Advance lecture of anesthesia equipments 2020

Mohammed _Al mosawi

Collage of health and medical technology

Department of anesthesia
Lecture of anesthesia equipment
Teaching by
Mohammed_ AL Mosawi
MSc. of anesthesia and intensive care medicine
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

Mechanical ventilator, a machine designed to move breathable air into

and out of the lungs, to provide breathing for a patient who is physically
unable to breathe, or breathing insufficiently OR is a device designed to
provide or augment patient ventilation. Newer anesthesia ventilators have
more features and ventilatory modes than earlier models and are an
integral part of the anesthesia workstation.

Anesthesia machine ventilator

Ventilators are used to provide controlled ventilation (intermittent
positive pressure ventilation; IPPV). Some have the facilities to provide
other ventilatory modes. They can be used in the operating theatre,
intensive care unit, during transport of critically ill patients and also at
home (e.g. for patients requiring nocturnal respiratory assistance).

The ventilator replaces the reservoir bag in the breathing system. It may
be connected to the breathing system by a bag or ventilator selector valve.
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

Important definitions:

Barotrauma: Injury resulting from high airway pressure.

Volume trauma: injury resulting from high volume inside the lungs

Compliance: Ratio of a change in volume to a change in pressure.

Volume
C=
Pressure

It is a measure of distensibility and is usually expressed in milliliters per

centimeter of water (mL/ cm H2O).

Most commonly, compliance is used in reference to the lungs and chest

wall. Breathing system components, especially breathing tubes and the
reservoir bag, also have compliance.

Exhaust Valve: Valve in a ventilator with a bellows that allows driving

gas to exit the bellows housing when it is open.

Expiratory Flow Time: Time between the beginning and end of

expiratory gas flow.

Expiratory Pause Time: Time from the end of expiratory gas flow to the
start of Inspiratory flow.

Expiratory Phase Time: Time between the start of expiratory flow and
the start of inspiratory flow. It is the sum of the expiratory flow and
expiratory pause times.
Fresh Gas Compensation: A means to prevent the fresh gas flow from
affecting the tidal volume by measuring the actual tidal volume and using
this information to adjust the volume of gas delivered by the ventilator.
Fresh Gas Decoupling: A means to prevent the fresh gas flow from
affecting the tidal volume by isolating the fresh gas flow so that it does
not enter the breathing system during inspiration.

Inspiratory Flow Time: Period between the beginning and end of

inspiratory flow.
Inspiratory Pause Time: The portion of the inspiratory phase time
during which the lungs are held inflated at a fixed pressure or volume
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

(i.e., the time during which there is zero flow). It is also called the
inspiratory hold, inflation hold, or inspiratory plateau. The inspiratory
pause time may be expressed as a percentage of the inspiratory phase
time.
Inspiratory Phase Time: Time between the start of inspiratory flow and
the beginning of expiratory flow. It is the sum of the inspiratory flow and
inspiratory pause times.

Inspiratory: Expiratory Phase Time Ratio (I:E Ratio): Ratio of the

inspiratory phase time to the expiratory phase time.

Minute Volume: Sum of all tidal volumes within 1 minute.

Peak Pressure: Maximum pressure during the inspiratory phase time.

Plateau Pressure: Resting pressure during the inspiratory pause. Airway
pressure usually falls when there is an inspiratory pause. This lower
pressure is called the plateau pressure.

Positive End-Expiratory Pressure (PEEP): Airway pressure above

ambient at the end of exhalation. This term is commonly used in
reference to controlled ventilation.
Triggering
Triggering is the term used to describe how a patient lets the ventilator
know that he wants a breath.
 Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

Classification of anesthesia ventilators:

