Lung Transplant (Single or Bilateral)
Patient phenotype
End-stage lung disease: COPD/emphysema, IPF, CF, pulmonary HTN, sarcoid. Often on home O₂ + steroids. Donor lung availability dictates timing. Single vs bilateral depends on diagnosis.
Procedure
Bilateral: clamshell or bilateral anterolateral thoracotomy. Single: lateral thoracotomy. CPB or ECMO support variable (always available). Pulmonary vein → bronchus → pulmonary artery anastomoses. 4-8 hours.
Anesthetic plan
GETA with double-lumen tube (or bronchial blocker) for OLV. A-line, CVC, PA catheter, TEE. CPB/ECMO support if recipient cannot tolerate OLV. Lung-protective ventilation throughout.
Setup
- ·A-line
- ·CVC + PA catheter
- ·TEE
- ·Double-lumen tube + bronchoscope
- ·ECMO/CPB primed + accessible
- ·iNO 20-40 ppm
- ·Cell saver
- ·Multiple inotrope/pressor infusions
- ·Type & cross 4 units
Biggest concerns by phase
Severe pulmonary disease physiology
Hypoxemia + hypercarbia chronic. Permissive hypercapnia OK. Avoid sudden BP/PVR changes that worsen pulmonary HTN. Patient may be on home O₂ — continue equivalent.
Cardiovascular collapse risk
Pulmonary HTN + RV strain → induction-related drop in preload + SVR can crash. Slow titrate. Etomidate. A-line first. Norepinephrine infusion ready.
OLV in already-compromised lungs
OLV may not be tolerated → CPB/ECMO. Lung-protective TV (4-6 mL/kg IBW dependent lung), PEEP 5-10, low FiO₂ if possible. Permissive hypercapnia.
Reperfusion injury + primary graft dysfunction
Reperfusion of ischemic lung → edema, hypoxemia, pulm HTN. Strategies: protective ventilation, low FiO₂ (24-30% post-reperfusion), iNO, fluid restriction, treat with diuretic/ECMO if severe.
Fluid balance — restrictive
Fluid overload → graft edema. Goal-directed fluid + vasopressors. Aim near-zero balance. Avoid bolus crystalloid — use albumin or pressor.
DLT exchange + ICU disposition
DLT exchanged for single-lumen at end. Transport to ICU intubated. iNO continued.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
55-yo F with IPF, FVC 38% predicted, on 4 L home O₂, mild pulmonary HTN. Bilateral lung transplant. Donor cold time 4 h. Plan for OLV vs upfront ECMO?
What an examiner probes for
- ▹Recognizes severe pulmonary compromise — OLV likely not tolerated
- ▹Plans for upfront VA ECMO support
- ▹Lung-protective ventilation parameters
- ▹Reperfusion injury prevention
- ▹Fluid + iNO management
Sources
- Slinger Thoracic 2e Ch 19
- ISHLT Lung Transplant Guidelines
Anatomy reference
Sourced reference images. 4 matches for "lung pulmonary respiratory thoracic".
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