Portal de Periódicos da CAPES

Anaesthesia for lung volume reduction surgery and endobronchial valves

2018; Elsevier BV; Volume: 18; Issue: 7 Linguagem: Inglês

10.1016/j.bjae.2018.04.002

2058-5357

A.K. Elayaperumal, Rupert Jackson,

Obstructive Sleep Apnea Research

Learning objectivesAfter reading this article you should be able to:•Explain the rationale for lung volume reduction surgery (LVRS) for patients with severe emphysema.•Distinguish how specific preoperative investigations impact on anaesthetic management.•Anticipate complications that can occur during and after lung volume reduction surgery.•Discuss non-surgical alternatives to LVRS.Key points•Lung volume reduction surgery aims to improve the quality of life for patients with severe chronic obstructive pulmonary disease on maximum medical therapy.•Evidence-based patient selection has reduced mortality and morbidity.•Perioperative multidisciplinary rehabilitation is vital to achieve the best results.•Gas trapping of lung and dynamic hyperinflation can lead to intraoperative haemodynamic instability.•Bronchoscopic lung volume reduction procedures are a less invasive alternative to open surgery, with comparable results in selected patients. After reading this article you should be able to:•Explain the rationale for lung volume reduction surgery (LVRS) for patients with severe emphysema.•Distinguish how specific preoperative investigations impact on anaesthetic management.•Anticipate complications that can occur during and after lung volume reduction surgery.•Discuss non-surgical alternatives to LVRS. •Lung volume reduction surgery aims to improve the quality of life for patients with severe chronic obstructive pulmonary disease on maximum medical therapy.•Evidence-based patient selection has reduced mortality and morbidity.•Perioperative multidisciplinary rehabilitation is vital to achieve the best results.•Gas trapping of lung and dynamic hyperinflation can lead to intraoperative haemodynamic instability.•Bronchoscopic lung volume reduction procedures are a less invasive alternative to open surgery, with comparable results in selected patients. Lung volume reduction surgery (LVRS) is used to improve exercise tolerance and relieve dyspnoea in patients with severe emphysema who have poor symptom control despite maximal medical therapy. It was first described in 1959 by Brantigan and Mueller, who demonstrated clinical improvement in 75% of patients.1Brantigan O.C. Mueller E. A surgical approach to pulmonary emphysema.Am Rev Respir Dis. 1959; 80: 194-202PubMed Google Scholar However, these promising results were clouded by an operative mortality rate of 18% and the procedure was not widely adopted. In 1995, Cooper and colleagues described a modified Brantigan approach in which 20–30% of the lung was resected via a median sternotomy.2Cooper J.D. Trulock E.P. Triantifillou A.N. et al.Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease.J Thorac Cardiovasc Surg. 1995; 109: 106-119Abstract Full Text Full Text PDF PubMed Scopus (891) Google Scholar This approach resulted in an improvement in the patients' respiratory function without any associated operative mortality. More recent trials including the National Emphysema Treatment Trial (NETT), the largest randomised trial of LVRS, have demonstrated improvements in quality of life and reduced mortality in highly selected patient groups.3Miller J.D. Malthaner R.A. Goldsmith C.H. et al.A randomized clinical trial of lung volume reduction surgery versus best medical care for patients with advanced emphysema: a two-year study from Canada.Ann Thorac Surg. 2006; 81: 314-320Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 4Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1668) Google Scholar, 5Geddes D. Davies M. Koyama H. et al.Effect of lung-volume-reduction surgery in patients with severe emphysema.N Engl J Med. 2000; 343: 239-245Crossref PubMed Scopus (352) Google Scholar Patients undergoing LVRS present significant challenges to the anaesthetist because of their comorbidities and the nature of the procedure. Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Whilst smoking is the main risk factor in most patients, uncommon conditions including inherited α-1 antitrypsin deficiency can also lead to severe COPD. COPD is a chronic inflammatory disease that results in central and peripheral airflow dysfunction and destruction of the lung parenchyma and lung vasculature in varying proportions. Parenchymal destruction can lead to the development of distended, air-filled emphysematous bullae, which do not contribute effectively to gas exchange. The characteristic pathophysiology is expiratory flow limitation that is not fully reversible and is usually progressive over the long term. In addition to inflammatory processes, oxidative stress and an imbalance of proteinase and antiproteinase activity play an important role in the pathophysiology