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Rationale: The aim of bronchial thermoplasty is to improve asthma symptoms by reducing central airway smooth muscle mass. Up to now, the reduction of smooth muscle mass has been documented for only 1 group of 10 patients who had 15% or more of their pretreatment total bronchial biopsy area occupied by smooth muscle., Objectives: To evaluate the effects of bronchial thermoplasty on airway smooth muscle mass and airway collagen deposition in adult patients with asthma, regardless of pretreatment smooth muscle area., Methods: Seventeen patients with asthma underwent bronchial thermoplasty over the course of three visits. At Visit 1, bronchial biopsies were taken from the lower lobe that was not treated during this session. At Visit 2 (3-14 wk after the first visit), all 17 patients underwent biopsy of the lower lobe treated during the first procedure. At Visit 3 (7-22 wk after the first visit), nine patients agreed to undergo biopsy of the same lower lobe. Histological and immunohistochemical analyses were performed on the biopsy specimens., Measurements and Main Results: Bronchial thermoplasty decreased airway smooth muscle from 12.9 ± 1.2% of the total biopsy surface at Visit 1 to 4.6 ± 0.8% at Visit 2 (P < 0.0001). For the nine patients who underwent a third biopsy, mean airway smooth muscle area was 5.3 ± 1.3% at Visit 3 (P = 0.0008 compared with baseline). Bronchial thermoplasty also decreased Type I collagen deposition underneath the basement membrane from 6.8 ± 0.3 μm at Visit 1 to 4.3 ± 0.2 μm at Visit 2 (P < 0.0001) and to 4.4 ± 0.4 μm for nine patients at Visit 3 (P < 0.0001 compared with baseline). Over the course of 1 year after treatment, the doses of inhaled corticosteroid, the number of severe exacerbations, and asthma control all improved (P ≤ 0.02)., Conclusions: For patients with severe asthma, bronchial thermoplasty reduced the smooth muscle mass of treated airway segments, regardless of the baseline level of muscle mass. Treatment also altered the deposition of collagen. At follow-up, bronchial thermoplasty improved asthma control; however, the limited number of subjects did not allow us to evaluate possible correlations between these improvements and the studied histological parameters. Further studies are needed to confirm these results and evaluate their persistence.

Background: Management of asthma in chronically affected patients is a serious health problem. Our aim was to show that surgical treatment of chronic bronchial asthma by unilateral resection of the internal branch of the superior laryngeal nerve (ib-SLN) is an adequateand lasting remedial response., Patients and Methods: In a retrospective study, 41 (26 male and 15 female) patients with bronchial chronic asthma were treated surgically during the period between 2005 and 2013. It consisted of a unilateral resection of the ib-SLN under optical zoom, on patients placed in supinator position. 35 patients (24 male and 11 female) who were un-operated were included as a control., Results: In all patients, medication was reduced progressively. When the results were compared with the control group, it was seen that in 26% of the patients, both forced expiratory volume (FEV) and peak expiratory flow (PEF) increased significantly (p <05) and only modestly in 53.6% of patients (FEV, p <05 and PEF, p <05). In the remaining 20% of patients, these parameters remained however unchanged. Overall, in 80% of patients unilateral resection of the ib-SLN gave satisfactory results because it shortened the intervals and duration of asthmatic attacks, rendering thereby a reduction in medication., Conclusion: This minimal-invasive method helped prevent/cure asphyxias in chronic bronchial asthma without affecting cough reflex,respiratory control and phonation and it helped patients avoid severe crisis. This approach is of interest for patients with severe and/or uncontrolled bronchial asthma in settings with limited access to drug treatment.

Approximately 5% of the ~3 million asthmatics in South Africa have severe asthma that is associated with substantial morbidity, cost, absenteeism, preventable mortality, and the requirement for costly chronic medication that may be associated with significant adverse events. There is an unmet need for alternative safer and more effective interventions for severe asthma. A recently introduced option, bronchial thermoplasty (BT), imparts radiofrequency-generated heat energy to the airways to cause regression of airway smooth muscle. The effectiveness of this technique has been confirmed in randomised control trials and is now endorsed by several international guidelines, including the Global Initiative for Asthma (GINA) guideline, the British Asthma Guideline, and the UK National Institute of Clinical Excellence (NICE) guideline. We recommend BT as a potential therapeutic intervention for severe uncontrolled asthma, provided that it is performed by an experienced pulmonologist at an accredited centre and done within the broader context of appropriate management of the disease by doctors experienced in treating difficult-to-control asthma.

Rationale: Bronchial thermoplasty is an alternative treatment for patients with severe, uncontrolled asthma in which the airway smooth muscle is eliminated using radioablation. Although this emerging therapy shows promising outcomes, little is known about its effects on airway inflammation., Objectives: We examined the presence of bronchoalveolar lavage cytokines and expression of smooth muscle actin in patients with severe asthma before and in the weeks after bronchial thermoplasty., Methods: Endobronchial biopsies and bronchoalveolar lavage samples from 11 patients with severe asthma were collected from the right lower lobe before and 3 and 6 weeks after initial bronchial thermoplasty. Samples were analyzed for cell proportions and cytokine concentrations in bronchoalveolar lavage and for the presence of α-SMA in endobronchial biopsies., Measurements and Main Results: α-SMA expression was decreased in endobronchial biopsies of 7 of 11 subjects by Week 6. In bronchoalveolar lavage fluid, both transforming growth factor-β1 and regulated upon activation, normal T-cell expressed and secreted (RANTES)/CCL5 were substantially decreased 3 and 6 weeks post bronchial thermoplasty in all patients. The cytokine tumor-necrosis-factor-related apoptosis-inducing ligand (TRAIL), which induces apoptosis in several cell types, was increased in concentration both 3 and 6 weeks post bronchial thermoplasty., Conclusions: Clinical improvement and reduction in α-SMA after bronchial thermoplasty in severe, uncontrolled asthma is associated with substantial changes in key mediators of inflammation. These data confirm the substantial elimination of airway smooth muscle post thermoplasty in the human asthmatic airway and represent the first characterization of significant changes in airway inflammation in the first weeks after thermoplasty.

