What to Expect From a Lung Transplant

Lung transplant surgery is a complex procedure in which a patient’s diseased lung or lungs are replaced with lungs from a deceased donor in an effort to cure or improve a variety of end-stage pulmonary diseases, including cystic fibrosis and pulmonary hypertension. An increase in the number of lung donors in recent years has meant shorter wait times for people who need a lung transplant.

Reasons for a Lung Transplant

A lung transplant is appropriate when your lung disease is so severe that the lungs are no longer able to support your body's requirements and all other treatment options have failed to improve pulmonary function. This is referred to as end-stage pulmonary disease.

Common lung conditions that may require a lung transplant include:

• Cystic fibrosis (CF): A genetic condition, CF causes lung infections and increased mucus production, often leading to scarring of the lungs.
• Chronic obstructive pulmonary disease (COPD): This condition, which most commonly affects longterm smokers, makes it hard for the lungs to expand properly, affecting breathing. 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.
• Pulmonary hypertension: Pulmonary hypertension is a condition where the arteries of the lungs have much higher blood pressure than they should, 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. 

The typical lung transplant candidate:

• Requires oxygen and possibly a ventilator to meet their oxygen needs
• Is typically worsening with time
• Will die if their lung function does not improve
• Has a life expectancy of two years or less

Other criteria include:

• Having an FEV1 of less than 20%
• Experiencing chronic hypercapnia (excessive carbon dioxide) and reduced blood oxygen levels
• Having a BODE Index score of under 7 (indicating a shortened life expectancy)

To qualify for a lung transplant, you'll also undergo an assessment to determine whether you are ambulatory, have a strong support system, and are motivated to participate in physical therapy, exercise, smoking cessation (if necessary), and other lifestyle changes leading up to and following surgery.

If you've had previous lung surgery, such as a lung volume reduction surgery (LVRS) or a bullectomy, you may also qualify if you are able to meet the criteria.

Who Is Not a Good Candidate?

You are not likely to qualify for a lung transplant if:

• You currently have a substance use disorder
• You smoke cigarettes or use vaping devices
• You have cancer that won’t be cured by the transplant or is likely to return after the transplant
• You have dementia or Alzheimer’s disease
• You have severe disease in another organ
• You are severely obese
• It seems unlikely that you'll be able to adhere to post-transplant recommendations and care

In some cases, a contraindication may only be temporary. For example, you cannot have transplant surgery if you have an active infection, but you would become eligible again after the infection resolved.

Types of Lung Transplants

There are three types of this procedure: a single, a double, and a heart-lung transplant.

Single-Lung Transplant

In this procedure, one lung from a donor replaces one of your lungs. Single-lung transplants are commonly used for pulmonary fibrosis and other diseases where replacing just one lung will restore function.

Double-Lung (Bilateral) Transplant

A double-lung transplant involves the replacement of both lungs with two donor lungs. Research has shown that there are distinct advantages to double-lung transplants for people with cystic fibrosis. Since both lungs are diseased with CF, a single-lung procedure would leave behind one diseased lung.

However, there are no definitive guidelines for when one procedure (single vs. double) must be used over the other. In general, the decision depends on the reason for the transplant, your age, and the availability of lungs that meet your specific requirements.

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.

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

A heart-lung transplant is a complex and demanding surgery that carries a high risk of complications, some of which can be fatal. This procedure is done very rarely, as it can only be performed when a donated heart as well as donated lungs are available at the same time—and hearts for people who need only a transplanted heart are prioritized.

Donor Recipient Selection Process

Once it is determined that you are eligible for a lung transplant, you will undergo an extensive battery of tests, including:

• Pulmonary function tests (PFTs)
• Computed tomography (CT) scan of the chest
• Heart tests, such as an electrocardiogram (EKG) and an echocardiogram, as lung impairment can also affect heart health
• Chest X-ray
• Blood tests to check the function of other organs and levels of blood chemicals
• Blood type testing
• Antibody tests for donor matching

Based on your test results, you will be given a lung allocation score (LAS). Your score will be determined at each visit to your transplant center and updated if necessary.

The LAS ranges from 0 to 100, with the sickest patients usually receiving a score of 48 and above.

When an appropriate deceased donor lung becomes available, transplant candidates are matched based on three factors:

• Medical urgency
• Distance from the donor hospital: 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.
• Pediatric status

Types of Donors

The vast majority of donated lungs come from deceased donors who suffered an injury or medical problem that led to brain death. Once brain death is declared by a physician, the pre-established wishes of the donor or those of their family lead to the donation of their organs.

Blood type, body size, and other medical information are key factors in the matching process for all organs.

The ideal lung donor:

• Was 18 to 64 years old
• Was a non-smoker
• Did not have a bleeding disorder such as hemophilia
• Did not have HIV
• Was not an IV drug user or sex worker

Rarely, lungs can be donated by living donors. In this case, one lobe of a lung from two different donors is removed and transplanted. This may be an option for people who are too ill to wait for a deceased donor lung to become available.

Before Surgery

Upon arrival at the hospital, you will undergo pre-operative testing to make sure you are strong enough to undergo the surgery. This includes blood tests, an EKG, and a chest X-ray to look at your lungs.

