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)

• Novel endobronchial valve therapies for advanced emphysema

  Advanced emphysema can leave people breathless after a short walk, shower or conversation. Damaged lung tissue traps air, overinflates the chest and forces healthier areas and the diaphragm to work inefficiently. When inhalers, smoking cessation support, oxygen assessment and pulmonary rehabilitation no longer provide enough relief, bronchoscopic lung volume reduction may be considered.

  Endobronchial valves are small, one-way devices placed through a bronchoscope. They allow trapped air to escape from a targeted lobe while limiting the entry of new air. As the treated lobe deflates, adjacent lung may expand more effectively. This therapy is relevant to selected Australians with severe hyperinflation, although suitability, hospital access and funding arrangements vary between respiratory centres.

  Treatment approach	How it works	Main advantage	Important limitation
  Endobronchial valves	Block airflow into a diseased lobe while allowing air out	Minimally invasive and potentially reversible	Works best when collateral ventilation is absent
  Lung volume reduction surgery	Removes the most damaged lung tissue	Can produce substantial volume reduction in carefully selected patients	Greater surgical risk and recovery burden
  Medical treatment and rehabilitation	Improves airway function, fitness and symptom control	Available across Australia and valuable for every stage of COPD	Does not remove severely overinflated lung
  Lung transplantation	Replaces diseased lungs	Option for advanced, life-limiting disease in selected patients	Limited donor supply and demanding lifelong care

  How one-way valve therapy works

  A specialist uses a flexible bronchoscope, usually under sedation or general anaesthesia, to examine the airways and place valves in the bronchial branches supplying a target lobe. During exhalation, gas can leave the treated region. During inhalation, the valve closes, reducing fresh airflow into the damaged area.

  The aim is atelectasis, or controlled collapse, of the most emphysematous lobe. This can reduce residual volume and improve the mechanical position of the diaphragm. People may notice better walking capacity, less breathlessness and improved quality of life, although the response differs considerably between individuals.

  Valve treatment is not a cure for chronic obstructive pulmonary disease. The remaining lung remains vulnerable to infection, exacerbations and progressive damage. Continued inhaler use, vaccination, exercise training and avoidance of tobacco smoke remain important after the procedure.

  Selecting the right person

  The strongest candidates generally have severe, heterogeneous emphysema, marked lung hyperinflation and significant symptoms despite optimised treatment. Assessment commonly includes high-resolution CT, pulmonary function testing, exercise evaluation and a review of exacerbation history. Measurements such as FEV1, residual volume and diffusing capacity help define risk and potential benefit.

  A crucial question is whether air can pass between neighbouring lobes through damaged or incomplete fissures. This is called collateral ventilation. If collateral ventilation is present, air may continue entering the target lobe through alternative pathways, preventing effective deflation. CT fissure analysis and, in some services, the Chartis assessment system can help determine eligibility.

  The patient also needs enough functional reserve to tolerate a temporary change in ventilation. Active respiratory infection, uncontrolled asthma, severe pulmonary hypertension, frequent unstable exacerbations and certain cardiac conditions may increase risk. A respiratory physician should review the whole clinical picture rather than relying on a single scan result.

  Benefits and risks to discuss

  Clinical trials have shown that appropriately selected patients can achieve reductions in hyperinflation, improved lung function and better exercise tolerance after endobronchial valve implantation. Benefits may develop over weeks as the treated lobe loses volume and the chest wall and diaphragm adapt.

  The principal early complication is pneumothorax, caused when the untreated lung expands against a weakened area and air leaks into the pleural space. Risk is high enough that patients are usually observed in hospital after treatment, often with chest imaging and access to prompt drainage if required. In an Australian public hospital, the length of admission can depend on bed availability, the pneumothorax course and local protocols.

  Other possible problems include coughing, chest discomfort, valve migration, mucus obstruction, pneumonia and worsening breathlessness. Valves can usually be removed bronchoscopically if necessary, which gives the therapy a degree of reversibility that surgery does not provide. Follow-up remains essential because valve position and lung response may change.

  The Australian treatment pathway

  In Australia, evaluation is usually coordinated by a tertiary respiratory service with expertise in advanced COPD, interventional bronchoscopy and pulmonary rehabilitation. Patients may be referred through a general practitioner, private respiratory physician or hospital respiratory clinic. Services are concentrated in major centres such as Sydney, Melbourne, Brisbane, Perth and Adelaide, so people from regional New South Wales, Queensland or Western Australia may need to travel.

  The work-up often involves a multidisciplinary team including a respiratory physician, interventional bronchoscopist, radiologist, respiratory scientist, physiotherapist and anaesthetist. Before a procedure, the team may check inhaler technique, nutrition, exercise capacity, vaccination status and readiness to manage a hospital stay. “Doing the rehab” is commonly treated as part of preparation, rather than an optional extra.

  Access is shaped by public hospital capacity, private insurance, device availability and local funding arrangements. Medicare may cover eligible consultations and hospital services, but the specific valve procedure, consumables and out-of-pocket costs should be clarified with the treating centre. People living far from a metropolitan hospital also need a plan for transport, accommodation and follow-up imaging.

  Living with the result

  A valve procedure works best as part of a broader emphysema management plan. Pulmonary rehabilitation can improve strength and confidence after the lungs have been mechanically unloaded. Regular walking or prescribed exercise, adequate protein intake, action plans for flare-ups and timely treatment of infections all support recovery.

  Smoking cessation remains one of the most effective ways to slow further lung damage. Australian patients may use Quitline services, local Aboriginal Community Controlled Health Organisations or respiratory programs through public hospitals. For Aboriginal and Torres Strait Islander peoples, care should be culturally safe and coordinated with trusted local health teams, particularly when specialist travel is required.

  The practical takeaway is to seek assessment at an experienced respiratory centre, bring recent lung tests and CT imaging, and ask specifically about collateral ventilation, pneumothorax planning, hospital observation, rehabilitation and total costs. Endobronchial valves can offer meaningful relief for the right person, but careful selection and structured follow-up are as important as the implantation itself.

  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)