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My problems in delivering the service when the present gen- own advice now is that cheap lithium, so far as possible cheap lithium online mastercard, obstetricians eration of seniors retire buy generic lithium 150mg online. In contentious cases I suspect that we will soon ment about whether the procedure is in the patient’s advise obstetricians to transfer the decision to the place best interests? If the indication for where it should properly be made order lithium 300mg, Her Majesty’s the procedure is choice, how can or should the doctor Judiciary. When Parliament said that it will be very unfortunate if the first time that any guide- wanted the decision to be taken by doctors and patients lines as to the law’s assessment of the meaning of sub- together, did it mean that the patient should have com- stantial risk of serious handicap comes to be decided is in plete freedom to decide if the doctor believed that the the context of a criminal prosecution. Under the law, unborn child would suffer from any recognizable handi- until 1990 the reluctance of the police to intervene meant cap? What is the extent to which it is proper to expect that no‐one attempted to find out what ‘capable of being obstetricians to be put in the guise of judges at all in born alive’ meant between its passage into law in 1929 such circumstances? The assessment of the degree of  and the advent of a negligence action in respect of an handicap should be undertaken by those appropriately obstetrician’s failure to advise a woman of the failure of trained for the purpose. I established that ‘capable of being born alive’ meant capa- wonder if we will not go further in the future: sometimes ble of maintaining life by means of ones’ own breathing, the assessment of long‐term handicap might be even though 60 years had elapsed since the Act was enhanced by a multidisciplinary assessment involving passed. The effect cover themselves by seeking to buttress their decisions of a given physical lesion will vary greatly from case to by obtaining the sort of written evidence that a court case, depending on the personality of the victim and the would demand. That evidence should explicitly answer resources available, as well as the severity of the lesion. How a court would interpret ensuring that she is not forced to carry to term a baby the meaning of ‘substantial’ could well determine on which she does not want. We could against the right of the unborn child; since Parliament get almost any answer, from 20% – on the basis that a has decreed that the unborn fetus has no right, this has substantial risk is one that sensible people would take to be expressed as society’s interest in protecting the into account in ordering their affairs – to beyond all fetus. Few think it appropriate to provide women with reasonable doubt, on the basis that a mature fetus an unqualified right to demand the destruction of a should not be killed unless you are sure it will be normal third‐trimester fetus. The latter is perhaps an extreme and issues calls for a political and judicial assessment. The result is that the newly minted consult- ant acquires a fraction of the clinical hours of experience Professional discipline of their predecessor 30 years ago. The standard of proof was reduced cannot be entrusted, even under supervision, with the from the criminal to the civil standard: it was empha- simplest procedures that recent predecessors could sized that the civil standard does not simply mean the manage alone. Seniors report occasions when assistants balance of probabilities but the panels tend to take a have walked out at 17. The sense is that doctors are were surrounded with honeyed words about reform there to do a job within the hours for which they are paid, and rehabilitation, but in practice those doctors who rather than to undertake a commitment to patients have been identified as under‐performing through the throughout the clinical pathway. The National Clinical tude to handover that depends on written records rather Assessment Service also grapples with the problem of than real communication to another doctor who will the under‐performing doctor, but its success rate for accept the same responsibility. Far more time is devoted getting doctors back into practice once they have been to handover so that the proportion of junior time availa- identified as under‐performing has not been good. A newly appointed It was also agreed by the profession that it should senior registrar of the 1970s would be likely to have per- embark on some formal system of revalidation. It was agreed that revalidation purpose is all to the good, in the sense that the juniors needed to be something more, involving not only evi- are well taught in a procedure‐specific sense. But it is no dence of learning and reflection but also evidence of con- way to acquire an understanding of the natural history of tinuing ability, but the more ambitious programmes disease in humans, or the flexibility to recognize when of revalidation fell on the stony ground of the things are