Respiratory distress syndrome (RDS) represents a core clinical challenge in the management of extremely preterm infants. While the incidence of ventilator-associated lung injury has declined substantially, the failure rate of conventional nasal continuous positive airway pressure (NCPAP) remains persistently high among extremely preterm infants with very low gestational age. In recent years, noninvasive high-frequency oscillatory ventilation (NHFOV), as an emerging non-invasive ventilation modality, has garnered attention owing to its potential advantages in facilitating carbon dioxide elimination and preserving functional residual capacity. However, high-level evidence-based medical data supporting its efficacy and safety as an initial respiratory support strategy for extremely preterm infants are still lacking. Recently, the team led by Professor Shi from the Children's Hospital Affiliated to Chongqing Medical University published findings of a multicenter randomized controlled trial in The BMJ. This trial enrolled 342 preterm infants diagnosed with RDS, with gestational ages ranging from 24⁺⁰ to 28⁺⁶ weeks, across 20 neonatal intensive care units in China, thereby providing critical evidence addressing this pivotal clinical question. This article not only summarizes the landmark implications of the study but also identifies its inherent limitations, while offering commentary on its guiding value for clinical practice and future research endeavors.