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• W2892355825 abstract "Bronchial thermoplasty (BT) delivers targeted radiofrequency energy to bronchial airway walls and results in the partial ablation of the airway smooth muscle that is responsible for bronchoconstriction. It is approved for the treatment of severe persistent asthma. Multiple, large clinical trials including a recent “real-world” study demonstrate significant improvements in asthma-related quality of life, reduction in asthma exacerbations, emergency department visits, and hospitalizations after BT that is sustained out to 5 years. In this article, we review the state of the art of BT treatment in severe persistent asthma and share a decade of BT research and clinical experience. We share our personal experience and introduce the three “I”s (identification, implementation, and intense follow-up) that we believe promote successful patient outcomes and help build a successful BT program. Bronchial thermoplasty (BT) delivers targeted radiofrequency energy to bronchial airway walls and results in the partial ablation of the airway smooth muscle that is responsible for bronchoconstriction. It is approved for the treatment of severe persistent asthma. Multiple, large clinical trials including a recent “real-world” study demonstrate significant improvements in asthma-related quality of life, reduction in asthma exacerbations, emergency department visits, and hospitalizations after BT that is sustained out to 5 years. In this article, we review the state of the art of BT treatment in severe persistent asthma and share a decade of BT research and clinical experience. We share our personal experience and introduce the three “I”s (identification, implementation, and intense follow-up) that we believe promote successful patient outcomes and help build a successful BT program. Mayse et al1Mayse M. Laviolette M. Rubin A.S. Lampron N. Simoff M. Duhamel D. et al.Clinical pearls for bronchial thermoplasty.J Bronchology Interv Pulmonol. 2007; 14: 115-123Google Scholar published their expert opinion and clinical pearls for bronchial thermoplasty (BT) in 2007. Since their publication, BT has been performed across multiple countries with more than 6000 patients treated worldwide. The vast expansion in BT clinical experience resulted in reassurance of safety and addressed the initial fears of what this technology would do to our patients. It has also led to an improved BT technique, patient and BT team preparation, interdisciplinary planning, and performance of BT. Our state-of-the-art review offers an updated perspective and clinical pearls from experts at various centers of excellence for BT. Since approval by the US Food and Drug Administration (FDA) in 2010, BT endures as a proven and safe procedure indicated for the treatment of severe persistent asthma that is not controlled with high-dose inhaled corticosteroids (ICSs) and long-acting β2-agonists (LABA). The procedure decreases hypertrophied airway smooth muscle (ASM) that contributes to airway hyperreactivity in severe asthmatics.2Chakir J. Haj-Salem I. Gras D. Joubert P. Beaudoin E.L. Biardel S. et al.Effects of bronchial thermoplasty on airway smooth muscle and collagen deposition in asthma.Ann Am Thorac Soc. 2015; 12: 1612-1618PubMed Google Scholar, 3Pretolani M. Dombret M.C. Thabut G. Knap D. Hamidi F. Debray M.P. et al.Reduction of airway smooth muscle mass by bronchial thermoplasty in patients with severe asthma.Am J Respir Crit Care Med. 2014; 190: 1452-1454Crossref PubMed Scopus (130) Google Scholar No other treatments, including biologics for severe asthma, directly alter the anatomy of bronchial smooth muscle. BT consists of tightly controlled delivery of radiofrequency (RF) thermal energy to the airway wall via the Alair catheter electrode. As a result, BT decreases ASM mass, bronchial nerve endings, and neuroendocrine cells.4Pretolani M. Bergqvist A. Thabut G. Dombret M.C. Knapp D. Hamidi F. et al.Effectiveness of bronchial thermoplasty in patients with severe refractory asthma: clinical and histopathologic correlations.J Allergy Clin Immunol. 2017; 139: 1176-1185Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar RF electrical energy is systematically applied to airways between 3 and 10 mm in diameter throughout the tracheobronchial tree. The delivery of the energy during BT uses continuous feedback to tightly control the degree of tissue heating to avoid bronchial perforation, scorching, and stenosis. BT underwent extensive preclinical studies that demonstrated unequivocal attenuation of airway narrowing in response to endobronchial installation of methacholine using dog airways. Evaluation of the airway histology in the dogs revealed that the ASM was reduced by 40% to 60%.5Danek C.J. Lombard C.M. Dungworth D.L. Cox P.G. Miller J.D. Biggs M.J. et al.Reduction in airway hyperresponsiveness to methacholine by the application of RF energy in dogs.J Appl Physiol (1985). 