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Pneumonia, sepsis, respiratory failure and multiple organ system failure are among the most common causes of death in critically ill patients (1). Particularly pneumonia and respiratory failure are frequently associated to protein calorie malnutrition (2-4), which can modify respiratory muscle function, ventilatory drive and lung defence mechanisms (5, 6). Both drive and muscle derangement can be corrected by nutritional support (1, 7, 8); however, the improvement of nutritional status does not always result in a better prognosis (9, 10). Nevertheless, many clinicians suggest the administration of a nutritional therapy to all patients at risk for metabolic complications due to starving (1, 6, 11, 12). The planning of nutritional support for patients under mechanical ventilation and/or suffering from respiratory failure should carefully consider the diet induced thermogenesis (DIT), gas exchanges, the effect on lung tissue of single substrates and protein sparing effect of nutrition.

Single lung transplantation (SLT) is now successfully used in patients with severe emphysema. Mechanical imbalance between the native emphysematous and the healthy transplanted lung can be easily managed, unless severe graft failure occurs, leading to acute respiratory failure. Emergency retransplantation has been used in this setting, since the conventional approach to adult respiratory distress syndrome (ARDS) (mechanical ventilation and positive end-expiratory pressure [PEEP]) fails, due to the mechanical discrepancy between the two lungs. We describe two cases of severe graft failure following SLT in emphysema patients that were successfully treated with prolonged independent respiratory treatment. Mechanical ventilation and PEEP were applied to the failing transplanted lung while the native emphysematous lung was maintained on spontaneous breathing to avoid hyperexpansion and barotrauma. The independent lung respiratory treatment lasted 35 and 25 days, respectively: to our knowledge, these are among the longest-lasting independent respiratory treatments reported. The management was simplified by the early use of a double-lumen tracheostomy cannula as an alternative to orotracheal double lumen tube.