Emerging understanding of the mechanism of action of Bronchial Thermoplasty in asthma

Juan Carlos Ivancevich Tuesday, 22 August 2017 14:09
Elsevier Pharmacology & TherapeuticsAvailable online 27 July 201 In Press, Corrected Proof
Associate editor: J. Burgess

J.N.S.d'Hooghea. N.H.T.ten Hackenb. E.J.M.Weersinka. P.J.Sterka. J.T.Annemaa. P.I.Bontaa. 

Abstract

Bronchial Thermoplasty (BT) is an endoscopic treatment for moderate-to-severe asthma patients who are uncontrolled despite optimal medical therapy. Effectiveness of BT has been demonstrated in several randomized clinical trials. However, the asthma phenotype that benefits most of this treatment is unclear, partly because the mechanism of action is incompletely understood. BT was designed to reduce the amount of airway smooth muscle (ASM), but additional direct and indirect effects on airway pathophysiology are expected. This review will provide an overview of the different components of airway pathophysiology including remodeling, with the ASM as the key player. Current concepts in the understanding of BT clinical effectiveness with a focus on its impact on airway remodeling will be reviewed.

Abbreviations

ACQ asthma control questionnaire
AHR airway hyperresponsiveness
Anti-IL5 anti-interleukin 5
AQLQ asthma quality of life questionnaire
ASM airway smooth muscle
BAL bronchoalveolar lavage
BT Bronchial Thermoplasty
ECM extracellular matrix
ED emergency department
FEV1 forced expiratory volume in 1 s
GINA Global Initiative for Asthma
ICS inhaled corticosteroids
IL-4 interleukin-4
IL-5 interleukin-5
IL-6 interleukin-6
IL-13 interleukin-13
IL-17 interleukin-17
LABA long acting beta-agonist
NANC non-adrenergic, non-cholinergic
OCS oral corticosteroids
OCT optical coherence tomography
PC20 provocative concentration leading to a fall in FEV1 of 20%
RANTES Regulated on Activation Normal T Cell Expressed and Secreted
RBM reticular basement membrane
RCT randomized control trial
RF radio-frequency energy
RML right middle lobe
TGF-ß Transforming Growth Factor-Beta
TLD targeted lung denervation
TNFα tumour necrosis factor α

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Prognostic nomogram for inpatients with asthma exacerbation

Juan Carlos Ivancevich Monday, 07 August 2017 12:58

Wakae Hasegawa, Yasuhiro Yamauchi, Hideo Yasunaga, Hideyuki Takeshima, Yukiyo Sakamoto, Taisuke Jo, Yusuke Sasabuchi, Hiroki Matsui, Kiyohide Fushimi and Takahide Nagase

Background

Asthma exacerbation may require a visit to the emergency room as well as hospitalization and can occasionally be fatal. However, there is limited information about the prognostic factors for asthma exacerbation requiring hospitalization, and no methods are available to predict an inpatient’s prognosis. We investigated the clinical features and factors affecting in-hospital mortality of patients with asthma exacerbation and generated a nomogram to predict in-hospital death using a national inpatient database in Japan.

Methods

We retrospectively collected data concerning hospitalization of adult patients with asthma exacerbation between July 2010 and March 2013 using the Japanese Diagnosis Procedure Combination database. We recorded patient characteristics and performed Cox proportional hazards regression analysis to assess the factors associated with all-cause in-hospital mortality. Then, we constructed a nomogram to predict in-hospital death.

Results

A total of 19,684 patients with asthma exacerbation were identified; their mean age was 58.8 years (standard deviation, 19.7 years) and median length of hospital stay was 8 days (interquartile range, 5–12 days). Among study patients, 118 died in the hospital (0.6%). Factors associated with higher in-hospital mortality included older age, male sex, reduced level of consciousness, pneumonia, and heart failure. A nomogram was generated to predict the in-hospital death based on the existence of seven variables at admission. The nomogram allowed us to estimate the probability of in-hospital death, and the calibration plot based on these results was well fitted to predict the in-hospital prognosis.

