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Advanced emphysema unsuitable for lung volume reduction — SCE Respiratory MCQ

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HardEmphysemaAdvanced emphysema unsuitable for lung volume reductionSCE Respiratory

A 58-year-old man with smoking-related COPD remains limited by breathlessness at rest and on minimal exertion despite optimised triple inhaled therapy, smoking cessation 3 years ago and completion of pulmonary rehabilitation. His BMI is 22 kg/m² and 6-minute walk distance is 210 m. He has no significant cardiac, renal or hepatic disease and is not frail. Post-bronchodilator FEV1 is 19% predicted, residual volume is 260% predicted and TLCO is 18% predicted. Unenhanced quantitative CT shows homogeneous bilateral emphysema without a bulla occupying one third of either hemithorax and without a discrete, relatively avascular target region. Physiological assessment demonstrates collateral ventilation across the candidate lobes. His symptoms substantially impair his quality of life, and he wishes to pursue advanced intervention. Which recommendation is most appropriate?

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Correct answer: E — Refer to a specialist lung-transplant multidisciplinary team for assessment

He meets NICE criteria for consideration of lung-transplant assessment: severe COPD with major quality-of-life limitation despite optimal treatment, sustained smoking cessation, completed pulmonary rehabilitation and no stated transplant contraindication. LVRS is not the best recommendation. The combination of FEV1 at or below 20% predicted with either homogeneous emphysema or TLCO at or below 20% predicted defined the NETT high-risk phenotype, associated with 16% 30-day mortality and little benefit. Although modern expert centres may consider selected patients beyond classical thresholds, this patient has both adverse physiological features and no heterogeneous target. Endobronchial valves are inappropriate because NICE specifies treatment of lung volumes without collateral ventilation; collateral ventilation is demonstrated here. Coils may initially appear attractive because their effect is not dependent on fissure integrity, but NICE recommends them only within a clinical trial. Bullectomy is not indicated because there is no bulla occupying at least one third of a hemithorax. Continuing medical treatment alone would overlook an eligible advanced-disease referral: the appropriate action is transplant assessment, not an assumption that transplantation will necessarily be offered.

Reference: Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115) — Recommendations (2018 recommendations; current page checked 18 August 2026) — https://www.nice.org.uk/guidance/ng115/chapter/Recommendations Endobronchial valve insertion to reduce lung volume in emphysema (HTG457) — Recommendations (20 December 2017; current guidance checked 18 August 2026) — https://www.nice.org.uk/guidance/HTG457/chapter/1-recommendations Patients at high risk of death after lung-volume-reduction surgery (11 October 2001) — https://pubmed.ncbi.nlm.nih.gov/11596586/