Chapter 1 Medical Gas Cylinders and Containers

P.2

Definitions Psi, Psig, Psia

Psi stands for pounds per square inch. Psig stands for pounds per square inch gauge, which is the difference between the measured pressure and surrounding atmospheric pressure. Most gauges are constructed to read zero at atmospheric pressure. Psia stands for pounds per square inch absolute. Absolute pressure is based on a reference point of zero pressure for a perfect vacuum. Psia is psig plus the local atmospheric pressure. For example, at sea level, the atmospheric pressure is 0 psig but 14.7 psia. Table 1.1 shows some units of ex pressing pressure and their conversion fac tors.

Nonliquefied Compressed Gas

A nonliquefied compressed gas is a gas that does not liquefy at ordinary ambient temperatures regardless of the pressure applied (1). Examples include oxygen, nitrogen, air, and helium. These gases do bec ome liquids at very low temperatures, at which point they are referred to as cryogenic liquids.

TABLE 1.1 Units of Pressure kPa cm H2O Kilopascal Centimeters of water

psi

Pounds per square inch

mbar

Millibar

mm Hg

Millimeters of mercury

100 kPa = 1000 mbar = 760 mm Hg = 1030 cm H2O = 14.7 psi = 1 atmosphere

Therefore,

1 kPa = 10.3 cm H2O

1 cm H2O = 0.098 kPa

1 kPa = 0.147 psi

1 psi = 6.8 kPa

1 kPa = 7.6 mm Hg

1 mm Hg = 0.13 kPa

1 kPa = 10 mbar

1 mbar = 0.1 kPa

1 mbar = 1.03 cm H2O

1 cm H2O = 0.97 mbar

1 mbar = 0.76 mm Hg

1 mm Hg = 1.32 mbar

1 mbar = 0.0147 psi

1 psi = 68 mbar

Liquefied Compressed Gas

A liquefied compressed gas is one that becomes liquid to a large extent in containers at ambient temperature and at pressures from 25 to 1500 psig (172 to 10,340 kPa) (1). Examples include nitrous oxide and carbon dioxide.

Regulatory Agencies and Industry Standards

All those who produce, s upply, transport, or use medical gases must comply with a variety of safety regulations promulgated and enforced by agencies at the federal, state, prov incial, and loc al levels of government.

The purity of medical gases is specified in the United States Pharmacopoeia and is enforced by the Food and Drug Administration (FDA). The Department of Transportation (DOT) and Transport Canada (TC) have published requirements for the manufacturing, marking, labeling, filling, qualification, transportation, storage, handling, maintenance, requalification, and disposition of medical gas cylinders and containers. U.S. states and Canadian prov inces vary widely in their regulations for compressed gases (1). In addition, many local governments have regulations that apply to compressed gases. The U.S. government regulates matters affectin g the safety and health of employees in all industries through P.3

the Department of Labor (DOL) and the Occupational Safety and Health Administration (OSHA). The National Fire Protection Association (NFPA), the Compressed Gas Association ( CGA), and the Canadian Standards Association (CSA) have published a number of standards. Although termed voluntary, many regulatory agencies have made adherenc e to these standards mandatory.

Medical Gas Cylinders Components

Body (1,2)

Most medical gas cylinders (tanks) are constructed of steel, with various alloys added. In recent years, manufacturers have moved away from traditional steel cylinders toward steel carbon fiber cylinders. These can hold more gas than their older steel counterparts and are lighter in weight. Cylinders made from aluminum are available. These are especially useful when anesthesia is administered in a magnetic resonance imaging (MRI) environment (Chapter 30). Cylinders that have a marking of 3AA are manufactured by using steel. The marking 3AL or 3ALM indicates that the cylinder is made from aluminum (3). Cylinders have flat or concave bases. The other end may taper into a neck that is fitted with tapered screw threads that attac h to the valve. In recent years, cylinders with integral pressure regulators and flow-metering devices as well as handles have become available (Fig. 1.1) (4). This eliminates the need for pressure regulator maintenance by the health care facility and simplifies use of the cylinder.

Valve
Cylinders are filled and discharged through a valve (spindle valve) attached to the neck (see Fig. 1.7). The valve, which is made of bronze or brass, is an integral part of the cylin der and should be removed only by the cylinder owner.

Port
The port is the point of exit for the gas. It should be protected in transit by a covering. W hen installing a small cylinder on an anesthesia machine, it is important not to mistake the port for the

conical depression on the opposite side of the valve. The conical depression is designed to receive the retaining screw on the yoke. Screwing the retainin g screw into the port may damage the port and/or index pins.

Stem
Each valve contains a stem, or shaft, that is rotated during valve opening or closing. To close the valve, the stem seals against the seat that is part of the valve body. W hen the va lve is opened, the stem moves upward, allowing gas to flow to the port.

Figure 1.1 Cylinder with integral pressure regulator and flow-metering device.

Packed Valve
Most cylinder valves are of the packed type (Fig. 1.2). The stem is sealed by a resilient packing such as Teflon, which prevents leaks around the threads. This type of v alve is also called direct

acting, because turning the stem causes the seat to turn. In a large cylinder valv e, the force is transmitted by means of a driver square (Fig. 1.2, right). This type of valve is capable of withstanding high pressures.

Diaphragm Valve
In a diaphragm valve (Fig. 1.3), closure between the cylinder interior and the atmosphere is accomplished by using a seal, usually metal-to-metal, and a b onnet nut that clamps one or more circular disks in place (1). These disks, or diaphragms, separate upper and lo wer stems, which may be permanently attac hed to the diaphragms. The upper stem is actuated by a manual or automatic means, and the lo wer stem shuts or P.4

permits flo w through the valve. This type of valve has the fo llo wing advantages:

Figure 1.2 Small (left) and large (right) packed valves. The packing seals the stem and prevents leaks. Turning the stem on the large cylinder valve counterclockwise causes the seat to turn in its thread, opening the valve. (From drawings furnished by Puritan-Bennett Corp.)

It can be opened fully by using a one-half to three-quarters turn, whereas the packed valve requires two or three full turns.

The seat does not turn and is therefore less likely to leak. No stem leakage can occur because of the diaphragm.

For these reas ons, the diaphragm type is generally preferable when the pressures are relatively low and when no leaks can be

allo wed, such as with flammable gases. It is some what more expensive than the packed type.

Figure 1.3 Small (left) and large (right) diaphragm valves. Turning the handle clockwise forces the diaphragm downward and closes the seat. Upon opening the valve, the upward force of the spring opens the seat. (From drawings furnished by Puritan-Bennett Corp.)

Handle or Handwheel
A handle or handwheel is used to open or close a cylinder valve. It is turned counterclockwise to open the v alve and clockwise to close it. This causes the stem to turn. A handle (cylinder wrench) is used to open a small c ylinder valve. Handles come in a variety of shapes (Fig. 1.4). Some handles, such as the one in the middle of Figure 1.4, have a

hexagonal opening that fits the packing (gland) nut of the valve (Fig. 1.2). This handle may be used to tighten the packing nut if it becomes loose. A hazard associated with this handle is that a person unacquainted with cylinders could loos en the packing nut under the mistaken impression that he or she was opening the valve. This could cause the valve stem and retaining nut to come off the c ylinder with great force (5). P.5

Figure 1.4 Small cylinder valve handles. The hexagonal opening at the top of the middle handle can be used to tighten the packing nut on the cylinder valve. A ratchet handle is at the right.

After a cylinder has been opened, this handle must be removed, inverted, and reapplied to close the cylinder valve.

A ratchet-type handle is supplied with some anesthesia mac hines (Fig. 1.4). After the cylinder is opened, the handle must be removed, inverted, and reapplied to close the cylinder (6). A good practice is to attach a handle to eac h anesthesia machine or other apparatus for which it may be needed. It is also important to check that the cylinder can be opened before use. Cases where the valve could not be opened have been reported (7,8). Each large cylinder valve has a permanently attached handwheel that uses a spring and nut to hold it firmly in place (Figs. 1.2, right, and 1.3, right).

Pressure Relief Device

Every cylinder is fitted with a pressure relief (safety relief, safety) (see Fig. 1.7) device whose purpose is to vent the cylinder's contents to atmosphere if the pressure of the enclosed gas increases to a dangerous level (1).

Rupture Disc
The rupture (frangible, burst) disc is a non-reclosing device with a disc held against an orifice (Fig. 1.5). W hen the predetermined pressure is reached, the disc ruptures and allows the cylinder contents to be discharged. The pressure opening is the orifice against which the disc functions. The rated burst pressure is the pressure at which the disc is designed to burst. It is determined

by the material, thickness, and shape of the disc as well as the diameter of the pressure opening. This device is used on some air, carbon dioxide, carbon dioxideoxygen, helium, nitrous oxide, helium-oxygen, nitrogen, and oxyge n cylinders. It protects against excess pressure as a result of high temperature or overfilling.

Fusible Plug
The fusible plug is a thermally operated, non-rec losing pressurerelief device with the plug held against the discharge channel. It offers protection from excessive pressure caused by a high temperature but not from overfilling. The yield temperature is the temperature at which the fusible material becomes sufficiently soft to extrude from its holder so that cylinder contents are discharged. A fusible plug with a yield temperature of 212 F is sometimes used on certain nitrogen and air cylinders.

Combination Rupture Disc/Fusible Plug

A combination rupture disc/fusib le plug can be used to prevent bursting at a predetermined pressure unless the temperature is high enough to cause the fusible material to yield. Devices with a yield temperature of 165F may be found on cylinders of air, oxygen, nitrogen, nitrous oxide, helium, helium-ox ygen mixtures, carbon dioxide, and carbon dioxideoxygen mixtures. Becaus e these devices function only in th e presence of both excessive heat and excessive pressure, they do not offer protection from high pressure due to overfilling.

Pressure Relief Valve

The pressure relief valve (Fig. 1.6) is a spring-loaded device designed to reclose and prevent P.6

cylinder contents from being discharged after a normal pressure has been restored. The set pressure, at whic h it will start to discharge, is marked on the valve. A pressure relief valve may be found on air, h elium, oxyge n, nitrogen, helium-oxygen mixture, carbon dioxide, and carbon dioxideoxygen mixture cylinders with up to 500 psig charging pressure. Pressure relief valves are generally more susceptible to leaks than rupture discs or fusible plugs (1).

Figure 1.5 Rupture disc device. When the rated burst pressure is exceeded, the disc ruptures and gas flows from the approach channel into the pressure opening and to atmosphere through the discharge channels. (Redrawn from Frangible disc safety device assembly. Pamphlet S-3. New York: Compressed Gas Society, 4.)

Figure 1.6 Pressure relief valve. When the set pressure is exceeded, the pressure in the cylinder forces the spring to the left, and gas flows around the safety valve seat to the discharge channel. (From a drawing furnished by Ohmeda, a division of the BOC Group, Inc.)

Figure 1.7 Small cylinder valves. Left: The conical depression is above the pressure relief device. Right: The port is above the Pin Index Safety System holes. A washer is over the port.

Conical Depression
Above the safety relief device on small cylinders is the conical depression that receives the retaining screw of the yoke (Figs. 1.2, 1.3, 1.7). It must be distinguished from the safety relief device. If the retaining screw is tightened into the safety relief device, the device may be damaged and the cylinder contents escape (9).

Noninterchangeable Safety Systems

W ith widespread us e of cylinders containing different gases, a potential hazard is connection of a cylinder to equipment intended for a different gas (1,10). To help solv e this problem, color coding was developed; however, this did not give complete protection against human error. Through the cooperation of the CGA and others, two noninterchangeable systems were developed. Both of these systems are located between the cylinder valve and the pressure regulator and should not be confused with the Diameter Index Safety Sys tem (DISS) or proprietary quick connec ts that are on the intermediate (pipeline) pressure side of the pressure regulator, which will be discussed in Chapter 5.

Pin Index Safety System

The Pin Index Safety System consists of holes on the cylinder valve positioned in an arc below the outlet port (Figs. 1.7, 1.8). Pins on the yoke or pressure regulator are positioned to fit into these holes. Pins assigned to gases or gas mixtures used in P.7

anesthesia are shown in Table 1.2. Unless the pins and holes are aligned, the port will not seat. It is possible for a yok e or pressure regulator without pins to receive any cylinder valve, but ordinarily it is not possible for an undrilled cylinder valve to be placed in a yoke or pressure regulator containing pins.

Figure 1.8 Pin Index Safety System. The bottom figure shows the six positions for pins on the yoke. The pins are 4 mm in diameter and 6 mm long, except for pin 7, which is slightly thicker. The seven hole positions are on the circumference of a circle of 9/16 inch radius centered on the port.

W hile the pin index system works well for the common gases used in anesthesia, there are problems when specialized gas mixtures are used. As an example, a 5% CO 2 mixture with oxygen has a different pin index than 100% carbon dioxide. Carbon

dioxide mixtures of 7% or greater CO 2 would be fitted with the pin index of 100% CO 2 (11).

Valve Outlet Connections for Large Cylinders

Larger cylinder valves have threaded outlet (bull nose) connections (Fig. 1.9) (12). W hen the threads of this outlet mesh with those of the nut, the nut may be tightened, causing the nipple to seat against the v alve outlet. In this way, the gas channel of the valve is aligned with the channel of the nipple. The outlets and connec tions are indexed by diameter, thread size, right- and left-handed threading, external and internal threading, and nipple seat design.
TABLE 1.2 Pin Index System Gas Oxygen Index Pins 2, 5

Nitrous oxide

3, 5

Cyclopropane

3, 6

O2-CO2 (CO2 < 7.5%)

2, 6

O2-CO2 (CO2 > 7.5%)

1, 6

O2-He (He > 80.5%)

4, 6

O2-He (He < 80.5%)

2, 4

Air

1, 5

Nitrogen

1, 4

N2O-O2 (N2O 47.5%52.5%)

Sizes
Gas suppliers classify cylinders by using a letter code, with A being the smallest. Table 1.3 gives the approximate dimensions and capacities for some commonly used cylinders. The volume and pressure of gas in a particular size cylinder vary (13). Oxygen and air are similar in volumes and pressures. The same is true for carbon dioxide and nitrous oxide. Size E is the c ylinder most commonly used on anesthesia machines and for patient transport and resuscitation. Size D cylinders are used for limited supplies of gases where size and weight considerations are important. Aluminum c ylinders were originally longer than steel c ylinders with the same outside

diameter (14). Ones manufactured more recently have the same or a shorter length and a larger outer diameter than steel cylinders.

Contents and Pressure

As illustrated in Figure 1.10, in a cylinder containing a nonliquefied gas, the pressure declines steadily as the contents are withdrawn. Therefore, the pressure can be used to measure the cylinder contents. In a cylinder containing a liquefied gas, the pressure depends on the vapor pressure of the liquid and is not an indication of the amount of gas remaining in the cylinder as long as the contents are partly in the liquid phase. The pressure remains nearly constant (with constant temperature) until all the liquid has evaporated, after which the press ure declines until the c ylinder is exhausted. W eight can be used to determine the amount of liquid in these cylinders. In practice, weighing cylin ders is awk war d and rarely performed. P.8

Figure 1.9 Valve outlet connections for large cylinders. A: The valve outlet thread is external, i.e., the threads are on the outside of the cylinder valve outlet and the nut screws over the valve outlet. B: The valve outlet thread is internal so that the nut screws into the outlet. The specification for cylinder connections are often shown as in the following example for oxygen: 0.903-14-RH EXT. The first number is the diameter in inches of the cylinder outlet. The next number gives the number of threads per inch. The letters following this indicate whether the threads are right hand or left hand and external or internal. (Redrawn courtesy of the Compressed Gas Association.)

During use, the temperature is not likely to remain constant. Evaporation of the liquid and expansion of a gas requires energy in the form of heat, which is supplied mainly by liquid in the cylinder. This results in cooling. If the outer surface of a cylinder that contains liquefied gas becomes cold as gas is discharged, this indicates that residual liquid remains in the cylinder (15). As the temperature falls, the vapor pressure of the liquid also falls

so that a progressive fall in pressure accompanies the release of gas from the cylinder (15). If liquid remains when withdrawal stops, cylinder pressure will s lo wly increase to its original level as the temperature rises.
TABLE 1.3 Typical Medical Gas Cylinders, Volumes, Weights, and Pressures Cylinde r Dimens Carbon ions Empty Capacit Helium Dioxid (O.D. Cylinde ies and e Length r Pressur Carbon OxygenOxygen Dioxid Cylinde in Weight es (at Nitrous Nitroge Mixtur Mixtur r Size Inches) (lb) 70F) Air e Helium Oxide Oxygen n esa esa

The + indicates that the pressures of these mixed gases will vary according to the composition of the mixture. b An E-size cylinder of nitrous oxide contains approximately 250 L when the pressure begins to decrease below 745 psig. c 7,800-L cylinders at 2,490 psig are available.

Testing
A cylinder must be inspected and tested at least ev ery 5 years or, with a special permit, up to every 10 years. P.9

The test date (month and year) must be permanently stamped on the cylinder (1).

Figure 1.10 The relationship between cylinder weight, pressure, and contents. A: A gas stored partially in liquid form, such as nitrous oxide, will show a constant pressure (assuming constant temperature) until all the liquid has evaporated, at which time the pressure will drop in direct proportion to the rate at which gas is withdrawn. B: A nonliquefied gas such as oxygen will show a steady decline in pressure until the cylinder is evacuated. Each cylinder, however, will show a steady decline in weight as gas is discharged.

Each cylinder must pass an internal and external visual check for corrosion and evidence of physical impact or distortion. Cylinders are checked for leaks and retention of s tructural strength by testing to a minimum of 1.66 (1.50 in Canada) times their service pressures. The service pressure is the maximum pressure to which the cylinder may be filled at 70F. Table 1.3 gives the service pressures for gases commonly used in anesthesia. P.10

Filling
If a cylinder containing gas under a safe pressure at normal temperature is subjected to higher temperatures, the press ure may increase to a dangerous level (1). To prevent this, the DOT has drawn up regulations limiting the amount of gas a cylinder may contain.

The pressure in a filled cylinder at 70F may not exceed the service pressure marked on the cylinder except for some nonliquefied, nonflammable gases such as oxygen, helium,

carbon dioxideoxygen mixtures and helium-oxygen mixtures, which may be allowed an additional 10%.

For gases other than nitrous oxide and carbon dioxide, the pressure in the cylinder at 130F may not exceed 1.25 times the maximum permitted filling pressure at 70F.

As illustrated in Figure 1.10, in a cylinder containing a liquefied gas, the pressure will remain near ly constant as long as there is liquid in the cylinder. Thus, if only the pressure were limited, these cylinders could be filled with any amount of liquid. To prevent a cylinder containing a liquefied gas from being ov erfilled, the maximum amount of gas allo wed is defined by a filling density (filling or fill ratio) for each gas. The filling density is the percent ratio of the weight of gas in a cylinder to the weight of water that the cylinder would hold at 60 F (1). The filling densities of gases commonly used in anesthesia are shown in Table 1.4.

The filling density is not the same as the v olume of the full cylinder occ upied by the liquid p hase. For ex ample, in a full nitrous oxide cylinder, the liquid phase typically occupies 90% to 95% of cylinder volume, whereas the filling density is 68%.
TABLE 1.4 Medical Gases

Gas Oxygen

Formula O2

United States International Green White

State in Cylinder Gasa

Filling Density

Carbon dioxide

CO2

Grayb

Gray

Gas + Liquid (below 88F)

68%

Nitrous oxide

N2O

Blue

Blue

Gas + Liquid (below 98F)

68%

Helium

He

Brownc

Brown

Gas

Nitrogen

N2

Black

Black

Gas

Air

Yellowd

White & black

Gas

a b

Special containers for liquid oxygen are discussed later in this chapter. In carbon dioxideoxygen mixtures in which the CO2 is greater than 7%, the cylinder is predominantly gray and the balance is green. If the CO2 is less than 7%, the predominant color is green. c If helium is greater than 80% in a helium-oxygen mixture, the predominant color is brown and the balance is green. d Air, including oxygen-nitrogen mixtures containing 19.5%23.5% oxygen, is color coded yellow. Cylinders with nitrogen-oxygen mixtures other than those containing 19.5%23.5% oxygen are colored black and green.

Color
Accidental confusion of cylinders has been a signific ant cause of mortality. Color can be used to help identify gases. The color code used in the United States is shown in Table 1.4. The top and shoulder (the part sloping up to the neck) of each cylinder are painted the color assigned to the gas it contains or the entire cylinder may be covered by using a nonfading, durable, waterinsoluble paint. In the case of a cylinder containing more than one gas, the colors must be applied in a way that will permit each color to be seen when viewed from the top. In some countries, the body of the cylinder is painted with the color of the major gas and the shoulder the color of the minor gas (11). In this situation,

a 14% mixture of CO 2 in O 2 might look more like an oxygen cylinder than a CO 2 cylinder but would fit a CO 2 pin indexed yoke. Color coding is commonly used on valve protection caps, hoses, connectors, knobs, and gauges on medical equipment. An international color code (Table 1.4) has been adopted by several countries, including Canada (16). This system differs from the one used in the United States in that ox ygen's color is white and air is black and white rather than yello w. A number of countries besides the United States use a color code that differs from the international code (17). W hen people trained in one country work in another country that has a different color code, confusion frequently results. Color standardization is not applicable in areas where specialty gases, suc h as those used for calibration, are used (18). It is important that the label be read carefully when these gases are used. Because of variations in color to nes, chemical changes in paint pigments, lighting effects, and differences in color perception by personnel, color should be not be used as the primary means for identification of P.11

cylinder contents. Cylinder labels are the best method to identify cylinder contents. However, color is useful to identify the contents of a cylinder from a distance and for sorting purposes and provides a useful check on labeling accuracy.

Markings
DOT and TC regulations require specific markings on each cylinder (1,19). These are permanently stamped, usually onto the shoulder of the cylinder. The markings of a typical cylinder might be arranged as follo ws:

DOT-3A2015 8642 XYZ JCN

In this example, the DOT specification is 3A, the service pressure is 2015 psig at 70F, the serial number is 8642, the manufacturer is XYZ, and the owner's symbol is JCN. These same markings could be arranged in a horizontal line around the shoulder. The initial qualifying test date (month and year) with an identifying mark for the testing facility between the month and year is required. If a c ylinder has been retested, the retest date and testing facility must appear below the original qualifying date. A five-pointed star stamped after the most recent test date indicates that the cylinder may be retested every 10 instead of every 5 years. If a plus (+) sign appears immediately after the test date marking on a cylinder, it means that the cylinder is authorized to be charged up to 10% in excess of the marked service pressure. The word SPUN must be stamped on cylinders that have the bottom end closure produced by spinning or the

word PLUG when the bottom closure has been produced by spinning, drilling, and plugging.

Figure 1.11 Cylinder label, showing the basic CGA marking system. The diamond-shaped figure denotes the hazard class of the contained gas (NONFLAMMABLE). To the left is a white panel with the name of contained gas (NITROGEN). The signal word (CAUTION) is to the right, followed by a statement of hazards and measures to be taken to avoid injury.

Labeling
Each cylinder must bear a label or decal on the side or, when space permits, the shoulder of the cylinder (but it may not cover any permanent markings) (1). Figure 1.11 shows a typical cylinder label. It has a diamondshaped figure denoting the hazard class of the contained gas and

a white panel with the name of the contained gas to the left. The diamond indicates whether the contents contain an oxidizer, a nonflammable gas, or a flammable gas. A signal word (DANGER, W ARNING, or CAUT ION, depending on whether the release of gas would create an immediate, le ss than immediate, or no immediate hazard to health or property) is present. Following the signal word is the statement of hazard, which gives the dangers with cus tomary or reasonably anticipated handling or use of the gas. A brief precautionary statement giving measures to be taken to avoid injury or damage is usually present. The label should contain the name and address of the cylinder manufacturer or distributor and a statement about its content, usually the volume in liters at 70 F. Other information such as the cylinder weight when empty and full may also be present. The expiratory date for the c ontents may also be present. It should be possible to read the expiratory date while the cylinder is connected to the anesthesia machine (20). DOT regulations permit the use of a combination label-tag, one side of which contains the prescribed wording of the DOT label, while the other side is used as a shipping tag with space for the names and addresses P.12

of the shipper and consignee. Medical gas manufacturers usually use these on large cylinders, attached to the cylinder cap. The tag is perforated so that when the cylinder is empty, part of the tag may be torn off at the perforation, obliterating the label

wording. The part of the tag that remains attached to the cylinder contains the return address of the supplier.

Tags
A typical tag is sho wn in Figure 1.12. It has three sections labeled FULL, IN USE, and EMPTY connected by perforations. W hen a cylinder is put into s ervice, the FULL portion of the tag should be detached. W hen the c ylinder is empty, the IN USE portion should be removed, leaving the EMPTY label. The tag sometimes contains a washer (seal) that fits between the s mall cylinder valve and the yoke or regulator. Tags normally bear the same color as the c ylinder. The tag is primarily a means of denoting the amount of cylinder contents, not an identification device.

Rules for Safe Use of Cylinders

General

Cylinders should be handled only by personnel who have been trained in safe practices (21,22). Frequently, personnel involved in the transport, storage, and use of cylinders do not receive adequate instructions regarding their safe handling (23). Even those who do receive adequate training may become complacent.

Cylinder valves, pressure regulators, gauges, or fittings should never be permitted to come into contact with oils, greases, organic lubricants, rubber, or other combus tible substances. Cylinders or valves should not be handled with

hands, rags, or gloves contaminated with oil or grease. Polishing or cleaning agents should not be applied to the valve, as they may contain c ombustible c hemicals.

Figure 1.12 Cylinder tag. When the cylinder is first opened, the FULL portion of the tag should be removed. When the cylinder is empty, the IN USE portion should be removed.

No part of any cylinder should ever be subjected to a temperature above 54C (130F) or below -7C (20F) (22). A flame, torch, or sparks from any source should never be permitted to come in contact with any part of a cylinder. A cylinder should not be supported by or placed in proximity to a radiator, steam pipe, or heat d uct. If a cylinder is exposed

to a high temperature, it s hould be returned to the manufacturer for testing. Exposure to extremes of cold should also be avoided. If ice or snow accumulate on a cylinder, it should b e tha wed at room temperature or with water at a temperature not exceeding 54C (130F).

Connections to piping, pressure regulators, and other equipment should always be kept tight to prevent leaks. If a hose is used, it should be in good condition.

The discharge port of a pressure relief device or the valve outlet must not be obstructed.

Regulators, hoses, gauges, or other apparatus designed for use with one gas should nev er be used with cylinders containing other gases.

Adapters to change the outlet size of a cylinder valve should not be used, as this defeats the purpose of standardizing valve outlets.

The valve should be kept clos ed at all times except when the cylinder is in use. It should be turned OFF by using no more force than necessary to prevent damage to the seat.

The valve is the most easily damaged part of the cylinder. Valv e protection caps (metal caps that screw over the valve on large cylinders [Fig. 1.13]) protect the valve in case the cylinder topples over and should be kep t in place and hand tightened, except when the cylinder is connected for use.

No part of the cylinder or its valve should be tampered with, painted, altered, repaired, or modified by the user. Cylinders should be repainted only by the supplier.

Markings, labels, decals, or tags must not be defaced, altered, or removed.

A cylinder should not be us ed as a ro ller, support, or for any other purpose other than that for which it was intended, even if it is believed to be empty.

Care must be tak en to prev ent the cylinder from being damaged by an electric arc. This requires that cylinders not be placed or used in a manner where they can become part of an electrical circuit.

Cylinders should not be dropped, dragged, slid, or rolled, even for short distances. Cylinders should be P.13

transported by using a cart or carrier made especially for that purpose (Figs. 1.14, 1.15). They should not be moved or lifted by the valve or valve protection cap.

Figure 1.13 Large cylinder valve protection cap. This cap should be kept in place at all times, except when the cylinder is connected for use.

Cylinders should be proper ly secured at all times to prevent them from falling or being knocked over (Fig. 1.16). They should not be dropped or permitted to violently strike each other or other surfaces. They should not be chained to movable apparatus such as a bed.

Figure 1.14 This cart is designed to store and transport E cylinders in an upright position.

Figure 1.15 Special baskets on transport beds are available to hold the cylinder during transport.

Cylinders should never be used where they cou ld become contaminated by other gases or foreign material.

The owner of the cylinder must be notified if any damage that might impair its safety is noticed or if any condition that might permit a foreign substance to enter the cylinder or valve has occurred.

Disposition of unserviceable cylinders is potentially dangerous and should be done only by qualified personnel.

Storage

A definite area should be designated for storing cylinders. They should not be stored in an operating room. P.14

Figure 1.16 A: An unsafe practice. Cylinders should not be allowed to be upright and unsecured. B: If there is no means to secure a cylinder upright, it is safer to have it on its side. However, personnel may trip over it or damage it.

P.15

The storage area should be in a cool, clean area that is constructed of fire-resistant materials. Conductive flooring must be present where flammable gases are stored but is not required where only nonflammable gases are kept. Adequate ventilation should be provided so that if there is a leak in a cylinder, g as will not accumulate in the room. Easily visible signs with texts such as GAS CYLINDERS. REMOVE TO A SAFE PLACE IN THE EVENT OF FIRE and OFF LIMIT S TO UNAUTHORIZED PERSONNEL should be hung outside the storage area. Signs reading NO SMOKING, NO OPEN FLAMES OR SPARKS, NO OIL OR GREASE, and NO COMBUSTIBLE MAT ERIALS should be posted inside the room and on the door.

Cylinders may be stored in the open but should be protected against extremes of weather and from the ground beneath. During winter, stored cylinders must be protected from accumulations of ice and snow. T he temperature should not be allo wed to fall below 10C where Entonox cylinders are

stored. In summer, cylinders must be protected from continuous exposure to direct ra ys of the sun in localities where high temperatures prevail.

Cylinders should be stored in a secure area, with removal only by authorize d personnel. Cylinders in public areas should be protected from tampering.

Cylinders of nitrous oxide should be stored where the opportunity for theft and/or indiscriminate use is minimized. There should be a system for detecting unusually heavy use or loss of nitrous oxide. Thefts should be reported promptly to the police and the supplier.

Cylinders containing flammable gases should not be stored in an enclosure containing oxidizing gases (nitrous oxide, oxygen, or compressed air). Nonflammable (inert) medic al gases may be stored in the same enclosure as oxidizing gases.

Combustible materials should not be kept near cylinders containing oxygen or nitrous oxide. An exception to this may be made in the case of c ylinder shipping cartons or crates (5). Cylinder storage racks may be made of wood.

Sources of heat in storage locations must be protected or located so that cylinders are not heated to the point where integral safety devices are activated. In no case shall the temperature of the cylinder exceed 125F.

Smoking or open flames s hould be prohibited in storage areas.

Cylinders should not be exposed to continuous dampness, corrosive chemicals, or fumes, as these may damage the cylinders and/or cause valve protection caps to stick .

Cylinders should be protected from mechanical shock. They should not be stored where heavy mov ing objects may strike or fall on them.

Sma ll cylinders are best s tored upright or horizontally in bins or racks constructed of a nonflammable materia l that will not damage the cylinder surface when it is moved (Fig. 1.14). Large cylinders should be stored u pright against a wall and chained in place.

Wrappings should be removed from c ylinders before storage. Their presence in the storage area is undesirable because they are frequently dirty, provide a combustible medium, and conceal the cylinder labels.

A cylinder should not be draped with any material. A combustible mixture may accumulate under the drape, and its removal could cause a spark.

W hen different types of gases are stored in the same location, containers should be grouped by contents and sizes (if different sizes are present). Full cylinders should be stored so that they are used in the order they were receiv ed from the supplier. Empty cylinders should be marked as such and segregated from full cylinders to avoid confusion and delay.

There should be a system of inventory for both empty and fu ll cylinders.

Use

Before use, the contents of the cylinder shou ld be identified by reading the label (24,25,26). T he color of a cylinder should not be relied on for identification. If the label is missing, illegible, or altered or if the cylinder color and label do not correspond, the cylinder should be returned to the manufacturer unused. The user should read the precautionary information on the label and fo llow the recommendations.

Only cylinders with the letters DOT or ICC ( Interstate Commerce Commission) should be used. In Canada, equivalent cylinders are marked BTC (Board of Transport Commissioners) or CT C (Canadian Transport Commission). A cylinder that does not show evidence of inspection within the required period should not be used. The cylinder valve, especially the pressure relief device, outlet, and pin index holes, should be checked for defects. The va lve outlet should be clean and pin indexed or have a proper large valve outlet co nnection.

The release of high-pressure gas from a cylinder can be hazardous unless adequate means are provided for reducing the gas pressure to usable levels and for controlling the gas flo w. Accordingly, a pressure regulator should always be used when withdrawing the contents of a cylinder. For small cylinders attac hed to an anesthesia machine, the regulator

inside the mac hine performs this function. W hen con nected to P.16

a pipeline system, the regulator is part of that s ystem (Chapter 2).

Figure 1.17 Protective cover over small cylinder valve outlet.

Full cylinders are usually supplied with a tamper-evident seal (Fig. 1.17). The seal usually is shrink-wrapped around

the valve or is in the form of a tear off. This seal should be removed immediately before fitting the cylinder to the dispensing equipment.

The valve protection cap on large cylinders should be removed just before connecting the cylinder for use.

Before a regulator is connected to a cylinder, it should be inspected for signs of damage and to make certain that it is free of foreign materials. Regulators should be kept in good condition and stored in plastic bags to av oid contamination.

Before any fitting is applied to the cylinder valve, particles of dust, metal shavings, and other foreign matter should be cleared from the outlet by removing the protectiv e cap or seal and slo wly and briefly opening (cracking) the valve with the port pointed away from the user and any other persons (27). This reduces the possibility of a flash fire or explosion when the valve is later opened with the fittings in place; also, the dust will not be blown into the anesthesia machine or other equipment wher e it could clog filters or interfere with the internal workings.

A sealing washer (gasket) in good condition should always be used with a small cylinder valve. It fits over the port (Fig. 1.7). Only one washer should be used. If more than one washer is used, the pins on the yoke or regulator may not extend far enough to engage the mating holes, and the Pin Index Safety System may be bypassed or a leak may occur (28,29,30).

The threads on the regulator-to-cylinder valve connection and the pins on the yok e-to-cylinder valve connections should mate proper ly. Connectors that do not fit should never be forced.

Only wrenches or other tools provided or recommended by the manufacturer should be used to tigh ten outlets and connections. W renches with misaligned jaws should not be used because they may damage the equipment or slip and injure personnel. Excessive force should not be used. The handwheel should never be hammered in an attempt to open or close the valve.

The cylinder valv e should be opened before bringing the apparatus to the patient or the p atient to the apparatus. If a Bourdon gaugetype regulator (Chapter 5) is being used, the lo w-pressure adjustment screw on the regulator should be turned counterclockwise until it turns freely before the cylinder valve is opened. If the cylinder is attached to the yoke on an anesthesia machine or a regulator/flowmeter, the flo w control valve for that gas should be closed before the cylinder valve is opened.

The person opening a cylinder valve should be positioned so that the v alve outlet and/or the face of the pressure gauge points away from all persons. The P.17

user should stand to the side rather than in front or in back. Using goggles or a face mask is also recommended.

A cylinder valve should always be opened SLOW LY. If gas passes quickly into the s pace between the valve and the yoke or regulator, the rapid recompression in this space will generate large amounts of heat. Because there is little time for this heat to dissipate, this constitutes an adiabatic process (one in which heat is neither lost nor gained from the environment). Particles of dust, grease, and such in this space may be ignited by the heat, causing a flash fire or explosion. Opening the valve slowly prolongs the time of recompression and permits some of the heat to dissipate. The cylinder valv e should continue to be opened slowly until the pressure on the gauge stabilizes and then fully opened.

After the cylinder valve is opene d, the pressure should be checked. A cylinder with a pressur e sub stantially greater than the service pressure should not be used but instead should be marked as defective and returned to the supplier. A cylinder arriving with a pressure substantially below the service pressure should be check ed for leaks.

If a cylinder valve is open but no pressure is registered on the gauge or no gas flo ws, the cylinder valv e should be closed and the cylinder should be disconnected from the dispensing apparatus, marked defective, and returned to the supplier with a note indicating the problem.

If a hissing sound is heard when the valve is opened, this indicates that a large leak exists and the c onnection should be tightened. If the sound does not disappear, the sealing washer should be replaced (in the case of a small cylinder valve). Under no circumstances should more than one washer be us ed. If the hissing sound persists, soapy water, a commercial leak detection fluid, or other suitable solution should be applied to all parts. Bubbles will appear at the site(s) of the leak(s). A flame s hould never be used for this purpose. Should a leak be found in the cylinder valve itself, it may be possible to tighten the packing nut by turning it slightly in a c lockwise direction (see special handle in Fig. 1.4) unless the manufacturer recommends otherwis e. If the leak cannot be remedied by tightening connections without using excessive force, the valve should be closed, and the cylinder should be marked defective and returned to the supplier with a note indicating the fault.

Even if no hissing sound is audible when the valve is opened, a slo w leak may be present and should be suspected if there is loss of pressure when no gas is being used. These leaks should be located and corrected.

W hen in use, a cylinder must be secured to a cylinder stand or to apparatus of sufficient size to render the entire assembly stable.

Cylinders in service or storage at user locations must be secured to prevent falling.

The valve should always be fully open when a cylinder is in use. Marginal opening may result in failure to deliver adequate gas flo w.

After Use

At any time an extended period of nonuse is anticipated, the cylinder valve should be closed completely and all pressure vented (bled) from the system.

An empty or near-empty cylinder should not be left on an anesthesia machine. A defective check valv e in the yoke could result in accidental filling if the valve is left open. In addition, the presence of an empty cylinder may create a fa lse sense of security. A yoke should not remain empty after a cylinder is removed. If a full cylinder is not available, a yoke (blanking) plug (Chapter 5) should be in place. Some gas suppliers prefer that cylinders be returned with enough pressure (e.g., 25 psig) remaining to maintain the integrity of the cylinder.

Before removing a cylinder from a regulator or yoke, the valve should be closed and all downstream pressure released.

W hen a cylinder is empty, the lower part of the tag should be removed. A DOT green, yellow, or red label should be covered with an Empty label, or if the cylinder is provided with a combination label-tag, the lower portion should be removed.

Valv es should be completely closed on all empty cylinders. Often, cylinders are not completely empty, and accidents have resulted from release of gas from a supposedly empty cylinder. If the valve remains open on an empty cylinder, debris and contaminants could be sucked into it when the temperature changes.

W here provided, valve outlet caps or plugs should be securely affixe d to the valve outlet prior to transportation.

Transfilling
Transfilling should not be performed by unskilled, untrained persons (5). It is best performed by a gas manufacturer or distributor. If performed by a user, it should be in accordanc e with suggested procedures and not in a patient c are area. There are several hazards.

Transferring medical gas from one cylinder to another may adversely affect purity.

W hen a small cylinder is transfille d from a large cylinder containing gas at high pressure, rapid recompression of the gas in the small cylinder may cause the P.18

temperature to rise sufficiently to ignite combustible materials and oxidize metals.

The hazard of overfilling small cylinders is always present (31). Filling c apacities may vary for cylinders even though their sizes appear to be the same. Overfilling may result in damage to the cylinder or dispensing equipment.

Cylinders used for one gas may accidentally be charged with a gas other than that originally contained in the cylinder, resulting in a dangerous mixture (32,33). If an oxygen cylinder were filled with a gas other than oxygen, hypoxia would likely occur with use.

Safety relief devices and other parts must be inspected at frequent intervals to ensure safe operation and repairs and to ensure that replacements are made when defects are found. If transfilling is performed by users, this may not be done.

Hazards
Incorrect Cylinder
Despite a lmost universal use of the Pin Index Safety System and other s ystems to prevent an incorrect cylinder from being attached to an apparatus, reports of incorrect tanks being connected to yok es or regulators continue to appear (25,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50). Yokes or regulators may be incorrectly built or altered. Pins can be bent, broken, removed, or forced into the yoke or regulator; pin index holes may become worn; and more than one washer may be used. Some lasers hav e yokes that lack pins (39). In one

reported case, the index system had been altered to accept Entonox (a mixture of oxygen and nitrous oxide) (51). The hole for the pin had been drilled through the valve. W hen a nitrous oxide cylinder was put on the yoke and tightened, the pin was pushed through the hole, and an incorrect cylinder could have been attached.

Incorrect Contents
A cylinder may not contain the gas for which it is indexed and labeled (32,33,34,52,53,54,55). In a cylinder with a mixture, the gases may not be properly mixed (56).

Incorrect Valve
A cylinder may be correctly labele d for the gas contained but have a valve for another gas (52,57,58,59). This usually will prev ent its attachment to the correct dispensing apparatus. Industrial rather than medical gas cylinders are sometimes used to power surgical tools. These may have connections that fit equipment designed for other gases (60).

Incorrect Color
Cylinders may be painted with other than their standard color (57,61).

Incorrect Labeling
A cylinder with the correct color and valve may have an incorrect label (52,62).

Inoperable Valve

A cylinder may be delivered with an inoperable or blocked valv e (7,57,63,64).

Damaged Valve
If the retaining screw on the yoke is screwed into the safety relief device instead of the conical depression, the valve will be damaged. This may result in a leak of cylinder contents (9). A pressure relief device may prematurely release gas (65).

Asphyxia
Sudden discharge of large quantities of gas other than ox ygen from a c ylinder into a clos ed space could displace the air from that space, creating a dangerous condition. If an oxygen-deficient atmosphere is su spected, the space should be checked with an oxygen monitor. A number of deaths due to nitrous oxide inhalation have been reported (66,67).

Fires
If an oxidizing gas is present, fires are likely to oc cur if a source of ignition and flammable material(s) are also there. Both oxygen and nitrous oxide are oxidizing gases, a nd their presence should be considered a source of risk. Materials that burn in air will burn much more vigorously and at a higher temperature in oxygen at normal pressure and explosively in oxygen under pressure. Some materials that do not burn in air will burn in an oxygen-enriched atmosphere, particularly under pressure. Materials that can be ignited in air have lower ignition energies in oxygen.

Many materials may be ignited by friction at a v alve seat or stem packing or by adiabatic compression produced when gas at high pressure is rapidly introduced into a system initially at low pressure. If ox ygen equipment is contaminated with dirt, grease, oil, hand cream, paraffin, or other combustible substances, explosiv e rupture and burning of components may occur (27,68). Oxygen regulators and cylinders contaminated with oil have been sold (69,70,71). Fires have been reported when the incorrect gas was used to inflate the abdomen during laparoscopy (50,72,73). Chapter 32 discusses additional information on fires.

Explosion
A cylinder that has been incorrectly filled may exp lode if the valve does not have the proper pressure relief device (74). P.19

Projectile Damage
If a cylinder is improperly s ecured and falls over, the valve may break off. Because gas in cylinders is under pressure, rapid escape of cylinder contents can c ause the cylinder to s hoot like a rocket or to spin out of control (34,74,75,76,77). This could cause serious damage to equipment and personnel. Improper handling or storage of cylinders can cause them to fall over. If a va lve protection cap is not present, the valve cou ld snap off. If the packing nut rather than the stem is loosened, the

stem may be ejected when the v alve is opened. Cylinders with defective valves may be manufactured (78,79,80,81). If a steel cylinder is taken into the MRI environment, it can be drawn into the magnet (3). This will occur with such force that the magnet will be damaged or a patient or health care personnel in the room could be seriously injured or killed. Equipment for use in the MRI env ironment is discussed in Chapter 30.

Contaminated Cylinder Contents

Gases in cylinders ma y contain contaminants (57,81,82,83,84). Medical-grade oxygen is required to be 99% pure (81,85,86). Of the remaining 1% (10,000 ppm), not more than 300 ppm of carbon dioxide, 10 ppm of carbon monoxide, or 5 ppm of oxides of nitrogen can be present. No other contaminants are specifically excluded from the other 9,685 ppm. Thus, the possibility exists that oxygen or other gases may contain potentially dangerous amounts of other compounds and not be in violation of existing standards. An industrial-grade gas may not have the same requirements for purity as a medical- grade gas and may contain relatively large amounts of impurities (60). Accidental use of such gas could cause significant problems. Cases of poisoning due to contamination of nitrous oxide cylinders with higher oxides of nitrogen have been reported (82,87). A cylinder should not be us ed if the gas has an odor. The cylinder should be sequestered and the appropriate authorities contacted.

Moisture may contaminate a cylinder and flow into the dispensing equipment if the cylinder is inverted (83). Adiabatic gas expansion as gas is released causes cooling, and the moisture could form ice and jam the regulator or yoke. In the past, this has been a signific ant problem with nitrous oxide cylin ders.

Nitrous Oxide Theft

Nitrous oxide theft for substance abuse purposes can be a serious problem, and deaths have been reported (67,88,89).

Overfilled Cylinders
An ov erfilled cylinder may be delivered (52,57,90,91).

Thermal Injury
Frostbite injury from nitrous oxide has been reported in people who use the drug recreationally and in anesthesia providers and others who handle it occupationally (6,92,93,94,95).

Blocked Flowmeter
If a flo w-metering device that is integral with a cylinder does not have a continuous scale but has fixed flo w rates, then no ox ygen may be delivered between flo w rate settings (4).

Liquid Oxygen Containers

Sma ll, specially designed containers filled with liquid oxygen have become popular, especially for patient transfer. Another use is when anesthesia is administered outside a health care facility, such as by armed forces. Adv antages include low pressure, compactness, lo w weight, and simplicity.

Equipment
A stationary unit (reservoir, supply container) is kept in a suitable area and is refilled by the gas supplier as needed (Fig. 1.18). The smaller, portable (receiving) units are filled from the stationary unit. They are broader and shorter than cylinders. The portable unit has a means of regulating oxygen flow. The amount of gas contained can be determined by its weight. Each container must have a pressure relief device and a means to limit the amount of liquid oxygen contained. W hen not in use, the pressure in the container is controlled by venting excess gas to atmosphere. This limits the time that oxygen can be stored in the portable unit (96). Liquid gas containers are manufactured, maintained, filled, and transported in accordance with DOT regulations. Required markings include the specification number, service pressure for which the container is designed, an identifying mark of the original container owner, and a serial number. The date of original manufacture and a symbol identifying the inspector are also present. An international standard covers these devices (97).

Rules for Safe Use

If liquid oxygen is spilled, a considerable time must be allo wed for the oxygen to dissipate.

Contact between the skin and liquid oxygen must be avoided.

P.20

Figure 1.18 Liquid oxygen containers. Left: The stationary unit, which is refilled by the gas supplier as needed. Note the pressure relief valve at right front. Right: The portable unit is attached to the stationary unit for transfilling.

Liquid oxygen equipment must be kept clean of organic or combustible materials. These materials can react violently with liquid oxygen.

Cryogenic transfilling devices must be k ept free of moisture to prev ent accumulation of frost on valves or couplings that may caus e them to freeze open or shut.

Containers should not be subjected to extremes of heat or cold.

Containers should be handled in a manner to avoid physical damage.

Markings and lab els on containers must be legible and must not be altered.

Under no circumstances s hould any attempt be made to loosen, tighten, or otherwise tamper with the pressure relief device.

Storage

Both the statio nary and portable units should be kept in open, cool, well-ventilated areas. Containers should not be stored in a closed space such as a closet.

Liquid oxygen containers should be stored away from any heat source.

Containers should be protected from corrosive atmospheres. Containers should be stored in an upright position.

Transfilling
Liquid oxygen may be transferred by means of a cryogenic flexible hose assembly or the manufacturer's noninterchangeable direct connection. If a flexible hose assembly is used, its end

connectors must conform to CGA regulations (1) or the manufacturer's noninterchangeable connectors and must have a pressure relief device. Transfilling must be performed in a well-ventilated location that is remote from patient care areas, has no sources of ignition, and is posted with NO SMOKING signs.

Hazards
Fires
If liquid oxygen equipment becomes contaminated with hydrocarbons such as oil or grease or other combustible materials, ignition may occur. Vaporized spilled liquid oxygen will result in an oxygen-enriche d atmosphere, increasing the fire hazard. Fires are discussed in detail in Chapter 32.

High Pressure
The large volume of gaseous oxygen resulting from vaporization of liquid oxyge n has the potential, if trapped in a closed space that is not protected by adequate P.21

pressure relief devices, to generate pressures high enough to cause danger to life, limb, and property.

Burns
Contact with cold liquid or frosted valves or couplings may cau se cryogenic burns. Physical damage to or failure of liquid oxygen equipment can result in liquid spilling or spraying in an

uncontrolled manner (98,99). A pressure relief valve on a portable container may open prematurely and vent liquid oxygen during or immediately after filling ( 100).

Equipment Freezing
Valv es or couplings may freeze shut if they are not kept free of moisture.

Inaccurate Flows
One study showed that a high percentage of portable liquid oxygen devices had flows that differed substantially from those set (101).

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67. Garriott J, Petty CS. Death from inhalant abus e: toxicological and pathological evaluation of 34 cases. Clin Toxic 1980;16:305 315. 68. Anonymous. Medical gas cylinders. Technol Anesth 2005;25:11. 69. Anonymous. Medical gas cylinders. Technol Anesth 1985;6:17. 70. Anonymous. Oxygen regulators may be contaminated with oil. Biomed Safe Stand 1990;20:13. 71. Anonymous. Oxygen cylinders recalled because of oil contamination. Biomed Safe Stand 1991;21:20. 72. Anonymous. Use of wrong gas in laparoscopic insufflator causes fire. Technol Anesth 1995;15:3. 73. Greilich PE, Greilich NB, Froelich EG. Intraabdominal fire during laparoscopic cholecystectomy. Anesthesiology 1995;83:871874. 74. Tracey JA, Kennedy J, Magner J. Explosion of carbon dioxide cylinder. Anaesthesia 1984;39:938939. 75. Anonymous. Medical gas cylinders. Technol Anesth 1987;7:10. 76. Morse HN. Legal case: who is responsible for the oxygentank explosion?manufacturer or user. Med Elect Prod 1980:6. 77. Brooks JA. Oxygen tanks at home. Nursing 1982;12:1112. 78. Anonymous. Oxygen cylinder valves could break off. Biomed Safe Stand 1997;27:1213. 79. Anonymous. Oxygen cylinder valve stems subject to high velocity ejection. Biomed Safe Stand 1998;28:101

80. Anonymous. Medical gas cylinders. Technol Anesth 2001;21:8. 81. Bassell GM, Rose DM, Bruce DL. Purity of USP medical oxygen. Anesth Analg 1979;58:441442. 82. Clutton-Brock J. T wo cases of poiso ning by contamination of nitrous oxide with higher oxides of nitrogen during anaesthesia. Br J Anaesth 1967;39:388392. 83. Coveler LA, Lester RC. Contaminated oxygen cylinder. Anesth Analg 1989;69:674676. 84. Herlihy W J. Report: contamination of medical oxygen. Anaesth Intens Care 1973;1:240241. 85. Rendell-Baker L. Purity of oxygen, USP. Anesth Analg 1980;59:314315. 86. W right W W . USP oxygen standards. Anesth Analg 1980;59:314. 87. Barankey MA. Contaminated N 2 O is possible toxic etiology. APSF Newslett 1994;9:10. 88. Anonymous. Hospital staff death linked to NO 2 inhalation. Biomed Safe Stand 1993;23:145146. P.22

89. Anonymous. Editor's note. ASA Ne wslett 1993;57:38. 90. Meyer RM, Ferderbar PJ. Liquid full nitrous oxide cylinders. Anesthesiology 1993;78:584586. 91. Newstead J. Ov erfull nitrous oxide cylinders. Anaesth Intens Care 1991;19:473.

92. Svartling N, Ranta S, Vuola J, et al. Life-threatening airway obstruction from nitrous oxide in duced frostbite of the oral cavity. Anaesth Intens Care 1996;24:717720. 93. Hwang J, Himel H, Edlich R. Frostbite of the face after recreational misus e of nitrous oxide. Burns 1996;22:152153. 94. Rowbottom SJ. Nitrous oxide abuse. Anaesth Intens Care 1988;16:241242. 95. Craig D. Thermal injury by liquid nitrous oxide. Can Anesth Soc J 1982;29:181. 96. Ramage CMH, Kee SS, Bristow A. A new portable oxygen system using liquid oxygen. Anaesthesia 1991;46:39 5397. 97. International Standards Organization. Transportable liquid oxygen systems for medic al useparticular requirements (ISO 18777). Geneva, Switzerland: Author, 2005. 98. Anonymous. Frostbite hazard from liquid oxygen unit leak. Biomed Safe Stand 1992;22:134135. 99. Anonymous. Relief valve configuration on portable oxygen units could cause liquid O 2 leak and patient injuries. Biomed Safe Stand 1997;27:163. 100. Anonymous. Valves may open & release liquid oxygen. Biomed Safe Stand 1990;20:2021. 101. Massey LW , Hussey JD, Albert RK. Oxygen deliver y in s ome portable liquid oxygen devices. Am Rev Respir Dis 1988;137:204205. P.23

Questions
For the following questions, answer

if A, B, and C are correct if A and C are correct if B and D are correct if D is correct if A, B, C, and D are correct.

1. Liquefied compressed gases at room temperature include the following: A. Carbon dioxide B. Air C. Nitrous oxide D. Ox ygen View Answer2. A typical cylinder label includes A. A statement of hazard B. The name of the gas in the cylinder C. A signal word D. The manufacturer or distributor View Answer3. Adiabatic compression A. Refers to compression of a gas in a small s pace B. Occurs downstream of a re gulator C. Can cause a fire D. Occurs when a c ylinder valv e is opened slowly View Answer4. T he likelihood of a fire is reduced by the following measures:

A. Cracking the cylinder valve before use B. Opening the cylinder valve slowly C. Storing pressure regulators in plastic bags D. Keeping the cylinder draped during storage View Answer5. Hazards of transfilling the cylinder include the following: A. Flash fires B. Overfilling C. Contamination of gases D. Filling with the wrong gas View Answer6. T he filling density is A. The ratio of the weight of gas in a container to the weight of water that container would hold B. The percentage of a cylinder volume occupied by liquefied gas C. A means to limit the amount of a liquefied gas in a c ylinder D. Proportional to the density of the gas in the cylinder View Answer7. Cracking a cylinder valve A. Is momentarily opening it to blow away foreign matter from the outlet B. Should be performed before attachment of a dispensing device C. Reduces the likelihood of flash fires D. Refers to a fracture of the stem of the valve View Answer8. Noninterchangeable systems that prevent a large or small cylinder from being connected to the incorrect piping system include A. The Pin Index Safety System B. Manufacturer-specific quick-connect systems

C. Outlet v alves with special threaded c onnections D. The Diameter Index Safety System View AnswerFor the following questions, select the correct answer. 9. The gover nment agency responsible for regulating medical gas cylinders and containers in the United States is the A. Food and Drug Administration B. Department of Health and Human Services C. Department of the Interior D. Department of Transportation E. Department of Labor View Answer10. An E cylinder of oxygen contains approximately how many liters? A. 500 B. 650 C. 750 D. 900 E. 1200 View Answer11. All of the following are required permanent makings on a cylinder except A. The service pressure B. The serial number C. The name of the contained gas D. The test date E. The symbol of the producer, user, or manufacturer View Answer12. The best means for identifying the contents of a cylinder is the

A. Color B. Label C. Tag D. Markings on the cylinder shoulder E. Pin index holes View Answer13. The cylinder siz e most commonly used on anesthesia machines and for patient transport is A. Size A B. Size B C. Size C D. Size D E. Size E View AnswerP.24

14. If an empt y oxygen cylinder is found on an anesthesia machine, the best action to take is to A. Remove the empty cylinder and leave the yoke empty B. Remove the cylinder and replace it with a yoke plug C. Mark the cylinder empty and leav e it in place D. Remove the empty c ylinder and replace it with a full cylinder E. Open the adjacent cylinder valve fully View Answer15. 1 kPa is approximately equivalent to A. 10 cm H 2 O B. 14.7 psi C. 0.76 mm Hg D. 100 mbar

E. 1.47 psi View Answer

Chapter 2 Medical Gas Pipeline Systems

P .26

Hea lth care f ac il iti es use pipeline sys tems to deliv er nonf lammable gases such as ox ygen , ni trous ox ide, ai r, c arbon diox ide, and ni trogen to anes theti zing locati ons and o the r patient ca re areas . Central pipin g s ys tems are ins talled by mec hanical contrac tors and are ma in taine d b y the en gin eerin g o r maintenanc e departme nt of the heal th c are fac il ity, usuall y with li ttl e i np ut f rom anes th esia prov iders . This not only neglec ts a po te nti al ly v aluabl e con tributi on bu t also le av es thos e wh o use the gases uninf ormed as to ho w the s ys tems work . Becaus e the s ys tems are mostly o ut of s ig ht and as a rule f unc tion wel l , they of ten do no t attrac t a ttenti on until a problem occ urs . A s urv ey by the Anes thesi a P a ti ent S afety Founda tion (A PS F) determined that there is a s ignifican t kno wle dge def ici t among anes thes ia prac ti ti oners related to the pipe line s ys te ms (1). W hen a new f ac ili ty or add ition is being plan ned, anes thesia pers onnel s hould play a k ey role in des igning the piping sys tems . Their input is impo rtant to help pro perly s ize the s ys tems and to locate outlets (incl uding those i n remote parts of the fac i lity whe re pati ents are taken f or diagnos tic s tudies or v arious types of the rap y). Careful planning may av oid expens iv e and inc onv enient al terati ons at a later da te.

Standards and Sources of Information

The Na tional Fi re P ro tec tion As sociation (NFPA ), the Compress ed Gas Ass oc iation (CGA ), the Canadian S ta ndards Ass oci ation (CSA ), and the In ternational S tandards Organi zation (IS O) hav e publ ished nu merous doc uments related to p iping s ys tems (2,3 ,4,5,6). Many of thei r prov is ions a re incorporated in to law. Th ere are also many s tate and local c odes that supe rse de th ese s tandards . Comp lianc e wi th these s tandards is one of th e bases f or ac c redi tati on by the Joint Commissi on on the Acc reditation of Heal thcare Orga ni zatio ns (J CAHO). T hese organ iz ations d o not approv e, inspec t, or c ertify any ins tal lations, proce dures , equi pment, or materia ls . In mos t cases , c ompl iance wi th s tandards is the respons ibili ty of the indiv idual gas suppl ie r and fac i li ty. A l though mos t medical gas pipel ine s ys tems in the Un ited S tates and Canada are d esigned to conform to NFPA recommendations , failure to adhere to exis tin g regu la tions is wid espread (7).

Components
A medical gas dis tri bution s ys tem incl udes a c entral s uppl y, pip ing ex tendi ng to l ocations whe re the gas may be requi red, an d termina l uni ts a t eac h use poi nt. Hos es th at ex tend f rom termi na l uni ts to the a nes thes ia mac hine or other equipment, al though no t part of the piped sy s tem, are inc luded here because they are impo rtant to anes thes ia.

Supply Sources
A central su ppl y sys tem may be located outdoors (with th e c ontrol panel protec ted f rom the weather) in an enclosure used o nly f or this purpose or in a ro om o r enclosure withi n a buil di ng. Access to the cen tral su pply area should be res tric ted to indiv iduals fami li ar wi th and res pons ib le for the sys tem. A common type of centra l sup pl y f or a sma ll f ac ility is s hown i n Figure 2.1. T wo c ylinde r bank s (un its ) are presen t (Fi g. 2 .2 ). E ach bank mus t c on ta in at l eas t an av erage day's s uppl y with a minimum of two c yl inders . Larger amounts may be necess ary in areas re mote f ro m suppl ie rs . The cyl inders are c onnec ted to a co mmon ma nifol d (heade r) that c onv e rts the m i nto one con ti nuo us s upp ly . A chec k (nonreturn ) v alv e is p laced betwee n each cy linde r lead and the head er to p rev ent l oss of gas from the man ifolded cy linde rs if th ere is a leak in an i ndiv idua l cyl inder or l ead . The prima ry (duty, running) supp ly i s the po rtion supplying the s ys te m at any ti me, whi le the other b ank is the sec ond ary (s tandby) su ppl y. W hen the primary suppl y is un able to suppl y the sys tem, the seco ndary supply a utomatic all y bec omes the pri mary s upp ly . A res erv e supply is of ten added, as shown i n Figure 2 .3. The reserv e is used for emergenc ies or when ma intenanc e or repa ir i s needed. The reserv e sys tem s ize depends on the rate at whic h gas is used . A p rec aution a gains t gas s uppl y dis ruption is to place the rese rv e s uppl y in a different a rea f rom the pri mary and secondary s uppl ies and for the res erv e s upp ly to ente r th e fac il ity by a different route (8,9,10). Furthe r saf ety may be achiev ed by separa ting the primary and secondary s uppl ies so th at the sec ondary supply c an be acc ess ed if the prima ry suppl y fai ls (10 ). A pressu re-re duc ing (operatin g) regul ator is i ns tal led in the main s uppl y l ine ups tream of the press ure relief v alv e. The pre ssures at whic h gases a re piped v ary , dependi ng on the c ountry. In the United S tates , gases other tha n n itrogen and i ns trume nt P .27

ai r are normall y piped at 345 to 38 0 k Pa (50 to 55 psi ). Nitro gen and ins trument ai r are us ua ll y del iv ered at 1100 kPa (1 60 ps i ). The NFPA now permits press ures up to 2068 kP a (3 00 ps i ) (2 ). A l l final l in e regula tors mus t be duplexed with sui ta ble v alv ing to permit s erv ic e without c ompletel y shutti ng do wn the pi ped gas sys tem.

Figure 2.1 Cylinder supply system without reserve supply. This is known as an alternating supply system. The manual shutoff valves permit isolation of either bank of cylinders. Fluctuations in the distribution pressure can be decreased by reducing the pressure in two stages, so a pressure regulator is installed in the outgoing pipe. A manual shutoff valve must be located upstream of and a shutoff or check valve downstream of each pressure regulator. This makes it possible to service the regulator without shutting down the entire system. (Redrawn from a figure in

National Fire Protection Association. Standard for health care facilities [NFPA 99]. Quincy, MA: Author, 2005 .)

Oxygen
Ox ygen may be s tored ei the r as a c ryoge nic l i quid at l ow p res sures or as co mp res sed gas in c y linde rs .

Gaseous Supply
Ox ygen may be suppl ie d f rom c ompressed g as cyl inders (usuall y G and H c ylinde rs ) (Cha pte r 1) that are trans porte d b etwe en the d is trib uto r and the c entral suppl y are a o r from c yl in ders tha t are fixed at the s i te and ref ill ed by the dis tributor.

Liquid Supply
W hen large amounts of oxygen a re requi re d, i t is l es s expens iv e and more conv enient to s tore it as a l iquid. Mos t frequ ently , liquid ox ygen c ontainers a re refil led f rom suppl y truck s without in terrupting se rv ice . A l ternativ el y, f ill ed li qu id containers may be transpo rted between the sup plier a nd th e fac il ity. Liquid ox ygen c onta in ers are ins ta lled at g round lev el s o tha t they are readi l y ac cess ib le to s upp ly truc ks (F ig. 2.4 ). The containers should be loca ted wh ere ex posu re to potenti al ignition sourc es is min imal . NFP A P .28 s tandards spec if y how fa r th e c ontai ner mus t be from s idewal ks , parked v ehic les , and o the r objec ts .

Figure 2.2 Cylinder supply system. This shows both the primary and secondary supplies with switching mechanism. Note the header and cylinder leads.
To prev ent the liquid from ev apora ting, i t mus t be kept at o r bel ow its boi ling po int (-29 7F) b y keeping i t in spec ia l insulated ves sels . These c onta iners v a ry in s ize and s hape . They a re c ons truc ted l ike Thermos bottles wi th oute r and inner me tal j ack ets s eparated by ins ul ation a nd a layer that is near v acu um to re tard heat transfe r from the ex te rior. Eac h contain er sh ould hav e a con tents indica tor and lo w l iquid lev el alarm. Gaseous ox ygen is d rawn off as required and passed through a heate r to bring i t up to ambi ent tempe rature and ra is e i ts p res sure. A l though the tank is we ll i ns ula ted , a smal l amou nt of heat wi l l be con tinuous ly absorbed from the s urroun dings , c aus ing the l iqu efi ed gas to ev aporate. The amou nt of this unc ontrol led ev aporation is normall y l ess than the demand f or the piped s ys tem. If there is no fl ow from the c ontainer to the pipel ine s ys tem, the press ure in the c ontai ner wi ll s lowl y i nc rease until the s afe ty relief v alv e ope ns and ox ygen is v ented to atmosphe re. If a l iquid s ys tem is left s tanding unused for a long period of time, a s ignificant amoun t of ox ygen wi l l be los t. Usi ng li qu id containers is ec onomical onl y when there is a fairly c ons tant demand . Hav ing the proper s iz e container wi ll mi ni miz e ox ygen loss from v enting. Mos t of the time, the oxy gen is kept c ol d b y the latent heat of v apo ri zation as gaseous ox yg en is remov ed and the tempe rature falls . As the temp era ture fa lls, the press ure wi th in the tank also falls . To mai ntain pressure, l iquid oxygen mus t b e

remov ed f rom the tank and passed through a v apori ze r (ev aporator, v apori zing co lumn , gas if ie r), whi ch suppl ies heat. This consis ts of a c oil, tube , or mes h tha t is heate d b y us ing el ec trici ty o r hot wa ter.

Oxygen Concentrator
A third poss ible oxy gen s ourc e to feed the ox yg en pipel ine is a s upp ly s ys tem with ox ygen c once ntrators (11). These are d is cuss ed in Ch apter 9. A n international s tandard c ov ering these s ys tems has been publis hed (12).

Nitrous Oxide
Mos t fac il i ties us e manif ol ded c y linders to supp ly ni trous oxi de to the pi peline s ys tem. One probl em with nitrous ox ide c y linders is th at th e regula tor ma y beco me so co ld that i t f ree zes . Nitrous ox ide may also be s tored as a liqu id at low press ure i n s pec ial insulated v ess els simi lar to thos e us ed for ox ygen . W arnin g sig ns should be p os ted around areas wh ere ni trous oxide tanks are l ocated to c aution tha t ni trous ox id e is an asphyx ian t and that if there is a leak , a hypoxic mix tu re may be produced.

Medical Air
Medical ai r (a ir f or breathing) is def ined by the NFPA as ai r, rega rdles s of its sourc e, that mee ts U.S . P ha rmac opoe ia (USP ) quali ty s tandards . A ir may b e suppl ie d f rom man ifolded cy linde rs , a p roporti oning dev ic e that P .29 mixes gas f rom ox ygen a nd ni trogen c ylind ers , or motor-driv en comp res sors .

Figure 2.3 Cryogenic oxygen supply system with reserve supply. A liquid oxygen container serves as the operating supply with cylinders in the reserve supply. Operation of the reserve should activate the reserve-in-use alarm. This is known as a continuous-type system because under normal operating conditions, one primary source (which is refilled periodically) always supplies the system. (Redrawn from a figure in National Fire Protection Association. Standard for health care facilities [NFPA 99]. Quincy, MA: Author, 2005 .)
The v ast majority of p ipe d a ir s ys tems employ two or more c ompress ors that operate al te rna tel y or s imul taneousl y, depending on demand . A typ ica l sys tem is shown in Figure 2.5. Mos t components mus t b e dupl exed a nd equipped with ups tream and do wns tre am s hutoff v alv es that allow both is olation and c ontinued s ys tem operation if a component fai ls .

Eac h compress or takes in ambient a ir, c omp res ses i t to abov e the work in g press ure , and suppl ies it to one or more receiv ers (ac cumulators , reserv oir tank s , s torage receiv ers , rese rv oirs , holdin g tanks, rece iv er tanks ) from whic h a ir c an be wi th dra wn a s needed. The rece iv er mus t be equipped with a p res sure rel ief v alv e, automatic dra in, s ight glas s to permit v isual chec king that the dra ins are ope rating properl y, an d a pres sure gauge . The intake loca tion is important to ensure th at the ai r wil l be as f ree of contamina nts as poss ible. It s hould be located where it wil l take in a ir that is , as much as p oss ible, f ree of di rt, f umes , and odo rs . The in tak e is us ual ly l oca ted outside bu t may be wi thi n the buildi ng if a source that is equal to o r bette r th an outside ai r is av ai lable. It sho ul d not be c los e to or do wn wi nd of v acuum or other ex haus ts , loading doc ks , o r other s ourc es of polluted ai r. Ambien t ai r taken f rom a l ocation free from exhaus ts or other s ourc es of pollu ti on is normall y wel l wi thi n the l imi ts requ ired fo r compress ed ai r by the USP and NFPA fo r medical air (13). P .30

Figure 2.4 Liquid oxygen storage tank. Behind the large tank is a smaller liquid oxygen tank. To the left of this are two vaporizers.
The air at the intake should be chec ked pe riodical l y. A i r qua li ty v aries and may ex ceed the con taminant l imi ts of USP a ir f or unacc eptabl y long periods (13 ). There

are cases where an intak e became impro perly l oca ted as the env ironment around the in tak e c hanged due to c hanges i n the fac ili ty (14). To render the ai r su itable fo r medical use, its wate r con ten t mus t be reduced . An af te rco ol er in wh ic h the ai r is cooled an d the c ondensed moisture remov ed is us ual ly ins tal led downs tream of each c ompres sor. More wa ter ma y c ondense i n the receiv er. Additional wate r may be re mov ed by running the ai r th rough a dry er. A i r down s tream of the dryers and ups tream of the pi pi ng s ys tem mus t be moni to red for carbon monoxi de and de w p oin t and , with c erta in types of c omp res sors , for gaseous a nd liquid hy drocarbons . Valv es, press ure regul ators , and ala rms ana logous to those in ox ygen s uppl y s ys tems are needed . The reserv e s uppl y ma y be manifolded c yl inders o r a sepa rate co mp res sor s ys tem.

Instrument Air
A pipel in e s ys tem tha t us es air for p owering s urg ic al tools and other equipment may be prov ide d. The ai r prov ided b y this sys tem does not h av e to meet the requi rements for medic al ai r. It is piped at higher p res sure than medic al ai r.

Nitrogen
Cen tral ni trogen supp lies may i nclude high -press ure c yl inders o r c ry ogenic l iquid containers .

Carbon Dioxide
Carbon di ox ide is being pi ped more frequently becaus e i t is used f or lapa ros cop ic su rge ry. The sou rce is high-pressure c yl inders .

Nitric Oxide
A pipel in e i ns tall ation for ni tric oxide has be en des c ri bed (15). This gas is usu all y suppl ie d i n cyl inders connec ted to the dispens ing dev ice.

Piped Distribution System

The re are three genera l cl ass es of piping:

Mai n lines P ipes connec tin g the s ourc e to ri se rs or b ranch lines o r both. RisersVertical pipes c onnec ting the ma in l ine wi th b ranch lines on v arious l ev els of the fac i li ty. B ranch (la teral ) l ines The sec tions of th e p ip ing s ys tem tha t serv ice a room or g rou p of rooms on the s ame lev el of the fac il ity.

P iped sys tem layouts v ary c ons ide rably . A typ ica l piped sys tem is sho wn in Fi gure 2.6. P ipes a re made of copper. Ge neral ly, ox ygen is ins tal led in 1/2-inch outer diameter (OD) and other gases in 3/8-inc h OD pipes . P ipes mus t be identif ied at l eas t ev ery 20 fe et an d a t leas t once in ev ery roo m and s tory trav ers ed by th e piping s ys te m to ensu re that those ins tall ing and ma in taining the pipeline a re aware of i ts content. The n ame and pressu re of the gas ins ide the pipe and i ts f lo w di rec tion mus t be dis pl ay ed. Fl exible hos es are res tric ted to expos ed areas where they can be inspec ted and mai ntained. T hey cannot p enetra te or be c onc eal ed in wa lls , f lo ors , cei lings , o r partitions (2 ).

Pressure Relief Valves

Eac h centra l suppl y s ys tem mus t h av e a pressu re re li ef v alv e set a t 50% abov e normal l ine pressu re down s tream of the l in e regu la tor(s ) and ups tream of a ny shutoff v alv e. Th is rel ief v alv e prev en ts press ure buildu p i f a shutoff v alv e is c los ed. Th e v alv e should c los e automatic ally when the exc ess pres sure h as been reliev ed.

Shutoff Valves
Shu toff (ON-OFF , is olating, sec tion, z one) v alv es pe rmi t s pecific areas of the piping s ys te m to be iso la ted i n the ev ent of a pro bl em as well as fo r main ten anc e, repai r, tes ting, or expans ion wi th out the whole s ys te m be ing P .31 turned OFF. Th ere are two types of shu toff v alv es: Manual and serv ic e. Ma nual shutoff v alv es mus t be ins talled whe re they are v is ible and acces sible a t al l times . Serv ic e shuto ff v alv es are des igned to be us ed onl y by authorized person nel . They are in lock ed c ases or hav e the ir handl es secured and tagged to prev ent acc idental c los ing .

Figure 2.5 Central supply for medical air. The filter/muffler on the inlet side of each compressor removes large particles from aspirated air. Each compressor is provided with an isolation (shutoff) valve and has a pressure relief valve and a check (one-way) valve in its outlet line. Receivers are sized according to the capacity of the compressors. Final line filters trap particulate, oil, and odors introduced by the system. In environments with high concentrations of carbon monoxide, special scrubbers may be used to remove this or other pollutants. Dryers may be of desiccant or refrigerant type. (Redrawn from a figure in National Fire Protection Association. Standard for health care facilities [NFPA 99]. Quincy, MA: Author, 2005 .)
Manu al sh utoff v alv es are ins talled i n boxes wi th f rangible or remov able wi ndo ws (Fig . 2.7A ). A quarter-turn v alv e wi th an i ndi cating handle has b ecome s tand ard (Fig . 2.7B ). Each v alv e s hould be marked to i ndica te i ts f unc tion, gas , a nd area control led as wel l as a c aution that i t should be c los ed only in an emergency . A shutoff v alv e is requi red a t the outlet f rom the supply s ourc e. This allows the enti re su pply s ourc e to be isola ted .

The main suppl y l ine mus t b e equi ppe d wi th a man ual s hutoff v alv e near the entry i nto the building unless the sou rce s hutoff valv e is accessi bl e f rom wi thin the building. It shoul d be at a locatio n well known a nd readily ac cess ib le to those respons ible f or ma intaining the s ys tem but wh ere any attempt to ta mper wi th i t wou ld be no ticed . Eac h riser mus t be equ ipped wi th a manua l shu toff v alv e adj acen t to the c onnec tion to the main supply l ine. Eac h bra nch (lateral ) li ne ex cept those li nes s uppl ying P .32

P .33 anes thetiz ing loc ations and oth er v i tal lif e support and c ritical a reas (s uch as pos tanes thesia c are , in tensiv e care, and c oronary care uni ts ) mus t hav e a serv ice shutoff v alv e where the latera l branch es off the ris er. A manual s hutof f v alv e is requi red immediatel y outsi de eac h v ital l ife support or c ri tic al care are a and must be readil y accessible in an emergenc y.

Figure 2.6 Typical medical gas piped distribution system. The main line runs on the same level as the central supply and connects it to risers or branch lines or both. In anesthetizing locations,

individual room shutoff valves are located downstream of the area alarm. Other locations have a single shutoff valve for the entire area with the area alarm actuator downstream from the shutoff valve. The master alarm is activated by a 20% increase or decrease in the main line pressure. Area alarms must be installed in branch lines leading to intensive care units, postanesthesia care units, and anesthetizing locations to signal if the pressure increases or decreases 20% from normal operating pressure. (Redrawn from a figure in National Fire Protection Association. Standard for health care facilities [NFPA 99]. Quincy, MA: Author, 2005 .)

Figure 2.7 A: Box with shutoff valves. The window can be easily removed by pulling the ring in the center. Note that the operating room controlled by the shutoff valves is identified. B: Box with cover removed. To close a valve, the handle is pulled a quarter turn. Note that the pipe is labeled to show the gases contained. The front cover cannot be installed if a valve is closed.
A separate manu al s hutoff v alv e is requi red for each anes thetiz ing loc ation so that shutti ng off the gas supply to one l ocation wil l no t affec t other l oca tions . Shutoff v alv es should be loca ted wh ere they wi ll be readi ly ac cess ible to those who need to us e them i n an emerg ency and where access is unlik ely to be obs truc ted. Th e mos t co mmon l oc ati on is outs ide the anes thetizing location s o tha t in an e me rgenc y , people ins ide the room c an exi t and then s hut off g as supp lies to the room. A fac i li ty is no t precl uded f rom ins tal ling a shu toff v alv e ins ide a n anes theti zing l ocation, a lthough addi tional alarms would be req uired. Any person us ing p ip ed gases should k now not onl y where s hutoff valv es a re located but exac tl y what the y

control . The J CA HO has emphasized that sh utoff v alv es are to be properl y labeled and that personnel mus t k now thei r loc ations .

Emergency Oxygen Supply Connector

W hen the cen tral ox ygen s uppl y is loc ate d o uts id e the bu ilding it serv es an d there i s not a connec ted ox ygen rese rv e s uff ici ent f or an av erage day 's s uppl y insi de the building, a f itting for c onnec ting a tempora ry auxi li ary s uppl y s ourc e for eme rgenc y or maintenance s i tuatio ns is requi red (2). The i nl et mus t be located on the building's ex terior and be protec ted from tampe ring and un authorized acc ess . The pipe f rom th is f itting attaches to th e main su pply line i mmedi ate ly do wns tream of the main l ine s hutof f v alv e (Fig. 2.6). The inle t should b e l oc ated where a suppl y v ehic le wi l l hav e y ear-round acces s . In-bui lding eme rgenc y reserv es may be used i n p lace of the emergenc y ox ygen sup ply c onnec tor.

Alarms
Alarm Types Master Alarm System
A mas ter alarm s ys tem monitors th e c entral supply and the dis tri bu tion s ys te m for al l medic al gas s ys tems . To e nsure con tinuo us res pons ible obs erv atio n, mas ter s igna l panels mus t be loca ted in two se parate loc a ti ons , wi red in parall el to a s ingle sensor f or each condi ti on. On e panel should be i n the princ ipal work ing a rea of the department res pons ible for maintainin g the s ys tem and one or more pane ls l ocated to assu re c on tinuous surv ei l lance duri ng all work ing hours (e.g., telephone s wi tchboard , sec uri ty off ice, or other con tinuousl y s taffed loc ati on) (2). A central ized compute r s ys tem may be subs tituted fo r one of the mas ter a larms .

Area Alarm Systems

Critic al l ife support areas suc h as operating room sui tes , p ostanes thesi a care uni ts , i nte nsiv e ca re uni ts , co ronary c are un its , and the l ik e mus t hav e an area (l oca l) alarm s ys tem to indicate i f the pressu re inc reas es or dec reases 20 % f rom normal l ine p res sure. In anes the ti zi ng locations , the al arm wi ll be ups tream of the s hutoff v alv es to the indiv idual rooms . In other a reas , i t wi ll be placed downs tream of the shutoff v alv e for the area. A rea a larms are s ometimes p lac ed in each anes thetizi ng l ocation. An app rop ri atel y lab ele d warn ing s ignal panel for area alarms mus t be ins tal led a t the nurses ' s tati on or o ther s ui table loc ation that wil l prov ide respo nsi bl e

su rv eil lance (Fig . 2.8). Many area alarms also so und at the mas ter a la rm panel . The alarm c omponents shou ld be mon itored dai ly and the tes t b utton ex erc is ed monthl y (16). P .34

Figure 2.8 Part of area (local) alarm panel. The gas pressure is monitored and a warning provided if the pressure increases or decreases from the normal operating pressure. A button for testing the alarm is provided. Area alarm systems are provided for anesthetizing locations and other vital life support areas such as the postanesthesia care, intensive care, and coronary care units.

Local Alarms
Local alarms are i ns tall ed to moni tor the func tion of the c entral medical and i ns trume nt ai r s ys tems as wel l as the v acuum and anes thetic gas s cav engi ng s ys tems . Th e s ig nals may be located on or in the c ontrol pane l of the mach ine ry being mon itored, wi th in a moni tori ng dev ic e, or on a s eparate ala rm panel. T he mas ter a larm sys tem mus t inc lude at leas t one signal from each sourc e equipmen t l ocation to indicate a problem.

Alarm Conditions and Responses General Requirements

Eac h a la rm mus t be labe led f or the gas and area mo nitored. S ign als s hould be both audible an d v is ual . Some s ystems allow the audible s ignal to be audio paused (temporari ly s i lenc ed). The v isual s ignal s ho uld c ontinue until the problem is co rrec ted. E ach panel should c ontain a mechan is m to tes t th e a larms . A larms shoul d be des igned to f unc tion during e lec tric al po wer f ailure. Cl ear, c oncis e ins truc tions should be giv en to the pers ons moni toring the alarms to ensure that s ignals are repo rted promptl y to the prope r parties . Cases hav e been reporte d i n which an employee did n ot know wh at to d o when an alarm so unde d (7). An ac tiv ated s ignal s hould be repo rted immedia tely to the department res pons ib le for ope rati ng and mai ntain ing the pi ping s yste m. The ac ti on to be taken wi l l depend on the in div idual a rrangements for e ach fac ili ty. These sho ul d be reco rde d in a procedure ma nual , that is rev ie wed periodical ly , and ne w e mp lo yees s hould be giv en c lea r ins truc tions regarding nec ess ary ac tions . It is important to update alarms wh en source equip ment is upda ted o r rep laced (17).

Alarm Conditions
An al arm should s ignal (a) wh en the main supply reac hes an av erage day 's s uppl y, (b) when the reserv e s upply o r in -building emergenc y res erv e begins to s upp ly the s ys tem, (c ) when the res erv e s upp ly is reduced to one av erage day's s uppl y, (d) whe n the press ure in the rese rv e s uppl y is b elo w that required to func tion properl y, (e) when the sec onda ry su pply beco mes th e p ri mary s uppl y, (f) when the pressure i n the mai n line i nc reas es or dec reases f rom no rmal o perating pres sure, or (g) whe n the dew po int has been exce eded in the medic al ai r or i ns trument c entra l suppl y s ys tem. In the c entra l medical air supply s ys tem, there mus t be l ocal ala rms that indica te c omp res sor ma lfunc ti on and when the ca rbon monoxide l ev el exc eeds 10 pp m.

Pressure Gauges
A pressu re gauge mus t be ins tal led down s tream of each press ure regul ator. It i s i mportan t th at the gauge be o n the do wns tre am s ide of a zone v alv e s o tha t when the v alv e is c losed, this wi ll be ind ic ated b y the pres sure gauge (17). P ipel in e press ure gauges a re presen t on al l anesthes ia machines . Th is allows th e anes thes ia prov ider to k eep a c ontinual c heck on pi pe li ne press ure in tha t location.

If a signi fican t dec rease or inc reas e i n pressu re oc curs , the anes thes ia prov ider shoul d notif y the p rop er personnel a nd cons ider us ing gas from the c ylinde rs on the machine.

Terminal Units
The termina l uni t (s ta tion outlet, ju nc tional poin t, interfac e, pi peli ne outle t, e nd use terminal , s e rv ice outlet, terminal outlet, ou tlet poin t, outlet s ta ti on, o utl et asse mbly , wal l ou tlet) is the poi nt in a pi ped gas dis tribu ti on s ys tem at whic h the us er normal ly makes connec ti ons an d d is conn ec tions . E quipment ma y be c onnec ted to a terminal uni t ei ther di rec tl y or by a f lex ible h ose. P .35

Components Base Block

The base block is the part of a terminal u nit tha t is attac hed to the pipeline dis tributi on s ys tem.

Primary Valve
The primary v alv e (au tomatic shutoff v alv e; te rminal unit v alv e or c heck v alv e; terminal v alv e; s elf-sea ling v alv e, dev ic e, or u nit; prima ry check v alv e) ope ns and al lows the g as to f lo w wh en the male probe is i ns erted and c los es automatical ly whe n the co nnec tion is b rok en. This s erv es to prev ent gas l os s when the remov abl e co mponen t is d is conn ected. A l thoug h often call ed a c hec k valve, it is not a unidi rec tional v alv e and when op en wil l permi t f low i n either direc tion. In some terminal uni ts , the fac e p late and pri ma ry va lv e a re an integral uni t.

Secondary Valve
The s ec ondary v alv e (s hutoff v alv e, terminal s top v alv e, maintenanc e v alv e, automatic serv ice v alv e, is ola ti ng v alv e, sec onda ry v alv e, s econd ary s hutoff v alv e, secondary c heck v alv e) is des igned so that when the primary v alv e is remov ed (e.g ., for c leaning or serv ic ing), the gas flow i s shut off . W hen the primary v alv e is i n p lace, the s ec ond ary v alv e s ta ys open. W ith hos e booms and pendan ts i ncorporating hoses , the secondary v alv e is fi tted at o r nea r the end of the permane nt pipework .

Gas-specific Connection Point (Socket Assembly)

The rece pto r fo r a n oninterc hangeabl e gas -spec ific connec tor tha t is ei ther pa rt of or a ttached to the base bloc k is incorporated into eac h te rminal u nit. The c onnec tor may be a threaded Di ameter Index S afety Sys tem (DISS ) o r a propri etary (manufac turer-specific ) qu ic k c onnec tor. The c orrespo ndi ng male c ompon ent of the nonin terchangeabl e c onnec tion is attac hed to the equip ment to be used o r to a f lex ib le hose leading to the equipme nt. The fe male c omponent is called an outle t connec tor or soc ket. The male member is ca lled an inlet connec tor, probe, plu g, s trike r, or jac k . Eac h DIS S or quic k conn ec tor mus t be equipped with a back fl ow check v alv e to prev ent gas f low f rom the anes th esia appa ratus or o th er dispensi ng appara tus into the piping s ys tem.

The Diameter Index Safety System

The DISS was dev eloped to p rov ide noninterc hang eable c onnec tions for medica l gas l ines at p res sures of 1 380 kP a (200 psi) or les s (18 ). As s hown i n F igu re 2.9, each DISS connec tor c ons is ts of a body, nip ple , and nu t c omb ina ti on. There a re t wo c onc entric and spec ific bores in the body and two c once ntric and spec ific shoul ders on the n ipp le (Fig . 2.10). The smal l bore (BB ) mates wi th the smal l shoul der (MM), a nd the large bore (CC) mates wi th the la rge shoul der (NN) (Fig . 2.9). To achiev e noninterc hangeabil ity between d iffe ren t connec tors , the two diameters on each pa rt v ary in oppos i te di rec tions s o that as on e d iame ter i nc reas es , the other dec reases . Onl y properly mated pa rts wil l f it toge th er and al low the threads to engage. The American Soc ie ty f or Tes ting and Materia ls (A STM) anes thesi a works tation requ ires that ev ery anes thes ia mac hine hav e a DISS f i tting for each pipel ine inlet (Fig. 2 .11 ) (19 ).

Quick Connectors
Quick connec tors (automatic quick c ouplers v alv es , quick connec ts , quick -c onnec t f ittings , quick c ouplers ) al low apparatus (hoses , flowme ters , e tc .) to be c onn ec ted or d is conn ec ted by a si ngle ac tio n b y us ing one or both h ands wi th out the us e of tools or undue fo rce . Quick connec tors are more c onv enient than DISS fi ttings bu t tend to l eak more. Eac h quick connec tor c onsis ts of a pair of gas -s pec ific male a nd fe ma le co mponen ts (Fig . 2.12). A releas abl e sprin g mechan is m lock s the compone nts together. Hos es and other equi pment are prev ented from being inserted into an i ncorrec t ou tlet by usi ng differe nt shapes an d/or different s paci ng of ma ting portions .

Face Plate
The f ace plate should be p erman ently marked wi th the name and/or s ymbol of the gas that it c onv eys . T he identif ying col or ma y als o be present.

Types Wall Outlets

W al l outl ets (Fig. 2.13) a re mechanicall y s imple an d we ll sui ted to smal l rooms whe re th e equi pmen t to be connec te d wi l l be nea r th e wa ll . In l arger rooms , th e hoses to the equipment f requentl y mus t be long and a re of ten d raped ac ross the f loo r. T his l eads to personnel tripp in g ov er the hos es , dif ficu lty in mov ing equipment, wear and tea r on th e hoses , and d ebris ac cumulation. For large rooms , more tha n one set of wal l outlets may b e adv isab le .

Ceiling-mounted Hoses
Ceil ing -mounted hoses wi th the terminal unit at the end of the hose (F ig. 2.14) may be us ed.

Ceiling-mounted Pendants
A cei ling -mou nted pendant wi th one o r more artic ula ted a rms (F ig. 2.15) kee ps wi res a nd hoses from c lu tteri ng the floor and c an eas i ly be mov ed to v a ri ous positions . In add iti on to termi nal uni ts , the p enda nt may hav e el ec trical and data mana gemen t outle ts , space for moni tors , telephones , in trav enous solu ti on mounts , and s uc tion bottles and regulators .

Ceiling Column
Ceil ing -mounted columns (F ig . 2.16) can prov ide the sa me s erv ic es as a pendant but are less v ers atile with res pec t to pos itioning (2 0). They can b e made mov able by mounti ng them on track s. Th ey can be retrac tab le s o that the c olumn ca n be l owered to attach or de tac h hoses and then ra is ed to av oid obstruc tion. Disadv antages inc lude the p ossibi lity tha t people wi l l hi t their heads on the co lu mn and d ifficu lty gaining acc ess to h oses i ns ide the column. S hort personnel ma y h av e diff icul ty a ttac hing hoses to them. P .36

Figure 2.9 Diameter Index Safety System. With increasing Compressed Gas Association (CGA) number, the small shoulder (MM) of the nipple becomes larger, and the large diameter becomes smaller. If assembly of a nonmating body and nipple is attempted, either MM will be too large for small bore (BB) or large shoulder (NN) will be too large for large bore (CC). (Redrawn courtesy of the Compressed Gas Association.)

Figure 2.10 End of Diameter Index Safety System connection. Note the two concentric shoulders on the nipple.
P .37

Figure 2.11 Pipeline inlets to the anesthesia machine have DISS connectors.

The Nitrogen Piping Terminal Unit

Bec ause the press ure requi red for n itrogen-driv en to ols v aries , a means of adjus ting the pressure at the s tation ou tlet is needed. A n adjus table regula tor s imilar to those desc rib ed in Chapte r 5 is us ed. Figu re 2.17 s ho ws a n itrogen terminal uni t bui l t in to the wal l. T wo g auges are pres ent, one indicatin g the dis tributi on pressu re and the other the reduced p res sure.

Figure 2.12 Quick connector. The two prominences on the hose connector mate with the two slots on the wall outlet to ensure noninterchangeability.

Hoses
Hos es (droplines , hos e assemb lies , low-press ure hos e ass embl ies , low-pre ssure f lex ib le connec ting as sembli es , f lexi bl e hose as sembl ies , pipeline press ure s uppl y hoses , hose pi pes ) are used to c onnec t anes thes ia mac hines and other apparatus to terminal uni ts (5). Eac h end mus t h av e a permanen tl y attac hed, nonin terchangeabl e c onnec tor. The con nec tor that a ttaches to a P .38 terminal uni t is c al led the inle t (s upply ) c onnec tor. T he connec tor that a ttac hes to equipment s uch as an anes thesia mach in e is th e outlet (equip ment) c onnec tor.

Figure 2.13 Wall outlets with quick-connector fittings.

A color-co ded hose and the name and /or c hemical s ymbo l of the con tai ned gas on each conn ec tor are des i rable. Mos t hos es hav e an imbedded braid in the wall for added s trength. Hos es shou ld be k ept awa y from any hea t source , espec ially operati ng room l ights , bec aus e c ontac t may caus e the hose to rupture (21,22). W henev er p oss ible, hoses s houl d be k ep t off the f loor.

Figure 2.14 Ceiling-mounted hoses. A spring-actuated chain keeps the hose close to the ceiling.
P .39

Figure 2.15 Pendant with double-articulated arm. On one side (A) is a shelf for equipment and electrical and data management system outlets. On the other side (B) are terminal units for the piped gases and additional electrical outlets. The pendant can be raised or lowered or moved from side to side.
It sometimes is neces sary to disconnec t the pip eline hoses to mov e the anes thesia machine. This should be performed quick ly and p referabl y withou t ope ning the c ylinde r v alv e on the anes thes ia machine becaus e the cy linde r may bec ome deple ted if the v alv e is not cl os ed af ter the hose is reconnec ted . If the hose must be disc onnec ted for mo re than a few seconds , a cy linder shou ld be op ened and then c losed as soon as the hos e is reconnec ted. Us ing sev eral ex tens ion hos es is undes irable. It is better to use one lon g hose, as resis tance c aus ed b y mu lti ple c onnec ti ons ma y i nterfere with gas f lo w. One l ong

hose is less lik el y to l eak , because mos t leaks occ ur i n the connec to rs or wh ere the connec tor fi ts i nto the hos e. Hos es sho uld be k ept in good repair and approac h the anes thesi a mach in e wi th a gentle curv e, av oiding acu te angul ations or s tretch ing. Af ter y ears of us e, hoses can we ak en , s wel l , or c rac k (23,24 ). P e rso nnel shou ld pe riodical ly c hec k for thes e problems and hav e the hoses repa ired or replace d, if nec ess ary .

Testing Medical Gas Distribution Systems

Bec ause p rob lems wi th med ic al gas s ys tems are mos t likel y to oc cur wi th a ne w s ys tem or one that has been modified o r rep ai red , it is es senti al that s uc h a s ys tem be thorough ly tes ted bef ore being used (2,4). If a s ys tem is brand new, the enti re s ys tem mus t be tes ted. Fo r a new or modif ie d porti on of an ex is ting s ys te m, the ex ten t to whi ch i t is tes ted wi l l dep end on how muc h of the ex is ting s ys tem c an be i sol ated and no t affec ted by the work . The re has been controv e rs y ov er who s hould c arry out the final (commiss ion ing) tes ts to mak e c ertai n tha t the piping s ys tem compli es with reg ul ati ons . Commerc ial se rv ices tha t inspec t medical gas pipeli nes and off er c e rtif ic ation a re av ailabl e. Tes t procedures and resul ts s hould be made pa rt of the fac i lities permanent records . The A meric an Soc iety of San itary E ngi neeri ng (ASSE ) has published a s tandard on profess ional q ualif ications for ins pec tors and v e rifi ers for medical gas s ys tems (25 ). Anes thes ia personnel hav e an obli gation to ens ure that the s ys tem is properly desig ned and is fu nc tio ni ng correc tl y, s o a memb er of the department s hou ld wi tn ess the tes ts pe rforme d, es pecial l y those for c ross con nec ti ons . A pe rs onal i ndependent c heck us ing a n ox yge n anal yzer or other gas moni tor is a n exce ll ent i dea.

Installer-performed Tests
Initial Blow Down
Af ter the pipelines hav e been ins tal led but b efo re the ins ta ll ation of te rmi nal uni ts and o the r s ys tem componen ts (e.g ., s ourc e equ ipme nt, sens ors for alarms , press ure gauges , or pres sure relief v alv es), the line mus t be bl own c lea r of fore ign material by usi ng oi l-f ree dry ni trogen . P .40

Figure 2.16 Retractable rigid column. Pipeline outlets are on the bottom. Electrical outlets and hook mounts for intravenous solutions are on the sides.

Initial Pressure Test

Before sys tem components are a ttach ed but a fter the termi nal units are ins tal led and b efo re cl osing of the wal ls , each sec tion of the piping s ys te m mus t be subjec ted to a tes t press ure of 1.5 ti mes the s ys tem work ing p res sure, bu t not les s than 1035 k P a (150 ps i ), b y us ing oi l-free nitroge n with the s ourc e v alv e close d. This press ure is main ta ine d until e ach j oi nt has been exa mined for leak age . If any l eaks a re found, the y mus t be c orrec ted.

Test for Cr oss Connections

Tes ting f or c ross connec ti ons (anticonfus ion or continui ty tes t) is done to e nsure that the gas deliv e red at each terminal uni t i s tha t s hown on the ou tlet label and that the proper c onnec tors are presen t at s tatio n outlets . One gas s ys tem is tes ted at a time. Each gas is turned off at the sourc e v alv e and the pressures reduc ed to atmospheric . The pipel ine being tes ted is then f ill ed with oi l -f ree ni trogen at i ts worki ng press ure . Wi th appropria te adapters match ing ou tlet l abels , each s tatio n outlet is ch ecked to ens ure that tes t gas eme rges o nl y f rom the

outl ets of the medic al gas s ys tem being tes ted. T he c ross -con nec tion tes t is then repeated for each gas sys tem in tu rn.

Pipeline Purge Test

To remov e pa rtic ula te matte r, a heav y inte rmi ttent purgin g must be pe rf ormed on each outle t until no discoloratio n is produc ed on a whi te c loth tha t is he ld ov er the outl et. The purgi ng is s tarted at the outle t cl oses t to the zone shutoff v alv e and is continued to the farthes t outlet withi n the zo ne.

Standing Pressure Test

Af ter the wa lls hav e b een c losed and af ter i ns tal lation of s ta tion outlet v alv e bodi es and o the r distri butio n s ys tem components (e .g., press ure alarm dev ices , pressu re i ndicators , press ure rel ie f v alv es , etc .), the enti re s ys te m is subj ec ted to a 24-hour tes t wi th a press ure 20% a bov e the normal opera ti ng line pres sure wi th the sourc e v alv e c losed. Leak s mus t be loc ated and repaired, and the tes t mus t be repeate d unti l no leaks a re fo und.

System Verification
S ys te m v erifica tion tes ts s hall be pe rf ormed a fter al l the ins taller-p erformed tes ts hav e been c ompleted. Tes ti ng shall be c onduc ted by a party wh o is techn ic all y co mpetent and expe rienc ed with pipel ine ins tal lations a nd who meets the requi rements of ASSE 6000 (25).

Standing Pressure Test

P iping s ys tems s hall be su bjec ted to a 10-min ute s tanding pressure tes t at operati ng li ne press ure .

