In the last decades, developing thoracic surgery raised the demands for sophisticated anesthesiological management. Especially patients with end-stage thoracic emphysema challenge the anesthesiologist to make modern surgery possible and to provide a safe and effective perioperative management. The development and scientific work-up of single lung ventilation (SLV) laid the cornerstone for surgery of the non-ventilated lung and hemi-thorax. However, modern medicine extended surgical options to extensive tracheal surgery and to patients suffering from severely insufficient lung-capacity precluding single-lung ventilation or artificial ventilation in se. For those critically ill, different techniques were thus developed and evaluated in recent research, among others, non-intubated surgery and surgery under extracorporeal perfusion support that temporarily avoids pulmonary gas exchange and ventilation via the trachea in any way. To tackle postoperative pain with its successive problems of immobilization, insufficient respiration and airway-clearance, regional anesthesia offers great advantages. Thoracic epidural anesthesia (TEA) is considered as the gold standard; complementary, modern ultrasound techniques make regional anesthesia possible even when contraindications prohibit neuraxial blocks. Especially paravertebral block, musculus serratus anterior block, intercostal block and the musculus erector spinae block provide good postoperative pain relief and appear to influence chronic post-thoracotmy pain positively. Careful preoperative preparation, intraoperative monitoring and patient-tailored, individual perioperative management by a well-trained team ensure good results, a good survival and favorable quality of life. This article provides a brief overview over state-of-the-art techniques and future perspectives to provide anesthesia in emphysema surgery.