Bronchoscopic and Surgical Interventions for Patients With COPD: A State-of-the-Art Review.

COPD remains a leading cause of global morbidity and mortality, and a substantial minority of patients remain disabled by hyperinflation, chronic bronchitis, and exacerbations despite optimized inhaled pharmacotherapy and pulmonary rehabilitation. Over the past two decades, bronchoscopic interventions have matured from clinical trial investigation into guideline-endorsed treatments for patients with refractory symptoms despite optimal medical treatment. This state-of-the-art review synthesizes the mechanistic rationale, evidence-based clinical trial data, patient-selection criteria, key controversies, and future research needs for bronchoscopic lung volume reduction (BLVR) and airway-directed therapies. In rigorously selected patients with severe emphysema, hyperinflation, and absence of interlobar collateral ventilation, endobronchial valves deliver clinically meaningful, durable improvements in FEV1, 6-min walk distance, dyspnea, and quality of life with moderate-to-high certainty and carry the highest guideline rating (GOLD Evidence A). Pneumothorax, occurring in roughly 18-34% of valve recipients, is the principal early complication, necessitating several days of in-patient monitoring that add complexity and cost to care. Endobronchial coils and thermal vapor ablation offer fissure-independent but more modest benefit; airway scaffolds are an emerging, tissue-sparing option that may extend candidacy to patients ineligible for existing bronchoscopic approaches; targeted lung denervation may stabilize lung function and symptoms but did not reduce exacerbations in its pivotal trial; and bronchial rheoplasty and metered cryospray are emerging options for the chronic bronchitis phenotype. The field is now advancing toward expanding candidacy for endobronchial valve therapy through collateral ventilation conversion, individualized complication prediction, and phenotype-matched airway therapies. Multidisciplinary, imaging-driven patient selection that addresses the key features of a patient's symptoms while avoiding significant comorbidity remains the cornerstone of successful outcomes.