going wrong. At the moment, the position is still being mitigated by the presence of senior consultants who benefited from the old‐fashioned model of training. We are pedalling Postgraduate training backwards to protect this year’s patients at the expense of the experience of next year’s consultants; thus, the last Another issue that is concerning for the future of the three National Confidential Enquiry into Perioperative profession arises from the developments in professional Outcome and Death case studies have advised that all training over the last 15 years. The Law and the Obstetrician and Gynaecologist 1005 Every year these consultants retire and are replaced by to quit poorer countries – it cannot provide a sustainable colleagues who simply do not have the same sort of train- solution. To some extent the problems can be mitigated in already find an unforgiving atmosphere and an assump- elective surgery by increasing subspecialty and higher tion that someone must have done something wrong training in courses post appointment as consultant, but whenever a patient has died. The notion of being just to we are encountering a brave new world in more and the doctor who is the respondent to a complaint is low more hospitals where there is no consultant who bene- down on a set of priorities which are headed by making fited from the old‐fashioned sort of training. The idea sure that the service is ‘safe’ and giving satisfaction to that junior consultants are going to acquire the experi- somebody simply because they have complained. The advice that one gives there to train them if they do have the modesty to ask for to professionals in these circumstances is much the same help and guidance. The patient has an unfettered right to refuse sur- beyond the hours for which they were paid, that it would gery for good reason, bad reason or no reason. The result doctor must ensure that the risks of inaction are spelled was a massive bill that that threatened to cripple many out as clearly as the risks of the intervention in question. This the doctor’s role is to advise and to recognize that while change represented a turning point: the older doctors their skills are for their patient, their notes are for them- continue to provide the service their patients need selves and their own protection. It is as important to despite the nominal fact that they are not being paid for make detailed records of what is said to and by the patient it, but their attitudes already appear old‐fashioned and as it is to make records of the clinical history that is elic- are being replaced by a new respect for an appropriate ited and the signs that are found. A new generation has emerged, It must also be recognized that the patient’s right to shaped in a fashion devised by the managers of the ser- choose in effect must sometimes mean a right to demand vice rather than their clinical seniors. The the modern intolerance of risk makes demands that are patient who demands an unfair share of resources in the challenging the training of the next generation of form of a caesarean section that the doctor thinks is not consultants. Both are demanding a share of medical resources the conflict between the lack of training that seems to exceed the clinical indication in the eyes of and the hostile environment the medical attendant, but the woman who demands an the combination of this crisis in professional training operation is demanding that her doctor does something and the less‐forgiving professional environment in which that appears to be inappropriate. She should be offered doctors work means that the prospects for the individual referral to a colleague where practical, but doctors should doctor are ever gloomier. The basic premise of the never find themselves doing an operation that they reforms proposed by the Shipman Inquiry was that there believe is contrary to their patient’s best interests. America, and over the succeeding 30 years we have There is a long‐established line of cases in which patients become used to a much more measured assessment of have demanded extravagant, conservative restoration of causation in these cases. The courts almost invariably criticize the for future payments are dominated by these cases and dentist or the cosmetic surgeon for having performed a these are growing at double the amount paid by commis- procedure contrary to the patient’s best interests as the sioners for obstetric services. The conventional advice to a pro- ber of children in the population suffering from cerebral fessional is that when a patient demands a procedure palsy has remained roughly constant despite improve- which appears to be contrary to their best interests, the ments in obstetrics and paediatrics that have transformed professional should decline to perform it and offer to the rates of infant mortality and the prospects of survival refer to someone else. This is probably due to the be good in 2018, but as professional autonomy advances increased age of the parturient woman since the introduc- the question must arise as to whether the patient’s right to tion of in vitro