leading to deteriorating lung function. These include mucus hypersecretion, ciliary dysfunction, and limitation of airflow with resulting hyperinflation and abnormal gas exchange. There is progressive enlargement in the volumes of the lung and thorax leading to flattening of the diaphragm and compromised chest wall mechanics. Patients who present for LVRS typically have severe emphysema, with a forced expiratory volume in 1 s (FEV1) of <50% of predicted, low carbon monoxide diffusing capacity (DLCO), and significantly increased total lung capacity and residual volume. Furthermore, based on radiological investigations, patients are only likely to benefit from LVRS if the pattern of their emphysema is heterogeneous, i.e. there are some areas of emphysematous lung, usually at the apices with relatively normal lung tissue elsewhere. Pulmonary hypertension (PHT) is common in patients with severe COPD. Cellular mediators including endothelin-1 are expressed in response to chronic hypoxia, which leads to vascular remodelling, increased pulmonary vascular resistance, and increased pulmonary artery pressures.6Giaid A. Yanagisawa M. Langleben D. et al.Expression of endothelin-1 in the lungs of patients with pulmonary hypertension.N Engl J Med. 1993; 328: 1732-1739Crossref PubMed Scopus (1665) Google Scholar Patients with PHT may have significant right heart failure, which requires assessment and optimisation before surgery. Specific treatments for PHT include prostacyclins, endothelin receptor antagonists, and phosphodiesterase inhibitors. LVRS may be conducted via median sternotomy, thoracotomy, or using video-assisted thoracoscopic surgery (VATS). Mortality rates are similar whether surgery is performed by thoracotomy or VATS.4Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1668) Google Scholar The individual expertise of the surgeon will dictate which approach is used. Possible reasons for clinical improvements in patients who undergo LVRS are: (i) Resection of poorly functioning, overdistended lung tissue gives room for expansion of better functioning lung that has been compressed. As lung with better elastic recoil and less expiratory flow limitation is recruited, the FEV1 improves and the ventilation perfusion mismatch reduces.7Sciurba F.C. Rogers R.M. Keenan R.J. et al.Improvement in pulmonary function and elastic recoil after lung-reduction surgery for diffuse emphysema.N Engl J Med. 1996; 334: 1095-1099Crossref PubMed Scopus (449) Google Scholar (ii) Reduction in lung volume corrects the effects that hyperinflation has upon the chest wall and diaphragm. This improves the efficiency of the respiratory muscles and reduces the work of breathing.8Lando Y. Boiselle P.M. Shade D. et al.Effect of lung volume reduction surgery on diaphragm length in severe chronic obstructive pulmonary disease.Am J Respir Crit Care Med. 1999; 159: 796-805Crossref PubMed Scopus (68) Google Scholar, 9Gorman R.B. McKenzie D.K. Butler J.E. et al.Diaphragm length and neural drive after lung volume reduction surgery.Am J Respir Crit Care Med. 2005; 172: 1259-1266Crossref PubMed Scopus (45) Google Scholar (iii) Dynamic hyperinflation of the lung has an effect on the heart similar to cardiac tamponade. LVRS may improve cardiac function and performance by decreasing intrathoracic pressure.10Mineo T.C. Pompeo E. Rogliani P. et al.Effect of lung volume reduction surgery for severe emphysema on right ventricular function.Am J Respir Crit Care Med. 2002; 165: 489-494Crossref PubMed Scopus (53) Google Scholar (iv) Improved systemic endothelial function and reduced systemic arteria after LVRS have been demonstrated.11Clarenbach C.F. Sievi N.A. Brock M. Schneiter D. Weder W. Kohler M. Lung volume reduction surgery and improvement of endothelial function and blood pressure in patients with chronic obstructive pulmonary disease. A randomized controlled trial.Am J Respir Crit Care Med. 2015; 192: 307-314Crossref PubMed Scopus (29) Google Scholar The NETT is the largest multicentre randomised control trial published to date comparing LVRS with medical therapy.4Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1668) Google Scholar The primary outcomes measured were mortality rate and exercise capacity. Secondary outcomes included the distance walked by the patient in 6 min, and the responses to health-related quality of life questionnaires. An interim analysis 3 yr into the trial identified a particularly high-risk group of patients with either FEV1 or DLCO ≤20% of predicted values, whose 90 day mortality rate was higher if they underwent LVRS compared with the medical therapy group (28.6% vs 0%). Patients in this high-risk group who underwent LVRS were also unlikely to receive functional benefits from surgery. After the interim analysis, these patients were excluded from the study. Of the patients who entered the trial under the revised criteria, 30 day mortality was 2.2% after