2004; 97: 1946-1953Crossref PubMed Scopus (175) Google Scholar The first randomized controlled trial of BT (Asthma Intervention Research [AIR] 1) demonstrated significant improvements in asthma symptom-free days and asthma-related quality of life as measured by the Asthma Control Questionnaire (ACQ) (−1.2 ± 1.0 vs −0.5 ± 1.0; P = .001) and the Asthma Quality of Life Questionnaire (AQLQ) (1.3 ± 1.0 vs 0.6 ± 1.1; P = .003). There were no differences in forced expiratory volume in 1 second (FEV1) or airway hyperresponsiveness (defined by a provocative concentration of methacholine required to lower the FEV1 by 20% [PC20] of less than 8 mg per milliliter).6Cox G. Thomson N.C. Rubin A.S. Niven R.M. Corris P.A. Siersted H.C. et al.Asthma control during the year after bronchial thermoplasty.N Engl J Med. 2007; 356: 1327-1337Crossref PubMed Scopus (486) Google Scholar A second trial was designed to evaluate BT in more severe symptomatic patients (Research in Severe Asthma [RISA]). Prebronchodilator FEV1 was 62.9% of predicted for the BT group and 66.4% of predicted in the control group. BT subjects had a significant improvement in FEV1 (14.9 ± 17.4 vs −0.9 ± 22.3; P = .04) and in ACQ (−1.04 ± 1.03 vs −0.13 ± 1.00; P = .02).7Pavord I.D. Cox G. Thomson N.C. Rubin A.S. Corris P.A. Niven R.M. et al.Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma.Am J Respir Crit Care Med. 2007; 176: 1185-1191Crossref PubMed Scopus (360) Google Scholar While compelling, these trials were not blinded and the world's first sham bronchoscopy controlled trial (AIR2) was designed in consultation with the FDA. This multicentered, double-blind, sham bronchoscopy controlled trial enrolled a total of 288 patients to BT in a 2:1 fashion. This pivotal trial demonstrated a significant improvement in the AQLQ score as well as a reduction in the frequency of severe asthma exacerbations, emergency department visits, and days lost from school or work in the year after BT.8Castro M. Rubin A.S. Laviolette M. Fiterman J. De Andrade Lima M. Shah P.L. et al.Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial.Am J Respir Crit Care Med. 2010; 181: 116-124Crossref PubMed Scopus (579) Google Scholar On the basis of this trial, BT was approved by the FDA for the treatment of severe persistent asthma not controlled with high-dose ICS and LABA. FDA approval was made contingent on the performance of a postmarketing study (the PAS2 study). The 3-year follow-up results of this trial were recently published, confirming the results of the pivotal AIR2 study. As a registry study, it was not randomized or controlled and AQLQ scoring was not performed. However, it did demonstrate a reduction in severe exacerbations, emergency department visits, and hospitalizations by 45%, 55%, and 40%, respectively.9Chupp G. Laviolette M. Cohn L. McEvoy C. Bansal S. Shifren A. et al.Long-term outcomes of bronchial thermoplasty in subjects with severe asthma: a comparison of 3-year follow-up results from two prospective multicentre studies.Eur Respir J. 2017; 50: 1700017Crossref PubMed Scopus (88) Google Scholar BT is conceptually straightforward; however, achieving a successful outcome and building a successful BT program are not. The bronchoscopist should at minimum be trained and complete the BT curriculum as provided by the manufacturer. Although the bronchoscopist's skill and experience are of paramount importance, individual patient outcome and long-term program success are highly dependent on other factors, and a multidisciplinary approach to patient selection, patient preparation, patient management, postoperative care, and careful follow-up is essential. According to the latest 2014 American Thoracic Society (ATS)/European Respiratory Society (ERS) task force on severe asthma,10Chung K.F. Wenzel S.E. Brozek J.L. Bush A. Castro M. Sterk P.J. et al.International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma.Eur Respir J. 2014; 43: 343-373Crossref PubMed Scopus (2453) Google Scholar it was recommended that access to BT should not be limited as a form of therapy11Chung K.F. Wenzel S.E. Brozek J.L. ERS/ATS Task Force on Definition, Evaluation and Treatment of Severe Asthma. From the authors.Eur Respir J. 2014; 44: 267-268Crossref PubMed Scopus (5) Google Scholar but be performed in the context of a registry or clinical study; although we agree that all BT centers should keep track of their patient outcomes for quality control purposes, these same recommendations also pose an undue burden on the nonacademic practicing pulmonologist. There is a new ATS/ERS workshop, but it is unclear if BT will be readdressed at this time. The updated guidelines outlined here are based on the 2018 Global Initiative for Asthma recommendations and the expertise of the authors and their combined 34 years of experience in BT. A complete BT procedure requires 3 bronchoscopy sessions, each lasting less than 1 hour, spaced approximately 2-3 weeks apart.5Danek C.J. Lombard C.M. Dungworth D.L. Cox P.G. Miller J.D. Biggs M.J. et al.Reduction in airway hyperresponsiveness to methacholine by the application of RF energy in dogs.J Appl Physiol (1985). 