Table 1

Approach to selecting patients with emphysema for a possible lung volume reduction procedure

General criteria when considering a lung volume reduction procedure
▸ Significantly reduced exercise capacity.
▸ Lung function impairment with significant hyperinflation.
▸ Sufficiently well to cope with surgery.
▸ Prepared to accept some procedural risk (requires clinicians to be able to communicate this accurately).
▸ There is a ‘window of opportunity’ for intervention. In ‘end-stage’ patients, it may be too late to intervene safely.
▸ Are they too well to consider intervention?▸ Lung function, exercise capacity, prognosis, Medical Research Council dyspnoea score <3
▸ Are they too unwell for intervention to be safe?▸ Lung function, frailty, exercise capacity <100 m, oxygen dependence
▸ Is treatment optimal?▸ Smoking cessation, pulmonary rehabilitation, flu vaccination, inhaled and oral medication
▸ Is their lung function likely to rule out a procedure on safety grounds?▸ All three of FEV1, TLco and Kco <20% predicted
▸ Do they have comorbidities that limit likely benefit or increase risk?▸ For example, pulmonary hypertension, unstable cardiac disease, malignancy, cerebrovascular disease. Ongoing smoking (possibility of intervention may help to promote quit attempts)
▸ Have they ever had a CT thorax and if so has it been reported in terms of emphysema pattern?▸ Review existing CT's or obtain a CT if a potential candidate as above
Review CT and lung function in multi-disciplinary teams including respiratory physician, radiologist, thoracic surgeon
Further investigations including echocardiogram, lung perfusion scan and a formal field exercise test (shuttle walk or 6 minute walk test) may be indicated.