Chapter 12

Anesthesia Ventilators
A venti lator (breat hi ng machi ne) is an automati c device desi gned to provi de or
augment pati ent venti lati on. Newer anesthesi a venti l ators are an i ntegral part of the
anesthesi a workst ati on. They are desi gned wi th more f eatures and venti l at ory
modes than earl i er models and have t he abi l i t y to venti l ate more di ff icul t pati ents
and to al low venti l at ion to be tai l ored to t he pati ent' s needs.
Tradi ti onal anesthesi a venti l ators coul d not provi de as hi gh i nspi ratory pressures or
f lows as thei r i ntensive care uni t (I CU) counterpart s (1,2, 3,4). As a resul t , some
I CU vent il at ors needed t o be adapted f or use during surgery i n order t o care f or
pati ents who were dif f i cul t to venti late. If posi ti ve end-expi ratory pressure (PEEP)
were needed, of ten the anest hesia provi der had to add a PEEP val ve to t he
anesthesi a breathi ng system. Some of these valves were i mpreci se, not vari abl e,
and coul d be misconnected (Chapter 7). On some ol der venti l at ors, t he user had to
manual l y enabl e the l ow pressure al arm when the venti l ator was turned ON. Also, i t
may have been necessary to cl ose t he adj ustable pressure l i mi t ing (APL) val ve
and/or turn the bag/venti lator swi tch when turni ng on the vent i lator. Another
drawback of ol der vent i lators was that separate model s or di ff erent bel l ows
assembl i es were requi red for adul t and pedi at ri c pat ients. The del i vered t idal
volume was aff ect ed by f resh gas f l ow and breathi ng system compl iance. Final l y,
ol der venti l at ors off ered onl y vol ume control vent i l at ion.
The demand f or performance equi valent t o ICU venti lat ors has l ed to a number of
i mprovements i n anesthesi a vent i l ators. Hi gh inspi ratory pressures and fl ows can
be del ivered. Newer anesthesia venti l ators have an integral PEEP val ve, and many
have several vent i l atory modes. Another i mprovement i s improved fl exi bi l i t y so that
t he vent i lator can del i ver volumes for a wi de range of pat ients f rom the smal lest
chil d to t he largest adul t . The new vent i l ators are desi gned to overcome t he ef fects
of f resh gas, breathing system compl i ance and gas compressi on on ti dal vol ume.
Turni ng the vent i lator ON i nvolves f ewer steps and automati cal l y enables the l ow
ai rway pressure al arm.
Venti lators used in anesthesi a are covered by i nt ernati onal and U.S. standards
(5,6,7).
Thi s chapt er wi l l cover a number of venti lators avai l abl e at t he ti me of t hi s wri ti ng.
I t i s i mpossi ble t o provi de al l of t he detai ls that need to be mastered t o saf el y use a
part icular venti l ator. Sof t ware updat es and upgrades occur f requentl y. I t i s
i mportant that the user manual be studi ed bef ore usi ng a vent il ator t hat i s
unfami l i ar t o the anesthesi a provider.
Definitions
Barot rauma: I nj ury resul t ing f rom hi gh ai rway pressure.
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Compl i ance: Rati o of a change in volume to a change in pressure. It i s a
measure of di stensi bi l i t y and is usual l y expressed i n mi l l i l i t ers per centi meter
of water (L or mL/cm H
2
O). Most commonl y, compl i ance i s used i n ref erence
t o t he l ungs and chest wal l . Breathi ng system components, especial l y
breat hi ng tubes and the reservoi r bag, al so have compl i ance.
Conti nuous Posi ti ve Ai rway Pressure (CPAP): Ai rway pressure mai ntained
above ambi ent . This t erm i s commonl y used i n reference to spontaneous
venti l ati on.
Exhaust Val ve: Valve i n a venti lator wi t h a bel lows t hat when open al l ows
driving gas to exi t the bell ows housi ng.
Expi ratory Fl ow Ti me: Ti me bet ween t he begi nning and end of expi rat ory
f low.
Expi ratory Pause Ti me: Ti me f rom the end of expi rat ory f low t o the start of
i nspi ratory f low.
Expi ratory Phase Ti me: Ti me bet ween t he st art of expi ratory f low and the
start of i nspi ratory f low. It i s t he sum of t he expi ratory f low and expi ratory
pause ti mes.
Fresh Gas Compensati on: A means to prevent the f resh gas f l ow f rom
af fecti ng the ti dal vol ume by measuri ng the act ual ti dal vol ume and usi ng thi s
i nformati on to change the vol ume of gas del i vered by the venti l at or.
Fresh Gas Decoupl i ng: A means to prevent t he f resh gas f l ow f rom aff ect ing
t he ti dal vol ume by isol ati ng t he f resh gas fl ow so that i t doesn' t enter t he
breat hi ng system duri ng inspi rati on.
I nspi ratory Fl ow Ti me: Period between the begi nni ng and end of i nspi ratory
f low.
I nspi ratory Pause Ti me: That porti on of t he i nspi ratory phase ti me during
whi ch the lungs are hel d i nf l ated at a fi xed pressure or vol ume (i .e., the t i me
duri ng whi ch the i nspi ratory phase has zero f l ow). It i s al so cal l ed the
i nspi ratory hold, inf l ati on hold, and i nspi ratory pl ateau. The i nspi ratory pause
t i me may be expressed as a percentage of the i nspi ratory phase ti me.
I nspi ratory Phase Ti me: Ti me between the start of i nspi rat ory f l ow and the
beginni ng of expi ratory f l ow. I t i s t he sum of t he i nspi ratory f low and
i nspi ratory pause ti mes.
I nspi ratory: Expi ratory Phase Ti me Rat i o (I :E rati o): Rati o of t he i nspi ratory
phase ti me to t he expi ratory phase t ime.
I nspi ratory Fl ow Rate: Rat e at whi ch gas f l ows to t he pat i ent expressed as
volume per uni t of t i me.
I nverse Rat i o Vent il at ion: Vent i l ati on in whi ch t he i nspi ratory phase ti me is
l onger than the expi rat ory phase t i me.
Mi nute Vol ume: Sum of al l ti dal volumes wi t hi n one mi nute.
Peak Pressure: Maximum pressure duri ng the i nspi rat ory phase t i me.
Pl ateau Pressure: Rest ing pressure during the i nspi ratory pause. Ai rway
pressure usual l y f al ls when there i s an inspi ratory pause. This l ower
pressure i s cal l ed the pl ateau pressure.
Posi t i ve End-expi ratory Pressure (PEEP): Ai rway pressure above ambient at
t he end of exhal at ion. This term i s commonl y used i n reference to control led
venti l ati on.
Resistance: Rati o of the change in dri vi ng pressure to t he change i n f l ow
rate. It i s commonly expressed as centi meters of water per l i ter per second
(cm H
2
O/L/second).
Si gh: Del i berat e i ncrease i n t i dal volume f or one or more breaths.
Sol enoid: A component t hat cont rols pneumat i c f l ow by means of an
el ect roni c si gnal .
Spi l l Val ve: The val ve i n an anesthesi a venti l ator t hat all ows excess gases i n
t he breathi ng system to be sent t o the scavengi ng system af ter the bel l ows
or piston has become f ul l y f i l l ed during exhalat i on.
Ti dal Vol ume: Vol ume of gas enteri ng or l eavi ng the pati ent during t he
i nspi ratory or expi ratory phase ti me.
Venti latory (Respi ratory) Rate or Frequency: Number of respi ratory cycl es
per mi nute.
Vol ut rauma: I nj ury due to overdi stent i on of t he l ungs.
Work of Breathing: Energy expended by t he pati ent and/or venti lat or t o move
gas i n and out of the l ungs. It i s expressed as t he rati o of work to volume
moved, commonl y as j oules per l i t er. It i ncludes the work needed to
overcome the el asti c and f low-resi stive f orces of the both t he respi ratory
system and apparat us.
Relationship of the Ventilator to the Breathing System
A venti lator repl aces the reservoi r bag in t he breathi ng system. I t may be
connected t o the breathi ng system by a bag/venti lat or sel ect or val ve (Chapter 9).
On some newer workst at ions, t urni ng the bag/vent i l ator sel ector swi t ch to t he
venti l ator posi t ion or a mode sel ecti on swi tch turns ON the vent i l at or. On other
venti l ators, there i s an ON-OFF swi t ch.
Most anesthesi a venti lat ors have a bel l ows i n a box (bag i n a bot tl e, doubl e ci rcui t )
design (Fi g. 12.1). The bel lows i s housed i n a pressure chamber, and the i nsi de of
t he bel lows is connected to the breathi ng system. The bel l ows acts as an i nterface
bet ween t he breat hi ng system and t he venti l ator drivi ng gas, j ust as the reservoi r
bag acts as an interface bet ween the breathi ng system and the anesthesi a
provi der' s hand. It separat es
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breat hi ng system gas f rom dri vi ng gas. The pressure of t he anesthesi a provi der' s
hand is repl aced by the driving gas pressure t hat compresses the bel l ows.

View Figure

Figure 12.1. Functioning of the bellows-in-box ventilator.
A: Beginning of inspiration. Driving gas begins to be
delivered into the space between the bellows and its
housing. The exhaust valve (which connects the driving gas
pathway with atmosphere) is closed. The spill valve (which
vents excess breathing system gases to the scavenging
system) is also closed. B: Middle of inspiration. As driving
gas continues to flow into the space around the bellows, its
pressure increases, exerting a force that causes the bellows
to be compressed. This pushes the gas inside the bellows
toward the breathing system. The exhaust and spill valves
remain closed. If the pressure of the driving gas exceeds the
opening pressure of the safety relief valve, the valve will
open and vent driving gas to atmosphere. C: End of
inspiration. The bellows is fully compressed. The exhaust
and spill valves remain closed. D: Beginning of expiration.
Breathing system (exhaled and fresh) gases flow into the
bellows, which begins to expand. The expanding bellows
displaces driving gas from the interior of the housing. The
exhaust valve opens, and driving gas flows through it to
atmosphere. The spill valve remains closed. E: Middle of
expiration. The bellows is nearly fully expanded. Driving
gas continues to flow to atmosphere. The spill valve
remains closed. F: End of expiration. Continued flow of gas
into the bellows after it is fully expanded creates a positive
pressure that causes the spill valve at the base of the bellows
to open. Breathing system gases are vented through the spill
valve into the scavenging system.

During i nspi rat i on, dri vi ng gas i s del ivered i nt o the space between the bel l ows and
i ts housi ng. This causes the bel l ows t o be compressed so that gas f l ows i nto the
breat hi ng system. At the same ti me, t he spi l l valve (whi ch vents excess gases t o
t he scavenging syst em) and exhaust valve (whi ch vents dri vi ng gas) are cl osed.
During exhalat i on, the bel l ows re-expands as breathi ng system gases and f resh gas
f low i nt o i t . Dri vi ng gas i s vented t o atmosphere t hrough the exhaust valve. Af ter
t he bel lows is f ul l y expanded, excess gas f rom the breathi ng syst em i s vented to
t he scavenging syst em t hrough t he spi l l valve.
I nst ead of a bel l ows i n a box, some vent i lators have an electri cal l y dri ven pi ston.
By el i mi nati ng the need f or a dri ve gas ci rcui t (an addi t i onal source of compressi bl e
volume), a stabl e fl ow del i very can be provi ded. In piston venti l at or systems that
are presentl y avai l abl e, the reservoi r bag i s not i sol ated f rom the breathi ng syst em
duri ng the exhal at ion phase of automatic vent i l at ion and acts to modul ate pressure
i ncreases in the system. Duri ng i nspi rati on, when the pi ston forces gases i nto the
breat hi ng system, the bag is i sol ated f rom the breathi ng system and col lects the
f resh gas fl ow enteri ng t he breat hi ng system. On some venti lators, the bag can be
seen to expand and cont ract wi th respi rati on even though the pi ston i s actual l y
venti l ati ng the pat i ent . A problem wi th pi st on venti l ators may be ai r entrai nment
wi th a di sconnecti on
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(8,9). I n thi s case, the machine may not al arm and the pati ent wi l l conti nued to be
venti l ated, but ai r wi l l be entrai ned, resul ti ng in l ower concent rati ons of oxygen and
anesthet ic agents.
Factors That Affect the Delivered Tidal Volume
Fresh Gas Flow
Wi th ol der vent il ators, t he del ivered t i dal and mi nute vol umes changed when t he
f resh gas fl ow, I: E rat i o, or respi ratory rate was al tered despi te the bel l ows
excursi on remaini ng unchanged. If t he f resh gas fl ow i ncreased, the ti dal and
mi nute vol umes i ncreased (10, 11,12,13). I f t he f resh gas f l ow decreased, t he ti dal
and mi nute vol umes decreased. Si nce f resh gas was added to t he i nspi red ti dal
volume onl y duri ng i nspi rati on, vent i lator sett i ngs t hat prol onged the i nspi ratory
t i me (and thereby i ncreased t he I:E rat i o) woul d cause an i ncreased ti dal vol ume.
Lower I: E rat i os decrease the t i dal volume. As respi ratory rate i ncreased, t he
i ncrease i n ti dal vol ume f rom f resh gas f l ow was less, al though the eff ect on mi nut e
volume remai ned the same. Slowi ng the respi ratory rate had the opposi te ef f ect .
Manuf acturers have re-engi neered thei r vent i l ators t o el i mi nat e the f resh gas ef fect
on the inspi red vol ume. One method i s to measure t he i nspi red f resh gas f l ow and
compensate f or i t by al teri ng the bel lows excursi on (f resh gas compensat i on).
Another method is t o prevent the f resh gas f rom enteri ng t he breat hi ng system
duri ng inspi rati on by usi ng a valve that divert s the f resh gas i nto a reservoi r bag
duri ng inspi rati on (f resh gas decoupli ng).
Compliance and Compression Volumes
Decreases i n compl i ance i n the breathi ng system can be accompani ed by
decreases i n ti dal vol ume as more of the i nspi ratory f l ow i s expended by expandi ng
t he components. Gas compression l osses depend on t he vol ume of t he breathi ng
system and the pressure duri ng i nspi rati on. Advanced t echnol ogy now al l ows t he
venti l ator to compensat e f or changes in breat hi ng system compl i ance by al teri ng
t he vol ume del ivered. Breat hi ng system compl i ance is determi ned duri ng the
checkout procedure bef ore use. For accurate compl i ance compensat ion, t he
breat hi ng system must be in the conf i gurat ion that is t o be used when the checkout
procedure i s performed. Changes i n t he ci rcui t confi gurat ion (such as lengtheni ng
t he breathi ng tubes or addi ng components) wi l l cause t he compensati on to be
i naccurate (14).
Ot her venti l at ors measure inspi red volumes at t he pat ient connecti on and adjust t he
venti l ator excursi ons accordingl y.
Leaks
A leak around t he tracheal tube or supragl ot ti c device wi l l cause a decrease i n ti dal
volume that i s not taken into account by the venti lat or. Si dest ream gas moni tors
may decrease t he vol ume del i vered to the pat ient.
Components
Driving Gas Supply
Most currentl y avai l abl e anesthesi a vent i lators are pneumat i cal l y powered but
el ect rical l y control l ed. The dri ving (drive, power) gas i s ei t her oxygen, ai r, or a
mi xture of ai r and oxygen. I t i s usuall y less expensive to power the venti l at or wi th
ai r. Some vent i lators can swi t ch bet ween dri vi ng gases so that i f there i s a l oss of
pressure i n the pri mary dri vi ng gas suppl y, t he other gas can be used.
Some venti l at ors use a devi ce cal l ed an i nject or (Vent uri mechanism) to i ncrease
t he dri vi ng gas f l ow. An i nj ector i s shown i n Fi gure 12.2. As the gas fl ow meets a
rest ri ct ion, i ts l ateral pressure drops (Bernoul li pri ncipl e). When the l ateral
pressure drops below atmospheri c, ai r wi l l be ent rai ned. The resul t i s an increase
i n the total gas f l ow l eaving the i nj ector, and a decreased consumpti on of dri vi ng
gas.
A si gni f i cant fl ow of gas is necessary to drive a bel l ows (15, 16,17). The amount wi l l
vary, dependi ng on the venti l at or and t he sett ings. The use of a gas cyl inder t o
power a vent i l ator may qui ckl y depl ete the gas suppl y.
Controls
The vent il ator control s regul ate t he f l ow, vol ume, t imi ng, and pressure of the
bel l ows compressi on or pi ston movement .
Alarms
The vent il ator and workstati on st andards (6, 7) group al arms i nto three categori es:
hi gh, medi um, and l ow pri ori t y, dependi ng on whet her t he condi ti on requi res
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i mmedi ate acti on, prompt acti on, or operat or awareness but not necessari l y act i on
(Chapter 26).

View Figure

Figure 12.2. Injector (Venturi). Gas flows through the
constricted area at a high velocity. The pressure around it
drops below atmospheric, and air is entrained. The net result
is an increase in total gas flow leaving the outlet of the
injector.

The vent il ator st andard (6) mandates an al arm that i ndi cates t hat t he pressure i n
t he breathi ng system has exceeded a set l imi t (hi gh-pressure al arm). On modern
venti l ators, thi s t hreshol d is adjustabl e by the user, usual l y wi th a def aul t around
50 cm H
2
O. There must be an alarm t o indi cat e that the pressure in t he breathing
system has not reached a mini mum val ue wi thin a certain t ime peri od (l ow ai rway
pressure al arm).
Pressure-limiting Mechanism
A pressure-l i mi ti ng mechani sm (pressure-l imi t ing val ve, maximum l i mi ted pressure
mechani sm, dri vi ng gas pressure rel ief val ve, pressure l i mi tat i on mechanism,
maxi mum worki ng pressure control , pressure l i mi t control ler, i nspi rat ory pressure
l i mi t, adj ust abl e pressure rel i ef val ve, hi gh pressure saf ety rel ief val ve,
overpressure rel ease) i s desi gned to l i mi t the i nspi rat ory pressure. The anesthesi a
workstat ion standard (7) mandates t hat thi s be adj ust abl e. An adj ustabl e
mechani sm carri es t he hazard of operator error. I f set too l ow, i nsuf f icient pressure
f or venti l ati on may be generated; i f set too hi gh, excessi ve ai rway pressure may
occur. Set ti ng the pressure l i mi t 10 cm H
2
O above the peak pressure achieved wi th
t he desi red ti dal vol ume and f low rate wi l l avoid most barotrauma (18).
Pressure-l imi ti ng devi ces work i n one of two ways. When t he maxi mum pressure i s
reached, one t ype hol ds the pressure at that l evel unti l the start of exhal at i on, at
whi ch t ime t he pressure decreases. The ot her t ype t ermi nates i nspi rat ion when the
pressure l i mi t i s reached so t hat the pressure drops immediat el y.
Bellows Assembly
Bellows
The bell ows i s an accordionl i ke devi ce that i s attached at ei ther t he top or bot tom
of t he bell ows assembl y. Latex-f ree bel lows are avai labl e. There are t wo types of
bel l ows, disti nguished by thei r moti on duri ng exhal ati on: ascendi ng (standi ng,
upri ght , fl oati ng) and descendi ng (hanging, i nverted). Vent il at ors wi t h descendi ng
bel l ows were common unti l t he mi d 1980s. Af t er t hat , most new venti l at ors had
ascendi ng bel l ows, but descendi ng bel l ows are used by a number of more recent
venti l ators.
Wi th an ascendi ng bell ows (Fi gs. 12.36, 12.44), t he bel lows is at tached at the base
of t he assembl y, and the bel l ows i s compressed downward duri ng i nspi rati on.
During exhalat i on, the bel l ows expands upward. These venti lators i mpose a sl i ght
resi st ance at the end of exhal ati on, at whi ch t i me the pressure i n the bel l ows ri ses
enough (2 to 4 cm H
2
O) t o open the spi l l val ve. The ti dal vol ume may be set di rectl y
by adj usti ng the inspi ratory ti me and f low or by a plate that l imi ts upward excursi on
of t he bell ows. Wi th a di sconnecti on or l eak i n t he breathi ng system, t he bel l ows
wi l l col lapse to t he bot tom or fail t o expand ful l y. The venti lator may cont inue to
del i ver smal l ti dal vol umes (19).
To del i ver the enti re t idal volume, the bel l ows must descend t o the proper l evel or,
dependi ng on the venti l ator, be f ul l y compressed at the end of t he inspi ratory
phase. If t he inspi ratory f l ow i s i nsuff i ci ent to ful l y compress t he bel l ows or achi eve
t he desi red ti dal vol ume, a l ower t i dal volume wi l l be del i vered.
Wi th a descendi ng bell ows (Fi g. 12.50), t he bel lows is at tached at i ts top and is
compressed upward duri ng i nspi rati on. There is usual l y a wei ght i n the dependent
port ion of the bel l ows t hat f aci l i tat es downward re-expansi on duri ng exhalati on. As
t he wei ght descends, i t can cause a smal l negative pressure i n the bel l ows and
breat hi ng system. Wi th a l eak or disconnecti on in t he breathing system, the wei ght
i n the bel l ows wi l l cause the bel l ows t o expand, and room ai r wi l l enter the
breat hi ng system. Al l or part of the next i nspi rati on wi l l then be l ost i nto t he room.
Newer venti lators wi t h hanging bel l ows empl oy sophisti cated sof t ware t o detect
di sconnecti ons or l eaks (20,21). The sof t ware anal yzes sensor outputs and t ri ggers
appropri at e alarms. A negative pressure rel i ef valve prevents the pati ent f rom bei ng
exposed t o negative pressure.
Housing
The bell ows i s surrounded by a clear pl ast ic cyl inder (cani ster, bel l ows chamber or
cyl i nder, pressure dome) t hat al l ows t he bel l ows movement t o be observed. A scal e
on the si de of t he housi ng provides a rough approxi mat ion of the ti dal vol ume bei ng
del i vered. The housing f or piston vent il ators usual l y has a scal e that can be
observed.
Exhaust Valve
The exhaust valve (exhal ati on valve, venti l ator rel i ef valve, compressed gas
exhaust, bel l ows cont rol val ve) communi cates wi t h t he i nsi de of t he bel l ows
housi ng on pneumatical l y powered vent il at ors. It is cl osed duri ng i nspi rat ion.
During exhalat i on, i t opens to al l ow dri vi ng gas i nside the housi ng to be exhausted
t o atmosphere. Wi th a pi ston venti lator, t here is no need for an exhaust val ve.
Spill Valve
Because the APL valve i s isol ated f rom the breat hi ng system duri ng vent i lator
operati on, a spi l l valve (vent valve, dump valve, overf l ow val ve, expi red gas out l et,
expi ratory valve or port , saf et y dump val ve, pop-of f val ve, reli ef valve, f lapper
valve, pressure reli ef valve, overspi l l
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valve, gas evacuati on outl et valve, exhaust gas valve, gas evacuat ion or evacuat or
valve, expi ratory pressure rel i ef val ve) is used to di rect excess respi red gases i nt o
t he scavenging syst em. Thi s valve i s cl osed duri ng i nspi rati on. During exhal at ion, i t
remai ns cl osed unti l the bel l ows or pi ston i s f ul l y expanded, then opens to vent
excess breathi ng system gases. The scavengi ng transfer t ubing connects the
exhal ati on port of the spi l l val ve to t he scavenging system i nterface (Chapter 13).
Wi th an ascendi ng bell ows, the spi l l val ve has a minimum openi ng pressure of 2 t o
4 cm H
2
O (22). This enabl es the bel lows to f il l duri ng exhalati on. Thi s amount of
PEEP i s appl i ed to the breathing system. I t i s not appl i ed wi th a pi st on or a hangi ng
bel l ows venti l ator.
Wi th a pi ston vent il ator, excess gas i s vented through a spi l l valve, whi ch may not
i n the venti l ator, or through an el ect ronical ly control led APL val ve, which acts as a
spil l valve.
Ventilator Hose Connection
The vent il ator st andard (6) requi res that the f i tt ing on the tubi ng connect i ng the
venti l ator to the breathi ng system be a standard 22-mm mal e conical f i t ti ng. A f i l t er
may be used on the t ubi ng to lessen t ransmi ssi on of pathogens and parti cl es. In
most newer vent i lators, a separate hose is not present, and the connect ions
bet ween t he venti l at or and t he breat hi ng system are i nternal . Thi s reduces t he
l ikel i hood of mi sconnecti ons, di sconnect i ons, or ki nked hoses (23).
Positive End-expiratory Pressure Valve
PEEP valves are di scussed in Chapter 7. Modern vent i l ators have i ntegral
el ect rical l y operat ed PEEP valves. Some vent i l ators appl y PEEP to t he ent i re
system, whi l e ot hers appl y i t onl y to t he expi rat ory hose (23).
A standi ng causes a smal l amount (2 to 4 cm H
2
O) of PEEP. There i s no unset
PEEP wi th hangi ng bel l ows or pi st on-driven venti lat ors.
Ventilation Modes
Anesthesi a venti lators of fer one or more vent i lati on modes (18). Many off er dual
modes to gai n the advantages of both. Vent i l ator set ti ngs must be caref ul l y
i ndi vi dual i zed i n each mode t o avoid hypoventi l at ion, hyperventi l at ion, volutrauma,
or barotrauma. I t i s import ant when swi tchi ng f rom one mode t o another t o ensure
t hat the ti dal vol ume, peak pressure, and al arm sett i ngs are appropriate.
A venti lator can del i ver gas by generat i ng f l ow or pressure. Wi th f l ow generators,
t he f l ow pat tern can be constant (square wave) or nonconstant (accel erat ive or
decel erati ve). Pressure generators produce a constant or nonconstant pressure.
I nspi ratory f low rate vari es accordi ng to t he preset pressure and the pati ent' s
resi st ance and compl i ance.
The characteri st i cs of i nspi rat i on and exhalati on rel ated t o the venti l ator set t ings,
compl i ance, and resistance are ref lected i n the pressure and f low-volume l oops.
These are discussed in detail i n Chapter 23.
Features of some commonl y used venti latory modes are shown i n Table 12.1. The
t ermi nol ogy used t o descri be the way a vent i l ator operates has not been universal l y
agreed on, and some manuf act urers have coi ned new terms for thei r vent il ators.
Volume Control
The most commonl y used mode i n the operati ng room i s volume cont rol (vol ume-
control led or vol ume) vent i l at i on, i n whi ch a preset t i dal volume i s del i vered. The
t i dal or mi nute vol ume and respi ratory rate are set by the anest hesi a provi der and
del i vered by t he venti lator, i ndependent of pati ent ef fort. It i s ti me ini t iated, vol ume
l i mi ted, and cycl ed by volume or ti me.
Fl ow rat e is f i xed at a constant val ue during i nspi rati on. If the i nspi ratory f l ow i s t oo
l ow to provi de the set t i dal volume, t he bel lows or pi ston wi l l not compl ete i ts
excursi on. If the f l ow i s set at a f aster rate than i s needed to provi de t he ti dal
volume, there wi l l be an
P. 317

