Revised April 2021
COMPONENTS & SYSTEMS> DELIVERY> USING BREATHING CIRCUITS AND VENTILATORS
- Choosing the best fresh gas flow
- How to denitrogenate ("preoxygenate")
- Malignant hyperthermia implications for equipment.
- Ventilator and Breathing circuit problems and hazards
- Increased inspired carbon dioxide (troubleshooting and treatment)
Using Breathing Circuits and Ventilators
Dry gas supplied by the gas machine may cause clinically significant desiccation of mucus and an impaired mucociliary elevator. This may contribute to retention of secretions, blocking of conducting airways, atelectasis, bacterial colonization, and pneumonia.
Absolute humidity is the maximum mass of water vapor which can be carried by a given volume of air (mg/L). This quantity is strongly determined by temperature (warm air can carry much more moisture). Relative humidity (RH) is the amount present in a sample, as compared to the absolute humidity possible at the sample temperature (expressed as a %).
- 0 mg/L are supplied by the machine,
- 9 mg/L is found in normal room air at 20 degrees C and 50% relative humidity,
- 44 mg/L is found in tracheal air at the carina, at 37 degrees C and 100% relative humidity.
It is ideal to provide gases at body temperature and 100% RH to the patient’s airway. For cases lasting longer than 1 hour, humidification measures are often employed including:
- Use the circle with carbon dioxide absorbent granules and low flows
- This can provide 100% RH at room temperature at the lowest flows (such as closed circuit with FGF of less than 1 L/min)
- Heat and moisture exchanger ("artificial nose")
The heat and moisture exchanger has large thermal capacity, hygroscopic, and (sometimes) bacterial filtration. It can do no more than return the patient’s exhaled water- it can’t add heat or moisture- and it is less efficient with longer cases or higher flows. But it’s easy to use, inexpensive, silent, won’t overheat or overhydrate the patient.
Heated airway humidifiers provide perfect conditions- 100% RH at body temperature. However, these are no longer used because of various problems: overhydration, overheating (burns), require higher flows (flow-over type), melted circuits, aspiration.
How is the "best" fresh gas flow (FGF) determined?
The fresh gas flow used determines not just FIO2, but also the speed with which you can change the composition of gases in the breathing circuit.
- 4 L/min was common- a legacy from days when a safety margin was needed for flowmeters & vaporizers which were much less accurate, and much leakier breathing circuits.
- A circle at 1-1.5 times minute ventilation (VE) is essentially a nonrebreather (5-8 L/min for an adult). FGF should be this high during preoxygenation and induction (allows washin) and emergence (washout).
- Low flows (0.5-2 L/min total FGF) should be used during maintenance to conserve tracheal heat and humidity, and economize on volatile agents.
- Key points
- Don't close down to low flows until you have delivered enough molecules of agent to saturate the brain. This takes 5-10 minutes of high flows after induction. Remember, brain concentration lags behind the end-tidal agent concentration displayed on the monitor (both at induction, and during emergence).
- Don’t fear low flows with sevoflurane or desflurane—provided you use absorbent that doesn't produce Compound A or carbon monoxide. The package insert (2014) advises against it. But in an excellent recent article, a trio of experts explains why low flows absolutely need not be avoided with sevoflurane. See Anaesth Intensive Care 2019;47:223
- Good information on Low flow anesthesia from GE, and from Draeger
Low flows are used to decrease the usage, cost, and pollution of volatile anesthetics. A 50% reduction in FGF translates to a 50% savings, without placing the patient at risk or lessening the quality of their care. Tracheal heat and humidity, and patient core body temperature are preserved better than at higher flows.
Since the fresh gas flowing during the inspiratory phase of each breath augments delivered tidal volume (VT), changing FGF on older machines changes delivered tidal volume. Newer machines employ fresh gas decoupling or compensation to eliminate this problem. A decrease to low flows on older machines will cause delivered VT to decrease, and end tidal carbon dioxide to increase to an extent, particularly with low compliance or low VT.
The composition of gases in the breathing circuit may change as lower flows are employed, since a greater fraction of the gas inspired by the patient will be rebreathed.
- Oxygen: inspired oxygen may decline to less than the amount set on the flowmeter, especially as delivered oxygen approaches the metabolic requirement for oxygen (250-300 mL/min in an adult). This can readily and rapidly occur with low fresh gas flow and low set FIO2. Inspired oxygen declines because of uptake, and dilution of oxygen distal to the common gas outlet by leaks, exhaled nitrogen, carbon dioxide, and water vapor.
