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Anesthesia machines: Prevention, diagnosis, and

management of malfunctions
Author: Robert Loeb, MD
Section Editor: Joyce A Wahr, MD, FAHA
Deputy Editor: Nancy A Nussmeier, MD, FAHA

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2023. | This topic last updated: Jun 16, 2021.

INTRODUCTION

Anesthetic care is provided using an anesthesia machine and integrated monitors (ie, the anesthesia
workstation ( figure 1 and figure 2 and figure 3 and figure 4 and figure 5)) that include
systems for:

● Blending a precision mixture of respiratory and anesthetic gases (anesthesia machine and
vaporizers)
● Dispensing those gases to the patient (anesthesia breathing system)
● Delivering positive pressure ventilation (anesthesia ventilator)
● Removing waste gases (scavenger system)
● Monitoring respiratory and machine function (integrated system monitors)

Misuse or malfunction of the anesthesia machine and its integrated monitors has been cited as the
cause of 1 to 2 percent of closed claim lawsuits involving anesthesiology personnel, with equipment
misuse being three to five times more frequent than equipment failure [1,2]. This topic will discuss
strategies to prevent, diagnose, and manage the most common and/or severe misuses and
malfunctions of the anesthesia machine and its integrated monitoring systems.

A separate topic describes preparing anesthesia machines for use during the COVID-19 pandemic and
repurposing anesthesia machines as intensive care ventilators. (See "COVID-19: Intensive care
ventilation with anesthesia machines".)

Other hazards involving anesthesia and other equipment in the operating room (eg, electrical injuries,
burns) are discussed in separate topics. (See "Safety in the operating room" and "Fire safety in the
operating room".)

STANDARDIZED ANESTHESIA MACHINE CHECKOUT

Anesthesia machine checkout procedures: General principles — Investigators have noted that
meticulous adherence to published guidelines for a pre-use anesthesia machine and equipment
checkout would prevent most critical incidents and lawsuits due to anesthesia workstation misuse or
failure [1-4]. Without a formal checkout procedure, anesthesia providers are not likely to detect all
machine problems. A prospective study published in 1984 noted that fewer than 5 percent of a sample
of attendees at a professional anesthesia meeting could find all five faults intentionally created in an
anesthesia machine (the average number of faults detected was 2.2) [5]. In a 2007 follow-up study,
attendees found an average of 3.1 of five intentionally created faults [6]. Notably, formal checklists
were not used by the participants in these studies.

A number of national and international organizations have created pre-use checklists for the
anesthesia workstation. The American Society of Anesthesiologists (ASA) Anesthesia Machine Checkout
Recommendations are used in the United States ( table 1) [7]. Similar anesthesia workstation
checkout recommendations have been published in other countries (eg, the Association of
Anaesthetists of Great Britain and Ireland [AAGBI] and the Australian and New Zealand College of
Anaesthetists [ANZCA]) [8,9]. The ASA recommendations are unique since they specify that some
checks can be routinely accomplished by support personnel (eg, anesthesia technicians) to ensure
compliance and lessen clinician workload.

Since no single checkout procedure is applicable to all machines, the ASA and other professional
society recommendations are meant to serve as general guidelines and should be modified as
necessary for the anesthesia delivery system(s) available in a local practice as well as the patient
population. For example, when caring for infants under 10 kg, it is especially important to expand the
breathing system hoses prior to performing the compliance compensation portion of a self-check [10].

With advances in integrated computer technology, many new anesthesia workstations perform an
automated pre-use checkout when powered on. Electronic prompts on the workstation screen
communicate additional steps that the anesthesia provider must perform to complete the non-
automated portions of the checkout procedure. In one prospective study, the proportion of cases with
failure to perform all necessary pre-induction steps decreased from 10 to 6.4 percent before and after
implementation of a computerized pre-induction anesthesia checklist [11].

American Society of Anesthesiologists Anesthesia Machine Checkout — In the United States, the
ASA Anesthesia Machine Checkout Recommendations are most commonly used ( table 1). These
guidelines note 15 specific checks that are to be performed daily, and eight of these items are
completed before beginning anesthetic care for each individual patient [7].

ANESTHESIA WORKSTATION ALARMS

Alarms for the most common and/or serious anesthesia machine problems, possible causes, and
suggested clinician responses are shown in the tables:

● Electrical power loss alarm ( table 2)

● Oxygen (O2) supply pressure alarm ( table 3)
 ● Apnea alarm overview ( table 4)
● Apnea-pressure alarm [12] ( table 5 and algorithm 1)
● Apnea-flow alarm ( table 6)
● Apnea-carbon dioxide (CO2) alarm ( table 7)
● High airway pressure alarm ( table 8 and algorithm 2)
● Continuous airway pressure alarm ( table 9)
● Negative airway pressure alarm ( table 10)
● Low inspired oxygen alarm ( table 11)
● High inspired CO2 alarm ( table 12)
● Low inspired anesthetic agent alarm ( table 13)

These alarms are generated by integrated monitors within the anesthesia workstation. They may fail to
alert the clinician to a critical situation if the alarm is disabled, the sound volume is set too low, or the
threshold settings for the monitored parameter are not appropriate (which may occur if settings are
not changed for each individual patient). (See 'Malfunction of integrated anesthesia monitors' below.)

MALFUNCTION OF ANESTHESIA MACHINE COMPONENTS

Anesthesia workstations are well-designed machines that rarely malfunction. Typically, they are used
daily for 10 to 20 years.

Leaks and obstructions are the most common causes of problems with anesthesia delivery equipment
[4]. Most problems with machine function are preventable, and the root cause is more likely to be
improper use than frank equipment failure [1-4,13].

Loss of electrical supply — The electrical power loss alarm warns that the system is running on
battery ( table 2).

● Potential problems – Anesthesia workstations require electrical power for monitors and alarms,
screen displays, and ventilator controls. In addition, newer anesthesia machines may have
electrically powered ventilators, compressed gas flowmeters, and vaporizers for administration of
volatile anesthetics. Thus, the functionality of anesthesia workstations is severely compromised if
electrical power fails, although all have integrated backup batteries that allow continued
operation for a short period of time (typically, 30 minutes to approximately one hour).

● Prevention – Alternating current (AC) and battery power should be confirmed during the pre-use
checkout (item #3) ( table 1) (see 'American Society of Anesthesiologists Anesthesia Machine
Checkout' above). The power source indicators on the anesthesia workstation show the presence
of both AC and backup battery power.

● Diagnosis – The first obvious sign of power failure may be an electrical power loss alarm, or even
complete workstation shutdown once the batteries are no longer providing power ( table 2).

● Response – All anesthesia workstations are able to support manual ventilation with oxygen in the
event of total electrical failure. This should be initiated while the root cause of the problem is
 sought. In some workstations the normal flowmeter controls and displays are used for this; in
other machines, backup mechanical flowmeter controls and displays must be used.

Troubleshooting strategies for loss of electrical are described in the table ( table 2).
Malfunctions of electrical supply include local power loss due to a blown fuse, tripped circuit
breaker, or tripped ground fault circuit interrupter (GFCI) outlet (see "Safety in the operating
room", section on 'Electrical injury'). In one case known to the authors, the hospital maintenance
crew shut off electrical supply to the operating room without verifying that the room was not in
use.

More widespread power loss can also occur throughout a health care facility or the surrounding
community. In the United States, anesthesia workstations are only used in facilities with a backup
generator.

Compressed gas supply malfunction — Compressed gas supply malfunction should trigger alarm
messages for oxygen supply pressure and low inspired oxygen ( table 3 and table 11).

● Potential problems – Anesthesia workstations require a source of compressed oxygen, and

other compressed respiratory gases are also typically available (eg, air, nitrous oxide [N2O]).
These compressed gases are dispensed via pipelines and hoses from central facility sources.
Oxygen and other gases may also be dispensed from cylinders attached to the anesthesia
workstation, if necessary.

• Pipeline malfunctions include:

- Inadequate gas line pressure

- Wrong gas in the pipeline [14]
- Particulate contamination
- Water contamination (eg, in compressed air)

• Hose malfunctions include:

- Disconnection
- Connection to the wrong gas source
- Leak in the hose
- Obstruction of the hose

• Cylinder malfunctions include:

- Empty cylinder
- Wrong gas in the cylinder [15]
- Attachment of the cylinder to the wrong yoke

• Malfunctions in the high-pressure sections of the anesthesia workstation (between the

compressed gas inlets and the flowmeters) include:

- Leak
 - Cross connection to the wrong flowmeter
- Obstruction

● Prevention – Verify that the piped gas pressures are ≥45 and not >55 pounds per square inch
gauge (psig) (equivalent to 310 to 380 kilopascals [kPa]), and that pressure is adequate on the
spare oxygen cylinder gauge mounted on the anesthesia machine ( table 1). (See 'American
Society of Anesthesiologists Anesthesia Machine Checkout' above.)

Wrong gas administration due to a misconnection of pipeline tubing or a cylinder that was filled
with the wrong gas would be difficult to detect. Notably, this situation is very rare, but potentially
devastating. This is another reason to calibrate the oxygen analyzer as part of the pre-use
checkout of the anesthesia machine, thereby ensuring that the oxygen analyzer reads 21 percent
in-room air and >90 percent when the breathing system is flushed with oxygen ( table 1). The
oxygen analyzer is the only device that can definitively tell the anesthesiologist what percent
oxygen is being delivered to the patient. (See 'Standardized anesthesia machine checkout' above
and 'Oxygen analyzer' below.)

● Diagnosis – There is only an alarm for low oxygen supply pressure. If the supply pressure of any
gas is low, the flowmeter reading for that gas will be lower than the expected setting, or even
zero. Gauges on the anesthesia workstation show the pressures of all compressed gases.
Pipelines should nominally supply gases at 45 to 55 psig (310 to 380 kPa). A full oxygen cylinder
has a pressure of 2000 psig (13,790 kPa) and contains 625 L of oxygen; however, cylinder gauges
show the correct pressure only if the cylinder is open.

An inspired oxygen alarm (low or high) may indicate wrong gas administration due to
misconnection anywhere in the gas supply chain (eg, wrong gas in cylinder, wrong gas in the
pipeline, misconnected hose). Wrong gas administration should be suspected whenever steady-
state gas concentrations in the breathing circuit are dramatically different than those predicted
from compressed gas flowmeter settings.

● Response – In the event of low oxygen supply pressure during a case, open the oxygen cylinder,
conserve anesthesia machine oxygen supply (turn off auxiliary flowmeter if in use, lower fresh
gas oxygen flow, turn off pneumatically driven ventilator), and obtain additional backup cylinders.

In the event of a wrong gas coming from the oxygen pipeline, it is critically important to
disconnect the anesthesia machine from the oxygen pipeline source and open the backup
cylinder. If the backup cylinder is opened while the pipeline source is still connected the problem
will persist since gases are preferentially drawn from the pipelines instead of the cylinders (ie,
cylinder pressures are reduced to ≤45 psig by a regulator inside the anesthesia machine). If low
oxygen supply pressure is a persistent problem, disconnect the patient from the anesthesia
machine and initiate positive pressure ventilation with a self-inflating manual ventilation device
attached to a fresh oxygen cylinder (see 'Backup equipment for oxygenation and ventilation'
below). Do not use the auxiliary oxygen flowmeter on the anesthesia workstation since it has the
same oxygen source as the anesthesia breathing circuit.
Compressed gas flowmeter malfunction — There are no specific alarms for the compressed gas
flowmeters (ie, the fresh gas flowmeters). Compressed gas flowmeter malfunction may trigger the
apnea-pressure alarm and the low inspired oxygen alarm ( table 5 and table 11).

● Potential problems – While many new workstations have electronic flowmeters, some new and
most older anesthesia machines have glass flowmeters ( figure 3). Glass flowmeters may be
more prone to malfunction due to physical issues (eg, contamination, leaks, cracks) compared
with electronic flowmeters.

• Miscalibration – All flowmeters are factory calibrated for a specific gas based on that gas's
density, viscosity, and specific heat; thus, any flowmeter gives incorrect readings for other
gases. Glass flowmeters consist of a tube and a float that are calibrated as a matched set, and
register incorrect readings if mismatched. Also, dirt, oil, or water contamination and static
electricity buildup can cause incorrect readings.

• Leak – Flowmeters may become cracked, broken, or loosened, resulting in a leak in that
flowmeter and any upstream flowmeters. For this reason, oxygen flowmeters are always
positioned downstream, so that oxygen will not be lost unless the leak is in the oxygen
flowmeter itself ( figure 6).

● Prevention – Flowmeter malfunctions are very rare with the glass and electronic flowmeters
installed on newer anesthesia machines. For this reason, checks of flowmeter function have been
removed from the standard American Society of Anesthesiologists (ASA) Anesthesia Machine
Checkout Recommendations [7].

● Diagnosis – A flowmeter leak is easily detected with a pre-use negative pressure leak test. In this
test, with all compressed gas flows set to zero, a suction bulb is attached to the anesthesia
machine common gas outlet and repeatedly squeezed until it collapses ( picture 1). The bulb
will not stay collapsed if there is a leak in any low-pressure components internal to the anesthesia
machine, which includes the flowmeters. A leak in the circle breathing system may alert the
clinician to a flowmeter leak ( table 5), while unexpected gas concentrations in the breathing
circuit may alert the clinician to a flowmeter leak or a calibration problem ( table 11).

However, this suction bulb leak test will not detect all leaks that can occur within the anesthesia
machine. Depending on machine design, certain types of leaks can occur in components that are
encased within the interior of the machine and are inaccessible to clinicians [16]. It is also important to
check for a leak by pressurizing the breathing system, as explained below. (See 'Breathing system leak'
below.)

● Response – If water is seen in the glass flowmeter, cracks in glass flowmeters are noted during
the anesthesia machine checkout, or inaccurate flowmeter readings are suspected then the
machine should be taken out of service in order to correct the problem ( table 1).

During a case, if the pressure in the breathing circuit cannot be maintained or the gas
concentrations in the breathing circuit cannot be controlled, initiate positive pressure ventilation
 with a self-inflating manual ventilation device and an auxiliary oxygen cylinder until a new
anesthesia machine is available. (See 'Backup equipment for oxygenation and ventilation' below.)

Proportioning system or pressure sensor shut-off (fail-safe) valve malfunction — Proportioning

system or pressure sensor shut-off valve (also called fail-safe valve) malfunction could trigger a low
inspired oxygen alarm ( table 11).

