ARBAMINCH UNIVERSITY DEPARTMENT OF ANESTHESIA

Anesthesia Machine
05/21/2024 1
Modern Anesthesia Workstation
BASIC FUNCTIONS
1. Receives medical gases from gas supply
2. Controls flow & reduces pressure to safe levels
3. Vaporizes volatile anesthetics into the mixture
4. Delivers gasses to a breathing circuit connected to
patient
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The Anesthesia
Machine
Consists of high pressure,
intermediate pressure, and low
pressure circuits

High Pressure
Intermediate
Pressure

Low Pressure

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 Medical gas supply
What are the main gases used in anaesthesia?
Oxygen Essential for almost all general anaesthesia;
physiological changes during GA mean patient requires
higher FiO2

Air
Preferable to avoid excessive FiO2 if possible (requires

judgment)  excessive FiO2 causes lung damage an

decreases post-operative respiratory function

N2O Variable use by anaesthesiologists. Used particularly for

smooth gas inductions and for intra-operative analgesia

05/21/2024 by some. 4
 Medical gas supply
How are they produced?

Oxygen (1) Fractional distillation of liquid air

(2) Oxygen concentrators

Air Compression of clean air

N2O Thermal decomposition of ammonium nitrate:

NH4NO3  2H2O + N2O

250°C

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 Medical gas supply
How are they supplied?
Oxygen (1) Cylinders in theatre
(2) Cylinder manifold (piped to theatre)
(3) Oxygen concentrator
• Piped to theatre
• To fill cylinders
• Directly at bedside
(4) Vacuum insulated evaporator (piped to theatre)

Air (1) Cylinders in theatre

(2) Directly from air compressor (via wall pipes)

N2O (1) Cylinders in theatre

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(2) Cylinder manifold (piped to theatre) 6
 Medical gas supply
How are they supplied?
Cylinders
Thin walled
Molybdenum steel
Can withstand high pressures
Cylinder
Tapered neck
features
Colour coding
Heat sensitive substance in valve; allows as escape
if too hot
Regular examinations; should be recorded on
cylinder
Cylinder sizes
E holds 680 L oxygen
(A J)
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& 1800 L N2O 7
 Medical gas supply
How are they stored? (cont.)
Reference table for gas cylinders

Body Shoulderc Pressure State in

colour olour (kPa) cylinder

Oxygen Black White 13700 Gas

White/black
Air Grey 13700 Gas
quarters

Nitrous Liquid /
Blue Blue 4400
oxide vapour
05/21/2024 8
Gas Supply: Cylinders
& Pipeline
Wall Supply @ 50 psig
Tank Pressure depends on how full
they are and what gas it is

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 Medical gas supply
How is the pressure reduced?

Pressure reduction valves:

These supply gases to the anaesthetic machine at about 4 Bar

(or 400 kPa)

low pressure out

high pressure in

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 Critical Temp 36.5°C
PISS
Full Full
745 psig 2000 psig

½ ½
745 psig 1000 psig

¼ ¼
745 psig
Pin 500 psig
Index
Safety
Must be weighed! System
05/21/2024 11
Calculating how long cylinder contents will last

05/21/2024 12
Calculating how long cylinder contents will
last
• An E cylinder of O2 contains 1800 psig. If the respiratory therapist
runs the cylinder at 4 L/min through a nasal cannula, how long will
it take for the cylinder to reach a level of 200 psig?

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Calculating how long cylinder contents will
last
• The Bourdon gauge on an E cylinder of oxygen shows 800 psi. lfyou
turned on the cylinder with flow at 4 liters per minute, how many
hours will elapse before the tank is empty?

• A full oxygen cylinder has a pressure of 2200 psi and will release
approximately 660 liters of oxygen. The amount of oxygen
remaining in the cylinderis 800/2200 x 660 liters = 240 liters. 240
liters divided by 4 literslmin = 60 min =1 hour.

05/21/2024 14
Check Valves
Prevent backflow of gases throughout
the system as well as prevent
equilibration / loss in cylinders

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Pressure Regulator
These can decrease high pressures to
more moderate values (ie. From cylinder
to 50 psig and in some from 50 to ~15.

