Background <p>Selecting the appropriate mode of respiratory support in cases of acute respiratory failure is clinically challenging and has relevant implications for patient outcomes. Despite the widespread use of noninvasive techniques, uncertainties remain regarding optimal indications, timing of escalation and patient-centered aspects.</p> Aim of this study <p>This paper summarizes the chapter on interpretation of indications and alternatives to invasive mechanical ventilation from the German S3 clinical guidelines “invasive ventilation and extracorporeal life support in acute respiratory failure”.</p> Methods <p>For the guideline revision a&#xa0;systematic literature search and critical appraisal were conducted, including national and international guidelines. Recommendations were developed using the evidence to decision framework and a consensus was reached in several conferences.</p> Results <p>Noninvasive respiratory support, including noninvasive ventilation (NIV) and high-flow nasal oxygen (HFNO), is effective in patients with moderate impairment of oxygenation (PaO₂/FiO₂ 100–300 mm Hg) and can avoid endotracheal intubation but requires close clinical monitoring. In patients with severe respiratory failure (PaO₂/FiO₂ &lt; 100 mm Hg) or treatment failure under noninvasive respiratory support, invasive ventilation is required. Further recommendations concern specific patient groups.</p> Discussion <p>The available evidence supports an individualized approach to the choice of respiratory support that incorporates patients’ preferences. Key elements include a regular reassessment, avoidance of delayed intubation, adequate personnel and expert resources and transparent communication within the interdisciplinary treatment team.</p>