Anesthesia Delivery Systems Part I

Anesthesia Machine and Ventilators

Sue Ranasinghe, MD

Contents Outline

High pressure/ low pressure circuits

Gas cylinders and contents
Critical temperature
Diameter Index Safety System / Pin Index Safety System
Check valve
Second –stage oxygen regulator
Fail-safe valve/ fail safe system
Flow Meters
Proportioning System
O2 flush Valve
Testing of Leaks in the Anesthesia Machine and Breathing System
Scavenging System
Anesthesia Bellow Assembly Problems
Causes of high pressure in the breathing system
Peak Inspiratory Pressure and Plateau Pressure
PEEP Valve
Auto PEEP
Anesthesia ventilators
Classic modes of ventilation
Ventilator –induced lung injury (VILI)
Anesthesia ventilators driving mechanisms

Key Words 2006-2014

Nitrous oxide (N2O) in tank: calculate
Oxygen: E cylinder volume
E cylinder: pressure and volume relationship
Cylinder content: weight versus pressure
O2 and N2O pipeline cross over
Common gas outlet check valve
Physical behavior of gas mixtures
O2 regulator: characteristics
Gas machines: safety features
Wall O2 failure: signs
Gas laws: temperature/pressure changes
N2O: gas proportioning system
O2 supply failure alarm

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Subambient pressure alarm
Flowmeter, rotameter: laminar, turbulence
Factors affecting turbulent flow
Flow meter: gas properties
Flowmeter damage
High altitude anesthesia
Gas flow: variable-orifice flow meter
Anesthetic machine low pressure leak test
Waste gas scavenging
Ventilator disconnect: detection
Peak versus Plateau airway pressure
Mechanical vent airway press patterns
Ventilator bellows leak/ Effects of ventilator bellows hole
Ascending vent bellows advantages
ARDS- optimal TV- 2014
ARDS: ventilator management- 2014

Anesthesia Machine- High pressure/ Low pressure Systems

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 Diagram of a generic two-gas anesthesia machine.

High pressure circuit: is confined to the cylinders and the cylinder primary pressure regulators.
Intermediate pressure circuit: Includes cylinder supply sources at a pressure of 45 psig and the
pipeline sources at 50 to 55 psig. This circuit begins at the primary pressure regulators of the
cylinders and extends to the flow control valves.
Low pressure circuit: Begins at the flow control valve. Therefore, on the anesthesia machine
the low pressure circuit includes the flow meters and vaporizers.
Depending on the specific machine design a second stage pressure regulator is used to decrease
the pressures to the flow control valve to 14 or 26 psig.

Gas cylinders and contents

A common exam question:
How long will an O2 cylinder last?
If only the O2 pressure is given and you cannot remember the volume of O2 in a full cylinder,
use the following equation. The answer comes in hours.

Approximate remaining time (hrs)

≈ O2 cylinder pr (psig) / (200 x O2 flow rate in L/min)
Example:
The "E" cylinder of oxygen in a mobile lithotripter unit has a pressure reading of 1200 psig. At
an oxygen flow of 3 L/min, there will be sufficient oxygen for approximately how long?
= 1200 / 200 x 3 = 2 hours (approximately)

Hand ventilating with low FGF consume less than 5% the amount of O2 compared with
intermediate flow and machine ventilation.
Because:
Ventilator driving gas supply = 35 to 70 psig at 100 L/min !
The driving gas in the Datex-Ohmeda 7000, 7810, 7100, and 7900 is 100% oxygen.
In the North American Dräger AV-E, a Venturi device mixes oxygen and air.

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 Gas United States State in Cylinder

Oxygen Green Gas

Nitrous oxide Blue Gas + Liquid (below 88oF)
Carbon dioxide Gray Gas + Liquid (below 88oF)
Helium Brown Gas
Air Yellow Gas

Critical Temperature
.
This is the temperature above which a substance cannot be liquefied however much pressure is
applied.
The critical Temperature of N2O is 36.5oC. Therefore, at the normal room temperature of 20oC it
remains a liquid (below the critical temperature).
If the liquefied N2O temperature rises above its critical temperature, it will revert to its gaseous
phase.

Because N2O is not an ideal gas and is easily compressible, the transformation in to gaseous
phase is not accompanied by a greater rise in tank pressure.

The critical temperature of O2 is –119oC, therefore can be liquefied by pressure, only if stored
below its critical temp.
Liquid O2 in the storage vessel is at a temperature around –160oC.

Units of Pressure:
100 Kpa = 760 mmHg = 1030 cm H2O = 14.7 psi = 1 Atms. Pr. At sea level

A common exam question: How long will an O2 cylinder last?

