Anaesthesia Breathing Circuits (EORCAPS 2009)

Dr.
A K Sethis EORCAPS-2009
Dr. A K Sethis EORCAPS-2009
Breathing System
Anaesthesia Breathing Circuits
A breathing system is defined as an assembly of

components which connects the patients airway to the
anaesthetic machine creating an artificial atmosphere, from
Dr. Pradeep Jain
and into which the patient breathes
Link machine to the patient
Eliminate CO2
Requirements of
Breathing System
Component of Breathing system
A fresh gas entry port/delivery tube through which the gases

are delivered from the machine to the systems
A port to connect it to the patients airway
A reservoir for gas, in the form of a bag or a corrugated tube

to meet the peak inspiratory flow requirements
An expiratory port/valve through which the expired gas is

vented to the atmosphere
A CO2 absorber if total rebreathing is to be allowed
Corrugated tubes for connecting these components
Requirements of
A Breathing System
Essential: The breathing system must
Have minimal apparatus dead space
Have low resistance
Deliver the gases from the machine to the alveoli in the

same concentration as set and in the shortest possible time
Effectively eliminate CO2
Desirable: The desirable requirements are
Economy of fresh gas
Conservation of heat
Adequate humidification of inspired gas
Light weight
Convenience during use
Efficiency during spontaneous as well as controlled ventilation
Adaptability for adults, children and mechanical ventilators
Provision to reduce theatre pollution
History
McMohan 1951 classified them as open, semi closed &

closed - criteria rebreathing
Dripps 1984 - Insufflation, Open, Semi open, Semi closed

& Closed - criteria presence or absence of Reservoir,
Rebreathing, CO2 absorption & Directional valves
Conway 1985 suggested functional classification according

to the method used for CO2 elimination
Breathing systems with CO2 absorber
Breathing systems without CO2 absorber
Miller 1995 new breathing system called Maxima
Classification of Breathing Systems

Breathing Systems Without Co2 Absorption.
Breathing Systems With Co2 Absorption.
Unidirectional flow:
a.
Non rebreathing systems.
Unidirectional flow
Circle system with absorber.
Bi-directional flow:
a) Afferent reservoir systems.
Mapleson A
Mapleson B
Mapleson C
Lacks system.
B) Enclosed afferent reservoir systems
Millers (1988)
c) Efferent reservoir systems
Mapleson D
Mapleson E
Mapleson F
Bains system
d) Combined systems
Humphrey ADE
Bi-directional flow
To and Fro system.
Non Rebreathing System

Non Rebreathing Valves - Unidirectional Flow
FGF has to be constantly adjusted, not economical
No humidification of inspired gas
No conservation of heat
Inconvenient as the bulk of the valve near the patient
Valve malfunction due to condensation of moisture
Eg. Ruben valve, Ambu valve & Laerdal valve
Open System
Insufflation
Four Basic Circuits
Open
Blow anesthetic gas over face
Semi-open
No direct contact
Semi-closed
No rebreathing of gases
Closed
Ventilation cannot be controlled
Unknown amount delivered
Open Systems
Semi-open Systems
Open drop anesthesia
Gauze covered wire mask
Anesthetic dripped
Inhaled air passes through gauze & picks up anesthetic
Concentration varies
Environmental pollution
Reservoir
No rebreathing
Bi-Directional Flow
Semi Closed
Mapleson Breathing System
Absence of unidirectional value to direct gases to and fro

from the patient
No device for absorbing CO2
Flow controlled breathing systems
FGF must wash CO2 out of the circuit
No clear separation of inspired and expired gases rebreathing will occur when inspiratory flow exceeds FGF
Composition of inspired mixture will depend upon
rebreathing
Depend on the FGF for effective CO2 elimination
Functions can be manipulated by changing
Fresh Gas Supply
Elimination of CO2
Apparatus Dead Space
Classification
Low do not eliminate CO2 effectively

High wastage
If the system has to deliver a set concentration in the shortest possible time
to the alveoli, the FGF should be delivered as near the patients airway as
possible
Five Basic types
Elimination of CO2
Fresh Gas Supply;
Systems extensively used
CO2 without circuit
Bi-Directional Flow
parameters like
Normal production of CO2 in a 70 kg patient 200 ml/min

