Endobronchial Lung Volume Reduction

Emphysema is a form of chronic obstructive pulmonary disease, or COPD, in which the walls of the tiny air sacs are destroyed. Air enters the damaged areas easily but cannot leave them fully, so the lungs stay overinflated, a state called hyperinflation. The chest becomes barrel-shaped, the diaphragm flattens and the breathing muscles lose their mechanical advantage. Lung volume reduction aims to remove or shrink the most damaged, air-trapping part of the lung so that the remaining lung can expand and the diaphragm can move better. Surgery can do this by cutting out the damaged tissue, but the endobronchial approach works from inside the airways. One-way valves, small silicone and metal devices, are placed in the airways supplying the target lobe; they let air and mucus out but block air from entering, so the lobe gradually collapses. Coils, which work by compressing damaged tissue, are offered in fewer centres.

This treatment is considered for people with severe emphysema who remain significantly breathless in daily life despite optimal inhaler treatment, stopping smoking and a completed course of pulmonary rehabilitation. Breathing tests must show severe airflow obstruction together with marked hyperinflation, meaning a large volume of air is left in the lungs after breathing out. A CT scan then identifies a target lobe, typically the most damaged one, and it is used both where damage is concentrated in one area and, in selected cases, where it is spread more evenly. It is not suitable when breathlessness is mainly due to heart disease, when there are frequent chest infections or bronchiectasis, very large single air pockets called bullae, or significant pulmonary hypertension. It is one option among several, alongside surgical volume reduction and, for some, lung transplantation, and a specialist team discusses which fits your lungs and general health.

The procedure is done under general anaesthesia or deep sedation. A flexible bronchoscope is passed through the mouth into the airways of the chosen lobe. If collateral ventilation has not already been excluded from the CT scan, a small balloon catheter can be used first to block the lobe's airway and measure whether air still flows in from neighbouring lobes; if it does, valves would not make the lobe collapse, and they are not placed. When the lobe is suitable, the team sizes each airway branch and places usually three to five valves through the bronchoscope, sealing off the whole lobe. The session usually takes about 30 to 60 minutes. A chest X-ray is taken afterwards, and you are observed on a ward for several nights, because the shrinking lobe can tug on the lung surface and cause a leak of air, most often in the first few days.

Selection is the most important step. You need to have stopped smoking, usually for at least several months, and teams commonly check this with breath or blood tests. You will have full breathing tests including lung volumes and gas transfer, a walking test, a heart assessment that may include an echocardiogram, and a high-resolution CT scan of the chest, which is analysed with software to grade emphysema in each lobe and to check that the fissures between lobes are complete. Most programmes require a completed course of pulmonary rehabilitation, because fitter patients recover better and some no longer need the procedure. Your usual inhalers are optimised, and any chest infection must be treated and settled beforehand. International patients can usually send recent breathing tests and the CT images in their original digital format in advance, so the team can say early whether there is a suitable target lobe.

After the procedure most people stay in hospital for about three to five nights, with regular checks and chest X-rays, because a pneumothorax is most likely during this period. Some people feel better within days, while for others the lobe collapses more slowly and the improvement builds over the following weeks. Coughing and some breathlessness at first are common. Light walking can start straight away, and pulmonary rehabilitation continues once you are home. For travel, plan a longer stay than for a routine bronchoscopy: a pneumothorax can still occur in the first weeks, and flying is usually delayed for several weeks after the procedure, on the advice of your team and often after a follow-up X-ray. A follow-up visit at about one to three months, in person or with your home specialist, assesses the result and checks the valves are in the right place.

The main risk is a pneumothorax, a leak of air between the lung and the chest wall, which occurs in a meaningful minority of patients, mostly within the first days. Many need a chest drain and a longer hospital stay, and a few need a valve removed or further surgery. Other possible problems include a flare-up of COPD, pneumonia, coughing up blood, and a valve that moves, is coughed up or causes scar tissue, which may need a repeat bronchoscopy to adjust or replace it. Because valves can be removed, the treatment is reversible if it does not help. When the target lobe collapses as intended, people typically report less breathlessness, can walk further and have better breathing test results and quality of life. Not everyone responds, especially if the lobe does not fully collapse, and the treatment does not cure emphysema or stop it from progressing.