Connecting the dots: historical perspective on lung volume reduction

Lung volume reduction (LVR) has evolved over nearly a century as a therapeutic strategy for advanced emphysema, reflecting cycles of innovation, skepticism, and renewed acceptance informed by advances in physiology, imaging, and patient selection. Early surgical approaches-including bullectomy, intracavitary drainage techniques, and nonselective lung resection-laid the conceptual groundwork but were limited by high morbidity and inconsistent outcomes. The modern era of LVR was catalyzed by refined surgical techniques and culminated in the National Emphysema Treatment Trial, which established the critical importance of phenotype-based patient selection. Parallel advances in bronchoscopic lung volume reduction (BLVR) expanded treatment options, particularly through the development of endobronchial valves (EBVs), coils, thermal vapor ablation, and biologic approaches. Among these, EBVs have achieved the strongest evidence base and regulatory approval, supported by improved understanding of collateral ventilation and fissure integrity. More recently, minimally invasive surgical approaches, robotic-assisted techniques, hybrid procedures, and expanded indications-including lower-lobe disease, very severe airflow limitation, and alpha-1 antitrypsin deficiency (AATD)-have further broadened the therapeutic landscape. LVR also plays an evolving role as an adjunct to lung transplantation, both as a bridge and for management of native lung hyperinflation (NLH). This narrative review traces the historical arc of LVR, highlighting how past successes and failures inform contemporary practice. As technology advances, multidisciplinary evaluation and increasingly personalized, data-driven decision-making will be central to optimizing outcomes and guiding the future of emphysema management.