BREATHING SYSTEM :

ASSEMBLY AND FUNCTIONAL

ANALYSIS

Dr ashutosh verma
Moderator- Dr chetna
INTRODUCTION
• The breathing system is a gas pathway connected to the patients through which gas flows
occur at respiratory pressures and into which a controlled composition of a gas mixture is
dispensed

• Extends from the point of fresh gas inlet to the point at which gas escapes to atmosphere
or a scavanging system
CONTD…
• Delivers gas mixture to patients , removes CO2 and conditions temperature and humidity
of inspired mixture
• Allows continuous flow from the anaesthesia machine to be converted into an intermittent
flow
• Allows spontaneous, controlled or assisted respiration
• Gas sampling
• Monitoring of airway pressures , flow and volume
BASIC PRINCIPLE
• Resistance
• Compliance

• Rebreathing-
 Factors affecting rebreathing- FGF, mechanical dead space, design of breathing system
 Effects of rebreathing- heat and moisture retention, altered inspired gas concentration
COMPONENTS OF BREATHING SYSTEM
COMPONENTS
Bushings ( mounts)-
• modify internal diameter of a component ,
• cylindrical,
• used with a pliable component such as reservoir bag

Sleeves –
• Alters the external diameter of a component
CONNECTORS AND ADAPTORS
 Extend the distance between the patient and the breathing system

 Change the angle of connection between the patient and the breathing system

 Allows a more flexible / less kinkable connection between the patient and the breathing
system

 Increase the dead space

CONTD…
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CONTD…
• Principle-
 Resistance increases with sharp curves and rough side walls

 Add dead space if positioned between breathing system and patient( significant in infants)

 Connectors increase the number of locations at which disconnections can occur

RESERVOIR BAG

 Ellipsoidal
 Rubber ( now latex free , neoprene ) or plastic
 Parts- neck and tail , loop may be present
 Common sizes- 2 l, 1l,0.5l
 Larger bag – difficult to squeeze , monitoring spontaneous respiration difficult as
excursion are smaller
 Small bag- less safety, may not provide enough reservoir or tidal volume
CONTD…
Functions
 Allows gas to accumulate during exhalation
 Means of assisted or controlled ventilation
 Used to monitor patient’s spontaneous respiration
 Protects from excessive pressure in the breathing system ( most distensible part of
breathing system
PRESSURE VOLUME CHARACTERISTICS OF BAG
• Adding volume to a bag causes negligible rise in pressure until a nominal capacity is
reached
• More volume addition, rapid rise in pressure to peak and then plateau
• Further distension of bag will cause fall in pressure slightly
• This peak pressure represents the maximal pressure that can develop in a breathing
system
CONTD…
• ASTM standard for reservoir bag requires-
 For bags of 1.5 l or smaller pressure shall not be less than 30 cm H2O or over 50 cm H2O
when bag is expanded to 4 times its capacity
 For bags larger than 1.5 l the pressure shall be not less than 35 cm H2O or over 60 cm of
H2O when bag is expanded to 4 times its capacity
BREATHING TUBES - CHARACTERISTICS
• Appropriate diameter to provide low resistance to gases.
• Smooth and uniform cross section to promote laminar flow
• Flexible , no kinking
• Should drape easily , a loop may hang between the patient and the apparatus which can
trap moisture preventing it from going back to apparatus
• transparent
PLASTIC VS RUBBER TUBES

Corrugated rubber tubes corrugated Plastic tubes

• Ends are more easily stretched • Transparent
• Better union with other components of • Smooth inner walls
different diameter
• Light weight
• Reusable
• Inexpensive
• Non-transparent
• disposable
• Irregular walls
VALVES
• APL valve –
 Allows escape of exhaled and surplus gases from a breathing system without permitting
entry of the outside air even during negative phase.

 Used to control pressure in the breathing system

 Fully open during spontaneous respiration

CONTD…
 Partially closed during manually assisted or controlled ventilation

 with ventilators a spill valve replaces the APL valve in the breathing system to vent
excess respiratory gases

• PEEP valve, CPAP valve

FILTERS
• Uses
 To protect the patient from microorganism and airborne particulate matter
 To protect anaesthesia equipments and the environment from exhaled contaminants
 Increases the inspired humidity
 Prevents exposure to latex allergens

• Efficiency ( relation with HEPA device)

