Bronchial Thermoplasty for Severe Asthma: A Review of the Clinical and Cost-Effectiveness, and Guidelines

Juan Carlos Ivancevich Tuesday, 03 January 2017 22:52

Rapid Response Report: Summary with Critical Appraisal

Severe asthma is a chronic condition in which patients experience airway inflammation and airway muscle contraction leading to symptoms of breathlessness, wheezing, coughing, and chest tightness. It is one of the most common chronic conditions with an estimated 235 million people affected worldwide, an increasing global prevalence, and a lifetime of impacts on healthcare systems. Exacerbations of this condition can be serious, negatively impact patient quality of life, require hospitalization and emergency department (ED) services. The standard approach to care employs regular maintenance medications, usually inhaled corticosteroids (ICS) and a long-acting β2-agonist (LABA), while other medications may also be used including omalizumab and oral corticosteroids. Bronchial thermoplasty (BT) is an endoscopic therapy, the first nonpharmacologic intervention approved by Health Canada for the treatment of severe asthma. BT employs radiofrequency energy pulses to selectively reduce the thicker airway smooth muscle found in asthmatic patients. This selective ablation is thought to reduce airway hyper-responsiveness, airway obstruction, and asthma symptoms. Further research is required to help more clearly determine the mechanisms of action of bronchial thermoplasty. Limitations of the technique include the inability to treat distal symptomatic airways due to their small diameter, and contraindications for patients with implanted medical devices.

This report is an update to a previous Canadian Agency for Drugs and Technologies in Health (CADTH) Rapid Response Report published in March 2014 that provided a summary of abstracts on bronchial thermoplasty. The purpose of this report is to retrieve and review the current evidence from full text articles of clinical efficacy, safety, and cost-effectiveness of BT. In addition this report aims to retrieve and review existing guidelines on the use of BT for the treatment of severe asthma.

Fatal asthma; is it still an epidemic?

Juan Carlos Ivancevich Tuesday, 03 January 2017 22:41
Logo of waoj BioMed Central search submit a manuscript register this article World Allergy Organization Journal

Abstract

Background

Asthma mortality has declined since the 1980s. Nevertheless the World Health Organization (WHO) identified asthma as responsible for 225.000 deaths worldwide in 2005, and 430.000 fatal cases are expected by 2030. Some unexpected and concentrated fatal asthma events all occurred between 2013 and 2015 in Veneto, a North Eastern region of Italy, which prompted a more in-depth investigation of characteristics and risk factors.

Methods

A web search including key words related to fatal asthma in Italy between 2013 and 2015 has been performed. Concerning the cases that occurred in Veneto, subjects’ clinical records have been evaluated and details about concomitant weather conditions, pollutants and pollen count have been collected.

Results

Twenty-three cases of asthma deaths were found in Italy; 16 of them (69%) occurred in the Veneto Region. A prevalence of male and young age was observed. Most of patients were atopic, died in the night-time hours and during the weekends. The possible risk factors identified were the sensitization to alternaria, previous near fatal asthma attacks and the incorrect treatment of the disease. Weather condition did not appear to be related to the fatal exacerbations, whereas among the pollutants only ozone was detected over the accepted limits. Smoking habits, possible drug abuse and concomitant complementary therapies might be regarded as further risk factors.

Discussion

Although not free from potential biases, our web search and further investigations highlight an increasing asthma mortality trend, similarly to what other observatories report. The analysis of available clinical data suggests that the lack of treatment more than a severe asthma phenotype characterizes the fatal events.

Conclusions

Asthma mortality still represents a critical issue in the management of the disease, particularly in youngsters. Once more the inadequate treatment and the lack of adherence seem to be not only related to the uncontrolled asthma but also to asthma mortality.

Formats:

Article  PubReader  ePub (beta)  PDF (3.2M)  Citation

 

Suicidal ideation and suicide attempts among asthma

Juan Carlos Ivancevich Friday, 16 December 2016 13:01

Abstract

BACKGROUND:

The present study aimed to investigate the mental health status in patients with asthma and assess the effects of asthma on suicidal ideation and attempts using a representative sample from Korea.

METHODS:

Individual-level data were obtained from 228,744 participants (6372 with asthma and 222,372 without asthma) of the 2013 Korean Community Health Survey. Demographic characteristics, socioeconomic status, physical health status, and mental health status were compared between patients with asthma and population without asthma. Multivariable logistic regression was performed to investigate the independent effects of the asthma on suicidal ideation and attempts.

