Effectiveness of bronchial thermoplasty in patients with severe refractory asthma: clinical and histopathological correlations

Juan Carlos Ivancevich Tuesday, 11 April 2017 13:19

JACI Journal Club

Asthma is a disease in which the airways of the lung become very sensitive to certain triggers, leading to spasms, in turn causing shortness of breath, coughing and wheezing.  The ultimate cause of asthma is unclear, but it has been shown in previous studies that there is remodeling of the airways in severe asthma. Airway smooth muscle (ASM) increases, along with fibrosis, infiltration of new blood vessels, and growth of cells that line the airways.   Recently, a procedure called bronchial thermoplasty (BT) has been developed, in which an endoscope is inserted into the airways.  This endoscope then delivers a temperature-controlled radio frequency to the airway wall.  In this month’s issue of JACI, Pretolani and colleagues look at bronchial thermoplasty and its effect on various clinical and histopathological findings (J Allergy Clin Immunol 2017; 139(4): 1176-1185).
In order to do this, they recruited 15 patients with severe uncontrolled asthma that did not respond to medications.  They looked at the symptoms through the Asthma Control Test (ACT) and the Asthma Quality of Life Questionnaire (AQLQ), as well as breathing patterns via spirometry and biopsy samples.  Bronchial thermoplasty was then performed.  At 3 and 12 months, the clinical and airway effects were examined.
What they found is that asthma control and quality of life increased considerably.  Exacerbations requiring oral steroids, emergency room visits, and hospitalizations were also decreased by approximately 90%.  Biopsy samples from 3 months showed a decrease in ASM size, as well as nerve fibers and neuroendocrine cells.
Based on these results, Pretolani and colleagues conclude that bronchial thermoplasty is an option for severe, uncontrolled, treatment refractory asthma.  Bronchial thermoplasty seems to affect the structure of airways, especially muscle size and nerve connections.  Targeting these structures, through thermoplasty or other means may be an effective way to help control these difficult-to-control cases.

Association between rhinovirus wheezing illness and the development of childhood asthma: a meta-analysis

Juan Carlos Ivancevich Monday, 10 April 2017 13:31
Lu LiuYilin PanYanting ZhuYang SongXiaofan SuLan Yang, Manxiang Li

Author affiliations: 

Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Xi'an Jiaotong UniversityXi'an, PR China
Correspondence to Dr Manxiang Li; This email address is being protected from spambots. You need JavaScript enabled to view it.


Objective The relation between early-life rhinovirus (RV) wheezing illness and later onset of wheezing/asthma remains a subject of debate. Therefore, we conducted this meta-analysis to evaluate the association between RV wheezing illness in the first 3 years of life and the subsequent development of wheezing/asthma.

Design Systematic review and meta-analysis.

Methods The PubMed, EMBASE, Web of Science, Chinese National Knowledge Infrastructure (CNKI) and Wanfang databases were systematically searched for studies published between 1988 and February 2017, and additional studies were found by searching reference lists of relevant articles. 2 reviewers independently extracted data and assessed the quality of each study. Results were pooled using fixed-effect models or random-effects models as appropriate.

Results The meta-analysis included 15 original articles which met the criteria, while 10 articles reported the results of 4 longitudinal cohort studies with different follow-up periods. RV wheezing illness in the first 3 years of life was associated with an increased risk of wheezing/asthma in later life (relative risk (RR)=2.00, 95% CI 1.62 to 2.49, p<0.001). In subgroup analysis by age at follow-up, the association still remained significant in <10 years (RR=2.02, 95% CI 1.70 to 2.39, p<0.001) and ≥10 years (RR=1.92, 95% CI 1.36 to 2.72, p<0.001).

Conclusions The meta-analysis suggests an association between RV-induced wheezing in the first 3 years of life and the subsequent development of wheezing/asthma. Large-scale and well-designed studies that adequately address concerns for potential confounding factors are required to validate the risk identified in the current meta-analysis.

Obstructive sleep apnoea accelerates FEV1 decline in asthmatic patients

Juan Carlos Ivancevich Monday, 27 March 2017 16:33
BMC Pulmonary Medicine
BMC series – open, inclusive and trusted 201717:55

DOI: 10.1186/s12890-017-0398-2

Tsai-Yu Wang, Yu-Lun Lo, Shu-Min Lin et al. 




