A recent randomized controlled trial found that delivering budesonide mixed with surfactant directly into the airways of extremely premature infants failed to reduce bronchopulmonary dysplasia (BPD) or mortality rates. The BiB trial contradicts earlier positive findings from Yeh et al, creating uncertainty around this intervention for preventing chronic lung disease in vulnerable neonates. This discrepancy highlights the challenge of translating promising pilot studies into larger clinical populations. BPD remains a major complication affecting up to 40% of infants born before 28 weeks gestation, often leading to long-term respiratory problems and developmental delays. The failure to replicate earlier success suggests that either the original study had methodological limitations, patient populations differed significantly, or the intervention's benefits are more marginal than initially believed. For neonatologists, this represents another setback in the quest for effective BPD prevention strategies. The field may need to explore alternative corticosteroid delivery methods, different timing protocols, or combination therapies. Given the substantial healthcare burden of BPD survivors requiring prolonged ventilation and oxygen support, identifying truly effective interventions remains a critical research priority.