RESULTS:

A depressed mood for 2 or more continuous weeks was reported by 12.0% of subjects with asthma and 5.7% of controls (p < 0.001). Suicidal thoughts were reported by 21.4% of patients with asthma and 9.8% of controls (p < 0.001). Suicidal attempts were reported by 1.0% of the patients with asthma and 0.4% of controls (p < 0.001). Following adjustment for age, sex, income, education, job, marital status, smoking, alcohol, exercise, and presence of diabetes mellitus, hypertension, stroke, arthritis, and depression, the ORs for suicidal ideation with asthma were 1.53 (95% CI 1.42-1.65) and that for suicidal attempts was 1.32 (95% CI 1.01-1.73).

CONCLUSIONS:

We found that asthma increased the risk for suicidal ideation and attempts, even controlling for the effects of socioeconomic status, physical health status, comorbid chronic medical diseases, and depressive mood. Our finding suggests that asthma per se may be an independent risk factor for suicidality.

Formats:

Article PubReader ePub (beta) PDF (762K) Citation

Prenatal exposure to selenium may protect against wheezing in children by the age of 3

Juan Carlos Ivancevich Sunday, 18 December 2016 16:21

Early View
Immunity, Inflammation and Disease

Browse  Early View Articles 

Original Research


Authors: Nour Baïz, Julie Chastang, Gladys Ibanez, Isabella Annesi-Maesano

Abstract

Introduction

It has been suggested that human in utero exposure to heavy metals such as selenium can reduce the prevalence of childhood asthma and allergic diseases. However, data on this topic are scarce. The objective of the present study was to assess the putative associations between maternal selenium level during pregnancy and the risk of asthma, wheezing, allergic rhinitis, and atopic dermatitis in children from the EDEN birth cohort by the age of 1 and 3 years.

Methods

Plasma selenium concentrations were measured in maternal blood during mid-pregnancy (24–28 weeks of gestation) in 861 mothers. Cohort children were followed up from birth to 3 years using health questionnaires filled out by the parents for asthma, wheezing, allergic rhinitis, and atopic dermatitis. Maternal plasma selenium was related to the childhood outcomes by the age of 1 and 3 years.

Results

Our results showed a significant negative association between a high maternal plasma selenium level during pregnancy and the risk of wheezing in the child by the age of 1 and 3 years. However, maternal plasma selenium during pregnancy was not associated with the prevalence of asthma, allergic rhinitis or atopic dermatitis.

Conclusions

The results of this study suggest that the level of fetal exposure to maternal selenium could have an influence on the risk of wheezing in infancy and potentially on the risk of developing asthma later in life.

Abstract
Introduction
Materials and Methods
Results
Discussion
Conclusion
Acknowledgments
Conflict of Interest

References
Related Content

Procedural and short-term safety of bronchial thermoplasty in clinical practice: evidence from a national registry and Hospital Episode Statistics.

Juan Carlos Ivancevich Tuesday, 13 December 2016 13:10
J Asthma. 2016 Dec 1:0. [Epub ahead of print]
 

Abstract

OBJECTIVE: Bronchial thermoplasty (BT) is a novel treatment for severe asthma. Its mode of action and ideal target patient group remain poorly defined, though clinical trials provided some evidence on efficacy and safety. This study presents procedural and short-term safety evidence from routine UK clinical practice.

METHODS: Patient characteristics and safety outcomes (procedural complications, 30-day readmission and A&E attendance, length of stay) were assessed using two independent data sources, the British Thoracic Society UK Difficult Asthma Registry (DAR) and Hospital Episodes Statistics (HES) database. A matched cohort (with records in both) was used to estimate safety outcome event rates and compare them with clinical trials.

RESULTS: Between June 2011 and January 2015, 215 procedure records (83 patients, of whom 68 were treated in England) were available from DAR and 203 (85 patients) from HES. 152 procedures matched (59 patients; 6 centres), and of these, 11.2% reported a procedural complication, 11.8% resulted in emergency respiratory readmission and 0.7% in respiratory A&E attendance within 30 days (20.4% had at least one event); 46.1% involved a post-procedure stay. Compared with published clinical trials which found lower hospitalisation rates, BT patients in routine clinical practice were, on average, older, had worse baseline FEV1 and lower AQLQ scores.

CONCLUSIONS: A higher proportion of patients experienced adverse events compared with clinical trials. The greater severity of disease amongst patients treated in clinical practice may explain the observed rate of post-procedural stay and readmission. Continued data collection will allow long-term safety and efficacy to be studied.

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Editor: Juan C. Ivancevich, MD

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