Despite advancements in supportive therapies for chronic obstructive pulmonary disease (COPD), many patients continue to suffer from persistent breathlessness, often due to progressive lung hyperinflation.^1-3 Management traditionally focused on symptom control, with long-term oxygen therapy (LTOT) introduced in advanced or palliative stages.^4,5 However, recent innovations in interventional pulmonology have brought forward non-surgical lung volume reduction (LVR) techniques as promising alternatives.⁶ In an interview with Omnihealth Practice, Dr. Syed Ajmal Syed Ali presented a clinical case showcasing the use of bronchoscopic thermal vapor ablation (BTVA)—the latest addition to the bronchoscopic lung volume reduction (BLVR) armamentarium—to treat heterozygous emphysema in a patient with advanced COPD. He also discussed other minimally invasive BLVR techniques, highlighting a growing shift toward tailored interventional strategies in selected patients with emphysema. 

Background 

COPD is currently the third leading cause of death worldwide, after ischemic heart disease and stroke, accounting for approximately 3 million deaths annually.^6,7 Notably, over 90% of COPD-related deaths occur in low- and middle-income countries, driven by a higher prevalence of cigarette smoking among adults.⁸ COPD-related lung damage is generally considered irreversible.⁹ In emphysema, alveolar destruction leads to the loss of alveolar walls, resulting in large, inefficient air spaces and a permanent reduction in surface area for gas exchange.⁹ In chronic bronchitis, persistent inflammation leads to airway remodeling characterized by thickened airway walls, excessive mucus production, and airway narrowing.¹⁰ While treatment may alleviate symptoms, structural changes tend to persist over time.⁶ 

The management of COPD primarily focuses on relieving symptoms, improving quality of life (QoL), slowing disease progression, and preventing exacerbations.⁵ Treatment strategies include pharmacologic therapy with inhaled bronchodilators and corticosteroids, pulmonary rehabilitation, and interventions such as lung volume reduction procedures.¹¹ Additional supportive measures include smoking cessation, vaccinations (e.g. influenza, pneumococcal and respiratory syncytial virus [RSV] vaccines), and patient education on action plans.^3,7 Patients with advanced disease may require LTOT, home non-invasive ventilation (NIV), or, in selected cases, lung transplantation.^3,7,12 

Although inhaled therapies and other medical treatments can improve symptoms and reduce exacerbations, they offer limited benefit in addressing the primary underlying cause of breathlessness in many patients: lung hyperinflation.³ Lung hyperinflation impairs breathing mechanics and gas exchange, contributing significantly to dyspnea and exercise limitation.⁹ 

According to Dr. Syed Ali, respiratory medicine is undergoing a dynamic shift, with a growing emphasis on interventional strategies. He noted that respiratory physicians are proactively offering novel, minimally invasive treatments beyond conventional supportive care. While traditional medical therapies remain the cornerstone of COPD management, newer interventional approaches are opening up additional therapeutic avenues for selected patients.¹² 

The 2025 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report recognizes BLVR as a valuable treatment option for selected patients with advanced emphysema.¹² BLVR techniques, including endobronchial valves (EBVs) and BTVA, are minimally invasive procedures aimed at reducing lung hyperinflation, thereby improving respiratory mechanics, symptoms, and QoL.¹³ 

The GOLD 2025 report states: “In selected patients with advanced emphysema refractory to optimized medical care, surgical or bronchoscopic interventional treatments may be beneficial”.¹² Hence, for appropriate candidates— those with severe, heterogeneous emphysema, significant hyperinflation, and persistent symptoms despite optimal care—BLVR offers a minimally invasive alternative to surgical interventions, particularly when surgical risks are prohibitive.¹² Careful patient selection is critical to achieving favorable outcomes.³ 

Key considerations include: 

• Disease heterogeneity: Patients with heterogeneous emphysema (i.e. regional variation in disease severity) are more likely to benefit from BLVR^3,11 

• Collateral ventilation (CV): The absence of interlobar CV is essential for the success of EBVs^3,11 

• Lung function parameters: Candidates typically exhibit significant hyperinflation, as indicated by elevated residual volume (RV) 

and total lung capacity (TLC) measurements³ 

To illustrate the application of BLVR in local clinical practice, Dr. Syed Ali shared a case involving a male patient who recently underwent BTVA at his center. This procedure represented a significant milestone as the first BTVA case performed in a private healthcare facility in Malaysia. Since undergoing BTVA, the patient hasvachieved clinical stability with no reported adverse events. 

Case sharing 

A 63-year-old male with a 5-year history of progressively worsening dyspnea and reduced exercise tolerance was referred for consideration of BLVR. He had a diagnosis of severe COPD with emphysema and was already on maximal medical therapy, including LTOT at 1-2L/min. His baseline mMRC dyspnea score was 3, and his St. George’s Respiratory Questionnaire (SGRQ) score was 84, indicating a significant impact on QoL. 

