Outcome in neonates with acute respiratory failure supported initially either by rescue mechanical ventilation (IPPV) or by nasal continuous positive airway pressure (NCPAP) was compared in a retrospective review of cases seen at King Edward VIII Hospital between January and December 2000. IPPV and NCPAP were required by 89 and 85 neonates, respectively. The median weights (1900 vs 1650 g), male to female ratios (1.74:1 vs 1.34:1) and median gestational ages (32 vs 34 weeks) were similar in the two groups. Of the 89 neonates who required IPPV, 17 failed initial NCPAP and seven required ventilatory support for secondary reasons after NCPAP was initially successful. In the remainder (n = 65) who initially received IPPV, the mortality rate was 39% (n = 25) compared with 25% (n = 21) in the group who received NCPAP initially. Sixty-three neonates (74%) were initially successfully supported with NCPAP alone. Of these, fifty (79%) required no further respiratory support until discharge and seven received IPPV subsequently, five of whom died; six who were not offered mechanical ventilation also died. NCPAP did not provide adequate respiratory support in 22 newborns (26%). Of these, 17 received IPPV, five of whom died, and five who were not offered mechanical ventilation also died. Hyaline membrane disease and congenital pneumonia were the common primary diagnoses in both groups. NCPAP was a useful adjunct to mechanical ventilation in treating newborns for a variety of disorders causing respiratory failure. The delay in instituting mechanical ventilation by initial use of NCPAP did not adversely affect outcome.