Anesthesia Machine

2011
Dr Azam's Notes in Anesthesiology

– Second Edition
Machine & Instruments
Dr. Mohammed Azam Danish

Consultant Anesthesiologist & Critical Care Specialist
www.DrAzam.com
Dr Azam's Notes In Anesthesiology 2010
-Second Edition
Dr Azam’s Notes in Anesthesiology

2nd Edition
Machines & Instruments

By
Dr. Azam
Consultant Anesthesiologist & Critical Care
www.DrAzam.com Machine & Instruments

-Second Edition
PREFACE
This book grew from notes first written in 2003 - 2004 for the students at the J J M
Medical College in Davangere.
There are many textbooks to choose from when preparing for the “Anesthesiology
examination”. The candidate suffers not from the lack of information but rather from
being inundated with it. The candidate then has the task of information sorting and data
compression to memorize and utilize all this information.
Graphic representation of data is an excellent form of data compression; figures or

drawings are frequently asked about at the viva examination, particularly since the
candidate’s understanding of a problem comes across most clearly when drawing a
figure or a using a picture. Figures are also a good way of approaching a topic.
I constructed parts of Dr Azam’s Notes in Anesthesiology for Postgraduate students

when preparing for the Anesthesiology examination and later when preparing for
tutorials.
Dr Azam’s Notes is aimed primarily at trainees in Anesthesia though more experienced

practitioners may find it useful as a refresher in recent concepts and advances
Dr Azam’s Notes is not a substitute for the major anesthesiology text books but
concentrates on principles of management of the most challenging anesthetic cases.
The format is designed to provide easy access to information presented in a concise

manner. I have tried to eliminate all superfluous material. Selected important or
controversial references are presented as well as suggestions for further reading. Some
relate more to basic principles, physiology, pharmacology, etc. – bookwork. Others are
more practical in nature, discussing the principles of anesthetic techniques for certain
high-risk situations.
Dr Azam’s Notes have been created keeping the Postgraduate needs while preparing
for the exams, and also help in his day to day practice. I am sure that Dr Azam’s Notes
will not only help him to secure highest marks but also help him to gain knowledge to
its full.

-Second Edition
A NOTE TO THE READER
Anesthesiology is an ever-changing field. Standard safety precautions must be followed,

but as new research and clinical experience broaden our knowledge, changes in
treatment and drug therapy may become necessary or appropriate. Readers are advised
to check the most current product information provided by the manufacturer of each
drug to be administered to verify the recommended dose, the method and duration of
administration, and contraindications.
However, in view of the possibility of human error or changes in medical sciences,

neither the author nor the publisher nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein
is in every respect accurate or complete, and they disclaim all responsibility for any
errors or omissions or for the results obtained from use of the information contained in
this work. Readers are encouraged to confirm the information contained herein with
other sources. It is the responsibility of the licensed prescriber, relying on experience
and knowledge of the patient, to determine dosages and the best treatment for each
individual patient. Neither the publisher nor the editor assumes any liability for any injury
and/or damage to persons or property arising from this publication.

-Second Edition
DEDICATION
To Mohammed Shafiulla, my father, my oxygen,

companion, and best friend; for being my major pillar of
support and making this vision a reality. Thank you for your
continual sacrifices with boundless love and limitless
gratitude, for the sake of your children. I owe you a debt I can
never repay.
I also would like to thank my mom (Naaz Shafi), my wife

(Roohi Azam), my two lovely kids (Falaq Zohaa &
Mohammed Izaan),for their support, ideas, patience, and
encouragement during the many hours of writing this book.
I also thank my Colleagues Dr Rajshekar Reddy & Dr Sachin for

their support.
Finally, I would like to thank my teachers. The dream begins

with a teacher who believes in you, who tugs and pushes and
leads you to the next plateau, sometimes poking you with a
sharp stick called "truth."

-Second Edition
Contributions
01. Dr. Rajshekar Reddy – UAE
02. Dr. Surendra – UAE
03. Dr. Nagaraj Chandy – Hubli
04. Dr.Kusuma – Bangalore
05. Dr Sachin Doijode – London
06. Dr Chandrashekar – Bangalore
07. Dr Sidhu – Bangalore
08. Dr Ravindra B K – Bangalore
09. Dr Harshavardhan – Mangalore
10. Dr Anil Kumar – Tamil Nadu
11. Dr Mashooda – Kerla
12. Dr Anusuya – Bangalore
13. Dr Sudhir – Bangalore
14. Dr Uma – Davangere
15. Dr Rajeev – UAE
16. Dr Surendra – UAE
17. Dr Shivananda – Shimoga
18. Dr Soujanya – Bangalore
19. Dr Aslam Faris – Kerla
20. Dr Nandakumar – Tamil Nadu
21. Dr Anuradha – Bangalore
22. Dr Arun G Pai – Kerla
23. Dr Geetha – Bangalore

-Second Edition
Table of Contents
PREFACE .......................................................................................................................................................... 3
DEDICATION .................................................................................................................................................... 5
CHAPTER 1 - HISTORY OF ANESTHESIA MACHINE .......................................................................................... 16
CLASSIFICATION: ................................................................................................................................................... 16
CHAPTER 2 - BOYLE’S APPARATUS – MAJOR AND MINOR .............................................................................. 18
Types ........................................................................................................................................................... 18
TYPES OF MACHINE .......................................................................................................................................... 18
DIFFERENCES: ...................................................................................................................................................... 18
CHAPTER 3 - MEDICAL GAS CYLINDERS .......................................................................................................... 20
MEDICAL GAS CYLINDER: ....................................................................................................................................... 20

COMPONENTS OF CYLINDER: ................................................................................................................................... 20
TESTING: ............................................................................................................................................................. 22
Types of tests are ........................................................................................................................................ 22
COLOR: ............................................................................................................................................................... 22
Oxygen Tanks: ............................................................................................................................................. 23
CHARACTERISTICS OF LIQUID MEDICAL OXYGEN: .......................................................................................................... 23
RULES FOR SAFE USE OF CYLINDERS: .......................................................................................................................... 25
CHAPTER 4 -PRESSURE SYSTEMS .................................................................................................................... 29
MACHINE IS DIVIDED INTO 3 PARTS: ......................................................................................................................... 29

High Pressure System: ................................................................................................................................. 29
CHAPTER 5 - PRESSURE GAUGES .................................................................................................................... 31
BOURDON’S GAUGE ......................................................................................................................................... 31

Mechanism: ................................................................................................................................................. 32
Requirements: ............................................................................................................................................. 32
Safety features: ........................................................................................................................................... 32
LOW PRESSURE ANEROID GAUGE: .............................................................................................................. 33
CHAPTER 6 - YOKE ASSEMBLY ........................................................................................................................ 34
CHAPTER 7 - PRESSURE REGULATOR / REDUCING VALVE ............................................................................... 36
TYPES: ................................................................................................................................................................ 36
Working Principle: ....................................................................................................................................... 36
CHAPTER 8 - OXYGEN FAILURE DEVICES: ........................................................................................................ 39
OXYGEN FAILURE SAFETY DEVICE: ............................................................................................................................ 39

-Second Edition
Types: .......................................................................................................................................................... 39
Oxygen Failure Alarms: ............................................................................................................................... 39
CHAPTER 9 - FLOW METERS ........................................................................................................................... 43
TYPES: ................................................................................................................................................................ 43
FLOW INDICATOR ASSEMBLY CONSISTS OF: ................................................................................................................. 43
Tube: (Thorpe tube) .................................................................................................................................... 43
ARRANGEMENTS OF FLOW METER TUBE: ........................................................................................................ 46
OTHER TYPES OF FLOW METERS: .............................................................................................................................. 46
CHAPTER 10 - SAFETY DEVICES....................................................................................................................... 48
TYPES USED ARE: .................................................................................................................................................. 48

OXYGEN RATIO MONITOR (ORM) .................................................................................................................... 48
OXYGEN RATIO MONITER CONTROLLER (ORMC) ............................................................................................. 48
LINK – 25 CONTROL SYSTEMS ........................................................................................................................... 49
BACK BAR .................................................................................................................................................... 49
UNIDIRECTIONAL VALVE (BACK FLOW CHECK VALVE)...................................................................................... 49
Causes for Back Pressure are: ..................................................................................................................... 49
PRESSURE RELIEF VALVE ............................................................................................................................. 50
STATIC ELECTRICITY: .................................................................................................................................... 50
OXYGEN ANALYZER .......................................................................................................................................... 50
COMMON GAS OUTLET .................................................................................................................................... 51
CONTINUOUS FLOW ANSESTHESIA MACHINE ............................................................................................ 51
CHAPTER 11 - CHECK LIST BEFORE USING MACHINE ...................................................................................... 52
HIGH PRESSURE SYSTEM: ....................................................................................................................................... 52

LOW PRESSURE SYSTEM: ........................................................................................................................................ 52
Modifications in Boyle mark III S: ................................................................................................................ 53
CHAPTER 12 - SAFETY FEATURES IN ANESTHETIC MACHINE ........................................................................... 54
AIMED AT AVOIDING THE FOLLOWING HAZARDS: ......................................................................................................... 54

TO PREVENT DELIVERY OF HYPOXIC MIXTURES .......................................................................................... 54
TO PREVENT DELIVERY OF EXCESSIVE ANESTHETIC CONCENTERATION ..................................................... 55
TO PREVENT EXCESSIVE PRESSURES ON MACHINE ..................................................................................... 55
CHAPTER 13 - SAFETY FEATURES IN ANESTHETIC MACHINES (CME) ............................................................... 56
CHRONOLOGY OF “INTRODUCTION OF MAJOR SAFETY FEATURES” FOR THE ANESTHESIA MACHINE: ........................................ 56
1950-1060: Pin index safety system. .......................................................................................................... 56
1960-1970: Ventilator pressure relief system ............................................................................................. 56
1970-1980: Ventilator low pressure disconnection .................................................................................... 56
1980-1990: ANTI DISCONNECT FITTING ON FRESH GAS OUTLET .................................................................................... 57
CONSIDERATION OF INDIVIDUAL SAFETY FEATURES: ...................................................................................... 57
TO THE O.T. PERSONNEL: ............................................................................................................................ 57
PIN INDEX ......................................................................................................................................................... 58
MAINTENANCE OF ANESTHESIA EQUIPMENT ............................................................................................. 63

-Second Edition
CHAPTER 14 - ELECTRICAL HAZARDS IN OPERATION THEATRE ....................................................................... 65
THE MAGNITUDE OF DAMAGE DEPENDS UPON: ........................................................................................................... 65
CHAPTER 15 - MONITORED ANESTHESIA CARE (MAC) ................................................................................... 72
DEFINITION:......................................................................................................................................................... 72
PROCEDURES PERFORMED UNDER MAC: ................................................................................................................... 73
COMBINATION OF SEDATION + ANALGESICS................................................................................................................ 76
CHAPTER 16 - HUMIDITY AND HUMIDIFIERS .................................................................................................. 79
CONSIDERATIONS FOR ANESTHESIA: ............................................................................................................... 79

HUMIDIFIERS: ...................................................................................................................................................... 83
UNHEATED HUMIDIFIERS: ....................................................................................................................................... 83
HEATED HUMIDIFIERS: ........................................................................................................................................... 83
CHAPTER 17 - NEBULIZERS ............................................................................................................................. 87
DESCRIPTION: ...................................................................................................................................................... 87
USE:................................................................................................................................................................... 87
HAZARDS: ........................................................................................................................................................... 87
CHAPTER 18 - VENTURI MASK ........................................................................................................................ 88
CLASSIFIED INTO: .................................................................................................................................................. 88

WORKING PRINCIPLE: ............................................................................................................................................ 88
INDICATIONS: ....................................................................................................................................................... 88
CONTAINS: .......................................................................................................................................................... 88
CHAPTER 19 - RUBEN (NON-REBREATHING) VALVE ....................................................................................... 91
CHAPTER 20 - RAE – TUBE (RING – ADAIR – ELWYN) ...................................................................................... 94
CHAPTER 21 - ARMORED TUBES .................................................................................................................... 96
INDICATIONS: ....................................................................................................................................................... 96
CHAPTER 22 - LASER SHIELDED E.T. TUBE....................................................................................................... 97
FIRST ENDOTRACHEAL TUBE: ................................................................................................................................... 97
CHAPTER 23 - COLE’S TUBE .......................................................................................................................... 100
CHAPTER 24 - AMBU /LAERDAL RESUSCITATION / MANUAL RESUSCITION.................................................. 103
PARTS............................................................................................................................................................... 103
SIZES ................................................................................................................................................................ 103
NON-REBREATHING VALVE:................................................................................................................................... 104
CHAPTER 25 - RESERVOIR OR RESPIRATORY BAG......................................................................................... 106
VOLUME PRESSURE RELATIONSHIP .......................................................................................................................... 106

Uses: .......................................................................................................................................................... 106
ASTM standard for Reservoir Bag: ............................................................................................................ 107
Size selection: ............................................................................................................................................ 107
9

-Second Edition
CHAPTER 26 - ACCESSORIES ......................................................................................................................... 109
MOUTH PROPS OR BITE BLOCKS: ................................................................................................................... 109

MASK STRAPS: ................................................................................................................................................ 109
INTUBATING FORCEPS: .................................................................................................................................. 109
TYPES OF CONNECTORS: ................................................................................................................................ 110
CHAPTER 27 - ANESTHETIC BREATHING SYSTEMS ........................................................................................ 112
DEFINITION:....................................................................................................................................................... 112
REQUIREMENTS FOR BREATHING SYSTEMS................................................................................................................ 112
CLASSIFICATION OF BREATHING SYSTEMS: ................................................................................................................ 113
CLASSIFICATION OF BREATHING SYSTEM BASED ON CO2 ............................................................................... 113
ABSORPTION .................................................................................................................................................. 113
BREATHING SYSTEM WITH CO2 ABSORPTION............................................................................................................ 114
MAPLESON ‘A’/MAGILL’S SYSTEM: ........................................................................................................................ 115
It consists of the following: ....................................................................................................................... 115
LACK SYSTEM: .................................................................................................................................................... 118
MAPLESON B SYSTEM: ......................................................................................................................................... 118
MAPLESON C SYSTEM: ......................................................................................................................................... 119
MAPLESON D SYSTEM:......................................................................................................................................... 120
FUNCTIONAL ANALYSIS: ........................................................................................................................................ 121
MAPLESON ‘E’ SYSTEM: ....................................................................................................................................... 124
MAPLESON ‘F’ SYSTEM: ....................................................................................................................................... 124
COMBINED SYSTEM: ............................................................................................................................................ 126
HUMPHREY ADE SYSTEM: .................................................................................................................................... 126
SEMI CLOSED SYSTEM: ......................................................................................................................................... 127
CHAPTER 28 - CIRCLE SYSTEM ...................................................................................................................... 129
Functions of the bag:................................................................................................................................. 131

Optional equipments that can be connected to the circle system: ........................................................... 132
Modification of circle system: ................................................................................................................... 133
TO AND FRO SYSTEM: ............................................................................................................................... 135
CHAPTER 29 - CLOSED CIRCUIT ANESTHESIA (CME) ...................................................................................... 137
UNDERSTANDING CLOSED CIRCUIT ANESTHESIA ........................................................................................... 137

BRODY'S EQUATION OR KILOGRAM X 3/4 ................................................................................................ 137
UPTAKE OF ANESTHETIC ................................................................................................................................ 138
USING 65 PERCENT N2O ............................................................................................................................ 139
PRACTICAL DETAILS OF THE CONDUCT OF ANESTHESIA ................................................................................ 139
CHAPTER 30 - LOW FLOW ANESTHESIA (LFA) ............................................................................................... 141
DEFINITION:....................................................................................................................................................... 141
CHAPTER 31 - SCAVENGING SYSTEM ............................................................................................................ 145
DEFINITION:....................................................................................................................................................... 145
COMPLETE SCAVENGING SYSTEM .................................................................................................................. 145
10

-Second Edition
CHAPTER 32 - SODALIME ............................................................................................................................. 149
ABSORBER CANISTER: .................................................................................................................................... 149

COMPOSITION ............................................................................................................................................... 149
CHEMICAL REACTION ..................................................................................................................................... 149
PEAKING OR REGENERATION ......................................................................................................................... 150
INDICATORS ................................................................................................................................................... 150
VARIOUS INDICATORS IN USE ARE: ................................................................................................................ 150
INTERACTIONS OF INHALED ANESTHETICS WITH ABSORBENTS: ................................................................... 150
CHAPTER 33 - GAS LAWS AND ANESTHETIC IMPLICATIONS ......................................................................... 152
SATURATED VAPOUR PRESSURE:............................................................................................................................. 152

BOILING POINT: .................................................................................................................................................. 152
GAS LOW VARIABLES: ..................................................................................................................................... 153
TEMPERATURE: .................................................................................................................................................. 153
PRESSURE:......................................................................................................................................................... 153
BOYLE’S LAW “ ............................................................................................................................................... 153
Applications:.............................................................................................................................................. 155
CHARLES LAW................................................................................................................................................. 156
GUY-LUSSAC LAW: ......................................................................................................................................... 158
AVOGADRO’S HYPOTHESIS: ........................................................................................................................... 159
VARIATIONS FROM IDEAL GAS BEHAVIOUR .............................................................................................. 161
Adiabatic compression: ............................................................................................................................. 162
Filling of N2O cylinder: ............................................................................................................................... 163
Dalton’s low of partial pressure: ............................................................................................................... 163
HENRY’S LAW: ................................................................................................................................................ 164
BERNOULLI EFFECT AND VENTURI PRINCIPLE ................................................................................................ 165
EVOLUTION OF THE INJECTOR WITH ENTRAINMENT DUCT ........................................................................... 166
Jet ventilation: ........................................................................................................................................... 168
Venturi Mask: ............................................................................................................................................ 168
POISEULLE’S LAW ........................................................................................................................................... 169
CONADA EFFECT: ........................................................................................................................................... 171
CHAPTER 34 - ADIABATIC EFFECT ................................................................................................................. 172
DEFINITION:....................................................................................................................................................... 172
MECHANISM:..................................................................................................................................................... 172
CLINICAL APPLICATION: ........................................................................................................................................ 172
CHAPTER 35 - MEDICAL GAS SUPPLY AND PIPELINE SYSTEM ....................................................................... 175
MEDICAL GAS:.................................................................................................................................................... 175

PIPED MEDICAL GAS SYSTEM ......................................................................................................................... 175
CENTRAL SOURCE OF GAS ......................................................................................................................... 176
Components of each Bank ......................................................................................................................... 176
Oxygen ...................................................................................................................................................... 177
THE DIFFERENT TYPES OF CYLINDERS ARE.................................................................................................................. 177
11

-Second Edition
The Colour coding of cylinders .................................................................................................................. 178
COMPRESSED MEDICAL AIR ...................................................................................................................... 179
SPECIFICATIONS ........................................................................................................................................ 181
FUNCTIONS................................................................................................................................................ 182
COMPONENTS ........................................................................................................................................... 183
TYPES: ........................................................................................................................................................ 184
TESTING OF MEDICAL GAS DISTRIBUTION SYSTEM................................................................................... 185
OXYGEN CONCENTRATION ........................................................................................................................ 190
CHAPTER 36 - FACE MASKS, AIRWAYS, ENDOTRACHEAL AND ENDOBRONCHIAL TUBES .............................. 194
FACE MASKS OR FACE PIECE ........................................................................................................................... 194

DEFINITION .................................................................................................................................................... 194
PARTS OF FACE MASKS .............................................................................................................................. 194
Body .......................................................................................................................................................... 194
SPECIFIC MASKS ........................................................................................................................................ 195
Anatomical mask (Connell mask) .............................................................................................................. 195
Randell – Baler – Sousek Mask (RBS) ........................................................................................................ 195
COMPLICATIONS ....................................................................................................................................... 198
AIR WAYS ....................................................................................................................................................... 199
ANATOMY ................................................................................................................................................. 199
TYPES ......................................................................................................................................................... 199
SPECIFIC AIRWAYS:......................................................................................................................................... 200
GUIDED AIRWAY ................................................................................................................................................. 200
LARYNGEAL MASK AIRWAY ............................................................................................................................ 203
HISTORY AND INVENTORY......................................................................................................................... 203
DEFINITION................................................................................................................................................ 204
TYPES ......................................................................................................................................................... 204
INDICATIONS OF CORRECT POSITIONING.................................................................................................. 207
ENDOTRACHEALTUBE .................................................................................................................................... 208
DEFINITION AND DESCRIPTION ................................................................................................................. 208
CLASSIFICATION OF TUBES ........................................................................................................................ 210
DESIGNATION OF SIZE OF ETT ................................................................................................................... 210
DOUBLE LUMEN BRONCHEAL TUBES ........................................................................................................ 220
INDICATIONS FOR USE OF DLT: ................................................................................................................. 220
Robertshaw Endobronchial tube: .............................................................................................................. 223
SIZE OF THE TUBE: ............................................................................................................................................... 225
CHAPTER 37 - CAPNOGRAPHY AND PULSE OXYMETRY ................................................................................ 226
TERMINOLOGY ............................................................................................................................................... 226

DEFINITIONS: ................................................................................................................................................. 226
CHAPTER 38 - VAPORIZERS .......................................................................................................................... 234
PHYSICS RELATED TO VAPORIZERS: ................................................................................................................ 234

VAPOR PRESSURE ........................................................................................................................................... 235
BOILING POINT ............................................................................................................................................... 235
12

-Second Edition
SPECIFIC HEAT & THERMAL CAPACITY............................................................................................................ 236
THERMAL CAPACITY ....................................................................................................................................... 236
THERMAL CONDUCTIVITY & THERMOSTABILIZATION .............................................................................. 236
CLASSIFICATION OF VAPORIZERS. .................................................................................................................. 237
METHODS OF VAPORIZATION: - ..................................................................................................................... 239
FACTORS AFFECTING VAPOR CONCENTRATION ............................................................................................ 242
PUMPING EFFECTS ......................................................................................................................................... 244
MECHANISMS .................................................................................................................................................... 244
In concentration calibrated vaporizers:..................................................................................................... 244
MODIFICATIONS TO MINIMIZE PUMPING EFFECT ARE .................................................................................................. 244
In measured flow vaporizers: .................................................................................................................... 245
Alterations in anesthesia machine to minimize pumping effect: .............................................................. 245
Pressurizing effect: .................................................................................................................................... 245
Mechanism: ............................................................................................................................................... 245
MACHINE STANDARDS .............................................................................................................................. 246
SPECIFIC VAPORIZERS ................................................................................................................................ 247
Boyle vaporizers: ....................................................................................................................................... 247
Classification: ............................................................................................................................................ 247
Boyle ether vaporizers: .............................................................................................................................. 247
TEC AND VAPORIZER:........................................................................................................................................... 250
TEC 5 VAPORIZER: ............................................................................................................................................... 251
TEC 6 VAPORIZER ................................................................................................................................................ 253
Classification: ............................................................................................................................................ 253
CHAPTER 39 - CLASSIFY VAPORIZER? DRAW A DIAGRAM & DISCUSS HOW VAPOUR CONCENTRATION IS
MAINTAINED IN TEC 5 VAPORIZER? ............................................................................................................. 262
DEFINITION:....................................................................................................................................................... 262
APPLIED PHYSICS ................................................................................................................................................. 262
CLASSIFICATION: (VCR – SALT) ........................................................................................................................... 262
I. ..................................................................................................................................................................... 262
II. METHOD OF VAPORIZATION (FBI) ................................................................................................................ 262
III. TEMPERATURE COMPENSATION ................................................................................................................... 262
IV. SPECIFICITY .............................................................................................................................................. 263
V. RESISTANCE.............................................................................................................................................. 263
VI. DEPENDING ON THE LOCATION .................................................................................................................... 263
VII. DEPENDING ON ARRANGEMENT .............................................................................................................. 263
I. Methods of regulating output concentration .................................................................................. 263
II. Method of vaporization: (FBI) ......................................................................................................... 265
a). Flow over: ........................................................................................................................................ 265
b). Bubble through: .............................................................................................................................. 265
c). Injection type: .................................................................................................................................. 265
III. Temperature Compensated ............................................................................................................. 265
a). Thermo compensation: .................................................................................................................... 265
b). Supplied Heat:.................................................................................................................................. 266
13

-Second Edition
IV. Specificity: ........................................................................................................................................ 266
VI. Depending on location of vaporizer ................................................................................................. 266
VII. Depending on the arrangement of vaporized ............................................................................. 267
Factors affecting Vapor concentration: .................................................................................................... 268
CHAPTER 40 - BOURDONE GAUGE ............................................................................................................... 271
ANATOMY ......................................................................................................................................................... 271

MECHANICS: ...................................................................................................................................................... 271
BOURDON PRESSURE GAUGE ........................................................................................................................ 271
CHAPTER 41 - UNIVENT TUBE....................................................................................................................... 274
TECHNIQUE .................................................................................................................................................... 274

OTHER TYPE OF BRONCHIAL BLOCKER ........................................................................................................... 274
14

-Second Edition
This page intentionally left blank
15

-Second Edition
Chapter 1 - HISTORY OF ANESTHESIA MACHINE
It starts from 1846 Oct. 16th when WILLIAM THOMAS GREEN MORTON
demonstrated the first successful ether anesthesia for an operation on the jaw at
MASSACHUSETTS GENERAL HOSPITAL, BOSTON.
Since then lots of efforts were made in developing anesthetic machine, directed
towards increasing safely, improving accuracy, ergonomic aspect of machine
design and adding to sophistication.
The development of machine from simple folded handkerchief or modified
version of Morton’s inhaler to machines using N2O, O2, vaporizer and breathing
circuit was a continuous process.
GWATHOMEY AND MARSHALL, developed use all N2O and O2 and produced new
method of measuring gas flow.
In 1917. HENRY EDMUND GASKIN BOYLE introduced the anesthetic. Machine. In
1917 November, it was first used at St. BARTHOLOMEW’S HOSPITAL. This was
N2O – O2 system with water sight feed type of flow meter.
In 1920 – was modified by incorporating a vaporizing bottle to the flow meter.
In 1926 – 2nd vaporizing bottle and by pass controls were added.
In 1930 – plunger device in vaporizing bottle was added.
In 1933 – dry bobbin type of flow meter was introduced in place of water sight
feed type.
In 1937 – Rota meters displaced dry bobbin type.
Boyle and his colleagues played important part in bridging the gap between
earlier methods and those which were development into technique of today.
In 1952 – Pin Index safety system was introduced.
Classification:
1. Anesthetic apparatus 2 types
Continuous type – Boyel’s, Forregar, Dragger.
Intermittent typeGas flows only during inspiration
They operate on demand system
Used in – Dental anesthesia
-Labour analgesia
- OPD diagnostic procedures
e.g.: Watton 5 apparatus
N2O and O2 system
16

-Second Edition
Fail safe system
Lucy Baldwins (Modified Walton)
Mackessons apparatus
Entonox apparatus
Continuous type Gas flow is continuous during inspiration and expiration
e.g.: - Boyle Machine (London) Forregar apparatus (America)
Dragger apparatus (Germany)
17

-Second Edition
Chapter 2 - BOYLE’S APPARATUS – MAJOR AND MINOR
Original Boyle was built by the firm, COXTERS.
Types Field type
Boyle Mark II, III, S, III F,
King Boyle / wall unit
Boyle petit / portable Boyle
Modern Boyle Machine consists of various safety features like pin index system,
pressure regulators, O2 failure safety device/alarms, pressure relieving valve,
Vaporizers etc.
It is important for the anesthesiologist to know and understand the working
principles of Anesthesia machine, for the safe conduct of anesthesia. Anesthetic machine
creates an artificial atmosphere to which patients is exposed to and so has the
responsibility of
Maintaining O2 concentration To prevent hypoxia
Elimination of CO2.
Avoidance of excessive, accidental administration of anesthetic gases.
TYPES OF MACHINE
- Intermittent  EMO
- Continuous – Boyle’s
o Major
o Minor
Differences:
Major Minor
1) Working pressure 60 Psi 25 Psi cannot run a medisys ventilator
2) N2O / or separate -N2O slave to O2 slave mechanism
3) Trilene value absent Present
(Trilene should not be used with soda
lime produces phosgene – nerve gas
4) Flow meters -12L N2O, 8L O2 = 20 L 10L N2O, 5L O2 = 15L
5) N2O pressure gauge - present Absent
(weight of cylinder was used to assess
N2O)
6) Common gas outlet - lower Higher
7) Flush valve – lower Higher
18

-Second Edition
8) Get ventilator port - present Absent
9) Shelf - Present Absent
10) O2 reserve Present Absent
(Aluminium tank)
11) Yokes 2 each 3 each
12) Flow meters 2 4
19

-Second Edition
Chapter 3 - MEDICAL GAS CYLINDERS
INTRODUCTION:
The gases used in anesthesia may be supplied in cylinders small enough to be
man handled or in bulk in liquid form which is vaporized and transmitted to the
anesthetic machine via pipe lines.
1. Non-liquefied compressed gas: Gas that does not liquefies at ordinary
temperatures and under pressures from 2000-2500 psig. E.g. O2, Nitrogen, air,
helium.
2. Liquefied compressed gas: One that becomes liquid to a large extent in
containers at ordinary temperatures at a pressure from 25 to 2500 psig. E.g. N 2O,
CO2.
I. Cylinder: A cylinder is a supply tank containing high pressure gas or gas
mixture at a pressure that can be excess of 2000 psig.
II. Container: A container in a low pressure, vacuum insulated vessel
containing gases in liquid form.
Medical Gas Cylinder:

Made up of molybdenum steel, on alloy, to minimize weight and thickness of the
wall.
Components of alloy Percentage
Carbon 0.3 - 0.4
Manganese 0.4 – 0.9
Silicon 0.3
Sulphur 0.35
Molybdenum 0.15 – 0.25
Thickness 5/65 to ¼ inch uniform all through. Aluminium cylinder useful in MRI
environment.
Components of cylinder:
Body: Made up of steel with various alloys added for strength. Cylinders have flat bases
to stand on end with other end tapers into a neck that is fitted with tapered screw
threads for attachment of the valve.
Valve: Cylinders are filled and discharged through a valve attached to the neck
20

-Second Edition
Port: Port is the point of exit for gas. Conical depression on the opposite side of the
valve to receive the retaining screw on the yoke.
Stem: Each valve contains a stem, that closes the valve by sealing against the seat.
When the valve opens the stem moves upward, allowing the gas to flow to the port.
Pressure Relief Device:

Each cylinder is fitted with a pressure relief device whose purpose is to vent the
cylinders contents to the atmosphere if the pressure of the enclosed gas increases to
dangerous level.
The commonly used devices are:

1. Rupture disc: It is non reclosing device. When the predetermined pressure is
reached. The disc ruptures and allows the cylinder content is to be discharged. The
device is used in O2, N2O, CO2, helium – oxygen cylinders.
2. Fusible plug: It is thermally operated, non reclosing pressure relief device, used on
nitrogen and air cylinders.
3. Pressure relief valve: It is spring loaded device designed to reclose and prevent
discharge of cylinder contents after normal pressure have been restored. Used in
air,CO2, N2, Helium, O2, CO2 – O2 mixture with upto 500 psig, charging pressure.
Bodok Seal:
Is a sealing washer fitted in between the cylinder the yoke part of machine to
prevent the leak.
Bodok seal is made up of non combustible material and has a metal periphery
which makes it long standing. It should be less than 2-4 mm thick prior to compression
and only one seal is allowed between the valve and yoke. If more than one washer is
used the pins may not extrude adequately to fit in the holes. Thus pin index system may
be passed and a wrong cylinder may be attached.
Sizes:
Medical gases are supplied in different size cylinders which are A, B, D, E, M, G, H.
Size E is the cylinder most commonly used on anesthetic machine.
Contents and Pressures:

The pressure decreases steadily as the contents are withdrawn from a cylinder
of a non liquefied gas. For a liquefied gas the pressure depends on the vapor pressure of
the liquid and is not an indication of the amount of gas remaining in the cylinder as long
as the contents are partly in liquid phase, weight of cylinder determine the amount of
liquid in the cylinder.
21

-Second Edition
Testing:
Cylinders are hydraulically tested every 5 years with special permit upto every
10 years. These are checked for leaks and retention of structural strength by testing to
minimum of 1.66 times of their service pressure. their service pressure is the maximum
pressure to which the cylinders are fitted at 700F (210C).
Types of tests are

a. Tensile Test: It is done in 1 in 100 finished cylinders. Longitudinal strips are cut
form cylinders and stretched until they elongate. Field point should not be <15
tons/inch2.
b. Flattening Test: Pressure is applied over 2 compression blocks keeping 1 cylinder
in between. Flattened till the block distance becomes 6 times of wall thickness.
Approval is given only if no cracks.
Impact Test: Three longitudinal and three transverse cylinders strips are struck. Mean
energy needed to crack should not be less than –
5ft Lb. – transverse strips
10ft Lb – longitudinal strips
c. Bend Test: A ring of 25mm width is cut from 1 randomly choosen cylinder out of
100. It is equally divided into four, then each is bent inwards until the inner edge are
apart not greater than the diameter of strip. Approved cylinder should not develop
any crack.
d. Hydraulic or pressure test: Usually done by water jacket or non-jacket method.
Water jacket method: Proof pressure applied inside is 236.2kg/cm2. Change in
cylinder volume on applying a withdrawal of proof pressure is measured by
changes in water level in a gauge projecting from upper end of water jacket.
Non Jacket method: Here jacket is not enclosed. A change in volumes is
determined through a gauge attached to the vessel from which water is drawn by
the pump in applying the internal hydrostatic pressure.
Color:
Color of the cylinders will help to identify the gas. The top and shoulder of each cylinder
are painted the color assigned to the gas it contains. This color coding is used on the
hoses, connectors, knobs and gauges.
22

-Second Edition
Gas Formula USA International State in cylinder
Oxygen O2 Green White Gas
Carbondioxide CO2 Gray Gray Gas + liquid (below
880F)
Nitrous oxide N2O French French Blue Gas + liquid
Blue
Helium He Brown Brown Gas
Nitrogen N2 Black Black Gas
Air Yellow White and black Gas
Cyclopropane C3H6 Orange Orange Liquid
Oxygen Tanks:
O2 molecular weight is 32 and boiling point is – 1830C at atmospheric pressure
760 mmHg (14.7 psia). Critical temperature is – 1180C and Critical pressure is
737 psig. Boiling points is related to ambient pressure E cylinders are filled to
approximately 1900 psig. At room temperature.
Same as O2, N2 and air are also stored as compressed gases
These do not liquefy at the pressure to which they are filled at 200C since their
critical temperature is low. (O2=118.380C, N2=1400C, Air=1250C)
Pressure falls linearly as the gas flow from cylinder, so this estimated by
pressure gauge always reflect amount of gas remaining in the cylinder.
Liquid Oxygen Tanks:

Liquid oxygen stored in a special container and kept under pressure. this
container has an inner and outer layer of inculcation and a near vacuum. This
construction is similar to that of thermos bottle and serves to keep the liquid a cold. The
liquid oxygen system contains vaporizers that heat that liquid and convert it to a gas
before it enters pipe line systems.
Characteristics of liquid medical oxygen:

Pale blue
Odorless, tasteless
Relative density = 1.1
Boiling point – 183.10C
Slightly soluble in water
Advantages of liquid medical oxygen:
Holds large volume, since 1Lt of liquid medical oxygen if converted into gaseous
stage, increases by approximately 840 times.
23

-Second Edition
Ensures security of supply by providing approximately 10 days stock as against 1
day from cylinders.
Major cost reduction since no cylinder record management or documentation is
needed.
Hazards: Fires, Cryogenic burns.
Nitrous Oxide Tanks:
Molecular weight is 44 and boiling point of -880C at 760mmHg. Critical
temperature of 36.50C and critical pressure of 1054 psig
Alike N2O; CO2 and cyclopropane (C3H3) liquefy at pressure to which the
cylinders are filled at 200C, therefore stored as liquids
The cylinders are filled only upto “filling ratio” (wt. of liquid with which it is
filled/wt of the water it can hold). Filling ratio of N2O is 0.67
E cylinder of N2O are filled to 90%-95% capacity with liquid N2O evolve
,approximately 1590 Lt of gas at 1 atm pressure ( 14.7 psig ).
Since pressure gauge only measure the pressure of the gas (vapor) above the
liquid level which remains constant till all the liquid is converted to gas, so the
contents can be accurately measures only by weighing.
Entonox (50% nitrous oxide + 50% oxygen):
This mixture is used for the administration of inhalational analgesia, principally in the
obstetric department. Additional safeguards are required in the handling because the
mixture has a pseudo-critical temperature of approximately -60C so if the cylinder were
allowed to cool below this point, the nitrous oxide and oxygen might separate out by a
process known as lamination.
There is an internal tube form valve block, leading down to within 10cm of the bottom
of the cylinder supplying the contents prevents the discharge of pure nitrous oxide if
lamination had occurred.
No single cylinder should supply gas at a rate greater than 300 liters/min. cylinders
should be stored for 24 h after delivery before being connected to the manifold in a
horizontal position at a temperature between 10 and 380C.
Medical Compressed air:

Medical compressed air (CA) differs from industrial compressed air in that industrial CA
may contain water vapor, oil mist, lubricant.
Medical CA may be administered to patients through both anesthetic equipment and
lung ventilators in the theater and the intensive therapy unit and it is also employed to
power some surgical instruments. Pressure of 420 kPa (60 psi) is sufficient for the
former, but many surgical instruments require a higher pressure of about 700 kPa (105
psi).
24

-Second Edition
It can be supplied either form a manifold of cylinders or by a compressor. Since the
cylinders of compressed air have the same right hand thread on a bull-nosed outlet as
oxygen, care must be taken in the storage.
Markings:
Department of transportation (DOT), transport Canada (TC) regulations require
specific markings on each cylinders. These are permanently stamped on shoulder of
cylinders.
Labeling:
Each cylinder must contain label. It should have name and address of cylinder
manufactures, name of content, volume in Lt at 700F(210C).
Tags:
Tags normally have the same color as cylinder. The lable has three section. Full,
in use, empty. The full portion is detached when the cylinder is put into service. In sue
portion should be removed when the cylinder is empty, leave the empty label.
Rules for safe use of cylinders:

General rules:
1. Cylinders should be handled only by personnel only by personnel trained safe
practices
2. Cylinder valves, regulators, organic lubricants, rubber or other combustible
substances
3. No part of any cylinder should ever by subjected to a temperature above 1250F
(520C)
4. Connections to piping, regulators, should kept tight to prevent leakage
5. The discharge port of a pressure relief valve must not be obstructed.
6. The valve should be kept close except when the cylinder is in use
7. The valve is the most easily damaged part of cylinder and should be protected by
valve protection caps
8. Markings, labels, deals or tags must not be altered or removed.
9. A cylinder should not be placed where come in contact with electrical apparatus.
10. Cylinders should be not be draped, dragged or rolled.
11. Cylinders should be properly secured at all times to prevent from falling.
12. Disposition of unserviceable cylinders is potentially dangerous and should be
done only by qualified personnel.
25

-Second Edition
Storage:
1. A definite area should be designated for storage of cylinders
2. The storage area should be in a cool, clean room which is constructed of fire
resistant materials.
3. Sources of heat in storage locations must be protected or located so that
cylinders are not heated.
4. Cylinders should be protected from mechanical shock.
5. Cylinders should be kept in upright position
6. Empty cylinders should be marked and keep separately from full cylinders.
Use:
1. Before use the contents of cylinders should be identified by labels, color of
cylinder
2. Only cylinder with letters DOT should be used. A cylinder which does not show
evidence of inspection within the required period should not be used
3. The cylinder valve, pressure relief device, pin index, holes, tags should be
checked for defects.
4. The valve protection cap on large cylinders should be removed just before
connecting cylinders for use.
5. The regulator should be inspected for signs of damage and to ensure it is free of
foreign materials before it is connected to cylinder.
6. Before any fitting is applied to the cylinder valve. Particles of dust should be
cleared from the out let by removing the protective cap or seal slowly open the
valve with the port pointed away from the user.
7. The threads on the regulator to cylinder valve connection (or) the pin indexing
devices on the yoke to cylinder valve connection should mate properly.
Connections that do not fit should never be forced.
8. The person opening a cylinder valve should position himself or herself and the
apparatus so that the valve out let and the face of regulator gauge point away
from all persons.
9. The cylinder valve should always be opened slowly if the gas passes quickly into
the space between the valve and the yoke or regulator, the rapid recompression
in the space will generate large amount of heat. Particles of dust, grease present
in this space may be ignited by the heat causing fire or explosion. The cylinder
valve should continue to be opened slowly until the pressure on the gauge
stabilizes, then open fully.
10. After cylinder valve is opened the pressure should be checked. A cylinder with a
pressure greater than the service pressure should be used
26

-Second Edition
11. If a cylinder valve is open but no pressure is registered on the gauge or no gas
flows the cylinder valve should be closed and cylinder should be disconnected
from apparatus.
12. If a hissing sound is heard when the valve is opened a large leak exists and the
connection should be tightened. If it does not disappear the sealing washer
should be replaced.
13. Even if no hissing sound is audible when the valve is opened, a slow leak may be
present and should be suspected if there is loss of pressure when no gas is being
used. These leaks should be located and corrected.
14. The valve should always open fully when a cylinder is in use. Marginal opening
may result in failure to deliver adequate gas.
After Use:
1. The cylinder valve should be closed completely and all pressure vented from the
apparatus.
2. An empty cylinder should not be left on an anesthetic machine. A defective check
valve in the yoke could result in accidental filling if the valve is left open.
3. Yoke should not be left empty, a full cylinder or yoke plug should be placed.
4. The valve should be closed and all pressure released before removing a cylinders
from the regulators (or) yoke
5. Valves should completely closed on all empty cylinders. If the valve is left open
contaminants could be sucked into it when the temperatures changes.
Hazards:
1. Incorrect cylinder
2. Incorrect contents: Cylinders may not contain the gas for which they are indexed
and labeled
3. Incorrect valve
4. Incorrect color
5. Incorrect labeling
6. Inoperable valve: Cylinders may delivered with blocked valve outlets
7. Damaged valve
8. Suffocations
9. Fires
10. Explosions
11. Contamination of cylinder contents
12. Overfilled cylinders
27

-Second Edition
28

-Second Edition
Chapter 4 -PRESSURE SYSTEMS
Machine is divided into 3 parts:
High Pressure System:
Which receives gases at cylinder pressure and reduces it to more constant pressure.
N2O-745psig, O2 1900 to 2200psig
Includes:
1. Hanger Yoke [connects cylinder to machine]
2. Cylinder pressure gauge [indicates gas pressures to cylinder]
3. Pressures regulator [converts high variable pressure to lower constant pressure]
II. Intermediate pressure system: (37 to 55 psig)
Receive gas from regulator or hospital pipeline and delivers then to flow control valves
or O2flush valves. (1atm=760mmHg=0 psig= 14.7 psia)
Includes:
1. Pipeline inlet connections
2. Pipeline pressure gauges
3. Pipeline
4. Gas power outlet for ventilator
5. Master switch that provides both pneumatic and electric power to the system.
6. O2 pressure failure devices.
7. O2 flush
8. Flow control valves.
III. Low pressure system: (3 to 6 psig)
Which takes gases from flow control valves to common gas outlet, pressure is slightly
above atmospheric pressure.
Includes:
Flow meters.
Back pressure safety devices.
Low pressure piping.
Common gas outlet.
If gas flow is traced from its source to the patient through the machine it will be easier
to understand the machine. Following components are encountered.
1. Source of gas supply
2. Yoke assembly
29

-Second Edition
3. Pressure gauge
4. Pressure Regulators
5. O2 pressure failure safety / warning device
6. Flow meters
7. O2 ratio control device
8. Vaporizer.
9. Common gas outlet.
10. 10) Breathing systems
30

-Second Edition
Chapter 5 - PRESSURE GAUGES
SIMPLE DIAPHRAGM PRESSURE GAUGE.
Pressure exerted at (C) causes deflection of diaphragm (D). This pushes the rack (R)
against the pressure of the spring (S), thereby turning the cogwheel so that the pressure
is indicated on the scale by a pointer.
BOURDON’S GAUGE
Device used to measure gas cylinder or pipeline pressure.

