• lung volume reduction surgery
• chronic obstructive pulmonary disease

Most textbooks and many physicians now use the term “chronic obstructive pulmonary disease” (COPD) to define airflow obstruction that results from a variable combination of small airways disease and loss of elastic recoil due to emphysema. A detailed knowledge of the underlying pathology does not normally influence the treatment prescribed, with one important exception.¹ Patients who have large space occupying bullae visible on their plain chest radiograph can experience significant improvements in lung function and exercise capacity if these lesions are resected, a treatment that is now well established.² Initial attempts to extend this approach to include the resection of gross emphysematous areas of lungs were scorned by physiologists as being irrational and were associated with significant perioperative morbidity and mortality.³ The pressures of a lengthening lung transplantation waiting list led Cooper and colleagues to revisit this approach using modern techniques of intensive care and better surgical methods of strengthening the previously suspect suture lines between friable areas of lung. Their report of significant improvements in spirometry, breathlessness, and 6-minute walking distance after surgery compared with historical controls had a dramatic effect on thoracic surgical practice in the USA.⁴ Their findings were replicated by others using a variety of surgical approaches and techniques and were reported in a series of uncontrolled case studies⁵ which suggested variable benefit when meta-analysed.⁶ After some debate, this procedure is now known as lung volume reduction surgery (LVRS). Detailed physiological testing before and after surgery showed that there was a significant improvement in resting lung volumes in most cases, together with less dynamic hyperinflation during exercise,⁷ …