ARBAMINCH UNIVERSITY

C O L L E G E O F H E A LT H S C I E N C E
AND MEDICINE
D E PA RT M E N T O F A N E S T H E S I A

Anesthesia Machine & Breathing

systems

Kuchulo G.(MSc)
 Outline
2

Anesthesia work station

Breathing systems
 Insufflation
 Maplison circuits
 Circle system
 Resuscitation breathing systems
 Objectives
3

At the end of this session you will able to

operate/ use Anesthesia machine and
breathing systems.
 Anesthesia workstation
4

 The term anesthesia workstation is often used for

modern anesthesia machines.

 Anesthesia machine
 receives medical gases from a gas supply
 controls the flow and reduces the pressure of
desired gases to a safe level
 vaporizes volatile anesthetics into the final gas
mixture
 delivers the gases at the common gas outlet to the
breathing circuit connected to the patient’s airway
 Cont…
5

 We uses the anesthesia machine to

 control the patient’s ventilation
 ensure oxygen delivery
 administer inhalation anesthetics

 Proper functioning of the machine

is crucial for patient safety.
Anesthesia Machine
6
Anesthesia Machine
7
 GAS SUPPLY
8

 Most machines have gas inlets for oxygen, nitrous

oxide, and air.
 Separate inlets are provided for the primary pipeline
gas supply that passes through the walls of health
care facilities and the secondary cylinder gas supply.

 Machines therefore have two gas inlet pressure

gauges for each gas:
 one for pipeline pressure
 and another for cylinder pressure.
 Pipeline Inlets
9

 Oxygen and nitrous oxide (and often air) are

delivered from their central supply source to the
OR through a piping network.
 The tubing is color coded and connects to the
anesthesia machine through a non-interchangeable
DISS fitting that prevents incorrect hose
attachment.

 The tubes has filter helps trap debris from the wall
supply and a one-way check valve
 The approximate pipeline pressure of gases
delivered to the anesthesia machine is 50 psig.
 Cylinder Inlets
10

 Cylinders attach to the machine via hanger-yoke

assemblies that utilize a PISS to prevent accidental
connection of a wrong gas cylinder.
 The yoke assembly includes
 index pins
 a washer
 a gas filter
 a check valve that prevents retrograde gas flow.

 The gas cylinders are also color-coded for specific gases

to allow for easy identification.
 Pressure of gas supplied from the cylinder to the
anesthesia machine is 45 psig.
 Flow control circuits
11

Pressure Regulators
 To enhance safety and ensure optimal use of
cylinder gases, machines utilize a pressure
regulator to reduce the cylinder gas pressure to 45
to 47 psig.

 After passing through pressure gauges and check

valves, the pipeline gases share a common pathway
with the cylinder gases.
 Cont…
12

Oxygen Supply Failure Protection Devices

 These devices permit the flow of other gases only if
 there is sufficient oxygen pressure in the safety device
 and help prevent accidental delivery of a hypoxic
mixture in the event of oxygen supply failure.

 Oxygen pass through oxygen flow control valve, to the

common inlet pathway and here pressurize safety
devices

 Safety devices sense oxygen pressure via a small

“piloting pressure” line
 Cont…
13

 In some anesthesia machine designs (eg, Datex-

Ohmeda Excel)
 if the piloting pressure line falls below a threshold
(eg, 20 psig), the shut-off valves close, preventing
the administration of any other gases.
 Most modern machines use a proportioning safety
device instead of a threshold shut-off valve.

 All machines also have an oxygen supply low-

pressure sensor that activates alarm sounds when
inlet gas pressure drops below a threshold value
(usually 20–30 psig).
 Cont…
14

Flow Valves & Meters

 Once the pressure has been reduced to a safe level

 each gas must pass through flow control valves
 and is measured by flowmeters before mixing with
other gases, entering the active vaporizer, and
exiting the machine’s common gas outlet [CGO].
 Cont…
15

 Gas lines proximal to flow valves are considered to

be in the high pressure circuit

 whereas those between the flow valves and the

CGO are considered part of the low-pressure
circuit of the machine.

 Touch and color-coded control knobs make it more

difficult to turn the wrong gas off or on.

 As a safety feature the oxygen knob is usually

fluted, larger, and protrudes farther than the other
knobs.
 Cont…
16

 Flow control knobs control gas entry into the

flowmeters by adjustment via a needle valve.

