Chapter 7. The Breathing System

Chapter 7
The Breathing System: General Principles,

Common Components, and Classifications
P. 192

The breathi ng system (breathing or pat i ent ci rcui t, respi ratory ci rcui t or system) i s a
gas pathway connected to t he pati ent , t hrough whi ch gas f l ows occur at respi rat ory
pressures, and i nto whi ch a cont rol l ed composi ti on of a gas mixture is dispensed
(1). I n pract ice, t he breathi ng system is usual ly regarded as extendi ng f rom the
poi nt of f resh gas inlet to t he poi nt at whi ch gas escapes t o at mosphere or a
scavengi ng system. Scavengi ng equi pment i s not consi dered part of the breathi ng
system.
The breathi ng system receives the gas mixture f rom the anest hesi a machine,
del i vers gas to t he pati ent , re-moves carbon di oxide, and the condi ti ons
t emperat ure and humi di t y of the inspi red mi xture (2). It al l ows t he conti nuous fl ow
f rom the anesthesi a machi ne to be converted into an i ntermi tt ent fl ow; al l ows
spontaneous, cont rol l ed, or assist ed respi rati on; and provi des f or other f uncti ons
such as gas sampl i ng and ai rway pressure, f l ow, and vol ume moni t ori ng (2).
General Principles
Resistance
Physics
When gas passes through a tube, the pressure at t he out let wi l l be l ower than that
at t he i nl et (3). The drop i n pressure i s a measure of t he resistance that must be
overcome as the gas moves through t he tube. Resi stance vari es wi th t he vol ume of
gas passi ng through per uni t of t i me. Theref ore, f low rate must be stated when a
speci f i c resi stance i s ment ioned.
The nature of the fl ow i s i mportant i n determi ni ng resi stance. There are t wo types
of f l ow: l ami nar and t urbul ent . I n cli ni cal pract ice, f l ow i s usual l y a mi xture of bot h.
Laminar Flow
Fi gure 7.1A i l lustrates l aminar gas f low t hrough a t ube. The f l ow i s smooth and
orderl y, and part icles move paral lel to t he wal ls of the tube. Fl ow i s fast est i n the
center of the tube, where there i s l ess f ri ct ion.
When f low i s l ami nar, t he Hagen-Poiseui l l e l aw appl ies. This l aw st ates that
P = (L v V)/r
4

where r i s t he radi us of t he tube, P i s the pressure gradient across the t ube, v i s
t he vi scosi t y of t he gas, L is l ength, and V i s the f l ow rat e. Resi stance i s di rectl y
proport ional to f l ow rat e during l ami nar f l ow.
Turbulent Flow
Fi gure 7.1B i l lustrates turbul ent gas f l ow t hrough a tube. The f l ow l i nes are no
l onger paral lel . Eddies, composed of parti cl es moving across or opposi t e the
general di recti on of f l ow, are present. The fl ow rat e i s the same across the
di ameter of the t ube.

View Figure

Figure 7.1 Laminar and turbulent flow. A: Laminar flow;
the lines of flow are parallel and flow is slower near the
sides of the tube because of friction. B: Generalized
turbulent flow, which occurs when the critical flow rate is
exceeded. Eddies move across or opposite the general
direction of flow. CF: Localized turbulence, which occurs
when there is change in direction or the gas passes through
a constriction.

During turbul ent fl ow, t he f actors responsi bl e for the pressure drop al ong t he t ube
i ncl ude t hose descri bed for
P. 193

l aminar f low, but i n this si t uat ion, gas densi t y becomes more i mportant than
vi scosi ty.
P = (L V
2
K)/r
5

I n t hi s equati on, K i s a constant that i ncl udes such f actors as gravi ty, f ricti on, and
gas densi t y and vi scosi ty. Resi st ance i s proporti onal t o the square of the f l ow rat e
wi th t urbul ent f l ow.
Turbul ent fl ow can be general i zed or l ocal i zed.
Generalized Turbulent Flow
When t he f l ow of gas through a t ube exceeds a certai n val ue, cal l ed t he cri ti cal fl ow
rate, general i zed t urbul ent f low resul ts.
Localized Turbulent Flow
As seen in Fi gure 7.1CF, when gas f low i s bel ow the cri ti cal f l ow rate but
encounters constri cti ons, curves, valves, or other i rregul ari t i es, an area of local i zed
t urbulence resul ts. The i ncrease in resi stance wi l l depend on the type and number
of obst ructi ons encount ered.
To mi ni mi ze resi stance, gas-conducti ng pathways shoul d have mi ni mal lengt h and
maxi mal i nternal diameter and be wi thout sharp curves or sudden changes i n
di ameter.
Signi ficance of Resi stance
Resistance imposes a st rain, especi al l y wi th vent il atory modes where the pati ent
must do part or al l of the respi rat ory work (e.g. , spontaneous respi rati on,
i ntermi ttent mandatory vent i l ati on, or pressure support venti lati on). Changes i n
resi st ance tend t o parall el changes i n the work of breathi ng. The tracheal t ube i s
usual l y the source of more resi st ance and a more i mportant factor when
determining t he work of breat hi ng than the breathi ng system (4).
There i s l ack of agreement about what l evel of resi stance i s excessi ve. Anesthesi a
provi ders shoul d be aware of how much resi stance components of breathi ng
systems off er and to empl oy, wherever possi ble, those of feri ng the l east resi stance.
For some pat i ents, i ncreased expi ratory resi stance may be desi rable. Thi s should
be achi eved by using devi ces desi gned f or t hat purpose.
Fl ow-vol ume l oops (Chapter 23) can show changes i n resistance to f low i n a
breat hi ng system.
Compliance
Compl i ance i s the rat io of a change in volume to a change in pressure. It i s a
measure of di stensi bi l i t y and is usual l y expressed i n mi l l i l i t ers per centi meter of
wat er (mL/cm H
2
O). The most distensi ble breathi ng system components are the
reservoi r bag and the breathi ng tubes. Compl i ance wi l l hel p to determine the t idal
volume (5). Compl i ance can be i l l ustrat ed graphi cal l y wi t h a pressure-vol ume loop
(Chapter 23).
Rebreathing
Rebreathi ng means to i nhal e previ ousl y respi red gases f rom whi ch carbon di oxi de
may or may not have been removed. There i s a t endency to associ at e the word
rebreat hi ng wi t h carbon di oxi de accumul ati on. This i s unf ort unate because al t hough
i t is t rue that rebreathi ng can resul t in hi gher i nspi red carbon di oxi de
concentrati ons than normal , i t i s possible t o have part i al or t otal rebreathing
wi thout an i ncrease in carbon dioxide.
Factors Influencing Rebreathing
Fresh Gas Flow
The amount of rebreathi ng vari es i nversel y wi th t he total f resh gas f l ow. I f the
volume of f resh gas suppl i ed per mi nute is equal to or greater t han the pat i ent 's
mi nute vol ume, t here wi l l be no rebreathi ng, as l ong as provisi on i s made f or
uni mpeded exhaust to at mosphere or to a scavengi ng system at a poi nt close to the
pati ent 's respi ratory t ract (6). I f t he total vol ume of gas suppl i ed per mi nute i s l ess
t han the mi nute volume, some exhal ed gases must be rebreathed to make up the
requi red vol ume (assumi ng no ai r di luti on).
Mechanical (Apparatus) Dead Space
Mechani cal dead space i s the volume i n a breathing syst em occupi ed by gases that
are rebreathed wi t hout any change i n composi t i on. Apparatus dead space can be
mi nimi zed by separat i ng the i nspi rat ory and expi ratory gas streams as cl ose to the
pati ent as possi bl e. If there is a l eak around a f ace mask, dead space decreases
(7).
The mechani cal dead space shoul d be di stingui shed f rom the physi ol ogi cal dead
space, which includes (a) anatomi cal dead space, consi sti ng of t he pati ent ' s
conducti ng ai rway down to t he al veol i , and (b) al veolar dead space, whi ch is t he
volume of alveol i venti l at ed but not perfused.
The gas composi ti on in the mechani cal dead space wi l l vary accordi ng to whet her i t
i s occupi ed by anatomi cal dead space gas, al veolar gas, or mixed exhal ed gas. Gas
exhal ed f rom the anat omical dead space has a composi ti on si mi l ar t o inspi red gas
but is saturated wi th wat er vapor and is warmer. Al veol ar gas is saturated wi th
wat er vapor at body t emperature and has l ess oxygen and more carbon dioxi de
t han i nspi red gas. The concent rati on of anestheti c agent i n alveolar gas wi l l dif f er
f rom that i n t he i nspi red gas. Mixed expi red gas wi l l have a composi ti on
i ntermediate bet ween t hat of anatomi cal dead space and alveol ar gas.
Breathing System Design
I n addi ti on t o the above f act ors, the various components of a breat hi ng system may
be arranged so that t here is more or l ess rebreat hi ng. Chapters 8 and 9 provide
more det ai l s on breathi ng systems.
P. 194

