Chapter 9

The Circle System

P. 224


The ci rcl e system is so named because gases f low i n a ci rcul ar pathway t hrough
separate i nspi ratory and expi ratory channel s. Carbon di oxi de exhal ed by the pati ent
i s removed by an absorbent . Internati onal and U.S. standards f or breathi ng syst ems
wi th part icul ar emphasi s on ci rcl e systems have been publ i shed (1,2).
Components
Absorber
The absorber i s usual l y at tached to the anesthesia machi ne but may be separat e.
An absorber assembl y consi sts of an absorber, two ports f or connecti on to
breat hi ng tubes and a f resh gas i nlet. Ot her components that may be mounted on
t he absorber assembl y i nclude inspi ratory and expi ratory uni di rect i onal valves, an
adj ustable pressure l i mi t i ng (APL) val ve, and a bag mount. Modern anest hesi a
machi nes of ten i ncorporat e components of the anest hesi a venti lator i nto the
absorber assembl y. Disposable absorbers and absorber assembl i es are avai labl e.
Canisters
Construction
The absorbent is held i n cani sters (carbon dioxi deabsorbent cont ai ners,
chambers, uni ts, or cartri dges). The side wal l s are t ransparent so that the
absorbent col or can be moni tored. A cani ster wi t h ti nt ed si de wal ls may make i t
di ff i cul t to detect color changes
P. 225

i n the absorbent (3). A screen at t he bottom of each cani st er holds the absorbent i n
pl ace.

View Figure

Figure 9.1 Absorber with two canisters in series, a
dust/moisture trap at the bottom and a drain at the side. The
lever at the right is used to tighten and loosen the canisters.
Note that the date the absorbent was last changed is marked
on the lower canister.

Many absorbers use t wo cani sters i n seri es (Fi g. 9.1). A si ngl e canister may also
be used (Fi g. 9.2). Some newer machines use a si ngl e, smal l di sposabl e canister
t hat can be qui ckl y changed duri ng an anest hetic wi t hout i nterrupti ng breathi ng
system cont inui t y (Figs. 9. 3, 9. 4).

View Figure

Figure 9.2 Absorber with a single canister. It is loosened
and tightened by twisting.

Prepackaged absorbent containers are avai l abl e and are placed i nsi de the
canisters that are a part of an absorber. These el i mi nate the need to pour
absorbent i nt o the cani ster. These cont ai ners can cause an obstructi on if the l abel
or wrap covering them is not removed or an excessi ve number of hol es are
occl uded (4,5,6).
P. 226



View Figure

Figure 9.3 Absorber with single disposable canister. A:
With the canister in place. B: With canister removed. The
two valves at the top prevent loss of gas when the canister is
removed.

Size
Canisters of varyi ng capaci t y have been used. An advant age of l arge canisters i s
l onger interval s bet ween absorbent changes (7). Thi s advantage may be of fset by
t he possibil i ty that absorbent may become desi ccated when i t resides in t he
absorber f or a long ti me.
Newer use anesthesi a machines use small cani sters that must be changed more
f requent l y. Frequent changes hel p t o provi de f resh absorbent wi t h proper water
content. Thi s wi l l l essen the l i kel ihood that carbon monoxi de or Compound A wi l l be
produced (8,9, 10). Some manuf acturers recommend that a new cani ster be used for
each anestheti c.
Another advantage of small absorbers i s that the i nt ernal vol ume of the breathing
system i s reduced. Thi s wi l l al l ow changes i n the f resh gas f low concentrat ion to be
ref l ected more qui ckl y i n the i nspi red concent rati on and i mprove venti lator
perf ormance.
Absorption Pattern
The pattern of absorpti on wi thi n a properl y packed cani ster i s shown i n Fi gure 9.5.
I t makes no dif ference whet her t he gases enter at the top or bottom. The f i rst
absorpti on occurs at t he inl et and al ong the cani ster sides. As t hi s absorbent
becomes exhausted, carbon dioxi de wi l l be absorbed f arther downst ream in t he
canister.
Housing
The head and base of the absorber (Fi g. 9.1) are const ruct ed of metal or plast ic.
There are spaces at t he top and bot tom of the absorber f or i ncomi ng gases to
di sperse before passi ng through the absorbent or f or out goi ng gases to col lect
before passing on through t he ci rcle. Thi s promotes even di st ri buti on of f l ow
t hrough the absorber. I n the base, t hi s space al lows dust and condensed water to
accumul ate (Fi g. 9.1). Some bases have a means of drai ni ng wat er f rom t he bot tom
(Fi g. 9.1). Because this wat er wi l l be hi ghl y al kal i ne, care shoul d be taken that i t
does not contact ski n.
On many modern machines, t he canister is at t ached t o a housing t hat incorporates
valves that wi l l close the entrance and exi t f rom t he cani ster when the cani st er i s
removed (Fi gs. 9.3, 9.4). This al l ows breathi ng system conti nui t y t o be mai ntained
when t he canister is changed.
Baffl es
Baf f l es, whi ch are annul ar ri ngs that serve to di rect gas f low t oward the cent ral part
of t he canister, are f requentl y used to i ncrease the t ravel path f or gases that pass
al ong the si des of the cani ster and compensate f or t he reduced f l ow resistance
al ong the wal ls of the cani ster.
Side or Center Tube
There must be a way to conduct gases to or f rom t he bot tom of the cani st er and
return them t o the pat ient. Some absorbers have a side t ube external to t he
canister(s). The tube may al so be in the center of the absorber (Fi g. 9.6).
Bypass
On ol der absorbers, there was a bypass val ve t hat al l owed exhal ed gases to
compl etel y or part i all y bypass the absorber. As has been discussed earl i er i n this
chapter, most modern absorbers wi t h smal l canisters al l ow t he canister to be
changed duri ng a case wi t hout di srupti ng t he breathing system integri ty. If the
canister is i ntent ional l y removed and not repl aced, thi s becomes a bypass. Care
must be taken to repl ace t he canister
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so t hat another anestheti c wi l l not begi n wi t hout i t in pl ace. Low-f l ow anesthesi a i s
dangerous i n the absence of the carbon di oxi de absorbent . The bypass can be used
t o al l ow carbon di oxi de t o accumul ate i n the breathi ng system.

View Figure

Figure 9.4 Absorber with a single disposable canister. A:
With canister in place. B: With canister removed. The
canister fits into grooves in the bracket and is pushed up to
lock it in place. Note the release button.


View Figure

Figure 9.5 Pattern of carbon dioxide absorption in a
canister. Darkened circles represent exhausted absorbent.
A: After limited use; absorption has occurred primarily at
the inlet and to a lesser extent along the sides. B: After
extensive use; the granules at the inlet and along the sides
are exhausted. C: Carbon dioxide is filtering through the
canister; in the distal third of the canister, a spot remains
where the granules are still capable of absorbing carbon
dioxide. (Redrawn from
Adriani J, Rovenstein EA. Experimental studies on carbon
dioxide absorbers for anesthesia. Anesthesiology 1941;2:10
.)

Absorbents
Composition
Carbon di oxide absorpt ion empl oys the general pri nci pl e of a base neut rali zi ng an
acid. The aci d is carboni c aci d formed by the react ion of carbon di oxide wi t h
P. 228

wat er. The end products of t he reacti on are wat er and a carbonate. Heat is
l i berated by the reacti on.

View Figure

Figure 9.6 Center tube in canister. Note the grooves around
the edge that allow the canister to be screwed tightly in
place.

High-alkali Absorbents
Some absorbents, i ncluding such t radi t i onal ones as some formul ati ons of soda
l i me, contai n rel at i vel y hi gh amounts of potassi um and/ or sodi um hydroxi de. When
t hese absorbents become desiccated, t hey react wi t h vol at il e anestheti cs to f orm
carbon monoxi de. Compound A can be f ormed wi th sevof l urane. These absorbents
of ten do not change color when dry. The capaci ty t o absorb carbon di oxide i s
decreased by decreased moisture (11).
Low-alkali Absorbents
Some carbon dioxi de absorbents contai n reduced amounts of sodi um or potassi um
hydroxi de. Studi es di f f er on whet her t hese produce smal l er amounts of Compound
A and carbon monoxi de t han absorbents wi t h more strong al kal i s
(12,13,14, 15, 16,17).
Alkali-free Absorbents
Al kal i -f ree absorbents consi st mai nl y of calcium hydroxi de wi t h smal l amounts of
ot her agents added to accel erate carbon dioxi de absorpt i on and bi nd wat er. There
i s no evi dence of carbon monoxi de f ormati on wi th any anest het i c agent , even if the
absorbent becomes desi ccated (14,18,19,20,21,22,23,24,25). There is l i t tl e or no
Compound A formati on wi t h sevofl urane even wi t h a closed ci rcui t and desi ccated
absorbent (12, 17,18,22,26,27,28,29,30,31,32, 33).
The i ndi cator i n these absorbents changes color on dryi ng (34,35,36,37). Thi s
propert y can be used to i ndi cate dehydrati on i n absorbents wi th st rong bases by
pl aci ng t he absorbent wi t h no strong base at t he si te where f resh gas ent ers t he
canister (34). Once exhausted, these absorbents do not revert to t hei r ori gi nal
color.
The carbon di oxi de absorpti on capaci ty of these absorbents is l ess t han absorbents
contai ni ng strong al kal i (11, 22,25,31, 38,39,40,41,42) but does not deteri orat e when
moi st ure i s lost (11).
Lithium Hydroxide
Li thium hydroxi de reacts wi t h carbon di oxi de t o f orm carbonat e. I t does not react
wi th anesthet ic agents, even i f desi ccated (17,43,44,45,46). However, i t i s
expensive and requi res careful handl i ng because i t may cause burns to the eyes,
ski n, and respi ratory tract (47).
Indi cators
An i ndi cator i s an aci d or base whose col or depends on pH. It i s added to t he
absorbent t o si gni fy when the absorbent' s abi l i t y to absorb carbon di oxi de i s
exhausted. The i ndi cator does not aff ect absorpt i on. Some of the commonl y used
i ndi cators and thei r col ors are shown i n Tabl e 9. 1. Ethyl vi ol et i s most commonl y
empl oyed, because the col or change i s vivid wi th a hi gh contrast (48). Confusi on
may resul t because one i ndi cator i s whi te when f resh whereas another i s whi t e
when exhaust ed. The user shoul d al ways know whi ch i ndicator i s bei ng used and
what col or change i s seen when the absorpti on capaci ty i s exhausted.
TABLE 9.1 Indicators for Absorbents
I ndicator Color When Fresh Color When Exhausted
Phenolphthalein White Pink
Ethyl violet White Purple
Clayton yellow Red Yellow
Ethyl orange Orange Yellow
Mimosa Z Red White

Shape and Size
Absorbents are suppl i ed in pel l ets or granul es. Pel lets or small granul es provi de
great er surf ace area and decrease gas channel ing along l ow-resi stance pathways.
However, they may cause more resi st ance and caking.
Granul e si ze is measured by mesh number. A 4-mesh strai ner has four openi ngs
per square i nch whereas one of 8 mesh has eight openi ngs per square i nch.
Granul es graded 4 mesh wi l l pass through the 4-mesh strainer but not t hrough a
st rai ner wi th smal l er hol es. In other words, t he hi gher t he mesh number, the smal ler
t he parti cl es. Most absorbents used i n anest hesi a today consi st of granul es in t he
range of 4 to 8 mesh.
Hardness
Some absorbent granul es f ragment easil y, produci ng dust (f i nes). There may be
vari ati ons in the dust content of di ff erent absorbents (49). Excessi ve powder
produces channel i ng, resi st ance to f l ow, and caking. Dust may be bl own t hrough
t he system to the pat i ent or may cause system components to mal f uncti on (50,51).
To prevent this, smal l amounts of a hardeni ng agent are added. Some
manuf acturers coat the outside of the granul es wi t h a f i l m to whi ch dust part i cl es
adhere. If a f i l t er i s used on t he i nspi ratory si de of the breathi ng system, dust
shoul d not reach the pat i ent .
Reacti ons between Absorbents and Anesthetic Agents
Haloalkene Formation
Hal othane degradat i on most of ten occurs duri ng cl osed-ci rcui t anesthesia and
produces the hal oal kene 2-bromo-2-chl oro-1, 1-dif l uoroethene (BCDFE). Al though
BCDFE i s nephrotoxi c i n rats, halothane has not been f ound t o be nephrotoxic i n
humans af ter over f our decades of use (52).
Compound A Formation
Sevof l urane decomposes i n the presence of some carbon di oxi de absorbents t o
f orm
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several degradat ion compounds. Onl y one, Compound A, a vinyl et her t hat has a
dose-dependent nephrotoxic ef fect i n rats, reaches si gni f icant concentrat ions
(53,54,55, 56, 57,58). I t has been the subj ect of i ntense debate regardi ng possi bl e
nephrotoxi ci t y i n humans (59,60,61, 62,63,64, 65,66). A l arge number of sci enti f i c
reports on thi s topic have been publ ished, somet imes wi t h cont radi ctory resul ts and
concl usi ons
(59,62,65, 67, 68,69,70, 71,72,73,74,75,76,77,78,79, 80,81,82, 83,84,85, 86, 87,88, 89).
Several f act ors i nf luence the amount of Compound A i n t he breat hi ng system.
Fresh Gas Flow
More Compound A i s produced wi t h l ower f resh gas f l ows (90,91). However, a
number of studies have been carri ed out in cl osed system wi thout si gni f icant
Compound A formati on (17, 26,32).
Absorbent Composition
Compound A producti on is greatest wi th absorbents contai ni ng pot assium or sodi um
hydroxi de. Absorbents wi t h decreased potassi um hydroxi de/sodium hydroxi de
produce lower concent rati ons of Compound A (92). Absorbents that are f ree of
st rong al kal i produce li tt l e or no Compound A, even during closed system
anesthesi a (12,18,26,92, 93).
Absorbent Temperature
Temperature in t he absorber correl ates wi t h t he amount of Compound A t hat i s
generated (94,95,96). Loweri ng t he absorber temperature decreases the amount of
Compound A produced (94,97). I ncreased absorber t emperature associ ated wi th an
i ncrease i n carbon di oxide el i minated by the pati ent may resul t in modest i ncreases
i n Compound A producti on (98, 99).
The reacti on bet ween desi ccated absorbent and sevof lurane produces heat , whi ch
i ncreases the reacti on speed, so t he rate of sevofl urane breakdown can accel erat e
rapi dl y (100,101,102). Sevofl urane may be so extensivel y consumed that
mai ntai ning anesthesi a i s di ff i cul t.
The si ze and shape of the cani st er may be i mportant i n determi ni ng the
t emperat ure of the absorbent . Smal l chambers may resul t i n l ower temperatures.
One study f ound t hat if dead space were added between the ci rcl e system and t he
Y-pi ece and the vol ume of venti l at ion increased t o compensat e for the i ncreased
dead space wi t hout changi ng alveol ar vent il at ion, the temperature of the absorbent
woul d be reduced (103). However, anot her study f ound that sevofl urane breakdown
i ncreased wi t h hi gher mi nut e vol umes (100).
Concentration of Sevoflurane
Hi gher concent rat i ons of Compound A occur when hi gher concentrat ions of
sevof lurane are used (95,101).
Anesthetic Length
Compound A concent rati on i ncreases wi t h l onger anesthet i cs.
Water Content
The eff ect of absorbent dryness i s compl ex (101, 104, 105,106, 107). Dehydrated
absorbents increase both t he degradati on of sevof l urane to Compound A and t he
degradat ion of Compound A (104,108). The absorbent i n smal l canisters i s l ess
l ikel y to become desi ccated probabl y because i t i s changed more f requentl y.
Absorbent dryness can be predicted by measuri ng the percent of water i n the
outf l ow gas (109). Small er pati ents are less l i kel y t o rehydrate t he absorbent
t hrough exhal ed water vapor and carbon dioxi de neut rali zati on.
Absorbent can be rehydrat ed to some extent by usi ng humi dif i ed gases (110).
Absorbent manuf acturers have caut i oned agai nst addi ng moi sture di rectl y t o
absorbent (111). Poured water wi l l not uni f orml y hydrate al l of t he absorbent . Thi s
wi l l l eave desiccat ed granul es that can react wi th anesthet ic agents. Al kal i ne wat er
could potenti al l y be carri ed to the pat ient (112). Adding water coul d l ead to
agglomerati on of t he absorbent granules, whi ch coul d i ncrease the resi stance to
gas f l ow and cause a signi f i cant loss in absorpt ion capaci t y (111).
Carbon Monoxide Formation
Carbon monoxi de is produced when desf l urane, enfl urane, or isof lurane i s passed
t hrough dry absorbent containi ng a st rong al kal i (pot assi um or sodi um hydroxi de)
(9,10,22,113, 114, 115,116,117,118,119,120,121,122). When sevofl urane i s
degraded by absorbent , carbon monoxi de i s f ormed if the temperature exceeds
80C (100). The inci dence of carbon monixi de f ormati on i s not known but i s
probably greater t han thought (117, 123,124). Cases of severe carbon monoxide
poisoni ng have been reported (117, 118,120, 125).
Most report ed cases have occurred during the f i rst general anesthet i c of the day
and on Monday morni ng, presumabl y because f resh dry gas was fl owi ng i nt o the
ci rcle system over t he weekend, causing the absorbent to become dehydrated
(126). Carbon monoxi de format i on has al so been report ed when anest hesi a was
admi ni stered f rom a l i tt le-used machi ne i n a remote locat ion (124).
The carbon monoxide concentrat ion i n the breathing syst em varies wi t h t i me,
t endi ng t o peak i n the f i rst 60 mi nut es (10,114,121).
Carbon monoxi de can present a seri ous hazard t o the pati ent. Si gns and sympt oms
of moderate carbon monoxi de t oxi ci ty such as conf usi on, headache, and nausea
are masked duri ng and af ter anesthesia and may resembl e common sequel ae (127).
The consequences are more severe in pati ents wi t h l ow hemogl obi n l evel s and i n
smal l pati ents (100, 128).
Carbon Monoxide Detection
Some desi ccat ed absorbents wi l l cont inue to absorb carbon di oxi de; t heref ore, the
presence of an acceptable capnographi c wavef orm shoul d not be taken as evi dence
t hat the i nspi red gas i s f ree f rom carbon monoxide (129).
Most pul se oxi meters (Chapter 24) cannot det ect carbon monoxide and read
carboxyhemogl obi n as oxyhemoglobi n. However, a very high carboxyhemogl obi n
concentrati on may cause a sl i ght decrease i n SpO
2
(117).
Respi rat ory gas moni tors i n current use cannot di rectl y detect carbon monoxi de.
Mul ti wavel ength inf rared anal yzers may provi de warni ng of i sof l urane or
P. 230