1. Power source – Compressed gas
– Electricity – Both
2. Method of cycling - Volume cycling
- Time cycling
- Pressure cycling
- Flow cycling
3. Drive mechanism – Double-circuit ventilators with bellows: A driving
and circuit force, such as pressurized gas compresses a component
designation analogous to the reservoir bag known as the ventilator
bellows. The bellows then in turn delivers ventilation to
**pressure generator the patient
- Driving gas
• 100% oxygen in the Datex-Ohmeda
• Oxygen and air through a venturi device in the North
American Dräger
• User selectable compressed air or oxygen in some
***flow generator
newer pneumatic anesthesia workstations
– Piston-driven single-circuit ventilators
4. Bellows - Ascending (standing) bellows ascend during the
expiratory phase
- Descending (hanging) bellows descend during the
expiratory phase
5. Modes – Volume controlled mode (VCV)
– Pressure controlled mode (PCV)
– Synchronized intermittent mandatory ventilation
mode (SIMV)
– Pressure support mode (PSV)
– PSV-Pro
– PCV with volume guarantee
6. Inspiratory phase gas - Volume
control - Pressure
7. Suitability for use - Operating theatre
- Intensive care unit
- Both
8. Pediatrics use Yes/no
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

Characteristics of the ideal ventilator:

1. The ventilator should be simple, portable, robust and economical to
purchase and use. If compressed gas is used to drive the ventilator, a
significant wastage of the compressed gas is expected. Some
ventilators use a Venturi to drive the bellows, to reduce the use of
compressed oxygen.
2. It should be versatile and supply tidal volumes up to 1500 mL with a
respiratory rate of up to 60/min and variable I: E ratio. It can be used
with different breathing systems. It can deliverany gas or vapour
mixture. The addition of positive end expiratory pressure (PEEP)
should be possible.
3. It should monitor the airway pressure, inspired and exhaled minute
and tidal volume, respiratory rate and inspired oxygen concentration.
4. There should be facilities to provide humidification. Drugs can be
nebulized through it.
5. Disconnection, high airway pressure and power failure alarms should
be present.
6. There should be the facility to provide other ventilatory modes, e.g.
SIMV, CPAP and pressure support.
7. It should be easy to clean and sterilize.

***Different type of ventilator****

1. Manley MP3 ventilator:
This is a minute volume divider (time cycled, pressure generator). All the
FGF (the minute volume) is delivered to the patient divided into readily
set tidal volumes.
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

During inspiration

*During expiration

Advantages
No electrical power required.
Simple to use and reliable.
does not waste pressurized gas, because all of the FGF is divided and
supplied to the patient; no additional gas flow is required to drive the
ventilator.
the ventilator may be used in conjunction with a circle system.

Disadvantages
only a single mode of mechanical ventilation is possible.
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

Generates back pressure within the breathing circuit, which can affect
the accuracy of vaporizers within the circuit.
2. Penlon Nuffield 200 ventilator:

The Penlon Nuffield 200 is an an intermittent blower ventilator. It is

small, compact, versatile and easy to use with patients of different sizes,
ages and lung compliances. It can be used with different breathing
systems. It is a volume-preset, time-cycled, flow generator in adult use. In
paediatric use, it is a pressure-preset, time-cycled, flow generator.

Components

1. The control module, consisting of an airway pressure gauge (cm

H2O), inspiratory and expiratory time dials (seconds), inspiratory flow
rate dial (L/s) and an on/off switch. Underneath the control module there
are connections for the driving gas supply and the valve block. Tubing
connects the valve block to the airway pressure gauge.

2. The valve block has three ports: a) a port for tubing to connect to the
breathing system reservoir bag mount.

b) An exhaust port which can be connected to the scavenging system

c) A pressure relief valve which opens at 60 cm H2O.
3. The valve block can be changed to a paediatric (Newton) valve.
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

Important note:

With its standard valve, the ventilator acts as a time-cycled flow

generator to deliver a minimal tidal volume of 50 mL. When the valve is
changed to a paediatric (Newton) valve, the ventilator changes to a time
cycled pressure generator capable of delivering tidal volumes between 10
and 300 mL. This makes it capable of ventilating premature babies and
neonates. It is recommended that the Newton valve is used.

Problems in practice and safety features

1. The ventilator continues to cycle despite breathing system
disconnection.
2. Requires high flows of driving gas.

Uses
It is used for short periods of ventilation most commonly in the anesthetic
room, but also sometimes in remote locations such as the radiology
department. An MRI compatible unit is available.
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

3. BAG IN A BOTTLE, DOUBLE CIRCUIT ANESTHESIA

VENTILATOR.

**It has bellows in a box design.

Components: Driving gas, bellows, bellows housing, spill valve, drive

gas exhaust valve, ventilator hose and positive end expiratory pressure
(PEEP) valve.