Cross-connection Test
E i ther of the followi ng tes ts can be us ed:

A ll medica l gas sys tems are reduc ed to a tmos pheric p res sure. A l l sourc es of tes t gas from all medical gas s ys tems , wi th the exception of the one s ys tem to be c hec ked, are disc onnec te d. The s ys tem is then press uri zed to 345 kP a (50 ps ig). Eac h termina l uni t of ev ery medical g as sys te m is the n c hec ked to v e rify that tes t gas is being dispens ed onl y f rom the outlets of the medical gas s ys tem being tes ted. Each medical g as s ys tem is chec ked i n this way.

The pres sures of all med ic al gas s ys tem are reduc ed to atmos pheric . The tes t gas pressu re in a ll the medica l gas piping sys tem is inc re ased to v al ues i n Table 2.1 . Fol lowin g adjus tment of pressu res , eac h s tation outle t is

i dentified by label , and a gas -spec ific c onnec tor wi th a tes t ga uge is a ttached to v erif y tha t the p res sure indic ated is that li s ted. P .41

Figure 2.17 Termination of nitrogen piping system. Two gauges are present, showing pipeline and outlet (reduced) pressure. The reduced pressure can be altered by using the regulator (pressure adjust). The station outlet is at the right.

Valve Test
Valv es mus t be tes ted to v eri fy p roper ope ration and rooms or areas that the y control .

Alarm Test
A ll mas ter a nd area a la rm s ys tems mus t be tes ted for p rop er f unc tioning.

Piping Purge Test

To remov e pa rtic ula te matte r depos i ted in th e p ipe line, a heav y intermittent purgi ng of the pi peline is c arried out un ti l the purge produc es no discoloration i n a whi te c loth tha t is held ov er an adapter du ring the p urg e.

TABLE 2.1 Test Gas Pressure

Medical Gas Gas mixtures Nitrogen

Pressure (Gauge) 140 kPa (20 psi) 210 kPa (30 psi)

Nitrous oxide Oxygen

275 kPa (40 psi) 345 kPa (50 psi)

Medical air

425 kPa (60 psi)

Piping Particulate Test

A minimum of 1000 L of gas mus t be f il te red through a cl ean , whi te 0.45 mic ro n f il te r at a mi nimu m flow rate of 100 L/minute . The f il te r shall acc rue no more than 1 mg of matte r from any outl et tes ted. T wenty-fiv e perc en t of the zones mus t be tes ted at the outle t mos t remote from the s ource.

Piping Purit y Test

Eac h me dical a ir s ys tem mus t be tes ted for dew poi nt, methane, and halogena ted hydrocarbons at the o utl et mos t re mote f rom the sou rce . Max imum allowa ble v alues are giv en in NFPA 99 (2).

Final Tie-in Test

Af ter connec tion of any wo rk , ex tensi on , or add iti on to an ex is ting pi ping s ys tem, each joint in the final connec tion between th e addi tion an d the ex is ting s ys te m mus t be l eak tes ted wi th the gas of s ys tem des igna ti on at the normal operati ng press ure. Af ter the f inal co nnec tion is made and leak tes ted, the area down s tream of the point or area of i ntrus ion mus t be purged . P .42

Operational Pressure Test

Ox ygen, nitrous ox ide , and medica l ai r outle ts mus t del iv er 10 0 L /minute with a press ure drop of n o mo re than 35 kPa (5 psi ) at a s tatic press ure o f 345 to 3 80 kPa (50 to 55 ps i). Ni trogen ou tl ets and i ns trume nt ai r mus t del iv er 140 L/mi nute with a press ure drop of n o mo re than 35 kPa (5 psi ) at a s tatic press ure o f 1100 to 1275 kPa (160 to 185 psi ) (2).

Gas Concentration Test

Af ter purging each sys tem wi th the gas f or wh ic h the s ys tem is des igned, e ach s ys tem mus t be analy zed for gas c oncentration. Al lo wable c onc entra tions are giv en i n NFP A 99 (2).

Medical Air Purity Test

The med ic al ai r s ourc e mus t be analyzed for de w po in t, c arbon monox id e, carbon diox ide , gas eous hydrocarbons , and halogena ted hy drocarbons . Max imum al lowable v alues a re giv en in NFPA 99 (2).

Labeling
A ll c omp onen ts mus t be checke d for c orrec t lab eling .

Source Equipment Verification

Sou rce equipment mus t be tes ted fo r proper f unc ti on. A ll source appara tus mus t be checke d for p roper func ti oning and label ing, i nc lud ing c hang eov e rs , si gnals , maste r s igna l panels , and p res sure g auges . Th e qual ity of med ic al ai r produced mus t be checke d after the machine ry has run co nti nu ousl y fo r a minimum of 24 hours .

Periodic Testing and Preventive Maintenance

A planne d p rev entiv e ma in tenance program can prev ent po ten ti al ly ha zardous condi tions and unex pec ted loss of serv ice, reduc e the ec onomic burden f rom leak s, and reduce emergenc y repairs (2 ). Maintena nce should be performed at leas t as f requentl y as rec ommended by the pi peline manufac tu rer and more f requentl y if requi red by heav y us e or l ocal c ondi tions . Bef ore maintenanc e is undertak en , th e s ys tem s hould be exa mined and the accu rac y of exis ting di agrams v erif ie d. Ins pec tion and tes ting should be p erf ormed on a regular bas is and the resul ts recorded in a permanent l og . If tes t buttons are prov ide d at area pane ls (Fig. 2.8), audible an d v is ual a larm ind ic ato rs should be tes ted mon thly. A ll hos es and s tation outle ts i n the anes thetiz in g loc ations and pos tan es thes ia ca re units shou ld be check ed at leas t monthly f or we ar, d amage , and prope r func tion . Terminal un its should b e c heck ed fo r eas y ins erti on, lock ing, unloc ki ng, and

connec tor remov al ; le akage, wea r, a nd damage ; con tamina ti on; g as spec ific i ty ; l abel ing; flo w; and pres sure. Shu toff v alv es to an es thetizing loc ations c an be checke d for ti ghtness and co mponen ts do wns tream of the v alv e for leaks by the fol lowi ng tes t. An anes thes ia machine with a pipeline press ure ga uge is connec ted to the piping sys tem. Cylind er v alv es on the machines are c losed , th e zone s hutoff v alv e outs ide the o perating room is c los ed, and gas is releas ed until each pipel ine pressu re gauge reads 280 kPa (40 psi g). This pressu re is the n mo nitored fo r 4 hours . It shoul d remain at 280 kPa . If the press ure ri ses , the shutoff v alv e is not work i ng properly . If the press ure falls , the re is a leak i n the pipe to the room, the s tation outlet, or the hose to the anes thes ia mach ine. It is es sential that the shutoff v alv es be re opened af ter this tes t has been pe rf ormed. It is good prac tic e to check alarms regularl y. Gauges in a rea an d mas te r al arm panels shou ld be moni tored daily f or prope r pressure. The tes t button on alarm panels shou ld be press ed monthly to v eri fy audible an d v is ual s ig nals . Bu rned out bulbs s hould be replaced , and the tes ti ng sh ould be docu mented. A l l mas ter ala rm s igna ls s houl d be tes ted at leas t annuall y to v erify p roper ope ration. Th ese si gnals are req uired to b e wired so that if a wire gets cut, i t wil l alarm. If remov ing the wi re f rom the s ens or does not ac tiv ate an alarm, it i s not properly wi re d (16).

Planned Shutdowns
An ex is ting pipel ine s ys tem s ometi mes must b e s hut down to ex ten d the s ys tem, was h o r purge it, pe rform prev entiv e maintenance, o r make replacements (26,27,28). Parti all y o r comp letel y shu tting d own a medi cal gas pipel in e s ys tem is a co mplex task that inv olv es many ris ks . The anes thesi a d epartment shoul d be ac tiv el y i nv olv ed. Careful plann ing, goo d communica tion, and cl ose cooperation wi l l minimi ze probl ems and assure uni nterrupted gas serv ice. If the s hutdown wi l l affec t rela tiv el y fe w p atien ts , the s imples t al ternativ e sup ply is cyl inders . A n a lternativ e method is to bac k -fee d the isolated sec tions . Foll owing the sh utdown, p uri ty and c ross ov er tes ti ng of all outlets inv olv ed and immed iatel y adj acent areas s hould be performed.

Problems
Many p rob lems as soc iated wi th piping sys tems are c aused b y anes thes ia p rov iders being un aware tha t these s ys te ms can fa il as wel l as bec aus e they a re not suff ic ientl y fa mil iar wi th the s ys tem to mak e e mergenc y adjus tments . Lack of

co mmunicatio n between cl in ic al and mai ntenance departments and c ommerc ia l suppl ie rs may also be a con tributing fac tor. Fi nally , comp li anc e wi th ex is ting c odes i s not un iv ers al . P .43

Inadequate Pressure
Inade quate pressu re is the mos t freque ntly reporte d ma lfunc ti on (7 ). P ress ure los s may res ul t in a f low inadequate to power a v entilator bu t suffici ent for other purposes . Anesthes ia v entilators requ ire a minimum d riv ing gas pres sure to ope rate properl y.

Causes
Causes of i nadequate press ure i nc lude damage , esp eci al ly du ri ng cons truc tion projec ts unrelated to the piping s ys tem (7,9,29,30,31,32); fires (33,3 4); v ehicular ac c idents ; n itrous ox ide tank th eft (7); env ironme nta l fo rc es (ea rthquake, exces siv e co ld, tornado, l ig htn ing) (9 ,35 ,36 ); depl etion of or damage to the central su pply (10,37,38,39,40); human e rror, inc lu ding a c losed shu toff v alv e (7,28,41,42 ); i napp rop riate main l in e p res sure regula tor adjus tment (43); equipment f ai lu res (leaks , c los ed shutoff v alv e) (44,45,46); s tandb y supp ly fai lu re during rou ti ne mai ntenance (47); p res sure regula to r malfunc tion (7,48,4 9); problems with automatic s wi tc hing g ear (48,50); pipel ine obs truc tion (frequ ently by debris lef t followi ng ins talla tion (7 ,51 ); failu re of a qu ic k c oup ler to fi t i nto a s tati on outle t or to allow gas flo w (52,53,54,55); f rac tu red qu ic k c onnec tor (5 6); plugged c onnec to r (57); ki nking, leak , or o bs truc tion of a hose (2 1,2 2,29,58,59,60,61,62); and a detac hed terminal uni t (6 3). Delibe rate tamp ering is a poss ibi l ity that s hould not be ov erlook ed.

Disaster Plan
Bec ause the consequenc es that occ ur whe n ox yg en or ai r pi peli ne pressure is l os t can be s ev e re, each f aci li ty s hou ld hav e a plan to deal with it (43 ,58 ). Becaus e no s ingle plan wi ll fi t ev ery faci li ty , this s ec tion i s i ntended on ly to prov ide guidanc e in the preparation an d i mplemen tation of that plan . A key to eff ec tiv e emergenc y preparedness planni ng is flexi bi l ity, wh ich is attaine d by co nsidering all poss ibil i ti es and dev eloping op tions for ac ti on that are maxi mally ef fec tiv e under each pos sibi li ty . It is i mportan t that the pl an be func tio nal at any

time of d ay or ni ght and on any day of the year. Th e p lan s hould inc lude s tra teg ies for cons erv ing exis ting supp li es and acqui ring ad di tional supplies f rom other fac i li ties o r v endors , i f nec essa ry. Efforts sh ould be c oordi nated to dete rmine needs and s uppl ies on hand as well as to de termine the du rati on th at the gas wi ll be unav ail able with the departmen t responsi ble for the piping sys tem. An effec tiv e response mus t include re liabl e communic ation pa th ways and indiv idu al respons ibi li ties that tak e into acc ount p rac tical ci rcums tances . The deta ils should be disc ussed and rehearsed i n a mock dis as ter d ri ll if an effec tiv e response is to be ex pec ted during a rea l emergenc y. E ach indiv id ual s hould be aware of his or he r role . Shutoff v alv e loc a ti ons s hould be known by the s taff s o that if the pressu re l oss is caus ed by a leak in one area, the pip el ine to tha t sec tion c an b e iso lated to prev ent further l os s . An indiv idual who discov ers a faul t in the piped s uppl y should immediatel y inform the telep hone op era tor who, i n turn, s hould i nfo rm the departmen t responsible for mai ntaining the s ys tem, res pi ra tory th era py, s urgery , th e pos tanes th esia c are uni t, obs te tric s , the emergenc y room, s pec ial c are uni ts s uch as intensiv e ca re an d the nurse ry, the nu rsing superv isor, and adminis tration. E ach departmen t should hav e ca reful ly es tabl ished procedures to dea l wi th the emergency . These sho uld be rev i ewed regularly , rev is ed as nec ess ary , and pu t in polic y and procedu re manuals . Bec ause ev ery anes thes ia machine should h av e at leas t one ox ygen c ylinder, the re shoul d be no immed iate th rea t to life i n the ope rati ng roo ms , bu t it would be prudent to use lo w f res h gas flows a nd manual v en tila ti on. Gas -powered v entilato rs shoul d not be us ed, as the y wil l deple te the c yl inder c ontents quickl y (64). E lec trica ll y powe red pis ton v enti lato rs can c ontin ue to be us ed. E lec tiv e su rge ry shoul d be pos tponed until adequate supplies can be g uaranteed. A ttention shou ld be focus ed on the pos tanesthes ia care uni t (rec ov ery roo m). It may be adv antageous to mov e anes thes ia machines that a re no t in us e into th e rec ov ery room to suppl y oxygen until other sou rc es can be ob tained. A l ternatel y, patien ts can be returned to opera ting ro oms . The heart-l ung mach ine may a ls o n eed suppl emental ox ygen (30 ). Po ten ti al eme rge ncy ox ygen s ources other than co mp res sed c ylinders inc lud e portable liqu id ox ygen c ontainers and ox ygen conc en trators (Chapter 1 ).

Emer gency Auxiliary Suppl y

Bec ause the dangers associ ated with fai lure of piped ox ygen and ai r s ys tems , spec ial areas s uc h as intensiv e ca re un its , recov ery rooms , emergenc y roo ms , an d

the like may add a n aux il iary ox ygen and /o r air supp ly . When an emergenc y aris es , the shutoff v alv e to the a rea is c losed and the aux iliary s ource con nec ted to an outl et no t in us e withi n the zone or by means of a spec ially ins tal led T . Outlets wi th in the area c an then operate from the aux il iary s ource.

Leaks
Leaks i n v arious piping s ys tem c omponents are c ommon (7). Th ey may occ ur anywhere in the pi pi ng s ys tem. Leaks in pipel ine outlets are especiall y common. These are usual l y sealed by O-ri ngs that c an fail (65). Leaks are expensiv e and poten tial ly ha zardous if ox idizing gases are al lowed to ac cumul ate in c losed spac es . Nitrous ox ide leak s ma y pose a health hazard to pers onnel (Chapter 13 ). P .44

Excessive Pressure
Exc ess iv e p res sure c an cause damage to equipment an d baro trauma to patien ts (49,66,67). Few anes thes ia machines o r v en ti la tors hav e mechan is ms to prev en t dama ge from high pressures . Some v enti la tors wil l not ope rate properly if the li ne press ure is too high . A rep ort has been documented rega rding an inco rrec t output gas c onc entration from a bl ender whe n the press ure in th e a ir pipe li ne was adjus ted u pward (68). As shown in Figure 2.6, a pressu re relief v alv e in the main s uppl y l ine is re qui red . Howev er, th is can be set improperly o r malfunc tion . The mos t commo n c ause of high pressure is regu lator failu re. This proble m has been rep orted in assoc ia tion wi th a c ryogeni c ox ygen tank (69 ). In humid atmospheres , ice may f orm on the v apo ri zers in a l iqu id ox ygen s ys tem. This wi ll hamp er hea t trans fe r and may resul t i n liquid oxy gen pas sing in to the pipin g s ys tem wi th res ul tant damage to the re gulator and p res sure rel ief v alv e . This also has been reporte d after l iquid ox ygen was added to th e ma in tank (66). Othe r causes of h ig h press ure incl ude forei gn mate ri al c ombus tion in a pipel ine (7) and del iberately i nc reas ing the pressu re se tting a t th e ma in l ine regu la tor in an attemp t to co mpens ate for l ow pre ssure from the c entral s ys tem (4 9). W henev er excess iv e pipel ine pressure occ urs , i t is bes t to dis connec t a pparatus f rom the pip eline sys tem a nd us e cy linde rs un ti l the problem is c orrec ted.

Alarm Problems

Fail ure , abs ence , or disc onnec tion of an alarm is not unc ommon (7 ,49 ). T he alarm may no t be heard or the person who hears it may no t k no w the proper c ourse of ac tion or fail to respond (7 ,70 ). False alarms can als o oc cur. They may resu lt f rom c alibratio n d rift in l ine pres sure sens ors (43). Repeated f alse alarms can c aus e c omplace ncy among p ers onnel, whi c h may hav e serious consequences if a real e mergenc y occurs .

Cross Connection of Gases

A l though an uncommon ev ent, acc id ental subs titution of one gas for another c an hav e dev astati ng co nsequenc es (71). The mos t c ommon c ross ov ers hav e bee n between n itrous oxide an d ox yge n, bu t v ario us other co mbinations hav e been reporte d. P ipel ine ala rms indicate onl y pressu re fa ul ts and giv e no s ignal if an i ncorrec t gas is present. Because the cons equences a re mos t s ev e re when the c ross ov er resul ts in hy poxi a, i t is ess ential tha t a rel iable ox ygen ana ly zer be i ncl ude d as a c omponent of ev ery breathing s ys tem. Ox ygen mon itors shou ld be us ed in other a reas where ox ygen is adminis tra ted s uch as obs tetrics , the nursery, and intens iv e c are un its (7 2).

Central Supply
Cas es hav e been reported i n which liqu id ox ygen tank s were f il led with ni trogen (73,74,75,76,77) o r arg on (78 ). Inc o rrec t tanks hav e been place d on the ce ntral suppl y manifold (5 2,79,80,81). A ll employees who deal with the piping s ys tem mus t be famil iar wi th the s tanda rds that hav e been dev eloped to prev ent med ic al gas mix -ups (82). If an i ns ti tution uses both med ic al an d indus tri al gases , they should be s tored separa tel y (8 3).

Distribution S ystem
Crosse d pipelines usuall y occ ur during s ys tem ins tall ati on, al tera tion, o r re pai r (84,85,86,87,88,89,90,91,92). In one cas e, a fis tula was c reated between two pipes during c ons truc ti on (93 ). Fl ood ing the oxy gen l ine wi th n itrogen has occurred when ni trogen was used to tes t for l eaks and the shutoff v alv e to that a rea did not prev ent back flow (33 ,9 4,95,96). NFPA no w requi res that when ne w p iping is connec ted to a n ex is ti ng s ys tem, the sourc e g as , rather than ni trogen, be used to tes t for l eaks (2 ).

Terminal Units
The re are numerous reports of outle ts l abeled for on e gas that del iv ered ano the r (97,98). The wrong outle t connec tor ma y be ins tal led (52,93,99,100). A terminal

unit may accep t an inc orrec t connec tor (101,1 02,103,104 ). A n a ir f lo wmeter may be f itte d wi th an ox yg en outle t but retain the air pi pel ine connec tion. In one cas e, a problem occ urred when an ox ygen f lowmeter was c onnec ted to a nitrous ox ide outl et bec aus e a c onnec tor pi n was broken on the fl owmeter quic k connec tor (106,107 ,108). In ano the r cas e, the ox ygen fi tting bas e f lexe d enough to al lo w i t to be fitted to a ni trous ox ide termina l uni t (109). In o rde r to prev ent thes e erro rs , the medical dev ic es that c onnec t to terminal units mus t be re gularl y inspec ted and those wi th wo rn or damaged c onnec to rs repai red.

Hoses
Cas es hav e been reported i n which the wro ng c onnec to r was put on one or more hoses (7 ,94,110,111,112 ,1 13). Mos t of these hav e inv olv ed re pai rs or alterations performed b y hospi tal pe rsonnel . B lue hoses turn ing green hav e been repo rted (114). This cou ld resul t in an ox ygen-spec ific fi tting being attached to one end of a green (prev ious l y blue) h ose. W henev er a hos e is al te red or repa ired, i t s houl d be checke d carefu ll y before i t is put i nto serv ice to mak e c ertain th at the proper connec tors are on each end. W ith ex tens io n h oses , th is is eas il y performed by i nserting one end of the hos e into the o the r. A hos e c onnec tor can become worn, all owi ng the h ose to be c onnec ted to the i ncorrec t wal l outlet (104 ,115). P .45

Hos es th at run ac ross the fl oor c an make i t diff icul t to mov e the anes thes ia machine o r drug c art. They can impede operati ng room personnel f rom mov ing about wi th out trippi ng on the hos es (116). Dev ices a re av ailable to p rev ent equipment f rom being ensnared by hoses . This is disc uss ed in Chapte r 14.

Peripheral Devices
Numerous c ases hav e bee n reported in wh ic h an a ir/oxygen or an ox ygen /ni trous ox ide mixer, v entil ato r, o r anes thesi a machine us ing b oth ox ygen a nd another gas had a defec t that al lowed the gas suppl ies to bec ome interconnec ted, and oxy gen f lowed into the o th er pipel ine or the other gas into the ox ygen piping (48,117,118 ,119,120,121 ,122,1 23,124,125,1 26,127,128 ,129,130). Often , the f aul ty dev ic e was not in use bu t was connec ted to the p ipe line s ys tems . The contamina ti on lev el depends on the difference in s upp ly press ure be twe en the two gases . Gas from the pipel ine with the hig her press ure wi l l con tamina te the gas in

the pipel ine wi th the lower p res sure (13 1). It i s sugges ted that respi ra to ry equipment be disc onnec ted from the pi peline when no t in use (12 6,131).

Gas Contamination
Vari ous types of contamination c an be found in the pi pel ine sys tem. Currently, no av ailab le moni tor can detect the entire spectrum of po ten tial c ontaminants in a pipel ine s ys tem. If c ontamination of piped gas es is s uspec ted, a s wi tc h to c y linde r suppl y shou ld be made a nd the anes thes ia mac hi ne discon nec ted f rom th e p ipeline . If the p ipeline is not disc onnec ted, the mach ine may p ref erentia ll y us e gas f rom the pipel ine ev en thou gh th e c yl ind er is open . Fi lters can be us ed to prev ent co ntaminants s uch as partic les , bac te ri a, and li qui d water f ro m entering the apparatus and harming attach ed medical dev ices and pati ents (132,133) (Fi g. 2.18). NFP A s tand ard s (2) require tha t medical compress ed ai r s ys te ms hav e an in-line fil tratio n s ys tem of 98% effic ienc y at 1 and that f il te rs hav e a v is ual ind ic ation of f i lter l ife. Ho wev e r, fil ters do not re mov e water v apor and o ther gas es . As a las t l ine of defens e, many v entil ators , anes thes ia mach ines , regulators , an d other dev ices that use medical gases hav e fil ters (Fig. 2.18). These fil ters can se rv e as a n earl y warni ng of pipel ine c on taminati on (133). Howev er, thes e fi lters are typ ic al ly c oars e (e.g., 50 ). Fi lters requ ire rou tine ins pec ti on and p rev entiv e mai ntenance and can be a s ourc e of obs truc tion or leak s (134 ).

Particulate
Parti cu la te matter can acc umul ate in the pip in g s ys tem during c ons truc tion (28,135,136 ,137). Othe r common sourc es of p articulate c ontamination are ai r co mp res sors , rece iv ers , and dryers (14,1 38). P artic les can damage equip ment, es pecial l y v entilators , blenders , and l ine pressure sensors , and c an cause a s ignif ic ant reduc tion in flow (43 ,13 7,139). Partic ul ate matter c an be harmfu l to pati ents if inhale d.

Figure 2.18 Water trap with drain and filter in the air hose leading to the anesthesia machine.
Durin g ins ta ll ation , ev e ry effo rt s hould be made to k eep pi pes , f ittings , and v alv es as c lea n as poss ib le. The majori ty of particles ca n be remov ed by purging, whic h may requi re s ev eral days , but may nev er be c omplete, es pec iall y in tall bui ld ings (94).

Gaseous
Volatile subs tances can be unp leas an t and ha rmful to p atien ts if inhal ed, ma y dama ge equi pme nt, o r c reate a f ire hazard . Gas eous contamination may resul t f ro m materials re maining in the pip es af ter cons truc tion (66,93). The inlet to the ai r comp res sors is another sourc e of contamina ti on (66). NFPA reg ul ati ons requ ire tha t gas eous hydrocarbons be moni tored on a quarterl y basis (2). P .46

Ni tric oxide can be a c on tami nan t in ambie nt ai r. Low lev els of ni tric oxi de fo und in ambien t ai r may cause improv ed ox ygenation in v entil ated patients (140 ,14 1,142).

The role tha t unwi tti ng ni tric ox ide lev els p lay in medical air needs to be ev aluated (143). A numbe r of contamination problems hav e been reporte d. In one cas e, the ai r i ntake was located in the fac i lity's heating and ai r-condi tioning sys tem (14). W ashing the sys tem's co ils wi th an ac idic so lution res ul ted in fumes bei ng drawn i nto the s ys te m. In another c ase, a f il te r wa s soaked in cl eaning flui d and replaced wi th out al lowi ng it to dry (144 ). In yet another c ase, a c leaning s olv en t was no t purged f rom the hos e that connec ted the gas del iv ery truck and the mai n s to rage tank (1 45). A si mil ar inc iden t res ul ting i n s ev eral deaths occ urred when an ox yg en tank that had been cl eaned with tri chloroethyl ene was c onnec te d to the pip el ine s ys tem befo re al l the solv en t had been remov ed (146,147). In another c ase, tri chloroethyl ene us ed to c lean a v alv e was imp licated i n a c hi ld's dea th (28). Usi ng tri chloroethyl ene on -s ite has been banned by th e NFPA because c on trolling and dispos ing it c an be diffic ul t (2 ). Resi dual tric hlo roe thy le ne can not be eas i ly remov ed a nd can present a hazard to patien ts and pers onnel. One i mportan t lesson to be learn ed from these acc id ents is that pipe li ne odo rs shoul d alwa ys be tak en se ri ous ly . A ll medical gases s hould be odo r-free. A ny odor originating f rom a medical gas s ys te m mus t be traced to i ts so urc e, and s teps mus t be taken to correc t the pro blem. W henev er a pi peli ne s ys tem is b reached f or an y reason, the gases comi ng from the s ys tem s houl d be tes ted.

Water
W ater that is in troduc ed th rough malfunc tioning ai r co mpressor c omponents c an dama ge equi pme nt suc h as v en tila tors and gas mixe rs , fac il i tate oxi dation of copper p iping , attac k and weak en s ol der joints , and prov ide gro wth media for bac te ria (14 ,28 ,126,148,149 ). W ater in pi pel ines tha t are s ubjec ted to low temperatures c an freeze and occ lude gas f low.

Bacteria
P iped medic al gas es are n ot s terile, and bac terial c on tami nation has be en documented (150,151 ,15 2,153). W ater th at ac cumulates in a pipe line can p rov ide a cu lture medium. In so me c ases , co nta mina tion may be mixed, as occu rred when a bi rd bec ame ca ught i n an impro perly ins tal le d a ir intake (105).

Fires
To av oid fires , equipmen t us ed with a p ipeline sys tem mus t be c lean and free from oi l , grease, and partic ula te matter. In addi tion to caus in g i nadequa te press ure , a

f ire ma y res ul t in ha zardous f umes that a re i nhaled by pa ti ents . A hose can rupture and b urn if i t comes in con tac t wi th a li ght (21 ,22 ). A leak in a hos e i nside a su rgical boom can exace rba te a fi re (154 ). Chapter 32 disc usses fi res in the operati ng room. W hen a ro om with medical gas outle ts is conv erted to another use and the outle ts are not remov ed and not ma intai ned , the outlets can l eak , resul ti ng in a pote ntial f ire haza rd (155). Al l medical gas lines to the roo m shoul d be c ut and capped, and a bl ank cov er p late s hould be put ov er eac h termin al un it. If an entire zone is taken out of se rv ic e , the l ine s hould be c ut and c apped jus t downs tream of the zone v alv e box .

Depleted Reserve Supply

The rese rv e s uppl y may bec ome depleted by a connec tion fail ure, press ure i mbal anc es , and leaks (43,49).

Theft of Nitrous Oxide Cylinders

Theft of ni trous ox id e c yl inders f rom a central s uppl y area fo r rec rea ti ona l purpos es i s a recu rrent p rob lem.

References
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80. Anonymous . A rgon-ox ygen tank mix up caus es th ree deaths at army hospital . B iomed S afe S tand 1983 ;13:8889 . 81. Anonymous . Nitrogen i n ox ygen sys tem k ills two. B iomed S afe S tand 2001;31:17. 82. Anonymous . P rev enting medical g as mix -ups . Technol Anes th 2001;22:2. 83. Anonymous . P rev enting deaths and s erious injuries f rom med ic al gas mix -ups . Acc ess ed (Nov 2002), f rom http://www.fd a.gov /cdrh/psn /show1.html. B roadcas t #1. FDA Patient Safety News , 2002 . 84. Anonymous . Emerg enc y room mix up, deaths link ed. Am Bi omed News , A ugus t 8, 1977: 3. 85. Anonymous . Intercha nged ox ygen and ni trous ox ide l ines caused death , s ui t charges . Bi omed Safe S tand 1980;10:2829. 86. Anonymous . Undetec ted c ros sed ai r-ox ygen lines may hav e c ontributed to deaths o f 7. B iomed Safe S tand 198 2;12:41. 87. Anonymous . Cros s -connec ted anes thes ia s upply l ines alle gedl y resul t i n two deaths : negligence s ui ts fi led. Bi omed Saf e S tand 1984 ;14:1 516 . 88. Anonymous . Medical gas /v ac uum sys tems . Tec hnol Anes th 1987;7 :12. 89. Anonymous . Cros sed gas lines all eged in O.R. death. B iomed Safe S tand 1989,19:4. 90. Emmanue l ER, Teh J L. Den tal anaes thetic emergenc y caused by med ic al gas pipel ine installatio n error. A us t D ent J 1983;28:7981. 91. LeB ourdais E . Nine d eaths link ed to c ross -co ntamin ati on: S udbury Gen eral i nques t mak es hos pital h is tory. Di mens Heal th S erv 1974 ;51 :1 012 . 92. Sato T . Fatal pipe line acc id ents spur J apanese s tandards . A PS F Ne ws l ett 1991;6:14. 93. Tin gay MG, Ils le y A H, W illis RJ , e t al . Gas identi ty hazards and maj or contamina ti on of the medica l gas s ys tem of a new hos pital . A naes th Intens Ca re 1978;6:202209. 94. Din nic k OP . Medical gas espiping probl ems . Eng Med 1979;8:243247. 95. McA leav y J C. Bel iev e you r moni to rs . Anes thesiology 1993 ;7 9:409410. 96. E li za ga A M, Freric hs RL . Nitrogen pu rging of ox yg en pip el ines: an unusu al caus e of intraoperativ e h ypox ia . Anes th Ana lg 2000;91:242 243. 97. Anonymous . Ins ta llation of ox ygen sys te m probe d in ni trous ox ide death sui t. B iomed S afe S tand 1980 ;10:4142 . 98. Anonymous . Cros sed N 2 O & O 2 l ines blamed fo r outpatient su rge ry dea th . B iomed S afe S tand 1992 ;22:14.

99. Anonymous . Cros sed co nnec tions in medical gas s ys te ms . Techno l A nes th 1984;5:3 . 100. Anonymous . Ni trogen dis tribu ti on s ys te ms . Tec hnol A nes th 1989;9:2 . 101. Anonymous . Fi ttings /adapte rs , pneumati c , quick con nec t. Technol Anes th 1990;11:11. 102. Sca mma n, FL. A n anal ys is of the fac tors leading to c ross ed gas l ines caus in g profound hyperc arbi a duri ng general an es thes ia. J Cl in Anes th 199 3: 5:439441 . 103. Lane GA . Medical gas outlets a hazard from i nterchan geable quick co nnec t coupl ers . A nes thes iology 1980;52:868 7. 104. Anonymous . Mis con nec ti on of O 2 l in e to CO 2 outlet c laimed in de ath. B iomed Safe S ta nd 1991;21:9 293 . 105. Moss E . Medical gas con tamination: an unrecogn ized patie nt danger. APS F News le tt 1994;9:737 6. 106. Anonymous . Patients asphyx iated by medical gas miscon nec tions . B io med Safe S ta nd 2002;32:5 758 . 107. Anonymous . Ox ygen fl owmeters : repo rt of death caus ed by misconnec ted f lowme ter. Health Dev ice A lerts 2005;29:3. 108. Anonymous . Fatal g as line mix -u p: how to av oi d mak ing the gas tly mistak e. Acc ess ed (J an 2005 ), f rom http ://www.i s mp.org/MSAa rtic les /GasP rin t.htm. Hun tingdon Valley , PA : Ins ti tute fo r Safe Me dicatio n P rac tic es , 2004 . 109. Anonymous . Mis matc hi ng of prev ision brand medic al gas f i ttings . Health Dev ic es 1990 ;19:333334. 110. Anonymous . The W es tmins ter i nqui ry. Lancet 1977;2:175176 . 111. Robins on JS . A conti nuing sa ga of pi pe d me dic al gas supp ly . A naes th esia 1979;34:6670. 112. Neub arth J . An other ha zardous gas s upply misconnec tion. A nes th Analg 1995;80:206. 113. Jardine DS . A n ep id emic of hypoxemia in two i ntens iv e c are units : caus e and huma n res pons e. Anes th esiology 19 92;77:10381043. 114. Anonymous . Compress ed gas hoses . Tech nol Anes th 1986 ;7:5. 115. Barnow E , B rowne G. Faul ty ni trous oxi de Sc hraeder v alv e. Anaes th esia 1997;52:392393. 116. Nav ar JJ. Letter to the Edi tor: f loo r hos es are another gas source haz ard. APS F News le tt 1994;9:20.

117. W ei ghtman W M, Fenton-May V , S aunders R, et a l. Func tionall y c rossed pipel ines . An intermitte nt condi tion caused by a faul ty v entilator. A naes thesi a 1992;47:500502. 118. Anonymous . Bou rns Bear 1 v enti la tor. Hea lth Dev ices 1983;12:167 168 . 119. Bageant RA , Hoyt J W , Eps tei n RM. E rror i n a pipeline gas c onc entration: an unantic ipa ted c onse quenc e of a def ec tiv e check v alv e. Anes th esiology 1981;54:166169. 120. Bedsole S C, Kempf J . More faul ty B ear c heck v alv es . R espi r Care 1984;29:1159 . 121. Jen ner W , Geo rge B F . Ox ygen-air s hun t s yn drome s trik es again. Res pi r Care 1982;27:604. 122. Shaw A , Richardson W , Railton R. Malfunc ti on of ai r-mix ing v alv es . Anaes thes ia 1985;40:711. 123. Shaw R, B each W , Metzler M. Medica l ai r c on tami nation with ox ygen as soc iated wi th the B ear 1 and 2 v entil ators. Crit Ca re Med 1988;16:362. 124. Karmann U, Roth F. P rev ention of accidents as soc ia ted wi th ai r-ox ygen mixers . Ana es thes ia 1982;37:680 682. 125. Tho rp J M, Rail to n R . Hypox ia due to air i n the ox ygen pi pe li ne. A cas e fo r ox ygen mon itoring in th eatre. A naes thesia 1 982;37 :683687. 126. Anonymous . Ov erv iew of ox ygen-a ir propo rtio ners . Techno l Anes th 2000;20:1 3. 127. Anonymous . Hos pital death probe conti nues . Am Med News , Augus t 15, 1977. P .48

128. Kane W , Ridley JD, S heehan MW , e t al. Contamination of the medical a ir suppl y with ox ygen. A c li nic al engineering inc ident inv estigation. J Clin Eng 1990;15:295300. 129. Anonymous . Foc us is on v entilator problems f rom Augus t den repo rt. B iomed Safe S ta nd 1984;14:1 231 24. 130. Lye A , Patri ck R. Ox ygen con tamina tion of the ni trous ox ide pipeline suppl y. Anaes th Intens Ca re 1998;26:207209. 131. Miyasaka K . Ox ygen s uppl y p res sure shou ld be the hi ghes t. A naes th Inte ns Care 1989 ;17 :51351 4. 132. Anonymous . Us e of fi lters on medical g as sys te m ou tl ets and v ac uum s ys tem i nlets . Tec hnol A nes th 199 5;15(8 ):35.

133. Anonymous . Hav e you ins pec ted y our v entilator f il te rs late ly ? Heal th Dev ic es 2000;29:253. 134. Sch wartz A J , Ho wse J , El l is on N, et al. The gas line f il ter: a c aus e of hypoxi a. Anes th An al g 1980;59:617618 . 135. Anonymous . Medical gas lines may pos e peri ls . Ope n A ir ways 1995;12:2, 18 . 136. Anonymous . Soldered medic al gas piping. Technol A nes th 1995 ;16 :7. 137. W eis man E . NFPA and J CAHO look at medical gas s ys tems . He alth Fac il Mana ge 1992 ;5 :22 , 2426, 30 , 32. 138. Bus hman JA , Clark PA . Oi l mis t haz ard and piped ai r sup plies . B r Med J 1967;3:588590. 139. Anonymous . Medical c ompres sed ai r: i s i t cl ean enough? . Heal th Dev ices A lerts 2003;27:12. 140. Lee K H, Tan P SK , Rico P , e t al . Low lev els of ni tri c ox ide as c onta minant in hospi tal c ompres sed ai r: p hys iologica l s ignif ic ance ?. Crit Ca re Med 199 7;25:1143 1146. 141. Benzing A , Loop T, Mois G, e t al . Unintende d i nhala tion of n itric oxide by contamina ti on of c ompressed air. Anes thes iology 1999;91:945 950 . 142. Nak ata Y, K awasak i Y, Ma tsukawa K , e t al . Pollu tion of the medica l ai r at univ e rs ity hosp ital in th e me tropoli tan Tok yo area. J Cl in A nes th 2002;14:1 93195. 143. P insk y MR. Contamination of hospital c ompressed a ir wi th n itric oxi de . Ches t 1997;111:175917 63. 144. Lac kore LK , P erk ins HM. Ac ci dental narc osis . Contamina tion of c ompressed ai r s ys te m. JA MA 1970;2 11:18461847. 145. Gilmou r IJ , Mc Comb C, Palah ni uk RJ . Con tamina tion of a hospi ta l ox ygen suppl y. Anes th A nalg 1990;71 :302304. 146. Anonymous . Ox ygen s ys te m contaminati on probed in patie nt de aths . B iomed Safe S ta nd 1996;26:5 758 . 147. Anonymous . Fi nal rul ing on Texas h ospi tal deaths . Bi omed Safe S tand 1996;26:124. 148. Cone ly J IM, Rai l to n R, MacKenzie A I. Ve nti lator problems caused by humidi ty i n the ai r s upplied f rom s impl e comp res sors. B r J An aes th 1981 ;53:5 49550. 149. Moss E . Dange rs seen poss ib le f rom con taminated med ic al gas es . A PS F News le tt 1993;8:67. 150. B jerri ng P , Oberg B . Bac teri al conta mina ti on of c ompressed air for med ic al us e. Ana es thes ia 1986;41:148150.

151. B jerri ng P , Oberg B . Pos s ible rol e of vac uum s ys tems and compress ed ai r generato rs i n c ros s -infec tion in the ICU. B r J Anaes th 1987;59:648650. 152. W arren RE , Ne ws om SW B , Matthe ws JA , et al. Medical g rade c ompress ed air. Lancet 1 986;1:1438. 153. Oberg B , B jerri ng P . Pne umatic su rgica l ins trumen ts an d pos tope rativ e i nfec tion . Lancet 1 985;2:1436 . 154. Anonymous . Risk of fire in s urgica l boo ms . Hea lth Dev ices Al erts 2005;29. 155. Ev ans F. Pi pedreams : don 't a band on your medical gas s ys te m. Medic al Gas Matte rs 2001;2:1 . P .49

Questions
For the fol low ing ques tions , s elec t the co rrec t answer. 1. T he normal pip eline pressure for o xyge n, nitrous oxide, and air in the Unite d S tates is A . 240 to 275 k Pa B . 275 to 345 k Pa C. 34 5 to 380 k Pa D. 38 0 to 410 k Pa E . 410 to 440 k Pa V iew A ns we r2. The most frequently re ported malfunction in medical gas pipeline s ystems is A . Inad equa te press ure B . Cross c onnec tion C. Ex ces siv e pressure D. A larm dysfunction E . Contamina ti on of gases V iew A ns we r3. Compressed air is most often supp lied by A . P ropo rtio ning dev ices B . Cylinde r bank s C. Concen trato rs D. Comp res sors E . Liqu id containers

V iew A ns we r4. The DIS S is used fo r devices at pressures of _____ or less. A . 345 kP a B . 690 kP a C. 10 00 kPa D. 13 80 kPa E . 2000 k Pa V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i f D is correc t i f A , B , C, and D a re co rrec t.

5. Wha t are the res ults of increased press ure in the oxygen pip eline sys tem? A . A i rway pos i tiv e end-exp irato ry press ure B . Gas b lender malfunc tion C. Flowmeter rupture D. Venti lato r malfunc tion V iew A ns we r6. The follow ing provide standards fo r pipeline sys tems: A . Na tional Fi re P ro tec tion As sociation (NFPA ) B . Underwri te rs Labora to ri es (UL ) C. Comp res sed Gas As soc iati on (CGA ) D. As soc iati on for the Adv anc ement of Medical Ins trumen tation (AA MI) V iew A ns we r7. Functio ns of th e Join t Commiss ion on Acc reditation of Hea lthcare Organ iza tions (JCAHO) in relation to medical gas pipeline syste ms include A . Inspec ting s ys tems B . Ce rtifying pipel ine ins tallatio ns C. Certif ying procedures rel ating to pi peline us age D. Ensuring c ompliance wi th the v ario us s tanda rds that appl y to pi peli ne s ys tems V iew A ns we r8. Central gas supplies may b e loca ted A . Insi de in a s peci al roo m us ed onl y for this purpos e B . Outdo ors C. In an enclos ure

D. In a nonsterile area in the ope rating room s uite V iew A ns we r9. Oxygen may be supplied to the pipeline syste m by A . G and H c yl inders B . Ox ygen c once ntrators C. Bu lk l iq uid s ys tems D. C c yli nders V iew A ns we r10 . V aporization of liq uid oxygen in a bu lk tank w ill re sult in A . Loss of ox ygen to the atmos phe re B . Loss of ox ygen tha t may be greater than demand C. S ignif ic ant loss of oxy gen ev en though th ere is no use D. Less loss if the rate of use is lo w V iew A ns we r11 . Heat mus t be supp lied to vap orize liquid oxygen beca use A . Liqu id ox ygen wi l l freeze because of the l ow s to rage tempe rature B . As the temperatu re falls , the pres sure in th e tank fal ls C. Vaporization c auses the pressu re to f al l D. The h eat o f v aporizati on wil l c ause the te mperatu re to fal l V iew A ns we r12 . NFPA reg ula tions re quire a shutoff valve A . A t ev ery la teral b ranch, adjacent to the connec tion to th e riser B . Outsi de eac h operatin g room C. Ins ide each c ri tic al ca re area D. A t e ach ris er, a dj acen t to the c onnec tion to the main s upply line V iew A ns we r13 . A master ala rm system panel s hould be loca ted A . In the off ic e of the pers on respons ible f or maintenance of the s ys tem B . In the operating room C. A t the s wi tchboard o r secu ri ty off ic e D. In c ri tic al ca re areas V iew A ns we r14 . T he DISS A . Is used f or gases at pressures of 250 psig or less B . Is used a t all wal l outlets C. Ac hiev es noninte rchangeabi li ty by us ing different s c re w threads D. Is requi red on all pipe li ne inle ts on an es thes ia mac hin es V iew A ns we r15 . P reuse testing of a pipeline syste m should include A . P ress ure testing B . P u rge tes ting C. Tes ting for c ross c onnec tions D. Tes ting for the purity of the gas es

V iew A ns we r16 . Quick connecto rs A . P rov ide noninte rch ange able connec tions B . A l low appa ratus to be c onnec ted or disconnec te d b y a s ingle ac ti on C. May require the us e of one or b oth h ands D. Do no t requi re the use of tools V iew A ns we rP .50

17. Cros s c onnec tions of pipelines A . Mos t commo nly inv olv e ox yg en and ni trogen B . May b e c aus ed by dev ices not i n use C. Can b e detec ted by al arms requi red by NFPA s tanda rds D. A re most c ommonl y ass oci ated with construc tion, alterati ons , or repai r V iew A ns we r18 . Whic h componen ts are p art o f a med ica l gas distribution system? A . Te rminal uni ts B . Central s upply C. P ipel ines D. Hoses betwee n the wal l ou tl et an d the an es thes ia mac hine V iew A ns we r19 . Loca tion of area ala rms in clude A . Critical l ife support areas B . Ups tream of the shutoff v alv e in anes thetiz in g loc ations C. Each anes th etizing l ocation D. Downs trea m of the s hutoff v alv e in the c ritic al l ife su pport areas V iew A ns we r20 . Whic h of the follow ing w ill activate an alarm? A . Th e ma in s uppl y reaches two days ' supply B . Th e res erv e s uppl y be gins to sup pl y the s ys tem C. The res erv e s uppl y reach es an av erage of two da ys ' supp ly D. The s eco ndary supply begins to su pply th e s ys tem V iew A ns we r

Chapter 3 Suction Equipment

The purpose of s uc tioning is to remov e and/or co ll ec t solids , gases , and l iqu ids f rom the patien t, air way dev ic es , a nd the pati en t's env i ronment. S uc ti oning is an i mportan t part of anes thes ia prac tice and an es sen tial proc edure for patien ts requi ri ng prolonged intuba tion to p rev ent infec tions and na rrowi ng of artif ic ial ai rwa ys . S hould v omi ti ng or regu rgi tation oc cur, suc tioning c an be lifes av ing . P .52

TABLE 3.1 Pressure Equivalents Unit 1 kPa 1 inch Hg 1 mm Hg 1 3.386 0.1333 kPa Inches Hg mm Hg 0.295 1 0.004 7.501 25.4 1 cm H2O 111.5 330 0.77

1 cm H2O

1.73

0.052

13

General Principles Negative Pressure

V acuu m wil l be used in this chap te r to denote a pres sure les s than a tmos pheric (negativ e pressu re). S uc ti on (mechanic al as pi rati on) is the mov ement of gas es , l iquids , or s olids c aus ed by v ac uum. Vac uum is us ual ly s ta ted in gauge p res sure, the difference be twe en the measured press ure and ambient atmos pheric pres sure ( whi ch is zero o n the gauge). P ressu re i s the amo unt of forc e ac ting on a giv en area, s ometimes to mainta in a l iquid (me rc ury or wate r) at a c ertai n height. Tab le 3.1 giv es so me c ommonl y us ed press ure units .

Flow
A complete s uc ti on appara tus is sho wn i n Fi gure 3.1 . A ll the s uction equi pme nt from the s ource to the patient co nnec tion c an b e tho ught of as a tube of v arying di ameter. W he n the v acuum sourc e is attached or turned ON, f lo w through the equ ipment wi ll occu r. The rate of f low wi ll depend on th e press ure differenc e between the ends of the tube and the res istanc e to flow. T o ensure good flow, the max imum v acuum and the sho rtest possi bl e length of tubing shoul d be used ; the internal diame ter of tu bi ngs , connec tors , and the suc tion ca the ter should be as large as pos s ible ; and the v ac uum s ys tem s hould not leak (1). Inc reasing the nu mber of intak es to the piped v ac uum s ys tem wi ll res ult in a dec reas e i n v acuum and flow at each intak e.

Figure 3.1 Complete suction system. Normally, liquids and solids do not move any farther than the collection container. Note the deflector on the collection container.
View Figure

Fl ow th rough s uc tion appa ratus is also affec ted by the phys ical c harac teris tics (elas tic i ty, v isc osi ty , adhes ion, and c ohes ion) of the ma terial being s uc tioned. W ater or s aline drawn through a suc tion catheter befo re us e may ac t as a l ubric ant and improv e f low. A fter materia l enters the co ll ec ti on con taine r, i t no longe r causes resis tance to fl ow.

Equipment Vacuum Sources

Suc tion appara tus requ ires a source that c an gene rate a suba tmos phe ric pressure. The mos t commo n s ourc e of v acuum in health c are faci li ties is the pipel in e s ys tem.

In loc ati ons wh ere termina l inle ts are unav ai lab le , portable dev ices (s ee Fi g. 3.5) can be us ed.

Piped Vacuum
In the Uni ted S ta tes , the Na tiona l Fi re P rotec tion As soc iati on (NFP A ) produc es the s tandard that appl ies to piped v acuum sys te ms (2). The re is a ls o a n International S tanda rd (3). P .53

Figure 3.2 Piped vacuum system.

View Figure

The piped v acuum s ource inc ludes pu mp(s ) and one o r more reserv o irs (ho lding tanks , receiv ers , receiv er tanks ) (Fig. 3 .2). The s ys tem mus t be c apab le of mai ntaining a v acuum of 40.6 k P a (12 inches Hg) at the i nl et farthes t from th e v acuum sou rce wh en the c alculated demand for the faci li ty is drawn in to the s ys tem (2).

Pumps
The s ource mus t hav e at l eas t two pumps moun ted i n parallel , each c apable of mai ntaining the mi ni mum v acuum lev el with th e l arges t pump out of s e rv ice (2). These s erv e the s ys tem al te rna tel y or s imultaneo usl y, depending o n the de mand. Vac uum pumps mus t be con nec ted to the eme rgenc y elec trica l powe r supply . The exhaus t f rom the pumps should be dis cha rged o utdoors . The exhaust s hould not be loc ated nea r a door, wi ndow, a ir i ntake , or other opening in the building.

P rev ail in g wi nds , ad jac ent buildings , topograph y, an d other fac tors need to be cons idered when c hoos ing the exh aus t location.

Receiver
The rece iv e r (rese rv oir) has the same func tion i n a piped v acuum s ys tem as in a co mp res sed ai r s ys tem. It helps to ev en out the v acuum an d dec reas es pump c ycl ing . Fluids or so lids may enter the v acuum sys tem and c ol lec t in thes e tanks. The re sh ould be a d rain mechanism tha t prev ents thei r bui ldup yet does no t i nte rrupt s erv ic e f rom the sys tem.

Piping
The pipe li ne s ys tem (Fig. 3.3) connec ts the cen tral v acuum sou rc e to te rminal u nits (inlets ) throughout the fac ili ty . Components suc h as shut-off v alv es, pressure gauges , al arms , and such are s imila r to those of medical gas pipel ines (2 ). The pipes are us ual ly of the s ame mate ri al as used fo r medical gases but are l arger. The in ternal pi pe diameter is the mos t c ri tic al fac tor i n assu ri ng adequate performance in a piped v acuu m sys tem. W hen a pipel ine sys tem is des igned, pipes are s i zed acc ordin g to the expec ted loa d. If addi tional inlets a re added to the s ys tem, the v acuum av ai la bl e to the ex is ti ng inlets is reduce d.

Vacuum Inlets
A v ac uum inlet (see F ig. 3.8 ) mus t be n oninterc hangeabl e with those of o ther se rv ices , inc luding those for anes thetic gas-scav eng ing s ys tems . They sho ul d remain c losed when there is no c omponent attached. W hen an area of a health care fac i li ty is planned, i t is impo rtant that an adequate number of v ac uum in lets be i ns tal led. If this is not done, one or more Y connec tors wi ll need to b e used (Fig . 3.4). This wil l dec rease the v ac uum and ai rflo w. P .54

Figure 3.3 Pipeline distribution system for vacuum.

View Figure

P .55

Figure 3.4 Use of multiple Y connectors will result in reduced vacuum and flow.

View Figure

Portable Suction Units

Porta bl e s uc tion uni ts (Fig . 3.5) are useful in locations where piped v ac uum is not av ailab le. Wh il e thes e dev ic es may not perform as we ll as piped v ac uum s ys tems , they are usuall y adequate for c li nical purpos es (4,5). Mos t mo bi le uni ts hav e the pump , c ol lec tion c ontainer, gauge, and contro ls on a c a rt wi th c as ters . Some units

can be h andheld. Heal th c are fac il iti es usi ng mobi le uni ts s hould rea lize that thei r mai ntenance requi rements are s ignificant (6). P ortable s uc tion equipme nt may be contamina ted more frequ ently than piped units (7 ). If a portable s uc tion s ource is us ed, the exhaus t is ev acua ted into the room. This c oul d be a s ourc e of inf ec tion for both the pati en t and pe rso nnel in the roo m. Mos t units hav e a b ac terial fi lter to prev ent this , but the fil ter can become he avi ly s oiled and needs to be changed regularly (8).

Figure 3.5 Portable suction unit.

View Figure

Electrically Powered
E lec tric i ty, ei th er f rom the ma in l ine o r batte ry, powers mos t portable suc tion dev ic es . B attery life v aries wi th the indiv idual u ni t but c an be as high as 45 minutes . A n i nternation al s tand ard c ov ers th ese dev ic es (9 ).

Manually Powered
Manu al ly-po were d s uc tion dev ices hav e a pumping dev ice powe red by hand or foot (4,5 ,10 ). Us ual ly , th is is a spring-loaded bello ws arrangement wi th unidirec ti onal v alv es (11 ). Many of these dev ices do no t hav e p res sure regula tors or pres sure gauges . Handheld uni ts are av ai lable. An internati onal s tandard cov ers these uni ts (12). For tra nspo rt, a s imp le dev ice can be c reated by attaching a s uc ti on ca the ter to a s yringe (13).

Venturi Powered

A V enturi tube (ej ec tor) po were d b y a c ompressed gas (us uall y air) ca n be used as the source of negativ e pressu re i n portable suc tion apparatus (5,14). This type of dev ic e can be noisy and was tes gas .

Vacuum Regulator and Gauge

A v ac uum reg ula tor (Fi g. 3 .6) allows the ope rator to c ontro l the max imum negativ e press ure at the inlet to the suc tion a pparatus . There usuall y is a gauge to indicate the pressure on the patien t s ide of the regulator. The gauge ma y ind ic ate pres sure c loc k wi se or counterc lock wi se. There ma y als o be a c ontro l th at al lows the P .56 operator to s wi tc h between regulated v ac uum, full v ac uum, and OF F (Fig. 3.6). Magn etic reson ance imaging (MRI)-s afe and -compatible v ac uum regula tors are av ailab le.

Figure 3.6 Vacuum regulators and guages. Note that the indicator on the gauge may move clockwise (A) or counterclockwise (B).

View Figure

The re are two types of c ontroller: conv en tional hi gh suc tion and low s uc tion (11 ). Low suc tion c ontroll ers a re deliberate ly l imited to prov ide s afe suc tion for c e rtai n us es suc h as intrapleural drainage or gas tri c suc tion ing .

Trap Bottle
A trap (s afe ty ) bottle (ov erfl ow saf ety trap) (Fig . 3.7) si tuated between the co ll ec ti on container and the v acuum s ourc e or regulator wi ll pro tec t aga ins t l iqu ids and s olids flo win g i nto th e v acuum s ys tem. Some times , ov erfl ow dev ic es on th e co ll ec ti on container (se e page 59 and Fig. 3.1 1B) do no t fu nc tion c orrec tl y.

Inte rmi ttent s uction tub in g obs truc tion c an c aus e f ro th ing and s pl ashing in the co ll ec ti on container, whi ch c ould escape into the v acuum s ys tem. This mak es the us e of a trap bottle nec essa ry .

Filters
Fi lters are used to mi ni miz e partic les and f luids passing i nto and contaminating the disc harge are a and to protec t downs tream equi pmen t (es pec ial l y regula to rs and pumps ) (Fig . 3.8). The fil ter ma y be part of the coll ectio n c ontai ner. Us ing f il te rs in suc tion s ys tems is con trov ers ial (15). If wet or d irty , they can be a sourc e o f obs truc tion. W i th piped sys tems , a fil te r is reco mmended but not es senti al becaus e aerosols are d irec ted into the pipel in e, presenting no di rec t contamina ti on risk . W ith portab le s uc tion s ources , a f i lter on the pump disc harge is es senti al to p rev ent aerosols from contaminatin g the room air. Fi l ters requi re routine i nspec tion and frequent repl acement.

ON-OFF Valve
To reduc e the load on the v ac uum s ys tem and to e nsure good p erf ormance wh en v acuum is needed, s uc ti on apparatus shou ld be turn ed OFF when no t in us e. The ON-OFF v alv e may be on the anes thesia machine (F ig. 3.9A) or independent f rom the mac hi ne (Fig . 3.9B ). The ON-OF F v alv e may also be part of a regulator (Fig . 3.6).

Tubing
The intermediate tubing is loc ated between the collection c ontainer and the v acuum sourc e (9,16) (Fig. 3.1). The s uc tion (patient, dra inage) tubi ng is between the P .57 co ll ec ti on container and the patien t. It i s better to hav e a long leng th of intermitte nt tubi ng th an a long len gth of suc ti on tubing. The wa ll thickness of both tubings shoul d be adequate to prev en t th em f rom co llaps ing when exp osed to high nega tiv e press ures .

Figure 3.7 Trap bottle. A trap bottle is needed to prevent liquids and solids that pass through the collection container from entering the vacuum source.

View Figure

The s uc tio n tubing should be trans parent s o that ma te ri als c an be seen pass ing through i t. It s hould be arranged to mi nimi ze loops that can acc umulate l iqui d and i nc reas e the poten tial for oc c lusi on. S hort, large-bore tub ing wi l l re duce resis tance , resul t i n a higher f low rate , and is less likely to obs truc t (17,18). The suc ti on tubi ng shoul d be long enough so that i t is wi th in eas y reach and the catheter c an be mane uv ered eas ily once it is attached . If the s uc tion c atheter is not l arge enough to c lear particulate mate rial or the v olume of fluid, the s uc tion tu bing can be us ed withou t a catheter.

Collection Container
The c ollec tion (c ollec ti ng, suc tion) c ontai ner (bottl e, c anis ter, d ev ice, jar, v essel) (Fig . 3.10) is where aspi ra ted materia ls are coll ec ted and measured. A t p res ent, mos t collec tion c ontai ners a re made of plastic an d a re disposable. Reusable plas tic containers that c an be c leane d and disinfected in au toma tic machines a re av ailab le.

Figure 3.8 A filter will help to protect the vacuum source from liquids or solids.

View Figure

The re is usua ll y a scale on the side of the col lec tion c ontainer to allow an es timation of the amo unt o f its con ten ts . A d efl ec tor ma y be present at th e bas e of the inlet port to turn the s tream en te ri ng the c ontainer toward the c ontainer wal l and p rev ent i ncoming l iquid from o bstruc ting the ex i t po rt (Fig . 3.1). It a lso dec reas es fluid ag itatio n, whic h causes foam and ae ros ol ge nerati on . S ome containers hav e an antifoam s ubs tanc e i ns ide the patient po rt to re duce f rothing (9,19). Foaming is undes irabl e beca use i t may cause premature cl os ure of the ov erf ill p rotec ti on dev ic e; may pas s beyond th e c ollec tion container and contamina te the fil ter o r pump, c aus ing p ump fai lure ; and mak es it diff ic ult to es timate the amount of as pi ra te i n the v essel (11 ). A su bstance (gel ling a gent) may be present or added to the co llec tion con taine r to cause the fluid ins ide the container to s olidify . A typic al dispos able canis te r has a remov ab le l id that h as a v ac uum port with an ov erf ill p rotec ti on mechanism P .58 and a n i nl et port (Fi g. 3.11). A n ad ditional port may be pres en t to allow tan dem suc tion ing (the use of two or more c anis ters c onnec ted in se ries so that as pi rate f lows i nto the s econ d c anis ter whe n the f irst f ills ). A tandem a rrange ment is used whe n a large v olume of as pi rate is antici pated. Thes e ports s hould b e c learl y

l abeled. A pouring p ort ma y be present. Eac h port s hou ld hav e an attac hed tig htf itting sn ap-on cov er.

Figure 3.9 A: On-off valve for suction on the anesthesia machine. B: On-off valve near the regulator

View Figure

Semi dis posable col lec tion containers are av ai lable . In thes e, a line r is attached to the lid and s eats in a reusable housing. The as pi ra te c ollec ts in the line r. The li d and li ner are discarded a fter us e. P .59

Figure 3.10 Collection container attached to the side of an anesthesia machine.

View Figure

The v olu me of the c ol lec tion c onta in er is important. It needs to be la rge enough s o that i t does not need frequent emp ty ing . Howev er, a large con taine r wil l prol ong the time nee ded to reac h maxi mum v acuu m and f low at the patient connec tion. W i th the pedia tric pa ti ent, s ma ller c ontainers s hould be used for mo re acc urate meas urement. The loca ti on of the co llec tion container is importan t. It should be c lose to the point of use and plac ed where i t is unlikel y to be tipp ed or cause tri pping. An adv antage of hav ing i t lo wer than the patien t is that grav ity helps to remov e liquids and s ol ids . If it is located highe r than the p ati ent, i t may be eas ier to observ e, but more negativ e p res sure wil l be requi red to l if t materi als in to the con tai ner. An additi onal problem with a hig her loc a ti on is that if the v acuum is i nterrup ted , fl ui d in the suc tion tubing c ou ld retu rn to the pa tient. For i ntermitte nt gas trointes tin al s uc ti on , i t is p referable to hav e the c ontainer abov e th e patien t (20). For co ntinuous gas trointes tinal suc ti on , the c ontai ner may b e p lac ed below th e patien t. A new c on taine r shou ld be us ed fo r eac h p ati en t. W hen s uc tion is no l onge r needed or wh en the aspi ra te l ev el approac hes the las t gradua tion on the v olume sca le , the canis te r should be c appe d (or the patient an d v acuum ports con nec ted wi th a piece of tubing ) and dispos ed of o r c leaned and di sinfec ted.

Overfill Protection Device

If liquid or f oam fl ows do wns tream of the c ol lec ti on container, the v acuum s ou rc e and regu lator may b e damage d (14). To av oi d this , an ov erfill pro tec tion dev ic e (ov erfi l l, c ut-off, ov erflow, anti-ov e rf lo w or shut-o ff v alv e, dev ice, o r mecha nis m) is us ual ly plac ed in the c ol lec tio n c ontainer l id. A typic al dev ice consis ts of a f loat that is lif ted by the f luid as the contai ner fi lls (Fig. 3 .11B). It s hould not ac tiv ate unti l the canis ter c ontains at leas t 90% of its nominal capaci ty (9). P roblems hav e been reported wi th ov erfil l protec tion dev ices . Some may be ac tiv ated i f v ibra ted, jarred, o r ti l ted .

Special Adaptors
A specia l adapto r with an opening can be us ed to al low a s uc tion c atheter to be i ntroduc ed into the ai rwa y during mec hanica l v en ti lation wi th out disc onnec ting the pati ent f rom the v en tila tor c i rc uit and with min imal or no ai r l eak . These c an be us ed to reduc e h ypox emia assoc ia ted wi th s uc tioning (21 ,22 ,23,24,25,26,27).

Suction Catheters
Suc tion cathe ters (nozzles or h and piec es ) are us ua ll y made of plas tic . Rubbe r ca the ters are no l onger i n gene ral use. There is an intern ati ona l (28) and a U.S . s tandard (29) on s uctio n catheters .

Shaft
The s haf t is the main part of the catheter. A transp arent shaft mak es i t eas ie r to determine if material is b eing remov ed (30). T he dis tance f rom the patien t end is marked on s ome c atheters . Suc tion cathe ters are s ized by th e ex ternal diameter and shaf t l ength, both in mi ll ime ters . F or c lose d s ys tem catheters , the mark ed length is the length tha t c an be i nserted in to the patient's ai rwa y. The outs ide diame ter ma y als o be express ed i n F rench gauge (Cha rrie re) s ize, whi ch is three times the ex ternal d ia me te r in mi ll ime ters . A n optional s ys tem of color i den tification at the mac hine en d has bee n i ncorporated in to the In ternational S tandards Organi zation (IS O) but not the U.S . ca the ter s tandard (28 ,3 1). Tabl e 3.2 s hows the color identification. P .60

Figure 3.11 Lid for collection container. A: The top of the lid has two ports. The center one is the inlet port, and the other (at the 1 o'clock position) is an outlet port. There is an additional port (capped) for use with tandem suctioning. At the left is a drain spout. Note the caps at the perimeter. These should be placed over the ports before transporting a used container. B: The underside of the lid. The overfill protection device is in the center.

View Figure

The c athete r should b e l arge enough to remov e s ec retions rapi dl y but not bloc k the ai rwa y. Catheter s iz e is es peci al ly important i f the catheter is placed ins ide a trac heal or trac heos tomy tube . Smal ler catheters a llow more ai r to be entrai ned around the cathe ter, l imi ting the nega tiv e press ure that is applied to the lungs . Thin, c opi ous s ec reti ons c an usually be remov ed wi th a rel ativ ely s mall catheter, whi l e thick, tenac ious s ec retions requ ire a larger o ne. The re are a number of di fferent suc tion c ath ete rs des igned for partic ula r uses (Fig. 3.12). The ax is at the p ati ent end may be at a n angl e to the long axis of the shaft (Coud ) (Fi g. 3 .12 D). Cu rv ed-ti p c atheters fac il itate ins erti on in to the desi red mai ns tem bro nchus (32 ,33 ,3 4,35,36). A gu id e ma rk makes it eas ier to d irec t the tip (37). J -s haped c atheter tips a re us efu l fo r suc tioning the right upper lobe b ronc hus (38,39,40). Double-lumen catheters with a lumen f or oxygen ins uffl ation or for i ns til l ing s al ine are av ail able (41,42,43,44). A s ingle -l umen insuff la ting suc ti on ca the ter tha t allows e ither ins uffl ati on or suc tion has been desc ri bed (45). A ri gid (Yanka uer, tons i l suc ti on ) c atheter (Fi g. 3.13) is useful for suc tioning under di rec t v ision, espec ially i n the oral c av i ty . It c an re mov e large v olumes of fluid more rapidl y than a f lex ible c athete r but c arri es the ris k of denta l damage. Ev en the Yankaue r ti p may not be big en ough to cl ear c ommon particulate P .61

material suc h as v omi tus (46). The ref ore, l arg e-d iame ter s uc ti on tu bing s hould be av ailab le.

TABLE 3.2 Color Identification for Designated Size of Suction Catheter and French Gauge Sizes Nominal Outside Diameter (millimeters) 1.67 French (Charriere) Size Equivalent 5 Color Identification Gray

2.0 2.5 2.67

6 7.5 8

Light green Pink Light blue

3.0 3.33

9 10

Turquoise Black

4.0 4.67

12 14

White Green

5.0 5.33 6.0 6.67

15 16 18 20

Brown Orange Red Yellow

Patient End
The patient end of the suc tion ca the ter shou ld be rounded to prev ent muc os al dama ge. A v a riety of ti ps are av ail able (47 ,4 8) (F ig. 3.1 2). The American S ociety for Tes ting and Materials (AS TM) ca the ter sta ndard (31 ) re qui res that the re be one or more eyes (s ide ho les ) nea r the pa tient end. T he diameter of the te rmi nal o rifice (the ce ntral openi ng at the pa tient end) must be at leas t 90% of the i nside diameter of the ca the ter (28 ,31 ). The tip and s ide holes (eyes ) s hould be s mooth. Tips wi th s ide holes g rab less muc osa than si ngle-holed cathe ters (49 ). Ho wev e r, hav ing more tha n one hole at the ti p wil l reduc e the av aila ble v acuum (50).

Figure 3.12 Flexible suction catheter tips. A: The whistle tip catheter has two side holes, usually perpendicular to each other. B: Tip with a single side hole. C: Tip with a single end hole and no side holes. D: A curved (Coud) tip is often used for bronchial suctioning.

View Figure

Figure 3.13 Yankauer suction catheter. Most Yankauer suction catheters have a single hole and several eyes near the tip. Some have finger vents.

View Figure

Machine End
The mac hine end is connec ted to the sou rce of v acuum. It usuall y has a se mirig id or e las to meric male c onnec tor but ma y be fema le (28,31). If the pa tient end of the ca the ter is c u rv ed, the machine en d s hould hav e a means to indica te the direc tion i n whic h the tip po in ts . P .62

Vacuum Control
W hatev e r type of ca the te r is us ed fo r tracheal or bronchial s uc tio ning, there mus t be a method to periodica ll y in terrupt the suc tion wi thout hav ing to s wi tch the wh ole unit off . This allows the ca the te r to be introduced wi th out appl ied s uc tio n and permi ts inte rmi ttent suc tion when wi th dra wing the c athe ter (51). If the c atheter tip i s occl uded by tiss ue, the fu ll v acuum forc e wi ll b e appl ied, and a ttempts to pull the ca the ter away could resu lt in trauma. The vac uum control ca n be opened to break the seal and al lo w the tis sue to fal l away f ro m the c atheter. The v acuum co ntrol port (f in gerhole, v ent, vacu um b reaker, s ide port, leak -in opening) c an eithe r be part of the mach ine end of the catheter (Fig . 3.14) or can be part of a s eparate connec tor be tween the ca the te r and suc tion tubing. This a llows the operator to s witch the flow in the catheter ON and OFF by s impl y cov ering o r uncov ering the v ent.

Closed Suction Catheter System Description

A c losed (in -l ine) suc tion c a thete r (Fi gs . 3.15, 3.16) u ti l iz es an enc los ed transparent, f lex ib le plas tic sl eev e (s heath ) th at is a ttach ed to a spec ial ly des igned T-piec e adaptor, wh ic h is left in place a djacent to the trache al tube. It a ls o c an be attached to a T -piec e a daptor (52). The adaptor co nta ins a s eal in g assembly ( washe r, c leansi ng co llar) to prev ent gas l eak s around the catheter an d to remov e sec re tions f rom i ts ex ternal s urface as it is drawn bac k in to the shea th. A t the o ther end a re a manua l v ac uum control and a co nnec tion for th e suc ti on tubing. It may be possible to lock the suc tion control v alv e in th e OF F posi tion. An irri gation (f lus h, i njec tion) port may be pres ent at e ither end fo r tracheal lav age with th e c atheter i nserted or fo r ri ns ing the catheter, cl eans ing c ol la r, and suc tion tubing after the ca the ter is wi th dra wn f rom the ai rwa y. A phy sic al P .63 partition (rota ting piece of plas tic , duck bill , or p las tic sl ide) may be present between the suc tion c athete r and the patient (53).

Figure 3.14 Vacuum control on a suction catheter.

View Figure

Figure 3.15 Closed suction catheter. Note the mark on the catheter that is visible when the catheter is withdrawn.

View Figure

Figure 3.16 Closed suction catheter.

View Figure

W hen no t in us e, the c atheter res ts in the wi thd rawn p osi tion j us t outs ide the ai rwa y. Mos t catheters hav e a mark ing that i s v is ib le when the ca the ter is prope rl y wi th dra wn (Fi g. 3.15). Vari ous catheter s iz es and lengths as we ll as a c atheter wi th a di rec tional ti p are av ailab le. Othe r featu res that ma y be present inc lu de an acc ess v alv e on the adaptor, a means to thread a bronchosco pe through the pa ti ent c onnec tor, a s wiv el l av age port, c olo r-coded c atheters , and the abi l ity to replace the catheter i ndependentl y of the adaptor (5 4).

Advantages
A c losed s uc tion s ys tem offers s ev eral adv antages ov er an op en s ys tem (a ttach ing a c atheter to a v acuum s ource, dis connec tin g the pa tient f rom the v enti lato r, i nserting the catheter through the tracheal tube, suc tioning , th en rec onnec ting the pati ent to the v entil ator). Th ere is no need to discon ti nue v entilation o r pos itiv e end-expi ratory pressu re (PE EP ) whi le s uc tio ning, al thoug h both the minute v ol ume and e nd-expi rato ry press ure wi l l be s omewhat lowered (5 5,56,57,58,59,60,61,62). Ox ygena tion is usual l y supe rior to the open suc tion technique (56,58,63,64,65,66,67,68). Close d s uc tioning may make i t unneces sary to hyperox yg enate prior to suc ti oning (69). It is as soc iated wi th fewer c ard iov asc ula r dis turbanc es ; dec rease d c oughing, agitation , and s tre nuous muscl e ac tiv i ty; and l ess pa tient anx iety (68 ,70 ,71 ). The c los ed suc ti on s ys tem is conv enient. Suc tion ing c an be performed eas il y and quick ly b y one caregiv er. It allo ws easy i nsti llatio n of fluids into the trac hea. Equipme nt se tup and cleanup is s impl e. It is pe rce iv ed by s taff to be easi er and l ess time co nsuming than open s uc tioning (72 ). It do es not c ause mec hanica l v enti lato r malfunc tion (60). Bec ause the cathe ter is enc losed wi th in a steri l e clos ed s ys tem, c on ta mi na tion from ac c idental b reaches in s teri le tec hni que s hould not oc cur. Rates of nosoc omia l i nfec tion hav e bee n fou nd to be less than or c omparable to rates assoc iate d with open suc tioni ng (71,7 2,73,74,75,76). A utoco ntamina ti on does not ap pear to be more of a problem wi th c losed than ope n s uc tioning (77 ). Cl osed s uc tion s ys tems l imi t co ntamina tion of the env ironment around the patient (78). Heal th c are pe rso nnel who use the s ys tem do no t need to fea r that sec re tions may be sp lashed back into thei r faces becaus e exha led materia l is p ropel led into the expi rato ry l imb of the v enti lator tubing. Howev er, c ondensate s howe ri ng from the irri gation port c an be a problem (79 ,8 0). F or th is reas on, gl ov es, a mas k , an d protec tiv e c lo thing shoul d be worn wh en perfo rming c losed s uc tioning. A c losed s ys tem suc tion catheter cos ts a pproxi matel y 1 0 ti mes more than a s ingle disposable ki t for ope n s ystem suc tioning (65,81,82,83). W hether i t is cos t eff ec tiv e depends on how often the patient is s uc tioned an d how long i t is use d. A l though mos t ins ti tuti ons c hange the ca thete r ev ery 24 hou rs , s tu di es in dic ate that longer us e is saf e and can further reduc e c os ts (84 ). So me researc hers hav e s ugges ted that the clos ed s ys tem s hou ld s tay in place as long as the patient is rec eiv ing

mechanical v enti la tion (8 5). Clos ed s ys te m suc tion ing c an lo wer c os ts by reduc ing personnel time and the s pread of inf ec tion.

Disadvantages
Some health care prov iders bel iev e that c losed s uc ti oni ng is not as effec tiv e in remov ing P .64 sec re tions as open s uc ti oning (52,71,76,79,80,81,86 ,87 ). In part, this may be becaus e with the ca th ete r encased i n a s heath, the suc ti on or s ec retions mov ing through the catheter are more diffic ul t to fee l, a nd the s ound is less (53 ,54). One s tudy foun d no s ig nifican t difference be twee n the two tec hniques i n th e quanti ti es of s ec retions remov ed ev en though th e s taff b eliev ed th at cl osed suc tion was less ef fec tiv e (87). Other s tudies f ound that open s uctioning wa s supe rior i n remov ing sec re tions (67,88). Perio dic use of open suc tion may be us efu l to i nc reas e sec re tion remov al in pa tients with thic k , tenac ious sec retions . Ho wev e r, this i nc reas es cos ts and may resu lt in loss of s teri li ty assoc ia ted wi th the c losed s ys tem (80). Ano the r disadv antage of c losed suc tion s ystems is that the ex tra wei ght may pull on the ai rway , caus ing trauma or acciden tal ex tubation. It is i mpo rtant that the s ys tem be s uppo rted to prev ent these problems . Yet another problem is inc reas ed resis tance in hygros copic condens er humidifiers due to s aline ins tal lations (89). Some health care prov iders hav e c omplain ed that the s ys tem is more diff ic ul t to us e, does not prov ide the same fee l associa te d wi th c onv entional suc tioning, and may cause more trauma (52,8 0,81,87,90). The v ac uum con trol v alv e may s tick (91).

Continuous Irrigation Suction Catheter

The c ontinuous i rrig ati on suc tion c athete r is a doubl e-lumen c atheter that al lows s imul ta neous ins ti ll ati on of flui d and as pi rati on. S tudies s how tha t this is more ef fec tiv e than a co nv en tional suc tion catheter i n cl earing s ec retions (44 ,9 2).

Packaging
Fl exible c atheters ma y be pack aged e ither c oiled or s trai ght. Catheters tha t are packaged s traight are eas ier to remov e f rom the pac kage , c an be i ntroduced i nto the patie nt more eas il y, and a re more e ffec tiv e for lef t bronc hi al s uc tioning (93).

Suction Apparatus Efficiency

The eff ic iency of s uc tion apparatus dep ends on the s ubatmosph eric pressu re generate d and the ti me tak en to ach iev e it, the displacement (the v olume of ai r that the pump is able to mov e in uni t ti me), the internal res is tanc e of the suc tion apparatus as a wh ole, and the v iscosi ty of the matte r being asp irated (11).

Suctioning Techniques
The f irs t s tep in s uc tioni ng tec hn ique is to set the maxi mum nega tiv e press ure . Before adjus ting tha t pressu re, the regul ator ou tlet mus t be occ luded. This c an be done either by plac ing a fi nge r ov er the c ollec tion c on taine r in tak e or by c rimping the suc tion tubing c losed (Fig . 3.17). The gauge wi ll then regis ter the max imum v acuum th at can be gene rated at that setti ng.

Figure 3.17 The negative pressure should be set by occluding the suction tubing and adjusting the regulator while observing the gauge.

View Figure

W hen no t in us e, the v ac uum s ourc e should be turned OFF or the suc tion tubing k ink ed (Fig. 3 .18 ) to reduc e the load on the s ys tem and i mprov e the pressure and f low av ailab le at o th er inle ts . It a ls o p rev ents dust and deb ris from b eing suc tioned i nto the regul ator and othe r equipmen t. K ink ing the suc tion tubing al lo ws maximum v acuum to be q uic k l y res tored. Dev ic es for holding the s uc tion c atheter betwee n uses are av ai lable (94 ). Th e anes thes ia prov ider c an put the suc tion c a th ete r in the holder a rm between us es .

Suctioning under Direct Vision

A ri gi d catheter wi th a terminal opening (Yank auer) may be us ed to qu ick ly remov e l arge mucous p lugs , v omitus , blood c lots , or l arge v olumes of fluid. It s hould be

us ed onl y unde r di rec t v is ion and wi th a v acuum con trol dev ice. In a s ev e re emergenc y, the suc tion c athete r may be P .65 remov ed a nd the en d of the suc tion tubing used di rec tly . A fl exible s uction catheter can als o be used f or suc tioning un der d irec t v is io n. It cannot be di rec ted as eas il y but is less lik el y to damage the teeth.

Figure 3.18 Keeping the suction tubing kinked when not in use will allow maximum vacuum to be restored quickly. It also reduces the strain on the vacuum system.

View Figure

An end osc ope can be used to d irec t the c a the ter to c lots or mucous plugs in the l ower a irway (9 5,96,97). Large blood c lots or muco us plugs in the lower a irways may requi re a tube wi th a la rge diame ter (such as a trache al tube) (96 ).

Mouth and Pharyngeal Suctioning

Suc tioni ng the mouth and pha rynx can be performed by us ing ei the r a ri gid o r f lex ib le ca the te r. If the tee th are c lenc hed, it may be possi bl e to insert the catheter l ate ral ly behind the las t molar or where teeth are miss ing . Damage to the teeth may oc cur i f a ri gi d catheter is us ed . Mos t f luids found in the mouth and pha rynx are no t highl y v iscous and are eas il y remov ed. If there is a large amount o f blood or v omi tus , i ns ti lli ng water i nto the area being suc tioning may ai d re mov al . Us ually s ize 14 18 French c athete rs are us ed in adul ts . Many a nes thes ia prov ide rs us e unregula ted v acuum for oral or pharyng eal s uc tionin g. This may resul t i n mucos al trau ma (98,99).

A flex ible catheter c an be inserted through a nasophary ngea l or orophary ngeal ai rwa y. Th e ex ternal su rface of the ca the ter should f irs t be thoroughly lubricated. Suc tioni ng through the nas al c av ity wi thout an ai rwa y may res ul t in ep is tax is . The v acuum co ntrol on the ca th ete r shou ld be op en whi le ins e rting the ca the ter. The c athete r should b e wi thdrawn s lowl y with a twi s ting motion whi le inte rmi ttentl y oc c luding the v acuum c ontrol .

Suctioning Associated with Extubation

Prior to ex tubation , s ec retions in the mouth and pharynx s hould be remov ed. Th is can be acco mp lis hed with th e s ame catheter that wa s used f or trac heal tube suc tion ing . Af ter oro pharyngeal s uc tioni ng, the tracheal tube c uff shou ld be defl ated and the tube remov ed whi l e appl ying co ntinuo us pos itiv e pressure. An a lternativ e is to hav e the patie nt take a deep b rea th wi th ex tubation at the end of ins pi ra tion. S ec reti ons around the tube sho ul d be expell ed as the patie nt exh al es. The oropharynx s hould then be suc ti oned to remov e ex pel le d s ec retions . In the pas t, some anes thes ia prov iders ex tubated the patient whi l e s uc tion was applied to the trac heal tube. The rational e behi nd this maneuv e r was to remov e any sec re tions that may hav e passed into the trachea when the c uff was def lated . This i s not good prac tic e, bec aus e i t de ple tes the lungs of oxy gen, remov es th e path of reox ygena tion, and may resul t in n egativ e pre ssu re pulmona ry edema (10 0,101).

Open Suctioning through a Tracheal or Tracheostomy Tube

Mos t authorities adv ocate tha t trach eal s uc tioning be perfo rmed no more freque ntly than indicated by the cl inica l si tuation (93,102,103 ,104,105,106 ,107,108). Indications incl ude aud ib le sec re tions , a rise in peak inspi rato ry press ure , or an i nc reas e in the p eak i nspi rato ry press ureplateau press ure dif ferenc e, inc reas ed ai rwa y res is tance, dec reased dyna mic co mpli ance, dec reased tidal v olume deliv ery during pressu re-li mi ted v entilatio n, dec rement in arteria l blood-gas v alues or sa turatio n, inc reased end-ti dal carbon di oxide , al tered homodynamic , patient res tlessness , unre liev ed coughin g, an d ev idenc e of atelec tas is on ches t x -ra y (109). Routine suc ti oning may ac tuall y s timulate produc tion of ai rway s ec retions and c an be ass oc iated with more adv erse effec ts (110 ,11 1). The c athete r should b e i n the trac hea n o lon ger than nec ess ary and nev e r more than 10 to 15 s econds i n adul ts

P .66 (48,51,57,104,108,112). S horte r ti mes shoul d b e used for pedia tric pa tients (1 13). The negativ e pressure s hould be s et by oc cl uding the s uction tub in g and adjus ting the regulato r whi le observ i ng the gauge (Fig . 3.17). If the press ure is not deliberately s et, dangerous pressu res may b e generated (98 ). The nega tiv e press ure for suc tion in g the trac hea should b e no gre ate r than 70 to 150 mm Hg (9.3 to 20 k Pa, 50 to 115 cm H 2 O) in adu lts (20 ,4 8,57,81,1 04,108,110,1 12,114,11 5). For i nfa nts , the nega tiv e press ure should be no greater than 60 to 80 mm Hg (8.0 to 10.7 kPa ) (116,117). W hen co pious sec reti ons are present, i t may be nec ess ary to i nc reas e s uc tion p res sure to al low mo re effec tiv e remov al. Normal s ali ne, water, o r water-soluble j el ly may be us ed to l ubric ate the outs ide of the catheter prior to ins e rtion. Drawi ng wate r or sa li ne through a c atheter before us e ma y improv e flo w and chec ks catheter p atenc y. Hyperoxygenation, hy perv entila ti on, a nd hype rinf la tion prior to and follo wing suc tion ing wi l l help prev en t hypox emia (21,103,114 ,118,119,120 ,121,1 22,123,124,1 25,126,127 ,128), as wil l oxygen i nsuff lation during the procedure (41,42,129,1 30). Ins till ing s aline into the trac heal tube bef ore s uctio ning to dilu te sec re tions or generate a cough is c ontrov ersia l. It s hould hav e li ttle effec t on c leari ng sec re tions , becaus e mucus and wa ter are immis cible (112,131 ). A n excep tion may be pos toperativ e head and neck surgery patients wh o often hav e bloody sec re tions (132). The re are a number of pos si ble ne gativ e cons eque nces to ins til ling s aline into the trac hea. It c an dis lo dge bac te ri a or sec re ti ons f rom the tracheal tube wal l and wash them into the lowe r ai rway s (133,134). V ials a re frequently c ontamin ated during opening (135). Irri gation fl ui d ma y pool in the s wiv el and v entilator c onnec tors , caus ing s al ine to mix with bacteria in this area. Subs equent procedu res s uch as turn ing the patient or loweri ng the head may cause c onta minate d f luid to enter the pati ent's lowe r air way s . Ins till in g s al ine may h av e an adv erse eff ec t on patient co mfort and c ause hy pox emia (136,137,1 38,139,140 ,141). Another c onc ern is more env ironmental con tamina tion due to inc reased splashing. The s aline us ed to f lush in trav enous lines or no rmal s al ine intrav enous solutio ns shoul d not be us ed bec ause of the pres erv ativ es tha t may burn lung tissu e (113 ). A mask an d gown should be wo rn to p rotec t the he al th ca re prov ider.

Trac heal s uc tionin g requ ires as eptic techniq ue by us ing s terile glov es and a disposable s terile catheter. It ma y be helpful to wrap the s teri le c atheter around the glov ed hand to reduce the risk of c ontaminati on . If the suc ti on ca thete r is disc onnec ted, i t s hould b e p lac ed on a s teril e d rap e or glov e (104). A suc tion catheter used f or trac heal s uc ti oni ng also c an be us ed fo r oral and pharyngea l suc tioning. A c athete r th at has b een used for s uc tioning in the upp er ai rwa y shou ld be disc ard ed and a new, s te rile c athete r to uched only with a s teri le glov e used if further trac heal suc tioning is needed. The s ma ll es t c atheter neces sary to remov e the sec retions sho uld be used. The ex ternal diamete r of the catheter s hould be no more than half the i nside diameter of the tracheal tube (17,45,142,143). T his ma y b e d ifficult to ac hiev e in infants (103). The c athete r should b e i ns erted wi th a smoo th, gentle moti on, wi thout forc e and wi th out appl ying any neg ativ e pres sure (144 ). The tracheal tube shoul d be hand led ca reful ly to av oid c oughi ng and s training. If deep trac hea l suc tioning (enteri ng a mains tem bronchus ) is not needed , the ca the ter should be passed jus t beyond the e nd of the trach eal tube (103,113 ,115,145,146) (Fi g. 3-19). If the c atheter is ins erted too fa r, muc os al trau ma is more l ikel y to oc cur. If ins erti on is too sha ll ow, s ec retions in the tube ma y not be c leared (145). The bes t way to d ete rmine how f ar to ins e rt the catheter is to place an a ppropriately s i zed suc tion c athete r in to another trac heal tube of the s ame s ize. If the length from the pa tient end is ma rked on the ca the te r, this scal e can be us ed to determine the co rrec t depth o f inserti on . If resis tanc e is met duri ng ca the ter ins ertion, the cathe ter s hould be wi thdrawn 0 .5 cm before s uc tion is applied to av oid inv agina ti on of muc osa into the cathe ter (145 ).

Figure 3.19 Unless deep suctioning is needed, the suction catheter should extend only just beyond the end of the tracheal tube. Placing a piece of tape on the suction catheter will prevent deep insertion.

View Figure

P .67

If deep trac hea l suc tioning is req ui red , most a uthors recommend adv ancing the ca the ter ful ly until i t reac hes th e carina , as determined by resis ta nce to ins erti on or the patie nt coughing (112). It shou ld then be wi th dra wn a few mil limeters pri or to i ni ti ating s uc tionin g (103). In in fants , res is ta nce i n the tube i ts elf c an make detec tion of resis tanc e a t the end of the c atheter d iffic ult, s o the c atheter s hould be meas ured and premark ed to ensure that i t is no t inserted mo re than 1 cm beyond the carin a (147 ). Af ter the c athete r is ins e rted, s uc tioning should begin i mmedi ately. Mos t authors recommen d tha t the v acuum c ontrol be c losed i ntermi tten tl y whi le the c atheter is wi th dra wn, al though s ome rec ommend continuous suc tioning (112). The c athete r may be rota ted gently du ri ng wi thd rawa l. It shoul d not be jabbed up and do wn. If the operator feels res is tance during withdrawal , the v ac uum c ontro l should be opened i mmediate ly . A conv enient wa y to dispos e of the catheter is to co il it, pull of f the glov e wi th the c atheter ins ide, and dispos e of bo th as a uni t (148,149 ). If hyperoxygenation is used, i t is important to turn the oxygen down to the prev ious l ev el at the conc lus ion of suc tion in g (150 ).

Tracheal Suctioning without a Tracheal Tube

If it is nec ess ary to s uc tion th e trachea when no tracheal tube is in plac e, the suc tion c a thete r may be di rec ted into the larynx by us ing a nasopharynge al ai rway

(Chapter 16 ). This s erv es to guide the ca the ter, mi ni mize the trauma to the nas al mucosa, reduce gag an d c ough reflex es from the pos teri or pharyngeal wa ll , and reduc e the introduc tion o f pharyng eal f lora into the trac hea. This tec hni que is dangerous . If laryngospas m occu rs whi l e the c a the ter is betwee n the v ocal c ords , hypoxemia ca n quickl y res ul t. If this occurs , the v acuum con trol s houl d be ope ned and ox yge n ins ufflated through the ca the te r.

Closed Suctioning
If pos sible , clos ed s uc tioning shou ld no t be use d wi th v ol ume c ontrol v entil ati on becaus e o f the ri sk of high ai rway pressu re during c atheter inse rtion and ex treme negativ e p res sure during s uc tioning (54,57 ,60 ,79 ,151). P ressure control v enti lation (Chapter 12 ) produc es less in trins ic P EEP d uring c a thete r inserti on and less subatmos pheric press ure du ring suc ti oning. P res sure support v entilation with th e tri gger lev el se t low i s ev en better i n this regard (5 9,151). S tudi es show that with c losed s uc tioning, ne gativ e p res sures as great as -400 c m H 2 O (-30 0 mm Hg) c an be used to remov e sec retions wi thout i mpai ring gas ex change (88 ). The c los ed sys tem suc tion c athete r is c onnec ted to the v acuum s ource at the dis tal end, th readed through the plas tic sh eath, an d adv anced do wn the trac heal tube by us ing the thumb and forefinger of the dominant hand whi l e the nondominan t hand s tabi l iz es the adaptor. The suc tion c ontrol valv e is depresse d and the c atheter drawn bac k into its sheath. If it is not full y withdrawn, the ai rway may be partial ly oc c luded (52,152). The c athete r and co llar s hould be rins ed after eac h suc ti oning attempt by f lushing sa li ne into the in jec tion po rt wh il e depress in g the s uc tion c ontrol v alv e. If res idual sec re tions are s till pres ent, the c los ed suc tion sys tem s houl d be re placed. Af ter use, the ca thete r s hou ld be disc onnected from the v acuum sourc e to av oid negativ e p res sure bei ng appli ed to the breathin g sys tem if the v acuum control v alv e i s fau lty (153).

Bronchial Suctioning
Selec tiv e suc tioning of one or bo th bronc hi i s sometimes required. The left mai ns tem bro nchus is more diff ic ult to enter than the righ t in pa ti ents ov e r 15 yea rs of age. The succ ess rate may be higher wh e n the pa tient has a trac heos tomy (32,36,154,155 ,156,157). If the trac hea l tu be tip is less than 2 c m abov e the c arina , the catheter is less like ly to enter the lef t bronc hus than if the tube is pos itioned more c eph alad (36).

A higher rate of s uc ces s wil l be ac hiev ed wi th a cu rv ed tip catheter di rec ted to the desired s ide (32,33,34,35,36,93,156 ,158,159,160 ). A dua l-curv ature catheter may also be of benefi t (1 61A ). A tip-def lec ting wi re c an b e used to manipulate a suc tion ca the ter into the d esi red b ronchus (161 B ). Ca th ete rs that are pac kaged s trai ght rather th an coi led are more effec tiv e for l eft bronc hi al s uc tio ni ng (93 ,162). It i s i mportan t to prev ent the catheter f rom rota ting i n the trac heal tube a nd in the trac hea. This wil l be eas ier if the c athete r has a means to determine the di rec tion to wh ic h the tip is pointing (35,155 ). Durin g bronchial s uc tioning, i t is rec ommended tha t the head be turned to the contralatera l s ide or be plac ed in the mid li ne (93,155,160 ,162,163,164). Some s tudies hav e sho wn a s lightl y higher success rate fo r left b ronchial s uc tioning if the pati ent is in the l eft lateral pos i tion (3 5,165) o r if the trac heal tub e is in the lef t or central p art of th e patien t's mouth (157).

Hazards Associated with Suctioning Hypoxemia

A rteri al ox ygen s atu rati on dec reas es duri ng trache al s uc tioning a nd fo r some time af te rward (4 8,166). Chi ld ren desaturate more quickl y th an adul ts . The P .68 magn itude of the dec rease is related to the duratio n of suc tioni ng as we ll as whe the r the v entilatio n was continued or dis con tinued during suc tion ing . The s ize of the ca the ter in rela tion to the si ze of the trac heal tube is also importan t. The magn itude of the negativ e pressure is also a fac tor. The pattern and a mount of negativ e a irway press ure du ring cl osed s ys tem suc tion may be in fl uenced by v enti lato ry mode, s ettings , and v entilator (61,167 ). Ano the r caus e of hy poxemia is laryngeal s pas m. The v oc al c ords may c lose whi le the suc tion catheter i s in the trac hea, wh ic h c ould res ul t in rapi d des atu rati on. A numbe r of maneuv e rs hav e been recommended to p rev ent h ypox emia assoc ia ted wi th s uc tion ing. These may be used s eparatel y or i n c ombi nation.

Maintaining Ventilation
If suc tioni ng is performed by us ing a method that allows artific ial v enti lation to continue, the drop i n ox ygena ti on is l es s (64 ,65 ,70 ). Th is c an be done by usi ng spec ial adaptors , c losed s ys tem suc tioning, or high-frequenc y jet v entilatio n through a c hannel i n the trac heal tube wal l (168).

Hyperoxygenation
Hypoxemia c an be av oided or a ttenua ted b y a dmin is tering ox ygen at an FiO 2 greater than the patient was receiv ing or required prior to (p reox ygenation), durin g (ins uffl ation ), o r after (pos tox ygenatio n) suc ti oning . In adults , this is usual l y with an Fi O 2 c los e to 100%, a lthoug h 20% abov e maintenanc e is adeq uate i n mos t cas es (121,169 ). In newbo rns , an Fi O 2 10% to 20% abov e bas el ine is rec ommended (103,170 ,171,172). A p roblem wi th us ing 100% oxyg en is that the health c are prov ider ma y fai l to return the ox ygen c once ntration to the prev ious lev el . S ome v enti lato rs hav e a temp ora ry O 2 -enrichment fea tu re that deliv ers 100% oxy gen f or a prese t perio d of ti me (110,173). This av oids the problem of the heal th c are p rov ider faili ng to return the Fi O 2 to the base li ne level . S ome v entil ators a re equ ip ped wi th alarms that are ac tiv ated if the ins pi red ox ygen lev el is too high . P reox ygena tion and pos tox ygena tion c an be c arried out by us ing a v entilator or a manu al resus c i ta tion bag . A v entilator is preferred (174). It is eas ier to con tinue PEE P when a v entil ator is used . W ith a v entil ator, a period of time (bl eed or was hout time) is requ ired bef ore the desi red c oncentration of ox ygen is del iv ere d. The wa shou t time depends on v enti latory rate, fl ow, ti dal v ol ume, dead space, the i ni ti al Fi O 2 , and the v olume of the tubing. W hen us in g a manual resusc i ta tion bag , an elev ated ox ygen c onc entration depe nds on the oxy gen flow, s iz e of the res erv oi r, a nd minu te v olume (Chapter 10). Not all manu al resus c i tation bags c an del iv er 100% ox ygen (175). Us in g PEEP during manu al v entilation may i mprov e posts uc tio ni ng P aO 2 s li ghtly (176,177). Ins ufflati on can be ac compl ished b y usi ng a suc tion c atheter or a trachea l tu be with an ex tra lume n that all ows d eliv e ry of ox ygen (43 ,178). This c an be an effec tiv e method of av oi di ng or minimizing hy pox emia (41,179,180). A n ox yge n fl ow of 10 to 15 L/min ute s hould be used (174).

Hyperinflation
Hyperinfla ti on (infl ati on of the lungs wi th a v olume g rea ter than baseli ne tida l v olume ) before o r after s uc tioning when us ed in c onjunc tion with hype rox ygenation may be effec tiv e in mai nta in ing P a O 2 (121,150,166 ,18 1,182,183,184). Hyperinfla ti on wi thout hy perox ygenati on does not cons is tently prev ent hypox emia (121,150 ,182). There is a progress iv e improv emen t in oxygenation with inc reasing v olume (125). Up to 1 .5 times the bas eline tidal v olu me has been rec ommended (114,122 ,128,183,185). Ano ther re commen dation is a peak pres sure that is 10% to

20% abov e bas eline (103). Three hyperinflations a re more effec tiv e than one (128). The use of an insp irato ry ho ld is not more effec tiv e (186). Hyperinfla ti on may be ac compl ished by i nc reasing the v entil ator-se t ti dal v ol ume, manu al ly trigge ring preset s ighs on a v entila tor equipped wi th this fe atu re, or manu al ly wi th a resus ci tati on bag. Using the v entil ator is us ua ll y supe rior to the bag (175 ,185,187,188,189). It i s also more ef fic ien t, as i t requi res onl y one pe rson and n o addi tional equ ip ment. Mos t man ual resusc i tation bags are no t attached to a sp irometer, s o there is no way to accuratel y measure v olumes . Hyperinfla ti on can resu lt in patient disc omfo rt, cardiov ascular d is turbances , and barotra uma (11 2,121,125,12 6,182,190). It could propel sec retions fa rther into the ai rwa y. Fo r these reasons , each patient sh ould be assessed i nd iv iduall y to determine the need for hype rinflati on and the appropri ate v olu me (150 ). If sa turatio n d rops despite hype rox ygenation , hyp erinf la tion should be adde d and the changes in S pO 2 and other parameters assesse d (110 ). Hyperinflation s hould be av oid ed in s ev erel y head -injured patien ts whe re intrac ranial pressure is a conc ern and used wi th c aution in uns table c ardiac patients (174).

