BREATHING SYSTEMS, CIRCLE SYSTEM

AND COMPONENTS
DR T Y J SHAMU DZVANGA
 OUTLINE

INTRODUCTION
DEFINTION
TYPES OF BREATHING SYSTEMS
CLASSIFICATION
CIRCLE SYSTEM
ADVANTAGES AND DISADVANTAGES
 INTRODUCTION-The Ideal Breathing System
• Simple and safe to use
• Delivers the right gas mixture
• Allows all methods of ventilation in all age groups
• Efficient
• Pressure relief
• Sturdy, small and light
• Allows easy removal of waste gases
• Easy to maintain with low running costs
• minimal dead space
• low resistance
• heat conservation
• economy of fresh gas
 DEFINITION
• Breathing system / Circuit
• structure used to connect patient airway to anaesthetic
machine
• delivers gas to the patient and removes carbon dioxide
• we can thus achieve:
spontaneous/ manual/ controlled ventilation
• RESULT: artificial environment through which a patient
can breathe during anaesthesia
 Breathing System Components
• Fresh Gas connection
• Patient connection
• Adjustable Pressure Limiting (APL) Valve
• Reservoir (Bag or bellows)
• Tubing
• Waste gas connection
 components
• 1. APL valve- variable pressure
• a one-way, spring-loaded valve
• xs FGF and exhaled gases are vented out
• room air does not enter
• At pressure > opening P of valve, controlled leak of gas
• Control of the patient’s airway pressure.
• valce actuates at min P of 1cm H2O.
• P>60cm , safety mechanism activated
• spring adjusts P for
opening valve
APL VALVE
• low surfce area
contact:knife edge
seating
• P>opening valve P gas
escapes
• spont vent: pt
generates pos P in exp
=valve opens
• pos P vent:adjust vave
dial =controlled leak
safety ft problems
• hydrophobic disc • risk of barotruma when
• P relief at 60cmH2O closed during PPV
• malfunxn=xs neg P =high
deadspace
RESERVOIR BAG
 2.Reservoir bag
• Plastic or anti static rubber, and can come in sizes between 0.5 to
6L
• a. Acts as a reservoir for gases to be stored during exhalation
• b. Acts as a reservoir , ensures adequate supply of required flows
during inhalation
• c. assess, assist or control ventilation manually
• d. Protects the patient from excessive pressure; up to 40cmH2O
• Laplace’s Law = 2T/R: P falls when R inc
 TUBING
• The inspiratory limb - fresh gas flow to the patient for
inspiration.
• The expiratory limb -passage of expired gas from the
patient.
• diameter is of standard size: 22mm for adult and 18mm
for paediatric systems.
• corrugations=less kinking
• should promote laminar flow
• gas reservoir
• Apparatus dead space can be defined as that part of the
breathing
• system from which exhaled alveolar gases are rebreathed
without any significant change in their carbon
• dioxide concentration. The volume of the apparatus dead
space should be kept to as small as possible or
• else rebreathing of carbon dioxide could result in
hypercapnia.
 types of breathing systems
• 1. open - FGF from atmosphere alone (no circuit)
• 2. semi open- atmosphere and an apparatus eg.
Schimmelbusch mask, Mapleson systems
• 3. semi closed- closed to atmosphere : FGF >uptake, xs
is scavenged
• can be : A. rebreathing(exp 5%co2 +lessO2) eg. circle
circuit
• B. non rebreathing eg. ICU ventilator
• 4. closed - closed to atmosphere ; FGF=UPTAKE,CO2
eliminated, total rebreathng
 factors affecting amount of rebreathing
• 1. circuit design
• 2. ventilatory mode
• 3.FGF rate
• 4. breathing pattern of patient
• FGF= measure of efficiency
 another classification
• 1. CO2 absorber
• 2. no CO2 absorber
• this classification was proposed by Conway
 Semi-open Systems

• -described by Prof. WW
Mapleson from University of
Wales, Cardiff 1954
• -It is known today as “
MAPLESON ALPHABET”
• -aka CO2 washout
circuits(no absorber) / flow
controlled systems
• -no valves
• -rebreathing occurs when
insp flow> FGF
 Types of Semi-open Circuit Systems
• Mapleson D or Bain System
• Mapleson A or Magill System
• Mapleson A or Lack System
• Mapleson F or Ayres T Piece System
• Mapleson F with APL Valve
• Mapleson C Bagging System
Mapleson Systems Uses FGF SV FGF IPPV

