Chapter 8

Mapleson Breathing Systems

The Mapleson systems are characteri zed by t he absence of uni di recti onal valves to
di rect gases t o or f rom the pati ent . Because t here is no devi ce f or absorbing CO
2
,
t he f resh gas f l ow must wash CO
2
out of the ci rcui t . For t hi s reason, t hese systems
are somet i mes cal led carbon di oxi de washout ci rcui ts or fl ow-control led breathi ng
systems.
These systems were f i rst cl assi f i ed i nto f ive basi c types: A through E (1). A si xth,
t he Mapl eson F system, was added later (2). The classi fi cati on is shown i n Fi gure
8. 1. There are many vari at ions of t hese syst ems, but onl y the ones i n common use
wi l l be di scussed.
Because there is no cl ear separati on of i nspi red and expi red gases, rebreathi ng wi l l
occur when the i nspi ratory f l ow exceeds the f resh gas f low. The composi ti on of the
i nspi red mixture wi l l depend on how much rebreathing t akes place. A number of
studi es desi gned to determi ne t he f resh gas f l ow needed to prevent rebreathing
wi th t hese syst ems have been perf ormed, wi th of ten wi del y di f feri ng resul ts. Thi s i s
part l y because dif f erent cri teri a have been used to def i ne t he onset of rebreathi ng
and because vari abl es such as mi nute venti l ati on, respi ratory wavef orm, CO
2

producti on, pati ent responsi veness, and stimul ati on and physi ol ogi cal dead space
may be unpredi ctabl e i n anestheti zed pat ients (3,4,5). Moni t ori ng end-t i dal CO
2
i s
t he best method to determi ne the opti mal f resh gas f low. It shoul d be not ed that
wi th rebreathi ng, the arteri al CO
2
to end-ti dal CO
2
gradi ent decreases (6).
P. 210



View Figure

Figure 8.1 The Mapleson systems. Components include a
reservoir bag, corrugated tubing, APL valve, fresh gas inlet,
and patient connection. They lack CO
2
absorbers,
unidirectional valves, and separate inspiratory and
expiratory limbs. (Redrawn from
Mapleson WW. The elimination of rebreathing in various
semiclosed anesthetic systems. Br J Anaesth 1954;26:323
332
[CrossRef]
[Medline Link]
.)

Mapleson A System
Configurations
Classic Form
The Mapleson A system (Magil l at t achment or system) i s shown i n Fi gure 8.1A. It
di ff ers f rom t he ot her Mapl eson systems in t hat f resh gas does not enter the system
near the pat ient connect i on but enters at t he other end of t he system near the
reservoi r bag. A corrugat ed tubi ng connects t he bag to the adj ustabl e pressure
l i mi ti ng (APL) valve at the pat i ent end of the system.

View Figure

Figure 8.2 Lack modification of the Mapleson A system.
The coaxial version is shown. APL, adjustable pressure
limiting.

A sensor f or a nondiverti ng respi rat ory gas moni tor or t he sampl i ng si te f or a
di verti ng moni tor (Chapter 22) may be pl aced bet ween the APL val ve and t he
corrugated tubi ng. In adul ts, i t may be pl aced bet ween the APL val ve and t he
pati ent . In smal l pat ients, this l ocati on could resul t i n excessi ve dead space. I t
could also be pl aced bet ween t he neck of the bag and i ts mount , bet ween the bag
and the corrugated tubi ng, or i n the f resh gas suppl y t ube. However, i n these
l ocat i ons, the concentrat ion shown on t he moni tor may di ff er substant i al l y f rom the
i nspi red concent rati on, especi al l y during cont rol l ed venti l ati on.
Lack Modificati on
The Lack modi f icati on of t he Mapl eson A system (Fi g. 8.2) has an added
expi ratory l i mb, whi ch runs f rom the pati ent connect i on to t he APL valve at t he
machi ne end of the system (7,8). This makes i t easi er t o adj ust the valve and
f aci li t ates scavengi ng excess gases, but i t i ncreases t he work of breat hi ng sl i ghtl y
(3).
The Lack system i s avai l abl e in both a dual (parall el ) tube arrangement and a tube-
wi thi n-a-tube (coaxi al ) confi gurati on i n whi ch the expi ratory l i mb runs concent ri cal l y
i nsi de the outer i nspi ratory l i mb (9).
Techniques of Use
For spontaneous vent i l at ion, t he APL val ve i s kept i n the ful l y open posi t i on.
Excess gas exi ts t hrough i t duri ng the l at ter part of exhal ati on.
For cont roll ed or assi st ed venti lati on, i ntermi t tent posi t i ve pressure i s appl ied to
t he bag. The APL val ve i s parti al l y cl osed so t hat when the bag i s squeezed,
suff icient pressure t o i nf l ate t he lungs i s achi eved. The APL val ve opens during
i nspi rati on.
Functional Analysis
Spontaneous Respiration
The sequence of events during the respi ratory cycl e usi ng the Magi l l syst em wi t h
spontaneous venti lati on i s shown i n Figure 8. 3 (10,11). As the pati ent exhales (Fi g.
8. 3C), f i rst dead space and then alveol ar gases f low i nt o t he corrugated tubi ng
t oward t he bag. At t he same t ime,
P. 211

f resh gas fl ows i nt o the bag. When the bag i s ful l , the pressure in t he system ri ses
unti l the APL val ve opens. The f i rst gas vent ed wi l l be al veol ar gas. The remai nder
of exhal at i on, whi ch contains onl y al veol ar gas, exhausts t hrough the open APL
valve. The cont inuing i nf l ow of f resh gas reverses the f l ow of exhal ed gases in t he
corrugated tubi ng. Some alveol ar gas that bypassed the APL valve now ret urns and
exi ts through i t . If the f resh gas f low i s hi gh (Fi g. 8.3A), i t wi l l also f orce the dead
space gas out. If t he f resh f l ow gas is i nt ermedi ate (Fi g. 8. 3D), some dead space
gas wi l l be retained i n the system. If t he f resh gas f l ow i s l ow (Fi g. 8.3E), more
al veolar gas wi l l be retai ned.