Hyperventilation
Hyperv entil ation, an inc reas e in v en ti lation abov e bas el in e, is often perfo rmed before or af te r suc tioning. Bec ause of i ncons istenc ies i n del iv ery with a man ual resus ci tati on bag, it is recommend ed th at a v en ti la tor be used (191 ,192). Hyperv entil ation is of te n used i n conjunc tion wi th hy peroxy gena tion. It sh ould be us ed with c aution in head-in jured pa tients (115).

Limiting the Duration of Suctioning

The longer suc tion is appl ied to the tracheobronc hial tree , the g rea ter the magn itude of the hy pox emia . P .69 Suc tioni ng shoul d be limited to les s than 1 0 to 15 sec onds in adu lts (48,51,81,104,108,112). Howev er, s inc e mos t of the f al l oc curs within the f irs t 5 seconds , this is of li mited v alue (193). Adequate res t periods should b e tak en between s uc tioning procedu res to al lo w c o rrec tion of hypox ia and hy percarbia.

Avoiding Laryngeal Spasm

Laryngeal spas m may be av oided by inse rting the c athe ter during i nsp iration and us ing topica l or i ntrav enous l idoc ain e. If la ryngeal spas m oc curs , the ope rator shoul d immedi atel y open the v ent to ai r and ins ufflate ox yge n through the ca the ter.

Proper Technique
Negativ e press ure s hould be applied onl y whi le the ca the ter is be ing wi thdra wn. Exc ess iv e negativ e pressu re should not be us ed. Fi na ll y, the outside diameter of the catheter s hould be no greater than one half of th e i ns ide d iame ter of the trac heal or trac heos tomy tube .

Adverse Effects on Respiratory Mechanics

Trac heal s uc tionin g i nc reases respi rato ry res istance (184,19 4). The effec t is trans ient and not su ppress ed by 2 -adrene rgic receptor b lockade. Intrins ic PEEP is dec reas ed wi th s uc tioning. A loss of end-expi ra tory l ung v olume is commonl y see n. A fall in pul mona ry co mp li anc e may occ ur. Ri gh t uppe r lobe c ol laps e i n child ren has been associated with deep suc tion in g (195 ).

Trauma
W henev er s uc tioning is pe rformed, there is the poss ib il ity that there wil l be damage to the ai rway. Reported probl ems inc lude i rritation, ed ema, inf lamma ti on, dec reas ed muc oci liary func tion, ulc eratio n, nec ros is , perfora tion, g ranula tion tis sue suff ic ient to c ause bronc hial s tenos is , and lobar emph ysema . Trauma is related to the frequenc y of suc tioning, the techn iq ue used , and the magn itude of the negativ e pressure (98 ,196). Deep suc tioning is ass oci ated with more trauma, espec ia lly to the carina, than shallow s uc ti oning (103,11 7,145). A l though the common c linical perc eptio n is that intermi tten t suc tion is les s inj urious than con ti nuous suc tion, both c an c ause mucos al damage (197). The s uction ca the ter has a minor ro le in determini ng the a mount of mucosal d amage (49,198,199 ). Smaller tips hav e be en reported to c aus e i nc reased mucosal damage (99). A faul ty s uc ti on catheter can caus e c ons ide rab le damage (2 00). To minimi ze trauma, unnecessary suc tioning s hould be av oide d. The c athete r shoul d be ins erted on ly s lightly more th an th e l eng th of the trac heal tube unless deep tracheal suc tion ing is requi red. P ok ing o r proddi ng sho uld be av oided . If blood -s tai ned s ec retions a re obs erv ed in the abs enc e of obv ious reasons (lung contusi on, recent trac heos tomy ), the enti re suc tion ing techniq ue sho uld be ex amined.

Suc tioni ng v ia th e naso pharynx of ten caus es trauma to the nasal muc os a. If the tip of the ca the ter is di rected gentl y a long an inferior and medial path with rotation, i t wi ll ten d to follow th e f loor of the nasal c av ity, and trauma to the turbi nates wi ll be minimi ze d. P rior ins erti on of a nas al ai rway wil l u sual l y res ult in l ess trau ma and more c ons is ten t pos itio ni ng of the suc tion catheter.

Cross Infection
Many aspi rated fluids c ontain high c onc entratio ns of mic roorganisms or blo od, s o c ross c ontamination be twe en patients or s taff is a hazard (8,2 01,202). Cau tion shoul d be used in hand ling al l suc tion equipment. Cross infec tion c an occ ur ei ther by di rec t co ntac t wi th c ontaminated equipmen t or f luid or f rom ae ros ols . Mic ro organisms are a erosol ized in to the col lec tio n c ontainer during s uc tioni ng and remai n in the s pace abov e the l iq uid. W hen the container is opened, the mic roorganisms may be release d i nto the e nv i ronment. During o pen suc tion ing , the s pray of condensate and tracheal s ec retions expe lled during ex hal ation or coughing ma y contaminate the operato r and atmosphere . Some health care faci li ti es hav e adop ted the risk y prac tice o f emptyi ng and reusi ng disposable suc tion ca nis te rs (203,204 ). E mp tying the canis ter expos es personnel to mic roorganisms in the as pirate and risk s contaminatin g the ou ts ide of the canis te r. Cross co ntamina ti on can be p rev ented by us ing f il ters , anti-ov erflow d ev ices and co ll ec ti on containers that c an b e s ealed prio r to mov ement, c lose d s uc tion s ys tems , and n ot ov e rfil ling the co ll ec ti on con tai ner. Materials that c aus e the fl ui d inside a canis te r to s olidify are av ailable. T his mi nimizes aerosoli zation and s plas hi ng of the co ll ec ted f luids . Disin fec tant s oluti ons placed in c ollec tion c ontainers of ten i nc reas e f ro thing . Fi lters s hould be ex amined and changed f requen tl y. Pe rsonnel shoul d be encoura ged to rega rd al l suc ti on was te as po te nti al ly infec tious and to handle a nd dispos e of i t pro perly . Hands s hould be was hed af te r touching s uc ti on equipment, ev en if glov es were wo rn. Special disposal s ys tems for was te fluid are av ai lable (204 ,205,206). These dispose of liquid was te into the s ewer wi th n o pouring required. A l though the ir i ni ti al c os t is somewhat hi gh, the y may be cos t effec tiv e if la rge v olu mes of f lu id are gene rated by su rgica l procedures .

Bacteremia
Trans ien t bac teremia can occ ur du ri ng suc tioni ng through a trac heal tube (207) o r nasotrac heal suc tioning (208). Min imi zi ng trauma and using aseptic techniqu e c an reduc e this risk .

P .70

Cardiovascular Disturbances
Cardi ac dys rhy thmias , tachycardia , bradyc ard ia , hyp otens ion, h ypertension, or ev en cardi ac arres t can oc cur du ri ng suc tioning (64,68,71,125,126,170,190,191 ,209,210,211 ,212,213,214 ,215,216,217,218). T hese problems are often re la ted to hypoxemia. An other pos s ible c ause is c oughing. In the unintubated pati ent, v oc al co rd s timula tion may cause cardiac dys rhythmias (102). Cardi ov as cular dis turbances are les s with cl osed s uc tionin g (65,68,70,217,219) us ing a v enti lato r rathe r than a manual resusci tati on bag for hyperinf lation /hyperox ygena tion (1 85,187) and us ing ins uffla ti on ra the r than preox ygenation (43). Li miting the de pth that the ca the ter is inse rted shou ld reduc e the risk of v agal s timulation (220 ).

Increased Intracranial Pressure

Intrac ranial pressure may inc reas e du ri ng suc tioning (209,214 ,215,221,222,223,224,225,226 ,227,228,229 ). Measures to li mit the i nc reas e inc lude p reox ygenation; hy perv enti la ti on prior to and fol lo win g s uc tioning; l imi ting the duration of suc tioning; not rota ting the head ; li mi ting the depth of ca the ter ins ertion; a llowi ng adequate rec ove ry time followi ng suc tioning ; and adminis tering d rugs s uch as i ntratrac heal lid ocai ne, seda tiv es , or pa ral yz in g agents (115,117 ,174,221,224,225,229,230,231 ). F or s ev erely head-in ju red pa ti ents where i ntrac ranial pressure is a c oncern, h yperinflatio n during and/or af ter s uc ti oni ng shoul d not be added to hyperox ygen ati on (174).

Negative Pressure Pulmonary Edema

Pulmona ry ed ema c an occ ur i f negativ e pres sure is app lied to a ca thete r tha t is i nserted through the co rds c los ed from la ryn geal spas m. If this happens , suc tion shoul d be dis con ti nue d and ox ygen insufflated through th e s uc ti on catheter. Application of suc tion to the trachea l tube connec tor c an res ul t in pu lmonary edema (100).

Inadequately Removed Material

Consequences of inadequate remov al of mate ri al s uch as sec re tions o r v omi tus i ncl ude hypox ia, atelec tas is, i nfec tion , inc rease d a irway press ures (wi th i nc reas ed risk of barotrauma , hyp oxia, pa tient dis comfort, a nd anxiety), and ex ces s iv e

coughing (232). Trache al tube narro win g f rom the buil dup of s ec retions ma y occu r, es pecial l y wi th p rol onged i ntubation (83).

Inadequate Suction
Mi sass embl y of a suc tion sys tem s o that no col lec tion jar is incorporated in the s ys tem c an res ul t in l oss of suc tion (2 33). The sys tem wi ll appear to f unc tion during tes tin g, but once flu id reaches th e s uc ti on contro ller, th e fi lter wi l l occ lude and suc tion wi ll be los t. Obs truc tion of th e s uc ti on tubing b y v is cous o r particu late v omi tus whi le s uc ti on ing a patient's oroph arynx is a c ommon problem (18). It is possible for the ov erfill pro tec ti on mech anism to inte rrupt the f low i f it is bump ed or j arred. Res torati on of s uc tion req uires disc onnec ti on of the v acuum sourc e a nd reopening of this v alv e. This problem c an be av oided by mounti ng the container sec urely and not al lowi ng th e c ontainer to beco me too full . If the f i lter becomes wet or cl ogg ed, the flow wi ll be interru pte d. This c an b e caus ed by li quid, f oam, or aerosol produc ts from las ers o r elec trosurgery. The v acuum co ntrol on a s uc tion c atheter may be a sou rc e of obs truc tion if the glov e on the f ing er oc cluding it is sucked i nto the ca the te r (23 4).

Impacted Suction Catheter

A suc tion catheter c an bec ome impac te d in a trach eal tube (235,236,237,238). This can occur if the suc tion c a thete r exi ts through the Murphy eye . The patient may need to be rein tubated. A n al ternativ e is to cu t the machine end of the trac heal tube and try to remov e the c athete r from the s hortened tub e (236).

Inability to Pass Suction Catheter through a Tracheal Tube

The re are a number of re asons why a s uc tion c atheter may no t pas s through a trac heal tube. The c ath ete r may be to o large. The tracheal tube may h av e a specia l configuration tha t makes passage diff ic ul t. T he inner s u rf ace of the trac heal tube may be s ticky , c aus ing the ca thete r to hang up as it is ins e rted (239). There may be an obs truc tion or na rrowi ng withi n the trac heal tube lu men.

Other
In one ins tance , a parti ally reusa bl e c ol lec tion conta ine r suffered a n implos ion that resul ted in a sho wer of plas tic shards a nd canis ter c ontents (24 0). A s uc tion

ca the ter may break , and the tip may fall off (2 41). P art of the s uc ti on ca the ter packaging may s tick to the c a thete r and be depos i ted in the ai rway (242). Us ing sa line ins til lation i n associ ati on wi th c los ed s ys te m suc ti on ing may resu lt i n greatly inc reased res is tance i n a h eat and mois ture exc hanger (243). A cas e has been repo rted where a high n egativ e pressure caused by s uctioning resul ted in the lock up of a v entil ato r (2 44,245). A trans ien t high ai rwa y p res sure ma y occu r during ins ertion of a s uc tion ca the ter through a trac heal o r P .71 trac heos tomy tube (bef ore s uc tioning has begun) i f the v entila tor is in v olume control mode (60 ).

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218. Chas e DZ, Campbell C, B yram D, et al. Hemodynamic c hanges associ ated wi th en dotrac heal suc tioni ng. Heart Lung 19 89;18:292293 . 219. Ruof H, Fahnens tich H. Clos ed v ers us open endotracheal suc tion ing in v enti lated prema tu re infa nts . Pedi atr Res 20 00;47:430A . 220. Knox A M. Performing e ndotrachea l suc ti on on ch ildren: a l iterature rev iew and i mplica tions f or nu rs ing practice. Intens Crit Ca re Nurs 1993 ;9 :48 54. 221. Rudy EB , Baun M, S tone K , e t al . The rela tions hip between end otracheal suc tion ing and chan ges i n intrac ra ni al press ure : a rev ie w of the literature . Heart Lung 1986 ;15 :488494. [Med li ne Link ] 222. Fis he r DM, Fre wen T, S we dlo w DB . Inc rease in intrac rania l pressu re du ri ng suc tion ings timu la tion v s ris e i n PaCO 2 . A nes thesi ology 1982;5 7:416417. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 223. Gemma M, Tommas ino C, Cerri M, et al. Intrac ranial eff ec ts of endotrac heal suc tion ing i n the acute phas e of head injury. J Neu ros urg A nes th 2 002;14:5054. 224. Rudy E , Turner B , Baun M, et al . En dotrac heal s uc tioni ng in a dul ts wi th head i njury . Heart Lun g 1991;20 :66767 4. [Med li ne Link ] 225. Cros by LJ , Parsons L C. Cerebrov as cular respons e of c losed head-injured pati ents to a s tanda rdi zed e ndotrache al tube s uc tioni ng and manual hyperv enti lation proced ure . J Neurosci Nurs 1 992;24:4049. [Med li ne Link ] 226. Kerr ME , W ebe r BB , Sereika S M, et a l. E ff ec t of endotrach eal s uc tioning on ce reb ral ox ygenation in traumatic brain-i nj ured patients . Cri t Care Med 1999;27:2776278 1. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 227. W ai nwri ght SP , Gould D. Endotrac heal suc tioning in adul ts wi th s ev ere head i njury : li tera ture rev ie w. In tensiv e Cri t Care Nurs 1996;12:303308. [Cross Ref] [Med li ne Link ]

228. Durand M, Sangha B , Cabal LA , et al . Cardi opu lmonary and intrac ranial press ure c hanges related to endotrachea l suc tioning in pre term inf ants . Crit Care Med 1989;17:506510. [Cross Ref] [Med li ne Link ] 229. Fanconi S , Duc G. Intratracheal s uc ti oning i n sick pre te rm infants : p rev ention of intrac ranial hypertensi on and cerebral h ypoperfus ion by muscl e paral ysis . Pediatric s 1987;79:53 854 3. [Med li ne Link ] 230. Kerr ME , Rudy E B , W eber B B , et al . Effec t of short-duration hyperv entil ation during endo tracheal s uc tionin g on intrac ranial pres sure in sev ere head in ju red adults . Nu rs Res 1997;46:195201 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 231. Ni nan A , O'Donn ell M, Hamilton K , et al. Phys iolog ic al changes induc ed by endotrac heal ins ti llation and suc tion in g in critic ally i ll pre term infants wi th and wi th out s edation. Am J P erina tol 1986 ;3:94 97. [Med li ne Link ] 232. Ash urs t S . Suc tion therapy in the c ritical ly i l l patient. B r J Nurs 1992;1:485 489. [Med li ne Link ] 233. Anonymous . Suc tion sys tems : misass embl y can cause failure during emergenc y us e . Heal th Dev ices Al erts 2005;29:10. 234. Mc Don al d DS . Blocked Yankauer sucke r. An aes thes ia 1996;51:405406 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 235. Anonymous . Trac heobronc hial suc tion cathe ters . B iomed Safe S tand 1982;12:135. 236. Karis J H, Mis adv enture du ring endotracheal anes thes ia . JA MA 1973;226:675 . [Med li ne Link ] 237. W eiss HH. Mis adv enture duri ng endotrac heal anes thes ia. JA MA 1973;225:524 . [Med li ne Link ]

238. S ingh B , Chugh V . A n unusua l compl icatio n of suc tion through the tracheal tube. A naes thesia 2002;57:718. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 239. P rinc e GD, Perks D, Fraser G, Difficu lti es with trac heal s uc tion. Ana esthes ia 1987;42:84. [Cross Ref] [Med li ne Link ] 240. Anonymous . Omni wal l 1 wal l suc tion uni t. Heal th Dev ices 1983;12:257258. 241. W oode y R, Daley M, Torda T, et al. A d angerous p rob lem wi th plas tic Yankaue r suc kers . Anaes th Intens Ca re 19 95;23:519 20. [Med li ne Link ] 242. Lac k JA . Another ai rwa y foreign body . Anaes thesia 200 2;57:189. [Fu ll tex t Link ] [Med li ne Link ] 243. Martinez FJ , P ietc hel S , Wise C, e t al . Inc reased resis tanc e of hyg ros cop ic condenser humidifie rs when usi ng a c losed c i rc ui t suc tion s ys te m. Cri t Care Med 1994;22:1668167 3 [Med li ne Link ] 244. Barahad D, S ims C. Ve nti lator fa ilure duri ng us e of a new anes thes ia machine . Anes thes iology 2001;95:568569 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 245. Feldman J M, Smith JA . Venti lato r fa ilure duri ng us e of a new anes thes ia machine. In reply. A nes thes iology 2001 ;95 :5 69. [Fu ll tex t Link ] [Cross Ref] P .74

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t

i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. T he interme dia te tu bing in the suction sys tem A . Is located between the wal l i nlet and the coll ec tion b ottle B . Can c arry liquids and s ol ids C. Shoul d be s hort to reduce resis ta nce D. Shoul d be as th in as possi bl e V iew A ns we r2. S ituations w here larg e c ollectio n c ontainers sho uld be use d include the follow ing : A . P ediatric s urgery B . W hen max imu m v acuum is needed quickly C. Ope n suc ti oning D. W hen large v olumes of aspi rate are exp ec ted V iew A ns we r3. The best loca tion(s) of the suctio n collection container include A . On the wal l cl ose to the pipeline i nle t B . B elow the patient C. Bes ide the v aporizers on the anes thes ia machine D. W here it wil l no t be ti pped V iew A ns we r4. Wh ich statement(s) a bout s uction catheter tips are correct? A . Th e diamete r of the te rminal o rifice of the c a the ter mus t be at leas t 95 % of the i nsi de diameter of the c a the te r B . Th e holes should b e s mooth C. Tips wi th a s ingl e hole grab the mucosa less than if th ere a re mul tiple holes D. Mul tiple s ide holes wi l l reduce the av ailable v ac uum V iew A ns we r5. Functio n(s) of th e vacuum contro l on the suction catheter include A . Interrupting suc tion wi thout s wi tching off th e v acuum B . Fac ili ta ti ng insertion of the c athete r C. B reak ing the seal if th e c atheter ti p bec omes oc cluded D. Reduc ing tis sue trauma V iew A ns we r6. Advantages o f closed suc tion inc lude

A . B e tter ox ygenation wh il e suc tioning B . Dec reased c oughing and agi tati on C. Reduc tion of nos ocomial infec tion D. Faci li ta ting hyperv entilation durin g s uc tio ni ng V iew A ns we r7. P rope r techniques for clearing secretio ns during extuba tion inc lud e A . Ex tubation duri ng app li ed positiv e pressu re B . S uc tion ing the pha ry nx after ex tubation C. Ex tub ating af ter the patient takes a dee p breath D. Suc tion ing through the tracheal tube as it i s remov ed V iew A ns we r8. Wh ich is n ot an in dic ation fo r trachea l suctionin g? A . A ri se in peak p res sure B . Inc reas ed ai rway res is tanc e C. Dec re ased tidal v olu me d uring press ure -l imi ted v enti lation D. Dec re ased end-tidal c arb on diox ide V iew A ns we r9. Importan t factors related to proper suctioning techniques include A . Limi ting the nega tiv e press ure to 70 to 150 mm Hg in adu lts B . Limi ting the nega tiv e press ure to 60 to 80 c m H 2 O i n i nfants C. Hyperoxyg enation pri or to suc ti oning wi ll hel p prev ent h ypoxemi a D. Drawi ng water through th e c atheter may reduc e s uc tion flow V iew A ns we r10 . P rob lems associated w ith instilling sa line prior to suc tioning inc lud e A . B ac teria may be washed in to the lo wer airwa ys B . S aline i ns til lation may promote hypoxemia C. Sa line v ials may be con taminated during open ing D. B lood y sec retions are mo re diff icul t to remov e V iew A ns we r11 . P roper technique w ith a suctio n c athete r inc ludes A . Choosi ng the la rges t ca the ter tha t wil l f it through the trac heal tube B . Us ing a s mooth , gen tle moti on during inserti on C. Negativ e p res sure appli ed as the c atheter i s ins erted i nto the tracheal tube D. The c atheter shoul d be pass ed jus t be yond the ti p of the tracheal tube V iew A ns we r12 . Correct tech niques after the suc tion cathete r has bee n inserted into the tracheal tu be inc lude A . Di rty cathe ters coil ed and fold ed insi de of the operator's glov e B . Gentle ro tation as th e c atheter is wi thdrawn

C. If resis tance is fel t, the v acuum c ontrol shou ld be opened at once D. Continuous suc ti on as the catheter i s remov ed V iew A ns we r13 . Whic h factors promote a highe r rate of suc cess during bronchial s uctioning? A . A tip-def lec ting wire B . Ca the ters that are del iv ered coi led C. Tu rni ng the head to the c ontral ateral s ide D. Us ing a ca the te r with a s trai ght tip V iew A ns we r14 . Factors that p romote hypoxemia during suctioning include A . Inc reas ed duration of s uc ti oning B . Inc reas ed magni tude of the neg ativ e p res sure used C. Diameter of c atheter large in rela tion to the si ze of the trac heal tube D. Continua ti on of v entil ation during s uc tioning V iew A ns we r15 . Tech niques that w ill minimize th e c hance s o f hypo xemia associated with suctioning inclu de A . Us ing PE E P duri ng manu al v entil ation B . Conti nuing artif ic ia l v en ti la tion C. Insuffla ti on wi th ox ygen du ri ng suc tioning D. Hyperoxyg enation bef ore s uc tioning V iew A ns we r16 . Whic h s tatements about hyperin flation to prevent hypoxemia are correct? A . Only one h yperinflation is necess ary B . Th e peak press ure s hould be 10% to 20% abov e us ual C. Hyperoxyg enation is no t nec essa ry whe n p erf ormin g h yperinflation D. Up to 1 .5 times the tidal v olume has been recommended V iew A ns we rP .75

17. Hazards associated w ith hy perinfla tion inc lud e A . P a tient dis comfort B . B a rotrauma C. Cardiov ascular dis tu rba nces D. Sec re tions may be pushe d down wa rd in to the ai rway V iew A ns we r18 . Whic h factors are frequently related to airw ay trau ma ? A . Mag ni tude of th e negativ e pressu re

B . Depth of s uc ti oni ng C. Frequenc y o f suc ti oning D. La rge -tip s uc tion c atheters V iew A ns we r19 . Mecha nis m(s) respo nsible for spreading mic roorganisms betw een pa tients include A . Condensate from the trac hea duri ng open s uctioning B . Di rec t c ontac t wi th c ontaminated fluid or equ ipme nt C. Emptying the col lec tio n bottle D. Ae ros oliza ti on f rom the c ol lec tion co nta in er V iew A ns we r20 . P ractices that preve nt cross contamination include A . Us ing f i lters B . A n tiov erflo w dev ices C. Close d suc tion s ys tems D. Addin g dis infec tant solution to the c ol lection c ontainer V iew A ns we r21 . Card iac disturb ances a re most ofte n assoc iated w ith w hich situations? A . Coughing in the un intub ated patien t B . A rti f ic ial v enti la tion C. Vocal c ord s timulation D. Close d suc tioning V iew A ns we r22 . Measu res that limit the increase in intracran ial pressure durin g s uctioning include A . Ro tati ng the head to the s ide B . Hyperv enti la tion C. Mi nimizing the time between s uc tioning D. Limi ted the dep th of c atheter i nserti on V iew A ns we r23 . Causes of nega tive pressure pulmo nary edema inc lud e A . Ligh t anes thes ia B . Ca the ter ins erted thro ugh the v ocal cords , s timulatin g laryngospas m C. Disc ontinuation of ox ygen flow D. Applica tion of s uc tion to th e tracheal tube V iew A ns we r24 . P oss ible caus es for interruption of s uction include A . Clogg ed fi l ter B . Ov erf illed coll ectio n bottl e C. Obs truc ti on by particu late material D. Trach eal tube narrowi ng

V iew A ns we r

Chapter 4 Oxygen Concentrators

Introduction
The re are c i rc ums tanc es wh ere ob taining ox ygen f rom c ylinde rs or a l iqui d s to rage tank is inc onv enient, imposs ible, o r prohibitiv el y expens iv e. This has resul ted in i nc reas ed interes t i n al te rna tiv e so urc es of suppl y, es pec iall y ox yg en conc en trators . There are n ow we ll ov er 500,000 of these uni ts i n use world wid e.

Technology
Mos t ox ygen concentrato rs use p res sure s wi ng adso rbe r (P SA ) tec hnology, whi ch i nc reas es the ox yge n c onc entration by ads orb ing n itrog en onto a mo lecular si ev e and a llows ox ygen and trace gas es , es pecia lly argon, to pas s through. The resu lt is a gas wi th an oxygen conc entration between 90 % and 96% (1,2,3 ,4,5,6,7). The produc t gas f ro m the c oncentra tor is refe rred to as Ox ygen 93 % USP (U .S . Pha rmac opoe ia), Ox y gen 90+, or ox ygen-enri ch ed air (3,4,8). Two i nternational and one U.S . s tandard for medical ox ygen c onc entrators hav e been publis hed (8,9,10). Mos t conc entra tors use an inorgan ic si l ic ate be longing to a cl as s of c rys tal li ne co mpounds known as z eolites for the molecular s iev e. W i thin eac h zeol i te granule i s a s ys tem of prec isel y arrayed cav ities and pores that a re uniform in s ize s o tha t mol ecules a re ei th er readi ly adsorbed or compl etel y excl uded. The molec ul ar s i ze and p ola ri ty of a gas determine wh ether i t is retained by the siev e material . P ress uri zed ai r is pas sed th rough a s iev e bed . Oxygen (alon g with argon) passes through freel y, whil e ni trogen, c a rbon diox id e, ca rbon monoxide , water v apor, and hydrocarbons are trapp ed. These are the n deso rbe d (re leas ed ) by v enting the s iev e bed to atmosphere, the reb y reduc ing the adsorptiv e force. Regenera tion of the s iev e b ed is then comple ted by purg ing wi th s ome produc t gas . A conti nuous output of oxy gen-enric hed gas i s ach iev ed by us ing two s iev e beds in a s equenti al adsorption -des orption process kno wn as pressure s wi ng ads orp tion. As one s iev e adso rbs nitrogen under pressure, the othe r s iev e is d eso rbed and purged. The ou tpu t depends on the s ize of the i ns tallati on. The molec ular si ev e has a s trong af fi ni ty f or wa ter. W ater in the s iev e wi l l displ ac e other mo lec ules , reduci ng the c apac ity to adsorb nitrogen. Duri ng no rmal operation , room humi dity does not aff ec t the s iev e 's adsorbent abi li ty. A s iev e at the en trance

to the bed o r column ac ts to adsorb mois tu re. This is re turned to the a tmos phere during the purge (exhaus t) phase. Ox yge n P .77 conc en trators c an be used under humid co ndi tions if the concentra to r has been desig ned wi th adequa te purges , low d ead space, and enough heat to as sis t desorpti on of the water (11). The beds mus t b e k ept s eal ed from the a tmos phere to prev ent mois ture f ro m migra ting in to them.

Concentrator Design
A schematic des ign for a typica l ox ygen concen trator is s hown i n F igure 4.1. Des igns v ary among manufac tu rers , and al l th e c omponents tha t are s hown may no t be present in ev ery conc entra tor. Fi lters at the in let remov e particl es and bacteri a. A muffler reduces the sound lev el . The c ompresso r rec eiv es the fil tered ai r and c ompresses i t to a h igher press ure . A heat exc hanger i n the form of a co iled tubing may be used downs tream of the co mp res sor to coo l th e gas . In some concen trators , the c ompress ed gas enters a reserv oi r (s urge tank ), whic h ac ts to dampen pulsa tions generated by th e co mp res sor.

Figure 4.1 Typical oxygen concentrator.

View Figure

E lec trica ll y or pneumatic al ly c ontroll ed v alves di rec t the gas f low though the conc en trator. T he two beds fi lled wi th z eolite al lo w c ontinuous ox ygen produc tion and s iev e regeneration.

The produc t (acc umulato r) tank func tions as a reserv oi r of produc t gas . It may also se rv e as a s ourc e of purge gas . A pressu re re gulator is used to reduce th e press ure of the gas flowi ng to the outl et to a lower, more c ons tan t lev el . A chec k v alv e b etwe en the p res sure regula tor and th e outlet prev ents room a ir f ro m be in g sucked into the si ev e beds when the concen trator is turned OFF. A fil ter i s l oc ated near the outlet to prev ent s iev e materia l, bac teri a, and other matte r from contamina ti ng the outflow. Concentra tors fo r domici liary use a fl owme tering dev ice to contro l th e f low of produc t gas (Fig. 4.2). It mus t be ac curate to 10 % of indica ted f low o r 0.5 L/minute , whi chev er is greater (9 ,10 ). An oxyge n c onc entrati on s tatus i ndic ato r (OCS I) is re qui red b y the internationa l and P .78 U.S . s tandards to warn o f lo w ox ygen c onc entration in the produc t gas (8,9 ,10 ).

Figure 4.2 Oxygen concentrators for domiciliary use. Note flowmeter and oxygen concentration status indicator on each. (Pictures courtesy of Puritan Bennett, Inc., and AirSep Corporation.)

View Figure

Operation
Af ter being tu rned o n, the appa ratus wi ll req ui re two a nd a half to 19 mi nutes to ac hiev e max imum conc entra ti on (1 ,6,12,13). The c onc entration process becomes l ess effici en t if the f lo w rate is inc reas ed a bov e the optimum lev el (1,4 ,6,12,13 ,14 ,15 ).

Applications Domiciliary Use

Ox ygen c oncen trato rs are wid ely used to p rov ide oxygen-enric hed gas for domes tic us e (1,14,16,17). These uni ts a re compac t, l igh twe igh t dev ic es with wheels and a handle f or easy de liv ery and transport.

Remote Locations
In loc ati ons wh ere the ox ygen suppl y from p res surized ox ygen cy linde rs and li quid ox ygen are unav ailable , unrel iable o r prohibitiv el y ex pens iv e ox ygen c once ntrators can p rov id e a reliab le sourc e of ox ygen (2,11,18,19,20,21). The y may a ls o be us eful in field hospi tals , disas ter s ituations , ambulanc es , a irc raft, and s hips at sea. An ox ygen c oncen trator can be c ombined wi th an ai r compressor, breathing s ys tem, draw-ov er v apori zer, and v entilator to form an an esthes ia deliv ery s ys te m si mi lar to those found in more d ev el oped areas (5,18,22,23 ,24 ).

Source of Supply for Oxygen Pipeline Systems

Large-sc ale ox ygen conc entrators hav e been used to prov ide ox ygen for pipel ine s ys tems and to s uppl y a pi peline s ys tem during delibe rate or ac cidental s hutdown (2,3 ,4,25,26 ,27 ) (Fig. 4 .3). The pipe li ne s ys tem is sup plied f rom a pressu ri zed reserv oi r of ox yg en 90+ that is l arge e nough to c ope with the pe ak fl ows . This prov ides protectio n agai ns t temporary e lec tric ity fail ure. The rese rv oir i s us ual ly s uppl ied by a number of ox ygen c once ntrators c onnec ted in paral lel. A f al l in p res sure in the res erv oi r caus es one or more c onc entrators to be brough t in to us e u ntil the press ure is res tored. P .79

Figure 4.3 Oxygen concentrator supply system for a piped gas system. (Picture courtesy of AirSep Corporation.)

View Figure

The re needs to be a reserv e suppl y tha t automatically s upplies the s ys tem if there i s a c onc entrator malf unc ti on or i f th e ox yge n conc entration fa lls below a preset minimum. The sys tem may be s et up s o that the c ylinde rs are fi lled wi th gas from the ox ygen con -c entrator. Mode rn anes thesia mach ines are no t adv ers el y aff ected by ox ygen -en ric hed gas f rom oxy gen co ncen trators (3). A rgon d oes no t al ter ox ygen fl ow c ha rac ter-is tics (3).

Advantages Cost Savings

The produc t gas of an ox ygen c oncentrator can be les s expensiv e than liquid or c ylinde r oxy gen (4 ,17 ,1 8,21,25,2 8,29). This depe nds on the cos t of the conc en trator, ox ygen supp lied by other means , elec trici ty , and maintenance.

Contaminant Filtration
Mos t airborne contaminants , incl uding ex haus t hyd roc arb ons , eth yl ene oxide , sulfur diox ide , and c hemic al warf are gases , are filtered b y the molec ula r si ev e and released back into the atmosphere (3).

Compatibility with Most Gas Monitors

Infrared, galv anic , a nd paramagnetic gas an al yzers (Chapter 22 ) are no t adv ers el y af fec ted by the p res ence o f argon.

Reliability

Mos t conc entra tors perfo rm wel l fo r long periods of time (18,2 8). They are not af fec ted s ignifican tl y by al ti tude changes .

Simplicity
Ox ygen c oncen trato rs prov ide an inc reas ed ox ygen conc entration wi th out dependi ng on c ompresse d o r liquefied gas a nd their assoc iate d del iv ery probl ems .

Disadvantages Maintenance
Regula r serv ic ing is requ ired, particularl y for th e c ompress or. It i s important tha t the ai r intak e f ilters be cleaned o r rep lac ed at the inte rv als recommended by the manufac tu rer.

Less Than 100% Oxygen Produced

The max imu m attain able ox yg en yield for a mol ecular s iev e concen tration is abou t 96%. Howev e r, i n medici ne, i t is rarel y ess entia l to us e 1 00% ox ygen (30).

Hazards Fires
The c oncentrator sh oul d be k ept away f rom sou rces of hea t, open f lames , or elec tric al equ ip ment that may s park or bec ome heated du ring operation (16). A tube could rub agains t ano the r part, rupture, release ox ygen, and igni te liv e conduc tors i n the concen trator (3 1,32). Ov erheated el ec tric al componen ts and loose connec tions c an als o caus e a f i re (3 3,34). Oil and grease shoul d not be allowed to contac t the concentra tor. W arnings suc h as NO S MOK ING OR NAKE D FLA MES shoul d be pos ted i n the area where th e ox yg en conc entrator is in use.

Water Contamination
Under normal c irc ums tances , humi dity is n ot a problem. Howev er, v ery high humidi ty c an cause the ox ygen c onc entration in the produc t gas to be lowered (16,35).

Contaminated Intake Air

The air i ntake s hould be loc ated where it is not l ikel y to be c ontamin ated by fumes , water, or other a tmos phe ric pollu tan ts (1). T hese c ontaminants coul d damage the P .80

s iev e medium and lead to prematu re siev e exhaus tion (28).

Device Malfunction
Elec trica l or mec hanica l malfunc tion may oc cur and in terru pt the fl ow of ox yge n (1). It may be pos s ible for the concentrato r to be runni ng bu t not c once ntrating ox ygen. In one c as e, this wa s repo rted af ter a l iquid caus ed an in take fi lter to bec ome nonfu nctio nal (35). Compress or faul ts c an caus e malf unc ti on. Malfunc tion c aused by f ai lure of the v alv e l ink ing the two s iev e beds has been reported (16,30). If the s iev e b ed v alv e bec omes s tuck in one posi tion, the ou tpu t gas wi ll become the sa me as room ai r (16). Circui t board failures hav e been reported (36 ). If the a ir f low to th e c onc entrator is res tric te d, the dev ice c an ov erhea t, dec rease performance, emanate an odo r, c ause ex ces siv e noise, a nd pos sib ly s hut do wn (37). One c ommon c aus e is the intak e fil ter bec oming c lo gged (16). Cas es hav e been rep orted where ki nked transf er hoses i n the un its affec ted the output (38 ,39 ).

Argon Accumulation
Argon is not trap ped by the molecular s iev e and is c onc entrated much the same as ox ygen . It c an reach co ncen trations a bov e 5 %. If Ox ygen 93 is add ed to a c i rc le s ys tem used wi th l ow f res h gas f lo ws , the argon may ac cumulate. This has not been found to be a p rob le m i f the f res h gas f lo w i s abov e 0.5 L /mi nute (11 ). There are no known patient effec ts f rom l ong - or short-term ex pos ure to low c oncen trations of argon (3).

References
1. Ca rter JA , Bask ett PJ , S imps on P J . The Permox oxyg en conc entra tor. Anaes thes ia 1985;40:560 565. [Med li ne Link ] 2. E zi-Ash i TI, Papwo rth DP , Nunn J F. Inhalation anaes thes ia in dev eloping countries . P art II. Rev iew of ex is ting ap paratus . Anaes thes ia 19 83;38:736747. [Cross Ref] [Med li ne Link ] 3. F ri esen RM. Ox ygen c onc entrators and th e p rac tic e of a naes th esi a. Can J Anaes th 1992 ;39 :R80 R84. [Med li ne Link ] 4. Ho wel l RS C. Ox ygen concen trators . B r J Hos p Med 1 985;34:221223 . [Med li ne Link ]

5. J arv is DA , B roc k -Utne J G. Use of an ox ygen conc entrator l inked to a d raw-ov er v aporizer (a nes thes ia de liv e ry s ys tem f or un derdev elop ed nations ). Anes th Analg 1991;72:805810. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 6. J ohns DP , Rock ford P D, S tree ton J A . Eva lua ti on of s ix ox yge n c once ntrators . Tho rax 1 985;40:806810 . [Med li ne Link ] 7. Lush D. Ox ygen concentrators . Anaes thes ia 1986;4 1:83. [Cross Ref] [Med li ne Link ] 8. International S tandards Organ ization . Oxygen conc entra tor s upp ly s ystems for us e wi th medical gas pi pelin e s ystems (IS O 1008 3). Genev a, S wi tz erl and: A uthor, 2006. 9. International S tandards Organ ization . Oxygen conc entra tors fo r medical use safety re qui rements (IS O 8359). Genev a, Swi tzerlan d: Author, 1996 (Reaffi rmed 2003). 10. Associ ati on f or Tes ting and Materia ls . Sta ndard specification for oxygen conc en trators for do mic il ia ry us e (AS TM 1484 ). W es t Cons hohocken, PA : Au tho r, 1993. 11. Dobs on M, Peel D, K hall af N. Field tria l of ox ygen c oncentrators in upper Egypt. Lancet 1 996;347:15971599. [Cross Ref] [Med li ne Link ] 12. Eas y W R, Douglas GA , Merri field AJ . A combined oxygen concentra to r and co mp res sed ai r un it. Ass ess ment of a p rototype and d is cuss ion of its potential applica tions . Anaes thes ia 1988 ;43:3 741 . [Cross Ref] [Med li ne Link ] 13. Harris CE , S impson PJ . The Mi ni O2 and Healthdyne ox ygen concentra tors . The ir performance and potentia l application. A naes thes ia 1985;40:120 61209. [Cross Ref] [Med li ne Link ]

14. Wils on IH, v an Heerd en PV , Leigh J . Domic il iary ox ygen c onc entrators in anaes thes ia : preox ygena tion techniqu es and inspi red oxy gen concentrations . B r J Anaes th 1990 ;65 :342345. [Cross Ref] [Med li ne Link ] 15. Tig he S QM. Domici liary oxy gen concentrato rs i n anaes thes ia. B r J A naes th 1991;66:273274. [Cross Ref] [Med li ne Link ] 16. Anonymous . Ov erv iew of ox ygen co ncen trators . Tec hnol A nes th 2004;25(1 2):1213 . 17. S ta rk RD, B ishop J M. New method fo r ox ygen therapy in the home us ing an ox ygen c once ntrator. B r Med J 1973 ;2:105106. [Med li ne Link ] 18. Fenton P M. The Malawi anaes thetic mac hine. Ana es thes ia 1989;44:498503. [Cross Ref] [Med li ne Link ] 19. S wan BB . Ox ygen co ncentrators . Can J Anaes th 1987;34:538539. [Med li ne Link ] 20. Shres tha B M, Singh BB , Gautam M, et al. The oxygen co ncen trato r is a su itable al te rna tiv e to ox ygen c yl inders in Nep al. Can J A naes th 20 02; 4 9:812. [Med li ne Link ] 21. Moll JR, Guttman A , Roch a J F. Ox ygen conc en trators as p ri mary s uppl y connec ted to the hos pi tal pi peli ne. Could thi s be an option for c ountries in dev el opmen t? Anes thesiology 2004;101:A53 3. 22. E ltring ham RJ , V arv insk i A . The Ox yv ent. A n anaes th etic mach ine desi gne d to be us ed in dev eloping countries and difficult s i tuatio ns . An aes thes ia 1997;52:668 672. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 23. S war B B . Ox ygen c onc entrators . Can J Anaes th 1987 ;34 :538539. [Med li ne Link ] 24. de Sous a H. Use of an ox ygen c onc entrator as the gas s ource fo r gene ral anes thes ia. A nes th Analg 1990;70:S 82.

25. Fri es en RM, Raber MB , Reimer DH. Ox ygen concen trators : a pri mary ox ygen suppl y source. Can J Anaes th 1999;46:11851190. [Med li ne Link ] 26. Fri es en RM, Raber M, Reimer DH. Canadian experi enc e with ox ygen conc en trators as a so urc e of primary oxy gen s uppl y. Can J An aes th 1999 ;46:A 15. 27. Robinson J S . An app rais al of pipe d me dic al gas s ys tems . B r J Hosp Med 1982;28:160164. [Med li ne Link ] 28. Ev ans TW, Wa terhouse J , Ho ward P . Cl inical experience wi th the ox ygen conc en trator. B r Med J 1983;28 7:4594 61. [Med li ne Link ] 29. Dobs on MB . Ox ygen conc entra tors offer cos t sav ings for dev eloping countri es . A s tudy bas ed on Papua, New Gui nea . Anaes thesi a 1991;4 6:217219. [Cross Ref] [Med li ne Link ] 30. Petty TL, Block AJ, Ch erniak RM, et al . P roblems in pres c ribing and s upplying ox ygen for Medica re patients . Am Rev Res pir Dis 1986;134:34034 1. [Med li ne Link ] 31. Anonymous . Oxygen conc entra tors . Technol Anes th 1999;19:8. 32. Anonymous . Oxygen conc entra tor wi th s ens ing dev ice recalled; f ire poss ib le. B iomed S afe S tand 1999 ;29:3435 . 33. Anonymous . Oxygen conc entra tors recal led for f ire hazard . Bi omed Safe S tan d 1999;29:156. 34. Anonymous . Safety alert warns of e lec tri cal c onnections to ox ygen conc en trators . B iomed Saf e S tand 1 996;26:27 . 35. Solank i T, Nev il le E . Ox ygen c onc entrator malf unc tion. Lance t 1990 ;336:512. [Cross Ref] [Med li ne Link ] 36. Anonymous . Reported c i rcu it board f ai lure s i n porta bl e ox ygen gene rator l ead to fi eld c orrec tion. Bi omed Safe S tand 1999;29:93. 37. Anonymous . Res tric ted ai r flow prompts rec all of ox ygen c once ntrator. B iomed Safe S ta nd 2001;31:1 39. 38. Anonymous . Kinked transfe r hos es may re s tric t gas fl ow i n oxy gen conc en trators . B iomed Saf e S tand 1 996;26:149. 39. Anonymous . Oxygen conc entra tors . Technol Anes th 1997;17:5. P .81

Questions
For the fol low ing ques tions , s elec t the co rrec t answer. 1. In an oxyg en concentrator, w hich of the fo llow in g is most like ly to cause deterioration of the ads orbent medium? A . Ca rbo n d ioxide B . Ni trogen C. Hydrocarbons D. W ater v apor E . Ca rbo n mo noxi de V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

2. Which gases can pass through an oxygen concentrator? A . Ca rbo n d ioxide. B . A rgon C. Helium D. Ox ygen V iew A ns we r3. The product gas fro m a concentrator is referred to as A . USP 96 % B . Ox ygen 90+ C. Ox ygen 96 D. Ox ygen USP 93% V iew A ns we r4. In an oxy gen concentrator, A . Th e produc t gas is used to purg e the reta ined gas es f rom the si ev e bed B . A luminum s i lic a tes a re us ed to trap spec ific molecules C. Po lari ty and s ize d ete rmine whi ch mol ecules a re re tai ned by the co ncen trator medium D. Adsorption eff ici ency is g rea tl y enha nced by the us e of s ubatmosphe ric pressure V iew A ns we r5. P resent-day ap plications of oxy gen concentrators include

A . Do mic il ia ry us e B . S uppl ying ambulances C. Suppl ying medical gas pipel ine s ys tems D. Suppl ying anes thesi a machi nes V iew A ns we r6. Advantages o f the ox ygen concentra tor include A . S av ings as soc iated wi th the purchas e, ha ndlin g, and d eliv e ry of g as c yli nders . B . Inf requent main ten ance C. Conta mi nants in the a ir a re fil te red ou t of the produc t gas D. Cons tant ox ygen output V iew A ns we r7. Hazards associate d w ith us ing oxy gen concentrators include A . A rgon ac cumulation B . Fi res C. Unrec ogni zed f ai lu re to c once ntrate D. Conta mi na tion of the siev e medium V iew A ns we r

Chapter 5 The Anesthesia Machine

P .84

The Anesthesia Workstation

The tra ditional pneumatic anes th esia machine has ev olv ed i nto a c omplex elec tric al, mechanic al , and pne umatic mul tic omponent works tati on. A n an esthes ia work s tatio n integrates mos t of the components nec essa ry for adminis tration of anes thes ia into on e uni t. It c ons ists of th e anes thes ia machi ne, v apori zers , v enti lato r, b rea thing s ys tem, sc av enging s ys tem, and moni to rs . A dded to this may be drug del iv ery sys tems , suc tion equ ipment, and a data management s ys tem. Th is chapter is l imited to the anes thes ia mach ine po rtion of the work s tati on. Mos t of the other c omponents are cov ered in othe r chap ters . The anes thes ia works tation offers many ben efits . Mon itoring and c ontrol func tions as wel l as a la rms can be integrated and data displayed o n a s ingle or multi ple sc reens . Reduc ed ex tern al c onnec tions s hould reduce the like lihoo d of miscon nec ti ons , discon nec ti ons , or k inked c onnec tions (1). A certa in amount of the preus e c hec king procedu re (Chapter 33 ) can be pe rf ormed a uto maticall y. These work s tatio ns hav e built-i n saf egu ards in cas e of machine fai lure (2,3 ). Disadv antages of works tations inc lude potential dis ruption of mechanical v entilation and g as deliv ery, display fai lure, e lec tric al fai lu re, fi res , and l iquid s pi lls (2 ,4,5,6). The y ma y malf unc ti on or ac t in a wa y tha t th e anesthes ia prov ide r does not recognize. Th e anes thes ia p rov ide r mus t tak e the time to u nders tand how thes e work s tatio ns func tio n and what n eeds to be done in cas e of failure. It is n ot possible in a tex t such as th is to prov ide enough information that a user c an be qualif ied to us e an y p articular work s tation. It i s essential tha t the user manual be s tudied prio r to us ing these dev ices. The abil i ty to use one mak e or mode l does not automatic al l y qual if y th e clinic ian to use other mak es or mode ls .

Standards
Anes thes ia works tations and thei r components are c ov ered by A merican Soc ie ty for Tes ting and Materials (AS TM) s tan dard (7). A ll manufac turers s elling anes thesi a machines in the Uni ted S tates hav e agreed that mac hi nes sold af te r the year 2000

wi ll c ompl y with th at s tandard . P rev ious s tandards were published by Americ an National S tandards Ins ti tute (A NS I) (8) and AS TM (9 ).

System Components Electrical Components

Many c ompon ents of modern anes thesi a machines a re powere d b y elec trici ty. Turni ng the machi ne ON enab les thes e dev ices . This ov e rcomes the p roblem of the operator forgetting to turn ON indiv idual dev ic es .

Master Switch
On mos t a nes thes ia mac hines , a maste r (main power) s witc h ac tiv ates bo th the pneumatic and elec trical func tions (Fi gs . 5 .1 , 5.2 ). On mos t mach ines , whe n the mas ter s witc h is in the OFF pos i tion, the onl y elec trical c ompon ents tha t are ac tiv e are the ba ttery c harger and the elec tric al ou tlets . On some mac hi nes , elec trical co mponen ts can be ac tiv ated withou t pneumatic powe r. T he P .85 s tandby pos ition is f req uently used on c omputer-con trolled mac hines to a llow th e s ys tem to be powe red up qu ic kl y.

Figure 5.1 Master switch. Turning the master switch to the ON position activates both pneumatic and electrical functions of the machine as well as certain alarms and safety features.

View Figure

Figure 5.2 Master switch. Turning the master switch to the ON position activates both pneumatic and electrical functions of the machine as well as certain alarms and safety features.

View Figure

E lec tronic mac hi nes utili ze a complicated power-up proced ure that inc ludes a s ys tem c heck out wh en the mac hine is turned ON. In addi tion to a n elec tron ic checko ut, the c omputer ga the rs da ta that is necessa ry f or proper func tion . Compu te r-driv en machines sh ould be turned OFF an d res tarted with a f ul l ch eckout at leas t ev ery 24 hours . If the S TANDB Y mode is used for an ex tended period, co mputer i nfo rmation ma y beco me c orrupted, s ome c omponen ts may no t func tio n properl y or the entire mac hi ne may c ease to func tion. Mos t elec tron ic mac hines hav e a means to bypas s the ch eck out in an emergenc y. Some mac hines limi t th e number of consecutiv e times this bypass can be used. A machine ma y k eep a record of when and how of ten the bypass is used , and this i nfo rmati on may be discov erable in l egal proceed ings . One of the charac teris tic s of mode rn mach in es is the coo rdina tion of al l the func ti ons under a cen tral control . On mos t machi nes , th e ON-OFF s wi tc h ac tiv ates both th e elec tron ic an d mec han ic al comp onen ts of the mac hi ne. Cas es hav e been reporte d wh ere the mas ter s witch has b een acc identally turn ed OFF (10,11,12,13,14). Cas es hav e been re ported whe re the mas ter s wi tch was in a n i nte rmed iate pos ition between OFF or STA NDB Y and ON, an d this res ul ted in no gas o the r th an ox ygen from the oxygen f lush be ing de liv e red to the common gas outl et (15,16).

Power Failure Indicator

Mos t mac hines a re equipped wi th a v isual and/or audible indic a to r to alert th e anes thes ia prov ider to the los s of mains powe r (Fi g. 5 .3).

Figure 5.3 The machine will usually give an indication when mains power is lost.

View Figure

Reserve Power
S ince el ec tric ity is c ruc ial for many mach ine func tions , a back up sou rc e of power for th e occas ional outage is neces sary. The anes thes ia p rov id er should c hec k the battery s tatus du ring the p reuse checkou t procedure . On ol der mac hines , many indiv idual mo ni tors had thei r own bac kup po wer. Thes e backup s ys tems may need to be tu rned ON i ndiv idual ly or may be ac tiv ated automatic al l y wh en the machine is powered up. A disadv antage of th is arrangement i s tha t it is necess ary to check the battery status of eac h monitor. The du rati on of the back up wi ll v ary . On new anes thesi a works tations , c ompone nts may be back ed up with a s ingle power sou rc e. A n adv antage of this s ys tem i s tha t onl y one backup s ourc e needs to be check ed. Th e dura tion wi ll depend on the number of ins truments being supported. Manual or s pontaneous v entilatio n may ex tend batte ry lif e, as v entilator control is elec tronic i n mos t of th e new work s tations . W hi le so me o ld er anes th esi a machines used replac eable b atteries , mos t new machines use recha rgeable batteries . Ba ttery rec harge times v ary. If the machine is continuall y connec ted to ma ins e lec tric al power, bac kup power s hould be a t its highes t poss ible lev el . If a mac hi ne is unplugged f or an ex tended peri od, the charge ma y be inc ompl ete. It usua lly takes a number of h ours to fu lly rec harge a battery after i t has co mpletely disc harged. T he duration of battery bac kup wi ll depend on the powe r us age. A noni nterrup tible power s ource may be added to the anes thes ia mach ine for a longe r bac kup (F ig. 5.4 ).

Mos t elec tron ic anes thes ia mac hines hav e a wa y f or the use r to de termine the charge on the ba ttery and if the ba ttery is in us e (Fi g. 5 .5, als o see Fig. 5.43).

Electrical Outlets
Mos t modern anes thes ia machines hav e elec trica l outle ts (Fig . 5.6). Thes e a re i nte nded to power moni tors and P .86 other dev ices . The y usual l y cannot su pply elec tric i ty i n the c ase of a po wer f ailure.

Figure 5.4 An extra source of power may be attached to the anesthesia machine to extend the life of the electrical power in the machine.

View Figure

As a gen era l ru le, these outle ts should onl y be used for anes thes ia moni tors . Other appliances should be connec ted di rec tl y to mai ns po wer. If the p ower requi rements exc eed th at for which the outle t was des igned, a c irc ui t break er wi ll be ac tiv ated. High-frequ ency s urg ic al dev ic es or opera ting ro om b eds shoul d not be c onnec te d to these outlets , becaus e this may c ause the leakage cu rrent to ris e abov e th e permi tted v alue o r th e rated powe r to be ex ceeded.

Circuit Breakers
The re are c i rc uit b reakers for both the anesthesia mach ine and the ou tlets (Fig. 5.6). Anes thesia p rov id ers s hould consul t the ins truc tion manua l to become fa mil iar wi th thei r locations . W hen a c ircui t break er i s ac tiv ated, the el ec trical load shou ld be reduc ed and the c i rcu it b reaker rese t.

Figure 5.5 A: In the right upper corner of the screen, the amount of energy in the battery is displayed. B: If the battery does not carry a full charge, it can be charged by using mains power.
View Figure

Data Communication Ports

Mos t modern anes thes ia machines hav e data c ommun ic ati ons p orts (F ig. 5.7 ). These are used to c ommunicate between the anes thesi a mach ine , moni to rs , and the data management s ystem.

Pneumatic System
As shown in Figure 5.8, the pneu matic part of the mac hine c an be conv enien tl y div ided into three parts : High-, intermediate-, and l ow-p res sure sys tems .

The High-pressure S ystem

The high -press ure s ys tem rec eiv es gas es from cyl inders at high, v ariable pres sures and reduces those pres sures to l ower, more c onstan t pressu re sui tabl e for use in the mac hi ne.

Hanger Yoke
The hanger yoke ori ents and sup ports the cyl inder, prov ides a gas -tight s eal , and ensures a unidi rec ti ona l gas flo w. The works tatio n s tandard requi res that there be at leas t one yoke f or ox ygen and n itrous ox ide. If the machine is like ly to be used i n l ocations that do n ot hav e piped gas es , i t is adv isable to hav e a double y oke , es pecial l y for ox yge n. The hanger yoke is compos ed of s ev e ral parts : The bod y, whic h is the pri nci pal f ramework an d supporting s truc ture; the re taining sc rew, whi ch ti ghtens the c y li nde r i n the yoke; the nippl e, through wh ic h gas enters the machine; the index pi ns ,

whi c h prev ent attaching an incorre c t c ylinder; the was her, whi ch hel ps to f orm a seal P .87 between the c ylinde r and the yok e; a fi l ter to re mov e particu la te matte r; and the check v alv e assemb ly , which ens ures a unid irec ti onal f low of gas through the yok e.

Figure 5.6 Convenience electrical outlets on the back of the anesthesia machine. These should be used only for anesthesia monitors and not for general operating room use. Note the cautions regarding the total electrical load. Next to each outlet is a circuit breaker.

View Figure

Body
The body of the yok e is threaded into the f rame of the mac hine. It prov ides s uppo rt for th e cyl inder(s ). On the s wi nging gate (toggl e han dl e, s wiv el gate) type yok e (Fig . 5.9), the dis tal part is hi nge d. W hen a c ylinder is being mounted onto o r remov ed f rom a yoke, the hinged part c an be s wun g to the s ide.

Retaining Screw
The retainin g s c rew (c lamping dev ic e, reta in ing bar) i s th rea ded into the dis tal en d of the yok e (Fig. 5 .9). Tightening the sc rew presses the c ylind er v alv e ou tlet agains t the was her and ni pp le so that a gas-ti ght s eal is ach iev ed. The conic al point of the retaining sc rew is s haped to fi t the conica l dep res s ion on the c yl in der v alv e (Chap ter 1).

Nipple
The nipp le is the pa rt of the yoke through which the gas enters th e mac hine. It projec ts from the yoke and fits in to the port on the c ylinder v alv e. If the nip ple is dama ged, it may be i mposs ibl e to obtain a ti ght s eal wi th the c y linde r v alv e.

Inde x Pins
The P in Index Safety S ys tem (Ch apter 1) pins are below th e nipple (Fig. 5.9). The holes into whic h the pi ns are fi tted mus t be of a spec ific dep th. If they ex te nd too far i nto the bod y of the y oke , it ma y be poss ible to ins ert an inc orrec t c yli nder i nto the yok e (17).

Washer
A washer (g ask et) is pl aced a round the n ipp le (Fi g. 5.9) to p roduce a sea l between the cyl inder v alv e and the yoke . A was he r is usual l y s upplied wi th eac h ful l c ylinde r. W hen a c y linde r is f itted to a yok e, ca re sho ul d be tak en to ensure that the wa sher i s present and in good condition. A broken o r curled washe r shou ld no t be use d.

Figure 5.7 Data communication ports.

View Figure

P .88

Figure 5.8 Diagram of a generic three-gas anesthesia machine. The components and their arrangement may differ somewhat with machines from different manufacturers.

View Figure

An ex tra was her s hou ld be kept i n case one becomes damaged. No more than one was her s houl d be used, bec aus e mu ltip le was hers ma y prev ent a tight s eal f rom being es ta blished or may ov erri de the P in In dex Saf ety S ys tem (17 ).

Filter
The anes thes ia works tation s tandard re qui res that a fi lter be i ns talled between the c ylinde r and press ure regul ator or flow c ontrol v alv e to prev ent parti culate matter f rom entering the mach ine (7).

Check Valve Assembly

The c heck v alv e assembly a llows gas f rom a c y li nde r to en ter the mac hi ne but prev ents gas from exi ting the machine when there is no c yl inder in the yok e. This al lows an empty c yl inder to be replaced wi th a full one wi thout losi ng gas . It als o P .89 prev ents gas from being trans ferred f rom a c ylinde r with a higher p res sure to anoth er one wi th l ower pressure when bo th are connec ted to a double yoke and turned ON at the s ame time.

Figure 5.9 Swinging gatetype yoke. Note the washer around the nipple and the index pins below.

View Figure

A typic al c heck v alv e assembly is sho wn in Fi gure 5.10. It consis ts o f a plu nger that s lides awa y f rom the si de where the p res sure is greater. W hen c yli nder pressure ex ceeds the press ure on the machine s ide, the plunge r is pushed to the rig ht, and gas pass es around i t and into the mach ine. W hen mac hine p res sure exceeds c ylinde r pressu re, the pl unger mov es to the left, bl ock ing the gas f low. These c heck v alv es a re not des igned to ac t as permanen t seals f or empty yokes and may a ll ow a s mall amount of gas to es cape . To minimi ze s uch losses , a yok e shoul d not be lef t v ac ant. As s oon as a c yl in der is ex haus ted, i t s hould be replaced by a full one. If a f ull c yl inder is not av ai lable, a yoke plug (dummy c yl ind er block o r plug, blank ing c ap o r plug) (Fig . 5.11) should be placed in th e emp ty yoke. A yoke plug is a s olid pi ece of me tal or other ma teri al that has a c onical depress ion on one s ide to fi t the ti p of the retaining sc rew and a hollo wed area on the o the r s ide to f it ov er th e nipple. W hen i n p lace, the plug fo rms a sea l to prev ent the gas f rom es caping f rom the machine. In the abse nce of a yoke plug, g as can f lo w retrog rade through an open flow c ontro l v alv e and out through the yok e (18). Manufac tu rers of ten c hai n yok e p lu gs to the mac hi ne .

View Figure

Figure 5.10 Yoke check valve assembly. This assembly allows gas to enter the machine but does not allow gas to exit the yoke. When the pressure in the machine exceeds that in the cylinder, the plunger moves to the left, preventing escape of gas from the machine. When cylinder pressure exceeds machine pressure, the plunger moves to the right, and gas flows into the machine. (From a drawing furnished by Ohmeda, a division of BOC, Inc.)

To prev ent transfil ling between pai red c ylind ers as a res ul t of a defec tiv e c heck v alv e, onl y one c yli nder of a gas shou ld be open at a time.

Placing a Cylinder in a Yoke

It is important that c ylinder v alv es and yok es not be c ontami nated wi th oi l or greas e, bec aus e this cou ld pres ent a fi re hazard (Chapte r 32). P ersons placi ng a c ylinde r in a yoke shou ld al way s was h thei r hands fi rs t. Before a c yl inder is mounted in plac e, the yok e s hould be checke d to make ce rtain that the two P in In dex Saf ety S ys tem pi ns are p res ent. A miss ing p in c ould a llow the safety s ys tem to be bypas sed (19). P .90

Figure 5.11 Yoke plug in place. Note the chain to the machine.

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The f irs t s tep in pl acing a c yli nder i n a yok e i s to retrac t th e retaining sc rew. W i th the gate-type yoke , the g ate is s wung o pen. The wash er is p laced ov e r the nipple . The c ylinder is then s uppo rted with the foo t and rais ed in to the yok e (Fig. 5.12). The port on the c ylinde r v alv e is guided ov er the nipple a nd th e i ndex pins engaged i n the ap propriate holes . The gate is then c lose d. The retainin g s c rew is tigh te ned so that i t contac ts the c onical depressi on on the c ylinder v alv e and pushes the v alv e ov er the nipple and index pins . It is importan t to ens ure tha t the c ylin der is co rrec tly plac ed bef ore ti ghteni ng th e retaini ng sc rew. Otherwis e, the retaining sc rew may be ins e rted in to the saf ety rel ief dev ic e on the cy linde r. Af ter the c ylinde r has been tightened o nto the yoke, it sh ould be opened to make c ertain tha t the cyl inder is fu ll and that there is no leak (as ev idenc ed by a hiss ing s ound). The mos t common ca use of a leak is a defec tiv e or mis si ng washer. If the c yli nder v alv e l eaks o r is diffic ul t to operate, the c yl inder s houl d be re turned to the s uppli er.

Figure 5.12 Placing cylinder in yoke. The cylinder is supported by the foot and guided into place manually.

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Af ter the c ylinder has b een attached to the yoke, the valve sho uld be close d unles s it is to be the primary gas s uppl y fo r th e mac hi ne. If i t remains open, f luc tu ati ons in th e gas press ure in the mac hi ne coul d allo w s ome o r al l of the gas to ex it the cy linde r. In the ev ent tha t pi peline p res sure is l ost, gas c oul d be used f rom the cyl inder wi thout the us er being awa re of the change . The f irs t time that the use r might be aware of the los t p ipeline press ure c ould be when the c yl inder b ecomes empty. If on ly on e gas c yl inder is prese nt, the re wou ld be no gas av ail able.

Cylinder Pressure Indicator (Gauge)

The anes thes ia works tation s tandard re qui res that the re be a pressu re i ndicator that disp la ys the c yl inder press ure for each gas suppl ied by c yli nders (7). The i ndicator may be loc ated near the c yl inders or on a panel on the front of the machine (Figs . 5 .13, 5.14). The sc al e mus t be at leas t 33 % greater than the maxi mum fi l ling press ure of the c ylinder or the fu ll i ndic ati on position. Many indica tors are of the B ourdon tube (Bo urd on spring, elas tic ele ment) ty pe, i llus trate d in Fi gure 5 .1 5. A hol lo w metal tub e is ben t in to a curv e, then s eal ed and l inked to a c loc kl ik e mec han ism. The other end is P .91 connec ted to the gas s ource . An inc rease in g as pressu re i nside the tube c auses it to s traighten. As the press ure f al ls , th e tube resu mes its curv ed shape. Bec ause the open end is fix ed, the sea led end mov es . Thes e motions a re trans mitted to the

i ndicator, whi ch mov es ov er a ca librated scale. Gauges a re requi red to be ca li brated in k i lopas cals (k P a) but pounds per s quare inc h (ps i) ma y als o be us ed (Fig . 5.13).

Figure 5.13 Cylinder and pipeline pressure indicators. Kilopascals 100 are indicated in the inside of the dial while pounds per square inch gauge are on the outside.

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Figure 5.14 Digital pressure indicators. Pipeline pressures are at the top. Cylinder pressures are below. At left below is the vacuum regulator and gauge and ON-OFF control for suction. To the right of this is the alternative oxygen source, which can be used if there is total loss of electrical power. To the right is the recessed oxygen flush control.

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Figure 5.15 Bourdon pressure gauge. As gas pressure within the flexible tube increases, the tube tends to straighten. The motion is translated through the gearing mechanism so that the indicator shows a higher pressure. The tail end of the pointer is shorter than the indicating end and blends into the background. The lowest pressure indication is between the 6 o'clock and 9 o'clock positions on a clock face.

View Figure

Di gi tal pressure readou ts are used on s ome modern electronic anes thesia mach ines (Fig . 5.14). Some elec tronic machines h av e light-emi ttin g d iodes (LE Ds ) to indic ate c ylinder press ure (Fig. 5.16A ). If the c ylinder v a lv e is open a nd the p res sure is adequa te, the LE D is green . If the v alv e is open but the pressu re is ina dequ ate , the LE D wi l l f las h red . It wil l be da rk if the c yl inder v alv e i s not open. Thes e machines may also display the ac tual pressu re fo r pi pelines and c y li nde rs on a sc reen d uring the checko ut (Fig . 5.16B ). It c an be av ail ab le on demand or on a co ntinuous bas is (see Fi g. 5.43 ).

Pressure Regulators
The pres sure in a cyl inder v aries . To mai nta in co ns tant fl ow with changing supp ly press ure , th e anes thes ia mac hine is f itted with pre ssu re re gulators (reduci ng v alv es, reduc ing regu la tors , reduc tion v alv es , regu la tor v alv es, gas press ure reduc ing dev ice/s ys tem). A pressu re regulator reduc es the high and v aria ble press ure found in a cyl inder to a lowe r, more c ons tant press ure s ui tab le for use i n an an esthes ia machine. W ithou t a regulato r, i t wou ld be necess ary for the anes thes ia prov ider to c ons tantly al te r the fl ow c ontro l v alv e to main tain a cons ta nt f low thro ugh the fl owmeter as the press ure in the c y linder dec reased. The anes thes ia works tation s ta ndard req uires a press ure regulator f or each gas suppl ie d f rom c ylinders (7). P .92

Figure 5.16 A: LEDs indicate cylinder pressure. If the cylinder valve is open and the pressure is adequate, the LED will be green. If the valve is open but the pressure is inadequate, the LED will flash red. It will be dark if the cylinder valve is not open. B: Some machines use LEDs to indicate cylinder pressure. These do not give adequate information when it is necessary to know how much gas is in a cylinder. The specific information can be brought up on the screen during the checkout phase.

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P .93

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Figure 5.17 A large pressure acting over a small area is balanced by a smaller pressure acting over a large area. The relative sizes of the arrows represent the magnitudes of the pressures.

Physical Principles

P ress ure is def ined as fo rce ac ting against an area. Forc e can be inc reas ed either by inc reas ing the press ure or b y inc reas ing th e a rea ov er whi ch the pressu re ac ts . To illus trate this , cons ider the si mple balanc e s hown i n F ig ure 5.17. A la rge press ure, Pc , ac ting on a s ma ll a rea, A 1 , is ba lanced by a s ma ller press ure, P r, ac ting on a l arge area, A 2 . The f orce exe rted by th e h igher press ure is Pc A 1 This is b al anced b y the forc e on the ri ght: Pr A2 Bec ause thes e forces are equal, it fol lo ws tha t P r A 2 = Pc A 1 Solv ing f or P r, P r = A 1 /A 2 Pc These s ame princ iples appl y in a pres sure regu la tor. Fi gure 5.1 8 shows a c ylinde r of gas under a high pressure, Pc (inle t pressu re). R is the inside of a pressu re regulator co nta in ing gas at reduc ed pressure, P r (ou tlet press ure). The opening between C an d R is occ luded by a s eat o f area A 1 . A 2 is the area of a flex ibl e diaph ragm on whic h P r ac ts . W hen the s topcock , S , is c los ed, the f orc es are in balance. The s eat seals the o pening f rom the c ylinder s o that no gas f lo ws f rom C i nto R.

Figure 5.18 The simplified pressure regulator is in the closed state. (See text for details.)

View Figure

In F igu re 5.19, the s topcock is open and gas f lows f ro m R, c aus ing the pressu re, P r, to drop. The fo rces are no longer balanced bec ause Pc A 1 > P r A 2 . The f lex ib le diaph ragm becomes fl atter, th e balance tips to th e right, and the sea t no

l onge r occ ludes th e openi ng f rom the c ylinder s o that gas flows f rom the c yli nder i nto R. A s long as the s topc ock is open, the forces wi l l be in balance , and gas wi l l continue to fl ow from the c ylinder. This is analogous to open ing the flow c ontrol v alv e o n the anes thesi a mac hine. W hen the s topcock is c los ed, gas wil l c ontinue to f low brie fl y in to R, until P r inc reases to the poi nt where a balance of forc es is res tored. The s mall inc re ase i n P r after the s topc ock is c losed is called the s tatic i nc rement. The pres sure regula tor s hown i n Figures 5.1 8 and 5.19 wil l yield a cons ta nt reduc ed pressure onl y if the s uppl ied pressure, P c , is c ons tan t. If Pc dec reases , as whe n the c y li nde r pressu re fa lls, P r mus t dec rease to preserv e the balance of forc es . W i th this type o f pressu re regulator, the f lo w i ndica tor woul d cons tan tly need to be adjus ted to compens ate fo r th e p res sure drop. To remedy this , a main s pri ng , S 1 , is added (Fi g. 5 .20). T his s pring ex erts a downward f orce on th e flexi bl e diaphragm. T he magni tude of this force depends on an ad jus ta ble s c re w. Now, the forc es ac ting to pus h the diaphragm upward remain at Pr A2 Forc es ac ting to push the diaphragm down ward a re (Pc A 1 ) + Fs 1 whe re Fs 1 is the force ex erted by the spring. If the v alues fo r Pc , P r, A 1 , and A 2 remain unchanged , th ere wo uld be an imbalanc e of f orc es , because the f orce of the mai n sprin g wo uld b e added to the force of Pc ac ting on A 1 . To compensa te fo r th is i mbal anc e, A 1 may be reduc ed, A 2 ma y be inc reased , or bo th. A t equ ilib ri um, (Pc A 1 ) + Fs 1 = P r A 2 Solv ing this equati on for P r, The f orce exerted by P r ac ting on the diaphragm, theref ore , is oppos ed by two forc es : A co ns tant force from the s pring (Fs 1 /A 2 ) and a v ariable forc e from Pc ac ting on the seat, Pc (A 1 /A 2 ). If the force ex erted by the P .94 sp ri ng is l arge in c omparis on with the f orce exe rted by Pc , large v ariations in Pc wi ll c aus e only s ligh t v aria tions in P r.

Figure 5.19 The pressure regulator with its stopcock (S) open. An imbalance of forces is created, allowing gas to pass from the cylinder into the pressure regulator. (See text for details.)

View Figure

The v alu e of P r wi ll depend on Fs 1 . The tens ion in the s pri ng can be v aried by means of the adjus table sc rew, a nd in this way, P r c an be v aried. Fo r this re ason, the main s pring is sometimes cal led the ad jus ting s p ring. One mo re addition to the regulator is necessary. In Figure 5 .2 1, a sea ling (s hutoff) s p ring, S 2 , is added. Th is ac ts to forc e the s eat agains t the op ening from the c ylinder. This p rev ents gas f rom f lowing f rom C to R when the adjus ting sprin g is comp letel y re lax ed and the s topc ock open. Equation 1 then becomes

Figure 5.20 A mainspring (S 1) and adjusting screw have been added to the pressure regulator. (See text for details.)

View Figure

The v alu e of Fs 2 is cons iderabl y smal le r than Fs 1 s o that (Fs 1 Fs 2 ) is large co mpared with Pc , and P r wil l remain relativ el y cons tan t des pite v ari ati ons i n Pc . The re wi ll , ho wev er, be some v ariations i n P r with v aria tions in Pc . A cha nge, Pc , i n c yl in der press ure wi l l P .95 produce a c hange, P r, i n the reduc ed pressu re. F rom E qua tion 2,

Figure 5.21 A sealing spring has been added to complete the pressure regulator. (See text for details.)

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P r = Pc (A 1 /A 2 ) As Pc dec re ases , P r also dec reases (pressu re-proporti oned reduc tion). The magn itude of the c hange i n P r is g ov erned b y the ratio A 1 :A 2 . The pres sure regula tor i l lus trated i n F igu res 5 .18 to 5.21 is an ex ample of a di rec tac ting pressu re regulator. This is becaus e the compone nts a re arranged so that the c ylinde r pressu re tends to open the v alv e. An indi rec t-ac ting pressu re regul ator is s hown i n Figure 5.22. In this c ase, Pc ac ts to c lose the v alv e. Equation 2 then becomes P r = (Fs 1 -Fs 2 )/A 2 - Pc (A 1 /A 2 ) The v ariation in P r wi th v ari ation in Pc is g iv en by the equati on P r = Pc (A 1 /A 2 ). As Pc dec re ases , P r i nc reas es (press ure inv ers ion ).

The Modern Pressure Regula tor

Mode rn press ure regulators are depic te d i n Fi gures 5.23 and 5.24. A di rec t-ac ti ng press ure regulator is sho wn i n Figure 5 .23. Its f unc ti on is de termined by a balanc e

of forc es ac ti ng to pos i ti on the sea t, A 2 . W ith the v alv e c losed , the force of the sealing s p ring, S 2 , pushi ng the seat up agains t the n ozzle, is greater than the downward f orce exe rted by the main s pring, S 1 , and the inlet press ure , Pc , agai ns t the seat. No gas f lows from the i nl et into the press ure regul ator. P r is 0. W hen the v alv e is opened by ti ghtening the adj us ting sc rew, the down ward force of the main s pring, S 1 , is inc reased. This fo rc e i s trans mitte d along the v alv e thrus t pin to the sea t and, in c omb inati on wi th the in le t pressu re, ov ercomes the forc e of the seal ing spring. Gas at reduc ed pres sure f lows in to the space unde r the diaph ragm and exerts an up ward f orce on th e diaphragm. Gas then flo ws to the outl et. The fo rc es are no t in balance, but P r wil l remain c ons tan t becaus e a s tead y s tate is so on ac hi ev ed. Gas wi l l continue to flow until eithe r the c ylinder is e mpty o r the gas f low i s turned OFF at a point down strea m of the press ure regulator. If it is turned OFF, gas wil l c ontinu e b ri efly to f low into the s pac e u nder the diaph rag m. Here, i ts p res sure wil l i nc reas e (s tatic i nc rement) un ti l the forc e of the reduc ed gas on the di aphragm (P r A 2 ) plus the forc e of the sealing s pri ng, S 2 , balance the forc e o f the c ylinder pres sure and the main spri ng (Pc A 2 + F 2 ), as in E qua tion 2. Fi gure 5.24 il lus trates an indi rec t-ac ting pressu re regulator. Wi th the v alv e c losed, gas ente rs the space surroundi ng th e seal ing s pring, S 2 , and the v alv e seat, A 1 . Its own press ure, Pc , tends to ho ld the v alv e sea t agains t the nozzle . When th e adjus ting sc rew i s turned s o that the main spring ex erts a do wnward f orc e on the diaph ragm, Fs 1 , the v alv e th rus t pi n mov es downward, opening the s eat, so that gas a t reduc ed p res sure, P r, exp ands through the holes for the thrus t pin and in to the cav i ty unde r the d iaphragm. W hen the gas f lo w i s turned OFF dis tal to the press ure regulator, gas continues to flo w bri efl y i nto the space und er the diaph ragm. Here, i ts press ure inc reas es (s tatic inc reme nt), pushing P .96 the diaphragm upwa rd unti l the s eat c loses aga ins t the nozz le , s topping f urther f low.

Figure 5.22 Indirect-acting pressure regulator. The components are arranged so that cylinder pressure tends to close the valve. (See text for details.)

View Figure

A pressu re regul ator may be ad jus table or pre set. A n adjus table press ure regulator has a means fo r the user to adjus t the del ivery pressu re. T his type of v alv e is us ual ly found on transp ort gas c yl inders . A prese t pressu re regul ator re qui res a tool to adj ust the de liv ery pressu re. P ress ure regulators used i n anes thes ia machines are preset a t the fac tory. One regulator may se rv e a s ing le- o r a dual -hange r yok e. The a nes thes ia works tati on s tandard requi res that the fl ow from the c y linde r not exceed 10 mL/minute when press ure in the gas pi peline s ystem is 34 5 k Pa (50 ps ig ) (7). Th is can b e ac complished by k eeping the pressu re del ivered by the regula tor at a lo wer l ev el than pipel ine pressure.

View Figure

Figure 5.23 Direct-acting pressure regulator. The darker shades are used for gas under high pressure, whereas the lighter shades represent gas under reduced pressure. The arrows indicate the path of gas flow. The valve is opened by turning the adjusting screw. (See text for details.) (Redrawn from a drawing furnished by Ohmeda, a division of BOC, Inc.)

A defec tiv e pressu re regulator may block the gas f lo w f ro m a c y li nde r or cause wi del y fluc tua ting fl ows (20,21).

Intermediate Pressure System

The intermediate press ure s ys tem (Fig. 5 .8) rece iv es gas es from the press ure regulator or the pipel ine P .97 i nlet to the anes thesi a mac hine . Ox ygen may enter the pneumatic componen ts by way of the mas ter s wi tc h . W hen the mas ter s wi tch is turned OFF, the press ure in the in termedi ate pressure s ys tem wi ll drop to zero. The intermedi ate pres sure s ys tem pneumatic compon ents include the p neuma tic part of the mas ter s witch, pipel ine inlet conn ec tions , p ipeline press ure indica tors , piping , the gas powe r outl et, ox ygen pressu re failure dev ices , the ox ygen flus h, additional pressure regulators (if so equi pped), and the flow c on trol v alv es.

Figure 5.24 Indirect-acting pressure regulator. The cylinder pressure opposes the opening of the valve. When the adjusting screw is opened, gas flows from the lower to the upper chamber along the valve thrust pin. (Redrawn from a drawing furnished by Ohmeda, a division of BOC, Inc.)
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Master Switch (Pneumatic Component)

The pneumatic porti on of the mas ter s witc h is l oc ated in the intermediate p res sure s ys tem downs tream of th e i nl ets for the c y linder and pi pe li ne sup pl ies . The ox yge n f lus h is us ual ly inde pendent of th is s wi tch. T he mas ter s wi tch may be a total ly elec tronic s wi tch that when ac tiv ated c on trol s the v a rious pneumatic c omponents i n the anes thes ia machine.

Figure 5.25 Pipeline inlets. Note the DISS connections.

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Pipeline Inlet Connections

The pipe li ne inle t con nec tion is the entry poin t fo r gas es from the pipelines . The anes thes ia works tation s ta ndard req uires pipel ine inle t connec ti ons fo r ox ygen and ni trous ox ide (7). Mos t machi nes a ls o h av e an i nl et connec tor for a ir. These in lets are fi tted wi th threaded noninte rchangeabl e Diame ter Index S afety S ys tem (DISS ) f ittings (Chap ter 2) (F ig. 5.25). Eac h inl et mus t c onta in a unidi rec tional (c hec k ) v alv e to prev en t rev ersed gas f low f rom the machine into the piping s ys tem (o r to atmosphere if no hos e is c onnec ted). P roblems hav e been reported wi th this check v alv e. In one c ase, the c heck v alv e s tuck in th e c losed pos ition, obs truc ting ox ygen f lo w (22). The re are c ase P .98 reports wh ere the v alv e failed to prev ent rev ers e f low (23 ,24 ). Eac h pipeline inlet is required to hav e a fil te r with a pore s ize of 100 m or less . The f il ter may become cl ogg ed, resul ting in a red uc tion in gas flo w (25).

Pipeline Pressure Indicators

Indicators to moni to r the pipeline press ure of eac h gas (Figs . 5.13, 5.14) are requi red by the anes thes ia work s tation s tandard (7 ). They are usuall y found on a panel on the front of the machine and ma y b e c ol or c oded fo r the gases that they moni tor. On s ome machines , the correc t ra nge of p res sures is i ndica ted by a co lored zo ne. Some mac hines hav e d ig ital pres sure ind ic ato rs (F ig . 5.14). The pi peline pressure i s dis pl ayed ei ther c ontinuous ly or o n demand . On some ne wer el ec tronic machines , LEDs indicate pipel ine pressure (Fi g. 5 .16A). A gre en LE D indicates that the pip el ine is connec ted an d the press ure is adeq uate. If the L ED is OFF, the press ure is inadequate o r the pip eline is not c onnec te d. If the trans duc e r is i nop era ble , th e LE D is dark . A di gi tal press ure ca n be d is pl ayed on the sc reen to augmen t the informati on f rom the LE Ds (s ee Fig. 5.43). The wo rks tation s tanda rd requi res tha t the indica tor be on the pipe li ne s ide of the check v alv e in the p ip eline i nl et (Fig . 5.8). If the indicator i s on the pipeline si de of the chec k v alv e, it wi l l moni to r pi peline p res sure onl y. If the hose is disconnec ted or i mproperl y c onnec ted, i t wi ll read 0 ev en if a c yl inder v alv e is open (26,27 ). If the indic ator were on the mac hine (do wns tre am) s ide of the check v alv e, it would not giv e a true indic ation of the pi pe li ne suppl y pressure unless the c ylinde r v alv es were c l osed . If a c yl ind er v alv e is open and th e p ipe line s uppl y fai ls, there wil l be no change in the p res sure on the indicator u nti l the c ylinde r is nearl y empty (28).

Figure 5.26 Gas power (auxiliary gas) outlet on an anesthesia machine.

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The indica tion of an a dequ ate press ure on the pipel ine indicator does not guarante e that gas is not be ing d rawn f rom a c yli nder. If fo r any reason the gas press ure c omin g f rom a cy linde r v ia a p res sure regula tor exceeds the pipel in e press ure and a c ylinder v a lv e is ope n, gas wi l l be drawn from the c yl inder. The refore, c y li nder v alv es s hould al ways remai n cl osed wh en the pipe li ne suppl y is i n use. P ipel ine pressure in dicators s hould al ways be c heck ed before the mach ine is use d. The pres sure s hould be betwee n 5 0 and 55 ps ig (345 and 380 k Pa). The indicators shoul d be scanned repeated ly du ri ng use .

Piping
P iping is us ed to c onnec t c omponen ts ins ide the machine . It mus t be able to wi th s tand four ti mes the in tended se rv ice press ure wi thout rupturing (7). The anes thes ia works tation s tandard s peci fies that leak s b etween the pip eline i nl et or c yl inder press ure reduc ing s ys tem and the flow c on trol v alv e not ex ceed 25 mL/minute (7). If the yok e and press ure reduc ing s ys tem are inc lude d, the leakag e may no t exc eed 150 mL/min ute. P iping c ross connec ti ons insi de the machi ne hav e been reported (29 ). Disconnec tions in the p iping may oc cur b ut are rare (30 ).

Gas Power Outlet

One or mo re gas power (auxi l ia ry gas ) outlets may be p res ent o n an anes thesia machine (Fig. 5.26). It may serv e as the sou rce of driv ing gas for the

P .99 anes thes ia v en ti lato r or to s uppl y gas for a j et v enti lator. E ither ox ygen o r ai r may be us ed, and if there is a choice, there shou ld be a gas p ower ou tl et for eac h gas .

View Figure

Figure 5.27 Oxygen failure safety valve. When oxygen pressure in the machine is normal, it will push the diaphragm and stem downward, opening the valve. The anesthetic gas then flows in at A, around the stem, and out at C. When the oxygen pressure falls, the stem moves upward, closing the valve. The middle chamber is vented to atmosphere to prevent mixing of anesthetic gas and oxygen in the event that the diaphragm ruptures or the packing leaks. (Redrawn from a drawing furnished by Ohmeda, a division of BOC, Inc.)

In the pas t, the po wer ou tl et was usual ly p resent when the v entilator wa s a n add-on part of the anes thes ia mac hine, and o ne of sev eral different v entilators could be us ed. Howev er, wi th modern anes thesia mach ines , the v en ti lato r is an i ntegral pa rt of the mac hine and breathing s ys tem and is connec ted to the v en ti lato r with in ternal piping. T herefo re, the po wer ou tl et is not f ound o n ma ny anes thesi a machi nes today .

Oxygen Pressure Failure Devices

One of the mos t serio us mis haps that occu rred with early mac hines was depletion of the ox ygen s upply (usual l y from a cy lind er) wi thout the us er's awa reness . The resul t was deliv e ry of 100% anes the tic gas . Numerous i nv en tions hav e been dev is ed to prev ent this p rob le m. Among these are dev ic es tha t s hu t of f the s uppl y of gases o the r than ox ygen (oxygen f ai lure safety dev ic e) or alarm when ox ygen press ure has fall en to a dangerous lev el .

Oxygen Failure Safety Device

The anes thes ia works tation s tandard re qui res that whenev er the oxy gen su pply press ure is reduced belo w the manufac tu rer-s peci fied minimum, the del iv ered

ox ygen c once ntration s hal l not dec reas e bel ow 19% at the c ommon gas outlet (7,31). The oxygen f ai lure safety v alv e (oxy gen failure saf ety dev ice, low-press ure guardian s ys tem, ox ygen failu re protec tion dev ice, p res sure sens or s hutoff s ys tem or v alv e, fai l safe, p res sure s ens or sys tem, ni trous ox ide s hutof f v alv e) shuts off or proportionally dec re ases and ul ti mate ly interrupts the s upp ly of nitrous oxide if the ox ygen s uppl y pressu re dec reases . On many mode rn mach ines , the ai r s upply is also cu t off but may not be (1,3 2). W hen the pneu matic sys tem is ac tiv ated, oxyge n p res sure reaches the ox ygen failure safety dev ice, allowi ng other gases to flow. Turn ing OF F the pne umatic s ys tem c auses ox ygen in the machine to be v ented to a tmos phere. T he res ul ti ng dec reas e i n ox ygen pressure causes the oxy gen fa ilure s afety dev ice to interrupt the supp ly of oth er gas es to thei r f lo w c ontrol v alv es . One such dev ic e is sho wn diagramma tic al l y in Figure 5.27. W hen oxygen p res sure i s norma l, the plunger an d s eal assemb ly are depres sed s o that anes thetic gas can f low thro ugh the v alv e. W hen the ox yge n p res sure dec reas es , the s p ring fo rc es the plunger and s eal assembly up ward , narro wi ng the v alv e openi ng in p rop ortion to ox ygen suppl y pressu re loss . If the ox ygen suppl y pressu re fails completel y, the v alv e c loses . To determine if a machine has a prope rl y func tioning oxygen failure safety dev ic e, the flows of ox ygen and the oth er gas (usuall y ni trous oxide) are turned ON. The sourc e of ox ygen press ure is th en remov ed. The fa ll in oxy gen press ure is noted on the c ylinder or pipel ine pres sure gauge . If the ox ygen fai lu re safety dev ic e is func tioning properly , the flow ind ic ato r fo r the othe r gas wi ll fal l to the bottom of the tube j us t befo re the oxygen in dic ator fa lls to the bottom of its tube.

Oxygen Supply Failure Alarm

The anes thes ia works tation s tandard s peci fies that whe nev er the oxygen supp ly press ure fal ls be lo w a manu fac tu rer-s pec if ie d thresho ld (usuall y 30 psi g (205 kPa)), at leas t a medium priority alarm shall be enunciated withi n 5 s econds (7,33 ,34 ,35 ). It shall n ot be poss ible to dis able this a larm. Bec ause b oth the ox ygen failure safety dev ice and a larm depend on pressure and not flow, they hav e li mi tations that a re not alwa ys full y app rec ia ted by the use r. The y aid i n prev enting hypox ia caus ed by problems occ urri ng ups tream in the machine c ircui try (dis con nec ted ox ygen hose, low ox ygen press ure in the p ipe line, and d epl etion of ox ygen cyl inders ). These dev ices do not offer total protec ti on

agains t a hypoxic mix ture being deliv ered, b ecause they do not p rev ent a nes the tic gas f ro m f lo win g if there is no flo w of ox ygen. Equipment p roblems (s uc h as leaks ) or operato r errors (such as a c losed o r partial ly c los ed ox ygen f low c ontrol v alv e) that oc cur P .100 downs trea m are not p rev ented by these devi ces . They do no t gua rd aga ins t ac c idents from c rossov ers in the p ip eline s ys tem o r a c yl in der c ontainin g the wrong gas .

Figure 5.28 Gas selector switch. In the N2O position, only oxygen and nitrous oxide can be used. In the air position, only oxygen and air can be administered.

View Figure

Gas Selector Switch

Some mac hines hav e a gas selec tor s witch that prev ents air a nd ni trous ox ide f rom being us ed together. Two ty pes of s wi tches are s hown i n F ig ures 5 .28 and 5.29.

Figure 5.29 Electronic gas selector switch. Either nitrous oxide or air can be selected by pushing the appropriate button (lower left). Total gas flow and oxygen percentage are set by pushing the hard keys and rotating the wheel at the lower right. The balance of the fresh gas flow will be the other gas chosen (nitrous oxide or air).

View Figure

Second-stage Pressure Regulator

Some mac hines hav e p res sure regulato rs in the intermedia te press ure s ys tem j us t ups tream of the flow i ndicators . Thes e rec eiv e gas f rom ei ther the pipel in e o r the press ure regulator and red uce it further to aro und 26 psi (17 7 k Pa) for ni trous ox ide and 1 4 psi (95 kPa) for ox ygen. The p urp ose of this pressu re regulator is to el imina te f luc tuations i n pressu re suppl ied to the f low ind ic ato rs caused by f luc tu ati ons in pipel ine pressure. B y reduc ing the pres sures bel ow th e n ormal f luc tu ati on range , th e f low wil l remai n mo re cons tant. Not al l anes thes ia mac hines are equipped with this dev ic e.

Oxygen Flush
The oxygen f lush (ox yg en bypass, emerg enc y ox yge n bypass ) rec eiv es oxy gen from the pipel ine inlet or c ylinder p res sure regu la tor and di rec ts a hi gh unme tered f low di rec tly to the common gas outlet. It i s common ly l abe led O 2 +. On mos t anes thes ia mach ines , the ox ygen f lus h can be ac tiv ated re gardl ess of wh ether the mas ter s witc h is turned ON or OFF . The anes thes ia works tation requires that the ox ygen f lush be a singl e-purpose, se lf -c los ing dev ice op era ble wi th one hand and d esigned to min imi ze uni ntentional ac tiv ation (7). A flow between 35 and 75 L/minute mus t be deliv ere d. An ox ygen flush is s hown i n F igu re 5.30. It cons is ts of a button and s tem connec ted to a ba ll . The ball is in contac t with the s eat. W hen the butto n is dep res sed, the ball

i s forc ed away from the se at, allowi ng the ox ygen to f low to th e o utlet. A spring oppos ing the bal l wi ll close th e v alv e when the button is not depress ed. T he button P .101 i s commonl y reces sed or plac ed in a co llar to prev ent acc iden ta l ac tiv ation (Figs . 5.14, F ig . 5.31).

Figure 5.30 Oxygen flush valve. Depressing the button causes the pin to push the ball away from the seat, allowing oxygen to pass directly to the machine outlet. (Redrawn from a diagram furnished by Ohmeda, a division of BOC, Inc.)

View Figure

Ox ygen flus h ac tiv ation may or may not resul t in other gas f lows being shut off and may res ul t in eithe r a p osi tiv e or nega tiv e pressu re i n the mac hin e circu itry , dependi ng on the des ign of the i nl et and the flus h line i nto the common gas line . This press ure wi ll be trans mitted back to o th er s truc tu res in the mac hi ne, s uch as f low i ndicators and v apori ze rs , and may change the v aporizer output and the flo w i ndicator readings . The e ffec t c aus ed by oxy gen flus h ac tiv ation wi ll depe nd on the press ure generated, the presence or absenc e of check v alv es i n the machine, and the rel ationsh ip of the ox ygen f lus h v alv e to o ther componen ts . The anes th esia work s tation s tandard requi res that the co nnec tion of the f lus h v alv e del iv ery line to the common gas outlet be des igned so th at ac tiv ation does no t inc rease or dec reas e the pressure at the v aporize r outle t by more than 10 k Pa o r inc rease the v apor ou tpu t by more than 20% (7).

Figure 5.31 Oxygen flush valve. Note the protective ring to prevent accident activation. O2+ is a symbol for the oxygen flush valve.

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Reported hazards ass oc iated with the oxyge n fl ush incl ude ac cidental ac tiv ation (36,37,38) and internal leakage , whi ch resulte d i n an oxy gen-en ric hed mixture being de liv ered (39,40). The f lush v alv e may s tick in the ON pos i tion (41,42,43). The re is a repo rt of a f lush v alv e s ticki ng an d obs truc ting the flow of the gas es from the flowmeters (44 ). Ba rotrauma and awareness during anes thes ia h av e resul ted f rom its ac tiv atio n (38,45 ). Ox ygen f lush ac tiv ation during i nspi ration de liv ered by the anes thes ia v enti lator wi l l re sul t i n delive ry of high tidal v olumes and poss ible barotra uma. Venti lato rs that ex cl ude f res h gas flow f rom the b rea thing s ys tem during ins pi ra tion wi ll n ot present th is problem. These f eatures are dis cuss ed in Chapte rs 9 and 12 . Us ing the oxy gen fl us h to v en ti late through a c atheter ins erted percutaneous ly has been inv estigated (46 ). S ome machines prov ide suffic ient press ure for effec tiv e jet v enti lation , but o the rs do no t. Mos t anes thes ia machine manufac ture rs do no t recommen d usi ng the ox yge n flush f or this p urp ose.

Flow Adjustment Control

The f lo w a djus tment controls re gulate the flow of oxygen, ai r, and other gases to the flow in dic ators . There are two ty pes of fl ow adjus tment c ontrols : mechanic al and e lec tronic . The anes th esia work s tation s tandard requi res that there be o nl y o ne f low c ontrol for eac h gas (7). It mus t be ad jac ent to or identifi able wi th i ts as soc iated f lowme ter.

Mechanical Flow Control Valve

The mec hanic al flow c ontrol v alv e (ne edl e valv e, pin v alv e, f ine adjus tme nt v alv e) controls the rate of gas f lo w through i ts as soc ia ted f lo wmete r (47 ). S ome als o hav e an ON-OFF func tion . On some mach ines , the ON-OF F func tion is c ontrolled by the mas ter s witc h. Mechanical f lo w c ontrol v alves a re used with both mechan ic al and elec tronic flowmeters .

Components
Body
The f lo w c ontrol v alv e body sc rews i nto the anes thes ia machine .

Stem and Seat

The s tem and s eat are shown i n Figure 5 .32. The s tem and se at hav e fi ne th reads so that the s tem mov es on ly a short d is tance when a co mple te turn is made. When the v alv e is c losed, the pin at the end of the s tem fi ts into the s eat, oc cluding the orifice s o that no gas can pas s throug h the v alv e. W hen the s tem is tu rned outward , an op eni ng between the pin and the P .102 seat is c reated, al lowin g gas to f lo w through the v alv e. The greater the space between the pin and the sea t, the greater the v olume of gas tha t can flo w. To el imina te any loos eness in the th rea ds , the v alv e may be s pri ng loaded (48 ). Th is also mi nimi zes f low fl uc tuati ons from la teral o r ax ial p res sure appl ied to the flow control k nob.

Figure 5.32 Flow adjustment control, shown in the closed position. Turning the stem creates a leak between the pin and seat so that gas flows to the outlet. The stop collar prevents overtightening of the pin in the seat. (Redrawn from a drawing furnished by Foregger Co., a division of Puritan Bennett Co., Inc.)

View Figure

Figure 5.33 Flow control valves. Note that the oxygen flow control valve is fluted and larger than the other flow control valve. Also note the guard around each flow control valve. To the left of each valve is the flow. At the left is a flowmeter for total flow.

View Figure

It is adv an tageous to hav e s tops f or the OFF and MAX IMUM f low pos i tions . A s top for th e OFF posi tion av oids damage to the v alv e sea t. A s top for the MA X IMUM flow position prev en ts the s te m f rom becoming di seng aged f rom the body .

