The NHS Lung Cancer Screening Programme is changing the pipeline of patients reaching the lung volume reduction MDT. Spirometry and low-dose CT performed at scale on ever-smokers aged 55 to 74 are identifying substantial numbers of patients with previously undiagnosed airflow obstruction and visible emphysema. Some of these patients meet criteria for endobronchial valve therapy or lung volume reduction surgery — and a meaningful proportion would, in earlier years, never have reached a specialist surgical assessment at all. This note is written for GPs and respiratory clinicians who receive a screening result letter mentioning emphysema and want to know how to interpret it, when to escalate, and what happens after referral.
Last reviewed: April 2026 · Mr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382 · Co-chair, Lung Volume Reduction session, SCTS Annual Meeting 2026, Belfast
The NHS Lung Cancer Screening Programme — formerly the Targeted Lung Health Check — invites ever-smokers aged 55 to 74 to a structured assessment that combines symptom enquiry, pre-bronchodilator spirometry, and a low-dose CT scan in those at higher risk. Coverage has expanded substantially across England since 2023, with rollout continuing through 2026.
The programme’s primary purpose is the detection of early lung cancer. Its secondary yield, however, has proven clinically substantial. Spirometry performed at scale identifies airflow obstruction in patients who have never been formally diagnosed. Low-dose CT identifies emphysema visible on imaging in a meaningful proportion of attendees. Many of these patients have not previously crossed a respiratory clinic threshold — they have been functioning, getting on with life, and dismissing breathlessness as ageing or smoking damage they cannot reverse.
The clinical implication for referring clinicians is concrete. Some of these patients — not all, but a meaningful subset — will, on closer assessment, meet criteria for either endobronchial valve therapy or lung volume reduction surgery. The assumption that nothing more can be done for severe emphysema is increasingly being tested earlier in the disease, by patients arriving with an LDCT report rather than just a cough.
Two abstracts in the Lung Volume Reduction session at the Society for Cardiothoracic Surgery Annual Meeting 2026 in Belfast (March 2026) addressed this question directly: a Liverpool group reporting on whether lung screening data can identify LVR-suitable patients, and a Norfolk and Norwich group reporting on a formal emphysema pathway following lung cancer screening and asking whether screening should expand beyond cancer detection.
Mr Okiror co-chaired this session.
Most GPs will see screening result letters routinely from 2026 onwards. The patient may be functioning well, mildly symptomatic, or significantly limited. The letter rarely answers the question that matters most: which of these patients warrants escalation beyond optimisation in primary care?
First step · Primary care
Optimise & ConfirmConfirm smoking cessation. Establish optimal inhaled therapy in line with NICE NG115 and GOLD 2025. Refer for pulmonary rehabilitation if not already completed. Document MRC dyspnoea score. Repeat post-bronchodilator spirometry to confirm airflow obstruction (the screening programme uses pre-bronchodilator spirometry for throughput reasons).
Most patients identified by screening with mild-to-moderate disease will be appropriately managed at this level. Optimisation alone — particularly if not previously delivered — can produce meaningful symptomatic improvement.
When to escalate · Specialist MDT
Severe Disease & Persistent BreathlessnessPatients who remain significantly breathless despite optimal medical therapy — and whose imaging or lung function suggests severe disease — warrant specialist multidisciplinary assessment. NICE explicitly recommends MDT review by a team experienced in managing emphysema, which should include a thoracic surgeon.
The patient does not need to be a confirmed surgical candidate at the point of referral. The MDT determines what, if anything, is appropriate — that is the purpose of the assessment.
A practical observation: the patients most likely to benefit from specialist assessment are not always the most overtly symptomatic. Some are functional but breathless on exertion they have learned to avoid. The honest test is whether the patient’s exercise tolerance has been silently constrained by the disease — not whether they are presenting in extremis. Screening is identifying exactly this group.
Specialist surgical and multidisciplinary review is appropriate for patients meeting the following composite criteria. Each parameter is approximate and not a hard cut-off — the MDT considers the whole picture.
GOLD stage III or IV airflow obstruction. FEV1 typically 20–45% predicted. FEV1/FVC ratio under 0.7 post-bronchodilator. mMRC dyspnoea 2 or above on optimal inhaled therapy.
Significant hyperinflation when measured: residual volume above 150% predicted, total lung capacity above 100% predicted. If static lung volumes have not been measured locally, that is not a barrier to referral — it can be done as part of the workup.
Emphysema visible on CT, ideally with at least one area of visually heterogeneous distribution. Bullous emphysema is acceptable. Lower-lobe and homogeneous patterns also warrant assessment under specific criteria. Screening LDCT is sufficient to start; targeted high-resolution CT can be arranged at workup.
Confirmed non-smoker (cessation typically for at least 4 months). BMI under 35. No active malignancy. No clinically significant pulmonary hypertension or bronchiectasis. Pulmonary rehabilitation completed or in progress. Patient willing to attend assessment.
When in doubt, refer
If the patient is breathless despite optimisation and screening has identified emphysema, the threshold for referral should be low. Patients do not need to be confirmed candidates at the point of referral. The MDT exists to make that determination, with the full evidence base of imaging, lung function, and Chartis assessment in front of it. A formal letter is sent to the referring clinician documenting the recommendation, regardless of outcome.
