ContContSophisticated computerized controls are able to provide advanced types of Sophisticated computerized controls are able to provide advanced types of ventilatory support such as ventilatory support such as synchronized intermittent mandatory ventilation synchronized intermittent mandatory ventilation ((SIMVSIMV), pressure-controlled ventilation (), pressure-controlled ventilation (PCVPCV),), and pressure-support (and pressure-support (PSVPSV) ) assisted ventilationassisted ventilation, in addition to the conventional , in addition to the conventional control-mode control-mode ventilation(ventilation(CMVCMV))..

Because the patient's mechanical breath is Because the patient's mechanical breath is delivered without the use of delivered without the use of compressed gas to actuate a bellowscompressed gas to actuate a bellows, these systems consume , these systems consume dramatically dramatically less compressed gas during ventilator operation than traditional pneumatic less compressed gas during ventilator operation than traditional pneumatic ventilators doventilators do..

This improvement in efficiency may have clinical significance when the This improvement in efficiency may have clinical significance when the anesthesia workstation is used in a setting where no pipeline gas supply is anesthesia workstation is used in a setting where no pipeline gas supply is available (e.g, available (e.g, remote locations or office-based anesthesia practicesremote locations or office-based anesthesia practices).).

FGC FGC (fresh gas coupling=DCD)(fresh gas coupling=DCD) FGD FGD (fresh gas decoupling=SCD)(fresh gas decoupling=SCD)

(Piston-driven single-circuit ventilators) (Double-circuit driven ventilators)

PointPointNew ventilators that use fresh gas decoupling technology virtually eliminate New ventilators that use fresh gas decoupling technology virtually eliminate the possibility of the possibility of barotraumabarotrauma from from oxygen flushing oxygen flushing during the inspiratory during the inspiratory phase because fresh gas flow and oxygen flush flow are diverted to the phase because fresh gas flow and oxygen flush flow are diverted to the reservoir breathing bag. reservoir breathing bag.

However, if the However, if the breathing bag has a leak or is absentbreathing bag has a leak or is absent, patient , patient awarenessawareness under anesthesia and delivery of a lower than expected under anesthesia and delivery of a lower than expected oxygenoxygen concentration could occur because of entrainment of room air.concentration could occur because of entrainment of room air.

3) Cycling Mechanism3) Cycling Mechanism

Most anesthesia machine ventilators are Most anesthesia machine ventilators are time cycledtime cycled and provide ventilator and provide ventilator support in the support in the control modecontrol mode..

The The inspiratory phase is initiated by a timing device.is initiated by a timing device.

Older pneumatic ventilators use a fluidic timing device. Older pneumatic ventilators use a fluidic timing device.

Contemporary electronic ventilators use a solid-state electronic timing device and Contemporary electronic ventilators use a solid-state electronic timing device and are thus classified as are thus classified as time cycled and electronically controlledtime cycled and electronically controlled. .

More advanced ventilation modes such as More advanced ventilation modes such as SIMV, PCVSIMV, PCV, and modes that use a , and modes that use a pressure-supportpressure-support option may have an adjustable threshold pressure trigger as option may have an adjustable threshold pressure trigger as well.well.

In these modes, pressure sensors provide feedback to the ventilator control In these modes, pressure sensors provide feedback to the ventilator control system to allow it to determine when to initiate or terminate the respiratory cycle.system to allow it to determine when to initiate or terminate the respiratory cycle.

4) Bellows Classification4) Bellows Classification

The direction of bellows movement during the The direction of bellows movement during the expiratory phaseexpiratory phase determines the determines the bellows classification.bellows classification.

Ascending (standing) bellows ascend during the expiratory phaseAscending (standing) bellows ascend during the expiratory phase , whereas , whereas descending (hanging) bellows descend during the expiratory phasedescending (hanging) bellows descend during the expiratory phase..

Older pneumatic ventilatorsOlder pneumatic ventilators and some new anesthesia workstations use and some new anesthesia workstations use weighted weighted descending bellowsdescending bellows, but most , but most contemporary electronic ventilators contemporary electronic ventilators have an ascending bellows designhave an ascending bellows design..

Of the two configurations, the Of the two configurations, the ascending bellows is generally saferascending bellows is generally safer..

An ascending bellows will not fill if a total disconnection occursAn ascending bellows will not fill if a total disconnection occurs. .

However, the However, the bellows of a descending bellows ventilator will continue its bellows of a descending bellows ventilator will continue its upward and downward movement despite patient disconnectionupward and downward movement despite patient disconnection. .

ContCont

Anesthesia ventilators with Anesthesia ventilators with ascending bellows (bellows that ascend ascending bellows (bellows that ascend during the expiratory phase) are safer than descending bellows during the expiratory phase) are safer than descending bellows because disconnections will be readily manifested by failure ascending because disconnections will be readily manifested by failure ascending bellows to refill.bellows to refill.

