Perceptions and knowledge of lung volume reduction procedures for chronic obstructive pulmonary disease in the Republic of Ireland: A survey of respiratory healthcare professionals

Abstract

OBJECTIVE:

Lung volume reduction (LVR) procedures can improve quality of life and survival in appropriately selected individuals with emphysema. LVR is recommended in national and international guidelines for the management of chronic obstructive pulmonary disease. Between 2016 and May 2023, less than 300 procedures were completed in the Republic of Ireland (ROI). Therefore, this survey of Irish Thoracic Society (ITS) members aimed to explore respiratory healthcare professionals’ knowledge of the LVR referral pathway and criteria. It also aimed to identify and understand any obstacles which currently limit referral and assessment for LVR procedures as well as any training needs which may exist.

METHODS:

An online survey was developed and distributed to ITS members in April 2023. The survey focused on respondents’ knowledge of the LVR service, perceptions of LVR procedures and understanding of the referral pathway and criteria.

RESULTS:

There were 84 responses from 423 potential respondents, with a response rate of 20%. Most respondents are aware of the LVR service in the Mater Misericordiae University Hospital, with 30% reporting good knowledge of the eligibility criteria and 18% reporting a good understanding of the referral pathway. Appropriate patient selection and surgical complications are the main concerns cited by respondents.

CONCLUSIONS:

Work is needed to develop the knowledge and understanding of LVR procedures and referral process in ROI, particularly the eligibility criteria and referral pathway. Survey responses highlight the need for educational resources around LVR and this research will help to give focus to the development of these resources.

Keywords

COPD lung volume reduction emphysema

1 Introduction

It is estimated that approximately 500,000 people are living with chronic obstructive pulmonary disease (COPD) in the Republic of Ireland (ROI) with 200,000 of these having moderate or severe disease [1]. The symptomatic burden of COPD can have a detrimental impact on health status, quality of life (QOL) and on an individual’s ability to complete daily activities independently [2, 3]. Frequent exacerbations accelerate the progression of the disease, as well as significantly increasing the risk of hospitalisation and mortality in COPD [4]. Lung volume reduction (LVR) is a management technique for end-stage emphysematous lung disease targeting hyperinflation by resecting or collapsing the worst affected areas of lung tissue, which contribute disproportionately to gas trapping and hyperinflation [5]. LVR techniques can improve exercise capacity, pulmonary function and QOL and prolong survival compared with medical management alone, in appropriately selected patients [6, 7]. The National Institute for Health and Care Excellence (NICE) guideline for the management of COPD gives a Grade A recommendation that patients with severe COPD should be assessed by a healthcare professional for suitability for bronchoscopic or surgical LVR procedures [8].

This recommendation is further supported in the national clinical guideline for the management of COPD as well as international guidelines [9, 10]. Despite this, less than 300 LVR procedures were completed in ROI, by the single LVR centre, between 2016 and May 2023. Given the size of the population with COPD, the pool of potentially eligible candidates is likely to be much larger than this meaning that many patients who may benefit are not being considered for these procedures [11, 12]. LVR procedures have been commissioned for use in the management of severe emphysema in the United Kingdom [13], but no such process is in place in ROI. NICE recommend that the first assessment for suitability for LVR would be completed by a general practitioner, physiotherapist, or respiratory nurse, either at the completion of pulmonary rehabilitation or at routine monitoring appointments [14].

It has been suggested that physicians are reluctant to refer patients for LVR procedures due to a perceived high risk of morbidity and mortality with limited benefit to patients [6]. However, this perception likely stems from the early results reported from the National Emphysema Treatment Trial (NETT), which was a large multi-centre trial in the United States of America (USA) that launched in 1996 [15]. Initial results from NETT studies reported high surgical and short-term mortality rates following LVR surgery [16]. However, NETT subgroup analysis showed improved survival and function in people with upper lobe predominant emphysema and low exercise tolerance compared with medical therapy alone [6]. Increased mortality was shown amongst people with non-upper lobe predominant emphysema [6]. There have since been significant advancements in surgical approaches and techniques and improved knowledge around patient selection for these procedures [17]. Appropriate patient selection is described in the NICE guideline for the management of COPD [8] and a more recent audit of current practice suggests that morbidity and mortality rates are significantly lower than early LVR studies reported [18].

