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 Advanced COPD

  Advanced chronic obstructive pulmonary disease can leave patients breathless after a short walk, shower, or conversation. The problem is often severe air trapping: damaged lung regions remain overexpanded, limiting the space available for healthier lung tissue and making each breath inefficient.

  Bronchoscopic lung volume reduction offers a less invasive way to address this hyperinflation in carefully selected patients. Endobronchial valves, lung volume reduction coils, and other bronchoscopic techniques require detailed testing, experienced respiratory teams, and realistic discussion about benefits, risks, access, and long-term follow-up.

  Why Hyperinflation Changes Breathing

  In emphysema, destruction of alveolar walls reduces elastic recoil. During exhalation, small airways can collapse before trapped air escapes. The lungs become chronically inflated, the diaphragm flattens, and the respiratory muscles work harder. This explains why a patient may feel breathless even when resting oxygen levels appear acceptable.

  Bronchoscopic treatment aims to reduce the volume of the most damaged lung areas. Endobronchial valves are one-way devices placed into selected airways. They allow trapped air to leave while preventing fresh air from entering, potentially producing lobar atelectasis and giving relatively healthier lung regions more room to function.

  The treatment does not repair emphysema or remove the underlying cause of COPD. Its value lies in improving mechanics, exercise tolerance, and sometimes quality of life for patients whose disease pattern matches the treatment criteria.

  Selecting Patients For Valve Treatment

  Selection is more complex than confirming severe airflow obstruction. A respiratory physician will usually review high-resolution CT imaging, lung volumes, gas transfer, exercise capacity, symptom burden, smoking status, exacerbation history, and current inhaled therapy. The distribution of emphysema matters, as does the presence or absence of collateral ventilation between lung segments.

  Pulmonary rehabilitation and smoking cessation remain essential before considering an intervention. Patients may need optimisation of inhaler technique, vaccinations, nutrition, oxygen assessment, and treatment of anxiety or sleep-related breathing problems. A good “have a yarn” about expectations is important because the procedure may improve breathlessness without restoring normal lung function.

  Educational forums connected with respiratory medicine, such as the big-five lung diseases workshop, can help clinicians place bronchoscopic interventions within the broader management of complex lung disease.

  Treatment approach	Best suited to	Main potential benefit	Important limitations
  Endobronchial valves	Heterogeneous emphysema with little collateral ventilation	Reduced hyperinflation and improved exercise capacity	Pneumothorax, valve migration, mucus plugging, repeat bronchoscopy
  Lung volume reduction coils	Selected patients where valves are unsuitable	Mechanical reduction in overinflated lung regions	Variable availability, technical complexity, respiratory complications
  Surgical lung volume reduction	Carefully selected upper-lobe predominant emphysema	Larger and sometimes durable volume reduction	Major surgery, longer recovery, higher perioperative risk
  Lung transplantation	End-stage disease with appropriate overall fitness	Potential survival and quality-of-life benefit	Donor shortage, lifelong immunosuppression, extensive assessment
  Medical and rehabilitative care	Every patient with COPD	Symptom control and reduced exacerbation risk	Does not directly remove severely hyperinflated tissue

  How Assessment Works In Australia

  Australian assessment commonly involves a tertiary respiratory service, often through a public hospital such as Royal Prince Alfred Hospital in Sydney, The Alfred in Melbourne, or a major Queensland centre. The pathway may include a COPD specialist, interventional bronchoscopist, thoracic radiologist, physiotherapist, respiratory nurse, and thoracic surgeon.

  Access can differ between metropolitan and regional patients. Someone living in regional New South Wales, Western Australia, or far north Queensland may need several trips for CT analysis, lung function testing, bronchoscopy, and follow-up. Telehealth can reduce some travel, but procedural planning still requires face-to-face assessment and a hospital with suitable expertise.

  Funding and availability also influence decisions. Public referrals may involve waiting lists and strict eligibility criteria, while private pathways depend on insurance, specialist access, and hospital capability. The cost discussion should include the device, procedure, possible admission for pneumothorax, rehabilitation, and follow-up imaging rather than focusing only on the initial bronchoscopy.

  Culturally safe care is particularly important for Aboriginal and Torres Strait Islander patients, whose respiratory health may be affected by housing, remoteness, occupational exposure, and access to preventive care. Involving Aboriginal health workers, interpreters, family, and local services can make the assessment more practical and trusted.

  Comparing Benefits And Risks

  Clinical trials have shown that appropriately selected patients can experience meaningful improvements in forced expiratory volume, residual volume, six-minute walking distance, and health-related quality of life after valve treatment. The response is not uniform, and a technically successful procedure does not guarantee that a person will feel dramatically different.

  Pneumothorax is the key early complication, particularly when a treated lobe rapidly loses volume and the neighbouring lung expands. Patients are commonly observed in hospital after valve placement, with chest imaging and a clear plan for managing pain, breathlessness, or an air leak. Other risks include pneumonia, haemoptysis, valve blockage, COPD exacerbation, and the need for valve removal or repositioning.

  The decision should therefore compare bronchoscopic therapy with continued medical care, surgical reduction, or transplantation. Age alone should not determine suitability. Functional reserve, frailty, pulmonary hypertension, cardiac disease, nutrition, social support, and the patient’s goals are all relevant.

  Practical Priorities For Safer Care

  A multidisciplinary team can make the pathway clearer by agreeing on objective criteria, documenting baseline function, and planning follow-up before the procedure. Useful priorities include:

  • Confirm persistent smoking cessation and optimise inhalers, vaccinations, oxygen assessment, and pulmonary rehabilitation.
  • Use quantitative CT and collateral ventilation testing to identify a target lobe with meaningful emphysema and a low likelihood of valve failure.
  • Discuss expected gains in walking, daily activities, and breathlessness rather than promising a cure.
  • Explain pneumothorax symptoms, hospital observation, emergency contacts, and the possibility of further bronchoscopy.
  • Coordinate public, private, regional, and Aboriginal health services so travel and follow-up are realistic.
  • Record baseline spirometry, lung volumes, exercise capacity, exacerbations, and patient-reported quality of life.

  Patient selection remains the central safeguard. A person with advanced COPD may be highly symptomatic yet unsuitable if emphysema is too uniform, collateral ventilation is present, infection is uncontrolled, or overall health makes the procedure unsafe.

  For an Australian respiratory service, the practical takeaway is to treat bronchoscopic lung volume reduction as a carefully staged program: optimise the basics, verify the anatomy, involve the full team, and match the intervention to outcomes the patient genuinely values.

  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)