Contr ol Knob
The c ontrol k nob is jo ined to the s tem. If i t is a rotary s tyle knob, the ox ygen flo w control k nob mus t hav e a f luted prof il e (Figs 5.13, 5.28, 5.33, 5.34) and be as large as or larger than that for any other gas (7). A ll other f lo w c ontrol knobs mus t be round. The knob is turned c oun te rc loc k wi se to i nc reas e f low. If other types of fl ow

control v alv es are present, the ox ygen con trol mus t look and feel dif fe ren t from the other c ontro ls . Acc idental c hanges in pos ition can also be minimize d by a s hield, bar, or o the r protec tiv e barri er (F igs . 5.33, 5 .34 ) and by plac ing them high abov e the wo rk ing su rface to l es sen the likel ihood of c ontac t with obj ec ts on that su rface .

Use
The f lo w c ontrol knob s houl d be tu rned c lock wi se on ly un til the gas f low c eases . Further tightening ma y res ul t in da mage to the pin or sea t (4 9). W hen a mach in e is not bei ng used , th e gas sou rc e (cyl inder or pipel ine) sh ould be c los ed or disconnec ted. The f lo w c ontrol v alv es s houl d be opened until the gas press ure is reduced to zero and th en c losed. If the gas source is not disc onnec ted, the flow c on trol v alv e s hould be turned OFF to av oid the fresh gas des icc ati ng the ca rbon d ioxide abso rbent (C hapter 9) a nd to c onserv e gas . Before mac hine us e is resumed , the f low c ontro l v alv es s hould be checked to make ce rtain that the y a re cl os ed. S ome ti mes , a fl ow c ontro l v alv e remains open P .103 af te r the gas is bl ed ou t or op ened wh en the mac hine is c lea ned or mov ed. If the gas s uppl y to an o pen f low c ontrol v alv e is res tored and the assoc iate d flow i ndicator i s not observ ed , the ind ic ato r may ri se to the top of the tube where i ts presenc e may not be notic ed. Ev en if no harm to the pa tient res ults , the sudden i ndicator ris e ma y damage i t and impai r the flowmeter accurac y (50).

Figure 5.34 Flow control valves below conventional flowmeters.

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Problems with Flow Control Valves

If the f low c ontro l v alv e knob is loos e o r wo rn, i t may respond to a light touch or ev en acc idental brushi ng (48). Fl ow control v alv es shou ld be c los ed when no t in us e. If there is no yok e plu g o r c ylinde r in the yok e o r the one-way v alv e i n the p ipe line inlet does not work wel l, gas f ro m an unus ed g as s ys tem could f lo w r etrog rade through a flo wmete r with an open flow c ontrol v alv e a nd leak to atmosphere (18,51,52,53 ,54 ). The s tem or s eat c an block the f low (21 ,55 ,56 ,57 ).

Electronic Flow Control Devices

E lec tronically ac tiv ated f lo w c ontrol dev ices c an be used to al te r gas f lows (Fi g. 5.29). In this cas e, the k nob is turned c lockwi s e to inc rease the f lo w. The f lo w adjus tmen t may util i ze a solenoid v alv e (58). The re is usual l y a mix ing area that co ll ec ts the gas mix tu re. A c ommon confi gurati on is tha t one control a lters the ox ygen c once ntration a nd another control th e total f low. If less than 100% ox ygen i s des i red, the difference is made up f rom th e s econd gas (a ir o r ni trous ox ide ) se lec te d. Flow and press ure transducers as wel l as temperatu re se nsors are used to ma intai n acc uracy.

Low-pressure System
The low-pressu re s ys te m (Fig . 5.8) is downs tream of the flow c on trol dev ices . P ress ure i n this sec tion is onl y s li gh tly abov e atmos phe ric and v ariable, depend ing on the fl ow from the flo w c ontrol v alv es , the p res enc e of bac k p res sure dev ices

(c hec k v alv es ), and back pres sure f ro m the breathi ng s ys tem. Co mponents f oun d i n this s ec tion inc lude flowmeters , hy poxi a prev en tion safety dev ic es , un id irec tional v alv es, pres sure rel ief dev ic es , and the c ommon gas outl et. Vapo ri zers and thei r moun ting dev ic es are found in the low-press ure s ys tem but wi ll be c onsidered in Chapte r 6.

Flowmeters
Fl owmeters (f low i ndicators , f lo w tubes , ro ta me te rs ) indic ate the ra te of flo w o f a gas pass ing through them. They may be mechanical o r elec tronic . E lec tronic f lowme ters us ually hav e a rep res entation of a mechan ic al flowme ter on a s c reen or a numbe r re pres enting the f lo w. Ev e n wi th elec tron ic f lowme ters , the re P .104 may be a mech anical fl owmeter for total fresh gas flow at the common gas outle t to prov ide a sense of security fo r c l inic ians who do not ful ly trus t el ec tronic f lowme ters .

Mechanical Flowmeters
Meas uri ng gas fl ow in a mech anical fl owmeter is base d on the pri nci pl e tha t fl ow pas t a resis tance is p roporti onal to press ure . Mech anical fl owmeters measure the drop in p res sure tha t occ urs whe n a g as pas ses through a res is tance.

Physical Principles
Tradi ti onal mechanical flow in dic ators us ed in a nes thes ia mac hines hav e been of the v aria ble o rifice (v ariable area, Thorpe tu be) type . A v ertical g lass tube (Fig. 5.35) is inte rnall y ta pered with its s mall es t diameter a t the bottom. It co nta ins a n i ndicator that is free to mov e up and do wn ins ide the tube. W hen the re is no gas f low, the i ndica tor res ts at the bo ttom of the tube. As sho wn in Figure 5.3 5B , when the flow c on trol v alv e is opened, gas enters at the bottom and f lo ws up the tube , elev ating the ind ic ato r. T he gas passes through the annu la r opening b etween the i ndicator and the tube an d on to th e outlet at the top of the tube . The i ndicator f loa ts f reely in the tube at a p osi tion whe re the down wa rd forc e c aus ed by grav i ty equals the up ward force caus ed by the gas press ure on the bottom of the indica tor. As gas fl ow i nc reases , the n umber of gas molecu les hitting the indicator bottom i nc reas es , and it ris es . B ecause the tube is ta pered, the s ize of the annular opening around the in dic ator inc reases with hei ght, and more gas f lows . W hen the f low i s dec reas ed, g rav ity causes the indic ator to s ettle to a lower l ev el . A sca le marked on or besi de the tube ind ic ates the gas fl owrate .

Figure 5.35 Variable orifice flow indicator. A: No gas flow. B: Gas enters at the base and flows through the tube, causing the indicator to rise. The gas passes through the annular opening around the float. The area of this annular space increases with the height of the indicator. Thus, the height of the indicator is a measure of gas flow.

View Figure

The rate of flow th rou gh th e tube wi l l dep end on th ree fac tors : The p res sure dro p ac ros s the c ons tric tion, the s i ze of the annula r ope ning, and the phys ical properti es of the gas .

Pressure Drop across the Constriction

As gas fl ows around the indicator, it e ncounte rs f ric tional res is tanc e between the i ndicator and the tube wal l . There is a resultant loss of energy refl ec ted in a press ure drop. This pressure drop is co ns tant for all posi tions i n the tube and is equal to the we igh t of the float div ided by i ts c ross -s ec tional area.

Size of the Annular Opening

In the v a riable orif ic e f lowmeter, the annular c ross -s ec tio nal a rea v a ries whi le the press ure drop ac ros s the indicator remains cons tant f or a ll pos i tions in the tube. For this re ason , these f lowme ters are often call ed constant-press ure flow mete rs . Inc reas ing the flow does not i nc reas e the press ure drop bu t c auses the ind ic ato r to rise to a higher pos i tion in the tube, thereby p rov id ing greater f low a rea for the gas . The elev ation of the indic ator is a measu re of the annular area fo r fl ow and, therefo re, of the flow its elf .

Physical Character istics of the Gas

W hen a l ow g as flow pas ses through the tub e, the annula r open in g betwe en th e f loa t and the wal l of the tube wi ll be narrow. As f low i nc reases , the annular openi ng becomes larger. The physical p roperty that rela tes g as fl ow to the pressu re differenc e ac ross the cons tric ti on v ari es with the f orm of the c ons tric tion. W i th a

l onge r and narrower c ons tric tio n (low fl ows ), f low i s lamina r and is a func tion of the v isc osi ty of the gas (Hag en-Poiseuil le equation). W hen the c ons tric tion is s horter and wi der (high flows ), f low is more turbulen t and dep ends o n gas dens ity (Grah am's law).

Temperature and Pressur e Effects

Fl owmeters are ca li brated at atmosph eric press ure (760 torr) and room tempera ture (20C). Tempera tu re and press ure c hanges wi ll a ffec t both the v iscosi ty and the densi ty of a gas and so inf luence the acc urac y of the in dicated flow ra te. V ariations i n tempe rature as a rule are s li ght and do not produce s ign if ic ant c hanges . In a hyperbaric c hamber, a f lowme ter wil l de liv er les s gas than indicated. W i th dec reas ed ba rome tric pres sure (i nc reased a lti tud e), the ac tual f low rate wi l l be greater than that indica ted . The foll owi ng eq uation c an be used to deriv e an approxima te co rrec tion f ac tor f or c hang es in atmos pheric pres sure (58A ): F 1 = F o (d o /d 1 ) whe re

F 1 is the f low a t ambi ent pressure, F o i s the f low ind ic ated o n the sc ale c al ib rated at s ea lev el , d o i s the d ens ity of the gas at s ea lev el , and d 1 is the d ensi ty of gas a t ambient p res sure.

P .105

Flowmeter Assembly
The f lo wmeter ass embl y cons is ts of the tube through whi ch the gas flows , the i ndicator, a s top at the top of the tube , and the scal e that i ndicates the flow. L ights are av ai lable on mos t mac hi nes to allow th e f lowmeters to be obs erv ed in a dark room. Eac h assembly mus t be c learl y and permanen tl y mark ed wi th the appropria te co lor and name or c hemic al s ymbo l of the gas measured. Fl owmeters are us ual ly p rotec ted by a plas ti c s hi el d. The f lo wmete r ass embl y empties in to a common manifold tha t deliv ers the measured amoun t of gases into the lo w press ure s ys tem.

Tube

Fl owmeter tubes (flow tubes ) are us ual l y ma de of gl ass . Gl ass tubes intende d for a ball indica tor hav e rib gu ides , wh ich a re thic kened bars that run the length of the tube (F ig. 5.36). As the tube wi dens , the spac e between the indic ato r and the ins ide of the tube inc reases . Th e rib guides hol d th e ball indic ator i n the cente r of the tube. The f lo wmeter tube can hav e a s in gl e o r double taper (Fig. 5.37 ). S ingl e-taper tubes hav e a gradual inc re ase in d iame ter from the bottom to the top. They are us ual ly us ed where there are different tubes for l ow and high flows . Dual -taper f lowme ter tubes hav e two diff erent tape rs on the ins ide of th e same tubeone co rres ponding to f in e f lows and one f or c oars e flows . Thes e tubes are used when only one tube is use d for a gas .

Figure 5.36 Flow indicator tube with rib guides. This is used with ball indicators. The triangular thickening of the inside of the tube keeps the ball centered. The area through which the gas flows increases with increasing height in the tube. (Redrawn courtesy of Fraser Harlake, Inc.)

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Figure 5.37 Dual- and single-taper flow indicator tubes. With the single-taper tube, the opening gradually increases from the bottom to the top of the tube. With the dual-taper tube, the opening size increases more rapidly above 1 L/minute.

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Indicator
The indica tor (f loa t or bobbi n) is a f ree-movi ng dev ice wi th in the tube. It is i mportan t to observ e th e i nd ic ato r frequently du ring an anes thetic and es pec iall y whe n the f low i s altered. If the in dicator mov es erratic all y, the readings ma y be i nacc urate . The nonro ta ting floattype indica tor (Fig. 5.38) is des igned so that gas flow k eeps the float in the center of the tube if the tub e i s kept v ertica l. The reading is taken a t the uppe r ri m. Rotatin g i nd ica to rs (rotameters ) (F igs . 5.38, 5 .39 ) hav e an u pper ri m of whic h the diameter is la rge r than tha t of the bod y. Sl anted groov es , or fl utes , are cut i nto the rim. There is of ten a co lored dot on one si de of the P .106 i ndicator that makes i t eas ier to obs erv e tha t the indic ato r is rotating. A rotating

i ndicator i s ev idence that gas is fl owi ng and the indicator is not s tuck. W he n gas passes betwe en the rim and the tu be wal l, the flu tes c aus e the in dic ator to rotate. If the tub e is v e rtic al, the f ree s pinning mainta ins the f loat i n the c ente r of the tube. This prev ents f luc tuations , reduc es wear and tear, assis ts the p ass age of s ma ll partic les , and reduc es errors caused by f riction betwe en the tube and the indica tor. Dev iati ons f rom the v ertical pos i tion wi l l resul t in the ro to r s trik ing the s ide o f the tube. The reading is take n a t the u pper ri m.

Figure 5.38 Flow indicator indicators. The plumb bob and skirted floats are kept centered in the tube by constant rotation. The reading is taken at the top. The ball indicator is kept centered by rib guides. The reading is taken at the center. The nonrotating float does not rotate and is kept centered by gas flow. (Adapted from Binning R, Hodges EA. Flowmeters. Can they be improved? Anaesthesia 1967;22:643646 .)

View Figure

W ith a bal l indicator (Fi gs . 5.33 , 5.34A , 5.38 ), the reading is taken a t the ball's midpoint. The ba ll is ke pt in the cente r of the tube by rib guides . The ball rotates and s ometimes h as two co lo rs so that the ro tati on can be easi ly seen. Ro tation is an i ndication tha t th e bal l can mov e freel y in the tube and that the reading is ac curate .

Stop
The s top at the top of the flowme ter tube (Fi g. 5.39) p rev ents the indica tor from plugging the outl et, whic h could lead to damage to the tube (47). It also prev ents the indic ator from asc ending to a po in t in the tube where i t c anno t be seen. This is i mportan t, b ecause a flowmeter wi th the indi cator hidden at the top look s much lik e one that is turned OFF.

Figure 5.39 Skirted float indicators. Note the stops at the top of the flow indicator tubes. The flow indicator tubes are in series. The total flow is that shown on the higher flow tube, not the sum of the two tubes.

View Figure

In s ome ins tances , a s top has been known to bre ak off and f al l down i nto the tube. If it desc ends f ar enough to res t on the ind ic ato r, i t wi ll caus e the indicator to regis ter less flow than is ac tual ly oc curri ng.

Scale
The anes thes ia works tation s tandard re qui res that the f lo w i ndica tor s cal e ei ther be marked on (Figs 5.33, 5.34, 5 .39) or immediatel y adjacen t to the tube (7). Fl owmeters are ca li brated in l iters per minute. For flows below 1 L/minu te, the f lo w may be ex pressed e ither i n mil lil i ters or in dec imal f rac tions of a li ter per minu te wi th a zero before the dec imal point.

Lights
Fl ow in dic ator l igh ts are offered as an op tion on mos t mo dern anes thes ia machines . These are useful wh en the mac hine is us ed in a dark ened ro om.

Flowmeter Tube Ar rangement

Fl owmeter tubes for d iffe ren t gases are grouped s ide by side. The v arious gas f lows me et at the co mmo n ma nifol d (mix ing cha mber) at the top . Sometimes , there are two f lowme ters fo r the s ame gas : One fo r low and one fo r hi gh flows . The tubes are arrang ed in se ri es (tandem) (F igs . 5.39 and 5.40). There is one flow co ntrol v alv e for the both flowmeter tubes . Gas f rom the flow c on trol v alv e f i rs t pass es through a tube cal ib rated up to 1 L /minute, then passes to a s econd tube tha t is ca li brated f or higher f lows . The P .107

total fl ow i s not the s um of the two tubes but that s hown on the higher flow tube . Seri es flowmeter tubes offer inc reas ed acc ura cy (5 9).

Figure 5.40 Flow indicator tubes in series. The total flow is that shown on the higher flow tube, not the sum of the two tubes.

View Figure

Fl owmeter tube sequence c an be a caus e of h ypox ia (60). Figure 5 .41 s hows f our different a rrange ments for oxygen, ni trous ox ide, and air flowmeters . Normal gas f low i s from bottom to top in each tube and then from le ft to ri ght a t the top . In Fi gure 5.41A /B , a leak is s hown i n the un used ai r f lo wme ter, showi ng potentia ll y dangerous arrangements because the n itrous ox ide flowme ter is located in the downs trea m posi tion. A subs tantial portion of oxygen flow pas ses through the leak whi l e a ll the ni trous oxide is di rec ted to the common gas outle t. Sa fer configurations are s hown i n Figure 5.41C /D. B y plac in g the ox ygen flo wmete r neares t the manifol d outlet, a leak u ps tre am f ro m the ox ygen res ul ts in loss of ni trous ox ide rather tha n ox yge n. Before dis cov ering that flo wmete r seq uenc e was impo rtant in prev en ti ng hyp oxia, there wa s no cons ens us on where the oxyge n fl owmeter shoul d be in rela tion to the f lowme ters fo r other gases . To av oid con fusion, the A STM work s tation s tandard requi res tha t the oxygen flowmeter be pl ac ed on th e right si de of a g rou p of f lowme ter as v iewed f rom th e f ront (7). It s houl d be noted that hav ing the ox ygen f lowme te r on the rig ht is s pec if ic to North Americ a. In ma ny countri es , the ox ygen f lowme ter is on the left wi th the ou tlet also on the left. This s e ts the s tage fo r poten tial opera to r error i f a use r adminis te rs anes thes ia in a c ountry othe r tha n whe re he or s he was trained . There is no c onse nsus on the location of the ai r or

ni trous ox ide fl owmeters as long as they do not occup y the loca tion nex t to the manifold o utl et.

Figure 5.41 Flow indicator sequence. A,B: Potentially dangerous arrangements, with the oxygen flow indicator upstream. If a leak occurs, oxygen will be selectively lost. C,D: Oxygen is downstream from other gases, which is a safer situation because anesthetic gas rather than oxygen will be lost. Arrows represent flows of gases. (Redrawn from Eger EI, Hylton RR, Irwin RH, et al. Anesthetic flow meter sequencea case for hypoxia. Anesthesiology 1963;24:396397 [Fulltext Link] [CrossRef] ).

View Figure

Auxiliary Oxygen Flowmeter

An aux il iary (cou rtesy ) ox ygen flowmeter (Fi g. 5.42) is a self -co nta ined fl owmeter wi th i ts own flo w c ontrol v alv e, fl ow in dic ator, a nd outle t. It us ual ly h as a short tube wi th a maxi mum fl ow of 10 L/minute a nd a barbed fi tti ng on the outle t. It is usua lly moun ted o n the left si de of the machine. Thi s can be us ed to su ppl y oxygen to the pati ent wi thout turni ng ON the anes thesi a mach ine . P .108

On some ol der machines , th is flo wmete r wi ll wo rk only on pi pel ine gas . On newer machines , i t wi ll work o n both c ylind er and p ipeline s uppl ies .

Figure 5.42 Courtesy (auxiliary) oxygen flowmeter.

View Figure

A cas e has been repo rted where a c ourtesy flowmeter had a l eak y v alv e that al lowed a c ontinuous low f lo w of ox ygen des pite the ox yg en bei ng tu rne d OF F (61). This res ul ted in a s erious fi re.

Problems with Flowmeters

Inaccuracy
The f lo wmeter scale , tube, and ind ic ato r mus t b e rega rded as an ins epa rab le uni t. Should a ny one of the componen ts ne ed replacemen t, a comple te ne w s et mus t be obtained . If the re is mix ing betwee n any of the comp onen ts of the f lowme ter as sembly, the flowme ter wil l be inac curate . The tube as sembl y cali brated f or one gas ca nnot be used for a diff erent gas . In one i ns tanc e, when the enti re as sembl y of indicator s cales and tubes were us ed fo r a gas o the r th an the o ne for whic h the y were ca li brated, inac curac y resul ted (62 ,63 ). The degree of inacc urac y that wi ll occ u r if flowmeters a re transpos ed depends on the gases for whic h the f lo wmete rs were in tended. If a ca rbon d iox ide flowmeter is transpos ed with a ni trous ox ide f lo wmete r, the differenc e in acc uracy wi ll b e minimal bec aus e both gases hav e s imil ar de nsi ties and v is cos ities (64 ). Us ing heliox in plac e of ai r wi ll res ult in deliv ery of a flow hi ghe r than tha t set (65).

The greates t acc urac y in f lo wmeter tubes is in the middle ha lf o f the tube . Hav ing one tube in the s eri es arrangement fo r lo w f l ows (l ess than 1 L/minute ) and one f or high flows (1 to 10 L/minute) wi ll resu lt in greater ac curac y .

Indicator Problems
Damage to the fl ow indic ator can result f rom a sud den projec tio n to the top of the tube when a c ylinde r is o pened o r a pip eline hose is c onnec ted with the f lo w c ontrol v alv e o pen. F lo w i ndicators c an become worn o r dis torted by handl in g (66). The s top at the top of the flowmeter tube c an b ecome disl odged and res t on top of the i ndicator.

Leaks
A leak in a f lowme ter downs tream of the in di cator but ups tream of the c ommon manifold wi l l res ul t i n a lower than expec ted c oncentration of that gas in the fresh gas (67,68,69,70 ,71 ). A leak may oc cur i f a flow c on trol v alv e is lef t open and the re i s no c ylinder o r yok e p lug i n the y oke (18,53,71A ). The indicator a t the bottom of the tub e wil l no t prev ent gas backf lo w.

Using the Wrong Flowmeter

Anes thes ia prov iders are ac cus tomed to a certain flowme ter s equ ence . W hen this sequence is al tere d, there f requen tl y are mis takes tha t res ul t in an unin tended gas being ad ministered (72,7 3). The problem is mos t likel y to oc cur b etween ai r and ni trous ox ide, as the pos ition of ox ygen is gene ral l y fixed by national c us tom or s tandards . Mechanical flowmeters should be protec ted by turn ing each fl ow con trol v alv e OFF whe n a c ylind er v alv e is opened or a pipel ine hose is connec ted to the mac hin e. This prev ents the indicator f rom s uddenl y ris ing to the top of the tube, wh ich might dama ge th e i ndica tor or allo w i t to go unnoti ced.

Electronic Flowmeters
Mos t of the elec tron ic an es thes ia mac hines av ailable at this time use a conv en tiona l flow c on trol v alv e and an elec tro nic fl ow s ens or. T he flow meas ured by the sens or is then rep res ented digi tal ly and/or by a s imulated flowmeter on the anes thes ia mach ine s c reen (Fi g. 5 .43). A n a dv an tage of elec tronic fl ow meas urement is that this i nforma tion is av ail able in a fo rm tha t can be s ent to a data mana gement s ys tem. Diff erent tec hnologies are used to me asu re gas flo w. They a re discussed in Chapte r 23.

Hypoxia Prevention Safety Devices

One of the hazards ass ociated with flow i ndi cators is the poss ib ility that the operator wi l l set the flo ws so that a hypox ic mix ture wil l be deliv e red . Various dev ic es hav e been dev eloped to prev ent this . P .109

View Figure

Figure 5.43 The flowmeters are represented electronically at the lower left part of the screen. The flows are set by using conventional flow control valves, then the flows are measured electronically. Note that the simulated flowmeter tubes are in series. At the top are a series of messages, including ones showing that there is no mains power and the battery has 85% of its charge. This screen also shows the pipeline and cylinder pressures. (Courtesy of Drager Medical.)

Mandatory Minimum Oxygen Flow

Some anes thes ia mach in es requi re a min imum (50 to 250 mL/minute ) flow of ox ygen be fore other gases wi ll fl ow. T his is preset b y the man ufac ture r (s ometimes to the cus tomer's spec ification). On some mach ines , the min imum flow may be deleted at the us er's reques t. S ome machi nes ac tiv ate an al arm if the oxygen flow goes below a c ertain min imum, ev en if no other gases are bei ng us ed. The mi ni mum fl ow i s ac tiv ated when the mas ter s witch is turned ON. On some machines , i t is dis abled whe n a ir is use d. It may be prov ided by a s top on the ox ygen f lo w c ontrol v alv e or a resis tor that pe rmi ts a small flo w to byp ass a to tal l y c los ed oxygen flow c on trol v alv e (33,59 ). The mi ni mum ox ygen fl ow does no t in i tsel f prev en t a hypoxic gas concentrati on f rom being deliv ered. A hypox ic gas mix ture c an be deliv ered with only modes t anes thetic gas fl ows .

Minimu m Oxygen Ratio

The anes thes ia works tation s tandard re qui res that an anes thes ia machine be prov ided wi th a dev ice to protec t a gains t an operator-selec ted de liv ery of a mix ture of oxygen and ni trous ox ide h av ing an ox ygen c oncentratio n below 2 1% ox ygen (V /V ) in the f resh gas o r the i nsp iratory g as (7).

Mechanical Linkage
A mecha nical l inkag e between the nitro us ox ide and ox yg en flow c ontrol v alv es is shown in Figure 5.44. Th ere is a 14-too th sp roc ket on the ni trous ox ide flow c ontrol P .110 v alv e a nd a 29-too th sproc ket on the oxygen flo w c o ntrol v alv e. If the fl ow con trol v alv es are adjus ted so tha t a 25% conc entra tion of ox ygen is reache d, a pin on the ox ygen s procket engages a pin on the ox ygen flo w c ontrol k nob . This caus es the ox ygen an d nitrous ox ide flo w co ntrol v alv es to turn tog ether to ma in tai n a minimum of 25% ox ygen. This minimu m ox ygen ratio dev ice (propo rtionin g sys tem) permi ts i ndependent c ontrol of eac h gas as long as the percentage of ox ygen is abov e the minimum. If the opera tor a ttempts to inc reas e the ni trous ox ide fl ow beyond that rati o, the ox ygen f lo w i s automatic al ly inc reas ed. If the operator attempts to lower the ox ygen fl ow to o much, the ni trous ox ide flow is lowered proportional ly. It s houl d be no ted that thes e dev ices o nl y l ink two gases , normally ni trous oxide and ox ygen . Admi nis tering a third gas s uch as hel ium c an resul t in a hypox ic mix tu re.

View Figure

Figure 5.44 Mechanically linked flow control valves. Sprockets are secured to the stems of the oxygen and nitrous oxide flow control valves. A chain linking the sprockets limits the minimum oxygen concentration that can be set. Either nitrous oxide or oxygen flow can be adjusted independently, but the minimum oxygen concentration is maintained. If the nitrous oxide flow is increased beyond the maximum allowed, there is a proportional increase in oxygen flow. If the oxygen flow is lowered, there is a proportional decrease in nitrous oxide flow.

P roblems hav e been reported wi th these dev ices (74,75,76,77,78,79,80,81,82,83 ,84 ,85 ).

Electronic Linkage
An el ec tronic s ys tem can be us ed to prov ide a minimum ratio of ox ygen to ni trous ox ide flo w. A n elec tronic p roporti oning v alve c ontrols the ox ygen conc entration in the fresh gas. A compu te r continuous l y c alculates the max imu m all owabl e ni trous ox ide flo w g iv en the ox ygen f low. If th e nitro us oxi de f low c ontrol v alv e is opened suff ic ientl y to c ause a f low hi ghe r than the max imum al lowable, the proportion ing v alv e reduc es the ni trous ox ide f lo w to supply a minimum of 25% oxygen.

Alar ms
A larms a re av ailable on so me mac hines to a lert the operator that the ox ygen :ni trous ox ide fl ow ra ti o has fall en be lo w a pres e t v alue.

Unidirectional (Check) Valve

W hen v enti lation is c on trol led or assis ted, pos i tiv e p res sure from the breathi ng s ys tem c an be trans mi tted back into the mach ine. Us ing the ox yg en flus h v alv e may also c reate a posi tiv e b ack press ure . This pressu re can a ffec t f lowmeter readi ngs and the concen trati on of v ol atile anes the tic agents d eliv e red f rom the v apo ri zers on the mac hi ne. Some machines hav e a unidi rec tion al (chec k ) v a lv e to minimi ze these ef fec ts . This v alv e is located between the vapori ze rs and the c ommon g as outle t, ups tream of wh ere the oxy gen f lus h fl ow joins the fres h g as fl ow. T his v alv e wil l l ess en the pres sure inc rease but n ot prev ent i t, b ecause gas wi ll be conti nual l y f lowing f rom the flowmeters . These c heck v alv es a re of g rea t importanc e when checki ng the machi ne for l eaks . Tes ting the breath ing s ys tem for leaks wi ll n ot de tec t a leak ups tream of th e chec k v alv e in a machine equip ped wi th a c heck valv e (86,87). This is d is cuss ed fu rther in Chapte r 33. P .111

Pressure Relief Device

Some mac hines hav e a p res sure rel ief dev ic e near the c ommon g as outle t to protec t the mach ine f ro m high press ures . Th is v alv e opens to atmosphe re and v ents gas to atmosph ere if a preset p res sure is ex ceeded. A pressu re re li ef dev ice may l imi t the abi li ty o f an anes th esia machine to p rov ide adequate press ure f or jet v entil ati on through a catheter i ns erted th rough the c ric othyroid memb rane (88). Anes thes ia mach ine man ufac ture rs do no t rec ommend

that the common gas outle t be used to prov ide je t v enti lation. Some mac hi nes off er a c onnec tion from the pipe line or intermedia te press ure s ys tem for a j et v entilation dev ic e.

Low-pressure Piping
Low-press ure gas pipin g has a large nu mber of c onnec tions . Co mponen ts loca ted wi th in this a rea are s ubj ec t to break age and l eaks .

Common (Fresh) Gas Outlet

The c ommon (f res h) gas outlet rec eiv es al l of the gases an d v apors from the machine a nd del iv ers the mix ture to the breathi ng s ys tem. Some outle ts hav e a 15mm female s lip -joint f itting (tha t wi ll accept a trach eal tube c onnec to r), with a coax ial 22 -mm male c onnec to r. They may also hav e a manufac ture r-specific fi tti ng. Bec ause the common gas outle t is a c ommon location for a disc onnec tion , the machine s ta ndard manda tes that i t be difficul t to acc identall y disengage the deliv ery hos e f ro m the outle t (F ig. 5.4 5). The fresh gas supply tube, whi ch conv eys gas to th e f resh gas inlet i n the breathing sy s tem, attac hes to the co mmon gas outl et.

Figure 5.45 Common gas outlet with retaining device to prevent a disconnection. The flowmeter indicates the total fresh gas flow.

View Figure

Some ne w anes thes ia mac hin es prov ide two c ommon gas ou tlets . A hazard wi th this a rrange ment is tha t the fresh gas may b e d irec ted to the wrong outlet (89). The anes thes ia works tation s ta ndard s ta tes that the re shall be only one func tional co mmon gas outl et at a time (7). An interlock prev ents both outlets f ro m being i nadv ertently operativ e a t the s ame ti me (90 ,91 ).

Many new a nes thesia mac hines hav e in ternal connec tions to the breathing s ys tem. These mach ines ma y not hav e the c onv entio nal c ommon gas ou tlet desc rib ed prev ious ly . The c ommon gas ou tlet s hould not be used to admin is ter suppleme nta l ox ygen to a pati ent (92,93,94,95 ,96 ). This wi l l del ay us e o f the b rea thing s ys tem if an emergenc y aris es . Another poten tial problem is that a v apori zer on the bac k bar may be ac cidental ly lef t ON, leading to undes ired adminis tra tion of inha la tional agent. Eithe r the auxi liary ox ygen fl owmeter o r a s eparate fl owmeter should be us ed to su pply ox ygen.

Alternative Oxygen Control

W hen us in g an anes thesia mac hine, there is al ways the possibi li ty tha t the elec tronics wi ll fai l. There needs to be a mecha nis m to deal with th is problem. Diff erent mac hines dea l wi th this p roblem in d iffe ren t ways . As sho wn in Fi gures 5.14 and 5.46, some mach ines prov ide an al ternativ e means to adminis te r oxy gen. This is s epa rate from the auxi liary (co urtesy ) fl owmeter. If the re is a mechan ic al total fl ow flowme ter, i t c an be used to measure the deliv ered ox ygen . A nes thes ia can be a dminis tered wi th i ntrav enous agents . P .112

Figure 5.46 Alternative oxygen source. This can be used to supply oxygen in case of total loss of electrical power.

View Figure

Power Failure

Powe r fa ilure is add res sed firs t by e quipping the anes thesia machine wi th a batte ry that wi l l s upply power f or 30 minutes or more, depend ing on the ba ttery c harge and the elec trical loa d. A noninterrup tible power s upply (Fig . 5.4) can be added to prolong the back up perio d. Anes thes ia machines usua lly hav e a means to tes t the backup s uppl y and giv e a reading of the battery charge (Fi g. 5.5). Mess ages a re prov ided to tel l the anes thes ia prov ider that battery powe r is in use as wel l as wh en the back up powe r is nearl y ex haus ted (Fig. 5.43). Ol der an es thes ia mac hines that were pneumatic all y driv en used elec tric al power fo r moni tors and ala rms . If the power fa iled and the battery was exhaus ted, the moni tors wo uld be los t, bu t the machine cou ld c arry on its pneumatic func tions . W ith el ec tro nic c omputer-driv en anes thes ia machines , the need f or a dep endable and c ontin uous po wer su pply inc reas ed . V arious mac hines deal wi th this problem in different wa ys . In mos t c ases , there is a way of b ypas si ng the e lec tronic fu nctio ns that al lows the breath ing s ys tem to be us ed in the manual/sponta neous mode. It may s ti ll be poss ibl e to d eliv e r ox ygen, espec ia ll y from mac hi nes that hav e conv en tiona l mechanical f lowmeters . If the v aporizers a re mech anical , i t may be possible to del iv er v ola ti le agent. If ni trous ox ide o r ai r is also be in g deliv e red , so me manuf acture rs recommen d tha t they be discon ti nue d because moni to ring wi ll be l os t.

Service
The re are three opti ons for machine s erv ic in g. These inc lude the manufac turer's se rv ice organ ization , in dependent serv ice organi zations, and i n-h ouse tra ine d personnel . Indep ende nt se rv ice organ iz ati ons wil l of ten s erv ic e machines f ro m sev eral different ma nufac turers . If the health c are faci li ty is la rge and has a numbe r of machines f rom one manufacture r, i t may be eff ici en t to trai n biomedical personnel to serv ice the equipmen t in-house. No ma tter whi ch op ti on is used , it is i mportan t th at the tec hnic ian be trained an d certi fi ed for the parti cul ar mac hine being s erv ic ed. Manufac ture rs offe r training for thei r equipment a nd certi fica ti on upon succ ess ful completion of th e cours e. The faci li ty s hould re tai n a copy of th e tec hnic ian 's c ertification. Manufac tu rers and independent s e rv ice organizations offer se rv ice c ontrac ts for thei r machines . W i th s uc h a c ontrac t, a s erv ic e repres entativ e wi l l inspec t and perform ro uti ne mai ntenance (i nc luding testi ng, c le aning, lubrication, adjus tmen ts , and replac ement of worn o r damaged parts ) on the mac hine at regul ar interv als , us ual ly two to four times a y ear. Sof twa re upg rades th at offe r new featu res c an

of ten b e made. If the upgrade is used to corre c t a probl em, i t lik ely wi ll not be a t ex tra c os t. The qual ity of s e rv ice v ari es . It s houl d not be tak en fo r gra nted tha t the work has be en performed correc tly . W henever a mach ine has been s erv ic ed, i t shoul d be tho rou ghl y c hec ked before use (Chapter 33). Mos t s e rv ice pe rs onnel wil l l eav e a mes sage on the mach ine i ndica ting th at recen t serv ic e has b een perfo rmed , the date of serv ice, and when the nex t serv ice sh ould be performed This can be remov ed after the machine has been f ound to be in work ing order. Thes e notes may be check ed by acc reditation agenc ies . Rec ords mus t be k ept on each mach ine , incl uding problems that oc cur, serv ice performed, date perfo rmed, and by whom. Reco rds on eq ui pment a re requi red by the Joint Commiss ion on A cc redi ta tion of He althc are Organi zations , and they can be v ery helpful in th e ev en t of legal ac tion. It should b e noted, howev er, that routine s erv ic ing does not rel iev e the user of the res pons ibi l ity fo r checki ng the machine b efore each use.

Choosing an Anesthesia Machine

Onl y machi nes tha t meet al l the re qui re ments of the appl icable AS TM s tanda rd (7 ) shoul d be c ons idered f or p urc hase (97,98,99). Sev era l c riteria sh ould be cons idered when c hoos ing an anes thes ia mac hine.

Service
A ll mach in es that c omp ly wi th the ASTM s tanda rd should perform we ll wh en new. A ll mach in es , howev e r, P .113 wi ll req uire serv ici ng. S e rv ice qual ity v aries among companies and f rom area to area wi thi n the s ame company. If one c ompany is prov iding satisfac tory s erv ic e, i t makes sens e to cons ider pu rc has ing mode ls of tha t company's mac hines . If this is not the c ase, it is adv is able to i nqui re ab out the ex periences of colleagues i n th e area. Important co nsideratio ns include whether the re are lon g down ti mes wai ting for re pai rs , whether machines are av ailabl e fo r loan, an d whether se rv ice c ontrac ts are hono red .

Cost
Both th e purc has e c ost and the ongoing cost of ma intena nce should be cons id ered. Some mac hines requi re that man y expensive parts be replac ed on a regula r bas is . This i nc reas es the c os t. It may be poss ib le to get co nces sions for maintenance

cos ts as part of a purc hase con trac t. Exis tin g problems s hould be f ix ed withou t additi onal cos t unl ess ne w f eatures (upgrades ) are pe rformed (98).

Figure 5.47 A small anesthesia machine may be a good choice for a small room or when it is necessary to transport the machine. (Courtesy of Blease.)

View Figure

Many heal th ca re fac i li ties hav e contrac ts wi th buying g rou ps . If a particu lar anes thes ia mach ine is part of this contrac t, th ere may be a co nsiderable cos t sav ing compa red wi th mac hines not cov e red in this c ontrac t. The heal th ca re fac i li ty ma y pressure th e department to p urc has e mac hines under that c ontrac t.

Size
Some manufac tu rers offer compac t machines . A s mal l mac hine wil l f it better in a smal l room and wi ll be eas ier to mov e (Fig . 5.47). Larger machi nes us ual ly off er more drawers , v apori zers , and a larger work top . P .114

Suitability for Intended Use

Certain mac hines offer spec ia l featu res that ma y mak e them parti cul arl y des irable. Some v enti lators may f it the i ns ti tuti on's needs better than o the rs . The abi l ity to add o n o r incorporate a ddi ti ona l equ ipment i s impo rtant. One mach ine may be mo re us er-fri endl y than another. S ince da ta managemen t s ys tems a re like ly to be used in th e future , the abili ty to automatic al l y gather da ta from a machine is impo rtant. In ge neral , the mo re

elec tronic the mac hine, the more data wi ll be av ailabl e fo r the data management s ys tem.

Equipment Standardization
If al l anes thes ia machines a re the same, the re may be fewer ac c idents related to operator e rror and tra ini ng is eas ier. If the machi nes are purchas ed fo r a new fac i li ty, s tandard ization is easi l y acc ompl is hed. T here might be c ons iderable c os t sav ings in p urc hasing a large number of machines at one time f rom one v endo r. Some ins titutions lease thei r machines , and when the lease runs out, th ey may trade them for new mach ines . S tanda rdi za tion is d ifficu lt if an es thes ia mac hines are repl ac ed graduall y. A machine that had been purchas ed in the pas t may no lo nger be av ail abl e or sui table for th e prac tice . This res ul ts in a number of different mac hines i n the dep artment. Ev en if the sa me model mac hine is pu rch ased , there wi l l usu all y be different features or different s oftware. It may be pos s ibl e to upg rad e s oftware in ex is ti ng machines so that so me u niformity is achieve d.

Box 5.1 Guidelines for Obsolescence American Society of Anesthesiologists Guidelines for Determining Anesthesia Machine Obsolescence*
This doc ument has been deve loped by th e A SA Co mmitte e on E quipment and Fac il i ties and has not b een rev iewed or approved as a prac tice parameter or policy s tatement by the AS A Hous e of De leg ates (1). The f ol lo win g guidelines hav e be en dev eloped to ass is t anes thes ia prov ide rs an d other heal th ca re pe rsonnel , ad minis tra tors , a nd regulato ry bodies in determin ing whe n an a nes thesia mac hine is obsolete. Anes thes ia equ ipme nt can become obsol ete if es senti al c omponents we ar out and cannot be repl ac ed. The equipment may also become obs olete as a resul t of c hanges in medical prac tic es , c hanges i n the trai ning and exp erienc e of anes thesia prov i ders , and/or dev elopmen t of ne w safety featu res . An anes thesi a mac hine s houl d not be c ons ide red obsolete solel y beca use i t has reached an arbitra ry ag e. Furthermo re, a mac hine should no t be exp ec ted to mee t al l of the pe rf ormance and s afe ty requi rements spec if ied in i nternationa l or U.S . equipment s tandards publ ished after the machine was manufac tured. It is the respons ibi li ty of th e anesthes ia prov ide r to de termine if a mac hine's fai lure to meet

newer s tandards represents a s uff icie nt thre at to patien t s afety to render the machine o bsolete. The A SA S tandards for B as ic Anes the tic Moni tori ng (2) appl y to all anes thes ia ca re. The equipment nec ess ary to acco mplish this moni tori ng may be in teg ral to the anes thes ia mach ine o r sepa rate from it. The c ri teria for defining obs olesc ence that are desc ribed i n this doc ument relate onl y to the gas and v apor d el iv e ry po rtion of the mac hi ne. Integ ral mo ni tors (e.g., elec trocardiograph, ox ygen moni to r, blood press ure mon itor, pulse ox imeter, carbon diox ide mon itor) s hould be c onside red separate ly and a re no t address ed in thes e g ui del in es . These guidel ines apply only to exis ting machines and are no t in tended to undul y res tric t the des ign of machines in the future. It is recogni zed that future mac hines may i ncorporate diff ere nt safety mech anis ms th an th ose in use today to accomp lish the same goals .

Absolute Criteria
An anes thesi a mac hine s hal l be c onsi dered to be obsolete if any of the fol lowi ng c riteria apply.

Lac k of Esse ntial Sa fety Features

o

Mi nimum ox ygen ratio dev ic e (O 2 /N 2 O propo rtioning s ys tem) on a machine that can deliv er nitrous oxide Rationale: Hypoxia has b een a majo r cause of pa tient death or sev ere brain injury during a nes thes ia . An anes thes ia machine that c annot deliv er ox ygen mus t au to ma ticall y be rendered incapable o f del iv ering ni trous ox ide as wel l.

Ox ygen fail ure s afety (f ai l-s afe) dev ic e Rationale: One of th e mos t se ri ous mishaps tha t occ urred wi th anes thes ia mach ines in the pas t was dep leti on of the ox ygen s uppl y (usua lly from an exha us ted c ylinder) wi th out the use r bei ng aware. The resu lt wa s del iv ery of a hypox ic mixture. This mis hap can occur ev en with pi ped gas s uppl ies . A n ox yge n failu re safety dev ic e p rev ents this h azard by s toppi ng the flow of ni trous ox ide when there is a loss of oxygen s upp ly press ure.

Ox ygen s uppl y pressure fai lure a larm Rationale: W hi le the suppl y of ox ygen f rom a pi peline s ys tem or c ylinde rs is usuall y v ery rel iable, interruptions in that supp ly c an oc cur. Giv en the c ri tica l nature of ox ygen de liv ery, the ope rator of an anes thes ia mach ine s hould be made awa re i mmediate ly of the f ai lu re of the ce ntral oxygen supp ly so that appropria te remedi al meas ures (e.g ., openi ng a c yli nder, reduc in g the us e of oxy gen, obtain in g additi onal c yl in ders ) can be tak en.

Vapori ze r in terlock dev ic e Note 1: This does not apply to an anesthes ia mach ine that allows on ly one v aporizer to be mounted at a time. Note 2: It may be pos si bl e to add a v apori ze r in terl ock dev ic e to a machine. Rationale: Tu rning on two v apo ri zers at the same time c an res ult in dangerous ly high anes thetic v apor c onc entratio ns being de liv ered and contamina ti on of the downs tream v aporizer.

P in Index S afety S ys tem Rationale: This s ys tem is needed to p rev ent mounting a c y li nder on an i ncorrec t yoke.

Non intercha ngeable , gas -spec ific (e.g ., Di ameter Index S afe ty Sys tem [DISS ]) connec tors on the gas pi peli ne in lets Rationale: These co nnec to rs are n eede d to prev en t attac hment of an i ncorrec t gas del iv ery hose to the mach ine .

P resence of Unac ceptable Feature s

o

Meas ured flow (f lo wmete r-controlled) v apo rizers (e.g., Cop per Kettle, Verni -tro l)

Rationale: These v aporizers hav e not b een manufac tu red for so me time, and serv ici ng fo r th em is no longe r avai lable. Man y anes thesia prov iders are not s uff ic ie ntly famili ar wi th them to use them correc tly, whi c h may resul t in del iv ery of in adeq uatel y l ow or d angerous ly h igh anes thetic v apor c oncentrations . S ome of th ese v aporizers lack the s ide-fil l feature ne eded to prev ent acc identa l ov e rf il l ing and s pi lli ng of l iquid anes thetic into the b rea thing s ys tem.
o

More tha n one fl ow con trol k nob fo r a s in gle g as del iv ered to the co mmon gas outl et of the mach ine Note: Th is does not i nc lu de the f lo w c ontrol knob for an aux iliary ox ygen f lo wmete r. Rationale: Hav ing more than one f lo w c ontrol knob for a gas ma y resul t i n an unintende d h igh o r low f lo w of gas bei ng deliv ered. Paral le l fl owme ters may c ause ambigui ty b ecaus e on al l recentl y manufac tu red mac hines , flowmeters a re i n s eri es wi th one flow c ontrol knob for eac h gas del iv ered to th e machine's common gas outle t.

Vapori ze r with rotary conc entra tion di al s uch that the anes thetic v apor conc en tration inc reas es when the di al is turned c lock wis e Note: It may be possible to replace an unacceptable v apori zer wi th out replac ing the entire machine. Rationale: Al l v aporizers ma nufac tured in recen t years are des igned to deliv er i nc reased v apor c oncen tration wh en the d ial is turned counterc lock wi se. Uniformity in v aporizer co ntrols wil l p rev ent errors and inc rease saf ety.

Connec ti on(s ) i n s cav engi ng s ys tem of the s ame (i .e., 15 mm or 22 mm) di ameter as a breathi ng s ys tem c onnec tion Note: It may be possible to replace an un acceptable s cav engi ng connec tion wi thout repl aci ng th e entire machine.

Rationale: Hav ing 15- or 22-mm diameter co nnec tions in the sc av engi ng s ys tem can result i n incorrec t connec tions be tween the breathi ng s ys tem and the sc av enging s ys tem, potentiall y res ulting in negativ e o r high pressure in the breathing sys tem. Cu rrent s tandards mand ate 3 0-mm (preferred ) or 19-mm c onnec tions in the scav eng ing s ys tem.

Adeq uate Ma intena nce No Longe r P ossible The man ufac ture r or c e rtif ied s erv ice personnel wi l l not o r cannot se rv ice the machine with acceptable replac ement parts so that i t perfo rms wi th in the tole ranc es to whic h it wa s original l y des igne d. Note 1: A l though a manufac tu rer ma y dec lare tha t its own subs idiaries wi ll no l onge r s erv ice, s uppo rt, or c ertify a partic ular machi ne, the es senti al co re co mponen ts of the mac hine may s til l be se rv iceable. Note 2: Obtaining acc eptable rep lac ement parts can be a problem. In some cases , it ma y be poss ibl e to obta in the parts f rom the party who s uppl ied them to the machine manufac tu rer. A l te rna tiv el y, s uch pa rts ma y be obtai ned f rom mach ines tha t hav e a lread y been taken ou t of se rv ice . Note 3: W hen a manufac tu rer dec lares th at i t wil l no longer prov ide support for a machine , res pons ib il i ty is typ ic al ly transfe rred to the use r (heal th ca re fac i li ty) and /o r the thi rd pa rty who serv ices the mac hi ne . Rationale: A machine that cannot be se rv ice d o r fo r whi ch replac emen t parts are not av ai lable c anno t be mainta ined acco rding to the s tandards and spec ifica tions to whic h it wa s ori gi nall y designed and is dangerous .

Relative Criteria
Cons ideration s hould be giv en to replaci ng an an esthes ia machine if any of the followi ng apply :

Lac k of Certain Safe ty Fea tures

o

Means to isolate the APL (adjus table pressu re l imi ti ng) v alv e duri ng mechanical v enti la tion

Note: Is ol ati on of the APL v alv e can be done in a nu mber of ways (e.g ., mec hanicall y, e lec tronica lly). Rationale: The AP L v alv e is desi gne d for use with manual, not mechanical , v entilatio n. If an APL v alv e is lef t open and is not isolated f rom the b rea th ing s ys tem duri ng mec hanica l v en ti la tion, a p ortion of the inspi red tidal v olume ma y be los t.
o

Ox ygen flow co ntrol k nob that is fluted and l arger than the oth er flow control k nobs Rationale: Cu rrent s tandards manda te that the ox ygen flow co ntrol knob be la rge r than other flow c ontrol k nobs and fluted. A l tera tions to gas fl ows may be perfo rmed du ri ng low l i ght c ondi tions or when the anes thes ia prov ider i s not looki ng di rec tl y at the machi ne . Tac ti le i dentification of the ox ygen flow c on trol k nob s hould reduce errors .

Ox ygen flus h contro l protected from acciden tal ac tiv ation Note: P rotec tion can be ei ther by plac ement o r des ign of the c ontrol . Rationale: Ac cidental ac tiv ation of the ox ygen flush can resul t in barotra uma.

Mai n ON/OFF s witch fo r el ectric al power to i nte gra l moni to rs an d alarms Rationale: Cu rrent s tandards manda te that the main power s witc h, whe n turned ON, enables integral moni to rs and a la rms . Op era tors unfami liar with old er anes thesia mach ines may not apprec iate that moni tors and ala rms are not au toma ticall y enab led a nd may negl ec t to turn on one or sev era l of them if the y are no t ac tiv ated by a si ngle s wi tch.

Antidis con nec tion dev ice at the f resh gas ou tlet Rationale: Disc onnec ti on of the f resh gas inflow to the breathi ng s ys tem mi ght lead to und esi rab le anes thetic o r ox ygen concentrati ons

deliv ered to the patient o r c re ate a s ignif ic ant leak i n the b rea thing s ys tem wi th rapid loss of gas . Dep ending on the mode of v entilation (s pon taneous or c ontro ll ed), disc onnec tion of the f resh gas hos e may not be immedia tely app are nt.
o

A i rwa y p res sure alarm (for de tec ti ng sus tain ed pos itiv e p res sure, negativ e p res sure, and h ig h peak press ure ) Note: An alarm f or de tec ting disc onnec tions (l ow-p res sure alarm) is a c riterion of the ASA S tandards fo r B asic A nes thetic Moni to ring. Rationale: These press ure c ondi tions rep res ent an immediate threat to pati ent s afe ty an d need to be b rou ght to the i mmediate attenti on of the anes thes ia prov ider.

P r oblems w ith Maintenan ce The maintenanc e his to ry indicates that problems wi th the machine (e.g ., inc reasing frequenc y of s erv ic e calls , machine f requentl y not av ail able f or us e) are impac ting c linic al serv ice in a mann er that is unac cep tab le to the ins titution or whi ch thre atens patient safety Note: Maintenance records or logs s hould be k ep t fo r al l anes thes ia machines in c li nical use and problems documented . Thes e rec ords s houl d be rev i ewed regularly to determi ne wha t ty pe of probl ems are occu rrin g wi th each mac hi ne, how of ten they oc cur, and thei r effec t on the anes thes ia prac tice.

P otentia l for Hu man E rro r Differe nces be twe en ol der an d newer mac hines can be a s ourc e of co nfus ion and erro r if c ertai n fe atu res (e.g., automatic ac tiv ation of moni tors and ala rms by a main ON-OFF s wi tc h) are presen t on so me mac hi nes bu t not on o the rs or a re i n d iffe ren t locations on th e machines . Rationale: Hav ing certai n mac hine features in d iffe ren t locations on different machines can c reate confus ion and inc re ase the likelihood of operator erro r. Anes thes ia prov iders who are more fa mi l ia r with anes thes ia machines manufac tu red recentl y may mis takenl y exp ec t that certain fe atures a re

present on ol der machines , and i t may not be rea dil y apparent that they a re different. S tanda rdi za tion of anes thes ia mac hines th roughou t an ins titution shoul d be c ons idered.

Inability to Meet P ractice Nee ds Examp les :

o

The mac hine c annot ac cept v apo ri zers fo r newer potent inhaled v olati le agents Note: A v aporize r should n ev er be placed downs trea m of the common gas outlet. This is a d ange rous p rac tice.

The mac hine c annot de liv er fresh gas f lows th at are low enough for cu rrent anes thetic tec hniques . The integral anes thes ia v enti lator is i nc apab le of s afe ly and eff ec tiv el y v enti lating the lu ngs of the targ et pa ti ent p opul ation. Rationale: Ne w ag ents , techniques , and/or v entilators ma y not be co mpatible wi th older a nes thes ia mac hines . If thei r us e is consi dered to be n ecessary fo r optima l patient managemen t, a ne w a nes thes ia machine s hould be obtai ned . W hen i t has been determined tha t a machine is o bsolete, i t sh ould not be plac ed s omewh ere in the f aci lity where it might be used c linical l y (e.g ., as an oxygen deliv ery dev ice). A machine that has been determined to be obsolete s hould ei ther be des troye d or donate d to a worth y party (e .g ., a dev elopi ng country, zoo, o r la borato ry ). If the l atter c ourse is fol lo wed, i t wou ld be prudent to obtain l ega l adv ic e about po ten ti al l iabi li ty relatin g to the d onati on. Also , it is pruden t to ensure that the rec ipient poss esses the i nf ras truc ture (e.g., elec trical power, medical gases ), acces s to drugs an d s uppl ies (e .g., v ola tile anes thetic s , c i rcui ts , replacemen t parts ), technical expertise , and trai ning to s afe ly us e the mac hine. Rationale: Pl ac ing a n obsolete mac hi ne whe re i t mig ht be us ed i nv olv es ma ny hazards . Many o f the hazards no ted prev ious l y a re rela ted to the poss ible mis use of a n o lder anes thes ia machine by personnel who are unfami l ia r with its id ios ync rasies and dev ia tions

f rom more modern mac hines . P lac emen t of an obsolete anes thes ia machine in a location wh ere i t wou ld be us ed only infreque ntly during high-acu ity s i tuations , pos s ibly b y personnel wi th out anes thes ia trai ning, can onl y magn if y these risk s . Us e r ex pec tations tha t it is a modern mach ine with mode rn safety features wi ll s ti ll be presen t. The pres ence of an anes thesia machine i n a n a typic al l oca tion may tempt pe rs onnel unfamil iar wi th the machine to modify i t. Nonanes thes ia pers onne l may av oid us in g it b ecause they are no t famil iar wi th i t. T he need to prov ide pos i tiv e-p res s ure v entilati on with ox ygen in remo te locations ca n be me t by us ing an ox yge n c yl ind er or f lowme ter connec ted to a pipel ine outle t and a non reb rea thing bag. This is inex pens iv e, e asy to use, and c an eas il y be made av aila ble in remote loc ations . 1. V arianc es from the recommendations co nta ined in this d ocume nt may be ac ceptable bas ed on th e j udgment of th e responsible anes thesi ol ogis t. The recommen dations are desi gned to encourage qua li ty patient care and safety in the work plac e but c annot guarantee a spec ific o utcome. T hey are subjec t to rev ision f rom ti me to time as wa rranted by the ev olution of techno logy and prac tic e. P os ted June 22, 2004 2. S tan dards fo r Bas ic Anes th etic Moni to ring App rov ed by Hous e of Delegates and l as t a mended on Oc tober 21 , 1998 . Av ai lable from the Americ an S oc ie ty of Anes thes iologis ts , 520 N. Northwe s t Highwa y, P ark Ri dge, IL 60068-2573. http ://www.A SA hq.org If the ins ti tu tion is teac hing anes th esia res idents o r s tuden t nurse anes thetis ts, different mac hi nes ad d to the d iv ers ity of thei r ex perience. Ho wev e r, trai nees wil l need to be moni tore d mo re c lose ly i f they use a v a riety of different mac hines .

Guidelines for Determining Anesthesia Machine Obsolescence

Rep lac ing outdated equipmen t is a neces sary, ongoi ng proces s . A ppara tus that was the bes t av ailabl e at one time may become unacceptabl e as improv ed mo dels become av ail abl e. A ques tionnai re s en t to anes thetis ts s el ec ted from Nati onal Heal th Serv ic e hospi tals f rom all re gi ons of the Uni ted Kingdom in 2001 found that 27 % of anes thes ia mach ines did not hav e an antihypox ic dev ice that co uld prev ent

adminis tra tion of hy pox ic gas mix tures (100). Mos t we re i n l i ttle -us ed ope rating theaters , emergenc y departments , a nd radio logy, wh ich mad e the ir pres ence ev en more likel y to pres ent a probl em, becaus e users may not s usp ect that the y lac k these s afe ty dev ic es . The E quipment a nd Fac il ities Committee of the American S oci ety of Anes thes iologis ts (A SA ) has dev el oped guid el ines to ass is t anes thesi a prov iders and o the r heal th c are pers onnel, adminis trators , and s tate regula to ry bodies i n determin ing wh en an anes th esi a machine is obsolete. The guidel ines are shown i n Box 5.1. P .115

P .116

P .117

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26. Craig DB , Longmui r J . A naes thetic mach ine pipe line inle t press ure gauges do not al ways meas ure pipe li ne press ure . Can Anaes th S oc J 1980 ;27 :51051 1. [Med li ne Link ] 27. Wils on A M. The pressure gauges on th e B oyle Internatio nal anaes thetic machine. A naes thes ia 1982;37:218219. [Cross Ref] [Med li ne Link ] 28. Din nic k OP . More p rob le ms wi th piped gases . Anaes thes ia 19 76;31:790792. [Cross Ref] [Med li ne Link ] 29. Bons u A K , S tead AL. Ac c idental c ross -connex ion of ox yge n and ni trous ox ide in an an aes thetic machine. A naes thesi a 1983;38 :76 776 9. [Cross Ref] [Med li ne Link ] 30. Kua J SW , Tan I. A ra re cause of ox yge n f ai lu re. A naes th esia 1994 ;49 :650 651. [Med li ne Link ] 31. Eps tein RM, Rack ow H, Lee ASJ , et al . P rev ention of acciden tal breathing o f anoxic gas mix tu res duri ng anes thesia. A nes thes io logy 1962 ;23 :14. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 32. Hearn CM, Chand radev a K . A hidden s afety feature in the ev en t of ox ygen failure. An aes thes ia 2003;58:124 0. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] P .118

33. E is enk raf t JB . The anes thesi a del iv ery s ys temPart I. P rog An esth 1989;3(7 ):17. 34. Fauv el N. Ox ygen f ai lu re warni ng dev ices . A naes thes ia 19 99;54:505. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

35. Anonymous . Oxygen fai lure wa rni ng dev ic es . A repl y from the manufac tu rer. Anaes thes ia 1999;54:505 506. 36. Coope r CMS . Capnography . Anaes thes ia 198 7;42:1238 1239. [Cross Ref] [Med li ne Link ] 37. Hanaf iah Z, Sell ers W FS . Nudgi ng the emergenc y ox ygen. An aes thes ia 1991;46:331. [Cross Ref] [Med li ne Link ] 38. Morri s S , Barc la y K . Ox yg en flus h buttons : more c ri tica l incidents . A naes thesia 1993;48:1115111 6. [Med li ne Link ] 39. Anonymous . Internal leakage f ro m an esthes ia uni t f lush v alv es. Hea lth Dev ices 1981;10:72. 40. Mann DP , Der Ananian J , A ls ton TA . Oxygen flush v alv e boob y trap. Anes thes iology 2004;101:558. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 41. Bai le y P L. Fai led releas e of an ac tiv ated ox ygen f lush v alv e . Anes thesi ol ogy 1983;59:480. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 42. Puttick N. Haz ard f ro m the ox ygen flus h contro l. A naes thesi a 1986;41:22 2 224. [Cross Ref] [Med li ne Link ] 43. Anonymous . Anes thesi a uni ts . Tech nol An es th 1997 ;18 :5. 44. Mc Maho n DJ , Holm R, Batra MS . Yet another machine fault. Anes thesiology 1983;58:586587. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 45. Dodd KW . Inadv ertent adminis tration of 100 % ox ygen du ri ng anaes thes ia. B r J Anaes th 1979 ;51 :573.

[Cross Ref] 46. Galapo S , W olf G, Si deb otham G, e t al . Las er igni tion of s urg ic al drapes in an ox ygen en ri ched a tmos phere. A nes thes io log y 1998 ;89 :A 580. 47. Hutton P , B oaden RW . Pe rformanc e of n eedle v alv es. B r J Anaes th 1986;58:919924. [Cross Ref] [Med li ne Link ] 48. Emmett CP , Cl utton-B rock TH, Hu tton P. The Ohmeda Exc el anaes thetic machine. A naes thes ia 1988;43:581583. [Cross Ref] [Med li ne Link ] 49. Chand radev a K . A se rious inc iden t with th e B lease Frontline Genius an aes the tic machine. A naes thes ia 2004;59:627. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 50. Coope r M, A l i D. Ox ygen fl owme ter d is locatio n. Anaes th Intens Ca re 1989;17:109110. [Med li ne Link ] 51. Jenk ins IR. A too c los e to the door knob. Anaes th In tens Care 1991;19:614 . [Med li ne Link ] 52. Leno ir RJ , Eas y W R. A ha zard assoc iate d wi th remov al of carbon diox ide c ylinde rs . Anes thesiolo gy 198 8;43:892893. 53. Wil liams A R, Hi l ton PJ . S el ectiv e oxy gen leak : a p otential caus e of patient hypoxia. A naes thes ia 1 986;41:11331134. [Cross Ref] [Med li ne Link ] 54. Anonymous . Anes thesi a uni ts . Tech nol An es th 1994 ;14 :78. 55. Beudoin MG. Ox ygen needle v alv e obs truc tion. Anaes th In tens Care 1988;16:130131. [Med li ne Link ] 56. Khal i l SN, Neuman J . Fai lure of an oxy gen fl ow c ontrol v alv e. Anes thesi ol ogy 1990;73:355356. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

57. Fitzp atrick G, Moore KP . Malfunc tio n i n a needle v alv e. Ana es thes ia 1988;43:164. [Med li ne Link ] 58. White DC. E lec tronic me asurement and con trol of gas f low. A naes th Intens Care 1994;22:409414. [Med li ne Link ] 58a. Campo res i E M. Anes thes ia at different env i ronmental p res sures . In: Ehrenwe rth J , Eisenk raft J C, eds . Anes thesi a Equi pment: P rinciples and Applications. S t. L ouis : Mos by, 1993:588598 . 59. Cic man JH, J acoby MI, Ski bo V F, et al . Anes thes ia s ys tems . Part 1: Ope rati ng princi ples of funda mental co mponen ts . J Clin Moni t 1992;8 :2953 07. [Cross Ref] [Med li ne Link ] 60. Eger E I, Hy lton RR, Irwi n RH, et al . An es thetic f lowmeter s equenc ecause for hypoxia. A nes thes iolog y 1963 ;24 :39 6397. [Fu ll tex t Link ] [Cross Ref] 61. Anonymous . A c linic ian's guide to s urgic al f ires . How the y occur, ho w to prev ent them, ho w to put them out. Health Dev ices 2003;32:524. 62. S la ter E M. Trans posi tion of rotameter bobbins . An es thes iolog y 1 974;41:101. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 63. Thomas D. Interchangeable rotamete r tu bes . Anaes th Intens Care 1983;11 :385 386. [Med li ne Link ] 64. Wil lick J. Routine e quipment serv ice. Third Annual Anes thesi a Equipmen t Mana gemen t Conf erence . Orlando, FL, Feb. 1 995. 65. Tung A , Mo rgan S . Del iv ery of hel iox b y anes thes ia machine produc es error in f res h g as fl ow and tid al v olume measurements . A nes thes io lo gy 2001 ;95 :A576. 66. Hodge EA . Accu rac y of anaes thetic gas flowmeters . B r J An aes th 1979;51:907. [Cross Ref] [Med li ne Link ] 67. Dudley M, W alsh E . Ox ygen l oss f rom ro tame ter. B r J A naes th 1986 ;58:1201 1202.

[Cross Ref] [Med li ne Link ] 68. Hanning CD, K ruc hek D, Chunara A . P referential ox ygen l eak an u nus ual case. Anaes thesia 1987;42:13291330. [Cross Ref] [Med li ne Link ] 69. Wil liams OA . Po ten tial hazard of a c rack ed rotameter. Anaesthes ia 1989;44:523. [Cross Ref] 70. Mc Hale S . A c ri tic al inc iden t with the Oh meda Exc el 410 machine. A naes thes ia 1991;46:150. [Cross Ref] [Med li ne Link ] 71. Wishaw K . Hypox ic gas mix ture wi th Quan tiflex Mon itored Dia l Mix er and i nduc tion room s afety . A naes th Intens Care 1991;19:1 27. [Med li ne Link ] 71a. S toneh am MD, Is mail F, Sans ome AJ . Leakag e of fresh gas from v acant CO 2 c ylinde r yok e. Anaes thes ia 1993;48:730 731. [Cross Ref] [Med li ne Link ] 72. James RH. Rotamete r sequ enc ea v ariant of read the label . A naes thesi a 1996;51:8788. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 73. Moon J RA . Rota mete r sequenc e. Anaesthesia 199 6;51:508. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 74. Abraham ZA , B asago itia J . A pote ntial l y lethal anes thesi a mac hi ne failure. Anes thes iology 1987;66:589590 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 75. Dav is TM. Fai lure of a new s ys tem to prev ent de liv ery of hypox ic gas mix ture. A repl y. Anesthes iology 1 981;54:437 .

[Fu ll tex t Link ] [Cross Ref] 76. Malo ne B T. Fa il ure of a new s ys tem to p rev ent deliv e ry of h ypox ic gas mix ture. Anes thes iology 1981;54:436437 . [Med li ne Link ] 77. Ric hards C. Fail ure of a nitro us oxi deox ygen p rop ortioning dev ice . Anes thes iology 1989;71:997999 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 78. Ferguson S , W hite E . An unusual and dangerous anaes thetic machine fail ure. Anaes thes ia 1997;52:283 284. [Fu ll tex t Link ] [Med li ne Link ] 79. Goody ear CM. F ailure of ni trous ox ideox ygen p rop ortioning dev ic e. Anes thes iology 1990;72:397398 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 80. Lohma nn G. Faul t wi th a n Ohmeda Exc el 410 mac hi ne. An aes thesia 1991;46:695. [Cross Ref] [Med li ne Link ] 81. K idd A G, Hal l I. Faul t wi th an Ohmeda Exce l 210 an aes thetic machine. Anaes thes ia 1994;49:83. [Cross Ref] [Med li ne Link ] 82. Sharma ML . P roblem wi th Oh meda Exc el 21 0 SE anes thetic machine. Ca n J Anes th 2 002;49:438439 . 83. Cheng CJ C, Garewal DS . A failu re of the c hain -l ink mechanis m on the Ohmeda Exc el 21 0 anes the tic machi ne . A nes th A na lg 2001;92:913 914. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

84. Gordon PC, J anes MFM, La pham H, et a l. Failure of the proportioni ng s ys tem to prev ent hypox ic mix tu re on a Modulus II plus anes thes ia machine . Anes thesiology 1995;82:598599. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 85. Paine GF, Koc han JJ I. F ailure of the c hain-link mec hanis m of the Ohmed a Exc el 21 0 anes thes ia machine. A nes th Analg 2002 ;94:1374. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 86. Andrews JJ . Unders tand ing your an es thes ia mac hine (ASA Ref resher Cours e #254) Park Ridge, IL: AS A , 2002. 87. Berner MS . P rofound hypercapnia d ue to disc onnec tion wi th in an an aes thetic machine. Can J Anaes th 1987 ;34 :62 262 8. [Med li ne Link ] 88. Gaughan SD, Benumof J L , Ozak i GT. Can an anes thes ia mac hine flush v alv e prov ide f or effec tiv e jet v entilatio n?. A nes th A nal g 1993 ;76 :80 0808. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 89. Dal ley P , Robi nson B , We ll er J , et al . Th e use of high f id eli ty human patient s imulation and the introduc tion of new anaes thes ia de liv ery s ys tems . A nes th A nalg 2004;99:1737174 1. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 90. Oly mpio MA . Common gas outlet c oncern le ads to c orrec tiv e ac tion. A PS F News le tt 2004;19:34. 91. Abramov ich A . Common g as outlet c oncern lea ds to c orrec tiv e ac tion. Res pons e. APS F News le tt 2004;19:34 . 92. S to ne A G, Howel l PR. Use of the c ommon gas outle t fo r the adminis tration of suppl emental ox ygen during Caesarean s ection under regional anaes thes ia . Anaes thes ia 2002;57:690 692. [Fu ll tex t Link ] [Cross Ref]

[Med li ne Link ] 93. Edse ll ME G, E ras mus P D. Use of the c ommon gas ou tl et for suppl ementary ox ygen du ri ng Caes arean sec tion. Anaes thes ia 2005;60 :11 52. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 94. S to ne A GH. Supplementary ox ygen during Caesarean s ection . Anaes thes ia 2006;61:298. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 95. Greenwood J . Generic machine checks . Anaes thesia 2005 ;60:12481249 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 96. Smith W Q. Inadv ertent inha lation anaesthesia during surgery under retro bul bar eye block . B r J A naes th 1998;81:793794. [Med li ne Link ] 97. Anonymous . Purc has ing s trategy guide . A nes thes ia s ys tems. Technol An es th 2002;22(10):14. 98. Abens te in JP . How to ev aluate new tec hnol ogy and mak e ra ti ona l dec is ions whe n purc has ing ne w e quipment (ASA Ref resher Cours e #20). Park Ridge, IL: ASA , 2005. 99. Merc hant RN.S peci al c hal le nges wi th ne w d igi tal anes thes ia mach ines . Ca n J Anes th 2 001;48:1049. 100. Saunders DI, Meek T. A lmos t 30% of anaes thetic mac hines in UK do no t hav e anti -hypox ia dev ic e. B MJ 2001;323:629 . [Fu ll tex t Link ] [Med li ne Link ] P .119

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t

i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. T he high press ure syste m of the anes thesia mac hine includes A . Th e ox ygen fl ush B . Flowme ters C. The p ip eline i nl et D. The h ange r yok es V iew A ns we r2. The P in Index Safety System A . Cons is ts of two p ins on the c ylinde r v alve that f it two co rrespondi ng hol es i n the yoke B . Is located abov e the n ipple on the yok e C. Mak es it impossi bl e to plac e an inc orrec t c yl in der i n a yoke D. Has s pec ific loca tions for pins an d holes for each gas V iew A ns we r3. Wh en placing a cy linder in the yoke, A . Th e fi rs t s tep is to ful ly retrac t the retaining sc rew B . Th e was he r s hould be plac ed on the c ylin der v alv e C. The P in Index S afety S ys tem componen ts mus t be mate d D. The s c rew i s tigh tened in to the c yl inder rel ief v alv e V iew A ns we r4. The pressure regu lator A . Reduces cyl inder pres sure to below 345 kP a B . S uppl ies a relativ ely c ons tant outle t pressure whi le the s ou rce p res sure is reduc ed C. W ill n ot work properly if gas is bei ng remov ed f rom the low-p res sure s ide D. Can b e e ither d irec t o r indi rec t ac ti ng V iew A ns we r5. The intermediate pressure sys tem in clu des A . Th e pipel ine pres sure gauge B . Th e flowmeter manifold C. The ox yg en flush D. Vaporizer(s ) V iew A ns we r6. The oxygen failu re safety valve A . W i ll prev ent a h ypox ic gas mix ture from b eing del iv ered B . W i ll cut off the fl ow of ox yge n s hou ld the nitrous oxide suppl y fa il C. P rev ents the us er from di aling a hypoxic mix ture on th e fl owmeters

D. May or may not c ut of f the fl ow of ai r if th e ox ygen s upp ly fai ls V iew A ns we r7. The oxygen supply pre ssure ala rm w ill A . B e ac tiv ated by a disc onnec te d ox ygen pi pel ine hose B . He lp prev ent del iv ery of a hypox ic mix ture C. Be ac tiv ated if th e ox ygen pipel ine p res sure is l ow D. P rotec t the pati ent f rom hypox ia due to le aks in the mac hine V iew A ns we r8. The oxygen flush valve A . W i ll del iv er oxy gen at between 30 and 60 L /minute B . Can be loc ked i n the ON pos itio n C. May inc reas e the pres sure in v apori ze rs up to 2 00 cm H 2 O when ac tiv ated D. Mus t be protec ted agains t acc ide ntal ac tiv ation V iew A ns we r9. Wh ich of the fo llow ing s tatements about flow mete rs are correct? A . P a ral lel f lo wmete rs are used in new anes th esia machines B . Flowme ter tubes work on the principle of the v ari able orif ice C. The ins ide of a flow tub e contai ni ng a bal l is s mooth D. The p res sure drop ac ross the ind ic ato r is c onstant for all posi tions in the tube V iew A ns we r10 . T he ra te of flow throu gh a flow me ter tube depends on A . Th e pressure drop ac ross the cons tric tion B . Th e size of the annu lar opening C. The p hys ic al properties o f the gas D. The len gth of the tube V iew A ns we r11 . If a flowme ter tube is b roken A . Only the tube needs to be replac ed B . Th e ind ic ato r can be us ed in the new tube if it is a bal l C. The s cale mus t be repl ac ed if i t is in teg ral to the tube D. The tube, indicator, and sc ale mus t be replaced as a un it V iew A ns we r12 . E ffects of th e p hysical characteristics of the gas passing throu gh the flow meter include A . A t low f lows , f low i s a func tion of the v isc os i ty of the g as B . V isc os i ty of the g as is more important with a long er and narrower c ons tric tion C. W i th high f lows , fl ow depends more on th e dens ity of the gas D. The d ens ity of the gas is mo re i mportan t with a shorter and wi der c ons tric tion V iew A ns we r13 . Correct s tatements concern ing the orde r of flow meter tubes include A . Th e lef t tube shoul d be either ox ygen or ai r

B . A l eak i n the flowme te r tha t is farthes t f rom the manifol d outlet may resul t in los s of gas from the mi ddle flowmeter C. A smal l leak in the middl e flowmeter wi l l caus e loss of gas from the flo wmete r nex t to the manifold D. The ox yg en flowmeter s hould be nex t to the mani fo ld ou tl et V iew A ns we r14 . Conce rning mandatory minimu m ox ygen flow , A . It wi ll prev ent d el iv ery of a h ypox ic mix ture B . It cannot be remov ed C. The a mount of flow i s user adjus tabl e D. It i s s ometimes assoc ia te d wi th an ala rm V iew A ns we r15 . Correct s tatements concern ing the minimum oxygen ra tio control include A . If the fl ow of ni trous ox ide is inc reas ed, the ox ygen flo w i s automatic al ly i nc reas ed with a mechan ic al l inkage B . Th e gases a re i ndep endently c ontrolle d when the oxygen percentage is abov e the minimum C. It can be a mec hanica l or pneumatic li nk D. It i s usual l y set a t 25% ni trous ox ide V iew A ns we r16 . What are the function s o f the hanger yoke? A . E nsurin g a unidirec tional gas flow i nto the anes th esi a machine B . P rov iding a gas -tight se al C. Orie nti ng and s uppo rting the cy linde r D. P rov iding a c yli nder c onn ec tion for each gas us ed in the mach ine V iew A ns we rP .120

17. Gas cylinder valves on the anes thesia machin e w ith a pipeline supply should be ke pt closed for th e follow ing re asons : A . S o that a pipeline press ure failure wil l be recogni zed ea rl y B . To prev ent gas from f lowi ng retrograde in to the pipeline s ys tem C. To prev ent press ure alterati ons in th e p ip eline f rom drawi ng down the c yli nder contents D. To prev ent fires V iew A ns we r18 . Whic h physical p rinciples g overn the gas flow throug h a mechanical flow me ter? A . Th e e lev ation of th e ind ic ato r is a meas ure of the annular area for flow

B . Te mperatu re c hanges affec t the dens i ty a nd v iscos ity of gases and thus s ignif ic antly al ter the accu rac y of f lowme te rs C. Short, wi de cons tric ti ons caus e mo re tu rbulent f low D. The p res sure drop as gas f lows a rou nd the i ndica tor v aries wi th the diameter of the inside of the flow tub e V iew A ns we r

Chapter 6 Vaporizers
P .122

Mos t of the inhal ati onal anes thetic agents in us e today are li quids at atmos pheric press ure and room temperature and mus t be c onv erted into v apors befo re they can be us ed. A v apori ze r (a nes thetic a gent or vapor de liv ery dev ic e) is a dev ice that changes a l iquid anes the tic agen t in to i ts va por and adds a controlled a mount of that v apor to the f res h gas f lo w o r the breathing sys tem. Up to three v apori zers are co mmonl y a ttached to an an es thes ia mach in e.

Physics Vapor Pressure

Fi gure 6.1A s hows a v olati le liquid insi de a containe r that is c losed to a tmos phere. Mol ecules of liqu id break awa y from the su rfac e and ente r the s pace abov e , forming a v apor. If the con tai ne r is k ept at a c ons tan t tempera ture, a dynamic equil ib ri um is formed b etwe en the li quid and v apor phases s o that the nu mber of mo lecules in the v apor phase remains cons ta nt. Thes e mo lec ules bomba rd the wal ls of the container, c rea ti ng a pressu re. This is ca ll ed the satura ted v apor p res sure and is represen ted by the densi ty of d ots abov e the l iqu id . If heat is suppl ie d to the container (Fi g. 6.1B), th e equi l ibrium wi l l be shif ted s o that more molecules en ter the v apor ph ase and the v apor press ure wi l l ri se . If heat i s tak en away f rom the sys tem (F ig. 6.1 C), more molecules wi l l enter the liquid s tate, an d the v apor press ure wi l l be lower. It i s mean ingless , therefore, to talk about v apor pres sure wi thout spec if ying the temperature. Vapor press ures of some anes thetic agents at 20 C are shown in Tabl e 6 .1. Vapor pressure depends only on the liqui d and the temperatu re. It is not aff ec ted by ambi en t pressu re wi thi n th e range of barometric p res sures enc ountered i n a nes thes ia .

Boiling Point
A liquid's boil in g poin t is the temperature at whic h its v apo r pressu re is equal to the atmospheric press ure . The bo il in g point wi ll be lower wi th l ower atmos pheric press ure . Anes thetic agents wi th l ow boil ing p oin ts are more s usceptible to v a ri ations in barometric press ure than agents with higher boil ing points . The boil ing points fo r s ome anes thetic agents are s hown in Tabl e 6 .1 .

P .123

View Figure

Figure 6.1 Vapor pressure changes with varying temperature. A: The liquid and vapor are in equilibrium. B: The application of heat causes the equilibrium to shift so that more molecules enter the vapor phase, as illustrated by the increased density of dots above the liquid. C: Lowering the temperature causes a shift toward the liquid phase and a decrease in vapor pressure. D: Passing a carrier gas over the liquid shifts the equilibrium toward the vapor phase. The heat of vaporization is supplied from the remaining liquid. This causes a drop in temperature.

Gas Concentration
Two methods a re c ommonly used to express the concentra ti on of a gas or v apor: Parti al pressure and v olumes perc ent (v ol %).

Partial Pressure
A mix ture of gases i n a c los ed con taine r wil l ex ert a p res sure on th e wa lls of the container. T he part of the to tal pressure due to any one gas in the mix ture is called the parti al p res sure of that gas . The total press ure o f the mixture is the s um of the partial pressu res of the c ons tituent gas es . T he parti al p res sure exerted b y the v apor of a l iquid agen t depends only on the te mpera ture of that agent and is unaffec ted by the to tal pressu re abov e the li quid. Th e h ighes t parti al press ure that can be ex erted b y a gas at a giv en temperature is its v apor press ure .

TABLE 6.1 Properties of Common Anesthetic Agents

Agent Haloth ane

Trade Name Fluot hane

Boiling Heat of Specific Heat Point Vapor Vaporization of Liquid (C, Pressu 760 re Density MACa in O2 mm (torr, of Liquid Hg) 20C) (g/mL) cal/g cal/mL cal/mL cal/g (%) 5 0. 2 2 4 3 1.8 6 (20 C) 1.5 17 (25 C) 1.4 96 (25 C) 35 (20 C) 65 (20 C) 0. 3 5 0. 1 9 0. 7 5

Enflur ane

Ethra ne

5 6. 5

1 7 5

42 (25 C)

63 (25 C)

1. 6 8

Isoflur ane

Fora ne

4 8. 5

2 3 8

41 (25 C)

62 (25 C)

1. 1 5

Desflu rane

Supr ane

2 2. 8

6 6 9

1.4 5 (20 C)

6. 4

Sevofl urane

Ultan e

5 8. 6

1 5 7

2. 0

Minimum anesthetic concentration. Adapted with permission from Quasha AL, Eger EL, Tinker JH. Determinaion and applications of MAC. Anesthesiology 1980;53:315334.

Volumes Percent

The c oncentration of a gas in a mixture c an also be exp res sed as i ts pe rc entage of the total v olume. V olumes perc ent is the numbe r of uni ts of v olume of a gas in rela tion to a total of 100 uni ts of v olume fo r the total gas mix ture. In a mix ture of gases , each c ons titue nt gas exerts the same proportion of the total press ure as i ts v olume is of the to tal v olume. V olumes percent express es th e relativ e ratio of gas mol ecules i n a mix ture, wh ere as parti al p res sure express es an abs olute v alue. Parti al P res sure/Total press ure = V ol umes p erc ent A l though gas and v apor concen trations deliv ered by a v aporizer are usua ll y ex pressed i n v ol umes pe rc ent, patient up tak e and anes th etic dep th are di rec tl y rela ted to P .124 partial pressu re but onl y ind irec tl y to v olumes perc ent. W hile a giv en partial press ure represents the same anes thetic p ote ncy under v a rious ba rome tric press ures , this is not the c ase wi th v o lumes p erc ent (1).

Heat of Vaporization
It ta kes ene rgy f or the molecules in a liquid to break away and enter the gas eous phase. A l iquid's heat of v apo ri zation is the numbe r of calo ries nec ess ary to conv ert 1 g of l iquid i nto a v apor. Hea t of va porization can a ls o be express ed as the numbe r of c alories nec essa ry to c onv ert 1 mL of l iqui d into a v apo r. T he heats of v apori zation of s ome anes thetic agents are s hown i n Tabl e 6.1 . Liquid temperatu re dec re ases as v aporizatio n p roc eeds . As the tempe rature fal ls , a gradient is c reated so that heat f lo ws from the su rround ings into the l iquid. The l ower the l iqu id temperature , the g rea ter the gradi en t and the greate r the f low of heat from the s urroun di ngs . E v entuall y, equi librium is es tabl is hed so that the hea t l os t to v apori zati on is matc hed by the h eat s uppl ied from the su rround ings . A t this point, the tempera tu re ceases to d rop . In F igu re 6.1D, a f lo w of gas (c arri er gas ) is p assed through the container and ca rries a way mol ecules of v apo r. This ca uses the equil ibri um to shif t so that mo re mol ecules ente r the v apor phas e. Unless s ome means of s upp lying heat is av ailab le, the l iquid wil l cool. As the temperature d rops , so does th e v apor pressure of the l iquid , and f ewer molec ules wil l be pick ed up by the carri er gas so that there i s a d ec rease i n concentra ti on in the gas f lowi ng out of the c ontainer.

Specific Heat

A subs tance's s peci fic hea t is the qua nti ty of hea t requi red to raise the tempera tu re of 1 g of the s ubs tanc e b y 1 C. The higher the spec ific heat, the more heat that is requi red to rais e the temperature of a g iv en quan ti ty of tha t s ubs tanc e . A s lightly different defini tion of spec if ic heat is the amount of hea t requi red to raise the temperature of 1 mL of the s ubs tanc e b y 1C. W ater is th e s tandard with a spec if ic heat of 1 ca l/g/C or 1 cal /mL/C. Specific heat is i mportan t when co nsidering the amount of heat tha t mus t be suppl ie d to a liqui d anes thetic to ma intain a s ta bl e tempe rature when hea t is los t during v apori zati on. Sp ecific hea ts for some a nes thetic agents are giv en in Table 6.1. Specific heat is also i mportan t fo r cho osing th e ma terial to c ons truc t a v aporizer. Tempera ture cha nges more gradual l y for ma terials wi th a high s peci fic hea t than fo r those wi th a low s pec ific heat.

Thermal Conductivity
Ano the r cons ideration i n c hoosin g ma terial f rom whi ch to c ons truc t a v aporizer is thermal conduc tiv i ty . This is a meas ure of th e s peed wi th wh ic h heat f lo ws through a s ubs tance . The highe r the thermal c onductiv i ty, the better the s ubs tanc e conduc ts he at. The rmos tab il i zation is ac hiev ed by co ns tructing a v aporizer of a metal wi th h igh thermal conduc tiv i ty (copper, bronze) to min imi ze temperature changes when the v aporizer is in use . In a v apori ze r c on taining a wic k , i t is impo rtant that the wi ck be i n c ontac t with a me tal part so that heat los t as a result of v apori zation c an be quick ly repl aced.

Vaporizer Design Concentration Calibration

Nea rl y all the v aporizers in use toda y i n th e United S tates are c alibrated by agent conc en tration as express ed in pe rce ntage of v apor ou tput. They are k nown as conc en trated-calib rated va porizers . The y are also c alled di rec t-reading, dia l-con trol led , automatic p lenum, pe rce ntagetype, and tec -ty pe v apori zers . Vapori ze r output is c ontrol le d b y a s ingle k nob or dial that is calibrated in v olumes perc ent. Concentra ti on-cal ibra te d v aporizers a re designed to be loc ated between the f lowme ters and the common gas outle t on th e anesthes ia mac hi ne. They are not desig ned to be used be tween the co mmon gas outlet and the breathi ng s ys tem or in

the breathing s ys tem, becaus e the y are no t cali bra ted f or the high gas f lo ws tha t oc cur wi th the oxy gen f lush in thes e l oca ti ons and offer too much res is tanc e.

Variable B ypass Vaporizers

The v apor p res sures of mos t anes thetic ag ents a t room tempe rature are muc h greater than the partial p res sure required to p rod uce anes thes ia. To p roduce c linic al ly us eful co ncen trations , a v apori ze r di lutes s atu rated v apor. This can be ac complished by s pli tting the gas flow that p asses throug h the v aporizer (F ig. 6.2 ). Some of the gas flows through the v apori zing c hamb er (the pa rt c ontaining the l iquid anes thetic a gent), and the remainder goes through a by pas s to the v apo ri zer outl et. Both gas flows j oin downs tream of the v apo ri zing c hamber, where gas ex its the v apo ri zer a t th e des i red conc entration. The ratio of b ypas s gas to gas going to the v aporizing c hamber is called th e sp li tti ng ratio a nd depends on the ra tio of res istances in the two pathwa ys (2 ,3). This i n turn depends on the v ariable (adjus tabl e) o ri fic e . This orif ic e may be in the i nlet to the v apori zing c hamber but is in P .125 the outle t in mos t modern v apori ze rs . The spl i tting ratio may also d epend on the total fl ow to the v aporize r.

Figure 6.2 Concentration-calibrated vaporizer. A: In the OFF position, all of the inflowing gas is directed through the bypass. B: In the ON position, gas flow is divided between the bypass and the vaporizing chamber. In the MAX position, all of the gas flow allowed by the vaporizer goes to the vaporizing chamber.
View Figure

Electronic Vaporizers

In an e lec tronic v aporize r, the v olume of carri er gas n ecessary to produc e the desired agent c oncentratio n may be d etermined by a c omputer that c alc ulates the ca rrier gas flow that ne eds to pass through the v apo ri zing cha mber i n order to produce the des i red a nes thetic a gent c onc entra tion. Ano the r ty pe of elec tronic v apo ri zer withdraws a calcul ated amount of l iqui d agen t f rom the agent bottle and injec ts tha t li quid i nto the breathing s ys tem or f res h gas f low. The amou nt of l iquid tha t is injec ted is adj us ted to ac hiev e the desi red anes thetic agent c oncentratio n.

Vaporization Methods
Flow-over
In a f lo w-ov er v aporizer, a s tream of ca rrie r gas pas ses ov er the surface of the l iquid . Inc reas ing the are a of the c arri er gas-l i quid interfac e can enh anc e the ef fic ienc y of v aporiz ati on. This can be done by using baf fles o r s pi ra l track s to l engthen the gas path way ov e r the l iquid. Ano the r method is to empl oy wi cks that hav e the ir bases in the l iquid. Th e l iqui d mov es u p the wi ck by capil lary ac tion . Mos t of the v apo ri zers used in anes thesi a empl oy th is v aporiz ation method .

Injection
Certain v aporizers c ontrol the v apor c oncentration by injec ting a kno wn amount of l iquid anes thetic into a known v olu me o f gas .

Temperature Compensation
As a liqu id is v apo ri zed , energy in the form of heat is los t. As the l iquid temp era ture dec reas es , so does the v apor p res sure. Two methods hav e be en employed to mai ntain a c ons tant v apo r output wi th f luc tuatio ns in l iqui d anesthe tic tempera ture.

Mechanical Thermocompensation
Mos t conc entra ti on-cal ibra ted v aporiz ers c ompensate for c hanges in v apor p res sure wi th temperature c hanges by al tering the s pli tti ng ra tio so that the percentage of ca rrier gas that is direc ted through the v apori zi ng c hamber is inc reased o r dec reas ed . As the v apori zer c ools , the thermal el ement res tric ts the bypass flow, caus ing more c arri er gas to pass through the v apori zing c hamber. The oppos i te c an oc cur i f the v apo ri zer b ecomes too warm.

Supplied Heat
An el ec tric hea te r can be us ed to su pply heat to a v apori zer and mai nta in i t at a cons tant tempe rature.

Computer ized Thermocompensation

The rmoc ompensation ma y b e accomplished by compute r c ontrol. Two meth ods hav e been used . The amount of agent injec ted i nto the breathing s ys te m or f resh gas f low may be al tered. If th e v apori zer wi th dra ws an amoun t of l iq ui d f rom a bottle and injec ts it, the hea t loss due to v apori zation ma y not be i mportant. The sec ond method is compu terized c on trol of the amount of carri er gas tha t flows through the v aporizing c hamber.

Effects of Altered Barometric Pressure

Mos t v apo rizers are c al ibrated at s ea lev el (4). B ecause they are s ometimes used i n h yperbaric chambers or a t high al ti tudes whe re atmospheric press ure is lo w, it is i mportan t to hav e some kn owl edge of how they P .126 wi ll perform wh en the barometric p res sure is changed. The A me rican Soc ie ty of Tes ting and Materials (AS TM) an es thes ia works tation s tandard (5) requires that the ef fec ts of changes in ambient p res sure on vapo ri zer performance b e s tated i n the ac companying doc uments .

Effects of Intermittent Back Pressure

W hen as s is ted or con trol le d v entilation is us ed, the pos itiv e pressure gen era ted during ins pi ra tion is trans mi tted f rom the b rea thing s ys tem back to the mac hine and the v apo ri zers . Back press ure als o oc curs when the oxygen flus h is ac tiv ated. B ack press ure may ei ther i nc reas e (pumping effec t) or dec rease (pressu ri zi ng effec t) the v aporizer output. The A ST M an es thes ia works tation s tandard (5) li mits th e c hanges in c once ntration f rom in te rmi ttent back press ure . Manufac turers are requi red to s tate in ope rators ' manu als the ex ten t to wh ich b ack press ure af fec ts a v apori zer's pe rformance.

Pumping Effect
Factors
S tudi es hav e shown that c onc entrati ons deliv ered by so me v aporizers duri ng control led o r ass is ted v entil ation a re hi ghe r than when the v apo ri zer wa s used wi th f ree f lo w to atmosphe re (6 ). T his c hang e is mos t pronounced when there is less agent in the v aporiz ing c hambe r, wh en carri er gas fl ow is l ow, wh en the press ure f luc tu ati ons a re high and f requen t, and when the dia l setting is lo w.

Figure 6.3 The pumping effect in a concentration-calibrated vaporizer. (See text for details.) (From Hill DW. The design and calibration of vaporizers for volatile anesthetic agents. Br J Anaesth 1968;40:656 .)
View Figure

Mechanisms
A pro pos ed mechanis m for the pumping effec t in the c once ntration-c al ibrated v a ri able-bypass v apori ze rs is shown i n Figure 6.3A C. Figure 6 .3A s hows the v aporizer during exhalation. Th e relativ e res is tances of the ou tlets f rom the bypass and v aporizing chamber determine the flows to each (items 3 and 4 in the f igure). Fi gure 6.3B s hows i nspiration . Pos i tiv e p res sure at point C prev ents gas and v apor outflo w. P ressure is transmi tted to poin ts A and B . This resu lts in gas bei ng co mp res sed in the v aporizin g c hambe r and bypass . Bec ause the bypass has a smal ler v o lume than the v apori zing c hamber, more gas enters the v aporizing chamber s o that the normal ratio between th e fl ow to the v apo rizing cha mber an d that through the byp ass is dis turbed . The resul t is an inc rease d fl ow to th e v aporizing c hamber, whi ch then pick s up addi tion al anes thetic v apor. Fi gure 6.3C s hows the si tuation jus t after the beginn ing of exha la tion. T he pressu re at point C fal ls rapidl y, and gas f lo ws from the v aporizing chamber and the b ypas s to the ou tlet. B ecause the bypass has less res is tanc e than the v aporiz ing c hamber outl et, the p res sure i n the bypass fa lls more quic kl y than that in the v apo rizing chamber, and gas containing v apor flows f ro m the v apori zing chamber i nto the bypass . Bec ause the gas in the bypas s (whi ch di lutes the gas from the v aporizi ng chamber) now c arries v apor a nd the gas flowi ng from P .127

the v apo ri zing cha mber is s till s a turated, the c oncen tration i n the v aporizer ou tpu t i s inc reased .

Modifications to Minimize the Pumping Effect Alterations to the Vaporizer

Bec ause the inc reased output is related to the rela tiv e s i zes of the s pace a bov e the l iquid in the v aporizing chambe r and the space in the bypass , keeping the v aporizing c hamber smal l or i nc reas ing the s ize of the bypass wi l l dec rease th e ef fec ts of bac k p res sure (2). Ano the r method is to employ a long, s piral o r la rge diameter tube to l ead to the v apori zing c hamber (F ig. 6.3DF). The ex tra gas forc ed in to this tube and subs eque ntl y re turned to the bypas s does no t reac h the v aporizing c hamber. A no the r method is to exc lude wic ks from the area whe re th e i nlet tube jo ins the v aporizing c hamber. Fi nal ly, an ov erall inc rease in res istanc e to gas fl ow through the v aporize r may be us ed.

Alterations to the Anesthesia Machine

These dev ic es (pres suriz ing v alv e, un idi rec tional v alv e, and pressure rel ief dev ice) were di scus sed in Chapter 5. A c heck v alv e near the mac hine outlet but ups tream of the junction with the oxygen flush offers less p rotection from the pumpin g effec t than a c heck v alv e at the outl et of a v aporizer (7).

Pressurizing Effect
Factors
The outp ut of s ome v apo ri zers used in c on ju nc tio n wi th automatic v enti lato rs has been found to be l ower than during f ree f low to atmosphe re (8 ). The eff ec t is greater wi th high f lo ws , large pressure fl uc tua ti ons , and low v apo ri zer s ettings .

Mechanisms
The expl anation fo r the pres surizing effec t is sho wn in Figure 6.4 . Fi gure 6 .4A shows a v apo ri zer f lowi ng free to atmosphere. The p res sure in the v apo ri zing chamber a nd the bypas s is P . As gas flows to the ou tlet, the p res sure is reduc ed to R. The n umber of molec ul es of anes the tic agent picked up by each mi lli li ter of ca rrier gas depends on the dens i ty of the an es thetic v apor molec ules in the v aporizing c hamber. This , in turn , depends on the age nt's v apor press ure . The v apor press ure depends solel y on the tempe rature and is n ot affec ted by alterations i n the atmospheric press ure.

Fi gure 6.4B s hows the s i tu ati on whe n an inc reased press ure is appli ed to the v aporize r outlet and tra nsmi tted to the v apori zi ng c hamber. The inc reas ed pressu re wi ll c ompress the carri er gas so that there wil l be more molecul es per mi lli liter. The numb er of anesthetic v apo r mol ecules i n the v aporiz ing c hambe r wil l no t be i nc reas ed, ho wev er, becaus e this depends on the s aturated v apor pressu re of the anes thetic and not on the pressu re in the co nta iner. The net resu lt is a dec reas e in the conc entra ti on of anes thetic i n the v apo ri zing chamber and the v apori ze r outle t.

Figure 6.4 The pressurizing effect. An increase in pressure (p) causes an increase in pressure (p) inside the vaporizer. The vapor pressure of the volatile anesthetic is unaffected by changes in the total pressure of the gas mixture above it. As a result, the concentration is reduced.

View Figure

Interplay between Pressurizing and Pumping Effects

The c hang es in v aporiz er output caus ed by the pumping effec t us ually are greater than th ose as soc iated wi th the pressu ri zing ef fec t. The pressuri zing eff ec t is s een wi th hi gh gas f lows and the pumping effec t at low f lows .