● Potential problems – Each anesthesia workstation has components to prevent administration of

a hypoxic gas mixture. A proportioning system ( figure 3) prevents the user from setting a
hypoxic mixture of oxygen and nitrous oxide. A separate pressure sensor shut-off mechanism
automatically turns off the flow of N2O if the oxygen supply pressure is lost. Rare mechanical
failures may occur in these components that would allow administration of a hypoxic gas
mixture.

● Prevention – To test the proportioning system function during the pre-use machine checkout,
attempt to create a hypoxic mixture by turning up the N2O flow while the oxygen flowmeter is off.
A functioning proportioning system will either keep the N2O flow off or automatically turn on the
oxygen flow, depending on the manufacturer of the workstation.

To test the function of the pressure sensor shut-off mechanism during the pre-use machine
checkout, close the backup oxygen cylinder and disconnect the oxygen pipeline connector while
all gases (eg, oxygen, air, N2O) are flowing. A functioning mechanism will automatically decrease
or turn off the flow of N2O, and in some workstations will also turn off the flow of air, in
synchrony with the decrease in oxygen flow.

Failure or malfunction of these internal components is rare. For this reason, tests of
proportioning system and pressure sensor shut-off valve function have been removed from the
ASA Anesthesia Machine Checkout Recommendations ( table 1).

● Diagnosis – Proportioning system or pressure sensor shut-off valve malfunction is suspected if a

lower than expected fraction of inspired oxygen (FiO2) is noted during the pre-use machine
checkout.

During a case, FiO2 is predictably less than the set FiO2 whenever the fresh gas flow is less than
the patient's minute volume, because of rebreathing. At very low fresh gas flows, this can result
in hypoxic inspired oxygen levels within the breathing system, regardless of functioning
proportioning and pressure sensor shut-off systems [17]. Therefore, the fresh gas flow should be
increased as the first step if the FiO2 is lower than the set value, rather than assuming that there
may be a proportioning system or fail-safe valve malfunction.

● Response – If a malfunctioning fail-safe valve or proportioning system is detected, the machine

should be taken out of service in order to correct the problem.

These components are quiescent safety devices that are only active in specific situations. They do
not affect the normal function of the anesthesia workstation. If only oxygen is administered, the
 workstation can be used for the remainder of the case in the unlikely event that such a
malfunction is detected after beginning anesthetic administration.

Vaporizer malfunction — Vaporizer malfunction may trigger the apnea-pressure alarm and the low
inspired anesthetic agent alarm ( table 5 and table 13).

● Potential problems – Vaporizer malfunctions may occur due to human errors during refilling or
installation. Although newer anesthesia workstations have automated leak check procedures,
these do not check for a vaporizer leak or a leak at the vaporizer manifold unless that vaporizer
control is dialed to the "on" position.

Newer vaporizers have features to prevent errors. All have keyed filling systems that discourage
refilling the vaporizer with the wrong agent; many have filling systems containing a one-way
valve that does not leak when left open. Injector vaporizers, such as all those for desflurane and
those that inject liquid anesthetics into the fresh gas flow stream, are unlikely to leak. Some
vaporizers alarm when empty.

Common user errors include:

• Failing to refill the vaporizer

• Refilling the vaporizer with the wrong agent [18]
• Failing to close the filler port, resulting in a leak in the breathing system (see 'Breathing
system leak' below)

Another user error is failure to turn on the vaporizer (eg, after transport of an unconscious
intubated patient into the operating room), resulting in awareness with recall of the surgical
procedure. There is no standard alarm warning of absence of a volatile anesthetic agent [19].

Vaporizers are installed on the anesthesia workstation, typically by the anesthesia provider,
technician, or assistant. Installation errors may occur due to:

• Improper seating of a compatible vaporizer on the manifold of the anesthesia machine (eg,
without an O-ring or askew)
• Installation of a vaporizer that is incompatible with the anesthesia machine
• Installation of a vaporizer in a way that defeats the interlock mechanism that normally
prevents turning on more than one vaporizer at a time (eg, if two vaporizers are mounted on a
manifold that normally accommodates three vaporizers, with a gap in the middle)

True vaporizer malfunctions include:

• Output of very high concentrations due to tipping or mechanical impact [20]

• Minor miscalibration due to pumping effect or fresh gas flow effects
• Leaks
• Electrical failure or electronic control failure [21]
• Mechanical failure of vaporizer interlock mechanism
 ● Prevention – A crucial pre-use step in the anesthesia machine checkout is to ensure that all
vaporizers are filled, closed, and not leaking. Also, the leak check, either during the anesthesia
workstation automated checkout or using a suction bulb, requires checking for a leak with each
vaporizer dialed on (one at a time). Furthermore, alarm settings for high and low inspired
anesthetic agent concentrations can be set ( table 13).

● Diagnosis – Vaporizer misuses and malfunctions are more likely to cause output of a volatile
anesthetic that is too low rather than too high. Low inspired anesthetic agent concentration may
result in awareness, as well as signs of "light" anesthetic depth (eg, patient movement,
tachycardia, hypertension, sweating) and/or a low inspired anesthetic agent alarm ( table 13)
(see "Accidental awareness during general anesthesia", section on 'End-tidal anesthetic
concentration'). A leaking or open vaporizer will create a breathing circuit leak that occurs as
soon as the vaporizer is turned on ( table 5).

● Response – The problem may be resolved if an empty or loosely capped vaporizer is found and
fixed, or the vaporizer can be properly remounted. Vaporizers are easily removable so that a
defective vaporizer can be removed from service for repairs. In such cases, anesthetic care can be
continued with a replacement vaporizer, or a different vaporizer already mounted on the
workstation, or with administration of intravenous agents.

If a large leak does not resolve after vaporizer removal, discontinue use of the anesthesia
workstation and initiate positive pressure ventilation with a self-inflating manual ventilation
device and an auxiliary oxygen cylinder. (See 'Backup equipment for oxygenation and ventilation'
below.)

Circle breathing system malfunction — In the United States, the majority of general anesthetics are
delivered with a circle breathing system ( figure 4 and figure 2 and figure 5). Both leaks and
obstructions may occur in a circle system.

Breathing system leak — A large breathing system leak should trigger an apnea alarm: apnea-
pressure, apnea-flow, and/or apnea-carbon dioxide (CO2) alarm ( table 4 and table 5 and
table 6 and table 7). The algorithm provides a systematic response to an apnea-pressure alarm
( algorithm 1).

● Potential problems – A large breathing system leak (or a disconnection) is a major malfunction
that prevents positive pressure ventilation and anesthetic gas delivery [12]. Small and moderate
leaks can be overcome by increasing fresh gas flow, but can cause anesthetic gas pollution of the
operating room. Leaks can occur in many breathing system locations including:

• Cracks in disposable tubing

• Loose tubing connection sites
• Loose or cracked gas analyzer sample line
• Poorly seated oxygen sensor
• Cracked or poorly seated CO2 absorbent container [22]
• Cracked or loose unidirectional valve housing
 • Hole in the reservoir bag
• Incompetent adjustable pressure-limiting (APL or "pop-off") valve
• Leaks or disconnects internal to the anesthesia machine (eg, flowmeters, tubing, vaporizers)

● Prevention – Many anesthesia machines test for a circuit leak during the self-test. A quick
manual circuit leak test may be performed by occluding the Y-piece and pressurizing the
breathing system by pressing the oxygen flush with the reservoir bag attached. However, this
circuit leak test is relatively insensitive to small leaks (eg, <100 mL/minute with a generated
pressure of 30 cmH2O) and does not detect internal leaks in some anesthesia machines.

Thus, in anesthesia machines that do not perform an automated leak test, we instead employ a
more sensitive method to test for leaks. This involves removing the reservoir bag and occluding
the circuit at both the Y-piece and the site of the reservoir bag connection, then pressurizing the
breathing system by slowly turning up the oxygen flow. With this test, the leak rate is the oxygen
flow rate at the point where the circuit pressure remains steady at 30 cmH2O. This method also
tests for internal leaks in the anesthesia machine that are downstream of the flow meters,
including those caused by an anesthetic vaporizer with a dial that is turned on (see 'Vaporizer
malfunction' above). A leak >50 mL/min at 30 cmH2O should prompt a search for the source of
the leak.

Notably, newer machines have few visible connections to the fresh gas outlet, ventilator,
scavenging system, or airway flow and pressure analyzers. Thus, there is a low risk of
misconnection, which was historically a relatively common source of gas delivery system
malfunction [23]. These newer anesthesia machines use sensitive methods during the automated
pre-use checkout to measure any breathing system leak and the compliance of the system. While
the specific method depends on the make and model of the anesthesia workstation, in most
cases the breathing circuit is pressurized with the reservoir bag in place, and the machine adjusts
the flow of gas into the breathing circuit to maintain a stable circuit pressure as measured by a
sensitive electronic gauge. However, as noted above, these automated machine pre-use checks
will not detect a leak in the vaporizer or its manifold unless repeated with each vaporizer turned
on. (See 'Vaporizer malfunction' above.)

● Diagnosis – A large leak manifests as an empty reservoir bag or ventilator bellows (with inability
to ventilate due to leakage of respiratory gases), as well as sounding of apnea alarms ( table 6
and table 7 and table 4 and table 5). During anesthetic administration, new onset
breathing system leaks are most commonly due to an imperfect seal or disconnection around the
patient's airway device (eg, facemask, laryngeal mask airway [LMA], or endotracheal tube [ETT]).
After rapidly ruling out this most common cause, the potential problems listed above must be
rapidly checked (eg, hole in the breathing system tubing, disconnection of the tubing, open or
leaking vaporizer).

● Response – Switch to manual ventilation, fill the breathing circuit with oxygen flush or high fresh
gas flows, look for a breathing circuit disconnection, and briefly disconnect the patient from the
breathing circuit to perform a circuit leak test, as described above. If the cause is not immediately
found and fixed, discontinue use of the anesthesia workstation and initiate positive pressure
 ventilation with a self-inflating manual ventilation device and an auxiliary oxygen cylinder. (See
'Backup equipment for oxygenation and ventilation' below.)

Fresh gas decoupled breathing systems, found on modern Dräger (ie, Draeger) anesthesia
machines ( figure 5 and figure 7), do not pressurize the absorbent canister or reservoir bag
during mechanical ventilation. If a large leak occurs in the canister or the reservoir bag is
missing, the patient can be mechanically ventilated, but room air will be entrained [22,24].

Breathing system obstruction — Breathing system obstruction is a rare but severe malfunction
( table 4 and table 5 and table 6 and table 7).

● Potential problems – Obstruction may occur due to user error, malfunction of a unidirectional
valve, defects in the breathing system hose or CO2 absorbent canister.

● Prevention – A crucial step in the pre-use anesthesia machine checkout is to verify that gas flows
properly through the breathing system during both inspiration and exhalation ( table 1). This is
accomplished by connecting a second reservoir bag at the patient Y-piece connection site to
serve as a "test lung," and then ensuring that breaths can be delivered both manually and with
the anesthesia machine ventilator without evidence of obstruction manifesting as inability to
inflate the test lung, high airway pressure, or slow emptying of the test lung.

● Diagnosis – Obstruction manifests as inability to manually ventilate due to obstruction to air flow
(or a non-moving ventilator bellows), as well as sounding of apnea alarms ( table 6 and
table 7 and table 4 and table 5), and sometimes high or continuous airway pressure
alarms ( table 8 and table 9), depending on the site of the obstruction.

Diagnosis must rule out obstruction due to patient-related issues, which are more common.
Examples include bronchospasm, endobronchial intubation, or a problem with the ETT such as
kinking or mucous plugging.

● Response – Check for user errors that can obstruct the breathing system (eg, an occlusive plug
that was left on the inspiratory port during the pre-use checkout procedure ( picture 2), CO2
absorbent that was placed in the absorbent container without unwrapping the product,
disposable tubing wrapping getting caught at a connection site, backward insertion of a
unidirectional positive end-expiratory pressure [PEEP] valve into the breathing circuit). Also, check
for visual evidence of a unidirectional valve that might be stuck in the closed position or a
manufacturing defect affecting patency of the disposable tubing. During long cases, water can
accumulate in breathing circuit hoses or the absorbent canister [25], causing low-grade
obstruction or inadvertent PEEP.

If the cause is not immediately found and fixed, discontinue use of the anesthesia workstation
and initiate positive pressure ventilation with a self-inflating manual ventilation device and an
auxiliary oxygen cylinder. (See 'Backup equipment for oxygenation and ventilation' below.)

Carbon dioxide absorbent exhaustion or toxicity — Carbon dioxide (CO2) absorption is used in all
circle breathing systems ( figure 4 and figure 2 and figure 5) to prevent hypercapnia due to
rebreathing of CO2 in previously exhaled gas [26]. These absorbents all contain calcium hydroxide,
which ultimately reacts with the CO2 to yield calcium carbonate. Older types of absorbents (eg,
Baralyme, soda lime) contain strong bases (eg, sodium hydroxide, potassium hydroxide, barium
hydroxide), which accelerate this process by reacting with CO2 to form a carbonate. These strong bases
can also react with volatile anesthetics to form toxic substances.

Newer types of absorbents (eg, Amsorb, LoFloSorb, SpiraLith) do not contain such strong bases and
thus do not react with volatile anesthetic agents.

● Potential problems

• Exhaustion – Failure to change the absorbent when it is exhausted leads to CO2 rebreathing
and hypercarbia. Absorbents become exhausted more quickly if fresh gas flow rates are low
[27]. Absorbents become less alkaline as they absorb carbon dioxide, and an incorporated
colorimetric pH indicator changes color to purple, signaling that the absorbent is exhausted.
Notably, soda lime reverts to white during periods of non-use even though it remains
exhausted. An alternative to using the indicator to guide when to change the absorbent is to
change the absorbent when the inspired CO2 concentration reaches around 5 torr or 0.05
percent.

A risk associated with changing an absorbent canister during use is that an unintended leak
can be introduced if the canister is cracked [22]. A temporary method to overcome increasing
levels of inspired CO2 due to exhausted absorbent is to increase the fresh gas flow rate until
the absorbent can be exchanged.

• Reaction with volatile anesthetic agents – Barium hydroxide lime and soda lime absorbents
contain strong bases that react with volatile anesthetic agents, particularly when the
absorbent becomes desiccated. Absorbent desiccation occurs when fresh gas is left flowing
into the breathing system during periods of non-use, especially if the reservoir bag is not
attached. All volatile anesthetics can break down to produce carbon monoxide (desflurane >
isoflurane > sevoflurane) and heat. Enough heat has been produced by the reaction of
sevoflurane with desiccated barium hydroxide lime to cause combustion within the absorbent
canister [28,29] (see "Fire safety in the operating room", section on 'Other potential ignition
sources'). Because of these concerns, Baralyme has been removed from the United States
market.

