But. J. Anaesth.
(1968), 40, 660
APPARATUS FOR CARBON DIOXIDE ABSORPTION
BY
A. BRACKEN AND L. A.
Carbon dioxide absorption in anaesthesia became
increasingly popular following the introduction of
cyclopropane and continues in wide use today
largely because it conserves the new and relatively
expensive volatile anaesthetic agents such as halo-
thane. Some of the arguments put forward in the
earlier days to justify the closed circuit have been
shown to be largely fallacious, for example, the
claim that it conserves heat. This, and the chang-
ing trends in anaesthetic techniques are good
reasons why the design specification for a canister
to operate with optimum efficiency should be
reviewed periodically.
The efficiency of carbon dioxide absorption is
governed not only by the absorbent and the de-
sign of the soda-lime canister, but also by circuit
arrangements including the location of the spill
valve and the directional valves, the rate of flow
of fresh gases and where they enter the circuit,
and the possible effects of a ventilator if employed.
Some of these topics are not necessarily pertinent
to the absorber itself, in which there is a close
interrelationship between size of canister and
nature of absorbent, and therefore they will not
be discussed in detail here.
THE CANISTER
The most important change in apparatus design
in recent years has been the introduction of large
transparent canisters (Hale, 1967). There are two
points in favour of making these transparent; first
and foremost is the obvious one that it permits
visual inspection of soda-lime throughout the
absorption process, and in this respect has helped
to increase the popularity of colour indicators;
secondly, it is not unreasonable to expect that a
large transparent canister could be constructed
more cheaply than, say, a chromium-plated metal
one. There are, however, certain problems asso-
ciated with transparent absorbers which need to
be considered.
Cox
Clearly the choice of material will lie between
glass and one of the plastics. Glass has the advan-
tage of being dimensionally stable despite re-
peated sterilization by autoclaving and as a raw
material it is cheap. It is however, very fragile,
and furthermore there are difficulties in manufac-
turing a large tubular item to the reasonably close
dimensional tolerances necessary, bearing in mind
the need to effect a gastight seal with its mating
components. Some plastics, on the other hand,
can be readily moulded or otherwise fabricated
and, provided the right material is used, not only
is the cost of the item more likely to be brought
down to an acceptable level but there would be
the attendant advantage of less frequent replace-
ment due to breakages. There is an increasing
range of plastics to choose from nowadays, includ-
ing acrylic, polycarbonate, polystyrene, and cellu-
lose acetate, all of which are available in a dear
colourless form. All these materials are thermo-
plastic and until recendy there were limitations in
the mavimnm temperature to which they could be
subjected; this precluded sterilization by auto-
clave. Some of the more recently developed plas-
tics, however, are better in this respect but
unfortunately are also considerably more expen-
sive.
One fundamental difficulty in regard to the use
of transparent canisters arises from the fact that
the observer sees only the outside layer of the
absorbent In all the absorbers we have examined,
this layer does a disproportionate amount of the
work of absorption because the gases will prefer-
entially pass between the granules and the smooth
inner surface of the canister. One effect of this
channelling has been referred to by Robson and
Pask (1954) who stated that when they devised a
pot-scrubber compression device it stopped chan-
nelling, but the pressure drop increased from 42
mm H2O at a flow rate of 40 litres per minute,
to 7.8 mm HjO, because the gases passed through
the bed of soda-lime instead of partially bypass-
APPARATUS FOR CARBON DIOXIDE ABSORPTION
ing it. Some commercial designs embody a ring-
shaped partition which partially divides the canis-
ter into equal upper and lower compartments, and
this is fairly effective in diverting the gas stream
into the soda-lime bed.
