Anesthesia Breathing Systems Juan E Gonzalez CRNA MS

Anesthesia Breathing Systems Juan E Gonzalez, CRNA, MS Assistant Clinical Professor Anesthesiology Nursing Program Florida International University

Anesthesia Breathing Systems v Purpose v To deliver anesthetic gases and oxygen v Offer a means to deliver anesthesia without significant increase in airway resistance v To offer a convenient and safe method of delivering inhaled anesthetic agents v To annoy you with yet one more thing to memorize

Anesthesia Breathing Systems v Basic Principles v All anesthesia breathing systems have 2 fundamental purposes v Delivery of O 2/Anesthetic gases v Elimination of CO 2 v All breathing circuits create some degree of resistance to flow

Anesthesia Breathing Systems v Resistance to flow can be minimized by: Reducing the circuit’s length v Increasing the diameter (who’s law is that? ? ) v v Hagen-Poiseuille P = (L)(v)(V) r v v v 4 P is pressure gradient. L is length. v is viscosity. V is flow rate RESISTANCE IS INDIRECTLY PROPORTIONAL TO FLOW RATE WITH LAMINAR FLOW v Flow = P 1 -P 1/R where P 1 is pressure at one end of a tube and P 2 is pressure at the other end of the tube FOR TURBULENT FLOW, GAS DENSITY IS MORE IMPORTANT THAN VISCOSITY RESISTANCE IS PROPORTIONAL TO THE “SQUARE” OF FLOW RATE (TURBULENT FLOW) IN CLINICAL PRACTICE, FLOW IS USUALLY A MIXTURE OF LAMINAR & TURBULENT FLOW Avoiding the use of sharp bends (turbulent flow) v Eliminating unnecessary valves v Maintaining laminar flow v

Another look at Poiseuille’s Law Laminar flow: orderly movement of gas inside a “hose” (gas in the center of the tube moves faster than gas closer to walls) v Turbulent flow: resistance is increased (seen with sudden narrowing or branching of tube) v Laminar flow becomes Turbulent when Reynold’s number is >2000 v Poiseuille’s Law follows Laminar flow v v R = 8 n l (R: resistance, n: viscosity, l: length, r: radius) r 4 Example: doubling the radius of the tube will decrease the resistance 16 times (2)4=16

Anesthesia Breathing Systems v Classifications (controversial) Traditional attempts to classify circuits combine functional aspects (eg, extent of rebreathing) with physical characteristics (eg, presence of valves) v Based on the presence or absence of v v A gas reservoir bag v provides gas for the moments during inspiration where flow in the trachea is greater than fresh gas flow (FGF) v Rebreathing of exhaled gases v Means to chemically neutralize CO 2 v Unidirectional valves

Anesthesia Breathing Systems v Classifications v Open v Semiopen v Semiclosed v Closed

Function of any breathing circuit v Deliver oxygen and anesthetic gases v Eliminate CO 2 (either by washout with adequate fresh gas flow (FGF) or by soda lime absorption)

Anesthesia Breathing Systems

Anesthesia Breathing Systems v Classifications v Open v NO reservoir v NO rebreathing v No neutralization of CO 2 v No unidirectional valves v Examples include v Nasal Cannula v Open drop ether

Anesthesia Breathing Systems v Classifications v Open v Nasal cannula v Open drop ether v Think of it as anything where there is NO rebreathing and NO scavenging

Anesthesia Breathing Systems v Classifications v Semiopen v Gas reservoir bag present v NO rebreathing v No neutralization of CO 2 v No unidirectional valves v Fresh gas flow needed exceeds minute ventilation (two to three times minute ventilation to prevent rebreathing). Minimum FGF 5 L/min v Examples include v v v Mapleson A, B, C, D Bain Jackson-Rees

Anesthesia Breathing Systems v Classifications v Semiclosed v A type of “circle system” v Always has a gas reservoir bag v Allows for PARTIAL rebreathing of exhaled gases v Always provides for chemical neutralization of CO 2 v Always contains 3 unidirectional valves (insp, exp, APL) v Fresh gas flow is less than minute ventilation v Examples – The machine we use everyday!