Effects of Rebreathi ng
Wi th no rebreathi ng, t he composi ti on of i nspi red gas i s ident ical t o that of t he f resh
gas del ivered by the anesthesi a machine. Wi th rebreathing, the i nspi red gas i s
composed part l y of f resh gas and part l y of rebreathed gas.
Heat and Moisture Retention
Fresh gas f rom the anest hesi a machi ne i s dry and at room temperature. Exhal ed
gases are warm and saturated wi th moi sture. Rebreathi ng reduces heat and
moi st ure l oss f rom the pat ient . In most breat hing syst ems, heat i s rapi dly l ost to
at mosphere, and gas that is rei nhal ed has a l ower temperature and moi st ure
content t han exhal ed gas.
Altered Inspired Gas Tensions
The eff ects of rebreathing on inspi red gas tensi ons wi l l depend on what parts of the
exhal ed gases are rebreathed and whet her t hese pass t o the alveoli (and so
i nf l uence gas exchange) or onl y to the anatomi cal dead space.
Oxygen
Rebreathi ng al veolar gas wi l l cause a reduct i on i n the i nspi red oxygen t ensi on.
Inhaled Anesthetic Agents
Rebreathi ng al veolar gas exerts a cushi oni ng eff ect on changes i n inspi red gas
composi ti on wi th al terati ons i n f resh gas composi t i on. Duri ng i nducti on, when
al veolar tensi ons are lower than those i n t he f resh gas f l ow, rebreathed alveol ar
gas wi l l reduce the i nspi red tensi on and prol ong i nducti on. Duri ng recovery, the
al veolar tensi on exceeds that of the i nspi red gases, and rebreathi ng slows agent
el i mi nati on.
Carbon Dioxide
Rebreathi ng al veolar gas wi l l cause an increased i nspi red carbon di oxi de tensi on
unl ess the gas passes through an absorbent before bei ng rebreat hed. Because
carbon dioxi de is concentrat ed in t he al veol ar port i on of expi red gases, the
ef fi ci ency wi t h whi ch i t is el i minated f rom a breat hi ng system vari es. If t he system
i s desi gned so that al veolar gas i s pref erenti all y el imi nated t hrough the adj ustabl e
pressure l i mi t ing (APL) val ve or t he venti lator spi l l val ve, carbon di oxi de retenti on
wi l l be mi ni mal , even wi t h a l ow f resh gas f l ow. Systems that do not mai ntain the
separati on between f resh gas, dead space gas, and alveol ar gas requi re relat ivel y
hi gh f resh gas f l ows t o el i mi nate carbon di oxi de.
Wi th spontaneous respi rat ion, carbon dioxi de ret ent i on is general l y consi dered
undesi rabl e. Al though t he pat ient can compensate by increasi ng minut e vol ume, a
price is paid i n terms of i ncreased work of breathing. In some cases, compensat ion
by i ncreasing mi nute vol ume may not be adequat e.
During cont roll ed venti l ati on, some carbon dioxide in t he inhal ed gases may be
advantageous. Rebreathi ng wi l l al l ow normocarbi a t o be achieved despi te
hyperventi lat i on. Hypocarbi a can be avoi ded and heat and moisture retai ned.
Discrepancy between Inspired and Delivered Volumes
The volume of gas di scharged by a venti l ator or reservoi r bag usual l y di ff ers f rom
t hat which enters the pat i ent. The vol ume actual l y i nspi red may be l ess or greater
t han that del i vered.
Causes of Increased Inspired Volume
When a venti l ator is i n use and the f resh gas f l ow rate i s greater than the rate at
whi ch i t i s absorbed by the pat i ent or lost t hrough l eaks i n the breathi ng syst em,
t he f resh gas f l ow del ivered duri ng i nspi rat ion may be added t o the t idal volume
del i vered by t he venti lator (8, 9). Thi s augmentati on increases wi t h higher f resh gas
f lows and I: E rat ios and l ower respi ratory rates (10). Modern anesthesi a venti l ators
have been desi gned t o el i mi nat e the addi ti onal ti dal vol ume caused by f resh gas
f low. For an i n-dept h di scussi on of t hi s subj ect and how modern venti l ators deal
wi th i t, see Chapter 12.
Causes of Decreased I nspired Vol ume
A reducti on in the ti dal vol ume del ivered to t he pat ient wi l l resul t f rom gas
compressi on and di st ent i on of breat hi ng system components duri ng i nspi rati on (11).
Thi s i s ref erred t o as wasted venti l ati on. Wast ed vent i lat i on increases wi t h
i ncreases in ai rway pressure, t i dal vol ume, i ncreased breathing system vol ume, and
component di stensi bi l i t y (11,12,13,14,15). Proport i onal l y, more of t he set t i dal
volume i s lost wi th smal l pati ents (11, 16).
Ti dal vol ume is al so decreased by l eaks i n the breathi ng system. The amount lost
wi l l depend on the si ze and l ocat ion of the l eaks and t he pressure in t he breat hi ng
system.
Ti dal vol umes are best measured between the pati ent and the breathi ng tubes
(Chapter 23). Measuri ng t i dal vol ume at the end of t he expi rat ory l i mb wi l l ref l ect
i ncreases caused by f resh gas f l ow and decreases resul t i ng f rom l eaks i n the
breat hi ng system but wi l l mi ss decreases f rom wasted venti l at ion. Leaks bet ween
t he vol ume sensor l ocated at the pati ent port and the pat ient can be det ected by
compari ng the i nspi red and exhaled t i dal vol umes. If there is a si gni f icant l eak, the
exhal ed vol ume wi l l be less than the i nspi red vol ume.
Discrepancy between Inspired and Delivered Oxygen
and Anesthetic Gas Concentrations
The composi t ion of the gas mixture that exi ts the machi ne may be modi f i ed by t he
breat hi ng system so that t he mi xture the pat i ent i nspi res di ff ers consi derabl y f rom
t hat del i vered t o the system. There are several cont ri buti ng factors.
P. 195

