Anesthesia Circuits and Systems 1,2

, Niels F.Jeilsen, MD
Copyright2007 Written Board P,R.E,P. ''Big,Blue''
The: Best Me,dicine: fo.r Yow Written Boards
Phone:' 319-337-670(}, www.boardprep.com

Let's Boil Some Water by the Spring and Make Coffee

. "Crowding Out-Vietnam I"
Don't allow a "crowding out" to occur when it comes to Bo;:rrd,s:and espeo.ally When it comes to t'Oplcs like
Oreuits and Machines which many study with little enthusiasm. These are the very topics whi<;:h so often
determine victory or defeat for the Corporal. RecogIliz;e their importance, as1< corredqJ,:1E1stions, and then
plan and Win the war! '

One does not have to look far to see historical examples of where "crowding ~ut" was ~agic. Certainlythj.s
was the Qlse with, United, States jnvolvlmlent in S(julh~ast Asia, '
"Readers must wonder by now--if they have not be~n mystified lo,ng before-how PJ.:esumably int~ligent
hardworking, and experienced officials-both civilian andmi1itary~failed to, address systematically and
thoroughly questions whose answers so deeply affected'the lives of our citizens and the w~1fareof our
nati.o,n., Simp,ly put such an orderly, ration,alap,.I?roachwas precluded b.'Y the "crowdingout"wl:Lich resl,l1ted
fro~ the fact that Vletnam was but one oIa multitude of problems we confronted!' Robert S. McNamara,
Former Secretar of Defense, In Renos ect

I. General Considera~ons: Circuits and Systems

1. There, are open, semiop.en, semiclosed,and closed anesthesia circuits and syst~ms.

4. When evaluating advantages and disadvantages of various circuits and systems cOl1sider:
a. Dead space & Resistance
b. Heat& Humidity
c. Scavenging & E<:onomy
d. Pre~nce of valves

n. Mapleson systems (semi-open) ,

1. The Maplesonsystemsare of five types: A, B; C, D, E. The Mapleson F was added to th~
original five. It is important to visualize these for Written Boards but perhaps'more sq to
understand their advanta~es and disadvantages.

2. Some of the most impottqI;lt and famous of the Mapleson systems are theA (McGill), C
(Water's), D CBain represents a coaxial moqification of D), E (modification of the Ayres T-piece),
and F aackson~Reesmodificationofthe Mapl~son D; ~ost common T-p~ece sY9tem).

3. Advantages and disadvantages of semiopen circuits include: (1995-'05 Beach Pillbox)

a. Advantages
1) Small resistance to spontaneous ventilation and small dead space
~) Easy to use, not pulky
3) Ap~ce of valves, ll).inimizingproblems with malftJ.n!=tion
b' Disadvantages
1) Loss of heat and humigity
2) Poor ability to scav~nge and poor economy
3) Relatively high fresh gasflow5 required to prevent rebreatlling. Usefulness is
greatly decreased as body weight increa,ses because fresh gas flow requirements
to preventrebreathjng become excessively high.

fStoelting, RK, Miller, Rb. Anesthesia Systems. Basics of Anesthesia, Stoelting, RK, MUler, RD
(eds.), Chllrchill Livingstone.
2Andrews, JJ. Anesthesia Systems. Clinical Anesthesia. Barash, PG, Cullen,BF, artdStoelting,
RI<, (eds.t Lippincott.

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3. In semiopen systems, the presence of a reservoir bag signals the possibility for controlled
ventilation.

4. A unidirectional valve in a semi open system enables one to decrease minute ventilation by
directing gas flow either toward or away from the patient at appropriate times. Such a valve also
increases resistance in the system.

5. (Don't get complacent: '03 Written Boards) The possibility of rebreathing in semiopen
systems during spontaneous ventilation from least to most can be remembered by this
rrmemonic: A Dog Can Bite (usually a spontaneous event)

Sb. The possibility of rebreatrung in semiopen systems during controlled ventilation from least to
most can be remembered by this: Dog Bites Can Ache (after the situation is controlled.)
a. Therefore, for example, the Mapleson A is best used in the presence of spontaneous
ventilation.