You will be asked to sign a consent form stating that you understand the risks involved in surgery and authorize it to be done. (This is standard procedure for all surgeries.)

Just before the actual surgery, an anesthesiologist will place an intravenous (IV) line into your arm or your hand, as well as into your neck or collarbone to take blood samples. 

You will be placed on a heart-lung bypass machine to oxygenate your blood while your lungs are removed.

Surgical Process

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

For both procedures, 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 lung(s) can begin.

Surgical clamps are used to keep blood in the blood vessels while the new lung(s) is being transplanted. The new lung(s) is sewn into place and the blood vessels are reconnected.

In a heart-lung transplant, an incision is made in the chest, and the surgeon removes both the heart and lung(s). The donated heart is placed first, followed by the lung(s). The organs are reconnected to the surrounding blood vessels and the lungs are attached to the windpipe.

Once this work is done, the heart-lung bypass machine is no longer needed and you will be put on a ventilator. The incision will then be closed.

Complications

There is no underplaying the fact that a lung transplant is a major procedure that carries a significant risk of complications, including death. Risks can either be respiratory-related or non-respiratory-related, and some are in addition to common risks associated with surgery or general anesthesia.

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
• Bone loss (osteoporosis)
• Systemic hypertension
• Post-transplant diabetes
• Kidney failure
• 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)

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 you 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. You will likely need physical therapy and occupational therapy to regain your strength, as your lung disease may have led to significant weakness in the months or years before surgery.

After your lung transplant, you'll need to take immunosuppressant medications for life to prevent rejection. Your treatment team will explain your medications and potential side effects, including increased susceptibility to infections. They will help you manage your immunosuppressant medications based on how they are affecting you and any signs of rejection. You may need rehabilitation if your stay in the ICU is lengthy and results in physical weakness.

Follow-up visits to the transplant center will initially be frequent after surgery, and become less frequent as time passes. The risk of rejection is highest in the first few months after surgery.

During these visits your lung transplant team will monitor any signs of infection, rejection, or other problems. You may also be asked to measure your lung capacity daily with a home spirometer. 

It is extremely important to make sure you only enter environments that are smoke-free and free of fumes that could damage your new lung(s).

Among the medication options that may be used for people with lung transplants, the most common ones include:

• Simulect (basiliximab)
• CellCept (mycophenolate mofetil)
• Imuran (azathioprine)

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

Prognosis

The first year after a lung transplant is the most critical. This is when serious complications, such as organ rejection and infection, are most common.

While survival rates depend on many factors, such as the medical reason for your transplant, your age, and general health, the National Heart, Lung, and Blood Institute reports the following overall rates of survival:

• 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. Data from 2017 show that the median survival for single-lung recipients is 4.6 years. The median survival for double-lung recipients is 7.3 years.

Support and Coping

The journey to receiving a lung transplant takes a toll on your mental health as well as your physical health. For that reason, it is very important to have people and programs in place to offer emotional support.

Your transplant team will include a social worker who can provide information on assorted types of support services.

Participating in support groups for lung transplant patients—whether in-person or online—can be very important as you await a donor lung(s) as well as after the transplant. People who have gone through the same process know better than anyone what is involved. You can also find information on groups on the UNOS's website.

You may also want to see a mental health provider one-on-one to help you cope with anxiety and depression that is common during the transplant process. Again, your transplant team can help you get in touch with an appropriate mental health professional if necessary.

Finally, if you've had to take an extended medical leave, your team may be able to help you with services that can provide assistance with re-entering the work environment smoothly.

Diet and Nutrition

Healthy eating may be even more important after your transplant than it was before the surgery.

Healing from surgery requires a substantial amount of protein and calories. Furthermore, some of the medications you'll need to take can lead to weight gain, as well as elevated blood pressure, blood sugar, cholesterol. Levels of potassium, calcium, and other minerals will also need to be regulated.

A dietitian on your transplant team will tailor a program to help you eat the right foods as you recover and move forward. In general, you will be asked to:

• Focus on protein sources such as lean meats, fish, eggs, beans, lowfat dairy products, and nut butters. You may need more protein than normal right after your transplant to repair and rebuild muscle tissue and help you heal.
• Eat foods that are high in fiber, such as vegetables, fruits, and whole grains.
• Limit high-calorie, sugary, and fatty foods
• Limit sodium, which is found in many processed meats, snack foods, canned foods, and some sports drinks.
• Drink adequate amounts of water and other fluids each day.

Exercise

Getting regular physical activity is important after a lung transplant to maintain a healthy weight and overall good health, but you'll need to increase your activity gradually as your incision heals and you regain your strength. You may want to start with short walks, eventually building up to 30 minutes a day.

Strengthening and resistance exercises will help you regain muscle tone that you may have lost due to long periods of inactivity that follow surgery. Do not, however, lift anything over five pounds for two months after surgery.

Avoid any sports that could cause injury to your lung(s) and always stop and rest if you are tired or in any pain.

Your physical therapist can help you design an exercise plan that works for you.

A Word From Verywell

Lung transplant surgery is a complex procedure that can extend your life for years or even decades. Advances in technology and post-surgical care have led to greater success rates than ever before. While the process is stressful both physically and emotionally, the likelihood is great that you will be able to resume the activities you formerly enjoyed and experience a dramatic improvement in your quality of life.