Dear Editor, Post-traumatic pneumonectomy is rare, but burdened by high mortality (50–80 %) and high morbidity, with a complication rate of [85 %, most commonly pneumonia and respiratory failure [1]. Life-threatening acute respiratory distress syndrome (ARDS) can develop, and the worst outcome is associated with right pneumonectomy [2]. Extracorporeal membrane oxygenation (ECMO) is a rescue option in ARDS that allows for protective mechanical ventilation and potentially less ventilator-induced damage [3]. In the past, trauma cases requiring anticoagulation for ECMO implantation posed a clinical dilemma that has now been partially overcome with the advent of latest generation devices. We report a case of multifactorial ARDS (pneumonia, polytransfusion, and fluid overload) after right pneumonectomy due to blunt chest trauma in which the patient was non-responsive to protective ventilation and conventional therapy [4]. The patient survived with early implantation and 29 days of ECMO support. A 25-year-old male (170 cm, 61 kg) was admitted to another facility with major blunt thoracic trauma causing right hemothorax, right main bronchial disruption, left pneumothorax, and pneumomediastinum. Surgical treatment consisted of right pneumonectomy, left chest drainage, and tracheostomy. Despite lung-protective ventilation, the patient developed ARDS, with hypoxic–hypercapnic respiratory failure [partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2) 40 at 36 h]. A PaO2/ FiO2 ratio of\100 with a FiO2 of 1.0 for more than 6 h indicates that a patient has a [80 % risk of death (Extracorporeal Life Support Organization guidelines) (Fig. 1). The referring center requested a consultation, and despite the recent trauma and surgery, we decided to start the patient on veno-venous ECMO (VV-ECMO) which achieved stabilization and allowed the patient to be safely transported about 200 km by helicopter to our institute. Vessel cannulation [18 Fr return (jugular) and 24 Fr drainage (femoral)] was performed after the administration of a heparin bolus (80 IU/kg). VVECMO support (miniaturized tip-totip heparin-coated circuit; Cardiohelp System; Maquet, Rastatt, Germany) was initiated, with the initial goal of achieving a blood flow of about 4 l/ min (3,000 rpm and 2 l/min of sweep gas flow) in order to provide maximal oxygenation support, but avoid iatrogenic alkalosis. Protective mechanical ventilation for transport was a FiO2 of 40 %, peak inspiratory pressure (PIP) of 20 cm H2O, positive end-expiratory pressure (PEEP) of 10 cm H2O, and respiratory rate (RR) of 10 breaths/min (Oxylog 3000 Plus; Draeger, Menlo Park, CA). On arrival at our institute, after a few hours of ECMO, gas exchange parameters were adequate (pH 7.34, PaO2 116 mmHg, PaCO2 58 mmHg). Microbiological screening revealed colonization by Acinetobacter baumannii (multi-drug resistant), which was confirmed by the swab test and bronchoalveolar lavage. Continuous heparin infusion was initiated to maintain an activated partial thromboplastin time of 40–50 s, and an