With ascending bellows anesthesia ventilators, fresh gas flow and oxygen With ascending bellows anesthesia ventilators, fresh gas flow and oxygen flushing during the inspiratory phase contribute to the patient's tidal volume flushing during the inspiratory phase contribute to the patient's tidal volume because the ventilator relief valve is closed. because the ventilator relief valve is closed.

Oxygen flushing Oxygen flushing during the inspiratory phase can cause volutrama and/or during the inspiratory phase can cause volutrama and/or barotrauma, (particularly in pediatric patients). barotrauma, (particularly in pediatric patients).

Therefore, the oxygen flush should never be activated during the inspiratory Therefore, the oxygen flush should never be activated during the inspiratory phase of mechanical ventilation.phase of mechanical ventilation.

What is good about the What is good about the bellows?bellows?

What is bad about the bellows?What is bad about the bellows?

What is good about the What is good about the bellows?bellows?

Low opening pressure

What is good about the What is good about the bellows?bellows?

What is bad about the bellows?What is bad about the bellows?Low opening pressure

Tachycardia and Hypertension

What is good about the What is good about the bellows?bellows?

What is bad about the bellows?What is bad about the bellows?Low opening pressure

Tachycardia and HypertensionIn the anesthesiologist

Who feels total obstruction

Operating Principles of Ascending Bellows VentilatorsOperating Principles of Ascending Bellows Ventilators

Operating Principles of Ascending Bellows VentilatorsOperating Principles of Ascending Bellows Ventilators

Contemporary examples Contemporary examples of ascending bellows, double-circuit, of ascending bellows, double-circuit, electronic ventilators.electronic ventilators.

It may be viewed as It may be viewed as a breathing bag (bellows) located within a clear a breathing bag (bellows) located within a clear plastic boxplastic box. The bellows physically separates the driving gas circuit from . The bellows physically separates the driving gas circuit from the patient gas circuit. the patient gas circuit.

The driving gas circuit is located outside the bellowsThe driving gas circuit is located outside the bellows, and , and the patient the patient gas circuit is inside the bellows. gas circuit is inside the bellows.

During the inspiratory phase, the driving gas enters the bellows chamber, During the inspiratory phase, the driving gas enters the bellows chamber, which causes the pressure within it to increase. This increase in pressure is which causes the pressure within it to increase. This increase in pressure is responsible for two events:responsible for two events:

First, the ventilator relief valve closes, thereby preventing anesthetic gas from First, the ventilator relief valve closes, thereby preventing anesthetic gas from escaping into the scavenging system.escaping into the scavenging system.

Second, the bellows is compressed, and the anesthetic gas within the bellows Second, the bellows is compressed, and the anesthetic gas within the bellows is delivered to the patient's lungs. is delivered to the patient's lungs.

This compression action is analogous to the hand of the This compression action is analogous to the hand of the anesthesiologist squeezing the breathing bag.anesthesiologist squeezing the breathing bag.

During the expiratory phase , the driving gas exits the bellows housing. During the expiratory phase , the driving gas exits the bellows housing.

This produces a drop to atmospheric pressure within both the bellows housing This produces a drop to atmospheric pressure within both the bellows housing and the pilot line to the ventilator relief valve. and the pilot line to the ventilator relief valve.

The decrease in pressure to the ventilator relief valve causes the “mushroom The decrease in pressure to the ventilator relief valve causes the “mushroom valve” portion of the assembly to open.valve” portion of the assembly to open.

Exhaled patient gases refill the bellows before any scavenging can begin.Exhaled patient gases refill the bellows before any scavenging can begin.

The bellows refills first because a weighted ball (like those used in ball-type The bellows refills first because a weighted ball (like those used in ball-type positive end-expiratory pressure [PEEP] valves) or similar device is positive end-expiratory pressure [PEEP] valves) or similar device is incorporated into the base of the ventilator relief valve.incorporated into the base of the ventilator relief valve.

Because this ball produces Because this ball produces 2 to 3 cm H2O 2 to 3 cm H2O of backpressure, scavenging of backpressure, scavenging occurs only after the bellows fills completely and the pressure inside the occurs only after the bellows fills completely and the pressure inside the bellows exceeds the pressure threshold of the “ball valve.” bellows exceeds the pressure threshold of the “ball valve.”

This design causes all ascending bellows ventilators to produce 2 to 3 cm This design causes all ascending bellows ventilators to produce 2 to 3 cm H2O of PEEP within the breathing circuit when the ventilator is in use.H2O of PEEP within the breathing circuit when the ventilator is in use.