View Figure

Figure 8.3 Magill system with spontaneous ventilation.
(See text for details.) (Redrawn from
Kain ML, Nunn JF. Fresh gas economies of the Magill
circuit. Anesthesiology 1968;29:964974
[Fulltext Link]
[CrossRef]
[Medline Link]
.)

At t he start of i nspi rati on, the f i rst gas i nhal ed wi l l be f rom dead space bet ween t he
pati ent and the APL val ve. The next gas wi l l be ei ther alveol ar gas (i f the f resh gas
f low i s low), dead space gas (if t he f resh gas f l ow i s i nt ermedi ate), or f resh gas (i f
t he f resh gas f l ow i s hi gh) (Fi g. 8.3B). Changes i n respi ratory pat tern have l i tt le
ef fect on rebreathi ng (11,12,13).
Wi th the classi c Magi ll system, i nvest igat ors have found that rebreat hi ng begi ns
when t he f resh gas f l ow i s reduced t o 56 t o 82 mL/kg/minute (3,14, 15,16,17), or
58% t o 83% of minute volume (3,10,18, 19,20, 21). Fresh gas f l ows of 51 to 85
mL/kg/minute (3,14,22, 23,24) and 42% to 88% of mi nut e vol ume (3,19,23) have
been recommended to avoid rebreathi ng.
Control led or Assisted Ventilati on
During cont roll ed or assi sted venti lati on (Fig. 8.4), t he pat t ern of gas f l ow changes.
During exhalat i on (Fi g. 8.4A), t he pressure i n the syst em wi l l remain l ow and no
gas wi l l escape t hrough t he APL valve, unl ess the bag becomes di stended. Al l
exhal ed gases, both dead space and alveolar, remai n i n the corrugated tubing, wi th
al veolar gas nearest t he pati ent. If t he ti dal vol ume i s l arge, some alveol ar gas may
enter t he bag (25).

View Figure

Figure 8.4 Magill system with controlled ventilation. (See
text for details.)

