European Journal of Anaesthesiology 2003; 20: 259–281

© 2003 European Academy of Anaesthesiology

ISSN 0265-0215

Review

Important physical principles in anaesthesiology

A. Manohin*, M. Manohin†
*
Medical Center, Department for Anaesthesiology; †Elementary School Vodmat, Ljubljana, Slovenia

Summary
The aim of this Review is to introduce anaesthesiologists to the basic physical principles that are important for
their work. A better understanding of the underlying processes during anaesthesia is required for greater safety
and efficiency. Relevant physical quantities are presented along with the area of anaesthesiology where they are
used. This approach provides better targeting to the needs of practising anaesthesiologists. This text has been a
part of a specialist course in anaesthesiology at the University of Ljubljana for some years. Current results show
that both the students and the specialist anaesthesiologists now show a better understanding of the underlying
physical principles required for their work and are more successful in fulfilling the needs of their practical work.

Keywords: ANAESTHESIOLOGY; MONITORING, PHYSIOLOGICAL; NATURAL SCIENCES, physics;

EQUIPMENT AND SUPPLIES.

Physics is a basic science about nature. It investigates
those phenomena in nature that can be observed and
measured, and the measurement of which can be
repeated in a controlled situation. Physics employs
mathematics as the basic language for expressing the
relationship among quantities. The term ‘physics’
probably originates from Aristotle (384–322 BC)
who chose it for his principal work on nature. Physi-
cal principles are involved in any process on the Earth,
or indeed in the Universe. It is of course not the aim
of this paper to create some ‘special physics’ valid only
for anaesthesiologists – instead, a review of physical
principles with an application in anaesthesiology is
provided.
Physical quantities and units
A physical quantity is one of the basic notions in
physics defined with a measuring method and its
units. It matches a property of a physical body, a
characteristic of a phenomenon or a state of the
Correspondence to: Aleksander Manohin, Medical Center, Department for
Anaesthesiology, Zaloška 7, SLO-1000 Ljubljana, Slovenia. E-mail: manohin@
link.si; Tel/Fax: ⫹386 1 522 35 57
Accepted for publication July 2002 EJA 640
observed body. Since 1981 there has been an interna-
tional agreement dividing physical quantities into
base units and derived units, the latter being defined
in terms of base units [1]. The base quantities are
mass, length, time, electric current, thermodynamic
temperature, luminous intensity and the amount of
substance measured with respect to the number of
elementary entities (atoms, molecules, ions, elec-
trons or other particles or groups of particles). The
derived quantities, on the other hand, include velocity,
acceleration, force, pressure, work, density, voltage,
resistance, etc. By agreement, the symbols denoting
physical quantities are typeset italicised.
Physical quantities can be either scalar or vector.
Scalar quantities (e.g. length, work, power) are defined
with a single value (i.e. magnitude); with vectors
(e.g. direction, force, momentum), we have to specify
for direction along with the magnitude. Two angles
are required to describe a given direction in space,
thus making three values needed to describe a vector
completely.
Every base quantity corresponds to a base unit
(Tables 1a and 1b), defined with the international
system of units, usually abbreviated as SI (French for
Système International). Base units are defined in such a
manner that any adequately equipped laboratory in

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 260 A. Manohin and M. Manohin

the world can produce a measure for any given unit
and that those measures are equal throughout the
world. SI specifies the permitted set of units and their
symbols. All countries that ratified this agreement
are obliged to enforce their use in practice.
A derived SI unit is obtained from the appropriate
equation expressing a derived quantity in terms of
base quantities and the base units. Some derived
units have special names, e.g. the unit for pressure.
When the derived units have a form of a quotient
they can be written as a fraction e.g. ms , or using a
solidus (slash symbol), e.g. m/s (no more than one
solidus can be used) or using a negative exponent,
e.g. m s⫺1. The chosen notation has to be consistent
throughout the text. Scientific journals such as the
European Journal of Anaesthesiology use the exponent
convention because, if there are more than two quan-
tities, confusion is otherwise introduced.
The units, both base and derived, are typeset in
upright symbols. Unit symbols are unaltered in plu-
rals and are not followed by a period (full point)
unless at the end of a sentence. Most unit symbols are
Latin small letters, an exception being those units the
Table 1a. Base physical quantities, their symbols, units and
abbreviations.
Base quantity Symbol Base SI unit
Time t second
Mass m kilogram
Length l metre
Electric current I ampere
Temperature T kelvin
Amount of substance n mole
Luminous intensity cd candela
names of which are derived from a family name (e.g.
N from Newton, Pa from Pascal, K from Kelvin,
J from Joule, W from Watt). Furthermore, several
scientific journals including the European Journal of
Anaesthesiology use the capital letter L for litre instead
of prescribed small letter l to avoid confusion with
the cardinal numeral 1.
Measuring physical quantities
During clinical or research work physical quantities
are measured. Measuring a quantity means counting
its units. The numeric value is called the measured
number. An example might be to measure the length
of a peripheral venous catheter or the time to awaken
after an induction dose of anaesthetic.
Experimental errors
Experimental data can be obtained using either a sin-
gle measurement or several repeated measurements,
from which the average can be calculated. The errors
can be due to either the observer’s subjective error or
the inadequate precision of the instrument used in
the measurement. As an example, let us take the
actual width of the front panel of an anaesthesia
machine as being 1.295 m, while our measured value
is 1.285 m. The experimental error can be expressed
Abbreviation either as an absolute error or as a relative error. The
s
absolute error is the difference between our measured
kg value (single or average) and the actual value. It is
m expressed in the same units as the measured quantity.
A In our example, the absolute error is equal to
K 1.285 ⫺ 1.295 ⫽ ⫺0.01 m.
mol
cd
The relative error is the quotient between the
absolute error and the actual value.

Table 1b. Some units used with SI or examples of the use of prefixes.

Base SI unit Larger unit Smaller units

Units for measuring length metre 1 km ⫽ 1000 m 1/10 m ⫽ 1 dm

Units for measuring amount
of substance
Units for measuring
electric current
Other units for measuring
temperature
Units for measuring mass
1/100 m ⫽ 1/10 dm ⫽ 1 cm
1/1000 m ⫽ 1/100 dm ⫽ 1/10 cm ⫽ 1 mm
1/106 m ⫽ 1/105 dm ⫽ 1/104 cm ⫽ 1/103 mm ⫽ 1 µm
1/109 m ⫽ 1/108 dm ⫽ 1/107 cm ⫽ 1/106 mm ⫽ 1 nm
mole 1 kmol ⫽ 1000 mol 1/1000 mol ⫽ 1 mmol
ampere 1/1000 A ⫽ 1 mA
kelvin (Other
unit: degree
Celsius (°C))
kilogram 1 tonne ⫽ 1000 kg 1 ⫻ 100⫺1 kg ⫽ 1 dag
1 ⫻ 1000⫺1 kg ⫽ 1 ⫻ 10⫺1 dag ⫽ 1 g
1 ⫻ 10⫺6 kg ⫽ 1 ⫻ 10⫺4 dag ⫽ 1 ⫻ 10⫺3 g ⫽ 1 mg
1 ⫻ 10⫺9 kg ⫽ 1 ⫻ 10⫺7 dag ⫽ 1 ⫻ 10⫺6 g ⫽ 1 ⫻ 10⫺3 mg ⫽ 1 µg
1 ⫻ 10⫺12 kg ⫽ 1 ⫻ 10⫺10 dag ⫽ 1 ⫻ 10⫺9 g ⫽ 1 ⫻ 10⫺6 mg ⫽ 1 ng

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 Physics for anaesthesiologists 261

In our example, the relative error is equal to defining one second as the fraction 1/86 400 of the
mean solar day.
⫺0.01 m
⬇ ⫺ 0.008 Mass, symbol m (symbol italicised). This is a physical
1.295 m quantity measuring the amount of matter. The base
unit is a kilogram (kg). One kilogram is the mass of
Calculated errors should be presented with a sen-
the international prototype of the kilogram, kept at
sible precision. The number of decimal places used
the International Bureau of Weights and Measures in
should be decreased to the precision achievable at
Sèvres, near Paris, France.
the measurement. For instance, if there are only 1 cm
Length, symbol l (symbol italicised). This is a physi-
units marked on the measuring tape used for a meas-
cal quantity measuring the distance between two
urement, the result should be rounded to 1 cm. Usu-
points in space. The base unit is a metre (m). The
ally, two significant figures suffice for practical work
original definition was where one metre equalled one
except that three figures may be desirable if the first
forty-millionth of the length of the meridian through
figure is 1, 2 or possibly 3. If the digit in the third
Paris. Since 1983, it has been defined as the length of
place after the decimal point is equal to or greater
the path travelled by light in vacuum during a time
than (⭓) 5, the digit on the second place would be
interval of 1/299 792 458 of a second.
increased by one (rounded up). The equals sign is
Current, symbol I (symbol italicised). This is a phys-
then replaced by the ‘approximates to’ symbol (⬇).
ical quantity related to the movement of the carriers
In our case, the relative error is ⬇⫺0.01. A sensibly
of an electric charge. It is defined in terms of the
rounded relative experimental error can be expressed
flow of charge. The base unit is an ampere (A). The
in per cent or per mille. In our example, it is equal to
ampere is that constant current that, if maintained in
1% or 10‰.
two straight parallel conductors of infinite length, of
negligible circular cross-section and placed 1 metre
Decimal exponents and the corresponding prefixes apart in vacuum, would produce between these
A physical unit can sometimes be too large or too conductors a force equal to 2 ⫻ 10⫺7 N per metre of
small to express conveniently the results of a meas- length.
urement of a physical quantity. In that case, we can Temperature, symbol T (symbol italicised). This is a
use either larger or smaller units denoted by prefixes. thermodynamic variable, used to describe a state of
The most common prefixes are shown in Table 2. a thermodynamic system. The base unit, kelvin (K), is
Only one prefix at a time can be used with a unit, i.e. 1/273.16 of the thermodynamic temperature of the
millimillimetre is incorrect. triple point of water.
Apart from the thermodynamic temperature
Basic physical quantities measured in kelvin, temperature is often given in
Time, symbol t (symbol italicised). The base unit is a degrees Celsius (°C). 0°C ⫽ 273.15 K, 100°C ⫽
second (s). A second is 9 192 631.770 periods of the 373.15 K. The numerical value of the temperature
radiation corresponding to the transition between the difference measured in kelvin is the same as the
two hyperfine levels of the ground state of the 133Cs numerical value of the temperature difference meas-
atom. This definition is consistent with an older one, ured in degrees Celsius, therefore the latter unit can
also be used to express the temperature difference.
Table 2. Decimal prefixes that can be added to physical units The thermodynamic temperature measured in kelvin
and their numerical value. is often referenced as absolute temperature, and 0 K
(⫺273.15°C) equals the temperature at which all
Power of Number of molecular movement stops.
Prefix Abbreviation 10 units Luminous intensity, symbol cd (symbol italicised).
giga G 109 1 000 000 000
Base unit is a candela (cd). This is the luminous inten-
mega M 106 1 000 000 sity, in a given direction, of a source that emits
kilo k 103 1 000 monochromatic radiation of frequency 540 ⫻ 1012
hecto h 102 100 Hertz and that has a radiant intensity in that direc-
deca da 10 10 tion of 1/683 watt per steradian.
Base unit: 1 1
deci d 1/10 0.1
Amount of substance, symbol n (symbol italicised).
centi c 1/102 0.01 This is a physical quantity, measuring the number of
milli m 1/103 0.001 elementary entities in the substance. The base unit is
micro µ 1/106 0.000 001 a mole (mol). One mole is the amount of substance
nano n 1/109 0.000 000 001 that contains as many elementary entities as there are
pico p 1/1012 0.000 000 000 001
femto f 1/1015 0.000 000 000 000 001
atoms in 0.012 kilograms of 12C. When the mole is
used, the elementary entities must be specified and