i nspi ratory pause. An excessi vel y hi gh peak i nspi ratory pressure may resul t f rom
sett ing the i nspi ratory f low rat e t oo hi gh (24). The inspi ratory phase may be
t ermi nated before the t idal volume has been deli vered i f t he peak ai rway pressure
reaches the set pressure l imi t .
TABLE 12.1 Ventilatory Modes
Mode I nitiation Limit Cycle
Volume control ventilation Time Volume Volume/Time
Pressure control ventilation Time Pressure Time
Intermittent mandatory
ventilation
Time Volume Volume/Time
Synchronized intermittent
mandatory ventilation
Time/Pressure Volume Volume/Time
Pressure support ventilation Pressure/Flow Pressure Flow/Time

Typical l y, a vol ume cont rol wavef orm shows steadi l y i ncreasing pressure during
i nspi rati on. Changes in compl i ance or resi stance are ref l ected i n changes i n peak
i nspi ratory pressure and the di f f erence bet ween peak and pl ateau pressure (25).
For a given set t idal volume, the pressure in t he breathi ng system i s determi ned by
t he resistance and compl iance of t he breat hi ng system and the pat ient. Plateau
pressure i s a ref lecti on of compl i ance. Peak pressure is al so i nf luenced by
resi st ance. The pressure-volume and f l ow-vol ume loops associ ated wi th volume
control venti l at ion are seen i n Fi gures 23.22 and 23.23.
Addi ng PEEP decreases the t idal volume del i vered, wi t h the eff ect greater wi t h
smal l t i dal volumes (26,27). On newer venti l at ors wi th i ntegral PEEP, venti lati on
may be better mai ntai ned (4).
I f cl osed syst em suct i oni ng is perf ormed duri ng vol ume cont rol venti lati on, there
wi l l be a si gnif i cant ri se i n ai rway pressure when t he catheter i s i nsert ed and l ow
ai rway pressure during sucti oni ng (28,29,30).
Pressure Control
Pressure control (pressure-l i mi ted, pressure-cont rol l ed, pressure-preset control ,
l ung protect ive, or pressure) venti l ati on i s avai l abl e on many anest hesi a venti l ators
(2,31,32,33). Wi th thi s mode, the operator sets the i nspi ratory pressure at a level
above PEEP. The venti lator qui ckl y increases t he pressure to the set l evel at the
start of i nspi rat ion and maintai ns t hi s pressure unt il exhalati on begins.
I nspi ratory gas f l ow i s hi ghest at the begi nni ng of i nspi rati on, then decreases.
I ncreased resistance may change the shape of the f l ow-v ersus-ti me wavef orm to a
f lat t er, more square-shaped pattern as ti dal vol ume del i very shi f ts into the l at ter
part of the i nspi rat ion (25). Thi s al lows the venti l at or t o preserve ti dal vol ume wi t h
i ncreased resistance unt il resistance becomes severe. The pressure-vol ume and
f low-volume l oops show speci al characteri sti cs seen wi t h pressure-cont rol l ed
venti l ati on (Fi gs. 23.29, 23.30).
When pressure cont rol venti lati on is used, t i dal vol ume is determined by the ri se
t i me and set pressure. Ti dal vol ume i s not set or constant but f l uct uates wi th
changes i n resi stance and compl i ance and wi t h pati ent-venti lator asynchrony (25).
I f resistance i ncreases or compli ance decreases, t he t idal vol ume wi l l decrease. I t
has been postul ated t hat a decrease i n t i dal vol ume wi t h pressure control
venti l ati on woul d detect a parti al l y occl uded t racheal t ube, but i t was f ound t hat
t i dal vol ume was not decreased unti l the occl usi on was nearl y compl ete (25).
Unl i ke most I CU vent i l ators, an anesthesia venti l at or i n t he pressure cont rol mode
operates wi th a preset I: E rat i o, so i ncreasing the respi ratory rate short ens
i nspi ratory t i me and l owers ti dal vol ume (2). An i ncrease i n PEEP causes a
reducti on i n t idal volume. Ti dal vol ume is not af fected by f resh gas f l ow because
excess gas is vented through the spi l l valve.
On some venti l at ors, the i nspi ratory f l ow i s adj ustable (Fi g. 12.48). There may al so
be a set t ing that cont rols the inspi ratory ri se t i me. For pati ents wi t h good
compl i ance, i nspi ratory f l ow shoul d be hi gh to ensure that the i nspi rat ory pressure
i s rapi dl y at tained. Li mi t i ng the maxi mum i nspi ratory f l ow i s usef ul to avoid
overshooti ng the target pressure, especi al l y when compl i ance i s l ow.
I n pati ents wi th l ung i nj ury or during singl e-l ung venti l ati on, pressure control
venti l ati on may i mprove oxygenati on and produce great er t i dal vol umes t han
volume cont rol vent i lat i on because of t he decel erati ng f l ow pattern t hat del ivers gas
t o t he al veol i earl y duri ng inspi rati on (31). It i s of ten used wi t h supraglott ic devi ces
and pati ents wi th narrow or parti al l y obst ructed t racheal t ubes to provide vent i lat i on
at rel at ivel y l ow pressures (34, 35). I t may be useful if there is an ai rway l eak (e.g.,
uncuf fed t ube, supraglot t ic ai rway devi ce, bronchopl eural f istul a). However, i f there
i s a l arge leak, t he cycl ing pressure l i mi t may not be reached, causi ng a prol onged
i nspi rati on (18).
During cl osed system suct ioni ng (Chapter 3), pressure control vent i l at ion resul ts in
l ess i nt ri nsi c PEEP during catheter i nsert ion and less subatmospheri c pressure
duri ng sucti oni ng t han during vol ume control venti l ati on (28, 29).
Intermittent Mandatory
Wi th intermi tt ent mandatory vent i l at i on (I MV), t he venti l ator del ivers mechanical
(mandatory, automati c) breaths at a preset rate and permi ts spontaneous,
unassi sted breat hs of a control l abl e i nspi ratory gas mixture bet ween mechani cal
breat hs. The venti lator has a secondary source of gas f low f or spont aneous
breat hs. Thi s uti l i zes ei ther conti nuous gas f l ow wi thi n the ci rcui t or a demand
valve that opens to al low gas to f l ow f rom a reservoi r. Conti nuous gas f l ow at a rate
great er t han peak inspi ratory fl ow i nvol ves no addi ti onal work of breathi ng but
requi res a l arge vol ume of f resh gas. The demand val ve syst em, al though more
ef fi ci ent in f resh gas use, can i mpose signif i cant work of breat hing on the pati ent .
Thi s mode i s of ten used for weani ng pati ents f rom mechanical venti l at i on. The I MV
rate i s gradual l y
P. 318

reduced, al l owi ng increased t ime f or t he pati ent 's spont aneous breat hs.
Synchronized Intermittent Mandatory
Synchroni zed i ntermi t tent mandatory venti l ati on (SIMV) synchroni zes venti l ator-
del i vered breaths wi th the pat ient' s spontaneous breaths. If pati ent i nspi ratory
acti vi ty i s detected, the vent il ator synchroni zes i ts mandat ory breaths so that the
set respi ratory f requency i s achi eved. Posi ti ve pressure (mandat ory) breaths may
occur at i rregul ar i ntervals.
The t i me between the end of each mandatory breath and the begi nni ng of t he next
i s subdivided i nt o a spontaneous breathi ng t i me and a t ri gger ti me. Duri ng the
t ri gger ti me, t he venti lator checks whet her t he ai rway pressure has dropped a
mi nimum amount bel ow t he pressure measured at the end of the expi ratory phase.
I f a drop i s not sensed, t he venti l ator del ivers a breat h. The tri gger wi ndow may be
adj ustable (Fi g. 12.49).
A mandatory ti dal vol ume and a mi nimum mechani cal venti l ati on rate must be
selected. Thi s determines the mi ni mum mi nut e venti lati on. When set ti ng t he
venti l ator rate, the pati ent ' s spont aneous rat e must be consi dered. I f the SIMV rate
i s set too hi gh, t he pati ent may become apnei c. Sett i ng an I:E rat io i s not requi red
i n SIMV. The I: E rati o wi l l change as t he pat i ent' s respi ratory rate and rhythm
changes.
SI MV i s used t o faci l i tate emergence f rom anesthesi a as the pati ent transi t ions
f rom control led to spontaneous vent il ati on. I t ensures a mi ni mal amount of
venti l ati on whi l e f reei ng the anest hesi a provider f rom periodical ly venti l ati ng t he
pati ent by hand. It reduces the incidence of pati ent-venti l ator di sharmony where the
pati ent t ri es to f i ght the venti l ator and the need f or sedati on or narcosis f or t he
pati ent t o tolerate mechanical venti l at ion. Duri ng anesthesia, SI MV may be used to
provi de backup mechani cal venti lati on f or spontaneousl y breathi ng pati ents. SIMV
can be combi ned wi th pressure support vent i l at ion (PSV).
Mandatory Minute
Mandatory mi nute vent i l ati on (MMV) i s a method of mechani cal vent i l ati on in whi ch
t he amount of venti l at ory support i s automat i cal l y adj usted t o f l uctuati ons i n
spontaneous venti lati on so that a preset minute venti l at ion i s del i vered. The
venti l ator ci rcui t ry moni t ors spontaneous expi red vol ume and, i f i t f al l s bel ow a
predetermined l evel , provi des the di ff erence between the sel ect ed and actual
mi nute vol ume.
Pressure Support
PSV (pressure-assi sted or assi sted spontaneous vent i lat i on) has been a f eature of
I CU vent il at ors f or years and is now on many anesthesi a venti lat ors (36,37,38,39).
I t i s desi gned t o augment the pat ient' s spontaneous breathing by appl yi ng posi ti ve
pressure to the ai rway i n response t o pat ient-i ni t i ated breaths. A di sadvantage of
t his mode of venti l ati on i s that if the pati ent f ai l s to make any respi rat ory eff ort, no
pressure-support ed breaths wi l l be i ni ti at ed. To avoi d thi s pot ent i al l y di sastrous
si tuat ion, most vent il ators have a backup or apnei c SI MV rate i n case that the
pati ent 's spontaneous respi rati on ceases (assist/cont rol venti l ati on).
A supported breath may be pressure or f l ow i ni t iated. Flow t ri ggeri ng i mposes l ess
i nspi ratory workl oad t han pressure t ri ggeri ng and i s used more f requent l y (40).
When t he user-sel ect ed f low or sub-basel i ne pressure caused by a spontaneous
breat h is reached, f l ow f rom the venti l ator begi ns and t he set pressure i s qui ckl y
reached. The vent il ator t hen modulates t he f low t o maintai n that pressure. The f l ow
decreases unti l i t f all s bel ow a predetermi ned f racti on of the i ni ti al rate (usual ly 5%
or 25%) or a f i xed f l ow (usual l y 5 L/minut e) or af t er a specif i c durati on as a backup
(41). At t his poi nt, f l ow i s t ermi nated and exhal ati on begi ns. Because the PSV l evel
i s reached earl y in i nspi rat ion and is mai ntai ned throughout the i nspi ratory phase,
t he pressure waveform has a square, f l at -t opped shape. PEEP may be added i f
needed.
The anesthesi a provi der must set t he tri gger sensi ti vi t y and the i nspi rat ory pressure
(usual l y f rom 5 t o 10 cm H
2
O). The t ri ggeri ng sensi t i vi ty shoul d be set so that i t wi l l
respond to i nspi ratory ef f ort wi t hout aut o-cycl ing in response to art i f actual changes
i n ai rway pressures. The i ni ti al inspi ratory fl ow i s usual ly nonadjustable but can be
changed on some venti lators by adj usti ng the i nspi rat ory ri se ti me (Fi g. 12.48). The
opti mal i ni ti al i nspi ratory f low i s hi ghest i n pati ents wi th l ow compl i ance, hi gh
resi st ance, and most act ive vent i lat ory dri ve. On some venti l ators, the t ri gger
wi ndow can be changed (Fi g. 12.49).
Ti dal vol ume is determi ned by the pressure support l evel , l ung characteri st ics, and
pati ent eff ort . The desi red t i dal vol ume should be calculated and the pressure
support l evel adj usted so that the desi red vol ume i s del ivered. If the exhal ed
volume i s inadequat e, the i nspi rat ory pressure shoul d be i ncreased or i nspi ratory
ri se t i me decreased (i f adj ustabl e). PEEP may cause an i ncrease i n ti dal vol ume
(42). Very high i nspi ratory f l ow (due to a high set pressure) may decrease ti dal
volume by prematurel y terminat ing i nspi rat ion (37). As the pat ient' s ef fort
i ncreases, the level of i nspi ratory pressure can be reduced. Undesi red
hyperventi lat i on can be t reated by adj usti ng t he t ri gger sensi ti vi t y, pressure level ,
or t ri gger wi ndow or, i f these seem adequate, addi ti onal sedat ion.
PSV can be used t o reduce the pati ent' s work of spontaneous breathing (38, 43,44).
I n addi ti on, i t can increase t he functi onal resi dual capaci ty. It may be useful for
preoxygenati ng obese pat i ents by improving t he ef f i ci ency
P. 319

of spont aneous vent i l at ion and during weani ng f rom mechanical vent i l at ion. I t can
be useful wi th a supraglot t ic ai rway devi ce to keep t he ai rway pressure lower t han
t he supragl ot ti c device leak pressure (38,42,45). If there is a l eak around the
device, PSV wi l l be abl e to compensate f or t he l eak to some extent , as the ai r way
pressure i s mai ntai ned i rrespecti ve of the vol ume.
An advantage of PSV i s the synchrony bet ween the pat i ent and the vent i l ator. The
pati ent cont rol s rate, vol ume, and inspi ratory ti me. This may i ncrease pati ent
comf ort. Breath st acking and f i ghti ng the venti l ator are decreased. Even pat i ents
who are ini t iall y tachy-pneic may be successf ul l y managed i n this mode, as the
pressure support can be set suf f i ci ent l y hi gh t o augment ti dal vol ume and hence
reduce t he respi ratory rate. Peak and mean ai rway pressures are l ower than wi t h
volume cont rol vent i lat i on, reducing the risk of barot rauma (42).
Too hi gh an i nspi rat ory f low may cause pati ent di scomf ort (33). PSV wi l l del i ver a
vari abl e minute volume i n a pat ient wi th a changi ng respi ratory dri ve. Inappropriate
venti l ator tri ggeri ng can occur wi th PSV (40, 46,47). Thi s may be caused by a l eak
or a decrease i n ai rway pressure caused by cardi ac cont ract ions.
Wi th cl osed syst em suct i oni ng, PSV resul ts i n a l ower ai r way pressure duri ng
catheter i nsert i on and hi gher end-expi ratory pressure during sucti oni ng t han ei t her
volume cont rol or pressure control vent i l at ion (28,48).
Specific Ventilators
Drager AV2+
The AV2+ is t he successor t o the AVE and AV2 ven-ti l ators.
Description
The AV2+ is shown in Fi gures 12.3 and 12.4. It has an ascendi ng bel l ows. Ti dal
volume i s adj usted by using t he knob above the bel l ows assembl y, whi ch rai ses or
l owers a plate at the top of the bel lows. A scale on the bel l ows housing provides a
rough i ndi cat i on of the ti dal vol ume del ivered.
Most vent i lator cont rols are locat ed across the top of the vent i l ator. To the l ef t of
t he ti dal vol ume control and above the bel l ows i s the i nspi ratory pressure l imi t
control . On the l ef t above the pressure l i mi t and ti dal vol ume control s is the
f requency cont rol wi th a di gi tal
P. 320

readout to the l ef t . To the ri ght of the f requency control are the cont rol and di spl ay
f or the I:E rat io. In order t o set an inverse rat i o, an extended range but t on bel ow
t he di spl ay and cont rol must be depressed.

View Figure

Figure 12.3. Drager AV2+ ventilator. I:E,
inspiratory:expiratory.


View Figure

Figure 12.4. Drager AV2+ ventilator. (Courtesy of Drager
Medical.)

To the ri ght of the I : E rat i o control are the inspi ratory f l ow cont rol and gauge. The
scal e on the gauge is divided i nto l ow, medi um, and high f l ow.
To the ri ght i s t he venti lat or ON/ OFF swi tch. A green l ight next to t he swi tch
i ndi cates t hat t he venti l ator is turned ON. The vent i l ator may be t urned ON at this
swi t ch or by t urni ng the Manual /Automati c swi tch on t he absorber t o the automati c
posi t i on. The venti lat or cont rol swi tch can onl y be turned ON wi th t he
Manual /Automat i c swi tch i n the Automati c posi t ion. I f the ON/ OFF swi t ch is turned
ON wi t h the bag/vent sel ector swi t ch i n t he bag posi ti on, a f aul t l i ght to the l ef t of
t he ON/OFF swi t ch wi l l be i l luminated.
The spi l l val ve (Fi g. 12.5) is at the base of the bel l ows assembl y. A pi lot l i ne f rom
t he cani ster connects through the top of the spi ll val ve to a ball oon di aphragm.
Pressure i n the cani ster causes the bal loon di aphragm to be i nf l ated, cl osi ng t he
openi ng to the scavenging syst em. The bal l i n t he spi l l val ve ensures that a certain
pressure must be present to al l ow gas f l ow t hrough the spi l l val ve, even i f the
bal l oon di aphragm i s def l ated. Thi s resul ts i n approxi mat el y 2 cm H
2
O PEEP i n the
breat hi ng system.
The i nt ernal const ructi on i s shown i n Fi gures 12.6 to 12.9. The inspi ratory pressure
regul at or reduces the gas f rom approxi mat el y 50 psi g to the val ue indi cat ed on the
i nspi ratory f low gauge. A solenoi d i n the oxygen l i ne l inks the pneumati c and
el ect roni c porti ons of the venti l ator. When the sol enoi d is energi zed, i t al lows gas
t o f l ow t hrough t he control val ve in t he oxygen l ine to the Venturi mechanism.
A smal l -di ameter t ube carri es oxygen f rom the i nspi ratory f low regul at or t o the t op
of t he auto-rangi ng val ve, whi ch control s t he amount of ambi ent ai r entrai ned at any
gi ven i nspi ratory sett i ng. The auto-ranging valve cont ai ns a di aphragm that i s
depressed when pressure is appl i ed. The pl unger moves downward, cont roll i ng the
openi ng through whi ch ambi ent ai r i s ent rained during i nspi rat ion.

