Bronchial Thermoplasty for Severe Asthma: From Past to Present and Future

Background: Approximately 3-10% of all asthmatics are refractory with severe disease, although they use optimal preventive treatment. This is reflected as a disproportionate increase in the cost of health care. Thus, bronchial thermoplasty has been developed as an add-on therapy for these refractory asthmatics. Objective: This review aims to give an update on bronchial thermoplasty in severe asthma regarding pathophysiological mechanisms of action, patient selection, procedural details, history, evidence- based effectiveness, safety and cost-effectiveness, place in management, and challenges in current clinical practice. Methods: A thorough search for the eligible and recent studies and reviews on bronchial thermoplasty and asthma has been conducted in PubMed. Results: In bronchial thermoplasty, radiofrequency energy delivered to bronchial airway walls leads to ablation of the airway smooth muscles that cause bronchoconstriction. Several large trials and a real-world study confirm its safety, and effectiveness, as shown by considerable reduction in asthma exacerbations, emergency department visits and hospitalizations as well as improvement in asthma-related quality of life, maintained up to 5 years. These improvements are more significant in more severe airway obstruction. Bronchial thermoplasty is more cost-effective if hospitalization and emergency department care cost high, but the procedure costs low. Properly performed patient identification, implementation and follow-up are critical for successful and safe outcomes with the procedure. Conclusion: A 10-year research and clinical experience has proved the long-term safety, and effectiveness of bronchial thermoplasty for improving asthma control and quality of life in severe asthma. Predictors of response (e.g. biomarkers, responder endotype/phenotype) remain to be studied further and better qualified.