**14. The impact of volume reduction interventions for the patient and family**

The major limitation to exercise tolerance, and therefore to functional performance in COPD, is dynamic hyperinflation (O'Donnell & Webb, 2008). Surgical procedures, such as Lung Volume Reduction Surgery (LVRS) and Endobronchial Valve Insertion (EBVTM) have expanded the therapeutic possibilities for people with emphysematous hyperinflation. The procedures aim to reduce the amount of space taken up by hyperinflated lung tissue to improve elastic recoil, and chest wall and diaphragm dynamics. LVRS is an invasive procedure that requires the resection of between 20-40% of the total volume of each lung. It is safest and most effective for people with an FEV1 greater than 20% of predicted and a heterogenous rather than diffuse pattern of emphysema (NETT, 2001). LVRS is not a firstline treatment, but should be considered where optimal medical management and pulmonary rehabilitation fails to improve the person's clinical status (Ries et al., 2005). LVRS is known to result in significant improvements in quality of life, exercise performance and lung function, and the best results occur where surgery is complemented with an extended period of pulmonary rehabilitation (Criner et al., 1999).

In response to the potential morbidity and mortality following the major surgical procedure of LVRS, minimally invasive alternatives have been developed, and these are usually targeted towards upper zone, heterogenous emphysema. To date, the most commonly utilised approach is to insert one or more one-way endobronchial valves (EVB) to allow air to escape from hyperinflated zones and to prevent the return of air to those zones.

Whilst some patients are known to benefit from this procedure, only a minority (these tend to be those with the most hyperinflation at baseline) experience long term improvements in lung function (Kotecha et al., 2011). This improvement comes at a cost of more frequent hemoptysis, pneumonia distal to the valves and more frequent exacerbations of COPD in the few months after valve implantation (Sciurba et al., 2010). These results are confirmed in the only qualitative study of lung volume reduction procedures to date, demonstrating sustained wellness amongst most of the LVRS participants in contrast to a gradual decline in effectiveness for those who had endobronchial valve insertion (Gullick & Stainton, 2009).

Importantly, FEV1 as the hallmark of COPD measurement, frequently does not predict the person-centred outcomes of surgery (Gullick & Stainton, 2009, Leyenson et al., 2000, Moy et al., 1999). Patients and families who accept surgical intervention for COPD feel the need to 'take a chance' on a procedure, even if they perceive that to be high-risk decision. Whilst COPD leads to shrinking of the boundaries of the self, for some, undergoing a surgical intervention allows an increase in physical effectiveness and a regaining of self. Gail explained of her husband Jim after EBV insertion, *"He can dig in his garden…he's got a lovely veggie garden at the moment. There's lots of things he wouldn't have been able to do had he not had it done"*. Claire, (52 yrs) describes her husband Sam's regaining of self after LVRS: *"It was important for all of us to get back what he wanted; his mobility, his freedom, his right to choose what he wants... It was a chance for Sam to continue being Sam, and the surgery achieved that. He could go on being the same person that he was – he was able to continue being himself."* 
