Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 9 2 2023 04 15 178 180 Kasra Karvandian Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Shabnam Beigi Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Zahra Ataie-Ashtiani University of Melbourne, Melbourne, Australia. Mohammad Ashouri Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Narjes Mohammadzadeh Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. 2022 05 14 2022 06 11 Since the first wave of COVID-19, different methods for management of COVID-19 ARDS were proposed. Early intubation and mechanical ventilation was performing more than other methods. after several mounths, limitation of equipment in hospitals, made the specialists think of less aggresive methods. NIV was one of suggestion performed before intubation which improve oxygenation of patients. They don't get any sedation and have regular diet. As a result, the need for ICU and ventilator for respiratory support decreases. In this case study, we report a patient that had permanent tracheostomy and hospitalised for COVID-19 ARDS. At first we connected the tracheostomy to a CPAP devise. https://aacc.tums.ac.ir/index.php/aacc/article/view/550