November 2025

PULMONARY

BRONCHOSCOPIC LUNG VOLUME REDUCTION WITH ENDOBRONCHIAL VALVES: CONSENSUS GUIDANCE FOR PATIENT SELECTION AND PERIPROCEDURAL CARE

Featuring: Momen M. Wahidi, MD, and Christopher M. Kapp, MD
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide, and its burden is expected to rise in the coming decades. Among COPD phenotypes, emphysema is characterized by irreversible destruction of distal airspaces, resulting in loss of elastic recoil and progressive hyperinflation. Hyperinflation contributes to severe breathlessness, impaired cardiac function, increased exacerbation risk and higher mortality.

Management strategies for emphysema range from pharmacologic therapy and pulmonary rehabilitation to advanced interventions such as lung volume reduction surgery (LVRS), bronchoscopic lung volume reduction (BLVR) and lung transplantation. BLVR, performed via endobronchial valve placement, has demonstrated significant improvements in lung function, exercise capacity and dyspnea in randomized trials, and is now included in the Global Initiative for Chronic Lung Disease (GOLD) guidelines. Despite these benefits, BLVR remains underutilized — performed in only about 5% of eligible patients — though adoption is expected to increase.

As BLVR utilization grows, practical guidance on patient selection and perioperative management is essential. This newly published international consensus statement addresses these needs, offering evidence-informed recommendations based on expert experience and current literature.

Methods
An international panel of 11 BLVR experts — selected for their extensive procedural experience and leadership in major clinical trials — developed these recommendations using a modified Delphi process. Topics were identified through initial surveys and refined during virtual meetings. Draft recommendations were formulated in PICO format and supported by targeted literature reviews.

Consensus was defined as more than 80% agreement across three Delphi voting rounds conducted between January and June 2024. Of 23 initial recommendations, 21 achieved consensus. One topic (pulmonary rehabilitation) did not reach consensus, and two areas (staged BLVR and sequential bilateral BLVR) lacked sufficient evidence for formal recommendations.

Key recommendations

Pre-procedure: patient and target lobe selection
  • Multidisciplinary review: When possible, involve specialists in COPD, LVRS and transplant for comprehensive evaluation.
  • Clinical considerations: Exercise caution in patients requiring ≥4 L/min supplemental oxygen, with elevated PaCO₂ (>55 mm Hg), systolic dysfunction (LVEF <40%), or moderate pulmonary hypertension. Avoid BLVR in cases of severe pulmonary hypertension or decompensated heart failure.
  • Body habitus: High or low BMI alone should not exclude patients, but comorbid conditions related to body habitus warrant careful assessment.
  • BLVR considerations: Suitable for heterogeneous or homogeneous emphysema, but generally avoided in paraseptal emphysema or giant bullae. Valve placement is discouraged on the same side as prior lobectomy or pleurodesis, though it may be considered with other surgical histories.
  • Imaging and targeting: Quantitative CT is essential for assessing fissure integrity and emphysema severity. Ideal target lobes show ≥50% destruction at −910 HU or ≥20% at −950 HU with ≥80% fissure integrity.
  • Perfusion testing: Consider in patients with multiple potential targets or homogeneous disease.

Procedural guidance
  • Collateral ventilation testing: Perform physiological assessment before left-sided valve placement if fissure integrity <95%, and for all right-sided placements.
  • Hospital stay: Admit patients for at least three nights post-procedure to monitor for complications.

Post-procedure management
  • Follow up: Assess clinical status, imaging and lung function at four to six weeks, three to six months and one year.
  • Troubleshooting: Lack of improvement or loss of response should prompt imaging and possible valve revision. Evaluate for complications such as pneumothorax, infection or valve malfunction.
  • Oxygen needs: A sudden increase in oxygen requirement warrants investigation for reversible causes like pneumothorax or pulmonary embolism.

These recommendations provide practical, real-world guidance for clinicians performing BLVR with endobronchial valves. They aim to standardize care, improve patient outcomes and identify areas for future research.
Momen M. Wahidi, MD, Medical Director for the Canning Thoracic Institute, Health System Director for Interventional Pulmonology, Professor of Pulmonary and Critical Care
Christopher M. Kapp, MD, Professor of Pulmonary and Critical Care

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