6. The Bain system is a coaxial version of the Mapleson D circuit. Oaimed advantages are better
heat conservation, humidification, and ability to scavenge.
a. A fresh gas flow rate equal to about 70 ccl kg is necessary to maintain normocarbia
during controlled ventilation and the requirement during spontaneous ventilation is
higher, approximately 200-300 ccl kg.

III. Semiclosed (circle) system

1. Advantages and disadvantages of a semiclosed (circle) system:
a. Advantages
1) Conservation of heat and humidity
2) Good scavenging possible and is economical to use
b. Disadvantages
1) More resistance to spontaneous ventilation and more dead space
2) Bulkier, harder to move
3) Valve malfunction more likely due to many parts

2. The essential components of a circle system are a gas reservoir bag, two corrugated tubes, two
unidirectional valves, a carbon dioxide absorbent, and an overflow valve.

3. The gas reservoir bag maintains an available reservoir volume to satisfy an inspiratory flow of
601/ min, which greatly exceeds the conventional fresh gas flow from the machine (3-6
liters I min).

4. The setup of a circle system requires passage of expired gas through the carbon dioxide
absorber before rebreathing. Incompetence of either valve results in rebreathing.

IV. Closed systems

1. Fresh gas inflow into the circuit of a circle system is decreased enough to permit closure of the
pop-off valve. Partial rebreathing of C02 is permitted and exhaled C02 is neu tralized in the CO2
absorber.

2. The fresh gas inflow (150-500 eel min) satisfies body metabolic oxygen requirements and
replaces anesthetic gas taken-up by the body.

3. Advantages and disadvantages of a closed system:

a. Advantages include:
1) Maximal conservation of heat and humidity
2) Economical to use and associated with low pollution

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 b. Disadvantages inch,tde:
1) Anesthetic concentrationqmnot be ,rapidly changed

4. Dangers of a closedsystem:
a, Oxygen uptake is noh:hanged greatlyl:>utthe uptake of nitrous pxide ca,n decrease.
Therefor~ concentrations of 02; in alveoli relative to N20can be deerea$ed.. This is one
reasqh why an oxygen analyzer and a pulse .oximeter must be llsed in: these caseS.
b. Delivered anesthetic cooCcentr<cltion is uncertain during closed circuit anesthesia
because concentrations ofexhaled gases depend upon tissue uptake. High inflows are
needed initially butover time this demand decreases. High fresh gas flows (31/tnin) for
about 15 minutes before beginning closed circuit anesthesia diminish this unknown.

VI. Open systems: .

1. Advantages i).nd disadvant<lges of an open system
a~ Adv~1l-tagesinclude: . .
1) No .artificial airway resistance and no d~ad space,
2) Easy to use in open field situations
b. Disadvantages include:
1) Loss,of he.at and humidity
aIt
2) Poor scavenging. It can't get much worse since. exhaled gases are vented to
the atmosphere. '.
3) Ventilation cannot be controlle,d
4) Inherently unstable anesthel;ic levels. Duringlight anesthesia, ti<;l~ volume
increases and more room air is entrained. This decreases the anesthetic
concentration -and further lightens anesthesia. . .

Vll. What is the difference between a semiopen and semiclosed circle system? -In a semidosed
system, there is partial rebreathing of C02. If soda lime is not present in a semidosed circle,
C02 build-up occurs, The reserv6ir bag is also important in a semiclosed system (with partial
rebreathing occurring). Without it, fresh gas flow would have to equal minute ventilation.

VIII. Soda lime J

1. Soda lime consists of 94% Ca(OH)2J 5% NaOH, 1% KOH, a.nd a small amount of $ilica.
Therefore, Ca(OBh is predominant. Baralyme contains predominantly barium hydroXide and
calcium hydroxide. Both also contain water. Baralyme is inherE:ntlyharder and sili<;a-is not
required to induce hardness (to impede the formation of dust pa~ticles).

2. The famous soda lime equation: Carbon dioxide enters and reacts with water to form carbonic
acid. This rei:lcts with hydroxides of barillin-calcium~potassium-sodiu-in ttiJotm Wateri heatf and
carbonates of barium-calcium-potassium-sodium. To summarize and memorize: . .
1) C02 + H20 = H2C03
2) H2C03 +2 NaOH = Na2C03+ 2 H20 + Heat
3) NaiC03 + Ca(OHh = CaC03 + 2' NaOH

3. Water is necessary to dissipate heat and humidifr gases. In fact, as the equ.ationshows, a
small amount of HiO must be present for C02 absotption to occur.