ASTM (American Society of Tested Materials) requires that each hanger yoke /
group of interconnected yokes be provided with pressure gauge or other
quantitative contents indicator that will display the delivery pressure of the
cylinder – supplied gas. Bourdon type tube pressure is one such pressure gauge.
31

-Second Edition
Mechanism:
Here the pressure of a cylinder is allowed to pass through flexible copper alloy
tube. As a result of the transmitted pressure, the tube tries to straighten out. This
motion is transmitted in a clock wise mechanism and a gas flow is indicated on a
calibrated scale on a dial.
Requirements:
Diameter of the circular gauge should be at-least 35 mm.
Span angle should be equal in all pressure gauzes ranging from 1800 – 2800, from
lowest to highest pressure markings.
With lowest marking between 6O’ clock to 9 O’ clock passion.
The instrument should be capable of measuring pressure at-least 1/3 greater
than the mean cylinder pressure.
The pointer / indicator should be easily recognized at tail end & is made as short
as possible and the other end should be long enough but should not obscure the
scale.
Units of calibration should be in KPa (kilopascals) or psig (pounds / square inch).
Safety features:
The gauge is usually color coded and the name and symbol of the gas are written
over the dial.
If bourdon tube ruptures, the escaping gas is generally vented out from back side
rather than front window.
Some gauzes are angled and are placed in such a way that it can be easily read by
anesthetist.
Instructions are written like “use no oil” on the gauge.
Face of the gauge is made of heavy glass / plastic as an additional measure.
Caution:
If there is a tight check valve in the yoke, the gauze may continue to display a
reading even after the cylinder has been removed from yoke, indicating a
cylinder gas supply that does not exist.
High pressure gauge should not be used to measure low pressure gas as this may
lead to inaccurate readings.
If Bourdon gauge is used on cylinder, the adjusting knob should be turned
counter clock wise until it turns freely before cylinder valve is opened.
32

-Second Edition
LOW PRESSURE ANEROID GAUGE:
Used in barometer. Diaphragm is made of neoprene or rubber.
In high pressure, diaphragm is made of metallic alloy
Pressure transducer: Is an electronic device which gets deformed by pressure and

converts it into electrical unit for easy and fast interpretation.
Unit of pressure: High pressure in psi, kg/cm2, atmospheres
(1 atm = 15 psi = 1.03 kg/cm2), KPa or bar.
Hyperbaric O2 measured in absolute pressure (Pabs).
For low pressures: Gauges are calibrated in mmHg or cm H2O. The term torr is
commonly used now. (1 atm = 760 torr).
Once new cylinder is fitted pressure is checked.
Before each case check the pressure in the cylinder.
All machine should have pressure gauge in the front panel to show pressure in
the pipeline, cylinder and E type cylinder.
High pressure system have Bourdan tube gauge.
When pressure is low the pointer is at 6 or 9 ‘o’ clock.
The Bourdan tube when open to very high pressure can burst. To prevent this it
is made with a special heavy glass window and a safety pressure fuse which
automatically opens and releases pressure.
33

-Second Edition
Chapter 6 - YOKE ASSEMBLY
To support and connect the cylinder to the machine
Provide gas tight seal
Ensure a unidirectional flow of gas into machine.
1) Body: Frame work and supporting structure.
2) Retaining screw: Threaded into distal part of yoke. Tightens the cylinder in the
yoke. Conical point of the screw fits the conical depression on the cylinder valve.
3) Nipple: Through which gas enters the machine. Projects from the yoke and fits
into port on the cylinder valve.
4) Index Pins: Just below the nipple. To prevent attachment of incorrect cylinder.
5) Washer (Bodok seal): Placed around the nipple. Helps to form gas tight seal
between cylinder and yoke. Thickness 2 mm – noncombustible material with
metallic rim.
6) Filter: To remove the dirt from the gas in cylinder (100 µm size)
Dummy cylinder block or plug:

Fits to the tip of retaining screw and on the other side over the nipple.
Prevents escape of gases from machine when cylinder is not there.
Serves to keep the nipple clean.
7) Check valve assembly: To ensure unidirectional flow so that, there is no
retrograde flow of gases from machine to atmosphere when there is no cylinder
in the yoke.
In case of double yoke, Check valve prevents the transfer of gas from one cylinder to the
other cylinder of lower pressure.
Working Mechanism of check valve:

It consists of a plunger that slides away from side of higher pressure. When
cylinder pressure is greater than machine side pressure, plunger moves to the right and
gas passes in to the machine.
When pressure in the machine is greater than cylinder pressure, plunger moves
to the left blocking the flow of gases.
34

-Second Edition
35

-Second Edition
Chapter 7 - PRESSURE REGULATOR / REDUCING VALVE
It is device that converts a variable high input gas pressure to a constant lower
output pressure (usually around 50 PSIG) so that
Frequent adjustments are not necessary to maintain the constant flow.
Fine adjustment of low flow is possible.
Less chance of damage to tube and connections.
(pressure reduced to 15—20 lbs in old boyle, where as preset to 60 lbs in Marc
IIIS)
Types:
1. Adam’s pressure reducing valve (Adam’s regulator)
Present in order machines- for N2O
Reduces the pressure to 2-7 lb/sq inch.
Principle of working  Toggle levers occlude the orifice when pressure falls.
Disadvantage  Impurities in N2O cylinder and water vapour --valve does
not operate efficiently so outdated.
2. Mackessons Regulator
3. Medishield valve
4. Endurance valve
5. Modern preset type of reducing valve
Direct (spring loaded rubber diaphragm
Indirect controls the size of the outlet through
Which gas escapes.)
Working Principle:
P = F/A F= P x A
Works on the principle that, a high pressure (P) over a small area (a) can be
balanced by a low pressure (p) over a large area (A). i.e, P x a= p x A
Using this principle, pressure can be reduced but can not be kept constant. As the
inlet pressure falls. Outlet pressure will also fall correspondingly. So to keep the
outlet pressure constant. A large force (F) much more than the cylinder pressure
is added over the balancing diaphragm (D) by means of spring and area(A) of the
diaphragm is further increased. In this way fall in outlet pressure is minimized.
Direct Action Type:

Here cylinder pressure tends to open the valve while force on the spring S2
closes the valve.
36

-Second Edition
With the valve is closed, the force of scaling spring S2 pushing the seat up against
the nozzle is greater than downward force exerted by main spring S 1 and
cylinder pressure against the seat. So no gas flows from cylinder (C) to the
regulator (R).
When valve is opened by tightening the adjustable screw the downward force of
main spring S1, is increased. This force is transmitted along the valve pin to the
seat and in combination with the inlet pressure overcomes the force of sealing
spring S2.
Gas at reduced pressure Pr flows into the space under diaphragm and exerts an
upward force on diaphragm and gas flows out of the outlet. Forces are not in
balance, but Pr will remain constant.
As Pc decreases Pr increases to maintain a constant gas flow at the outlet.
Indirect type:
In this, cylinder pressure tends to close the value while force on the spring opens
the valve.
With the valve closed, gas enters the space surrounding the spring S2 and valve
seat A1, its own pressure Pc tends to hold the valve seat against the nozzle.
When adjusting screw is turned, sot that main spring S1 exerts a downward force
on the diaphragm (F), the valve thrust pin moves downwards opening the seat.
So that gas at reduced pressure Pr expands thro the holes for thrust pin and into
the cavity under the diaphragm.
Here, as the area A1a and force F are constant, outlet pressure increases as the
cylinder pressure falls to maintain equilibrium.
2nd Stage Regulator:

Some machines have regulator just upstream of flow meter. E.g. Ohmeda
machine.
This receives gas either from pipeline or reducing device and reduces it to 26
PSIG for N2O and 14 PSIG for O2.
This is to eliminate any fluctuation in pressure supplied to flow meter.
37

-Second Edition
38

-Second Edition
Chapter 8 - OXYGEN FAILURE DEVICES:
1. Cuts of the supply of gases other than O2 (Oxygen failure safety device)
2. Gives an audible / visible alarm when O2 pressure falls to a dangerous level.
Oxygen failure Safety Device:

Machine is designed so that whenever the O2 supply pressure is reduced below
normal, set O2 concentration at common gas outlet does not fall below 19%. Safety
device shuts off or proportionately decreases and ultimately stops the supply of N2O
and other gases if O2 supply pressure decreases.
Incorporated at the level of pressure regulators.
O2 pressure regulator works as primary regulator. The output from this
regulator controls the secondary regulator, which are located in N2O line. If O2
pressure falls N2O flow will be automatically stopped.
Oxygen failure safety valve closes the line at a pressure between 15 & 30 psig .
Types:
1) In which N2O regulator will be totally cutoff when O2 pressure falls below critical
level ( 20-25 psig ) ( In ohmeda machine )
2) In which, N2O outlet pressure will also fall proportionate to fall in O2 pressure. But
when O2 pressure decreases further. N2O will fall and finally stops. (As in Drager
Narcomed)
Oxygen Failure Alarms:

On activation i.e. within 5 sec, device cuts of N2O or diverts flow to the
atmosphere.
Mechanism – Pressurised canister is filled with O2 during Normal use. When O2
pressure falls, oxygen flows from this canister through a whistle, giving rise to
audible alarm of 60 DB for 7-10 sec.
But ending of the whistle does not mean that low pressure condition has been
corrected.
Limitations:
Can permit the hypoxic mixture in conditions like
Cross over in pipeline system or cylinder with wrong gas.
Accidentally closed or partially closed O2 flow control valve in down stream
Low O2 flow (depleted cylinders, disconnected O2 hose)
Prevention is by addition of oxygen analyzer in the breathing system.
39

-Second Edition
Flow Pathways for O2 in intermediate pressure system in five directions:
Oxygen flush
O2 supply failure alarm system
Pneumatically powered anesthesia ventilator.
Oxygen failure safe valves.
Flow meters.
Oxygen Flush Valve / O2 Bypass / Emergency O2:

Receives the oxygen from pipeline inlet/cylinder reducing device and directs it
to common gas outlet.
Flow will be 35-75 L/min.
Only oxygen is flushed through this valve.
Consists of a button and a stem connected to a ball which is in contact with the
seat. When button is depressed, ball is forced away from seat allowing O2 to flow
to the outlet. Spring forces the ball to close the seat when button is not pressed.
Activation of O2 flush may produce a negative or positive pressure in the
machine circuit which will be transmitted back to the flow meter and vaporizers,
causing the reading to change. It depends on the pressure generated. Presence or
absence of check valve in the machine and relation of flush valve to other
components.
Hazards:
1. Barotrauma
2. Internal leakage – O2 enriched mixture delivery – so that dilution of anesthetics
in low flow (closed circuit)
3. Sticking of flush valve and thereby obstructing flow of anesthetic gas and O2 from
flow meter.
4. Accidental activation (to prevent this the ball is placed in a collor)
Flow Control valve:

Controls the rate of flow of a gas through it by manual adjustment of a variable
orifice.
Components:
1) Body 2) Stem 3) Control Knob.
Body: Screws into base of flow meter.
Stem: Has fine threads so that it moves only a short distance when one complete turn is
made.
40

-Second Edition
Pin at the end of stem is conical and fits onto seat. When the valve is closed, this
pin at the end of stem fits onto seat and so no gas can pass through valve. When stem is
turned outwards, opening is created between the pin and seat through which gas flows.
A stop for off position, avoids damage to valve seat and the stop for maximum flow
position prevents disengagement of stem from the body.
Control knob:
Joined to the stem.
O2 flow control knob must have fluted profile and larger than other gases.
Other knobs for other gases should have smaller rounded knobs.
Knobs are turned anticlockwise to increase the flow and clockwise to decrease
the flow.
Problems:
1) Loose knobs
2) Leaks through open flow control valve
3) Failure to allow adequate flow because of the breaking of stem.
4) Inability to turn it because stop pins become locked.
41

-Second Edition
42

-Second Edition
Chapter 9 - FLOW METERS
Belongs to low pressure system.
Measures and indicates the rate of flow of gas passing through it. This flow is the
drop in pressure that occurs when gas passes through a resistance. (Bernoulli’s
effect)
Types:
1) Constant pressure variable orifice – Rota meter
2) Constant orifice variable pressure – Pressure gauge
3) Variable pressure variable orifice – Water sight feed flow meter.
4) Constant pressure constant orifice – Bubble flow meter.
Flow indicator assembly consists of:

Tube through which gas flows
Indicator
Stop at the top of the tube
Scale
} Protected by a plastic shield
Tube: (Thorpe tube)

Usually made of glass. Kept vertical, Tapered at the bottom. An indicator that is
free to move up and down is inside the tube. Gas flows in the area between the indicator
(bobbin) and inside of the glass tube i.e. Annulus. As this area increases from below
upwards flow also increases.
Rate of flow of gases through this tube depends on 3 factors.
Pressure drop across the construction

As gas flows in the annulus, it encounters frictional resistance between the bobbin and
the wall of the tube. Flow becomes less laminar and more turbulent resulting in loss of
energy, reflected as drop in pressure. This pressure drop is constant for all positions in
the tube
Graham’s law for turbulent flow
Rate of diffusion of a gas varies inversely as the square root at its density or molecular
weight
1
V =
Density
Poiseuille’s lawapplies when flow is laminar
43

-Second Edition
Flow directly proportional
1) Pressure drop across constriction (P)
2) Radius of the tube (r)
Flow indirectly proportional
1) Viscosity of gas (v)
2) Length at bobbin (l)
pr 4
Flow =
8 Vl
Size of the annular opening

Larger the opening around the float, greater the flow because the pressure drop across
the constriction is always balanced by the weight of float. Increase or decrease in lifting
force caused by change in the gas flow. P= F/A.
Pressure drop across the float is same in all positions. So increasing the flow doesn’t
increase the pressure drop but allows greater flow area for gas. Therefore elevation of
the float is a measure of annular area of the flow.
Physical character of gas: As the flow increases the annulus becomes larger.
Physical property that relates the gas flow to pressure difference varies with size
of constriction.
With narrower constriction (low flow) flow will be laminar and so depends on
viscosity of gas (Poiseuille’s equation).
With wider and shorter constriction (i.e. High flow) flow is turbulent and
depends on the density of the gas. (Graham’s Law).
As flow indicators are calibrated at atmosphere pressure (760 torr) and room
temp (200 C), changes in these will affect both viscosity and density and hence
the flow.
With decreased pressure (high altitude), actual flow will be more than that
indicated by the flow indicator.
With increased pressure, delivery of gas flow will be less than that indicated by
setting .
Verticality of Thorpe tube is:

1) To avoid friction between bobbin and inside of the tube.
2) To avoid asymmetrical annulus.
3) To avoid resistance on the flow.
44

-Second Edition
Indicator: Float / Bobbin:
Made of antistatic and very light material like aluminum. This prevents sticking
of the float to the wall of flow meter due to static electricity.
Floats at a position where downward force on it (gravity) equals the upward
force (gas flow). Three types
Non-rotating
Rotating (Rota meter)
Ball floats
Non-rotating: Designed so that gas flow keeps it in the center of the tube. Reading
taken at upper rim.
Rotating type: Diameter of upper rim is larger than the body. Rim has grooves (flutes)
on it. When gas flows, it impinges into these grooves making the bobbin to rotate. Kept
centered by this constant rotation. Reading taken at the upper rim.
Rotating bobbin indicates that gas is flowing.
Ball floats: Kept centered by rib guides. Reading taken at the center of the ball.
Advantage of Centered bobbin:

Prevents fluctuation in flow
Reduces wear and tear
Reduces friction between float and tube
Stop: Present at the top of the tube. Prevents the bobbin from plugging the outlet. It also
prevents the indicator from ascending to a point where it is hidden.
Scale: Tubes are individually calibrated at room temp and atmospheric pressure for a
particular gas.
Linear
Calibrated in mL/min calibrated-- Non- linear
For O2 upto 8 L/m upto 5L for O2
In newer In Older
N2O  upto 12 L/min Machines 10L for N2O Machines
Flow meter gives inaccurate reading if:
Float sticks to the tube due to dirt on tube or float or due to static electricity.
It tube is not vertical.
Dislodgement of stop which rests on bobbin
Sudden opening of cylinder or connecting the pipeline hoses with flow control
valve open.
Lead due to crack in the flow meter.
Wrong gas in the flow meter.
45

-Second Edition
Back pressure caused by obstruction to common gas outlet.
ARRANGEMENTS OF FLOW METER TUBE:

Normal gas flow is from bottom to top in each tube and left to right at the top.
Sequence should avoid the delivery of hypoxic mixture.
In old machines. O2 flow meter is to the extreme left in upstream. If a leak occurs
in flow meter not in use, considerable portion of O2 will be leaked. Where as N2O
is delivered, to common gas outlet leading to hypoxia.
To reduce this, modern machine has O2 flow meter at right and downstream of
all flow meters. Here leak will be that of N2O and air and O2 is delivered
unaffected to the common gas outlet. Wherever oxygen flow meter is kept (either
right extreme or left extreme) it should be placed downstream of all flow meters.
Other types of Flow meters:

Head brink flow meter.
Connel flow meter
Forager flow meter
Spirometers – vitalograph single breath spirometer.
Ultrasonic flow meter
Fluidic flow meter (Ohmeda machines)
Anemometer or insertion meters [gas velocity at given point.]
Inferent flow meter-Wright’s respirometer (measure volume)
Differential pressure flow meter.
46

-Second Edition
47

-Second Edition
Chapter 10 - SAFETY DEVICES
Modern machines utilize a proportionating system in an attempt to prevent the
delivery of hypoxic mixture.
O2 and N2O are interfaced either mechanically or pneumatically so that minimum
O2 concentration at outlet is 25%.
Types used are:

Oxygen Ratio Monitor (ORM)
Oxygen Ratio monitor Controller (ORMC)
Link – 25 control system.
OXYGEN RATIO MONITOR (ORM)

It is developed after recognizing the limitations of O2 pressure fail safe system,
incorporated in Drager machine.
Consists of linear resistors inserted between O2 and N2O flow control valves and
respective flow meters.
Pressure drop across the resistors is monitored and transmitted via pilor lines to
an arrangement of opposing diaphragms. These opposing diaphragms are linked
together with a capacity of closing a leaf spring contact and activating an alarm. If
O2 percentage drops in mixture of O2 and N2O below a predetermined level.
Drawbacks:
It gives an alarm but does not control the gas flow.
It will not give an alarm if a hypoxic mixture is administered when a piping
system contains a gas other than O2.
OXYGEN RATIO MONITER CONTROLLER (ORMC)

Basic design principle is same as ORM with the exception that slave regulator is
additionally controlled by the mechanism of opposing diaphragms which
controls N2O delivery pressure to N2O control valve and thus N2O flow.
So this not only monitors the ratio of O2 flow and gives an alarm when it falls
below 30% but also reduces the flow of N2O proportionately to maintain the
ratio.
Disadvantage – is that the operator cannot override the function of device
when desired.
48

-Second Edition
LINK – 25 CONTROL SYSTEMS
This is present in Ohmeda machine and Boyle ultima. There is mechanical
integration of N2O and O2 flow control valves, allowing independent adjustment
of either valve, also automatically intercede to maintain a minimum O2
concentration of 25%.
N2O had a gear with 14 teeth which is fixed to the spindle and O2 has a gear with
29 teeth which is mounted in the O2 spindle with threads so that is can float over
the spindle.
The link arrangement is so set, that for every 2.07 rotations of N2O spindle, O2
gear will rotate once but the gear itself will engage the O2 control valve spindle
only when the proportion of N2O in the mixture exceeds 75%.
The thread mounting of O2 gear is such that it allows even independent rotation
of O2 flow control valve.
Flows in the flow meter are linked to the rotation by regulating supply pressure
of the gases with secondary regulators situated just before the flow meters. i.e.,
N2O is supplied at 26 PSIG and O2 at 14 PSIG.
Disadvantages:
Malfunctioning of the spindle and gear if not properly aligned or if the threads in
the spindle undergo wear and tear.
This device can link only O2 and N2O, so if a third gas like air is included in the
flow meter assembly, then there is no longer assurance of 25% O2 delivery in the
mixture.
BACK BAR
Flow meters and vaporizers are bolted to horizontal part of frame of machine
called back bar. Connected to each other by tapered fittings.
Fittings between vaporizer and flow meters are 23 mm Cage mount tapers.
UNIDIRECTIONAL VALVE (BACK FLOW CHECK VALVE)

This may be inserted between vaporizer and common gas outlet upstream of
where O2 flush flow joins the fresh gas flow. Helps to minimize the back pressure.
Causes for Back Pressure are:

Use of O2 flush
When ventilation is controlled or assisted, positive pressure from breathing
system is transmitted back to the machine.
Increased leak in flow meter
Decreased concentration of volatile agent supply
49

-Second Edition
Damage to low pressure components.
PRESSURE RELIEF VALVE

To prevent high pressure form being transmitted into the machine and to protect
the patient form high pressure from the machine.
This valve opens to atmosphere and vents the gas if pressure exceeds 5 PSIG
(30-40 kilopascal)
STATIC ELECTRICITY:
Is produced when 2 dissimilar surface are brought together and separated and also at
the point of contact of highly charged conductor with a nonconductor.
These changes cause explosion in presence of spark and courtesy. Static charges
can get accumulated on the surfaces of nonconductive materials like plastic, nylon etc,
so they are avoided.
Antistatisity due to  Carbon mixed rubber

(microscopic chain at carbon particle)
Places where kept  wheels
-Cylinders / yoke bar
-At rota meter
-At ET tube and connection
(moisture – conductive)
-At the sodalime canister (plastic)--expiratory most.
-At the chain at cork in vaporizing bottle.
OXYGEN ANALYZER
It is placed at the common gas outlet or in the breathing system or near the
endotracheal tube.
It is the only safety device which provides the single most full proof measure to
prevent delivery of hypoxic mixture.
It is not dependent on pneumatic or mechanical links, but measures oxygen
percentage in the gas mixture by paleographic method or by using a fuel cell.
The analyzer is calibrated at regular intervals, preferably with room air to read
21%. So gives most accurate measurement around the concentration which is
used for its calibration.
50

-Second Edition
COMMON GAS OUTLET
Present at the end of back bar to which breathing system is attached. Receives all
gases and vapors from the machine.
Has 15mm female slip joint connection with a coaxial 22mm male connector. This
prevents connection of vaporized to CGO.
CONTINUOUS FLOW ANSESTHESIA MACHINE

Components of machine are mounted on a table with ANTISTATIC WHELS –
which helps by preventing generation of static electricity so as to prevent accidental
fires in O.T.
Machine has provision for O2 and N2O cylinders and pipeline connections.
Each gas cylinder is connected via its yoke to pressure regulator. There is a
pressure gauge before this to read cylinder pressure. Connections between yoke inlet of
pressure regulator and pressure gauge are made of high pressure metal tubing. The
output of the oxygen pressure regulators are connected together and to the flow control
valve of the oxygen flow meter, with a metal tubing which are made of compression
couplings.
The pressure regulators in all modern machine are present to 55 PSIG so that
outlet pressure does not exceed 60 PSIG.
Nitrous oxide regulators work only when the oxygen pressure is adequate [Slave
regulators]. The outputs of N2O regulators are connected to flow control valve.
The O2 and N2O flow control valves control the flow of gas is through the flow
meters. The flow meters are mounted together as flow meter manifold. This manifold is
secured to the backbar of machine by 1 or 2 bolts. Flow meters and vaporizers are
connected to each other by tapered fittings and are bolted to backbar.
At the end of backbar is the common gas outlet to which breathing system is
attached.
Before this outlet there is –
Back flow check valve
Relief valve
Oxygen flush.
51

-Second Edition
Chapter 11 - CHECK LIST BEFORE USING MACHINE
High Pressure System:
Prevent connection of wrong gas

Gas cylinders – check they are connected to correct yoke
Open O2 cylinder and see to it has at least ½ is full 1000 PSIG
Open oxygen flow control valve and register the flow of 4-5 L/m
Open N2O flow control valve and note that no flow
Close the cylinder and note bobbin to fall to zero.
Check O2 pressure fail safe mechanism

Open N2O cylinder and note the pressure gauge shows any flow
Open O2 cylinder, now flow should be seen both in O2 and N2O flow meters.
Close O2 cylinder, note bobbins in both fall to zero and O2 pressure fail alarm is
activated
Now close both flow control valves.
Check pipeline supply
Low Pressure System:

Check initial status
Close flow control valves and turn of vaporizer
Check fill level of vaporizer
Leak check of machine
Close the flow control valves
Attach suction bulb to common gas outlet
Squeeze the bulb till it collapses.
Verity the bulb stays collapsed for 10 sec.
Reconnect the fresh gas hose.
Testing flow meter
Test if proportionating device is working.
Calibrate O2 analyzer (if there)
Calibrate to read 21% in room air
Connect to common gas outlet and flush with 100% O2
Verify if it reads above 95%.
52

-Second Edition
Modifications in Boyle mark III S:
1) Extra shelf on the top of machine
2) Bigger size, facility for extra cylinder
3) Pressure gauge for N2O
4) Only 2 flow tubes with He flow (O2-8L, N2O – 12L others O2 – 5L N2O – 10L)
5) O2 is made downstream.
6) O2 flow control valve – color and touch coded
7) Master and slave regulator system
8) and Link -25 control system
9) Space for another vaporizer.
10)Connections for jet ventilator [with preset valve press ion reduce to 60 psig. In
older machine  15-20 Psig]
11)To change between open and close circuits –simple lever movement
12)No trilene lock
13)Change of circuits at platform level
14)Emergency O2 - button type.
53

-Second Edition
Chapter 12 - SAFETY FEATURES IN ANESTHETIC MACHINE
“Look after the equipment as a body”.
Modern machine is the results of advances in technology and growing

understanding of patient’s safety consideration. But these safety features are not full
proof and are prone to failure due to operational errors, misuse and occasionally
machine failure.
Aimed at avoiding the following hazards:

1) Delivery of Hypoxic Mixtures
2) Delivery of excessive anesthetic concentration
3) Development of excessive pressure in the machine
TO PREVENT DELIVERY OF HYPOXIC MIXTURES

1. Before flow control valve
2. At flow control valve
3. After gas leaves flow control valve.
Before Flow control valve:

Pipelines – Color coding, Non interchangeable quick couplers. Flexible pipelines,
Diameter indexed safety system (DISS)
Cylinder – Color coding (1949), Cracking of cylinders, Markings. Pin index
system (1952).
Master switch - Turning the master switch causes all alarms, safety devices as
well s monitors to get activated automatically.
Pressure regulators.
O2 pressure failure safety and warming devices.
At the Flow control valve level:

O2 ratio control devices like – O2 ratio monitor
O2 ratio monitor controller
Link 25 control system.
After gas leaves the flow control valve:

Flow meter – touch and color coded knob, calibration, flow meter sequence .
Vaporizers – Use of only one vaporizer, careful handling
Absorption canisters – in closed circuits
O2 analyzer.
54

-Second Edition
TO PREVENT DELIVERY OF EXCESSIVE ANESTHETIC
CONCENTERATION
Back flow check valve – to prevent pumping effect.
Trilene interlock (in order machines) to prevent operating of trilene vaporizers
and closed circuits at the same time (so as to prevent formation of phosgene).
Vaporizers – constructed with back flow compensation.
Locking device – to prevent use of more than one vaporizer simultaneously.
TO PREVENT EXCESSIVE PRESSURES ON MACHINE

Pressure relief valve after pressure regulator – protects the intermediate
pressure system from high pressure if any defect in pressure regulator.
Pressure relief valve before common gas outlet – protects the low pressure
system (flow meters, vaporizers) by decreasing the pressure when exceeds 200
cm H2O (in Boyle machine) due to any obstruction at or after common gas outlet.
APL (Adjustable pressure limiting) valve in the breathing system – can be
adjusted according to the breathing system used. And it’s application. It itself can
vent gases to the atmosphere when pressure exceeds 60 cm H2O even they are
full closed.
Reservoir Bag – In the breathing system.
Give away pressure builds up above 50 cm H2O.
OHMEDA DRAGER NARCOMED
2 stage regular present
nd Absent
Key index system for knobs -Link -25 No such system
Pressure sensor shut off valve present. If Has O2 present failure device. When O2
O2 pressure is <25 PSIG, N2O flow is cutoff pressure decreased, a proportionate
and increased O2 flow seen. decrease in N2O supply occurs & complete
cutoff seen at <12 PSIG. Limits N2O flow
according to O2 flow.
Back slow check valve present, which No such valve seen.
prevents gas flow from outlet to
vaporizer
55

-Second Edition
Chapter 13 - SAFETY FEATURES IN ANESTHETIC MACHINES (CME)
The anesthesiologist is once a physician, a scientist and an artist. As an artist he
judged by the condition of the equipment.
“Look after the equipment as a baby”

Modern anesthesia machine is the result of advances in technology and a growing
understanding of patients safety consideration. Every anesthesiologist needs to have a
good working knowledge of the safety principles associated with the use of medical
gases and volatile agents.
Also it is extremely vital to realize that these safety features are not fool proof and are
prone to failure due to operational errors, misuse and occasionally machine failure.
Injuries that can result during anesthesia to a patient-
1. Insufficient oxygen supply
2. Insufficient CO2 removal
3. Excessive anesthetic concentrations.
4. Trauma to lungs due to excessive pressure
5. Foreign matter injuring the airway.
6. Administration of the wrong agent.
Chronology of “Introduction of major safety features” for the

anesthesia machine:
1950-1060: Pin index safety system.
1. Oxygen flush
2. Temperature / flow compensated vaporizers.
3. Oxygen supply failure alarm system
4. Vaporizer inter lock system
1960-1970: Ventilator pressure relief system

1. Check valve between vaporizer and fresh gas outlet
2. Gate – style cylinder yokes
3. Ascending filling ventilator bellows
4. Single agent vaporizers
5. Key index safety system for filling vaporizers
1970-1980: Ventilator low pressure disconnection

i. Machine – mounted pipeline pressure gauges
ii. Diameter index safety system
iii. Minimum O2 flow
56

-Second Edition
iv. N2O /O2 proportioning device (O2 ratio monitoring device)
v. Oxygen analyzer
1980-1990: Anti disconnect fitting on fresh gas outlet

i. Master switch on / off .
ii. Airway pressure monitoring system
iii. Battery backup for power supply
CONSIDERATION OF INDIVIDUAL SAFETY FEATURES:

TO THE O.T. PERSONNEL:
Antistatic rubber has been made use of in the Anesthesia cart / machine wheels and in
the tubings and reservoir bags. This helps by preventing generation of static electricity
which can further lead on to accidental fires in the O.T.
TO THE PATIENT:
The following hazards can occur against which safety measures are to taken
I. Delivery of hypoxic mixtures
II. Delivery of excessive anesthetic concentrations
III. Development of excessive pressures in the machine
Safety Features to prevent delivery of Hypoxic mixtures:
Safety measures are incorporated at one of the these following sites:
Before flow control valve --Pipelines carrying medical gases terminate at various
locations within the hospital. Some safety features for use of piped gas supply include
colour coding and use of non interchangeable quick couplers to tap gases at the wall
outlets. Each quick coupler consists of a pair of non threading, gas specific male and
female components. Insertion into an incorrect outlet is prevented by use of different
shapes, space or combination of both for the mating portions. The wall outlet and
connector for flexible pipeline should be from same manufacturer, as an international
standard has not been developed and varies from one manufacturer to other.
Cylinders –Safety features included in Cylinders are

Colour coding – Adopted in 1949.
Cracking of cylinders – The cylinder valve should be opened slightly for a
moment to clear the outlet of possible dust, which might otherwise enter the
regulator and this also helps to know whether the cylinder is full or empty. The
outlet should be pointed away from the operator and other personnel. This is
performed before attaching the cylinder to yoke.
Cylinder marking with name of the gas along with service pressure and volume.
57

-Second Edition
Pin index system – First presented by Philip D Woodbridge to Mr I.G. Shohi in
1939. Introduced in 1952 to prevent connection of wrong gas cylinders to
anesthesia machine. Used in small cylinders (E type) which fit directly onto the
machines. Consists of two pins projecting from inner surface of yoke and two
corresponding holes in the cylinder valve. There are seven hole locations on the
circumference of circle of 9/16 inch radius centered in the port. Pins are 4 mm in
diameter and 6mm long. Two pins are assigned to each gas one on either side of
midline.
PIN INDEX
On the Yoke (Correspondingly opposite holes on the cylinder)
Pin Index Gas Colour Code of cylinder
1-3 Ethylene Red
1-4 N2 Grey
1-5 Air Grey, white and black shoulder
1-6 O2-CO2(CO2>7.5%) Predominant green
2-4 O2-He(He<80.5%) Predominant brown
2-5 O2 Black with white shoulder
2-6 O2-CO2(CO2<7.5%) Predominant green, rest grey
3-5 N2O Blue
3-6 Cyclopropane Orange
4-6 O2-He(He>80.5%) Predominant Brown, rest green
7 Entonox Blue / blue and white shoulder
Use only one cylinder at a time. If both the cylinders or machine cylinder and manifold
are simultaneously used, the oxygen fail safe is activated only when both the cylinders
are empty.
The cylinder key should always be on the cylinder.
a) DISS – Diameter Index Safety System – Was developed to provide non
interchangeable connections for medical gas pipelines, consists of a body, nipple
and nut combination. There are two concentric and specific bores in the body and
two concentric and specific shoulders on the nipple. Small bore mates with small
shoulder and large bore with large shoulder. Diameters of each part vary for specific
gases. Colour coding and labeling of outlets, hoses and quick couplers are additional
safety features. ( DISS not followed in our country.)
b) Master switch – Turning on master switch causes both the pneumatics and
electronic functions of the machine to be activated. This has the advantage that all
58

-Second Edition
alarms and safety devices as well as many of the monitors are automatically
activated before machine can be used. There should be batteries for backup should
the main power fail.
c) Pressure regulators: Reduces the pressure and keeps it constant till the end. Fine
adjustment is possible. As it reduces the pressure it prevents damage to the flow
meters, vaporizers and ventilators.
After the work is over, close the cylinders. Close the N2O cylinder first. Empty the entire
system; bring the Bourden gauge to zero. Then close the O2 cylinder, bring the bourden
gauge to zero. This is useful because –
1. There is no pressure in the regulator. So there is no damage to the diaphragm
and to regulator.
2. The person who comes to use the machine next knows that the cylinder is closed.
d) Oxygen pressure failsafe precautions– Depletion of O2 when unnoticed can lead
to delivery of 100% anesthetic gases with disastrous consequences. Safety devices
to prevent such accidents are:
Cut off supply of gases other than O2
Give an audible or visible warning (alarms)
The oxygen failure safety device shuts off or proportionately decreases and
ultimately interrupts the supply of N2O and other gases if O2 supply and therefore
pressure falls below critical levels. One such device is pressure sensor shut off valve
where O2 pressurizes and holds open pressure- sensor shut off valve that interrupts the
supply of N2O and other gases if O2 pressure falls below a threshold setting. If O2
pressure is adequate, diaphragm and stem of valve will be pushed allowing anesthetic
gases to pass around the seat and on to outlet.
Another type of O2 failure safety device is gas-loaded regulator where O2 pressure
regulator (Primary regulator) controls secondary regulators (slave regulators) located
in N2O line. If primary regulator pressure falls, slave valves ensure that at low O2
pressures only O2 may be delivered at machine outlet.
If O2 pressure is adequate other gases may flow through their flow meters and O2 flow is
not ensured unless flow control valve is opened. Thus a normally functioning failsafe
mechanism still permits a flow of 100% N2O provided machine has adequate O2
pressure.
59

-Second Edition
At the flow control valve level

Operator regulates flow entering low pressure circuit by adjusting the flow control
valves. Safety features included here are
Proportioning systems
I. Link – 25 system
II. Oxygen ratio monitor controller
III. Failure of proportioning system can occur under following conditions.
1. Wrong supply of gas
2. Defective pneumatics / mechanics
3. Inert gas administration (3rd gas – He, N2,CO2)
4. Leaks down stream.
After Gas Leaves Flow Control Valve

Flow meters and flow control knobs have been rearranged and redesigned in an
attempt to avoid setting hypoxic mixtures.
a. Gas flow to flow meter tube is controlled by touch and colour coded knob, which
in linked to the needle valve.
b. O2 – White, fluted, larger, flow control is more projected than N2O
c. N2O – Blue, not fluted, smaller.
d. A bar is placed in some machines in front of knobs to protect against accidental
alterations in setting.
e. The float has a radiolucent material incorporated so that the float can be seen in
darkness. The Glass behind the flow meter bank is radiolucent to facilitate
reading the flow meter in the dark.
f. Use the flow meters only to calibration. It is not possible to give less than the
calculated flow meters. When you give more than the calibration, the float may
get stuck and if the cylinder is empty, it will not fall. The float should always be
spinning when the flow meter is in use.
a. Flow meter sequence: One safety measure is to have O2 flow meter down
stream, because if O2 is upstream, and a leak occurs through the flow meter not
in use, a substantial portion of O2 escapes through the leak where as N2O is
directed towards the common gas outlet leading to delivery or hypoxic mixtures.
b. Oxygen analyzer: Only safety device which can reliably detect problems of
hypoxic mixture delivery. Depends on actual measurement of O2 percentage
using a fuel cell or by polarographic method. Calibration is done daily at room air
to read 21%.
60

-Second Edition
Safety features to prevent delivery of excessive anesthetic concentrations:
Hazards associated with use of vaporizer are
Incorrect agent in wrong vaporizer.
Tipping - High concentration is delivered.
Overfilling – High, sometimes lethal concentrations are delivered.
Reversed flow.
Leaks – usually due to failure to replace the filler cap or to tighten it adequately.
Change of carrier gas.
Safety features incorporated are:
a. Use of back flow check valve at common gas outlet to prevent pumping effect.
b. Trilene interlock in some old machines is a mechanism which prevents operating
of trilene vaporizer and closed circuit at the same time there by preventing
formation of “Phosgene” a toxic chemical formed by reaction between trilene and
soda lime.
c. Construction of vaporizers with back flow compensation.
d. Use of only one precision vaporizer at a time facilitated by a locking device which
ensures that only one vaporizer can be turned on at a time.
e. Use of keyed filling devices to prevent filling of one vaporizer with a different
agent.
Safety measures to prevent development of excessive pressure on the machine and

breathing systems:
High pressures may develop upstream of the flow meters and be transmitted to the
backbar and the patient.
Safety blow off valves are often fitted on the down stream of regulators to allow escape
of gas, if by accident, the regulators were to fail and allow high out put pressures.
On an anesthetic machine, with regulated pressure of 60 psig, much damage might be
done if gases were flowing but the outlet or breathing circuit is obstructed; the whole
back bar would be subjected to pressure of 60 psig, patient may be exposed to that
pressure leading to barotraumas. For this reason, pressure relief valve may be fitted to
protect the backbar, which opens at 3-5 psig.
The breathing circuit itself has the APL valve to open at over 60 cm water pressure and
the reservoir bag which is made of compliant material but gives way when the pressure
exceeds 50 cm of H2O.
Whatever be the safety features incorporated in the machine, a thorough pre anesthetic
anesthesia machine check out [Cock Pit Drill] is a must to rule out any failure of these
features. Three points gain utmost significance when carrying out a daily machine
check. These are:
61

-Second Edition
1. To ensure that when we set a certain percentage of O2 the machine is giving that
percentage of O2
2. To rule out leaks in the system
3. To rule out obstructions.
The following protocol is done to confirm the proper functioning of the safety features.
The protocol takes around 5-7 min and to a large extent protects against human errors
if performed routinely before starting a list, by the individual anesthesiologist.
1. Check high pressure system to prevent wrong gas connection. Before starting all
pipelines should be disconnected and cylinders shut off.
a. Check gas cylinders by colour coding and by label to confirm that they are
connected to correct yoke.
b. Open O2 cylinder, verify that it is at-least ½ full
c. Open O2 flow control valve and register flow of 4-5 Lt /min.
d. Open N2O flow control and note that the flow meter registers no flow.
e. Close the flow meter & note bobbin falls to zero.
f. Listen to O2 pressure failure alarm if present.
Check O2 pressure fail safe mechanism.

a. Open N2O cylinder and note the pressure in gauge.
b. Open the N2O flow meter. It should not register any flow as O2 line is not
pressurized
c. Open the O2 cylinder, now flow should be registered in both O2 and N2O flow
meters.
d. Close the O2 cylinder and note flow meter bobbins in both fall to zero and O2 fail
safe alarm is activated.
Check the pipeline supply – Pipeline pressure should be between 55 and 60 psig.
Check initial status of the low pressure system (flow control knob to common gas
outlet)
a. Close the flow control valves and turn vaporizer off.
b. Check fill level and tighten the filler caps.
Perform leak test of machine low pressure system
a. Verify the flow control valves are closed.
b. Attach suction bulb to common gas outlet.
c. Squeeze the bulb repeatedly till it is fully collapsed
d. Verify that it stays fully collapsed for at least 10 sec.
e. Open vaporizer one at a time and repeat suction bulb test again.
f. Remove the suction bulb and reconnect the breathing system hose.
62

-Second Edition
Test flow meter.
a. Perform a test flow of all gases through their full range checking smooth
operation of the floats.
b. If the machine has proportioning device, attempt to create a hypoxic mixture and
verify the correct changes in flow.
Turn on the main switch (if present) and all electrical monitoring equipment. Connect
breathing system and O2 analyzer (if available)
a. Calibrate to read 21% at room air.
b. Connect to common gas outlet and flush with 100% O2, verify that it reads over
95%.
Check breathing systems – that it is complete, undamaged and unobstructed.
Perform leak test of breathing systems.
If Bain system is used, check integrity of inner and outer tubes separately.
Check ventilator as per manufacturer’s instructions.
Check laryngoscope, suction, self inflating AMBU bag, endotracheal tubes, air ways,
masks and other accessories for intubation.
MAINTENANCE OF ANESTHESIA EQUIPMENT

Arrangements should be made to ensure that all anesthetic equipment is clean,
sterile, and in good working order.
Maintenance of anesthesia machine falls into 3 categories.
1. Day to day cleaning, replenishment of empty cylinders, vaporizers, general
fitting.
2. Planned preventive maintenance (PPM)
3. Break down repairs.
In case of essential apparatus including life support systems, the scale of equipment
should be such that if one particular item were to break down, sufficient serves are
available on which one would call to continue the service.
Items of anesthetic equipment that are faulty should “Never” be sent to ordinary
hospital engineer. Since although they are mechanics, they are often ignorant of
principle of anesthetic equipment. Service engineers from appropriate manufacturers
should attend to such problems.
PPM should be carried out at regular intervals, usually every 3 months for machine and
every 6 months for ventilators.PPM is best undertaken by manufacturer’s engineers.
With regard to malfunction or apparent break down, repairs are better initiated by
reporting the incident first to consultant anesthesiologist responsible or to the
Electronic and Biomedical Engineer (EBME).Ordinary hospital engineers should not be
allowed to tamper with the equipment.
The EBME department should obtain circuit diagrams etc. of equipment under its care.
63

-Second Edition
64

-Second Edition
Chapter 14 - ELECTRICAL HAZARDS IN OPERATION THEATRE
Tremendous progress has been noticed in the field of Medical Science in the past three
decades. A large part of this progress can be attributed to the development of diagnostic
equipment-A Marvel of progress in Electronics. Likewise the safety factors involved in
the use of these equipment have also assumed importance. It is heartening to note that
the aspects of safety are also being put to a thorough test by the manufacturers before
the instruments are released into the market. As a large number of surgical and
diagnostic equipments are used in the operation theatres and ICU's. There is an express
need to undertake precautions to prevent electric injury to patients and personnel
Thus, a medical electrical equipment, which is a single, self contained unit, provided
with a single electrical connection to the supply mains, which is for use in that patient
environment and related in such a way that the patient's safety can be influenced is a
description often used to describe all electrical equipment used in the operation theatre.
After much study, it was found that the best electrical current that could be supplied to
various consumers without loss during distributions has been found to be 240 V AC at
50 Hz. Unfortunately, this right frequency has been associated with damage to muscles,
nerves and respiration.
The effect of A.C. current can be in the form of macro shock-where a person gets
incorporated into a current circuit. The current enters the body through a contact point
and leaves through some other point. This could happen:
1. When a person comes into contact with wires of an electric circuit i.e., the 'hot'
and neutral line.
2. With the 'hot -line and the 'ground' line.
3. With a part that has come into contact with a ground and the person in contact
with a ground forming a leakage pathway, in which case, the current flowing
through the person would be inversely proportional to their respective
resistance.
The magnitude of damage depends upon:

1. Tissue resistance: Different tissues have different electrical resistance. Dry skin
has a resistance of 1 M Ohm, while skin which is sweating has a resistance of 15 K
Ohm. Likewise, punctured skin can provide 1000 Ohm resistances and the internal
organs can provide resistances varying between 2000-5000 Ohm. Tissue damage
depends upon the direction of current. It is maximum, if current passes vertically
through the body.
65

-Second Edition
Potential difference: High voltage of alternating current may cause both electrocution
and thermal injury.
10% of the current can pass through the heart if current passes vertically thorough the
body. Ventricular fibrillation can occur when a current strength of 90-100ma is
indirectly applied to the heart.
2. Frequency: The heart is most vulnerable to the normal distribution frequency of 50
Hz at 240 volts A.C.
3. Duration of contact: The muscular effects are reversible after short periods of
contact.
4. Individual patient’s response-women apparently are more vulnerable.
5. Arcing-Arcing between loose ground plate and skin.
6. Local electrochemical changes which can occur due to ionic movements in tissues,
8. AC/DC
9. Size and area of contact.