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 262 A. Manohin and M. Manohin
may be atoms, molecules, ions, electrons, other parti-
cles or specified groups of such particles. One mole of
gas contains at standard conditions (273.15 K,
101.325 kPa) 6.023 ⫻ 1023 molecules. The latter con-
stant is called the Avogadro or Loschmidt number.
Derived units
In anaesthesiology, the following derived physical
quantities and units are most often used.
• Velocity is a physical quantity that measures the
rate of movement. We can define it mathemati-
cally as v ⫽ ⌬s/⌬t, where ⌬s is the distance and
⌬t is the time during which the movement
occurred. Its unit is m s⫺1.
• Acceleration is a physical quantity measuring the
rate of change in velocity, i.e. the change in
velocity ⌬v which occurred during the time ⌬t, or
mathematically a ⫽ ⌬v/⌬t. Its unit is m s⫺2.
• Force is a quantity describing the action of one
physical body on another. Its symbol is F. Because
of force, a free body with a mass m starts to move
with acceleration a ⫽ F/m. The unit of force is the
newton (N). One newton is equal to the force
required to give a free body of mass 1 kg an accel-
eration of 1 m s⫺2. Therefore 1 N ⫽ 1 kg m s⫺2.
• Weight is the force with which the Earth attracts
another body. It is equal to the mass of the body
multiplied by the acceleration of gravity: Fg ⫽ mg.
The acceleration of gravity equals 9.81 m s⫺2. For
practical purposes, 10 m s⫺2 is often used. Acceler-
ation of gravity means that a physical body falling
freely in the absence of drag increases its velocity
by 9.81 m s⫺1 each second.
• Momentum is a physical quantity defined as either
the product of mass and the velocity of a body for
a point object, or the product of mass and the
velocity of the centre of mass for an object with
non-zero dimension; G ⫽ mv. Its unit is kg m s⫺1.
Taking into account the definition of a newton as
kg m s⫺2, we can also express momentum in units
of newton seconds, N s.
• Work is a physical quantity defined as the product
of the resultant force acting in the direction of
movement and the movement itself. If the force
is constant, one can write A ⫽ Fs, otherwise
A ⫽ 冮F ds. The unit of work is N m, also known as
the joule (J).
• Energy is a capability of a body or a system of bod-
ies to perform work. Its unit is the joule ( J). The
energy of a body or a system of bodies can be
kinetic, potential or internal.
• Kinetic energy is the energy due to movement. The
kinetic energy of a point object with a mass m mov-
ing with a velocity v is equal to Wk ⫽ 12 mv2.
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• Potential energy is the energy due to the position of
a body. The gravitational potential energy for a
body of mass m at the height h is equal to Wp ⫽
mgh ⫽ Fg h, where g is equal to the acceleration of
gravity. Another form of potential energy is elastic
energy, for instance the energy of a coiled spring.
• Internal energy is the energy due to the movement
of the entities of matter. The change of internal
energy when a body with a mass m is heated
through a temperature difference ⌬T is equal to
Wn ⫽ mc⌬T. Here, c is the specific heat, i.e. the
heat needed to heat 1 kg of a given matter for 1 K.
Specific heat depends on external conditions; the
extreme cases are the specific heat at constant vol-
ume cv and the specific heat at constant pressure
cp. However, the two values differ significantly
only in gases – whereas in solids and liquids the
difference is small and can often be neglected. In
this latter case the subscript letter is omitted.
• Power is a physical quantity defined as the work
done per unit time P ⫽ A/t. Its unit is J s⫺1, also
known as the watt (W). Taking into account the
definition of a newton, kg m s⫺2 one can write the
unit of power as kg m2 s⫺3.
• Pressure is a physical quantity. When a force F
is evenly distributed over a flat surface, S, p ⫽
F S⫺1. The unit of pressure is N m⫺2 also called the
pascal (Pa). A popular larger unit is the kilopascal
(kPa): 100 kilopascals ⫽ 1 bar.
The use of older units of pressure: mmHg, cmH2O
or atmospheres is not encouraged and they should
be converted into SI units. Thus, 1 mmHg ⫽
0.133 kPa, 1 kPa ⫽ 7.5 mmHg, 1 cmH2O ⫽ 0.1 kPa,
1 kPa ⫽ 10 cmH2O, and 1 atm ⫽ 1 bar (Table 3).
The European Journal of Anaesthesiology and many
other journals use mmHg for intravascular pressures
and cmH2O for pressures in the airway because these
are what anaesthesiologists see and use in everyday
clinical practice. When publishing graphs, which
also serve as nomograms, the use of the older units of
pressure is permitted as an exception if transforma-
tion into the SI units could lead to misreading of
these nomograms. It is useful to add conversion fac-
tors to the figure captions.
When quoting pressures, the relation to atmos-
pheric pressure should be stated. To avoid possible
confusion, it is often recommended that the pressure
difference should be quoted instead, i.e. the differ-
ence between the measured pressure and atmospheric
pressure. The term absolute pressure is also used
when atmospheric pressure is included.
• Volume flow is a physical quantity measuring
the volume of fluid that flows in a given amount
of time, ⌽ ⫽ ⌬V ⌬t⫺1. The unit is m3 s⫺1. In
 Physics for anaesthesiologists 263

Table 3. Some older units for pressure with their conversion factors. Except kPa and bar, none conforms to the SI unit system and should
be converted to SI units.

Pounds per Inches of mercury Physical Technical Torr* (mmHg

Unit for pressure square inch (psi) (in. Hg) atmospheres kPa Bar atmospheres at 0ºC)

Pounds per square inch (psi) 1 2.036 0.068 6.895 0.0689 0.0703 51.715
Inches of mercury (in. Hg) 0.4911 1 0.0334 3.386 0.0338 0.0345 25.4
Physical atmospheres 14.696 29.921 1 101.325 1.0133 1.0332 760
kPa 0.145 0.295 0.01 1 0.01 0.01 7.501
Bar 14.503 29.53 0.9869 100 1 1.0197 750.06
Technical atmospheres 14.2233 28.959 0.9678 98.067 0.9807 1 735.56
Torr (mmHg at 0°C) 0.01934 0.03937 0.00132 0.133 0.00133 0.00136 1
*
Torr was popular for a time (see issues of Anesthesiology) following the first landing on the Moon by the US astronauts in 1969 because it is a
gravitationally independent unit.

anaesthesiology, the units L s⫺1, L min⫺1, mL s⫺1
and mL min⫺1 are also used.
• Density is a physical quantity measuring the mass
of a volume element. For a homogeneous body
one can write ␳ ⫽ m V⫺1. The unit is kg m⫺3.
• Specific weight is a physical quantity measuring the
weight of a volume element. For a homogeneous
body one can write ␴ ⫽ Fg V⫺1. The unit is
N m⫺3.
State of matter
Matter consists of minute, randomly moving enti-
ties. Those entities can be atoms, groups of atoms
(i.e. molecules) or ions. Both attractive and repul-
sive forces act between them. It is the nature of these
forces, the kinetic energy of the entities and the
external condition that define in which state the
matter exists: as solid, as liquid or as gas.
In solids, the kinetic energy of the entities is small
enough so that the entity remains bound and local-
ized vibrating around its equilibrium position. Solids
thus retain their shape and volume. When an exter-
nal force acts upon them they may change their
shape but return to their original shape if the acting
force was small enough.
In liquids, the molecules randomly move and col-
lide with other molecules. The average distance
between molecules is approximately the same as in
solids but the molecules are not bound in any fixed
location. A liquid acquires the shape of the vessel and
forms a surface. The surface of a still liquid is perpen-
dicular to the resultant external force. If the only
external force is weight, the surface is horizontal. If
the vessel containing the liquid rotates, the centrifu-
gal force also has to be taken into account and the
surface attains the shape of a rotational ellipsoid. A
liquid can be either wetting or non-wetting. If it
wets the walls of the vessel, a rise due to capillary
action can be observed (e.g. water/glass); if not, there
is a fall (e.g. mercury/glass). A wetting liquid spreads
evenly over a horizontal surface while a non-wetting
one forms droplets.
In gases, the average kinetic energy is large enough
for the entities to move freely. Movement is random,
with the entities colliding with other entities as well
as with the vessel walls. The interaction between the
entities is small except when collisions occur. Gas
completely fills the volume at its disposal. The inter-
nal energy of an ideal gas is completely determined
by the kinetic energy of its molecules. We describe
such gases as systems of volumeless particles, which
do not interact except at collisions. Very low-density
gases can be approximately described as ideal gases.
Real gases are the ones usually encountered in nature.
In real gases molecules weakly interact even between
collisions. Real gases can only fill a finite volume.
Diluted real gases can approximately be treated as
ideal gases.
Both liquids and gases have a common character-
istic: they can flow. Therefore, the common name
fluids can be used for them. They share many com-
mon characteristics.
Influence of temperature on the state of matter
The temperature at which a solid turns into a liquid
is called the melting point, and conversely the tem-
perature at which the liquid transforms to solid is
called the freezing point. Both temperatures are
equal for the same substance at the same pressure.
The temperature at which the liquid transforms to
gas or vice versa is called the boiling point (Fig. 1).
By heating a body towards the melting point, or
from the melting point towards the boiling point,
its temperature increases. Analogously the tempera-
ture of a body decreases if the body is either cooled
from the boiling point towards the freezing point or
below the freezing point. The absorbed heat in the
first case is used to weaken the bonds between the
entities and increase the volume. A notable excep-
tion is water. Owing to its anomalous behaviour, the

