COVID-19 is highly infectious and can lead to fatal comorbidities especially ARDS. There are currently no recommended specific anti-COVID-19 treatments, so supportive treatment is important.

Fully understanding the characteristics of COVID-19-related ARDS is conducive to early identification and precise treatment.

We aimed to describe the characteristics of COVID-19-related ARDS and to elucidate the differences from ARDS caused by other factors. COVID-19 mainly affected the respiratory system with minor damage to other organs. Injury to the alveolar epithelial cells was the main cause of COVID-19-related ARDS, and endothelial cells were less damaged with therefore less exudation.

The clinical manifestations were relatively mild in some COVID-19 patients, which was inconsistent with the severity of laboratory and imaging findings.

The onset time of COVID-19-related ARDS was 8–12 days, which was inconsistent with ARDS Berlin criteria, which defined a 1-week onset limit.

Some of these patients might have a relatively normal lung compliance.

The severity was redefined into three stages according to its specificity: mild, mild-moderate, and moderate-severe.

HFNO can be safe in COVID-19-related ARDS patients, even in some moderate-severe patients. The more likely cause of death is severe respiratory failure. Thus, the timing of invasive mechanical ventilation is very important.

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