P. 212


At t he start of i nspi rati on (Fig. 8. 4B), gases i n t he tubi ng f l ow to t he pati ent.
Because alveol ar gas occupies the space nearest t he pat ient, i t wi l l be i nhal ed f i rst .
As the pressure in the system rises, t he APL valve opens so that gas both exi ts
t hrough the APL val ve and f l ows to the pat ient. When al l the exhal ed gas has been
driven f rom the t ube, f resh gas f i ll s the tubing (Fi g. 8. 4C). Some f resh gas ent ers
t he pat ient, and some i s vented through the val ve. Thus, duri ng cont rol l ed
venti l ati on, there i s considerabl e rebreathi ng of al veol ar gases and venti ng of f resh
gas. The composi ti on of the i nspi red gas mi xture depends on the respi ratory
pat tern (25,26). The syst em becomes more ef fi ci ent as the expi ratory phase is
prol onged. Most invest i gat ors beli eve that i t i s i l l ogi cal to use the Mapl eson A
system f or cont rol l ed vent i lat i on. However, i f the APL valve i n the Mapl eson A
system does not vent gas during i nspi rat i on, t he Mapl eson A syst em can be as
ef fi ci ent as the Mapleson D duri ng cont rol l ed venti l ati on (27).
During assi st ed venti l ati on, the Mapleson A system i s somewhat less ef f i ci ent than
wi th spont aneous venti lati on but is more eff i ci ent than wi th cont rol l ed venti lati on
(28).
Hazards
A mechani cal venti l at or t hat vents excess gases should not be used wi t h thi s
system, because the ent i re system t hen becomes dead space. The venti l at ors f ound
on most anesthesi a machi nes i n the Uni ted St ates are unsui tabl e f or use wi t h the
Mapl eson A syst em.
Cases have been reported where a Lack ci rcui t was i ncorrectl y manuf actured or
assembl ed so t hat t he f resh gas inl et was mounted adjacent to the APL valve rather
t han the reservoi r bag (29,30, 31). Thi s woul d resul t in a substanti al increase i n
dead space.
Preuse Checks
The Mapleson A system i s test ed f or l eaks by occl udi ng the pat i ent end of the
system, cl osi ng t he APL val ve, and pressuri zi ng the system. Openi ng the APL val ve
wi l l conf i rm proper f unct i oni ng of that component . In addi ti on, the user or a pati ent
shoul d breathe through the system.
The coaxi al Lack syst em requi res addi t ional t esti ng to conf i rm t he integri ty of the
i nner t ube. One method i s to at tach a t racheal t ube t o the i nner t ubi ng at the
pati ent end of the system (32). Bl owi ng down the t ube wi th t he APL val ve closed
wi l l produce movement of the bag if there i s a l eak between the t wo l i mbs. Another
method i s to occlude both l i mbs at the pat i ent connect ion wi th t he APL valve open
and then squeeze the bag (33). I f there i s a l eak in t he inner l imb, gas wi l l escape
t hrough the APL val ve, and the bag wi l l col l apse.
Mapleson B System
The Mapleson B system i s shown i n Figure 8. 1B. The f resh gas i nl et and APL valve
are both l ocated near t he pat i ent port . The reservoi r bag is at the pati ent end of the
system, separated f rom t he f resh gas i nl et by corrugated tubi ng.
Techniques of Use
To use t he Mapl eson B system wi t h spontaneous respi rat ion, the APL val ve i s
opened compl etel y. Excess gas i s vented through the val ve duri ng exhal ati on.
Assisted or cont rol l ed venti l ati on i s accompl ished by cl osing t he APL valve
suff icientl y to al l ow the l ungs to be i nf l at ed. Excess gases are vent ed during
i nspi rati on.
Functional Analysis
Spontaneous Respiration
As the pat i ent exhal es, dead space gas wi l l pass down the corrugated t ubi ng, al ong
wi th f resh gas. At the end of exhal at ion, the t ubi ng near t he pat ient wi l l be f i l l ed
wi th f resh gas and some alveol ar gas. When t he bag reaches full capaci t y, the APL
valve opens, and both f resh gas and al veolar gas wi l l exi t f rom the system. When
t he pat ient begi ns to i nspi re, the APL val ve cl oses, and the pat i ent i nhales f resh
gas and gas f rom the tubing. No gas wi l l be i nhal ed f rom the bag if the vol ume of
t he tubing exceeds the ti dal vol ume.
To avoid rebreathi ng, t he f resh gas f l ow must be equal to peak inspi ratory f l ow rate
(normal l y 20 to 25 L/mi nute) (34). A f resh gas f low more than doubl e mi nut e vol ume
has been recommended (34,35), but f lows as low as 0.8 t o 1.2 t imes mi nute vol ume
may be suff icient (25).
Control led or Assisted Ventilati on
The behavior of the Mapl eson B system duri ng control l ed or assi sted venti l ati on i s
si mi l ar t o that of the Mapl eson A, but i t i s sl i ght l y more eff i ci ent because f resh gas
accumul ates at t he pat i ent end of the tubi ng duri ng t he expi ratory pause (25,34).
Because the composi ti on of inspi red gas is great l y i nf luenced by the venti l at ory
pat tern, this system has vari abl e perf ormance duri ng control l ed venti l at i on (25). A
f resh gas fl ow of 2 t o 2.5 t i mes mi nute vol ume has been recommended (25,34,36).
Mapleson C System
The Mapleson C system is i denti cal to t he Mapl eson B syst em except that t he
corrugated tubi ng is omi t ted (Fi g. 8. 1C).
Techniques of Use
Use of thi s system i s si mi l ar t o that descri bed f or t he Mapl eson B system.
P. 213


Functional Analysis
The Mapleson C system behaves simi l arl y to t he Mapl eson B system. Wi t h
spontaneous venti lati on, the Mapl eson C system is al most as ef fi ci ent as the
Mapl eson A when the expi ratory pause is mi ni mal , but i t becomes l ess ef f i ci ent as
t he expi ratory pause i ncreases (11,13,37). A f resh gas f l ow of 2 t i mes mi nute
volume has been recommended f or spontaneous breat hi ng. During cont roll ed
venti l ati on, a f resh gas f l ow of 2 to 2. 5 ti mes mi nute vol ume is recommended
(25,38).
Mapleson D System
The Mapleson D, E, and F syst ems al l have a T-pi ece near t he pat i ent and functi on
si mi l arl y. The T-pi ece i s a three-way t ubul ar connector wi t h a pat ient connecti on
port , a f resh gas port , and a port f or connecti on t o a corrugated t ubi ng. The
Mapl eson D system is popul ar because excess gas scavengi ng is rel ati vely easy,
and i t i s the most ef fi ci ent of the Mapl eson systems during cont roll ed venti l ati on.
Configuration
Classic Form
The Mapleson D system is shown i n Fi gures 8.1D and 8.5. A l ength of t ubi ng
connects the T-piece at the pat ient end to the APL val ve and t he reservoi r bag
adj acent t o i t . The l ength of t he t ubi ng determi nes the di stance the user can be
f rom the pat ient but has minimal eff ects on venti l at ion (39).
The sensor or sampl i ng si te f or a respi ratory gas moni tor may be pl aced bet ween
t he bag and i ts mount , bet ween t he corrugat ed tubing and the T-pi ece, or between
t he corrugated tubing and the APL val ve. I n adul ts, i t may be pl aced between the T-
pi ece and the pati ent .

View Figure

Figure 8.5 Mapleson D system. A tube leading to the
scavenging system is attached to the APL valve.