 Causes of flowmeter malfunction include

 debris in the flow tube
 vertical tube misalignment
 sticking or concealment of a float at the top of a
tube.
 Cont…
17

 Should a leak develop within or downstream from

an oxygen flowmeter,
 A hypoxic gas mixture can be delivered to the
patient

 To reduce this risk, oxygen flowmeters are always

positioned downstream to all other flowmeters
(nearest to the vaporizer).
 Cont…
18

Oxygen/Nitrous Oxide Ratio Controller

 Another safety feature of anesthesia machines is a

linkage of the nitrous oxide gas flow to the oxygen
gas flow; this arrangement helps ensure a
minimum oxygen concentration of 25%.
 Cont…
19

Vaporizers

 Volatile anesthetics must be vaporized before being

delivered to the patient.
 have concentration calibrated dials that precisely
add volatile anesthetic agents to the combined gas
flow from all flowmeters.

 They must be located between the flowmeters and

the common gas outlet.
 Cont…
20

Moreover, unless the machine accepts only

one vaporizer at a time

 all anesthesia machines should have an

interlocking or exclusion device that prevents
the concurrent use of more than one
vaporizer.
 Cont…
21

 All modern vaporizers are agent specific and

temperature corrected

 capable of delivering a constant concentration of

agent regardless of temperature changes or flow
through the vaporizer

 Turning a single calibrated control knob

counterclockwise to the desired percentage diverts
an appropriate small fraction of the total gas flow
into the carrier gas
 Cont…
22

 Given that these vaporizers are agent specific,

filling them with the incorrect anesthetic must be
avoided.

 For example, unintentionally filling a sevoflurane

specific vaporizer with halothane could lead to an
anesthetic overdose.
 First, halothane’s higher vapor pressure (243 mm
Hg versus 157 mm Hg) will cause a 40% greater
amount of anesthetic vapor to be released.
 Cont…
23

 Second, halothane is more than twice as potent as

sevoflurane (MAC 0.75 versus 2.0).

 Conversely, filling a halothane vaporizer with

sevoflurane will cause an anesthetic under dosage.

 Modern vaporizers offer agent-specific, keyed,

filling ports to prevent filling with an incorrect
agent.
 Common (Fresh) Gas Outlet-CGO
24

 In contrast to the multiple gas inlets, there is only

one CGO that supplies gas to the breathing circuit.

 The term FGO is also often used because of its

critical role in adding new gas of fixed and known
composition to the circle system.

 An anti-disconnect retaining device is used to

prevent accidental detachment of the gas outlet
hose that connects the machine to the breathing
circuit.
 Cont…
25

 The oxygen flush valve provides a high flow (35–75

L/min) of oxygen directly to the CGO, bypassing the
flowmeters and vaporizers.

 It is used to rapidly refill or flush the breathing

circuit

 but because the oxygen may be supplied at a line

pressure of 45 to 55 psig, there is a real potential
for lung barotrauma to occur.
 Cont…
26

 For this reason, the flush valve must be used

cautiously whenever a patient is connected to the
breathing circuit.

 Some machines use a second-stage regulator to

drop the oxygen flush pressure to a lower level.

 A protective rim around the flush button limits the

possibility of unintentional activation
Anesthesia Machine
27
 THE BREATHING SYSTEMS
28

 Breathing systems provide the final conduit for the

delivery of anesthetic gases to the patient.
 Breathing circuits link a patient to an anesthesia
machine
 Many different circuit designs have been
developed, each with varying degrees of
 Efficiency
 convenience
 and complexity
 Cont…
29

 Most classifications of breathing systems artificially

consolidate functional characteristics (eg, the
extent of rebreathing) with physical characteristics
(eg, the presence of unidirectional valves).
 The most important breathing systems:
 Insufflation
 draw-over
 Mapleson circuits
 the circle system
 and resuscitation systems.
 Cont…
30

Insufflation
 The term insufflation usually denotes the blowing
of anesthetic gases across a patient’s face.
 Is a technique that avoids direct connection
between a breathing circuit and a patient’s airway.
 Because children often resist the placement of a
face mask (or an IV line)
 insufflation is particularly valuable during
inductions with inhalation anesthetics in children
 Cont…
31

