What to Expect From a Lung Transplant

Lung transplant surgery is an extremely complex procedure that replaces a patient’s diseased lung or lungs with donated lungs in an effort to treat end-stage pulmonary disease. One or both lungs may be replaced with donor organs; the patient’s own lungs are surgically removed so the healthy lungs from a donor can be put in their place.

Reasons for a Lung Transplant

Transplants are appropriate when lung disease is so severe that the lungs are no longer able to support the needs of the patient’s body and there are no medical interventions available that will correct the problem. This is referred to as end-stage pulmonary disease.

A lung transplant is the final option for treatment of severe pulmonary disease and is appropriate when all other options have failed to improve lung function. The typical lung transplant candidate requires oxygen and possibly a ventilator to meet their oxygen needs, is typically worsening with time, and will die if their lung function does not improve. 

Generally speaking, a person is considered a candidate for a lung transplant if he or she has a life expectancy of two years or less. Moreover, an age limit of 65 is typically advised for a single-lung transplant and 60 years for a bilateral transplant. Statistics have shown little benefit in either the survival time or quality of life for persons older than this.

Common lung conditions that lead to the need for a lung transplant include:

  • Cystic Fibrosis: A genetic condition, cystic fibrosis (CF) causes lung infections and increased mucus production, often leading to scarring and the need for a lung transplant.
  • COPD: Chronic obstructive pulmonary disease is a lung condition that makes breathing difficult, and can make it difficult for the lungs to expand properly. Typically caused by polluted air, including cigarette smoke and environmental pollution leading to poor air quality. Symptoms typically worsen over years.
  • Interstitial lung diseases: These conditions, which include pulmonary fibrosis, cause stiffening of the lungs, making it difficult for the lungs to expand and contract with each inhalation and exhalation. The alveoli are also affected, making gas exchange difficult.
  • Antitrypsin deficiency: A genetic condition that affects many areas of the body, a deficiency can lead to emphysema in the lungs that can cause permanent damage over time. Non-alpha 1 and alpha 1 antitrypsin deficiency can both lead to the need for transplantation.
  • Pulmonary Hypertension: Pulmonary hypertension is a condition where the arteries of the lungs have much higher blood pressure than they should. The pulmonary artery, the blood vessel carrying blood from the heart to the lungs, will have increasingly high blood pressure, making it difficult for blood to flow out of the heart and through the lung to maintain the flow of oxygen and carbon dioxide.
  • Sarcoidosis: A systemic disease, sarcoidosis causes inflammation that can occur in any organ, including the lungs. In severe cases, the damage that is caused leads to shortness of breath, weakness and, eventually, pulmonary fibrosis. 

Other criteria include:

  • Having an FEV1 of less than 20 percent.
  • Experiencing chronic hypercapnia (excessive carbon dioxide) and reduced blood oxygen levels
  • Having a BODE Index score of under seven (indicating a shortened life expectancy)

There may be some leeway in these numbers, based on a review of the individual case. Selection would also involve an assessment of whether the person is ambulatory, has a strong support system, and is motivated to undergo physical therapy, exercise, smoking cessation, and other lifestyle changes leading up to and following surgery.

Persons with a previous lung surgery, such as a lung volume reduction surgery (LVRS) or a bullectomy, may also qualify if they are able to meet the criteria.

Who Is Not a Good Candidate?

Contraindications are dealt with on an individual basis, and in some cases may only be temporary. For example, an individual cannot have a transplant surgery while they have an active infection, but they would become eligible for transplant when they are well again. 

In the case of addiction, current alcoholism would prevent transplantation, but a history of alcohol abuse would typically not be an issue if the individual had been without alcohol for a period of time, typically longer than one to two years.

Other contraindications include:

  • Current addictive behavior, including the use of illegal drugs and legal ones, such as prescription drug abuse, cocaine, and alcohol abuse
  • Cancer that won’t be cured by the transplant and that is likely to return after the transplant
  • Dementia or Alzheimer’s disease
  • The presence of another disease that is severe or life-ending
  • Infection
  • Untreatable severe disease of another organ, but for some a dual transplant, such as a heart-lung combination, is possible
  • Smoking marijuana or tobacco/nicotine, including vaping
  • Inability to manage current medication regimen
  • Inability to manage post-transplant regimen
  • Incurable severe vascular disease, such as heart disease
  • No support system such as caregivers, friends, or family
  • Severe obesity
  • Critically ill (too sick to survive transplant surgery)

Types of Lung Transplants

Lung transplants can involve the transplantation of one or both lungs. Whether one or the other is recommended depends on assorted factors, including:

  • The reason for the transplant
  • Your age
  • The availability of lungs that meet your specific requirements

Single lung transplant

In this procedure, one lung from a donor replaces one of your lungs. In this case, the incision will be made on the side of the lung to be transplanted.