View Figure
Figure 12.5. Spill valve on Drager AV2+ ventilator.
(Courtesy of Drager Medical.)


P. 321


The cont rol val ve al lows gas t o f l ow t hrough i t when pressure is appl i ed. The
Venturi recei ves oxygen f rom the cont rol val ve and ai r f rom the aut o-rangi ng valve
and combi nes them to f orm the dri ve gas that pushes the bel l ows downward during
i nspi rati on.
The pi l ot actuator, whi ch cont rol s t he opening of the exhaust valve, operates i n
response to oxygen pressure that enters at t he top. When suf f ici ent pressure i s
appli ed, the valve moves downward agai nst the spri ng, whi ch cl oses the valve when
no pressure i s appli ed. Duri ng i nspi rati on, the pressure of the dri vi ng gas i nsi de t he
bel l ows housi ng pushes the bel l ows downward. When no pressure is appl ied to the
pi l ot act uator, t he exhaust val ve opens, and t he driving gas f l ows t o atmosphere
t hrough the exhaust valve.
Control s
The vent il ator can del iver ti dal vol umes f rom 20 t o 1500 mL. Respi ratory rate can
be set f rom 1 to 99 breat hs per mi nute (bpm). I nspi rat ory f l ow can be set bet ween
10 and 100 L/mi nute. The I:E rat i o can be set f rom 1:4.5 to 4:1. The inspi rat ory
pressure l i mi t range i s 15 to 120 cm H
2
O.
Alarms
The AV2+ al arms are associ ated wi t h the anesthesia machi ne and are not part of
t he vent i lator. Al arm messages are di spl ayed on the anesthesia machi ne moni tori ng
screen. Warni ngs are accompani ed by a three-pulse patt ern that is i ni ti al l y
repeated every f ew seconds i n a series of descendi ng volume and then constantl y
at f ul l volume unti l t he al arm condi ti on is resolved. Cauti ons are accompanied by a
t hree-pulse tone pat tern that i s repeated every 30 seconds. Advi sori es ut il i ze a
si ngl e tone or no sound, dependi ng on the advi sory. The hi ghest pri ori ty current ly
acti ve al arm condi ti on i s annunci ated. Audio si gnal s f or l ower-pri ori t y al arm
condi ti ons are temporari l y suppressed to mi ni mi ze conf usi on caused by
si mul taneous al arms.
Venti lation Modes
Vol ume control i s the onl y vent i l atory mode on this vent i l ator. The venti lator is t ime
cycl ed and vol ume preset.
Inspiration
During i nspi rat i on (Fi g. 12.6), t he control l er energi zes the sol enoid and pressuri zes
t he cont rol valve, causi ng i t t o open. Thi s al l ows oxygen f rom the pressure
regul at or t o f l ow to the bel lows assembl y. A smal l porti on of the oxygen i s di verted
t o t he pi l ot actuator. Thi s causes t he pi lot actuator t o move downward, seal i ng the
exhaust val ve and preventi ng dri ve gas f rom escaping t o atmosphere. A smal l
port ion of the regulat ed oxygen al so f lows to t he auto-ranging val ve and opens i t in
proport ion to the sett i ng on the i nspi ratory f l ow regulator.
Oxygen f l ows t hrough t he Venturi , ent rai ni ng room ai r. The dri ve gas, consisti ng of
oxygen and ent rai ned ai r, then pressuri zes t he space bet ween the bel l ows and the
canister. This causes the bel l ows t o be compressed and gases insi de the bel l ows
f low t o t he breat hi ng system.
The spi l l val ve prevents gases f rom enteri ng t he scavengi ng system duri ng
i nspi rati on. Dri ve gas f l ows through the pi l ot l i ne and inf l at es a bal loon di aphragm
t hat bl ocks the out let bet ween t he inside of the bel lows and the scavengi ng system.
Thi s valve remai ns cl osed unt il t he bel l ows has reached i ts l i mi t of expansi on
duri ng exhalati on.
Inspiratory Pause
During the i nspi ratory pause (Fig. 12.7), the cont rol l er conti nues to energize the
solenoi d. As l ong as oxygen f l ows to the bel l ows assembl y, pressure on the pi lot
actuator is mai ntai ned, and the exhaust valve remai ns cl osed. Si nce t he bel l ows i s
compl etel y compressed, no addi t ional gas can ent er t he bel l ows housi ng, and no
more ai r i s ent rained by the Venturi . Excess oxygen is vented to atmosphere
t hrough the ai r ent rai nment port. The pi lot li ne and the bal l oon di aphragm
P. 322

i n the spil l valve remai n pressuri zed, so gas f low t o the scavengi ng system remai ns
bl ocked.

View Figure

Figure 12.6 Drager AV2+ ventilator. Inspiration. I:E,
inspiratory:expiratory. (Redrawn courtesy of Drager
Medical.)

Exhalation
During exhalat i on (Fi g. 12.8), t he control l er de-energi zes t he solenoi d, whi ch stops
t he f l ow of oxygen through i t. The oxygen i n t he tubi ng bet ween t he sol enoi d and
t he suppl y valve is vented to atmosphere via a smal l exhaust tube at t he top of the
solenoi d. Once t hi s oxygen is vent ed, t he control val ve cl oses and stops the f l ow of
oxygen to the Venturi . Thi s al so al lows the pi l ot actuator to depressuri ze. Wi th the
pi l ot act uator depressuri zed, the spri ng f orces t he pl unger upward, openi ng the
exhaust port. Exhal ed gases push the bell ows upward. Dri ve gas vents to
at mosphere through the exhaust port. As t he pressure i n the cani st er decreases,
t he pressure wi thi n the pi l ot l i ne for the spi l l valve also decreases, and the ball oon
di aphragm def l ates. The bal l check val ve below t he bal l oon di aphragm presents
more resistance to t he f l ow of exhal ed gas than does the bel l ows, so exhal ed gases
P. 323


P. 324

conti nue t o fi l l the bel lows. Expi rat ory f low ends when t he bel l ows reaches t he pl at e
at t he t op.

View Figure

Figure 12.7. Drager AV2+ ventilator. Inspiratory pause.
I : E, inspiratory : expiratory. (Redrawn courtesy of Drager
Medical.)


View Figure

Figure 12.8. Drager AV2+ ventilator. Exhalation. I:E,
inspiratory:expiratory. (Redrawn courtesy of Drager
Medical.)

Expiratory Pause
Af ter the bel l ows has reached maxi mum expansion (Fi g. 12.9), the expi ratory pause
t i me begins. The solenoi d and t he supply valve remai n cl osed. The pressure i n the
pi l ot l i ne t o the spi l l valve decreases to at mospheric, and t he bal l oon di aphragm
defl ates. When pressure f rom gas in t he bel l ows exceeds t he resi stance created by
t he wei ght of the ball in t he spi ll val ve, the bal l is l if ted, and gases can f l ow i nto t he
scavengi ng system.
Special Features
A saf et y rel i ef val ve vents dri ve gas t o atmosphere i f the dri ve gas pressure
exceeds 120 cm H
2
O.
I n t he event of mains power f ai l ure, a f ul l y charged battery wi l l power the venti l at or
f or approxi matel y 20 minut es. There are yel l ow i ndicators t o signif y that there is
al ternati ng current (AC) power f ai l ure and that the bat tery power i s l ow. I f t he
machi ne has swi tched to
P. 325

bat tery power, a three-pul se t one sounds every 30 seconds. A battery t est but ton i s
present on t he machi ne. A green batt ery test i ndi cat or si gnif ies that the batt ery
power i s sat isf actory. Batt ery messages are displ ayed on t he moni tor screen.

View Figure

Figure 12.9. Drager AV2+ ventilator. End exhalation. I:E,
inspiratory:expiratory. (Redrawn courtesy of Drager
Medical.)

Hazards
The probl ems di scussed bel ow were report ed wi t h the predecessor AV-E vent i lator.
Si nce t he two venti l at ors are si mi l ar i n construct i on, t here is a possi bi l i t y t hat
si mi l ar probl ems coul d occur wi th t he AV2+ venti lator.
A case has been report ed in whi ch the muf fl er pl aced over the dri ving gas exhaust
became saturated wi t h wat er and obstructed t he f l ow f rom the bel l ows chamber
(49). Thi s resul ted i n hi gh ai r way pressures as gas cont inued to f low i nt o the
venti l ator.
I n anot her report ed case, the cont rol valve mal f unct i oned, resul ti ng i n conti nuous
driving gas f l ow to t he bel l ows (50). Hi gh ai r way pressures resul ted.
P. 326


Prol ongat i on of the inspi ratory phase owi ng to i nsuff icient parts l ubri cati on has
been report ed (51).
Venti latory i rregul ari t i es resul ti ng f rom i mproper seati ng bet ween t he bel l ows and
i ts mount have been reported (52).
There has been a report of the spi l l val ve becomi ng incompetent, resul t ing in
hypoventi l at ion (53). In other report ed cases, the pi l ot l i ne connect ing t he bel l ows
chamber t o the spi ll val ve became kinked so t hat i t was occl uded (54,55). I f the
pi l ot l i ne becomes occl uded duri ng i nspi rati on, hypoventi l ati on wi l l resul t because
t he spi l l val ve wi l l be open. If t he occl usi on occurs duri ng exhal ati on, gas wi l l be
unabl e t o exi t the ci rcui t , and the pressure i nsi de t he ci rcui t wi l l i ncrease.
PEEP can resul t under certai n ci rcumst ances. This was report ed when some hoses
were draped over the spi l l val ve, part i al l y obstruct i ng the pi l ot l i ne (56,57).
Cleani ng and Sterilization
Cl eani ng and disinf ecti on or steri l i zati on are compl icated matt ers beyond t he scope
of t hi s text. They are expl ai ned i n det ai l i n the operat or' s manual .
Drager Divan
The Divan venti l at or (digi tal vent i l ator f or anesthesi a) i s a component of t he Nort h
American Drager 6000 seri es machi nes.
Description
The vent il ator control panel (Fi g. 12.10) i s si t uat ed at t he f ront of t he anesthesi a
machi ne bel ow t he deskt op. To al t er a f uncti on, t he key f or t hat f uncti on i s pressed.
Changes are made by usi ng t he rotary knob at t he ri ght of the cont rol panel and the
change conf i rmed by pressi ng t he knob. If the al tered val ue or mode i s not
confi rmed wi t hi n 10 seconds, the vent i l ator returns to the previous val ue.
At t he l ef t side of the cont rol panel i s a Manual / Spontaneous key. Af t er pressing
t his key and confi rming t he set t i ng, the pat ient can breathe spont aneousl y or be
venti l ated manual l y by adj ust i ng the APL val ve.
Bel ow the Manual /Spont aneous key is t he Vol ume Mode key. When i t i s pressed
and i ts f uncti on conf i rmed, t he venti l ator goes i nt o the vol ume cont rol mode. Below
t he vol ume mode key i s the SIMV key. To t he ri ght of this key i s the key f or
pressure cont rol venti lat i on (Pres Mode).
To the ri ght of the Manual / Spont aneous key i s a wi ndow wi th a bar graph that
i ndi cates pi st on movement and displ ays the percent of the set t i dal vol ume (0%
represents f ul l exhalati on, whi l e 100% i ndi cat es i nspi rati on to t he set ti dal vol ume).
Bel ow the bar graph wi ndow i s a numeric di splay wi ndow t hat di spl ays t he val ues
f or the keys below i t . At the lef t i s the sett i ng for maxi mum all owable pressure
(Pmax) i n the vol ume and SIMV modes or preset ai rway pressure (Pset) i n the
pressure cont rol mode. I n the mi ddl e i s t he sett ing f or t i dal volume i n the SIMV and
volume cont rol modes. At the ri ght i s the respi ratory rat e set ti ng. To al ter a
parameter, the key under i t is pressed and the rotary knob rotat ed to i ncrease or
decrease the set ti ng. The new val ue i s di spl ayed i n the wi ndow above t he key.
When t he proper
P. 327

value i s di spl ayed, i t is conf i rmed by pushi ng the rotary knob.

View Figure

Figure 12.10. Control panel of Divan ventilator. (Redrawn
courtesy of Drager Medical.)

To the ri ght of the numeric di spl ay i s an al phanumeric di splay. Thi s prompts the
operator t o take certain acti ons duri ng the checkout procedure and updates t he
progress of the checkout . Af ter a change i n venti latory mode or parameter is made,
t here wi l l be a prompt t o conf i rm the change. Other messages report i ng status and
f aul ts are di spl ayed here.
Under the alphanumeri c di spl ay are addi t ional keys. The I:E key sets t he I: E rat i o.
The % I. P./ Fl ow key sets t he rati o of i nspi ratory pause ti me to i nspi rati on phase
t i me i n the vol ume cont rol and SI MV modes and the inspi rat ory f l ow rate i n t he
pressure cont rol mode. The PEEP key i s used to set t he PEEP i n al l modes. The
SI MV Rate key sets t he mi ni mum vent il atory rat e i n the SIMV mode.
At t he ri ght si de of the cont rol panel i s a standby key. I n thi s mode, drive gas use i s
mi nimi zed, and i nspect ion or repai rs can be perf ormed.
Above the standby key is a test key. This causes the venti l ator to measure system
compl i ance and l eakage. This can onl y be ini t iated when the venti l at or i s in the
standby mode.
Bel ow the tablet op i s an el ect ri cal l y powered pi st on (Fi g. 12.11). The manufacturer
of fers an opti onal top cover wi t h a t ransparent wi ndow t hat al l ows the user t o see
pi ston movement . If there is i nadequate gas i n the breathi ng system t o al low t he
pi ston to ret ract ful l y, t he pi st on wi l l stop and alert t he anest hesi a provi der. Thi s
wi l l prevent a negat ive pressure f rom bei ng exert ed (23).
A heater i s i ncorporated into the absorber head to mini mi ze moi sture condensati on.
The i nt ernal const ructi on of the vent il at or and breathi ng syst em i s shown i n Fi gures
12.12 t o 12. 17. V1 i s the f resh gas decoupl i ng valve. V2 is the surpl us gas val ve.
V3 i s t he valve that cont rols gas f l ow to t he APL and gas rel i ef valves. Gas i s
aspi rated f rom near t he pati ent port , anal yzed, and returned t o the ci rcui t
downst ream of the expi rat ory uni di recti onal val ve. An ul t rasonic f l ow sensor
(Chapter 23) and PEEP valve are l ocated i n the expi ratory l i mb.
Control s
The vent il ator cannot be set to val ues resul t i ng i n an i nspi ratory f l ow greater t han
75 L/minute, a minute volume greater t han 25 L/mi nute, or an expi ratory t i me of
l ess than 400 ms.
PEEP can be set f rom 0 to 20 (def aul t 0) cm H
2
O. PEEP i s not avail abl e i n the
Man/Spont or SI MV modes.
The peak ai rway pressure (Pmax/Pset ) can be set f rom 10 to 80 (def aul t 25) cm
H
2
O i n the volume cont rol and SI MV modes and 10 to 70 (defaul t 10) cm H
2
O i n the
pressure cont rol mode. When the maximum al lowabl e pressure is reached, f l ow i s
adj usted so t hat the pressure remai ns constant through the end of inspi rat i on. I n
t his si tuat i on, the full t i dal vol ume may not be del ivered.

Figure 12.11. Piston ventilator of Divan ventilator.
(Courtesy of Drager Medical.)

View Figure

The mi ni mum dif ference bet ween Pmax and PEEP is 5 cm H
2
O. If t he pressure
i ncreases by more than 5 cm H
2
O above Pmax, i nspi rat ion is i mmedi atel y stopped
and expi rat i on begins.
The % inspi ratory pause/f l ow (% I. P./ Fl ow) sets t he lengt h of t he inspi ratory pause
i n the volume cont rol and SI MV modes or t he inspi ratory f l ow i n t he pressure
control mode. The pause range i s 0% to 60% (defaul t 10%). Duri ng pressure cont rol
venti l ati on, the i nspi ratory f l ow rat e can be set f rom 5 t o 75 (defaul t 50) L/mi nut e.
The avai labl e t idal volumes are 10 t o 19 mL, 20 to 100 mL, and 110 to 1400
(def aul t 600) mL.
The respi ratory rate range i s 6 to 80 (def aul t 12) bpm in t he vol ume and pressure
control modes and 3 to 80 (def aul t 12) bpm i n the SI MV mode.
The range of avai l abl e I:E rat i os is 1: 3 to 2:1 (defaul t 1:2). I f an i nverse I :E rati o is
set and confi rmed, a message i s displ ayed.

View Figure

Figure 12.12. Divan ventilator. Spontaneous inspiration.
APL, adjustable pressure limiting; PEEP, positive end-
expiratory pressure. (Redrawn courtesy of Drager Medical.)

P. 328


Alarms
Al arm l i mi ts, whi ch depend on the vent i latory mode and t he pati ent , are presented
i n an alarm wi ndow on the machi ne moni tor screen. If an al arm l i mi t is exceeded or
not reached, the alarm li mi ts menu i s di spl ayed, and t he val ue i s hi ghl i ghted.
Rel ated al arms are combi ned. A message that i ndi cates t he computer anal ysis of
t he probl em wi l l appear.
The al arm si l ence key i n the al arm wi ndow al l ows t he alarms t o be audi o paused
(si l enced) f or 60 seconds i f pressed once and f or 120 seconds i f pressed t wi ce.
Al arms can be suspended by pressi ng a key on the bott om of the screen.
Warnings are announced by a t hree-t one sequence of high, hi gh, l ow. The tones
are also in a sequence of di ff erent vol umes wi th t he fi rst and f ourth sequence bei ng
at f ul l volume. Al arm messages are di spl ayed on a f l ashi ng red background wi th
whi t e t ext . The f l ashi ng st ops when the alarm si l ence but ton i s depressed. Flashi ng
resumes when the audi o pause (si l ence) peri od has ended.

View Figure

Figure 12.13. Divan ventilator. Spontaneous exhalation.
APL, adjustable pressure limiting; PEEP, positive end-
expiratory pressure. (Redrawn courtesy of Drager Medical.)

P. 329


Cauti ons are di spl ayed on a f lashi ng yell ow background i n bl ack text . The
messages are announced by a three-t one burst of low, l ow, hi gh. Announcements
occur every 30 seconds.
Advisori es are di spl ayed on a whi t e background wi th bl ack text that does not f lash.
A si ngl e tone may sound.
An al arm l og can be accessed. It wi l l al low t he cl inici an to observe al l alarm events
t hat have occurred duri ng the case. It can st ore up to 500 events.
Venti lation Modes
The desi red mode (Vol ume or Pressure Control or SIMV) i s sel ected by pushing the
key f or t hat mode and conf i rming that choi ce.
I n t he pressure cont rol mode, i nspi rat ory f l ow rat e can be set independent of ai rway
pressure (Pset ). However, Pset may not be achieved i f the i nspi rat ory f l ow rat e i s
t oo l ow. In t hi s case, an al arm message wi l l be displ ayed.

View Figure

Figure 12.14. Divan ventilator. Inspiration during manual
ventilation. APL, adjustable pressure limiting; PEEP,
positive end-expiratory pressure. (Redrawn courtesy of
Drager Medical.)

P. 330


During SIMV, t he t i me bet ween each mandatory respi rati on and the beginni ng of
t he next is subdi vi ded i nto a spont aneous breathi ng ti me (Tspont ) and a t ri gger
t i me (Ttri gger). Duri ng the t ri gger ti me, t he system checks whet her t he ai rway
pressure has dropped at least 0.5 cm H
2
O bel ow the pressure measured at t he end
of expi rati on. If t hi s has not occurred, t he venti l ator del ivers a breath.
Spontaneous Breathing
To al l ow spont aneous breat hi ng, the MANUAL/SPONTANEOUS key i s pressed and
t he APL val ve set to SPONT. Val ves V1 and V3 are open, whi l e V2 i s cl osed. When
t he pat ient i nspi res (Fi g. 12.12), the i nspi rat ory valve opens, and gas fl ows f rom
t he reservoi r bag. Duri ng exhal at ion (Fi g. 12.13), t he expi rat ory valve opens, and
exhal ed gases pass through t he absorber and i nto the bag. Duri ng l ate exhal ati on,
t he pressure ri ses,
P. 331

and excess gas f l ows through V3 and the gas rel i ef val ve to the scavengi ng system.

View Figure

Figure 12.15. Divan ventilator. Inspiration during
mechanical ventilation. APL, adjustable pressure limiting;
PEEP, positive end-expiratory pressure. (Redrawn courtesy
of Drager Medical.)

Manual
For manual vent i lati on, t he Manual /Spontaneous key i s pressed, and the APL val ve
i s set to MAN. The pressure duri ng i nspi rati on wi l l be li mi t ed by t he APL val ve
sett ing. When the pressure l i mi t i s reached, excess gas wi l l f l ow through V3 and the
APL valve to the scavengi ng system t hrough t he gas rel ief val ve (Fi g. 12. 14).
During exhalat i on, exhal ed gases f l ow t hrough the absorber i nto the reservoi r bag.
Mechanical
When mechani cal venti lati on i s sel ect ed, t he APL valve i s cl osed. The bag
f uncti ons as a reservoi r f or f resh gas.
During i nspi rat i on (Fi g. 12.15), val ves V1, V2, and V3 are cl osed. Pi st on movement
produces gas f l ow t hrough t he i nspi ratory val ve t o the pati ent port. Fresh gas
P. 332

conti nues to enter t he reservoi r bag but does not aff ect t he t idal vol ume, because
valve V1 i s cl osed (f resh gas decoupl i ng).

View Figure

Figure 12.16. Divan ventilator. Mid exhalation during
mechanical ventilation. APL, adjustable pressure limiting;
PEEP, positive end-expiratory pressure. (Redrawn courtesy
of Drager Medical.)

