Bronchial Thermoplasty in Severe Asthma: Bridging Randomised and Real-World Evidence: A Systematic Review and...

Introduction: Bronchial thermoplasty (BT) reduces airway smooth muscle and may benefit severe asthma, but its role alongside biologics remains unclear. We assessed randomised and real-world evidence on efficacy and safety. Methods: We searched PubMed, Scopus, and Cochrane Library for RCTs and observational studies of BT in adults with severe uncontrolled asthma, analysing them separately. Results: Twenty studies were included (five RCTs, 15 observational). In RCTs, BT improved asthma-related quality of life (AQLQ;MD, 0.69; 95% CI 0.30-1.09), asthma control (ACQ; MD,-0.64; 95%CI, -1.10 to -0.19), and morning peak expiratory flow (MD, 20.62 L/min; 95% CI, 4.92-36.32), but did not improve rescue medication use or symptom-free-days. BT increased the risk of hospitalisation during the treatment period (RR, 3.50; 95%CI, 1.26-9.68), with no significant excess thereafter. Real-world studies showed improvements in AQLQ (MD,1.38; 95%CI, 0.97-1.80), ACQ (MD,-1.24; 95%CI, -1.86 to -0.62), and annualised exacerbation rates (MD, -3.79 exacerbations/patient-year; 95%CI, -6.98 to -0.61). Evidence suggested a possible, inconsistent corticosteroid-sparing effect; data on biologics and long-term safety were limited. Conclusions: BT improved asthma-related quality of life and control, mainly in trials without sham controls, but increased short-term hospitalisation risk. Real-world findings were similar but came from uncontrolled studies. BT is not an established alternative to biologics, but may suit carefully selected patients with severe asthma who cannot use or do not respond to them.