Summary

Bronchopulmonary dysplasia (BPD) remains the most common severe adverse pulmonary outcome of preterm birth. Low gestational age and birth weight are the strongest risk factors for the development of BPD, but the pathogenesis is complex. The strategy for respiratory support immediately after birth and during the initial neonatal period may have a critical impact on the development of BPD. The preterm lung is highly susceptible to injury. An understanding the physiology of the first breath, the initiation of breathing and respiratory adaptation after birth is essential for ad-equate resuscitation measures and a lung protective ventilation strategy. Excessive oxygen use in preterm infants can increase the risk of BPD. The recently developed nomograms for oxygen saturation levels during the neonatal transition phase have become part of the newly revised resuscita-tion guidelines. For term neonates, starting resuscitation with air, rather than 100 % oxygen, is now advised. Preterm infants may require a higher initial inspiratory oxygen fraction than term infants; however, the ideal level remains to be defined. Primary intubation is no longer a prerequisite for preterm survival. Recent trials have demonstrated that even very preterm infants can be safely stabilised after delivery with continuous positive airway pressure and later be selectively treated with surfactant for respiratory distress syndrome. This initially less invasive strategy has the advan-tage of reducing the need for mechanical ventilation and, thereby, the risk of lung injury; however, to date, it has not been clearly shown to reduce the incidence of BPD. Combining an approach of noninvasive ventilator support with a strategy of minimally invasive surfactant administration is important, but questions remain about the optimal timing, mode of delivery and value of predictive tests for surfactant deficiency. Key points • The risk and severity of bronchopulmonary dysplasia (BPD) is strongly associated with th