Bronchoscopic Lung Volume Reduction (BLVR): A Minimally Invasive Treatment for Severe Emphysema

Living with severe emphysema, a chronic and progressive lung disease, can significantly impact daily life. For many individuals, even simple activities like walking or speaking can become exhausting due to persistent shortness of breath. This debilitating condition, a form of chronic obstructive pulmonary disease (COPD), causes irreversible damage to the air sacs (alveoli) in the lungs, leading to air trapping and hyperinflation – a state where the lungs become overinflated and cannot effectively exchange oxygen and carbon dioxide. While medical therapies offer symptom management, they often fall short for those with advanced disease. 

In recent years, a groundbreaking, minimally invasive treatment called Bronchoscopic Lung Volume Reduction (BLVR) has emerged, offering new hope. Unlike traditional surgery, BLVR is a non-surgical procedure designed to alleviate symptoms by improving lung function and reducing hyperinflation. This innovative approach involves placing tiny, one-way valves in the airways to block off the most diseased parts of the lung. This allows trapped air to escape, enabling healthier lung tissue to expand and function more efficiently, ultimately helping patients breathe easier and improve their quality of life. 

At Froedtert & the Medical College of Wisconsin, our expert pulmonology team utilizes advanced BLVR techniques to provide comprehensive, personalized care for individuals seeking relief from severe emphysema. BLVR is only available at select centers across the United States, including Froedtert Hospital. 

How Bronchoscopic Lung Volume Reduction Works 

BLVR represents a significant advancement in the treatment of severe emphysema by directly addressing the problem of hyperinflation. The core principle behind BLVR is to reduce the volume of the most diseased, overinflated parts of the lung, thereby allowing the healthier lung tissue to expand more effectively and the diaphragm to function better. This process relies on the strategic placement of tiny, one-way valves into the airways leading to the damaged lung segments. 

The procedure itself is minimally invasive, performed using a bronchoscope – a thin, flexible tube with a camera and light at its tip. The pulmonologist guides the bronchoscope through the mouth, down the windpipe and into the bronchial tubes of the lungs, avoiding any external incisions (there is no cutting). The procedure is performed under general anesthesia while the patient is asleep and comfortable. 

A critical step before valve placement is a thorough assessment of the lung’s anatomy, particularly checking for a condition called collateral ventilation. Collateral ventilation refers to alternative air passages between lung segments or lobes that bypass the main airways. If collateral ventilation is present in the targeted area, a one-way valve might not effectively trap air because air can still enter the diseased segment through these alternative routes. Specialized diagnostic tools, such as the Chartis Pulmonary Assessment System, are used during the bronchoscopy to measure airflow and confirm the absence of collateral ventilation in the target lobe, ensuring optimal patient selection and valve effectiveness. 

Once the target lobe is identified and confirmed to be free of collateral ventilation, small, self-expanding, one-way endobronchial valves (such as the Zephyr Valve system) are carefully deployed. These valves act like tiny gates: they allow trapped air and fluids to exit the diseased portion of the lung, but they prevent new air from entering. Over time, as air leaves and cannot re-enter, the treated, overinflated lung segment collapses. This reduction in volume creates space for the healthier parts of the lung to expand, restoring more normal lung mechanics. The diaphragm can then move more efficiently, reducing the effort required to breathe. Patients often experience significant improvements in lung function, reduced shortness of breath and enhanced exercise capacity.