fertilization, and has been associated with choose will sooner or later entitle them to demand sur- increased rates of maternal obesity, diabetes and associ- gery which the doctor thinks is contraindicated, with the ated complications. If the autonomy of the vors from the extremes of prematurity, but still many suf- patient is paramount and the playing field of knowledge fer from the associated disability. It is also true that social of the implications of medical procedures becomes ever expectations for a perfect result have made it difficult for more level, it is difficult to understand how the status quo us to defend such cases, even where the extremity of pre- can be preserved indefinitely. Claims handling was centralized concern of the obstetrician with the law was as it had in 2002, so that there is an additional level of insulation been since 1980 when the House of Lords gave judge- between the individual doctor and the damage. Risk man- ment in Jordan v Whitehouse  that the doctors agement and clinical governance demand ever higher and involved would be sued by children suffering from cere- more intolerant standards, but the massive financial bral palsy who sought to blame their disability on the impact of these claims is insulated from the services deliv- doctor. Although Mr Jordan’s case resulted in a victory ered in the individual Trust in that year. There was a for the defence, the experience of the defence organiza- period when a multimillion pound claim against the Trust tions was that the public remembered only that a claim would or could cause cashflow problems that sent the had been brought in respect of a brain‐damaged child, Chief Executive cap in hand to the regional office of the not that it was lost. Case 1: Elderly woman with history of vomiting 7 Visual field of the left eye Visual field of the right eye Never forget that the image on the retina is inverted Nasal Temporal half halves Temporal half of the left of retinas of the right retina retina Optic nerve Optic chiasma Optic tract Geniculo- calcarine Lateral tract geniculate body the cerebral cortex Primary visual receives the encoded area (= striate images of the contralateral cortex) visual fields of both eyes ure 1. Elevated prolactin may be due to physiological factors, such as emotional stress, pregnancy and breast feeding; drugs especially dopaminergic antagonists such as chlorpromazine, risperidone, domperidone and metaclopramide; pituitary tumours; polycystic ovary syndrome; and severe thyroid failure. Dopamine agonists, such as cabergoline or bromocriptine, are suitable for treat- ment of prolactin-secreting pituitary tumours and may act to shrink large tumours, avoiding the need for surgery. On examination, his jugular venous pressure is raised 6 cm, there is ankle oedema and scattered crepitations at both bases. On follow up, the patient reports improved exercise tolerance, but com- plains that his ankle oedema has not improved. At about the same time, the patient learns of the role of sodium in cardiac failure and decides to reduce his salt intake by using LoSalt in cooking. Case 2: Elderly man with shortness of breath 9 After two months on treatment Follow-up tests Reference range Sodium 140 mmol/L 139 mmol/L 135–145 mmol/L Potassium 4. The two major routes are viral infections (more frequent in those who have lived in areas where these virus diseases are endemic) and inherited metabolic conditions. Inherited/metabolic: alpha-1 anti-trypsin; iron, transferrin and ferritin (haemachromatosis); copper and caeruloplasmin (Wilson’s disease) 4. Acute renal failure, Addison’s disease, metabolic acidosis of any aetiology, tumour lysis syndrome may all be associated with hyperkalaemia. In this case, the hyperkalaemia was probably due to two factors: first, the switch to spironolactone and second, the patient increasing his potassium intake through use of LoSalt, in which sodium salts are largely replaced by potassium salts. The hospital physician confirmed hypertension and arranged for repeat electrolytes, ran- dom urine potassium and resting and ambulant renin and angiotensin levels. Ramipril was stopped for three days prior to the tests and it was checked that she was not taking oral contraception.
These patients may also be receiving β2- adrenergic antagonists that are making control of their asthma worse order line lithium. Physical Examination Physical examination is important for excluding other causes of dyspnea (see Differential Diagnosis section) and assessing the degree of airway obstruction generic 300mg lithium amex. Tachycardia (greater than 120 beats per minute) purchase lithium 300mg, tachypnea (greater than 30 breaths per minute) generic lithium 150 mg online, diaphoresis, bolt-upright posture in bed, pulsus paradoxus greater than 10 mm Hg, and accessory respiratory muscle use all should be regarded as signs of severe airway obstruction . However, because the absence of these signs does not rule out severe obstruction, physical examination cannot be relied on exclusively to estimate the severity of airway obstruction. The amount of wheezing