It is very necessary to take into account the
hazard of static electrification. Large areas of
insulating material on which simple friction can
generate a high charge of static electricity (and
conceivably a spark) have in the past been con-
sidered dangerous. This danger is currently felt
to be less serious than it was because increased
awareness of the explosion risks has led to better
precautions for their prevention, and because of
the wider use of non-explosive agents like
halothane. Nevertheless, some basic objections
were raised following the introduction of the
transparent canister. It was claimed by some that
the change from a metal conductive item to a
non-metallic insulating one was a retrograde step
which could not be defended by instancing the
use of glass containers for vaporizers of volatile
and flammable anaesthetics such as ether. After
all, glass bottles have been used for anaesthetic
vaporizers since the earliest days, and any hazards
arising therefrom have always been present. Also,
owing to its attraction of a thin moisture film in
all except the driest atmospheres, glass has a
surface resistivity of about 1010 ohms, which is
ostensibly less dangerous than most plastics whose
surface resistivities are usually around lO14 ohms.
Notwithstanding this, tests in our laboratory have
shown that a canister filled with soda-lime (a
relatively good conductor of electricity) cannot
retain a dangerous static charge even on its outer
surface since any high charge will leak away
through the soda-lime.
THE ABSORBENT
In considering apparatus used for carbon dioxide
absorption, reference must be made to the absor-
bent itself. In anaesthetic practice, only two ab-
sorbents have been widely used—soda-lime and
barium hydroxide octahydrate (baryta-lime).
Others have been recommended from time to
time; for example, sodium peroxide which like
some other substances will absorb carbon dioxide
and at the same time liberate oxygen; lithium
hydroxide absorbs more carbon dioxide than does
661
the same weight of soda-lime. Absorbents such
as monoethanolamine, used in industry (Sharp,
1958), can readily be regenerated and so can
various types of ion exchange resins now avail-
able; molecular sieves can be good carbon dioxide
absorbents and can also be regenerated. Inves-
tigations (e.g. Bracken, 1955) have shown that in
some cases there are numerous technical objec-
tions to their use in anaesthesia whereas in other
cases the high cost is the dominating disadvan-
tage.
This last point bears upon apparatus design
because following American work, notably by
Kappesser (1953), Ham (1958) and Brown, Seniff
and Elam (1964), it has become usual to provide
large absorbers which are constructed in two
parts, the principle being that the exhausted half
can be refilled with fresh soda-lime and the
canister reversed so that the relatively fresh
second half makes first contact with the incoming
gas. With this reverse flow principle, the soda-
lime is used right through to the end without en-
dangering the patient by carbon dioxide breaking
through. However, it has been suggested to us
that the apparatus is not always used in the
manner prescribed and it would seem that in
some hospitals attention to the absorption appara-
tus rates very low in the list of duties carried out
by the theatre staff. The large canister concept
should be a boon to busy theatre staff, as even
with continuous use one complete charge may last
two weeks or more before needing replacement.
Despite the popularity of indicator soda-lime,
frequent analysis of the gas stream is the only
really satisfactory way of detecting when the
soda-lime is about to be exhausted and this should
be carried out as a regular routine.
The moisture content of soda-lime and its con-
sequent efficiency as an absorbent, are closely
related to the canister size and even the choice
of a colour indicator can be affected by this rela-
tionship. The moisture content should be around
15 per cent, the upper limit being dictated only
by considerations of waterlogging (Brown, Bakam-
jian and Seniff, 1959). In a 1 lb. canister, soda-
lime containing below about 10 per cent moisture
falls off sharply in its performance. On the other
hand, if soda-lime with a low moisture content is
used in a large canister there is not the same fall-
off. One reason is that it does not become as hot
662
in use as a small canister. Therefore, water liber-
ated in the reaction
CO, + 2NaOH=Na 2 CO 3 + H3O
does not escape and there is a greater tendency
(a) for the drier soda-lime to approximate to an
ideal moisture content;
(fc) for the soda-lime to become waterlogged
if initially it has a high water content; and
(c) for the indicator to wash out if this is very
water-soluble.
Further, the longer residence time of the gas in
a large canister assists by giving a longer reaction
time, and removes one of the objections to drier
soda-lime, i.e. "peaking" or "regeneration". This
was one of the problems of earlier years which is no
longer considered of any great importance. It was
the name given to the reactivation of apparently
spent soda-lime on standing for a few hours.
