Comprehensive Review and Management Strategies of Airway Complications Post-lung Transplantation

Airway complications following lung transplantation are a major cause of morbidity (2%-18%) and mortality (2%-4%). These complications include necrosis, dehiscence, granulation tissue, bronchial stenosis, tracheobronchomalacia, fistulas, and infections. Donor bronchial ischemia, aggravated by poor graft preservation, prolonged mechanical ventilation, and donor-recipient size mismatch, is the primary driver. Although advances in bronchoscopic surveillance and endobronchial therapies have improved outcomes, airway complications remain a significant clinical challenge.

We performed a comprehensive review of the literature focusing on classification systems, risk factors, pathophysiology, diagnostic strategies, and management of airway complications post-lung transplantation. Emphasis was placed on recent innovations in surgical and bronchoscopic interventions, as well as consensus recommendations such as the International Society for Heart and Lung Transplantation classification system.

Airway complications have decreased substantially in incidence compared to earlier decades, yet they continue to contribute to early and late post-transplant morbidity and mortality. Advances in organ preservation, refined surgical techniques, and early bronchoscopic surveillance have reduced ischemia-related complications. Endoscopic interventions such as balloon dilation, cryotherapy, and stenting remain cornerstones of management, while newer strategies including biodegradable stents, tissue-engineered scaffolds, and novel adhesives offer promise but require further validation. Despite these improvements, the absence of standardized bronchoscopic grading and the risk of stent-related complications remain key limitations.

Effective management of airway complications requires early detection and a multidisciplinary approach integrating surgery, interventional pulmonology, and optimized immunosuppression. While recent innovations have improved patient outcomes, consensus on standardized diagnostic systems and long-term strategies remains lacking. Continued research is essential to further reduce complication rates and improve the quality of life of lung transplant recipients.