Anesthesia Breathing Systems v Classifications v Closed v Always has a gas reservoir bag v Allows for TOTAL rebreathing of exhaled gases v Always provides for chemical neutralization of CO 2 v Always contains unidirectional valves v We don’t use these…. Suffice to say you can do this with the machines we have now if you keep your fresh gas flow to metabolic requirements around 150 ml/min (supply of O 2, N 2 O and VAA just matches pt’s requirements) If pt spontaneously ventilating, APL valve should totally closed (no scavenging since no waste total rebreathing)

Anesthesia Breathing Systems v Nonrebreathing circuits v Mapleson Classification – 1954 v Mapleson D still commonly used v Modified Mapleson D is also called Bain. Arrangement of components (entry point of fresh gas, reservoir gas, APL valve) is similar in both. The main difference is that the Bain has the fresh gas hose inside the expiratory corrugated limb (tube within a tube). Unrecognized kinking of inner inspiratory hose will convert the expiratory outer hose into dead space. v Mapleson F is better known as Jackson-Rees modification of Ayre’s T- piece v Used almost exclusively in children v v Very low resistance to breathing The degree of rebreathing is influenced by method of ventilation Adjustable overflow valve Delivery of FGF should be at least 2 x the minute volume

Anesthesia Breathing Systems (APL) APL Insp Exp

Non-rebreathing Circuits v All non-rebreathing (NRB) circuits lack unidirectional valves (insp & exp) and soda lime CO 2 absorption v Amount of rebreathing is highly dependent on fresh gas flow (FGF) v Work of breathing is low (no unidirectional valves or soda lime granules to create resistance)

How do NRB’s work? During expiration, fresh gas flow (FGF) pushes exhaled gas down the expiratory limb, where it collects in the reservoir (breathing) bag and opens the pop-off (APL) valve. v The next inspiration draws on the gas in the expiratory limb. The expiratory limb will have less carbon dioxide (less rebreathing) if FGF inflow is high, tidal volume (VT) is low, and the duration of the expiratory pause is long (a long expiratory pause is desirable as exhaled gas will be flushed out more thoroughly). v All NRB circuits are convenient, lightweight, easily scavenged (if using appropriate FGF). v

Anesthesia Breathing Systems v Mapleson v Advantages v Used during transport of children v Minimal dead space, low resistance to breathing v Scavenging (variable ability, depending on FGF used) v Disadvantages v Scavenging (variable ability, depending on FGF used) v High flows required (cools children, more costly) v Lack of humidification/heat (except Bain) v Possibility of high airway pressures and barotrauma v Unrecognized kink of inner hose in Bain v Pollution and higher cost v Difficult to assemble

Anesthesia Breathing Systems Press-relief valve (APL) Press-relief valve FGF Breathing Bag FGF Mask Mapleson Circuits FGF Breathing Bag Press-relief valve FGF Press-relief valve

Mapleson Components v Breathing Tubes v Corrugated tubes connect components of Mapleson to pt v Large diameter (22 mm) creates low-resistance pathway for gases & potential reservoir for gases v Volume of breathing circuit = or > TV to minimize FGF requirements v Fresh Gas Inlet (position will determine type of Mapleson performance and classification)

Mapleson Components v Pressure-Relief Valve (Pop-Off Valve, APL) If gas inflow > pt’s uptake & circuit uptake = press buildup opens APL (gas out via scavenger) v APL fully open during spontaneous ventilation v APL partial closure while squeezing breathing bag (assisted ventilation) v v Breathing Bag Reservoir Bag of gases v Method of generating positive pressure ventilation v

Mapleson A v Mapleson A Since No gas is vented during expiration, high unpredictable FGF (> 3 times minute ventilation) needed to prevent rebreathing during mechanical ventilation (Poor choice) v Most efficient design during spont. Aneous ventilation since a FGF = minute ventilation will be enough to prevent rebreathing) v http: //www. capnography. com/Circuits/maplesona. htm v

Mapleson D *FGF forces alveolar gas away from pt toward APL valve *Efficient during Controlle. D Ventilation

Mapleson D Mapleson C Mapleson F (Jackson. Rees)

Anesthesia Breathing Systems v Bain system (http: //www. capnography. com/Circuits/bainsystem. htm) v Coaxial (tube within a tube) version of Mapleson D v Fresh gas enters through narrow inner tube v Exhaled gas exits through corrugated outer tube v FGF required to prevent rebreathing: v 200 -300 ml/kg/min with spontaneous breathing (2 times VE) v 70 ml/kg/min with controlled ventilation

