Bronchial Thermoplasty

Gabrielle Morris

69-year-old lady, consult request for consideration of bronchial thermoplasty

Background

  • Severe refractory asthma
  • Intermittent vocal cord dysfunction
  • IHD – cardiac arrest in 2010, emergency PCI to RCA. Well since. Recent normal stress and resting echocardiogram.
  • NIDDM – reasonable control
  • Good exercise tolerance. 5.6 METS

Issues

  • Severe refractory asthma – frequent exacerbations despite optimal therapy. Wakes at night to use salbutamol
  • Postoperative bronchospasm – after recent shoulder surgery. Required reintubation in PARU and had a 3-day ICU admission on BiPAP and steroids
  • Patient apprehensive given recent experience but understands risks and is keen to proceed given current QoL.

Discussion

Bronchial Thermoplasty

  • Targeted application of radiofrequency to the airways. No current RCT evidence but is approved for use in severe refractory asthma. Case study evidence supports post-procedure reduction in asthma severity and frequency of exacerbations
  • Ablation is carried out in 10-second bursts
  • Cough suppression is imperative during radiofrequency ablation and patient is required to remain still
  • Frequently performed in 2-3 staged procedures

Conduct of anaesthesia

  • Little collective experience at JHH but one anaesthetist has significant experience from overseas hospitals
  • Anaesthetic options:
  • GA – ETT and muscle relaxant provide perfect conditions for procedure but will increase risk of perioperative bronchospasm and asthma exacerbation
  • Sedation – with minimal airway instrumentation. Previous experienced anaesthetist suggests use of dexmedetomidine and/or remifentanil with propofol.
  • Airway topicalisation – necessary to topicalise airway effectively, increased risk of layngo-and bronchospasm. Recommendations are as for AFOI. Consider nebulised local anaesthetic and proceduralist will employ “spray as you go technique.”
  • Minimise secretions – consider use of glycopyrrolate
  • Postoperative disposition – critical care monitoring required due to risk of postoperative bronchospasm.
  • See article for further discussion of anaesthetic considerations (Anesth Analg 2018;126:1575–9)

Optimisation

  • Regular respiratory physician review but consider perioperative course of steroids in consultation with team.

Plan

  • Proceed as planned
  • ICU 2 bed postoperatively
  • Liaise with proceduralist regarding anaesthetic requirements, management of medications perioperatively, consideration of steroid therapy, and appropriateness of planned disposition