EQUIPMENT Cat about to undergo surgical

repair of a ruptured diaphragm.

Its lungs are being ventilated
using a Newton valve attached
to a Pneupac Ventipac 5
ventilator

The ins and outs of ventilation

2. Mechanical ventilators ALEX DUGDALE

THIS article discusses some of the commonly available machines that can be used for ventilatory
support of anaesthetised patients. An article in the last issue of In Practice (April 2007, volume 29,
pp 186-193) reviewed physiological aspects of mechanical ventilation. An appreciation of these
factors is important for understanding the features and limitations of the ventilator in use.

VENTILATOR VARIABLES
Variables determined directly or
The main controls available on an anaesthetic ventilator indirectly using an anaesthetic
Alex Dugdale
graduated from relate to the following equation: ventilator
Cambridge in 1990.
She spent six years ■ Breathing frequency
in mixed practice in Minute ventilation
(minute respiratory =
Breathing
x Tidal volume ■ Tidal volume (commonly inspiratory,
Lancashire before rate
undertaking a three- volume) but sometimes expiratory)
year residency in ■ Ratio of inspiratory time:expiratory time (I:E ratio)
anaesthesia and
critical care at the ■ Inspiratory time
It follows that it is only possible to preset two of these
Animal Health Trust ■ Inspiratory flow rate
in Newmarket. She variables because the third is dependent on the first two.
■ Expiratory time
is currently head Hence, a ventilator will not normally have controls for
of the Division ■ Peak inspiratory pressure
of Veterinary
all three variables. For example, the Manley Pulmovent
■ Positive end expiratory pressure (PEEP)
Anaesthesia at MPP and Manley MP3 models (see later) have controls
Liverpool veterinary for tidal volume and minute ventilation (determined by
school. She holds the
RCVS and European setting the fresh gas flow); the breathing rate is deter- Therefore, if there is no breathing (ventilation) rate
College of Veterinary mined by the ventilator. control knob, there should be controls for inspiratory
Anaesthesia and
Analgesia diplomas ■ TIDAL VOLUME is derived as follows: time and expiratory time (or I:E ratio) instead.
in veterinary Overall, this equates to:
anaesthesia.
Inspiratory tidal Inspiratory Inspiratory flow
= x
volume time rate
60
Minute
ventilation
=
Inspiratory Expiratory
x
( Inspiratory
time
x Inspiratory )
flow rate
+
time time
If the ventilator does not have a control knob for tidal
volume, it should have controls for inspiratory time and
inspiratory flow rate instead.
■ BREATHING RATE is derived from the cycle time, which VENTILATOR FUNCTION
equates to the number of complete cycles per minute:
For a ventilator to deliver intermittent breaths, it must be
able to provide the four basic phases of breathing:
Breathing rate = 60
■ End of expiration and beginning of inspiration;
(breaths per Time (seconds) for a
minute) ■ Delivery of inspiration;
complete respiratory cycle
■ End of inspiration and beginning of expiration;
■ Expiratory phase (exhalation is usually passive).
60 These are controlled by the following phase variables:
Breathing rate =
In Practice (2007) (bpm) ■ Triggering variable, which ends expiration and begins
Inspiratory time + Expiratory time
29, 272-282 inspiration;