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 The anaesthetic machine
Pressures in the anaesthetic machine
O2 failure
alarm

The pressure in the cylinder is 137 Bar;

too high for the anaesthetic machine

The pressure is reduced to 4 Bar to protect the machine (it would still harm or kill
a patient)

After the rotameters, the pressure is reduced to < 1/3 Bar to protect the PATIENT

This requires pressure regulators or pressure release valves

05/21/2024 17
 The anaesthetic machine Pressure

Key concepts
(1) Pressure
N
N / m2 Pressure = force
area
(Pa) m2

Pressure regulators and pressure release valves maintain a constant

pressure

Different regulators may protect the anaesthetic machine (providing

4 Bar) or the patient (by providing <35 kPa, or 1/3 Bar)

These regulators do NOT limit flow; the pressure should be the

same whether the anaesthetic machine is providing 15 L/min or is off

The pressure down-stream of a pressure regulator is NOT

dependent on the pressure up-stream (within wide limits) i.e. the
05/21/2024 cylinder pressure can vary, but the down-stream pressure does 18
not
 The anaesthetic machine Pressure

How does a pressure regulator work?

Spring (force F)
Diaphragm (area A)

High pressure Constant low

in to regulator pressure ‘down-
stream’

Valve
Gas enters the high pressure chamber and passes to the low
pressure chamber via the valve
The pressure in the low pressure chamber exerts a force on the
diaphragm which is balanced by the spring (P = F / A)
If the downstream pressure is too low, the valve opens; if it is too
05/21/2024 high, it closes 19
 The anaesthetic machine Pressure

How is pressure regulated? (cont.)

Pressure release valves have a similar mechanism to

regulators

Excessive pressure allows a valve to open

This allows gas to vent out of the system

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 The anaesthetic machine Pressure

How is pressure measured?

There are a variety of different pressure gauge designs

A Bourdon gauge is common on anaesthetic machines:

Scale
Tubing in
cross section:

Increasing
pressure
Gas in curved tubing

The curved tube is oval in cross-section, and tends to straighten

out with increased internal pressure

The tubing is connected to a pointer such that the pressure in the

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tube is displayed 21
Oxygen “Fail-Safe”
Valve
Safety mechanism whereby a drop in
the supply pressure of O2 will result
in closure of valve and cut off the
non-O2 gas (N2O)

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Oxygen “Fail-Safe” Valve

• Describe the purpose of the fail-safe valve on the anesthesia

machine.
 The fail-safe valve prevents the delivery of hypoxic gas mixtures from the machine in
the event of failure of the oxygen supply. The fail-safe valve goes by many other
names-the oxygen failure safety valve, oxygen failure safety device, low-pressure
guardian system, oxygen failure protection device, pressure sensor shutoff system or
valve, pressure sensor system, and nitrous oxide shutoff valve. [Miller & Stoelting,
Basics. 5e. 2007 pp186; Dorsch, UAE. 5e. 2008 pp991

• At what pressure does the fail -safe valve shut off the flow of N,O or
other gases?
 Line pressures of 15-30 psi will usually close the flow of all gases, except oxygen, to
the common gas outlet. [Dorsch and Dorsch, UAE, 1994, p68]
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Oxygen “Fail-Safe” Valve

• Which anesthetic gas has no fail-safe valve?

Oxygen. [Dorsch and Dorsch, UAE, 1994, ~671-97
• During an anesthetic the fail-safe valve shuts down all non-oxygen
gas flow. What hap- pened?
The oxygen pressure fell below 25-30 psi. When oxygen pressure falls
below 25-30 psi (roughly 50% of normal), a fail-safe valve automatically
closes the nitrous oxide and other gas lines to prevent accidental delivery of
a hypoxic gas mixture to the patient. A gas whistle or electric alarm sounds
to alert the anesthetist to this occurrence. [Morgan and Mikhail, Clin. A
nesthesiol., 1996, p35; Stoelting and Miller, Basics, 2000, p13 11-01

05/21/2024 24
 The anaesthetic machine Oxygen delivery

The oxygen supply failure alarm

Reservoir

Diagram
of alarm Whistle

Machine
circuit

Activation depends on a drop in the oxygen pressure

It does not depend on electricity
Loud alarm
Duration ≥ 7 seconds
Tamper proof
It should turn off other gases and open the circuit to air
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Low-pressure alarm sounds

