An in-depth review
by
M Ravishankar  MD
 Professor and Chair of Anesthesia 
JIPMER
Pondicherry, India

Table of contents

Introduction

Definition

Requirements of a Breathing System

Classification (Table 1)

Breathing systems without CO2 absorption

Unidirectional Flow

Bidirectional Flow

Subclassification

Afferent reservoir system

Magill system

Enclosed afferent reservoir system

Efferent reservoir system

Bain system

Combined system

Breathing systems with CO2 absorption

Circle system

Totally closed system

References


INTRODUCTION

Since the introduction of diethyl ether as an anaesthetic in 1846, the speciality of anaesthesia has come a long way. In the initial phase, the attention was mainly diverted to administering a single agent and apparatus were developed to suit the purpose. The reintroduction of nitrous oxide in 1868, and facility to store it in cylinders, created an interest in administering a combination of agents to anaesthetise patients. Any resemblance to a breathing system was developed by Barth (1907) using his valve with a nitrous oxide cylinder, a reservoir bag and Clovers inhaler. Different positions of the lever in the valve allowed a range from complete rebreathing to completely breathing from the atmosphere. The development of Boyles machine (1917) and mastering of endotracheal intubation with a soft red rubber single lumen tube by Magill and Rowbothom were the forerunners for development of a simple anaesthetic delivery system by Magill, popularly known as the Magills circuit. Introduction of cyclopropane in 1929 and cuffed endotracheal tube in 1931; prompted Waters to develop the to and fro canister and use it for closed system anaesthesia with cyclopropane. In 1936, Brian Sword introduced the circle system. The Ayres T-piece was introduced in 1937, EMO inhaler in 1941 and Minnitts gas and air apparatus with demand valve in 1949.

With the introduction of many breathing systems attempts were made to classify them in the 50s and 60s, but lack of a proper definition, lead to more confusion than clarity.

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DEFINITION:

A breathing system is defined as an assembly of components which connects the patients airway to the anaesthetic machine creating an artificial atmosphere, from and into which the patient breathes.

It primarily consists of

a) A fresh gas entry port/delivery tube through which the gases are delivered from the  machine to the systems;

b) A port to connect it to the patients airway;

c) A reservoir for gas, in the form of a bag or a corrugated tube to meet the peak inspiratory flow requirements;

d) An expiratory port/valve through which the expired gas is vented to the atmosphere;

e) A carbon dioxide absorber if total rebreathing is to be allowed and

f) Corrugated tubes for connecting these components.

     Flow directing valves may or may not be used.

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REQUIREMENTS OF A BREATHING SYSTEM:

The components when assembled should satisfy certain requirements, some essential and others desirable.

Essential:

The breathing system must

a) deliver the gases from the machine to the alveoli in the same concentration as set and in the shortest possible time;

b) effectively eliminate carbon-dioxide;

c) have minimal apparatus dead space; and

d) have low resistance.

Desirable:

The desirable requirements are

a) economy of fresh gas;

b) conservation of heat;

c) adequate humidification of inspired gas;

d) Light weight;

e) convenience during use;

f) efficiency during spontaneous as well as controlled ventilation (Efficiency is determined in terms of CO2 elimination and fresh gas utilization);

g) adaptability for adults, children and mechanical ventilators;

h) provision to reduce theatre pollution.

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CLASSIFICATION OF BREATHING SYSTEMS:

One will realize the reason for the failure of the attempts at classification in the 50s to 60s, if this definition and requirements are taken into account. There are numerous classifications of breathing systems according to the whims and fancy of the person classifying. Many of them are irrelevant as they do not define a breathing system. Different authors classified the same system under different headings, adding to confusion1.  McMohan in 1951 classified them as open, semiclosed and closed taking the level of rebreathing into account. It as follows:

Open        

        no rebreathing

Semiclosed 

        partial rebreathing

Closed

        total rebreathing

Dripps et al have classified them as Insufflation, Open, Semiopen, Semiclosed and Closed taking into account the presence or absence of Reservoir, Rebreathing, CO2 absorption and Directional valves1. The ambiguity of the terminology used as open, semi open, semi closed and closed allowed inclusion of apparatus that are not breathing systems at all into the classification.

To overcome this problem Conway2 suggested that a functional classification be used and classified according to the method used for CO2 elimination as:

1. Breathing systems with CO2 absorber

2. Breathing systems without CO2 absorber.

Miller.D.M.3 in 1988 widened the scope of this classification so as to include the enclosed afferent reservoir system.  

A new breathing system called The Maxima4 has been designed by Miller in 1995 and to include it in the classification5, the enclosed afferent reservoir systems have been grouped under displacement afferent reservoir systems.

Table 1. Classification of breathing systems

BREATHING SYSTEMS WITHOUT CO2 ABSORPTION.

BREATHING SYSTEMS WITH CO2 ABSORPTION.

Unidirectional flow:

a) Non rebreathing systems.

B) Circle systems.

 

Unidirectional flow

Circle system with absorber.

 

 

Bi-directional flow:

a) Afferent reservoir systems.

Mapleson A

Mapleson B

Mapleson C

Lacks system.

B) Enclosed afferent reservoir systems

Millers (1988)

c) Efferent reservoir systems

Mapleson D

Mapleson E

Mapleson F

Bains system

d) Combined systems

Humphrey ADE

 

Bi-directional flow

To and Fro system.