heard on auscultation of the chest is a notoriously poor method of assessing the severity of airway obstruction . Pulmonary Function Tests To evaluate a patient who is having an acute exacerbation of asthma, an objective measure of maximal expiratory airflow should be performed [1,2]. An exception to this is the patient who is unable to perform a testing maneuver due to a severe, life-threatening exacerbation with obvious airway compromise and cyanosis. These tests are valuable for the initial assessment and for assessing responses to therapy, especially after 1 hour of treatment . Guidelines recommend reassessment of lung function one hour after initiation of treatment and then frequent reassessments thereafter (Table 172. A partial pressure of arterial1 oxygen (PaO ) less than 60 mm Hg or a pulse oximeter oxygen saturation2 value less than 90% on room air should be regarded as additional evidence that the patient’s exacerbation is severe. With modest airway obstruction, the patient’s mild dyspnea stimulates an increase in minute ventilation that meets or exceeds the level required to maintain normal alveolar ventilation. As airway obstruction worsens,2 dyspnea becomes more severe and the central nervous system drive to increase minute ventilation becomes intense. As the airway obstruction becomes more severe and prolonged, high minute ventilation can no longer be maintained by the respiratory musculature and alveolar ventilation decreases. Any coexisting conditions (malnutrition, advanced age) or medications (sedatives) that weaken respiratory muscle function or depress respiratory drive should be expected to accelerate the onset of hypercapnic ventilatory failure during acute exacerbations of asthma. Other Laboratory Studies For acute exacerbations of asthma, routine chest radiographs reveal few abnormalities other than hyperinflation . However, although not recommended for routine assessment, for severe exacerbations chest radiography can be helpful when there is clinical suspicion of other causes of dyspnea and wheezing (see Differential Diagnosis section) or complications of severe airway obstruction . Chest radiographs should be examined for evidence of enlarged cardiac silhouette, upper lung zone redistribution of blood flow, pleural effusions, and alveolar or interstitial infiltrates because any one of these findings suggests a diagnosis other than or in addition to acute asthma. In addition, chest radiography allows the early detection of common complications of severe airway obstruction, including pneumothorax, pneumomediastinum, and atelectasis. Also, lung infiltrates on chest radiographs can be compatible with a diagnosis of asthma complicated by mucoid impactions (e. Among the elderly, for patients with severe hypoxemia, and for individuals with suspected cardiac ischemia or arrhythmias, an electrocardiogram should be performed. This initial assessment and repeated objective measures of airway obstruction guide treatment that combines supportive measures, bronchodilator therapy, and anti-inflammatory therapy (Table 172. Because corticosteroids take at least 4 to 6 hours to begin to have a beneficial effect and many of the inflammatory causes of airway obstruction may take days to resolve, the medical challenge is to support patients until the inflammatory processes have responded to corticosteroids. Although these bronchodilators relieve only one component of the airway obstruction during severe exacerbations of asthma, even small improvements of airflow can lead to important clinical benefits in the acute setting. Of the available bronchodilators, β2-adrenergic agonists are the most effective and rapidly acting and, therefore, most useful during that critical time before the onset of corticosteroid action . Other measures that support the patient until the inflammatory processes in the airways have resolved include supplemental oxygen, judicious fluid administration, and, when indicated, mechanical ventilation. Although the primary cellular target of β2-adrenergic agonists is airway smooth muscle, other cell types in the airways also express β2-adrenergic receptors that may regulate mediator release by mast cells, epithelial cells, and nerves. These short-acting agents are rapidly acting with an onset of action less than 5 minutes and are the mainstay of bronchodilator therapy for acute asthma, especially albuterol [1,2]. The potential advantage of this preparation is that the S-enantiomer present in racemic albuterol does not contribute to bronchodilation and might have deleterious effects on the airways. However, there have not been large, randomized, double-blind, and controlled trials in adults to show that this theoretical concern is clinically important. Moreover, a systematic review and meta-analysis of smaller studies concluded that levalbuterol was not superior to albuterol with respect to either efficacy or safety in the treatment of acute asthma exacerbations . The major side effects of β2-adrenergic agonists during the treatment of severe asthma exacerbations are tremor, cardiac stimulation, hypokalemia, and