Comparing Respiratory Support Modalities in Pediatric Asthma Exacerbation–A Systematic Review and Meta-Analysis

Objectives: To compare clinical outcomes and racial disparities of children hospitalized for acute asthma exacerbation who required any respiratory support: invasive mechanical ventilation (IMV), non-invasive modalities (non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC)). Methods: We searched PubMed, Embase, Cochrane, and Scopus for randomized controlled trials (RCTs) and observational studies published between 2010 and 2025 that involved pediatric asthma patients (0–18 years) who received HFNC, NIV, or IMV. Network meta-analyses (NMA) were conducted separately for RCTs (change in asthma score) and observational studies (PICU length of stay). Subgroup analyses compared respiratory support modalities and failure rates. Racial and ethnic disparities were analyzed narratively. Results: In five RCTs (n = 233), compared to oxygen, HFNC showed no significant benefit (MD = 0.24; p = 0.58), whereas NIV showed the greatest improvement in asthma scores (mean difference [MD] = 1.24; p = 0.07), reaching significance in sensitivity analysis (MD = 2.5; p < 0.001). Observational NMA found no differences in PICU stay between respiratory support modalities, but HFNC was associated with 2-fold increase in PICU stay in a subgroup analysis compared to standard oxygen (p = 0.04) and with a higher failure rate compared to NIV (12.6% vs. 2.6%; OR = 5.3, p < 0.001). Black children had higher odds of intubation. Conclusions: Available evidence suggests that NIV may confer greater short-term clinical benefit in children with severe acute asthma requiring respiratory support, although findings should be interpreted cautiously given the limited and heterogeneous data. Further high-quality studies with standardized outcomes are needed to inform respiratory support selection.