Rebreathi ng
The eff ect of rebreathing wi l l depend on the vol ume of t he rebreathed gas and i ts
composi ti on. Thi s wi l l depend on the f actors discussed previ ousl y.
Air Dilution
I f the f resh gas suppl i ed per respi rati on i s less than the t idal volume, negati ve
pressure i n the breathi ng system may cause ai r di l ut ion i f t here i s a leak.
Ai r di luti on makes i t di f fi cul t t o maintai n a st abl e anestheti c state. It causes the
concentrati on of anestheti c i n the i nspi red mi xture to fall . This resul ts i n a l i ght er
l evel of anesthesi a wi th st i mul ated vent il ation. The i ncreased venti l ati on causes
more ai r di l ut ion. The opposi te is al so t rue. Deepeni ng anesthesi a depresses
venti l ati on. Respi rat ory depressi on decreases ai r di l ut ion, whi ch causes an
i ncrease i n the i nspi red anesthet ic agent concent rati on. This i n turn leads to f urther
depressed respi rati on.
Leaks
When a l eak occurs, posi ti ve pressure i n the system wi l l force gas out of the
system. The composi t i on and amount of t he gas l ost wi l l depend on the l ocati on and
si ze of t he l eak, the pressure i n t he system, and the compl iance and resi stance of
both the syst em and t he pati ent.
Anesthetic Agent Uptake by the Breathi ng System
Components
Anesthet ic agents may be taken up or adhere to rubber, pl ast i cs, metal , and carbon
di oxi de absorbent (17). This wi l l l ower t he inspi red concentrat ion. Upt ake wi l l be
di rectl y proport i onal to the concentrat ion gradi ent bet ween t he gas and the
components, the part i ti on coeff icient, the surf ace area, the di f fusion coef fi ci ent ,
and the square root of ti me.
Anesthetic Agents Rel eased from the System
El i mi nat i on of anesthet ic agent f rom the breat hi ng system wi l l depend on the same
f act ors as uptake. The system may f uncti on as a l ow output vapori zer for many
hours af ter a vapori zer has been t urned OFF even if t he rubber goods and
absorbent are changed. Thi s can resul t i n a pati ent bei ng i nadvertentl y exposed to
t he agent.
Common Components
Some components are found i n onl y one type of breat hi ng system. These wi l l be
di scussed under the i ndi vi dual systems. Others components are f ound i n more t han
one system, making t hei r i ncl usi on i n a general chapter such as t hi s appropri ate.
Bushings (Mounts)
A bushing serves to modif y the i nternal diameter of a component . Most of ten, i t has
a cyl i ndrical f orm and i s inserted i nt o, and becomes part of , a pl i abl e component
such as a reservoi r bag or a breat hi ng tube.
Sleeves
A sl eeve al ters t he external diameter of a component.
Connectors and Adaptors
A connector i s a f i tt i ng int ended to j oi n together t wo or more si mi lar components.
An adaptor is a speci al i zed connector t hat establ ishes f uncti onal conti nui ty between
ot herwi se di sparat e or incompati bl e components.
An adaptor or connector may be di sti ngui shed by (a) shape (e.g., strai ght , ri ght
angle or elbow, T, or Y), (b) component (s) to whi ch i t is at tached, (c) added
f eatures (e.g. , wi th ni ppl e or APL valve), and (d) si ze and t ype of f i tt i ng at ei ther
end (e.g., 15-mm mal e, 22-mm f emale).
Al l anest hesi a breat hi ng systems t ermi nate at t he pat i ent connecti on port . Thi s is
t he poi nt where t he breathing system connects to a device that establ i shes
conti nui t y wi t h the pati ent ' s respi ratory system (a t racheal tube, f ace mask, or
supraglott ic ai rway device).
Al l f ace masks have a 22-mm f emal e opening whi l e most other devices have a 15-
mm mal e f i t ti ng. To f aci l i tate the change f rom mask to t racheal tube, and the l ike, a
component having a 22-mm male f i t t ing wi t h a concentric 15-mm femal e f i t t i ng i s
used at t he pati ent connecti on port. Usual l y, t hi s component i s a ri ght angl e
connector (Fi g. 7.2), al so known as an el bow adaptor, el bow j oi nt , el bow connect or,
mask angl e pi ece, mask adaptor, or mask el bow.
Connectors and adaptors can be used t o:
Extend the di stance between the pati ent and t he breathing system. This i s
especi al l y i mport ant i n head and neck surgery when t he presence of t he
breat hi ng system near the head may make i t i naccessible to t he anesthesi a
personnel and/or i nterf ere wi t h the surgi cal f i el d.
Change the angl e of connecti on bet ween the pat i ent and the breathi ng
system.
Al l ow a more fl exi bl e and/ or l ess ki nkabl e connect i on bet ween the pat ient
and the breat hi ng system.
I ncrease t he dead space.
A variety of connect ors are avai l abl e (Fig. 7.2), and many more have been
descri bed in t he l i terature. I n sel ecti ng a connector, several pri nci pl es shoul d be
kept i n mi nd.
P. 196

View Figure

Figure 7.2 Various connectors. 1: A swivel connector that
can be used to insert a flexible fiberscope. It has a flexible
accordion-type side arm. 2: A flexible metal connector that
can be used between the tracheal tube and the breathing
system. It cannot be used with a mask. 3: Straight connector
with a side gas sampling port. 4: Right angle connector for
insertion of a flexible fiberscope. It can accommodate
different sized fiberscopes by changing the diaphragm. The
large cap is used if no diaphragm is present. 5: Right angle
connector with gas sampling port.

Resistance increases wi t h sharp curves and rough si dewal ls.
Connectors add dead space i f posi ti oned bet ween the breathi ng system and
t he pat ient. In t he adul t pati ent , t his may not be of much si gni f i cance.
However, in i nf ants, any increase i n dead space may be excessive.
Connectors increases t he number of l ocati ons at whi ch di sconnect i ons can
occur.
Reservoir Bag
Most breathing syst ems have a reservoi r bag, also known as t he respi rat ory,
breat hi ng, or somet i mes erroneousl y, rebreathi ng, bag. Most bags are composed of
rubber or pl ast i c and are el l ipsoi dal in shape so that t hey can be grasped easi l y
wi th one hand. Latex-f ree reservoi r bags are avail abl e. The neck is t he part of the
bag that connects wi t h the breathi ng system. The neck must have a 22-mm f emal e
connector (18,19). The tai l i s the end opposi t e f rom the neck. A l oop may be
provi ded near t he tai l to hol d the bag upsi de down, whi ch f aci l i tat es drying i f the
bag i s reusable.
The bag has the fol l owi ng funct ions:
I t al lows gas to accumul ate during exhal at i on. This provi des a reservoi r of
gas f or t he next inspi rati on. Thi s permi ts rebreat hi ng, al l ows more
economi cal use of gases, and prevents ai r di l ut ion.
I t provi des a means whereby venti lati on may be assi sted or control l ed.
I t can serve through vi sual and t acti l e observat i on as a moni tor of a pat ient' s
spontaneous respi rati on (20).
Because the bag i s the most di stensibl e part of the breathi ng system, i t
protects the pati ent f rom excessi ve pressure i n the breathi ng system.
The pressure-vol ume characteristi cs of bags become i mport ant if t here is no way
f or gases to escape f rom t he system and i nf l ow cont inues. Addi ng vol ume to a bag
normal l y causes a negl igible ri se i n pressure unt i l the nominal capaci ty is reached.
As more vol ume cont i nues to be added, t he pressure ri ses rapidl y to a peak and
t hen reaches a plateau. As t he bag di stends f urther, t he pressure f al ls sl i ght l y. The
peak pressure is of parti cul ar i nt erest , because t hi s represents the maximal
pressure that can develop in a breat hi ng system. The Ameri can Soci et y f or Test ing
and Materi als (ASTM) st andard f or reservoi r bags requi res that for bags of 1.5 L or
smal l er, the pressure shal l be not less than 30 cm H
2
O or over 50 cm H
2
O when t he
bag i s expanded t o four t i mes i ts capaci t y (18). For bags l arger t han 1.5 L, the
pressure shal l be not less than 35 cm H
2
O or over 60 cm H
2
O when the bag is
expanded to f our t i mes i ts si ze. Latex-f ree reservoi r bags may al l ow hi gher
pressures to devel op (21).
New bags develop greater pressures when f i rst overinf l at ed than do bags that have
been overi nf l at ed several ti mes or have been prest retched (22). I t i s good pract ice
t o overinfl at e or st retch a new bag duri ng the preuse checkout. Thi s wi l l not li mi t
t he abi li t y t o produce high ai r way pressures when the bag is squeezed.
Bags are avai l able i n a vari et y of si zes. The size that should be used wi l l depend
on the pat ient, the breathi ng system, and t he user' s preference. A 3-L bag is
t radi t ional f or use in adul ts. A l arger bag may be dif f icul t to squeeze and wi l l make
moni tori ng the pat ient' s spontaneous respi rat i on more di f fi cul t because the
excursi ons wi l l be smal ler. A smal l bag, on t he other hand, provides less saf et y
wi th respect to pressure fl uct uat i ons and may not provi de a l arge enough reservoi r
or t i dal volume.
A spare bag shoul d al ways be kept i mmedi atel y avai lable i n case the bag devel ops
a leak or becomes l ost .
Breathing Tubes
A large-bore, corrugated plasti c breat hi ng (conducti ng) tube (hose) provi des a
f lexible, low-resi st ance, l ightwei ght connecti on f rom one part of t he system to
another. Corrugat i ons i ncrease f l exi bi li t y and hel p to prevent ki nki ng. Breathing
t ubes have some di stensibil i t y but not enough to prevent excessi ve pressures f rom
devel opi ng. Smal l er di ameter breathing t ubi ngs are avail abl e f or ci rcle systems
used for pedi at ri c pat i ents. There
P. 197

are int ernati onal and U.S. standards f or breat hi ng tubes (23,24).

