Comparison Between High-Flow Nasal Cannula (HFNC) Therapy and Noninvasive Ventilation (NIV) in Children With Bronchiolitis-Associated Acute Respiratory Failure: A Systematic Review and Meta-Analysis.

The optimal noninvasive respiratory support for infants and children with severe viral bronchiolitis remains unclear. While continuous positive airway pressure (CPAP) has traditionally been considered the gold standard, high-flow nasal cannula (HFNC) therapy is a better-tolerated alternative. This systematic review and meta-analysis aimed to evaluate the comparative efficacy and safety of HFNC versus noninvasive ventilation (NIV) in pediatric patients with bronchiolitis-associated acute respiratory failure. We searched major electronic databases through June 2026. We included randomized controlled trials (RCTs) and observational cohorts comparing HFNC with NIV (CPAP/bilevel positive airway pressure (BiPAP)). The primary outcomes were treatment failure, as defined by the individual studies, and endotracheal intubation. Data were synthesized using random-effects models, and heterogeneity was explored via subgroup analysis and meta-regression. Eleven studies (seven RCTs and four observational studies) comprising 7,574 patients were included. There was no statistically significant difference in the overall risk of treatment failure between HFNC and NIV (RR 1.99, 95% CI 0.65-6.10); however, study design was a significant moderator (p = 0.0019). Observational studies reported significantly higher failure rates with HFNC (RR 7.78), whereas RCTs showed no significant difference (RR 1.11). There were no significant differences in endotracheal intubation rates (RR 0.75, 95% CI 0.51-1.09) or pediatric intensive care unit length of stay (MD -0.16 days, 95% CI -0.79 to 0.47) between the groups. HFNC demonstrated a trend toward fewer local adverse events, such as nasal/skin trauma (RR 0.30, 95% CI 0.06-1.52), than did NIV. The certainty of evidence according to GRADE was low for all outcomes. HFNC showed no significant differences from NIV in critical clinical endpoints, including intubation rates and intensive care duration. Differences in treatment failure rates appeared to be influenced by study design, highlighting potential confounding by indication in observational data. Given its improved tolerability and trend toward reduced mucosal trauma, HFNC may represent a viable first-line noninvasive intervention for pediatric bronchiolitis.