Only the O2 pressure is given and you cannot remember the volume of O2 in a full cylinder.
Approx remaining time (hrs)
≈ O2 cylinder pr (psig) / 200 x O2 flow rate (L/min)
Hand ventilating with low FGF consume < 5% the amount of O2 compared with intermediate
flow + IPPV.

Pin Index Safety System / Diameter Index Safety System

Pin Index Safety System (PISS): A device to prevent the attachment of a cylinder of one gas to
the hanger yoke of another in the anesthesia machine.
There is a special pin index configuration to each medical gas.
PISS used in cylinders of sizes A to E, A = smallest; E = most commonly on anesthesia machine.

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Two pins on the yoke are so arranged that they project in to the cylinder valve.
N2O (3-5), O2 (2-5), CO2 (2-6)

DISS (Diameter Index Safety System): Provides non-interchangeable connection for

medical gas lines at pressure of 200 psig or less.
2 bores mate with 2 shoulders.

Check valve
A check valve is located downstream from each cylinder if a double-yoke assembly is used. A
check valve has several functions:
1. Minimizes transfer of gas from a cylinder at high pressure to one with lower pressure.
2. Allows replacement of an empty cylinder with a full one while gas flow continues from the
other cylinder into the machine with minimal loss of gas.
3. Minimizes leakage from an open cylinder to the atmosphere if one cylinder is absent.

A check valve located downstream from the pipeline inlet prevents reverse flow of gases from
machine to the atmosphere or to the pipeline.

The cylinder gauge located downstream from the check valves indicates the pressure in the
cylinder with higher pressure when both reserve cylinders of the same gas are opened at the same
time.

Pipeline crossover:

The operator must take two actions if a pipeline crossover is suspected.

First, the backup oxygen cylinder should be turned on.

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 Second, the pipeline supply must be disconnected. This step is mandatory because the
machine preferentially uses the wrong gas coming from 50 psig pipeline supply source
instead of the lower-pressure (45 psig) oxygen cylinder source.

The cylinders should be turned off after preoperative machine check. If left on, the reserve
cylinder supply can be silently depleted whenever the pipeline pressure (usually at 50 psig) falls
lower than the regulated cylinder pressure (45 psi).

Trans-filling (if the check valve malfunctions):

When a small cylinder is trans-filled from a large cylinder containing gas at high pressure, rapid
recompression of the gas in the small cylinder may cause the temperature to rise sufficiently to
ignite combustible materials and oxidize metals.

Second-stage regulator
The second-stage regulator supplies a constant pressure to the oxygen flow control valve,
regardless of fluctuating oxygen pipeline pressures.
Most Datex-Ohmeda machines have a second-stage oxygen regulator located downstream from
the oxygen supply source in the intermediate-pressure circuit. It is adjusted to a precise pressure
level, such as 14 psig. For example, the flow from the oxygen flow control valve remains
constant if the oxygen supply pressure is greater than 14 psig.

Fail-safe valve/ Oxygen failure cut-off valve

Purpose: An attempt to prevent delivery of a hypoxic mixture to the flowmeters.

In Ohmeda machines, when the O2 supply pressure falls below 20-25 psig (roughly 50% of
normal), the flow of N2O and air to their flowmeters is interrupted.
The pressure sensor shut –off valve used by Ohmeda is an “all-or-nothing” threshold
arrangement, open at O2 pressures greater than 20 to 25psig and closed at pressures below
20psig (in addition, a gas whistle or electric alarm sounds).

(The 2000 ASTM F1850-00 standard mandates that medium priority alarm shall be activated
within 5 seconds when the oxygen pressure decreases below a manufacturer-specified
threshold pressure.)

The fail-safe valve in Drager Narkomed machine is called an O2 failure protection device
(OFPD) and, as in the Ohmeda systems, there is one for each of the other gases supplied to
the machine. As the O2 supply pressure falls, OFPDs proportionately reduces the supply
pressure of other gases to their flowmeters. The supply of N2O and other gases is completely
interrupted when the O2 supply pressure falls to below 12+/- 4psig.
It is important to understand the differences of these fail-safe devices; the Datex-Ohmeda
pressure sensor's shut-off valve is an all-or-nothing threshold device, whereas the Dräger
OFPD is a variable-flow proportioning system.

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 Both designs ensure that at low or zero oxygen supply pressures only O2 may be delivered to
the machine’s common gas outlet.
The fail-safe system does not ensure O2 flow at its flow meter, only a supply pressure to the
O2 flow meter.

O2 failure safe device helps in preventing hypoxia caused by some problems only:
1. Disconnected O2 hose
2. Low O2 pressure in pipeline
3. Depletion of O2 cylinders
- All these occurring upstream of flow meters.

Do not guard against:

1. Accidents from crossover in pipeline system
2. A cylinder containing wrong gas
2. Equipment leaks
- Or things that occur downstream of the flow meters.
Therefore, O2 analyzer is essential in the breathing system.

