AbstractObjectiveTo compare immediate extubation versus delayed extubation after 36 hr in extremely low‐birth weight infants receiving gentle mechanical ventilation and perinatal lung protective interventions. Our hypothesis was that a delayed extubation in this setting would decrease the rate of reintubation.Study design/MethodologyA prospective, unmasked, randomized, controlled trial to compare immediate extubation and delayed extubation after 36 hr. Optimized ventilation in both groups included continuous tracheal gas insufflation (CTGI), prophylactic surfactant administration, low oxygen saturation target and moderate permissive hypercapnia. Successful extubation for at least 7 days was the primary criterion and ventilatory support requirements until 36 weeks gestational age the main secondary criteria.Patient selectionEighty‐six infants under 28 weeks gestational age in a single neonatal intensive tertiary care unit.ResultsDelayed extubation (1.9 ± 0.8 days vs. 0.5 ± 0.7 days) did not improve the rate of successful extubation but had no long‐term adverse effects. CTGI and the lung protective strategy we describe resulted in a very gentle ventilation. The rate of survival without bronchopulmonary dysplasia (BPD, defined as any respiratory support at 36 weeks gestational age) was similar in the two groups and remarkably high for the global population (78%) and for the subgroup of infants <1,000 g at birth (75%).ConclusionsAdding 36 hr of optimized mechanical ventilation before first extubation does not improve the rate of successful extubation but has no adverse effects. Pediatr Pulmonol. 2008; 43:117–124. © 2007 Wiley‐Liss, Inc.