Considerable share of patients admitted to the intensive care unit, during the current Covid-19 pandemic, are obese. Obesity is associated with chronic low-grade inflammation, higher endothelial injury, higher levels of angiotensinogen II and increased expression of angiotensin-converting enzyme 2 receptors in the adipose tissue. These alterations along with accompanying comorbidities make the obese patients susceptible for the development of severe respiratory complications, including acute respiratory distress syndrome (ARDS) during SARS-CoV-2 infection. The choice of optimal mode of oxygen delivery rests on both a prior patient's functional status and the progress and severity of Covid-19 in obese patients. Non-invasive ventilation and high-flow nasal cannula, prone position and hyperbaric oxygen therapy are effective in obese patients with mild or moderate ARDS. If mechanical ventilation is unavoidable, lung protective ventilation mode with lower tidal volume and optimal positive end-expiratory pressure is crucial for treatment of SARS-CoV-2-induced ARDS. Extracorporeal membrane oxygenation is reserved only for patients with inadequate response to previous oxygen therapy. Optimal knowledge of physiological changes in obesity and timely treatment with adequate oxygen therapy could improve clinical outcome of these sensitive patient subgroup.
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