This was a nuisance because it was difficult to
decide whether to discard the soda-lime at the
end of the day. Regeneration was a failing of dry
soda-lime when used in small canisters (Adriani,
1962). We have confirmed earlier reports (Lund,
Andersen and Erikson, 1956) that a large canister
rilled with drier soda-lime does not exhibit this
phenomenon because of self-moistening of the
charge.
It is interesting to note that these earlier
workers have indicated that only 80-88 per cent
of the carbon dioxide is absorbed in small canis-
ters. The question arises as to what is an accept-
able carbon dioxide return to the patient from
an anaesthetic apparatus. Obviously opinions will
differ on this point but most writers who have
expressed themselves have followed the lead of
Woolmer and Iind (1954) that the figure should
not be more than 0.1 or 02 per cent of carbon
dioxide by volume. Using this criterion, 1-lb.
absorbers are satisfactory; larger absorbers are
fully effective even when hah0 the soda-lime is
exhausted.
This aspect of canister size has a bearing on
reports on the efficiency of baryta-lime. Some
authors say it is inefficient, others claim it is satisfac-
tory. Some at least of the diverging views can be
explained by the fact that with a large canister the
gas stream stays in contact with the absorbent
for a longer rime and under these conditions
baryta-lime can be as efficient as soda-lime
BRITISH JOURNAL OF ANAESTHESIA
(Nealon, Chase and Gibbon, 1958). When it is
used in a 1-lb. canister the volume is such that the
gas does not have time to react completely and
in this case baryta-lime is inefficient.
Questions of mesh size and storage conditions
of soda-lime have been well aired (e.g. Bracken
and Sanderson, 1955). Most brands are made
either 4-8 mesh or, for greater efficiency, 5-10
mesh. The slight increase in resistance to gas
flow in the smaller canister resulting from the use
of finer mesh soda-lime appears to be acceptable,
whilst in larger canisters the pressure drop is less
anyway, because of their larger cross-sectional
area. There appears to be no objection to combin-
ing the above mesh sizes to produce a single stan-
dard of 4-10 mesh. The storage conditions of
soda-lime do not affect carbon dioxide absorption
efficiency so much as they do moisture loss. In
some tests we carried out we have shown that
soda-lime stored in a badly sealed container may
lose moisture but not gain very much carbon
dioxide except in the surface layers, so that over-
all efficiency is little impaired.
Some figures for the degree of exhaustion of
soda-lime relating to size of canister are given by
Miles and Adriani (1959). They showed that 1
g of spent soda-nine from a standard 8 x 13 cm
canister (holding 1 lb. of soda-lime) liberated
100-125 ml of carbon dioxide, whereas with 1 g
from a large double canister (holding a total of
4 lb.) the average was 175 ml. Expressing this
another way, the same authors stated that for
every extra 100 g of soda-lime in the canister
there was an extra hour of absorption capacity.
One big advantage of the large canister stems
from its large inter-granular air space. In anaes-
thetic practice large canisters should only be used
in a circle system as they are quite inappropriate
in the Waters to-and-fro circuit. This is because
in a to-and-fro circuit the soda-lime nearest the
patient would become exhausted first and the
deadspace would increase until the patient's ex-
halation would eventually contact only exhausted
soda-lime. Then, because the fresh gas flow is
insufficient to drive all the exhaled gas to the far
end of the canister, only about 1 lb. of a 4-lb.
charge is likely to be effective and any attempt
to utilize the remaining 3 lb. would be unavailing.
The patient, after a few hours, would re-inhale
exhalations not freed from carbon dioxide, as the
APPARATUS FOR CARBON DIOXIDE ABSORPTION
deadspace will have increased until it is equal to
the tidal volume. The situation would then be
especially dangerous because a carbon dioxide
analysis taken from the rebreathing bag might
show that all is well, yet the patient could be
suffering from carbon dioxide accumulation.
TABLE I
Effect of canister size on carbon dioxide absorption
capacity using circle system.
Tidal volume 500 mL
Respiration rate 20 per minute.
Carbon dioxide input 200 ml per minute.
