Neonatal self-inflating bags: Achieving titrated oxygen delivery using low flows: An experimental study


  • Funding: None.
  • Competing interest: None.

Correspondence: Dr Ramesh Agarwal, Division of Neonatology, Department of Pediatrics, New Private Ward-1st Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. Fax: 91 11 26588663, 26588641; email:



To determine delivered O2 concentration (dFiO2) during manual inflations using neonatal self-inflating resuscitation bags (SIBs) at oxygen (O2) flow rates <1 L/min.


This experimental study, determined dFiO2 during 216 sets of manual inflations at different O2 flow rate (L/min; 0.2, 0.4, 0.6, 0.8, 1.0 and 5.0), controlling peak inspiratory pressures (PIP; cm of H2O; 10–15, 15–20 and 20–25), inflation rates (per min; 30, 40 and 60), with and without O2 reservoir using two SIBs – the Laerdal infant resuscitator (240 mL) and Ambu Mark IV resuscitator (300 mL).

A leak proof circuit connecting the SIB in series with pressure transducer, O2 analyzer and test lung was used. All possible combinations were tested four times each. The dFiO2 with each possible combination was compared using generalised estimating equation.


The mean dFiO2 with SIB even without reservoirs varied with rates and PIP from 75 to 93% at O2 flow rate of 5 L/min. At 1 L/min flow itself, 65–85% O2 is delivered. The dFiO2 was reduced to approximately 40% with flow of 0.2 L/min, PIP 20–25 cmH2O and inflations 40–60 per min.


During manual breaths using neonatal SIBs, the delivered O2 concentration of nearly 40% is attained at clinically used inflation pressures and rates by using lower flows. A graded increase in O2 delivery from 40 to 99% was obtained with flow varying from 0.2 to 5 L/min and addition of reservoir. However, even at such low flows, reduction in O2 concentration below 40% was unattained.