 8 had Samter's triad (ST), and 15 had allergic fungal sinusitis (AFS). Overall mean follow-up was 46.5 months. Overall, SNOT-20 scores and endoscopy scores were significantly lower with montelukast (p < 0.005 for both). On subgroup analysis, SNOT-20 scores were significantly improved for patients with eCRSwNP and AFS (p < 0.001 and p = 0.001, respectively). Endoscopy scores were significantly improved for patients with eCRSwNP (p = 0.044). Outcomes approached, but did not reach, significance for patients with ST (p = 0.123 for SNOT-20 and p = 0.146 for endoscopy). There was also significant improvements in patients with asthma., Conclusion: The addition of montelukast as postoperative therapy may be beneficial for patients with eCRSwNP and AFS., (© 2016 ARS-AAOA, LLC.)

Background: The long-term impact of chronic rhinosinusitis (CRS) with or without allergic rhinitis (AR) on asthma is poorly documented. This study analyzed potential associations of ongoing CRS and AR on asthma., Methods: Using the MarketScan™ claims database, patients with CRS and endoscopic sinus surgery (ESS) in 2010 were identified. The date of first sinusitis was determined for all. Patients with asthma at time of first sinusitis diagnosis were excluded. The remaining patients were grouped based on duration of sinusitis, from first diagnosis to surgery-group 1: 1 to <2 years (n = 181); group 2: 2 to <3 years (n = 195); group 3: 3 to <4 years (n = 292); and group 4: 4 to <5 years (n = 536). Yearly incidence and prevalence of newly diagnosed asthmatics was analyzed for all groups. A secondary analysis evaluated the association between AR and asthma., Results: Preoperatively, yearly incidence of patients with new asthma diagnoses averaged 4.48% (95% confidence interval [CI], 3.93% to 5.11%) and was significantly greater for patients with AR (5.93%; 95% CI, 4.56% to 7.66%) vs non-AR (4.15%; 95% CI, 3.56% to 4.82%); p = 0.03. Postoperatively, yearly incidence of asthma was 0.42% (95% CI, 0.18% to 0.88%). No patient had asthma at time of first diagnosis; however, by time of surgery, 9.4%, 12.8%, 18.2%, and 22.40% of patients had been diagnosed with asthma, in groups 1 through 4, respectively., Conclusion: AR was a significant risk factor for asthma in patients with CRS. Medically recalcitrant CRS was associated with high incidence rates of asthma, which declined post-operatively. Patients operated earlier in the disease continuum were therefore at decreased risk of developing asthma., (© 2015 ARS-AAOA, LLC.)

Published information on the effectiveness of bronchial thermoplasty (BT) for severe asthma in 'real life' patients is limited. We compared safety and efficacy outcomes 12 months post procedure in 10 clinic patients and 15 patients recruited to clinical trials of BT at the same centre. Baseline asthma severity was greater in the clinic group. Adverse events were similar. Clinical improvements occurred in 50% of the clinic patients compared with 73% of the research patients., (© The Author(s), 2015.)