Background: Research on nonsurgical weight loss interventions has failed to demonstrate consistent efficacy on asthma control, although these interventions resulted in only modest weight reductions., Objective: We sought to test the hypothesis that bariatric surgery is associated with a rapid and sustained decrease in risk of asthma exacerbation., Methods: We performed a self-controlled case series study of 2261 obese patients with asthma aged 18 to 54 years who underwent bariatric surgery using the population-based emergency department (ED) and inpatient sample in 3 states (California, Florida, and Nebraska). The primary outcome was an ED visit or hospitalization for asthma exacerbation from 2005 through 2011. We used conditional logistic regression to compare each patient's risk of the outcome event during sequential 12-month periods using presurgery months 13 to 24 as the reference period., Results: During the reference period, 22.0% (95% CI, 20.3% to 23.7%) of patients had an ED visit or hospitalization for asthma exacerbation. In the subsequent 12-month presurgery period, the risk did not materially change (21.7%; 95% CI, 20.0% to 23.4%), with an odds ratio (OR) of 0.98 (95% CI, 0.85-1.13) compared with the reference period. By contrast, significantly fewer ED visits or hospitalizations for asthma exacerbation occurred within 12 months after bariatric surgery (10.9%; 95% CI, 9.6% to 12.2%), corresponding to an OR of 0.42 (95% CI, 0.35-0.50). Similarly, in the subsequent period of 13 to 24 months after bariatric surgery, the risk remained significantly lower (10.9%; 95% CI, 9.6% to 12.2%), corresponding to an OR of 0.42 (95% CI, 0.35-0.50)., Conclusion: In obese patients the risk of an ED visit or hospitalization for asthma exacerbation decreased by half after bariatric surgery. This reduction suggests the effectiveness of significant weight loss on asthma morbidity., (Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Chronic rhinosinusitis (CRS) is a prevalent multifactorial disease process in which bacteria are believed to play a role in the propagation of inflammation. Multiple subtypes of CRS have been described based on clinical and pathologic features, but a detailed examination of the sinus microbiota in patients with CRS and its clinical subtypes has yet to be performed., Objective: We sought to examine the resident microbiota of CRS subtypes and determine whether bacterial diversity is a predictor of disease outcomes., Methods: Sinus swabs from patients with CRS and healthy subjects collected during endoscopic sinus surgery were analyzed by means of molecular phylogenetic analysis of 16S rDNA pyrosequences., Results: Fifty-six patients with CRS and 26 control subjects were studied. Biodiversity was similar between the CRS and control groups. Among the CRS subtypes examined, only 2 conditions (presence of purulence and comorbid condition of asthma) were associated with significant alterations in microbial community composition. In 27 patients with CRS who were followed postoperatively, those with better outcomes had more diverse bacterial communities present at the time of surgery, along with higher relative abundances of Actinobacteria., Conclusion: Analysis of microbiota in a large cohort reveals that particular CRS phenotypes (asthma and purulence) are characterized by distinct compositions of resident bacterial communities. We found that bacterial diversity and composition are predictors of surgical outcome, promoting the concept of community ecology in patients with CRS., (Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Bronchial thermoplasty is a recent endoscopic technique for the treatment of severe asthma. It is an innovative treatment whose clinical efficacy and safety are beginning to be better understood. Since this is a device-based treatment, the evaluation procedure of risks and benefits is different that for pharmaceutical products; safety aspects, regulatory requirements, study design and the assessment of the magnitude of effects may all be different. The mechanism of action and optimal patient selection need to be assessed further in rigorous clinical and scientific studies. This technique is in harmony with the development of personalised medicine in the 21st century. It should be developed further in response to the numerous challenges and needs not yet met in the management of severe asthma., (Copyright © 2014 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Background: Despite modern medicine's greatest efforts, many patients suffering from chronic obstructive pulmonary disease (COPD) and asthma remain refractory to the best treatments available. Bronchoscopy is increasingly being used to explore new approaches for treating these diseases, and several new techniques have recently shown encouraging results. The purpose of this review will be to shed some light on these methods., Methods: We searched Pubmed and Embase for English language articles from 1995 to September 2014, as well as ongoing trials on ClinicalTrials.gov. The following prespecified terms were used to search for clinical trials and case reports from the past 20 years: "endoscopic treatment of COPD", "endobronchial valve", and "bronchial thermoplasty"., Results and Discussion: In search for new COPD treatments, several trials have assessed the efficacy of one-way valves and other conceptually similar techniques including biological sealants and thermal vapor ablation. These methods all operate within a similar paradigm where the intention is to maximize ventilation of the remaining healthy parts of the lung, and to minimize the use and the space occupied by the diseased lung tissue. Similarly, a new non-pharmacologic therapeutic approach in asthma, bronchial thermoplasty (BT), was recently approved for use in the United States for adults with severe disease. The goal is to reduce the mass of hypertrophied smooth muscle in the bronchi to decrease bronchoconstriction., Conclusion: Both BT and the bronchoscopic treatments for COPD have shown promising results in recent studies, suggesting the onset of a new direction in obstructive lung disease treatment.

