Abstract
BackgroundIn randomized controlled trials, bronchial thermoplasty (BT) has been proven to reduce symptoms in severe asthma, but the mechanisms by which this is achieved are uncertain as most studies have shown no improvement in spirometry. We postulated that BT might improve lung mechanics by altering airway resistance in the small airways of the lung in ways not measured by FEV1. This study aimed to evaluate changes in measures of gas trapping by body plethysmography.MethodsA prospective cohort of 32 consecutive patients with severe asthma who were listed for BT at two Australian university hospitals were evaluated at three time points, namely baseline, and then 6 weeks and 6 months post completion of all procedures. At each evaluation, medication usage, symptom scores (Asthma Control Questionnaire, ACQ-5) and exacerbation history were obtained, and lung function was evaluated by (i) spirometry (ii) gas diffusion (KCO) and (iii) static lung volumes by body plethysmography.ResultsACQ-5 improved from 3.0 ± 0.8 at baseline to 1.5 ± 0.9 at 6 months (mean ± SD, p < 0.001, paired t-test). Daily salbutamol usage improved from 8.3 ± 5.6 to 3.5 ± 4.3 puffs per day (p < 0.001). Oral corticosteroid requiring exacerbations reduced from 2.5 ± 2.0 in the 6 months prior to BT, to 0.6 ± 1.3 in the 6 months after BT (p < 0.001). The mean baseline FEV1 was 57.8 ± 18.9%predicted, but no changes in any spirometric parameter were observed after BT. KCO was also unaltered by BT. A significant reduction in gas trapping was observed with Residual Volume (RV) falling from 146 ± 37% predicted at baseline to 136 ± 29%predicted 6 months after BT (p < 0.005). Significant improvements in TLC and FRC were also observed. These changes were evident at the 6 week time period and maintained at 6 months. The change in RV was inversely correlated with the baseline FEV1 (r = 0.572, p = 0.001), and in patients with a baseline FEV1 of < 60%predicted, the RV/TLC ratio fell by 6.5 ± 8.9%.ConclusionBronchial thermoplasty improves gas trapping and this effect is greatest in the most severely obstructed patients. The improvement may relate to changes in the mechanical properties of small airways that are not measured with spirometry.
Highlights
In randomized controlled trials, bronchial thermoplasty (BT) has been proven to reduce symptoms in severe asthma, but the mechanisms by which this is achieved are uncertain as most studies have shown no improvement in spirometry
The improvement may relate to changes in the mechanical properties of small airways that are not measured with spirometry
That large numbers of asthmatic patients in a controlled clinical trial can experience an improvement in their symptoms and quality life, without improvement in physiological parameters such as Forced expiratory volume in 1 s (FEV1)? One explanation might lie in the placebo effect, known to be a powerful force in surgical treatment [9]
Summary
Bronchial thermoplasty (BT) has been proven to reduce symptoms in severe asthma, but the mechanisms by which this is achieved are uncertain as most studies have shown no improvement in spirometry. Radiofrequency thermal impulses are delivered to airways ranging in size from 2 to 10 mm, with the intention of inducing atrophy in hypertrophied airway smooth muscle Histological studies in both canine and humans have demonstrated that this occurs [2,3,4,5]. Three randomized controlled trials have established that patients feel better after this treatment, with fewer asthma symptoms, reduced exacerbations and improved quality of life [6,7,8]. Two of these three clinical trials showed no effect of BT on the one-second forced expiratory volume (FEV1) [6, 7]. An alternative hypothesis might be that BT leads to physiological changes which are not measured by spirometry - such as might occur in the peripheral airways
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