Lung transplantation has undergone remarkable changes in clinical practice to address the higher rate of rejection and mortality. Our protocols include increased immunosuppression and strategies to address non-alloimmune injury, including GER. New and innovative approaches to lung transplantation are still needed to improve short- and long-term outcomes. The LAS implementation has had a strong influence on the type of native disease transplanted at our center as well as our waiting list time. However, the LAS was not predictive of survival posttransplant at one year. Further refinements of the LAS and protocols may improve survival posttransplant.