Over the last 20 years, lung transplantation has emerged as a valid treatment option for a wide range of advanced lung diseases. Surgical advances combined with newer immunosuppressant medications have improved outcomes; however, both the short-term and long-term survival after lung transplant continues to lag behind other solid-organ transplants. Survival for lung transplant recipients at 1 year, 3 years, and 5 years is approximately 76%, 58%, and 47%, respectively.1– Early respiratory failure and death after lung transplant can result from airway complications, hyperacute rejection, acute rejection, infection, or ischemia/reperfusion lung injury (IRLI). Graft failure secondary to bronchial dehiscence is now rare with improved surgical techniques. Hyperacute rejection, infrequently described in lung transplantation, results from preformed antibodies that target antigens in the allograft vascular endothelium and cause extensive thrombosis and complement activation. Acute rejection occurs in > 60% of lung recipients despite current immunosuppressive protocols, but usually responds to augmented immunosuppression and rarely leads to early graft loss. Infectious complications, such as bacterial pneumonia or cytomegalovirus, have been described as a common etiology of respiratory failure and mortality in the early posttransplant period. IRLI or reimplantation response is characterized by the development of bilateral pulmonary infiltrates, declining lung compliance, and worsening of gas exchange in the immediate posttransplant period after exclusion of rejection, infection, and heart failure. Severe IRLI has been reported to occur in 15 to 30% of patients.2 Despite the increasing experience with lung transplantation, all of these problems contribute to the development of early respiratory failure and a 1-year mortality of approximately 25%.