2004; 97: 1946-1953Crossref PubMed Scopus (175) Google Scholar, 12Cox G. Miller J.D. McWilliams A. Fitzgerald J.M. Lam S. Bronchial thermoplasty for asthma.Am J Respir Crit Care Med. 2006; 173: 965-969Crossref PubMed Scopus (248) Google Scholar BT is performed during bronchoscopy with most patients undergoing moderate or deep sedation. All accessible airways (between 3 and 10 mm) distal to the mainstem are treated under bronchoscopic visualization with the right middle lobe typically being avoided due to concerns of right middle lobe syndrome.13Cox P.G. Miller J. Mitzner W. Leff A.R. Radiofrequency ablation of airway smooth muscle for sustained treatment of asthma: preliminary investigations.Eur Respir J. 2004; 24: 659-663Crossref PubMed Scopus (130) Google Scholar Although not recommended by the manufacturer, various sites have safely and successfully performed BT in the right middle lobe (RML) with no reports of BT-induced right middle lobe syndrome. Moving the Alair catheter from distal to proximal along the length of the visualized airway, contiguous and nonoverlapping activations are performed systematically from airway to airway. BT is performed using the Alair Bronchial Thermoplasty System that delivers RF energy—a combination of magnetic and electrical energy (electromagnetic energy). The system comprises the Alair RF Controller and the flexible Alair Catheter, a single use device with an expandable electrode array attached at one end and a deployment handle at the other. Under direct visualization through the working channel of a high-frequency compatible flexible bronchoscope, the electrode array is introduced and expanded to contact the airway walls. Only when the electrodes are appropriately contacting the airway walls, will activation of the Alair RF controller result in RF energy being delivered. RF energy is transferred from the electrode through the airway wall and is converted to thermal energy when absorbed preferentially by high-resistance tissue such as smooth muscle. With each activation, the Alair RF controller delivers the correct intensity and duration of RF energy. The controller also monitors the system, ensuring that energy is not delivered unless all accessories are properly connected. If activation is attempted while the electrode array is not in proper contact with the airway wall, a specific audible error sequence is sounded. A standard adhesive gel-pad patient return electrode is affixed on the patient and connected to the controller to provide a complete circuit. BT is best performed with an RF-compatible bronchoscope with an outer diameter of 4.9 to 5.2 mm and a minimum 2.0-mm working channel. Larger-diameter therapeutic bronchoscopes are not required and may limit access to airways, whereas thinner-diameter bronchoscopes are not usually necessary, are more difficult to navigate, and may have a working channel that is too small in diameter (Table I).Table IClinical pearls—equipment•Adhesive gel-pad return electrodes should not be placed on regions of the body that contain a lot of hair or excessive fat. Placing the gel-pad on a hairy/fatty region of the body could result in higher impedance. The higher system impedance could potentially trigger the high-energy 120J safety cutoff more often. This could result in a less effective treatment of the airway smooth muscle. Ideally, the adhesive gel-pad should be placed on areas of high muscle content (ie, back) with minimal hair (shaving may be required) and not on fatty regions of the body. Perform BT with a 2.0 working channel scope•The Alair BT system is the only FDA-approved equipment for BTBT, Bronchial thermoplasty; FDA, Food and Drug Administration. Open table in a new tab BT, Bronchial thermoplasty; FDA, Food and Drug Administration. A complete treatment of BT consists of 3 separate bronchoscopy sessions, each separated by approximately 2 to 3 weeks. Treatments are divided to minimize the risk of inducing an asthma exacerbation of diffuse airway edema and inflammation that might occur if the entire tracheobronchial tree is treated in 1 session. The first BT treatment is performed in the right lower lobe, the second in the left lower lobe, and the final in both the right upper and left upper lobes.12Cox G. Miller J.D. McWilliams A. Fitzgerald J.M. Lam S. Bronchial thermoplasty for asthma.Am J Respir Crit Care Med. 2006; 173: 965-969Crossref PubMed Scopus (248) Google Scholar During all prior clinical trials, the right middle lobe was not treated due to concerns of inducing right middle lobe syndrome. Of note, the lingula was treated. Longer-term studies have not seen an increase in bronchiectasis. The concerns for RML syndrome with BT have not been adequately studied.14Gudmundsson G. Gross T.J. Middle lobe syndrome.Am Fam Physician. 