View Figure

Figure 7.3 Some breathing tubes can be extended or
compressed. Note the filter. (Picture courtesy of Kendall
Healthcare Products, a division of Becton Dickinson.)

I f i t i s necessary to have t he anesthesi a machine at some di stance f rom the
pati ent 's head, several breathing t ubes may be connected in seri es or ext ra-long
t ubi ngs can be used. Special tubings that can be el ongat ed are avai l abl e (Fi g. 7.3).
A tube hol der (tree) (Fi g. 7.4) can be used to support breathing t ubes and prevent
t hem f rom exerti ng a pul l on t he ai rway device.

View Figure

Figure 7.4 Tube holder. The large rounded openings are for
adult breathing tubes. The opposite openings are for
pediatric tubes. The small grooves can be used for pulse
oximeter cables, gas sample lines, pressure monitoring
lines, blood pressure tubing, and the like. The device can be
rotated.

Adjustable Pressure-Limiting Valve
The APL val ve is a user-adj ustabl e valve that rel eases gases to a scavengi ng
system. It is used to control the pressure i n the breathi ng system. Other commonl y
used names f or t hi s component i ncl ude pressure rel i ef valve, venti ng port , rel i ef
valve, overspi l l valve, pop-off val ve, overfl ow val ve, dump val ve, bl ow-off valve,
saf ety rel i ef valve, excess val ve, Heidbri nk valve, adj ustable pressure l i mi ter,
excess gas vent i ng val ve, spi l l valve, exhaust val ve, expi ratory val ve, excess gas
valve, pressure release valve, and rel ease valve.
Construction
Control Part
The cont rol part serves t o cont rol the pressure at whi ch t he val ve opens. Most of
t hese valves are cal i brated f or the openi ng pressure (see Fi gs. 7.8, 7.9). Several
t ypes are avail abl e.
Spring-loaded Disc
The most commonl y used APL valve uses a di sc hel d onto a seat by a spri ng (Fig.
7. 5). A threaded screw cap over the spri ng al l ows the pressure exerted by the
spri ng on the disc to be vari ed. When the cap i s f ul l y ti ghtened, the di sc wi l l
prevent any gas f rom escapi ng f rom t he syst em. As the cap is l oosened, the tensi on
on the spring i s reduced so that the disc can rise.
When t he pressure i n the breat hi ng system i ncreases, i t exert s an upward f orce on
t he di sc. When thi s upward
P. 198

f orce exceeds the downward f orce exerted by t he spri ng, t he di sc rises and gas
f lows t hrough the val ve. When the pressure i n t he system f al l s, the di sc ret urns to
i ts seat. When the cap is at i ts maxi mum open posi t i on, t here wi l l be only mi ni mal
pressure exerted by the spri ng. This al l ows the pat ient' s exhal ati on t o l i f t t he di sc
wi th onl y mi ni mal pressure. The wei ght of and pressure on t he di sc ensures that t he
reservoi r bag f i l l s bef ore the di sc rises.

View Figure

Figure 7.5 APL valve with spring-loaded disc. Gas from
the breathing system enters at the base and passes into the
gas collecting assembly at left. Turning the control knob
varies the tension in the spring and the pressure necessary to
lift the disc off its seat. When the cap is fully tightened, the
spring is compressed enough to prevent the valve leaflet
from lifting at any airway pressure.

View Figure

Figure 7.6 APL valve with stem and seat. Rotation of the
control knob causes the opening between the stem and seat
to change. The disc ensures that the reservoir bag will fill
before the valve opens. It also prevents transmission of
positive pressure or gas from the scavenging system to the
breathing system. (Redrawn courtesy of North American
Drager, Inc.)

I ncreased pressure downstream of t he APL val ve wi l l i ncrease the pressure needed
t o open the val ve. Posi ti ve end-expi ratory pressure (PEEP) may then be t ransmi t ted
t o t he pati ent .
Stem and Seat
Another control part employed i n APL val ves i s the st em and seat (Fi g. 7. 6). Thi s i s
si mi l ar t o a f l ow control valve i n that a threaded stem al l ows vari abl e contact wi th a
seat. As the valve i s opened, the openi ng at t he seat becomes l arger and more gas
i s all owed to escape. Some of these valves have a disc or bal l valve i n a ret ai ni ng
cage (Fi g. 7.6). Thi s served t he dual f unct i on of preventi ng gas f rom the
scavengi ng system f rom f l owi ng back into the breathing syst em and supplying a
sl i ght pressure to keep t he reservoi r bag i nf l ated. St icki ng of t his part has been
reported (25).
Control Knob
Most APL val ves have a rot ary cont rol knob. The ASTM standard requi res that
valves wi t h rot at ing cont rols be desi gned so t hat a clockwi se mot ion i ncreases t he
l i mi ti ng pressure and ul t i matel y cl oses the val ve (1). I t al so requi res an arrow or
ot her marki ng to i ndicate the di recti on of movement requi red to close the val ve
(Fi g. 7.8A). The st andard recommends that t he ful l range of rel i ef pressure be
adj usted by l ess than one f ul l turn of the cont rol . Some of these valves are marked
t o show the pressure at whi ch t hey wi l l open (Fi gs. 7.7, 7.8).
Collection Device and Exhaust Port
I n order to remove excess gases f rom the breathi ng system and di rect them to a
scavengi ng system, t hey must be col l ected by using a col l ecti on device at the APL
valve. The gases are then di rected to t he scavengi ng system through the t ransf er
t ubi ng. The exhaust port i s t he aperture through whi ch excess gases are
di scharged to t he scavengi ng system. I t must have a 19- or 30-mm male connector
(26). Anesthesi a gas scavenging i s di scussed i n Chapter 13.
Use
Spontaneous Respiration
Wi th spontaneous respi rat ion, t he APL val ve remai ns cl osed duri ng i nspi rati on and
opens duri ng exhalat i on. Normal l y, t he val ve i s ful l y open duri ng spontaneous
venti l at ion. It shoul d be cl osed sl ightl y onl y i f gas i s wi t hdrawn f rom the breathi ng
system by negat ive pressure f rom the scavengi ng system and t he reservoi r bag
coll apses. Part ial l y cl osi ng t he val ve duri ng spontaneous respi rati on wi l l resul t i n
conti nuous posi t i ve ai rway pressure (CPAP).
P. 199

View Figure

Figure 7.7 APL valve with spontaneous/manual
changeover. Note the pressures markings. A: When the
lever is in the spontaneous position, the valve is fully open,
regardless of the set pressure. B: When the lever it is placed
in the manual position, the knob is rotated to adjust the
opening pressure. C: In the manual position, the valve can
be fully opened by pressing down on the lever.

