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 for severe asthma in Australian practice

  Refractory asthma affects a meaningful slice of the Australian adult population, with estimates suggesting roughly 5 to 10 percent of people with asthma continue to experience frequent symptoms despite optimised inhaler regimens. In Sydney and Melbourne, where bushfire smoke and thunderstorm asthma events create sudden air pollution spikes, this subgroup carries a disproportionate share of emergency visits and unplanned medical leave. Learn more about リウマチ性疾患の診断における新しい分類基準 Acr Eular の使い方.

  When clinicians refer to refractory asthma, they describe disease that remains uncontrolled despite high-dose inhaled corticosteroids combined with a second controller, or that worsens as oral steroid courses taper. The burden includes sleep disruption, missed work, hospital admissions, and long-term systemic corticosteroid side effects such as osteoporosis and dysglycaemia.

  Bronchial thermoplasty is a bronchoscopic procedure that delivers controlled radiofrequency energy to the airway walls, reducing hyperplastic smooth muscle that drives bronchoconstriction. Performed across three sessions roughly three weeks apart, it sits within interventional pulmonology rather than biologic therapy, offering a non-pharmacological mechanism complementing existing treatment layers.

  Australian access is governed by Therapeutic Goods Administration listing of the catheter system and by hospital credentialing. Tertiary centres in Brisbane, Perth, and Adelaide have incorporated the procedure, with reimbursement typically negotiated through private health insurers rather than the Pharmaceutical Benefits Scheme, since it is a device-based service.

  Defining refractory asthma in local practice

  Severe asthma in Australia is defined by the Australian Asthma Handbook, maintained by the National Asthma Council, as asthma that remains uncontrolled despite optimised management or that requires high-dose treatment to maintain control. Patients who appear refractory on initial review often improve once inhaler technique, adherence, and treatable traits such as allergic rhinitis or obesity are addressed.

  Subspecialty clinics at major centres, including the Royal Prince Alfred in Sydney and The Alfred in Melbourne, run dedicated severe asthma multidisciplinary meetings. These teams phenotype patients before escalating to advanced therapies and share their findings at events such as the regional respirology congress.

  A practical priority is ruling out alternative drivers before procedural intervention. Common confounders include untreated chronic rhinosinusitis, vocal cord dysfunction, gastro-oesophageal reflux, and occupational exposures linked to mining regions of Western Australia and Queensland. Many Australians hold private hospital cover, and out-of-pocket costs vary by insurer and should be raised in shared decision-making.

  Comparing available treatment pathways

  Pathway	Mechanism	Typical candidate	Onset of effect	Reimbursement in Australia
  Bronchial thermoplasty	Radiofrequency reduction of airway smooth muscle	Severe asthma uncontrolled on maximal inhalers, low or mixed eosinophils	Gradual over weeks to months	Private insurers; not PBS listed
  Anti-IL5 biologics	Block eosinophil-driven inflammation	Eosinophilic phenotype with elevated blood eosinophils	Weeks	PBS subsidised for eligible severe eosinophilic asthma
  Anti-IgE (omalizumab)	Block IgE-mediated allergic cascade	Allergic phenotype with elevated IgE	Months	PBS subsidised for severe allergic asthma
  Anti-TSLP (tezepelumab)	Block upstream epithelial alarmin	Broad severe asthma including low eosinophils	Weeks	PBS subsidised for defined severe asthma
  Daily oral corticosteroids	Broad anti-inflammatory suppression	Last-line, frequently exacerbating	Days	PBS listed, low acquisition cost

  This comparison frames where thermal ablation fits among biologic options subsidised through the Pharmaceutical Benefits Scheme over the past decade. The procedure is most attractive when eosinophil counts are modest, biologics have failed, or patients prefer to avoid long-term injectable therapy.

  The decision is rarely either-or. Many patients at Fiona Stanley Hospital in Perth and the Royal Adelaide Hospital proceed with biologics and thermoplasty sequentially, using biologic response to guide timing.

  Selecting patients for thermal ablation

  A systematic workup precedes listing. Spirometry, body plethysmography, high-resolution chest CT, and a recent Asthma Control Questionnaire score establish a baseline for response. Bronchoscopy is part of staging rather than a separate diagnostic step, allowing the operator to confirm airway anatomy and rule out occult tumour or tracheobronchomalacia.

  Comorbidities that increase procedural risk include recent myocardial infarction, severe coagulopathy, and active respiratory infection. Anaesthesia review is mandatory because each session involves general anaesthesia or deep sedation with neuromuscular blockade, managed by a thoracic anaesthetist.

  Key selection criteria

  • Adults aged 18 to 65 with confirmed severe asthma despite maximal inhaled therapy
  • Stable on maintenance oral prednisolone at or below 10 mg daily when possible
  • No active airway infection and acceptable bronchoscopic airway calibre
  • Motivated to attend three procedural sessions and structured follow-up

  Careful selection reduces periprocedural complications and supports realistic expectation-setting, a point emphasised in patient materials from Asthma Australia.

  The procedure pathway and recovery

  Each session treats a different lobe or paired lobes, totalling roughly 30 to 40 minutes of activation within a 45 to 60 minute anaesthetic. Patients are observed for 24 hours because post-procedure airway oedema can trigger wheezing, managed with short prednisolone courses and nebulised bronchodilators.

  Recovery between sessions usually allows return to desk work within several days, though construction workers on the Gold Coast or manufacturing staff in Geelong are counselled to allow more time before heavy exertion. Lung function typically dips transiently before stabilising or improving over the following weeks.

  Symptom burden rises during the first week after each session, then declines below pre-treatment levels by six weeks in most responding patients. Spirometry often shows smaller changes than symptom scores, reflecting the disconnect between physiology and patient-reported benefit that characterises the procedure.

  Long-term outcomes and integration with biologics

  Long-term follow-up from the AIR2 trial and subsequent registries suggests benefit persists for at least a decade, with reduced exacerbations and improved quality of life scores. The PAS2 study reaffirmed safety in a broader cohort with consistent gains in patients previously reliant on long-term oral steroids.

  Australian real-world experience is accruing through audits at John Hunter Hospital in Newcastle and the Princess Alexandra Hospital in Brisbane, both maintaining procedural registries. These datasets will refine selection and support future applications to the Medical Services Advisory Committee.

  When biologics produce partial response, thermal ablation can be layered to address residual structural change. Many clinicians initiate biologics first to reduce exacerbation risk during the procedural period. For clinicians working at the interface with other inflammatory disease, decision frameworks analogous to the updated ACR-EULAR criteria help formalise shared decision-making in patients with overlapping rheumatological comorbidities.

  Practical points for the treating team

  • Coordinate biologic dosing around the three-session window to minimise infection risk and overlapping inflammation
  • Capture baseline ACQ and AQLQ scores and repeat at six months to document response
  • Discuss expected out-of-pocket costs pre-procedure, given variable insurer rebates
  • Link patients with Asthma Australia for ongoing self-management education

  The next practical step is to schedule a structured severe asthma review at a credentialed interventional pulmonology centre in Brisbane, Sydney, Melbourne, or Adelaide to confirm phenotype and chart the therapeutic pathway.

  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)