1996; 53: 2547-2550PubMed Google Scholar As a result of this theoretical concern with evidence of consistently low ventilation defects in the right middle lobe via hyperpolarized magnetic resonance imaging studies, various BT centers have safely and successfully treated the RML.15Thomen R.P. Sheshadri A. Quirk J.D. Kozlowski J. Ellison H.D. Szczesniak R.D. et al.Regional ventilation changes in severe asthma after bronchial thermoplasty with (3)He MR imaging and CT.Radiology. 2015; 274: 250-259Crossref PubMed Scopus (104) Google Scholar We recommend that during second and third bronchoscopy sessions, the previously treated BT airways be inspected to ensure proper healing before proceeding with the planned BT procedure. If the previously treated airways appear to have considerable inflammation (ie, significant erythema, edema, friable mucosa, narrowing of airway), consideration should be given to postponing the current treatment. Postponement of the BT procedure due to considerable airways inflammation is not common and should be tailored to the patient's clinical and airway findings. After a complete airway inspection, the bronchoscope is navigated to the targeted region of the lung. The bronchoscopist then formulates a sequential order in which airways will be accessed and treated and communicates the plan to his/her assistant. Having an organized treatment plan is critical to the completion of a proper and safe BT treatment session. A systematic approach working from distal to proximal, superior to more inferior, or from right to left, in a methodical organized fashion ensures that all regions are treated appropriately while minimizing the error of treating the same airway twice. Within each segment, the subsegmental airways should be properly explored and treated in a systematic manner. Although seemingly straightforward, it is striking how dramatically and rapidly the airways can change due to edema and bronchospasm, disorienting even experienced bronchoscopists. The Alair catheter is introduced into the working channel of the bronchoscope and advanced until the distal end is in view (Figure 1) within the targeted airway. The catheter is then expanded until the 4 electrode array wires are in contact with the airway wall. Proper contact of the electrodes is necessary for complete activation. Pressing and releasing the controller footswitch will initiate activation, and provided there is proper contact and there is no cancellation, the entire 10-second treatment cycle will be completed. Depressing the footswitch before completion of the treatment cycle will cancel and prematurely terminate the treatment—and sound the error sequence. After each activation, the electrode array should be partially collapsed and repositioned proximally 1 black line (5 mm) (Figure 1). The bronchoscopist should pay careful attention not to overlap the previous activation site. A detailed road “map” of the airways can assist in keeping track of the progression of treatments and assist in minimizing errors for each session (ie, treating the same airway twice). A recent study performed by Langton et al16Langton D. Sha J. Ing A. Fielding D. Thien F. Plummer V. Bronchial thermoplasty: activations predict response.Respir Res. 2017; 18: 134Crossref PubMed Scopus (35) Google Scholar described the importance of delivering the sufficient number of activations and the positive effect on clinical response. Using a regression equation, they recommend 40 activations to each of the lower lobes and 60 activations to the combined upper lobes to achieve an improvement in ACQ-5 score of 0.5 units. Although further validation studies are necessary, the BT proceduralist should be mindful that varying activations can significantly affect patient outcomes.16Langton D. Sha J. Ing A. Fielding D. Thien F. Plummer V. Bronchial thermoplasty: activations predict response.Respir Res. 2017; 18: 134Crossref PubMed Scopus (35) Google Scholar There are situations in which one of the electrodes on the Alair catheter becomes inverted or mucous buildup obscures visualization (Figure 2). When these problems are encountered, the Alair catheter should be completely removed from the bronchoscope, the electrode gently reshaped and cleaned, and the bronchoscope irrigated (Table II).Figure 2Inverted electrode array.