3Andrews, Jl. Anesthesia Systems. Clinical Anesthesia, Barash, PGi Cullen; 13F, .and Stoelting,
RK, (eds.), Lippincott.

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4. The maximal absorbent capacity of soda lime is 26 liters C02/100 grams of absorbent. A pH
sensitive dye is activated by carbonic acid when absorbent capacity is exhausted.

5. A balance is necessary between absorbent capacity and thereby granule size and resistance to
flow. For example, if granules are very small absorbent capacity will be large but so is resistance
to flow. If granules are large, resistance to flow is minimized but so is absorbent capacity.

6. If heat in the cannister does not form, neutralization of carbon dioxide is probably not
occurring and rebreathing is taking place.

7. Tidal volume should be accommodated within the void space of the cannister or rebreathing
of C02 will occur. This is very important and has been tested several times in recent years.

IX. Other important systems4

1. Nasal cannula
a. Nasal cannula represents a low flow system and does not provide sufficient gas to
supply the entire inspired volume.
b. The numbers vary according to source but most agree that each liter adds 4-5% Fi02
and six liters/ minute is maximal, bringing the maximum Fi02 practically deliverable to
about 55%.
c. Oxygen flow rate usually does not exceed peak inspiratory flow rate when nasal
prongs are used. Specifically, the peak flow rate is about 40 liters/ min at normal tidal
breathing and it is not practically possible to exceed this with nasal cannula. Therefore
the "reservoir" of oxygen in the nasopharynx deliverable by nasal cannula can be diluted.
This "reservoir" effect is important for Written Boards.
d. The concentration of oxygen actually reaching the trachea is a function of oxygen flow
rate from the cannula and minute ventilation of ambient air. In the setting of
hypoventilation, the Fi02 will be high and in the setting of hyperventilation it will be
low. Little humidity is supplied by nasal cannula. Again, the range of Fi02 is
approximately 0.25-0.55.

2. Face mask
a. The recommended flow if a face mask is used is 8-10 liters/min.
b. This system normally provides concentrations of 40-60%.

3. Venturi mask
a. The Venturi mask has the advantage of delivering oxygen over a narrow range of
concentration. Fi02 is independent of both minute ventilation and inspiratory flow rate
(providing inspiratory flow rate does not exceed about 40 liters/ min). In addition,
because a Venturi mask guarantees that Fi02 will not exceed a prescribed level it is a
good choice in hypoxic or hypercarbic patients. Venturi masks are deficient with respect
to humidification.
b. Venturi masks are useful in the setting of hypoxia driven ventilation ("hypoxic drive").
Oxygen concentration can be controlled so the risk of respiratory depression is
decreased. (If oxygen concentration is excessive, ventilatory drive may be stopped.)

4Mickler, TA, and Hoellerich, VL. Respiratory Intensive Care. Clinical Anesthesia Procedures of
the Massachusetts General Hospital, Firestone, LL (ed.), Little, Brown.

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 A Question From Dr. lensen's Written Course
Ktype
During spontaneou,s respiration, causes of carbon dioxid~ retention in a circle system include
l} Low flow rates
2) Incompetentinspiratory valve
S) Incoirectly adjusted pop-off valve
4) Small tidal volumes

1.. LOw flow rates don't ca~se carbon dioxide retention unless the carbon dioxide absorber is
exhausted.
2. Incompetence of either iAspiratory or e?'piratory valves will caUSe rebreathing of carbon
dioxide.
3. A pop-off valve could affect circuit pressure but shoulq not impair carbon'dioxide absoq>ijon.
4. Decreased alveolar ventilation causes carbon dioxide retention. Decreaseq minute ventilation
is the most common cause of hypercarbia.

c.

