The lung has historically been the most challenging of the human organs to be successfully transplanted in clinical practice. It is possible to transplant lungs singly (SLT) or sequentially as a bilateral lung transplant (BSLT) depending on patient characteristics and the nature of the pathological lung condition present. Lung transplant assessment tests typically include sputum tests for Aspergillus and Aspergillus precipitins. Right heart catheterization is undertaken in patients considered for lung transplantation for pulmonary hypertension. Smokers and patients with a history of mild asthma may still be considered as potential lung donors. At many centers, anesthesia for sequential bilateral lung transplantation is undertaken as sequential single lung transplants to avoid the perceived increase in acute lung injury post-operatively which is said to accompany extracorporeal perfusion. Immunosuppression commences pre-operatively with the administration of azathioprine and cyclosporin A. Quality of life is significantly improved by transplantation for pulmonary failure.

Esophagectomy is commonly performed for cancer of the esophagus and gastric cardia. The surgical approach to esophagectomy depends on several factors: anatomic location of tumor; preferred method of reconstruction: transposed stomach, interposed colon, pedicled jejunum; and location of the esophageal-enteric anastomosis. Conventional esophagectomy requires either a laparotomy with a trans-hiatal dissection or laparotomy combined with thoracotomy. A trans-hiatal approach is the most commonly performed operation for esophageal cancer resection. Evidence of chronic pulmonary disease, the ability to stand one-lung anesthesia and the likelihood of post-operative pulmonary complications may be predicted with the aid of the lung function test and cardiopulmonary exercise testing. The spectrum of gastro-esophageal reflux disease (GERD) involves the gastrointestinal and pulmonary organ systems. There is an association between GERD and end-stage lung disease, especially idiopathic pulmonary fibrosis (IPF). The presence of GERD may predispose to the development of bronchiolitis obliterans following lung transplantation.

Patients presenting for pleurectomy often have associated lung diseases such as asthma, emphysema and cystic fibrosis. Appropriate pre-operative optimizing of their condition should occur. One-lung anesthesia is required to assist access for pleurectomy procedure during which the pleura is stripped where possible. Although the commonest association of bacterial infection of the pleural space is a concomitant pneumonia, other causes include trauma or surgery to the thorax; and extension of a suppurative process from either neck or abdomen. Over half of patients presenting with empyema have concomitant chronic disease (for example, diabetes mellitus; malignancy) or conditions that predispose to aspiration pneumonia. The commonest set of operations for acquired chest wall disorders are those requiring chest wall resection. Chest wall resection requires careful operative planning including the extent of resection, the options for chest wall stabilization and the method of tissue coverage to be employed, usually a muscle flap.