Diathermy is most frequently used in operation theatres. The principle involves the
passage of high frequency electrical current higher than 20-KHZ. It has been shown that
currents above these frequencies do not cause electrocution. At the active electrode, a
high density current is released and this could be used to burn tissues and coagulate
blood vessels.
There is an indifferent electrode of a large surface, which is fixed to a limb. The current
flows through this circuit. As opposed to the unipolar cautery, the bipolar cautery
consists of two prongs which allow current to pass through the smallest gap between
them. The bipolar cautery today is the 'preferred choice as a loose ground plate could
become a source of a thermal burn. Secondly, occult capacitance could also occur due to
a defective circuit or contact with the operation table or ECG line.
The intensity of injury depends upon the following factors: 1. voltage of current, 2.
ampere range 3.frequency 4.AC/DC 5.Duration of contact. 6. Size and area of contact.
The human being is made of various constituents like blood, muscle, fat, ligaments etc.,
each having its own electrical resistance with the fat having the highest. The intact dry
skin which acts as a resistive bag may provide a resistance as high as 1 mega ohm. With
a perforated skin, the resistance could come down to 100 ohms. Application of
conduction jelly can also bring down the resistance to 1000 ohm.
66

-Second Edition
Features that make patients in OT/ICU vulnerable to electrocution-
The patient under anesthesia may not be able to withdraw himself due to his
unconscious state or restriction.
The electrical current may be passing through an instrument into an area of high
conductivity like an open abdomen.
Monitors, transducers could be in direct contact with high power circuits. (this
hazard has been largely eliminated in latest circuits)
Draped alcohol containing scrub fluids, electrolyte solutions, use of oxidizers like
N2O and Co2 and a dry atmosphere, all of which can increase the risk of
electrocution and also cause an electric fire.
Added to these factors, an element of human error could also be responsible for
the causation of a shock hazard. In addition, both the Patient and handler could
be affected by the current during routine use or due to inherent defect in the
continuity. The resultant injuries to the patient could also result in thermal,
mechanical, chemical or electromagnetic effects.
Even though the use of flammable anesthetics has been completely eliminated,
the presence of oxidizers like oxygen and nitrous oxide as supporters of
combustion should always be kept in mind. Hence, the standards of electrical
equipment should not result in the causation of electric hazard.
It is ironical that electrical current could be used to defibrillate a heart which is
fibrillating and also could result in fibrillation in a normal heart. The resistance
between the chest wall and heart being around 80 ohm, a current of about 04 A
can produce arrhythmia. If an electrode is placed near the heart, a current
strength of 100mA AC is enough to cause rhythm anomalies. A DC current of
nearly 5-6 times may be required to cause similar changes.
Effects of an electrical current depend upon its intensity:

1-5mA-tingling sensation
15 mA- ‘let go’ current
50 mA- muscular contraction
100 mA-ventricular fibrillation
Above this rating respiratory paralysis.
High intensity burns, Death
A Micro shock, is defined as an accidental passage of minute electrical currents by
some path directly through the body or heat via some medically intentional, indwelling
electrical conductor. Earlier, intravenous, transthoracic wires cautery points were
sources of such current leakages.
67

-Second Edition
A current sufficient to produce tingling say, 500 micro amperes in the skin is capable of
causing a cardiac arrhythmia as the combined resistance inside the thorax could be very
low compared to that of the dry skin.
This increase in current intensity can be expressed through the equation I=ER, where I
represents current, E=voltage and the resistance. ‘I’ will increase when 'R' decreases
and 'E' remains constant, conditions thus becomes favorable when current passes
through conductive tissues.
Adverse effects of electrical injury:

Cardio-respiratory arrest
Neuronal damage
Burns
Anesthetic explosions
Electrocution to personnel
All hospital wiring systems start as a 3 wire system having a live, neutral and ground
wires. However, in an isolating transformer the equipment is connected to a secondary
circuit. The live and neutral circuits becomes line 1 and line 2 since current flows
through the isolated circuits by induction and no direct connection exists between the
equipment and the distribution system. This system also is sometimes referred as
'floating ground1 system. A ground fault alarm goes on, if there is a leakage current
exceeding 0.2 ma.
Leakage currents were a bane in all circuits that were directly connected to distribution
systems. Minute leakage were present in earlier systems due to faulty or damaged
insulation. The ground wire allowed these leakages to get grounded'. Potentially
harmful currents could "'leak' through patients and personnel if the ground is defective
or the current seeks an alternate pathway through, for instance a ECG cable. The
permissible limits of leakage current depends upon the type of equipment. Nevertheless
it should not exceed 0.1 ma.
Primary protection measures:

Many biomedical instruments are comprising of complex semiconductor based 'chips' in
their circuits. The low DC Current required by them for use will involve the use of lower
voltage in the patient circuits. Some of them also incorporate a DC battery powered
circuit which carries a lower power. Many pulse oximeters, and monitors are, examples
of this principle of isolation. The conductors are properly insulated and care is taken to
see that the line does not come in contact with the neutral and ground leads. A
protective earth lead connects all 'exposed' conductive parts to the common earth
which results in 'conducting away all leakage currents. If the current is large, then a fuse
68

-Second Edition
will be incorporated or a Miniature circuit broken MCB) will be incorporated so that -
currents as low as 30mA will trip the circuit.
Other safety measures that could be incorporated are:

1. While new OT's are being constructed, special care must be taken to ensure
electrical safety. Special conductive flooring, has been in use -for many years.
2. To prevent static electricity generation, all rubber equipment should be
conductive.
3. All distribution boards should be firmly fixed and placed away from the zone of
risk which is determined as 25cms away from the active gas pathway. Since
flammable liquids like alcohols, can reach the bottom of the OT tables
4. All distribution boards should have individual residual current circuit breakers
and fuses of proper rating.
5. The BS 5724 for class 1 equipment permits a leakage current of less than 0.5ma
Hence, all equipment from one single distribution point should have a common
grounding.
6. Distribution boards should withstand at least 15ma load. However, the total
current load imposed by multiple equipment should be kept below this
maximum limit.
7. All plug points should have covers when not in use. The cabling should confer to
ISO standards. They should be inspected frequently for breaks and damages.
8. All cable joints should be well made and covered with insulation tapes of BIS
standards. Under no circumstance, Zinc Oxide tape should be used as a covering.
9. Equipment which are likely to get heated like electrosurgical equipment,
defibrillators, lasers should be watched for abnormal heating (90°c). Plastic
disposables, alcohol containing solution, ether, rubber wear, should be stored
away from these equipment.
10. Domestic type equipment with 2pin plugs like music amplifiers, fans, should not
be connected to the same switch board to which electric equipment like
monitors are connected. These are likely to have a single layer insulation which
may be damaged resulting in large leakage current.
11. Isolation transformers may be preferred--wherever instruments like monitors
are directly connected to patients. In fact, many of the latest equipment either
use a fiberoptic cable or a battery current rather than a direct AC line.
12. The OT table could provide "capacity coupling' during use of diathermy. Hence,
appropriate care to be taken to see no direct contact, occurs between patient and
the table.
13. Such equipment which are marked 'Anesthetic Proof and category 'G' should be
used if flammable anesthetics are used.
69

-Second Edition
14. LASER INSTRUMENTS should be treated with great care, since ignition of
flammable material like endotracheal tubes, sprit, solution is a possibility.
15. Domestic MCB's are not suitable for OT use.
16. Use of multiplier plugs should be discouraged.
17. All repairs should be done by qualified biomedical engineers
Preventive maintenance is like the popular advantage A stich in time saves time. Thus,
despite introduction of safer electrical instruments, the remote possibility of an
electrocution to the patient must always kept in mind. Young anesthesiologists should
acquaint themselves with basic principles of Electrical safety.
70

-Second Edition
71

-Second Edition
Chapter 15 - MONITORED ANESTHESIA CARE (MAC)
Introduction:
It has become increasingly important in the practice of anesthesiology. In
most instances the patient is undergoing procedure LA in OT, diagnostic and
therapeutic procedures performed by use of minimal invasive techniques (fiberoptic or
laser) in outside the operating suits or in the office based setting. Anesthetists are often
consulted for sedation and monitoring of these patients as they are expertise in sedation
– analgesia.
Definition:
ASA defines MAC as instance in which an anesthesiologist has been called on to
provide specific anesthesia services to a particular patient undergoing a planned
procedure in connection with which a patient receives local anesthesia or in some cases,
no anesthesia at all. In such a case the anesthesiologist is providing specific services to
the patient in control of his or her vital organs and is available to administer anesthetics
or provide other medical care as appropriate.
The policy of ASA states that some standard of care should be provided by an
anesthesia practitioner during MAC as for GA or RA.
Provisions: MAC shall include the following
Performance of a pre-anesthetic examination and evaluation
Prescription of the anesthesia care required and personal participation or medical
direction of the entire plan of care.
Physical presence of anesthetist or medical direction of the resident or nurse
anesthetist.
Proximate presence or availability of the anesthesiologist for diagnosis or treatment of
emergencies.
Service provided by an anesthesiologist (include but not limited to the following):

Non-invasive cardio circulatory and respiratory monitoring.
Oxygen administration when indicated.
IV administration of sedative, tranquilizers, anti emetics, narcotics, other analgesics, -
adrenergic blocker, vasopressors, bronchodilators, anti hypertensive or other
pharmacologic therapy or may be required in the judgment of the anesthesiologist.
72

-Second Edition
Procedures performed under MAC:
I) Head and neck procedures:
III molar extraction
Blepharoplasty
Rhytidoplasty
Palate repair
Rhinoplasty
Endoscopic sinus surgery
Repair of laceration
Cervical node biopsy
Excision of neck mass
Cataract extraction
Trabeculectomy
II. Superficial thoracic procedure:
Breast mass biopsy
Breast mass excision
Excision of axillary node
Lipoma excision
ICD insertion
III. Extremity procedure:

Carpal tunnel syndrome
Trigger finger release
Tendon repair
Excision of neuromas
Removal of superficial FR
Knee orthoscopy
Closed reduction of fractures.
IV. GIT-abdominal surgery
Herniorraphy
Laparoscopy
Endoscopic retrograde cholangio-pancreatography
Gastroscopy
Colonoscopy
Percutaneous ultrasonic lithotripsy
73

-Second Edition
VI. Gynecology/urologic procedure
D&C
Laparoscopy fulgaration of Vaginal & anal lesions
Cystoscopy
I and D of bartholin cyst
Transvaginal ovum retrieval and other in vitro fertilization procedure.
Circumcision.
Vasectomy archiopexy .
ESWL
ROLE OF MAC IN ANESTHESIA PRACTICE: With the technology of minimum invasive
surgery and the development of rapid and short acting sedative and analgesia the
number of variety of procedure being performed in the outpatient setting is increased
and MAC technique are likely to become widely used in the future.
Anesthetic procedure performed under MAC:

With LA with sedation
Sedation + analgesia technique
When MAC technique compared to RA and GA advantages being
1. Shorter recovery time
2. Decreased use of drugs and disposable anesthetic supplies
3. Lesser duration in OT with higher awakeness score
4. Decreased post operative pain, sore throat, a reduction in perioperative costs.
MAC techniques:
Local anesthesia and MAC:
Variety of procedures performed LA or regional technique with much advantages.
They are:
1. May avoid common side- effect of GA
2. Minimize the risk of aspiration pneumonitis
Post-anesthesia care
3. Provide residual analgesic in the early post op period.
Disadvantages: Patients are reluctant to undergo LA or regional anesthesia without
supplemental medications because of the a) discomfort of the local injection, concern
about b) Incisional pain and c) awareness during surgery.
Anxiety regarding can be eliminated by pre-op explanation of the anesthesia.
Recurrence - Patient is explained that adjuvant therapy is available to control
pain and provide sedation, amnesia and anxiolysis.
74

-Second Edition
a) Peripheral nerve block
1. Hernia block – Herniorraphy
2. Paracervical block – D&C
3. Penile block – Circumcision
4. Brachial P. block – arm forearm hand surgery
5. Peri & retro bulbar – Ophthalmology surgeries
6. Mandibular / maxillary n-block – oral surgery
7. IVRA – Arms and legs.
b) Tissue infiltration and wound instillation
1. Cosmetic and ENT procedures (Blepharoplasty, SMR, sinus surgery)
2. Excision of mass biopsy (breast, axilla, lipoma)
3. Field block (hernia repair)
4. Laparoscopic procedures (tubectomy, Cholecystectomy)
5. Thoracoscopic procedure.
c) Topical analgesia:
1. EMLA (lithotripsy i.e. skin grafts)
2. Lidocaine spray (endosopy)
3. Lidocaine gel or cream (circumcision, urologic, oral surgery)
4. Cocaine push (nasal, endocrine surgery)
II) Role of sedative – Analgesics drug in MAC
Sedation with LA
1. Used to alloy anxiety and fear associated with OR and surgical procedure.
2. Prior administration can discomfort associated with painful injection of LA
3. Drugs used – Diazepam, Midazolam, Propofol
Analgesics with LA
1. To pain during administration of local injection
2. To discomfort of positioning
3. It also produces some amount of sedation
Widely used drugs are
1) Fentanyl – Mostly used, with onset of 3-5 min i.e., 45-65 min.
2) Alfentanyl – Given intermittently or continuous infusion
3) Remifentanyl – Extremely short acting 3-5 mins duration given intermittent or
infusion.
When centrally acting sedatives / analgesics are given in it should be
individualized to patients discomfort, patients drug and medical history.
75

-Second Edition
In order to prevent o cardio-respiratory depression it is better given in infusion or PCA
technique.
Combination of sedation + analgesics

There is a ever present risk of synergistic interaction between sedative and analgesic
drugs with respect to cardio respiratory depression. So
Careful titration of these drugs
May diminish
Use of Supplemental O2
undesirable
Vital organs monitoring
complications of the
Various combinations are:
drugs
Midazolam + fentanyl
Propofol + fentanyl / alfentanil / remifanil
[However short acting analgesics fen, remi, alfentenil with propofol are much better
combination with good recovery].
Ideal drug for sedation should have
1. Rapid onset
2. Predictable dose – effect relationship with respect to its action
3. Excitatory effect should be minimal
4. Minimum CVS and RS depression
5. Rapid recovery
Propofol – It fulfills a ideal sedation drug. Recovery is much faster when compared to
benzodiazepine.
Benzodiazepines –Diazepam and midazolam.
Midazolam comparatively better than diazepam for sedative, amnestic effects
with less pain on injection, short acting compared to diazepam. But midazolam dose –
response curve is much steeper and small margin of safety when compared to
diazepam. However diazepam recovery is late compared to midazolam.
Analgesics – Short acting narcotics like fentanyl, Remifentanyl and Alfentanyl and
sufentanil are preferred over longer acting. As these drugs are potent and duration of
action is minimal.
Demerits: As these drugs are potent cardio-RS depressants –careful titration of dose
should be considered.
Ketamine: 0.25 – 0.5 mg/kg /IV produce sedation / analgesia. It is widely used along
with benzodiazepam.
Others: N2O 30-50% in O2 + MAC of volatile anesthetics are also used.
76

-Second Edition
Recommended doses of sedative / analgesic during MAC
Sedatives:
Adult Pediatric
Diazepam – 5-10mg IV 0.05 – 0.2 mg/kg IV
0.02 – 0.5 mg /kg PO
Midazolam – 2.5-5mg IV, 0.035 – 0.1 mg / kg IV / IM
1-2µg/kg/min 0.3-0.7 mg/kg PO
Propofol – 25-100mg/IV
25-75 µg/kg/min
Thio – 50-150 mg IV Chlorhydrate – 25-100mg/kg PO or PR
Ketamine – 20-40mg IV
Antagonist Flumzenil 0 .5- 1mg Ketamine – 4mg / kg / IM
- 0.2 -1 mg / kg IV
Phenargan – 0.5mg/kg
Analgesics:
Adult
Fentanyl 25-50 µg, 0.5µg/kg/min
Alfentanil 0.25-0.75 mg – 5-10µg /kg
0.5-1g/kg
Remifentanil 12.5-25 µg 0.025-0.15 µg/kg/min
Sufentanil 1µg/kg
Opoid antagonist
Naloxone 0.1-0.4mg
VIII. Complications of MAC technique

Incidence was least when LA technique used alone.
Increased incidence were found in patient when combination of sedative
analgesics were used.
Incidence of complication was dependent upon site and type of surgery,
duration, patient with co-existing disease.
The common complications being – respiratory obstruction, hypoxia, circulatory
collapse secondary to arrhythmias
IX. Monitoring: ASA standard.
Standard I – Qualified anesthesia personnel to be present in the room.
Standard II – Objective measurement of patient oxygenation, ventilation,
circulation and body temperature. Ex: pulse oximetry, NIBP, ECG.
77

-Second Edition
However, vigilance of observer responsible for monitoring patient undergoing
procedure MAC remain the best protection against adverse event.
IX. Monitoring the level of sedation:
Observer assessment of alertness / sedation (OAA/S) scale

It is based on assessment in four separate categories
1) Responsiveness 2) Speech 3) Facial expression 4) Ocular afference.
Score 5 = Awake for test
Score 1= Deeply sedated.
(Demerits of the OAA/S scale - patient must be stimulated to perform the test and need
patient co-operation).
EEG – Bispectral index –shown to correlate with depth of sedation with that of
OAA/S scale.
Sedation visual analog scale.
Ramsay scale.
X. Discharge criteria after MAC technique
1. CVS function and airway patency are satisfactory and stable
2. Patient is easily arousable
3. The patient can talk (if age – appropriate)
4. Patient can sit up unaided.
5. For only young and handicapped – level as close as to possible to the normal
level for that child should be achieved.
6. The state of hydration is adequate
78

-Second Edition
Chapter 16 - HUMIDITY AND HUMIDIFIERS
Is a general term used to describe the amount of water vapor in a gas.
Absolute humidity: is the mass of water vapor present in a volume of gas.
Expressed in mg of H2O / liter of gas.
Humidity at saturation:
Maximum mass of water vapor that can be carried in a given volume of gas is the
humidity at saturation.
It varies with temperature.
Relative humidity or percent saturation: is the ratio of absolute humidity to the
humidity at saturation. Expressed as %.
Body humidity: refers to humidity of saturated gas at body temperature is at 370C 
44 mg H2O/L.
Interrelationships:
If a gas saturated with water vapor is heated it can hold more water – so relative
humidity , absolute humidity remains normal.
E.g.: gas with 100% saturated vapor at room temperature  warmed to body
temperature without additional humidity  will be only 40% saturated.
If gas saturated with water vapor is cooled  it will condense absolute humidity
but relative humidity will remain 100%.
So to achieve relative humidity of 100% in inspired gas, humidified air should be
maintained at body temperature of heat it above body temperature and is allowed to
cool to body temperature as it flows to the patient.
CONSIDERATIONS FOR ANESTHESIA:

Normal mechanics of humidification (unintubated patients):
Inspired gas is brought to body temperature and 100% relative humidity during
passage to the alveoli. It is done by upper respiratory tract (nose)  which acts as heat
and moisture exchanger. Water is lost by body as saturated vapor in expired gases and
heat is lost mainly because the heat of vaporization of water must be supplied by the
body.
Effects of anesthesia:
As water is intentionally removed from medical gases (piped or cylinder) – to
prevent corrosion and condensation in regulators and valves. Gases emerging from
anesthesia machine are dry at room temperature. Tracheal intubation bypasses the
79

-Second Edition
upper airway, so that tracheo-bronchial mucosa must assume more of burden of heating
and modifying gases before they reach alveoli. To some extent breathing system, t-tube
performs the function of upper airway in condensing expired moisture and adding it to
inhaled gases but rather less efficiently.
Damage to respiratory tract:

Respiratory tract mucosa dries as its temperature  thickened secretions -
ciliary function  surfactant activity  mucosa more susceptible to injury.
Dried secretion: Plugging of tracheal tube or obstruction of lower airway  atelectasis
 FRC, compliance, alveolar – arterial O2 difference → Thickened secretion 
loci for infection.
Dry gases: bronchoconstriction (in sensitive individuals)
Complete cessation of ciliary activity occurs following prolonged exposure to inspired
gas with an absolute humidity to < 22 mg/L.
Recommendation: to prevent pathological changes  12-35 mg H2O/L but
international standard on humidifiers considers 30 mg of H2O/L to prevent –
pathological changes to dry gases. Some recommend 34-37 mg H2O/L (mimicking
respiratory tract system).
However effect of dry gas inhalation depends upon the time of exposure.
time of exposure  damage to respiratory tract mucosa or pulmonology
complications.
Loss body heat:

Body temp is as inspired gas is brought equilibrium with body temp and
saturating it with water.
This is a problem in pediatric pt.
So shivering O2 demand  CO during immediate postoperative use of humidification
will prevent heat loss that normally occurs in anaesthetized patients.
Summary:
Importance of humidification in anesthesia remains uncertain. It is of greatest
benefit in
1. Pediatric patient
risk for developing pulmonary complications
2. Long duration of surgery
Sources of humidity:
1. CO2 absorbent.
2. Exhaled gases
80

-Second Edition
3. Moistening breathing tubes and reservoir bag.
4. Heat and moisture exchangers
5. Humidifiers
6. Nebulizers
Heat and moisture exchanger:

HME  conserver some of the exhaled water and heat and returns them to
inspired gases.
Also called:
- Condenser humidifier
- Swedish nose
- Artificial nose
- Passive humidifier
- Regenerative humidifier
- Moisture exchanger
- Vapour condenser
Description:
15 mm female connection port  proximal (pt) end.
22 mm male  distal end.
May be  port for aspiration of respiratory gases.
Hygroscopic HME 
- Coated with moisture retaining chemicals
- Impregnated with bactericide
- Large pore felt layer  filtration
Hydrophobic HME:
- Pleated membrane
- Microbial filters
- Allow passage of water vapour but not liquid water.
Dead space:
- Varies
- Pediatric and neonatal HME  dead space and resistance.
Delivery tube conveys humidified gas from humidifier outlet. It may be heated to
body temp
Action Exchange of heat and moisture between gas and the surface over which it
flows.
81

-Second Edition
Expired gas normally saturated when it comes into contact with a surface at lower
temperature, the gas is cooled and some vapor condenses onto the surface. Surface is
warmed.
Inspired gasDry when comes in contact with same surface takes up vapour and it is
also warmed.
Performance:
Inspired humidity achieved using HME depend on
- Humidity of inspired gases
- Inspiratory and expiratory flows
- Efficiency of HME
Hygroscopic and hydrophobic HME  more efficient
Decrease performance > 2 – 3 hrs - performance.
Connecting HME in series  performances
Uses:
HME  placed between patient and breathing system, as close to patient as
possible.
Can be used with any breathing system (or) ventilator.
Especially useful during transport of intubated patient.
Pressure – sensing  for an airway pressure monitor placed between patient
and HME.
Nebulizer  Inserted between HME and tracheal tube.
HME  used as sole source of humidity (or) may be combined with another such
as an unheated humidifier.
Hazards 
Obstructed due to  fluid, blood, secretions.
Weight of HME  kinking of tracheal tube
Particles (or) dust from HME  inhaled by patient
Large leaks  by separation of parts
Dead space  re breathing.
Advantages of HME:
Inexpensive
Easy to use
Small
Light weight
82

-Second Edition
Reliable
Simple in design
Low compliance and resistance
Do not require water, energy source (or) temperature monitors (or) alarms
No danger of over hydration burns of skin and respiratory tract (or) electric
shock.
Barrier to passage of bacteria.
Prevent inhalation of large particles.
Disadvantages
Limited humidity.
Some loss of water from tracheo-bronchial tree
Not suitable for lengthy cases.
Not suitable for copious (or) thickened secretions, poor hydration (or) airway
injury.
Increase dead space.
Humidifiers:
A humidifier (vaporizer or vaporizing humidifier) is an instrument that passes a
stream of gas over water (or) across wicks dipped in water (pass over) or
through water (bubble).
Unheated humidifiers:
- Usually disposable
- Bubble through
- Via face mask (or) nasal catheter
- Not > 9 mg H2O/L
Heated humidifiers:
- Use in anesthesia
- Electricity to supply heat
Description:
1. Humidifying chamber  from which water derived.
2. Heat source 
- Heated rods  immersed in water (or)
- Heated plate at the bottom
3. Delivery tube  Conveys humidified gas from humidifier outlet. It may be
heated.
83

-Second Edition
4. Temperature monitors  to measure delivered gas temp.
5. Thermostats  servo controlled units.
Non servo controlled units
There are 2 thermostats in series so that if one fails, the other will still cut off the power
supply before dangerous temperature is reached.
Controls:
- Temperature
- Relative humidity
- Saturated vapour
Alarms  Warns temp deviation.
- Temperature deviation from set temperature at patient end.
- Temperature probe  not correctly placed
- Heater wire not connected
Action:
Superheating  some, humidifiers heat gas to a temperature exceeding the
desired patient airway temperature so that cooling that occurs as it flows to
patient will result in desired temperature at patient connection.
Some humidifiers  temperature increase as it passes through the delivery tube,
so that gas with < 100% relative humidity is delivered.
Standard requirements: International standard
Intubated patient  30 mg/L of gas at least, upper airway – 10mg/L of gas.
Servo control mechanism > 20C fluctuation at delivery tube outlet.
Humidifier is heated  gas temperature not > 410C at delivery tube and activate
auditory and visual alarms if temperature > 410C.
Accessible surface  not > 550C if metal (or) 750C if nonmetal.
No spillage of water  if humidifier tilted 200.
All operator controls and digital indicators  accurate with in 10% of their full
scale value.
If humidifier, is capable of producing water > 44 mg/L  warning on humidifier
that increase water can be delivered.
If intended to be placed in breathing system, connectors of 22 mm for adult use
and 15 mm for pediatric use.
Use:
Heated humidifier  most commonly used in circle system connected into
inspiratory limb downstream from inspiratory unidirectional valve.
84

-Second Edition
If bacterial filter used  it should be upstream of humidifier to prevent it from
clogging.
Humidifier always kept at lower level than the patient.
Clear tubing used  water can be seen.
Condensed water  drained periodically (or) water trap – in dependent part of
delivery tube.
Humidification chamber and delivery tube  changed between patients.
Advantages:
Most heated humidifiers are capable of delivering saturated gas at body
temperature or above, even with high flow rates.
Disadvantages:
Bulky and difficult to mount.
Difficult to clean and sterilize
Costly than HME.
Water level  checked periodically
Needs electrical power.
Hazards:
Bacterial contamination  bubbling heated humidifiers.
Breathing system problems  sticking valves, leaks, disconnections,
obstructions, clogging, melting of delivery tube.
Water splashing back in to machine  if humidifier placed in fresh gas line and a
sudden obstruction occurs.
May change breathing system volume and compliance.
Over hydration  in infants
Undesirable heat gain
Water may enter ETT and drown the patient or cause burns of respiratory tract.
Fires  by short circuiting of heated wires.
Halothane  may altered by passage through humidifier.
May add enough resistance to prevent activation of low airway pressure alarm, if
sensor is upstream of humidifier.
Hyperthermia, tracheitis, respiratory tract burns  if temperature > 400C body
temperature.
85

-Second Edition
86

-Second Edition
Chapter 17 - NEBULIZERS
Description:
Nebulizers are also called aerosol generators, atomizers and nebulizing
humidifiers.
Nebulizer is an instrument that emits water in the form of an aerosol mist.
Commonly used – pneumatic and ultrasonic.
Provides  humidification and deliver drugs to breathing system.
Use:
Pneumatic nebulizer  because high flow of gas must be used it is placed in
fresh gas line.
Ultrasonic nebulizer  can be used in fresh gas line or inspiratory limb.
Hazards:
Nebulized drugs  may cause obstruction of HME.
Deleterious effects on lungs  used for prolonged time.
Bronchospasm
Over hydration
Hypothermia  if droplets are not warmed.
Transmission of infection.
Advantages:
Nebulizers can deliver gases saturated with water without heat and can
produce gases carrying more water.
Disadvantages:
Costly
Pneumatic Nebulizer  requires high gas flows.
Ultrasonic Nebulizer require electricity and thus electrical hazards
Water deposition  in tubing’s, requiring frequent draining and posing dangers
of water draining into patient and blockage of tubing.
87

-Second Edition
Chapter 18 - VENTURI MASK
Face masks are used for oxygen therapy. Also known as a high airflow oxygen
enrichment device. It is a type of fixed performance device.
Classified into:
Simple
Partial rebreathing.
Non rebreathing.
Air entrainment.
Fixed
Patient independent
Patient variable
Patient dependent performance.
Working principle:
Bernoulli principle: lateral pressure =1/ surface area
Venturi principle: when fluid or gas flows from region of constricted to a wider
area, velocity decreases and lateral pressure increases. To regain same pressure
on the downstream of constrictor, tube must open out gradually.
Indications:
Where fixed oxygen concentration is needed.
Where ventilation is dependent on hypoxic drive.
Cyanotic
Following major operation, chest wounds, rib fracture.
In shock, severe hemorrhage, coronary occlusion.
To decompress distended bowel, reduce surgical emphysema, pneumothorax,
and air embolism ( along with 20% N2)
When metabolic rate is high – thyroid crisis, hyperthermia, shivering.
In CO poisoning leading to decreased respiratory drive.
Pre-oxygenation before induction of anesthesia.
In the treatment of pnemocystitis coli.
Contains:
Plastic facemask with holes on both side.
Proximal end of the mask incorporates venture device.
88

-Second Edition
This device is colour coded and recommended oxygen flow rate to provide
required oxygen concentration is marked.
OXYGEN OXYGEN FLOW AIR
CONCENTRATION(%) (L/min) ENTRAINMENT(L/min)
24 2-4 50-100
28 4-6 40-60
32 6-8 56
36 8-10 40
40 8-12 24-36
Resultant mixture of gases produces stable inhaled concentration of oxygen (24-

40%) depending on the bore of the oxygen injector.
Expired gases passes out of the holes and mask.
High flow of gases into the facemask, results in constant inhaled concentration of
patients ventilation.
No apparatus dead space.
Fio2 delivered to patient is 5% less than the read one because of dilution.
89

-Second Edition
90

-Second Edition
Chapter 19 - RUBEN (NON-REBREATHING) VALVE
This is a non-rebreathing valve, allows respiration to occur only from the
reservoir and permit the expired gases pass only to the atmosphere. Thus it prevents
rebreathing by ensuring the unidirectional flow of exhaled gases outside the circuit.
Advantages:
1. The inspired concentration of gases and vapors can be accurately controlled as
there is no mixing with the exhalations.
2. It helps to dissipation of heat and elimination of water vapor.
3. Used for both spontaneous and controlled ventilation.
Ideal non-rebreathing valve:

Competent, leak proof, of low resistance, and with minimal dead space.
Light weight and transparent.
Require minimal pressure for opening the valve.
Easily cleaned and sterilized.
In expensive
Common, re-breathing valves are--------
Stephen slater valve, Fink valve, Ruben valve and AMBU valve.
Ruben valve:
This is a transparent piece of non-rebreathing valve.
It has a clear plastic body with metal fitting. One end of it is connected to the patient via
face mask on endotracheal tube and other end to the gas supply. The perforated end is
to void the exhalation to the atmosphere.
- It works on a bobbin which moves against the tension of a light spring.
- It has a dead space of about 9ml. The cleaning of this valve is usually difficult.
Dust accumulate inside and the bobbin may stick easily.
- Rubber valve mark II obviates such disadvantage.
91

-Second Edition
Mechanism of action:
Weak spring holds the bobbin away from the expiratory port. so, it occludes the
respiratory port. so, it does not hinder the expiratory flow from the patient end. So, the
reservoir beg will be filled with the fresh gas.
When the bag is squeezed, the bobbin is forced to close the expiratory port and
the patient is allowed to take fresh gas.
It can be effectively sterilized by soaking with 5% chlorhexidine in water 5 min in gas

sterilization.
Disadvantage:
Due to the high flow rate it has tendency to block the expiratory port and gets
jammed. In this case the fresh gas will be mixed with the expiratory gases and can also
cause Barotrauma.
92

-Second Edition
93

-Second Edition
Chapter 20 - RAE – TUBE (RING – ADAIR – ELWYN)
Pre-shaped (or) preformed tubes.
Plastic tubes longer than most other tubes.
Nasal and oral versions available.
Uncuffed – Pediatric tubes
o Have 2 lateral ports near the tip, one above the bevel and other
opposite the bevel.
Cuffed 
- Low pressure cuff.
- Adult tubes
- Murphy eye port opposite the bevel to provide ventilation if bevel is occluded.
Nasal tubes:
Slightly longer than oral tubes.
Acute upward bend at the place of emergence from the nose.
Maxillo-mandibular, oral, dental and neck surgery facilitated.
When in place outer portion of the tube is directed over patients forehead.
Reduces pressure on the nares.
Oral tubes:
Shorter than nasal tubes.
External portion bent at acute toward the concavity of curvature of the tube, so
that when in position it rests on patients chin.
Each tube has a rectangular mark at centre of the bend. Distance from this mark
to the distal tip is printed on each tube.
In majority of cases when this mark is at the teeth (or) nares, cuff will be
satisfactorily positioned in trachea, if proper diameter tube for the patient is
selected.
Advantages:
Easy to secure and decrease risk of unintended extubation.
Breathing system connection can be placed away from surgical fields with out
use of special connectors.
Protect against kinks.
Disadvantages:
Difficult to pass suction catheter.
94

-Second Edition
Offer more resistance than conventional tubes since they are designed to fit
average patient, tube may be either too long (or) too short for given patient.
When selecting tube size, reference to height and weight may be more useful
than age
Possibility of bronchial intubation (or) accidental extubation.
95

-Second Edition
Chapter 21 - ARMORED TUBES
Also called spiral embedded tube /Flexo-metallic tubes / reinforced tubes / metal
woven tubes.
- These tubes have a metal (or) nylon spiral wound reinforcing wire covered both
internally and externally by rubber, latex, PVC (or) silicone.
- The spiral does not extend into proximal and distal ends.
- A forceps and / or a stylet will often be needed for intubation.
- Only proximal machine end of tube is of sufficient length to accommodate a
straight slip joint (straight tube connector).
- Care must be taken to be sure that the slip joint completely fills machine end of
tube.
Indications:
Most head and neck surgery.
Maxillo-facial surgery – common do procedure.
Intracranial neurosurgery.
Abnormal positions  hyper flexion of head / chest
o Prone position
o Severe hyper extension.
- Surgery entailing compression of neck (or) airway.
Advantages:
Resistance to compression (or) kinking.
Portion of tube, outside the patient can be easily angled away from surgical field
without causing kinking.
Spiral embedded silicon tube  less pressure on larynx.
May pass more easily over a fiberscope than a tube with preformed curve.
Disadvantages:
- Tube may rotate on stylet during insertion.
- Insertion through nose is difficult and sometimes impossible.
- Because of the spiral, these tubes cannot be shortened.
- Secure fixation is more difficult.
- Reports of respiratory obstruction, most have been with tubes that have been
resterilized.
- Kinking could occur at the patient and if connector were not pushed down into
spiral.
- Cuff deflation occurs relatively frequently.
- Failure of cuff to deflate as a result of debris in pilot tubing (or) double layering
of cuff.
96

-Second Edition
Chapter 22 - LASER SHIELDED E.T. TUBE
Plastic and rubber tubes can be ignited by heat of laser becomes.
Rubber tubes  readily damaged.
Plastic tubes  catch fire.
- To withstand heat of laser beam and avoid ignition, tubes are currently formed of
a material of silicone impregnated with metal particles (aluminum oxide).
- All cuffs inflated with saline, because an air interface may result in some fire (or)
principally bursting of the cuff.
First endotracheal tube:

- Standard red rubber tube with latex rubber cuff, wrapped with a spiral overlay of
metallic tape from upper portion of cuff joined upto 5 cm superiorly along the
tube.
Advantages:
Reusable after proper cleansing.
Non inflammable, although it may be punctured by laser beam.
Disadvantages:
Difficult to wrap the tube smooth and have tape adhere.
Tape may crumble or fragment .
Norton tube:
Resembles “Goose neck” lamp stand. Reusable, flexible, spiral wound metal tube
with stainless steel connector designed for laser surgery.
Exterior of tube  matt finish to reflection of laser beam.
Finish  obtained by creating microscopic pits from which laser beam deflected
in all directions.
It has no cuff.
Separate cuff may be placed over distal tip or packing can be used to achieve a
seal.
This tube is acceptable for use with KTP, Nd-YAG, and CO2 lasers.
Disadvantages:
Total airway seal not possible – no cuff and requires special ventilating
techniques.
If separate cuff is used, cuff and its inflating tube can be ignited.
97

-Second Edition
Tube leakage through spiral joints  flexible coils are not airtight and angulation
can result in large leak.
Rough exterior surface  tissue damage.
Large external diameter and stiffness  surgical exposure and positioning of an
operating laryngoscope difficult.
Tube tends to twist on stylet during intubation.
Expensive.
Laser – flex tracheal tube:

Flexible stainless steel tube with smooth surface designed for use with CO2 and
KTP lasers.
- Adult version  2 PVC cuffs and PVC tip with murphy eye.
- 2 cuffs are inflated by 2 separate inflation tubes which run along inside of tube.
- Distal cuff can be used if proximal one is damaged by laser.
- Small uncuffed tubes are available.
- Distal cuff filled first until sealing occurs, then proximal cuff filled with saline
colored with methylene blue.
- Cuff and distal tip  vulnerable to all lasers.
Disadvantages:
- Stiffness and roughness
- Cannot be trimmed, can be bent and will hold its shape.
- Double cuff  time of intubation and extubation.
- Large diameter  problem in small patients.
- Expensive.
Advantages:
- 2 cuffs – added safety.
Sheridan YAG tracheal tube:

- Clear PVC with Murphy eye designed for used to Nd-YAG laser.
- Tube has no markings.
- Tube size indicated on pilot balloon.
- Ignited – when drops of blood or saline or mucus applied to outside of tube.
Bivona foam – cuff laser tube:

- Aluminium and silicone spiral with silicone covering.
- Use with CO2 laser.
- It has a self inflating cuff that consists of polyurethane foam sponge with silicone
envelope.
98

-Second Edition
- Cuff retains its shape and keeps a seal when it is punctured.
- Inflation tube – runs along exterior of tube and is coloured black so that it can be
positioned away from areas where laser will be used.
- High incidence of sore throat with this cuff.
- If inflation tube is severed or cuff punctured, the cuff cannot be deflated.
Other considerate in laser surgery:

- All operating room personal were protective glasses to deflect stray laser beams.
- Patient eyes protected with damp eye pads.
- All drapes – cloth or nonflammable paper.
- Cuff filled with methylene blue sterile water in case of cuff puncture with laser
beam to reveal a leaking system and potential aspiration.
99

-Second Edition
Chapter 23 - COLE’S TUBE
Introduction:
As the narrowest part of airway in pediatric age group is subglottic region, the
ETT which can pass through vocal cords may not be able to pass through subglottic
region. Forceful insertion of ETT in these patients will lead to trauma and subglottic
edema which is a dangerous complication.
The cole tube was designed especially for neonates, infants and younger
children, to prevent the above said complication and to perform oral intubation. It was
used mainly for resuscitation and ventilation.
History:
It was designed by cole
Presterilized, disposable made by WILLIUM WARNE.
Parts:
Smallbore (patient end)  To go into trachea.

Shoulder: Prevents advancement into the lower part of the trachea, or into stem of
bronchus. The tube should not however be inserted so far that the widened portion
contacts larynx because this will result in pressure on, and possibly dilates larynx.
Large bore: Machine end
Bevel: 45 80 in relation to axis of the tube and opening faces to left when viewed
towards the concave aspect from machine end.
Designing:
- Manufactured from clear, nontoxic PVC
- Meets ANSI standards, and implantation test.
- It is fitted with a 15 mm endotracheal adapter.
- Presented in individual peel package, and gas sterilized, ready for immediate use.
100

-Second Edition
Sizes: According to inner diameter of the tracheal portion
Range 2 mm – 5 mm.
Advantages: The resistance to airflow to these tubes is less than the tubes of constant
lumen (but some other study found resistance more in cole tube).
Disadvantages:
Cannot pass nasally because wider part won’t go through nares.
Wide bore section increases dead space slightly, but this believed to be non
significant.
101

-Second Edition
102

-Second Edition
Chapter 24 - AMBU /LAERDAL RESUSCITATION / MANUAL
RESUSCITION.
Parts
Self inflating bag
O2 source port or O2 reservoir bag (2600 adult /600ml infant)
Non rebreathing valve or Rubin valve.
Sizes
- Adult  1600 ml volume
- Children  500 ml volume with pressure relief valve
- Infants  240 ml volume with pressure relief valve
Self inflating bag: Made of thick foam rubber so that in resting state it is inflated.
It is double ended: 1) One end has part of O2 source.
2) Other end has one way valve.
The gas inlet has 3 parts
O2 source inlet
Large bore air inlet
Non return flap valve
103

-Second Edition
Non-rebreathing valve:
Rubin valve: Contains spring loaded bobbin with the valve housing.
In spontaneous ventilation this valve has 0.8 cm H2O of inspiratory resistance and 1 cm
H2O of expiratory resistance.
It can get jam in inspiratory phase (during light plains) leading to over inflation of lungs.
Ambu ‘E’ valve: This has 2 labial flap valves.
- It needs high inspiratory flow rates to open the inspiratory limbs.
- Valve getting jammed is less here.
- Should not be used with automatic resuscitators.
The Ambu Hesse valve: Allows low resistance to gas flow due to large valve diameter.
Ambu E-2 valve

The Ambu mark III valve: Here there is no leakage across the valves at low flow rates.
Valve has 3 components
- Inspiratory leaf valve.
- Expiratory leaf valve.
- Mush room valve.
Diameter of valve hosing  34 mm
Weight  40 gram
O2 flow in
L/min FiO2
3 56%
5 81%
10 100%
12 100%
15 100%
104

-Second Edition
Ambu Resuscitator:
O2 L/min FiO2
13 85 – 100% } 1000 TV x 15 (RR)
4 > 40%
5 85 – 100% } 300 ml x 200
2 > 40%
AMBU BAG – Augmented Mechanical Breathing Unit
“AUGMENTED MECHANICAL BREATHING UNIT” AMBU
105

-Second Edition
Chapter 25 - RESERVOIR OR RESPIRATORY BAG
Respiratory bag / Breathing bag / Re-breathing bag.
Composition: Rubber Neoprene.
Loop is provided at the tail to facilitate drying neck- 22 mm female fitting.
Volume pressure relationship
Initial negligible rise in pressure till nominal capacity is reached.

- Rapid rise to peak and then plateau
- Further increase is volume---slight fall in pressure.
- Peak pressure is important & it is airway pressure that develops.
Uses:
1. Acts as reservoir of gases
2. Provides peak inspiratory flow ( PIF )
3. Allows rebreathing  Economy of gas
4. Assist / control ventilation
5. Visual / tactile observation
6. Protect airway from excess pressure ( shock absorber)
106

-Second Edition
7. Access the compliance of lung
8. To know Tidal Volume.
ASTM standard for Reservoir Bag:

1.5 Lt bag or Small bag  Peak pressure 30 cm H2O OR 50 cm H2O when bag
expanded 4 times volume
Larger than 1.5 Lt  35 cm H2O and 60 cm H2O
New bag: Develop greater pressure when first inflated so stretch and over inflate new
bag before use.
Disposable plastic bag: Inelastic ,so excessive pressure may develop.
Size selection:
- Patient size
- Breathing circuit used
- User preference
Large bag  Difficult to squeeze.
 Monitoring of spontaneous breathing difficult.
Small bag  Less safety fraction for distention
 Reservoir may not be enough.
Ideally  Bag should be 3 times tidal volume.
Always keep spare bag.
107

-Second Edition
108

-Second Edition
Chapter 26 - ACCESSORIES
MOUTH PROPS OR BITE BLOCKS:
A bite block (gag, Mouth prop). It is placed between the teeth or gums to prevent
them from occluding a tracheal tube or damaging a fiber scope and to keep the mouth
open for suctioning. It is also used during electro convulsive therapy and in unconscious
patients to protect tongue and lips. As the bite block does not extended in to the
pharynx. It is usually less irritating then an oral airway. A gauze sponge roll may serve
as a bite block. A bite block may be part of a device used to secure a tracheal tube.
MASK STRAPS:
It is also called as mask holder, inhaler retainer, head strap, head harness, mask
harness, mask retainer, head band, head restraining strap. It helps to hold the mask
firmly on the face. Its use may decrease leak. Atypical mask strap consists of thin strips
arranged in a circle with 4 or 6 projections.
The precise application of the straps is matter or individual preference. The
straps at the jaw may tend to pull the jaw posteriorly. Crossing the 2 lower straps under
the chin may result in a better fit. Another method is to insert a tongue depressor
transversely under the straps bellow the jaw.
Care must be taken that the straps are no tighter than necessary to active a seal
to avoid pressure damage from the mask or strap. They should be released periodically
and the mask moved slightly.
Particular care must be taken to maintaining the airway when using a mask strap
as obstruction is more likely to go unrecognized than when the mask is being held by
hand
INTUBATING FORCEPS:
Types:
1. Magill military forceps
2. Modified ROVENSTINE Magill forceps
3. Tongue forceps with rubber cushion.
Uses:
1. To guide the endotracheal tube in to the glottis (tonsillectomy)
2. To guide Levine tubes in to oesophagus
3. To insert pharyngeal packing.
4. To remove foreign body of dislodged tooth.
109

-Second Edition
CONNECTORS:
Any fitting that connects directly to the endotracheal tube is called as
endotracheal tube connector.
Parts:
1. The part nearest to the patient is called as patient end.
2. The part near to the machine is called as machine end.
Methods of connections:
o After endotracheal intubation the patient may be connected to the
anesthesia apparatus by two methods.
Connecting the anesthesia apparatus directly to the endotracheal tube or
breathing system.
By facing the mask over the tube and face. This is used as a temporary stop gap
until appropriate condition and equipment are present.
A connector is fitted into the machine end of the endotracheal tube. The non
tapered male end of patient end is available in a range of all bore sizes of
endotracheal tube.
The machine end is a male connector with a normal 15mm connector and is the
common size for all tube. The slip joint is available both in straight and curved.
The appropriately fitted connectors should fit snugly into the tracheal tube upto
the KNURL.
Straight connectors should be used for infants and children at least to age 6
years.
TYPES OF CONNECTORS:
Magill oral plain ET connection / curved:
Wide bore with maximum laminar type of gas flow.
Suctioning cannot be done through it.
It is less resistance.
Magill metal nasal plain ET connection / curved:
More acute curve
Turbulent type of gas flow
Suctioning cannot be done through it
It has more resistance.
Magill suction union type connection:
Suctioning can be done through it
Commonly used in lung surgeries.
110

-Second Edition
Cobs suction union type connection:
It comes with a black colored rubber cap.
Advantage of doing suction during anesthesia.
Gas flow can be laminar or turbulent type
1. Magill’s ‘Y’ type pediatric connection:
2. Rowbothomn right angled connection:
Wire threaded
Fits well to tracheostomy tube while giving anesthesia
Turbulent type of gas flow.
Note worthy universal connection – Metallic, Plastic.
111

-Second Edition
Chapter 27 - ANESTHETIC BREATHING SYSTEMS
Definition:
A breathing system is defined as an assembly of components, which connects the
patient’s airway to the anesthetic machine creating an artificial atmosphere, from and
into which the patient breaths.
The primary components of breathing system include:
1. A fresh gas entry port
2. A port to connect it to the patient airway
3. A reservoir for gas (Bag/corrugated tube to meet the peak inspiratory flow
requirement)
4. An expiratory port / valve
5. A carbondioxide (CO2) absorber if total re-breathing is to be allowed
6. Corrugated tubes for connecting these components
Requirements for breathing systems

I Essential: The breathing system must
Deliver of the gasses from the machine to the alveoli in the same concentration
as set and in the shortest possible time.
Effective elimination of carbondioxide (CO2)
Minimal apparatus dead space (It is the volume of the breathing system from the
patient end to the point upto which and from movement of expired gas takes
place)
Low resistance
Circuits Spontaneous Controlled
A 80 ml/kg/min High
B 2 x MV 2-2.5 MV
C 2 x MV 2-2.5 MV
D 2-3 MV 2 x MV
E 2-3 MV 3 x MV
F 2-3 MV 2 x MV
II Desirable:
Economy of fresh gas
Conservation of heat
Humidification of inspired gas
Light weight
112

-Second Edition
Convenience during use
Efficiency during spontaneous and controlled ventilation
Applicable for adults, children and mechanical ventilators
Provision to reduce O.T. pollution
Classification of breathing systems:

There are numerous classifications or breathing systems according to the
WHIMS AND FONCY of the person classifying it. Different authors classified the same
system under different headings, adding to the confusion.
CLASSIFICATION OF BREATHING SYSTEM BASED ON CO2

ABSORPTION
Breathing system without CO2 absorption
Unidirectional flow
1. Non re-breathing system
2. Circle system without CO2 absorption
Bi directional flow
Afferent reservoir system (ARS)
- Mapleson A
- Mapleson B
- Mapleson C
- Lack’s system
Enclosed afferent reservoir system (EAR)
Efferent reservoir system (ERS)
Mapleson D
Mapleson E Controlled 100 to 240ml/kg/min
Mapleson F
Bain’s system 1.5 to 3 times MV spontaneous
(or) 100-300 ml /kg/min
Combined system
Humphrey ADE
Multi circuit system
113