Ranger Run
"People are alway~ being looked at as points and they ought to be looked at as lines. There
weren't any points, it was false to assume that a person ever was,anything~ Be was always
becoming something, always changing, always continuous and moving, like the wiggly lilleon a
maChine used to m~asure earthquake shocks. He was always what he was in the beginning, but
never quite exactly as he was; he moved along a line dictated by his heritage and his
environment, buthe was subjectto every sort ofvariation within the narrow limits of his
capabilities."
-Wallace Stegner, The Big Rock Candy Mountain

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 Circuits Keywords
Niels F. Jensen, MD
Copyright 2007 Written Board P.R.E.P. "Big Blue"
The Best Medicine for Your Written Boards
Phone: 319-337-3700, www.boardprep.com

Recent keywords of importance--most all of which are covered in Big Blue and/or at the Course:

Circle system
1. Deadspace in circle system
2. Circle system dead space; Adult circle system: peds
3. Components
4. Reverse flow in circle system

Closed circuits
1. Closed circuit anesthesia
2. Closed system anesthesia: calculation isoflurane requirements
3. Anesthetic circuit: time constant

Nasal prongs
1. Fi02 with nasal prongs

Other: circuits
1. 02 delivery: characteristics
2. Mechanics of anesthetic breathing system
3. Complications: nebulized hUmidifier
4. Humidification of anesthetic gases
5. Mapleson D: rebreathing

Pediatric circuits
1. Pediatric breathing circuits
2. Bain circuit (94); Bain vs circle
3. Pediatric circuits: FCF requirements

Other related keywords from recent past years are outlined below.

Circle System
Benumof, J.. Respiratory physiology and respiratory function during anesthesia. Anesthesia, R. Miller, (ed.),
Churchill Livingstone. .
Circle system dead space
1. The Mapleson circuits increase Vd/Vt in two ways. First they increase anatomic dead space such that
Vd/Vt is increased from 33 to 64% in intubated patients and up to 64% in patients breathing through a
mask. Second, the circuit results in the rebreathing of expired gases, which is physiologically equivalent to
dead space ventilation.
2. In a non-rebreathing system such as circle system IF THE VALVES ARE FUNCTIONING properly, dead
space is essentially zero for the circuit. Other factors which affect dead space include:
a. Supine position. Decreases by 101 to 147 ml
b. Sniffing position. Increases by 24 to 130 ml
c. Face mask. Increases by 80 to 200 ml
d. Endotracheal tube. Decreases by 50 ml

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Circle system
Andrews, J.. Anesthesia systems. Clinical Anesthesia, ed., P. Barash, C. BF and R. Stoelting, (ed.), JB
Lippincott.
Circle Rebreathing-Prevention
1. The circle breathing system is the most popular system in use in the U.S. The typical arrangement of this
system is as follows:
a. Fresh gas enters just upstream from the inspiratory undirectional valve and during inspiration
passes down the circle's inspiratory limb to the Y piece connector.
b. During expiration, gas passes along the expiratory limb to the expiratory unidirectional valve.
Just beyond the expiratory valve are the "pop-off" valve and a reservoir bag.
c. Gas then passes through a canister containing CO2 absorbent and emerges to rejoin fresh gas.
2. At high gas flows C02 absorption becomes unnecessary. At lower fresh gas flows, C02 absorption is
necessary. To minimize C02 rebreathing certain conditions must be met:
a.A unidirectional valve must be present between the reservoir bag and the patient on both
inspiratory and expiratory sides.
b. Fresh gas must not enter the system between the expiratory unidirectional valve and the patient.
c. The overflow valve must not be placed between the patient and the inspiratory unidirectional
valve. Overall the goal is to prevent bidirectional flow and hence rebreathing.
(also Principles and Practice of Anesthesiology, Rogers M, p. 1001.)

Closed circuits
Andrews, J.. Inhaled anesthetic delivery systems. Anesthesia, R. Miller, (ed.), Chruchill Livingston.
Applications: Closed System Anesthesia
Closed circuit anesthesia
1. A closed circle system entails the following:
a. Gases must be completely confined (venting is excluded).
b. Inflow gas must equal exactly that being taken up (consumed) by the patient.
c. Complete rebreathing after the C02 is absorbed.
2. Closed systems were originally developed by Dennis Jackson in 1915 and were further developed by
Ralph Waters in Sioux City, IA in 1924. A primary concern was containment of flammable gases (i.e. diethyl
ether and cyclopropane) in earlier years. The primary advantages now include:
a. Economy
b. Reduction of ahnospheric pollution
c. Better hUmidification of respired gases
d. Conservation of body heat, both by H2O
retention and by heat production resulting from C02 and absorbent reaction.
3. Potential drawbacks include:
a. Monitoring inspired 02. The mass spec. may draw more 021 min than the volume of 02
delivered.
b. Patient safety--anesthetic overdose is difficult to detect.