Purpose: To quantify regional lung ventilation in healthy volunteers and patients with severe asthma (both before and after thermoplasty) by using a combination of helium 3 ((3)He) magnetic resonance (MR) imaging and computed tomography (CT), with the intention of developing more effective image-guided treatments for obstructive lung diseases., Materials and Methods: With approval of the local institutional review board, informed consent, and an Investigational New Drug Exemption, six healthy volunteers and 10 patients with severe asthma were imaged in compliance with HIPAA regulations by using both multidetector CT and (3)He MR imaging. Individual bronchopulmonary segments were labeled voxel by voxel from the CT images and then registered to the (3)He MR images by using custom software. The (3)He signal intensity was then analyzed by evaluating the volume-weighted fraction of total-lung signal intensity present in each segment (segmental ventilation percentage [ SVP segmental ventilation percentage ]) and by identifying the whole-lung defect percentage and the segmental defect percentage. Of the 10 patients with asthma, seven received treatment with bronchial thermoplasty and were imaged with (3)He MR a second time. Changes in segmental defect percentages and whole-lung defect percentages are presented., Results: Ventilation measures for healthy volunteers yielded smaller segment-to-segment variation (mean SVP segmental ventilation percentage , 100% ± 18 [standard deviation]) than did the measures for patients with severe asthma (mean SVP segmental ventilation percentage , 97% ± 23). Patients with asthma also demonstrated larger segmental defect percentages (median, 13.5%; interquartile range, 8.9%-17.8%) than healthy volunteers (median, 6%; interquartile range, 5.6%-6.3%). These quantitative results confirm what is visually observed on the (3)He images. A Spearman correlation of r = -0.82 was found between the change in whole-lung defect percentage and the number of days between final treatment and second (3)He imaging., Conclusion: Regional quantification of lung ventilation is indeed feasible and may be a useful technique for image-guided treatment of obstructive lung diseases, such as bronchial thermoplasty for severe asthma. In these patients, ventilation defects decreased as a function of time after treatment.

Emphysema and asthma are responsible for economic and social burden. Altering the natural course of these diseases is a field of intense research. The National Emphysema Treatment Trial showed that lung volume reduction surgery (LVRS) could significantly reduce both morbidity and mortality in properly selected patients. LVRS is seldom performed, however, due to the high morbidity associated with the surgery. Numerous bronchoscopic interventions have been introduced with the goal of providing the clinical benefits of LVRS without the surgical complications. Thus far, these modalities have not produced the results once hoped. However, through active modification of both technique and patient selection, the role of minimally invasive modalities in the treatment of emphysema continues to evolve. Bronchial thermoplasty (BT) is a method of delivering controlled heat to airway mucosa with the goal of reducing airway smooth muscle mass and hence bronchoconstriction. In patients suffering from asthma who cannot achieve control with standard medical care, BT has been shown to be safe and improves symptoms, with long lasting benefit. BT does not seem to affect traditional markers of asthma severity such as forced expiratory volume in 1 second and questions remain regarding proper patient selection for this therapy and its true physiologic effects. This article is a review of bronchoscopic modalities for emphysema and asthma., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Childhood asthma and obstructive sleep apnea (OSA), both disorders of airway inflammation, were associated in recent observational studies. Although childhood OSA is effectively treated by adenotonsillectomy (AT), it remains unclear whether AT also improves childhood asthma. We hypothesized that AT, the first line of therapy for childhood OSA, would be associated with improved asthma outcomes and would reduce the usage of asthma therapies in children., Methods and Findings: Using the 2003-2010 MarketScan database, we identified 13,506 children with asthma in the United States who underwent AT. Asthma outcomes during 1 y preceding AT were compared to those during 1 y following AT. In addition, 27,012 age-, sex-, and geographically matched children with asthma without AT were included to examine asthma outcomes among children without known adenotonsillar tissue morbidity. Primary outcomes included the occurrence of a diagnostic code for acute asthma exacerbation (AAE) or acute status asthmaticus (ASA). Secondary outcomes included temporal changes in asthma medication prescriptions, the frequency of asthma-related emergency room visits (ARERs), and asthma-related hospitalizations (ARHs). Comparing the year following AT to the year prior, AT was associated with significant reductions in AAE (30.2%; 95% CI: 25.6%-34.3%; p<0.0001), ASA (37.9%; 95% CI: 29.2%-45.6%; p<0.0001), ARERs (25.6%; 95% CI: 16.9%-33.3%; p<0.0001), and ARHs (35.8%; 95% CI: 19.6%-48.7%; p = 0.02). Moreover, AT was associated with significant reductions in most asthma prescription refills, including bronchodilators (16.7%; 95% CI: 16.1%-17.3%; p<0.001), inhaled corticosteroids (21.5%; 95% CI: 20.7%-22.3%; p<0.001), leukotriene receptor antagonists (13.4%; 95% CI: 12.9%-14.0%; p<0.001), and systemic corticosteroids (23.7%; 95% CI: 20.9%-26.5%; p<0.001). In contrast, there were no significant reductions in these outcomes in children with asthma who did not undergo AT over an overlapping follow-up period. Limitations of the MarketScan database include lack of information on race and obesity status. Also, the MarketScan database does not include information on children with public health insurance (i.e., Medicaid) or uninsured children., Conclusions: In a very large sample of privately insured children, AT was associated with significant improvements in several asthma outcomes. Contingent on validation through prospectively designed clinical trials, this study supports the premise that detection and treatment of adenotonsillar tissue morbidity may serve as an important strategy for improving asthma control. Please see later in the article for the Editors' Summary.

Bronchial thermoplasty is a device-based therapy for treatment of severe refractory asthma that uses radiofrequency energy to reduce airway smooth muscle and decrease bronchoconstriction. BT improves quality of life and decreases the rate of severe exacerbations with no known major long-term complications. The effectiveness of bronchial thermoplasty persists at least 5 years after the treatment is completed. Further investigation is needed to better define the specific subpopulation of patients with severe asthma who would best benefit from this treatment.

