Severe emphysema is more treatable than many patients are told. For carefully selected patients, endobronchial valve therapy or lung volume reduction surgery can deliver meaningful improvements in lung function, walking distance, and quality of life. The difference between being told there are no further options and being offered an effective treatment usually depends on whether a specialist multidisciplinary assessment has taken place. Dr Lawrence Okiror is the sole operator for both endobronchial valve therapy and lung volume reduction surgery at London Bridge Hospital, and the sole designated EBV operator at Guy’s and St Thomas’ NHS Foundation Trust — one of the centres nationally commissioned by NHS England for the Advanced Emphysema Surgical Service. He leads a monthly specialist MDT that uniquely includes a lung transplant physician and surgeon from Harefield Hospital, ensuring every option is considered before any decision is reached. Private appointments at London Bridge Hospital within 2–3 days.
Last reviewed: May 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
Dr Okiror is the sole operator for both EBV therapy and lung volume reduction surgery at London Bridge Hospital and at Guy’s and St Thomas’, with 100+ combined interventions since 2019. Newsweek World’s Best Hospitals 2026: St Thomas’ #1, Guy’s #2, London Bridge Hospital #10 UK.
Monthly specialist MDT includes respiratory physicians, COPD nurse specialist, thoracic radiologist, nuclear medicine physician, and — uniquely — a lung transplant physician and surgeon from Harefield Hospital. All four treatment options on the table at every discussion.
Appointments within 2–3 days at London Bridge Hospital. Days to intervention after completed workup, compared to 4–6 months on the NHS pathway. Both options discussed openly at every consultation.
Emphysema affects more than 1.2 million people in the UK and is a major contributor to the burden of chronic obstructive pulmonary disease. For a substantial subset — patients with severe disease, significant hyperinflation, and persistent breathlessness despite optimal inhalers and pulmonary rehabilitation — medical therapy alone is not enough. Two specialist interventions can deliver meaningful improvements in this group: endobronchial valve therapy and lung volume reduction surgery.
Both have been available on the NHS through nationally commissioned centres since 2018. Both are NICE-recommended. Yet many eligible patients never reach a multidisciplinary assessment. The phrase Dr Okiror hears most frequently in the second-opinion clinic is some version of I was told there was nothing more that could be done. In a meaningful proportion of cases, that is not correct — it reflects the absence of a specialist surgical opinion in the pathway, rather than the absence of an effective option.
The three things that decide whether a patient benefits are: the right phenotype on imaging, the right physiology on testing, and access to a multidisciplinary team that can match the modality to the patient. The first two are objective. The third is where most patients fall through.
Bronchoscopic valve placement. No incision. Reversible.
Keyhole resection of the most damaged tissue.
Assessed in the same MDT, with the Harefield team.
Optimisation, rehab, oxygen, palliative strategies.
All four options are considered for every patient referred to the GSTT MDT — including transplant candidacy, which is uniquely assessed in the same discussion.
Two questions decide whether a patient is suitable for endobronchial valve therapy, lung volume reduction surgery, or neither. Both are answered objectively, before any treatment decision is made.
Question 1 · CT imaging
Heterogeneous or Homogeneous?Heterogeneous emphysema — one part of the lung dramatically more diseased than the rest — gives the strongest results for both EBV and LVRS, because there is a clear target lobe to deflate or remove and healthier tissue ready to expand into the freed space. Upper-lobe predominant heterogeneous disease is the classical responder phenotype originally identified by NETT.
Homogeneous emphysema — disease distributed evenly across both lungs — is more challenging. EBV remains an option in carefully selected patients (supported by IMPACT and subset analyses of LIBERATE), but selection criteria are stricter and outcomes more variable. LVRS is generally not appropriate for homogeneous disease.
Question 2 · Chartis bronchoscopy
Is There Collateral Ventilation?EBV therapy only works if the target lobe has no collateral ventilation — meaning no air can enter the targeted lobe through pathways that bypass the normal airway. If collateral ventilation is present, the lobe will not deflate after the valves are placed, and the procedure will not work.
The Chartis pulmonary assessment system is a balloon catheter passed through a bronchoscope that measures airflow from the target lobe over 5–10 minutes, definitively confirming whether collateral ventilation is absent. Chartis-positive (collateral ventilation present) patients are usually directed instead toward LVRS, where intact fissures are not required.
Why the distinction matters in practice: matching the modality to the phenotype is what separates a procedure that works from one that does not. A patient with heterogeneous, Chartis-negative disease typically benefits most from EBV; a patient with heterogeneous, Chartis-positive disease typically benefits most from LVRS; a patient with homogeneous Chartis-negative disease may benefit from EBV under specific selection criteria. The decision is made at the multidisciplinary meeting, not by individual clinician preference, and is documented in a structured letter to the referring clinician.