In addition, sevoflurane can break down in desiccated soda lime to produce Compound A,
which is nephrotoxic in rats. However, no clinically significant renal toxicity has been observed
in humans (see "Maintenance of general anesthesia: Overview", section on 'Sevoflurane').
Regardless, the sevoflurane package insert (US Food and Drug Administration [FDA]
mandated) states that fresh gas flows of at least 2 liters per minute must be used for cases
more than two hours duration to limit exposure to Compound A. In our practice, sevoflurane
is administered at low flow with absorbents (eg, Amsorb, LoFloSorb, SpiraLith) that do not
contain strong bases.
 Because of these potential reactions, less reactive absorbents are used in many institutions.

• Dust – Absorbents can release dust into the breathing system that can become deposited on
valves causing them to fail over time [30].

● Prevention

• Exhaustion – The color of the absorbent should be checked during the pre-use checkout and
at the end of each case. If it is violet, purple, or blue, rather than white, then the absorbent
should be replaced before the case ( table 1) unless it is in a quick-connect canister. Some
anesthesia workstations have quick-connect absorbent canisters designed to be exchanged
during an anesthesia case so that it is safe to continue use of the partially exhausted
absorbent temporarily, until inspired CO2 reaches some threshold value (typically 5 mmHg).

• Reaction with volatile anesthetic agents – Since there is no easy way to identify desiccation
of CO2 absorbent, the canister should be changed if the anesthesia provider or technician
notices that compressed gas flow (eg, oxygen, air, or N2O flow) was left on during a period
when that anesthesia workstation was not in use. Low alkalinity absorbents may change color
when desiccated but are still safe to use [31].

● Diagnosis

• Exhaustion – High inspired CO2 will be evident on the capnometer, an anesthesia monitoring
standard that may be integrated into the anesthesia workstation. If properly set, a high
inspired CO2 alarm alerts the clinician regarding exhausted CO2 absorbent ( table 12). The
diagnosis is confirmed if the problem disappears after increasing the fresh gas flow.

• Reaction with volatile anesthetic agents – There is no easy way to test for the presence of
carbon monoxide or Compound A in the breathing circuit, but there may be other signs of
anesthetic breakdown such as low agent concentration in the breathing system, high
temperature of the absorbent canister, or color change of the absorbent at the opposite end
of where it typically changes color [31]. Although the patient exposed to high levels of carbon
monoxide will have high carboxyhemoglobin levels measured by co-oximetry, the signs of
carbon monoxide poisoning in an anesthetized patient are typically too subtle to detect.

● Response

• Exhaustion – If absorbent exhaustion is suspected, increase the fresh gas flow rate
immediately to reduce rebreathing until the inhaled CO2 concentration drops below 5 mmHg,
and increase minute ventilation as needed to reduce exhaled CO2. If inspired CO2 is not rapidly
educed by these measures, the problem is CO2 rebreathing from another source, such as an
incompetent one-way valve.

• Reaction with volatile anesthetic agents – If anesthetic agent breakdown by desiccated

absorbent is suspected, change the absorbent immediately (while ventilating with a self-
inflating manual ventilation device and an auxiliary oxygen cylinder while the breathing circuit
 is opened to rapidly change the absorbent). Then administer 100% oxygen to the patient and
obtain a venous or arterial blood gas with co-oximetry to check for carboxyhemoglobin.

Valve malfunctions

Adjustable pressure-limiting valve — The adjustable pressure-limiting (APL) valve, also known
as the "pop-off" valve, is the interface between the breathing system and the scavenger system during
spontaneous or manual ventilation ( figure 4 and figure 2 and figure 5). This valve allows the
anesthesia provider to control how much gas exits the breathing system, which is one of the factors
determining the gas volume and pressure within the reservoir bag during this mode of ventilation.

● Potential problems – Although the APL valve rarely malfunctions, it can remain open when its
control knob is closed [32] (resulting in a massive circuit leak) or fail to open after closure
(resulting in excessive continuous airway pressure). APL valve settings may not be linear, so the
dial position does not necessarily set a dependable airway pressure. Thus, continuous monitoring
of airway pressure is necessary [33].

● Prevention – The APL valve is checked during the pre-use checkout by pressurizing the breathing
system (which tests that the APL valve closes and does not leak), and then opening the APL valve
and observing that the breathing system pressure falls to zero (which tests that the APL valve
opens fully).

● Diagnosis – An incompetent (leaking) APL valve should be suspected if there is a large circuit leak
with an inability to generate positive pressure by squeezing the reservoir bag, particularly if other
possible sites of disconnection have been ruled out. It can be confirmed by filling the bag with
the oxygen flush and observing a rush of gas into the scavenger system when the bag is
squeezed. Notably, the APL valve is included in the breathing circuit only during the
spontaneous/manual ventilation mode.

An obstructed APL valve should be suspected if inspiratory and expiratory pressures build up in
the breathing circuit when the APL valve is open.

● Response – If the APL valve is stuck in either the open or closed position, ventilation is not
possible in the spontaneous/manual ventilation mode. However, ventilation should be possible
by switching to a controlled ventilation mode.

A reasonable alternative is to discontinue use of the anesthesia workstation and initiate positive
pressure ventilation with a self-inflating manual ventilation device and an auxiliary oxygen
cylinder, and administer intravenous anesthetic agents. (See 'Backup equipment for oxygenation
and ventilation' below and "Maintenance of general anesthesia: Overview", section on 'Total
intravenous anesthesia'.)

Unidirectional (inspiratory and expiratory) valves — Inspiratory and expiratory one-way

valves ( figure 4 and figure 2 and figure 5) prevent rebreathing of previously exhaled CO2.

● Potential problems – If a unidirectional valve is incompetent, it may not close completely, which
results in the patient inhaling CO2. In particular, expiratory valve incompetence may result in a
 high concentration of inspired CO2 because of the large volume of exhaled gas that is contained
in the tubing and reservoir bag on the expiratory side of the breathing system.

● Prevention – Presence of the unidirectional valves should be confirmed during the pre-use
check. Proper function of unidirectional valves may not be detected during a pre-use check since
subtle valve incompetence is difficult to recognize with visual inspection. However, unidirectional
valve incompetence can be detected using the three-step modified pressure decline method [34],
which is not a part of the ASA Anesthesia Machine Checkout Recommendations ( table 1). This
method may not be used daily during a pre-use check, but the procedure should be performed at
regular intervals by a trained technician.

The test must be performed after routine system leak checks. Step 1 tests for inspiratory valve
occlusion: With fresh gas flows set to zero and the APL valve closed, a second reservoir bag is
attached to the inspiratory hose mount and the circuit is pressurized to 30 cm H20 with the
oxygen flush. If the second reservoir bag does not inflate, then the inspiratory valve is occluded.
Step 2 tests for expiratory valve incompetence: If the primary reservoir bag on its normal mount
starts deflating over 20 seconds (ie, faster than it deflated during the routine breathing circuit
pressure test), then the expiratory valve is incompetent. Step 3 tests for inspiratory valve
incompetence: The APL valve is opened. If the secondary reservoir bag starts deflating over 20
seconds, then the inspiratory valve is incompetent [34].

● Diagnosis – Manifestations of unidirectional valve incompetence include an increasing

inspiratory CO2 level that does not decrease when the fresh gas flow is turned up ( table 12), as
well as delayed return or failure of the capnogram to zero before onset of the next inspiration, as
shown in the figure ( figure 8) (see "Basic patient monitoring during anesthesia", section on
'Capnography'). Some anesthesia machines also have flowmeters in the inspiratory and/or
expiratory limb of the breathing circuit that generate an alarm if flow in the wrong direction is
detected.

Unidirectional valves can also become stuck in the closed position, resulting in obvious total
occlusion of the breathing system. (See 'Breathing system obstruction' above.)

● Response – If valve incompetence is detected during use, minute ventilation can be increased to
compensate for CO2 rebreathing. If the amount of rebreathing is too large to be safely tolerated
by the patient, the anesthesia machine should be taken out of service ( table 1). In such cases,
initiate positive pressure ventilation with a self-inflating manual ventilation device and an
auxiliary oxygen cylinder until a replacement anesthesia machine is available. (See 'Backup
equipment for oxygenation and ventilation' below.)

Positive end-expiratory pressure valve — In modern anesthesia machines, electronically-

controlled positive end-expiratory pressure (PEEP) valves are integrated into the anesthesia ventilator
(eg, ventilator-controlled PEEP/maximum pressure valve in the figure ( figure 2) and PEEP/Pmax
valves and PEEP/APL valve in the figures ( figure 5 and figure 7 and figure 9)). In older
machines built prior to 2000, mechanical PEEP valves were built into the breathing system, or even
added to the breathing system on an as needed basis.
 ● Potential problems – The primary hazard of all types of PEEP valves is that PEEP may be
unknowingly enabled if the ventilator settings remain unchanged after a previous case, rather
than being reset for the current patient.

Additional hazards for removable mechanical valves that were inserted into the expiratory limb of
the breathing system include:

• Erroneous insertion into the inspiratory limb of the breathing circuit, resulting in no PEEP.

• Backward insertion into either the inspiratory or expiratory limb of the breathing circuit,
causing complete obstruction of flow if the valve only allows unidirectional flow.

• Failure to recognize that PEEP is not registering even though the patient is receiving PEEP. This
can occur when the airway pressure gauge senses pressure downstream of the PEEP valve
(eg, in the CO2 absorbent canister or within the expiratory tubing mount).

● Prevention – During the pre-use checkout, verify that the airway pressure declines to zero during
exhalation. If not, check for the cause of inadvertent PEEP.

● Diagnosis – Unexpected PEEP is indicated on the airway pressure gauge, and fluctuations in end
expiratory pressure may indicate a sticking or malfunctioning valve [30]. A continuous airway
pressure alarm may be triggered for high PEEP ( table 9).

If PEEP is enabled due to settings used in a previous case, this typically results in a stable end
expiratory airway pressure over multiple breaths. Conversely, an obstruction in the breathing
system exhaust (at the APL valve, ventilator relief valve, or scavenger) results in a gradually
increasing level of PEEP proportional to the fresh gas flow rate into the breathing circuit.
Complete obstruction to flow in the expiratory limb of the breathing circuit results in a rapid
increase in PEEP up to the level of the peak inspiratory pressure.

● Response — In the event of very high PEEP levels (>20 cmH2O), the patient should be rapidly
disconnected from the breathing system to prevent barotrauma and cardiovascular collapse. The
patient can then be reattached for two breaths to attempt to find the source of the obstruction. If
the source is not quickly found and fixed, then positive pressure ventilation is initiated with a self-
inflating manual ventilation device and an auxiliary oxygen cylinder until a replacement
anesthesia machine is available. (See 'Backup equipment for oxygenation and ventilation' below.)

Ventilator malfunction — Anesthesia ventilators and breathing systems facilitate some rebreathing
of previously exhaled gas (after removal of CO2), unlike intensive care unit (ICU) ventilators that deliver
fresh gas during every breath.

Modern anesthesia ventilators are controlled by embedded computer processors that use sensor
feedback from the breathing system to provide many of the same modes of ventilation used in the
ICU. (See "Mechanical ventilation during anesthesia in adults".)

Anesthesia ventilator and breathing system technology has changed dramatically since 2000, and
various manufacturers have taken adopted radically different designs ( figure 5):
 ● Anesthesia machines manufactured by GE Healthcare (formerly Datex-Ohmeda), as well as many
older anesthesia machines, have a traditional circle breathing system and a ventilator that
powers a bellows ( figure 4 and figure 10). In these machines, the ventilator delivers drive
gas during the inspiratory phase, which compresses the bellows containing respiratory gases.
During the expiratory phase, the ventilator releases drive gas into the room, thereby allowing the
bellows to re-expand with exhaled gas from the patient. The bellows expands until full and the
pressure within exceeds the pressure outside by more than 3 cmH2O, whereupon excess gas exits
the breathing circuit via the ventilator relief valve. Thus, the bellows ventilator exerts a minimal
obligatory PEEP of 3 cm H2O.

● Anesthesia machines manufactured by Dräger (ie, Draeger) anesthesia workstations have a

nontraditional circle breathing system with a ventilator that is driven by a piston or a turbine,
rather than by drive gas outside of a bellows ( figure 2 and figure 5 and figure 7). These
ventilators are electrically powered and do not consume fresh gas; therefore, they continue to
function in the event of oxygen supply pressure loss (see 'Compressed gas supply malfunction'
above). Excess gas bypasses the APL valve and exits the breathing circuit into the scavenger
through a single very low-pressure (<1 cmH2O) exhaust valve. Thus, the ventilator exerts no
obligatory PEEP.

● Anesthesia machines manufactured by Getinge (formerly MAQUET) such as the Flow-i anesthesia
workstations have a volume reflector in place of a bellows. During inspiration, drive gas enters
the back-end of the reflector which compresses gas toward the patient so that there is minimal
mixing of patient gases with drive gases within the reflector. On exhalation, drive gas and excess
patient gas exit out the back-end of the reflector into the scavenger through a single very low-
pressure exhaust valve. Thus, the ventilator exerts no obligatory PEEP.

During mechanical ventilation, the ventilator relief valve (not the APL valve) is the interface between
the breathing system and the scavenger system. Examples are the ventilator exhaust valve and
ventilator-controlled exhaust valves in the figures ( figure 2 and figure 4), or the exhalation valve,
exhaust valve, and PEEP/APL valve ( figure 5) (see 'Waste gas disposal (scavenger) system
malfunction' below). Ventilator relief valves, unlike APL valves, do not open during the inspiratory
phase of ventilation. Thus, fresh gas flows continuously into a traditional circle breathing circuit,
thereby contributing to the patient’s total inspired tidal volume, and changes in the fresh gas flow can
significantly alter delivered tidal volume. Modern anesthesia machines use one of two approaches to
prevent changes in delivered tidal volume when fresh gas flow is changed:

● Dräger Fabius, Tiro, and Apollo workstations use modified "fresh gas decoupled" circle breathing
systems where fresh gas enters the breathing circuit upstream of the location of the ventilator
supply of inspiratory flow. Thus, fresh gas flow is isolated from inspired tidal volume ( figure 5).
On machines with a fresh gas decoupled breathing circuit, the oxygen flush can be activated
without affecting delivered tidal volume.

