This systematic review and meta-analysis evaluated the clinical effectiveness of high-flow nasal cannula (HFNC) versus bilevel positive airway pressure (BiPAP) as adjunctive noninvasive respiratory therapies for children with critical asthma admitted to the pediatric intensive care unit (PICU). The review aimed to synthesize available evidence on patient-centered outcomes to inform critical-care management in pediatrics.
The authors conducted a comprehensive literature search following PRISMA 2020 guidelines. Databases searched included PubMed, Scopus, Google Scholar, Embase, Lilacs, and ProQuest through September 2025. Risk-of-bias assessment for included studies used the JBI risk of bias tool. Quantitative synthesis was performed in STATA version 16 (2019), with meta-analysis results presented using 95% confidence intervals where applicable.
Five studies met eligibility criteria and were included in the analysis. The majority of included studies demonstrated a moderate to low risk of bias according to the JBI assessment. The publication is a review article by Jayapriya Thirupathi and colleagues, published online ahead of print in the Indian Journal of Pediatrics (2026), with PMID 42766072 and DOI 10.1007/s12098-026-06461-w.
Meta-analysis findings showed no statistically significant difference between HFNC and BiPAP for length of stay in the PICU (p = 0.48). Likewise, there was no statistically significant difference in overall hospital length of stay between the two modalities (p = 0.13). These comparisons form the primary reported quantitative outcomes in the pooled analysis.
Across the included studies, the authors report no statistically significant differences between HFNC and BiPAP for several secondary clinical outcomes. Specifically, the rate of escalation of respiratory support, the total duration of respiratory support, the level of sedation required, and the amount of adjunctive medication administered did not differ significantly between groups according to the pooled data.
The review identified insufficient data to draw conclusions about intubation rates and mortality; the included studies did not provide adequate information on these outcomes for robust pooled analysis. The authors also note considerable heterogeneity across study results, which complicates interpretation of pooled estimates.
Overall, the certainty of the evidence was judged to be low. Contributing factors reported by the authors include sizeable heterogeneity between studies and limited outcome reporting for critical endpoints such as intubation and mortality. While risk-of-bias assessments were moderate to low for most studies, the small number of eligible studies (five) and variability in reported outcomes limit the strength of conclusions.
The authors conclude that current evidence remains inconclusive regarding superiority of HFNC versus BiPAP for children with critical asthma in the PICU. No statistically significant differences were found for PICU or hospital length of stay or for several secondary outcomes. Given the low certainty of evidence, the review emphasizes the need for well-designed, adequately powered randomized controlled trials to provide definitive guidance on the comparative effectiveness of HFNC and BiPAP in this population.
This review was authored by Jayapriya Thirupathi, Sagar S Kamat, Shubham Verma, and Atul Jindal from the Department of Pediatrics, All India Institute of Medical Sciences, Raipur, India. It appears online ahead of print in the Indian Journal of Pediatrics (2026). The PubMed identifier is 42766072 and the DOI is 10.1007/s12098-026-06461-w. The authors declared no conflicts of interest.
Current pooled evidence does not show a clear advantage of HFNC over BiPAP, or vice versa, for PICU or hospital length of stay in pediatric critical asthma.
Important outcomes such as intubation and mortality lack sufficient reporting; clinicians should interpret existing comparative data cautiously.
Consideration of individual patient physiology, device availability, and local expertise remains necessary pending higher-certainty trial data.
The review highlights an evidence gap and a need for randomized controlled trials specifically powered to assess escalation to intubation, mortality, and other patient-centered outcomes.