272 In Practice ● ? !Y 2 0 0 7
■ Cycling variable, which ends inspiration;
■ Limiting variable, which places a maximum (limit)
value on a control variable during delivery of a breath.
The ventilator-dependent control variables, which
can be used to control the phase variables, are:
■ Pressure;
■ Volume;
■ Time;
■ Flow.
DESCRIPTION OF VENTILATORS
Many different classification systems have been described
but, with the advent of modern highly sophisticated venti-
lators, some older systems of classification are not easily
applicable. Some simple ways of distinguishing between
ventilators are given below; of these, the general mode of
operation provides a convenient means of discussing ven-
tilators that might be encountered in the practice setting
(see later). The key, however, is to get to know how the
particular ventilator available within the practice operates.
Triggering variable
Ventilators can be:
■ TIME-TRIGGERED;
■ PATIENT-TRIGGERED. Such systems are activated:
– When a patient makes an inspiratory effort, and the
ventilator senses a drop in pressure (pressure-triggered),
where the operator chooses the trigger sensitivity;
– After a certain volume has been exhaled (volume-trig-
gered), where the trigger volume is set by the operator;
– When the patient finishes an exhalation and the venti-
lator senses the decrease in flow (flow-triggered), where
the operator chooses the trigger flow rate;
■ OPERATOR-TRIGGERED.
The type of triggering helps to determine whether the
breath is spontaneous, assisted or mandatory (see table
on page 191, Part 1).
Cycling variable
The cycling variable refers to the changeover from the
inspiratory phase to the expiratory phase, and can be:
■ VOLUME-CYCLED, where the changeover occurs when a
predetermined volume has been delivered. Note that the
volume leaving the ventilator may not necessarily be the
volume entering the animal’s lungs due to some expan-
sion of compliant tubing/compression of gases and leaks;
■ PRESSURE-CYCLED, where the changeover occurs when
a predetermined inspiratory pressure has been reached;
■ TIME-CYCLED, where the changeover occurs when a
predetermined inspiratory duration has been reached;
■ FLOW-CYCLED, where the changeover occurs when the
inspiratory flow falls to a predetermined flow rate.
Limiting variable
Ventilators can be:
■ PRESSURE-LIMITED;
■ VOLUME-LIMITED;
■ FLOW-LIMITED.
Although these limiting variables can be used to
limit the inspiratory phase, where their value cannot be
exceeded, this does not necessarily mean that inspiration
is terminated – that is, the cycling that terminates inspi-
ration may be controlled by another variable.
Breath waveforms
Delivered breath waveforms (see Part 1), especially for
In Practice ● ? !Y 2 0 0 7
Guidelines for ventilator settings
Aim for normocapnia
■ Tidal volume should be around 6-10-20 ml/kg (lower if there is pulmonary
parenchymal disease)
■ Breathing rate should be eight to 20 breaths per minute (higher if the
lungs are diseased)
■ I:E ratio of 1:2 to 1:3
■ Inspiratory time should be around one second for small animals or just long
enough to allow delivery of tidal volume (longer if the lungs are diseased)
■ Inspiratory flow usually needs to be between 0·25 and 1 litre/second for
small animals (and more for horses)
■ Peak inspiratory pressure (PIP) for healthy animals should be ≤15 to 25 cmH2O
(at the lower end for cats and cattle). Higher pressures may be required for
animals with diseased lungs or where compliance is low or resistance is high
■ PEEP should be 0-5-15 cmH2O, if necessary. It is best to start at about 2 to
3 cmH2O
■ The fraction of inspired oxygen (FiO2 ) should be at least 0·3 for anaesthe-
tised animals
Basic requirements of ventilators
■ Simple to use, and easy to clean and sterilise
■ Robust and portable
■ Efficient/economical to use
■ Versatile and compatible with different (anaesthetic) breathing systems, and
able to be used for a wide range of patient sizes and needs
■ Able to deliver any gas/vapour mixture, as required
■ The facility for humidification of gases, if intended for intensive care use
■ The option of different modes of ventilation, if intended for intensive care
use (see Part 1)
■ Suitable alarms, especially for ‘patient disconnect’ and ‘high airway pressure’
ventilators in the intensive care setting, are described as
either volume- (flow-) controlled or pressure-controlled,
whereby inspiration depends on either the delivery of
a fixed tidal volume over a given time, or on the main-
tenance of a given airway pressure for a given time,
respectively.
Method of operation
■ PRESSURE GENERATORS produce inspiration by gener-
ating a predetermined pressure. The maximum pressure
is lower than that achievable from flow generators (see
below) and, hence, these are sometimes called low pow-
ered ventilators. Weighted bellows tend to produce a con-
stant inflation pressure, while bellows attached to a weak
spring or those using gases stored in a distensible bag
produce a decreasing pressure as the bellows/bag empties.
■ FLOW GENERATORS produce inspiration by deliver-
ing a predetermined flow of gas. They deliver gas under
high pressure (either compressed gas or gas from a bel-
lows compressed by a heavy weight or powerful spring)
through a variable orifice flow-restrictor proximal to the
patient, which determines the flow and pressure wave-
forms delivered. These generators are also referred to as
high powered ventilators.
Source of power
Ventilators can be powered by:
■ Mains electricity;
■ Compressed gas (ie, pneumatic);
273
 ■ A combination of the two – that is, pneumatically
powered, but electronically or microprocessor controlled
(which requires electrical power).