LVRS compared with 0.2% in those receiving medical therapy alone. The group who underwent LVRS had greater improvements in exercise capacity, FEV1, quality of life, and degree of dyspnoea compared with the medical therapy group. A more detailed analysis of patient subgroups identified that patients with upper lobe emphysema and low baseline exercise capacity were more likely to have sustained improvements in exercise capacity and quality of life after LVRS compared with patients who had non-upper lobe emphysema and higher baseline exercise capacity. LVRS is indicated for patients with severe heterogeneous emphysema and severe dyspnoea despite maximum medical therapy and pulmonary rehabilitation. In addition to the patients' respiratory comorbidity, there is often a high degree of co-existent cardiovascular disease, which necessitates careful evaluation. Patients should complete a pulmonary rehabilitation programme, a multidisciplinary intervention aimed to maximise exercise capacity before surgery. Rehabilitation includes optimisation of medical treatment with bronchodilators and the aggressive management of infective exacerbations with antibiotics. Some patients who require LVRS may also be established on long-term oxygen therapy. Many patients require steroids, but these should be at the lowest possible dose to avoid their adverse effects and complications. As a preventative measure, patients should be vaccinated for seasonal influenza and pneumococcus. In addition to medical management, rehabilitation should incorporate a physiotherapy and exercise programme, dietetic and occupational therapy input, psychological support, and health education. Rehabilitation programmes help to ensure that patients are well motivated and able to gain the maximum possible benefit from LVRS. Patients with advanced COPD often have repeated respiratory infections. It may not be practical to cancel surgery in all patients who have active infections. In these cases, there should be a careful evaluation of the patient's condition and a discussion with the surgical and respiratory teams before deciding on whether to proceed. Patients should have a thorough assessment of the severity and distribution of their emphysema and an assessment of their cardiopulmonary function to determine suitability for LVRS. There is a high degree of co-existent cardiovascular disease in patients who undergo LVRS and careful cardiovascular assessment is mandatory. In particular, a 15% prevalence of asymptomatic but significant coronary lesions has been demonstrated.12Thurnheer R. Muntwyler J. Stammberger U. et al.Coronary artery disease in patients undergoing lung volume reduction surgery for emphysema.Chest. 1997; 112: 122-128Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar The rationale for specific additional preoperative investigations is summarised in Table 1.Table 1Rationale for specific preoperative tests in patients considered for lung volume reduction surgery (LVRS)Preoperative testRationaleEchocardiography and coronary angiographyTo assess cardiac function and identify significant pulmonary hypertension, which might contraindicate surgery.Significant coronary artery disease, heart failure and ejection fraction <40% are comorbidities that increase surgical mortality.12Thurnheer R. Muntwyler J. Stammberger U. et al.Coronary artery disease in patients undergoing lung volume reduction surgery for emphysema.Chest. 1997; 112: 122-128Abstract Full Text Full Text PDF PubMed Scopus (60) Google ScholarLung function testsForced expiratory volume in 1 s (FEV1) expected to be 150% of predicted.Total lung capacity is often >100% predicted.A marked abnormality of alveolar gas exchange (DLCO<20%) or a FEV1 <20% of predicted are contraindications for LVRS.High resolution CT of chestTo identify if the lungs are suitable for surgery (i.e. a heterogeneous distribution of emphysema in which there are areas of relatively normal lung tissue).Homogenous distribution of emphysema without areas of preserved lung, presence of large bullae, interstitial lung disease and nodules are contraindications to LVRS.Cardiopulmonary exercise testingTo determine cardiopulmonary functional status and to assess potential operative risk.To quantify and monitor clinical response to surgery.A pharmacological stress test is advisable if an exercise test cannot be performed.Shuttle walk testA distance of 150 m is an accepted minimum requirement post pulmonary rehabilitation. Open table in a new tab Sedative premedication is avoided as these patients already have compromised respiratory function. However, use of anxiolytics before the induction of anaesthesia has been described.13James M.F.M. Dyer R.A. Anaesthesia for lung volume reduction surgery.South Afr J Anaesth Analg. 