Br. J. Anaesth.
(1988), 61, 397-402
PREDICTED AND MEASURED OXYGEN
CONCENTRATIONS IN THE CIRCLE SYSTEM USING LOW
FRESH GAS FLOWS WITH OXYGEN SUPPLIED BY AN
OXYGEN CONCENTRATOR
C. J. R. PARKER AND S. L. SNOWDON
Oxygen concentrators are being used increasingly
to supply the requirements for medical oxygen,
and have been installed in a limited number of
District General Hospitals [1]. The oxygen con-
centrator uses a zeolitic molecular sieve to separate
oxygen from nitrogen in atmospheric air; the
affinity of the zeolite for argon and oxygen is
similar. Since the atmosphere contains 0.93%
argon, and purification of oxygen from air repre-
sents a five-fold concentration, such oxygen
inevitably contains about 5 % argon. In addition,
should there be malfunction of one of the
concentrator modules, nitrogen would appear in
the product gas. In preliminary studies on the
concentrator installed at the Countess of Chester
Hospital, up to 3.7 % nitrogen has been observed
in the product gas and, on occasion, the delivered
oxygen fraction decreased to 92.9% [2]. Whilst
such a degree of purity might be acceptable in
most areas of clinical practice, this may not be the
case during low flow and closed circuit anaes-
thesia, where selective oxygen uptake by the
patient will lead to the accumulation of argon in
the breathing system.
The present study addresses the problem of the
accumulation of inert gas in the breathing system
with low fresh gas flows. Initial studies were
carried out in the laboratory, using a human
volunteer to simulate oxygen consumption by the
patient. Later studies were performed during
routine low flow anaesthesia to examine the effect
of the accumulation of inert gas on oxygen
concentration in the breathing system in clinical
practice.
C. J. R. PARKER, M_A., M.B., B.CHIR., F.F.A.R.C.S.; S. L. SNOW-
DON, M.B., CH.B., F.F.A.R.CS. ; University Department of
Anaesthesia, Royal Liverpool Hospital, Prescot Street, P.O.
Box 147, Liverpool L69 3BX. Accepted for publication:
March 14, 1988.
SUMMARY
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An oxygen concentrator based on a zeolitic
molecular sieve has been used to supply piped
oxygen in a District General Hospital; such
oxygen contains 5% argon. If concentrator
oxygen is used in the closed circuit, argon
accumulates. The present investigation defines
the extent and time course of argon accumulation
in partially and fully closed breathing systems. A
theoretical model is presented which predicts the
extent and rate of inert gas accumulation. The
predictions have been tested in a volunteer under
laboratory conditions and in five anaesthetized
patients. It is recommended that concentrator
oxygen may be used for low flow anaesthesia of
indefinite duration, provided the fresh oxygen
flow to the circuit is at least twice the oxygen
consumption. If the circuit is totally closed,
periodic opening of the circuit is necessary.
A theoretical treatment is described in the
Appendix.
SUBJECTS AND METHODS
All anaesthetic machines and circle systems used
in the present study were tested for leaks on the
day of use; the maintenance of a pressure of 40 cm
HjO in the apparatus after cessation of gas input
was confirmed using an aneroid pressure gauge.
The circle systems were arranged as shown in
figure 1, so that gas was vented after carbon
dioxide absorption.
Laboratory study
Laboratory studies used an anaesthetic machine
with flowmeters calibrated volumetrically for the
398
_l
FIG. 1. Arrangements of the circle system for laboratory and clinical studies. 1 = Wright respirometer;
2 = end-tidal gas sample site; 3 = expiratory unidirectional valve; 4 = inspiratory unidirectional valve;
5 = fresh gas supply; 6 = soda-lime cannister; 7 •= to paramagnetic oxygen analyser (clinical); 8 =
vented gas sample site (volunteer); 9 = shrouded Heidbrink valve; 10 = reservoir bag; 11 = patient.