FILTERS CONTD..
• Two types-mechanical and electrostatic ; both with /without additional heat and moisture
exchange elements
• Problems-
 Increased resistance and dead space
 Obstruction
 Leaks
 Liquid penetration
CLASSIFICATION OF BREATHING SYSTEM
 CLASSIFICATION – BY REBREATHING

parameters Rebreathing Non- rebreathing

Valve Spill ( APL) unidirectional

Access of expired yes no

gases

Closed reservoir bag + +/-

Volume emerging from Equivalent to FGF Equivalent to MV

valve
CLASSIFICATION –CO2 ABSORPTION +/-
NON REBREATHING SYSTEMS
CONTD….
• Non rebreathing valves ( unidirectional flow)

• Can be used for both spontaneous and assisted / controlled ventilation

• FGF rate must not be less than the MV required by the patient
MAPLESON BREATHING SYSTEM
OPERATING PRINCIPLE
• Unidirectional valves are absent

• No co2 absorption so FGF must wash CO2 ; aka co2 washout system/flow controlled
breathing system

• Rebreathing depends upon FGF through the system

• To and fro movement of inspiratory and expiratory gases within the breathing system
CONTD…
• Mapleson ( 1954 ) classified these system ( A to E) according to efficiency in eliminating
CO2 during spontaneous respiration

• F system was added by Willis ( 1975)

image
WORKING PRINCIPLE OF BREATHING
SYSTEM
MAPELSON A ( MAGILL ATTACHMENT)
CONTD…
• Theoritically,
if there is no mixing of fresh gas , dead space gas and alveolar gas and a sufficient end
expiratory pause , the FGF rate need only match alveolar ventilation ( 66% of MV) as only
alveolar gas will be vented through the APL valve
 CONTD..
• Practically-
 Mixing of various gaseous interfaces
 Occasionally , larger than expected tidal volumes may be exhaled ; CO2 contamination of
reservoir bag
 Rapid respiratory rate will reduce/ eliminate an end expiratory pause ; decreased potential
for CO2 elimination

 FGF closer to patients Minute ventilation (including dead

space)-MV @ 80 ml/kg/min for an adult male comes to approx
6l/min
MAPELSON A CONTROLLED BREATHING

image
CONTD…
• Wasteful and inefficient
• FGF of 2.5 times the minute ventilation

• Advantages –
 Best for spontaneous respiration
 Minimal wastage of gases during spontaneous breathing. No rebreathing if FGF is about
one minute volume
CONTD…
• Disadvantage-
 Not efficient for controlled ventilation ( high FGF 12-14l/min
 Expiratory valve required – slight resistance during expiration
 Expiratory valve is heavy
 Expiratory valve near patient end inconvenient to use esp. head and neck surgery
 Not suitable for pediatric use
OTHER MAPLESON A BREATHING SYSTEMS
• The lack co axial breathing system- to overcome problems in Mapleson A i.e.

 Reduced access to valve in head and neck surgery

 Increased drag on the mask or ETT when valve is connected to scavenging tubing
• Image
LACK PARALLEL BREATHING SYSTEM
• Lack parallel breathing system-
 image
MAPLESON B AND C
• Functionally similar and also in construction
• FGF entry and the expiratory valves located at the patient end of circuit
• C system differs from B in not having a corrugated tube
• Complete mixing of FGF and exhaled gases , not good for spontaneous or controlled
ventilation
• FGF of 2-3 times MV
• Not commonly used in clinical practice
AYRE’S T PIECE
• Phillip Ayre in 1937
• A light metal 1 cm in diameter , 5 cm in length with a side arm
• Functions as a non rebreathing system
EFFERENT RESERVOIR SYSTEM
• Mapleson D, E and F
• All are modification of ayre’ s T piece
• Afferent limb supplies FGF from the machine
• Efferent limb is wide bored corrugated tube to which reservoir bag is attached and the
expiratory valve is near the bag
• Work efficiently and economically for controlled ventilation as long as the FGF entry and
the expiratory valve are separated by atleast one tidal volume
CLASSIC MAPLESON D
• Image
SPONTANEOUS RESPIRATION-

image
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BAIN’S MODIFICATION OF MAPLESON D
• Most commonly used modification( 1972 Bain and Spoerel
• Universal circuit
• Can be used for both spntaneous and controlled ventilation
• Best among mapleson for controlled ventilation
• Coaxial- inner tube green with int. dia 7 mm for FGF to the patient and exhaled gas travel
in outer corrugated tubing with int. dia 22 mm
CONTD..
• PEEP valve and pressure manometer

