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ASTHMA
PROBLEM: ASTHMA
Asthma is a disease that has spread widely throughout the world in the last 20 years.
The term asthma comes from the Greek word which means panting. In simple term,
asthma is the chronic inflammation in the lungs and the obstruction of the airways due to the
increased responsiveness of the immune system. Based on the figures from World Health
Organisation, 300 million people suffer from asthma worldwide. (1)
Normally, the flow of air in the airways is smooth and clear. When a person suffers
from asthma, the airways are sensitive to factors such as dust, fur, air pollution and cold. In
the presence of these factors, the airways are inflamed and swollen; making them smaller, but
the air can still barely flow. Consequently, the person may experience cough, chest tightness,
wheezing, shortness of breath and exhaust. In worst attack, the airways become more swollen
and develop phlegm. The airway muscles contract and the air is trapped in the alveoli,
making it difficult for the air to flow through the airways, and can even block them
completely. The person may suffer from extreme wheezing, cough and hardness in breathing.



Figure 1
The airways in different conditions in a person with asthma (2)


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SOLUTION: BRONCHIAL THERMOPLASTY
Introduction
Bronchial thermoplasty is the latest non-drug treatment for severe asthma by
delivering heat to the airways to reduce excessive airway smooth muscles. (3) This will
reduce the vasoconstriction of the airways, thus reduces the frequency of asthma attacks.

Equipment
Bronchial thermoplasty is carried out using Alair Bronchial Thermoplasty System
which consists of Alair catheter and Alair RF controller. Alair catherer is designed to be
delivered into the airways and monitored using RF channel. It has an electrode-tissue
interface to deliver heat to the airway tissues. Alair RF controller is an electrical generator
to control the temperature of the interface and adjust the rate of energy transferred into the
airway tissues.

Figure 2
The Alair catherer (4)


Figure 3
The Alair RF controller (4)
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Procedure
Before the treatment, the patient will be subjected to moderate sedation. It is
administered using the intravenous catherer to give relaxation and reduce discomfort to the
patient. The patient may be drowsy or sleep throughout the operation. (5)


Figure 4
The procedures of bronchial thermoplasty (4)

In the beginning of the operation, the bronchoscope, together with the Alair
catherer, is inserted into the airways either through the nose or mouth of the patient. First, the
bronchoscope is navigated to the treatment site, commonly the most distal airway in the
targeted lobe as shown in (A). Next, the electrode array at the tip of the Alair catherer is set
to expand and touch the airway tissues as shown in (B). After that, the Alair RF controller
is switched on and the heat is delivered to the airway tissues through the electrode array as
shown in (C). This will reduce the amount of excessive airway muscles and thus, limit the
ability of the muscles to contract. After the procedure, the electrode array partially collapses
and the Alair RF controller is switched off for a while. Both bronchoscope and the Alair
catherer are navigated away, approximately 5 mm from the previous treatment site as shown
in (D). The Alair RF controller is then switched on again and the procedures are repeated as
shown in (E).



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Effectiveness
Bronchial thermoplasty is proven to reduce the symptoms of asthma greatly in most
asthmatic patients. By introducing the sufficient heat onto the walls of the airways using the
Alair catherer, this burns the extra airway smooth muscles in the lungs; thus it reduces the
constriction of the airways to the greater extent during the asthmatic attacks. Hence, the
patients will not suffer greatly from the symptoms. Compared to the other treatments such as
inhaled corticosteroids and bronchodilators, those treatments may only relieve the symptoms
or prevent the asthmatic attacks for a relatively short period, but with bronchial thermoplasty,
the patients may remain healthy from next asthmatic attack for a few months to years.
Many researches have been conducted to prove the effectiveness of the bronchial
thermoplasty. For example, the Asthma Intervention Research 2 (AIR2) Trial of the Alair
Bronchial Thermoplasty System had been conducted to evaluate the safety and effectiveness
of the treatment in adult patients compared to the treatments using drugs. (6) The study was
carried out using randomized, double-blind and sham-controlled trials onto 297 patients at 30
sites in 6 countries. Based on the results, there were many significant clinical findings from
the trial, such as:
Improvement in the average Asthma Quality of Life Questionnaire (AQLQ) score at 6, 9
and 12 months over sham control;
4 out of 5 Alair-treated patients responded with a clinically significant improvement in
AQLQ compared to 64% of sham control;
32% reduction in asthmatic attacks;
84% reduction in emergency room visits for respiratory symptoms;
36% reduction in patients reporting episodes of asthmatic (multiple symptoms) adverse
events; and
66% reduction in days lost from work, school or other activities due to respiratory
symptoms.