gas mixture used. The circle system was a BOC
Mk3. Gas analysis was performed using a mass
spectrometer (BOC MS2), including a multi-
plexed output unit set to atomic mass units (u) 28,
32 and 40. Electrical zero was established from the
output at u 10 and a full calibration against
certified gas mixtures of medical oxygen, " white
spot" nitrogen and argon was performed before
and after each study. Calibrations were verified
frequently during the study and correction made
for any observed drift in performance. The
observed drift was less than 5 % of the measure-
ment range throughout the study. Gas samples
were collected at a flow rate of 30 ml min"1
through a sample tube heated to a temperature
greater than 40 °C to prevent condensation of
water vapour and, hence, maintain vapour pres-
sure.
A cylinder containing 9.5% argon in oxygen
was prepared by the decantation of argon at high
pressure into a partially empty cylinder of medical
oxygen; the process was controlled by regulation
of the filling pressure, and the approximate
composition guided by the partial pressures of the
component gases. The composition of the result-
ing mixture was then measured accurately by the
use of the mass spectrometer. The composition
was chosen to simulate the worst condition of
oxygen dilution by inert gas likely to be found in
clinical practice. The gas was used to supply the
fresh gas requirement of a conscious, postprandial
non-smoking human adult seated at rest and
breathing through a mouthpiece attached to a
circle system; a noseclip was used to eliminate
nasal breathing. The subject's tidal volume was
BRITISH JOURNAL OF ANAESTHESIA
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measured using an electronic Wright respirometer
and displayed on a chart recorder.
After a period of 5 min when the subject
breathed through the circle system with a fresh
gas flow rate of 8 litre min"1, to diminish pul-
monary nitrogen stores, the fresh gas flow was
reduced to a predetermined rotameter setting.
Gas was sampled from the breathing system at
three points. Intermittent samples were taken at
the mouthpiece and the fresh gas inlet for a period
of about 30 s every 2-5 min, depending on the
expected rate of change of system gas composition.
The regular sampling of fresh gas facilitated
correction of any performance drift of the mass
spectrometer. At all other times vented gas was
sampled, except at the lowest fresh gas flow used
when the circle was closed. Gas samples were
analysed for oxygen, argon and nitrogen and the
results were displayed on a chart recorder.
The volume of the circle system and the
functional residual capacity of the subject were
each measured by dilution, using argon as a
marker gas.
Clinical study
A Penlon IM500 anaesthetic machine, with a
Fluotec Mk2 Type MJ halothane vaporizer
(Cyprane) (calibrated 0-10%) placed outside the
circle system was used. Apparatus used for gas
analysis comprised a paramagnetic oxygen ana-
lyser (Servomex type OA 101 Mk2) calibrated on
each day of the study and an infra-red absorption
capnometer (Datex "Normocap"). The para-
magnetic oxygen analyser included the facility for
drying of sampled gas by passage over silica gel
LOW FLOWS AND THE OXYGEN CONCENTRATOR 399
before entry to the analytical cell. The purity of 40i
the concentrator oxygen was confirmed on each
day of the study against a cylinder of pure
oxygen. 35
The investigation was approved by the Hospital
Ethics Committee. Patients scheduled to undergo
surgery to varicose veins were studied; all were
30
free from cardiac, respiratory and renal disease.
None had received halothane anaesthesia within
the previous 3 months.
25
Premedication was with diazepam 10 mg by
mouth. After the establishment of venous access,
and pretreatment with tubocurarine 3 mg, anaes-
thesia was induced with thiopentone and followed 20

by suxamethonium 100 mg. The trachea was

sprayed with 4% lignocaine solution and intu-

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bated. Spontaneous ventilation was established 15
and the patient allowed to breathe halothane in
oxygen from the circle system, with a fresh gas
flow rate of 10 litre min"1. After a period of about 10
20 min, when the oxygen fraction in sampled gas
had stabilized, the fresh gas flow rate was reduced
to 500 ml min"1, and the vaporizer setting was
adjusted to maintain stable anaesthesia, an initial
value of 8% being typical [3]. The tidal volume
was measured with a Wright respirometer.