 Because insufflation avoids any direct patient

contact, there is no rebreathing of exhaled gases if
the flow is high enough.
 Ventilation cannot be controlled with this technique
 the inspired gas contains unpredictable amounts
of entrained atmospheric air.
 Cont…
32

MAPLESON CIRCUITS
 The components
 breathing tubes
 fresh gas inlets
 APL valves
 reservoir bags

 The relative location of these components

determines circuit performance and is the basis of
the Mapleson classification
 Cont…
33

Components of Mapleson Circuits

A/ Breathing Tubes
 Corrugated tubes—made of rubber (reusable) or
plastic (disposable)—connect the components of the
Mapleson circuit to the patient
 The large diameter of the tubes (22 mm) creates a
low-resistance pathway and a potential reservoir for
anesthetic gases.
 To minimize FGF requirements, the volume of gas
within the breathing tubes in most Mapleson circuits
should be at least as great as the patient’s tidal
volume.
 Cont…
34

B. Fresh Gas Inlet

Gases (anesthetics mixed with oxygen or air)
from the anesthesia machine continuously
enter the circuit through the fresh gas inlet.
The relative position of the fresh gas inlet is a
key differentiating factor among Mapleson
circuits.
 Cont…
35

C. Adjustable Pressure-Limiting Valve (Pressure-Relief

Valve, Pop-Off Valve)
 All APL valves allow a variable pressure threshold for
venting.
 The APL valve should be fully open during spontaneous
ventilation so that circuit pressure remains negligible
throughout inspiration and expiration.
 Assisted and controlled ventilation require positive
pressure during inspiration to expand the lungs.
 Partial closure of the APL valve limits gas exit,
permitting positive circuit pressures during reservoir
bag compressions.
 Cont…
36

D. Reservoir Bag (Breathing Bag)

Reservoir bags function as a reservoir of

anesthetic gas and a method of generating
positive-pressure ventilation.
They are designed to increase in compliance
as their volume increases.
 Cont…
37

Classification and characteristics of Mapleson

circuits
 Cont…
38

Classification and characteristics of Mapleson

circuits.
Cont…
39
Cont…
40
 Cont…
41

Bain circuit
 is a coaxial version of the Mapleson D system
 it incorporates the fresh gas inlet tubing inside the
breathing tube
 This modification
 decreases the circuit’s bulk
 and retains heat and humidity better than a
conventional Mapleson D circuit
 as a result of partial warming of the inspiratory
gas by countercurrent exchange with the warmer
expired gases.
 Cont…
42

A disadvantage is :
 the possibility of kinking
 disconnection of the fresh gas inlet tubing

 Periodic inspection of the inner tubing is

mandatory to identify this complication
 if unrecognized, either of these mishaps
could result in significant rebreathing of
exhaled gas.
 Cont…
43

Bain circuit
 Circle system
44

The components of a circle system include:

 A CO2 absorber containing CO2 absorbent
 A fresh gas inlet
 An inspiratory unidirectional valve and inspiratory
breathing tube
 A Y-connector
 An expiratory unidirectional valve and expiratory
breathing tube
 An APL valve
 A reservoir bag
Cont…
45
 Cont…
46

Carbon Dioxide Absorber and the Absorbent

 Rebreathing alveolar gas conserves heat and
humidity
 However, the CO2 in exhaled gas must be eliminated
to prevent hypercapnia.
 CO2 chemically combines with water to form
carbonic acid.
 CO2 absorbents (eg, soda lime or calcium hydroxide
lime) contain hydroxide salts that are capable of
neutralizing carbonic acid.
 Reaction end products include heat (the heat of
neutralization), water, and calcium carbonate.
 Cont…
47

 Soda lime is an absorbent and is capable of absorbing up

to 23 L of CO2 per 100 g of absorbent.
 It consists primarily of calcium hydroxide (80%), along with
sodium hydroxide, water, and a small amount of potassium
hydroxide.
 Its reactions are as follows:
CO2 + H2O → H2CO3
H2CO3 + 2NaOH → Na2CO3 + 2H2O + Heat (a fast
reaction)
Na2CO3 + Ca(OH)2 → CaCO3 + 2NaOH (a slow reaction)