Benefits of BLVR

For individuals with severe emphysema, BLVR provides significant advantages by reducing lung hyperinflation and restoring more normal lung mechanics: 

Improved Breathing

• Noticeable reduction in shortness of breath 
• Allows trapped air to escape from damaged lung segments 
• Patients often report deeper, fuller breaths with less effort 

Enhanced Lung Function 

• Increased lung capacity and airflow (e.g., FEV1) 
• Healthier lung tissue has more room to expand 
• Diaphragm operates more efficiently 

Greater Exercise Tolerance 

• Ability to walk farther and perform daily activities with less fatigue 
• Increased participation in physical activity 
• Improvements often confirmed by objective measures (e.g., six-minute walk test) 

Better Quality of Life 

• Fewer hospitalizations due to COPD exacerbations
• Improved sleep quality and independence
• More active involvement in social events, hobbies and family life 
• Positive impact on mental and emotional well-being 

Minimally Invasive Approach 

• Performed bronchoscopically—no external incisions
•  Faster recovery time and reduced pain 
• Lower risk of surgical complications compared to LVRS 
• Suitable for patients who are not candidates for invasive surgery 
• Provides durable relief for carefully selected patients

Potential Risks and Complications of BLVR

While BLVR is minimally invasive and generally safe for carefully selected patients, it does carry potential risks. Patients and families should be fully informed before deciding. 

Most Common Risk: Pneumothorax (Collapsed Lung) 

• Occurs in 10% of cases when air leaks into the space between the lung and chest wall 
• Related to the intended collapse of diseased lung segments 
• Usually mild and manageable: 
  • May resolve on its own 
  • Sometimes requires temporary chest tube placement or valve removal 
  • Patients are closely monitored for this complication after the procedure 

Other Potential Risks (Less Common) 

COPD Exacerbation or Infection 

• Valve placement can trigger COPD flare-ups or pneumonia 
• Managed with antibiotics and supportive care 

Hemoptysis (Coughing Up Blood) 

• Minor bleeding may occur during or after the procedure 
• Typically resolves spontaneously; significant bleeding is rare 

Valve Displacement or Malfunction 

• Rarely, a valve may shift or become blocked 
• May require additional bronchoscopic procedures for repositioning or removal 

Respiratory Failure 

• Very rare, severe cases may require intensive care support 
• Some patients may not experience expected improvements despite proper technique and selection 

Risk Reduction Strategies 

Careful patient selection: 

• Comprehensive evaluation 
• Assessment for absence of collateral ventilation  
• Review of overall health status 

Post-procedure monitoring and close follow-up: 

• Early detection and management of complications 
• Ensures best possible outcomes 

Is BLVR Right for You? Candidacy and Evaluation

Deciding whether BLVR is the right treatment requires a comprehensive and rigorous evaluation process by a specialized multidisciplinary team. This ensures that the procedure offers the best chance of benefit with the lowest possible risk. Generally, candidates for BLVR are individuals with severe emphysema who continue to experience significant shortness of breath and limited physical activity despite receiving optimal medical management, including medications like bronchodilators and participation in pulmonary rehabilitation programs.

Key eligibility criteria typically include: 

• Severe Airflow Obstruction: Patients usually have a severely reduced forced expiratory volume in one second (FEV1), often below 45% of predicted, indicating significant airway obstruction.
• Significant Hyperinflation: Evidence of severe air trapping and lung hyperinflation on CT scans and pulmonary function tests. This is a primary target of BLVR. 
• Heterogeneous or Homogeneous Emphysema: While BLVR was initially primarily used for heterogeneous emphysema (where damage is unevenly distributed, with more severe disease in specific lung regions, often the upper lobes), advancements have made it viable for certain patients with homogeneous emphysema (where damage is more evenly spread). The absence of collateral ventilation in the target lobe remains a crucial factor for valve therapy success in both types. 
• Non-Smoking Status: A strict requirement is that patients must have quit smoking for at least four months and preferably longer, before the procedure. Continued smoking after BLVR would negate the benefits and increase risks. 
• Participation in Pulmonary Rehabilitation: A history of participating in and benefiting from a comprehensive pulmonary rehabilitation program demonstrates a patient's commitment to improving their health and prepares them for better post-procedure outcomes. 
• Overall Health Status: Candidates must be stable enough to undergo the procedure. This includes evaluation for significant heart disease, recent respiratory infections or other conditions that might increase surgical risks. 
• Absence of Collateral Ventilation: As discussed, the lack of air passages between lung segments is paramount for valve efficacy. This is assessed with advanced imaging and intra-procedural tests. 