2005; 11: 103-106Google Scholar Anaesthetic monitoring in line with AAGBI standards with arterial BP monitoring should be commenced before induction of anaesthesia to enable prompt recognition and management of haemodynamic instability. Interpretation of central venous pressure monitoring has limitations in patients undergoing LVRS as their chest cavity is open, they are often positioned in the lateral position and they may have significant pulmonary hypertension or valvular disease. However, a central venous catheter may be indicated for drug delivery or postoperative monitoring in patients with cardiovascular comorbidity. A large-bore i.v. cannula should be inserted, preferably on the same side as the surgery so that it is accessible if the patient is positioned laterally. The patient's lungs should be thoroughly preoxygenated as they are likely to be chronically hypoxic and prone to desaturation. After induction of anaesthesia, the options for airway management are either tracheal intubation with an appropriately sided double-lumen tracheal tube, or a single lumen tube with a bronchial blocker. A double-lumen tube's position can be checked clinically; however, whilst experienced clinicians may find this satisfactory and reliable, a fibreoptic bronchoscope can be used as a further confirmatory step, and indeed is mandatory in some centres. Particular care should be taken when using right-sided double lumen tubes to ensure that the right upper lobe can be ventilated adequately when the lung is isolated. Once the tube position is confirmed, the patient is positioned for surgery and lung isolation confirmed again before the procedure starts. Anaesthesia can be maintained by inhalation or i.v. routes. Some practitioners may prefer to use i.v. anaesthesia, particularly if the patient undergoes bronchoscopy as this technique separates the delivery of anaesthesia from ventilation. Theoretical benefits of using propofol for maintenance of anaesthesia are that it reduces the shunt fraction by maintaining pulmonary vasoconstriction and that its offset does not depend on pulmonary elimination. Nitrous oxide is avoided as it can worsen gas trapping (see below). When one-lung ventilation is commenced, it may take longer for the non-dependent lung to deflate because of air trapping and secretions compared with a healthy lung. Endobronchial suction of the isolated lung and external pressure by the surgeon may be required to help collapse the lung. Before one-lung ventilation is established, a tension pneumothorax may occur in either lung because of the use of positive pressure ventilation in emphysematous lungs. However, during one-lung ventilation, pneumothorax of the dependent (ventilated) lung may be difficult to detect. It should be considered if cardiovascular instability is associated with increasing ventilatory pressures. Gas trapping can occur in emphysematous lungs. Air empties slowly during the expiratory phase because of airway obstruction, and may not fully empty before expiration is terminated by the next inspiratory phase. This generates intrinsic PEEP, also known as dynamic hyperinflation, leading to further gas trapping. Gas trapping can be recognised by progressively increasing ventilator pressures. One method to prevent or minimise intrinsic PEEP includes using external PEEP which will, to some extent, maintain airway patency in late expiration so improving expiratory flow rate. Other strategies include using low tidal volume (e.g. 5 ml kg−1), low respiratory rate with a prolonged expiratory time, but these may result in hypoventilation and hypercapnia. In this instance alveolar ventilation can be improved by increasing the ventilatory rate, ensuring complete neuromuscular block, suctioning endobronchial secretions, and treating any bronchospasm. Temporary permissive hypercapnia may be a necessary compromise; however, if it results in significant respiratory acidosis (i.e. pH<7.2) despite optimisation of ventilation, then it may be necessary to revert to intermittent two lung ventilation.14Brister N.W. Barnette R.E. Kim V. Keresztury M. Anesthetic considerations in candidates for lung volume reduction surgery.Proc Am Thorac Soc. 2008; 5: 432-437Crossref PubMed Scopus (22) Google Scholar These interventions require close liaison with the surgeon. Gas trapping and dynamic hyperinflation can also cause sudden hypotension, which usually resolves after temporary disconnection of the breathing circuit from the tracheal tube by allowing the air to escape. However, it is important to consider other causes of hypotension, including pneumothorax, hypovolaemia, and myocardial ischaemia. Adequate analgesia is essential for successful extubation and reduction of complications after surgery. I.V. opioid doses can be minimised with good regional analgesia, i.v. paracetamol and COX-2 inhibitors (if not contraindicated). Gabapentin can be used as an adjunct, particularly in patients at risk of chronic postoperative pain, for instance patients with pre-existing chronic pain or those with long standing analgesic requirements. Thoracic epidural analgesia can be used and may be particularly indicated for bilateral LVRS and median sternotomy approaches. Alternatively, where a unilateral thoracotomy or VATS approach is used, paravertebral catheters can be inserted under direct vision by the surgeon. For patients who have a thoracotomy, paravertebral blocks have been shown to be as effective as epidural analgesia and have a better adverse effect profile.15Richardson J. Sabanathan S. Jones J. