Bronchial Thermoplasty Technique

Updated: Dec 15, 2015
  • Author: Said A Chaaban, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Approach Considerations

Bronchial thermoplasty (BT) is performed via fiberoptic bronchoscopy in 3 separate procedures, each separated by approximately 3 weeks, as demonstrated by previous studies. [10, 11] Dividing the treatments into 3 bronchoscopy sessions minimizes the risk of inducing an asthma exacerbation or diffuse airway edema. This also avoids excessive procedural length, as bronchial thermoplasty procedures take longer (30-60 minutes) than a standard fiberoptic bronchoscopy (5-20 minutes), which implies larger doses of medication used for sedation. All accessible airways are treated with the exception of the right middle lobe, because of the theoretical concern of inducing right middle lobe syndrome. [38]

Oxygen should be started via a nasal or oral cannula during the procedure, with appropriate monitoring of vital signs. Heart rate, pulse oximetry, and noninvasive blood pressure should be continuously monitored.

Bronchial thermoplasty can be performed through the nasal or oral approach, with preference of the nasal approach because patients tend to have less gagging and fewer secretions. Most bronchial thermoplasty procedures are performed under conscious sedation. The procedure is generally well tolerated provided the patients are given periprocedural corticosteroids and bronchodilators and receive appropriate sedation.


Nasal or Oral Approach

After the airway has been examined bronchoscopically, the Alair catheter is introduced under direct visualization through the bronchoscope working channel. The single-use catheter of the Alair System (Boston Scientific, Natick, MA) fits through a 2-mm working channel of a standard 5-mm fiberoptic bronchoscope. This catheter has an expandable 4-electrode basket at its distal tip that has heating- and temperature-sensing elements for feedback control.

Bronchial thermoplasty catheter in airway. Bronchial thermoplasty catheter in airway.

Once the catheter is in the site to be treated, the 4-electrode array is expanded until the 4 wires are in firm contact with the airway wall circumferentially. The bronchoscopist initiates the delivery of energy through a footswitch, and the controller delivers energy automatically using an active feedback to maintain the desired treatment temperature of 65°C for 10 seconds.

Bronchial thermoplasty video

The left lower lobe and the right lower lobe are treated in separate procedures, and both upper lobes are treated during a third procedure. Each procedure usually requires 50-75 activations of the device to cover the targeted airways, as determined during treatment planning. The sites are treated meticulously and are recorded on bronchial airway map to ensure that the treatment sites are not skipped or overlapped.