The clinical time course from onset until full clinical presentation of acute respiratory distress syndrome (ARDS) is largely unknown. The main reason is the inhomogeneity of patients who develop ARDS, especially septic patients or trauma victims. Furthermore the initiating event that leads to ARDS in those patients is unknown. We therefore investigated the time course of ARDS in a homogeneous group of patients undergoing esophageal resection (n = 40, 9 patients or 22.5% developed ARDS) utilizing a validated lung injury score. The full clinical picture of ARDS with diffuse alveolar infiltration and deterioration of pulmonary function develops 5-6 days after esophagectomy. Radiological changes are most pronounced in the lower quadrants. Total thoracic compliance was lowest 3 weeks after esophagectomy, possibly as a sign of the late or fibrotic stage of ARDS.