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses.Br J Anaesth. 1999; 83: 387-392Abstract Full Text PDF PubMed Scopus (243) Google Scholar Early tracheal extubation, ideally immediately after the operation, will reduce the incidence of complications. This will be more easily achieved in a warm, pain free, and haemodynamically stable patient with fully restored neuromuscular function and adequate respiratory effort at the end of surgery. Patients should be recovered in a semi-recumbent position to help maximise respiratory effort. After surgery, common concerns are respiratory failure and air leaks. Although air leaks from the lung parenchyma can occur after any lung resection, patients with advanced emphysema are at particularly high risk because of the nature of their disease. Large air leaks can cause a tension pneumothorax and lead to rapid cardiopulmonary deterioration. This can be avoided by having an appropriately sized, positioned and functioning chest drain. Respiratory failure can be caused by bronchospasm, pneumothorax, infection, and inadequate analgesia. A trial of non-invasive ventilation should be considered to prevent hypoxia and hypercapnia and to avoid reintubation. The rationale for bronchoscopic procedures is to collapse areas of hyperinflated emphysematous lung and to achieve a similar effect to LVRS without the morbidity associated with surgery. Different methods are described, including; insertion of one-way endobronchial valves, application of endobronchial biological sealants, thermal ablation of bronchi, or insertion of bronchial blockers, all of which aim to create atelectasis of the worst affected lung regions and remodel the hyperinflated lung.16Herth F.J. Gompelmann D. Ernst A. Eberhardt R. Endoscopic lung volume reduction.Respiration. 2010; 79: 5-13Crossref PubMed Scopus (49) Google Scholar Alternatively, stents may be inserted into airways to promote lung emptying in regions of the lung in which there is significant emphysema and airway obstruction. Multiple one-way valves can be inserted in the target area of the lungs during one procedure using a bronchoscope. These valves allow air and mucous to exit the treated area, but do not allow air to re-enter, which facilitates atelectasis of the emphysematous lung distal to the valve. Two types of valves are available, which differ in their design: duckbill-shaped (Zephyr®, PulmonX) valves and umbrella-shaped (Spiration®) valves. Several recent studies have shown modest improvements in symptoms and lung function after placement of endobronchial valves.17Davey C. Zoumot Z. Jordan S. et al.Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial.Lancet. 2015; 386: 1066-1073Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar, 18Klooster K. Ten Hacken N.H.T. Hartman J.E. Kerstjens H.A.M. Van Rikxoort E.M. Slebos D.J. Endobronchial Valves for emphysema without interlobar collateral ventilation.N Engl J Med. 2015; 373: 2325-2335Crossref PubMed Scopus (323) Google Scholar, 19Strange C. Herth F.J. Kovitz K.L. et al.Design of the endobronchial valve for emphysema palliation trial (VENT): a non-surgical method of lung volume reduction.BMC Pulm Med. 2007; 7: 10Crossref PubMed Scopus (24) Google Scholar Patients with intact interlobar fissures and no collateral ventilation gain the greatest benefit from the procedure.17Davey C. Zoumot Z. Jordan S. et al.Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial.Lancet. 2015; 386: 1066-1073Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar, 19Strange C. Herth F.J. Kovitz K.L. et al.Design of the endobronchial valve for emphysema palliation trial (VENT): a non-surgical method of lung volume reduction.BMC Pulm Med. 2007; 7: 10Crossref PubMed Scopus (24) Google Scholar Collateral ventilation in the human lungs is defined as the ventilation of alveolar structures through passages that bypass the normal airways. Although accessory pathways such as interalveolar pores, accessory bronchiolar-alveolar communications and accessory respiratory bronchioles exist in a normal lung, they do not cause significant collateral ventilation because they have high resistance to air flow compared with normal airways. In emphysema the resistance through collateral flow communications can be markedly reduced to such an extent that the resistance of air flow via segmental airways may be higher than that of the collateral flow. In emphysematous lung, a lobe may not