Vapor Ablation Research Articles

New and Emerging Technologies in Treatment of Lower Urinary Tract Symptoms From Benign Prostatic Hyperplasia.

Lower urinary tract symptoms (LUTS) from bladder outlet obstruction from benign prostatic hyperplasia (BPH) occur in a large percentage of urologic patients. Treatment of this condition with medical and surgical therapy provides symptom relief but has serious adverse effects and causes sexual dysfunction. New technologies to treat BPH-associated LUTS aim to effectively treat urinary symptoms and minimize side effects and sexual dysfunction. To review the efficacy of new and emerging therapies for treatment of LUTS from BPH. A literature search was performed to identify therapies for LUTS from BPH with early outcomes data within the past 5 years. Improvement in International Prostate Symptom Score (IPSS) and effect on sexual functions such as erectile and ejaculatory functions as measured on the International Index of Erectile Function and the Male Sexual Health Questionnaire. Technologies introduced within the past 5 years include techniques using intraprostatic injectables, mechanical devices, and prostatic tissue ablation. Most technologies remain in the development phase and have only phase I and II studies available that show promising alleviation of urinary symptoms. Injectables have not typically surpassed placebo or sham effects, although special cohorts could be exceptions. Thus far, convective water vapor ablation therapy and prostatic urethral lift have shown the most promise, with short- and medium-term data available on phase III studies demonstrating significant improvement in IPSS with minimal impact on sexual function. Many of these technologies are limited in their potential treatment population by prostate size and conformation, whereas other therapies might be more generalizable. Many new technologies aim to treat LUTS from BPH and minimize sexual side effects. Most therapies remain experimental, although prostatic urethral lift and water vapor ablation therapy have been brought to market and show promise. Long-term durability of symptom relief remains to be demonstrated. Gupta NK, Gange SN, McVary KT. New and Emerging Technologies in Treatment of Lower Urinary Tract Symptoms From Benign Prostatic Hyperplasia. Sex Med Rev 2018;7:491-498.

Interventional pulmonology in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) and emphysema are widespread diseases associated with progressive dyspnea because of airflow limitation and hyperinflation. Fundamental therapeutic strategies consist of pulmonary rehabilitation, pharmacotherapy, long-term oxygen therapy, noninvasive ventilation, and surgical therapeutic approaches. In the last 14 years, endoscopic therapeutic modalities emerged as a substantial part of severe COPD and emphysema treatment. Techniques of the endoscopic lung volume reduction (ELVR) aim at reduction of hyperinflation. Thereby, the reversible valve implantation of which the efficacy was confirmed in various randomized controlled trials (RCT) results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation. Nonblocking ELVR methods that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation and polymeric lung volume reduction both inducing inflammatory reaction. The nonblocking methods have been examined in only a few RCTs. The targeted lung denervation as a novel bronchoscopic therapy for COPD patients aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves. The review summarizes the various endoscopic treatment approaches for managment of COPD and emphysema, their mechanism of action, their complications and the current available results of the most important RCTs.

Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease.

Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease.

Segmental volume reduction using thermal vapour ablation in patients with severe emphysema: 6-month results of the multicentre, parallel-group, open-label, randomised controlled STEP-UP trial

