Lung Transplantation

01 Overview

Lung transplantation, involving one or both lungs, is offered to selected patients with end-stage lung disease when medical therapy no longer controls symptoms or preserves adequate quality of life.

02 Anatomy

Single or bilateral sequential lung transplantation involves anastomosis of the bronchus, pulmonary artery, and pulmonary veins — the latter via a cuff of donor left atrium — for each implanted lung.

03 Physiology

The transplanted lung restores gas exchange but has denervated airways, altered mucociliary clearance and cough reflex, and disrupted lymphatic drainage, which affects early post-operative fluid handling.

04 Indications

Indications include:

• Advanced interstitial lung disease
• Chronic obstructive pulmonary disease
• Cystic fibrosis and other suppurative lung diseases
• Pulmonary arterial hypertension refractory to therapy

05 Contraindications

Contraindications include:

• Active malignancy
• Uncontrolled infection
• Significant untreatable dysfunction of another major organ
• Severe deconditioning or nutritional compromise unlikely to improve
• Ongoing substance use

06 Donor Assessment

Donor lungs are assessed for gas exchange, chest imaging, and bronchoscopic findings, with attention to size compatibility with the recipient's chest cavity to reduce the risk of primary graft dysfunction.

07 Recipient Assessment

Evaluation includes pulmonary function testing, exercise capacity, right heart assessment for pulmonary hypertension, and nutritional and psychosocial evaluation to gauge candidacy and timing.

08 Surgical Technique (Summary)

Performed via thoracotomy or sternotomy, with or without cardiopulmonary bypass, the technique involves sequential pneumonectomy and implantation with bronchial, arterial, and venous anastomoses for each lung.

09 Immunosuppression (Overview)

Triple maintenance therapy with a calcineurin inhibitor, an antiproliferative agent, and corticosteroids is standard, reflecting the lung's relatively high immunogenicity and rejection risk compared with other solid organs.

10 Complications

Recognised complications include:

• Primary graft dysfunction
• Acute rejection
• Chronic lung allograft dysfunction
• Airway anastomotic complications
• Infection

11 Follow-up

Regular spirometry, imaging, and bronchoscopy are used to detect rejection or infection early, alongside monitoring for chronic allograft dysfunction and the metabolic effects of immunosuppression.