In the United Kingdom, members of the British Thoracic Society (BTS) were surveyed regarding attitudes and access to LVR in 2013 [19]. The results of this survey indicated a lack of knowledge among members regarding the indications and referral process for LVR procedures. As well as this 48% of respondents were either unsure about or overestimated the risk of morbidity and mortality associated with the procedure. The response rate to this survey was extremely low at 2.6%, with only 65 completed responses from the 2,498 BTS members at that time. The authors speculated that the low response rate may be representative of the general lack of engagement with LVR as a treatment technique among respiratory healthcare professionals.

The national LVR service is based in the Mater Misericordiae University Hospital (MMUH), Dublin, which is the national tertiary referral unit for lung transplantation, with access to endobronchial valve and robotic LVR procedures. As there is only one LVR service in ROI, the barriers and facilitators for referral may differ from those identified in the BTS survey which included National Health Service (NHS) staff in Great Britain and Northern Ireland, across multiple providers of LVR services. As well as this, 95% of respondents in the BTS survey were physicians or surgeons, meaning that the results of that survey are not representative of all staff involved in planning the care of patientswith COPD.

The Irish Thoracic Society (ITS) is the official society for healthcare professionals involved in the care of people with chronic or acute respiratory disease in Ireland. The ITS membership pool includes respiratory physicians, thoracic surgeons, general practitioners, junior doctors, nurses, physiotherapists, and other allied health professionals. Currently little is known about the knowledge of the LVR referral pathway and criteria amongst these members. Therefore, this survey of ITS members aimed to explore respiratory healthcare professionals’ knowledge of the LVR referral pathway and criteria and to identify and understand any obstacles which are currently limiting referral and assessment for LVR procedures as well as any training needs which may exist.

2 Methods

2.1 Survey content and development

A survey investigating perceptions and knowledge of LVR procedures was designed with members of the LVR multidisciplinary team (MDT) in MMUH. The survey included a mixture of closed- and open-ended questions focusing on the respondent’s professional experience, knowledge of LVR referral and assessment criteria, facilitators and barriers to referral and assessment and training and education needs and priorities. Once the draft survey content was agreed amongst the LVR MDT, it was piloted with a select group of healthcare professionals (n = 3) from different clinical areas with experience of survey research, to optimise content, acceptability, and feasibility. There were no changes made based on feedback from the pilot and the survey process functioned as intended. There were 12 questions included, and the survey took approximately five minutes to complete. A copy of the final survey is presented in Appendix 1 and 2. Ethical approval for this research was granted by Ulster University Institute of Nursing and Health Research Ethics Filter Committee (FCNUR-23-024). There were no conflicts of interest to be declared on behalf of any of theauthors.

2.2 Survey population and administration

The survey was hosted on the online platform Jisc and a link to the survey was sent to the ITS to distribute to members. No paper versions of the survey were requested. The link was sent out by the ITS via email along with a short information sheet describing the purpose of the survey (See appendix 1 and 2). Targeting the ITS members provides a representative sample of the key healthcare professionals involved in the planning and provision of care to people with COPD in ROI. Responses were only accepted from ITS members who were working in ROI. The link was sent to consultants, non-consultant hospital doctors (NCHD), nurses and physiotherapists who were currently registered as members of the ITS. Responses were not accepted from those who had no experience in respiratory care. There were 423 potential respondents, excluding the project management team. Response to the link implied consent. The survey remained open for eight weeks with reminder emails being sent to ITS members on two occasions, after four weeks and again after six weeks. No personal details were collected as part of thisresearch.

2.3 Data analysis

Completed survey responses were transferred from the Jisc survey platform to Microsoft Excel for analysis. Descriptive statistics were utilised to describe the survey data. Percentage frequency distribution was calculated for each survey question. Cross tabulation of responses allowed for subgroup analysis of the data between respondent groups. Responses to open questions were categorized under key themes (DP) and a second member of the project management team (BO’N) reviewed the themes separately for accuracy.

2.4 Patient and public involvement

The concept of this research was informed by patients who have accessed LVR services and their family members. They have provided informal feedback regarding the benefits of LVR procedures, and this prompted the need to undertake a survey to help better understand patient identification and referral rates for LVR procedures from healthcare professionals in ROI. Patients or the public were not involved in the conduct, reporting, or dissemination plans of this research. However, if there is an opportunity to inform patients about the results of this research via a public engagement event this will be utilised.

3 Results

There were 84 respondents to the survey, 19.9% of the ITS distribution list. There were 30 (36%) physiotherapists, 24 (29%) consultant physicians, 16 (19%) nurses and 14 (17%) NCHDs (Table 1). Fifty-eight respondents (70%) reported over ten years’ experience in respiratory care. Almost half of respondents (41, 49%) are working in hospital inpatient settings with 24 (29%) working in specialist ambulatory care and 19 (23%) as specialist support for general practice. There were no responses from general practitioners or those working in general practice settings. One response was excluded as the respondent identified that they work in an NHS hospital outside of ROI.

