Underutilized Yet Effective: Lung Volume Reduction in the Treatment of Severe COPD

Lung volume reduction is a valuable treatment option for carefully selected patients with severe emphysema and hyperinflation. While LVRS remains an important therapy in the right surgical candidate, bronchoscopic lung volume reduction (BLVR) has emerged as a less invasive and increasingly important option for appropriately selected patients.

The landmark NETT trial established that LVRS can improve quality of life, exercise capacity, and survival in specific subgroups, especially patients with upper-lobe predominant emphysema and low exercise capacity after pulmonary rehabilitation. However, because LVRS is invasive and requires strict selection, many patients who could benefit are never referred or evaluated.

Now, BLVR deserves greater emphasis in the treatment pathway for advanced emphysema. Endobronchial valve therapy can achieve meaningful volume reduction, improve dyspnea and exercise tolerance, and shorten recovery compared with surgery. For many patients, particularly those with severe hyperinflation who are poor surgical candidates or who prefer a less invasive approach, BLVR may be the more practical first-line lung volume reduction strategy.

“Severe hyperinflation creates a major mechanical disadvantage for breathing,” explains Michael Machuzak, MD, staff member in Cleveland Clinic’s Department of Pulmonary, Allergy and Critical Care Medicine. “BLVR is attractive because it can reduce trapped gas and improve mechanics without the physiologic burden of surgery.”

The role of patient optimization

Patients considered for lung volume reduction should first receive guideline-directed COPD therapy, including long-acting bronchodilators and pulmonary rehabilitation. They should also undergo objective assessment with pulmonary function testing, six-minute walk testing, and high-resolution CT imaging to define emphysema distribution and hyperinflation. They should not have smoked for at least four months. For both LVRS and BLVR, careful cardiopulmonary evaluation is essential to exclude major contraindications and identify the patients most likely to benefit.

“The best outcomes are in patients with emphysema that is worse in their upper lobes and have a lower exercise capacity,” says Dr. Machuzak.

“In advanced COPD, the goal is not cure but symptom relief and functional improvement,” adds Diego Maldonado, MD, FCCP, an interventional pulmonologist at Cleveland Clinic Florida. “Both LVRS and BLVR require thoughtful selection, but BLVR has expanded the number of patients we can consider because it is less invasive and often easier to recover from.”

BLVR candidates generally need heterogeneous emphysema, severe hyperinflation and favorable fissure integrity with minimal collateral ventilation. Those features are central to achieving lobar deflation with endobronchial valves. In contrast to surgery, BLVR can be adjusted or reversed, which makes it especially attractive for patients where the balance of risk and benefit is less certain.

“BLVR has become a major part of modern emphysema care,” says Dr. Maldonado. “The evidence is strong, the procedure is less invasive, and for the right anatomy it can produce very meaningful improvement in quality of life.”

BLVR vs. LVRS

LVRS removes diseased lung tissue and is irreversible, while BLVR uses one-way valves to collapse the most diseased lobe and reduce hyperinflation. BLVR is generally associated with shorter hospitalization and faster recovery, and it may be preferable when the procedural risk of surgery is high. BLVR is also reversible in almost all patients. LVRS may still offer more durable benefits in selected patients, especially those with classic upper-lobe predominant disease and good operative candidacy.

“Both approaches have a role,” explains Dr. Maldonado. “LVRS can be more durable, but BLVR is less invasive and is now an essential option for many patients who would not be ideal surgical candidates.”

Current evidence supports BLVR as an effective therapy for a carefully selected subgroup of severe emphysema patients, particularly when collateral ventilation is absent. In practice, BLVR should not be viewed as an alternative of last resort; rather, it should be considered early in the evaluation of patients with advanced emphysema and hyperinflation.

Barriers to broader adoption

Despite growing evidence, lung volume reduction remains underutilized overall, and BLVR in particular is still not offered widely enough. Many clinicians are unfamiliar with the selection process, including CT-based assessment, fissure analysis and collateral ventilation evaluation. Access to multidisciplinary programs also remains limited, which can delay or prevent referral.

“When patients are not referred, they lose the opportunity to benefit from a therapy that may meaningfully improve their breathing and daily function,” says Dr. Machuzak.

In 2025, Cleveland Clinic’s lung volume reduction program treated a substantial number of patients with both surgical and bronchoscopic approaches, reflecting the growing role of BLVR in advanced emphysema care. As awareness increases, clinicians may be more likely to identify appropriate candidates earlier and route them to centers with the expertise needed to assess both LVRS and BLVR.

“The key is to evaluate the patient as a phenotype, not just as a COPD diagnosis,” says Dr. Maldonado. “For many patients, BLVR may offer the best balance of effectiveness, safety and recovery.”