Wi th spontaneous respi rat ion, t he anesthesi a provi der must be constantl y aware of
volume of gas i n the bag. If att ent i on is divert ed, t he bag may col l apse or become
overdistended. Negat ive pressure transmi t ted f rom t he scavenging syst em may
cause gases to be evacuated f rom t he breathi ng system. An obst ructi on i n the
scavengi ng system may resul t i n the bag becomi ng overdistended and t he pati ent
bei ng subj ect ed to CPAP.
Manually Controlled or Assisted Ventilation
During manual l y cont roll ed or assi st ed venti l ati on, the valve i s usual l y l ef t parti al l y
open. Duri ng inspi rati on, t he bag i s squeezed and pressure i ncreases unt i l the
rel i ef
P. 200

pressure i s reached. Bef ore t hi s, t he pat i ent receives al l of t he gas di splaced f rom
t he bag (l ess a small amount due t o gas compressi on and expansi on of the tubes).
Once t he APL valve opens, the addi ti onal vol ume that the pat i ent receives is
determined by the rel at ive resi stances to f l ow exerted by t he pati ent and the APL
valve.

View Figure

Figure 7.8 Another type of APL valve. The control knob is
rotated counterclockwise to increase the opening pressure.
A: The valve is set for manual ventilation. The valve can be
fully opened by pulling up on the control knob. B: The
valve is set for spontaneous ventilation. Note that the
control knob is slightly elevated.

The APL val ve must be adjusted on the basi s of chest movements and/or exhaled
volume or pressure measurements to achi eve t he desi red l evel of vent i l at ion and to
mai ntai n adequate bag vol ume. The resistance fel t duri ng bag compressi on (t he
educated hand) cannot be rel i ed on t o ensure adequate venti l ati on (27,28,29). If
compl i ance fal l s or resi stance i ncreases, the valve must be t ightened. I f the f resh
gas f l ow i s i ncreased or decreased, the APL valve must be opened or cl osed
somewhat .
Some APL valves have a l ever for changi ng bet ween spontaneous and manual
venti l ati on (Fi g. 7. 7).
Mechanical Ventilation
Bag-venti l at or sel ector swi tches (sel ect or valves) t hat f aci l i tate the change f rom
manual t o aut omat ic venti l at ion are avai l abl e and are di scussed i n Chapt er 9.
These isol ate the APL valve when the sel ect or val ve i s turned t o automatic
venti l ati on. When isol ated f rom the breathi ng system, the APL valve need not be
cl osed during mechani cal venti l ati on.
Positive End-expiratory Pressure Valves
PEEP and cont inuous ai rway pressure (CPAP) are used to improve oxygenat ion
(30). PEEP may be used wi t h spontaneous or cont rol l ed venti l at ion. CPAP is used
duri ng spontaneous vent il at i on and duri ng one-lung venti lati on (Chapt er 20).
Some ol der anesthesi a machi nes had manual l y cont roll ed PEEP valves that were a
component of the breathi ng system. Newer anesthesia machines have electroni call y
control led PEEP val ves (Chapters 9, 12). For a machi ne not equi pped wi t h a PEEP
valve, a di sposabl e PEEP val ve can be placed i n the exhal at ion l imb (Fi g. 7. 9).
Fi xed-pressure PEEP val ves are marked to i ndi cate the amount of PEEP that t hey
provi de (Fig. 7.9B). More t han one can be used t o obtai n an addi ti ve ef f ect .
Vari abl e-pressure PEEP val ves have a means t o adj ust t he amount of PEEP. Some
have a scal e that i ndi cat es t he PEEP at a gi ven sett ing. I f no scale i s present , a
manometer must be used t o measure the pressure.
A PEEP val ve can be uni di recti onal or bi di recti onal (31). A bidi rect ional val ve has a
second f low channel wi th i ts own one-way val ve. It has been recommended that
onl y bi di recti onal PEEP valves be used (32). Onl y a bi di rect i onal val ve shoul d be
used bet ween the breathi ng system and t he venti lator.
I t i s i mportant that a di sposabl e PEEP valve be placed i n the correct posi ti on and
ori ented properl y. The ASTM st andard requi res that a PEEP valve be marked wi th
an arrow i ndi cati ng the proper di recti on of gas f low or t he words i nlet and outl et or
both (1). I mmedi atel y af t er a PEEP valve i s i nserted, t he breathing system pressure
gauge shoul d be checked to make certai n that PEEP i s bei ng del i vered, and the
pati ent shoul d be checked f or eff ect ive venti l ati on. A uni di rect ional PEEP valve
i ncorrect l y ori ented agai nst the f l ow of gas i n the i nspi ratory or expi ratory l imb wi l l
bl ock gas fl ow (31,32). Incorrect l y ori ent i ng a bi di rect i onal PEEP val ve in ei t her t he
i nspi ratory or expi ratory li mb wi l l not obstruct f l ow, but no PEEP wi l l be appl i ed.
I f a PEEP val ve i s used wi th a ci rcl e breat hi ng system i n whi ch the pressure gauge
i s on the absorber side of
P. 201

t he expi ratory unidi rect ional valve, PEEP wi l l not be i ndicated on t he gauge
(33,34,35). The user must depend on the accuracy of the PEEP val ve marki ngs to
determine t he l evel of PEEP or use a second pressure gauge upstream of t he PEEP
valve to determi ne the actual pressure (31).

View Figure

Figure 7.9 Disposable positive end-expiratory valve. A:
Side view. Note that is shows the direction of flow. B: Top
of PEEP valve showing the amount of PEEP.

Usi ng PEEP i n a spontaneously breathi ng pat i ent wi l l resul t in i ncreased work of
breat hi ng (36,37). Usi ng PEEP wi t h certai n venti l atory modes may resul t i n a
subst ant ial decrease in t he ti dal vol ume del i vered to t he pat i ent . The breat hi ng
system may become occl uded and barotrauma may resul t i f a PEEP val ve
mal f unct ions (38).
Filters
Fi l ters are used to prot ect the pati ent f rom mi croorgani sms and ai rborne parti culate
mat ter and to prot ect anesthesi a equi pment and the envi ronment f rom exhal ed
contaminants. When pl aced bet ween the pat i ent and t he breathi ng system, a f i l ter
may help t o i ncrease the i nspi red humi di ty (see heat and moisture exchangers i n
Chapter 11). Anot her benef i t of f i l ters i s preventi ng exposure to l atex al lergens
(39).
The use of f i l ters i s cont roversi al (40,41,42,43,44, 45,46,47,48). Convi nci ng
evidence that thei r use i s of benef i t i n preventi ng postoperat ive i nf ecti ons i s
l acki ng. Probl ems wi t h f i l ters (see bel ow) have resul ted i n seri ous compl i cat i ons.
The Centers f or Di sease Cont rol and Preventi on (CDC) and the Ameri can Soci ety of
Anesthesi ol ogi sts (ASA) make no recommendat ion f or pl acing a f i l ter i n the
breat hi ng system unl ess there i s suspici on that the pati ent has an infecti ous
pul monary di sease (45,49). The Associ at ion of Anaesthet ists of Great Bri tain and
I rel and (AAGBI ) and ot hers recommend t hat ei ther a f il t er be pl aced bet ween the
pati ent and the breathi ng system wi t h a new f i l t er bei ng used for each adul t pat i ent
or t hat a new breathing system be used f or each pat ient (50). Studi es show t hat
f il ters do become contami nated on t he machine side (50A). For pedi at ri c pat ients,
t he i ncreased resi st ance and rel at i ve ineff i ci ency of pedi at ri c fi l ters may make
ot her means of humidif icat ion and inf ecti on control more att ract ive (51,52,53). The
AAGBI recommends t hat f i l t ers not be used for pedi at ri c pati ents; rather, the
breat hi ng system shoul d be replaced bet ween cases.
Two i nt ernati onal st andards cover f i l ters (54,55). These st i pul at e that the f i l ter
manuf acturer must decl are t he f i l trati on perf ormance, as wel l as pressure drop and
i nternal vol ume, but the ranges wi t hi n which f i l ters must perf orm are not given.
Types
Mechanical Filters (Pleated Hydrophobic)
Mechani cal f i l t ers uti l i ze a compact fi ber matrix. They are pl eated t o i ncrease
surf ace area. They have very smal l pores and act by physi cal l y prevent i ng
mi croorgani sms and part icles f rom passi ng.
Electrostatic Filters
El ect rostati c f i l ters use a f el tl ike materi al t hat i s pol ari zed in an el ectromagneti c
f iel d. They rel y on electrost at ic f orces t o hol d organi sms wi t hi n a l oosel y woven
charged f i l t er el ement. The f i bers are less dense than those i n mechani cal f i l t ers;
hence, t he pore si ze i s greater. Most studi es show t hat the f i l t rat i on performance of
t hese f il t ers i s less sati sf actory t han t hat of mechani cal f i l ters, especi al l y wi t h
extreme chal l enges (50,56,57,58,59,60,61,62, 63,64,65, 66,67). However, cl inical
studi es show that they are eff ect ive in preventi ng breat hi ng system contami nati on
duri ng cl inical use (50A, 68,69).
Bot h types of f i l t ers are manufactured wi th and wi t hout addi t ional heat and moisture
exchange el ements.
P. 202

