DIVA is a pragmatic randomized clinical trial (RCT) to determine: among (P) preterm infants born 23 0/7-28 6/7 weeks gestation undergoing extubation from mechanical ventilation, whether (I) Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) (C) compared with Non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV), will reduce the incidence of (O) extubation failure within (T) 5 days (120 hours) of extubation.

Bronchopulmonary dysplasia (BPD) is the most common complication of prematurity and is the leading respiratory cause of childhood morbidity. Ventilator induced lung injury (VILI) an accepted and important contributor to BPD. Exposure to oxygen and positive pressure ventilation leads to developmental arrest and parenchymal injury in the immature preterm lung. Because even brief exposure to intubated positive pressure ventilation is injurious, avoiding invasive mechanical ventilation is the most widely acknowledged strategy to prevent VILI and the long-term sequela of BPD. Therefore, time on ventilators and rates of successful extubation are important endpoints of therapy.

Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) is an FDA approved technology that consistently synchronizes non-invasive respiratory support with infant respiratory drive. The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial is an unblinded, pragmatic, multicenter phase III randomized clinical trial in extremely preterm infants 23 0/7- 28 6/7 weeks gestational age to determine if NIV-NAVA, compared with non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV), prevents extubation failure within 5 days (120 hours) of extubation from mechanical ventilation

Inclusion Criteria:

• Gestational age of 23 0/7- 28 6/7 weeks at birth
• Intubated in the first 7 days of life
• Undergoing extubation following at least 12 hours of invasive mechanical ventilation
• Post-natal age <32 weeks Post menstrual age at time of extubation

Exclusion Criteria:

• Major congenital anomalies, including pulmonary hypoplasia
• Neurologic disorders affecting respiratory drive (other than apnea of prematurity)
• Esophageal bleeding or other contraindication to NG/OG catheter placement
• Current weight <500 grams (based on Edi catheter approval)
• Study ventilator not available at time eligibility criteria are met
• Planned surgery or invasive procedure within 5 days of extubation
• Informed consent not provided

Research records will be retained at each study site, and at the DCC for 3 years after completion of the study. We will follow NIH sharing policies with regards to sharing of data and specimens to public repositories, where appropriate

3 years after completion of the study

Trial PIs are unaware of treatment allocation for individual subjects