COVID-19 in its initial manifestations has strikingly peculiar characteristics (e.g., hypoxemia with vasocentric injury and high gas lung volume), is so evident that atypical ARDS should not be a matter of further discussion. Yet, in an apparent attempt to preserve the concept of “classical” ARDS during their discussion of our data Goligher et al. come to the rather surprising conclusion that it is not the ARDS we observed to be atypical but rather that our patients were atypical for COVID-19 pneumonia.

Beyond the purely semantic arguments, what really matters is the respiratory treatment administered to single individuals.

We may wonder if the currently applied protocols guiding ARDS treatment, which were developed on evidence gathered from unselected populations with different etiologies, need to be equally applied without caution to this new, single-etiology disease.

For example, a tidal volume of 6 ml/kg—a standard of care for the ARDS ‘baby lung’—is obviously acceptable, although somewhat higher tidal volumes of 7–8 ml/kg were proven to be not-harmful in randomized controlled trials.

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