A thorough history should be performed. In particular, any history of prior chest operation, hypercoagulability, malignancy, frequent respiratory tract infections, or cardiovascular disease should be explored. A list of absolute and relative contraindications is detailed in Chapter 46. The patient’s family history for these risk factors should also be obtained.

Both obesity and sarcopenia are risk factors for worse survival. Although exact body mass index (BMI) criteria vary by transplant center, typically, a BMI less than 32 is preferred, depending on the patient’s functional status and comorbid conditions. Patients who have significant weight loss and deterioration of functional status, such as indicated by worsening 6-minute hall walk testing, may not have adequate reserves to undergo transplantation.

A full physical should be performed, with particular attention for peripheral vascular disease, cardiovascular disease, and prior chest interventions. Laboratory examination, including a comprehensive metabolic panel; electrolytes; pregnancy testing (in women); prostate specific antigen (in men); and serology testing for hepatitis B and C, HIV, cytomegalovirus (CMV), Epstein-Barr virus (EBV), and syphilis. Testing for thiopurine S-methyltransferase (TPMT) deficiency/polymorphism is recommended as defects in TPMT activity can lead to azathioprine-related toxicity, particularly myelosuppression. In addition, tuberculosis testing should be performed, along with an electrocardiogram and chest x-ray. Drug testing is usually performed.

During evaluation for transplantation, radiographic evaluation can include chest computed tomography (CT) scan, chest radiography, quantitative radionuclide ventilation/perfusion scan, and appropriate cardiac function testing such as stress echocardiography and cardiac catheterization (right heart, left heart, or both as indicated). If there is a concern for gastroesophageal reflux disease, then contrast esophagogram and functional testing, including esophageal manometry and esophageal pH/impedance probe testing, can be considered.

Potential donors (deceased) should have a meticulous history obtained, with attention to any malignancy, systemic infection, prior chest operation, cardiovascular disease, pulmonary hypertension, tobacco use, asthma, and substance abuse. The donor must be ABO compatible with the recipient. Donor evaluation can include right heart catheterization to evaluate for evidence of pulmonary hypertension, or fluid overload, as well as chest CT if there is concern for parenchymal disease, such as in potential donors with a history of extensive tobacco use (>20 packyears) or asthma.

Donor organ management should include frequent assessment of arterial Po₂, with ideal ranges greater than 300 during 100% FiO₂ “challenges.” For donors who have lower or deteriorating arterial oxygen concentration, alveolar recruitment measures can include increasing positive end-expiratory pressure (PEEP) or using ventilator strategies such as inverse ratio or airway pressure release ventilation (APRV) modes. Prone positioning also can be considered. Use of an opioid inverse agonist, for example, naloxone, can be considered to ameliorate neurogenic pulmonary edema. After successful recruitment with such measures, reassessment of arterial Po₂ should be considered to determine whether acceptable oxygenation can be maintained.