Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Bronchial Thermoplasty and Long-Term Asthma Outcomes

  Severe asthma can remain uncontrolled even when a person uses high-dose inhaled corticosteroids, long-acting bronchodilators and carefully selected add-on medicines. Frequent flare-ups, emergency visits, oral steroid courses and limitations on work or exercise may continue, particularly when airway inflammation is combined with fixed airway narrowing.

  Bronchial thermoplasty is a specialised procedure designed for some adults with persistent, severe asthma. It uses controlled radiofrequency energy to reduce excess airway smooth muscle during a series of bronchoscopies. The treatment does not replace preventer inhalers or biologic medicines, and its value depends on careful patient selection and long-term follow-up.

  How The Procedure Works

  Treatment is usually delivered in three sessions, with each session targeting a different region of the lungs. During bronchoscopy, a catheter applies thermal energy to accessible airways, reducing the amount of smooth muscle that can contract during bronchospasm. The procedure is performed under sedation or general anaesthesia, depending on the hospital and clinical circumstances.

  Temporary worsening of cough, wheeze, chest tightness or breathlessness is common after treatment. Some patients require additional observation, corticosteroids or an unplanned hospital review during the treatment period. For this reason, bronchial thermoplasty is generally considered only when asthma remains poorly controlled after inhaler technique, adherence, trigger management and other established therapies have been assessed.

  It is a structural treatment rather than a treatment aimed directly at a particular inflammatory biomarker. The same principle of matching treatment to disease biology underpins personalised medicine, although asthma decisions also depend on exacerbation history, lung function, comorbidities and previous response to medication.

  What Long-Term Studies Show

  The strongest long-term evidence comes from follow-up of the AIR2 study and related research. Participants who received bronchial thermoplasty generally maintained improvements in asthma-related quality of life and experienced fewer severe exacerbations and respiratory-related hospital presentations than before treatment. Benefits were observed over several years rather than disappearing soon after the procedure.

  Follow-up data have also suggested durable reductions in emergency department visits and courses of oral corticosteroids for many treated patients. However, these outcomes should be interpreted carefully. Long-term studies have often followed selected patients from specialist centres, and some follow-up designs lack a continuing sham-treatment comparison. Results therefore demonstrate sustained benefit for an appropriate group, rather than a guaranteed response for every person with severe asthma.

  Lung function measurements may improve only modestly, even when symptoms and flare-ups become less disruptive. A patient may still have abnormal spirometry and need daily preventer treatment. The practical success of treatment is usually judged by the whole pattern: fewer attacks, better sleep, more activity and less exposure to steroid-related harm.

  Potential Benefits And Risks

  A meaningful benefit may be a reduction in severe asthma attacks that lead to hospital care. For someone who repeatedly visits an emergency department in Sydney, Melbourne or Brisbane, avoiding even a small number of admissions can represent a major improvement in safety and daily life. Better symptom control may also make walking, swimming or returning to work more realistic.

  Repeated oral corticosteroid use carries risks such as weight gain, diabetes, osteoporosis, cataracts, mood effects and high blood pressure. If thermoplasty reduces the frequency of steroid-treated exacerbations, it may reduce cumulative exposure, although it does not remove steroid risk altogether. Clinicians still need to monitor inhaled treatment and manage conditions such as allergic rhinitis, reflux, obesity or obstructive sleep apnoea.

  The main procedural concerns include airway irritation, temporary bronchospasm, infection, bleeding and anaesthetic complications. Rarely, an exacerbation may be serious. The intervention is unsuitable for some people with unstable disease, significant coexisting lung conditions or an inability to tolerate bronchoscopy. A respiratory physician must weigh expected benefit against these risks.

  Comparing Long-Term Treatment Options

  Bronchial thermoplasty sits within a broader treatment pathway rather than replacing standard care. Before referral, clinicians typically confirm the diagnosis, review inhaler technique, investigate adherence and assess exposure to smoke, occupational irritants and allergens. Blood eosinophils, immunoglobulin E and other clinical features may indicate that a biologic medicine is more suitable.

  Option	Main target	Long-term role	Important limitations
  Inhaled corticosteroid and long-acting bronchodilator	Airway inflammation and bronchoconstriction	Foundation treatment for most persistent asthma	Requires regular use and correct technique
  Biologic therapy	Specific inflammatory pathways	Reduces exacerbations in eligible phenotypes	Injections, cost and eligibility requirements
  Bronchial thermoplasty	Excess airway smooth muscle	Option for selected adults with uncontrolled severe asthma	Invasive, delivered in stages, variable response
  Oral corticosteroids	Rapid systemic suppression of inflammation	Rescue treatment, sometimes maintenance	Significant cumulative adverse effects
  Trigger and comorbidity management	Avoidable drivers of poor control	Supports every other treatment	Cannot always remove environmental or biological triggers

  In Australia, access to biologic therapy can depend on Pharmaceutical Benefits Scheme eligibility, while procedural funding varies between public hospitals, private hospitals and health insurers. Bronchial thermoplasty equipment and expertise are concentrated in specialist respiratory centres, so a person living in regional Queensland, Western Australia or Tasmania may need to travel and arrange several visits.

  Choosing Patients In Australia

  Australian specialists generally reserve the procedure for adults with severe asthma that remains uncontrolled despite optimised therapy. Assessment may include repeated spirometry, exacerbation records, imaging when appropriate, blood tests and a review by a multidisciplinary team. The team should discuss available biologics, expected recovery, anaesthetic risk and what will happen if symptoms do not improve.

  The treatment is regulated within Australia’s therapeutic goods framework, but regulatory availability does not mean that every hospital offers it or that every private policy covers it. Patients should ask the treating centre about referral criteria, Medicare-covered appointments, admission costs, anaesthesia fees and possible out-of-pocket expenses. Written consent should explain both expected benefits and recognised uncertainties.

  Local exposures can influence the outcome. Bushfire smoke, cigarette smoke, dust from construction and occupational chemicals may continue to provoke symptoms after treatment. On poor air-quality days, checking state air-quality advice, keeping reliever medication available and limiting strenuous outdoor activity can remain important. An asthma action plan should be updated before and after each procedure.

  Living With The Results

  Bronchial thermoplasty is best understood as a long-term control strategy, not a cure. Patients usually continue inhaled preventers and carry a reliever, while follow-up tracks symptoms, lung function, exacerbations, medication use and quality of life. A reduction in attacks may develop gradually rather than immediately after the final session.

  The procedure may be especially valuable when severe exacerbations continue despite meticulous conventional care, but it is not automatically preferable to a biologic or another advanced therapy. Shared decision-making should account for asthma phenotype, previous treatments, travel demands, work responsibilities and the person’s tolerance of invasive care.

  The key point is that bronchial thermoplasty can provide durable reductions in severe asthma attacks and hospital-based care for carefully selected adults, while its risks, costs and variable response require specialist assessment. Long-term success means fewer dangerous flare-ups and a more manageable daily life—not freedom from inhalers or the need for ongoing respiratory care.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)