- See J Clin Monit Comput 2015;29:491 including especially the video content.
- More on the danger of very low FIO2 with very low flows J Clin Monit Comput 2016;30:251 Starting with FIO2 in breathing circuit of 75%, the author breathes air at 1 L/m FGF. Within 6 min, FIO2 was 8% and SpO2 was 72%.
- Note that the Maquet Flow-i workstation utilizes an active hypoxic guard, which overrules settings when FIO2 declines towards a hypoxic breathing mixture. See J Clin Monit Comput 2016;30;63
- Agent: inspired agent may be much less than that dialed on the vaporizer when low flows are employed, also due to leaks, uptake and dilution.
Heater fan and Heat mix controls. Click on the thumbnail, or on the underlined text, to see the larger version (60 KB).
Large discrepancies between dialed and inspired agent concentration can be unsettling, raising apprehensions about vaporizer or breathing circuit malfunction. An analogy may help to clarify why this is an expected result of low flows. Imagine you are entering an automobile in the winter. You turn the heater on at maximum heat level and fan speed. After the car is warmed to a comfortable temperature, you can't turn the heater entirely off. Heat must still be supplied, since it is always dribbling out (the car is not airtight). To keep the car at equilibrium, you may either flow a moderate to high fan speed, but decrease the heat mix to nearly room temperature air, or you may leave the heat mix level high, and slowly blow in a small amount of very hot air. It makes no difference- in either case the car stays at the desired temperature.
Similarly, we begin cases with higher flows. Since there is little rebreathing at 4 L/min FGF and above, the dialed and inspired agent concentration are very similar. We induce with overpressure until the patient is saturated (reflected in an end-tidal agent concentration which approaches the dialed agent concentration). Then we may either leave the flows high with a moderate agent concentration near MAC, or turn the flows to low flow. But if we use low flows, we must still provide the same number of molecules of agent in order to replace that lost due to dilution, leaks, and uptake to fat and muscle. So we must turn the vaporizer dial well beyond what we might have at higher flows.
Advantages of low flows
- Decreased operating room & environmental pollution
- Estimation of agent uptake and oxygen consumption
- At some point below 1 L/m, low flows become closed circuit: the APL valve is closed and only enough gases and agent are supplied to keep the bellows or bag volume constant. One can then infer uptake from changes in volume and composition of the gases in the breathing circuit.
- Buffering of changes in inspired concentration
- Conservation of heat and humidity
- Less danger of barotrauma
Disadvantages of low flows
- More attention required
- Inability to quickly alter inspired concentrations
- If you must lighten or deepen the agent level quickly, switch for a moment to higher flows
- Danger of hypercarbia
- Absorbent granules are used at a faster rate with low flows because of the higher degree of rebreathing
- Greater knowledge required (only if closed circuit employed)
- Accumulation of undesired gases in the circuit (only if closed circuit employed)
- Carbon monoxide, acetone, methane, hydrogen, ethanol, anesthetic agent metabolites, argon, nitrogen
Contraindications for low flows- Absolute and relative
- High VO2 needed (e.g. Malignant Hyperthermia)
- Toxic gases to washout (e.g. smoke inhalation)
- Necessary equipment broken/missing (e.g. Oxygen analyzer, agent analyzer, absorbent)
- Case duration < 15 minutes
- Leaks to be expected
- older gas machine (less leak-proof)
- face mask anesthesia or LMA
- uncuffed endotracheal tubes
- during rigid bronchoscopy (huge leaks)
How to denitrogenate ("preoxygenate")
You can "preoxygenate" with a nasal cannula. We need to do more- denitrogenate (cleanse the functional residual capacity of nitrogen)- to help our patients tolerate a potential 2 or more minutes of apnea if we have difficulties with intubation.
- Fresh gas flow 6-8 L/min
- APL valve open fully
- Tight mask fit
- the most significant factor. It cannot be compensated for by increasing time of preoxygenation, because the patient will not be breathing 100% oxygen with a loose fit (Benumof-Pre-O2: Best method for efficacy and efficiency Anesthesiology 1999;91:603).
- Every time you place a mask on a patient's face, look back at the breathing bag (to ensure it is fluctuating with respirations) and the oxygen flowmeter (to ensure it is on).
- Pay attention to complaints that it "smells funny"- you may have left a vaporizer on.
- Thus you can avoid the threats to patient safety inherent in an apneic patient (pretreatment with non-depolarizing muscle relaxants, relative overdose of narcotics), or one to whom oxygen is not being provided, or one exposed to anesthetic vapor before this is intended.
