Noninvasive Respiratory Support for Pediatric Critical Asthma

Pediatric asthma is a common cause of emergency department visits and hospital admissions. Whereas most patients respond well to standard pharmacologic treatments, those with more severe disease frequently require noninvasive respiratory support (NRS) and adjunct therapies or admission to an ICU-a condition termed critical asthma. NRS modalities include high-flow nasal cannula, CPAP, and noninvasive ventilation to deliver standard air-oxygen mixtures or helium-oxygen (heliox). Each NRS modality offers distinct physiological benefits, primarily aimed at reducing work of breathing, enhancing gas exchange, and optimizing aerosol delivery. Despite the growing use of NRS, robust evidence supporting its efficacy in pediatric critical asthma is limited, with few published clinical trials and a heavy reliance on observational studies to inform clinical practice. This narrative review explores the current evidence, physiological rationale, practical considerations, and future research directions for the use of NRS in pediatric critical asthma. The goal is to provide clinicians with a comprehensive overview of the benefits and limitations of NRS modalities to better inform therapeutic decisions and improve patient outcomes.