Double lung transplant

A double lung transplant involves the replacement of both lungs with two donor lungs. For a bilateral transplant, an incision will be made horizontally across the chest or vertically in between the breast area.

Research has been done weighing the pros and cons of single versus double transplants, but there are no definitive guidelines for when one procedure must be used over the other.

Heart-lung transplant

A heart-lung transplant is used to treat people who have severe or life-threatening conditions that are affecting both their heart and their lungs, such as severe congenital heart disease (birth defects that affect the normal working of the heart).

During a heart-lung transplant, a donated heart and pair of lungs are taken from a recently deceased donor and are used to replace the patient’s diseased heart and lungs.

A heart-lung transplant is a complex and demanding surgery that carries a high risk of complications, some of which can be fatal.

Donor Recipient Selection Process

Once it is determined that you are eligible for a lung transplant, your transplant center enters medical data—such as the donor’s blood type and body size and the location of the donor hospital—into the United Network for Organ Sharing's (UNOS) database.

The candidates who will appear highest on the waiting list are those who are in most urgent need of the transplant, and/or those most likely to have the best chance of survival if transplanted.

The distribution of organs is based on the lung allocation score (LAS). Your score will be determined at each visit and updated if necessary. The LAS ranges from zero to 100, with the sickest patients usually receiving a score of 48 and above.

The wait for a donor lung can take anywhere from a few days to several years, depending on your position on the waiting list, and whether or not the donor lung is compatible. If there is a problem with the donor lung or if you have an infection, the surgery cannot be performed. About 20% of all lung transplants are canceled the first time. If this happens, you must wait for another donor organ to become available.

Types of Donors

Donated lungs must come from a deceased donor. The lungs typically come from a donor who suffered an injury or medical problem that led to brain death. Once brain death is declared by a physician, the wishes of the donor or their family lead to the donation of their organs. 

Once the lungs are recovered by a surgeon, there is a short window of opportunity to transplant the lungs into a recipient. Modern technology is increasing the length of time that the lungs can be out of the body, but they typically must be transplanted into the recipient within four to six hours. This often means the organs travel by private jet in order to get to the transplant center to get there quickly enough to be safely used as a transplant.

Before Surgery

The typical journey of a transplant patient starts with the diagnosis of a pulmonary problem. This may happen at birth, after a cough continues for too long, or during a hospitalization. A diagnosis may happen after an X-ray, or when shortness of breath becomes a problem. 

If the problem is severe, the patient is typically sent to a pulmonologist, a specialist in the area of lung disease. If treatment with pulmonology is unsuccessful, or if the disease continues to worsen despite treatment, the physician can refer the patient to a transplant center where they can potentially be added to the transplant list to wait for donated lungs to become available.

Common tests include:

  • Pulmonary function tests 
  • CT scan of the chest
  • Heart tests to determine if the heart is strong enough for anesthesia
  • Chest X-ray
  • Blood tests to check the function of other organs, CBC to check blood levels, CMP to check electrolyte levels and kidney function, as well as other blood tests that are needed
  • Blood type
  • Antibody tests for donor matching

The process starts with a referral to the transplant center, where there will be a thorough evaluation of the patient’s disease state, emotional state, insurance review and assistance, and the care needed after the surgery. Extensive testing is typically performed to make sure that the patient is a good candidate for a lung transplant, that a lung transplant is necessary, and the patient has the necessary skills to take care of themselves during and after the transplant. 

If the patient is a good candidate, they are placed on the transplant list and wait for a donated organ to become available.

Transplant centers are typically selected by location. Depending on where the patient lives there may be several centers to choose from, or there may be one logical choice for treatment. Not all transplant centers offer all types of organ transplants. Major university transplant centers will typically offer more types of transplants, while smaller regional programs may only transplant kidneys or other abdominal organs. For this reason, you may be referred to a transplant center that is not the closest one to your home. The pulmonologist will typically choose the transplant center that will be most appropriate for the patient's needs.

Most transplant centers have multiple surgeons who are trained and ready to perform the transplant surgery. If there is a preference for which surgeon will be primarily responsible for the care provided, it is acceptable to make that preference known, but the entire team will typically share responsibility for patient care during hospitalizations.