A Magill
Lack
Spontaneous
Gen Anaesthesia
70-100 ml/kg/min Min 3 x MV

B Very uncommon,
not in use today

C Resuscitation
Bagging
Min 15 lpm

D
Bain Spontaneous 150-200 70-100 ml/kg/min
IPPV, Gen. Anaes ml/kg/min

E Ayres T Piece Very uncommon,

not in use today

F Jackson Rees Paediatric

<25 Kg
2.5 – 3 x MV
Min 4 lpm
 A-magill (1920)system

1950’s

• best for spontaneous FGF =MV

• 110cm tubing , vol 550 ml
• drag due to position of APL valve
• inefficient for mechanical ventilation FGF 3X
 spont breathing with Magill
• 1st insp: pt breathes in FG rate greater than FGF , RB
empties partially
• expiration: exhaled gas pushes FG to RB filling it
• P builds up opening APL valve, exhaled gases vented out
• 1st part of EG = ANATOMICAL DEAD SPACE
• 2nd part = ALVEOLAR GAS (vented out )
• end exp pause: prevents rebreathing , cont FGF vents out
all alveolar gas and some dead space gas
 possible problems enocuntered with magill
• high RR = small end exp pause inc rk of rebreathing
• gas mixture may occur
• Vt that is too large may be exhaled and enter RB
 controlled ventilation
• insp phase: close APL
• FG vented out when bag is squeezed
• exp phase: RB almost empty, pt exhales and pushes
DSG+AG along hose and into RB
• APL valve not actuated( RB not full)
• 2nd squeeze : AG enters pt lungs , high FGF required
• APL valve eventually opened when enough P builds up
 LACK SYSTEM

1976

• modified magill
• parallel or single(coaxial) tubing
• less drag due to APL position
• better access to valve during head and neck surgery
• double tubing makes it heavy
 components of lack
• 1,8m tubing
• coaxial - inner 15mm, outer 30mm
• RB and APL at machine end
• problems:coaxial system may split reducing efficiency
• parallel tubes preferred but inc weight
 MODIFIED MAPLESON A - LACK
• FGF thru the outside tube & exhaled gases travel
down the inner tube towards the exp valve;
• The inner tubing is wide enough to prevent resistance
to exp & hence an ↑ in the work of breathing
• A FGF of ~70ml/kg/min is required in order to prevent
rebreathing making it efficient for spont vent
• It is not suitable for controlled vent
• A parallel tubing version exists and retains the same
flow characteristics as the coaxial version
 Mapleson D (Bain)

1972

• best for mechanical ventilation

• Low dead space as FG enters close to pt end
 spontaneous resp-Mapleson D
• 1st breath:
• FGF enters tubing and RB is filled so patient breathes FG
• inspiratory rate is greater than FGF bag begins to empty
• Expiration: exhaled gases mix with FG entering and
move down tubing
• displace fresh gas remaining and fill the reservior bag
• RB full= remainder of the exhaled gases + FGF are voided
via the APL valve
• DSG voided first then AG
• During End- expiratory pause: FGF moves down tubing
and pushes EG+FGF = vented via APL VALVE
• FG in pt end of tubing depends on:
a. the fresh gas flow rate
b.The duration of the end expiratory phase
c.The degree of mixing (due to turbulence)
• 2nd inspiration :IG = stored fresh gas then EG +FG
• Expiratory pause may be short eg use of volatile agents
with minimal opioid supplementation.
• The FGF has to be high at least 2-3 times the minute
ventilation to counter this.
 Mapleson D with controlled ventilation

1st inspiration:
• anaesthetist squeezes the bag , FG goes to pt , some
gas from RB vented out via APL valve
Expiration
• FGF + EG passes along the hose, eventually entering the
now partially deflated reservoir bag causing it to refill
• During EP FG replaces and drives mixed gas out the
valve
2nd inspiration(anaesthetist squeezes bag)
• FGF + Stored FG+EG pass to the patient
• some of the mixed gases within the bag escape via the
APL valve.
 The bain system
• Modified Mapleson D
• co-axial circuit, introduced in 1972 by bain and spaerel
• 1metre in length of corrugated tubing
• inner tube - FGF 7mm
• outer tube - EG 15mm
- the nuffield penlon 200 for mechanical ventilation
• Outer tubing of a bain circiut is made of clear plastic and
the inner green/black
• In an adult fresh gas flow of 70-80ml/kg/min will maintain
a normal arterial CO2 tension
 problems with BAIN
• damage /detachment of inner tube may inc dead space
• reduce efficiency of ventilation
• inc rebreathing if leak present
• A leak will result in rebreathing of ventilator gas resulting
in ,awareness, hypoxaemia and hypercapnia
• In an adult fresh gas flow of 70-80ml/kg/min will maintain
a normal arterial CO2 tension
 CHECKING THE BAIN CIRCUIT

