Lung Volume Reduction: Surgical Versus Endobronchial

Emphysema is a subgroup of chronic obstructive disease where there is destruction of alveolar tissue leading to coalescing air sacs with consequent air trapping and reduced gas exchange. Breathlessness is caused by both of these mechanisms, but hyperinflation and respiratory dynamics may be improved by lung volume reduction. The concept of lung volume reduction surgery (LVRS) for severe emphysema has been around for over 60 years, but has only very recently become recognised as an established treatment, in spite of no other therapy providing the same benefits in lung function, exercise tolerance, and quality of life in this group of patients. Initial concerns about safety and mortality have now largely been addressed, and a greater understanding of physiological, anatomical and clinical phenotypes most likely to benefit, together with an improvement in surgical techniques, has driven a renewed interest in LVRS. The development of minimally invasive endoscopic treatments, initially designed to overcome some of the complications of surgery, has ironically helped drive this renaissance, and has also broadened the eligible patient population. There is now a body of evidence in all emphysema subtypes, and this chapter discusses initial work with lung volume reduction surgery, why take-up has been poor despite the evidence, the data supporting the introduction of a number of endobronchial approaches and which patients are likely to benefit the most. Lung volume reduction now provides a suite of interventions to offer patients with severe emphysema, a group in whom traditional medical management is all too often ineffective.