Respiratory diseases
Understanding When to Use Bronchial Thermoplasty and Identifying Appropriate Candidates With Severe Refractory Asthma Requiring Intervention.
This evergreen guide clarifies bronchial thermoplasty, outlining criteria, benefits, risks, and decision-making steps to help patients and clinicians identify when intervention is appropriate for severe refractory asthma.
Published by
Louis Harris
July 31, 2025 - 3 min Read
Severe asthma presents a substantial burden for patients, families, and healthcare systems, with frequent hospitalizations, limited daily function, and persistent symptoms despite guideline-directed pharmacotherapy. Bronchial thermoplasty offers a nonpharmacologic option aimed at reducing airway smooth muscle mass and relaxing constricted airways. The therapy involves delivering controlled thermal energy to the larger airways during a series of outpatient sessions, under careful monitoring, with the goal of decreasing bronchial hyperreactivity over time. Understanding who may benefit requires an integrated view of clinical history, attack frequency, lung function trends, and prior responses to high-dose inhaled therapies. This context helps clinicians identify patterns indicating potential impact from thermoplasty.
Decision-making about bronchial thermoplasty should balance potential symptom relief against procedural risks, latency to benefit, and the patient’s overall health status. Eligible candidates typically have persistent, difficult-to-control asthma despite optimized inhaled corticosteroids and long-acting beta-agonists, plus evidence of frequent exacerbations or hospital visits. Preprocedure assessment emphasizes airway anatomy, comorbidities such as vocal cord dysfunction or chronic rhinosinusitis, and the absence of contraindications like active smoking. Shared decision-making with the patient—covering expectations, recovery time, and possible need for ongoing biologic therapies—ensures alignment of goals. Clinicians must also verify that maintenance plans remain feasible after the intervention.
Practical steps clinicians take before and after procedure.
The modern criteria for eligibility emphasize persistent symptoms despite maximal standard therapy, repeated emergency room visits, and a demonstrable impact on quality of life. Clinicians typically confirm that the patient has nonallergic or mixed phenotypes, with evidence of bronchial hyperresponsiveness on testing. Importantly, a comprehensive review excludes alternative explanations for wheezing and obstruction, such as COPD overlap or obesity-related hypoventilation. Patients must be willing to attend multiple procedures and adhere to postprocedural care plans, including infection prevention measures and pulmonary rehabilitation when available. The goal is to select individuals who have a realistic chance of meaningful, durable improvement.
Beyond eligibility, there is a need to ensure informed consent reflects a nuanced understanding of benefits, uncertainties, and potential complications. Patients should learn that bronchial thermoplasty does not cure asthma but can lessen attack severity and frequency for many. They should also anticipate a recovery period with temporary throat discomfort, wheeze, or mild chest tightness following treatments. Real-world results vary, and some patients may still require ongoing controller medications. It is essential to integrate thermoplasty into a broader asthma action plan, including trigger avoidance, vaccination, and adherence strategies, to maximize long-term outcomes.
How to interpret trial results and real-world experience.
Pre-treatment workup includes imaging to rule out structural airway anomalies and spirometry to quantify airflow limitation. Allergy testing contributes to phenotype characterization, while infectious screening helps minimize post-procedure infections. A careful discussion about smoking cessation, environmental controls, and comorbidity management reduces future complications. Scheduling considers bronchial thermoplasty as a staged outpatient process, often carried out over several weeks, with post-procedure observation and a plan for pain control and activity guidance. The coordinating team may involve respiratory therapists, nurses, and patient educators to reinforce self-management skills and ensure adherence to follow-up visits.
Post-procedure care focuses on monitoring for adverse events, such as transient wheezing or bronchospasm, and ensuring timely management of any deterioration. Patients are encouraged to continue or optimize inhaled therapies as advised by their clinician, with adjustments based on symptom trajectory. Rehabilitation services, breathing exercises, and pulmonary education can support functional gains. Shared decision-making continues after the procedure, with periodic reassessment of medication needs, acceleration of step-down therapy when appropriate, and consideration of adjunctive biologic options if asthma remains uncontrolled. The overall aim is to sustain improvements while minimizing long-term risks.
Patient education and empowerment through the decision journey.
When evaluating evidence, clinicians look at randomized trials and registry data that report reductions in emergency visits, fewer hospitalizations, and better symptom control for a subset of patients. Real-world experiences may reveal greater heterogeneity, influenced by patient selection, comorbidity burden, and adherence to concurrent therapies. The practical takeaway is not universal applicability but targeted potential benefit for those who meet strict criteria and engage in comprehensive follow-up. Shared decision-making remains central, with transparent discussion about the likelihood of benefit, timing of improvement, and the possibility of nonresponse guiding subsequent treatment choices.
To support appropriate selection, guidelines emphasize individualized assessment rather than blanket recommendations. Clinicians consider asthma phenotype, age, and coexisting sinus disease or nasal polyposis, which often accompany severe asthma and can influence outcomes. It is also important to evaluate psychosocial factors, support networks, and economic considerations that affect access to care and long-term management. By combining objective measures with patient-reported outcomes, teams can tailor expectations and decide whether thermoplasty aligns with the person’s goals and daily living needs.
Ongoing care, monitoring, and future directions.
Effective patient education starts with clear explanations of how bronchial thermoplasty works, what to expect during and after treatment, and how it fits within the broader asthma plan. Visual aids, written summaries, and decision aids can help patients grasp the trade-offs between immediate discomfort and potential long-term relief. Clinicians also discuss the likelihood of requiring ongoing controller therapy to maintain gains. Empowered patients participate actively in scheduling, reporting symptoms promptly, and engaging in pulmonary rehabilitation or breathing pattern training when offered, thereby maximizing the chances of a favorable outcome.
Equally important is aligning expectations with realistic timelines. Improvements may accrue gradually over months as airway remodeling stabilizes, rather than providing instant symptom relief. Patients should recognize that success varies across individuals and may depend on consistent follow-up and adherence to medical advice. Regular monitoring allows clinicians to detect early signs of nonresponse and adjust the care plan accordingly. The collaborative approach ensures that decisions remain patient-centered and grounded in current evidence.
After considering thermoplasty, many patients pursue a layered strategy combining pharmacologic control with lifestyle changes. Regular check-ins enable timely optimization of inhalers, biologics, and non-drug therapies, while vaccinations and infection prevention reduce asthma-triggering illnesses. For some, nonpharmacologic interventions such as weight management and exercise training contribute to improved respiratory efficiency. Ongoing research seeks to identify biomarkers that predict who will benefit most, refine patient selection, and explore combinations with emerging therapies. The ultimate objective is to offer safer, more effective options for those with severe refractory asthma, preserving lung function and daily activity.
While bronchial thermoplasty is not universally suitable, it remains a critical option for carefully chosen patients who experience substantial disease burden despite comprehensive management. Clinicians must balance anticipated benefits with individual risk profiles and patient preferences, ensuring that decision-making is transparent and collaborative. By integrating rigorous assessment, patient education, and coordinated follow-up, the healthcare team can help patients navigate this complex choice and pursue improved quality of life through appropriate intervention when indicated.