The evaluation process at Froedtert & MCW involves a collaborative approach, bringing together pulmonologists specializing in interventional pulmonology, thoracic surgeons, radiologists and rehabilitation therapists. This team thoroughly reviews a patient's medical history, performs advanced lung function tests, conducts high-resolution CT scans of the chest and assesses their exercise capacity. This detailed assessment ensures that BLVR is not only clinically appropriate but also aligned with the patient's individual goals and expectations, distinguishing it from other treatments like Lung Volume Reduction Surgery (LVRS) or lung transplantation.

The BLVR Procedure: What Patients Can Expect

Understanding what to expect before, during and after the (BLVR) procedure can help patients feel more prepared and less anxious. The journey towards BLVR is carefully planned and executed by a dedicated medical team. 

Before the Procedure: The preparatory phase is crucial. After determining candidacy through a rigorous evaluation, patients will undergo several diagnostic tests. These typically include comprehensive pulmonary function tests to measure lung volumes and airflow, a detailed CT scan of the chest to map the precise location and extent of emphysema damage, an ultrasound of the heart (echocardiogram) to assess for heart failure or pulmonary hypertension, a six-minute walk test to assess exercise capacity, an arterial blood gas (ABG) to measure oxygen and carbon dioxide levels in the blood and a nuclear medicine SPECT to measure how much blood flows to each part of the lungs. These tests help the team pinpoint the most diseased lung areas suitable for valve placement and confirm the absence of collateral ventilation. You'll also have consultations with the interventional pulmonologist to discuss the procedure details and potential risks. 

During the Procedure: The BLVR procedure is performed in a hospital setting, usually in an operating room or specialized procedural suite, under general anesthesia. This means you will be completely asleep and won't feel any pain. The interventional pulmonologist begins by inserting a flexible bronchoscope through your mouth, guiding it down your windpipe and into the airways of your lungs. The bronchoscope is equipped with a small camera, allowing the doctor to visualize the inside of your lungs in real-time on a monitor. 

Using precise anatomical maps derived from your CT scans and often employing intra-procedural tools to confirm target lobe isolation, the doctor navigates to the airways leading to the most damaged, hyperinflated parts of your lung. Small, self-expanding, one-way endobronchial valves are then carefully deployed into these specific airways. The number of valves placed can vary, typically ranging from three to five, depending on the individual's lung anatomy and the treatment plan. Each valve is designed to allow trapped air to escape from the diseased lung segment but prevents new air from entering. The entire procedure usually takes about 45 minutes.

Immediately After the Procedure: Following valve placement, you will be moved to a recovery area where medical staff will monitor you closely as you wake up from anesthesia. A short hospital stay, typically three days, is required to monitor for potential complications, particularly pneumothorax (collapsed lung), which is the most common immediate risk. During this time, you may experience some mild discomfort, a cough or a feeling of chest tightness, which can be managed with medication. The medical team will ensure you are stable and comfortable before discharge, providing detailed instructions for your recovery at home.

Recovery, Long-Term Outlook and Ongoing Care

The journey with BLVR extends beyond the procedure itself, encompassing a period of recovery, ongoing care and the realization of long-term benefits. Understanding this continuum is vital for patients. 

Recovery Timeline: After a BLVR procedure, most patients spend at least three days in the hospital for observation, primarily to monitor for pneumothorax and ensure stability. Upon discharge, individuals typically return home and the initial recovery phase can range from a few weeks to several months. During this time, patients may experience some residual cough, chest discomfort or fatigue as their body adjusts to the changes in lung mechanics. The full benefits of the procedure, such as significant improvement in breathing and exercise tolerance, often become more apparent over the first few weeks to months. 