-Second Edition
Breathing system with CO2 absorption
Unidirectional flow
Circle system with absorber
Bi directional flow
To and fro system
Classification by function:
With the presence or absence of A) Reservoir B) Re-breathing C) CO2 absorber
D) Directional valves, the system can be classified into:
1. Insufflation
2. Open
3. Semi open
4. Semi closed
5. Closed
INSUFFLATION
Insufflation is defined as a delivery of a direct stream of anesthetic gas mixture into the
mouth by a metal hook (Sclocum) or into the pharynx by oropharyngeal or
nasopharyngeal catheter. There is no use of reservoir bag and CO2 abnormal
Low flow FGF of 2-4 liters per minute and under the pressure of 5-10mm of Hg,
high flow of 6-8 L/min under the pressure of 20-25 mm of Hg are used. Flow rates
above 10 L/min are not used in catheter technique. Size of the catheter 4F to 6F in
children, 6F to 12F in adults. An extended catheter may be placed in the trachea and
enable to delivery of gas mixture to mix more completely with tracheo-pulmonary
gases. Disadvantage include wastage of gases.
OPEN SYSTEM
Open system is the one in which there is no reservoir or valves and it allows the patient
to have ready access to the atmosphere both on inhalation and exhalation. Exhale CO2 is
diluted and washed out into the room air.
“Open drop” anesthesia is one type of open system in which the anesthetic gases are
delivered from anesthesia machine by a tube that is inserted under the mask. The
anesthetic liquid is dropped on to the layer of gauze stretched over a frame shape like a
facemask made of metal. Re-breathing usually does not occur. Inhaled anesthetic are
diluted by air, unless high flow are used. The patient as to breath spontaneously. The
only advantage was simplicity of the equipment.
Disadvantage include: Difficulty to predict anesthetic depth, so the
anesthesiologist must relay upon in the clinical signs to assess the depth. Pollution of
O.T. with CO2 and other anesthetic gases. Inability to assist and control ventilation.
114

-Second Edition
Inability to control the delivered oxygen level and other anesthetic agents, Reaction is
skin and eye by anesthetic agents.
SEMI OPEN SYSTEM:

Exhaled gases flow into the surrounding atmosphere and also to the inspiratory line of
the apparatus to be re-breathed, there is no chemical absorption of exhale CO2. Re-
breathing depends on FGF reservoir bags and directional valves are optional.
The Mapleson breathing system are characterized by the absence of valves to
direct gases to or from the patient. Because there is no device for absorbing CO2. The
fresh gas flow must wash CO2 out of circuits or flow control breathing systems. These
systems are classified by Mapleson into five basic types A to E. A sixth Mapleson F was
added later.
Mapleson ‘A’/Magill’s system:

It consists of the following:
At one end an inlet for fresh gas linked to a distensible rubber reservoir.
APL Valve
115

-Second Edition
116

-Second Edition
a. A length of corrugated tube (with a length of 110 cm with a internal volume of

550 ml. This volume is critical as it minimizes the backtracking of exhaled
alveolar gas back to the reservoir bag).
b. Variable tension spring loaded flap valve close to the patient end so as to vent the
exhaled gas.
c. It differs from other circuits in this system in that the fresh gas does not enter the
system near the patient end but near the reservoir bag at the other end of the
system.
Technique of use:
For spontaneous ventilation the APL valve is kept in fully opened position. For
control or assisted ventilation the APL valve is tightened so that when the bag is
squeezed, sufficient pressure is built up to inflate the lung.
117

-Second Edition
Functional analysis:
Hazard: A mechanical ventilator that relieves excess gas should not be used with this
system because that entire system then become dead space. Ventilators seen in most of
the machines are incompatible with this system.
Test for Mapleson ‘A’ system: It is tested by occluding the patient end of the system,
closing the APL valve and pressurizing the system. Maintenance of pressure confirms
the integrity of the system.
Lack system:
This system functions like Mapleson ‘A’ system both during spontaneous and
controlled ventilation. Lack system has an added expiratory limb which run from the
patient connection to the APL valve at the machine end of the system. This makes it
easier to adjust the valve and facilitates scavenging of excess gases. Lacks is available in
both parallel (dual tube) arrangement and a co-axial arrangement.
Test for lack system: Co-axial lack modification requires additional testing to confirm
the integrity of the inner tube. Occlude both the limbs at the patient connection with
APL valve open, then squeeze the bag. If there is a leak in the inner tube the bag will
collapse and gas will escape through the APL valve.
Mapleson B system:
In this system, the fresh gas inlet and APL valve are both located near the patient
end. The reservoir bag is at the distal end of the system, separated from the fresh gas
inlet by corrugated tubing.
Technique: In spontaneous ventilation, the APL valve is opened completely excess gas
vented during expiration. In assisted or controlled ventilation tightening the APL valve
sufficiently to allow the lungs to be inflated. Excess gas vented during inspiration.
Functional analysis: Spontaneous respiration, no gas should be inhaled from the bag is
the volume of corrugated tubing exceeds the tidal volume. The amount of rebreathing
will depend on the fresh gas flow. To avoid rebreathing completely, the FGF more than
double the minute volume recommending, but flow as low as 0.8 to 1.2 times minute
volume may be sufficient. In assisted or controlled ventilation, FGF of 2 to 2.5 time
minute volume has been recommended. The end result is that these system is neither
efficient during spontaneous nor during controlled ventilation.
118

-Second Edition
Mapleson C system:
119

-Second Edition
Mapleson D system is popular because scavenging of excess gases is relatively
easy and it is the most efficient of Mapleson system during controlled ventilation.
Mapleson D system:
Mapleson D system is popular because scavenging of excess gases is relatively
easy and it is the most efficient of Mapleson system during controlled ventilation.
Classic form: Consists of a T-piece fresh gas inlet at the patient end, a length of
corrugated tube connects the T-piece to the APL valve and reservoir bad adjacent to it.
The volume of the tube and the reservoir bag exceeds the patients tidal volume.
Bain’s modification: In Bain’s modification the fresh gas supply tube (6mm) runs
coaxially inside the corrugated tube with a uniform diameter of 22 mm and length of
150-180 cm (about 85ml/30cm of tubing). The patient end has a 15 mm female/22 mm
male adopter for the connection of elbow joint or directly to the endotracheal tube.
Technique of use: For spontaneous respiration the APL valve is left completely open
and gas is discharged during expiration. Manually controlled or assisted ventilation is
performed by partially closing the APL valve and squeezing the bag. Mechanically
controlled ventilation is achieved by connecting the hose of anesthesia ventilator in
120

-Second Edition
place of reservoir bag and closing the APL valve, excess gases are vented through the
ventilator.
Analysis of the system’s performance:
Analyzing the system during controlled ventilation has derived two relations.
1. When FGF is very high the PaCO2 becomes ventilatory dependent.
2. When the minute volume exceeds the FGF substantially, the PaCO2 is dependent
of FGF.
Hazard of Bain System:

System should not be used with intermittent flow machines unless the machine
is set for continuous flow. If the inner tube gets detached from its connection or develop
a leak at the machine end or the FG.
121

-Second Edition
122

-Second Edition
Techniques of use:
For spontaneous ventilation the expiratory limb is left open. Controlled
ventilation can be performed by intermittently occluding the expiratory limb and letting
the FGF inflate the lung. Satisfactorily assisted is difficult to achieve.
The presence or absence and the amount of re-breathing or air dilution
will depend on the FGF, the patient minute volume, the volume of expiratory limb, the
type of ventilation and respiratory pattern.
Air dilution:
No air dilution can occur during controlled ventilation. During spontaneous ventilation
air dilution can not occur if the volume of the expiratory tubing is greater than patient
tidal volume. If there is no expiratory limb or if the volume of expiratory limb less than
patient tidal volume air dilution can be prevented by providing FGF exceeding the peak
inspiratory flow rate i.e. 3-5 times of minute volume. A FGF of two times minute volume
and reservoir volume of 1/3 of tidal volume will prevent air dilution.
123

-Second Edition
Hazard:
Controlling ventilation by intermittently occluding the expiratory limb may lead to over
inflation and barotraumas. This is because the user does not have the feel of inflation as
in bag ventilation, there is no APL supply or the tube become kinked or twisted, the
entire expiratory limb will become dead space.
Testing of the system before used:

Mapleson ‘D’ is tested for leaks by occluding the patient end closing the APL valve and
pressurizing the system. If there is no leak the pressure will be maintained. When the
APL valve is open the bag will deflate easily.
The Bain’s modification requires special testing to confirm the integrity of the inner
tube. This can be performed by:
a. Setting a low flow of oxygen on the flow meter and occluding the inner tube at
the patient end. If the tube is intact flow meter indicator will fall.
b. After closing the APL valve activate the oxygen flush and observe the bag. A
venture effect caused by oxygen flow at the patient end will create a negative
pressure in the outer expiratory tube, which will cause the bag to deflate
(Pethicks test). If the inner tube is not intact this will cause the bag to inflate.
Mapleson ‘E’ system:

Mapleson E system for anesthesia has decreased because of difficulties in scavenging
excess gases, but it is still commonly used to administer oxygen humidified gas to
intubated patient breathing spontaneously. It consists of a length of tubing attached to a
T-piece to form a reservoir valve too. To overcome potential hazard it is recommended
that a pressure-limiting device be placed in the system.
Mapleson ‘F’ system:

This is also known as Jackson-Rees modification of T-piece. This system is
extremely efficient for infants and small children. It has a bag with mechanism of
venting excess gases on the expiratory limb. The mechanism is most commonly a whole
in the tail of the bag. It may be fitted with a device to prevent the bag from collapsing
while at the same time allowing excess gas to escape. Several mechanical devices are
developed which can be placed at the tail so as to produce variable pressures to provide
controlled ventilation. An anesthesia ventilator may be used in place of the bag.
Techniques of use:
For spontaneous respiration, the relief mechanism is fully open. For assisted or
controlled respiration the relief mechanism is occluded sufficiently to distend the bag.
Respiration can then be controlled or assisted by squeezing the bag. The hole in bag can
be occluded by user’s finger during inspiration.
124

-Second Edition
Mapleson ‘F’ function much like Mapleson ‘D’ system. The flows required to
prevent re-breathing during spontaneous and controlled respiration are same as those
required for Mapleson ‘D’
Hazard:
Excessive pressure is some times likely to develop because the pressure regulating
valve at the tail end may be accidentally turned off occluding the expiratory limb
completely.
125

-Second Edition
Combined system:
None of the above described system is ideal for every situation. Some systems are better
for spontaneous breathing and others are more efficient with controlled ventilation.
When comparing the system during spontaneous ventilation, the relative order of merit
is, A, D, F, E, C and B. During controlled ventilation the order is D, F, E, B, C, and A. In an
attempt to develop a universal system a number of combinations of systems have been
introduced. They are:
Humphrey ADE system
Multicircuit system
Humphrey ADE system:

In A configuration it is similar to lack version of Mapleson A system. In D configuration,
it is similar to Bain’s modification of Mapleson D system. It also allows the APL valve to
be bypassed in D configuration so that it resembles. Mapleson E system. Both coaxial
and non-coaxial versions are available.
The inspiratory limb consists of fresh gas inlet, a reservoir bags with a lever, and
length o corrugated tubing that runs to the patient connection port. When the lever is
vertical, gas can flow in out of the bag. When the lever is horizontal, gas flow into the
bag is blocked, making the inspiratory limb simple tube the expiratory limb consists of a
length of tubing running from patient connection, an APL valve, a valve bypass outlet,
and lever that directs the flow of gas is through either the APL valve or valve bypass
outlet.
126

-Second Edition
Technique of use:
To use the system in ‘A’ mode (spontaneous ventilation) both the levers are
placed vertical and APL valve is left open. During controlled ventilation the bag is
squeezed and the leak is controlled by adjusting the APL valve.
To use the system in D/E mode (controlled ventilation) both levers are moved to
horizontal position if mechanical ventilation is desired, the hose from the ventilator is
attached to valve-bypass outlet. Excess gases are scavenged through the ventilator. The
APL valve does not need to be closed because it is bypassed. To use manual ventilation
in D/E mode, a length of flexible tubing with a bag is attached to the valve bypass outlet.
The bag s squeezed to ventilate the patient. The leak is adjusted by rotating the
expiratory lever between vertical and horizontal with the APL valve fully open. To use
spontaneous ventilation in D/E mode the expiratory lever is placed in horizontal and
the valve bypass outlet is connected to scavenging system.
Hazards: Accidental displacement of expiratory lever from vertical to horizontal,
obstruction to expiratory port in ‘A’ mode result in dangerous rice in pressure.
Multicircuit system:
The multicircuit system is available in parallel and coaxial version. It has a single lever
of switching between modes. A lock prevents the lever from being moved accidentally.
The inspiratory part of the system, which receives the FGF, as a bag mounts for the ‘A’
mode. The gas flows from this part through a corrugated tube to the patient. The
expiratory portion, which receives the gas from the patient. The expiratory portion,
which receives the gas from the patient, has connections for a pressure limiting valve
and hose to ventilator.
In A mode (lever facing down), the reservoir bag is connected into the system. On
expiratory side, the gas flow is directed through the APL valve. The ventilator is
excluded from the system.
When used in D/E mode (lever facing up), the bag is excluded from the inspiratory side.
APL valve and ventilator the both connected into the system on the expiratory side.
“The APL valve must be closed when the ventilator is used. If manual ventilation is
desired, a bag is attached at the ventilator connection and the APL valve adjusted to
provide adequate ventilation.
Semi closed system:

Part of the exhale gases passes into the atmosphere where as part mixes with FGF and is
re-breathed. Chemical absorbent of CO2, reservoir bag and directional valve present.
127

-Second Edition
Circle system with moderate to high flows.
128

-Second Edition
Chapter 28 - CIRCLE SYSTEM
A circle system gases flow is circular pathways, through separate inspiratory and
expiratory channels. The direction of flow is determined by two unidirectional valves.
The essential components of the circle system include:
a) Soda lime canister, b) Unidirectional valves, c) Fresh gas entry. d) Y-piece. e)
Reservoir bag. f) Relief valve, g) Low resistance interconnecting tubing.
a) Soda lime canister: The canister / absorbent container, which holds the absorbent
is made of transparent material. The modem absorbers two canister one on top of the
other.
Absorbents: CO2 absorption employs the general principal of a base neutralizing an
acid. The acid carbonic acid formed by reaction of CO2 with H2O. The base is hydroxide
of an alkali. The end products of reaction are water and a carbonate. There are two
absorbents – Soda lime, and Barium hydroxide lime.
Soda lime: Most of the soda lime used today is wet composition. By weight 4% NaOH,
1% KOH, 14-19% water and remaining 80% Ca(OH)2 to make it 100%. Small amount of
silica is added to prevent excessive powdering by increase hardness. Silica tends to clog
the pores of the soda lime and reduces its efficiency, a drawback over come by the
addition of Kieslguhr. Size of soda lime granules ranging from 4 to 8 mesh. Indicator
added to it to allow assessment of absorption capacity.
Chemical reaction:
CO2 + H2O  H2CO3
H2CO3 H+ + HCO3-
NAOH  OH-+Na+
Ca(OH)2 2OH-+Ca2+
NaOH + H2CO3 + Ca(OH)2CaCO3 + Na2CO3 + 4H2O
129

-Second Edition
130

-Second Edition
Barium hydroxide lime:
It contains 20% Ba (OH)2 8H2O and 80% Ca(OH)2 it may contains some amount
of KOH and indicator. Size of the granules: 4-8 mesh size. NO need of adding any
hardening agent.
Chemical reaction:
Ba(OH)2 8H2O +CO2 BaCO3 + 9H2O
9H2O + 9CO2 9H2CO3
9H2O + 9Ca(OH)2 9CaCO3 + 18H2O
2KOH + H2CO3 K2CO3 + 2H2O
Ca(OH)2 + K2CO3 CaCO3 + 2 KOH
b) Unidirectional valves: Two unidirectional valves are used in the circle system to
ensure that the gas flow toward the patient in one breathing tube and away in the other.
They are usually part of the absorber assembly. A transparent dome allows observation
of disc movement. The gas enters the bottom and flows through the center of the valve
raising the disc from the seat. Reversing the gas flow will cause the disc to contact the
seat stopping – the retrograde flow of gases. Unidirectional valves are positional and
must be vertical for the disc to seat properly.
c) Fresh gas inlet: FGI is a point at which gas from anesthesia machine enters the
system. Most commonly it is connected to the common gas outlet on the anesthesia
machine by flexible rubber / plastic tubing. The inlet should have an internal diameter
of at least 4 mm and the delivery tube to have a diameter at least 6.4 mm.
d) Y-piece: Y-piece is a tubular connector with 22 mm male port for connection to the
breathing tube and 15mm female/22 mm male fitting for the patient end. The dead
space in the system extends up to the point of bifurcation of inspiratory and expiratory
limb. A septum may be placed in the Y-piece to decrease the dead space.
e) Relief valve of APL valve: During spontaneous breathing the valve should be fully
open. It will open and when the expiratory gases when the bag has become extended
during expiration or expiratory pause. When manually assisted controlled ventilation is
used the APL valve should be partially closed enough that desired pressure could be
achieved. When pressure is attained the valve opens and excess gas is vented out.
f) Reservoir bag: Most bags are made of rubber or neoprene. There will be carbon
added to the rubber to prevent accumulation of static electricity. The neck of the bag
must be a 22 mm female fitting.
Functions of the bag:

1. To allow accumulation of gases during exhalation so that a reservoir as; available
for next inspiration.
131

-Second Edition
1. It provides a means where by anesthesiologist may assist or controlled
ventilation.
2. Can acts as a visual and tactile observation to monitor patient’s breathing.
3. It acts to protect patient from excessive pressure in the breathing system.
4. If mechanical ventilation is desired the bag should be removed from its port, the
APL valve should be closed and ventilator hose should be connected to the bag
port.
g) Low resistance connecting tube: Most commonly used type of hosing is the
corrugated rubber (elephant tubing) or neoprene. Both end of the tube has a smooth
area of 2-4 cm to fit tapered components of the breathing system. It has a diameter of 22
mm and length of 110 cm. The corrugations allow acute angulations of the hose without
kinking.
The Disadvantage of this tubing is that the irregular surface lodges dirt and
infection. They are also heavy and if unsupported may drag on facemask or ETT.
The advantages are that the ends are more easily stretched and will make good
union with other components of different diameter.
Optional equipments that can be connected to the circle system:

1. PEEP valve: Must be connected in the expiratory limb and upstream of the
absorber.
2. Filters: To avoid transmission of pathogens and dirt from the canister.
3. Humidify: Should be used in the inspiratory limb.
4. Respirometer: To measure the ventilator volumes.
For the-efficient functioning of the circle system the following criteria should be
fulfilled:
1. The unidirectional valves should be on either side of the reservoir bag and must
function properly.
2. Relief valve should be position on the expiratory limb only
3. The FGF should enter the system proximal to the inspiratory to the
unidirectional valve.
When FGF is high, the gas component of the system unmixed and CO2 absorber is
not used. When FGF is reduced below alveolar ventilation, the CO2 absorber is a must as
gas in the system become more uniformly mixed.
Advantages:
The close system provides maximal humidification, warming of inhale gases,
reuse of agents, minimizations of pollution and reduction of cost.
132

-Second Edition
Disadvantages:
Resistance to breathing, complex design, disconnection and leak from various
components, malfunctioning of valves can cause serious rebreathing and CO2
accumulation. Total occlusion of the circuit can occur in the valve get stuck. Bulk of the
circle system offers less convenience and portability compare to Mapleson system.
Test for circle system:

a) Leak test b) Flow test
Leak test: This is performed by closing the APL valve, occluding the Y-piece and
pressurizing the system with oxygen flush. If the pressure is maintained the system is
leak proof.
Flow test: This is no check the integrity of the unidirectional valves. This is performed
by removing the Y-piece and then the person should try to inhale from the inspiratory
limb. He will be able to so but will be unable to exhale through the limb and in the same
way the person will be able to exhale through the expiratory limb but will not be able to
inhale from that.
Modification of circle system:

1) Mera-F coaxial version:
Advantages include small size and lightweight. Disadvantages are kinking of the inner
tube, miss assembly and reversed attachment to the absorber.
2) Revells circle system:

This is a type of circle system with assisted circulation. To reduce problem of resistance
to the flow of gases, a small fan which help to assist the circulation of gases in the closed
system was introduced. This called revels circulation. This design is of particular benefit
in pediatric anesthesia and enables the circle system design for adults to be used for
small children.
5) Closed system:
There is complete re-breathing of expired gas. CO2 absorber reservoir gag and
directional valve are present circle system with low flow.
Low flow: Anesthesia has been defined as an inhalational technique in which a closed
system with CO2 absorbent used with a FGF less than the patient’s minute ventilation.
Low flow: 500-1000 ml/min.
133

-Second Edition
To and FRO canister:

Size: L × D cm
Adult – 13 x 8 m (450 gm) 1602
Medium 12 x 7 cm (285 gm) 1002
Closed 8 x 6 cm (155 gm) 5502
Infant size 4.5 x (in (8.5 gm) 302.
Advantages:
Economy: Significant saving can be achieved with low flow of N2O, O2 and
volatile agents.
Reduction of operation room pollution.
Conservation of heat and humidity.
Less danger of barotraumas.
134

-Second Edition
Buffering in the changes in inspired concentration, with lower FGF, longer it
takes for change in concentration in the FGF to result in a comparable change in
the impact concentration.
Disadvantages:
More attention is required to take good care in adjusting the flows frequently.
Inability to alter quickly inspired concentration.
Danger of hypercarbia.
Accumulation of undesirable gases- like carbon monoxide, acetone, methane,
hydrogen and ethanol.
TO AND FRO SYSTEM:

The closed To-and-for system of administration of inhalation anesthetic agent
was developed by WATERS and JACKSON in 1924.
It is a non re-breathing system and is distinct from the circle system in having a
single channel for both inspiration and expiration. The assembly consists of a metal
connector between the facemask and a breathing bag, this connector is provided with
an inlet port anesthetic gases, oxygen and vapors. A CO2absorption canister open at
both the ends is interposed between the connector and the breathing bag. It is thus a
single line breathing channel and eliminates the two corrugated tube of circle system. It
is a prototype of Mapleson C configuration with interposed CO2 absorption canister.
Advantages: This system is simple and requires minimum breathing components. The
resistance of the system to spontaneous breathing is minimal and less than circle
system. It is also easy to clean and sterilize so ideal for infected patients.
Disadvantages: The system is cumbersome because it is all assembled near patient’s
head and is difficult to mange especially the CO2 absorber. There is progressive increase
135

-Second Edition
in the dead space of the apparatus as the soda lime is exhausted. There is a possibility of
inhalation of soda lime dust and excessive heat production close to patient’s airway
WATER CANISTER:
1. Face mark
2. Angle piece
3. Expiratory wall
4. Water’s canister
5. Corrugated rubber tube connector
6. Rebreathing bag
7. Fixing device of cannister
Advantages:
Cheap
Simple
Easy to operate
Low resistance
136

-Second Edition
Chapter 29 - CLOSED CIRCUIT ANESTHESIA (CME)
Closed Circuit Anesthesia is defined as delivery of gases in amounts sufficient to replace
the gases-oxygen and anesthetic-removed by the patient.
UNDERSTANDING CLOSED CIRCUIT ANESTHESIA

The topic will be discussed under following headlines:
1. The Brody's equation.
2. Uptake of anesthetic from the circle system.
3. Concept of unit dose.
4. Application of the principles of closed circuit anesthesia in relation to halothane
and isoflurane.
5. Practical details.
BRODY'S EQUATION OR KILOGRAM X 3/4

Understanding Brody's equation is central to the understanding of closed circuit
anesthesia, using which we can arrive at various physiological and pharmacological
variables. The knowledge of which is essential to the conduct of closed circuit
anesthesia.
To derive Brody's equation we have to first (1) measure the body weight of the patient
in kilograms, then (2) find the logarithm of the weight, (3) multiply the logarithm of the
weight in kilograms by ¾, and (4) look up the antilogarithm of the above obtained
value, that is, the kg3/4 of the patient.
When kg3/4 is calculated as described above for various weights of the patients, we get
the following values:
Body weight in kg kg3/4
50 18.80
60 21.56
70 24.20
80 26.75
The value kg3/4 changes approximately by 2 for every 10-kg rise or fall.
The various physiological and pharmacological variables can be derived from the
Brody's equation. They are:
When Kg3/4 derived as described for the weight of the patient is
Multiplied by 10 we get O2 consumption (VO2) in ml/min.
Multiplied by 2 we get cardiac output in dl/min.
Multiplied by 5 we get maintenance fluid requirement in ml/hour.
Multiplied by 8 we get CO2 production (VCO2) in ml/min.
137

-Second Edition
Multiplied by 1.6 we get Alveolar ventilation in dl/min that is necessary to keep FaCO2 ~
5%.
It is necessary to know the VCO2 of the patient as it reflects the Alveolar ventilation. VO2
shows the basal O2 consumption as, that muchof the calculated O2 flow as is necessary to
keep in the flow meter to prevent hypoxia. VA as described earlier, is necessary to keep
FaCO2 – 5%, so that hypercarbia and hypocarbia are prevented.
It is necessary to know the cardiac output (CO) as it is one of the determinants of
anesthetic uptake. VO2/VCO2 = Respiratory quotient = 0.8 normally, can also be
determined.
UPTAKE OF ANESTHETIC
Uptake of anesthetic can be described as the cumulative anesthetic uptake, i.e. the total
amount of anesthetic taken from the system into the body and unit dose, i.e. the amount
of anesthetic vapour which should be introduced into the system in the 1st minute and
between next subsequent time intervals, to keep the patient anesthetized.
Anesthetic uptake is maximum in the 1st minute, as mixed venous blood that is
coming to pulmonary circulation is devoid of any anesthetic whatsoever, and the
gradient between alveolar gas and blood in pulmonary circulation is greater for the
anesthetic in the 1st minute. Hence, uptake is also maximum; this drops down
exponentially.
Cumulative uptake in the 1st minute is the same as in the 4th minute, in the 0th minute, in
the 16th minute and so on. When observed, the 1st minute, 4th minute, 9th minute and
16th minute, and so, on time intervals are all squares of 1, 2, 3, 4, 5 and so on, and the
peculiar feature of the same is that intervals at each time period, i.e. 1st, 9th, 16th, 25th,
and so on is 1 minute, 3 minutes, 5 minutes, 7 minutes, 9 minutes, 13 minutes etc. are all
odd members. The unit dose requirement is also same and equal as it is in the 1st
minute, as it is in the 9th minute, in the 16th minute etc.) or the unit dose is same as it is
in the 1st minute, as it is in the next 3 minutes, in the next 9 minutes, in the next 11
minutes.
In the figures time is plotted on the X-axis and cumulative anesthetic uptake is
plotted on the Y-axis. The value 100 is taken as the cumulative anesthetic uptake, as
Number 100 is easy to remember and for no other reason.
Cumulative anesthetic uptake in ml can be calculated as 2 x 1.3 MAC x blood gas
coefficient of the anesthetic x cardiac output in (dl) x time in minutes.
1.3 MAC is the ED 95 of the anesthetic where, when given to a group of patients
undergoing surgery, 95 per cent of the patients will not move in response to stimulus.
When we calculate cumulative anesthetic up take for halothane in the 1" minute
in a 70 kg man, for example, we have:
138

-Second Edition
B/G of halothane is 2.3,
MAC in O2 = 0.75,
CO = 2 x (kg),
= 2 x 24.2, and = 48.2 dl.
Unit dose = 2 x 1.3 x 0.75 x 2.3 x 48.4 x 1 = 217 ml.
Therefore, in each time interval we must introduce 217 ml of halothane vapour into the
circle system.
Now, with how many ml of liquid halothane does that come from?
From Avagardo's law we know that I mole of halothane will give 22.42 of halothane
vapour at STP (dry). The molecular weight of halothane is 197.4.
At ATPD from Charles's law 197.4 grams of halothane should give 22,400 x 293/273 -
24,041 ml of vapour. The specific gravity of halothane is 1.86. Therefore, 24,041 ml of
vapour will give 197/1.86 = 105.91 ml of liquid halothane. Each ml of liquid halothane
will, therefore, give 22,041/106 = 207.9 ml of vapour.
One unit dose of halothane is approximately equal to one ml of halothane liquid. So one
ml of liquid halothane will provide one unit dose for a 70-kg man in the absence of
nitrous oxide.
In the 1st minute we have to give 2 unit doses of the anesthetic (one for the road
and one for the patient), i.e. 2 ml of liquid halothane. In the next 1-4 minutes 1 ml
halothane, the next 4-9 minutes 1 ml halothane, and so on.
When the unit dose is calculated for another agent which is used commonly, i.e.
isoflurane, for a 70-kg man, it comes to 225 ml of vapour. So the unit dose is 1.1-1.2 ml
of liquid isoflurane for a 70-kg man.
USING 65 PERCENT N2O

When N2O is to be used in maintaining anesthesia we cannot give 1.3 MAC of N2O
without producing hypoxia. Since MAC of N2O is 100, 1.3 multiplied by 100 is 130 per
cent. So there is no way we can produce anesthesia without hypoxia, hence 65 per cent
of N2O is used. When 0.65 MAC N2O is used, we can reduce the unit dose by half or half
of 1-3 MAC of other inhalational anesthetic agent is sufficient to produce anesthesia.
PRACTICAL DETAILS OF THE CONDUCT OF ANESTHESIA

With this background we go on to describe in brief the conduct of closed circuit
anesthesia. Induction is done routinely with intravenous induction agent after pre-
oxygenation. After tracheal intubation the patient is ventilated with 100% O2 for 5-7
minutes, preferably using non-rebreathing valve, to ensure adequate denitrogenation of
the patient.
Prepare the circle system.
Check for leaks.
139

-Second Edition
Calibrate and attach O2 analyzer to expiratory limb. This is mandatory if N2O is
used to produce anesthesia.
Connect Y-piece to the suction and suck out air, after creating a vacuum clamp
the catheter mount. Do not worry of hypoxia during this period; our pre-
oxygenation and ventilation with pure oxygen for 5-7 minutes would have
produced oxygen reserves to prevent hypoxia.
Fill the system with pure N2O and connect to patient.
Inject two unit doses of liquid volatile agent into expiratory limb in the first
minute, one for the road and one for the patient as described earlier, and one
unit dose subsequently for the next successive odd time intervals.
Constant volume in the reservoir hag is maintained by adjusting the expiratory
valve.
When N2O is used two principles should be followed:
1. Maintaining constant volume in the circuit.
2. Maintaining FEO2 constant at a value believed to be safe.
This is done by starting with basal requirement of O2 flows at the flow meter with N2O
(unit dose of N2O is two liters) and slowly adjusting the N2O flows according to FEO2
reading, to keep FEO2 at the value believed to be the safest, i.e. around 35-40 per cent.
During the end of the surgery, i.e. 2-3 time intervals before the end of the
procedure, injection of inhalational anesthetic agent is stopped, expiratory valve
is opened and gases are coasted.
Anesthetic agent analysis is of great help; with the help of it correct plane of
surgical anesthesia can be produced without producing too deep or light plane of
anesthesia.
With ETCO2 analyzer, i.e. capnography, O2 analyser and anesthetic gas analyser,
closed circuit anesthesia is a piece of cake! Nothing great.
140

-Second Edition
Chapter 30 - LOW FLOW ANESTHESIA (LFA)
INTRODUCTION:
Dr. John show used caustic soda to absorb CO2 from expired gas and reused
expired gas during the next breath.
This concept was simplified further by introduction of the “To and fro” system by
WATERS and circle system by BRIAN SWORD which utilized sodalime for CO2
absorption.
The introduction of less explosive agents like halothane and plenum vaporizes
which performed optimally only in the presence of high flows resulted in less
popularity of low flow anesthesia.
However O.T pollution and high cost of volatile anesthetics used in high flows
again has helped low flow anesthesia popularity.
Definition:
Any technique that utilizes a FGF less than alveolar ventilation is called LFA. (OR)
Defined as a technique where in at least 50% of expired gases had been returned
to lung after CO2 absorption.
Baker classified that FGF used in anesthesia into following:
- Metabolic flow: about 250 ml/min
- Minimal flow: 250-500 ml/min
- Low flow: 500 – 1000 ml/min
- Medium flow: 1 – 2 Lt/min
For most practical considerations, FGF of 2L/min is a LFA (Low flow anesthesia).
Need for LFA: No gas escapes out of the circle and this would provide for maximal
efficiency for the utilization of the FGF. LFA involves utilizing a FGF, which is higher
than the metabolic flows, but which is considerably lesser than the conventional flows.
Hence there is a safety margin and also economic.
Equipment: one require a circuit with CO2 absorber to reutilize expired gases. Two
circuit for this purpose are
- To and fro by waters (is bulky near the patient end)
- Closed circuit by Brian sword.
Monitoring:
1. Inspired O2 analyser (when N2O is being used along with O2).
2. Monitoring of end tidal anesthetic concentration done by—Mass spectrometry/
Raman spectrometry/ Riken gas indicator/ Photo acoustic surface absorption/
Infrared absorption
141

-Second Edition
Practice of LFA: Done under 3 categories
1. Initiation of LFA.
2. Maintenance LFA
3. Termination LFA
1) Initiation: Aim at the start by LFA is to achieve an alveolar concentration of agent
that is adequate to produce surgical anesthesia. Factors which influence this are
1. Factors governing the inhaled tension of agent.
2. Factors responsible for the rise in alveolar tension
3. Factors responsible for the uptake from the longs thus reducing the alveolar
tension.
Inhaled tension of agent: First de-nitrogenation is done using non-rebreathing
circuit with high flow or circle system. Bulky circuit holds 6-7 liters + FRC of
patients is 3 liters amounting to 10 L into which agents have to be added.
Anesthetic agent could be lost to breathing circuits also.
Alveolar tension: depends on
a. Concentration effect: Higher the inspired concentration, higher the alveolar
concentration.
b. Alveolar ventilation: higher the VA, higher the alveolar concentration.
c. Uptake from the lungs thus reducing the alveolar tension is the product of 3
factors.
a. Solubility of the agent
b. Cardiac output
c. A-V partial pressure gradient
Greater the solubility of the agent: slower the induction.
Greater the cardiac output, more the agent is taken up by the blood from lungs
resulting in low alveolar tension.
Greater the A-V gradient, higher is the uptake of agents from the lungs resulting
in low alveolar tension.
Methods to achieve desired gas and agent concentration:
1. Use of high flows for a short time: called LOADING. Here 10 L / minute with high
concentration i.e. upto 2 MAC is used to achieve initial rapid rise of alveolar
tension .Major disadvantage is high flows and O.T pollution.
2. Prefilled circuit: Use Magill’s for preoxygenation. Simultaneously, the circle is
fitted with a test lung and entire circuit filled with gas mixture of desired
concentration following intubation the circuit is connected to achieve desired
concentration very rapidly.
3. Use of large doses of anesthetic agents: Fill circuit with agents so that the circuit
+ FRC rapidly achieves desired concentration as well as compensates for the
142

-Second Edition
initial large requirements (not used for dangers of hypoxia) usually it requires
(50 ml of vapor / minute) during first 10 minutes.
4. Injection technique: Injecting agents directly into circuits
1 ml halothane yields 226 ml of vapour
1 ml isoflurane yields 196 ml of vapour At 200C.
Dose calculated by = Desired concentration x (FRC + circuit volume) + (output x

blood / gas coefficient)
2) Maintenance of LFA: This phase allows one to save the agent and hence cost
effective.
Consider:
1. Steady state of anesthesia.
2. Minimum uptake by body
3. Prevent hypoxic gas mixture.
Gothenburg technique to maintain LFA:

Initially high flows, O2 at 1.5 L/min and N2O at 3.5 L/min is used for 6 minutes
after induction, called loading phase. This is followed by O2 4ml/kg/minute and
N2O adjust to maintain O2 concentration in the circuit. Minimum of 40% O2 has to
be maintained & O2 analyzer is important here.
Injection method: by KENNEDY AND LOWE’S formula: For halothane in 50 kg
patient --
0 – 5 min 27 ml/hr
5 – 30 min 5.5 ml/hr Without N2O /with N2O.
30 – 60 min 3.5 ml/hr reduced by half
60 – 120 min 2.5 ml/hr
One should also look for leaks and to return gas samples which are taken out of
the circle system for gas analysis to avoid hypoxia.
LFA states that agent required decreases as the time elapses.
3) Termination of LFA: By 2 Methods
1. At the end of surgery, open the circuit and use high flows to let out agent. But this
causes wastage of gases and O.T. pollution.
2. Use of activated charcoal which is heated to  2200C to adsorb volatile agents.
This is placed in a circuit where at the end of surgery the gases are directed to
flow through this.
143

-Second Edition
Advantages of LFA:
1. Economic
2. Humidified gases are provided.
3. Maintains body temperature in prolong surgery.
4. Less O.T. pollution.
Disadvantages:
1. Accurate adjustment of FGF.
2. Accumulation of trace gases.
3. O2 analyzer.
4. Expired gas mixture analysis.
5. Risk of hypoxia if leaks or O2 supply failure.
144

-Second Edition
Chapter 31 - SCAVENGING SYSTEM
Definition:
The collection of excess gases from equipment used in administering anesthesia or
exhaled by patient and removal of these gases to an appropriate place of discharge
outside the working environment.
Consists of 5 basic parts: (1) A gas-collecting assembly, (2) A transfer (3) The
interface with reservoir capacity (4) The gas disposal (5) And gas disposal
assembly.
COMPLETE SCAVENGING SYSTEM

1) Gas – collection assembly:
It can be attached to or be an integral part of a source.
The ASTM standard and international standard specify that the outlet connection
must be a 30 mm male fitting.
Breathing systems – containing APL valve include Circle system and Mapleson
A,B,C and D system. The APL valve can be fitted with a shroud. Because of weight
and dragging on breathing system Bain, Lack and Humphrey were developed in
which the APL valve were present at machine end. One more example is HAFNIA
breathing system.
T-piece system without APL valve – Connection to suction.
Resuscitation equipment – With scavenging adapter is available.
Masks or nasal cannula – Keep tent or hood around the head and attached to a
suction source.
Ventilators: Attach assembly outlet to a ‘Y’ that joins the effluent from APL valve.
In some ventilator a unidirectional valve is necessary between ventilator and Y
to prevent back flow when ventilator is not in use.
Respiratory gas monitors: Should travel either back to breathing system or to a
scavenging system.
2) Transfer means: Conveys gas from the collecting assembly to the interface, when
the interface is not an integral part of the assembly. (Gas-collecting).
It is a tube with a connector at either end.
The inlet and outlet fitting should be 30 – 19 mm.
It should be short and broad.
Should be resistant to kinking.
Should be different from breathing system tubing (color and or configuration).
145

-Second Edition
3) Interface: Serves to prevent pressure increase or decrease in the scavenging system
from being transmitted to the breathing system, ventilator etc.
The inlet should have 30 or 19 mm male connection.
Interface may be part of gas – collecting assembly in breathing system,
incorporated into a ventilator or a separate device. Ideally it should be close to
the gas-collecting assembly as possible.
There are 3 basic elements
- Positive pressure relief
- Negative pressure relief
- Reservoir capacity
Positive pressure relief is must, irrespective of disposal system used.
Negative pressure relief is necessary if an active disposal system is used.
Reservoir is necessary to match the intermittent flow from G.C.A to the
continuous flow of the disposal system.
It may be a rigid container, wide tubing, a bag or a combination of these.
Bag should be used only when the active disposal system is used.
Divided into 2 types: - Open interface
- Close interface
OPEN INTERFACE:
An open interface is open to atmosphere and contains no valve. It should be used
only with an active disposal system.
146

-Second Edition
a. T – Tube Interface
b. Tube within a tube interface
c. (B) with distensible bag for monitoring efficiency.
d. (B) with escape tube at top.
e. Two parallel tubes are inside the canister.
Closed interface:
Connection with the atmosphere are through valves.
Without reservoir or negative relief device for use with passive disposal system.
With reservoir bag and negative pressure relief valve for use with either active
or passive disposal system.
If active disposable system is used, the bag will be collapsed. (Except high flow
from G.C.A and inadequate outflow will be indicated by bag distension.)
4) GAS-DISPOSAL ASSEMBLY TUBING:

Connects interface to disposable Assembly.
It should be different in size and appearance from the breathing system hoses to
avoid misconnections.
It should be resistant to collapse and free of leaks.
It should be short and wide is P.D.A. to minimize resistance.
5) GAS-DISPOSAL ASSEMBLY:
This contains the components used to remove waste gases from the
anesthetizing location.
These gases must be vented at a point that is isolated from personnel and any air
consumer.
Two types:
Active – Pressure will be negative
Passive – Pressure will be positive
In active -a flow inducing device moves the gases.
147

-Second Edition
In passive the pressure is raised above atmospheric by the patient exhaling,
manual squeezing of Reservoir bag or Ventilator.
Active systems are complex but effective.
Passive systems are simple but not effective.
Examples:
Active - Central vacuum or
Active duct system.
Passive - Room ventilation system.
Direct piping to atmosphere.
Adsorption device
148

-Second Edition
Chapter 32 - SODALIME
The closed and semi-closed system essentially contain a carbondioxide
absorbent, of which the most commonly used are Sodalime and Barylyme.
Jackson was the first to find use of sodalime in absorption of CO2, but Waters
was the one who developed sodalime as it is used today.
ABSORBER CANISTER:
Consists of two clear plastic canisters arranged one above the other being separated by
a wire screen, which have a clear plastic sides for better visualization, a metal frame for
dissipation of heat and a reservoir at the bottom to collect excess water vapor from
exhaled gases.
COMPOSITION
Sodalime is composed of 80% calcium hydroxide, 14 to 15% of moisture, 4% sodium
hydroxide and 1% potassium hydroxide with a small amount of silica (to increase
hardness) and kieselburg (to prevent clogging of pores by silica). Indicators are also
added to show the exhaustion of sodalime absorptive capacity.
Size of granules that are commonly used is of 4 to 8 mesh that is the granules can pass in
a strainer with 4 to 8 openings in a square inch. This size has been chosen after a series
of trial and error experiments so that there is minimum resistance to air flow with
maximum available surface area for absorption.
Barylyme consists of 80% Barium hydroxide with 20% calcium hydroxide, and barium
hydroxide more active component like that of sodium hydroxide in soda lime.
Hardening substance is not necessary for this.
CHEMICAL REACTION
CO2 in the exhaled air combines with water on the surface of granules to form carbonic
acid
H2O + CO2 H2CO3
Carbonic acid reacts with sodium or potassium hydroxide to form sodium and
potassium carbonate and water. Sodium hydroxide is an active component and the
reaction is almost instantaneous but over a period of one minute sodium and potassium
carbonate react with calcium hydroxide to form calcium carbonate and water.
H2CO3 + 2NaOH [KOH] Na2CO3 [K2CO3] + 2H2O + HEAT
Na2CO3 [K2CO3] + Ca[OH]2 CaCO3 + 2NaOH [KOH]
By this reaction sodium and potassium hydroxide is regenerated. When sodalime is
exhausted the principal end product is calcium carbonate.
149

-Second Edition
Reaction of Barylyme differs from sodalime in that more water is liberated by direct
reaction between barium hydroxide and carbon dioxide.
Approximately 13,700 calories of heat is released for every mole of water formed and
this heat does not affect absorption capacity.
PEAKING OR REGENERATION
Occurs with a period of rest, where more soluble sodium carbonate dissolves in
the moisture on granules and penetrates into the granules to react with the less
active calcium hydroxide releasing sodium hydroxide which imparts renewed
activity to absorbent.
The capacity of sodalime to absorb CO2 is 26 liters of CO2 /100g of absorbent.
However because of channeling it is substantially reduced to 10 to 20 liters of
CO2/100g of absorbent.
INDICATORS
Indicators are needed to show the exhaustion of sodalime and it is based on principal of
change in PH which will be initially around 10.3 that is changed to a lesser PH because
of absorption of CO2.
VARIOUS INDICATORS IN USE ARE:

Indicator Color [fresh] Color [exhausted]
Phenolphthalein White Pink
Ethyl violet White Purple
Clayton yellow Red Yellow
Ethyl orange Orange Yellow
Mimosa –z Red White
INTERACTIONS OF INHALED ANESTHETICS WITH

ABSORBENTS:
Ideally the absorbent should neither be intrinsically toxic nor toxic when
exposed to commonly used inhalational anesthetics. However trichloroethylene
is known to react with sodalime and gets degraded into a potent neurotoxin
called dichloroacetylene that can cause cranial nerve lesions and encephalitis.
It also forms phosgene gas that is a potent pulmonary irritant that can cause
ARDS. Other agents known to react are Sevoflurane which produces
Trifluromethyl or compound A. Production of compound A is more with
Barylyme than Sodalime but no known side effects of compound are recorded.
150

-Second Edition
Desiccated Sodalime and Barylyme are known to degrade the inhalation
anesthetics to form a clinically significant amount of CO that may result in
carboxyhaemoglobin and this potential is more with Barylyme than sodalime.
Also the CO production depends on the kind of inhalational anesthetic used--
Desflurane > Enflurane > Isoflurane >> Halothane = Sevoflurane.
10) OTHER USES: Lithium Hydroxide is more potent than sodalime and
Barylyme in absorption of CO2 . It is used in submarines
151

-Second Edition
Chapter 33 - GAS LAWS AND ANESTHETIC IMPLICATIONS
INTRODUCTION:
All matter exists in one of three phases solid liquid and gas. In the solid phase
molecules cannot alter their relative position and merely oscillate about a fixed point.
The molecules in the liquid phase are mobile and gradually shifts their positions
throughout the whole liquid. The free path of a molecule in a liquid however is very
short before it collides with its neighbour. In the gas phase molecules have a much
greater degree of mobility & travel longer distance before colliding with others. Gases
and liquids are both known of FLUIDS.
Speed of which molecules move at any given temperature is approximately same,
whether the substance is in solid, liquid or gaseous state. However because of fewer
collisions in a given time, the molecules in the gas travel a greater distance than a liquid.
Owing to the mobility of its molecules a fluid has no fixed shape, however a liquid has a
visually fixed volume, whereas the volume of a gas is determined by its container.
Saturated vapour pressure:

