If a lung transplant is thought to be an option for you, you'll be referred for a transplant assessment.

There are a number of specialist centres that carry out lung transplants in England.

They are:

• Freeman Hospital, Newcastle
• Harefield Hospital, London
• Papworth Hospital, Cambridge
• Queen Elizabeth Hospital, Birmingham
• Wythenshawe Hospital, Manchester

A small number of children's lung transplants are carried out at Great Ormond Street Hospital and Freeman Hospital.

Transplant assessment

You'll need to stay in hospital for up to 3 days for a lung transplant assessment.

Tests will be carried out to make sure your other major organs, such as your heart, kidneys and liver, will function properly after the transplant.

These may include blood tests and any of the following investigations:

• a chest X-ray
• an echocardiogram to check how well your heart is pumping
• an electrocardiogram (ECG), which records your heart's electrical activity
• an angiogram, a type of X-ray that can be used to check the blood flow in the blood vessels of your lungs 

During the assessment, you'll be able to meet members of the transplant team and ask questions. 

Your transplant team will include:

• surgeons
• anaesthetists
• intensive care specialists
• lung specialists
• specialists in infection
• a transplant nurse
• physiotherapists
• psychologists
• social workers
• a transplant co-ordinator

The transplant co-ordinator will be your main point of contact.

They'll talk to you and your family about what happens during a lung transplant and the risks involved.

After the assessment is complete, a decision will be made as to whether a lung transplant is suitable for you and whether it's the best option.

It may be decided that:

• you should go on the active waiting list – which means you could be called for a transplant at any time
• a transplant is suitable for you, but your condition is not severe enough – you'll be reviewed regularly and if your condition worsens, you'll be put on the active waiting list
• you need more investigations or treatment before a decision can be made
• a transplant is not suitable for you – the assessment team will explain why and offer alternatives, such as medicine or other surgery
• you need a second opinion from a different transplant centre

Why a lung transplant might be unsuitable

The supply of donor lungs is limited, which means there are more people who'd benefit from a lung transplant than there are donor lungs.

This means people who are unlikely to have a successful transplant are not usually considered suitable for transplant.

You may also be considered unsuitable if:

• you have not complied with previous advice or been reliable – for example, if you have not given up smoking, you have a poor history of taking prescribed medicine, or you have missed hospital appointments
• your other organs, such as your liver, heart or kidneys, do not function well and may fail after the stresses of the transplant operation
• your lung disease is too advanced, so it's thought you'd be too weak to survive surgery
• you have a recent history of cancer – there's a chance that the cancer could spread into the donated lungs; exceptions can be made for some types of skin cancer as these are unlikely to spread
• you have an infection that would make the transplant too dangerous
• you have psychological and social problems that may affect whether you take post-transplant treatments; such as being addicted to drugs or having a serious mental health condition
• you're significantly underweight with a body mass index (BMI) of less than 16, or very overweight (obese) with a BMI of 30 or above

Age also plays a part because of the effect it has on likely survival rates.

There are no set rules and exceptions can always be made, but as a general rule:

• people over 50 years of age would not be considered suitable for a heart-lung transplant
• people over 65 years of age would not be considered suitable for a single or double lung transplant (although those over 65 and otherwise healthy may be considered for a single lung transplant)

The waiting list

The length of time you'll have to wait will depend on your blood group, donor availability and how many other people are on the list and how urgent their cases are.

While you wait, you'll be cared for by the doctor who referred you to the transplant centre.

They'll keep the transplant team updated with changes to your condition.

Another assessment is sometimes necessary to make sure you're still suitable for a transplant.

Your transplant team will often be given short notice of donor organs, so will have to move swiftly.

When a suitable donor is found, you'll usually need to be in hospital ready for your transplant within 6 to 8 hours.

If you live a long way from a transplant centre, you'll be flown to the centre or taken by ambulance.

Getting the call

When a suitable donor lung is found, the transplant centre will contact you and ask you to go to the centre.

When you hear from the transplant centre:

• do not eat or drink anything
• take all current medicines with you
• take a bag of clothes and essentials for your stay in hospital

At the transplant centre, you'll be quickly reassessed to make sure no new medical conditions have developed.

At the same time, a second medical team will examine the donor lungs.

The lung transplant must be carried out as quickly as possible to ensure it has the best possible chance of being successful.

A lung transplant usually takes between 4 and 12 hours, depending on the complexity of the operation.

After you have had a general anaesthetic, a breathing tube will be placed down your throat so your lungs can be ventilated.

The surgeon will make a cut in your chest so your chest can be opened and preparations made to remove the diseased lung or lungs.

