Intraoperative ventilation strategies must be based on recipient physiology, with different strategies for obstructive vs restrictive disease. One-lung ventilation begins at pneumonectomy; ABG monitoring is critical due to unreliable EtCO2. Air leaks, hypoxia, and poor compliance are common, with ECMO increasingly used to optimize oxygenation and hemodynamics. Inhaled nitric oxide (iNO) is reserved for severe graft dysfunction or pulmonary hypertension, though long-term benefits are uncertain. Careful coordination between anesthesia, perfusion, and surgery—including lung recruitment, bronchoscopy, and echocardiography—is essential to identify complications and guide management.