Morgan 6th Bab Machine

4
C H A P T E R
The Anesthesia Workstation
KEY CONCEPTS
1 Equipment-related adverse outcomes are arrangement helps ensure a minimum

rarely due to device malfunction or failure; oxygen concentration of 25%.
rather, misuse of anesthesia gas delivery 5 All modern vaporizers are agent specific and
systems is three times more prevalent temperature corrected, capable of delivering
among closed claims. An operator’s lack of a constant concentration of agent regardless
familiarity with the equipment, an operator’s of temperature changes or flow through the
failure to verify machine function prior to vaporizer.
use, or both are the most frequent causes.
Such mishaps accounted for about 1% 6 A rise in airway pressure may signal worsening
of cases in the ASA Closed Claims Project pulmonary compliance, an increase in tidal
database from 1990 to 2011. volume, or an obstruction in the breathing
circuit, tracheal tube, or the patient’s
2 The anesthesia machine receives medical airway. A drop in pressure may indicate an
gases from a gas supply, controls the flow improvement in compliance, a decrease in
and reduces the pressure of desired gases tidal volume, or a leak in the circuit.
to a safe level, vaporizes volatile anesthetics
into the final gas mixture, and delivers the 7 Traditionally ventilators on anesthesia
gases to a breathing circuit that is connected machines have a double-circuit system
to the patient’s airway. A mechanical design and are pneumatically powered and
ventilator attaches to the breathing circuit electronically controlled. Newer machines
but can be excluded with a switch during also incorporate microprocessor controls
spontaneous or manual (bag) ventilation. and sophisticated pressure and flow sensors.
Some anesthesia machines have ventilators
3 Whereas the oxygen supply can pass directly that use a single-circuit piston design.
to its flow control valve, nitrous oxide, air, and
other gases must first pass through safety 8 The major advantage of a piston ventilator is
devices before reaching their respective its ability to deliver accurate tidal volumes to
flow control valves. These devices permit the patients with very poor lung compliance and
flow of other gases only if there is sufficient to very small patients.
oxygen pressure in the safety device and 9 Whenever a ventilator is used, “disconnect
help prevent accidental delivery of a hypoxic alarms” must be passively activated.
mixture in the event of oxygen supply failure. Anesthesia workstations should have at
4 Another safety feature of anesthesia least three disconnect alarms: low peak
machines is a linkage of the nitrous oxide inspiratory pressure, low exhaled tidal
gas flow to the oxygen gas flow; this volume, and low exhaled carbon dioxide.
—Continued next page
47
Butterworth_Ch04_p0047-0080.indd 47 23/04/18 9:37 am

48 SECTION I Anesthetic Equipment & Monitors
Continued—
10 Because the ventilator’s spill valve is closed ventilator–fresh gas flow coupling, and leaks
during inspiration, fresh gas flow from the in the anesthesia machine, the breathing
machine’s common gas outlet normally circuit, or the patient’s airway.
contributes to the tidal volume delivered to 13 Waste-gas scavengers dispose of gases that
the patient. have been vented from the breathing circuit
11 Use of the oxygen flush valve during the by the APL valve and ventilator spill valve.
inspiratory cycle of a ventilator must be Pollution of the operating room environment
avoided because the ventilator spill valve with anesthetic gases may pose a health
will be closed and the adjustable pressure- hazard to surgical personnel.
limiting (APL) valve is excluded; the surge of 14 A routine inspection of anesthesia equipment
oxygen (600–1200 mL/s) and circuit pressure before each use increases operator familiarity
will be transferred to the patient’s lungs. and confirms proper functioning. The U.S.
12 Large discrepancies between the set and Food and Drug Administration has made
actual tidal volume are often observed in the available a generic checkout procedure for
operating room during volume-controlled anesthesia gas machines and breathing
ventilation. Causes include breathing systems.
circuit compliance, gas compression,
No piece of equipment is more intimately associated Much progress has been made in reducing the
with the practice of anesthesiology than the anesthe- number of adverse outcomes arising from anes-
sia machine (Figure 4–1). On the most basic level,
1 thetic gas delivery. Equipment-related
the anesthesiologist uses the anesthesia machine to adverse outcomes are rarely due to device
control the patient’s ventilation, ensure oxygen deliv- malfunction or failure; rather, misuse of anesthesia
ery, and administer inhalation anesthetics. Proper gas delivery systems is three times more prevalent
functioning of the machine is crucial for patient among closed claims. Equipment misuse includes
safety. Modern anesthesia machines have become errors in preparation, maintenance, or deployment
very sophisticated, incorporating many built-in of a device. Preventable anesthetic mishaps are fre-
safety features and devices, monitors, and multiple quently traced to an operator’s lack of familiarity
microprocessors that can integrate and monitor all with the equipment, an operator’s failure to verify
components. Moreover, modular machine designs machine function prior to use, or both. Such mis-
allow a variety of configurations and features within haps accounted for about 1% of cases in the
the same product line. The term anesthesia worksta- American Society of Anesthesiologists’ (ASA)
tion is therefore often used for modern anesthesia Closed Claims Project database from 1990 to 2011.
machines. While two manufacturers of anesthe- Severe injury was found to be related to provider
sia machines in the United States, GE Healthcare errors involving, in particular, improvised oxygen
(Datex-Ohmeda) and Dräger Medical, have the larg- delivery systems and breathing circuit failures, sup-
est market share, other manufacturers (eg, Mindray, plemental oxygen supply problems outside of the
Maquet, Spacelabs) also produce anesthesia deliv- operating room, and problems with an anesthesia
ery systems. Anesthesia providers should be famil- ventilator. In 35% of claims an appropriate preanes-
iar with the operations manuals of all varieties of thetic machine check (see the ASA’s 2008 Recom-
machines present in their clinical practice. mendations for Pre-Anesthesia Checkout) would

CHAPTER 4 The Anesthesia Workstation 49
A Auxiliary O2 flowmeter Flowmeters
Display
Vaporizers
Suction regulator
Bellows assembly
Flow controls
System switch
Rebreathing Secondary gas

bag supply pressure gauges
Breathing (cylinder gauges)
system
Primary gas
Carbon dioxide
supply gauges
(CO2) absorber
(usually pipeline)
Oxygen (O2)
flush button
Brake
B Electrical
outlets with
circuit breakers
Main circuit breaker
Oxygen power
Pipeline inlets outlet
Cylinder yokes Waste gas

receiver
Back cover
Cylinders
Scavenging
connector
FIGURE 4–1 Modern anesthesia machine (Datex-Ohmeda Aestiva). A: Front. B: Back.

TABLE 4–1 Essential safety features on a modern anesthesia workstation.

Essential Features Purpose
Noninterchangeable gas-specific connections to pipeline Prevent incorrect pipeline attachments; detect failure, depletion,
inlets (DISS)1 with pressure gauges, filter, and check valve or fluctuation
Pin index safety system for cylinders with pressure Prevent incorrect cylinder attachments; provide backup gas
gauges, and at least one oxygen cylinder supply; detect depletion
Low oxygen pressure alarm Detect oxygen supply failure at the common gas inlet
Minimum oxygen/nitrous oxide ratio controller device Prevent delivery of less than 21% oxygen
(hypoxic guard)
Oxygen failure safety device (shut-off or proportioning Prevent administration of nitrous oxide or other gases when the
device) oxygen supply fails
Oxygen must enter the common manifold downstream Prevent hypoxia in event of proximal gas leak
to other gases
Oxygen concentration monitor and alarm Prevent administration of hypoxic gas mixtures in event of a low-
pressure system leak; precisely regulate oxygen concentration
Automatically enabled essential alarms and monitors Prevent use of the machine without essential monitors
(eg, oxygen concentration)
Vaporizer interlock device Prevent simultaneous administration of more than one volatile agent
Capnography and anesthetic gas measurement Guide ventilation; prevent anesthetic overdose; help reduce
awareness
Oxygen flush mechanism that does not pass through Rapidly refill or flush the breathing circuit
vaporizers
Breathing circuit pressure monitor and alarm Prevent pulmonary barotrauma and detect sustained positive,
high peak, and negative airway pressures
Exhaled volume monitor Assess ventilation and prevent hypo- or hyperventilation
Pulse oximetry, blood pressure, and ECG monitoring Provide minimal standard monitoring
Mechanical ventilator Control alveolar ventilation more accurately and during muscle
paralysis for prolonged periods
Backup battery Provide temporary electrical power (>30 min) to monitors and
alarms in event of power failure
Scavenger system Prevent contamination of the operating room with waste

anesthetic gases
1
DISS, diameter-index safety system.
likely have prevented any adverse event. Fortu- The American National Standards Institute and
nately, patient injuries secondary to anesthesia subsequently the ASTM International (formerly
equipment have decreased both in number and in the American Society for Testing and Materials,
severity over the past two decades. However, claims F1850–00) published standard specifications for anes-
for awareness during general anesthesia have thesia machines and their components. Table 4–1 lists
increased. essential features of a modern anesthesia workstation.

