Breathing circuits

Articles on breathing circuits

Introduction to breathing circuits

Non-rebreathing circuits
Mapleson A (Magill circuit)
Mapleson A (flash animation)
Lack circuit
Mapleson B
Mapleson C
Mapleson D
Ayre's T-Piece
Mapleson F
Circle system

Introduction to breathing circuits

Anaesthetic gas exits the anaesthesia machine (via the common gas outlet) and then enters a
breathing circuit. The function of the circuit is to deliver oygen and anaesthetic gases to the patient
and to eliminate carbon dioxide. The carbon dioxide may be eliminated by gas inflow or by soda
lime absorption.

Various classification systems have been developed to aid understanding of how breathing systems
operate.

Open, semi-open, semi-closed and closed

This most basic classification of breathing systems divides them into open, semi-open, semi-closed
or closed.

Non-rebreathing and rebreathing systems

The classification of non-rebreathing versus rebreathing systems is more widely used. The term
rebreathing implies that expired alveolar gas containing 5% carbon dioxide is inspired as part of the
next tidal volume. Anaesthetic circuits are designed to minimise this, as it may lead to serious
elevations in blood CO2 levels. The amount of rebreathing that occurs with any particular
anaesthetic breathing system depends on four factors: the design of the individual breathing circuit,
the mode of ventilation (spontaneous or controlled), the fresh gas flow rate and the patient's
respiratory pattern. Circuits may eliminate rebreathing either by ensuring an adequate flow of fresh
gas which flushes the circuit clear of alveolar gas, or, in the case of a circle system, by the use of
soda lime, which absorbs the CO2 so that low fresh gas flows may be used.

Mapleson systems

Mapleson described five different arrangements of breathing circuits. He classifed these circuits and
they are now known as the Mapleson systems, termed A-E. This classification does not include
systems with carbon dioxide absorption.

Adjustable pressure-limiting valve (APL valve)

In the open position, the valve is actuated by pressures of less than 0.1 kPa (1 cm H 2O).
In the closed position, the breathing system pressure, and therefore the intrapulmonary pressure, is
protected by a pressure relief mechanism, actuated at 6 kPa (60 cmH 2O).

Non-rebreathing circuits

The distinguishing feature of non-rebreathing circuits is that elimination of carbon dioxide is

accomplished by removing all expired gases from the system and venting them to the atmosphere.
This is normally achieved by using the fresh gas flow from the anaesthetic machine to direct the
expired gases out of the circuit via a valve or other arrangement.

In general, non-rebreathing systems provide good control of the inspired gas concentrations, since
fresh gas delivered from the anaesthetic machine is inspired in each breath. They are, however, less
economical in use than rebreathing systems because the minute volume of ventilation (or more)
must be supplied to the patient to prevent rebreathing, and they contribute more to the problem of
atmospheric pollution with anaesthetic agents.

Mapleson's classification of non-rebreathing circuits

Professor W W Mapleson, Professor Emeritus of the Physics of Anaesthesia, University of Wales

College of Medicine, Cardiff.

Mapleson's classification divides non-rebreathing circuits into functionally similar groups, on the
basis of the fresh gas flow required to prevent rebreathing and the ease with which intermittent
positive pressure ventilation may be performed.
 Mapleson A - the Magill and Lack circuits

Mapleson B and C - Rebreathing of exhaled gases occurs even when very high fresh gas flow
rates are used, since inspiration is taken from the same space into which the previous breath was
expired. These are unsatisfactory for anaesthesia, but may be used in emergency for resuscitation.

Mapleson D - the modified Bain circuit.

Mapleson E - Ayre's T piece

"Mapleson F" - not originally classified by Mapleson, but is used to refer to Jackson-Rees'
modification of Ayre's T-piece.

The Humphrey ADE circuit provides the ability to switch between the Mapleson A, D and E
arrangements.
ArticleDate:20040601
Lack Circuit

A co-axial modification of the Mapleson A system, designed to facilitate scavenging of expired gas.
(Dr A Lack, retired Salisbury anaesthetist).