• Note that the water and sodium hydroxide initially required

are regenerated.
 Cont…
48

 Another absorbent, barium hydroxide lime, is no

longer used due to the possible increased hazard of
fire in the breathing system.
 A pH indicator dye (eg, ethyl violet) changes color
from white to purple as a consequence of
increasing hydrogen ion concentration and
absorbent exhaustion.
 Absorbent should be replaced when 50% to 70%
has changed color.
 Silica added to increases the hardness of soda lime-
since soda lime irritant if inhaled
 Cont…
49

 Commercial soda lime has a water content of 14%

to 19%.
 Absorbent granules can absorb and later release
medically active amounts of volatile anesthetic.
 This property can be responsible for modest delays
of induction or emergence.
 The drier the soda lime, the more likely it will
absorb and degrade volatile anesthetics.
 Cont…
50

The granules of absorbent are contained

within one or two canisters that fit snugly
between a head and base plate.
Together, this unit is called an absorber
Cont…
51
Cont…
52
 Cont…
53

Unidirectional Valves
 which function as check valves
 Inhalation opens the inspiratory valve, allowing the
patient to breathe a mixture of fresh and exhaled
gas that has passed through the CO2 absorber.
 Simultaneously, the expiratory valve closes to
prevent rebreathing of exhaled gas that still
contains CO2.
 The subsequent flow of gas away from the patient
during exhalation opens the expiratory valve.
 Cont…
54

 This gas is vented through the APL valve or

rebreathed by the patient after passing through the
absorber.

 Closure of the inspiratory valve during exhalation

prevents expiratory gas from mixing with fresh gas
in the inspiratory limb.

 Malfunction of either unidirectional valve may

allow rebreathing of CO2, resulting in hypercapnia.
 Cont…
55

Optimization of Circle System Design

 Although the major components of the circle
system can be placed in several configurations, the
following arrangement is preferred
 Cont…
56

 Unidirectional valves are relatively close to the

patient to prevent backflow into the inspiratory
limb if a circuit leak develops.

 However, unidirectional valves are not placed in

the Y-piece, as that makes it difficult to confirm or
maintain proper orientation and intraoperative
function.
 Cont…
57

 The fresh gas inlet is placed between the absorber

and the inspiratory valve.
 Positioning it downstream from the inspiratory
valve would allow fresh gas to bypass the patient
during exhalation and be wasted.
 Fresh gas introduced between the expiratory valve
and the absorber would be diluted by recirculating
gas.
 Furthermore, inhalation anesthetics may be
absorbed or released by soda lime granules, thus
slowing induction and emergence.
 Cont…
58

 The APL valve is usually placed between the

absorber and the expiratory valve and close to the
reservoir bag.
 Positioning of the APL valve in this location (ie,
before the absorber) helps to conserve absorption
capacity and minimizes the venting of fresh gas.
 The APL valve regulates the flow of gas from the
expiratory limb of the circuit into the gas
scavenger system.
 Resistance to exhalation is decreased by locating
the reservoir bag in the expiratory limb.
 Performance Characteristics of the Circle System

59

A. Fresh Gas Requirement

 With an absorber, the circle system prevents

rebreathing of CO2 at reduced FGF (≤1 L) or even
fresh gas flows equal to the uptake of anesthetic
gases and oxygen by the patient and the circuit
itself (closed-system anesthesia).

 At FGF greater than 5 L/min, rebreathing is so

minimal that a CO2 absorber is usually unnecessary.
 Cont…
60

 With low fresh gas flows, concentrations of oxygen

and inhalation anesthetics can vary markedly
between fresh gas (ie, gas in the fresh gas inlet)
and inspired gas (ie, gas in the inspiratory limb of
the breathing tubes).

 The latter is a mixture of fresh gas and exhaled gas

that has passed through the absorber.
 Cont…
61

 The greater the fresh gas flow rate, the less time it
will take for a change in fresh gas anesthetic
concentration to be reflected in a change in
inspired gas anesthetic concentration.