A bi di recti onal posi t ive end-expi ratory pressure (PEEP) valve may be pl aced
bet ween t he corrugated tubi ng and the APL val ve of t he Mapleson D system (40).
Thi s permi ts PEEP t o be admi nistered duri ng manual or mechani cal venti l ati on.
However, some PEEP valves wi l l close when a negati ve pressure i s appl i ed, so
spontaneous breathing i s i mpossible wi th t hat t ype of PEEP val ve i n t he system.
The PEEP valve may be pl aced i n the hose l eadi ng to t he anesthesi a venti l ator. I n
t his l ocati on, i t wi l l be ef f ective onl y duri ng mechani cal vent i lat i on. A uni di rect ional
PEEP valve can be used at the bag at tachment si t e by usi ng speci al connect ors
and unidi rect i onal val ves (41). Such an arrangement al l ows PEEP to be appl i ed
duri ng spontaneous or mechani cal but not manual venti lati on (40).
Bain Modification
I n t he Bai n modi fi cati on (Fig. 8.6), t he f resh gas suppl y tube runs coaxi al ly i nsi de
t he corrugated tubing and ends at the point where the f resh gas woul d enter if t he
cl assic Mapleson D f orm were used (42). The outer t ube is clear so that t he inner
t ube can be i nspected (43). The outer t ubi ng of most commerci al l y avai l abl e
versi ons of the Bain system i s narrower t han conventi onal corrugated tubing (25).
The Bai n syst em i s avai l abl e wi th a metal head wi t h channel s dri l l ed i nto i t . Thi s
provi des a f ixed posi t ion f or t he reservoi r bag and APL val ve and attachment of
corrugated tubi ng. Some heads also have a pressure manometer.
A long versi on of t he Bai n system may be used for remote anesthesi a i n l ocat i ons
such as the magnet i c resonance i maging (MRI) uni t (44). Compared wi t h the usual
Bai n system, stati c compl i ance i s i ncreased wi t h a
P. 214

reducti on i n peak i nspi ratory pressure and ti dal vol ume wi t h the same vent i lat or
sett ings. Al so, PEEP is i ncreased. A l onger Bai n system al so presents i ncreased
resi st ance to spontaneous breathi ng (45).

View Figure

Figure 8.6 Bain modification of the Mapleson D system.
The fresh gas supply tube is inside the corrugated tubing.
APL, adjustable pressure limiting; Pt, patient.

Techniques of Use
For spontaneous respi rat ion, the APL val ve i s l ef t open, and excess gases are
vented duri ng expi rati on. Manual l y cont rol l ed or assi sted vent i l ati on is perf ormed
by part ial l y cl osi ng the APL val ve and squeezing the bag. Excess gases are vented
duri ng inspi rati on. Mechanical l y control led venti l at i on is achi eved by connecti ng t he
hose f rom a vent il ator i n place of the reservoi r bag and closi ng the APL val ve.
Excess gases are vented through the vent i lator spi ll val ve.
Functional Analysis
Spontaneous Breathi ng
During exhalat i on (Fi g. 8.7), exhal ed gases mix wi t h f resh gases and move t hrough
t he corrugated tube toward the bag. Af ter t he bag has f i l l ed, gas exi ts via the APL
valve. During the expi ratory pause, f resh gas pushes exhal ed gases down the
corrugated tubi ng.
During i nspi rat i on, the pat i ent wi l l inhal e gas f rom the f resh gas i nl et and the
corrugated tubi ng. If t he f resh gas f l ow i s hi gh, all the gas drawn f rom t he
corrugated tube wi l l be f resh gas. If the f resh gas f low i s low, some exhal ed gas
contai ni ng CO
2
wi l l be i nhal ed. The venti latory pat t ern wi l l hel p to det ermine the
amount of rebreat hi ng. Fact ors that tend to decrease rebreathing i nclude a hi gh
i nspi ratory: expi rat ory (I :E) t i me rat io, a sl ow ri se i n i nspi ratory f l ow rate, a low f l ow
rate duri ng the l ast part of exhal at ion, and a l ong expi ratory pause, wi th t he long
expi ratory pause havi ng the greatest ef fect (11,12,13, 37, 46,47,48).
As gas contai ni ng CO
2
is i nhal ed, the end-ti dal CO
2
wi l l ri se. I f the pati ent' s
spontaneous respi rati on then increases, the end-ti dal CO
2
wi l l f al l whi le i nspi red
CO
2
wi l l i ncrease (49). Provided rebreathing i s not extreme, a normal end-t idal CO
2

can be achi eved but onl y at the cost of increased work on the part of the pat ient.
The end-ti dal CO
2
t ends to reach a pl ateau. At that poi nt , no mat ter how hard the
pati ent works, the end-ti dal CO
2
cannot be l owered f urt her. I f the pati ent' s
respi rati on i s depressed, end-t i dal CO
2
wi l l ri se f urther (49).
End-t idal CO
2
depends on both t he rati o of mi nute vol ume and f resh gas f l ow and
t hei r absol ute values (49). I f expi red volume i s great er than f resh gas f l ow, end-
t i dal CO
2
wi l l be determi ned mai nl y by f resh gas fl ow. I f f resh gas f l ow i s greater
t han minute vol ume, end-t i dal CO
2
wi l l be det ermi ned mainly by mi nut e vol ume.
Recommendati ons f or f resh gas f lows based on body wei ght vary f rom 100 to 300
mL/kg/minute (14, 17,23,24, 29,50,51). Most studi es have recommended that the
f resh gas fl ow be 1. 5 to 3.0 ti mes the mi nute volume (20, 23,50,52, 53,54,55, 56)
whi l e others have hel d that a f resh gas f l ow approxi matel y equal to t otal venti l ati on
i s adequat e (57). I n t erms of body surf ace area, f resh gas
P. 215

f lows of 4000 t o 4700 mL/m
2
/ mi nut e have been recom-mended (58).