• Special test to check prior to use-

 Pethick test
 Blocking the inner tube
• IMAGE
MAPLESON E
• A length of tubing attached to T piece to form reservoir ( no bag)
• Fresh gas enters the system through side arm and the expired gas is vented into the
atmosphere through the expiratory limb
• Exp limb volume grater than the patient’s tidal volume prevents entrainment of room air
• FGF > 3 times MV
CONTD..
• For spontaneous respiration expiratory limb is open to atmosphere
• Controlled ventilation performed by intermittently occluding the expiratory limb and
allowing the fresh gas to inflate the lung
• Sequence of events similar to mapleson D
• Used for administering oxygen
MAPLESON F (JACKSON REES )
• Open ended reservoir bag fitted to expiratory limb of ayre’s T piece ( relief mechanism for
venting exhaled gases

• Internal volume of tube between the patient and the bag should exceed patient’s tidal
volume

• Light weight , no valve, low resistance – suitable for use in pediatric patients( under 20 kg
weight
CONTD…
• Spontaneous ventilation- exhaled gases pass down the expiratory limb , mix with fresh
gas
• Expiratory pause allows fresh gas to push the exhaled gas down the expiratory limb ,
including the reservoir bag
• FGF of 2-3 times MV – with spontaneous ventilation ( for a 20 kg child MV 3l/min; FGF
6-9 l/min)
• Controlled ventilation – normocapnia can be maintained with a FGF of 1l+ 100 ml/kg/min
ADVANTAGES OF MAPLESON SYSTEM
• Simple
• Light weight
• Inexpensive
• Low resistance
• Low dead space
• All parts can easily be sterilised and cleaned
DISADVANTAGES
• High FGF- wasteful, costly
• Rebreathing if inadequate FGF
• Loss of heat and humidity
COMBINED BREATHING SYSTEM
• David Humphrey desgined Humphrey ADE
• Two reservoir one in afferent other in efferent limb
• Single circuit that can be changed from mapleson A to a Mapleson D by moving a lever
CONTD…
CIRCLE SYSTEM
• Gases flow in a circular pathway through separate inspiratory and expiratory channels

• Exhaled CO2 is removed by an absorbent

COMPONENTS
• Absorber ( in canisters , are transparent )

• Two ports for connection to breathing tubes and a fresh gas inlet

• Other – insp/exp unidirectional valves, an APL valve, a bag mount

CONTD….
• Image
CONTD….
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ABSORPTION PATTERN
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 ABSORBENTS
• Base neutralising acid, exothermic reaction- for each molecule of CO2 removed one mole of
water is produced
• Mainly calcium hydroxide
• Others-sodium hydroxide (1.5%-5%) (soda lime)
• Barium lime (85% CaOH,11 % BaOH and 4 % KOH)
• Moisture content is between 14% to 16%
• Reaction – CO2 + H2O= H+ + HCO3-
2 NaOH + H+ + HCO3 = Na2CO3 + 2H2O
Na2CO3 + Ca(OH)2 = CaCO3 + 2 NaOH
CONTD……
• Absorbents with high conc of sodium/potassium hydroxide- when desicated
 React with volatile anaesthetics to form CO
 With sevo, compound A, forrmaldehyde and methanol
 Do not change colour on drying
 With decreasing moisture decreased CO2 absorption
CONTD…
• Alkali free absorbents- indicators are present which change colour on drying
• image
CONTD…
• Absorbents are supplied as pellet or granules optimal size between 1.5 and 5 mm in
diameter

• In USA soda lime supplied at between 4-8 mesh size while in UK 3-10 mesh size
• Absorptive capacity – traditional soda lime 25 l of CO2 per 100 g and barium lime 27 l per
100 g
 SODALIME VS BARIUM LIME
sodalime
• CaOH – 84 %
• Contains NaOH(1.5-5%)
• Water content 14-16%
• Needs hardener
• Some CO is produced
• Increase in temperature much less
with soda lime
Barium lime
• 80%
• BaOH (11%)
• As water of crystalisation
• No hardener needed
• Greater tendency to produce CO
• V high temperature with sevoflurane
HARDENERS
• Commonly used zeolite, calcium chloride and silica

• Normal hardness no should be greater than 75

OTHER COMPONENTS
• APL valve

• Reservoir bag

• Bag/ventilator switch
SUMMARY
• At present among mapleson only systems A,D,E, and F and some of their modifications
are used
• Ranking based on superiority-
spontaneous ventilation- A>D,F,E>C,B
controlled ventilation- D,F,E>B,C>A
THANK YOU