Nasal high-frequency oscillatory ventilation as primary respiratory support in preterm infants with respiratory distress syndrome: current evidence and clinical implications.

Continuous positive airway pressure (CPAP) is the standard initial therapy for respiratory distress syndrome (RDS) and associated with failure rates of up to 50% in extremely preterm infants. Nasal intermittent positive pressure ventilation (NIPPV) has demonstrated consistent benefits over CPAP in reducing respiratory failure and intubation. Nasal high-frequency oscillatory ventilation (nHFOV) has also shown reduced treatment failure compared with CPAP, particularly in extremely preterm infants. However, direct head-to-head comparisons between nHFOV and NIPPV as primary support are lacking, and available evidence from indirect comparisons has low certainty. Both NIPPV and nHFOV represent viable advanced non-invasive ventilation options beyond CPAP, each with distinct physiological mechanisms and evidence profiles. The current evidence base supports the use of both modalities in clinical practice, but robust head-to-head randomized controlled trials comparing nHFOV and NIPPV as primary respiratory support are urgently needed to guide optimal clinical decision-making. What is Known: • CPAP is the standard first-line support for RDS but fails in up to 50% of extremely preterm infants. • Both NIPPV and nHFOV reduce treatment failure and intubation compared with CPAP. What is New: • Neither NIPPV nor nHFOV has proven superior to the other, as direct comparisons are few and of low certainty. Head-to-head RCTs of nHFOV vs. NIPPV as primary support in extremely preterm infants are urgently needed. • Modality choice should also be guided by local expertise, available equipment, and gestational age.