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table IIClinical pearls—technique•Some patients require more than 2-3 wk to recover. Adequate time should be allowed for healing before the next BT procedure•While in the airway and before activating the Alair catheter, verification of the proposed targeted site for the current BT session by the bronchoscopist to the BT assistant and nursing staff helps assure treatment of the correct site•Authors at various sites have moved beyond direct end catheter visualization and advance the catheter until resistance is met; the Alair catheter is then repositioned back 5 mm before the first treatment is initiated with contiguous activations described above•When cleaning the electrode array, vigorously shake it within a bath of room temperature saline as cooling of the catheter wires may cause malfunction•After completion of the BT procedure, consider applying lidocaine through the bronchoscope to the treated regions to lessen postprocedural cough and pain (lidocaine limit of 600 mg or 8.2 mg/kg)BT, Bronchial thermoplasty. Open table in a new tab BT, Bronchial thermoplasty. Patients should be rigorously screened to (Figure 3): (1) confirm a correct diagnosis of asthma (includes phenotyping), (2) verify criteria for severe persistent asthma despite adherence to appropriate pharmacologic and nonpharmacologic interventions (at minimum high-dose ICS and LABA), (3) review and address comorbidities that could affect asthma control (eg, gastroesophageal reflux disease [GERD], postnasal drip, obstructive sleep apnea [OSA], smoking, vocal cord dysfunction), (4) reinforce medication adherence and proper inhaler technique, and (5) rule out contraindications to BT (ie, implantable electronic device, under 18 years of age, previously treated with BT). Although caution is advised in treating patients with an FEV1 < 65% of predicted, our clinical experience and case series indicate that patients with a mean FEV1 of 37% could safely undergo and benefit from BT17Doeing D.C. Mahajan A.K. White S.R. Naureckas E.T. Krishnan J.A. Hogarth D.K. Safety and feasibility of bronchial thermoplasty in asthma patients with very severe fixed airflow obstruction: a case series.J Asthma. 2013; 50: 215-218Crossref PubMed Scopus (43) Google Scholar(Tables III and IV).Table IIIPatient selection•Adults diagnosed with severe asthma as defined:10Chung K.F. Wenzel S.E. Brozek J.L. Bush A. Castro M. Sterk P.J. et al.International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma.Eur Respir J. 2014; 43: 343-373Crossref PubMed Scopus (2453) Google Scholar, 18Bel E.H. Sousa A. Fleming L. Bush A. Chung K.F. Versnel J. et al.Diagnosis and definition of severe refractory asthma: an international consensus statement from the Innovative Medicine Initiative (IMI).Thorax. 2011; 66: 910-917Crossref PubMed Scopus (298) Google Scholar○Alternative diagnoses to asthma have been excluded○Comorbidities have been treated and controlled○Triggers have been removed○Compliance with treatment regiments have been verified and checked○Symptomatic despite treatment with stable maintenance medication (ie, high-dose inhaled corticosteroids and long-acting β2-agonist)○Asthma that requires treatment with guidelines suggested medications for GINA19Global Initiative for Asthma (GINA)Global Strategy for Asthma Management and Prevention. Updated 2018.https://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-prevention/Date accessed: September 20, 2018Google Scholar step 4-5 asthma for the previous year or systemic corticosteroids for ≥50% of the previous year to prevent uncontrolled or which remains uncontrolled despite this therapy•Caution with prebronchodilator FEV1 <60% predicted—experienced BT centers may use lower cutoff•Able to undergo bronchoscopy safely•No internal pacemaker or neurostimulatorBT, Bronchial thermoplasty; FEV1, forced expiratory volume in 1 s; GINA, Global Initiative for Asthma. Open table in a new tab Table IVClinical pearls—patient selection•Patients with persistent asthma symptoms while currently on biologic therapy should be considered to undergo BT (or alternatively, “current or past asthma biologic therapy does not preclude BT”)•Consider environmental factors at the time of BT (ie, severe cold, forest fires, regional epidemic illness, eg, influenza) that could result in a severe exacerbation after BT and if necessary perform BT at another time•Perform BT earlier in the week to ensure ample time for follow-up and assistance if needed from the BT team•Patients with multiple comorbidities, near fatal asthma, or who have to travel great distances to receive treatment may benefit from staying overnight locally but should rarely need to be admittedBT, Bronchial thermoplasty. Open table in a new tab BT, Bronchial thermoplasty; FEV1, forced expiratory volume in 1 s; GINA, Global Initiative for Asthma. BT, Bronchial thermoplasty. The success of BT is dependent not only on proper patient selection but also on multiple other dynamic variables. The technical skill of the bronchoscopist and careful patient management during and after the procedure are both of great importance in ensuring patient safety and successful BT outcomes. It is therefore of paramount importance that the BT bronchoscopist complete the proper training from the manufacturer and