Lung volume reduction (LVR) procedures are treatments that can help some people with emphysema. Emphysema is a type of COPD. By reducing the amount of air trapped in your lungs, LVR can make it easier to breathe. This page explains what LVR is and who can benefit from it.
- What is lung volume reduction (LVR)?
- Who can have lung volume reduction (LVR)?
- What tests will I need?
- Lung volume reduction surgery (LVRS)
- Endobronchial valves (EBV)
- Are valves or surgery better?
- Experimental techniques
- Lung volume reduction (LVR) webinars
What is lung volume reduction (LVR)?
Lung volume reduction (LVR) is a treatment for emphysema. Emphysema is a type of COPD. It removes the most damaged bits of your lungs so that the healthier parts can work better. The treatment should make it easier for you to breathe.
LVR may be done using:
- lung volume reduction surgery (LVRS). A surgeon will operate and remove the most damaged parts of your lung.
- endobronchial valves (EBV), or bronchoscopic lung volume reduction (BLVR). [anchor link] Valves are placed into your airways to stop air from getting to the most damaged parts of your lung. This causes it to shrink down making more space for the healthier part of your lung to work.
- experimental treatments. Your specialist can talk about these options with you.
What are the benefits of LVR?
If you are carefully selected for LVR, it can improve your:
- lung function
- breathlessness
- ability to do daily activities
- quality of life
- life expectancy.
Who can have lung volume reduction (LVR)?
Lung volume reduction (LVR) is available on the NHS in England. It should be available to anybody with emphysema who will benefit from it. If you live in Scotland, Wales or Northern Ireland and think LVR might work for you, you should talk to your GP or specialist.
LVR can be very effective, but only around 1 in 100 people with COPD are likely to be suitable, with the right pattern of lung function tests and emphysema on their CT scan.
Pulmonary Rehabilitation (PR) is an effective treatment for breathlessness. If at the end of the PR programme, you’re still limited by your shortness of breath, your healthcare professional should consider if you are suitable for a lung volume reduction procedure.
Your lung specialist will review whether LVR is right for you if:
- You have significant emphysema
- You are limited by breathlessness, meaning that you get breathless after walking for a few minutes on flat ground
- You haven’t smoked in at least four months
- You have completed pulmonary rehabilitation (PR) within the last 12 months or are taking part in a post-PR exercise programme
- You are not too underweight or frail
- You don’t have other long-term conditions that mean that LVR would not be safe for you, like pulmonary fibrosis or heart failure
- Your lung function tests show that you are someone who is likely to benefit – this usually means that the amount of air you can blow out in one second (your forced expiratory volume/FEV1) is less than 50% of what it should be
- For LVR to help there also needs to be a lot of air trapped in your chest after you have breathed out. This is called residual volume (RV) and it needs to be more than 150% of what it should be.
If these apply, your specialist should refer you to a multidisciplinary team (MDT). An MDT is a healthcare team that anybody being considered for LVR must meet.
MDTs have a surgeon, a COPD physician, an interventional bronchoscopist, a radiologist, and a specialist nurse. They will assess you and decide:
- whether LVR is right for you
- what type of LVR is best for you.
Why wouldn’t lung volume reduction (LVR) be right for me?
LVR might not work for you if you:
- have other long-term conditions as well as COPD, like pulmonary fibrosis, severe pulmonary hypertension, or heart failure
- your emphysema is evenly spread (homogenous) across your lungs. This makes finding suitable parts of your lung to remove harder.
If LVR is not right for you, your specialist can speak to you about other treatment options.
What tests will I need?
You’ll need to have tests to make sure lung volume reduction (LVR) is right for you. You may have some tests before meeting your multidisciplinary team (MDT). This depends on how the NHS works where you live.
They can include:
- A CT scan (a special X-ray to get a picture of a cross-section of your body). A CT scan will find out if your emphysema is evenly spread (homogeneous) or uneven and patchy (heterogeneous). If it is uneven, lung volume reduction is more likely to work because there are areas that can be removed or blocked off.
- A spirometry test. This measures how much air you can blow out in one second (your forced expiratory volume/FEV1).
- A walk test. These tests measure your exercise capacity and overall fitness.
- A lung ventilation-perfusion scan (sometimes called a VQ scan). This scan works by injecting you with a special material that shows areas of your lungs that don’t have much blood supply. These areas don’t help your breathing, so they could be removed.