When exhal at ion begi ns, t he expi ratory valve opens, al l owi ng exhaled gases to fl ow
t hrough the absorber and i nto the retract ing piston and to t he reservoi r bag through
V1, whi ch opens. Valves V2 and V3 remain cl osed. Fresh gas fl owi ng i nto the
system mi xes wi t h some of the exhaled gases i n the piston vent i l ator. Mi d
exhal ati on i s depi cted i n Fi gure 12.16. The pi ston retracts, al l owi ng the cyl inder t o
f il l wi th gas f rom the reservoi r bag and f resh gas. Duri ng the l at er part of exhalat i on
(Fi g. 12.17), V2 opens, and gases are vented to the scavengi ng system t hrough t he
gas rel ief (spi l l ) val ve.
Special Features
The Divan venti l at or decouples f resh gas f low f rom t idal vol ume. Fresh gas enteri ng
t he ci rcui t duri ng i nspi rat ion
P. 333

i s isolated f rom t he pat ient ci rcui t and accumul ates i n the reservoi r bag. If the
oxygen f lush is acti vated duri ng i nspi rati on, the gas wi l l not be added to the ti dal
volume but wi l l enter the reservoi r bag (23). The reservoi r bag wi l l i nf l ate and
defl ate duri ng mechani cal vent i l ati on.

View Figure

Figure 12.17. Divan ventilator. Late exhalation during
mechanical ventilation. APL, adjustable pressure limiting;
PEEP, positive end-expiratory pressure. (Redrawn courtesy
of Drager Medical.)

Thi s venti l ator compensat es f or breathi ng system compl i ance and gas compressi on
so t hat t he pat i ent receives the set t idal vol ume. Inf ormat ion that makes t idal
volume compensat ion possi bl e is gathered duri ng t he automated checkout. The Y-
pi ece must be occluded and f resh gas f low set at a mi ni mum t o perform t hese
measurements.
Smal l -di ameter breathi ng tubes are recommended for pedi at ri c pat i ents where ti dal
volumes are l ess than 200 mL. Af ter swi t chi ng to t he pediatric tubes, the leak and
compl i ance test shoul d be perf ormed bef ore t he pat i ent i s connected t o the
venti l ator. I f a l ow-compl iance ci rcui t such as a pedi at ri c ci rcui t were added wi thout
P. 334

conducti ng a compl i ance t est , t he venti lator coul d del iver excessi ve vol umes. To
prevent this f rom occurri ng when a ti dal volume of l ess than 200 mL is selected, t he
venti l ator wi l l use the measured ci rcui t compl i ance onl y i f i t is 0.8 mL/cm H
2
O or
l ess (58). If the measured ci rcui t compl iance i s higher, a def aul t value of 0.6 mL/cm
H
2
O i s used.
The breathi ng system and piston assembl y are desi gned to mi ni mi ze ci rcui t volume
and the t ime that i t takes the system to respond t o changes in f resh gas
composi ti on. A l ow-f l ow wi zard hel ps the cl i ni ci an to assess the f resh gas surpl us.
I t provi des graphical i nformat i on of f resh gas surpl us, a message report , and a hel p
key. The message area gi ves recommendati ons f or use wi t h l ow f lows, i ncl udi ng
bag si ze and vent i lator set ti ngs.
When t he anesthesi a machi ne i s turned ON, an automated checkout process that
requi res about 5 mi nutes i s set i n mot ion. Other t han a few prompts remi nding t he
anesthesi a provi der t o set a pressure at the APL valve and to occl ude the Y-pi ece
on the breathing system, t hi s checkout is f ul l y automati c. The checkout al l ows t he
computer to determi ne informat ion about gas compressi on, l eaks, and compl iance
of t he breathi ng system.
I f the venti l at or detects an i nternal f aul t t hat mi ght af f ect pat i ent saf et y duri ng
mechani cal vent i lati on, i t i ni ti at es a saf e state i n which vent i l at i on can be cont inued
i n the Manual /Spont aneous mode. When the vent il ator enters the saf e state, t he
cl i nician i s al erted by a di splay reading Equi pment Faul t , and an audi bl e tone
sounds. The venti l ator now performs as i f i t were i n the manual /spontaneous mode.
The vent il ator overri de but ton i s on the machi ne near the absorber head. It i s
provi ded i n the event there i s an unf oreseen condi ti on t hat t he sof t ware does not
recogni ze. Acti vat i ng thi s override removes power f rom t he venti l at or and al l ows
manual or spontaneous vent il ati on.
The Narkomed 6000 has bat tery backup t hat wi l l power the machi ne and venti l ator
f or at l east 30 minut es. An al arm i ndi cates when the battery has onl y another 10
mi nutes. Af t er the bat teri es are exhausted, t he machi ne can cont inue to be used
wi th manual venti l at ion or spontaneous breathi ng.
Respi tone i s an opti on on the 6400 anesthesi a machi ne. It is a venti l ati on sound
composed of two di st i nct tones. One tone annunci ates when the pressure wavef orm
crosses the apnea threshold duri ng inhal at ion. Anot her tone annunci ates on the
ri si ng edge of a carbon dioxide wavef orm correspondi ng to exhal at ion.
Evaluation
A compari son between a Di van and an AV2+ venti l ator was made duri ng si mul ated
venti l ati on of pedi at ri c pat ients (59). The Di van off ered advantages i n t he l ow ti dal
volume range duri ng vol ume control venti l ati on.
The Divan and an ICU venti l ator were compared by using both an i nf ant l ung model
and i nf ants wi t h congeni t al heart disease (60, 61). Bot h vent i lators provi ded
adequate venti l ati on i n the volume cont rol mode.
I n compari son wi th an ICU venti l at or and an anesthesia vent il ator wi th a gas-
powered bel l ows duri ng pressure cont rol vent i lat i on, t he Divan mai ntained ti dal
volume wi th i ncreasing respi ratory rat es better than the other anesthesi a vent i lator
but not as wel l as the I CU vent i l ator (2).
Hazards
A hi gh negati ve pressure appl ied to the ai rway can exceed t he abi l i t y of t he
venti l ator' s negati ve pressure rel ief val ve, causing the pi st on to l ock (62, 63). The
probl em can be remedi ed by openi ng the vent i l ator cover and removi ng the pi st on
t o break the negat ive seal .
The vent il ator overri de but ton i s in a rather i nconspi cuous pl ace (64).
A case of power suppl y f ai lure that i nt errupted venti l ati on has been reported
(64,65). The l i nkage t o the backup batt eries prevented them f rom kicking i n.
Cleani ng and Disi nfecti on
Most of t he venti lator parts, i ncluding those exposed t o breathi ng gases, can be
steam autocl aved. See t he operati on manual f or speci f i c di sassembl y and
steri l i zi ng instructi ons.
Drager Fabius GS
Description
On the Fabi us machine, the vent i l atory modul e, whi ch i ncludes a pi ston, i s locat ed
behind a door on the l ef t si de of the machi ne (Fi g. 12. 18). The pi ston is i nside a
metal case that wi l l swi ng out when the door i s opened (Fi g. 12.19). A wi ndow
al l ows the operator to vi ew pi ston movement.
The pist on assembl y i s shown i n Figures 12. 20 and 12. 21. Electri cal power i s used
t o rai se and l ower the pi st on. The motor is near t he bot tom of the cyli nder that
hol ds t he pi ston. There are two rol l i ng di aphragms that seal the pist on and prevent
mi xi ng of ambi ent and respi red gases. The upper diaphragm i s at tached at the top
and f i ts over the upper end of the pi ston. The l ower part of upper diaphragm rol l s
upward and downward as the pi ston moves upward and downward (Fi g. 12. 20). The
l ower di aphragm i s connect ed between the pi ston wal l and the i nsi de of t he
cyl i nder. As the pi st on moves downward, t he space above the upper diaphragm
i ncreases, al l owi ng exhal ed gases to enter t hat space. There are high pressure and
negat ive pressure rel i ef valves on the top of t he pi ston, connecti ng wi th t he space
f or respi red gases.

View Figure

Figure 12.18. Drager Fabius GS ventilator. A window
allows the operator to view piston movement.

P. 335


The display screen i s shown i n Figure 12.22 (see page 338). At t he l ef t si de are
keys that det ermi ne the venti l atory mode (vol ume control , pressure control ,
manual /spontaneous). A rot ary mouse i s at t he bot tom ri ght of the screen. Once a
parameter i s sel ected, the val ue is al t ered by turni ng the rot ary mouse and i s
confi rmed by depressing i t . The St andby key i s to the ri ght of the rotary mouse. To
t he ri ght of the rotary mouse and above the Standby key is the Mai ns Power l i ght -
emi tt i ng di ode (LED), which, when l i t, conf i rms that the machi ne i s connected to a
f uncti oni ng el ect ri cal system.
To the ri ght of the screen are t hree keys. The bott om one i s the Home key. I t
causes t he mai n screen t o be displayed. The Setup key i s above the Home key.
When pressed, the di spl ayed wi ndow enables t he operator t o vi ew and change
venti l ati on and t o revi ew set ti ngs.
P. 336

Above the Setup key is the Al arms key. When pressed, al arm l i mi ts are shown on
t he ri ght si de of the screen. To t he ri ght of the Al arms key is t he Al arm Si lence key.
Pushi ng thi s causes acti ve al arms to be audio paused f or 2 mi nutes.

View Figure

Figure 12.19. Drager Fabius GS ventilator. When the door
is opened, the piston ventilator, which is inside a metal case,
will swing out.


View Figure

Figure 12.20. Piston assembly. As the piston moves
downward, the upper diaphragm moves downward with it,
creating a space for respired gases.

To the ri ght of the Alarms key are two LED l amps that i ndi cate t he urgency of the
al arm message. A status bar near the top of t he screen displ ays the vent i latory
mode being used. It also displ ays al arm si l ence st atus, bat tery power l evel , and the
t i me.
To the lef t side of the screen are vi rtual f l owmeters for ai r, oxygen, and ni t rous
oxide. To the ri ght of the f lowmeters i n the upper t hi rd of t he screen i s an al arm
wi ndow. Thi s displ ays up to four of t he hi ghest pri ori ty
P. 337

al arms. To t he ri ght of this wi ndow, the i nspi red oxygen concentrati on and al arm
l i mi ts f or oxygen concent rat i on are di splayed. The respi rat ory vol ume moni tor
wi ndow i s the mi ddl e wi ndow to t he ri ght of t he f l owmeter wi ndow. It di spl ays
respi ratory rate and t i dal and mi nute volumes. Bel ow t he respi ratory vol ume wi ndow
i s the breathi ng pressure moni t or wi ndow. It displays PEEP val ues and peak and
mean i nspi ratory pressures. Below t he fl owmeters and t he breathing pressure
wi ndow i s the breathi ng pressure wavef orm wi ndow. Below t hi s are si x wi ndows
associ ated wi th venti l ator parameters. Bel ow these wi ndows are keys f or the
associ ated parameters.

View Figure

Figure 12.21. As the piston moves upward, gases are forced
out of the space at the top.

Control s
The range f or t he maxi mum vent i lati on pressure (P
MAX
) is 10 to 70 (defaul t 40) cm
H
2
O. Other control s are di scussed under t he i ndi vi dual venti l ati on modes.
Wi th vol ume control vent il ati on f requency can be set f rom 4 to 60 (def aul t 12) bpm.
The t i me rat io bet ween t he i nspi ratory and expi ratory ti me phases (Ti : Te) range i s
4: 1 to 1:4 (def aul t 1:2). The i nspi rat ory pause can be set f rom 0% t o 50% (def aul t
10%). PEEP can be set f rom 0 to 20 (def aul t 0) cm H
2
O. The range f or t i dal vol ume
i s 20 to 1400 (def aul t 600) mL.
I n t he pressure cont rol mode, the i nspi ratory pressure (P
I NSP
) can be set f rom 5 t o
60 (def aul t 15) cm H
2
O,
P. 338

and the i nspi ratory f low can be set f rom 10 t o 75 (def aul t 30) L/ minute. PEEP can
be set f rom 2 to 20 (def aul t 0) cm H
2
O. Vent i l at ion f requency can be set f rom 4 to
60 (def aul t 12) bpm.

View Figure

Figure 12.22. Display screen for the Drager Fabius GS
ventilator.

Alarms
Al arms are automat i cal l y enabl ed when the venti l ator is swi t ched to a vent i lati on
mode. Al arm messages are di spl ayed i n t he alarm box i n the cent er of the top of
t he dat a screen. The text di spl ays are f ol lowed by exclamati on marks (! ). There are
t hree marks (!! ! ) for warni ngs, t wo (! ! ) f or cauti on, and one (! ) f or advi sori es. The
LEDs to the ri ght of the al arm si l ence key i ndi cate the urgency of t he al arm
condi ti on. A warni ng i s si gnal ed by a bl inki ng red LED. A caut i on i s expressed by a
bl i nki ng yel l ow LED. An advisory i s i ndi cated by a conti nuous yel low LED. Warning
t ones are conti nuous. Cauti on tones enunci at e every 30 seconds. An advisory has
a si ngl e or no t one.
Venti lation Modes
The Fabi us of fers vol ume control and pressure control venti l at i on. PSV can be
added. When the vent i l at ion mode is changed, the funct ion i s di spl ayed across t he
bot tom of the data screen and above the appropri ate key.
Standby
I n t he St andby mode, the venti l ator stops, and the moni tori ng and al arms are
t urned OFF. I f gas f low i s det ected, a Gas St i l l Fl owi ng message appears i n the
al arm wi ndow. If t he machine is i n the Standby mode for 5 mi nutes and there i s no
user i nput , the machi ne goes i nto the Sleep mode, and a screen saver appears.
Manual/Spontaneous
I n Man/Spon mode, the pi ston i n the vent il at or i s moved to i ts topmost posi ti on to
mi nimi ze system compl iance. The APL bypass valve i s cl osed, di recting excess gas
t hrough the APL val ve.
For spontaneous vent i l at ion, t he APL val ve i s put i n the SPONT posi ti on, in whi ch i t
i s ful l y open. Duri ng i nspi rati on (Fi g. 12. 23), gas f rom t he bag f lows through the
f resh gas decoupl i ng val ve and the i nspi ratory uni di recti onal valve to t he Y-pi ece.
During exhalat i on (Fi g. 12.24), exhaled gases f l ow t hrough t he expi ratory
uni di rect ional valve and the absorber. The reservoi r bag f i l ls wi th a combinati on of
f resh gas and gas that has passed t hrough t he absorber. Excess gas exi ts through
t he APL val ve.
During manual venti lati on, the APL valve i s set to the MAN posi ti on. The opening
pressure can be adj usted f rom 5 to 70 cm H
2
O. As the bag i s compressed (Fig.
12.25, see page 341), t he gas i n t he bag f l ows through the f resh gas decoupl i ng
valve, the i nspi rat ory uni di recti onal val ve, and the Y-piece. Some gas fl ows
retrograde t hrough the absorber and the APL val ve, whi ch is adjusted to provi de
t he proper pressure. During exhal ati on, exhal ed gases f l ow t hrough the expi ratory
uni di rect ional valve and the absorber. The reservoi r bag f i l ls wi th a combinati on of
f resh gas and gas that has passed t hrough t he absorber.
Mechanical
When t he Fabi us i s i n automati c mode, the APL bypass val ve is held open. Fresh
gas decoupl ing i s accompl ished by usi ng a decoupl i ng valve between the f resh gas
i nl et and t he breat hi ng system. The reservoi r bag wi l l i nf l ate and def late duri ng
mechani cal vent i lati on. I f the oxygen fl ush i s acti vated duri ng inspi rat i on, t he gas
wi l l not be added to t he t idal volume but wi l l enter the reservoi r bag (23).
During i nspi rat i on (Fi g. 12.26, see page 342), t he pressure generated by the pi st on
cl oses the f resh gas decoupl i ng valve. Fresh gas f l ows ret rograde through the
P. 339

absorber and enters the reservoi r bag. The pi ston pushes gas through t he
i nspi ratory unidi rect ional valve and the inspi rat ory hose t o the Y-pi ece. If the
pressure exceeds the pressure l i mi t , t he Pmax val ve opens.

View Figure

Figure 12.23. Drager Fabius GS ventilator. Inspiration
during spontaneous breathing. PEEP, positive end-
expiratory pressure; APL, adjustable pressure limiting.

During exhalat i on (Fi g. 12.27, see page 343), exhal ed gas f l ows t hrough the
expi ratory uni di recti onal val ve and i nto the reservoi r bag, where f resh gas has been
coll ecti ng during i nspi rat ion. The piston retracts, drawi ng i n gas. Excess gas f lows
t hrough the APL bypass val ve and the exhaust val ve t o the scavengi ng system.
Special Features
A hi gh pressure and a negat ive pressure rel i ef val ve are locat ed at the top of the
venti l ator pi ston (Fi gs. 12.20, 12.21). The hi gh pressure reli ef valve opens at 75 5
cm H
2
O. The negative pressure safety reli ef val ve lets i n ai r at -2 t o -5 cm H
2
O.
I f a faul t i n the venti l at or i s not corrected and the anest hesi a provi der cannot swi tch
t o manual vent i lat i on by usi ng t he Man/Spont mode, manual venti lat i on is sti l l
possi bl e. To do t hi s, t he ON/OFF system power s wi t ch on t he rear panel i s swi t ched
OFF, then ON.
The Fabi us GS has bat tery backup that wi l l power the machi ne and vent i l ator f or at
l east 45 minutes i f the bat teri es are f ul l y charged. If t he power fai l s, the mai ns LED
wi l l go out , a message wi l l appear, and a batt ery symbol wi l l appear i n t he status
bar. Af ter the battery is exhausted, t he patient can be vent i l at ed i n the
manual /spontaneous mode.
Breat hi ng system compl i ance i s determi ned during t he checkout procedure. For
accurate compl iance compensati on, t he breat hi ng system must be in the
confi gurati on in whi ch i t is t o be used f or t he pat i ent when the checkout procedure
i s performed.
The Fabi us GS i s equipped wi th f resh gas decoupl i ng. Duri ng mechani cal
i nspi rati on, the f resh gas decoupli ng valve closes. Thi s di rects the f resh gas to the
reservoi r bag, thereby stopping i t f rom bei ng added to t he inspi red t i dal vol ume.
During exhalat i on, the decoupl i ng val ve
P. 340

opens, al l owi ng exhal ed gas and t he accumul at ed f resh gas to f i l l t he pi ston.

View Figure

Figure 12.24. Drager Fabius GS ventilator. Exhalation
during spontaneous breathing. PEEP, positive end-
expiratory pressure; APL, adjustable pressure limiting.

Hazards
Ai r can be entrai ned duri ng mechani cal vent i l at ion i f t here is a di sconnecti on or
l eak or t he f resh gas fl ow i s di rected t o the wrong ci rcui t (9,66,67). This coul d l ead
t o pati ent awareness and hypoxi a. Such a probl em shoul d be di scovered during the
checkout procedure but coul d occur l ater.
Venti lator fai l ure resul t ing f rom worn parts of the motor t hat dri ves t he bel l ows has
been report ed (68,69). A vent i l ator f ai lure warning was posted and manual
venti l ati on was possi bl e af ter the vent i l ator was pl aced in t he st andby mode.
Cleani ng and Sterilization
External parts of the venti l ator may be cl eaned wi t h det ergents and di si nf ectants.
The parts that are exposed to respi ratory gases can be removed f rom the vent i l ator.
The vent il ator di aphragm, cover, and hoses can be st eam autoclaved.
Drager Apollo
Description
The mai n screen of the Drager Apol l o machi ne is shown i n Figure 12.28 (see page
344). At the l ef t on the bot tom are vi rt ual f lowmeters. Above t hi s is gas-moni tori ng
i nformati on. To t he ri ght of t his i s the carbon di oxi de waveform and pressure- and
f low-volume l oops. Bel ow t he pressure-vol ume l oop are bar graphs f or t i dal vol ume
and ai rway pressure. To the ri ght of the carbon dioxi de wavef orm and f l ow-vol ume
l oop are the val ues for vent i lat ory parameters. Bel ow thi s are the pipel i ne and
cyl i nder pressures. At the ri ght are sof t keys f or vari ous other f uncti ons.
Venti latory f unct ions are cont rol l ed by using t wo sets of keys bel ow the bot tom of
t he screen (Fig. 12.29, see page 345). The keys in the bot t om row are used to
P. 341

set the venti l at ory mode (manual /spontaneous, vol ume mode, pressure mode, or
pressure support ). To select a mode, the key is pressed, and the knob to t he right
i s pressed to conf i rm the change. The ri ght key i s used to sel ect the auxi l i ary
common gas outl et, which is an opti onal f eature.

View Figure

Figure 12.25. Drager Fabius GS ventilator. Inspiration
during manual ventilation. PEEP, positive end-expiratory
pressure; APL, adjustable pressure limiting.

Above this row of keys is another row t hat i s used to set the vent il ati on parameters.
To al ter the set ti ng, t he key i s pressed, and the knob is rot ated t o i ncrease or
decrease the val ue shown above t he sof t key unti l the desi red value i s reached.
Then, the knob i s pressed to conf i rm that sett ing.
To the ri ght of the knob (not shown i n Fig. 12. 29) i s the standby key, whi ch i s used
t o swi t ch between operat ing and standby modes.
The i nt ernal const ructi on of the Apoll o venti l ator is shown i n Fi gures 12.30 to 12. 35
(see pages 345,346,347,348,349,350,351). Fresh gas enters the breathing system
and passes through t he f resh gas decoupl er val ve. The vent i l ator, whi ch has an
el ect rical l y driven pi ston, i s connected to t he inspi ratory si de of t he ci rcui t
downst ream of the f resh gas decoupler valve. A f low sensor j ust downst ream of the
uni di rect ional valve moni tors the i nspi rat ory f l ow.
On the exhal at i on si de of the ci rcui t another f l ow sensor, a pressure gauge and a
PEEP valve are l ocated upstream of t he expi ratory unidi recti onal val ve. The
reservoi r bag and APL val ve as wel l as an APL bypass val ve l eadi ng to the exhaust
valve f rom t he venti lator are between the expi ratory uni di recti onal val ve and the
absorber.
Control s
The range f or pressure l i mi tat ion (P
MAX
) i s 10 to 70 (def aul t 40) cm H
2
O, wi th a
mi nimum of PEEP +10 cm H
2
O. The range for t i dal vol ume is 20 t o 1400 (def aul t
600) mL. Wi th PSV, t he t idal volume range i s 10 to 1400 mL. Respi ratory f requency
can be set f rom 3 to 80 (def aul t 12) bpm in volume cont rol and pressure control
venti l ati on. During PSV, the f requency i s Of f or 3 t o 20 (defaul t 3) bpm. I nspi ratory
t i me (T
I NSP
) can be set f rom 0.2 to 6.7 (def aul t
P. 342

1. 7) seconds. I nspi rat ory pause t ime can be set f rom 0% to 60% (def aul t 10%) of
i nspi ratory t i me. PEEP can be set f rom 0 t o 20 (defaul t 0) cm H
2
O, wi t h a maximum
of Pmax -10 cm H
2
O. Tri gger sensi t i vi ty can be set f rom 0.3 to 15 (def aul t 3)
L/ mi nute i n pressure support mode. Rise t i me (T
SLOPE
) can be set f rom 0.0 to 2. 0
(def aul t 0.0) seconds. The pressure support range (Pps) is 3 t o 50 (defaul t 5) cm
H
2
O. The i nspi ratory pressure i n the pressure mode is PEEP +5 cm H
2
O, up to 70
cm H
2
O. Pati ent age can be set f rom <1 to 120 (defaul t 40) years.