• What are your actions when the oxygen low-pressure alarm sounds?
 When the oxygen low-pressure alarm soun ds-indicating profound loss of
02, pipeline pressure-fully open the E cylinder, disconnect the pipeline, and
consider use of low fresh gas flows. [Nagelhout &Zaglaniczny, NA, 3rd ed.,
2004, p 1-07

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Flow Control & Flow
Meters
Manual adjustment of the valves
allows different flow of gases to
displace the floating “bobbins”

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 The anaesthetic machine Flow

Key concepts
(2) Flow
Flow = ΔP
R

Flow controllers limit flow, NOT pressure

If a flow control supplies an anaesthetic machine from a cylinder,

the pressure reaching the machine will vary, depending on the
flow settings in the machine:
Suppose the flow meter on the cylinder is set to 10 L/min:
If the flow through the machine rotameters is high, the pressure
reaching the machine may be too low  the flow through the
machine will be limited
But, if the gas flow through the machine is turned off at the
rotameters, the pressure reaching the machine will be the cylinder
05/21/2024 pressure  this may destroy the machine 28
 The anaesthetic machine Flow

How is the flow controlled?

(1) One-way valves within the anaesthetic machine

These prevent gases passing backwards along another pipe, or

being lost from the back of the machine
(2) Flow control (needle) valves are positioned below flowmeters
(rotameters)

Needle

Knob Gas in

A screw thread allows fine adjustment of the needle

The controls are colour coded
The oxygen knob has a different feel to the others (e.g. larger
05/21/2024 knob and different shaped ridges) 29
 The anaesthetic machine Flow

How is flow measured?

(1) Rotameters

These are the obvious vertical glass (or plastic) tubes with a
floating bobbin which indicate gas flow rates through an
anaesthetic machine

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 The anaesthetic machine Flow

How is flow measured? (cont.)

Rotameters
Wider at the top

Read here
Bobbin

Tapered glass tube (which is wider at the top)

A light rotating bobbin or ball in the tube
“Bobbin-stops” at the top and bottom of the tube, to prevent

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the bobbin going out of view (or leaving the tube) 31
 The anaesthetic machine Flow
How is flow measured? (cont.)
Rotameters
Gas passes up the tube
The bobbin floats freely on the gas
Fluting (angled slits) in the bobbin cause it to rotate as it
floats
A pressure difference occurs around the bobbin:
This allows visual
confirmation that it is
floating (not stuck)
Pressure
difference

05/21/2024 32
 The anaesthetic machine Flow
How is flow measured? (cont.)
Rotameters

Gravitational
force (weight)

Force due to pressure

difference
• The pressure difference acts to lift up the bobbin
• Gravity pulls it down
Higher up the tube, it is wider, so the pressure difference is less
At a certain height up the tube, the bobbin reaches an equilibrium
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 this position indicates the flow rate 33
 The anaesthetic machine Flow

How is flow measured? (cont.)

Rotameters: a few details

They must be used vertically

If the bobbin sticks, the reading is inaccurate

An interlock limits risk of hypoxic mixture of N2O and O2

being given (turning off O2 automatically turns off N20)

O2 is last gas to be added to circuit

This reduces risk of only non-oxygen gas reaching patient

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Oxygen Flush Valve
Simple release valve that allows the
50 psig pressure O2 in the
intermediate-pressure circuit to be
released to the common gas outlet.

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 The anaesthetic machine Oxygen delivery

The oxygen flush

This allows rapid filling of the circuit with oxygen

However caution is required:

The flush pressure is 4 Bar; it would cause severe

barotrauma (damage to lungs due to high pressure) –
though it is generally not transferred to the patient

It dilutes volatile agents in a circle circuit (since the O 2

does not go through the vaporiser)

Be CAUTIOUS if you use the oxygen flush,

or you may harm the patient
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Vaporizers
Increase or decrease the amount of FGF
that passes by the vaporized gas thus
controlling the percent of gas delivered.

