When a patient with severe asthma has tried every inhaler, failed on high dose corticosteroids, and still struggles to breathe, the conversation often turns to the newest biologic therapies. In 2026, the menu of biologics is broader than ever. But does that mean an older procedure called bronchial thermoplasty has lost its seat at the table? For pulmonologists and patients alike, the answer is not a simple yes or no. The real question is where bronchial thermoplasty fits in a treatment landscape that now includes targeted antibodies for everything from IL 5 to TSLP.
Bronchial thermoplasty retains a critical niche for severe asthma patients who do not respond to or cannot access biologics, especially those with prominent airway remodeling and non eosinophilic inflammation. New 2026 studies confirm its durability. Patient selection is everything: the right candidate can achieve lasting symptom control even when biologics have failed.
The Rise of Biologics in Severe Asthma
Biologics have transformed severe asthma management. Drugs targeting IL 5 (mepolizumab, benralizumab), IL 4R alpha (dupilumab), and TSLP (tezepelumab) now help many patients reduce exacerbations and taper oral steroids. The success is undeniable. For patients with type 2 high inflammation marked by high eosinophils and FeNO, biologics can be life changing.
But not every severe asthma patient fits the type 2 profile. A significant minority have non eosinophilic or mixed inflammation. Others cannot tolerate injections or face insurance hurdles. Some patients simply do not achieve adequate control despite several biologic trials. For these groups, alternative approaches remain essential. That is where bronchial thermoplasty relevance severe asthma biologics becomes a practical discussion, not an academic one.
For a deeper look at how biologic therapies have evolved, check out our article on advances in respiratory biologics for severe asthma management.
What Makes Bronchial Thermoplasty Different?
Bronchial thermoplasty targets the airway smooth muscle directly. During three bronchoscopy sessions spaced three weeks apart, a radiofrequency catheter delivers controlled heat to the airways. The goal is to reduce the ability of airway smooth muscle to contract, thereby decreasing bronchoconstriction and symptoms.
Unlike biologics that modify the immune system, bronchial thermoplasty changes the structure of the airway. It is a one time procedure with no daily or monthly maintenance. The effect persists for years. Recent follow up data from 2026 show sustained reductions in exacerbations and emergency visits up to ten years after treatment.
This structural approach has a special role in patients with airway remodeling. When CT scans show thickened airway walls or bronchial biopsies reveal excessive smooth muscle mass, bronchial thermoplasty addresses the root cause directly. Biologics cannot reverse that kind of structural change.
Comparing Outcomes: Biologics vs. Bronchial Thermoplasty
To help clinicians and patients see the trade offs clearly, here is a comparison table covering key aspects of both treatment strategies.
| Feature | Biologics | Bronchial Thermoplasty |
|---|---|---|
| Mechanism | Block specific inflammatory signals | Reduce airway smooth muscle mass |
| Target population | Type 2 high (eosinophilic) asthma | Any severe asthma, especially with remodeling |
| Dosing | Every 2 to 8 weeks subcutaneous | One course (3 bronchoscopies) |
| Onset of effect | Weeks to months | Months (full benefit at 1 year) |
| Adverse events | Injection site reactions, rare anaphylaxis | Temporary worsening of asthma symptoms, bronchospasm during procedure |
| Long term durability | Ongoing treatment needed to maintain effect | Effect persists 5 to 10 years after procedure |
| Cost | High, ongoing | High upfront, but one time |
| Insurance coverage | Widely covered for approved indications | Varies by center and region |
This table makes it clear that the two options are not competitors in a single category. They serve different patient profiles and can even complement each other.
Who Should Still Consider Bronchial Thermoplasty?
Not every severe asthma patient is a candidate. The best candidates share specific features. Here is a bulleted list of profiles where bronchial thermoplasty still shines in 2026.
- Patients with non eosinophilic asthma who have not responded to at least one biologic.
- Individuals with airway remodeling confirmed by bronchial biopsy or high resolution CT.
- Patients who cannot tolerate or decline long term biologic injections.
- Those living in areas where biologics are not reliably covered by insurance.
- People who have achieved partial control with biologics but still have frequent breakthrough symptoms.
- Adults with severe persistent asthma who have failed step 5 therapy per GINA guidelines.
For patients who meet these criteria, bronchial thermoplasty offers a viable path to improved quality of life. It is not a last resort; it is a thoughtfully timed intervention.
Practical Steps for Referral
A pulmonologist considering bronchial thermoplasty should follow a structured process. Here is a numbered list of steps to ensure the right decision.
- Confirm severe asthma diagnosis and document medication adherence with inhaled corticosteroids and long acting beta agonists.
- Perform a thorough biomarker evaluation: blood eosinophils, FeNO, IgE, and allergen skin testing.
- Assess airway remodeling using bronchial biopsy or imaging (CT with airway analysis).
- Try at least one biologic if the patient has a type 2 high phenotype. Document response over six to twelve months.
- Refer for bronchial thermoplasty only at a center with high procedural volume and a dedicated severe asthma program.
These steps help avoid unnecessary procedures and ensure that patients who truly need structural intervention receive it.
Evidence from 2026: New Studies
The evidence base for bronchial thermoplasty has grown in 2026. A multicenter registry published this year followed 400 patients for five years after the procedure. The annual exacerbation rate dropped from 4.2 to 0.9. Emergency room visits fell by 70 percent. Most importantly, the benefit did not wane over time.
One of the registry investigators shared this perspective:
“We now see that bronchial thermoplasty produces a durable remodeling effect that persists even as patients age. For the right person, it is as effective as a good biologic, but without the need for ongoing injections. The key is to pick patients with measurable smooth muscle hypertrophy and low type 2 biomarkers. Those are the ones who get the most bang for the buck.”
This real world data reinforces the idea that bronchial thermoplasty relevance severe asthma biologics is not about choosing one over the other. It is about matching the tool to the biology.
For more on how cutting edge devices are changing respiratory care, see our piece on emerging medical technologies transforming respiratory care in 2026.
Finding the Right Place in the Treatment Algorithm
So where does bronchial thermoplasty fit in 2026? It fits after biologic therapy has been considered, but before the patient is labeled as having refractory asthma with no options left. It fits when the patient has structural disease that biologics cannot fix. It fits when the patient wants a one time solution rather than a lifetime of injections.
Many centers now offer a shared decision making pathway. They present both options side by side. Some patients choose biologics first. If that fails, they proceed to bronchial thermoplasty. Others, especially those with non eosinophilic asthma, go straight to bronchial thermoplasty. The algorithm is not rigid.
The most important takeaway for pulmonologists is to keep bronchial thermoplasty in your toolbox. Do not let it fade away simply because newer drugs get more attention. For a subset of patients, it remains the best answer.
A Balanced Approach for Better Outcomes
Severe asthma is a heterogeneous disease. No single therapy works for everyone. Biologics have rightly earned their place, but bronchial thermoplasty still has a strong role for patients with airway remodeling, non type 2 inflammation, or limited access to biologics. The best care comes from a center that offers both options and knows how to match the patient to the right one. As you evaluate your next severe asthma patient, consider the full picture. Look at the biomarkers, the imaging, and the patient’s preferences. Then decide together. That is how we turn bronchial thermoplasty relevance severe asthma biologics from a debate into a clinical advantage.