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 264 A. Manohin and M. Manohin
100
4 tion. The temperature of vaporization increases with
80
Temperature (°C)
60
3
40
20
2 substance the specific latent heat of vaporization has
0
1
⫺20
0 2 4 6 8
Time (min)
Figure 1.
Temperature as a function of time. A total of 1 kg ice with an initial
temperature of ⫺10°C is uniformly heated at a pressure of 1 bar. In
Phase 1, the ice is heated, but it remains a solid. The received heat for
1 kg of water at 1 bar is 21 kJ. In Phase 2, the ice melts, changing its
state from solid to liquid and it absorbs 335 kJ of heat. In Phase 3,
the liquid is heated, but it remains a liquid absorbing 420 kJ of
heat between 0 and 100°C. In Phase 4, evaporation occurs as the liq-
uid has reached its boiling point. It changes state from liquid to gas
consuming 2260 kJ of heat. A graph showing the uniform cooling of
1 kg of water vapour from 100°C down to ice at ⫺10°C would look
identical, but would travel in a reverse direction.
volume of water is actually decreased – and its den-
sity is increased – when heated from 0 to 4°C.
When exactly at the melting or the boiling point
the temperature does not increase with the absorbed
heat. Instead, all of the absorbed heat is used to break
the bonds between the entities and change the state
of the matter. The heat, absorbed during melting or
boiling is called latent heat because it does not result
in an increase of temperature. At the melting point
and the corresponding melting pressure, the solid
and the liquid phases are in equilibrium. The phase
change (the change in the state of matter) from solid
to liquid is called melting and the opposite process is
called solidification. The temperature of the melting
point increases with pressure if the density of the
solid phase exceeds that of the liquid phase and vice
versa. Melting 1 kg of a substance at its melting
point requires an input of heat energy. This is cor-
rectly called the specific latent heat of fusion, but
commonly abbreviated to the latent heat of fusion
(symbol qt). Conversely, 1 kg of liquid cooled to the
freezing point releases the same amount of heat while
freezing. To calculate the total amount of heat
required to melt a given amount of substance the spe-
cific latent heat of fusion has to be multiplied by the
mass of substance, Qt ⫽ qtm.
At the boiling point and the corresponding pres-
sure the liquid phase is in equilibrium with the
gaseous phase. The phase from liquid to gas is called
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evaporation and the reverse process is called condensa-
pressure. Boiling 1 kg of liquid heated up to its boil-
ing point requires an input of heat energy equal to the
specific latent heat of vaporization (or latent heat of
vaporization, qi). While liquidifying, vapour releases
the same amount of heat. To calculate the total
amount of heat required to boil a given amount of
to be multiplied by the mass of substance, Qi ⫽ qim.
• Evaporation: note that the liquid-to-gas transition
also occurs at temperatures lower than the boiling
point. Here, the process is called evaporation. This
terminology is used to discriminate this process
from the liquid-to-gas transition at the boiling
point when it is called boiling.
• Sublimation: direct conversion from solid to gas is
called sublimation. Its reverse process deposition
of crystals from gas shares the name with conden-
sation. Both transitions occur at a given pressure
and temperature (called the sublimation tempera-
ture). During sublimation an input of heat (heat
of sublimation) is required while at condensation
heat is released.
Dependence of the state of matter on pressure
The state in which a quantity achieves its maximal
value under given conditions is called saturation. The
saturated vapour pressure (or boiling pressure) is the
pressure at which the vapour is in equilibrium with
the liquid or solid at a given temperature. At its boil-
ing point the saturated vapour pressure is equal to
the pressure above the liquid (Fig. 2). From this we
can deduce that the boiling point can be affected by
varying the pressure of gas above the liquid phase. At
high altitude, where the atmospheric pressure (which
equals to the pressure above the liquid) is lower, the
boiling point is lower. For instance, on the top of
Mount Everest water boils at as low as 70°C. On the
other hand, in a closed environment where the pres-
sure can be kept above the atmospheric pressure, the
boiling point is higher. In a pressure cooker for exam-
ple, where the pressure is 1 bar above the atmospheric
pressure, water boils at 120°C.
The liquefaction of gas is governed by both pres-
sure and temperature. Gas can be liquefied by increas-
ing the pressure, but only up to the point where the
critical temperature is reached. Above critical tem-
perature, no phase change occurs as the pressure is
further increased. The pressure at which gas liquefies
when the critical temperature is reached is called the
critical pressure. At temperatures higher than the
critical temperature the densities of the liquid and
gas phase become equal, the surface dividing the two

222
Melting
Pressure (bar)
Water
Ice
Boiling
1.01
0.30
0.006 T3 Vapour
Sublimation
0 0.01 70 100 374
Temperature (°C)
Figure 2.
Phase diagram for water, with the triple point, T3, at which all three
phases can coexist and the critical point, C, at which temperature and
pressure attain their critical value. Note that the pressure and temper-
ature scales are non-linear (used with permission of the publisher [4]).
phases disappears and so does the boiling point. The
gas in the state below the critical temperature is also
called a vapour.
At condensation, the pressure does not increase as
long as some of the gas phase is still present (Fig. 3,
points 2–5). If the volume is then further decreased,
the pressure rises abruptly (Fig. 3, points 5 and 6
and beyond point 6), since the compressibility of the
liquid phase is much lower than that of the gaseous
phase. In the opposite direction, decreasing the pres-
sure induces the transition from the liquid to
gaseous phase as the volume increases (Fig. 3,
beyond point 6 and between points 6 and 5). As long
as the liquid phase is still present, the pressure does
not decrease any further (Fig. 3, points 5, 4, 3 and 2).
Then, if the volume is further increased, the pressure
drops abruptly (Fig. 3, points 2 and 1 and beyond
point 1) due to the much greater compressibility of
the gaseous phase.
The critical temperature for oxygen is ⫺118°C,
for nitrogen ⫺147°C and for air ⫺141°C. All of these
substances are thus in the gaseous phase at room
temperature, regardless of pressure. Not all sub-
stances have such low critical temperatures: for car-
bon dioxide it is 31°C, and for nitrous oxide 36.4°C.
The corresponding critical pressures are 73.8 and
72.5 bar, respectively. This means that cylinders
containing either of these gases at higher pressure
(but below the critical temperature) contain a
mixture of liquid and gas.
Pressure in gases
Clinical application of the gas laws
The kinetic theory of gases describes a gas as a
collection of equal molecules moving randomly;
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Physics for anaesthesiologists 265
C
6
Pressure
5 4 3 2
1
Volume
Figure 3.
Phase diagram of pressure versus volume at a constant temperature
(isothermal compression or expansion of gas). Above point 1 and
between points 1 and 2, only the gaseous state is present. At point 2,
the liquid phase appears; between points 2 and 5, the liquid and
gaseous phases coexist, the liquid phase gradually replacing the
gaseous one. Beyond point 5, only the liquid phase is present.
the molecules collide elastically with each other as
well as the walls of the vessel. Collisions with the
vessel walls represent the pressure of gas, which is
linearly proportional to the temperature of the gas
and its density. The pressure is perpendicular to the
vessel wall.
The pressure, volume and temperature of an ideal
gas are interconnected with a relationship called the
universal equation of state: pV ⫽ nRT, where p is the
pressure of gas (units N m⫺2), V is the volume of gas
(m3), n is the number of moles of gas, R is the univer-
sal gas constant (8314 J K⫺1 kmol⫺1; modern usage
seems to favour 8.314 J K⫺1 mol⫺1) and T the absolute
temperature of gas (expressed in K).
The compression and expansion of a gas usually
occur adiabatically, i.e. without any exchange of heat
between a gas and its environment. Therefore, the gas
usually cools down at expansion and heats up when
compressed.
The universal equation of state embodies three
ideal gas laws, which pair-wise connect two thermo-
dynamic variables.
• Boyle’s Law: at a constant temperature the pressure
is inversely proportional to its volume: pV ⫽ k1.
• Gay-Lussac’s Law or Charles’s Law: at constant
pressure the volume of gas is proportional to its
absolute temperature: V ⫽ k2T.
• Amontons’s Law: at constant volume the pressure of
gas is proportional to its absolute temperature:
p ⫽ k3T.
 266 A. Manohin and M. Manohin
There are in fact four laws that describe the behaviour
of pressure, temperature and volume in relation to
one another: Charles’, Boyle’s, Amontons’ plus the
Universal Gas Law. Toward the end of the 1600s, the
French physicist Guillaume Amontons built a ther-
mometer based on the fact that the pressure of a gas
is directly proportional to its temperature. The rela-
tionship between the pressure and temperature of a
gas is therefore known as Amontons’ Law. Joseph
Louis Gay-Lussac (1778–1850) began his career in
1801 by very carefully showing the validity of Charles’
Law for a number of different gases. Gay-Lussac’s
most important contributions to the study of gases,
however, were experiments performed on the ratio of
the volumes of gases involved in a chemical reaction.
The law was first discovered by French physicist
Guillaume Amontons (1663–1705) in 1699 or 1702.
His experiments were repeated by Jacques Alexander
Cesare Charles (1746–1823) in 1787 who realized that
it applied to other gases besides air. Charles did not
publish it, but Gay-Lussac did in 1802 (called Charles’
Law or Gay-Lussac’s Law, but not Amonton’s Law (in
other publications Amonton’s (Gay-Lussac’s) Law)).
All three laws together yield a relationship between
the pressure, volume and absolute temperature of a
gas: pV ⫽ kT or p0V0/T0 ⫽ p1V1/T1. The constant k
can be calculated from the constants k1, k2 and k3.
From this latter relationship, we can calculate the
amount of oxygen available for the ventilation of the
lungs of a patient. Here, we use the index ‘0’ to denote
the values in the gas cylinder, and index ‘1’ to denote
the values in the reservoir bag. In this calculation we
will neglect the cooling of gas at adiabatic expansion
and postulate both temperatures are equal. Then, the
temperature can be removed from the equation:
p0V0 ⫽ p1V1. The pressure in the cylinder is equal to
p0; the value can be read on the pressure gauge. V0 is
the volume of the cylinder, specified on the cylinder
itself. p1 is the pressure of the oxygen at inhalation,
which is equal to 1 bar (the pressure on the outer side
of the flowmeter). The formula for V1 can thus be
rewritten as V1 ⫽ p0V0/p1. If, for instance, the pressure
gauge on the 3-L cylinder displays the value 80 bar,
then the amount of oxygen available for lung venti-
lation is equal to 80 ⫻ 3 ⫽ 240 L. Taking into account
the respiratory minute volume, and the percentage of
oxygen in the inspired mixture of anaesthetic gases,
we can calculate the time for which we can ventilate
the patient. This is particularly important during the
transport of patients.
It is important to understand that a simple calcu-
lation like this is only possible for oxygen, since
pressurized oxygen in the cylinder is still in gaseous
state. Nitrous oxide, on the other hand, is partially
liquified – only its vapour above the surface leaves
the cylinder. Therefore, the pressure in a cylinder of
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oxygen is proportional to the amount of oxygen in
the cylinder, while in a cylinder of nitrous oxide it
remains constant (51 bar at 20°C) provided that
emptying is relatively slow. In rapid emptying, cool-
ing will occur and the pressure will fall. The pressure
remains constant as long as there is still some liquid
nitrous oxide in the cylinder, and only starts to drop
afterwards. The amount of nitrous oxide in the cylin-
der is instead determined by weighing a partially
filled cylinder (the weight of an empty cylinder is
marked on the cylinder).
A cylinder of nitrous oxide must never be com-
pletely filled with liquid nitrous oxide. Instead, some
space has to be left for the vapour. The saturated
vapour pressure increases with temperature and at
higher temperatures the pressure of vapour within
the cylinder could rise enormously and cause an
explosion. Usually, at room temperature, the cylinder
is filled to 90%, and 10% of the cylinder volume is
left for the vapour. The ratio of the masses of nitrous
oxide and water if the cylinder were to be completely
filled with water is also important. It is called the
filling ratio and its usual value is 0.67 for tropical
countries and 0.75 for the UK.
A standard mixture of 50% oxygen and 50%
nitrous oxide is known as Entonox® (BOC Gases,
Guildford, Surrey, UK). The pressure in an Entonox®
cylinder is 137 bar. The nitrous oxide is not liquified,
since both gases dissolve in one another at high
pressure. This means that oxygen lowers the critical
temperature of nitrous oxide and this is known as
the Poynting effect (John Henry Poynting, a British
physicist, 1852–1914). The critical temperature for
Entonox® mixture is ⫺7°C. If a cylinder is cooled
below this temperature the two gases separate. In
such conditions, a mixture rich in oxygen exits the
cylinder first being followed later with a hypoxic
mixture rich in nitrous oxide. If a cylinder has been
cooled it needs to be put into a horizontal position
and left to rewarm at 5°C or above for at least 24 hours
before use. During that period, the cylinder should
be occasionally turned around its longitudinal axis
(rolled) to promote remixing of the contents.
• Dalton’s Law: The total pressure of a gas mixture
is equal to the sum of the partial pressures of all of
the gases in the mixture. The partial pressure of a gas
is proportional to the concentration of that gas in the
mixture. The partial pressure is equal to the pressure
of this gas in the absence of other gases in the vessel.
As an example: in a cylinder containing pressurized
air at 100 bar, the partial pressure of nitrogen is
79 bar, since 79% of air represents nitrogen.
Dalton’s Law actually applies only to ideal gases.
• Henry’s Law: The concentration of a dissolved gas
in a liquid solvent is proportional to the partial
 Physics for anaesthesiologists 267

pressure of this gas in the gaseous phase above Spring

the surface of solution. This is only valid if the sol-
vent (liquid) and the solute (gas) do not interact
chemically.
• Avogadro’s Law: Equal volumes of gases under the
same temperature and pressure contain the same
number of molecules (Avogadro’s Number).