Effects of Rebreathing
The v aporizer dial s etting refl ec ts the c onc entration of inhal ational a gent deliv ere d to the breathing s ys te m. When the f resh gas f lo w i s hi gh, there may be li ttle, if any , ex hal ed gas rebreathed, and th e ins pi red co ncentration s hould be cl ose to the v aporizer s etting . As the f resh gas f lo w i s lowered, ex haled gas es con tribute a more s ig nifican t porti on of the i nspi red gases . Reb rea th ing c auses a d iffe rence between the v aporizer s etting and the insp ired concentration. A ls o, if min ute v olume is P .128

i nc reas ed, there wil l be more reb rea thi ng an d a greater effec t. W ith si gnific ant rebreathing, only an ag ent anal yze r c an prov ide an ac curate v alue for the i nspired agent co ncentration.

Vaporizers and Standards

An inte rna tional s tanda rd c ov ers v apo ri zers (9). The AS TM anes thes ia works tation s tandard (5) c onta ins the fol lowi ng prov isions rega rding v aporiz ers :

The effec ts of v a riations in ambien t te mpera ture and press ure, ti l ting, back press ure , and input flow rate and gas mix ture c ompos iti on on v apori zer performance mus t be s ta ted i n the accomp anying documen ts .

The av erage del iv ered c oncentra tion f rom th e v aporizer s hal l not dev iate f rom the s et v alue b y mo re than 20 % or 5% of the maximu m se tting, whi c hev er is greater, withou t bac k p res sure.

The av erage del iv ered c oncentra tion f rom th e v aporizer s hal l not dev iate f rom the s et v alue b y mo re than +30 % or -20% or by more th an +7.5% o r -5% of the max imum setting , whi chev er is greate r, wi th p res sure fluc tuations at the common gas outlet of 2 kPa wi th a to ta l gas flo w of 2 L /minute or 5 kPa wi th a to ta l gas f lo w of 8 L /mi nute.

A s ys tem that prev ents g as from pass ing through the v apori zing chamber o r reserv oi r of one v apori ze r and then th rough tha t of another mus t be prov ided. The outp ut of the v aporize r sha ll be les s tha n 0 .0 5% i n the OFF or ze ro position if the zero position is als o the OF F pos ition. A ll v aporize r con trol kn obs mus t open c ountercl ock wis e . E i ther th e maxi mum and mini mum fi l li ng levels or the ac tual us ab le v olume and c apac ity shall b e d is played . The v aporizer mus t be des igned so th at i t cannot be ov erfilled when in the normal operating pos i tion. Vapori ze rs uns ui table for us e in the b rea th ing s ys tem mus t hav e nonin terchangeabl e p rop ri etary or 23-mm f itti ngs . Conica l fi ttings of 15 mm and 2 2 mm c annot be used. When 23-mm fitti ngs a re us ed, the in le t of the v aporizer mus t be male an d the ou tlet female. Th e d irec ti on of gas f low mus t be marked .

Vapori ze rs sui table for use in the breathing s ys tem mus t hav e s tan dard 22mm f i ttings or sc rew-thre aded , wei ght-be aring fitti ngs with the inlet femal e

and the outlet male. Th e d irec ti on of gas f low mus t be indica ted by a rrows and the v aporize r mark ed for us e in the bre ath ing s ys tem.

Concentration-calibrated Vaporizers Tec 5

Tec 5 v aporizers a re des ig ned fo r use wi th halo thane, enfl urane, is oflurane, and sev oflu ran e.

Construction
Tec 5 v aporizers a re sho wn in Figure 6.5 . The control d ial is at the top. A rel ease button loc ated at the re ar of the dial mus t be pus hed i n before the v apori zer can be turned ON. A t the rea r is a lock ing lev er that i s connec ted to the con trol dial s o tha t the v apo ri zer c annot be turned ON un ti l i t is l oc ked on the manifo ld. A t the bottom righ t front is a s ight g lass that s ho ws the l iquid agent lev el i n the v apori zing chamber. Tec 5 v aporizers a re av ailable wi th ei th er of t wo fi lling dev ic es . One is a k eyed s ys tem (Fi g. 6.5). The fi l li ng /draining port is a t the f ro nt of the v aporizer on the lef t near the bottom. A lock ing lev e r to s ecure the fil ler block is located on the left s ide of the v aporizer. A s mall lev er at the bas e all ows li quid to be added to or d rained f rom the v apori zer. The other f ill ing dev ice is a funnel f i ll that has a drain plug that can be loos ened to drain the v apori ze r. A schematic diagram of a Tec 5 v aporizer is s hown in F igure 6.6. The internal baffle s ystem is des ig ned to k eep liqu id f rom re achi ng the outle t if the v aporizer i s tipp ed or i nv erted. W hen the conc entra tion dial is in the zero pos ition, al l of the gas from the f lowme ters bypass es the v apori zer thro ugh the Selec t-a -tec bar (Fi g. 6.74). W hen the dial is turned pas t ze ro, inf lowi ng gas is spl it i nto two s treams by the rotary v alv e. One s tream is di rec ted to th e v apori zi ng chamb er, the other through the bypass . Gas f lo win g through the bypass flo ws d own one si de of the v aporizer and p as t the thermos tat, whi ch is a bi metallic s tri p i n the base . As th e tempe rature in the v aporizer dec reases , the thermos tat permi ts less gas flow th rou gh the b ypas s so that more gas passes through the v apori zing c hamber. From the thermos tat, gas f lows up the other s id e of the v apo ri zer and near the ou tlet joins the gas that has passed through the v apori zi ng cha mber.

The gas flowi ng to the v apori zing ch amber fi rs t pass es th rough the c entral part of the rotary v alv e, after wh ic h i t is direc ted thro ugh a hel ical c hannel then pas t a sp iral wi ck that is in c ontac t wi th the wi ck sk i rt, wh ic h d ips into the l iquid agent. Gas wi th v apor leav es the v apo ri zing c hamb er v ia a c hannel i n the c onc entration dial rotary v alv e and flows to the outlet.

Evaluation
The man ufac ture r's performanc e curv es are shown in Figure 6 .7. Grea tes t acc uracy i s at a fres h gas flow of P .129

P .130

P .131

P .132 l ess than 5 L/minu te an d d ial settings les s than 3 %. A t higher flows and higher dial se ttin gs , there is a dec re ase in o utput (10).

View Figure

Figure 6.5 Tec 5 vaporizers. The locking lever for the filling device is on the lower left side of each vaporizer. The lever for filling-draining is at the base, below the sight glass. To fill, the bottle adaptor is inserted into the port and clamped in place by pulling the locking lever down. The bottle is then lifted up, and the filling-draining lever is pulled forward. When filling is completed, the fillingdraining lever is returned to the closed position, the bottle is lowered, the clamping lever is pushed upward, and the bottle is removed. Draining of the vaporizer is accomplished by using the same levers but by lowering the bottle rather than lifting it. Behind each control dial is a locking lever in the locked position. (Courtesy of Ohmeda, a division of BOC Health Care, Inc.)

Figure 6.6 Diagram of Tec 5 vaporizer in the ON position. (See text for details.) (Redrawn from a drawing furnished by Ohmeda, a division of the BOC Health Care, Inc.)

View Figure

Figure 6.7 Performances of four Tec 5 vaporizers. (Redrawn from drawings furnished by Ohmeda, a division of the BOC Health Care, Inc.)

View Figure

The greates t acc urac y is betwe en 15C and 35C. The thermos tat does not respond to tempe ratures below 15C, and the output wil l be less than indicated on the dial. If the tempe rature is abov e 35C, the output wi l l be unp red ic tably high . The Tec 5 is prone to i nc reas es in output f rom the pumping effec t (11). Carri er gas co mpos i tion af fec ts the ou tp ut of the Tec 5 v aporizers . A t low fl ows , the ou tpu t is l ess when air o r ni trous ox ide is use d tha n wh en oxy gen is the ca rrier gas . A t high f lows , a smal l inc reas e in output wil l oc c ur.

Hazards

If the loc king lev er is parti al ly loos e o r the fi ll ing port open , th ere wi l l be a gas leak (12,13,14,15). Liquid agen t may be los t if the v apo ri zer is fairl y ful l . These v apori ze rs can be ov erfi lled if the bottl e adap to r is loos e and the c ontrol di al i s in the ON posi tion (1 6,17,18). Til ting the v aporizer c an resu lt in ov e rf il l ing (19). This wi ll caus e the v apor ou tpu t to be e lev ated. Rev ersed flow thro ugh the v aporizer res ul ts in inc reased output (20).

Maintenance
The ex te rior of the v aporizer may be wi ped wi th a damp c loth. No other c leani ng or disi nfec tion s hou ld be attempted. The man ufac ture r rec ommends tha t if the ag ent c ontains addi tiv es or s tabi l iz ing agents , the v apo ri zer s hou ld be drained ev ery 2 wee ks or whe n the lev el is low. If there a re no additiv es or s tabili zing agen ts , the v aporizer c an b e dra ined a t less f requent interv als . The v apo ri zer s houl d be re tu rne d to a s erv ice center ev ery 3 years . There may be s ome f lex ibili ty in the reco mme nded s erv ic e f requenc y when agent analysis is us ed.

Tec 6
The Tec 6 v apori zer is des igned fo r use only wi th desflurane (21,22,23).

Construction
The Tec 6 v apori zer is sho wn i n Figure 6 .8 . It i s some what larger than the Tec 5 v aporizers . The concen trati on dial at the top is calib rated f rom 1% to 18% in gradati ons of 1 % up to 10% and 2% between 10% and 18 %. A d ial rel ease at the back of the dial mus t be depres sed to turn the dial f rom the s tandb y posi tion o r to dial c onc entrations ov e r 12%. This release cannot be depress ed unles s the operati onal li ght-emitting diode (LE D) is ill uminated. The f ill er po rt is at the front o n the l ef t. It is designed s o tha t onl y a desfl ura nespec ific bottle c an b e i ns erted into i t. The powe r c ord attachment and battery c as e are on the bottom. Th e battery prov ides power f or th e ala rms and l iquid c rys tal l ev el indic ator during ma ins power fai lu res . The po wer c o rd exi ts at the s ide. The v aporizer c as ing is warm to the touc h when it is c onnec ted to the elec trical s uppl y, whi c h wi ll c aus e s li gh t heating of ad jacent e quipment (24 ). The drain pl ug is l ocated at the base. A sp eci al k i t is re qui red to dra in the v apo ri zer.

Figure 6.8 Tec 6 vaporizer. The filler port is at the bottom left. At the bottom right are the liquid level indicator and the visual signals for monitors of vaporizer function. A bottle of desflurane with the protection cap in place is to the left of the vaporizer. The locking lever behind the control dial is in the unlocked position. (Courtesy of Ohmeda, a division of BOC Health Care, Inc.)

View Figure

On the f ront l ower ri ght of the v aporizer is the display panel , whi ch has v isual i ndicators for v apori zer func tions (Fi g. 6.8). W i th the ex ception of the ti l t conditi on, there is a 10-sec ond delay be twe en detec tin g a mal func tion and al arm ac tiv ati on. An aud itory ala rm is mounte d behi nd th e upper part of the display panel . An audio OFF (mu te) button is located abov e the disp la y panel . The amb er warm-u p L ED indica tes an ini tial warm-up period after the v aporize r is f irs t c onnec ted to the ma ins power. Once warm-up is co mple te, the green operati onal LED is i lluminated, ind ic ati ng that the v aporizer has reached its operati ng temperatu re and the concentration di al c an be tu rned ON. A s hort tone sounds at the trans i tion f rom warm-up to operation al . The red no output LE D flashes and an au ditory alarm of repeti tiv e tones sounds if the v apo ri zer is not able to del iv er v apor. This can be c aus ed by an agent lev el les s than 20 mL, til ting the v aporizer more than 10 degrees , power f ailu re, or an inte rna l malfunc tion. Turning the conc entration dial to s tandby wi l l mute this ala rm and i llumi nate the red ligh t. P .133

The amb er low agent LED accompani ed by an audible a larm is i ll uminated if the re i s les s than 50 mL of agen t in the v apori ze r. Th is alarm c an be aud io paused (mu ted) fo r 120 s econds . If less than 20 mL remai n i n the v aporize r, the no ou tpu t alarm is ac tiv ated.

The amb er alarm ba ttery low LE D i lluminates to indicate th at a new battery is requi red. The re is no audi tory s ign al f or this c ondi tion . The l iquid lev el indicator has a liquid c rys tal disp lay (LCD) that ind ic ates the amou nt of l iquid in the v apori zer between 50 and 425 mL. The LC Ds a re v isible whe nev er the v aporizer is powered. There are 20 ba rs . A s ingle ba r corre spon ds to a v olume of approx imately 20 mL . A n arrow on the s id e i nd ic ates the 25 0 mL refi l l mark . If the lev el is below thi s mark , the v ap ori zer wil l ac cept a f ul l bo ttle (240 mL) of desf lu rane.

View Figure

Figure 6.9 Diagram of Tec 6 vaporizer. (1) agent, (2) level sensor, (3) sump heaters, (4) electrical mains, (5) shut-off valve, (6) agent pressure-regulating valve, (7) battery for alarms, (8) LCD level display, (9) alarm electronics, (10) heater electronics, (11) control electronics, (12) alarm battery low LED, (13) warm-up LED, (14) low agent LED, (15) no output LED, (16) pressure transducer, (17) pressure monitor, (18) heater in vapor manifold, (19) heater in valve plate, (20) solenoid interlock, (21) variable resistor (controlled by rotary valve), (22) fixed restrictor, (23) tilt switch, (24) operational LED. (See text for details.) (Redrawn from a diagram furnished by Ohmeda, a division of BOC Health Care, Inc.)

W hen the uni t is plu gged i n, the elec tronics go th rou gh a s elf-tes t. For 2 sec onds , the alarm sou nds , and eac h LE D a nd LCD ill umin ates . Th is self -tes t c an be repeated at any ti me by press ing the mute b utton for 4 sec onds o r more . Once the v aporizer is plugged i n, the power is al way s ON, and the sump hea ters are operati onal . Ini tial ly , the v apo ri zer wi l l take 5 to 10 minutes to reac h operating temperature . The internal c ons truc ti on is shown i n Fi g. 6.9. Desflurane is heated to 39C (102F), whic h is wel l ab ov e i ts bo ili ng poi nt, by two h eaters in the b ase. A n ex ternal heat s ourc e is needed, becaus e the po tency of desf lurane requ ires that l arge a mounts be v apori ze d. In addi tion, the desf lurane boil ing point is nea r room temperature and depending on ambient tempe rature woul d make the output unpredic table . Thes e fac to rs make P .134

thermocompensa tion us ing the us ual mech anical dev ices impos sible. A trans former and a lternating c urrent (AC) to direc t curre nt (DC ) c onv erter p rov id e DC power fo r the v apo ri zer. The s ump assembly holds the agent and incl udes the fi lling port, dra in , heaters , and a gent lev el se nsor. It has a capac i ty of 425 mL. The temp era ture is monitored, and the as soci ated elec tronics ac t as a thermos tat. Two hea te rs i n the upper pa rt of the v apo ri zer p rev ent a gent c ondensa tion where the wa rm v apo r meets the c old gas f rom the c ommon mani fold . The l iquid agent lev el is sensed by a probe and s heath in the sump as sembly. These meas ure the capaci tance by us ing the age nt as a di el ec tric . The display is on the front of the v apori zer. W hen the proper tempe rature is re ached, the green ope rational LED i llumina tes . A s igna l from the c ontrol el ec tronic s operates th e s olenoi d in terlock , allowi ng the dial and rotary v alv e to be turned. W hen the dial a nd rotary v alv e are turned, the s hutof f v alv e opens . Fres h gas f low enters the v apori ze r and enc oun ters a fixed res is tor that c rea tes back pressu re. The higher the f res h g as fl ow, the greater the bac k pressure generate d. E lec tromechanic al dev ices maintain the agent v apor pres sure a t the v a ri able res is tor in the rotary v alv e at the same lev el as the fresh gas p res sure at the fixed res tric tor. This pressu re balance between the des flurane and the di luent f low c ompens ates for c hanges i n tempe rature, v apor press ure, or di luent flow rate. The pres sures are s ensed by a transduc er that sends a s ignal to the c ontrol elec tronics , wh ic h i n turn al ters the age nt press ure at the v a ri able resis to r by opening or c los ing the agent press ure -regulatin g v alv e to ba lance the pressures . W ith this ba lance of p res sures maintained, the concentra tion del iv ered by the v aporizer dep ends on ly on the ra tio of f res h gas fl ow thro ugh the f ixed res tric tor and a gent v apor fl ow through the v a riable res is to r, wh ic h depends on th e conc en tration dial setti ng. When the c onc entration dial is turned to a highe r v alue, resis tance to desf lurane fl ow dec reases and the flow of desf lu rane inc reases . Wi th an i nc reas e i n di luent flo w, th e elec tron ics wi l l i nc rease the fl ow i n the des fl urane l imb to ma intai n the p res sure balance . The v apor mix es wi th f resh gas jus t before the la tter ex its the v aporiz er. The f ill in g s ystem is disc uss ed later i n the c hap ter under Desf lu ran e Fil li ng S ys te m (s ee Fi g. 6.73). The v aporizer c an be filled whi l e i n use , but the f res h gas flow shoul d be less than 8 L /minute, the conc entrati on di al s et at n o mo re than 8%, an d

the v apo ri zer s hou ld not be subjec ted to high back p res sure. The v aporizer can be f il led while i t is in its warm-up cyc le.

Evaluation
The man ufac ture r's data are shown in Figu re 6.10. The v apo ri zer is cal ibra ted for f lows f ro m 0.2 to 10 L /mi nute. The o utput is almos t l in ear at the 3%, 7%, and 12% se ttin gs , wi th s lightl y lowe r outputs at f lo ws les s than 5 L /minute and sl ig htly greater ou tpu ts at hig her flo ws . Th e v aporizer is des igned to be us ed at amb ie nt temperatures between 18C a nd 30C. S tudi es hav e s hown that the output is wi th in 1 5% of the dial setting. Til ting does not render the v apo ri zer i noperativ e or dangerous to operate (25). Ni trous ox id e i n th e carri er gas d ec reas es the outp ut s lightly .

Figure 6.10 Performance of Tec 6 vaporizer, with oxygen as the carrier gas. (From a graph furnished by Ohmeda, a division of BOC Health Care, Inc.)

View Figure

Fl uc tuating bac k p res sure does no t s ignifica ntl y affec t the Tec 6 v apori ze r output. Carri er gas compos i ti on af fec ts v aporiz er ou tpu t (25,26,2 7,28). The output is dec reas ed wi th ai r or nitrous oxide as the carri er g as. E lec tric i ty c ons umption by the v aporizer is low (2 9). The batte ry mus t be rep laced annual ly .

Hazards
Vapor c an leak into the f resh gas wi th the vapori zer turned OFF . W hen f ill ing the v apori ze r, the bottle mus t be gripp ed tightl y when it is rota ted downward. If not g ripped tightly, the b ottle may be d ropped when i t is released under press ure at the lower pos i tion .

A cas e has been repo rted where a v alv e pisto n in the attac hment s tuc k in the depressed posi tion, c aus ing a l arg e leak of fres h g as (3 0). Other v apo ri zers moun ted o n the mach in e c ould not b e turned ON. If the Tec 6 is us ed on an anes th esia machine that turns OFF the f resh gas flow during ins pi ra tion (f resh gas decoup li ng; Chapter 12), the i nte rmi ttent fl ow wil l tri gger an ala rm if the s oftware to av oid this p rob le m is not in pl ace (31,3 2,33). Cas es of s park s and smok e around th e c onn ec tio n between th e mains power c ord and the socket hav e be en P .135 reporte d (34). This was be liev ed to be the res ul t of a loos e plug . The Tec 6 s hould be moun ted on the far ri ght-hand s ide on the bac k b ar of the anes thes ia mach ine (35). In o the r pos itions , the power c ord may in terfere wi th the v aporizer in te rlock mec hanis m fo r the o the r v apo ri zers (3 6,37). Leaks hav e been reported with this v apori ze r (3 8). Two c ases of c ardiac arres t s econdary to a mass iv e ov erdos e c aus ed by a defec tiv e control v alv e hav e be en reported (39).

Maintenance
This v aporize r requi res s erv ic ing ev ery year a t an authori zed cen ter. The ex tern al su rface may be wi ped by us ing a c loth s lightly da mpened wi th a c lea ning agen t. No other c le aning or dis infec tion shou ld be attempted.

Tec 7
The re are Tec 7 v apo rizers fo r hal othane , enf lurane, isof lurane, and s ev ofl urane.

Construction
A Tec 7 v apori ze r is shown in Figu re 6.11. On top is the c oncen tration control d ia l. A t the rear of the dial is a release button that mus t be pus hed in before the v aporizer c an be turned ON. A t the re ar is a l oc ki ng lev er that is connec ted to the control d ial so that the v apo ri zer c ann ot be turned ON un ti l i t is loc ked on the manifold. A t the botto m rig ht front of eac h vapo ri zer is a si ght g lass that indicates the liqui d lev el in the v apo ri zing c hamber.

Figure 6.11 Tec 7 vaporizer with Easy-Fil system. Note the locking lever behind the control dial. The interlock device can be seen near the back on the right of the vaporizer. (Courtesy of Datex-Ohmeda, a division of General Electric.)

View Figure

Figure 6.12 Back of Tec 7 vaporizer. The rectangle at the lower right is the identification label. At the top is the locking lever. Note the interlock connectors at either side.

View Figure

The back of the v aporize r is s hown i n F igu re 6.12. A v aporizer identificati on label is af fixe d to the b ack . An anes thes ia s ys tem fitted wi th a v aporizer identif ication uni t us es this label to identi fy the v apo ri zer. A l though there are a number of improv eme nts in this v aporizer compared wi th the Tec 5 , the s chema tic diagram of the Tec 7 v apo ri zer is ess entia ll y the s ame as fo r the Tec 5 (Fig. 6 .6 ). Tec 7 v aporizers a re av ail ab le wi th three fi lli ng dev ices : a funne l fi ller, the Quik -F il , or the E as y-Fil s ys tem (Fig. 6.11).

App rox imatel y 300 mL of li quid is nee ded to f i ll a v aporiz er wi th dry wi c ks . App rox imatel y 75 mL is reta ined in the wic ks when the v apori ze r is drai ned . P .136

Evaluation
The man ufac ture r's performanc e curv es are s imil ar to thos e of the Tec 5 (Fig. 6 .7 ). Greates t accuracy is at a f res h gas fl ow of 5 L/minute a nd dial se ttin gs less than 3%. A t higher f lo ws and higher dia l se ttin gs, there is a dec rease in output below the se t v alue. The greates t acc urac y is betwe en 15C and 35C. The thermos tat does not respond to tempe ratures below 15C, and the output wil l be less than indicated on the dial. If the tempe rature is abov e 35C, the output wi l l be unp red ic tably high . Changes in barometric changes are compensated for automatical ly . Fl uctuating back pressu re can aff ec t the v aporize r and inc reas e the deliv ered c oncen tration . W hen ai r or n itrous ox ide is part of the c arrier gas , the output is lowered c ompa red wi th the output wh en oxy gen is the ca rrie r gas . The effec t is g rea tes t during low f low rate s and lo w d ial s ettings . The effec t is greates t (up to 20% of s etting) a t low f lows wh en ni trous ox id e is used. If the a nes thes ia mac hine and v aporize r are o ut of s erv ic e for a pe riod of time wi th out gas flowi ng, low c oncentra tions of th e agent ma y be detec ted at the machine o utlet immediatel y af ter the gas f low is turn ed ON. W hen the v apo ri zer is turned ON after a perio d of nonus e, a h igh c onc entration o f agent may be de liv ered for app rox imatel y 10 s ec onds .

Hazards
The Tec 7 v apori zers are intended to be ope rated in the upri ght posi tion. If a v aporizer is inv erted, it s hould be con nec ted to a s cav enging s ys te m, the d ial set to 5%, and the v aporizer purged wi th c arri er gas at 5 L /minute fo r 5 minutes .

View Figure

Figure 6.13 Aladin cassette vaporizer in place. The cassette fits into a recess on the front of the anesthesia machine. It can be removed by squeezing the handle. The concentration dial is to the left of the cassette. The wheel on the left of the cassette is used to lock the keyed filler in place and open the inlet to the vaporizer. The liquid level indicator is at the bottom near the center of the cassette. To its left is the keyed filling receptacle.

The v aporizer could be ov erfi lled if i t is not f il le d i n the uprigh t pos itio n. The dial mus t not be turned ON during f ill in g to preven t ov e rf il l ing .

Maintenance
The halo thane v apori zer should be drained ev ery 2 weeks when the lev el is low and the liqui d disca rded if there are ad di tiv es or s ta bil izing agents . Other v apori ze rs shoul d be drained once a ye ar. Thre e years from the da te of purc has e and ev ery 6 months thereaf te r, the v apori ze rs s hould undergo a saf ety inspec tion and the outpu t c hecked . The ex te rna l surfaces can be c leaned wi th a mois t c lo th and n eutral deterg ent. The c lean in g agent mus t no t be al lo wed to ac cumul ate in the fil ler, the gas inlet, or outl et po rts or around the con trol dial .

Aladin Vaporizer
The A ladin v apori ze r is d esigned for desf lurane , is of lurane , s ev of lurane , halothane , and e nfl urane.

Construction
The v aporizer cons is ts of two p arts . T he elec tron ic c ontrol mec hanis m is in the anes thes ia mach ine. The ag ent is in a po rtable cass ette that is inserted into a s lot i n the an es thes ia mach ine. The c oncentration d ial is o n the anesthes ia machine n ex t to where the casse tte is place d (Fig. 6.13 ). A magn etic sensor iden tifies the cas sette . A g ree n LE D on the f ron t panel bes ide the ag ent whe el is used to in dic ate that the v aporiz er is turned

ON. On the display sc reen (Fig. 6.14), the agen t is i den tified by na me a nd color code and the s etting in numbers and on a tri angular graph. P .137

Figure 6.14 Display screen showing the agent and setting at the bottom in the center. The agent is identified in text and color code. The setting is in numerals and a triangular graph.

View Figure

The c asse tte is shown in Fi gu res 6.15 an d 6 .16 . It is co lo r coded for the agent that i t is des igned to contain and is magne tical ly c oded s o that the mac hine can automatic al l y identif y whic h cass ette has been inserted. A handle on the front is us ed to ca rry the casse tte and to inse rt i t i nto and remov e it f rom the mach ine. The re is a releas e on the insi de of the han dl e that when s queez ed rel eas es the cassette f rom the machine . It c an be transported and s tored in any pos i ti on. The c asse ttes for halothan e, enfl ura ne, and isoflurane hav e keyed fillers or the Eas y-fi l s ys tem. Sev oflurane cassettes may be equi pped with ei the r a keyed fi ller or the Quik -Fil s ys tem. A lock -and -fil l wheel on the left loc ks th e k eyed fi ller in place and o pens the ai r v en t and liquid f il l ing c hannel . The des fl urane cassette has a f il ling s ys tem s imi lar to the one on the Tec 6 v aporizer (F ig. 6.17). The liquid lev el i ndicator and the f il l ing port are located on the front. The c ass ette holds up to 250 mL when f ul l. W hen the ba ll in the s ight tube is a t the bottom, the cassette c ontains 80 mL or less . The l iq uid l ev el may also be displayed on the machi ne. W hen onl y 10% of li quid remains in the c ass ette, a n a larm message appears . The internal c ons truc ti on is shown i n Fi gure 6 .18 . Fresh gas ente rs the v apo rizer and is spl i t between the bypass flo w that is i n the machine a nd th e v aporizin g

chamber. S ens ors in the v apo ri zing chamb er outlet and b ypas s moni tor the f lo w through eac h. W icks i n the v aporiz ing c hambe r inc rease the surfac e are a. A chec k v alv e in th e inlet to the v apori zing c hamb er protec ts agains t agent back flow in to the bypass . The f lo w at the ou tl et of the v aporizing c hambe r is c ontrol led by the central process ing uni t (CPU) i n the anes thes ia mach ine. This receiv es i nforma tion, i ncl uding the fresh gas c ompos iti on, anes thetic a gent, di al s etting, tempe rature in the rea r of the cas sette , and flow. This information is used to determine the ra tio of gas fl ow through the by pass an d the v aporiz ing c hambe r. A mix in g c hambe r s tabi l iz es the outp ut an d reduces the effec ts of back press ure f luc tuatio ns . Ins ide the v apo ri zing c hamber, me tal pl ates inc rease hea t capaci ty , heat conduc tiv i ty , and v aporiz ing s urfac e, all of wh ic h i mprov e temperature s tab il ity and v aporization. When cas sette temperature dec reases to less than 18C, a fan belo w i t is ac tiv a ted to fac il i tate hea t trans fer to the v apo ri zer. W hen the cas sette is remov ed, two s pring-lo aded v alv es automatic ally c los e the channe ls to and from the v aporiz er. When th e c ass ette is inse rted in to the machine , these v alv es open to make the connec tions wi th the infl ow and outflow c hanne ls. In erro r s i tua ti ons , th e P .138 v alv es operate to c ut off anes the tic agen t del iv ery. A pressu re relief v alv e opens to the scav enging l ine if a high press ure is detec ted in the casse tte or the l iquid lev el meas uri ng dev ice detec ts ov e rf il l ing.

Figure 6.15 Aladin cassette vaporizer. The handle is used to transport the vaporizer, which can be held in any position. Inside the handle is a release that when squeezed will release the cassette from the machine. The cassette is color coded for the agent contained.

View Figure

If the c ass ette pressu re is higher than the pre ssure dis tal to the cassette outflow, the v apo ri zer s ta rts to work as an in jec to r. A lock ing mechanism holds th e c ass ette in the slot on the mach ine. The connec ti on i s automatic when the casse tte is pus hed into pos i ti on . The c as sette is unloc ked by squeezing the handle. The c ontrol dial (F ig. 6.13) is turned to s et the concentration. The setting is displayed on the a nes thes ia mac hine sc reen (Fig . 6.14). Durin g fill ing, the cas sette mus t be on a level s urfac e o r in i ts s lo t withou t being l ock ed. Th e k eyed fi ller is sc rewed f irmly o nto the bottle and then inse rted in to the f il ling po rt. The f ill er is loc ked in place by tu rning the lock -and-f il l wheel on the left full y cloc k wi se (Fi g. 6 .15 ). There wi l l be a sl ight resis tance whe n the fil ling po rt is opened. The bottle is turned ups ide down. Liquid s hould th en flow in to the cas sette. W hen the v apori zer is f ill ed, the bottl e is rotated downward and the ke yed fi l le r released by turning the lock -and-fi ll wheel coun tercl ock wis e. The f i ll er is then remov ed f rom the fi lling port.

Figure 6.16 Back of Aladin cassette vaporizer. A magnetic identification system is used by the anesthesia machine to determine which cassette is in place.

View Figure

Figure 6.17 Aladin cassette vaporizer for desflurane.

View Figure

Evaluation
The man ufac ture r indic ates th at th e accu rac y for a ll agen ts is 10% of the setting or 3% o f the max imu m dial s etting (wh ic hev e r is greater) wi th fres h g as fl ows f rom 200 mL/minute to 8 L/mi nu te. Figure 6.19 sh ows v aria ti ons in output with changes i n f resh gas c ompos itio n. One s tudy found tha t the output remai ned wi thi n 10% of the dial concen trati on wi th mos t c ommonly used fres h g as fl ows (40). Desfl ura ne v aporizer acc uracy was s li ghtly l ess and accu rac y with al l anes th etics d ec reased at the ex tremes of f res h g as fl ow. T he effec ts of s udden changes in f resh gas f lo w o r ca rrier gas compos i tion , back p res sure, an d ti pping were minimal . If the temperature falls below 20 C or the fresh gas f low is ov er 8 L/mi nu te, the v aporizer may be unable to produc e high c onc entrations and the mess ages ins uffic ient agent and d ec reas ed flow wil l appear on the mac hine. The deliv e red c oncentratio n wi l l inc rease wi th a dec reas e i n ambient press ure. Inacc ura te ou tpu t may occ ur briefl y if the temperature of the l iquid agent added to the cas sette is cons id era bly lower tha n the no rmal operating temperature .

Hazards
The c asse tte is fitted with an ov erfil l protec tion mechanis m. If a ir is al lo wed in to the agent bo ttle , this mec hanis m is deac tiv ated. Th is may resu lt in ov e rf ill ing and anes thetic ov erdose . Turni ng the v apo ri zer ON whi l e f ill ing ma y pre ssuri ze the c ass ette and cause l iqu id to leak a t the f ill ing port.

P .139

Figure 6.18 Diagram of Aladin cassette vaporizer. (See text for details.)

View Figure

W hen the fresh gas fl ow is lowered, the on e-wa y v alv e that prev ents backf low of sa turated v apor from th e c ass ette to ward the bypass channe l may fa il to cl ose , resul ting in high del iv ered conc entrations (41). This problem may b e mo re s ignif ic ant wh en desf lurane is us ed.

Maintenance
The c asse tte surface can be c leaned wi th a c loth mois tened in a mild s oap s oluti on . The c asse tte should be emp ti ed before send ing i t to a s erv ic e c enter.

Vapor 19.1, 19.3

The V apor 19 .1 v aporizors are des ign ed fo r hal othane , is oflurane , s ev oflurane , and enfl ura ne.

Construction
The V apor 19 .1 is shown i n Fi gure 6 .20 . The 0 must be depress ed before the conc en tration dial can be turned. A fi l li ng sp out, s ight glass , and drain are loc ated at the bo ttom. The V apor 19 .1 is shown s chema ticall y in Fi gure 6.21. In the OFF pos ition, the v aporizing c hamber inlet and outle t are interc onnec ted and v ented to the outs ide. This prev ents anes thetic agent from leak ing into the f resh gas . Fresh gas passes

di rec tly through the inlet port and ON-OF F s witch to the ou tlet po rt wi thout enteri ng the in terio r of the v apori ze r (42 ). In the ON posi tion, at d ial settings abov e 0.2%, inco ming g as is div e rted pas t the bypass c one to the l ower v aporizing s ec tion. P art of the f res h gas flows through a press ure c ompens ator that is designed to prev ent P .140 press ure f luc tuations ups tream o r down s tream of the v aporize r from affec ting the outpu t. Pa rt of the f resh gas then f lows to th e v aporizing chamber, where i t becomes sa turated. The gas that passes through the v aporizing c hamber ex i ts past a c on trol c one that is contro ll ed by the concentra ti on dial . As the c onc entrati on is i nc reas ed or dec reased, the s pace be twe en the c one and i ts hous ing inc reas es or dec reas es , allo wing more or l ess gas -c ontaining age nt to leav e the v aporiz in g chamber. The gas not f lo win g to the v apori zing chambe r is routed pas t the bypass cone, wh ere i t mix es wi th gas f ro m the v apori zi ng c hamber and flows to the v aporizer output. The b ras s s hell around the bypass c one contrac ts and ex pands wi th c hanges in temperature . If the v aporizing c hamber c ools , the s hell wil l co ntrac t and the bypass c one wi ll mov e upward, reduc ing the f lo w through the byp ass and i nc reas ing the flow through the v apori zing chamb er (42A ,43).

Figure 6.19 Output of Aladin cassette vaporizer with changes in fresh gas composition. The electronic control unit in the machine makes adjustments for changes in fresh gas composition to maintain a steady output.

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Figure 6.20 Vapor 19.1 vaporizer. (Courtesy of North American Drager.)

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The 19.3 v e rs ion of this v aporize r is s imila r to the 19.1 but h as a mountin g adapter that wi l l attac h to a pl ug-in sys tem. This is a qu ic k releas e dev ice si milar to, but no t i nte rc hangeabl e with, the Selec t-a-tec moun ting sys tem.

Evaluation
The man ufac ture r's data for the Vap or 19.1 are s hown i n Fig ure 6.22 . Outp ut is i ndependent of f resh gas flo w i n the range of 0.3 to 15 L/min ute wi th l ower d ia l se ttin gs , but P .141 wi th hi gh gas f lows output fal ls . An ac curacy of 10% can be ex pec ted betwee n 10C and 40C. A t temperatures outsi de th is range , th e v apori zer wi ll be less ac curate . Inv es tigatio ns of V apor 19 .1 v aporize rs for is oflu rane, enflurane, sev oflu ran e, and halo thane with hi gh and low fl ows f ound that they pe rf orm ac curate ly (44,45).

Figure 6.21 Vapor 19.1 vaporizer in the ON position. (See text for details.) (Redrawn from a drawing furnished by North American Drager.)

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The V apor 19 .1 is cal ib rated by us in g a ir as the ca rrie r gas . Wi th 100% oxygen, the deliv ered concentration is 4% to 10% higher than the s et conc entrati on (44 ,46). W hen opera ted wi th 30% ox yge n and 70% nitrous ox ide , the d el iv e red conc en tration is 5% to 10% lo wer. Chang ing f ro m 66 % ni trous oxi de in ox ygen to 100% ox yge n results in an inc reas e in ou tpu t fo ll owed by a dec rease (47). If helium i s in the c arri er gas , the output d oes no t v ary by more than 10% (48,49). W hen the v apori zer was exposed to pressures up to 4 a tm, the output dec reas ed wi th i nc reas ing p res sure but remained wi thin 20% of s etti ng (50 ). Moun ting the v apo ri zer o n a mov ing troll ey or rev ers ed flow th rough it has no effec t on ou tpu t (20,51). The V apor 19 .1 wi th a ke yed fil le r wil l no t ov e rfil l , ev en wh en the v apori zer is in the ON pos i tion a nd the b ottl e adaptor is loosen ed (52 ).

Hazards
If a filled Vap or 19.1 is tilted, l iquid agen t may spi l l in to the con trol dev ice whether the v apo ri zer is turn ed ON or OFF. This can resu lt in ei th er an inc rease o r dec reas e i n del iv ered c onc entration. If the v apori zer is tipped mo re than 45, i t shoul d be fl ushed with a fl ow of 10 L/minute wi th the concen tration dial at the highes t se tting for a t leas t 20 minutes . A cas e has been repo rted where a rubber f ragme nt obs truc ted the liqu id lev el i ndicator (53). This gav e the appearanc e of a liquid lev el although th e v apori zer was emp ty.

W hen this v apori zer is equ ipped with a keye d fi lli ng dev ice, a meta l plug is us ed to seal the fill ing port (F ig. 6.62). There is also a v ent on the top of the f il ler bloc k . If the v ent is no t cl osed o r the p lug is not s ecurel y placed in the k ey fi l ler, there wil l be a s ignif icant gas l eak when the v apo ri zer i s tu rne d ON. Unl ik e s ome oth er v aporizers that f i ll below the l iq uid l ev el, the re wi ll not be an es cape of liquid anes thetic .

Maintenance
The oute r part of the v apori ze r can be c leaned with a damp c loth s oak ed with detergen t. The manuf ac turer recommends th at the halothane v aporizer be rins ed wi th f res h halothane when the liquid in the s ight gl ass s hows disco lo ration or partic les . The v aporizer shoul d be ins pec ted b y trained pers onnel ev ery 6 mon ths . The v aporizing c hamber should be c leaned and the wic ks changed ev ery 2 y ears .

Vapor 2000
The V apor 2000 is des igned f or isof lurane, sev oflu ran e, ha lothane, an d enflurane .

Construction
Vapor 200 0 v apo ri zers are s hown i n Fi gu res 6.23 and 6 .24. The 0 button on the handwhe el (contro l dial ) mus t be d epressed to turn the v apo rizer ON. To the rig ht of the P .142 OFF pos iti on is the T (tran sport) pos i tion . This is us ed when the v apori ze r is to be remov ed f rom the anes th esia machine. When the h andwh eel is tu rned to th is position, the button loc ks in p lace.

Figure 6.22 Output of Vapor 19.1 vaporizers at an ambient temperature of 22C. (Redrawn from graphs furnished by North American Drager.)

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An ada pter at the bac k of th e v apo ri zer has hol es that match pi ns on the anes thes ia machine. The v aporiz er is secu red /release d by turni ng th e loc king lev er at the top. A pin on the lock ing lev e r mus t engage a g roov e in the top of th e handwh eel to release the v apo ri zer. This c an be done only whe n the handwhe el is at the T se ttin g. The re are two i nte rlock s ys tems to prev ent more than one v apori ze r being tu rned ON at the same time. For s ys tems in whi ch the v apo ri zer is eas il y remov able , there i s a s lide lev er tha t c auses a shaft to engage a hole in the P .143 unused v aporizer handwheel that then ca nnot be us ed (Figs . 6.23, 6.24). For permane ntl y moun ted v aporizers , there is a roc ker-s tyle l ev er tha t engages a groov e i n the back of the handwhe el . If one end is in this g roov e, the handwheel cannot b e rotated and the v apo ri zer c annot be us ed (see F igs . 6.77, 6 .78).

Figure 6.23 Vapor 2000 vaporizers. The left vaporizer has a funnel filler. The right vaporizer has a keyed filling system. Note the locking levers at the top. An interlock mechanism is between the two vaporizers at the top. The lever is turned toward the vaporizer in use.

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Figure 6.24 View of Vapor 2000 vaporizers from the top. The 0 button on the handwheel (control dial) must be depressed to turn the vaporizer ON or to put it into the transport position. To the right of this is the T (transport) mark. When the handwheel is turned to this position (left vaporizer), the lever at the back of the vaporizer fits into the groove on the top of the dial so that the dial cannot be moved. The vaporizer can then be removed.

Three diff erent f ill ing s ys tems are av ailable. A s impl e fun nel is av ailabl e (F ig. 6.23, l eft v apo ri zer). There is also a keyed fi l li ng dev ic e s imi lar to that av ai lable on other v aporizers (Fig . 6.23, right v aporizer). S ev oflurane v aporiz ers may hav e a Quik -Fil s ys tem. A drain is loc ated unde r the v aporizer. The Quik -Fil sys tem has a drain under the fi l ler. The d rain v alv e is opened by inserti ng a 2.5-mm Al len k ey and turn ing i t c ounterc lock wi se. The Quik -Fil s ys tem is dis cuss ed la ter in this c hapter (s ee Fi gs . 6 .66 ,6 .68 ,6.69) The internal v aporiz er co ns truc tion is shown in Figures 6.25, 6.26, and 6.27. W he n the v apo ri zer is turn ed OFF (Fi g. 6.25 ), the inflowi ng gas passes through two

bypass es . P art of the g as fl ows around the f lo w c ontrol cone . Two is olation v alv es (A an d B ) s eparate the v apo ri zing chamb er f rom the bypass gas s tream. The v aporizing c hamber is v ente d to the o utside through iso lation v alv e A to prev ent press ure buildup , th us prev enting a v apo r surge when the v apori ze r is turned ON. W hen the hand wheel is turned to the trans port pos ition (Fi g. 6 .26 ), iso lation v alv es A and B s eal the v ent c hannel as wel l as both c hann els to th e v aporizing chamber. Ano the r is ol ation v alv e (C) seals the bypass c hannel around the concen trati on cone. W hen the hand wheel is turned ON and s et to a concentra ti on greater than 0.2% (Fig . 6.27), is olation v alv e C cl oses one byp ass and iso la tion v alv es A and B are opened, allowi ng a s tream of gas to pass through the v apo ri zing chamber. The v ent i s clos ed . The s tream of gas that passes through the v aporizing c hamber bypass passes the temperatu re-co mpensa ti on mech anism. As the v apori ze r c ools, the bypass c hann el is narrowe d and more gas pass es th rough the v aporiz ing chambe r. The remainde r of the gas passes through the v apori zing c hamber. An elonga ted channe l to the v apori zing c hamber P .144 reduc es the pumping effec t. T he v apo r-saturated c arri er gas then passes through the is ola ti on v alv e a nd pas t the flo w c ontrol cone , where it joins the bypass gas and f lows to th e v apori zer ou tlet.

Figure 6.25 Vapor 2000 vaporizer in OFF position. (Redrawn from graphs furnished by Drager Medical.)

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Evaluation

The performance da ta suppl ied by the man ufac tu rer are i ll us trated in Figures 6.28 to 6 .31 . Some v ari ati on in v apo ri zer output oc curs , mos tl y at higher settings , highe r f lows , and temperature ex tremes . W hi le the v apo ri zer c an compensa te f or cooling that oc curs as th e v apo ri zer is use d, af te r a certain runni ng time, the v aporize r s tabi l iz es at a s l ightly lower tempe rature and deliv ers c onc entrati ons that dev iate s lightly f rom the set v alue. Al ti tude ch anges b etween 700 and 1100 mbar wil l cause only mi nor dev iations in output. The V apor 2000 is c ali brated by usi ng ai r. One hund red pe rc ent ox yge n wi l l cause an i nc reas e i n th e output by a max imum of 1 0% bu t no more than 0.4 v ol % (Fig . 6.32). A 30:70 ratio of ox ygen an d n itrous ox ide wi ll lowe r th e o utput by the s ame amou nt.

Hazards
The v aporizer mus t be uprig ht and s ecured whi l e being fi lled . Ov erfi lling c an occur i f th e v aporizer is til ted du ring fil li ng . If this happ ens , the v aporiz er may de liv er conc en trations tha t are too high or too lo w. If the v aporizer is ti lted more than 30, anes thetic agent may escape into the f resh gas , caus ing a h igh c onc entration to be deliv ered. The outp ut is not defined i n the area betwee n 0 % and 0 .2%. T he hand wheel should not be s et i n th is area. The v aporizer shoul d not be lef t in the ON pos i tion wi th n o gas flow th rou gh it, becaus e a gent ma y accu mulate i n the anes thes ia mac hin e. Leakag e i n the k eyed f i ll ing sys tem has been reported (54,55). This was though t to be the res ul t of us ing ov ers i zed f ill ing ad aptors that damaged the s ealing co mponen t or ex ces s iv e pressu re on the fi lli ng dev ice l ev er that brought the lev er mechanism out o f alignment. W hen this problem occ urs , there is a s trong s mell of agent near the v apo ri zer and red uced o r no output f rom the v apori ze r. This problem may be co rrec ted on more rec ent v e rs ions of the v apo ri zer. P .145

Figure 6.26 Vapor 2000 vaporizer in transport position. (Redrawn courtesy of Drager Medical.)

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Figure 6.27 Vapor 2000 vaporizer in ON position. (Redrawn courtesy of Drager Medical.)

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P .146

Figure 6.28 Performance of halothane Vapor 2000 vaporizer. (Redrawn from graphs furnished by Drager Medical.)

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P .147

Figure 6.29 Performance of enflurane Vapor 2000 vaporizer. (Redrawn from graphs furnished by Drager Medical.)

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If the c onnec tion be twe en the f il lin g adapter a nd the agent bottle is not le ak ti ght, the v apo ri zer c an be ov e rfil led and anes thetic agent v apor can esc ape. If flow th rou gh the v aporizer is rev ers ed, the de liv ered concen tration wi ll be i ncorrec t and often too high.

Maintenance
The ex te rna l parts of the v aporizer can be wip ed with a dis posable c lo th s oaked wi th c l eaning s ol uti on . Halogen -releas ing co mpounds , s trong organic ac ids , and ox ygen -releas ing c ompounds are no t s ui tabl e. P .148

Figure 6.30 Performance of isoflurane Vapor 2000 vaporizer. (Redrawn from graphs furnished by Drager Medical.)

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P .149

Figure 6.31 Performance of sevoflurane Vapor 2000 vaporizer. (Redrawn from graphs furnished by Drager Medical.)

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The v aporizer shoul d be ins pec ted ev ery 6 mon ths by train ed serv ice pers onnel . The c alibration s hould be checked we ekl y if the conce ntration is not c ontinuously moni tored.

Drager D-Vapor
The Drage r D-Va por is onl y for desf lurane.

Construction
The D-Vapo r is s hown i n Figu re 6.33. The power c able is c onnec ted to the v aporizer at the rear. The con trol dial on the top is used to s witch the v apo ri zer ON or OF F, put i t in the transpo rt posi ti on, and adj us t the deliv e red agent conc en tration . P ush ing the 0 button on the f ro nt of the dial a llows the di al to be rota ted . The c ontrol d ial locks in the ze ro (0) and tra nspo rt (T ) pos itions . The c oncentration range is 2% to 18 %. Concentratio ns higher than 1 2% a re sho wn i n inv erted order. The 0 button on the c ontro l dial mus t be depres sed to a llow ac cess to th is hi gh co ncen tration range . W hen the v apori zer mus t be remov ed from the anesthes ia machine , the 0 button i s depress ed, and the c oncentratio n d ia l is mov ed to the T posi tion . This allo ws the v apo ri zer to be trans ported in any posi tion. A lock ing lev er at the rear of the v aporizer is used to d is enga ge the v aporizer f rom its moun ting. The D-Vapo r fi lling s ys te m (Saf -T-Fi l S ys tem) (Fi g. 6.33) i s l ocated on the front of the v apo ri zer. A sea ling plug cl oses the fil ling s ys tem when the v apo ri zer i s not P .150 being f il led. To f ill the v aporize r, the button on the ri ght s ide of the v aporizer is depressed to allow the seal ing pl ug to be remov ed. The desf lurane bottle is i nserted into th e fi lli ng mecha nism. W hen i t is l ock ed in p lac e, an audible c lick is heard. P ressing th e bottle downwa rd wi ll allow th e agent to fil l the v apori zer. W hen the v apo ri zer is full , the bottl e re trac ts , s top pi ng the agent f low. A f te r wai ti ng 2 to 3 seconds to al lo w a ll of th e agent to enter the v apori ze r, the button is depressed to release the bottle from the f ill in g dev ice. The s ealing cap is pressed into th e fi ller unti l i t locks i n place, as determined by an a udibl e c lick .

Figure 6.32 Effect of carrier gas composition on output of the halothane Vapor 2000 vaporizer. (Redrawn from graphs furnished by Drager Medical.)

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The agent-lev el indicator i s at the front on the righ t side. There a re three h ori zontal l ines . The top line ind ic ates tha t the v aporizer is full . The second l ine, whic h is near the bottom, ind ica tes when one comple te bo ttle of desfl ura ne (24 0 mL ) wil l be needed to f i ll the v aporizer. The bottom line i nd ic ates tha t there are onl y 30 mL of agent remaini ng in the v apori zer. The v apori zer has a c apac ity of 300 mL . The D-Vapo r can be f ill ed when the dev ice is s wi tc hed OFF (no power to th e v aporizer), during the heating phase , or duri ng operation. If fil led duri ng ope ration, the fill ing proces s wil l be slowe r. The disp la y and al arm i ndicators a re l ocated on the front of the v apo ri zer to the l eft. Fo r a high p ri ority alarm, there is a red flash in g LE D accompanied by two groups of fiv e tones , eac h e mitted for 10 s econds . For a medi um pri ority alarm, there is an ambe r flash ing LED and one group of three tones emi tted ev ery 25 seconds . The indica tion alarm is a c ontin uous ly glowi ng ambe r LE D with a si ngle tone ev e ry 1 to 2 seconds . The re is a b utton an d LE D a t the top and f ive LEDs below. P ushing the butto n audi o pauses (s i lences ) the a larms fo r 2 minu tes and caus es the a mber LE D to il lumina te . The s ec ond LED is green and i ndica tes that the v aporizer is ope rational . The third LE D is red an d ind ica tes no outpu t. The fourth LED is a mber an d ind ic ates warm up. Th e fi fth LE D is ambe r and i ndicates that the v aporize r needs to be refil le d (Fi ll UP ). The bo ttom LE D is amb er and indicates Battery. In the ev ent of a mai ns power fa il ure, i t wi ll b link . If i t gl ows continuall y, the ba ttery s hou ld be

change d. If the re is an appa ratus f aul t, a ll of the LE Ds bl ink . The reader is referred to the us er manual for fu rther deta ils . If no powe r is suppl ied to the v apo rizer, there wi l l be no illumi nated LE Ds . When power i s s uppl ied to the v aporize r, a se lf -tes t is au toma tical ly performed. A ll s ix LE Ds s houl d ligh t, and an audible al arm si gnal sounds . Duri ng the 5-minute heati ng phase, the green operation LE D flas hes . When the h eating phase is compl ete, this LE D glows continuous ly, and an aud ible s ignal is e mi tted. P .151 The v aporizer is the n read y for use. T he v apo ri zer mus t be s et to 0 at l eas t ev ery 24 ho urs for a to ta l of 5 seconds . This wi ll i ni tiate a self-tes t.

Figure 6.33 Drager D-Vapor. (Courtesy of Drager Medical.)

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The D-Vapo r has i ts own battery back up. If the batte ry is not suff ic iently c harged, the amber LE D g lows . The backup battery wil l las t onl y 5 minutes . After 5 minutes, the v apo ri zer is s wi tched OFF, and an alarm s ounds . If power i s res tore d i n less than 5 minutes, there wi l l be no interruptio n in outpu t. The internal c ons truc ti on is shown i n Fi gure 6 .34 . The res erv oi r c ontain in g the l iquid desflurane is hea ted to 40C and is at a c ons tant p res sure of 2 bar. This al lows the d esflu rane that leav es the reservoi r to b e a f ul ly sa tu rated v apor. A shutoff v alv e prev ents the res erv oi r from del iv ering v apor whe n the control d ia l is a t the zero setting, duri ng the hea ting phase, o r in the ev en t of v aporizer fai lure.

Fres h gas f rom the fl owme ters is c onduc ted through the bypass and on to the machine o utlet. There is a f low res is tance in the bypass that i nc reas es the p res sure i n the line and causes press ure to be appl ied to a di aphragm i n the regulating sens or. This sensor c aus es the proportio ni ng v alv e to deliv er as muc h sa tu rated desflurane v apor as is nec ess ary to balance the press ures b etween the f resh gas f low an d the desflurane flo w. The del iv ered des flurane concen trati on is determi ned by the re lationsh ip be tween the by pas s resis tanc es and the flow c ontrol c one, whi c h is determined b y the control d ial setting.

Evaluation
Carri er gas compos i ti on wi ll aff ect v apori zer o utput. Wi th a ir o r nitrous ox ide , th e deliv ered concentration is reduc ed in compa ris on to tha t deliv ered when the carri er gas is ox ygen. For ai r, the output is red uced approx imately 10 %. Wi th a ni trous ox ide :oxygen in a 70:30 ra tio as the c arri er gas , the output is reduced approx i matel y 20%. Vapori ze r performanc e is no t s ubs tanti al l y inf luenc ed by ambi ent tempe rature f luc tu ati ons wi thin the range of 18C to 30C. The D-Vapo r is c alibrated in v olu me p erc ent. S inc e this c al ibratio n is independe nt of ambie nt press ure , th e c ontro l dial se ttin gs need to be adjus ted hi gher at hi gher al ti tudes to ac hi ev e the s ame c onc entration. The outp ut ac curac y is related to the v olume of gas that pas ses through the v aporizer (F ig. 6.35). The des fl urane conc entra tion is accu rate fo r dial conc en tration and flows i n the s haded areas of the graph . In the uns haded a reas , the output is lo wer than the setting.

Hazards
Cellula r phones s hould n ot be us ed withi n 10 m of the v aporizer. The D-Vapo r is not des igned to be used at a n angle of more tha n 10 degrees . A t greater angles , an u ncon trolled c once ntratio n of v apor may resul t, connec tions to the v apo ri zer ma y leak , and the lev el in the s ight glas s wil l no t be c orrec t. This could lead to ov erfi l li ng.

Maintenance
Con tinuous agen t moni to ri ng is recommended . In the abs enc e of th is , a week l y check of v apor output is rec ommended. Th e manuf ac turer re qui res that the v aporizer be inspec ted and serv ic ed by s ki lled personnel a t yea rl y in terv als .

Detergents mus t not be al lowed to get under the c on trol di al o r in to the inlet for gas f low or the fil ling s ys tem. Halogen-releas in g c ompou nds , s trong organ ic ac ids , or ox ygen -releas ing c omp ounds s hou ld no t be use d to c lean the v apo ri zer.

Penlon Sigma PPV

The P enlon Sigma P P V v aporizer is designed to dispe nse halothan e, enflurane, i sof lu rane, and s ev ofl urane.

Construction
The P enlon Sigma P P V v aporizer is shown i n Figure 6 .36 . The upper pa rt of the v aporizer and c oncentratio n d ial are c olo r coded. To s et a concentra tion, the di al is pushed in and ro tated . The fil ling dev ice can be ei ther a funnel fill , Qu ik -Fil, or ke yed fil le r. The liquid lev el P .152 i ndicator has lines for the minimum and max imum l ev els . The di rec ti on of gas flow i s ma rk ed on the top.

Figure 6.34 Internal construction of Drager D-Vapor. (Redrawn courtesy of Drager Medical.)

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Inte rna l v aporize r cons truc tion is s hown i n F igu re 6.37. Gas enters the v apori ze r and is spl i t in to two s treams , one passing th rou gh th e b ypas s and the other through the v apo ri zing cha mber. In the zero lock pos i tion, the bypass re mains open, but the v aporizing c hamber is isolated. If the zero loc k port is open, gas pas ses through a sp iral tube into the v aporizing chamber, whi ch co nta ins a s tai nles s -s tee l wi ck . Gas sa turated with v ap or ex its the v aporizin g c hambe r th rou gh the v apor c ontrol orif ic e.

The s ize of th is orif ice is c ontroll ed by the conc entration di al s e tting. Gas s a turated wi th v apor then joins th e b ypas s gas and f lows to the outle t. Tempera ture compens ati on is p rov ided by a li quid-fi lled ex pans ion bellows control li ng a v ariable res is tance v alv e in the bypas s . As the v apo ri zi ng cha mber cools , the ori fice becomes s maller s o tha t a greate r proporti on of gas pas ses through the v apo ri zi ng cha mber.

Evaluation
The performance c harac teris tic s supp lied by the manufac turer are ill us tra ted in Fi gure 6.38. The v apori zer i s acc ura te at tempe ratures from 15C to 35C. A t highe r tempera tures , output is inc reased. If ni trous ox ide is in the carrier gas , the outpu t wil l be s lightl y higher. A ir or hel ium in the c arri er s tream c auses the ou tput to d rop s lightly . Inte rmi ttent b ack press ure may res ult in a smal l inc reas e in output. Rev ers ed gas flo w resul ts in inc reas ed output (20).

Hazards
If the v apori zer is trans ported wh il e filled , th e c ontrol mus t be in the zero p osi tion, and a t le as t 2 mi nutes should e laps e wi th the v apo ri zer i n a s ec ure up ri ght p osi tion before use. If the v apori ze r has be en trans ported wi th the con trol in the o pen position, i t s hould be flushed with gas at 4 L /mi nute for 2 minutes . The c oncentration d ial mus t be in the zero p osi tion du ri ng fil ling or d raining. The v aporizer mus t be uprigh t to av oid ov erfi l li ng. A v aporiz er that has been ov erf illed shoul d be withdrawn f rom use . Ov e rfil ling c an occu r if the v aporizer is turned ON and the bottle adapto r loosened (56). A h igh output wi ll then occu r when the v apo ri zer is used. P .153

Figure 6.35 The desflurane concentration is accurate for dial settings and flows in the shaded areas of the graph. In the unshaded areas, the output is lower than the setting. (Redrawn from a graph furnished by Drager Medical.)

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The k ey fi l ler port is c los ed with a block that i s shaped like the end of the ke yed f il ler. If the bl ock is not repl aced o r the s c rew n ot tigh tened, there wi ll be a gas l eak whe n the v aporizer is turned ON. Th is wi ll res ul t in l oss of the gas tha t pas ses through the v apo ri zi ng cha mber, and littl e or no v apor wi l l re ac h the breath ing s ys tem (57,58). Liquid agen t wi ll not be los t through a l oos e f i ll er bloc k .

Maintenance
The v aporizer shoul d be c al ib rated ev ery 3 to 6 mon ths , wi th a major ov erhaul ev ery 5 ye ars . The ex teri or should b e c le aned wi th a dry c loth . No li quids , incl uding water, s ho uld be appl ied to the s urfac e. The ha lo thane v apori zer should be drained periodicall y and the l iquid discarded to prevent thymol bu il dup .

Penlon Sigma Delta

The S igma Del ta v aporizer is used to dispense halothane , enf lu ran e, is ofl ura ne, and s ev oflurane.

Construction
The S igma Del ta v aporizer is s hown i n Fi gure 6 .39 . The f ron t has a co lor-c oded control d ial tha t locks i n the 0 pos i tion. T o us e the v apo ri zer, th e dia l is pushed i nward and ro tated counterc lock wi se to the desired co ncen tration . W hen the c ontro l dial is tu rned P .154

OFF, it wi l l automatic al ly s pri ng outward to the locked posi tion.

Figure 6.36 PPV Sigma vaporizer with screw cap filler and back entry connections. (Courtesy of Penlon, Ltd.)

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A t the bottom is the li quid lev el indica tor, wi th max imum and minimum lev el marks . Three different f ill ing dev ices a re av ailab le: funnel f i ll , k eyed f ill, and Quik -Fil . The ke yed fil le r util izes a plug tha t is held in pl ace by us ing a s c re w on the si de. A t the bas e of the fi ll ing mec hanism is a means of dra inage. If a keyed fi l le r is us ed, the same bo ttle adaptor that is us ed to fi l l the v apo ri zer i s used to drain i t. For the Quik -Fi l and funne l-fi ll mech anisms , a s c re w a t the b ase of the fil le r block opens th e drain. The fi l ler c ap mus t be remov ed from the v apori zer to dra in i t. The l iquid c an drain di rec tly into the bottle f or the funnel fi ll . For the Quik -Fi l, a recep tac le is s lid ov er the base of the fil ler mechanism and is used to catc h the l iquid (s ee Fi gs . 6.6 8, 6.69).

Figure 6.37 Diagram of PPV Sigma vaporizer. (See text for details.) (Redrawn from a drawing furnished by Penlon, Ltd.)

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The v aporizer has a li qui d c apacity of 250 mL. A t the MIN mark , the v olume wi ll be 35 mL. A pprox imately 60 mL of l iquid wil l remai n i n the wic k after the v apori ze r is drained. The internal c ons truc tion is sho wn i n Fi gure 6 .40. The v aporiz ing c hambe r contains a wi ck . Te mperatu re c ompens ation is by means of a thermos tat i n th e bypass . In the zero pos i tion , the bypas s rema ins o pen, but the v aporizing chamber is is olated f rom the gas flow.

Evaluation
The operating temperature range is 15C to 35C. The temperature -co mpens ati ng mechanism reac ts s lo wly to room temperature c hanges and may need a mi ni mum of 1 to 2 hours to compens ate for a c hange in room tempe rature. The v apori zer is desig ned to operate b etwe en fresh gas flows of 0 .2 and 15 L /mi nute. Graphs of P .155

P .156

P .157 v aporizer output in re la tion to f resh gas flow an d tempe rature are giv en i n Fi gures 6.41 to 6.44 .

Figure 6.38 Performances of PPV Sigma vaporizers with oxygen as the carrier gas. (Redrawn from graphs furnished by Penlon, Ltd.)

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Figure 6.39 Sigma Delta vaporizers. Left: With keyed filler. Right: With Quick-Fil. (Photo courtesy of Penlon Company UK.)

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Barometric press ure effec ts a re no t usua ll y c lin ic al ly i mportan t. A s tead y back press ure of 10 to 15 kP a (100 to 150 cm H 2 O) wi l l re duce the v aporizer output. Inte rmi ttent back press ure ma y resu lt in some c hanges in ou tpu t. T he effec t is greates t at low v apori zer s ettings and low flow ra tes . The v aporizer is c al ib rated wi th 10 0% oxyge n. Ni trous ox id e i n the c arri er gas wi l l produce a dec reas e in output. Ai r wi ll reduce the v apori zer output by a maxi mum of 5%. He lium in the fresh gas wil l resul t in low c oncen trations .

Hazards

The P enlon Sigma De lta may malf unc tion if exp osed to exc essiv ely high temperatures . This may affec t the cal ibra tion. The v apo ri zer s hould be s tored between -20C and 50C. The v aporizer control d ia l should be a t zero, and the v aporizer s hould be u prigh t during fi l li ng. If i t is not up ri ght, there is a poss ib il i ty of ov erfi l li ng. A n agent bottl e that is c racked o r a filler that is no t tightl y attac hed to the bottle or is broken s hould not be used because ov erfil ling may occur o r con taminated agent may e nte r the v aporizer. A n ov erfi ll ed v aporizer mus t be taken out of serv ice and the manufac tu rer c ons ulted. If the v apori zer is trans ported wh il e filled , th e c ontrol dial should be in the 0 position. The dia l mus t remain in the 0 pos ition for a t le as t 10 minutes af ter th e v aporizer is a ttached to the anes thesia machine. A nes thetic agen t ov erdos e can oc cur i f not enough ti me for any liqu id to d rain into the normal posi tion has elaps ed. If a v apori ze r has been trans ported wi th the con trol dial in an op en position, i t mus t be flus hed wi th a 5 L/minute flow of gas for at l eas t 1 0 minu tes before use. If a v aporizer has been ti pped or i nv erted during tra nspo rt, th e c ontro l dial mus t be s e t to max imum output and run a t 5 L/mi nute fo r 10 minutes prior to us e. This v aporize r is f low-d irec tion sens itiv e. If th e gas flow i s rev ers ed, the output wil l be i nac curate .

Maintenance
Calibra tion can be p erformed by using a suitabl e agent gas ana ly zer. If the ca li brati on is outs ide the performance l imi ts, the v apo ri zer mus t be se rv ic ed. The man ufac ture r rec ommends tha t a ma jo r ov erhau l be perfo rmed ev ery 10 years . Halothane models should hav e a major ov erhau l ev e ry 5 yea rs . The hal othane v aporizer s hould be d raine d peri odica ll y and the liqu id disca rded.

Penlon Sigma Alpha

The P enlon Sigma A lpha v apori zer is an elec trical ly powered v aporize r des igned fo r desflurane. P .158

Figure 6.40 Internal construction of Sigma Delta vaporizer. (Redrawn courtesy of Penlon Company UK.)

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Construction
The v aporizer is s hown i n Fi gure 6 .45 . The f ron t has a co ntrol dial to se t the conc en tration . The dial is locked a t 0 when not in us e. To se t a conc entration, the dial is pus hed in a nd rotated to the des ired settin g. Below th e contro l dial is a dis play sc reen . W hen the v apori zer is fi rs t turned ON, a WARM-UP mes sage a ppea rs . A fter warm-u p is comp lete, a STANDB Y message i s shown . W hen the contro l dial is turned ON, an IN US E message appears . If mai ns elec trici ty is los t, a BA T TERY IN USE mes sage a ppea rs . Agent lev el is i ndicated v ertic all y on the left s ide of the mes sage wi ndow. To the right of the message wind ow are the ON-OF F s witc h, an in-use i ndica tor, and a n alarm mute/des us ed bu tton. W hen c onnec ted to mains power, the ambe r power i ndicator to the lef t of the in-use ind ic ato r wil l be i l lumina ted . W hen the ON-OFF s wi tc h is ac tiv ated, the green in-use indic ator at the ri gh t is i lluminated and the power i ndicator ex tinguis hed. W arm-u p tak es approx imately 2 minutes . No v apor ou tpu t is possi bl e during tha t period. Af ter the warm-u p p eriod , the v apori zer s wi tches to the s tan dby mode . The ON-OFF button is presse d to s wi tc h OFF the v aporizer. If the v apori zer is s till c onnec ted to mains elec tric i ty, the amber li ght wi l l be i lluminated. P ress ing the alarm mu te/des used c ontro l in iti ates an audi o OFF s tate an d ac tiv ates the agen t c onsumpti on mecha nis m. This al lo ws the us er to q uantify the v olume of desf lurane used .

The f ill in g c apac ity at the max imum mark is 330 mL. W hen the low ag ent mess age i s dis pl ayed , the c ontents are 70 mL or l es s. A t 50 mL , agen t output is turned OFF. P .159

Figure 6.41 Performances of halothane Sigma Delta vaporizer. (Redrawn from graphs furnished by Penlon Company UK.)

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P .160

Figure 6.42 Performances of enflurane Sigma Delta vaporizer. (Redrawn from graphs furnished by Penlon Company UK.)

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P .161

Figure 6.43 Performances of isoflurane Sigma Delta vaporizer. (Redrawn from graphs furnished by Penlon Company UK.)

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P .162

Figure 6.44 Performances of sevoflurane Sigma Delta vaporizer. (Redrawn from graphs furnished by Penlon Company UK.)

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The f ill in g s ystem is at the f ront of the v aporize r near the bo ttom. To f il l the v aporizer, the fil te r cov er is l ifted and the bottle aligned wi th the fil ler rec eiv er. The bottle is ins erted un ti l i t is fully engaged. Th e fi ller l ock in g ring, wh ich is jus t below whe re th e bottl e is inse rted, is then rotated c lock wis e until i t cl icks i nto posi tion . It i s the n rotated further cl oc k wis e until it again c l ick s in to pos ition. Li qu id wi ll the n f low i nto the v aporize r until it is f illed to the lev el desi red on the LCD display or the f low of air bubbles into the bo ttle has stopped . After the v aporizer is f i ll ed, the l ock ing rin g is ro tated c ounterc lock wi se un til the bottle is releas ed. The v apori zer may be f ill ed whi le gas is flowi ng through the v apo ri zer. The v aporizer is powered by mains elec tric ity transformed down to a low v ol tage. It has a backu p battery. It has a fas t wa rm-up ti me and l ow p ower c onsumpti on . The v aporizer c an c alc ulate the amount of desf lu ran e used for eac h c ase . Fi gure 6.46 shows the i nte rna l cons truc tion. T he fi lli ng dev ic e is use d to add desflurane to the agent res e rv oir (cartri dge). A s ens or measures the l iquid lev el , whi c h is dis played on the f ron t of the v aporizer. The v apori zer may be f ill ed whi le moun ted o r off of the P .163 anes thes ia mach ine. W hen the bottle is remov ed, the agen t reserv oi r is automatic al l y s ealed and then press uri zed a bov e the v apor press ure o f desf lurane. This causes the des flurane to remai n in the li qu id s tate. Liquid des flurane is mov ed v ia a tube f rom the res erv oi r to the control p art of th e del iv ery dev ice.

Figure 6.45 Sigma Alpha vaporizer. (Courtesy of Penlon Company UK.)

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Gas f lo ws are measured in the v apori zer inlet and outle t. S enso rs can detec t ni trous ox ide in the fresh gas and calcu late th e c onc entrati ons of oxygen and ni trous ox ide. W i th no desflurane be ing deliv e red , the inlet and outle t flow s ensors wi ll prov ide simil ar f low readings . Onl y with th e addi tion of desflu rane wil l there be a difference . The desflurane concen tration is determined from the differenc e. The l iquid desf lu rane flow is measured by a li quid-fl ow sensor. The central processor calcul ates th e f low of liqu id desflurane ne eded for the s et conc entrati on and f resh gas flo w and adjus ts the p roportional v alv e to de liv er the requi red amoun t of agent. The l iquid agen t fl ows thro ugh a dev ic e that main tains a co ns tant back press ure . It is then del iv ered v ia a s hutoff (ON-OFF v alv e) into a heating dev ice whe re i t is v aporiz ed. The heating element has a feedbac k c ontrol that ens ures tha t the agen t is heated acc ord ing to the f lo w ra te and its therma l properties . This arra ngemen t means that the temperature a nd power a re c ontinu all y moni tored and adjus ted to min imi ze powe r cons umptio n. Th e v aporized agent then pas ses through to the f res h gas sup pl y. The s econ d fl ow sens or moni tors the inc rease d f low resul ting f rom the adde d v apor. In the ev ent o f a dev ice f ai lure, the s ys tem wi l l s top deliv ery of desflurane and e nter in to a s afe mode . It a ls o g enerates v isua l and audible alarm s ign als .

Evaluation

The man ufac ture r's data for output are s hown i n Fi gure 6 .47. The v aporizer i s desig ned to be used at a temperature between 15C and 30C. The ou tpu t is mai ntained wi thin 20 % of the se t c onc entra tion. The flow ra nge is 0 .5 to 12 L/minute . The max imum flow thro ugh the v apori zer is 20 L/minu te . Abov e this flow, the v apo ri zer turns OFF. The v aporizer is c al ib rated wi th pu re ox ygen . Adding ni trous oxi de to the fresh gas wi ll dec reas e the ou tpu t by up to 1 5%. A i r as th e c arri er gas wi l l re duce the output below the set v alue by a max imum of 5%.

Hazards
Exc ess iv e e lec tronic noise caus ed b y a devi ce suc h as an elec tros urgery uni t may adv ersel y interfe re wi th v aporizer func tion. To av oid this , the el ec tros urgery dev ice shoul d not be plugged i nto the same wal l s ocke t or ou tl et s trip as the v apori ze r. E lec tromagne tic in terfe renc e may occ ur if th e v aporizer is use d wi th an ex tensi on co rd. Mov ement d uring transport can resu lt in increased v apor output unless ti me is al lowed fo r the li quid to drai n i nto the norma l area. If th e v apori zer has been remov ed f rom the anes th esia machine and tra nspo rted, i t s hould be purged at 5 L/minute for 2 minutes before use. Sudden i nadv ertent mov emen t can c ause an inc reas ed output unless the v apo ri zer i s secu rel y fixed to th e anes thes ia machine and in an upright pos ition.

Maintenance
The man ufac ture r rec ommends a peri odic serv ice c heck by a manufac tu rer-tra ined engineer. A train in g c ours e is av ai la bl e for thos e wh o wis h to carry ou t routine mai ntenance.

Blease Datum
B leas e Da tum v aporizers are av ai lable fo r halothane , enf lu ran e, isof lu rane, and sev oflu ran e.

Construction
The v aporizer is s hown i n Fi gure 6 .48 . The agent-spec ific c olored l abel is on the f ron t of the v aporizer below the di al . Th e c once ntration contro l dial lock s automatic al l y in th e OF F p osi tion . To set a c onc entration, the dia l is pushed inward and rotated coun terc lock wis e. The c once ntratio n dia l should not be se t between ze ro and the P .164

f irs t s etti ng. The fi lling dev ice ca n be either a funn el fil l or a k eyed f il ler mechanism. Th e s ev oflurane v apori ze r does n ot hav e a funnel f ill bu t may hav e the Quik -Fil s ys tem (F ig . 6.48).

Figure 6.46 Internal construction of Sigma Alpha vaporizer. (Redrawn from a drawing furnished by Penlon Company UK.)

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The internal v aporiz er co ns truc tion is shown in Figures 6.49 and 6.50. Gas ente rs the v apo ri zer and is s pli t i nto two s treams , one pass ing through the bypass and the other through the v apori zing chamber. In the ze ro lock pos ition, the bypass remai ns open, bu t the v apori zi ng chamber i s c ompletely s eparated from gas f low by the c los ed zero loc k v alv e. W hen the v aporizer i s turned ON, the zero lock v alv e op ens , and g as pas ses through a s pi ra l tu be to minimi ze the effec ts of intermitte nt pos i tiv e press ure v entilation and the n into th e v apori zing chamber that contains a main and a c oi l wi ck . Gas saturated with v apo r exi ts the v aporiz ing c hamber through the v apor co ntrol v alv e. T he conc entra ti on con trol dial s etting con trols the s ize of the orifice in this v alv e. Gas satura ted wi th v apor then joins the bypass gas and fl ows on to the ou tl et. Tempera ture compens ati on is p rov ided by a mechan is m wi th i ts b ase i n the v aporizing c hamber. It is c onnec te d to a v ariable bypas s v alv e. As the v aporiz in g chamber c ools , the orific e in the v alv e bec omes sma ll er s o that a g rea ter p roporti on of gas pas ses through the v apo ri zing c hamb er.

Evaluation
The c oncentration d ial mus t be in the zero p osi tion whi l e dra ining or fi lli ng the v aporizer. T he effec t of al titude on the output is sh own in Figure 6.51. Vaporize r

outpu t in relation to dial setti ng , flow, a nd te mpera ture is s hown i n F igures 6 .52 to 6.55. Tempera ture compens ati on is i n the range of 15C to 30C. Tempe ratures outs ide of this range wi ll c ause the output to v ary. W hen the liquid lev el is below P .165 the minimum mark ing on the si gh t glass , the ou tp ut may fall .

Figure 6.47 Output of Sigma Alpha vaporizer. (Redrawn from graphs furnished by Penlon Company UK.)

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P .166

Figure 6.48 Blease Datum vaporizer with Quick-Fil system. (Photograph courtesy of Blease.)

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Barometric press ure ch anges a re no rmal ly n ot cl inic ally s ign if ic ant. A smal l i nc reas e in output c onc entration can be produced by intermi ttent back p res sure, mos t notic eabl y at low c oncentra tions and low f lo w rates . The outp ut is affec ted by the gas c ompos i tio n. The v a ri ation is unl ikely to be more than 10% of the set conc entration. The v apo ri zer is cali bra ted b y usi ng ai r. Ox ygen wi ll pro duce a sl ight inc reas e in outpu t. This eff ec t is greates t a t lo w f lo ws . Helium has negl ig ib le ef fec ts on the sev oflu rane o utput (49). Rev e rse d f low has a negligible effec t on output (59,60).

Hazards
Exc ess iv e output may oc cur if the v apori zer is mov ed suddenl y during use. The v aporizer s hould be d raine d p ri or to transport. If th e v apori zer is trans ported wi th l iquid agent, the control di al s hould be in the OFF pos ition. The v aporizer mus t then be secured in the upright pos i ti on fo r at l eas t 1 hour b efo re i t is c onnec ted to a machine. It is then f lushed wi th 4 L/minute of oxy gen fo r 2 minu tes befo re being us ed. If the v apo ri zer has been tra nspo rted wi th th e c ontro l dial i n the ON pos ition, the operator s hould contac t the manufacture r for adv ice .

If the v apori zer is ov erf illed, i t shoul d not be us ed, and the manufac ture r shou ld be contac ted for adv ice. If the v apori zer is subjec ted to ex tremes in temperature , the tempe rature co mpens ati on mec hanism may be damaged. T he tempera ture range at whi ch the v aporizer c an be s tored is -20C to 50C. Changes in atmosphe ric pressu re do not usuall y affec t the output, but a ltitud es greater than 1500 m may requi re a co rrec tio n fac tor. P roblems wi th moun ti ng th is v aporizer hav e been reported (61 ).

Maintenance
Mai ntenance inc ludes c lea ni ng the ex te ri or of the v aporizer wi th a c lean, damp c loth. Th e halothane v apori ze r should be d rained at regul ar in te rv als to p rev ent thymol bui ldup. S ince s ome agen ts turn yellow or bro wn whe n expos ed to light, this i s not in itself a re ason to change the a gent.

In-system Vaporizers
A l though in-s ys tem v apori ze rs are n ot of ten us ed in dev eloped c ountri es , thei r l ow cos t, s imp le des ign, and portab il ity hav e made them popular i n dev elo pi ng countries and in the mi li tary (62). The av aila bil i ty of anes the tic agent moni to rs has spark ed renewed interes t in thei r us e.

Characteristics of In-system Vaporizers

Of ten , th e v apori zing chamber is a s imple reserv oi r wi th a gl ass that allows the anes thes ia prov ider to determine the amount of l iqui d present. The re may or ma y not be a means of tempe rature compens ati on. Th e output depends o n the v aporizer dial s etting, f resh gas flo w, and the composi ti on and c oncentration of the gas enterin g the v aporiz er, whic h in turn depends on the patient's minu te v olume , ox ygen , and anes thetic a gent uptak e and the breathing s ys tem configuration (63,64,65). A mbi ent air is of te n used as the princ ipal ca rrie r gas. Ox ygen can be su pplied through a T-p iece tha t inc ludes a reserv oi r tube (Fig . 6.56). The inspi red oxygen conc en tration depends on oxygen fl ow, res erv oir v olume, and v enti latory v olume. The re are two way s tha t gas flo ws through a v aporizer: push through and d raw ov er (Fig . 6.56) (66). Some v apori ze rs deliv er h ig her ou tpu ts i n the push-th rou gh configuration. P .167

Figure 6.49 Internal construction of Blease Datum vaporizer in the OFF position. (Redrawn from information supplied by Blease.)

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S ignificant water c ontamin ation may oc cur after prolonge d closed -c i rc le anes thes ia (67).

Oxford Miniature Vaporizer

The re are Oxfo rd minia tu re v apori ze rs (OMV s ) fo r halothane , enf lurane, isofl urane, and s ev oflurane.

Description
The v aporizer is s hown i n Fi gure 6 .57 . On the top is a c ontrol lev er wi th a ca li brated s cale. There a re cali brated s cales for eac h agent, and onl y the agent marked on the v apori zer should be us ed. Each v apori ze r can ho ld up to 50 mL . The re are mark ings at 10 mL and 50 mL. A n a rrow ind ic ates the c o rrec t d irec ti on of f low. Rig ht-to -lef t fl ow v apori ze rs hav e 22-mm connec tors fo r attac hment to a breathi ng s ys tem. Lef t-to -righ t flow v apori ze rs hav e 23-mm c onnec tors fo r use on the anes thes ia machine between the f lowme ters and the common gas outle t or attached to the f resh gas ou tlet. The sc al e is onl y acc ura te if the ma rk ed direc ti on of fl ow i s us ed. A sealed c ompartmen t in the bas e c ontains antifreeze , whic h ac ts as a temperatu re buffer. On the top of the v apo ri zer is a con trol l ev e r with a c al ib rated sc ale that i ndicates the del iv ered c onc entration. W i th the con trol lev er in the c ounte rc loc k wi se

position, a s li ding v alv e isol ates th e v aporizi ng chamb er inle t and ou tlet. As the l ev er is rota ted c loc k wi se, the v alv e b lock ing the v apo ri zing chamb er inle t and outl et is gradual l y opened to al lo w g as to en ter tha t chamb er. The v aporizer can be fi ll ed or d rained , ev en if g as is passing through th e v apo rizer, as long as the indicator is in the OFF pos i tion . The v aporizer is fi lled by remov ing the filler c ap and pouri ng the liqui d into the v apori ze r. S inc e the top of the filler orifice is lower tha n the v aporiz ing c hamber, i t i s not possi bl e to ov e rf ill the v aporizer. P .168

Figure 6.50 Internal construction of Blease Datum vaporizer in the ON position. (Redrawn from information supplied by Blease.)

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The v aporizer is drained by inv erting the c ap that has a g roov e to f it the top of the drain s c rew. Loosening the drain s c re w wi l l al lo w l i quid to be drained from the v aporizer. A ll of th e l iqui d wil l drain out ex cep t fo r the 2 to 4 c c tha t rema in in the wi c ks .

Evaluation
The Ox ford miniature v apo ri zer has a res is tance to f lo w of les s than 1 c m H 2 O at a f low of 40 L/mi nute. It is des igned to be us ed in an up right pos i tion bu t can be til ted up to 3 0 degrees . If i t has been til ted more than this o r has bee n transported full of l iquid , 2 or 3 minutes shou ld be al lowed f or li qu id to d rai n bac k into the v apori zing chamber. The c ontrol pointe r should be a t zero during transpo rt.

The Ox ford miniature v apo ri zer is cal ibra ted a t a flow rate of 6 L/minute at 20C . The v aporizer does not hav e an ac tiv e thermocompensating mechanism, so ou tpu t i s affec ted by amb ient temperatu re ch anges (68). A plas tic c ard that is suppl ied wi th the v apori zer ind ic ates the ou tpu t v ariati on wi th temperature and fl ow rate. The v aporizer is des ign ed for c ontinuous f low rates between 3 and 8 L/mi nute o r drawov er ra tes between 4 and 10 L/minute and ambient temperatures between 18 C and 2 8C. P res sure fl uc tuations from con troll ed breathi ng hav e li ttle effec t on v aporizer output. The output is reduced at high mi nu te v olumes a nd with con tinuous ca rrier gas flow (69). Us ing a self-refi ll ing bag (Chapter 10 ) with th e Oxfo rd minia ture v apori ze r in the pus hov e r conf igurati on may c ause a highe r output than so me mec han ica l v enti lato rs (62). These v apori ze rs are not recommended f or us e wi thi n a c los ed s ys tem. Rapid anes thetic ov erdose may resul t because of thei r high effici enc y. The ir P .169 performance wi ll dete riorate wi th time because water condens es on the wic k .

Figure 6.51 Effect of altitude on output of the Blease Datum vaporizer. (Redrawn from information supplied by Blease.)

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The s ev ofl ura ne v apo ri zer ma y not be ab le to produce a high eno ugh concen tration for an i nhalatio n i nduc tion (69,70). It may be pos si bl e to us e two v apo ri zers in se ri es fo r inhalation induc tions .

Service

Agents s uch as ha lothane tha t le av e a res idue should periodic all y be drai ned and disc arded. To c lean the v aporizer, i t s hould be emptied and the inlet c los ed wi th a s topper and turned on i ts si de wi th the outle t upp er-mos t. E ther is pou red i nto the outl et, and the contro l dial is mov ed repeate dl y u ntil the mov ement is free. A fter this is acc ompl is hed, the c ontrol is turned fu lly c ounte rc loc k wi se, a nd the v aporizer i s agi tated gentl y to wa sh the wi ck s . The c ontro l is opened fully , and the ether is poured o ut of the outlet. E ther is then poured through the ou tlet. The fil le r cap and drain s c rew a re opened, and ether i s allo wed to run out through the drain s c re w. The v aporizer is lef t wi th the c on trol lev e r fu lly c lock wis e unti l all of th e e the r has ev aporated. W i th the con trol lev er full y open , dry gas is passed through the c i rc uit unti l no trac e of ether v apor c an be detected.

Filling Systems
The re are a number of di fferent f ill in g s ys tems av ailabl e at this time (Fig. 6 .58 ). Fun nel fi lling s ys tems are av ail able. Others are desi gned to al low a v apori ze r to P .170

P .171

P .172

P .173 be fil led onl y with a spec if ic agent. Some s ys tems are s pec ific to one v apori ze r manufac tu rer o r anes th etic agent. Some can be us ed wi th v apori ze rs f rom di fferent manufac tu rers .

Figure 6.52 Performances of halothane Blease Datum vaporizer. (Redrawn from information supplied by Blease.)

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Figure 6.53 Performances of enflurane Blease Datum vaporizer. (Redrawn from information supplied by Blease.)

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Figure 6.54 Performances of isoflurane Blease Datum vaporizer. (Redrawn from information supplied by Blease.)

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Figure 6.55 Performances of sevoflurane Blease Datum vaporizer. (Redrawn from information supplied by Blease.)

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The A ST M mac hi ne s tandard (5 ) rec ommends , but does no t re qui re, tha t a v aporizer des igned fo r a s ingle agent be fi tted wi th a permanentl y attached , agen tspec ific dev ic e to prev en t acc idental f il ling wi th the wro ng agen t. S ome of thes e dev ic es are c ov e red by international an d U.S . s tandards (71). In add ition to prev enti ng a v apori ze r from being fi lled wi th a wrong agent, th ese s ys tems ma y reduc e the ai r pol lution assoc ia ted wi th f ill in g and draining v aporizers .

Funnel Fill System

Vaporizer Components
The v aporizer f il l ing c omponents inc lude a funnel an d c ap. W he n the c ap is remov ed , liqu id ca n be poured in to the v apori zi ng c hamber through the funnel . W hen the fu ll lev el is reac hed , liqu id wi ll accu mula te in the f unne l, and no more l iquid wi l l enter the v apori ze r. A fu nnel -fi ll P .174 v aporizer c an be c onv e rted to an ag ent-s pec ific ke yed f il ling s ys tem b y the ad di tion of an a daptor that sc rews into the v apori ze r fi ll er (Fig. 6.59).

Figure 6.56 Systems for using an in-system vaporizer. The unidirectional valve prevents retrograde flow through the vaporizer.

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Figure 6.57 Oxford miniature vaporizer. (Courtesy of Penlon Company UK.)

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Bottle Component
A color-co ded adaptor is av ai la bl e to aid the fil ling p roc ess (Fig . 6.60). A t one end i s a c onnec tor wi th a sc rew th rea d to match the thread on the bottle (Fig. 6 .61 ) and a sk i rt that ex tends beyond the s c rew threads . It has s lots tha t match th e projec tions on th e bottle c ol la r. The adaptor f or a di fferent agen t tha n the adaptor i s intended fo r wil l no t sc rew on ei ther bec aus e of differe nt threads or bottle opening s i ze or becaus e the projec tions wi ll n ot line u p with the s lots on the adaptor.

Filling Procedure
The f ill er c ap is re mov ed by turning it c ountercl ock wis e. Agent is poured in to the f il ling po rt unti l the lev el reaches the fu ll ma rk . The lev el ma y fall s l ightly as the wi c ks abs orb the agent. The f iller cap is then s ec ure ly replace d.

Draining Procedure
To drain the v aporizer, a c ontainer is pl aced under the drain . Remov ing the f il ling cap wi l l us ually sp eed drainage . The mec hanism for open ing the drain v aries wi th the v apo ri zer. Af te r dra ining is compl ete, the drain p lug s hould be re placed and tigh tened to mi ni mize l eak s . P .175

Figure 6.58 Various filling systems for vaporizers. Left to right: Keyed fill, Quik-Fil, keyed filled, funnel fill, and keyed filled.

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Keyed Filling System

The k eyed f il l ing s ys tem has bee n used by man y manuf acturers for a v a riety o f anes thetic agents (71 ).

Vaporizer Component
The v aporizer f il ler re ceptac le (fi ll er s ock et or bloc k , v aporizer fil le r uni t, fi ll and drain s ys tem) pe rmi ts on ly the intended bo ttle adaptor to be ins erted. A v ari ety of methods a re us ed to f ix the adap tor into the v apori zer to prev ent leaks whi le the v aporizer is being fi ll ed (Figs . 6.62, 6.63). There mus t also be a means to sea l the recep tac le whe n the bo ttle ad aptor is not inse rted. A metal fil ler bloc k (plug) ma y be us ed (Fi g. 6 .62 ). T here ma y be a s ingle po rt f or bo th fil ling and dra ining or two ports , the uppe r one for fil ling and the lower o ne for draining (Figs . 6.62, 6.63). An ai r v ent may be loc ated on the v apori ze r. Th is mus t be opened prior to f illing to prev ent an ai r l ock .

Figure 6.59 Adaptor to convert a funnel fill system to an agent-specific keyed filling system. (Picture courtesy of Sharn Inc.)

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Bottle Component
Eac h bottle of liqu id anes thetic h as a color-coded col lar attached s ecurel y at the neck (Fi g. 6 .61 ). The colors a re red for haloth ane, orange fo r enf lu ran e, pu rple fo r i sof lu rane, and y el low f or sev oflurane . These c olors are also us ed on the bottle l abels . E ach co ll ar has two projec tions , o ne thick er than th e o th er, whic h are desig ned to ma te wi th co rresponding indentations on the bottle adap tor. Bottle adaptors (adap tor tubes or as sembl ies , tube adaptors , fi lle r tubes ) a re shown i n Figures 6 .64 and 6.6 5. They are also c olo r cod ed. A t one end, the adaptor has a connec tor with a s c rew thread to ma tch the thread P .176 on the bottle and a sk irt that ex ten ds beyond the sc rew threads a nd has slots that match th e projec ti ons o n the bottle co llar. At the other end is the male connec to r that f its i nto the v apori ze r fi ller rec eptac le. A sho rt leng th of p las tic tubing with two i nner tubes connec ts th e ends . The tu bing all ows the bottl e to be h el d h igher or l ower than the v apori ze r.

Figure 6.60 Bottle adaptors for vaporizers with funnel filling systems. The skirt fits over the bottle ring. The caps allow the adaptors to remain on the bottles without vapor being lost.

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Fi gure 6.65 shows a male con nec tor on the adapto r (k ey, p rob e, tube block , fil ler plug, ma le adaptor). It c ons ists of a rec tangular piec e of plas tic wi th a groov e on one s ide a nd two holes on another s urf ace . The groov e is i n d iffe ren t loc ations , dependi ng on the age nt that is to be us ed. T his p rev ents the probe f rom being i nserted into an i ncorrec t v aporizer. T he la rge r hol e is for the agen t to en ter or l eav e the v apori ze r, a nd the s ma ller hole is fo r ai r to leav e the v apori zing c hamber, prev enti ng an ai r lock f rom dev eloping. A on e-wa y bal l v alv e in the a ir l ine occludes the ai r port af ter the v aporizer is f i ll ed. This p rev ents ov erfil ling and floodi ng the ai r channe l with liquid an es thetic .

Figure 6.61 Bottle collar. The collar is color coded according to the bottle contents. It has two projections, one thicker than the other, which are designed to mate with corresponding grooves on the bottle adaptor.

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Figure 6.62 Dual-port vaporizer filler receptacle. Note the plug to prevent leaks, the vent at the top, the drain valve at the bottom, and the two retaining screws at the right. A separate vent is not present on all filling receptacles. It must be loosened to fill the vaporizer. If the plug is not reinserted and the screw tightened, the vaporizer will leak.

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Filling
To f ill a v aporize r, the cap f rom the appropri ate bo ttle is remov ed , and the bottl e adaptor is s c rewed to the bottle unti l tigh t. If the connec tion is no t ti ght, the v aporizer may be ov e rf il led or a leak may oc cur. The v aporizer should be turned OFF before proc eed ing furthe r. T he plu g, if presen t, is re mov ed. The bottle co mponen t is then inse rted wi th th e groov e matching that on the v apori ze r recep tac le . During inse rtion, the bottle should be belo w the i nle t lev el . Af te r the

f il ler block is inserted , the retaining dev ice is tightene d, an d the fil l v alv e (v en t) is opened. The bottle is the n held higher than th e filler rec eptac le s o tha t liqu id enters the v apo ri zer (Fi g. 6.63, top ). Gentle up-and -do wn mo tion may hel p to c lea r ai r bubbles and fac i li tate f ill in g. P .177

Figure 6.63 Keyed filling device with one front screw and top vent. Top: Filling the vaporizer. To fill, the plug is removed, the filler block is inserted, and the retaining screw is tightened. The vent is opened, and the bottle is tipped upward. Bottom: Draining the vaporizer. The filler block is inserted into the drain receptacle, the retaining screw is tightened, and the drain is opened. The bottle is held below the vaporizer.

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Af ter the desi red l iquid lev el has been reach ed, the fil l v alv e is cl osed , the b ottl e l owered, a nd the retain ing dev ice l oosened. The bottle adapto r is remov ed, and the plug is reinse rted and tig htened in plac e.

Draining
To drain the v aporizer, the bo ttle adaptor is attac hed to a n appropriate bottl e. In the dual -port fi ller, the botto m socket is us ed. The filler p lug is remov ed, the mal e adaptor inserted, an d the re taini ng dev ice tightened. The bottle is held below th e recep tac le (Fig . 6.63, b ottom), and the dra in (spool) v alv e is opened . Fluid d rains through one tube into the bottle, and ai r mov es upward from the bo ttle through the other tube . Af ter the v aporizer is d raine d, the dra in v alv e is c losed, the retai ni ng dev ic e loosened, an d the bo ttle adaptor remov ed. The fil ler plug should b e reinserted a nd the retain ing dev ice tigh tened.

Figure 6.64 Bottle adaptor. The bottle connector is at the left, and the male adaptor is at the right.

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Figure 6.65 Male adaptor. The groove corresponds to a projection on the vaporizer filler receptacle. The larger hole is for anesthetic agent, and the smaller hole is for air.

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Problems with Keyed Filling S ystems

If the b ottle c ollar for enf lurane or halothane is upside do wn o n the bo ttle , the bottle ad aptor for th e other age nt wi ll fi t (7 2). Liquid c an leak if the dev ice that h ol ds the k eyed c ompone nt i nto the v aporize r is not tight. Fai lure to ti ghten the adap tor on the bo ttle, a blocke d fl ui d path insi de the v aporizer, o r leakag e i n a v alv e or the ad apter can resu lt in liqu id anes thetic agent l eak ing du ring fil ling (73). V apo r can leak out if the f ill or d rain v alv e is not c losed (74).

P .178

Mi sal ignment of the fi lli ng channel a nd th e a ir c hannel be twee n the fil ler and the v aporizer wi ll make it d ifficu lt to fi l l the v apo ri zer. Other problems that wi ll make i t diff icul t to f i ll the v aporizer i nc lude the adap tor not se al ing a t th e bottl e end or a l eak in the adaptor (73). If the b ottle d oes no t hav e a ke yed c ollar or the f il ler tube is l os t, f il l ing is awk ward (75). W i th some fi lling dev ic es , up to 27 mL of l iq uid agent may be lef t i n the bo ttle af te r the v apori zer is fi l led (76,77,78). The res idual l iqu id c an be poured in to a bottle of the sa me a gent (79 ). Some prac ti tione rs turn the v apori zer ON an d l oosen the bottle adap tor to speed f il ling . One of thes e ma neuv ers alon e wi l l not c aus e the v aporizer to ov erfill , but both to gether may a llow ov e rfil ling to occ ur (5 2,5 6,80). Inc orrec tly manufac tured sc rew thre ads on the bottle nec ks may resul t in leak s with ov erfil li ng (81). If the b ottle lac ks a keyed c ol la r, i t is necessary to d ev el op a s peci al techn iq ue to f il l the v apo ri zer (75).

Quik-Fil System
The Quik -Fi l sys tem is onl y use d for s ev oflura ne. It is s een in F igures 6 .39 , 6.48, 6.58, a nd 6.66.

Vaporizer Component
The v aporizer f il ler has a sc rew-on ca p. The fil ler neck has three g roov es that c an ac cept onl y a s peci al fi ll er dev ice, whic h c omes attac hed to the bottle (Fi g. 6.66).

Bottle Component
The bottle has a permanently attach ed, a gent-s pec if ic fil ling d ev ice that has three ridges th at f it into s lots in the f i ll er. A v alv e prev ents l iquid f rom draining when the bottle is inv erted bu t not ins erted into the vapori ze r (Fi g. 6 .67).

Figure 6.66 Vaporizer filler block for Quik-Fil system. Note the three indentations, which allow only a bottle with the correct fitting to the inserted.

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Figure 6.67 Bottle inserted into the filler block. Note the projections on the bottle that fit into the indentations on the filler block.

