Lung transplant:

Issues:

Allograft

Airway:

· Anastomosis -> risk of rupture if fresh

· ↓Mucociliary clearance + ↓carinal reflex -> risk of pneumonia

*Aspiration pneumonia is probably lethal*

Breathing:

· Differential mechanics -> risk barotrauma, volutrauma (if single lung)

· ↓Lymphatic drainage -> risk of APO

Underlying disease

· Pulmonary hypertension / RV failure -> risk of CVS collapse

· CF -> pancreatic insufficiency

· α₁-antitrypsin deficiency -> cirrhosis

· Sarcoidosis -> anything

Drug side effects

· Immunosuppression -> risk infection, wound breakdown

· Adrenocortical suppression -> risk Addisonian crisis

· Pancytopaenia

· Organ failure

Questions	· Severity of presenting illness? · Severity of comorbidities? · Function of transplanted lung?
Hx	· HOPC · General function: exercise tolerance, NYHA, MMRC · Transplant: uni vs bilat, function, complications · Lung disease: nature, severity, treatment · Heart disease: PHTN, RV failure, accelerated CAD · Medications: immunosuppressants, side effects
Ex	· General · Vital signs · Airway · Resp · CVS
Ix	Resp: · ABG: P/F ratio · ±CT: bronchiolitis obliterans · ±Spirometry (?) Cardiac: · ECG: ? cor pulmonale · TTE

Airway	No soiling: · Secure airway · Aseptic technique · Awake extubation No damage: · Bronchoscopy to confirm · Manometry · If single lung transplant: contralateral-sided DLT
Breathing	· Lung-protective ventilation · Restrictive fluid strategy · If single: differential ventilation vs good lung only via DLT
Circulation	· Not sure. Assume PHTN?
Drugs	· Immunosuppressants: need advice · Glucocorticoids: need advice, likely stress dosing