desfl urane (but not sevof lurane) breakdown by di spl ayi ng t he wrong agent or mi xed
agents (100,117,118,130,131,132).
An unusual l y del ayed ri se or unexpected decrease i n the i nspi red concentrati on of
a vol at i l e anesthetic i n the breathi ng system compared wi t h the vapori zer sett i ng, a
f ai l ed i nhalat i on induct i on, i nadequate anest hesi a, or an unexpected decrease i n
i nspi red concent rati on may i ndi cate that chemical breakdown (wi t h possibl e
producti on of carbon monoxide) i s occurri ng (120,133,134, 135).
Carbon monoxi de moni tors t hat work i n t he presence of cli ni cal concent rat i ons of
volat i le anesthet ics are commerci al l y avai l abl e (124,136,137,138).
Carboxyhemoglobi n moni tori ng i s avai l able t hrough co-oximet ry but i s not rout inel y
assessed. A combi nati on pulse oxi meter and carbon monoxi de detector is
commerci al l y avai l abl e (Chapter 24).
Si nce t he react ion of anestheti cs wi t h desi ccated absorbent is exot hermi c, an
unusual l y hi gh temperature i n the canister may be a sign of carbon monoxi de
f ormati on (139, 140). However, this i s not a rel i abl e met hod of detect ing carbon
monoxi de format ion (141). Wi th gas channel i ng i nsi de t he absorber, the outsi de of
t he cani ster may f eel onl y warm despi te hi gh i nternal temperatures.
Factors Associated with Carbon Monoxide Formation
Absorbent Composition
Onl y absorbents that contai n sodium and/or potassi um hydroxide are associ ated
wi th t he format ion of carbon monoxi de.
Absorbent Desiccation
No si gni f icant carbon monoxi de producti on occurs wi t h normal ly hydrated
absorbents (100, 142). Fresh gas f l owi ng through t he absorbent during an extended
peri od of nonuse i s thought to be the mai n f act or t hat causes desiccati on. The
i mpact of f resh gas f l ow i n vari ous ci rcl e system conf i gurat ions that can l ead to
absorbent desi ccati on i s discussed more f ul l y l ater i n thi s chapt er. Use of a heat
and moi st ure exchanger (HME) wi l l resul t i n decreased humi di ty i n the ci rcl e
system.
Detect i ng absorbent desi ccat i on is di f f i cul t . The l ack of signi f i cant col or change
wi th many of the absorbents does not ensure adequat e absorbent hydrati on (134).
An absorbent wi t h no strong bases can be used t o detect dehydrat i on bef ore carbon
monoxi de is f ormed f rom anest het i c degradat i on by l ayeri ng i t at the si te of f resh
gas i nf l ow (34). These absorbents wi l l change col or when dry. Another way t o
detect desiccat ion i s to f i l l the breathi ng system wi th gas cont ai ni ng sevofl urane
and ci rcul ate i t t hrough the absorbent whi l e moni tori ng the sevofl urane
concentrati on (143). A rapi d decl i ne i n sevof l urane concentrat ion may i ndicate
desiccated absorbent .
Anesthetic Agent
The hi ghest carbon monoxide l evels have been seen wi th desf lurane f ol lowed by
enfl urane then isof l urane (9,144). The amount of carbon monoxide produced wi t h
hal othane i s smal l . Si gni fi cant amounts of carbon monoxi de have been reported
wi th sevof lurane onl y when the absorbent temperature was greater t han 80C
(10,100,120,145,146).
Temperature Inside the Absorber
Hi gh temperatures i n the absorbent f aci l i tate carbon monoxi de producti on f rom
sevof lurane (102,145). However, i f an exot hermic react i on is occurri ng deep i n the
absorber, i t may not be detected by f eeli ng t he outsi de of t he canister.
Fresh Gas Flow
Hi gher f resh gas f l ows remove more carbon monoxide, producing l ower carbon
monoxi de concent rati ons, al though more carbon monoxi de is produced at higher
f resh gas fl ows because of the greater quanti t y of anesthetic react i ng wi t h
desiccated absorbent (9,100,137,147). High f resh gas f lows are more li kel y t o
promote absorbent desiccati on.
Carbon Dioxide Absorption
Carbon monoxi de format i on is reduced by carbon di oxide absorpti on (141,148).
Thi s could be si gni f i cant wi t h smal l er pat ients who produce l ess carbon di oxi de.
Carbon monoxi de l evel s are i ncreased wi th reduced pat i ent si ze (147).
Preventing Carbon Monoxide Formation
The Anesthesia Pat i ent Safet y Foundat i on (APSF) has recommended t hat carbon
di oxi de absorbents that do not degrade when they are desi ccated and exposed to
volat i le agents shoul d be used (129). These i nclude absorbents wi t hout KOH and
l i t tl e or no NaOH. Since the composi ti on and names of these absorbents change
f requent l y, cl i nicians must l ook at the composi t i on of a parti cular absorbent to see
i f i t f i ts the above recommendati on.
The APSF has provi ded a number of recommendati ons that an anest hesi a
department shoul d take t o prevent absorbent desiccati on i f the depart ment
conti nues to use strong al kal i absorbents wi th vol ati l e anest het i c agents (129).
These, i ncludi ng a f ew more di scussed in t he l i terature, are presented below.
Al l gas f l ows should be t urned OFF af ter each case. Thi s i s probabl y t he
most i mport ant measure. When t he dai l y schedul e is f inished, t he anesthesia
machi ne shoul d be di sconnected f rom t he medi cal gas pi pel i ne system at t he
pi pel i ne out let.
Vapori zers shoul d be turned OFF when not i n use. At the end of each case,
t he breathi ng system should be f lushed wi t h gas that i s f ree of volat i le anes-
t hetic.
The absorbent should be changed routi nel y, at l east once a week, pref erably
on a Monday morning, and whenever f resh gas has been f l owi ng f or an
extensi ve or i ndeterminate peri od of t ime. The canister should be l abel ed
wi th t he fi l li ng date (Fi g. 9.1). Checki ng
P. 231

t his date shoul d be part of t he dai l y machi ne checkl i st (112). I f a double-
chamber absorber i s used, the absorbent i n both cani sters shoul d be
changed at the same ti me.
Canisters on an anesthesi a machi ne t hat i s commonl y not used for a l ong
peri od of t ime shoul d not be f il l ed wi t h absorbent t hat contai ns st rong alkal i
or shoul d be f i l l ed wi t h f resh absorbent before each use.
The i nt egri t y of the absorbent packagi ng shoul d be veri fi ed pri or to use.
Opened contai ners that cont ai n absorbent should be careful l y closed af ter
use, and t he rest of the absorbent should be used as soon as possi bl e.
The practi ce of suppl yi ng oxygen f or admi ni st rati on to a pati ent who is not
receivi ng general anest hesi a through the ci rcl e syst em should be strongl y
di scouraged (124). Thi s i s associated wi t h other hazards, i ncl udi ng
acci dent al admi nistrati on of ni t rous oxi de and vol ati l e anestheti cs (149).
Suppl emental oxygen shoul d be obtai ned f rom a f l owmet er t hat is connected
di rectl y t o the oxygen pi peli ne system or an auxi l iary oxygen f lowmeter on
t he anesthesi a machi ne (Chapt er 5).
Usi ng f resh gas to dry breathi ng system components shoul d be di scouraged
(124).
The negative pressure rel i ef valve on a closed scavenging syst em (Chapter
13) should be checked regul arl y. Fail ure of t his val ve to pull i n room ai r may
resul t i n f resh gas f rom the machi ne being drawn t hrough t he absorbent i f t he
APL valve i s open (124).
The t emperature i n the cani ster shoul d be moni tored and t he absorbent
changed i f excessi ve heat is detected. A si mpl e pati ent temperature moni tor
may be used for thi s purpose. If the t emperat ure approaches 50C, excessi ve
heati ng f rom anesthet ic breakdown shoul d be suspected (127). However, if
t he probe is not in the area where the t emperature i ncrease occurs, the ri se
i n temperat ure may be missed.
Consi derati on shoul d be given to removi ng absorbent f rom cani sters i n
i nducti on rooms and t o usi ng hi gh f resh gas f l ows to el i minate rebreat hi ng
(146).
I t i s i mportant to i nvolve anesthesi a techni ci ans, cl eani ng staf f , nursi ng personnel ,
and anyone else who mi ght come i nto cont act wi t h an anesthesi a machi ne in the
program to prevent absorbent dryi ng. These personnel need t o be trai ned to look
out for f l owmet ers that are l ef t ON. They shoul d be i nst ructed to t urn OFF any f l ows
at t he end of the day and to reduce the f l ow to a mini mum bet ween cases. The
absorbent shoul d be changed i f i t i s l i kel y that prol onged exposure to dry gases has
occurred. One study f ound t hat t hese measures reduced, but di d not el i minat e,
absorbent desi ccati on (150).
Absorbent can be rehydrat ed to some extent by usi ng humi dif i ed gases (110).
Absorbent manuf acturers have caut i oned agai nst addi ng moi sture di rectl y t o
absorbent (111). Poured water wi l l not uni f orml y hydrate al l of t he absorbent . Thi s
wi l l l eave desiccat ed granul es that can react wi th anesthet ic agents. Al kal i ne wat er
could potenti al l y be carri ed to the pat ient (112). Adding water coul d l ead to
agglomerati on of t he absorbent granules in addi ti on to i ncreased resistance to f l ow
and a si gnif icant l oss i n absorpti on capaci t y i f moi st ure content standards are
exceeded (111).
Fl ushi ng t he breat hi ng system wi th f resh gas bef ore use wi l l not prevent carbon
monoxi de exposure.
Excessive Heat and Fires
The i nt eract ion of desi ccat ed barium hydroxi de absorbent and sevof l urane can
produce temperatures of several hundred degrees cent i grade (100,104,120). Cases
of f i res and/or mel ted components i n the absorber have been reported
(100, 112,120,134, 135, 139,146, 151). Because of these probl ems, bari um hydroxide
has been removed f rom t he market (152). Usi ng soda li me resul ts i n l ess elevated
t emperat ures (153), al t hough f i res i nvol ving desi ccated soda l ime have al so been
reported (135,154).
I t i s possi bl e that damage f rom excessi ve heat is not reported more of ten because
pati ent absorpti on of the t oxic products reduced thei r concent rati ons below t he
l ower l i mi t of fl ammabi l i t y. Cases of mel ted or burned absorber parts shoul d be
reported to the Food and Drug Admi ni stration (FDA), suppl i ers, and the Emergency
Care Research Insti tute (ECRI) (112).
Absorbent Storage and Handli ng
Absorbents are suppl i ed in several t ypes of contai ners: reseal abl e packages, pai l s,
cans, cartons, and di sposabl e pref il l ed contai ners. Once opened, contai ners shoul d
be resealed as soon as possi bl e to prevent absorbent reacti on wi th carbon dioxi de
i n the ai r, i ndicator deacti vati on, and moi sture l oss. High temperatures wi l l have no
ef fect on absorbents i f the contai ners are seal ed, but temperatures bel ow f reezi ng
are harmful because the moisture wi l l expand and cause the granul es to f ragment .
Absorbents shoul d al ways be handled gent ly t o avoi d f ragmentati on and dust
f ormati on. Al l personnel i nvol ved i n handli ng absorbents should be peri odi call y
warned t hat absorbent dust is i rri tat i ng to t he eyes and respi rat ory t ract and that
absorbents are causti c to the ski n, part icul arl y when damp. When a canister is
empt i ed, care shoul d be taken to remove dust part icl es, because they wi l l cause
t he seal s to warp, maki ng i t dif f icul t to achieve a t i ght f i t. Screens shoul d be
cl eared t o reduce resistance t o gas fl ow.
The cani st er shoul d al ways be f i l l ed wi t h care. It should be held over a sui tabl e
contai ner to avoi d get ti ng parti cl es on the f l oor. The absorbent shoul d be
P. 232

poured slowl y i nto t he canister whi l e the cani ster i s rotated, stoppi ng occasi onal l y
t o t ap t he si des. The canister shoul d be f il led compl et el y but not overf i l l ed. A smal l
space shoul d be l ef t at the top to promote even gas f l ow through the cani ster. The
upper l ayer of absorbent shoul d be l evel .
When using disposabl e, pref i l led contai ners, i t i s i mport ant to remove the top and
bot tom l abels or plast ic wrap, i f present, bef ore i nsert i on. I f these are not removed,
gas cannot fl ow through the contai ner, and compl ete breathi ng system obstructi on
wi l l occur (4).
When and How to Change the Absorbent
There are a vari et y of opinions about when t he absorbent shoul d be changed.
Changi ng i t too of t en is uneconomical . However, absorbent t hat has become
desiccated or exhausted must be changed.
Inspired Carbon Dioxide
The appearance of carbon dioxide i n the inspi red gas is t he most rel iabl e method t o
detect absorbent exhausti on (155). Thi s al lows the absorbent to be used most
ef fi ci ent l y.
Indicator Color Change
I ndi cat or col or change can be used but does not demonst rate carbon di oxi de
breakthrough as rel i abl y as inspi red carbon di oxi de when absorbents containi ng
st rong bases are i n use (3).
The f ol lowi ng consi derati ons shoul d be kept i n mi nd when usi ng an i ndi cator:
A phenomenon known as peaki ng or regenerati on i s seen wi th absorbents
t hat cont ai n strong bases. The absorbent appears to be reactivated wi th rest .
The amount of regenerat ion depends on how l ong the absorbent i s rested.
Af ter a number of such peri ods of ef f i ci ent absorpt i on wi t h i ntervening
peri ods of rest , termi nal exhaust i on occurs. Regenerati on has some
i mportance when i ndi cators are used. An absorbent that shows an exhausted
color, i f al l owed to rest , wi l l of t en show col or reversal . The absorpt ion
capaci t y wi l l be l ow, and t he exhausted col or wi l l reappear af ter onl y a bri ef
exposure to carbon di oxi de. The rested cani ster, theref ore, can give a f al se
i mpressi on of i ts usef ul ness.
When t he exhausted col or shows strongl y, the absorbent is at or near the
poi nt of exhausti on. When l i tt l e or no col or change shows, active absorbent
may be present, but the amount i s i ndetermi nat e and may be qui t e smal l .
Absorbents wi t hout a strong base change color when dried (34).
I f channel i ng occurs, the absorbent al ong the channel s wi l l become
exhausted, and carbon di oxi de wi l l pass through the cani ster. If t he
channel i ng occurs at si tes other than the sides of the cani ster, the col or
change may not be vi si bl e.
The absorbent may not cont ai n an i ndicator (156, 157, 158). Some compani es
make an i ndust ri al absorbent that does not contai n an i ndi cator, and thi s
product may be suppl ied as the resul t of an admi ni st rat i ve error.
Et hyl violet undergoes deacti vati on even i f i t i s stored i n the dark (159).
Deacti vati on i s accelerated i n the presence of l ight , especi al ly hi gh-i ntensi ty
or ul t raviol et l i ght .
Col orati on i n the outer wal l of t he canister may obscure the col or change (3).
Heat in the Canister
The reacti on of carbon dioxi de wi t h absorbent produces heat. Changes in absorbent
t emperat ure occur earl i er than changes i n the col or of the i ndi cator. Peri odicall y
checki ng t he canister t emperat ure is useful (160). Some heat producti on should be
apparent , unl ess high f resh gas f lows are bei ng used. Studies suggest t hat when
t he temperature of the downstream canister exceeds that of the upst ream chamber,
t he absorbent i n the upst ream canister should be changed (161). Recent
recommendat ions are t hat both cani st ers be changed even i f onl y one shows col or
change (129).
To change t he absorbent , the absorber is opened and t he canister removed. The
absorbent i s di scarded and the cani ster f il l ed wi t h f resh absorbent . Care should be
t aken when pl aci ng the l ast of t he absorbent i nt o the canister. I f excessive dust i s
present, the remai ni ng absorbent shoul d be di scarded and fi l l i ng compl eted f rom a
new container (162).
Absorpti on of Other Agents
Carbon di oxide absorbents remove ni tri c oxi de and/or ni t rogen di oxi de f rom the
i nspi ratory l imb of a vent il ator ci rcui t (163). Absorbents vary wi del y i n t hei r abi l i ty
t o absorb these enti ti es. If ni t ri c oxi de i s bei ng used, ni tri c oxi de moni tori ng shoul d
be perf ormed downst ream f rom t he absorber.
Unidirectional Valves
Two unidi recti onal (fl ut ter, one-way, check, di recti onal , dome, f l ap, nonreturn,
i nspi ratory, and expi rat ory) valves are used i n each ci rcl e system t o ensure that
gases f l ow t oward t he pati ent i n one breathi ng tube and away i n the other. They are
usual l y part of the absorber assembly. The Ameri can Soci et y f or Testi ng and
Mat eri al s (ASTM) standard requi res that the di recti on of i ntended gas f l ow be
permanentl y marked on the val ve housi ng or near i ts associ ated port wi th ei ther a
di recti onal arrow or wi t h the marki ng i nspi rati on or expi rati on so that i t i s visi bl e to
t he user (1).
A typical hori zontal uni di recti onal valve i s shown di agrammati cal l y in Fi gure 9.7. A
l i ght, t hi n di sc (l eaf l et or poppet) seats hori zont al l y on an annul ar seat. The di sc
has a sl i ghtl y l arger diameter than t he ci rcul ar knif e
P. 233

edge on whi ch i t si ts. A cage or gui de mechani sm (ret ai ner) (such as proj ecti ons
f rom the seat and dome) may be present to prevent the disc f rom becomi ng
di sl odged lateral ly or verti cal l y (Fi g. 9.8). The di sc shoul d be hydrophobi c so that
condensat e does not cause i t to st ick and increase t he resi stance to openi ng. The
t op of t he val ve i s covered by a cl ear pl astic dome so that the disc can be
observed. Gas enters at the bott om and f lows t hrough the center of t he val ve,
raising the di sc f rom i ts seat. The gas then passes under t he dome and on through
t he breathi ng system. Reversi ng the gas f l ow wi l l cause the di sc to cont act the
seat, prevent i ng ret rograde f l ow.