Filtration Efficiency
Fi l ter ef f iciency vari es (48). A hi gh-ef f i ci ency parti cul ate aerosol (HEPA)-grade
device is defi ned as one capable of trappi ng at least 99.97% of parti cl es having a
di ameter of 0.3 m (70). Fi l ter ef f i ci ency depends on the experi ment al t est
condi ti ons. Theref ore, when f i l t er ef fi ci ency i s stated, the si ze of the chal l enge
part icl e or organism shoul d be di scl osed. The approxi mate size of the human
i mmunodef i ci ency vi rus (HIV) part i cl e i s 0. 08 ; hepat i ti s C vi rus, 0.06 m;
mycobacteri um t ubercul osi s, 0.3 m; pseudomonas aerugi nosa, 0.5 ; and
staphl ococcus aureus, 1.0 .
Filter Locati on in the Breathing System
Fi l ters used i n anesthesi a breathi ng systems are suppli ed i n three forms: (a)
at tached t o a disposabl e breathi ng t ube (Fig. 7.3), (b) att ached to a venti lator hose,
and (c) as a separate component . A f i l ter pl aced at t he pati ent port may permi t
di sposabl e breat hi ng systems t o be reused. However, t he external surface of t hese
systems wi l l not be protected.
A f i l ter shoul d not be pl aced downst ream of a humi dif i er or nebul i zer, because i t
may become less ef f i ci ent when wet . In addi ti on, an increase i n resi st ance,
someti mes t o a hazardous l evel , may be seen.
Problems Associated with Filters
Increased Resistance and Dead Space
A f i l ter i ncreases the resistance to gas fl ow (71,72). Resi stance wi l l i ncrease as
condensat ion accumul ates (73, 74). Whi l e i ncreased resistance is usual l y not a
probl em duri ng cont rol l ed venti lati on, i t may be problemati c wi t h spontaneous
respi rati on.
Addi ng a f i l ter bet ween t he pati ent and the breat hi ng system i ncreases the dead
space. Unl ess venti l ati on i s increased, si gni f i cant rebreathing can occur (75).
Spontaneousl y breathi ng pati ents who deri ve a major porti on of t hei r mi nute vol ume
f rom shall ow breat hs may fi nd the i ncrease i n dead space excessive (70). A l arge
f il ter should not be used in t his l ocati on wi th pedi atric pati ents. Pedi at ri c fi l ters are
avai l able.
Obstruction
Fi l ters may be obstruct ed by exhal ed bl ood, edema or regurgi tated f l ui d, a
manuf acturi ng def ect , steri l i zat ion of a di sposabl e f i l t er, nebul i zed drugs, or
i nsert i ng a unidi rect ional f il t er backward (76,77,78,79,80,81, 82,83,84, 85, 86). A
f il ter should not be used wi t h a pat ient who produces copious secret ions or
downst ream of a humi di f i er or nebul izer. An i ncrease in peak i nspi ratory pressure
may i ndi cate the need t o repl ace a f i l ter.
Leaks
A def ect i n a f i l ter can cause a l eak (79,87).
Liquid Penetration
Si nce f i l ters l ocated between the breathi ng system and the pati ent are someti mes
exposed t o l i qui ds, the abi l i t y to contai n that l i quid i s import ant . Mi crobes can
t ransi t the f i l t er by way of a li qui d that passes t hrough a f i l ter. There i s a great
vari abi l i t y among f i l ters i n regard t o the pressure that wi l l cause l i quid to penetrate
t he f i l t er materi al (87A). In general , pleat ed mechanical f i l ters are more resi st ant to
l i quid passage than el ect rostat i c f i l ters.
Other
Usi ng a f i l ter bet ween the pat ient and the breathi ng system may resul t i n erroneous
end-t i dal gas concent rat i ons and poor carbon dioxi de waveforms (88,89,90,91).
Equipment to Administer Bronchodilators
I ntraoperati ve bronchospasm can be a very seri ous probl em.
St udi es show t hat medi cat i ons admi ni st ered by the i nhal ati onal route are j ust as
ef fective as parenteral therapy wi t h fewer si de ef fects (92, 93).
Apparatus
Manuf acturers have adapted metered-dose i nhal ers (MDI s) f or use wi t h anesthesi a
breat hi ng ci rcui ts. An i nhaler may be pl aced i nsi de t he barrel of a l arge syri nge and
actuated by pressi ng the syri nge plunger (94, 95,96,97). Most adapters are T-
shaped wi th t he injecti on port on t he si de (Fi g. 7. 10). Numerous commerci al
adapt ers and homemade devi ces have been descri bed i n t he l i terature
(98,99,100,101,102,103,104,105,106,107,108). The gas sampli ng port i n the
breat hi ng system or t he sampli ng l umen of a speci al i zed tracheal tube (Chapter 19)
may be used to del iver medi cat ions (96,109). Medi cati on may be del ivered by a
catheter that extends to the t i p of the tracheal t ube. Thi s method resul ts i n more
ef fi ci ent del ivery (94,110,111,112).
The adapter shoul d be pl aced cl ose to the pat ient port. There should not be a f i l ter
or heat and moisture exchanger (HME) bet ween the adapter and the pat ient.
A spacer (aerosol hol di ng chamber, reservoi r chamber, auxi l iary or accessory
device, [ extension or reservoi r] ) (Fi g. 7.11) may be pl aced downstream or upstream
of t he MDI t o sl ow t he f low of aerosol and to i ncrease i mpacti on and sedi ment at ion
of l arge parti cl es (113,114). Ri gi d spacers resul t in more eff i cient medicati on
del i very than col lapsi bl e ones (115).
Aerosol nebul i zers may al so be used to del i ver bronchodi lat ors to an anest hesi a
breat hi ng system. The gas used to aerosol ize t he agent wi l l af f ect the composi t i on
of t he i nspi red gas (116).
Technique of Use
The i nhaler should be shaken wel l pri or t o admi ni strat ion (93). Bronchodi l ator
di scharge is maxi mal when t he cani ster i s upri ght. The hol e in t he adapter should
poi nt toward t he pat ient, unl ess an upstream spacer i s used. Actuati ng the i nhal er
j ust af t er i nspi rati on begi ns wi l l
P. 203

maxi mi ze del i very to the ai rways (117). I f a spacer i s used, t he MDI should be
actuated 1 to 2 seconds bef ore i nspi rat ion or near end-exhal ati on, dependi ng on
t he rate (118).

View Figure
Figure 7.10 Adaptor for administering bronchodilators by
using a multidose inhaler. Note the cap that can be fitted
over the port when it is not in use. The hole in the inhaler
should port toward the patient unless an upstream spacer is
used.

A sl ow, deep inspi rati on, f ol lowed by a pause of 2 to 3 seconds bef ore exhal at i on,
wi l l enhance the amount of medi cati on deposi ted i nt o the ai rway (117, 119, 120).
There shoul d be 30 to 60 seconds bet ween puf f s. The i nhal er must be shaken pri or
t o each puff (93, 118).
Low humidi f icati on i s desi rabl e when del i veri ng medicati on (93, 115). Hi gh
humi di f icati on causes t he aerosol dropl ets to increase i n si ze, whi ch causes them
t o rai n out . If possibl e, humi dif i cati on should be di scont inued when an MDI i s used.
Usi ng a spacer wi l l i ncrease bronchodi l ator del i very and reduce the number of puff s
(92). However, even wi th a spacer, as many as 10 to 15 puff s may be requi red t o
reach t he desi red resul ts (92, 121). The pati ent should be moni tored for the
appearance of benefi ci al and si de eff ects.