The volume of one mole of gas at standard temperature Disc

and pressure occupies 22.4 L. Standard temperature
and pressure (STP) is defined as 0°C, 101.325 kPa.
One mole is the molecular weight of that substance in
grams. For example, the molecular weight of nitrous
oxide is 44, so 44 g of nitrous oxide amounts to 1 mole,
which expands to 22.4 L at STP. One gram of nitrous
oxide expands to 22.4 L/44 ⫽ 0.5091 L (509.1 mL).
If this value is multiplied by the amount of liquid
nitrous oxide (in grams) in the cylinder, we can thus
calculate the amount of gaseous nitrous oxide that
exits the cylinder at STP.
We might wish to perform a similar calculation
for a highly volatile liquid anaesthetic kept in a bot-
tle where its volume is known. Here its mass in
grams that enters the formula above can be calcu-
lated if we know the volume V of the anaesthetic in
millilitres and its density ␳ (the conversion factor
between its mass and its volume): m ⫽ ␳V. The fol-
lowing is the calculation for halothane. The mass
of one mole of liquified halothane is 197 g, and its
density is 1.85 g cm⫺3. So, 1 mL (1 cm3) of liquified
halothane expands to (22.4 L/197) ⫻ 1.85 ⫽ 0.210 L
of halothane vapour at STP.
‘Pop-off’, expiratory and pressure-reducing valves
A ‘pop-off’ valve enables the release of gas from a sys-
tem when the pressure within it rises beyond a cer-
tain limit. In many anaesthetic breathing systems
(e.g. the Magill attachment) it is based on the
Heidbrink valve (Fig. 4). When the force due to the
gas pressure equilibrates with the opposing force of
the spring (regulated by the anaesthetist), the valve
opens and gas is released from the system. At that
point the force is equal to the pressure of gas multi-
plied by the area of the plate connected to the spring.
Depending on the type, the pressure needed for open-
ing the valve is either 0.2–0.3, 7 or 35 kPa. The force
needed for opening the valve can be regulated by set-
ting the tension of the spring.
The pressure-reducing valve has two principal
functions: to reduce the pressure in the gas cylinder
to the operating pressure and to minimize fluctua-
tions in gas pressure. The latter would otherwise
require frequent adjustment of the flowmeter. When
the gas is obtained from the central supply further
reduction of the gas pressure is usually necessary, as
Pressure
Figure 4.
Heidbrink valve. The gas enters, pushing the plate up and exits
through the release outlets (used with permission of the publisher [5]).
Spring
Membrane
P inlet Valve P outlet
Figure 5.
Schematics of a pressure-reducing valve. The gas enters and applies
pressure on the membrane compressing the spring in the direction of the
arrows. Also connected to the membrane is a valve, which closes the gas
inlet as the force on the membrane increases, thus reducing the inflow
of gas. When the spring is relaxed, the ratio between the reduced and
non-reduced pressure is approximately equal to the ratio in the areas
of the inlet valve and the membrane. If additional force is applied to
the spring, it opposes the closing of the valve. Without the spring, the
reduced pressure would decrease along with the decreasing non-
reduced pressure in the gas cylinder. The spring reduces this unwanted
effect but does not eliminate it entirely (used with permission of the
publisher [5]).
the gas is supplied at the operating pressure (e.g. 5
bar in Slovenia, 4 bar in the UK, 3–4 bar throughout
the rest of the world). When high-pressure cylinders
are used (this includes the auxiliary cylinders pro-
vided with the anaesthesia machine) reduction of the
gas pressure is required. The simplest mechanism of
the operation of a pressure-reducing valve is shown
in Figure 5.
If the valve on the oxygen cylinder is opened too
quickly, the gas flowing from the cylinder com-
presses at the point of entering the valve and can

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 268 A. Manohin and M. Manohin
Safety valve
Corrugated
Spring
hose
Diaphragm
2nd stage pressure 1st stage
reduction Filter reduction
Non-interchangeable
cylinder valve
and yoke
Sensing 2nd stage 1st stage
diaphragm valve valve Gas
cylinder
Figure 6.
Entonox® two-stage pressure demand regulator (used with permis-
sion of the publisher [5]).
adiabatically heat up to approaching 800°C [2]. The
danger of overheating is reduced by building a nar-
row nozzle followed by a chamber, where the gas
expands and cools down. If the gas cools down to
below 0°C any water vapour can freeze if the relative
humidity is high enough. The danger of freezing is
reduced by using a series of pressure-reducing noz-
zles, so the pressure is reduced step-wise and by
gradually increasing the nozzle size towards the exit,
thus preventing any ice crystals from blocking the
outlet. It is nevertheless recommended that the gas
humidity should be kept as low as possible.
A pressure-controlled valve reduces the inflow pres-
sure to the outflow limb of the valve in two stages.
The first stage operates as a standard pressure-reducing
valve. In the second stage a decreased pressure in the
outflow limb opens the valve and enables gas to flow
from the high pressure source. A two-level control of
the gas pressure is used in the Entonox® apparatus
(Fig. 6).
Hydrostatics
Hydrostatic pressure
Hydrostatic pressure ph is the pressure in a stationary
fluid. It depends on the depth, the density of fluid
and the acceleration due to gravity. However, it does
not depend on the orientation of the surface: it is
equal at every point at the same depth. It also does
not depend on the shape of the vessel: ph ⫽ ␳gh,
where ␳ is the density of the fluid expressed in
kg m⫺3; g is the acceleration due to gravity expressed
in m s⫺2; and h is the depth. The latter is measured
vertically from the surface and is expressed in
metres. The equation is always valid in liquids but
only holds true for gases when the density does not
depend on the depth (height). It is thus a useful
approximation for small height differences.
© 2003 European Academy of Anaesthesiology, European Journal of Anaesthesiology 20: 259–281
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If the atmospheric pressure above the liquid sur-
face is also considered, we have to add this to the
hydrostatic pressure: p ⫽ ph ⫹ pa.
Hydrostatic pressure in blood vessels depends on
the patient’s body position. It affects the distribution
of the intravascular volume (orthostatic hypotension).
We also have to take it into account during direct
measurement of arterial pressure (correct setting of
manometer to the tip of the measuring tube) or
when measuring central venous pressure (correct
setting of the null point of the measuring system).
Relationship between pressure and tension
in the vascular wall
In the vascular system, pressure depends on the vol-
ume of the total vascular system as well as on the
elasticity of the vascular walls. The cross-sectional
area of a blood vessel depends on the transmural
pressure (the difference between the pressure inside a
blood vessel and the pressure outside): pt ⫽ pn – pz,
where pt is the pressure difference, pn is the vascular
pressure and pz is the extravascular pressure (intra-
pleural space, abdominal cavity or other tissue). When
the external pressure is equal to atmospheric it can
be neglected; in that case the ‘pressure difference’ is
equal to the vascular pressure: pt ⫽ pn.
In a spherical or cylindrical vessel, the relationship
between the pressure of fluid inside the vessel and the
tension in the vessel wall (the pressure exerted on the
vessel wall) is expressed by Laplace’s Law. This states
that at equilibrium (no change in pressure), the dis-
tending pressure (pt, transmural pressure, or pressure
across the wall) equals the developed wall tension (t),
i.e. force per unit longitudinal cross-sectional area of
the wall divided by the two principal radii of curva-
ture (r1 and r2).
pt ⫽ t(1/r1 ⫹ 1/r2) ⫽ t/r1 ⫹ t/r2.
In a sphere (the heart), r1 ⫽ r2, so pt ⫽ 2t/r or
t ⫽ rpt/2.
In a vessel, one radius is infinite, so pt ⫽ t/r or
t ⫽ rpt.
Since wall thickness is another factor that influ-
ences the load on an individual muscle fibre, the
Laplace relation – when applied to sheets of muscle –
is frequently expressed in terms of stress s (rather
than tension t) by also including the wall thickness d:
• For a cylindrical pipe (blood vessel): sc ⫽ (r/d )pt,
where sc is the wall stress, r is the vessel radius, d
is its thickness and pt is the pressure difference
across the wall.
• For a spherical shell (heart): sk ⫽ (r/2d )pt, where
sk is the wall stress, r is the radius of the spherical
shell, d is its thickness and pt is the pressure dif-
ference across the wall.
 Physics for anaesthesiologists 269

From the given expressions it follows that the tension

in the vessel (cardiac) wall is directly proportional to
the pressure difference and the vessel (cardiac cavity)
radius, and inversely proportional to the thickness of
the vessel (cardiac) wall.
h
Pressure–volume ratio
As the pressure difference (pt) increases, so does the
volume of blood in the vascular system. The increase
in volume is largest at low pressure and decreases Figure 7.
with increasing pressure. The ratio between the pres- Bernoulli principle. h ⫽ Height of the column is proportional to the
sure and the volume depends on the vessel cross- pressure difference (used with permission of the publisher [5]).
section. The stronger the vessel is squeezed (muscles
in the vascular wall are activated) the greater the pres-
sure difference needed for a blood volume increase.
Conversely, the more the vessel is expanded (muscles
in the vascular wall are relaxed), the smaller is the
Flow
pressure difference needed for an increase of the blood
volume within the vessel.
The ratio between the change in the vessel volume
⌬V and the change in the pressure difference ⌬pt
is called vascular compliance and denoted by C: Suction
C ⫽ ⌬V/⌬pt. It is expressed in mL kPa⫺1. Its recip-
rocal value is vascular elastance: E ⫽ 1/C ⫽ ⌬pt/⌬V.
It is measured in kPa mL⫺1. Figure 8.
For a series of vessels, the compliances are addi- Venturi tube (used with permission of the publisher [5]).
tive. Thus, the total vascular compliance for an adult
is 1500 mL kPa⫺1 (200 mL mmHg⫺1). From this the
compliance of vessels in the thorax is 750 mL kPa⫺1
(100 mL mmHg⫺1), and the compliance of vessels Hydrodynamics
outside the thorax is also 750 mL kPa⫺1 (100 mL The two parameters important for the movement of
mmHg⫺1). The compliance of larger arteries (aorta) fluids in pipes, e.g. gas in the airways or blood in the
is low, only 7.5 mL kPa⫺1 (1 mL mmHg⫺1). Some- blood vessels, are the pressure difference between the
times the term ‘effective compliance of the vascular ends of the pipe and the resistance against the flow.
system’ is used for the compliance of the total vascu-
lar system, which emphasizes that vascular compli-
ance depends not only on the vascular wall but also Movement of gas
on the exchange of liquid between the capillaries and The injector system is often named after Venturi,
the surrounding tissue (Starling equilibrium). although its operation is actually based on the princi-
Apart from compliance, compressibility (␭) of ple discovered by Bernoulli in 1738, which is approx-
a blood vessel is also an important parameter: ␭ ⫽ imately 60 years before Venturi. Figure 7 illustrates
⌬V/(V⌬pt), i.e. fractional change of volume per the Bernoulli principle.
unit change of pressure. It is expressed in kPa⫺1. Its If a liquid flows along a pipe of varying diameter,
reciprocal value is volume elasticity modulus (K): its velocity increases as it passes through a constric-
K ⫽ (⌬p/⌬V)V, expressed in kPa. tion with a smaller cross-section and returns to the
Taking blood density into account, pulse wave previous value when the diameter returns to the
velocity (c) can be calculated from the volume previous value. The Bernoulli principle states that
elasticity modulus: K/␳ , where K is the volume the pressure reduces through the constriction – where
elasticity modulus and ␳ is the blood density. It is the velocity of fluid is high – and is higher where the
measured in m s⫺1. diameter is greater and the velocity is low. The pres-
Pulse wave velocity connects the vascular elastic- sure difference can be calculated as ⌬p ⫽ ␳g⌬h.
ity with the haemodynamics. It governs the propa- The shape of the pipe after the constriction is
gation of the pressure wave and the formation of a important. If it has a conical shape (Fig. 8) there is a
pressure curve (it causes an increase in the blood large pressure drop on the output side (the pressure
pressure amplitude in the peripheral arteries). can drop even below atmospheric pressure), which can

