BACKGROUND. Initial ventilation strategy may play an important role in the development of bronchopulmonary dysplasia in very preterm infants. Early nasal continuous positive airway pressure is an accepted approach, but randomized clinical trials are lacking. Our aim was to determine whether early nasal continuous positive airway pressure, preceded by a sustained inflation, is more effective and less injurious in very preterm infants than conventional intervention. METHODS. Two hundred seven very preterm infants were assigned randomly in the delivery room to either a sustained inflation through a nasopharyngeal tube followed by early nasal continuous positive airway pressure (early functional residual capacity intervention) or repeated manual inflations with a self-inflating bag and mask followed by nasal continuous positive airway pressure, if necessary, after arrival at the NICU. The primary outcome measure was intubation <72 hours of age and bronchopulmonary dysplasia at 36 weeks was used as secondary outcome. This trial was registered as an early functional residual capacity intervention trial (ISRCTN 12757724). RESULTS. In the early functional residual capacity intervention group, fewer infants were intubated at <72 hours of age or received >1 dose of surfactant, and the average duration of ventilatory support was less. Infants in the early functional residual capacity intervention group developed bronchopulmonary dysplasia less frequently. CONCLUSIONS. A sustained inflation followed by early nasal continuous positive airway pressure, delivered through a nasopharyngeal tube, is a more efficient strategy than repeated manual inflations with a self-inflating bag and mask followed by nasal continuous positive airway pressure on admission to the NICU.