Lung volume reduction surgery (LVRS)
Lung volume reduction surgery (LVRS) is an operation which removes the most damaged parts of your lung so the healthier parts of your lung can work better. This should make your breathing more comfortable.
LVRS is a keyhole surgery. Your surgeon will make small cuts in your chest. They’ll use a special tool to cut away and staple your lung shut at the same time. This will seal it and prevent or reduce any air leaks.
The procedure is done using general anaesthetic, so you should be comfortable and unaware of it happening. It takes around 1-2 hours.
What is keyhole surgery?
Keyhole surgery is a minimally invasive type of surgery. This means that surgeons can operate without making large cuts in your body. Sometimes this is called video-assisted thoracoscopic surgery (VATS) too.
Recovery
How long you spend in hospital afterwards varies from person to person, as the lung takes time to heal, but it is usually between 4 and 10 days. After the procedure, the person has one or more chest drains in place to allow air to escape until the lung heals up.
For around 30 to 90 days after LVRS, you may experience some extra coughing, pain and breathlessness.
Endobronchial valves (EBV)
EBV is sometimes called bronchoscopic lung volume reduction (BLVR).
Small, one-way valves are placed in your lungs to block off some of your airways. The valves stop air from getting to the most damaged part of your lung. This is done using a small flexible camera (a bronchoscope).
As the valves block air from getting into the damaged area of your lung, it shrinks down. Instead of being big, baggy and getting in the way of your breathing, it will only take up a tiny space in your chest. This will leave more room for healthier parts of the lung.
EBV only works if it is possible to treat a whole lobe of the lung. The procedure won’t work if your emphysema has broken down the division between the lobes of your lung. This is because even though the airways are blocked by the valves, air can still get into the lungs another way. When this happens, it is called collateral ventilation (CV).
Your MDT can test to see whether EBV will work for you. This procedure is called Chartis. Your CV is measured using a special balloon catheter. If you have CV, you are CV positive and EBV will not work for you.
EBV is usually done with a general anaesthetic so that you are unaware of what is happening and comfortable during the procedure. Putting the valves in takes less than an hour.
Recovery
You’ll need to stay in hospital for two to three nights afterwards for observation. Once you’re home you should be fully recovered after two to three weeks.
The most common risk of LVR is an air leak. This can cause your lung to collapse (a pneumothorax). This happens to around 1 in 4 people who undergo EBV. It normally happens in the first few days after the procedure, when you’re still in hospital. This means it can be treated easily. An air leak may heal by itself. If not, you will need to have a chest drain inserted until your lung recovers.
Your multidisciplinary team (MDT) should talk to you about the risks with you before your treatment. It’s important that you are fully informed before LVR.
Are valves or surgery better?
LVRS has been happening for more than 30 years. EBV started taking place more recently. Both approaches are approved by the National Institute for Health and Care Excellence and happen on the NHS in England.
Depending on how your emphysema is spread, you might only be eligible for one type of treatment. Your MDT team will decide this.
Studies so far suggest that both types of treatment have similar results.
Usually, you will be offered EBV first. This is because the procedure is less invasive. If EBV doesn’t work for you, LVRS is still an option. Your MDT will talk to you about the different options and ask what you would prefer.
Asthma + Lung UK supports research by the national network of centres to study the effectiveness of LVR techniques.
Experimental techniques
Clinical trials are developing new experimental techniques using bronchoscopy.
These include:
- using steam to scar the worst areas of the lung and shrink them down
- targeting the nerves in the lung to improve airway relaxation.
These techniques are being evaluated in specialist centres. They are only available as part of clinical trials right now. If you are interested in them, talk to your GP or specialist.
Lung volume reduction webinars
Professor Nick Hopkinson, Asthma + Lung UK’s Medical Director, has produced two webinars to explain what lung volume reduction procedures involve:
- Watch the webinar for patients. This is an introduction to lung volume reduction. It is useful if you have emphysema or are currently doing pulmonary rehabilitation.
- Watch the webinar for healthcare professionals. This is an introduction to lung volume reduction aimed at healthcare professionals. It is useful if you are a physiotherapist or a health care professional involved in pulmonary rehabilitation. It can help you discuss surgery or endobronchial valves with patients and increase your understanding of who to recommend for lung volume reduction.