Table 1
Respondent Demographics

Total Percentage

What is your role? (n = 84)

Consultant physician 24 29

Non-consultant hospital doctor 14 17

General practitioner 0 0

Nurse 16 19

Physiotherapist 30 36

Which level of care best describes your main place of work? (n = 84)

Level 1 General practice 0 0

Level 2 Specialist support for general practice 19 23

Level 3 Specialist ambulatory care 24 29

Level 4 Hospital inpatient specialist care 41 49

How many years of experience do you have in respiratory care? (n = 83)

Less than ten years 25 30

More than ten years 58 70

	Total	Percentage
What is your role? (n = 84)
Consultant physician	24	29
Non-consultant hospital doctor	14	17
General practitioner	0	0
Nurse	16	19
Physiotherapist	30	36
Which level of care best describes your main place of work? (n = 84)
Level 1 General practice	0	0
Level 2 Specialist support for general practice	19	23
Level 3 Specialist ambulatory care	24	29
Level 4 Hospital inpatient specialist care	41	49
How many years of experience do you have in respiratory care? (n = 83)
Less than ten years	25	30
More than ten years	58	70

3.1 Knowledge of LVR services

In relation to the national LVR service in MMUH, Dublin, four respondents (5%) had no awareness of the service (Table 2). The remainder reported some (31, 37%) or full (49, 58%) awareness of the service. Most respondents reported some (49, 58%) or good (25, 30%) knowledge of the eligibility criteria for LVR procedures. Almost half of the respondents (40, 48%) had referred no patients for LVR over the past five years with 48% (40) having referred between one and five patients. When asked to rate their understanding of the referral pathway for LVR, 31 (37%) reported no understanding, 38 (45%) reported some understanding of the pathway and 15 (18%) good understanding.

Table 2
Understanding of LVR service and procedures

Total Percentage

Rate your level of awareness of the LVR service in MMUH. (n = 84)

Not aware 4 5

Some awareness 31 37

Fully aware 49 58

Rate your level of knowledge of the eligibility criteria for LVR

procedures. (n = 84)

No knowledge 10 12

Some knowledge 49 58

Good knowledge 25 30

Approximately how many patients have you referred for lung volume

reduction procedures in the last 5 years? (n = 84)

0 40 48

1 9 11

2 7 8

3 7 8

4 4 5

5 13 15

More than 5 4 5

Rate your understanding of the referral pathway for LVR services in ROI. (n = 84)

No understanding 31 37

Some understanding 38 45

Good understanding 15 18

Which group of patients do you think would derive the most benefit from LVR

procedures? (n = 84)

Homogenous emphysema, low exercise capacity 18 21

Homogenous emphysema, high exercise capacity 6 7

Heterogenous emphysema, low exercise capacity 33 39

Heterogenous emphysema, high exercise capacity 6 7

I do not know 21 25

Total	Percentage
Rate your level of awareness of the LVR service in MMUH. (n = 84)
Not aware	4	5
Some awareness	31	37
Fully aware	49	58
Rate your level of knowledge of the eligibility criteria for LVR
procedures. (n = 84)
No knowledge	10	12
Some knowledge	49	58
Good knowledge	25	30
Approximately how many patients have you referred for lung volume
reduction procedures in the last 5 years? (n = 84)
0	40	48
1	9	11
2	7	8
3	7	8
4	4	5
5	13	15
More than 5	4	5
Rate your understanding of the referral pathway for LVR services in ROI. (n = 84)
No understanding	31	37
Some understanding	38	45
Good understanding	15	18
Which group of patients do you think would derive the most benefit from LVR
procedures? (n = 84)
Homogenous emphysema, low exercise capacity	18	21
Homogenous emphysema, high exercise capacity	6	7
Heterogenous emphysema, low exercise capacity	33	39
Heterogenous emphysema, high exercise capacity	6	7
I do not know	21	25

Thirty-three respondents (39%) correctly identified patients with heterogenous emphysema and a low exercise tolerance are the group who would derive the most benefit from LVR procedures. The remaining respondents either did not know which group would derive the most benefit (21, 25%) or chose a different patient group.

