From Louisiana State University Health Sciences Center.
Correspondence to: Tayyab Rehman, MD, Louisiana State University Health Sciences Center, 1901 Perdido St, MEB, Ste 3205, New Orleans, LA 70112; e-mail: firstname.lastname@example.org
Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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We read with interest the article in CHEST (March 2012) by Good et al1 on the application of bronchoscopy to improve the management of patients with refractory asthma. In this study, patients with refractory asthma underwent bronchoscopy with the aim of (1) obtaining data to define the refractory asthma phenotypes and (2) individualizing therapy based on bronchoscopically defined refractory asthma phenotype. Outcomes measured included changes in Asthma Control Test scores and FEV1. The study reported significant improvements in these outcomes for four out of the five bronchoscopically defined phenotypes at 12 to 60 weeks postprocedure. These findings are interesting because they enhance the possibility of personalized care for patients with refractory asthma and extend the clinical usefulness of bronchoscopy. However, caution is required in interpreting these data. The lack of a separate control arm and the nonrandomized design of the trial raise the following issues:
1. The role of a placebo effect in asthma was highlighted in a study by Wechsler et al,2 in which treatment with either a placebo inhaler or sham acupuncture led to equivalent improvement in subjective perception of asthma, as did treatment with active albuterol. Both placebos were superior to no intervention. It is not clear how much of the improvement in asthma control in response to bronchoscopy-directed therapy can be attributed to a placebo effect and how much to a true treatment effect.
2. The subjects in the study were enrolled from the authors’ clinic. Subjects with asthma are more likely to seek an encounter with health-care providers when their disease is uncontrolled or getting out of control. Hence, a regression to the mean is likely if the same cohort is evaluated at a later time point.3 Lack of a control group limits evaluation of the true efficacy of bronchoscopy-directed care.
As a proof of principle, the findings of this study are novel, significant, and provocative. A well-designed randomized controlled trial is now required to clearly delineate the true treatment effect attributable to a bronchoscopy-directed strategy of care. Judgment on the usefulness of bronchoscopy in defining refractory asthma phenotypes and the therapeutic benefit accruing from this approach must wait until such a study has been performed.
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