The misnomer "fail-safe" has led to the misconception that the device prevents administration of
a hypoxic mixture. This is not the case.

Flow meters
The flow meter assembly precisely controls and measures gas flow to the common gas outlet.

1. Traditional mechanical flow meters

2. Electronic flow meters

1. Traditional mechanical flow meters:

- Classified as constant- pressure (constant pressure-decrease), variable- orifice flowmeters.

Variable orifice around the bobbin (tapered tube) depends on the gas flow.

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Pressure decrease across the float (bobbin) stays constant for all positions in the tube -
Increase in the area of the annular orifice as the bobbin rises reduces flow resistance at higher
flows.

At low flow rates, when the tube is narrow gas flow varies according to the viscosity of the gas
(laminar flow).
At high flow rates, tube is wider - gas flow becomes a function of density of the gas (turbulent
flow).

Therefore for calibration purposes both the density and viscosity of the gas is important (i.e.,
flow meter are not interchangeable). Careful re-calibration is required if a flow meter is used for
a different gas than that for which it was initially designed.

Flow meters are meant to be used within a certain range of temperature and pressures. (i.e., at
atmospheric pressure of 760 mmHg and room temperature of 20oC)
Practically speaking, temperature changes are slight under working environments and do not
cause significant changes.

As altitude increases, barometric pressure decreases, resulting in increased flow.

At low flow rates, flow is laminar and dependent on gas viscosity, a property that is independent
of altitude.

However, at high flow rates, flow becomes turbulent and flow becomes a function of density, a
property that is influenced by altitude.
Decrease in density causes increase in actual flow rate
i.e., flow meter will read lower than the actual flow rate.

Contemporary anesthesia machines use several different types of bobbins or floats, including
plumb-bob floats, rotating, skirted floats, and ball floats.
Flow is read at the top of plumb-bob and skirted floats and at the center of the ball on the ball-
type floats.

Leaks in the anesthesia circuitry:

This could be a significant hazard because the flow meters are located down stream from fail
safe device, and oxygen analyzer may be the only safety device.

Leaks can occur at the O-ring junctions between flow meter tubes and the metal manifold or
cracked or chipped glass flow meter tubes.

A leak in the oxygen flow tube can produce a hypoxic mixture even when oxygen is located in
the downstream position, particularly at high ratios of nitrous oxide to oxygen flow.

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.

2. Electronic Flow Meters (Virtual Flow Meters)

New anesthesia stations (Datex-Ohmeda S5/ ADU, Drager Fabius GS):
Gas flows are still set and controlled using conventional flow control valves.
But flows are measured using electronic flow sensors.
The output from the flow control valve is displayed graphically or numerically or both in liters
/min. Although these systems depend on electric power to provide display of gas flow, gas
should continue to flow even when the power is totally interrupted because the flow control
valves are not electronic.

Flow sensors are based on the principle of pneumotachometer. The mesh screen provides a slight
resistance to airflow. The pressure drop across this laminar flow resistance is measured using
differential pressure transducer and displayed on a screen in the form of a virtual flow meter with
a digital display (Obeys Hagen-Poiseuille law)

Flow =  x P x r4/ 8 x ή x L

If r, ή, and L are constant, P can be used to measure flow.

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Electronic flow sensors
Advantages:
Less expensive than rotameters
Data can be used elsewhere in the work station (to record gas consumption, adjust
ventilator bellows tidal volume etc.)

Concern:
What happens to the display if electrical power were totally lost?
Gas should continue to flow even when the power is totally interrupted because the flow control
valves are not electronic.
Some work stations offer a rotameter that is placed at the common gas outlet (CGO) that displays
approximate total flow of gas leaving CGO.

Proportioning Systems:
Purpose: An attempt to prevent delivery of a hypoxic mixture to the patient.
Nitrous oxide and oxygen are interfaced mechanically or pneumatically in order to deliver
minimum oxygen concentration of 23% to 25% (depending on the manufacturer) at the common
gas outlet.
The system is not 100% foolproof.
Limitations are:
1. Wrong gas supply (Oxygen analyzer will detect)
2. Defective mechanics or pneumatics of the system. (Oxygen analyzer will detect)
3. Downstream leaks (detected by pre-anesthetic leak tests)
4. Administration of gases other than nitrous oxide or air. The proportioning system does
not link other gases such as helium, nitrogen and carbon dioxide.