Minutes before Endurance factor
CO, in inspired (min of use
Canister ens exceeded per 1 oz. of
size 0.6% soda-lime)
3 oz. 4 1.3
5±oz. 74.5 13.6
1 lb. 322.5 20.2
4 1b. 1725 27.0
6 1b. 2904 30.3
Some data obtained in our laboratory relating
to size of canister and efficiency may be given
here. The investigation covered canisters of
various sizes, set up under standard "circle" con-
ditions in the apparatus described by Bracken
(1955) where pulses of carbon-dioxide-laden air
are pushed through the canister. The results are
given in table I, and reveal that there is a further
advantage in using a large canister inasmuch as
4 lb. of soda-hme will last for a much longer
time than would be expected merely from the
increased weight of soda-lime. In fact the 4-lb.
canister lasted more than five times as long as the
1-lb. canister. This applies to circle absorption
only and not to to-and-fro, where a small canister
suffers less by comparison because the gas passes
through the charge twice. Thus, with the very
small 3-oz. canister it took 4 minutes to reach
0.6 per cent in a circle system but over 8 minutes
in a to-and-fro system. These are average figures
the results being rather scattered because of
sampling problems arising from the rapid rise
in carbon dioxide concentration.
Confirming previous studies (Miles and Adri-
ani, 1959) we have found that it does not make
any difference, especially in regard to large canis-
ters, whether the pulses of air are put through to
simulate a rapid respiratory rate with a small
663
tidal volume, or a slow respiratory rate with a
large tidal volume or whether there are variations
in the ratios between inspiration, expiration and
respiratory pause; nor does the input gas tempera-
ture have any significant effect.
CIRCUIT ARRANGEMENTS
In assessing the overall performance of the equip-
ment, one must not confuse the increased size of
the absorber with the circuit arrangements pro-
vided for venting excess gas during the patient's
exhalations. Brown, Seniff and Flam (1964) re-
cord how they were surprised at the extremely
long life of the canister being tested, this being
due to blowing off excess gas as well as to extra
soda-lime. They found that depending upon cir-
cuit arrangements, a greater or lesser proportion
of <rhn1<-H gas is mixed with fresh gases and
blown off in part to atmosphere before reaching
the soda-lime. Since the fully closed circuit is
comparatively rarely used today, this is another
reason why large canisters, given the right circuit
arrangements, can be used for such very long
periods of time.
TABLE II
Effect of circuit arrangements on inhaled oxygen
percentage.
Human subject (A.B.)
Minute volume 9 L
Respiratory rate 14 respirations per minute.
Volume vented 4-5 1. per minute.
Oxygen concentration, % v/v
Point in circuit where In Inhaled by
venting took place circuit subject
On face mask 21 19-20
54 51.5-52.6
At fresh gas inlet, Le.
remote from face
mask 54 50-50.5
Arising from this work and following the com-
munications by Fitton (1958, 1963) we considered
it desirable to find out how much, if any, of the
patient's much-needed oxygen is vented at the
same time as exhaled gas. In order to test this,
subjects breathed in and out of the Boyle Mark
HI absorber and oxygen measurements were taken
at various parts of the circuit Even with input
gas containing as little as 21 per cent oxygen
there was no significant fall in inspired oxygen
concentration (table LI). A recent paper by Eger
664
and Ethans (1968) and an annotation by Rendell-
Baker (1968) in the same publication refer to the
effect of different circuit arrangements on system
economy.
A great deal of thought has gone into the de-
sign of large canisters and one author (Hampton,
1967) has commented that some U.S. manufac-
turers had not at his time of writing paid due
attention to the design points raised by one of
the pioneers, Elam (1958). In particular he re-
ferred to the absence of a small air space at the
top of the soda-lime where the patient's exhaled
gas enters the canister. Such a space allows dif-
fusion and helps to prevent gas channelling.