hyperlactatemia [52,54]. These side effects are potentially serious, especially in the elderly, who frequently have underlying cardiac disease. Cardiac toxicity can be minimized by using agonists with high β2-adrenergic receptor selectivity, by avoiding systemic administration of β2-adrenergic agonists, and by maintaining adequate oxygenation . Numerous studies have shown that the bronchodilator effects of inhaled β2-adrenergic agonists are rapid in onset and equal to the effect achieved by systemic delivery . Because the inhaled route allows administration of comparatively small doses directly to the airways with minimal systemic toxicity, this route is almost always preferable to systemic delivery [1,2]. Frequent, multiple inhalations of the medication may allow for progressively deeper penetration of the drug into peripheral airways. In fact, continuous administration by nebulizer may be more effective for severely obstructed patients [59,60]. Because of its lower density than oxygen, helium–oxygen (heliox)– powered nebulizer treatments have the potential to improve penetration of aerosols into the lungs. However, a systematic review with meta- analysis comparing heliox versus air–oxygen driven nebulization found no support for helium-powered nebulization in the routine care of acute exacerbations of asthma . Theoretically, systemic administration of β-adrenergic agonists could deliver drugs via the bloodstream to obstructed airways that are poorly accessible to inhaled aerosols. More selective β2-adrenergic agonists, such as terbutaline, are available for subcutaneous use, but cardiac toxicity among elderly individuals is still a significant concern even with these more selective agents. However, intravenous delivery of β2-adrenergic agonists is no longer recommended for the routine treatment of even severe exacerbations of asthma [1,2]. No convincing evidence has shown intravenous administration to be superior to inhaled delivery of β2- adrenergic agonists [56,62]. Both the lack of enhanced efficacy and the potential cardiac toxicity of intravenous β2-adrenergic agonists have led most authorities to reserve intravenous delivery for those rare adult patients, closely monitored, who continue to deteriorate on mechanical ventilation despite maximal routine therapy with inhaled β2-adrenergic agonists. It is important to emphasize again that intravenous β2- adrenergic agonists are not recommended in guidelines and are unlikely to be any more effective than inhaled β2-adrenergic agonists such as albuterol [1,2]. Exceptions may be bronchospasm induced by acetylcholinesterase inhibitors or β2-adrenergic antagonists and patients with severe cardiac disease who are unable to tolerate β2-adrenergic agonists. However, inhaled cholinergic antagonists have a low incidence of side effects and are a recommended adjunct to β2-adrenergic agonists for the initial treatment of severe exacerbations of asthma [1,2,65,66]. Because even small improvements of airway caliber could prove clinically significant for the severely obstructed and deteriorating patient, it is recommended that ipratropium be routinely added to β2-adrenergic agonist therapy during the initial treatment of severe asthma exacerbations in the emergency department  (see Management section). However, inhaled ipratropium bromide currently is not recommended for routine use once a patient is hospitalized with a severe exacerbation of asthma [1,2]. The long-acting anticholinergic, tiotropium, has a role in treating outpatients with difficult to control asthma, but it does not have any established role for treating hospitalized patients with acute exacerbations of asthma [1,2,67]. Methylxanthines Because the literature does not demonstrate a benefit to adding methylxanthines to β2-adrenergic agonists in the acute setting and because they increase toxicity, methylxanthines are no longer recommended for the treatment of asthma exacerbations [1,2,68–70]. For the rare, critically ill patient whose condition is acutely deteriorating despite maximal recommended therapy with bronchodilators, corticosteroids, and other adjuncts [1,2], the use of methylxanthines might be considered by some physicians, although data are not supportive . For patients not already taking methylxanthines, a loading dose of aminophylline (6 mg/kg lean body weight) can be administered over 20 to 30 minutes, followed by an intravenous infusion at the rate of 0. This infusion rate should be decreased when conditions are present that decrease methylxanthine clearance, especially congestive heart failure, cirrhosis, and the use of drugs such as cimetidine, ranitidine, allopurinol, oral contraceptives, erythromycin, ciprofloxacin, or norfloxacin. Six hours after initiation of the infusion, the serum theophylline level should be checked and the infusion rate adjusted accordingly, with 10 to 15 μg/mL being therapeutic. Their beneficial effects are attributed to their many potent anti-inflammatory effects on multiple cell types [72,75]. Compared with betamethasone and dexamethasone, neither prednisone nor methylprednisolone contain metabisulfites, and both have shorter half- lives. Although hydrocortisone has the shortest half-life, it has greater mineralocorticoid effect and may cause idiosyncratic bronchospasm in some aspirin-sensitive individuals .