Conclusion

Our nomogram allows physicians to predict individual risk of in-hospital death in patients with asthma exacerbation.

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Bronchial thermoplasty induces immunomodulation with a significant increase in pulmonary CD4+25+ regulatory T cells

Juan Carlos Ivancevich Wednesday, 02 August 2017 14:01
 
Abstract
Bronchial thermoplasty (BT) is a method of treating airways and randomized prospective trials have shown positive clinical effects of BT in patients with severe asthma.1 The mechanisms underlying BT airway treatment are not completely understood. Animal and human studies have shown that BT decreases airway smooth muscle mass and contraction.2 Because airway smooth muscle is a source of many proinflammatory factors and mediators, another result of BT could be the attenuation of airway inflammation.
 
 

Bronchial thermoplasty: implementing best practice in the era of cost containment

Juan Carlos Ivancevich Sunday, 06 August 2017 22:59

Journal of Asthma and Allergy » Volume 2017:10 Pages 225—230

Laren D Tan,1 Nicholas Kenyon,2 Ken Y Yoneda,2 Samuel Louie2

1Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA; 2Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, USA

Abstract: Increasing dependence on advanced technologies in the 21st century has created a dilemma between the practice and business of medicine. From information technology to robotic surgery, new technologies have expanded treatment possibilities and have potentially improved patient outcomes and safety. Simultaneously, their escalating costs limit access for certain patients and health care facilities. Nevertheless, medical decisions should not simply be based on cost. Input from physicians and other health care specialists as well as adherence to best practice position statements, are vital to implementing truly cost-effective strategies in medicine. Bronchial thermoplasty (BT), a US Food and Drug Administration approved bronchoscopy procedure in difficult-to-control persistent asthma, is a prime example of a new technology facing cost and implementation challenges. We discuss the specific indications and contraindications for BT and review recent real-world experiences that can provide the foundation for building a comprehensive asthma program that provides BT for difficult-to-control asthma patients who fail national guideline treatment recommendations after an adequate clinical trial of one. We also offer insight into the barriers to implementing a successful BT program and strategies for overcoming them.

Keywords: asthma, severe asthma, severe refractory asthma, biologic resistant asthma, BT

Creative Commons License This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.

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Specific allergen immunotherapy for the treatment of allergic asthma: a review of current evidence.

Juan Carlos Ivancevich Monday, 31 July 2017 21:07

J Investig Allergol Clin Immunol. 2017 Jun;27(Suppl. 1):1-352

Authors: Dominguez-Ortega J, Delgado J, Blanco C, Prieto L, Arroabarren E, Cimarra M, Henriquez-Santana A, Iglesias-Souto J, Vega-Chicote JM, Tabar AI

Abstract
Asthma is frequently associated with atopy, characterized by the production of specific immunoglobulin E in response to environmental allergens. Currently, two types of allergen immunotherapy (AIT) are used in clinical practice: subcutaneous and sublingual immunotherapy, both accepted as key components of the therapeutic repertoire for allergic rhinitis and conjunctivitis. However, their role in asthma remains controversial. The present document is aimed at providing the clinicians with a review of the evidence on the use of AIT in asthma, focusing on the most relevant aspects of its mechanism of action, its efficacy, and existing data on safety, tolerability, and cost-effectivity, both in pediatric and adult populations. A systematic search of MEDLINE, Cochrane, and Clinical Trials databases from 2000 to April of 2016 was carried out by a panel of experts from the Spanish Allergy and Clinical Immunology Scientific Society. Relevant studies prior to the year 2000 included in ulterior systematic reviews were also considered. More than 4000 articles were identified during the search and 241 were selected to retrieve available evidence on AIT, which was graded according to the Oxford classification. All the group members reviewed the resulting text until the final version reached the consensual agreement. A summary of recommendations on the more relevant topics are proposed. The role of AIT as a valuable therapeutic strategy for prevention of exacerbation and progressive decline in lung function is highlighted. Future research should include specific tools for asthma evaluation when assessing AIT effectiveness in asthmatic patients.

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Editor: Juan C. Ivancevich, MD

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