The modern lung volume reduction pathway is built on four landmark randomised trials over twenty years. Each answered a piece of the puzzle: whether the principle works, who responds, how to select them, and how the two available modalities compare. The result is one of the better-defined evidence bases in modern thoracic medicine — and the foundation of NICE-recommended care in the UK.
NETT · 2003
Fishman A et al. · New England Journal of Medicine · 2003 · 1,218 patients
The National Emphysema Treatment Trial randomised patients with severe emphysema to lung volume reduction surgery or maximum medical therapy. Patients with upper-lobe predominant disease and low baseline exercise capacity had improved survival, exercise tolerance, and quality of life with surgery. NETT established lung volume reduction as a valid principle and identified the heterogeneous upper-lobe phenotype as the responder group — a finding that still defines selection two decades later.
The trial that opened the door — and identified the high-risk phenotype the field has avoided ever since.
VENT 2010 → STELVIO 2015
Sciurba FC et al. (VENT) NEJM 2010 · Klooster K et al. (STELVIO) NEJM 2015
VENT was the first major randomised trial of endobronchial valve therapy for emphysema. Outcomes were modest overall — but post hoc analysis identified the central problem: patients with collateral ventilation between lobes did not respond, because the target lobe could not deflate. STELVIO solved it by using Chartis assessment to confirm absence of collateral ventilation before treatment. Properly selected STELVIO patients showed significant improvements in FEV1, walking distance, and quality of life. The modern EBV pathway begins here.
Two trials, one lesson: selection is everything.
LIBERATE · 2018 · The Pivotal RCT
Criner GJ et al. · Am J Respir Crit Care Med · 2018 · 190 patients
LIBERATE randomised patients with heterogeneous emphysema and Chartis-confirmed absence of collateral ventilation to Zephyr endobronchial valve therapy or standard medical care. At 12 months, the EBV group showed substantial, sustained benefit:
FEV1: improvement of approximately 18%
6-minute walk distance: improvement of around 39 metres
St George’s Respiratory Questionnaire: meaningful quality-of-life improvement (mean change ~−7 points)
FDA approval of the Zephyr valve followed in 2018, and the trial underpins the current NICE recommendation in the UK (HTG457, formerly IPG600, December 2017).
CELEB · 2023
Buttery S et al. · European Respiratory Journal · 2023 · 88 patients · 5 UK centres
CELEB was the first direct randomised comparison of LVRS versus EBV in patients suitable for either procedure. At 12 months, both groups showed similar improvements across the composite iBODE disease severity score and its components. Length of stay was substantially shorter for EBV (median 3 days versus 9 days for LVRS), but EBV patients had a higher rate of subsequent intervention. Mortality was low and equivalent. The trial reframed the question: not which is better, but which is right for this patient.
Both modalities work in the right patient. Choosing between them is a multidisciplinary decision.
The arc in one sentence
NETT showed that lung volume reduction works. VENT and STELVIO showed that selection — specifically, Chartis-confirmed absence of collateral ventilation — is what determines who responds. LIBERATE was the pivotal trial that secured FDA approval and underpins NICE recommendation HTG457. CELEB confirmed that EBV and LVRS are complementary rather than competing — the right choice depends on phenotype. Dr Okiror is the sole operator for both procedures at London Bridge Hospital and at Guy’s and St Thomas’.
No option is excluded before the multidisciplinary discussion concludes. Every referred patient is considered for the full ladder. A formal letter is sent to the referring clinician documenting the recommendation, regardless of outcome.
Option 1 · Medical
For patients who do not meet selection criteria for intervention, or who choose not to proceed: inhaler optimisation, supervised pulmonary rehabilitation, oxygen assessment, and palliative breathlessness strategies. The MDT often identifies optimisations that have not yet been tried.
Option 2 · EBV
Bronchoscopic placement of one-way Pulmonx Zephyr valves to deflate the most diseased lobe. No incision, reversible, typically 2–3 days inpatient. Requires Chartis-confirmed absence of collateral ventilation.
An expected post-procedure pneumothorax occurs in around one in four patients as the targeted lobe collapses, and is managed routinely with a chest drain — this is why patients are kept inpatient for 2–3 days afterwards.
Option 3 · LVRS
Keyhole surgical removal of the most damaged emphysematous tissue, allowing healthier lung to expand and function more effectively. Performed for patients with heterogeneous disease where EBV is not feasible (collateral ventilation present) or not preferred. Median inpatient stay around 7–9 days in the CELEB trial.
