In a recent issue of CHEST (March 2011), Yang et al1 demonstrated a surprisingly clear benefit of protective-ventilation strategy compared with conventional ventilation (CV) for thoracic surgical procedures in a small sample of patients. With 50 patients in each study arm, they demonstrated a 22% rate of pulmonary dysfunction in the conventional group vs 4% in the protective-ventilation cohort. Yet, serious problems with randomization and study design cast some doubts over the suggestive results. In the CV group, the majority of the procedures (>50%) were performed by one surgeon. In addition, in the same group, <40% of the patients (vs 60% in the protective ventilation group) had an epidural for postoperative pain management, making the two groups almost incomparable.2 Furthermore, in 30% of the patients in the CV group, a change in ventilation mode was necessary for the continuation of the procedures. Too many variables, such as Fio2, positive end-expiratory pressure, mode of ventilation, postoperative pain management, open vs video-assisted operation, and so forth, make a statement about the advantage of one strategy over the other nearly impossible.3 Although Yang et al1 intended to show some evidence in favor of a protective strategy, the jury on this issue is still out.