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The pressure is on! The danger of a broken blow off valve on a bag valve mask

Neonatal Unit, Directorate of Women & Children’s Health, Forth Park Hospital, Kirkcaldy KY2 5AH, Scotland, UK

Correspondence to:
Correspondence to:
Dr Ainsworth
sean.ainsworth@faht.scot.nhs.uk

Keywords: resuscitation equipment; bag valve mask; pressure relief valve

The first 150 words of the full text of this article appear below.

We would like to draw the reader’s attention to a potentially dangerous occurrence with bag valve mask systems when repair and reassembly is carried out incorrectly. Bag valve masks are in common use in neonatal and paediatric resuscitations^1,2 and incorporate a pressure relief valve to prevent excessive pressures being delivered.

In this case, checking of a Laerdal paediatric (500 ml) resuscitator (catalogue number 86005033) before use revealed that the blow off valve was not working despite the initial cursory inspection failing to detect any problem (fig 1). Closer inspection revealed that the yellow over-ride button had been broken off and the device reassembled in such a way that the button was placed inside the valve the wrong way round (fig 1 inset). The resuscitator was taken out of use and subjected to further testing. The problem was then brought to the attention of the manufacturer.

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