To improve long-term outcomes, several investigators have attempted to identify factors during the acute illness that are associated with adverse long-term outcomes. With respect to this issue, Burnham and colleagues11 publish data in this issue of CHEST (see page 1196) that supplements previous evidence linking physiologic abnormalities present on the day of ARDS onset with long-term outcomes. In a retrospective analysis of prospectively collected data from an ARDS clinical trial, they found static respiratory system compliance measured on the first day or averaged over the first 14 days of MV had an inverse correlation with the severity of reticular changes on chest high-resolution CT (HRCT) scan. HRCT scan reticular changes are thought to most often reflect areas of tissue fibrosis. This study complements data previously published by the same group in which they showed that HRCT scanning at day 14 correlated with poorer HRQoL at 6 months.12 The strengths of the present study include a prospective collection of data, an explicit protocol for low-tidal-volume MV and weaning, as well as a defined protocol for performance of HRCT scan and interpretation by blinded readers. One significant limitation of the study is that the included subjects were a “convenience cohort” that was substantially different than the cohort of patients who were eligible but were not enrolled. The excluded patients had more severe physiologic derangements, which precluded safe transport for an HRCT scan and much higher 28-day mortality. This limits generalizability of the studies’ findings and raises the question of whether a noninvasive physiologic measure that could be assessed at the bedside, such as dead-space fraction or oxygenation index, would work as well as an HRCT scan in identifying patients destined for long-term morbidity. In addition, it is not clear from this work whether compliance abnormalities measured in the first 14 days reflect pulmonary edema, an exuberant fibroproliferative response,3 or most likely a combination of both.