● All GE Healthcare anesthesia workstations, as well as the Getinge Flow-i and Dräger Persius
anesthesia workstations use fresh gas compensation to adjust the volume of drive gas or turbine
flow that is delivered ( figure 7 and figure 10 and figure 9). Older GE workstations adjust
 drive gas over sequential breaths to maintain a set inspired tidal volume. The Perseus, Flow-i, and
newer GE ventilators instantaneously adjust ventilator gas flow based on measured fresh gas
flow. Of the anesthesia machines with fresh gas flow compensation, only the Perseus
compensates during oxygen flush. In the others, activating the oxygen flush during ventilator
inspiration dramatically increases the delivered tidal volume.

● Potential problems – Anesthesia ventilators are relatively complex electromechanical devices

that are generally reliable but occasionally fail. There are over 150 reports from 2007 through
2016 in the FDA Manufacturer and User Facility Device Experience (MAUDE) database involving
the anesthesia ventilator. In many of these cases the ventilator suddenly stopped working, and in
some cases the screen suddenly went blank. Cell phones and ultrahigh frequency radio
communication devices may affect electronically controlled anesthesia ventilator output and
displays.

• Hypoventilation or apnea ( table 6 and table 7 and table 4 and table 5):

- Sudden cessation of ventilator activity, with or without loss of the integrated display
screen and alarm function [35]

- Loss of patient ventilation due to valve failure while the ventilator continues to cycle [36]

- User error by temporarily turning off the ventilator and forgetting to turn it back on

- Inadequate inspiratory pressure due to user error in setting the high pressure limit

- Leakage of patient gas from a hole in the ventilator bellows, improperly seated bellows,
break in the bellows housing, or malfunctioning ventilator pressure relief valve causing a
leak

- Addition of PEEP, which may decrease the delivered tidal volume in ventilators without
automatic adjustment of peak airway pressure

• Hyperventilation or high airway pressure ( table 8):

- User error in activating the oxygen flush during the inspiratory phase of ventilation

- Fresh gas flows that are too high during mechanical ventilation (this is possible only in
older anesthesia machines that do not have either a fresh gas compensated ventilator or
a fresh gas decoupled breathing system)

- Malfunctioning ventilator relief valve causing obstruction

- Obstruction in the scavenger system

• Dilution of anesthetic gas ( table 13):

- Entrainment of room air into the breathing system by a piston ventilator, turbine
ventilator, or a ventilator with a descending bellows
 - User error in refilling the breathing circuit after a disconnection using the oxygen flush.

- Leakage of drive gas into an improperly seated bellows or one with a hole

● Prevention – During the pre-use checkout, verify that the ventilator is able to ventilate a test lung
or second reservoir bag attached to the patient connector (Y-piece). Measured inhaled and
exhaled volumes should be approximately equal to the set tidal volume on the ventilator. If not,
check ventilator connections and function, and check inspiratory and expiratory valve function.
For example, an incompetent inspiratory valve will cause a lower than expected exhaled tidal
volume. The last step in the pre-use check is to confirm that ventilator settings are appropriate
for the patient.

Habits that decrease the chance of forgetting to resume ventilation after a temporary period of
apnea are employed to prevent user error. One technique is to disconnect the breathing circuit
rather than turning off the ventilator, leaving all apnea alarms active and all ventilator settings
intact. Another technique is to leave one's hand on the ventilator control during the period of
apnea or to hold one's own breath. Some anesthesia workstations have a control to temporarily
suspend ventilation for a fixed duration (typically one minute). It is never wise to disable apnea
alarms while ventilation is briefly suspended. The ventilator bellows should be refilled by
temporarily turning up the fresh gas flow rather than by pressing the oxygen flush.

Checklists are useful to ensure that ventilation is resumed after a more prolonged period of
apnea (eg, during weaning from cardiopulmonary bypass [CPB]). (See "Weaning from
cardiopulmonary bypass", section on 'Checklist'.)

● Diagnosis – Usually, problems with mechanical ventilation are resolved by switching to manual
ventilation (ie, moving the selector switch from "mechanical" to "spontaneous/manual"
ventilation). This maneuver replaces the bellows, piston, or turbine and the ventilator relief valve
with the reservoir bag and its APL valve. Thus, leaks and obstructions in the former are removed
from the system. If the problem is not resolved by switching to manual ventilation, then the
problem is probably not in the ventilator components of the system.

● Response – If the ventilator suddenly stops working, immediately switch to manual ventilation. If
the problem does not resolve rapidly, initiate positive pressure ventilation with a self-inflating
manual ventilation device and an auxiliary oxygen cylinder, and administer intravenous
anesthetic agents (see 'Backup equipment for oxygenation and ventilation' below and
"Maintenance of general anesthesia: Overview", section on 'Total intravenous anesthesia'). With
the patient disconnected, the anesthesia machine can be powered off and restarted; such a
"reset" may resolve the problem. If not, replacement of the anesthesia machine is the best
alternative.

Waste gas disposal (scavenger) system malfunction — The primary purpose of the waste anesthetic
gas disposal (WAGD) system (commonly termed the scavenger system) is to prevent excessive positive
or negative pressure at the outlet of the exhaust valves (ie, downstream of the APL valve and ventilator
relief valve) ( figure 11). The secondary purpose is to prevent venting of waste anesthetic gases into
the operating room; rather, these gases are evacuated from the building.

● Potential problems – The scavenger system can malfunction due to:

• Inadequate or absent suction flow (causing waste gas to leak into the room, resulting in room
pollution, and, in some makes of anesthesia workstations, additional PEEP in the breathing
circuit).

• Passive waste gas evacuation (eg, waste gas passed through activated charcoal) used with an
open scavenger interface.

• Exhausted activated charcoal (when used for waste gas capture).

• Excessive suction flow (causing background noise and wasting suction).

• High pressure at the breathing circuit exhaust valve (ie, APL valve or ventilator relief valve) due
to [37]:

- Inadequate scavenger suction flow if the outflow safety valve is obstructed or

- Scavenger obstruction proximal to the outflow safety valve.

This situation typically causes gradually increasing breathing circuit PEEP and peak airway
pressures, with the increase being more rapid with high fresh gas flow rates.

• High vacuum suction at the breathing circuit exhaust valve (ie, APL valve or ventilator relief
valve) due to a blocked inflow safety valve. This situation typically sucks gas out of the
breathing circuit, creating negative airway pressure. High vacuum suction at the breathing
circuit exhaust valve (ie, APL valve or ventilator relief valve) can paradoxically cause the valve
to become stuck closed, which increases breathing circuit PEEP and peak airway pressures.

• Misconnections to the breathing system (causing breathing system obstruction).

● Prevention – Scavenger system function should be checked daily to ensure that the suction flow
setting is adequate and the positive and negative pressure relief mechanisms are functioning
properly.

• With a closed scavenger system ( figure 12), the scavenger reservoir bag is usually totally
deflated, indicating that the vacuum is connected and the negative-pressure relief valve is
open. During the pre-use check, the outflow safety valve can be checked by opening the APL
valve, obstructing the Y-piece, and pressing the oxygen flush; this will cause gas to rapidly
pass out of the breathing circuit and into the scavenger system. With this test, the scavenger
reservoir bag should fill but not continue to inflate, which indicates that the scavenger system
is connected to the breathing circuit and that the positive-pressure relief valve is opening.

• With an open scavenger system, the vacuum flow should be adjusted so that the integrated
flowmeter float is between the two setting lines. During the pre-use check, scavenger
 openness can be checked by opening the APL valve, obstructing the Y-Piece, and pressing the
oxygen flush; the breathing circuit reservoir bag should fill but not inflate.

● Diagnosis – Malfunction of the scavenger system may be indicated by negative pressure in the
breathing system manifesting as an airway pressure less than zero, a collapsed reservoir bag or
bellows, and/or a negative airway pressure alarm ( table 10). Conversely, obstruction of the
scavenger system outflow and outflow safety valve may result in a hyper-inflated reservoir bag
and continuous airway pressure on the airway pressure gauge, as well as a continuous airway
pressure alarm ( table 9). (See 'Airway pressure' below.)

● Response – With a negative airway pressure alarm, immediately disconnect the patient from the
breathing system and ventilate with a self-inflating manual ventilation device and an auxiliary
oxygen cylinder until the source of the negative pressure is found and fixed (eg, scavenger
malfunction, gastric suction misplaced into the airway, suctioning during bronchoscopy)
( table 10).

Likewise, with a continuous airway pressure alarm, immediately disconnect the patient from the
breathing system and ventilate with a self-inflating manual ventilation device and an auxiliary
oxygen cylinder until the source of the obstruction is found and fixed (eg, scavenger system
obstruction or malfunction, or obstruction of the APL valve, ventilator relief valve, or expiratory
valve) ( table 9).

Leakage from the scavenger system is difficult to detect, but there may be a smell of anesthetic
agents in the room. Look for evidence that the scavenger system is not connected properly or
that the waste anesthetic gas vacuum is disconnected or turned too low. Conversely, a loud
background hissing from the scavenger system indicates that the vacuum is turned too high.

Mapleson breathing system malfunction — In the United States, Mapleson breathing systems are
used much less often than circle breathing systems during anesthesia, but are more commonly
employed for transport of small children and neonates. In other countries, a modified Mapleson D
system (the Bain system) is often used during anesthesia. Anesthesia providers using different types of
Mapleson circuits must be specifically trained in their use because different circuit configurations,
ventilation modes, fresh gas flow rates, and minute ventilation all interact to affect the partial pressure
of arterial CO2 (PaCO2) level. In general, high fresh gas flow rates must be used to prevent hypercapnia.

Modified Mapleson D (Bain) circuit — In a Mapleson D circuit, fresh gas enters near the patient
connector and the APL valve is located at the end of the corrugated tube that the patient breaths in
and out through, near the reservoir bag, or at the end of the reservoir bag itself. The Bain modification
has the fresh gas tube running inside the corrugated tube (a coaxial arrangement) ( picture 3).

● Potential problems – A particular hazard of the Bain circuit is that the inner fresh gas tube can
become detached from its connection at either end, develop a leak, or become obstructed. These
problems with the inner tube of the circuit may prevent fresh gas from flowing out of the distal
end of the system, which results in hypercapnia because the outer corrugated tube becomes
dead space.
 ● Prevention – To confirm the integrity of the inner tube, it should be occluded during the pre-use
check by placing a finger over the distal end while oxygen is set at a low flow. If the tube is
properly connected and intact, the oxygen flowmeter float will slowly fall due to the increasing
backpressure.

● Diagnosis – Capnometry is important when using any Mapleson circuit to adjust the end-tidal
CO2 by titrating the amount of CO2 rebreathing. For accuracy, the capnometer sample should be
taken as close to the patient's airway as possible (for instance, distal to the elbow connector or
from within the endotracheal tube) to minimize fresh gas dilution of exhaled gas. Some degree of
rebreathing is expected, which results in a distinctive capnogram, as shown in the figure
( figure 13). However, hypercapnia is typically prevented by increasing the fresh gas flow rate,
increasing minute ventilation, and decreasing the inspiratory to expiratory ratio.

In some patients, it may not be possible to achieve high enough fresh gas flow rates. Examples
include large patients, those with high metabolic rates (eg, fever, malignant hyperthermia), or if
there is malfunction preventing delivery of fresh gas flow to the distal end of the circuit (eg,
disconnected fresh gas line, leak in fresh gas line).

● Response – If end-tidal CO2 cannot be adequately controlled by increasing the fresh gas flow
rate, then the patient should be ventilated with another breathing system that includes valves
that prevent CO2 rebreathing (eg, a circle breathing system or a self-inflating manual ventilation
device and an auxiliary oxygen cylinder. (See 'Circle breathing system malfunction' above and
'Backup equipment for oxygenation and ventilation' below.)

Mapleson E (T-piece) circuit

● Potential problems – A particular hazard of the T-piece is that the expiratory port can become
occluded simply by placing a hand over it to inflate the lungs. This may lead to pulmonary
overinflation and barotrauma because:

• Gas will keep flowing from a flowmeter or anesthesia machine fresh gas outlet until the outlet
pressure is equal to the supply pressure (nominally 50 psig, which equals 3515 cmH2O)
( picture 4).

• There is no pressure-buffering effect of a reservoir bag in a T-piece, unlike other Mapleson

circuits or circle system.

• The clinician cannot accurately judge the airway pressure with tactile sensation of the hand
exposed to the expiratory port.

There are 11 reports of this type of overinflation and/or barotrauma injury in the ASA Closed
Claims database from 1990 through 2011; each of these incidents occurred with misuse of a
Mapleson E (T-piece) circuit or supplemental oxygen delivery outside the operating room [2].

● Prevention – The key to preventing overinflation or barotrauma by this mechanism is to

recognize that a flowmeter or anesthesia machine directly connected to the lungs will pressurize
to thousands of cmH2O. To prevent patient injury, there must always be an outlet for that
 pressure, as provided by the open end of a T-piece or a compliant reservoir bag or a safety
exhaust valve.

● Diagnosis – Injuries of this type result in pneumothorax, bilateral tension pneumothorax,

pneumomediastinum, cardiac tamponade, and cardiorespiratory collapse.

● Response – Prompt diagnosis and venting of the chest cavity (eg, needle decompression, chest
tubes) is potentially life-saving. (See "Intraoperative management of shock in adults", section on
'Tension pneumothorax or hemothorax' and "Intraoperative management of shock in adults",
section on 'Pericardial tamponade'.)

MALFUNCTION OF INTEGRATED ANESTHESIA MONITORS

Anesthesia workstations have integrated monitors that may malfunction. Each monitor displays
selected parameters on an integrated screen and has one or more alarms to alert the clinician to a
potential problem. (See 'Anesthesia workstation alarms' above.)

Oxygen analyzer — All anesthesia workstations must have an oxygen analyzer either in the
inspiratory limb of the breathing system, or in the multigas analyzer. These devices monitor the
fraction of inspired oxygen (FiO2). Some utilize an electrochemical (polarographic or galvanic) sensor
cell, and the FiO2 reading appears as a continuously updated digital display on the screen of the
anesthesia workstation. A low inspired oxygen alarm occurs if FiO2 falls below the lower set limit
( table 11). (See "Mechanical ventilation during anesthesia in adults", section on 'Fraction of inspired
oxygen'.)

Some newer anesthesia workstations have an integrated multigas analyzer that samples gas from the
airway and analyzes both inhaled and exhaled oxygen concentrations, as well as the concentrations of
other respiratory gases (eg, carbon dioxide [CO2], nitrous oxide [N2O], volatile anesthetic agents).
Typically, these multigas analyzers use a paramagnetic oxygen sensor that has a faster response time
than electrochemical ones.