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 The anaesthetic machine Vaporisers

The role of vaporisers

• to add a clinically useful concentration of

anaesthetic vapour to a carrier gas

• to produce a controlled and predictable

concentration of anaesthetic vapour

• ideally independent of carrier gas flow rate

• ideally independent of temperature

05/21/2024 38
 The anaesthetic machine Vaporisers

Factors affecting vaporiser output

Gas flow rates

By varying the ‘splitting ratio’, the vaporiser output is
controlled

Temperature
As SVP increases, vaporiser output will tend to increase

Ambient pressure
SVP is solely a function of temperature

Therefore, if ambient pressure is reduced, the (constant) SVP

becomes a greater proportion of the total pressure, and the
output concentration rises
05/21/2024 39
 The anaesthetic machine Vaporisers

Vaporiser classification
Draw-over vs plenum vaporisers

Gas is pulled through vaporiser by Gas passes through vaporiser under

negative or low positive pressure pressure at the back bar

Low resistance High resistance; must be outside-circuit

Vaporiser in circle (VIC) vs out of circle (VOC)

Vaporiser is placed within the circle Generally uses plenum vaporiser, but
draw-over vaporisers can be used
Low resistance vaporiser required
Concentration of volatile agent within
High concentrations are possible → the circle is less than that dialled on
safer in spontaneous ventilation the vaporiser output, due to dilution
(because respiration will decrease with with exhaled gas
05/21/2024 excess agent and draw less agent in) 40
 The anaesthetic machine Vaporisers

Vaporiser classification (cont.)

Simple plenum vaporisers

They consist of a glass vaporising

chamber holding the volatile agent

A tap controls the proportion of

gas passing through the chamber

The major advantage is their relatively low cost

05/21/2024 41
 The anaesthetic machine Vaporisers
Vaporiser classification (cont.)
Disadvantages of simple plenum vaporisers

No compensation is
made for changes in
temperature:

The concentration leaving the vaporising chamber is usually unknown

The variable output means these are generally not calibrated

05/21/2024 Adjustments are made according to the response of the patient 42

 The anaesthetic machine Vaporisers
Vaporiser classification (cont.)
Precision plenum vaporisers

• Channels and wicks inside ensure the gas is fully saturated with volatile (at
SVP)

• Compensatory mechanisms for temperature and gas flow

• The proportion of the total gas flow passing through the vaporising chamber is
controlled by a dial which accurately indicates the concentration of the
anaesthetic delivered by the vaporiser
05/21/2024 43
 The anaesthetic machine Vaporisers

Precision plenum vaporisers: temperature compensation

(1) A heavy copper construction acts as heat sink  minimises
temperature fluctuations
(2) Compensation for temperature changes: a valve varies the
proportion of the gas that flows through the vaporising chamber

e.g. in Tec 3 designs, a bimetallic

strip increases flow through the
bypass chamber when
temperature increases

Altered temperature causes differential

05/21/2024
expansion of two metals in bimetallic strip 44
 The anaesthetic machine Vaporisers

Precision plenum vaporisers

Other design and safety features

Stable mechanical mounting

Clear liquid level gauge
Safeguards against leakage if tilted
Interlock system
Agent specific filling ports

05/21/2024 45
 The anaesthetic machine Vaporisers

Precision plenum vaporisers

Advantages
Highly accurate
Independent of time, gas flow rate and temperature

Disadvantages
Expensive

Built for use with a specific agent - can be dangerous if

the wrong agent is used

High internal resistance prevents them from being used

in the breathing circuit
05/21/2024 46
 The anaesthetic machine Vaporisers

Precision plenum vaporisers

The effect of ambient pressure on precision vaporisers

SVP is dependent only on temperature

For a given dial setting; at half normal pressure, volatile agent
partial pressure is unchanged, but will represent twice the relative
concentration in the carrier gas

• The relative concentration of volatile is increased at altitude

• However, the partial pressure will be unaltered
• It is the partial pressure which determines the blood concentration
• Therefore;
the same dial setting is required to anaesthetise
05/21/2024 47
 The anaesthetic machine Vaporisers
A brief note about desflurane vaporisers
Desflurane is extremely volatile (the boiling point of 22.8°C is only
slightly above room temperature)

A desflurane vaporiser is totally different from others

The desflurane is heated and then “injected” into the carrier gas as a spray

The Tec 6 is electrically powered and electronically controlled and so

05/21/2024
requires a mains power supply 48
The anaesthetic machine

• What will happen to the concentration deli-vered to the patient if

isoflurane is placed in a halothane vaporizer? Why?
The delivered concentration of isoflurane will not be different than expected
by the dial setting because isoflurane and halothane have very similar vapor
pressures.
• What will happen to the concentration deli-vered to the patient if
isoflurane is placed in an enflurane or Sevoflurane vaporizer? Why?
The delivered concentration of isoflurane will be greater than expected by
the dial setting because isoflurane has a higher vapor pressure than either
enflurane o r sevoflurane.