Closed circuits
Andrews, J.. Inhaled anesthesia delivery systems. Anesthesia, R. Miller, (ed.), Churchill Livingstone.
Closed Circuit Anesthesia: Calculating Isoflurane Requirements
1. A closed anesthetic breathing system occurs when the fresh gas inflow into a circle system is decreased
sufficiently to permit closure of the overflow valve, and all the exhaled C02 is neutralized in the C02
absorber. The fresh gas inflow for a closed system (150-500 eel min) satisfies the patient's 02 requirements
(150-250 mll min) and replaces anesthetic gas lost by tissue uptake.

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2. Advantages: Maximal humidification and warming of inhaled gas, decreased pollution of atmosphere,
money saved using less gas
Disadvantages: inability to rapidly change delivered anesthetic/ 02 inflow, 02 analyzer unpredictability of
02 delivered, and unknown concentration of inhalational agent delivered.
3. Formula for calculating anesthetic vapor delivered:
C=(PV. FV)/ [(PB-PV) .(FD+FV)]
where PV= vapor pressure of the anesthetic (Iso, Halo= 240 mmHg; Enf= 175 mmHg), PB=Barometric
pressure, FV=Flow through the vaporizer, FD=Diluent flow
Example: If 51/ m of diluent flow is mixed with 100 ml/min of flow through an isoflurane vaporizer
(PV=240 mmHg, PB=760 mmHg) the concentration would be approximately 1%. If :FD is increased to 200
mI/ min the concentration would equal 2%; 300 mI / min would correlate to a delivered concentration of
about 3%.

Closed circuits
Andrews, J.. Anesthesia systems. Clinical Anesthesia, P. Barash, B. Cullen and R. Stoelting, (ed.), JB
Lippincott.
Oosed circuit anesthesia
(Oosed circuit anesthesia is not something we use or think about every day. Let's readdress this issue in
another keyword-- reiterating points made as well as plowing important new ground.)
1. Closed circuit anesthesia is a system that depends entirely on rebreathed gases, with those gases
metabolized or taken-up being replaced by fresh gas.
2. C02 must be absorbed within the system to prevent hypercarbia.
3. When beginning a closed system anesthetic, the system must initally be opened temporarily to allow for
the rapid uptake of volatile agents and to equilibrate the circuit components with the anesthetic. (circuit
tubing, C02 absorbent, rubber connections, etc.)
4. Advantages of closed circuit include preservation of body heat, increased circuit humidity, decreased
anesthetic use, decreased OR pollution, quicker diagnosis of circuit leaks.
5. Disadvantages include the need for a very tight circuit with minimal leaks, slower changes in anesthetic
concentration, and the need for closer vigilance. Also, when employing closed circuit anesthesia, the N2
eluted from the patient may decrease the inspired 02 and N20 concentrations, necessitating monitoring of
these gases.

Other: circuits
Eger, E.. Uptake and distribution. Anesthesia, R. Miller, (ed.), Churchill Livingstone.
Anesthetic uptake by anesthetic circuits
1. Uptake of anesthetic by the breathing apparatus will hinder development of an adequate inspired
inhaled anesthetic concentration. The rubber or plastic components of the circuit may remove agent.
2. This is a significant problem with methoxyflurane but is a relatively minor consideration with halothane,
enflurane, isoflurane or nitrous oxide.
3. Uptake by soda lime is small unless the soda lime becomes dry, in which case substantial amounts may
be absorbed. Dry soda lime may slow induction by this mechanism and may subsequently also slow
awakening by releasing absorbed agent.