View Figure

Figure 8.7 Functioning of the Mapleson D system. (See text
for details.) Pt, patient; F.G.F., fresh gas flow.

Control led Venti lation
During exhalat i on (Fi g. 8.7), gases f low f rom t he pat ient down t he corrugated
t ubi ng. At the same ti me, f resh gas ent ers the tubi ng. Duri ng t he expi ratory pause,
t he f resh gas f l ow conti nues and pushes exhal ed gases down the tubi ng.
During i nspi rat i on, f resh gas and gas f rom t he corrugated t ubi ng enter t he pat i ent .
I f the f resh gas f low i s low, some exhal ed gases may be i nhal ed. Prol onging the
i nspi ratory t i me, increasi ng the respi rat ory rat e, or addi ng an i nspi ratory pl at eau
wi l l i ncrease rebreathing (47,59). Rebreathi ng can be decreased by al lowi ng a l ong
expi ratory pause so that f resh gas can f l ush exhal ed gases f rom the tubi ng.
When t he f resh gas fl ow i s hi gh, there i s li tt l e rebreat hi ng, and the end-ti dal CO
2
is
determined mai nl y by mi nute venti lati on. Tidal volume, the vol ume of t he expi ratory
l i mb, and expi rat ory resi st ance also aff ect i t (60). When mi nute vol ume
subst ant iall y exceeds the f resh gas fl ow, t he f resh gas f l ow i s t he mai n factor
control li ng CO
2
el i minati on. The hi gher the f resh gas f l ow, the l ower the end-t i dal
CO
2
.
Combi ni ng f resh gas fl ow, mi nute vol ume, and arteri al CO
2
l evels, a seri es of
curves can be const ructed (Fi g. 8. 8). An inf i ni te number of combi nat ions of f resh
gas f l ow and mi nute volume can be used t o produce a gi ven PaCO
2
. Hi gh f resh gas
f lows and low mi nute vol umes or high mi nute vol umes and low f resh gas f lows or
combi nati ons i n bet ween can be used. I n Figure 8.8, at the l ef t, wi t h a hi gh f resh
gas f l ow, t he ci rcui t i s a nonrebreathi ng one and end-ti dal CO
2
depends onl y on
venti l ati on. Such hi gh f lows are uneconomical and are associat ed wi th l ost heat and
humi di ty. End-t i dal CO
2
depends on mi nute vol ume, whi ch is dif fi cul t t o adj ust
accuratel y, especi al l y i n smal l pati ents. On t he ri ght i s the region of
hyperventi lat i on and part i al rebreathi ng. End-ti dal CO
2
i s regul ated by adjusti ng t he
f resh gas fl ow. Lower f resh gas f lows (and i ncreased rebreathing) are associ ated
wi th hi gher humi di ty, less heat l oss, and greater f resh gas economy.
Hypervent il ati on can be used wi t hout induci ng hypocarbi a. I ndivi dual di f ferences i n
dead space:t i dal vol ume are mi ni mi zed at hi gh l evel s of mi nute vol ume. For these
reasons, i n most cases, i t is advant ageous to ai m for the ri ght side of the graph. In
pati ents wi t h stif f l ungs, poor cardi ac performance, or hypovol emia, usi ng the lef t
si de of the graph and a rel ati vel y smal l tot al venti l at ion wi t h a high f resh gas f low
may be better (61).
P. 216



View Figure

Figure 8.8 Mapleson D system used with controlled
ventilation. Each isopleth represents a constant level of
PaCO
2
. Note that essentially the same PaCO
2
can be
achieved for fresh gas flows from 100 to 240 mL/kg/minute.
(Redrawn from
Froese AB. Anesthesia circuits for children [ASA Refresher
Course]. Park Ridge, IL: ASA, 1978
.)

