Bronchial thermoplasty for severe asthma: Systematic review and meta-analysis of benefits and harms

Background: The efficacy and safety of bronchial thermoplasty (BT) for severe asthma remains unclear. Objective: We systematically synthesized the efficacy and safety of BT in patients with severe asthma. Methods: As part of the upcoming American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology Joint Task Force on Practice Parameters severe asthma guidelines, we searched the Medline, Embase, and Central databases to July 29, 2025, for randomized trials comparing BT to control for asthma. Paired reviewers independently screened records and extracted data. Random-effects meta-analyses addressed asthma control (Asthma Control Questionnaire 6 [scale, 0-6; lower better]), asthma-related quality of life (Asthma Quality of Life Questionnaire [range, 1-7; higher better]), severe asthma exacerbations, and harms, stratified by procedural, postprocedural, and overall. The GRADE approach informed certainty-of-evidence ratings (PROSPERO: CRD42023408565). Results: Six trials randomized 573 adults. Procedurally, BT likely increases severe exacerbations (incidence rate ratio [IRR] 2.95; 95% CI, 1.20-7.25; risk difference [RD] 0.08 more events per patient-year; moderate certainty) and serious respiratory adverse events (IRR 5.98; 95% CI, 1.07-33.29; RD 0.18 more events per patient-year; moderate certainty). Postprocedurally, BT may reduce severe exacerbations (IRR 0.67; 95% CI, 0.50-0.89; RD 0.67 fewer events per patient-year; low certainty). Overall, BT may improve asthma control (mean difference -0.37; 95% CI, -0.67 to -0.07; RD for 0.5-point decrease: 15.9% more; low certainty), asthma-related quality of life (mean difference 0.55; 95% CI, 0.28-0.82; RD for 0.5-point increase: 19.1% more; low certainty), and severe exacerbations (IRR 0.81; 95% CI, 0.68-0.97; RD 0.11 fewer events per patient-year; low certainty). Conclusion: Among adults with severe asthma, BT may improve asthma control and asthma-related quality of life and may reduce overall severe exacerbations, but it likely increases procedural severe exacerbations and serious respiratory harms.