Elam's article contains some useful quantitative
statements; for example, the service interval of 8
hours of intermittent use, and the patient's res-
piratory parameters of 0.5 to 1.0 litres tidal
volume, producing 12-18 litres per hour carbon
dioxide output. Thus, allowing for the fact that
100 g of soda-lime absorbs 15 litres of carbon
dioxide before the exit gas contains 1 per cent
carbon dioxide, he arrived at the figure of 870 g
of soda-lime for an 8-hour period, this quantity
occupying about 1 litre in bulk. About 47 per cent
of this soda-lime would be void space which
would accommodate one average tidal volume,
and it would increase at the rate of 60 ml per
hour as absorption proceeded. This could be
countered by a second chamber of a similar
capacity. This followed Kappesser's suggestion
(1953) that the canister should be in two halves,
each being filled separately and the canister re-
versed during use so that partly exhausted soda-
lime becomes the top half, meeting the patient's
exhaled gases, and the lower half containing fresh
soda-lime completes the carbon dioxide elimina-
tion. Elam (1958) calculated the resistance to air
flow as less than 1 cm HjO at a flow rate of 60
L/minute if the length of the combined canisters
was less than 18 cm and the diameter greater than
12 cm. To assist in eliminating channelling Elam
suggested the annular ring baffles which arc now
so widely used. The foregoing considerations
amount to a design justification for a 4-lb. canis-
ter, and have been widely accepted.
The introduction of large and complicated ab-
sorbers would at first sight appear to increase the
hazard of cross-infection as compared with small
absorbers, if only because they are used success-
BRITISH JOURNAL OF ANAESTHESIA
ively on a number of patients without intermed-
iate sterilization. The evidence of cross-infection
is not very conclusive but there is no doubt that
a soda-lime canister is not a reliable bacterial
filter (Stark, Green and Pask, 1962). Naturally,
there will be some kind of valve system to control
the direction of gas flow and this should be de-
signed with ease of cleaning and sterilizing in
mind. However, there is the question of who
will do the cleaning and, perhaps more import-
ant, of the safe and correct reassembly of the
apparatus, and this raises difficulties. A circle
absorber does not lend itself to being put into
an autoclave, and although other sterilization
methods can be used (such as ethylene oxide, for-
malin, combinations of heat and biodetergents,
and aerosol disinfection), these are not always
applicable because of lack of apparatus and trained
staff. Bacterial filters (Bishop, Roper and Wil-
liams, 1963) are not yet widely used as a solution
to the problem of apparatus cross-infection, so to
some extent this problem of hygiene remains un-
resolved.
One final point concerns packing the canisters
with soda-lime. If a canister is packed by putting
layers 1-2 inches deep and then tamping more or
less vigorously, there is a risk that this will break
up some of the granules and form powder (Sam-
son, 1956). This risk is obviously greater with the
more friable, soft, porous types which incidentally
have the most efficient absorptive properties. On
the other hand, if soda-lime is produced with
harder granules (and this is within the power of
the manufacturer to control by varying the con-
ditions of drying of the original cake in the oven)
then it will be more resistant to breaking up and
powdering. Unfortunately, there is the disadvan-
tage that the calcium carbonate produced on the
outer surface by the absorption process will make
the granules still harder and less permeable, thus
decreasing efficiency. It follows from this that
there is less objection to using hard soda-
lime in a large canister as it gives th: manufac-
turer more tolerance in the direction of less rapid
absorption. On the other hand, a certain amount
of personal skill will always be required in pack-
ing the canisters. It is known that a properly
packed canister absorbs as efficiently in a hori-
zontal position as it does in a vertical position
(Robson and Pask, 1954), rhannfiiing along the
APPARATUS FOR CARBON DIOXIDE ABSORPTION
top of a horizontal canister being serious only
with a loosely packed canister.
REFERENCES
Adriani, J. (1962). The Chemistry and Physics of Anes-
thesia, 2nd ed., p. 173. Springfield, Illinois:
Thomas.
Bishop, C , Roper, W. A. G., and Williams, S. R.
(1963). The use of an absolute filter to sterilize the
inspiratory air during intermittent positive pres-
sure respiration. Brit. J. Anaesth., 35, 32.
