From the Guidelines
Lung transplantation for severe COPD is considered when patients have end-stage disease despite optimal medical therapy, with primary criteria including an FEV1 less than 20% of predicted, a BODE index greater than 7, or severe exacerbations requiring hospitalization, as supported by the most recent guidelines 1. The criteria for lung transplantation in patients with severe COPD include:
- An FEV1 less than 20% of predicted with either a BODE index greater than 7 or experiencing severe exacerbations requiring hospitalization
- Evidence of secondary pulmonary hypertension or cor pulmonale despite adequate oxygenation
- A history of hospitalization with acute hypercapnic respiratory failure with PaCO2 greater than 50 mm Hg
- Patients should be free of single major contraindications or multiple minor contraindications
- A BODE score of 7 or more is proposed as another indicator for lung transplantation, although its applicability is unclear 1 The selection criteria for lung transplantation also consider the patient's overall health, including:
- Age, typically under 65 years old, though this varies by center
- Absence of significant comorbidities that would compromise post-transplant survival
- Adequate nutritional status, with a BMI between 17 and 30
- Freedom from active infections, malignancies, or substance abuse
- Good rehabilitation potential, psychological stability, and strong social support
- Additional considerations include pulmonary hypertension, rapid decline in lung function, frequent hospitalizations, and hypercapnia 1 The most recent guidelines recommend referral for lung transplantation in COPD patients with a BODE index of 5 to 6, P CO2 greater than 50 mm Hg or 6.6 kPa, and/or Pa O2 less than 60 mm Hg or 8 kPa, and FEV1 less than 25% predicted, and listing criteria include a BODE index greater than 7, FEV1 less than 15 to 20% predicted, or other indicators of severe disease 1.
From the Research
Criteria for Lung Transplantation in Severe COPD
The criteria for lung transplantation in someone with severe Chronic Obstructive Pulmonary Disease (COPD) include:
- A forced expiratory volume in 1 second (FEV1) < 25% predicted in the absence of exacerbation, as stated in the study 2
- Hypoxia (PaO2 < 60 mm Hg/8 kPa) and/or hypercapnia (PaCO2 > 50 mm Hg/6.6 kPa) 2
- Satisfactory general clinical condition 2
- Progressing disease despite maximal medical therapy 2
Patient Selection and Special Considerations
Patient selection for lung transplantation in COPD involves:
- Assessments of functional status and multivariable indices such as the BODE index to identify patients at increased risk for mortality 3
- Consideration of single or bilateral lung transplantation, with some studies suggesting better long-term survival with bilateral lung transplant, especially in younger patients 3
- Awareness of potential complications of transplant for COPD, including native lung hyperinflation and development of lung cancer 3
Treatment Options and Referral
Treatment options for severe COPD include:
- Roflumilast, a selective phosphodiesterase 4 inhibitor, which has been shown to improve lung function and reduce exacerbations in patients with severe COPD 4, 5
- Referral to a lung transplant center should be considered in the presence of progressing disease despite maximal medical therapy, as stated in the study 2
- Lung transplantation, which has been a viable option for patients with end-stage COPD, with more than 20,000 procedures performed worldwide 2, 6