We describe a case of severe acute lung injury after attempted strangulation. The patient presented initially with cerebral irritability and florid, noncardiogenic pulmonary oedema which were followed by a prolonged period of the adult respiratory distress syndrome, severe sepsis and multiple system organ failure, although the patient eventually survived. The pulmonary injury following strangulation is proposed to be a result of the generation of marked subatmospheric pressures within the lungs during vigorous inspiration against an obstructed airway, although the processes involved in the so-called neurogenic pulmonary oedema are difficult to exclude.