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Anaesthesia, 1995, Volume 50, pages 239-242

The Epstein-Macintosh-Oxford (EMO) inhaler

This superbly designed piece of apparatus barely requires an bellows, when indicated, to deliver ether/air. Its low resist-
introduction. It is an example of the application of the basic ance allows spontaneous ventilation. With minor modifi-
laws of physics to vaporization of a liquid, combined with cations it will deliver known concentrations of vapor of
high quality engineering. The result is a robust, calibrated, other liquid anaesthetics. It can deliver any concentration of
accurate and portable anaesthetic vaporizer that can be anaesthetic irrespective of variations in temperature
used anywhere. It is still in extensive use in the third world throughout the range likely to be encountered in clinical
where the facilities for high technology anaesthesia, and practice. This piece of apparatus will be as useful in 100
frequently oxygen, are lacking. It has been used safely, often years time as it was at the time of its description.
by nonmedically qualified personnel, on hundreds of thou-
sands of patients.
The apparatus was designed primarily as a ‘drawover’
inhaler, to be used in conjuction with an Oxford inflating M . MORGAN

0195-668)3/95/030239 + 04 $08.00/0 @ 1995 The Association of Anaesthetists of G t Britain and Ireland 239

FIG. 2
When the patient inspires (through tubing attached to D) air is
drawn through (A) and (B). The air passing through (B) flows over
the liquid antesthetic, mixing with the vapour above it. The vapourl
AN ANESTHETIC INHALER WITH air mixture leaves the vaporising chamber through (c), and is then
diluted by the air by-passed through (A). The final mixture passes to
AUTO MAT1C TH ERMO-COMPENSATlON the patient through (D).

0 0
Nuffield Department of Anasthetics
University of Oxford

This inhaler, the EMO,has been designed to deliver any desired

concentration of anzsthetic vapour, irrespective of variations in the
temperature of the liquid anmthetic throughout the range likely
to be encountered in clinical practice. The inhaler described in this FIG. 3 FIG. 3a FIG. 3b
article is calibrated in terms of percentage ether vapour: with minor
modificationsit will deliver known concentrations of vapour of other FIG. 3
liquid anzsthetics. The hand operated control tap (F) governs entry of air through (B)
Some of the principles involved are shown in the schematic and (A). The pointer fitted to the end of this control moves over a
diagrams. In order not to overload the diagrams, the various scale (G) calibrated in terms of percentage of vapour leaving the
key letters (A-H) appear on them only once. inhaler through (D). In this diagram the pointer is set at 0; (B) is
shut, and the patient breathes air only through (A).
FIG. 1
(A) Entry to air by-pass duct. FIG. 3a
(B)and (c) Inlet and outlet of vaporking chamber. Tbe control tap has been moved to its other extreme position;
(D) Connectionfor breathing tube leading to patient.
further movement is limited by a stop which ensures that (A) is
(E) Vaporising chamber. never completely occluded. On inspiration air passes freely through
(B) into the vaporking chamber, while the size of the entry (A) is
D considerablyreduced.
FIG. 3b
The control is set to deliver a low concentration of vapour. (B) is
slightly open, and the volume of air which will be drawn through
the vaporising chamber is correspondinglysmall.
FIG. 4
As the concentration of vapour within the inhaler depends on the
temperature of the liquid anaesthetic, an automatic thermo-com-
pensator (H) is introduced to ensure that for any one setting of the
tap (F), the strength of the vapour in the inspired mixture remains
FIG. 1 FIG. 2 constant despite changes in temperature. This device, a small metal