● Potential problems

• Malfunctions of electrochemical oxygen analyzers may be caused by inaccurate calibration, an

exhausted sensor, or poor electrical connections (typically between the sensor and monitor).

• Malfunction of a paramagnetic oxygen analyzer may be caused by inaccurate calibration,

dilution of respiratory gases due to entrainment of room air through a leak in the sampling
line, or obstruction or disconnection of the sampling line.

● Prevention – Oxygen analyzer sensor cells must be calibrated at least once per day during the
pre-use checkout. Calibration is accomplished by exposing the sensor to room air after the
monitor has warmed up, and ensuring that the FiO2 reading is at 21 percent. An important
follow-up step is to then expose the sensor to 100 percent oxygen to ensure that the FiO2 reading
approximates 100 percent. If the reading is <90 percent, the sensor cell should be replaced
 before the next anesthetic administration. All sensor cells must be replaced at intervals for
proper function. Although they do not require frequent recalibration, the oxygen channel of a
multigas analyzer should also be checked daily with both room air and 100 percent oxygen. If
flushing with 100 percent oxygen does not result in a monitor reading of approximately 100
percent, a wrong gas situation should be strongly suspected and another analyzer should be
used to determine whether the oxygen flowmeter and/or oxygen flush are actually dispensing
oxygen. (See 'Compressed gas supply malfunction' above.)

● Diagnosis – During anesthetic administration, the FiO2 may fall below the lower set limit due to
causes such as compressed gas supply problems in the pipeline or cylinder (see 'Compressed gas
supply malfunction' above), flowmeter malfunction (see 'Compressed gas flowmeter malfunction'
above), proportioning system or fail-safe valve malfunction (see 'Proportioning system or
pressure sensor shut-off (fail-safe) valve malfunction' above), or air entrainment into the
breathing system (see 'Circle breathing system malfunction' above). At low fresh gas flow rates,
the FiO2 is less than the oxygen concentration set on the flowmeters (termed "delivered oxygen
concentration" [FdO2]) because of rebreathing of exhaled gas that has a lower oxygen
concentration than fresh gas. Because of this, the FiO2 may decrease below 21 percent over time
[17].

● Response – Immediately increase the oxygen flow rate and decrease the flow rate of other gases.
If FiO2 does not increase, check for possible wrong compressed gas administration (see
'Compressed gas supply malfunction' above); if confirmed, initiate positive pressure ventilation
with a self-inflating manual ventilation device and a fresh oxygen cylinder (see 'Backup
equipment for oxygenation and ventilation' below). Do not use the auxiliary flowmeter on the
anesthesia workstation since it has the same oxygen source as the breathing circuit.

Capnometer and respiratory gas analyzers — A capnometer measures the partial pressure of CO2 in
gas that is continuously sampled from the airway and displays both the nadir during inspiration and
the peak (end-tidal) CO2 values. The capnogram appears as a continuously updated waveform whose
shape contains information not necessarily apparent in the digital values ( figure 14 and
figure 15). Alarms for apnea ( table 7), high inspired CO2 ( table 12), and high and low end-tidal
CO2 are integrated into the anesthesia workstation. (See "Basic patient monitoring during anesthesia",
section on 'Capnography'.)

Some newer anesthesia workstations have multigas analyzers that measure CO2, N2O, and
halogenated anesthetic agent concentrations using infrared spectroscopy, as well as oxygen
concentration using a paramagnetic sensor (see 'Oxygen analyzer' above). These multigas analyzers
actually measure the partial pressure of each gas (mmHg or KPa), and calculate gas concentrations (%)
using the current barometric pressure measured by an integrated barometer. Inspired and exhaled
digital values for each gas are displayed, as determined from the inspiratory and expiratory timing of
the capnogram.

● Potential problems – Similar to O2 analyzers, inaccurate readings for end-tidal CO2 may be
caused by dilution of respiratory gases due to entrainment of room air via a leak in the sampling
 line. Obstruction or disconnection of the sampling line causes the apnea-CO2 alarm to sound
( table 7).

The following factors affect end-tidal CO2 readings:

• Although end-tidal CO2 generally correlates well with the partial pressure of arterial CO2
(PaCO2), a number of factors (eg, age, lung disease, surgical positioning) affect the capnogram
and can cause a significant and variable discrepancy ( figure 16). Thus, differences of 8 to 10
mmHg between end-tidal CO2 and PaCO2 may occur.

• CO2 and multigas analyzers are typically self-zeroing, which causes loss of the visual display of
the waveform at regular intervals.

• CO2 and multigas analyzers typically sample gases from the airway (termed sidestream
analyzers). Disconnection of the sample line will cause a leak in the breathing circuit and
analyzer readings of room air. Partial disconnection of the sample line will cause low
measured CO2 and anesthetic values due to room air entrainment during spontaneous
ventilation; during positive pressure ventilation the leak is phasic with the respiratory cycle,
which can result in a "steeple sign capnogram", as shown in the figure ( figure 17).

• Since CO2 and multigas analyzers draw respiratory gas through a sampling tube into an
analyzer chamber, a delay in the readout occurs due to transit time of gas through the
sampling tube. Also, some gas mixing occurs during its transit through the sampling tube
causing waveforms that are somewhat smoothed. Particularly when respiratory rate is rapid
(ie, >40 breaths per minute), inspired CO2 values may be artificially high and end-tidal CO2
values may be artificially low.

• Sidestream CO2 analyzers incorporate a water trap to protect the sensor optics from liquids.
This trap introduces a small false peak (ie, an artifact) during positive pressure ventilation in
the inspiratory section of the displayed capnogram, which may become more pronounced
when peak airway pressures are high ( waveform 1). Since the appearance of the artifact is
similar to the appearance of a capnogram of a patient who is "overbreathing" the set
ventilator parameters, the clinician may be prompted to unnecessarily administer a
neuromuscular blocking agent (NMBA) to stop patient effort [38].

● Prevention – Basic function of the capnometer can be confirmed during the pre-use check by
blowing into the sample line. Capnometers and multigas analyzers require periodic recalibration
by a service technician who samples calibration gas mixtures of known concentrations.

● Diagnosis – A false apnea-CO2 alarm occurs when the capnometer sample line becomes
disconnected ( table 7), but the clinician should confirm that ventilation is actually appropriate
by observing respiration, auscultating the chest, and thoroughly checking all respiratory monitors
and the pulse oximetry reading.

Obstruction of the sample line or a full water trap will typically trigger an obstruction alarm and
the analyzer will stop working until the obstruction is resolved. In this case, the capnogram
 tracing disappears and the analyzer displays a message alerting the clinician to change the
sample line and/or water trap.

● Response – In many cases, replacement of the capnometer sample line or sensor with the extra
equipment stocked in the anesthesia workstation will resolve problems with a false alarm.
Critically important responses to true alarms for apnea ( table 7) or high inspired CO2
( table 12) are described in the tables.

Airway pressure and flow measurements

Airway pressure — Airway pressure is visualized on a mechanical gauge, and an electronically

sensed pressure waveform is often shown on the screen of the anesthesia workstation; derived peak,
nadir (ie, peak end-expiratory pressure [PEEP]), and often mean airway and pause airway pressures are
often displayed as well. Alarms for high airway pressure ( table 8), continuous airway pressure
( table 9), and negative airway pressure ( table 10) are standard.

● Potential problems

• Mechanical airway pressure gauges can be inaccurately calibrated, which is usually apparent if
the needle on the gauge does not read zero when the breathing system is open to ambient
pressure.

• An electronic pressure sensor connected to the breathing system by a flexible tube can
become obstructed or disconnected.

• Airway pressure is usually measured at a permanent site within the breathing system of the
anesthesia machine (eg, at the patient side of the unidirectional inspiratory valve or the
unidirectional expiratory valve, or within the CO2 absorbent canister). These locations are not
ideal due to distance from the patient's airway. Thus, measurements may not accurately
indicate the patient's airway pressure if the breathing system becomes partially or totally
obstructed. Although airway pressure is most accurately measured at the closest connector to
the airway (eg, at the Y-piece connection site of the breathing system to the endotracheal tube
[ETT] or laryngeal mask airway [LMA]), disconnection of the breathing circuit is a risk with this
site.

● Prevention – The zero value of airway pressure is easily checked by opening the breathing circuit
to atmosphere at the patient connector. Basic function of airway pressure gauges is confirmed
when the breathing circuit is pressurized for a leak test. The pressure readings will not change if
the sensor is nonfunctional or if the sample line is disconnected or broken.

● Diagnosis – Although airway pressure sensor accuracy is not routinely checked by the user, most
newer anesthesia workstations have multiple pressure sensors, with alerts regarding the need
for service if sensor measurements are not in agreement.

● Response – Because so many alarms and ventilator settings are dependent on a functioning
airway pressure sensor, a case should not be started if a broken airway pressure sensor is
suspected.
 Airway flow — All anesthesia workstations have a device to measure exhaled tidal volume. Older
workstations typically incorporated respirometers that did not measure instantaneous flow. New
workstations have an airway flowmeter that does measure expiratory flow (typically within the
expiratory limb of the breathing circuit). Derived values that are displayed include respiratory rate, tidal
volume, and minute volume. Some workstations automatically adjust the volume dispensed from the
ventilator bellows during inspiration based on measured tidal volumes (ie, fresh gas compensation).

Some workstations measure both inspired and exhaled flows, which is necessary for displaying
pressure and flow volume loops. (See "Mechanical ventilation during anesthesia in adults", section on
'Pressure volume loops' and "Mechanical ventilation during anesthesia in adults", section on 'Flow
volume loops'.)

Some anesthesia machines have flowmeters that can detect flow direction, which is useful to diagnose
unidirectional valve malfunction.

● Potential problems

• Differential pressure sensor flowmeters can malfunction if the flow channel or tubing
becomes contaminated with liquid. The erroneous values can lead to hyper- or
hypoventilation of the patient during pressure-control volume guaranteed ventilation [39].

• Hotwire anemometers stop functioning if the wire filament burns out [40].

• Breathing circuit leaks can occur if the sensor housing breaks or cracks, or if the differential
pressure sensor lines become disconnected.

• Airway flowmeters are only accurate to ±15 percent because their readings are influenced by
the composition and humidity of the respiratory gases. Anesthesia workstations with an
integrated multigas analyzer can automatically correct flowmeter sensor readings. However, if
there is no integrated analyzer, the user typically must indicate which specific gas is being
used (eg, desflurane, N2O) to allow compensation for gas effects on flowmeter
measurements.

• Airway flow is most accurately measured at the airway opening, similar to airway pressure
(see 'Airway pressure' above). Tidal volumes derived from flows measured in the inspiratory
and expiratory limbs are overestimated by the amount of gas that is compressed in the
corrugated breathing tubes during positive pressure ventilation [41]. Some newer anesthesia
workstations apply corrections using measurements of tubing compliance obtained during
the automated pre-use checkout. If the tubing compliance changes after the checkout (eg, by
stretching out the tubing or adding additional tubing), then the derived tidal volumes will be
overestimated [10].

• Very small tidal volumes (eg, those used for neonates) may trigger a false apnea alarm. The
clinician must confirm that ventilation is actually appropriate by observing respiration,
auscultating the chest, and thoroughly checking all respiratory monitors, including CO2,
 airway pressure, and pulse oximetry readings. However, disabling the apnea-flow alarm may
be appropriate in this instance.

● Prevention – Basic function of the airway flowmeter(s) is confirmed when the breathing circuit is
tested for gas flow during inspiration and exhalation. The breathing circuit pressure test checks
for leaks in the flowmeter housing or connections. To maximize flowmeter accuracy, the user
should extend breathing circuit tubing before performing any pre-use automated checkout that
includes compliance testing. For some machines, it is necessary to ensure appropriate preset gas
compensation settings by entering the anesthetic gas that will be used when performing the pre-
use machine checkout.

● Diagnosis – Flowmeter accuracy is not routinely checked by the user, and measured tidal
volumes may be different from ventilator set tidal volumes. In general, measured tidal volumes
are less accurate than set tidal volumes with a piston ventilator (assuming that breathing system
compliance and leak volume has not changed since the automated pre-use checkout). Also, in
general, measured tidal volumes are more accurate than tidal volumes indicated on a bellows
housing.

● Response – Since many alarms and ventilator settings are dependent on a functioning airway
flowmeter, an anesthetic should not be started if a broken airway flowmeter is suspected. If a hot
wire anemometer filament burns out during an anesthetic, the sensor should be replaced
immediately after the case ends.

BACKUP EQUIPMENT FOR OXYGENATION AND VENTILATION

If malfunction of the anesthesia machine occurs during anesthetic administration and the problem is
not resolved immediately, positive pressure ventilation is initiated with a self-inflating manual
ventilation device and an auxiliary oxygen cylinder. A total intravenous anesthesia (TIVA) technique
may be employed until the problem is resolved or a replacement machine is available. (See
"Maintenance of general anesthesia: Overview", section on 'Total intravenous anesthesia'.)

Missing backup equipment for oxygenation and ventilation may result in inability to oxygenate and
ventilate a patient if anesthesia machine malfunction occurs. Thus, the American Society of
Anesthesiologists (ASA) Anesthesia Machine Checkout Recommendations stipulate that a full auxiliary
backup oxygen "E" cylinder and a self-inflating manual ventilation device should always be available on
the anesthesia workstation for emergency use. This is a critical part of the pre-use anesthesia machine
checkout procedure (item #1) ( table 1) [7]. If needed, additional oxygen "E" cylinders are typically
available in several nearby locations in the operating room suite because they are often used for brief
periods during patient transport within the hospital.

Failure to oxygenate and/or ventilate is a major cause of anesthesia morbidity and mortality [1-4].
When a critical anesthesia workstation malfunction results in an inability to ventilate the patient, fixing
the root cause may distract the clinician for several minutes. For this reason, the anesthesia provider
should rapidly employ backup equipment if the patient cannot be ventilated, while a second
anesthesia provider or technician is called to find and fix the cause of the malfunction and/or bring a
second anesthesia machine to serve as a replacement.

The ASA recommendations also specify that airway suction equipment (which is attached to the side of
the anesthesia machine in many institutions) should be checked by the anesthesia provider before a
procedure begins (item #2) ( table 1), to ensure that it is sufficient to clear the patient's airway.
Missing components of the suction apparatus, system leaks, occluded tubing, insufficient tubing
length, and incorrectly set vacuum settings are common causes of suction malfunction.