OVERVIEW for mobility, magnetic resonance imaging (MRI)

compatibility, or compactness.
2 In its most basic form, the anesthesia machine
receives medical gases from a gas supply, con-
trols the flow and reduces the pressure of desired
gases to a safe level, vaporizes volatile anesthetics
GAS SUPPLY
into the final gas mixture, and delivers the gases at Most machines have gas inlets for oxygen, nitrous
the common gas outlet to the breathing circuit con- oxide, and air. Compact models often lack air inlets,
nected to the patient’s airway (Figures 4–2 and 4–3). whereas other machines may have a fourth inlet
A mechanical ventilator attaches to the breathing for helium, heliox, carbon dioxide, or nitric oxide.
circuit but can be excluded with a switch during Separate inlets are provided for the primary pipeline
spontaneous or manual (bag) ventilation. An aux- gas supply that passes through the walls of health
iliary oxygen supply and suction regulator are also care facilities and the secondary cylinder gas sup-
usually built into the workstation. In addition to ply. Machines therefore have two gas inlet pressure
standard safety features (Table 4–1) top-of-the-line gauges for each gas: one for pipeline pressure and
anesthesia machines have additional safety features another for cylinder pressure.
and built-in computer processors that integrate
and monitor all components, perform automated Pipeline Inlets
machine checkouts, and provide options such as Oxygen and nitrous oxide (and often air) are deliv-
automated record-keeping and networking inter- ered from their central supply source to the operat-
faces to external monitors and hospital information ing room through a piping network. The tubing is
systems. Some machines are designed specifically color coded and connects to the anesthesia machine
through a noninterchangeable diameter-index
safety system (DISS) fitting that prevents incorrect
hose attachment. Noninterchangeability is achieved
Pipeline gas supply Cylinder gas supply
by making the bore diameter of the body and that of
Gas inlets the connection nipple specific for each supplied gas.
A filter helps trap debris from the wall supply and
Safety Pressure reduction Monitors
a one-way check valve prevents retrograde flow of
devices gases into the pipeline supplies. It should be noted
Flowmeters that most modern machines have an oxygen (pneu-
matic) power outlet that may be used to drive the
Vaporizers ventilator or provide an auxiliary oxygen flowmeter.
The DISS fittings for the oxygen inlet and the oxygen
Ventilator Common gas outlet
power outlet are identical and should not be mistak-
Breathing circuit enly interchanged. The approximate pipeline pres-
sure of gases delivered to the anesthesia machine is
Scavenger Airway 50 psig.
system
Patient Cylinder Inlets
Remote monitor
Cylinders attach to the machine via hanger-yoke
assemblies that utilize a pin index safety system to
Hospital information prevent accidental connection of a wrong gas cylin-
management system der. The yoke assembly includes index pins, a washer,
a gas filter, and a check valve that prevents retrograde
FIGURE 4–2 Functional schematic of an anesthesia gas flow. The gas cylinders are also color-coded for
machine/workstation. specific gases to allow for easy identification. In

Nitrous
oxide
Oxygen
Oxygen flush line

and button Common gas
outlet/fresh
gas inlet
FIGURE 4–3. The anesthesia machine reduces the pressure from the gas supply, vaporizes anesthetic agents, and
delivers the gas mixture to the common gas outlet. The oxygen flush line bypasses the vaporizers and directs oxygen
directly to the common gas outlet. (Reproduced with permission from Rose G, McLarney JT, eds. Anesthesia Equipment Simplified. New York,
NY: McGraw-Hill Education, Inc; 2014.)
North America, the following color-coding scheme optimal use of cylinder gases, machines utilize a
is used: oxygen = green, nitrous oxide = blue, car- pressure regulator to reduce the cylinder gas pres-
bon dioxide = gray, air = yellow, helium = brown, sure to 45 to 47 psig.1 This pressure, which is slightly
nitrogen = black. In the United Kingdom, white is lower than the pipeline supply, allows preferential
used for oxygen and black and white for air. The use of the pipeline supply if a cylinder is left open
E-cylinders attached to the anesthesia machine are a (unless pipeline pressure drops below 45 psig). After
high-pressure source of medical gases and are gener- passing through pressure gauges and check valves,
ally used only as a backup supply in case of pipeline the pipeline gases share a common pathway with
failure. Pressure of gas supplied from the cylinder to the cylinder gases. A high-pressure relief valve pro-
the anesthesia machine is 45 psig. Some machines vided for each gas is set to open when the supply
have two oxygen cylinders so that one cylinder can pressure exceeds the machine’s maximum safety
be used while the other is changed. At 20°C, a full limit (95–110 psig), as might happen with a regula-
E-cylinder contains 600 L of oxygen at a pressure of tor failure on a cylinder. Some machines also use a
1900 psig, and 1590 L of nitrous oxide at 745 psig. second regulator to drop both pipeline and cylinder
pressure further (two-stage pressure regulation). A
second-stage pressure reduction may also be needed
FLOW CONTROL CIRCUITS for an auxiliary oxygen flowmeter, the oxygen flush
Pressure Regulators mechanism, or the drive gas to power a pneumatic
ventilator.
Unlike the relatively constant pressure of the pipe-
line gas supply, the high and variable gas pressure 1
Pressure unit conversions: 1 kiloPascal (kP) = kg/m · s2 =
in cylinders makes flow control difficult and poten- 1000 N/m2 = 0.01 bar = 0.1013 atmospheres = 0.145 psig =
tially dangerous. To enhance safety and ensure 10.2 cm H2O = 7.5 mm Hg.

Oxygen Supply Failure is measured by flowmeters before mixing with other

Protection Devices gases, entering the active vaporizer, and exiting the
machine’s common gas outlet. Gas lines proximal
3 Whereas the oxygen supply can pass directly to to flow valves are considered to be in the high-
its flow control valve, nitrous oxide, air (in some
pressure circuit, whereas those between the flow
machines), and other gases must first pass through
valves and the common gas outlet are considered
safety devices before reaching their respective flow
part of the low-pressure circuit of the machine.
control valves. In other machines, air passes directly
Touch- and color-coded control knobs make it more
to its flow control valve; this allows administration of
difficult to turn the wrong gas off or on. As a safety
air even in the absence of oxygen. These devices per-
feature the oxygen knob is usually fluted, larger, and
mit the flow of other gases only if there is sufficient
protrudes farther than the other knobs. The oxygen
oxygen pressure in the safety device and help prevent
flowmeter is positioned furthest to the right, down-
accidental delivery of a hypoxic mixture in the event
stream to the other gases; this arrangement helps to
of oxygen supply failure. Thus, in addition to supply-
prevent hypoxia if there is leakage from a flowmeter
ing the oxygen flow control valve, oxygen from the
positioned upstream.
common inlet pathway is used to pressurize safety
Flow control knobs control gas entry into the
devices, oxygen flush valves, and ventilator power
flowmeters by adjustment via a needle valve. Flow-
outlets (in some models). Safety devices sense oxygen
meters on anesthesia machines are classified as
pressure via a small “piloting pressure” line that may
either constant-pressure variable-orifice (rotameter)
be derived from the gas inlet or secondary regula-
or electronic. In constant-pressure variable-orifice
tor. In some anesthesia machine designs (eg, Datex-
flowmeters, an indicator ball, bobbin, or float is sup-
Ohmeda Excel), if the piloting pressure line falls
ported by the flow of gas through a tube (Thorpe
below a threshold (eg, 20 psig), the shut-off valves
tube) whose bore (orifice) is tapered. Near the bot-
close, preventing the administration of any other
tom of the tube, where the diameter is small, a low
gases. The terms fail-safe and nitrous cut-off were pre-
flow of gas will create sufficient pressure under the
viously used for the nitrous oxide shut-off valve.
float to raise it in the tube. As the float rises, the
Most modern machines use a proportioning
(variable) orifice of the tube widens, allowing more
safety device instead of a threshold shut-off valve.
gas to pass around the float. The float will stop rising
These devices, called either an oxygen failure protec-
when its weight is just supported by the difference in
tion device (Dräger) or a balance regulator (Datex-
pressure above and below it. If flow is increased, the
Ohmeda), proportionately reduce the pressure of
pressure under the float increases, raising it higher
nitrous oxide and other gases except for air. (They
in the tube until the pressure drop again just sup-
completely shut off nitrous oxide and other gas flow
ports the float’s weight. This pressure drop is con-
only below a set minimum oxygen pressure [eg,
stant regardless of the flow rate or the position in
0.5 psig for nitrous oxide and 10 psig for other gases]).
the tube and depends on the float weight and tube
All machines also have an oxygen supply low-
cross-sectional area.
pressure sensor that activates alarm sounds when
Flowmeters are calibrated for specific gases, as
inlet gas pressure drops below a threshold value (usu-
the flow rate across a constriction depends on the
ally 20–30 psig). It must be emphasized that these
gas’s viscosity at low laminar flows (Poiseuille’s law)
safety devices do not protect against other possible
and its density at high turbulent flows. To minimize
causes of hypoxic accidents (eg, gas line misconnec-
the effect of friction with the tube’s wall, floats are
tions), in which threshold pressure may be main-
designed to rotate constantly, which keeps them
tained by gases containing inadequate or no oxygen.
centered in the tube. Coating the tube’s interior with
a conductive substance grounds the system and
Flow Valves & Meters reduces the effect of static electricity. Some flow-
Once the pressure has been reduced to a safe level, meters have two glass tubes, one for low flows and
each gas must pass through flow control valves and another for high flows (Figure 4–4A); the two tubes

A B
1000 10
2
900 9
800 8
Millimeters/minute
700 7 1
Liters/minute
Liters/minute
600 6
500 5
400 4 0.8
300 3
200 2
0.6
100 1
0.4
Fine Coarse
flowtube flowtube
FIGURE 4–4 Constant-pressure variable-orifice flowmeters (Thorpe type). A: Two tube design. B: Dual taper design.
are in series and are still controlled by one valve. A can be delivered to the patient (Figure 4–5). To
dual taper design can allow a single flowmeter to reduce this risk, oxygen flowmeters are always posi-
read both high and low flows (Figure 4–4B). Causes tioned downstream to all other flowmeters (nearest
of flowmeter malfunction include debris in the to the vaporizer).
flow tube, vertical tube misalignment, and stick- Some anesthesia machines have electronic
ing or concealment of a float at the top of a tube. flow control and measurement. In such instances,
Should a leak develop within or downstream a backup conventional (Thorpe) auxiliary oxy-
from an oxygen flowmeter, a hypoxic gas mixture gen flowmeter is provided. Other models have
A B C
Oxygen Air Nitrous oxide Air Nitrous oxide Oxygen Nitrous oxide Air Oxygen
Incorrect sequence Datex-Ohmeda sequence Dräger sequence
FIGURE 4–5 Sequence of flowmeters in a three-gas machine. A: An unsafe sequence. B: Typical Datex-Ohmeda
sequence. C: Typical Dräger sequence. Note that regardless of sequence a leak in the oxygen tube or further downstream
can result in delivery of a hypoxic mixture.

