Brian Lipworth
Bronchial Thermoplasty (BT) for severe asthma was recently endorsed by NICE.
To be up front I am not a big fan of BT. I was asked to do an interview with BBC which I declined. You can read all the trials for yourself and make your own mind up.
Fundamentally my issue here is that BT does not deal with the underlying inflammatory problem in severe T2 high asthma. It is not something I would consider for T2 high oral corticosteroid (OCS) dependent patients where biologics are the way to go. So we are really talking about BT being used for refractory T2 low asthma (i.e. low Eos, low IgE, low FeNO) where there is a big unmet need – despite known adherence to maximum prescription dose of high dose inhaled corticosteroid, long-acting beta-agonists or long-acting muscarinic antagonists +/- leukotriene receptor antagonist, theophylline.
No doubt there is a big placebo effect involved with having a bronchoscopy under sedation in theatre with your pulmonologist in greens.
Conclusion
BT may have a niche role for a few pts with refractory severe T2 low asthma who have evidence of airway remodelling and who have adhered to but not responded to maximum prescription doses. I suspect in years to come we will look back on BT like using hot-wire cautery for treating severe persistent allergic rhinitis i.e. it is a bit medieval.
Surely the tenet is to treat the underlying inflammation and now with biologics, we have the tools to effectively do this.
Professor Brian Lipworth is the head of Scottish Respiratory Research.