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Figure 5
The AQLQ Score for Bronchial Thermoplasty and Sham Thermoplasty in AIR2 Trial (7)

Implications
(a) Economic Issue
Bronchial thermoplasty is indeed an expensive treatment for asthma. For example, in
United State of America (USA), an asthmatic patient may spend roughly about $12,000 till
$18,000 for a complete treatment of bronchial thermoplasty. (8) In addition, for any hospital
in USA which provides this treatment, it costs about $1,500 and $30,000 for the Alair
catherer per single use and the Alair RF controller respectively. (9) Roughly saying, the
treatment of asthma using bronchial thermoplasty is more expensive for the government to
support the citizens compared to using medications for asthma. Thus, this treatment will
increase the governments expenditure on health. Figure 6 shows the incremental cost of
asthma in USA in the year 2002 till 2007.





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Figure 6
The incremental cost of asthma in USA from 2002 till 2009 (10)

From Figure 6, it is expected that the incremental cost of asthma in USA will increase
dramatically if bronchial thermoplasty is introduced to the citizens.

(b) Ethical Issue
Bronchial thermoplasty is indeed a new treatment for asthma. Therefore, despite its
curative ability towards the disease, its side effects are still unknown. In a study by Cox et al,
it is found that there are some adverse effects after the procedure; 74% mild, 25% moderate
and 1% severe. The most frequent side effects may include cough, dyspnea, wheeze and
bronchospasm. However, all cases are solved within one week after the treatment by applying
bronchodilators. (4)
Some people raise the issue that this treatment shall be monitored and studied for a
few more years until the safety and effectiveness of this treatment have been completely
defined before it is introduced to the patients. On the other hand, another group of people
argues that it shall be allowed to be applied now because it may save many lives of the severe
asthmatic patients.






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Benefit, Risk and Disadvantage
(a) Benefit
Bronchial thermoplasty is very effective in treating severe asthma. Compared to other
treatments, it greatly reduces the symptoms of asthma in the patients. In general, the patients
treated with bronchial thermoplasty will experience the following benefits (11):
32% reduction in asthmatic attacks;
84% reduction in emergency room visits for respiratory symptoms;
66% reduction in days lost from work, school or other daily activities due to asthmatic
symptoms; and
73% reduction in hospitalizations for respiratory symptoms.

(b) Risk
Although it is effective in treating asthma, but it may bring post-procedure
compilations because it is still new and more researches need to be done to study the safety
and effectiveness of this treatment. Some may include pneumonia, operative haemorrhage,
abnormal breath sounds, bronchial obstruction, acute bronchitis, bronchospasm and viral
infection. (11)

(c) Disadvantage
Bronchial thermoplasty is only appropriate and safe for a certain group of patients.
For example, the treatment is only limited to adults, non-smokers for 1 year or greater,
patients who have no severe asthma exacerbation within the last 2 weeks or people who has
no internal pacemaker or neurostimulator. (4) This is not suitable for the children who suffer
from asthma since childhood, smokers who get asthma from smoking and old and asthmatic
citizens who use pacemaker due to heart failure. Therefore, it is not beneficial to all groups of
patients.
Moreover, since it is still new, bronchial thermoplasty is only available in certain
countries. Up till now, this treatment is only available in United State of America (USA),
Canada and United Kingdom. (12) Therefore, it is a disadvantage to the citizens who live
other than these countries to get access to this treatment. They need to pay more for the
travelling fee to the countries to get this treatment.


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Alternative Treatments
(a) Medications (13)
Since bronchial thermoplasty has a few drawbacks, most patients prefer to take
medications because they are relatively cheap, available in most pharmacy stores, easy to
consume and less risky. Most medications taken by the patients are the short-acting

agonist (SABA) bronchodilators and inhaled corticosteroids (ICS).
SABA bronchodilators include salbutamol, levalbuterol and pirbuterol. Inhaled
SABAs are very effective for fast symptom relief of bronchospasm. They are very easy to be
used and last for 4 to 6 hours. On the other hand, ICSs are effective for persistent asthma.
ICSs work by reducing and suppressing inflammation in the airways, thus, prevent the
asthmatic symptoms. They are often prescribed as daily-use medicines.