Scavenging occurs just during the expiratory phase because the ventilator Scavenging occurs just during the expiratory phase because the ventilator relief valve is open only during expiration.relief valve is open only during expiration.

It is important for anesthesia care providers to understand that on most It is important for anesthesia care providers to understand that on most anesthesia workstations, gas flow from the anesthesia machine into the anesthesia workstations, gas flow from the anesthesia machine into the breathing circuit is continuous and independent of ventilator activity.breathing circuit is continuous and independent of ventilator activity.

During the inspiratory phase of mechanical ventilation, the ventilator During the inspiratory phase of mechanical ventilation, the ventilator relief valve is closed ,and the breathing system's APL valve (pop-off relief valve is closed ,and the breathing system's APL valve (pop-off valve) is most commonly out of circuit.valve) is most commonly out of circuit.

Therefore, the patient's lungs receive the volume from the bellows Therefore, the patient's lungs receive the volume from the bellows plus that from the flow meters during the inspiratory phase.plus that from the flow meters during the inspiratory phase.

Usually, the volume gained from the flow meters during inspiration is Usually, the volume gained from the flow meters during inspiration is counteracted by the volume lost to compliance of the breathing circuit, and counteracted by the volume lost to compliance of the breathing circuit, and the the set tidal volume generally approximates the exhaled tidal volumeset tidal volume generally approximates the exhaled tidal volume..

Factors that influence the correlation between set tidal volume and exhaled Factors that influence the correlation between set tidal volume and exhaled tidal volume include the flow meter settings, inspiratory time, compliance of tidal volume include the flow meter settings, inspiratory time, compliance of the breathing circuit, external leakage, and the location of the tidal volume the breathing circuit, external leakage, and the location of the tidal volume sensor.sensor.

However, certain conditions such as inappropriate activation of the oxygen However, certain conditions such as inappropriate activation of the oxygen flush valve during the inspiratory phase can result in barotrauma or flush valve during the inspiratory phase can result in barotrauma or volutrauma (or both) because excess pressure and volume may not be able volutrauma (or both) because excess pressure and volume may not be able to be vented from the circle system .to be vented from the circle system .

Ventilator Problems & HazardsVentilator Problems & Hazards

Circuit disconnect ,misconnection(Circuit disconnect ,misconnection(MOST COMMONLYMOST COMMONLY): Pplatu↓, PIP↓): Pplatu↓, PIP↓

Occlusion ,obstruction : Pplatu↑ ,PIP↑Occlusion ,obstruction : Pplatu↑ ,PIP↑

Barotrauma ,velotrauma : Pplatu↑ ,PIP↑Barotrauma ,velotrauma : Pplatu↑ ,PIP↑

Leak in bellows assembly: Pplatu ↑,PIP↑,SPO2↓,AwarnessLeak in bellows assembly: Pplatu ↑,PIP↑,SPO2↓,Awarness

Mechanical problemsMechanical problems

Electrical problemsElectrical problems

Circuit disconnectCircuit disconnect

Breathing circuit misconnections and disconnection are a leading cause of Breathing circuit misconnections and disconnection are a leading cause of critical incidents in anesthesia.critical incidents in anesthesia.

The most common disconnection site is at the Y-piece.The most common disconnection site is at the Y-piece.

Disconnections can be complete or partial (leaks).Disconnections can be complete or partial (leaks).

In the past, In the past, a common source of leaks with older absorbers was failure a common source of leaks with older absorbers was failure to close the APL valve (or pop-off valve) on initiation of mechanical to close the APL valve (or pop-off valve) on initiation of mechanical ventilation.ventilation.

On today's anesthesia workstations, the bag/ventilator selector switch has On today's anesthesia workstations, the bag/ventilator selector switch has virtually eliminated this problem because virtually eliminated this problem because the APL valve is usually out of the APL valve is usually out of circuitcircuit when the ventilator mode is selected. when the ventilator mode is selected.

Preexisting undetected leaks can exist in compressed, corrugated, Preexisting undetected leaks can exist in compressed, corrugated, disposable anesthetic circuits. disposable anesthetic circuits.

To detect such a leak preoperatively, the circuit must be fully expanded To detect such a leak preoperatively, the circuit must be fully expanded before being checked for leaks. before being checked for leaks.

As mentioned previously, disconnections and leaks are manifested more As mentioned previously, disconnections and leaks are manifested more readily with the readily with the ascending bellows ascending bellows ventilator systems because they result ventilator systems because they result in a situation in which the bellows will not refill.in a situation in which the bellows will not refill.