In a closed vessel containing liquid and vapour at a given temperature, an
equilibrium is established in which, number of molecules leaving the liquid equals those
re-entering. The concentration of molecules in the vapour remains constant and the
vapour concentration is said to be saturated for that temperature. The saturated vapour
now above the liquid is the strongest vapour it is possible to have at that particular
temperature. Any stronger concentration at that temperature would result in
condensation of surplus vapor to liquid. The higher the temperature greater will be the
average kinetic Energy of the molecules and greater will be the concentration of
molecules in the vapour phase at equilibrium.
Boiling point:
When vapour pressure of a liquid which is in open vessel becomes equal to
atmospheric pressure, the vapour occupies 100% of the space immediately above the
liquid, that is the vapour is undiluted with air. Boiling point of any given liquid is the
temperature at which its vapour pressure equals pressure of atmosphere. At normal
atmospheric pressure water boils at 1000C. At high altitudes, the atmospheric pressure
is lower and water boils at lower temperature.
All matter may be affected by temperature and pressure, but solids and liquids
are relatively incompressible. Gases on the other hand can be squeezed into a smaller
volume and are there fore affected by a third factor, volume. This is the basis of the gas
lows.
152

-Second Edition
GAS LOW VARIABLES:
Volume – volume of the gas is defined as a 3 dimensional space inturn defined by
container walls. The container has no leaks. Variable for volume is “V”.
Unit – Liter, ml.
Volume man change in accord with a change in other parameter. The container walls
change in other parameter. The container walls may be movable to accommodate these
volume changes. However in all cases a perfect seal is present such that despite volume
changes molecules do not escape from the container. Some times, volume need to be
held constant, e.g.-when increase in the temperature. For these cases materials in the
container will are very resistant to the pressure and do not move readily.
Temperature:
Gases are defined by a temperature that may be measured and represented in “C”.
Temperature is represented in terms of symbol “T”. All gas law problem use Kelvin
temperature. If Celsius degree is used, the answers will be wrong.
Kelvin = Celsius + 273.15
Standard temperature by definition is O0C or 273 K.
Kelvin temperature of a gas is directly proportional is its kinetic energy. Therefore
tripling the Kelvin temperature, triples the kinetic energy of the system.
Pressure:
Pressure is a consequence of gas molecules banging against the container wall and is
defined as force / area. Units -- atm, mm Hg, KPa, torr. Standard pressure is 1 atm /760
mm Hg /101.325kpa.
BOYLE’S LAW “
Take a syringe, block the end of it with your finger and push the plunger. The
further down the plunger the goes, the harder it is to advance. This is because the
pressure inside the syringe is increasing due to compression of air. This is the basis of
first law.
153

-Second Edition
VARIABLES VARIABLES HELD RESULTING FORMAL
ALLOWED TO CONSTANT RELATIONSHIP DISIGNATION
CHANGE
Pressure and Number of P1V1 = P2V2 Boyle Law
volume molecules and
temperature.
Pressure may be defined in terms of molecular collisions since reducing the volume,
while retaining the same number of molecules increases the number of molecular
collisions, pressure must increase.
Figure 1 shows that, relationship between pressure and volume is non linear. The curve
is a hyperbola.
Since the quantity of gas has remained same throughout the experiment V is
therefore proportional to specific volume –V.
Figure -2 shows the relationship between pressure and reciprocal of volume (Density).
There is a linear relationship.
Therefore pressure is directly proportional to reciprocal of volume in the
container.
P 1/V or PV=K
Boyle’s low states that, for a fixed mass at constant temperature, the product of the
pressure and the volume is a constant.
154

-Second Edition
Boyle’s law can be expressed in the following ways.
a. The pressure of a gas kept at constant temperature varies inversely as the
specific volume.
b. The pressure of a gas kept at constant temperature is proportional to its density.
c. The product of the pressure and the specific volume of a gas kept at constant
temperature is constant.
Applications:
1. Volume of oxygen:
Consider an oxygen cylinder with internal capacity of 5 liters. When full, it has a
pressure of 13.800 KPa. How much oxygen will be available at atmospheric
pressure according to Boyle’s law P1V1 = P2V2
P1 = Cylinder pressure = 13,800
V1 = Volume of the cylinder = 5lt
P2 = Atmospheric pressure = 100kp
V2 = Volume of gas available at atmospheric pressure.
PV 13,800 x 5
Therefore V2= 1 1 = 690 l.
P2 100
Relationship between Pressure in cylinder and amount of oxygen and nitrous oxide at
constant temperature.
Oxygen cylinder when full contains oxygen at 137 bar pressure. If gas is allowed
to escape, mass of gas per unit volume in cylinder will decrease and the pressure
155

-Second Edition
also falls. A pressure reading at any stage gives an indication of the amount of
oxygen remaining in the cylinder and hence it obeys Boyle’s law.
But in case of nitrous oxide cylinder, the pressure exerted by the saturated
vapour over liquid is 51 bar and the pressure remains unaltered as long as any
Nitrous oxide exists in liquid phase.
Any accurate indication of amount of nitrous oxide remaining in the cylinder can
only be obtained by weighing the cylinder. It is evident that when the liquid is
volatilized, the pressure of gas within cylinder begins to fall. Therefore Boyle’s
law applies only when pressure of nitrous oxide is below its saturated vapour
pressure.
CHARLES LAW
In a way this law was discovered by
Joseph Louis Guy-Lussac in 1802. This law
illustrates the relation ship between
volume and temperature if pressure and
the amount of gas are held constant.
156

-Second Edition
Imagine the same syringe filled with air, the plunger half way along and the end
blocked. A heat source is applied. The gas expands and the plunger moves
backwards and the volume increases.
Variables allowed Variables held Resulting Formal
to change constant relationship designation
Volume and Number of Charle’s Law
Temperature molecules and V1 V2
=
pressure T1 T2
If a graph is plotted with gas volume versus temperature on the Celsius scale, a
linear relationship is obtained. When the line is extended in order to predict the
temperature at which the volume would become zero, it is found that, a
temperature of -2730C is obtained.
Charles law states that the volume of a given quantity of gas at constant pressure
is directly proportional to the temperature in degree Celsius plus 273 degrees.
V T0C + 273 or
V
=K
TC 273
For an ideal gas the increment in volume is 1/273 of the volume of gas at zero degree
Celsius for each degree Celsius rise temperature.
Applications:
Determination of the amount of halothane vapour at room temperature.
If one ml of halothane gives 207 ml of vapour at 273 K, how much vapour is present at
293 K.
157

-Second Edition
V1 V2
T1 T2
V1T2
= 221 ml of vapour.
T1
2. Ambient temperature pressure and saturated conditions to Body temperature

pressure and saturated condition corrections.
Volume of gas measured by spirometer is usually measured at room temperature which
is lower temperature than the body temperature. So according to Charles’s Law if
pressure remains constant, volume of gas is directly related to temperature. Volume
measured by spirometer are at ambient temperature pressure and saturated conditions,
it gives a lower volume and therefore must be adjusted for the temperature difference
between the spirometer and the patient’s body temperature. To make this adjustment,
multiply the volume measured by ATPS to BTPS correction factor. These can be a 5% to
10% difference between volumes measured at ATPS and BTPS conditions.
GUY-LUSSAC LAW:
Consider the same syringe, syringe is maintained at constant volume. If heat is added to
this constant volume container, the molecules of gas gain kinetic energy and collides
with the walls of the container more frequently thus resulting in increase in pressure.
The third perfect gas law states that at constant volume that absolute pressure of a
given mass of gas varies directly with the absolute temperature.
P T or P/T =a constant.
Applications:
If a cylinder were completely filled with liquid oxygen, the valve closed and
cylinder allowed to acquire room temperature, the previous liquid oxygen would
become gaseous since volume of the cylinder and weight of oxygen is unchanged the
pressure in the cylinder would rise to enormous height of 4000-4500 bar. The storage
158

-Second Edition
of oxygen under this pressure is impracticable. The cylinder walls would have to be
extremely thick. Packing glands to withstand these pressures are difficult to construct.
At these great pressure oxygen is likely to cause spontaneous ignition. Cylinders in
common use for medical gases have comparatively thin walls. Into these cylinders
gaseous oxygen is pumped until the pressure reaches 137 bar. The cylinders are now
stated to be full although in order to leave a wide margin of safety they are tested to
withstand a pressure of 200 bar.
AVOGADRO’S HYPOTHESIS:
Consider two syringes each of volume V containing two different gases, oxygen and
hydrogen maintained at the same temperature. If the appropriate gas molecules are
added to each until the pressure in the two syringes are the same, it is found that each
syringe must contain the same number of molecule. Of course the mass is different as
the molecules are different.
Avogadro’s hypothesis states that equal volumes of gases at the same temperature and
pressure contains equal number of molecules.
Avogadro introduced a molecular numbering system known as the mole. One
mole contains 6.02x1023 molecules. One mole is one gram multiplied by the molecular
weight.
One molecular of oxygen = 32gram.
It has been found that one mole of any substance occupies 22.4 liters. So
6.022X1023 Molecules of oxygen =32 gram and occupies 22.4 liters.
Applications:
Volume of nitrous oxide in a cylinder

Consider a N2O cylinder which when full weighs 4.4 kg [Molecular wt=44gm]
According to Avogadro’s law 1 Mole of nitrous oxide 22.4 liter volume.
Therefore 44gm occupy 22.4 lt at STP.
159

-Second Edition
Therefore 4.4 kg occupy 2240 lt at STP.
In practice weight of N2O is used to indicated how full cylinders are. The weight of an
empty N2O cylinder is known and is stamped at the top.
Therefore weighing the cylinder, the N2O content may be calculated.
Calculation of density of a gas.

Density is the ratio of a substance mass to its volume. The density of a gas at STP can
easily computed by dividing its molecular weight expressed in grams by the universal
molar volume of 22.4 liter.
Gas density at STP for oxygen is
gm wt 32
dO2 = = = 1.43 g/l.
molar volu me 23.4
Calculation of amount of volatile liquid needed to make a known percentage of vapour.
Let us consider sevoflurane. Molecular weight = 200 gm; Liquid density = 1.5 kg/liter.
At room temperature 200gm sevoflurane occupy 22.4 liter.
1 gram = 22400/200 =112 ml
Liquid density = 1.5 kg/liter.
Therefore 1ml of sevoflurane = 1.5 grams
22400
Therefore 1.5 gram of sevoflurane occupy × 1.5 =168ml of Vapour
200
Therefore 1 ml of sevoflurane vaporizes to 168 ml.
If 10 liter of oxygen is added to 1 ml of sevoflurane and vaporized then percentage of
sevoflurane vapour will be
volumeofpurevapor 0.168
= = 0.016 or 1.6% sevoflurane vapour.
Totalvolume 10 0.168
Universal gas constant:

The concept of gas Laws can be combined with that of Avogadro’s Hypothesis
and the mole as follows.
PV=K1 [Boyle’s Law]
V/T = K2 [Charle’s Law]
P/T = K3 [Guy – Lussac’s Law]
So PV is a constant for a given quantity of any gas. For one mole of any gas
PV
=a
T
T
unique constant known as the universal gas constant. R- Rearranging PV= n RT where
n=number of moles of the gas. Value of the gas constant is 8.3145 Joules per mole –
Kelvin.
160

-Second Edition
Applications:
This formula is applied in anesthetic practice in the use of a contents gauge for a
gas cylinder.
Consider an oxygen cylinder with a fixed internal volume V. Therefore V in the
equation PV= nRT is a constant. R is a constant value and if cylinder is at fixed
temperature, T is also a constant. Thus from this formula P is directly proportional to ‘n’
the number of Moles, which is the amount of gas in the cylinder. The pressure gauge
then act as contents gauge provided the cylinder contains a gas.
VARIATIONS FROM IDEAL GAS BEHAVIOUR

During isothermal conditions the temperature of the ideal gas should not change with
either compression or expansion.
Adiabatic change is a charge of physical state of a gas without the transfer of heat
energy to or from the surrounding environment.
Adiabatic expansion:
A rapidly expanding gas cools because energy is required to overcome the
vander waal’s forces of attraction, as this energy cannot be gained from the
surrounding, it is taken from the kinetic energy of the molecules. Thus the temperature
drops and this drop in temperature is enough to liquefy the gas. This is the working
principle of a cryoprobe.
The gas flows through a capillary tube in the cryoprobe and expands in probe tip,
where a temperature is as low as -700C, may be produced. Cryoprobe is used for rapid
freezing of tissues in the treatment of skin lesions, in gynecology and in ophthalmic
surgery. When applied to nerves it causes local degeneration of nerve bundles and this
results in long term [3-6 months] local analgesia. This action has been used in the
161

-Second Edition
treatment of pain. Adiabatic expansion is also the primary method used to liquefy air for
the production of oxygen.
Adiabatic compression:
In rapid compression the energy level between molecules is reduced. As this
energy cannot be dissipated to the surroundings, it manifests as increase in
temperature. If a gas cylinder connects to an anesthetic machine or regulator is turned
on quickly, the pressure of gas in the connecting pipes and gauge rise rapidly. Thus gas
is compressed adiabatically and larger temperature rise and associated risk of fire can
occur.
Adiabatic cooling:
Consider a N2O cylinder. If the cylinder valve is opened widely and evaporisation
is rapid, the consumption of heat is correspondingly rapid. In the manufacture of N2O,
great care is taken to ensure that the gas is free from water vapour before it is
compressed to the liquid state in cylinders. The cooling which inevitably takes place
when the cylinder valve is open is sufficient to freeze any water vapour which might be
present and thus block the exit valve with ice.
Critical temperature:
It is the highest temperature at which a substance can exist as liquid. It is defined
as the temperature above which a substance cannot be liquefied however much
pressure is applied.
Critical temperature of oxygen is – 1160C.
Critical temperature of N2O is 36.50C.
Since critical temperature of O2 is – 1160C if follows that, it cannot be liquefied by
pressure at room temperature.
Critical pressure is the pressure at which a gas liquefies at critical temperature.
Critical pressure of N2O at 36.50C is 73 bar.
Critical pressure of O2 at -1160C is 50 bar
A gas is a substance in the gaseous phase above its critical temperature.
A vapour is a substance in the gaseous phase below its critical temperature. O2
and N2 are gas at atmospheric temperature and pressure while CO2 and N2O are vapors.
Since N2O have critical temperature above ambient then can be liquefied by
simple compression and stored as liquid at room temperature without cooling. But the
liquid O2 has to be maintained below its boiling point [-1830C] at atmospheric pressure.
If higher temperatures are required, higher pressures must be used. If any time the
liquid O2 exceeds its critical temperature of -1160C, it will convert immediately to gas.
162

-Second Edition
Filling of N2O cylinder:
Consider N2O cylinder filled completely with liquid N2O. Any increase in
temperature causes the N2O to expand, but unlike a gas, a liquid is not compressible. As
a result these would be a great increase of pressure and considerable risk of explosion.
The manufactures always ensure that the cylinders are only partially filled to leave a
volume of N2O vapour above the liquid. Any increase in temperature will cause liquid to
expand which converts it into vapour. As vapour is compressed, some of it condenses
and thereby keeping the pressure from rising excessively.
The term filling ratio is used to describe how much gas is used to fill a cylinder.
Filling ratio is the mass of gas in cylinder divided by the mass of water which would fill
the cylinder. As one liter of water weighs one kg, the filling ratio represents the mass of
N2O in kg divided by the internal volume of the cylinder in liters. For N2O this ratio is
0.65.
Dalton’s low of partial pressure:

If a mixture of gas is put inside a container, such as a jar of air, which contains
oxygen and nitrogen. Each of the molecules of nitrogen and oxygen bash against the wall
of the container applying a pressure.
Dalton’s law states that in a mixture of gases, the pressure exerted by each gas is
the same as that which it could exert if it alone occupied the container.
We know that, the air is 21% O2 and 79% N2 so we can calculate the partial
pressure of each gas by multiplying the total pressure by fractional concentration of
each gas.
760 mm Hg x 0.21 = 157 mmHg is the partial pressure of O2 in the jar.
Application:
Alveolar gas which is at atmospheric pressure of 100kpa,is composed of a mixture of
gases. Their partial pressure when added will equal the total pressure of one
atmosphere.
PO2 = 13.3 kpa
PCO2 = 5.3 kpa
PH2O = 6.26 kpa
PN2 = 75.2 kpa
Total = 100 kpa.
1. Filling gas cylinder with gas mixture of 10% CO2 in O2 is needed to be produced.
First CO2 is filled to an absolute pressure of 13.8 bar. At this pressure CO2 is still
gaseous, at room temperature. Oxygen is then added to a total absolute pressure
of 138 bar. The overall percentage of CO2 is then 10%. The same as ratio of
pressures.
163

-Second Edition
HENRY’S LAW:
This law predicts how much of a given gas dissolves in a liquid. According to this
principle at a constant temperature, the volume of gas that dissolves in a liquid is equal
to its solubility co efficient times its partial pressure.
V = x P gas.
V= volume of the gas dissolved
= Solubility co efficient of the gas is the given liquid
P = Partial pressure of the gas in a liquid.
Applications:
1) Oxygen therapy:
Amount of gas carried in solution is blood is governed by Henry’s Law. Solubility co
efficient of O2 in plasma is 0.0034 ml /mm of Hg (PO2/ dl) since PO2 in blood is
100mm of Hg, the oxygen that dissolves in blood equal 0.3 ml.
When the O2 in the alveoli exerts a partial pressure of 100 mm of Hg, the Hb in the blood
leaving the lungs is saturated with O2. Any increase in the partial pressure of O2 in the
alveoli result in a very small increase in amount of O2 carried by Hb. When 100% of O2 is
breathed, the partial pressure of O2 in the alveoli can be raised from 100mm Hg to
700mm Hg. This results in seven fold increase in the amount of O2 dissolved in plasma.
Dissolved O2 fraction in blood can also be increased by breathing oxygen of increased
atmospheric pressure.
The benefits of hyperbaric oxygenation are associated with 4.8 fold increase in
oxygen carrying capacity of plasma. When an individual inhales at 3 atmospheric
pressure.
An individual can carry enough O2 in solutions under these conditions to satisfy his
tissue oxygenation demands.
Hyperbaric oxygenation therapy is useful for patients suffering from anaerobic
bacterial infections, in extreme anemia and CO poisoning.
2) Deep sea diving:

Compressed air illness or caisson’s disease is a sequele to deep sea diving. Here
air is breathed upto 10 bar pressure. When breathing air at very high pressure, Nitrogen
is in solution in the tissues and in the blood. Its tension is in equilibrium with the partial
pressure of N2 in the alveoli.
As diver rises to the surface, his tissues are subjected to less pressure. When the
ambient pressure falls below the sum of partial pressure of the gases dissolved in the
tissues, minute gas bubbles are formed. If the rate of ascend is two rapid gas bubbles
coalesce and expand resulting in decompression sickness.
164

-Second Edition
Volume of quantity of trapped gas increases upon decompression and is
inversely proportional to the pressure [Boyle’s law].
Therefore in practice decompression should be carried out in stages. So that
dissolved gas can diffuse from poorly perfused tissues into the blood stream and then
into the alveoli.
Another option is to recompress to 2.8 bar and give pure O2 to breathe the
pressure greatly reduces the volume of any trapped gas and absence of N2 from the
inhaled gas increases the N2 pressure gradient across the alveolar membrane so that N2
diffuses more readily from the tissues.
3) Second Gas Effect:

When an individual switches suddenly from breathing air to a mixture of 79%
N2O, 21% O2, rate of absorption of N2O is sufficient to cause a fall in pressure in the
alveoli, were if not prevented by entry of an equal flow of an inhaled gas mixture. Since
N2O is removed faster than the N2 being added from the circulation, the concentration of
O2 in the alveoli rises. This is second gas effect and occurs whenever one component of
an inhaled gas mixtures is replaced by a highly soluble gas and ventilation and
circulation continues. If a third component such is volatile anesthetic is introduced, its
alveolar concentration will be enhanced for as long as rapid absorption of N 2O
continues.
BERNOULLI EFFECT AND VENTURI PRINCIPLE

Daniel Bernoulli in 1738 formulated the laws for the flow of fluids through pipes of
varying diameter.
When a fluid flows thought a tube of uniform diameter pressure decreases
progressively over its entire length. However, when the fluid passes through a
constriction, the pressure drops even further. As the fluid passes into the constricted
portion of the tube, its velocity must increase.
According to Bernoulli principle, as the velocity increases, the lateral pressure exerted
by the fluid decrease, fall in pressure at the narrowing of a tube arises in the following
way. Flowing fluid contains energy in two forms. Potential energy associated with its
pressure and kinetic energy associated with its flow . At the constriction, there is
considerable increase of fluid velocity and a great gain of kinetic energy. Such an
165

-Second Edition
increase in kinetic energy can only occur if there is a fall in potential energy because the
total energy is constant.
Some 60 year later venture showed that in order for a streaming fluid to regain a
pressure much higher than that at the constriction, it was necessary for the tube
immediately distal to the constriction to open up very gradually and the angle of
dilatation should be less than 150 such a tube is venture tube .Now if the pressure gauge
at position P2 is removed leaving the side tube open and if at this point the pressure is
below atmospheric air or other fluid can be entrained through the side tube. Apparatus
like this is called an injector. This effect is called fluid entrainment. Entrainment is the
result not only of the suction effect of the fast stream of driving gas, but also the friction
between O2 moving at high speed and pulls more air along with flow of oxygen. This is
called jet entrainment.
EVOLUTION OF THE INJECTOR WITH ENTRAINMENT DUCT
Gas flows through constriction in the tube. An entrainment duct is attached to

the tube.
Jet replaces the constriction and tube is modified to give the characteristics of
venture tube. The specially shaped part downstream of the jet is known as the diffuser.
166

-Second Edition
The function of the conical diffuser is to reduce turbulence as the gas stream slows
down and transforms as much as possible, the kinetic energy into pressure energy, to
entrain larger volume of gas and to make this volume independent of fluctuations in
pressure distal to the diffuser. Final composition of the mixture issuing from the exit
port is not dependent on the volume flow rate of the driving gas but on the size of the
entrainment port.
Applications:
1) Use of a simple air injector for supplying gas mixtures of constant compositions.
A compact source of gases for emergency use can be provided by use of an injector
driven with O2 from a cylinder. The dilution of stored and with air increases the volume
of gas available the amount of gas entrained can be increased by either increasing the
entrainment port or having a smaller jet.
167

-Second Edition
2) Nebulizers
Commonly used to humidify the inspired gases and nebulizer drugs. The
gas driven nebulizers depend on Bernoulli effect and the process of Jet entrainment. A
high speed flow of gas causes a drop in pressure at the end of a tube which allows water
to be drawn up and entrained from the tube. The entrained water is then broken up into
a spray of droplets of various sizes by the fast moving gas stream. If the gas stream hits
the anvil the larger droplets can be baffled out or divided into smaller droplets. And
thus carries the droplets into the region of trachea.
Jet ventilation:
Jet ventilation is based on Bernoulli’s principle and venturi application
where by a flow of gas flowing through a tube is made to exit from a narrow nozzle will
create a negative pressure at the point of exit and will entrain gas, augment its volume,
and produce positive pressure ahead. The jet ventilator is a pressure generator
ventilator. It is powered by a source of compressed gas at pressure of 50 psi.
O2 jet produces negative pressure proximally entrains from room air and
produce positive pressure distally and inflates the lung even through the airway is kept
open to atmosphere.
Jet ventilation is accomplished by introducing the venturi injector to the
proximal end of the bronchoscope to which jet of O2 is applied from manual on/off valve
connected to the oxygen pressure source.
Venturi Mask:
These systems deliver a precise concentration of inspired O2 which is unaffected by
patient’s breathing pattern. O2 enters the mask as a jet and entrains a constant flow of
air via the holes at the bottom of mask. In use total flow delivered to the patient must
exceed the PIFR of the patient if the inhaled mixture is not to be further diluted by air
sucked in through the side holes of the mask. When used correctly they will deliver a
known Fio 2 greater than the patients inspiratory flow rate. So the patient does not
inspire air from outside the mask. To achieve this flow rate at high Fio2 [50%]
proportionally high flows of oxygen are required which necessitates the use of relatively
large jet.
The colour of the mask’s aperture reflects the Fio2 achieved.
Blue – 24%; white -28%; yellow – 35%; Red- 40%; Green – 60%.
Hudson’s multi-vent mask also employs the injector principle in which concentration of
O2 can be varied pure O2 flows through the jet of an injector. The air entrainment port is
covered by a rotating sleeve.
168

-Second Edition
POISEULLE’S LAW
Laminar flow occurs when the gas passes down parallel sides tube at less than a
certain critical velocity, with laminar flow, the pressure drop down the tube is
proportional to the flow rate and is calculated from the equation derived by poiseulle.
V
P= x M x l x where
r4 t
P= Pressure drop
V
= Volume flow rate
t
l = Length of tube
r = Radios of tube
M= Viscosity.
This relationship is true only for laminar flow in a tube and is known as Hagen –
poiseulle Law. According to this formula, the driving pressure will increase whenever
the fluid viscosity tube length or flow increases. A greater pressure will be required to
maintain a given flow if the radius decreases. If the radius reduces by half, the pressure
gradient required to maintain the same flow will go upto 16 times, which may be
adjusted in steps to provide a known variation in the area of entrainment orifice. The
number to which the indicator points gives the percentage of O2 in the mixture. If the O2
flow rate is changed there is a corresponding change in the amount of air entrained
consequently, the delivered concentration of O2 remains unchanged.
Mask of the device has two large holes
to allow free expiration and passage of the gas
mixture to the atmosphere. This is necessary
to ensure that no pressure builds up in the
mask, since if it did so, it would tend to reduce
the subatmospheric pressure adjacent to the
jet of the injector.
Applications:
1. Intravenous infusions: The flow rate obtained is governed by Poiseuille’s law.
ν πpr4
=
τ 8nl
169

-Second Edition
Hence flow rate obtain is higher. When the cannula is large and short and pressure head
is higher, doubling the size of the cannula effectively increases the flow 16 times. With a
standard transfusion set, it is more practicable to double the diameter of the cannula
than to increases the pressure 16 fold.
Air flow to the lungs.

Laminar flow occurs when the gas passes down very small airways [less then 2
mm in diameter]. This is because the repeated branching of the airways results in a total
cross-sectional area which is much larger than the cross sectional area of the trachea or
medium sized bronchi, so that velocity of air flow is greatly reduced.
Flow meter
In a flow meter, the bobbin with fluted edges to encourage rotations, is supported by the
stream of flowing air through a calibrated tube whose bore is wider at the top than at
the bottom.
At the lower end of the tapered tube, the area through which the gas passes is relatively
small compared with the distance which it has to travel in order to pass the bobbin.
Here the constriction takes the form of a tube. Hence the flow is laminar in this area and
obeys Poiseuille’s law. That is, viscosity of gas plays a dominant role in determining the
rate of flow of gas. On the other end of the flow meter tube the gas passes through an
area which is large when compared with the distance it has to travel.
That is the constriction takes the form of an orifice. In an orifice flow, flow rate
1
[Graham’s Law]
density of gas.
170

-Second Edition
When the float spins at the lower part of tube viscosity of the gas plays a much
more important part than does density. At high flow rate, density plays a more
important part. Therefore flow meters are individually calibrated according to density
and viscosity of the gas. If wrong gas is introduced into the flow meter wrong readings
of the flow would be obtained.
CONADA EFFECT:
Fall in pressure in fluid flowing through a tube when the tube narrows occur. If
such a strain flows along the wall of a wide tube air cannot be entrained where the
stream touches the wall. So a region of low pressure remains in this area and the stream
is held against the wall. This behaviour is known as conada effect and may be of
important in explaining the uneven distribution of gas flow to alveoli where there has
been a slight narrowing of the bronchiole before it divides. It may also explains some
cases of MI where there may be narrowing before branching of coronary artery.
A valve mechanism can be made, if two tubes are inserted at each side at the exit of the
narrow tube, the flow through either of these tubes can switch the main flow from one
exit tube to the other. Have been transfer the flow continues into the appropriate
branch after the switching flow gets removed. Such device are incorporated in
ventilators to reduce the number of valves and moving part but such ventilators
consume extra gas which is used as power for fluid logic.
171

-Second Edition
Chapter 34 - ADIABATIC EFFECT
Definition:
The term adiabatic implies the change in state of gas without exchange of heat energy
with its surroundings which means the volumes change of a gas in which there is no
transfer of heat.
Mechanism:
Sudden compression of a gas without removal of resultant heat causes rise in
temperature. When the cylinder valve is opened rapidly there may be rapid raise of
temperature due to sudden release and instantaneous compression of gas inside the
cylinder. A shock wave may also be formed and there is sudden increase of pressure.
There may cause violent, combustion and explosion in the presence of O2.
Clinical Application:
A cylinder valve should be opened slowly. If gas passes quickly into the space between
the valve and the yolk the rapid recompression of the compressed gas in this space will
generate large amounts of heat. Because there is little time for dissipation of this heat,
an adiabatic process occurs (Adiabatic effect means neither heater lost nor gained from
environment).
Particles of dust or grease present in this space may get ignited by the heat, causing a
flash fire or explosion.
Adiabatic effect can be abolished by 2 ways.
1. Opening the valve slowly, prolongs the time of recompression. And permits some
of the heat to dissipate into environment. Hence the cylinder should be
continued to be opened slowly until the pressure on the gauge stabilized.
2. A non-combustible Bodakseal (washer) placed between the valve and yoke
decreases combustion to certain extent.
3. In N2O cylinders sudden adiabatic expansion of the gas results in cooling. This
principle with used in cryoprobe.
Q. Describe the circuit used for elimination of CO2?
Ans. Breathing system with CO2 absorber
Unidirectional flow Bidirectional flow

Eg. circle system with Eg. To and Fro
absorbs system
172

-Second Edition
Q. Filling ratio
Wt. of gas with which it is filled
Ans. Filling ratio (%) = Wt of water the cylinder can hold
N2O
0.68%
CO2
Cyclopropane – 0.55%
Vary in different countries according to climate
Filing ratio is good to avoid over filling.
Filling ratio is also known as filling density.
It is expressed in %.
173

-Second Edition
174

-Second Edition
Chapter 35 - MEDICAL GAS SUPPLY AND PIPELINE SYSTEM
Medical gas:
The term medical gas is used to describe gases which are administered to the patients
or used to power lung ventilators or drive surgical tools.
The medical gases for health care facilities may be supplied by means of
1. CYLINDERS 2. CONTAINERS
For small setups Cylinders can be used as a sole source of supply, whereas for bulk
requirement containers containing liquid form are used which is vaporized and
transmitted to anesthetic machine via pipelines.
PIPED MEDICAL GAS SYSTEM

The piped medical gas system is a network of pipes distributing medical gases from a
central source to wherever they are required in a medical hospital.
The advantages of piped gases are:

Reduction in the cost of gases and also saving the cost of labour for transporting
cylinders.
Reduction in the introduction of cylinders which may carry infection into the
operating room.
Reduction in the incidence of accidents due to cylinders getting exhausted.
Common characteristics in piped medical system

1). A central source of gas (i.e. cylinders, pumps etc)
2). A pipeline distribution system
3). Terminal units in the clinical areas of the hospital to which apparatus can be
connected.
4). Alarm system to warm of failure of the system.
Standards and sources of information

The National Fire Protection Association (NFPA), the compressed Gas Association
(CGA), the Canadian Standards Association (CSA) and the International Standards
Organization (ISO) have published a number of documents related to piping systems.
Compliance with these standards is one the criteria for accreditation by the Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO).
175

-Second Edition
CENTRAL SOURCE OF GAS
3 main types:
1).Cylinder manifold
2).Liquid gas store
3).Atmospheric air compressor
A central supply system may be located outdoors in an enclosure used only for this
purpose or in an enclosure situated inside a building.
Cylinder supply system for a small facility contains
Two banks of cylinders = Bank # 1

Bank # 2
Among these two banks, one will be the primary supply (duty or running), while the
other bank is the secondary supply (standby or Reserve Bank). Only one of the bank is
utilized at any given time, the other constituting “Reserve Bank”. Change over from
primary bank to reserve bank takes place automatically when the pressure in the
primary bank drops below a pre-set value. This switch over is accomplished by
pressure sensitive switch (manifold change over device).
Components of each Bank

Each bank contains a minimum number of two cylinders or cylinders equivalent to the
average day’s supply of that particular health care facility. Each gas enters the high
pressure header of the manifold via coiled high pressure copper lines. A check or non-
return valve is placed between each cylinder lead and the header to prevent loss of gas
from the manifold cylinder if there is a leak in an individual cylinder or lead. The
manual shutoff valves permit isolation of either bank of cylinders.
Pressure – reducing or Operating regulator

Fluctuations in distribution pressure can be decreased by reducing the pressure in two
stages, so a regulator is installed in the outgoing pipe. A manual shutoff valve must be
located upstream of and a shutoff or check valve downstream of each regulator. This
arrangement, plus having two regulators makes it possible to service a regulator
without shutting down the entire piped system.
This kind of arrangement without a reserve supply is called “alternating supply system”.
176

-Second Edition
Emergency supply manifold:
When the main manifold is out of action, such as during maintenance or repair,
emergency supply manifold may be used to continue the supply. The change over from
main manifold system to emergency supply is done manually.
A main pipeline isolating valve must be provided for the use in the event of fire or the
emergency.
Bulk Supply System (liquid gas store)

A liquid oxygen container serves as the operating supply with cylinders
constituting the reserve supply. This is also known as the continuous type
system because one primary source always supplies the system under normal
operating conditions.
The reserve supply operates in the event that the operating supply is unable to
furnish sufficient gas to the system. The reserve is used for emergencies or when
maintenance or repair of the operating supply is needed. Operating of the
reserve should activate the reserve in use alarm on the master signal panel. The
reserve may consist of manifold cylinders or small liquid containers.
The gases commonly supplied by the pipeline include Oxygen, Nitrous Oxide,
Medical air, Entonox, Carbon dioxide and Nitrogen.
Oxygen
Oxygen may be stored either as a liquid at low pressures or as a compressed gas in
cylinders.
Gaseous Supply
Oxygen may be supplied from G or H cylinders that are transported between the
distributor and the central supply area. A third possible source is oxygen concentrators.
The different types of cylinders are

Cylinder Dimensions Capacity (Volume and Pressure)
Size Air N2O Oxygen
H 9 ¼ x 51 Lt. 6.550 15800 6900
Psig 2200 745 2200
KPA 14960 5066 14960
G 8 ½ x 51 Lt 5050 13800 3400
Psig 1900 745 2013
Kpa 12920 5066 13700
E 4 ¼ x 26 Lt. 625 1590 660
Psig 1900 745 1900
Kpa 12920 5066 12920
177

-Second Edition
The Colour coding of cylinders
Gas Colour State in Cylinder
Oxygen White Gas
Nitrous Oxide Blue Gas + Liquid (below 98o F)
Carbon dioxide Gray Gas + Liquid (below 88o F)
Helium Brown Gas
Nitrogen Black Gas
Air White & Black Gas
Liquid supply
It is used when large amounts of oxygen are required. It is less expensive and more
convenient and it takes comparatively less space to be stored. Liquid Oxygen container
refilled in 2 ways supply trucks carrying liquid oxygen directly filling the containers or
alternatively filled liquid containers transported to the facility.
Liquid oxygen is stored and supplied from vacuum insulated evaporator (VIE). It is
stored at a temperature of 150o C to 170o C to prevent liquid from evaporation.
STRUCTURE OF CONTAINER
To maintain very low temperatures high degree of insulation is required. For this
purpose, containers are manufactured similar to thermos bottles containing a inner
shell of stainless steel, separated from a outer shell of carbon steel by vacuum which
also contains perlite powder.
There may be four connections to the inner cylinder:
1. The Filling Port, through which fresh supplies of liquid oxygen are introduced.
2. Gaseous withdrawal line: Gaseous oxygen is withdrawn from the top of the
containers through this line and passed through the super heater to bring it upto
ambient temperature and raise it’s a pressure and then into the distribution pipe
work.
3. A liquid (lower) withdrawal line – during pressure drops secondary to high
consumption rates, liquid oxygen withdrawn from the bottom of containers,
vaporized by the pressure building coil (evaporator) and then either to the
hospital pipeline system or to the gaseous compartment of the VIE.
4. A second (upper) Liquid withdrawal line – in case of exceptionally high demand,
liquid oxygen may pass through the upper liquid withdrawal line and vaporized
in the super heater and then into distribution pipe work.
RELATIVE CAPACITIES OF CYLINDERS AND CONTIANERS

The maximum amount of oxygen that can be stored in a health care facility is 20,000
cubic feet. The pressure within a full cylinder of oxygen is 13700KPa (1980psi). Thus
when used on a pipeline it gives 130 times its capacity of oxygen at atmospheric
178

-Second Edition
pressure. Compared to this one volume of liquid oxygen gives 842 times its volume of
gas at 15oC and normal atmospheric pressure.
At Source: Inside the oxygen containers: 1055 kPa or 155 psi.
Pipeline System: The medical gases are usually piped at pressures (other than
nitrogen) at 410 kPa (60 psig). Nitrogen is delivered at 1100 kPa (160 psig).
NFPA now permits pressures upto 2068 kPa (300 psig).
Terminal outlets: The pressure at the terminal outlets is 420 kPa or 60 psig.
Nitrous Oxide
It is supplied to a piped medical gas system from a manifold of cylinders similar to those
for oxygen. The problem with nitrous oxide cylinders is that, in case of heavy demand,
the gas may cool to such a low temperature that water vapour in the ambient
atmosphere condenses and may even freeze on the surface of the pipe work in
particular pressure regulator. So, a thermostatically controlled heater (at 47o C) may be
needed to warm the gas and prevent condensation. Nitrous oxide liquefies at room
temperature when stored under pressure. Alternatively, nitrous oxide can be stored in
insulated vessels similar to those used for oxygen.
Warning signs should be posted around areas where nitrous oxide is stored to warm
that nitrous outside is a asphyxiant and that a hypoxic mixture can be produced in case
there is a leak.
COMPRESSED MEDICAL AIR

Medical air (air for breathing) is defined by the NFPA as air, regardless of its source, that
has detectable liquid hydrocarbons, less than 25 ppm gaseous hydrocarbons, less than 5
mg / m3 of particulates of 1 micron size or greater at normal atmospheric pressure and
a dew point at 50 psig (345kPa) of less than 39o F.
A special air system for non breathing purpose sand for gas powered devices may be
provided. The air provided by this system may not meet the requirements for medical
air. It is often piped at pressures of upto 175 psig (1210 kPa) whereas for breathing
purposes pressures upto 60 psig (420 kPa) are used. Air may be supplied by:
Manifold cylinders
A proportioning device, which mixes gas from oxygen and nitrogen cylinders.
Motor driven Compressors.
Air from compressors is usually less clean and dry than that from cylinders but is less
expensive if a large volume is required.
179

-Second Edition
A typical system is shown here: Most components must be duplexed and equipped with
upstream and downstream shutoff valves to allow isolation and continued operation of
the system in the event of failure of the component.
Each compressor takes in ambient air, compresses it to above the working pressure and
supplies it to one or more receivers (accumulators or reservoir tanks) from which air
can be withdrawn as needed. The intake of air should be from a location where it will
take in air that is free of dirt, fumes, and odors. The location of the intake is usually
outside.
To render air suitable for medical use its water content is reduced. An after cooler in
which the air is cooled and the condensed moisture removed is usually installed
downstream of each compressor. More water may condense in the receiver. Additional
water may be removed by running the air through a dryer. Valves, pressure regulators,
and alarm analogous to those in oxygen supply systems are needed. The reserve may be
manifold cylinders or a separate compressor system.
ENTONOX (50% nitrous oxide + 50% oxygen)

This mixture is used for administration of inhalational analgesia principally in the
obstetric department. The manifolds employed are essentially the same as those for
nitrous oxide and oxygen, but additional safeguards are required in the handling of the
cylinders. This is because contents of the mixture starts to separate into its
constitutional gases when it is cooled below 7o C and this process of separation is
known as lamination.
Entonox cylinders should be provided with an internal tube from the valve block,
leading down to within 10 cm of the bottom of the cylinder, position of which would
prevent the discharge of pure nitrous oxide if lamination had occurred.
Cylinders of entonox should be stored for 24 hrs after delivery before being connected
to the manifold to allow them to warm up if necessary. The cylinders in store should be
stored horizontally at a temperature between 10o C and 38oC.
NITROGEN
Central nitrogen supplies may consist of manifold high pressure cylinders or cryogenic
liquid containers.
CARBON DIOXIDE
Carbon dioxide is being piped more frequently because of its use for laparoscopic
surgery. The source for piped carbon dioxide is high pressure cylinders.
PIPED MEDICAL VACUUM

Piped medical vacuum can be the most advantageous of all piped services.
180

-Second Edition
COMPONENTS
The distribution pipe work is setup in the form of a “ring” the two ends of which pass
towards the pump through isolating valves (check) and then a drainage trap. Drain
serves to remove the aspirated liquid or condensed vapour. The pipe then pass through
bacterial filters and from there to vacuum reservoir. At the bottom of reservoir is a
drainage pipe with a manual drain valve.
The connection between reservoir and vacuum pump is made through flexible hoses in
order to reduce vibration and noise. Two vacuum pumps are fixed one “on duty” and
other “stand by”
SPECIFICATIONS
The vacuum should contain a negative pressure of about 400mmHg (-53kpa) at outlets.
Free air intake should be at least 40 liters / min. There should be at least two outlets
per OT and one per anesthetic room and one per recovery bed.
PIPED DISTRIBUTION SYSTEM

There are three general classes of piping:
1. Main Lines: Pipes connecting the source to risers or branch lines or both.
2. Risers: Vertical pipes connecting the main line with branch lines on various
levels of the facility.
3. Branch (lateral) lines: The sections of the piping system that service a room or
group of rooms on the same level of the facility.
Pipes are made of special copper (phosphorous deoxidized non-arsenical copper) which
is resistant to degradation by pressurized gases. Generally oxygen is installed in ½ inch
outer diameter (OD) and other gases in 3/8 inch OD pipes. Identification of the pipes at
least every 20 feet and at least once in every room. The name and pressure of the gas
inside the pipe and its direction of flow must be displayed.
The colour coding for pipeline system is:

Oxygen – Yellow with white
Nitrous oxide – French blue with yellow ochre
Medical air – Black and White
Medical Vacuum – Light blue and Yellow
181

-Second Edition
PRESSURE RELIEF VALVES
Each central supply system must have a pressure relief valve set at 50% above normal
line pressure downstream of the line regulator (s) and upstream of any shutoff valve.
This is to prevent a buildup of pressure if a shutoff valve is closed. The valve should
close automatically when the excess pressure has been relieved.
SHUTOFF VALVES
Shutoff or on-off or isolating or section valves permit isolation of specific areas of the
piping system in the event of a problem and allow sections to be isolated for
maintenance, repair, testing, or expansion without the whole system having to be
switched off.
Two types of shutoff valves exist manual and service
Manual valves are installed where they are visible and accessible t all times. Service
shutoff valves are designed to be used only by authorized personnel. JCAHO has
emphasized the importance of properly labeling and informing personnel of the
locations of these valves.
ALARMS
Master Alarm System:

A master alarm system monitors the central supply and the pressure in the main line for
all medical gas systems. To ensure continuous responsible observation, master signal
panels with auditory and visual alarms and pressure gauges must be located in two
separate locations wired in parallel to a single sensor. One panel should be in principal
working area of the department responsible for maintenance of the system and one
more located in continuous staffed locations like telephone room or security office.
FUNCTIONS
An alarm should signal when
A changeover from the primary supply to the secondary bank has occurred.
Just before reserve supply goes into operation.
Reserve supply is reduced to one average day’s supply.
Pressure in reserve is below that required to function properly.
Liquid level of a cryogenic supply reached a certain level.
Pressure in main line increases or decreases from normal operating pressure.
Area Alarm System:

An area alarm system consists of an alarm panel(s) and associated actuating device(s)
that provides audible and visual signals for medical gas systems serving a specific area
such as operating rooms, post anesthesia care units, intensive care units etc.
182

-Second Edition
The area alarm is activated by a 20% increase or decrease in pressure.
PRESSURE GAUGES
A pressure gauge must be installed in the main line adjacent to the actuating switch for
the main supply line pressure alarm and in each line being monitored at each area
alarm panel.
TERMINAL UNITS
The terminal unit is the point in a piped gas distribution system at which the user
normally makes connections and disconnections.
COMPONENTS
Base block
The block is the part of a terminal unit that is attached to the pipeline distribution
system.
Primary valve
The primary valve opens and allows the gas to flow when the male probe is inserted and
closes automatically when the connection is broken. Although often called a check
valve, it is not a unidirectional valve and will permit flow in either direction.
Secondary Valve
The secondary valve is designed so that when the primary valve is removed (for
cleaning or servicing) the flow of gas is shutoff. When the primary valve is in place the
secondary valve stays open. The secondary valve is fitted at or near the end of
permanent pipe work.
Gas-Specific connection point

Also called the socket assembly. The receptor for non interchangeable gas specific
connector, which is either part or attached to the base block, is incorporated into each
terminal unit.
The connector may be a threaded Diameter index safety system (DISS) or a proprietary
Quick Connector. The female component is called an outlet connector or socket. The
male member is called an inlet connector, probe, plug, striker or jack. The male
component is attached to the equipment to be used or to a flexible hose leading to the
equipment. Each DISS or Quick Connector should be equipped with a back flow check
valve to prevent flow of gas from the anesthesia apparatus or other dispensing
apparatus into the piping system.
The diameter index safety system: DISS was introduced in 1959 as a non-
interchangeable low pressure connection system devised for medical gas applications.
183

-Second Edition
The DISS is used only for connections with less than 200 PSIG and does not replace the
pin index safety system designed for the compressed gas tank anesthesia machine
connection. DISS connection consists of a body, nipple and nut combination. There are
two concentric and specific bores in the body and two concentric and specific shoulders
on the nipple. The small bore (BB) mates with the small shoulder (MM) and the large
bore (CC) mates with the large shoulder (NN).
Quick connectors: They allow apparatus like hose or flow meter to be connected or
disconnected by a single action using one or both hands without the use of tools or
undue force. Quick connectors are more convenient than DISS fittings but tend to leak
more.
Each quick connector consists of a pair gas specific male and female components. A
releasable spring mechanism locks the component together. Insertion into an incorrect
outlet is prevented by the use of different shapes for mating portions or by different
spacing. A natural standard has not been developed for quick connectors.
Face Plate
The face plate should be permanently marked with the name and symbol of the gas it
conveys.
TYPES:
Wall outlets:
Wall outlets are well suited for small rooms, but problems like tripping, difficulty in
moving equipment and wear tear of hose are encountered. For large rooms, more than
one set of wall outlets are advisable.
Ceiling – Mounted Hoses

Ceiling Mounted hoses with the terminal unit at the end of hose may be used.
Ceiling – Mounted Pendants

A ceiling mounted pendent with one or more articulated arms avoids cluttering the floor
and can be easily be moved to various locations. In addition to terminal units it may
have electric and data management outlets, space for monitors, telephones, intravenous
solution mounts, and suction bottles and regulators.
Ceiling Column
Ceiling mounted columns can provide the same services as a pendant but are less
versatile with respect to positioning.
184

-Second Edition
HOSES
Hoses are used to connect anesthesia machines and other apparatus to terminal units.
Each end should have a permanently attached, non interchangeable connector. The
connector that attaches to a terminal unit is called the inlet or supply connector and the
connector that attaches to equipment such as on an anesthesia machine is the outlet or
equipment connector. Color coding of the hose and having the name and chemical
symbol of the contained gas on each connector are desirable.
PRECAUTIONS:
Hoses should be kept away from any heat source especially operating room
lights because contact may lead to rupture.
Hoses should be kept off floor.
Use of several extension hoses is undesirable, better to use one long hose.
Hoses should approach the anesthesia machine at a gentle curve and avoid acute
angulation or stretching.
Wear & tear of hoses should be inspected regularly especially after many years of
service.
TESTING OF MEDICAL GAS DISTRIBUTION SYSTEM

Testing is a integral part of maintenance of infrastructure of hospital. It should be
tested periodically and test procedures and results should be made part of the
permanent records of the facility. The extent of testing for a new or modified portion of
an existing system will depend on how much of the existing system can be isolated and
not affected by the work.
There has been controversy over who should carry out the final tests to make sure the
piping system complies with regulations. Commercial services that inspect medical gas
pipelines and offer certification are available. No certified agencies are present as such.
Anesthesia personnel have an obligation to ensure that the system is properly designed
and functions correctly, so a member of the department should witness the tests
performed, especially those for cross connections.
Testing can be studied under 3 headings. 1). Initial testing 2). System verification 3).
Periodic Testing and preventive maintenance.
INITIAL TESTING
Blow Down: This is done after the pipeline shave been installed but before the
installation of terminal units and other components (gauges valves etc.). The line
must be blown clear using oil free dry nitrogen.
185

-Second Edition
Initial Pressure Testing: This is done after the installation of terminal units but
before the attachment of system components and before closing the walls. Each
section is subjected to a test pressure of 1.5 times the working pressure with oil
free nitrogen with the source valve closed. All joints are examined and any leaks
that are found must be corrected.
Standard Pressure testing: This is done after all the components have been
installed and the entire system is subjected to a 24 hour standing pressure test at
20% above the normal operating line pressure with the source valve closed. Any
leaks that are found must be corrected and the test is repeated until no leaks are
found.
Piping Purge test: This is done to remove particulate matter, where heavy
intermittent purging is done until no discoloration on a white cloth is noted.
Test for Cross Connections: Also called the Anti confusion or continuity test.
This is done to confirm that the gas delivered at each terminal unit is the one that
shown on the label. One gas system is tested at a time. Each gas is turned off at
the source valve and the pressure reduced to atmospheric. The pipeline being
tested is the filled with oil free nitrogen at its working pressure. Each individual
station outlet is checked with appropriate adapters matching outlet labels to
ensure that test gas emerges only from the outlets of medical gas system being
tested.
SYSTEM VERIFICATION
This is done with oil free dry nitrogen after the walls have been closed.
Cross connection test: This can be done in 2 ways.