Although the prevalence of both obstructive sleep apnoea (OSA) and asthma are both increasing, little is known about the impact of OSA on the natural history of lung function in asthmatic patients.


A total of 466 patients from our sleep laboratory were retrospectively enrolled. Of them, 77 patients (16.5%) had asthma with regular follow-up for more than 5 years. Their clinical characteristics, pulmonary function, emergency room visits, and results of polysomnography results were analysed.


The patients were divided into three groups according to the severity of the apnoea-hypopnea index (AHI). The decline in FEV1 among asthma patients with severe OSA (AHI > 30/h) was 72.4 ± 61.7 ml/year (N = 34), as compared to 41.9 ± 45.3 ml/year (N = 33, P = 0.020) in those with mild to moderate OSA (5 < AHI ≤ 30) and 24.3 ± 27.5 ml/year (N = 10, P = 0.016) in those without OSA (AHI ≤ 5). For those patients with severe OSA, the decline of FEV1 significantly decreased after continuous positive airway pressure (CPAP) treatment. After multivariate stepwise linear regression analysis, only AHI was remained independent factor for the decline of FEV1 decline.


Asthmatic patients with OSA had substantially greater declines in FEV1 than those without OSA. Moreover, CPAP treatment alleviated the decline of FEV1 in asthma patients with severe OSA.

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Social media use for occupational lung disease

Juan Carlos Ivancevich Wednesday, 29 March 2017 13:53

Harber, Philip; Leroy, Gondy

OCCUPATIONAL DISEASE: Edited by Susan M. Tarlo and Piero Maestrelli
Editor&apos;s Choice


The Internet and the World Wide Web (WWW) revolutionized information and data availability. The early WWW was one-directional; information spread from one website to a multitude of readers. Following this ‘static’ phase, Web 2.0 added user-generated content and social interaction. Social media both increase the scope of available data and provide new channels for sharing information. Facebook, Instagram, Twitter, and blogs are examples with impact on all aspects of modern personal life (e.g. Meetups and online dating) and business (e.g. Amazon) in both developed and developing countries. They create global awareness and interaction.

In medicine, the paternalistic patient–physician relationship has changed as patients inform themselves using information from many online sources including other patients. Health professionals themselves use the WWW to interact with their patients and with their peers. The WWW increasingly accumulates information from and about the public. Using electronic rather than print media, these methods very rapidly disseminate information from a single source to many persons. They are a platform for peer-to-peer (many-to-many) communication and a rich source of data for monitoring population health. Social media support research in two ways – analysis of publicly available WWW information not primarily intended for research and, second, through direct interaction, surveys, and experiments between the public and the researchers.

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Addition of anti-leukotriene agents to inhaled corticosteroids for adults and adolescents with persistent asthma

Juan Carlos Ivancevich Tuesday, 21 March 2017 11:12

Bhupendrasinh F Chauhan, Maya M Jeyaraman, Amrinder Singh Mann, Justin Lys, Ahmed M Abou-Setta, Ryan Zarychanski, Francine M Ducharme




Asthma management guidelines recommend low-dose inhaled corticosteroids (ICS) as first-line therapy for adults and adolescents with persistent asthma. The addition of anti-leukotriene agents to ICS offers a therapeutic option in cases of suboptimal control with daily ICS.


To assess the efficacy and safety of anti-leukotriene agents added to ICS compared with the same dose, an increased dose or a tapering dose of ICS (in both arms) for adults and adolescents 12 years of age and older with persistent asthma. Also, to determine whether any characteristics of participants or treatments might affect the magnitude of response.

Search methods

We identified relevant studies from the Cochrane Airways Group Specialised Register of Trials, which is derived from systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, the Allied and Complementary Medicine Database (AMED), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the trial registries clinicaltrials.gov and ICTRP from inception to August 2016.

Selection criteria

We searched for randomised controlled trials (RCTs) of adults and adolescents 12 years of age and older on a maintenance dose of ICS for whom investigators added anti-leukotrienes to the ICS and compared treatment with the same dose, an increased dose or a tapering dose of ICS for at least four weeks.