Diagnostic of Diagnostic of disconnection or leak disconnection or leak ::

1. 1. Ascending bellows will not refill

2. The most important monitor is a vigilant anesthesia (breath sounds and chest wall excursion )

3. Pneumatic and electronic pressure monitors (peak inspiratory pressure, threshold pressure alarm limit, autoset)

4. Respiratory volume monitors (exhaled tidal volume, inhaled tidal volume, minute volume)

5. Carbon dioxide monitors (↓P- END -Tidal Co2 )

Several disconnection monitors existSeveral disconnection monitors existThe most important monitor is a vigilant anesthesia The most important monitor is a vigilant anesthesia care provider care provider monitoring breath sounds and chest wall excursion in addition to both the monitoring breath sounds and chest wall excursion in addition to both the mechanical (spirometers and pressure sensors) and physiologic monitors.mechanical (spirometers and pressure sensors) and physiologic monitors.

Pneumatic and electronic pressure monitors are helpful in diagnosing Pneumatic and electronic pressure monitors are helpful in diagnosing disconnections. Factors that influence monitor effectiveness include the disconnections. Factors that influence monitor effectiveness include the disconnection site, the location of the pressure sensor, the threshold disconnection site, the location of the pressure sensor, the threshold pressure alarm limit, the inspiratory flow rate, and the resistance of the pressure alarm limit, the inspiratory flow rate, and the resistance of the disconnected breathing circuit.disconnected breathing circuit.

An audible or visual alarm is actuated if the peak inspiratory pressure of the An audible or visual alarm is actuated if the peak inspiratory pressure of the breathing circuit does not exceed the breathing circuit does not exceed the threshold pressure alarm limitthreshold pressure alarm limit. . When an adjustable threshold pressure alarm limit is available, such as on When an adjustable threshold pressure alarm limit is available, such as on many workstations from Dräger Medical, the operator should set the many workstations from Dräger Medical, the operator should set the pressure alarm limit to pressure alarm limit to within 5 cm H2O of the peak inspiratory pressure. within 5 cm H2O of the peak inspiratory pressure.

systems that have an “systems that have an “autosetautoset” feature, when activated, the threshold limit ” feature, when activated, the threshold limit is automatically set at is automatically set at 3 to 5 cm H2O pressure below the current peak 3 to 5 cm H2O pressure below the current peak inspiratory pressure.inspiratory pressure.

On such systems, failure to reset the threshold pressure alarm limit may On such systems, failure to reset the threshold pressure alarm limit may result in either an “result in either an “apnea pressure” or “threshold low” alertapnea pressure” or “threshold low” alert. Figure 25-. Figure 25-29 illustrates how a partial disconnection (leak) may be unrecognized by the 29 illustrates how a partial disconnection (leak) may be unrecognized by the low-pressure monitor if the threshold pressure alarm limit is set too low or low-pressure monitor if the threshold pressure alarm limit is set too low or the factory preset value is relatively low.the factory preset value is relatively low.

Respiratory volume monitors are useful in detecting disconnections. Respiratory volume monitors are useful in detecting disconnections. Volume monitors may sense exhaled tidal volume, inhaled tidal Volume monitors may sense exhaled tidal volume, inhaled tidal volume, minute volume, or all three.volume, minute volume, or all three. The user should bracket the high The user should bracket the high and low threshold volumes slightly above and below the exhaled volumes.and low threshold volumes slightly above and below the exhaled volumes.

For example, if the exhaled minute volume of a patient is 10 L/min, For example, if the exhaled minute volume of a patient is 10 L/min, reasonable alarm limits would be 8 to 12 L/min.reasonable alarm limits would be 8 to 12 L/min.

Volume monitor sensors that use infrared light/turbine technologyVolume monitor sensors that use infrared light/turbine technology. . These volume sensors are usually located in These volume sensors are usually located in the expiratory limb the expiratory limb of the of the breathing circuit and thus measure exhaled tidal volume.breathing circuit and thus measure exhaled tidal volume.

This device is actually placed at or near the level of the patient connection This device is actually placed at or near the level of the patient connection and permits measurement of both inhaled and exhaled volume and and permits measurement of both inhaled and exhaled volume and pressurepressure

Carbon dioxide monitors Carbon dioxide monitors are probably the best devices for revealing are probably the best devices for revealing patient disconnections.patient disconnections.

Either a sudden change in the difference between inspiratory and end-tidal Either a sudden change in the difference between inspiratory and end-tidal carbon dioxide concentration or the acute absence of measured carbon carbon dioxide concentration or the acute absence of measured carbon dioxide indicates a disconnection, a nonventilated patient, or other dioxide indicates a disconnection, a nonventilated patient, or other problems.problems.

MisconnectionsMisconnections of the breathing system are unfortunately not uncommon. of the breathing system are unfortunately not uncommon.

Anesthesia workstations, breathing systems, ventilators, and scavenging Anesthesia workstations, breathing systems, ventilators, and scavenging systems incorporate many of these diameter-specific connections.systems incorporate many of these diameter-specific connections.