View Figure

Figure 9.7 Unidirectional valve. Left: Reversing the gas
flow causes the disc to contact its seat, stopping further
retrograde flow. Right: Gas flowing into the valve raises
the disc from its seat and then passes through the valve. The
guide (cage) prevents lateral or vertical displacement of the
disc. The transparent dome allows observation of disc
movement.

Uni di recti onal valves may be verti cal rather than hori zont al (Fi g. 9. 9). They have
t he di sc hi nged at the top. Vert ical unidi recti onal val ves reduce the resi stance to
gas f l ow (164).

View Figure

Figure 9.8 Horizontal unidirectional valves. Note the cages
that prevent the discs from being displaced.

One or both unidi recti onal val ves may become i ncompetent
(165, 166,167,168, 169, 170). Movement of t he di sc does not guarantee val ve
competence. Because an i ncompetent valve off ers l ess resistance to f l ow t han one
t hat must open, the f l ow of gas wi l l be pri mari l y through t he incompetent val ve,
resul ti ng i n rebreathi ng. The valve on t he exhal at ion si de i s most prone t o this
probl em because i t is subj ected t o more moi sture, but i ncompetence has al so been
descri bed wi t h the i nspi rat ory val ve (171,172). A uni di recti onal val ve l eak produces
a characteri st ic waveform on the capnograph (Chapt er 22).
A uni di recti onal val ve may j am, obst ructi ng gas f l ow (173,174). In one report ed
case, t he di sc was l ost duri ng cl eani ng and not recovered (175). It was later f ound
out of si ght bel ow the seat , where i t had moved i nt o such a posi t i on that i t covered
t he opening t o the bag mount and functi oned as a one-way valve. Gas f rom the bag
could f l ow i nt o the system, but not back i nto t he bag agai n.
Inspiratory and Expiratory Ports
The i nspi ratory port has a 22-mm mal e connector downst ream of the i nspi rat ory
uni di rect ional valve through whi ch gases pass toward the pati ent duri ng i nspi rat ion.
The expi rat ory port has a 22-mm male connector upst ream of the uni di recti onal
valve through whi ch gases pass duri ng exhalat i on. These ports are usual l y mounted
on the absorber (Fi gs. 9. 3B, 9. 10).
P. 234



View Figure

Figure 9.9 Vertical unidirectional valves.

Y-piece
The Y-pi ece (Y-pi ece connector, Y-connector, Y-yoke, Y-adaptor, t hree-way
breat hi ng system connector) i s a three-way tubul ar connector wi t h t wo 22-mm male
ports f or connect ion t o the breat hi ng tubes and a 15-mm f emale pati ent connector
f or a tracheal tube or supragl ot ti c ai rway devi ce. The pat ient connecti on port
usual l y has a coaxial 22-mm mal e fi tt i ng to al l ow di rect connect ion between the Y-
pi ece and a f ace mask. In most disposable systems, t he Y-piece and breathi ng
t ubes are permanentl y at tached. The Y-piece may be designed so t hat t he pati ent
port swivels. A septum may be pl aced i n the Y-pi ece t o decrease the dead space.

View Figure

Figure 9.10 The breathing tubes attach to the inspiratory
and expiratory ports.

Coaxi al breathi ng systems (Fi g. 9.11) have a component that repl aces but serves
t he same f unct i on as the Y-pi ece. The i nner (i nspi ratory) tube ends j ust before t he
connecti on to the pat i ent . The exhal at ion channel though t he outer t ube begi ns j ust
downst ream of the end of the inspi ratory tubing.
Fresh Gas Inlet
The f resh gas i nl et may be connected to the common gas outl et on the anest hesi a
machi ne by f l exi bl e tubing. The ASTM standard requi res that the f resh gas i nl et
port , or ni ppl e, has an i nsi de di amet er of at l east 4.0 mm and
P. 235

t hat the f resh gas del ivery tube has an insi de di ameter of at least 6.4 mm (1). The
f resh gas may enter t he breathi ng system downst ream of t he i nspi ratory
uni di rect ional valve. This l ocat i on and i ts consequences are discussed l ater i n t hi s
chapter. On most newer anesthesi a machi nes, t here i s a di rect connecti on bet ween
t he machi ne outl et and the breathi ng system, so the user does not see a f resh gas
hose.

View Figure

Figure 9.11 Coaxial circle system. If there is a break in the
inspiratory tube or the inspiratory tube becomes retracted,
there will be an increase in dead space.

Adjustable Pressure-limiting Valve
The APL val ve is di scussed in Chapter 7. Duri ng spontaneous breathi ng, the val ve
i s l ef t f ul ly open and gas f l ows through the valve during exhal at ion. When manual l y
assi sted or control led vent il ati on i s used, t he APL val ve shoul d be cl osed enough
t hat the desi red inspi ratory pressure can be achi eved. When t hi s pressure is
reached, the valve opens and excess gas i s vented t o the scavengi ng system
duri ng inspi rati on. There i s a case report where t hi s val ve jammed in the cl osed
posi t i on (176). Duri ng mechani cal venti lati on the APL valve i s i solat ed f rom t he
breat hi ng system.
Pressure Gauge
Many ci rcl e syst ems have an anal og pressure gauge (manometer) at tached to the
exhal ati on pathway. The gauge i s usual ly t he di aphragm type that i s shown i n
Fi gure 9.12. Changes i n pressure i n the breat hi ng system are transmi t ted to the
space bet ween t wo di aphragms, causi ng them to move inward or out ward.
Movements of one di aphragm are t ransmi t t ed to the poi nt er, whi ch moves over a
cali brated scal e. The ASTM standard
P. 236

requi res that the gauge be marked i n uni ts of kPa and/or cm H
2
O (1).

View Figure

Figure 9.12 Diaphragm-activated pressure gauge. Two thin
metal diaphragms are sealed together, with a space between
them. This space is connected to the breathing system.
Variations in pressure in the breathing system are
transmitted to the diaphragms, which bulge outward or
inward. A series of levers is activated, moving the pointer,
which records the pressure.

On newer machi nes, breathi ng system pressure i s of ten moni t ored elect ronical l y
and displayed on a screen. The anal ogue pressure gauge may not be present. A
vi rtual pressure gauge may be di spl ayed on the screen (Fi gure 23.19).
Breathing Tubes
Two breathi ng tubes carry gases t o and f rom the pat ient. Each tube connects to a
port on the absorber at one end and the Y-pi ece at t he other. The dead space i n
t he system ext ends f rom the Y-pi ece t o the pati ent . The l engt h of t he tubes does
not aff ect the amount of dead space or rebreathi ng because of the uni di recti onal
gas f l ow. Longer t ubes al l ow t he anesthesi a machi ne and other equi pment to be
l ocated f art her f rom t he pat i ent ' s head (177). Expandable t ubes are avail abl e (see
Fi g. 7. 3).
The maj ori t y of breathi ng tubes used i n the Uni ted States are pl astic, di sposabl e,
and nonconducti ve. Reusabl e breathi ng t ubes are avail abl e. A usef ul device to
keep the t ubi ngs i n pl ace and separat e f rom other tubings is shown i n Figure 9.13
(also see Fi g. 7. 4).
Coaxi al ci rcl e syst ems are avai labl e. The breathi ng tubes may be concentri c or si de
by si de (Fi g. 9.14). As shown i n Fi gures 9.15 and 9.16, the t ubi ngs at t ach t o a
conventi onal absorber assembl y. Gases f l ow t hrough the i nner t ube to t he pat i ent ,
and exhal ed gases f l ow t o t he absorber assembl y vi a the outer corrugated tube
(Fi g. 9.11). The i nspi red gas i s somewhat warmed in the process. Advantages of
t his system include compactness and moderat el y i ncreased i nspi red heat and
humi di ty
P. 237

(178, 179,180). A di sadvantage is the i ncreased resi stance. I f the i nner tube has a
l eak or becomes ret racted at the pati ent end (Fi g. 9.11), the dead space wi l l be
i ncreased. This probl em may not be easi l y detected and may resul t i n hypercapnea
(181). I f the f low of gases is reversed, ent eri ng t he pati ent t hrough t he outer t ube
and returning t hrough t he smal l er i nner t ubi ng, the resi stance duri ng exhal at ion wi l l
be i ncreased.

View Figure

Figure 9.13 A tube retainer (tube tree) is useful to hold the
breathing tubes and other tubes in place.


View Figure

Figure 9.14 The inspiratory and expiratory pathways are
side by side in one tubing.


View Figure

Figure 9.15 Coaxial system attached to the absorber.


View Figure

Figure 9.16 Having the reservoir bag on an
extended arm may make it easier for the
anesthesia provider to move around. Note the
coaxial system attached to the absorber
assembly.

Reservoir Bag
Bags were di scussed i n Chapter 7. The bag i s usual l y attached to a 22-mm mal e
bag port (bag mount or ext ensi on). I t may al so be pl aced at the end of a l engt h of
corrugated tubi ng or a metal tube l eadi ng f rom the bag mount (Fi g. 9.16), provi di ng
some f reedom of movement for t he anest hesi a provi der.
Ventilator
I n t he past, the vent i l ator was consi dered a replacement f or the reservoi r bag and
was at t ached at the bag mount . As machi nes and vent i l ators have evolved, t he
venti l ator has become an i ntegral part of the ci rcl e system. The venti l at or's pl ace i n
t he breathi ng system is di scussed lat er i n this chapter. Individual venti l at ors are
di scussed i n Chapter 12.
Bag/Ventilator Selector Switch
A bag/venti l ator sel ector swi t ch (swi tch val ve, mode sel ector valve, selector valve,
bag-vent il ator swi t ch val ve, swi tching valve, swi t chover val ve, manual /automati c
selector val ve, venti lat or val ve assembl y) (Fi g. 9.17)
P. 238

provi des a convenient met hod t o shi f t rapi dl y bet ween manual or spontaneous
respi rati on and automati c venti l ati on wi thout removi ng the bag or t he venti l ator
hose f rom i ts mount . As shown i n Fi gure 9.18, the sel ector swi t ch i s essent ial l y a
t hree-way stopcock. One port connects t o the breathing syst em. The second i s
at tached t o the bag mount . The thi rd at taches t o the vent il ator hose. The handl e or
knob that is used t o sel ect the posi ti on indicates the posi ti on i n which t he swi t ch is
set.

View Figure

Figure 9.17 This bag/ventilator selector switch and APL
valve are on the front of the ventilator.

A sel ect or swi t ch wi th APL valve i sol ati on is t he onl y t ype al l owed by the ASTM
standard (1). When the sel ector swi t ch is i n the vent i l ator posi ti on, the APL valve i s
i sol ated f rom the ci rcui t, so i t does not need t o be cl osed. Swi tchi ng to the bag
mode causes the APL valve t o be connected i nt o the breathi ng system.

View Figure

Figure 9.18 Bag/ventilator selector switch. In the Bag
position, the reservoir bag and APL valve are connected to
the breathing system. In the Ventilator position, the APL
valve and bag are excluded from the breathing system. On
most new machines, putting this in the ventilator position
turns ON the ventilator.

On newer anesthesi a machi nes, turni ng t he bag/ venti lator sel ect or swi t ch to the
venti l ator posi t ion causes the vent i l at or t o be turned ON. Some modern anesthesi a
machi nes do not have a bag/vent il ator selector swi tch. Turni ng the venti l at or ON
causes el ectroni cal l y cont roll ed valves to di rect gases i nt o the proper channel s.
P. 239


Respiratory Gas Monitor Sensor or Connector
Respi rat ory gas moni tors are di scussed i n Chapt er 22. Both mainst ream and
si destream devices can be used wi t h the ci rcl e system.
Airway Pressure Monitor Sensor
Ai rway pressure moni tors are discussed i n Chapt er 23. The sensor can be inserted
i nto t he ci rcle system by usi ng an adaptor, or i t may be i ncorporated i nto the
absorber assembl y.
Respirometer
A respi rometer i s commonl y used i n the ci rcl e system to measure vent i l at ory
volumes. These are discussed i n Chapt er 23.
Optional Equipment
Positive End-expiratory Pressure Valve
On most modern machi nes, the posi ti ve end-expi ratory pressure (PEEP) valve i s an
i ntegral part of the breat hi ng system or venti l ator. On other machi nes, i t can be
added when needed. It i s cri t i cal that the val ve be pl aced i n the expi ratory l i mb and
ori ented correctl y. Pl acing a unidi recti onal PEEP val ve backward wi l l bl ock gas
f low. If a bi di rect ional PEEP valve is pl aced backward, gas f low wi l l not be
occl uded, but no PEEP wi l l be produced.

View Figure

Figure 9.19 Classic circle system. Not all these components
may be present in a given system. For example, a heat and
moisture exchanger and a humidifier would not be used at
the same time. PEEP, positive end-expiratory pressure;
APL, adjustable pressure limiting.

Filters
One of t he di sadvantages of t he ci rcl e system i s that i t is di f fi cul t t o cl ean and/or
steri l i ze certain components. Fi l t ers are di scussed i n Chapter 7. They are used to
protect t he equipment f rom the pat ient and/or t o protect the pat ient f rom the
equipment .
Heated Humidifier
A heated humi di f i er can be pl aced i n the inspi ratory l i mb of t he ci rcl e system.
These are discussed in Chapt er 11.
Arrangement of Components
Fi gure 9.19 shows an arrangement of components that has been used commonl y i n
t he past and i s sti l l used i n many syst ems. Because i t has been around so long and
has been used so f requent ly, i t i s of ten ref erred t o as the
P. 240

