Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Bronchoscopic Lung Volume Reduction for Upper Lobe Emphysema

  Severe emphysema can leave parts of the lung permanently overinflated, reducing the space available for healthier tissue to work. When disease is concentrated in the upper lobes, bronchoscopic lung volume reduction (BLVR) may offer a less invasive alternative to surgery for carefully selected patients. The treatment aims to reduce trapped air and improve the mechanics of breathing.

  BLVR is an umbrella term covering several endoscopic techniques. The best-established option is endobronchial valve placement, which uses one-way valves to let air and secretions leave a diseased lobe while preventing new air from entering. Other approaches, including bronchial coils and thermal or biological methods, have different evidence bases and availability.

  The potential benefits are meaningful but not universal. Selected patients may experience improved exercise capacity, breathlessness scores and quality of life, although the procedure does not reverse the underlying chronic obstructive pulmonary disease (COPD). Careful imaging, lung function testing and assessment of collateral ventilation are central to deciding whether treatment is appropriate.

  For Australian patients, access is likely to depend on specialist expertise, hospital resources and local funding arrangements. Assessment may occur in major respiratory centres in Sydney, Melbourne, Brisbane, Perth or Adelaide, while patients from regional and rural areas may need coordinated travel and follow-up. Treatment decisions should be made through a multidisciplinary service rather than from scan findings alone.

  How Upper Lobe Emphysema Changes Breathing

  Emphysema destroys alveolar walls and reduces elastic recoil. In upper lobe-predominant disease, damaged areas may become highly compliant and retain air, especially during expiration. This hyperinflation pushes against more functional lung and the diaphragm, increasing the work required for every breath.

  A CT scan can show the distribution and severity of emphysema, while pulmonary function testing measures obstruction, residual volume and gas transfer. The pattern matters because BLVR generally works best when a clearly diseased target lobe sits beside better-preserved lung. A diffuse, evenly distributed pattern may offer less opportunity for meaningful volume reduction.

  Symptoms alone cannot identify suitable candidates. Breathlessness may also reflect pulmonary hypertension, cardiac disease, deconditioning, anaemia or ongoing smoking. These factors need assessment before attributing all functional limitation to an overinflated upper lobe.

  Endobronchial Valves and Other Techniques

  Endobronchial valves are placed during bronchoscopy under sedation or general anaesthesia. They are designed to block inhaled airflow into the selected lobe while allowing trapped gas and secretions to escape. As the lobe loses volume, adjacent lung may expand into the available space, potentially improving ventilation mechanics.

  A critical requirement is the absence of significant collateral ventilation between the target lobe and neighbouring lobes. Quantitative CT analysis can estimate fissure completeness, and some centres use specialised bronchoscopic testing to confirm whether air can bypass the valves. If collateral ventilation is substantial, valve treatment is less likely to produce lobar collapse.

  Coils and other bronchoscopic approaches may be considered in circumstances where valves are unsuitable, but their availability and supporting evidence vary. The choice depends on anatomy, emphysema distribution, local expertise and the balance between expected benefit and procedural risk.

  Selecting Patients Safely

  Typical assessment includes high-resolution CT, complete pulmonary function tests, oxygenation review, exercise testing and evaluation of exacerbation history. A patient should generally have severe symptomatic emphysema despite optimised inhaled therapy, smoking cessation support and pulmonary rehabilitation. Target-lobe destruction should be sufficiently marked, with a viable area of lung that may benefit from reduced compression.

  Active smoking is a major concern because it worsens disease progression and raises peri-procedural risk. Australian services commonly incorporate smoking cessation into COPD care, with support through general practices, hospital programs and Quitline services. Exposure to wood smoke, dust and seasonal bushfire haze may also aggravate respiratory symptoms, particularly in areas such as regional New South Wales, Victoria and South Australia.

  The team also considers frailty, frequent infections, bronchiectasis, severe hypoxaemia and cardiovascular disease. A person who cannot tolerate bronchoscopy or manage follow-up may not be a suitable candidate, even if the CT appearance seems favourable. Shared decision-making should cover realistic functional goals, the chance of no improvement and the possibility of later valve removal.

  Benefits, Risks and Follow-Up

  Clinical studies of valves in selected patients with severe emphysema have reported improvements in lung function, exercise performance and health-related quality of life. The greatest gains are usually seen when there is a strongly diseased target lobe, little collateral ventilation and enough functional reserve in the remaining lung.

  Pneumothorax is the most important early complication because the treated lobe may deflate rapidly while neighbouring lung expands. It can require observation, chest drainage or additional intervention. Other risks include pneumonia, COPD exacerbation, valve migration, bleeding and airway blockage by mucus. A planned post-procedure admission and prompt access to imaging are therefore important.

  Follow-up commonly includes chest imaging, symptom review, oxygen assessment and repeat lung function testing. Valves can sometimes be removed or repositioned if complications occur or if the intended response is not achieved. Patients should receive clear instructions about sudden chest pain, acute breathlessness, fever or a rapid change in sputum.

  Access and Governance in Australia

  BLVR is a specialised procedure rather than a routine treatment delivered in every bronchoscopy unit. Australian patients may be referred through a respiratory physician, COPD clinic or tertiary hospital. Public access, waiting times and private costs can vary between states and between metropolitan and regional services; a specific Medicare Benefits Schedule item or private insurance benefit should not be assumed without checking current arrangements.

  Devices used in Australia must meet applicable Therapeutic Goods Administration requirements, and hospitals apply their own credentialing, procurement and clinical governance processes. The treating centre should explain whether a proposed device is approved for the intended use, whether treatment is part of an established service or a study, and which costs are covered.

  Specialist multidisciplinary review is especially valuable when the patient lives outside a capital city. Telehealth can support some consultations, but CT review, bronchoscopy and early monitoring still require attendance at an equipped hospital. Planning transport, accommodation and access to urgent care is part of safe care for patients travelling from places such as northern Queensland, the Northern Territory or Western Australia.

  BLVR for upper lobe emphysema can provide a substantial improvement for the right patient, but it is a targeted intervention, not a general treatment for advanced COPD. The most reliable pathway combines smoking cessation, inhaler optimisation, vaccination, pulmonary rehabilitation and management of comorbidities with detailed anatomical assessment.

  The practical next step is to ask a respiratory physician for referral to a multidisciplinary lung volume reduction service for CT fissure analysis and formal suitability testing.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)