conventional flowmeters but electronic measure- A. Physics of Vaporization

ment of gas flow along with Thorpe tubes and digital At temperatures encountered in the operating room,
or digital/graphic displays. The amount of pressure the molecules of a volatile anesthetic in a closed
drop caused by a flow restrictor is the basis for mea- container are distributed between the liquid and
surement of gas flow rate in these systems. In these gaseous phases. The gas molecules bombard the
machines oxygen, nitrous oxide, and air each have a walls of the container, creating the saturated vapor
separate electronic flow measurement device in the pressure of that agent. Vapor pressure depends on
flow control section before they are mixed together. the characteristics of the volatile agent and the tem-
Electronic flowmeters are required if gas flow rate perature. The greater the temperature, the greater
data will be acquired automatically by computerized the tendency for the liquid molecules to escape into
anesthesia recording systems. the gaseous phase and the greater the vapor pres-
sure (Figure 4–6). Vaporization requires energy (the
A. Minimum Oxygen Flow latent heat of vaporization), which results in a loss of
The oxygen flow valves are usually designed to heat from the liquid. As vaporization proceeds, tem-
deliver a minimum oxygen flow when the anesthesia perature of the remaining liquid anesthetic drops
machine is turned on. One method involves the use and vapor pressure decreases unless heat is readily
of a minimum flow resistor. This safety feature helps available to enter the system. Vaporizers contain a
ensure that some oxygen enters the breathing circuit chamber in which a carrier gas becomes saturated
even if the operator forgets to turn on the oxygen flow. with the volatile agent.
A liquid’s boiling point is the temperature at
B. Oxygen/Nitrous Oxide Ratio Controller which its vapor pressure is equal to the atmospheric
4 Another safety feature of anesthesia machines pressure. As the atmospheric pressure decreases (as
is a linkage of the nitrous oxide gas flow to in higher altitudes), the boiling point also decreases.
the oxygen gas flow; this arrangement helps ensure Anesthetic agents with low boiling points are more
a minimum oxygen concentration of 25%. The oxy- susceptible to variations in barometric pressure than
gen/nitrous oxide ratio controller links the two flow agents with higher boiling points. Among the com-
valves either pneumatically or mechanically. To main- monly used agents, desflurane has the lowest boiling
tain the minimum oxygen concentration, the system point (22.8°C at 760 mm Hg).
(Link-25) in Datex-Ohmeda machines increases the
flow of oxygen, whereas the oxygen ratio monitor B. Copper Kettle
controller (ORMC) in Dräger machines reduces the The copper kettle vaporizer is no longer used in
concentration of nitrous oxide. It should be noted clinical anesthesia; however, understanding how it
that this safety device does not affect the flow of a works provides invaluable insight into the delivery
third gas (eg, air, helium, or carbon dioxide). of volatile anesthetics (Figure 4–7). It is classified as
a measured-flow vaporizer (or flowmeter-controlled
Vaporizers vaporizer). In a copper kettle, the amount of car-
Volatile anesthetics (eg, halothane, isoflurane, des- rier gas bubbled through the volatile anesthetic is
flurane, sevoflurane) must be vaporized before controlled by a dedicated flowmeter. This valve is
being delivered to the patient. Vaporizers have turned off when the vaporizer circuit is not in use.
concentration-calibrated dials that precisely add Copper is used as the construction metal because
volatile anesthetic agents to the combined gas flow its relatively high specific heat (the quantity of heat
from all flowmeters. They must be located between required to raise the temperature of 1 g of substance
the flowmeters and the common gas outlet. More- by 1°C) and high thermal conductivity (the speed
over, unless the machine accepts only one vaporizer of heat conductance through a substance) enhance
at a time, all anesthesia machines should have an the vaporizer’s ability to maintain a constant tem-
interlocking or exclusion device that prevents the perature. All the gas entering the vaporizer passes
concurrent use of more than one vaporizer. through the anesthetic liquid and becomes saturated

1600
e
1400
n
ra
lu
sf
De
1200
e
Vapor pressure mm Hg
an
r
lu
of
1000 Is
ne
a
th
alo
800 H
e
ne ra
600 flu
lura vo
Enf Se
400
200
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65
Temperature °C
FIGURE 4–6 The vapor pressure of anesthetic gases.
with vapor. One milliliter of liquid anesthetic yields flow, and anesthetic concentration exists. However,
approximately 200 mL of anesthetic vapor. Because if total gas flow decreases without an adjustment in
the vapor pressure of volatile anesthetics is greater copper kettle flow (eg, exhaustion of a nitrous oxide
than the partial pressure required for anesthesia, cylinder), the delivered volatile anesthetic concen-
the saturated gas leaving a copper kettle has to be tration rises rapidly to potentially dangerous levels.
diluted before it reaches the patient.
For example, the vapor pressure of halothane is C. Modern Conventional Vaporizers
243 mm Hg at 20°C, so the concentration of halo- 5 All modern vaporizers are agent specific and
thane exiting a copper kettle at 1 atmosphere would temperature corrected, capable of delivering a
be 243/760, or 32%. If 100 mL of oxygen enters
the kettle, roughly 150 mL of gas exits (the initial
100 mL of oxygen plus 50 mL of saturated halo- Oxygen
and 4850 mL
thane vapor), one-third of which would be saturated nitrous
halothane vapor. To deliver a 1% concentration of oxide
5000 mL
halothane (MAC 0.75%), the 50 mL of halothane 1%
vapor and 100 mL of carrier gas that left the copper halothane
to patient
kettle have to be diluted within a total of 5000 mL of
150
fresh gas flow. Thus, every 100 mL of oxygen passing
through a halothane vaporizer translates into a 1%
increase in concentration if total gas flow into the
Halothane
breathing circuit is 5 L/min. Therefore, when total Oxygen 100 mL
flow is fixed, flow through the vaporizer determines
FIGURE 4–7 Schematic of a copper kettle vaporizer.
the ultimate concentration of anesthetic. Isoflurane Note that 50 mL/min of halothane vapor is added for
has an almost identical vapor pressure, so the same each 100 mL/min oxygen flow that passes through the
relationship between copper kettle flow, total gas vaporizer.

constant concentration of agent regardless of tem- bypass area and lead to dangerously high anesthetic
perature changes or flow through the vaporizer. concentrations. In the event of tilting and spillage,
Turning a single calibrated control knob counter- high flow of oxygen with the vaporizer turned off
clockwise to the desired percentage diverts an appro- should be used to vaporize and flush the liquid anes-
priate small fraction of the total gas flow into the thetic from the bypass area. Fluctuations in pressure
carrier gas, which flows over the liquid anesthetic in from positive-pressure ventilation in older anesthe-
a vaporizing chamber, leaving the balance to exit the sia machines may cause a transient reversal of flow
vaporizer unchanged (Figure 4–8). Because some through the vaporizer, unpredictably changing agent
of the entering gas is never exposed to anesthetic delivery. This “pumping effect” is more pronounced
liquid, this type of agent-specific vaporizer is also with low gas flows. A one-way check valve between
known as a variable-bypass vaporizer. the vaporizers and the oxygen flush valve (Datex-
Temperature compensation is achieved by Ohmeda) together with some design modifications
a strip composed of two different metals welded in newer units limit the occurrence of some of these
together. The metal strips expand and contract dif- problems. Variable-bypass vaporizers compen-
ferently in response to temperature changes. When sate for changes in ambient pressures (ie, altitude
the temperature decreases, differential contraction changes maintaining relative anesthetic gas partial
causes the strip to bend, allowing more gas to pass pressure). It is the partial pressure of the anesthetic
through the vaporizer. Such bimetallic strips are also agent that determines its concentration-dependent
used in home thermostats. As the temperature rises physiological effects. Thus, there is no need to
differential expansion causes the strip to bend the increase the selected anesthetic concentration when
other way restricting gas flow into the vaporizer. using a variable-bypass vaporizer at altitude because
Altering total fresh gas flow rates within a wide range the partial pressure of the anesthetic agent will be
does not significantly affect anesthetic concentration largely unchanged. Although at lower ambient pres-
because the same proportion of gas is exposed to the sures gas passing through the vaporizer is exposed to
liquid. However, the real output of an agent would increased vaporizer output, because of Dalton’s law
be lower than the dial setting at extremely high flow of partial pressure the partial pressure of the anes-
(>15 L/min); the converse is true when the flow rate thetic vapor will remain largely unaffected compared
is less than 250 mL/min. Changing the gas composi- with partial pressures obtained at sea level.
tion from 100% oxygen to 70% nitrous oxide may
transiently decrease volatile anesthetic concentra- D. Electronic Vaporizers
tion due to the greater solubility of nitrous oxide in Electronically controlled vaporizers must be utilized
volatile agents. for desflurane and are used for all volatile anesthet-
Given that these vaporizers are agent specific, ics in some sophisticated anesthesia machines.
filling them with the incorrect anesthetic must be 1. Desflurane vaporizer—Desflurane’s vapor pres-
avoided. For example, unintentionally filling a sevo- sure is so high that at sea level it almost boils at
flurane-specific vaporizer with halothane could lead room temperature (Figure 4–6). This high volatil-
to an anesthetic overdose. First, halothane’s higher ity, coupled with a potency only one-fifth that of
vapor pressure (243 mm Hg versus 157 mm Hg) will other volatile agents, presents unique delivery
cause a 40% greater amount of anesthetic vapor to problems. First, the vaporization required for gen-
be released. Second, halothane is more than twice as eral anesthesia produces a cooling effect that would
potent as sevoflurane (MAC 0.75 versus 2.0). Con- overwhelm the ability of conventional vaporizers to
versely, filling a halothane vaporizer with sevoflu- maintain a constant temperature. Second, because it
rane will cause an anesthetic underdosage. Modern vaporizes so extensively, a tremendously high fresh
vaporizers offer agent-specific, keyed, filling ports to gas flow would be necessary to dilute the carrier gas
prevent filling with an incorrect agent. to clinically relevant concentrations. These problems
Excessive tilting of older vaporizers (Tec 4, Tec 5, have been addressed by the development of spe-
and Vapor 19.n) during transport may flood the cial desflurane vaporizers. A reservoir containing

A
Concentration Internal
dial on/off switch
Inlet port
Pressure Temperature-
compensator compensating
bypass
Concentrating
cone
Wick
Vaporizing
chamber
Anesthetic
agent
B Concentration
dial
Bypass path
Mixed gas to
Vaporizer common gas
manifold manifold
Carrier gas
Cooler temperatures
Bimetallic strip
Wick
Vaporizer Warmer temperatures

chamber
Sump
FIGURE 4–8 Schematic of agent-specific variable-bypass vaporizers. A: Dräger Vapor 19.n. B: Datex-Ohmeda Tec 7.