Bellows assembly consists of a rubber or latex-free material bellows in a

clear rigid plastic enclosure. Inside of the bellows is connected to the
breathing system. Pressurized oxygen or air from the ventilator power
outlet (45–50 PSIG) is routed to the space between the inside wall of the
plastic enclosure and the outside wall of the bellows. The ventilator
contains its own pressure-relief (pop-off) valve, called the spill valve. The
pressure of the anesthesia provider’s hand is replaced by the driving gas
pressure that compresses the bellows.

INSPIRATION
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

EXSPIRATION

Driving mechanism:
2 distinct pneumatic circuits within the vent that are separated
by the bellows wall:
The external circuit of compressed gas is the driving gas force
that compresses the bellows
The internal circuit is extension of the An. Breathing circuit
delivers An. Gas to the patient.

Important note: the valve of the double circuit will open when
the pressure inside the bellow reached 2-3 cmH2O to vent the
remaining expired gas inside the bellow.

Ascending bellows (standing) Descending bellows (hanging)

Bellows type:

Determined by bellows direction during exp.

Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

Ascending bellows (standing): ascend during exp; disconnection

won't fill.

Descending bellows (hanging): descend during exp; disconnection

will continue movement upward/ DG, downward/ gravity

Electronic control box:

The components in modern anesthesia vent:

Different modes;

Wide range VT; (0–1500 mL), (a paediatric version with a range of (0–
400 mL exists)
Respiratory rate of frequency; (6–40/min)

I: E ratio and alarm system.

Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

*Breathing circuit Problems & hazards:

1. Disconnection

2. Leak

*Bellow assembly problems:

A leak or hole in the bellows can cause the high pressure. Driving gad
enter the anesthetic circuit barotrauma.

Barotrauma: Injury resulting from high airway pressure.

*control assembly problems:

Electronic failure or mechanical failure

* malfunction of the vent p. relief valve:

Can cause 2 problems:

- sticking of the valve abnormally high pressure barotrauma.

- Incompetence of the valve airway pressure is inadequate to vent

the patient hypoventilation.

Problems in practice and safety features.

1. Positive pressure in the standing bellows causes a PEEP of 2–4 cm

H2O.
2. The ascending bellows collapses to an empty position and remains
stationary in cases of disconnection or leak.

3. The descending bellows hangs down to a fully expanded position in a

case of disconnection and may continue to move almost normally in a
case of leakage
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

PISTON-DRIVEN SINGLE-CIRCUIT VENTILATORS:

A computer-controlled stepper motor is used instead of compressed drive
gas to actuate gas movement in the breathing system.

Advantages:
1. Ability to deliver accurate tidal volumes to patients with very
poor lung compliance and to very small patients.
2. Sophisticated computerized controls are able to provide
advanced types of ventilatory support, such as synchronized
intermittent mandatory ventilation (SIMV), pressure controlled
ventilation (PCV), and pressure support–assisted ventilation, in
addition to the conventional control mode ventilation
3. There is no need of driving gas (more economically).
Electrically working not pneumatic.
4. Quiet and no PEEP.
Dis-advantages:
1. Loss of the familiar visible behavior of standing bellows.
2. Quiet (less easy to hear regular cycling).
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

Problems associated with anesthesia ventilators

and their solutions.
***Tidal Volume Discrepancies:
Large discrepancies between the set and actual tidal volume can occur
because of following reasons:

Tidal volume gain is because of ventilator-fresh gas flow coupling: In

most anesthesia workstations, gas flow from the anesthesia machine into
the breathing circuit is continuous and independent of ventilator activity.

During the inspiratory phase of mechanical ventilation, the ventilator

relief valve is closed, and the breathing system’s adjustable pressure
limiting valve is most commonly out of circuit. Therefore, the patient’s
lungs receive the volume from the bellows plus that from the flowmeters.

Gain due to excessive fresh gas flow (FGF) can be calculated as per
following formula: Tidal volume gain per breath (mL) = FGF (mL/min) ×
Inspiration:Expiration (I:E) ratio (%)/Respiratory rate per minute

For example if fresh gas flow rate is set at 6 L/minute, I:E ratio is 1:2
and respiratory rate is 10 per minute then Tidal volume gain per breath
(mL) = 6,000 (mL/min) × 33 (%)/10 per minute = 200 mL. This is in
addition to ventilator output.

