In extremely preterm infants less than 28 weeks gestation who are receiving invasive mechanical ventilation, does extubation to a higher level of continuous positive airway pressure compared to standard practice prevent deterioration and return to mechanical ventilation.

Very premature babies — those born before 28 weeks of pregnancy — often need mechanical ventilation (a breathing machine) in the days after birth because their lungs are not yet mature enough to breathe independently. When doctors feel a baby is ready, they remove the breathing tube — a process called extubation — and switch the baby to a gentler form of breathing support called nasal CPAP, which delivers a constant gentle pressure to keep tiny airways open. However, many babies need to be re-intubated because they cannot manage on their own, which is stressful and carries risks. This study tests whether using a higher CPAP pressure (10 cm of water pressure) when babies are first taken off the ventilator reduces the chances of them needing to go back on it, compared to the standard pressure (around 6-8 cm). Two hundred extremely preterm babies will be randomly assigned to one of the two pressure levels immediately after their first extubation. To be eligible the baby must have been born before 28 weeks gestation, be receiving mechanical ventilation, and be ready for their first extubation attempt. Babies with major congenital abnormalities affecting breathing, or those receiving palliative rather than intensive care, are not eligible. This study is conducted in neonatal intensive care units across multiple hospitals.