Circuit

A four-way block is attached to the fresh gas outlet (F). This block is connected to an outer reservoir
tube (R) attached to the patient (P), an inner exhaust tube (E), a breathing bag (B) and a spring-
loaded expiratory valve (V).
 Function

The Lack circuit is essentially similar in function to the Magill, except that the expiratory valve is
located at the machine-end of the circuit, being connected to the patient adapter by the inner
coaxial tube.

Inspiration - The valve closes and the patient inspires fresh gas from the outer reservoir tube.

Expiration - The patient expires into the reservoir tube. Towards the end of expiration, the bag fills
and positive pressure opens the valve, allowing expired gas to escape via the inner exhaust tube.

Expiratory pause - Fresh gas washes the expired gas out of the reservoir tube, filling it with fresh
gas for the next inspiration.

Controlled ventilation

As for the Magill circuit.

Advantages

The location of the valve is more convenient, facilitating intermittent positive presure ventilation
and scavenging of expired gas.

Disadvantages

In common with other co-axial systems, if the inner tube becomes disconnected or breaks, the
entire reservoir tube becomes dead-space. This can be avoided by use of the 'parallel Lack' system,
in which the inner and outer tubes are replaced by conventional breathing tubing and a Y-piece:
Mapleson A circuit

This is the first in our series of flash animation images that have developed to depict the gas flow
occurring in anaesthetic breathing circuits.

Below is a demonstration of the gas flow that occurs in a Mapleson A circuit. This circuit is efficient
for spontaneous ventilation because exhaled dead space gas is reused at the next inspiration, and
exhaled alveolar gas passes out through the spill valve.
Mapleson B

The Mapleson B system features the fresh gas inlet near the patient, distal to the expiratory valve.
The expiratory valve opens when pressure in the circuit increases, and a mixture of alveolar gas and
fresh gas is discharged. During the next inspiration a mixture of retained fresh gas and alveolar gas
is inhaled. Rebreathing is avoided with fresh gas flow rates of greater than twice the minute
ventilation for both spontaneous and controlled ventilation.

Mapleson C

This circuit is also known as the Water's circuit without an absorber. It is similar in construction to
the Mapleson B, but the main tubing is shorter. A fresh gas flow equal to twice the minute
ventilation is required to prevent rebreathing. Carbon dioxide builds up slowly with this circuit.
Mapleson D

The Mapleson D may be described as a co-axial modification of the basic T-piece system, developed
to facilitate scavenging of waste anaesthetic gases.

Circuit

A tube carrying fresh gas (F) travels inside an outer reservoir tube (R) to the endotracheal tube
connector (P).

Function

The Bain circuit is a modification of the Mapleson D system. It is a coaxial system in which the fresh
gas flows through a narrow inner tube within the outer corrugated tubing.
Essentially, the Bain circuit functions in the same way as the T-piece, except that the tube supplying
fresh gas to the patient is located inside the reservoir tube.

Inspiration - The patient inspires fresh gas from the outer reservoir tube.

Expiration - The patient expires into the reservoir tube. Although fresh gas is still flowing into the
system at this time, it is wasted as it is contaminated by expired gas.

Expiratory pause - Fresh gas from the inner tube washes the expired gas out of the reservoir tube,
filling it with fresh gas for the next inspiration.

Spontaneous ventilation

Normocarbia requires a fresh gas flow of 200-300 ml/kg.

Controlled ventilation

A fresh gas flow of only 70 ml/kg is required to produce normocarbia.

Bain and Spoerel have recommended the following:

2 L/min fresh gas flow in patients <10 kg

3.5 L/min fresh gas flow in patients 10-50 kg
70 ml/kg fresh gas flow in patients >60 kg

The recommended tidal volume is 10 ml/kg and respiratory rate is 12-16 breaths/minute.
Modifications
A bag may be added to the tail of the reservoir tube, as in the T-piece.