Post-Procedure Care: Continued engagement in a pulmonary rehabilitation program is highly recommended and often crucial for maximizing the benefits of BLVR. Rehabilitation helps patients build strength, improve endurance and learn effective breathing techniques, reinforcing the positive physiological changes from the procedure. Regular follow-up appointments with the pulmonology team are essential to monitor lung function, assess symptom improvement and address any ongoing concerns. Medication management for COPD will continue, as BLVR is an additive therapy, not a replacement for medical treatment. CT scans and pulmonary function testing will be performed periodically to evaluate valve placement and lung response. 

Long-Term Benefits and Durability: Studies have shown that the benefits of BLVR, including improved lung function, reduced shortness of breath and enhanced quality of life, can be sustained for several years. The valves are designed to remain in place indefinitely. In rare cases, if a valve needs to be removed or replaced due to migration or malfunction, this can be done bronchoscopically. Ongoing research continues to explore ways to optimize long-term outcomes and expand the applicability of BLVR to an even broader range of emphysema patients. 

Life Expectancy Considerations: It's important to understand that while BLVR can significantly improve the quality of life, breathing ability and exercise capacity for individuals with severe emphysema, it is not a cure for the underlying disease. Emphysema remains a progressive condition. BLVR primarily addresses the mechanical problem of hyperinflation. Inhalers will still be required after the procedure. Patients should continue to work closely with their medical team to manage their overall health and other co-existing conditions, which can influence long-term prognosis. BLVR aims to help patients live better, more active lives, rather than solely extending life expectancy, though improvements in respiratory function can contribute to overall health.

BLVR vs. Lung Volume Reduction Surgery (LVRS): A Comparison 

When considering advanced treatment options for severe emphysema, two primary approaches aim to reduce lung hyperinflation: Bronchoscopic Lung Volume Reduction (BLVR) and Lung Volume Reduction Surgery (LVRS). While both share the goal of improving breathing by reducing lung volume, they differ significantly in their invasiveness, eligibility criteria and recovery profiles. 

LVRS is a traditional surgical procedure where a thoracic surgeon removes approximately 20-30% of the most diseased, non-functional lung tissue. This is an open-chest or thoracoscopic (keyhole) surgery, requiring general anesthesia and incisions. LVRS can be very effective for specific patient populations, particularly those with upper lobe predominant emphysema, but it is a major operation with a longer recovery period, more significant pain and higher risks of complications such as prolonged air leaks, infection and potential need for re-operation. Due to its invasiveness, candidacy for LVRS is typically restricted to individuals who are otherwise in relatively good health and can tolerate major surgery. 

BLVR, as described, is a minimally invasive, non-surgical procedure. Instead of removing tissue, it uses one-way endobronchial valves placed via a bronchoscope to block air entry to the diseased lung segments, causing them to collapse and reduce in volume. This approach avoids incisions and the associated surgical trauma. The recovery period is generally shorter and the procedure carries a lower risk profile compared to LVRS, making it suitable for a broader range of patients, including some who may be deemed too frail for traditional surgery. BLVR is particularly effective for patients with heterogeneous emphysema or certain types of homogeneous emphysema where target lobes can be successfully isolated from collateral ventilation. 

In essence, BLVR offers a less invasive alternative for lung volume reduction, providing similar benefits to LVRS for carefully selected patients, but with a potentially safer and quicker recovery. The choice between BLVR and LVRS is highly individualized and determined by a multidisciplinary team based on the patient's specific lung anatomy, the distribution of their emphysema, overall health and personal preferences. Many patients who are not candidates for LVRS may be excellent candidates for BLVR.

Advanced Emphysema Treatment in Southeastern Wisconsin with BLVR at Froedtert & MCW 

By precisely addressing the debilitating effects of lung hyperinflation, BLVR empowers individuals to regain independence and engage more fully in their daily lives. If you or a loved one is living with severe emphysema and seeking advanced treatment options, we encourage you to consult with the pulmonary specialists at Froedtert & MCW to explore if BLVR could be a life-changing solution for you. 

If you would like to talk with our care team to determine if you may be a candidate for BLVR, call 414-777-7700. If you are a physician with a patient who may be a candidate for BLVR or you would like more information, please call 414-805-4700.