Breathing System
Breathing systems
• functional characteristics (eg, the extent of rebreathing)
• physical characteristics (eg, the presence of unidirectional valves)
INSUFFLATION
• the blowing of anesthetic gases across a patient’s face
• avoids direct connection between a breathing circuit and a patient’s
airway
• valuable during inductions with inhalation anesthetics in children
• avoids any direct patient contact there is no rebreathing of exhaled
gases if the flow is high enough.
• be used to maintain arterial oxygenation during brief periods of apnea
(eg, during bronchoscopy) oxygen is directed into the lungs through
a device placed in the trachea.
INSUFFLATION
• Carbon dioxide (CO2 ) accumulation under head and neck draping is a
hazard of ophthalmic surgery performed with local anesthesia high
flow rate (>10 L/min)
• Ventilation cannot be controlled with this technique, however, and
the inspired gas contains unpredictable amounts of entrained
atmospheric air
OPEN-DROP ANESTHESIA
• As the patient inhales, air passes through the
gauze, vaporizing the liquid agent and carrying
high concentrations of anesthetic to the
patient.
• Modern
draw-over vaporizers that depend on the
patient’s inspiratory efforts to draw ambient air
through a vaporization chamber-- compressed
medical gases are unavailable (eg, battlefields)
DRAW-OVER ANESTHESIA
• non-rebreathing circuits
• use ambient air/supplemental
oxygen
• Portable and simple
• Low resistance to gas flow
• Usable with any agent
• Controllable vapor output
• Can be fitted with connections and
equipment allow intermittent
positive-pressure ventilation
(IPPV), passive scavenging,
continuous positive airway
pressure (CPAP), and positive end-
expiratory pressure (PEEP).
DRAW-OVER ANESTHESIA
Oxygen flow rate
• 1 L/min Fio2 30%-
40%
• 4 L/min Fio2 60%-
80%.
• poor control of inspired gas concentration
Insufflation poor control of depth of anesthesia
• mechanical drawbacks during head and neck
Disadvantages
surgery
Draw-over systems • pollution of the operating room with large
volumes of waste gas.
MAPLESON CIRCUITS
• breathing tubes
• fresh gas inlets
• adjustable pressure-limiting [APL] valves
• reservoir bags
Components of Mapleson
Circuits • Large diameter of the tubes
A. Breathing Tubes (22 mm) low-resistance
pathway and a potential
reservoir for anesthetic
gases.
• To minimize fresh gas flow
requirements, the volume of
gas within the breathing
tubes in most Mapleson
circuits ≥ the patient’s tidal
volume.
A. Breathing Tubes (cont’d)
• The compliance of the breathing tubes largely determines the
compliance of the circuit.
• Long breathing tubes with high compliance increase the difference
between the volume of gas delivered to a circuit by a reservoir bag or
ventilator and the volume actually delivered to the patient.
B. Fresh Gas Inlet
• Gases (anesthetics mixed with oxygen or air) from the anesthesia
machine continuously enter the circuit through the fresh gas inlet.
C. Adjustable Pressure-Limiting Valve
(Pressure-Relief Valve, Pop-Off Valve)
• Spontaneous ventilation fully open of the APL valve
• Assisted and controlled ventilation requires positive pressure during
inspiration to expand the lungs. Partial closure of the APL valve
• Mapleson A design is the most efficient Mapleson circuit for
spontaneous ventilation, because a fresh gas flow equal to minute
ventilation is sufficient to prevent rebreathing.
• The Mapleson D circuit is efficient during controlled ventilation
because fresh gas flow forces alveolar air away from the patient and
toward the APL valve
D. RESERVOIR Bag
(Breathing Bag)
Function as a reservoir of
anesthetic gas and generating
positive-pressure ventilation.
To increase in compliance as
their volume increases
There are three distinc phases of
reservoir bag filling
Performance Characteristics of Mapleson
Circuits
• Mapleson circuits are lightweight,
inexpensive, and simple.
• Breathing-circuit efficiency is
measured by the fresh gas flow
required to reduce CO2 rebreathing
to a negligible value.
• The APL valve in Mapleson A, B, and C
circuits is located near the face mask,
and the reservoir bag is located at the
opposite end of the circuit.
The circle system • Characteristic of breathing
circuit
• Mapleson circuits overcome
some of the disadvantages of
the insufflation and draw-over
systems, the high fresh gas flows
required to prevent rebreathing
of CO2 result in waste of
anesthetic agent, pollution of
the operating room
environment, and loss of patient
heat and humidity
A circle system. APL, Adjustable pressure-
limiting (valve)
• The components of a circle
system include: (1) a CO2
absorber containing CO2
absorbent; (2) a fresh gas inlet;
(3) an inspiratory unidirectional
valve and inspiratory breathing
tube; (4) a Y-connector; (5) an
expiratory unidirectional valve
and expiratory breathing tube;
(6) an APL valve; and (7) a
reservoir
Components of the Circle System
• A. Carbon Dioxide Absorber and the Absorbent
• CO2 absorbents (eg, soda lime or calcium hydroxide lime) contain
hydroxide salts that are capable of neutralizing carbonic acid
• . 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
• Increasing the hardness of soda lime by adding silica minimizes the
risk of inhalation of sodium hydroxide dust and also decreases the
resistance of gas flow
• Absorbent granules can absorb and
later release medically active amounts
of volatile anesthetic
• The formation of carbon monoxide is
greatest with desflurane; with
sevoflurane, it occurs at a higher
temperature
• 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
Unidirectional Valves
• Function as check valves, contain
a ceramic or mica disk resting
horizontally on an annular valve
seat.
• The expiratory valve is exposed
to the humidity of alveolar gas
• 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. 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.
Optimization of Circle System Design
Although the major components of the circle system can be placed in several configurations, the following
arrangement is preferred :
• Unidirectional valves are relatively close to the patient to prevent backflow into the inspiratory limb if a
circuit leak develops.
• 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.
• The APL valve is usually placed between the absorber and the expiratory valve and close to the reservoir
bag. Positioning the APL valve in this location (ie, before the absorber) helps 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
A. Fresh Gas Requirement
• With an absorber, the circle system prevents rebreathing of CO2 at reduced fresh gas
flows (≤1 L) or even fresh gas flows equal to the uptake of anesthetic gases and oxygen
by the patient and the circuit itself. At fresh gas flows greater than 5 L/min, rebreathing
is so minimal that a CO2 absorber is usually unnecessary.
• 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.
• 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 and can compensate for
leaks in the circuit.
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.
• Unlike Mapleson circuits, the circle system corrugated breathing 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 they are lighter in weight.
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.
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 reduced flows allow
greater water saturation. CO2 -absorbent granules provide a significant source of heat and
moisture in the circle system.
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 incorporated
into the inspiratory or expiratory breathing tubes or at the Y-piece.
Disadvantages of the Circle System
Although most of the problems of Mapleson circuits are solved by the circle system, these improvements
have led to other disadvantages:
• Greater size and less portability
• Increased complexity, resulting in a greater risk of disconnection or malfunction
• Complications related to use of absorbent
• The difficulty of predicting inspired gas concentrations during low fresh gas flows.
RESUSCITATION BREATHING SYSTEMS
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 nonrebreathing valve.
• 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. The compressible, selfrefilling 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. 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. 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.
• Although a normally functioning patient valve has low resistance to inspiration and expiration, exhaled
moisture can cause valve sticking. Finally, venting exhaled gas into the atmosphere can lead to local
contamination if the expiratory gases are contaminated with infectious agents.
