Advanced Emphysema
& Lung Volume Reduction

Beyond Medical Optimisation

For patients with severe emphysema who remain symptomatic on maximal inhaled therapy and have completed pulmonary rehabilitation, the clinical assumption is often that nothing further can be offered. In many cases this assumption is wrong. A spectrum of interventional and surgical options exists — endobronchial valve placement, lung volume reduction surgery, and lung transplant assessment — that can produce meaningful improvements in breathlessness, exercise tolerance, and quality of life in appropriately selected patients. The critical step is a comprehensive specialist assessment.

Which Patients to Refer

Intervention is not appropriate for all COPD patients — but the eligible population is larger than is commonly recognised. The MDT assessment determines which, if any, intervention is appropriate. GPs should refer for assessment, not for a specific procedure.

V/Q SPECT-CT scanning provides functional heterogeneity mapping to guide target lobe selection. A nuclear medicine physician with specific expertise in emphysema functional imaging attends every MDT. Patients do not need to be surgical candidates at the point of referral — the MDT will determine what is appropriate.

Endobronchial Valves
Deployed Bronchoscopically

Intraoperative bronchoscopic images from Mr Okiror's own clinical practice, showing endobronchial valves immediately following deployment. The valve creates a one-way seal in the target airway, allowing air to escape from the diseased lobe on exhalation while preventing re-entry — causing progressive deflation of the hyperinflated tissue.

Endobronchial valve in situ immediately following bronchoscopic deployment. The valve is visible at the target airway orifice.

Bronchoscopic view showing the deployed valve. The procedure requires no surgical incision and is performed under general anaesthesia.

All Four Options
On the Table

A monthly specialist MDT at GSTT considers every referred patient. The MDT includes respiratory physicians, a COPD clinical nurse specialist, thoracic radiologist, nuclear medicine physician, and — uniquely — a lung transplantation physician and surgeon from Harefield Hospital. This means all four management options are evaluated within the same discussion.

How to Refer

Patients can be referred directly for MDT assessment without specifying a preferred intervention. A brief referral letter with recent spirometry, CT chest report, and current inhaler therapy is sufficient. Private assessments are available within 2–3 working days, with the full workup and MDT presentation typically completed within weeks. No GP referral letter is required for private assessment; patients may also self-refer.