OLB is not without risk in a critically ill patient who is mechanically ventilated. The meta-analysis by Libby and colleagues22 reported an overall surgical complication rate of 22%. In more recent case series including only patients who are mechanically ventilated, the complication rate ranged from 20% to 59%.18‐21,27 Video-assisted thoracoscopic surgery (VATS) was included as an alternative to open thoracotomy in some studies enrolling both inpatients and outpatients but was used in < 10% of cases.22 The main limitation of VATS for a critically ill patient with hypoxemia is the necessity of tolerating single lung ventilation during the procedure.55 Because this is not feasible for many patients and given a more robust published experience with OLB through a minithoracotomy, sometimes at the patient’s bedside, OLB is more conventional.28,33 The surgical complication rates in OLB and VATS have not been compared directly in a population with ARDS; we compare the risks and benefits of OLB with those of transbronchial biopsy in Table 2. The most common postoperative complication of OLB is a persistent air leak, with incidence varying depending on the case series examined and the definition applied.18,19,21,22,33,56 The strongest association with persistent air leak in one review was higher preoperative peak airway pressure (43 cm H2O in those with a persistent air leak compared with 32 cm H2O in those without; P = .0005).57 Minimizing airway pressures is recommended immediately prior to and during the lung biopsy to reduce this risk. Other reported complications include procedure-related bleeding,19,20,33,56 hypotension,21,56 acute myocardial infarction,58 and worsening of hypoxia.56 Although pain is not mentioned explicitly in any case series of OLB in patients who are ventilated, it is difficult to imagine that chest tubes would be pain free; thus, it is our practice to counsel patients and their proxies that if a chest tube is required, pain will be present and likely will require treatment.