Things that make sure you are delivering O2 to the patient:

1. DISS / PISS
2. Colored tubing and cylinders
3. Fluted handle on the O2 control knob. The oxygen flow control knob is larger,
distinctively fluted, and projects beyond the control knobs of the other gases. All
knobs are color coded for the appropriate gas.
4. O2 on the far right of the manifold. A leak in the flow meter tube is less likely to
deliver a hypoxic mixture.
5. Fail-safe mechanism- Alarms and shuts off of other gases when O2 PRESSURE
falls below 25 psig.
6. O2 ratio control monitor to link N2O flow to O2 flow (proportioning system)
7. Disconnect alarm on the ventilator.
8. Apnea alarm on most monitors if CO2 fails to register.
9. O2 analyzer- very important

O2 Flush Valve

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Actuation of the valve delivers 100% oxygen at a rate of 35 to 75 L/min to the breathing circuit
at 50 psig.
The oxygen flush valve can provide a high-pressure oxygen source suitable for jet ventilation.
Hazards:
If the O2 flush valve sticks in the open position, this may lead to awareness.
It is possible to cause barotraumas if the flush valve activation occurs during the inspiratory
phase of the ventilator.

Machine Compliance
This could cause large discrepancy between the tidal volume that is actually delivered to the
patient and the tidal volume that has been preset.
Some of each breath is retained in the machine due to compression of the gas itself and the
elasticity of the hoses of the circuit.
For every 10 cm H2O pressure, approximately 1% of the compressible volume is retained in the
circuit instead of going to the patient.

Computerized Compensation- New Anesthesia Work Stations

(Datex –Ohmeda Anesthesia Delivery Unit- ADU)

The gas flows (FGF) are measured electronically and the information is transmitted to the CPU
(central processing unit).
The information from the Aladdin vaporizing system is also transmitted to the CPU.
The total FGF and vapor leaving the CGO (common gas outlet), therefore, is constantly
measured.
ADU uses circle system with FGI (fresh gas inflow) on the patient side of the imps unidirectional
valve (explained later).
ADU ventilator controls are integrated with the CPU.
Therefore, when the tidal volume (VT) is set, CPU adjust bellow’s excursion according to the
FGF. If a high FGF but a small VT is set, bellows may move only slightly because most of the
VT is now provided by the FGF.
During automated pre-use check-out the user occludes the Y-piece and work station measures
compliance of the breathing system and this is also taken into account by the ventilator
(compression volume).

Testing of Leaks in the Anesthesia Machine and Breathing System:

Leaks in LPC (low pressure circuit ) can cause: Hypoxia and awareness.
“vulnerable area” of the anesthesia machine
 breakage and leaks - cracks or breaks in flow tubes, leaks in O-rings
(16 in most machines), loose filler caps.

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Many Datex-Ohmeda anesthesia machines have a one-way check valve between the vaporizers
and the common gas outlet. Its purpose is to prevent backflow into the vaporizer during positive-
pressure ventilation.

The presence or absence of this check valve influences which preoperative leak test is
indicated.

The low pressure circuit of an anesthesia machines without an outlet check valve can be tested
using a positive pressure leak test.
The machine with a check valve (many modern Datex Ohmeda machines) require negative
pressure leak test because the positive pressure closes the outlet check valve and the area from
the check valve to the flow control valve therefore remains untested.

Positive pressure Leak test (Leak test for machines without an outlet check valve):
This is performed by closing the pop-off valve, occluding the Y-piece, and pressurizing the
circuit using the oxygen valve to 30 cm H2O. If the system is leak free the pressure gauge will
not decline.

A leak in the vaporizer mount results in failure of the system to hold pressure. Such a leak would
not be detectable by this test if an outlet check valve were present.

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 Application of generic checkout to a system with an outlet check valve.
Application of a positive pressure of 20 cm H2O causes the check valve to close
so that only components downstream are being tested for leaks.

Negative pressure Leak test: for low pressure system

Air or gas being sucked in through leaks (vaporizers, flow meters)
Check valve held open by –65 mm Hg vacuum

1. Anesthesia Machine Master switch, flow control valves, and vaporizers are turned
off (no gases in the low pressure system).
2. Negative pressure leak bulb is attached to the common gas outlet.
3. The bulb is repeatedly squeezed and released until it remains fully collapsed.
4. If the bulb re-inflates within 10 seconds there is a leak in the low pressure system.
5. Repeat the test with each vaporizer “on” in order to check internal vaporizer
leaks.
This test can detect leaks as small as 30 ml/min.

Datex-Ohmeda negative-pressure leak test

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 Datex-Ohmeda negative-pressure leak test. With a leak in the machine, the evacuated
bulb reinflates.