• prior to use mst be tested for leaks by :

• 1.occluding the patient end, closing the APL valve, and
pressurizing the system.
2. APL valve is opened.
3. The bag should deflate easily if the valve and scavenging system
are working properly.
• Either the user or a patient should breathe through the system to
detect obstructions.
 testing the bain circuit
• the inner tube must be tested for damage by:
1.set a low flow
2.occlude inner tube with plunger of 2ml syringe at the
patient end while observing the flowmeter indicator.
• intact and correctly connected=the indicator will fall .
• also confirmed by activating the oxygen flush and
observing the bag . (pethick test)
• venturi effect caused by high flow of 02 at pt end- neg
pressure created at outer tube
The bain system
 Mapleson E and F systems
• T-piece system
• body of the T-piece is within the breathing system
• two ends
• 1. connected to pt via short tubing
• 2.connected to length of tubing - reservoir
• The volume of this limb makes up the apparatus dead
space
 mapleson E
• A.K.A Ayre’’s ‘’T’’-
piece(1937)
• low R , good for paeds
• similar to D system
• tube fills with
FG+EGduring expiration
• fills with FG durg exp
pause
• FGF 2-3X MV
• MIN flow of 4L/min
• The dimensions of the reservoir limb and the FGF rate are governed
by the following considerations:
1.diameter of the reservoir limb must give low R
2. volume of the expiratory limb >Vt
reasoning:
a. Too great a volume would matter only in that the greater length
would lead to increased resistance.
b.Too great a diameter would lead to altered mixing of the fresh gases
with alveolar gas and to inefficiency of the system.

For an adult a standard 110cm length of corrugated hose is

satisfactory.
• attaching a feather to the open end- visual indicator
• CPAP by occluding open end with finger
• problems were overcome by adding open ended bag
 Mapleson F
• A.K.A. Jackson –Rees
modification
• Has a bag attached to the
expiratory limb
• Movement of the bag can
be seen during
spontaneous breathing
• bag can be compressed to
provide manual ventilation
 Advantages of the bag
• Provides visual evidence of breathing during spontaneous
ventilation
• Provides a convenient method of assisting or controlling
ventilation
• Provides a degree of CPAP during spontaneous
ventilation and PEEP during IPPV
• By occluding the open end of the bag temporarily it is
possible to confirm that fresh gas is entering the system
• Suitable for children under 20kgs
• FGF of 2-3 times minute volume should be used during
spontaneous ventilation
• During controlled ventilation in children normocapnia can
be maitained with a fresh gas flow of 1000mls
+100mls/kg
 Mapleson F with APL Valve

1998 • Intersurgical decided to

modify the Jackson-
Rees by using a closed
tail bag and a specially
modified APL valve.
Now the waste gases
can be removed safely
from the system via the
APL valve’s 30mm
outlet.
 Mapleson B and C systems
• FGF, RB and APL valve closer to the patient
• easy access
• Allows the fresh gas source to be sited at a distance if
necessary
• inefficient system
• 1st inspiration: pt breathes FGF only
• expiration: DSG + AG +FGF pass to reservior bag.
• After the refilling is complete, the remainder of the
exhaled gases and the FGF are voided via the APL valve
End-expiratory pause:
• It is the fresh gas that escapes from the APL valve as this is
closer to the valve than the bag
2nd inspiration:
• It is supplied by contents of the bag which has a mixture of
fresh ,dead space and alveolar gas
• The proportion is determined by the fresh gas flow rate and the
rate at which exhalation occurred
• If the fresh gas flow is high and the exhalation rate was slow,
there will be a greater amount of fresh gas in the inspirate
Mapleson C Bagging System

• It can be found all over

the hospital for use as
an emergency bagging
system for resuscitation
or manual ventilation
using oxygen, as well
as being a standard
induction system in
some countries.
 Advantages of the Mapleson Systems