desflurane (desflurane sump) is electrically heated supplies gas to the breathing circuit. The term fresh
to 39°C (significantly higher than its boiling point) gas outlet is also often used because of its critical
creating a vapor pressure of 2 atmospheres. Unlike a role in adding new gas of fixed and known composi-
variable-bypass vaporizer, no fresh gas flows through tion to the circle system. Unlike older models, some
the desflurane sump. Rather, pure desflurane vapor newer anesthesia machines measure and report
joins the fresh gas mixture before exiting the vapor- common outlet gas flows. An antidisconnect retain-
izer. The amount of desflurane vapor released from ing device is used to prevent accidental detachment
the sump depends on the concentration selected by of the gas outlet hose that connects the machine to
turning the control dial and the fresh gas flow rate. the breathing circuit.
Although the Tec 6 Plus maintains a constant des- The oxygen flush valve provides a high flow
flurane concentration over a wide range of fresh (35–75 L/min) of oxygen directly to the common gas
gas flow rates, it cannot automatically compensate outlet, bypassing the flowmeters and vaporizers. It is
for changes in elevation as do the variable-bypass used to rapidly refill or flush the breathing circuit,
vaporizers. Decreased ambient pressure (eg, high but because the oxygen may be supplied at a line
elevation) does not affect the concentration of agent pressure of 45 to 55 psig, there is a real potential for
delivered, but decreases the partial pressure of the lung barotrauma to occur. For this reason, the flush
agent. Thus, at high elevations one must manually valve must be used cautiously whenever a patient
increase the desflurane concentration control. is connected to the breathing circuit. Moreover,
inappropriate use of the flush valve (or a situation
2. Aladin (GE) cassette vaporizer—Gas flow from of stuck valve) may result in backflow of gases into
the flow control is divided into bypass flow and liq- the low-pressure circuit, causing dilution of inhaled
uid chamber flow. The latter is conducted into an anesthetic concentration. Some machines use a sec-
agent-specific, color-coded, cassette (Aladin cas- ond-stage regulator to drop the oxygen flush pres-
sette) in which the volatile anesthetic is vaporized. sure to a lower level. A protective rim around the
The machine accepts only one cassette at a time and flush button limits the possibility of unintentional
recognizes the cassette through magnetic labeling. activation
The cassette does not contain any bypass flow chan-
nels; therefore, unlike traditional vaporizers, liquid
anesthetic cannot escape during handling and the THE BREATHING CIRCUIT
cassette can be carried in any position. After leav- In adults, the breathing system most commonly
ing the cassette, the now anesthetic-saturated liquid
used with anesthesia machines is the circle system
chamber flow reunites with the bypass flow before (Figure 4–9); a Bain circuit is occasionally used. The
exiting the fresh gas outlet. A flow restrictor valve components and use of the circle system were previ-
near the bypass flow helps to adjust the amount of ously discussed (see Chapter 3). It is important to
fresh gas that flows to the cassette. Adjusting the note that gas composition at the common gas outlet
ratio between the bypass flow and liquid chamber can be controlled precisely and rapidly by adjust-
flow changes the concentration of volatile anesthetic ments in flowmeters and vaporizers. In contrast,
agent delivered to the patient. Sensors in the cas- gas composition, especially volatile anesthetic con-
sette measure pressure and temperature, thus deter- centration, in the breathing circuit is significantly
mining agent concentration in the gas leaving the affected by other factors, including anesthetic uptake
cassette. Correct liquid chamber flow is calculated in the patient’s lungs, minute ventilation, total fresh
based on desired fresh gas concentration and deter- gas flow, volume of the breathing circuit, and the
mined cassette gas concentration. presence of gas leaks. Use of high gas flow rates dur-
ing induction and emergence decreases the effects
Common (Fresh) Gas Outlet of such variables and can diminish the magnitude
In contrast to the multiple gas inlets, the anesthe- of discrepancies between fresh gas outlet and circle
sia machine has only one common gas outlet that system anesthetic concentrations. Measurement of

A
Patient
Bag
Fresh gas
Inhalation
B C
Patient Patient
To ventilation
bellow
Bag Bag
Fresh gas Fresh gas

To To
scavenger Inhalation scavenger Exhalation
FIGURE 4–9 Diagram of a typical breathing circuit (Dräger Narkomed). Note gas flow during A: spontaneous
inspiration, B: manual inspiration (“bagging”), and C: exhalation (spontaneous or bag ventilation).

inspired and expired anesthetic gas concentration the anesthesia machine. The sensor should be placed
also greatly facilitates anesthetic management. into the inspiratory or expiratory limb of the circle
In most machines, the common gas outlet is system’s breathing circuit—but not into the fresh gas
attached to the breathing circuit just past the exhala- line. As a result of the patient’s oxygen consumption,
tion valve to prevent artificially high exhaled tidal the expiratory limb has a slightly lower oxygen par-
volume measurements. When spirometry measure- tial pressure than the inspiratory limb, particularly
ments are made at the Y-connector, fresh gas flow can at low fresh gas flows. The increased humidity of
enter the circuit on the patient side of the inspiratory expired gas does not significantly affect most mod-
valve. The latter enhances CO2 elimination and may ern sensors.
help reduce desiccation of the CO2 absorbent.
Newer anesthesia machines have integrated inter- Spirometers
nalized breathing circuit components (Figure 4–10). Spirometers, also called respirometers, are used to
The advantages of these designs include reduced measure exhaled tidal volume in the breathing cir-
probability of breathing circuit misconnects, dis- cuit on all anesthesia machines, typically near the
connects, kinks, and leaks. The smaller volume of exhalation valve. Some anesthesia machines also
compact machines can also help conserve gas flow measure the inspiratory tidal volume just past the
and volatile anesthetics and allow faster changes in inspiratory valve or the actual delivered and exhaled
breathing circuit gas concentration. Internal heating tidal volumes at the Y-connector that attaches to the
of manifolds can reduce precipitation of moisture. patient’s airway.
A common method employs a rotating vane of
Oxygen Analyzers low mass in the expiratory limb in front of the expi-
General anesthesia must not be administered with- ratory valve of the circle system (vane anemometer
out an oxygen analyzer in the breathing circuit. or Wright respirometer, Figure 4–11A).
Three types of oxygen analyzers are available: The flow of gas across vanes within the respi-
polarographic (Clark electrode), galvanic (fuel rometer causes their rotation, which is measured
cell), and paramagnetic. The first two techniques electronically, photoelectrically, or mechanically.
utilize electrochemical sensors that contain cathode In another variation using this turbine principle,
and anode electrodes embedded in an electrolyte the volumeter or displacement meter is designed to
gel separated from the sample gas by an oxygen- measure the movement of discrete quantities of gas
permeable membrane (usually Teflon). As oxygen over time (Figure 4–11B).
reacts with the electrodes, a current is generated that During positive-pressure ventilation, changes
is proportional to the oxygen partial pressure in the in exhaled tidal volumes usually represent changes
sample gas. The galvanic and polarographic sensors in ventilator settings, but can also be due to circuit
differ in the composition of their electrodes and leaks, disconnections, or ventilator malfunction.
electrolyte gels. The components of the galvanic cell These spirometers are prone to errors caused by iner-
are capable of providing enough chemical energy so tia, friction, and water condensation. For example,
that the reaction does not require an external power Wright respirometers under-read at low flow rates
source. and over-read at high flow rates. Furthermore, the
Although the initial cost of paramagnetic sen- measurement of exhaled tidal volumes at this loca-
sors is greater than that of electrochemical sensors, tion in the expiratory limb includes gas that had been
paramagnetic devices are self-calibrating and have lost to the circuit (and not delivered to the patient;
no consumable parts. In addition, their response discussed below). The difference between the vol-
time is fast enough to differentiate between inspired ume of gas delivered to the circuit and the volume of
and expired oxygen concentrations. gas actually reaching the patient becomes very sig-
All oxygen analyzers should have a low-level nificant with long, compliant breathing tubes; rapid
alarm that is automatically activated by turning on respiratory rates; and increased airway pressures.

To oxygen sensor To volume sensor

interface
19-mm scavenger
22-mm breathing hose
hose
Expiratory valve APL valve with
with 22-mm 19-mm scavenger
breathing hose hose terminal
terminal
Inspiratory valve Manual/automatic
with 22-mm selector valve
breathing hose with 22-mm hose
terminal terminal (optional)
Absorber Fresh gas locking

device with 15-mm
Absorber female fitting
mounting stud
O-ring Fresh gas hose

Swivel bag mount
with 22-mm
breathing bag
terminal Breathing bag
Y-piece
Absorber pole with
CO2 monitor 19-mm scavender
airway adapter hose terminal
19-mm scavenger
hose
B
PEEP/MAX valve Selection knob for
Expiratory connection port MAN and SPONT on
valve pressure-limiting valve
Expiration
port
Connector for
breathing bag
Inspiratory APL bypass valve

port connection port
Inspiratory
valve
Carbon dioxide
absorber
FIGURE 4–10 Breathing circuit design. A: Conventional external components. B: Compact design that reduces
external connections and circuit volume (Dräger Fabius GS).