View Figure

Figure 12.26. Drager Fabius GS ventilator. Inspiration
during mechanical ventilation. PEEP, positive end-
expiratory pressure; APL, adjustable pressure limiting.

Alarms
Al arms are i ndi cat ed on the status f i eld at the top of the screen (Fi g. 12.28).
Warning messages f l ash ON and OFF on a red background, and a conti nuous tone
sounds. Caut i on messages f lash ON and OFF on a yel l ow background, and an
i ntermi ttent tone sounds every 30 seconds. Advisory messages appear on a whi te
background, and depending on the advi sory, a si ngl e tone may sound.
Venti lation Modes
Vol ume control (wi th or wi t hout synchroni zat i on and opt ional pressure support ) and
pressure cont rol (wi th or wi t hout synchroni zat ion and opt i onal pressure support )
venti l ati on are standard f eatures. There i s a 15-second t i meout period f or making
venti l ati on mode changes, wi t h an audi bl e tone af t er t he f i rst 10 seconds. If the
new sett i ng is not conf i rmed wi thi n thi s t i me, t he previ ous venti l atory mode remai ns
i n ef f ect .
Manual/Spontaneous
To use t he manual /spont aneous venti l ati on mode, the user must f i rst set the APL
valve to the appropri ate mode (manual or spontaneous), then sel ect the mode on
t he f ront display panel . The f resh gas decoupl er val ve stays open.
During spontaneous respi rat ion (Fi g. 12.30), t he pati ent i nhal es gas f rom t he
reservoi r bag and f resh gas. Duri ng exhalati on (Fi g. 12.31), gas f l ows i nto the
reservoi r bag. Fresh gas wi l l al so f low t oward t he reservoi r
P. 343

bag. Excess gas wi l l exi t via the APL val ve, whi ch should be f ul l y open.

View Figure

Figure 12.27. Drager Fabius GS ventilator. Exhalation
during mechanical ventilation. PEEP, positive end-
expiratory pressure; APL, adjustable pressure limiting.

During manual inspi rati on (Fi g. 12.32), the APL val ve is t urned to the desi red
pressure. When the bag is squeezed, gas f l ows t hrough the absorber and past the
f resh gas i nl et. The pressure wi l l be l i mi ted to t hat set on t he APL val ve. Pul li ng up
on the APL val ve knob wi l l t emporari l y rel i eve excessi ve pressure. Duri ng
exhal ati on, the reservoi r bag f i l ls wi th exhal ed gas and f resh gas f l owi ng ret rograde
t hrough the absorber.
Mechanical
During mechanical venti l at ion, the f resh gas decoupler val ve cl oses duri ng
i nspi rati on (Fig. 12.33). Thi s causes f resh gas t o f l ow ret rograde through t he
absorber.
During earl y exhal at ion (Fi g. 12. 34), exhal ed gas f lows through the absorber and
i nto t he retract i ng piston vent i l ator. Fresh gas al so f lows i nto the venti l at or. Af ter
t he pi ston has ful l y retract ed (Fig. 12.35), excess gas f l ows through the exhaust
valve to the scavenger system. Some f resh gas wi l l f l ow retrograde t hrough t he
absorber.
Volume Control
The parameters f or vol ume-control l ed respi rat ion can be preset bef ore t he vol ume
mode i s act i vated. Compl i ance compensat i on is appl i ed duri ng volume-control l ed
venti l ati on. Compl iance i s determi ned duri ng t he leak test perf ormed i n the standby
mode. For compl i ance compensati on to work accuratel y, i t is i mportant that t he
hoses used during the test match t hose used during the procedure.
Act i vat ing synchroni zat ion i s opt i onal . I t is acti vated by enteri ng a val ue f or tri gger
sensi ti vi ty. A breath t ri ggered by the pati ent i s represented by a vert ical bl ack l i ne
on the pressure and f low curves. The active wi ndow f or a breath tri ggered by the
pati ent i s the l ast 25% of t he expi rat ory t ime. In order t o mai ntai n a const ant
f requency, a breath tri ggered prematurel y is compensated f or in t he next cycle.

View Figure

Figure 12.28. Main screen of the Apollo anesthesia
machine.

P. 344


Pressure Control
Pressure control vent i l at i on is a st andard f eat ure on t he Apol l o vent i l ator. The rate
at whi ch t he pressure rises i s set vi a the ri se ti me (T
SLOPE
). The maximum ti me f or
control led vent il ati on is set vi a the f requency. I n the pressure cont rol mode, the
maxi mum inspi ratory f l ow i s 150 L/ mi nute. The venti lator can be confi gured so t hat
t he i nspi rat ory pressure wi l l be aut omati call y changed when PEEP is changed i n
t he pressure control mode.
Synchroni zat i on wi t h spontaneous breathing can be acti vated in t hi s mode by
entering a val ue for t ri gger sensi ti vi ty. A vent i lati on st roke tri ggered by the pati ent
i s represented by a verti cal bl ack l ine i n the pressure and f l ow curves (t ri gger
i ndi cator). The wi ndow f or
P. 345

t ri ggeri ng by the pati ent is the l ast 25% of the expi ratory phase t i me. I n order to
mai ntai n a constant f requency, a breath t ri ggered prematurel y i s compensated f or
i n the next cycl e.

View Figure

Figure 12.29. Two sets of keys below the screen are used to
set ventilatory mode and parameters. The control knob is at
the right, and to its right is the edge of the Standby key.


View Figure

Figure 12.30. Apollo ventilator. Inspiration during
spontaneous breathing. PEEP, positive end-expiratory
pressure; APL, adjustable pressure limiting. (Redrawn
courtesy of Drager Medical.)

Pressure Support
Pressure-assi sted spontaneous breathi ng, if present , is opti onal i n the pressure
control and vol ume control modes. I t can be used as a separate mode. I t is
acti vated by enteri ng a val ue for the l evel of support (Pps). I f the pat ient is being
venti l ated wi t hout synchroni zat ion when pressure support i s turned ON,
synchroni zati on wi l l be aut omat ical l y act ivated. Synchroni zati on wi l l be mai ntained
when pressure support i s deactivated.
The rat e at whi ch the pressure ri ses i s set by usi ng the ri se ti me (T
SLOPE
). The
manuf acturer recommends that the ri se t i me be set so that t he pl ateau pressure i s
reached wi t hi n one thi rd of the inspi ratory ti me. Inspi rat ion ends as soon as the
i nspi ratory f low drops below 25% of the i nspi ratory peak fl ow.
The i nspi ratory t i me f or spontaneous breathi ng cannot be greater t han 1.5 seconds
i n pati ents under 4 years of age or more than 4 seconds i n pati ents over that age.
Special Features
The machi ne has an automated checkout procedure that i ncl udes a compl i ance
measurement .
Ent ering the pati ent ' s body wei ght and age causes t he venti l ator to produce def aul t
sett ings based on the given i nf ormati on. These set ti ngs need to be conf i rmed.
The i nspi ratory pressure can be automati cal l y changed when PEEP i s al tered i n the
pressure cont rol mode. This f eature can be di sabled. The i nspi ratory t i me can be
automati cal l y al tered in t he vol ume-control led or pressure-control led vent il at i on
modes wi t hout synchroni zati on so that the resul tant I:E rat io remai ns constant .
P. 346

I f this sett i ng i s di sabled, t he inspi ratory ti me wi l l be i ndependent of the change i n
f requency, and the I :E rati o wi l l change accordi ngl y.

View Figure

Figure 12.31. Apollo ventilator. Exhalation during
spontaneous breathing. PEEP, positive end-expiratory
pressure; APL, adjustable pressure limiting. (Redrawn
courtesy of Drager Medical.)

The Apol l o has f resh gas decoupl i ng. Duri ng i nspi rati on wi th mechani cal venti l ati on,
t he f resh gas decoupl er valve closes. Thi s di rects the f resh gas that enters t he
system t o the reservoi r bag, t hereby st opping i t f rom bei ng added t o the i nspi red
t i dal vol ume. Duri ng exhal at i on, the f resh gas decoupl er val ve opens, al lowi ng
exhal ed gas and t he accumul at ed f resh gas to f i l l the venti lator.
Cleani ng and Sterilization
The breathi ng system and vent i lator may be disassembl ed f or cleani ng and
steri l i zat ion. Al l parts of the breathi ng syst em except the Spi rol og f low sensor can
be thermal l y di si nf ected i n an automati c cl eani ng and disi nfecti ng machine at 93C
f or 10 mi nut es. Onl y neutral cleani ng agents and f ul l y demi neral i zed water may be
used. Chemical di si nf ectants should not be added for thermal di sinfecti on, as they
may cause corrosi on. The internal parts of the venti l ator can be steam steri l i zed at
134C for 8 mi nutes. The Spi rol og sensor al so can be i mmersed i n 70% alcohol f or
approxi matel y 1 hour and al l owed to dry f or 30 minutes.
General Electric Datex-Ohmeda 7900 Series
Description
The 7900 (Smart Vent ) venti l ator is an i nt egral part of a number of Datex-Ohmeda
anesthesi a machines (4,12). There are a vari et y of sof t ware versi ons i n use, and a
part icular venti l ator may have added f eat ures such as addi ti onal venti latory modes.
Si nce t here are so many variat i ons i n use, i t i s not possi bl e to di scuss each
vari ati on. The i nst ructi ons f or t he versi on that t he user has shoul d be consul ted.

View Figure

Figure 12.32. Apollo ventilator. Inspiration during manual
ventilation. PEEP, positive end-expiratory pressure; APL,
adjustable pressure limiting. (Redrawn courtesy of Drager
Medical.)

P. 347


The bell ows assembl y (Fi g. 12.36, see page 351), whi ch has an ascending bel lows,
i s separat e f rom the cont rol port i on. On newer machines, t he Bag/Vent sel ector
swi t ch on the top of t he carbon dioxi de absorber serves as the ON-OFF cont rol f or
t he vent i lator. Pl aci ng t he swi tch i n the Vent posi ti on turns the venti l ator ON. Ol der
models have an ON-OFF swi t ch on the venti l ator (Fi g. 12.37, see page 352).
The vent il ator can be powered by ai r or oxygen and has a peak i nspi rat ory f l ow of
70 L/minute. Inspi red and exhaled vol umes are measured usi ng vari able ori f i ce fl ow
sensors at t he out let and i nl et on the absorber (Chapt er 23). I nf ormati on f rom the
i nspi ratory sensor i s used to regul ate the bel l ows compressi on duri ng inspi rat i on.
Several breaths are needed to al low equi l i brati on so t hat t he venti l at or del i vers the
set ti dal vol ume. The vent i lator can compensate for f resh gas f l ows f rom 15 to 200
mL/minute and moderate breathi ng system l eaks. This el i minates the ef fect of f resh
gas f l ow on the del ivered t idal vol ume but does not prot ect compl etel y f rom added
volume i f the oxygen fl ush i s acti vated during i nspi rat i on (23). The f l ow sensor i n
t he expi ratory l imb measures exhaled vol ume, whi ch i s then displ ayed on t he
screen. Because t he f low sensors are at the absorber, changes i n ti dal vol ume
resul ti ng f rom gas compressi on and ci rcui t compl iance cannot be compensat ed for.
The f ront panel on ol der model s (Fi g. 12. 37) has the cont rol s for the vent i l ator
f uncti ons and a di splay screen. The ON-OFF key, whi ch has a bel l ows i con, is t o
t he l ef t of the screen. On some machi nes, thi s key i s repl aced by an End Case key
t hat puts t he apnea and vol ume al arms i nto standby and causes user sel ecti ons to
be returned t o def aul t sett i ngs. Above the ON-OFF key is a key to audio pause
(si l ence) al arms. On the ri ght i s a key t o disabl e/enabl e the apnea and vol ume
al arms. Bel ow this i s the menu access key. Bel ow the menu key i s a rotary mouse
(ComWheel ) t hat i s used t o sel ect menus and change set ti ngs.

View Figure

Figure 12.33. Apollo ventilator. Inspiration during
mechanical ventilation. PEEP, positive end-expiratory
pressure; APL, adjustable pressure limiting. (Redrawn
courtesy of Drager Medical.)

P. 348


The screen di spl ays al arm messages, alarm status, venti latory modes, venti l atory
control val ues, various measured val ues, and wavef orms. Above the wavef orm, the
stat us of the apnea al arm and vol ume moni tor are di spl ayed. Inspi red oxygen
concentrati on; exhaled ti dal and minute volumes; respi rat ory rate; and peak, mean,
and plat eau ai rway pressures are shown on the l ef t si de of the screen. Al arm l i mi ts
can be displ ayed to the ri ght of some val ues. Al arm messages are di spl ayed above
t his area (Fi g. 12. 38, see page 352).
Bel ow the screen are sel ect ion keys. When a key i s pressed, t he box around the
di spl ay wi ndow above that key f l ashes. The set ti ng can be adj ust ed by t urni ng the
rotary mouse. Pressi ng the key or the rot ary mouse confi rms t he sel ected val ue. If
t he set ti ng i s not conf i rmed i n 8 seconds, the set ti ng remai ns unchanged. Once a
change i n a parameter is conf i rmed, i t usual l y t akes several breaths for t he
venti l ator to adjust t o the new sett ing.
Menus (Fi g. 12.39, see page 353) are accessed by pressing the butt on above the
rotary mouse. These are used f or set ti ngs that are changed l ess f requent l y. The
content of the menus depends on t he sof tware i n pl ace.
The cont rol panel for a newer model i s shown i n Fi gure 12. 40 (see page 353). On
t he l ef t are control s f or t he t imer. On the ri ght at the top i s t he Si l ence Al arms
(audi o pause) key. Bel ow t his i s the key for the alarm set up, which when pressed
wi l l bri ng up an al arm menu. Bel ow t hi s i s a Hel p key. Bel ow t hat i s a key f or
Trends. The next key is f or t he Main Menu. Bel ow thi s i s the Checkout key. Bel ow
t his i s the Start /End Case key.
At t he bot tom l ef t i s the Gas Setup key. Above this are three keys that control the
parameters in the boxes above them (O
2
%, t otal fl ow, and vapori zer set ti ng). To t he
ri ght of t hi s is t he Venti l at or Setup key. Above t his are three keys that cont rol
parameters rel ati ng to the sel ect ed venti l ati on mode. To the ri ght i s the Spi romet ry
key. To t he ri ght i s a key to
P. 349

bri ng up the Normal Screen. To i ts right i s the rotary mouse.

View Figure

Figure 12.34. Apollo ventilator. Exhalation during
mechanical ventilation. PEEP, positive end-expiratory
pressure; APL, adjustable pressure limiting. (Redrawn
courtesy of Drager Medical.)

Fi gure 12. 42 (see page 355) shows the Vent i l ator Set up screen. To t he lef t are the
choices f or venti lati on mode. On the ri ght are vent i latory parameters. Some of
t hese parameters can al so be set by using the keys at the bot tom center of t he
control panel (Fi g. 12.40).
Controls
The cont rol s and t hei r arrangement wi l l depend on which versi on of the 7900
venti l ator is being used. Earl i er models had al l of t he control s on the venti l ator
i tself , whi l e the l at er models have them on the screen.
The cont rol s f or ti dal vol ume (20 t o 1500 mL), Pi nspi red (t he pressure deli vered
wi th each pressure control led breath) (5 to 60 cm H
2
O), respi ratory rate (4 to 100
bpm i n vol ume cont rol or pressure cont rol venti lati on, 2 t o 60 bpm i n PSV or SIMV),
I :E rati o (2: 1 to 1:8), ai rway pressure li mi t (Pl i mi t , 12 to 100 cm H
2
O), and PEEP
(OFF or 4 to 30 cm H
2
O) are set by usi ng t he sel ect i on keys.
The f ol lowi ng are set through menus: inspi rat ory pause (0% to 60% of t he
i nspi ratory t i me), Psupport (i nspi ratory pressure del i vered during PSV or SIMV) (2
t o 40 cm H
2
O), t ri gger wi ndow ( whi ch cont rols the percent of the exhal ati on phase
wi thi n whi ch t he pat ient may t ri gger the next mechani cal breath i n SI MV and PSV)
(0% t o 80% i n i ncrements of 5%), i nspi ratory t i me i n SI MV and PSV (0.2 t o 5.0
seconds), the f low t ri gger l evel ( whi ch sets t he mini mum f l ow that t ri ggers the
venti l ator to del iver a mechanical breath duri ng SI MV or PSV (0.2 t o
P. 350

10 L/minute), and the i nspi rat ory terminal l evel (whi ch sets t he percentage of the
peak i nspi rat ory f l ow where the vent i l ator stops a pressure-support ed breath i n
SI MV or PSV) (5% t o 50%).

View Figure

Figure 12.35. Apollo ventilator. Late exhalation during
mechanical ventilation. PEEP, positive end-expiratory
pressure; APL, adjustable pressure limiting. (Redrawn
courtesy of Drager Medical.)

A normal screen i s shown i n Fi gure 12. 41 (see page 354). Vi rt ual f lowmeters are
di spl ayed on the l ef t. In the mi ddle are wavef orms. To the ri ght are measured
parameters.
Alarms
There are variati ons i n the al arms off ered, dependi ng on the sof t ware i nstal l ed. In
l ater versi ons, the alarms are categori zed into hi gh, medi um, and l ow pri ori ty. A
hi gh priori ty consi sts of ten tones and a 10-second pause. The cause of t he al arm
i s shown i n reverse col ors on the screen. The medi um pri ori ty alarm consists of
t hree t ones wi t h a 25-second pause. A low pri ori t y alarm has a si ngl e tone.
Al arm l i mi ts may be displayed on t he screen next to the parameters wi th whi ch they
are associ ated. They are accessed f rom the alarm menu. The val ue to be al tered is
selected, then set and confi rmed by usi ng the rot ary mouse.
Al arm messages are di spl ayed at t he top of the screen (Fi g. 12.40). Al arms can be
audio paused (si lenced) for 120 seconds by usi ng the but ton at the upper l ef t of the
screen. Thi s t ime wi l l be counted down on the screen just under t he bel l wi th an X
t hrough i t.
Venti lation Modes
Vol ume control and pressure control venti l at i on are standard and have been
avai l able si nce t hi s vent i l ator was f i rst i ntroduced. SIMV and PSV wi th apnea
backup (PSVPro) are opt ional . PEEP is avai l abl e i n al l modes. Af ter a mode is
selected, the highl i ghted cont rol parameters must be set.
Special Features
Bat t ery backup permi ts approxi mat el y 30 mi nutes of mechanical venti l ati on and
operati on of moni t ors duri ng a power fai l ure.
A hel iox mode may be avai l abl e. Thi s automatical l y corrects f or t he l ower densi ty of
hel i ox.

View Figure

Figure 12.36. Bellows assembly of the 7900 ventilator. The
Bag/Vent switch, which also turns the ventilator ON or
OFF, is between the bellows assembly and the APL valve.

P. 351


A mi ni mum moni tori ng mode shows pat i ent data but does not permi t mechanical
venti l ati on.
The cardiac bypass mode turns OFF t he vol ume and apnea al arms.
A ci rcui t l eak al arm is acti vat ed i f l ess than hal f of the i nspi red vol ume i s sensed at
t he exhalati on sensor. It can be turned off to prevent nui sance al arms f rom a known
l eak (e.g., an uncuf f ed tracheal t ube).
The 7900 venti l ator has f resh gas compensati on. The bel lows excursion i s al tered
t o del iver the correct ti dal vol ume by subtract i ng the f resh gas i nput duri ng
i nspi rati on f rom the vol ume that the vent i lator del i vers. Thi s is medi ated by
measuri ng the i nspi red and exhaled t i dal vol umes through use of the f l ow sensors
l ocated i n the ci rcl e syst em.
Evaluation
The 7900 venti l ator has i mproved pressure and f l ow capabi l i ti es and provides a
more stabl e t i dal volume wi t h al tered f resh gas fl ow than ol der model venti l ators
f rom the same manuf acturer (4, 12).
When t he Aest i va 5 versi on of the 7900 vent i l ator i s in t he pressure control mode,
i ncreasi ng respi ratory rate decreases t he del ivered t idal vol ume more than wi t h an
I CU vent il at or or t he Narkomed 6000 venti l ator (2).
The vari abl e orif ice f l ow sensors are sensi ti ve t o moisture bui l dup. Heated
humi di f i ers can al so cont ri but e to moi st ure bui l dup and probabl y shoul d not be used
wi th t hi s vent i l ator (70,71). Water can mi grate i nt o the sensor i nterface board in t he
venti l ator. The fi rst warni ng that there i s a problem may be a reverse f l ow warni ng
(72,73). A f l ow sensor designed to mi ni mize moist ure bui ldup has been desi gned. A
si mi l ar probl em has been noted i n operat ing rooms that are part icul arl y col d (70).
St ress f ractures where the pneumat i c tube enters t he sensor have been report ed
(74,75,76). The sensor or the t ubi ng t o i t can become f ractured and leak (77,78).
Cleani ng and Sterilization
When used wi t h the Aest iva machi ne and breathi ng system, nearl y all parts except
t he f l ow sensors and oxygen sensor t hat are exposed to respi ratory gases are
steam autocl avabl e. The f l ow sensors can be di si nf ected by usi ng gl ut araldehyde.
Aut ocl avabl e f l ow sensors are avai l able.
General Electric Datex-Ohmeda 7100
The 7100 venti l ator is si mi lar to the 7900 venti l at or. The mai n dif ference bet ween
t hem is that t he 7100 has f ewer f eatures.
Description
The 7100 venti l ator is t urned ON by set ti ng the Bag/ Vent sel ector swi t ch to t he
Vent posi t ion. Vol ume measurements are made by usi ng two vari abl e orif ice
sensors (Chapter 23) at the absorber assembl y. The displayed moni tored vol ume is
obtai ned f rom the exhalati on sensor. I nformat ion f rom t he i nspi ratory sensor i s
used to adj ust the del ivered t i dal volume. Thi s method el i mi nates t he ef fect of f resh
gas on t he del i vered t idal vol ume but does not protect f rom the eff ect of added
volume i f the oxygen fl ush i s acti vated during i nspi rat i on (23). This mechani sm
does not compensate f or gas compression or ci rcui t compl i ance i n the breathi ng
system.
The display screen i s shown i n Figure 12.43 (see page 355). To t he lef t of the
screen are t wo keys. The top key i s f or audi o pausing (si l enci ng) al arms up t o 120
seconds. The screen shows t he t ime remai ni ng in t he si l enci ng period. Pressi ng
and holding the key f or one second when no al arms are active suspends audi o
t ones f or medi um and l ow pri ori t y al arms f or 90 seconds. When t he al arms
P. 352

are audi o paused, a l arge X covers t he li mi t s. Below t hi s key i s an End of Case
key.