3.2 Perceptions of LVR procedures

Respondents’ perceptions of LVR procedures were analysed with regards to the key benefits and areas for concern around LVR procedures (Table 3). When identifying the key benefits of LVR procedures the most common responses were reduced breathlessness (67, 80%), improved QOL (50, 60%) and improved exercise tolerance (33, 39%). Other responses included improved pulmonary function (10, 12%), reduced oxygen requirement or improved gas exchange (8, 10%) and reduced hyperinflation (8, 10%). Improved survival was mentioned by three respondents (4%). The main fears and concerns about referring patients for LVR procedures were surgical complications, infection, and death (29, 35%), no improvement or worsening of symptoms or QOL after LVR procedures (19, 23%) and patient selection or suitability for procedures (19, 23%). A lack of knowledge around LVR procedures (11, 13%), patient expectations or disappointment if they are not appropriate for the procedure (11, 13%) and waiting lists (5, 6%) were also reported as concerns by respondents.

Table 3
Perceptions of LVR Procedures

Total Percentage

In appropriately selected patients, what do you feel are the key benefits

of LVR procedures? (Include up to three) (n = 84)

Reduced breathlessness/work of breathing 67 80

Improved QOL 50 60

Improved exercise tolerance 33 39

Improved pulmonary function 10 12

Decreased oxygen requirement/improved gas exchange 8 10

Reduced hyperinflation 8 10

Reduced frequency of exacerbations/hospitalisations 6 7

Survival 3 4

Psychological benefits 1 1

What are your biggest fears or concerns about referring patients

for LVR procedures? (Include up to three) (n = 84)

Surgical complications, infection, and death 29 35

No improvement or worsening of symptoms or QOL 19 23

Patient selection/suitability for procedures (eg. unsuitable candidate, 19 23

    inappropriate referral, disease severity)

Lack of knowledge around procedures 11 13

Patient expectations/disappointment if not suitable 11 13

No fears or concerns 8 10

Waiting list 5 6

Patient support (Eg. explaining procedures to patients, 4 5

   supporting patients after procedures)

Geographic burden 4 5

Age related comorbidities 4 5

Continuity of care 3 4

Unable to refer (e.g. physiotherapist in a service where LVR 3 4

    referrals are generated by doctors only)

Not sure 2 2

Inadequate optimisation 1 1

Delay of transplant referral 1 1

Long assessment time 1 1

Which group of patients do you think would derive the most benefit from

LVR procedures? (n = 84)

Homogenous emphysema, low exercise capacity 18 21

Homogenous emphysema, high exercise capacity 6 7

Heterogenous emphysema, low exercise capacity 33 39

Heterogenous emphysema, high exercise capacity 6 7

I do not know 21 25

	Total	Percentage
In appropriately selected patients, what do you feel are the key benefits
of LVR procedures? (Include up to three) (n = 84)
Reduced breathlessness/work of breathing	67	80
Improved QOL	50	60
Improved exercise tolerance	33	39
Improved pulmonary function	10	12
Decreased oxygen requirement/improved gas exchange	8	10
Reduced hyperinflation	8	10
Reduced frequency of exacerbations/hospitalisations	6	7
Survival	3	4
Psychological benefits	1	1
What are your biggest fears or concerns about referring patients
for LVR procedures? (Include up to three) (n = 84)
Surgical complications, infection, and death	29	35
No improvement or worsening of symptoms or QOL	19	23
Patient selection/suitability for procedures (eg. unsuitable candidate,	19	23
inappropriate referral, disease severity)
Lack of knowledge around procedures	11	13
Patient expectations/disappointment if not suitable	11	13
No fears or concerns	8	10
Waiting list	5	6
Patient support (Eg. explaining procedures to patients,	4	5
supporting patients after procedures)
Geographic burden	4	5
Age related comorbidities	4	5
Continuity of care	3	4
Unable to refer (e.g. physiotherapist in a service where LVR	3	4
referrals are generated by doctors only)
Not sure	2	2
Inadequate optimisation	1	1
Delay of transplant referral	1	1
Long assessment time	1	1
Which group of patients do you think would derive the most benefit from
LVR procedures? (n = 84)
Homogenous emphysema, low exercise capacity	18	21
Homogenous emphysema, high exercise capacity	6	7
Heterogenous emphysema, low exercise capacity	33	39
Heterogenous emphysema, high exercise capacity	6	7
I do not know	21	25

3.3 National training resource

Two thirds (55, 66%) of respondents rated patient selection as the highest priority item for inclusion in a national training resource for LVR (from the four choices; Patient selection, Benefits of LVR, Referral process and Cost of LVR) (Table 4). The benefit of LVR procedures was rated as the highest priority by 18 (21%) respondents with the cost of LVR procedures being rated the lowest priority by 75 (89%) respondents.