Objective: To investigate the efficacy of endoscopic sinus surgery (ESS)-based multidisciplinary therapy for patients with chronic rhinosinusitis (CRS), nasal polyps and bronchial asthma., Method: The study included 32 patients with CRS, nasal polyps and bronchial asthma who received ESS, besides surgery, who also used glucocorticoid inhalation, nasal spray and nasal irrigation perioperatively. The evaluation of the treatment was performed 3 years post after ESS., Result: In the 32 cases treated with ESS, 19 cases were cured, 9 cases were improved, 4 cases were inefficient by the treatment. The cure rate was 87.5%. The asthma symptoms were improved in 9 patients (P < 0.01), compared to 2 before surgery. The numbers of patients with improved symptoms were increased from 2 before the surgery to 9 after the surgery., Conclusion: As the main treatment, endoscopic si- nus surgery was effective on CRS with asthma.

Bronchial thermoplasty (BT) involves the application of radiofrequency energy to visible proximal airways to selectively ablate airway smooth muscle. BT is the first nonpharmacologic interventional therapy approved by the US Food and Drug Administration (FDA) for severe asthma. This approval was based on the results of the pivotal Asthma Intervention Research (AIR)-2 trial, which is the only randomized, double-blind, sham-controlled trial of BT. The primary end point of the AIR-2 trial was improvement in the Asthma Quality of Life Questionnaire (AQLQ). The results of the AIR-2 trial have generated enormous interest, controversy, and confusion regarding the true efficacy of BT for severe asthma. Current marketing of BT highlights its use for patients with "severe" asthma, which is interpreted by most practicing clinicians as meaning oral corticosteroid dependence, frequent exacerbations, or a significantly reduced FEV1 with a poor quality of life. Did the AIR-2 trial include patients with a low FEV1, oral steroid dependence, or frequent exacerbations? Did the trial show efficacy for any of the primary or secondary end points? The FDA approved the device based on the reduction in severe asthma exacerbations. However, were the rates of asthma exacerbations, ED visits, or hospitalizations truly different between the two groups, and was this type of analysis even justified given the original study design? This commentary is designed to specifically answer these questions and help the practicing clinician navigate the thermoplasty literature with confidence and clarity. We carefully dissect the design, conduct, and results of the AIR-2 trial and raise serious questions about the efficacy of bronchial thermoplasty.

Objective: The aim of this study was to understand the effect of different treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS) for refractory asthma in children., Methods: Fifty two children (32 in surgical group, 20 in conservative group) with refractory asthma and OSAHS were included in the study. All children received asthma condition assessment and polysomnography (PSG) examination before and after treatment, and were followed up for 6 months., Results: All children got improved in PSG values 3 months after treatment, more significant improvement was achieved in surgical group than in conservative group (P < 0.05). While compared of OSAHS treatment, there were 2 cure, 6 notable effective, 9 effective, 3 in vain cases in conservative group, 8 cure, 16 notable effective, 8 effective, 0 in vain cases in surgery group. There was significant difference between the two groups (χ² = 8.91, P = 0.031). All children got improved in asthma condition evaluation parameters and decreased the use number of short acting β2 agonists after 6 months treatment. More significant improvement was achieved in surgical group than in conservative group. The differences of all the items had statistical significance (P < 0.05). There was statistical correlation between days mutation rate of peak expiratory flow (PEF) and apnea hypopnea index (r = 0.712, P < 0.01), and between days mutation rate of PEF and lowest oxygen saturation (r = 0.726, P < 0.01)., Conclusions: Active treatment of OSAHS can improve asthma symptoms and reduce asthma medication effectively. The curative effect of surgical treatment is superior to conservative treatment.

Bronchial thermoplasty is a relatively new therapy for the management of severe asthma. It involves the direct bronchoscopic application of thermal energy to airways by a catheter-directed expandable basket. The airways of the lower and upper lobes are treated in 3 separate sessions spaced 3 weeks apart. The therapy targets airway smooth muscle, with studies showing a decrease in airway smooth muscle after bronchial thermoplasty therapy. After therapy, an improvement in quality of life and decrease in asthma exacerbations can be expected. Adverse events can occur with bronchial thermoplasty and careful patient selection is critical to ensure benefits outweigh the potential risks., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Chronic adenoiditis (CA) and chronic rhinosinusitis (CRS) in children are difficult to distinguish based on symptoms alone. A computed tomography (CT) scan is one way to distinguish between the two entities. The purpose of this study was to determine whether CT scores can predict outcome of adenoidectomy., Methods: A retrospective review was performed over a 10-year period. All children who failed medical treatment had a CT scan and an adenoidectomy, which were reviewed. Children who had a CT score of ≥5 were included in the CA with concurrent CRS group, whereas those who had a CT score of <5 were included in the CA without CRS group., Results: Two hundred thirty-three children met the aforementioned criteria. Mean age was 5.5 years and mean CT score was 6.4. The CRS group had a success rate of 43%, whereas the CA group had a 65% success rate (p = 0.0017). Those children who were asthmatic and had CRS had a success rate of 28% compared with 53% for those who had CA (p = 0.022)., Conclusion: Making the diagnosis of CRS in children seems to be critical in determining whether, initially, an adenoidectomy alone is an appropriate treatment, specifically for those who have asthma.

