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Often performed in candidates with:

  • Chronic pulmonary infections
  • Pulmonary hypertension
  • Congenital heart disease
  • Cystic fibrosis (absolute indication)

Usually performed via clamshell incision (Figure 96-1) and sequentially rather than en bloc as

  • Cardiopulmonary bypass can be avoided
  • Fewer complications with bronchial versus tracheal anastomoses

Figure 96-1. Clamshell Incision

Reproduced from Sugarbaker DJ, Bueno R, Krasna MJ, Mentzer SJ, Zellos L. Adult Chest Surgery. Figure 137-10. Available at: Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

Traditionally performed in candidates with

  • COPD
  • IPF

Poses challenges in postoperative ventilation and perfusion due to the discrepant compliance in the transplanted versus native lungs. Performed via thoracotomy in the fifth intercostal space.

Consider thoracic epidural for postoperative pain management in patients with lower likelihood of needing cardiopulmonary bypass during the procedure

Usually at least 6 hours notice prior to induction: patient NPO as for elective case

Preinduction: A large bore IV and an arterial line.


  • Consider ‘gentle’ rapid sequence induction based on NPO status
  • Induction goals are to avoid increases in pulmonary vascular resistance and myocardial depression
  • Induction is usually performed with a combination of midazolam, fentanyl, and etomidate
  • PAC and TEE placed post-induction
  • A single lumen endotracheal tube should be placed to enable an initial bronchoscopy to clear secretions, which will facilitate single-lung ventilation
  • One-lung ventilation via a double lumen endotracheal tube


  • Maintenance is achieved with cautious titration of volatile anesthetics, opioids, and benzodiazepines
  • One-lung ventilation is needed to avoid cardiopulmonary bypass when performing sequential double-lung transplant or single-lung transplant
  • One-lung ventilation may result in hypoxemia, hypercarbia, acidosis, and subsequent pulmonary hypertension and right ventricular compromise
  • Clamping of the pulmonary artery, while improving oxygenation by decreasing shunt, may further increase pulmonary arterial pressures and compromise right ventricular function
  • Norepinephrine and vasopressin may be required to maintain systemic hemodynamics
  • In patients with pulmonary hypertension, milrinone (0.25–0.375 μg/kg/min) may be added to lower pulmonary vascular resistance and augment right ventricular function
  • In case milrinone is insufficient, inhaled nitric oxide (20 ppm) may be added. Inhaled nitric oxide also helps improve V/Q mismatch and may reduce hypoxemia during one-lung ventilation
  • Following pulmonary anastomosis, retrograde flow to wash out the pneumoplegia solution ensues, which may result in profound hypotension due to systemic vasodilation;
    • Vasoactive support is usually necessary
    • Avoid hypertension as it might result in pulmonary edema due to capillary leak
    • Blood transfusion is helpful in maintaining blood pressure. Maintain hematocrit around 30
  • Reinflation of the donor lung should be done manually on room air with low tidal volumes to minimize reperfusion injury and pulmonary edema
  • During one-lung ventilation, SpO2 >85% is tolerated to avoid cardiopulmonary bypass
  • Later FiO2 may ...

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