• simple, inexpensive,
• no moving parts except the APL valve
• easy to disassemble and can be disinfected or sterilized in a
variety of ways.
• Variations in minute volume affect end-tidal CO2 less than in a
circle system.
• In coaxial systems (Lack, Bain), the inspiratory limb is heated
by the warm exhaled gas in the coaxial expiratory tubing.
• Resistance is usually low at flows likely to be experienced in
practice .
• lightweight and not bulky.
• less drag on the mask or tracheal tube or accidental
extubation.
• easy to position conveniently.
• may be used to ventilate a patient in the MRI unit .
• Changes in fresh gas concentrations result in rapid
changes in inspiratory gas composition.
• no CO2 absorbent, no production of possibly toxic
products
 Disadvantages of the Mapleson Systems

• high gas flows- expensive, pollution

• low inspired heat and humidity .
• change the flow when changing from spontaneous to
controlled ventilation
• rebreathing may occur. with changes in FGF
• APL valve may be inaccessible to the user.
• Mapleson E and F systems are difficult to scavenge,
• not suitable for patients with malignant hyperthermia
 Combination of the Mapleson A, D and E Systems
- The Humphrey A D E Circuit

• David Humphrey designed

• can be changed from A to D to E
• Done by moving a lever on the metallic block .
• RB at FGF inlet
• gas is conducted to and from the patient down the
inspiratory and expiratory limbs of the circuit.
• position of the control lever at the Humphrey block, gases
either pass through the expiratory valve or the ventilator port.
• It consists of :
1. 2 parallel tubes -15 mm bore one delivers fresh gas and
the other carries exhaled gas.
• One end -connects to the patient via a Y-connection
• other end -contains the Humphrey block
2. APL valve,
3.a lever to select spontaneous or controlled ventilation,
4.reservoir bag,
5. connection port
6. a ventilator and a safety pressure relief valve which opens
at a pressure above 6 kPa.
 MOA - HUMPHREY BLOCK
1.“up” the reservoir bag and the expiratory valve are used,
creating a Mapleson A type circuit.
2 “down” position the bag + valve are by-passed =ventilator
port is opened Mapleson D controlled ventilation.
3. If port is left open the system will function like an Ayre's T
piece (Mapleson E ).

Possible problems :
• moving lever “up” to “down” whilst gases are flowing,RB
remains full causing obstruction to manual ventilation.
 tri service apparatus
• simple , portable, draw over
• designed by the British armed forces for use in battle conditions .
• It comprises :
1. self-inflating bag,
2. a non-rebreathing valve which vents all expired gases to
atmosphere,
3.2 Oxford miniature vaporizers
4.an oxygen supply + corrugated tubing
-spont/controlled vent
 Re-breathing systems

• reduce the risk of atmospheric pollution

• increase the humidity of inspired gases
• reduce heat loss from the patient.
• may be used as 'closed ' systems,
• used with a small leak through a spill valve
• exceeds basal oxygen requirements.
• require CO2 absorber
 circle system
• can be closed(FGF same as pt uptake), semi closed
(intermediate FGF), semi open (high FGF)
• most commonly used system
• allows for conservation of moisture and heat
• allows for adjustment of vent settings
• economy of gases
• easy scavenging
• first devised by Brian Sword in 1926 and require smaller
amounts of fresh gas each minute.
• The soda lime canister is mounted on the anaesthetic
machine,
• and inspiratory and expiratory corrugated tubing conducts
the gases.
MOA-CIRCLE SYSTEM
• Inspiration - Inspiration causes the expiratory valve to
close
• gas flows from the RB to the patient via the inspiratory
limb of the circuit.
• Anaesthetic is taken up from the in-circuit vaporiser (VIC),
if fitted.
• Expiration - The inspiratory valve closes and gas flows
into the RB via the expiratory limb.
• CO2 is absorbed by the soda lime canister. Excess gas is
vented when necessary via the pressure-relief valve.
 CLOSED AND SEMI CLOSED
The circle absorber may be used as a closed or semi-closed
system:
• Closed systems: the pressure-relief valve is closed so that
no gas escapes from the system.
• O2 flows into the system to replace that consumed by the
patient, and exhaled CO2 is absorbed by the soda lime.
• The advantage of closed systems :
• 1.anaesthetic and O2 consumption and atmospheric
pollution, is minimised.
• The disadvantages are:

• (a) The system is inherently unstable, in that if the fresh

gas flow is not matched exactly to the patient's O2
consumption, the system will over-fill or empty, and the
patient will be unable to breathe.
• (b) The fresh gas flow rate is usually too small to allow
use of a precision, out of circuit vaporiser.
• Semi-closed systems:
• a.the pressure relief valve is opened, allowing excess gas
to escape from the system.
• This allows higher fresh gas flow rates to be used.
• The advantages of semi-closed systems are:

• (a) The system is more stable in that, if the system fills to

capacity, the excess gas is simply lost via the pressure-
relief valve.
• (b) The higher flow rates allow use of a precision, out of
circuit vaporiser.