The usual donor selection criteria are age younger than 60 to 65 years buy lithium once a day, no history of clinically significant lung disease 300 mg lithium visa, normal results from a sputum Gram stain 150 mg lithium free shipping, and a limited history of smoking (less than 20 pack- years) order generic lithium line. The2 main goal of the endobronchial evaluation is to rule out gross aspiration or purulent secretions in the distal airways. In the Euro transplant community, lungs from extended donors are used for rescue offers with comparable outcomes . Some centers are actively engaged in developing protocols for optimizing marginal donor lungs, thereby rendering them transplantable [26–29]. By instituting a protocol including educational and donor management interventions, and changing donor classification and selection criteria, a single-organ procurement organization was able to increase the percentage of lungs procured from 11. The use of lung protective ventilation strategies such as low tidal volume ventilation to limit lung injury is now recommended when managing the potential lung donor, resulting in adequate functioning lungs [26–28,30]. A multicenter randomized controlled trial of potential organ donors managed with conventional versus protective ventilator strategies revealed that the latter resulted in a significant increase in the number of eligible (54% vs. There were no differences in 6- month survival among recipients receiving lungs from donors ventilated by either strategy . Donors are excluded from potential lung donation if there is evidence of active infection, human immunodeficiency virus, hepatitis, or malignancy. Donor and recipient compatibility is assessed by matching A, B, and O blood types and chest wall size. During transportation to the recipient site, the partially inflated donor lung graft is placed into preservation solution, usually a low-potassium dextran solution with extracellular electrolyte composition or a modified Euro-Collins solution with an intracellular electrolyte composition at 4°C. Most centers start with the bronchial anastomosis, without a vascular anastomosis of the bronchial circulation of the recipient and donor lungs. Initially, most transplant procedures involved an end-to-end anastomosis, which was wrapped with a piece of omentum or pericardial fat with an intact vascular pedicle for assistance in bronchial revascularization. Subsequently, a telescoping technique was recommended, with the recipient and donor bronchi overlapping by approximately one cartilaginous ring. More recently, most anastomoses are performed with an end-to-end single suture in the membranous portion and a single or continuous suture in the cartilaginous portion, without omental wrap, and telescoping is performed when the donor and recipient bronchi differ in size and there is a natural, unforced telescoping of both bronchi . After the bronchial anastomosis has been performed, the donor pulmonary veins are anastomosed end-to-end to the recipient’s left atrium, and the pulmonary arteries are attached with an end-to-end anastomosis. Cardiopulmonary bypass may be required for patients with pulmonary hypertension or those who cannot tolerate single-lung ventilation or perfusion and who experience marked hypoxemia or hemodynamic instability. Most patients are ventilated in a volume- control mode, although in recent years some transplant centers have changed to pressure-control ventilation, or airway pressure release ventilation. Airway pressures are kept as low as possible so that barotrauma and anastomotic dehiscence can be avoided. Both postural drainage and chest physiotherapy can be routinely employed without concern for mechanical complications at the anastomosis, and patients should perform incentive spirometry soon after extubation. Tidal volumes were based on recipient, not donor, characteristics, and most respondents selected 6 mL per kg of recipient ideal body weight as a target. Occasionally, clinically significant acute native lung hyperinflation can occur and can compromise the newly transplanted lung and lead to hypotension and hemodynamic instability. As a consequence, the more compliant emphysematous lung becomes overexpanded and can herniate toward the contralateral hemithorax . Attempts to prevent this possible complication by using selective independent ventilation with a double-lumen endotracheal tube have been tried. Pain control is usually provided by opiates, usually fentanyl, administered intravenously, or morphine sulfate via an epidural catheter with a patient-regulated pain-control system. Because many patients are nutritionally depleted before transplantation as a result of their underlying disease, postoperative nutrition is important. Antibiotic regimens include broad-spectrum antibiotic coverage for both gram-negative and gram-positive bacteria. Gram stains