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Filling
To f ill the v apo ri zer, the fi l ler c ap and the bottle c ap a re re mov ed. The bottle is i nserted s o that the pro jec tions fi t in to the corres ponding g roov es in the f ill er nec k (Fig . 6.67). The bottle is pushed in to the v apo ri zer c omponent as far as i t wi ll go and h eld firml y in place . This wil l op en a v alv e and al low li qui d agent to fl ow i nto the v apo ri zer. Af te r fill ing, the bottle is remov ed, and th e fi ller c ap and bottle cap are rep lac ed. P .179

Figure 6.68 Drain attachment fitted to the filler block. The filler cap should be removed. Note the tool for opening and closing the drain plug.

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Draining
To empty th e v apo ri zer, the fi ller c ap is remov ed from the v aporize r. T he dra in attachmen t is fitted to the bottom of the bloc k (Fig. 6.68). The bottle is then i nserted into th e d rai n attachmen t (Fig. 6 .69 ). T he dra in plug is unsc rewe d by using the too l attached to the f ill er ca p. Fluid wil l f low f rom the v apo ri zer. Af ter d raining, the dra in plug is tightened, and the fil le r cap is rep lac ed and tighte ned.

Easy-Fil System
The E asy-Fi l s ys tem is us ed on all f our T ec 7 v apo ri zers .

Vaporizer Component
The v aporizer co mponent (b lock ) (Fig. 6.70) h as a cap wi th a tool that is used to open and c lose the drain o n the end that is i nserted into th e v apo ri zer. Insi de th e f il ler cha nnel are two keys (ri dges ) that f it gro ov es o n the bo ttle adapter.

Bottle Component
The bottle adaptor (Fi g. 6.71) a ttaches to the bottle by al ig ni ng the no tc hes wi th the projec tions on th e bottle c ol la r. The adaptor h as groov es tha t mus t be aligned with the pro jec ti ons o n the v aporizer.

Figure 6.69 Draining the vaporizer.

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Filling
To f ill the v apo ri zer, the bottle ada pto r is attac hed s ecu rel y to the bottle, and th e f il ler cap on the v apori ze r is remov ed. Th e b ottl e nozz le is i ns erted into the fil le r block , al igning the adaptor groov es wi th proj ec tions in the fil ler block . W hen the bottle is full y ins erted , liqui d wi ll f low into th e v aporizer. W hen the v apo ri zer i s fu ll or the bottle empty, the bo ttle is rel eased and then remov ed f rom the v apori ze r f il ler. T he fi ller c ap is repl ac ed, and the ca p i s repl aced on the agent bo ttle . The f il ler cap is tightened to minimize l eaks .

Draining
To drain, the cap is remov ed from the v aporiz er fil ler. A su itable con taine r is plac ed under the drain no zzle. The drain plug is u nsc rewe d b y us ing the tool attac hed to the filler c ap. Liquid s houl d th en flow in to the c ontainer. Af ter draining , the d rain plug is tightened , and the fil le r cap is replac ed and tighte ned. P .180

Figure 6.70 Easy-Fil system on a vaporizer. The inside of the cap fits into the screwlike attachment above the drain port at the bottom. (Courtesy of Datex-Ohmeda.)

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Desflurane Filling Systems

Fi lli ng s ys tems f or v aporizers used wi th desflurane are different f rom other fi lling s ys tems . A l l us e the sa me b ottle to fi l l the vapo ri zer. This bottle has a c ri mped-on adaptor (F ig. 6.7 2). The bottle ada pto r has a s p ring-loaded v alv e that opens when the bottl e is pushe d i nto the f il l ing port on the v aporiz er.

Figure 6.71 Bottle adaptors for the East-Fil system. (Courtesy of Datex-Ohmeda.)

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Figure 6.72 Bottle for desflurane. The protection cap has been removed and is at the right. (Courtesy of Ohmeda, a division of BOC Health Care, Inc.)

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To f ill the Tec 6 v apori ze r, the bottl e protection c ap is remov ed, an d the bottle is f itte d to the f iller po rt and pushed up aga ins t the spring. Af ter the bo ttle is fu ll y engaged in the p ort, i t is rotated upward (Fi g. 6 .73 ). T he bottle is held i n this position whi le f ill ing . W hen the liqui d lev el g auge indic a tes that the s ump is full or whe n the P .181 bottle is empty, the bottle is rotate d down wa rd and remov ed from the v aporize r. The v alv e on the bottl e c loses automatically to prev ent agen t spi l l. The fi l li ng port has a s pri ng v alv e to prev ent agen t from escaping.

Figure 6.73 Filling Tec 6 vaporizer. The bottle is fitted to the filler port. After it is engaged in the filler port, it is rotated upward. When it reaches the upper stop, agent will enter the vaporizer. (Courtesy of Ohmeda, a division of BOC Health Care, Inc.)

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P roblems wi th these f ill ing s ys tems hav e been reported. Bottles c ontaining desflurane that do not hav e the c ap properly i n place c an leak agent (82,83). If the O ri ng on the bottle is damaged or miss ing , age nt may leak duri ng fi lling (84,85,86).

Vaporizer Mounting Systems Permanent Mounting

Permanent moun ting means that too ls are requi red to remov e or i ns tall a v apo ri zer on the anes thesi a mac hine. Adv an ta ges of this s ys tem inc lude l ess ph ysical dama ge to v aporizers and fewe r le aks . Vapori zers are al way s filled i n the v e rtic al position. The re are pro blems with permanent mounting. Th e machi ne may not hav e enough moun ting l ocations to accommodate a ll of th e v apo rizers that are l ikel y to be needed. A malfunc tioning v aporize r c annot easi ly be ex changed, especi al ly whi le anes thes ia is being admi nis te red .

Detachable Mounting
Detach able mounting sys tems are s tanda rd on mos t new anes thes ia machi nes . The y allow the v apo ri zer to be moun ted and remov ed without the use of tools . T he Selec t-a-tec s ys tem and a s imi lar s ys tem f rom Drager Medic al are wid ely used. Vapori ze rs cannot b e exchanged between th ese two s ystems . S ome other anes thes ia mach ine man ufac ture rs us e thes e mounting s ys tems as wel l . Some

v aporizers f rom other manufac ture rs are equipped with mounting sys tems that a re co mpatible wi th one of these s ys te ms . The S elec t-a-tec s ys tem is sh own in Figures 6.74 and 6 .75 . It c ons is ts of a pair of port v alv es fo r each v aporizer pos i ti on. E ach v apori ze r has a spec ial mounting brack et co nta in ing two pl ungers (s pi ndles ), whi c h f its ov er the po rt v alv es . The wei ght of the v apo ri zer and an O-ring a round eac h p ort v alv e c reate a s eal between the mounting s ys tem and the v apori zer. On the back o f each v aporizer i s a loc ki ng l ev er. Before mo unting a v aporizer, the c ontrol di al mus t be in the OFF pos i tion, and an y adjac ent v apori zer mus t be tu rned OFF. The lock ing lev er on the v apo ri zer s hould be un loc ked . The v apori ze r is f itted onto the mou nti ng s ys tem and locked i n position. To remov e a v apori ze r, the con trol dial is turn ed OFF, and the l ock in g l ev er mov ed to the un loc k pos i tion . The v aporiz er can then be l ifted off the man ifold. W hen the v apori zer is turn ed ON (Fig. 6.75, ri ght), the two p lungers mov e downward, opening the v alv e ports an d c onnec ting the v apori ze r in to the fres h gas s tream. W hen the v apori zer is turned OFF (Fi g. 6 .75 , left), i t is is olated f rom the f res h g as fl ow. The Drage r Medical mounting s ys tem is sh own in Fi gu res 6.24 an d 6 .76 . The V apor 2000 v apo ri zer mus t be in the T (trav el ) pos ition before i t can be unl ock ed from the mac hi ne. This pos i tion isolates the v apori zi ng c hamber and p rev ents li quid f rom passing in to the byp ass during the time that the v aporizer is n ot on the machine . Af ter a v aporizer has been added to a mac hi ne, s ev eral c heck s shou ld be made to ensure p roper pos itioning. T hese inc lude s igh ti ng ac ros s the tops of the v aporizers to ensure that they are lev el an d a t the s ame height. An attempt should be made to l if t each off the man ifold withou t unlock ing it. If the v aporizer can be remov ed, i t is i mproperly pos i tioned . It s hou ld be poss ible to turn ON onl y one v aporiz er at a time. Fin all y, the an es thes ia mac hine mus t be check ed for leaks wi th eac h v aporizer in both the ON and OFF pos i tion as desc ribed i n C hapter 33 . These mounting s ys tems hav e a numbe r of adv antages . The anes thesia mac hine can hav e f ewer mounting loca tions , al lowing a more c ompac t mach in e. Vap ori ze rs can be e asi l y remov ed and replaced , ev en d uring a case. If mal ignant hype rthermia i s a p otential pro ble m, th e v apori zers can be re mov ed. This giv es be tter res ul ts than if the v aporiz ers remai n on the machine in the OFF pos ition (87 ). The re are a number of dis adv antages o f these moun ti ng s ys tems . P artial or co mple te obs truc tion to gas f low

P .182

P .183 f rom probl ems with th e mo unting s ys tem has been rep orted (88,89,90,91). Leak s may oc cur (92,93,94,95,96,97 ,98 ,99 ,100,101,102 ). A commo n leak s ource is an absent o r damaged O-rin g (103 ,1 04,105,106 ,107,108). Anothe r caus e is leav ing the l ock ing lev e r in the unloc ked pos iti on (109). If s omething is pus hed under the v aporizer eno ugh to lift i t s l ightly of f of the O-ri ng, a leak may result wh en th e v aporizer is turned ON. Diff erenc es among v aporizers and interlocks f rom diff erent manufac tu rers can pose problems of compatibil ity (98,100).

View Figure

Figure 6.74 Select-a-tec mounting system. A vaporizer is mounted on the right. In the center position, the nipples and O rings are in place, ready to accept a vaporizer. Caps are over the nipples and O rings on the left, to protect them. The projections between the sets of nipples are to prevent two vaporizers from being turned ON at the same time (vaporizer exclusion or interlock system). The plastic projections are interconnected so that they move from side to side. The rod shown on the vaporizer to the right contacts the right projection. When that vaporizer is turned ON, the rod moves to the left, causing that projection to move to the left. The left projection also moves to the left. If there were vaporizers in those positions, their rods would also be moved in a way that their dials could not be turned ON. The inlet and outlet pipes are below the mounting system. They enter at opposite ends so that they cannot be interchanged.

View Figure

Figure 6.75 Select-a-tec mounting system. The mounting system has channels for the fresh gas flow from the flowmeters toward the machine outlet. When a vaporizer is mounted and turned ON, two plungers push the valves down so that gas passes through the vaporizer. If the mounting position is empty or the vaporizer is turned OFF, the gas passes directly through the mounting system. (Reproduced from a drawing furnished by Datex-Ohmeda.)

Figure 6.76 Drager vaporizer mounting system. Between the two nipples is the receptacle for the locking mechanism.

View Figure

Sev era l cas es hav e been reported where there was fa ilure to deliv er a nes thetic agent as soc iated wi th problems wi th mou nting sys tems (110,111,112). In another case, a s wi tch malfunc tion c aused the f res h gas fl ow to be d irec ted to the wrong v aporizer (1 13). This res ul ted i n del iv ery of fresh g as with no v apor to the breathing s ys tem.

Interlock Devices
Inte rlock (v apori zer exc lus ion) sys tems p rev ent more than one v aporizer from being turned ON at a ti me (114 ). Check ing the in terl ock dev ice should be inc lud ed with

the anes thes ia apparatus ch eckout proce dure. S ys te ms a re sho wn in Figures 6.24, 6.74, 6 .77, and 6.78 . Interlock sys te m fai lures hav e been reported (115,116 ,117,118,119). For Datex -Oh meda v apori ze rs , operating the di al releas e ac tiv a tes two ex tens ion rods th at prev ent op era tion of an y oth er v apori ze r ins talled on the manifo ld . Older v e rsions of the S elec t-a-tec s ys tem that prov ide moun ti ng pos itions fo r th ree v aporizers requi re that if only two v apori ze rs are f i tted, then the cente r posi tio n mus t be occ upied. If the c enter p osi tion is not oc cup ied , the interlock th at helps to ensure that onl y one v apori ze r at a time can be turned ON is ineffec tiv e . Later v e rsions i nc orpora te an ad ditional interlock th at he lps to ens u re that only one v aporizer c an be turned ON at a time, ev en if the c enter pos ition is no t occ upi ed.

Hazards Incorrect Agent

Mos t contempo rary concentrati on-ca librate d v apori zers are ag ent s pecif ic . Fil ling a v aporizer wi th an agent other than the one for wh ic h i t was desi gned is s till a hazard but is les s likel y if the v apori zer is equi pped with an agent-spec ific fi lling s ys tem (120). If an agent of low potenc y or low v olati lity is plac ed in a v aporizer des igned fo r an agent of higher po te ncy or v olati lity, the effec t wi ll b e an output of lo w po tenc y (121,122 ). Conv ersely, if an agent of high potenc y or v ol atil i ty is used in a v aporizer in tended f or an agent of low po tenc y or v o la ti li ty, a dangerous l y high conc en tration may be deliv e red . If an incorrec t age nt is placed in a v aporizer, th ere wi ll likel y be a mix tu re of ag ents i n the v aporizer. T his wil l re sul t f rom the res idual amount of the c orrec t agent as wel l as the amount conta ined in the wic ks . S ome a nes the tic agen t moni to rs (Chapter 22 ) wil l detec t ag ent mix tures . Smel ling c anno t be relied on to tel l which agent is in a v apori ze r, b ecause the s mell of a small amount of one agent ca n co mple tel y mask the odo r of a less -pun gent agen t, ev en if the s econd agent is present i n muc h higher c onc entration (12 3). A nes thes ia pers onne l can de tec t the presenc e of a v ola ti le agent but are not ab le to identif y an agen t by s mell (124). If a v apo rizer is fil le d wi th the wrong age nt, it mus t be c ompletely drained an d a ll l iquid disc arded. Gas s hou ld P .184

be all owed to f low through i t un ti l no agent can be detec ted in the outf low. Drai ning cannot b e rel ied on to comple tel y empty a vapo ri zer.

Figure 6.77 North American Drager interlock system. When the vaporizer of choice is turned ON, a pin is forced into a notch on the concentration control knob of each of the other vaporizers. These vaporizers are then locked in the OFF position. (Reproduced from a drawing furnished by North American Drager, Inc, Telford, Pa.)

View Figure

Tipping
If some v aporizers are tipped suffici ently , liquid f rom the v apo ri zi ng cha mber may get in to the bypass or ou tlet. If this occ urs , a hi gh conc entra tion wi ll be del iv e red whe n the v aporizer is fi rs t used . Ti pping ca n be p rev ented by moun ting v aporize rs securel y and han dling them with ca re when they are not mounted. V aporiz ers s houl d be tu rned OF F o r placed in a trav el se tting if they are bei ng mov ed. Shoul d tipping occ ur, a h igh f low o f gas shoul d be run through the v apo ri zer with the c oncentration d ial set a t a low conc en tration un til the output s hows no exces s iv e agent. Many new v apori zers hav e a mec hanism tha t bl ock s the en trance a nd ex i t from the v aporizing c hamber. This prev ents the problems ass oci ated with ti pping the v aporizer when i t is transported. P .185

Figure 6.78 North American Drager interlock system. The top picture (A) shows the adjustment screw at the back. It is connected to the pin (B), which interlocks with the concentration control dial of the vaporizer.

View Figure

Overfilling
If a v apo rizer is ov e rf il led, liqui d agent may enter the fres h gas line, and le tha l conc en trations ma y be deliv ered. Ano ther resul t of ov erfill ing may be c omp le te v aporizer fa il ure s o tha t it produces no output (19). On mos t v apori zers , the fi l li ng port is si tua ted s o that ov erfil ling ca nnot occu r. Liquid wi ll p our ov er the edge of the f unnel before the l ev el i nside the v apori zer rises to a dangerous l ev el . If a v apo rizer is tipp ed during the f illing process , i t is pos sible that i t c ould b e ov erf illed. The v apo ri zer should be sec urel y a ttached to the anes thes ia machine and in a v ertical pos i tion. Agent-s pec ific fi lling dev ic es prev ent ov e rfill ing by c onnec ting the ai r in take in the bottle to the ins ide of the v aporiz er chamber. To fac il i ta te fil ling whe n us ing k ey f il ling dev ices , many use rs hav e found that s lightly unsc rewi ng the b ottle adap tor can s peed the fi l ling process . Turning the concentration di al of th e v aporizer ON during fi l li ng wi ll accomplish the same en d. Suc h p rac tices s hould be av oided, becaus e they c an resul t in ov erfi ll ing (1 6,17,5 6,125).

Reversed Flow
A l though the anes th esia machine s tand ard (5) requi res tha t the v apori zer i nlet be mal e and the outle t fema le , the direc tion of gas flo w b e ma rke d, and the inle t and

outl et labeled , it is possi bl e to connec t the fre sh gas de liv ery li ne f rom the anes thes ia mach ine to th e outlet and P .186 the del iv ery tube to the breathing sys tem to the inlet, es peci al ly if th e v apo ri zer is us ed in a frees tanding pos ition (12 6). Rev ersed flo w through a v apori ze r has been reporte d after i mpro per c onnec tion or repa irs to the selec tor v alv e (12 7,128). If the f low through a v aporizer i s rev ers ed, in mos t c ases there wil l be an inc reased outpu t. The cons eque nces of rev ersed flow to a pa rtic ular v apori ze r are disc uss ed wi th i ndiv idua l v apori zers earlier i n th is c hapter.

Control Dial in Wrong Position

Af ter prev ious v apori ze r use or s erv ic in g, the v apo ri zer c ontro l dial may be lef t ON (114,129 ,130,131). For this reason, the dial should be i nspec ted as part of the preus e c hec king procedu re. The c ontrol dial may be changed duri ng a cas e withou t th e operato r's k no wledge. Operatin g room pers onnel mov ing a machine or s impl y pas sing by may grab the d ial and c hange the se ttin g.

Leaks
The effec ts of a leak on a v apori zer wil l depend on the s i ze and loca tion of the leak and wh eth er or not there is a chec k v alv e at the v aporizer outlet. In add ition to af fec ting f resh gas composi tion an d flow, l eak s ma y pol lu te the operating room ai r. A common cause of leaks is failu re to replac e o r adeq uatel y tighten th e f iller c ap. If the fill v alv e or v ent on a ke yed f ill ing s ys tem is not cl osed or the plug is not replaced and ti ghtened in pl ace , a leak wil l oc cur wh en the v aporizer is turned ON (Fig . 6.79) (74,132). If an incorrec t ca p is used on the f il ler dev ic e, a leak may resul t (133). The f itting betwe en a v apo ri zer a nd its inlet or outl et connec ti on may bec ome lo ose or b rok en (134,135). A v apo ri zer ma y n ot be mou nted p roperl y (37,95,96,97,105,108,1 09,136,137). W ith a leak in a v apori ze r or i ts mount, the mac hi ne wil l of ten func tion no rmal l y unti l the v apo ri zer is tu rned ON . A t that poin t, f resh gas f lo w f ro m the machine wi ll be l os t through the l eak , and th e total f lo w wi l l be reduced. Th e l eak may c ontain l ittl e or no v apor, es pec ial ly if i t is in th e mo unting mechanis m. A leak s hould be suspec ted if a v apori ze r appears to requi re f il ling wi th unusua l frequenc y, if an odo r can be d etec ted, o r if there is a loss or reduc tion in the f resh gas f lo w i nto the

breathi ng s ys tem af te r th e v aporizer is tu rne d ON. A l oos e o r mis si ng fi ll er c ap may be de tec ted by l iquid being fo rc ed out under pres sure when the v apori zer is tu rned ON (138,1 39). If the lev el is low or be lo w the fi l ler, l iquid ma y n ot be spla ttered (14). If the dev ic e to hold the key f ille r in plac e is broke n, a leak wil l occur (54,55 ). Splatte ring may not be seen wi th the key f i ller s ys tem on c ertain v apori ze rs .

Figure 6.79 Failure to replace the filler plug will result in a leak when the vaporizer is turned ON.

View Figure

A leak c an be i den tified by us ing the sampling tube from an anes thetic agent moni tor to sni ff around the v aporizer (55). Person nel wh o fill v apo ri zers shou ld be ins truc ted to al ways c lose fi l ler c aps and v ents tightly. A leak in a v apo ri zer c an be detec ted whe n the anes thes ia machine is tes ted before use if the v aporizer is turned ON (Chapter 33). Ev en after a prope r preus e c hec k , if any thi ng is push ed unde r th e v aporizer and the v aporizer is l ifted ev en sl igh tl y from its mount, a leak may oc cur.

Vapor Leak into the Fresh Gas Line

Some v aporizers l eak s mall amounts of v apor i nto the b ypas s when turn ed OFF (87). Interlock dev ic es or se lec to rs wi ll not prev ent this p rob lem if there is s til l a diffus ion path way v ia the se lec tor v alv e (140). The amo unt o f suc h a leak depends on the ambient tempe rature as wel l as the siz e and configuration of the internal ports . A l th ough the amoun ts deliv ered are usua ll y too s mall to produce a c linic al ef fec t, it might caus e a sensi ti zed indiv idual to re ac t to a halogenated a gent or

tri gger an episode of mal ignant h yperthermia. These leak s c an be reduced by not turn ing a v aporizer from th e OF F to the 0 se ttin g unless i t is to be used. P .187

Figure 6.80 Corrosion in vaporizer caused by water and other foreign substances.

View Figure

Contaminants in the Vaporizing Chamber

It is possible for v arious subs tances to be poured i nto a bo ttle that s hould con tain anes thetic agent (141 ). Cleaning a gents may coll ec t i n the fun nel fil ler an d be was hed i nto the v apori zi ng chamber wh en it i s f il led with li quid agent. Wa ter and other forei gn subs tances c an caus e corros io n (Fig. 6.80). If fo reign subs tanc es are known to hav e entered the v aporiz er, the manufac ture r should be c ontac ted to determine what measures need to be taken.

Physical Damage
Shock, excessiv e v ibration , or mistreatment ma y lead to malfunc tion. Damage to v aporizers pe rmanently mounte d on a mac hi ne is s ign if icantl y l es s than wi th those that c an be discon nec ted and a re f requently mov ed (142). A s ufficient n umber o f v aporizers s hould be purchas ed so that they do no t nee d to be mov ed d uring routine use. If a v apori zer mus t be remov ed, ca re sh ould be tak en to protec t i t f ro m phys ical damage .

No Vapor Output

The mos t commo n c ause of no v apor output is an emp ty v aporizer. Inc orrec t v aporizer moun ting can result i n littl e or no v apor ou tpu t (1 12,143). In mos t cas es , this can be detec ted by c heck in g for l eak s with the v apori zer ON (Chapter 33 ). A n ov erfilled v aporiz er may del iv er no v apor (19 ). B lood e nte ring th e v aporizer c an c ause v aporiz er failure (14 4). If an a nes thes ia mac hine is turn ed OFF and then ON again, the v aporiz er se ttin gs may def aul t to zero (145 ). Fa ilure to deliv er adequate v apor c an be detec ted by an anesthetic gas moni to r (Ch apter 22).

Projectile
A cas e has been repo rted in whic h a portabl e v apo ri zer c arri ed into the magnetic resonance imagi ng (MRI) su ite was rapid ly attrac ted to the magnet (146 ). The v aporizer was c onsi dered MRI safe but onl y when attac hed to a rack .

Disposing of Liquid Anesthetics

Af ter a v aporizer has been drained , the ques tion of wha t do with the l iquid agen t aris es . S ome of these agents wil l reac t with plas tic . A s imple s ol uti on is to plac e the agen t in a bo ttle or tray and se t it outs id e, whe re person nel wi l l not be exposed to the v apor. An ev apora to r has bee n desc ribed (147). It c onsis ts of a g lass flas k wi th a s topper th at has two holes . A g lass tu bing open to room ai r is ins erted through one hole . The glass tubing that is inserted through the other ho le is connec ted to the v acuum s ys tem. The l iq ui d i s allo wed to ev aporate, an d the v apor i s remov ed by the v acuum s ys tem.

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59. Yee S , Old S . Any which way b ut loose ?the s ignif ic anc e of gas flo w di rec tion through a v apori zer. A naes thes ia 20 00;56:598600. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 60. Cook e R. Any whi ch way but loose: The s ignificance of gas flow di rec ti on through a v apori zer. A re ply . Anaes thesi a 2000;5 6:65:600 601. 61. Gupta S . P oor i nterlock saf ety with datum s ev oflurane v aporise rs . Anaes thes ia 2000;55:404. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 62. Bel l GT, Ralph JK . Dra wback s of pus hov ers . Anaes thes ia 2000;55:1 000 1002 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 63. B rosnan S , Ro yston B , W hi te D. Isoflurane concentrations usi ng uncompensated v aporise rs wi th in c i rc le s ystems . An aes thes ia 1998;53:560564 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 64. White D, Roys ton B . Resp iratory f eedb ack eff ec ts on v apo risers in ci rcle s ys tems . A naes thes ia 19 98;53:555559. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 65. Monga n P D, Hol lenbec k K , Solomon J , e t al . Compl iance , fl ow ra te, and v enti lato ry mode effec ts on drawov e r v aporizer output prof iles . A nes thes iology 2003;99:A575. 66. Tayl or J C, Res tall J . Can a drawov er v apori zer be a pushov er? Anaes thes ia 1994;49:892894. 67. Harrison GR. The c ontaminatio n of v olatil e anaes thetic s in an i n-c irc le v aporizer wi th water du ring prolonged c los ed-ci rcl e anaes thes ia. Anaes thesi a 2000;55:791792. [Fu ll tex t Link ] [Cross Ref]

[Med li ne Link ] 68. Craig GR, Berry CB , Yeats MJ . An ev alu ation of the un iv ers al PA C and Ox ford minia ture v apori ze rs for ped iatric f ie ld anaes thes ia . Anaesthes ia 1995 ;50 :789 792. [Cross Ref] [Med li ne Link ] 69. Liu E HC, Dhara SS . S ev ofl urane ou tpu t from the Ox ford miniature v apo ri zer i n drawov er mode . A naes th Intens Care 2000 ;28 :532536. [Med li ne Link ] 70. B rook P N, Perndt H. Sev oflurane drawov e r anaes thes ia wi th t wo Ox fo rd minia ture v apori ze rs in s eri es . Anaes th Intens Care 2001;29:6166 18. [Med li ne Link ] 71. Anes the tic v aporizers ag ent-s peci fic fi lli ng s ys tems (AS T M/IS O 5360). W es t Conshohocken, PA : A uthor, 2003 . 72. Rie gle EV , Desertsprin g D. Fai lure of the age nt-specific fil ling dev ic e. Anes thes iology 1990;73:353 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 73. Ric hardson W , Carter KB . Ev aluation of keyed fillers on TE C v aporizers . B r J Anaes th 1986 ;58 :353356. [Cross Ref] [Med li ne Link ] 74. Urmey W F, El l io tt W , Raemer DB . V aporiz er fil l sys tem leak . A nes th Analg 1988;67:711. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 75. Hooda S . Where wrong prac tic e is a nec ess ity. Anes th Analg 1999 ;88 :233. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 76. Wi ttmann P H, W ittmann FW , Conno r T, et al. The nonempty e mpty bo ttl e. Anaes thes ia 1992;47:721 722. [Cross Ref] [Med li ne Link ]

77. Uncles DR. A compariso n of keyed and non-k eyed v aporizer fil ling modes and v olati le agent wa s ta ge. A naes thesia 1993;48:795 798 . [Cross Ref] [Med li ne Link ] 78. Wi ttmann P H, W ittman n FW , Conno r J , et al. A n ew k eye d v apori zer fil ler. Anaes thes ia 1994;49:710 712. [Cross Ref] [Med li ne Link ] 79. Marti n L VH. The non-empty b ottle. A na es thes ia 1993;48:94. 80. Craig DB . V aporizer ov e rf il l ing. Can J Anaes th 1 993;40:10051006. [Med li ne Link ] 81. Anonymous . Safety alert: anes thetic bottle & metal fi lle r incompatibi li ty . Bi omed Safe S ta nd 1992;22:3 7. 82. Uncles DR, Si bell DM, C onway NE . Desf lu rane and the Tec 6 fi ller s ys tem. Anaes thes ia 1994;49:547 548. [Cross Ref] [Med li ne Link ] 83. Jolly DT , Young J . S us pec ted malfu nc tio n of the S A F-T -FILL
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88. Rie ndl J . Hypoxic g as mix ture del iv ery due to malfunc tioning inlet port of a Selec t-a-tec v aporizer manif old . Can J Anaes th 1987;34:431 432 . [Med li ne Link ] 89. Hogan TS . Selec tatec s wi tc h malf unc tion. A naes thes ia 1985;40:66 69. [Cross Ref] [Med li ne Link ] 90. Godda rd J M, A bbott TR. Se lec ta tec s ys tem: misplaced blood. Anaes thes ia 1986;41:439. [Cross Ref] [Med li ne Link ] 91. Col e A GH, Thompson JB , Fodor IM, et al. Anaes thetic mach ine ha zard from the Selec tatec bloc k . Anaes thes ia 198 3;38:175 177. [Cross Ref] [Med li ne Link ] 92. Chi ldres W F. Malfunc tion of Ohio Modulus anes thes ia mac hin e. Anes thesi ol ogy 1982;56:330. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 93. Jov e F, Millike n RA . Los s of anes thetic gases due to defec tiv e safety equipment. A nes th A na lg 1983;62:369370. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 94. Jablonsk i J , Reynolds A C. A potential cause (and cure) of a major g as le ak . Anes thes iology 1985;62:842 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 95. Powel l J F , Morgan C. S el ec tatec gas l eak . A naes th Intens Ca re 199 3;21:892 893. [Med li ne Link ] 96. Hartle A J , Daum RE O. Fail ure of Ohmed a T ec 4 safety i nterlock . A naes thesia 1992;47:171. [Cross Ref] [Med li ne Link ]

97. Loughnan TE . Gas le ak ass oci ated with a Sel ec tatec . Anaes th In tens Care 1988;16:501. 98. Cartwrigh t DP , Freeman MF. Vapori zers. A naes thes ia 1999;54:519520. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 99. Duff PJ , Ro ll is on RA , Lee TW. Selec tatec pro blems : again a nd agai n. An aes th Intens Care 1994;22:622 . [Med li ne Link ] 100. Dwye r M, Hol land R, Shep herd L , et al. V aporiz er and S elec ta tec leak s . Anaes th Intens Ca re 1994;22:739. [Med li ne Link ] 101. W ilkins on DJ, Curti s C. A s trange le ak from the anaes the tic machine. Anaes thes ia 2002;57:1038 1039. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 102. Ong B -C, bin K atij o J , Tan B -L, et al. Acute fai lure of oxygen del iv ery. Anes thes iology 2001;95:10381039. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 103. W raigh t W J . Ano the r fa ilure of Sel ec tatec bl ock . Anaes thesi a 1990 ;45 :795. [Cross Ref] [Med li ne Link ] 104. James RH. Defec tiv e S elec tatec O-rings . A naes thes ia 19 95;50:184185. [Med li ne Link ] 105. Nott MR, J ackl in F. Mis sing O-ri ngs and v olatile agents . Anaes thes ia 1995;50:1001100 2. [Cross Ref] [Med li ne Link ] 106. Ti ghe S QM, J ones DA . A naes the tic machine c heck s duri ng an aes thesia . Anaes thes ia 1993;48:88. [Med li ne Link ] 107. Pandit JJ , J akub owsk i P , W ai t CM. B roken O-ri ng caus ing hypov en ti la tion. Anaes thes ia 1993;48:1114 1115.

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111. Lum ME , Ngan K ee WD, Robinso n B J . Fau lt in a Selec tatec manifold res ul ting i n a warenes s. Anaes th Intens Ca re 199 2;20:501 503. [Med li ne Link ] 112. Beards SC. Mis use of a Bodok seal . An aes thes ia 1993;48:175176 . [Med li ne Link ] 113. Cudmo re J , K eogh J . A nother S elec ta tec s witc h malfu nc tion. Anaes thes ia 1990;45:754756. [Cross Ref] [Med li ne Link ] 114. Petty C. E quipment safety : v apori ze r exc lus io n o r in terl ock s ys tems . APS F News le tt 1992;7:10. 115. Anonymous . Imp roper se tting of anes th esia v apo ri zer i nterlock sys tem leads to safety alert. Bi omed Safe S tand 1990;20:91. 116. S i lv asi DL , Hayn es A , B rown ACD. P oten ti al ly lethal f ai lu re of the v apor ex c lusi on s ys tem. Anes thesi ology 1989;7 1:2 89-291 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 117. V iney JP , Gartre ll A D. Incorrec tl y adj us ted v aporiz er ex clus ion s ys tem. Anes thes iology 1994;81:781 . [Fu ll tex t Link ] [Cross Ref]

[Med li ne Link ] 118. Buettner A U. Failure of v aporizer i nte rlock mec hanism. Anaes th Intens Care 2000;28:451452. [Med li ne Link ] 119. W ebb C, Ri ngrose D, S ton e A . Faul ty interlock on Drager v aporis ers . Anaes thes ia 2005;60:628 629. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 120. Popic P M, J ameson LC, A rn dt GA . P reliminary res ul ts on the inci denc e of v aporizer c on tamination in s elec ted U.S . hosp itals . Anes thes iology 1991;75:A902 . 121. Abel M, E isenk raf t JB . Performanc e of erroneous ly f ill ed sev oflurane, enfl ura ne and other agent-s pec if ic v apori zers . J Clin Moni t 1996;12:119 125 . [Cross Ref] [Med li ne Link ] 122. B lock FE , Schul te GT . Obse rv a ti ons on use of wrong age nt i n an anes thesi a agent v aporizer. J Cl in Moni t 2000 ;15:5 761 . 123. Paull J D, S leeman KW . An anaes thetic haza rd. B r J Anaes th 19 71;3:1202. [Cross Ref] [Med li ne Link ] 124. Robe rts SL, Fo rbes RB , Moye rs JR, e t al . Can olfac tion iden tify and quantify v olati le anes thetic s? A nes thes iology 1985;63:A193 . 125. Hardy J -F. Vapori ze r ov erfil ling. Can J A naes th 1993;40:12 . [Med li ne Link ] 126. Anonymous . Death from mis connec ted v apori ze r leads to $750,000 se ttle ment. B iomed S afe S tand 1992 ;22:78. 127. Chen g CJ C, Bai ley A R. Fl ow rev ers al through the anaes thetic machine bac k bar: an unusual as sembly fault. A naes thes ia 2002;57:8688. [Fu ll tex t Link ] [Med li ne Link ] 128. W al ters C. Fl ow rev ers al through the anaes thetic mac hine back bar: an unusua l ass embly fau lt. A reply . A naes thesia 2002 ;57:88. [Fu ll tex t Link ] 129. Colesh il l GG. S afe v aporizers . Can J Anaes th 1988;35:667668 . [Med li ne Link ]

130. W ill iams L , B arton C, Mc Vey J R, e t al . A v is ual wa rni ng dev ice for improv ed safety. A nes th Analg 198 6;65:1364. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 131. Ludbrook GL, W ebb RK , Fox MA , et a l. P rob lems befo re induc tion of anaes thes ia : an anal ys is o f 2000 inci dent re ports . Anaesth Intens Care 1993 ;21 : 593595. [Med li ne Link ] 132. Meis ter GC, Bec ker K E . Potential fres h gas flow le ak th rou gh Drger Vap or 19.1 v apori ze r with k ey -i ndex f i ll port. An esthesiology 1993;78:211 212 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 133. Ngan J , Cas hen D, Nichols G. Sev oflurane v aporizers . Can J Anes th 1999;46:200. 134. Anonymous . Anes thes ia uni t v apori ze rs . Technol Anes th 1991 ;12 :7. 135. Marsh RHK , Thomas NF. A hazard of the Penlon off -l ine v apori zer mounting s ys tem. Anaes thes ia 1986;4 1:438. 136. Anonymous . Anes thes ia uni t v apori ze rs , Technol Anes th 1997 ;17 (10 ):9. 137. Moore C, Harmon P . More p roble ms wi th the S el ec tatec s ys tem. Ana es thes ia 1993;48:635636. [Cross Ref] [Med li ne Link ] 138. Rajah A , Zidema n DA . A p rob le m wi th the TEC 5 v apo ri zer. Anaes thesi a 1992;47:271272. [Cross Ref] [Med li ne Link ] 139. B ridges R. A pro bl em wi th a TE C 5 v ap ori ze r. A reply. Ana es thes ia 1992;47:272. [Cross Ref] 140. Robins on JS , Thompson J M, Barratt RS . Inadv erte nt contamination of anaes thetic c irc ui ts with hal othane . B r J Anaes th 1977;49:745753 . [Cross Ref] [Med li ne Link ]

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Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t C if B an d D are correc t

i s D is correc t i f A , B , C, and D a re co rrec t.

1. Which fa cto rs w ill ca use a shift from th e liq uid to the vapor phas e? A . Heati ng the v aporizer B . Cooling the room C. Inc reas ing the f low thro ugh the v apo rizer D. Dec re asing atmospheri c pressu re V iew A ns we r2. Wh ich statements c once rning boiling point are true? A . B oil ing point is independent of the atmosphe ric pressu re B . B oil ing points for c ommonl y us ed v olati le a nes the tic agen ts v a ry between 4 8C and 5 9C at 760 torr C. Anes thetic agents with high boiling po in ts are more susceptible to v ariations in barometric press ure than agents with lower boi l ing poin ts D. A tmospheric press ure and the v apor p res sure of an agent are equal at the boil ing point V iew A ns we r3. The concentration of a vola tile anesthetic may be expressed as A . V olumes perc ent B . Th e number of uni ts of the v apo r in rela tion to a total of 100 uni ts C. The p artial press ure D. The p res sure of the v apo r in rel ati onship to the total p res sure exerted by al l of the gases in the sample V iew A ns we r4. Wh ich of the fo llow ing accurate ly reflects the heat of va porization? A . It is the amount of heat giv en off in the proces s of conv erting a li qu id into a v apor B . Th e temperature of the liquid inc reases as v apo ri zation proceeds C. The g rea te r the f lo w, the higher the temperatu re of the l iq uid wi l l bec ome D. It i s express ed as c al ories per gram V iew A ns we r5. Wh ich of the fo llow ing accurate ly reflect specific heat? A . It is the amount of heat needed to rais e the temperature of a s ubs tance by 1F B . Th e higher the spec ific heat the more heat tha t is requ ired to raise the temperature of a quanti ty of a s ubs tanc e C. It i s the heat re qui re d to ra ise 1 mill ili te r of a subs tance by 1 F

D. Subs tanc es with high s pec if ic heats are preferred whe n choos ing the materia l f rom whi ch to c ons truc t a v aporize r V iew A ns we r6. Most concentratio n-c alibrate d vaporiz ers A . Receiv e a fl ow from a d edicated flowme ter B . A re pl aced do wns tre am o f the f resh gas inlet C. Hav e a dia l that is turned cloc k wi se to inc reas e the concen tration D. A re calib rated in v olumes pe rcent V iew A ns we r7. Me tho ds used by vap orizers to vap orize age nts include A . B ubble through B . Flow ov er C. Injec tion into a v apo ri zing chamber D. Injec tion into a known v olume of gas V iew A ns we r8. Therma l compensation in a vaporiz er is ac complis hed by A . W arming the room B . S uppl ying heat to the v apori zer C. Us ing glas s in the v apo ri zing c hamber to conduc t h eat D. A l tering the fl ow th rough the v aporiz ing c hambe r V iew A ns we r9. How do changes in back press ure affec t the ou tpu t of a va porizer? A . Th e pumping effec t wi ll i nc rease v apori ze r output B . A c heck v alv e a t the mac hine outle t is not an effec tiv e s olu ti on to the pumping ef fec t C. The p res suriz ing effec t wil l dec re ase v aporiz er output D. The p umping effec t is g rea ter with low f res h gas flows , l arg e p res sure f luc tu ati ons , and low v apori ze r setti ngs V iew A ns we r10 . Acceptab le locatio ns for a va poriz er on the anesth esia mach ine include A . B e twe en the c heck v alv e and the c ommon gas outl et B . B e twe en the c ommon gas ou tlet and the breathi ng s ys tem C. Be twee n the ox ygen fl ush and the breathi ng s ys tem D. Be twee n the flo wmete rs and the mach in e o utl et V iew A ns we r11 . Advan tages of having de tachable vaporiz ers include A . A more c ompac t mach ine is pos sible B . E asy re mov al if v aporizer failure occ urs C. Comp le te remov al during mal ignan t hyp erthermia D. Vaporizers c an be used on d iffe ren t brands of anes thes ia mac hi ne

V iew A ns we r12 . If a n a gent o f low potency or vola tility w ere placed in a va porizer for ag ents of hig h vola tility and po tency, A . A mix tu re of agents wi ll l ik el y be del iv ered B . Th e v apo r output wi l l be highe r than the sc ale read in g C. The v apori zer output wi ll be lower th an th e read ing on the dial D. The mix ture c an be determin ed by s mel ling the age nts i n the f res h gas f lo w V iew A ns we r13 . Actions that could c ause a vapo riz er to be o verfilled include A . Loose ning the connec ti on between the ag ent bo ttle a nd the fil l ing d ev ice B . Tipp ing the v apori ze r C. Tu rni ng the con trol dial on the v aporizer ON D. Fi lling a v apori ze r in the anes thes ia work a rea V iew A ns we r14 . A vaporiz er located dow nstream of the common gas outle t A . May b e i ns talled bac k ward B . P rese nts s ignificant res is tance to gas flow C. May deliv e r a high c onc entration into the breath ing s ys tem D. Can b e used if the v apori zer is fi rml y fixe d to a horizontal su rface V iew A ns we r

Chapter 7 The Breathing System: General Principles, Common Components, and Classifications
P .192

The breathing s ys tem (breathing or patient c i rcui t, res piratory c irc ui t or s ys tem) is a gas path way connec ted to the pa ti ent, through which gas f lows occ ur at respiratory press ures , an d into whi ch a c ontrolled comp osi tion of a gas mix ture is d ispens ed (1). In prac tic e, the breathing s ys tem is us ual ly rega rded as ex tendi ng f rom the point of fres h gas in let to the point at whi ch gas es capes to atmosph ere or a sc av engi ng s ys tem. S cav enging equipme nt i s not c onsi dered part of the breathing s ys tem. The breathing s ys tem receiv es the gas mix ture from the anes thes ia mach in e, deliv ers gas to the pa tient, re-mov es carbon di ox id e, and the condi tions temperature and humidity of the inspi red mix ture (2). It allows the con ti nuo us fl ow f rom the anes thesia machine to be c onv e rted in to an i nte rmi ttent fl ow; al lows spontaneous , c ontrol led, o r ass is ted respi rati on ; and prov ides for other func tions such as gas s ampling and airway press ure, flow, and v olume moni toring (2).

General Principles Resistance

Physics
W hen gas pass es th rough a tube , th e pressure at the outle t wi ll b e l owe r than tha t at the inlet (3 ). The dro p in pressu re is a me asure of the res is tance th at mus t be ov erc ome as th e gas mov es through the tu be. Res is tance v a ries wi th the v ol ume of gas pass ing through pe r uni t of time . Therefore, f low rate mus t be s tated when a spec ific res is tanc e is mentioned. The natu re of the fl ow i s impo rtant in determining resis tance . There are two ty pes of fl ow: l aminar and turbulent. In c li nical prac tice , flow i s usual ly a mix ture o f both.

Laminar Flow
Fi gure 7.1A i l lus trates lamin ar gas f lo w through a tube. T he flow is s mooth and orderly , and pa rtic les mov e paral lel to the wal ls of the tube. Flo w i s fas tes t i n the cente r of the tube, whe re there is less f ric tion .

W hen f lo w i s lamina r, the Hagen-P ois eui lle l aw appl ies . Th is l aw s tates that P = (L v V )/r 4 whe re r i s the radius of the tube, P is the p res sure g rad ie nt ac ros s the tube, v is the v iscos ity of the gas , L is l eng th, and V is the flow rate. Resis tance is di rec tl y proportional to flow rate durin g l aminar f low.

Turbulent Flow
Fi gure 7.1B i l lus trates tu rbulent gas fl ow through a tube. The flow l ines are no l onge r parallel . Eddies , c ompose d of partic les mov ing ac ross or op posi te the general di rection of flow, are pres en t. The flow rate is the same ac ross the diameter of the tube .

Figure 7.1 Laminar and turbulent flow. A: Laminar flow; the lines of flow are parallel and flow is slower near the sides of the tube because of friction. B: Generalized turbulent flow, which occurs when the critical flow rate is exceeded. Eddies move across or opposite the general direction of flow. CF: Localized turbulence, which occurs when there is change in direction or the gas passes through a constriction.

View Figure

Durin g turbulent fl ow, the fac tors resp onsi ble for the pres sure d rop along the tube i ncl ude thos e desc ribed fo r P .193 l amin ar f low, but i n th is si tuation, gas dens ity b ecomes mo re importan t th an v isc osi ty . P = (L V 2 K )/r 5

In this equa ti on, K is a c ons tant that inc ludes such fac tors as grav i ty, fric tion, and gas dens i ty and v iscosi ty. Resis tanc e is proportion al to the square of th e f low rate wi th turb ulent flo w. Turbulen t fl ow can be general ized or local ized.

Generalized T urbulent Flow

W hen the flow of gas through a tube ex ceeds a c ertain v al ue, called the c ri tical fl ow rate , gene ral i zed turb ul ent f lo w res u lts .

Localized Turbulent Flow

As seen in Fi gure 7.1CF, wh en gas f lo w i s bel ow th e c ri tica l flow ra te but encoun ters constric ti ons , cu rv es , v alv es , o r other i rregulariti es, an a rea of local ized turbule nce resul ts . The inc reas e in res is tance wi l l depend on the typ e and numbe r of obs truc ti ons e ncountere d. To minimi ze res is tanc e, gas -c onduc ting pa thwa ys sho ul d hav e minima l length and maxi mal internal d ia me te r and be wi tho ut sh arp c urv es or su dden c hanges in diameter.

Significance of Resistance
Res is tance imp oses a s tra in , esp eci al ly wi th v entil atory mod es where the patien t mus t do part or all of the respiratory work (e .g., spontaneous respi ra ti on, i nte rmi ttent mandatory v entila ti on, o r pressu re support v en ti la tion). Cha nges in resis tance tend to para ll el c hang es in the work of breathing. The tracheal tube is us ual ly the sou rce of more resis tanc e a nd a mo re i mportan t fac to r when determin ing the work of breathi ng th an the b rea thi ng s ys tem (4). The re is lac k of agreeme nt ab out wha t lev el of res is tanc e is excessiv e. A nes thes ia prov iders should be a ware o f how muc h resis tance c ompone nts of breathing s ys tems offer and to employ , wherev e r poss ib le , those of fering the leas t resis tance . For s ome patients , i nc reas ed expi rato ry resi s tance may be des i rab le . This should be ac hiev ed by us ing dev ices desi gne d for that purpos e. Fl ow-v olume loops (Chapter 2 3) can s how c hanges in res is tance to f lo w i n a breathi ng s ys tem.

Compliance
Compl ianc e is the ratio of a change in v olume to a c hange in press ure . It is a meas ure of dis tensi bi li ty and is usuall y express ed in mill ili ters pe r cen ti meter of water (mL/c m H 2 O). T he mos t d is tensible breathing s ys te m c ompone nts a re the reserv oi r ba g and the b rea thing tubes . Compl iance wi l l hel p to de termine the tid al

v olume (5). Compliance can be i llus trated graphical ly with a pressure-v olume loop (Chapter 23 ).

Rebreathing
Reb rea thi ng means to i nhale prev ious ly respi red gases from wh ic h c arbon dioxi de may or ma y n ot hav e been remov ed. There is a tendenc y to ass oc iate the word rebreathing with carbon di oxide ac cumul ation. This is unfortunate becaus e although i t is tru e that reb rea thing can res ult in highe r inspi re d c arbon di oxi de conc en trations than n orma l, i t is poss ib le to h av e pa rtia l or total rebre ath ing wi th out an inc reas e in ca rbo n d iox ide.

Factors Influencing Rebreathing Fresh Gas Flow

The amo unt o f reb rea thing v aries inv ersely wi th the to tal fresh gas f low. If th e v olume of fresh gas s uppl ied per minute is e qual to or greater than the patient's minute v olume, there wil l be no rebreathing, as long as prov is ion is made for unimpeded ex haus t to atmosphere o r to a sc av enging s ys tem at a point c lose to the pati ent's resp iratory trac t (6). If the to tal v olume of gas supplied per minu te is l es s than th e minu te v olume , some ex hal ed gas es mus t be rebreathed to make up the requi red v olume (as suming no ai r di lu tion).

Mechanical (Apparatus) Dead Space

Mechanical dead s pace is the v olu me in a bre athin g s ystem occ upi ed by gas es th at are reb rea thed without any c hange i n compos ition. Apparatus dead space ca n be minimi ze d b y sepa rating the i nspiratory and ex pi ra to ry gas s treams as cl os e to the pati ent as poss ibl e. If there is a l eak around a face mask , dead s pac e dec reas es (7). The mec hanic al dead s pac e s hould be dis tin guished f ro m the physi ological dead spac e, whic h inc lu des (a) ana tomical dead s pac e , cons is ti ng of the pa tient's conduc ting ai rwa y d own to the alv eoli , and (b) alv eola r dead s pace , which is the v olume of alv eol i v enti lated but no t perfused . The gas composi ti on in the mec hanical dead s pace wi ll v ary acco rding to wh ether i t i s occupied by anatomical dead sp ace gas , alv eola r gas, or mix ed exh al ed gas . Gas ex hal ed from the anatomic al dead spac e has a compos i tion s imilar to inspi red g as but is s a tu rated wi th water v apor and is warmer. Alv eol ar gas is sa tu rated wi th water v apor a t body tempe rature a nd has less ox yge n and more c arbon diox ide than inspi red gas . T he conc entra tion of anes thetic agent in alv eo la r gas wi ll differ

f rom that in the insp ired gas . Mix ed expi red gas wi ll hav e a c omp osi tion i nte rmed iate between that of ana tomica l dea d s pace and alv eol ar gas .

Breathing System Design

In addi tion to the ab ov e fac tors , th e v arious components of a breathi ng s ys tem may be arra nged s o that the re is mo re or less rebreathi ng. Chapters 8 an d 9 prov ide more details on breathing sys tems . P .194

Effects of Rebreathing
W ith no rebreathing, the compos iti on of insp ired gas is id entic al to that of the fresh gas deliv e red b y the an es thes ia mach ine. W ith reb rea th ing , the ins pired gas is co mposed partl y of fresh g as and partly of rebreathe d gas .

Heat and Moisture Retention

Fres h gas f rom the anes thesi a mac hine is dry a nd at room temperature. Ex hal ed gases are warm and sa turated wi th mois ture . Rebreathing re duces heat a nd mois ture loss f ro m the patient. In mos t breathin g s ys tems , heat is rapidly los t to atmosphere, and gas tha t is rei nhaled has a l owe r tempera ture and mois ture content than exhaled gas .

Altered Inspired Gas Tensions

The effec ts of rebreathing on inspi red gas tensions wi ll depe nd on what p arts of the ex hal ed gas es are rebreathed and whether thes e pass to the alv eo li (an d s o i nflue nce gas exchange) or only to the ana tomica l dead s pace .

Oxygen
Reb rea thi ng alv eola r gas wi ll caus e a reduction in the insp ired oxy gen tensi on .

Inha led Anesthetic Agents

Reb rea thi ng alv eola r gas ex erts a cus hi oning effec t on changes in inspi red gas co mpos i tion wi th a ltera tions in fresh gas compositi on. Du ring induc tion, wh en alv eola r tensions are lower th an those in the f res h gas flow, rebreathed a lv eolar gas wi l l reduce the i nspi red tens ion and prol ong i nduc tion. Du ri ng recov ery , th e alv eola r tension exc eeds that of th e i ns pired gases , and rebreathing s lo ws agen t el imina tion.

Carbon Dioxide

Reb rea thi ng alv eola r gas wi ll caus e an inc re ased insp ired carbon diox ide tens ion unles s the gas pass es th rough an abs orb ent befo re bei ng rebreathed. B ecause ca rbon d ioxide is concen trated in the alv eolar porti on of ex pired gas es , the ef fic ienc y with whi ch it is el imina ted f rom a breathi ng s ys tem v aries . If the s ys tem i s des igned so tha t alv eolar gas is p ref erentia ll y el iminated through the adjus table press ure limi ting (APL) v alv e or the v enti la tor s pill v alv e, c arb on diox ide re ten tion wi ll be mini mal , ev en with a low f res h gas flow. S ys tems that do no t mai nta in the separati on be tween fresh gas , dead s pac e g as , and alv eolar gas require re lativ el y high f res h gas flows to eliminate carbon diox ide. W ith s pontaneous res piration, c a rbon d iox ide retention is generally co nsidered undes i ra bl e. A l though the patient ca n c ompensate by inc reas ing minute v ol ume, a pric e is pa id in terms of i nc reased work of bre ath in g. In s ome cas es , compens ation by inc reas ing mi nute v ol ume may not be adequate. Durin g contro ll ed v enti lation , some ca rbon d iox ide in the inhaled gases may be adv antageous. Rebreathing wil l al low normocarbia to be ach iev ed des pi te hyperv enti lation. Hy poca rbi a can be av oided and heat and mois ture re taine d.

Discrepancy between Inspired and Delivered Volumes

The v olu me of gas disc harged by a v entil ato r or res erv oi r ba g usual l y differs f rom that wh ic h ente rs the patient. The v ol ume ac tuall y inspi re d ma y be les s or greater than th at deliv ered.

Causes of Increased Inspired Volume

W hen a v en til ato r is in use and the f res h gas flow ra te is greate r th an the rate a t whi c h i t is absorbed by the patient o r los t thro ugh leaks i n the b rea thing sys tem, the fresh gas fl ow del iv ered during insp iration may be a dded to the tidal v olume deliv ered by the v enti la tor (8,9). This augmen ta tion inc reases with hig her f res h gas f lows and I:E ratios and l ower respi rato ry rates (10 ). Modern anes thes ia v entil ators hav e been designed to eliminate the addi tional tidal v ol ume caused by f res h gas f low. For an in-depth discus sion of this s ubjec t and how mode rn v enti lators de al wi th i t, s ee Chap ter 12.

Causes of Decreased Inspired Volume

A red uc tion in the tidal v olume del iv ered to the patie nt wi ll res ult from gas co mp res sion and distention of breathi ng s ys te m componen ts du ri ng inspi ra tion (11). This is referred to as was ted ven tilati on. Was ted v enti lation inc reas es wi th i nc reas es in ai rway pressure, tidal v olume, i nc reas ed bre ath ing s ys tem v olume, and

co mponen t dis tensibi lity (11 ,12 ,13,1 4,15). P rop ortional l y, more of the set tidal v olume is los t wi th small p atien ts (11,16). Ti dal v olume is also dec reased b y leaks in the breathing sys tem. The amoun t los t wi ll depend on the s iz e and location of the leaks and the pressu re in the breathi ng s ys tem. Ti dal v olumes are bes t measured be twee n the pa tient and the b rea thing tubes (Chapter 23 ). Measuring tidal v olume at the end of the expiratory li mb wi l l re flec t i nc reas es caus ed by f res h gas flow and decre ases resu lting from l eaks in the breathi ng s ys tem but wil l miss dec reases f rom was ted v entilatio n. Leaks between the v olume sensor l oca te d a t the p ati en t port and the patient c an b e detec ted by co mpari ng the inspi re d and exhale d tidal v ol umes . If there is a signi fic ant l eak , th e ex hal ed v olume wi ll be les s than the insp ired v olume.

Discrepancy between Inspired and Delivered Oxygen and Anesthetic Gas Concentrations
The c ompos ition of th e gas mix ture that ex its th e mac hine may be modified by the breathi ng s ys tem s o that the mixtu re the patient i nspi res diff ers c ons ide rably f rom that de liv ered to the s ys tem. The re are seve ral contri bu ting fac tors . P .195

Rebreathing
The effec t o f reb rea th ing wi l l depend on th e v olume of the reb rea thed gas and i ts co mpos i tion . This wil l depend on the fac tors d is cuss ed prev iousl y.

Air Dilution
If the f resh gas suppl ied per res pi ration is less than the tidal v olu me , negativ e press ure in the b rea thi ng s ys tem may c ause air di lution if there is a leak . A i r di lu tion makes i t difficul t to main tain a stabl e anes the tic s tate. It caus es the conc en tration of anes the tic in the i nspi red mix ture to fa ll . This resul ts in a lighter l ev el of anes thesi a wi th s timula ted v entil atio n. The inc reas ed v en tila ti on causes more air d ilution. The o ppos ite is also true . Deep ening anes th esia depres ses v enti lation . Respiratory depression dec reases ai r dil ution , whi ch caus es an i nc reas e in the ins pired anes thetic agent c once ntration. Th is i n turn leads to f urthe r depressed respi ration .

Leaks

W hen a l eak oc curs , pos itiv e pressu re i n the s ys tem wi l l fo rc e gas out of the s ys tem. The composi tion and amount of the gas l os t wi l l depend on the loc ation a nd s ize of the leak , the p res sure in the s ys tem, a nd th e c ompl ia nce and resis tanc e of both th e s ystem and the patient.

Anesthetic Agent Uptake by the Breathing System Components

Anes thetic agents ma y be tak en up or adhere to ru bber, plas tics, me tal , and c arbon diox ide absorbent (17 ). This wi l l lo wer the ins pi red c oncentration. Uptake wi l l be di rec tly propo rtional to the c oncentration g radient between the gas and the co mponen ts , th e parti ti on coeff ic ie nt, the s urf ace area, the diffus ion coeffic ient, and the square root of time.

Anesthetic Agents Released fr om the System

E limination of anes thetic a gent f rom the breathi ng s ys tem wi ll d epend o n the s ame fac tors as uptake. T he s ys tem may func ti on as a low ou tpu t v apori ze r for many hours af ter a v apo ri zer has been turned OFF ev en if the rubber goods and absorbent a re c hanged. This can resu lt in a patient being inadv erten tl y expos ed to the agen t.

Common Components
Some co mponents a re found i n onl y o ne type of breathi ng s ys tem. Thes e wil l be disc ussed under the i ndiv idua l s ys tems . Oth ers c ompon ents are f ound i n more than one s ys tem, mak ing thei r inc lus ion in a general c hapter s uch as this a ppropria te.

Bushings (Mounts)
A bus hing s erv es to modif y the internal d iame ter of a component. Mos t of ten , it has a c yli ndric al form and is inserted into, and beco mes part of , a pliable comp onen t such as a res erv oi r bag or a breathing tube.

Sleeves
A s leev e al ters the ex ternal diamete r of a co mponen t.

Connectors and Adaptors

A connec tor i s a fi tting intended to j oin tog eth er two o r more s imi la r components . An ada ptor is a spec ialized connec tor that es tabl is hes f unc ti onal conti nui ty be twe en otherwi s e disparate o r inc ompa ti bl e components .

An ada ptor or c onnec to r may be dis tinguished by (a) sh ape (e .g ., s trai ght, ri ght angle or elbow, T, o r Y ), (b) c omponent(s ) to whi ch i t is attac hed, (c ) added features (e.g., wi th nippl e or APL v alv e), a nd (d ) si ze and type of fi tting a t ei the r end (e.g., 15-mm male, 22 -mm fema le). A ll anes thesi a breathi ng s ys tems termina te at the patient c onnec tion po rt. This is the point whe re the bre ath ing s ys tem connec ts to a dev ic e tha t es tabl ishes continuity with the p ati ent's res pi ratory s ys tem (a trac heal tube, f ace mas k, or supraglo ttic airway dev ic e). A ll face mask s hav e a 22 -mm femal e opening whil e mos t oth er dev ic es hav e a 15mm male fitti ng . To fac ili tate the change from mask to trachea l tu be, and the l ik e, a co mponen t hav ing a 22 -mm male f itting wi th a c oncentric 15-mm female fitting is us ed at the patient co nnec tion port. Us uall y, this c omponent is a ri ght angle connec tor (Fi g. 7.2), also known as an elbow adapto r, elbo w j oi nt, el bow c onnector, mask angle piece, mask adap to r, or mask elbow. Connec tors and adapto rs ca n be used to:

Ex tend the dis tanc e between the patien t and the bre athing s ys tem. This is es pecial l y i mportant in head and n eck s u rge ry whe n the prese nce of the breathi ng s ys tem near th e head may mak e it i nac cess ib le to the anes thes ia personnel and/or i nterfere with the s u rgica l field.

Change th e angl e of co nnec tion betwee n the patient and the breathing s ys tem. A llo w a more flex ible and/or les s k inkable connec tion between the patient and the breathing s ys tem. Inc rease the dead s pac e.

A v arie ty of c onnec tors a re av ailabl e (F ig. 7.2 ), a nd many more hav e been desc ribed in the li terature. In selec ti ng a c onnec tor, s ev e ral princ iples sh oul d be kept i n mind. P .196

View Figure

Figure 7.2 Various connectors. 1: A swivel connector that can be used to insert a flexible fiberscope. It has a flexible accordion-type side arm. 2: A flexible metal connector that can be used between the tracheal tube and the breathing system. It cannot be used with a mask. 3: Straight connector with a side gas sampling port. 4: Right angle connector for insertion of a flexible fiberscope. It can accommodate different sized fiberscopes by changing the diaphragm. The large cap is used if no diaphragm is present. 5: Right angle connector with gas sampling port.

Res is tance inc reases wi th s harp curv es an d roug h s idewal ls . Connec tors add dead s pac e if posi tioned betwe en the b rea thing s ys tem a nd the patie nt. In the adul t pa ti ent, this may n ot be of much s ignificance. Howev er, in i nfants , an y inc rease in d ead space may be ex cess iv e.

Connec tors inc reases the numbe r of l oca tions at which disconnec tions ca n oc cur.

Reservoir Bag
Mos t breathin g s ystems hav e a rese rv oir b ag, als o k nown as the respi ratory, breathi ng, o r sometimes erroneous ly, reb rea thi ng, bag. Mos t bags are c ompos ed of rubber or plas tic a nd are e ll ipsoidal in shape s o that they ca n be gras ped easi ly wi th on e hand. Latex -free reserv oi r bags a re av ailable. The nec k is the part of the bag that connec ts with the b rea thing s ys tem. The neck mus t h av e a 22-mm f emale connec tor (18,19 ). Th e tail is the end opposite from the neck . A loop may be prov ided near the ta il to hol d th e bag ups ide do wn, whic h fac il itates dry in g i f the bag is re usab le . The bag has the foll owi ng func tions :

It al lows gas to ac cumul ate during exhalation. Th is prov ides a res e rv oir of gas for the nex t inspi ra ti on. This permi ts rebreathi ng, allows more ec onomical use of g ases , and prev ents a ir d ilution.

It prov ides a means wh ereby v en ti la tion may be as sis ted or con trolled. It can se rv e through v isual and tac tile observ ation as a moni tor of a patie nt's spontaneous respi rati on (20 ). Bec ause the bag is the mos t dis tens ible part of the breathing sys tem, it protec ts the pa tient from exces siv e pressu re in the breathing s ys te m.

The pres sure-v olume c harac teris tics of b ags become important if there is no wa y for gas es to es cape f rom the s ys te m an d i nflo w c ontinues . Adding v olume to a bag normal ly c aus es a negl ig ib le ris e in pressu re until the nomin al ca pac i ty is reach ed. As more v olume c ontinues to be added, the pressu re rises rap idl y to a pe ak and then reaches a p la teau. As the bag dis tends furthe r, the press ure fal ls sl ightly . The peak pressure is of parti cular interes t, bec aus e this rep res ents the max imal press ure that c an dev elop in a breathing s ys tem. The A merica n S oc iety for Tes ting and Materials (AS TM) s tandard for res erv oir b ags requi res that for bags of 1.5 L or smal ler, the p res sure s hall be no t less than 30 cm H 2 O or ov er 50 c m H 2 O when the bag is expanded to fo ur times i ts c apac ity (1 8). For bags larger than 1 .5 L, the press ure s hal l be not les s than 35 cm H 2 O o r ov e r 60 cm H 2 O when the bag is ex pand ed to four times i ts s iz e. La tex -f ree rese rv oir bags may all ow higher press ures to dev elop (21 ). New bags dev elop g rea ter p res sures when fi rs t ov erinflated th an do bags that hav e been ov erinflated sev era l times or hav e been pres tretched (22). It is g ood prac tic e to ov erin flate o r s tretch a new bag duri ng the pre use checko ut. This wil l no t li mi t the abi li ty to produc e high air way press ures when the bag is s quee zed. Bags are av ailab le in a v ariety of si zes . The s iz e that shou ld be us ed wil l depend on the patient, the breathing sys tem, and the use r's preferenc e. A 3-L b ag is trad itional f or use in ad ults . A larger bag ma y be diff ic ult to squeeze and wil l mak e moni tori ng the patie nt's spontaneous respi ration more dif ficul t because the ex cursi ons wi ll be smal le r. A smal l bag, on the other hand, p rov ides les s safety wi th res pec t to p res sure fl uctuations and ma y not prov ide a l arg e enoug h res e rv oir or ti dal v olu me. A spare bag s hould al ways be k ept immediate ly av ai lable in c as e the bag dev elops a le ak or becomes l os t.

Breathing Tubes
A la rge -bo re, c orrugated plas tic breathi ng (c onduc ting) tub e (hos e) prov ides a f lex ib le , lo w-resis tanc e, l igh twe igh t c onnecti on from one part of the s ys te m to

anoth er. Corrugations inc reas e fl exibi li ty and help to prev ent k ink ing . B re ath ing tubes hav e some dis tens ib il ity but not enough to prev ent excessiv e press ures from dev el oping. S maller diame ter breath ing tubings a re av ail able f or c i rc le s ys tems us ed for pedi atric patients . The re P .197 are international a nd U.S . s tandards for breathi ng tu bes (23,24).

Figure 7.3 Some breathing tubes can be extended or compressed. Note the filter. (Picture courtesy of Kendall Healthcare Products, a division of Becton Dickinson.)

View Figure

If it is nec ess ary to hav e the anes thes ia mach ine at some dis tanc e f rom the pati ent's head, s ev eral breath ing tubes ma y be conn ec ted in s eries or ex tra-lo ng tubi ngs can be used . Spec ia l tubings that ca n be elongated are av ail abl e (Fig. 7.3). A tube holder (tree) (Fi g. 7.4) c an be use d to s upport breath ing tubes and prev en t them from exerti ng a pull on the ai rwa y d ev ice.

Figure 7.4 Tube holder. The large rounded openings are for adult breathing tubes. The opposite openings are for pediatric tubes. The small grooves can be used for pulse oximeter cables, gas sample lines, pressure monitoring lines, blood pressure tubing, and the like. The device can be rotated.
View Figure

Adjustable Pressure-Limiting Valve

The A PL v alv e is a us er-adjus table v alv e that releas es gas es to a sc av engi ng s ys tem. It is us ed to control the press ure i n the b rea thi ng s ys tem. Other commonly us ed names for this c ompon ent inc lud e p res sure rel ief v alv e , v en ting port, rel ief v alv e, ov e rs pill v alv e, pop-off v alv e, ov erfl ow v alv e, dump v alv e, blo w-o ff v alv e, safety re lief v alv e, ex ces s v alv e, He id brink v alv e, adj us tab le press ure l imi ter, ex cess g as v enting v alv e, s pi ll v alv e, exhaus t v alv e, ex pi ratory v alv e, excess gas v alv e, press ure release v alv e, and release v alv e.

Construction Control Part

The c ontrol part serv es to control the pressure at whi ch the v alv e opens . Mos t of these v alv es are c alibrated fo r the o pening press ure (s ee Fi gs . 7.8 , 7.9). Sev eral types are av ail able.

Spring-loaded Disc
The mos t commo nly us ed AP L v alv e uses a disc held onto a s eat b y a s pri ng (Fig . 7.5). A threaded sc rew cap ov e r the s pring al lows the p res sure ex erted by th e sp ri ng on the dis c to be v aried. W he n the ca p is full y tigh tened, the disc wi ll prev ent any gas from esca pi ng from the s ystem. As th e c ap is loos ened, the tensi on on the s pring is reduc ed so that the dis c can ris e .

W hen the pressu re in the breathi ng s ys tem i nc reas es , i t ex erts an upwa rd forc e o n the disc . W hen this upwa rd P .198 forc e exce eds the down wa rd forc e exerte d b y the sp ri ng, the disc ris es and gas f lows through the v alv e . W hen th e pressure in the s ys tem f alls , the disc returns to i ts seat. When the c ap is at its maximum open pos ition, there wil l be only minimal press ure ex erted by the spring. This al lows th e patien t's exh ala tion to l ift the disc wi th on ly minimal press ure . The wei ght o f and press ure on the disc ens ures that the reserv oi r ba g f ills before the disc ris es .

Figure 7.5 APL valve with spring-loaded disc. Gas from the breathing system enters at the base and passes into the gas collecting assembly at left. Turning the control knob varies the tension in the spring and the pressure necessary to lift the disc off its seat. When the cap is fully tightened, the spring is compressed enough to prevent the valve leaflet from lifting at any airway pressure.

View Figure

Figure 7.6 APL valve with stem and seat. Rotation of the control knob causes the opening between the stem and seat to change. The disc ensures that the reservoir bag will fill before the valve opens. It also prevents transmission of positive pressure or gas from the scavenging system to the breathing system. (Redrawn courtesy of North American Drager, Inc.)
View Figure

Inc rease d pressure down s tream of the AP L v alv e wi l l inc re ase the pressu re nee ded to open the v alv e. P os i tiv e end-expi ra tory pressu re (P E EP ) may then be transmitted to the pa tient.

Stem and Seat

Ano the r con trol pa rt emp lo yed in AP L v alv es is the s tem and seat (Fig . 7.6). This is s imilar to a flow c on trol v alv e in th at a th rea ded s tem allows v ariable con tac t wi th a seat. As the v alv e is opened, the opening at the seat bec omes larger and more gas i s all owe d to esc ape. S ome of these v alv es hav e a d isc o r bal l v alv e in a retai ning cage (Fig. 7 .6). This se rv ed the dual func tion of prev enting gas from the sc av engi ng s ys tem from flowi ng bac k into th e b rea th ing s ys tem a nd supply in g a s light pres sure to k eep the reserv oi r ba g infl ate d. S tic king of this part has been reporte d (25).

Control Knob
Mos t APL v alv es hav e a rotary control kn ob. The A S TM s tandard requires that v alv es with rotating controls be des igned s o that a c lock wi se motion inc reases the l imi ting press ure and ultimately c los es th e v alv e (1 ). It also requi res a n a rrow or other ma rki ng to indic ate the di rec ti on of mov emen t requi red to c lose the v alv e (Fig . 7.8A ). The s tanda rd recommends th at the ful l range of rel ief press ure be adjus ted b y les s than o ne full turn of th e contro l. S ome of th ese v alv es are marked to s how th e p res sure at which they wi ll open (Figs. 7.7, 7 .8).

Collection Device and Exhaust Port

In o rde r to remov e ex ces s gases f ro m the breathing s ys tem and di rec t them to a sc av engi ng s ys tem, they mus t be c ollec ted by us in g a c ollec ti on dev ic e a t th e APL v alv e. The gases are then direc ted to the sc av enging s ys tem through th e transfer tubi ng. The exhaus t port is the apertu re thro ugh whi ch ex cess gases are disc harged to the scav enging s ys tem. It mus t hav e a 19 - or 30-mm ma le co nnec tor (26). Anes thes ia g as scav eng ing is discusse d i n Chap ter 1 3.

Use Spontaneous Respiration

W ith s pontaneous res piration, the APL v alve remains cl osed d uring i nspi ration and opens during exha lation. No rmal l y, the v alve is ful l y open during s ponta neous v enti lation . It should be c los ed sl igh tl y only if gas is withdrawn from the b rea thi ng s ys tem by negativ e pressu re from the s cav engi ng s ys tem and the reserv oir bag co ll aps es . P a rtia lly c los ing the v alv e during spon taneous resp iration wi l l res ul t i n continuous pos itiv e ai rway pres sure (CPAP ). P .199

Figure 7.7 APL valve with spontaneous/manual changeover. Note the pressures markings. A: When the lever is in the spontaneous position, the valve is fully open, regardless of the set pressure. B: When the lever it is placed in the manual position, the knob is rotated to adjust the opening pressure. C: In the manual position, the valve can be fully opened by pressing down on the lever.

View Figure

W ith s pontaneous res piration, the anes th esia prov ider mus t be cons ta ntly awa re of v olume of gas in the ba g. If attention is div erted, the bag ma y c ollapse or become ov erd is ten ded. Negativ e pressure trans mitte d f rom the scav engin g s ystem may

caus e gas es to be ev acuated from the breathing sys tem. A n obs truc tion in the sc av engi ng s ys tem may resul t i n the ba g becoming ov erd is ten ded and the pati ent being s ubjec ted to CPA P .

Manually Controlled or Assisted Ventilation

Durin g ma nual ly c ontro ll ed or assis ted v en tila tion, the v alv e is us ual ly lef t partial ly open. Duri ng inspi rati on, the bag is squeeze d and pressu re i nc reas es until the relief P .200 press ure is reached. Before this , the patient rece iv es al l of the gas dis plac ed from the bag (les s a s mall amoun t due to gas compres s ion and expans ion of the tubes ). Onc e the A PL v alv e o pens , the a ddi ti onal volume that the patient receiv es is determined by the relativ e res is tances to f low e xerted by the pa tient and the A P L v alv e.

View Figure

Figure 7.8 Another type of APL valve. The control knob is rotated counterclockwise to increase the opening pressure. A: The valve is set for manual ventilation. The valve can be fully opened by pulling up on the control knob. B: The valve is set for spontaneous ventilation. Note that the control knob is slightly elevated.

The A PL v alv e mus t be adjus ted on the b asis of c hes t mov ements and /or exha led v olume or pressure measu reme nts to ac hi ev e the desi red lev el of v entilation and to mai ntain a dequate bag v olume. Th e res is tance fel t duri ng bag c ompression (the educated hand) cannot be relied on to ensu re adequate v en tila ti on (27,28,29). If co mpliance fal ls or res is tance i nc reas es , the v alv e mus t be tigh tened. If the fresh gas fl ow i s inc reased or dec reased, the APL v alv e mus t be opene d o r c losed so me what.

Some AP L v alv es hav e a lev e r fo r c han gi ng between sp ontaneo us and manual v enti lation (Fig . 7.7).

Mechanical Ventilation
Bag -v entilator s elec tor s wi tc hes (s elec tor va lv es) that faci l itate the c hange f rom manu al to automatic v enti lation are av ailable and are discus sed i n Chapter 9. These is olate the APL v alv e wh en the s elector v alv e is tu rned to automatic v enti lation . W hen is ol ated from the breathing s ys te m, the APL v alv e need no t be c los ed during mec hanica l v enti lation.

Positive End-expiratory Pressure Valves

PEE P an d c ontinuous ai rway pressu re (CPAP ) are used to improv e ox ygenation (30). PEEP may be used with spon taneous o r contro lled v enti lation . CPAP is used during s pontaneous v entil ation and during one-lung v enti la tion (C hapter 20 ). Some older anes thesi a machines had ma nual ly c ontro ll ed PEEP v alv es tha t were a co mponen t of the breathing s ys tem. Newer anes thes ia mach ines hav e e lec tronica ll y control led P EEP v alv es (Chapters 9, 12). Fo r a machine not equipped with a PE EP v alv e, a dis pos able P EEP v alv e can be p laced i n the ex halation l imb (Fig. 7.9). Fixed -press ure P E EP v alv es are mark ed to i ndicate the amount of PEEP that they prov ide (Fig . 7.9B ). More than one c an be used to obtain a n addi tiv e effec t. Vari able-p res sure PEEP v alv es hav e a means to adjus t the amou nt of P EEP . S ome hav e a s cale that indicates the P EEP at a giv en se tting. If no sca le is present, a mano mete r mus t be used to me asure the p res sure. A P EEP v alv e can be uni direc tional or bi di rec tion al (31). A b idi rec tio nal v alv e has a second f lo w c hannel wi th i ts own o ne-way v alv e. It has been reco mme nded that only bidi rec tional PE EP v alv es be used (32). Onl y a bidirec tional v alv e should be us ed between the breathing s ys tem and the v enti la tor. It is important that a disposable PE EP v alv e b e p laced i n the c o rrec t pos i tion and oriente d properly. The AS TM s tanda rd re quire s tha t a P EE P v alv e be mark ed wi th an arro w i ndica ting the p roper di rec tion of gas f low or the words inle t and ou tlet or both (1 ). Immediatel y after a PEEP v alv e is inserted, the bre ath ing s ys tem pressure gauge s hould be c hec ked to mak e certain th at PEEP is bei ng del iv ered, and the pati ent s hould be c hecked f or effec tiv e v enti lati on. A unidi rec tional PEE P v alv e i ncorrec tly oriented agai ns t the fl ow o f gas in the insp iratory or expi rato ry l imb wi ll block g as fl ow (3 1,32). Inc orrec tl y ori enting a bidirec tional P EEP v alv e in either the i nspi rato ry or expi ra tory li mb wil l not obs truc t flow, bu t no P EEP wi ll be appl ied.

If a PEEP v alv e is used wi th a ci rc le breathing sys tem in whic h the p res sure gauge i s on the absorber s id e of P .201 the expi rato ry un idi rectio nal v alv e, PEE P wi l l not be ind ica te d on the gauge (33,34,35). The us er mus t depe nd on the accurac y of the PE E P v alv e mark ings to determine the lev el of PEEP or use a sec ond pressu re gauge ups tream of the P EEP v alv e to determine the ac tual pressure (31).

Figure 7.9 Disposable positive end-expiratory valve. A: Side view. Note that is shows the direction of flow. B: Top of PEEP valve showing the amount of PEEP.
View Figure

Us ing PEEP in a s pontaneous ly breathing patient wi ll res ul t in inc reas ed work o f breathi ng (36,37). Us ing PEEP with certain v enti lato ry modes may res ul t in a subs tantia l dec rease in the tidal v ol ume deliv ered to the patient. The breathi ng s ys tem may b ecome oc cluded and baro trauma may resul t if a PEEP v alv e malfunc tions (38).

Filters
Fi lters are used to protec t the pa tient f rom mic roorganisms and a irborne particu la te matte r and to p rotec t anes thes ia e quipment and the env i ronment from exhaled contamina nts . W hen plac ed between the patient and the breathing s ys tem, a f il ter may he lp to i nc rease th e i ns pired humi di ty (see heat and mo is ture exc hangers in Chapte r 11). Another benefi t of fil ters is prev en ting exp osu re to latex al le rge ns (39).

The use of f il te rs is controv ers ial (40,41,42,43,44,45,46 ,47 ,48 ). Conv incing ev ide nce that thei r us e is of benefi t in preve nti ng pos toperativ e inf ec tions is l ack ing . P roblems with fi lters (s ee below) h av e res ul ted in serious complications . The Cente rs f or Diseas e Control and P rev en tion (CDC) and the A merican Soc iety of Anes thes iologis ts (A SA ) make no recommen dation f or plac in g a f il ter i n the breathi ng s ys tem unles s the re is s usp ic ion that the pa tient has an infec tious pulmonary disease (45,49). The Ass ociatio n o f Anaes thetis ts of Great B ri ta in and Irel and (AA GB I) and others rec ommend that e ither a f il ter be plac ed between the pati ent a nd the b rea thi ng s ys tem wi th a new f il ter being us ed fo r eac h adul t patient or that a new b rea th ing s ys tem b e used for each patie nt (50). S tu dies show that f il te rs do become c on ta mi na ted on the mach ine s id e (50A ). For pediatric patients , the inc re ased res istanc e and relativ e ineff ici enc y of pediatric fi l ters may make other me ans of humid if ic ation and inf ec tion con trol more attrac tiv e (51,52 ,53 ). The AA GB I rec ommends that f ilters not be us ed fo r pediatric pati ents ; rath er, the breathi ng s ys tem s hould be rep lac ed between c ases . Two i nternational s tand ards c ov er fi lters (54 ,55 ). T hese s tipulate that the fil ter manufac tu rer mus t declare the fi l trati on pe rformance, as wel l as press ure drop and i nte rna l v olume , but the ranges wi thin wh ic h f il ters mus t perf orm are not giv en .

Types Mechanical Filters (Pleated Hydrophobic)

Mechanical filters uti l ize a c ompac t fi ber ma trix . The y a re pleated to inc rease su rface area. They hav e v ery s mall pores and ac t by ph ysical ly prev enting mic roorganisms and pa rtic les f rom passing.

Electrostatic Filters
E lec tros tatic fil ters us e a fel tl ik e ma terial that is pol arized in an elec tromagn etic f ield. They rely on e lec trostatic forc es to hol d o rga nis ms within a l oosel y wov en charged filter eleme nt. The fibe rs are les s dens e tha n thos e in mechanical filters ; hence, the po re s i ze is g rea te r. Mos t s tudi es show that the fil tration performanc e of these f il ters is less satisfac tory than that of mechanical f i lters , espec ially wi th ex treme chal lenges (50 ,56 ,57 ,58,59,60,61,62,63,64,65,66,67). Howev er, cl in ic al s tudies s how tha t they are e ffec tiv e in preve nti ng breathi ng s ys tem c onta mination during c l in ical use (50A ,68,69 ). Both types of f ilters a re manufac tu red wi th a nd withou t addi tional heat and mo is ture ex change el ements .

P .202

Filtration Efficiency
Fi lter effic ienc y v a ri es (4 8). A high -effici enc y particulate aerosol (HEP A )-gra de dev ic e is de fi ned as one c apable of trapping at leas t 99 .97 % of parti cl es hav ing a diameter of 0.3 m (70). Fil ter effic ienc y depends on the expe ri mental tes t condi tions . The refore, whe n f ilter effic iency is s tated, the s ize of the c hallenge partic le or o rganis m s hould be disclos ed. Th e approx imate s iz e of the h uman i mmunodeficienc y v irus (HIV ) partic le is 0.08 ; he patitis C v i rus , 0.06 m; myc obac teri um tube rc ulosis , 0.3 m; pse udomonas aeruginos a, 0.5 ; and s taphlococc us aureus , 1.0 .

Filter Location in the Breathing S ystem

Fi lters used i n anes thes ia breathing s ys tems are supp lied in three fo rms : (a) attached to a dis posable b rea thing tube (Fig . 7.3), (b) a ttach ed to a v enti la tor hose , and (c ) as a s eparate c omponent. A f i lter plac ed at the patient port may pe rmi t disposable breathi ng s ys tems to be reus ed. Howev er, the ex ternal surface of these s ys tems wil l no t be protec ted. A fi l ter s hould not be placed do wns tream of a humidif ier or nebuli zer, bec ause i t may become less effic ient when wet. In addi ti on, an inc rease in resis tanc e, so me times to a ha zardous lev el, may be s een .

Problems Associated with Filters Increased Resistance and Dead Space

A fi l ter i nc reases the res is tance to g as fl ow (7 1,7 2). Res is tance wi l l inc rease as condensatio n accumula tes (73,74). W hile inc reas ed res is tance is us ual l y not a problem during c ontrol led v en ti la tion, it may b e p rob le ma tic with sponta neous respi ra tion. Adding a fil ter between the pati ent a nd the breathi ng s ys tem inc reas es the dead spac e. Unless v en ti lati on is inc reas ed , s ignificant re bre ath ing c an occ ur (75). Sponta neousl y breathing p ati ents who de rive a majo r portion of thei r minute v olume f rom s ha llow breaths may fi nd the inc re ase i n d ead sp ace exc ess iv e (70). A la rge f il te r s hould no t be us ed in this l oc ati on wi th pediatric patien ts . Pediatric fi lters are av ailab le.

Obstruction

Fi lters may be obs tructed by ex haled bl ood, edema or regu rgi ta te d f luid , a manufac tu ring def ec t, s teril ization of a dispos abl e filter, neb ul ized dru gs , o r i nserting a un idi rec tio nal f il ter bac k ward (76,7 7,78,79,80,81,82,83,84,85,86). A f il te r s hould no t be us ed with a patien t who produc es cop ious sec retions or downs trea m of a humidifie r or nebul iz er. An inc rease in peak inspi ra to ry press ure may i ndicate the n eed to repl ac e a fil ter.

Leaks
A defec t in a fil ter c an cause a leak (79 ,87 ).

Liquid Penetration
S ince f il ters l oca ted betwe en the b rea thing s ys tem and the pa tient are s ometimes ex posed to liquids , the abili ty to c on tain that l iquid is important. Mic robes ca n trans i t the f ilter by way o f a li quid that pas ses through a fil te r. Th ere is a great v a ri abili ty among fil te rs in regard to the press ure that wil l c ause liqu id to pene trate the filter ma teri al (8 7A ). In general, pleated mechanic al f il ters are more resis tant to l iquid passage than electros tatic fi lters .

Other
Us ing a fi l te r between the patie nt and the breathing s ys tem may resul t i n erroneous end-tidal gas conc entrations and p oor c a rbon dioxi de wav eforms (88 ,89 ,9 0,91).

Equipment to Administer Bronchodilators

Intraopera tiv e bronc hospasm c an be a v ery seri ous problem. S tudi es show that medications admi nis tere d b y the inhalati onal rou te are jus t as ef fec tiv e as pare nte ral therapy with fe wer s ide effec ts (92,93).

Apparatus
Manufac tu rers hav e a dapted metered-dose inhalers (MDIs ) f or us e with anes thesi a breathi ng c i rc uits . A n i nhale r may be placed i ns ide the barre l of a l arg e s yring e and ac tua ted by p res si ng th e s yri nge p lunger (94,95,96,97 ). Mos t adapte rs are Tshaped wi th the in jec ti on po rt on the si de (Fig . 7.10). Numerous co mme rc ial adapters and homemade dev ices hav e bee n d esc ribed in the l iterature (98,99,100,101 ,102,103,104 ,10 5,106,107 ,10 8). The gas sa mpli ng po rt in the breathi ng s ys tem or the sa mp li ng lumen of a s peci al ized trach eal tube (Chapter 19) may be us ed to de liv er medications (96 ,109). Medic ation may be deliv ered by a ca the ter tha t ex tends to the tip of the trac he al tube. This me tho d res ults in mo re ef fic ient deliv ery (94,110 ,111,112).

The adapter s hould be placed c los e to the patien t port. There s hou ld no t be a fi lter or heat and mois ture exc hanger (H ME ) between the adap ter and th e patien t. A spacer (aerosol hol di ng cha mber, res erv oi r chamb er, auxi l iary or ac ces sory dev ic e, [ex tens ion o r res erv oi r]) (F ig. 7.11) may be pl aced downs tream or ups tream of the MDI to slo w the f low of aerosol and to inc reas e i mpac tion and s edi mentation of large partic les (113,114 ). Rigid spacers res ult in more eff ic ient med ica tion deliv ery than c ol la psible ones (115). Aeroso l nebulize rs may also be us ed to deliv er bronchodi lators to an anes thesi a breathi ng s ys tem. The gas us ed to ae ros ol iz e the agent wi ll affec t th e c ompos ition of the inspi red gas (116).

Technique of Use
The inha ler s hou ld be shake n we ll p ri or to admi nis tration (93). B ronchodi lato r disc harge is max imal when the canis ter is upright. The hole in the adapte r s hould point towa rd the patie nt, unless an upstream s pacer is used. Ac tua ting the inh al er j us t after ins pi ration begins wil l P .203 maxi mi ze deliv ery to the airway s (117 ). If a spac er is used, the MDI s hould be ac tua ted 1 to 2 s econ ds bef ore ins piration or nea r end-exhalation, depending on the rate (118).

Figure 7.10 Adaptor for administering bronchodilators by using a multidose inhaler. Note the cap that can be fitted over the port when it is not in use. The hole in the inhaler should port toward the patient unless an upstream spacer is used.

View Figure

A s low, de ep inspi rati on, f ol lo wed by a paus e of 2 to 3 seconds b efore ex halation , wi ll enhance the amount of medica tion dep os i ted into the a irway (1 17,119,120 ). The re sh ould be 30 to 60 s econds between puffs . The inhale r mus t b e s hake n prior to each puff (93,118 ). Low humidif ic ation is des i rable when deliv erin g medic ation (93,115 ). High humidific a ti on causes the aerosol droplets to inc rease in s i ze, wh ich c auses the m to rain out. If poss ible, humidific ation should be disc ontin ued when an MDI is used. Us ing a spacer wi l l inc rease bronc hodil ator del iv ery and re duce the number of puffs (92). Howev er, ev en wi th a sp acer, as man y as 10 to 15 puffs may be req ui red to reach the des ired resul ts (92,121). The p atien t should be mon itored for the appearanc e of benefic ial and si de eff ec ts .

Figure 7.11 Multidose inhaler with downstream spacer in place between the breathing system (right) and the patient connection (left).

View Figure

Advantages
MDIs a re easy to us e, take l ittle time to se t up, and occ upy l ittl e space on the anes thes ia cart (122). They are more effic ient at del iv eri ng medica ti ons a nd les s cos tl y than nebuli ze rs (114,118 ,123,124).

Disadvantages
A la rge amo unt of drug is l os t due to ra inout i n the b rea thing s ys tem and trac heal tube. Improper tec hni que is one fac tor (125). The smaller the tracheal tube , the more drug is deposi ted in the tube (112 ,115,117). Ano the r problem is that the carri er gas may caus e erroneous re adi ngs wi th an anes thetic agent anal yze r (125,1 26) (Chap ter 22).

Size and Type of Fittings

The Co mp res sed Gas As soc iation (CGA ) and the A S TM hav e pub lished s tandards that s pec if y the si ze and type of fi ttings for co mponen ts in the breathi ng s ys tem (1,18,23). V irtually al l breathi ng s ys tem c omponents manufactured in th e United S tates in recen t yea rs co nfo rm to these s tan dards . The s af ety p rov ided by s tandard iz ing the diameters of v arious connec tors can be jeopa rdi zed by the use of adaptors and adhes iv e tape. Any c omponent or accessory use d in th e b rea th ing s ys tem tha t permits onl y unidi rec tional f lo w o r any dev ic e whose c orrec t func tion depends on the di rec tion of gas fl ow through i t mus t be so labeled and marke d wi th an a rrow in dic ati ng the

proper direc tion of f lo w o r the wo rds inlet an d outlet o r both. Dis tal and proxima l are P .204 us ed to designate the prox imi ty of a c ompon ent to the pa tient. A fi tting that is p art of a componen t s uc h as a n abso rbe r, Y-piece , or reserv oi r bag moun t, wh ose pu rpose is to permi t attaching this c omponent to a res erv oi r bag, breathi ng tube, or mask , mus t be male and rigid. F ittings on the breathi ng tu be, mask , and rese rv o ir bag connec tors mus t be female and non ri gid (res ilient). A ll c onnec tors in an a dul t breathing s ystem are 2 2 mm. The patient port mus t hav e a c oaxi al 15 -mm f emale fi tting. The inspi ra tory and ex piratory ports moun ted on the absorber and the reserv oi r bag c onnec tor mus t hav e mal e fi ttings . To av oid problems wi th c onnec tions be twe en the breathi ng and s cav engi ng s ys tems , the ex i t port f or the AP L v alv e mus t hav e either a 19 - or 30 -mm male fitti ng . A 30-mm fi tting i s preferre d.

Breathing System Classification

A fav orite pas time among anes thes ia prov iders has been the c las si fication of breathi ng s ys tems . The resul t has been a hopelessl y confused termi nology . The re i s no agreement abou t how breathing s ys tems s hould be cl ass if ied. In a n a ttempt to prov ide so me relief from this confus ion, a des c ripti on of v a rious au tho rs ' c las sif ications wi ll b e p res ented. S ubsequen tl y, a nomenc lature that the present autho rs bel iev e is more us efu l wi ll be desc ribed.

Classification by Function
Dripps, Eckenhoff, and Vandam
W ith this c las s ificati on, breathi ng s ys tems are div ided into f iv e catego ries ac cording to the presenc e or abs ence of (a) a rese rv o ir bag, (b) rebreathing, (c ) an absorber to remov e carbon diox ide, and (d ) di rec ti ona l v alv es (127). T he fiv e s ys tems are ins uffla ti on, open, s emiopen , semic lose d, an d c losed. The insu ffla ti on s ys tem is one in whic h gases a re de liv ered di rec tl y into the pati ent's airway. T here a re no v alv es , res e rv oir bag, or c arbon diox ide absorption . In the open s ys tem, the pa tient inhales onl y the mix ture deliv ered by the anes th esi a machine. V alv es direc t each ex hal ed breath into atmosphere . A res e rv oir bag may or may not be prese nt. Rebreathing is mi nimal, and there is no c arbon diox ide

absorpti on. This inc lu des s ys tems us ed wi th intermi tten t flow anes thes ia machines and n onrebreathing v alv es . In the se miopen sys tem, exha led gases f low o ut of the sys tem and to the i nspi rato ry l ine of th e apparatus to be rebreathed . There is no c hemic al absorption of c arb on diox ide. Rebreathin g depends on the fresh gas fl ow. A reserv oi r bag and a di rec tional v alv e are optional . In the se mic los ed sys tem, part of the exhale d gases passes into atmosphere an d part mix es wi th f resh gases and is rebreathed . Chemica l abs orp tion of c arbon diox ide , di rec tional v alv es, and a reserv oir bag are prese nt. In the c los ed s ys tem, there is c omplete rebreathing of ex pi red gas . Carbon d iox ide absorpti on, a res erv oir bag, and di rec tional v alv es a re prese nt.

Moyers
This class ific ation is bas ed on the presenc e o r abs ence of a rese rv oir b ag and rebreathing. An open sys tem has no rese rv o ir o r reb rea thing (128). The s emio pen s ys tem has a res erv oir but no rebreathing. The semiclosed s ystem has a res erv oi r and p artial rebreathin g, and the cl osed s ys tem has a reserv oi r and c omplete rebreathing.

Collins
This class ific ation d efines an open s ystem as one in wh ic h a n anesthetic agen t is brought to the patient's respirato ry trac t wi th atmos pheric ai r as the di luent (129). The resp iratory trac t has acces s to the atmosphe re duri ng both ins pi ration and ex piration. The re is no res erv oi r or rebreathing. A semi ope n s ys tem is on e i n which the patie nt's respi ra tory s ys tem is open to atmosphere duri ng bo th inspi ration and ex pira ti on. There is a res erv oi r that is open to a tmos phere, rebreathing is abs en t, a nd atmosphe ri c ai r ei the r c arri es or dilutes the anes thetic agent. The s emic losed s ystem is one i n whic h the pa ti ent's res piratory s ys tem is co mple tel y cl osed to atmosphere on ins piration but is open on ex pi rati on. A reserv oi r cl os ed to atmosphere is presen t. W ith a cl osed s ys tem, there is no ac cess to atmosphe re ei ther du ring ins pi ra tion or ex piration. Reb rea thing is complete, and a rese rv o ir is requi red.

Adriani
This class ific ation d iv ides s ys tems into open v aporization, ins ufflation , semic los ed, and c losed (rebreathing) (130 ). An open s ys te m is one employing an open drop

mask . W ith th e i ns uff lation techniq ue, a c onti nu ous s tream of gas flo ws to the pati ent's nasop harynx , oropharynx , or tra chea . The se mic los ed sys tem is one in whi c h there is comple te enc losure of the ins pi red atmosp here and no ai r di lu tion. The c los ed sys tem pe rmi ts co mple te rebreathing.

Conway
W ith this c las s ificati on, an open s ys tem is one wi th infini te boundari es an d no res tric tion to fresh gas flow (13 1). The semiopen s ys tem is one partial ly bo unde d, wi th s ome res tric tion to f res h gas f low. The c losed s ys tem is defined as hav ing no prov ision for gas ov erflow. Th e s emiclos ed s ys tem is one al lowi ng for ov erflow of ex cess g as . It is d iv id ed into s emiclos ed reb rea thi ng, P .205 se mic los ed abs orption, and s emicl osed n onrebreathing s ys tems .

Hall
In this class ific ation , an open s ys tem has no reserv oi r bag o r rebreathing (132 ). The s emiopen sys tem also has no res erv oi r bag but has partial reb rea thing . Semic lose d sys tems hav e a res erv oir bag and pa rtia l re breath ing. The y a re div ided i nto thos e with and wi thout c a rbon d iox ide abso rption. The c losed s ys te m has co mple te rebreathing and a res erv oi r.

McMahon
This sys te m us es rebreath ing as the basis for c lassifica tion of b rea thi ng s ys tems i nto open, s emic losed , and c lose d (133). A n o pen techn iqu e is one in whi ch there is no rebreathing. This inc ludes tec hniques in whi c h gas es are admin is tered at a total f low rate equal to or greater than the res pi ratory minu te v olu me . Tec hni ques wi th f lows l es s than the respi ra tory minute v ol ume would a ls o be cons idered open i f there we re no inc reas e in dead s pac e. The se mic los ed s ys te m wou ld employ s ome rebreathing. The c losed sys tem emp loys total rebreathi ng.

Baraka
This sys te m c las sifies s ys tems acco rding to their mec hanism of c arbon dioxi de el imina tion (134). Open sys tems are thos e that eli minate c arbon diox ide by was hout and h av e no reserv oi r bag. Semiopen s ys tems also was h out ca rbon d iox ide but hav e a res erv oir bag. S emic los ed s ys tems use c arbon diox ide absorption and hav e a fresh gas flow th at exc eeds patien t uptake . Closed s ys tems also use c a rbon diox ide absorption and hav e a f res h gas flow th at equals patient uptak e.

The International Standards Organization

The International S tanda rds Organ ization (IS O) c las sifies breathi ng s ys tems as nonrebreath ing and parti al rebreathing. The terms semi ope n and semicl osed a re not used . A nonrebreathing sys tem is an anaes thes ia breathing s ys tem from whic h al l of the ex pi red mix ture is discha rge d. A parti al rebreathing sys te m is an anaes thes ia breathing sys tem in whic h a porti on of the expired mix ture is retained wi th in the s ys tem (135).