Occlusion (obstruction)Occlusion (obstruction) of the breathing circuit may occur. of the breathing circuit may occur.

Tracheal tubes can become kinked.Tracheal tubes can become kinked.

Tighten Expiratory Valve CoverTighten Expiratory Valve Cover

Tighten Expiratory Valve Tighten Expiratory Valve CoverCover

Gas Line Filters sometimes crack

Hoses throughout the breathing circuit are subject to occlusion by internal Hoses throughout the breathing circuit are subject to occlusion by internal obstruction or external mechanical forces that can impinge on flow and have obstruction or external mechanical forces that can impinge on flow and have severe consequences. severe consequences.

For example, For example, blockage of a bacterial filter in the expiratory limb blockage of a bacterial filter in the expiratory limb of the of the circle system has resulted in bilateral tension pneumothorax.circle system has resulted in bilateral tension pneumothorax.

Excess inflow to the breathing circuit from the anesthesia machine Excess inflow to the breathing circuit from the anesthesia machine during the inspiratory phase can cause barotraumaduring the inspiratory phase can cause barotrauma. The best example of . The best example of this phenomenon is this phenomenon is oxygen flushing.oxygen flushing.

Excess volume cannot be vented from the system during inspiration Excess volume cannot be vented from the system during inspiration because the ventilator relief valve is closed and the APL valve is out of because the ventilator relief valve is closed and the APL valve is out of circuit.circuit.

A high-pressure alarm, if present, may be activated when the pressure A high-pressure alarm, if present, may be activated when the pressure becomes excessive.becomes excessive.

Maximal inspiratory pressure may be set by the user to a desired peak airway Maximal inspiratory pressure may be set by the user to a desired peak airway pressure. An adjustable pressure relief valve will open when the pressure. An adjustable pressure relief valve will open when the predetermined user-selected pressure is reached.predetermined user-selected pressure is reached.

This feature is dependent on the user having This feature is dependent on the user having preset the appropriate “pop-preset the appropriate “pop-off” pressure. off” pressure.

The setting is too low, insufficient pressure for ventilation may be generated The setting is too low, insufficient pressure for ventilation may be generated and result in inadequate minute ventilation; if set too high, the excessive and result in inadequate minute ventilation; if set too high, the excessive airway pressure may still occur and result in barotrauma.airway pressure may still occur and result in barotrauma.

The piston-driven Fabius GS, as well as others, may also include a factory The piston-driven Fabius GS, as well as others, may also include a factory preset inspiratory pressure safety valve that opens at a preset airway preset inspiratory pressure safety valve that opens at a preset airway pressure, such as 75 cm H2O, to minimize the risk of barotrauma.pressure, such as 75 cm H2O, to minimize the risk of barotrauma.

These strategies may reduce the risk of barotrauma and These strategies may reduce the risk of barotrauma and volutrauma;however, they are no substitute for vigilance of the anesthesia volutrauma;however, they are no substitute for vigilance of the anesthesia care provider.care provider.

Bellows Assembly ProblemsBellows Assembly Problems Leaks can occur in the bellows assembly. Leaks can occur in the bellows assembly.

Improper seating of the plastic bellows housing can result in inadequate Improper seating of the plastic bellows housing can result in inadequate ventilation because a portion of the driving gas is vented to the atmosphere.ventilation because a portion of the driving gas is vented to the atmosphere.

A hole in the bellows can lead to alveolar hyperinflation and possibly A hole in the bellows can lead to alveolar hyperinflation and possibly barotrauma in some ventilators because high-pressure driving gas can enter barotrauma in some ventilators because high-pressure driving gas can enter the patient circuit. the patient circuit.

The oxygen concentration of the patient gas may increase when the driving gas The oxygen concentration of the patient gas may increase when the driving gas is 100% oxygen, or it may decrease if the driving gas is composed of an air-is 100% oxygen, or it may decrease if the driving gas is composed of an air-oxygen mixture.oxygen mixture.

The The ventilator relief valveventilator relief valve can cause problems. can cause problems. Hypoventilation occurs if the Hypoventilation occurs if the valve is incompetentvalve is incompetent because anesthetic gas is delivered to the scavenging because anesthetic gas is delivered to the scavenging system during the inspiratory phase instead of to the patient. Gas molecules system during the inspiratory phase instead of to the patient. Gas molecules preferentially exit into the scavenging system because it represents the path of preferentially exit into the scavenging system because it represents the path of least resistance, and the pressure within the scavenging system can be least resistance, and the pressure within the scavenging system can be subatmospheric. subatmospheric.

The Dräger Medical Narkomed 6000 Series and Fabius GSThe Dräger Medical Narkomed 6000 Series and Fabius GS

Several important differences exist between the traditional circle breathing Several important differences exist between the traditional circle breathing systems of the newest Dräger products.systems of the newest Dräger products.

