This case report described improvements in the exertional breathing pattern as the novel mechanism by which BT improved exertional dyspnea in a patient with intractable asthma. BT is a bronchoscopic treatment that can ameliorate the subjective symptoms of severe bronchial asthma that is difficult to control [
5‐
9]. In the future, BT is expected to be one of the treatment strategies for severe asthma. However, the mechanisms by which BT improves the subjective symptoms of asthma without significantly changing the resting pulmonary function [
6,
8] are yet to be elucidated. Exertional dyspnea is a common symptom in asthma, and the mechanisms of it in asthma are complex [
10]. In the present case, we focused on the pattern of exertional ventilation because minute ventilation (
\( {\dot{\text{V}}}_{\text{E}} \)) decreased during exercise after BT (Fig.
2a). Although not all asthmatics develop dynamic hyperinflation (DH) [
10], before BT in this case, the patient presented with DH during mid-exercise at pre-BT, because, based on the finding that the expiratory tidal volume (V
Tex) reached a plateau followed by a sharp increase in respiratory frequency (f
R). At 1 year after BT, the breathing pattern of DH improved (Fig.
2b, c). Similarly, a study by Thomen et al. [
11] used a combination of helium 3, magnetic resonance imaging, and CT to demonstrate that after BT, the ventilation defects decreased with time.
Although improvement of DH was important, the reduced
\( {\dot{\text{V}}}_{\text{E}} \) requirement throughout exercise and the prolonged exercise time obtained in the present case were noteworthy (Fig.
2a and Table
2). Considering that both V
Tex and f
R during exercise were reduced after BT (Fig.
2b, c), exertional dyspnea, especially during mid-exercise, may have pathophysiologic mechanisms other than the occurrence of DH only in the late exercise phase. V
Tex exceeded inspiratory tidal volume (V
Tin) form resting to peak exercise, especially at 1 year after BT (Fig.
2d). This implied that the patient could exhale sufficiently after BT, which improved both the static and dynamic hyperinflation throughout exercise. Furthermore, mean expiratory flow (V
Tex/expiratory time: Te) was reduced throughout exercise (Fig.
2e). We deduced that the obtained ventilation pattern at 1 year after BT might be related to the decrease in respiratory resistance during expiration (Table
1 and Fig.
1), and may have been affected by a reduction in the airway smooth muscle by BT, as demonstrated in multiple studies [
12]. After BT, the sufficient exhalation obtained increased the time for inhalation, as shown by the increase in the inspiratory duty cycle (Ti/Ttot) (Fig.
2f) from resting to peak exercise, and shortened the time for the expiratory flow-volume curve to reach a nadir (Fig.
1). In general, the Ti/Ttot at rest is lower in asthmatics than in normal subjects [
13,
14]; however, the exertional relationship between Ti/Ttot and dyspnea has not been studied completely. On the other hand, in patients with chronic obstructive pulmonary disease, we have confirmed that under similar ventilation conditions during exercise, the ability to absorb oxygen was higher when the Ti/Ttot increased than when the Ti/Ttot decreased [
15]. Therefore, the increase in the ventilation equivalent for oxygen was suppressed during the late exercise phase (Fig.
2g); this implied that adequate ventilatory efficiency to absorb oxygen was obtained after BT. Laveneziana et al. [
16] reported that the predominant exertional symptom in asthmatics was increased inspiratory effort, rather than expiratory effort, regardless of the presence of DH. Given the report, after BT in the present case, the longer inspiration time obtained by exhalation of enough trapped air may have led to effective and effortless pattern of breathing and reduction of the asthmatic symptoms during exercise (Fig.
2h).
There were some limitations of the present case study. First, although FOT might not be universally accepted, detailed analyses, including bronchial challenge test, should have been performed to confirm the presence of bronchial responsiveness before and after BT. Second, monoclonal antibody treatment prior to invasive BT should have been indicated in the present patient. However, in the light of the cost of prolonged asthma therapy [
17], BT was chosen instead monoclonal antibody treatment for the present case. BT could become costly and therapeutically effective, if the mechanisms by which BT improves the symptoms of asthma are elucidated and if the patients who can respond to BT are identified.