A plausible explanation for these negative results is that complications related to the surgical procedure may have cancelled out any potential benefit of obtaining a definitive diagnosis. Indeed, complications were noted in as much as 39% of patients, were defined as major (eg, death, myocardial infarction, stroke, institution of dialysis, or hemothorax within 48 h of surgery) in 7% of patients, and were defined as minor (eg, acute renal failure, 11% of patients; persistent air leak for > 1 week, 21% of patients) in 32% of patients.1We do not agree with the authors’ statement that, due to its low rate of major complications, OLB is a safe procedure in ARDS patients. In contrast, we think that the impact of the so-called minor complications has been underestimated by the authors, especially when it comes to the problem of persistent air leak. Persistent air leak (in effect, a bronchopleural fistula) requires prolonged chest tube drainage, may pose important problems in achieving adequate ventilation, and is associated with a poor prognosis in mechanically ventilated patients with severe respiratory failure.2–4 As such, the occurrence of a bronchopleural fistula has to be regarded as an ominous complication of OLD, rather than a minor complication, in the series reported by Patel et al. It would be meaningful to know about the outcomes of patients who developed such a complication in this study.