Defects in the unidirectional valves:

Flow test (breathing method) or valve tester checks the integrity of the unidirectional valves
Incompetence of the unidirectional valve may cause reversed flow, hypercarbia and hypoxia.
Breathing method:
1. Close the APL valve.
2. Detach the inspiratory limb of the breathing circuit from the absorber and occlude with
the palm of the hand.
3. Wearing a mask try to breath through the Y-piece. With a properly functioning expiratory
unidirectional valve, it is possible to exhale freely but not inhale.
4. Next, detach the exhalation tube, occlude, and try to breath through the Y-piece. With a
properly functioning inspiratory unidirectional valve, it is possible to freely inhale but not
exhale.
Valve tester utilizes a bulb. When the compressed bulb is attached to the inspiratory port it
should immediately reinflate and there is a firm resistance to compression of the bulb. The
expiratory valve is checked by attaching the inflated bulb to the expiratory port. It is possible
to squeeze the bulb and will remain deflated.
.
Checking the Anesthesia Workstation
The most important part of the anesthesia workstation checkout procedure is verifying the
presence of a self-inflating resuscitation bag.

The Three most important pre-operative checks are:

1. Oxygen analyzer calibration:
This is the only machine monitor that detects problems downstream from the flow-control
valve because the other devices such as the fail-safe valve, oxygen failure alarm and the
proportioning system are all situated upstream of the flow meters.
2. Low-pressure circuit leak test (positive pressure or negative pressure leak test)

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 3. Circle system test (Common gas outlet to Y-piece)- which includes the positive pressure
leak test (i.e., pressurizing the circuit to 30 cm H2O using flush valve), the flow test
to check the integrity of unidirectional valves and detect obstruction in the circle system.

Machine self-test:
Many new anesthesia work stations incorporates self tests to check the above components

Scavenging System
Typical scavenging system consist of
1. a relief valve whereby gas leaves the circuit, i.e., APL or vent pr. relief valve
2. tubing to conduct the gas to a scavenging interface, 19 or 30 mm and rigid tubing
3. the interface with suction or evacuation system, open or closed
4. a disposal line

classified as – Active: hospital vacuum system connected to the disposal line

Passive: via a wide bore tube connected to the operating room ventilation outlet

Scavenging Interface
Closed scavenging system consists of spring loaded relief valves to prevent transmission of
high or low pressures to the patient.

Open scavenging system is valveless, and has continually opened relief ports to protect the
breathing circuit or ventilator from excessive positive or negative pressures. Open system
should be used only with active disposal system that utilizes central vacuum system.

A positive pressure relief valve is mandatory irrespective of the type of disposal system used
(active or passive). A negative pressure relief valve is required if active system with vacuum
attachment is used to protect the breathing circuit or ventilator from excessive subatmospheric
pressure.

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Schematic of anesthesia circuit and scavenging system tubing showing diameters for hose
connections.

The open canister provides reservoir capacity. The efficiency of an open interface depends on the
vacuum flow rate per minute, the volume of the reservoir, and the flow characteristics within the
interface. Spillage will occur if the volume of a single exhaled breath exceeds the capacity of the
reservoir or if a large-scale turbulence occurs within the interface.

Closed and Open Systems

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 Table 9-3. NIOSH trace gas recommendations, 1977
Anesthetic Gas Maximum TWA* Concentration (ppm)
Either agent alone
• Halogenated agent alone 2
• Nitrous oxide 25
Combined halogenated agent and nitrous oxide
• Halogenated agent 0.5
• Nitrous oxide 25
Dental facilities (nitrous oxide alone)
• Nitrous oxide 50

Scavenging Interface
Reservoir bag (3-5L): This is highly desirable with an active system, in the closed and
sometimes open reservoir interface in order to:
1. contain the flow of waste anesthetic gases during exhalation
2. serve as a visual indicator of properly functioning disposal route (active or passive)
i.e., an over distended bag indicates an occluded disposal route or a weak vacuum and
a collapsed bag indicates an excessive vacuum. With normal operation the bag should fill
during exhalation, and empty during inhalation.

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 A closed scavenging interface with a reservoir bag

E.g., Ohmeda closed reservoir active scavenging safety interface: the negative pressure relief
valve opens at a pressure of –0.25 cm H2O and the positive pressure relief valve opens at +4
to+5 cm H2O pressure.

Checking Scavenging System

In some recent models of workstations (ADU) waste gas scavenging interface is internal to the
machine and invisible to external inspection.
Principle of operation is open reservoir system.
Checkout requires:
Machine scavenging connector is connected to the hospital vacuum.
Scavenging flow meter indicates that flow is present.
With the flow meter indicator ball floating between the two lines, the vacuum is drawing about
25L/min from the interface.

Anesthesia Bellow Assembly

Anesthesia Ventilator Bellows -descending (hanging bellows) or ascending
Descending bellows: With leaks or partial disconnection bellows continue to move because
its own weight tends to draw gas.
Ascending bellows: Collapse and remains stationary with leaks.