SUMMARY AND RECOMMENDATIONS

● Anesthetic care is provided using an anesthesia machine and integrated monitors (ie, the
anesthesia workstation) that include systems for (see 'Introduction' above):

• Blending a precision mixture of gases (anesthesia machine, respiratory gases, anesthetic

gases and vaporizers)
• Dispensing those gases to the patient (anesthesia breathing system)
• Delivering positive pressure ventilation (anesthesia ventilator)
• Removing waste gases (scavenger system)
• Monitoring respiratory and machine function (integrated system monitors)

● The American Society of Anesthesiologists (ASA) Anesthesia Machine Checkout ( table 1), or
similar recommendations should be performed daily, and selected items should be checked
before administration of each anesthetic to prevent anesthesia workstation misuse or failure.
(See 'Standardized anesthesia machine checkout' above.)

● Alarms for the most common and/or serious anesthesia machine problems, possible causes, and
suggested clinician responses are shown in the tables (see 'Anesthesia workstation alarms'
above):

• Electrical power loss alarm ( table 2)

• Oxygen (O2) supply pressure alarm ( table 3)
• Apnea alarm ( table 4)
• Apnea-pressure alarm ( table 5)
• Apnea-flow alarm ( table 6)
• Apnea carbon dioxide (CO2) alarm ( table 7)
• High airway pressure alarm ( table 8)
• Continuous airway pressure alarm ( table 9)
• Negative airway pressure alarm ( table 10)
• Low inspired oxygen alarm ( table 11)
• High inspired CO2 alarm ( table 12)
• Low inspired anesthetic agent alarm (if indicated) ( table 13)

● Prevention, diagnosis, and troubleshooting strategies for misuses and malfunctions of

anesthesia machine components are discussed above:
 • Loss of electrical supply (see 'Loss of electrical supply' above)
• Compressed gas supply malfunction (see 'Compressed gas supply malfunction' above)
• Compressed gas flowmeter malfunction (see 'Compressed gas flowmeter malfunction' above)
• Proportioning system or fail-safe valve malfunction (see 'Proportioning system or pressure
sensor shut-off (fail-safe) valve malfunction' above)
• Vaporizer malfunction (see 'Vaporizer malfunction' above)
• Circle breathing system leak or obstruction (see 'Breathing system leak' above and 'Breathing
system obstruction' above)
• CO2 absorbent exhaustion or toxicity (see 'Carbon dioxide absorbent exhaustion or toxicity'
above)
• Valve malfunctions:
- Adjustable pressure-limiting (APL) valve (see 'Adjustable pressure-limiting valve' above)
- Unidirectional valves (see 'Unidirectional (inspiratory and expiratory) valves' above)
- Positive end-expiratory pressure (PEEP) valve (see 'Positive end-expiratory pressure valve'
above)
• Ventilator malfunction (see 'Ventilator malfunction' above)
• Waste gas disposal (scavenger) system malfunction (see 'Waste gas disposal (scavenger)
system malfunction' above)
• Mapleson breathing system malfunction (see 'Mapleson breathing system malfunction'
above):
- Modified Mapleson D (Bain) circuit (see 'Modified Mapleson D (Bain) circuit' above)
- Mapleson E (T-piece) circuit (see 'Mapleson E (T-piece) circuit' above)

● Prevention, diagnosis, and troubleshooting strategies for misuses and malfunctions of

anesthesia monitors that are integrated into the anesthesia workstation may cause failure to
alert the clinician to a potential problem, as discussed above:

• Oxygen analyzer (see 'Oxygen analyzer' above)

• Capnometer and respiratory gas analyzers (see 'Capnometer and respiratory gas analyzers'
above)
• Airway pressure and flow measurements:
- Airway pressure (see 'Airway pressure' above)
- Airway flow (see 'Airway flow' above)

● Missing backup equipment for oxygenation and ventilation (eg, full auxiliary oxygen cylinder and
self-inflating manual ventilation device) may result in inability to oxygenate and ventilate a
patient if malfunction of the anesthesia machine occurs. (See 'Backup equipment for oxygenation
and ventilation' above.)

Use of UpToDate is subject to the Terms of Use.

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38. van Genderingen HR, Gravenstein N. Capnogram artifact during high airway pressures caused by
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Topic 94594 Version 18.0
GRAPHICS

Representation of a typical anesthesia workstation

Reproduced with permission from: Butterworth JF, Mackey DC, Wasnick JD. The anesthesia machine. In: Morgan &
Mikhail's Clinical Anesthesiology, 5th ed, McGraw-Hill 2013. Copyright © 2013 McGraw-Hill Education. McGraw-Hill
Education makes no representations or warranties as to the accuracy of any information contained in the McGraw-Hill
Education Material, including any warranties of merchantability or fitness for a particular purpose. In no event shall
McGraw-Hill Education have any liability to any party for special, incidental, tort, or consequential damages arising
out of or in connection with the McGraw-Hill Education Material, even if McGraw-Hill Education has been advised of
the possibility of such damages.
Graphic 113607 Version 2.0
Fresh gas decoupled breathing system

APL: adjustable pressure-limiting ("pop-off") valve; PEEP: positive end-expiratory pressure; Pmax: maximum pressur

From: Loeb RG, Feldman J. Anesthesia Machines. In: Encyclopedia of Medical Devices and Instrumentation, 2nd ed, Webster JG (Ed), Wiley, Hobo
2006. http://onlinelibrary.wiley.com/book/10.1002/0471732877. Copyright © 2006. Reproduced with permission of John Wiley & Sons Inc. This i
been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Pl
contact Wiley's permissions department either via email: permissions@wiley.com or use the RightsLink service by clicking on the 'Request Permi
accompanying this article on Wiley Online Library (http://onlinelibrary.wiley.com).

Graphic 114871 Version 2.0

Anesthesia machine internal piping

Anesthesia machine internal piping, Draeger Narkomed.

N 2 O: nitrous oxide; O 2 : oxygen.

From: Loeb RG, Feldman J. Anesthesia Machines. In: Encyclopedia of Medical Devices and Instrumentation, 2nd ed, Webster JG (Ed), Wiley, Hobo
http://onlinelibrary.wiley.com/book/10.1002/0471732877. Copyright © 2006. Reproduced with permission of John Wiley & Sons Inc. This image
provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Please c
permissions department either via email: permissions@wiley.com or use the RightsLink service by clicking on the 'Request Permission' link accom
article on Wiley Online Library (http://onlinelibrary.wiley.com).

Graphic 114872 Version 1.0

Components of the circle breathing system

APL valve: adjustable pressure-limiting ("pop-off") valve.

From: Loeb RG, Feldman J. Anesthesia Machines. In: Encyclopedia of Medical Devices and Instrumentation, 2nd ed, Webster JG (Ed), Wiley, Hobo
2006. http://onlinelibrary.wiley.com/book/10.1002/0471732877. Copyright © 2006. Adapted with permission of John Wiley & Sons Inc. This imag
been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Pl
contact Wiley's permissions department either via email: permissions@wiley.com or use the RightsLink service by clicking on the 'Request Permi
link accompanying this article on Wiley Online Library (http://onlinelibrary.wiley.com).

Graphic 113608 Version 2.0

Simplified functional diagram of Fabius, Tiro, or Apollo anesthesia machine

The diagram depicts the machine during the inspiratory phase of a mechanical breath (dashed blue arrows,
direction of FGF; dotted red arrows, gas flow generated by the ventilator) with the inspiratory valve open and the
expiratory valve closed. Lightning bolts indicate sites of electronic control. During spontaneous or manual
ventilation, excess gas is vented out of the breathing circuit through the APL valve, which is excluded from the
system during mechanical ventilation. From the wall outlets or cylinders, pressurized gases (O 2 , green; air, yellow;
N 2 O, blue) pass through pressure regulators on entrance of the anesthesia machine. Fresh gas is metered by
mechanical controls with electronic flowmeters, and then flows through a conventional mechanical vaporizer (excep
for desflurane, which is electronic). A fresh gas decoupling valve directs the FGF during the inspiratory phase to the
reservoir bag, and once that is filled, to the exhaust valve. During the prior expiratory phase, the electronically
driven piston ventilator would have filled with gas from the reservoir bag, and if the reservoir bag were empty, the
ventilator's negative pressure relief valve would have opened to entrain room air. On inspiration, tidal volume from
the piston ventilator is delivered directly to the patient without contribution of FGF. The ventilator-controlled
PEEP/Pmax valve is closed during inspiration so that only the patient side of the breathing circuit is pressurized.
During exhalation excess gas is vented from the circuit through an exhaust valve that contributes negligible PEEP.
O 2 : oxygen; N 2 O: nitrogen oxide; FGF: fresh gas flow; APL: adjustable pressure limiting; PEEP: positive end-
expiratory pressure; Pmax: maximum pressure.

Adapted from: Hendrickx JF, De Wolf AM. The Anesthesia Workstation: Quo Vadis?. Anesth Analg 2018; 127:671. DOI:
10.1213/ANE.0000000000002688. Copyright © 2018 International Anesthesia Research Society. Reproduced with permission from Wolters
Kluwer Health. Unauthorized reproduction of this material is prohibited.

Graphic 120028 Version 3.0

American Society of Anesthesiologists Summary of Anesthesia Machine Checkout
Recommendations

Responsible
Item to be completed
party

To be completed daily

Item #1: Verify that auxiliary oxygen cylinder and self-inflating manual ventilation Provider and
device are available and functioning technician

Item #2: Verify that patient suction is adequate to clear the airway Provider and
technician

Item #3: Turn on anesthesia delivery system and confirm that AC power is available Provider or
technician

Item #4: Verify availability of required monitors, including alarms Provider or

technician

Item #5: Verify that pressure is adequate on the spare oxygen cylinder mounted on Provider and
the anesthesia machine technician

Item #6: Verify that the piped gas pressures are ≥50 psig Provider and
technician

Item #7: Verify that vaporizers are adequately filled and, if applicable, that the filler Provider or
ports are tightly closed technician

Item #8: Verify that there are no leaks in the gas supply lines between the Provider or
flowmeters and the common gas outlet technician

Item #9: Test scavenging system function Provider or

technician

Item #10: Calibrate, or verify calibration of, the oxygen monitor, and check the low Provider or
oxygen alarm technician

Item #11: Verify that carbon dioxide absorbent is not exhausted Provider or
technician

Item #12: Breathing system pressure and leak testing Provider and
technician

Item #13: Verify that gas flows properly through the breathing circuit during both Provider and
inspiration and exhalation technician

Item #14: Document completion of checkout procedures Provider and

technician

Item #15: Confirm ventilator settings and evaluate readiness to deliver anesthesia Provider
care (anesthesia time out)

To be completed prior to each procedure

Item #2: Verify that patient suction is adequate to clear the airway Provider and
technician

Item #4: Verify availability of required monitors, including alarms Provider or

technician
 Item #7: Verify that vaporizers are adequately filled and, if applicable, that the filler Provider
ports are tightly closed

Item #11: Verify that carbon dioxide absorbent is not exhausted Provider or
technician

Item #12: Breathing system pressure and leak testing Provider and
technician

Item #13: Verify that gas flows properly through the breathing circuit during both Provider and
inspiration and exhalation technician

Item #14: Document completion of checkout procedures Provider and

technician

Item #15: Confirm ventilator settings and evaluate readiness to deliver anesthesia Provider
care (anesthesia time out)

AC: alternating current; psig: pounds per square inch gauge.

Reproduced with permission from: Riutort KT, Eisenkraft JB. The Anesthesia Workstation and Delivery Systems for Inhaled Anesthetics.
In: Clinical Anesthesia, 7th ed, Barash PG, Cullen BF, Stoelting RK, et al. (Eds), Lippincott Williams & Wilkins, Philadelphia 2013.
Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 101563 Version 6.0

Electrical power loss alarm

Manifestations Alarm message that system is running on battery.

Loss of room lighting.

Power loss in other devices.

Blank display(s).

Ventilator stops cycling if no battery backup.

Potential causes Patient factors (none).

Equipment factors.

Mains failure

Facility-wide

At circuit breaker

At ground fault circuit interrupt (GFCI) outlet

Blown fuse (potentially in extension outlet)

Anesthesia workstation unplugged

Battery exhausted

Suggested responses Check patient – may need to manually ventilate, may need to manually
monitor if power loss to electronic monitors.

Anesthesia workstation pneumatic oxygen delivery preserved. Electronic

displays and ventilator work until battery is exhausted.

Obtain other light sources if lighting power is lost (emergency flashlight,

cell phone).

Try another electrical outlet (most ORs supplied by more than one circuit
breaker), ideally an outlet connected to the emergency power grid.

Unplug last device plugged in or activated, then reset circuit breaker or

replace blown fuse.

Conserve battery supply.

Convert to spontaneous/manual ventilation mode (if electrically

powered ventilator)

Notify facility.

OR: operating room.

Graphic 113667 Version 1.0

O 2 supply pressure alarm

Manifestations Alarm message for O 2 supply pressure low

Loss of O 2 and nitrous oxide flow

Loss of air flow on some anesthesia workstations (with failsafe valve on

the air piping)

Loss of auxiliary O 2 flow

Loss of ventilator cycling (with pneumatically powered ventilator)

Potential causes Patient factors (none)

Equipment factors

Loss of pipeline O 2 supply

Facility-wide

At zone valve

O 2 pipeline hose disconnected

Empty backup O 2 cylinder

Suggested responses Open backup O 2 cylinder

If this does not restore O 2 flow, then the backup cylinder is empty or
not properly mounted

Conserve O 2

Terminate mechanical ventilation (if pneumatically powered

ventilator)

Decrease O 2 flows (main and auxiliary flowmeters)

May still be able to administer air with inhalational anesthetics even with
loss of O 2 pressure

Obtain additional backup O 2 cylinder that fits the anesthesia

workstation yoke

Ventilate with manual resuscitation bag connected to separate O 2

cylinder if no O 2 or air flow from anesthesia workstation

O 2 : oxygen.