Background: Patients with chronic rhinosinusitis (CRS) and nasal polyps (NPs) may be subdivided into aspirin-sensitive (AS) and aspirin-tolerant (AT) populations. These cohorts are not well characterized., Objective: To examine phenotypic characteristics and determine the extent of medical/surgical interventions in patients with CRS+NP and to compare the AS with the AT subset in the CRS+NP sample., Methods: Retrospective chart review was performed at a tertiary academic respiratory hospital. Data included patient demographics, asthma severity, peripheral eosinophilia, Lund-Mackay computed tomographic score, symptomatic dysosmia, and therapeutic interventions., Results: Of the 182 patients included, 81 had aspirin sensitivity (45%) and 101 had aspirin tolerance (55%). Asthma was present in 94% of patients with CRS+NP (100% in AS subgroup vs 89% in AT subgroup, P = .001). Eighty-eight percent of the CRS+NP sample had moderate to severe persistent asthma. In the AS and AT subgroups, asthma severity was similar (P > .6). The CRS+NP sample showed a mean computed tomographic score of 14.0 (44% with eosinophilia and 46% with dysosmia). More severe sinus disease was noted in the AS group (Lund-Mackay computed tomographic scores, P = .002; olfactory symptoms, P = .001). Serum eosinophil levels were not statistically different between groups (51% in AS group, 39% in AT group, P > .1)., Conclusion: This study is one of the broadest reviews of patients with CRS+NP, with unique findings in the high prevalence of asthma in AS and AT patients, greater olfactory dysfunction in AS patients, and a minority of patients with CRS+NP and circulating eosinophils. Most AS patients do not have increased circulating eosinophils, as is often believed. These results shed further light on the association between asthma and upper respiratory tract disease in those with nasal polyposis., (Copyright © 2013 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Patients suffering from both chronic rhinosinusitis (CRS) and asthma demonstrate improved asthma outcomes when upper airway inflammation is controlled with medications. It is unclear if similar benefits exist when the upper airway is treated surgically. This study presents a systematic review and meta-analysis to assess the effects of endoscopic sinus surgery (ESS) on asthma outcomes., Methods: Ovid MEDLINE and the Cochrane databases were searched to identify studies examining asthma outcomes in patients with CRS following ESS. Included studies involved a cohort of at least 5 patients and reported at least 1 postoperative asthma outcome., Results: Twenty-two studies involving a total of 891 patients were identified. Mean follow-up across all studies was 26.4 months. Patients reported improved overall asthma control in 76.1% (95% confidence interval [CI], 71.9% to 80.3%) of cases. The frequency of asthma attacks decreased in 84.8% (95% CI, 76.6% to 93.0%) of patients and the number of hospitalizations decreased in 64.4% (95% CI, 53.3% to 75.6%). Decreased use of oral corticosteroids was seen in 72.8% (95% CI, 67.5% to 78.1%) of patients; inhaled corticosteroid use decreased in 28.5% (95% CI, 22.6% to 34.5%) and bronchodilator use decreased in 36.3% (95% CI, 28.9% to 43.7%) of patients. Mean improvement in predicted forced expiratory volume at 1 second (FEV1 ) was 1.62%, but was not statistically significant (p = 0.877)., Conclusion: ESS in patients with concomitant bronchial asthma improves clinical asthma outcome measures, but not lung function testing. Difficulty conducting controlled clinical trials of ESS limits the strength of conclusions which can be reached., (© 2013 ARS-AAOA, LLC.)

This article presents an overview of bronchial thermoplasty, a novel treatment for severe asthma. Within, the authors discuss the rationale for bronchial thermoplasty in severe asthma, current clinical evidence for the use of this procedure, clinical recommendations, and future directions., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The advent of bronchial thermoplasty (BT) provides a novel therapeutic option for asthma refractory to traditional medical therapy. Insurance coverage poses significant frustration for centers performing BT. Although clinical research has provided evidence of the usefulness and long-term safety of BT, establishing "reasonability and necessity" remains a daunting challenge in securing private and governmental insurance coverage. As a result, obtaining coverage poses significant frustration for centers capable of performing BT for patients suffering from severe asthma. Until recently, BT had been categorized by a temporary set of Current Procedural Terminology (CPT) codes as an emerging technology, service, or procedure (category 3). Based on increasing implementation of BT nationwide, the American Medical Association CPT Editorial Panel has assigned category 1 CPT codes for BT in their published 2013 professional edition. It is hoped that such a recommendation will reinforce the medical community's belief in the usefulness of BT and help facilitate decisions on insurance coverage. The ability to secure coverage for BT through physician advocacy and Centers for Medicare and Medicaid Services support will help move the treatment of refractory asthma forward.

Introduction: Bronchial thermoplasty (BT) is an emerging therapy for patients with severe persistent asthma who remain poorly controlled despite standard maximal medical therapy. Thermoplasty elicits asthma control over time by applying thermal radiofrequency energy to airways to ablate underlying smooth muscle. While this therapy is suggested to eliminate such smooth muscle permanently, no human studies have examined the possibility of treatment failure., Case Report: We present a 62-year-old female with severe, refractory asthma symptoms who underwent BT without apparent complications. However, severe symptoms including multiple clinical exacerbations persisted despite BT treatment. Repeat endobronchial biopsy done six months after BT treatment demonstrated persistent smooth muscle hyperplasia in multiple airways that previously had been treated. The patient continued to have uncontrolled, refractory asthma despite multiple therapies., Conclusion: This case is the first to describe a failure of BT to reduce or eliminate airway smooth muscle in a patient with severe persistent asthma. It suggests the potential for treatment failure in the management of these patients after BT and highlights the need for further study of potential BT-refractory patients.

A patient presented having an acute abdomen on a background of a twelve-month history of worsening asthma. Computed tomography showed giant bilateral intrathoracic hernias extending to both thoracic apices. Our case was unusual as the defect was bilateral and left-sided. Surgical repair revealed each hernia sac measuring >20 cm and to contain the entirety of the small bowel and colon (including retroperitoneal bowel). The appendix was discovered adjacent to right superior pulmonary vein. Both sacs were excised and the defects dissected and transfixed in a single stage operation. In the post-operative stage, he developed a 6.3 cm fluid collection anterior to the right atrium and a left-sided pleural effusion. Morgagni hernias can escape detection and be attributed to other diagnoses courtesy of false localising signs on clinical examination and symptoms in the history.