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 270 A. Manohin and M. Manohin
Figure 9.
Schematic illustration of the Coanda effect (used with permission of
the publisher [5]).
be used to generate a suction force from the lower
narrow pipe.
The injector principle can be used for oxygen
therapy to increase the concentration of inspired
oxygen. Using a Venturi oxygen mask with an oxy-
gen inflow of more than 4 L min⫺1 in a considerable
amount of air is entrained. The total flow of air and
oxygen exceeds the patient’s maximal inspiratory
flow and thus ensures a relatively stable concentra-
tion of oxygen. The injector principle can also be
used for humidification. With a suitably placed
water reservoir and sufficient gas velocity a fine
spray can be formed. A portable suction apparatus
can also be driven by a Venturi injector and the
principle can also be used to drive a ventilator.
Coanda effect
In the 1930s the Romanian aerodynamicist Henri-
Marie Coanda (1885–1972) observed that a stream
of air (or other fluid) emerging from a nozzle tends
to follow a nearby curved or flat surface if the curva-
ture of the surface or angle the surface makes with
the stream is not too sharp (Fig. 9). The principle is
used by fluid logic ventilators, where a minor increase
in pressure before the constriction can toggle the
flow of gas from one side to another.
Movement of blood
Resistance in blood vessels arises from both the
intrinsic friction between the molecules and the fric-
tion against the vessel walls.
Flow of a liquid through a pipe obeys Ohm’s Law:
I ⫽ V/R, where I is current, V is voltage and R is
resistance. Resistance can be expressed here as R ⫽
V/I. When a flow of liquid is considered, voltage is
replaced with the pressure difference ⌬p between the
ends of the pipe and current is replaced by flow rate
⌽, i.e. the amount of blood which flows through a
pipe per unit time. Resistance is then R ⫽ ⌬p/⌽.
Pressure difference is expressed in kPa, volume flow
in L s⫺1 or mL s⫺1, and resistance in N s m⫺5.
The total resistance of a group of blood vessels (R)
depends on how the vessels are connected. If they are
connected in series, the total resistance equals the
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Flow Flow
Figure 10.
Laminar (left) and turbulent (right) flows.
sum of the individual resistances: R ⫽ R1 ⫹ R2 ⫹
… ⫹ Rn. If, however, they are connected in parallel,
the reciprocal value of resistance is equal to the sum
of the individual reciprocal values:
R⫺1 ⫽ R1⫺1 ⫹ R⫺1 2 ⫹
… ⫹ R⫺1 n .
In both cases, R1 to Rn stand for any given number of
particular resistances.
Resistance to the laminar flow of a viscous liquid
through a pipe with a circular cross-section is given
by the Hagen-Poiseuille Law:
␲ r ⌬p
⌽⫽
8l ␩
where ⌽ is the flow rate, r is the pipe (or blood ves-
sel) radius, l is its length, ␩ is viscosity and ⌬p is the
pressure difference between the ends of the pipe.
Viscosity denotes the opposition of a liquid to flow,
and its units are kg m⫺1 s⫺1 (or Pa s). If the flow rate
⌽ is substituted by the ratio ⌬p/R – from the modi-
fied Ohm’s Law and the equation is rearranged – the
resistance, R, can be determined: R ⫽ (8/␲)␩(l/r4).
It is expressed in N s m⫺5.
The resistance is therefore linearly proportional to
the viscosity and the length of the pipe and recipro-
cally proportional to the fourth power of the pipe
radius. This equation is valid for laminar flow, where
thin layers of liquid slide past one another. The layer
adjacent to the wall is stationary, and the velocity
increases towards the centre of the pipe, reaching its
maximum in the middle. However, the equation does
not hold for turbulent flow where the liquid under-
goes irregular fluctuations and mixing (Fig. 10).
At laminar flow, the drag of the medium is lin-
early proportional to the velocity of a body moving
in the liquid. We call this linear or Stokes’ Law of
drag. At turbulent flows, drag increases as the sec-
ond power of velocity. The boundary between the
two modes depends on many parameters. A useful
criterion is the Reynolds’ Number (Re), named after
English engineer and physicist Osborne Reynolds.
Re is proportional to the velocity of a fluid v, its den-
sity ␳ and the diameter of the pipe, 2r, and inversely
proportional to the viscosity of the fluid ␩: Re ⫽
v␳2r/␩. It has been shown that the flow is laminar
for Re ⬍ 1, turbulent for Re ⬎ 2000, but it can be
either laminar or turbulent in the intermediate range.

In the vascular system, the flow of blood is usually
laminar. Turbulence can however arise if the velocity
overly increases, e.g. if the cross-section narrows.
The viscosity of homogeneous fluids (e.g. water,
electrolyte solution or blood plasma) depends only on
the temperature of the fluid (in liquids, viscosity
decreases as temperature increases, while in gases it
increases with temperature). However, the viscosity
of non-homogeneous fluids (e.g. blood, including
blood cells) depends also on the haematocrit and
the velocity of the flow (the higher the haematocrit or
the lower the velocity, the higher the viscosity, and
vice versa – the lower the haematocrit or the higher
the velocity, the lower the viscosity). Viscosity also
increases in stored blood because of coagulation dur-
ing storage. With a healthy heart and a normal blood
volume, the body can adjust to the changes in viscos-
ity and consequently the resistance, so that the blood
pressure can remain approximately constant even
though the haematocrit fluctuates between 0.2 and
0.5. However, at diminished blood volume or with a
weakened heart regulation cannot be maintained.
Flow through an orifice
The flow of fluid through an orifice is proportional to
the square root of the pressure difference between the
two sides, to the square of the orifice diameter and to
the density of the fluid – as the flow through an orifice
is always at least partially turbulent. Practically this
means that every change in the diameter of the airway
(e.g. the change in the diameter of an endotracheal
tube) can create turbulent flow and thus increase the
resistance. We try to prevent this by using short, wide
tubes with smooth internal walls and without any
constrictions. Another possibility (unusual in anaes-
thesia) is substituting oxygen with an oxygen–helium
mixture, as the density of helium (0.16 kg m⫺3) is sig-
nificantly less than the density of oxygen (1.3 kg m⫺3).
Pressure–flow ratio
By changing the pressure difference (⌬p), blood flow
in the vascular system also changes. The ratio
between pressure and flow in particular organs is not
linear (as it is in the case of rigid tubes). This is
because blood vessels can change their radius both
passively (due to pressure difference) and actively
(due to muscular activity), which affects their resist-
ance against the flow and the flow itself. The vessels
whose walls contain a great amount of innervated
muscle fibres change their radius actively while
those whose walls do not, change it passively.
Time constant
The time constant is a parameter of an exponential
function. An exponential function describes a process
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Physics for anaesthesiologists 271
τ
0 1 2 3 4
500 100
Volume (mL)
Volume (%)
V⬁
0
0 0.5 1 1.5 2
0
Time (s)
Figure 11.
Increase of gas volume in the lungs during inspiration when inflated
by the application of a constant pressure.
at which a change of some quantity (y) in time (t) is
linearly related to this quantity itself: dy/dt ⫽ ky,
where k is a constant. This means that the larger
the quantity y, the larger the rate of change of a
quantity dy.
For our purpose, two examples of exponential
functions are of particular importance:
• When the initial value of the observed quantity is
zero (y ⫽ 0) and the quantity increases over time t
(e.g. the increase of volume in the lungs during
inspiration when inflated by the application of
a constant pressure).
• When the quantity y is maximal at the beginning
and decreases during time t (e.g. the excretion of
anaesthetic from an organ).
In both cases, the quantity y would attain its final
value only in the infinite time (t → ⬁). As an example,
the increase of the volume of gas in the lungs during
inspiration is shown in Figure 11. On the abscissa,
time t is shown in seconds (s). On the ordinate, the
volume V is shown, both in mL on the left-hand side,
and as percentage of change on the right-hand side.
As the volume increases, the rate of volume change
decreases. The total inhaled volume approaches
100% (500 mL), but does not attain it, because it is
hindered by the resistance of the airways and the
compliance of the lungs and the thorax. If a tangent
is drawn through the initial value of y, it crosses the
100% line (drawn parallel to the abscissa) at some
point in time (marked as ‘1’). The distance on the
abscissa between the initial value and this point is
called the time constant. It is denoted with the Greek
letter ␶. This is the time that would be required for
attaining 100% if respiration were hindered only by
the resistance of the airways instead of also being hin-
dered by the compliance of the lungs and the thorax
and the already inspired volume of gas. We can mark
the abscissa at 2␶, 3␶ and 4␶ values (marks 2–4 on the
graph), and thus show the percentage of total volume
 272 A. Manohin and M. Manohin

pb

Figure 12.
Liquid manometer. p ⫽ Pressure; pb ⫽ barometric pressure;
h ⫽ height of the column is proportional to the pressure (used with
permission of the publisher [5]).

Pressure

achieved at 2␶, 3␶ and 4␶. This depends on the Figure 13.

properties of the lungs. Aneroid barometer. The pressure acts on the measuring chamber and
deforms the flexible membrane; its deformation is mechanically con-
nected to the indicator (used with permission of the publisher [5]).
Measurements of pressure in fluids
Measurement of gas pressure
The simplest method for measuring gas pressure is
with a manometer (Fig. 12). For measuring minor
pressure differences manometers filled with water are
used, while for measuring major pressure differences,
manometers filled with mercury are used (the density
of mercury is 13.6 times greater than that of water).
A liquid manometer is a ‘U’-shaped tube, open on
both sides, and filled with either water or mercury.
On one side the pressure exerted is the atmospheric
pressure pa while on the other side there is the meas-
ured pressure p. If the measured pressure is greater
than atmospheric pressure the liquid in the column
open to atmospheric pressure rises (p ⫽ ␳gh ⫹ pa).
However, if the measured pressure p is smaller
than atmospheric pressure then the liquid level rises
in the column that is connected to the measured Pressure
pressure:
Figure 14.
p ⫹ ␳gh ⫽ pa, or p ⫽ pa – ␳gh. Bourdon tube. The pressure within the tube deforms the curved tube
made from a flexible material (metal). The deformation is mechan-
In both cases, the measure for the pressure is the ically connected to the indicator (used with permission of the
density ␳ of the liquid (1 g cm⫺3 for water or publisher [5]).
13.6 g cm⫺3 for mercury) multiplied by the acceler-
ation of gravity g and the difference h in the height
of liquid in one and the other column. The quantity membrane deforms and vice versa. They can be used
␳gh is thus a measure of the gas pressure. for measuring pressures from 100 bar to 10 mbar.
Another form of liquid manometer is the mem- When the use of liquid manometers is not feasible
brane manometer where the measuring chamber is in clinical practice, pressure can be measured with
closed with a flexible membrane made from either sensitive electronic transducers or with barometers,
rubber or metal. It is thus suitable for measuring pres- e.g. aneroid barometers (Fig. 13) or a Bourdon gauge
sure in liquids. The higher the pressure the more the (Fig. 14).

