These are only general guidelines and every patient will be evaluated on an individual basis.

Inclusion:

• Ex-smokers (≥4 months)
• PFT:
  • Post BD FEV1 15 – 45%
  • TLC ≥100%
  • RV ≥150%
• 6MWD
  • ≥ 100 – <500 meters after pulmonary rehabilitation program
• BMI <35 Kg/m2
• Completed pulmonary rehabilitation program (or is enrolled and completed 6-8 sessions)
• ABG: PaCO2 <60 on room air, PaO2 >45 on room air
• Stable on prednisone <20mg/day

Exclusion:

• Any contraindication to bronchoscopy and/or general anesthesia
• Lung findings:
  • Pulmonary nodule requiring work up
  • Giant bullae (>1/3 hemithorax). May be referred for bullectomy
• Comorbidities:
  • Recent CV event (6 months)
  • Recent CVA (3 months)
  • Known uncontrolled PAH sPAP >60
• Prior lobectomy, LVRS, lung transplant, median sternotomy
• Careful consideration in:
  • CHF w/EF <45%
  • FEV 1 < 15%
  • DLCO <20%
  • Baseline 6MWD <100m
  • Lack of access to medical care

Tests required within 1 year:

• Chest CT:
  • Chest CT with SD (super dimension protocol done at HFHS)
  • We can rule in with outside CT (minimum requirement HRCT inspiration only <1.5mm cuts, contrasted images are not analyzable) if done within 1 year. However, we do not rule out based upon outside images
• Complete PFT
• ABG
• 6MWT
• TTE
• Perfusion scan ordered on an individual basis. To be determined after IP clinic visit and complete evaluation

Lobe selection process

1. Little to No Collateral Ventilation
   • Fissure completeness ≥80% preoperatively (StratX). Fissure <80% rules out
   • Intraoperative confirmation with balloon (Chartis) that lobe is CV-
2. Higher Destruction
   • Emphysema score ≥45% on QCT (Stratx)
   • Prefer lobe with greatest destruction
3. Larger Lobe Volume
4. Less Perfusion
   • Perfusion scan may be used when multiple valid target lobes are available
   • Consider if ipsilateral heterogeneity score is low
5. Greater Heterogeneity
   • Heterogeneity score ≥10% (difference in emphysema score between the target and ipsilateral lobe)