Bronchoscopy is the most important tool in diagnosis of respiratory diseases, but also provides therapeutic options in various disorders. Besides hemoptysis, airway stenoses are a frequent indication for therapeutic bronchoscopy interventions. Thereby, a broad spectrum of endoscopic techniques including electrocautery, argon plasma coagulation, laser treatment, cryosurgery and stent implantation is available. In the last decade, development of new endoscopic modalities provides also treatment of patients with chronic obstructive pulmonary disease and uncontrolled asthma.

Background: The purpose of this level 4, retrospective cohort study was to detail the outcomes of primary, revision, and endoscopic modified Lothrop procedure (EMLP) (Draf III) frontal sinus surgery and evaluate whether risk factors would help determine which patients would benefit from which procedures., Methods: The study used a retrospective chart review. Endoscopic assessment of frontal ostium patency and patient reported symptoms were prospectively collected on patients who underwent frontal sinusotomy between January 2003 and December 2009. High-risk cohorts were studied to assess their response to standard endoscopic sinus surgery (ESS) compared with EMLP., Results: A total of 339 patients who met the inclusion and exclusion criteria underwent either primary or revision endoscopic frontal sinus surgery. The average ± standard deviation (SD) length of follow-up was 20.8 ± 18.7 (95% confidence interval [CI], 18.0-22.9) months. Postsurgical recurrence of disease with persistence of symptoms requiring an EMLP occurred in 9 patients in the primary group and 38 in the revision group. The highest risk groups for failure of standard frontal sinusotomy were patients with nasal polyps, asthma, Lund-Mackay score >16, and frontal ostium size <4 mm (relative risk = 9.9, p < 0.0001)., Conclusion: Patients with underlying asthma and polyposis as well as narrow frontal ostia and extensive radiological disease have a high failure rate from standard endoscopic frontal sinusotomy. In this patient group consideration should be given to offering the patient a primary EMLP procedure, which has excellent success rates with low risks and low morbidity., (© 2013 ARS-AAOA, LLC.)

Objective: Bronchial thermoplasty (BT) can provide relief for patients with severe, uncontrolled asthma despite maximal medical therapy. However, it is unclear whether BT is safe in patients with very severe airflow obstruction., Methods: We performed BT in eight patients with severe asthma as defined by Expert Panel Report 3 (EPR-3) guidelines who were poorly controlled despite step 5 therapy. Data were available on each subject for 1 year prior to and 15-72 weeks following BT., Results: The mean (±SEM) pre-bronchodilator forced expiratory volume in one second (FEV(1)) prior to BT was 51.8 ± 8.6% of predicted, and the mean (±SEM) number of hospitalizations for asthma in the year prior to BT was 2.9 ± 1.2. No subject had an unexpected severe adverse event due to BT. Among the eight patients with follow-up of at least 15 weeks, there was no significant decline in FEV(1) (p = .4)., Conclusion: We suggest that BT may be safe for asthma patients with severe airflow obstruction and higher hospitalization rates than previously reported.

A 2 yr old castrated male cat presented to an emergency referral facility for several episodes of gagging, nonproductive coughing, and increased respiratory effort. He was diagnosed with inspiratory stridor and referred to another emergency referral practice for further diagnostics. Three separate, sedated oral examinations, nasal computed tomography (CT), rhinoscopic biopsies, and tracheoscopy showed no structural causes for the cat's stridor. An endotracheal wash was consistent with feline asthma. Blood work showed a peripheral eosinophilia and exposure to Dirofilaria immitis (D. immitis). The feline asthma was treated with albuterol, fluticasone, dexamethasone sodium phosphate, and terbutaline. Despite aggressive therapy for feline asthma, the cat had several episodes of severe inspiratory respiratory distress and stridor secondary to an upper airway obstruction. After 3 days of hospitalization, a temporary tracheostomy was performed and no further episodes of respiratory distress were noted. The tracheostomy tube was removed 3 days later, and the cat was discharged on the fourth day. At a 14 mo follow-up examination, the client reported no further episodes of respiratory distress, coughing, or gagging. To the authors' knowledge, this is the first report of dynamic upper airway obstruction secondary to feline asthma.

Introduction: Obesity and asthma have become increasingly prevalent conditions in recent years; they often coexist and place a significant burden on the National Health Service. Asthma in the obese is more difficult to treat than in those with a normal body mass index (BMI) and is associated with resistance to traditional asthma therapies and increased use of healthcare resources. Weight loss can improve asthma control in such patients. The degree of weight loss achieved through dietary strategies, however, is often only modestly successful in this group. Bariatric surgery is increasingly used to achieve sustained significant weight loss in morbid obesity. It may offer under-recognized benefit in the difficult asthma-obesity phenotype., Case Study: We describe the case of a 32-year-old female with difficult asthma who had a BMI of 45 kg/m(2) at the time of referral to our clinic. Her asthma was uncontrolled despite maximal inhaled therapy, oral therapy with Zafirlukast, and daily high-dose (25 mg) oral prednisolone. Additional therapies (subcutaneous Terbutaline and the steroid-sparing agent Methotrexate) had little impact on asthma control and she remained morbidly obese. She underwent gastric bypass surgery and, over the following 18 months, her BMI dropped to 27.7 kg/m(2), her corticosteroid dose was reduced to 7.5 mg (adrenal insufficiency proven), and maintenance inhaled therapy and oral medications were stopped as she maintained good asthma control., Conclusion: This case demonstrates the dramatic improvement that bariatric surgery can have on asthma symptoms and medication use in morbidly obese patients with very difficult to control asthma.