Lung volume reduction of emphysematous lobes results in clinical improvement for patients with severe emphysema. However, some segments within a lobe are often substantially more diseased than others, thereby warranting a more targeted approach of the emphysematous parts of a lobe. We therefore did a study to assess whether or not selective sequential treatment of the more diseased upper lobe segments with bronchoscopic vapour ablation led to clinical improvement. For the multicentre, parallel-group, randomised, controlled, open-label Sequential Staged Treatment of Emphysema with Upper Lobe Predominance (STEP-UP) trial, adult patients aged 45-75 years with severe, upper lobe-predominant emphysema with a forced expiratory volume in 1 s (FEV1) between 20% and 45%, substantial hyperinflation, and post-rehabilitation 6-min walk test (6MWT) greater than 140 m were enrolled from 13 hospital sites in Europe (ten sites) and Australia (three sites). A computer-generated blocked randomisation scheme (block size three per site based on a random table from an independent biostatistician) stratified by site was used to randomly assign enrolled patients 2:1 to segmental vapour ablation (treatment group) or standard medical management (control group). Patients and investigators were not masked to group assignment. The primary efficacy endpoints were statistically significant changes in FEV1 and St George's Respiratory Questionnaire (SGRQ-C) scores between trial groups at 6 months, analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01719263. Between June 30, 2013, and Oct 1, 2014, 134 patients were screened and 70 were enrolled and randomly assigned: 46 to the treatment group and 24 to the control group. One patient in the treatment group did not receive treatment because of physician decision post-randomisation; this patient is excluded from all analyses. The mean relative improvement in FEV1 between the treatment group versus the control group was 14·7% (95% CI 7·8-21·5%; p<0·0001) and in SGRQ-C was -9·7 points (95% CI -15·7 to -3·7; p=0·0021). COPD exacerbation was the most common serious adverse event, occurring in 11 (24%) of 45 patients in the treatment group and one (4%) of 24 in the control group. One exacerbation resulted in a patient death 84 days after treatment; this was judged by the data and safety monitoring board to be possibly related to treatment. No pneumothorax occurred within 30 days of treatment. Compared with standard medical management, targeted thermal vapour ablation of more diseased segments and preservation of less diseased segments resulted in clinically meaningful and statistically significant improvements in lung function and quality of life at 6 months, with an acceptable safety profile. Uptake Medical.

Status of and prospects for bronchoscopic lung volume reduction for patients with severe emphysema.

Bronchoscopic lung volume reduction (BLVR) is a minimally invasive treatment for severe emphysema, providing treatment options for patients who are unable to undergo lung volume reduction surgery (LVRS) or lung transplantation. Current BLVR techniques include bronchoscopic volume reduction with valve implants, use of a lung volume reduction coil (LVRC), bronchoscopic thermal vapor ablation (BTVA), biological lung volume reduction (BioLVR), and use of airway bypass stents (ABS). To date, several randomized controlled trials of these bronchoscopic therapies have been conducted in patients with emphysema, and bronchoscopic volume reduction with valve implants remains the best approach thus far. Recent studies indicate that BLVR may be of great value in improving lung function, exercise capacity, and quality of life and that BLVR has the potential to replace conventional surgery for patients with severe emphysema. Optimal patient selection and the proper selection of the BLVR technique in accordance with patient characteristics are crucial to the success of BLVR. More multicenter, prospective, randomized controlled trials need to be conducted in the future to optimize the current selection strategy and evaluate the safety, efficiency, and long-term benefit of BLVR techniques.

Update on Nonsurgical Lung Volume Reduction Procedures.

There has been a surge of interest in endoscopic lung volume reduction (ELVR) strategies for advanced COPD. Valve implants, coil implants, biological LVR (BioLVR), bronchial thermal vapour ablation, and airway stents are used to induce lung deflation with the ultimate goal of improving respiratory mechanics and chronic dyspnea. Patients presenting with severe air trapping (e.g., inspiratory capacity/total lung capacity (TLC) < 25%, residual volume > 225% predicted) and thoracic hyperinflation (TLC > 150% predicted) have the greatest potential to derive benefit from ELVR procedures. Pre-LVRS or ELVR assessment should ideally include cardiological evaluation, high resolution CT scan, ventilation and perfusion scintigraphy, full pulmonary function tests, and cardiopulmonary exercise testing. ELVR procedures are currently available in selected Canadian research centers as part of ethically approved clinical trials. If a decision is made to offer an ELVR procedure, one-way valves are the first option in the presence of complete lobar exclusion and no significant collateral ventilation. When the fissure is not complete, when collateral ventilation is evident in heterogeneous emphysema or when emphysema is homogeneous, coil implants or BioLVR (in that order) are the next logical alternatives.

Endoscopic bronchial valve treatment: patient selection and special considerations.

As well as lung volume reduction surgery, different minimally invasive endoscopic techniques are available to achieve lung volume reduction in patients with severe emphysema and significant hyperinflation. Lung function parameters and comorbidities of the patient, as well as the extent and distribution of the emphysema are factors to be considered when choosing the patient and the intervention. Endoscopic bronchial valve placement with complete occlusion of one lobe in patients with heterogeneous emphysema is the preferred technique because of its reversibility. The presence of high interlobar collateral ventilation will hinder successful treatment; therefore, endoscopic coil placement, polymeric lung volume reduction, or bronchoscopic thermal vapor ablation as well as lung volume reduction surgery can be used for treating patients with incomplete fissures. The effect of endoscopic lung volume reduction in patients with a homogeneous distribution of emphysema is still unclear and this subgroup should be treated only in clinical trials. Precise patient selection is necessary for interventions and to improve the outcome and reduce the risk and possible complications. Therefore, the patients should be discussed in a multidisciplinary approach prior to determining the most appropriate treatment for lung volume reduction.