At first glance, the most notable difference lies in the appearance and At first glance, the most notable difference lies in the appearance and design design of the ventilatorsof the ventilators used with these systems. used with these systems.

From the inconspicuous horizontally mounted Divan piston ventilator of the From the inconspicuous horizontally mounted Divan piston ventilator of the Narkomed 6000 series to the vertically mounted and visible piston ventilator of Narkomed 6000 series to the vertically mounted and visible piston ventilator of the Fabius GS with its absent flow tubes and glowing electronic fresh gas flow the Fabius GS with its absent flow tubes and glowing electronic fresh gas flow indicators, these systems appear drastically different from traditional indicators, these systems appear drastically different from traditional anesthesia systems. anesthesia systems.

The The piston ventilatorpiston ventilator of the Dräger Narkomed 6000 and Fabius GS anesthesia of the Dräger Narkomed 6000 and Fabius GS anesthesia systems may be classified as systems may be classified as electrically powered, piston driven, single circuit, electrically powered, piston driven, single circuit, electronically controlled with fresh gas decoupling.electronically controlled with fresh gas decoupling.

The key concept of the The key concept of the FGD breathing system can be illustrated during the FGD breathing system can be illustrated during the inspiratory phase of mechanical ventilation.inspiratory phase of mechanical ventilation.

ContCont

On workstations equipped with adjustable inspiratory pressure limiters (e.g., the On workstations equipped with adjustable inspiratory pressure limiters (e.g., the Datex-Ohmeda S/5 ADU and Aestiva and the Dräger Medical Narkomed 6000 series, Datex-Ohmeda S/5 ADU and Aestiva and the Dräger Medical Narkomed 6000 series, 2B, 2C, GS, and Fabius GS), maximal inspiratory pressure may be set by the user to a 2B, 2C, GS, and Fabius GS), maximal inspiratory pressure may be set by the user to a desired peak airway pressure. desired peak airway pressure.

An adjustable pressure relief valve will open when the predetermined user-selected An adjustable pressure relief valve will open when the predetermined user-selected pressure is reached. pressure is reached.

This theoretically prevents the generation of excessive airway pressure. This theoretically prevents the generation of excessive airway pressure. Unfortunately, this feature is dependent on the user having preset the appropriate Unfortunately, this feature is dependent on the user having preset the appropriate “pop-off” pressure.“pop-off” pressure.

If the setting is too low, insufficient pressure for ventilation may be generated and If the setting is too low, insufficient pressure for ventilation may be generated and result in inadequate minute ventilation; if set too high, the excessive airway pressure result in inadequate minute ventilation; if set too high, the excessive airway pressure may still occur and result in barotrauma. may still occur and result in barotrauma.

The piston-driven Fabius GS, as well as others, may also include a factory-preset The piston-driven Fabius GS, as well as others, may also include a factory-preset inspiratory pressure safety valve that opens at a preset airway pressure, such as inspiratory pressure safety valve that opens at a preset airway pressure, such as 75 cm H2O75 cm H2O, to minimize the risk of barotrauma., to minimize the risk of barotrauma. These strategies may reduce the risk These strategies may reduce the risk of barotrauma and volutrauma; however, they are no substitute for vigilance of the of barotrauma and volutrauma; however, they are no substitute for vigilance of the anesthesia care provider.anesthesia care provider.

A and B, Inspiratory- and expiratory-phase gas flows of a A and B, Inspiratory- and expiratory-phase gas flows of a Dräger Dräger Narkomed 6000Narkomed 6000 circle system with a piston ventilator and fresh gas circle system with a piston ventilator and fresh gas decoupling. NPR valve, negative-pressure relief valve.decoupling. NPR valve, negative-pressure relief valve.

ContContCurrent Current FGDFGD systems are designed with either systems are designed with either piston-type or descending bellows–piston-type or descending bellows–type ventilatorstype ventilators..

Because the bellows in either of these types of systems refills under slight negative Because the bellows in either of these types of systems refills under slight negative pressure, the accumulated fresh gas from the reservoir bag can be drawn into the pressure, the accumulated fresh gas from the reservoir bag can be drawn into the ventilator for delivery to the patient during the next ventilator cycle. ventilator for delivery to the patient during the next ventilator cycle.

As a result of this design requirement, it is unlikely that FGD, as described here, can As a result of this design requirement, it is unlikely that FGD, as described here, can be used with conventional ascending bellows ventilators, which refill under slight be used with conventional ascending bellows ventilators, which refill under slight positive pressure.positive pressure.

The most significant advantage of circle systems using FGD is a The most significant advantage of circle systems using FGD is a decreased risk for decreased risk for barotrauma and volutraumabarotrauma and volutrauma..

