There has been considerable evolution in the pre-, peri- and postoperative management of patients with severe lung disease undergoing LTx. Compared with where we started at the Alfred Hospital in 1990, in 2008 we now recognize that the majority of donor lungs that are offered for LTx (including DCD lungs) are useable, patients with a wide range of ages and disease processes are suitable to be considered for LTx and modern surgical, anesthetic and ICU management should result in a 90% one-year survival rate. It is likely that the procedural mix in LTX servicing will remain little changed in the years to come, with BLTx being the pre-eminent service modality for the majority of end-stage lung disease patients. SLTx will remain a viable procedure almost exclusively for the IPF recipient, with HLTx a necessity for the congenital heart disease patient, for whom all other medical and surgical options have been exhausted. Notwithstanding theseconsiderable achievements, including the factthat one-third of patients now survive more than10 years, it is also apparent that BOS and recurrent infections remain a problem limiting the overall success of LTx. Understanding more about the interactions between the immunosuppressive regimen, infective agents (particularly viruses) and the recipients responses to all of the abovehold the keys to improving these late outcomes.