Thermal Vapor Ablation for Lung Lesions in a Porcine Model

Background: Various methods for ablating peripheral lung lesions are being investigated; however, none have been successfully adapted for delivery via bronchoscopy. Vapor ablation is currently being used to bronchoscopically create lung volume reduction in emphysema patients. Objectives: In this study, an adaptation of that technology is evaluated for potential treatment of lung lesions in a live pig model. Methods: In 5 anesthetized healthy pigs, vapor of varying energy levels was delivered bronchoscopically to 66 different lung subsegments with airway diameters of 2-5 mm. Two hours after treatment, a necropsy was performed and the ablated regions were assessed for ablation and tissue structure disruption. In 6 additional pigs, vapor was applied to 3 subsegments each. To evaluate the progression of the response to treatment, 2 were kept alive for 10 days, 2 for 21 days, and 2 for 32 days. Results: Histopathological evaluation of the sections demonstrated that vapor is capable of creating a uniform field of necrosis following the subsegment anatomical boundary. The reliability of a uniform field is dependent on the level of energy delivered. An energy level that reliably creates a uniform field of necrosis was applied in chronic animals. The animals tolerated the procedure and posttreatment care. No cardiac arrhythmias, hemorrhage, stroke, respiratory distress, or pneumothorax occurred during or after treatment. Conclusions: Vapor ablation is a potentially safe and efficient means of ablating a targeted region of the lung. We hypothesize that vapor may be useful in treating lesions of the lung in humans.

Endoscopic volume reduction in COPD- a critical review.

Chronic obstructive pulmonary disease (COPD) is common in Germany, with a prevalence of 13.2%. The available treatments are exclusively symptomatic, except for lung transplantation, from which no more than a few patients can benefit. Over the past decade, endoscopic lung volume reduction (ELVR) has broadened the therapeutic spectrum for patients with advanced pulmonary emphysema. We review pertinent publications that were retrieved from Pubmed using the search terms "endoscopic lung volume reduction," "endobronchial valves," "endobronchial coil," and "bronchoscopic thermal vapor ablation," along with current data from the annual meeting of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie). ELVR is now performed with three different techniques. Endoscopic valve implantation has been studied in three randomized controlled trials (RCTs) and several noncontrolled trials, which have shown a benefit from valve therapy particularly for patients who have only a small amount of interlobar collateral ventilation or none at all. A reduction of lobar lung volume by 56-80% was found, in association with a significant improvement of lung function (a 16-26% increase of forced expiratory volume in one second [FEV1]). The main complication of valve therapy is pneumothorax, which arises in up to 23% of cases. Coil implantation has been studied to date in only a single RCT, which revealed a significant improvement in quality of life as the primary endpoint (St. George´s Respiratory Questionnaire [SGRQ]: -8 points). Bronchoscopic thermoablation has been studied only in noncontrolled intervention trials; in patients with emphysema mainly affecting the upper lobes, it has been found to reduce lobar volume by an average of 48%. Endoscopic lung volume reduction has broadened the therapeutic spectrum for selected patients with advanced pulmonary emphysema. Further prospective trials are needed to evaluate the benefits, risks, and long-term effects of the available techniques for ELVR.

Design of the randomized, controlled sequential staged treatment of emphysema with upper lobe predominance (STEP-UP) study.