With a With a traditional circle systemtraditional circle system, increases in fresh gas flow from the flow meters or , increases in fresh gas flow from the flow meters or from inappropriate use of the from inappropriate use of the oxygen flush valveoxygen flush valve may contribute directly to tidal may contribute directly to tidal volume, which if excessive, may result in volume, which if excessive, may result in pneumothoraxpneumothorax or other injury. or other injury.

Because systems with Because systems with FGDFGD isolate fresh gas coming into the system from the isolate fresh gas coming into the system from the patient while the ventilator exhaust valve is closed, the risk of patient while the ventilator exhaust valve is closed, the risk of barotrauma is greatly barotrauma is greatly reducedreduced..

Scavenging SystemsScavenging Systems Scavenging is the collection and subsequent removal of waste anesthetic gases Scavenging is the collection and subsequent removal of waste anesthetic gases from the operating room.from the operating room.

In most cases, the amount of gas used to anesthetize a patient for a given In most cases, the amount of gas used to anesthetize a patient for a given anesthetic far exceeds the minimal amount needed. anesthetic far exceeds the minimal amount needed.

Therefore, scavenging minimizes operating room pollution by removing this Therefore, scavenging minimizes operating room pollution by removing this excess of gases.excess of gases.

In 1977In 1977, the National Institute for Occupational Safety and Health , the National Institute for Occupational Safety and Health (NIOSH)(NIOSH) prepared a document titled “Criteria for a Recommended Standard: Occupational prepared a document titled “Criteria for a Recommended Standard: Occupational Exposure to Waste Anesthetic Gases and Vapors.Exposure to Waste Anesthetic Gases and Vapors.

Although it was maintained that a minimal safe level of exposure could not be Although it was maintained that a minimal safe level of exposure could not be defined, the NIOSH proceeded to issue the recommendations .defined, the NIOSH proceeded to issue the recommendations .

In In 19911991, ASTM released the ASTM F1343-91 standard titled “Standard , ASTM released the ASTM F1343-91 standard titled “Standard Specification for Anesthetic Equipment—Scavenging Systems for Anesthetic Specification for Anesthetic Equipment—Scavenging Systems for Anesthetic Gases.Gases.

The document provided guidelines for devices that safely and effectively The document provided guidelines for devices that safely and effectively scavenge waste anesthetic gases to reduce contamination in anesthetizing areas. scavenge waste anesthetic gases to reduce contamination in anesthetizing areas.

NIOSH Recommendations for Trace Gas LevelsNIOSH Recommendations for Trace Gas Levels

ContContThe two major causes of waste gas contamination in the operating room are the The two major causes of waste gas contamination in the operating room are the anesthetic technique anesthetic technique used and used and equipment issuesequipment issues. .

Regarding the anesthetic technique, the following factors cause operating Regarding the anesthetic technique, the following factors cause operating room contamination: room contamination:

1) failure to turn off the gas flow control valves at the end of an anesthetic 1) failure to turn off the gas flow control valves at the end of an anesthetic procedure,procedure,

2) poorly fitting masks,2) poorly fitting masks, 3) flushing the circuit,3) flushing the circuit, 4) filling anesthetic vaporizers, 4) filling anesthetic vaporizers, 5) use of uncuffed endotracheal tubes, 5) use of uncuffed endotracheal tubes, 6) use of breathing circuits that are difficult to scavenge, such as the Jackson-6) use of breathing circuits that are difficult to scavenge, such as the Jackson-

Rees. Rees.

Equipment failure or lack of understanding of proper equipment useEquipment failure or lack of understanding of proper equipment use can also can also contribute to operating room contamination.contribute to operating room contamination.

LeaksLeaks can occur in the high-pressure hoses, the nitrous oxide tank mounting, can occur in the high-pressure hoses, the nitrous oxide tank mounting, the high- and low-pressure circuits of the anesthesia machine, or the circle the high- and low-pressure circuits of the anesthesia machine, or the circle system, particularly at the carbon dioxide absorber assembly. system, particularly at the carbon dioxide absorber assembly.

3737

Components Scavenging systemsComponents Scavenging systems Scavenging systemsScavenging systems generally have five components : generally have five components :

1) the gas-collecting assembly, 1) the gas-collecting assembly,

2) the transfer means,2) the transfer means,

3) the scavenging interface, 3) the scavenging interface,

4) the gas disposal assembly tubing, 4) the gas disposal assembly tubing,

5) an active or passive gas disposal assembly.5) an active or passive gas disposal assembly.