General mode of operation

■ MECHANICAL THUMB;
■ MINUTE VOLUME DIVIDER;
■ BAG SQUEEZER. This can be further classified in terms
of the type of bellows used (ie, how the bellows move
during exhalation):
– Standing/ascending;
– Hanging/descending; Newton valve for use with Pneupac Ventipac ventilators
– Horizontal;
Ascending bellows are said to be safer than descend-
ing bellows if a leak is present because they will fail to
fill, while descending bellows will hang down and seem
to be filling;
■ INTERMITTENT BLOWER.

VENTILATORS FOR VETERINARY

ANAESTHESIA

Newton valve for use with Nuffield series 200 ventilators

MECHANICAL THUMBS
If an Ayre’s T-piece (Mapleson E system) is attached to
the common gas outlet of an anaesthetic machine and
connected to a patient’s endotracheal tube, then simply
occluding the expiratory limb produces inflation of the
patient’s lungs by continuing fresh gas flow from the
anaesthetic machine. Removal of the occlusion allows
the lungs to deflate. By rhythmically repeating this
occlusion/relief procedure, intermittent positive pressure
ventilation (IPPV) can be achieved. This action of the
anaesthetist’s thumb has been mechanised over the years
– primarily in ventilators for use in baby care units. The
Newton valve can function in this mode.
higher driving gas flow from the ventilator, the expira-
tory limb is more effectively occluded and, thus, the
device acts like a thumb occluder, cyclically damming
back gases in the expiratory limb and resulting in infla-
tion of the patient’s lungs, again consequent to the
continued fresh gas flow;
■ BAG SQUEEZER. When the ventilator delivers an even
greater gas flow to the Newton valve, not all of it can

Newton valve
The Newton valve is attached to/driven by another
ventilator (eg, Nuffield series 200 or Pneupac Ventipac).
The patient port is connected via hosing to the expira-
tory limb of a Jackson Rees modified Ayre’s T-piece,
where it replaces the bag. The normal fresh gas flow for
the breathing system is delivered from the anaesthetic
machine to the inspiratory limb. It is suitable for use in
patients up to 10 kg bodyweight.
The Newton valve acts in
Drive gas from ventilator one of three modes, depend-
ing on the flow rate delivered
by the ventilator it is attached
to:
■ PARTIAL THUMB OCCLUDER.
When the ventilator cycli-
cally delivers low flows to the
Newton valve, the pressure
developed inside the valve
Pressure relief valve To the is only low because there is
patient
continual leakage through the
orifice outlet. Therefore, it
cyclically only partially dams
Control back gases in the expiratory
orifice
limb of the T-piece, thus pro-
To air/scavenge ducing small tidal volumes Newton valve (red arrow) connected to a Pneupac Ventipac
depending on the continued 5 ventilator and T-piece hosing. The ventilator requires a
pressurised gas supply, which in this case is provided via
fresh gas flow; a mini-Schrader socket oxygen supply from the anaesthetic
Operation of a Newton valve ■ THUMB OCCLUDER. With a machine (white arrow)

