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e1368 www.ccmjournal.org December 2020 • Volume 48 • Number 12 is in a way acknowledged by the authors, we truly appreciate their opinion letter and we share their position. This correspondence gives me the opportunity to relate a story I have recently been involved with, albeit only from a distance. Following the publication of the article, I was contacted by email by a desperate relative who was witnessing the slow agony of a beloved friend in an American hospital. The patient was a 40-year-old native American pediatric nurse practitioner, father of three, who had contracted the severe acute respiratory syndrome coronavirus 2 and quickly developed an extremely severe hypoxemic form of bilateral pneumonia. He received antiviral remdesivir, dexamethasone, convalescent plasma, but despite this medicinal cocktail, his respiratory status continued to deteriorate, and he was intubated. Rapidly, the Pao 2 / Fio 2 ratio dropped below 60 despite paralysis and a positive end-expiratory pressure set at 14 cm H 2 O. In her letter, my correspondent stated “due to weight (136 kg) and size his doctors state he does not qualify for prone position.” Along the same lines, she confessed “Extra Corporeal Membrane Oxygenation (ECMO) treatment has also been deemed unfit for him due to his weight.” This case illustrates the fact that when obesity is taken into consideration, it is too often only as a barrier that prevents the implementation of many useful therapeutic options rationally supported by physiology and evidence based medicine. If the critically ill patient is a special case to whom many concepts and evidence available in the different specialties of medicine cannot apply, the severely obese patient in the ICU is even more special by many aspects (4). For instance, the chief mechanism of hypoxemia in the hospitalized obese patient is ventilation/perfusion mismatch due to gravitational atelectasis in the supine posture. While COVID-19 pneumonia generates pulmonary vascular disorders significantly affecting the pulmonary gas exchange, obesity adds some lung derecruitment and increased mechanical workload, all of which dramatically deteriorate even further the pulmonary function, especially so when the obese patient is lying down. In the ICU, given the higher nurse-to-patient ratio and the availability of specialized bariatric equipment, obesity in itself should not be an excuse for avoiding procedures that are physically taxing for the staff. Specific obese patient’s positioning (prone position or sitting position) and early rehabilitation are inexpensive but nevertheless efficient interventions with solid evidence for their beneficial effect (5, 6). According to the medical literature and experts’ recommendations, the obese patient population should not be deprived of ECMO support if needed (4). To conclude, we agree that obesity in intensive care should be given more consideration as a standalone condition rather than a simple risk factor and that clinical teams should offer critically ill obese patients an individualized approach based on their unique physiologic features. The authors have disclosed that they do not have any potential conflicts of interest.