Rebuttal From Drs Michaud and ErnstRebuttal From Drs Michaud and Ernst FREE TO VIEW

Gaetane Michaud, MD, FCCP; Armin Ernst, MD , FCCP
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From Yale New Haven Hospital and Yale School of Medicine (Dr Michaud), and Department of Pulmonary and Critical Care Medicine (Dr Ernst), St. Elizabeth Medical Center/Tufts University School of Medicine.

Correspondence to: Armin Ernst, MD, FCCP, Department of Pulmonary and Critical Care Medicine, St. Elizabeth Medical Center/Tufts University School of Medicine, 736 Cambridge St, Brighton, MA 02135; e-mail: armin.ernst@steward.org

Financial/nonfinancial disclosures: The authors have reported to CHEST the following potential conflicts of interest: Dr Ernst was a principle investigator on the AIR2 trial but received no payment for his involvement. Dr Ernst received consultancy fees (< $5,000) from Asthmatx, which developed and markets the Alair Bronchial Thermoplasty System discussed in this article, and currently has a research and development consultancy agreement with Boston Scientific, unrelated to bronchial thermoplasty. Dr Michaud has reported that she has no potential conflicts of interest with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

© 2011 American College of Chest Physicians

Chest. 2011;140(3):578-579. doi:10.1378/chest.11-1391
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We thank our honorable colleagues in this debate for pointing out some obvious concerns that we, as clinicians caring for asthma, face on a daily basis.1 Patients with chronic persistent asthma, despite appropriate therapy with corticosteroids and bronchodilators, prove particularly challenging because of a lack of effective treatment regimens. As physicians, it is our duty to offer effective and safe care for as many patients as possible.

Although we agree with our colleagues that add-on therapies are often necessary and that omalizumab is not effective in all cases of asthma, we contend that this is an insufficient reason to recommend bronchial thermoplasty at this point as part of a management algorithm. It is a recently approved therapy with a short track record and has only been trialed in several hundred patients. Despite this fact, many of our peers are already considering it an established form of therapy that should be incorporated into clinical practice guidelines.

To be clear, we do perform bronchial thermoplasty in select patients and agree that the approach holds potential. However, we perform the procedure with a commitment to collecting efficacy and safety data, particularly focusing on yet-unknown longer-term side effects. As expert bronchoscopists, we have developed a profound respect for the airways. Applying controlled injury to airways in a potentially large patient population does require long-term follow-up. We need to ensure that we are not trading small improvements in asthma-specific quality of life with problems related to late fibrosis of the treated airways.

In the interest of our patients and to minimize risk, we propose limiting the use of bronchial thermoplasty to centers with an appropriate level of research infrastructure. These centers would be tasked with enrolling in a rigorous postmarket study of the technology using standardized technique, clear and reliable patient selection, and meticulous postprocedure follow-up until the unresolved efficacy and safety questions are fully addressed.


Shifren A, Chen A, Castro M. Point: efficacy of bronchial thermoplasty for patients with severe asthma. Is there sufficient evidence? Yes. Chest. 2011;1403:573-575




Shifren A, Chen A, Castro M. Point: efficacy of bronchial thermoplasty for patients with severe asthma. Is there sufficient evidence? Yes. Chest. 2011;1403:573-575
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