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Health, Beauty & Fashion

Hope for severe asthma sufferers

A new treatment for people with severe asthma can help reduce the number of attacks without the use of drugs.
The Straits Times - August 30, 2012
By: Lea Wee
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Hope for severe asthma sufferers -- ST FILE PHOTO

A new non-drug treatment is bringing hope to people with severe asthma who are constantly in hospital because conventional medicine cannot help them.

In June, the National University Hospital (NUH) performed bronchial thermoplasty on two patients who have since experienced remarkable improvement in their symptoms.

The hospital said it is the first to perform the procedure in the Asia-Pacific region.

In the minimally invasive procedure, a radiofrequency catheter inside a flexible scope is inserted into the smaller airways, or bronchioles, of the lungs.

When the doctor activates a foot switch, heat energy at the tip of the catheter is transmitted to the airway wall to ablate or "burn away" part of the thickened muscles.

These muscles are responsible for constricting and narrowing the airways, causing asthma symptoms such as wheezing, coughing, chest tightness and shortness of breath. They become thickened from the repeated constricting and widening.

The procedure is done in three outpatient visits made three weeks apart.

Studies from the United States, Canada, Australia and parts of Europe, including Britain, over the last five years show that bronchial thermoplasty is safe and effective for those with severe asthma.

One study published in the American Journal Of Respiratory And Critical Care Medicine in 2010, involved 297 patients aged 18 to 65. It found bronchial thermaplasty reduced the number of severe attacks by 32 per cent, emergency admissions by 84 per cent and hospitalisations for respiratory symptoms by 73 per cent a year later.

Sixty-six per cent of patients had a reduction in time lost from work, school or other daily activities due to asthma.

The control group received only bronchoscopy, in which a lighted tube is inserted into the airways of the lungs to obtain tissue samples for diagnostic purposes.

Bronchoscopy is not a form of treatment for patients with asthma. In the study, it served as the placebo.

Those in this group showed no reduction in the number of severe attacks, emergency admissions or hospitalisations for respiratory symptoms.

The study also found 85 per cent of those who underwent the procedure had transient respiratory problems, compared to 75 per cent of those who underwent only bronchoscopy.

The most common problems were typical of airway irritation, including worsening asthma symptoms such as wheezing. These usually occurred within a day of either procedure and resolved within five days.

To minimise the risk of breathing problems, Associate Professor Lee Pyng, a senior consultant at the NUH division of Respiratory and Critical Care Medicine, said oral steroids are prescribed a day before bronchial thermoplasty, on the day of the procedure and a day after.

The procedure has been able to sustain its effects on these patients so far. The first patient who underwent it 10 years ago in the United States is reportedly still benefiting from it.

The procedure was approved by the Health Sciences Authority (HSA) here in March.

The NUH is collecting local data on its safety and efficacy.

The procedure is potentially useful for adults with severe asthma who are unable to control their symptoms despite complying with their medication requirements, said Prof Lee.

The medication includes reliever inhalers to open up the airway during a severe attack as well as long-term control steroid inhalers. Sometimes, multiple courses of oral steroids are prescribed to treat the chronic inflammation in the airways.

Such patients, who make up about one in 10, or about 15,000 to 20,000, of adult asthma patients here, often end up seeking treatment in emergency departments.

After bronchial thermoplasty, these patients are likely to need less of their reliever inhalers. They will still need to be on long-term control steroid inhalers to control their symptoms, but they may be weaned off oral steroids, said ProfLee. Long-term use of oral steroids has been linked to side effects such as high blood pressure.

Asthma affects about 5 per cent of the adult population here, which works out to about 200,000 people.

Although severe asthma patients comprise just a fraction of asthma patients, it accounts for more than half of health-care spending in countries such as the United States, as these patients require expensive drugs and resources, said Prof Lee.

Long-term inhaled therapy for asthma can cost between $70 and $100 a month for high doses.

Bronchial thermoplasty costs about $6,600 at subsidised rates and about $11,000 at private rates.

Most of the costs go to the catheters. Each catheter, which is for single use only, costs $3,500. Singaporeans and permanent residents can use their compulsory medical savings Medisave to pay for part of the treatment cost.

The two NUH patients who had the procedure in June are happy with its results.

Retiree Tan Hua Fong, 57, an asthma patient for more than 20 years, completed her third session recently without experiencing any respiratory symptoms afterwards.

Her asthmatic cough improved to such an extent that she could eat ice cream and fruit, climb three flights of stairs and walk the distance of two to three bus stops, all without severe coughing. She also took the MRT for the first time in years.

She said: "I used to avoid public transport because I was afraid that I would not be able to get help in time if I had an attack."

Before the procedure, her asthma had been worsening. She went to the emergency department at least once a month and had one of the worst attacks of her life, in January, when she also suffered a mild heart attack. She was admitted to intensive care for three days and had to be on life support.

Another patient, Mr Chang Yoon Sin, 64, who has been an asthma patient for about 40 years, has visited the emergency department once every three to four months and was hospitalised twice within six months recently.

In April, his asthma deteriorated to such an extent that he had to use his short-term reliever inhaler up to 10 times a day and could not continue his work as a taxi driver.

When the asthma medication prescribed by his family doctor did not work, he went to a hospital, where he was put on antibiotics and oral steroids. But despite repeated courses of oral steroids, his condition did not improve.

Finally, he underwent bronchial thermoplasty. He experienced a temporary increase in wheezing after each procedure, but that cleared within five days.

He said: "Now, I hardly wheeze. I also feel more energetic."

Like Madam Tan, he has also been relishing the taste of ice cream and other food which he used to avoid.

What happens during bronchial thermoplasty

During the procedure, a radiofrequency catheter is inserted into a bronchoscope (a flexible scope), which is then introduced into one of the lower airways of the lungs.

At the tip of the catheter is a four-pronged electrode array, which, when expanded, comes into contact with the airway wall at four points.

When the interventional pulmonologist (a lung specialist trained in bronchoscopy) activates a foot switch, a 10-second pulse of radiofrequency energy-induced heat of about 65 deg C is transmitted to the airway wall.

Bronchial thermoplasty targets the smaller airways (bronchioles) instead of bigger structures such as the main bronchi or trachea (windpipe).

It is the muscle constriction in these smaller airways that leads to the symptoms of asthma.

The heat "burns away" part of these muscles, which have become thickened from their repeated constricting and widening in patients with severe asthma.

This then reduces the number of severe asthma attacks.

The procedure was developed in the United States more than 10 years ago.

It is done in three outpatient or day surgery visits, three weeks apart. Each procedure takes about 30 minutes and treats the airways in a different lobe of the lungs.

The patient is lightly sedated and conscious throughout the procedure, which does not hurt.


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