and cultures of sputum from the donor and the recipient may be used when available to guide the choice of appropriate antibiotics. Many centers routinely use antifungal agents such as inhaled amphotericin B, voriconazole, or itraconazole postoperatively. After the transplantation procedure, most patients begin a triple immunosuppression protocol with a combination of prednisone, a calcineurin agent, tacrolimus or cyclosporine, and a cell-cycle–inhibiting agent, mycophenolate mofetil or azathioprine . A stenosis at the venous anastomosis presents with similar signs and symptoms, but this diagnosis can be excluded by transesophageal echocardiography. The radiographic findings of these patients include a perihilar haze, patchy alveolar consolidations, and, in the most severe form, dense perihilar and basilar alveolar consolidations with air bronchograms. Pathology reports from biopsy specimens, autopsies, or lung explants removed during retransplantation indicate diffuse alveolar damage. The postoperative mortality rate has decreased because of improved surgical techniques and perioperative care, and approximately 97% of patients are discharged alive after transplantation . These patients frequently require mechanical ventilation (53%), and the mortality rate is generally close to 40%. The incidence of anastomotic complications has decreased as surgical techniques have improved and surgeons have gained experience with the procedure. The reported incidence of this complication ranges widely: some studies report it to be as high as 33%; others, as low as 1. However, in reality, most recent series suggest a range of 7% to 18% , with a related mortality rate of 2% to 4%. Early airway complications usually occur during the first 4 to 12 weeks after transplantation and manifest themselves as a partial or complete anastomotic dehiscence or a fungal (usually Aspergillus or Candida species) or bacterial (usually Staphylococcus or Pseudomonas species) anastomotic infection. Clinically, bronchial dehiscence may cause prolonged air leaks in the early posttransplantation period. In some cases, the dehiscence may also lead to infection or the formation of peribronchial abscesses or fistulas. In addition, the anastomosis is also evaluated carefully during surveillance or clinically indicated bronchoscopy particularly during the 1st year. The integrity of the mucosa should be assessed, and specimens from a bronchial wash or brush should be sent for cultures and cytologic examination. If there is any evidence of infection, antibiotics and antifungals (usually inhaled amphotericin with or without itraconazole or voriconazole) should be administered on the basis of culture results. Late bronchial anastomotic complications, including stenosis (most common), bronchomalacia, and development of exophytic granulation tissue are often the result of ischemia, infection, or dehiscence during the early weeks after transplantation. These complications manifest themselves as cough, shortness of breath, wheezing, dyspnea on exertion, and worsening obstruction as documented by pulmonary function testing. The characteristic flow volume loop demonstrates a concave appearance in both the inspiratory loop and the expiratory loop. Therapeutic options for anastomotic complications include balloon dilation of a stricture, stent placement, cryotherapy, argon beam coagulation, laser procedures, and, rarely, surgery. Rejection Graft rejection is categorized clinically according to the time of onset after transplantation and the histopathologic pattern. It is not uncommon (20% of lung transplant recipients) for a single patient to experience either recurrent (more than two episodes) and/or persistent (failure to resolve with standard therapy) rejection. The majority of transplantation centers advocate surveillance bronchoscopy for the detection of this condition, although outcome data are not available . Typically, during the 1st month the results of chest radiography can be abnormal in as many as 75% of rejection episodes; however, the results of radiography are abnormal in only 25% of rejection episodes that occur more than 1 month after transplantation. The most common radiographic patterns associated with acute rejection are a perihilar flare, and alveolar or interstitial localized or diffuse infiltrates with or without associated pleural effusion. The characteristics of the fluid are consistent with those of an exudate: the total lymphocyte count is often more than 80% of the total number of white blood cells. Physiologic findings during periods of acute rejection include hypoxemia and deterioration in pulmonary function. Once again, these changes are nonspecific and can also be seen with infectious processes and graft complications. A histologic grading system for acute pulmonary rejection was proposed in 1990 and revised in 1996 and 2007 . Pathologically, acute rejection is characterized by perivascular, mononuclear lymphocytic infiltrates with or without airway inflammation; histologically, it is graded from A to A on the basis of the degree of0 4 perivascular inflammation.