Emphysema is the fifth leading cause of death in North America. It is now the most common indication for lung transplantation worldwide. Since 1986, evolution in operative techniques and improvements in organ preservation and post-operative immunosuppression have resulted in impressive long-term survival results. Significant problems remain in terms of inadequate organ supply and chronic rejection; many more candidates could be transplanted if not for these two major limitations. However, other options are now available for the surgical management of patients with end-stage emphysema. The decision making surrounding transplantation for emphysema has been radically altered by the advent of lung volume reduction surgery. This review will highlight new data that pertains to recipient and donor selection, choice of transplant procedure, either single or bilateral, and the role of lung volume reduction surgery. At the University of Toronto we generally favour bilateral lung transplantation for superior functional results and possibly enhanced long-term survival. We have been particularly interested in combining lung transplantation with synchronous lung volume reduction surgery and the rationale and results of this procedure are reviewed.