Anaesthesia, 1995, Volume 50, pages 239-242
The Epstein-Macintosh-Oxford (EMO) inhaler
This superbly designed piece of apparatus barely requires an
introduction. It is an example of the application of the basic
laws of physics to vaporization of a liquid, combined with
high quality engineering. The result is a robust, calibrated,
accurate and portable anaesthetic vaporizer that can be
used anywhere. It is still in extensive use in the third world
where the facilities for high technology anaesthesia, and
frequently oxygen, are lacking. It has been used safely, often
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
0195-668)3/95/030239 + 04 $08.00/0 @ 1995 The Association of Anaesthetists of G t Britain and Ireland
bellows, when indicated, to deliver ether/air. Its low resist-
ance allows spontaneous ventilation. With minor modifi-
cations it will deliver known concentrations of vapor of
other liquid anaesthetics. It can deliver any concentration of
anaesthetic irrespective of variations in temperature
throughout the range likely to be encountered in clinical
practice. This piece of apparatus will be as useful in 100
years time as it was at the time of its description.
M . MORGAN
239
VOL 11 NO 1 ANESTHESIA JANUARY 1956 84 ANESTHESIA

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).

H. G . EPSTEIN, P H D , FFARCS
SIR ROBERT MACINTOSH, DM, FFARCS
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
article is calibrated in terms of percentage ether vapour: with minor
modificationsit will deliver known concentrations of vapour of other
liquid anzsthetics.
Some of the principles involved are shown in the schematic
diagrams. In order not to overload the diagrams, the various
key letters (A-H) appear on them only once.
FIG. 1
(A) Entry to air by-pass duct.
(B)and (c) Inlet and outlet of vaporking chamber.
(D) Connectionfor breathing tube leading to patient.
(E) Vaporising chamber.
D considerablyreduced.
/
FIG. 1 FIG. 2 constant despite changes in temperature. This device, a small metal
83
FIG. 3 FIG. 3a FIG. 3b
FIG. 3
The hand operated control tap (F) governs entry of air through (B)
and (A). The pointer fitted to the end of this control moves over a
scale (G) calibrated in terms of percentage of vapour leaving the
inhaler through (D). In this diagram the pointer is set at 0; (B) is
shut, and the patient breathes air only through (A).
FIG. 3a
Tbe control tap has been moved to its other extreme position;
further movement is limited by a stop which ensures that (A) is
never completely occluded. On inspiration air passes freely through
(B) into the vaporking chamber, while the size of the entry (A) is
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
 ANESTHESIA 85 86 ANESTHESIA

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

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:
 ANESTHESIA
attached to and rotates a metal cylinder in which two tapering slots
have been cut. Rotation of the cylinder within its closely fitting
barrel (K) is accompanied by changes in the effective areas of the
two portholes in the right-hand side of the barrel. These openings
play a large part in determining which fraction of the inspired air
is diverted through the vaporisii chamber. Continuous arrows
denote the air diverted through the chamber (E), interrupted ar-
rows, the air which by-passes the chamber. The pointer is set to
delivera low concentration of vapour; the effective area of the lower
port is greatly r e d u d ; the upper port is still but little obstructed.
If the pointer of the control tap is set at zero the lower opening is
completely occluded, the upper completely free. With the pointer
at the maximum concentration on the scale, the lower inlet is fully
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:
PIO. 6
87 88 A N ES T H E S I A
(1) slowing down the effect of rapid changes in ambient temper-
ature on the tempexatwe of the liquid ether,and (2) delaying the
fall in ether temperature when large quantities of vapour are dram
from the inhaler. An even distribution of temperature throughout
the apparatus, and prevention of rapid changes in its temperature,
play important parts in ensuring an accurate output of vapour for
any setting of the controltap.
When the pointer is moved to the extreme left - well below the
zero mark - it presses the shaft (L) of an obturator which then o e
cludes the entry to the vaporisiig chamber.Only in this way is the
vaporising compartment cut off from the rest of the inhaler.
The apparatus has been designed pninany as a 'draw-over' in-
haler to be used in conjunction with an Oxford Inflating Bellows1
FIG. I
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.
Aclmowkdgemnt
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.
RCf-
'MACINTOSH, R.R. (1953). Brit. Med. J., 2,202.