Gas sampling in the clinical study was confined 20 40 60 80 100 120
to two sites. A continuous sample was taken from Time (min)
near the reservoir bag to the oxygen analyser at a FIG. 2. Predicted ( ) and measured ( • A A O I ) argon per-
rate of 15 ml min"1; the deadspace of the sample centages in end-tidal gas in the laboratory studies. Fresh gas
tube was 4.5 ml. Intermittent samples were taken flows: • = 310mlmin-'; A = 500 ml min"1; A = 700 ml
from the catheter mount for the measurement of min"1; O = 900 ml min- 1 ; • = 2000 ml mirr1. Predictions
end-tidal carbon dioxide concentration—to facili- based on an estimated oxygen consumption of 310 ml min"1
ATPS.
tate routine monitoring of the patient.

functional residual capacity of the volunteer was

RESULTS
3250 ml.
Details of the volunteer and of the patient are
shown in table I. The volume of the circle system, Laboratory study
including the reservoir bag was 5630 ml; the The argon fractions in end-tidal gas are shown
in figure 2; at each fresh gasflowsetting the argon
fraction increased with time. Both the rate and
TABLE I. Details of sex, age, weight and tidal volume of the sub- extent of the increase in argon fraction were
jects studied
greater as the fresh gas flow was reduced. At the
Tidal lowest fresh gas flow, when the circle was fully
Age Weight volume closed, the increase in end-tidal argon fraction
Subject Sex (yr) (kg) (ml) was linear—about 0.3 % min"1. At all higher flow
Volunteer M 30 92 728 rates the increase had the form of a wash-in
Patient 1 F 37 57 370 exponential function.
Patient 2 F 66 90 — The argon fractions in end-tidal and vented gas
Patient 3 M 58 85 450 were similar. As the argon fraction approached its
Patient 4 F 45 66 340
Patient 5 F 22 58 390
steady value, the argon fraction in vented gas
exceeded that in end-tidal gas by 0.5-1 %.
400 BRITISH JOURNAL OF ANAESTHESIA
85 flow rates, the increase in nitrogen fraction was
much smaller and never exceeded 3 % of end-tidal
,•:
gas.
6 o o o
75 4 4 4 Clinical study
The measured purity of concentrator oxygen
ranged from 94.3 % to 95.1 % at the times of the
65 study.
The oxygen fractions measured in gas sampled
near the expiratory valve are shown in figure 4. In
each patient there was a decrease during the
55 period of measurement of between 3.8% and
5.1 %. There was a delay of about 5 min before
the rate of decrease in oxygen fraction was
maximal, at around 0.17% min"1. Thereafter, in
45
20 40 80 100 120 each patient, the rate of decrease in oxygen

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Time (min)
FIG. 3. Measured oxygen percentage in end-tidal gas in the
laboratory studies. Fresh gas flows: • = 310 ml min"1; A =
500 ml min" 1 ; A = 700 ml min"1; O = 900 ml min"1; B =
2000 ml min"1.
fraction decreased with time and the oxygen
fraction approached a new steady value.
DISCUSSION

95 The presence of small concentrations of argon in

inspired gas appears to be of no biological
consequence. Argon has anaesthetic properties at
a partial pressure of about 15 atmospheres in a
variety of species, and it is likely that this is the
case in man [4]. However, prolonged inhalation of
a mixture of 80 % argon-20 % oxygen at atmos-
pheric pressure in the rat appears to have no effea
90 [5], and exposure of experienced divers to a
6 similar mixture produced no detectable effect [6].
* » 4
». " 4 » Thus the major problem arising from the accumu-
lation of argon would seem to be simple encroach-
ment upon the partial pressure of oxygen or
anaesthetic gases.