collapse when its bronchus is obstructed by tumour, secretions, or selective lobar intubation because air can pass from other lobes via collateral channels. Therefore, it is important to be able to identify areas of lungs that are emphysematous but do not have collateral ventilation as these are more likely to benefit from the placement of endobronchial valves. High-resolution CT of the chest is commonly used to quantify the heterogeneity of emphysema and identify intact interlobar fissures as a surrogate indicator for lack of collateral ventilation. Another method used to identify areas of low or no collateral ventilation uses the Chartis system® (PulmonX, Redwood City, California, USA).18Klooster K. Ten Hacken N.H.T. Hartman J.E. Kerstjens H.A.M. Van Rikxoort E.M. Slebos D.J. Endobronchial Valves for emphysema without interlobar collateral ventilation.N Engl J Med. 2015; 373: 2325-2335Crossref PubMed Scopus (323) Google Scholar During a Chartis® assessment, a balloon catheter is inserted into the target region via a rigid bronchoscope, and a balloon inflated to block airflow. While the rest of the lung is ventilated, the Chartis console displays expiratory airflow, pressure and resistance of the blocked segment of the lung, distal to the inflated balloon. If the console indicates there is gradual reduction of expiratory airflow over several breathing cycles, then there is little or no collateral ventilation from adjacent lung segments into the target region. This demonstrates that the target area is suitable for valve placement. Nitinol coils are passed through the working channel of a bronchoscope in straightened configurations into the subsegmental airways and into the lung parenchyma. Once deployed, they resume their coiled shape and hence collect and collapse the lung tissue in that area. Unlike valve techniques, the collateral ventilation has no effect on its results. In biological lung volume reduction, a sealant or remodelling system is directly applied via a bronchoscope to the emphysematous area of the lungs to facilitate collapse. In a technique called BioLVR, fibrin and thrombin solutions are delivered simultaneously to the affected subsegmental airway via a dual lumen catheter. Once delivered, the liquid fills up the alveoli and polymerises, blocking the collateral ventilation. Usually, four to eight subsegments are treated during a single procedure. In thermal airway ablation, steam is selectively administered to the affected segmental airway using a specialised catheter via a flexible bronchoscope. This induces an inflammatory response, which causes occlusion and atelectasis of the target area of the lung. One benefit of this technique is that, unlike valve techniques, no foreign body is involved. Patients who undergo endobronchial procedures have similar characteristics to those who have LVRS, therefore their extensive lung disease and comorbidities must be considered. The precise anaesthetic technique varies depending on the procedure. Whilst many of the flexible bronchoscopic procedures are done in awake or sedated patients, procedures performed via a rigid bronchoscope necessitate a general anaesthetic. Thermal ablation can be performed using flexible bronchoscopy; however, general anaesthesia is used for patient comfort. Endobronchial valves can be inserted under sedation or general anaesthesia. The procedure starts with a bronchoscopy examination and Chartis assessment may be performed at the beginning of the procedure to identify areas of the lung that may benefit from valve placement. Once the target area is identified, measurements are taken to select the appropriate valve size, and these are then inserted using the bronchoscope. Patients may need multiple valves to target different segments of the planned area. In our centre a rigid bronchoscope is used as a working channel, and the most common anaesthetic technique is total i.v. anaesthesia with a neuromuscular blocker. During the procedure a rigid bronchoscope and jet ventilator are used to deliver ventilation. Good communication with the surgical team is essential to correctly time the delivery of jet ventilation during the different phases of valve placement. At the end of the procedure either an tracheal tube or a supraglottic airway can be inserted to allow ventilation of the patient whilst they emerge from anaesthesia. LVRS is major thoracic procedure performed on patients with significant comorbidities and has a high risk of complications. The decision of whether to operate or not should be based on current evidence, multidisciplinary team discussions, and detailed discussions with the patient about the intended symptom control and quality of life benefits balanced against the risks of surgery. Bronchoscopic lung volume reduction procedures have been developed as a less invasive option and are now becoming more widespread as the evidence base for their use grows.