If assistance with your circulation is needed, a cardiopulmonary bypass machine may be used to keep your blood circulating during the operation.

The old lung will be removed and the new lung sewn into place.

When the transplant team is confident the new lung is working efficiently, your chest will be closed and you'll be taken off the bypass machine.

Tubes will be left in your chest for several days to drain any build-up of blood and fluid.

You'll be taken to the intensive care unit, where more tubes will be attached to supply your body with medicine and fluids and to drain pee from your bladder.

New surgical techniques

There are 2 new surgical techniques that will hopefully increase the number of donor lungs available for donation.

Transplant after a non-heart beating donation

Most donations are from people who have died but whose heart is kept beating using life support equipment.

These are often people who have died after a long illness.

It's now also possible for lungs to be taken from a person who's died suddenly and keep their lungs "alive" for around an hour by passing oxygen into them.

The oxygen keeps the biological processes of the lungs going, which preserves them.

Ex vivo lung perfusion

Lungs can be damaged when the brain dies, before they're removed for donation.

Because of this, only 1 in 5 lungs are suitable for donation.

Ex vivo lung perfusion is a new technique designed to overcome this problem. 

It involves removing the lungs from the body and placing them in a piece of equipment called a perfusion rig.

Blood, protein and nutrients are then pumped into the lungs, which repairs the damage.

The technique is still in its infancy, but hopefully it'll eventually lead to an increase in the number of lungs available for donation.

A lung transplant is a complex operation and the risk of complications is high.

Some complications are related to the operation itself. Others are a result of the immunosuppressive medicine, which is needed to prevent your body rejecting the new lungs.

Reimplantation response

Reimplantation response is a common complication affecting almost all people with a lung transplant.

The effects of surgery and the interruption to the blood supply cause the lungs to fill with fluid.

Symptoms include:

• coughing up blood
• shortness of breath
• difficulties breathing while lying down

The symptoms are usually at their worst 5 days after the transplant.

These problems will gradually improve, and most people are free of symptoms by 10 days after their transplant.

Rejection

Rejection is a normal reaction of the body. When a new organ is transplanted, your body's immune system treats it as a threat and produces antibodies against it, which can stop it working properly. 

Most people experience rejection, usually during the first 3 months after the transplant.

Shortness of breath, extreme tiredness (fatigue) and a dry cough are all symptoms of rejection, although mild cases may not always cause symptoms.

Acute rejection usually responds well to treatment with steroid medicine.

Bronchiolitis obliterans syndrome

Bronchiolitis obliterans syndrome (BOS) is another form of rejection that typically occurs in the first year after the transplant, but could occur up to a decade later.

In BOS, the immune system causes the airways inside the lungs to become inflamed, which blocks the flow of oxygen through the lungs.

Symptoms include:

• shortness of breath
• a dry cough
• wheezing

BOS may be treated with additional immunosuppressant medicine.

Post-transplantation lymphoproliferative disorder

After having a lung transplant, your risk of developing a lymphoma (usually a non-Hodgkin lymphoma) is increased. Lymphoma is a type of cancer that affects white blood cells.

This is known as post-transplantation lymphoproliferative disorder (PTLD).

PTLD occurs when a viral infection (usually the Epstein-Barr virus) develops as a result of the immunosuppressants that are used to stop your body rejecting the new organ.

PTLD affects around 1 in 20 people who have a lung transplant. Most cases occur within the first year of the transplant.

It can usually be treated by reducing or withdrawing immunosuppressant therapy.

Lymphoma Action has more information about lymphoma.

Infection

The risk of infection for people who have received a lung transplant is higher than average for a number of reasons, including:

• immunosuppressants weaken the immune system, which means an infection is more likely to take hold and a minor infection is more likely to progress to a major infection
• people often have an impaired cough reflex after a transplant, which means they're unable to clear mucus from their lungs, providing an ideal environment for infection
• surgery can damage the lymphatic system, which usually protects against infection
• people may be resistant to 1 or more antibiotics as a result of their condition, particularly those with cystic fibrosis

Common infections after a transplant include:

• bacterial or viral pneumonia
• cytomegalovirus (CMV) 
• aspergillosis, a type of fungal infection caused by spores

Long-term use of immunosuppressants

Taking immunosuppressant medicine is necessary following any type of transplant, although they do increase your risk of developing other health conditions.

Kidney disease

Kidney disease is a common long-term complication.

It's estimated 1 in 4 people who receive a lung transplant will develop some degree of kidney disease a year after the transplant.

About 1 in 14 people will experience kidney failure within a year of their transplant, rising to 1 in 10 after 5 years.

Diabetes

Diabetes, specifically type 2 diabetes, develops in around 1 in 4 people a year after the transplant.

