Type of respiratory support
Non‐invasive respiratory support	High flow nasal oxygen and other modes of non‐invasive ventilation ► Consider using high flow nasal oxygen or non‐invasive ventilation* therapy for neonates, children and adolescents with hypoxaemia or respiratory distress associated with COVID‐19 and not responding to low flow oxygen. Due to the potential for aerosol generation, use non‐invasive ventilation with caution and pay strict attention to staff safety, including the use of appropriate personal protective equipment (Consensus recommendation) Prone positioning (non‐invasive ventilation) ► For neonates, children and adolescents with COVID‐19 and respiratory symptoms who are receiving non‐invasive respiratory support, consider prone positioning if patient cooperation is possible. When placing a patient in the prone position, ensure close monitoring of the patient (Consensus recommendation) Respiratory management of the deteriorating child ► Consider endotracheal intubation and mechanical ventilation in neonates, children and adolescents with COVID‐19 who are deteriorating despite optimised, non‐invasive respiratory support (Consensus recommendation)
Patients requiring invasive mechanical ventilation	Prone positioning (mechanical ventilation via an endotracheal tube or tracheostomy) ► For mechanically ventilated neonates, children and adolescents with COVID‐19 and hypoxaemia despite optimising ventilation, consider prone positioning if there are no contraindications. Ensure close monitoring of the patient (Consensus recommendation) Positive end‐expiratory pressure (PEEP) ► For mechanically ventilated neonates, children and adolescents with COVID‐19 and moderate to severe ARDS with atelectasis, consider using a higher PEEP strategy over a lower PEEP strategy. The absolute PEEP values that constitute a high and low PEEP strategy will depend on age and patient size (Consensus recommendation) Recruitment manoeuvres ► For mechanically ventilated neonates, children and adolescents with COVID‐19 and hypoxic respiratory failure characterised by severe atelectasis unresponsive to other ventilation strategies, consider using applied airway pressure recruitment manoeuvres (Consensus recommendation) Neuromuscular blockers ► For intubated neonates, children and adolescents with COVID‐19, do not routinely use continuous infusions of neuromuscular blocking agents (NMBAs). However, if effective lung‐protective ventilation cannot be achieved, consider targeted intermittent use of NMBAs. If indicated, the choice of NMBA should be guided by the age group and regional practice (GRADE: very low certainty; conditional recommendation against) High frequency oscillatory ventilation (HFOV) ► Do not routinely use HFOV as a first line mode of mechanical ventilation in neonates, children and adolescents with severe COVID‐19. HFOV should be limited to a rescue therapy in neonates and children not responding to conventional mechanical ventilation in a specialist centre with experience with HFOV. HFOV delivers gas at very high flow rates. This may increase the aerosol‐generating potential compared with other forms of respiratory support used in intensive care. This may limit the suitability of HFOV in patients with COVID‐19 unless strict attention to staff safety and infection control measures can be applied (Consensus recommendation) Videolaryngoscopy ► In neonates, children and adolescents with COVID‐19 undergoing endotracheal intubation, consider using videolaryngoscopy over direct laryngoscopy, if available, and the operator is trained in its use (GRADE: very low certainty; conditional recommendation) Extracorporeal membrane oxygenation (ECMO) ► Consider early referral to an ECMO centre for venovenous or venoarterial ECMO in mechanically ventilated neonates, children and adolescents with COVID‐19 with refractory respiratory or cardiovascular failure despite optimising other critical care interventions (Consensus recommendation)

ARDS = acute respiratory distress syndrome; COVID‐19 = coronavirus disease 2019; GRADE = Grading of Recommendations Assessment, Development and Evaluation.

^*Non‐invasive ventilation modes include any mode of applied pressure support delivered without an endotracheal tube during spontaneous breathing, such as continuous positive applied pressure, bilevel positive applied pressure, non‐invasive intermittent positive pressure ventilation via mask or nasal prongs.