These problems are at least partially overcome by information about airway and lung mechanics.
measuring the tidal volume at the Y-connector to Modifications have been required to overcome inac-
the patient’s airway. curacies due to water condensation and temperature
A hot-wire anemometer utilizes a fine platinum changes. One modification employs two pressure-
wire, electrically heated at a constant temperature, sensing lines in a Pitot tube at the Y-connection
inside the gas flow. The cooling effect of increasing (Figure 4–11D). Gas flowing through the Pitot
gas flow on the wire electrode causes a change in elec- tube (flow sensor tube) creates a pressure difference
trical resistance. In a constant-resistance anemome- between the flow sensor lines. This pressure differ-
ter, gas flow is determined from the current needed ential is used to measure flow, flow direction, and
to maintain a constant wire temperature (and resis- airway pressure. Respiratory gases are continuously
tance). Disadvantages include an inability to detect sampled to correct the flow reading for changes in
reverse flow, less accuracy at higher flow rates, and density and viscosity.
the possibility that the heated wire may be a potential
ignition source for fire in the breathing manifold. Circuit Pressure
Ultrasonic flow sensors rely on discontinui- A pressure gauge or electronic sensor is always used
ties in gas flow generated by turbulent eddies in the to measure breathing-circuit pressure somewhere
flow stream. Upstream and downstream ultrasonic between the expiratory and inspiratory unidirec-
beams, generated from piezoelectric crystals, are tional valves; the exact location depends on the
transmitted at an angle to the gas stream. The Dop- model of anesthesia machine. Breathing-circuit
pler frequency shift in the beams is proportional to pressure usually reflects airway pressure if it is mea-
the flow velocities in the breathing circuit. Major sured as close to the patient’s airway as possible. The
advantages include the absence of moving parts and most accurate measurements of both inspiratory and
greater accuracy due to the device’s independence expiratory pressures can be obtained from the
from gas density.
6 Y-connection. A rise in airway pressure may
Machines with variable-orifice flowmeters usu- signal worsening pulmonary compliance, an
ally employ two sensors (Figure 4–11C). One mea- increase in tidal volume, or an obstruction in the
sures flow at the inspiratory port of the breathing breathing circuit, tracheal tube, or the patient’s air-
system, and the other measures flow at the expiratory way. A drop in pressure may indicate an improve-
port. These sensors use a change in internal diam- ment in compliance, a decrease in tidal volume, or a
eter to generate a pressure drop that is proportional leak in the circuit. If circuit pressure is being mea-
to the flow through the sensor. The changes in gas sured at the CO2 absorber, however, it will not always
flows during the inspiratory and expiratory phases mirror the pressure in the patient’s airway. For exam-
help the ventilator to adjust and provide a constant ple, clamping the expiratory limb of the breathing
tidal volume. However, due to excessive condensa- tubes during exhalation will prevent the patient’s
tion, sensors can fail when used with heated humidi- breath from exiting the lungs. Despite this buildup in
fied circuits. airway pressure, a pressure gauge at the absorber will
A pneumotachograph is a fixed-orifice flow- read zero because of the intervening one-way valve.
meter that can function as a spirometer. A parallel Some machines have incorporated auditory
bundle of small-diameter tubes in chamber (Fleisch feedback for pressure changes during ventilator use.
pneumotachograph) or mesh screen provides a
slight resistance to airflow. The pressure drop across Adjustable Pressure-Limiting Valve
this resistance is sensed by a differential pressure The adjustable pressure-limiting (APL) valve, some-
transducer and is proportional to the flow rate. times referred to as the pressure relief or pop-off
Integration of flow rate over time yields tidal vol- valve, is usually fully open during spontaneous ven-
ume. Moreover, analysis of pressure, volume, and tilation but must be partially closed during manual
time relationships can yield potentially valuable or assisted bag ventilation. The APL valve often

A
To absorber
exhalation port
From
breathing Forward flow
circuit
Sensor clip
Light
emitting
diode A Light
emitting
Light diode B
detector B Light
detector A
Cartridge with vanes

B MIN
VOL 5.6
TID
VOL
0.58
RR 10
Display Hall effect

transistor (A)
Processor Armature
Magnet (4x) Rotor
Interface panel
Hall effect
Volume transistor (B)
sensor
Exhaled patient gas
Expiratory valve
Spiromed sensor
Absorber
FIGURE 4–11 Spirometer designs. A: Vane anemometer (Datex-Ohmeda). B: Volumeter (Dräger). C: Variable-orifice
flowmeter (Datex-Ohmeda). D: Fixed-orifice flowmeter (Pitot tube).
Butterworth_Ch04_p0047-0080.indd 64 12/06/18 2:27 pm

C
Lower flow
Differential Transducer
pressure diaphragm
transducer
Higher flow
Flow sensor
connector
Reverse flow
Flow sensor
lines
Flow sensor
tube
Gas flow
Flow sensor
flap
FIGURE 4–11 (Continued)
requires fine adjustments. If it is not closed suffi- (eg, pneumothorax) or hemodynamic compromise,
ciently excessive loss of circuit volume due to leaks or both. As an added safety feature, the APL valves
prevents manual ventilation. At the same time, if it is on modern machines act as true pressure-limiting
closed too much or is fully closed, a progressive rise devices that can never be completely closed; the
in pressure could result in pulmonary barotrauma upper limit is usually 70 to 80 cm H2O.

Humidifiers resistance and the work of breathing during sponta-

Absolute humidity is defined as the weight of water neous respirations. Excessive saturation of an HME
vapor in 1 L of gas (ie, mg/L). Relative humidity is the with water or secretions can obstruct the breathing
ratio of the actual mass of water present in a volume circuit. Some condenser humidifiers also act as effec-
of gas to the maximum amount of water possible at tive filters that may protect the breathing circuit and
a particular temperature. At 37°C and 100% relative anesthesia machine from bacterial or viral cross-
humidity, absolute humidity is 44 mg/L, whereas at contamination. This may be particularly important
room temperature (21°C and 100% humidity) it is when ventilating patients with respiratory infections
18 mg/L. Inhaled gases in the operating room are or compromised immune systems.
normally administered at room temperature with B. Active Humidifiers
little or no humidification. Gases must therefore be Active humidifiers are more effective than passive
warmed to body temperature and saturated with ones in preserving moisture and heat. Active humid-
water by the upper respiratory tract. Tracheal intu- ifiers add water to gas by passing the gas over a water
bation and high fresh gas flows bypass this normal chamber (passover humidifier) or through a satu-
humidification system and expose the lower airways rated wick (wick humidifier), bubbling it through
to dry (<10 mg H2O/L), room temperature gases. water (bubble-through humidifier), or mixing it with
Prolonged humidification of gases by the vaporized water (vapor-phase humidifier). Because
lower respiratory tract leads to dehydration of increasing temperature increases the capacity of a gas
mucosa, altered ciliary function, and, if exces- to hold water vapor, heated humidifiers with ther-
sively prolonged, could potentially lead to inspissa- mostatically controlled elements are most effective.
tion of secretions, atelectasis, and even ventilation/ The hazards of heated humidifiers include ther-
perfusion mismatching, particularly in patients with mal lung injury (inhaled gas temperature should
underlying lung disease. Body heat is also lost as be monitored and should not exceed 41°C), noso-
gases are warmed, and even more importantly, as comial infection, increased airway resistance from
water is vaporized to humidify the dry gases. The excess water condensation in the breathing cir-
heat of vaporization for water is 560 cal/g of water cuit, interference with flowmeter function, and an
vaporized. Fortunately, this heat loss accounts for increased likelihood of circuit disconnection. Use of
about only 5% to 10% of total intraoperative heat these humidifiers is particularly valuable in children
loss, is not significant for a short procedure (<1 h), as they help prevent both hypothermia and the plug-
and usually can easily be compensated for with a ging of small tracheal tubes by dried secretions. Of
forced-air warming blanket. Humidification and course, any design that increases airway dead space
heating of inspiratory gases may be most important should be avoided in pediatric patients. Unlike pas-
for small pediatric patients and older patients with sive humidifiers, active humidifiers do not filter
severe underlying lung pathology, eg, cystic fibrosis. respiratory gases.
A. Passive Humidifiers
Humidifiers added to the breathing circuit minimize
water and heat loss. The simplest designs are con- VENTILATORS
denser humidifiers or heat and moisture exchanger All modern anesthesia machines are equipped with
(HME) units (Figure 4–12). These passive devices a ventilator. Historically ventilators used in the oper-
do not add heat or vapor but rather contain a hygro- ating room (OR) were simpler and more compact
scopic material that traps exhaled humidification and than their intensive care unit (ICU) counterparts.
heat, which is released upon subsequent inhalation. This distinction has become blurred due to advances
Depending on the design, they may substantially in technology together with an increasing need for
increase apparatus dead space (more than 60 mL3), “ICU-type” ventilators as more critically ill patients
which can cause significant rebreathing in pediatric come to the OR. The ventilators on some modern
patients. They can also increase breathing-circuit machines have almost the same capabilities as those

HME unit
Patient
circuit
Gas
sample line Patient circuit
Cool, dry, fresh gases

to and from the machine
HME unit
(heat and moisture exchange)
Warm, moist gases

to and from the patient
FIGURE 4–12 Heat and moisture exchanger (HME) functions as an “artificial nose” that attaches between the tracheal
tube and the right-angle connector of the breathing circuit.
in the ICU. A more complete discussion of mechani- A. Inspiratory Phase

cal ventilation in relation to ICU practice is con- During inspiration, ventilators generate tidal vol-
tained in Chapter 57. umes by producing gas flow along a pressure gra-
dient. The machine generates either a constant
Overview pressure (constant-pressure generators) or constant
Ventilators generate gas flow by creating a pressure gas flow rate (constant-flow generators) during
gradient between the proximal airway and the alve- inspiration, regardless of changes in lung mechan-
oli. Ventilator function is best described in relation ics (Figure 4–13). Nonconstant generators produce
to the four phases of the ventilatory cycle: inspira- pressures or gas flow rates that vary during the cycle
tion, the transition from inspiration to expiration, but remain consistent from breath to breath. For
expiration, and the transition from expiration to instance, a ventilator that generates a flow pattern
inspiration. Although several classification schemes resembling a half cycle of a sine wave (eg, rotary pis-
exist, the most common is based on inspiratory ton ventilator) would be classified as a nonconstant-
phase characteristics and the method of cycling flow generator. An increase in airway resistance or
from inspiration to expiration. a decrease in lung compliance would increase peak

A B C
Airway pressure
Gas flow rate
Lung volume
Time Time Time
FIGURE 4–13 Pressure, volume, and flow profiles of different types of ventilators. A: Constant pressure. B: Constant
flow. C: Nonconstant generator.
inspiratory pressure but would not alter the flow rate markedly decrease tidal volume, because cycling will
generated by this type of ventilator (Figure 4–14). be delayed until the pressure limit is met. Volume-
cycled ventilators vary inspiratory duration and
B. Transition Phase from pressure to deliver a preset volume. In reality, mod-
Inspiration to Expiration ern ventilators overcome the many shortcomings of
Termination of the inspiratory phase can be trig- classic ventilator designs by incorporating secondary
gered by a preset limit of time (fixed duration), a cycling parameters or other limiting mechanisms.
set inspiratory pressure that must be reached, or a For example, time-cycled and volume-cycled venti-
predetermined tidal volume that must be deliv- lators usually incorporate a pressure-limiting feature
ered. Time-cycled ventilators allow tidal volume that terminates inspiration when a preset, adjustable
and peak inspiratory pressure to vary depending safety pressure limit is reached. Similarly, a volume-
on lung compliance. Tidal volume is adjusted by preset control that limits the excursion of the bellows
setting inspiratory duration and inspiratory flow allows a time-cycled ventilator to function some-
rate. Pressure-cycled ventilators will not cycle from what like a volume-cycled ventilator, depending on
the inspiratory phase to the expiratory phase until the selected ventilator rate and inspiratory flow rate.
a preset pressure is reached. If a large circuit leak
decreases peak pressures significantly, a pressure- C. Expiratory Phase
cycled ventilator may remain in the inspiratory phase The expiratory phase of ventilators normally reduces
indefinitely. On the other hand, a small leak may not airway pressure to atmospheric levels or some preset