cl assic ci rcl e system. This i s the basi c system that wi l l be di scussed i n rel at i on to
t he sequence of components.
Wi th the i nt egrati on of the vent il ator i nto the ci rcl e system, many new
confi gurati ons have been i ntroduced. These wi l l be di scussed i n great er detai l l ater
i n thi s chapter and i n Chapt er 12. They dif fer pri mari l y i n where the venti l ator is
l ocated and i n the components necessary f or venti l ator funct ion.
Objectives
There are a number of obj ect ives i n det ermi ni ng the best arrangement of
components i n the cl assi c ci rcl e system. Unf ort unatel y, not al l can be met.
Mi ni mi zi ng absorbent desi ccati on. Desi ccated absorbent has been i dent if i ed
as a si gni f icant cause of degradat i on of anesthetic agents and carbon
monoxi de format ion. Thi s was di scussed earl i er i n thi s chapter.
Maxi mum incl usi on of f resh gas i n the i nspi red mixture and maxi mum venti ng
of alveol ar gas (182). Pref erenti al l y incl udi ng f resh gas i n the i nspi red
mi xture wi l l resul t i n f aster i nducti ons and emergences. The l ower the f resh
gas f l ow, t he more i mportant this objecti ve becomes, because one of the
ef fects of usi ng l ower f resh gas f lows is that changes in concentrat ion i n the
f resh gas fl ow are ref lect ed more sl owl y i n i nspi red concentrati ons.
Mi ni mal consumpti on of absorbent . For eff i ci ent absorbent use, t he gas
vented t hrough t he APL valve shoul d have t he hi ghest possi bl e concent rati on
of carbon di oxi de. Thi s wi l l occur when (a) exhal ed gas does not pass
t hrough the absorber bef ore being vented, (b) exhal ed gas i s di luted as l i tt l e
as possi bl e bef ore vent ing, and (c) t he vented gas i s that exhal ed l ate i n
exhal ati on, because t he f i rst gas exhal ed i s that f rom the dead space and
has a l ow carbon di oxide concentrat ion.
As f resh gas f l ow i s reduced, more exhal ed gas must pass through the
absorbent , so thi s obj ect ive becomes less import ant . When using a cl osed
system, the arrangement of components shoul d have no ef fect on absorbent
ut i l i zati on, because al l exhal ed gases wi l l pass through t he absorber.
Accurate readi ngs f rom a respi rometer pl aced i n the system. I f the f resh gas
i nl et i s posi ti oned so that the f resh gas conti nuousl y f lows through the
respi rometer, t he measured vol umes may not be accurate.
Maxi mal humi di f i cat ion of inspi red gases.
Mi ni mal dead space.
Low resi st ance.
Mi ni mal pul l on t he tracheal t ube, mask, or supragl ott i c devi ce.
Conveni ence. Components shoul d be arranged so that they do not creat e
di ff i cul ti es duri ng use. Tubi ngs and wi res shoul d not become t angl ed.
There i s no si ngl e arrangement of components that wi l l meet al l of the menti oned
obj ecti ves, and objecti ves may conf l ict in some cases. For exampl e, venti ng carbon
di oxi de upst ream of the absorber wi l l conserve absorbent but may reduce i nspi red
humi di ty. In cert ai n cl ini cal si tuati ons, part icular obj ect i ves need to be gi ven
pri ori ty. In pedi atri c pati ents, dead space and humi dif i cat ion are usual l y more
si gni f icant t han i n adul ts.
Consideration of Individual Components
Fresh Gas Inlet
Fi gure 9.20 shows possi bl e locat ions of the f resh gas i nl et i n the cl assi c ci rcl e
system. It is most commonl y pl aced upst ream of the i nspi rat ory uni di recti onal val ve
and downst ream of the absorber (posi ti on A). In t his posi ti on, duri ng exhal at ion and
t he expi ratory pause, f resh gas wi l l f l ow i n a retrograde di recti on i nto the absorber
and then, dependi ng on the f resh gas f l ow, i nt o components bet ween the expi ratory
uni di rect ional valve and the absorber. This f low can cause absorbent desiccat ion at
t he absorber out let. At low f resh gas f lows, no gas vented through the APL val ve
wi l l have passed t hrough t he absorber. Wi th higher f resh fl ows, some gas that has
been in t he absorber may be vented. At very hi gh f l ows, some f resh gas may be
vented.
Pl aci ng t he f resh gas i nl et j ust upstream of t he absorber (posi ti on B) wi l l resul t i n
l ess i ncl usi on of f resh gas i n the i nspi red mi xture. Because of t he proxi mi t y to t he
APL valve, f resh gas wi l l be vent ed. Pl acing t he f resh gas i nlet i n thi s posi t ion wi l l
i mprove humi di f i cat i on of i nspi red gases but wi l l resul t i n more absorbent
desiccat i on. Another probl em is that absorbent dust may be bl own i nto t he
i nspi ratory l imb when the oxygen f lush is acti vated.
Pl aci ng t he f resh gas i nl et upst ream of the bag and the APL val ve (posi ti on E) has
al l of t he di sadvantages of posi ti on B and wi l l resul t i n more vent ing of f resh gas
and di l ut ion of exhal ed gas bef ore i t i s vented.
Pl aci ng t he f resh gas i nl et upst ream of the expi ratory uni di recti onal val ve (posi ti on
D) has all of the di sadvantages of posi t ion E. In addi t i on, duri ng i nspi rati on, the
f resh gas fl ow wi l l f orce exhal ed gases that contai n carbon di oxi de back t oward t he
pati ent .
Posi t i on C, downstream of the i nspi ratory uni di recti onal valve, i s used on at l east
one modern anesthesia machi ne. An advantage i s that changes i n the f resh gas
composi ti on wi l l be ref l ect ed more rapi dl y in t he i nspi red gases. Another advantage
i s that there wi l l be no retrograde fl ow of f resh gas through t he absorbent wi th a
conti nuous f l ow of f resh gas when the machi ne is not
P. 241

i n use. Duri ng exhal ati on, f resh gases j oi n exhal ed gases and escape though the
APL valve wi t hout reachi ng the pati ent. This resul ts i n poor economy of f resh gas
and absorbent, because f resh gas wi l l be l ost during exhal at ion and wi l l di l ut e the
concentrati on of carbon di oxi de i n the gas vented t hrough the APL val ve. Another
di sadvantage of posi t ion C i s that a respi rometer placed on t he exhal ati on si de of
t he ci rcui t wi l l not record volumes accuratel y unl ess t he f resh gas f l ow i s turned
OFF. Thi s i s not a problem i f the respi red volumes are measured bet ween t he Y-
pi ece and the pati ent . Fi nal l y, end-t i dal val ues may be af fect ed by f resh gas f l ow
(183).

View Figure

Figure 9.20 Possible locations for the fresh gas inlet. (See
text for details.) PEEP, positive end-expiratory pressure;
APL, adjustable pressure limiting.

Reservoir Bag
Fi gure 9.21 shows possi bl e locat ions for the reservoi r bag in t he cl assic ci rcle
system. It is most commonl y pl aced bet ween t he expi ratory unidi rect ional valve and
t he absorber (posi ti on A). A disadvantage of pl acing the bag upst ream of the
absorber i s that a sudden i ncrease i n pressure f rom squeezi ng the bag may f orce
dust f rom the absorber int o the i nspi ratory t ubi ng (184).
During spontaneous respi rat ion, absorbent use is equal ly ef f ici ent if the bag is
downst ream (posi ti on A) or upstream (posi ti on D or E) of the absorber. Wi th
manual l y control led or assisted vent il at i on, more eff i ci ent use occurs wi th t he bag
upstream of the absorber. If t he bag were i n posi ti on D, exhal ed gases woul d pass
t hrough the absorber to the bag duri ng exhalati on. Squeezing the bag duri ng
i nhal at i on woul d cause the gases t o reverse f l ow and pass ret rograde through the
absorber, to be vent ed through the APL valve. Thi s would resul t i n ineff icient
absorbent use, because gases cl eared of carbon dioxi de woul d be vented. Thi s
woul d al so l ead to absorbent desiccat ion, as dry f resh gas woul d be part of the
retrograde f l ow t hrough t he absorber.
On some modern machines, t he bag i s connect ed to t he ci rcl e system just
downst ream of the f resh gas i nl et (posi ti on E). Thi s wi l l be discussed i n detail l ater
i n thi s chapter.
I f the bag is pl aced bet ween the pat ient and ei ther of the uni di recti onal val ves
(posi ti on B or C), i t wi l l f orm a reservoi r f or exhal ed gases that wi l l t hen be
rebreat hed.
Unidirecti onal Val ves
Two l ocati ons have been used for the uni di rect i onal val ves: in t he Y-piece and
at tached t o the absorber. Valved Y-pi eces are no l onger avai l abl e commerci al l y and
are not permi tt ed by t he ASTM st andard (1). Valves in t hi s posi ti on are bul ky, and
seri ous acci dents have
P. 242

occurred when a valved Y-piece was pl aced i n a ci rcle system that cont ai ned
absorber-mounted valves (185).

View Figure

Figure 9.21 Possible locations for the reservoir bag. (See
text for details.)

Adjustable Pressure-Limiti ng Valve
Fi gure 9.22 shows possi bl e locat ions for the APL val ve in t he cl assic ci rcle system.
I t i s most commonl y l ocated near t he reservoi r bag downst ream of the expi ratory
uni di rect ional valve and upstream of the absorber (posi ti on A). In t hi s posi t ion,
f resh gas wi l l be vented onl y i f the f resh gas f low i s hi gh (186).
During manual l y cont roll ed or assi st ed venti l ati on, excess gas overf l ow occurs
duri ng inspi rati on. Fresh gas and gas t hat has passed t hrough t he absorber wi l l be
vented i f the APL val ve i s pl aced between the f resh gas i nl et and t he pat i ent
(posi ti on B, C, or D). If t he valve i s l ocat ed at posi ti on E, upst ream of the
expi ratory uni di recti onal val ve, absorbent use wi l l be i nef f i ci ent , because al l gas i n
t he reservoi r bag wi l l have t o pass through t he absorber bef ore bei ng vented.
Locati ng t he APL valve at the reservoi r bag wi t h an extender hose bet ween t he bag
and the bag mount has been suggested (187). This wi l l al l ow f resh gas that t ravel s
retrograde t hrough the absorber duri ng exhalat i on more space i n which to col l ect .
During spontaneous respi rat ion, the most ef f i ci ent use of absorbent wi l l occur wi t h
t he APL val ve on t he Y-piece (posi ti on B). Thi s i s because duri ng spontaneous
respi rati on, overf l ow occurs i n the lat t er part of exhal at i on. Gas exhal ed duri ng the
f i rst part of expi rati on i s dead space gas wi t h a l ow concentrati on of carbon
di oxi de. Because t he APL val ve i s not open, t hi s gas bypasses i t . When t he bag i s
f il l ed, the pressure i n the system rises and the APL val ve opens. Si nce this openi ng
occurs duri ng t he latter part of exhal ati on, the gas vented t hrough the APL val ve is
mai nl y alveol ar gas (wi th a hi gh carbon dioxi de content ). No such di scri mi nati on i s
possi bl e when the APL val ve is distant f rom the pati ent . However, i f the APL val ve
i s at the Y-pi ece, t he added wei ght (especial l y when scavengi ng apparatus i s
added) may i ncrease the i ncidence of disconnecti ons. Transfer tubing to the
scavengi ng interface (Chapt er 13) mi ght become ent angl ed wi th other obj ects. The
valve wi l l be di f f i cul t to adjust duri ng head and neck surgery. Fi nal l y, pl aci ng the
valve at posi ti on B wi l l cause a decrease i n i nspi red heat and humi di t y (178).
During spontaneous vent i l at ion, absorbent use is i nef f ici ent if the APL valve is
downst ream of the absorber (posi t i ons C and D) because vent ed gas wi l l have
passed through the absorber. I f the APL val ve i s pl aced at
P. 243

posi t i on C, f resh gas wi l l be vented. I f the APL val ve i s in posi t i on D, exhal ed
gases wi l l move retrograde i n the i nspi ratory t ubi ng during exhalat i on, causi ng an
i ncrease i n dead space.

View Figure

Figure 9.22 Possible locations for the adjustable pressure-
limiting valve. (See text for details.) PEEP, positive end-
expiratory pressure.

Filters
Fi gure 9.23 shows possi bl e posi t ions for a f i l t er wi thi n the cl assic ci rcl e syst em.
Most di sposabl e systems do not al low a f i l ter to be pl aced at posi ti on A or B.
Convi nci ng evi dence that use of a f i l ter prevents postoperati ve i nfecti on i s lacki ng.
Posi t i on A i s bet ween t he inhal at ion t ubi ng and the Y-pi ece. A f i l ter here wi l l
protect t he pat i ent f rom contaminati on and absorbent dust but wi l l not prot ect
system components or the operati ng room envi ronment f rom contami nat ion f rom the
pati ent . If the f i l ter i s heavy or bul ky, pl aci ng i t in t his posi ti on may be awkward. A
f il ter should not be pl aced i n this l ocati on i f a humi dif i er i s l ocated upst ream.
Posi t i on B i s bet ween t he Y-piece and t he exhalati on tubi ng. In thi s posi ti on, t he
system components and operat ing room wi l l be protected. Water, mucus, or edema
f lui d can col l ect in t he f i l ter i n thi s posi ti on, causing an increase i n resi stance or
obstruct i on to gas f l ow. The bul k and wei ght of a f i l ter may make i t unsui t abl e f or
t his l ocati on.
Posi t i on C i s bet ween the i nspi ratory tubi ng and the inspi rat ory uni di recti onal val ve.
The si ze or wei ght of the f i l ter i s not a probl em i n this posi ti on. If a humidi f ier is
used, i t shoul d be downstream of the fi l ter. A f i l ter i n this posi ti on wi l l prot ect the
pati ent f rom contami nati on f rom the absorber and i ts at tached parts. I t wi l l catch
absorbent dust . I t wi l l not protect ci rcl e system components or t he operat ing room
ai r f rom contami nat i on f rom the pati ent .
Posi t i on D i s bet ween the exhalati on tubi ng and the expi ratory unidi rect ional valve.
I n t hi s posi ti on, t he f i l t er wi l l protect the system components f rom contaminati on.
Because the f i l ter is on the expi rat ory side, obstruct i on f rom f l uid i s possi ble,
al though l ess l i kel y than wi t h posi t ion B. Thi s posi ti on may cont ri bute to absorbent
desiccat i on and producti on of Compound A and carbon monoxi de as discussed
earl i er in t hi s chapt er.
Posi t i on E i s bet ween t he Y-piece and t he pat ient. In t his posi ti on, the f il t er wi l l
protect t he pat i ent f rom the equi pment and the equipment f rom the pat i ent. This
suggests a st rategy f or i nf ect i on cont rol i n anesthesia (188). Usi ng a new f i l t er
bet ween t he pati ent and the breathi ng system wi t h each pati ent may permi t reuse
P. 244

of t he breathi ng system. Pot ent ial probl ems wi t h this si t e i ncl ude i ncreased dead
space, i ncreased possi bi li t y of di sconnecti ons, and i ncreased resistance. The f i l ter
may become cl ogged wi t h bl ood, secreti ons, or edema f lui d.

View Figure

Figure 9.23 Possible locations for filters. (See text for
details.) PEEP, positive end-expiratory pressure; APL,
adjustable pressure limiting.

Some f i l ters act as HMEs. To f uncti on i n thi s capaci t y, t hey must be posi t ioned at
l ocat i on E. An HME that is l ocated between the pati ent and the gas sample l i ne wi l l
reduce t he amount of moisture that enters the respi ratory gas moni tor (Chapter 22).
Usi ng an HME wi l l decrease the humi di ty i n the exhal ati on tubi ng, and t hi s may
contri but e to dehydrati on of the absorbent .
Posi t i on F i s i n the hose leadi ng to the venti l ator. Thi s wi l l prot ect the pati ent f rom
t he vent i lator and the vent i l ator f rom t he pat i ent. Disposabl e hoses wi th f i l ters are
avai l able.
Respiratory Gas Monitor Sensor or Sampl e Site
Oxygen Monitor
Fi gure 9.24 shows possi bl e locat ions for a mai nstream oxygen moni tor sensor i n
t he cl assi c ci rcl e syst em. I t may be f i t ted i nt o t he dome of a uni di recti onal valve
(H), t he top of the absorber assembl y, or a T-shaped adapter. The sensor shoul d be
pl aced so that the membrane poi nts downward to prevent water f rom accumul ati ng
on the membrane.
Posi t i ons A, F, and H are on the i nspi rat ory si de, whereas posi ti ons C, E, G, and I
are on the exhal at ion si de. Pl aci ng t he sensor on t he expi rat ory side wi l l usual l y
expose i t to more humi di ty, but t hi s is not a probl em wi t h most sensors. I f l ow f resh
gas f l ows are used, the readi ng on t he expi rat ory si de wi l l be l ower t han on the
i nspi ratory si de, but even wi th a cl osed system, the i nspi red-expi red dif ference is
onl y 4% to 6%.
I t has been advocated that t he oxygen analyzer be pl aced near the Y-pi ece
(posi ti on B, F, or G) so that i t wi l l al arm i n the event of a disconnect ion bet ween
t he breathi ng system and t he tracheal t ube or supragl ot ti c devi ce. However, an
oxygen anal yzer shoul d not be rel i ed on to detect a di sconnecti on. Al t hough thi s i s
t he most common si te f or di sconnecti ons, they can occur i n ot her l ocati ons. Wi th a
hi gh f resh gas f l ow, t he oxygen concentration may not f al l suf f i ci entl y for the al arm
t o sound i f a di sconnecti on occurs.
Pl aci ng t he sensor near the pat ient i n posi ti on B, F, or G may make i t dif f icul t to
mai ntai n i n an upri ght posi ti on. In addi t ion, t he cabl e to the moni tor may become
entangled wi t h other t ubi ngs or stretched, resul ti ng i n a pul l on the Y-pi ece. Placi ng
i t i n posi ti on B, between the Y-pi ece and the t racheal tube or mask, wi l l i ncrease
dead space.
P. 245



View Figure

Figure 9.24 Possible locations for oxygen monitor sensor.
(See text for details.) PEEP, positive end-expiratory
pressure; APL, adjustable pressure limiting.

