lung transplantation in COPD patients according to
the most recent guidelines from ISHLT.98
It is recognized that FEV1 alone is a poor marker
of severity of lung disease or need for lung transplantation, as it does not reflect the complete lung
functional pathology nor does it reflect the systemic
involvement from COPD. 1,99 Based on studies that
suggest BODE (body weight, airway obstruction,
degree of dyspnea, and exercise tolerance) is a
reasonable estimator of the systemic involvement
in COPD, 1 guidelines recommend the use of BODE
index rather than FEV1 alone when making listing
decisions. A BODE index greater than 7 is associated with a mortality rate greater than 80% at 52
months (less than the expected mortality rate from
lung transplantation), and a BODE index of less
than 7 is associated with a survival rate of more
than 50% at 5 years (more than the expected survival rate from lung transplantation). 1
When patients are candidates for both LVRS and
lung transplantation, the decision is complicated,
with no consensus guidelines at present. LVRS is
not considered a bridge to transplantation, nor is
lung transplantation a rescue procedure for failed
LVRS. In making this decision, the quality of life and
life expectancy for each procedure alone and for
LVRS followed by transplantation should be taken
into consideration. A recent study by Nathan et al
did not show significant differences in the mortality
rate at 1 month, post-transplant hospital stay, and 12-
month survival rate between transplant patients with
and without prior LVRS,100 suggesting that LVRS is
not a contraindication for future lung transplantation.
In conclusion, the care of patients with COPD
requires a multidisciplinary approach that involves
not only pharmacologic therapies but also meticu-
lous attention to the physical, social, and psycho-
logical well-being of the individual. An individual-
ized prescription of nonpharmacologic therapies is
necessary to address the systemic disease that is
COPD. More research is needed in identifying the
individual elements of such therapies that would
garner the most success in reducing the health
and economic burdens of COPD.
1. Celli BR, Cote CG, Marin JM, et al. The body-mass index,
airflow obstruction, dyspnea, and exercise capacity index
in chronic obstructive pulmonary disease. N Engl J Med
2. National Heart, Lung, and Blood Institute. Direct and indirect
economic costs of illness by major diagnosis, U.S., 2009.
Accessed November 27, 2013.
BOARD REVIEW QUESTIONS
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Table 4. Disease-Specific Timing for Lung Transplantation in Patients with COPD
BODE index 7–10 or at least 1 of the following:
History of hospitalization for exacerbation associated with acute
hypercapnia (PCO2 > 50 mm Hg)
Pulmonary hypertension or cor pulmonale, or both, despite LTOT
BODE = body mass index, airflow obstruction, dyspnea, and exercise
capacity; DLCO = diffusion capacity of carbon monoxide; FEV1 = forced
expiratory volume in 1 second; LTOT = long-term oxygen therapy.
Adapted with permission from Orens JB, Estenne M, Arcasoy S, et al:
International guidelines for the selection of lung transplant candidates:
2006 update—a consensus report from the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. J
Heart Lung Transplant 2006;25:745–55.