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Bronchiolitis obliterans syndrome (BOS) is a major complication of lung transplantation that is associated with poor survival. The International Society for Heart and Lung Transplantation, American Thoracic Society, and European Respiratory Society convened a committee of international experts to describe and/or provide recommendations for 1) the definition of BOS, 2) the risk factors for developing BOS, 3) the diagnosis of BOS, and 4) the management and prevention of BOS.A pragmatic evidence synthesis was performed to identify all unique citations related to BOS published from 1980 through to March, 2013. The expert committee discussed the available research evidence upon which the updated definition of BOS, identified risk factors and recommendations are based. The committee followed the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach to develop specific clinical recommendations.The term BOS should be used to describe a delayed allograft dysfunction with persistent decline in forced expiratory volume in 1 s that is not caused by other known and potentially reversible causes of posttransplant loss of lung function. The committee formulated specific recommendations about the use of systemic corticosteroids, cyclosporine, tacrolimus, azithromycin and about re-transplantation in patients with suspected and confirmed BOS.The diagnosis of BOS requires the careful exclusion of other post-transplant complications that can cause delayed lung allograft dysfunction, and several risk factors have been identified that have a significant association with the onset of BOS. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Adequately designed and executed randomised controlled trials that properly measure and report all patient-important outcomes are needed to identify optimal therapies for established BOS and effective strategies for its prevention. Executive summaryMany lung transplant recipients develop delayed allograft dysfunction that has been traditionally referred to as bronchiolitis obliterans syndrome (BOS), which is thought to be caused by inflammation, destruction and fibrosis of small airways in the lung allograft that leads to obliterative bronchiolitis (OB). Because a definitive diagnosis of OB is difficult to make without a surgical lung biopsy, a decrease in the forced expiratory volume in 1 s (FEV1) has been used as a surrogate marker to identify patients who develop a syndrome of significant and persistent loss of lung allograft function with onset three or more months following transplantation. However, it is now recognised that numerous factors apart from OB can lead to a delayed onset, significant decline in lung function, and these causes of delayed onset graft dysfunction must be carefully excluded when a diagnosis of BOS is made. In general, BOS responds poorly to therapeutic interventions but may stabilise, and some patients may have a significant improvement in FEV1 with certain ther...