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Pressures significantly smaller than atmospheric
pressure can be measured using a vacuum gauge.
The most commonly used ones are the McLeod
gauge, the Pirani gauge and the Penning gauge.
The McLeod gauge is essentially a closed U-tube
manometer, which uses Boyle’s law (pV ⫽ constant)
to determine gas pressure. By raising the mercury
level, a certain amount of gas is sealed off from the
system to which the gauge is connected and trapped
in the closed side of the manometer. When the mer-
cury level is raised further the trapped gas is isother-
mally compressed. The difference in mercury levels
on both sides of the U-tube corresponds directly to
the difference in pressure.
The Pirani gauge employs the dependence of ther-
mal conductivity of a gas on its pressure. The resist-
ance of two equal heated filaments is measured
differentially. When the pressure of the gas con-
nected to the vacuum system drops, the temperature
of one filament increases due to its lower thermal
conductivity and consequently its electrical resist-
ance is changed.
The Penning gauge makes use of the fact that the
rate of ion production by a stream of electrons in a
vacuum system is dependent on the pressure and the
ionization probability of the residual gas.
Pressures – significantly larger than atmospheric
pressure – can be measured using a specially adapted
membrane manometer. The piezoelectric manome-
ter exploits the voltage that arises between the sides
of some crystals (e.g. quartz) when deformed, or a
manometer exploiting the pressure dependence of
any other material property, e.g. the electric conduc-
tivity of manganese alloys.
Measurement of pressure in the circulation
The central venous pressure is measured with a
manometer filled with water connected to a patient
lying horizontally. The zero point must be set to the
height of the right atrium.
Arterial pressure is commonly measured using
a sphygmomanometer. A cuff on the upper arm is
inflated until the flow in the brachial artery is
occluded. The pressure is then measured using a mer-
cury manometer or other suitable pressure gauge.
The flow in arteries can be determined by feeling the
radial artery, with auscultation of the brachial artery
or ultrasound flow measurement in the radial artery
(especially in paediatrics), with a pulse oximeter on
the finger or with a special double cuff as in the oscil-
lotonometer. The cuff must be of an appropriate size;
too wide or too narrow can lead to a measurement
error. An alternative method is directly using an elec-
tronic pressure transducer connected to a cannula in
the artery via a tube filled with liquid.
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Physics for anaesthesiologists 273
Measurement of gas volume
For the measurement of small volumes of gas, spirom-
eters are used. These can be divided into the dry type
(e.g. Vitalograph® (Vitalograph Ltd Company UK,
Maids Moreton, Buckingham, UK), which is conven-
ient for simple lung function tests) and those using a
water bath (e.g. Benedict–Roth spirometer). For the
measurement of larger volumes of gas, dry types are
used exclusively (e.g. the domestic gas meter is sur-
prisingly accurate and reliable if maintained [3]). A
‘wet gas meter’ (consisting of helical channels, half
immersed in water, which are rotated by the flowing
gas) may also be used for measuring larger volumes. In
anaesthesiology, the Wright respirometer (or anemo-
meter) is also used for measuring gas volume.
Measurement of flow
Flowmeters
There are two designs of flowmeters in use: flow-
meters with a fixed orifice (with a variable pressure
drop across it) and those with a variable orifice (but
a constant pressure drop across it).
Flowmeters with a fixed orifice at the gas inlet
function by measuring the pressure drop across a
narrow orifice for which the pressure in the fluids
does not fluctuate much. Therefore, the measured
pressure drop can be used as a direct measure of flow.
An example of a flowmeter with a variable orifice is
the Rotameter® (Omega Engineering Inc, Stamford,
CT, USA) or Platon Gapmeter® (ABB, Gloucester-
shire, UK). This is a transparent glass or plastic tube,
usually placed vertically, which is conically widened
towards the top (Fig. 15). This conical shape can be
either uniform or with two successive cones with dif-
ferent tapers. The latter is used for precise measure-
ment of smaller flows as well as larger flows.
Gas enters the meter at the bottom and flows
upwards, pushing the float up as it flows past it and
finally leaving the tube from the top. The higher the
float is pushed, the wider is the space between it and
the tube walls, and vice versa. If the flow rate is low,
the flow is laminar like the flow in a narrow tube.
At higher flow rates the flow approximates to that
through an orifice and is thus turbulent. This means
that at lower flow rates the viscosity of a gas is impor-
tant, while at higher flow rates the density of gas
predominates. Therefore, a flowmeter has to be cali-
brated for one particular gas.
The rotation of the float diminishes the measure-
ment error due to friction between the float and the
measuring tube while at the same time demonstrates
the presence of gas in the tube. To diminish the elec-
trostatic charge and potential for the float to stick to
the tube walls, most measuring tubes used in modern
 274 A. Manohin and M. Manohin
Figure 15.
Conical glass tube flowmeter. On the left-hand side is a flowmeter
with a spherical float; the right-hand side has a cylindrical float.
Flowmeters with cylindrical floats are often referred to generically
by their industrial name, Rotameter®. Most modern flowmeters use
cylindrical floats.
flow meters are anodized with a thin layer of tin.
When the force of gas jet acting on the float equals
the gravitational pull, the float is in equilibrium and
does not move along the tube. However, it does not
cease to rotate or vibrate. The flow rate is read from
the top of float for a cylindrical float and at the mid-
dle of the sphere for a spherical float.
Flowmeters are usually calibrated for use at a tem-
perature of 20°C and a pressure of 1 bar. Using them at
significantly lower or significantly higher temperature
or at increased pressure (e.g. in a hyperbaric chamber)
can therefore lead to errors. The described principles
also serve as the basis for the Wright peak flow meter.
Measuring gas flow with a pneumotachograph
The pneumotachograph is a device that indirectly
determines flow by measuring the pressure difference
across both sides of a lamellar resistance (Fig. 16).
Measurement of liquid flow (including blood)
In the limb plethysmograph, arterial volume flow is
determined by the volume increase in a limb when
the venous outflow is occluded. The change in vol-
ume can be measured either by monitoring the water
level (volume displaced) with the limb submerged in
a chamber filled with water, or by measuring changes
in the limb’s circumference (strain gauge method).
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p1 p2
Flow
Heating coil
Figure 16.
In the Fleisch pneumotachograph, an array of smaller tubes are
placed lengthwise within the measuring tube. These tubes of small
diameter ensure laminar flow. The flow is determined by the measured
difference pressures, p1 and p2, using a differential pressure trans-
ducer. To diminish the levels of condensation, which is the primary
problem with this method, a heater is built in. The temperature has
to be kept as constant as possible to avoid the measuring error owing
to changed viscosity.
According to the Fick principle, the amount of a
certain substance or indicator that enters or leaves an
organ in a certain unit of time is linearly dependent
on the blood volume flow through this organ, mul-
tiplied by the arteriovenous difference in concentra-
tion of the given substance or indicator. This can be
used as an indirect method for measuring cardiac
output:
V
O2
Q
t ⫽ .
CaO2 ⫺ C␯O2
.
The cardiac minute volume. (Qt) can be calculated
from the oxygen uptake (VO2) measured with a
spirometer and the oxygen concentration measured
simultaneously in the arterial (CaO2) and mixed
venous blood (C␯– O2).
An electromagnetic flowmeter requires a blood
vessel to be placed with its long axis across the field
between the poles of a magnet. The passage of blood,
which is a solution of electrolytes (and thus a con-
ductor), induces a voltage perpendicular both to the
lines of force and to the blood flow and can be picked
by electrodes appropriately arranged outside the ves-
sel (Fig. 17). Flow can also be measured using an
ultrasonic flowmeter with the indicator-dilution
technique or via indicator temperature change.
Heat and temperature
The heat capacity of a body is the amount of heat
needed to increase the temperature of the body
through 1 K. For a homogeneous body, it is equal