All medical gas systems are reduced to atmospheric pressure. All sources of test gas
from all medical gas systems. With the exception of one system to be checked, are
disconnected. The system is then pressurized to 345kPa (50 psig). Each terminal
unit of every medical gas system is then checked to determine that test gas is being
dispensed only from the outlet of the medical gas system being tested.
Alternatively, the test gas pressure in all medical gas piping system is increased to the
following values:
Medical Gas psig kPa

Gas Mixtures 20 140
Nitrogen 30 210
Nitrous Oxide 40 280
Oxygen 50 350
Compressed Air 60 420
Following adjustments of pressures each station outlet is identified by label and the
pressure indicated on the test gauge must be as listed above.
186

-Second Edition
Tests of Valves: Valves must be tested to verify proper operation and rooms or
areas of control.
Outlet flow test: Flow tests must be performed at station outlets using oil-free
dry nitrogen or the gas of the designated system. Oxygen, nitrous oxide and air
outlet must deliver 1001/min with a pressure drop of no more than 35 kPa (5
psig) at a static pressure of 345kPa (50 psig). Nitrogen outlet must deliver 1401
/ min with a pressure drop of no more than 35 kPa (5 psig) at a static pressure of
1100 kPa (160 psig)
Alarm Testing: Master and area alarm systems must be tested for super
functioning.
Piping Purge Test: This is done to remove particulate matter with large rates of
at least 3251/min which is applied to each outlet until the purge produces no
discoloration of white cloth.
Piping Purity Test: Each system must be tested for dew point, methane and
halogenated hydrocarbons at the outlet most remote from the source.
Final Tie-In Test: This done to check for leaks between new & existing systems
if any additional typing work has been done.
Operational Pressure Test: Pressure should be maintained at 345 kPa to all

terminal units while delivering 1001/min with a pressure drop of no more than
35 kPa – for all gases other than nitrogen. Piping systems for nitrogen should
maintain a pressure of 1100 kPa at a flow of 5.0 standard cubic feet per minute
with a pressure drop of not more than 35 kPa at a static pressure of 1100kPa.
Medical Gases Concentration
Medical Air Purity Test: Air source should be analyzed for dew point, carbon
monoxide, carbon dioxide, gaseous hydrocarbons and halogenated
hydrocarbons.
Source Equipment Verification: This is done following installation of pipeline

accessories. A pressure test is performed at the highest system operating
pressure for 2 hours, with no more than a 10% pressure drop allowed.
187

-Second Edition
PERIODIC TESTING AND PREVENTIVE MAINTENANCE
A planned preventive maintenance program can avert potentially hazardous conditions
and unexpected loss of service, reduce the economic burden of leakage and reduce
repairs performed as emergencies. Periodic testing should be performed at least as
frequently as recommended by the manufacturer of the pipeline.
PLANNED SHUTDOWNS
The process of partially or completely shutting down a medical gas pipeline system is a
complex task that involves many risks. The anesthesia department should be actively
involved to ensure uninterrupted gas service. Purity and crossover testing should be
performed at all outlets following the shutdown.
PROBLEMS
They mainly occur due to the 1). Lack of awareness among personnel who have false
belief that the pipeline system cannot fail 2). Lack of communication between clinical
and maintenance department and commercial suppliers 3). Lack of adherence to
existing codes.
Inadequate Pressure: This is the most frequently reported malfunction
Causes: 1). Damage, especially during construction projects related to piping system 2).
Fires 3). Vehicular accidents 4). Depletion of or damage to central supply 5). Human
error including closure of a shutoff valve. 6). Equipment failure such as leaks 7). Failure
of a Quick Connector to fit into station outlet.
Causes: 1). Damage, especially during construction projects unrelated to piping system
2). Fires 3). Vehicular accidents 4). Depletion of or damage to central supply 5). Human
error including closure of a shutoff valve. 6). Equipment Failures such as leaks 7).
Failure of a Quick connector to fit into station outlet.
Disaster Plan: Every health facility should have a disaster plan to deal with
emergencies arising from loss of oxygen or pipeline pressure. The plan should include
conservation of existing supplies and acquisition of additional supplies from other
facilities or vendors if necessary. Locations of shutoff valves should be known by staff,
so that if the loss of pressure is caused by leak in one area, the pipeline to that section
can be isolated to prevent further loss.
188

-Second Edition
To prevent immediate threat in the operating rooms, every anesthesia machine should
have at least 1 emergency oxygen cylinder.
Emergency Auxillary Supply: Because of the grave consequences associated with

oxygen failure special areas such as ICU, recovery rooms and emergency rooms may add
an auxillary oxygen and air supply.
Leaks: They are also commonly seen. Leaks are expensive and potentially
hazardous if oxidizing gases are allowed to accumulate in closed spaces
especially nitrous oxide.
Excessive Pressure: It is a relatively common problem which can damage

equipment especially regulators and cause barotraumas to patients. The most
common cause of high pressure is failure of a regulator. Ice may form on the
vaporizers in a liquid oxygen system in humid atmospheres. Whenever
excessive pressure occurs, it is best to disconnect apparatus from the pipeline
system and use cylinders until the problem is corrected.
Alarm problems: Failure, absence or disconnection of an alarm is not

uncommon. False alarms are also a common problem. They may result from
calibration drift in line pressure sensors.
Cross connection of Gases: This can have devastating consequences, the most
common being between oxygen and nitrous oxide. It can occur at various levels.
Central supply: Where liquid oxygen has been filled with nitrogen or argon.
Distribution System: Crossing of pipelines usually occurs during installation,

alteration, or repair of a system.
Terminal units: Labeling may be wrong or wrong outlet connector may be

installed.
Hoses: Wrong connector being installed on one or more hoses.
Contamination of Gases:
Particulate: Particulate contamination is frequently seen when a new pipeline is opened.
A common source of contamination is air compressors, receivers or dryers. It may
cause 1). Damage to equipment especially to ventilators 2). Decrease in flow of gases
3). Harmful to patients if inhaled.
189

-Second Edition
Gaseous: Inhalation of volatile hydrocarbons can be unpleasant and harmful to
patients, may damage equipment and create a fire hazard. The source may be
material left in pipes during construction or the inlet to the air compressors.
Many accidents involved cleaning of pipeline system with trichloroethylene,
therefore NFPA has banned onsite use of trichloroethylene. Pipeline odors
should be dealt seriously. All medical gases should be odor free. Gas should be
smelled before administering it to patients to ensure it is odor free.
Bacterial: Piped Medical gases are not sterile. This can be overcome by placing
a filter between the station outlet and the equipment.
Water: Water in an air pipeline can pass through particulate filters and make its
way into equipment and patients. Hazards include damage to equipment,
causing particulate formation, promoting bacterial growth.
Fires: Equipment used with a pipeline system must be clean and free from oil,
grease and particulate matter to avoid fires.
Depletion of Reserve Supply
Theft of Nitrous Oxide cylinders: for substance abuse is also seen.
OXYGEN CONCENTRATION
It is an alternative source of supply of oxygen which can be utilized when obtaining
oxygen from cylinders or pipeline is inconvenient, impossible or prohibitively
expensive.
METHOD OF OPERATION:
Membrane Filtration: It uses an oxygen permeable membrane or lattice to
collect oxygen. It produces 30 – 40% oxygen and is not used.
Pressure Swing Adsorption: It acts by adsorbing nitrogen onto a molecular sieve
currently being used in is an inorganic silicate which belongs to a class of
crystalline compounds and is known as zeolite.
CONCENTRATOR DESIGN
The typical components include:
Inlet Filters and Silencer: Two filters, on eat inlet and outlet of compressor trap
particles and bacteria and a muffler reduces the sound level.
Compressor: It compresses filtered air to a high working pressure. Cooling of the
compressor is important because, if inefficient, it can lead to decrease in the
performance.
190

-Second Edition
Heat Exchanger: When a gas is compressed its temperature increases, so heat
exchanger in the form of coiled tubing is placed.
Reservoir Canister: This dampens the pulsations generated by the compressor.
Valves: They may be electrical pneumatic directing the flow through the concentrator.
Sieve Beds: Also called Canisters or Columns. Two beds filled with zeolite allow
continuous production of oxygen and regeneration of sieve.
Product Tank: Also called accumulator, it not only acts as reservoir but also is a source
for purge gas.
Pressure Regulator: Reduces the pressure of the gas flowing to outlet to a constant
lower value.
Check Valve: Prevents room air contaminating sieve beds when the machine is turned
off.
Outlet Gas Filter: prevents contamination of outlet gas by sieve material or bacteria.
Flow meter: Controls the flow of product gas on concentrators for domiciliary use. It
must be accurate to 10% of indicated flow or 0.51/min.
Oxygen – Concentration status Indicator (OSCI): it is used to warm of low oxygen in
the product gas.
OPERATION
It involves admission of air to a molecular sieve bed while the opposite bed is vented
and purged with product gas. This cycle is repeated with the beds reversed. The
apparatus will require 2.5 to 19 minutes to achieve maximum concentration after being
turned on.
APPLICATIONS
Domiciliary Use: widely used for domestic use as they are compact light weight and
easily movable.
Remote Locations: In some places oxygen cylinders are unavailable or unreliable for
their purity, so concentrators can be used as a reliable constant source in such
circumstances.
Hospital Pipeline Systems: Large – scale oxygen concentrators have been used to
provide oxygen for complete pipeline system during deliberate or accidental shutdown.
The pipeline system is supplied from a pressurized reservoir of concentrated oxygen
that is large enough to cope with peaks usage. The reservoir is supplied by many
concentrators connected to a parallel. A reserve supply in the form of cylinder manifold
should be present.
ADVANTAGES:
Cost Saving: it is less expensive than a liquid or cylinder oxygen.
191

-Second Edition
Filtration of Contaminants: Airborne contaminants like exhaust hydrocarbons,
ethylene oxide, sulfur dioxide and chemical warfare gases are filtered by the molecular
sieve.
Reliability: They perform well for long periods and unaffected by altitude.
Simplicity: provides increased inspired oxygen concentration without dependent on
compressed or liquefied gas and no transportation problems unlike cylinders.
DISADVANTAGES:
Maintenance: Regular servicing is required particularly for the compressor. Air intake
filters be cleaned at the intervals.
Backup supply Needed: It can give an assured supply when only a reserve power
supply or emergency cylinders of oxygen are there.
HAZARDS:
Fires: Oxygen greatly accelerates combustion, so it should be kept away sources of heat,
smoking open flames of electric equipment.
Contamination of the intake medium: air intake may be contaminated by fumes or
other atmospheric pollutants.
Contamination of Sieve Medium: Water can contaminate sieve medium. High
humidity can lower oxygen concentration.
Device Malfunction: Electric or mechanical malfunction may occur interrupting flow of
oxygen.
Argon Accumulation: can reach 5% concentration. But no long term or short term
adverse effects have been reported in patients.
192

-Second Edition
193

-Second Edition
Chapter 36 - FACE MASKS, AIRWAYS, ENDOTRACHEAL AND
ENDOBRONCHIAL TUBES
FACE MASKS OR FACE PIECE

DEFINITION
Defined functionally as a device which allows administration of O2 or other gases from
the breathing system without introducing any apparatus into the patient.
PARTS OF FACE MASKS

Body
Seal (rim. Flap_
Connector (Orifice, collar)
Mask strap / head harness / head band
Body
Constitutes main part of the mask
Transparent body allows to observe the patients vomits, secretions, blood, lip
colour and condensation of exhaled moisture.
Malleable body allows a better fit to the patient and decreases dead space.
Seal
Comes in contact with the face
Of two types
- Pad or cushion: Often inflatable or filled with a material that conforms to the
face when pressure is applied. It may be high volume, low pressure or low
volume, low pressure.
- Flange: Often non inflatable flexible extension of the body.
Connector
- Is at the opposite side from the seal
- Consists of thickened fitting with a 2mm internal diameter.
- A ring with hooks may be placed around the connector to allow the mask strap to
be attached.
Head Harness
- It decreases the air leak and holds face mask firmly.
-
194

-Second Edition
SPECIFIC MASKS
Anatomical mask (Connell mask)

Can be moulded to confirm to anatomy of face
Has slightly malleable rubber body, a sharp notch for the nose and a curved chin
section.
The low volume high pressure cushion may be factory sealed or have nipple for
inflation with additional air.
Available in variety of sizes
Randell – Baler – Sousek Mask (RBS)

Designed for pediatric patients
Has a triangular body.
May be scented or may have a pacifier
Used to administer positive pressure ventilation to patient with acheostomy
Importance:
Low dead space of 4 ml
Reduced re breathing
Syracuse Endoscopic Mask

Called intubating mask as it allows oral or nasal fiberoptic intubation rough a port of
diaphragm in the body of the mask. And for covering the port is attached to the mask.
Mask requires two operators: One to perform intubation and other obtain airway, mask
fit and ventilation.
Mask:
For acceptability and pleasant experience of induction may be incorporated into the
mask by the manufacturer or added anesthesia provider.
Trimar mask:
- Similar to anatomical mask but has shallower body and less dead space.
Scram
- Selective contour retaining anatomic mask
- Designed for difficult to fit patients
- Seal is a cushion filled plastic and entire mask body and seal can be moulded
195

-Second Edition
Bridge less mask
- Designed for a face with flat features or little or nose bridge.

- Has an air filled cushion and nose notch is eliminated
- Shallow body, flat seal curvature than that of anatomical mask.
Ambu transparent mask
- Has a body of clear plastic

- Seal is pneumatic cuff
- There is thumb rest built into the body
Flotex multi fitting mask
- It is antistatic having a rubber flange instead of a pneumatic cushion which can

be extended to be placed under the skin.
Laerdal Mask:
- It is a soft one piece silicon rubber mask with an inward curving circular face
seal.
- Can be boiled and autoclaved
- Superior to other for ventilation of new born infant and pediatric patients.
Clear disposable mask
- A number of clear disposable masks are available from different manufactures in

various sizes.
MASK SELECTION
Smallest mask is most desirable because it will cause the least increase in dead space,
easiest to hold and unlikely to result in pressure on the eyes.
MASK FIT
Considerable manual strength and dexterity may be necessary to achieve a tight seal
and to lift the jaw to prevent airway obstruction.
Failure to obtain a tight fit with spontaneous respiration results in air dilution and
reservoir bag no longer serves as a mean of monitoring ventilation and with assisted or
controlled respiration, development of adequate positive pressure to ventilate the
patient will be impossible.
196

-Second Edition
MASK HOLDING TECHNIQUES
One Hand Technique;

The mask is held with one hand
Fingers should not be kept on soft tissue as it decreases patency of the airway.
The thumb and the index finger are placed on the body on opposite side of the
connector and they press downward to hold the mask to the face and prevent
leaks. Additional downward pressure can be exerted by the anesthesiologists
chin on the mask elbow.
Other four fingers are placed on the mandible such that middle is applied to the
mentum and the ring finger on the body of mandible with little finger at the angle
of the mandible to thrust the jaw anteriorly.
Two Hand technique

This requires an assistant to provide manual ventilation.
The thumbs are placed on either side of the body of the mask.
The index fingers are placed under the angle of the jaw.
The mandible is lifted and head extended.
If leak still occur, downward pressure on the mask can be increased by
anesthesiologist chin on the mask elbow.
Another method:
1st individual stand at the head of the patient and perform a jaw thrust with his
left hand at the angle of the left mandible while the right hand compress the
reservoir bag.
2nd person stands facing the 1st individual at the patient’s shoulder with his right
hand covering the left hand of the 1st person and the left hand achieves right
sided jaw thrust and mask seal.
ADVANTAGES AND DISADVANTAGES
Advantages
Lower incidence of sore throat
Require less anesthetic depth
No need of muscle relaxant
For short cases face mask may be the most cost efficient choice of airway
management.
Disadvantage:
Anesthetist’s hands are tied up
197

-Second Edition
Higher fresh gas flow is required and OT gets polluted.
Remote airway access is difficult (CT and MRI)
More episodes of oxygen desaturation
Require more intraoperative airway manipulations and present more difficult in
maintaining an airway.
Clinical Googly’s
Fat patients
Emaciated patients
Edentulous patients
Burns patients
Flat nose
Receeding jaws
Beard patients
Patients with drainage tubes in nose
COMPLICATIONS
Skin problem – Dermatitis
Nerve Injury – Branches of trigeminal and facial nerves
Aspiration of gastric contents
Eye injury – Pressure on medial angle of eye – chemosis and corneal injury.
Temporary blindness due to occlusion of central retinal artery.
Latex allergy
Lack of correlation between arterial and end tidal CO2
User fatigue
Sterilization
Masks are immersed in suitable soap solution (5 – 10 ml of spirit soap per lt. of
water) and after end of the day thoroughly washed.
Should not be autoclaved or should not use detergent.
DEAD SPACE
Face mask and its adaptor increases of mechanical dead space by 30 – 40 ml.
It can be reduced by increasing the pressure on the mask, changing the volume of
cushion, using a smaller size mask, extending the separation of the inspiratory
and expiratory channels close to or into the mask, and blowing a jet of fresh gas
into the mask.
198

-Second Edition
AIR WAYS
A fundamental responsibility of the anesthesiologist is to provide and to maintain a
patent airway. Failure to do so for more than few minutes will result in serious brain
damage or death.
ANATOMY
Normal patent airway: it has rigid posterior wall and collapsible anterior wall
made of tongue and epiglottis.
Obstructed airway: Tongue and epiglottis fall back as muscles of pharynx and
mouth relax.
TYPES
Oropharyngeal airway
Nasopharyngeal airway
Oropharyngeal airway:
It extends from the lips to the pharynx, fitting between the lips and the teeth, the
tongue and posterior pharyngeal wall.
The pharyngeal end rest between the posterior wall of the oropharynx and base
of the tongue and by pressure along the base of the tongue, pulls the epiglottis
forward. The bite portion is between the teeth and the flange is out side the lip.
Uses
It may be used to prevent patient from biting and occluding ETT, protect the
tongue during biting, to facilitate suctioning, obtain a better mask fit and to
provide a pathway for insertion of tubular devices into the esophagus or
pharynx.
General description
Made up of elastomeric material or plastic
It has a flange at the buccal end to prevent it from falling back into the mouth and
also to fix the airway in place.
The bite portion is straight and fits between the teeth and gums. It must be firm
enough that the patient cannot close the lumen by bitting.
The curved portion extends backward to correspond to the shape of the tongue
and palate.
The American Standard specifies that the size of oral airway and be designated
by a number that is the length in cm.
199

-Second Edition
NUMBERING OF AIRWAYS
Length
000 Violet 30
00 Blue 40
0 Black 50
1 White 60
2 Green 70
3 Orange 8-
4 Red 90
5 Yellow 100
SPECIFIC AIRWAYS:
Guided airway
Most frequently used type
Has a large flange at the buccal end and a bite portion
Has a gentle curve which follows the contour of the tongue and palate
Tubular channel for air exchange and suctioning.
Berman airway
Has no closed air channel
Has got centre support with sides open
Centre support may have opening
Has got a flange at the buccal end
Water airway:
It is metallic, hollow inside with two holes on the tip and at the base
Has a nipple (obturator) on the right side of the tip, which helps in suctioning
and insufflation of oxygen, sizes are from 0 to 7.
Cordulls airway
Same as water but without insufflation, sizes are from 0 to 7.
Patil Syracus oral airway

Designed to aid fiberoptic intubation
Has lateral suction channels and a central groove on the lingual surface to allow
passage of a fiber scope.
A slit in the distal end allows the fiber scope to be manipulated in the
anterioposterior direction but limits lateral movement.
200

-Second Edition
Williams Airway intubator
Designed for blind tracheal intubation and can also be used for fiberoptic
intubation or as an oral airway.
Available on 2 sizes # 9 and # 10 which will admit upto an 8 or 8.5 mm tracheal
tube respectively.
The proximal half is cylindrical, while the distal half is open on its lingual surface.
Ovassapian fiberoptic intubating airway:

Designed for fiberoptic intubation
Has a flat lingual surface which gradually widens at the distal end and two
vertical side walls at buccal end.
Between the side walls are a pair of guide walls that curve towards each other,
which are flexible and permit removal of the airway from around the tracheal
tube.
The proximal half is tubular and acts as bite block, distal half is open posteriorly
to provide an open space in which fiberscope can be maneuvered.
It can accommodate a tracheal tube upto 9mm ID.
Tongue retracting airway

Has a latching mechanism that allow the pharyngeal tip to be manipulated so
that it moves the tongue anteriorly.
Berman intubating / pharyngeal airway:

Is tubular along its entire length, open on one side so that it can be split and
removed from around a tracheal tube.
Cuffed oropharyngeal airway (COPA)
It is Guedel’s airway with an inflatable cuff designed to seal the oropharynx has
an integral bite block and a 15mm connector for attachment to the breathing
circuit.
Cuff is inflated with 25 to 40 cc of air to displace the base of the tongue, form a
low pressure seal with the pharynx and elevates the epiglottis from the posterior
pharyngeal wall to provide an open airway.
Available in several sizes and inserted in similar manner as an oropharyngeal
airway.
INSERTION
Pharyngeal and laryngeal reflexes should be depressed before placement of an
oral airway to avoid coughing or laryngospasm.
201

-Second Edition
Size of an airway can be estimated by measuring the length from the chin to the
temporomandibular joint by holding the airway next to the patient mouth.
The tip should rest cephelad to the angle of mandible, jaw opened with left hand,
teeth and gum are separated by passing the thumb against the lower teeth or
gums. The index finger or third finger should be against the upper teeth or gums.
Oral airway may be inserted in two ways. The air way is inserted with its
concave side towards the upper lip and when the junction of the bite portion and
the curved section is near the incisors, the airway is rotated 180o and slipped
behind the tongue into the final portion.
A tongue blade may be used to push forward and depress the tongue, airway is
inserted with the concave side towards the tongue and is advanced.
Nasopharyngeal airway (Nasal airway or nasal trumpet)

Extends from nose to the pharynx, the pharyngeal end should be below the base
of the tongue but above the epiglottis.
Better tolerated in patients with intact airway reflexes.
It resembles a shortened tracheal tube with a flanged end.
Made up of plastic or rubber
Size is designated by a number expressing the ID in mm.
SPECIFIC TYPES
Bordex airway (Robertazzi)

Made up of rubber and pharyngeal end has a bevel.
There is large flange at the nasal end.
Rusch airway:
Made up of red rubber and has adjustable flange at the nasal end.
Linder nasopharyngeal airway

Clear plastic airway with a large flange and flat distal end.
Has an introducer which has balloon on its tip.
Before insertion the introducer is inserted into the airway until the tip of the
balloon is just past the end.
When the tube is in place the balloon is deflated and the introducer is removed.
Binasal airway:
Consists of two nasal airways joined together by a connection that has adaptor
for attachment to the breathing system.
202

-Second Edition
It can be used as an alternative to intubation and to maintain ventilation during
oral fiberoptic endoscopy.
Cuffed nasopharyngeal airway

Similar to shortened cuffed tracheal tube
It is inserted through the nose into the pharynx and the cuff inflated, then pulled
back until resistance is felt.
INSERTION
The length of the airway can be estimated as the distance from the tragus of the
ear to the tip of the nose plus 1 inch or the distance from the tip of the nose to the
meatus of the ear.
The airway is held in the hand on the same side or it is inserted with the bevel
against the septum and gently advanced posteriorly while rotating back and
forth gently.
COMPLICATIONS
Airway obstruction
Epistasis
CNS trauma
Uvular edema
Dental damage
Laryngospasm and coughing
Ulceration necrosis
Aspiration or swallowing of the airway.
Equipment failure
Latex allergy
Gastric distention
Cardiovascular response – increase in BP and heart rate following the insertion.
LARYNGEAL MASK AIRWAY

HISTORY AND INVENTORY
Invented by ARCHIE- BRAIN (Honorary Consultant Anesthetist, Royal
Berkshiere Hospital, England) in 1981. LMA was introduced into practice from
1988. From 1993 – 200 he introduced 3 more LMAs:
- LMA – Flexible
- LMA - Proseal
- LMA – Fastrach
203

-Second Edition
(WORDS OF INVENTOR – “An alternative to either the endotracheal tube or face
mask with either spontaneous ventilation or positive pressure ventilation).
DEFINITION
Also called LMA, Brain Mask Airway (BMA), Brain Laryngeal Mask (BLM).
It is a mask designed to secure airway by establishing an end to end
circumferential seal around the laryngeal inlet with an inflatable cuff.
It is a useful advance in airway management, filling a niche between the face
mask and tracheal tube in terms of both anatomical position and degree of
invasion.
TYPES
Classic or standard LMA
Consists of curved tube (shaft) connected to an elliptical spoon shaped mask
(cup) at an angle of 30o. There are two flexible vertical bars at the entry of the
tube into the mask to prevent obstruction of tube by epiglottis. The mask is
surrounded by an inflatable cuff. An inflation tube and self sealing pilot balloon
are attached to the proximal wider end of the mask. A black line running
longitudinally along the posterior aspect of the tube helps to orient it after
placement. At the machine end of the tube there is standard 15mm connector.
The LMA is made from medical grade silicone to withstand repeated steam
autoclaving and contains no latex.
Inflation cuff
Sizes Mm Cm Uses
volume
1 5.25/8.2 8 Neonates / infants upto 5 kgs Upto 4ml
1.5 6.1/9.6 10 Infants between 5-10 Kgs Upto 7 Ml
2 7/11 11 Children between 10 – 20 Kgs Upto 10 Ml
2.5 8.4 / 13 12.5 Children between 20 – 30 Kgs Upto 14 ml
3 10/15 16 Children and small adults over 30 Kgs Upto 20 ml
4 10/15 16 Adults between 50-90 Kgs Upto 30 ml
5. 11.5 / 16.5 18 Large Adults Over 90 Kgs Upto 40 ml
Personal LMA:
Separates the airway and oesophagus more completely than classic LMA
Adult sizes are 3 to 5 with smaller sizes in production for children.
The stem consists of two separate tubes, one supplying gases to the bowl and the
other passing as a separate duct to the tip of the mask, which overlies the upper
esophageal sphincter. An additional posterior cuff (absent in pediatric size)
204

-Second Edition
applies the bowl more firmly around the larynx so that inflation pressure of 30
cm H2O may be applied.
When Proseal is inserted correctly, a naso-gastric tube can be passed through the
drainage tube into the stomach and there should be no leak through the drainage
tube when the mask is positioned correctly.
Flexible LMA (Wire reinforced, reinforced)

Has a flexible, wire reinforced tube and can be bent to any angle.
Available in sizes 2, 2 1/2 , 3, 4 and 5 and cuff size is same as with classic LMA
but in each size the tube is longer and has a smaller diameter than the classic
LMA.
Less likely to be displaced during rotation of the head or repositioning of the
tube than standard LMA.
More resistant to kinking and compression but does not prevent obstruction
from biting.
Unsuitable for prolonged spontaneous ventilation, MRI scanning
Short tube LMA

Has a tube 2 cm shorter than a standard LMA
Only size available is # 3
Disposable single use standard LMA
Available in sizes 3, 4 and 5
Fastrach LMA
It is intubating LMA with shorter, wider bore tube and a metal handle.
Available in sizes 3, 4 and 5
It will allow intubation with a tracheal tube up to 8mm.
Advantages and disadvantages of LMA compared with face mask or tracheal intubation
Advantages Disadvantages
Compared Hands – face operation More invasive
with face Better seal in beard patients More risk of airway trauma
Less cumbersome in ENT surgery Requires new skill
Often easier to maintain airway. Requires new skill
Protect against airway secretion Requires deep anesthesia
Less facial nerve and eye trauma Requires some TMJ mobility
Less operating room pollution N2O diffusion into cuff
Compared Less invasive Increased risk of gastrointestinal
with Very useful in difficult intubation aspiration
tracheal Less tooth and laryngeal trauma Less safe in prone position
Intubation Less laryngospasm and bronchospasm Limits maximum PPV
Does not require muscle relaxation Greater risk of gas leak and pollution
Does not require neck mobility Can cause gastric distention
No risk of esophageal or Endobronchial
intubation
CHECKLIST OF LMA
205

-Second Edition
1). Tube - Check for transparency (no particles / fluid)
- Exterior – for cracks / abrasion / foreign body
- Flexed to 180o Kinking
2). Mask
3). Valve - Deflate and check
- Inflate for 2 min at least
4). Cuff - Integrity i.e. > 50% of recommended – Check for
herniation / thinning / asymmetry
5). Pilot
6). 15mm connector
INSERTION TECHNIQUES
Airway reflexes should be obtruded by general or topical anesthesia.
Standard Technique
Involves using a midline or slightly diagonal approach with the cuff only deflated
Head should be extended and neck flexed (sniffing position) by stabilizing the
occiput by using non intubating hand the tube portion is grasped like a pen with
the index finger pressing on the point where the tube join the mask with the
aperture facing anteriorly and the black line facing the patients upper lip, the tip
of the cuff is placed against the inner surface of the upper incision or gums. At
this point the tube should be parallel to the floor rather than vertical, the jaw
should be released during further insertion.
The mask is pressed against the hard palate to keep it flattened as it is advanced
into the oral cavity, using the index finger to push upward against the palate.
This means that the direction of applied pressure is difficult from the direction in
which the mask moves.
A change of direction can be sensed as the mask tip encounters the posterior
pharyngeal wall and follows it downward. Then the index finger is advanced by
withdrawing the other fingers and slight pronation of the forearm to insert the
mask fully into position with a single movement.
Then the cuff is inflated over 3 to 5 seconds without holding the tube unless the
position is obviously unstable.
The mask now rests on hypopharyngeal floor, sides of which face the pyriform
fossae and upper border of the cuff is behind the base of the tongue of the tip at
the upper part of the oesophagus. The epiglottis may rest either within the bowl
of the mask or under the proximal cuff.
180 degree technique:
206

-Second Edition
LMA is inserted with the laryngeal aperture pointing cephalad and rotating it 180o as it
enters the pharynx.
Partial inflation technique

LMA is inserted with partially inflating the cuff before insertion.
INDICATIONS OF CORRECT POSITIONING

Normal breath sounds heard on bilateral auscultation.
Normal chest movement
An expired CO2 wave form
Normal excursion of reservoir bag
Absence of stridor, intercostals recession, use of accessory muscles of
respiration, tracheal tug, or out of phase respiratory movements of chest
abdomen or reservoir bag.
Fiberoscope, X-ray or MRI.
USEFUL SITUATIONS
Can be used for surgical procedures lasting upto 8 hrs and in ICU to provide
respiratory support for 10 – 24 hours.
Use of a face mask difficult
Difficult airway
Failed intubation (cannot ventilate / cannot intubate scenario)
Head and neck surgery
Pediatric patients in whom unusual anatomy makes tracheal intubation difficult
Tracheal suctioning
Remote anesthesia provider
Supplementation of regional block
Ventilatory support without tracheal intubation
Access to the upper GIT.
COMPLICATIONS
Aspiration of gastric contents
Airway obstruction
Injury to airway
Dislodgement and damage to LMA
Laryngopharyngeal complaints like sore throat, dysphagea and mild dyspnea.
Failure of cuff to inflate or deflate
Nerve injury (hypoglossal, recurrent laryngeal and lingual)
Bronchospasm
207

-Second Edition
Pulmonary edema
ENDOTRACHEALTUBE
DEFINITION AND DESCRIPTION
An endotracheal tube is one through which anesthetic gases or vapors and respiratory
gases are conveyed into and out of the trachea. The end of the tube, which is seated in
the tracheal of the patient, is tracheal end or distal end. The other end which projects
from the patient and connected to the breathing system, is called the machine end or
proximal end.
The tip of the tracheal end of the tube is beveled. The bevel is defined as the slanted
part of the tube at the tracheal end. An oral tube should have a minimum bevel angle
not less than 45o and nasal tube not less than 30o with the longitudinal axis. The
standard specifies a bevel of 38 8o for oral tubes. The oral tubes are available at
angulation ranging from 38o to 56o. the opening of the bevel faces the left side when the
tube is viewed from the concave aspect. Because most often the tube is introduced from
the right. Having the bevel facing left facilitate visualization of larynx as the tube being
inserted. A simple bevel tip is the Magill tip. When, an opening in the tube is present on
the opposite side of the bevel, it is designated as Murphy’s tip endotracheal tube.
Currently used tubes are manufactured from synthetic rubber, plastic materials and
silicone.
Indications for tracheal intubation

Airway protection
Maintenance of patent airway
Pulmonary toilet
Application of positive pressure ventilation
Maintenance of adequate oxygenation
MATERIALS
Rubber Tubes
Can be cleaned and sterilized, reused multiple times.
Harden with age and becomes sticky.
Have poor resistance to kinking and lack transparency
Become clogged by secretion more easily
Do not soften at body temperature
Later allergy is another problem
Polyvinyl chloride
208

-Second Edition
Inexpensive, compatible with tissues and so widely used.
Have lesser tendency to kink
Soften at body temperature and hence the tube conform to the anatomy of
patients upper airway reducing pressure at the point of contact.
Transparency allows observation of tidal movement of respiratory moisture as
well as objects or materials in the lumen.
Silicon
More expensive can be sterilized and reused
REQUIREMENTS OF IDEAL ETT

1). Inertness – A non toxic non allergic substance capable of resisting deterioration
from chemical sterilization or autoclaving.
2). Smoothness of outer surface to avoid damage to mucosa.
3). Inner surface should be smoothed and non-wettable to prevent building of
secretions and allowed free passage of suction catheter and bronchoscope.
4). Non inflammable
5). Transparent
6). Easily sterilized
7). Non kinking
8). Sufficient strength to allow thin waited construction with comparatively large
inner diameter and ability to retain a curve shape.
9). Thermoplasticity to confirm to anatomic passage and to be self centering within
the trachea.
10). Extension of low pressure on area of contact with pharynx, larynx, and vocal
cords.
11). Non reactive with lubricants or anesthetic agents.
12). Tube should be clearly marked according to internal diameter of lumen
13). A range of size should be available to satisfy the need.
14). Non injurious catheter tip
15). A 15mm male connector designed to avoid accidental disconnection from tube
16). Radiopaque to demonstrate in vivo tube position
RESISTANCE AND WORK OF BREATHING

A tracheal tube places a mechanical burden on spontaneously breathing patient. It is a
source of more resistance and is an important factor in determining the work of
breathing than the breathing system components. The factors determining the
resistance include
209

-Second Edition
1).Internal diameter: The tube with thick wall decreases the ID and thereby increases
the resistance and vice versa. Resistance will be increased if a suction catheter or a
fibroscope is introduced through the tube as it decrease the ID, so to decrease the work
of breathing the widest ETT that will fit the larynx should be used.
2).Length: Decreasing the length of the tube decreases the resistance.
3).Configuration: Abrupt change in the diameter and direction increases the
resistance. Curved connectors offer more resistance than straight ones. Gentle curve
connectors offer less resistance than right angled ones as there will be increased
resistance because of turbulent flow of gases.
DEAD SPACE
The volume of tracheal tube and connector is usually less than that of the natural
passage. Dead space is normally reduced by intubation. In pediatric patients long tubes
and connectors may increase the dead space considerably.
CLASSIFICATION OF TUBES
1). Based on type of material used
a). Red rubber
b). Portex (PVC)
c). Metallic tubes
2). Based on presence of cuff
a). Uncuffed, standard tubes, cole tube
b). Cuffed tubes
High volume low pressure cuffed tubes e.g. portex tubes
Low volume high pressure tubes (e.g. red rubber tubes)
3). Based on construction and purpose
a). Double lumen tubes
b). Semi rigid tubes e.g. armored tubes
c). Pre-shaped tubes e.g. RAE tubes
d). Laser protected tubes
e). Combitube
DESIGNATION OF SIZE OF ETT

The internal diameter (ID) in mm is the internationally accepted standard. The other
standards are External Diameter and French catheter gauge.
Conversion of French Gauge into OD in mm.
3 French gauge = 1 mm OD
210

-Second Edition
STANDARD TUBE
As per standard recommended by American National Standard Institute (ANSI), an ETT
should be sized according to the internal diameter in mm, this has to be marked on the
bevel side. The number of sizes is determined by increments of 0.5 mm.
Oral tubes should be radius of curvature of 14 cm 10%. Oral tube should have
minimum bevel angle of not less than 45o and nasal tube should have a minimum bevel
angle of not less than 30o with the long axis. The tip should be rounded with no sharp
points or edges.
In some tubes there will be a hole through the tube wall on the side opposite to the
bevel known as Murphy’s eye, which provides alternative pathway for gas flow if bevel
is occluded. The standard specifies the area of Murphy side must not be less than 80%
of cross sectional area of the tube lumen.
Radiopaque marker is placed at the tip or all along the entire length of the tube to aid in
determination of tube position. The marker is made up of barium sulphate.
STANDARD MARKETING OF ETT

The markings are situated on the bevel side below the cuff as follows:
Type of the tube: Oral or nasal or oral / nasal
Size: ID in mm
Length of the tube in cm measured from tracheal end
External diameter may also be indicated
Manufacturer’s name or trade mark
Z-79 or F-29 designates that tubes accomplish ANSI standard
Implantation tests (IT) or Z-79 indicating the tube has been tested for tissue
toxicity.
Opaque lines may also be included at the tracheal or distal portion of the tubes.
Precautions are usually noted: Disposable / Do not Resuse.
CUFFED ENDOTRACHELA TUBE

Cuff: The cuff is a inflatable sleeve near the patient end of ETT. The cuff material should
be strong and tear resistant but thin, soft and pliable. Cuffs are usually made of the
same material as the ETT. A cuff should distended symmetrically until a no leak seal is
achieved at a cuff pressure of 20 – 30mm of Hg. This called seal point. When properly
size ETT is used, the seal point is achieved when the cuff as expended to 1.5 times the
external diameter of the tube.
Purpose: To provide a no leak inhalation system, to allow positive pressure ventilation,
to prevent aspiration of foreign materials into the lung and to center the tube in the
trachea.
211

-Second Edition
Disadvantages of Cuff: It is possible for an over inflated cuff to balloon over the tip of
the tube. Distension of the cuff may cause compression of the tube lumen and the
obstruction from these causes may not occur for sometime after initial cuff inflation, it
may manifest when the cuff softens with increased temperature or after diffusion of
nitrous oxide into the cuff.
CUFF PRESSURE
Intracuff pressure and pressure on tracheal wall:

It is desirable that cuff seal the airway without extending so much pressure on the
trachea that its circulation is compromised or trachea is dilated.
The capillary perfusion pressure of the trachea mucosa is 22mm of Hg. When cuff is
inflated in the trachea, there is a linear decreased in the perfusion. It becomes reduced
when the lateral pressure on the tracheal wall attains 30 cm of H2O (22mmHg) and
ceases completely at 50 cm of H2O (42mmHg). So it is recommended that the pressure
on the lateral tracheal wall should be kept between 25 – 35 cm of H2O.
Intracuff pressure and use of nitrous oxide:
The resting intracuff pressure and volume of the cuff inflated with air rise during
nitrous oxide anesthesia, which results in ischemia of the tracheal mucosa or
compression of the tube, and increase in volume may lead to cuff herniation.
Steps to prevent the increasing pressure includes the following:
a).Filling the cuff with gas mixture to be used for anesthesia or saline
b).Fitting the cuff system with pressure relief valve or pressure regulating devices.
c).Use of special system e.g. Lanz pressure regulating valve, sponge cuff and special
tubes like Brandt tubes.
d).Monitoring cuff pressure and deflating the cuff as needed.
Other factors that increase the cuff pressure are cough and positive pressure ventilation
etc.
Types of Cuffs:
a). Low volume high pressure

b). High Volume low pressure
c). Foam cuff
Low volume high pressure cuff: They have a small diameter at rest and low residual
volume. It requires a high intra cuff pressure to achieve a seal with the trachea.
It has a small area of contact with the trachea and distends and deforms the
trachea to a circular shape. In this cuff most of the pressure inside the cuff is
used to overcome cuff wall compliance so that the pressure exerted laterally on
212

-Second Edition
the trachea wall will be less than intracuff pressure. The intracuff pressure and
lateral pressure on the tracheal wall increase sharply as increments of air are
added to the cuff. For this reason use of largest ETT has been advised, so that the
cuff will be minimally inflated when a seal is created.
Evaluation: These cuffs offer some advantage over low pressure cuff because they are
usually reused, less expensive and offer better protection against aspiration and better
visibility during intubation than low pressure cuffs. There is also low incidence of sore
throat.
The most serious risk associated with these cuffs is ischemic damage to the trachea
following prolonged use.
High volume low pressure cuffs: They have a high resting volume, large diameter and
a thin competent wall that enables a seal with trachea to be achieved without stretching
of its wall. This type of cuff is floppy and easily deformed. As it is inflated, it first
touches the trachea at its narrow point. As cuff inflation continues the area of contact
become larger and the cuff adopts itself to irregular tracheal surface. If the cuff inflation
is continued the area in contact will be subjected to increasing pressure and trachea will
be distorted to a circular cross section similar to high pressure cuff.
A significant advantages of these cuffs is that provided the cuff wall is not stretched the
intracuff pressure closely approximates that of the wall of the trachea. Thus with this
type of cuff it is possible to measure and regulate the pressure exerted by the cuff on the
tracheal mucosa.
It is desirable that cuff circumference at residual volume be at least equal to
circumference of the trachea. If the cuff is smaller it must be stretched beyond its
residual volume to create a seal. At this point it will act like a high pressure cuff. On the
other hand if residual diameter of the cuff is much greater than the diameter of the
trachea, cuff in folding may occur with the possibility of aspiration along the folds.
Evaluation: These tubes are more difficult to insert, obscure the view of the tube tip and
larynx so that trauma to the airway is common. The cuff is more friable and thus more
likely to be torn during intubation. Incidence of sore throats has been found to be
greater with these tubes.
It is relatively easy to pass devices such as esophageal stethoscope, temperature probes,
naso-gastric tubes around a low pressure cuffs,
c). Foam cuff: The foam cuff has a larger diameter, high residual volume and greater
surface area. It is filled with polyurethane foam covered with a seal. Applying suction
to the inflation tube causes the foam to contract. When the negative pressure is
released the cuff expands.
When in place in the trachea, the degree of the foam determines the resting pressure
extended laterally on the tracheal volume. If too large cuff is used, the tracheal wall
213

-Second Edition
pressure will be high. If too small cuff is used there is a risk of aspiration and leak
during IPPV.
Evaluation: Use of this cuff obviates the need for measurement of cuff pressure or use
of pressure regulating device. A reduce incidence of tracheal dilatation has been
noticed. But the incidence of soar throat is high. If the inflation tube is accidentally
pulled out deflation of the cuff is impossible.
PARTS OF A CUFFED ETT

