Getting on the lung transplant list is a multi-step process that typically takes several weeks to a few months, starting with a referral from your pulmonologist and ending with a formal listing decision made by a transplant center’s review board. The process involves medical testing, psychosocial evaluation, and insurance verification, all designed to determine whether a transplant is both necessary and likely to succeed for you.
Who Qualifies for a Lung Transplant
Lung transplants are reserved for people with advanced lung disease who are getting worse despite the best available treatments. The conditions that most commonly lead to transplant fall into four broad categories: obstructive diseases like COPD and alpha-1 antitrypsin deficiency, pulmonary vascular diseases like pulmonary arterial hypertension, infectious lung diseases like cystic fibrosis, and restrictive lung diseases like idiopathic pulmonary fibrosis (IPF).
Each disease has its own triggers for when a transplant referral makes sense. For COPD, that’s typically when lung function drops below 25% of what’s predicted for your age and size, or when blood oxygen levels stay persistently low despite treatment. For cystic fibrosis, referral is common when lung function falls below 30%, when exacerbations become more frequent, or when antibiotic resistance limits treatment options. For pulmonary fibrosis, any need for supplemental oxygen or a lung capacity below 40% of predicted can prompt a referral. Pulmonary hypertension patients are generally referred when symptoms are severe and worsening despite escalating therapy.
The common thread across all these conditions: your disease is progressing, standard treatments aren’t controlling it, and without a transplant your outlook is poor.
What Would Disqualify You
Transplant centers screen for factors that would make surgery too risky or reduce the chances of a good outcome. At Johns Hopkins, for example, the absolute age cutoffs are 65 for a single or double lung transplant (with evaluation needing to start before your 63rd birthday) and 55 for a combined heart-lung transplant. Active smoking is a hard disqualification: you need at least six months of confirmed abstinence.
A BMI over 30 is considered a relative contraindication, meaning it doesn’t automatically rule you out but the team will weigh it heavily. Other factors that can complicate or prevent listing include active cancer, uncontrolled infections, significant dysfunction in other major organs, active substance use disorders, and an inability to comply with the demanding post-transplant medication and follow-up schedule. “Relative” contraindications are evaluated case by case, so a borderline issue at one center might be handled differently at another.
Step 1: Referral and Initial Screening
The process starts when your pulmonologist refers you to a lung transplant center. The transplant team’s pre-transplant coordinator will conduct a brief phone interview to gather basic information. The center then contacts your referring physician to collect your medical records, including pulmonary function tests, lab work, chest CT scans, and lung biopsy results if available.
At your first transplant clinic visit, a transplant pulmonologist performs a screening exam and reviews your test results. If you appear to be a reasonable candidate based on that initial look, you move into the full evaluation. Some patients who are hospitalized with rapidly declining health may undergo an accelerated inpatient evaluation instead.
Step 2: The Full Evaluation
The formal evaluation is thorough. It typically includes a chest CT to rule out active infection or developing cancer, an echocardiogram to assess heart function, an electrocardiogram, an abdominal ultrasound to check liver health, and tuberculosis screening. Depending on your underlying disease, additional specialized tests may be required. Patients with cystic fibrosis, for instance, need detailed cultures to map their infection history, while those with autoimmune conditions need specific antibody testing.
Beyond the medical workup, the evaluation also covers your mental health, social support system, and financial readiness. Transplant centers want to know that you have a reliable caregiver who can support you during recovery, that you understand and can commit to the lifelong medication regimen, and that you have a realistic plan for covering costs. A social worker or financial coordinator will walk through your insurance coverage to identify any limitations or requirements specific to transplant. If you have private insurance, it’s worth contacting your insurer directly to ask about transplant-specific coverage, out-of-pocket caps, and any network restrictions on which centers you can use.
The full evaluation can take anywhere from a few days (for urgent inpatient cases) to several weeks for outpatient testing, depending on how quickly appointments can be scheduled and whether any additional workup is needed.
Step 3: The Review Board Decision
Once all testing is complete, your case goes before a multidisciplinary review board, typically during the week after your evaluation wraps up. This panel includes transplant surgeons, pulmonologists, coordinators, social workers, and other specialists. They review everything and arrive at one of three decisions: you’re approved for listing, you’re not a candidate, or you need further assessment or specific interventions before a final call can be made.
If the board identifies a correctable issue, like needing to lose weight, complete a pulmonary rehabilitation program, or address a dental infection, you’ll be given a plan and timeline. Once those conditions are met, the board revisits your case.
How You’re Prioritized on the List
Being listed doesn’t mean joining a first-come, first-served line. Since March 2023, lung allocation in the United States uses a composite allocation score (CAS) that’s calculated individually for each donor organ that becomes available. Your score combines several weighted factors: how urgently you need the transplant, how likely you are to do well after surgery, whether biological factors like blood type or body size make you harder to match, whether you’re under 18, whether you’ve previously been a living organ donor, and how practical it is to transport the lungs from the donor hospital to yours.
The score extends to decimal points, so ties are rare. When they do occur, the person who has waited longer gets priority. This system replaced the older Lung Allocation Score (LAS), which used a simpler 0-to-100 scale, though many centers still reference LAS terminology in conversation.
How Long the Wait Typically Lasts
The median wait time across all diagnoses is about 2.3 months, but that number varies dramatically depending on your condition and urgency. Patients with restrictive lung diseases like pulmonary fibrosis tend to wait the shortest time, with a median of 1.7 months, because their disease often progresses rapidly and their urgency scores reflect that. Cystic fibrosis patients wait a median of 2.1 months, COPD patients about 4 months, and pulmonary hypertension patients the longest at 6.2 months.
Urgency scores make a big difference. Under the older LAS system, patients scoring 50 or above waited a median of just 0.7 months, while those below 35 waited 4.4 months. The new composite system follows similar patterns: sicker patients with fewer alternatives get organs faster.
Choosing a Transplant Center
Not all transplant centers have the same volume, expertise, or outcomes. The Scientific Registry of Transplant Recipients (SRTR) maintains a public database at srtr.org where you can search and compare lung transplant programs by location. The site provides program-specific reports with outcome data, and a newer patient-friendly version of the site is in development to make this information easier to navigate. You can search by organ type and zip code, and results are organized into performance tiers so you can quickly see how a center compares to the national average.
If you live far from a high-performing center, it’s still worth exploring. Some patients relocate temporarily for the transplant period, and some centers offer virtual initial consultations. Being listed at a center with higher volume generally means more surgical experience and, in many cases, access to more donor organs because of geographic proximity to larger donor pools. You can be evaluated at more than one center, though each will run its own evaluation process.