In patients with Covid-19 acute respiratory failure (ARF), prolonged observation could save lives by avoiding invasive mechanical ventilation (IMV) and its associated risks. For a study, researchers sought to link ARF management strategy and in-hospital mortality. Patients in the Weill Cornell Covid-19 registry who developed ARF between March 5 – March 25, 2020, were assigned to an early IMV strategy, an intermediate strategy between March 26 – April 1, 2020, and a prolonged observation strategy after April 2. In-hospital mortality was modeled using Cox proportional hazards regression, and interaction between ARF management strategy and modified sequential organ failure assessment was tested (mSOFA). Among 632 ARF patients, 24% died in the early IMV strategy versus 28% in the prolonged observation strategy. The prolonged observation was associated with lower mortality than early IMV at lower mSOFA (at mSOFA = 0, HR 0.16 [95% CI 0.04–0.57]). However, each increase in the mSOFA score increased the risk of death in the prolonged observation strategy group (HR 1.29 [95% CI 1.10–1.51], P=0.002). When compared to early IMV, prolonged observation was associated with a mortality benefit at lower mSOFA scores and increased mortality at higher mSOFA scores in Covid-19 ARF.