COVID-19 can be associated with acute respiratory distress syndrome (ARDS) which increases the likelihood of morbidity and mortality. Ventilator-induced lung injury (VLI) is a known complication of mechanical ventilation (MV) and can further compound lung injury and recovery. Escalation to extracorporeal membrane oxygenation (ECMO) can be required in patients who deteriorate on MV. We report our experience with complete avoidance of MV using an ECMO First strategy deployed in an awake non-intubated COVID-19 patient with severe pneumonia.