Bain at work (spontaneous) Spontaneous: The breathing system should be filled with FG before connecting to pt. During inspiration, the FG from the machine, the reservoir bag and the corrugated tube flow to the pt. v During expiration, there is a continuous FGF into the system at the pt’s end. The expired gas gets continuously mixed with the FG as it flows back into the corrugated tube and the reservoir bag. Once the system is full, the excess gas is vented to the scavenger. v During the expiratory pause the FG continues to flow and fill the proximal portion of the corrugated tube while the mixed gas is vented through the valve. v

Bain at work (spontaneous) During the next inspiration, the pt breathes in FG as well as the mixed gas from the corrugated tube. Many factors influence the composition of the inspired mixture (FGF, resp rate, expiratory pause, TV and CO 2 production in the body). Factors other than FGF cannot be manipulated in a spontaneously breathing pt. v It has been mathematically calculated and clinically proved that the FGF should be at least 1. 5 to 2 times the patient’s minute ventilation in order to minimize rebreathing to acceptable levels. v

Bain at work (controlled) v v v Controlled: To facilitate intermittent positive pressure ventilation, the APL has to be partly closed so that it opens only after sufficient pressure has developed in the system. When the system is filled with fresh gas, the patient gets ventilated with the FGF from the machine, the corrugated tube and the reservoir bag. During expiration, the expired gas continuously gets mixed with the fresh gas that is flowing into the system at the patient’s end. During the expiratory pause the FG continues to enter the system and pushes the mixed gas towards the reservoir.

Bain at work (controlled) v When the next inspiration is initiated, the patient gets ventilated with the gas in the corrugated tube (a mixture of FG, alveolar gas and dead space gas). v As the pressure in the system increases, the APL valve opens and the contents of the reservoir bag are discharged into the scavenger (gas follows the path of least resistance)

Anesthesia Breathing Systems v Bain v Advantages v Warming of fresh gas inflow by surrounding exhaled gases (countercurrent exchange) v Improved humidification with partial rebreathing v Ease of scavenging waste gases v Overflow/pressure valve (APL valve) v Disposable/sterile

Anesthesia Breathing Systems v Bain v Disadvantages v Unrecognized disconnection v Kinking of inner fresh gas flow tubing v Requires high flows v Not easily converted to portable when commercially used anesthesia machine adapter Bain circuit used v Look at the Bain and identify what makes it modified from the standard Mapleson D

Bain is a Modified Mapleson D (APL)

Anesthesia Breathing Systems

Pethick’s Test for the Bain Circuit v A unique hazard of the use of the Bain circuit is occult disconnection or kinking of the inner hose (fresh gas delivery hose). To perform the Pethick’s test, use the following steps: Occlude the patient's end of the circuit (at the elbow). v Close the APL valve. v Fill the circuit, using the oxygen flush valve (like pressurizing the circuit when you are doing a leak test) v Release the occlusion at the elbow and flush. A Venturi effect flattens the reservoir bag if the inner tube is patent. v

Circle System CAN: Canister of CO 2 absorber RB: Reservoir bag

Optimization of Circle Design v Unidirectional Valves v Placed in close proximity to pt to prevent backflow into inspiratory limb if circuit leak develops. v Fresh Gas Inlet v Placed b/w absorber & inspiratory valve. If placed downstream from insp valve, it would allow FG to bypass pt during exhalation and be wasted. If FG were placed b/w expiration valve and absorber, FG would be diluted by recirculating gas

Optimization of Circle Design v APL valve v Placed immediately before absorber to conserve absorption capacity and to minimize venting of FG v Breathing Bag v Placed in expiratory limb to decrease resistance to exhalation. Bag compression during controlled ventilation will vent alveolar gas thru APL valve, conserving absorbent

Circle system can be: v v v closed (fresh gas inflow exactly equal to patient uptake, complete rebreathing after carbon dioxide absorbed, and pop-off closed) semi-closed (some rebreathing occurs, FGF and pop-off settings at intermediate values), or semi-open (no rebreathing, high fresh gas flow)

Anesthesia Breathing Systems v Circle systems v Most commonly used v Adult and child appropriate sizes v Can be semiopen, semiclosed, or closed dependent solely on fresh gas flow (FGF) v Uses chemical neutralization of CO 2 v Conservation of moisture and body heat v Low FGF’s saves money

