The Effectiveness of Non-Invasive Ventilation in Pediatrics Acute Respiratory Distress: A Systematic Review

Abstract

Background: Acute respiratory distress in children—arising from bronchiolitis, pneumonia, severe asthma, or Pediatric Acute Respiratory Distress Syndrome (PARDS)—remains a leading cause of morbidity and mortality in pediatric intensive care units (PICUs) worldwide. Non- Invasive Ventilation (NIV), including Continuous Positive Airway Pressure (CPAP), Bi-level Positive Airway Pressure (BiPAP), and High-Flow Nasal Cannula (HFNC), has been increasingly adopted as an alternative to invasive mechanical ventilation (IMV). However, the evidence regarding its effectiveness, optimal patient selection, and safety remains heterogeneous.  Objective: This systematic review aims to synthesize current evidence on the effectiveness of NIV in pediatric acute respiratory distress, focusing on its impact on intubation rates, mortality, length of stay, and treatment safety.  Methods: This review followed the PRISMA 2020 guidelines. A comprehensive search was conducted across PubMed, Scopus, Cochrane Library, Web of Science, and Google Scholar up to September 2025. Eligible studies included randomized controlled trials (RCTs), cohort, and case-control studies involving children aged 0–18 years treated with NIV for acute respiratory distress. Extracted outcomes included intubation rate, mortality, length of stay, treatment failure, and adverse events. Data extraction and study selection were independently performed by two reviewers, with discrepancies resolved by consensus or a third reviewer.  Results: Out of 1,301 identified records, 40 studies met inclusion criteria, encompassing approximately 4,500 pediatric patients. NIV significantly reduced the need for IMV in children with bronchiolitis, pneumonia, and moderate PARDS. HFNC demonstrated similar efficacy to CPAP in mild-to-moderate respiratory failure, with improved comfort and fewer interface complications. In severe PARDS, however, NIV failure rates remained high (30–77%), often associated with worse outcomes and longer PICU stays. Predictors of NIV failure included severe hypoxemia (PaO₂/FiO₂ <100), multi-organ dysfunction, and septic shock. Across studies, NIV was generally safe, with minimal adverse effects such as nasal irritation and gastric distension.  Discussion: The accumulated evidence indicates that NIV is an effective and safe therapeutic option for children with mild-to-moderate acute respiratory distress. Early initiation and close monitoring can improve oxygenation, reduce IMV exposure, and shorten hospitalization. Nevertheless, high failure rates in severe PARDS underscore the need for careful patient selection and clear escalation criteria. HFNC provides comparable outcomes to CPAP for less severe cases, while CPAP or BiPAP may offer superior support in more hypoxemic patients.  Further multicenter RCTs are needed to refine patient selection criteria and establish standardized NIV protocols.  Conclusion: Non-Invasive Ventilation serves as a crucial bridge between conventional oxygen therapy and invasive ventilation in pediatric acute respiratory distress. When applied early and appropriately, NIV can reduce intubation rates and improve outcomes while maintaining a favorable safety profile. Future research should focus on optimizing modality selection, standardizing initiation thresholds, and identifying predictors of treatment success and failure in diverse pediatric populations.