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Effectiveness and Safety of Bronchial Thermoplasty in Management of Asthma

Systematic Review

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Key Messages

Purpose of Review

To evaluate the effectiveness and safety of bronchial thermoplasty (BT), a procedure that uses heat to remove muscle tissue from the airways of adults with moderate to severe asthma. BT is usually given as three treatments 3 weeks apart.

Key Messages

  • BT along with standard medical management, compared to medical management alone, may improve asthma control and quality of life, but evidence is insufficient to determine impact on asthma exacerbations.
  • BT along with standard medical management, compared to a similar procedure without the heat (sham procedure), does not improve asthma control or hospitalizations but may reduce severe exacerbations and emergency room visits.
  • BT causes more adverse events (such as worsening of asthma symptoms, respiratory infections, and coughing up blood) during the treatment period than standard treatment. Based on the available literature, there is still uncertainty about the balance of benefits and harms, and about which patients are most likely to benefit from the procedure.

Structured Abstract

Objective. This review assesses the effectiveness and safety of bronchial thermoplasty (BT) in adults with asthma.

Data sources. We systematically searched the gray literature and five bibliographic databases, MEDLINE®, Embase®, PubMed®, CINAHL®, and the Cochrane Library, through April 20, 2017.

Review methods. Eligible studies included systematic reviews, meta-analyses, randomized controlled trials (RCTs), and nonrandomized interventional studies with concurrent controls. Case reports and series were also considered for describing adverse events. Studies were evaluated for risk of bias using the Cochrane Risk of Bias instrument, and the evidence base was assessed using the methods guidance established by the Evidence-based Practice Center program.

Results. Fifteen studies, including three RCTs with 5-year single-arm followup in BT-treated patients (n=432 for the RCTs), examined the impact of BT in addition to standard care (continued medical management) on patients with asthma. BT and standard care improved asthma control (defined by the Asthma Control Questionnaire [ACQ] change from baseline to 12 months) and Asthma Quality of Life Questionnaire (AQLQ) scores more than standard care alone to a degree that was statistically significant but not clinically important (low strength of evidence [SOE]). However, BT and standard care, compared with a sham bronchoscopic procedure and standard care, did not improve asthma control (defined as ACQ change from baseline to 12 months), hospitalizations for respiratory symptoms, use of rescue medications, pulmonary physiology measures, or AQLQ scores (in the intention-to-treat analysis) (low SOE). In the same sham-controlled trial, BT reduced severe exacerbations after the 12-week treatment period to a statistically but not clinically important degree (low SOE), and patients undergoing BT had fewer emergency department visits than patients who had the sham bronchoscopic procedure (moderate SOE). In the RCTs comparing BT and standard care to standard care alone, evidence was insufficient to assess if BT reduced rates of severe exacerbations.
Common adverse events following BT during the 12-week treatment period in the RCTs included bronchial irritation, chest discomfort, cough, discolored sputum, dyspnea, night awakenings, and wheezing. Hospitalizations were more common in patients undergoing BT than with either standard care alone or sham bronchoscopy during the 12-week treatment period, as were upper respiratory tract infections, wheezing, dyspnea, lower respiratory tract infections, anxiety, and segmental atelectasis, but the events were too infrequent to achieve statistical significance. Severe adverse events (including post-procedure segmental atelectasis due to mucus plugging, hemoptysis, chest infections requiring hospitalization, and bronchial artery pseudoaneurysm) were also reported in six case reports and two small case series. Following the 12-week treatment period, rates of respiratory-related hospitalizations were not significantly different between groups for up to 5 years of followup. No deaths were attributed to BT.

Conclusions. While asthma control and quality of life measures modestly improved in patients undergoing BT compared to medical management alone in two controlled but nonblinded studies, these measures did not improve in the sham-controlled study. The sham-controlled, blinded study found modest improvements in severe exacerbations and significantly fewer viii
emergency department visits following BT compared to the sham bronchoscopic procedure, but serious adverse events and post-procedure hospitalizations were more common during the 12-week treatment period in patients undergoing BT than in patients undergoing sham treatment. The available body of literature on BT is small and uncertainty remains about appropriate patient selection criteria and the effects of the treatment beyond 5 years.

Citation

D’Anci KE, Lynch MP, Leas BF, Apter AJ, Bryant-Stephens T, Kaczmarek JL, Umscheid CA, Schoelles K. Effectiveness and Safety of Bronchial Thermoplasty in Management of Asthma. Comparative Effectiveness Review No. 202. (Prepared by the ECRI Institute–Penn Medicine Evidence-based Practice Center under Contract No. 290-2015-00005-I.) AHRQ Publication No. 18-EHC003-EF. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. www.effectivehealthcare.ahrq.gov/reports/final.cfm. DOI: https://doi.org/10.23970/AHRQEPCCER202.