Table 4
Priorities for a national training resource

It is planned to develop a national training resource. Please rate the following items in

order of priority for inclusion in this resource. (1 = highest priority, 4 = lowest priority)

1 2 3 4

Patient selection 55 (66%) 24 (28%) 3 (4%) 2 (2%)

Referral process 8 (9%) 31 (37%) 39 (46%) 6 (7%)

Benefits of LVR 18 (21%) 28 (33%) 37 (44%) 1 (1%)

Cost of LVR 3 (4%) 1 (1%) 5 (6%) 75 (89%)

It is planned to develop a national training resource. Please rate the following items in
Patient selection	55 (66%)	24 (28%)	3 (4%)	2 (2%)
Referral process	8 (9%)	31 (37%)	39 (46%)	6 (7%)
Benefits of LVR	18 (21%)	28 (33%)	37 (44%)	1 (1%)
Cost of LVR	3 (4%)	1 (1%)	5 (6%)	75 (89%)

Cross-tabulation of responses allowed the researchers to investigate trends in answers amongst different respondent groups. Out of 24 consultant physician respondents, most were fully aware of the LVR service in MMUH (21, 88%), Most (17, 71%) reported a good understanding of the eligibility criteria for LVR and 13 (54%) reported a good understanding of the referral pathway. Of the remaining respondents (n = 60), less than half reported full awareness of the LVR service (28, 47%), eight (13%) reported a good understanding of the eligibility criteria and four (3%) reported a good understanding of the referral pathway. 58% (14/24) of consultant physician respondents correctly identified the group of patients who would benefit most from LVR procedures compared with 32% (19/60) of the remaining respondents.

There were 19 respondents working in level 2 specialist support for general practice. This comprised of fourteen physiotherapists and five nurses. Just over one quarter (5, 26%) of this group reported full awareness of the LVR service. No respondents from this group reported a good understanding of the referral pathway and two (11%) reported a good knowledge of the eligibility criteria for LVR.

3.4 Additional comments

Participants were invited to add any final comments they had regarding LVR procedures or services in the free text section. There were comments from n = 20 respondents. Ten respondents stated that they would like more information about LVR procedures and the referral pathway. Two respondents made suggestions about the proposed learning resource with one respondent stating that patient testimonies and case studies should be included and the other indicating a preference for a blended learning approach over eLearning alone. Two respondents indicated that there is a need for a national leading group for LVR services with specialist representatives from the relevant professions.

One respondent (consultant physician) suggested that the proportion of COPD patients who qualify for LVR procedures is low in practice; they felt that given the rising prevalence of obesity in ROI and the negative impact it can have on symptomatic burden in COPD patients, bariatric surgery might be more beneficial than LVR in this patient cohort.

4 Discussion

This is the first survey in Ireland to provide insight into the perceptions and knowledge of LVR procedures among respiratory healthcare professionals. Although most respondents were aware of the LVR service and identified the key benefits of LVR, there is uncertainty around the referral pathway and appropriate patient selection which may be affectingreferrals.

Differences were noted in responses between consultant physicians and other respondent groups, and also between different care settings. Referrals to the LVR service are generally made by consultant physicians, however, referrals are also accepted from specialist nurses, physiotherapists and NCHDs and therefore a good understanding of the eligibility criteria and referral pathway is important for all these groups.

The key benefits of LVR identified by respondents were reduced breathlessness, improved QOL, increased exercise tolerance and improved pulmonary function. The reported benefits in this survey are consistent with the published efficacy markers associated with LVR procedures [20].

The survey also aimed to uncover any obstacles which are limiting referral and assessment for LVR procedures as well as any training needs. A need for information about the referral pathway and criteria around patient eligibility and selection was identified. While the eligibility criteria for LVR procedures are outlined in the NICE (2018) guideline for the management of COPD [8], the results of this survey suggest that there is a need to disseminate the criteria to further support implementation in practice. There is potential to achieve this through the development and distribution of specific LVR educational resources and support to those working with patients with COPD.

There was a wide variety of responses provided about the main fears and concerns around referring patients for LVR procedures which made creating themes from the responses more difficult. However, the final themes were agreed by the research team to ensure that the results are representative of the responses provided. Respondents (13%) mentioned concerns about patients feeling disappointed if deemed not suitable for LVR procedures. This highlights the potential need for specific education around expectations or clinical psychology input during the assessment phase to help to manage patient expectations and support them through this process as has been incorporated into lung transplant assessment [21].

