Bilateral heterogenous emphysema was the most comment presentation in patients referred for bronchoscopic lung volume reduction (BLVR), based on data from more than 200 individuals presented at the European Respiratory Society (ERS) 2025 International Congress.

“In patients with emphysema, heterogenous disease has greater magnitudes of improvement and durability in physiologic and functional outcomes [after BLVR] compared to homogeneous disease,” said lead author Ahmad Raza, MBBS, of the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine and Temple University Hospital, Philadelphia, in an interview.

Heterogeneity is defined as the difference in the percentage of emphysematous destruction between the target lobe and the nontargeted ipsilateral lobe by 10% or 15%, Raza said. The bilateral or unilateral presence of heterogenous or homogenous emphysema patterns becomes important because bilateral treatments are indicated in patients undergoing LVR or other bronchoscopic forms of lung reduction, he noted. In addition, knowing distribution patterns provides a descriptive framework to help with referral and research, he said.

In the study, Raza and colleagues reviewed data from 214 adults who underwent BLVR at a single center between January 2018 and December 2024. The mean age of the patients was 68.8 years; 107 were women. All participants underwent quantitative CT, and heterogeneity was defined as a difference of 10% or more between upper and lower lobe disease.

Overall, the study population was severely obstructed (mean forced expiratory volume/s, 0.81 L), severely air trapped (mean residual volume, 4.48 L), and hyperinflated (mean total lung capacity, 7.08 L).

Overall, 91 patients (42.5%) had bilateral heterogenous emphysema at 10%, 60 patients (28%) had bilaterial homogenous emphysema, and 63 (29.4%) had a combination of homogenous and heterogenous emphysema.

The results of the analysis were not unexpected, Raza told Medscape Medical News. “This is a descriptive study to show the prevalence of different types of emphysema in patients referred for BLVR,” he said. Most patients referred to BLVR have upper lobe predominant emphysema related to smoking or second-hand exposures, which leads to preferential destruction of upper lobes and relative sparing of lower lobes, he noted.

Takeaways and Next Steps

The current study’s limitations included the use of data from a single center, which challenges generalizability, said Raza. Although the researchers would expect similar results in the community based on the pathophysiology and etiology of emphysema, they recognize the potential for variation among communities based on factors including ethnic and social influences, he said. “A large database study involving regional or multiregional cohorts would be interesting to see the overall population trends,” he added. In the meantime, the current findings may be useful in planning future trials in patients with emphysema and hyperinflation, he added.

Guiding Patient Care

“Understanding emphysema patterns and outcomes associated with LVR may help guide therapy for patients referred for BLVR and related interventions,” said Arianne K. Baldomero, pulmonologist and assistant professor of medicine at the University of Minnesota, Minneapolis, in an interview.

The finding that 28% of patients referred for BLVR in this study had bilateral homogeneous emphysema was interesting, noted Baldomero, who was not involved in the study. “Lung volume reduction surgery has historically been recommended primarily for those with heterogeneous emphysema patterns as these patients have demonstrated the greatest physiological and functional benefit from the procedure,” she said.

“Traditional selection criteria for lung volume reduction procedures may need to be revisited in light of these results, and clinical trials should be conducted to clarify outcomes for different emphysema patterns,” Baldomero said.

More research is needed to directly compare clinical outcomes, such as improvements in exercise tolerance, exacerbation rates, and mortality, across BLVR patients with homogeneous vs heterogeneous emphysema patterns and to evaluate differences between bilateral and unilateral procedures, Baldomero told Medscape Medical News. “Clarifying these impacts will help refine patient selection criteria and optimize treatment benefits in diverse emphysema presentations,” she said.

The study received no outside funding. Raza and Baldomero had no financial conflicts to disclose.