Alternatively, the circuit may be attached to a block assembly with a pop-off valve and mounted
directly to the common gas outlet of the anaesthesia machine. This arrangement facilitates
scavenging and intermittent positive pressure ventilation.

Advantages

Low dead space.

Low resistance to breathing.
Facilitates scavenging of waste gases.

Disadvantages

High fresh gas flow requirement.

High gas flow rates, e.g. if the oxygen flush valve is used, may cause lung barotrauma.
As with other co-axial systems, if the inner tube becomes disconnected or breaks, the entire
breathing tube becomes dead space, leading to severe alveolar hypoventilation. This may be
detected in systems fitted with a bag by closing the valve and activating the oxygen quick-flush. If
the inner tube is intact, the venturi effect of the rapidly-moving stream of gas leaving the inner tube
will suck gas out of the bag and the bag will empty. If the inner tube is damaged, the stream of gas
will be directed into the bag and it will fill.
Alternatively, the so-called 'parallel Bain' system may be used. In this system, the inner and outer
tubes are replaced by conventional circle-absorber-type tubing and Y-piece. This arrangement is
also used in the Humphrey ADE system.

Reference
[i] Flow requirements for a modified Mapleson D system during controlled ventilation.
Bain JA, Spoerel WE.

Ayre's T-Piece

The Mapleson E is a modification of Ayre's T-piece which was developed in 1937 by Phillip Ayre
(a Newcastle anaesthetist) for use in paediatric patients undergoing cleft palate repair or intracranial
surgery.

Construction

A three-way T-tube whose limbs are connected to (F) the fresh gas supply from the anaesthesia
machine, (R) a length of corrugated reservoir tube and (P) the patient connector. It has minimal
dead space, no valves and minimal resistance.
Function

Inspiration: The patient inspires fresh gas from the reservoir tube.

Expiration: The patient expires into the reservoir tube. Although fresh gas is still flowing into the
system at this time, it is wasted, as it is contaminated by expired gas. An expiratory limb volume
greater than the patient's tidal volume prevents entrainment of room air (which would dilute
anaesthetic gases and oxygen).

Expiratory pause: Fresh gas washes the expired gas out of the reservoir tube, filling it with fresh
gas for the next inspiration.

A fresh gas flow greater than three times the minute ventilation prevents rebreathing.

Spontaneous ventilation
The fresh gas and exhaled gas flow down the expiratory limb. Peak expiratory flow occurs early in
exhalation. Thus, the proportion of fresh gas added to the exhaled gases increases. During the next
breath, fresh gas is drawn from the fresh gas inlet and the expiratory limb.

The original analysis of the Mapleson E system suggested that a gas flow rate of 2.5 to 3 times the
minute volume was required to prevent rebreathing of expired gas. However, this assumed a
square-wave respiratory pattern, and investigations using a more realistic breathing pattern have
suggested that 1.5 - 2 times the minute volume is acceptable in spontaneously breathing patients:

Body weight (kg) Fresh gas flow

(L/min)
5 1.4 - 1.8

10 2.4 - 3.2

20 4.1 - 5.4

40 7.2 - 9.6

Again, these values are guidelines only - if there is evidence of rebreathing, the flow rate should be
increased.

Controlled ventilation
In contrast with Mapleson A systems, Mapleson D and E circuits are more efficient during controlled
than spontaneous ventilation. This is because the tidal volume must be supplied during the
expiratory pause. With the almost sinusoidal respiratory pattern of spontaneous respiration, there is
relatively little time for this volume to be supplied, so the fresh gas flow rate must be high. The
pattern of controlled ventilation, however, is usually one of a rapid inspiration, expiration and a
relatively prolonged expiratory pause. This long expiratory pause gives ample time for the tidal
volume requirement to be supplied, even with a fairly low fresh gas flow rate. Consequently, during
controlled ventilation, the recommended fresh gas flow rate is similar to that of the Mapleson A
systems during spontaneous ventilation (see above).

