The most challenging application of NPPV may be in patients with ARDS. Studies of NPPV for the treatment of ARDS in adult population have reported failure rates of 50-80% [40] . A meta-analysis of the topic in adult population concluded that NPPV was unlikely to have any significant benefit [41] . In children, the use of NPPV for the treatment of ARDS was associated with a failure rate of 78%, and 22% of them died (Table 1 ) [27] . Therefore, NPPV use in such a patient group is rarely justified. However, if a trial of NPPV is initiated, patients should be closely monitored and promptly intubated if their conditions deteriorate, so that inordinate delays in needed interventions are avoided.