• The disadvantage is increased anaesthetic and O2

consumption and atmospheric pollution.
 unidirectional valves
• usually of the turret type
-pressure generated by the
pts breathing causes the
disc to rise and allows gas to
pass in one direction only.
- operation of the valve may
be observed via a
transparent dome.
• mica, ceramic or plastic.
• Plastic- tends to warp and allow the
valve to become incompetent.
• valve sticking in the open position
due to water vapour- reduce the
efficiency
• results in rebreathing and
consequent CO2 retention.
• may be made of rubber-harden with
time
 Inspiratory and Expiratory Ports

Y-piece
• The Y-piece (Y-piece connector, Y-connector, Y-yoke, Y-adaptor, three-
way breathing system connector)
• three-way tubular connector -22-mm male ports -breathing tubes
• 15-mm female patient connector for a tracheal tube or supraglottic
airway device.
• The patient connection port usually has a coaxial 22-mm male fitting to
allow direct connection between the Y-piece and a face mask.
• Y-piece and breathing tubes are permanently attached.
• septum may be placed in the Y-piece to decrease the dead space.
• The breathing tubes attach to the inspiratory and expiratory ports.
.
Fresh Gas Inlet
• connected to common gas outlet by flexible tubing.
• fresh gas inlet port inside diameter of 4.0 mm
• fresh gas delivery tube has an inside diameter of at least 6.4 mm .

Adjustable Pressure-limiting Valve

• spontaneous breathing: valve is left fully open and gas flows through the
valve during exhalation.
• manual vent: the APL valve should be partially closed
• the valve opens and excess gas is vented to the scavenging system
during inspiration.
• mechanical ventilation : APL valve is isolated from the breathing system.
 Pressure Gauge

• attached to the exhalation pathway.

• usually the diaphragm type.
• P changes in are transmitted to the space between two
diaphragms, they move inward or outward.
• Movements of one diaphragm are transmitted to the
pointer, which moves over a calibrated scale.
The analogue pressure gauge may not be present.
 Breathing Tubes

• Two breathing tubes carry gases to and from the patient.

• Each tube connects to a port on the absorber at one end
and the Y-piece at the other.
• unidirectional gas flow hence dead space indepdt on tube
length.
• The breathing tubes may be concentric or side by side.
• Gases flow through the inner tube to the patient, and
exhaled gases flow to the absorber assembly via the
outer corrugated tube .
• The inspired gas is somewhat warmed in the process
Reservoir bag
• The bag is usually attached to a 22-mm male bag port (bag mount
or extension).
Ventilator
• the ventilator has become an integral part of the circle
Bag/Ventilator Selector Switch
• provides a convenient method to shift rapidly between manual or
spontaneous respiration and automatic ventilation
• The selector switch is essentially a three-way stopcock.
• One port connects to the breathing system.
• The second is attached to the bag mount.
• The third attaches to the ventilator hose.
SWITCH IN ventilator position-the APL valve is isolated
from the circuit, so it does not need to be closed.

Switching to the bag mode causes the APL valve to be

connected into the breathing system.
 Components

Absorber
• The absorber is usually attached to the anaesthetic machine but may be
separate.
• consists of an absorber, two ports for connection to breathing tubes and a fresh
gas inlet.
• inspiratory and expiratory unidirectional valves, an adjustable pressure limiting
(APL) valve, and a bag mount.

Canisters
• The absorbent is held in canisters (carbon dioxide–absorbent containers,
chambers, units, or cartridges).
• The side walls are transparent so that the absorbent color can be monitored.
• A canister with tinted side walls may make it difficult to detect color changes in the
absorbent .
• A screen at the bottom of each canister holds the absorbent in place.
 Absorbents

High-alkali Absorbents
• high amounts of potassium and/or sodium hydroxide.
• When these absorbents become desiccated, they react with volatile
anesthetics to form carbon monoxide.
• Compound A can be formed with sevoflurane.
• These absorbents often do not change color when dry.
• The capacity to absorb carbon dioxide is decreased by DESSICATION.

