Aim: To investigate the incidence, clinical management, mortality and its risk factors, major outcome and costs of acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS) in a Chinese network of 26 paediatric intensive care unit (PICU). Methods: In a consecutive 12-month period, AHRF and ARDS were identified and followed up for 90 days or until death or discharge. Results: From a total of 11 521 critically ill patients, 461 AHRF were identified in which 306 developed ARDS (66.4%), resulting in incidences of 4% and 2.7%, respectively, with pneumonia (75.1%) and sepsis (14.7%) as main underlying diseases and 83% were 5 years and 1 month-old. In-hospital mortality of AHRF was 41.6% (44.8% for ARDS), accounted for 15.5% of all PICU deaths. For those of pneumonia or sepsis with AHRF and ARDS, mortality and its relative risk were significantly higher than those without. Relatively lower tidal volume and total fluid balance, adequate upper limit of PaCO2 in the early PICU days, and family affordability, tended to result in better outcome. Conclusion: In this prospective study, AHRF had high possibilities to develop ARDS and death risk, as impacted by ventilation settings and fluid intake in the early treatment, as well as socioeconomic factors, which should be considered for implementation of standard of care in respiratory therapy.