End-tidal concentration of CO2 is 5%
For elimination 200ml of of CO2 as a 5% gas mixture, the alveolar
ventilation has to be: 200 x 100 = 4,000 ml.
5
4 litres is the normal alveolar ventilation.
A through E
F added by willis in 1975
Apparatus Dead Space
It is the volume of the breathing system from the patient-end to the point up
to which, to and fro movement of expired gas takes place
Mapleson A
Mapleson Classification
Reservoir bag
Corrugated tubing
Magill Circuit
Popularized by Sir Ivan Magill in 1920s
It differs from the other Mapleson systems in that fresh gas does not
enter the system near the patient connection but enters at the other
APL valve
end of the system near the reservoir bag.
FGI
Patient connection
A corrugated tubing connects the bag to the adjustable pressure

limiting (APL) valve at the patient end of the system
Length of corrugated breathing tube 110 cm with an internal volume
of 550 ml
Functional Analysis
Mapleson A
Mapleson A with Spontaneous Breathing
Most efficient for spontaneous respiration
Resistance 2.5cm of H2O when expiratory valve is fully open
No rebreathing if FGF equal to minute volume
Rebreathing occurs if FGF less than alveolar ventilation
Mapleson B & C systems
Functional Analysis
Mapleson A with Control Ventilation
In order to reduce the rebreathing of alveolar gas and to

improve the utilization of FG during controlled
a = at the end of inspiration
ventilation, the FG entry was shifted near the patient.
b = at the end of expiration
This allows a complete mixing of FG and expired gas.

c = during subsequent inspiration
The end result is that these systems are neither efficient

during spontaneous nor during controlled ventilation.
d = at the end of subsequent inspiration
Modifications of Mapleson A Circuit

Lack Circuit
Added expiratory limb which runs from pt end to APL

valve at machine end
This limb is coaxially placed inside the affarent limb
Length 1.5 m, resistance 1.63 cm H2O
Advantage
Enclosed Afferent Reservoir System
Miller & Miller 1988
Mapleson A system enclosed within a non

distensible structure
reservoir bag alone in a bottle and connecting
Facilitates easy scavenging

Easy adjustment of APL valve
the expiratory port to the bottle with a

corrugated tube and a one way valve
Disadvantage
Increased resistance to breathing
It may also be constructed by enclosing the
To the bottle is also attached a reservoir bag

and a variable orifice for providing positive
pressure ventilation.
Efferent Reservoir Systems

Mapleson DEF
Enclosed Afferent Reservoir System

Functional analysis:
During
spontaneous ventilation it is identical to the Mapleson A system
this mode the variable orifice is kept widely open to allow free communication
to the atmosphere
In
In
controlled ventilation the reservoir bag B is squeezed intermittently & the

variable orifice is partly closed to allow building up of pressure in the bottle
function similarly
a FGF port & a port for connection to a
pressure thus developed closes the expiratory valve squeezes the enclosed
afferent reservoir and the patient gets ventilated
this system should function efficiently during spontaneous and
controlled ventilation with a FGF equivalent to alveolar ventilation
The T-piece is a three-way tubular

connector with a patient connection port,
The
Hence
All have a T-piece near the patient and
corrugated tubing
Light metal tube 1cm in diameter ,5cm in

length with a side arm
6 mm tube as the affarent limb that supplies

the FG from the machine
Mapleson D
Mapleson D Functional Analysis

Spontaneous Ventilation
A length of tubing connects the T-piece at the patient end

to the APL valve and the reservoir bag adjacent to it
The length of the tubing determines the distance the user

can be from the patient but has minimal effects on
ventilation
Popular because excess gas scavenging is relatively easy
Most efficient of the Mapleson systems during controlled

ventilation
Mapleson D Functional Analysis

Controlled Ventilation
Bain Breathing Circuit
Modified Mapleson D
Bain 1972
The fresh gas supply tube runs coaxially inside the corrugated tubing
and ends at the point where the fresh gas would enter if the classic
Mapleson D form were used
The outer tube is clear so that the inner tube can be inspected
The outer tubing of most commercially available versions of the

Bain system is narrower than conventional corrugated tubing
A long version of the Bain system may be used for remote

anesthesia in locations such as MRI
Bain Circuit
Bain System
Depends on fresh gas flow to flush out CO2
Spontaneous ventilation
Coaxial length 1.8m
200 - 300 ml / kg / min
Inner inspiratory tubing - 7 mm diameter
Controlled ventilation
Outer expiratory tubing - 22 mm diameter
Resistance - < 0.7 cm H2O
infants <10kg
2 L/m
adult > 60 kg
70 ml/kg/min
Relation Between Alveolar