To breathing
circuit
Expiratory phase
Drive mechanism
Drive gas
To breathing
circuit
Inspiratory phase
Drive mechanism Drive gas
FIGURE 4–14 Rotary piston ventilator.
value of positive end-expiratory pressure (PEEP). achieve multiple ventilatory modes, PEEP, accurate
Exhalation is therefore passive. Flow out of the lungs tidal volumes, and enhanced safety features. Some
is determined primarily by airway resistance and anesthesia machines have ventilators that use a
lung compliance. Expired gases fill up the bellows; single-circuit piston design.
they are then relieved to the scavenging system.
A. Double-Circuit System Ventilators
D. Transition Phase from In a double-circuit system design, tidal volume
Expiration to Inspiration is delivered from a bellows assembly that con-
Transition into the next inspiratory phase may be sists of a bellows in a clear rigid plastic enclosure
based on a preset time interval or a change in pres- (Figure 4–16). A standing (ascending) bellows is
sure. The behavior of the ventilator during this phase preferred as it readily draws attention to a circuit
together with the type of cycling from inspiration to disconnection by collapsing. Hanging (descending)
expiration determines ventilator mode. During con- bellows are rarely used and must not be weighted;
trolled ventilation, the most basic mode of all ven- older ventilators with weighted hanging bellows
tilators, the next breath always occurs after a preset continue to fill by gravity despite a disconnection in
time interval. Thus tidal volume and rate are fixed the breathing circuit.
in volume-controlled ventilation, whereas peak The bellows in a double-circuit design ven-
inspiratory pressure and rate are fixed in pressure- tilator takes the place of the breathing bag in the
controlled ventilation (Figure 4–15). anesthesia circuit. Pressurized oxygen or air from
the ventilator power outlet (45–50 psig) is routed
Ventilator Circuit Design to the space between the inside wall of the plastic
7 Traditionally ventilators on anesthesia enclosure and the outside wall of the bellows. Pres-
machines have a double-circuit system design surization of the plastic enclosure compresses the
and are pneumatically powered and electronically pleated bellows inside, forcing the gas inside into
controlled (Figure 4–16). Newer machines also the breathing circuit and patient. In contrast, during
incorporate microprocessor controls and sophis- exhalation, the bellows ascend as pressure inside the
ticated and precise pressure and flow sensors to plastic enclosure drops and the bellows fill up with

A A Mechanical ventilation
VE/VT
Vol Alarms On
VE L/min O2 Pmax cmH2O Volume Mode Circle
5.0 OFF
OFF 25OFF 30
18
40
30
20
VTE ml ƒ /min Pmean 10
500 OFF 12 0
OFF 10 3 6
Sec
9 12 15
Vent On
VT Rate I:E Plimit PEEP
500 mL 10 / min 1:1 40 cmH2O OFFcmH2O
B C
AC power VT
VE/VT
Vol Alarms On
VE L/min O2 Pmax cmH2O Pressure Mode Circle
5.0 OFF
1.4 100OFF 30 18
40
30
20
VTE ml ƒ /min Pmean 10
475 OFF 9 0
OFF 10 3 6
Sec
9 12 15
Vent On
Pinspired Rate I:E Plimit PEEP
20 cmH2O 10 / min 1:2 30 cmH2O OFFcmH2O
D
Pinspired
FIGURE 4–15 Ventilator controls (Datex-Ohmeda). A: Volume control mode. B: Pressure control mode.
the exhaled gas. A ventilator flow control valve regu- L/min and a ventilator is delivering 6 L/min to the
lates drive gas flow into the pressurizing chamber. circuit, a total of at least 8 L/min of oxygen is being
This valve is controlled by ventilator settings in the consumed. This should be kept in mind if the hospi-
control box (Figure 4–16). Ventilators with micro- tal’s medical gas system fails and cylinder oxygen is
processors also utilize feedback from flow and pres- required. Some anesthesia machines reduce oxygen
sure sensors. If oxygen is used for pneumatic power consumption by incorporating a Venturi device that
it will be consumed at a rate at least equal to min- draws in room air to provide air/oxygen pneumatic
ute ventilation. Thus, if oxygen fresh gas flow is 2 power. Newer machines may offer the option of

A
Inspiration Ventilator Expiration Ventilator
driving gas driving gas
Membrane Membrane
and metal lid and metal lid
Spill valve Spill valve
To EVAC To EVAC
To patient circuit From patient circuit
B
Inhalation Drive gas Exhalation Drive gas
To From
patient patient
circuit circuit
To
scavenger To
scavenger
FIGURE 4–16 Double-circuit pneumatic ventilator design. A: Datex-Ohmeda. B: Dräger.
using compressed air for pneumatic power. A leak collapse if the patient generates negative pressure
in the ventilator bellows can transmit high gas pres- by taking spontaneous breaths during mechanical
sure to the patient’s airway, potentially resulting in ventilation.
pulmonary barotrauma. This may be indicated by a
higher than expected rise in inspired oxygen con- B. Piston Ventilators
centration (if oxygen is the sole pressurizing gas). In a piston design, the ventilator substitutes an elec-
Some machine ventilators have a built-in drive gas trically driven piston for the bellows, and the venti-
regulator that reduces the drive pressure (eg, to 25 lator requires either minimal or no pneumatic
psig) for added safety.
8 (oxygen) power. The major advantage of a pis-
Double-circuit design ventilators also incor- ton ventilator is its ability to deliver accurate
porate a free breathing valve that allows outside air tidal volumes to patients with very poor lung com-
to enter the rigid drive chamber and the bellows to pliance and to very small patients.

C. Spill Valve TABLE 4–2 Causes of increased peak

Whenever a ventilator is used on an anesthesia inspiratory pressure (PIP), with or without
machine, the circle system’s APL valve must be an increased plateau pressure (PP).
functionally removed or isolated from the circuit. Increased PIP and PP
A bag/ventilator switch typically accomplishes this. Increased tidal volume
When the switch is turned to “bag” the ventilator is Decreased pulmonary compliance
excluded and spontaneous/manual (bag) ventila- Pulmonary edema
tion is possible. When it is turned to “ventilator,” the Trendelenburg position
Pleural effusion
breathing bag and the APL are excluded from the
Ascites
breathing circuit. The APL valve may be automati- Abdominal packing
cally excluded in some newer anesthesia machines Peritoneal gas insufflation
when the ventilator is turned on. The ventilator con- Tension pneumothorax
tains its own pressure-relief (pop-off) valve, called Endobronchial intubation
the spill valve, which is pneumatically closed during Increased PIP and Unchanged PP
inspiration so that positive pressure can be gener- Increased inspiratory gas flow rate
ated (Figure 4–16). During exhalation, the pressur- Increased airway resistance
izing gas is vented out and the ventilator spill valve Kinked endotracheal tube
Bronchospasm
is no longer closed. The ventilator bellows or piston
Secretions
refill during expiration; when the bellows is com- Foreign body aspiration
pletely filled, the increase in circle system pressure Airway compression
causes the excess gas to be directed to the scavenging Endotracheal tube cuff herniation
system through the spill valve. Sticking of this valve
can result in abnormally elevated airway pressure
during exhalation.
of a suction catheter. Flexible fiberoptic bronchos-
copy usually provides a definitive diagnosis.
Pressure & Volume Monitoring
Peak inspiratory pressure is the highest circuit
pressure generated during an inspiratory cycle, Ventilator Alarms
and provides an indication of dynamic compli- Alarms are an integral part of all modern anesthesia
ance. Plateau pressure is the pressure measured
during an inspiratory pause (a time of no gas
9 ventilators. Whenever a ventilator is used
“disconnect alarms” must be passively acti-
flow), and mirrors static compliance. During nor- vated. Anesthesia workstations should have at least
mal ventilation of a patient without lung disease, three disconnect alarms: low peak inspiratory pres-
peak inspiratory pressure is equal to or only slightly sure, low exhaled tidal volume, and low exhaled car-
greater than plateau pressure. An increase in both bon dioxide. The first is always built into the
peak inspiratory pressure and plateau pressure ventilator whereas the latter two may be in separate
implies an increase in tidal volume or a decrease in modules. A small leak or partial breathing-circuit
pulmonary compliance. An increase in peak inspira- disconnection may be detected by subtle decreases
tory pressure without any change in plateau pressure in peak inspiratory pressure, exhaled volume, or
signals an increase in airway resistance or inspira- end-tidal carbon dioxide before alarm thresholds
tory gas flow rate (Table 4–2). Thus, the shape of the are reached. Other built-in ventilator alarms include
breathing-circuit pressure waveform can provide high peak inspiratory pressure, high PEEP, sustained
important airway information. Many anesthesia high airway pressure, negative pressure, and low
machines graphically display breathing-circuit pres- oxygen-supply pressure. Most modern anesthesia
sure (Figure 4–17). Airway secretions or kinking of ventilators also have integrated spirometers and
the tracheal tube can be easily ruled out with the use oxygen analyzers that provide additional alarms.

A 40
Inspiration Expiration
Peak inspiratory
30 pressure
Paw (cm H2O)

Plateau pressure
20
10
0
1 2 3 4 5 6
Time (secs)
B 40
30
Paw (cm H2O)
20
10
0
1 2 3 4 5 6
Time (secs)
C 40
30
Paw (cm H2O)
20
10
0
1 2 3 4 5 6
Time (secs)
FIGURE 4–17 Airway pressures (Paw) can be diagrammatically presented as a function of time. A: In normal persons,
the peak inspiratory pressure is equal to or slightly greater than the plateau pressure. B: An increase in peak inspiratory
pressure and plateau pressure (the difference between the two remains almost constant) can be due to an increase in tidal
volume or a decrease in pulmonary compliance. C: An increase in peak inspiratory pressure with little change in plateau
pressure signals an increase in inspiratory flow rate or an increase in airway resistance.

