Acute breathing problems are a common reason for children to be admitted to the pediatric intensive care unit, and many of these children need breathing support without a breathing tube. High-Velocity Nasal Insufflation (HVNI) and nasal Continuous Positive Airway Pressure (nCPAP) are commonly used to help children breathe, but there is limited information comparing how well they work and how comfortable they are for children. This study aims to compare the clinical outcomes and tolerability of HVNI and nCPAP in children aged 1 month to 5 years with acute respiratory distress admitted to the pediatric intensive care unit, using clinical assessment and lung ultrasound findings.

Acute respiratory distress represents a major cause of morbidity and mortality in infants and young children and accounts for a significant proportion of pediatric intensive care unit admissions. A considerable number of affected children fail conventional low-flow oxygen therapy and require escalation to non-invasive respiratory support.

High Velocity Nasal Insufflation delivers heated and humidified oxygen at high flow rates through nasal cannulae and may improve oxygenation by washing out nasopharyngeal dead space, reducing inspiratory resistance, and providing a degree of positive end-expiratory pressure. Nasal Continuous Positive Airway Pressure delivers a continuous distending airway pressure with supplemental oxygen, improving lung recruitment, reducing atelectasis, and enhancing ventilation-perfusion matching.

Both modalities are commonly used in pediatric intensive care practice; however, evidence comparing their clinical effectiveness, tolerability, and impact on lung aeration in young children remains inconclusive. Lung ultrasound has emerged as a reliable, non-invasive bedside tool for assessment of lung aeration and disease severity in critically ill children.

This prospective interventional study will enroll 80 children aged 1 month to 5 years admitted to the pediatric intensive care unit with acute respiratory distress who have failed low-flow oxygen therapy. Patients will be randomized into two groups: one group receiving High Velocity Nasal Insufflation and the other receiving nasal Continuous Positive Airway Pressure. All patients will undergo daily clinical assessment and lung ultrasound scoring during their pediatric intensive care unit (PICU) stay. Tolerability will be evaluated using the FLACC (Face, Legs, Activity, Cry, Consolability) pain scale.

The primary outcome is improvement in lung aeration as assessed by lung ultrasound score. Secondary outcomes include assessment of clinical response to therapy based on respiratory rate, oxygen saturation (SpO₂), and need for escalation of respiratory support . The results of this study aim to provide evidence to guide selection of optimal non-invasive respiratory support in children with acute respiratory distress.

Inclusion Criteria:

• Children aged 1 month to 5 years
• Admitted to the Pediatric Intensive Care Unit (PICU)
• Diagnosed with acute respiratory distress
• Failure of low-flow nasal oxygen therapy
• Requiring non-invasive respiratory support
• Informed consent obtained from parent or legal guardian

Exclusion Criteria:

• Presence of congenital or acquired cardiac disease
• Neuromuscular disorders
• Chronic lung disease
• History of recurrent wheezing
• History of cardio-respiratory arrest
• Presence of significant comorbid chronic illness
• Contraindication to non-invasive ventilation

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