Bubble continuous positive airway pressure (BCPAP) is a low cost nasal CPAP delivery system with potential benefits to developing nations. Objective: To compare the efficacy and safety of BCPAP with ventilator-derived CPAP (VCPAP) in preterm neonates with respiratory distress. Methods: In a randomized controlled trial, preterm neonates with Silverman-Anderson score (4 and oxygen requirement (30% within first 6 h of life were randomly allocated to BCPAP or VCPAP. Proportion of neonates with success or failure was compared.Results: In all, 47 of 57 (82.5%) neonates from BCPAP group and 36 of 57 (63.2%) neonates from the VCPAP group completed CPAP successfully (p = 0.03). Neonates who failed CPAP had higher Silverman-Anderson score (p ( 0.01), lower arterial to alveolar oxygenation ratio (p ( 0.05) and needed surfactant more frequently (p ( 0.01).Conclusion: BCPAP has higher success rate than VCPAP for managing preterm neonates with early onset respiratory distress, with comparable safety. © The Author . Published by Oxford University Press. All rights reserved.