Changes in the surfactant system have been observed in patients with acute respiratory distress syndrome (ARDS). These alterations in surfactant are thought to contribute to lung dysfunction in this disease. In this report we describe the changes in surfactant subfractions in bronchoalveolar wash obtained from five patients with established ARDS compared with five non-ARDS patients. Our results show that, in addition to the changes in surfactant composition and yield reported previously, the ratio of small to large surfactant aggregates is significantly increased in patients with ARDS compared with non-ARDS patients (0.48 +/- 0.09 versus 0.20 +/- 0.05 respectively [p < 0.05]). This increased ratio was associated with a decreased level of SP-A in the large aggregate fraction. We suggest that this increased ratio represents a marker for surfactant alterations in ARDS that is independent of lavage technique and can be measured in a very small surfactant sample.