Non-invasive ventilation for general paediatricians

Over the past two decades, non-invasive ventilation (NIV) has transitioned from being primarily used in specialist intensive care units to becoming a standard intervention in high dependency units, general paediatric units, emergency departments, and increasingly, patients' homes. Despite this expansion, many general paediatricians still perceive NIV as outside their primary expertise. With this review, we aim to address that gap and equip general paediatricians with the knowledge and confidence to appropriately initiate NIV, monitor its effectiveness, and recognise when escalation of care is required. We narratively reviewed the physiological rationale for non-invasive respiratory support (NRS), including high-flow nasal cannula (HFNC) and the two principal modalities of NIV-continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP)-and summarised disease-specific evidence from recent literature, including randomised trials, systematic reviews, and international consensus statements. This is a narrative rather than a systematic review: we searched PubMed/MEDLINE and Paediatric Respiratory Reviews for English-language publications from January 2018 to June 2026 using the terms "non-invasive ventilation", "high-flow nasal cannula", "CPAP", "BiPAP", and "children", supplemented by references already known to the authors, and selected articles for relevance and recency, prioritising randomised trials, systematic reviews, and consensus statements. HFNC is an oxygenation device rather than a ventilatory device, and its mechanism, clinical applications, and therapeutic goals differ from CPAP and BiPAP. We introduce the Indications, Contraindications, Equipment, Mode and settings, Assessment and monitoring, Next steps (ICEMAN) framework as a practical tool for structured and safe initiation of NIV in routine clinical practice, and apply it across bronchiolitis, acute severe asthma, pneumonia and hypoxaemic respiratory failure, neuromuscular disease, and obstructive sleep apnoea.

The essential requirements to initiate NIV outside the PICU are well-trained staff, appropriate monitoring, a reliable oxygen supply, and a clear plan for escalation to a higher level of care. Selection of patients for NIV outside the PICU requires careful attention to indication, contraindications, equipment, monitoring, and escalation pathway by using frameworks like ICEMAN.

• HFNC, CPAP, and BiPAP are established, physiologically distinct respiratory therapies now used well beyond the PICU.

• The ICEMAN framework, updated with PALICC-2 ARDS criteria, gives non-specialists a structured, teachable approach to safe NIV initiation.