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It is an interesting time for the management of emphysema. In this condition, destruction of lung parenchyma associated with reduced elastic recoil and dynamic airways closure produce gas trapping and increased operating lung volumes, leading to breathlessness and exercise limitation. It has historically been defined as an irreversible process, which has led to a degree of therapeutic nihilism. One manifestation of this has been the curious neglect of lung volume reduction surgery (LVRS). Clinical guidelines,1 reflecting trial evidence,2 recommend consideration of LVRS in selected patients with upper lobe predominant emphysema and poor exercise capacity, the phenotype where surgery has been shown to produce a survival benefit. Modern surgical techniques, unilateral treatment and improved postoperative care and patient selection mean that LVRS is also associated with lower morbidity and mortality than data published at the turn of the century had suggested,3 ,4 with one recent case series reporting zero 90-day mortality following unilateral surgery.5
Nevertheless, little effort seems to be going into identifying this patient population and LVRS remains vastly underused with just 90 procedures taking place in the UK in 2010–2011. A partial explanation for this may be found in a recent survey of British Thoracic Society members that revealed that a significant proportion overestimated the morbidity and mortality associated with LVRS.6 Only 30% had access to a dedicated chronic obstructive pulmonary disease (COPD) multidisciplinary meeting to review patients, and there was no consensus as to the correct strategy to adopt to identify appropriate patients.
Over the last decade, bronchoscopic approaches for lung volume reduction in emphysema have proliferated. These include one-way endobronchial valves to induce lobar collapse,7–10 airway bypass approaches to create low-resistance extra-anatomical pathways that allow trapped …