Wi th a si dest ream moni tor, posi t i on B i s the pref erred l ocati on because both
i nspi red and exhal ed gases can be moni t ored. The sampl i ng si t e can be
i ncorporated i nto other components so that i t does not add dead space.
Posi t i on D i s i n the f resh gas l i ne. Thi s posi t i on wi l l i ndicat e onl y the concentrat ion
of oxygen in t he gas mi xture del i vered to the breathi ng system and not that i nspi red
by t he pati ent .
Capnometer and Agent Monitor
Mainstream Devices
To obtai n sat i sfactory exhal ed val ues, a mai nst ream carbon di oxi de sensor must be
bet ween t he pati ent and the breathi ng system (posi t ion B i n Fi g. 9.24), as cl ose as
possi bl e t o the pat ient. There are no mai nstream agent moni tors.
Sidestream Devices
Gases can be aspi rat ed f rom an adaptor in t he breat hi ng system or f rom a port i n a
component. To obtain sati sf act ory sampl es of both i nspi red and exhal ed gases, the
si te must be cl ose t o the pati ent (posi ti on B i n Fi g 9.24).
Respirometer
Fi gure 9.25 shows possi bl e locat ions for a respi rometer (Chapter 23) i n the ci rcle
system. Some have speci al adaptors f or at tachi ng them securel y at part icular
l ocat i ons.
A respi rometer i s usual l y pl aced on the expi ratory si de on ei ther si de of t he
expi ratory uni di recti onal val ve (posi ti ons A and B). Duri ng spontaneous respi rat ion,
t he vol umes recorded wi l l be accurate. Duri ng cont rol l ed respi rat i on, a respi rometer
i n thi s locat ion wi l l over-read inspi red volumes because of the expansion of the
breat hi ng tubes and gas compressi on i n the breathing system. If the respi rometer
can detect reverse f low, a malf uncti oni ng unidi recti onal val ve may be detect ed.
A respi rometer pl aced bet ween t he pati ent and the Y-pi ece (posi t i on C) wi l l record
accuratel y duri ng both spontaneous and control led venti l at ion i f i t can read
bi di recti onal f low. By measuri ng bot h inspi red and exhaled vol umes, problems such
as a l eaki ng t racheal tube cuf f can be detected. If the pati ent is breat hi ng
spontaneousl y, i t wi l l not detect a di sconnecti on bet ween t he sensor and the Y-
pi ece. However, some respi rometers are too bulky to be pl aced i n this posi ti on, and
t he i ncrease i n dead space may be si gni f icant . If the respi rometer does not
measure bidi recti onal f low, i t i s of no val ue i n thi s locat ion. Usi ng t hi s posi ti on may
resul t i n increased l ikel ihood of damage due t o water condensati on, mucus, edema
f lui d, and secret i ons. The wei ght of a mechanical respi romet er coul d cause a
di sconnecti on or t racheal t ube ki nki ng.
P. 246



View Figure

Figure 9.25 Possible locations for a respirometer. (See text
for details.) PEEP, positive end-expiratory pressure; APL,
adjustable pressure limiting.

I f the respi romet er sensor is pl aced on the i nspi ratory si de (posi ti on D), i t wi l l over-
read duri ng cont rol l ed or assi sted venti l ati on because of the expansi on of t he
t ubi ngs and l eaks bet ween the respi rometer and the pat i ent. This posi ti on can be of
value i f a second sensor i s pl aced on the exhal ati on side (posi t i on C). This al l ows
both i nspi ratory and expi rat ory ti dal vol umes to be measured. Thi s combi nat i on is
used wi t h the Ohmeda 6900 seri es vent i l ators and Drager Apol l o vent i l ator. These
si tes al l ow t he venti lator t o compensate f or the f resh gas f l ow t hat is added t o the
breat hi ng system duri ng inspi rati on (Chapter 12). These si tes also make i t possible
t o gather t he inf ormat ion necessary to produce fl ow-vol ume loops, whi ch are
di scussed i n Chapter 23.
A respi rometer shoul d not be l ocated downstream of t he absorber (posi t ion E),
because t he absorbed carbon dioxide wi l l decrease the vol ume of gas measured.
Sensor for Airway Pressure Monitor
Possi bl e posi ti ons i n the classi c ci rcle system f or an ai rway pressure sensor are
shown i n Fi gure 9.26. Pl acing the sensor i n posi t ion C, bet ween t he pat ient and t he
breat hi ng system, wi l l ensure that the pressure measured i s cl ose to that of the
pati ent 's ai rway. The more di stant the si te is f rom the pat ient, t he l ess usef ul i t is
as an esti mat e of ai rway pressure (189,190). Breathing syst em resistance, l eaks,
obstruct i ons, and other mechanical fact ors may resul t i n a measured pressure t hat
di ff ers substanti al l y f rom the pressure i n the pati ent ' s ai rway (191). Probl ems wi t h
t his si te incl ude increased dead space, disconnect ions, t racheal tube ki nki ng,
contaminati on, and wat er bui l dup i n the pi l ot l i ne. I t is necessary t o connect the
pi l ot l i ne f or every case.
Pl aci ng t he sensor on the expi ratory si de (posi t ions A and B) has an advantage
over pl acement on t he inspi ratory si de (posi ti on D). If there i s gas f l ow obstructi on
i n the i nspi ratory l imb and t he sensor f or ai rway pressure i s locat ed upstream of the
obstruct i on, the l ow pressure near t he pati ent wi l l not be sensed.
Posi t i on E, i n the venti l ator i tsel f , was used i n t he past but i s now not
recommended. Cert ai n ci rcumstances may cause suff i ci ent back pressure t o
devel op, which wi l l i nhi bi t the l ow pressure al arm (191,192). Al so, pl acement i n t he
venti l ator may resul t i n f ai l ure to detect an i ncorrectl y set bag/vent il ator selector
valve.
A combi nati on of si tes A and D i s bei ng used for machi nes equi pped wi t h t he
Datex-Ohmeda 6900 seri es
P. 247

venti l ators and the Drager Apol l o venti l ator. These si tes can be used t o generate
i nformati on for a pressure-vol ume l oops, whi ch are di scussed in Chapter 23.

View Figure

Figure 9.26 Possible locations for the sensor for an airway
pressure monitor. (See text for details.) PEEP, positive end-
expiratory pressure; APL, adjustable pressure limiting.

Positive End-expiratory Pressure Valve
Possi bl e posi ti ons f or a PEEP valve are shown i n Fi gure 9. 27. A PEEP val ve must
be pl aced in t he expi ratory si de of the breathi ng system. A disposable PEEP valve
shoul d be pl aced between t he expi ratory breathing t ube and t he expi ratory
uni di rect ional valve (posi t i on B). Bui l t -i n PEEP val ves are usual l y si tuated
downst ream of the expi rat ory uni di recti onal val ve and upst ream of the absorber
(posi ti on A). A bi di rect i onal PEEP valve may be i nsert ed bet ween t he anesthesi a
venti l ator and breathi ng system (posi t ion C).
Pressure Gauge or Sensing Site
To measure PEEP accuratel y, the pressure gauge or sensi ng si te must be on the
same si de (pat i ent or absorber) of t he unidi recti onal val ves as t he PEEP val ve
(193). On most older absorber assembl ies, t he pressure gauge is on t he absorber
si de (posi t ion B). I f a PEEP val ve i s added to the expi ratory l i mb on the pati ent si de
of t he unidi rect ional valve, PEEP wi l l not regi ster on t he manometer gauge. Most
new absorber assembl i es have a buil t -i n PEEP val ve l ocat ed on the absorber si de
of t he unidi rect ional valve wi t h the pressure gauge or sensi ng si te in cl ose
proxi mi t y.
Venti lator
Possi bl e l ocati ons f or a venti l ator are shown i n Figure 9.28. Posi ti on A i s upst ream
of t he absorber, near the APL valve. If the venti l at or l ocati on and ot her components
are in t he cl assi c posi t i on (posi ti on A), gas f lows do not di f f er f rom t he cl assic
ci rcle system.
The other l ocat ion f or t he venti l ator is posi ti on B, upstream of the i nspi ratory
uni di rect ional valve. When the venti l ator is pl aced i n thi s l ocati on, duri ng
i nspi rati on, the gas must be prevent ed f rom f l owi ng retrograde t oward t he bag and
absorber. To accompl ish thi s, an i sol ati ng val ve i s placed between the reservoi r
bag and the vent i l ator. The reservoi r bag col l ects the f resh gas. This causes f resh
gas decoupl ing, whi ch i s discussed i n detai l i n Chapter 12.
P. 248



View Figure

Figure 9.27 Possible locations for a positive end-expiratory
pressure valve. (See text for details.) PEEP, positive end-
expiratory pressure; APL, adjustable pressure limiting.


View Figure

Figure 9.28 Possible locations for a ventilator. (See text for
details.) PEEP, positive end-expiratory pressure; APL,
adjustable pressure limiting.

P. 249


Gas Flows through the Breathing System
Thi s secti on wi l l exami ne the gas f low t hrough di ff erent conf igurati ons of the
breat hi ng system t hat are currentl y commerci al l y avai l abl e duri ng di f ferent modes
of respi rat ion. For t hi s purpose, f resh gas ref ers to dry gas that has entered the
system f rom the anesthesi a machi ne.
Rebreathed gases are exhal ed gases that may or may not have had the carbon
di oxi de removed. These gases have a hi gher humi di ty t han f resh gas.
Ret rograde gas f low i ndi cates t hat gas is f lowi ng i n a di recti on opposi te to the f low
di rected by the unidi rect i onal valves. Ret rograde f l ow i s i mportant, because dry gas
t hat i s fl owi ng t hrough the absorber can potenti al l y desi ccate the absorbent.
Experi mental work t o conf i rm that retrograde dry gas f l ow t hrough the absorber
duri ng the vari ous modes of the respi ratory cycle cont ri butes t o desi ccati on has not
been publ i shed. Thi s needs to be studi ed, as there are a number of steps t hat can
be taken t o lessen desi ccati on duri ng t he respi ratory cycl e. The descripti on of gas
f lows given here are assumed, gi ven the conf i gurati on of t he vari ous el ements of
t he breathi ng system and t hei r interrelati onships. The problems created by
desiccated absorbent and anestheti c agents were di scussed earl i er i n t hi s chapter.
Classic Circle System
The classi c ci rcl e system i s shown i n Fi gure 9.29. It has the vent i l ator i n proxi mi t y
t o t he reservoi r bag. The classi c ci rcl e system has been used f or most of the
Ohmeda anesthesi a machi nes wi th t he except ion of the ADU. It has al so been used
on North Ameri can Drager Narkomed machi nes.
Spontaneous Breathi ng
Inspiration
During spontaneous i nspi rat i on (Fi g. 9.29), gas f l ows f rom the reservoi r bag and
t hrough the absorber, where i t joins wi t h the f resh gas and f l ows to the pat i ent.
Exhalation
During exhalat i on (Fi g. 9.30), exhal ed gases pass into the reservoi r bag unt i l i t is
f ul l . Then excess gases are vented through the APL val ve. Si nce the i nspi rat ory
uni di rect ional valve is cl osed, f resh gas enteri ng the breat hi ng system f l ows in a
retrograde di rect ion t hrough the absorber, pushing the gas i n the absorber toward
t he APL val ve. The f i rst gas to be vented t hrough the APL val ve wi l l be previ ousl y
exhal ed gas containing carbon di oxi de that was i n the tubi ng between the APL
valve and the absorber. I f the f resh gas f low i s hi gh, some gas that was i n or has
passed through the absorber wi l l f l ow ret rograde and pass i nto the reservoi r bag or
be expel led t hrough t he APL valve. If the f resh gas f low i s hi gh enough, f resh gas
may al so be l ost t hrough the APL valve. Low f resh gas f l ows may not f l ow
retrograde i nt o the absorber.
Manual Venti lation
Inspiration
During manual venti lati on (Fi g. 9.31), excess gases are vent ed through the part i all y
open APL val ve duri ng inspi rat i on. The gas f l owi ng through t he absorber and
ul ti mat el y to the pat ient wi l l be a mi xture of f resh gas and exhal ed gases. The
amount of f resh gas wi l l depend on the f resh gas f l ow and the degree that
retrograde f l ow occurred duri ng the previ ous exhal ati on.
Exhalation
During exhalat i on wi t h manuall y control led venti l at ion (Fi gs. 9.32, 9. 33), exhal ed
gases f l ow i nto the reservoi r bag. Fresh gas f l ows ret rograde through the absorber.
I f the f resh gas f low i s low (Fi g. 9. 32), f resh gas may not enter the absorber. I f the
f resh gas fl ow i s high (Fi g. 9. 33), some f resh gas may f l ow ret rograde through the
absorber and even enter t he bag.
Mechani cal Ventil ation
Inspiration
During i nspi rat i on, gas f l ows f rom the venti l at or t hrough t he absorber and
i nspi ratory unidi rect ional valve to t he pati ent. The gas i n the venti l at or bel l ows wi l l
consi st of exhaled gas and, if the f resh gas f l ow i s hi gh, f resh gas that has passed
retrograde t hrough the absorber.
Exhalation
During exhalat i on (Fi g. 9.34), exhal ed gases wi l l fl ow i nto the vent i l ator bel l ows.
Fresh gas wi l l pass ret rograde through the absorber. Excess gases are vented
t hrough the spi l l val ve i n t he venti l ator in t he latt er part of exhalati on. The longer
t he exhalati on ti me and t he hi gher t he f resh gas fl ow, the more li kel y that f resh gas
wi l l pass ret rograde t hrough the absorber.
Continuous Fresh Gas Flow
A conti nuous fl ow of f resh gas can enter the ci rcl e system i f a f l ow cont rol valve i s
l ef t turned ON when t he machine i s not i n use, such as bet ween cases or at the end
of t he surgery schedul e. Fresh gas f low may cont inue overni ght or over a weekend.
There are two possi bl e pat hways t hat a cont i nuous f resh gas f l ow can f ol l ow (Fi g.
9. 35). One i s through t he i nspi ratory unidi rect ional valve to the Y-piece and to
at mosphere (Fi g. 9. 35A). The other pat hway i s through the absorber and out t he
open APL val ve or bag mount (Fi g. 9.35B). The f resh gas wi l l take the path of l east
resi st ance. It i s possi bl e t hat both paths may be used.
I n most cases, the path of l east resi st ance wi l l be past the i nspi rat ory uni di recti onal
valve and out through the Y-pi ece. However, a common practi ce t o i ndi cate t hat the
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P. 251


P. 252


P. 253


P. 254

breat hi ng system on t he machi ne i s unused i s to leave a pl ast ic bag over the mask
or i nsi de the bowl (Fi g. 9.36). I f t he plast ic bag i s ti ght, t he resi st ance wi l l be hi gh,
and the pat h of l east resi stance wi l l be through the absorber i f the APL val ve i s
open (Fi g. 9.35A). I f the APL val ve i s cl osed (Fi g. 9.35B), al l of the gas wi l l be
di rected down t he i nspi rat ory tubi ng. If the reservoi r bag is removed, i t is more
l ikel y that gas wi l l f l ow ret rograde through the absorber.

View Figure

Figure 9.29 Gas flow through classic circle system during
spontaneous inspiration. APL, adjustable pressure limiting.


View Figure

Figure 9.30 Gas flow through classic circle system during
spontaneous exhalation. APL, adjustable pressure limiting.


View Figure

Figure 9.31 Gas flow through the classic circle system
during inspiration with manual ventilation. APL, adjustable
pressure limiting.


View Figure

Figure 9.32 Gas flow through the classic circle system
during exhalation with manual ventilation and a low fresh
gas flow. APL, adjustable pressure limiting.


View Figure

Figure 9.33 Gas through the classic circle system during
exhalation with manual ventilation and a high fresh gas
flow. APL, adjustable pressure limiting.


View Figure

Figure 9.34 Gas through the classic circle system during
exhalation with mechanical ventilation. APL, adjustable
pressure limiting.


View Figure

Figure 9.35 Possible paths of gas flow through the classic
circle system during a period of nonuse, with a continuing
fresh gas flow. APL, adjustable pressure limiting.


View Figure

Figure 9.36 The plastic bag over the mask will cause
increased resistance to gas flow. If the bag is not on the bag
mount or the APL valve is open, fresh gas may flow
retrograde through the absorber, causing the absorbent to
become desiccated.


View Figure

Figure 9.37 Gas flow through the Anestar breathing system
during spontaneous inspiration. APL, adjustable pressure
limiting.

Anestar Breathing System
The Anestar breat hi ng system (Fi gs. 9.37,9.38,9.39,9.40,9.41,9.42,9.43,9.44)
di ff ers f rom t he cl assi c ci rcl e system. The reservoi r bag i s near
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P. 258

t he f resh gas i nl et , and the venti l ator is upst ream of t he i nspi ratory unidi rect ional
valve. There i s a f resh gas decoupl i ng val ve downst ream of the reservoi r bag. I t i s
cl osed onl y duri ng i nspi rati on wi t h mechanical venti l at ion.

View Figure

Figure 9.38 Gas flow through the Anestar breathing system
during the early part of exhalation. APL, adjustable pressure
limiting.


View Figure

Figure 9.39 Gas flow through the Anestar breathing system
during late exhalation. APL, adjustable pressure limiting.


View Figure

Figure 9.40 Gas flow through the Anestar breathing system
during manual inspiration. APL, adjustable pressure
limiting.


View Figure

Figure 9.41 Gas flow through the Anestar breathing system
during inspiration with mechanical ventilation. APL,
adjustable pressure limiting.


View Figure

Figure 9.42 Gas flow through the Anestar breathing system
during mid exhalation with mechanical ventilation. APL,
adjustable pressure limiting.


View Figure

Figure 9.43 Gas flow through the Anestar breathing system
during late exhalation with mechanical ventilation. APL,
adjustable pressure limiting.


View Figure

Figure 9.44 Gas flow through the Anestar breathing system
during nonuse with continuing fresh gas flow. APL,
adjustable pressure limiting.

