BREATHING SYSTEMS 3-1

Anesthetic Breathing Systems

• Insufflation: The blowing of gases across a patient’s face (e.g., via a facemask). There is no permanent
connection between the breathing circuit and the patient’s airway. If fresh gas flow rates are high enough
(>10 L/min), very little rebreathing of gases occurs.
• Draw-over anesthesia: Draw-over devices have nonrebreathing circuits that use ambient air or supplemen-
tal oxygen as the carrier gas. Air is drawn through a low-resistance vaporizer as the patient inspires. The
fraction of inspired oxygen (FIO2) can be supplemented using an open-ended reservoir tube attached to a
t-piece at the upstream side of the vaporizer. The devices can be fitted with connections and equipment that
allow intermittent positive-pressure ventilation, continuous positive airway pressure, and positive end-
expiratory pressure. The greatest advantage of the draw-over systems is their simplicity and portability; they
are useful in places where compressed gases or ventilators are not available.
• Mapleson circuits: Incorporate breathing tubes, fresh gas inlets, adjustable pressure-limiting (APL) valves,
and reservoir bags into the breathing circuit for greater control of gas delivery. The relative location of these
components determines circuit performance and is the basis of the Mapleson classification system.
BREATHING SYSTEMS 3-2

Anesthetic Breathing Systems

• Disadvantages of insufflation and draw-over systems: Poor control of inspired gas concentration and
depth of anesthesia, difficult airway management during head and neck surgery, and pollution of the operat-
ing room with large volumes of waste gas with inability to scavenge waste gas.
• Mapleson classification:
Mapleson A: Expiratory valve is close to a facemask separated by a corrugated tube from a reservoir bag
and supply of fresh gases.
Mapleson B: Expiratory valve and supply of fresh gases are close to the facemask separated by a corrugated
tube from a reservoir bag.
Mapleson C: Expiratory valve, supply of fresh gases, and a reservoir bag are all close to the facemask; there
is no corrugated tube.
Mapleson D: Supply of fresh gases is close to the facemask separated by corrugated tube from the reservoir
bag and expiratory valve.
Mapleson E: Supply of fresh gases is close to the face mask. There is an open length of corrugated tube
(i.e., no connections). There is no reservoir bag or expiratory valve.
Mapleson F: Supply of fresh gases is close to face mask, which is separated by a corrugated tube from a
reservoir bag with an expiratory port, but no expiratory valve.
BREATHING SYSTEMS 3-3

Components of Mapleson Circuits

• Breathing tubes: Made of rubber or plastic; connect the patient to the Mapleson circuit. Large-diameter
tubing is often used to ensure low resistance.
• Fresh gas inlet: The point of entry of anesthetic gases and oxygen into the Mapleson circuit. The relative
positioning of the fresh gas inlet is a key differentiating factor in determining the Mapleson classification
and system performance.
• Reservoir bag: Function as a reservoir of anesthetic gas and a method of generating positive-pressure ven-
tilation. They are designed to have high compliance.
• Adjustable pressure-limiting (APL) valve: An expiratory valve that allows for exit of gases from the cir-
cuit. It allows for a variable pressure threshold for venting gases from the circuit. Partial closure of the APL
valve limits gas exit, thus permitting positive pressures during reservoir bag compressions.
BREATHING SYSTEMS 3-4

Components of the Circle System

• Fresh gas inlet: the point of entry of anesthetic gases and oxygen into the circle system.
• CO2 absorber: allows for removal of CO2 from alveolar gas so that rebreathing can safely occur, thus con-
serving heat and humidity.
• Inspiratory unidirectional valve with inspiratory breathing tube (inspiratory limb): opens to allow entry of
fresh gas to the patient during inspiration without backflow to the machine side of the circuit.
• Expiratory unidirectional valve with expiratory breathing tube (expiratory limb): opens to allow egress of
expired gases without backflow to the patient side of the circuit.
• Y-connector: located near the patient, the point where the inspiratory and expiratory tubing limbs converge.
• Adjustable pressure limiting (APL) valve: a variable pressure threshold valve that is placed between the CO2
absorber and the unidirectional expiratory valve, and closely to the reservoir bag.
• Reservoir bag: function as a reservoir of anesthetic gas and a method of generating positive-pressure venti-
lation. They are designed to have high compliance.
BREATHING SYSTEMS 3-5

CO2 Absorber Systems

• CO2 combines with water to form carbonic acid. CO2 absorbents such as soda lime, calcium hydroxide lime,
and Amsorb contain hydroxide salts that neutralize carbonic acid. The end products of this reaction include
heat (the heat of neutralization), water, and calcium carbonate.
• The most commonly used CO2 absorber is soda lime. It is capable of absorbing up to 23 L of CO2 per 100 g
of absorbent. It consists primarily of calcium hydroxide (80%) along with sodium hydroxide, water, and a
small amount of potassium hydroxide.
• Barium hydroxide lime is no longer used as a CO2 absorbent because of a risk of fire in the breathing system.
• Amsorb is a CO2 absorbent consisting of calcium hydroxide and calcium chloride with calcium sulfate and
polyvinylpyrrolidone added to increase hardness. It possesses greater inertness than soda lime, resulting in
less degradation of the volatile anesthetics.
BREATHING SYSTEMS 3-6

CO2 Absorber Systems

• Color conversion of a pH indicator dye (e.g., ethyl violet from white to purple) by increasing hydrogen ion
concentration signals absorbent exhaustion. Absorbent should be replaced when 50% to 70% has changed
color.
• Hydroxide salts are irritating to the skin and mucous membranes. Increasing the hardness of soda lime by
adding silica minimizes the risk of inhalation of sodium hydroxide dust and decreases resistance of gas flow.
• Absorbent granules can absorb and later release significant amounts of volatile anesthetic. This can contrib-
ute to delayed induction or emergence. The drier the soda lime, the more likely it will absorb and degrade
volatile anesthetics.
• Volatile anesthetics can be broken down to carbon monoxide by dry absorbent (e.g., sodium or potassium
hydroxide). The formation of carbon monoxide is highest with desflurane.
• Compound A is a byproduct of degradation of sevoflurane by absorbent. Higher concentrations of sevoflu-
rane, prolonged exposure, and low-flow anesthetic technique appear to increase the formation of compound
A. Compound A has been shown to be nephrotoxic in animal models.