Inflation valve: It should match with the male luer’s syringe tip and upon removal of
the syringe the valve seals and gas cannot escape.
Pilot Balloon: Its function is to give an indication of inflation or deflation of the cuff and
a rough idea of the cuff pressure.
Flat – Under inflation
Cylindrical – Normal inflation
Spherical – Over inflation
External inflation tube: The standard specifies that the external diameter should not
exceed 2.5mm and it is recommended that the inflation tube should be attached to the
ETT at a small angle. The tube should extend at least 3 cm beyond the machine end of
the ETT before a pilot balloon or inflation valve is incorporated.
4). Inflation lumen: This connects the inflation tube to the cuff. It is located within
the wall of the tracheal tube.
5). The cuff
THE GUIDELINES TO DETERMINE THE SIZE OF ETT

Adult male – 8-9mm ID
Adult female – 7.5 – 8.5 mm ID
1. 1-6 months 3 to 4mm ID
6 – 1 years 3.5 to 4.5 mm ID
Older than 1 year ID in mm = (16 + age in years) / 4
2. Premature Gestational Age in weeks + 0.5 = ID in mm
10
Younger than 6.5 yeas 3.5 + age in years / 3 = ID in mm
Older than 6.5 years 4.5 + age in years / 4 = ID in mm
3. Infants below 1Kg 2.5 mm
Infants 1-2 Kg 3.0 mm
Infants 2-3 Kg 3.5 mm
Infants 3 Kg 4.0 mm
4. Choosing a tube whose external diameter is same width as the patient’s distal
little finger.
214

-Second Edition
DEPTH OF INSERTION
The tube should be in the middle third of the trachea with the head in neutral position.
The following calculations can be used.
1). Length in cm = Age / 2 + 12
2). Length in cm = Weight in Kg /12 + 12
3). Length in cm = Height in cm / 10 + 5
4). Rule of 7-8-9: Infant weighing 1 kg are intubated to a depth of 7 cm at the lip, 2
kg infant to a depth of 8 cm and 3 kg infant to a depth of 9 cm.
The tube should be passed until the cuff is 2.25 to 2.5 cm below the vocal cords. If no
cuff is present, the tube tip should be inserted not more than 1 cm past the cords in
children under 6 months. Not more than 2 cm past the cords for a patient up to 1 year
and not more than 3-4 cm past the cord in larger patients.
In average size adult patients, securing the tube at the anterior incisor at 20 – 23 cm in
males and 19 – 21 cm in females will usually avoid endobronchial intubation. For nasal
intubation 3 cm should be added to these lengths for positioning at the nares.
In children the optimal depth can be calculated by using the formula
L = (3 x S) + 2
Where L – Length in cm
S – Internal diameter of the tube
SPECIFIC ET TUBES
Cole tube:
Designed for pediatric patients. The patient end is smaller in diameter than the rest of
the tube. They are sized according to the internal diameter of the tracheal portion. It
ranges from 2mm to 5mm. the bevel of the tube is 45 8o angle. The shoulder, the
portion at which transition from oral portion to the laryngotrachela portion occurs,
provides some protection against inadvertent bronchial intubation. The tube should
not be inserted so far that the widened portion contact the larynx, because this will
result in pressure on and possible dilatation of the larynx.
Disadvantage of this tube is that it cannot be used nasally because the large segment
will not pass through an infant’s nares.
Usually used for resuscitation and not for long term intubation.
Spiral embedded tubes:

Also known as Armored. Anode, metal spiral woven tubes. These tubes have a metal or
nylon spiral woven reinforcing wire covered both internally and externally by rubber,
latex, PVC or silicone. The spiral does not extend into the distal and proximal ends. A
stylet is often needed for intubation.
215

-Second Edition
Indication:
1). Head and neck surgeries

2). Maxillofacial surgeries
3). Neurosurgeries
4). Abnormal positioning including hyperflexion, hypertension of the head, prone
position etc.
5). Surgeries which causes compression of the neck and the airway.
Advantages:
Resistance to kinking and compression. The portion of the tube outside the patient can
be easily angled away from the surgical field without kinking, can be used for patients
with tracheostomies and pass more easily over fibroscope than preformed tubes.
Disadvantages:
Tube may rotate on the stylet during intubation. Insertion through nose is difficult,
these tubes cannot be shortened. Fixation of these tubes are more difficult compared to
the conventional tubes. If the patient bites the tube it will cause permanent deformity
resulting in obstruction of the tube. Inflation tube passes outside distal to the point
where the spiral ends. If the connector is pushed into the spiral to prevent kinking, it
may pinch of the inflation tube so that cuff can be neither inflated nor deflated. In the
newer tubes inflation tube is attached outside the wall of the tube or the connector is
permanently sealed against the coil to prevent this problem.
Ring – Adair – Elwyn (RAE) preformed tubes:

The tubes are available in cuffed, uncuffed nasal and oral version. There is a preformed
bend in the tube that may be temporarily straightened for suctioning. As the diameter
increases, the length and distance from the distal tip to the curve also increases. Each
tube has a rectangular mark at the center of the bend. Distance from this mark to the
distal tip is printed on each tube.
Nasal RAE have a curve opposite to the curvature of the oral tube, so that when in place
the outer portion of the tube is directed towards patient’s forehead reduced pressure on
the nares. This tube may be useful for oral intubation of patients who are to be in
prone position.
Oral or RAE tubes are shorter than the nasal ones. The external portion is bent at an
acute angle towards the concavity of curvature of the tube and rests on patient’s chin.
216

-Second Edition
Advantages:
Easy to secure and reduce the risk of unintended extubation.
Breathing system remains away from surgical field.
Disadvantages:
It is offer more resistance than conventional tubes
Suctioning is difficult
Dwyer – Sakland – Lindholm tube:

Designed to minimize the traumatic effect of curvature of the standard tube, which
tends to exert backward pressure on the cartilage of posterior commisures and to be
angled anteriorly after passage through vocal cords to accept a pressure and mucosal
erosion on tracheal valve by providing a second posterior curve in the lower part of the
tube and thereby producing an S-Shaped tube, pressure effect was minimized.
Laryngectomy tube:
Designed for insertion into a tracheostomy site. The tube is preformed in a J
configuration. This allows the part of the tube external to the patient to be directed
away from the surgical field. The tip may be short and / or without a bevel to avoid
inadvertent advancement into a bronchus.
Carden Bronchoscopy tube:

Designed for fiberoptic bronchoscopy. The machine end is wider than the patient end.
The tube is sized by the internal diameter at the patient end. The larger diameter of the
machine end decreases the increase in resistance caused by passage of the
bronchoscope. The tube is made of silastic and can be sterilized and reused.
Carden Laryngoscopy Tube:

Used for microlaryngeal surgery. It is less than 7 cm long. It is manufactured from
silicone and has a low pressure cuff and a jet tube built into the side. It can be sterilized
for reuse.
After insertion, the cuff is inflated to hold it in position. Intermittently jetting gases into
the tube causes intermittent inflation of the patient’s lungs. During the non-inflation
phases, the patient can passively exhale through the tube and the cords. To remove the
tube, the cuff is first deflated, and then the jet is activated. This causes the tube to be
blown from the trachea.
Problems include accidental dislodgements, cephalad movement, and difficulty with
removal. Respiratory obstruction resulting in high pressures in the lower airway.
217

-Second Edition
Injectoflex:
Also is used for laryngeal microsurgery. It is a short cuffed silicone tube designed to be
placed below the vocal cords. The tube has an embedded wire spiral to prevent kinking
and compression. The cuff inflation lumen and the gas jet lumen are integrally joined in
a sheath with a malleable introducer. The introducer remains in place during the
procedure.
Microlaryngeal tracheal surgery tube:

Is available with an ID of 4, 5 or 6mm each of which has the same length and cuff
diameter as a standard 8mm ID tube.
Designed for microlaryngeal tracheal surgery or for patients whose airway has been
narrowed to such an extent that a normal size tracheal tube cannot be inserted.
Endotracheal tubes:
A tip control system is incorporated in this plastic tracheal tube to change the direction
of the tip. A cable extends from a ring loop at the proximal machine end of the tube just
below the slip joint connector. While holding the tube between the thumb and index
finger of the hand, the index finger is placed through the ring. Pulling the ring causes
change in the radius of curvature of tube, principally at the tip of the tube, which then
moves anteriorly. This is useful when laryngoscopy is difficult and only epiglottis is
seen.
Tubes with monitoring lumens:

Tubes are available with one or more separate lumens terminating near the tip. They
are useful for respiratory gas sampling, pressure monitoring, and injection of fluids and
drugs.
Laser – shield II Tracheal Tube

The Laser Shield II is the successor to the laser shield tube. It is designed for use with
CO2 KTP lasers. Made from silicone with an overlapping spiral aluminum wrap and a
smooth Teflon outer wrap. There is 1 cm of unprotected silicone tubing proximal to the
cuff and also the distal to the cuff. The cuff contains methylene blue crystals.
Cottonoids for wrapping around the cuff are supplied with each tube. These must be
moistened and kept moist during the entire procedure.
Laser Flex Tubes:

Laser flex tube is flexible stainless steel tube with a smooth surface designed for used
with CO2 and KTP (potassium – titanylphosphatase) lasers. Adult version has two PVC
cuffs and PVC tips with Murphy eye. The tube cuffs are inflated by two separate
218

-Second Edition
inflation tubes, which run along the inside of the tube. The distal cuff can be used if
proximal one is damage by laser. Small uncuff tubes are also available.
The cuff should be filled with saline. The distal cuff should be filled first until sealing
occurs, then the proximal cuff is filled with saline coloured with methylene blue.
Problems with the laser flex tube include stiffness, roughness, cannot be trimmed. The
double cuff adds to the time of intubation and extubation.
Sheridan YAG Tracheal tube:

These tubes are clear PVC tubes with Murphy eye designed for used with Nd-YAG
(Neodymium – Yttrium – Aluminium – Garnet) laser. The tube itself has no marking,
the tube size is indicated on the pilot balloon. The tube will be ignited when drops of
blood or saline or mucus were applied to the outside of the tube.
Bivona Foam – Cuff Laser Tube

These tubes have aluminum and silicone spiral with a silicone covering. It is marked for
use with CO2 laser. It has self inflating cuff that consists of polyurethane foam sponge
with silicone envelope. The cuff must be deflated before intubation or extubation and
should be filled with saline during use. The tube retains its shape and keeps a seal when
it is punctured.
Combitube:
The combitube is a double lumen tube. It has two cuffs. The large pharyngeal cuff is
inflated with 100ml of air. The distal cuff requires only 15 ml. there are 8 ventilating
eyes between the cuffs.
Tube with in-built flexible connectors:

These tubes avoid the use of connectors in between the tubes and breathing system and
thereby decrease the chances of accidental disconnection. This tubes also helps to
position the breathing system away from the surgical site.
Brandt Tube:
Designed to compensate the diffusion of nitrous oxide into the cuff by means of large
pilot balloon with a thin cuff. Nitrous oxide entering the tracheal tube cuff will migrate
through the inflation tube into the pilot balloon and then diffuses through it into the
atmosphere thereby decreasing the chance of ischemia of the tracheal mucosa and
decreasing the incidence of sore throat.
ANTISEPSIS FOR USED TUBES

Proper cleaning and care of tubes, connectors and adopters is a three fold process that
includes:
219

-Second Edition
1). Mechanical cleaning
2). Sterilization
a). Autoclaving
b). Chemical
c). Gas Sterilization
3). Storage
Mechanical cleaning: Thorough cleaning of both sides of the tube in soap water and
mechanical scrubbing done directly after use.
Sterilization:
a). Autoclaving: Mechanically cleaned tubes should be thoroughly dried. Packed
and submitted for autoclaving / sterilization / pasteurization. Steam sterilization or
ethylene oxide sterilization is done.
b). Chemical Sterilization: done with quaternaries, phenol, iodophors, alcohols. For
routine antisepsis, tubes may be immersed in weak germicidal solutions such as 70%
ethylalcohol or an orthophenyl phenol or glutaraldehyde solution for one hour.
c). Gas sterilization: Varying concentration of ethylene oxide from 10 – 20% mixed
with CO2 has been found effective.
- A concentration of ethylene oxide of about 450 mg/L
- Adequate moisture through a humidity maintained at 45 – 50%.
- Temperature of 130 F
- Exposure period of 2 – 6 hours.
Hazards: A toxic and persistent reaction product ethylene chlorohydrins is formed, the
amount of this substance is increased when tubes are pre irradiated by manufacturer.
To avoid such a hazard “De-gassing” should be done by storing it for at least one week
after the gas sterilization.
Storage of the tube: ETT of plastic or rubber should be left in a cool place and out of
sunlight. To be stored in a circular or curved plastic container.
DOUBLE LUMEN BRONCHEAL TUBES

A double lumen tube (DLT) is used when it is desired to isolate one lung from the other.
INDICATIONS FOR USE OF DLT:

Absolute
Prevention of spillage or contamination from diseased to non diseased lung.
Infection – abscess, bronchiectasis, hyadatid cyst
Massive hemorrhage
220

-Second Edition
Controlled ventilation distribution
Bronchopleural fistula
Bronchopleural cutaneous fistula
Gaint unilateral lung cyst, bullous emphysema
Tracheobrochial trauma, rupture, tear
Unilateral bronchopulmonary lavage
Pulmonary alveolar proteinosis
Thoracoscopy
Relative: (ability to alternate deflation and inflation of lung help surgeon to visualize
lobar and inter segmental planes)
Surgical exposure – high priority thoracic aortic aneurysm, pneumonectomy

Surgical exposure – low priority
Esophageal reaction, lobectomy (upper), segmental resection
Occluding pulmonary emboli miscellaneous:
Treatment of refractory atelectasis
CONTRAINDICATIONS FOR DLT

Patients who are at risk of aspiration.
Patient who will not tolerate being taken off the ventilator for short time.
Patients who had lesions along the pathway of DLT (Endoluminal tumor)
Those with life threatening hemorrhage
Cystic fibrosis – may be difficult to clear the thick secretions from double lumen
tube.
ANATOMY
Tracheal length – 11 – 13 cm i.e. C6-T5.
Right Bronchus Left Bronchus

Wider lumen Longer and small lumen
Diverge at 25o angle Diverge at 45o angle
Has 3 branches – Upper, Middle, Lower Has 2 branches – Upper and Lower
Right upper lobe bronchus orifice 1-2.5 cm Left upper lobe – 5 cm from carina
from carina
(These differences should be kept in mind before placement of DLT i.e. introducing of
tube into right stem will occlude right upper lobe bronchus)
221

-Second Edition
General parts of DLT:
1). Connector – allow attachment of 2 lumen to building system.
2). Tube – Right or left sided
3). Carinal hook – for a proper placement and minimization of tube movement.
4). Cuff - Bronchial – Right and Left side
- Tracheal
Types of double lumen tube:

Type Bronchus intubated Carinal hook Shape of lumen
Carlen Left Yes Oval
White Right Yes Oval
Robert – Shaw Right or left No D shaped
MARGIN OF SAFETY IN POSITIONING DLT:

The length of the tracheobronchial tree between the most distal and proximal
acceptable position for DLT is called the margin of safety. It is the length that the tube
may be moved without obstructing a conducting airway.
The margin of safety will depend on the length of the lumen into the main stem
bronchus is long the margin of safety will be wider. This does not apply to slotted cuff
in which the margin of safety is related to the length of the slot. The margin of safety
will be smaller in females, because the main stem bronchus is shorter. Commonly used
DLTs are
1). Carlen’s Double Lumen Tube
2). White Double Lumen Tube
3). Robert Shaw Double Lumen Tube
4). Broncho cath Double Lumen Tube
5). Sher-i-Bronch Double Lumen Tube
Carlen’s double lumen tube:

Description: This DLT is designed for left sided endobronchial intubation, made of
rubber and is available in 4 sizes. The cross section of each lumen is D shaped. The long
portion of the tube, the bronchial lumen side, enters the left bronchus. An opening on
the right side of the tube above the bronchial tip, the terminal part of the right lumen
ortrachreal limb, provides main stream ventilatory access to the right stem bronchus
and right lung.
Two cuffs are present, one on the long bronchial tube extension and a tracheal cuff
above the right side opening of the tracheal part. There is a carinal hook, which get
lodged at the carina when the tube is in position. Pressure should be just sufficient to
prevent the leakage. The tube is maintained in correct position by hook and by inflated
cuffs. Margin of safety varies from 18-23mm in females and 22-27mm in males.
222

-Second Edition
White double lumen catheter:
The white DLT tube is designed to fit the right main stem bronchus, made of red rubber
or PVC and has a carinal hook. On red rubber version, the bronchial cuff has a slot to
correspond to the position of right upper lobe bronchus. On PVC version the cuff for the
right main bronchus and continues distally behind the opening. This pushes the tube
towards the wall of the bronchus.
Robertshaw Endobronchial tube:

Description: Most commonly used double lumen tube. D-shaped lumens placed side by
side. Both left sided and right sided tubes are available. There is no cranial hook and
are relatively inexpensive and may be reused.
Left endobronchial tube – concavity on left side – 40o angle at bronchial portion.
In viewing the concavity of the left sided tube from above, it is noted that the tip curves
to the left. This is the long part of the tube and contains the bronchial lumen. It is fitted
with a small cuff known as the bronchial cuff. A second cuff, the tracheal cuff,
surrounds the entire tube is situated more proximally. The tip of the tube, which enters
the left bronchus, is angled to the left from the main tracheal shaft by 45o. between the
two cuffs is an opening in the right side of the tube where the right lumen terminates.
Margin of safety 12 to 23mm.
Right endobronchial tube: Concavity to right side – 20o angle at bronchial portion.
In viewing the concavity of the right sided Robertshaw endobronchial tube from above,
the tip of the tube is seen to curve to the right by about 30o. To this tip is attached the
right endobronchial cuff, with a slot facing laterally to allow inflation of the right upper
lobe with minimal upper lobe occlusion and with a wide zone of inflation above and
around the slot for amore reliable seal. Thus, the right lumen terminates both at the
side port (slot) to the upper lobe and at the tip for ventilation of the middle and lower
lobes. A second cuff the tracheal cuff is located more proximally on the tube and
surrounds the entire tube. Margin of safety 1 to 4mm. The left sided Robertshaw tube
is often used in left thoracic surgery, as well as for right thoracic surgery.
Technique of Robertshaw double lumen insertion without stylet:

Throughout the technique of endobronchial intubation, laryngoscopy with Macintosh
blade should be continued until the tube is considered in the proper bronchus.
Introduction of left tube:

Bronchial intubation with left lung endobronchial tube is accomplished easily. This can
be done by the following steps.
1). Insertion through vocal cords
223

-Second Edition
a). Pass the tube with the distal curve or tip facing anteriorly (concave anteriorly).
The proximal curve or concavity of the shaft faces to the right.
b). When the tip passes the larynx, it is rotated 90o to the left i.e., counter clockwise
so that the tip faces the left wall fo the trachea, the proximal curve or shaft of the tube is
now concave anteriorly.
2). Advancement in trachea
a). The tip slips along the trachea wall with minimal resistance until most of
the tube has been introduced.
3). Insertion in the bronchus
a). Wooden moderate resistance to further advancement is encountered, the

tip is in the stem bronchus. Occasionally a flip or loss of resistance may be
experienced as the tube enters the bronchus, when further advancement
meets with significant resistance and the tube is now firmly seated.
Insertion of right side tube:

For the insertion of right side tube into the right stem bronchus, the only difference in
technique is related to the passage through the vocal cords when a stylet is not used.
The principle is that the tip of the tube should face anteriorly and the distal curve be
concave anteriorly. This means that the proximal end of the tube should be to the
operator’s left and the curve of the shaft concave to the left. When the tip passes
through the glottis, it is then rotated about 90% to the right, clockwise, so that the tip
faces the right tracheal wall.
Bronchocath double lumen tubes:

Right Side Tube: Bronchocath right side tube differs from other right side DLTs in the
design of bronchial cuff, which has roughly the shape of ‘S’ OR a slanted ‘doughnut’.
With the edge of the cuff nearest the right upper lobe bronchus closer to the trachea
than the part of the cuff touches the medial bronchial wall. A slot in the tube just
beyond the cuff roughly corresponds to the opening of the right upper lobe bronchus.
The margin of safety is 9mm in male and 5mm in female. Ti should be noted that the
unique slanted doughnut shape of the right bronchial cuff allows the right upper lobe
ventilation slot to right off the right upper lobe orifice, thereby increasing the margin of
safety of the tube.
Left side tube: Broncho left sided DLT is similar to right sided model. It is available
with a Carinal hook. The bronchial portion of the tube is at an angle of approximately
224

-Second Edition
35o and extends approximately 4.5 cm beyond the tracheal cuff. The margin of safety is
20mm in male and 15mm in female.
Sher-i-Bronch double lumen tubes:

Left side tube: Sher-i-Bronch left sided DLT is similar to other left sided DLTs. The
bronchial segment diverges from the main tube at an angle of 34o. The average margin
of safety is 14mm in female and 19mm in male.
Right side tube: Sher-i-Bronch right sided DLT has two arrow 5mm cuffs on the
bronchial segment, proximal and distal to the right upper lobe ventilation slot, which is
13-14mm long. The narrow proximal cuff fits the short right main stem bronchus.
Confirmation:
1). Auscultation
2). Fiberoptic – most accurate
3). Bronchospirometry
4). Capnography
5). Chest x-ray
Size of the tube:

For female adult patients
Carlen tube of French gauge No. 35 or 37 (external diameter 11-13mm)
Robertshaw medium size DLT can be used
Bronchocath French gauge 35-37 can be used
For male adult patients

Carlen tube of French gauge No. 39 or 41
Robertshaw medium / large size DLT can be used
Bronchocath French gauge 3-41 can be used.
For adolescent patients:

Carlen tube of French gauge No. 35
Robertshaw small size DLT can be used.
For small children

A small French gauge 28 DLT can be used.
Hazard associated with double lumen tubes

Difficulties with insertion and positioning.
Tube malpositioning
Circulatory collapse
Increased resistance
Problem related to defective manufacturing of the tubes
225

-Second Edition
Chapter 37 - CAPNOGRAPHY AND PULSE OXYMETRY
CAPNOGRAPHY
HISTORY
YEAR SCIENTIST ACHIEVEMENT
1943 Luft Developed the principles of Capnography
Collier & Collegues Established the accuracy of
Rapid IR CO2 analysis
Ramwell Established the value of the end
Tidal sample
1978 Holland was the first country to adopt capnography as a Standard
monitoring during anesthesia.
TERMINOLOGY
Capnography is the graphic record of CO2 concentration on a screen or a paper.
A Capnography is the machine that generates a waveform and Capnogram is the actual
wave form.
Capnometer is the device that performs the measurement and displays the reading.
DEFINITIONS:
Delay time (transit time, response time, transport time, lag time, time delay) is the time
to achieve 10% of a step change in reading at the gas monitors. Response time is the
time required for a rise from 10 – 90% of the change in a gas value with a step change at
the sampling site.
The total response time is the sum of the delay and rise time. Fast response time is
essential to obtain to obtain accurate values and wave forms.
The sensor (measuring head or chamber) is the part of a respiratory gas monitor that is
sensitive to the presence of the gas.
The sampling site is the location from which respiratory gases are diverted for
measuring in a diverting monitor or the location of the sensor in a nondiverting
monitor.
Absorption, this allows the CO2 absorption band to be identified and is proportional to
the amount of CO2 in the mixture.
Raman spectrography uses the principle of “Raman Scattering” for CO2 measurement.
The gas sample is aspirated into the analyzing chamber, where the sample is
illuminated by a high intensity monochromatic argon laser beam. The light is absorbed
by molecules, which are then excited to unstable vibration or rotational energy states.
Raman scattering signals are then measured.
226

-Second Edition
EFFECT OF ATMOSPHERIC PRESSURE ON CO2
A change in atmospheric pressure directly influences the readings of capnographs since
CO2 concentration in measured as partial pressure (direct effect).
An increase in pressure proportionately increases the number of IR absorbi8ng CO2
molecules and thereby increases the CO2 signal. A 1% increase in pressure causes a 1%
relative increase in the CO2 signal. This effect is eliminated by calibrating the
capnograph with a known partial pressure of the gas using a commercially available
calibrating gas.
THE INFLUENCE OF WATER VAPOUR

Erroneous results will occur if water that has a high IR absorbance enters the cell.
Water vapour is invariably present in expired air (at 30 degree C). This condenses at
lower temperature on sampling tube walls. An effective water separation system is
required for continuous use. The presence of water vapour also affects the reading
since usually the temperature of the patient is 37 degree C, while that of the instrument
cell is, say, 25 degree C, i.e. a difference of 3 kpa in PH2O resulting in an overestimate of
PCO2 by 0.15%.
TYPES OF MONITORS.
There are two types of monitors

1). Non diverting monitors
2). Diverting monitors
Non diverting monitors:

Non diverting monitors are one which measures the gas directly in the breathing
system. The sensor is connected to the monitor by a cable. These are commonly used to
measure oxygen and carbon dioxide. In a non diverting CO2 monitor, the patient
respiratory gas stream passes.
Disadvantages:
1). The sensor will add weight and may cause traction on the tracheal tube.
2). Use of adapter between the patient and breathing system will increase the dead
space.
3). Condensed water, secretions, or blood on the windows of the cuvette, will
interfere with light transmission.
4). The sensor may become dislodged from the cuvette.
5). Leak, disconnection, and circuit obstructions can occur.
6). At present main stream monitors can measure only CO2 and N2O.
7). Difficult to use with unintubated, spontaneously breathing patients.
227

-Second Edition
8). Thermal skin burns have been reported.
DIVERTING MONITORS
In diverting monitors the sensor is located in the main unit and pump aspirates gas
from the sampling site through a sampling tubing. Keeping the sampling tube as short
as possible will decrease the delay time and result in more satisfactory wave forms.
Accuracy decreases with increasing respiratory rate, with changes in the I: E ratio from
1: 1 and longer sampling lines.
Most diverting capnometers are accurate at the respiratory rate normally counted (20-
40/min) above 40/min there is slightly decay in end tidal accuracy and elevation of the
capnographic base line.
When I: E greater than 1: 1 errors appear first in the end tidal expiratory values, and
when it is less than 1: 1 errors first appear in the inspiratory data.
It has been suggested that a sampling flow rate less than 150ml/min not be used
because delay time and rise time are inversely proportional to the flow rate and low
sampling may result in an elevated base line, erroneously low peak readings and
absence of an end tidal plateau especially when respiratory rate is high and tidal volume
is small.
The SAMPLING SITE will vary depending on the anesthetic technique being used.
Intubated patients:
In intubated patients the sensing site can be an adapter placed between the components
or a port in a component. To measure both inspired and expired gases, the site must be
between the patient and breathing system.
The sampling site should be away from the fresh gas port.
Face mask in use:

The sampling catheter can be attached to the upper lip or placed in the patients nares or
the lumen of the oral or nasopharyngeal airway under the mask.
Laryngeal mask:
The sampling tube can be inserted through the elbow connector. The preferred
sampling site is the distal end of the shaft.
Unintubated patients breathing spontaneously

Sampling tube may be connected to the mask outlet, inserted through a vent hole or
slipped under the mask and attached near the nostril.
Sampling tube can be advanced into the nasopharynx or hypopharynx.
228

-Second Edition
Jet ventilators
For capnography during jet ventilation for laryngoscopy, a modified injector
incorporating a sampling lumen may be used.
ADVANTAGES:
1). Sampling from the patients who are not intubated is relatively easy.
2). Calibration and zeroing are usually automatic.
3). The patient interface is light weight and inexpensive.
4). The sampling port can be used to localize the site of leaks in CO2 insufflation,
equipment, diagnose a tracheoesophageal fistula or bronchoesophageal fistula.
5). The sampling port can be used to administer bronchodilators.
DISADVANTAGES
1). Problems with catheter sampling system can occur, particulate matter, blood,
secretions or water can cause obstruction of the tubing.
2). Some delay time is inevitable.
3). A supply of calibration gas needs to be kept.
4). When used with Mapleson system, there may be deformation of the wave forms
and erroneously low CO2 readings due to dilution by fresh gas. The CO2 may be
reported as either partial pressure or volume percent and may be displayed
continuously or peak value.
CALIBRATION
Capnograph should be calibrated periodically, at different intervals in various models as
per the manufacturers guidelines, but at-least daily.
For accurate measurement capnographs should be calibrated first, zeroing the monitor
to room air, and then administering a gas of known CO2 concentration. Main stream
capnographs are often equipped with calibration sample cells saled with mixtures of
CO2 and N2.
CLINICAL SIGNIFICANCE OF CAPNOMETRY

CO2 is produced in the body by cellular metabolism, conveyed by the circulatory system
to the lungs, excreted by the lungs and transported by the breathing system. Therefore,
changes in the respiratory CO2 may reflect alteration in metabolism, circulation,
respiration, the airway, or breathing system.
METABOLISM
An increase in end tidal CO2 is a reliable indicator of increased metabolism only in
mechanically ventilated patients. Metabolic causes of increases in expired CO2 included
increased temperature, shivering, convulsions, excessive production of catecholamines,
administration of blood or bicarbonate, release of arterial clamp or tourniquet, glucose
229

-Second Edition
in IV fluid, parenteral hyperalimentation and CO2 used to inflate the peritoneal cavity
during laproscopy.
Malignant hyperthermia is a hypermetabolic state with a massive increase in CO2
production. The increase occurs early, before the rise in temperature. Early detection
of this syndrome is one of the most important reason for routinely monitoring CO2.
CIRCULATION
A decrease in end tidal CO2 is seen with a decrease in cardiac output if ventilation
remains constant. Reduced blood flow to the lungs can result from surgical
manipulations of the heart, thoracic vessels. Wedging of pulmonary artery catheter and
pulmonary embolism (thrombus, tumor, fat, marrow, or amniotic fluid)
During resuscitation, exhaled CO2 is a better guide to the presence of the circulation
than ECG, pulse, BP. The effectiveness of resuscitation measures can be gauged by
capnometry.
A sudden increase in end tidal CO2 is an early clue that spontaneous cardiac output has
been restored. The patient is more likely to be resuscitated if the concentration of
exhaled CO2 is greater than 10-15 mm of Hg.
End tidal CO2 is not a good indicator of resuscitation if high doses of epinephrine or
bicarbonate is used. Epinephrine injected sc has been shown to increase the end tidal
CO2. One possible explanation is that cardiac output may be increased with additional
CO2 being transported to lungs. Peripheral vasoconstriction might increase central
blood volume and pulmonary blood flow.
RESPIRATION
CO2 monitoring gives information about the rate, frequency and depth of respiration.
Patient breathing spontaneously, exhaled CO2 level can provide an estimate of depth of
anesthesia. It can also be used to evaluate the effects of bronchodilators or nitric oxide
or changing ventilatory parameters.
A capnometer can warn of oesophageal intubation, apnea, extubation, disconnection,
ventilatory malfunction, change of compliance or resistance, partial obstruction of
tracheal tube, airway obstruction, poor mask fit, or leaking tracheal tube cuff.
End tidal CO2 can aid in performing in a blind oral or nasal intubation. Capnography
can be used in conjunction with styllet introducer in cases where the glottic opening
cannot be visualized.
Capnography can also be used to identify needle placement during trans-tracheal
cricothyrotomy.
It can also be used to determine the proper position and detecting dislodgement of
double lumen bronchial tube.
It also serves as a warming of accidental bronchial intubation.
It can also be used to aid in weaning the patient from artificial ventilation.
230

-Second Edition
CAPNOGRAPHY
Most CO2 monitors include a waveform and are calibrated so that values for end tidal
CO2 can be estimated. Waveforms can be displayed on arm oscilloscope or printed on
paper. Slow speed can be used to show trends. Trends are used for examination of
individual waveform.
The waveform should be examined systematically for height, frequency, rhythm,
baseline, and shape.
Height depends on the end tidal level of CO2
Frequency depends on the respiratory cycle.
The base line should be zero (unless CO2 in each breath is equal to the area
under the curve of the capnogram)
Elevation of the baseline can result from deliberate administration of CO2,
rebreathing, artifact. It is also associated with exhausted absorbent or an
incompetent expiratory unidirectional valve.
Elevation of the baseline can result from deliberate administration of CO2,
rebreathing, artifact. It is also associated with exhausted.
Absorbent or an incompetent expiratory unidirectional value. A sudden elevation in
both the base line and end tidal CO2 usually indicates contamination of the sample cell
with water, mucus, or dirt.
The shape of the normal waveform in “top hat” or “Sine wave” normal capnograph
consists of 4 phases.
PHASE 1:
It begins at E. the CO2 concentration is zero. At the end of normal inhalation, the CO2
tension in perfused alveoli is in equilibrium with and equal to that in end capillary
blood. At the airway and dowm to some point proximal to the alveoli, CO2 is zero
(inspired gas). At the start of exhalation the airway gas sampled is CO2 free anatomic
dead space so measured CO2 remains zero.
PHASE 2:
It begins at B and continues till C. As exhalation continues, CO2 containing gas from the
respiratory tree enters the trachea and displaces dead space gas. CO2 arrives at the
airway and first appears on the capnograph at point B from which it rises. In the normal
capnogram this rise in CO2 produces a sharp and smooth upward stroke (segment B-C).
with airway obstruction phase 2 will become slanted and shortened and may continue
into phase 3.
231

-Second Edition
PHASE 3:
It begins at C and continues to just before D. As gas coming almost entirely from alveoli
is exhausted, a plateau (CD) is seen. It includes expiratory flow and expiratory pause.
The very last portion of the phase 3, identified by point
D, is termed the end tidal point. The CO2 level here is at its maximum. In normal
individuals this is 5 to 5.5% or 35 to 40 torr. End tidal CO2 approximates alveolar CO2.
this value is often taken as an estimate of arterial PCO, neglecting gas exhaled from non
perfused alveoli which reduces the CO2 measured.
The angle between phase 2 and phase 3 is called the alpha angle. Normally it is between
100 to 110 degrees. It increases as the slope of phase 3 increases.
Conditions which increases the angle.

a. Airway obstruction
The slope of phase 3 depends on the ventilation perfusion status of the lung.
The other factors which affect the angle are the response time of the capnometer, sweep
time, and respiratory cycle time.
The angle between the end phase of phase 3 and descending limb of the capnogram is
called the Beta angle. It is normally approximately 90 degrees. This angle is used to
assess the extent of rebreathing. If there is rebreathing, the angle will be increased.
Other possible cause of an increased beta angle is prolonged response time compared to
the respiratory cycle time of the patient particularly in children.
PHASE 4:
In Phase 4, the patient inhales and the level of CO2 falls abruptly to zero and remains at
zero until the next exhalation.
232

-Second Edition
233

-Second Edition
Chapter 38 - VAPORIZERS
INTRODUCTION
A Vaporizer is an instrument designed to facilitate the change of liquid anesthetic
into its vapor in a controlled manner.
The need for an equipment to deliver the volatile anesthetic agent in its gaseous
form to the patient was felt right from the time of first successful demonstration of ether
anesthesia by Dr.W.T.G.Morton in 1846.
The development of vaporizers slowed down initially because of the ease of
administration of chloroform using a handkerchief. The deaths under chloroform
anesthesia indicated the relative danger of using the volatile agents without control.
Almost a century later, with the introduction of potent agents like halothane in mid 50’s,
the necessity to have precision vaporizers was felt & the modern vaporizers came into
existence.
PHYSICS RELATED TO VAPORIZERS:

Certain physical principles relevant to the understanding of the operating
principles, construction and design of contemporary vaporizers are being discussed in
this section. The following terms will be considered.
VAPORS AND GASES

Crucial to the scientific distinction between a Vapor & Gas about concept is a
concept called “CRITICAL TEMPERATURE”.
Critical Temperature: -
Is defined as the highest temperature at which a substance can exist as a liquid ie
the temperature above which a substance cannot be liquefied however much pressure
is applied.
Example: - Critical Temp. of O2 is -116oC
Critical Temp. of N2O is - 36.5oC
Another relatively minor term called “CRITICAL PRESSURE” can be defined as
the pressure at which a substance liquefies at critical temperature.
Critical Pressure of N2O at 36.5oC is 73 bar.
Critical Pressure of O2 at 116oC is 50 bar.
Thus, vapors and gases can be defined as per critical temperature as follows.
“GAS” → A substance in the gaseous phase above its critical temperature.
234

-Second Edition
“VAPOUR” → A substance in the gaseous phase below its critical temperature.
VAPORIZATION & HEAT OF VAPORIZATION

Liquids consist of molecules which are in constant motion and have a mutual
attraction to each other.
If the surface of a liquid is exposed to air, or any other gas, or to a vacuum, some
molecules will escape from the surface when their energy exceeds that of their mutual
attraction for other molecules at the surface. This is the process of “EVAPORATION”,
which increases with heating.
“HEAT OF VAPORIZATION”
Energy is required to convert a substance from a liquid state into vapor or gas.
The amount of heat required to convert a given volume of a liquid into a vapor
without change an temperature is termed as “HEAT OF VAPORIZATION”. Usually,
measured as MOLAR HEAT OF VAPORIZATION” which is the amount of heat (in joules)
required to change the state of 1 mol of liquid into its vapor without change in
temperature
Similarly, when vapor condenses, the same amount of heat per mol is liberated
provided that both processes occur at same temperature.
Unit is Joule/mole or KJ/gm or KJ/mol.
VAPOR PRESSURE
As in any other gas, the molecules of a vapor are continually in violent
movement. The bombarding force which they exert on each unit area of the walls of
their container or on a measuring instrument, is called the “PRESSURE OF THAT
VAPOR”
If this container containing a volatile agent is kept at a constant temperature, a
dynamic equilibrium is formed between the liquid and vapor phases so that the number
of molecules in the vapor phase remain constant ie the number of molecules entering
and leaving the liquid is equal. Thus saturated vapor pressure is defined as pressure
exerted by molecules in the vapor at the point of equilibrium with the liquid phase at a
given temperature. Vapor pressure depends only on the liquid and temperature and not
on ambient pressure.
BOILING POINT
Boiling point of a liquid is defined as the temperature at which its vapor pressure
is equal to atmospheric pressure. Lowering the atmospheric pressure lowers the boiling
point.
235

-Second Edition
SPECIFIC HEAT & THERMAL CAPACITY
Specific heat of a substance is the quantity of heat required to raise the
temperature of a 1 gram of that substance by 1o C . Higher the specific heat more is the
heat required to raise the temperature of that substance.
The concept of specific heat is important for 2 major working considerations of a
vaporizer.
1. The amount of heat that must be supplied to a volatile agent to maintain a
constant temperature when heat is lost as a result of vaporization.
2. The choice of material from which the vaporizer is constructed depends on its
specific heat.
THERMAL CAPACITY
Is defined as products of specific heat and mass and represents the amount of
heat stored in the vaporizer body.
Thus vaporizers should ideally be made from substances with a high specific
heat and thermal capacity to compensate temperature changes due to vaporization.
THERMAL CONDUCTIVITY & THERMOSTABILIZATION

Thermal conductivity is the measure of speed with which heat flows through a
substance i.e. higher the thermal conductivity better the heat conductance.
Thermostabilization is achieved by using materials with high thermal
conductivity to minimize temperature changes when vaporizer is in use.
VOLATILITY
More volatile an agent, less energy required to convert liquid into vapor and thus
more pressure exerted by that vapor at a given temperature.
CONCENTRATION
Concentration of gas/vapor can be expressed in two methods.
Partial pressure – A mixture of gases in a closed container exert a pressure on the walls
of the container. Partial pressure is part of the total pressure that results from any one
of the gas in the mixture.
Volumes percent – Is defined as number of units of volume of a gas in relationship to a
total of 100 units of volume for total gas mixture. It expresses the relative ratio of gas
molecules in a mixture, while partial pressure expresses an absolute value.
COEFFICIENT OF LINEAR EXPANSION

Any substance when heated expands and different metals expand to a different
extent. Thus, if two strips of dissimilar metals are bonded together side by side and
heated, one expands more than the other, causing a deflection of the bimetallic strip that
236

-Second Edition
they form. This principle is used in thermostats, dial thermometers, temperature
compensating mechanisms of vaporizers.
CLASSIFICATION OF VAPORIZERS.
DORSCH AND DORSCH – 1979
METHOD OF REGULATING OUTPUT CONCENTRATION

Concentration calibrated
Measured flow
METHOD OF VAPORIZATION
Flow over
Bubble through
Injection
TEMPERATURE COMPENSATION
Thermocompensation
Supplied heat
LOCATION OF VAPORIZER
Vaporizer outside breathing system
Vaporizer inside breathing system
SPECIFIC ANESTHETIC AGENT USED

Agent specific
Multiple agents
GRAY AND NUNN- 1971

a. PLENUM VAPORIZERS
b. DRAWOVER VAPORIZERS / INHALERS
c. SIMPLE VAPORIZERS FOR USE IN CIRCLE SYSTEM
Method of Regulating output concentration:

To produce clinically useful concentration, a vaporizer must bring about dilution
of saturated vapour. This is accomplished by a 2 methods.
CONCENTRATION CALIBRATED VAPORIZERS: -

Also called VARIABLE BYPASS : PERCENT TYPE
DIRECT READING : TEC TYPE
DIAL CONTROLLED : VAPORIZER CHAMBER BYPASS
AUTOMATIC PLENUM :
237

-Second Edition
The total gas flow from the anesthesia machine goes through the vaporizer, and
is divided into 2 parts. Some passes through vaporizing chamber and picks up a
predictable amount of vapour; the remainder goes through a bypass to the
vaporizer outlet.
Agent concentration is controlled by a single calibrated knob or dial and is
usually calibrated in VOLUMES PERCENT.
The ratio of bypass gas to gas going to the vaporizing chamber is called
‘SPLITTING RATIO’ and this depends on the ratio of resistances in the two path
ways which in turn depends upon on the ‘VARIABLE ORIFICE’.
Oxygen is mostly used as the carrier gas in vaporizers.
Working mechanism is illustrated in the diagram below
OFF POSITION: Bypass mechanism occludes the inlet and outlet of the
vaporizing chamber and gas flows through the bypass to the outlet.
ON POSITION: Incoming gas is divided into two streams, one part goes through the
bypass and the other flows to vaporizing chamber picking up vapor of anesthetic agent
and then both the streams join downstream.
MEASURED FLOW:
Kettle type, flow metered or flow controlled.
A measured flow of carrier gas usually oxygen is used to pick up anesthetic vapour. It is
then diluted by additional flow from machine.
Three components are present and include VAPORIZER, FLOW METER ASSEMBLY AND
AN ON – OFF VALVE.
Vaporizer concentration can be calculated by:
Vaporizer output of Anesthetic
Percentage concentration = ---------------------------------------- X 100
Total flow
(VF)(Vpa)
= ------------------------- X 100
AP(VF+DF)- (Vpa)(DF)
Where, VF = Vaporizer flow
238

-Second Edition
Vpa = Vapor pressure of anesthetic agent
DF = Diluent flow
AP = Atmospheric pressure
Thus, a vaporizer of this type can be used accurately with a number of different
anesthetic agents.
METHODS OF VAPORIZATION: -
FLOW OVER TYPE:
Here carrier gases are allowed to flow over the surface of the anesthetic liquid
for vaporization. Efficiency of vaporization largely depends upon effective area of
gas liquid interface, speed of gas flow over liquid surface, distance of gas flow
over liquid surface (if distance is minimized with plunger as in Boyle’s type,
concentration increases significantly)
Carrier gas liquid interface can be increased by using
BAFFLES: are simple plates/channels that encourage mixing of carrier gas with
vapour ensuring satuaration
SPIRAL TRACKS: Pathway of gas over liquid increases.
WICKS: Through capillary action, liquid moves up the wick.
Examples: Tec 2 , 3, 4, 5.
BUBBLE THROUGH TYPE:

Here carrier gas is allowed to bubble through the anesthetic liquid so as to
provide good contact between liquid and gas. Vaporization may be enhanced by
reducing the size of the bubbles as it provides greater surface area for contact.
Speed of movement of bubbles and depth of liquid agent influence the
vaporization.
Examples: Boyle’s vaporizer, Copper Kettle.
INJECTION:
Certain vaporizers controlled vapour concentration by injecting a known amount
of liquid anesthetic into a known volume of gas.
Examples: Tec 6, Siemens vaporizer.
TEMPERATURE COMPENSATION:
During vaporization temperature of liquid decreases as heat is lost thus, leading
to a fallen partial pressure of vapour. Therefore, to obtain predictable and accurate
control of vapour concentration various methods of thermo compensation are adopted.
239

-Second Edition
NO MEANS OF THERMO COM PENSATION:
These THERMALLY CONFUSED VAPORIZERS have no means of thermo
compensation, hence their output is semi quantitative
Examples: Boyle’s vaporizer, Goldman, McKesson, Rowbotham, FNS vaporizers.
SUPPLIED HEAT:
a. DIRECT HEATING:
Either by providing HOT WATER BATH JACKETS /OR/ ELECTRIC HEATER.
b. INDIRECT SOURCES OF HEAT:

They are more efficient than direct heating and three systems are available.
1. Use of copper container with its high specific heat acts as a physical means of
furnishing heat by rapid transfer. Heat capacity of copper is low (0.093 cal/gm.),
but density is high (9 gms/ml.) so, that one ml of copper holds 0.81 cal. which is
easily transferable.
2. Heat of adsorption principle using substances of high adsorptive capacity like
inactivated charcoal resulting in exothermic reaction.
Example; 1 gm. of ether when in contact with activated charcoal produces 30
cal. of heat, as in Edison vaporizer.
3. Chemical heat for vaporization:
a. When a substance solidifies, heat is given up to the surrounding
environment. This latent heat of crystallization defined as amount of heat
given off when 1 gm of a substance is converted from liquid to solid state
without alteration of temperature is used as means of thermo
compensation in certain vaporizers like Oxford vaporizer. Substances of
low melting point like hydrated calcium chloride or paradichloro benzene
are used.
Thermocompensation:
Temperature compensation is achieved by regulating the flow of carries gases. In
such vaporizes, a THERMAL ELEMENT perform this function in mechanical vaporizes, is
under computer control in electric vaporizes, can be performed manually by adjusting
the flow through vaporizes in measured flow vaporizers.
LOCATION OF VAPORIZES
Vaporizer outside breathing system: Vaporizes present between flow meter and
machine or between machine on let and breathing system.
Vaporize inside breathing system: Vaporizes is used inside the circle system, may also
be used as inhaler.
240

