Non-invasive ventilation (NIV) refers to the use of techniques of ventilatory support that do not include the utilization of invasive airways such as endotracheal tubes or tracheostomies. Thus, the full spectrum ranges from high-flow humidified nasal oxygen (HFHNO), through nasal continuous positive airways pressure (CPAP), to a wide range of positive (and negative) pressure support modes of ventilation.

Over the last decade, there has been a progressive increase in interest (in 2013 there were 230 publications on Pubmed including the search term NIV, vs. 14 in 1993 and 88 in 2003) and utilization [1] of NIV (both within and outside the intensive care unit) across the world. In adult intensive care, there has recently been particular focus on the use of NIV in: acute respiratory failure and ARDS [2]; patients with terminal conditions or following refusal of endotracheal intubation [3]; in patients who are being weaned off ventilator support [4]; and in patients following major surgery. A recent review has pointed out that there has been a substantial increase in the use of NIV across all diagnoses and in all settings of acute respiratory failure [5], and at the same time there has been substantial increase in the use of NIV for chronic ventilator support.

CPAP in various forms has been extensively used in neonatal care across the world for many years. More recent is the recognition that infants who fail nasal CPAP may be managed successfully without intubation, by use of additional forms of NIV [6]. HFHNO has also been utilized in the neonatal setting throughout the world [7], although there is limited evidence comparing this mode of support with alternative strategies.

In paediatrics, there has also been extensive interest in NIV, and in many centres there has been a dramatic increase in the utilization of NIV for respiratory support in a variety of settings from the emergency department [8], through transport services [9], to the intensive care unit [10, 11] (and other less well-equipped clinical areas) [7]. There is evidence that the increased use of nasal CPAP in bronchiolitis has been associated with a dramatic reduction in duration of PICU and hospital stay as well as costs [11].

While there has been increased focus on NIV (in multiple forms), there is very little formal study evidence to underpin the use of NIV in children. Currently, there are few randomized controlled studies of NIV in children (Table 1), and they do not compare conventional ventilation with NIV. A relatively recent systematic review [12] of the use of CPAP in children with bronchiolitis concluded that there is insufficient high-quality evidence to support the use of CPAP in this setting. There is currently a registered RCT collecting data (ISRCTN82853500) on the use of CPAP in immune-compromised children with acute respiratory distress. Thus, there is a real need for extensive international collaborative research to clarify the role of NIV.

Table 1 Prospective studies with paediatric NIV since 2000
Full size table

However, the research programme is potentially challenged by a number of issues including: selection of patients for NIV; the optimal timing and implementation of NIV; the interfaces used to provide care; the modes of NIV and the triggering modalities utilized to optimize delivery of NIV.

There is a need for predictive tools to select those patients who might benefit most from NIV. A recent multicentre study of children who required respiratory support for bronchiolitis [13] showed that it was possible to some extent to predict children who would require ventilatory support for bronchiolitis, and identified a subgroup who rapidly progressed to respiratory failure. However, as the range of indications for NIV expands, it is going to be difficult to focus research on the appropriate identification of children who are likely to benefit from NIV.

The quality of interfaces may play a crucial role in the success of NIV, regardless of the mode which is used to provide it. Although most interfaces have focussed on the use of nasal cannulae or face masks, there is recent evidence that helmets may be useful [14]. Velasco et al. [15] have recently reported their positive experience in using a simple nasopharyngeal tube as the interface for bi-level NIV in young infants (6 months or less).

The range of modes of NIV that are applicable and available is also expanding and there is the potential to use tools such as the neurally adjusted ventilatory assist (NAVA), which is potentially capable of providing proportional and better synchronized support even in the presence of large air leaks, both in invasive and non-invasive modes, in neonatal, paediatric, and adult patients.

Finally, NIV is not new, but, as we reflect on the challenges of ventilator support for children (in multiple settings across the world), it would seem that this technique(s) has the potential to substantially improve the safety of ventilator support for children, and improve access to ventilatory support for both acute and chronic conditions. Given that respiratory problems are among the most important cause of childhood deaths across the world, it behoves us to explore the potential and collect the data.