Selected patients with terminal lung disease have been managed effectively by lung transplantation. Strict selection criteria for donors and recipients, attention to technical detail, and avoidance of perioperative corticosteroids increase the likelihood of success. The underlying pulmonary disease determines the appropriate procedure. Single-lung transplantation is most appropriate for patients with pulmonary fibrosis. Patients with emphysema or septic pulmonary disease who have adequate or recoverable cardiac function can be well served by double-lung transplantation. However, such patients are still treated in some centers by combined heart-lung transplantation. Patients with right-heart failure secondary to vascular or parenchymal pulmonary disease are best managed by combined heart-lung transplantation. Donor availability, airway healing, and diagnosis of rejection remain significant problems and are the focus of experimental and clinical investigation in many centers.