Intermittent positive pressure ventilation may be performed by intermittently occluding the end of
the reservoir tube.

Mapleson F

The most commonly used T-piece system is the Jackson-Rees' modification of the Ayre's T-piece
(sometimes known as the Mapleson F system). This system connects a two-ended bag to the
expiratory limb of the circuit; gas escapes via the `tail' of the bag.

This allows respiratory movements to be more easily seen and permits intermittent positive
ventilation if necessary. The bag is, however, not essential to the functioning of the circuit.

Intermittent positive pressure ventilation (IPPV) may be performed by occluding the tail of the bag
between a finger and thumb and squeezing the bag. Alternatively, a `bag-tail valve', which employs
an adjustable resistance to gas flow, may be attached to the bag tail. This causes the bag to remain
partially inflated and so facilitates one-handed performance of IPPV.

Another aid to IPPV is the Kuhn bag, which has the gas outlet on the side of the bag, rather than
the tail. This allows the outlet to be occluded with the thumb during IPPV, but leads to difficulties in
scavenging the waste gases.

A number of different designs of T-piece are available, which function in essentially the same way.

Modern T-pieces incorporate 15 mm fittings for the reservoir tube and endotracheal adapter.
Advantages of T-piece systems

Compact
Inexpensive
No valves
Minimal dead space
Minimal resistance to breathing
Economical for controlled ventilation

Disadvantages

The bag may get twisted and impede breathing

High gas flow requirement

Uses

Children under 20 kg weight

Circle system

Circuit

The essential features of the circle absorber are: a carbon dioxide absorber canister (C), breathing
bag (B), unidirectional inspiratory (Vi) and expiratory (Ve) valves, fresh gas supply (F) and
pressure-relief valve (V). The absorber is connected to the patient via corrugated hoses and a Y-
piece (not shown) attached to the inspiratory and expiratory valves (Vi and Ve).

The position of the breathing bag and pressure-relief valve may vary in relation to the absorber, but
the above is a common and satisfactory arrangement.
Function

Inspiration:
Inspiration causes the expiratory valve to close, and gas flows from the breathing bag to the patient
via the inspiratory limb of the circuit. Anaesthetic is taken up from the in-circuit vaporiser (VIC), if
fitted.

Expiration:
The inspiratory valve closes and gas flows into the breathing bag via the expiratory limb. Carbon
dioxide is absorbed by the soda lime canister. Excess gas is vented when necessary via the
pressure-relief valve.

Closed and semi-closed

The circle absorber may be used as a closed or semi-closed system:

Closed systems: the pressure-relief valve is closed so that no gas escapes from the system.
Oxygen flows into the system to replace that consumed by the patient, and exhaled carbon dioxide
is absorbed by the soda lime.

The advantage of closed systems is that anaesthetic and oxygen consumption, and atmospheric
pollution, is minimised.

The disadvantages are:

(a) The system is inherently unstable, in that if the fresh gas flow is not matched exactly to the
patient's oxygen consumption, the system will over-fill or empty, and the patient will be unable to
breathe.
(b) The fresh gas flow rate is usually too small to allow use of a precision, out of circuit vaporiser.

Semi-closed systems: the pressure relief valve is opened, allowing excess gas to escape from the
system. This allows higher fresh gas flow rates to be used.

The advantages of semi-closed systems are:

(a) The system is more stable in that, if the system fills to capacity, the excess gas is simply lost via
the pressure-relief valve.
(b) The higher flow rates allow use of a precision, out of circuit vaporiser.

The disadvantage is increased anaesthetic and oxygen consumption and atmospheric pollution.

Unidirectional valves
The unidirectional inspiratory and expiratory valves in most circle absorbers are of the turret type,
in which the pressure generated by the patient's breathing causes the disc to rise and allow gas to
pass in one direction only. Most have a transparent dome so that the operation of the valve may be
observed.

