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Chronic rejection is manifested as bronchiolitis obliterans. Dyspnoea, cough, colonisation with pseudomonas aeruginosa resulting in purulent tracheobronchitis. refl.in/72

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Clinical manifestations of acute rejection are malaise, low grade fever, dyspnoea, impaired oxygenation & leukocytosis. refl.in/72

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Consider side effects on immunosuppressive drugs patient may be on. Hypertension & renal dysfunction from cyclosporin are present in many patients. refl.in/72

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Consider postponing surgery if history suggestive of infection or rejection. Quantify pathology with arterial blood gases, CXR and pulmonary function tests. refl.in/72

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Bronchial hyperreactivity & bronchospasm are common. refl.in/72

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Consider the position of the tracheal anastamoses (usually heart-lung transplants) or bronchial anastamoses (usually lung only transplants).

When positioning an endotracheal tube in tracheal anastamoses place the cuff just beyond the vocal cords to minimise the risk of traumatising the anastamosis.

If inserting a DLT in a patient with bronchial anastamoses visualising the anastamoses with a flexible bronchoscope is essential.
[Edit based on comments] refl.in/72

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Lung transplants utilise bronchial anastomoses, tracheal anastomosis is only used now for heart-lung transplants. Endotracheal intubation as normal but if inserting a double lumen tube use of a fibre optic bronchoschope to check position is essential.
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Good points, thanks Derek
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Lung denervation ablates afferent sensation below the level of the tracheal anastamosis. Patients lose the cough reflex & are prone to retention of secretions & silent aspiration. refl.in/72

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Fluid preloading before a neuraxial block may be risky because disruption of the lymphatic drainage in the transplanted lung causes interstitial fluid accumulation. refl.in/72

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If placing a double lumen tube, place the endobronchial lumen in native lung to avoid damage to anastmosis. refl.in/72

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