Ventilation and FGF
Bain System Advantages
Light-weight, Compact, easy to handle
Warming of inspired gases
Partial rebreathing improves humidification
Ability of scavenging
Can be used with ventilator
Mapleson E
Disadvantage
Accidental disconnection of inner tube, kinking & twisting of

inner tube converts entire exhalation limb into dead space
FGF may be connected to outer tube
Lower FGF may result in re-breathing
Tests-visual inspection for damage, disconnection
Pethicks test, occlusion test
Ayres T Piece, 1937

Low resistance, low dead space
Simple piece of metal with 3 limbs & a port at the end of
each limb
Exhalation tube is a reservoir
No bag
FGF near mask
Mapleson E
Mapleson F
Hazards
Jackson Rees Modification
Addition of a bag with an opening to exhalation limb of T- piece
Over inflation and barotrauma by prolonged occlusion
Corrugated hose 15cm X 11 mm
and no feel of inflation
Reservoir bag 0.5 1 L
Green tube for FGF 1.5m in length
Advantage
Also pressure buffering effect of bag absent
Early to assist / Controlled ventilation
Easy to monitor ventilation
Advantage of the Mapleson Systems

Simple,
inexpensive, light weight. With the exception of the APL

valve, there are no moving parts
coaxial systems (Lack, Bain), the inspiratory limb is heated by the
warm exhaled gas in the coaxial expiratory tubing
Disadvantage of the Mapleson Systems
atmospheric pollution, and difficulty assessing spontaneous

ventilation
In
Resistance
is usually low at flows likely to be experienced in practice
Require high gas flows - results in higher costs, increased
Inspired heat and humidity tend to be low because of high FGF
In the Mapleson A, B, and C systems the APL valve is located close
Easy
to position conveniently. A long Mapleson D system may be

used to ventilate a patient in the MRI unit
to the patient, where it may be inaccessible to the user.
The Mapleson E and F systems are difficult to scavenge
system
Air dilution can occur with the Mapleson E system.
Changes
Mapleson systems are not suitable for patients with malignant
Compression
& compliance volume losses are less than with the circle
in fresh gas concentrations result in rapid changes in

inspiratory gas composition
hyperthermia
Combined System
Humphrey ADE
different modes of ventilation

Humphery designed a system called Humphery ADE in 1983
Two reservoirs, one in the afferent limb and the other in the
work of breathing
Prevent rebreathing
Volume of the non rebreathing circuit is small as
efferent limb
compared with that of circuit system, the compression
Only one reservoir will be in operation and the system can be
and compliance volume will be significantly less. This
changed from ARS to ERS by changing the position of a lever
Can be used for adults as well as children
Functional analysis is the same as Mapleson A in ARS mode and

as Bain in ERS mode
To over come the difficulties of changing the breathing system for
Paediatric Circuit
Not yet widely used
improves the ability to observe respiratory effect as

reflected by movement of the anaesthesia bag
Mapleson D recommended for use in children < 10 kg wt
Which system have the FGF
Questions ?
near the reservoir bag
Apparatus Dead Space extend

upto
In ARS
Expiratory valve
In ERS
Fresh Gas entry
F circuit was introduced by

Whom & When?
Willis 1975
Bain Circuit
Coaxial length
1.8 meter
Inner inspiratory tubing diameter
7 mm
Outer expiratory tubing diameter
22 mm
Resistance
<0.7 cm H2O
The Reservoir bag ruptures at

what pressure?
50 cm H2O (5 KPcs)
The efficiency of the circuit

is determined in terms of
Which system is most efficient with

respect to prevention of rebreathing
during Spontaneous Respiratory
A > DEF > BC
CO2 elimination
FGF utilization
Which system is most efficient with

respect to prevention of rebreathing
during Controlled ventilation
To prevent rebreathing of CO2

system DEF require a FGF of
2.5 times the minute volume
DEF > BC > A
In spontaneous respiration to
prevent rebreathing the
Mapleson A requires flow rate
Equal to minute volume

Anaesthesia Breathing Circuits (EORCAPS 2009)

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Dr.

Dr. A K Sethis EORCAPS-2009

Dr. A K Sethis EORCAPS-2009