Prematurity is associated with respiratory distress due to variable reasons including immature lungs with inadequate surfactant production and relatively weak respiratory muscles with increased lung compliance ultimately leading to atelectasis, poor functional residual capacity, and lung collapse. In the past, preterm infants with signs of moderate or severe respiratory distress were intubated and mechanically ventilated. This invasive approach resulted in inflammation of the lungs in the short term and impaired development and scarring known as bronchopulmonary dysplasia (BPD) in the long term. Efforts to decrease rates of BPD in the surfactant/antenatal steroid era have led to increased use of non-invasive respiratory support for even the most immature infants. Non-invasive ventilation is preferred to use instead of invasive mechanical ventilation. Nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV) are the most commonly used non-invasive respiratory support modalities in neonates with respiratory distress compared with others such as high-flow nasal cannula, nasal high-frequency oscillatory ventilation, neutrally adjusted ventilator assist. NCPAP reduces upper airway resistance, helps to establish functional residual capacity, stabilizes the chest wall, and preserves endogenous surfactant. NIPPV was also studied as another method for the RDS treatment. It is a time-cycled pressure-limited ventilation mode, that superimposes an intermittent peak pressure on NCPAP. In addition to the benefits of NCPAP, NIPPV improves ventilation in apnea by providing a backup rate and using sufficient peak inspiratory pressure. Due to the use of higher mean airway pressure, NIPPV results in better alveolar recruitment and improved carbon dioxide clearance. 

The majority of clinical trials in preterm infants have compared NIPPV with CPAP as either the primary mode of treatment for neonatal respiratory distress syndrome (RDS), or after extubation. Of these trials, Kirpalani’s NIPPV Trial dominates the literature. This large, pragmatic trial differs from the smaller studies in that it recruited a heterogeneous study population and permitted a variety of devices to deliver NIPPV, including some that delivered synchronized pressure changes. Although pragmatic, the considerable degree of methodological and clinical heterogeneity makes the interpretation of pooled trial results difficult. The primary outcome, death or bronchopulmonary dysplasia (BPD) occurred in 38.4% of randomized neonates on NIPPV and in 36.7% of neonates with CPAP (adjusted odds ratio, 1.09; 95% confidence interval [CI], 0.83–1.43; P 5 .56). There were no significant differences between NIPPV and CPAP in the individual components of death or BPD. Majority of clinical trials in preterm infants compared NIPPV with CPAP as a modality after extubation, In this study, we aimed to compare NCPAP vs. NIPPV as an initial treatment of Respiratory distress in terms of prematurity-related morbidities and mortality. This study aim to compare nasal intermittent positive pressure ventilation (NIPPV) versus continuous positive airway pressure (CPAP) as primary respiratory support for preterm infants (≤ 34 weeks) with primary outcome  to assess the need for intubation within the first 72 hours after randomization (within 6 hours after birth) in preterm infants(≤ 34 weeks) with respiratory distress between NIPPV and CPAP.