05/21/2024 49
The anaesthetic machine

• What will happen to the concentration deli-vered to the patient if

halothane is placed in enflurane o r sevoflurane vaporizer? Why?
The delivered concentration of halothane will be greater than expected dial
setting than enflurane o r sevoflurane. because halothane has a higher
vapor pressure than either

05/21/2024 50
 The anaesthetic machine
The anaesthetic machine: a “circuit diagram” Note: the
pressure of
O2 failure the O2 flush
Wall alarm is 4 Bar
supply

Oxygen
Pressure flush
Oxygen
cylinder regulator Rotameter
with needle
valve
!
13700 kPa (=137 Bar)
CGO
400 kPa (=4 Bar)
<35 kPa (< 1/3 Bar)
Pressure
Vaporiser relief valve
05/21/2024 51
 The anaesthetic machine
Pressures in the anaesthetic machine
O2 failure
alarm

The pressure in the cylinder is 137 Bar;

too high for the anaesthetic machine

The pressure is reduced to 4 Bar to protect the machine (it would still harm or kill
a patient)

After the rotameters, the pressure is reduced to < 1/3 Bar to protect the PATIENT

This requires pressure regulators or pressure release valves

05/21/2024 52
 How anesthesia circle breathing systems work explained simply.

Breathing Circuit
05/21/2024 53
 Breathing systems
Why is this knowledge relevant?

There are several different types of breathing circuit

Here, circle circuits are used currently

There are benefits and disadvantages to any breathing

system

Knowing about the different systems will allow you to make

informed choices about which system is best for a given
situation

Also, it is important to know the limitations of the system

you are using
05/21/2024 54
 Breathing systems
What is the ideal breathing system?
Simple and safe to use

Delivers the intended gas mixture

Permits spontaneous, manual and controlled ventilation

Suitable for all age groups

Efficient (uses low gas flow rates  saves halothane)

Protects the patient from barotrauma

Compact, lightweight and durable design

Permits easy removal of waste gases

Easy to maintain
05/21/2024 55
 Breathing systems
A few definitions

Tidal volume
The volume of gas inspired & expired with each breath
Typically ≈7 mL / kg
(or 500 mL for 70 kg patient)
Minute volume
The total volume breathed in a minute
Typically ≈100 mL / kg / min
(or 7000 mL / min for 70 kg patient)
Alveolar minute volume
The volume undergoing gas exchange per minute
( = RR x [tidal vol – dead space] )
Typically ≈70 mL / kg / min
(or 5000 mL / min for 70 kg patient)
05/21/2024 56
 Breathing systems
A few definitions
Physiological dead space
The volume of inspired gas that does not undergo gas
exchange in the alveoli

Physiological dead space = anatomical dead space + alveolar dead space

gas from upper airways, where gas volume of lung which is ventilated
exchange does not occur with gas but not perfused with blood
Typically ≈2 mL / kg  cannot take part in gas exchange
or 140 mL for 70 kg patient

Functional residual capacity

The volume of gas in the lungs at the end of expiration
05/21/2024 57
 Breathing systems
A few definitions
Rebreathing

Definition in anaesthesia; rebreathing is the inspiration

of gas which was exhaled and still has pCO2 = 5 kPa

So, if soda lime is used, “rebreathing” does not occur

because the inhaled gas may have been previously
exhaled, but it has had the CO2 removed

What affects rebreathing?