The disc material may be mica, ceramic or plastic. Plastic is less expensive, but tends to warp and
allow the valve to become incompetent. Incompetence may also be caused by the valve sticking in
the open position, owing to condensation of water vapour. Incompetent inspiratory or expiratory
valves will reduce the efficiency of gas circulation and result in rebreathing and consequent carbon
dioxide retention.

Some machines are equipped with valves made of deformable rubber:

As the rubber ages, these discs tend to harden in a semi-open position, again allowing the valve to
become incompetent.
Connecting tubing
The body of the absorber is connected to the patient by means of inspiratory and expiratory tubes
and a Y-piece. This may be constructed of corrugated black rubber, neoprene or, more recently,
plastic.

Recently, the so-called Universal F circuit has become popular. This is a co-axial system, the
inspiratory tube running inside the expiratory limb:

This arrangement aids warming and humidification of the inspired gases, albeit at the expense of an
increase in inspiratory resistance to breathing. One problem with this system, as with other co-axial
circuits, is that, if the inner tube breaks or becomes disconnected at the absorber end (which may
not be noticed on casual inspection), the entire volume of the tube becomes apparatus dead space.
It should also be noted that, in all other aspects, this system is identical in function to a
conventional, dual-limb system, and does not provide an economical alternative to the Bain system
(although it is occasionally marketed as doing so).

Patient size
Most circle absorbers are satisfactory for use in patients weighing up to around 100 kg.
The major problem with using standard circle absorbers in smaller patients is that of dead
space. Patients with very small tidal volumes may not generate enough pressure to open the valves
effectively. The effective dead space of the Y-piece is larger than it appears. Inevitably, some
portion of the expired gas is directed down the inspiratory limb of the circuit, and some portion of
the inspired gas comes from the expiratory limb, and some mixing of inspired and expired gases
occurs.

These difficulties may be reduced by the use of purpose-built infant absorbers, which are smaller
than the standard models. Paediatric tubing and Y-pieces, which are simply smaller in diameter than
the standard type, may be helpful.
In- and out-of-circuit vaporisers
An inhalation anaesthetic agent may be supplied from a vaporiser positioned in the circle itself
(vaporiser in circuit, VIC) or in the fresh gas flow from the anaesthetic machine (vaporiser out of
circuit, VOC).

Vaporiser in circuit (VIC)

These arrangements have a low-resistance vaporiser placed in the inspiratory limb of the circle,
from which the anaesthetic agent is vaporised by the gases circulated around the system by the
patient's breathing.

VIC systems are still occasionally used, since they employ an inexpensive vaporiser and provide
some degree of autoregulation of the anaesthetic concentration. If the plane of anaesthesia
becomes too light, respiration will be less depressed, minute volume will increase, more agent will
be vaporised and the plane of anaesthesia will deepen. It is, however, found that this is not very
reliable in practice.

Although low-resistance vaporisers are usually relatively inefficient (with the output of, for example,
halothane limited to around 2.5% to 3%), the concentration of anaesthetic inspired by the patient
may be very much higher than this because the gas entering the vaporiser also contains anaesthetic
from previous circulations. Indeed, after full equilibration of the circuit and patient, the inspired
concentration would equal the saturated vapour pressure of the anaesthetic, although, obviously,
the patient would have expired long before this point was reached. It is therefore strongly
recommended that an inhalation anaesthetic analyser be used to monitor the inspired concentration
whenever such systems are used.

In-circuit vaporisers can be used with closed or semi-closed systems.

Since water vapour exhaled by the patient condenses in the vaporiser, it is necessary to drain in-
circuit vaporisers regularly.

