Objective To evaluate the clinical impact of nasal mask ventilator-delivered positive pressure ventilation (PPV) versus face mask manual T-piece resuscitator PPV during resuscitation of preterm neonates.

Design We conducted a pre-post cohort study in a tertiary neonatal unit, comparing consecutive neonates born 25^0/7–28^6/7 weeks of gestational age (GA) who received PPV ≤10 min after birth, before and after changing the approach during resuscitation from face mask manual T-piece resuscitator PPV (epoch 1, April 2018–April 2020) to nasal mask ventilator-delivered PPV (epoch 2, May 2020–February 2022). The association between birth epoch and the primary outcome of emergent intubation (EI) during resuscitation was examined by multivariable logistic regression and inverse probability of treatment weighting models. Additional outcomes compared between epochs were rates of advanced resuscitation, and early (≤7 days) and late (>7 days) prematurity-related morbidities.

Results Of 545 eligible births, 336 (62%) received PPV; 176 (58%) in epoch 1 and 160 (66%) in epoch 2. Neonates in epoch 1 had lower GA (26.7 (25.9–27.9) vs 27.4 (26.0–28.1) weeks; p=0.02) but similar birth weight (900 (730–1060) vs 880 (740–1085) g; p=0.53). Neonates in epoch 2 had lower rates of EI (16% vs 44%; p<0.001) and less use of post-resuscitation invasive ventilation (22% vs 59%; p<0.001). After accounting for confounders, nasal mask ventilator-delivered PPV remained associated with lower odds of EI (adjusted OR 0.23 (95% CI 0.13 to 0.42)). Secondary outcomes were similar between groups.

Conclusion Nasal mask ventilator-delivered PPV may reduce EI during resuscitation of preterm neonates. Our observations support a large trial of nasal mask ventilator-delivered PPV in this context.