An “An “active systemactive system” uses a central evacuation system to eliminate waste gases. ” uses a central evacuation system to eliminate waste gases. The “weight” or pressure of the waste gas itself produces flow through a The “weight” or pressure of the waste gas itself produces flow through a

““passive systempassive system

Components of a scavenging system. APL valve, Components of a scavenging system. APL valve, adjustable pressure-limiting valveadjustable pressure-limiting valve

The interface The interface should limit the pressure should limit the pressure immediately downstream from the gas-collecting immediately downstream from the gas-collecting assembly to between -0.5 and +10 cm H2O under assembly to between -0.5 and +10 cm H2O under

normal working conditions.normal working conditions.

Scavenging interfacesScavenging interfaces

Open(no valve)Open(no valve)

Close(with valve):Close(with valve):

1) One has 1) One has positive-pressure relief onlypositive-pressure relief only; ;

2) the other has 2) the other has both positive- and negative-pressure reliefboth positive- and negative-pressure relief

A and B, Two A and B, Two open scavenging interfacesopen scavenging interfaces. Each requires an active . Each requires an active disposal system. APL, adjustable pressure-limiting valve; Vent, disposal system. APL, adjustable pressure-limiting valve; Vent,

ventilator relief valveventilator relief valve

ContCont

The efficiency of an open interface depends on several factors. The efficiency of an open interface depends on several factors.

The vacuum flow rate per minute must equal or exceed the minute The vacuum flow rate per minute must equal or exceed the minute volume of excess gases to prevent spillage.volume of excess gases to prevent spillage.

The volume of the reservoir and the flow characteristics within the The volume of the reservoir and the flow characteristics within the interface are important. interface are important.

Spillage will occur if the volume of a single exhaled breath exceeds Spillage will occur if the volume of a single exhaled breath exceeds the capacity of the reservoir.the capacity of the reservoir.

The flow characteristics of the system are important because gas The flow characteristics of the system are important because gas leakage can occur long before the volume of waste gas equals the leakage can occur long before the volume of waste gas equals the reservoir volume if significant turbulence occurs within the interface. reservoir volume if significant turbulence occurs within the interface.

Closed InterfacesClosed Interfaces   A closed interface communicates with the atmosphere through valves. A closed interface communicates with the atmosphere through valves.

All closed interfaces must have a positive-pressure relief valve to vent All closed interfaces must have a positive-pressure relief valve to vent excess system pressure if obstruction occurs downstream from the excess system pressure if obstruction occurs downstream from the interface. interface.

A negative-pressure relief valve is mandatory to protect the breathing A negative-pressure relief valve is mandatory to protect the breathing system from subatmospheric pressure if an active disposal system is system from subatmospheric pressure if an active disposal system is used.used.

Two types of closed interfaces are commercially available:Two types of closed interfaces are commercially available:

1) One has 1) One has positive-pressure relief onlypositive-pressure relief only; ;

2) the other has 2) the other has both positive- and negative-pressure reliefboth positive- and negative-pressure relief. .

Closed scavenging interfaces. Left, Interface used with a passive Closed scavenging interfaces. Left, Interface used with a passive disposal system. Right, Interface used with an active systemdisposal system. Right, Interface used with an active system

Scavenging SystemsScavenging SystemsProtects the breathing Protects the breathing circuit or ventilator from circuit or ventilator from excessive positive or excessive positive or negative pressurenegative pressure. .

Gas Disposal Assembly ConduitGas Disposal Assembly Conduit

The gas disposal assembly conduit conducts waste gas from the scavenging The gas disposal assembly conduit conducts waste gas from the scavenging interface to the gas disposal assembly.interface to the gas disposal assembly.

It should be collapse proof and should run overhead, if possible, to minimize It should be collapse proof and should run overhead, if possible, to minimize the chance of accidental occlusion.the chance of accidental occlusion.

HazardsHazards Scavenging systems minimize operating room pollutionScavenging systems minimize operating room pollution, yet they add , yet they add complexity to the anesthesia system.complexity to the anesthesia system.

A scavenging system functionally extends the anesthesia circuit all the way A scavenging system functionally extends the anesthesia circuit all the way from the anesthesia machine to the ultimate disposal site. from the anesthesia machine to the ultimate disposal site.

This extension increases the potential for problems.This extension increases the potential for problems.

Obstruction of scavenging pathways can cause excessive positive pressure in Obstruction of scavenging pathways can cause excessive positive pressure in the breathing circuit, and barotrauma can occur.the breathing circuit, and barotrauma can occur.

Excessive vacuum applied to a scavenging system can result in undesirable Excessive vacuum applied to a scavenging system can result in undesirable negative pressures within the breathing system. negative pressures within the breathing system.

Fires Fires in engineering equipment rooms that house the in engineering equipment rooms that house the vacuum pumpsvacuum pumps used for used for evacuation of waste anesthetic gases. evacuation of waste anesthetic gases.