Low-alkali Absorbents
• carbon dioxide absorbents contain reduced amounts of sodium or potassium
hydroxide.
Alkali-free Absorbents
• Alkali-free absorbents consist mainly of calcium hydroxide
• There is no evidence of carbon monoxide formation with any anesthetic agent.
• There is little or no Compound A formation with sevoflurane even with a closed
circuit .
• The indicator in these absorbents changes color on drying .
• The carbon dioxide absorption capacity of these absorbents is less than
absorbents containing strong alkali but does not deteriorate when moisture is lost

Lithium Hydroxide
• Lithium hydroxide reacts with carbon dioxide to form carbonate.
• It does not react with anesthetic agents.
• expensive and requires careful handling because it may cause burns to the eyes,
skin, and respiratory tract .
Composition of soda lime
 SODA LIME
• CO2 + H2O → H+ + HCO3- → H2CO3,
• then

• 2KOH + H2CO3 → K2CO3 + 2H2O,

• then

Ca(OH)2 + K2CO3 → CaCO3 + 2KOH

or
• CO2 + 2NaOH → Na2CO3 + H2O + heat,
• then

Ca(OH)2 + Na2CO3 → CaCO3 + 2NaOH

• There is regeneration of both NaOH & KOH at the
expense of Ca(OH)2 explaining the soda lime’s
mixture
• Water is required for efficient absorption.
• more is added from the patient's expired gas and from the
chemical reaction.
• The reaction generates heat and the temperature in the
centre of a soda lime canister may exceed 60°C.
• Trichloroethylene degenerates at high temperatures, forming
toxic substances including the neurotoxin dichloroacetylene;
• consequently, trichloroethylene must never be used in
rebreathing systems which contain soda lime.
• Sevoflurane interactS with soda lime to produce
substances that are toxic in animals.
• There is new evidence suggesting that the presence of
strong alkalis such as sodium and potassium hydroxide
could be the trigger of the interaction between volatile
agents and soda lime.
• New carbon dioxide absorbers are now being
manufactured without these hydroxides in order to reduce
this interaction.
 Indicators
• An indicator is an acid or base whose color depends on
pH.
• It is added to the absorbent to signify when the
absorbent's ability to absorb carbon dioxide is exhausted.
• The indicator does not affect absorption.
• Ethyl violet is most commonly employed, because the
color change is vivid with a high contrast .
Indicator Colour when fresh Color when exhausted

Ethyl violet white purple

phenolphthalein white Pink

Clayton yellow red yellow

Ethyl orange orange Yellow

Mimosa Z red white

Shape and Size
• Absorbents are supplied in pellets or granules.
• Pellets or small granules provide greater surface area and
decrease gas channeling along low-resistance pathways.
• they may cause more resistance .
• Granule size is measured by mesh number.
• A 4-mesh strainer has four openings per square inch one
• 8 mesh has eight openings per square inch.
• Granules graded 4 mesh will pass through the 4-mesh
strainer but not through a strainer with smaller holes.
• higher the mesh number, the smaller the particles.
 HARDNESS

• Some absorbent granules fragment easily, producing dust (fines).

• Excessive powder produces , resistance to flow,

• Dust may be blown through the system to the patient or may cause
system components to malfunction.
• small amounts of a hardening agent are added.
• Some manufacturers coat the outside of the granules with a film to
which dust particles adhere.
• If a filter is used on the inspiratory side of the breathing system, dust
should not reach the patient.
 Carbon Monoxide Formation

