C25-24 Comparing Respiratory Support Modalities in Pediatric Asthma Exacerbation: Systematic Review and Network Meta-analyses

Abstract Rational Acute asthma exacerbations are a leading cause of pediatric emergency department visits and hospitalization. Some patients require respiratory support, including standard oxygen, high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), or invasive mechanical ventilation (IMV). The optimal respiratory strategy remains unclear, particularly the comparative effectiveness of HFNC and NIV. Our study compared clinical outcomes and racial disparities among children with asthma exacerbation receiving IMV, NIV, or HFNC. Methods This systematic review was registered in PROSPERO and followed PRISMA guidelines. PubMed, Embase, Cochrane, and Scopus (2010-2025) were searched for randomized controlled trials (RCTs) and observational studies in pediatric acute asthma (0-18 years). Two reviewers independently screened studies, assessed bias (ROB2), and rated certainty (GRADE). Random-effects network meta-analysis (REML, mvmeta, Stata18) estimated mean differences (MDs) with 95% confidence intervals and treatment hierarchy was assessed by network rank. Network meta-analyses were performed separately for RCTs (change in asthma score after 2 hours) and observational studies (pediatric intensive care unit (PICU) length of stay). Subgroup analyses evaluated modality-specific failure rates. Racial and ethnic disparities were analyzed narratively. Results In five RCTs (n = 233), NIV (mostly bilevel positive airway pressure BiPAP) yielded the greatest reduction in asthma score compared to standard oxygen, with the latter had higher score (MD = 1.24; p = 0.07), reaching statistical significance in a sensitivity analysis (MD = 2.5; p 0.001). HFNC showed no difference compared to standard oxygen (MD = 0.24; p = 0.58). (Figure 1) Forest plot of individual and pooled RCTs comparing BiPAP and HFNC to standard oxygen; positive MDs favor the second modality. Seven observational studies (n = 11,200) found directionally longer PICU stays with HFNC (logMD =0.16; p = 0.37) and NIV (logMD = 0.34; p = 0.09), but neither was statistically significant. In a subgroup analysis HFNC was associated with two-fold longer PICU stay versus standard oxygen (logMD = 0.41; p = 0.04) and higher failure rates than NIV (12.6% vs 2.6%; OR = 5.3; p 0.001). Black children had higher odds of intubation. Conclusion NIV demonstrated the greatest immediate improvement among respiratory support modalities for asthma exacerbation in children. HFNC showed no clear clinical benefit over standard therapy and was associated with increased PICU stay and higher failure rates. Persistent racial disparities in IMV use highlight the need for equitable care delivery. Further studies with standardized outcome measures are needed to guide optimal respiratory support strategies in pediatric asthma. This abstract is funded by: None