There have been significant surgical advancements, including minimally invasive techniques (video assisted thoracoscopic surgery, robotic and bronchoscopic LVR) and improved stapling technology, which have decreased the risk associated with the procedures [22]. Currently, in surgical practice, unilateral thoracoscopic or robotic approaches are favoured compared with open sternotomy or thoracotomy in the NETT study. These advances in surgical and bronchoscopic approaches to LVR as well as improved understanding of appropriate patient selection have made the procedures safer [19]. Despite this, surgical complications, infection, and death were still the most commonly cited fear or concern by respondents. Appropriate selection of suitable patients for LVR procedures was cited by 23% of respondents as a main fear or concern, while a lack of knowledge around LVR procedures was cited by 13% of respondents. Therefore, these could be factors affecting referrals for LVR procedures. Remote satellite assessment clinics supported by the LVR MDT in MMUH may be one method to reassure clinicians and address the concerns around complications and appropriate patient selection. The development of a regional network of LVR specialist sites with referral to the national unit in MMUH for high risk cases is another model which should be considered for LVR services going forward. These clinics could be developed along a similar model to the eight lung rapid access clinics nationally which offer direct access to assessment and diagnosis for suspected lung cancers. Either option would require appropriate staffing and infrastructure.

Although considered to be a costly intervention, long term data from NETT has shown LVR to be cost-effective compared with optimal medical management for people with COPD [23]. The cost of LVR was not cited as a concern by any respondent in this survey and it was the lowest priority for most respondents for inclusion in a training resource.

A response rate of 19.9% from this specialist group of clinicians is higher than the 2.6% response rate to the previous survey of BTS members in 2013 [19]. Nonetheless, future surveys to multiple healthcare professionals could be improved on with advertisement of the survey on social media platforms or at national conferences. Inclusion of profession-specific groups or clinical interest groups outside of the ITS may also have increased the potential pool of respondents. One limitation of this study is that there were no responses from general practitioners or general practice care settings. The ITS is a society for specialist respiratory healthcare professionals, and although general practitioners can be members of the ITS, this is not the ideal forum through which to access this professional cohort. Future research should focus on understanding the opinions of LVR amongst general practitioners through the Irish College of General Practitioners or a similar body. A full breakdown of the ITS membership pool by clinical role was not carried out and therefore it was not possible to identify potential differences between responders and non-responders. Additionally, this survey was specifically directed at respiratory healthcare professionals and patient perspectives were not captured. However, patients will be key stakeholders in the development of training resources and their experiences and voices will be explored at a later stage. Views of patients and their families may also help to identify further concerns or considerations which have not been reflected in this research.

As there is only one LVR service in ROI currently, up to date learning tools need to be explored to make education and training as accessible as possible nationally. Blended learning approaches have been shown to have consistently superior effects on knowledge outcomes compared with traditional learning approaches in health education [24]. Some options for this resource could include flash cards and infographics supported by online educational seminars and these have already been used by the ITS [25].

5. Conclusion

There is a real opportunity to enhance LVR services for people with COPD in ROI. This survey has provided data which can be used to assist in the development of national training resources for respiratory healthcare professionals targeted to the whole range of profession groups and levels of care. Educational resources must focus on patient selection and the referral criteria and pathway. The structure of LVR services nationally also needs to be reviewed. Collaboration is required between the LVR MDT and the National Clinical Programme for COPD, respiratory integrated care hubs, and specialist respiratory clinics nationally to ensure that all potentially eligible candidates for LVR procedures are being considered.

Further development of the national LVR service may require a team approach with leadership from a designated national coordinator for LVR in ROI, who in turn could facilitate education seminars locally around the country and improve links between local centres and the specialist LVR service.

Footnotes

Acknowledgments

The assistance of the LVR MDT in MMUH and the Irish Thoracic Society is gratefully acknowledged.

The Appendix is available in the electronic version of this article: .

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It is planned to develop a national training resource. Please rate the following items in
order of priority for inclusion in this resource. (1 = highest priority, 4 = lowest priority)
	1	2	3	4
Patient selection	55 (66%)	24 (28%)	3 (4%)	2 (2%)
Referral process	8 (9%)	31 (37%)	39 (46%)	6 (7%)
Benefits of LVR	18 (21%)	28 (33%)	37 (44%)	1 (1%)
Cost of LVR	3 (4%)	1 (1%)	5 (6%)	75 (89%)