Helping the Tiniest Babies Breathe Without a Breathing Tube: Can a Little Extra Help Through the Nose Make a Difference?

What two recent studies from China, one on gentle air vibrations and one on extra nasal "breaths", found about the first breathing support given to very premature babies

Many babies born very early need help to breathe, and doctors try to give that help through soft prongs in the nose rather than a tube in the windpipe. Two large studies from China found that adding either rapid, gentle air vibrations or extra timed "breaths" to the usual steady nasal pressure meant fewer babies needed a breathing tube in their first three days. The studies did not compare those two methods with each other, and longer-term effects are not yet known.

Why breathing is so hard for babies born very early

When a baby is born months before the due date, the lungs are not finished growing. They are stiff and lack enough surfactant, a natural soapy substance that stops the tiny air sacs from collapsing each time the baby breathes out. Doctors call the resulting breathing difficulty respiratory distress syndrome (RDS). For parents, it can look like fast, effortful breathing, a grunting sound or the chest pulling in with every breath. A breathing tube connected to a ventilator (a breathing machine) can take over completely, but in such fragile lungs it can also cause damage, so neonatal teams work hard to avoid it when they safely can.

How care for these babies has changed

For the most premature babies, the usual approach used to be a breathing tube placed soon after birth so that surfactant medicine could be put into the lungs [1]. A large study called SUPPORT, run in many hospitals by the Neonatal Research Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, changed thinking: in babies born between 24 and almost 28 weeks of pregnancy, starting with nasal pressure from birth instead of a tube meant fewer babies were put on a ventilator, and it did not lead to more deaths or more long-term lung problems [2]. That nasal pressure is called continuous positive airway pressure, or CPAP: a steady stream of air that gently holds the lungs open. Doctors also learned to give surfactant through a very thin tube slipped briefly past the vocal cords while the baby keeps breathing on CPAP, which reduced deaths and lung problems compared with the old way of using a breathing tube [3]. Today, European expert guidelines recommend starting nasal support from birth for babies at risk who do not need a breathing tube, and giving surfactant by this gentler route [4].

The difficulty is that CPAP does not always work for the smallest babies. In one large review of hospital records from Australia and New Zealand, 43 in every 100 babies born at 25 to 28 weeks still needed a breathing tube within three days of starting CPAP, and those babies had more lung problems afterwards [5]. Doctors therefore wondered whether nasal support could be made stronger. One idea, nasal intermittent positive pressure ventilation (NIPPV), adds regular puffs of extra pressure, like small breaths, on top of CPAP. Studies of NIPPV were mixed: a large trial in babies weighing under 1000 grams found it did not improve survival without long-term lung disease [6], while a review of other studies found it reduced breathing tubes, though mostly in somewhat bigger babies [7]. Another idea, non-invasive high-frequency oscillatory ventilation (NHFOV), adds very fast, tiny vibrations of air that help clear carbon dioxide, the waste gas the body breathes out [8]. Earlier NHFOV studies gave mixed results [9]; one trial of 302 babies in China did not show a clear benefit overall [10].

The two new studies

The first study, led by Li and colleagues and published in The BMJ in 2025, took place in 20 neonatal intensive care units (NICUs) across China between August 2022 and August 2024 [9]. It included 342 babies born between 24 and 28 completed weeks of pregnancy who already needed some extra oxygen on CPAP. Every baby first spent at least half an hour on the same standard CPAP. Then, like tossing a coin, chance decided whether each baby continued on CPAP or switched to NHFOV, using the same small nose prongs. Letting chance decide is what makes such a study fair: the two groups start out alike, so any difference that follows is likely due to the breathing method itself. Babies in both groups received surfactant through a thin tube if they needed more than a set amount of oxygen.

The second study, called the NIV-MISA-RDS trial (a study of nasal breathing support given alongside a gentle surfactant treatment for respiratory distress syndrome) and published by Zhang and colleagues in JAMA Network Open in 2026, took place in 11 NICUs in China between December 2021 and October 2024 [1]. It included babies born between 24 and 29 completed weeks. Chance decided whether each baby received CPAP or NIPPV in which the extra breaths were timed to match the baby's own breathing. Every baby also received surfactant through a thin tube within two hours of birth. Babies who already needed a breathing tube before they could join were not included, and there were many of them (363 of the 996 babies first considered), so this study tells us most about babies who were managing on nasal support at the start.

What the researchers found

Both studies counted how many babies needed a breathing tube in their first three days, using rules written in advance, such as the oxygen level staying too low despite a lot of extra oxygen, or long pauses in breathing. This kept the decision as fair as possible, even though the doctors knew which method each baby was on.

In the NHFOV study, about 16 in every 100 babies on NHFOV needed a breathing tube in the first three days (27 of 170 babies), compared with about 28 in every 100 on CPAP (48 of 172 babies) [9]. The difference was still there at one week. The most common reason for needing a tube in both groups was that the baby's oxygen level stayed too low. The two groups did not clearly differ in lung disease measured a few weeks before the due date, deaths, nose injuries or air leaking around the lungs.

In the NIPPV study, about 26 in every 100 babies on CPAP needed a breathing tube in the first three days (40 of 153 babies), compared with about 13 in every 100 on NIPPV (21 of 159 babies) [1]. The study had planned to include 960 babies, but an independent monitoring committee stopped it after 312 babies had been analysed, because CPAP was clearly doing worse than NIPPV by the measure the researchers had set in advance. Most other complications, including long-term lung disease and deaths, were not clearly different. A serious bowel illness of premature babies, necrotising enterocolitis, was somewhat more common with CPAP, but the difference could have been due to chance and the researchers say it needs more study.

