Lung Transplantation

NHS Policy – Lung Transplantation Candidate Criteria. Effective date: Oct 2023.

Article Last Updated:03/01/2026

Disclaimer:

This article is not intended to be memorised in full. Its aim is to provide a broad conceptual understanding, allowing students to recognise relevant clinical scenarios in exams, and perhaps to familiarity with the key indications and contraindications for lung transplantation.

For this reason, the content is a simplified educational summary rather than the complete guideline.

Conditions Considered for Lung Transplantation

High yield conditions that are often considered for lung transplantation:

Diffuse parenchymal lung disease	Idiopathic pulmonary fibrosis Sarcoidosis Chronic hypersensitivity pneumonitis Occupational lung fibrosis
Obstructive lung disease	Severe COPD (including alpha 1 antitrypsin deficiency) Obliterative bronchiolitis Asthma (however, lung transplant is very rare in practice)
Suppurative lung disease	Cystic fibrosis Severe bronchiectasis
Pulmonary vascular disease	Pulmonary artery hypertension that is refractory to medical therapy Congenital heart disease with Eisenmenger’s syndrome

Fibrotic lung disease is the most common indication for lung transplantation in adults, while cystic fibrosis is the most common indication in children.

Indications for Lung Transplantation

A patient being listed for lung transplantation must meet ALL the general eligibility principles PLUS at least 1 condition-specific criteria.

General eligibility principles:

Be on maximal medical therapy
Have a potential survival benefit or significant improvement in QoL from the transplantation
Have a >5 year projected post-operative survival, with a quality of life acceptable to the patient

Condition-specific criteria (for adult non-urgent lung allocation scheme registration):

Condition	Criteria
Obstructive lung disease (e.g. COPD)	FEV1 <20% of predicted despite maximal medical therapy, and DLCO <20% of predicted, or Homogeneous distribution of emphysema Pulmonary hypertension or cor pulmonale BODE score >7 History of hospitalisation + increasing frequency of this for exacerbations associated with acute hypercapnia (PaCO₂ >6.5) and worsening hypoxia
Idiopathic pulmonary fibrosis	Short rapid decline in symptoms pre-diagnosis SpO2 <88% (rapid decrease) during a 6-min walk test ≥10% decrease in FVC during 6 months of follow-up DLCO <40% with clinical deterioration and/or DLCO >15% decline over 6 months of follow-up
Cystic fibrosis and bronchiectasis	FEV1 <30% of predicted or rapid and irreversible decline in FEV1 Pulmonary disease exacerbation requiring at least 1 ICU / HDU admission Pneumothorax in association with advanced disease Haemoptysis not controlled by embolisation Progressive increase in medical therapy to maintain survival (including increased need for IV antibiotics due to increased or worsening exacerbation)
Pulmonary arterial hypertension	WHO functional class III or IV without an improvement on parenteral medical therapy over 3 months Declining 6-minute walk distance to <350 m despite maximal medical therapy Worsening refractory right heart failure as defined by increasing fluid retention despite optimal medical management with disease modifying therapy and diuretics Requirement for continuous IV inotropic support Recent (within 3 months) right heart catheter study showing ↑ right atrial pressure (>15 mmHg) and ↓ cardiac index (<2.0 L/min/m²) despite optimisation of therapy

One would not be expected to memorise the full list of indications for lung transplantation at an undergraduate level, however it is advised to be familiar with:

The general eligibility principles
Indications specific to obstructive lung disease (e.g. COPD)

Surgical Approach

Choice of procedure: ^[Ref]

Bilateral, sequential lung transplantation – most common
Single-lung transplantation
Heart-lung transplantation (reserved for those with both end-stage heart and lung failure, e.g. congenital heart disease with Eisenmenger’s syndrome)

Surgical approach: ^[Ref]

Bilateral thoracotomy with transverse sternotomy (“clamshell” incision) – most common

References

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