Chapter 50: Anesthesia for Lung Transplantation

INTRODUCTION

End-stage lung disease is a highly disabling pathology for which lung transplantation is the only possible therapeutic option in some cases. The median survival after lung transplantation at 5 and 10 years is 53% and 31%, respectively. Since the first successful lung transplant in the 1980s, the number of transplants had increased considerably all around the world (3600 in 2011). Lung transplantation includes lobar, single-lung, and double-lung transplants. The most commonly performed procedure is bilateral sequential lung transplant.

PREOPERATIVE ASSESSMENT

Lung transplantation may be indicated for patients with end-stage pathophysiology due to the following disorders:

• Obstructive lung disease (COPD, alpha-1 antitrypsin deficiency)

• Septic or suppurative disease (cystic fibrosis, bronchiolitis obliterans syndrome, bronchiectasis)

• Restrictive lung disease (pulmonary fibrosis, sarcoidosis)

• Vascular lung disease (primary or secondary pulmonary hypertension)

The most common indication for retransplantation is bronchiolitis obliterans syndrome.

Contraindications to lung transplantation include the following:

• Malignancy in the last 2 years

• Untreatable advanced dysfunction of another organ or system

• Progressive neuromuscular disease

• Noncurable chronic extra-pulmonary infection

• Significant chest wall or spine deformity

• Lack of compliance to medical therapy

• Untreatable psychiatric or psychological conditions

• Substance addiction in the last 6 months

• Absence of a reliable social support system

Preoperative assessment consists of a complete multidisciplinary evaluation at the time of listing. The assessment is based on complete pulmonary, cardiac, hepatic, and renal function data, as well as physiological and social work evaluation (Table 50-1). Once listed, patients are followed by their pulmonologist and undergo intensive physiotherapy to maintain optimal overall condition.

ANESTHETIC CONCERNS

1. Premedication—Standard premedication usually includes steroids and antibiotics. Therapy for any underlying condition should be continued until surgery, especially antibiotics, bronchodilators, steroids, and pulmonary vasodilators.

2. Monitoring—During lung transplantation, sudden hemodynamic instability due to mediastinal manipulation and pulmonary artery clamping is extremely common.

   For this reason, routine anesthetic monitoring should include the following:

   • Temperature...