View Figure

Figure 12.37. Front panel of the 7900 ventilator. Some
values have alarm limits to the right.

To the ri ght of the screen are t wo keys. The t op one turns the vol ume alarms ON or
OFF. Bel ow t hi s is a menu key that al lows the operator to access a number of
screens used to adj ust funct ions associ ated wi t h the vent il ator. Bel ow t hi s key i s a
rotary mouse that is used to al ter and conf i rm val ues on t he screen.
There are f i ve keys bel ow the screen. These al l ow the t i dal volume, respi rat ory
rate, I: E rati o, maxi mum ai rway pressure, and PEEP t o be adj usted. The set val ues
are displ ayed on t he screen above each key. If pressure control venti l at ion i s used,
t he l ef t -hand box wi l l i ndicate t he i nspi ratory pressure.
Above the f uncti on values on the screen is a space that i ndi cates t he mechani cal
venti l ati on status (ON or OFF), t he venti l at ion mode (vol ume or pressure cont rol ),
and the breat hi ng system bei ng used. Above t hi s on the l ef t are t he measured
values f or t i dal vol ume, mi nute vol ume, respi ratory rat e, and oxygen percent age. To
t he ri ght are values f or peak i nspi ratory and mean ai rway pressure and PEEP.
Above is a pressure bar graph or
P. 353

waveform. The alarm status message displ ay is at the top of t he screen.

View Figure

Figure 12.38. Alarm messages are displayed in the upper
left part of the screen.


View Figure

Figure 12.39. Main menu. This allows access to the next set
of menus.

Control s
The cont rol s f or ti dal vol ume (20 t o 1500 mL), Pi nspi red (t he amount of pressure
del i vered duri ng pressure-control l ed vent il at i on) (5 t o 60 cm H
2
O), respi rat ory rate
(4 t o 100 bpm i n vol ume cont rol or pressure cont rol venti lati on, 2 t o 60 bpm i n PSV
or SI MV), I: E rat io (2:1 t o 1:8), high ai rway pressure (P
l i mi t
, 12 t o 100 cm H
2
O), and
PEEP (OFF or 4 to 30 cm H
2
O) are set by usi ng t he sel ect i on keys at the bot tom.
The i nspi ratory pause (0% to 60% of i nspi ratory t i me) is set through a menu.
Alarms
The al arm sett i ngs are cont rol l ed through a menu. The al arm t o be al t ered sel ected
and adjust ed by usi ng the cont rol knob, t hen conf i rmed by pushing t he knob. Al arm
l i mi ts can be di spl ayed on the screen besi de each measured vari abl e.

View Figure

Figure 12.40. Control panel for newer models of the 7900
ventilator. The screen is the one that appears when the
machine is turned ON. It gives instructions for the
automatic checking procedure. Note the alarm messages at
the top.


View Figure

Figure 12.41. Normal screen on newer models of the 7900
ventilator.

P. 354


A hi gh pri ori t y al arm i ncl udes t wo bursts of f ive tones, af t er whi ch there i s a pause
and then the audi bl e al arm i s repeat ed. A medi um pri ori t y al arm sounds t hree tones
f ol l owed by a 25-second pause, and the al arm i s then repeat ed. A low pri ori t y alarm
has a si ngle sound t hat i s not repeated.
Venti lation Modes
The vent il ati on modes are accessed f rom t he mai n menu. Volume cont rol is
standard, whi l e pressure cont rol is opti onal .
Special Features
The 7100 venti l ator has a bat tery backup, whi ch wi l l suppl y power f or 90 minutes
when f ul l y charged. Under some ci rcumstances, t his power wi l l be avail abl e for onl y
30 mi nut es.
The vent il ator adjusts gas fl ow to t he bel l ows based on t he i nspi ratory vol ume
measured by the vari abl e orif i ce sensor on t he i nspi ratory breat hi ng system l i mb
(f resh gas compensati on). Thi s el i minates the eff ect of changes i n f resh gas f l ow on
t i dal vol ume. Duri ng some malf uncti ons, the venti l at or automati cal l y turns OFF
volume compensat ion.
I f the anesthesia machi ne is equi pped to use hel i um, the hel iox mode can be
selected through a menu. Thi s automat i cal ly corrects f or hel i um's l ower densi t y.
There i s an al arm for ci rcui t l eak that is acti vat ed when l ess than hal f of t he
i nspi red vol ume returns through the expi ratory f l ow sensor duri ng mechani cal
venti l ati on.
Evaluation
A probl em wi t h t he 7100 vent i lator has been report ed (79). The venti lat or woul d
peri odi cal l y shut down and t he sustai ned pressure alarm woul d be acti vat ed. I t was
determined that i f the f l ow t o the scavengi ng system was l ow, waste gas woul d
accumul ate in t he bag. When the pressure woul d reach 9 cm H
2
O, the vent i l at or
woul d shut OFF. The manuf act urer of fers a conversi on to f ul l fl ow f or the
scavengi ng system to remedy t hi s probl em.
Another reported probl em was i nabi l i t y to use vol ume cont rol venti l ati on when t he
f low sensor was subj ect to signif i cant amounts of moi sture (80).
Cleani ng and Sterilization
Most of t he parts of the 7100 vent i lator t hat have been exposed t o the respi red
gases can be disassembl ed and steam aut ocl aved. Parts t hat cannot be steam
autocl aved can be chemi cal l y disinf ected.
General Electric Datex-Ohmeda AS/3 Anesthesia
Delivery Unit
Description
Thi s venti l ator is an i ntegral part of the Datex-Ohmeda Anesthesi a Del ivery Uni t
(ADU). I t i s shown i n Fi gure 12.44. The bell ows assembl y, wi t h an ascendi ng
bel l ows, is l ocat ed t o the l ef t of t he di spl ay wi ndow. The
P. 355

AUTO/ MAN swi tch i s bel ow the bel lows. Turni ng i t to the AUTO posi t ion turns on
t he vent i lator.

View Figure

Figure 12.42. Ventilator Setup screen for the 7900
ventilator. This is displayed when the Ventilator Setup key
is depressed. It allows a choice of ventilator modes on the
left. On the right, ventilator parameters can be set.


View Figure

Figure 12.43. Screen for the 7100 ventilator.

Ei ther ai r or oxygen can be used as the dri ve gas. If t he pri mary drive gas pressure
i s l ost, the venti l ator wi l l automati call y swi tch t o the other gas. The maxi mum
i nspi ratory f low i s 80 L/mi nute. Vol ume i s measured bet ween the breathi ng system
and the pat i ent wi t h a D-li t e sensor (Chapter 23).
A di agram of the bell ows block is shown i n Fi gure 12. 45. Duri ng i nspi rati on (Fig.
12.45, top), t he control uni t di rects driving gas into the bl ock. The bel l ows canister
i s pressuri zed, dri vi ng the bel lows downward. At the same ti me, t he pressure i n the
overf l ow (spi l l ) val ve housi ng i ncreases, pushing downward on the rubber
membrane and metal l i d in t he overf low valve. This cl oses the val ve, prevent ing gas
t hat i s insi de the bell ows f rom bei ng l ost . At t he end of the i nspi ratory phase, the
pressure i n the outer cani st er ret urns to zero.
Fi gure 12. 45, bottom, depi cts t he venti l at or during lat e exhal ati on. Exhal ed gases
cause the bel l ows to return to i ts uppermost posi ti on. The pressure i n the overf l ow
valve housi ng returns to zero, al l owi ng the rubber membrane and met al l i d to ri se
f rom the seat so that excess gas can escape t o the scavengi ng system.
The vent il ator panel i s shown i n Fi gure 12.46. The keys vary i n posi t i on f or
di ff erent versions of thi s machi ne. To the right of t he screen are keys f or vent i l atory
mode, respi ratory rat e, I : E rat i o, and PEEP. Bel ow t he screen i s a handwheel .
When a parameter i s sel ect ed, i t i s adj usted by rot ati ng the handwheel . The new
sett ing i s confi rmed by pushing t he wheel or key or by pushi ng another key on the
di spl ay uni t . There i s also a key to bri ng up ot her screens.
At t he l ower ri ght of the screen, t he set t i dal volume, minut e vol ume, i nspi rat ory
pause, respi ratory rat e, I :E rati o, I :E t imes, venti l atory mode, and PEEP are
di spl ayed.
To the lef t of the vent il ator sett ings on the screen i s a mi ddl e f i el d wi t h gas- and
volume-moni tori ng i nf ormati on or t rends. To t he l ef t of the middle f ield i s the f resh
gas displ ay where f l ows of oxygen, ai r, and N
2
O are displ ayed as vi rtual f lowmeters
and numeri cal val ues. The anesthet i c agent set ti ng i s displ ayed i n a box to t he ri ght
of t he f lowmeter numerical di splay.
Above the vent i l atory set ti ngs, two wavef orms can be di spl ayed. One i s al ways
ci rcui t pressure. End-ti dal and i nspi red carbon di oxi de may be di splayed if the
carbon dioxi de wavef orm i s shown. An al arm message f ield i s at the top.
Pressi ng the venti lator key to t he ri ght of the PEEP key bri ngs up a menu t hat
al l ows the venti l at ory mode (volume, pressure, or SI MV) to be sel ected. Ti dal
volume, set pressure, respi ratory rate, I:E rat i o, and PEEP also may be al tered
f rom this menu.

View Figure

Figure 12.44. A: Datex-Engstrom AS/3 Anesthesia
Delivery Unit ventilator. To the right of this is the APL
valve. B: Close-up view of the bottom of the ventilator.

P. 356


The opti ons wi ndow i s accessed through the vent il ator menu. Subheadi ngs i nclude
t he trigger wi ndow ( whi ch is used i n SI MV and PSV), i nspi ratory pause (whi ch can
be used in t he vol ume and SI MV modes), i nspi ratory rise t i me ( whi ch i s used i n the
pressure cont rol mode), and si gh (whi ch can be used in the vol ume control mode).
Control s
There are a number of di ff erent sof t ware versi ons avail abl e, so there may be some
di screpancy between the user' s machine and the i nf ormati on presented here. Ti dal
volume (20 to 1400 mL), mi nute volume, inspi ratory pause (0% to 60% of
i nspi ratory t i me) (Fi gs. 12. 47, 12.48, see pages 358, 359), respi ratory rat e (2 to 60
bpm), I :E rati o (1:4. 5 to 2:1, defaul t 1:2), I :E t imes (inspi ratory ti me 0. 35 to 20
seconds), the venti l at ory mode (Vol ume Control , Pressure Cont rol , Pressure
Support, or SIMV) and PEEP (OFF or 5 t o 20 cm H
2
O) are set by usi ng the keys
bel ow t he screen. PEEP is l imi ted to 10 cm H
2
O i f the t i dal vol ume is l ess than 100
mL. In pressure control vent il ati on, t he pressure (5 to 40 cm H
2
O above PEEP) can
be set by usi ng a key. Changes are made by t he vent i lator over several respi rat ory
cycl es.
The f ol lowi ng are set through menus: tri gger sensi ti vi t y (-5.0 to -0.5 cm H
2
O),
t ri gger wi ndow (5% to 95% of the expi ratory ti me, def aul t 95%) (Fi g. 12.49, see
page 359), i nspi ratory t ime (0.35 t o 20 seconds), i nspi ratory ri se ti me (sl ow,
medi um, or fast) (Fi g. 12.48), and i nspi ratory pause (0% to 60% of i nspi ratory t i me)
(Fi g. 12.47). A fast ri se t i me reaches the t argeted pressure i n the f i rst 10% of the
i nspi ratory t i me, medi um i n 50%, and sl ow i n 90%. When t he si gh i s used, the
venti l ator del i vers a t i dal volume that is 1.5 ti mes l arger t han the normal ti dal
volume every 100th breath. It i s l i mi ted t o 1400 mL.
There i s an adj ustabl e (5 t o 40 cm H
2
O above PEEP) maxi mum ai rway pressure
rel ease. The venti lator automatical l y swi t ches t o expi rati on when t he pressure i s
reached.
Alarms
Al arms are accessed through the Al arm Setup key to t he upper ri ght of the screen
and set by usi ng the wheel bel ow t he screen. Al arms are arranged by pri ori t y. A
hi gh-pri ori ty al arm i s red and is annunciated by f i ve beeps fol l owed by a 1-second
del ay and then f i ve more beeps f ol lowed by a 5-second del ay. This i s repeated. A
medi um priori ty al arm i s yel l ow and is annunciated wi t h t hree
P. 357


P. 358

beeps and a 19-second pause, then repeat ed. An advi sory not e i s whi te, and a
beep sounds every 60 seconds.

View Figure

Figure 12.45. Datex ventilator. Top: Inspiration. Bottom:
Expiration.


View Figure

Figure 12.46. Panel for Datex ventilator.

Venti lation Modes
Vol ume control , pressure control , and SMIV are st andard. PSV i s opti onal . Breaths
t hat are pressure supported are col ored red on the pressure wavef orm.
Special Features
There i s an overpressure release valve that i s set at 80 cm H
2
O. Duri ng
spontaneous breathing, subat mospheri c pressure i s l i mi ted to -3 cm H
2
O.
Thi s machine has bat tery backup f or t he enti re machi ne as wel l as the venti l at or f or
at l east 20 mi nut es wi th f ul l y charged bat teri es. There i s a bat tery charge
P. 359

i ndi cator. When about 30 seconds remai n i n t he bat t ery, a red al arm message
i ndi cates Batt ery Empt y, Go Manual .

View Figure

Figure 12.47. The inspiratory pause can be displayed on the
left part of the screen. It is changed by using the rotary
mouse.


View Figure

Figure 12.48. The inspiratory time can be displayed on the
left part of the screen. It is changed by using the rotary
mouse.

There i s an automat ic checkout procedure that can be perf ormed bef ore the pat ient
i s connected to the uni t. The full checkout is recommended on each machi ne
power-up but can be bypassed. Breat hi ng system compl i ance, compressi on volume,
and l eakage are measured. If the bypass command i s sel ect ed, the defaul t val ue for
compressi bl e vol ume is 2 mL/cm H
2
O. The del ivered t i dal volume may not be
correct i f t he compressible vol ume dif fers f rom this value.
The amounts of f resh gas and l i qui d anesthet i c agent used since power-up are
calculated and can be di spl ayed. Gas usage can be di spl ayed.
I f the pati ent' s wei ght i s entered, t he venti lator automat icall y calculates and
suggests sett ings f or ti dal vol ume, respi ratory rat e, and mi nute vol ume. The def aul t
P. 360

wei ght is 60 kg and corresponds to a ti dal vol ume of 500 mL and a respi ratory rat e
of 10.

View Figure

Figure 12.49. The trigger window can be displayed on the
left part of the screen. It is changed by using the rotary
mouse.

The vent il ator has compensati on f or f resh gas f low and ci rcui t compl iance.
The ADU measures the f resh gas f low cont inuousl y. The del i vered vol ume i s
calculated f rom these values. Thi s does not protect the pat ient f rom an i ncreased
t i dal vol ume i f the oxygen fl ush i s acti vated during i nspi rat ion (23).
Hazards
Wi th a very hi gh f resh gas f l ow, t he f resh gas f l ow compensat i on may cause
venti l ator standsti l l (81).
Cleani ng and Sterilization
Most of t he parts of the venti l ator and breathi ng system can be steam autocl aved at
a maxi mum of 121C. Ref er to the user manual f or cleani ng, disassembly, and
di si nf ect ion of i ndi vi dual components.
Datascope Anestar
Thi s venti l ator is an i ntegral part of the Anestar anesthesia system (20,23). The
Anestar S is a scal ed-down versi on wi t h some f uncti onal di ff erences.
Description
The Anestar breat hi ng system i s posi t ioned at t he f ront l ef t of the machi ne (Fi g.
12.50). A heated alumi num bl ock engages wi t h a motori zed docki ng st at ion. When
at tached t o the docki ng st ati on, t he breat hing syst em' s pneumati c and el ectroni c
connecti ons are secured. The hangi ng bel l ows and housi ng are l ocated bel ow the
al umi num bl ock. The breat hi ng system contai ns a negat ive
P. 361

pressure rel ief (room ai r, emergency ai r) val ve. I t opens to atmosphere whenever
t he pressure fall s 3 cm H
2
O or more below ambient pressure.

View Figure

Figure 12.50. Anestar anesthesia machine. The bellows
assembly with a descending bellows is located to the left
and below. The dial below the screen and above the
vaporizers has four positions: standby, manual ventilation,
child (40 to 400 mL), and adult (300 to 1400 mL).


View Figure

Figure 12.51. Anestar anesthesia machine screen. Manual
ventilation.

Ei ther ai r or oxygen can be used as the dri vi ng gas f or the vent i l ator. If l i ne
pressure i s unavai lable, the machi ne wi l l automati call y swi tch to cyl i nders for
driving gas if the cyl i nders are open.
Ai rway pressure is measured in the inspi ratory l i mb. Expi red volume i s measured i n
t he expi ratory l imb by using a hot- wi re anemometer (Chapt er 23). Duri ng
mechani cal vent i lati on, t he del i vered ti dal vol ume i s conf i rmed by usi ng an i nternal
f low sensor.
The t ouch screen i s shown i n Figures 12.51, 12.52, and 12.53. Vent i l ator f uncti ons
are adj usted usi ng the keys surroundi ng the screen. When the parameter t o be
changed i s touched, the screen value i s hi ghl i ght ed. The up and down keys to the
ri ght of t he screen are used t o increase or decrease the sel ected parameter. The
change i s conf i rmed by pushi ng the ENTER key at the l ower ri ght . The VI EW
SETTINGS key at the l ower l ef t corner can be used to view t he set ti ngs along the
bot tom of the screen. Across the t op of the screen are measured val ues f or peak
pressure, mean pressure, minute vol ume, i nspi red oxygen concent rati on, and
venti l atory mode. The vent mode key is at the top ri ght of the screen.

View Figure

Figure 12.52. Anestar anesthesia machine. Volume control
ventilation.


View Figure

Figure 12.53. Anestar anesthesia machine. Pressure control
ventilation.

I n t he mi ddl e of the screen i s a pressure versus ti me graph. Bel ow t hi s is a box
where al arm condi ti ons are di spl ayed. Duri ng the start-up f or the machi ne, perti nent
i nformati on and i nst ructi ons that are needed t o compl ete the start-up are displ ayed
on the data screen.
The OPTIONS key to the l ef t of t he screen at the t op provi des access to the uti l i t i es
t hat are avai l abl e when the venti lati on mode di al is i n t he standby posi t i on. These
i ncl ude compl i ance, oxygen cal ibrat i on, l eak test i ng, runni ng hours, breat hi ng
system t emperature, breat hi ng system ej ecti on cont rol (Anestar onl y), and di spl ay
screen cont rast.
The ALARM LIMI TS key act i vates and deacti vates the alarm screen.
Control s
I n vol ume cont rol venti l ati on, ti dal vol ume can be vari ed f rom 40 to 400 (def aul t
200) mL in t he chi ld mode and 300 t o 1400 (def aul t 500) mL i n the adul t mode. The
t i dal vol ume/f low key, whi ch i s onl y on the Anestar, al l ows the operator to adj ust
t he i nspi rat ory f l ow rate, whi ch can be vari ed f rom 10 to 60 (def aul t 40) L/mi nute.
Pl ateau pressure can be set t o OFF, 20% or 30% (def aul t OFF) of i nspi ratory ti me.
The respi ratory rate can be vari ed f rom 10 to 60 (def aul t 20) bpm i n the chi l d mode
and 4 t o 30 (defaul t 10) bpm i n t he adul t mode. The I :E rati o range
P. 362

i s 4:1 t o 1:5 (defaul t 1:2). PEEP is adj ustabl e f rom 3 to 15 cm H
2
O (def aul t OFF).

View Figure

Figure 12.54. Anestar anesthesia machine. Inspiration
during spontaneous respiration. Fresh gas from the
anesthesia machine and gases from the reservoir bag flow
through the inspiratory valve to the patient. If the bag
empties, the subatmospheric pressure relief valve will open
and admit room air into the system. APL, adjustable
pressure limiting.