Diabetes is treated using a combination of:

• lifestyle changes, such as taking regular exercise
• medicine, such as metformin or injections of insulin

High blood pressure

High blood pressure develops in around half of all people a year after a lung transplant and in 8 out of 10 people after 5 years.

High blood pressure can develop as a side effect of immunosuppressants or as a complication of kidney disease.

Like diabetes, high blood pressure is treated using a combination of lifestyle changes and medicine.

Osteoporosis

Osteoporosis (weakening of the bones) usually arises as a side effect of immunosuppressant use.

Treatment options for osteoporosis include vitamin D supplements (which help strengthen bones) and a type of medicine known as bisphosphonates, which help maintain bone density.

Cancers

People who have received a lung transplant have an increased risk of developing cancer at a later date.

This would usually be 1 of the following:

• skin cancer 
• lung cancer 
• liver cancer 
• kidney cancer 
• non-Hodgkin lymphoma, a cancer of the lymphatic system

Because of this increased risk, regular check-ups for these sorts of cancers may be recommended.

After lung transplant surgery, you'll remain in the intensive care unit for around 1 to 7 days.

You may have an epidural (a type of local anaesthetic) for pain relief and will be connected to a ventilator to help your breathing.

You'll be carefully monitored so the transplant team can check your body is accepting the new organ.

Monitoring will include having regular lung X-rays and lung biopsies, where tissue samples are taken for closer examination.

The transplant team will be able to see whether your body is rejecting the lung from the biopsy results.

If it is, you'll be given additional treatment to reverse the process.

When your condition is stable, you'll be moved to a high dependency ward, where you'll stay for 1 or 2 weeks.

Follow-up appointments

You'll probably be discharged from hospital 2 to 3 weeks after surgery and asked to stay near the transplant centre for a month so you can have regular check-ups.

For the second month, you'll need to visit weekly for 4 weeks.

After that, for the rest of your life you'll have a blood test every 6 weeks and will be seen at the transplant centre every 3 months.

The recovery process

It usually takes at least 3 to 6 months to fully recover from transplant surgery.

For the first 6 weeks after surgery, avoid pushing, pulling or lifting anything heavy.

You'll be encouraged to take part in a rehabilitation programme involving exercises to build up your strength.

You should be able to drive again 4 to 6 weeks after your transplant, once your chest wound has healed and you feel well enough.

Depending on the type of job you do, you'll be able to return to work around 3 months after surgery.

Immunosuppressant therapy

You'll need to take immunosuppressant medicines, which weaken your immune system so your body does not try to reject the new organ.

There are usually 2 stages in immunosuppressant therapy:

• induction therapy – where you're given a combination of high-dose immunosuppressants immediately after the transplant to weaken your immune system; you may also be given antibiotics and antivirals to prevent infection
• maintenance therapy – where you're given a combination of immunosuppressants at a lower dose to "maintain" your weakened immune system

You'll need to have maintenance therapy for the rest of your life.

Most transplant centres use the following combination of immunosuppressants:

• tacrolimus 
• mycophenolate mofetil
• corticosteroids 

The downside of taking immunosuppressants is that they can cause a wide range of side effects, including:

• mood changes, such as depression or anxiety
• insomnia
• diarrhoea 
• swollen gums
• bruising or bleeding more easily
• convulsions
• dizziness
• headache 
• acne 
• extra hair growth (hirsutism)
• weight gain

Your doctor will try to find an immunosuppressant dose that's high enough to dampen the immune system, but low enough that you experience few side effects. This may take several months to achieve.

Even if your side effects become troublesome, you should never suddenly stop taking your medicine as your lungs could be rejected.

Long-term use of immunosuppressants also increases your risk of developing other health conditions, such as kidney disease.

Find out more about the risks associated with long-term immunosuppressants use

Preventing infection

Having a weakened immune system is known as being immunocompromised.

If you're immunocompromised, you'll need to take extra precautions against infection.

You should:

• practise good personal hygiene – take daily baths or showers and make sure that clothes, towels and bed linen are washed regularly
• avoid contact with people with infections that could seriously affect you, such as chickenpox or flu
• wash your hands regularly with soap and hot water, particularly after going to the toilet and before preparing food and eating meals
• take extra care not to cut or graze your skin – if you do, clean the area thoroughly with warm water, dry it and cover it with a sterile dressing
• keep up to date with regular immunisations – your transplant centre will supply you with all the relevant details

You should also look out for any initial signs that may indicate you have an infection. A minor infection could quickly turn into a major one.

Tell a GP or your transplant centre immediately if you have symptoms of an infection, such as:

• a high temperature
• a headache
• aching muscles