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Pediatric circuits
Andrews, J. Anesthesia systems. Clinical Anesthesia, P. Barash, B. Cullen and R. Stoelting, JB Lippincott,
New York.
Bain breathing circuit
1. The Bain circuit is a modification of the Mapleson D system.
2. Exhaled gases enter the corrugated tubing and are vented through the expiratory valve near the reservoir
bag.
3. Normocarbia during spontaneous breathing requires fresh gas flow of 200-300 ml/kg. Normocarbia
during controlled ventilation requires flow of 70 mll kg.
4. Advantages: Lightweight, convenient, easily sterilized, reusable. Exhaled gases in the outer reservoir
tubing add warmth and humidity to inspired gases.
5. Hazards: Kinking of inner fresh gas hose and unrecognized disconnect.
6. Safety check: High flow 02 is fed into the circuit while the patient end is occluded until the reservoir bag
is filled. Patient end is opened, and 02 is flushed into the circuit. If the inner tube is intact, the venturi
effect occurs at the patient end. This causes a decrease in pressure within the reservoir bag, and the bag
deflates. If there is a leak in the inner tube fresh gas escapes into the expiratory limb, and the reservoir bag
will remain inflated.

redia tric circuits

Jensen, N. Circuits. Essentials for the Anesthesiology Written Board Examination, N. Jensen, Privately
published, Iowa City.
Pediatric systems: CO2 control
Pediatric breathing circuits
To control carbon dioxide, rebreathing must be controlled, a purported advantage with Mapleson circuits,
which are semiopen-nonrebreathing circuits if minute vent is high enough.
1. Which are best for spontaneous ventilation? A Dog Can Bite (and this is usually a spontaneous event)
2. Which is best for controlled ventilation? Dog Bites Can Ache (occurs once the situation is under control
again)
3. Minute ventilation to prevent rebreathing: about 200 eel kg in infants ( TV=10ccl kg and rate=20
breathsl min.)
4. Advantages of the Mapleson Systems:
a. Low resistance I low dead space
b. No valves
c. Simple, light, and portable
4b. Disadvantages of the Mapleson Systems:
a. Loss of heat I humidity from the airway
b. Significant poll utionl less economical
5. Bam Modification (Mapleson D): C02 is dependent upon the degree of rebreathing.
a. Spontaneous breathing--3 factors determine the amount of rebreathing
1) MV
2) Resp flow
3) Fresh gas flow: FGF should be 2-3 X's the predicted MV to prevent significant
rebreathing.
b. Controlled ventilation
1) When FGF is very high, the PaC02 becomes
ventilation limited. The higher the MV, the lower the PaC02.
2) When MV exceeds the FGF, the FGF is the controlling factor for C02 elimina tion. In this
setting, and up to a point, the greater the FGF the lower the PaC02.

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Pediatric circuits
Andrews, J.. Anesthesia systems. Clinical Anesthesia, ed., P. Barash, B. Cullen and R. Stoelting, (ed.), JB
Lippincott.
Pediatric System C02 Control
Pediatric circuits: FGF requirements
1. Control of C02 elimination depends upon respiratory rate, tidal volume, and fresh gas inflow.
2. Mapleson A (Magill circuit): Rebreathing during spontaneous ventilation (SV) can be prevented with
relatively low fresh gas flows; i.e. fresh gas flows greater than or equal to minute ventilation (MY).
a. This is a very inefficient circuit for controlled ventilation (CV) and fresh gas flows greater than
20 liters per minute are required to prevent rebreathing.
3. Mapleson B & C: These circuits function the same during SV and CV. Rebreathing is prevented as long
as fresh gas flow is greater than two times the MY.
4. Mapleson 0: This circuit can be described as a T-piece with an expiratory limb.
a. In pediatric patients between 1-5 years, normocapnia was maintained with flow rates of 200
ml/kg min-1 despite rebreathing.
b. Mapleson determined that a fresh gas flow greater than two times the MY was sufficient to
prevent rebreathing during SV.
c. During CV, this system causes less rebreathing than Mapleson Band C. The following fresh gas
flows were recommended for CV.
--2 liter / min for infants less than 10 kg.
--3.5 liter / min for patients between 10-50 kg
--70 ml/kg min-l for patients greater than 60 kg
--The recommended tidal volume was 10 ml/kg and respiratory rate of 12-16.
5. Mapleson E: This is a modification of the Ayres T-piece. Rebreathing is prevented by a fresh gas flow of
three times the MY for both CV + SV.
6. Mapleson F (Jackson-Rees): This circuit also requires a fresh gas flows of three times the MY to prevent
rebreathing.
7. Bain: This circuit is a modification of the Mapleson D. Normocarbia during SV requires a fresh gas flow
of 200-300 ml/kg, but only 70 ml/kg will produce normocarbia during CV.