(b) Lifestyles (14)
Instead of relying on the medications, it is possible to lead a healthy lifestyle which
can prevent the asthmatic attacks. This may include the sport activities and environment.
Sport activities are indeed a good practice to a healthy life. Most people think that
sports may trigger asthmatic attacks, but it is not totally true. By taking a brief rest period in
any sport such as baseball, football, biking and hiking, this will make the patient less likely to
suffer from the asthmatic symptoms. In addition, taking regular exercises may prevent the
patients from being obese because there are researches proving that obese patient are more
likely to suffer from asthmatic attacks.
At home, the patients must always keep his room clean without dust. The furry pets
such as cats and dogs must be kept outside of the house because they may leave fur on the
couch, bed or floor. The dust and fur may trigger the attack on the patients. Moreover, the
patients themselves must not or stop smoking, and keep themselves away from the smokers,
as the cigarette smoke can trigger the asthmatic attack as well.







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EVALUATION OF SOURCES
Most information about bronchial thermoplasty is obtained from the websites
www.asthmatx.com and www.btforasthma.com, which are administered by Asthmatx Inc.,
a company who develops the method of bronchial thermoplasty. Therefore, sources (3), (5),
(6), (11) and (12) are reliable because they are written by the organization specialized in this
field.
The figures used to support the facts are taken from the news and journals on the web.
Source (1) is a press release regarding the Year of the Lung 2010 held by recognized
organization, Forum of International Respiratory Societies (FIRS). Source (7) is a journal
written by three specialized doctors in this treatment. Source (8) is the article originally
written by Wall Street Journal which provides health journals to the community. Source (9) is
a presentation written by medical professor from Quebec, Canada. Source (10) is also a
journal written by two medical professors from USA. Since the sources are written by
specialized medical professors and organization, they are considered reliable.
The information about asthma is obtained from source (2), which is written by
physicians from America. In addition, the facts about bronchial thermoplasty are further
taken from source (4), written by two medical professors who are specialized in this
treatment. The alternative treatments for asthma are written based on sources (13) and (14),
the books directed by medical specialists in asthma. Therefore, all these sources are reliable
because they are written by the medical specialists.













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BIBLIOGRAPHY
Websites
(1) World Asthma Day Year of the Lung [dated 4 May 2010]
http://yearofthelung.org/1713-4-may-2010-world-asthma-day.htm
(Retrieved on 21 December 2010)
(3) Bronchial Thermoplasty Overview - Asthmatx
http://www.asthmatx.com/bronchial-thermoplasty/bronchial-thermoplasty-overview/
(Retrieved on 15 May 2011)
(5) The Procedure Asthmatx
http://www.btforasthma.com/bronchial-thermoplasty/the-procedure/
(Retrieved on 15 May 2011)
(6) Press Releases Asthmatx
http://www.asthmatx.com/news-events/press-releases/?i=225
(Retrieved on 25 July 2011)
(7) Bronchial Thermoplasty: A New Treatment for Severe Refractory Asthma Cleveland
Clinic Journal of Medicine
http://www.ccjm.org/content/78/7/477/F2.expansion.html
(Retrieved on 26 July 2011)
(8) Bronchial Thermoplasty: New Surgery to Treat Asthma Center for Environment,
Commerce & Energy [dated 2 November 2010]
http://cenvironment.blogspot.com/2010/11/bronchial-thermoplasty-new-surgery-to.html
(Retrieved on 27 July 2011)
(9) Bronchial Thermoplasty: Ready but for Whom? Simon Martel
http://www.lung.ca/crc/pdf/SMartel.pdf
(Retrieved on 27 July 2011)
(10) Costs of Asthma in the United States: 2002-2007 by Sarah Beth L. Barnett and
Tursynbek A. Nurmagambetov MD Consult [dated January 2011]
http://www.mdconsult.com/das/article/body/269615893-
2/jorg=journal&source=&sp=23870552&sid=0/N/780573/1.html?issn=00916749&_retu
rnURL=http://linkinghub.elsevier.com/retrieve/pii/S0091674910016349?showall=true
(Retrieved on 27 July 2011)

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(11) What Can I Expect? Asthmatx
http://www.btforasthma.com/bronchial-thermoplasty/what-can-i-expect/
(Retrieved on 27 July 2011)
(12) Procedure Availability Asthmatx
http://www.btforasthma.com/bronchial-thermoplasty/procedure-availability/
(Retrieved on 27 July 2011)

Books
(2) American College of Chest Physicians (2004) When You Have Asthma, Controlling
Your Asthma. Northbrook : NIH
(4) Martin L. Mayse, Mario Castro (2010) Bronchial Thermoplasty, Interventional
Pulmonary Medicine. New York : Informa Healthcare
(13) Claudia S. Plottel (2011) Asthma : Inhaled Medications and Advances, 100 Questions
and Answers about Asthma (Second Edition). USA : Jones & Barlett Learning
(14) William E. Berger (2008) Asthma and Sports; Asthma and Your Social Life, Living with
Asthma. New York : Infobase Publishing