Endoscopic Lung Volume Reduction Selection Criteria
Patients with severe emphysema and hyperinflation (RV >175% predicted) with FEV₁ <50% predicted, 6-minute walk distance >100 m, heterogeneous emphysema distribution, and absence of collateral ventilation are ideal candidates for endoscopic lung volume reduction with endobronchial valves. 1, 2
Core Selection Criteria
Pulmonary Function Requirements
- Hyperinflation: Residual volume >175% predicted (essential marker of air trapping) 1
- Airflow obstruction: FEV₁ <50% predicted 1
- Exercise capacity: 6-minute walk distance >100 m 1
Anatomical Requirements
- Emphysema distribution: Heterogeneous pattern preferred (target lobe with more severe destruction than adjacent lobes) 2, 3
- Collateral ventilation: Must be absent or minimal for valve success 1, 2
- Assess using Chartis system during bronchoscopy
- Complete or near-complete fissure integrity on high-resolution CT (fissure completeness score) 4
Imaging Assessment
Quantitative HRCT analysis should evaluate:
- Fissure completeness (>90% predicts absence of collateral ventilation)
- Percentage of voxels with density <-910 HU and <-950 HU (quantifies emphysema severity)
- Lobar volumes to identify target lobe 4
- Perfusion scintigraphy to confirm poor perfusion in target lobe 2
Exclusion Criteria
Absolute Contraindications
- Repeated infectious complications or severe bronchiectasis 1
- Unstable cardiovascular comorbidities 1
- High collateral ventilation (Rcoll <10 cm H₂O/[mL/s]) 5
- Homogeneous emphysema (should only be treated in clinical trials) 3
Relative Contraindications
- Active smoking (must achieve smoking cessation)
- Significant pulmonary hypertension (though sPAP >35 mmHg has been successfully managed in experienced centers) 6
- Prior thoracic interventions (requires careful evaluation but not absolute exclusion) 6
Target Lobe Selection Algorithm
Upper lobe predominant disease is preferred, but lower lobe targets can be considered when:
- Clear heterogeneity exists with identifiable "airoma" (areas of excess residual volume and poor perfusion)
- Dynamic MRI during ventilation confirms compression of adjacent lung
- Complete fissure integrity documented 7
The target lobe should demonstrate:
- Most severe emphysematous destruction on quantitative CT
- Poorest perfusion on scintigraphy
- Complete fissure separating it from adjacent lobes
- Absence of collateral ventilation on Chartis assessment 2, 4
Additional Baseline Assessment
Beyond basic spirometry and imaging, optimal evaluation includes:
- Cardiopulmonary exercise testing (VO₂max assessment) 2
- Echocardiography (evaluate pulmonary pressures and cardiac function) 2
- Body composition (BMI, though patients with BMI <18.5 kg/m² can be considered in experienced centers) 6
Important Caveats
Collateral ventilation is the primary determinant of valve success—even with perfect patient selection otherwise, significant collateral flow will prevent lobar atelectasis and treatment failure. Always perform Chartis assessment during the procedure when possible 1, 5.
For patients with incomplete fissures or homogeneous disease, alternative ELVR techniques (coils, polymeric lung volume reduction, thermal vapor ablation) or surgical lung volume reduction should be considered instead of valves 3, 8.
Recent evidence suggests carefully selected patients beyond traditional NETT criteria (age ≥75 years, FEV₁ <20% predicted, prior thoracic surgery) may benefit when evaluated by experienced multidisciplinary teams, though this requires rigorous case-by-case assessment 6, 9.
The procedure should be performed in centers with expertise in managing complications, particularly pneumothorax, which occurs commonly in the first 2 days post-procedure 1.