There are currently two surgical therapies aimed at crippling, end-stage emphysema: lung transplantation and lung volume reduction surgery (LVRS). Unfortunately, most emphysema patients are poor candidates for any surgical intervention. The authors favor a meticulous selection process in which indications and contraindications are considered and the best solution is devised for each patient. Patients with ideal circumstances for LVRS--hyperinflation, heterogeneous distribution of disease, FEV1 of more than 20%, and normal PCO2--are offered LVRS. Patients with diffuse disease, low FEV1, hypercapnia, and associated pulmonary hypertension are directed toward transplantation. LVRS has not been a satisfactory option for patients with a1-antitrypsin deficiency, and we prefer a transplant in most of these patients. With these considerations, we find that few patients are serious candidates for both procedures. Combinations of lung volume reduction and lung transplantation, simultaneously or sequentially, are possible but rarely necessary.