“I think I've been hospitalized about 1,500 times, and visited emergency room about 1,000 times. One day, I drove to the ER, coughed up blood, and fainted. I woke up a week later, just before they announced my death. I used to think I wanted to die because there was no point in living. Having asthma is an extremely lonely fight. It was a fight for breathing.”

This story is about a patient with severe asthma who received bronchial thermoplasty (brand name: The Alair) at Asan Medical Center. (Credit: Asan Medical Center, www.amc.seoul.kr/asan/healthtv/video/videoDetail.do?videoId=3805)

The patient had severe asthma whose symptoms were not controlled by medications. The drugs that worked well in most asthma patients were not effective on him. As his symptoms were not controlled, he had to visit the ER frequently. The latter method he found was bronchial thermoplasty.

Bronchial thermoplasty is a technique that uses a therapeutic catheter (a disposable foot-controlled electrosurgical electrode), inserted into a bronchoscope, to expand the airway of the asthma patient. The physician delivers high-frequency thermal energy to all the accessible airways from the end of the bronchus to the central bronchus.

After bronchial thermoplasty, the patient did not have to visit the ER anymore. He could take stairs up and down that had not been possible before the procedure. He could even walk a long distance that had to be driven before. One procedure changed his life.

In this single case, bronchial thermoplasty seeks a remarkable breakthrough. However, experts say that the procedure cannot be applied to all severe asthma patients. Even after the procedure, it is hard to expect the same effect from every patient. Nevertheless, the procedure has started to enjoy partial insurance benefits (patient pays 50 percent of cost) since Dec. 1.

Korea Biomedical Review met with Lee Sei-won, a professor at the Department of Pulmonology and Critical Care Medicine at Asan Medical Center, to learn more about bronchial thermoplasty and what kind of effect patients can expect.

The Alair (manufacturer: Boston Scientific) is the only product authorized as bronchial thermoplasty in Korea.

Question: Why have you become interested in bronchial thermoplasty?

Answer: When I saw patients with chronic obstructive pulmonary disease (COPD) and severe asthma who have no place to get treated, I thought there must be a way to treat them. As I saw a patient coming to the ER so frequently, and another in his 40s taking systemic steroids who was expected to suffer side effects 10 years later, I wished I could break this vicious cycle. The method I found was bronchial thermoplasty.

Q: To which patients can you provide bronchial thermoplasty?

A: Generally, 90-95 percent of asthma patients can be treated with inhaled steroids. Half of the remaining 5 percent of patients who do not respond to inhaled steroids can be treated with the latest biologics. The problem is the rest of the patients. They have no alternative but systemic steroids, which cause inevitable side effects in long-term use. Also, their symptoms cannot be controlled with existing drugs, so they have frequent ER visits. The only alternative left for these patients is bronchial thermoplasty. (The Alair, a bronchial thermoplasty product, is indicated for patients with severe asthma aged 18 or older whose symptoms are difficult to control with medication alone.)

Q: What is the most significant effect you can expect from bronchial thermoplasty?

A: It is the reduction of ER visits, and this was proven in studies. After the procedure, some patients have a sudden bronchial contraction due to a sudden influx of a substance. But those who responded to bronchial thermoplasty rarely visit the ER.

Q: On how many patients did you perform the procedure? Can you tell us the results?

A: I performed it on six patients. These are all the patients who received bronchial thermoplasty in Korea. Three out of six had a dramatic result. One patient had to visit the ER every week. After the procedure, the frequency shrank to once a year. Another had suffered from a swollen face and cataracts due to the long-term use of systemic steroids. After the procedure, he quit the systemic steroids, and the body shape returned to normal. The rest of the three responded a little, but the other two did not respond at all. A 50 percent response rate is the same in Korea or other countries.
The limitation of the bronchial thermoplasty is that physicians do not know the predictive index. The more procedures, the more doctors will be able to find the predictive index.

Q: Is there an appropriate age group for the procedure? Are there any differences between races?
A: Major studies on bronchial thermoplasty include AIR on 100 people, RISA on 34, and AIR2 on 288. Their average age group was the 40s to 50s. Patients who received my procedure were mostly in their 40s and 50s. This procedure was performed a lot in the U.S., so I wondered whether it would work for Asian patients. But seeing the local results, the procedure seems to have no problem in terms of race.

Q: Bronchial thermoplasty’s response rate is only 50 percent, and it costs at least several millions of won even after reimbursement. Do you think this procedure is a must for severe asthma patients?
A: When I joined the discussion for the reimbursement of this procedure as an expert, participants raised concerns that giving insurance benefits would increase the government’s healthcare spending and encourage a reckless abuse of the procedure. I told them that such a scenario would be groundless. This was because the procedure is available to a tiny group among severe asthma patients. For physicians, the procedure is burdensome because the doctor should perform a serious of three operations on a patient in general anesthesia. I also told them how much pain such patients have to go through.

Q: Does the procedure have any side effects?
A: There were concerns over whether it could lower lung function in the long term, but a five-year follow-up study showed that it did not cause such a problem. As a short-term side effect, it can cause temporary exacerbation of asthma. But it will be naturally resolved over time.

Q: Isn’t the procedure demanding?
A: If you are a fully experienced doctor, you can do it easily. In terms of therapeutic endoscopy, I think it's easy. However, bronchial contraction may occur during the procedure, so it is better to seek cooperation with the anesthesiologist.

Q: Do you have any advice for doctors and patients interested in bronchial thermoplasty?
A: The 50 percent response rate could be seen as low. But there is no alternative to the patient. Also, this procedure does not harm a patient, at least. It could be tried to a patient with severe asthma who has no other option and who visits the ER frequently. The procedure can produce two effects – reducing ER visits and discontinuing systemic steroids. By these effects alone, the procedure can improve the patient’s quality of life significantly.