Flow-Inflating Bag vs. T-Piece Resuscitator: Does the Device Matter in Preterm Resuscitation?

Background

When a preterm baby is born, the first few minutes of life are critical. Many need help establishing breathing, and neonatal teams rely on devices like the flow-inflating bag (FIB) or the T-piece resuscitator (TPR) to deliver gentle positive-pressure ventilation (PPV).

While both devices are standard in neonatal units, the evidence comparing their real-world effectiveness in extremely preterm infants has been limited. This new Canadian Neonatal Network (CNN) cohort study—spanning five tertiary NICUs—provides valuable insights into whether one device leads to better outcomes for infants born between 24 and 29 weeks’ gestation.

Study Overview

Between 2018 and 2022, researchers analyzed 1,581 preterm infants who received mask ventilation at birth—745 with the FIB and 836 with the TPR.The main outcome was a composite of death, bronchopulmonary dysplasia (BPD), or severe neurological injury.

Statistical models adjusted for gestational age, antenatal exposures, mode of delivery, multiple births, and small-for-gestational-age status, with clustering by site.

Delivery Room Findings

Both groups started with the same oxygen concentration (FiO₂ = 30 %), but infants ventilated with the FIB received higher peak oxygen levels (median 100 % vs 70 %; p < 0.0001).

Intubation rates were also markedly different:

• 44 % with the FIB

• 24 % with the TPR (p < 0.0001)

After adjustment, infants ventilated with the TPR were 76 % less likely to require intubation (adjusted OR 0.24 [0.09–0.61]).

There were no differences in chest compressions or epinephrine use, indicating similar resuscitation intensity.

Early NICU Outcomes

Infants stabilized with the TPR were more often normothermic on admission and less likely to need mechanical ventilation on day 1 (48 % vs 59 %). These advantages weakened after statistical adjustment but remained directionally consistent, suggesting that TPR use may support gentler respiratory transition.

No differences were seen in pneumothorax or the need for inhaled nitric oxide.

Major Outcomes

The primary composite outcome—death, BPD, or severe neurological injury—was similar between groups (adjusted OR 0.87 [0.44–1.71]).

Looking at individual outcomes:

• Mortality was slightly lower with TPR before adjustment, but not after (aOR 0.66 [0.30–1.46]).

• BPD was marginally higher in TPR infants (aOR 1.10 [0.63–1.92]), possibly reflecting survival bias.

• Severe neurological injury showed no significant difference.

Importantly, none of the adjusted associations reached statistical significance, confirming that device type did not independently predict major outcomes.

Other Morbidities

The rates of late-onset sepsis, ROP, and pneumothorax were similar.However, necrotizing enterocolitis (NEC) was significantly lower in the TPR group (adjusted OR 0.56 [0.53–0.60]), suggesting more stable early perfusion and oxygenation—though this finding should be interpreted cautiously and confirmed in future studies.

What Does This Mean for Clinical Practice?

This large, multicenter study found no significant difference in survival, BPD, or severe brain injury between the FIB and TPR when used for delivery-room stabilization of preterm infants.The TPR was associated with less intubation, lower oxygen exposure, and possibly fewer early mechanical ventilations, but these did not translate into improved long-term outcomes.

The key takeaway?

It’s not the device—it’s the hands that use it.Provider skill, training consistency, and teamwork likely matter more than the choice between a flow-inflating bag and a T-piece resuscitator.

In Summary

• Both devices are safe and effective for delivery-room stabilization.

• TPR may offer gentler and more controlled ventilation, reducing early intervention needs.

• No difference in major outcomes after adjustment for confounding factors.

• Focus on provider training and consistency, not on switching equipment.