Table 3.

Assessment and management of common problems during lung transplantation. COPD, chronic obstructive pulmonary disease; CPB, cardiopulmonary bypass; ECLS, extracorporeal life support; ECMO, extracorporeal membrane oxygenation; PAH, pulmonary arterial hypertension; PAP,; PGD; primary graft dysfunction; PV, pulmonary venous; RV, right ventricular; TOE, transoesophageal echocardiogram; VA, venoarterial; VV, venovenous

Problem	Assessment	Management
Before surgery
All patients	Fragile cardiorespiratory status.	Avoid sedative hypnotic drugs.
		Preserve the right internal jugular vein for postoperative ECMO.
Suppurative lung disease (cystic fibrosis or bronchiectasis)	Chronic infection.	Specific antimicrobial prophylaxis or treatment.
	Adhesions, collaterals vessels, central venous obstruction.	CT angiogram or MRI to determine patency of central veins and presence of collateral blood vessels. If central venous obstruction, plan alternative sites for central venous access or ECLS cannula. Plan for adequate venous access in case of excessive bleeding.
COPD or pulmonary fibrosis	Suitability for single lung transplantation.	Discuss ventilation–perfusion scan with the surgeon.
Primary pulmonary hypertension or severe secondary pulmonary hypertension	Right heart catheter study to assess magnitude and reversibility of PAP and pulmonary resistance.	ECLS during and after surgery.
	Review TTE to assess RV function and severity of tricuspid regurgitation.
Connective tissue disease (e.g. scleroderma, mixed connective tissue disease)	Oesophageal problems.	Consider barium swallow or endoscopy to evaluate oesophageal function. Insertion of TOE probe may be difficult or contraindicated.
	Difficult tracheal intubation.	Consider advanced airway management for intubation and placement of double-lumen tracheal tube.
During surgery, before allograft reperfusion
Timing	Expected arrival of donor organs.	Allow at least 1 h for anaesthesia and 1 h for surgery before organ arrival.
		Ensure native lungs are not excised before donor organ on site.
Positioning	Planned incision.	Position the patient appropriately. Care with pressure points and excessive abduction of upper limbs.
Haemodynamic instability	Surgical manipulations, auto-PEEP if COPD, RV dysfunction if PAH, hypovolaemia.	Integrate findings from TOE and haemodynamic monitors.
		Be aware of the key differences between CPB and ECMO (see text).
		ECLS if progressive.
Impaired gas exchange	Malposition of double lumen tracheal tube, mucus plugs, blood in airway, atelectasis, low cardiac output.	Check ventilator settings; hand ventilate.
		Perform bronchoscopy and clear secretions.
		Review haemodynamics and acid–base status.
		ECLS if progressive.
During surgery, after allograft reperfusion
Haemodynamic instability	As above; additionally, consider reperfusion-induced vasoplegia.	ECLS (VA ECMO) if progressive.
Impaired gas exchange	As above; additionally, consider PV obstruction and PGD.	Assess pulmonary veins with TOE.
	Pulmonary oedema in airways suggests PGD or PV obstruction.	Fluid restriction.
		Surgical revision if PV obstruction.
		ECLS (VV ECMO) if progressive.
In the ICU
Haemodynamic instability	RV dysfunction, exacerbated by acidosis, fluid overload, tamponade, and haemothorax	VA EMCO if progressive.
Impaired gas exchange	PGD, large haemothorax; large pneumothorax because of kinked drain, pulmonary embolism, auto-PEEP associated with single lung transplant for COPD, obstructed pulmonary veins, pneumonia, bronchial anastomotic leak.	Check ventilator settings. Perform chest radiograph, chest ultrasound, bronchoscopy, TOE, CT angiogram if pulmonary embolism is suspected. VV ECMO if progressive.