Anesthesia Bellow Assembly Problems:

Leaks- Improper seating of the plastic bellows cause inadequate ventilation (portion
of the driving gas is vented to the atmosphere).

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 Hole in the bellows –
1. Alveolar hyperventilation - ventilator driving gas pressure (50 psig) is more than
the breathing circuit pressure.
2. Barotrauma (high pressure driving gas enter patient circuit)
3. Value on O2 analyzer may increase if 100% O2 as driving gas or decrease if air/
O2 mixture is used.

Vent. Relief valve problems – Hypoventilation if valve is incompetent

Barotrauma if stuck closed.

Schematic of function of ventilator pressure relief valve during Inspiration and expiration
(Ohmeda 7000 and 7810 ventilators)

Causes of high pressure in the breathing system:

Spontaneous ventilation
1. Inadequate opening (or complete closure) of APL valve
2. Kinking or occlusion of tubing between APL valve and scavenging interface
3. Malfunctioning of the interface positive pr. relief valve

Ventilator on
4. During inspiration, vent. Pressure relief valve is closed. High inspired gas flow,
such as opening O2 flush, will cause increased peak pressure
5. Failure of vent. Pressure relief valve to open during expiration
6. Occlusion of the tubing between vent. pressure relief valve and scavenging
interface.

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 7. Obstruction of scavenging interface pop-off valve- As the pressure in the patient
circuit rises, the ventilator bellows empties less completely.
8. Punctured ventilator bellows

Other causes of high pressure: Kinked or occluded endotracheal tube or breathing

system.
Patient coughing and staining.

High Pressure Monitor

This gets activated when the circuit pressure is in excess of +15 cm H2O for more
than 10 seconds.
In modern monitors, set by the user but has a default setting of 50-65 cm H2O.

E.g., In Ohmeda 7810, whenever the high pressure limit is exceeded ventilator
automatically switches from inspiratory to expiratory phase minimizing the
barotrauma.

Reservoir bag is highly distensible, limit circuit pressure to approx. 45 cm H2O

Low pressure monitor

Alarm threshold should be set just below ( <7 cmH2O) the minimum peak pressure
expected. Otherwise small leaks may not be detected.

Peak Inspiratory Pressure and Plateau Pressure

Peak inspiratory pressure (PIP) is the highest circuit pressure generated during an inspiratory
cycle and provides an indication of dynamic compliance.
Plateau pressure (PP) is the pressure measured during an inspiratory pause (a time of no gas
flow) and mirrors static compliance.

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Increase in PIP without any change in PP
This signals an increase in airway resistance (bronchospasm, secretions) or inspiratory gas flow
rate.

Increase in both PIP and PP

This implies an increase in tidal volume or decrease in pulmonary compliance (i.e. pulmonary
edema, pleural effusion, tension pneumothorax, ascites).

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PEEP valve:
PEEP valve is usually located between the patient circuit and the switch for bag or ventilator
mode. It is recommended that valve must permit bi-directional flow. Incorrectly oriented
bidirectional PEEP valve in the inspiratory or expiratory limb will not block gas flow, but no
PEEP will be applied.
Due to the location of the PEEP valve it allows PEEP during all modes of ventilation.

Auto-PEEP
Auto PEEP is defined as an alveolar pressure above the airway opening pressure.

Auto PEEP occurs as air is trapped in the alveoli when:

1. expiatory time is insufficient,
2. high ventilation rates are used

Therefore, Auto-PEEP can be caused by:

Flow limitations, dynamic hyperinflation, a high minute volume (MV), expiratory
muscle activity, and/or high intra-abdominal pressure.
E.g., in severe asthma, it is better to monitor the level of plateau pressure, as this will
increase or decrease when the total auto-PEEP increases or decreases.

Auto PEEP may result in decreased cardiac output, hypotension, and electromechanical
dissociation in a mechanically ventilated patient.
Diagnosis: Occluding the exhalation port of the ventilator while delaying the onset of the next
ventilator breath (or apply end-expiratory pause for 0.5 to 2 seconds). Alveolar pressure
equilibrates with the ventilator circuit, and auto-PEEP can be read on the airway pressure
monitor.

Flow graphics on the ventilator - expiratory flow does not return to zero before the next breath
begins.
Treatment: sufficient expiatory time, decrease MV (TV or RR), bronchodilators,
adjust I:E ratio, treat underlying condition.

