Lung Transplantation: When Every Breath Counts

By Asst Prof Chua Yang Chong, Senior Consultant, Cardiothoracic Surgery

For people living with severe and irreversible lung disease, every breath is a struggle. Breathlessness is one of the most difficult symptoms to relieve. Even with the best that modern medicine can offer, many patients describe the feeling as slowly drowning. For some, lung transplantation becomes the last resort, offering not just the chance to breathe normally again, but to truly live.

Who is lung transplantation for?

The procedure is most commonly performed for patients with interstitial lung disease, a group of conditions that cause progressive scarring of the lung tissue, and chronic obstructive pulmonary disease, a condition that causes airflow obstruction and breathing difficulties. Patients with severe and irreversible lung infections may also be considered.

In some cases, the lungs themselves may not be directly damaged. Patients with primary pulmonary hypertension, for instance, have structurally intact lungs, but abnormally narrowed blood vessels within them cause dangerously high pressure. This places such severe and progressive strain on the heart that a lung transplant becomes the only remaining solution.

Many patients referred for lung transplantation will have been living with chronic lung conditions for years, under the long-term care of a lung specialist. Medical treatment can at best slow the progression of these diseases but cannot completely cure or reverse their course. If a patient's condition is worsening or their symptoms are becoming increasingly difficult to manage, they may be referred to the lung transplant programme. By this point, the patients will have been struggling significantly with daily life and may have fewer than two years to live.

A lung transplant is not a decision to be taken lightly. While transplantation can be life-changing, it remains one of the most complex of all organ transplants, with long-term outcomes that are more uncertain than other procedures and survival at five years ranging from 50 to 70%. It is therefore only considered when all other treatment options have been exhausted, particularly for younger patients.

Before a patient can be listed for transplant, a thorough assessment is carried out to rule out major cardiac problems, other organ failures, and undetected cancers. Lung transplantation is a long journey that requires commitment and perseverance from both the patient and their caregivers. Patients must also be prepared to manage an intensive post-operative medication regimen.

What does a lung transplantation involve?

A lung transplant is one of the most complex operations in cardiothoracic surgery, requiring a highly specialised team with expertise across both cardiac and thoracic disciplines. Every stage, from assessing and retrieving the donor lungs to implanting them in the recipient, demands exceptional precision.

Of all transplantable organs, donor lungs are among the most fragile. Unlike the heart or kidneys, lungs are highly susceptible to infection and injury, particularly in donors who have been on a breathing machine for an extended period. Even factors such as cardiac events, kidney injury, or imbalances in fluid management can cause the lungs to become congested and waterlogged, making them unsuitable for transplant.

For the implant surgery, many patients with chronic lung conditions may have had previous surgeries, and the removal of their lungs must be carried out carefully to avoid excessive bleeding or air leaks. Lung transplant surgery is typically performed with the support of a machine that temporarily supports the pumping and oxygenation of blood, a technique known as veno-arterial extracorporeal membrane oxygenation.

Life after transplant

After a lung transplant, recovery varies from patient to patient. Some are taken off ventilation quickly and adjust well, while others may require a longer hospital stay. The right side of the heart has a close relationship with the lungs, and in the immediate post-operative period, this delicate relationship can occasionally result in irregular heart rhythms and challenges with fluid management. Because lungs are continuously exposed to inhaled particles, they are particularly susceptible to early rejection, and patients require some of the highest levels of immunosuppressant medication among all organ transplant recipients. The rapid rise in drug levels can sometimes lead to acute kidney injury. In some patients, the body has spent years compensating for damaged lungs, and even after receiving healthy new lungs, it takes time to readjust and relearn how to breathe normally. Once well enough to leave hospital, recovery continues with physiotherapy, nutrition support, and rehabilitation.

Throughout the journey, patients are supported by a dedicated multidisciplinary team including physicians, coordinators, dietitians, physiotherapists, medical social workers, and pharmacists, working alongside the patients' own carers. For most patients, the transformation after surgery is profound. Most are able to breathe without supplemental oxygen at home, and as recovery progresses, life gradually returns to normal. Many go on to take up activities that were once unimaginable, such as mountain climbing or swimming. Above all, what matters most to patients is the ability to breathe normally again, free from that constant feeling of drowning.

The team at an implantation surgery, November 2025.

Lung Transplants Are Uniquely Challenging

Connecting a new set of lungs to the body is a feat of surgical precision. The airway connection, known as the bronchus, relies on a network of tiny surrounding vessels for its blood supply rather than a single artery, and none of which can be reattached in the recipient. As a firm, rigid structure, it also leaves little room to accommodate size differences between donor and recipient. Once the airway is secured, the surgeon moves on to the more delicate connections to the major blood vessels, where even the slightest twist or kink could disrupt blood flow or trigger internal blood clotting.