Anesthesia Breathing Systems v Circle systems v Unidirectional valves v Prevent inhalation of exhaled gases until they have passed through the CO 2 absorber (enforced pattern of flow) v Incompetent valve will allow rebreathing of CO 2 v Hypercarbia and failure of ETCO 2 wave to return to baseline v Pop off (APL) Valve v Allows pressure control of inspiratory controlled ventilation v Allows for manual and assisted ventilation with mask, LMA, or ETT (anesthetist will regulate APL valve to keep breathing bag not too deflated or inflated)

Anesthesia Breathing Systems v Circle system v Allows for mechanical ventilation of the lungs using the attached ventilator v Allows for adjustment of ventilatory pressure v Allows for semiopen, semiclosed, and closed systems based solely on FGF v Is easily scavenged to avoid pollution of OR environment

Anesthesia Breathing Systems v Advantages of rebreathing v Cost reduction (use less agent and O 2) v Increased tracheal warmth and humidity v Decreased exposure of OR personnel to waste gases v Decreased pollution of the environment v REMEMBER that the degree of rebreathing in an anesthesia circuit is increased as the fresh gas flow (FGF) supplied to the circuit is decreased

Anesthesia Breathing Systems

Anesthesia Breathing Systems v Dead space Increases with the use of any anesthesia system v Unlike Mapleson circuits, the length of the breathing tube of a circle system DOES NOT directly affect dead space v Like Mapleson’s, length DOES affect circuit compliance (affecting amount of TV lost to the circuit during mech vent) v Increasing dead space increases rebreathing of CO 2 v To avoid hypercarbia in the face of an acute increase in dead space, a patient must increase minute ventilation v Dead space ends where the inspiratory and expiratory gas streams converge v Use of a mask is associated with greater dead space than an ETT v

Anesthesia Breathing Systems v Carbon dioxide neutralization v Influenced by v Size of granules v Presence or absence of channeling in the canister (areas of loosely packed granules, minimized by baffle system) v Tidal volume in comparison to void space of the canister v v TV should not exceed air space between absorbent granules (1/2 absorbent capacity) Ph sensitive dye v Ethyl violet indicator turns purple when soda lime exhausted (change when 50 -70% has changed color) v Regeneration: Exhausted granules may revert to original color if rested, no significant recovery of absorptive capacity occurs (change canister!!)

Anesthesia Breathing Systems v Carbon dioxide neutralization v Maximum absorbent capacity 26 L of CO 2/100 g granules v Granules designated by Mesh size (4 -8 mesh) v A compromise between higher absorptive surface area of small granules & the lower resistance to gas flow of larger granules v Toxic byproducts v The drier the soda lime, the more likely it will absorb & degrade volatile anesthetics (this is bad since the absorber is designed to absorb CO 2 and not to further degrade. VAA

Disadvantages of Circle System v Greater size, less portability v Increased complexity v Higher risk of disconnection or malfunction v Increased resistance (of valves during spontaneous ventilation) v Dissuading use in Pediatrics (unless a circle pedi system used) v Difficult prediction of inspired gas concentration during low fresh gas flow

Anesthesia Breathing Systems v Airway Humidity Concerns v Anesthesia machine FGF dry and cold v Medical gas delivery systems supply dehumidified gases at room temp. v Exhaled gas is saturated with H 2 O at body temp v High flows (5 L/min) low humidity v Low flows (<0. 5 L/min) allow greater H 2 O saturation v Absorbent granules: significant source of heat/moisture (soda lime 14 -19% water content) Normal upper airway humidification bypassed under General Anesthesia v Passive heat and humidity (“Artificial Nose”) v Active heat and humidity (electrically heated humidifier) v

Bacterial Contamination v Slight risk of microorganism retention in Circle system that could (theoretically) lead to respiratory infections in subsequent pts v Bacterial filters are incorporated into EXPIRATORY LIMB of the circuit

Mode Reservoir Rebreathing Example Open No No Semi-open Yes No Semi-closed Yes Closed Yes Open drop Nonrebreathing circuit or Circle at high FGF (>VE) Yes, partial Circle at low FGF (<VE) Yes, complete Circle (if APL valve closed)

The End 1. Mapleson WW. The elimination of rebreathing in various semiclosed anaesthetic systems. British journal of Anaesthesia; 1954; 26: 323 -32. v 2. Ward CS. In: Anaesthetic equipment. Physical principles and maintenance; W. B. Saunders, London; 2 nd ed. 1985. v