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Plateau Pressure (Pplat)
Plateau pressure is measured by applying an end-inspiratory breath hold for 0.5-2 sec, during
which pressure equilibrates through out the respiratory system so that the pressure measures at
the proximal airway approximates the peak alveolar pressure.
Pplat cannot be measured during active breathing, and with pressure support ventilation. During
pressure controlled ventilation, the flow may decrease to 0 before the end of inspiratory phase, in
which case PIP and Pplat are equal. Pplat is determined by tidal volume (VT) and respiratory
system compliance (C).
Pplat = VT / C
Pplat indicates the risk of alveolar over-distension during mechanical ventilation and should be
maintained at ≤ 30 cm H2O. The lower the Pplat, the lower is the risk of ventilator –induced lung
injury. However high Pplat may be safe (and necessary) if intra-pleural pressure is elevated
(abdominal distension or decreased chest wall compliance).

The difference between peak inspiratory pressure (PIP) and plateau pressure (Pplat) is
determined primarily by airway resistance and flow. The difference between Pplat and the level
of PEEP is determined by compliance and tidal volume.

Schematic representation of a pressure waveform during volume-controlled ventilation

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 Anesthesia Ventilators
Ventilator classification by TV
Effect on TV of increased
Behavior Best monitor Compliance Resistance Leak

Volume preset Stable TV Pressure None None 

Pressure preset Unstable TV Volume   None

Ventilator Classification by inspiratory flow

Effect on TV of increased
Behavior Best monitor Compliance Resistance Leak

Flow generator Stable insp. flow Pressure None None 

Pressure generator unstable insp. flow insp. flow   None

Volume-cycled ventilator provides fixed tidal volume. Inflation pressure is variable. Tidal
volume is maintained despite changes in the peak airway pressure. However, pressure limits can
be set to prevent high peak airway pressures. Volume cycled-ventilators cannot compensate for
leaks in the delivery system.
Pressure-cycled ventilator provides gas flows until preset airway pressure is reached. Therefore,
tidal volume varies with change in lung compliance and airway resistance.

Possible to construct a ventilator to be any one of the 4 combinations of these variables:

Pressure preset flow generator
Pressure preset pressure generator
Volume preset flow generator
Volume preset pressure generator

In the OR, the most commonly used mode is volume control ventilation (preset TV is delivered).
Flow rate is fixed at a constant value during inspiration.

Classic modes of ventilation

Control mode
Assist/control mode
Assist (pressure support)
Synchronized IMV
All these modes have been available on mechanical ventilation for > 25 years.

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CONTROL MODE: Controlled ventilation is available in both pressure and volume ventilation
formats. In this mode, ventilator controls all aspects of gas delivery and patient is assumed to be
a passive recipient of mechanical ventilation.

Volume- targeted square-wave flow-controlled mode ventilation (no negative reflection at

the start of the breath).

Pressure-targeted controlled –mode ventilation (no negative reflection at the start of the
breath).

Assist/Control mode
This is essentially the control mode with the sensitivity level set to trigger on a spontaneous
negative airway pressure ensuring that the patient initiates his or her own gas delivery. Although
the patient determines the ventilatory rate (by triggering the mechanical breath), a backup rate is
set to insure a minimum rate of ventilation.
During volume assist/ control, following variables are set: TV, flow wave form, backup rate,
peak inspiratory flow rate or inspiratory time, inspiratory trigger sensitivity, FiO2, PEEP.
With the pressure assist /control mode the peak pressure, inspiratory time, backup rate,
inspiratory trigger sensitivity, FiO2, PEEP, and rise time must be set.

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VCV flow pattern, constant flow insufflation.

PCV flow pattern, decelerating flow insufflation.

Cadi P et al. Br. J. Anaesth. 2008;100:709-716

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Pressure support ventilation (PSV)
Designed to augment the TVs of spontaneously breathing patients and overcome any increased
inspiratory resistance from the ETT, breathing circuit (tubing, connectors, and humidifier), and
ventilator (pneumatic circuitry and valves) .

When the patient initiates inspiratory flow, the ventilator promptly responds with an increase in
pressure (to a predetermined positive pressure) and an adequate breath.
When inspiratory flow decreases to a predetermined level, ventilator cycles to expiratory phase.
The only setting in this mode is inspiratory pressure.
The patient determines the RR, while TV varies according to inspiratory gas flow, lung
mechanics, and the patient’s own inspiratory effort.

Low levels of PSV (5-15 cm H2O) are usually sufficient to overcome any added resistance
imposed by the breathing apparatus.

The principal advantage of PSV is its ability to augment spontaneous TV and decrease the
patient’s work of breathing.
However, if patient fatigues or lung mechanic changes, TV may be inadequate (therefore often
used in conjunction with IMV).
It may also be useful in weaning.

Pressure support is very similar to pressure assist/ control.

The major feature of gas delivery that differs in this mode is the mechanism that terminates
inspiration.
With pressure assist/control the inspiration is always terminated by time; with pressure support,
inspiration is usually terminated by decreasing gas flow (when tracheal flow decreases to a
specific level, usually 25% of the peak flow for that breath). However newer ventilators allow
clinician to set inspiratory time (prolonged inspiratory time prolonged airway pressure 
reduce cardiac output).
Of the classic modes of ventilation, pressure support allows the patient the greatest control and
can be used to ventilate any patient with stable ventilatory drive.

