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Introduction Bronchiolitis represents one of the most common respiratory tract infections and a common cause of hospital and PICU admission. Paediatric patients with bronchiolitis may require respiratory support during admission. This study systematically reviewed and compared clinical effectiveness and safety of different respiratory support modalities (HFNC, LFNC, CPAP) in paediatric patients ≤24-months-old with bronchiolitis.Methods A literature search on PubMed, Scopus, Cochrane library, Embase and CINAHL was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted by two reviewers, and a random effect model was used to estimate pooled effects. Risk of bias was assessed using the Collaboration’s Risk of Bias for Randomized trials-2 (RoB-2) tool.Results Of the 5,636 non-duplicate studies, eighteen studies with 4,094 paediatric patients ≤24-months-old with bronchiolitis were included. Twelve studies compared HFNC to LFNC including data for 3,273 patients (HFNC (n=1,633) and LFNC (n=1640)) and six studies with 821 patients compared the use of HFNC (n=415) versus CPAP (n=406).Use of HFNC did not reduce the need for mechanical ventilation compared to LFNC (P = 0.32) or CPAP (P = 0.52). HFNC resulted in less treatment failure (RR 0.44, 95% CI 0.23 to 0.87, I2=92%, P = 0.02) and a significant reduction in length of PICU stay compared to LFNC (Mean Difference (MD) -0.40 95% CI -0.78 to -0.02, I2=85%, P = 0.04) but not compared to CPAP (RR 1.28, 95% CI 0.90 to 1.80, P = 0.17) and (MD -0.24, 95% CI -0.91 to 0.43, I2=0%, P = 0.47) respectively. respectively. HFNC reduced the total oxygen therapy duration compared to LFNC (MD -0.37 95% CI -0.63, -0.12, I2=81%, P = 0.004). There were no differences between HFNC and CPAP group in secondary outcomes.Conclusion HFNC was associated with significantly reduced treatment failure, length of PICU stay and total oxygen therapy duration compared to LFNC. There were no differences between HFNC and CPAP regarding clinical outcomes. Results of this meta-analysis shows that HFNC may be considered as initial treatment modality in paediatric patients with bronchiolitis requiring respiratory support especially as a step-up in patients that do not improve with LFNC. *presenting author