• Print

Asthma can be difficult to treat, so physicians at the Yale Center for Asthma and Airways Disease (YCAAD) are keen on finding new therapeutic approaches to treat severe cases. Now they are able to offer bronchial thermoplasty (BT), a new procedure made possible by the first FDA-approved device that uses radiofrequency energy to treat moderate to severe asthma.

YCAAD is the only center between Boston and New Jersey to offer BT and one of 30 centers in the country to participate in a phase IV post-market trial of the new device. The center’s multidisciplinary approach creates an ideal setting for the procedure, which uses a bronchoscopically introduced catheter with an electrode that is expanded to gently heat the airways. Studies leading to FDA approval of the procedure showed that it significantly mitigated asthma symptoms and flares of disease, improving quality of life.

Under the direction of Geoffrey Chupp, MD, and co-directed by Lauren Cohn, MD, thousands of patients visit YCAAD every year. “We now have a number of treatments for severe asthma, so we customize the treatment approach for every patient and determine if they’re a candidate for BT or some other advanced or investigational treatment for their asthma,” said Dr. Chupp.

Jonathan Puchalski, MD, director of the Thoracic Interventional Program, performs the procedure with the help of a team that includes Kimberly Ebel, RN, Suzanne Koshis, RN, and Kelsey Johnson, PA. Because BT can trigger an asthma attack en route to treating the patient’s asthma, it must be done in three sessions over a period of about three months. Patients are monitored closely before or after the procedure and admitted to the hospital if needed. “Technically it’s not significantly different than a lot of the therapeutic maneuvers that we already do with the flexible scope,” said Dr. Puchalski, who does bronchoscopies on a daily basis.

One patient who had the procedure has suffered from severe asthma his entire life. With poor lung function, he was chronically short of breath and had trouble exercising. Like many patients who undergo BT, his asthma worsened immediately after the procedure for a brief period. After four months, however, he decreased his medications, no longer uses a rescue inhaler when playing sports, and has increased his heart rate by 20 points when exercising on a treadmill. His lung function has slightly improved. “This is exactly the clinical response you would predict based on the trials evaluated by the FDA. The patient is pleased he went through the procedure,” said Dr. Chupp.

Patients undergoing BT are followed by a team that includes Nicole Grant, RA, and Carol Holme, who provide ongoing assessment immediately after the procedure, and Radhika Nandlal, RN, who sees them when they return to YCAAD over the long term.

“Yale is unique in that in YCAAD there’s a whole clinical realm for asthma care, but there’s also a correlate in the advanced bronchoscopy program,” said Dr. Puchalski. “I think combining those areas is extremely useful.”

YCAAD’s multidisciplinary team also includes Anish Sheth, MD, a gastroenterologist who treats asthma patients for problems related to gastroesophageal reflux disease; Eugenia Vining, MD, an otolaryngologist who treats sinus disease; and Ida Hsu, MD, a newly recruited allergist.

As the only major asthma center in the Northeast, YCAAD is also an important research center that offers unique opportunities to understand the biological pathways at the root of asthma as well as improve existing treatments. In 2007, Dr. Chupp and Jack Elias, MD, chair of the Department of Internal Medicine, found that asthmatic patients have high levels of the protein YKL-40, which helps regulate the immune response and causes lung inflammation. They went on to show that those with a particular mutation in the YKL-40 gene are at greater risk of developing asthma and have lower lung function.

Drs. Chupp, Cohn and Puchalski are also searching for biomarkers that predict response to BT and believe that the YKL-40 mutation or blood level is a good candidate as YKL-40 levels appear to decrease significantly after BT. “YKL-40 might be a clinically useful marker of responsiveness,” said Dr. Chupp.

YCAAD has a large sample repository that includes clinical and physiologic data, DNA, plasma and lung specimens from asthma patients who are stable or flaring. All of this data is uploaded into a web-based database so that information is readily available, making it easier to recruit patients for clinical trials and identify those that could benefit from specific treatments like BT. “We’re trying to get better at figuring out what therapy is best for what person,” said Dr. Cohn. “Because we see so many patients with this disease, we really are starting to understand how to group our patients and how to get the sense of who might need BT.”

For more information about YCAAD, visit the center's new website at http://ycaad.yale.edu.

Front page photo: John Puchalski, MD, works with a team to perform a bronchoscopy.