(1) breathing circuit design (e.g. soda lime or different configurations)

(2) the mode of ventilation (spontaneous or controlled)

(3) the fresh gas flow rate

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(4) the patient’s respiratory pattern 58
 Breathing systems
Key components

Soda lime One-way valve

FGF (with volatile APL valve Reservoir

agent) bag

Tubing Y-piece to patient

05/21/2024 59
 Breathing systems
Key components (cont.)
The APL valve = the Adjustable Pressure Limiting valve

Also called a Heidbrink valve, spill valve, relief valve, expiratory valve

3 ports;

inlet port

patient port

exhaust port  can be open to atmosphere or to

scavenging system

In open position, < 1 cm H2O (< 0.1 kPa) required to allow gas escape

In closed position, gas can escape at 60 cm H2O (to avoid barotrauma)

05/21/2024 60
 Breathing systems
Key components (cont.)
The reservoir bag

Standard adult size is 2L

Smallest paediatric bag is 500 mL

Roles of reservoir bag:

(1) Accommodates fresh gas flow during expiration

(2) Acts as a monitor of respiratory pattern (& “feel” of ventilation)

(3) Can be used to assist ventilation (hand ventilation)

(4) In a Mapleson F (Jackson-Rees modification of an Ayre’s T-

piece), the bag is double ended and acts as the expiratory outflow

(5) As bag expands, it reaches a maximal pressure of 40 cm H 2O;

05/21/2024
protects the patient from barotrauma 61
 Breathing systems
Which breathing systems are we going to discuss?
(1) Mapleson systems
A

E&F

(2) Humphrey ADE breathing system

(3) Circle system

vaporiser out of circle (VOC)
or vaporiser in circle (VIC)
05/21/2024 62
 Breathing systems
Mapleson breathing systems

Mapleson introduced a classification for anaesthetic circuits in

1954

It does not include systems with internal valves or soda lime

The circuits are labeled A to F

The efficiency of the circuits is defined as the fresh gas flow

required to avoid rebreathing

The order is from most efficient → least efficient for a

spontaneously breathing patient

The relative efficiency of each circuit is different for ventilated

patients
05/21/2024 63
 Breathing systems
Mapleson breathing systems (cont.)
Most efficient for
spontaneously
Fresh gas flow breathing patient
(FGF)

Least efficient for

spontaneously
05/21/2024 breathing patient 64
 Breathing systems
Mapleson breathing systems (cont.)
Reservoir bag on
inspiratory limb

Transitional position of
reservoir bag

Reservoir bag on
expiratory limb

05/21/2024 65
 Breathing systems Alternative Co-axial
Mapleson breathing systems (cont.) name design

Magill Lack

(not used)

Water’s (not used)

Bain

Ayer’s T-
(not used)
piece
Jackson-Rees
modification of an (not used)
05/21/2024 66
Ayer’s T-piece
 Breathing systems
An overview of circuit efficiency
FGF for FGF for 70 kg
FGF for FGF for
spontaneously patient with
Circuit spontaneous controlled
breathing controlled
ventilation ventilation
70kg patient ventilation
>alveolar minute 2.5 x minute
A ventilation 6 L/min ventilation 17 L/min
(85mL/kg/min) (250mL/kg/min)

B 1.5 x minute 1.5 x minute

ventilation 10 L/min ventilation 10 L/min
C (150mL/kg/min) (150mL/kg/min

2 x minute >alveolar minute

D ventilation 14 L/min ventilation 6 L/min
(200mL/kg/min) (85mL/kg/min)

E 2-3 x minute _ _
ventilation n/a
(always > 3 L) 1000mL +100
F n/a
05/21/2024 mL/kg 67
 Breathing systems
Humphrey ADE breathing systems

The Mapleson A circuit is inefficient for controlled

ventilation

The Mapleson D circuit is inefficient for spontaneous

ventilation

A Humphrey ADE circuit allows the advantages of both to

be used

A Humphrey ADE takes advantage of the properties of a

Mapleson A for spontaneous ventilation and a Mapleson D
for controlled ventilation
05/21/2024 68
 Breathing systems
Humphrey ADE breathing systems

05/21/2024 69
 Breathing systems
Humphrey ADE breathing systems
• reservoir bag is situated at the fresh gas inlet end of the circuit
• gas is conducted to and from the patient down the inspiratory and
expiratory limbs of the circuit
• depending on the position of the control lever at the Humphrey block,
gases either pass through the expiratory valve or the ventilator port
• when the lever is ‘up’ the reservoir bag and the expiratory valve are
used, creating a Mapleson A type circuit
• when the lever is in the ‘down’ position the bag and valve are bypassed
and the ventilator port is opened, creating a Mapleson D system for
controlled ventilation
• if no ventilator is attached and the port is left open, the system functions