Problems Associated mechanism of pressure limiting may be as simple as

with Anesthesia Ventilators a threshold valve that opens at a certain pressure or
electronic sensing that abruptly terminates the ven-
A. Ventilator–Fresh Gas Flow Coupling tilator inspiratory phase.
10 From the previous discussion, it is important
to appreciate that because the ventilator’s spill C. Tidal Volume Discrepancies
valve is closed during inspiration, fresh gas flow
from the machine’s common gas outlet normally 12 Large discrepancies between the set and actual
tidal volume that the patient receives are often
contributes to the tidal volume delivered to the observed in the operating room during volume-
patient. For example, if the fresh gas flow is 6 L/min, controlled ventilation. Causes include breathing-
the inspiratory-expiratory (I:E) ratio is 1:2, and the circuit compliance, gas compression, ventilator–
respiratory rate is 10 breaths/min, each tidal volume fresh gas flow coupling (described above), and leaks
will include an extra 200 mL in addition to the ven- in the anesthesia machine, the breathing circuit, or
tilator’s output: the patient’s airway.
The compliance for standard adult breathing
(6000 mL/min)(33%) circuits is about 5 mL/cm H2O. Thus, if peak inspi-
≈ 200 mL/breath
10 breaths/min ratory pressure is 20 cm H2O, about 100 mL of set
tidal volume is lost to expanding the circuit. For this
Thus, increasing fresh gas flow increases tidal vol- reason, breathing circuits for pediatric patients are
ume, minute ventilation, and peak inspiratory pres- designed to be much stiffer, with compliances as
sure. To avoid problems with ventilator–fresh gas flow small as 1.5 to 2.5 mL/cm H2O.
coupling, airway pressure and exhaled tidal volume Compression losses, normally about 3%, are
must be monitored closely and excessive fresh gas due to gas compression within the ventilator bellows
flows must be avoided. Current ventilators automati- and may be dependent on breathing-circuit volume.
cally compensate for fresh gas flow coupling. Piston Thus, if tidal volume is 500 mL another 15 mL of the
style ventilators redirect fresh gas flow to the reservoir set tidal gas may be lost. Gas sampling for capnog-
bag during inspiration thus preventing augmentation raphy and anesthetic gas measurements represent
of the tidal volume secondary to fresh gas flow. additional losses unless the sampled gas is returned
to the breathing circuit.
B. Excessive Positive Pressure Accurate detection of tidal volume discrepan-
Intermittent or sustained high inspiratory pressures cies is dependent on where the spirometer is placed.
(>30 mm Hg) during positive-pressure ventilation Sophisticated ventilators measure both inspira-
increase the risk of pulmonary barotrauma (eg, tory and expiratory tidal volumes. It is important
pneumothorax) or hemodynamic compromise, or to note that unless the spirometer is placed at the
both, during anesthesia. Excessively high pressures Y-connector in the breathing circuit, compliance
may arise from incorrect settings on the ventilator, and compression losses will not be apparent.
ventilator malfunction, fresh gas flow coupling (dis- Several mechanisms have been built into newer
cussed above), or activation of the oxygen flush dur- anesthesia machines to reduce tidal volume discrep-
ancies. During the initial electronic self-checkout,
11 ing the inspiratory phase of the ventilator. Use
of the oxygen flush valve during the inspira- some machines measure total system compliance
tory cycle of a ventilator must be avoided because the and subsequently use this measurement to adjust the
ventilator spill valve will be closed and the APL valve excursion of the ventilator bellows or piston; leaks
is excluded; the surge of oxygen (600–1200 mL/s) may also be measured but are usually not compen-
and circuit pressure will be transferred to the sated. The actual method of tidal volume compensa-
patient’s lungs. tion or modulation varies according to manufacturer
In addition to a high-pressure alarm, all venti- and model. In one design a flow sensor measures the
lators have a built-in automatic or APL valve. The tidal volume delivered at the inspiratory valve for the

first few breaths and adjusts subsequent metered drive Safety and Health (NIOSH) recommends limiting
gas flow volumes to compensate for tidal volume the room concentration of nitrous oxide to 25 ppm
losses (feedback adjustment). Another design contin- and halogenated agents to 2 ppm (0.5 ppm if nitrous
ually measures fresh gas and vaporizer flow and sub- oxide is also being used) in time-integrated samples.
tracts this amount from the metered drive gas flow Reduction to these trace levels is possible only with
(preemptive adjustment). Alternately, machines that properly functioning waste-gas scavenging systems.
use electronic control of gas flow can decouple fresh To avoid the buildup of pressure, excess gas vol-
gas flow from the tidal volume by delivery of fresh gas ume is vented through the APL valve in the breath-
flow only during exhalation. Lastly, the inspiratory ing circuit and the ventilator spill valve. Both valves
phase of the ventilator–fresh gas flow may be diverted should be connected to hoses (transfer tubing) lead-
through a decoupling valve into the breathing bag, ing to the scavenging interface, which may be inside
which is excluded from the circle system during venti- the machine or an external attachment. The pressure
lation. During exhalation the decoupling valve opens, immediately downstream to the interface should be
allowing the fresh gas that was temporarily stored in kept between 0.5 and +3.5 cm H2O during normal
the bag to enter the breathing circuit. operating conditions. The scavenging interface may
be described as either open or closed.
An open interface is open to the outside atmo-
WASTE-GAS SCAVENGERS sphere and usually requires no pressure relief valves
13 Waste-gas scavengers dispose of gases that (Figure 4–18). In contrast, a closed interface is closed
have been vented from the breathing circuit to the outside atmosphere and requires negative- and
by the APL valve and ventilator spill valve. Pollution positive-pressure relief valves that protect the patient
of the operating room environment with anesthetic from the negative pressure of the vacuum system
gases may pose a health hazard to surgical person- and positive pressure from an obstruction in the
nel. Although it is difficult to define safe levels of disposal tubing, respectively. The outlet of the scav-
exposure, the National Institute for Occupational enging system may be a direct line to the outside via
From ventilator From APL
Vented to room; too much

suction draws in room air;
too little spills into room so
Suction knob
no positive pressure to patient
Hospital
suction
Keep bobbin
in optimized
position by
adjusting
suction knob
FIGURE 4–18 Open interface scavenger system. (Reproduced with permission from Rose G, McLarney JT, eds. Anesthesia Equipment
Simplified. New York, NY: McGraw-Hill Education, Inc; 2014.)

TABLE 4–3 Anesthesia apparatus checkout recommendations.1,2

This checkout, or a reasonable equivalent, should be conducted before administration of anesthesia. These recommendations
are valid only for an anesthesia system that conforms to current and relevant standards and includes an ascending bellows
ventilator and at least the following monitors: capnograph, pulse oximeter, oxygen analyzer, respiratory volume monitor
(spirometer), and breathing-system pressure monitor with high- and low-pressure alarms. Users are encouraged to
modify this guideline to accommodate differences in equipment design and variations in local clinical practice. Such local
modifications should have appropriate peer review. Users should refer to the appropriate operator manuals for specific
procedures and precautions.
Emergency Ventilation Equipment Breathing System

*1. Verify backup ventilation equipment is available and *9. Calibrate O2 monitor
functioning a. Ensure monitor reads 21% in room air.
b. Verify low-O2 alarm is enabled and functioning.
High-Pressure System
c. Reinstall sensor in circuit and flush breathing system
*2. Check O2 cylinder supply
with O2.
a. Open O2 cylinder and verify at least half full (about
d. Verify that monitor now reads greater than 90%.
1000 psig).
10. Check initial status breathing system
b. Close cylinder
a. Set selector switch to Bag mode.
*3. Check central pipeline supplies; check that hoses are
b. Check that breathing circuit is complete, undamaged,
connected and pipeline gauges read about 50 psig.
and unobstructed.
Low-Pressure System c. Verify that CO2 absorbent is adequate.
*4. Check initial status of low-pressure system d. Install breathing-circuit accessory equipment (eg,
a. Close flow control valves and turn vaporizers off. humidifier, PEEP valve) to be used during the case.
b. Check fill level and tighten vaporizers' filler caps. 11. Perform leak check of the breathing system
*5. Perform leak check of machine low-pressure system a. Set all gas flows to zero (or minimum).
a. Verify that the machine master switch and flow b. Close APL (pop-off ) valve and occlude Y-piece.
control valves are off. c. Pressurize breathing system to about 30 cm H2O
b. Attach suction bulb to common (fresh) gas outlet. with O2 flush.
c. Squeeze bulb repeatedly until fully collapsed. d. Ensure that pressure remains fixed for at least
d. Verify bulb stays fully collapsed for at least 10 seconds.
10 seconds. e. Open APL (pop-off ) valve and ensure that pressure
e. Open one vaporizer at a time and repeat decreases.
steps c and d.
Manual and Automatic Ventilation Systems
f. Remove suction bulb, and reconnect fresh gas hose.
12. Test ventilation systems and unidirectional valves
*6. Turn on machine master switch and all other necessary
a. Place a second breathing bag on Y-piece.
electrical equipment.
b. Set appropriate ventilator parameters for next patient.
*7. Test flowmeters
c. Switch to automatic-ventilation (ventilator) mode.
a. Adjust flow of all gases through their full range,
d. Turn ventilator on and fill bellows and breathing bag
checking for smooth operation of floats and
with O2 flush.
undamaged flowtubes.
e. Set O2 flow to minimum, other gas flows to zero.
b. Attempt to create a hypoxic O2/N2O mixture and verify
f. Verify that during inspiration bellows deliver
correct changes in flow and/or alarm.
appropriate tidal volume and that during expiration
Scavenging System bellows fill completely.
*8. Adjust and check scavenging system g. Set fresh gas flow to about 5 L min–1.
a. Ensure proper connections between the scavenging h. Verify that the ventilator bellows and simulated
system and both APL (pop-off ) valve and ventilator lungs fill and empty appropriately without sustained
relief valve. pressure at end expiration.
b. Adjust waste-gas vacuum (if possible). i. Check for proper action of unidirectional valves.
c. Fully open APL valve and occlude Y-piece. j. Exercise breathing circuit accessories to ensure proper
d. With minimum O2 flow, allow scavenger reservoir function.
bag to collapse completely and verify that absorber k. Turn ventilator off and switch to manual ventilation
pressure gauge reads about zero. (Bag/APL) mode.
e. With the O2 flush activated, allow scavenger reservoir l. Ventilate manually and ensure inflation and deflation
bag to distend fully, and then verify that absorber of artificial lungs and appropriate feel of system
pressure gauge reads <10 cm H2O. resistance and compliance.
m. Remove second breathing bag from Y-piece.
(continued)

TABLE 4–3 Anesthesia apparatus checkout recommendations.1,2 (continued)

