Anesthesia for lung transplantation: A narrative review

Lung transplantation is considered the curative treatment of end-stage lung disease. Severe chronic obstructive pulmonary disease (COPD), interstitial lung disease, cystic fibrosis, idiopathic and secondary pulmonary artery hypertension are the main indications for lung transplantation. It can either be a single lung transplant as in COPD or pulmonary fibrosis or a bilateral sequential lung transplant as in suppurative lung disease (bronchiectasis, cystic fibrosis) and severe pulmonary hypertension. If cardiac decompensation is associated with the end-stage lung disease, combined heart-lung transplantation can be considered. Anesthesiologists have a significant role to play in the multidisciplinary assessment of the recipient before fitness for listing, pretransplantation bridging by extracorporeal life support (ECLS), anesthetic management during organ retrieval and implantation, implementation of the complex perioperative protocols, and management of one-lung anesthesia. Titration of intraoperative anticoagulation, hemodynamic management, close liaison with the perfusionist during cardiopulmonary bypass or extracorporeal membrane oxygenation, and performing transesophageal echocardiography also fall under the shared responsibility of the anesthesiologist. As part of the core team, anesthesiologists also actively take part in the postoperative care protocols, ventilatory and hemodynamic management, maintaining ECLS, immunosuppressant administration, pain management, and proactive management of complications. After half a century since its inception, lung transplantation is still considered a very high-risk procedure with significant perioperative morbidity and mortality. Because of its complexity, not too many centers are doing it worldwide. Till now, in our center, we have conducted 15 bilateral sequential lung transplants. Although we did not list any recipient from pulmonary hypertension point of view, most of our patients showed very high pulmonary pressures when measured by the pulmonary artery (PA) catheter intraoperatively, some even showing >100 mmHg. The article is a culmination of our experience and knowledge gained so far on this challenging procedure. We hope that in the near future, many centers will start their lung transplantation program and our article will be helpful in formulating protocols as per the available resources in our country.