Induced
electric
field
Magnetic
N field S liquid decreases and the temperature drops).
ow
Fl
Figure 17.
Electromagnetic flowmeter. The arrows indicate the direction of
blood flow, the direction of the magnetic field (lines of force) and the
direction of the induced electric field. Their direction can be deter-
mined by the Ampere–Maxwell law (right-hand law): if you try to
grab the current-carrying conductor with your hand, as shown with
the thumb pointing at the direction of the current, the other fingers
show the magnetic field direction.
to the mass of the body multiplied by its specific
heat (the specific heat is the amount of heat, needed
to increase the temperature of 1 kg of the substance
by 1K).
Measurement of temperature
In clinical practice, temperature is measured using a
mercury thermometer, a thermistor or a thermocouple.
• Thermistor: semiconductor device with a negative
temperature coefficient. Its resistance decreases
with increasing temperature. Resistance is meas-
ured with an electronic circuit and shown on an
indicator where the scale is already converted to
temperature.
• Thermocouple: operates on the principle of the
Seebeck effect. A small thermoelectric voltage arises
between two junctions of different conductors,
kept at different temperatures which is propor-
tional to the difference in temperatures. The cir-
cuit consists of two junctions of different metals.
When one junction is warmer than the other, the
resulting thermoelectric voltage can be measured
and displayed on a precalibrated scale.
Heat transport
Heat is carried spontaneously from a body with a
higher temperature to a body with a lower tempera-
ture. The process continues for as long as the two
temperatures are different. Heat can be carried in
one of four ways:
• Conduction (transfer between two bodies in direct
contact).
• Convection (heat transported by a fluid flow).
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Physics for anaesthesiologists 275
• Radiation (electromagnetic waves through a vac-
uum or a transparent substance).
• Evaporation (when a molecule with a higher kinetic
energy leaves the bulk of a liquid and evaporates,
the average kinetic energy of the molecules in the
Accidental hypothermia should be prevented in
anaesthetic practice. Since the specific heat capacity
of gases is up to 1000 times smaller than the specific
heat capacity of liquids, humidification of gases is
much more important than heating dry gases. At the
same time, humidification decreases an otherwise
major energy loss due to evaporation from the air-
way. Human skin can also serve as a heat source. With
sensitive patients, radiation of heat through the skin
can be prevented by enveloping the patient in a thin
aluminium foil (‘space blanket’).
Vaporizers
A vaporizer is a piece of equipment containing a liqui-
fied highly volatile anaesthetic through which gases
are passed. By adjusting a regulating knob, anaes-
thetic vapour is added to this carrier gas. As already
noted, the boiling point of a liquid is the temperature
at which the saturated vapour pressure of this liquid
equals the pressure above the liquid. At atmospheric
pressure, the boiling point for diethyl ether is 34.6°C,
for halothane 50.2°C, for enflurane 56.5°C, for iso-
flurane 49°C, for sevoflurane 58.5°C, for desflurane
22.8°C and for water 100°C. The construction of a
vaporizer must take the boiling point of the particular
liquified highly volatile anaesthetic into account.
Vaporizers can be classified according to their
location, the principle of operation and the method
of regulating the delivered concentration. According
to their location, vaporizers can be positioned either
within the breathing circuit or outside the breathing
circuit. In the first type (‘vaporizer inside circle’ (VIC)),
the gaseous (carrier) mixture is drawn through the
vaporizer by the patient’s inspiration or expiration
(depending on whether the vaporizer is in the inspi-
ratory or expiratory limb of the breathing hose). Its
efficiency needs only to be low. If too much vapour is
inhaled, breathing is depressed or stops so providing
some kind of safety system via this autoregulation.
However, the VIC mode can be extremely dangerous
if the patient’s lungs are ventilated by hand, or auto-
matically by a ventilator, as very high concentrations
of anaesthetic are quickly reached. The resistance of
a VIC vaporizer must be as low as possible so that it
does not pose extra difficulty for breathing. Its removal
and reinsertion must be simple, as well as its cleaning
and disinfection. In the second type, the vaporizer is
placed directly in the path of the incoming fresh gas
 276 A. Manohin and M. Manohin
flow (vaporizer outside circle (VOC)) – before these
gases are admitted to any kind of circle breathing sys-
tem. This is a plenum arrangement, i.e. it is necessary
for the incoming gases to be passed under pressure
(from a pipeline or cylinder supply) through the vapor-
izer (of high internal resistance) to achieve vaporiza-
tion of the liquid anaesthetic agent.
According to their principle of operation, vaporiz-
ers can operate in one of two ways. Varying the pres-
sure, which in turn regulates the amount of vapour
added to the fresh gas input, or varying the flow by
dividing the fresh gases into the port of entrance to
the vaporizer and the port which bypasses it.
Vaporizers can operate in various ways:
• First, as a carburettor where the liquified volatile
anaesthetic is injected into the mixture of anaes-
thetic gas and evaporates instantaneously.
• Second, on the basis of flow bypass (variable-flow
vaporizer) where part of the fresh gas is directed
through the vaporizer and is thus enriched by
vapour. This latter process can either be accom-
plished by the gas flowing above the liquid (where
the concentration regulator is placed either before
the vaporizer or after it), or by the gas actually
flowing (bubbling) through the liquid – where the
amount of fresh gases is regulated by a flowmeter
or a jet.
Variable-flow vaporizers are not suitable for use with
desflurane because of its specific physical properties.
Its saturated vapour pressure is three to four times
higher than the vapour pressure of other liquified
volatile anaesthetics, its boiling point is 22.8°C (which
is almost room temperature), and its minimal alveo-
lar concentration is 6–7%. A vaporizer therefore had
to be specially constructed for use with desflurane
(Ohmeda Desflurane Tec 6®; Datex-Ohmeda, Inc,
Madison, WI, USA): it has to be electrically heated
and pressurized. This is usually implemented by using
a special reservoir for desflurane, heated to 39°C. The
vapour pressure at this temperature is about 2 bar
(including atmospheric pressure). A special valve
keeps the reservoir closed until the desired concentra-
tion is reached and then opens it reducing the pressure
to 1.1 bar (including atmospheric pressure).
The concentration of volatile anaesthetic in the
respiratory mixture is directly dependent on the sat-
urated vapour pressure, the surface area where evap-
oration takes place, and inversely proportional to the
length of use (the anaesthetic cools during evapora-
tion, this in turn decreases its vapour pressure; even
if the regulator setting is left unchanged the concen-
tration of delivered anaesthetic falls). It also depends
on the ratio of the flow through the vaporizer and
the flow bypassing it (‘splitting ratio’) and on the
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construction of the vaporizer (imperfect mixing with
vapours due to the improper flow of gas through the
vaporizer). Modern vaporizers are designed to mini-
mize these difficulties with an increased area for evap-
oration and a reduced velocity of gas flow through
the device with built-in helical tubes, obstacles or
walls through which the gas mixture has to pass.
They also have to maintain a constant temperature.
Temperature compensation
A constant temperature in a vaporizer cannot be
achieved. Potential changes due to temperature can
be compensated for in several ways. A bimetallic
strip can be used that consists of two metal strips,
with different coefficients of thermal expansion,
bonded together. A change in temperature therefore
forces the strip to bend and this can be made to either
open or obstruct the gas port into, or out of, the
vaporizing chamber. An alternative method of ther-
mostat is to use a very thin metal (usually phosphor
bronze) bellows containing a gas, commonly diethyl
ether. This closed bellows expands as the temperature
rises, and shrinks as it falls because the vapour of the
contained liquid exerts a pressure depending upon its
temperature. This movement is linked to a lever and
disc (or metal pin) which covers or obstructs the port,
thus opening or closing the gas inlet (or outlet),
hence regulating the flow of gas. A massive metal
vaporizer (mostly made of copper) – with a large heat
conductibility which acts as heat sink – is used to
minimize the cooling of the vaporizer. Finally, the
anaesthesiologist can regulate the concentration
manually using an additional scale according to the
measured temperature of the liquid in the vaporizer.
Humidity and humidification
Humid air is a mixture of dry air and water vapour.
Dalton’s Law also applies to this mixture. Three
terms can be defined: absolute, maximal absolute
and relative humidity. Absolute humidity is the par-
tial density of water vapour in humid air:
␳w ⫽ mw/V ⫽ pwMw/(RT),
where mw is the total mass of water vapour contained
in the volume V, pw is the partial pressure of water
vapour, Mw is the mass of one mole of water, R is the
molar gas constant and T is the absolute temperature.
Maximal absolute humidity is achieved when the
partial water vapour pressure (pw) equals saturated
water vapour pressure (ps): ␳s ⫽ psMw /(RT). The
temperature, at which a given sample of air attains
its maximal absolute humidity, is called the dew
point.

Relative humidity is the ratio between absolute
humidity and maximal absolute humidity at a given
temperature:
␳w p M RT p water is heated to 45–60°C and inspired gases pass
␩⫽ ⫽ w w ⫽ w
␳s RT p s Mw ps
Measurement of relative humidity
Relative humidity can be measured with a hair
hygrometer, by comparing the measured tempera-
ture difference of wet and dry thermometer bulbs or
by determining the dew point at the cooling of air.
The operation of a hair hygrometer is based on the
fact that a human hair elongates in a humid environ-
ment. A hair is connected to the indicator, which
directly shows the relative humidity on an appropri-
ately calibrated scale. A hygrometer is accurate only
when the relative humidity is within the range
15–85%. If smaller precision is acceptable, a piece of
string can be used instead of a hair, as in the weather
indicator.
A wet and dry bulb hygrometer consists of two
identical thermometers. The bulb of one of them is
covered with a muslin sleeve that is kept moist with
clean distilled water. The dry thermometer shows the
actual temperature while the temperature shown by
the wet thermometer is lower because of the evapora-
tion of water. The amount of evaporation depends on
the humidity of the air. The difference in the two
measured temperatures is a measure of humidity. The
relative humidity then has to be read from tables.
A Regnault condensation hygrometer contains a
narrow silver pipe filled with ether and a thermome-
ter used to measure its temperature. Air is pumped
through the ether causing evaporation and thus cool-
ing of the silver pipe. When the air, which is in con-
tact with the silver pipe, becomes saturated with
water vapour, the vapour condenses on the silver pipe
which then appears as a fog (dew). The temperature
of this dew point is measured and the relative humid-
ity is read from tables. Relative humidity can also
be measured by electric instruments with variable
resistance.
Humidification in the airway
Inspired air achieves saturated humidity in the tra-
chea at 37°C. The saturated water vapour pressure is
6.3 kPa (47 mmHg), which corresponds to a partial
concentration of 6.2% in the inspired air. Water con-
centration here equals 44 mg L⫺1. At 21°C the partial
concentration of water equals 2.4% or 18 mg L⫺1.
From this it is apparent that a patient can lose a
significant amount of water and heat if the lungs are
ventilated with dry and non-heated gases.
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Physics for anaesthesiologists 277
Artificial humidification
Three basic methods of humidification can be dis-
tinguished. With heated humidifiers a chamber of
over the water. The upper value of this temperature
range is chosen to discourage the growth of bacteria.
Possible dangers are infection if the water tempera-
ture drops too low, and scalding if it rises too high.
Another problem is condensation of water in the res-
piratory hoses. The device is effective in approxi-
mately 80% of all cases.
The design of a spray humidifier is based on the
Venturi tube. Gas is forced into the water breaking
it into numerous minute droplets. An alternative is
to create a very fine spray using a plate oscillating
with a frequency of 2 MHz (ultrasound). The major
problem with this design, especially with infants
and children, is water overload.
The heat and moisture exchanger (‘artificial,
so-called ‘Swedish nose’) or condenser humidifier
was originally constructed from a pack of wire gauze
inserted between the endotracheal tube and the anaes-
thesia breathing system. During expiration, water
condensed on the wires and this water was vaporized
during the next inspiration – thus water, from the
patient, was conserved. Modern designs employ a
corrugated sheet of hygroscopic material rolled up
like corrugated cardboard, or use a hygroscopic foam.
They are efficient in approximately 80% of cases.
Great care must be taken that these devices do not
become blocked with secretions else respiratory
obstruction will occur; monitoring of pressure in the
airway is essential.
Dissolving of gases
The solubility coefficient is the ratio between the
volume of gas and the volume of solvent in which
the gas is dissolved. Originally, the solubility coeffi-
cient was defined as the dissolved concentration of
the gas when the liquid was equilibrated with 1 bar
(1 atm) pressure of the gas. To allow for the vapours
of volatile anaesthetics the definition was extended
to dissolved concentration per unit applied partial
pressure – with the unit usually being the bar (atm)
for consistency with figures for gases at 1 bar (atm)
pressure.
Two definitions of solubility coefficient are in use:
the Bunsen solubility coefficient and the Ostwald
solubility coefficient. The difference between the
two types of coefficient is that with the Bunsen coef-
ficient, the dissolved volume is expressed at standard
temperature and pressure, dry (0°C, 101.325 kPa),
while in the Ostwald it is expressed at the tempera-
ture and pressure of the experiment, dry (often 37°C,
 278 A. Manohin and M. Manohin
101.325 kPa). Both coefficients change with the
temperature at which the equilibration is performed,
so temperature is relevant to partition coefficients.
Partition coefficient is the ratio between the amount
of substance between one and another phase, if the
two volumes are equal and in a thermodynamic
equilibrium. With the partition coefficient, as with
the Ostwald solubility coefficient, temperature has
to be taken into account but not pressure. The parti-
tion coefficient can be used when two liquids are
considered, while the Ostwald solubility coefficient
applies to both a liquid and a gas.
Diffusion and osmosis
If two different gases, or two different liquids, in a
vessel are initially separated with an impermeable
membrane into two compartments, once the mem-
brane is removed they start to mix. Fick’s Law of dif-
fusion governs the movement of molecules. Graham’s
Law is also useful for determining the diffusion rate.
It states that the diffusion of molecules is inversely
proportional to the square root of their molecular
weight. Heavier molecules thus migrate slower than
those with a smaller molecular mass.
Diffusion of any given substance is caused by its
uneven distribution. At the beginning one substance
is on one side of the vessel, with the other substance
on the other side. The two substances move in oppo-
site directions – from the area of higher concentra-
tion to that of lower concentration. The flow, driven
by the concentration difference, persists until the
concentration is equal everywhere in the vessel.
Diffusion is faster in gases than in liquids while dif-
fusion through solids is usually so slow that it can-
not be noticed.
Diffusion has been illustrated here in a single com-
partment after the removal of a membrane. However,
in biological systems membranes are usually present.
The diffusion rate in such cases also depends on the
properties of the membrane. In the lungs, for instance,
the alveolar membrane is moist and acts as a film of
water so that diffusion of a gas also depends on its
solubility in water. Carbon dioxide is more soluble
than oxygen and thus moves faster even though its
pressure difference is smaller than the pressure dif-
ference for oxygen.
When the membrane is semipermeable, i.e. per-
meable for some substances but impermeable for
others, a special type of diffusion called osmosis takes
place. In this case only one component (i.e. the sol-
vent) can diffuse through the membrane while the
other (i.e. the solute) cannot. The membrane thus
separates both components and maintains the con-
centration difference. The system tends to equalize
the concentration of those components that can
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permeate through the membrane. A concentration
difference may manifest itself as pressure, which is
called osmotic pressure. Osmosis can be stopped if an
equal hydrostatic pressure is applied in the opposite
direction.
Osmotic pressure can be measured with an osmome-
ter. This is a tube closed on one side with a semiper-
meable membrane. It is filled with the solution for
which the osmotic pressure is to be measured and
placed vertically into a vessel filled with the solvent.
The solvent passes through the semipermeable mem-
brane and the level of solution in the tube rises until
the osmotic pressure is balanced by the hydrostatic
pressure. Once in equilibrium, on average an equal
number of solvent molecules crosses the membrane
in both directions. According to the pressure on
both sides of the membrane, solutions can be classi-
fied as hypertonic, isotonic or hypotonic. A living
cell, e.g. an erythrocyte, can also be used as an
osmometer. It either swells or shrinks depending on
whether the osmotic pressure outside the cell is
greater or smaller than inside the cell.
The behaviour of solutes in an ideal solution is
governed by laws that are analogous to the gas laws.
This means that 1 mole of substance, at standard
conditions, occupies 22.4 L and the osmotic pressure
at 273 K is equal to 1 bar. This might be easier to
follow if derived from the van’t Hoff equation for
osmotic pressure:
posm ⫽ cRT
where c is the concentration in mol L⫺1, R is the gas
constant, in J K⫺1, and T is the temperature in K.
This leads to the conclusion that 1 mol L⫺1 solution
produces an osmotic pressure of about 22.4 bar at
273 K (incidentally, the van’t Hoff equation can eas-
ily be derived from the ideal gas equation because
c ⫽ 1/V, where V is volume per mole). The total
osmotic pressure of a solution is equal to the sum of
partial osmotic pressures for each component. Osmotic
pressure depends on the number of dissolved parti-
cles in a unit of volume. This means that the osmotic
pressure of 1 mole of a solution that dissociates into
two ions is twice as large as the osmotic pressure of
1 mole of non-dissociating solution.
The number of moles of solute dissolved in 1 L of
solution is the molarity of the solution. The freezing
point of a solution is lower than the freezing point
of pure solvent and the difference in temperature
is proportional to the concentration of solute. One
mole of solute dissolved in 1 kg of water lowers its
freezing point by 1.86 K.
An older unit for measuring osmolar activity is the
osmol. One osmol is equal to 1 mole of dissolved sub-
stance provided that it does not dissociate nor perme-
ate through the membrane. When the molecules of

