Which patients should receive lung transplants?

Lung transplantation is a therapeutic option for selected patients with end-stage respiratory failure from a variety of pulmonary vascular and parenchymal lung diseases. Early problems due to ischaemic dehiscence of the bronchial anastomosis were avoided with heart-lung transplantation where the coronary bronchial collateral circulation remains intact. With the increase in number of cardiac transplantation, the number of heart-lung blocks available for heart-lung transplantation are declining significantly. Improved techniques now make double lung, bilateral single lung and single lung transplantations suitable alternatives to heart-lung transplantations for many patients, with good anastomotic healing and encouraging results. Patients should only be accepted onto the transplant waiting list if they have deteriorating chronic respiratory failure with a severely impaired quality of life. All patients require a detailed pre-transplant medical and psychosocial assessment. While the absolute contraindications to transplantation include pre-existing malignant disease, active aspergillus or mycobacterial infection, infection with HIV or hepatitis B and noncompliance with treatment, new haemostatic techniques have made it possible to treat many patients who have had previous thoracic surgery. Advances in immunosuppressive agents and post-operative medical care have led to improved survival and quality of life. However, obliterative bronchiolitis remains a serious problem. Demand will always be in excess of available human organs. It is hoped that the development of successful xenografting will enable more patients to benefit from lung transplantation.