Spontaneous Breathi ng
During spontaneous i nspi rat i on (Fi g. 9.37), gas f l ows f rom the reservoi r bag,
t hrough the f resh gas decoupl i ng valve, and past the i nspi ratory unidi rect ional
valve to the pati ent. I f the bag empti es, a subatmospheri c pressure valve opens,
and ai r i s drawn i nto the system.
During earl y exhal at ion (Fi g. 9. 38), exhal ed gases f l ow through the expi rat ory val ve
and absorber t o the reservoi r bag, where t hey mi x wi t h the f resh gas f rom the
anesthesi a machine. Duri ng l at e exhalati on (Fi g. 9.39) when t he bag i s ful l , the APL
valve opens, and exhal ed gases f l ow through the open val ve t o the scavengi ng
system. The f resh gas fl ow pushes gases retrograde through the absorber. I f t he
f resh gas fl ow i s high enough, dry f resh gas wi l l f low i nt o or through the absorber.
Manual Venti lation
During manual l y cont roll ed i nspi rati on (Fig. 9. 40), the reservoi r bag is squeezed,
causi ng f resh gas and exhal ed gas that has passed through the absorber and into
t he bag to f l ow t o the pati ent. Excess gas wi l l pass retrograde through t he
absorber, pushing gas out through the APL valve. During exhal at i on, gases f l ow
t hrough the expi ratory valve and absorber to t he bag.
Mechani cal Ventil ation
Wi th mechani cal vent il ati on (Fi g. 9.41), t he f resh gas decoupl i ng val ve cl oses
duri ng inspi rati on, causi ng f resh gas to enter the reservoi r bag and excl udi ng i t
f rom the rest of t he system. A mi xture of f resh and previousl y exhaled gas f l ows
f rom the venti l at or bell ows through t he inspi ratory uni di recti onal val ve to the
pati ent .
During the earl y and mi d port i on of exhal ati on (Fi g. 9. 42), exhal ed and f resh gases
f low i nt o t he venti l ator bel l ows. Af t er the bel l ows has fi l led (Fi g. 9. 43), t he APL
valve opens. There wi l l be ret rograde gas f l ow t hrough the absorberf i rst exhal ed
gases that have passed t hrough the absorber, t hen f resh gas. The hi gher t he f resh
gas f l ow and the l onger t he expi ratory t ime, the greater t he amount of f resh gas
t hat wi l l fl ow retrograde through the absorber.
Continuous Fresh Gas Flow
I f a cont i nuous f l ow of f resh gas passes t hrough the breathi ng system (Fi g. 9. 44),
t he gases wi l l t ake the path of l east resistance. I f the reservoi r bag i s removed f rom
t he bag mount, i t i s li kel y that al l t he f resh gas wi l l exi t at t his point. I f there i s a
bag i n pl ace, gas may f low ei t her t hrough the inspi ratory tubing and the Y-pi ece
P. 259

or ret rograde t hrough t he absorber and out t hrough the APL val ve, dependi ng on
whether or not the APL val ve is open and t he resistance at the pat i ent port on the
Y-pi ece.

View Figure

Figure 9.45 ADU breathing system during manual
inspiration. APL, adjustable pressure limiting.

ADU Breathing System
I n t he Ohmeda ADU breathi ng system (Fi gs. 9.45,Fi gs. 9.46, Fi gs. 9.47,9.48), f resh
gas enters the system bet ween t he i nspi ratory unidi recti onal valve and the Y-pi ece.
The reservoi r bag, APL valve, and venti l at or wi t h i t s spi ll val ve are l ocated as i n the
cl assic ci rcl e system posi t i on.
Spontaneous Breathi ng
During spontaneous i nspi rat i on, the pat ient draws gas f rom t he reservoi r bag,
t hrough the absorber and i nspi ratory valve. Downstream of the i nspi ratory
uni di rect ional valve, t he f resh gas f l ow mixes wi t h the exhal ed gases.
During spontaneous exhal ati on, the bag f il ls wi t h a mi xt ure of f resh and exhal ed
gases. Excess gases are rel eased through the APL valve.
Manual Venti lation
During i nspi rat i on wi t h manuall y control l ed venti l at ion (Fi g. 9. 45), gas passes f rom
t he bag and through the absorber to t he i nspi ratory uni di recti onal valve. Some gas
(both f resh and exhal ed) i s vented through the APL val ve. Duri ng exhal at ion, f resh
gas and exhaled gas f rom the pati ent pass through the expi ratory unidi recti onal
valve and into the bag.
Mechani cal Ventil ation
Wi th mechani cal vent il ati on during i nspi rat ion (Fi g. 9. 46), exhal ed and f resh gases
f rom the venti l at or pass through the absorber and i nspi ratory val ve, where they are
j oi ned by f resh gas on the way to t he pati ent.
During exhalat i on (Fi g. 9.47), f resh and exhal ed gases f l ow t o t he venti l ator, wi t h
t he excess bei ng vent ed through the venti l at or spi l l val ve duri ng l ate exhal at ion.
Continuous Fresh Gas Flow
I f there i s a cont inuous f l ow of gases into t he breathing system when t he
anesthesi a machine i s not i n use (Fi g. 9.48), t he f resh gases have two possi bl e
pathways.
P. 260



View Figure

Figure 9.46 ADU breathing system during mechanically
controlled inspiration. APL, adjustable pressure limiting.


View Figure

Figure 9.47 ADU breathing system during mechanically
controlled ventilation. APL, adjustable pressure limiting.

P. 261



View Figure

Figure 9.48 ADU breathing system with continuous fresh
gas flow during nonuse. APL, adjustable pressure limiting.

I f the Y-pi ece i s not obst ructed, t his i s the most l ikel y exi t poi nt . If i t i s obstructed,
gases can pass t hrough the exhalat i on tubing past t he expi ratory uni di recti onal
valve and out the APL valve, if i t i s open. If the bag is not in place, thi s may be the
pref erred pathway. Si nce t he f resh gas ent ers downst ream of the i nspi rat ory
uni di rect ional valve, t he val ve wi l l be cl osed and not al l ow backf l ow. This means
t hat there wi l l be no ret rograde f resh gas f low t hrough t he absorber duri ng
conti nuous gas f low.
Drager 6400 Breathing System
The Drager 6400 breathi ng system (Figs. 9.49,9.50,9.51,9. 52,9. 53,9.54,9.55,9.56)
has the reservoi r bag near t he f resh gas inlet , and t he venti l ator i s on the
exhal ati on side of the absorber downst ream of the expi ratory uni di rect ional valve.
The APL val ve and mechani cal exhaust valve are al so l ocated on t he exhal ati on
si de of the absorber.
Spontaneous Breathi ng
During spontaneous i nspi rat i on (Fi g. 9.49), gases f l ow t o t he pati ent f rom t he
reservoi r bag. The bag wi l l contai n a mi xture of exhal ed gases that have passed
t hrough the absorber into the reservoi r bag duri ng the previous exhalati on and
f resh gas f rom the anesthesia machi ne.
During exhalat i on, exhal ed gases pass through the absorber and into the reservoi r
bag, where they are combi ned wi th f resh gas. When t he bag i s f i l led, t he f resh gas
f low wi l l push gases retrograde t hrough t he absorber. These gases then exi t
t hrough the APL val ve.
Manual Venti lation
Wi th manual venti l ati on (Fi g. 9.50), squeezi ng the bag causes gases to f l ow toward
t he pat ient as wel l as ret rograde t hrough t he absorber t o the part ial l y open APL
valve. During exhal at i on, exhal ed gases pass through the expi ratory uni di rect i onal
valve and absorber to the bag.
Mechani cal Ventil ation
During mechanical i nspi rat ion, the reservoi r bag and f resh gas i nl et are i solated
f rom the breathing system by the f resh gas control val ve (Fi g. 9.51). As t he pi ston
moves, gas is pushed t hrough t he absorber and
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P. 263


P. 264


P. 265


P. 266

i nspi ratory unidi rect ional valve to t he pati ent. Thi s gas wi l l i nclude f resh gas t hat
has f l owed retrograde t hrough t he absorber during exhal at i on. Meanwhi l e, f resh gas
enters the reservoi r bag.

View Figure

Figure 9.49 Drager 6400 breathing system during
spontaneous inspiration. APL, adjustable pressure limiting.


View Figure

Figure 9.50 Drager 6400 breathing system during manual
inspiration. APL, adjustable pressure limiting.


View Figure

Figure 9.51 Drager 6400 breathing system during
mechanical inspiration. APL, adjustable pressure limiting.


View Figure

Figure 9.52 Drager 6400 breathing system during
mechanical mid exhalation. APL, adjustable pressure
limiting.


View Figure

Figure 9.53 Drager 6400 breathing system during
mechanical exhalation with low fresh gas flow. APL,
adjustable pressure limiting.


View Figure

Figure 9.54 Drager 6400 breathing system during
mechanical late exhalation with high fresh gas flow. APL,
adjustable pressure limiting.


View Figure

Figure 9.55 Drager 6400 breathing system with continuous
fresh gas flow and bag on the bag mount. APL, adjustable
pressure limiting.


View Figure

Figure 9.56 Drager 6400 breathing system with continuous
fresh gas flow during nonuse and no bag on the bag mount.
APL, adjustable pressure limiting.


View Figure

Figure 9.57 Fabius GS and Apollo breathing systems
during spontaneous exhalation. APL, adjustable pressure
limiting.

During mechanical exhal at ion, the piston ret racts and exhaled gases f i l l the
venti l ator. Si nce t he i nspi ratory valve i s cl osed, f resh gas wi l l f l ow ret rograde
t hrough the absorber toward t he vent i lator (Fi g. 9. 52). The f i rst gas to enter the
venti l ator wi l l be exhal ed gases. The magni tude of t he f resh gas f l ow wi l l determi ne
how much f resh gas wi l l reach the vent i l ator. Duri ng l ate exhalati on (Fi gs. 9.53,
9. 54), t he piston i s f ull y retracted, all owi ng excess gases to exi t by way of the
mechani cal exhaust val ve. The gas that exi ts the syst em wi l l contai n some exhaled
gas and f resh gas that has passed ret rograde f rom t he absorber. If the f resh gas
f low i s hi gh (Fi g. 9.54), f resh gas penet rat i on wi l l be great er, and i t i s possibl e that
some wi l l exi t t hrough the exhaust val ve.
Continuous Fresh Gas Flow
I f a cont i nuous f l ow of f resh gas ent ers t he system when the syst em i s not in use,
t here are three possi bl e pat hways f or t he gas t o travel . One is through t he
i nspi ratory unidi rect ional valve to t he Y-pi ece (Fi g. 9.55). The other potenti al
pathway is retrograde through the absorber and out an through an open APL val ve
(Fi g. 9.55). The thi rd possi bl e pathway is through the bag mount if the bag i s not
present (Fi g. 9.56). The gases wi l l t ake t he route of least resi stance. I f the
reservoi r bag i s removed f rom the bag mount, t he l east resistance wi l l be t hrough
t he bag mount.
Fabius GS and Apollo Breathing Systems
I n t hese systems (Figs. 9. 57,9. 58,9. 59,9. 60, 9. 61,9.62,9.63), t he venti l ator is
bet ween t he f resh gas decoupl i ng val ve and t he i nspi ratory unidi rect ional valve.
The reservoi r bag is between the expi ratory uni di recti onal val ve and t he absorber.
Spontaneous Breathi ng
During spontaneous i nspi rat i on, gases wi l l f l ow f rom the reservoi r bag and f resh
gas i nl et t hrough the i nspi ratory uni di recti onal valve t o the pati ent.
During spontaneous exhal ati on (Fi g. 9.57), exhal ed gas passes though the
expi ratory uni di recti onal val ve and i nto the reservoi r bag. When t he bag i s ful l , the
excess gases wi l l exi t t hrough t he open APL valve. Fresh gas f l owi ng i nto t he
breat hi ng system wi l l f l ow ret rograde through the absorber i nto the reservoi r bag,
wi th t he excess vented through the APL valve. The amount of ret rograde fl ow wi l l
depend on t he f resh gas f l ow, respi ratory rate, and l engt h of t he expi ratory pause.
P. 267



View Figure

Figure 9.58 Fabius GS and Apollo breathing systems
during manual inspiration. APL, adjustable pressure
limiting.


View Figure

Figure 9.59 Fabius GS and Apollo breathing systems
during manual exhalation. APL, adjustable pressure
limiting.

P. 268



View Figure

Figure 9.60 Fabius GS and Apollo breathing systems
during mechanical inspiration. APL, adjustable pressure
limiting.


View Figure

Figure 9.61 Fabius GS and Apollo breathing systems
during mechanical mid exhalation. APL, adjustable pressure
limiting.

P. 269



View Figure

Figure 9.62 Fabius GS and Apollo breathing systems
during mechanical late exhalation. APL, adjustable pressure
limiting.


View Figure

Figure 9.63 Fabius GS and Apollo breathing systems with
continuous fresh gas flow during nonuse. APL, adjustable
pressure limiting.

P. 270


Manual Venti lation
During manual inspi rati on (Fi g. 9.58), t he bag i s compressed, causi ng exhal ed gas
t o pass through the absorber af ter whi ch i t i s joined by f resh gas. The combi ned
gases then pass through t he i nspi ratory unidi recti onal valve to t he pat ient. Some
gas f rom the bag wi l l al so fl ow to t he scavengi ng system through the APL valve.
During exhalat i on (Fi g. 9.59), exhal ed gases f low i nt o t he reservoi r bag. At t he
same t i me, f resh gas wi l l f low ret rograde t hrough the absorber t oward t he bag,
pushi ng some exhal ed gas toward the bag.
Mechani cal Ventil ation
Wi th mechani cal vent il ati on during i nspi rat ion (Fi g. 9. 60), t he f resh gas decoupl ing
valve closes, isol ati ng the f resh gas f rom the inspi red gas. Fresh gas enteri ng the
breat hi ng system wi l l pass ret rograde through the absorber t o t he reservoi r bag. As
t he vent i lator cycl es, i t wi l l cause a mixture of f resh and exhal ed gases that have
passed through the absorbent t o fl ow toward t he pat ient.
During exhalat i on (Fi g. 9.61), exhal ed gases wi l l pass through t he expi ratory
uni di rect ional valve and the absorber and on t o the venti l ator. Fresh gas that has
passed retrograde t hrough t he absorber duri ng inspi rat i on wi l l be added t o the
conti nui ng f resh gas f low t hat also f i l l s the piston chamber. Lat e i n exhal at i on (Fi g.
9. 62), af ter the piston has f i l l ed, exhal ed gas wi l l exi t through the APL bypass
valve. Fresh gas wi l l f l ow retrograde t hrough t he absorber and exi t t he system at
t he APL bypass val ve. The degree of ret rograde fl ow wi l l depend on the I :E rati o
and the f resh gas fl ow.
Continuous Fresh Gas Flow
I f a cont i nuous f l ow of gas enters t he system when the machi ne i s not i n use, the
gas has two possi bl e routes to exi t (Fig. 9.63). One pat h is t hrough t he inspi ratory
valve and Y-piece. The other is ret rograde through the absorber and an open APL
valve or empt y bag mount . The gas f l ow wi l l t ake the path of l east resi stance. If the
machi ne i s i n standby mode and there i s sti l l gas f l ow, a message to t hat eff ect wi l l
be di spl ayed on the screen.
Resistance and Work of Breathing in the Circle
System
I n t he past, one of t he obj ecti ons to usi ng a ci rcl e system wi th smal l chi ldren was
t hat i t had a hi gh resi stance. However, invest i gat ions have shown t hat t he
resi st ance or work of breathi ng wi t h t he ci rcl e system is not si gni fi cantl y greater
t han wi th other breathi ng systems and may be l ess (194,195). Coaxi al t ubi ngs
i ncrease resi st ance.
Dead Space of the Circle System
I n t he ci rcle system, dead space extends f rom the pat ient port of the Y-pi ece t o the
part i t ion bet ween the inspi ratory and exhal ati on t ubi ngs. A Y-pi ece wi t h a sept um
wi l l decrease dead space. When exhalati on or i nhalat i on start s, the gases i n t he
breat hi ng tubes move i n the opposi t e di recti on f rom thei r usual fl ow unt il st opped
by cl osure of one of the uni di recti onal valves. This i s referred t o as backl ash and
causes a sl i ght i ncrease in dead space. If the uni di recti onal val ves are competent,
however, backl ash wi l l be cl i nical l y i nsi gni f i cant.
Heat and Humidity
I n t he ci rcle system, moi sture i s avai l abl e f rom exhaled gases, the absorbent, and
wat er l i berated f rom the neutral i zati on of carbon di oxi de. Gases i n the i nspi ratory
l i mb of a ci rcl e system are near room temperature. Even wi t h l ow f resh gas f lows,
gases reach the Y-pi ece onl y 1C to 3C above ambi ent temperat ure (196).
The humidi t y of a standard adul t ci rcl e system i ncreases gradual l y wi t h use and
t hen stabi l izes. A f resh gas fl ow of 0. 5 to 2 L/ mi nute wi l l resul t in humidi t y bet ween
20 and 25 mg H
2
O/L at 60 mi nutes (197). Hi gher humi di ty resul ts f rom l ower f resh
gas f l ows, i ncreasing venti lat i on, l ocati ng t he f resh gas upst ream of the absorber,
wet ti ng t he inspi ratory tubi ng, and by usi ng a humi di f i er, smal ler canisters, or
coaxi al breat hi ng t ubes. Pri or system use wi l l resul t in an i ni ti al l y hi gher humi di ty
t hat stabi l i zes i n t he same peri od of t i me and at the same f i nal humi di ty. Usi ng an
HME (Chapt er 11) wi l l resul t i n decreased humi di ty i n the ci rcl e system but
i ncreased humi di t y i n t he i nspi red gases.
Relationship between Inspired and Delivered
Concentrations
I n a system wi t h no rebreathi ng, the concent rat i ons of gases and vapors i n t he
i nspi red mixture wi l l be close to those i n f resh gas. Wi th rebreathing, however, the
concentrati ons in the inspi red mi xture may dif fer considerabl y f rom those i n the
f resh gas. The larger the breathi ng system's i nternal volume, the greater wi l l be the
di ff erence between inspi red and del i vered concent rati ons. Cani ster si ze i s the most
i mportant determi nant of i nt ernal vol ume i n t he ci rcl e system.
Nitrogen
Ni trogen i s i mport ant , because i t hinders est abl ishing hi gh concent rat i ons of ni t rous
oxide and may cause l ow i nspi red oxygen concent rati ons. Bef ore any f resh gas is
del i vered, t he concentrat ion of ni trogen i n the breathi ng
P. 271