05/21/2024 like an Ayre’s T piece 70

 Breathing systems
The circle breathing system

• an alternative to using high flow circuits is to absorb CO 2

from the expired gases which are then recirculated to the
patient

• this saves on gases and also on volatile anaesthetic agent

• the reaction of CO2 with soda lime generates some water

and considerable heat  the gases are warmed and
humidified prior to inspiration

circle circuits are potentially very efficient and cause minimal pollution

(however, they are expensive to buy and require soda lime)

05/21/2024 71
 Breathing systems
The circle breathing system
The components

Soda lime One-way valve One-way valve

(expiratory limb) (inspiratory limb)
FGF (with volatile APL valve Reservoir
agent) bag
FGF (with volatile
Y-piece to patient agent)

Soda lime

One-way valve
One-way valve
(inspiratory limb)
(expiratory limb)

APL valve Bag

05/21/2024
PATIENT 72
 Breathing systems
The circle breathing system
The soda lime

• CO2 is removed from the expired gas by passage through soda lime
• mixture of 94% calcium hydroxide, 5% sodium hydroxide, and 1%
potassium hydroxide, plus silica and dye
• it reacts with CO2 to form calcium carbonate:
CO2 + H2O → H+ + HCO3-

Ca(OH)2 + H+ + HCO3- → CaCO3 + 2H2O + heat

• the silica makes the granules less likely to disintegrate into powder
• the chemical dye changes colour with pH
• as CO2 is absorbed the pH decreases and the colour of the dye
05/21/2024 changes from pink to yellow/white 73
 Breathing systems
The circle breathing system
The soda lime (cont.)

• when around 75% of the soda lime has changed colour it should be
replaced

• the soda lime canister should be mounted vertically on the

anaesthetic machine to prevent the gases passing only through a part
of the soda lime (streaming)

• Baralyme is a commercially available CO2 absorber which contains

5% barium hydroxide instead of sodium hydroxide.

05/21/2024 74
 Breathing systems
The circle breathing system
Practical use

During the first five to ten minutes of anaesthesia high fresh gas flows
are required (roughly equivalent to the patient’s minute volume i.e. 6-8
L/min) because;

(1) a large amount of the agent is taken up by the patient,

causing a reduction in the agent concentration within the
system

(2) the total volume of the circle system (tubing and soda lime
canister) is a reservoir of air that needs to be replaced with
anaesthetic agent and fresh gas

05/21/2024
After 10 to 15 minutes, the fresh gas flow can be reduced 75
 Breathing systems
The circle breathing system
Practical use

• at low fresh gas flow rates (<1000mL/min) the oxygen concentration

within the circle is unpredictable

• circle systems should not be used at low flow rates without an oxygen
analyser in the inspiratory limb

• if only oxygen and a volatile agent is used in the circle system flows may
be reduced to 1500 mL/min (after the period of equilibration)

(the lowest fresh gas flow rate of oxygen and nitrous oxide which can be used, (ensuring that
05/21/2024 the FiO2 remains safe) is 2000mL/min (nitrous oxide 1200mL/min and oxygen 800mL/min)) 76
What to do every day before you start

The Machine Check

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1. Emergency Ventilation Equipment
• Verify backup ventilation
equipment is available and
functioning!

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2. High-Pressure System
• Check O2 Cylinder Supply
• At least ½ full or 1,000 psi
• Close Cylinder!
• Check Central Pipeline Supplies
• Hoses are connected
• Pipeline gauges read ~50 psi

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3. Low-Pressure System
• Check initial status of low-pressure
system
• Close the flow control valves
• Turn vaporizers off
• Check fill levels
• Tighten vaporizer filler caps
• Perform Leak Check
• Attach suction “bulb” to common fresh gas
outlet
• Squeeze bulb until fully collapsed
• Verify bulb stays collapsed for >10 seconds
• Repeat with each vaporizer open at a time
• Test Flowmeters
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Scavenging System
• Adjust & check scavenging system
• Ensure proper connections b/w
scavenging system and:
• APL (pop-off) valve
• Ventilator relief valve
• Inspect to make sure everything is
secure

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4. Breathing System
• Calibrate O2 Monitor
• Ensure monitor reads 21% on RA
• Verify low O2 alarm is on and functioning
• Reinstall the sensor and flush breathing
system w/ O2
• Verify that it now reads >90%