Option 4 · The differentiator
For patients whose disease severity, age, and functional trajectory make transplant listing appropriate, the GSTT MDT includes a lung transplantation physician and surgeon from Harefield Hospital — one of the UK’s two major transplant centres. Transplant candidacy is assessed within the same multidisciplinary discussion as EBV and LVRS, not as a separate downstream referral.
No patient is referred onward to one option without all options having been considered together. This integration of transplant expertise into the LVR MDT is uncommon — and is the single feature that most distinguishes this service from others.
For patients with a single dominant bulla
Bullectomy is a related but distinct surgical optionBullectomy is the surgical removal of a single large bulla — distinct from lung volume reduction surgery, which removes the most diseased portion of generally emphysematous lung. Indications include both breathlessness from a compressing bulla and complications such as recurrent pneumothorax, infection, haemoptysis, chest pain, or suspected cancer in or adjacent to a bulla. The dedicated bullectomy page covers selection, the operation, and outcomes in full.
Volume and continuous improvement matter in lung volume reduction. Both procedures have steep learning curves, and outcomes are measurably better in centres where the same operator, the same MDT, and the same care pathway handle every case. Three things distinguish the service Dr Okiror delivers privately at London Bridge Hospital and on the NHS at Guy’s and St Thomas’.
Dr Okiror is the sole operator for both endobronchial valve therapy and lung volume reduction surgery at London Bridge Hospital and at Guy’s and St Thomas’. 100+ combined EBV and LVRS interventions since 2019. The same operator selects, performs, and follows up every case.
In June 2025, Dr Okiror led the GSTT LVRS multidisciplinary team — lead respiratory physician, charge nurse, and lead thoracic physiotherapist — to UZ Leuven, Belgium, for clinical immersion with one of Europe’s largest LVRS programmes. The visit informed refinements to selection, technique, and pathway coordination at GSTT and LBH.
A prospective before-and-after outcomes audit comparing the GSTT LVRS programme pre- and post-Leuven is currently underway. Quality measurement is built into the service rather than left to assumption.
For private patients at London Bridge Hospital, this matters in a specific way: the same operator who handles the highest-complexity NHS workload at GSTT performs every private case. The pathway, the MDT, and the post-procedure care are unified across both settings.
The endobronchial valve has a second clinical application beyond lung volume reduction: the management of persistent air leak from a bronchopleural fistula. The valves are placed bronchoscopically in the airway segment supplying the leak; once occluded, the air leak typically resolves immediately, allowing chest drain removal and faster recovery. The technique is most often used for air leaks complicating pneumothorax (frequently in patients with underlying bullous emphysema), prolonged post-surgical air leak, and severe parenchymal lung disease in critically ill patients where surgery would carry an unacceptable risk.
This is a niche technique. Few thoracic surgeons in the UK perform it routinely. Dr Okiror has accumulated specific authority in this application through publication, trial leadership, and peer consultation.
Joint Senior Author
GSTT case series — J Clin Med 2023Ficial B, Whebell S, Taylor D, Fernández-Garda R, Okiror L, Meadows CIS. Bronchoscopic Endobronchial Valve Therapy for Persistent Air Leaks in COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation. J Clin Med 2023;12(4):1348.
Single-centre series of ten GSTT patients on VV-ECMO with refractory air leak, all successfully treated with bedside bronchoscopic valve placement. 80% survival to hospital discharge. Joint senior authorship per the equal-contribution footnote.
Co-PI at GSTT
PRO-SEAL randomised trialTrial registry: ISRCTN15099654. Multicentre randomised comparison of endobronchial valve therapy against alternative treatment for persistent air leak. Dr Okiror is Co-Principal Investigator at the Guy’s and St Thomas’ site.
Many patients with persistent air leak have underlying bullous emphysema or COPD — the overlap with the LVR population is substantial.
Peer Consultation
Surgical and critical care teams in the United Arab Emirates, Southampton, and Aberdeen have consulted Dr Okiror on the management of complex persistent air leak cases. He is also an invited speaker on bronchoscopic valve technique to UK and European thoracic units — including teaching sessions at North Tees NHS Foundation Trust and to UK and European clinical audiences.
Endobronchial valve therapy and lung volume reduction surgery are both performed privately at London Bridge Hospital. LBH offers the level of intensive care, respiratory medicine, and bronchoscopy support appropriate for patients with severe COPD undergoing either intervention. For straightforward EBV cases in well-selected patients, treatment can also be delivered at The Lister Hospital Chelsea.
For complex LVRS cases — particularly patients with significant comorbidities, severe gas trapping, or relevant cardiac disease — surgery takes place at London Bridge Hospital, where the perioperative support matches the complexity of the patient.
