Puchalski (center) works with a team to perform a bronchoscopy.
(May 2011) About 20 million people in the U.S. suffer from asthma, and those with the worst cases face frequent trips to the emergency room or constant shortness of breath that medications can’t always control. Now doctors at the Yale Center for Asthma and Airways Disease (YCAAD) are offering a new treatment that shows promise for moderate to severe asthma.
Bronchial thermoplasty (BT) involves a Food and Drug Administration (FDA)-approved device—the first of its kind – that uses radiofrequency energy to gently heat the airways and decrease the tissue in the lungs that is responsible for bronchoconstriction and asthma attacks.
“This new procedure offers an upgrade for treatment over inhaled drugs or other medications, because we are attacking the problem at its very root—the muscles in the lungs themselves," says Jonathan Puchalski, MD, who is performing the procedure on patients at YCAAD, the only center between Boston and New Jersey to offer the treatment.
Because BT can initially irritate the lungs, the treatment is performed in three outpatient visits, generally scheduled about three weeks apart to treat different areas of the lungs. The patient is given moderate sedation or light anesthesia before Dr. Puchalski inserts a probe-like device through a bronchoscope into the airways to deliver thermal energy. “The procedure in and of itself is relatively straightforward and lasts between 30 and 60 minutes,” he says.
The patient typically goes home the same day. Lung function is evaluated after each session before proceeding with the next treatment.
Doctors determine if patients are eligible for the procedure based on their medical history and the severity of their asthma. The procedure is intended for severe persistent asthma in patients 18 years and older whose asthma is not well controlled with inhaled corticosteroids and long-acting beta-agonists.
Geoffrey Chupp, MD, director of YCAAD, visits with a patient. Many of those treated with BT find their asthma will worsen for a brief period before it gets better.
YCAAD is one of 30 centers in the country to test bronchial thermoplasty in a phase IV clinical trial, which is a trial launched after the FDA has approved a treatment as safe over the long term. About 10 patients will be able to participate in the bronchial thermoplasty trial, although the treatment may be available to others.
One patient who had the procedure was a 55-year-old man who has suffered from asthma his entire life. Although he had never been admitted to the hospital because of an asthma attack, his shortness of breath frequently interfered with activities he enjoyed, such as playing basketball.
Like many patients who undergo BT, his asthma worsened immediately for a brief period after the procedure. After four months, however, he decreased his medications, has given up using a rescue inhaler when he plays basketball, and can get his heart rate up to 140 on the treadmill, versus 120 before the procedure. His lung function is now the highest it’s been since 2008.
Lauren Cohn, MD, right, discusses a case with Dr. Chupp. She says the team determines which treatment is best based on years of working with the disease.
About 3,000 patients a year visit YCAAD, a major asthma center in the Northeast that has offered unique opportunities to understand the causes of the disease and improve existing treatments. “When patients come to see us, we get a sense of which treatments might work best because we have so much experience with this disease,” says Lauren Cohn, MD, co-director of the center.
In 2007, Geoffrey Chupp, MD, director of YCAAD, and Jack Elias, MD, found that asthma patients have high levels of a protein called YKL-40, which causes lung inflammation. They later discovered that those with a particular mutation of the YKL-40 gene are at greater risk of developing asthma and having low lung function. The 55-year-old patient who underwent BT has the mutation; after the procedure, his YKL-40 levels dropped significantly.
“I’m hoping to study this and determine if it’s a good predictor of how people will do with the procedure,” says Dr. Chupp. He believes that YKL-40 levels could also be used after the procedure to show how well patients have responded.
Meanwhile, doctors expect bronchial thermoplasty to relieve suffering for many patients with severe asthmas. "In the past, these patients received high doses of medication and continued to suffer from frequent asthma attacks and limitations on routine daily activities, as well as frequent emergency room visits. Bronchial thermoplasty gives new hope to those asthmatic patients and a non-drug option to control their disease,” Dr. Chupp says. "For those with severe asthma, this is a terrific option where medication can fall short."
Story by Jill Max
Photos by Robert Lisak
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Bronchial thermoplasty is just one of the advanced or investigational treatments Yale Center for Asthma and Airways Disease (YCAAD) offers patients living with moderately controlled asthma. Others include:
YCAAD’s clinical trials and in-depth approach to treating asthma can make an important difference for patients, says Lauren Cohn, MD. “When a patient comes to me I can tell which treatments will work best because we have so much experience with the disease,” she says.
For more information about YCAAD and the latest treatments for asthma, visit the center’s website at http://ycaad.yale.edu.
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