Formul as to predi ct f resh gas f l ow requi rements have been based on body wei ght
(62,63,64), mi nute volume (65), and body surf ace area (66). I f the system i s used
f or pati ents undergoing l aparoscopy, the f resh gas f l ow needs to be i ncreased t o
overcome the CO
2
t hat is absorbed f rom the abdomen (67).
Wi th assisted vent i l at ion, t he eff i ci ency of the Mapl eson D system is i ntermedi ate
bet ween t hat for spontaneous and cont rol l ed venti l ati on (28). Sl i ghtl y hi gher f resh
gas f l ows shoul d be used.
Bain System Hazards
I f the i nner tube of the Bai n system becomes detached f rom i ts connecti ons at
ei ther end or develops a leak at the machi ne end, i f the f resh gas suppl y tube
becomes ki nked or t wi sted, if the system i s i ncorrect l y assembl ed (such as usi ng
standard corrugated tubi ng), or i f t here i s a def ect in the metal head so t hat f resh
gas and exhaled gas mix, the enti re l i mb becomes dead space
(43,68,69, 70, 71,72,73). I n one case, i t was reported that a manuf acturi ng def ect
caused the i nner t ube to be blocked (74).
Preuse Checks
The Mapleson D Syst em is tested for l eaks by occl udi ng the pat ient end, cl osi ng
t he APL val ve, and pressuri zi ng the syst em. The APL val ve i s then opened. The
bag shoul d def l ate easi ly i f the val ve and scavengi ng system are working properl y.
Ei ther the user or a pat ient shoul d breathe through the system t o detect
obstruct i ons.
The Bai n modi f icati on of the Mapleson D requi res speci al test i ng to confi rm t he
i ntegri t y of t he inner t ubi ng. This can be performed by sett i ng a l ow f l ow on t he
oxygen f lowmeter and occl udi ng the i nner tube (wi th a f i nger or t he barrel of a
smal l syri nge) at the pat i ent end whi l e observing the f l owmeter i ndicator. If t he
i nner t ube i s intact and correctl y connected, t he i ndi cator wi l l fall (70,75). The
i ntegri t y of t he inner t ube can also be conf i rmed by acti vat ing the oxygen f l ush and
observi ng the bag (76). A Venturi ef fect caused by the hi gh f low at t he pati ent end
wi l l create a negative pressure i n the outer exhal ati on t ubi ng, and this wi l l cause
t he bag to def l ate. I f the i nner t ube i s not i nt act , this maneuver wi l l cause t he bag
t o i nf l ate sl i ght ly. However, thi s t est wi l l not detect a system i n whi ch the i nner tube
i s omi t ted or does not extend to the pat i ent port or one that has holes at the pat ient
end of the i nner tube (77,78).
Continuous Positive Airway Pressure
During one-lung venti lati on usi ng a doubl e-l umen t ube (Chapt er 20), a modif ied
Mapl eson D system attached to t he lumen leadi ng to the nondependent lung is
of ten used to appl y conti nuous posi t ive ai rway pressure (CPAP) t o that l ung.
A number of conf i gurat i ons have been descri bed
(79,80,81, 82, 83,84,85, 86,87,88,89,90,91,92,93). One is shown i n Fi gure 8. 9. A
source of oxygen i s connected to t he system. The APL val ve i s set t o mai ntain t he
desi red pressure. A PEEP val ve may be added to f unct i on as a hi gh-pressure reli ef
device (94).
Mapleson E System
The Mapleson E (T-pi ece) system is shown i n Fi gure 8. 1E. A l ength of tubi ng may
be at tached t o the T-pi ece t o form a reservoi r. I t does not have a bag. The
expi ratory port may be encl osed in a chamber f rom whi ch excess gases are
evacuated.
The sensor or sampl i ng si te f or t he respi ratory gas moni tor may be pl aced bet ween
t he expi ratory port and the expi rat ory tubing. In l arger pati ents, i t may be placed
bet ween t he T-pi ece and the pat i ent , but t hi s locat ion
P. 217

shoul d be avoi ded i n smal l pati ents because i t i ncreases dead space.

View Figure

Figure 8.9 System for continuous positive airway pressure.
(See text for details.) PEEP, positive end-expiratory
pressure; APL, adjustable pressure limiting.

Numerous modif i cat ions of the origi nal T-piece have been made. Many have the
f resh gas i nl et extending i nsi de t he body of the T-pi ece t oward the pat ient
connecti on to mi ni mi ze dead space. A pressure-l i mi t ing devi ce may be added to t he
system.
Use of the Mapleson E syst em f or anesthesi a has decreased because of the
di ff i cul ty i n scavenging excess gases. I t i s commonl y used to admi ni ster oxygen or
humi di f i ed gas to pati ents breathing spontaneously.
Techniques of Use
For spontaneous vent i l at ion, t he expi ratory l i mb i s open to atmosphere. Cont rol l ed
venti l ati on can be performed by i ntermi tt entl y occl udi ng t he expi ratory l i mb and
al l owi ng the f resh gas f low t o i nf l ate the lungs. Assi sted respi rati on i s dif f i cul t to
perf orm.
Functional Analysis
The sequence of events during the respi ratory cycl e i s si mil ar t o that of the
Mapl eson D system shown i n Fi gure 8.7. The presence or absence and the amount
of rebreathi ng or ai r di l ut ion wi l l depend on the f resh gas f l ow, t he pati ent' s mi nute
volume, the vol ume of t he exhal ati on li mb, the t ype of vent i l at ion (spontaneous or
control led), and the respi rat ory pattern.
Rebreathi ng
Wi th spontaneous vent i l at i on, no rebreat hi ng can occur i f there is no exhal at ion
l i mb. If t here is an expi rat ory l i mb, t he f resh gas fl ow needed to prevent rebreathi ng
wi l l be the same as f or the Mapleson D system. Duri ng control l ed vent i l at ion, t here
can be no rebreathi ng, because onl y f resh gas wi l l i nf late the lungs.
Air Dilution
No ai r di luti on can occur duri ng control l ed venti lat i on. Duri ng spontaneous
venti l ati on, ai r di lut i on cannot occur i f the vol ume of t he t ubi ng is great er t han t he
pati ent 's t i dal vol ume. I f there i s no expi ratory l imb or i f the vol ume of the l imb i s
l ess than the pat ient' s ti dal vol ume, ai r dil uti on can be prevented by providing a
f resh gas fl ow t hat exceeds the peak i nspi ratory f l ow rate, normall y t hree to fi ve
t i mes t he mi nute vol ume. A f resh gas f l ow of t wo ti mes minute volume and a
reservoi r volume one thi rd of the t i dal volume wi l l prevent ai r di l uti on (95).
Hazards
Control l i ng venti lati on by i ntermi ttentl y occl udi ng the expi ratory l i mb may l ead to
overi nf lati on and
P. 218

