Bronchoscopic lung volume reduction in advanced pulmonary emphysema: the safety and efficacy of novel methods

volume reduction surgery (LVRS) in improving functional parameters and exercise tolerance in selected patients with severe pulmonary emphysema of upper lobe predominance. A number of bronchoscopic techniques have been developed under the term bronchoscopic lung volume reduction"(BLVR), which aim to lower the complications and cost of LVRS. These include airway bypass by creation of airway/parenchyma communications under ultrasound (US) guidance, the use of one-way endobronchial valves and endobronchial coils, hot vapour ablation, and "biological"lung volume reduction through alveolar filling with polymer material. These methods are generally simple and safe, with a favourable complications profile, and they require less infrastructure and interventional experience than the open surgical approach. Airway bypass, although effective and relatively safe, does not provide lasting effects. The use of valves and alveolar filling polymers, in contrast, has been shown to produce sustainable improvement of exercise tolerance and quality of life (QoL). Alveolar filling, at the cost of being non-reversible, presents advantages regarding spirometry values, QoL, exercise tolerance and dyspnoea, not only in patients with heterogeneous upper lobe emphysema, but also in patients with homogeneous emphysema, in whom most of the other bronchoscopic or surgical procedures are not indicated. Coils and vapour ablation still need more extensive research to validate their clinical effectiveness. To date, the research data on the effectiveness of BLVR are not yet considered to provide sufficient evidence for official therapeutic recommendations of their use to be launched by the regulating authorities. The cost/effectiveness issue is also under evaluation. New, more extensive multicentre studies are underway which aim at better selection and stratification of patients in order to further evaluate the safety and effectiveness of these techniques, before wider use of this revolutionary approach for severe lung emphysema can be advocated.