that the BT team receive appropriate education and training. Proper analgesia, topical anesthesia, and anxiolytics are critical in providing comfort and reducing excessive cough and patient movement. The approach described will not only facilitate procedure efficiency but also increase overall patient satisfaction with the procedure. As with other medical procedures, the risk and benefits of bronchoscopy, BT, and sedation should be fully discussed with the patient. To mitigate the risk of an asthma exacerbation from postprocedure inflammation of the treated airways, patients should be given prophylactic prednisone or the equivalent at a dose of 50 mg/day for the 3 days before the procedure, the day of the procedure, and the day after the procedure.8Castro M. Rubin A.S. Laviolette M. Fiterman J. De Andrade Lima M. Shah P.L. et al.Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial.Am J Respir Crit Care Med. 2010; 181: 116-124Crossref PubMed Scopus (579) Google Scholar In the days preceding each procedure, the asthmatologist and/or BT-certified bronchoscopist should ensure that the patient:•Has not had a respiratory infection in the days preceding the procedure•Has not had a recent asthma exacerbation requiring oral corticosteroids within the last 14 days•Has started systemic steroids as directed. On the day of each procedure, reevaluation is necessary to ensure that the patient continues to be a good candidate for BT. Spirometry is performed to ensure that the patient is at his or her established baseline and to provide an FEV1 benchmark for comparison with the post-BT FEV1. Postponement of the procedure should be considered if any of the conditions listed in Table V applies. We also recommend that physicians follow their institution's established prebronchoscopy guidelines.Table VDay of bronchoscopyPostponement of BT should be considered if any of the following criteria is present:•Recent asthma exacerbation requiring oral corticosteroids with completion of oral steroids less than 14 d before BT•Active respiratory infection or other clinical signs of instability the day of or days preceding BT•Prophylactic prednisone or prednisolone was not started 3 d before BT•Increase in asthma symptoms within the last 48 h requiring ≥4 puffs/d over the pretreatment usage•SpO2 less than 90% on room air•During bronchoscopy, airways are extremely edematous or inflamed, or there are excessive, purulent/tenacious airway secretions•FEV1 on the day of the procedure is <20% of established baseline FEV1•Inability to complete the procedure due to excessive coughing, excessive secretions, and tortuous anatomy•Bronchoscopist discretion to postpone the BT procedureBT, Bronchial thermoplasty; FEV1, forced expiratory volume in 1 s. Open table in a new tab BT, Bronchial thermoplasty; FEV1, forced expiratory volume in 1 s. When performing BT under moderate sedation or monitored anesthesia care (MAC), the transnasal bronchoscopic approach tends to cause less gagging and fewer secretions, and is safe and well tolerated. Applying topical lidocaine jelly or liquid to the nostril(s) will assist in achieving an anesthetized and lubricated nasal passage. If there are concerns with epistaxis, phenylephrine or oxymetazoline spray or topical cocaine may be used.1Mayse M. Laviolette M. Rubin A.S. Lampron N. Simoff M. Duhamel D. et al.Clinical pearls for bronchial thermoplasty.J Bronchology Interv Pulmonol. 2007; 14: 115-123Google Scholar Supraglottic topical anesthesia is not usually required for deep sedation or general anesthesia. Transoral with moderate sedation or MAC and laryngeal mask airway (LMA) are better tolerated in patients with a history of nasal congestion and chronic sinusitis. Transnasal or transoral approaches are viable options depending on the individual patient and the BT bronchoscopists experience and comfort level. Anesthetizing the hypopharynx can be effectively achieved by having the patient gargle 5 mL of 2% lidocaine. An alternative or an adjunct to gargling lidocaine is to aerosolize the posterior pharynx with 1% to 2% lidocaine. Regardless of the technique, anesthetizing the posterior pharynx will assist in not only diminishing the patient's gag reflex but also systemic sedatives. Careful attention to the amount of lidocaine administered and mindfulness of systemic absorption of lidocaine will assist in decreasing the likelihood of lidocaine toxicity (Table III). After anesthetizing the patient's upper airway, the bronchoscopist should promptly apply topical anesthesia to the vocal cords and bronchial tree. At the vocal cord level, 1% lidocaine can be applied in 2-mL aliquots until the patient appears to be comfortable with minim" @default.
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• W2892355825 title "Bronchial Thermoplasty: A Decade of Experience: State of the Art" @default.
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