Is it an outpatient procedure?

Dr. Khatri:  Yes, it’s an outpatient procedure performed in three different sessions separated at least three weeks apart. Most of the time you treat one part of the right lung first then you wait three weeks and you treat the lower part of the left lung. After at least another 3 weeks, the third procedure treats the upper parts of both lungs.

Can you walk through the procedure?

Dr. Khatri:  When a patient is eligible for the procedure, you have to make sure that they’ve not had any major flair ups.  One of the main side effects of the procedure is to have a flair up of asthma. You have to be stable from the asthma standpoint enough to tolerate the procedure and patients are also prescribed higher dose steroids around the time of the procedure. Patients are treated in a bronchoscopy suite as an outpatient procedure. After they are given some sedation, a bronchoscope, which is similar to other scopes people are familiar with, is introduced through the nose or the mouth and passed through their vocal cords into the airway. You look at the airways, make sure everything is okay, and then you put a small catheter through the bronchoscope, which has these struts. It looks a little bit like a basket and that basket is what delivers the heat to the airway walls.

Why does it work?

Dr. Khatri: We’re still trying to figure out why it works, but we do know that from a change in pathology standpoint, that areas that have been treated from previous studies show that the thickness of the muscle wall is reduced. If you think about the fact that you need a full circle of muscle to spasm and narrow a breathing tube, consequently if you reduce the thickness in certain areas it’s less strong. You don’t want overly strong muscles in your lung, you want them to be cooperative. We think that that’s the main mode of how it’s helpful. However, the body is interesting in the sense that there are signals that come from all cells in the body. We think that perhaps there’s inflammatory reduction just by the fact that the muscle cells in certain areas after thermoplasty are not there to send inflammatory signals. It’s important to note that thermoplasty is not a cure for asthma. Asthma is still a very multifactorial spectrum of disease. There are a lot of things that can make it worse and we have to treat it in different ways. Thermoplasty addresses the smooth muscle, which is one of the first therapies addressing the muscle in the lungs.

If you do it once will you ever have to do it again?

Dr. Khatri: Studies so far have demonstrated that you’re really only supposed to go through the session once. There are outcomes of people who had the treatment about five to eight years previously who have still some benefit and no changes in their spasm. But this is a new procedure. There’s a lot to be learned from it. Just because it’s available it doesn’t mean it’s for everybody, so you have to figure out who’s the right patient.

Can you talk about Karen?

Dr. Khatri: Karen is a very special person. She’s somebody who doesn’t let anything get in her way. However, no matter what she was doing for her asthma she felt that her breath was taken away. She was very sensitive to her environment. Just being around someone who was wearing any perfume or being around any aromas would trigger her asthma. It’s important to note even before the thermoplasty, her lung function tests, where you check how good somebody is at blowing out their breath, looked fairly reasonable. It’s interesting that it’s day to day changes and what she was around is what affected her asthma. It’s not just the numbers, it’s their symptoms and what triggers them.

She seems to be doing well.

Dr. Khatri: I would say she’s changed her life because she did what she needed to do and she was never afraid of trying what was necessary. We’re glad to have this in our tool box. I view very much as we are sort of navigators for our patients and that we will give them what they need to feel better whether or not it’s thermoplasty.

In the people you have treated, has it not worked for some?
Dr. Khatri: Everybody is different. It’s still early but overwhelmingly people are pleased with their changes. Again they still need their asthma medications because this isn’t a cure. Some people do better than others.

Treatments frequently result in flare-ups of their asthma. So that is the biggest hurdle.

Is there any danger to the procedure?

Dr. Khatri: There’s always risk to any procedure. Luckily throughout all the clinical trials there have been no extremely bad outcomes such as death. But there have been pneumonia and admissions to the hospital. In some cases bleeding in airways due to inflammation.

When it comes to asthma or allergies, is there any other (alternative) things that you try first?

Dr. Khatri: I’m not closed-minded to adjunctive therapies. If you are willing to consider other therapies that are out there while not ignoring the fact that really you need to treat inflammation in asthma. As long as it’s not harmful I’m usually okay with that. I think what’s also important is that patient should be comfortable to bring up different things they’re trying or want to try with their caregivers and it’s our responsibility to be open minded about it. I think acupuncture and relaxation therapy are good. Stress is a major trigger for asthma. There are some new breathing techniques that seem to help some patients. I’m okay with all of that as long as you really continue to keep your therapeutic relationship with your physician.

FOR MORE INFORMATION, PLEASE CONTACT:

Kelynn Brewer, RN BSN
Clinic Coordinator
The Asthma Center, Cleveland Clinic Respiratory Institute
(216) 444-0582
asthma@ccf.org