Vaporisers out of circuit (VOC)

These systems have the considerable advantage that a precision vaporiser may be used to introduce
a precisely-known concentration of anaesthetic into the circuit. However, since this delivered
concentration is diluted by the gas already contained in the circuit, the concentration inspired by the
patient is not known with certainty. The rate of change of anaesthetic concentration in the circuit
depends upon the fresh gas flow rate: a high fresh gas flow rate will achieve equilibration much
faster than if a low fresh gas flow rate is used:
The above graph shows anaesthetic concentrations in a typical paediatric circle system as a fraction
of the out-of-circuit vaporiser concentration, using different fresh gas flow rates (0.2 to 4 L/min).
When low flow rates are employed, the concentration of anaesthetic in the circuit will change very
slowly, which may cause difficulty in maintaining a satisfactory plane of anaesthesia.

Out of circuit vaporisers are usually used in semi-closed systems: the low fresh gas flow rate
required in closed systems usually makes their use impractical.

Double-canister absorbers
Many absorbers designed for use in human patients employ two canisters placed in series: the top
canister is exposed to the expired gases first and removes most of the carbon dioxide. Any
remaining carbon dioxide is then removed by the bottom canister. When the top canister is
exhausted, the absorbent is discarded, the bottom canister is placed in the top position and a
canister with fresh absorbent is inserted underneath it. This arrangement provides optimal efficiency
and economy in carbon dioxide absorption. However, these absorbers are bulkier, heavier and more
expensive than single-canister models.
If this type of absorber is used, it is a false economy to fill only one of the two canisters. The soda
lime will be exhausted at the same rate, the efficiency of absorption will be reduced and the greater
volume of the circuit will delay equilibration of the gas in the circuit with the fresh gas supplied from
the anaesthetic machine. This will not only slow induction and recovery, but will also tend to
increase consumption of the inhalation anaesthetic.

Operational requirements

The volume of the breathing bag must be greater than the patient's inspiratory capacity. This is
usually estimated at 30 ml/kg body weight.
Since soda lime contains 50% - 70% air around the granules, the volume of the absorber canister
should be at least double that of the tidal volume of the patient for optimal efficiency.

Fresh gas flow requirements

Closed systems

In truly closed systems, the patient consumes oxygen and expires carbon dioxide, which is removed
from the system by absorption. The volume of oxygen flowing into the system must, therefore,
equal the patient's oxygen consumption.

Resting oxygen consumption is approximated by the formula:

Oxygen consumption (ml/min) = 10 x BW 0.75

(where BW is the body weight (kg)).

Body weight (kg) Oxygen

consumption
(ml / min)
5 33

10 56

20 95

40 160
The use of nitrous oxide in closed systems presents the difficulty that, after equilibration, nitrous
oxide will accumulate in the circuit and result in a hypoxic breathing mixture. If it is desired to use
nitrous oxide in a closed system, it is mandatory to employ an inspired oxygen concentration
monitor.

Semi-closed
When using a semi-closed system, the oxygen flow rate must exceed the patient's oxygen
consumption. Any excess is simply lost via the pressure relief valve.

When using an out-of-circuit vaporiser, the fresh gas flow rates employed are a compromise
between achieving a reasonable rate of change of anaesthetic concentration and economy of
anaesthetic consumption.

Initially, it is necessary to use both a high flow rate and high vaporiser setting to raise the
concentration of anaesthetic in the circuit. For maintenance, both the vaporiser setting and fresh
gas flow rate may be reduced.

As a general rule, a flow rate of 2 to 3 litres per minute initially, and 500 ml to 1 litre per minute
during maintenance of anaesthesia, will usually prove satisfactory.

The following must be present to prevent rebreathing:

A unidirectional valve must be located between the patient and the reservoir bag on both the
inspiratory and the expiratory limb
The fresh gas inflow cannot enter the circuit between the expiratory valve and the patient
The overflow valve cannot be located between the patient and the inspiratory valve.

Advantages of the circle system

Economy of anaesthetic consumption

Warming and humidification of the inspired gases
Reduced atmospheric pollution

Disadvantages

Unstable if used closed

Slow changes in the inspired anaesthetic concentration with low flows and out-of-circuit vaporiser