***Increasing FGF increases tidal volume, minute ventilation, and peak

inspiratory pressure. To avoid problems with ventilator-fresh gas flow
coupling, airway pressure and exhaled tidal volume must be monitored
closely and excessive fresh gas flows must be avoided.

***Tidal volume loss:

The causes include breathing circuit compliance, gas compression, and
leaks in the anesthesia machine, the breathing circuit, or the patient’s
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

airway. The compliance for standard adult breathing circuits is about 5

mL/cm H2O. Thus, if peak inspiratory pressure is 20 cm H2O, about 100
mL of set tidal volume is lost to expanding the circuit. For this reason
breathing circuits for pediatric patients are designed to be much stiffer,
with compliances as small as 1.5–2.5 mL/cm H2O. Compression losses,
normally about 3%, are due to gas compression within the ventilator
bellows and may be dependent on breathing circuit volume.

***Several mechanisms have been built into newer anesthesia machines

to reduce tidal volume discrepancies.

***Fresh Gas Compensation.

***Fresh Gas Decoupling

There are two ways of decoupling FGF and tidal volume:

1. Stop the FGF during inspiration. Machines that use electronic control
of gas flow can decouple fresh gas flow from the tidal volume by delivery
of FGF only during exhalation.

2. Divert the FGF during inspiration. During the inspiratory phase, the
fresh gas via the fresh gas inlet is diverted into the reservoir bag by a
decoupling valve that is located between the fresh gas source and the
ventilator circuit. The reservoir bag serves as an accumulator for fresh gas
until the expiratory phase begins.
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

During expiratory phase, the decoupling valve opens, allowing the

accumulated fresh gas in the reservoir bag to be drawn into the circle
system to refill the descending bellows or piston ventilator chamber.

Important note: Current fresh gas decoupled systems are designed

with either piston-type or descending bellows-type ventilators. Since the
bellows in either of these types of systems refills under slight negative
pressure, it allows the accumulated fresh gas from the reservoir bag to be
drawn into the ventilator for delivery to the patient during the next
ventilator cycle. Conventional ascending bellows ventilators, which refill
under slight positive pressure, cannot be used with fresh gas decoupling.

Advantage of Fresh Gas Decoupling

Decreased risk of barotraumas and volutrauma: With a traditional
circle system, increases in FGF from the flowmeters or from
inappropriate use of the oxygen flush valve may contribute directly to
tidal volume, which if excessive, may result in pneumothorax or other
injury.

Disadvantage of Fresh Gas Decoupling

Generation of negative pressure: In a fresh gas decoupled system, the

bellows or piston refills under slight negative pressure. If the volume of
gas contained in the reservoir bag plus the returning volume of gas
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi

exhaled from the patient’s lungs is inadequate to refill the bellows or

piston, negative patient airway pressures could develop.

Reliance on the reservoir bag as accumulator: FGD system, such as

seen on the Narkomed 6000 series relies on the reservoir bag to
accumulate the incoming fresh gas. If the reservoir bag is removed during
mechanical ventilation, or if it has a significant leak from poor fit on the
bag mount or a perforation, room air may enter the breathing circuit as
the ventilator piston unit refills during expiratory phase. This may
potentially result in aware-ness, hypoxia and pollution of the operating
room.

***Excessive Positive Pressure:

• Incorrect settings on the ventilator.

• Ventilator malfunction.

• Sticking of spill valve:

• Excessive suction from the scavenging system

• Activation of the oxygen flush during the inspiratory phase of the

ventilator

• A leak in the ventilator bellows can transmit high gas pressure to the
patient’s airway

Effect:
• Increase the risk of pulmonary barotrauma (e.g. pneumo- thorax)

• Hemodynamic compromise during anesthesia.

Prevention:
• Fresh gas compensation

• Fresh gas decoupling • High-pressure alarm

• Factory preset inspiratory pressure safety valve.

• Pressure limiters.
Advance lecture of anesthesia equipments 2020
Mohammed _Al mosawi