Objectives/hypothesis: Patients with aggressive nasal polyp recurrence form an important subgroup of patients with refractory sinus disease. The objectives of this study were to establish patterns of polyp recurrence and evaluate the effect of frontal sinus surgery (Draf 2a vs. Draf 3) on polyp recurrence., Study Design: Retrospective cohort study reviewing 338 consecutive operations., Methods: Polyp recurrence was defined according to the Lund-Kennedy mucosal edema score. Survival analysis methods were used for statistics., Results: After complete sphenoethmoidectomies, Draf 2a frontal sinusotomies, and middle meatal antrostomies persistent polyp recurrence occurred in 19.8% of patients after 6 months and increased to 22.7% of patients after 12 months. Polyps first recurred in the area of the frontal sinus/ostium (55%) followed by the ethmoids (38%). Asthma and aspirin sensitivity were the most important variables affecting recurrence (hazard ratios, 1.71, 1.79, respectively; P < .05) The Draf 3 procedure was a significant factor in reducing recurrence, especially in asthma and aspirin intolerant patients. The overall revision rate was 18% (follow-up duration >12 months, median = 29 months), with a 37% revision rate in the FESS group versus 7% in the Draf 3 group (P < .001). Survival analysis showed that the Draf 3 significantly reduced the risk of revision (hazard ratio = 0.258, P = .0026)., Conclusions: Nasal polyposis is characterized by a high rate of recurrence. The presence of asthma or aspirin intolerance leads to more aggressive recurrence, and in these patients the Draf 3 drillout procedure becomes a good option for improved long-term outcomes and reducing the need for revision surgery., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Asthma is one of the most common conditions seen in clinical practice and carries both a significant disease burden in terms of patient morbidity and a high economic burden in both direct and indirect costs. Despite this, it remains a comparatively poorly understood disease, with only modest advances in treatment over the past decade. Corticosteroids remain the cornerstone of therapy. Both patient compliance with medications and physician adherence to evidence-based guidelines are often poor, and a high percentage of patients continue to have inadequately controlled disease even with optimal therapy. Following a contextual overview of the current treatment guidelines, this review focuses on novel asthma therapies, beginning with the introduction of the leukotriene receptor antagonist zafirlukast in the 1990s, continuing through advanced endoscopic therapy and into cytokine-directed biologic agents currently in development. Along with clinically relevant biochemistry and pharmacology, the evidence supporting the place of these therapies in current guidelines will be highlighted along with data comparing these agents with more conventional treatment. A brief discussion of other drugs, such as those developed for unrelated conditions and subsequently examined as potential asthma therapies, is included.

Background/aim: To evaluate the role of epidemiologic factors in surgical outcomes for patients with nasal polyposis (NP) and asthma., Methods: Data was prospectively collected on patients who underwent endoscopic sinus surgery over a 7-year period. Among patients with chronic rhinosinusitis (CRS) with NP and asthma, surgical outcomes were analyzed according to gender and race., Results: Patients with NP and asthma had significantly higher Lund-Kennedy and SNOT-20 scores--pre- and postoperatively--compared to CRS patients without NP or asthma. Both Caucasians and African-Americans in the CRS with NP/asthma group showed a statistically significant improvement at 6 months. Caucasians continued to have a significant improvement at 12 months, whereas African-Americans did not. There were no differences according to gender., Conclusion: In our patient population, African-Americans with NP and asthma had poorer outcomes following functional endoscopic sinus surgery., (© 2013 S. Karger AG, Basel.)

We previously found that mesenchymal stem cells (MSCs) derived from human-induced pluripotent stem cells (iPSCs) exerted immunomodulatory effects on Th2-mediated allergic rhinitis in vitro. However, their contribution to the asthma and allergic rhinitis in animal models remains unclear. In this study, we developed a mouse model of ovalbumin (OVA)-induced allergic inflammation in both the upper and lower airways and evaluated the effects of the systemic administration of human iPSC-MSCs and bone marrow-derived MSCs (BM-MSCs) on allergic inflammation. Our results showed that treatments with both the iPSC-MSCs and BM-MSCs before the challenge phase protected the animals from the majority of allergy-specific pathological changes. This protection included an inhibition of inflammatory cell infiltration and mucus production in the lung, a reduction in eosinophil infiltration in the nose, and a decrease in inflammatory cell infiltration in both the bronchoalveolar and nasal lavage fluids. In addition, treatment with iPSC-MSCs or BM-MSCs before the challenge phase resulted in reduced serum levels of Th2 immunoglobulins (e.g., IgE) and decreased levels of Th2 cytokines including interleukin (IL)-4, IL-5, or IL-13 in the bronchoalveolar and/or nasal lavage fluids. Similar therapeutic effects were observed when the animals were pretreated with human iPSC-MSCs before the sensitization phase. These data suggest that iPSC-MSCs may be used as an alternative strategy to adult MSCs in the treatment of asthma and allergic rhinitis., (Copyright © 2012 AlphaMed Press.)

Patients with severe asthma represent only a minority of the total asthma population; however, they account for the majority of the mortality, morbidity, and health care-related cost of this chronic illness. Bronchial thermoplasty is a novel treatment modality that employs radiofrequency energy to alter the smooth muscles of the airways. This therapy represents a radical change in our treatment paradigm from daily repetitive dosing of medications to a truly long-term and potentially permanent attenuation of perhaps the most feared component of asthma--smooth muscle-induced bronchospasm. A large, multicentered, double-blinded, randomized controlled trial employed the unprecedented (but now industry standard for bronchoscopic studies) approach of using sham bronchoscopy as a control. It demonstrated that bronchial thermoplasty is safe, improved quality of life, and decreased frequency of severe exacerbations in the treatment group compared to the control group. Although the mechanism of action of bronchial thermoplasty is not currently completely understood, it should be considered as a valid and potentially valuable option for patients who have severe persistent asthma and who remain symptomatic despite inhaled corticosteroids and long-acting beta-2 agonists. Such patients should however be carefully evaluated at centers with expertise in managing severe asthma patients and with physicians who have experience with this promising new treatment modality.