BackgroundAn innovative approach to lung volume reduction (LVR) for emphysema is introduced in the design of the Sequential Segmental Treatment of Emphysema with Upper Lobe Predominance (STEP-UP) trial where vapour ablation is administered bilaterally over the course of two sessions and is used to target only the most diseased upper lobe segments. By dividing the procedure into two sessions, there is potential to increase the total volume treated per patient but reduce volume treated and energy delivered per session. This is expected to correlate with improvements in vapour ablation’s safety and efficacy profiles.MethodsThe STEP-UP trial is a randomized, controlled, open-label, 12 month study of patients with upper lobe predominant emphysema (ULPE). The trial compares patients receiving standard medical management alone against patients receiving bilateral vapour ablation in addition to standard medical management. An intended sixty nine subjects will be randomized at a 2:1 (treatment arm:control arm) ratio. Inclusion criteria include a forced expiratory volume in 1 second (FEV1) between 20% and 45% predicted, total lung capacity > 100% predicted, residual volume > 150% predicted, marked dyspnea scoring ≥ 2 on the modified Medical Research Council (mMRC) scale, and PaCO2 ≤ 50 mm Hg. The primary endpoints are the change in FEV1 %predicted and St. George Respiratory Questionnaire (SGRQ) score between the treatment and control arm at 12 months. Adverse events will be monitored as secondary endpoints along with other efficacy outcomes at 6 and 12 months.DiscussionVapour ablation can reduce lung volume in the presence of collateral ventilation (CV). Due to this ability, it can be used to target specifically the more diseased segments of each upper lobe. Safety and efficacy outcomes are expected to improve by considering which segments to treat along with the volume treated per session and per patient.Trial registrationClinicalTrials.gov NCT01719263.

Advanced therapies for COPD-What's on the horizon? Progress in lung volume reduction and lung transplantation.

Advanced chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity. Treatment options beyond conventional medical therapies are limited to a minority of patients. Lung volume reduction surgery (LVRS) although effective in selected subgroups of patients is not commonly undertaken. Morbidity associated with the procedure has contributed to this low utilisation. In response to this, less invasive bronchoscopic lung volume techniques are being developed to attempt to mitigate some of the risks and costs associated with surgery. Of these, endobronchial valve therapy is the most comprehensively studied although the presence of collateral ventilation in a significant proportion of patients has compromised its widespread utility. Bronchial thermal vapour ablation and lung volume reduction (LVR) coils are not dependent on collateral ventilation. These techniques have shown promise in early clinical trials; ongoing work will establish whether they have a role in the management of advanced COPD. Lung transplantation, although effective in selected patients for palliation of symptoms and improving survival, is limited by donor organ availability and economic constraint. Reconditioning marginal organs previously declined for transplantation with ex vivo lung perfusion (EVLP) is one potential strategy in improving the utilisation of donor organs. By increasing the donor pool, it is hoped lung transplantation might be more accessible for patients with advanced COPD into the future.

Review of Endoscopic Lung Volume Reduction Interventions

Endoscopic lung volume reduction is a less invasive and potentially beneficial intervention for patients who may not be candidates for traditional lung volume reduction surgery. There are many different interventions, ranging from various stents and occluders to polymers, coils, and thermal vapor ablation. In this review article, we will discuss the various therapies available, analyze the available literature, provide insight into future direction, and offer guidance for the practicing pulmonologist in navigating this ever-expanding field.

Technology update: bronchoscopic thermal vapor ablation for managing severe emphysema.

Bronchoscopic thermal vapor ablation (BTVA) is an endoscopic lung volume reduction therapy that presents an effective treatment approach in patients with severe upper lobe-predominant emphysema. By instillation of heated water vapor, an inflammatory reaction is induced, leading to fibrosis and scarring of the lung parenchyma, resulting in lobar volume reduction. Clinical single-arm trials demonstrated great outcomes, with significant improvement of lung function, exercise capacity, and quality of life. As the BTVA-induced local inflammatory response that seems to be essential for the desired lobar volume reduction can be associated with transient clinical worsening, strict monitoring of the patients is required. In future, the balance between efficacy and safety will constitute a major challenge. This review summarizes the BTVA procedure, the mechanism of action, and the results of the clinical trials, including the efficacy and safety data.

Stagnation Region Radiative Ablation of Asteroidal Meteoroids in the Rosseland Approximation

The ablation rates of large iron-containing stony meteoroids are calculated at their stagnation point assuming the meteoroid to be spherical in shape. The flow is assumed to be thermochemically in equilibrium and inviscid. The Rosseland approximation is used in describing radiative transfer, using the Rosseland mean absorption coefficients determined previously by the present author. The calculation is performed for the range of freestream densities, velocities, and nose radii pertinent to meteoroid entry flights. The calculated ablation rates are smaller than the values calculated by Kosarev et al. (“Vapor Optical Properties and Ablation of Large Chondrite and Ice Bodies in The Earth’s Atmosphere,” Solar System Research, Vol. 30, No. 4, 1996, pp. 265–278) and Golub et al. (“Emission and Ablation of Large Meteoroid in the Course of Its Motion Through The Earth’s Atmosphere,” Solar System Research, Vol. 30, No. 3, 1996, pp. 183–197) and are only weakly dependent on the flight speed.