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Synchronized Intermittent Mandatory Ventilation
This mode combines spontaneous unsupported breathing with the assist/control mode (pressure
or volume targeted).
A mandatory respiration rate is set. Between the mandatory breaths patient can breathe
spontaneously. If ventilator does not sense a patient’s effort during this time period a controlled
positive pressure is delivered.
SIMV improve V/Q matching and cardiac output. However work of breathing during SIMV can
be excessive (dyssynchrony).
Pressure support mode can be applied to spontaneous breaths but increases complexity.

Volume-targeted SIMV showing spontaneous unsupported and mandatory (assist/control)

breaths.

When usual ventilator strategies fail

 alternative modes of ventilation (ICU ):
1. Airway pressure release ventilation (APRV)

2. Prone positioning

The benefits of APRV may be related to the preservation of spontaneous breathing.

àaugmenting venous return and improving cardiac output. Need for sedation is decreased.

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APRV

Prone Positioning
Several mechanisms proposed for improved oxygenation:
• Increased End Expiratory lung volumes (FRC)
• Better V/Q matching- reduction in ventilation/perfusion heterogeneity with improvement in
ventilation and reduction in shunt
• Recruitment of collapsed alveolar units
• Mobilization of secretions

Lung Protective Ventilation Strategies

•Keep plateau pressures < 30 cm H2O

•Use low tidal volume ventilation (6 mL/kg IBW)
•Use PEEP to restore the functional residual capacity (FRC)
This may require high RR (20-40 bpm), in order to maintain gas exchange at low TV.

Smaller the TV and the more severe the lung injury, the greater the probability that patient will
require permissive hypercapnia.

Ventilator –induced lung injury (VILI)

This occurs due to the over distension of the lung (volutrauma) at end inspiration and by collapse
and reexpansion of unstable regions during ventilation.
Excessive TV is accompanied by an excessive transpulmonary pressures. The single factor most
responsible for VILI appears to be the transpulmonary pressure (alveolar-pleural).
Application of 10 cm H2O PEEP in spite of a peak airway pressure of 45 cm H2O has been
shown to decrease the level of VILI as compared with similar animals ventilated with same peak
pressure but at a 0 PEEP.

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VILI is defined as an increase in alveolar capillary permeability, pulmonary edema,
accumulation of protein and neutrophils within lung and airways. There is disruption of
surfactant production and decreased lung compliance similar to ARDS.

Biotrauma: Defined as the activation of pulmonary and systemic mediators by an

inappropriate ventilatory pattern.
VILI is produced by at least 3 mechanisms.
1. Signaling of pro-inflammatory mediator release by mechanical stress.
2. Trauma to the epithelium of lung parenchyma by repetitive opening at high pressures and
subsequent closing with each breath.
3. Physical stress on the parenchyma by high peak alveolar pressures

Anesthesia Ventilators Driving Mechanism:

The driving gas in the Datex-Ohmeda 7000, 7810, 7100, and 7900 is 100%
oxygen.
In the North American Dräger AV-E, a Venturi device mixes oxygen and air.

With the introduction of circle breathing systems with FGD (fresh gas decoupling),
instead of the pneumatically driven ventilators, the mechanically driven (piston-type)
anesthesia ventilators have been added.
In these systems, rather than having dual circuits (gas for the patient in one and the
ventilator driving gas in another) there is only a single gas circuit for the patient.
They are classified as piston-driven, single-circuit ventilators.
New work stations sophisticated computerized controls provide:
1. synchronized intermittent mandatory ventilation (SIMV)
2. pressure-controlled ventilation (PCV)
3. pressure-support ventilation (PSV)
- in addition to the conventional control-mode ventilation (CMV).
Because the patient's mechanical breath is delivered without the use of compressed
gas to actuate the bellows, these systems consume less gas during the ventilator's
operation than a traditional pneumatic ventilator. This has an important clinical
significance when no pipeline gas supply is available such as remote locations, office-
based anesthesia practices.

References:
1. Barash PH, et al Clinical Anesthesia 7th ed. Philadelphia. Lippincott Williams & Wilkins,
20013.
2. Miller RD. Miller’s Anesthesia 8th ed. Philadelphia: Churchill Livingstone, 2014.
3. Longnecker DE. Anesthesiology. McGraw-Hill, 2008:767-820.
4. Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment 5th ed. Philadelphia.
Lippincott Williams & Wilkins, 2008: 83-118.
5. Hazards of Anesthesia workstation ASA 2014
6. Mechanical Ventilatory support ASA 2014

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