-Second Edition
AGENT USED:
1. Agent specific: Vaporizers are manufactured for a particular anesthetic agent
and calibrated accordingly.
2. Multiple agent: Can be used with various agents.
Plenum Vaporizers:
Plenum is a term divided from Latin, meaning “FULL”. It is opposite to vacuum.
In air conditioning terminology, it applies to air that is forced in, cleaned and
temperature adjusted.
Similarly, in plenum vaporizer, fresh air is forced into a chamber and are
designed for use with continuous flow of pressurized gas and have a high internal
resistance, thus unsuitable for use as draw-over vaporizers on in circle system. E.g.
Boyles vaporizers, Copper Kettle, Fluotec Mark, E Halox vaporizer, Pentec
(methoxyflurane) Titer (for trichloroethylene), Enflurane.
Modern various are unevenly agent specific and referred to as “FLOW
STABILIZED” is perform regularly well over a large range of fresh gas flow ( 20%
accurate 0.5-101/min)
Draw Over Vaporizers:

These vaporizes have a very low resistance to gas flow.
Gas is drawn through the vaporizes into the anesthetic circuit only in inspiration
or by the use of self inflating bag or bellows, therefore flow is not constant, but
PULSATILE
Do not require a pressurized gas supply,
e.g. EMO ether inhaler
Oxford miniature vaporizer
Goldman halothane vaporizer
Simple vaporizers for use inside circle system:

E.g. Goldman vaporizer
Rowbotham vaporizer
241

-Second Edition
FACTORS AFFECTING VAPOR CONCENTRATION
The various factors affecting vaporizer output are
1. How through the vaporizing chamber
2. Efficiency of vaporization
3. Temperature
4. Gas flow rate
5. Carrier gas composition
6. Barometric pressure
7. Effects of intermittent back pressure
8. Liquid level
1. Flow through vaporizing chamber: Varying the proportion of gas passing through
the vaporizing chamber and bypass is the method by which vaporizes output is
controlled.
2. Efficiency of vaporization: The corporation of wicks, channels in vaporizing
chamber may increases the efficiency of vaporization and output concentration.
3. Temperature: As temperature increases output concentration increases and vice
versa unless some compensatory mechanism is used.
4. Gas flow rate: Changes in gas flow rate may affect vaporizer output by alluring the
proportion of total gas flow flowing past vaporizing chamber. Altering the
efficiency of vaporization, e.g. At high gas flow rates – the gas leaving the vaporizing
chamber will tend to be less saturated (as gas spends less time in the chamber), so
output of vaporizer will tend to fall.
5. Carrier gas composition: Composition of carrier gas may affect vaporizer output by
Changes in viscosity and density of gas mixture affecting proportion of total flow that
passes through the vaporizing chamber
N2O dissolving in the anesthetic, thus altering the effective volume that passes through
the vaporizing chamber
Short term effect: Output concentration decreases
Long term effect: Output concentration may increase/decrease depending on vaporizer
design.
242

-Second Edition
Barometric pressure:
Vaporizers are calibrated at standard atmospheric pressures (sea level)
As they may at times be used in hyperbaric chamber or at high attitudes where
atm pressure is low, it is vital that we know the affects of pressure on vaporizers.
Anesthetic agents with low boiling points are more susceptible to influence of
variations in barometric pressures.
Low atmospheric pressure:

Concentration calibrated vaporizers: Splitting ratio is altered because of changes in
pressure. A low pressure causes a decrease in the resistance through the normally high
resistance pathway through the vaporizing chamber, thus the increasing the vaporizer
output.
Equation to calculate will be as follows (vaporizing concentration is in volumes present)
C1 = C (P/P1), where
C1 = output concentration at different pressure in volume
P = barometric pressure for which vaporizer is calibrated
P1 = barometric pressure fro which C1 is been established
C = vaporizer sitting in volumes %
1) Measured flow vaporizers: With low pressures, the increase in vaporizer output is
more significant.
a. Concentration calibrated vaporizers: A increase in vaporizes output is noted as,
changes in the density of the gases cause more resistance to flow, through the
vaporizing chamber. (At 2 atms – volume % is halved)
b. Measured flow: A decrease is noted
6. Effects of intermittent back pressure:

Sources of back pressure to the vaporizers in an anesthesia machine are
1. Positive pressure generated during inspiration while assist or controlled
ventilation is very used
2. O2 flush valve – output from O2 flush is at downstream of the vaporizers and
activating it produces high pressures
a. This back pressure may either increase (pumping effect) or decrease
(pressurizing effect) of the output of the vaporizer.
243

-Second Edition
PUMPING EFFECTS
i.e. increased vapor output at low flows. This effect applies to plenum vaporizers
especially at flow rates with IPPV when back pressure is high on vaporizer typically.
This happens when manually assisted or ventilator controlled ventilation is being used.
This change is most pronounced when there is
Less agent in vaporizing chamber
Carrier gas flow is low
Pressure fluctuations are high and frequent
Dial setting is low
Mechanisms
In concentration calibrated vaporizers:
Vaporizer during inhalation. Resistances of outlets bypass (paint 3) and
vaporizing chamber (point 4) determine the flow.
Vaporizes during inspiration. There is the pressure at point C prevents outflow
of gases and vapor, this positive pressure transmitted to point A and B and
results in compression of gas in vaporizing chamber and bypass. But, since
the bypass has smaller volume, more gas flows to vaporizing chamber, so
that the normal splitting rates is disturbed.
Implies there is an increased flow to vaporizing chamber which picks up
anesthetic agent
Vaporizer during early inhalation. Pressure at point and rapidly falls, thus
gas flows both from bypass and vaporizing chamber to outlet. But, then because
Bypass has less resistance than vaporizing chamber outlet, the pressure in
bypass falls more quickly than in vaporizing chamber and so gas containing
vapor flows from vaporizing chamber into bypass.
Concentration on vaporizer output increased because now bypass is also
carrying vapor laden gas and gas flowing from vaporizing chamber is still
saturated.
Modifications to minimize pumping effect are

1. keep vaporizing chamber small
2. Increase size of bypass
Since vaporizes output variations due to back pressure related to relative sizes of
the space above the liquid in vaporizing chamber and the space in the bypass.
1. Long, spiral or large diameter tube to lead to be vaporizing chamber
244

-Second Edition
This ensures gas does not reach vaporizing chamber early
2. Exclude wicks from area where inlet joins the vaporizing chamber
3. Overall increase in gas flow through vaporizes may be used (5.3 – D, E, F).
In measured flow vaporizers:

Because of back pressure, these is retrograde flow of gas for so that the diluted
gas mixture is forced back into vaporizes which will then pick up anesthetic mixture
resulting is increase in output.
Keeping vaporizing chamber small results in less unsaturated gas being forced
back into it.
Alterations in anesthesia machine to minimize pumping effect:

1. Machine standards mandate that connection of the O2 flush valve delivery line to
common gas outlet be designed so that activation does not increase/decrease the
pressure at outlet of a vaporizer by more 10 kpa or increase the vapor output by
more than 20%.
2. Pressure relief valve near common gas outlet to prevent high pressure from
being transmitted into the machine and to protect patient from high pressure
from machine. This valve opens to protect patient from high pressure from
machine. This valve opens to atmosphere and vents gas if a preset pressure is
exceeded.
Pressurizing effect:
i.e. decreased output is high flows
This applies to plenum vaporizers at high flow rates during IPPV and is of minor
significance. Effect is greater with
High flows
Large pressure fluctuations
Low vaporizer settings
Mechanism:
Positive pressure compresses the carries gas, thus concentrating it. When
pressure is released (expiration), volume increases, the gas density falls and the vapor
concentration also falls:
Pressure in bypass and vaporizing character is P
As it flows to outlet, pressure reduced to R
245

-Second Edition
When an increased pressure (P1) is applied to vaporizes outlet, this pressure will
compress to carrier gas, thus concentrating it.
MACHINE STANDARDS
ASTM (American Society for Testing and Materials) inserted standards regarding
vaporizers in 1988, they are as below.
1. Vaporizes must be capable of accepting a total gas flow of 151/min from
anesthesia machine and in turn, delivering a gas flow with a predictable
concentration of vapor
2. The effects of conditions of use (variations in temperature, pressure, back
pressure, input flow rates carrier gas composition) on vaporizer performance
must be stated in catalogs and operations manuals
3. The extent to which temperature and inflow rates influence the vapor
concentration must be stated.
4. A system that isolates vaporizes from each other and prevents gas from passing
through the vaporizing chamber of one vaporizes and then through that of
another must be provided
5. Controls must be provided to limit the escape of anesthetic vapor concentration
is less than 0.1% when vaporizer turned off.
6. All vaporizer control knobs must turn counter clockwise to increase the
concentration
7. The vaporizer must be equipped with a liquid level indicator visible from front of
anesthetic machine
8. The vaporizer must be designed so that it cannot be overfilled when in normal
position.
9. Vaporizer must permit maximal calibrated flows of O2 and N2O simultaneously
in the On and Off position with vaporizer filled to maximum safe indicated level
without discharging liquid through its outlet.
10. Vaporizers outside the circuit must have non interchangeable proprietary or
23mm fitting. The inlet must be male, outlet female and direction of gas flow
must be marked.
11. Vaporizes inside the circuit must have standard 22mm fitting and screw
threaded, weight bearing fillings with inlet female and outlet male. The inlet and
outlet ports must be marked, direction of gas flow indicated by arrows and
vaporizes marked as “For use in the breathing system”.
246

-Second Edition
SPECIFIC VAPORIZERS
Few of the contemporary vaporizers are discussed below:
Boyle vaporizers:
Classification:
Concentration calibrated, flow over/bubble through, multiple agent, not
thermocompensated.
The Boyel’s anesthetic machine is equipped with two vaporizers one for ETHER
and the other for TRICHOLRD ETHYLIN
Boyle ether vaporizers:

It consists of a glass bottle containing volatile anesthetic liquid, bottle being
calibrated upto 300ml. There is a metal top incorporating the controls, namely a
lever and a plunger to regulate concentration of agent. Leaves is turned from
‘OFF’ position to ‘ON’ position, so that gases pass through the bottle. In the OFF
position the inlet and outlet of vaporizer are closed.
When lever is lifted up i.e. in ON position, gas flows down a chrome plated U tube
of the vaporizer. A chrome plated plunger with a hood at the end is placed
directly above the end of delivery U tube, thus when plunger is up, gases pass
under the plunger down the surface of agent and to the vaporizer outlet when
plunger is depressed, hood comes under the surface of liquid anesthesia leading
to formation of bubbles which enhance vaporization. Thus, concentration of
agent can be varied by adjusting the plunger.
Precautions and hazards:

After prolonged use, plunger may loosen and fall down because of its own
weight, thus it should be properly tightened by a gland nut.
At the filling orifice, stopper should be in good condition to prevent leak. Thus is
usually retained by a small metal chain if chain broken then may act as sparking
point from metal core to core if changed with status electricity. Thus top of cork
should be insulated ------------
Sealing washer of vaporizer bottle should be in good condition to prevent leak
Dark coloured bottles used to prevent decomposition of ether
Copper acts as anti-catalyst and prevents decompensation of ether so metal parts
of U tube and hood of plunger not plated and bare copper used.
Which placing on back far, 1st ether to be placed next to rota-meter and then
trichloroethylene as ether has a lower boiling point otherwise condensation may
occur
247

-Second Edition
Before operating the ether vaporizer the filling orifice should be kept open to
remove the already existing ether vapor in the bottle.
Cooling should be minimized – use of water bath helps at 200C – SVP or ether is
425mmHg.
After use agent should be taken out, vaporizer kept clear and dry.
Not thermocompensated, so heat loss leads to reduced output increased flow
rate, plunger descending below surface of liquid, cause decrease in output
concentration.
Hood should be placed concentrically, eccentrically placed hoods increase output
concentration so does agitation and splashing of liquid especially halothane
bottles.
Trichloroethylene vaporizer:
Smaller than the ether bottle, inlet of U tubes hood of plunger are entirely
chrome plated
Chloroform can also be used. For chloroform and trillian no need to depress the
plunger as sufficient concentration may be obtained by controlling the knob fully
ON (methoxyflurane not suitable)
TEC 3 vaporizer:
Include Fluotec mark 3, enfluralce 3, forte 3
These are no longer manufactured
They are concentration calibrated, flow over with wick, automatic thermo
compensation, agent specific, plenum type
Construction:
Consists of a lower vaporizing chamber and an upper duct and valve system.
Control of delivered concentration is achieved by rotation of the knob at the top. This
opens and closes ports and thus regulates the amount of gas passing through vaporizing
chamber.
Off position:
Gas enters inlet, passes through a filter, and flows out through 2 BVPASS
channels, 1 channels directs a stream of gas pasta bi-metallic temperature sensitive
element that is located concentrically within the lower bypass so that its temperature is
close to that of anesthetic agent.
Inlet and outlet of vaporizing chamber closed.
248

-Second Edition
On position:
The top bypass channel is closed and channel to the vaporizing chamber and the
control channel (from the vaporizing chamber to vaporizes outlet) are open. Gas
still flows pass the resistance element in lower bypass channel.
The gas enters the vaporizing chamber by traveling down one vaporizing
chamber channel, over the liquid and by wicks where it becomes saturated with
vapor.
It then flows out of chamber through lower bypass channel and enters the
control channel.
Size of control channel is controlled by position of the control knob.
Delivered concentration is determined by resistances to flow past the
temperature sensitive element and in the control channel.
Cooling causes increased resistance to flow past the metallic element, so more
gas flows through the vaporizing chamber.
Concentration dial is near the top to the left of this is a locking lever that must be
depressed to turn the vaporizer ON.
At the bottom is a slight window on the left and a filling mechanism on right.
Evaluation:
They are accurate at low dial settings
At higher settings, most put out higher than expected concentration at low flows
and lower than expected concentrations at high flows.
N2O when used along which O2 as carries gas causes initial decrease in output
followed by a slow increase to a new value that is less than that seen when the
carrier gas is O2 alone
No effect on output from back pressure
Tec 3 vaporizers set to a dial of 1% and 61/min gas flow with no liquid level in
the sight glass still out put concentration upto 55-120tmts because of liquid
anesthetic sequestered in wicks, and in the bottom of vaporizer below the sight
indicator.
Hazards:
1. Even in Off position, they have been found to leak small amounts of vapor in to
the bypass
2. It was possible to turn the dial beyond Off position, resulting in vapor delivery
(no reports of this since 1984)
3. Tipping – Tipping to 900 – no effect
249

-Second Edition
After inversion to 1800 – with dial set at zero or higher, positive
concentration delivered was much greater than shown on dial.
Reversed flow causes output to be increased
Maintenance:
Yearly returned to manufactures for maintenance is recommended
Tec and Vaporizer:

Include Fluotec 4, Enfluratec 4, Fortec 4
Classification: They are concentration calibrated, flow over with wick,
automatic thermocompensation, agent specific and plenum type
Construction:
At the top is control dial
The release button to the left must be depressed before vaporizes can be turned
on
Wicking lever in located to rear of the control dial and is connected to control
dial so that the vaporizes cannot be turned on until it is locked on the manifold.
Filling mechanism – Two types either with
Screw cap – below the cap in drain plug that extends up into the center of cap
plug is unscrewed to drain the vaporizes
Keved system having a single port for filling and emptying
Off position:
Gas flow from inlet, through the bypass and to the outlet.
on position:
The inflowing gas split into two streams by to rotary valve attached to the
concentration dial
One stream is directed through the vaporizing chamber that surrounds the
bypass channels. In the vaporizing chamber, the gas passes through the inner
section, flows along the sides of the vaporizes where two concentric wicks
enclose a copper helix. The wicks dip into liquid and increase contact between
carrier gas and liquid agent. Thus gas is saturated with vapor and leaves the
vaporizing chamber and flows past the rotary valve to the outlet.
The other stream passes through the bypass channel inside this chamber is a
temperature sensitive element that causes more gas to flow into vaporizing
chamber as cooling ensues.
250

-Second Edition
Evaluation:
These vaporizers are calibrated at 210C, at higher temperature especially with higher
dial settings output rises.
Delivery is less precise at low and very high flow rates but various conflicting reports
have concentrated
Addition of N2O causes output concentration changes less than 10% of setting.
Hazards:
Any amount of heating even upto 1800 does not affect the output of vaporizer but
may give misleading impression of the amount of agent in vaporizing chamber
Leakage of liquid agent from drain past because of loosening of drain plug. Tec 4
with filling systems can be overfilled if vapors are in ON position and bottle
adapter is loosened.
Reversed gas flow – cause increase in output.
Maintenance:
Vaporizers should be drained every 6 months
Yearly serviced
Extensor can b e cleaned with damp cloth, no cleaning solution allowed
If vaporizer filled with wrong agent, then should be drained, liquid discarded and
with dial set at highest setting the vaporizer should be flushed of with a 51/min
flow until no trace of agent is detected.
If water or non volatile substance placed in vaporizer than vaporizes returned to
manufacturer for service.
Tec 5 vaporizer:
Include Isotec S, Fluotec 5, Enfluratec 5 and Sevotec 5
Classification: Concentration calibrated, flow over with wick, automatic
thermocompensation, agent specific plenum type.
Construction:
On top is control dial, at rear end of Dial is a release button that must be pushed in
before vaporizer is turned on. At rear is also a locking lever connected to concentration
dial, so that vaporizer cannot be turned On until it is locked on the manifold at bottom
front is the Sight Glass.
251

-Second Edition
Filling mechanism:
- Screw cap with a drain plug that can be loosened to drain the vaporizer
- Keyed system – A single port is present in front of vaporizer on the left near the
bottom for filling and drainage.
- A locking lower secures the filla block
- A small level at base allows liquid to be added to or drained from vaporizer
Off position:
All incoming gas flows directly to outlet through the bypass
On position:
Inflowing gas is split into 2 streams by the rotary value, one stream directed to
vaporizing chamber and the other through the bypass.
Gas flowing through bypass flows down one side of the vaporizer and part the
thermostat, an bimetallic strip in the base. As the temperature in the vaporizers
decreases, the thermostat allows less gas to flows through the vaporizing chamber.
From the thermostat, gas flows up the other side of the vaporizer and joins the gas that
has passed through vaporizing chamber at the outlet.
Gas flowing to the vaporizing chamber first passes through the central part of the
rotary valve, after which it is directed through the helical intermittent positive pressure
ventilation assembly and then past a spiral wick, which is designed to give maximum
contact between carrier gas and liquid agent. The spiral wick is contact with the wick
skirt which dips into the liquid chamber. Gas with vapor leaves the vaporizing chamber
through channel in the rotary valve and flows to the outlet
Evaluation:
Greatest accuracy is at a FGF of 51/min and dial settings less than 3%.
There is a decrease in output at higher flows and higher dial settings.
Greatest accuracy between 150 and 350C (thermostat does not respond below
150C and output unpredictably high above 350C)
More prone to increase in output concentration because of pumping effect
Carrier gas composition also affects output of Tee 5 at low flows output is less
and at high flows small increase in output occurs when N2O or air is use as
carries gas.
Hazards:
Vaporizes can be overfilled if bottle adapter or vaporizer turned On position
Reverse flow increase output
If filling port is accidentally open while vaporizer is turned on, there will be a
large loss of liquid agent. Even while the vaporizer is turned on.
252

-Second Edition
Maintenance:
Vaporizer drained every and weeks when level is low when agents contain
additives / stabilizing agents
Every 3 years – serviced
Extensor cleaned by damp cloth, no cleaning / disinfection are used.
Tec 6 vaporizer
Classification:
Concentration calibrated, injection, thermocompensation by supplied heat, agent
specific (only desflurane), plenum type.
Construction:
It us larger than Tec 4 and be 5 vaporizers. It can be used on both Ohmeda and
North America Drager anesthesia machines. The mounting is different for different
machines. For Ohmeda machines, the vaporizer mounts to the anesthesia machine by
selected mounting system that ensure that a vaporizer cannot be turned on unless it is
locked on the manifold and that gas flow enters a vaporizer only when that vaporizer is
turned on. It also has interlocks to prevent more than one vaporizer from being turned
N, at a line. Tec 6 can be interchanged with Tec 4, Tec 5 vaporized which mount on this
system.
Concentration dial at the top is calibrated from 1% to 18% in gradation of 1% upto
10% and 2% between 10% to 18%. A dial release at back of the dial must be depressed
to dial concentration more than 12%. This release cannot be depressed unless the
operational LED is illuminated.
Filler port is at front on the left. It is keyed so that only a desflurane specific to the can
be inserted into it. Power cord and battery cases are at bottom of vaporizer
A non-rechargeable battery provides power for alarms and liquid crystal level
indicator display during main power failure. The drain plug is located at the base of
vaporizer. A draining kit is required to drain the vaporizer.
On the front lower right of vaporizer is display panel which has visual indicators for
vaporizer functions. There is a 10sec delay between detection of malfunction and alarm
activity with exception of the tilt condition. An auditory alarm is mounted behind upper
port of display panel. A mute alarm button is located above the display panel.
1. Various LED’s and alarms and indication in Tec 6.
253

-Second Edition
2. Amber – Warm up LED – indicates initial worm up period flashing after
vaporizer is 1st connected to main power.
3. Green operational LED – indicates vaporizer has reached flashing its operating
temperature and concentration dial can be turned on. No audible signals for
these modes except for a short tone that sounds at transition from harm up to
operational mode.
4. Red – No output led – Indicates vaporizer is no longer able to deliver vapor and
along with this an audible alarm of repetitive tones signs. This can be caused
when
- Agent level less than 20ml
- Tilting of vaporizer
- Power failure
- Internal malfunction
Muting this alarm can be done by turned the concentration dial to stand by position (but
red light keeps flash) if it still continues – then mute button pressed to silence it.
1. Amber low agent led – indicates less than 50ml of agent flashing and is
accompanied by an audible alarm of repetitive tone can be muted for 120
seconds.
2. Amber battery low led – indicates new battery required flashing no audible
alarm
Liquid level indicator:

Has a liquid crystal display (LCD) that shows the amount of liquid in vaporizer
between 50 and 425 ml. the LCD is lit whenever the vaporizer is powered. There are 20
bars, single for corresponding to approximate 20ml of volume. An arrow on side
indicates to 250ml of volume. An arrow on side indicates to 250ml refill mark. If level is
below this mark, the vaporizer will accept a full bottle (240ml) of desflurane.
If vaporizer is tilted more than 100, the tilt switch activate.
Self test:
When the unit is plugged in, the electronics under go a self test, can be done by
pressing the mute button for more than 4 second, the alarm sounds of each LED and
LCD illuminates for 2 seconds.
Once vaporizer is plugged in, power is on, sump are operational and it takes
about 5-10 minutes for start, during this time concentration did is kept in stand by
mode. An internal shut off valve is closed to prevent flow of vaporizer for the sump.
254

-Second Edition
Internal mechanics:
This is quite different from other variable bypass vaporizers in that “that none of
the fresh gas flow passes through the vaporizing chamber.
In the vaporizer, desflurane is heated to 390C (1020F), which is well above its
boiling point and this requires external heat source because potency of desflurane
requires that range amounts be vaporized.
Power for heatus, alarms, controls furnished by electrical system, a transforms,
an AC to DC converter provides a DC power for vaporizer.
Inter components of vaporizer:

Sump assemble holds the agent and includes, heaters and agent level sensors, sump
has a capacity of 425 ml. two heaters are fitted the base and heat the agent to 39 0C
temperature is monitored and associated electronics act as thermostats two additional
heaters are in upper part of vaporizer to prevent condensation of agent where warm
vapor meets the cold gas from common manifold. The current goes back and forth
between sump and upper part of vaporizer thus keeping the current requirement to
minimum. The vaporizer is thus hot to touch when connected to electric supply.
Agent level sensor senses level of the liquid using agent as percentage and
displays it on front of vaporizer
In On position i.e. when the green operational LED illuminates, a signal from
control electronic operates the solenoid interlock, allowing dial and rotatory
valve to be turned, when they are turned, a signal from control electronics opens
the shut off valve. Fresh gas flow enters the vaporizer and encounters a fixed
resistor that creates a back pressure in FGF portion of vaporizer, higher the FGF,
higher the back pressure generated.
Electromechanical devices operates to maintain the agent vapor pressure at
Variable resistor in rotary valve at the same level as the fresh gas pressure at fixed
resistor.
Thus, pressure balance is achieved between desflurane and diluent flow.
Changes in temperature vapor pressure or diluent flow rate allows the pressure
and this is sensed by a pressure transducer that sends a signal to control electronics and
this allows the agent vapor pressure at variable resister by opening or closing the agent
pressure regulating valve to balance the pressure.
With this balance of pressure maintained, the concentration will depend only on
the ratio of FGF through the fixed resister and agent vapor flow through variable
resistor, which depends on setting of concentration dial.
255

-Second Edition
Thus, when dial is turned to higher value, resistance to desflurane flow decreases
and flow of desflurane increases.
And when diluent flow increases, the electrodes increase flow in desflurane limit to
maintain pressure balance. The vapor mixes with FGF before the later exists the
vaporizer.
Filling mechanism:
Because desflurane boils so closely to room temperature, it cannot be poured
into a funnel and allowed to drain into the vaporizer. Vaporizer can be filled even
when is use but FGF should be less than 81/minute and dial concentration set
below 8% and vaporizer not subjected to any high back pressure. The vaporizer
can be filled while in its warm up cycle.
The bottle (male component) was a crimped on adapter. This has a spring loaded
valve that opens when the bottle is pushed into filling part of vaporizer. The
female component of vaporizer consists of a a spindle. The bottle is inserted into
this port to a depth at which a spring is activated. The spindle is then rotated
upwards until a stop is encountered. Agent can enter the vaporizer at this point.
Evaluation:
Vaporizer calibrated for flows between 0.2 to 10 1/minutes (slightly lower
output at lower flows and greater output at greater flows).
In response to change in barometric pressure, only a constant output
concentration in volumes with varying pressure noticed.
Decrease in pressure causes decrease in partial present
Fluctuating back pressure has no significant effect
Carrier gas composition does effect, output is highest with pure O2, lower with
air, lowest with N2O.
Hazards and precautions:

Vapor can lead into FGF with the vaporizer turned off
Vapor filling should be done with due care
High dial setting and low flow can result in delivery of hypoxic mixture.
Battery must be annually replaced
If any of the LED’s/LCD do not illuminate or alarm not heard, vaporizer should
not be used.
Maintenance:
This vaporizer requires a full service every year at an authorized science centre.
256

-Second Edition
Agent specific filling system:
The ASTM machine standard recommends, that a vaporizer designed for a single
agent be fitted with a permanent attached, agent specific device (either keyed or agent
specific filling system, filler system and devices, pin safety system) to prevent accidental
filling with wrong agent.
Such devices prevent filling a vaporizer with wrong agent, minimize air pollution,
also prevent water and other contaminants from entering the vaporizing chamber.
The keyed filling system components are:
Bottle collar: Each bottle of liquid anesthetic has a special coloured colour attached at
the neck. The color coding is according to the bottle contents. Color coding for liquid
agents are, also used on bottle labels
- Red – Halothane
- Orange – enflurane
- Purple – Isoflurane
- Yellow – Sevoflurane
The collar has two projections one thicker than the other designed to fit in the
bottle adapter.
1. Bottle adapter: (Filler tubes, adaptor tubes, anaesthetizes) – they are color
coded as well. It has at end a bottle connector with a screw thread to match the
thread on bottle and a skirt that extends beyond the screw and has slots that
match on projections on bottle collar.
a. At the other end is male adaptor (filling plug, key, probe tube block)
consisting of a rectangular piece of steel with a groove on one side and
two holes on another surface.
b. The two ends are connected a short length of plastic tubing and allows the
bottle to be held higher or lower than the vaporizer. The tubing has two
inner tubes inner tube for air and the connective outer tube for liquid
anesthetic.
2. Filler receptacle: (Filler socket/block fills drain system) – The filler receptacle
on vaporizer permits insertion of only the intended bottle adaptor.
Means are provided to tighten the made adaptor to form a seal and also to close
receptacle while bottle adaptor not inserted.
257

-Second Edition
Problems with agent specific filling devices:
Difficulty in filling – due to misalignment, no seal, alert
Lost bottle adaptor
Vaporizer tipping
Lack of keyed system
Liquid leaks
Incomplete emptying of bottle
Overfilling
Location and mounting:

Concentration – celebrated vaporized are usually placed between flow meter and
common gas outlet or between common gas outlet and breathing system, though the
later is not recommended due to reasons as below.
Difficulty in securing the vaporize
Often disconnects
Increase in back pressure
Revened correction
More than are vaporizer can be turned on at a time if mounted in series
In system vaporizers
Mounting:
Permanent mounting:
Advantage are:
Vaporizers will not be dropped / otherwise abused
Leaks due to frequent removals/incorrect installations reduced
Disadvantages are:
Machine should have enough mounting space to accumulate man vaporizers
If vaporizer not attached, then gas leaks should be prevented at that space.
Detachable mounting:
Selectatec system is most commonly used to more the vaporizers, consists of a pair of
Porj valves on back far, a locking lever, vaporizer ahs a special mounting brackets.
Interlock devices: (Vaporizer exclusion)

They prevent more than one vaporizer from being turned on at a time
258

-Second Edition
Also ensures that only one vaporizer is turned on, gas enters only the one which
is on, trace of output is minimize when vaporizer is off and vaporizers are locked into
gas circuit thus ensuring they are seated correctly.
Hazards of vaporizers:
Incorrect agent:
Most concentration calibrated vaporizers are agent specific and thus common
hazard involves filling it with an agent it was not designed for.
Thus, if a low volatile agent is placed in vaporizer designed for highly potent one,
result will be a low concentration of that agent and similarly if a highly potent one
placed in one meant for less volatile agents, it would result in dangerously high
concentration of that agent.
Mistakes are more prone to occur when vaporizers placed in a row on the
machine
In multiple agent vaporizer – the vaporizer in use should be clearly marked and
should similarly be drained into a bottle of the same agent
If a wrong agent is filled, then vaporizer must be completely drained, liquid
discarded and gas allowed to flow till no agent can be detected in outflow.
Tipping:
If significant tipping occurs, liquid from vaporizing agent may inter
bypass/outlet causing increased concentration of agent to be delivered.
If tipping occurs – high flow of gas should be rule through vaporizes with
concentration dial set at low concentration till the output shares no examines
agent.
Overfilling:
This leads to high concentration being delivered
Is prevented by placing the filling part on vaporizer such that overfilling can’t
occur, agent specific filling devices prevent overfilling by connecting air intake in
bottle to inside of vaporizing chamber.
Practices such as when the bottle adapter and turning the concentration dial of
vaporizer On during filling speed the filling process and should be avoided as
they result in overfilling.
Reversed flow:
o Results in increase in output concentration machine standards mandate
the following safety measures to prevent reversed flow.
Vaporizer inlet male adaptor
259

-Second Edition
Vaporizer outlet female
Direction of gas for marked
Inlet and outlet parts be labeled.
Concentration dial in wrong position:

Could be due to user or technician fault that dial is left turned ON
Thus, as a part of peruse checking procedure of machine, the concentration dial
should be inspected.
Leaks:
A common cause of leak is failure to replace the filler cap or to tighten it
adequately. This usually detected by spillage of liquid anesthetic when vaporizer turned
on. Other causes could be failure to close the screw or plug not replace or tightened in
keyed filling system or damaged amount the drain screw shaft. Other locations include
selector valve, mounting mechanism interlock device, outlet connection
Leak should be suspected if
- Vaporizer has to be frequently filled
- Small of agent
- Splattering of agent if cap not tight
Vaporizer leak into fresh gas
Even when vaporizer is turned off, small amounts may leak into FGF this may not
produce clinical effect, but might cause a sensitized individual to react to a halogenated
agent or trigger are episode of malignant hyperthermia.
Leaks can be reduced by turning the vaporizer to off position when not in use.
Contaminants in the vaporizing chamber:

Water and other foreign substances can flow on and result in excessive carrier gas
passing through vaporizing chamber causing increase in vapor output.
650% increase in thymol concentration causes 5% in output of halothane should be
taken to manufactures for repair.
Physical damage: Shock examine vibration, misuse leads to damage
Obstruction to fresh gas flow: Because of mounting systems
Interlock malfunction
260

-Second Edition
261

-Second Edition
Chapter 39 - Classify vaporizer? Draw a diagram & discuss how
vapour concentration is maintained in TEC 5 vaporizer?
Definition: Vapour: A vapour is the gaseous form of a substance which is liquid at

room temperature.
Definition: Vaporizer: A vaporizer is an instrument designed to change a hood
anesthetic agent into its vapour and to add a controlled amounts of this vapour to the
freely gas flow.
Applied physics
Critical temperature: Temp above which a vapour cannot be liquefied.
O2 = 118o C ; N2O= + 36.5C, Co2 = 31o C
Boiling point: Temperature at which SVP (saturated vapour pressure) equals
atmosphere presence.
Halothane: 50.2 Isoflurane = 48.5
Enflurane: 56.5 Sevoflurane = 58.5
Desflurane = 22.8
Thermal conductivity: (TC)
As the TC Ser the substance in better conductor of heat. E.g: Copper
Classification: (VCR – SALT)

I. According to methods of regulating output once
a). Concentration calibrated / variable bypass
b). Measured flow
II. Method of Vaporization (FBI)

a). Flow over
b). Bubble through
c). Injection
III. Temperature Compensation

a). Thermo Compensation
b). Supplied heat
262

-Second Edition
IV. Specificity
a). Agent: Specific
b). Multiple agent
V. Resistance
a). Plenum (High resistance)
b). Low flow resistance (Draw over)
VI. Depending on the Location

a). Vaporizer inside circuit
b). Vaporizer at side circuit
VII. Depending on Arrangement

a). Parallel
b). Series
I. Methods of regulating output concentration

a). Concentration calibrated / variable bypass
b). Measured flow
a). Concentration calibrated: Ex: Tec 3, 4, 5, Drager

- It is also called variable bypass
- Direct reading
- Dial controlled
- Automatic plenum (thermo regulation)
- Percentage type
- Tech type vaporizer
263

-Second Edition
 Ratio b/w the bypass gas to charges gas is called splitting ratio.
b). measured flow vaporizer: Copper Kettle vernitrol
A measured amount of carrier gas is utilized for vaporization, vapour this obtained is
diluted with additional flow of gases from the machine.
264

-Second Edition
II. Method of vaporization: (FBI)
a). Flow over – eg: Tec, 2, 3, 4, 5
b). Bubble through
c). Injection
a). Flow over:

A stream of carrier gas paves over the surface of the anesthetic agent, this gas takes up
the vapour & pauses to the patient. By adding baffles, spiral tracks, twicks, we can use
the contact of the gas & liquid. By this efficacy of vaporized can be used. Tec 2, 3, 4, 5.
b). Bubble through:

In the carrier gas is bubbled through the beyond by small bubbles. This is another mean
provide contact blue the carrier gas & liquid.
e.g.: of Bubble through: Boyle’s Vaporizer
Copper Kettle
Vaporization is enhanced if size of the bubble is small as it provides more surface
area for contact.
Slow moving bubble use the vaporizer output, as they get more time for the
contact.
Depth of beyond also influences vaporization
c). Injection type:

A known amount of liquid anesthetic agent (or) pure vapour is injected into the known
value of gas. Accurate control
E.g.: Tech 6
III. Temperature Compensated

a). Thermo Compensation
b). Supplied Heat
a). Thermo compensation:

It is concentration calibrates vaporizer to adjust for change in vapour presence with
temp by altering the splitting ratio.
This is done by using a temperature sensitive bi-metallic element strip
By altering the flow of causes gas
265

-Second Edition
b). Supplied Heat:
To obtain accurate control of vapour care various methods are adopted, of these most
common requirement is supply of heat. This is achieved either by supplying heat
directly. (a). Indirectly to maintain a constant temperature
E.g.: Tech 6, (Water bath jackets)
IV. Specificity:
a). Agent specific
b). Multiple agents
a). Agent specific: Vaporizer should be used with that agent only. If another
agent is used it can
o React with seal & gasket
o Produce harmful products
o Definite care of vapour cannot be delivered
o Either high care (as low care is delivered)
V. Resistance
a). Plenum high
b). IDW resistance
a). Plenum:
A chamber in which the presence inside is greater than outside. They has (a) High
resistance (b) Depend on compressed gas driver under presence (c) Un-direction gas
flow
b). Low resistance:

Low resistance vaporizers are designed to be situated with in the breathing system.
Vaporizer is due to the patients breathing
e.g.: Draw over vaporizer
VI. Depending on location of vaporizer

a). Vaporizer inside the circuit (VIC)
b). Vaporizer outside the circuit (VOC)
266

-Second Edition
a). Vaporizer inside the circuit:
These are present inside the breathing system, the patient inspiration (on expiration go
through the vaporizer output cannot be predicted. They are low resistance.
Depend on : Uptake by patient
FGF
Volume in circuit
Liquid level
b). Vaporizer outside the circuit:

They are plenum, located outside the breathing circuit between the flow meter and
common gas outlet.
1). Spilling over can be avoided
2). Required concentration can be achieved
VII. Depending on the arrangement of vaporized

a). Parallel
b). Series
a). Parallel:
Here gas do not flow one vaporizer to other(selector value). The selector values direct
gas from flow meter to one vaporizer & isolate all other vaporizer.
Selection valve can be combined with an inter lock device so that one vapour is
tried on.
Problem: Improper seating, CO2 leak of FGF
Partial or complete of obstruction of gases
Malfunctioning results in no output of vapour
b). Series:
Gas flows through more than one vaporizer. Main hazard is that agent from up
steam vaporizer may be deposited in down stream vaporizer, when the two
vaporizer is timed on. This will had the centre is tuned on. This will charge the
conc. Of UP & Down stream.
Subsequent use down stream vaporizes is contained to.
It is not safe to use.
267

-Second Edition
Factors affecting Vapor concentration:
1). Temperature
2). Barometric pressure
3). Effect of intermittent back pressure
4). Liquid level
5). Cornice gas composition
1). Temperature:
a). At low temp – output will be low
b). At high temp – output will be high
2). Barometric pressure:

Most vaporizers are calibrated at standard atmospheric pressure (760mm of Hr)
a). In low atmospheric prune: In low atmospheric prune – output (High altitude)
b). In high atmosphere prune: in high atmospheric prune & output
3). Effects of intermittent back pressure
Two effects a). Pumping effect

b). Presuming effect
a). Pumping effect: Retrograde prune transmission, compress the gas in the
chamber & bypass. As bypass has a smaller volume more gas molecular go to the V.
chamber (splitting ratio is altered) which DRGs vapour. i.e. the concentration
b). Dressing effect: When the prune is used at the vaporizes outlet. The cashier gas
is compressed in the chamber. So there will be more molecules of gas per ml. The
number of molecules of vapour will not uses. The net result is decrease in the conc. Of a
anesthetic agent in vaporizing chamber & outlet, i.e. the concentration.
4). Liquid Level: If the vaporizer is overfilled it will result in high care due to
spilling of liquid into the part. If vaporizer is under filled there is in sufficient exposed
area of wicks which results in used conc.
Cornice gas composition: Most of the vaporizer are calibrated using O2. When N2O is
added to cornice gas there will be reduction in output, the length of Anesthetic effects.
268

-Second Edition
Ideal vaporizer
1. Simple 2. Safe
3. Low Cost 4. Temp Compounds
5. Accurate output core 6. Light weight
7. Free of corrosion
269

-Second Edition
270

-Second Edition
Chapter 40 - Bourdone gauge
It is a pressure indicator that will display. The presence of the cylinder supplied
gas. It belong to high pressure system. Indicates may be near the cylinder on as the
panel as the front of the machine.
Anatomy
It is circular with a diameter 38 mm, lowest pressure indicator is between 6o
clock & 9” clock position. It is covered by plastic shield.
The scale must be at least 33% more than the maximum filling pressure.
Indicating end of the pointer is usually in contract to the background, where as
tail end blends into the background.
It is stout: This design is to provide better resolution of dial number.
It is clearly marked with name / chemical symbol and colour assigned to that gas.
Mechanics:
The tube / spring is BOURDONE SPRING, which is made up of elastic element. It is a
hollow tube is bent into part of the circle. It is bent into a curve and scaled & linked to
a clock like mechanism.
The other end is connected to gas source and soldered into socket.
An increase in pressure gas inside the tube causes it to straighten.
As the pressure decreases the tube resumes the curved shape
BOURDON PRESSURE GAUGE
271

-Second Edition
272

-Second Edition
273

-Second Edition
Chapter 41 - Univent Tube
The univent tube is a single lumen cuffed silicon tube with a small lumen along
its concave side.
It is one of the tube used for Bronchial – Blockage
The small channel contains a tubular bronchial blocker, that has a blue cuff.
There are radiopaque rings at both ends the cuff.
The blocker can be advanced upto 8 cm beyond the main body of the tube and
can block airways smaller than the main stem branches.
All function possible with a DLT can be performed with a univent tube, except
differential leg ventilator.
The univent tube may be easier to insect and position correctly then a double
lumen tube.
Its smaller external diameter compared to that of a DLT may make it useful in
situations such as the patients with narrowing of the airway as a tracheotomy.
TECHNIQUE
1). After checking for the leaks, both the cuffs should be deflated.
2). Check the free to & fro movement of the univent tube.
3). The univent tube is inserted as a unit into the trachea.
4). The tracheal cuff is inflated, and patient is ventilated.
5). A fiberscope is inserted into the lumen of the tube while ventilation is
maintained around.
6). The main tube is rooted that the blocker is directed towards the side to be
occluded, under direct vision.
7). The fiberscope is then withdrawn, and a guide wire may be useful in directing
the blocker into place and cuff inflated.
8). Once the blocker is placed, its position should be checked using fiberscope, X-ray
as auscultation.
OTHER TYPE OF BRONCHIAL BLOCKER
1. Embolectomy catheter
2. Swan – Ganz catheter
3. Magill Blocker
4. Foley’s Catheter
274

Anesthesia Machine

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Anesthesia Machine

Uploaded by

Copyright:

Available Formats

2011

Dr Azam's Notes in Anesthesiology

Machine & Instruments

Dr. Mohammed Azam Danish

Dr Azam’s Notes in Anesthesiology

Machines & Instruments

www.DrAzam.com Machine & Instruments

Graphic representation of data is an excellent form of data compression; figures or

I constructed parts of Dr Azam’s Notes in Anesthesiology for Postgraduate students

Dr Azam’s Notes is aimed primarily at trainees in Anesthesia though more experienced

The format is designed to provide easy access to information presented in a concise

www.DrAzam.com Machine & Instruments

Anesthesiology is an ever-changing field. Standard safety precautions must be followed,

However, in view of the possibility of human error or changes in medical sciences,

www.DrAzam.com Machine & Instruments

To Mohammed Shafiulla, my father, my oxygen,

I also would like to thank my mom (Naaz Shafi), my wife

I also thank my Colleagues Dr Rajshekar Reddy & Dr Sachin for

Finally, I would like to thank my teachers. The dream begins

www.DrAzam.com Machine & Instruments

www.DrAzam.com Machine & Instruments

CHAPTER 1 - HISTORY OF ANESTHESIA MACHINE .......................................................................................... 16

CHAPTER 2 - BOYLE’S APPARATUS – MAJOR AND MINOR .............................................................................. 18

CHAPTER 3 - MEDICAL GAS CYLINDERS .......................................................................................................... 20

MEDICAL GAS CYLINDER: ....................................................................................................................................... 20

CHAPTER 4 -PRESSURE SYSTEMS .................................................................................................................... 29

MACHINE IS DIVIDED INTO 3 PARTS: ......................................................................................................................... 29

CHAPTER 5 - PRESSURE GAUGES .................................................................................................................... 31

BOURDON’S GAUGE ......................................................................................................................................... 31

CHAPTER 6 - YOKE ASSEMBLY ........................................................................................................................ 34

CHAPTER 7 - PRESSURE REGULATOR / REDUCING VALVE ............................................................................... 36

CHAPTER 8 - OXYGEN FAILURE DEVICES: ........................................................................................................ 39

OXYGEN FAILURE SAFETY DEVICE: ............................................................................................................................ 39

www.DrAzam.com Machine & Instruments

CHAPTER 9 - FLOW METERS ........................................................................................................................... 43

CHAPTER 10 - SAFETY DEVICES....................................................................................................................... 48

TYPES USED ARE: .................................................................................................................................................. 48

CHAPTER 11 - CHECK LIST BEFORE USING MACHINE ...................................................................................... 52

HIGH PRESSURE SYSTEM: ....................................................................................................................................... 52

CHAPTER 12 - SAFETY FEATURES IN ANESTHETIC MACHINE ........................................................................... 54

AIMED AT AVOIDING THE FOLLOWING HAZARDS: ......................................................................................................... 54

CHAPTER 13 - SAFETY FEATURES IN ANESTHETIC MACHINES (CME) ............................................................... 56

www.DrAzam.com Machine & Instruments

THE MAGNITUDE OF DAMAGE DEPENDS UPON: ........................................................................................................... 65

CHAPTER 15 - MONITORED ANESTHESIA CARE (MAC) ................................................................................... 72

CHAPTER 16 - HUMIDITY AND HUMIDIFIERS .................................................................................................. 79

CONSIDERATIONS FOR ANESTHESIA: ............................................................................................................... 79

CHAPTER 17 - NEBULIZERS ............................................................................................................................. 87

CHAPTER 18 - VENTURI MASK ........................................................................................................................ 88

CLASSIFIED INTO: .................................................................................................................................................. 88

CHAPTER 19 - RUBEN (NON-REBREATHING) VALVE ....................................................................................... 91

CHAPTER 20 - RAE – TUBE (RING – ADAIR – ELWYN) ...................................................................................... 94

CHAPTER 21 - ARMORED TUBES .................................................................................................................... 96

CHAPTER 22 - LASER SHIELDED E.T. TUBE....................................................................................................... 97

FIRST ENDOTRACHEAL TUBE: ................................................................................................................................... 97

CHAPTER 23 - COLE’S TUBE .......................................................................................................................... 100

CHAPTER 24 - AMBU /LAERDAL RESUSCITATION / MANUAL RESUSCITION.................................................. 103

CHAPTER 25 - RESERVOIR OR RESPIRATORY BAG......................................................................................... 106

VOLUME PRESSURE RELATIONSHIP .......................................................................................................................... 106

www.DrAzam.com Machine & Instruments

MOUTH PROPS OR BITE BLOCKS: ................................................................................................................... 109

CHAPTER 27 - ANESTHETIC BREATHING SYSTEMS ........................................................................................ 112

CHAPTER 28 - CIRCLE SYSTEM ...................................................................................................................... 129