The need for mechanical ventilation (MV) for acute respiratory failure is one the most common indications for children to be admitted to a paediatric intensive care unit (PICU). Despite worldwide daily use of MV in children, numerous issues remain unsolved and much of the current clinical practice is based upon anecdotal experience in combination with data originating from studies in critically ill adults. Current practice of paediatric mechanical ventilation for acute respiratory failure includes low tidal volume strategy (6 -8 ml/ kg ideal body weight), permissive hypercapnia (i.e. accepting respiratory acidosis with pH as low as 7.20 -7.25), application of a sufficient level of PEEP, and early switch to high-frequency oscillatory ventilation (HFOV). Whereas prone positioning and nitric oxide does not seem to have any benefit on patient outcome, the effects of exogenous surfactant and corticosteroids remains unclear. Liberation of mechanical ventilation is another important issue in paediatric critical care that is not yet positively influenced by the application of available weaning protocols. Importantly, the lack of available evidence should encourage those dealing with critically ill children to embark on multicentre randomized controlled trials. © 2010, Nederlandse Vereniging voor Intensive Care. All Rights Reserved.