• Carbon monoxide is produced when desflurane,

enflurane, or isoflurane is passed through dry absorbent
containing a strong alkali (potassium or sodium
hydroxide)
• sevoflurane is degraded by absorbent=carbon monoxide
is formed if the temperature exceeds 80°C .
• The carbon monoxide concentration in the breathing
system varies with time, tending to peak in the first 60
minutes .
• No significant carbon monoxide production occurs with normally
hydrated absorbents
• The highest carbon monoxide levels have been seen with
desflurane followed by enflurane then isoflurane .
• The amount of carbon monoxide produced with halothane is small.
• Carbon monoxide formation is reduced by carbon dioxide
absorption .
• This could be significant with smaller patients who produce less
carbon dioxide. Carbon monoxide levels are increased with reduced
patient size .
• Absorbent Storage and Handling
• Absorbents are supplied in several types of containers: resealable packages,
pails, cans, cartons, and disposable prefilled containers.
• Once opened, containers should be resealed as soon as possible to prevent
absorbent reaction with carbon dioxide in the air, indicator deactivation, and
moisture loss.
• High temperatures will have no effect on absorbents if the containers are
sealed, but temperatures below freezing are harmful because the moisture will
expand and cause the granules to fragment.
• Absorbents should always be handled gently to avoid fragmentation and dust
formation. All personnel involved in handling absorbents should be periodically
warned that absorbent dust is irritating to the eyes and respiratory tract and that
absorbents are caustic to the skin, particularly when damp.
• The canister should always be filled with care.
• It should be held over a suitable container to avoid getting
particles on the floor.
• If a double-chamber absorber is used, the absorbent in
both canisters should be changed at the same time.
 Spontaneous Breathing

• Inspiration
• gas flows from the RB and through the absorber, where it joins
with the fresh gas and flows to the patient.
• Exhalation
• exhaled gases pass into the reservoir bag until it is full.
• Then excess gases are vented through the APL valve.
• inspiratory unidirectional valve is closed= fresh gas entering the
system flows in a retrograde direction through the absorber,
pushing the gas in the absorber toward the APL valve.
• The first gas to be vented through the APL valve = exhaled gas
containing carbon dioxide
• HIGH FGF some gas that was in or has passed through the
absorber will flow retrograde and pass into the reservoir bag or be
expelled through the APL valve.
• If FGF is high enough, fresh gas may also be lost through the
APL valve.
• Low fresh gas flows may not flow retrograde into the absorber.
 Manual Ventilation

Inspiration
• manual ventilation: excess gases are vented through the partially open APL
valve during inspiration.
• The gas flowing through the absorber and ultimately to the patient will be a
mixture of fresh gas and exhaled gases.
• The amount of fresh gas will depend on the fresh gas flow and the degree
that retrograde flow occurred during the previous exhalation.

Exhalation
• exhaled gases flow into the reservoir bag
• Fresh gas flows retrograde through the absorber.
• AT LOW FGF :fresh gas may not enter the absorber.
• AT HIGH FGF: some fresh gas may flow retrograde through the absorber and
even enter the bag.
 Mechanical Ventilation

Inspiration
• gas flows from the ventilator through the absorber and inspiratory
unidirectional valve to the patient.
• The gas in the ventilator bellows will consist of exhaled gas and, if the
fresh gas flow is high, fresh gas that has passed retrograde through the
absorber.
Exhalation
• exhaled gases will flow into the ventilator bellows.
• FG will pass retrograde through the absorber.
• Excess gases are vented through the spill valve in the ventilator in the
latter part of exhalation.
• The longer the exhalation time and the higher the fresh gas flow, the
more likely that fresh gas will pass retrograde through the absorber.
 Heat and Humidity

• moisture is available from:

1. exhaled gases
2.the absorbent
3.water liberated from the neutralization of carbon dioxide.
Gases in the inspiratory limb of a circle system are near
room temperature.
• Even with low fresh gas flows, gases reach the Y-piece
only 1°C to 3°C above ambient temperature.
• The humidity increases gradually with use and then
stabilizes.
• Higher humidity results from :
1.lower fresh gas flows
2.increasing ventilation,
3.locating the fresh gas upstream of the absorber,
4.wetting the inspiratory tubing
5.humidifier, smaller canisters, or coaxial breathing tubes..
 Nitrogen

• Nitrogen is important, because it hinders establishing high concentrations

of nitrous oxide and may cause low inspired oxygen concentrations.
• Before any fresh gas is delivered, the concentration of nitrogen in the
breathing system is approximately 80%.
• Nitrogen enters the system from exhaled gases and leaves through the
APL valve, ventilator spill valve, and leaks.
• Using high fresh gas flows for a few minutes to eliminate most of the
nitrogen in the system and much of that in the patient is called
denitrogenation.
• There is no set time or flow that will produce adequate denitrogenation in
all cases .
• A tight mask fit is necessary for proper denitrogenation, as air will be
inspired around a loose-fitting mask.
 Anesthetic Agents