View Figure

Figure 7.11 Multidose inhaler with downstream spacer in
place between the breathing system (right) and the patient
connection (left).

Advantages
MDI s are easy to use, t ake l i t tl e ti me to set up, and occupy l i t tl e space on the
anesthesi a cart (122). They are more eff i ci ent at del iveri ng medi cati ons and less
costl y than nebuli zers (114, 118,123,124).
Disadvantages
A large amount of drug i s l ost due to rainout i n the breathi ng system and tracheal
t ube. I mproper techni que i s one fact or (125). The smal l er t he tracheal tube, the
more drug i s deposi ted i n the tube (112,115, 117).
Another probl em i s that t he carri er gas may cause erroneous readi ngs wi t h an
anesthet ic agent anal yzer (125,126) (Chapter 22).
Size and Type of Fittings
The Compressed Gas Associat i on (CGA) and the ASTM have publ i shed standards
t hat speci f y the si ze and t ype of fi t ti ngs f or components i n the breat hi ng system
(1,18,23). Vi rtual l y al l breat hi ng system components manuf act ured i n the Uni t ed
St ates in recent years conform to t hese st andards. The saf ety provided by
standardizing the di amet ers of vari ous connect ors can be j eopardi zed by the use of
adapt ors and adhesive tape.
Any component or accessory used i n the breathing system that permi ts onl y
uni di rect ional f low or any device whose correct f uncti on depends on the di rect ion of
gas f l ow t hrough i t must be so l abel ed and marked wi t h an arrow i ndicati ng the
proper di recti on of f low or the words i nl et and outl et or both. Di stal and proxi mal
are
P. 204

used to desi gnat e the proxi mi ty of a component to the pati ent .
A f i tt i ng that i s part of a component such as an absorber, Y-pi ece, or reservoi r bag
mount, whose purpose is t o permi t at tachi ng t hi s component t o a reservoi r bag,
breat hi ng tube, or mask, must be mal e and ri gi d. Fi t ti ngs on the breat hi ng tube,
mask, and reservoi r bag connect ors must be f emal e and nonri gi d (resi l i ent ).
Al l connectors in an adul t breat hi ng syst em are 22 mm. The pat ient port must have
a coaxi al 15-mm f emal e fi t ti ng. The inspi ratory and expi ratory ports mounted on t he
absorber and t he reservoi r bag connector must have mal e f i t ti ngs. To avoi d
probl ems wi th connecti ons between the breat hi ng and scavengi ng systems, t he exi t
port f or t he APL valve must have ei t her a 19- or 30-mm male f i t ti ng. A 30-mm f i t ti ng
i s preferred.
Breathing System Classification
A f avori te past i me among anesthesi a provi ders has been t he cl assi fi cat i on of
breat hi ng systems. The resul t has been a hopel essl y confused t ermi nol ogy. There
i s no agreement about how breat hi ng systems shoul d be cl assif ied. I n an attempt t o
provi de some rel i ef f rom thi s confusion, a descript i on of vari ous authors'
cl assif i cat ions wi l l be present ed. Subsequentl y, a nomencl ature t hat the present
authors bel i eve i s more useful wi l l be descri bed.
Classification by Function
Dripps, Eckenhoff, and Vandam
Wi th this cl assi fi cat i on, breat hi ng systems are di vi ded i nt o f ive categori es
accordi ng to the presence or absence of (a) a reservoi r bag, (b) rebreathi ng, (c) an
absorber t o remove carbon di oxi de, and (d) di recti onal val ves (127). The f i ve
systems are i nsuff l ati on, open, semi open, semi cl osed, and cl osed.
The i nsuff l ati on system i s one i n which gases are deli vered di rectl y i nto t he
pati ent 's ai rway. There are no valves, reservoi r bag, or carbon di oxi de absorpti on.
I n t he open system, the pati ent i nhales onl y the mi xture del i vered by t he anesthesi a
machi ne. Val ves di rect each exhal ed breat h i nto atmosphere. A reservoi r bag may
or may not be present. Rebreathi ng is mi ni mal , and there i s no carbon di oxide
absorpti on. Thi s i ncludes systems used wi th i nt ermi t tent f l ow anesthesi a machi nes
and nonrebreathi ng valves.
I n t he semi open system, exhaled gases f low out of the system and t o the
i nspi ratory l ine of the apparatus to be rebreat hed. There is no chemi cal absorpt ion
of carbon di oxi de. Rebreathing depends on t he f resh gas f l ow. A reservoi r bag and
a di recti onal val ve are opt i onal .
I n t he semicl osed system, part of t he exhaled gases passes i nto atmosphere and
part mi xes wi th f resh gases and i s rebreathed. Chemi cal absorpti on of carbon
di oxi de, di recti onal val ves, and a reservoi r bag are present.
I n t he cl osed system, there is compl ete rebreathi ng of expi red gas. Carbon dioxide
absorpti on, a reservoi r bag, and di recti onal val ves are present.
Moyers
Thi s cl assif i cati on i s based on the presence or absence of a reservoi r bag and
rebreat hi ng. An open system has no reservoi r or rebreathi ng (128). The semiopen
system has a reservoi r but no rebreathi ng. The semi cl osed syst em has a reservoi r
and part i al rebreat hing, and the cl osed system has a reservoi r and compl et e
rebreat hi ng.
Coll ins
Thi s cl assif i cati on def i nes an open syst em as one in whi ch an anest het i c agent is
brought to the pat i ent ' s respi ratory t ract wi th atmospheric ai r as t he di luent (129).
The respi ratory t ract has access to the atmosphere duri ng both inspi rat i on and
expi rat ion. There i s no reservoi r or rebreathi ng.
A semi open syst em is one i n whi ch t he pat ient' s respi ratory system i s open t o
at mosphere duri ng both i nspi rati on and expi rati on. There i s a reservoi r that i s open
t o atmosphere, rebreat hi ng is absent, and at mospheri c ai r ei ther carri es or di l ut es
t he anestheti c agent.
The semiclosed system i s one i n which the pati ent ' s respi ratory system is
compl etel y cl osed to atmosphere on i nspi rat i on but i s open on expi rati on. A
reservoi r cl osed to atmosphere i s present.
Wi th a cl osed system, t here i s no access to at mosphere ei ther duri ng inspi rati on or
expi rat ion. Rebreathi ng i s compl ete, and a reservoi r i s requi red.
Adriani
Thi s cl assif i cati on divides systems i nt o open vapori zati on, insuf f l at ion, semi cl osed,
and cl osed (rebreathi ng) (130). An open system i s one empl oyi ng an open drop
mask. Wi t h the i nsuff l ati on t echnique, a conti nuous st ream of gas f lows t o the
pati ent 's nasopharynx, oropharynx, or t rachea. The semi cl osed system i s one i n
whi ch there i s compl ete encl osure of the inspi red at mosphere and no ai r di luti on.
The closed system permi ts complete rebreat hi ng.
Conway
Wi th this cl assi fi cat i on, an open system i s one wi th i nf i ni t e boundari es and no
rest ri ct ion t o f resh gas fl ow (131). The semi open system is one part i al l y bounded,
wi th some rest rict i on to f resh gas f low. The cl osed system is def i ned as havi ng no
provi si on f or gas overf l ow. The semi cl osed system i s one al l owi ng for overf l ow of
excess gas. I t i s divided into semi cl osed rebreathi ng,
P. 205