Bracken, A. (1955). Discussion on carbon dioxide
accumulations in anaesthetic circuit Proc. roy. Soc.
Med., 49, 215.
Sanderson, D. M. (1955). Some observations on
anaesthetic soda lime. Brit. J. Anaesth., 27, 422.
Brown, E. S., Bakamjian, V., and Seniff, A. M. (1959).
Performance of absorbents: effect of moisture.
Anesthesiology, 20, 613.
Seniff, A. M., and Elam, J. O. (1964). Carbon
dioxide elimination in semi-closed systems. Anes-
thesiology, 25, 31.
Eger, E. I., and Ethans, C. T. (1968). The effects of
inflow, overflow and valve placement on economy
of the circle system. Anesthesiology, 29, 93.
Elam, J. O. (1958). The design of circle absorbers.
Curr. Res. Anesth., 19, 99.
Fitton, E. P. (1958). A theoretical investigation of oxy-
gen concentrations in gases inspired from various
semiclosed anaesthetic systems. Brit. J. Anaesth.,
30, 269.
CORRESPONDENCE
FOURTH WORLD CONGRESS OF ANAESTHESIOLOGISTS
Sir,—We are concerned that the reasons for not issuing
day membership tickets for consultants at the Fourth
World Congress of Anaesthesiologists do not seem to
be understood.
First, it must be realized that the costs of organizing
such a gathering must be shared by all who come to it
and that these costs are the same whether attendance
is for one day or for the whole period. Therefore the
registration fee must be for attending the whole Con-
gress and not fractions of it. The complications of
introducing "day membership" for consultants or any
variants on such a scheme would add enormously to
the cost of the secretariat—already a major expense.
Secondly, it must be borne in mind that we are
hosts to the rest of the world and at the time of writing
665
Fitton, E. P. ((1963). Theoretical investigation of oxy-
gen concentrations: correction and additional
observations. Brit. J. Anaesth., 35, 276.
Hale, D. E. (1967). The rise and fall of soda lime.
Curr. Res. Anesth., 46, 648.
Hampton, L.' J. (1967). Absorption of carbon dioxide:
influence of canister design on performance charac-
teristics of commercial absorbers. Anesthesiology,
28, 255.
Kappesser, R. C (1953). Modification of double
canister circle filter. Anesthesiology, 14, 415.
Lund, I., Andersen, K. L., and Erikson, H. (1956).
Efficiency of carbon dioxide absorption by soda
lime in a closed system. Brit. J. Anaesth., 28, 13.
Miles, G., and Adriani, J. (1959). Carbon dioxide
absorption: a closer look. Curr. Res. Anesth., 38,
293.
Nealon, T. F., Chase, H. P., and Gibbon, J. H. (1958).
Factors influencing carbon dioxide absorption dur-
ing anesthesia. Anesthesiology, 19, 75.
Rendell-Baker, L. (1968). On the promise of economy
denied. Anesthesiology, 29, 5.
Robson, J. G., and Pask, E. A. (1954). Some data on
the performance of Waters canister. Brit. J.
Anaesth., 26, 333.
Samson, H. H. (1956). An improved carbon dioxide
absorber. Lancet, 2, 1196.
Sharp, T. W. (1958). Carbon dioxide removal and re-
covery. Power Gas Group Rev., 5, 8.
Stark, D. C. C , Green, C A., and Pask, E. A. (1962).
Anaesthetic machines and cross-infection. Anaes-
thesia, 17, 126.
Woolmer, R., and Lind, B. (1954). Rebreathing with a
semiclosed system. Brit. J. Anaesth., 26, 316.
this letter anaesthetists from sixty-six countries have
signified their intention of being present and have paid
their registration fees. It behoves us, therefore, to be
generous. Every member of the Organizing Committee
has paid his full registration fee although it is unlikely
that any will be able to attend the meetings.
We hope that this will clear any misgivings on the
question of day registration for consultants.
GEORGE ELLIS
Chairman of the Organizing Committee
C. B. LEWIS
Chairman of Registration Committee
[This letter was received for publication too late for
inclusion in the list of Contents on front cover.]