The pl ateau pressure key i s used duri ng pressure control venti l at ion to set the
i nspi ratory (plateau) pressure, whi ch can be vari ed f rom 10 t o 60 (def aul t 20) cm
H
2
O i n bot h adul t and chi l d modes.
Alarms
The al arm l i mi ts key i s to t he lef t of the data screen. Pressing i t opens a wi ndow on
whi ch al arm sett i ngs and al arm vol ume can be al tered. Al arms are accessed by
t ouchi ng t he screen and are set by using t he up and down keys. There i s a MUTE
above the up and down arrow keys, whi ch audi o pauses al arms for 2 mi nutes. The
al arms vary wi t h t he mode of venti lati on.
Venti lation Modes
The Anestar has both vol ume cont rol and pressure cont rol venti lati on. When
swi t chi ng bet ween modes, sett i ngs are saved and wi l l resume when returni ng to a
mode. The Anest ar S has onl y vol ume control venti l at i on.
The Anestar breat hi ng system i s shown i n Fi gures 12.54 to 12.60 (see pages
362,363,364,365,366,367,368). The reservoi r bag serves to hol d f resh gas. Duri ng
mechani cal vent i lati on, t he bag i s ful l and appears t o pul sat e, i nf l ati ng sl i ght l y
duri ng inspi rati on. The bag, rather t han t he bel l ows, provides a visual i ndicati on of
a di sconnecti on. I f a l eak occurs and the vol ume of gas l ost is l ess t han t he f resh
gas f l ow, t he bag wi l l pul sat e more deepl y. I n case of a disconnect ion or maj or
l eak, the reservoi r bag wi l l def l at e af t er a f ew breaths.
The APL val ve shoul d al ways be set t o the OPEN posi ti on whi l e i n the CVM or PCV
modes.
Spontaneous Breathing
During spontaneous breat hi ng, the bel l ows remai ns ful l y expanded. During
i nspi rati on (Fig. 12.54), gas f l ows f rom the reservoi r bag. I f the bag empt i es, t he
subatmospheri c pressure reli ef val ve opens, and ai r i s drawn i nto the system.
During exhalat i on (Fi g. 12.55), exhaled gases pass through the absorber and mix
wi th f resh gas i n t he reservoi r bag. Excess gas is vented t o the scavengi ng system
t hrough the APL val ve.

View Figure

Figure 12.55. Anestar anesthesia machine. Exhalation
during spontaneous respiration. Gases exhaled by the
patient flow through the absorber and join fresh gases
flowing into the reservoir bag. At the end of exhalation,
excess gases flow through the APL valve to the scavenging
system. APL, adjustable pressure limiting.

P. 363


Manual
Wi th manual venti l ati on, the bell ows stays ful l y expanded. Duri ng i nspi rat ion (Fi g.
12.56), t he reservoi r bag i s squeezed so that gases f l ow to t he pat i ent . These
i ncl ude f resh gas and gas that has passed through the absorber. Duri ng the latter
part of i nspi rat i on, some gas may be vented t hrough t he partl y open APL valve.
During exhalat i on (Fi g. 12.57), the i nspi ratory unidi rect i onal valve cl oses. Fresh
gas f l ows into t he reservoi r bag. Exhal ed gas passes through the absorber and
mi xes wi th f resh gas i n t he reservoi r bag.
Mechanical
During i nspi rat i on (Fi g. 12.58), the f resh gas decoupl i ng, expi ratory control , and
bel l ows control valves cl ose. Fresh gas f lows into the reservoi r bag. Once the bag
i s fi l l ed, excess gas f l ows to t he scavengi ng system through the APL valve.
During exhalat i on (Fi gs. 12.59, 12.60), the f resh gas decoupl i ng valve i s open so
t hat f resh gas f l ows i nto the bell ows and inspi ratory l i mb. Exhal ed gases pass
t hrough the expi ratory uni di recti onal valve and the absorber. The open bel l ows
control val ve vents the dri ve gas to at mosphere, al l owi ng t he bel l ows to ref i l l . Fi rst
f resh gas, then the exhal ed gas, then possibl y gas i n the reservoi r bag f i l ls t he
descendi ng bel l ows. I n the event t hat f resh gas f l ow i s l ost , the subat mospheric
pressure rel ief val ve prevents a negat ive pressure i n t he ci rcui t by al l owi ng ambi ent
ai r t o enter the system. Af ter the bel lows has f i l led (Fi g. 12.60), t he pressure i n the
breat hi ng system i ncreases. When i t reaches approxi matel y 2 cm H
2
O, excess gas
passes t hrough the APL val ve to the scavengi ng system.
PEEP i s created by adj usti ng the expi ratory cont rol valve. Cl osi ng the valve bef ore
t he start of the next i nspi rat ion t raps vol ume returni ng f rom t he pati ent. The ti mi ng
i s fi ne tuned over several breaths to t rap the appropri ate vol ume in t he expi ratory
l i mb i n order to mai nt ai n the desi red l evel of PEEP.
Special Features
During mechanical venti l at ion, ti dal vol ume i s unaf fected by system compli ance.
The comput er compi l es the necessary i nf ormati on during the st artup procedure.
P. 364

Thi s task, which takes 30 seconds, can be bypassed and the previ ous measurement
retained for emergency cases. Ti dal vol ume i s unaff ected by f resh gas f l ow.

View Figure

Figure 12.56. Anestar anesthesia machine. Inspiration
during manual ventilation. When the bag is squeezed, gases
from it and fresh gases flow through the inspiratory valve to
the patient. APL, adjustable pressure limiting.

The maximum i nspi ratory pressure l i mi t i s 80 cm H
2
O.
The breathi ng system i s heated t o 35C (97F). This warms i nspi red gases and
el i mi nates moi sture condensati on wi thi n the breathing system, even wi t h low f resh
gas f l ows.
I n t he event of power f ai l ure, a f ul l y charged battery wi l l power the vent il ator and
i ts i ntegrated moni tor f or 30 mi nutes. Af ter 30 mi nut es, manual and assi sted
venti l ati on i s possible, and moni t ori ng conti nues unt i l the batt ery is depl eted.
A subatmospheri c pressure (room ai r) valve prevents negative pressure by
ent raining room ai r i f the pressure i n the breathing system fal l s 3 cm H
2
O or more
bel ow ambi ent pressure. An alarm is acti vated and a screen message appears i f
t here i s ambi ent ai r int ake.
The Anestar has a pressure rel ief but ton that rapi dl y di scharges ai rway pressure if
depressed. Thi s red butt on i s l ocated on the breathi ng system near t he APL valve.
Cleani ng and Sterilization
Di recti ons f or assembl y and disassembl y of the breathi ng system are given i n the
operati ng manual . Most of the part s of the breathing syst em that are exposed to
respi ratory gas can be steam autocl aved at 124C.
Pediatric Ventilation
I n t he past, pedi at ri c venti lati on has caused uneasiness among anesthesi a
provi ders because the l arge amount of space in t he absorber, t ubings, and
venti l ator resul ted i n relat i vel y large l oss of vol ume f rom gas compressi on and
compl i ance of t hese components (82, 83). Experi ence has shown that volume
control venti l at ion of i nf ants wi t h newer vent i l ators i s saf e and ef f ective, al though
t he del ivered ti dal vol ume may be somewhat i mpreci se (60,61). Pressure cont rol
venti l ati on can also be used wi t h pedi atri c pat ients (27,28, 59, 83,84). Some
venti l ators have a pedi at ri c mode that i s tai l ored to smal l i nf ants and chi l dren.

View Figure

Figure 12.57. Anestar anesthesia machine. Exhalation
during manual ventilation. Exhaled gases from the patient
pass through the absorber and join fresh gas flowing into the
reservoir bag. When the pressure set on the APL valve is
exceeded, excess gases will pass through it to the
scavenging system. APL, adjustable pressure limiting.

P. 365


Magnetic Resonance Imaging Ventilators
Consi derati ons f or practi ci ng anesthesi a in t he magneti c resonance i magi ng (MRI )
uni t are di scussed i n Chapter 30. St andard venti l ators wi th f errous materi al cannot
be used, because the electromagnet ic envi ronment wi l l int erf ere wi th t he cont rols
and the venti l ator can i nt erf ere wi t h the radi of requencies of the MRI . Anest hesi a
venti l ators sui tabl e for use i n an MRI uni t are avai l abl e. I CU venti l at ors can be
modi f i ed so t hat they are sui tabl e for such use (85).
There i s a report of a pati ent deat h due to an oxygen cyl i nder empt yi ng whi l e a
pneumat ical l y driven venti lator was bei ng used in an MRI sui t e (86). Al t hough there
was an al arm, i t was not not iced by personnel . In unusual si tuat ions such as an
MRI sui te, t he venti l ator should be at t ached to the cent ral pi pel i ne system when the
venti l ator is being used. If thi s is not avai l abl e, ext ra nonferrous cyli nders need to
be present and t he machine, venti l ator, and pati ent caref ul l y watched.
General Hazards
Hypoventilation
Venti lator Fail ure
Most anesthesi a venti lat ors perform rel iabl y f or l ong peri ods of ti me. Nevertheless,
one may occasi onal ly f ai l t o work properl y. Some probl ems are insi dious and resul t
i n l ess-t han-t otal f ai lure. Mal f uncti on may not be readi l y apparent, and a false
sense of securi ty may be generated by the sound that the venti l ator makes.
Causes of vent i l ator f ai lure i ncl ude di sconnecti on f rom or f ai lure of t he power
source (el ect ri ci t y or driving gas) and i nt ernal dysf uncti ons. An intermedi at e
f requency set ti ng may cause cycl i ng f ai lure (87). On some venti lat ors, wi th f resh
gas f l ow compensat ion, a very hi gh f resh gas f l ow can cause venti l ator standsti l l
(81). Problems wi t h the el ectric motor or power suppl y may cause the vent i lator t o
stop f unct i oni ng (64,65,68,88). Fluid enteri ng the el ectroni c ci rcui t ry may cause the
venti l ator to stop worki ng (89).

View Figure

Figure 12.58. Anestar anesthesia machine. Inspiration
during automatic ventilation. The fresh gas decoupling
valve is closed, so all of the fresh gas flows into the
reservoir bag. The bellows is compressed so that gas flows
through the inspiratory valve to the patient. APL, adjustable
pressure limiting.

P. 366


I f the bel l ows housi ng i s not t ightl y secured, dri vi ng gas can l eak, causi ng a
reducti on i n t idal volume (90). The housi ng may di sl ocated by hi t ti ng cei l i ng
columns or other obj ects as the venti l ator i s moved. Operati ng room personnel may
at tempt t o move a vent il ator by grabbi ng the housi ng, l ooseni ng i t, or causi ng i t to
break.
A mal functi on i n a comput er-cont rol l ed venti l ator may i nt errupt cycli ng. It i s good
pract i ce to t urn the anesthesi a machi ne OFF and restart i t by usi ng t he el ect ronic
checkout procedure at least dai l y so t hat t he comput er has f resh inf ormat ion i n i ts
data bank. A cycl i ng f ail ure may somet i mes be solved by t urni ng the anest hesia
machi ne OFF and then ON but usual l y requi res ref erence t o the operati on manual
or a cal l to t he manuf acturer.
Low maxi mum fl ow rates and variabi li ty i n fl ow rates wi t h i ncreased ai rway pressure
wi th ol der anesthesi a venti l at ors can reduce t he ti dal vol ume t hat can be del ivered.
Al though t hi s is usual l y not a probl em i n pati ents wi t h normal l ungs, i t can become
i mportant in pati ents wi th expi ratory ai rf l ow obstruct ion, f or whom a prolonged
expi ratory phase may be necessary to avoi d autoPEEP.
Loss of Breathi ng System Gas
Ol der anesthesia venti l at ors have no means of compensati ng for gas l oss i n the
breat hi ng system. New comput er-cont rol l ed venti lators can compensate f or small
l eaks. A vent i l ator may cycl e but f ai l t o occl ude the exi t port of the spi l l val ve,
bl owi ng part or al l of the t i dal vol ume int o the scavengi ng syst em (53, 54,91).
I f there i s l oss of breat hi ng system gas and an ascendi ng bel l ows venti l ator i s i n
use, t he bel l ows may not ret urn to i ts ful l y expanded posi ti on. This usual l y wi l l be
obvious. However, wi th t he i ntroducti on of cl osed scavengi ng systems, the bel lows
may remai n expanded i f there i s a disconnect i on (92). A descending bel lows
venti l ator may appear t o f uncti on normal l y i n t he f ace of l oss of breathi ng syst em
gas.
Incorrect Settings
I n a crowded anestheti zi ng area, venti l at or swi t ches or di als may be i nadvertent l y
changed as personnel move about . An operat or may f ai l to adj ust sett i ngs for a new
case (93). For venti l ators that provi de a control f or l imi t ing the peak inspi ratory
pressure, set ti ng that pressure
P. 367

t oo l ow may resul t i n an i nadequat e ti dal vol ume bei ng del ivered.

View Figure

Figure 12.59. Anestar anesthesia machine. Mid exhalation
during automatic ventilation. The bellows expands, drawing
in fresh gas and gas from the reservoir bag. Gas exhaled by
the patient passes toward the absorber. APL, adjustable
pressure limiting.

I f an anesthesi a machi ne i s turned OFF and t hen t urned back ON, the vent i l at or
may def aul t to di ff erent sett i ngs than were bei ng used (94).
I t i s essenti al t hat t here be suf f icient i nspi ratory ti me for the desi red t i dal volume to
be del ivered. Insuff i ci ent i nspi rat ory t i me may be i ndi cated by a bell ows that does
not make a ful l excursi on, causing a decrease i n the t i dal volume.
Venti lator Turned OFF
There are ti mes duri ng anesthesi a when the venti l at or must be turned OFF, such as
duri ng radi ological procedures where movement woul d compromi se t he image
quali t y. The operator may forget to t urn i t back ON.
Flow Obstruction
As wi l l be poi nted out i n Chapter 14, rest ri ct ed or occl uded gas f l ow can occur at a
vari et y of si tes and be caused by a vari ety of mechani sms. i ncl uding f ai lure to
change t he posi t ion of the bag-venti l ator sel ector valve when converti ng to
automati c vent i l ati on. If t he val ve i s l ef t i n the bag posi ti on, the venti l at or wi l l
operate against a dead end.
Wi th obstructi on to fl ow, the excursi on of the bel l ows wi l l be reduced but not tot al l y
el i mi nated. The pressure shown on t he system pressure gauge wi l l vary, dependi ng
on the locati ons of t he obstruct ion and the gauge.
Positive End-expiratory Pressure
Addi t ion of PEEP may decrease the ti dal vol ume del ivered wi t h some venti l ators
(21,22). The ef f ect i s more pronounced wi t h l ow t i dal vol umes but l ess i f l ung
compl i ance is l ow.
Hyperventilation
I n one report ed case, vent il ator sett ings f or a pat ient wi th l ow compl iance were not
modi f i ed pri or t o the next case, a pati ent wi t h normal lung compl i ance (93). The
resul t was excessi ve ti dal vol ume.
Wi th a hol e in t he bel l ows or a loose connecti on bet ween t he bel l ows and i ts base
assembl y, dri vi ng gas f rom t he housi ng can enter t he bel l ows, causi ng an
unexpectedl y hi gh t i dal volume (95). This can be
P. 368

accentuat ed by a hi gh i nspi ratory f l ow rate. A smal l hol e in the bel l ows may not
cause a change i n t he t idal vol ume (96).

View Figure

Figure 12.60. Anestar anesthesia machine. End exhalation
during automatic ventilation. The APL valve opens,
allowing excess gases to flow into the scavenging system.
APL, adjustable pressure limiting.

Hyperoxia
A hol e or t ear i n the bel l ows wi th oxygen as the dri ving gas can resul t i n an
i ncrease i n the i nspi red oxygen concentration and l ower-t han-expected anestheti c
concentrati ons (95,97,98). However, wi th a smal l tear, t here may be no eff ect (96).
Excessive Airway Pressure
Excessive ai rway pressure can develop very rapi dl y, especial l y if hi gh f resh gas
f lows are bei ng used. Quick action may be requi red to prevent pati ent i nj ury.
Because the venti l ator spi l l val ve i s cl osed duri ng i nspi rati on and t he APL val ve i n
t he breathi ng system is cl osed or i sol ated, acti vati ng the oxygen f l ush duri ng the
i nspi ratory phase can resul t i n barot rauma. Fresh gas decoupl ing reduces this
danger by divert i ng the oxygen to the reservoi r bag. Vent i l ators that compensat e by
al teri ng the bel lows excursi on may not al ways be able to prevent excessi ve ai rway
pressure i f the oxygen fl ush i s used duri ng i nspi rat ion.
A hol e in the bel lows or a l oose connecti on bet ween t he bel l ows and i ts base may
al l ow dri vi ng gas to enter t he bel lows, resul t i ng i n a higher-t han-expected pressure
duri ng inspi rati on. Pressure on the venti l ator spi l l val ve can resul t in excess
pressure (54,56,57). I n one case, a muf f l er designed t o si l ence the exhaust of
driving gas f rom the vent il ator became sat urated wi t h wat er and prevented gas f rom
exi t ing t he bel l ows housi ng (49).
Suf f ici ent ti me to al l ow f ul l exhal at ion must be al l owed. Insuff i ci ent expi ratory ti me
may be i ndi cat ed by a bel l ows t hat does not expand ful l y and carri es t he ri sk of ai r
t rapping and aut o (occul t , i ntrinsic) PEEP (99).
A properl y set pressure l imi ti ng mechani sm shoul d reduce the ri sk of barot rauma.
Some venti l at ors have adj ustable hi gh-pressure al arms. On others, t he al arms are
preset. Such an al arm may gi ve warni ng of a probl em in t ime to prevent harm to t he
pati ent . The risk of
P. 369

barot rauma and vol ut rauma are reduced wi t h f resh gas decoupl i ng (100).
When t here is hi gh ai rway pressure, a di sconnecti on shoul d be made i mmedi atel y
at t he t racheal tube and manual venti l ati on i nst i tuted. Taki ng ti me to f ind the
source of the problem may resul t i n harm t o the pati ent .
Negative Pressure during Expiration
Negati ve pressure i s consi dered undesi rable under most ci rcumst ances because of
adverse ef fects on pulmonary f uncti on and i ncreased ri sk of ai r embol ism. A
venti l ator wi th a wei ght ed hanging bel lows can generat e subatmospheri c pressure
duri ng the earl y part of expi rati on if expi ratory f low i s not i mpeded. This wi l l be
accentuat ed i f the f resh gas f l ow i s l ow. Newer vent i l ators wi t h a hangi ng bel l ows
have a negat i ve pressure valve t o admi t ai r i f negati ve pressure devel ops.
Alarm Failure
Al though l ow-pressure al arms have si gni f i cantl y advanced pat ient safet y, t hey can
f ai l . When t he l ow ai r way pressure al arm threshold i s adj ust abl e, i t shoul d be set
j ust bel ow t he peak i nspi rat ory pressure. Cases have been report ed where
resi st ance (f rom tracheal t ube connectors, Y-pi eces, f i l ters, and other components
or f rom t he pati ent port of the breat hi ng syst em being pressed against t he pat i ent
or a pi l low) coupl ed wi t h high i nspi ratory f l ow rat es created suf f icient back pressure
t o generat e a f al se-posi t ive si gnal at the sensing si te when the threshol d was set
t oo l ow.
The use of a PEEP val ve i n the breathi ng system may cause a l ow-pressure al arm
not to be acti vated i f the PEEP val ve raises the pressure above the al arm
t hreshol d.
Electromagnetic Interference
Ul tra-high-f requency (UHF) radi os and GSM cel l phones may i nterf ere
el ect romagneti cal l y wi t h ICU and operati ng room vent il ators (101). Eff ects incl ude
f aul ty readi ngs, mi sleadi ng al arm messages, modi f icati on of vent i l at i on paramet ers,
and output i nterrupt ion and were t emporary.
Loss of Electrical Power
Most vent i lators i n use today are el ectrical ly powered. I f there i s a power f ai l ure,
t here must be a bat tery backup f or at least 30 mi nut es (6). The screen wi l l note the
changeover t o bat tery power and give an i ndi cati on of battery l i fe. When al l
el ect rical energy i s lost , most anesthesi a machi nes wi l l def aul t to a
manual /spontaneous breathi ng mode. The anesthesi a provider may need to i ni ti ate
t his move. Wi thout t he venti lator or machine moni tors, most machi nes wi l l provi de
oxygen to the breathi ng system, and someti mes vol ati le agent . Si nce machines
handl e t hi s probl em i n di ff erent ways, t he user needs to determine how a part i cul ar
machi ne wi l l react to a power out age and devel op a pl an of acti on i f thi s probl em
occurs.
Advantages
Use of a vent i l ator al l ows the anesthesi a provider to devot e ti me and energy
t o other tasks and el i minat es the f at igue resul ti ng f rom squeezi ng a bag
(102).
A venti lator produces more regul ar venti l at ion wi t h respect to rate, rhyt hm,
and t i dal volume than manual vent il ati on.
Disadvantages
Probabl y t he greatest disadvantage to t he use of a venti l at or i s the l oss of
contact between the anesthesia provi der and the pat ient. The feel of the bag
can reveal such things as di sconnecti ons, changes i n resistance or
compl i ance, cont i nuous posi ti ve pressure, and spont aneous respi rat ory
movements. Wi th mechani cal venti lat i on, these may go undetected f or a
consi derabl e peri od of ti me.
A venti lator may induce a f alse sense of securi t y i n the user i f i t conti nues to
make the appropri at e sounds even when i t malf uncti ons.
Some anesthesia venti l ators do not incl ude al l the newer modes of
venti l ati on, and some cannot develop high enough i nspi rat ory pressures or
f lows t o venti late cert ai n pati ents (1,103). It may be necessary to take a
cri t i cal care vent i l ator i nto t he operat i ng room t o provi de adequate vent i l ati on
f or cri t i cal l y i l l pat ients.
Components that are subj ect to cont aminati on may not be easy to remove or
cl ean, especi al l y t hose on older venti l ators.
Some venti l at ors l ack user-f ri endl i ness. There i s room f or i mprovement i n the
design and groupi ng of cont rols.
Some venti l at ors are di st urbingl y noisy or too qui et.
Some venti l at ors requi re rel at ively hi gh f lows of driving gas (15). Gas
consumpti on i ncreases wi t h increased mi nut e vol ume and wi th some
venti l ators, an i ncreased I :E rati o. A venti l at or wi th a pi ston wi l l not consume
driving gas.
References
1. Marks JD, Schapera A, Kraemer RW, et al . Pressure and fl ow l i mi tati ons of
anesthesi a venti l ators. Anesthesiology 1989;71:403408.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
2. Tung A, Drum ML, Morgan S. Ef fect of i nspi ratory t i me on t i dal vol ume del ivery i n
anesthesi a and i nt ensi ve care uni t venti l at ors operati ng i n pressure control mode. J
Cl in Anesth 2005; 17: 815.
[CrossRef]
[Medli ne Li nk]
P. 370


