Roger Sharpe

www.anaesthesia4iraq.
com
1/10/09, www.anaesthesia4Iraq.com; Breathing systems and low flow anaesthesia, Roger Sharpe, North West London Hospitals
Breathing systems and Low‐flow
Anaesthesia
Dr Roger Sharpe FRCA.
Consultant Anaesthetist,
Northwick Park Hospital
Harrow on the Hill
Northwick Park Hospital
Contents
• Low‐flow anaesthesia
• Classification of breathing systems
– Non‐rebreathing
– Rebreathing
• Ventilators
• Safety aspects
• Controversies
What is Low‐flow?
• No standard
definition
– Low fresh gas flow
(FGF)
– CO2 absorption
What is Low‐flow?
Hi Flow
>12L
(Non‐rebreathing)
• No standard
definition
– Low fresh gas flow
4L Magill (spont resp)
(FGF)
2 L
– CO2 absorption Low Flow
1L (Rebreathing)
250ml “Closed”
Why Low‐flow anaesthesia?
Advantages Disadvantages
Humidification and warming of inspired Complex equipment – valves may stick

gases
Economy – low gas flows Risk of hypoxic gas mixtures

Less pollution Increased resistance to breathing
Requires careful monitoring of oxygen
and volatile agent
Some volatile agents interact with soda
lime
Breathing systems
Rebreathing Circle
(CO2 absorption) Waters canister
(to‐and fro)
Non‐rebreathing Mapleson
(CO2 flushed out)
• Magill (A)
• Waters (C)
• Ayres T‐piece (E)
• Jackson‐Rees (F)
Mapleson systems
Mapleson systems
FGF = 2‐3 x
patients minute volume
“
To prevent rebreathing
Magill (Mapleson A)
Magill – spontaneous respiration
FGF
Magill
FGF
FGF = Alveolar
Minute Volume
Magill (Assisted ventilation)
The circle system
The circle system
The circle system
FGF
Components of a circle
1. One way valves (x2)
2. APL (spill) valve
3. CO2 absorber (canister)
4. Reservoir bag
5. FGF inlet
6. Vaporisor (in or out of
circuit)
4. Reservoir bag
5. FGF inlet
circuit)
4. Reservoir bag
5. FGF inlet
circuit)
4. Reservoir bag
5. FGF inlet
circuit)
4. Reservoir bag
5. FGF inlet
circuit)
Position of the vaporisor
1.Vaporisor out of
circuit (VOC)
2.Vaporisor in
circuit (VIC)
Function – inspiratory limb
Function – expiratory limb
Function – dead space
The possibility of hypoxic mixtures
30% O2
20%
250 ml/min
30% 25%
20%
20%
250 ml/min
30% 25%
15%
250 ml/min
Vaporisor out of circuit
2%
2%
2%
2%
2%
2%
2%
1%
1%
2% 1.5%
1%
22
1%
2%
2%
1%
Vaporisor out of circuit (VOC)
Inspired
Hal (%)
5 5
5%
4 4
r Setting 4%
o
Va poris
3 3
3%
2 2
2%
1 1% 1
0
1 2 3
FGF (L/min)
Vaporisor in circuit (VIC)
2%
2%
2%
2%
1%
3% 1%
2%
1%
3%
1%
3%
Inspired
Hal (%)
5 5
4 2% 4
3 3
2 Vaporisor
Setting 2
1%
1 1
0
1 2 3
FGF (L/min)
Safe use of low flow with minimal
monitoring
• Start off with high flows (>4L) for at least 15
minutes
• Allows time for N2 to flush out of the system
• Allows time for N2O to equilibrate
• Keep flows relatively high >2L
• Keep FiO2 >50%
• Beware in ventilated patients
• Never combine VIC and IPPV!
• If in doubt increase FGF to >4L
‘To‐and‐fro’ (Waters) system
• Beware of channelling
Ventilators for use in the circle
• ‘Bag‐squeezers’
• Think of squeezing the reservoir
bag
• ‘Bag in a bottle’
– Bellows are in continuity with the
circle
– Driving gas for ventilator is
independent of circle gases
• Tube
– Trunk/piston ventilation
Bag in a bottle
To Circle
Driving gas
= 700ml
Bag in a bottle
Bag in a bottle
Trunk/Piston ventilation
Ventilator ‘Trunk’ Circle Patient
Tidal Volume
Ventilator ‘Trunk’ Circle Patient
Expiration
Ventilator ‘Trunk’ Circle
Trunk ventilation in the circle
Trunk ventilation in the circle
Controversies (1)
• Reactions with soda lime ‐ Desflurane
– Carbon monoxide
• 1994 reports of carboxyhaemoglobinaemia
• Monday morning lists with desflurane
– Found that Baralyme used with desflurane and
dry soda lime produced up to 1.5% carbon
monoxide
• Barlyme contains 4.7% KOH (3 x more than soda‐lime)
– No reports in UK – Baralyme not licensed
Controversies (2)
• Reactions with soda lime ‐ Sevoflurane
– Compound A ‐ ? Renal toxicity
– Large margin of safety in humans
• 250ppm in rats causes tubular necrosis
• typical concentrations of Compound A in circle with
sevoflurane = 15ppm
• Differences in rat vs. Human renal susceptibility
– But some countries have set a minimum FGF rate
• USA 1L/min
• Canada & Australia 2L/min
– No restrictions in UK
Controversies (3)
• Reactions with soda lime
• Compound A
• Carbon monoxide
• Excess Heat
• Lead manufacturers to reduce the amount of
KOH
• Baralyme – highest content 4.7%
• Soda‐lime ~1.5%
• Amsorb – hygroscopic agents to prevent drying
• Amsorb plus – no KOH
Practical tips
• Use high FGF for the first 10‐15 minutes
• Beware of dilution of oxygen and volatile agent
(VOC)
• If in doubt keep FGF above patients minute
volume
• Increase FGF to achieve rapid changes in
anaesthetic depth
• Be aware of soda‐lime containing KOH
• Don’t let soda‐lime dry out
Thank‐you
www.anaesthesia4iraq.com

Roger Sharpe

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www.anaesthesia4iraq.

Humidification and warming of inspired Complex equipment – valves may stick

Economy – low gas flows Risk of hypoxic gas mixtures

Ventilator ‘Trunk’ Circle Patient

Ventilator ‘Trunk’ Circle Patient

Ventilator ‘Trunk’ Circle

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