Theoretical considerations detailed in the Ap-
85 pendix predict the extent of argon accumulation
10 20 30 40 50 60 in the breathing system. Of the determinants of
Time (min) argon fraction, the anaesthetist has the greatest
FIG. 4. Measured oxygen percentages in gas vented from the control over the fresh gas flow. It is predicted
circle system in clinical studies using a fresh gas flow of that, in the totally closed circuit, the argon fraction
500 ml min"1. • = Patient 1; A = pati e n t 2; • = patient 3;
O = patient 4; A = patient 5.
will increase linearly whereas, at low flows with
some gas vented from the circuit, the argon
End-tidal oxygen fractions are shown in figure fraction should follow a wash-in exponential
3. The oxygen fraction decreased with time, at a function.
rate and to an extent related to the fresh gas flow. Figure 2 details predictions of this model which
Oxygen fractions in vented and end-tidal gas parallel the experimental observations. Although
decreased in parallel; the fraction in end-tidal gas there is some discrepancy in the absolute values,
was consistently less by about 5 %. laboratory results follow the pattern of the
Only when the circle was fully closed did the predictions. It is reasonable to suppose that the
end-tidal nitrogen concentration increase through- discrepancies between the predictions and the
out the period of observation; it increased from an experimental observations reflect, to some extent,
initial 1 % to reach 9 % after 80 min. At higher limitations of the model or of its quantification.
LOW FLOWS AND THE OXYGEN CONCENTRATOR
In comparing figure 2 and figure 3 it is seen that
the increase in argon fraction is closely comple-
mented by the decrease in oxygen fraction at each
fresh gas flow setting. However, when the circle
was fully closed the decrease in oxygen fraction
was greater than the increase in argon fraction—a
difference approaching 8% after 80 min; the
discrepancy is accounted for by the observed
increase in nitrogen fraction from 1 % to 9 % over
this period. This represents an accumulation of
about 700 ml of nitrogen and falls within the
range of results reported by previous workers in
man [7] and the dog [8].
It was noted in the laboratory study that there
were consistent small discrepancies between the
fractions of argon and oxygen in end-tidal and
vented gas. When the argon fraction in the
breathing system had stabilized, it was 0.5-1 %
higher in vented than in end-tidal gas, whereas
the oxygen fraction was typically 5 % higher in
vented gas. These discrepancies are not un-
expected for, whilst end-tidal gas contains about
5% carbon dioxide, the vented gas had been
subjected to carbon dioxide absorption; further-
more, whilst vented gas is at least partially
saturated with water vapour at ambient tempera-
ture, end-tidal gas collected through a heated
sample tube can be expected to be significantly
more humid. In addition to the dilution of
measured end-tidal gas fractions by carbon di-
oxide and a greater degree of water vapour, end-
tidal gas represents a sample from which oxygen
consumption by the subject ensures a lower
oxygen fraction than in the vented gas, which is
more representative of the gas in the circle system
as a whole.
In the clinical study, the accumulation of
nitrogen was minimized by a long period of
denitrogenation [9] and a fresh gas flow at which
laboratory studies had shown that a large increase
in nitrogen fraction does not occur. Any contri-
bution of possible changes in carbon dioxide and
water vapour fraction within the breathing system
to the observed changes in vented oxygen fraction
was minimized by measuring oxygen fraction in
gas vented after carbon dioxide absorption, and
dried before analysis.
Assuming the oxygen consumption of the
patients to have been about 250 ml min"1, that is
approximately 50 % the fresh gasflowrate, theory
would predict an increase in the fraction of argon
in the breathing system to twice that in the fresh
gas. If all of the observed decrease in the fraction
401
of oxygen (4-5%) were attributable to the
accumulation of argon, it would represent a
doubling of the argon fraction in the fresh gas
supply.
One may speculate on the use of nitrous oxide
in low flow anaesthetic techniques with concen-
trator oxygen. The margin of safety is greatly
reduced by the adoption of a baseline gas
composition which includes perhaps 33 % oxygen,
when a degree of argon accumulation, which
might be unimportant whilst using oxygen as the
sole carrier gas, would threaten a serious decrease
in oxygen fraction. However, if the fresh gas used
for the maintenance of anaesthesia consisted of
oxygen 500 ml min"1 and nitrous oxide 500 ml
min"1, then the absolute degree of argon accumu-
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lation would be no greater than in the present
clinical study. Indeed, it would be less, since the
use of nitrous oxide dilutes the argon fraction in
the fresh gas to a value typically around 2.5%.
