In Medicine, we have inherited the tendency to give names to diseases, and when they don't fit very well in the description of the clinical picture we tend to call them syndromes. The entry into the lower respiratory tract of any matter that is not air is considered aspiration. The clinical expression varies from a choking sensation, going through bronchospasm and coughing, up to dyspnea, malaise, and critical illness with need for intensive care, and even death. We could thereby give it many denominations: choking, asthma, bronchitis, aspiration syndrome, Mendelson's syndrome, bronchopneumonia, atelectasis, aspiration pneumonitis, aspiration pneumonia, drowned lung, acute respiratory distress syndrome, noncardiogenic pulmonary edema, and multisystem organ failure.Aspiration has indeed a significantly wide spectrum in its clinical expression. It depends upon what is aspirated, how fast, how much, how deep it gets settled, and how badly the hosts reacts to it.

Chendrasekhar et al. in this issue determined cytokine levels one hour after the instillation of gastric juice, but it is possible that some time before or after, the release of cytokines could have been greater, therefore a time relationship has to be established. We really don't know how much cytokines are enough to trigger the systemic inflammatory response that may lead to significant derangement in gas exchange and multisystem organ dysfunction. This threshold may even vary from person to person.

Undoubtedly this study has a significant value because it sets the stage for further investigative work in the area of early recognition of lung injury by biochemical means, but what is also important is to conceptualize the process of aspiration as a reaction of the host respiratory system to the insulting agent and not as a disease.