system i s approxi matel y 80%. Ni trogen ent ers t he system f rom exhal ed gases and
l eaves through t he APL valve, venti l ator spi l l val ve, and l eaks.
Usi ng hi gh f resh gas f l ows f or a f ew mi nutes to el i mi nate most of t he ni t rogen in t he
system and much of that i n the pat ient i s cal l ed deni trogenati on. There is no set
t i me or f l ow t hat wi l l produce adequat e deni t rogenat ion in al l cases (198). A ti ght
mask f i t is necessary f or proper deni t rogenati on, as ai r wi l l be i nspi red around a
l oose-f i t t ing mask.
Af ter deni t rogenat ion, ni t rogen el i mi nati on by the pati ent wi l l proceed at a sl ower
rate. In a cl osed syst em, t he ni trogen concent rat i on wi l l gradual ly ri se. Provi ded
t hat deni trogenati on has been carri ed out, even i f al l t he body's ni t rogen is exhal ed,
t he concent rati on in the breat hi ng system shoul d not i ncrease to more than 18% i n
t he average adul t (199,200). However, i f a sidest ream gas moni tor di rects gases
back to the anesthesi a ci rcui t , ni trogen concent rat i on may increase because many
analyzers ent rai n ai r as t he ref erence gas (201). A l eak i n the sampl ing l i ne can
resul t i n ai r ent rai nment (202).
When del i veri ng an ai r/ oxygen mixture into t he ci rcl e system, the i nspi red oxygen
concentrati on wi l l be l ower t han that set on the f l owmeters when the f resh gas f low
i s l ow. To compensate for thi s, higher oxygen concent rat i ons need to be
admi ni stered at l ow f l ows (203).
I n cert ai n anesthesi a machi nes, f resh gas compensati on (decoupli ng) (Chapt er 12)
i s accompl i shed by accumul at ing t he f resh gas fl ow during i nspi rat i on i n a reservoi r
bag and usi ng a vent i lator wi t h a piston or descendi ng bel l ows (164). Thi s
i ntroduces the possi bi l i ty of ent rai ni ng room ai r i nto the gas ci rcui t t hrough a
negat ive pressure rel i ef valve.
Carbon Dioxide
With Absorbent
The i nspi red carbon dioxide concent rat i on should be near zero, unl ess there i s
f ai l ure of one or both uni di recti onal valves, exhausted absorbent , or a bypassed
absorber (204). I f one of t hese condi ti ons exi sts, a hi gh f resh gas f low wi l l l i mi t the
i ncrease i n inspi red carbon di oxi de concentrati on.
Without Absorbent
I f the ci rcl e system is used wi thout absorbent , t he inspi red carbon di oxi de l evel wi l l
depend on t he f resh gas f l ow, t he arrangement of components i n the ci rcl e system,
and vent i l at ion.
Oxygen
The concentrat ion of oxygen i n the i nspi red mixture is aff ected by t he rate of
oxygen uptake by the pati ent, uptake and el i mi nati on of other gases by the pati ent ,
t he arrangement of the components, vent i l at i on, f resh gas f l ow, vol ume of t he
system, and t he concent rati on of oxygen in t he f resh gas. Because so many of
t hese are unpredi ctable and uncontrol lable, i t i s necessary t o use an oxygen
analyzer i n the breathi ng system. Oxygen anal yzers are di scussed i n Chapter 22.
Anesthetic Agents
Absorbents can remove volat i le anesthet ic agents by adsorpti on or degradati on.
Thi s can resul t i n sl ower i nducti ons and exposure of subsequent pat i ents to vol at i l e
agents. Dry absorbent removes more agent than wet (205,206,207, 208). The
rel ati onshi p of absorbent and anestheti c agents was discussed earl i er i n this
chapter. The f ol l owi ng inf l uence the concent rat i on of anesthet ic agent i n the
i nspi red mixture: uptake by the pati ent, uptake by components of t he system,
arrangement of system components, uptake and el imi nat i on of other gases by the
pati ent , vol ume of the system, concentrati on i n the f resh gas f low, degradati on by
t he absorbent, and f resh gas f l ow. I t i s not possi bl e to predi ct the concentrat ion
accuratel y unl ess a high f resh gas f l ow i s used. Several devices are now avai l abl e
t o measure the i nspi red anesthetic agent concentrati on (Chapter 22). The greatest
vari ati on occurs duri ng i nducti on, when anestheti c uptake i s high and ni trogen
washout f rom t he pati ent di l utes the gases i n the ci rcui t . For t hi s reason, most
authors recommend t hat anesthesi a be start ed wi th hi gh f resh gas fl ows. The ti me
i nterval unt i l there i s some equil i brati on between i nspi red and end-expi red agent
concentrati ons vari es wi t h t he agent , bei ng mi nimal wi t h desfl urane, i nt ermedi at e
wi th sevof lurane, and greatest wi th i sof lurane (209).
Hi gh f l ows are al so commonl y used at t he end of a case to i ncrease the el i minati on
of anest het i c agent. The rat e of el i mi nati on may be i ncreased by bypassi ng the
absorber (139,210).
When mal i gnant hypert hermia i s suspected, i ncreasi ng the f resh gas f l ow i s the
most i mport ant measure that wi l l ai d i n washi ng out anestheti c agents f rom t he
pati ent . Usi ng a charcoal f i l ter or changi ng the anesthesi a machi ne and breathi ng
system are of l i t t l e or no cl i ni cal advant age (211).
Circle System with Low Fresh Gas Flows
Definitions
Low-fl ow anesthesi a has been vari ousl y def i ned as an i nhalat i on techni que i n whi ch
a ci rcle system wi t h absorbent is used wi th a f resh gas inf l ow of l ess than the
pati ent 's alveol ar mi nute vol ume, l ess than 1 or 1.5 L/ minute), 3 L/minute or less,
0. 5 to 2 L/minute, less than
P. 272

4 L/minute, 500 mL/minute, 500 to 1000 mL/ minute, or 0.5 to 1 L/ mi nute
(212, 213,214,215, 216, 217).
Cl osed system anesthesi a i s a form of l ow-f l ow anesthesi a i n whi ch the f resh gas
f low equal s uptake of anestheti c gases and oxygen by t he pat i ent and system and
gas sampl ing. No gas i s vented through the APL valve.
Equipment
A standard anesthesi a machi ne can be used, but i t must have f l owmeters that wi l l
provi de l ow f l ows.
Vaporizers
Anesthet ic agent can be added to the ci rcl e i n t wo ways.
Calibrated Vaporizers
Vapori zers capabl e of deli veri ng hi gh concent rati ons and t hat are accurate at l ow
f resh gas fl ows are requi red. Vapori zers are discussed in Chapter 6.
Liquid Injection
Anesthet ic l i quid can be injected di rect l y i nto the expi ratory l i mb
(183, 218,219,220). Care must be t aken that onl y smal l amounts are injected at a
t i me and t hat t he syri nge cont aini ng t he l i qui d agent i s not conf used wi t h those
contai ni ng agents f or int ravenous i nject ion. Li qui d agent may cause deteri orat i on of
components i n the syst em (221).
In-circle Vaporizer
I n-system vapori zers are discussed in Chapt er 6. They have been used successful l y
wi th both spont aneous and control led venti l at i on (222,223,224,225).
Monitors
Conti nuous measurement of oxygen concent rat i on should be mandat ory. It is
hel pf ul to moni tor ot her gases and vapors. Wi th si dest ream moni tors, the f resh gas
f low must be increased t o compensate for gases removed by t he moni tor unl ess t he
gases are returned to the breat hi ng system (226).
Techniques
Induction
Anesthet ic i nducti on by using l ow f resh gas f l ows can be accompl i shed by injecti ng
measured amounts of l i qui d anestheti c di rectl y i nto the expi ratory l imb of t he
ci rcui t. Probl ems associ ated wi th t hi s include the f ol lowi ng: (a) l arge body stores of
ni trogen wi l l be rel eased i nto the breathi ng system and wi l l di l ute concentrat ions of
ot her gases; (b) i f ni t rous oxi de i s bei ng used, i t wi l l t ake a prol onged peri od of
t i me t o establ ish concent rat i ons hi gh enough to have a cl i ni cal ef fect; and (c) rapid
uptake of ni trous oxide and vol at i l e agent as wel l as hi gh oxygen consumpt ion
duri ng this peri od mean t hat t he anesthesi a provi der wi l l have t o make f requent
i nj ect ions and adj ustments at a t i me when he or she i s l i kely t o be busy wi t h other
t asks.
More commonl y, i nduct ion i s accompl i shed by using high f l ows to al l ow
deni t rogenati on, est abl ish anestheti c agent concent rati ons, and provide oxygen
wel l i n excess of consumpti on. Duri ng i nt ubat i on, the vapori zer should be l ef t ON
and the f resh gas fl ow turned to minimum or OFF (227, 228). Af t er gas exchange
has stabil i zed, l ower f resh gas f l ows are used.
Maintenance
During maintenance, ni trous oxide and oxygen fl ows and vapori zer set ti ngs shoul d
be adjusted to mai ntain a sat i sf actory oxygen concent rat i on and the desi red level of
anesthesi a. I f cl osed system anesthesi a i s used, a constant ci rcui t vol ume is
achieved by one of the f ol l owi ng methods.
Constant Reservoir Bag Size
I f the bag decreases i n si ze, t he f resh gas f l ow rat e is i ncreased; i f the bag
i ncreases in si ze, the f l ow i s decreased.
Ventilator with Ascending (Upright or Standing) Bellows
Constant volume can be achi eved by adj usti ng the f resh gas f l ow so that the
bel l ows i s bel ow t he t op of i ts housi ng at the end of exhal ati on. I t i s import ant t hat
no negat ive pressure be transmi t ted t o the bel l ows f rom t he scavengi ng syst em, as
t his coul d cause the bel l ows t o be hel d al of t i n the presence of inadequate f resh
gas f l ow (229).
Ventilator with Descending (Inverted or Hanging) Bellows
The f resh gas f low shoul d be adj usted so t hat t he bel l ows j ust reaches t he bot tom
of i ts housing at the end of exhal ati on.
I f a rapi d change i n any component of t he inspi red mi xt ure i s desi red, the f resh gas
f low shoul d be increased. If , f or any reason, t he i ntegri t y of the ci rcl e is broken,
hi gh f l ows wi t h desi red i nspi red concentrat ions should be used for several minutes
before returni ng to l ow f l ows. If closed system anesthesi a i s used, i t i s
recommended t hat hi gh f lows be used f or 1 to 2 mi nutes at l east once an hour t o
el i mi nate gases such as ni trogen and carbon monoxi de that have accumulated i n
t he system.
Emergence
Recovery f rom anesthesi a wi l l be sl ower i f l ow f l ows are used. Hi gh fl ows are
usual l y needed at least bri ef l y to clear ni trous oxide. Coasti ng, in whi ch anestheti c
admi ni st rati on i s stopped toward t he end of the operat i on and the ci rcui t i s
mai ntai ned cl osed wi t h enough oxygen fl ow to mai nt ai n a const ant end-ti dal vol ume
of t he venti l ator or reservoi r bag, can be used. A charcoal f i l ter placed i n t he
i nspi ratory or expi ratory li mb wi l l cause a rapi d decrease i n vol at i l e agent
concentrati on (230).
P. 273


Advantages
Economy
Si gni f i cant savi ngs can be achi eved wi t h l ower f l ows of ni t rous oxi de and oxygen,
but the greatest savings occurs wi th t he potent vol at il e agents
(217, 231,232,233, 234, 235,236, 237, 238,239). These are part l y of f set by i ncreased
absorbent usage, but thi s cost i s smal l . I ndi vi dual f eedback and educat i on
regardi ng vol ati l e agent use are ef fecti ve i n get ti ng anesthesi a provi ders to reduce
f resh gas fl ows (240).
Reduced Operati ng Room Poll uti on
Wi th lower f l ows, t here wi l l be l ess anestheti c agent put i nto t he operati ng room.
However, the use of l ow-f l ow techni ques does not el imi nat e the need f or
scavengi ng, because hi gh f l ows are sti l l necessary at ti mes. Si nce less vol ati l e
agent i s used, vapori zers have to be f i l l ed less f requent l y so that exposure to
anesthet ic vapors during f i l l ing is decreased.
Reduced Environmental Pollution
Fl uorocarbons and ni t rous oxi de att ack t he earth' s ozone l ayer, and ni trous oxide
contri but es to t he greenhouse ef fect (241,242,243,244,245,246, 247). Wi th l ow
f lows, t hese ecol ogi cal dangers are reduced.
Estimati on of Anesthetic Agent Uptake and Oxygen
Consumpti on
I n a cl osed system wi thout si gnif icant l eaks, t he f resh gas fl ow i s matched by the
pati ent 's uptake of oxygen and anestheti c agents (248,249,250, 251). Changes i n
volume may be att ri but ed princi pal l y t o upt ake of oxygen or ni trous oxi de because
t he vol ume contri buted by the potent i nhal ati onal agents is usual l y not si gnif icant .
Buffered Changes in Inspired Concentrations
The l ower the f resh gas f low, the l onger i t takes f or a change in concentrat ion i n
t he f resh gas f l ow to cause a comparable change i n the i nspi red concentrati on.
Heat and Humidity Conservation
Wi th lower gas f l ows, i nspi red humi di t y wi l l be i ncreased, and t he rate of fal l i n
body temperature reduced (178,252,253, 254,255,256). The i nci dence of shiveri ng
i s l owered (257).
Less Danger of Barotrauma
Hi gh pressures i n the breathi ng syst em take l onger t o devel op wi th l ower f l ows.
Disadvantages
More Attention Required
Wi th cl osed syst em anesthesi a, f resh gas f l ow i nto t he system must be kept i n
bal ance wi t h upt ake. Thi s requi res f requent adj ust ments.
Inability to Quickl y Alter I nspired Concentrati ons
The use of l ow f resh gas f l ows prevents the rapid changes i n f resh gas
concentrati on i n the breathi ng system t hat occurs wi th hi gh gas f l ows. As a resul t ,
i t may be more dif f i cul t t o control acute hemodynami c responses (258). Thi s is a
si gni f icant di sadvantage onl y if the user i nsi sts on usi ng low f l ows at al l t i mes. The
cl i nician who uses l ow f l ows shoul d accept t hat when i t i s necessary to change
i nspi red concent rati ons rapi dl y, hi gher f l ows shoul d be used.
Danger of Hypercarbi a
Hypercarbia resul t ing f rom exhausted absorbent, i ncompet ent uni di recti onal val ves,
or t he absorber bei ng l ef t i n t he bypass posi ti on wi l l be greater when l ow f l ows are
used.
Accumulation of Undesirabl e Gases i n the System
The accumulat i on of undesi rabl e gases i s most l i kel y onl y a probl em wi t h closed-
ci rcui t anesthesi a, because l ow f lows provide a cont inuous system f l ush. Wi th
cl osed system anesthesi a, f lushi ng wi th hi gh f resh gas f l ows once an hour wi l l
decrease the concent rat i on of most of t hese subst ances. Al ternat el y, a di verti ng
gas moni t or wi t h t he sample gas scavenged i nstead of being ret urned to the ci rcl e
system can be used t o remove smal l amount s of gas (212).
Carbon Monoxide
Carbon monoxi de f rom the i nteract ion of desi ccated absorbent and anest het i c agent
was di scussed earli er i n thi s chapt er. Since l ow-f l ow anesthesia t ends to preserve
t he moisture content of t he absorbent , i t may protect against t he producti on of
carbon monoxi de resul ti ng f rom desi ccated absorbent (113). However, i f desiccated
absorbent i s present, l ow f lows t end to increase the amount of carbon monoxi de
present i n the system. Carbon monoxi de produced f rom the breakdown of
hemogl obi n or exhal ed by smokers can accumulate i n t he cl osed ci rcl e system
(138, 259).
Acetone, Methane, Hydrogen, and Ethanol
Acetone, met hane, and hydrogen accumul ate during cl osed system anest hesi a
(260, 261,262). However, dangerous l evels are reached onl y af ter hours of cl osed
system anesthesi a (263). Met hane can di sturb i nf rared anal yzers (260,262). The
common i ntoxi cant et hanol can also accumul ate.
Compound A
The safety of usi ng sevofl urane wi th l ow f l ows i s sti l l under i nvesti gat i on. At the
t i me of wri ti ng,
P. 274