Graphic 113668 Version 1.0

Apnea alarm overview

Mechanical ventilation Apnea - pressure only

False alarm – threshold set too high

Breathing system leak

Pressure sensor tube disconnect or obstruction

Apnea - flow only

False alarm – high threshold (eg, neonate)

Malfunctioning flow sensor (eg, due to moisture or broken filament)

Apnea-CO 2 only

Capnometer sample line crack or disconnect

Esophageal intubation

Cardiac arrest

Apnea-flow and apnea-CO 2

Breathing system obstruction

Large cuff leak (no exhaled gas into breathing system)

Esophageal intubation

Apnea-pressure and apnea-flow and apnea-CO 2

Breathing system disconnect

Ventilator turned off or cycling failure malfunction

Lower airway suction (gastric tube in trachea, tracheal/bronchial

suction)
 Spontaneous or manual Apnea-pressure only
ventilation
False alarm – When switching from mechanical to spontaneous
ventilation (apnea-pressure not applicable in spontaneous mode)

Apnea-flow only

False alarm – high threshold (neonate)

Incomplete endotracheal tube kink or obstruction

Breathing system disconnect with patient still connected to CO 2

sampling site

Malfunctioning flow sensor (eg, due to moisture or broken filament)

Apnea-CO 2 only

Capnometer sample line crack or disconnect

Apnea-flow and apnea-CO 2

Patient apnea

Breathing system obstruction

Airway (ETT or LMA) obstruction

Breathing system disconnect

Lower airway suction (gastric tube in trachea, tracheal/bronchial

suction)

Esophageal intubation

Cardiac arrest

Differential diagnosis based on mode of ventilation and combination of alarms.

CO 2 : carbon dioxide; ETT: endotracheal tube; LMA: laryngeal mask airway.

Graphic 113669 Version 1.0

Apnea-pressure alarm

Manifestations Empty bellows

Empty reservoir bag (in fresh-gas-decoupled circle breathing system)

Non-moving ventilator bellows or piston

Potential causes Patient factors (none)

Equipment factors

False alarm

When switching from mechanical to spontaneous ventilation

Threshold pressure alarm setting too high

Pressure sensor line disconnect or obstruction

Reduction or loss of gas flow into breathing system

Leak within anesthesia machine downstream of flowmeters

Leak within vaporizer (only happens when vaporizer is dialed on;

often filler cap left open)

Detached or obstructed fresh gas hose

Fresh gas misdirected to auxiliary common gas outlet

Breathing system leak or disconnection

At airway (cuff or mask leak)

Within breathing system

Tubing connections loose or disconnected

CO 2 absorbent canister cracked or not sealed properly

Gas analyzer sample line loose or disconnected

Leaking ventilator relief valve

In ventilator

Negative pressure applied to breathing system (also refer to table on

negative airway pressure alarm)

Gastric tube in trachea

Intentional tracheal/bronchial suctioning (eg, fiberoptic)

Malfunctioning scavenger system via ventilator relief valve

Ventilator turned off or cycling failure malfunction

 Suggested responses Determine whether patient ventilation is occurring (examine chest,
auscultate lungs, check CO 2 waveform and respiratory monitors, check
SpO 2 )

Look for breathing circuit disconnection

Fill breathing circuit with high fresh gas flows

Disconnect patient and quickly pressure test breathing system to

determine if leak is in the workstation or at the airway

Verify that ventilator is operating

Switch to manual ventilation

If necessary, ventilate with manual resuscitation device connected to O 2

Only pertinent during mechanical positive pressure ventilation - refer to other apnea alarms for
spontaneous or manual ventilation.

CO 2 : carbon dioxide; SpO 2 : pulse oximetry; O 2 : oxygen.

Reference:

1. Raphael DT, Weller RS, Doran DJ. A response algorithm for the low-pressure alarm condition. Anesth Analg 1988; 67:876.

Graphic 113670 Version 1.0

Evaluation of low airway pressure apnea alarm during ventilation with an anesthesia

ETT: endotracheal tube; SGA: supraglottic airway; CO2: carbon dioxide; O2: oxygen; APL valve: adjustable pressure-li
tidal partial pressure of carbon dioxide.

* Please refer to UpToDate content regarding diagnosis and management of anesthesia machine malfunctions.

¶ Consider replacing anesthesia machine and ventilator.

Graphic 140292 Version 1.0

Apnea-flow alarm

Manifestations Non-moving ventilator bellows or piston

No patient respiratory motion

Potential causes Patient factors

Patient apnea (no respiratory effort)

Equipment factors

False alarm

High threshold (neonate)

Malfunctioning flow sensor (moisture, burnt out filament)

Exhaled gas exiting breathing system before flowmeter

Large cuff leak (no exhaled gas into breathing system)

Lower airway suction (gastric tube in trachea, tracheal/bronchial

suction)

Breathing system leak or disconnection

Breathing system obstruction

Airway (ETT or LMA) obstruction

Ventilator turned off or cycling failure malfunction

Suggested responses Determine whether patient ventilation is occurring (examine chest,

auscultate lungs, check CO 2 waveform and respiratory monitors, check
SpO 2 )

Look for breathing circuit disconnection or obstruction

Verify that ventilator is operating

Switch to manual ventilation

If necessary, ventilate with manual resuscitation device connected to

oxygen

ETT: endotracheal tube; LMA: laryngeal mask airway; CO 2 : carbon dioxide; SpO 2 : pulse oximetry.

Graphic 113671 Version 1.0

Apnea-CO 2 alarm

Manifestations Loss of capnogram

Potential causes Patient factors

Patient apnea (no respiratory effort)

Esophageal intubation

Cardiac arrest

Equipment factors

False alarm

Capnometer sample line crack or disconnect

Exhaled gas exiting breathing system before sampling site

Large cuff leak (no exhaled gas into breathing system)

Lower airway suction (gastric tube in trachea, tracheal/bronchial

suction)

Breathing system disconnect

Breathing system obstruction

Airway (ETT or LMA) obstruction

Ventilator turned off or cycling failure malfunction

Suggested responses Check circulation (electrocardiogram and plethysmogram)

Determine whether patient ventilation is occurring (examine chest,

auscultate lungs, check respiratory monitors, check SpO 2 )

Rule out esophageal intubation if recently intubated

Look for breathing circuit disconnection or obstruction

Verify that ventilator is operating

Switch to manual ventilation

If necessary, ventilate with manual resuscitation device connected to O 2

CO 2 : carbon dioxide; ETT: endotracheal tube; LMA: laryngeal mask airway; SpO 2 : pulse oximetry; O 2 :
oxygen.

Graphic 113672 Version 1.0

High airway pressure alarm

Manifestations Elevated airway pressure on gauge

Increased slope of pressure-volume loop

"Tidal volume not delivered, pressure limit" alarm message

Potential causes Patient factors

Low compliance

Coughing or bucking

Surgical peritoneal insufflation

Intentional single lung ventilation

Mainstem intubation

Pulmonary edema

Pneumothorax, especially tension pneumothorax

High resistance

Bronchospasm

Laryngospasm

Airway obstruction by mucous, blood, foreign body

Equipment factors

Kinked or obstructed endotracheal tube

Increased delivered tidal volume

High fresh gas flow rate with uncompensated ventilator

Oxygen flush during inspiration

Breath-stacking due to inadequate expiratory time

Obstructed breathing system at inspiratory hose

Improperly placed equipment such as PEEP valve or humidifier

Suggested responses Check patient (look for movement and signs of coughing, observe
patient chest movement, auscultate lungs)

Look at shape of airway pressure curve and expiratory portion of flow-

volume loop (to differentiate high resistance from low compliance)

Look at shape of capnogram (to diagnose small airway resistance)

Pass suction catheter down endotracheal tube (to detect kink, mucous
plug, or other obstruction)
PEEP: positive end-expiratory pressure.

Graphic 113673 Version 1.0

Evaluation of high peak airway pressure alarm during ventilation with an anesthesia
PEEP: positive end-expiratory pressure; APL: adjustable pressure-limiting valve; ETT: endotracheal tube; NMBA: neur

* Examine airway flow tracings or flow-volume loops to determine whether peak expiratory flow rate has changed. P
regarding mechanical ventilation in adults during anesthesia and mechanical ventilation in the intensive care unit.

Graphic 140291 Version 1.0

Continuous airway pressure alarm

Manifestations Continuous elevated airway pressure on gauge

Recent increase in PEEP setting

Hyperinflated reservoir bag

Recent conversion from facemask to ETT or LMA

Potential causes Patient factors (none)

Equipment factors

Obstruction of expiratory limb of breathing system

PEEP valve

Expiratory one-way valve

Obstructed breathing system exhaust

APL valve closed or obstructed

Ventilator relief valve closed or obstructed

Tubing obstruction between relief valve(s) and scavenger

Scavenger system outflow obstruction

Low scavenger outflow with blocked safety valve

Suggested responses Disconnect patient from breathing system

Open APL valve

Turn down fresh gas flow rate

Verify scavenger system operational

PEEP: positive end-expiratory pressure; ETT: endotracheal tube; LMA: laryngeal mask airway; APL: adjustable
pressure limiting.

Graphic 113674 Version 1.0

Negative airway pressure alarm

Manifestations Airway pressure less than zero

Collapsed reservoir bag or bellows

Potential causes Patient factors

Patient generated inspiratory pressure with empty reservoir bag or

ventilator bellows

Equipment factors

Suction applied below airway

Gastric tube in trachea

Tracheal/bronchial suction (eg, fiberoptic)

Suction applied above airway

Malfunctioning scavenger system

Suggested responses Immediately disconnect airway from breathing system

Fill breathing system with oxygen flush or high fresh gas flows

Graphic 113675 Version 1.0

Low inspired O 2 alarm

Manifestations Lower than expected FiO 2

Low SpO 2

Low anesthetic agent concentration (if air entrainment into breathing system)

Potential causes Patient factors

Patient O 2 consumption and gas sampling exceeds O 2 flow rate

Equipment factors

Gas piping system crossover

Mis-filled O 2 source

O 2 pipeline hose misconnection

Gas blender between O 2 pipeline and anesthesia machine

Gas piping crossover within anesthesia machine

Cracked O 2 flowmeter

Air entrainment into the breathing system

Circuit disconnection with spontaneous breathing

Circuit disconnection with hanging-bellows ventilator

Circuit disconnection with piston ventilator

Suggested Increase O 2 flow rate and decrease flow rate of other gases
responses
Consider wrong gas malfunction if inspired O 2 concentration does not increase

Open backup O 2 cylinder AND disconnect O 2 pipeline hose if pipeline crossover

suspected

Do not use auxiliary O 2 flowmeter on the anesthesia workstation - it has the

same O 2 source as main O 2 flowmeter

Ventilate with manual resuscitation bag connected to a different O 2 cylinder

FiO 2 : fraction of inspired oxygen; SpO 2 : pulse oximetry; O 2 : oxygen.

Graphic 113676 Version 1.0

High inspired CO 2 alarm

Manifestations Abnormal capnogram shape with elevated baseline

Discolored CO 2 absorbent

Abnormal motion of one-way valves

Potential causes Patient factors

High respiratory rate, small tidal volume in pediatrics

Malignant hyperthermia

Equipment factors

Exhausted CO 2 absorbent

Open self-sealing CO 2 canister connection (ie, quick-connect)

Intentional CO 2 administration (eg, single ventricle neonates)

Excessive apparatus deadspace relative to tidal volume (eg, neonate)

Incompetent (stuck open) inspiratory valve

Incompetent (stuck open) expiratory valve

Low levels of inspired CO 2 occur with rebreathing circuits such as

Mapleson D or Bain circuits

Breathing system disconnect (during spontaneous breathing)

Suggested responses Increase fresh gas flow rate to above minute ventilation (inspired CO 2
will disappear if absorbent is exhausted or decrease with Mapleson
breathing system)

Replace CO 2 absorbent and check that canister is properly connected

Increase minute ventilation (to compensate for rebreathing)

Inspect, vibrate, dry, and/or repair one-way valves

Switch ventilator mode (spontaneous-manual versus mechanical) if

incompetent one-way valve on fresh gas decoupled breathing system

CO 2 : carbon dioxide.

Graphic 113677 Version 1.0

Low inspired anesthetic agent

Manifestations Signs of "light" anesthesia

Lower than intended measured anesthetic concentration (typically no alarm

set for this)

Potential causes Patient factors (none)

Equipment factors:

Empty vaporizer

Loose vaporizer cap

Improperly seated vaporizer

Air entrainment into breathing system

Anesthetic degradation by soda lime or baralyme

User factors:

Wrong agent in vaporizer

Bellows refilled using oxygen flush

Very low fresh gas flow

Failure to turn on the vaporizer

Suggested responses Increase fresh gas flow rate

Increase vaporizer setting

Fill vaporizer

Check vaporizer cap and connection to manifold

Switch vaporizers

Check CO 2 absorbent for heat or discoloration at the opposite end of where it

typically changes color

Replace CO 2 absorbent

Convert to intravenous anesthetic

CO 2 : carbon dioxide.

Graphic 113678 Version 4.0

Flowmeter sequence

Oxygen is the last gas to enter the manifold to prevent hypoxic mixtures due to leaks in other flowmeters.

O 2 : oxygen; N 2 O: nitrous oxide.

Graphic 114773 Version 1.0

Negative pressure leak test

A negative pressure leak test is employed to test for leaks in a flowmeter or other
internal components of the anesthesia machine. With this test, all compressed gas
flows are set to zero, then a suction bulb is attached to the anesthesia machine
common gas outlet and repeatedly squeezed until it collapses, as shown in this
photo. The bulb will not stay collapsed if there is a leak. (See topics describing the
anesthesia machine for further information.)

Graphic 114772 Version 1.0

Simplified functional diagram of a Perseus anesthesia machine

The diagram depicts the machine during the inspiratory phase of a mechanical breath (dashed blue arrows,
direction of FGF; dotted red arrows, gas flow generated by the ventilator) with the inspiratory valve open and the
expiratory valve closed. Lightning bolts indicate sites of electronic control. During spontaneous or manual
ventilation, excess gas is vented out of the breathing circuit through the APL valve, which is excluded from the
system during mechanical ventilation. From the wall outlets or cylinders, pressurized gases (O 2 , green; air, yellow;
N 2 O, blue) pass through pressure regulators on entrance of the anesthesia machine. Fresh gas is metered by
mechanical or electronic controls (purchasing option) with electronic flowmeters, and then flows through a
conventional mechanical vaporizer (except for desflurane). An electronically driven turbine mixes the gases in the
system (shortening response times) and delivers a measured tidal volume (immediately compensating for the
continuous inflow of fresh gas). The ventilator-controlled PEEP/Pmax valve is closed during inspiration so that only
the patient side of the breathing circuit is pressurized. During exhalation excess gas is vented from the circuit
through an exhaust valve that contributes negligible PEEP.

O 2 : oxygen; N 2 O: nitrogen oxide; FGF: fresh gas flow; APL: adjustable pressure limiting; PEEP: positive end-
expiratory pressure; Pmax: maximum pressure.

