• Giacomo Grasselli, Emanuele Cattaneo, and Vittorio Scaravilli.
• Department of Pathophysiology and Transplantation, University of Milan.
• Curr Opin Crit Care. 2021 Feb 1; 27 (1): 6126-12.

Purpose Of ReviewTo summarize the current knowledge of pathophysiology and ventilatory management of acute respiratory failure in COVID-19.Recent FindingsEarly reports suggested that COVID-19 is an 'atypical ARDS' with profound hypoxemia with normal respiratory system compliance (Crs). Contrarily, several more populated analyses showed that COVID-19 ARDS has pathophysiological features similar to non-COVID-19 ARDS, with reduced Crs, and high heterogeneity of respiratory mechanics, hypoxemia severity, and lung recruitability. There is no evidence supporting COVID-19-specific ventilatory settings, and the vast amount of available literature suggests that evidence-based, lung-protective ventilation (i.e. tidal volume ≤6 ml/kg, plateau pressure ≤30 cmH2O) should be enforced in all mechanically ventilated patients with COVID-19 ARDS. Mild and moderate COVID-19 can be managed outside of ICUs by noninvasive ventilation in dedicated respiratory units, and no evidence support an early vs. late intubation strategy. Despite widely employed, there is no evidence supporting the efficacy of rescue therapies, such as pronation, inhaled vasodilators, or extracorporeal membrane oxygenation.SummaryGiven the lack of evidence-based specific ventilatory strategies and a large amount of literature showing pathophysiological features similar to non-COVID-19 ARDS, evidence-based lung-protective ventilatory strategies should be pursued in all patients with COVID-19 ARDS.Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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