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In severe emphysema the worst-damaged parts of the lung fill with trapped air and squash the healthier lung around them. Lung volume reduction surgery removes those useless areas so the better lung and the diaphragm can work properly again. It helps a specific group of people a great deal — and harms another group, which is why the assessment beforehand is so careful.
The problem being fixed
In advanced emphysema the elastic recoil of the lung is destroyed. Damaged regions ventilate poorly but empty even more poorly, so they inflate progressively through the breath cycle and behave as space-occupying lesions. The consequences are mechanical rather than simply obstructive: hyperinflation flattens the diaphragm, shortens its fibres and moves it away from its optimal length–tension relationship, the ribcage is pushed towards a permanently inspiratory position, and the inspiratory muscles are loaded at the point where they are least able to generate pressure.1
The result is dynamic hyperinflation on exertion, a rising end-expiratory lung volume, a fall in inspiratory capacity and the sensation patients describe as being unable to get a breath in rather than out. Lung volume reduction surgery (LVRS) treats this mechanical problem, not the underlying loss of alveolar tissue. Nothing is regenerated; the aim is to remove the regions that are stealing volume from the ones that still work.
What the operation involves
Twenty to thirty per cent of each targeted lung is resected, usually with staple lines buttressed to reduce air leak, most often bilaterally by video-assisted thoracoscopic surgery (VATS) and less commonly by median sternotomy. Target selection is imaging-led: the regions chosen are those with the most severe destruction and the least perfusion on computed tomography (CT) and quantitative perfusion scanning.
Prolonged air leak is the commonest complication, and the reason drains often remain for longer than after a standard resection. This is expected, not a setback, and it should not be allowed to keep the patient in bed.
Who benefits — and who is harmed
This is the unusual case where a single randomised trial defined practice and has not been overturned. The National Emphysema Treatment Trial (NETT) randomised 1,218 patients with severe emphysema to LVRS plus medical therapy or medical therapy alone after a mandatory course of pulmonary rehabilitation.2 Overall mortality did not differ, but the trial's value lies in what it found on subgroup analysis, which was pre-specified.
| Emphysema distribution | Baseline exercise capacity | Outcome with surgery |
|---|---|---|
| Upper-lobe predominant | Low | Survival benefit, plus improved exercise capacity and quality of life |
| Upper-lobe predominant | High | No survival benefit; improved exercise capacity and symptoms |
| Non-upper-lobe | Low | No survival benefit; modest symptom improvement |
| Non-upper-lobe | High | Higher mortality than medical therapy — surgery is harmful |
A separate NETT analysis identified a high-risk group in whom surgery should not be offered: a forced expiratory volume in one second (FEV1) of 20% predicted or less together with either homogeneous emphysema or a carbon monoxide diffusing capacity (DLCO) of 20% predicted or less carried a 30-day mortality of 16%.3 That finding is why the pre-operative work-up is as extensive as it is, and why a referral that looks reasonable on spirometry alone may still be refused.
Where bronchoscopic treatment fits
Endobronchial valve placement targets the same mechanical problem through the airway and is now the more commonly performed intervention in Australia, particularly where fissure integrity is intact and collateral ventilation absent — see Endobronchial Valves. Meta-analysis of surgical and bronchoscopic volume reduction shows both improve lung function, exercise capacity and quality of life against medical therapy, with differing risk profiles rather than a clear hierarchy.4 LVRS retains a role where valves are unsuitable, notably in upper-lobe predominant disease with collateral ventilation.
Rehabilitation is part of the treatment, not an adjunct
NETT required six to ten weeks of supervised pulmonary rehabilitation before randomisation and further rehabilitation afterwards.2 Every published benefit of LVRS is therefore a benefit on top of completed rehabilitation. A patient who has not had it has not had the intervention the trial tested, and this is the single most useful point a physiotherapist can make in a multidisciplinary meeting.