The following influence the concentration of anesthetic agent in the inspired

mixture:
• uptake by the patient,
• uptake by components of the system,
• arrangement of system components,
• uptake and elimination of other gases by the patient,
• volume of the system,
• concentration in the fresh gas flow,
• degradation by the absorbent,
• fresh gas flow.
• It is not possible to predict the concentration accurately unless a high fresh gas
flow is used.
• The greatest variation occurs during induction
• anesthetic uptake is high and nitrogen washout from the patient
dilutes the gases in the circuit.
• High flows are also commonly used at the end of a case to
increase the elimination of anesthetic agent. T
• rate of elimination may be increased by bypassing the absorber
• malignant hyperthermia- increasing the fresh gas flow is the
most important measure that will aid in washing out anesthetic
agents from the patient.
 Circle System with Low Fresh Gas Flows

• Definitions
• Low-flow anesthesia has been variously defined as an
inhalation technique in which a circle system with absorbent is
used with a fresh gas inflow of less than the patient's alveolar
minute volume, less than 1 L/minute),
• Closed system anesthesia is a form of low-flow anesthesia in
which the fresh gas flow equals uptake of anesthetic gases and
oxygen by the patient and system and gas sampling.
• No gas is vented through the APL valve.
 Techniques

• Induction
• More commonly, induction is accomplished by using high flows to
allow :
• denitrogenation,
• establish anesthetic agent concentrations,
• and provide oxygen well in excess of consumption.
• During intubation, the vaporizer should be left ON and the fresh
gas flow turned to minimum or OFF.
• After gas exchange has stabilized, lower fresh gas flows are used.
Maintenance
-nitrous oxide and oxygen flows and vaporizer settings
should be adjusted to maintain a satisfactory oxygen
concentration and the desired level of anesthesia.
 Advantages

• Economy of inhal agent

• Reduced Operating Room Pollution
• Reduced Environmental Pollution
• Fluorocarbons and nitrous oxide attack the earth's ozone layer,
and nitrous oxide contributes to the greenhouse effect .
• Estimation of Anesthetic Agent Uptake and Oxygen Consumption
• In a closed system without significant leaks, the fresh gas flow is
matched by the patient's uptake of oxygen and anesthetic agents .
• low FGF causes inc delay time from inc volatile agent to cause inc
effect
 Heat and Humidity Conservation

• With lower gas flows, inspired humidity will be increased,

and the rate of fall in body temperature reduced .
• The incidence of shivering is lowered
• Less Danger of Barotrauma
• High pressures in the breathing system take longer to
develop with lower flows.
 Disadvantages

• More Attention Required

• This requires frequent adjustments.
• Inability to Quickly Alter Inspired Concentrations
• The use of low fresh gas flows prevents the rapid changes
in fresh gas concentration in the breathing system that
occurs with high gas flows. .
• Danger of Hypercarbia
• Hypercarbia resulting from exhausted absorbent,
incompetent unidirectional valves, or the absorber being
left in the bypass position will be greater when low flows
are used.
 • Vaporizer inside the circle (VIC).

Drawover vaporizers with a low internal resistance may be

placed within the circle system.
• During each inspiration, vapour is added to the inspired gas
mixture. In contrast to a VOC system, the inspired
concentration is higher at low FGF rates because the expired
concentration is diluted to a lesser extent and the vaporizer
adds to the concentration present in the expired gas.
• Very high concentrations of volatile agent may be inspired if
minute volume is large; this risk is greatest if IPPV is employed.
 VOC

• precision vaporiser may be used to introduce a precisely

known concentration of anaesthetic into the circuit.
• rate of change of anaesthetic concentration in the circuit
depends upon the fresh gas flow rate:
a high fresh gas flow rate will achieve equilibration much
faster than if a low fresh gas flow rate is used
 Using the Circle System to Deliver Oxygen

• Supplemental oxygen should be delivered by using an auxiliary

flowmeter or a flowmeter attached to the piped oxygen system.
Advantages
• Low fresh gas flows can be used with the physiological,
economic, and environmental advantages of rebreathing.
• PaCO2 depends only on ventilation, not fresh gas flow.
• It may be the best system for patients with malignant
hyperthermia.
 ADVANTAGES OF CIRCLE SYSTEM
• Economy of anaesthetic consumption
• Warming and humidification of the inspired gases
• Reduced atmospheric pollution
 disadvantages of circle system

• The circle system is composed of many parts that can be arranged

incorrectly or may malfunction
• large number of connections that can become disconnected or
leak.
• Some components are difficult to clean.
• The system is relatively bulky and not easily moved.
• The use of an absorbent may result in formation of carbon
monoxide or Compound A.