Surgical Process

Lung transplant surgery requires two teams of surgeons: the surgeon who is recovering the donor lungs, and the surgeon who is leading the surgery on the recipient. These two teams are necessary because the donor and the recipient may be in different cities or even different states. It is a rare occasion when they are both in the same hospital. 

The process starts when the transplant center accepts an offer for the donated organs made by the organ procurement team caring for the donor. If the lungs are a good genetic match, a good size match, and in suitable condition to be transplanted, arrangements are then made to have a surgeon and other staff go to the donor's operating room to recover the lungs. Meanwhile, the recipient is asked to report to the hospital if they are not already there. Upon arrival, blood work is done, IVs are placed, and any necessary testing is performed. 

The recipient typically goes to the operating room about the same time the donor goes to the operating room. A breathing tube is placed, they are put on the ventilator, and general anesthesia is given. 

Once the donor lungs and transplant recovery team have safely landed or arrived near the transplant center, the surgeons can safely proceed and remove the recipient’s own lungs and prepare for the final portion of the transplant procedure. During this part of the procedure, where the patient cannot oxygenate their blood, a heart-lung bypass machine is used to oxygenate the blood and the ventilator is not used. 

An incision is made in the chest, and the sternum (breastbone) is cut in half, allowing the chest to be opened so surgery on the lungs can begin. 

Surgical clamps are used to keep blood in the blood vessels while the new lungs are being transplanted. Once the new lungs are sewn into place, and the blood vessels are reconnected, the ventilator can be started again and oxygen is provided to the body by the new lungs and the heart-lung bypass machine is no longer needed. Chest tubes are placed, as needed, and the incision is closed. 

A single lung transplant takes four to eight hours; a double transplant takes six to 12 hours.

Complications

In addition to common risks associated with surgery and the risks associated with general anesthesia, a lung transplant surgery poses additional risks The medications given to prevent organ rejection after surgery are known to increase the risk of cancer, kidney problems, stomach upset, bone loss (osteoporosis), and diabetes, particularly when high doses are used for extended periods of time. For this reason, the minimum necessary dose is used whenever possible.

There is no underplaying the fact that a lung transplant is a major procedure that carries a significant risk of complications, including death. They can either be respiratory-related or non-respiratory-related.

Respiratory-related complications are those that directly affect the lungs and may include:

  • Ischemia-reperfusion injury (damage caused when blood returns to tissue after a period of oxygen deprivation)
  • Bronchiolitis obliterans (respiratory obstruction due to acute inflammation)
  • Tracheal malacia (collapsed windpipe)
  • Atelectasis (collapsed lung)
  • Pneumonia

By contrast, non-respiratory-related complications are those affecting other organs or related to the immune suppressive drugs used to prevent organ rejection. While organ rejection is the most immediate concern following transplant surgery, others can include:

  • Infection
  • Lymphoproliferative disease (caused when too many white blood cells, called lymphocytes, are produced in persons with a compromised immune system)
  • Lymphoma (cancer of the immune system)
  • Systemic hypertension
  • Kidney failure
  • Post-transplant diabetes

After Surgery

After the surgery, you'll be taken to the surgical intensive care unit where you'll be watched closely and slowly permitted to wake up from anesthesia. You may receive sedation to slow this process if the lungs are having issues that need to be addressed, but they could potentially be off the ventilator a day or two after surgery.

The typical patient stays in the hospital for a few weeks after surgery, possibly longer if there are complications. Some patients will need physical therapy and occupational therapy to regain their strength, as their lung disease may have led to significant weakness in the months or years before surgery. 

The intensive care unit stay after surgery can also lead to the need for rehabilitation if it results in physical weakness. Follow-up visits to the transplant center will initially be frequent after surgery, and less frequent as time passes. The risk of rejection is highest in the first few months after surgery, so frequent lab draws are also typical.

You'll have regular appointments with your lung transplant team for the next few months and they'll monitor any signs of infection, rejection, or other problems.

After your lung transplant, you'll need to take immunosuppressant medications for life to prevent rejection. These medications may cause serious side effects, and they may cause you to be more susceptible to infections. Your treatment team will explain your medications and potential side effects. Your doctors will help you manage your immunosuppressant medications, based on your side effects and any signs of rejection.

Among the medication options that may be used for people with lung transplants, the most common ones include Simulect (basiliximab), CellCept (mycophenolate mofetil) and Imuran (azathioprine).