- Before surgery. Exercise capacity is both a selection variable and a modifiable one. Rehabilitation establishes the baseline used for selection, improves it, and identifies the patient who will not manage the post-operative course.
- Early post-operative. Expect prolonged air leak and drains. Mobilise regardless. Avoid vigorous positive-pressure techniques over fresh staple lines and favour breathing control, walking and upright positioning.
- Later. Deflation changes the mechanics the patient has adapted to over years. Breathing pattern retraining has a real target here, because inspiratory capacity has genuinely increased and the old pattern is no longer the efficient one.
Role of the physiotherapist
Know the selection criteria well enough to recognise the patient who should be discussed and the patient who should not. Deliver the rehabilitation the evidence assumes, before and after. In the early post-operative phase, protect the staple lines while refusing to let a drain justify bed rest. Afterwards, re-teach breathing at the new lung volume rather than reinforcing the pattern that suited the hyperinflated chest, and set expectations honestly: benefit is measured in exercise capacity and breathlessness, not in a normal spirogram.
Evidence summary
Framing. LVRS is the clearest example in thoracic surgery of a procedure whose benefit is entirely determined by phenotype. The same operation produces a survival advantage in one group and excess mortality in another, and the discriminating variables are emphysema distribution and baseline exercise capacity rather than the severity of airflow obstruction.2,3
Evidence — selectionNETT remains the definitive trial: no overall survival difference, a survival benefit confined to upper-lobe predominant disease with low baseline exercise capacity, and excess mortality in non-upper-lobe disease with preserved exercise capacity.2 The high-risk analysis (FEV1 ≤20% predicted with homogeneous emphysema or DLCO ≤20% predicted) reported 30-day mortality of 16% and effectively excluded that group from surgery.3 Long-term follow-up sustained the benefit in the responsive subgroup.5
Evidence — surgical versus bronchoscopicSystematic review and meta-analysis of volume-reduction interventions found both surgical and endoscopic approaches superior to medical management for FEV1, exercise capacity and quality of life, with no evidence supporting a universal preference; selection is by target lobe, fissure integrity and collateral ventilation.4 Current Global Initiative for Chronic Obstructive Lung Disease guidance positions both as options in carefully selected patients after optimal medical therapy and rehabilitation.6
Physiotherapy implicationsTreat pulmonary rehabilitation as a component of the intervention rather than preparation for it — the trial evidence is conditional on it. Use exercise capacity measurement knowingly: it is a selection variable, so the quality of the test affects the surgical decision. Post-operatively, mobilise through prolonged air leak and avoid high-pressure techniques over staple lines. Re-teach breathing pattern at the new operating volume; the patient's habitual pattern was an adaptation to hyperinflation that no longer serves them.
Evidence gapsNo trial has compared physiotherapy content or dose after LVRS, and practice is extrapolated from lung resection and pulmonary rehabilitation literature. Head-to-head randomised comparison of LVRS against endobronchial valves in patients eligible for both is lacking. The durability of mechanical benefit beyond five years, and whether repeat intervention is justified, remain unresolved.
References & evidence base
- O’Donnell DE, Laveneziana P, Webb K, Neder JA. Chronic obstructive pulmonary disease: clinical integrative physiology. Clin Chest Med 2014;35(1):51–69.
- Fishman A, Martinez F, Naunheim K, et al; National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003;348(21):2059–2073.
- National Emphysema Treatment Trial Research Group. Patients at high risk of death after lung-volume-reduction surgery. N Engl J Med 2001;345(15):1075–1083.
- van Geffen WH, Slebos DJ, Herth FJ, Kemp SV, Weder W, Shah PL. Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. Lancet Respir Med 2019;7(4):313–324.
- Naunheim KS, Wood DE, Mohsenifar Z, et al; National Emphysema Treatment Trial Research Group. Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema. Ann Thorac Surg 2006;82(2):431–443.
- Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: 2026 report. GOLD, 2026.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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