 

 

 

 

 

 

 

 

 

 

 

 

This classification also has a personal bias as the Humphrey ADE system is not included in the classification, even though he preferred to compare his system with that of Humphreys6. The classification suggested in table.1. is a partial modification of Millers3 classification.

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BREATHING SYSTEMS WITHOUT CO2 ABSORPTION

Unidirectional Flow

FIG 1. Nonrebreathing system. (Inset Nonrebreathing Valve)

 

a) Nonrebreathing systems.  They use non rebreathing valves and there is no mixing of fresh gas and the expired gas.

Functional analysis: When the patient takes a breath, or if the reservoir bag is squeezed, the inspiratory unidirectional valve opens and the gases flow into the patients lungs (Fig.1).  The expiratory unidirectional valve closes the expiratory port during spontaneous breathing.  The inspiratory unidirectional valve itself closes the expiratory port during controlled ventilation.  At the start of expiration, the inspiratory unidirectional valve returns back to position and expiration takes place through the expiratory port, opening the expiratory valve.

The fresh gas flow (FGF) should be equal to the minute ventilation (MV) of the patient. These systems satisfy all four essential requirements, but are not very popular because of the following reasons:

1) Fresh gas flow has to be constantly adjusted and is not economical.

2) There is no humidification of inspired gas.

3) There is no conservation of heat.

4) They are not convenient as the bulk of the valve has to be positioned near the patient.

5) The valves can malfunction due to condensation of moisture and lead to complications.

b) Circle Systems: These systems are designed with a CO2 absorber as an essential component of the system. To use it without absorber is uneconomical as it needs a FGF more than the alveolar ventilation.

The effect of arrangements of various components in the effective elimination of CO2 and fresh gas economy when used with high flows were analysed by Egar and Ethans7.  Detailed discussion on this is beyond the purview of this review.  However, some aspects of this is discussed under the section, Circle system with absorber.

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Bi-Directional Flow:

Systems with bi-directional flow are extensively used. These systems depend on the FGF for effective elimination of CO2. Understanding these systems is most important as their functioning can be manipulated by changing  parameters like Fresh gas flow, alveolar ventilation, apparatus dead space, etc.  We will analyze these in detail.

Fresh Gas Supply;  Fresh gas flow (FGF) forms one of the essential requirements of a breathing system.  If there is no FGF into the system, the patient will get suffocated.  If the FGF is low, most systems do not eliminate carbon-dioxide effectively, and if there is an excess flow there is wastage of gas.  So, it becomes imperative to specify optimum FGF for a breathing system for efficient functioning.

If the system has to deliver a set concentration in the shortest possible time to the alveoli, the FGF should  be delivered as near the patients airway as possible.

Elimination Of Carbon-Dioxide:  The following may be taken as an example for better understanding of CO2 elimination by the bi-directional flow systems.  Normal production of carbon-dioxide in a 70 kg adult is 200 ml per minute and it is eliminated through the lungs.  Normal end-tidal concentration of carbon-dioxide is 5%.  Hence, for eliminating 200 ml of carbon-dioxide as a 5% gas mixture, the alveolar ventilation has to be:

200 x 100  =  4,000 ml.

       5          

This 4000 ml or 4 litres is the normal alveolar ventilation.  Any breathing system connected to an adults airway should provide a minimum of 4 litres per minute of carbon-dioxide free gas to the alveoli for eliminating carbon-dioxide. If the alveolar ventilation becomes less than 4 litres per minute, it would lead to hypercarbia.  If the alveoli are ventilated with 5 litres/minute of a gas containing 1% carbon-dioxide, or 8 litres/minute of a gas containing 2.5% carbon-dioxide, it could still eliminate 200 ml of carbon-dioxide per minute from the alveoli.  It may be construed as 4 litres of CO2 free gas and 1 litre of gas with 5% CO2 in the first instant and as 4 litres of CO2 free gas and 4 litres of gas with 5% CO2 in the second instant.  In effect, 4 litres of alveolar ventilation with CO2 free gas is provided in both cases.

 

Apparatus Dead Space:  It is the volume of the breathing system from the patient-end to the point up to which, to and fro movement of expired gas takes place.

 

FIG 2. Extent of dead space in various systems

In an afferent reservoir system with adequate FGF, the apparatus dead space extends up to the expiratory valve positioned near the patient (fig.2).

 

If the FG enters the system near the patient-end as in an efferent reservoir system, the dead space extends upto the point of FG entry.  In systems  where inspiratory and expiratory limbs are separate, it extends upto the point of bifurcation.  The dynamic dead space will depend on the FGF and the alveolar ventilation.  The dead space is minimal with optimal FGF.  If the FGF is reduced below the optimal level, the dead space increases and the whole system will act as dead space if there is no FGF.  Increasing the FGF above the optimum level will only lead to wastage of FG.

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Sub-Classification Of Bi-Directional Flow Systems:

Mapleson8 did a theoretical analysis of the fresh gas requirements of the semiclosed systems available at that time. It is only proper to refer to it as Mapleson systems as he gave a nomenclature as A, B, C, D and E for easy identification as per their construction. For better understanding of the functional analyses, they have been classified as:

1

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