Researchers continue to study the potential use of other immunosuppressant medications for people with lung transplants.

Prognosis

The first year after a transplant is the most critical. This is when serious complications, like infection and rejection, are most common. (You can minimize these risks by following your lung transplant team’s instructions and immediately reporting any complications.) While survival rates depend on many factors, such as the medical reason for the transplant and the age and overall health of the recipient, here are overall rates of survival, according to the National Heart, Lung, and Blood Institute:

  • About 78% of patients survive the first year
  • About 63% of patients survive three years
  • About 51% of patients survive five years

Survival rates for double-lung transplants are slightly better than those for single-lung transplants. Recent data show that the median survival for single-lung recipients is 4.6 years. The median survival for double-lung recipients is 6.6 years.

Nearly 80 percent of all recipients survive the first year after transplant, and over 50 percent are alive five years after transplantation. The recipient’s age at the time of transplant and the severity of their disease are the best predictors of survival, with younger and healthier recipients having better long-term outcomes.

Support and Coping

It's normal to feel anxious or overwhelmed while waiting for a transplant or to have fears about rejection, returning to work, or other issues after a transplant. Seeking the support of friends, family members, and your transplant team can help you cope during this stressful time.

Your transplant team also can assist you with other useful resources and coping strategies throughout the transplant process, such as:

  • Joining a support group for transplant recipients. Talking with others who have shared your experience can ease fears and anxiety.
  • Getting additional treatment. If you're depressed, talk to your doctor. He or she may recommend medications or refer you to a mental health professional.
  • Finding rehabilitation services. If you're returning to work, your social worker may be able to connect you with rehabilitation services provided by your home state's vocational rehabilitation services.
  • Setting realistic goals and expectations. Recognize that life after a transplant may not be exactly the same as life before a transplant. Having realistic expectations about results and recovery time can help reduce stress.
  • Educating yourself. Read as much as you can about your procedure and ask questions about things you don't understand. Knowledge is empowering.

Diet and nutrition

After your lung transplant, you should adjust your diet to keep your lungs healthy and functioning well. Maintaining a healthy weight with diet and exercise can help prevent many common post-transplant complications, including infection, heart attacks, and bone thinning.

Your transplant team should include a nutrition specialist (dietitian) who can discuss your nutrition and diet needs and answer any questions you have after your transplant. Your dietitian's recommendations may include:

  • Eating at least five servings of fruits and vegetables each day
  • Eating lean meats, poultry, and fish
  • Eating whole-grain breads, cereals, and other products
  • Having enough fiber in your daily diet
  • Drinking low-fat milk or eating other low-fat dairy products to help maintain healthy calcium levels
  • Limiting salt and sodium intake by using fresh herbs and spices to season foods and avoiding processed foods
  • Limiting unhealthy fats, such as saturated fats in butter and red meats
  • Limiting your caffeine and avoiding excessive alcohol intake
  • Staying hydrated by drinking adequate water and other fluids each day
  • Avoiding grapefruit and grapefruit juice, pomegranate, and Seville oranges due to their effect on a group of immunosuppressive medications called calcineurin inhibitors
  • Following food safety practices to reduce the risk of infection

Exercise

Exercise and physical activity should be a regular part of your life after a lung transplant to continue improving your overall physical and mental health. Regular exercise helps boost energy levels and increase strength. It also helps you maintain a healthy weight, reduce stress, and prevent common post-transplant complications such as high blood pressure and cholesterol levels.

Your transplant team will recommend a physical activity program based on your individual needs and goals.

Walking, bicycling, swimming, low-impact strength training, and other physical activities you enjoy can all be a part of a healthy, active lifestyle after transplant. But be sure to check in with your transplant team before starting or changing your post-transplant exercise routine.

A Word From Verywell

Lung transplant surgery is a very serious and high-risk procedure that can extend the patient’s life for years or even decades. The lives of patients who have a lung transplant often change dramatically for the better after surgery, and they can often resume their normal activities within a few months of surgery. 

The decision to transplant one lung or both lies with the surgeon, but in either case, the patient can see enormous benefits. While there are significant risks that cannot be ignored with any major surgery, the risks of lung transplant are even more significant and should be considered before making the decision to be on the transplant list. Choosing to accept those risks and to pursue a lung transplant can also potentially lead to sweeping improvements in health and well-being. 

While lung transplants are always considered a last resort, advances in technology and post-surgical care have led to greater rates of success than ever before.

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