Furthermore, a substantial volume of nitrous
oxide is vented after the first few minutes of its
uptake, so that the total rate of gas venting from
the circle system is higher than in the present
clinical study. The argon fraction in the circle
would be expected to remain less than 5 % and
this might represent an acceptable dilution of
respirable gas.
Certain recommendations are justified con-
cerning the use of concentrator oxygen in low flow
anaesthesia. If nitrous oxide is omitted, serious
argon accumulation does not occur if the fresh gas
flow is about twice the oxygen consumption, and
the clinical study supports the use of fresh oxygen
flows of 500 ml min"1 in anaesthetized patients.
Fully closed circuit anaesthesia may also be used,
but argon will continue to accumulate indefinitely
until the circle is opened. In the laboratory study,
the argon fraction had quadrupled after about
90 min and it would seem wise to open the circuit
with at least this frequency. Whilst the present
experimental data do not extend to the use of a
low flow anaesthetic technique incorporating
nitrous oxide with concentrator oxygen, the
accumulation of argon in the breathing system
should not be hazardous, provided the fresh gas
mixture includes at least 50% oxygen at a total
flow rate of no less than 1 litre min"1.
APPENDIX
Certain assumptions simplify the theoretical treatment. Simi-
lar assumptions have been made elsewhere to facilitate analysis
of the behaviour of the nearly closed circuit [10].
402
(1) Argon is not taken up by the subject. In fact, the effective Therefore:
capacity of the body for argon is only about 3 litre at 1
atmosphere. The fat group of tissues accounts for 2/3 of this
volume and equilibrates with a time constant of about 5 h [11],
and so body uptake remains a small fraction of argon
accumulation in the gaseous phase in the present studies.
(2) Carbon dioxide is completely and instantaneously ab-
sorbed upon entry to the system. The circle systems used in
the present study were arranged to vent gas after carbon
dioxide absorption, so the equations for gaseous homeostasis
are unchanged.
(3) The functional residual capacity of the subject and the
circle system form a homogeneous unit, considered to exist at
ATPD. In effect, the gas in the circle and lungs will be mixed
over a time course much less than that of the accumulation of
argon; as has been discussed, the observed small differences
between argon fractions in the vented and end-tidal gas are the
result of the presence of carbon dioxide and the greater
humidity of the latter.
(4) The subject is initially totally denitrogenated. In the
laboratory study, nitrogen accumulation was noted only when
the circuit was fully closed, and in clinical studies, denitro-
genation was prolonged.
SYMBOLS
V = Volume of the circle system + functional residual capacity.
Vot = Oxygen consumption by the subject.
V, = Dry fresh gas input to the breathing system.
Farg, = Argon fraction in the dry fresh gas input.
Farg, = Argon fraction in the breathing system at time t.
dFarg = Change in argon fraction in the breathing system
during time dr.
Farglnf = Argon fraction in the breathing system after infinite
time.
t = time.
dr = a short time interval.
k = rate constant for argon accumulation.
V,Vot,V, considered to exist at ATPD.
ANALYSIS
Volume of gas vented in time dt =
Volume of argon vented in time di =
dtxFaig,x(V,-Vo,)
Volume of argon entering the system in time dt =
dt x Farg, x V,
Volume of argon accumulating in time di =
dFarg x V
In unit time argon accumulating = argon entering
argon vented.
BRITISH JOURNAL OF ANAESTHESIA
Vx dFarg
(Farg, x V,) - Farg, x (V, - Vot)
dt
This has the solution:
Farg, = Farg l n ,-(Farg, n f -Farg,) x exp"*1
Farg,xK,
=
It can readily be seen that the accumulation of argon follows
a wash-in exponential function [12].
The predictions of this analysis, corrected to ATPS, are
presented, together with experimental observations, in figure
2.
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