SEPAR (Sociedad Española de Neumologia y Cirugía Torácica) Clinical Protocol on Endoscopic Lung Volume Reduction for Severe Emphysema

Endoscopic lung volume reduction (BLVR) has emerged as an evidence-based, minimally invasive therapeutic option for patients with severe pulmonary emphysema who remain highly symptomatic despite optimal medical therapy and pulmonary rehabilitation. This SEPAR Clinical Protocol provides an updated, comprehensive, and standardized framework for the evaluation, selection, treatment, and follow-up of candidates for BLVR in Spain. The document synthesizes current scientific evidence on the efficacy and safety of available bronchoscopic techniques - principally endobronchial valves (EBV), bronchoscopic thermal vapor ablation (BTVA), and coils - highlighting the superiority and robustness of evidence supporting EBV therapy. Randomized controlled trials consistently show clinically meaningful improvements in lung function, hyperinflation, dyspnea, exercise tolerance, and health-related quality of life, particularly in patients without collateral ventilation. The protocol details the structural and organizational requirements for high-complexity BLVR programs, emphasizing the need for multidisciplinary teams, advanced imaging, comprehensive functional testing, and specialized inpatient care. It establishes clear inclusion and exclusion criteria, stressing the importance of radiological fissure assessment, physiological thresholds (FEV₁ 15-45%, RV >175%, DLCO >20%), smoking cessation, and appropriate symptom burden. Procedural sections describe indications, technical aspects, device characteristics, periprocedural management, and complication handling for EBV and BTVA. Finally, structured follow-up recommendations outline clinical, functional, radiological, and endoscopic monitoring to detect complications, evaluate loss of treatment effect, and guide valve revision or removal when necessary.