The ideal care of the critically ill infant or child should demonstrate a seamless service starting with recognition of potential critical illness and initiation of early resuscitative interventions, escalating to advanced life support and skilled transfer to an appropriate location where intensive care can be continued. This article discusses advances in the package of respiratory care commencing with the decision to provide respiratory support, which includes the decision whether or not to intubate, leading to the choice of mechanical ventilatory support mode in the critically ill child. Indications for intubation include protection of the airway, airway toilet and the need for positive pressure support. Respiratory support may not always require additional airway protection or airway toilet. Non-invasive respiratory support includes continuous positive airway pressure, biphasic positive airway pressure, or negative extrathoracic pressure. Recent advances in understanding and management of acute lung injury, such as appropriate use of positive end-expiratory airway pressure, alveolar recruitment manoeuvres, high frequency ventilation and use of inhaled nitric oxide, will be discussed in the light of recent randomised controlled trials providing evidence of benefit.