Malignant hyperthermia: Implications for equipment
Clinical presentation The cause of the tachycardia, tachypnea, and elevated end-tidal CO2 seen in malignant hyperthermia (MH) must be distinguished from ventilator or unidirectional valve malfunctions (producing respiratory acidosis), as well as hyperthyroidism, cocaine intoxication, pheochromocytoma, and sepsis.
Triggers Succinylcholine and all inhaled agents are the only anesthetic agents that will trigger MH.
Safe anesthetics Barbiturates, propofol, etomidate, ketamine, opioids, local anesthetics, catecholamines, nitrous oxide, and all non-depolarizing muscle relaxants are presently considered safe. MHAUS list of safe/unsafe (MHAUS= Malignant Hyperthermia Association of the United States)
Treatment of acute episodes in OR High fresh gas flow (10 L/min), notify surgeon, hyperventilation, use activated charcoal filters on inspiratory and expiratory limbs of breathing circuit, stop inhaled agents and remove vaporizers, stop succinylcholine, and as time permits change soda lime granules & breathing circuit. The mainstay of treatment is dantrolene 2.5 mg/kg (up to 10 mg/kg). Cooling by any and all means, NaHCO3, treatment of hyperkalemia, and other measures are also important. MHAUS Recommendations for management of acute crisis.
Management of known susceptible patients- MHAUS recommends four alternatives to prepare the gas machine:
- "Flush and prepare workstation according to manufacturer’s recommendations or published studies; this may take 10 to >90 minutes.
- Most studies also physically disconnect vaporizers from the workstation;
- use a new, disposable breathing circuit;
- and replace the carbon dioxide absorbent.
- During the case, fresh gas flow should be kept at 10 liters per minute to avoid “rebound phenomenon” (increased release of residual volatile anesthetic agent when fresh gas flow is reduced after a set period of flushing).
- OR Use commercially available activated charcoal filters that have been shown to remove trace levels of volatile anesthetic agents following a 90 second flush with high fresh gas flows. These filters have been demonstrated in one in vitro study to be effective for 12 hours.
- OR If available, use a dedicated “vapor free” machine for MH-susceptible patients. The machine must be regularly maintained and safety-checked.
- OR If appropriate to the institution, use an ICU ventilator that has never been exposed to volatile anesthetic agents."
- Note that guidelines for flushing (#1 above) do NOT apply to all machines. One study showed that a modern machine (Fabius GS) required 105 minutes of flushing before it was agent-free (Anesthesiology. 2011;114:205).
Ventilator and Breathing Circuit: Problems and Hazards
Most common site is Y piece. The most common preventable equipment-related cause of mishaps. Direct your vigilance here by:
- precordial ALWAYS
- if you turn the vent off, keep your finger on the switch
- use apnea alarms and don’t silence them.
- The biggest problem with ventilators is failure to initiate ventilation, or resume it after it is paused.
- Be extremely careful just after initiating ventilation- or whenever ventilation is interrupted: observe and listen to the chest for a few breathing cycles.
- Never take for granted that flipping the switches will cause ventilation to occur, or that you will always remember to turn the ventilator back on after an Xray.
Monitors for disconnection
Occlusion/obstruction of breathing circuit
Beside inability to ventilate, obstruction may also lead to barotrauma. Obstruction may be related to:
- Foreign objects or manufacturing flaws that block all flow in the breathing circuit. If no flow test is done in the morning checklist and between patients, failure to ventilate may be misdiagnosed as bronchospasm on induction. The results have been, and continue to be, fatal.
- Tracheal tube (kinked, biting down, plugged, or cuff balloon herniation). "All that wheezes is not bronchospasm".
- Incorrect insertion of flow-direction-sensitive components (older PEEP valves which are added on between the absorber head and corrugated breathing hoses)
- Excess inflow to breathing circuit (flushing during ventilator inspiratory cycle)
- Bellows leaks
- Ventilator relief valve (spill valve) malfunction
- APL valve too tight during mask ventilation or not fully open during preoxygenation.
Much less of a problem since breathing circuit and scavenger tubing sizes have been standardized. However, breathing systems ARE reconfigured for preventive maintenance and other reasons. One such incident resulting in apnea, inability to ventilate, and asystole in 2007 (US FDA. Adverse event report MW5003097, Manufacturer and User Facility Device Experience (MAUDE) database. 2007. Available here. Accessed February 16, 2016).