274 In Practice ● ? !Y 2 0 0 7
exit through the orifice. Some gas enters the expira-
tory limb of the T-piece so that cyclical inflation of the
patient’s lungs now depends on gases being driven back-
wards up the expiratory limb rather than on the fresh
gases continuing to enter while the expiratory limb is
blocked off.
Note that the driving gas from the ventilator should
not enter the patient’s lungs, despite mixing with gases
in the expiratory limb. In the bag-squeezer mode, an
elongated expiratory limb on the T-piece may be neces-
sary to prevent rebreathing of carbon dioxide.
Vetronic Small Animal Mark 3 (SAV03)
ventilator
For patients up to 10 kg bodyweight, an SAV03 uses a
T-piece but with a solenoid valve interposed between
the inspiratory and expiratory limbs. The valve allows
continued flow of fresh gases into the patient’s lungs by
occluding the expiratory limb until a chosen preset pres-
sure is reached, at which point exhalation is allowed.
The operator sets the expiratory time to between one
and 30 seconds. The respiratory rate depends on inspira-
tory flow (fresh gas flow) as well as expiratory length.
Ventilation is thus pressure-limited, pressure-cycled and
time-triggered. An adequate seal must be made around
the endotracheal tube for the pressure to increase. If
uncuffed endotracheal tubes are employed, use of a
throat pack can help to reduce ‘leakage’. Alternatively,
the fresh gas flow can be increased to cater for this
leakage.
A low dead space ‘Y’ piece is used for very small
animals (~10 g), with the ventilator again functioning to
block off the expiratory limb until the preset pressure is
reached, at which point exhalation is allowed. A selec-
Vetronic SAV03 set up for (above) a patient weighing about
5 kg and (below) a very small patient (eg, small bird, rodent
or snake)
276
tor switch on the back panel allows the expiratory length
set by the front dial to be reduced by a factor of 5, thus
providing much higher respiratory rates.
MINUTE VOLUME DIVIDERS
Minute volume dividers collect a continuous flow of gas
into a reservoir before delivery to the patient under positive
pressure. The reservoir is ‘pressurised’ either by a weight,
a spring or due to the elastic recoil of the material compris-
ing the reservoir. The fresh gas flow delivered is set to be
the intended minute respiratory volume, which is simply
divided up into the required number of breaths per minute.
These systems are relatively expensive in terms of fresh
gas flow (which may also include anaesthetic vapour).
Some examples still in use in the veterinary setting
are described below.
Manley Pulmovent MPP and Manley MP3 models
Manley Pulmovent MPP and Manley MP3 models are
the last versions of a series of minute volume dividers
that are robust, simple and easy to use, and found favour
in both the anaesthetic and intensive care settings. They
can provide ‘manual’ or ‘automatic’ ventilation. In man-
ual mode, spontaneous ventilation is allowed, with the
system acting as a Mapleson D system, which requires
appropriate high fresh gas flows to prevent rebreathing.
In this mode, the pop-off valve may be closed transient-
ly and the bag squeezed manually to deliver a breath. In
automatic mode, the bag port and normal pop-off valve
are bypassed. The fresh gas flow delivered (eg, from the
anaesthetic machine) is the estimated minute ventilation
(around 200 ml/kg/minute).
The tidal volume (eg, 10 to 20 ml/kg) in the MPP
model is adjusted by turning the tidal volume knob; in
the MP3 model it is determined by the position of the
catch on the lever arm of the main bellows. The tidal
volume, along with the fresh gas flow, helps to deter-
mine the ventilation rate. Each full turn of the knob
increases the tidal volume by 100 ml. The range of tidal
volumes available is 100 to 1000 ml for the MPP model,
and 200 to 1000 ml for the MP3 model.
Manley Pulmovent MPP (above) and Manley
MP3 (below) ventilators
In Practice ● ? !Y 2 0 0 7
Manley MPP with manual
mode selected (red arrows).
If the pop-off valve is
closed, manual compression
of the bag leads to inflation
of the patient’s lungs.
Scavenging is carried out
from the pop-off valve
(white arrow)

The inspiratory pressure in the MP3 model can

be altered by adjusting the position of the weight on
the bellows; the manometer is observed to help adjust
the weight position to avoid delivering excessive pres-
sures. The position of the weight also helps to deter-
mine inspiratory flow, although there is a knob to help
control this. These settings can affect inspiratory time
and therefore the I:E ratio and, to some extent, the
ventilation rate.
Manley MP3 with manual mode selected (red arrows).
The pop-off valve must be closed (white arrow) to deliver
a breath to the patient’s lungs when the bag is squeezed.
Scavenging is accomplished from the side port (green
arrow) in both manual and automatic modes, as gases
are ducted here from the visible pop-off valve, as well
as the ventilator’s internal valve

The storage bellows (inside the box) fills during

inspiration when the main bellows empties towards
the patient’s lungs. Inspiration ends when the storage
bellows is full so that, during expiration, the storage
bellows empties into the main bellows. The main bellows
is visible in the MP3 model, but not in the MPP model.
Cycling depends on filling of the storage bellows. This
is established by the time taken to reach the predetermined
volume, which can be affected by the fresh gas flow (a fast
flow means the bellows fills quicker, which shortens the
inspiratory time). The position of the inspiratory flow con-
trol can also affect the duration of the inspiratory phase. It
is therefore sometimes difficult to ascertain the principal
determinant of the cycling, although some authors pro-
nounce that volume cycling is the main mechanism!
Expiration ends and inspiration begins when the main
bellows has filled to a predetermined volume (adjusted
using the tidal volume knob or lever) and is therefore

Manley MPP with automatic mode selected (red arrows).

The pop-off valve and bag are bypassed, so scavenging
must occur via a different valve (green arrow)

Manley MP3 with automatic mode selected (red arrows).

