There are currently three surgical treatments for emphysema: bullectomy, lung transplantation, and lung volume reduction surgery (LVRS). Unfortunately, most emphysema patients are poor candidates for any surgical intervention. A meticulous selection process is favoured in which indications and contraindications are considered and the best solution is devised for each patient. Patients with giant bullae filling half the thoracic volume and compressing relatively normal adjacent parenchyma are offered bullectomy; those with hyperinflation, heterogeneous distribution of destruction, forced expiratory volume in 1 second (FEV1) >20%, and a normal carbon dioxide tension (Pco2) are offered LVRS; and patients with diffuse disease, lower FEV1, hypercapnia, and associated pulmonary hypertension are directed towards transplantation. Using these criteria, few patients are serious candidates for surgical procedures. Combinations of LVRS and lung transplantation, either simultaneously or sequentially, are possible but rarely necessary.