t he FDA was st il l recommendi ng that sevof lurane not be used wi t h f resh gas f l ows
of l ess t han 2 L/ mi nute. Thi s recommendat ion has been revi sed t o suggest that fl ow
rates of 1 L/mi nute are acceptabl e but shoul d not exceed 2 mi ni mum al veol ar
concentrati on (MAC)-hours. Some invest i gat ors f eel that Compound A shoul d not be
a real cl i ni cal concern and that restricti ng the use of l ow f resh gas f l ows wi th
sevof lurane cannot be j ustif i ed (45).
Argon
I f oxygen i s suppl i ed f rom an oxygen concent rator (Chapt er 4), there wi l l be an
accumul at ion of argon wi th l ow f resh gas f l ows (264).
Nitrogen
Even wi t h ini t ial deni t rogenat i on, ni t rogen wi l l accumulate i n t he cl osed breathing
ci rcui t (199). If oxygen is bei ng suppl i ed by an oxygen concentrat or, malf uncti on of
one of the concent rators can cause ni trogen t o appear i n the product gas (264).
I nf rared moni tors (Chapter 22) add ai r t o t he sample gas af t er t he sampl e i s
analyzed (212, 265). I f t he gas exhausted i s ret urned to t he breat hi ng system,
ni trogen accumul ati on wi l l be greater than expected.
Other
An acryl i c monomer i s exhal ed when j oi nt prostheses are surgical l y cemented
(266). During thi s peri od, t he system shoul d be vent ed to prevent rebreat hi ng of
t his chemi cal .
Uncertai nty about Inspired Concentrations
One of t he ef f ects of rebreathi ng i s that t he i nspi red concent rati ons cannot be
accuratel y predi cted. However, absol ute or near-absol ute knowl edge of inspi red
anesthet ic agent concent rat ions is not necessary f or safe anesthesia conduct,
because pati ents' responses to drugs vary wi del y.
Faster Absorbent Exhaustion
The l ower the f resh gas f low, the f aster t he absorbent i s exhausted.
Circle System for Pediatric Anesthesia
I t was once bel ieved that small pati ents requi red special breathing ci rcui ts and
venti l ators. However, studies show t hat adul t ci rcl e systems can be used even i n
smal l i nf ants and wi th l ow f resh gas f l ows
(194, 195,235,267, 268, 269,270, 271, 272,273, 274,275,276).
I t i s i mportant not to add devi ces wi th l arge dead space or resistance bet ween the
Y-pi ece and the pat i ent . Use of an HME/f i l ter (Chapter 7) i n this l ocat i on causes the
dead space to be unacceptably hi gh f or t he spontaneous breathing i nf ant (277).
One probl em wi t h the ci rcl e system is i ts l arge gas volume. The compressi on of that
gas makes i t di ff icul t to determi ne the actual mi nut e vent i l at i on that the pat ient is
receivi ng, unl ess measurements are done at t he Y-piece (278). In the past , speci al
pediatric ci rcl e systems wi th smal l absorbers were used. These are no l onger
commerci al l y avai l abl e. What is referred to as a pediatri c ci rcl e syst em today i s
usual l y a st andard absorber assembl y wi th short, smal l -diameter breathing tubes
and a small bag. This al l ows a rapid and easy changeover f rom an adul t to a
pediatric system and al lows use of equi pment wi t h whi ch most anest hesia provi ders
are f ami l iar.
Using the Circle System to Deliver Oxygen
I n some insti tuti ons, suppl ement al oxygen may be del i vered to pati ents by at tachi ng
t he oxygen tubi ng to a mask or nasal prongs to t he Y-pi ece of a ci rcl e system.
St udi es show t hat thi s met hod i s l ess accurat e than use of an auxi l iary f l owmeter
(279). A hazard i s that ni trous oxi de or a vol ati l e agent may be accidental l y
admi ni stered (149). Another disadvantage is that thi s may lead to absorbent
desiccat i on. Al so, the cont inuous posi tive pressure that resul ts may cause
acti vat i on of ai rway pressure al arms. Supplemental oxygen shoul d be del ivered by
using an auxi l i ary f l owmet er or a f l owmet er at tached t o the pi ped oxygen system.
Advantages
Low f resh gas f lows can be used wi t h t he physi ol ogi cal , economi c, and
envi ronmental advant ages of rebreathing.
PaCO
2
depends onl y on venti lati on, not f resh gas f low. It may be t he best
system f or pati ents wi th mal ignant hypert hermi a (280).
Disadvantages
The ci rcl e system is composed of many part s that can be arranged
i ncorrect l y or may malf uncti on and a l arge number of connect i ons t hat can
become di sconnected or l eak.
Some components are di f f i cul t to cl ean. However, modern ci rcl e syst ems are
designed t o make di sassembl y and di si nf ecti on easi er (Fi g. 9.64).
The system is relati vel y bul ky and not easi ly moved.
The compl iance of the ci rcle system i s hi gh compared wi t h other systems.
Thi s may make consi stent vent i lat i on more di f f i cul t than wi th t he Mapl eson D
or F syst ems (281). The trend toward smal ler absorbent cani sters wi l l reduce
t he i nternal vol ume of t he breathing system and reduce t he system
compl i ance.
The use an absorbent may resul t i n f ormat ion of carbon monoxi de or
Compound A.
P. 275



View Figure

Figure 9.64 A,B: Modern circle systems are easier to
disassemble and clean than older ones.

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P. 279


Questions
For the f ol lowing quest ions, sel ect t he correct answer.
1. Concerning degradation of sevoflurane by absorbent,
A. I t i s degraded more as the l ength of the anesthet i c increases
B. More degradati on occurs at l ower t emperat ures
C. More degradati on occurs wi t h lower concent rati ons
D. Desiccated absorbent decreases degradati on
E. Low f resh gas f lows decrease degradat i on
Vi ew Answer2. The most common l ocation for the fresh gas i nlet in the
cl assic ci rcl e system is
A. Just upst ream of the i nspi rat ory unidi recti onal val ve
B. Between the pressure manometer and the absorber
C. Between the i nspi rat ory uni di rect ional val ve and the Y-pi ece
D. Between the spi rometer and the expi ratory uni di recti onal valve
E. Between the i nspi ratory unidi recti onal val ve and the PEEP val ve
Vi ew Answer3. The most common l ocation for the reservoir bag i n the
cl assic ci rcl e system is
A. Just upst ream of the i nspi rat ory unidi recti onal val ve
B. Between the i nspi ratory unidi recti onal val ve and the absorber
C. Between the i nspi rat ory uni di rect ional val ve and the Y-pi ece
D. Between the expi rat ory uni di recti onal val ve and t he absorber
E. Between the Y-pi ece and t he spi romet er
Vi ew Answer4. Which anestheti c agent is associated with the hi ghest
l evel of carbon monoxi de formation?
A. Halot hane
B. Enf l urane
C. I sof l urane
D. Desfl urane
E. Sevof lurane
Vi ew Answer5. Which position of the fresh gas i nlet wi ll not result in
absorbent desiccati on?
A. Between the absorber and the i nspi ratory unidi rect i onal val ve
B. Between the APL valve and the absorber
C. Between the i nspi rat ory uni di rect ional val ve and the Y-pi ece
D. Between the Y-pi ece and the expi rat ory uni di rect i onal val ve
E. Between the expi ratory uni di recti onal val ve and t he APL valve
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 .
6. Whi ch statements correctly refl ect the fl ow through a carbon di oxi de
absorber?
A. Fl ow i s conti nuous
B. I t makes no di ff erence i f the f l ow i s f rom bot tom t o top or f rom t op to bott om
C. Larger canisters do not al l ow more carbon di oxi de absorpti on
D. Absorpti on t akes place fi rst at t he inlet and al ong t he si des of the cani ster
Vi ew Answer7. Baffles i n the absorber
A. I ncrease resistance
B. Separate the absorbent i nto dif f erent compart ments
C. I ncrease t he path of t ravel f or gases i n the absorber
D. Act as a buf f er f or dust and wat er generated i n the cani ster
Vi ew Answer8. Bypassing the absorber
A. I ncreases the i nspi red carbon dioxi de
B. Al l ows the absorbent to be changed during an anestheti c
C. Can be especial l y dangerous when used duri ng low-f l ow anesthesi a
D. Al l ows the absorbent to regenerate
Vi ew Answer9. Which statement(s) concerni ng the size and shape of
granul es in soda li me are correct?
A. Smal l granul es provi de a greater surface area f or absorpt ion
B. Smal l granul es may cause more resi st ance and caki ng
C. Granul es used today range i n si ze bet ween 4 and 8 mesh
D. Smal l granul es decrease channel ing
Vi ew Answer10. Concerni ng the hardness of soda li me granules,
A. I f the granul e is too sof t, i t wi l l f ragment easi l y and produce dust
B. Dust may be bl own i nto system components
C. Dust wi l l i ncrease resi stance and channel i ng
D. A coati ng on t he granul e wi l l produce a f i l m that wi l l adhere to dust part icl es
Vi ew Answer11. The absorbent i n the canister should be changed when
A. Carbon dioxi de appears i n the i nhaled gases
B. There i s no heat producti on wi t h l ow f resh gas f lows
C. Heat i s generated in t he downst ream cani ster
D. Col or change is seen in the downstream canister
Vi ew Answer12. Concerni ng the storage and handli ng of carbon di oxi de
absorbents,
A. They shoul d not be stored at f reezi ng temperatures
B. Absorbent dust can be i rri t at ing t o the eyes, respi ratory t ract , and skin
C. When f i l l ing t he cani ster wi t h absorbent , a smal l space shoul d be l ef t at t he top
D. Absorbent dust wi l l cause the seal s to warp
Vi ew Answer13. Which of the foll owi ng are objecti ves in the arrangement
of components of the circle breathi ng system?
A. Maximal humi di fi cati on of i nspi red gases
B. Low resi stance
C. Mi ni mal consumpti on of carbon dioxi de absorbents
D. Maximal incl usi on of dead space gases in t he inspi red mi xture
Vi ew AnswerP. 280


14. Which position(s) of the APL valve i n the ci rcle system woul d cause
i neffi cient use of the carbon di oxi de absorbent during controll ed venti lati on?
A. Just upst ream of the i nspi rat ory valve
B. Between the i nspi ratory unidi recti onal val ve and the Y-pi ece
C. At t he Y-pi ece
D. Between the exhal at ion unidi recti onal val ve and t he absorber
Vi ew Answer15. If a bacteri al fil ter i s located on the inspi ratory side of a
ci rcle system downstream of the i nspi ratory val ve,
A. The pat ient wi l l be prot ected f rom bacteri al cont aminati on i n the anesthesia
machi ne and components of the breathi ng system
B. I t wi l l catch absorbent dust
C. I f a humi di f i er i s used, i t should be pl aced downstream of thi s f i l t er
D. Use of a fi l ter i n this posi ti on has not been shown t o reduce the i nci dence of
pneumoni a af ter anesthesi a.
Vi ew Answer16. Sources of humi di ty i n the ci rcle breathing system
i ncl ude
A. Neutral i zat ion of carbon di oxi de
B. Water cont ent of the absorbent granul es
C. Exhal ed gases
D. The f resh gas f low
Vi ew Answer17. Which techniques are used duri ng the emergence from
anesthesi a wi th l ow fresh gas flows?
A. Turni ng of f al l anesthet i cs and al l owi ng the pati ent to awaken sl owl y
B. Usi ng a charcoal f i l ter t o remove vol at i l e agents
C. Using hi gh f resh gas f lows t o wash out anesthet ics
D. Bypassing t he absorber i n order t o i ncrease carbon di oxi de
Vi ew Answer18. Humidity i n the circle system i s increased by
A. Low f resh gas f lows
B. A reduct i on of carbon di oxi de out put f rom t he pat i ent
C. I ncreased minute vent i l at ion
D. Cooli ng the canister
Vi ew Answer19. Carbon dioxide i n inspired gases may be caused by
A. Not activating the bypass mechani sm
B. Fai l ure of one or both uni di rect i onal val ves
C. Hi gh f resh gas f l ow
D. Exhausted absorbent
Vi ew Answer20. What equipment is essential for performi ng low-flow
anesthesi a wi th a ci rcle breathing system?
A. An oxygen anal yzer
B. An anesthet i c agent anal yzer
C. Vapori zers wi th accuracy i n the high range of the scal e
D. A venti l ator wi t h a bel l ows that descends on exhalat i on
Vi ew Answer21. Which gases may accumul ate i n the ci rcl e breathing
system during cl osed circle anesthesi a?
A. Carbon monoxi de
B. Acetone
C. Toxi c metabol i t es of anesthet i c agents
D. Hydrogen
Vi ew Answer22. At which locati on(s) i n the ci rcle system wil l a
spi rometer over-read the i nspi red volume?
A. Just upst ream of the i nspi rat ory unidi recti onal val ve
B. Between the pressure manometer and the absorber
C. Between the i nspi rat ory uni di rect ional val ve and the Y-pi ece
D. Between the Y-pi ece and the expi rat ory uni di rect i onal val ve
Vi ew Answer23. Concerni ng uni directional valves,
A. Movement of the disc does not assure competence
B. The disc can obstruct gas f l ow t hrough the valve
C. The val ve on the exhalat i on si de is more l i kel y t o be i ncompet ent
D. Uni di rect ional valves are not posi ti onal and can be operated in a number of
posi t i ons
Vi ew Answer24. What are some of the advantages of low-fl ow
anesthesi a?
A. Less danger of barotrauma
B. Buff eri ng of changes i n i nspi red concentrat ions
C. Conservati on of heat and humi di t y
D. El i mi nati on of the need f or scavengi ng
Vi ew Answer25. Which of the foll owi ng are commonly found in soda
l ime?
A. Sodi um hydroxi de
B. Potassi um hydroxi de
C. Calci um hydroxi de
D. A hardening agent
Vi ew Answer26. Problems wi th hi gh-alkali absorbents include
A. They degrade enfl urane and i sof l urane i n t he normal l y hydrated state
B. They can react wi t h vol at il e agents to form carbon monoxide
C. Carbonic aci d i s an end product of carbon di oxi de absorpti on
D. They are l ess abl e t o absorb carbon di oxi de when the moisture content i s
decreased
Vi ew Answer27. There is no evi dence of carbon monoxide formati on wi th
A. Hi gh-al kal i absorbents
B. Normal l y hydrated soda l ime
C. Low-al kal i absorbents
D. Al kal i -f ree absorbents
Vi ew Answer28. Which factors i ncrease Compound A formati on?
A. Low f resh gas f lows
B. I ncreased absorber temperature
C. Hi gh concentrati ons of sevof lurane
D. Sodium- and potassi um-f ree absorbents
Vi ew Answer29. How can carbon monoxide formation be detected duri ng
an anestheti c?
A. Si gni f icant decrease i n SpO
2

B. Decreased end-ti dal carbon di oxi de
C. Sevof lurane wi l l be di spl ayed as another agent
D. An unusual l y del ayed ri se or unexpect ed decrease in the i nspi red vol ati l e agent
concentrati on
Vi ew Answer30. Which factors contribute to carbon monoxi de formati on?
A. Hi gh f resh gas f l ows
B. Anesthetic agent
C. I ncreased temperature of t he absorbent
D. Desiccated absorbent
Vi ew Answer31. Which procedures wi l l hel p to prevent carbon dioxide
absorbent from becomi ng desiccated?
A. Turni ng of f the f resh gas fl ow af ter each case
B. Turni ng vapori zers OFF when not i n use
C. Checki ng the negative pressure valve i n a cl osed scavengi ng system f or proper
f uncti on
D. Changi ng the top cani st er at l east once a week
Vi ew AnswerP. 281


32. Which statements about changi ng carbon di oxi de absorbent are accurate?
A. I t shoul d be changed when carbon di oxi de is present i n the i nspi red gas
B. Color change is an i ndi cati on of desi ccati on in cani sters t hat have hi gh sodium
and potassi um cont ents
C. I t shoul d be changed when the temperature i n t he downst ream cani ster is higher
t han that i n the upst ream canister
D. When changing a dual cani ster, t he absorbent i n the upst ream cani ster i s t hrown
away, t he downstream canister i s moved to the top posi ti on, and the cani ster wi th
new absorbent is pl aced downstream
Vi ew Answer33. Which of the statements about color i ndi cators are
correct?
A. When col or change shows st rongly, t he absorbent i s at or near exhausti on
B. I ndi cators do not become deact ivat ed if stored i n the dark
C. Absorbents wi thout a st rong base change color wi t h desiccat ion
D. I f the col or change reverses i tsel f , the absorbent is safe t o use
Vi ew Answer34. Which positi on(s) of the reservoir bag i n the classic
ci rcle system woul d result i n exhal ed gases being rebreathed?
A. Between the i nspi ratory unidi recti onal val ve and the Y-pi ece
B. Between the expi ratory uni di recti onal val ve and t he absorber
C. Between the Y-pi ece and the expi rat ory uni di rect i onal val ve
D. Between the absorber and the i nspi rat ory unidi rect i onal val ve
Vi ew Answer35. Potenti al problems with pl acing a fil ter between the
pati ent and the Y-piece i ncl ude
A. I ncreased dead space
B. I ncreased resistance
C. I ncreased ri sk of disconnecti ons
D. I t may al l ow water to ent er t he gas sampl e l i ne
Vi ew Answer36. Which are the potenti al paths of l east resistance i n the
cl assic breathing system used by fresh gas flow into the breathi ng system
whi le the system is not i n use?
A. Through the i nspi rat ory pathway
B. Through the reservoi r bag mount if the reservoi r bag i s removed
C. Through the APL val ve if f ul l y open
D. Through the expi ratory pathway
Vi ew Answer37. Sources of i ncreasi ng ni trogen concentrati ons in a
cl osed ci rcle system i ncl ude
A. A l eak i n the gas sampl e li ne
B. Excreti on by the pat ient
C. Reci rcul ated sample gas
D. Leaks i n the venti l at or bel l ows
Vi ew Answer38. Problems wi th i nduci ng anesthesia by using l ow fresh
gas flows i ncl ude
A. Rapidl y changi ng uptake of ni trous oxi de and vol at i le agent requi res f requent
adj ustments
B. I t t akes a l ong t ime to establ ish adequate ni t rous oxi de concent rati ons i n the
breat hi ng system
C. Large body st ores of ni trogen wi l l be rel eased i nto the breathi ng system
D. I t i s dif f i cul t t o ext ract gas f rom t he system
Vi ew Answer