bellows containing a liquid, is fitted within the vaporising chamber 1 The size and shape of the vaporising chamber and the disposi-
below an orifice (c), and automatically responds to temperature tion of wicks which provide a large surfacefor evaporation.
changes: any warming up is quickly followed by expansion when 2 The size and shape of the various passages which conkol the
the cone-shaped plunger is carried up into (c),thus diminishing the distributionof air currents.
effective area of the outlet. Coolinghas the opposite effect. 3 The range of movement of the metal bellows with changes in
FIG. 4a 4 The shape of the plunger, and the size of the orifice with which
The temperature of the inhaler is near the upper limit likely to be it is associated.
met in clinical practice. The concentration of vapour, represented We have not thought it helpful to encumber this brief article with
by the density of dots, is high within compartment (E). The bellows theoretical calculations since these provide only a few of the
has expanded in response to the high temperature, carrying the answers. In practice repeated laboratory experiments had to be
plunger upwards, thereby diminishing the area of (c).The resistance carried out: in fact, trial and error contribute significantly to the
to the passage of gases through (c) is high so that on inspiration finaldesign. '
the volume of vapour/air mixture leaving (E) is small. T h i s small F I G . 5 is meant to act as a stepping stone to the next illustration. The
volume of strong mixture is diluted wi;h the air by-passed through vaporising chamber (E) is annular in shape and its walls are lined
(A). The strength of the final mixture delivered to the patient is in-
with wicks (I). The pointer moving over the concentration scale is
dicated by the density of dots in (D).

FIG. 4 FIG. FIG. 4b

FIG. 4b
Here the temperature of the inhaler is much cooler. The bellows has
contracted, withdrawing the plunger thus increasing the effective
area of orifice (c). On inspiration a large volume of weak vapour
passes through (c);the volume of air by-passed through (A) is cor-
respondingly reduced. The strength of the final mixture is unaltered:
this is indicated by the equal density of dots in (D) in FIGS. 4a and
b. The position of control tap (F) is, of course, assumed to be the
same in the two diagrams.
Another factor likely to affect the concentration of vapour leav-
ing an inhaler is the depth of the patient's respiration. In the design
of an inhaler which for any one setting of the control tap will
deliver a constant strength of vapour irrespective of variations in
respiration, as well as in changes in temperature, various con-
structionalfeatures have to be correlated:

attached to and rotates a metal cylinder in which two tapering slots (1) slowing down the effect of rapid changes in ambient temper-
have been cut. Rotation of the cylinder within its closely fitting ature on the tempexatwe of the liquid ether,and (2) delaying the
barrel (K) is accompanied by changes in the effective areas of the fall in ether temperature when large quantities of vapour are dram
two portholes in the right-hand side of the barrel. These openings from the inhaler. An even distribution of temperature throughout
play a large part in determining which fraction of the inspired air the apparatus, and prevention of rapid changes in its temperature,
is diverted through the vaporisii chamber. Continuous arrows play important parts in ensuring an accurate output of vapour for
denote the air diverted through the chamber (E), interrupted ar- any setting of the controltap.
rows, the air which by-passes the chamber. The pointer is set to When the pointer is moved to the extreme left - well below the
delivera low concentration of vapour; the effective area of the lower zero mark - it presses the shaft (L) of an obturator which then o e
port is greatly r e d u d ; the upper port is still but little obstructed. cludes the entry to the vaporisiig chamber.Only in this way is the
If the pointer of the control tap is set at zero the lower opening is vaporising compartment cut off from the rest of the inhaler.
completely occluded, the upper completely free. With the pointer The apparatus has been designed pninany as a 'draw-over' in-
at the maximum concentration on the scale, the lower inlet is fully haler to be used in conjunction with an Oxford Inflating Bellows1
opened, the upper one appropriately reduced in area. It should be
noted that as in FIG. 3a the air by-pass is never completely closed.
PIG. 6 approximates more closely to a section through the E M 0
inhaler. The outer shell forms a reservoir for water (w)which sur-
rounds both outer and inner walls of the annular vaporising
chamber. The water* plays the part of heat buffer by:

to deliver ether/air (FIG. 7). The top of the inhaler is boxed in
leaving oniy one port of entry. This makes it possible to use the in-
haler in a 'plenum' system by plugging in a connection from the
nitrous oxide-oxygen machine.
The water acts as a heat buffer and normally them is no need to change it. It can.
however. be easily emptied away if weight is a factor, as m air transport. If for
any reason the inhaler has been stored at a temperature outside the range
55'-90"F. it should be prepad for use by being emptied and Med with water
within this temperatmrange.
W e are indebted to Mr. R. Salt, Senior Technician to this Department, for
building various prototypesof the inhalerdescribed.
particulars of the EM0 inhaler can be obtained from the Pentland Instm-
ment Co Ltd, 3 George St, Oxford.
'MACINTOSH, R.R. (1953). Brit. Med. J., 2,202.
PIO. 6