Patients with severe asthma have considerable morbidity related to their asthma and are at risk for serious, life-threatening exacerbations. Their management requires an intensive and comprehensive approach, including attention to reducing exposure to environmental inciters of airway inflammation and triggers of symptoms, patient education (including an asthma action plan), and opportunity for close patient-provider communication. Approved medical options include the lipoxygenase inhibitor, zileuton; the anti-immunoglobulin E monoclonal antibody, omalizumab; and bronchial thermoplasty. Nonapproved interventions of potential benefit are ultrahigh-dose inhaled corticosteroids, anticholinergic bronchodilators (tiotropium), macrolide antibiotics, and vitamin D supplementation for the vitamin D-deficient patient. Potentially toxic, "steroid-sparing" therapies such as methotrexate, cyclosporine, and etanercept are best reserved for patients participating in clinical trials. Recognition of specific subtypes of patients with therapy-resistant asthma permits more targeted treatment approaches, such as for aspirin-sensitive asthma, persistent eosinophilic asthma, asthma complicated by allergic bronchopulmonary aspergillosis, asthma with persistent airflow obstruction, and asthma with life-threatening (near fatal) asthmatic attacks. Novel therapies based on an improved understanding of the pathobiology of therapy-resistant asthma are greatly needed.

Introduction: Severe persistent asthma is a disabling condition associated with significant morbidity and rising mortality worldwide. The recent advent of bronchial thermoplasty (BT) has offered a revolutionary therapeutic option for the treatment of severe persistent asthma. This minimally invasive bronchoscopic procedure focuses on anatomical manipulation of bronchial smooth muscle to attenuate airway hyperresponsiveness., Case Report: This case report describes treatment of a 42-year-old female with BT for her debilitating asthma. Following a complicated treatment course of BT, she attained significant relief from her symptoms and had noticeably improved functionality., Conclusion: This case represents BT success and a change to the traditional paradigm governing the treatment of refractory asthma.

Purpose of Review: Bronchial thermoplasty, which involves the delivery of radio frequency energy to the airways to reduce airway smooth muscle mass, has been recently introduced for the treatment of severe asthma. This review summarizes the preclinical development, efficacy and adverse effects of bronchial thermoplasty. In addition, the potential mechanisms of action and place in management of severe asthma are discussed., Recent Findings: The efficacy and adverse profile of bronchial thermoplasty has been assessed in three randomized controlled trials, the first two of which showed clinical benefits of bronchial thermoplasty compared with usual care in patients with moderate or severe asthma. The third trial reports the results of a comparison with sham bronchial thermoplasty in 288 adults with severe asthma. Bronchial thermoplasty improved asthma quality of life questionnaire scores compared with sham bronchial thermoplasty; in the posttreatment period, there were fewer severe exacerbations and emergency department visits. Bronchial thermoplasty causes short-term increases in asthma-related morbidity. Follow-up data to date support the long-term safety of the procedure., Summary: Bronchial thermoplasty has a role in the management of patients with severe asthma who have uncontrolled symptoms despite current therapies. Future studies need to identify factors that predict a beneficial clinical response.

Bronchial thermoplasty is a new technique proposed to improve control of moderate to severe asthma. It delivers thermal energy to the large airways during a bronchoscopy to decrease the amount of bronchial smooth muscle. This intervention has been shown to reduce asthma exacerbations, and improve asthma control and quality of life over a three-year period without significant complications up to a five-year period. It could be considered as another option in the treatment of selected patients requiring oral and⁄or high doses of inhaled corticosteroids to control asthma. It should, however, be performed in specialized centres in patients who understand the potential benefits and side-effects of this technique. The response to this treatment varies from one patient to another. Consequently, further studies are required to better define the role of this option in the treatment of asthma.

Bronchial thermoplasty (BT) is a novel treatment of patients with severe asthma who continue to be symptomatic despite maximal medical treatment. It aims to reduce the smooth muscle mass in the airways by delivering controlled thermal energy to the airway walls during a series of three bronchoscopies. Randomized controlled clinical trials of BT in severe asthma have not been able to show a reduction in airway hyperresponsiveness or change in FEV(1) but have suggested an improvement in quality of life, as well as a reduction in the rate of severe exacerbations, emergency department visits, and days lost from school or work. Strict inclusion and exclusion criteria of these trials resulted in the elimination of patients with severe asthma who experienced more than three exacerbations per year. Therefore, the generalizability of this treatment to the broader severe asthma population still needs to be determined. The short-term adverse events consist primarily of airway inflammation and occasionally more severe events requiring hospitalization. Long-term safety data are evolving and have shown thus far clinical and functional stability up to 5 years after BT treatment. Additional studies on BT are needed to establish accurate phenotyping of positive responders, durability of effect, and long-term safety.

Background: Patients undergoing endoscopic sinus surgery (ESS) are at risk of complications because of the close proximity of the sinuses to the orbit and anterior skull base. The aim of this study was to evaluate the complications of ESS and to identify patient characteristics that were risk factors for the complications., Methods: We conducted a prospective study of 706 patients who underwent ESS for chronic rhinosinusitis. Patients completed preoperative examinations that included computed tomography, endoscopic observation for nasal polyps, and tests for comorbidities including asthma and vascular disease. Perioperative complications were evaluated based on information provided by the surgeons. Multivariate analysis was performed to identify patient characteristics that were risk factors for complications., Results: Overall, perioperative complications occurred in 41 patients (5.8%). A major complication, cerebrospinal fluid leakage, occurred in one patient (0.1%). Minor complications occurred in 40 patients (5.7%), with the most common being intraoperative hemorrhage (n = 18). Multivariate analysis indicated that presence of asthma and the total polyp score correlated significantly with the occurrence of complications., Conclusion: The risk factors for perioperative complications were asthma and the polyp score. We conclude that the surgeon should confirm whether the patient has lower airway disease, especially asthma, before operating. The surgeon should also determine the grade of nasal polyps.