Hoses and a bag are attached, and scavenging is carried Manley MPP ventilator set up for automatic ventilation
out via the side port (green arrow) with a scavenging system attached

278 In Practice ● ? !Y 2 0 0 7
considered primarily to be volume-triggered. Although
the tidal volume chosen determines the degree of filling
of the main bellows as well as the storage bellows, these
volumes are not exactly the same because some of the
fresh gas flow enters the main bellows too.
Flomasta
The Flomasta is a minute volume divider that attaches
to the common gas outlet of an anaesthetic machine.
The main control knob (housing several valves) allows
the operator to choose between spontaneous, manual or
automatic modes. Using the automatic mode, the opera-
tor can choose one of five positions that essentially
determine the inflation pressure and therefore volume
of the bag. The reservoir bag is enclosed in a harness
partly to avoid overdistension and partly to ensure that
adequate pressures/volumes are reached.
In automatic mode, the bag fills with fresh gas until
the pressure is sufficient to open a valve (against a spring
that is tensioned to predetermined positions 1 to 5).
Inspiration ends when the inspiratory pressure falls low
enough to allow the spring tension to close this valve,
thus initiating expiration. The tidal volume and ventila-
tion rate depend on the fresh gas flow and the control
position (1 to 5). At the same fresh gas flow (minute ven-
tilation), the tidal volume and ventilation rate are both
affected by altering the position of the control knob.
However, the tidal volume delivered to the patient’s
lungs also depends on the compliance/resistance of the
patient’s respiratory system and the compliance of the
reservoir bag, so these factors can indirectly affect the
ventilation rate too. The fresh gas flow itself may influ-
ence the tidal volume as the fresh gases can push against
the valve during inspiration.
The pressure/volume characteristics of black rubber
bags change as they become more compliant with use.
Therefore, with time, more fresh gases are required to
fill the bag to a sufficient pressure to open the inspira-
tory valve, and so the delivered tidal volume tends to
be increased as well. Eventually, if the bag becomes
too compliant, such that the pressure within it fails
to increase sufficiently, IPPV will cease to occur.
Consequently, the bag’s expansion is limited to about 5
litres by the enclosing harness, which prevents it over-
stretching and rapidly increasing its compliance. Also,
even if its compliance is increased, the harness (which
is minimally stretchy) will allow an eventual pressure
increase within the bag to ensure continued ventilation.
The changeover from inspiration to expiration is a
composite of pressure- and flow-cycling. Inspiration is
said to be time-triggered, but not in the traditional sense
because the patient’s respiratory system characteris-
tics also affect the delivered tidal volume and hence the
ventilation rate.
BAG SQUEEZERS
Bag squeezers are the most common type of ventilators
used for anaesthetised patients. The ventilator is con-
nected to the expiratory limb of a Mapleson E system, or
to the bag port of either a Mapleson D non-rebreathing
system (Bain) or circle rebreathing system.
The most familiar form of these ventilators is the ‘bag
(bellows) in a bottle’ arrangement. The bellows is placed
into an airtight perspex cylinder and high-pressure driv-
ing gas is forced into the space between the canister and
bellows. The bellows may be ascending, descending or
In Practice ● ? !Y 2 0 0 7
This anaesthetised dog’s
lungs are being ventilated
horizontal. Ascending bellows, which rise during exha- using a Flomasta.
Picture, Liz Leece
lation, are said to alert the operator to a bellows leak
by virtue of the bellows failing to fill. However, rising
bellows are also thought to add resistance to exhalation,
but whether this additionally provides some beneficial
PEEP is controversial. Descending bellows do not allow
easy detection of leaks in the bellows and are also full
of air before patient connection, which should ideally be
purged from the system before use.
The bellows may otherwise be inflated and deflated by
some form of pneumatic piston or by mechanical squeez-
