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Background:  Patients with coronavirus disease 2019 (COVID-19) may develop severe acute respiratory distress syndrome (ARDS). The aim of the study was to explore the lung recruitability, individualized positive end-expiratory pressure (PEEP), and prone position in COVID-19-associated severe ARDS.   Methods:  Twenty patients who met the inclusion criteria were studied retrospectively (PaO 2 /FiO 2  68.0 ± 10.3 mmHg). The patients were ventilated under volume-controlled mode with tidal volume of 6 mL/kg predicted body weight. The lung recruitability was assessed  via  the improvement of PaO 2 , PaCO 2 , and static respiratory system compliance (C stat ) from low to high PEEP (5–15 cmH 2 O). Patients were considered recruitable if two out of three parameters improved. Subsequently, PEEP was titrated according to the best C stat . The patients were turned to prone position for further 18–20 h.   Results:  For recruitability assessment, average value of PaO 2  was slightly improved at PEEP 15 cmH 2 O (68.0 ± 10.3 vs. 69.7 ± 7.9 mmHg, baseline vs. PEEP 15 cmH 2 O;  p  = 0.31). However, both PaCO 2  and C stat  worsened (PaCO 2 : 72.5 ± 7.1 vs. 75.1 ± 9.0 mmHg;  p  < 0.01. C stat : 17.5 ± 3.5 vs. 16.6 ± 3.9 ml/cmH 2 O;  p  = 0.05). Only four patients (20%) were considered lung recruitable. Individually titrated PEEP was higher than the baseline PEEP (8.0 ± 2.1 cmH 2 O vs. 5 cmH 2 O,  p  < 0.001). After 18–20 h of prone positioning, investigated parameters were significantly improved compared to the baseline (PaO 2 : 82.4 ± 15.5 mmHg. PaCO 2 : 67.2 ± 6.4 mmHg. C stat : 20.6 ± 4.4 ml/cmH 2 O. All  p  < 0.001 vs. baseline).   Conclusions:  Lung recruitability was very low in COVID-19-associated severe ARDS. Individually titrated PEEP and prone positioning might improve lung mechanics and blood gasses.

Lung Recruitment, Individualized PEEP, and Prone Position Ventilation for COVID-19-Associated Severe ARDS: A Single Center Observational Study