Failure of emergency oxygen supply
May be due to failure to check cylinder contents, or driving a ventilator with cylinders when the pipeline is unavailable. This leads to their rapid depletion, perhaps in as little as an hour, since you need approximately a VT of driving gas per breath, substantially more if airway resistance (RAW) is increased. Anesth Analg 2002;95:148
Clean the bellows after any patient with diseases which may be spread through airborne droplets, or don’t use the mechanical ventilator, or use bacterial filters, or use disposable soda lime assembly, or use a Bain.
Mechanical ventilator failure
Protocol for mechanical ventilator failure
- If the ventilator fails, manually ventilate with the circle system. (Why? Allows you to continue using vaporizers.)
- If #1 is not possible, then bag with oxygen (if a portable cylinder is available) or room air.
- If #2 is not possible, then try to pass suction catheter through the tracheal tube. (When in doubt, pull it out is not the best advice in all circumstances.)
- If #3 is not possible, then visualize the hypopharynx and cords with the tube in place, or reintubate (?).
Don’t delay reestablishing ventilation to diagnose a problem. Proceed expeditiously from one approach to another.
Look under Respiratory Care tab at Difficult Airway Algorithm which is Anesthesiology Feb 2013;118:251. (A new revision is in comments stage in 2021.)
Increased inspired carbon dioxide
Inspired unidirectional valve problem- bottom capnogram. Click on the thumbnail, or on the underlined text, to see the larger version (18 KB).
The causes of increased inspired carbon dioxide are almost exclusively either malfunctioning unidirectional valves, or exhausted absorbent.
Increased inspired carbon dioxide has other potential causes, but these are rare
- inadvertent administration of carbon dioxide
- low fresh gas flow in a Mapleson system
- improper assembly of Bain system
- excessive dead space [for example rebreathing under drapes]
- leak in inspiratory limb of circle
- capnograph artifact [water in sampling cell, or sampling rate too low]
Treatment must be accurately directed at the cause or it will be ineffective. Many approaches are useless: increasing minute ventilation, seeking signs of malignant hyperthermia, checking for leaks in the circuit, obtaining arterial blood gases, bronchoscopy for mucous plugs, central line insertion, recalibrating or replacing ventilator, capnograph, or entire gas machine.
Malfunctioning unidirectional valves can cause serious problems.
- If the inspiratory valve is incompetent, the patient exhales into both limbs. The capnogram may show a slanted downstroke inspiratory phase (as the patient inhales carbon dioxide-containing gas from the inspiratory limb) and increased end-tidal carbon dioxide (as in the bottom capnogram in the figure above).
- If the expiratory valve is incompetent, increased inhaled and exhaled carbon dioxide levels may appear with a normal appearing capnogram.
- The cardinal sign in either is an elevated baseline- a non-zero inspired CO2.
- Failure of granules or valves has been defined as inspired CO2 of 5 mm Hg (Anesth Analg 2021;132:993).
- Both situations result in respiratory acidosis unresponsive to increased ventilation.
- If the valves stick closed, all gas flow within the circle system ceases, and one cannot ventilate the patient.
- If either valve is stuck or obstructed, it causes immediate inability to ventilate (mechanically or manually). This must be differentiated from severe brochospasm or endotracheal tube kinked or obstructed. Obstructed breathing circuits are checked as part of the morning checklist, and between patients using a flow test. See Checklist in a subsequent section.
Differential diagnosis: Machine malfunction? Altered patient physiology?
Increased carbon dioxide production will not result in increased inspired carbon dioxide. The capacity of the soda lime granules is sufficient to cleanse each breath entirely, even if carbon dioxide production is increased. Further, respiratory acidosis will not cause visibly dark blood, or desaturation on the pulse oximeter.
Diagnosis and treatment
If the granules are not exhausted, and the inspiratory and expiratory unidirectional valves are forcing all exhaled gas through the granules, there can be no increase in inspired carbon dioxide. So, if it is detected:
- First, increase fresh gas flow (FGF) to much greater than minute ventilation.
- A fresh gas flow of 8-10 L/min creates a semi-open system, with essentially no rebreathing, since the amount of fresh gas is sufficient to dilute any exhaled carbon dioxide to very low levels (and send it to the scavenging system).
- If the granules are exhausted, inspired CO2 will return to normal when FGF is increased.
- Either leave FGF high and change granules at end of case, or change the granules as soon as practical and safe during the case and return to low flow.
- If the increased fresh gas flow didn't decrease inspired CO2, an incompetent valve is likely.
- Modern breathing circuits do not allow cleaning, drying, or replacing the valve while a patient is attached to the breathing circuit.
- The entire workstation should be replaced while bagging the patient, and assuring that anesthesia depth continues with TIVA.