Marini, Culver, and Kirk

This sys te m c las sifies breathing s ys tems on the bas is of c arbon diox ide el imin ation (136). S ys tems a re div ided into open, wh ic h d o not hav e a res erv oi r bag, and se miopen, wh ic h do h av e a reserv oi r bag . Examples of the o pen v ariety inc lude the open dro p mask , ins uffl ati on, and the T-p iec e (Mapl es on E ). S emiopen sys tems i ncl ude the Magi ll and Lac k (Map les on A ), Bain (Maples on D), J acks on-Rees (Ma ples on F), Mera F , and s ystems with non reb rea thing v alv es. The c arbon diox ide absorpti on units inc lude the c irc le s ys tem.

Classification by Equipment
Hami lton (137) rec ognized the sho rtcomings of the nomencl atures des c ribed prev ious ly and propose d tha t the terms open, s emiopen , and the like be dropped in fav or o f a desc ri ption of the equipment and th e total f resh gas f lo w to the s ys tem. An ex ampl e wo ul d be a c ircl e s ystem with a 2-L /mi nute fres h gas f low. The desc ription of the equ ipment wi ll be fami l iar to the reader af ter reading th e nex t two chapters . The f res h gas fl ow wi ll determine the amount of rebreathing, if any , that tak es plac e.

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52. Carter J A . Filters and smal l inf ants . A re ply . A naes thesi a 2004;59:719720. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 53. Moores A . Fi lters and smal l i nfants . Anaes thes ia 20 04;59:719 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 54. Internati onal S tandards Organi zatio n. Breathing s ys tem fi l te rs fo r ana es thetic and resp iratory us eP art 1: Sa lt tes t method to as sess f iltration perfo rmanc e (IS O 23328-1). Genev a, S wi tz erland: Author, 20 03. 55. Internati onal S tandards Organi zatio n. Breathing s ys tem fi l te rs for ana es thetic and resp iratory us eP art 2: Non -fil tration aspec ts (IS O 23328-2). Genev a, S wi tz erl an d: Author, 20 02. 56. Wilk es A , B enbough J , S pei ght S , e t al . The bac te ri al and v i ral fi ltra tion performance of breathing s ystem f il ters . Anaes thes ia 2000;55:4584 65. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 57. Hedley RM, A llt-Graham J . A c omparis on of the fi l tration p roperti es of heat and mois ture exchangers . Anaes thesia 1992;47:414420 . [Cross Ref] [Med li ne Link ] 58. Lee MG, Ford JL, Hunt PB , et al . B ac teri al retention prope rties of hea t and mois ture exchange fil te rs . B r J A naes th 1992;69:522525 . [Cross Ref] [Med li ne Link ] 59. Wilk es AR. The effec t of gas fl ow on the f il trati on perfo rmanc e of breathing s ys tem fil ters . Anaes thes ia 2004;59:2 78282. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 60. Mebi us C. Hea t and mois ture exchangers with bac teri al f il te rs : a l abora tory ev alu ation . Ac ta Anaes thes iol Sc and 1992;36:572576. [Med li ne Link ]

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Questions
For the fol low ing ques tion, s elec t the c orrec t ans wer.

1. Which of the follow ing offe rs th e mos t res istance? A . Nonre bre ath ing v alv e B . CO 2 c anis ter C. Trach eal tube D. Y-pi ece E . B reathing tubes V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

2. T he func tions of the breath ing sy ste m include the follow ing: A . Conv ey in g ox ygen and anesthetic gases to the pa tient B . De liv ering pos i tiv e p res sure C. Remov ing was te and anes thetic gases f rom the patien t D. Conv ey ing exces s gases to the scav enging s ys tem V iew A ns we r3. Resista nce to breathin g through a breathing sys tem is influenc ed by A . Lamin ar flow B . Gas fl ow rate C. Tu rbu lent flow D. Le ngth of the breath in g tubes V iew A ns we r4. Rebreath ing may be influenced by A . Fres h g as fl ow B . A rra ngeme nt of c omponents in the bre ath in g s ys tem C. Mec hanica l dead s pac e D. The s iz e of the res erv oi r bag V iew A ns we r5. E ffects o f reb rea thing inc lud e A . Reduced los s of hea t and water f ro m the patient B . Reduced ins pired ox ygen C. Less fluc tua ti on in ins pired anes thetic agent c onc entrati on D. Dec re ased insp ired carbon diox ide

V iew A ns we r6. Factors that ca use a dis cre pancy be tw een the composition o f the inspired gas mixture a nd that o f the fres h g as inc lude A . Rebre ath ing B . Leaks in the b rea thi ng s ys tem C. Uptak e of anes thetic ag ent by c omponents of the b rea th ing s ys tem D. Inc reas ed fresh gas flow V iew A ns we r7. Factors that ca n c ause a discrepancy betw een the vo lume of ga s discharged from a ve ntila tor or res ervo ir bag and tha t ins pired by th e patient include A . Fres h g as fl ow B . Co mp res sion of gases in the c ircui t C. Le aks D. Dis tention of breathing sys tem componen ts V iew A ns we r8. The reservoir b ag A . A l lows use of lower fresh g as flows B . P rov ides a means fo r del iv ering pos i tiv e press ure C. Can s erv e as a monitor o f spontaneous res piration D. Can c aus e exces siv e pressu re if the AP L v alv e is no t ope n V iew A ns we r9. Concerning the peak pressure than ca n be generated in the brea thing sys tem if there is a res ervoir b ag in place, A . If the res erv oi r bag is les s tha n 1 .5 L in s iz e, the pressure s ha ll not be less than 30 cm H 2 O B . If the res erv oi r bag is larger tha n 1 .5 L, the press ure s hall not be les s tha n 45 cm H 2 O C. If a 1.5-L bag is expande d to four times its n orma l si ze, the press ure s hal l not be greater than 50 cm H 2 O D. If a bag ov er 1.5 L is expanded to four times i ts s ize, the pressu re sha ll not be greater than 65 cm H 2 O V iew A ns we r10 . Func tions of breathin g tubes include A . Ac ting as a reserv oi r in c ertain s ys te ms B . P rotec tion agains t excessiv e press ure C. P rov iding a flex ible connec tion between the different pa rts of the breathing s ys tem D. Ex pand ing during spontaneous breathing to prev ent rebre ath ing V iew A ns we r11 . During spontaneous respiration, A . Th e APL v alv e s hould b e k ept parti all y clos ed

B . Mos t AP L v alv es open au toma tical l y C. An obs truc ti on in the sc av engin g sys tem may res ul t in gas bei ng remov ed f rom the breathing s ys tem D. Obs truc ti on of the ai r intak e v alv e in the scav enging s ys tem can resul t i n positiv e pressu re in the breathi ng s ys tem V iew A ns we r12 . With a PE E P valve in the breathing system, A . A n inc reas ed exhala tion effo rt is nec essa ry i f the patien t is b rea thing spontaneous l y B . A n inc reas e in tida l v olume may be se en wi th mec hanical v entilation C. The a mount of PEEP can be either fixed or adjus table D. A spri ng-loaded PEEP v alv e mus t be kept i n the up right pos i tion V iew A ns we r13 . Whic h of the follow ing connecto rs are male? A . Th ose on the breathing tubes B . Th ose on the reserv oi r bag mount C. Those on the mask D. Those on the Y-piec e connec ting to the breathing tubes V iew A ns we r14 . Depos ition of bronchodila tors in the patient's tracheobronchial tree is enha nced by A . Us e o f a spac er B . A l ow i ns pi ratory fl ow rate C. Lo w h umid ific ation D. An ex pi ratory paus e V iew A ns we r15 . Causes of lo caliz ed turbulent flow inclu de A . Cons tric tions in the fl ow channel B . V alv es C. Curv es D. Gas a t a flow rate below th e c ri tica l numbe r V iew A ns we r

Chapter 8 Mapleson Breathing Systems

The Map leson sys tems a re ch arac te ri zed by the abs enc e of unidi rec ti onal v alv es to di rec t gas es to o r from the pa ti ent. B ec aus e there is no d ev ice fo r abs orb ing CO 2 , the fresh gas fl ow mus t was h CO 2 out of the c ircui t. For this reas on, these s ys tems are sometimes c al led c arbon diox ide was hout c irc ui ts or flow -c on trol le d b rea thi ng sy s tems . These s ys te ms we re firs t cl as sified into f iv e b asic types : A through E (1 ). A s ix th, the Mapl eson F s ys tem, was added la te r (2). The c lass ific ati on is s hown i n Figu re 8.1. There are many v a ri ations of these s ystems , but onl y th e ones in c ommon us e wi ll be discus sed. Bec ause there is no c lea r s epara tion of insp ired and ex pi red gases , reb rea thing wi l l oc cur wh en the insp iratory flo w exc eeds th e f resh gas f lo w. The compos i tion of the i nspi red mix ture wil l de pend on how much reb rea th ing takes p lace. A number of s tudies desi gned to determine the fresh gas f low neede d to prev en t rebreath in g wi th thes e s ys tems hav e been performed , wi th of ten wi de ly differing res ults . This is partly bec aus e differe nt c riteria hav e bee n used to define the ons et of rebreathing and b ecause v ariables suc h as minu te v en til ation , res pi ratory wav eform, CO 2 produc ti on, patient respo nsiv eness , and s timulati on and phys iological dead sp ace may be unpredic table in anes theti zed patien ts (3,4 ,5). Monitoring end-ti dal CO 2 is the bes t meth od to de termine the op timal f resh gas f low. It s hould be noted that wi th rebreathing, the arterial CO 2 to end-ti dal CO 2 gradient dec reases (6). P .210

Figure 8.1 The Mapleson systems. Components include a reservoir bag, corrugated tubing, APL valve, fresh gas inlet, and patient connection. They lack CO2 absorbers, unidirectional valves, and separate inspiratory and expiratory limbs. (Redrawn from Mapleson WW. The elimination of rebreathing in various semiclosed anesthetic systems. Br J Anaesth 1954;26:323 332 [CrossRef] [Medline Link] .)

View Figure

Mapleson A System Configurations

Classic Form
The Map leson A s ys tem (Ma gil l attachment or s ys tem) is s hown i n Fi gure 8 .1A . It differs from the other Ma pl eson s ys tems in that f resh gas does not e nter the s ys tem near the patien t c onnec tion but ente rs at the other e nd of the s ys tem nea r the reserv oi r ba g. A corrugated tubing c onnec ts the ba g to the a djus table pressure l imi ting (APL) v alv e a t the patien t end of the s ys tem.

Figure 8.2 Lack modification of the Mapleson A system. The coaxial version is shown. APL, adjustable pressure limiting.
View Figure

A sensor for a nondiv erting respi ratory gas moni tor or the s amp ling s i te f or a div erting mon itor (Chapter 22) may be place d between the APL v alv e and the co rrugated tubing. In adul ts , i t may be pl ace d between th e APL v alv e and the pati ent. In s mall patie nts , th is loca tion could resul t in exc essiv e dead space. It could als o be plac ed between the nec k of the bag and i ts mount, between the bag and the corrugated tubing, or in the fres h gas s upply tube. H owev e r, in these l ocations , the c oncentration s hown on the moni to r may diff er s ubs tantiall y from th e i nspi red conc entra ti on, espec iall y during c ontro lled v en ti lation .

Lack Modification
The Lack modif ic ation of the Maples on A s ys tem (Fig. 8 .2) has an add ed expi ra to ry l i mb, whic h runs from the p ati en t c onnec tion to the AP L v alv e at the machine e nd of the s ys te m (7,8 ). This mak es it eas ier to adjus t the v alv e and fac i li tates scav engi ng ex ces s g ases , but it inc reases the work of breathing s ligh tly (3). The Lack sys tem is av ail able in bo th a dual (p ara ll el ) tu be arrangement and a tubewi th in-a-tube (c oaxi al ) con figuration in which the ex pi ra tory li mb runs conc entrica ll y i nsi de the outer i nspi rato ry l imb (9 ).

Techniques of Use
For s pon taneous v entilation, the A PL v alv e i s k ept in the ful l y open position. Exc ess gas exi ts through i t during the latter part of ex hal ation .

For c ontro ll ed or assis ted v en ti la tion, intermittent pos itiv e pressu re is appl ie d to the bag. The AP L v alv e is parti al ly c los ed so that whe n the bag is sq ueezed, suff ic ient press ure to inf late the lungs is achiev ed. The AP L v alv e opens during i nspi rati on .

Functional Analysis
Spontaneous Respiration
The s eque nce of ev ents during the respi rato ry cyc le using the Magil l s ys tem with spontaneous v en ti la tion is s hown i n Fig ure 8.3 (10,1 1). As the pa tient exha les (Fig. 8.3C), fi rs t dead s pac e a nd then alv eol ar gases f lo w i nto the co rrugated tubing toward the bag. A t the same time, P .211 f res h g as fl ows into the bag. W hen the bag i s full , the p res sure in the s ys tem ri ses unti l the APL v alv e ope ns . T he fi rs t gas v ented wil l be alv eolar gas . The remai nder of exhalation, which c ontains onl y alv eol ar g as , ex haus ts through the ope n AP L v alv e. The c ontinu ing i nflo w o f fresh gas rev ers es the fl ow o f exhaled gases in the co rrugated tubing. So me a lv eolar gas that bypasse d the APL v alv e n ow returns and ex its through it. If the f resh gas f low i s high (Fi g. 8.3A ), i t wi ll a ls o force th e dead spac e gas o ut. If the fres h f low g as is intermediate (Fig . 8.3D), some dead s pac e gas wi l l be re ta ine d i n the s ys tem. If the fresh gas flow is low (Fi g. 8 .3E ), more alv eola r gas wi ll be retained .

Figure 8.3 Magill system with spontaneous ventilation. (See text for details.) (Redrawn from Kain ML, Nunn JF. Fresh gas economies of the Magill circuit. Anesthesiology 1968;29:964974 [Fulltext Link] [CrossRef] [Medline Link] .)

View Figure

A t the s tart of i nspiration , the fi rs t gas inhaled wi ll be from dead space between the pati ent a nd the AP L v alv e. The n ex t gas wil l b e e ither a lv eolar gas (if the f resh gas f low i s low), dead space gas (if the f res h gas flow i s intermediate ), o r fresh gas (if the fresh gas fl ow is high) (Fi g. 8.3B ). Changes in res pi ratory pattern hav e l i ttle ef fec t on rebreathing (11 ,12 ,13). W ith the c lassic Magi ll s ys tem, inv estigators hav e found th at rebreathi ng begi ns whe n the f res h gas flow i s reduced to 56 to 82 mL/k g/minute (3,14,15,16,17), or 58% to 8 3% of minu te v olume (3,10,18,19,20,21). Fresh gas f lows of 51 to 85 mL/kg/min ute (3,14,22,23,24) and 42% to 88% of minute v olume (3 ,19 ,23) hav e been rec ommended to av oid rebreathing.

Controlled or Assisted Ventilation

Durin g contro ll ed or ass is ted v en ti la tion (F ig. 8.4 ), the pattern of gas flow c hanges . Durin g exha lation (Fig. 8 .4A ), the pressu re i n the s ystem wi l l re main low and no gas wi l l esc ape thro ugh the AP L v alv e, unless the bag becomes dis tended. Al l ex hal ed gas es , both de ad spac e and alv eo lar, remain in the c orrugated tub ing , wi th alv eola r gas neares t the patient. If the tidal v olume is large, s ome alv eolar gas may enter the bag (25).

Figure 8.4 Magill system with controlled ventilation. (See text for details.)

View Figure

P .212

A t the s tart of i nspiration (Fig . 8.4B), gas es in the tu bing f low to the patient. Bec ause a lv eolar gas occup ies the space ne ares t the patient, i t wi l l be inhaled firs t. As the pressure in the sys tem ris es , the A PL v alv e opens s o that gas both ex i ts through the AP L v alv e and flo ws to the patie nt. When all the exhaled gas h as been driv en from the tube , fresh gas f i lls the tubing (Fig. 8.4C). Some fresh gas enters the patie nt, and some is v ented through the v alv e. Thus , during c ontrol led v enti lation , there is cons idera ble rebreathing of alv eolar gas es and v enting of fresh gas . The c ompos i tion of the ins pired gas mix ture d epends on the res piratory pattern (25,26). The s ystem becomes mo re ef fic ient as the expi ra tory phase is prolonged. Mos t inv estigators believ e tha t it i s i llogica l to us e the Maples on A

s ys tem for c ontrol led v enti lation. Ho wev er, i f the AP L v alv e i n the Maples on A s ys tem does not v ent gas during ins pi ration, the Mapleson A sys tem c an be as ef fic ient as the Maples on D during c ontrol led v en tila ti on (27). Durin g assis ted v enti lation , the Map les on A s ys tem is s omewha t less effic ient than wi th s pontaneous v enti la tion but is more effi cient than wi th controll ed v enti la tion (28).

Hazards
A mecha nical v entilator that v ents excess gas es should n ot be us ed with this s ys tem, bec aus e the enti re sys tem then becomes de ad spac e. The v entilators found on mos t anes th esi a machines i n the Un ited S tates are unsui table f or us e with the Maples on A s ys tem. Cas es hav e been reported wh ere a Lac k c i rcu it was incorrec tl y manufac tured or as sembled so that the f res h gas inle t was moun ted ad jacent to the AP L v alv e ra the r than th e res erv oi r bag (29,30,31). This would res ul t in a subs tantial inc rease i n dead spac e.

Preuse Checks
The Map leson A s ys tem is tes ted for l eaks b y occluding the patient en d of the s ys tem, c los ing the A PL v alv e, and press urizi ng the s ys tem. Opening the A PL v alv e wi ll c onf i rm proper f unc tioning of that c omponent. In a ddi ti on, the us er or a pa tient shoul d breathe through the s ystem. The c oaxi al Lack sys tem requ ires additio nal tes ting to c onfirm the in tegri ty o f the i nner tube. One method is to attach a trache al tube to the i nner tubi ng at the pati ent e nd of the s ys tem (32). Blo wing down the tube wi th the APL v alv e c los ed wi ll pro duce mov ement of th e bag if the re is a leak betwe en th e two limbs . Another method is to oc c lude both limbs at the patient c onnec tion wi th the A PL v alv e o pen and then s queeze the bag (33 ). If there is a leak in the inner l imb , gas wi ll esc ape through the AP L v alv e, and the bag wil l c ollapse.

Mapleson B System
The Map leson B s ys tem is s hown i n F igure 8.1B. The fresh gas inlet a nd AP L v alv e are both loc ated near the patient port. The rese rv o ir bag is at the pa tient end of the s ys tem, s epara ted f rom the fresh gas inl et b y corrugated tubing .

Techniques of Use
To us e the Maples on B s ys tem with spon ta neous respiratio n, the APL v alv e is opened comple tely. Excess gas is v ented thro ugh the v alv e duri ng exhala ti on.

Ass is ted o r controlled v entil ation is acc ompl is hed by c los ing the AP L v alv e suff ic ientl y to allow the l ungs to be inflated. Excess gases are v ented during i nspi rati on .

Functional Analysis
Spontaneous Respiration
As the patient ex hal es , dead space gas wi l l pas s down th e c orruga ted tubing , along wi th f res h gas . A t th e end of ex hal ation , the tubing near the patient wi ll be filled wi th f res h gas and s ome alv eol ar gas . W hen the bag reach es fu ll c apac ity, the APL v alv e o pens , and bo th f res h gas and alv eola r gas wi ll ex i t f rom the s ys tem. W hen the patie nt begins to inspi re , th e A PL v alv e c loses , and the patient inha les f resh gas and gas f rom the tub ing . No gas wi ll be inhal ed from the bag if the v olume of the tub in g exceeds the tidal v ol ume. To av oid rebreathing, the f res h gas flow mus t be equa l to peak inspi ra tory flow ra te (norma lly 20 to 25 L /minute) (34). A f resh gas f lo w mo re than double minute v olume has been recommended (34,35), but f lo ws as lo w a s 0 .8 to 1 .2 times mi nute v ol ume may be su ffic ient (25).

Controlled or Assisted Ventilation

The behav ior of the Mapleson B s ys tem du ring con trolled or ass is ted v enti lation is s imilar to that of the Maples on A , but it is sli ghtly more eff ici ent because fresh gas ac cumulates at the patient en d of the tubing d uring the expi rato ry pause (25,34). Bec ause the composi tion of ins pi red gas is greatly inf luenc ed by the v entilatory pattern , this s ys tem has v ariable p erformance du ring controlled v entilation (25 ). A f res h g as fl ow of 2 to 2 .5 times minute v olume has been recommended (25,3 4,36).

Mapleson C System
The Map leson C s ys tem is iden tical to the Mapleson B sys tem excep t that the co rrugated tubing is omi tted (Fig. 8.1C).

Techniques of Use
Us e of this s ys te m is s imilar to tha t des c ri bed for the Maples on B s ys tem. P .213

Functional Analysis

The Map leson C s ys tem behav es s imila rl y to the Mapleson B s ystem. W ith spontaneous v en ti la tion, the Maples on C s ys tem is al mos t as effic ient as the Maples on A wh en the expi ra tory paus e is mi nimal, but i t bec omes less effic ien t as the expi rato ry paus e i nc reases (11 ,13 ,37 ). A f res h gas flow of 2 times minute v olume has been rec ommended for spontaneous breathing. Durin g contro ll ed v enti lation , a fresh gas f low o f 2 to 2.5 ti mes minute v olume is recommended (25,38).

Mapleson D System
The Map leson D, E , and F s ys tems al l hav e a T-piec e n ear the patient and func tion s imilarl y. The T-pi ece is a three-way tubul ar c onnec to r with a patie nt connec ti on port, a fresh gas port, an d a po rt for c onnecti on to a c orruga ted tubing. The Maples on D s ys tem is popular bec aus e excess gas sc av enging is relativ ely eas y, and i t is the mos t ef fic ient of th e Ma pl eson s ys tems durin g c ontro ll ed v en ti lation.

Configuration
Classic Form
The Map leson D s ys tem is s hown i n Figu res 8 .1D and 8 .5. A l eng th of tubi ng connec ts the T-p iece at the patie nt end to th e AP L v alv e and the res erv oi r bag adjac ent to it. The leng th of the tubing determines the dis tance the us er c an be f rom the patien t but h as min imal effec ts on v enti lation (39). The s enso r or s ampling s i te f or a respi rato ry gas monitor may be placed between the bag and i ts mount, between the corru gated tubin g and the T -piec e, or be twe en the corrugated tub in g and the AP L v alv e. In adul ts , i t may be place d between th e T piece and the pa tient.

Figure 8.5 Mapleson D system. A tube leading to the scavenging system is attached to the APL valve.

View Figure

A bidirec tional posi tiv e end-exp irato ry press ure (PEEP ) v alv e may be placed between the co rrugated tubing and the APL v alv e of the Map les on D s ys tem (40 ). This permits PEEP to b e adminis te red du ri ng manua l or mec hanical v en tila tion. Howev er, s ome PEEP v alv es wil l c los e when a negativ e press ure is app lied, s o spontaneous breathing is imposs ib le wi th that type of PEEP v alv e in the s ys tem. The P EE P v alv e may be pl aced in the h ose l eading to the anes thesia v en til ato r. In this loc ation, it wi l l be effec tiv e only duri ng mechanical v enti lation. A unidi rec tional PEE P v alv e c an be use d a t the b ag attac hment s ite by us ing s peci al c onnec tors and u nid irec tional v alv es (41). Suc h an a rrangement al lows PEEP to be applied during s pontaneous o r mechanical but not manual v en tila ti on (40).

Bain Modification
In the B ai n modi fica tion (F ig. 8.6 ), the fres h g as supply tube runs coax ial ly ins ide the corrugated tub in g and ends at the poin t where the f resh gas wou ld en ter if the c las sic Mapleson D form were us ed (42 ). The outer tube is c le ar s o that the in ner tube can be ins pec ted (43). The outer tubi ng of mos t comme rc iall y av ailabl e v e rsions of the B ain s ys tem is narrower than c onv entiona l corrugated tub ing (25). The B ain s ystem is av ailable wi th a meta l head with chan nels dri lled into it. This prov ides a fix ed pos ition f or the reserv oi r ba g and APL v alv e and a ttach ment of co rrugated tubing. So me h eads also hav e a pressu re mano me te r. A long v ersion of the Bain s ys tem may be used for remote anes thesi a in locations such as the magnetic res onanc e imag in g (MRI) uni t (44). Co mpared with th e us ual Bain s ys te m, s tatic complianc e is inc reas ed with a

P .214 reduc tion in peak i nspi ra to ry press ure an d ti dal v olume with the s ame v entilator se ttin gs . Als o , PEEP is inc reas ed. A l onge r Bain s ys tem also presen ts i nc reas ed resis tance to s pon taneous b rea thing (45).

Figure 8.6 Bain modification of the Mapleson D system. The fresh gas supply tube is inside the corrugated tubing. APL, adjustable pressure limiting; Pt, patient.

View Figure

Techniques of Use
For s pon taneous respiration , the A PL v alv e is l ef t open, and exces s gases are v ented d uring ex pi rati on. Manual ly c ontrol led or as sis ted v entilati on is pe rforme d by pa rtia ll y clos ing the APL v alv e and s quee zing the bag. Ex cess gases are v en ted during ins pi ra tion. Mechan ic all y control led v entilation is ac hi ev ed by c onnec ting the hose from a v entil ator i n p lace of the res ervoi r bag and c los ing the A P L v alv e. Exc ess gas es are v ented through the v enti la tor s pi ll v alv e.

Functional Analysis
Spontaneous Breathing
Durin g exha lation (Fig. 8 .7), ex haled gas es mix wi th f resh gas es and mov e through the corrugated tub e towa rd th e bag. A fter the bag has f illed, gas exi ts v ia the APL v alv e. Durin g the ex piratory pause , fres h gas pushes exh aled gas es down th e co rrugated tubing. Durin g ins pi ration, the patient wi ll in hale gas from the f resh gas i nl et and the co rrugated tubing. If the fresh gas f low is high, all the gas dra wn from the co rrugated tube wi ll be f resh gas . If the f res h gas f low i s low, s ome ex hal ed gas

containing CO 2 wi l l be inhaled. The v en ti la tory pattern wi ll help to determin e the amou nt of rebreathing. Fac tors tha t tend to dec reas e rebreath in g i nc lude a high i nspi rato ry:ex piratory (I:E ) time ratio, a s low ris e in inspi ra to ry flow rate , a low f low rate du ring the l as t part of exhalation, and a long ex pi ratory paus e, wi th the lo ng ex piratory pause hav ing the g rea tes t effec t (11,12,13,37,46,47,48). As gas c ontaining CO 2 is inhaled , the end-tidal CO 2 wil l ris e. If the patien t's spontaneous respi rati on th en inc reases , the e nd-ti dal CO 2 wil l f al l whi le i nspired CO 2 wi ll inc reas e (4 9). P rov ided reb rea th ing is not ex treme, a n orma l end-tida l CO 2 can be ac hi ev ed but on ly at the cos t of inc re ased work on th e part of the patient. The end-ti dal CO 2 ten ds to reach a plateau. A t that point, no matte r how hard the pati ent wo rks , the end-ti dal CO 2 c annot be lowered f urther. If th e patien t's respi ra tion is depress ed, end-ti dal CO 2 wil l ri se furthe r (49 ). End -tid al CO 2 depends on both the ratio of minute v olume and f res h gas flow and thei r abs olu te v alu es (49 ). If ex pired v olume is greater than fres h gas flow, en dtida l CO 2 wi ll be determined mai nl y by f res h g as fl ow. If f res h gas flow i s greate r than min ute v olume, end-ti dal CO 2 wi l l be determined ma in ly by minute v olume. Rec ommenda tions f or f resh gas f lows based on b ody wei ght v ary f rom 100 to 300 mL/kg/min ute (14,17,23,24,29 ,50 ,51 ). Mos t s tudies hav e rec ommended tha t the f res h g as fl ow be 1.5 to 3.0 times the mi nu te v olume (20,23,50,52,53,54,55,56 ) whi l e o the rs hav e held tha t a fresh gas flow approxi matel y equal to tota l v enti lation i s adequate (57). In terms of bod y surfac e are a, f res h gas P .215 f lows of 4000 to 4700 mL/m 2 /minute hav e be en rec om-me nded (58).

Figure 8.7 Functioning of the Mapleson D system. (See text for details.) Pt, patient; F.G.F., fresh gas flow.

View Figure

Controlled Ventilation
Durin g exha lation (Fig. 8 .7), gases f lo w f rom the patient down the corrugated tubi ng. A t the s ame time, f res h gas enters the tubing. During the expi rato ry pause, the fresh gas fl ow conti nues and pushes exhaled gas es down th e tubi ng . Durin g ins pi ration, f resh gas and gas from the co rrugated tubing enter the pati ent. If the f resh gas f lo w i s lo w, s ome ex haled gas es may be i nhaled. P rol onging the i nspi rato ry time, inc reas ing the resp iratory rate, or addi ng an inspi ra tory plateau wi ll inc rease rebreath in g (47,59). Reb rea thing can be dec reas ed by al lo win g a long ex piratory pause s o that fresh gas c an flus h ex hal ed gases f rom the tubing . W hen the fresh gas fl ow is high , there is li ttl e rebreathi ng, and th e end-tidal CO 2 is determined mainly by minute v en ti la tion. Tid al v olu me , the v olume of the expi rato ry l imb, and expiratory resis tanc e als o affec t it (60). W hen mi nute v olume subs tantia ll y exc eeds the fres h g as fl ow, the f res h gas flow i s the main fac to r control li ng CO 2 eli mination. The higher the fre sh gas flow, the lower the end-ti dal CO 2 . Combining f res h gas fl ow, mi nu te v olume , and arte rial CO 2 lev els , a series of cu rv es can be cons truc te d (Fig. 8.8). An infini te number of c ombinatio ns of f resh gas fl ow a nd minute v olu me c an be used to produc e a giv en PaCO 2 . High f resh gas f lows and lo w mi nute v olumes or h igh minute v olumes a nd lo w f res h gas f lows o r co mbinations in between c an be used. In F igu re 8.8, at the l ef t, wi th a high f resh gas fl ow, the c i rcu it is a non reb rea thi ng one a nd end-ti dal CO 2 dep ends only on v enti lation . Such hi gh f lo ws are un economic al and are as soc iated wi th l os t heat and

humidi ty . End -tidal CO 2 depends on mi nu te v olume , whic h is dif ficul t to adjus t ac curate ly , es peci al ly in smal l pati ents . On the right is the reg ion of hyperv enti lation and pa rtial reb rea thing . End-ti da l CO 2 is regulated by adjus ting the f res h g as fl ow. Lower f res h gas f lo ws (and inc reased rebreathin g) are associated wi th hi ghe r humidi ty , less hea t loss, and gre ate r fresh gas economy. Hyperv entil ation can be us ed withou t in duc ing hypoca rbia. Ind iv idual differenc es in dead spac e:tidal v olume are mini mize d at high lev els of minute v olume. For these reasons , i n mos t c as es , i t is adv antageous to aim fo r th e right s ide of the graph . In pati ents with s tif f l ungs , poo r cardi ac performanc e, or hypov olemia , usi ng the left s ide of the graph and a relativ ely sma ll total v entilatio n with a h igh f res h gas f lo w may be be tter (61). P .216

Figure 8.8 Mapleson D system used with controlled ventilation. Each isopleth represents a constant level of PaCO2. Note that essentially the same PaCO2 can be achieved for fresh gas flows from 100 to 240 mL/kg/minute. (Redrawn from Froese AB. Anesthesia circuits for children [ASA Refresher Course]. Park Ridge, IL: ASA, 1978 .)
View Figure

Formulas to predic t fresh gas f low requiremen ts hav e been based on body wei ght (62,63,64), minute v olu me (65), and b ody su rface area (66). If the s ys tem is used for pati ents unde rgo ing l apa ros copy , the fresh gas f low n eeds to be inc re ased to ov erc ome the CO 2 that is absorbed f rom the a bdomen (67). W ith ass is ted v entilation, the effic ienc y o f the Mapleson D sys tem is i ntermedi ate between that for spon tan eous and controlled v entil ati on (28). S ligh tl y higher f resh gas fl ows sho uld be used.

Bain System Hazards

If the inne r tube of the Bain s ys tem bec omes detached from its connec tions at ei th er end o r dev elops a leak at the machi ne end , if the f resh gas suppl y tube becomes k ink ed or twis ted , if the s ys tem is i ncorrec tly as sembled (such as using s tandard c orrugated tubing), or if there is a defec t in the meta l head s o tha t fresh gas and exhaled gas mix , the e ntire l imb beco mes dead spac e (43,68,69,70,71,72,73). In one c as e, i t was re porte d that a manuf ac turing defec t caus ed the inner tube to be blocke d (74).

Preuse Checks
The Map leson D Sys tem is tes ted fo r leaks by oc cluding the patien t end , cl osing the APL v alv e, and press uri zi ng th e sys tem. T he APL v alv e is the n opene d. The bag s houl d def late eas i ly if the v alv e and sc av enging s ys tem are work ing p roperl y. E i ther th e user o r a patient s hould b rea the through the s ys tem to detec t obs truc tions. The B ain modi fic ation of the Map les on D requires spec ial tes ting to co nfi rm the i nte gri ty of the inn er tubing. This c an be perfo rmed by se tting a low fl ow on the ox ygen f lo wmete r and oc c luding the i nner tu be (wi th a finger or the ba rrel of a smal l s yring e) at the patient end while obs erv in g the flo wmete r indic ator. If the i nner tube is in tac t and c orrec tl y connec ted, the indicator wi l l fa ll (70,75). The i nte gri ty of the inn er tube c an a lso b e c onf irmed by ac tiv atin g the ox ygen fl ush and observ ing the bag (76 ). A V enturi effec t c aused by the hi gh f low at the pa tient end wi ll c re ate a negativ e p res sure in the outer ex hal ation tubi ng, and this wi l l cause the bag to deflate. If the inner tube is not intac t, th is maneuv e r wil l c ause the bag to infla te s li ghtly . Howev er, this tes t wi l l not d etec t a s ys tem in whic h the inner tube i s omitte d or does not ex tend to the patient port or one tha t has ho les at the patien t end of the inne r tube (77 ,78 ).

Continuous Positive Airway Pressure

Durin g one-lung v enti la tion using a double-l umen tube (Chapter 20 ), a mod if ied Maples on D s ys tem attac hed to the lu men le ading to the non dependent lung is of ten us ed to appl y con tinuous posi tiv e airway press ure (CP AP ) to tha t lung. A numbe r of configu rati ons hav e been describ ed (79,80,81,82,83,84,85,86,87,88 ,89 ,90 ,91,92,9 3). One is shown in Fi gu re 8.9. A sourc e o f ox ygen is connec ted to the s ys tem. The AP L v alv e is set to mai nta in the desired press ure . A P EEP v alv e may be add ed to func tion as a high-pressure re li ef dev ic e (94 ).

Mapleson E System
The Map leson E (T-piece ) sys tem is s hown i n Figure 8.1E. A length of tubing may be attac hed to the T -piece to form a rese rv o ir. It does not hav e a bag. The ex piratory port ma y be encl os ed in a chamber f rom whi ch ex ces s g ases a re ev acua ted . The s enso r or s ampling s i te f or the respi ra tory gas mon itor may be plac ed between the expi rato ry po rt an d the ex pi ratory tub ing . In larger pa tients , i t may be p lac ed between the T-piec e an d the patient, but this location P .217 shoul d be av oided in s mall pa tients bec ause i t inc reases dead s pace.

Figure 8.9 System for continuous positive airway pressure. (See text for details.) PEEP, positive end-expiratory pressure; APL, adjustable pressure limiting.

View Figure

Numerous mo dif ications of the original T-p iece hav e been made. Many hav e the f res h g as inle t ex tend ing ins ide the bod y of th e T -piec e towa rd the patien t connec tion to minimize d ead sp ace. A press ure-l imi ting dev ice may be added to the s ys tem. Us e of the Map leson E sys tem fo r anes th esia has dec reas ed bec aus e of the diff icul ty i n scav engin g excess gas es . It is c ommonl y used to adminis ter ox ygen or humidified gas to pati ents breath ing s pontaneous ly.

Techniques of Use
For s pon taneous v entilation, the expi rato ry l imb is open to a tmos phere. Control led v enti lation can be performed by inte rmi ttentl y occl uding the exp iratory l imb an d

al lowin g the f res h gas f low to i nfl ate the lungs . Ass is ted respi ra tion is d ifficu lt to perform.

Functional Analysis
The s eque nce of ev ents during the respi rato ry cyc le is si milar to that of the Maples on D s ys tem s hown i n Figure 8 .7. T he pres ence or abs enc e and the a mount of rebreathing or ai r di lution wi l l depend on th e f resh gas flo w, the patient's minute v olume , th e v olume of the exhalati on li mb, the type of v entilation (spontaneous or control led), and th e res piratory p attern.

Rebreathing
W ith s pontaneous v entilation, no rebreathi ng c an oc cur i f there is no ex halatio n l imb. If there is an expi ratory limb, the fres h g as fl ow needed to prev ent rebreathing wi ll be the s ame as for the Map les on D s ys tem. Du ring con trolled v entilation, there can be n o rebreathing, bec ause only f res h g as wi ll inf la te the lu ngs .

Air Dilution
No ai r dilu ti on can oc cur during controll ed venti lation. Du ring spontaneous v enti lation , ai r di lution cannot oc cur i f the volume of the tubing is greater than the pati ent's tidal v olume. If there is no expi rato ry l imb or i f the v ol ume of the l imb is l ess than the patie nt's tida l v olume, air dil ution can be prev ente d b y prov id ing a f res h g as fl ow that ex ceeds the pe ak inspi ra tory flow rate , normall y three to fiv e times the minute v olume. A fres h gas flow of two ti mes minute v olume and a reserv oi r v o lume one thi rd of the tidal v olume wil l prev ent ai r dilu ti on (95).

Hazards
Con trolling v enti la tion by i ntermi tten tl y occ luding the exp iratory l imb may lea d to ov erinf la tion and P .218 barotra uma. Th is is a d ange r with th is s ystem in partic ular because the anes thesia prov ider does no t hav e the fee l of th e bag during i nfla ti on that she o r he has wi th other s ys tems . The pressu re-buff ering effect of the bag is abs ent, and there is no AP L v alv e to moderate the pres sure in the lungs . To ov ercome th is potential hazard, i t has been rec ommended tha t a pressure-limi ting dev ic e be placed in the s ys tem (96).

Mapleson F System

The Map leson F (J acks on-Rees , Rees , Jac kson -Rees modific ati on of the T-piec e) s ys tem has a bag with a mecha nis m for v enting exces s gases (97) (Fi g. 8 .1F ). Th e mechanism can be a hole in the tail or s ide of the bag that is oc cluded by us ing a f ing er to p rov ide p res sure. It may be f itted with a d ev ice to p rev ent the bag f rom co ll aps ing wh il e at the same time allo wing excess gas es to es cape . An anes th esi a v enti lato r may be used in pl ace of the bag (98 ). A n APL v alv e ma y be placed near the patie nt connec tion to prov ide protec tion from high p res sure (99 ). Scav eng ing c an be perfo rmed by enc los ing the bag i n a c hamber from wh ic h wa s te gases are suc tioned (100) o r by attaching vari ous dev ic es to the re lief mec hanism i n the ba g (101 ).

Techniques of Use
For s pon taneous respiration , the rel ief mech anism is left ful ly open . For as sis ted or control led res piration, the reli ef mec hanism is oc cl uded s uff iciently to dis tend the bag. Res piration c an then be controlled or assis ted by sq ueez ing the bag . A l te rna tel y, the hole in the ba g c an be occ lu ded by the user's fi nger during i nspi rati on . For mec hanica l v enti la tion, the bag is repl aced by the hos e from a v enti lato r. A heat and mois ture ex changer (HME ) can b e used wi th a Mapl es on F s ys tem eithe r by inse rting i t be tween the pa tient and the T -piec e o r by us ing the gas sampling port on the HME as the f resh gas i nl et (102). Howev er, this wi ll res ult in mos t of the f res h g as being v ente d f rom the dis tal end of the expi ra tory li mb durin g spontaneous respi rati on (103,104,105 ). To ov ercome th is problem, the ex piratory l imb ca n be parti al ly or total ly oc cl uded , the f resh gas f lo w i nc reased, o r th e HME not used wi th s pontaneous respi ration.

Functional Analysis
The Map leson F s ys tem func tions muc h l ik e the Map leson D s ys tem. The flows requi red to prev ent re bre ath ing during spontaneo us and c ontrol le d res piratio n a re the same as those requi red with th e Ma pleson D s ys tem. This s ys tem offers less work of breathi ng th an a pediatric c i rc le s yste m (106). W hi le one s tu dy did find that there wa s les s work of breathing with the J acks on-Rees sys tem, i t was cons idered by other inv estigators to be a negl ig ib le differenc e and of importance in only the s ick est patients breathing spon taneously (107 ). PEE P do es not affec t e nd-ti dal CO 2 during c ontrol led v en tila ti on but caus es an i nc reas e d uring s pontaneous breathin g when fres h gas flows are less than three

times mi nute v ol ume (1 08). PEEP should n ot be applied by us ing an underwater seal (109). If a heat and mois tu re ex changer (Chapter 1 1) is added to the Mapleson F s ys tem during an inhal ation induc tion , th e inc reased res is tance wi l l res ul t in more of the f res h g as fl ow entering the ex piratory l i mb, delay in g i nduc tion (104 ).

Hazards
The hazards of the Maples on F s ys tem are the same as thos e desc ribed f or the Maples on E s ys tem. Ex cess iv e pressure is less lik el y to dev elop, because th ere is a bag in the s ys tem. If a v enti lator that uses a ram of oxy gen to produce inspi ra ti on is used wi th a Tpiece s ys tem, a disco nnec tion at the commo n gas outlet may not be detec ted by an ai rwa y pressure moni to r due to the high resi s tance of the f resh gas tubing (1 10).

Respiratory Gas Monitoring with the Mapleson Systems

A ll of the Maples on s ys tems ex cep t the A sy s tem hav e the fresh gas i nl et near the pati ent c onnec tion po rt. This may make i t diff icul t to get a re liable s amp le of ex hal ed gas es . One s tud y exami ned f our s ampl in g s ites (Fig . 8.10): at the junc tion of the breathing s ys te m an d e lbo w c onnec tor, a t th e c orner of the elbow co nnec tor, 2 c m dis ta l in the elbow c onnec tor, and i n th e tracheal tube connec tor (111 ). It was found that if sa mpling we re carri ed ou t at the two s i tes c loses t to the pa tient, v alues were ac curate. S ignificant erro rs wer e noted when sa mples were take n f rom the corner of the e lbo w c onnec to r but onl y if a high f res h gas flow was us ed. S ignificant erro rs were noted when sa mpli ng was pe rf ormed at the junc tion o f the breathi ng s ys tem and elbo w c onnec to r ev en i f low fres h gas flows were used . A cannula th at projec ts into the airway c an be us ed to improv e s ampl ing (112). In another s tud y inv olv ing infan ts and c hildren, sampl ing at the junc tion of th e trac heal tube and breathing s ys tem resul ted i n fals ely low end -tidal CO 2 v alues in pati ents wei ghing less than 8 kg (59 ). The accu rac y of meas urements can be i mprov ed by inserting a s ma ll heat and mois tu re exc hang er between the breathing s ys tem and the tracheal tube conn ec tor (113). Howev er, usi ng a dev ic e a t this s ite wi ll inc rease dead s pac e and may res ul t P .219 i n excess iv e resis tance so that spon tan eous resp iration c annot be used (103 ,114).

View Figure

Figure 8.10 Respiratory gas sampling with a Mapleson system. Accurate values for expiratory concentrations can be obtained by sampling at sites 3 and 4. Sampling at site 2 will yield accurate values only if the fresh gas flow is not high. Sampling at site 1 will yield inaccurate values even at low fresh gas flows. (Redrawn from Gravenstein N, Lampotang S, Beneken JEW. Factors influencing capnography in the Bain circuit. J Clin Monit 1985; 1:610 [Medline Link] .)

Advantages of the Mapleson Systems

The equipment is si mple, inex pens iv e, and rugged. W i th the exception of the AP L v alv e, there a re no mov ing pa rts . Th e c ompon ents are easy to disas sembl e and c an be disi nfec te d or s teri liz ed in a v a riety of ways . For these reas ons , the y c ontinue to be a popular c ho ic e to prov ide pos itiv e press ure v entilation i n emergenc ies (115).

Vari ations in minute v olu me affec t end-ti dal CO 2 less than in a c i rc le s ys tem. In c oax ial s ys tems (Lack , Bain), the i ns pi ratory l imb is heated b y the warm ex hal ed gas i n the c oaxi al expi ra tory tubi ng. Res is tance is usual l y l ow at f lows likely to be expe ri enc ed in practice (116,117 ,118,119). A commonl y held v iew is that the work of breathing during s pontaneous v entil ation is si gn ific antly l ess wi th thes e s ys tems than wi th the c i rc le s ys te m. Howev er, s tudies indic ate that this is not al ways the case (12 0,121,122 ). Th e work of breath ing may be inc reased if the AP L v alv e i s not oriented pro perly .

These s ys te ms a re ligh twe igh t and no t bulky . They are not l ikel y to cause drag on the mask or trachea l tube or ac cidental ex tubation. The y are eas y to posi tion conv enien tly. A long Mapl es on D s ys tem with an alumi num APL v alv e may be us ed to v entilate a pati ent in the MRI uni t (123). Compres s ion and comp li anc e v olume losses a re less wi th the Mapleson s ys tems than with the ci rcl e s ys tem.

Changes in fresh gas c onc entrations res ul t i n rapid ch anges in ins pi ra tory gas c ompos ition. S ince there is no CO 2 absorbent, there wil l be no produc tion of poss ib ly tox ic produc ts s uch as ca rbo n mo noxi de and c ompound A (Chap te r 9).

Disadvantages of the Mapleson Systems

These s ys te ms requ ire high gas flows . This re sul ts i n higher c os ts , inc reas ed atmospheric po llution, and difficul ty assessing spontaneous v enti la tion. P .220

Bec ause of the high f resh gas flo w, ins pi red h eat a nd humidity tend to be l ow, un les s a humidif ication dev ice is used (124). The optimum fresh gas fl ow ma y be diffic ult to determin e. It is nec es sary to change the flow when c hanging f rom sp ontaneous to c ontroll ed v enti lation or v ice v ersa . Any thing that c auses the f res h gas f low to b e lowe red pres ents a hazard, bec aus e rebreathing may occ ur.

In the Maples on A , B , and C s ys tems the AP L v alv e is loca ted c los e to the pati ent, where it ma y be in accessible to the us er. In addi tion , scav enging is awk ward . This disadv antage can be ov ercome by us ing the Lack modifica tion of the Maples on A .

The Map leson E and F sys tems are diff ic ul t to s cav enge, and ai r di lution c an oc cur wi th the Maples on E s ys tem. Maples on s ys tems are not s ui tab le f or pa tients with mal ignant h yperthermia, becaus e i t may not be pos sible to inc rease the fresh gas fl ow enou gh to remov e the inc reas ed CO 2 l oad (125).

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[Cross Ref] [Med li ne Link ] 99. Anonymous . Mis loc ated pop-off v alv e ca n p roduce ai rway ov erpress ure i n manu al resus c i tator b rea thi ng c i rcui ts . Health Dev ices 19 96;25:212214. [Med li ne Link ] 100. Chan MS H, Kong AS . T-piece s cav engingthe doub le bag s ys tem. Anaes thes ia 1993;48:647. [Cross Ref] [Med li ne Link ] 101. Dhara S , Pua H. A nonocc ludin g bag and clos ed scav enging s ys tem for the Jacks on Rees modif ied T-piece b reathing sy s tem. Anaes thes ia 2000;55:4 504 54. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 102. Jerwoo d DC, J ones SE F. HME fi l ter a nd Ayre's t-piece. A naes thes ia 1995;50:915916. [Cross Ref] [Med li ne Link ] 103. Goddard J M, Benne tt HR. Fil ters and A yre's T-piec e . Anaes thes ia 1996;51:605. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 104. Da Fons eca J MG, W heeler DW , Pook J A R. The effec t o f a heat a nd mois tu re ex changer on gas flow in a Maples on F b rea thi ng s ys tem during inhalational i nduc tion. Anaes thes ia 2000 ;55 :571573. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 105. Marcus R, W andless J , Thompson J . Filters and Ayre's T-p iec e. P aediatr Anaes th 1999 ;9:93. [Cross Ref] [Med li ne Link ] 106. Nak ae Y. In response . A nes th A na lg 19 97;84:703. [Fu ll tex t Link ] [Cross Ref]

107. Gunter J . W ork of bre ath ing. Anes th An alg 1997;84:702 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 108. Dobb ins on TL, Fawc e tt E R, Bol ton DPG. T he effec ts of pos i tiv e end expi rato ry press ure on rebreathing and gas d ilution in the A yre 's T-piece s ys temla borato ry s tudy . Anaesth Intens Care 1978;6 :1925. [Med li ne Link ] 109. Lawrenc e J C. PE EP an d the Ayre's T-p iece s ys tem. Anaes th Intens Care 1978;6:359. [Med li ne Link ] 110. French R, K ennedy R. Disconnec t ala rm fa il ure in detec tion of co mmon gas outl et disc onnec ti on . Anaes th Intens Care 1998 ;26 :665670. [Med li ne Link ] 111. Grav ens te in N, Lampotang S , B eneke n JEW . Fac tors influenci ng capnography i n the Bain c i rc ui t. J Clin Monit 1985;1:610. [Med li ne Link ] 112. Bal l AJ . P aed iatric ca pnog raphy. An aes thes ia 1995;50:833834 . [Cross Ref] [Med li ne Link ] 113. B rock -Utne J C, Humphre y D. Multipurpose anaes the tic breathing s ys tems the ul timate goal . Ac ta A naes thes iol Scand S uppl 1 985;80:67. 114. Fox LM. Equi pment dead spac e i n paediatric breathing sys tems . Anaes thes ia 1992;47:1101110 2. [Cross Ref] [Med li ne Link ] 115. W ong G, W alsh K . Opti mum c ontents of a portable eme rgency ai rway equipment bag: resul ts of an ins titutional s urv ey. Can J An aes th 2005;52:659 660. [Med li ne Link ] 116. Martin DG, K ong K L , Lewi s GTR. Res is ta nce to airflow in anaes the tic breathi ng s ys tems . B r J A naes th 1989;62 :45 646 1. [Cross Ref] [Med li ne Link ] 117. Ooi R, Pattison J , Soni N. The addi tional wo rk of b rea thi ng imposed by Maples on A s ys tems . Anaes thesia 1993;48 :599603.

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Questions
For the fol low ing ques tions , s elec t the co rrec t answer. 1. In w hic h o f the follow ing is the fresh gas inle t most distant from the pa tient connectio n po rt? A . Map leson A B . Map leson B C. Mapleson C D. Mapleson D E . Map leson E V iew A ns we r2. Wh ich of the fo llow ing is most efficient du ring sponta neous ve ntila tion? A . Map leson A B . Map leson B C. Mapleson C D. Mapleson D E . Map leson E V iew A ns we r3. Wh ich of the fo llow ing systems lacks a rese rvoir bag? A . Map leson A B . Map leson B C. Mapleson C D. Mapleson D E . Map leson E V iew A ns we r4. Wh ich of the fo llow ing is the most effic ien t during con trolled ven tilation? A . Map leson A B . Map leson B C. Mapleson C D. Mapleson D E . Map leson E V iew A ns we r5. Advantages o f the Maples on systems inc lud e a ll o f the follow ing except A . B uffering effec t o n end-tidal CO 2 B . S i mple, inex pens iv e equi pment

C. Us efu l in treating mali gnan t hyperthermia D. Ligh twei gh t E . E ase of dis assemb ly V iew A ns we r

Chapter 9 The Circle System

P .224

The c irc le s ys tem is s o named bec ause gases f lo w i n a c irc ular pathway through separate insp iratory and expi ra to ry channels . Carbon di oxide exhaled by the pati ent i s remov ed by an absorbent. Inte rna tiona l and U.S . s tand ards for b rea thing sys tems wi th pa rtic ula r emphasis on ci rc le s ys tems h av e been published (1,2).

Components Absorber
The absorber is usually attached to the anes thes ia mac hine but may b e s eparate. An abs orber as sembly c onsis ts of an abs orb er, two ports for c onnection to breathi ng tubes and a f res h gas inle t. Other compon ents tha t may be moun ted on the abso rbe r ass embl y inc lu de inspi ra tory and ex piratory unidirec tional v alv es , an adjus table pres sure li miting (APL) v alv e, and a bag moun t. Mod ern anes thes ia machines of ten inco rpo rate components of the anesthes ia v enti la to r into the absorber as sembl y. Dis posable absorbers and abs orber as sembli es are av ai lable.

Canisters Construction
The absorben t is he ld in canis ters (ca rbo n d iox ideabsorbent contai ners , chambers , units , o r cartrid ges ). The s ide wa lls are transparent so that the absorbent c olor can be monitored. A canis te r with ti nted s ide wal ls may make it diff icul t to detec t c olo r changes P .225 i n the abs orbent (3). A sc reen at the bo ttom o f eac h c anis ter ho lds the abs orbent in place .

Figure 9.1 Absorber with two canisters in series, a dust/moisture trap at the bottom and a drain at the side. The lever at the right is used to tighten and loosen the canisters. Note that the date the absorbent was last changed is marked on the lower canister.

View Figure

Many abs orbers us e two canis ters in s eries (F ig. 9.1 ). A s ingle canis ter ma y a ls o be us ed (Fi g. 9 .2). S ome ne wer mac hin es use a singl e, s mal l disposabl e can is ter that c an be quick l y changed during an anesthetic wi thout i nterrup ting breathing s ys tem c ontinuity (F igs . 9.3, 9.4).

Figure 9.2 Absorber with a single canister. It is loosened and tightened by twisting.

View Figure

P repac kaged abso rbent containe rs are av ailabl e and are placed i nside the canis te rs that are a part of an absorber. These el imi nate the need to po ur absorbent into the c anis ter. Thes e c ontainers c an cause an obs truc tion if the l abel

or wrap cov ering them is not re mov ed or an exc ess iv e nu mber of holes are oc c luded (4,5 ,6). P .226

Figure 9.3 Absorber with single disposable canister. A: With the canister in place. B: With canister removed. The two valves at the top prevent loss of gas when the canister is removed.

View Figure

Size
Can is ters of v a rying capac ity hav e be en use d. An adv antage of large can is ters is l onge r in terv als between absorben t c hanges (7). This adv anta ge may be offs et by the poss ib il i ty that absorbent may bec ome d esicc ate d wh en it res ides in the absorber for a long ti me. Newe r us e an es thes ia mach ines use s ma ll c anis ters that mus t be change d mo re f requentl y. Freque nt changes h elp to prov ide fresh absorben t with proper wa ter content. This wil l l ess en the l ikel ihood th at ca rbon mo noxi de or C ompoun d A wi l l be produced (8 ,9,10). Some manufac ture rs recommend that a new c anis ter be us ed fo r each anes thetic . Ano the r adv antage of s mall abso rbe rs is tha t the internal v ol ume of th e breath ing s ys tem is reduc ed. This wi ll allow c ha nges in the f resh gas f lo w c oncentratio n to be

reflec ted more quick l y i n the ins pi red c onc entra tion and i mprov e v en ti la to r performance.

Absorption Pattern
The pattern of abs orp tion wi thin a properly packed c anis ter is s hown i n Figure 9 .5. It makes n o d iffe rence whether the gases en ter a t th e top or bottom. The fi rs t absorpti on oc curs at the inlet and along the canis ter s ides . As this abso rbent becomes ex haus ted, carbon d iox ide wil l be absorbed fa rther downs tream in the canis te r.

Housing
The head and base of the abs orber (F ig. 9.1 ) are c onstruc ted of metal or plas tic . The re are spac es at the top and bottom of the absorber for i nco ming gases to dispe rs e b efo re pas sing th rough the absorben t or for outgoing gases to c ol lec t before pass ing on through the c i rc le . This promotes ev en dis tribu tion of f low through the abso rbe r. In the base, this space al lows dus t and c ondensed wate r to ac cumulate (Fi g. 9 .1). S ome bases hav e a means of d rai ni ng water f rom the bottom (Fig . 9.1). B ecause th is water wi l l be highl y alkaline, ca re sh ould b e tak en that i t does not c ontac t s k in. On many mod ern mac hines , the ca nis te r is attached to a hous ing that inc orporates v alv es tha t wi ll c lose the entranc e and ex i t from the canis ter wh en the c anis ter is remov ed (Figs . 9 .3, 9.4 ). This al lows breathi ng s ys tem con tinui ty to be maintain ed whe n the ca nis te r is changed.

Baffles
Baffles , which are annul ar ri ngs that se rv e to di rec t gas f lo w toward th e c entral part of the ca nis te r, are frequently us ed to i nc reas e the trav el pa th f or gases that pass along the si des of the canis ter and compens ate for the re duced f low res is tance along the wal ls of the c anis ter.

Side or Center Tube

The re mus t be a way to co nduc t gas es to or f rom the bottom of the c anis ter and retu rn them to th e patien t. S ome a bso rbe rs hav e a s ide tube ex te rna l to the canis te r(s ). The tube may also be in the cen ter of the abso rbe r (Fi g. 9 .6).

Bypass
On ol der absorbers , there was a bypass v alv e that a llowed exhaled gases to co mple tel y or partia ll y bypass the abs orber. A s h as been d is cuss ed earlier i n th is chapter, most modern absorbers with smal l canis te rs allo w the canis ter to be

change d duri ng a c as e withou t dis rupting the breathing s ys tem in teg ri ty . If the canis te r is i ntentio nally remov ed and not replac ed, this bec omes a bypass . Ca re mus t be tak en to replace the can is ter P .227 so that a nother anes thetic wil l not begi n without i t in plac e. Low-f low an es thes ia is dangerous in the absence of the carbon di ox ide absorbent. The b ypas s c an be us ed to allow c arbon diox ide to acc umul ate in the b rea thing s ys tem.

Figure 9.4 Absorber with a single disposable canister. A: With canister in place. B: With canister removed. The canister fits into grooves in the bracket and is pushed up to lock it in place. Note the release button.

View Figure

View Figure

Figure 9.5 Pattern of carbon dioxide absorption in a canister. Darkened circles represent exhausted absorbent. A: After limited use; absorption has occurred primarily at the inlet and to a lesser extent along the sides. B: After extensive use; the granules at the inlet and along the sides are exhausted. C: Carbon dioxide is filtering through the canister; in the distal third of the canister, a spot remains where the granules are still capable of absorbing carbon dioxide. (Redrawn from Adriani J, Rovenstein EA. Experimental studies on carbon dioxide absorbers for anesthesia. Anesthesiology 1941;2:10 .)

Absorbents
Composition
Carbon di ox ide absorptio n employs the g eneral p ri nciple of a bas e neutra li zing an ac id. The aci d is c arb onic aci d formed by the reac tio n of carbon diox ide wi th P .228 water. The end p roduc ts of the reac tion are water and a ca rbo nate. Hea t is l ibera ted by the re ac tion.

Figure 9.6 Center tube in canister. Note the grooves around the edge that allow the canister to be screwed tightly in place.

View Figure

High-alkali Absorbents
Some absorbents , inc ludin g s uch trad itional ones as s ome formul ati ons of s oda l ime, contain relativ ely high amounts of p otass ium and/or s odi um h ydrox ide. When these abs orbents bec ome des icc ated, they reac t with v olatil e anes thetics to form ca rbon mo noxi de. Compou nd A c an be fo rmed wi th s ev oflu rane. Th ese abs orb ents of ten d o not c hange c olo r when dry. The c apaci ty to absorb carbon diox ide is dec reas ed by dec reased mo is ture (11 ).

Low-alkali Absorbents
Some ca rbo n d iox ide abso rbents c ontain reduced amou nts of sodium or p otassi um hydrox ide. S tudies differ on whether thes e p rod uce smal ler amounts of Compound A and ca rbo n mo nox ide than abs orbents wit h more s trong alk al is (12,13,14,15,16,17).

Alkali-free Absorbents
A lkali -f ree absorben ts co nsis t mainly of ca lc ium hy droxide with s mall amounts of other agents added to ac celerate ca rbon diox ide abso rption and bi nd water. There i s no ev idence of ca rbon monoxide forma tion wi th any anes thetic agent, ev en if the absorbent becomes des icc ated (14,18 ,19 ,20 ,21 ,2 2,23,24,25). There is l ittle or no Compound A fo rmation with sev oflurane ev en with a c losed ci rc ui t and des iccated absorbent (12,17,18 ,22 ,26 ,27,28,29,30,31,32,33). The indica tor in these absorbents c hanges c olo r on drying (34 ,35 ,36 ,3 7). This property c an be used to i ndicate dehydra tion in absorben ts wi th s trong bas es by plac ing the abs orbent wi th n o s trong base at the s i te whe re fres h g as enters the canis te r (34 ). Once exhaus ted, these abs o rbents do not rev ert to the ir original co lor. The c arb on diox ide abs orp tion capac i ty of these abs orb ents is less than absorbents containing s trong alkal i (11,22,25,31,38,39,40 ,41 ,42 ) but does not deteriorate when mois ture is los t (11).

Lithium Hydroxide
Li th iu m hydrox ide reac ts wi th c arbon di oxi de to form c arbonate. It does not reac t wi th an es thetic agents , ev en if des icc ated (17 ,43 ,44,4 5,46). Howev e r, i t is ex pens iv e and requi res c are ful handling bec aus e i t may ca use bu rns to the eyes , sk in, and respi ra tory trac t (47 ).

Indicators
An indic ator is an ac id or base whos e c olor depends on pH. It is added to the absorbent to si gnify wh en the abs orben t's abi lity to abs orb c arb on diox ide is ex haus ted . The indicator d oes not aff ect abso rption. Some of the c ommonl y us ed i ndicators and th ei r colors a re s hown in Table 9.1. E thy l v iolet is mos t c ommonly employed, because the c olo r change is v iv id wi th a hi gh co ntras t (48 ). Confusi on may res ul t becaus e one i ndicator is whi te when f resh whereas another is white whe n exhaus ted. The user s hould al ways know whi c h indic ator is being used and wha t color c hange is see n when the a bsorption capac ity is ex haus ted.

TABLE 9.1 Indicators for Absorbents

Indicator Phenolphthalein Ethyl violet

Color When FreshColor When Exhausted White White Pink Purple

Clayton yellow Ethyl orange

Red Orange

Yellow Yellow

Mimosa Z

Red

White

Shape and Size

Abs orb ents are s upplied in pellets o r granules . P el le ts or s mall gra nules prov ide greater s u rfac e area and d ec rease gas chan nelin g a long low-res is tance path ways . Howev er, they may cause more resis tanc e a nd cak ing . Granule s i ze is measured by mesh number. A 4 -mes h s trai ner has fo ur ope ni ngs per squa re i nch whe reas o ne of 8 mesh has eig ht op enings pe r s qua re inch. Granules graded 4 mes h wi l l pas s throug h the 4-mesh s trainer bu t not through a s trainer wi th s mall er hol es . In othe r word s , the higher the mes h n umber, th e smal le r the parti cles . Mos t absorbents used in anesthesia today c onsis t of granul es in the range of 4 to 8 mesh.

Hardness
Some absorbent granules fragment eas il y, p rod ucing dus t (f ines ). The re may be v a ri ations in the dus t content of diff erent a bsorben ts (49). Excessiv e po wder produces channeli ng, resis tanc e to flow, and c ak in g. Dus t may be blown through the sys tem to the patient or ma y caus e sys tem components to malfunc tion (5 0,51). To prev ent this , smal l amounts of a hardening ag ent a re added. So me manufac tu rers coa t the outs ide of th e g ranul es with a film to wh ic h dus t parti cles adhere. If a f ilter is used on the inspi rato ry s ide of the breathing sys tem, dus t shoul d not reach the patient.

Reactions between Absorbents and Anesthetic Agents

Haloalkene Formation
Halothane d egradation most of ten occ urs du ri ng c losed-c ircui t an es thes ia and produces the haloalken e 2 -bromo-2-chloro-1 , 1-dif luoroethene (BCDFE ). Al though B CDFE is neph rotox ic i n rats , ha lo thane has no t been found to be nep hro tox ic in huma ns af ter ov er four decades of use (52 ).

Compound A Formation
Sev oflurane decomposes i n the presence of some carbon diox ide a bsorben ts to form P .229 sev eral de gra dation c ompounds . Only one, Compound A , a v iny l ether that has a dose-depe nden t neph rotox ic effec t in rats , reac hes si gnific ant c onc entrations (53,54,55,56,57,58). It has been the s ubjec t o f in tense deb ate regarding pos s ible nephrotox icity in humans (59,60,61,62,63,64,65 ,66 ). A l arg e number of sc ien tific reports on this top ic hav e been p ublis hed, sometimes with contradic to ry resul ts and conc lus ions (59,62,65,67,68,69,70,71,72,73 ,74 ,75 ,76,77,7 8,79,80,81,82,83,84,85,86,87,88,89 ). Sev era l factors inf lu ence the amoun t of Compound A in the breathi ng s ys tem.

Fresh Gas Flow

More Compound A is pro duc ed with lo wer fres h gas flows (90,91). Howev er, a numb er of s tudies hav e be en carri ed out in c los ed s ys tem wi thout s ignif ic ant Compound A fo rmation (17,26 ,32 ).

Absorbent Composition
Compound A produc ti on is g rea tes t wi th abs orbents c ontaining potass iu m or s odium hydrox ide. Absorbents with dec reased potas si um h ydrox ide/s od ium hydroxide produce lower concentrations of Compound A (92). A bs orbents th at are free of s trong alk al i produc e li ttle o r no Compound A , ev en during c los ed s ys tem anes thes ia (12,18,26,92,93).

Absorbent Temperature
Tempera ture in the abs orb er co rrela tes wi th the amount of Compound A that is generate d (94,95,96). Lo weri ng the abs orber te mperatu re dec re ases the amount of Compound A produc ed (94 ,97 ). Inc reas ed abs orber temperatu re as soci ated wi th an i nc reas e in carbon diox ide elimin ated by the pa tient may res ul t in modes t inc reas es i n Compoun d A produc tion (98,99).

The reac tion between desicca ted absorbent and sev oflurane p rod uces heat, whi ch i nc reas es the reac ti on speed, s o the rate of sev oflurane break down c an ac celerate rapidl y (100 ,101,102). Sev oflurane may be s o extens iv el y co nsume d that mai ntaining anes thesi a is diff icul t. The s ize a nd shape of the c anister may be important in determining the temperature of the absorbent. S mall c hambers may resul t in lowe r te mpera tu res . One s tudy f ound that if dead s pace were added b etwe en the c ircl e s ys tem and the Y-pi ece and the v olume of v entilatio n inc reased to c ompensate for the inc reas ed dead spac e without changing alv eolar v entilatio n, the tempera ture of the abs orbent wou ld be reduc ed (103). Howev e r, another s tudy found tha t sev oflurane break down i nc reas ed with higher minute v olumes (100).

Concentration of Sevoflurane
Hi gher c onc entrati ons of Compound A oc cur wh en higher c onc entrations of sev oflu ran e a re us ed (95 ,101).

Anesthetic Length
Compound A conc entra tion inc reases with longer anes thetics .

Water Content
The effec t o f abs orbent dryness is c omplex (1 01,104,105,106,107). Deh ydrate d absorbents inc rease bo th the degrada tion of s ev ofl ura ne to Compo und A and the degradation of Compou nd A (104 ,10 8). The abs orb ent in s mall ca nis te rs is l es s l ik ely to bec ome desicc ate d p rob ably bec ause i t is c hanged more f requen tl y. Abs orb ent d ryness ca n be p redic ted b y measuri ng the perc ent of wate r in the outflo w gas (109). S ma ll er p ati ents are les s lik el y to rehydra te the abso rbent through ex haled wate r v ap or and c arb on diox ide neutrali za ti on. Abs orb ent c an be rehydrated to some ex tent by using humidifi ed gas es (110). Abs orb ent manuf ac ture rs hav e cauti oned agains t adding mois tu re di rec tly to absorbent (111 ). Poured wate r wil l no t uniforml y hyd rate al l of the abs orbent. This wi ll leav e des ic cated granul es that c an react wi th anes thetic a gents . A lka line water could pote ntial l y b e c arri ed to the patie nt (112). A dd ing wa ter c oul d lead to agglomera tion of the abs orbent granules , which co ul d i nc rease the res is tanc e to gas fl ow a nd cause a s ignifican t loss in a bsorption c apac ity (111).

Carbon Monoxide Formation

Carbon mon oxide is p roduced whe n desfl ura ne, enfl urane, o r is of lurane is pas sed through dry abs o rbent co nta ining a s tro ng al kal i (potassium or sodium hydroxi de)

(9,10,22,113,114,115,1 16,117,118,1 19,120,121 ,122). When sev oflurane is degraded by abs orbent, carbon monox ide is formed if the temperature exceeds 80C (100). T he inc idenc e of carbon monix ide forma tion is not kn own but is probably greater than thought (117,123,124). Cas es of sev ere c arbon monox ide poiso ni ng hav e been reported (117,118,1 20,125). Mos t reported c ases hav e occu rred durin g the firs t g eneral anes thetic of the d ay and o n Mo nday morni ng, p res umabl y bec ause f resh dry g as was flowi ng into the c i rc le s ys tem ov er the weekend , caus in g the absorbent to bec ome dehy drated (126). Carbon monoxide fo rmation h as als o been repo rted when anes thes ia was adminis tered from a li ttle -us ed mac hine in a remote locatio n (124 ). The c arb on monox ide c oncentration i n the bre ath in g s ystem v aries wi th ti me, tending to peak i n the firs t 60 minutes (10,114,121 ). Carbon mon oxide can prese nt a s erious hazard to the patien t. S igns a nd s ymptoms of moderate c arbon monox ide toxic i ty s uch as c onfus ion, headache, and nausea are masked during an d after anes thes ia and may resemble c ommon seq uelae (127). The c onsequences are more sev ere in pati ents with lo w he moglobin lev els and in smal l p ati en ts (100,128 ).

Carbon Monoxide Detection

Some desiccated absorbents wi ll c ontin ue to absorb c arbon dioxi de; the refore, the presenc e of an acceptable c apnogra phic wav eform s hould not b e tak en as ev idence that the inspi re d gas is f ree from c arb on monox id e (129 ). Mos t pulse ox imeters (Chapte r 24) cannot detec t c arbon monox id e and read ca rbox yhe moglobi n as ox yhemog lobin . Howev er, a v ery h igh c arbox yhemoglobin conc en tration may c ause a sl ight dec rease in SpO 2 (117). Res piratory gas moni to rs in curren t use cannot direc tl y detec t c arbon monox ide. Mul ti wav elength infrared anal yze rs may prov ide warni ng of isofl ura ne or P .230 desflurane (but no t sev oflurane ) breakdown by displaying the wro ng agen t or mixed agents (100 ,117,118,130 ,131,132). An unus ual l y del ayed rise or unexpec ted dec reas e in the ins pi red concen tration o f a v olatile anes thetic in the breathing s ys tem c ompared with the v apori zer s etting, a failed inha lation in duc tion, inadequa te anesthesia, o r an unexpec ted d ec rease in i nspi red conc entra ti on may i ndicate tha t che mic al breakdown (wi th p oss ible produc ti on of c arbon monox ide) i s occu rring (120 ,133,134,135 ).

Carbon mon oxide moni to rs that wo rk in the presenc e of c li nical conc entrations of v olati le anes thetic s are c ommerc iall y av ai lable (12 4,136,137 ,13 8). Carbox yhemoglobin monitoring is av ailab le through co-ox imetry but is not routin ely as sess ed. A combination pu ls e ox imete r and c a rbon monox ide de tec tor is co mme rci al l y av ai lable (Chapte r 24). S ince the reac tion of anes thetics wi th des icca ted abs orben t is ex othermic , an unusua lly high temp era ture in the c an is ter ma y be a s ig n of c arbon monox ide formati on (139,140). Howev er, th is is not a reliable method of d etec ting c arb on monox ide formation (141 ). W i th gas chan nel ing ins ide the abs orb er, the ou ts ide o f the canis ter may f eel onl y warm des pi te high inte rna l temperatu res .

Factors Associated with Carbon Monoxide Formation Absorbent Composition

Onl y abs orb ents tha t con tai n sod ium and /or potass ium hyd rox ide a re as soc iated wi th the fo rmation of carbon monoxi de.

Absorbent Desic cation

No si gnific ant ca rbo n mo noxi de produc tion oc curs with normal ly hydra ted absorbents (100,142). Fresh gas fl owi ng through the absorbent during an ex tended period of nonuse is th ough t to be the main fac tor that caus es des ic cation. The i mpac t of fres h gas flow in v arious c irc le s ys tem configurations tha t c an lead to absorbent desicc ation is dis cus sed more f ull y l ater i n this chapter. Use of a hea t and mois ture exchange r (HME ) wil l re sul t in dec reas ed humidi ty i n the ci rc le s ys tem. Detec ting abs orbent des iccation is difficul t. The lack of s ig nifican t color c hang e wi th many of the a bsorben ts does not ensure adequate abso rbe nt hydra tion (1 34). An abs orbent wi th no s trong bases ca n be used to detec t d ehyd ration before c arbon monox ide is formed from anes thetic degradation by layering it a t the s ite of f res h gas inflo w (34). These abs orbents wil l ch ange colo r when dry. Another way to detec t des ic cation is to fil l the breathing sys tem wi th gas c ontai ni ng sev oflurane and c irculate it through the abs orbent wh ile moni to ri ng th e s ev oflurane conc en tration (143). A ra pid dec line in sev oflurane c oncentratio n ma y indic ate desic cated abs orbent.

Anesthetic Agent
The highes t c arbon monox ide lev els h av e been seen wi th desf lurane follo wed by enfl ura ne then is oflurane (9,144). The amou nt of carbon monox ide pro duced wi th

halothan e is small . Si gnific ant amou nts of carbon monox ide hav e b een reported wi th s ev oflu rane onl y when the a bsorbent te mperatu re was greater than 80 C (10,100,120 ,145,146).

Temperature Inside the Absorber

Hi gh te mperatu res in the a bsorben t facil i ta te c arbon monox ide produc tion f rom sev oflu ran e (102 ,145). Howev er, if an exothermic reac tion is oc curri ng dee p in the absorber, it ma y not be de tec ted b y fee li ng the outs ide of the can is ter.

Fresh Gas Flow

Hi gher fresh gas f lows remov e more c arbon monox ide , produc ing lowe r c arbon monox ide c onc entra tions , al though more carbon monoxide is produced at higher f res h g as fl ows because of the greate r quanti ty of anes th etic reacting with desic cated abs orbent (9,100,137,1 47). High f resh gas f lo ws are more lik ely to promote abso rbent des ic cati on.

Carbon Dioxide Absorption

Carbon mon oxide fo rmation is reduc ed by carbon diox ide a bsorption (141 ,14 8). This could be s ignificant with s malle r patients wh o p roduce less ca rbon dioxi de. Carbon mon oxide lev els are i nc reased wi th re duc ed patient s ize (147).

Preventing Carbon Monoxide Formation

The A nes thes ia Patient Safety Foundation (APS F ) has recommended that c arbon diox ide absorbents that do no t deg rade wh en they are desicca ted and exposed to v olati le agents should be us ed (12 9). Thes e i nc lude abso rbe nts wi thout K OH an d l ittl e or no Na OH. S ince the compos iti on and names of th ese absorbents change f requentl y, cl inic ians mus t l ook a t the c ompos ition of a particu lar abso rbent to s ee i f it fi ts the abov e rec ommendation . The A PS F has prov ided a numbe r of recommendati ons th at an anes thes ia department should take to p rev ent absorben t des ic cation if the department continues to us e s trong alk ali a bsorben ts wi th v ola ti le anes thetic agents (129). These, i nc luding a f ew more disc uss ed in the li terature, are presen ted be lo w.

A ll gas f lows s hould be turned OFF af ter each c ase. T his is probably the mos t impo rtant me asure. W hen the dai l y sch edule is f in is hed, the anes thes ia machine s hould be disc onnec ted f rom the medical gas pipel ine s ys te m at the pipel ine outle t.

Vapori ze rs should be turned OFF whe n n ot i n use. A t th e end of each cas e, the breathing s ys tem shou ld be f lushed wi th g as that is f ree of v olati le an es thetic .

The absorben t s hould be c hanged rou tinel y, a t leas t onc e a week , prefe rab ly on a Mond ay morn ing , and whe nev er fresh g as has been flowi ng fo r an ex tensiv e or indetermin ate pe riod of time . The canis te r s hou ld be labeled wi th the fi l li ng date (Fig. 9 .1 ). Checki ng P .231

this d ate s houl d be part of the dai l y machi ne c heckl is t (112). If a doub lechamber a bsorber is us ed, the abs orb ent in both canis ters should be change d a t the s ame time.

Can is ters on an anes thes ia machine that is commonly no t use d for a long period of time s hould not be f il led with abs orb ent that c ontains s trong alk al i or s houl d be fi lled with fresh abs orbent befo re each use.

The integrity of the abs orbent packa ging should be v e rifi ed prio r to us e. Opened c on taine rs that contain absorbent shou ld be c arefull y c losed af te r us e, and the res t of the absorbent should be us ed as s oon as poss ible.

The prac tice of s uppl ying ox ygen f or adminis tra tion to a pa ti ent who is no t receiv ing general anes thesi a th rou gh the c irc le s ystem should be s trongl y disc ouraged (124). This is associa ted wi th o the r hazards , inc luding ac c idental adminis tration of nitrous ox ide an d v olatil e anes the tics (149). Supplemental ox ygen s houl d be obtained f rom a flowmeter that is connec ted di rec tly to the ox ygen pi pe li ne s ys tem or an auxi l ia ry oxy gen f lo wmete r on the anes thes ia machine (C hapter 5).

Us ing f res h gas to d ry breathing sys tem componen ts shoul d be discou raged (124). The negativ e pressure re lief v alv e on a c losed sc av engin g sys tem (Ch apter 13) shou ld be check ed reg ula rl y. Fail ure of this v alv e to pu ll i n ro om air may resul t i n fresh gas f ro m the mac hine bein g d rawn through the abs orb ent if the AP L v alv e is open (124 ).

The temperature in th e c anis ter s hould be moni to red and the absorbent change d if ex ces siv e heat is de tec ted . A simple pa tient tempe rature moni tor

may be us ed fo r this purpos e. If the tempe rature approac hes 50 C, ex ces siv e heating f rom anes thetic break down s hould b e suspec ted (127). Howev er, if the probe is no t in the area where the temperature inc rease occ urs , the rise i n tempe rature may be mis sed.

Cons ideration s hould be giv en to remov ing absorbent from c anis ters in i nduc tion rooms and to us ing high fresh gas flows to e liminate rebreathi ng (146).

It is important to inv olv e anes thesi a tec hnici ans , c leani ng s taff, nurs ing p ers onne l, and a nyone els e who migh t c ome into c ontac t wi th an anes thesi a mac hine in the program to prev en t abs orb ent d ryi ng. Thes e p ers onne l need to be trained to look out for flowmeters that are lef t ON. The y should be ins truc ted to turn OFF an y fl ows at the end of the day and to reduce the f low to a minimum between c ases . The absorbent s hould be changed if i t is l ikel y th at prolonged ex pos ure to dry g ases has oc curred . One s tudy f ound that thes e measu res reduc ed, b ut did not e liminate, absorbent desicc ation (150). Abs orb ent c an be rehydrated to some ex tent by using humidifi ed gas es (110). Abs orb ent manuf ac ture rs hav e cauti oned agains t adding mois tu re di rec tly to absorbent (111 ). Poured wate r wil l no t uniforml y hyd rate al l of the abs orbent. This wi ll leav e des ic cated granul es that c an react wi th anes thetic a gents . A lka line water could pote ntial l y b e c arri ed to the patie nt (112). A dd ing wa ter c oul d lead to agglomera tion of the abs orbent granules in add iti on to inc reas ed res is tance to flo w and a s ign if ic ant los s in abs orp tion ca paci ty i f mois ture c ontent s tandards are ex ceeded (111). Fl ushing the breathi ng s ys tem wi th f res h gas before use wi ll n ot prev ent c arbon monox ide exposure.

Excessive Heat and Fires

The interaction of desicc ated barium hydroxide abso rbent and s ev oflurane c an produce tempera tures of s ev eral hundred de gre es centigrade (1 00,104,120 ). Cas es of fi res and/or mel ted c ompon ents in the abso rbe r hav e been reported (100,112 ,120,134,135,139,146,151). Bec aus e of thes e problems , barium hyd rox ide has been remov ed f rom the mark et (152). Us ing so da li me res ul ts i n les s elev ated temperatures (153 ), althou gh fi res i nv olv ing desicc ated s oda l ime hav e also been reporte d (135 ,154).

It is possible that dama ge from excessiv e hea t is not reported more of ten because pati ent a bsorption o f the tox ic produc ts reduced thei r concentra ti ons be lo w the l ower l i mi t of fl ammabil ity. Cases of me lted or bu rned abso rbe r parts s hould be reporte d to the Food and Drug A dminis tratio n (FDA ), su pplie rs , and the Emergenc y Care Resea rc h Ins ti tu te (E CRI) (112).

Absorbent Storage and Handling

Abs orb ents are s upplied in sev eral types of con tai ners : res ealable pack ages , pails , cans , c artons , and disposable pref il led c ontainers . Once opened, c ontainers s houl d be res ea led as s oon as possi bl e to prev ent abs orbent reac tion wi th c a rbon d iox ide i n the ai r, indic ator deac tiv ation, and mois ture l oss . Hig h tempe ratures wi ll hav e no ef fec t on absorbents if the c ontainers a re se aled, bu t te mpera tu res below f reezing are harmful bec ause the mois tu re wi ll expan d and cause the g ran ules to f rag ment. Abs orb ents should al ways be hand led gently to av oid fragmen ta ti on and dus t formati on. A l l pers onne l inv olv ed in hand li ng absorbents s hould be p eriodica ll y warned that absorben t dus t is i rri tati ng to the eyes and res pi ratory trac t a nd tha t absorbents are c aus tic to the sk in, pa rtic ularl y when damp. W hen a canis te r is emptied, c are s hould be tak en to remov e d us t p artic les , becaus e they wil l ca use the seals to wa rp, maki ng it diff icu lt to achiev e a tight fi t. Sc reens sho uld be c leared to reduce res is tance to g as fl ow. The c anis ter should a lwa ys be fi lled wi th c are. It shou ld be he ld ov er a sui table container to av oi d getting parti cles on the floor. Th e absorben t sho uld be P .232 poured s lowly i nto the ca nis te r whi le the c anis ter is ro tated, s topping occ asi ona lly to tap the s ides . The c an is ter s hould be f il led c ompletel y but no t ov e rfil led. A smal l spac e should be lef t at the top to promote ev en gas flow th rou gh the c anis ter. T he upper l ayer of abs orbent s hould be l ev el . W hen us in g d is posable, prefil led c ontainers, i t i s i mportant to remov e the top and bottom l abels o r plas tic wrap, if prese nt, before inse rtion. If th ese are n ot remov ed, gas c anno t fl ow th rough the c ontainer, and co mple te breathing s ys te m obs truc tion wi ll occu r (4).

When and How to Change the Absorbent

The re are a v ariety of op in ions abou t when the abso rbent shoul d be c hanged. Changi ng it too of ten is unec onomic al . Howev er, abso rbent that has bec ome desic cated or exhaus ted mus t be c hanged.

Inspired Carbon Dioxide

The appearanc e of ca rbon diox id e in the ins pi red gas is the mos t rel ia bl e me thod to detec t abs orbent ex haus tion (155). This al lo ws the absorbent to be us ed most ef fic ientl y.

Indicator Color Change

Indicator c olo r change c an be us ed but does no t demons trate c arbon diox ide break through as rel iabl y as inspi red c arbon diox ide when absorben ts conta ini ng s trong bas es are in use (3). The f ol lo win g c onside rati ons sho ul d be k ept i n mind when usi ng an i ndicator:

A phen omenon k nown as pe aki ng or rege nerati on is seen wi th absorben ts that c ontain s trong bas es . The abs orbent ap pears to be reac tiv ated wi th res t. The amo unt o f regeneratio n depen ds on how l ong the abso rbent is res ted . Af ter a number of suc h peri ods of efficient a bsorption with interv en ing periods of res t, termina l ex haus tion occu rs . Regenera tion has s ome i mportance when i ndicators are us ed. A n a bsorben t that s hows an ex haus ted co lor, i f allo wed to res t, wi ll often sho w c olor rev ersal . The absorption capaci ty wil l be l ow, and the ex haus ted c olor wi ll reappear a fter on ly a brief ex posu re to c arbon diox ide. The res ted c anis ter, the refore, can giv e a false i mpress ion of i ts usefulness .

W hen the exh aus ted c olor shows s trongl y, the absorbent is at o r near the point of exhaus tion. W he n li ttle o r no color c hange s hows , ac tiv e abso rbe nt may be pres ent, but the amount is ind ete rmi nate and may be quite smal l.

Abs orb ents withou t a s trong b ase cha nge co lor when dried (34). If channel ing occu rs , the absorben t al ong the c hannels wil l become ex haus ted , and ca rbon dioxide wil l pass th rough the c anis ter. If the channe ling occ urs a t s i tes o the r th an the s id es of the canis ter, th e col or change may no t be v isi bl e.

The absorben t may not c ontain an ind ic ato r (156,157,158 ). S ome c ompanies make an i ndus tri al absorben t tha t does not contain an i ndic a tor, an d this produc t may be suppl ie d as the result of an adminis trativ e error.

E thyl v io le t unde rgo es deac tiv ation ev en if it i s s to red in the d ark (159). Deac tiv ation is acce lerated in the presence of l ight, espec ial ly hi gh-i ntens i ty or u ltrav iole t light.

Coloration in the o ute r wal l of the canis ter ma y obsc ure the color c hange (3).

Heat in the Canister

The reac tion of c arbon diox ide with abs orbent produces heat. Changes in absorbent temperature oc cur earl ier than changes in the c olo r of the indicator. Peri od ic all y check ing the canis ter tempe rature is us efu l (1 60). S ome hea t produc tion should b e apparent, unless h igh f res h gas f lows a re being us ed. S tud ies s ugges t that wh en the tempera ture of the down s tream c anis ter exce eds that of the u ps tream ch amber, the abso rbent in the upstream canis te r shou ld be c hanged (161). Recen t recommen dations are that both c anis ters b e c hanged ev en if on ly one s hows c olo r change (129). To change the abs orbent, the absorber is op ened and the ca nis te r remov ed. The absorbent is disca rded and the c anis ter f il led with fresh absorbent. Care s hould b e tak en wh en placing th e l as t of the abso rbent i nto the c anis te r. If ex cess iv e dus t is present, the remaining abso rbent should be discarded and fi lli ng compl eted from a new co ntainer (1 62).

Absorption of Other Agents

Carbon di ox ide absorben ts remov e ni tric oxi de and /or nitrogen diox ide f rom th e i nspi rato ry l imb of a v entil ator c i rc ui t (1 63). A bso rbents v ary wi del y in thei r abil i ty to absorb these enti ties . If n itric ox ide is bei ng used, ni tric oxi de moni toring should be pe rforme d downs tream from the abs orber.

Unidirectional Valves
Two un idi rec tional (flutte r, one-way, c heck , di rec ti onal, dome, fl ap, nonre turn, i nspi rato ry, and exp iratory ) v alv es a re us ed in each ci rc le s ys tem to ensu re that gases flow toward the pa tient in one breathing tube and awa y in the oth er. They are us ual ly pa rt of the absorber asse mbly . The A merican Soc iety for Tes ti ng and Materials (A S TM) s tanda rd requi res tha t the d irec ti on of i ntended gas flow be permane ntl y mark ed on the v alv e hous ing or near i ts as soc iated port wi th ei ther a di rec tional arro w o r wi th the marki ng inspi rati on or expi ra tion so that i t is v is ible to the user (1). A typic al ho ri zon tal unidi rec tiona l v alv e is sho wn diagramma ticall y in Figure 9.7 . A l ight, thi n disc (l eaf let or poppe t) s eats horizontall y on an annul ar se at. The disc has a s lightly larger d iame ter than the ci rc ul ar k nif e P .233 edge on whic h it s its . A c age or guide mec hanism (retainer) (such as projec tions

f rom the s eat and dome) ma y be present to prev en t the dis c from becomi ng disl odg ed la teral ly or v erticall y (Fig. 9.8). The disc s hould be hyd rop hobic so that condensate does no t c ause it to s tic k and inc rease the resis ta nce to openi ng. The top of the v alv e is cov ered by a cl ea r pl as tic dome s o tha t the dis c c an be observ ed. Gas enters a t th e bottom and f lows through the c en te r of the v alv e, rais in g the disc f rom i ts se at. The gas then passes under the dome and on through the breathing s ys tem. Rev ersi ng the gas flow wil l c ause the disc to c ontac t the seat, prev enting retro grade flow.

View Figure

Figure 9.7 Unidirectional valve. Left: Reversing the gas flow causes the disc to contact its seat, stopping further retrograde flow. Right: Gas flowing into the valve raises the disc from its seat and then passes through the valve. The guide (cage) prevents lateral or vertical displacement of the disc. The transparent dome allows observation of disc movement.

Unidi rec tion al v alv es may be v ertica l ra the r th an horizontal (Fig . 9.9). They hav e the disc hi nged at the top. V ertic al un id irec tional v alv es reduc e the res is tanc e to gas fl ow (164 ).

Figure 9.8 Horizontal unidirectional valves. Note the cages that prevent the discs from being displaced.

View Figure

One or both unid irec ti onal v alv es may become i ncompete nt (165,166 ,167,168,169,170). Mov emen t of the disc does not gu ara ntee v alv e co mpetence . B ecause an incompetent v alv e o ffers les s res is tance to flo w than one that mus t ope n, the flow of gas wi l l be prima ri ly through the incompe ten t v alv e, resul ting in reb rea thi ng . The v alv e on the ex halation s ide is mos t p rone to th is problem bec ause i t is s ubjec ted to mo re moi s ture , but i nc ompetenc e has also been desc ribed with the insp iratory v alv e (17 1,172). A unidi rec tional v alv e l eak produc es a c ha rac teris tic wav efo rm on the c apno graph (Chapter 22). A uni di rec tional v alv e may jam, obs truc ting gas fl ow (173 ,17 4). In one repo rted case, the disc was l os t duri ng c lea ning and not rec ov ered (175). It was la ter f ound out of s ight below the s eat, where it had mov ed into such a pos ition that i t cov ered the open ing to the bag mount a nd fu nc tioned as a one -way v alv e. Gas f ro m the bag could flo w i nto the s ys tem, bu t not back into the bag again.

Inspiratory and Expiratory Ports

The insp iratory port h as a 22-mm mal e conn ec tor do wns tream of the i ns piratory unidi rec tional v alv e through whic h gases pass toward the pa tient during insp iration . The expi ratory port has a 22-mm ma le connec tor ups tre am of the unidirec tional v alv e through wh ich gas es pass duri ng exha lation. These po rts are us ual ly mo unted on the abs orber (F igs . 9.3B, 9.10). P .234

Figure 9.9 Vertical unidirectional valves.

View Figure

Y-piece
The Y-piece (Y-p iec e connec tor, Y-c onnec to r, Y-yok e, Y-adapto r, three-way breathi ng s ys tem c onnec tor) is a three-way tu bular c onnec to r with two 22 -mm ma le ports f or c onnec tion to the breathing tubes and a 15-mm fema le pa tient c onn ec tor for a trach eal tube or supraglottic ai rwa y d ev ice. The patient co nnec tion port us ual ly has a c oax ial 22-mm mal e fi tti ng to al low d irec t c onnec tio n between th e Y piece and a fac e mask . In mos t disp osable s ys tems , the Y-piece and breathing tubes are permanen tly attac hed. The Y-p iece may be des igned so that the patient port s wiv e ls . A s eptum may be placed i n the Y-piece to dec reas e the dead space.

Figure 9.10 The breathing tubes attach to the inspiratory and expiratory ports.

View Figure

Coax ial breathing sys tems (Fig. 9.11) h av e a c omponent tha t re places bu t serv es the same func tion as th e Y-pi ece . The inner (i ns pi rato ry) tub e ends jus t befo re the connec tion to the patient. The ex halation c hannel though the outer tube b egins jus t downs trea m of the end of the ins pi ratory tub ing .

Fresh Gas Inlet

The f resh gas inlet may be c onnec ted to the c ommon gas ou tlet o n the anes thesi a machine b y flex ible tub ing. The AS T M s tandard requires th at the fresh gas inlet port, or ni pple, h as an ins ide di ameter of a t leas t 4 .0 mm a nd P .235 that the fresh gas deliv ery tube has an ins ide diamete r of at leas t 6.4 mm (1). The f res h g as may enter the breathing sys tem down s trea m of the insp iratory unidi rec tional v alv e. Th is location and i ts conse quences are dis cus sed late r in this chapter. On mos t newer anes thes ia machines , there is a di rec t connec ti on between the mac hi ne ou tl et an d the breathing sys tem, s o th e user does not see a fresh gas hose.

Figure 9.11 Coaxial circle system. If there is a break in the inspiratory tube or the inspiratory tube becomes retracted, there will be an increase in dead space.

View Figure

Adjustable Pressure-limiting Valve

The A PL v alv e is disc uss ed in Chapte r 7. Duri ng spon ta neous b rea thing , the v alv e i s lef t ful ly open and gas f lows th rou gh the v alv e during ex halation. W hen manual ly as s is ted o r con trol led v entil ation is used, the APL v alv e shoul d be c losed en ough that the des ired inspi ra tory press ure ca n be ac hiev ed. W hen this pressure is reached, the v alv e op ens an d exces s gas is v ented to the sc av enging s ys tem during ins pi ra tion. T here is a cas e repo rt wh ere this v alv e ja mmed in the cl osed position (176). During mec hanic al v en tila ti on the AP L v alv e is iso lated f rom the breathi ng s ys tem.

Pressure Gauge
Many c ircl e sys tems hav e an analog pres sure gauge (manometer) attached to the ex hal ation pa th way. The gaug e is usual ly the di aphragm type that is s hown i n Fi gure 9.12. Changes in pressu re in the breathi ng s ys tem are transmi tted to the spac e betwee n two diaphragms , causing the m to mov e in ward o r outward. Mov ements of one diaphragm a re transmitted to the pointer, whic h mov es ov er a ca li brated s cale. The AS TM s tandard P .236 requi res tha t the gauge be marked in uni ts of kP a and /or cm H 2 O (1).

Figure 9.12 Diaphragm-activated pressure gauge. Two thin metal diaphragms are sealed together, with a space between them. This space is connected to the breathing system. Variations in pressure in the breathing system are transmitted to the diaphragms, which bulge outward or inward. A series of levers is activated, moving the pointer, which records the pressure.

View Figure

On newe r machines , breathing sys tem press ure is often monitored elec tron ic ally and d is pla yed on a sc ree n. The analogue press ure gauge may no t be presen t. A v i rtual pressu re gau ge may be displaye d on the s c re en (Figure 23.19).

Breathing Tubes
Two breathing tubes ca rry gases to and f rom the patien t. E ach tube connec ts to a port on the abs orb er at one end and the Y-piece at the other. The dead spac e in the sys tem ex tends from the Y-piece to the pati ent. The l ength of the tu bes do es not aff ec t the amount o f dead s pace o r reb rea thing becaus e of the unidi rec ti ona l gas fl ow. Longer tubes allow the anes thes ia machine and other equi pmen t to be l ocated farther from the patient's head (177). E xpa ndab le tubes are av ail able (s ee Fi g. 7.3). The majority of b rea thing tubes us ed in the Uni ted S tates are pl as tic , dispos able, and n onconduc tiv e. Reusable b rea thing tubes a re av ailabl e. A us eful dev ic e to keep the tubings in pl ace and s eparate from o the r tubin gs is s hown i n F ig ure 9.13 (als o see Fig. 7.4). Coax ial ci rc le sys tems are av ai lable. The breathing tubes may be c oncentric o r s ide by s ide (Fig . 9.14). As sho wn in Fi gures 9.15 and 9.16, the tubings attach to a conv en tiona l abs orber ass embl y. Gas es flow thro ugh th e inner tube to the patient, and exhal ed gases flow to the absorber as sembly v ia the oute r corru gated tube (Fig . 9.11). The ins pi red gas is s omewha t warmed in the proces s . Adv antages of this s ys tem inc lude compac tness a nd moderately inc reased i nspi re d heat and humidi ty

P .237 (178,179 ,180). A disa dv an tage is the inc reased res is tanc e. If th e i nner tu be has a l eak or b ecomes retrac te d a t the p atien t end (Fig . 9.11), the dead s pace wi ll be i nc reas ed. Th is problem may not be e asi l y d etec ted and may resul t in hype rca pnea (181). If the f lo w o f gas es is rev erse d, entering the pa tient through the outer tube and return ing through the s mal ler i nner tubing , the res is tanc e during ex hal ation wi l l be i nc reas ed.

Figure 9.13 A tube retainer (tube tree) is useful to hold the breathing tubes and other tubes in place.

View Figure

Figure 9.14 The inspiratory and expiratory pathways are side by side in one tubing.

View Figure

Figure 9.15 Coaxial system attached to the absorber.

View Figure

Figure 9.16 Having the reservoir bag on an extended arm may make it easier for the anesthesia provider to move around. Note the coaxial system attached to the absorber assembly.

View Figure

Reservoir Bag
Bags were disc uss ed in Chapte r 7. The b ag is us ual ly a ttac hed to a 22-mm male bag p ort (bag mount or ex tensi on). It may also be place d a t the e nd of a length of co rrugated tubing or a metal tube leadi ng f rom the bag mount (Fig. 9.16 ), prov iding so me f reedom of mov ement for the anes thes ia prov ider.