barot rauma. This i s a danger wi t h this syst em i n parti cul ar because the anesthesi a
provi der does not have t he feel of the bag during i nf l ati on that she or he has wi t h
ot her systems. The pressure-buf f eri ng ef fect of the bag i s absent , and t here is no
APL valve to moderat e the pressure i n the l ungs. To overcome this potenti al
hazard, i t has been recommended that a pressure-l i mi ti ng device be pl aced i n t he
system (96).
Mapleson F System
The Mapleson F (Jackson-Rees, Rees, Jackson-Rees modi fi cati on of t he T-pi ece)
system has a bag wi t h a mechani sm f or vent i ng excess gases (97) (Fi g. 8.1F). The
mechani sm can be a hol e i n the t ail or si de of t he bag t hat i s occl uded by using a
f inger t o provide pressure. I t may be f i t ted wi t h a devi ce to prevent the bag f rom
coll apsing whi l e at t he same t ime al l owi ng excess gases to escape. An anesthesi a
venti l ator may be used in pl ace of the bag (98). An APL valve may be pl aced near
t he pat ient connecti on to provide protect i on f rom hi gh pressure (99).
Scavenging can be performed by encl osi ng t he bag i n a chamber f rom which waste
gases are suct i oned (100) or by at tachi ng vari ous devices to the rel i ef mechani sm
i n the bag (101).
Techniques of Use
For spontaneous respi rat ion, the rel ief mechani sm i s l ef t ful l y open. For assi sted or
control led respi rat ion, t he rel i ef mechani sm i s occl uded suff i ci entl y t o distend the
bag. Respi rati on can then be cont rol l ed or assi st ed by squeezing t he bag.
Al ternatel y, t he hol e i n the bag can be occluded by t he user' s fi nger duri ng
i nspi rati on. For mechani cal venti lati on, the bag i s repl aced by t he hose f rom a
venti l ator.
A heat and moi sture exchanger (HME) can be used wi th a Mapl eson F syst em ei t her
by i nsert i ng i t between the pati ent and the T-pi ece or by usi ng t he gas sampl i ng
port on the HME as the f resh gas i nl et (102). However, thi s wi l l resul t in most of t he
f resh gas bei ng vented f rom t he di stal end of the expi ratory li mb during
spontaneous respi rati on (103, 104, 105). To overcome this probl em, the expi rat ory
l i mb can be part i al l y or t ot al l y occl uded, the f resh gas f low i ncreased, or the HME
not used wi t h spontaneous respi rati on.
Functional Analysis
The Mapleson F system f uncti ons much l ike the Mapleson D system. The f l ows
requi red t o prevent rebreathing duri ng spont aneous and control led respi rat ion are
t he same as those requi red wi t h the Mapl eson D system. Thi s system of f ers less
work of breat hi ng than a pedi at ri c ci rcle system (106). Whi le one study di d f i nd that
t here was less work of breat hi ng wi t h the Jackson-Rees syst em, i t was consi dered
by other i nvest igators to be a negl igible di f ference and of i mportance i n onl y t he
si ckest pati ents breathi ng spontaneousl y (107).
PEEP does not aff ect end-ti dal CO
2
during cont rol l ed venti l ati on but causes an
i ncrease duri ng spont aneous breat hing when f resh gas f l ows are l ess than three
t i mes mi nute vol ume (108). PEEP should not be appl i ed by using an underwat er
seal (109).
I f a heat and moi sture exchanger (Chapt er 11) i s added t o the Mapl eson F system
duri ng an inhal ati on i nducti on, the i ncreased resi stance wi l l resul t in more of t he
f resh gas fl ow enteri ng t he expi ratory l i mb, del aying i nduct ion (104).
Hazards
The hazards of t he Mapl eson F system are the same as those descri bed f or the
Mapl eson E syst em. Excessive pressure is l ess l i kel y to devel op, because there i s
a bag i n the system.
I f a vent i lator t hat uses a ram of oxygen to produce inspi rati on i s used wi th a T-
pi ece system, a di sconnecti on at the common gas out l et may not be detected by an
ai rway pressure moni tor due to t he hi gh resi stance of the f resh gas t ubi ng (110).
Respiratory Gas Monitoring with the Mapleson
Systems
Al l of the Mapl eson systems except the A system have the f resh gas i nl et near t he
pati ent connect ion port . Thi s may make i t di ff i cul t to get a rel i abl e sample of
exhal ed gases. One study exami ned f our sampl ing si t es (Fi g. 8. 10): at t he junct ion
of t he breathi ng system and elbow connector, at the corner of t he el bow connector,
2 cm di stal i n the el bow connector, and i n the t racheal tube connector (111). I t was
f ound t hat i f sampl i ng were carri ed out at t he two si tes cl osest t o the pati ent ,
values were accurate. Si gni f i cant errors wer e noted when samples were t aken f rom
t he corner of the elbow connector but onl y i f a hi gh f resh gas f l ow was used.
Si gni f i cant errors were noted when sampli ng was perf ormed at the j uncti on of the
breat hi ng system and el bow connector even i f l ow f resh gas f l ows were used. A
cannul a that proj ects into the ai rway can be used to improve sampl ing (112).
I n anot her study invol vi ng infants and chi ldren, sampl i ng at t he junct ion of the
t racheal tube and breathing system resul ted i n f alsel y l ow end-t i dal CO
2
values in
pati ents wei ghi ng less than 8 kg (59). The accuracy of measurements can be
i mproved by i nsert i ng a small heat and moisture exchanger bet ween t he breathi ng
system and the t racheal tube connector (113). However, usi ng a device at this si te
wi l l i ncrease dead space and may resul t
P. 219

i n excessive resi stance so t hat spontaneous respi rati on cannot be used (103,114).