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NOTE: Proportioning Flow Meters

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4. Breathing System
• Check Initial Status of Breathing
System
• Set selector switch to ”bag” mode
• Check that circuit is complete,
undamaged, and unobstructed
• Verify CO2 absorbent is adequate
• Install breathing circuit accessory
equipment to be used during the case
• Humidifier
• PEEP valve

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4. Breathing System
• Perform Leak Check of the Breathing
System
• Set all gas flows to zero / minimum
• Close the APL (pop-off) valve and
occlude Y-piece on your hand
• Pressurize breathing system to about
30cm H20 using the O2 flush
• Ensure the pressure remains fixed for at
least 10 seconds
• Open APL (pop-off) valve and ensure
that the pressure decreases

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5. Manual and Automatic Vent
• Test ventilation Systems and
Unidirectional Valves
• Place a breathing bag on the Y-piece
• Set ventilator as if for your first patient
and turn on vent
• O2 about 5 L/min, all others off
• Check that bellows and “fake lung”
operate appropriately
• Repeat this in manual ventilation mode
using the bag/APL

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6. Monitors
• Check, Calibrate, and/or Set Alarm Limits of All Monitors
• Capnometer
• Sideline vs. Inline (CO2 only)
• O2 Analyzer
• Pressure Monitor
• Set high and low pressure limits
• Pulse Oximeter
• Respiratory Volume Monitor (Spirometer)

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7. Final Position
• Check the Final Status of the Machine
• Vaporizers off
• APL valve open
• Selector switch to “Bag”
• All flowmeters to zero/minimum
• Patient suction adequate
• Breathing System ready to use

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 How to check an anaesthetic machine

Dr Jude Cheong-Leen & Dr

Ben Silverman

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05/21/2024 90
05/21/2024 91
 it is best practice to check the anaesthetic machine before each case

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 This is only appropriate if the machine requires electrical power
However, the monitoring equipment should be securely connected to the electrical
supply

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 This is particularly important here, where the electrical connections are unreliable
– check all the monitoring available is working

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 The ‘tug’ test needs to be done with caution in the Gondar OR – essentially the test
involves pulling the oxygen pieline to check it is securely fixed to the wall outlet.
In the Gondar OR, be careful not to damage the wall fitting.

The pressure gauge for the gas input is on the front of the new anaesthetic
machines

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 The correct functioning of the oxygen rotameter is critical
Check that the nitrous oxide rotameter is turned off (this may not be obvious, since
there is no N2O supply)

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 It is important to check for leaks, but e careful with occluding the CGO, since this
can lead to a disconnection in the back-bar of the new anaesthetic machines. This
disconnection is obvious, but must be rectified.

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 This will be important for the new anaesthetic machine circuits, when they are
available.

At present, the old circuits fail a standard test (due to leaks), but should be checked
for any new massive faults. They are used in the knowledge that they have
significant limitations.

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 This only needs to be done if there is a functional ventilator

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 Making sure the scavenging system is functioning improves anaesthetic safety for
all the staff in the OR

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 Although this involves more than just the anaesthetic machine itself, it is important
to have all the necessary equipment to hand.

It is critical to know where the difficult airway equipment is stored.

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 • if the oxygen supply fails in the OR, there are limited options for
ventilating a patient (with air)
(1) self-inflating bag
(2) mouth-to-mouth (or mouth to ETT) ventilation

• option (2) is very unpleasant and potentially risky for the

anaesthetist
• so, a self-inflating bag, valve and mask should be readily available in
every OR
• if oxygen is available, a “BVM” can be connected to the O 2 supply
and this fills the reservoir bag  >90% O2 can be delivered
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 At present the anaesthetic machines do not have log books, but be aware that they
should have.

A brief note stating that the machine has been checked should be made on the
anaesthetic chart.

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Reference
1. Clinical anaesthesia (Paul [Link], 5thedition).
2. Clinical anesthesiology ([Link] Morgan, 4thedition)
3. Text book of anaesthesia, 4th edition.
4. Anesthsia and co-existing disease (Robert [Link], 5th edition)
5. Miller’s anesthesia volume2, (Ronald [Link], 7th edition)
Special thanks for≠Dr Chad
chad@[Link]

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