Lung volume reduction surgery and lung transplantation have emerged as viable surgical options for selected patients with end-stage pulmonary disease. Both procedures involve significant anesthetic and surgical perturbations, in patients whose physiologic balance is already tenuous. This article reviews important considerations from the anesthetic perspective, which require appreciation by the surgical and perioperative teams for a coordinated approach to these procedures. Particular emphasis is placed on the pathophysiology of severe chronic obstructive pulmonary disease and management issues at critical anesthetic junctures, including induction, one-lung ventilation, and emergence as well as cross-clamping of the pulmonary artery and graft reperfusion in the case of lung transplantation.