View Figure

Figure 8.10 Respiratory gas sampling with a Mapleson
system. Accurate values for expiratory concentrations can
be obtained by sampling at sites 3 and 4. Sampling at site 2
will yield accurate values only if the fresh gas flow is not
high. Sampling at site 1 will yield inaccurate values even at
low fresh gas flows. (Redrawn from
Gravenstein N, Lampotang S, Beneken JEW. Factors
influencing capnography in the Bain circuit. J Clin Monit
1985; 1:610
[Medline Link]
.)

Advantages of the Mapleson Systems
The equi pment i s si mpl e, i nexpensive, and rugged. Wi th the excepti on of the
APL valve, there are no movi ng parts. The components are easy to
di sassembl e and can be di si nfected or st eri l i zed in a vari et y of ways. For
t hese reasons, t hey cont i nue to be a popul ar choice to provi de posi t ive
pressure vent i l at ion i n emergenci es (115).
Vari ati ons i n mi nute volume aff ect end-ti dal CO
2
l ess than i n a ci rcle system.
I n coaxi al systems (Lack, Bai n), the i nspi ratory l i mb i s heated by t he warm
exhal ed gas i n the coaxi al expi ratory tubi ng.
Resistance is usual l y l ow at f l ows l i kel y t o be experi enced in pract i ce
(116, 117,118,119). A commonl y hel d vi ew i s that the work of breathi ng
duri ng spontaneous vent il at i on is si gnif icantl y l ess wi t h t hese systems t han
wi th t he ci rcl e system. However, studi es indi cate t hat thi s i s not al ways t he
case (120,121,122). The work of breathing may be i ncreased i f the APL val ve
i s not ori ent ed properl y.
These systems are l i ghtwei ght and not bul ky. They are not l i kel y to cause
drag on the mask or t racheal tube or acci dent al extubati on.
They are easy to posi ti on conveni entl y. A l ong Mapl eson D syst em wi t h an
al umi num APL val ve may be used to vent i l at e a pati ent in t he MRI uni t (123).
Compression and compli ance vol ume losses are less wi th t he Mapl eson
systems than wi t h the ci rcl e syst em.
Changes i n f resh gas concent rat i ons resul t i n rapi d changes i n inspi ratory
gas composi t i on.
Si nce t here is no CO
2
absorbent , t here wi l l be no product ion of possibl y toxi c
products such as carbon monoxi de and compound A (Chapter 9).
Disadvantages of the Mapleson Systems
These systems requi re high gas f l ows. Thi s resul ts i n hi gher costs, i ncreased
at mospheric pol l ut ion, and di f f i cul t y assessi ng spont aneous vent i lati on.
P. 220


Because of the hi gh f resh gas f l ow, i nspi red heat and humi di t y tend to be
l ow, unless a humi dif i cat ion devi ce i s used (124).
The opti mum f resh gas f l ow may be di ff icul t to det ermine. I t is necessary to
change t he f l ow when changi ng f rom spontaneous to control l ed vent i lat i on or
vi ce versa. Anythi ng that causes the f resh gas f low t o be l owered presents a
hazard, because rebreathi ng may occur.
I n t he Mapl eson A, B, and C systems the APL val ve is l ocated close to t he
pati ent , where i t may be inaccessi bl e to the user. I n addi ti on, scavenging i s
awkward. Thi s di sadvantage can be overcome by using the Lack modi f i cati on
of t he Mapl eson A.
The Mapleson E and F systems are di ff icul t to scavenge, and ai r di lut i on can
occur wi t h t he Mapl eson E system.
Mapl eson systems are not sui table f or pati ents wi t h mal ignant hyperthermi a,
because i t may not be possi bl e t o increase t he f resh gas fl ow enough to
remove the increased CO
2
l oad (125).
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Questions
For the f ol lowing quest ions, sel ect t he correct answer.
1. I n which of the foll owi ng is the fresh gas inlet most di stant from the pati ent
connection port?
A. Mapleson A
B. Mapleson B
C. Mapl eson C
D. Mapl eson D
E. Mapleson E
Vi ew Answer2. Which of the foll owing i s most effi ci ent duri ng
spontaneous venti lati on?
A. Mapleson A
B. Mapleson B
C. Mapl eson C
D. Mapl eson D
E. Mapleson E
Vi ew Answer3. Which of the foll owing systems lacks a reservoi r bag?
A. Mapleson A
B. Mapleson B
C. Mapl eson C
D. Mapl eson D
E. Mapleson E
Vi ew Answer4. Which of the foll owing i s the most efficient during
controlled venti lati on?
A. Mapleson A
B. Mapleson B
C. Mapl eson C
D. Mapl eson D
E. Mapleson E
Vi ew Answer5. Advantages of the Mapleson systems include all of the
foll owi ng except
A. Buff eri ng ef f ect on end-ti dal CO
2

B. Si mpl e, i nexpensive equi pment
C. Useful i n t reati ng mal i gnant hypert hermia
D. Li ghtwei ght
E. Ease of di sassembl y
Vi ew Answer