Data collection and analysis

We used standard methods expected by Cochrane. The primary outcome was the number of participants with exacerbations requiring oral corticosteroids (except when both groups tapered the dose of ICS, in which case the primary outcome was the % reduction in ICS dose from baseline with maintained asthma control). Secondary outcomes included markers of exacerbation, lung function, asthma control, quality of life, withdrawals and adverse events.

Main results

We included in the review 37 studies representing 6128 adult and adolescent participants (most with mild to moderate asthma). Investigators in these studies used three leukotriene receptor antagonists (LTRAs): montelukast (n = 24), zafirlukast (n = 11) and pranlukast (n = 2); studies lasted from four weeks to five years.

Anti-leukotrienes and ICS versus same dose of ICS

Of 16 eligible studies, 10 studies, representing 2364 adults and adolescents, contributed data. Anti-leukotriene agents given as adjunct therapy to ICS reduced by half the number of participants with exacerbations requiring oral corticosteroids (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.29 to 0.86; 815 participants; four studies; moderate quality); this is equivalent to a number needed to treat for additional beneficial outcome (NNTB) over six to 16 weeks of 22 (95% CI 16 to 75). Only one trial including 368 participants reported mortality and serious adverse events, but events were too infrequent for researchers to draw a conclusion. Four trials reported all adverse events, and the pooled result suggested little difference between groups (RR 1.06, 95% CI 0.92 to 1.22; 1024 participants; three studies; moderate quality). Investigators noted between-group differences favouring the addition of anti-leukotrienes for morning peak expiratory flow rate (PEFR), forced expiratory volume in one second (FEV1), asthma symptoms and night-time awakenings, but not for reduction in β2-agonist use or evening PEFR.

Anti-leukotrienes and ICS versus higher dose of ICS

Of 15 eligible studies, eight studies, representing 2008 adults and adolescents, contributed data. Results showed no statistically significant difference in the number of participants with exacerbations requiring oral corticosteroids (RR 0.90, 95% CI 0.58 to 1.39; 1779 participants; four studies; moderate quality) nor in all adverse events between groups (RR 0.96, 95% CI 0.89 to 1.03; 1899 participants; six studies; low quality). Three trials reported no deaths among 834 participants. Results showed no statistically significant differences in lung function tests including morning PEFR and FEV1 nor in asthma control measures including use of rescue β2-agonists or asthma symptom scores.

Anti-leukotrienes and ICS versus tapering dose of ICS

Seven studies, representing 1150 adults and adolescents, evaluated the combination of anti-leukotrienes and tapering-dose of ICS compared with tapering-dose of ICS alone and contributed data. Investigators observed no statistically significant difference in % change from baseline ICS dose (mean difference (MD) -3.05, 95% CI -8.13 to 2.03; 930 participants; four studies; moderate quality), number of participants with exacerbations requiring oral corticosteroids (RR 0.46, 95% CI 0.20 to 1.04; 542 participants; five studies; low quality) or all adverse events (RR 0.95, 95% CI 0.83 to 1.08; 1100 participants; six studies; moderate quality). Serious adverse events occurred more frequently among those taking anti-leukotrienes plus tapering ICS than in those taking tapering doses of ICS alone (RR 2.44, 95% CI 1.52 to 3.92; 621 participants; two studies; moderate quality), but deaths were too infrequent for researchers to draw any conclusions about mortality. Data showed no improvement in lung function nor in asthma control measures.

Authors' conclusions

For adolescents and adults with persistent asthma, with suboptimal asthma control with daily use of ICS, the addition of anti-leukotrienes is beneficial for reducing moderate and severe asthma exacerbations and for improving lung function and asthma control compared with the same dose of ICS. We cannot be certain that the addition of anti-leukotrienes is superior, inferior or equivalent to a higher dose of ICS. Scarce available evidence does not support anti-leukotrienes as an ICS sparing agent, and use of LTRAs was not associated with increased risk of withdrawals or adverse effects, with the exception of an increase in serious adverse events when the ICS dose was tapered. Information was insufficient for assessment of mortality.



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Editor: Juan C. Ivancevich, MD

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