Adapted from: Hendrickx JF, De Wolf AM. The Anesthesia Workstation: Quo Vadis?. Anesth Analg 2018; 127:671. DOI:
10.1213/ANE.0000000000002688. Copyright © 2018 International Anesthesia Research Society. Reproduced with permission from Wolters
Kluwer Health. Unauthorized reproduction of this material is prohibited.

Graphic 120114 Version 4.0

Red occlusive plug

This rubber plug, which had been recalled by the manufacturer, was
designed to be inserted into the expiratory port of the breathing
system during a pre-use low-pressure leak check. Complete
breathing circuit obstruction results if the breathing circuit hose is
attached to the other side of the plug. The manufacturer will replace
these potentially dangerous plugs with replacements that do not
allow the attachment of breathing circuit hoses.

Graphic 120029 Version 1.0

Incompetent inspiratory valve versus incompetent expiratory valve

Capnography can help distinguish an incompetent inspiratory valve from an incompetent

expiratory valve.

(A) Normally, the inspiratory and expiratory valves prevent rebreathing.

(B) An incompetent inspiratory valve causes some rebreathing, because exhaled gas flows into
the inspiratory limb, which is small. On inspiration, end-tidal gas is re-inhaled, followed by fresh
gas. The result is a long expiratory capnogram, a normal inspired CO 2 , and a slow rise in end-
tidal CO 2 .

(C) An incompetent expiratory valve causes more rebreathing, because the expiratory limb
contains the reservoir bag or ventilator bellows. On inspiration, fresh gas from the inspiratory
hose, and end-tidal gas from the expiratory hose is re-inhaled. The result is a normal length
expiratory capnogram, elevated inspired CO 2 , and a more rapid rise in end-tidal CO 2 .
Increasing the fresh gas flow does not decrease the inspired CO 2 (which it does when the CO 2
absorbent is exhausted).

CO 2 : carbon dioxide.

Graphic 114952 Version 1.0

Simple functional diagram of a FLOW-i anesthesia machine

The diagram depicts the machine during the inspiratory phase of a mechanical breath (long-dashed blue arrows, dir
FGF; short-dashed red arrows, gas flow generated by the ventilator; dotted green arrows, drive gas flow) with the ins
valve open and the expiratory valve closed. Lightning bolts indicate sites of electronic control. During spontaneous o
ventilation, excess gas is vented out of the breathing circuit through the APL valve, which is excluded from the syste
mechanical ventilation. From the wall outlets or cylinders, pressurized gases (O 2 , green; air, yellow; N 2 O, blue) pass
external pressure regulators prior to entrance of the anesthesia machine. Fresh gas is delivered via three electronica
controlled gas modules with a maximum flow of over 20 L/minute (O 2 , green; air, yellow; N 2 O, blue), and vapor is ad
an electronically controlled vaporizer that injects liquid agent into a heated vaporizing chamber. Exhaled gas is temp
stored in a long piece of tubing called the volume reflector that takes the place of a bellows. Gas mixing within the v
reflector is minimal. The inspired tidal volume consists of both drive gas from the volume reflector pushed toward th
by the reflector gas module and fresh gas from its inlet into the breathing circuit. The electronically controlled APL/P
closed during mechanical inhalation. During exhalation excess gas is vented from the circuit through the APL/PEEP v
contributes no obligatory PEEP.

O 2 : oxygen; N 2 O: nitrogen oxide; FGF: fresh gas flow; APL: adjustable pressure limiting; PEEP: positive end-expirator
Adapted from: Hendrickx JF, De Wolf AM. The Anesthesia Workstation: Quo Vadis?. Anesth Analg 2018; 127:671. DOI: 10.1213/ANE.00000000000
Copyright © 2018 International Anesthesia Research Society. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduct
material is prohibited.

Graphic 120116 Version 3.0

Simplified functional diagram of an Aisys anesthesia machine

The diagram depicts the machine during the inspiratory phase of a mechanical breath (long-dashed blue arrows, dir
short-dashed red arrows, gas flow generated by the ventilator; dotted green arrows, drive gas flow) with the inspirat
and the expiratory valve closed. Lightning bolts indicate sites of electronic control. During spontaneous or manual v
gas is vented out of the breathing circuit through the APL valve, which is excluded from the system during mechanic
From the wall outlets or cylinders, pressurized gases (O 2 , green; air, yellow; N 2 O, blue) pass through pressure regul
entrance of the anesthesia machine. Fresh gas is metered by electronic controls with electronic flowmeters, and the
flows through an electronically controlled variable bypass vaporizer. The resulting anesthetic gas mixture enters the
proximal to the inspiratory valve. Compressed oxygen from the wall outlet is electronically metered (compensating,
breaths, for the continuous inflow of fresh gas) to drive the ventilator bellows. The entire breathing circuit is pressur
inspiration. During exhalation excess gas is vented from the bellows through an exhaust valve that contributes an o
3 cmH 2 O.

O 2 : oxygen; N 2 O: nitrogen oxide; FGF: fresh gas flow; APL: adjustable pressure limiting; PEEP: positive end-expirator

Adapted from: Hendrickx JF, De Wolf AM. The Anesthesia Workstation: Quo Vadis?. Anesth Analg 2018; 127:671. DOI: 10.1213/ANE.00000000000
2018 International Anesthesia Research Society. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this m

Graphic 120085 Version 3.0

Components of a scavenging system

Diagram of the components of the waste anesthetic gas disposal system (commonly termed the
scavenger system) of an anesthesia machine. This system prevents excessive positive or negative
pressure at the outlet of the exhaust valves of the anesthesia machine, and also prevents venting
of waste anesthetic gases into the operating room. (An open/active scavenger system is depicted
in this graphic.)

APL: adjustable pressure-limiting valve; CO 2 : carbon dioxide.

Reproduced with permission from: Riutort KT, Eisenkraft JB. The anesthesia workstation and delivery systems for inhaled
anesthetics. In: Clinical Anesthesia, 8 th ed, Barash PG, Cullen BF, Stoelting RK, et al (Eds), Wolters Kluwer, Philadelphia
2017. Copyright © 2017 Wolters Kluwer Health.

Graphic 113609 Version 4.0

Closed scavenger system

APL: Adjustable pressure-limiting.

Reproduced with permission from: Butterworth JF, Mackey DC, Wasnick JD. The
anesthesia machine. In: Morgan & Mikhail's Clinical Anesthesiology, 5th ed, McGraw-
Hill, 2013. Copyright © 2013 McGraw-Hill Education. McGraw-Hill Education makes
no representations or warranties as to the accuracy of any information contained in
the McGraw-Hill Education Material, including any warranties of merchantability or
fitness for a particular purpose. In no event shall McGraw-Hill Education have any
liability to any party for special, incidental, tort, or consequential damages arising
out of or in connection with the McGraw-Hill Education Material, even if McGraw-Hill
Education has been advised of the possibility of such damages.

Graphic 114783 Version 2.0

Mapleson D (Bain) circuit

Bain circuit (a modified Mapleson D circuit) attached to a contemporary

anesthesia machine auxiliary common gas outlet. The green knob is the
adjustable pressure limiting (APL) valve, and the blue hose leads to the scavenger
system.

​ he anesthesia machine's circle breathing system and ventilator, seen in this

T
photo, are not used when the Bain circuit is attached. The circle breathing circuit
can be recognized by its domed unidirectional valves, breathing hose connectors,
black APL valve, carbon dioxide absorbent canister, and selector switch. The
ventilator can be recognized by its bellows. The inspiratory and expiratory hoses
for the circle breathing systems are not shown in this photograph.

Reproduced with permission. Copyright © 2019 Mindray North America.

Graphic 121270 Version 2.0

Mapleson capnograms

Capnography can help titrate the appropriate fresh gas flow when using a Mapleson breathing circuit,
and can indicate a leaking or detached fresh gas hose.

(A) With very high fresh gas flow rates, there may be little or no rebreathing and the capnogram will
look "normal". However, the fresh gas flow is higher than it needs to be in this case.

(B) When the fresh gas flow is optimal, there will be some inspired CO 2 , but the end-tidal CO 2 will be
normal with modest hyperventilation. The distinctive shape shown in panel B is from a Mapleson D
(Bain) circuit, where fresh gas is inhaled followed by some exhaled gas.

(C) When the fresh gas flow is too low, or when the fresh gas hose is broken or disconnected, there will
be high inspired CO 2 and no amount of hyperventilation will prevent hypercarbia.

CO 2 : carbon dioxide.

Graphic 114954 Version 1.0

Mapleson E (T-piece) circuit

Obstructing the outflow through the open limb of the "T" could result in airway pressures as high as 50 psig,
which equals 3515 cmH 2 O.

psig: pounds per square inch gauge; cmH 2 O: centimeters of water.

Graphic 114830 Version 1.0

Normal CO2 waveform

A - B: Dead space ventilation

B - C: Ascending expiratory phase

C - D: Alveolar Plateau

D: End-tidal CO 2

D - E: Descending inspiratory phase

Reproduced with permission from: Krauss B, Deykin A, Lam A, et al. Capnogram

shape in obstructive lung disease. Anesth Analg 2005; 100:884. Copyright © 2005
Lippincott Williams & Wilkins.

Graphic 67700 Version 11.0

Abnormal capnogram waveforms

(A) Prolonged phase II, increased alpha angle, and steeper phase III suggest bronchospasm or airway
obstruction.

(B) Expiratory valve malfunction resulting in elevation of the baseline, and the angle between the alveolar
plateau and the downstroke of inspiration is increased from 90°. This is due to rebreathing of expiratory
gases from the expiratory limb during inspiration.

(C) Inspiratory valve malfunction resulting in rebreathing of expired gases from inspiratory limb during
inspiration (reference 1 for details).

(D) Capnogram with normal phase II but with increased slope of phase III. This capnogram is observed in
pregnant subjects under general anesthesia (normal physiologic variant and details in reference 2).

(E) Curare cleft: Patient is attempting to breathe during partial muscle paralysis. Surgical movements on
the chest and abdomen can also result in the curare cleft.

(F) Baseline is elevated as a result of carbon dioxide rebreathing.

(G) Esophageal intubation resulting in the gastric washout of residual carbon dioxide and subsequent
carbon dioxide will be zero.

(H) Spontaneously breathing carbon dioxide waveforms where phase III is not well delineated.

(I) Dual capnogram in one lung transplantation patient. The first peak in phase III is from the transplanted
normal lung, whereas the second peak is from the native disease lung. A variation of dual capnogram
(steeple sign capnogram – dotted line) is seen if there is a leak around the sidestream sensor port at the
monitor. This is because of the dilution of expired PCO 2 with atmospheric air.

(J) Malignant hyperpyrexia where carbon dioxide is raising gradually with zero baseline suggesting
increased carbon dioxide production with carbon dioxide absorption by the soda lime.

(K) Classic ripple effect during the expiratory pause showing cardiogenic oscillations. These occur as a
result of to-and-for movement of expired gases at the sensor due to motion of the heartbeat during
expiratory pause when respiratory frequency of mechanical ventilation is low. Wave forms with a ripple
effect also occur when forward flow of fresh gases from a source during expiratory pause intermingles
with expiratory gases at the sensor.

(L) Sudden raise of baseline and the end-tidal PCO 2 (PETCO 2 ) due to contamination of the sensor with
secretions or water vapor. Gradual rise of baseline and PETCO 2 occurs when soda lime is exhausted.

(M) Intermittent mechanical ventilation (IMV) breaths in the midst of spontaneously breathing patient. A
comparison of the height of spontaneous breaths compared to the mechanical breaths is useful to assess
spontaneous ventilation during weaning process.
(N) Cardiopulmonary resuscitation: Capnogram showing positive waveforms during each compression
suggesting effective cardiac compression generating pulmonary blood.

(O) Capnogram showing rebreathing during inspiration. This is normal in rebreathing circuits such as
Mapleson D or Bain circuit.

References:
1. Bhavani-Shankar K, Kumar AY, Moseley HS, Ahyee-Hallsworth R. Terminology and the current limitations of time
capnography: A brief review. J Clin Monit 1995; 11:175.
2. Fletcher R. The single breath test for carbon dioxide (Thesis). Lund, Sweden, Berlings, 1980.
From: Kodali BS. Capnography outside the operating rooms. Anesthesiology 2013; 118:192. DOI: 10.1097/ALN.0b013e318278c8b6.
Copyright © 2013 American Society of Anesthesiologists. Reproduced with permission from Lippincott Williams & Wilkins.
Unauthorized reproduction of this material is prohibited.

Graphic 114771 Version 2.0

Capnogram with upsloping plateau

In patients with obstructive lung disease and an upsloping end tidal CO 2

plateau, inspiration may occur before the true end of expiration, and result in
a falsely low ETCO 2 (solid line). Reducing the respiratory rate (or briefly
stopping the ventilator) should allow full exhalation and an accurate ETCO 2
reading (dashed line).

Graphic 112619 Version 1.0

Steeple sign capnogram

A "steeple sign" capnogram occurs during positive pressure ventilation when

there is a leak in the sample line of a sidestream capnography monitor. This
occurs because air entrained through the leak dilutes the sampled carbon
dioxide, and the magnitude of the leak varies with phasic pressure changes in
the breathing circuit.

From: Kodali BS. Capnography outside the operating rooms. Anesthesiology 2013; 118:192. DOI:
10.1097/ALN.0b013e318278c8b6. Copyright © 2013 American Society of Anesthesiologists.
Reproduced with permission from Lippincott Williams & Wilkins. Unauthorized reproduction of
this material is prohibited.

Graphic 114960 Version 3.0

Capnogram artifact due to water trap

Capnograms during mechanical ventilation. The endotracheal tube was partially obstructed and peak
pressure in the circuit was 50 cm H 2 0. The waveforms indicate a brief expiration during mechanical
inspiration.

PCO 2 : partial pressure of carbon dioxide; H 2 O: water.

From: van Genderingen HR, Gravenstein N. Capnogram artifact during high airway pressures caused by water trap. Anesth analg 1987;
66:185. Copyright © 1987 International Anesthesia Research Society. Reproduced with permission from Lippincott Williams & Wilkins.
Unauthorized reproduction of this material is prohibited.

Graphic 114793 Version 2.0

Contributor Disclosures
Robert Loeb, MD Consultant/Advisory Boards: Masimo, Inc[Patient monitoring]. All of the relevant financial
relationships listed have been mitigated. Joyce A Wahr, MD, FAHA Other Financial Interest: Anesthesia Patient
Safety Foundation [Anesthesia patient safety]. All of the relevant financial relationships listed have been
mitigated. Nancy A Nussmeier, MD, FAHA No relevant financial relationship(s) with ineligible companies to
disclose.

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