3. Schapera A, Marks JD, Minagi H, et al . Peri operati ve pul monary f uncti on i n acute
respi ratory fai l ure: ef fect of vent i lator t ype and gas mi xture. Anesthesi ol ogy
1989; 71:396402.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
4. Katz J, Kal let R, Al onso J, et al . I mproved f low and pressure capabil i ti es of t he
Datex-Ohmeda Smart Vent anesthesi a vent i l at or. J Cli n Anesth 2000;12:4047.
[CrossRef]
[Medli ne Li nk]
5. I nternat ional Standards Organi zati on. Inhal at ional anaesthesia systemsPart 5:
Anaesthesia venti l ators (ISO 8835-5). Geneva, Swi t zerl and: Author, 2004.
6. Ameri can Soci ety f or Testi ng and Materi al s. Standard speci fi cat i on for vent i lat ors
i ntended f or use during anest hesi a (ASTM 1101-90). West Conshohocken, PA:
Aut hor, Reapproved 2003.
7. Ameri can Soci ety f or Testi ng and Materi al s. Standard speci fi cat i on for parti cul ar
requi rements for anesthesia workstati ons and thei r components (ASTM 1850-00).
West Conshohocken, PA: Author, 2005.
8. Beh T. A desi gn f aul t of t he Drager Cato anaesthesia workstat i on. Anaest h
I ntens Care 2006;34:125.
[Medli ne Li nk]
9. Murphy E, Wi l l i s S. Awareness and hypoxia risk wi th Drager Cato and Fabi us
anaesthesia machi nes. Anaesth Intens Care 2004; 32:721722.
[Medli ne Li nk]
10. Fei ner JR. Is l ow fl ow real l y safe? APSF Newsl ett 1996; 11:23.
11. Moyni han R, Cote C. Fresh gas fl ow changes duri ng control led mechanical
venti l ati on wi th t he ci rcle system have si gni f i cant ly great er ef fects on the
venti l atory parameters of t oddl ers compared wi th chi l dren. Paedi at r Anaesth
1992; 2: 211215.
[CrossRef]
12. Rothschil l er J, Uej i ma T, Dsi da R, et al . Eval uati on of a new operat i ng room
venti l ator wi t h vol ume-control led vent il ati on: t he Ohmeda 7900. Anesth Anal g
1999; 88: 3942.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
13. Gravenstei n N, Banner MJ, McLaughl i n G. Ti dal vol ume changes due to t he
i nteracti on of anesthesia machi ne and anest hesi a venti l ator. J Cl in Moni t
1987; 3:187190.
[CrossRef]
[Medli ne Li nk]
14. Lancaster CT, Boyl e PM, Kaczka DW. Del ivered ti dal vol ume from the Fabius
GS depends upon breathing ci rcui t confi gurat i on despi t e compl i ance compensat ion.
Anesthesi ol ogy 2005; 103: A863.
15. Klemenzson G, Perouansky M. Contemporary anest hesi a venti l ators i ncur a
si gni f icant oxygen cost. Can J Anesth 2004; 51:616620.
16. Taenzer AH, Kovatsi s PG, Raessl er KL. E-cyl inder-powered mechanical
venti l ati on may adversel y i mpact anesthet i c management and eff i ci ency. Anesth
Anal g 2002;95:148150.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
17. Szpi sj ak DF, Lamb CL, Kl ions KD. Oxygen consumpti on wi th mechani cal
venti l ati on i n a f i el d anesthesia machi ne. Anesth Anal g 2005;100:17131717.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
18. Bot z GH, Sl aden RN. Conventi onal modes of mechanical vent i l at ion. I nt Anesth
Cl in 1997; 35: 1927.
19. Gravenstei n JS, Nederst igt JA. Moni t ori ng for di sconnecti on: venti lators wi t h
bel l ows ri si ng on expi rati on can del i ver t i dal vol umes af ter disconnect i on. J Cl i n
Moni t 1990;6: 207210.
[Medli ne Li nk]
20. Ciochet ty DA. Descendi ng bell ows drives questi on. Fresh gas decoupl i ng
mi ni mi zes compl exi ty. APSF Newslett 2005; 20:34.
21. Abramovi ch A. Descendi ng bel l ows dri ves quest i on fresh gas decoupl ing
mi ni mi zes compl exi ty. Response. APSF Newslett 2005;20: 3435.
22. Eisenkraf t JB. The anesthesi a del ivery system. Part I I. Prog Anesth 1989;3:1
12.
23. Olympio MA. Modern anesthesia machi nes of fer new safety features. APSF
Newslett 2003;18: 2427.
24. Grogono AW, Travi s JT. Anesthesia vent i l ators. In: Ehrenwerth J, Ei senkraf t JB,
eds. Anesthesi a Equi pment. Pri nci pl es and Appl i cati ons. St. Loui s: Mosby,
1993: 140171.
25. Tung A, Morgan SE. Model i ng the effect of progressi ve endot racheal tube
occl usi on on ti dal vol ume i n pressure-cont rol mode. Anesth Analg 2002;95: 192
197.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
26. Pan PH, van der Aa JJ. Posi tive end-expi ratory pressure: ef fect on del i vered
t i dal vol ume. J Cl i n Anesth 1995;7:443444.
[CrossRef]
[Medli ne Li nk]
27. Pan PH, van der Aa JJ. Posi tive end-expi ratory pressure and l ung compl i ance:
ef fect on deli vered t idal vol ume. Can J Anaesth 1995;42: 831835.
[Medli ne Li nk]
28. Frengl ey RW, Cl osey DN, Sl ei gh W, et al . The ef fect of cl osed sucti on on
ai rway pressures when usi ng the Servo 300 venti lator. Cri t ical Care and
Resusci t ati on 2001; 230235.
29. Stenqvi st O, Lindgren S, Karason S, et al . Warni ng! Sucti oni ng. A lung model
evaluati on of cl osed suct ioning systems. Act a Anaesthesi ol Scand 2001;45:167
172.
[CrossRef]
[Medli ne Li nk]
30. Taggart JA, Dori nsky ML, Sheahan JS. Ai rway pressures duri ng cl osed syst em
sucti oning. Heart Lung 1988;17:536542.
[Medli ne Li nk]
31. Tugrul M, Camci E, Karadeni z H, et al . Comparison of vol ume control led wi t h
pressure cont rol l ed venti lati on duri ng one-lung anaesthesi a. Br J Anaesth
1997; 79:306310.
[Medli ne Li nk]
32. Stevenson G, Tobi n M, Horn B, et al . An adul t system versus a Bain system:
comparati ve abi l i ty to del i ver mi nute vent i l at i on t o an i nfant lung model wi t h
pressure-l i mi ted vent i l at i on. Anesth Anal g 1999;88:527530.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
33. Stevenson G, Horn B, Tobi n M, et al . Pressure-l i mi ted venti lati on of i nfants wi th
l ow-compl iance l ungs: the eff i cacy of an adul t ci rcl e system versus two free-
standi ng i nt ensive care uni t vent i l at or systems usi ng an i n vi tro model . Anesth
Anal g 1999;89:638641.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
34. Tung A, Morgan SE. Model i ng the effect of progressi ve endot racheal tube
occl usi on on ti dal vol ume i n pressure-cont rol mode. Anesth Analg 2002;95: 192
197.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
35. Klein AS, Bl anch PB, Koens JC. A new nonferromagnet ic venti l ator for use
duri ng magneti c i maging. Anest h Anal g 1990; 70:S208.
36. Mi renda JV, Val ley MA, Gut love DP. The use of pressure support venti l ati on i n
t he operat i ng room. Anest h Rev 1990;17: 4144.
37. Uchi yama A, I manaka H, Taenaka N. Rel ati onshi p between work of breathi ng
provi ded by a venti l at or and pati ents' i nspi rat ory dri ve duri ng pressure support
venti l ati on; ef fects of inspi rat ory ri se ti me. Anaesth Intens Care 2001; 29:349358.
[Medli ne Li nk]
38. Bri macombe J, Kel l er C, Hormann C. Pressure support vent i l at i on versus
conti nuous posi t i ve ai rway pressure wi th t he l aryngeal mask ai rway. Anesthesiology
2000; 92:16211623.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
39. Bosek V, Roy L, Smi t h RA. Pressure support i mproves eff i ci ency of
spontaneous breathing duri ng i nhalat i on anesthesi a. J Cl in Anesth 1996; 8:912.
[CrossRef]
[Medli ne Li nk]
40. Coxon M, Si ndhakar S, Hodzovi c I . Aut o t ri ggeri ng of pressure support
venti l ati on duri ng general anaesthesi a. Anaesthesi a 2005;61:7273.
41. Toki oka H, Tanaka T, Ishi zu T, et al . The ef fect of breath termi nat i on cri teri on
on breathi ng pat terns and the work of breathi ng duri ng pressure support venti l ati on.
Anesth Anal g 2001;92:161165.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
42. van Goedecke A, Bri macombe J, Kel l er C, et al . Posi t ive pressure versus
pressure support vent i l at ion at di fferent l evels of PEEP usi ng the ProSeal l aryngeal
mask ai rway. Anaesth I ntens Care 2004;32:804808.
[Medli ne Li nk]
43. Uyar M, Demi rag K, Ol gyn E, et al . Compari son of oxygen cost of breathi ng
between pressure-support venti lat i on and ai rway pressure rel ease venti l ati on.
Anaesth Intens Care 2005;33:218222.
[Medli ne Li nk]
44. Chri sti e JM, Smi t h RA. Pressure support venti l at ion decreases inspi ratory work
of breathi ng duri ng general anesthesi a and spontaneous venti lati on. Anesth Anal g
1992; 75:167171.
[CrossRef]
[Medli ne Li nk]
45. Groudi ne SB, Lumb PD, Sandi son MR. Pressure support vent il ati on wi t h the
l aryngeal mask ai rway: a met hod t o manage ai rway di sease postoperati vel y. Can J
Anaesth 1995;42:341343.
[Medli ne Li nk]
46. Al -Khafaj i AH, Manni ng HL. I nappropri ate vent i l ator t ri ggeri ng caused by an i n-
l i ne suct ion cathet er. Intensive Care Med 2002;28:515519.
[CrossRef]
[Medli ne Li nk]
47. Wi l lats SM, Drummond GB. Brai nst em death and vent i l at or t ri gger set ti ngs.
Anaesthesia 2000;55: 676677.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
48. Maggi ore SM, Lel louel te F, Pi geot J, et al . Preventi on of endot racheal
sucti oning-i nduced al veolar derecrui tment in acute l ung i nj ury. Cri t Care Med
2003; 167: 12151224.
49. Roth S, Tweedi e E, Sommer RM. Excessive ai rway pressure due to a
mal funct ioni ng anesthesi a vent i l ator. Anesthesi ol ogy 1986;65: 532534.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
50. Sprung J, Samaan F, Hensl er T, et al . Excessi ve ai rway pressure due to
venti l ator control valve mal functi on duri ng anesthesi a for open heart surgery.
Anesthesi ol ogy 1990; 73:10351038.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
51. Anonymous. Anesthesi a uni t venti lators. Technol Anesth 1990;11: 6.
52. Johnst one R, Graf D. Bel l ows f ail ure wi th Drager anesthesi a venti l ator. Anesth
Anal g 1993;76:685686.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
53. Sommer RM, Bhal la GS, Jackson JM, et al . Hypoventi l at i on caused by venti l ator
valve rupt ure. Anesth Anal g 1988; 67: 9991001.
[CrossRef]
[Medli ne Li nk]
54. Eisenkraf t JB. Potent ial for barotrauma or hypovent il at i on wi t h the Drager AV-E
venti l ator. J Cl i n Anesth 1989;1:452456.
[CrossRef]
[Medli ne Li nk]
55. Chaney MA. Del ivery of excessi ve ai rway pressure to a pati ent by the
anesthesi a machine. Anesth Analg 1993; 76:11661167.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
56. Bourke DL, Tolenti no D. Inadvertent posi ti ve end-expi ratory pressure caused by
a mal funct ioni ng vent i l at or rel i ef val ve. Anesth Anal g 2003;97:492493.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
57. Gai ti ni L, Vai da S, Somri M, et al . I ncreased ai rway pressure caused by a
venti l ator. Can J Anaesth 1999;46:201.
[Medli ne Li nk]
58. Fel dman JM. Compl i ance compensat i on of t he Narkomed 6000 expl ai ned.
Anesthesi ol ogy 2001; 94:543544.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
59. Stevenson G, Tobi n M, Horn B, et al . A comparison of two vent il ator systems
using an i nf ant l ung model . Anesthesi ol ogy 2000; 93:285291.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
60. Stayer SA, Bent ST, Campos CJ, et al . Compari son of NAD 6000 and Servo
900C vent il ators i n an i nfant l ung model . Anest h Anal g 2000;90:315321.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
61. Stayer SA, Andropoulos DB, Bent ST, et al . Vol ume vent il ati on of i nfants wi th
congeni tal heart disease: a compari son of Drager, NAD 6000 and Si emens Servo
900C vent il ators. Anest h Anal g 2001;92: 7679.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
62. Barahad D, Si ms C. Venti lator fai l ure duri ng use of a new anesthesi a machi ne.
Anesthesi ol ogy 2001; 95:568569.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
63. Fel dman JM, Smi t h JA. Venti l ator fai l ure duri ng use of a new anesthesi a
machi ne. I n repl y. Anest hesi ol ogy 2001;95:569.
[Full text Li nk]
[CrossRef]
64. Davi s AR, Kl ei nman B, Jel l i sh WS. Cause of venti l ator fai l ure i s unclear. APSF
Newslett 2005;20: 67.
65. Clark R. Manufacturer anal yzes inci dent provides feedback. APSF Newsl et t
2005; 20:8.
66. Sandberg WS, Kaiser S. Novel breathi ng ci rcui t archi tecture: new
consequences of ol d probl ems. Anesthesiology 2004;100:755756.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
67. Dal ley P, Robi nson B, Well er J, et al . The use of hi gh f idel i ty human pat i ent
si mul at ion and the i nt roducti on of new anaesthesia deli very systems. Anesth Analg
2004; 99:17371741.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
68. Anonymous. Vent i l ator f ai lures on Draeger Medi cal Fabi us GS and Fabius Ti ro
Anesthesi a Uni ts. Heal th Devi ces Al erts 2005;29: 12.
69. Anonymous. Vent i l ator f ai lures on Draeger Medi cal Fabi us GS and Fabius Ti ro
Anesthesi a Uni ts. Technol Anesth 2005;25:12.
70. Bli nder JL. Ambient O. R. temperatures and Datex-Ohmeda 7900 Smart Vent
mal funct ion. Anesthesi ol ogy 2002;97: 1645.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
71. Cant il l o J, Graqtz I , Domsky R, et al . Ambi ent O. R. temperature and Dat ex-
Ohmeda 7900 SmartVent mal funct i on. I n reply. Anesthesi ology 2002;97:1645.
[Full text Li nk]
[CrossRef]
72. Mi l ton M. Venti l at ory f ai l ures wi t h the Dat ex-Ohmeda 7900 SmartVent . In repl y.
Anesthesi ol ogy 1992; 96:768.
73. Cant il l o J, Domsky R, Gratz I , et al . Venti l atory f ail ures wi th t he Datex-Ohmeda
7900 Smart Vent. Anest hesi ol ogy 2002;96:766768.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
74. Krock J, Padda G, Moore J. Ohmeda 7900 vent i l ator f l ow sensor. Anest h Anal g
1998; 86:231232.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
75. Shogase A, Mi zut ani K, Toyoda Y. Protect ing Ohmeda 7900 venti l at or f low
sensor. Anesth Anal g 1999; 88:234.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
76. Hari MS, Jenni ngs M. Fl ow sensor f aul t causi ng venti l ator mal f uncti on.
Anaesthesia 2005;60: 10491050.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
77. Aldri dge J. Leak on Datex Aesti va/5 anaest het i c machi ne. Anaesthesi a
2005; 60:420421.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
78. Hari MS, Jenni ngs M. Fl ow sensor f aul t causi ng venti l ator mal f uncti on.
Anaesthesia 2005;60: 10491050.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
79. Mychaski w G, Morri s S. Dangerous desi gn fl aw i n the Ohmeda Aespi re
anesthesi a system. Anesth Analg 2005;100:15431544.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
80. Snyders S. Fai lure of a fl ow sensor of a Datex Ohmeda S/5 Aespi re.
Anaesthesia 2005;60: 941.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
81. Wong DT, Li AQ. Venti lator bel l ows standsti l l . Can J Anesth 2005; 52:774775.
82. Badgwel l JM, Swan J, Foster AC. Vol ume-cont roll ed venti l at ion i s made
possi bl e i n i nfants by usi ng compl i ant breathi ng ci rcui ts wi th l arge compressi on
volume. Anesth Anal g 1996;82:719723.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
P. 371


83. Stevenson G, Tobi n M, Jorn B, et al . The ef fect of ci rcui t compl i ance on
del i vered venti l ati on wi th use of an adul t ci rcl e system for ti me cycled vol ume
control led vent il ati on usi ng an i nfant l ung model . Paedi at r Anaest h 1998;8: 139
144.
[CrossRef]
[Medli ne Li nk]
84. Tobi n MJ, Stevenson GW, Babet te JH, et al . A compari son of three modes of
venti l ati on wi th t he use of an adul t ci rcl e system i n an i nf ant l ung model . Anesth
Anal g 1998;87:766771.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
85. Wi l l i ams EJ, Jones NS, Carpent er TA, et al . Testi ng of adul t and paedi at ri c
venti l ators for use i n a magneti c resonance i magi ng uni t. Anaesthesi a
1999; 54:969974.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
86. Anonymous. Anesthesi a vent i l ators wi th descendi ng bell ows: the need for
appropri at e moni tori ng. Technol Anesth 1996; 17:13.
87. Sosi s MB. Drager vent i l at or f ai lure on changi ng the respi ratory rat e set ti ng.
Anesth Anal g 1993;76:453454.
[Medli ne Li nk]
88. Usher AG, Cave DA, Finegan BA. Cri ti cal inci dent wi th Narkomed 6000
anesthesi a machine. Anesthesi ol ogy 2003;99: 762.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
89. Cowl ing M. Cato machine f ai l ure. Anaesth I ntens Care 1998;26:329330.
[Medli ne Li nk]
90. Lee K. Leak of dri vi ng gas f rom Ai r-Shi el ds vent i lator. Can Anaest h Soc J
1986; 33:263264.
[Medli ne Li nk]
91. Wagner K, Loy J. A strange pl ace t o fi nd a cable t ie. Anesth Analg
2006; 102: 655656.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
92. Blackstock D. Advant ages of standi ng bel l ows venti l ators and l ow-fl ow
t echni ques. Anesthesiology 1984;60:167.
[Full text Li nk]
[CrossRef]
93. Wong DT, Shi rzad T. Unusual case of volut rauma. Can J Anaest h
2000; 47:10461047.
[Medli ne Li nk]
94. Weinberg L, Sawhney S, Skewes D. Safety warning wi th Datex-Ohmeda S/ 5
anaestheti c del ivery uni t desi gn. Anaesth I ntens Care 2004;32: 719720.
[Medli ne Li nk]
95. Rigg D, Joseph M. Spl i t vent i lat or bel lows. Anaesth Int ens Care 1985;13:213.
[Medli ne Li nk]
96. Lampotang S, Sanchez JC, Chen B, et al . The ef fect of a bel l ows l eak i n an
Ohmeda 7810 venti l ator on room contami nat i on. Inspi red oxygen, ai rway pressure
and t i dal volume. Anesth Anal g 2005;101:151154.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
97. Ripp CH, Chapi n JW. A bel l ow' s l eak i n an Ohi o anesthesi a venti lat or. Anesth
Anal g 1985;64:942.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
98. Webb RK, Russel l WJ, Kl epper I , et al . Equi pment fai lure: an anal ysis of 2000
i nci dent reports. Anaesth Intens Care 1993;21:673677.
[Medli ne Li nk]
99. Biddl e C. Advances i n vent i lat i ng the pati ent wi th severe l ung di sease. AANA J
1993; 61:170175.
[Medli ne Li nk]
100. Brockwel l RC. Understanding your anesthesia machi ne (ASA Ref resher Course
#506). Park Ri dge, IL: ASA, 2005.
101. Barbaro V, Bartol i ni P, Benassi M, et al . Elect romagnet ic i nterf erence by GSM
cell ul ar phones and UHF radi os wi th i nt ensi ve-care and operati ng-room vent i l ators.
Bi omed I nst rum Technol 2002;XX:361369.
102. Amaranat h L, Boutros AR. Ci rcle absorber and soda l i me contami nati on.
Anesth Anal g 1980;59:711712.
[Full text Li nk]
[CrossRef]
[Medli ne Li nk]
103. Del Vall e RM, Hecker RB. A revi ew of vent i l at ory modal i ti es used i n the
i ntensi ve care uni t . Am J Anesth 1995;22:2330.
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Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
1. A hole or tear i n the bel lows may resul t i n
Hypervent il ati on
Hyperoxi a
Barot rauma
Pat i ent awareness
Vi ew Answer2. Excessive airway pressure may be caused by
Act i vat ing t he oxygen f lush duri ng i nspi rat i on
A hol e in the bel lows housing
A stuck spi l l valve
Ascension of the bel l ows
Vi ew Answer3. A standi ng bel lows
I s att ached at t he top
Expands duri ng exhal ati on
I mposes no pressure duri ng exhal at i on
Makes i t easy to detect di sconnect ions
Vi ew Answer4. When a venti l ator with a piston is used,
PEEP of 2 t o 4 cm H
2
O i s usual
Ai r ent rainment may occur
The reservoi r bag is i sol ated f rom the breathi ng syst em duri ng exhal at ion
The reservoi r bag may expand and contract wi t h mechani cal vent i l at ion
Vi ew Answer5. Regarding pressure control venti lati on,
Fl ow i s hi ghest at the begi nni ng of i nspi ration
Ti dal vol ume is not const ant
I t i s of t en used wi t h supragl ot ti c devices
I t i s usef ul f or det ecti ng a parti al l y occl uded t racheal tube
Vi ew Answer6. Regarding SIMV,
The vent il ator has a secondary source of gas f l ow f or spontaneous breaths
I t i s of t en used f or weani ng pat ients f rom mechani cal venti l ati on
A mandatory ti dal vol ume and mi ni mum mechanical venti l ati on rate must be
selected
Posi t i ve pressure (mandatory) breaths occur at regular i nterval s
Vi ew Answer7. Regarding PSV,
Most vent i lators have a backup or apnei c rate
The opti mal i ni ti al i nspi rat ory f l ow i s hi ghest i n pat ients wi t h high compl iance
The pressure wavef orm has a square, f lat-topped shape
I t i s associated wi th a decrease i n f uncti onal resi dual capaci ty
Vi ew Answer