Bronchoscopic lung volume reduction (BLVR) is an underutilized treatment that can meaningfully improve breathing and quality of life for carefully selected patients with severe emphysema and hyperinflation, yet many clinicians remain unfamiliar with the procedure and patient selection criteria. Unlike traditional surgical lung volume reduction, BLVR uses one-way valves placed through a bronchoscope to collapse the most diseased portions of the lung, reducing the mechanical burden of breathing without the risks and recovery time of surgery.

What Is Lung Volume Reduction, and How Does It Work?

Lung volume reduction comes in two forms. The traditional approach, lung volume reduction surgery (LVRS), physically removes diseased lung tissue. The newer bronchoscopic approach, BLVR, uses endobronchial valves to collapse hyperinflated lung regions and reduce the amount of trapped air that makes breathing mechanically difficult.

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

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

Michael Machuzak, MD, Cleveland Clinic Department of Pulmonary, Allergy and Critical Care Medicine

BLVR has emerged as a practical alternative, especially for patients who are poor surgical candidates or prefer a less invasive approach. The procedure is reversible in almost all patients, meaning it can be adjusted or removed if needed, which makes it especially attractive when the balance of risk and benefit is uncertain.

Why Are So Many Patients Missing Out on This Treatment?

Despite growing evidence supporting BLVR's effectiveness, the procedure remains significantly underutilized. The primary barrier is clinician awareness and familiarity with the selection process. Many pulmonologists are unfamiliar with how to assess patients using CT-based imaging, fissure analysis, and collateral ventilation evaluation, which are essential for identifying good candidates.

Access to multidisciplinary programs that can perform and manage these procedures is also limited, which delays or prevents referral altogether. When patients are not referred, they lose the opportunity to benefit from a therapy that may meaningfully improve their breathing and daily function.

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

Michael Machuzak, MD, Cleveland Clinic Department of Pulmonary, Allergy and Critical Care Medicine

Who Is a Good Candidate for Lung Volume Reduction?

Patient selection is critical for successful outcomes. Before considering lung volume reduction, patients should first receive guideline-directed COPD (chronic obstructive pulmonary disease) 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.

Additional requirements include not smoking for at least four months and undergoing careful cardiopulmonary evaluation to exclude major contraindications. The best outcomes occur in patients with specific characteristics:

• Emphysema Distribution: Disease that is worse in the upper lobes of the lungs rather than distributed throughout
• Exercise Capacity: Lower baseline exercise capacity, which often correlates with greater potential for improvement
• Lung Anatomy: Heterogeneous emphysema (uneven disease distribution), severe hyperinflation, and favorable fissure integrity with minimal collateral ventilation
• Smoking Status: No cigarette use for at least four months prior to the procedure

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

Michael Machuzak, MD, Cleveland Clinic Department of Pulmonary, Allergy and Critical Care Medicine

How Do BLVR and Surgical LVRS Compare?

Both procedures have a role in advanced emphysema care, but they differ in important ways. 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, making it preferable when the procedural risk of surgery is high.

LVRS may still offer more durable benefits in selected patients, especially those with classic upper-lobe predominant disease and good operative candidacy. However, BLVR should not be viewed as a last-resort alternative; rather, it should be considered early in the evaluation of patients with advanced emphysema and hyperinflation.

"Both approaches have a role. 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," said Diego Maldonado, MD, FCCP, an interventional pulmonologist at Cleveland Clinic Florida.

Diego Maldonado, MD, FCCP, Interventional Pulmonologist at Cleveland Clinic Florida

Steps to Improve Access and Awareness

Expanding the use of lung volume reduction requires systemic changes in how patients are evaluated and referred. Healthcare systems and individual clinicians can take several concrete steps to ensure more patients benefit from these life-changing procedures:

• Clinician Education: Pulmonologists and primary care physicians need training on patient selection criteria, CT-based assessment methods, and the differences between LVRS and BLVR to identify appropriate candidates earlier
• Multidisciplinary Program Development: Hospitals and health systems should establish or expand dedicated lung volume reduction programs with interventional pulmonologists, thoracic surgeons, and pulmonary rehabilitation specialists working together
• Patient Phenotyping: Evaluate patients as individual phenotypes rather than simply as a COPD diagnosis, considering their specific emphysema pattern, exercise capacity, and anatomical features to match them with the most appropriate procedure
• Early Referral Pathways: Create clear referral protocols so that patients with advanced emphysema and hyperinflation are routed to centers with expertise in assessing both LVRS and BLVR options

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 among clinicians, more patients may be identified as appropriate candidates and routed to centers with the expertise needed to assess both options.

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

Diego Maldonado, MD, FCCP, Interventional Pulmonologist at Cleveland Clinic Florida

For patients living with severe emphysema, the message is clear: if you have not been evaluated for lung volume reduction, ask your pulmonologist whether you might be a candidate. This procedure, once considered only for the most severe cases, is now reshaping how advanced emphysema is treated, offering meaningful improvements in breathing, exercise tolerance, and quality of life for the right patients.