• neonatology
• intensive care units
• neonatal

Bronchopulmonary dysplasia (BPD), the chronic lung disease of very preterm infants, is an important determinant of mortality and longer term morbidity. BPD is strongly associated with the duration of exposure to mechanical ventilation, and thus clinicians aim to support very preterm infants with ‘non-invasive’ ventilation (NIV) such as continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation (NIPPV) or nasal high-flow (nHF) wherever possible. There is evidence from a systematic review of clinical trials that the use of CPAP in spontaneously breathing very preterm infants in the delivery room, instead of routine endotracheal intubation, may have a modest beneficial effect on rates of survival free of BPD.1 But does the increasing use of NIV actually reduce BPD in very preterm infants? Is LESS really MORE?

Two studies report the change over time in NIV use in very preterm infants, and associated outcomes. Let us state from the outset that both are non-randomised, observational cohort studies and thus causation between interventions and outcomes cannot be determined. Avila-Alvarez et al 2 compared the use of NIV and in-hospital outcomes in a total of almost 18 000 very preterm (<32 weeks’ gestation) or very low birthweight (<1500 g) infants born in two 5-year periods: 2010–2014 and 2015–2019. In the more recent epoch, survival increased in a subgroup of infants born at 29–31 weeks’ gestation, but did not change in extremely preterm infants. There was …