ing/releasing using a motor-driven piston with linear or
rotary (cam-driven) linkage.
Rather than being used to drive a pneumatic pis-
ton, which, in turn, drives the bellows, the bellows can
be removed and the drive gas itself used to force gases
into the patient’s breathing system and lungs. A suitable
length of wide-bore hosing is needed to link the ventilator
to the bag port of the patient’s breathing system so that
drive gases and patient gases do not mix. Although there
is no physical separation of the gases, if used correctly,
the drive gases do not mix with, and potentially dilute,
the patient’s gases. The Newton valve, when set at high
ventilator flow rates, operates in this manner – hence, its
bag-squeezer mode of action. Pneupac Ventipac 5 and 10,
and the Nuffield series 200 ventilators connected to adult
valves both function in this way. However, they are also
referred to as intermittent blowers (see below).
Hallowell EMC ventilators
Hallowell Engineering and Manufacturing Corporation
(EMC) Small Animal Anesthesia Ventilator mod-
els 2000 and 2002 differ mainly in that the 2002 sys-
tem includes fine and coarse controls for tidal volume.
Otherwise, they function in a similar fashion. IPPV is
time-cycled and pressure-limited. The pressure limit
can be set to between 10 and 60 cmH2O to ensure
patient safety. Should the set pressure be exceeded,
an audible alarm sounds. This alarm also sounds if
6 cmH2O pressure is not reached (ie, if the patient’s
breathing system becomes disconnected).
Three sizes of ascending bellows and bellows hous-
ings are available, all of which are easily interchange-
able via a twist lock on/off system. The smallest bellows
provides tidal volumes of 20 to 300 ml and is suitable
for animals weighing between 1 and 25 kg. The interme-
279
diate-sized bellows provides tidal volumes of between
300 and 1600 ml and is suitable for animals weighing
between 20 and 120 kg. The largest bellows provides
tidal volumes of up to 3000 ml and is suitable for
animals of up to about 200 kg bodyweight.
The tidal volume is determined by turning a knob on
the control panel, which also includes a dial that adjusts
respiratory rates to between six and 40 breaths per minute.
The bellows can be easily attached, via a piece of
hosing, to the bag port of a circle rebreathing system or
a Bain non-rebreathing system.
JD-Bird Equine Ventilator
Bird ventilators are intermittent blowers. However, the
JD-Bird Equine Ventilator may be used to drive bag-
squeezer type ventilators. This is a pressure-cycled,
pressure-limited pneumatically driven flow generator
(above) Medium-sized bellows connected to a Hallowell
EMC 2000 system to provide IPPV via a circle. (below) The
same set-up viewed from behind. Note that the ventilator
hose passes from the bellows to the bag port of the circle
(yellow arrow). The pop-off valve (red arrow) is closed
and scavenging is carried out via the exhaust port (green
arrow). In this case, oxygen is being used as the drive gas
(white hose)
280
that can be used to provide mandatory IPPV or assisted
ventilation (see below).
INTERMITTENT BLOWERS
Intermittent blowers need a pressurised gas source to
drive them. An electronically timed and activated pro-
portional flow valve or a pneumatically timed oscillator
divides the driving gas up into tidal volumes of a set size
and rate. Anaesthetic ventilators tend to use pneumatic
oscillators, while more sophisticated intensive care ven-
tilators use proportional flow valves. Pneupac Ventipac
5 and 10 systems, and Nuffield series 200 ventilators are
examples of the former. Control knobs usually include
inspiratory flow and time, which determine tidal vol-
ume, as well as expiratory time, which helps to deter-
mine ventilation rate and I:E ratio. They are time-cycled,
with the tidal volume delivered depending on the chosen
Small bellows connected to a Hallowell EMC 2000
ventilator via the bag port of an anaesthetic breathing
system (eg, Bain)
Bellows mounting
In Practice ● ? !Y 2 0 0 7
inspiratory time and inspiratory flow. Ventilation rate is
determined by the inspiratory and expiratory times. The
side panels on the Ventipac ventilators display charts that
allow ‘ready-reckoning’ and, if necessary, adjustment of
values to set for required tidal volumes and I:E ratios.

