Lung Transplantation

Who is transplanted, and why

Lung transplantation is offered for end-stage lung disease where predicted survival without it is poor and function is severely limited. The main indications are chronic obstructive pulmonary disease (COPD) and emphysema (including alpha-1 antitrypsin deficiency), interstitial lung disease, particularly idiopathic pulmonary fibrosis (IPF), cystic fibrosis and bronchiectasis, and pulmonary arterial hypertension.¹

The proportion of transplants performed for cystic fibrosis has fallen markedly since CFTR modulator therapy became widely available, while transplantation for fibrotic disease has grown. Frailty and deconditioning are increasingly recognised as modifiable determinants of listing and outcome, which places physiotherapy directly in the selection pathway.¹

Bilateral transplantation is now the dominant procedure, usually via a clamshell incision or bilateral anterior thoracotomies. Single lung transplantation is still used selectively, most often in fibrotic disease. Heart–lung transplantation is now rare, reserved largely for Eisenmenger physiology and complex congenital disease.

The denervated lung — the fact that changes everything

Alongside denervation, several other mechanisms impair clearance simultaneously:

• Impaired mucociliary transport in the donor lung, worst in the early post-operative period.
• Disrupted lymphatic drainage, contributing to early graft oedema.
• Anastomotic complications — stenosis or malacia — which produce a barking cough, monophonic wheeze and clearance difficulty, and are treated bronchoscopically rather than by physiotherapy.
• Pain and chest wall disruption from the incision.
• Immunosuppression, which removes much of the margin for a chest infection.

In single lung transplantation the two lungs behave completely differently. In emphysema the native lung remains hyperinflated and compliant and can compress the graft; in fibrosis the native lung remains stiff. Positioning and ventilation strategies must account for which lung is which.

Rejection and chronic allograft dysfunction

Acute cellular rejection is common in the first year and may present with breathlessness, cough, a fall in spirometry or nothing at all. Chronic lung allograft dysfunction (CLAD) is the main limitation on long-term survival, and is defined by a persistent fall in FEV₁ of 20% or more from the established post-transplant baseline, subdivided into obstructive (bronchiolitis obliterans syndrome) and restrictive phenotypes.²

This has a direct practical consequence: home spirometry is a surveillance tool, not a physiotherapy outcome measure. A sustained drop that the patient reports to you should be escalated to the transplant service the same day, not attributed to deconditioning or a chest infection.

Why exercise capacity stays limited

Recipients often achieve near-normal spirometry and yet peak oxygen uptake typically remains around 40–60% of predicted. The limitation is peripheral, not ventilatory:

• Pre-transplant deconditioning and muscle wasting, often over years.
• Corticosteroid myopathy, affecting proximal muscle preferentially.
• Calcineurin inhibitor effects on skeletal muscle mitochondrial function.
• Reduced muscle oxidative capacity that does not resolve spontaneously with restored ventilation.
• Renal impairment, anaemia, osteoporosis and diabetes from long-term immunosuppression.

Because the limitation is muscular, the treatment is training — and specifically resistance training alongside aerobic work. Ventilatory reserve is usually ample, so patients can and should be pushed harder than their history suggests.

Rehabilitation before and after

Before

Pulmonary rehabilitation in transplant candidates improves exercise capacity and quality of life, and pre-transplant functional status predicts post-transplant outcome.^3,4 Programmes must be flexible — candidates deteriorate, are frequently admitted, and may be on oxygen or non-invasive ventilation. Training with high-flow oxygen, interval formats and continuous monitoring are all routine. Maintaining muscle mass through the waiting period is the central goal.

After

A randomised trial of structured exercise training after lung transplantation demonstrated improved daily physical activity and reduced blood pressure at one year, and structured rehabilitation is now standard of care.⁵ Practical priorities:

• Scheduled airway clearance early, independent of symptoms, taught explicitly as a daily habit.
• Early mobilisation, including from ventilated intensive care where required.
• Progressive resistance training targeting proximal muscle, which is where steroid myopathy bites.
• Bone health — osteoporosis is near-universal and vertebral fracture is common.
• Infection precautions, including advice on gardening, potting mix and soil exposure given the risk from environmental organisms. See Legionnaires' Disease and Non-Tuberculous Mycobacteria.
• Long-term follow-up, since gains are frequently lost once formal programmes end.

Role of the physiotherapist

Before listing, maintain and document function — it influences candidacy and outcome. After transplant, teach clearance as a scheduled discipline rather than a response to symptoms, train hard against a peripheral limitation, monitor for the spirometric fall that signals rejection or CLAD, and escalate rather than manage it. Work within the transplant service's protocols; these patients are managed centrally and local improvisation is rarely welcome.

Related: Cystic Fibrosis, Idiopathic Pulmonary Fibrosis, Pulmonary Hypertension.

References & evidence base

1. Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: an update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021;40(11):1349–1379.
2. Verleden GM, Glanville AR, Lease ED, et al. Chronic lung allograft dysfunction: definition, diagnostic criteria, and approaches to treatment. J Heart Lung Transplant 2019;38(5):493–503.
3. Wickerson L, Rozenberg D, Janaudis-Ferreira T, et al. Physical rehabilitation for lung transplant candidates and recipients: an evidence-informed clinical approach. World J Transplant 2016;6(3):517–531.
4. Hoffman M, Chaves G, Ribeiro-Samora GA, Britto RR, Parreira VF. Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review. BMJ Open 2017;7(2):e013445.
5. Langer D, Burtin C, Schepers L, et al. Exercise training after lung transplantation improves participation in daily activity: a randomized controlled trial. Am J Transplant 2012;12(6):1584–1592.

References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.