Monitors Final Position
13. Check, calibrate, and/or set alarm limits of all monitors: 14. Check final status of machine
capnograph, pulse oximeter, O2 analyzer, respiratory- a. Vaporizers off
volume monitor (spirometer), pressure monitor with high b. APL valve open
and low airway-pressure alarms. c. Selector switch to Bag mode
d. All flowmeters to zero (or minimum)
e. Patient suction level adequate
f. Breathing system ready to use
1
Data from US Food and Drug Administration. US Department of Health and Human Services.
2
APL, adjust pressure-limiting; PEEP, positive end-expiratory pressure.
*If an anesthesia provider uses the same machine in successive cases, these steps need not be repeated, or they can be abbreviated after the initial
checkout.
a ventilation duct beyond any point of recirculation conscientious use of a checkout list is mandatory
(passive scavenging) or a connection to the hospital’s before each anesthetic procedure. A mandatory
vacuum system (active scavenging). A chamber or check-off procedure increases the likelihood of
reservoir bag accepts waste-gas overflow when the detecting anesthesia machine faults. Some anesthe-
capacity of the vacuum is exceeded. The vacuum sia machines provide an automated system check
control valve on an active system should be adjusted that requires a variable amount of human interven-
to allow the evacuation of 10 to 15 L of waste gas tion. These system checks may include nitrous oxide
per minute. This rate is adequate for periods of high delivery (hypoxic mixture prevention), agent deliv-
fresh gas flow (ie, induction and emergence) yet ery, mechanical and manual ventilation, pipeline
minimizes the risk of transmitting negative pressure pressures, scavenging, breathing circuit compliance,
to the breathing circuit during lower flow condi- and gas leakage.
tions (maintenance). Unless used correctly the risk
of occupational exposure for health care providers CASE DISCUSSION
is higher with an open interface. Some machines
may come with both active and passive scavenger
systems. Detection of a Leak
After induction of general anesthesia and intu-
bation of a 70-kg man for elective surgery, a
standing bellows ventilator is set to deliver a
ANESTHESIA MACHINE tidal volume of 500 mL at a rate of 10 breaths/
CHECKOUT LIST min. Within a few minutes, the anesthesiolo-
Misuse or malfunction of anesthesia gas delivery gist notices that the bellows fails to rise to the
equipment can cause major morbidity or mortality. top of its clear plastic enclosure during expira-
tion. Shortly thereafter, the disconnect alarm is
14 A routine inspection of anesthesia equipment triggered.
before each use increases operator familiarity
and confirms proper functioning. The U.S. Food and Why has the ventilator bellows fallen and the
Drug Administration (FDA) has made available a disconnect alarm sounded?
generic checkout procedure for anesthesia gas
Fresh gas flow into the breathing circuit is inad-
machines and breathing systems (Table 4–3). This
equate to maintain the circuit volume required
procedure should be modified as necessary, depend-
for positive-pressure ventilation. In a situation
ing on the specific equipment being used and the
in which there is no fresh gas flow, the volume
manufacturer’s recommendations. Note that
in the breathing circuit will slowly fall because
although the entire checkout does not need to be
of the constant uptake of oxygen by the patient
repeated between cases on the same day, the

(metabolic oxygen consumption) and absorption fresh gas inlet (ie, within the breathing circuit).
of expired CO2. An absence of fresh gas flow could Large leaks within the anesthesia machine are less
be due to exhaustion of the hospital’s oxygen sup- common and can be ruled out by a simple test.
ply (remember the function of the fail-safe valve) Pinching the tubing that connects the machine’s
or failure to turn on the anesthesia machine’s flow fresh gas outlet to the circuit’s fresh gas inlet cre-
control valves. These possibilities can be ruled out ates a back pressure that obstructs the forward
by examining the oxygen Bourdon pressure gauge flow of fresh gas from the anesthesia machine. This
and the flowmeters. A more likely explanation is is indicated by a drop in the height of the flowme-
a gas leak that exceeds the rate of fresh gas flow. ter floats. When the fresh gas tubing is released,
Leaks are particularly important in closed-circuit the floats should briskly rebound and settle at their
anesthesia. original height. If there is a substantial leak within
How can the size of the leak be estimated? the machine, obstructing the fresh gas tubing will
not result in any back pressure, and the floats will
When the rate of fresh gas inflow equals the not drop. A more sensitive test for detecting small
rate of gas outflow, the circuit’s volume will be leaks that occur before the fresh gas outlet involves
maintained. Therefore, the size of the leak can attaching a suction bulb at the outlet as described
be estimated by increasing fresh gas flows until in step 5 of Table 4–3. Correcting a leak within the
there is no change in the height of the bellows machine usually requires removing it from service.
from one expiration to the next. If the bellows col- Leaks within a breathing circuit not connected
lapse despite a high rate of fresh gas inflow, a com- to a patient are readily detected by closing the APL
plete circuit disconnection should be considered. valve, occluding the Y-piece, and activating the
The site of the disconnection must be determined oxygen flush until the circuit reaches a pressure of
immediately and repaired to prevent hypoxia and 20 to 30 cm H2O. A gradual decline in circuit pres-
hypercapnia. A resuscitation bag must be imme- sure indicates a leak within the breathing circuit
diately available and can be used to ventilate the (Table 4–3, step 11).
patient if there is a delay in correcting the situation.
Where are the most likely locations of a How are leaks in the breathing circuit located?
breathing-circuit disconnection or leak? Any connection within the breathing circuit is a
Frank disconnections occur most frequently potential site of a gas leak. A quick survey of the cir-
between the right-angle connector and the tra- cuit may reveal a loosely attached breathing tube
cheal tube, whereas leaks are most commonly or a cracked oxygen analyzer adaptor. Less obvious
traced to the base plate of the CO2 absorber. In causes include detachment of the tubing used by
the intubated patient, leaks often occur in the tra- the disconnect alarm to monitor circuit pressures,
chea around an uncuffed tracheal tube or an inad- an open APL valve, or an improperly adjusted scav-
equately filled cuff. There are numerous potential enging unit. Leaks can usually be identified audibly
sites of disconnection or leak within the anesthesia or by applying a soap solution to suspect connec-
machine and the breathing circuit, however. Every tions and looking for bubble formation.
addition to the breathing circuit, such as a humidi- Leaks within the anesthesia machine and
fier, provides another potential location for a leak. breathing circuit are usually detectable if the
machine and circuit have undergone an estab-
How can these leaks be detected? lished checkout procedure. For example, steps 5
Leaks usually occur before the fresh gas out- and 11 of the FDA recommendations (Table 4–3)
let (ie, within the anesthesia machine) or after the will reveal most significant leaks.

SUGGESTED READINGS Somprakit P, Soontranan P. Low pressure leakage

in anaesthetic machines: Evaluation by positive
Baum JA, Nunn G. Low Flow Anaesthesia: The Theory and negative pressure tests. Anaesthesia. 1996;51:
and Practice of Low Flow, Minimal Flow and Closed 461.
System Anaesthesia. 2nd ed. Oxford, UK: Butterworth- Rose G, McLarnery J, eds. Anesthesia Equipment
Heinemann; 2001. Simplified. New York, NY: McGraw-Hill Education;
Block FE, Schaff C. Auditory alarms during anesthesia 2014.
monitoring with an integrated monitoring system.
Int J Clin Monit Comput. 1996;13:81.
Caplan RA, Vistica MF, Posner KL, Cheney FW. Adverse
anesthetic outcomes arising from gas delivery WEB SITES
equipment: A closed claims analysis. Anesthesiology. The Anesthesia Patient Safety Foundation web site
1997;87:741. provides resources and a newsletter that discusses
Dorsch JA, Dorsch SE. Understanding Anesthesia important safety issues in anesthesia. http://www.apsf
Equipment. 5th ed. Philadelphia, PA: Lippincott, .org/
Williams & Wilkins; 2008. The web site of the American Society of Anesthesiologists
Eisenkraft JB, Leibowitz AB. Ventilators in the operating includes a link to the 2008 ASA Recommendations
room. Int Anesthesiol Clin. 1997;35:87. for Pre-Anesthesia Checkout (https://www.asahq
Klopfenstein CE, Van Gessel E, Forster A. Checking the .org/resources/clinical-information/2008-asa-
anaesthetic machine: Self-reported assessment in a recommendations-for-pre-anesthesia-checkout).
university hospital. Eur J Anaesthesiol. 1998;15:314. https://www.asahq.org/clinical/fda.aspx
Mehta S, Eisenkraft J, Posner K, Domino K. Patient An extremely useful web site of simulations in anesthesia
injuries from anesthesia gas delivery equipment. that includes virtual anesthesia machine simulators.
Anesthesiology. 2013;119:788. http://www.simanest.org/

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4

The Anesthesia Workstation

1 Equipment-related adverse outcomes are arrangement helps ensure a minimum

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A Auxiliary O2 flowmeter Flowmeters

Rebreathing Secondary gas

Cylinder yokes Waste gas

FIGURE 4–1 Modern anesthesia machine (Datex-Ohmeda Aestiva). A: Front. B: Back.

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TABLE 4–1 Essential safety features on a modern anesthesia workstation.

Exhaled volume monitor Assess ventilation and prevent hypo- or hyperventilation

Scavenger system Prevent contamination of the operating room with waste

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OVERVIEW for mobility, magnetic resonance imaging (MRI)

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Oxygen flush line

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Oxygen Supply Failure is measured by flowmeters before mixing with other

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conventional flowmeters but electronic measure- A. Physics of Vaporization

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FIGURE 4–6 The vapor pressure of anesthetic gases.

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Vaporizer Warmer temperatures

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Fresh gas Fresh gas

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To oxygen sensor To volume sensor

Absorber Fresh gas locking

O-ring Fresh gas hose

Inspiratory APL bypass valve

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Cartridge with vanes

Display Hall effect

Magnet (4x) Rotor

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FIGURE 4–11 (Continued)

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Humidifiers resistance and the work of breathing during sponta-

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Cool, dry, fresh gases

Warm, moist gases

in the ICU. A more complete discussion of mechani- A. Inspiratory Phase

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Time Time Time

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Drive mechanism Drive gas

FIGURE 4–14 Rotary piston ventilator.

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Spill valve Spill valve

To patient circuit From patient circuit

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C. Spill Valve TABLE 4–2 Causes of increased peak

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Paw (cm H2O)

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