HFNC AND NIV IN PEDIATRIC ARDS POST-PALICC-2: FAILURE PREDICTORS, ESCALATION THRESHOLDS, AND OUTCOMES

Abstract

Noninvasive respiratory support via high-flow nasal cannula and noninvasive ventilation has become first-line therapy for many children with pediatric acute respiratory distress syndrome. The Second Pediatric Acute Lung Injury Consensus Conference provided updated guidance on noninvasive strategies, yet substantial gaps remain in defining failure predictors and escalation thresholds. This review synthesizes recent evidence on SpO₂/FiO₂ ratio, pediatric ROX-index variants, work-of-breathing assessment, and monitoring timepoints. We extracted data from observational cohorts and consensus statements to construct threshold tables and a practical escalation pathway. While severe hypoxemia and persistent respiratory distress are consistent triggers for intubation, no single numeric cutoff reliably identifies all children who will fail noninvasive support. Close reassessment at 1–2 hours and 6–12 hours, combined with trajectory-based decision-making, aligns with post-PALICC-2 recommendations. Outcomes including intubation rates, intensive care unit length of stay, and mortality vary with disease severity and timing of escalation. Future prospective studies are needed to validate composite scores and define optimal escalation windows that balance avoidance of intubation delay against premature invasive ventilation.