Sequential vapour ablation of adjacent segments in canine lung

Introduction: Vapour ablation is used to create lung volume reduction for emphysema patients to improve lung function and quality of life. This study characterises effects of vapour ablation treatment in lung segments within a lobe that are adjacent to lung segments previously treated with vapour in a healthy canine model. Because emphysema is a progressive disease, subsequent treatments could offer continued benefit to the patient. Method: Six healthy canines were treated with vapour at 8.5 cal/g in one upper lobe segment. After a 4-week healing period, the adjacent segment was treated. After a second 4-week healing period, necropsy was performed and the tissue inspected. Clinical effects were monitored during each healing period. Results: Each treatment was well tolerated and no significant abnormalities were observed during the healing phases, including death, pneumothorax, or major decline in health status. Animal health, oxygenation changes, pathology, and airway changes were monitored during the study. Analysis of these end points showed no difference in changes after treatment 2 as compared to changes after treatment 1. Conclusion: In this model, there was no evidence of increased or different clinical observations after a second adjacent vapour ablation. It was not possible to differentiate between the clinical effects of treatment 1 and the clinical effects of treatment 2. These results support investigation of sequential adjacent segmental vapour treatments in humans.

Efficacy of bronchoscopic lung volume reduction: a meta-analysis

BackgroundOver the last several years, the morbidity, mortality, and high costs associated with lung volume reduction (LVR) surgery has fuelled the development of different methods for bronchoscopic LVR (BLVR) in patients with emphysema. In this meta-analysis, we sought to study and compare the efficacy of most of these methods.MethodsEligible studies were retrieved from PubMed and Embase for the following BLVR methods: one-way valves, sealants (BioLVR), LVR coils, airway bypass stents, and bronchial thermal vapor ablation. Primary study outcomes included the mean change post-intervention in the lung function tests, the 6-minute walk distance, and the St George’s Respiratory Questionnaire. Secondary outcomes included treatment-related complications.ResultsExcept for the airway bypass stents, all other methods of BLVR showed efficacy in primary outcomes. However, in comparison, the BioLVR method showed the most significant findings and was the least associated with major treatment-related complications. For the BioLVR method, the mean change in forced expiratory volume (in first second) was 0.18 L (95% confidence interval [CI]: 0.09 to 0.26; P<0.001); in 6-minute walk distance was 23.98 m (95% CI: 12.08 to 35.88; P<0.01); and in St George’s Respiratory Questionnaire was -8.88 points (95% CI: −12.12 to −5.64; P<0.001).ConclusionThe preliminary findings of our meta-analysis signify the importance of most methods of BLVR. The magnitude of the effect on selected primary outcomes shows noninfe-riority, if not equivalence, when compared to what is known for surgical LVR.

Bronchoscopic treatment of end-stage chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease that in its final stages cripples the patient. The disappointing results of the National Emphysema Treatment Trial study led to a decrease in the acceptance of lung volume reduction surgery as a therapy. Thus, it became clear that debilitated COPD patients would need innovative alternative nonsurgical procedures to potentially alleviate their symptoms. This review will address the various techniques of bronchoscopic lung volume reduction (BLVR). In recent years, a variety of noninvasive BLVR procedures were developed in the hope of improving the respiratory status of these patients. BLVR aims to decrease the extent of hyperinflation due to emphysema and result in a beneficial effect similar to that from surgical resection. The most widely used BLVR devices are: endobronchial valves, foam sealant, metallic coils, airway bypass stents and vapor thermal ablation.In the USA, BLVR remains in the experimental phase. The treatment modalities should be individually tailored for each patient. Endobronchial valves are designed to exclude the most affected emphysematous regions from ventilation in order to induce lobar absorption atelectasis. Airway bypass stents target homogenous emphysema, whereas valves and thermal vapor ablation target heterogeneous emphysema. Biological sealants and endoscopic coil implants have been used in both homogenous and heterogeneous emphysema. BLVR appears to be safer than surgery and presents an attractive alternative for the treatment of COPD patients. Unfortunately, the outcome data to date are inconclusive; the procedures remain experimental and any benefits unproven. However, the data that are emerging continue to appear promising.

