Guidance on Belgian referral criteria for lung volume reduction and lung transplantation in patients with severe emphysema-COPD

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation and represents a major global public health burden. Despite optimized guideline-based pharmacological and non-pharmacological management, many patients remain highly symptomatic, largely due to emphysema-related lung hyperinflation. Hyperinflation plays a central role in the pathophysiology of dyspnea and exercise intolerance and is more closely associated with symptom severity and functional impairment than airflow obstruction alone, making it a key therapeutic target in advanced COPD. OBJECTIVES: To provide simplified and context-specific referral criteria for lung volume reduction and lung transplantation (LTx) in Belgian patients with severe COPD and emphysema, with the aim of facilitating timely identification and referral of eligible patients to specialized centers. METHODS: This guidance document was developed by experts of the Belgian Respiratory Society, taking into consideration evidence on lung volume reduction strategies, including lung volume reduction surgery (LVRS) and endoscopic lung volume reduction (ELVR), as well as LTx, and the specific requirements of the Belgian healthcare system, including national reimbursement criteria for ELVR. RESULTS: Lung volume reduction strategies and LTx have demonstrated clinically meaningful improvements in selected patients with severe emphysema. However, access to these interventions remains suboptimal in Belgium, with national registry data indicating substantial under-referral to specialized centers compared with neighboring countries. The proposed recommendations emphasize early referral to prevent irreversible physiological decline, optimize patient selection, facilitate multidisciplinary evaluation, and improve procedural and long-term outcomes. CONCLUSIONS: This standardized, evidence-based referral framework, tailored to the Belgian healthcare system, aims to improve access to advanced interventional therapies for patients with severe COPD and emphysema. Timely referral and appropriate multidisciplinary assessment may ultimately improve functional outcomes, quality of life, and survival in eligible patients.