Patients who develop severe COVID-19 disease can develop respiratory failure and subsequently Acute Respiratory Distress Syndrome (ARDS). However, it has to be noted that these patients may not follow the typical ARDS disease trajectory. The causes of this paradox are complex and not yet fully understood, with the result that varying pathophysiological hypotheses have been proposed. This article describes ARDS in COVID-19 patients and the use of the conscious and unconscious prone position as an intervention to improve oxygenation.