What this means, and what it does not

Both studies point the same way: for many very premature babies, adding a little extra help to nasal support from the start can mean fewer babies needing a breathing tube in the first days of life. That matters, because a breathing tube is an invasive treatment that families and doctors would rather avoid.

But there are important limits. The two studies did not compare NHFOV and NIPPV with each other. They involved somewhat different babies (the NIPPV study's babies were, on average, a little more mature), used surfactant differently, and decided when a breathing tube was needed in slightly different ways. So neither study can say which of the two newer methods is better. A review that pooled a few small studies directly comparing them found little or no difference, though the evidence was weak [11]. Stopping a study early, as in the NIPPV study, can make a difference look bigger than it really is, and the researchers say so themselves. Both studies were done only in China, few of the babies in the NHFOV study were born before 26 weeks, and neither study has yet reported how the children are doing as they grow.

It is also reassuring that, in both studies, the newer methods did not cause clear extra harm compared with CPAP. A long-standing worry that giving breaths through nose prongs might harm the bowel goes back to a small 1985 study that linked this kind of support with tears in the bowel wall [12]; a later review of NIPPV after a breathing tube is removed did not find more bowel problems [13].

What families can take from this

If your baby is born very early, the team will choose a breathing support based on your baby's needs, the equipment available and the staff's experience. CPAP remains a good, widely recommended starting point, and NIPPV is also listed in European guidelines as a reasonable first choice [4]. NHFOV is used in some hospitals but is still being studied. It is entirely reasonable to ask which method your baby is on, why it was chosen, and what the team watches for to decide whether more help is needed. In[Neo]Sight has also written about how these same nasal methods compare once a breathing tube is taken out, in NHFOV versus NIPPV after extubation.

What researchers are working on next

The next important step is a study that compares NHFOV and NIPPV directly in the very smallest babies, with surfactant given in the same way, and that follows the children for years to see whether fewer breathing tubes early on lead to healthier lungs and development later. Researchers also want to know whether these results hold true in hospitals outside China. Until then, these two studies offer genuine encouragement: gentle extra help through the nose can keep more of the tiniest babies breathing on their own in their first days.

References

  1. Zhang H, Zhang Y, Zeng L, et al. Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation in Preterm Infants With Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA Netw Open. 2026;9(6):e2619785. doi:10.1001/jamanetworkopen.2026.19785 ↩
  2. Finer NN, Carlo WA, Walsh MC, et al. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med. 2010;362(21):1970-1979. doi:10.1056/NEJMoa0911783 ↩
  3. Abdel-Latif ME, Davis PG, Wheeler KI, De Paoli AG, Dargaville PA. Surfactant therapy via thin catheter in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst Rev. 2021;5(5):CD011672. doi:10.1002/14651858.CD011672.pub2 ↩
  4. Sweet DG, Carnielli VP, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology. 2023;120(1):3-23. doi:10.1159/000528914 ↩
  5. Dargaville PA, Gerber A, Johansson S, et al. Incidence and Outcome of CPAP Failure in Preterm Infants. Pediatrics. 2016;138(1):e20153985. doi:10.1542/peds.2015-3985 ↩
  6. Kirpalani H, Millar D, Lemyre B, Yoder BA, Chiu A, Roberts RS. A trial comparing noninvasive ventilation strategies in preterm infants. N Engl J Med. 2013;369(7):611-620. doi:10.1056/NEJMoa1214533 ↩
  7. Lemyre B, Deguise MO, Benson P, Kirpalani H, Ekhaguere OA, Davis PG. Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. Cochrane Database Syst Rev. 2023;7(7):CD005384. doi:10.1002/14651858.CD005384.pub3 ↩
  8. De Luca D, Dell'Orto V. Non-invasive high-frequency oscillatory ventilation in neonates: review of physiology, biology and clinical data. Arch Dis Child Fetal Neonatal Ed. 2016;101(6):F565-F570. doi:10.1136/archdischild-2016-310664 ↩
  9. Li Y, Zhu X, Li LJ, et al. Non-invasive high frequency oscillatory ventilation for primary respiratory support in extremely preterm infants: multicentre randomised controlled trial. BMJ. 2025;391:e085569. doi:10.1136/bmj-2025-085569 ↩
  10. Zhu X, Feng Z, Liu C, Shi L, Shi Y, Ramanathan R. Nasal High-Frequency Oscillatory Ventilation in Preterm Infants with Moderate Respiratory Distress Syndrome: A Multicenter Randomized Clinical Trial. Neonatology. 2021;118(3):325-331. doi:10.1159/000515226 ↩
  11. Abdel-Latif ME, Tan O, Fiander M, Osborn DA. Non-invasive high-frequency ventilation in newborn infants with respiratory distress. Cochrane Database Syst Rev. 2024;5(5):CD012712. doi:10.1002/14651858.CD012712.pub2 ↩
  12. Garland JS, Nelson DB, Rice T, Neu J. Increased Risk of Gastrointestinal Perforations in Neonates Mechanically Ventilated with Either Face Mask or Nasal Prongs. Pediatrics. 1985;76(3):406-410. doi:10.1542/peds.76.3.406 ↩
  13. Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev. 2017;2(2):CD003212. doi:10.1002/14651858.CD003212.pub3 ↩