solvent dissociate to two ions, 1 mole of solution
produces 2 osmol of activity. Since the osmol is usu-
ally too large a unit for expressing osmolar activity of
body fluids, a 1000 times smaller unit the milliosmol
is usually used in practice.
Osmolarity is defined as the number of osmols of
solute dissolved in 1 L of solution, while osmolality
is defined as the number of osmols of solute dis-
solved in 1 kg of solution. Osmolarity thus differs
from osmolality because of the differences in density
and is affected by temperature. However, under
normal biological conditions, the difference is very
small. An important exception here is that, inside
the erythrocyte, water constitutes only about 70%
of the volume of the solution (of haemoglobin in
water); so the osmolality is markedly less than the
osmolarity.
Since 1984, a new unit has been used for osmolar-
ity, the molarity of solution. It is defined as the osmo-
larity of a solution, of which the osmotic pressure is
equal to the osmotic pressure of an ideal solution
with a concentration equal to 1 mole of solute per 1 L
of solvent.
Inside the vascular system, water and the majority
of ions permeate through endothelial membranes
while plasma proteins cannot enter the interstitial
fluid. The osmotic pressure of plasma proteins is
denoted by the term oncotic pressure. Oncotic pres-
sure is relatively small (approximately 1 milliosmol),
compared with the total osmotic pressure of blood
plasma (approximately 300 milliosmol).
Electrical safety
Electrical power lines supply us with alternating
electric current which in Europe has a voltage of
220 V and frequency 50 Hz. In North America it is
110 V at 60 Hz. According to Ohm’s Law, current
is equal to the quotient of voltage and resistance.
When an alternating current is used, it is more appro-
priate to use impedance rather than resistance. Imped-
ance is defined as the quotient of the effective voltage
across a circuit and the effective current through a
circuit. Impedance takes into account both the ohmic
(resistors) and non-ohmic (capacitors and inductors)
contribution. Direct current cannot flow through a
capacitor, while alternating current can. The imped-
ance of a capacitor is inversely proportional to the
frequency of the current.
Tissue damage caused by electric current depends
on the strength and density of a current. If a 1 mA
current with a frequency of 50 Hz flows through the
body, paraesthesia is felt. If the current is gradually
increased, it is accompanied by increasing pain and
muscular cramps until at 80–100 mA cardiac dys-
rhythmia and ventricular fibrillation occur.
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Physics for anaesthesiologists 279
Current density is defined as the electric current
divided by the cross-sectional area through which
the current is flowing. The smaller the cross-section
at equal current (i.e. the greater the current density)
the greater the risk of for tissue damage. Other fac-
tors that can cause ventricular fibrillation are the
duration of passage of the current and its frequency.
Radiofrequency currents, e.g. in diathermy do not
cause ventricular fibrillation.
Minimizing damage caused by electric current
When possible, conducting material that is antista-
tic should be used in place of non-conductors. All
material should be allowed to leak static charges
through the floor of the operating room. Apart from
this, insulation of electrical appliances is also an
important factor for protection. According to the
level of protection provided, electrical appliances can
be divided into three groups:
• Group 1: mains power cord with three wires (live,
neutral and ground). The ground is connected to a
conductive housing. In case of accident (e.g. short
circuit), the ground wire takes the current, causing
a fuse blowout.
• Group 2: does not have a ground wire but there
is an insulating housing that provides alternative
safety.
• Group 3: used for low-voltage current supplied
from remote transformers. Electrically heated blan-
kets, for example, fit into this group. If alternating
current is used, the voltage is not higher than 24 V;
if direct current, not higher than 50 V.
Apart from the listed safety measures, electrical dam-
age can also be reduced by building isolating trans-
formers into all electrical appliances coming into
touch with the patient (e.g. patient monitors). The
patient is therefore in contact only with the second-
ary electric circuit, which is not grounded, so that the
current does not flow through the patient’s body to
ground.
Dangers due to induced electric current
Electric current induced by electric appliances is
another possible danger. Also known as stray electric
current, it can flow through the patient or the med-
ical staff to the ground. Although this current is very
weak, it poses a possible source of danger for patients
with a pacemaker or during use of catheters filled
with saline, which have been inserted directly into
the heart. The International Electrotechnical Com-
mission (IEC) has specified the maximum allowed
 280 A. Manohin and M. Manohin
values for current leakage for those types of electrical
appliances used in medicine.
Fires and explosion
As the use of inflammable material (e.g. ether and
alcohol), as well as volatile anaesthetics, is still com-
mon in the operating theatre in many countries, there
is a possible danger of fire and even explosion. It is
referred to as fire if an inflammable material catches
fire and explosion if the ignition is quick enough to
produce a pressure wave, which also manifests as a
sound wave. If the pressure wave has sufficient energy
to ignite adjacent inflammable materials then the
ignition is very violent and causes detonation.
For ignition, three factors have to be met: inflam-
mable material; oxygen or any other oxidant; and
energy, to raise the temperature of the inflammable
material above the critical temperature for ignition
(also called the activation energy).
Inflammable material
Most modern liquified volatile anaesthetics are non-
flammable. However, oil and grease used to reduce
friction are inflammable. Under increased pressure,
they can ignite spontaneously (like fuel in diesel
engines), so they must not be used for greasing sys-
tems operating at increased pressure (oxygen, nitrous
oxide, compressed air). Alcohol used for disinfection
is inflammable in air and even more so in oxygen or
nitrous oxide. Methane or hydrogen present in the
patient’s intestine are also possible sources of fire, e.g.
during diathermy with an open abdomen, or at insuf-
flation if nitrous oxide for laparoscopy; it is therefore
recommended that carbon dioxide be used instead.
The use of paper and plastic clothing in surgical
rooms is an additional source of danger. Ether burns
slowly in air with a bluish flame; however, it is always
explosive when in contact with oxygen or nitrous
oxide. It is advisable to stop the ether supply 5 min
before exposing the patient to a possible source of
fire, and ventilate the lungs with a non-flammable
agent using a non-rebreathing system.
For an estimation of the danger of explosion it is
important to know the concentration at which the
amount of inflammable fumes matches the required
amount of oxidant in the reaction exactly. This con-
centration is called stoichiometric concentration
(stoichiometry is the branch of chemistry that deals
with the application of the laws of definite propor-
tions to chemical activity). At this concentration
ignition is most violent, while at either higher or
lower concentrations its intensity decreases, until
the danger fades away at the level of inflammability.
Ether, for example, ignites if the concentration in
© 2003 European Academy of Anaesthesiology, European Journal of Anaesthesiology 20: 259–281
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oxygen is 2–82%, the concentration in air 2–36%
or the concentration in nitrous oxide 1.5–24%. Its
stoichiometric concentration in oxygen is 14%, and
the range where danger of explosion is present is
12–40%. The stoichiometric concentration of ether
in air is 3.4%, so the criteria for explosion are
not met.
Sources of fire danger include static electricity
(present on all non-conductive materials, e.g. rubber,
plastic, fabric, synthetic materials; some parts of
anaesthesia apparatus and the respiratory system),
heat produced during diathermy (endoscopes, lasers,
electrical cutting devices or haemorrhage preventing
devices), faulty electrical appliances, electric sparks.
Measures for preventing static electricity include
the use of antistatic conductive materials instead of
insulators (specific conductivity within the range
50 k⍀ cm⫺1 to 10 M⍀ cm⫺1).
All materials have to provide a discharge of static
electricity to ground while at the same time the con-
ductivity should not be too large in order to avoid
electric shock and possible death in case of accidental
connection to the live and ground wires. The resist-
ance of the floor has to be 25–50 k⍀, measured by
two electrodes 1 m apart. The resistance of antistatic
footwear is required to be 0.1–1.0 M⍀. Moisture
facilitates the discharge of static electricity along the
floor surface and it is advisable to keep air humidity
above 50%.
Calculating percentage of solutions
In the literature, both old and modern units are
often encountered that are not part of the SI system.
A listing of those along with conversion factors often
proves helpful. This includes instructions for calcu-
lating the percentage of solutions (e.g. lidocaine,
which is available in concentrations of 1 or 2%) and
conversion tables for units used in physics.
Milligrams of active substance in 1 mL of liquid
solution can be calculated if the relationship between
mass (m), volume (V) and density (␳) is taken into
account: ␳ ⫽ m/V or m ⫽ ␳V. For practical purposes
it is sufficient to approximate the density of solution
with the density of water: ␳water ⫽ 1 g cm⫺3 (1 mL
equals 1 cm3). If we insert this into the formula
above, we have: m ⫽ 1 g mL⫺1 ⫻ 1 mL ⫽ 1 g. We
have thus calculated that 1 mL of solution which con-
tains 1 g (or 1000 mg) is a 100% solution. The mass
of a 1% solution is then 100 times smaller, or 10 mg
in 1 mL.
Acknowledgements
The authors thank Professor Saša Svetina, Head of
the Institute of Biophysics, Faculty of Medicine,

University of Ljubljana, for reading the manuscript
and for numerous helpful suggestions.
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