semi cl osed absorpt i on, and semi cl osed nonrebreat hi ng systems.
Hall
I n t hi s cl assif icati on, an open system has no reservoi r bag or rebreathi ng (132).
The semiopen system al so has no reservoi r bag but has part i al rebreathi ng.
Semi cl osed syst ems have a reservoi r bag and part i al rebreathing. They are di vi ded
i nto t hose wi t h and wi thout carbon dioxide absorpt i on. The closed system has
compl ete rebreat hing and a reservoi r.
McMahon
Thi s system uses rebreathing as the basi s for cl assi f i cati on of breathi ng systems
i nto open, semi closed, and cl osed (133). An open t echnique is one i n whi ch there i s
no rebreathi ng. This i ncl udes techni ques i n whi ch gases are administered at a t otal
f low rate equal to or greater t han the respi rat ory mi nute volume. Techni ques wi t h
f lows l ess t han t he respi ratory minute vol ume woul d also be considered open i f
t here were no i ncrease i n dead space. The semiclosed system would empl oy some
rebreat hi ng. The closed system employs total rebreat hi ng.
Baraka
Thi s system cl assi f i es systems accordi ng to thei r mechani sm of carbon di oxi de
el i mi nati on (134). Open syst ems are t hose that eli mi nate carbon di oxi de by washout
and have no reservoi r bag. Semi open systems al so wash out carbon dioxi de but
have a reservoi r bag. Semiclosed systems use carbon di oxide absorpt ion and have
a f resh gas f l ow that exceeds pati ent upt ake. Closed systems al so use carbon
di oxi de absorpt ion and have a f resh gas f l ow that equal s pat ient uptake.
The I nternational Standards Organization
The I nternati onal Standards Organi zati on (ISO) cl assi f i es breat hi ng systems as
nonrebreathing and parti al rebreathi ng. The terms semi open and semi cl osed are
not used. A nonrebreathi ng system i s an anaesthesi a breat hi ng system f rom which
al l of t he expi red mi xt ure i s di scharged. A parti al rebreathi ng system i s an
anaesthesia breathi ng system i n whi ch a port i on of t he expi red mixture is ret ai ned
wi thi n t he system (135).
Marini, Cul ver, and Kirk
Thi s system cl assi f i es breat hi ng systems on t he basis of carbon di oxi de el i minati on
(136). Systems are di vi ded i nto open, which do not have a reservoi r bag, and
semi open, whi ch do have a reservoi r bag. Exampl es of the open vari ety i ncl ude t he
open drop mask, i nsuf f l ati on, and the T-piece (Mapl eson E). Semiopen systems
i ncl ude t he Magi ll and Lack (Mapleson A), Bai n (Mapl eson D), Jackson-Rees
(Mapl eson F), Mera F, and syst ems wi t h nonrebreathi ng valves. The carbon di oxi de
absorpti on uni ts include the ci rcl e system.
Classification by Equipment
Hami l ton (137) recogni zed the short comi ngs of the nomencl atures descri bed
previ ousl y and proposed that the t erms open, semi open, and the l i ke be dropped in
f avor of a descri pt ion of the equi pment and the tot al f resh gas f low t o the system.
An exampl e woul d be a ci rcl e syst em wi t h a 2-L/mi nute f resh gas f l ow. The
descri pt i on of the equipment wi l l be fami l iar to t he reader af t er readi ng the next t wo
chapters. The f resh gas fl ow wi l l determi ne t he amount of rebreat hi ng, i f any, that
t akes pl ace.
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P. 208

Questions
For the f ol lowing quest ion, sel ect the correct answer.
1. Whi ch of the fol l owing offers the most resistance?
A. Nonrebreathing val ve
B. CO
2
cani ster
C. Tracheal tube
D. Y-pi ece
E. Breathi ng tubes
Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
2. The functi ons of the breathing system i ncl ude the foll owing:
A. Conveying oxygen and anesthet ic gases t o t he pati ent
B. Del iveri ng posi tive pressure
C. Removi ng wast e and anest het ic gases f rom the pat ient
D. Conveying excess gases to t he scavengi ng syst em
Vi ew Answer3. Resistance to breathing through a breathi ng system is
i nfl uenced by
A. Laminar f l ow
B. Gas f l ow rat e
C. Turbulent f l ow
D. Length of the breathing tubes
Vi ew Answer4. Rebreathing may be i nfl uenced by
A. Fresh gas fl ow
B. Arrangement of components in t he breathing syst em
C. Mechani cal dead space
D. The size of the reservoi r bag
Vi ew Answer5. Effects of rebreathi ng include
A. Reduced l oss of heat and wat er f rom the pati ent
B. Reduced i nspi red oxygen
C. Less f l uctuati on i n i nspi red anesthetic agent concent rati on
D. Decreased i nspi red carbon di oxi de
Vi ew Answer6. Factors that cause a discrepancy between the
compositi on of the i nspi red gas mixture and that of the fresh gas include
A. Rebreathing
B. Leaks i n the breathi ng system
C. Uptake of anesthet ic agent by component s of the breathing system
D. I ncreased f resh gas f l ow
Vi ew Answer7. Factors that can cause a di screpancy between the volume
of gas discharged from a venti lator or reservoir bag and that inspired by the
pati ent i ncl ude
A. Fresh gas fl ow
B. Compressi on of gases i n the ci rcui t
C. Leaks
D. Di stenti on of breathi ng system components
Vi ew Answer8. The reservoir bag
A. Al l ows use of l ower f resh gas f l ows
B. Provi des a means for del ivering posi ti ve pressure
C. Can serve as a moni t or of spontaneous respi rat ion
D. Can cause excessi ve pressure i f the APL val ve is not open
Vi ew Answer9. Concerni ng the peak pressure than can be generated i n
the breathi ng system if there is a reservoir bag in place,
A. I f the reservoi r bag i s less than 1.5 L i n size, the pressure shall not be l ess than
30 cm H
2
O
B. I f the reservoi r bag i s larger t han 1.5 L, the pressure shal l not be less than 45
cm H
2
O
C. I f a 1.5-L bag i s expanded to f our t i mes i t s normal si ze, t he pressure shal l not
be greater t han 50 cm H
2
O
D. I f a bag over 1.5 L i s expanded t o four t i mes i ts si ze, t he pressure shal l not be
great er t han 65 cm H
2
O
Vi ew Answer10. Functi ons of breathing tubes i ncl ude
A. Acti ng as a reservoi r i n certai n systems
B. Prot ecti on agai nst excessi ve pressure
C. Provi di ng a f l exibl e connect i on bet ween the di ff erent part s of t he breathi ng
system
D. Expanding duri ng spont aneous breat hi ng to prevent rebreathing
Vi ew Answer11. Duri ng spontaneous respirati on,
A. The APL val ve shoul d be kept part i al l y cl osed
B. Most APL valves open automati cal l y
C. An obstructi on in the scavenging syst em may resul t i n gas bei ng removed f rom
t he breathi ng system
D. Obstructi on of t he ai r i ntake val ve i n the scavengi ng system can resul t i n
posi t i ve pressure i n t he breat hi ng system
Vi ew Answer12. With a PEEP valve i n the breathi ng system,
A. An i ncreased exhalati on ef fort i s necessary i f the pat ient is breathi ng
spontaneousl y
B. An i ncrease in t idal vol ume may be seen wi th mechani cal vent i l at i on
C. The amount of PEEP can be ei t her f i xed or adjust abl e
D. A spri ng-loaded PEEP valve must be kept i n t he upri ght posi ti on
Vi ew Answer13. Which of the foll owi ng connectors are mal e?
A. Those on t he breathing tubes
B. Those on t he reservoi r bag mount
C. Those on the mask
D. Those on the Y-pi ece connecti ng t o the breathi ng t ubes
Vi ew Answer14. Deposition of bronchodi lators in the pati ent' s
tracheobronchial tree i s enhanced by
A. Use of a spacer
B. A l ow i nspi ratory f l ow rat e
C. Low humidif icati on
D. An expi rat ory pause
Vi ew Answer15. Causes of local ized turbul ent flow include
A. Const ri ct i ons i n the fl ow channel
B. Valves
C. Curves
D. Gas at a f l ow rat e bel ow the cri ti cal number
Vi ew Answer

Chapter 7. The Breathing System

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Chapter 7

The Breathing System: General Principles,

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