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Nasal Continuous Positive Airway Pressure (NCPAP) is commonly used as a noninvasive respiratory support to prevent extubation failure and apnea of prematurity in very preterm infants but some studies report that nasal trauma often occur. Heated Humidified High Flow Nasal Cannula (HHHFNC) is the alternative to NCPAP. However, data on the efficacy or safety of HHHFNC compared with NCPAP is limited. This study was performed to compare the efficacy and safety of HHHFNC and NCPAP for prevention of postextubation respiratory failure in preterm. In this unicenter, randomized, unblinded, noninferiority trial, preterm infants gestational age less than 32 weeks and birth weight less than 1,250 grams, who were planned for extubation, were enrolled. Of 48 infants meeting the inclusion criteria, 22 were randomized to HHHFNC group and 26 to NCPAP group. The primary outcome was evaluated within 3 days as a need for reintubation. The nasal trauma, neonatal infant pain score, nurses and the parents’ satisfaction were evaluated as secondary outcomes. There was no difference in baseline characteristic except less surfactant receiving rate in HHHFNC group (p = 0.030). The study showed both noninferiority of reintubation rate between two groups (HHHFNC 1/22 [4.6%] vs NCPAP 4/26 [15.4%]; p = 0.357) and the incidence of nasal trauma and neonatal infant pain score. However, nurses and the parents were more satisfied using HHHFNC than with NCPAP (p = 0.034 and 0.011 respectively). The findings imply that both HHHFNC and NCPAP remain alternative. For more satisfaction, it is recommended that HHHFNC should be considered.