The pathway is structured, evidence-led, and decision-oriented. From referral to MDT recommendation typically completes within days for private patients at London Bridge Hospital, and within several weeks on the NHS pathway at Guy’s and St Thomas’.
Full lung function with static lung volumes and gas transfer. V/Q SPECT-CT to confirm functional heterogeneity and identify a target lobe. Bronchoscopic Chartis assessment to determine collateral ventilation. High-resolution CT if not already available.
Monthly multidisciplinary meeting with respiratory physicians, COPD nurse specialist, thoracic radiologist, nuclear medicine physician, and a lung transplantation physician and surgeon from Harefield Hospital. The full pathway — medical optimisation, EBV, LVRS, transplant assessment — considered for every case.
A structured letter is sent to the referring clinician within days of the MDT, documenting the recommendation, the supporting evidence, and (where applicable) the proposed timing of intervention. The patient receives parallel correspondence and is offered direct contact with the team for questions.
A note on the transplant component
The integration of a Harefield lung transplantation physician and surgeon into the same monthly MDT discussion as EBV and LVRS is uncommon — and is one of the things that most distinguishes the Guy’s and St Thomas’ service. For patients whose disease severity or functional trajectory makes transplant listing potentially appropriate, the question is asked formally, in the same room, rather than deferred to a separate downstream referral that may never happen.
For appropriately selected patients, the magnitude of improvement after EBV therapy or LVRS is clinically meaningful. The following outcomes are drawn from the published trials that underpin current NICE recommendations and the FDA approval of the Zephyr endobronchial valve.
LIBERATE · The Pivotal RCT
Endobronchial Valve Therapy — 12-Month OutcomesCriner GJ et al. Am J Respir Crit Care Med 2018. 190 patients with heterogeneous emphysema and Chartis-confirmed absence of collateral ventilation, randomised to Zephyr EBV or standard medical care.
FEV1: ~18% improvement
6MWD: ~39 metres improvement
SGRQ: ~−7 points (clinically meaningful improvement)
Underpins NICE guidance HTG457 (formerly IPG600, December 2017) and FDA approval 2018.
CELEB · UK Head-to-Head
EBV vs LVRS — Similar ImprovementButtery S et al. European Respiratory Journal 2023. 88 UK patients suitable for either procedure, randomised to LVRS or EBV at five UK centres.
iBODE composite: similar improvement at 12 months
Length of stay: 3 days (EBV) vs 9 days (LVRS)
Re-intervention: higher in EBV arm
Confirms the two modalities are complementary — the right choice depends on phenotype, not preference.
The selection step is therefore not academic. Matching modality to phenotype, using Chartis-confirmed collateral ventilation status as the decisive variable, is what separates a procedure that works from one that does not. This is the substantive value the MDT adds.
A brief referral letter is sufficient to initiate the pathway. The team will arrange any further investigations required as part of the workup.
Private practice · LBH and Lister
Jo Mitchelson, Private PAPrivate outpatient appointments at London Bridge Hospital typically within 2–3 working days. Same-day or next-day virtual consultations available where clinically appropriate.
NHS pathway
For NHS referral to the Advanced Emphysema Surgical Service at Guy’s and St Thomas’, refer through the standard NHS e-Referral Service or via direct consultant-to-consultant correspondence. Mr Okiror is the sole designated EBV operator at GSTT and the sole operator for both EBV and LVRS at LBH.
AI-assisted referral letter generator: For GPs page →
Verified institutional and guideline sources relevant to the screening pipeline and the lung volume reduction pathway.
NICE recommendation supporting endobronchial valve insertion to reduce lung volume in emphysema (formerly IPG600, December 2017).
View guidance → NHS Lung Cancer Screening ProgrammeNHS England programme overview, formerly the Targeted Lung Health Check, with national rollout continuing through 2026.
View page → GSTT Thoracic SurgeryNHS thoracic surgery service at Guy’s and St Thomas’, where Mr Okiror is the sole designated EBV operator.
View page →Practical questions from primary care colleagues navigating screening result letters and from respiratory physicians considering when to involve a thoracic surgical opinion.
Refer a Patient →Or call Jo Mitchelson:
020 7952 2882
Private appointments at London Bridge Hospital within 2–3 working days. The same operator, the same MDT, and the same post-procedure pathway across NHS and private patients.
Jo Mitchelson, Private PA · 020 7952 2882 · pa@lungsurgeon.co.uk
St Thomas’ #1 UK · Guy’s #2 UK · London Bridge Hospital #10 UK · Newsweek World’s Best Hospitals 2026
Disclosures
Mr Okiror has received speaking and consulting fees from Pulmonx Corporation, the manufacturer of Zephyr endobronchial valves. This relationship is disclosed in his published peer-reviewed research (including J Clin Med 2023;12(4):1348) and is provided here in line with GMC Good Medical Practice and ABPI Code of Practice standards on transparency of industry relationships. Treatment recommendations are made by the multidisciplinary team based on patient phenotype and the published evidence base, not by individual clinician preference.