The Critically Ill Lung Transplant Candidate: How Sick is too Sick?

Abstract Purpose of Review This review examines contemporary expansion of lung transplant candidacy in critically ill patients, moving from strict exclusion criteria towards an individualized approach based on institutional experience. We aimed to evaluate how advances in bridging therapies, perioperative care, and ethical frameworks have reshaped candidate selection. Recent Findings Shifts in candidate selection practices have improved transplant access for older, sicker, and acutely decompensating individuals. This has enabled transplantation in carefully selected patients with malignancies, difficult to treat infections, and connective tissue disease associated Interstitial Lung Disease. Extracorporeal Life Support (ECLS) should not be thought of as an add-on therapy, but as a timely, planned intervention in those with acutely and rapidly progressive lung disease. Despite granting time for in-depth evaluation and prehabilitation, it also opens the door for new ethical dilemmas. Summary Modern candidacy evaluation is dynamic and individualized. Expanding indications and bridging strategies broaden access to transplantation.