Maximum expiratory and inspiratory flow-volume (MEFV, MIFV) curves, specific airway conductance (sG aw ), and flexible fiberoptic laryngoscopy were examined in 8 pediatric lung transplant recipients with vocal cord paralysis (VCP). Six were heart-lung (H-L) and 2 double-lung (D-L) recipients, 7 had left VCP, and 1 had right VCP. Based on the pulmonary function tests (PFT), 2 subgroups could be distinguished in the 8 recipients with VCP. Group A (5/8 recipients; mean age, 13 Β± 3.4 years; mean height, 144.3 Β± 12.3 cm) had significantly reduced specific airway conductance (sG aw ; < 2 SD from predicted) and normal MEF 25 , MEF 50 , peak expiratory flow (PEF), forced expiratory volume in 1 second (FEV 1 ), and %FEV 1 /forced vital capacity (FVC); this pattern suggested variable extrathoracic airway obstruction. PIF was normal in 4/5 and reduced in 1/5 of these recipients. Group B (3/8 recipients with VCP; mean age, 17 Β± 2.4 years; mean height, 156.3 Β± 12.0 cm) had significantly reduced sG aw , MEF 25 , MEF 50 , PEF, FEV 1 , and %FEV 1 /FVC, implying primarily small airway obstruction. These recipients had bronchiolitis obliterans. The results suggest that a pattern of reduced sG aw and normal MEFs, PEF, FEV 1 , and PIF should raise the possibility of VCP in patients after lung transplantation. sG aw is more sensitive than PIF and PEF in identifying airway obstruction due to VCP, and should be routinely included in the follow-up evaluation of lung transplant recipients.