Outpatient consultations — including for second-opinion patients told elsewhere that no further treatment is possible — are also available at HCA outpatients in Canary Wharf and the City of London. Same-day or next-day virtual consultations can be arranged for patients in other regions or internationally.
Insurance and self-pay: Dr Okiror is recognised by all major UK private medical insurers including AXA, BUPA, WPA, Vitality, Cigna, and Aviva. Lung volume reduction interventions involve significant inpatient and post-procedure care — transparent estimates are provided by Jo Mitchelson before any commitment is made — 020 7952 2882 or pa@lungsurgeon.co.uk.
Patients with severe emphysema are sometimes told there are no further treatment options. Sometimes that is correct. Sometimes it reflects the absence of a specialist surgical opinion in the pathway, rather than the absence of an effective intervention. Three questions are worth asking before accepting the verdict.
If your CT shows heterogeneous emphysema and your fissures look reasonable, you may well be a candidate for one of the interventions. The two-step assessment — phenotype on CT, collateral ventilation on Chartis — is standard at any centre that runs an LVR pathway. If it has not been done, that is a reasonable question to raise.
There is a difference between “not suitable” assessed by a respiratory physician and “not suitable” assessed by an MDT that includes a thoracic surgeon experienced in both EBV and LVRS. NICE explicitly recommends MDT assessment by a team experienced in managing emphysema, including a thoracic surgeon. If only your chest physician has reviewed your case, the assessment is incomplete.
For some patients with severe disease and a poor functional trajectory, transplant listing is the right answer. For others it isn’t — but the question deserves to be asked formally, by a transplant team, not assumed away. The GSTT MDT is unusual in including a transplant physician and surgeon from Harefield Hospital in the same monthly discussion as EBV and LVRS, which means the question is not deferred or lost.
A second opinion appointment with Dr Okiror is typically available within 2–3 days at London Bridge Hospital. Bring your CT chest, recent spirometry and lung function tests, current inhaler list, and any treatment recommendation already made.
If breathlessness is your main concern
Not sure whether emphysema is the cause?Breathlessness has many thoracic causes — emphysema, raised diaphragm, recurrent pleural effusion, undiagnosed nodule, post-COVID parenchymal disease. The breathlessness page explains what a thoracic assessment covers, what investigations are involved, and what to expect at the first appointment.
Both EBV therapy and LVRS are available privately at London Bridge Hospital, with consultations within 2–3 days and intervention typically within days of completed workup. The same operator, the same MDT discussion, and the same post-procedure follow-up apply across NHS and private patients.
Both procedures are also available on the NHS at the nationally commissioned centres for the Advanced Emphysema Surgical Service. Dr Okiror is the sole operator at GSTT. NHS waiting times from referral to intervention are typically 4–6 months. All options — NHS and private — are discussed openly at every consultation.
If breathlessness is your primary symptom and you are unsure whether emphysema is the cause, the breathlessness page explains what a thoracic assessment covers and what to expect.
Refer for assessment — let the MDT determine the treatment. Patients do not need to be surgical candidates at the point of referral. Consider specialist assessment for patients with:
A brief referral letter with recent spirometry, CT chest report, and current inhaler therapy is sufficient. Private assessments within 2–3 working days.
Contact Jo Mitchelson: 020 7952 2882 — pa@lungsurgeon.co.uk
AI-assisted GP referral letter generator: For GPs page →
Verified institutional information about Dr Okiror’s NHS programme and the GSTT Advanced Emphysema Surgical Service.
NHS thoracic surgery service at Guy’s and St Thomas’ NHS Foundation Trust.
View page → NICE Guidance HTG457NICE recommendation supporting endobronchial valve insertion to reduce lung volume in emphysema (formerly IPG600, December 2017).
View guidance → Pulmonx Zephyr Centres — UK RegisterPulmonx register of UK centres designated to perform Zephyr endobronchial valve therapy.
View register →Common questions from patients considering EBV therapy or LVRS, from families seeking a second opinion, and from referring physicians weighing whether to refer.
Book a Consultation →Or call Jo Mitchelson:
020 7952 2882
Private appointments at London Bridge Hospital within 2–3 days. Dr Okiror will review your investigations personally and advise honestly whether intervention is possible and appropriate for your situation.
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, independently assessed across 32 countries.
Disclosures
Dr 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.
All thoracic causes of breathlessness — what an assessment covers and what to expect
Specialist Second OpinionIndependent review for patients told no further treatment is possible — within 2–3 days
For Referring GPs & PhysiciansDirect referral pathway and AI-assisted referral letter generator