 Higher flows speed induction and recovery,

compensate for leaks in the circuit, and decrease
the risks of unanticipated gas mixtures.
 Cont….
62

B. Dead Space
 That part of a tidal volume that does not undergo
alveolar ventilation is referred to as dead space.
 Thus, any increase in dead space must be
accompanied by a corresponding increase in tidal
volume, if alveolar ventilation is to remain
unchanged.
 Because of the unidirectional valves, apparatus
dead space in a circle system is limited to the area
distal to the point of inspiratory and expiratory gas
mixing at the Y-piece.
 Cont…
63

 Unlike Mapleson circuits, the circle system tube

length does not affect dead space.
 Like Mapleson circuits, length does affect circuit
compliance and thus the amount of tidal volume
lost to the circuit during positive-pressure
ventilation.
 Pediatric circle systems may have both a septum
dividing the inspiratory and expiratory gas in the Y-
piece and low-compliance breathing tubes to
further reduce dead space, and are lighter in
weight.
 Cont…
64

C. Resistance
 The unidirectional valves and absorber increase
circle system resistance, especially at high
respiratory rates and large tidal volumes.
 Nonetheless, even premature neonates can be
successfully ventilated using a circle system.
 Cont…
65

D. Humidity and Heat Conservation

 Medical gas delivery systems supply dehumidified
gases to the anesthesia circuit at room temperature.
 Exhaled gas, on the other hand, is saturated with
water at body temperature.
 Therefore, the heat and humidity of inspired gas
depend on the relative proportion of rebreathed gas to
fresh gas.
 High flows are accompanied by low relative humidity,
whereas low flows allow greater water saturation.
 Absorbent granules provide a significant source of
heat and moisture in the circle system.
 Cont…
66

E. Bacterial Contamination

 The minimal risk of microorganism retention in

circle system components could theoretically lead
to respiratory infections in subsequent patients.

 For this reason, bacterial filters are sometimes

incorporated into the inspiratory or expiratory
breathing tubes or at the Y-piece.
 Cont…
67

Circle system advantages and

disadvantages
Circle advantages:
 constant inspired concentrations
 conserve respiratory heat and humidity
 useful for all ages (may use down to 10 kg, about
one year of age, or less with a pediatric disposable
circuit)
 useful for closed system or low-flow
 low resistance (less than tracheal tube, but more
than a NRB circuit)
 Cont..
68

Circle disadvantages:
increased dead space
malfunctions of unidirectional valves
 cont…
69

Characteristics of breathing circuits

no Character Mapleson circle

1 complexity Simple Complex
2 Control of anesthesia depth Variable Good
3 Ability to scavenge Variable Good
4 Conservation of heat & No Yes
humidity
5 Rebreathing of exhaled gases No Yes
 RESUSCITATION BREATHING
SYSTEMS
70

 Resuscitation bags (AMBU bags or bag-mask units)

are commonly used for emergency ventilation
because of their simplicity, portability, and ability to
deliver almost 100% oxygen.

 A resuscitator is unlike a Mapleson circuit or a

circle system because it contains a non-rebreathing
valve.
 Cont…
71

 High concentrations of oxygen can be delivered to

a mask or tracheal tube during spontaneous or
controlled ventilation if a source of high fresh gas
flow is connected to the inlet nipple.
 The patient valve opens during controlled or
spontaneous inspiration to allow gas flow from the
ventilation bag to the patient.
 Rebreathing is prevented by venting exhaled gas to
the atmosphere through exhalation ports in this
valve.
 Cont…
72

 The compressible, self-refilling ventilation bag also

contains an intake valve.
 This valve closes during bag compression,
permitting positive-pressure ventilation.
 The bag is refilled by flow through the fresh gas
inlet and across the intake valve.
 Connecting a reservoir to the intake valve helps
prevent the entrainment of room air.
 Cont…
73

 The reservoir valve assembly is really two

unidirectional valves: the inlet valve and the outlet
valve.

 The inlet valve allows ambient air to enter the

ventilation bag if fresh gas flow is inadequate to
maintain reservoir filling.
 Positive pressure in the reservoir bag opens the
outlet valve, which vents oxygen if fresh gas flow is
excessive.
 There are several disadvantages to resuscitator
breathing systems.
 Cont…
74

 First, they require high fresh gas flows to achieve a

high FiO2.
 FiO2 is directly proportional to the oxygen
concentration and flow rate of the gas mixture
supplied to the resuscitator (usually 100% oxygen)
and inversely proportional to the minute ventilation
delivered to the patient.
 Finally, although a normally functioning patient
valve has low resistance to inspiration and
expiration, exhaled moisture can cause valve
sticking.