Pulmonary function testing revealed a mixed restrictive and obstructive ventilatory defect: FVC was 1.97L (61% predicted), and FEV1 was 0.86L (33% predicted). Diffusing capacity for carbon monoxide (DLCO) was severely reduced at 33% predicted. Lung volumes were markedly elevated, consistent with severe hyperinflation: TLC 229% predicted, residual volume (RV) 602% predicted, and functional residual capacity (FRC) 408% predicted. These findings confirmed severe airflow limitation, significant hyperinflation, and severely impaired gas exchange. The six-minute walk test (6MWT) distance was 290 meters. Echocardiogram showed preserved left ventricular ejection fraction (LVEF) at 62%. 

High-resolution CT (HRCT) of the thorax demonstrated severe emphysematous destruction, predominantly affecting the upper lobes (figure 1). InterVapor CT protocol and IP3 analysis identified the right upper lobe—specifically the RB1 and RB3 bronchopulmonary segments—as the most diseased, with disease severity scores of 59% and 46%, respectively. 

 

The patient subsequently underwent BTVA under spontaneous general anesthesia. Treatment was targeted to the RB1 (activation time: 5.4 seconds) and RB3 (activation time: 6.8 seconds) segments  of the right upper lobe. The procedure was well tolerated without complications. A chest radiograph on postoperative day 1 showed a reduction in right upper lobe volume. Clinically, the patient reported improved exercise tolerance during the early recovery period. 

At the 4-week follow-up, the patient reported symptomatic improvement and no longer required supplemental oxygen, maintaining an SpO2 of 98% on room air. The SGRQ score improved by 10 points, reflecting a meaningful enhancement in QoL. Pulmonary function testing and the 6MWT remained stable at this early stage, with further physiological changes anticipated as the treatment effect continues to evolve. A follow-up chest radiograph also demonstrated a visible reduction in lung volume in the treated region (figure 2). 

 

Discussion 

The choice between BLVR methods (e.g. EBV, or BTVA) or surgical lung volume reduction depends on several factors, including the extent and pattern of emphysema assessed on HRCT, the presence of CV, regional availability of therapies, institutional expertise, and patient preferences.¹² BLVR is an important treatment approach for patients with advanced emphysema who experience significant lung hyperinflation despite optimal medical therapy.¹² Among the available techniques, BTVA and EBVs are the most established options.³ 

BTVA uses heated water vapor to trigger a localized inflammatory response, leading to fibrosis and collapse of diseased lung tissue.⁶ As highlighted in the STEP-UP trial, BTVA resulted in a 14.7% mean improvement in FEV1 and a 9.7-point mean reduction in SGRQ score at 6 months, demonstrating significant functional and QoL benefits (figure 3).¹⁴ 

 

Importantly, BTVA does not require the absence of CV, allowing a broader range of patients—including those who may not be suitable for valve therapy—to benefit from bronchoscopic treatment.¹¹ 

In comparison, EBVs involve placing one-way valves to block airflow into the most damaged lobes, gradually leading to lobar collapse and reduced hyperinflation.⁶ EBVs are highly effective for patients with severe heterogeneous emphysema and minimal CV, as demonstrated in the LIBERATE trial, but patient selection is critical.^3,15 Patients must undergo assessment (e.g. with the Chartis™ system) to ensure no significant collateral airflow between lobes.³ Additionally, EBV placement carries a notable risk of pneumothorax (up to 20%-30% of cases), usually within the first 72 hours post-procedure.^3,6 

As Dr. Syed Ali emphasized, selecting the appropriate BLVR strategy depends on individual patient factors—including emphysema distribution, presence of CV, and risk profile. With advances such as BTVA, bronchoscopic therapies are now more accessible to a wider population of emphysema patients, offering meaningful improvements in symptoms, exercise capacity, and QoL.¹⁴ 

Conclusion 

Minimally invasive BLVR techniques, including BTVA and EBVs, have demonstrated evidence-based, clinically meaningful benefits in appropriately selected patients with advanced COPD.⁶ The inclusion of EBV in GOLD report reflects a growing recognition of BLVR as part of the broader therapeutic landscape.¹² As Dr. Syed Ali notes, “It’s important for clinicians to stay abreast of evolving technologies in treatment. With greater awareness and timely referral, more patients can benefit from proactive, optimized care.” A personalized approach remains essential, guided by individual disease characteristics, comorbid risk factors, and patient preferences.12 Optimizing outcomes ultimately depends on early diagnosis, proactive risk factor modification, and the integration of targeted interventions such as BLVR into comprehensive management plans.¹² 

 

"It’s important for clinicians to stay abreast of evolving technologies in treatment. With greater awareness and timely referral, more patients can benefit from proactive, optimized care 

 

 

Dr. Syed Ajmal Syed Ali 

Consultant Respiratory Physician and Interventional Pulmonologist 

Sunway Medical Centre, 

Selangor, Malaysia