Endoscopic Lung Volume Reduction. A European Perspective

Endoscopic lung volume reduction (ELVR) offers a novel therapeutic approach for patients with severe pulmonary emphysema. In Europe, several types of ELVR are available. The choice of ELVR technique depends both on the distribution of emphysema and the presence or absence of interlobar collateral ventilation (CV). For this reason, accurate patient selection is crucial. Bronchial valve implantation is the technique that has been most widely studied and represents an effective treatment option for patients with severe heterogeneous upper- or lower-lobe-predominant emphysema. Lobar occlusion and low interlobar CV are predictive factors for positive outcomes. Lung volume reduction coil implantation is an effective option for patients with upper- and lower-lobe-predominant emphysema, and the efficacy is not influenced by CV; however, the technique should be regarded as mainly irreversible. Polymeric lung volume reduction relies on irreversible scarring and fibrosis and is especially effective in patients with chronic obstructive pulmonary disease classified as Global Initiative for Chronic Obstructive Lung Disease stage III; it also offers benefits to patients with upper-lobe-predominant emphysema and those with homogeneous emphysema. Like polymeric lung volume reduction, bronchoscopic thermal vapor ablation is also not influenced by CV and represents a good option for patients with upper-lobe-predominant emphysema. Exhale airway stents for emphysema--"airway bypass"--appeared to be a promising technique but proved ineffective in randomized clinical trials, likely in part due to long-term occlusion of the drug-eluting stents. Although European physicians are able to choose from a host of approved bronchoscopic interventions for emphysema, future studies for techniques in use are needed to further clarify patient selection criteria.

The Localized Inflammatory Response to Bronchoscopic Thermal Vapor Ablation

Background: Bronchoscopic thermal vapor ablation (BTVA) reduces lung volumes in emphysema patients by inducing a localized inflammatory response (LIR) leading to a healing process of fibrosis, but may also increase symptoms. Objectives: We sought to evaluate whether the clinical manifestation of LIR correlated with patient outcome. Methods: Respiratory adverse events and inflammatory markers were analyzed from a multicenter trial of BTVA in patients with upper-lobe-predominant emphysema. End points including changes in forced expiratory flow (FEV₁), lobar volume, St. George's Respiratory Questionnaire (SGRQ), modified Medical Research Council (mMRC) and 6-minute-walk distance (6-MWD) were analyzed according to the presence or absence of a respiratory adverse event requiring treatment with an antibiotic or steroid. Results: Forty-four patients received BTVA. Increases of inflammatory markers were observed with a peak between the second and fourth week. Eighteen respiratory adverse events occurred in 16 patients within 30 days of BTVA, requiring antibiotics and/or steroids. These patients had significantly greater lobar volume reduction (65.3 vs. 33.4%, p = 0.007) and a change in residual volume at 12 months (-933 vs. 13 ml, p < 0.001) associated with a greater improvement of exercise capacity and health-related quality of life than patients without respiratory adverse events. Conclusion: Patients with more prominent respiratory symptoms in the first 30 days following BTVA experience greater efficacy. The clinical manifestations of the LIR are predictive of long-term clinical benefits.

Bronchoscopic interventions in the management of chronic obstructive pulmonary disease

In the past few years, there have been exciting developments in bronchoscopic efforts at attaining lung volume reduction (LVR), given real and perceived risks of surgical LVR. The purpose of this review is to discuss these techniques, with special emphasis on what we have learnt in the past 1-2 years. Bronchoscopic techniques can be broadly classified as one-way valves, which allow air to exit but not enter, thus reducing air trapping; airway bypass stents, which create an extra-anatomical pathway for air to exit; biologic and polymeric substances, which seal the emphysematous lung, eventually collapsing it; bronchial thermal vapor ablation, which causes thermal damage and thus achieves LVR; and endobronchial elastic coils, which mechanically cause LVR. The specific role of these is being defined by recent publications. The central role of collateral ventilation in choosing amongst these procedures is now established, as it has become clear that in the presence of collateral ventilation, valves provide only modest benefit, if any at all. Thus it is of interest that the other modalities which are independent of collateral ventilation are being studied further. Though the preliminary results are quite encouraging, further trials need to be done before these procedures can be adopted in daily practice.