Rationale: Whilst surfactant replacement therapy is an established treatment in infant respiratory distress syndrome, the optimum strategy for ventilatory management before, during and after surfactant instillation remains to be elucidated. Objectives: To determine the effects of surfactant and lung volume recruitment on the distribution of regional lung ventilation. Methods: Acute lung injury was induced in 16 newborn piglets by endotracheal lavage. Optimum positive end-expiratory pressure was identified after lung recruitment and surfactant administered either at this pressure in the "open" lung, or after disconnection of the endotracheal tube in the "closed" lung. An additional recruitment maneuver with subsequent optimum end-expiratory pressure finding was executed in 8 animals, in the other 8 end-expiratory pressure was set at the same level as before surfactant without further recruitment. ("Open" and "closed" lung surfactant administration was evenly distributed in the groups.) Regional ventilation was assessed by electrical impedance tomography. Measurements and main results: Impedance tomography data, airway pressure, flow, arterial blood gases were acquired during baseline conditions, after induction of lung injury, after the first lung recruitment, before as well as 10 and 60 min after surfactant. Significant shift in ventilation towards the dependent lung regions and less asymmetry in the right-to-left lung ventilation distribution occurred in the post-surfactant period when an additional recruitment maneuver was performed. Surfactant instillation in an "open" versus "closed" lung did not influence ventilation distribution in a major way. Conclusions: The spatial distribution of ventilation in the lavaged lung is modified by a recruitment maneuver performed after surfactant administration.