He was started on sodium bicarbonate inhalation every 6 hours. Oxygen saturation post intubation was 89%. He was placed on AC 6.5 ml/kg/VT and PEEP of 15 with FIO2 of 100%. He was competent to make his own decision. He declined intubation initially for the first 2 days of hospitalization. He presented to the hospital with Oxygen saturation of 49 % on RA. His wife self-quarantined at home, while he developed dyspnea and intractable cough. Case 2Д¦0 year old male with a history of hypertension on amlodipine and Enalapril, He and his wife have been tested positive for COVID -19 via a clinic as an outpatient. The arterial blood gases were reviewed daily to monitor for possible metabolic alkalosis, which did not occur in any of the patients.ДЇigure 1: a) Chest x ray (Case 1) showing extensive infiltrate, largely on the right,Д«) imaging for the same patient, After sodium bicarb treatment. The cases were reviewed daily and assessed clinically and radiologically. Also, with the support of the pharmacy staff at our institution, the dose was addressed to be comparable to the doses used for mucoid impaction in cystic fibrosis (CF) patients. The treatment was discussed with the family members over the phone due to the hospitalвЂ™s no visitation policy and the families were in agreement with the application of sodium bicarbonate inhalation therapy. We applied ARDSnet Lung protective strategy (a well-known guidelines for ventilator management in ARDS) on all of the cases. Arterial blood gas (ABG) was also obtained daily to evaluate for the development of Hypercarbia and monitor the arterial blood PH. We obtained a daily chest x rays on every patient to evaluate the effect of the treatment radiologically. Once the FIO2 is down to 50%, the PEEP was reduced by 2.5 every 6-12 hours to keep the oxygen saturation > 88%. The FIO2 then reduced by 10% every 4-8 hours to keep oxygen saturation at > 88% as tolerated. The dose of sodium bicarbonate used was 10 ml of the nebulized solution and was delivered via the inspiratory limb of the ventilator tubing every 6 hours. Our patients were treated with nebulization of sodium bicarbonate 4.2 % solution. (These two patients who underwent bronchoscopy, were the sickest patients with APACHE score higher than 25). Two of the patients underwent a bronchoscopy to exclude airway obstruction (Case 1 and Case 4) and one patient initially received instillation of sodium bicarb of 40 ml in an increment of 2 ml in each segment during the bronchoscopy to dislodge mucous plugs. Also, a standard PEEP of 15 was used throughout the process to keep the alveoli patent to assure the delivery of the nebulized sodium bicarbonate via the ventilator circuit. Due to severe hypoxia despite 100% FIO2, these patients were placed on Positive end expiratory pressure (PEEP) of 15 to maintain their Oxygen saturation at 87% at minimum. All four patients had severe adult respiratory distress syndrome (ARDS) and required 100 % Fraction of inspired oxygen (FIO2). Each one of the patients received inhaled 4.2% sodium bicarbonate as a salvage therapy. All patients have proven positive COVID-19 RNA collected from the airwayвЂ™s secretions. It has not been administered for COVID -19 patients particularly prior to this study.ДЇour patients required mechanical ventilation due to COVID-19 pneumonia. The sodium Bicarbonate inhalation (4.2% concentration) has been used safely in Cystic fibrosis (CF) patients with inspissated mucoid impaction and in chloride inhalation toxicity by opposing the effect of the low PH induced by the insulting agent. The goal of our Case study was to prevent SARS- SARS-Cov2 from entering target cells by raising the airways PH using sodium bicarbonate inhalation. The evidence based literature describes three component for the virus to grant entry to the target cells including Cathepsin B/L (the viral cap protein needed for initial connectivity to the cell wall), the angiotensin converting enzyme 2 and a low PH environment to allow the first connectivity of the virus to the cell wall. We reviewed the available literature from China and Europe in regard to the behavior of SARS-Cov2 and ability to adhere to the cell wall. COVID-19 has a significant mortality, mostly from acute lung injury. The emergence of COVID-19 worldwide in an unprecedented pandemic.

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