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Lung Transplantation in COPD: Is it a Panacea?

Posted on 11/01/09

by Frank L. Urbano, MD, FACP

A 57-year-old male with severe COPD presents for follow-up.  He was recently hospitalized with an exacerbation of COPD, requiring the use of intravenous steroids.  At that time, the hospitalist caring for him asked him if he had ever been approached about getting a lung transplant, to which he replied no.

At this office visit, he reports compliance with his medical therapy, which includes nebulized albuterol, inhaled tiotropium, and inhaled salmeterol-fluticasone.  He wears oxygen around the clock.

The patient appears cachectic and is mild respiratory distress.  He is wearing portable oxygen and walks very slowly. Blood pressure is 120/65; pulse is 72; respiratory rate is 28 and shallow.  Oximetry in the office is measured at 91% on 3 liters oxygen.

General physical examination reveals a cachectic white male in mild respiratory distress.  HEENT examination is within normal limits.  Neck is supple without JVD or LAD.  Lungs reveals markedly decreased breath sounds bilaterally.  Cardiac examination reveals distant heart sounds with no audible murmur.  Abdomen is scaphoid without masses or organomegaly.  Extremity examination reveals diminished distal pulses bilaterally.  Neurological examination reveals no focal deficits.

The patient's FEV1 is 40% of predicted.  He scores 3 on MRC dyspnea scale, and when he is subjected to a 6 minute walk test, he is able to walk only 100 meters.  His body mass index is measured as 19.

Is this patient a candidate for a lung transplant?


COPD makes up the primary indication for the use of lung transplantation, involving more than 1/3 of all such procedures worldwide.  Lung transplantation has shown benefits in a number of different domains, including:

1. Long-term survival --> 1, 3 and 5 year survival is 81.5%, 64.0% and 49.0% in patients who underwent lung transplant for COPD

2. A dramatic improvement in pulmonary function and gas exchange, which reaches a maximum 6-9 months after transplantation

3. Improved respiratory muscle function in some patients

4. Increased exercise capacity

5. Improvement in multiple dimensions of quality of life, including physical functioning, social functioning, mental health, and health perception

Selection criteria are relatively straightforward, and employ the use of the BODE Index, which is a composite score that includes body mass index; FEV1 % of predicted; MMRC dyspnea scale score; and 6-minute walk test score.  Based upon this scale, those patients with COPD who have a BODE Index of 7-10 should be referred for lung transplantation.  Additional criteria include:

1. History of hospitalization for COPD exacerbation associated with acute hypercapnia

2. Pulmonary hypertension or cor pulmonale despite oxygen therapy

3. FEV1 of < 20% predicted and either DLCO < 20% predicted or homogenous distribution of emphysema

Clinical Follow-Up

Based upon the discussion above, the patient is a candidate for lung transplantation and should be referred for this.  While his condition is serious, the evidence suggests that he may benefit greatly with improvements in the parameters discussed above.


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