Merlin Small Animal Ventilator

The Merlin ventilator can be time-, volume- or pressure-
cycled. IPPV can be pressure-limited during volume-cycled
ventilation. This ventilator has a microprocessor-controlled
precision piston, which is driven by solenoid valves.
Tidal volumes of between 1 and 800 ml can be deliv-
ered making it suitable for patients from 50 g to 70 kg.
Inspiratory and expiratory times can be altered inde-
pendently and without the need to change fresh gas flow
or tidal volume. Peak inspiratory pressure can be limited
to between 1 and 57 cmH2O in 1 cmH2O increments.

Circle showing the bag disconnected, and the bellows in a

chamber connected instead. The pop-off valve of the circle
is closed, so scavenging is achieved via the exhaust valve
(green arrow) above the bellows chamber

Circle in use for spontaneous breathing, where the bag is

connected instead of the bellows. Scavenging is achieved
using the pop-off valve (green arrow)

Burtons LDS 3000 large animal anaesthesia

machine being used for spontaneous
ventilation. Picture, Burtons

Equivent system set up for use. This is a

Equine ventilator using a Bird modified Mark 7 to drive
bellows in a bottle. The one-way valves of the circle are
concealed within the Y piece
Burtons Equivent large animal anaesthesia
system with LDS 3000 and DHV 1000.
Picture, Burtons
pneumatically powered, microprocessor-
controlled, pressure-limited, time-cycled
ventilator. Controls for inspiratory time
and flow determine the tidal volume
delivered, which is limited by pressure.
Picture, Burtons

In Practice ● ? !Y 2 0 0 7 281
 Merlin Small Animal Ventilator. Picture, Vetronic Services
The inspiratory flow rate can be set to between 100 ml/
minute and 25 litre/minute. As the airway pressure and
volume delivered are measured, compliance is calculated
and displayed. A PEEP valve is also easy to use with this
ventilator.
Pneupac Ventipac 5
ventilator with adult valve
attached (blue arrow).
The hose (yellow arrow) is
connected to the bag port
of an anaesthetic breathing
system. Scavenging is
achieved by a different
port (green arrow)
(above) Nuffield series 200 ventilator with an adult valve
attached (blue arrow). Sufficient wide-bore hosing (yellow
arrow) should connect the ventilator to the bag port of
the breathing system to prevent drive gas from diluting
the anaesthetic gases. The green arrow indicates the port
from which scavenging is achieved. (below) Nuffield series
200 ventilator with an adult valve attached via wide-bore
tubing to the bag port of the circle. The circle’s pop-off
valve is closed, and scavenging is achieved via the exhaust
valve (green arrow) of the ventilator
282
Bird modified Mark 7 ventilator. The inspiratory pressure
control lever (blue arrow) is used to set the pressure
to cycle and limit inspiration, which helps to determine
the tidal volume delivered. The sensitivity control (black
arrow) can be set to determine what effort the patient
must make before the ventilator assists the breath and
can be used to determine whether ventilation is assisted
or fully controlled. The inspiratory flow rate control (yellow
arrow) sets the flow to zero when fully rotated ‘in’, which
effectively turns the ventilator off. Another dial (red
arrow), which controls expiratory time, will also effectively
switch the ventilator off if the expiratory time is greatly
lengthened
An inspiratory assist control, which covers a range of
pressures between –1 and –10 cmH2O, allows weaning
from the ventilator. The system also has audible alarms
and on-screen displays to alert the operator in the case
of disconnection or overpressure. In the event of power
failure, all valves open to allow manual IPPV.
Bird ventilators
First generation Bird Mark 7 ventilators are one of a
series of pneumatically powered ventilators that can be
used to ventilate intensive care patients directly, or anaes-
thetised patients by driving a bellows in a bottle in the
same way as the JD-Bird Equine Ventilator. Bird venti-
lators can be time-, pressure- or manually triggered and
are pressure-cycled. Peak inspiratory pressure is set
to cycle and limit the inspiratory phase and, therefore,
along with the patient’s respiratory system characteris-
tics, determines the delivered tidal volume. A pneumati-
cally driven expiratory timing device helps to control the
ventilation rate. Trigger sensitivity can be set for patient-
triggered breaths. Inspiratory flow can be controlled and
will also affect the ventilation rate and I:E ratio.
When the air–mix control is pushed in, oxygen from
the anaesthetic machine is delivered to the patient. A rec-
tangular waveform showing a constant flow pattern is pro-
duced throughout inspiration with an ascending pressure
waveform (see Part 1). With the air–mix control pulled out,
air can be entrained via a Venturi, so that less than 100 per
cent oxygen is delivered to the patient. A descending flow
pattern waveform is produced, with a variable (ascend-
ing to rectangular) pressure waveform depending on the
patient’s respiratory system compliance and resistance.
SUMMARY
This two-part article has aimed to demystify some of
the medical terminology surrounding ventilation and
mechanical ventilators. Hopefully, the information will
help general practitioners build up their confidence in
recognising those patients requiring ventilatory support
and selecting the most appropriate ventilators and venti-
lator settings.
In Practice ● ? !Y 2 0 0 7