Ventilator
In the pas t, the v entilator was cons idered a re placemen t fo r the rese rv oir b ag and was attached a t th e bag mount. As mac hines and v entilators hav e ev olv ed, the v enti lato r has become an integra l part of the c i rc le s ys tem. The v entilator's pl ac e in the breathing s ys tem is disc uss ed later in th is chapter. Indiv idual v entilators a re disc ussed in Chap te r 12.

Bag/Ventilator Selector Switch

A bag/v enti lato r s elec tor s witc h (s wi tc h v alve, mod e s elec tor v a lv e, se lec to r v alv e, bag-v entil ator s wi tc h v alv e, s wi tc hin g v alv e, s witchov er v alv e, manual /automatic se lec to r v alv e, v enti lator v alv e ass embl y) (F ig. 9.17) P .238 prov ides a c onv enie nt method to s hift rapidly between manual o r spon taneous respi ra tion and automatic v en ti lation wi th out remov ing the bag or the v entil ato r hose from i ts mount. As sho wn in Fi gure 9.18, the s el ec tor s witc h is essentiall y a

three-wa y s topcoc k . One p ort c onnec ts to th e b rea th ing s ys tem. The s econd is attached to the bag mount. The thi rd attaches to the v entil ator hose. The handle or knob tha t is used to s el ec t the pos iti on ind ic ates the posi tion i n wh ic h the s wi tc h is se t.

Figure 9.17 This bag/ventilator selector switch and APL valve are on the front of the ventilator.

View Figure

A selec tor s witch wi th A PL v alv e isola tion is the onl y type allo wed by the AS TM s tandard (1). When the s el ec tor s wi tc h is in th e v entilator posi tion, the APL v alv e is i sol ated from the ci rcui t, so it d oes no t need to be c losed . S wi tc hing to the bag mode c auses the APL v alv e to be c onnec ted into the breathing sys tem.

Figure 9.18 Bag/ventilator selector switch. In the Bag position, the reservoir bag and APL valve are connected to the breathing system. In the Ventilator position, the APL valve and bag are excluded from the breathing system. On most new machines, putting this in the ventilator position turns ON the ventilator.
View Figure

On newe r anes th esi a machines , tu rning the bag/ v enti la tor s elec tor s wi tch to the v enti lato r pos itio n caus es the v entilator to be turned ON. S ome modern anes thesi a machines do not hav e a bag /v entil ator se lec to r s wi tch . Turning the v entilator ON caus es elec tronic al l y contro ll ed v alv es to direc t gas es into the proper channels . P .239

Respiratory Gas Monitor Sensor or Connector

Res piratory gas moni to rs are discus sed i n Chapter 22 . B oth mains tream and s ides tream dev ic es can be us ed with the c irc le s ys tem.

Airway Pressure Monitor Sensor

A i rwa y p res sure moni tors are d is cus sed in Chapter 23 . The s ensor c an be inserted i nto the c i rc le s ys tem b y us ing an adapto r, o r it ma y be inc orpora ted into the absorber as sembl y.

Respirometer
A res pi rome ter is commonly used in the ci rcle s ys tem to meas ure v entilatory v olumes . These are dis cus sed i n Chapter 23.

Optional Equipment
Positive End-expirator y Pressure Valve
On mos t modern machines , the p osi tiv e end-e xpi ra tory pressu re (P EEP ) v a lv e is an i nte gra l part of the breathi ng s ys tem or v entil ator. On other mac hines , i t can be added when needed . It is c ritical that the v alv e be placed in the ex pi ratory li mb and oriente d correc tl y. P lac ing a un idi rec tional PE E P v alv e bac k ward wil l bl ock gas f low. If a bidi rec tion al PEE P v alv e is placed back ward , gas f lo w wi l l not be oc c luded, but no PE EP wi l l be produc ed.

Figure 9.19 Classic circle system. Not all these components may be present in a given system. For example, a heat and moisture exchanger and a humidifier would not be used at the same time. PEEP, positive end-expiratory pressure; APL, adjustable pressure limiting.

View Figure

Filters
One of the disadv an tag es of the ci rc le s ystem is that i t is di ffic ul t to cl ean and /or s teril i ze certa in co mponen ts . Filters a re discussed in Chap ter 7. The y a re us ed to protec t the equ ip ment f rom the patien t and /or to protec t the patie nt f rom the equipment.

Heated Humidifier
A heated hu midi fier can be pl aced in the ins pi ratory limb of the c i rc le s ys tem. These are d is cuss ed in Chapter 11.

Arrangement of Components
Fi gure 9.19 shows an a rrangement of compo nents that has been use d c ommonl y in the pas t and is s til l use d in many s ystems . Bec aus e it h as been around so long and has been us ed s o frequently , it is of ten ref erred to as the P .240 c las sic c irc le s ys tem. This is the bas ic s ys te m that wi l l be discussed in relation to the sequ enc e of components . W ith the integration o f the v entil ator i nto the c i rc le s ys tem, man y new configurations hav e been introduced. Thes e wil l be disc usse d i n greater de tai l l ater i n this cha pte r and i n Chapter 12 . They diffe r pri maril y in wh ere the v enti lato r is l ocated an d in th e c omponents necessa ry for v en tila to r func tion .

Objectives
The re are a number of objec tiv es i n determining the bes t a rrangement of co mponen ts in the c las sic ci rcl e s ys tem. Unfortuna tel y, not all c an be met.

Minimi zi ng absorbent des icc ati on. Des icca te d absorben t has been identif ied as a signif ic ant cause of degradation of anes thetic agents and c a rbon monox ide formation. This was disc uss ed earli er i n this chapter.

Maxi mum inc lus ion of fresh gas in the insp ired mix ture and max imum ven ti ng of alv eolar gas (182 ). P referential l y inc luding fresh gas in the ins pi red mix tu re wi ll res ult in fas ter i nduc tions and emergenc es . The lower th e f resh gas fl ow, the more i mporta nt th is objec tiv e b ecomes , bec aus e one of the ef fec ts of us ing l ower f resh gas f lo ws is that c hanges in c oncen tration i n the f res h g as fl ow are reflec ted more slowl y i n ins pired co ncen trations .

Minimal c onsumpti on of absorbent. For eff icient absorbent use, the gas v ented through the AP L v alv e s hould hav e the highes t possi bl e conc entrati on of c arb on diox ide. T his wil l oc cur whe n (a) exhal ed gas does no t pass through the abso rbe r before being v ented, (b) exhal ed gas is di lu te d as li ttle as possible before v enting , and (c ) the v ented gas is that ex haled l ate in ex hal ation , bec ause the fi rs t gas exhal ed is tha t from the dead s pace and has a low c arbon diox ide c oncentratio n. As f res h gas flow i s reduc ed, more ex haled gas mus t pas s throug h the absorbent, s o this objec tiv e becomes les s impo rtant. W hen us ing a c los ed s ys tem, the a rrangement of c omponents s ho uld hav e no effec t on absorbent utili zation, becaus e all exhaled g ases wi l l pas s through the absorber.

Acc urate readi ngs fro m a respi ro mete r placed i n the s ys tem. If the fresh gas i nlet is pos i tioned so th at the fresh gas c ontinuous ly f lo ws through the respi ro mete r, the meas ured v olumes may no t be acc ura te.

Maxi mal humi dificatio n o f inspi red gases . Minimal dea d s pac e. Low res istanc e. Minimal pull on the tracheal tube, mask , or supraglottic device. Convenienc e. Componen ts should be arrang ed so that they do no t c reate diff icul ti es du ri ng us e . Tubings and wi res sh ould not become tangled.

The re is no s ingl e a rrangement of components that wi ll meet al l of the men tioned objec tiv es , and ob jec tiv es ma y confl ic t in so me c ases . For example, v enti ng carbon diox ide ups tream of the abs orber wi ll conserv e abs orbent bu t may re duce insp ired humidi ty . In c ertain c l inical s i tu ati ons , pa rtic ula r objec tiv es ne ed to be giv en prio ri ty . In pediatri c patien ts , dead spac e an d humidif icatio n a re us ual ly more s ignif ic ant than in adul ts .

Consideration of Individual Components

Fresh Gas Inlet
Fi gure 9.20 shows poss ible locatio ns of the fresh gas inl et in the class ic ci rc le s ys tem. It is mos t commonly pl ac ed ups tre am of th e i ns pi ratory uni direc tional v alv e and d owns tream of the abso rbe r (posi tion A). In this posi tion, during exhalation and the expi rato ry paus e, f resh gas wi l l flow i n a retrograde d irec tion into the absorber and then , depending on the fresh gas f low, i nto c omponents between the expi rato ry unidi rec tional v alv e and the abso rbe r. This f lo w c an caus e abs o rbent des ic catio n at the abso rbe r outle t. A t lo w f re sh gas f lows , no gas v ented th rough the A P L v alv e wi ll hav e passed through the abs orber. W i th h igher f res h fl ows , s ome gas that has been in the abso rbe r may be v ented. A t v e ry high flows , so me f resh gas may be v ented. P lac ing the fresh gas i nl et jus t ups tream of the abso rbe r (pos i tion B ) wi ll res ul t in l ess i nclus ion of fresh gas in th e i ns pi red mi x ture . Beca use of the prox imity to the AP L v alv e, f res h g as wil l b e v ented. P lac ing the f res h g as inle t in this pos i tion wi l l i mprov e humidification of inspi red gas es but wi l l re sul t in more abs orbent desic cation. Another problem is that absorben t dus t may be blown in to the i nspi rato ry l imb whe n the ox ygen f lush is activ a ted . P lac ing the fresh gas inl et ups tream of the b ag and th e APL v alv e (p osi tion E ) has al l of the disadv an tag es of posi tion B and wi ll resu lt in more v enting of fres h g as and d ilution of exh aled gas before i t is v ented . P lac ing the fresh gas i nl et ups tream of the expi ratory unidi rec ti ona l v alv e (pos i tion D) has all of the disadv antages of pos i tion E . In ad dition, du ring ins pi ration, the f res h g as fl ow wi ll force exhaled gases tha t con tai n carbon di ox ide back toward the pati ent. Pos ition C, downs tream of the inspi rato ry unidi rec tional v alv e, is used on a t leas t one modern a nes thes ia mac hine. An adv antage is that c hanges i n the fres h gas co mpos i tion wi l l be reflec ted more rapi dl y in the inspi red gases . Ano the r adv antage

i s tha t there wi ll be no re trograde fl ow of f resh gas through the abs orb ent wi th a continuous flow of f res h gas whe n the mac hi ne is no t P .241 i n use. Du ring exhalation , fresh gases join exhal ed gases an d escape tho ugh the AP L v alv e wi thout reaching the patien t. This resu lts in po or ec onomy of f resh gas and a bsorben t, because fres h gas wil l be l os t during ex halatio n and wil l di lute the conc en tration of carbon di oxide i n the gas vented through the A PL v alv e. A nother disadv antag e of pos itio n C is tha t a res pi rometer p laced on the exhalati on s ide of the ci rcu it wil l not rec ord v olu mes acc ura tely unles s the f res h gas flow i s turned OFF. This is not a p rob le m i f the res pired vo lumes a re meas ured between the Ypiece and the pa tient. Final l y, en d-tidal v alues may be affec ted by fresh gas flow (183).

Figure 9.20 Possible locations for the fresh gas inlet. (See text for details.) PEEP, positive end-expiratory pressure; APL, adjustable pressure limiting.

View Figure

Reservoir Bag
Fi gure 9.21 shows poss ible locatio ns fo r the rese rv o ir bag in the c lass ic c i rc le s ys tem. It is mos t commonly pl ac ed between the ex pi rato ry unidi rec tional v alv e and the abso rbe r (pos i tion A ). A dis adv antage of plac ing the bag ups tream of the absorber is tha t a sudden inc re ase i n pressure from sque ezing the bag may fo rce dus t f rom th e abs orber into the ins piratory tubing (184). Durin g spon taneous respiration , abs orb ent us e is equal ly eff ic ien t if the bag is downs trea m (pos i tion A ) or ups tream (posi tion D or E ) of the absorber. W ith manu al ly control led or ass is ted v entilation, more eff icient us e occu rs wi th the bag

ups tream of the abs orber. If the bag we re in p osi tion D, ex haled gas es would pas s through the abso rbe r to the bag duri ng exha la tion. S quee zing the bag during i nhalation would caus e the gases to rev e rs e f low a nd pas s retrograde throug h the absorber, to be v ented through the APL v alv e. This wou ld resul t in ineff ic ient absorbent use, bec ause gas es cl eared of ca rbo n diox ide would be v ented . This wou ld also lead to absorben t des ic cation, as dry fresh gas would be part of the retrograde flo w through the abs orber. On some mod ern mac hines , the bag is con nec ted to the c i rc le s ys tem jus t downs trea m of the f resh gas inlet (pos i ti on E ). This wi ll b e d is cuss ed in d eta il l ater i n this cha pte r. If the b ag is plac ed between the patient and e ither of th e unidirec ti onal v alv es (pos i tion B or C), i t wil l f orm a reserv oi r for exh aled gases tha t wil l then be rebreathed.

Unidirectional Valves
Two l oc ati ons hav e been used fo r th e unidirec tional v alv es : in the Y-piece and attached to the abs orber. Valv ed Y-pieces are no l onger av ailable c omme rc iall y and are not pe rmi tted by the AS TM s tandard (1 ). V alv es in this pos i ti on are bulk y, and se ri ous ac ci dents hav e P .242 oc curred wh en a v alv ed Y-piece was place d in a c i rc le s ys tem that c ontai ned absorber-mounte d v alv es (185).

Figure 9.21 Possible locations for the reservoir bag. (See text for details.)

View Figure

Adjustable Pressure-Limiting Valve

Fi gure 9.22 shows poss ible locatio ns fo r the AP L v alv e in the cl ass ic c i rc le s ys tem. It is mos t commonly l oca te d near the reservoi r bag do wns tream of th e expi ra tory unidi rec tional v alv e and ups tream of the abs orber (p osi ti on A ). In this posi tion , f res h g as wi ll be v ented onl y if the f resh gas f lo w i s hi gh (186). Durin g ma nual ly c ontro ll ed or assis ted v en tila tion, excess gas ov erflow occu rs during ins pi ra tion. F res h gas and gas tha t has passed through the abs orber wi ll b e v ented if the APL v alv e is plac ed be twe en the f resh gas inlet and the patient (pos i tion B , C , or D). If the v alv e is located at pos i ti on E , ups tream of the ex piratory unidirec ti onal v alv e, abso rbent us e wi l l be i neffici ent, bec aus e all g as in the res erv oi r bag wi ll hav e to pass through the abs orb er before bei ng v en ted . Locating the APL v alv e a t the rese rv oir bag with an ex tender hose between the bag and the bag mount has been sugges ted (187). Th is wi ll allow f res h g as that trav els retrograde through the abso rbe r during exha lation more sp ace in whic h to co llec t. Durin g spon taneous respiration , th e mos t effici ent use of a bsorben t wi ll occur with the APL v alv e on the Y-p iec e (pos i ti on B ). This is becaus e duri ng sp ontaneous respi ra tion, ov erflow occ urs in the latter part of exhalation. Gas ex haled during the f irs t pa rt of ex piration is dead s pace gas with a l ow c oncen tration of carbon diox ide . Because the APL v alv e is not open, this gas bypass es it. W hen the bag is f il led, the pressu re i n the s ys tem ris es and the APL v alv e opens. Since th is op ening oc curs during the la tter pa rt of exh ala ti on, the gas v ented through the A PL v alv e is mai nl y alv eol ar gas (wi th a hi gh carbon d iox ide c ontent). No s uch disc ri mination is

possible when the A PL v alv e is d is tan t from the pa ti ent. Howev er, if the AP L v alv e i s at the Y-piec e, the added weig ht (espec iall y when s cav enging appara tus is added) may i nc rease the i nc idence of d is connec tions . Transfe r tubin g to the sc av engi ng interface (Chapter 13) migh t bec ome entangled wi th other o bj ec ts . The v alv e wi l l be difficul t to adjus t du ring head a nd neck s urg ery . Fi nally , pl acing the v alv e a t pos ition B wi ll caus e a d ec rease i n inspi red h eat a nd humidity (1 78). Durin g spon taneous v entilation, abs orbent use is inef fic ien t if the A PL v alv e is downs trea m of the absorber (pos itions C and D) bec aus e v ented gas wi ll hav e passed through the abs o rbe r. If the APL v alv e is placed at P .243 position C, fres h gas wil l be v ented. If the APL v alv e is in position D, exhaled gases wi ll mov e re trograde i n the i nspi rato ry tubi ng during exha lation, c aus ing an i nc reas e in dead s pace .

Figure 9.22 Possible locations for the adjustable pressurelimiting valve. (See text for details.) PEEP, positive endexpiratory pressure.

View Figure

Filters
Fi gure 9.23 shows poss ible pos itio ns fo r a fi lter wi th in the cl ass ic ci rcl e s ystem. Mos t dispos able s ys tems do no t al lo w a f il te r to be plac ed at posi ti on A o r B . Conv inci ng ev idence th at us e of a fi lter p rev ents pos tope rativ e infec tion is lac king. Pos ition A is between the inhal ation tubing and the Y-pi ece. A f il ter here wil l protec t the patient f ro m contamina tion and a bsorben t dus t but wi l l not p rotec t s ys tem c omponents o r the o perating room env i ronment from c ontami nation f ro m the

pati ent. If the f il ter is heav y o r bulk y, plac ing it in this posi ti on may be awk ward. A f il te r s hould no t be placed in th is l oca ti on if a humidif ier is loc ated ups tream. Pos ition B is between the Y-p iece and the exha la tion tu bing. In this pos iti on, the s ys tem c omponents and operating room wi ll b e pro tec ted . W ate r, mucus , or ede ma f luid can c ollec t in the fi l te r in this pos i tion , causin g an inc rease in res is tanc e or obs truc tion to gas fl ow. Th e bulk a nd wei ght of a f i lter may mak e it u nsui table for this loc ation. Pos ition C is between the inspi ra tory tu bi ng and th e ins pi ratory unidi rec tional v alv e. The s ize o r wei ght of the fil ter i s not a problem in this pos i tion. If a humidif ie r is us ed, i t should be downs tream of the fi l ter. A fi l ter i n th is pos i tion wi ll p rotec t the pati ent f rom c ontamination f rom the abso rbe r and i ts attac hed p arts . It wi ll c atch absorbent dus t. It wil l no t protec t c i rc le s ys tem components or the operatin g room ai r f rom con taminati on from the pa tient. Pos ition D is between the exhala tion tubing and the expi rato ry un idi rectio nal v alv e. In this pos ition, the filter wi l l protec t the s ys te m components f rom co nta mina tion. Bec ause the fil te r is on the expiratory s ide , obs truc tion from f luid is pos s ible , al th ough l ess l ikel y than with posi tio n B . Thi s pos i tion may c ontri bute to absorbent desic cation and produc tion of Compoun d A and c arbon monox ide as dis cus sed earlie r in this c hapter. Pos ition E is between the Y-p iece and the patie nt. In this pos i ti on, the f il ter wi ll protec t the patient f ro m the equi pmen t and the equipment f rom the patien t. This sugges ts a s tra teg y for i nfec tion control in a nes thes ia (188 ). Us ing a ne w f il ter between the pa ti ent a nd the b rea thi ng s ys tem wi th e ach pati ent ma y permi t reuse P .244 of the breathing s ys te m. Potential problems with th is si te inc lude inc reased de ad spac e, inc reased possibi li ty of disconnec ti ons , and inc reas ed res is tance. The fi lter may become c logg ed with blood, s ec retions, or edema f luid.

Figure 9.23 Possible locations for filters. (See text for details.) PEEP, positive end-expiratory pressure; APL, adjustable pressure limiting.

View Figure

Some f il ters ac t as HMEs . To func tion in this capaci ty, they mus t be posi tioned at l ocation E . An HME tha t is loca ted b etwe en th e patien t and the gas sa mple li ne wil l reduc e the amount of mo is ture that enters the res piratory gas moni tor (Chapte r 22). Us ing an HME wi ll d ec rease the humi di ty in th e exhal ation tubing, and this ma y contri bute to deh ydration of the abs orbent. Pos ition F is in the hos e leading to the v enti la tor. This wi ll p rotec t the patien t from the v enti la tor a nd th e v entilator f rom the patient. D isposa ble hoses wi th f il ters a re av ailab le.

Respiratory Gas Monitor Sensor or Sample Site Oxygen Monitor

Fi gure 9.24 shows poss ible locatio ns fo r a mains tream ox ygen moni tor sensor i n the cl assic ci rc le s ys tem. It may be fi tted i nto the dome of a unidi rec tiona l v alv e (H), the top of th e abso rbe r ass embl y, or a T-shaped ada pte r. T he sens or sh ould be place d so tha t th e me mbrane points d ownwa rd to p rev ent wa ter f ro m ac cumulati ng on the membrane. Pos itions A , F, and H a re on the inspi ratory s ide, wh ere as pos i tions C, E , G, and I are on the exhalatio n s ide. P lac ing the sensor on the expiratory s ide wi l l usu all y ex pose i t to mo re humidi ty , but this is n ot a problem wi th mos t se nsors . If l ow fresh gas fl ows are used, the reading on the ex piratory s ide wi l l be lo wer than on the i nspi rato ry s ide, but ev en wi th a c lose d s ys tem, the inspi re d-expi red dif fe rence is only 4% to 6%.

It has be en adv ocated that the oxy gen ana ly zer be plac ed near the Y-piece (pos i tion B , F , or G) s o that it wi l l alarm in the ev ent of a dis connec tion between the breathing s ys tem and the trache al tube or s upraglottic dev ice . Howev er, an ox ygen an al yzer should no t be reli ed on to de tec t a disco nnec tion. A lthou gh this is the mos t c ommon s i te f or disconnec tions , th ey c an oc cur i n other l oca ti ons . W ith a high f res h gas flow, the ox ygen c once ntratio n ma y not fal l suffici en tl y for the alarm to s ound if a disconnec ti on occ urs . P lac ing the sens or near the patien t in pos i tion B , F, or G may make it dif fic ult to mai ntain in an upright pos i ti on. In add ition, the cable to the moni to r may bec ome entan gle d with oth er tubings or s tretched , resul ting i n a pull on the Y-piec e . P laci ng i t in posi tion B , be twe en the Y-pi ece and the trac heal tube or mask , wi ll i nc rease dead spac e. P .245

Figure 9.24 Possible locations for oxygen monitor sensor. (See text for details.) PEEP, positive end-expiratory pressure; APL, adjustable pressure limiting.

View Figure

W ith a si des tream monitor, pos ition B is the preferred loc ation bec aus e both i nspi red and ex hal ed gas es can be moni tore d. The s ampling s ite can be i ncorporated in to other c omponents so th at i t does not add dead space. Pos ition D is in the fres h gas line. This pos ition wi l l indic ate onl y the concen tration of oxygen in the gas mix tu re deliv ered to the breathing s ys tem and not that i nspired by the patient.

Capnometer and Agent Monitor

Mainstream Devices
To obtain satisfac tory ex hal ed v alues , a mai ns tream c arb on diox ide s ensor mus t be between the pa ti ent a nd the b rea thi ng s ys tem (pos ition B i n Fig . 9.24), as clos e as possible to the patien t. T here a re no mai nstre am agent moni tors .

Sidestream Devices
Gas es can be as pi rated f rom an adapto r in the breathing s ys tem or f rom a port in a co mponen t. To obtain s atisf actory samples of both i ns pired and exhaled gases , the s i te mus t be c los e to th e patien t (posi ti on B in Fig 9.24).

Respirometer
Fi gure 9.25 shows poss ible locatio ns fo r a res pirometer (Chapter 23) i n the ci rc le s ys tem. Some hav e spec ial adap to rs for attac hing them s ecurely at pa rtic ula r l ocations . A res pi rome ter is us ual ly plac ed on the ex pira tory s ide on ei ther si de of the ex piratory unidirec ti onal v alv e (pos i ti ons A and B ). Du ring s pontaneous res piration, the v olumes recorded wi l l be acc ura te . During controll ed res pi rati on, a respi romete r i n this locatio n wil l ov er-re ad inspi red v olumes bec ause of the ex pans ion of the breathi ng tubes and g as compress ion in the breath ing s ys tem. If th e res pirometer can detec t rev erse f lo w, a ma lfunc tioni ng un idi rec tional v alv e may be detec ted. A res pi rome ter placed between the pati ent a nd the Y-pi ece (posi tion C) wil l rec ord ac curate ly du ring both s pontaneous and con trol led v entilatio n if i t c an read bidi rec ti onal f low. B y measu ring both inspi re d and exha le d v olumes , p rob lems s uch as a l eaki ng trac heal tube c uff can be de tecte d. If the p ati en t is breathi ng spontaneous l y, i t wi ll not de tec t a disconnec tion between the sensor and the Ypiece . Howev er, some respi ro mete rs are too bu lk y to be placed in th is pos i ti on, and the inc re ase in d ead sp ace may be s ignif ic ant. If the respi rometer does not meas ure b idi rec tional f lo w, i t is of no v al ue i n this locatio n. Us ing this pos i ti on may resul t i n inc reased l ik el ihood of da mage due to wate r condens ation , muc us , ede ma f luid, and sec retions . The wei ght of a mecha nic al respi rometer could c ause a disc onnec ti on or trache al tube k ink ing. P .246

Figure 9.25 Possible locations for a respirometer. (See text for details.) PEEP, positive end-expiratory pressure; APL, adjustable pressure limiting.

View Figure

If the resp irometer se nsor is plac ed on the insp iratory s ide (pos ition D ), i t wi ll ov erread during contro lled or assis ted v en tila ti on bec aus e of th e expansi on of the tubi ngs an d leaks between the respi rome ter and th e patien t. This pos i tion ca n be of v alue if a sec ond sensor is pl aced on the ex hal ation s ide (pos ition C). This al lows both inspi ra to ry and ex pi ratory tidal v olumes to be measured. This combination is us ed with the Ohmeda 6900 s eri es v entilators and Drager Apollo v entila tor. These s i tes allow the v enti la tor to compensa te for th e fresh gas fl ow that is ad ded to the breathi ng s ys tem duri ng inspi ra ti on (Ch apter 12). These s i tes als o make it poss ib le to gath er the information neces sary to produce fl ow-v ol ume lo ops , whic h are disc ussed in Chap te r 23. A res pi rome ter s hould not be located down stream of the abs orber (posi tion E ), becaus e the absorbed carbon d iox ide wil l dec rease the v olume of gas measured.

Sensor for Airway Pressure Monitor

Pos s ible p osi tions in the c lassic c i rc le s ys tem for an ai rway press u re s ensor a re shown in Figure 9.26. Pl ac ing the s ensor i n pos ition C , between the patient and the breathi ng s ys tem, wil l ensure tha t the p res sure measured is c lose to that of th e pati ent's airway. T he more dis tant the s ite is f rom the patien t, the less us eful i t is as an es timate of ai rwa y p res sure (189,1 90). B re athin g s ys tem res is tance, leaks, obs truc tions, and other mec han ica l fac tors may res ult in a measu red pres sure that differs subs tantiall y f rom the press ure in the pa tient's a irway (191). P roblems with this s ite incl ude inc rease d dead sp ace, d is connec tions , tracheal tube ki nking,

contamina ti on, and water bu ildup i n the pil ot l ine. It is neces sary to con nec t the pi lot line f or ev ery c ase. P lac ing the sens or on the exp iratory s ide (pos i tions A and B ) has an adv antage ov er place ment on the inspi ra tory s ide (p ositi on D). If the re is gas flow obs truc ti on i n the insp irato ry l imb and the se nsor for airway press ure is located ups tream of the obs truc tion, the low p res sure near the pa tient wi l l not be sens ed. Pos ition E , in the v en til ato r its elf , was us ed in the past but is now not recommen ded. Certain c i rcu ms tances ma y c aus e s uff icient back press ure to dev el op, wh ic h wi l l i nhi bi t the low pressu re alarm (191,192 ). Also , pl acement in the v enti lato r may resul t i n failu re to d etec t an inco rrec tly s et bag/v entil ator se lec to r v alv e. A combina tion of s ites A and D is being us ed fo r machines equipped wi th the Datex -Ohmeda 6 900 s e ries P .247 v enti lato rs and the Drager A pollo v enti lator. T hese s ites c an b e used to generate i nfo rmati on for a p res sure-v olume loops , whic h are disc uss ed in Chapte r 23.

Figure 9.26 Possible locations for the sensor for an airway pressure monitor. (See text for details.) PEEP, positive endexpiratory pressure; APL, adjustable pressure limiting.

View Figure

Positive End-expirator y Pressure Valve

Pos s ible p osi tions for a PEEP v alv e a re shown in Fi gure 9.27. A P EEP v alv e mus t be plac ed in the expi rato ry s ide of the breathing sys tem. A dis posable PE EP v alv e shoul d be placed be tween the ex pi ratory bre ath ing tube and the ex pi ratory unidi rec tional v alv e (pos ition B ). B ui lt-i n PEEP v alv es a re usually s i tuated

downs trea m of the ex pi ratory uni di rec tiona l v alv e and u pstre am of the absorber (pos i tion A ). A bidirec tional PE EP v alv e may be i nse rted between the anes thes ia v enti lato r and breathing s ys te m (posi tion C).

Pressure Gauge or Sensing Site

To meas ure PE E P accuratel y, the pressu re gauge or s ensi ng s i te mus t be on the sa me s ide (patient or abso rbe r) of the un idirec tional v alv es as the PEEP v alv e (193). On mos t olde r abs orber ass embl ies , the pressu re gauge is on the abs orber s ide (pos i tion B ). If a PEEP v alv e is a dded to the ex pi ratory li mb on the patient side of the un idi rec tio nal v alv e, PEE P wi l l not regis ter on the manome ter gaug e. Mos t new absorber assemblies hav e a buil t-i n PEEP v alv e located on the abs orb er s ide of the un idi rec tio nal v alv e with the p res sure g auge or s ens ing s ite in c los e prox imity.

Ventilator
Pos s ible loc ations for a v enti lator are s hown in Figure 9.28. Posi tion A is ups tream of the absorber, near the AP L v alv e. If the v entilator loca tion and othe r c omponents are in the c lassic pos ition (posi tion A ), gas f lows do not differ f rom the c lass ic c i rc le s ys tem. The othe r location for the v en tilato r is posi tion B , ups tream of the ins pi rato ry unidi rec tional v alv e. W hen the v en tila to r is plac ed in this loc ation , during i nspi rati on , the g as mus t b e p rev ented from flowi ng re trograde toward the bag and absorber. To acc ompl is h this , a n isolati ng valv e is placed be twee n the reserv oi r bag a nd the v entilator. The reserv oi r bag c oll ec ts the fresh gas . Th is causes f resh gas decou pl ing , whic h is dis cuss ed in detail i n Chap te r 12. P .248

Figure 9.27 Possible locations for a positive end-expiratory pressure valve. (See text for details.) PEEP, positive endexpiratory pressure; APL, adjustable pressure limiting.

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Figure 9.28 Possible locations for a ventilator. (See text for details.) PEEP, positive end-expiratory pressure; APL, adjustable pressure limiting.

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P .249

Gas Flows through the Breathing System

This sec ti on wi ll examine the gas f low thro ugh different c onf igura tions of the breathi ng s ys tem that are currentl y comme rc ial l y av ai lable duri ng different mo des of resp iration. For this purpos e, f res h gas refers to dry gas that has entered the s ys tem f ro m the anes thesi a machi ne.

Reb rea thed gases a re ex hal ed gases tha t may or may not hav e had the c arbon diox ide remov ed. These gas es hav e a high er humi di ty than f res h gas . Retrograde gas f lo w i ndicates that g as is f lo win g in a di rec tion opposi te to the f lo w di rec ted by the unid irec tional v alv es . Retrog rad e f low is importan t, because dry gas that is fl owi ng through the absorber can potenti al ly desiccate the absorben t. Exp erimental work to conf i rm tha t re trograde dry gas flow thro ugh the abso rbe r during the v arious modes of the respi ra tory c yc le c ontri butes to des icca ti on has not been publis hed . This needs to be s tudi ed , as th ere are a number of s teps that c an be taken to lessen desicca tion during the respi rato ry c yc le. The desc rip tion of g as f lows g iv en here a re as sumed , giv en the c onf igurati on of the v a rious elemen ts of the breathing s ys tem and thei r in terre la tions hips . The p rob lems c rea ted b y desic cated abs orbent a nd anes thetic agents we re discussed e arl ier in this chapte r.

Classic Circle System

The c las sic c i rc le s ys te m is shown i n Figure 9 .29 . It has the v entilator i n prox imity to the reserv oi r bag. The c las s ic circle s ys te m has been us ed for mos t of the Ohmed a anes thes ia machi nes wi th the exc eptio n of the A DU. It has also bee n used on North Ame ric an Drager Nark omed machines .

Spontaneous Breathing Inspiration

Durin g spon taneous insp iration (Fig. 9.29), gas fl ows from the rese rv o ir b ag and through the abso rbe r, wh ere i t jo ins with the f resh gas and f lows to the patient.

Exhalation
Durin g exha lation (Fig. 9 .30 ), exhal ed gases pass in to the res erv oi r bag until i t is full . Then exc ess gases are v ented through th e A PL v alv e. S inc e the i nspiratory unidi rec tional v alv e is cl os ed, f resh gas entering the breathi ng s ys tem flo ws in a retrograde di rec tion through the abs orber, push ing the gas in the abs orber towa rd the APL v alv e. The fi rs t gas to be v en ted through the APL v alv e wi ll be prev iousl y ex hal ed gas contain in g c arbon di oxide that was i n the tubing be twee n the APL v alv e a nd the absorber. If the f resh gas f low i s hi gh, s ome gas that was in or has passed through the abs o rbe r wi ll f low retro grade and pas s into the res erv oir bag or be ex pel led through the A PL v alv e. If the f resh gas f lo w i s hi gh enough, f resh gas may also be los t throug h the APL v alv e. Low f res h gas flows may not flow retrograde into the absorber.

Manual Ventilation

Inspiration
Durin g ma nual v enti la tion (Fig. 9.31), excess gas es are v ented through the pa rtia ll y open A PL v alv e during inspi ration. Th e gas flowi ng through the abso rbe r and ul timately to the patie nt wi ll be a mix ture of fresh gas and exhaled gases . Th e amou nt of f resh gas wi l l dep end on the fresh gas f low a nd the degree tha t retrograde flo w oc curre d d uring the prev ious ex hal ation .

Exhalation
Durin g exha lation with manua ll y c on trol le d v entilatio n (Fi gs . 9.32, 9.33), exhaled gases flow i nto the res erv oi r bag. Fresh gas f lows retrograde th rough the a bsorber. If the f resh gas f lo w i s lo w (Fi g. 9.32), fres h g as may not e nter the absorber. If the f res h g as fl ow i s h ig h (Fig. 9.33), some f resh gas may flo w retrog rad e through the absorber and ev en en ter the bag.

Mechanical Ventilation Inspiration

Durin g ins pi ration, gas flows f rom the v entilator through the abso rbe r and i nspi rato ry un idi rec tio nal v alv e to the patient. The gas in the v entilator bel lows wi ll cons is t of exha led gas and, if the f res h gas flow i s high, f res h gas that has p assed retrograde through the abso rbe r.

Exhalation
Durin g exha lation (Fig. 9 .34 ), exhal ed gases wi ll fl ow in to th e v entilator bellows . Fres h gas wil l pas s retrograde th rou gh the a bsorber. Exc ess gases are v ented through the spill v alv e in the v enti lato r in the la tter pa rt of exha la tion. T he longer the exha la ti on time and the higher the f res h gas fl ow, the more likel y that f resh gas wi ll pass retrog rade through the abs orber.

Continuous Fresh Gas Flow

A conti nuous fl ow of f res h gas c an en te r the c irc le s ys tem if a f low c ontrol v alv e is l eft turned ON when the mach ine is not i n use , suc h as between cases or a t the end of the su rge ry sc hedule. Fres h gas f low may continue ov ernight o r ov er a we ekend. The re are two possi bl e pathways that a c ontinuous f res h gas flow ca n fol low (Fi g. 9.35). One is through the inspi rato ry un idi rec tional v alv e to the Y-p iec e and to atmosphere (Fig. 9.35A). The o the r pathway is th rough the absorber a nd out the open A PL v alv e or bag mount (Fig. 9.35B). The f resh gas wi l l take the p ath of leas t resis tance . It is possible tha t both paths may be used.

In mos t cases , the pa th of leas t res istance wi l l be pas t th e i ns piratory u ni direc tional v alv e a nd out through the Y-piece. Ho wev er, a c ommon p rac tice to i ndica te that the P .250

P .251

P .252

P .253

P .254 breathi ng s ys tem on the machi ne is unus ed is to leav e a plas tic bag ov er the mas k or i ns ide the bowl (Fi g. 9 .36 ). If the plas tic bag is tigh t, the resis tance wi l l be hi gh, and the path of leas t res is tanc e wi ll be through the absorber if the APL v alv e is open (Fig. 9 .35A). If the APL v alv e is closed (Fig . 9.35B ), all of the gas wil l be di rec ted down the ins pi ratory tubing. If the rese rv o ir bag is remov ed, i t is mo re l ik ely that gas wi ll f low retro gra de through the absorber.

Figure 9.29 Gas flow through classic circle system during spontaneous inspiration. APL, adjustable pressure limiting.

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Figure 9.30 Gas flow through classic circle system during spontaneous exhalation. APL, adjustable pressure limiting.

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Figure 9.31 Gas flow through the classic circle system during inspiration with manual ventilation. APL, adjustable pressure limiting.

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Figure 9.32 Gas flow through the classic circle system during exhalation with manual ventilation and a low fresh gas flow. APL, adjustable pressure limiting.

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Figure 9.33 Gas through the classic circle system during exhalation with manual ventilation and a high fresh gas flow. APL, adjustable pressure limiting.

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Figure 9.34 Gas through the classic circle system during exhalation with mechanical ventilation. APL, adjustable pressure limiting.

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Figure 9.35 Possible paths of gas flow through the classic circle system during a period of nonuse, with a continuing fresh gas flow. APL, adjustable pressure limiting.

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Figure 9.36 The plastic bag over the mask will cause increased resistance to gas flow. If the bag is not on the bag mount or the APL valve is open, fresh gas may flow retrograde through the absorber, causing the absorbent to become desiccated.
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Figure 9.37 Gas flow through the Anestar breathing system during spontaneous inspiration. APL, adjustable pressure limiting.

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Anestar Breathing System

The A nes tar breathi ng s ys tem (Figs . 9.37,9.38,9.39,9.40,9.41,9 .42,9 .43 ,9 .44 ) differs from the c las sic c irc le s ys tem. T he res erv oi r bag is near P .255

P .256

P .257

P .258 the fresh gas inlet, and the v en til ato r is upstrea m of the inspi rato ry un idi rec tio nal v alv e. The re is a f resh gas decoup ling v alve do wns tream of th e res e rv oir bag. It is c los ed only during insp iration wi th mechan ic al v enti lation .

Figure 9.38 Gas flow through the Anestar breathing system during the early part of exhalation. APL, adjustable pressure limiting.

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Figure 9.39 Gas flow through the Anestar breathing system during late exhalation. APL, adjustable pressure limiting.

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Figure 9.40 Gas flow through the Anestar breathing system during manual inspiration. APL, adjustable pressure limiting.

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Figure 9.41 Gas flow through the Anestar breathing system during inspiration with mechanical ventilation. APL, adjustable pressure limiting.

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Figure 9.42 Gas flow through the Anestar breathing system during mid exhalation with mechanical ventilation. APL, adjustable pressure limiting.

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Figure 9.43 Gas flow through the Anestar breathing system during late exhalation with mechanical ventilation. APL, adjustable pressure limiting.

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Figure 9.44 Gas flow through the Anestar breathing system during nonuse with continuing fresh gas flow. APL, adjustable pressure limiting.

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Spontaneous Breathing
Durin g spon taneous insp iration (Fig. 9.37), gas fl ows from the rese rv o ir b ag, through the fresh gas decoupling v alv e, and p as t the ins pi rato ry unidi rec tional v alv e to the patien t. If the bag empti es , a su batmospheric press ure v alv e opens , and a ir is drawn in to the s ys tem. Durin g early ex halation (Fi g. 9.38), exhaled gases flow throug h the ex pi ratory v alv e and a bsorber to th e res erv oir bag, where they mix with th e f resh gas f rom the anes thes ia mach ine. During late exha la tion (F ig. 9.39) when the bag is fu ll , the APL

v alv e o pens , and ex haled gas es flow th rough the o pen v alv e to the s cav enging s ys tem. The f res h gas fl ow pus hes gases retrograde through the abs orber. If the f res h g as fl ow i s h ig h enough, dry fresh gas wil l f low i nto o r through the abs orber.

Manual Ventilation
Durin g ma nual ly c ontro ll ed inspi rati on (Fig . 9.40), the res erv oir bag is s quee zed, caus ing fresh gas and ex haled gas that has pass ed th rough the a bsorber and in to the bag to f low to th e patien t. Ex ces s gas wi ll p ass retrograde through the absorber, pus hing gas out through the APL v alv e. Durin g exhalati on, gases flo w through the expi ra to ry v alv e an d abso rbe r to the bag.

Mechanical Ventilation
W ith mech anic al v entil ati on (Fig. 9 .41 ), the fres h g as dec oupli ng v alv e cl oses during ins pi ra tion, c ausi ng f resh gas to ente r th e rese rv oir bag and ex cludi ng it f rom the res t of the s ys tem. A mix ture of fresh and p rev ious l y exha le d gas flows f rom the v entilator be ll ows through the inspira tory unidi rec ti ona l v alv e to the pati ent. Durin g the ea rl y and mi d porti on of ex halation (Fig. 9.42), exhaled and fres h g ases f low i nto the v enti lato r bel lows . Af ter the b el lows h as fi l led (Fi g. 9.43), the A PL v alv e o pens . There wil l b e retrog rade gas flow thro ugh the abs orberfi rs t exhaled gases that hav e pas sed thro ugh the a bsorber, then f res h gas . The higher the f res h gas fl ow a nd the lon ger the expirato ry time, the g rea ter the amou nt of fresh gas that wi l l fl ow re trograde through th e abso rbe r.

Continuous Fresh Gas Flow

If a continuous f low of fres h gas pas ses thro ugh the b rea thing s ys tem (Fi g. 9.44), the gases wil l tak e the path of leas t res is tance. If the res erv oi r bag is remov ed from the bag moun t, i t is likel y that all the fres h g as wil l ex it at this poin t. If there is a bag in place, gas may f low ei ther through the inspi ratory tub in g and th e Y-pi ece P .259 or retrog rade through the abs orber an d out through the AP L v alv e, depending on whe the r or not the AP L v alv e is open and the res is tance at the patient po rt o n the Y-pi ece.

Figure 9.45 ADU breathing system during manual inspiration. APL, adjustable pressure limiting.

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ADU Breathing System

In the Ohmeda A DU b rea thing s ys tem (Figs . 9 .45 ,Figs . 9.46,Figs . 9.47,9.48), fres h gas ente rs the sys tem between the inspi rato ry un idi rec tional v alv e and th e Y-pi ec e. The rese rv o ir bag, A PL v alv e, and v entilator wi th i ts s pi ll v alv e are l oc ated as in the c las sic c irc le s ys tem pos ition.

Spontaneous Breathing
Durin g spon taneous insp iration, th e patien t draws gas f rom the res erv oi r bag, through the abso rbe r and inspi rato ry v a lv e . Downs tream of the ins pi ra tory unidi rec tional v alv e, the fresh gas flow mix es with the exhaled gases . Durin g spon taneous exhal ation, the bag f il ls wi th a mix ture of fresh and exhal ed gases . Excess gas es are releas ed through the APL v alv e.

Manual Ventilation
Durin g ins pi ration with manua ll y con trolled v entilatio n (Fi g. 9.45), gas passes from the bag and through the abs orber to the inspi ra to ry unidi rec tional v alv e. Some gas (both f resh and ex haled) is v ented through the APL v alv e. During ex halation, f res h gas and exhaled gas from the patient pass through the exp iratory un id irec tional v alv e a nd in to the bag.

Mechanical Ventilation

W ith mech anic al v entil ati on during ins piratio n (Fig. 9.46), ex haled and f res h gases f rom the v entilator pass through th e absorber and inspi ra to ry v alv e, where the y are j oined by f res h g as on the way to the patient. Durin g exha lation (Fig. 9 .47 ), f resh and ex haled gas es flow to the v en ti lato r, wi th the exc ess being v ented through the v enti lator spil l v alv e du ring l ate ex halation.

Continuous Fresh Gas Flow

If there is a c ontin uous f low o f gas es in to the bre ath ing s ys tem when the anes thes ia mach ine is not in use (Fi g. 9.48), the fresh gases hav e two poss ible pathwa ys . P .260

Figure 9.46 ADU breathing system during mechanically controlled inspiration. APL, adjustable pressure limiting.

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Figure 9.47 ADU breathing system during mechanically controlled ventilation. APL, adjustable pressure limiting.

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P .261

Figure 9.48 ADU breathing system with continuous fresh gas flow during nonuse. APL, adjustable pressure limiting.

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If the Y-piece is not obs truc ted, this is the mos t l ik el y ex i t point. If it is obs truc ted, gases can p ass through the exha lation tubin g pas t the ex piratory unidirec ti onal v alv e a nd out the APL v alv e, if it is open. If th e bag is no t in plac e, this may be the preferred pathwa y. S ince the fresh gas enters do wns tream of th e i ns piratory unidi rec tional v alv e, the v alv e wi ll be c losed and not al low back flow. T his mea ns

that there wil l be no retrog rade f resh gas f lo w through the abs orb er during continuous gas f lo w.

Drager 6400 Breathing System

The Drage r 6400 breathing s ys te m (Figs . 9.49,9.50,9.51,9.52,9.53,9.54,9 .55,9 .56 ) has the reserv oi r bag n ear the fres h gas in let, and the v entil ator is o n the ex hal ation s ide of the absorber d owns tream of the expi ra to ry uni di rec tion al v alv e. The A PL v alv e and mechanical exhaus t v alv e are also l oca ted on the ex hal ation s ide of the absorber.

Spontaneous Breathing
Durin g spon taneous insp iration (Fig. 9.49), gas es flow to the pa tient f rom the reserv oi r ba g. The bag wil l contain a mix tu re of exhal ed gases that hav e pas sed through the abso rbe r in to th e res erv oi r bag during the prev ious exha la tion and f res h g as from the anes thes ia mac hine. Durin g exha lation, exhal ed gases pas s through the absorber a nd into the res erv oir bag, where they are c ombi ned wi th f res h gas . W hen the bag is fil led, the fresh gas f low wi ll push gases retrograde through the abs orb er. These g ases then ex it through the AP L v alv e.

Manual Ventilation
W ith manua l v enti lation (Fig . 9.50), s queezing the bag c auses gas es to flow to ward the patie nt as wel l as retrog rade through the absorber to the pa rtia lly open AP L v alv e. Durin g exhalati on, ex hal ed gas es pas s through the ex piratory unidirec tional v alv e a nd abso rbe r to the bag.

Mechanical Ventilation
Durin g mec han ic al i nspiration , the res e rv oir bag and f res h gas i nle t are iso lated f rom the b rea th ing s ys tem b y the f resh gas control v alv e (Fig. 9 .51 ). A s the pis ton mov es, gas is pushed through the abs orber and P .262

P .263

P .264

P .265

P .266 i nspi rato ry un idi rec tio nal v alv e to the patient. This gas wi ll i nc lude f res h gas that has fl owed re trograde through the abso rbe r during exhalation. Meanwhi le , fresh gas enters the rese rv oir b ag.

Figure 9.49 Drager 6400 breathing system during spontaneous inspiration. APL, adjustable pressure limiting.

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Figure 9.50 Drager 6400 breathing system during manual inspiration. APL, adjustable pressure limiting.

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Figure 9.51 Drager 6400 breathing system during mechanical inspiration. APL, adjustable pressure limiting.

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Figure 9.52 Drager 6400 breathing system during mechanical mid exhalation. APL, adjustable pressure limiting.

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Figure 9.53 Drager 6400 breathing system during mechanical exhalation with low fresh gas flow. APL, adjustable pressure limiting.

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Figure 9.54 Drager 6400 breathing system during mechanical late exhalation with high fresh gas flow. APL, adjustable pressure limiting.

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Figure 9.55 Drager 6400 breathing system with continuous fresh gas flow and bag on the bag mount. APL, adjustable pressure limiting.

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Figure 9.56 Drager 6400 breathing system with continuous fresh gas flow during nonuse and no bag on the bag mount. APL, adjustable pressure limiting.

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Figure 9.57 Fabius GS and Apollo breathing systems during spontaneous exhalation. APL, adjustable pressure limiting.

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Durin g mec han ic al ex halatio n, th e pis ton retrac ts an d exha led gases fil l the v enti lato r. S inc e the insp iratory v a lv e is c los ed, f res h gas wi ll f low retro gra de through the abso rbe r toward the v entila tor (Fi g. 9.52). The f i rs t gas to ente r the v enti lato r wi ll be exhaled gases . The magn itude of the f res h gas flow wi ll determine how muc h f resh gas wi l l re ach the v entilator. During late exha la tion (F igs . 9.53, 9.54), the pis ton is full y re trac ted, all owi ng ex cess g ases to ex i t by way o f the mechanical exhaus t v alv e. The gas th at ex its th e s ys tem wil l contain s ome exha led gas and fres h gas tha t has passed retrog rad e f rom the abs orb er. If the fres h gas

f low i s high (Fig. 9.54 ), f resh gas pe netration wil l be greater, and i t is poss ible that so me wi l l exi t through the exha ust v alv e.

Continuous Fresh Gas Flow

If a continuous f low of fres h gas enters the s ys tem wh en the s ys tem is no t in us e, there a re three possi bl e pathways for the gas to trav el. One is through the i nspi rato ry un idi rec tio nal v alv e to the Y-piec e (Fig. 9.55). Th e o the r potenti al pathwa y is retrograde through the abs o rbe r and ou t an th rough an open AP L v alv e (Fig . 9.55). The th ird pos sible pa thway is through the bag moun t if the ba g is not present (F ig. 9.56). The gas es wi ll take the ro ute of leas t res is tanc e. If th e reserv oi r ba g is re mov ed f ro m the bag moun t, the leas t res is tance wil l be through the bag moun t.

Fabius GS and Apollo Breathing Systems

In thes e s ys tems (Figs . 9.57,9.58,9.59,9.60,9.61,9.62,9 .63 ), the v enti lato r is between the f res h gas dec oupli ng v alv e and the inspi rato ry un idi rec tio nal v alv e. The rese rv o ir bag is be twe en the ex pi ratory uni di rec tional v alv e and the absorber.

Spontaneous Breathing
Durin g spon taneous insp iration, gas es wi ll fl ow f rom the reserv oi r bag and fresh gas inlet through the inspi ra tory uni di rec tion al v alv e to th e patien t. Durin g spon taneous exhal ation (Fig. 9.57), ex hal ed gas passes though the ex piratory unidirec ti onal v alv e and into the reserv oir bag. W hen the bag is full , the ex cess g ases wi l l exi t through the open APL v alv e. Fresh gas flowi ng in to the breathi ng s ys tem wi ll flow retro gra de th rough the a bsorber i nto the rese rv oir bag, wi th the exc ess v ente d throug h the APL v alv e. The amount of retrograde fl ow wi ll depend on the fresh gas flow, res pirato ry rate , and l ength of the exp iratory pause . P .267

Figure 9.58 Fabius GS and Apollo breathing systems during manual inspiration. APL, adjustable pressure limiting.

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Figure 9.59 Fabius GS and Apollo breathing systems during manual exhalation. APL, adjustable pressure limiting.

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P .268

Figure 9.60 Fabius GS and Apollo breathing systems during mechanical inspiration. APL, adjustable pressure limiting.

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Figure 9.61 Fabius GS and Apollo breathing systems during mechanical mid exhalation. APL, adjustable pressure limiting.

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P .269

Figure 9.62 Fabius GS and Apollo breathing systems during mechanical late exhalation. APL, adjustable pressure limiting.

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Figure 9.63 Fabius GS and Apollo breathing systems with continuous fresh gas flow during nonuse. APL, adjustable pressure limiting.

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P .270

Manual Ventilation
Durin g ma nual inspi rati on (Fig. 9 .58 ), the bag is comp res sed, caus ing exhal ed gas to pass through the abso rbe r af ter whic h i t is jo ined by fresh gas . Th e c ombi ned gases then pas s through the inspi rato ry un idi rec tional v alv e to the patient. S ome gas f ro m the bag wi ll also fl ow to the sc av enging s ys tem through the A PL v alv e.

Durin g exha lation (Fig. 9 .59 ), exhal ed gases f low i nto the reserv oi r ba g. A t the sa me time , fresh gas wil l f lo w retrog rade through the abs orber toward the ba g, pushi ng some ex hal ed gas toward the bag.

Mechanical Ventilation
W ith mech anic al v entil ati on during ins piratio n (Fig. 9.60), the fres h gas decoupl ing v alv e c loses , isola ting the fresh gas f rom the inspi red gas . F res h gas entering the breathi ng s ys tem wi ll pass retrog rade through the abs orber to the reserv oi r bag. As the v enti la tor c ycles , it wil l caus e a mix ture of f res h and exhaled gases tha t hav e passed through the abs orb ent to fl ow toward the patient. Durin g exha lation (Fig. 9 .61 ), exhal ed gases wi ll pass through the exp iratory unidi rec tional v alv e and the abso rbe r and on to the v enti lato r. F res h gas that has passed retrograde through the abs orber duri ng inspi ration wil l b e added to the continuing f resh gas f low that als o fi lls the p is ton c hamber. Late i n exhalation (Fig. 9.62), af te r the p is ton has f illed, exhaled g as wil l ex it throug h the APL by pass v alv e. Fresh gas wi l l flow re trograde thro ugh the abso rbe r and ex it the s ys te m at the APL bypass v alv e. The degree of retrograde fl ow wi ll depen d on the I:E rati o and the f res h gas flow.

Continuous Fresh Gas Flow

If a continuous f low of gas ente rs the s ys tem when the mac hine is not in use , th e gas has two possible rou tes to exi t (Fig . 9.63). One path is through the inspi ra tory v alv e a nd Y-p iec e. The o the r is retrog rade through the abs orb er and an open AP L v alv e o r empty bag mount. Th e gas flow wi ll tak e the path of leas t res is tance. If the machine is i n s tandby mode and there is s ti ll gas f low, a mess age to that effec t wil l be displayed on th e s c reen.

Resistance and Work of Breathing in the Circle System

In the pas t, one of the objec ti ons to usi ng a c i rc le s ys tem wi th small c hi ld ren was that i t had a high resis tance . Howev er, inv es tigatio ns hav e s hown that the resis tance or work of breathing wi th the c i rcle s ys tem is no t si gnific antly greater than wi th other b rea thing s ys tems and may be l ess (194,195 ). Co axial tubings i nc reas e resis tanc e.

Dead Space of the Circle System

In the c i rc le s ys tem, de ad spac e ex tends f ro m the patie nt po rt of the Y-piece to the partition between the ins pi ratory and exhalati on tubings . A Y -pi ece wi th a septum wi ll dec reas e dead space. When exha la tion or i nha lation s tarts , the gas es in the breathi ng tubes mov e in th e oppos ite di rec tion from their us ual fl ow until s topped by c los ure of one of the unidi rec tional v alv es . This is referre d to as bac k lash and caus es a sl ight i nc reas e in dead spac e. If th e unidirec ti onal v alv es a re compete nt, howev er, backlas h wi ll be c linic ally i nsignificant.

Heat and Humidity

In the c i rc le s ys tem, mois ture is av ailable from exha le d gas es , the abso rbent, and water l ib era ted f ro m the neu trali za tion of c arb on di oxi de. Gases in the insp iratory l imb of a c irc le s ys tem are near room tempera ture. Ev en with lo w f resh gas f lo ws , gases re ach the Y-piec e onl y 1C to 3 C abov e ambient temperature (196). The humid ity of a s tanda rd ad ult circle s ys te m i nc reas es gradual l y with use and then s tabi l izes . A fres h g as fl ow of 0.5 to 2 L/minute wi l l re sul t in h umid ity between 20 an d 25 mg H 2 O/L at 60 minu tes (197). Highe r humidi ty resul ts f rom lower fres h gas fl ows , inc reas ing v enti lation, loca ting the fresh gas u ps tre am o f the absorber, wetti ng the inspi ra tory tubing, an d b y us ing a humidifier, smal le r c an is ters , o r coax ial breathi ng tubes . P ri or s ys tem use wi ll res ult in an i ni tial ly high er humidi ty that s tab iliz es in the sa me period of time and at the same fina l humi di ty . Us ing an HME (Chapter 11) wil l resul t in dec reas ed humi di ty in the c i rc le s ys tem but i nc reas ed humidity in the inspi red gas es.

Relationship between Inspired and Delivered Concentrations

In a s ys tem with no reb rea thing , the c oncentrations of gases and v apors in the i nspi red mix ture wil l be c los e to those in fresh gas . W ith rebreath ing, howev er, the conc en trations in the ins pi red mix ture may d iffe r cons id era bl y f ro m thos e i n the f res h g as . T he la rge r the breathing sys tem's internal v olu me , the greate r wil l be the differenc e between inspi red a nd del iv ered conc entra tions . Canis ter si ze is the mos t i mportan t determinant of internal v olume in the ci rcl e sys tem.

Nitrogen
Ni trogen is important, bec aus e it h inders establ is hing high c onc entrations of n itrous ox ide and may caus e low i nspi red oxygen concentrations . B efore a ny fres h gas is deliv ered, the co ncen tration of ni trogen i n the b rea thing P .271

s ys tem is approx imatel y 80%. Ni troge n enters the s ys te m f rom exh al ed gases and l eav es through the A PL v alv e, v enti lato r spil l v alv e, and l eaks . Us ing high f res h gas flows for a few mi nutes to eliminate mos t of the ni trog en in the s ys tem and much of that i n the patien t is c al led d eni trogen ation . There is n o s et time or flo w that wil l produc e adequate denitrogenation in all cas es (198). A tight mask fi t is neces sary for p roper den itrogena tion, as air wil l be insp ired around a l oose -f itting mas k . Af ter deni trogenation, ni trogen elimination b y the pa ti ent wil l proceed at a slower rate . In a c lose d s ys tem, the ni troge n c onc entration wil l gradual ly ris e. P rov ided that de ni trogenati on has been ca rried out, ev en if al l the body 's n itrogen is exhaled, the conc entra ti on in the breathi ng s ys tem should not i nc reas e to more than 18% i n the av erage adul t (1 99,200). Howev er, if a s ides trea m gas moni tor d irec ts gas es back to the anes thes ia ci rcu it, ni trogen c onc entration may inc rease becaus e ma ny analy zers entrain ai r as the referenc e gas (201). A leak in the s ampl in g l ine can resul t i n air entrainmen t (202). W hen deliv eri ng an ai r/oxy gen mix ture in to the ci rc le sys tem, the ins pired ox ygen conc en tration wi l l be lo wer than that se t on th e flowmeters wh en the f resh gas f lo w i s low. To c ompensate fo r this, higher ox yge n c onc entrations need to be adminis tered at l ow flows (2 03). In c ertai n anes thesi a machi nes , fres h g as compe nsati on (decoupli ng ) (Chapter 12) i s accomplished by acc umul ating the fres h g as fl ow durin g i ns pi ration in a reserv oi r bag a nd us ing a v enti la tor with a p is ton or desc endi ng bellows (164). This i ntroduc es the pos sibil i ty of entrai ning room a ir i nto the g as c i rc uit through a negativ e p res sure reli ef v alv e .

Carbon Dioxide
With Absorbent
The insp ired carbon d iox ide c onc entration shou ld be near ze ro, unl ess there is failure of one o r both unidi rec tiona l v alv es , ex haus ted absorbent, or a bypas sed absorber (204). If one of thes e cond itions ex ists , a high f res h gas f low wi ll li mit the i nc reas e in inspi red c arbon dioxi de concen trati on .

Without Absorbent

If the c irc le s ys tem is used wi thout absorbent, the inspi red c arb on diox ide lev el wil l depend on the fresh gas flow, the arran gement of co mponen ts in the c irc le s ys tem, and v entilation.

Oxygen
The c oncentration of ox ygen in the insp ired mix ture is aff ec ted by the rate of ox ygen up take by the p ati en t, uptake and eli mina tion of othe r gas es by the patient, the arrangement of th e c omponents , v entilation, fres h gas flow, v olume of the s ys tem, and the concentra tion of ox yge n in the fresh gas. Bec ause s o many of these are unpredic tab le and uncon trol lab le , it i s nec ess ary to use an ox ygen analy zer i n the b rea thi ng s ys tem. Ox y gen analy zers are disc ussed in Cha pte r 22.

Anesthetic Agents
Abs orb ents can remov e v olati le anes thetic a gents by ads orp tion or degradation. This can resu lt in sl ower i nd uc tions and ex posu re of s ubse quen t patients to v olatile agents . Dry absorbent re mov es more agen t th an wet (205,206,207,208). The rela tions hip of abs orb ent and a nes the tic agen ts was disc uss ed earlier i n th is chapter. The followi ng influence th e c onc entrati on of anes thetic agent in the i nspi red mix ture: up take by the patien t, uptake by componen ts of the s ys tem, arra ngemen t of s ys tem c omponents , up tak e and el imination of other gases b y the pati ent, v olume of the s ys tem, concen trati on in the f resh gas f low, degrada tion by the abso rbent, and f res h gas flow. It i s not p ossible to predic t the concen tration ac curate ly unless a high fresh gas f low i s us ed. Sev eral dev ic es are n ow av ai labl e to meas ure the ins pired anes thetic agent c once ntration (Chapte r 22). The greates t v a ri ation oc curs during ind uc tion, when anes thetic uptake is h ig h and ni trogen was hout from the pati ent d ilutes the g ases in the c ircui t. For this reason, mos t autho rs recommend that anes thesia be s ta rted wi th hi gh fresh g as fl ows . The time i nte rv al unti l th ere is some equil ibra tion betwee n ins pired and end-expi red agen t conc en trations v aries wi th the agent, being minimal with des fl urane, intermediate wi th s ev oflu rane, and g rea tes t wi th i sof lu ran e (209 ). Hi gh flows are also common ly us ed at the end of a c ase to inc rease the elimin ati on of anes thetic agen t. The rate of el imina ti on may be inc reas ed by bypassing the absorber (139,210 ). W hen mali gnan t hype rthermia is sus pec ted, inc reas ing the f resh gas flo w i s th e mos t impo rtant me asure that wi ll a id i n washing ou t anes thetic age nts f rom the pati ent. Usi ng a c ha rco al fil ter or changing the anesthes ia machi ne and b rea thing s ys tem are of little or no c linic al adv antage (2 11).

Circle System with Low Fresh Gas Flows Definitions

Low -flow anes thes ia has b een v arious l y defi ned as an i nha lation tec hnique in whic h a c i rc le s ys tem wi th absorben t is used wi th a fresh gas inflow of less than the pati ent's alv eol ar mi nute v olume, less than 1 or 1.5 L/minute ), 3 L/min ute or les s , 0.5 to 2 L/minu te , less th an P .272 4 L/minu te, 500 mL/minute , 500 to 1000 mL/min ute , or 0.5 to 1 L/minute (212,213 ,214,215,216,217). Cl osed s ys tem anes thesi a is a fo rm of l ow-f l ow anes thesi a in whic h the fres h gas f low eq uals uptak e of a nes thetic gases and ox ygen by the patient and s ys tem and gas s ampl ing. No gas is v en ted through the AP L v alv e .

Equipment
A s tanda rd anes thesia machine can be used , but i t mus t hav e f lowmeters that wil l prov ide low fl ows .

Vaporizers
Anes thetic agent c an be added to the c irc le in two ways .

Calibrated Vaporizers
Vapori ze rs capabl e of de liv ering high conc entra tions and that are ac curate a t lo w f res h g as fl ows are re qui red . Vapo ri zers are d is cuss ed in Ch apter 6.

Liquid Injection
Anes thetic liquid c an be in jec te d d irec tl y into the ex pi ra tory li mb (183,218 ,219,220). Care mus t be taken that onl y s mal l amoun ts are in jec ted a t a time and that the s y ringe containing the liquid agent is not c onf used with those containing agents for intrav enous injec tion . Liquid agen t may c ause deterioration of co mponen ts in the s ystem (22 1).

In-circle Vaporizer
In-s ys tem v apo ri zers are d isc uss ed in Cha pter 6. They hav e been us ed s ucc ess ful l y wi th bo th spontaneous and control led v entilation (222,223,224,225).

Monitors

Con tinuous measu rement of ox ygen c onc entrati on s hou ld be mandatory . It is helpful to moni to r other gases and v apors . W i th s idestream moni tors , the f resh gas f low mus t be inc reased to compens ate fo r gas es remov ed by the moni to r unl ess the gases are returned to the breathi ng s ys tem (2 26).

Techniques
Induction
Anes thetic induc tion by us ing low f res h gas flows c an b e accomplished by in jec ting meas ured amounts of l iquid anes the tic di rec tly in to the expi rato ry l imb of the c i rc ui t. P roblems as soc iated wi th this inc lude the f ol lo win g: (a ) la rge bo dy s tores of ni troge n wil l be release d i nto the b rea thi ng s ys tem and wil l di lute c oncentratio ns of other gases ; (b ) if nitrous ox ide is being use d, i t wil l take a prolonge d peri od of time to es tablis h c oncentrations hi gh enough to hav e a c linica l effec t; and (c ) ra pid uptak e o f ni trous ox ide and v olatile agent as wel l as high ox ygen c ons umption during th is pe ri od mean that the anes thes ia prov ider wi l l hav e to make f requent i njec tions and adj us tmen ts at a time wh en he or sh e is like ly to be bus y wi th o the r tasks . More c ommonl y, i nduc tio n is ac compl ished by usin g high f lows to allow denitro gena ti on, es tablis h anes the tic agen t conc entrations , and prov ide oxygen wel l i n excess of c onsu mption . Duri ng intubation, the v apori ze r shou ld be l ef t ON and the f res h gas flow tu rne d to min imum or OFF (227,228). A fter gas exchange has s tabil i zed, lower fres h gas flows are used .

Maintenance
Durin g ma in tenance , ni trous ox ide and oxy gen fl ows and v apo ri zer s ettings sh ould be ad jus te d to mainta in a satisfac tory ox yge n c onc entration and the des i red lev el of anes thes ia. If cl os ed s ys tem anes thesi a is used, a c ons tan t c i rc uit v ol ume is ac hiev ed by one of the fol lowi ng meth ods .

Constant Reservoir Bag Size

If the b ag dec reas es i n s ize, the fresh gas fl ow rate is i nc reas ed; if the bag i nc reas es in s ize , th e fl ow i s dec reas ed .

Ventilator with Ascending (Upright or Standing) Bellows

Cons ta nt v olume c an be achiev ed by adj us ting the f res h gas f low s o tha t th e bellows is below the top of i ts hous ing at the end of exhala ti on. It is impo rtant that no ne gativ e p res sure be trans mi tted to the b ellows f rom the scav enging s ystem, as

this c ould c aus e the be llows to be held aloft i n the p res enc e of inadeq uate fresh gas fl ow (229 ).

Ventilator with Descending (Inverted or Hanging) Bellows

The f resh gas f lo w s hould be adj us ted so that the bell ows jus t reac hes the bottom of i ts hous ing at the end of ex hal ati on . If a rapid change in any componen t of the inspi red mix ture is des ired, the f resh gas f low s hould be inc reased . If , f or any reas on, the inte gri ty of the c irc le is brok en, high flows wi th d esi red ins pired co ncen trations shou ld be us ed fo r sev e ral minutes before returning to l ow flows . If c los ed sys te m an es thes ia is used, it is recommen ded that high f lo ws be used for 1 to 2 minutes at leas t onc e an hour to el imina te gas es s uc h as ni trogen an d carbon monoxide tha t hav e accumu la ted in the sys tem.

Emer gence
Rec ov ery from anes thes ia wil l be s lowe r if low f lows a re used. High fl ows are us ual ly needed a t le ast briefl y to c le ar ni trous ox id e. Coas ting , in whi ch anes thetic adminis tra tion is s topped toward the en d of th e operation an d the ci rcui t is mai ntained clos ed wi th enough oxygen fl ow to maintai n a c ons tant end-ti da l v ol ume of the v enti lato r or reserv oi r bag, ca n be used . A c harcoal fi l ter p laced in the i nspi rato ry or expi ra tory li mb wil l c ause a rapid dec reas e in v olatile agent conc en tration (230). P .273

Advantages
Economy
S ignificant s av ings can b e achiev ed wi th lowe r fl ows of nitro us oxi de and ox yg en, but the g rea tes t s av in gs occ urs wi th the potent v olatil e agen ts (217,231 ,232,233,234,235,236,237,238 ,239). Thes e a re pa rtly offset by inc reased absorbent usage, but this cos t is s mall . Indiv idua l feedback and education regarding v ol atile age nt use a re effec tiv e in getting anes thesia prov iders to reduc e f res h g as fl ows (240).

Reduced Operating Room Pollution

W ith lo wer f lo ws , there wil l be less anes thetic agent p ut i nto the ope rati ng roo m. Howev er, the use of low-fl ow te c hniques does no t el iminate the need for

sc av engi ng, because high flows are s ti l l nec ess ary at times . S inc e les s v ol atile agent is used , v apori ze rs hav e to be f ill ed les s frequently so that expos ure to anes thetic v apors durin g fi ll ing is dec reased .

Reduced Environmental Pollution

Fl uoroca rbons and ni trous oxide attac k the ea rth's o zon e l ayer, and ni trous ox ide contri butes to the greenhous e effec t (241,24 2,243,244,245 ,246,247). W ith lo w f lows , these ec ological dange rs are reduced .

Estimation of Anesthetic Agent Uptake and Oxygen Consumption

In a c los ed s ys tem wi th out s ign if ic ant leaks, the fres h g as fl ow is matched by th e pati ent's uptake of ox ygen and anes thetic agents (248 ,249,250,251). Changes in v olume may be a ttri buted princ ipally to uptake of ox ygen or ni trous oxide because the v olume con tribute d b y the po tent inhal ational agents is us ual l y n ot si gn ific ant.

Buffered Changes in Inspired Concentrations

The lower the f res h gas f low, the l ong er i t takes f or a chan ge in c oncentration in the fresh gas fl ow to cause a compa rab le ch ange in the insp ired concen tration .

Heat and Humidity Conservation

W ith lo wer gas f lows , i ns pired humidi ty wil l be i nc reas ed, and the rate of fal l i n body tempera ture reduced (178 ,25 2,253,254 ,255,256). The inc idence of sh iv eri ng i s lowe red (257 ).

Less Danger of Barotrauma

Hi gh pressu res i n the b rea thing sys tem take longer to dev elop wi th l ower f l ows .

Disadvantages
More Attention Required
W ith c lose d s ys tem anes thes ia, f res h gas flow i nto the s ys tem mus t be kep t in balance with uptake . This re qui res f re quen t adj ustments .

Inability to Quickly Alter Inspired Concentr ations

The use of low fresh gas fl ows prev en ts the rap id ch anges in fres h gas conc en tration in the b rea thing s ys tem that occu rs wi th high gas f lows . As a resul t, i t may be more d ifficult to con trol ac ute h emodynamic res pons es (258). This is a s ignif ic ant disa dv an ta ge onl y if the us er i nsis ts on usi ng lo w f l ows at all times . The

c linic ian who uses low fl ows shoul d acc ept that wh en it is nec ess ary to c hange i nspi red conc entra ti ons rapidl y, highe r flows s houl d be used.

Danger of Hypercarbia
Hyperc arb ia resul ting f ro m ex haus ted absorben t, inc ompetent u ni direc tional v alv es , or the abs orber being lef t in the by pass posi ti on wi ll be g rea te r when low fl ows are us ed.

Accumulation of Undesirable Gases in the System

The accumu lation of undes i rable g ases is mos t likel y only a problem wi th c losedc i rc ui t anes thes ia, becaus e lo w f lo ws prov ide a c ontin uous s ys tem fl ush. Wi th c los ed s ys tem anesthes ia, f lushing wi th hi gh f res h gas flows once an hou r wil l dec reas e the c onc entration of mos t of thes e s ubstances . A lternately, a div erti ng gas monitor wi th the sample gas scav enged ins te ad of be ing return ed to the c i rc le s ys tem c an be used to remov e small amounts of gas (212).

Carbon Monoxide
Carbon mon oxide from the interac tion of des icc ated abso rbent and anes thetic agent was disc uss ed earli er in this c hapter. S inc e low-f low an es thes ia tends to preserv e the mois tu re con tent of the abs orb ent, i t may protec t agains t the pro duc ti on of ca rbon mo noxi de resul ting f rom des iccated absorbent (113 ). Ho wev er, i f des ic cated absorbent is present, l ow f lows tend to inc re ase the amount of ca rbon monoxi de present i n the s ys tem. Carbon monoxide pro duced from the breakdown of hemo globi n or exhaled by smoke rs ca n accu mula te in the c los ed c i rc le s ys te m (138,259 ).

Acetone, Methane, Hydrogen, and Ethanol

Ace tone, methane, and h ydrogen ac cumul ate durin g c losed s ys tem anes thes ia (260,261 ,262). Howev e r, dange rous lev els a re reached onl y after hours of c lose d s ys tem anes thes ia (263). Methane c an dis tu rb infrared ana lyz ers (260 ,26 2). The co mmon i ntoxic ant ethan ol c an a ls o accu mula te.

Compound A
The s afe ty of usi ng sev oflurane wi th low fl ows i s s til l under i nv es tigation. A t the time of wri ti ng, P .274 the FDA was s til l recommendi ng th at sev oflurane not be us ed with fresh gas fl ows of les s than 2 L/minute. This recommen datio n has been rev ised to sugges t tha t fl ow

rates o f 1 L/minu te are acceptable b ut shoul d n ot ex ceed 2 mi ni mum alv eol ar conc en tration (MA C)-hou rs . S ome inv estigators feel tha t Compou nd A s hould not be a real c li nic al c once rn and that res tric ting th e use of l ow fresh gas flows wi th sev oflu ran e c anno t be j us tif ied (45 ).

Argon
If oxy gen is s uppl ied from an ox ygen c oncentrato r (Chapter 4), th ere wi ll be an ac cumulation of argon wi th low fresh gas flows (26 4).

Nitrogen
Ev en with ini tia l deni trogenati on, n itrogen wil l accumu late in the c lose d breath ing c i rc ui t (199). If oxygen is being s uppl ied by an ox ygen c oncen trator, ma lfunc tion of one of the c oncentrators c an cause ni trogen to appear i n the produc t gas (264 ). Infrared moni to rs (Chapter 22 ) add ai r to the s ample gas after the sample is analy zed (212,265 ). If the gas ex haus ted is returned to the breathi ng s ys tem, ni troge n accumula tion wi ll be greate r than expec ted.

Other
An ac rylic monomer is exhaled when joint pros thes es are s urgic ally c eme nted (266). Durin g this period, the s ys tem s hould b e v ented to p rev ent rebreathi ng of this c hemic al .

Uncertainty about Inspired Concentrations

One of the effec ts of rebreathing is that the inspi red c onc entrati ons can not b e ac curate ly predic ted. Howev er, absolute or near-abs ol ute knowl edge of ins pi red anes thetic agent c oncentratio ns is n ot nec ess ary for s afe anes thes ia co nduc t, becaus e p atien ts ' responses to d rugs v ary wide ly .

Faster Absorbent Exhaustion

The lower the f res h gas f low, the fas ter the abs orb ent is exh aus ted .

Circle System for Pediatric Anesthesia

It was onc e bel iev ed that s ma ll patien ts requi red spec ial bre athing c ircui ts and v enti lato rs . Howev er, s tudies show that adul t ci rc le sys tems can be us ed ev en in smal l infants and wi th low fresh gas fl ows (194,195 ,235,267,268,269,270,271,272 ,273,274,275 ,276). It is important not to add dev ices wi th l arge dead s pace or res is tance between the Y-pi ece and the pati ent. Use of an HME /f il te r (Ch apter 7) i n th is location c auses the dead spac e to be unacceptably high for the spo ntaneous bre ath ing inf ant (277 ).

One problem with th e c irc le s ys tem is i ts l arge gas v olu me. The c ompressi on of tha t gas makes i t diff ic ul t to de termine the ac tual minute v entilation tha t the patien t is receiv ing, unless measurements are done at the Y-p iece (27 8). In the pas t, sp ecial pedia tric c irc le s ys tems wi th sma ll abs orbers were used. Thes e a re no longe r co mme rci al l y av ai lable. W hat is refe rred to as a pedia tric c ircl e s ys tem to day is us ual ly a s tandard absorber assembly wi th s hort, s mall -d iamete r breath in g tubes and a s ma ll bag. This a llows a rapid a nd eas y c hangeov e r from an adul t to a pedia tric s ys tem and al lo ws use of eq ui pment with whic h mos t an esthes ia prov iders are famil iar.

Using the Circle System to Deliver Oxygen

In s ome ins ti tutions , supplemental ox ygen may be deliv ered to pati ents by attac hing the ox ygen tubing to a mask or n asal prongs to the Y-piece of a c irc le s ys tem. S tudi es show that this method is les s accu rate than use of an aux il iary flowmeter (279). A haza rd is tha t ni trous ox ide o r a v ol atil e agent may be acc identall y adminis tered (149). A nother d is adv anta ge is that this may le ad to absorbent desic cation. Als o, the c ontinuous pos i tiv e press ure that res ults may cause ac tiv ation of ai rwa y pressure alarms . Supp lemental oxy gen sh ould be del iv ered by us ing an a uxi liary flowmeter or a f lowmeter attached to the pipe d ox ygen sys tem.

Advantages

Low f res h gas f lows c an be used wi th the ph ys iological , ec onomic , and env ironmental adv antages o f rebreath ing . PaCO 2 depends onl y on v enti la tion, not f resh gas f low. It ma y be the bes t s ys tem for pa tients wi th mal ig nant h yperthermi a (280).

Disadvantages

The c irc le s ys tem is c ompos ed of many parts tha t can be a rranged i ncorrec tly or may ma lfunc tion and a large number of c onnec tions that c an become disco nnec ted or leak .

Some co mponents a re difficul t to c lean. Howe v er, modern ci rc le sys tems are desig ned to make disass embl y and disi nfec tion easi er (Fi g. 9.64). The s ys tem is rela tiv el y bulk y and not eas ily mov ed. The c ompl iance of the c i rc le s ys tem is hi gh compared wi th o the r s ys tems . This may make c onsis tent v enti lation more difficul t than wi th the Maples on D

or F sys tems (281). The trend toward smal le r abs o rbent ca nis te rs wi ll reduce the in ternal v olume of the breathing s ys tem and reduc e the s ys tem co mpliance.

The use an abs orbent may resul t in fo rmatio n of carbon monox ide or Compound A .

P .275

Figure 9.64 A,B: Modern circle systems are easier to disassemble and clean than older ones.

View Figure

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Questions
For the fol low ing ques tions , s elec t the co rrec t answer. 1. Concerning degradation of sevoflu rane by absorbent, A . It is degraded more as the length of th e a nes thetic inc reases B . More degradation oc curs at lower temperatures C. More degrada ti on oc curs with lowe r c oncentra ti ons D. Desic cated abs orbent d ec reases degrada tion E . Low f res h gas f lo ws dec reas e degradation V iew A ns we r2. The most common locatio n for the fresh gas inle t in the class ic circle sys tem is A . J us t ups trea m of the insp iratory un id irec tional v alv e B . B e twe en the pres sure manometer and the absorber C. Be twee n the i nspiratory unidirec tional v alv e and the Y-piec e D. Be twee n the s pirometer an d the ex piratory u nidirec tional v alv e E . B e twe en the insp iratory un id irec tional v alv e and the PEEP v alv e V iew A ns we r3. The most common locatio n for the reservo ir ba g in the class ic circle sys tem is A . J us t ups trea m of the insp iratory un id irec tional v alv e B . B e twe en the insp iratory un id irec tional v alv e and the abs orber C. Be twee n the i nspiratory unidirec tional v alv e and the Y-piec e D. Be twee n the ex pi ratory unidi rec tiona l v alv e and the absorber E . B e twe en the Y-piece and the sp irometer V iew A ns we r4. Wh ich anesthetic agen t is associated w ith the highest level o f carbon monoxide formation ? A . Ha lothane B . E nflurane C. Isof lurane D. Desfl urane E . S ev oflu rane

V iew A ns we r5. Wh ich pos ition of the fresh gas inlet w ill n ot res ult in abs orbe nt des iccation? A . B e twe en the absorber and the insp iratory u nid irec tional v alv e B . B e twe en the AP L v alv e and th e abso rbe r C. Be twee n the i nspiratory unidirec tional v alv e and the Y-piec e D. Be twee n the Y-pi ece an d the ex piratory u nidirec tional v alv e E . B e twe en the ex pi ratory unidi rec tiona l v alv e and the AP L v alv e V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

6. Which statements correctly re flect the flow through a carbon dioxide abs orbe r? A . Flow i s c ontinuous B . It makes no diff ere nce if the fl ow is f rom bottom to top or from top to bottom C. La rge r can is ters do not allow more c arb on di oxide abs orp tion D. Absorption takes p lace fi rs t at the in le t and along the s ides of the canis ter V iew A ns we r7. Baffles in the a bsorber A . Inc reas e res is tance B . S eparate the abs orbent i nto diff ere nt compartments C. Inc reas e the pa th of trav el for gases in th e absorber D. Ac t as a buffe r for dus t and water generate d i n th e c anis ter V iew A ns we r8. Bypassing the abso rber A. Inc reas es the ins pi red c a rbon d iox ide B . A l lows the abso rbent to b e c hanged durin g an anes the tic C. Can b e espec ia lly dan gerous when us ed during low-f low an es thesia D. A ll ows th e abs orben t to regen era te V iew A ns we r9. Wh ich statement(s) c once rning the size an d shape of granules in so da lime a re correc t? A . S ma ll g ranules prov ide a g rea ter surfac e area for absorption B . S ma ll g ranules may cause more resis tanc e and cak ing C. Granules us ed to day range in s ize between 4 and 8 mesh

D. Smal l g ran ules dec reas e channel in g V iew A ns we r10 . Conce rning the hardness of so da lime g ranu les , A . If the granule is too sof t, it wi l l fragment eas il y and produce dus t B . Dus t may be blown i nto s ys tem c omponents C. Dus t wi ll inc rease res is tance and c hann eli ng D. A coa ting on the gra nule wil l produc e a film that wi ll adhe re to dus t pa rtic les V iew A ns we r11 . T he abs orbent in the canister sho uld be ch anged w he n A . Ca rbo n d ioxide appea rs in the inha led gases B . Th ere is no hea t produc tion with lo w f resh gas f lo ws C. Heat is generated in the down s tream ca nis te r D. Color c hange is se en in the down s tream canis te r V iew A ns we r12 . Conce rning the s torage and ha ndling of ca rbon dioxide abs orbe nts , A . Th ey s hould not be s tored at f ree zi ng tempera tures B . A bsorbent dus t can be i rritating to th e e yes , res pi ratory trac t, and sk in C. W hen f ill ing the ca nis te r with abs orb ent, a s mall sp ace sho ul d be lef t at the top D. Absorbent dus t wil l ca use th e seals to wa rp V iew A ns we r13 . Whic h of the follow ing are objec tives in the arrange ment of c omponen ts of the circle b rea thing sys tem? A . Max ima l humidific ati on of ins pired gas es B . Low res is tanc e C. Mi nimal co nsump ti on of c arb on diox ide abs orbents D. Max imal inc lus ion of de ad space gases in the inspi red mix ture V iew A ns we rP .280

14. Wh ich po sitio n(s ) of th e AP L valve in the circle sy ste m w ould cause inefficie nt use of the carbon dioxide abso rben t during con trolled ven tilation? A . J us t ups trea m of the insp iratory v alv e B . B e twe en the insp iratory un id irec tional v alv e and the Y-piec e C. A t the Y-piece D. Be twee n the ex halatio n unid irec ti onal v alv e and the abs orb er V iew A ns we r15 . If a ba cte rial filter is located on the inspiratory s ide of a circle sys tem dow ns tream o f the inspira tory valve, A . Th e patien t wi ll be p rotec ted f ro m bac te rial c ontamin ati on in the an es thes ia machine a nd components of the breathing sys tem

B . It wi ll catc h abs orb ent dus t C. If a humidifier is used, i t shou ld be plac ed down s tream of this filter D. Us e of a fi lter i n th is posi tion has no t bee n s hown to reduce the inc idence of pneumonia af ter anes thesi a. V iew A ns we r16 . S ources of hu midity in the circle breath ing syste m include A . Neutral ization of carbon di oxide B . W ater c ontent of the absorbent granules C. Ex haled gas es D. The f resh gas f lo w V iew A ns we r17 . Whic h techn iques are us ed during the eme rgence from ane sthesia with low fresh gas flow s ? A . Tu rning off al l an es thetics and all owing the pa tient to awak en sl owl y B . Us ing a c harc oal fi lter to remov e v olatile agen ts C. Us ing high f resh gas f lows to wash ou t anes thetics D. B ypass ing the absorber in order to inc rease c arbon diox ide V iew A ns we r18 . Humid ity in the c ircle sy ste m is inc reased by A . Low f res h gas f lo ws B . A re duc tion of ca rbon dioxide output f rom the patient C. Inc reas ed minute v entilation D. Cooli ng the can is ter V iew A ns we r19 . Carbon dioxide in ins pired gases may be cause d by A . No t ac tiv ating the bypass mec hanism B . Fa ilure of one or both unidirec tional v alves C. High f res h gas flow D. Ex haus ted a bsorben t V iew A ns we r20 . What equ ipment is essentia l for performing low -flow ane sthesia with a circ le breathin g system? A . A n ox yge n anal yze r B . A n an es thetic a gent anal yzer C. Vaporizers wi th accurac y in the h igh rang e of the s cale D. A v en ti lato r with a bello ws tha t des cends o n exha lati on V iew A ns we r21 . Whic h gases may accumulate in the circle breath ing system during close d c ircle a nesthesia? A . Ca rbo n mo noxi de B . Ac etone

C. Toxic me tabolites of a nes thetic agents D. Hydro gen V iew A ns we r22 . At w hich loc ation(s) in the circle sys tem w ill a spiro me ter over-read the inspired volu me? A . J us t ups trea m of the insp iratory un id irec tional v alv e B . B e twe en the pres sure manometer and the absorber C. Be twee n the i nspiratory unidirec tional v alv e and the Y-piec e D. Be twee n the Y-pi ece an d the ex piratory u nidirec tional v alv e V iew A ns we r23 . Conce rning unidirectio nal valves, A . Mov ement of the dis c does n ot ass ure c ompetenc e B . Th e dis c c an obs truc t gas flow thro ugh th e v alv e C. The v alv e on th e exha lation si de is more lik ely to be inc ompetent D. Unidi rec tional v alv es are not posi tional and can b e operated in a numbe r of positions V iew A ns we r24 . What are some of th e a dvan tages of low -flow ane sthesia? A . Less danger of barotrauma B . B uffering of chan ges in ins pi red concen tratio ns C. Conserv ati on of heat and hu midity D. E li mina tion of the need for s cav engi ng V iew A ns we r25 . Whic h of the follow ing are co mmon ly fo und in so da lime? A . S odium hydroxi de B . P o tas s ium hydroxide C. Calc ium hyd rox ide D. A harden ing agent V iew A ns we r26 . P rob lems w ith high-alkali absorbents in clu de A . Th ey deg rad e enfl urane and isoflurane in the normal ly h ydrated s ta te B . Th ey c an reac t with v olatil e agents to form c arbon monox ide C. Carbonic acid is an end produc t of carbon di oxide abs orption D. They are les s able to abs orb ca rbon dioxi de when the mois tu re con ten t is dec reas ed V iew A ns we r27 . T here is no eviden ce of carbon monox ide formation w ith A . High-alkal i absorben ts B . No rmal ly h ydrated soda l ime C. Lo w-a lka li abso rbents

D. A lkali -f re e abs orben ts V iew A ns we r28 . Whic h factors increase Comp ound A forma tion? A . Low f res h gas f lo ws B . Inc reas ed abs orber temperatu re C. High concen trations of sev oflurane D. Sodiu m- and potas s ium-f ree absorben ts V iew A ns we r29 . How can carbon monoxide formatio n b e detected du ring an ane sthetic? A . S ignific ant dec rease i n SpO 2 B . Dec reased end-ti dal c arbon diox ide C. Sev oflu ran e wi l l be displayed as ano the r agen t D. An unusuall y delayed rise or unexpec ted dec reas e in the inspi red v ola tile agent conc en tration V iew A ns we r30 . Whic h factors co ntrib ute to c arbo n mon oxide formation? A . High f res h gas flows B . A nes thetic agent C. Inc reas ed tempera ture of the abs orbent D. Desic cated abs orbent V iew A ns we r31 . Whic h proce dures w ill help to pre vent c arbo n d iox ide abs orbe nt from becoming desiccated? A . Tu rning off the fresh gas fl ow after each case B . Tu rning v aporizers OFF wh en not i n use C. Checki ng the nega tiv e press ure v alv e in a c lose d s cav enging sys tem for prope r func ti on D. Changing the top c anis ter at leas t onc e a we ek V iew A ns we rP .281

32. Wh ich statements about changing carbon dioxide abso rben t are accurate? A . It should be changed when c arb on diox ide is p res ent i n the i nspired gas B . Co lor chan ge is an indica ti on of des iccati on in c aniste rs that h av e high s od ium and p otassi um contents C. It shoul d be c han ged when the temperatu re in the downs tream c anis ter is h igher than th at in the ups trea m canis te r

D. W hen c hang ing a du al ca nis te r, the abs orb ent i n the ups tream c anis ter is thrown awa y, the downs tream can is ter is mov ed to th e top pos i ti on, and the c anis ter wi th new absorbent is plac ed downs tream V iew A ns we r33 . Whic h of the statements a bout c olor indicators a re correct? A . W hen c ol or change shows s trongly , the abso rbe nt is at or near ex haus tion B . Indica tors do not b ecome deac tiv ated if s to red i n the da rk C. Absorbents wi thout a s trong b ase change c olo r with des ic cation D. If the color c hange rev ers es i tself, the absorbent is safe to use V iew A ns we r34 . Whic h position(s ) of the rese rvo ir ba g in the class ic circle sys tem w ould resu lt in exhaled gases being reb rea thed ? A . B e twe en the insp iratory un id irec tional v alv e and the Y-piec e B . B e twe en the ex pi ratory unidi rec tiona l v alv e and the absorber C. Be twee n the Y-pi ece an d the ex piratory u nidirec tional v alv e D. Be twee n the absorber and the i nsp iratory unid irec tional v alv e V iew A ns we r35 . P otential p roblems w ith placing a filte r betw een th e patient and the Y-p iece include A . Inc reas ed dead s pace B . Inc reas ed res is tance C. Inc reas ed ri sk of d is connec tions D. It may allo w wa ter to enter the gas s ampl e li ne V iew A ns we r36 . Whic h a re the po ten tial pa ths of leas t res istance in the class ic breathing system us ed by fresh gas flow in to th e b reathing system w hile the system is not in use? A . Th rou gh th e ins piratory path way B . Th rou gh th e rese rv oir bag mount if the reserv oi r bag is re mov ed C. Th rough the A P L v alv e if ful ly open D. Th rough the expi ra tory pathway V iew A ns we r37 . S ources of increasing nitrogen concentrations in a closed circle syste m include A . A l eak i n the gas s ample li ne B . Ex c retion by the patient C. Recirc ulated s ample gas D. Le aks in the v entilator bell ows V iew A ns we r38 . P rob lems w ith inducing anesthesia by u sin g low fresh gas flow s include

A . Rapid ly c hanging up take of ni trous ox ide and v olati le agent requi res frequent adjus tmen ts B . It takes a long time to establis h adequate ni trous oxi de concentra ti ons in th e breathi ng s ys tem C. La rge body s tores of ni troge n wil l be release d i nto the b rea thing s ys tem D. It i s d ifficult to ex trac t gas from the s ys te m V iew A ns we r

Chapter 10 Manual Resuscitators

Introduction
B reathi ng s ys tems that us e non rebreathing v alv es hav e l argel y disappeared from anes thes ia prac tic e. Howev er, th ese v alv es are s ti ll used in smal l po rtable manual resus ci tators , whi ch are used p rimaril y for patien t trans port, s uc tioni ng, a nd emergenc y s i tuations . The y can also be us ed to ad minister anes thes ia. A manual resus ci tator may be a dapted for use duri ng magn etic reson ance imaging (MRI) (1). Manu al resus c i tators are a lso k nown as ba g v entilators ; bag-assis t dev ices ; bagtype res us ci tators ; bag-v alv e dev ices , un its, o r res usc itators ; bag-v alv e -mas k uni ts , resus ci tators , or v entilators ; eme rgenc y manual v enti lators ; hand v entilators ; handoperated bag res usc i tato rs ; manual v entila tors ; hand-ope rated emergenc y v enti lato rs ; hand - or op era tor-powered resusc itators ; handbag resus ci ta tors ; manu al bag v entilators ; man ually opera ted resusc i ta tors ; manual pulmonary resus ci tators ; res pi rato ry ba gs ; resusci ta tor or re susc itation bags ; self-infl ati ng manu al resus c i tators ; s elf -inf lating respi rato r bags o r res usc itators ; v en ti lato r bags ; and s elf-inflating ba g-v alv e dev ic es.

Figure 10.1 Manual resuscitators. Note the pressurelimiting mechanism near the nonrebreathing valve on the smaller resuscitators. This can be overridden by placing a finger on top. Note also the air inlet and outflow valves between the self-refilling bag and the reservoir. (Picture courtesy of Hudson RCI.)

View Figure

P .283

Exa mples of these dev ices are s hown i n Fi gure 1 0.1 . Dis pos able manual resus ci tators tha t av oid the inconv enienc e a nd haz ards associa ted wi th reproces si ng and s teril ization a re c ommonly used. International and U.S . s ta ndards for re sus citators hav e been publ ished (2,3).

Components
A typic al manual resusc i ta to r is shown diagrammatic all y in F igu re 10.2. It has a co mp res sible s elf-expanding bag , a bag i nle t v alv e , and a non reb rea thing v alv e. The bag inlet and nonrebreathing v alv es are c ombined in s ome uni ts . Optional co mponen ts incl ude a press ure -l imi ting d ev ice, oxygen-enric hment dev ice, p osi tiv e end-expi ratory pressu re (PE EP ) v alv e , mech anism for s cav enging, carbon dioxi de detec tor, and a po rt for measurin g a irway press ure .

Self-expanding Bag
The s elf -expa nding bag (v enti lating or v entil ation bag, s elf -i nf la ting bag , s elf refil ling bag , comp res si ble unit, co mpressibl e res erv oi r) i s cons truc ted so that i t is i nflated in i ts res ting s tate. Some ba gs col lapse l ik e an acco rdi on f or s torage. Durin g exha lation, the bag ex pands . If the volume of ox ygen f ro m the del iv ery sourc e is i nadequate to fil l the bag , the dif fe rence is made up by room ai r. The ra te at wh ic h the bag rei nf lates wi l l determi ne the max imum minu te v olume .

Nonrebreathing Valve
The nonrebreathing v alv e is s ometimes c alled the di rec tional c ontrol v alv e, ex hal ation v alv e, ex pi ratory v alv e, inf la ting v alv e, inhal ation-exhalatio n v alv e, i nflating-exhalati on v alv e, inspi ratory-expi rato ry v a lv e , non return v alv e, p ati en t v alv e, routing v alv e, or one-way inflating v alv e. It has a number of parts that ensure that gas f lows out of the bag and into the patien t port duri ng inspi rati on and f rom the expi ra tory port wi th out mixi ng with fresh gas during ex hal ation.

Body
Mos t nonrebreathing v alv es are T-shaped. It i s prefe rab le that the hous ing be transparent so tha t th e internal mechan is m mov ement c an be obs erv ed. The expi ratory port is the opening through whic h exha led gases pass from the pati ent to atmosphere . It ma y hav e a means to def lec t ex haled gas (Fig. 10.3). A PEE P v alv e ma y be c onnec ted at this p oi nt. The exp iratory po rt may h av e a tapered 19- or 30-mm c onnec tor fo r attac hment to a scav enging s ys tem transfer tube (Chapter 13 ). The Americ an S ociety for Testing and Mate rials (AS TM) s ta ndard (2)

requi res tha t the c onnec tor fo r this po rt have a ridge (baulk ) in its inte rnal lu men s o that i t cannot acce pt a 22-mm mal e con nec tor. The patient c onnec tor is the pa rt that connec ts to a tracheal tube , face mask , or supraglo ttic dev ice. It has 15-mm femal e and 22-mm male coaxial f ittings . It may be desig ned to s wiv el . The insp iratory port i s the opening through whi c h gas enters the v alv e f ro m the bag. It is us ual ly p ermanently a ttached to the bag.

Unidirectional Valves
Unidi rec tion al v alv es di rec t the g ases f rom the bag to the pa ti ent d uring i nspiration and exhal ed gases f rom th e patien t to atmosphere. In o rde r to ac compl ish this , there a re us ual ly two v alv es . During ins piration, gas is di rec ted f rom the bag to the pati ent c onnec tion port. A t the same time , the expi ratory port is bloc ked . During ex hal ation , the expi ra tory port i s open, and th e ins pi ratory port is bloc ked so that the patie nt ex hal es to atmosp here. The v alve may hav e a means to prev ent ai r f rom enterin g when the patient is b rea thi ng spontaneous l y so that the patient wi ll inhale gas only f rom the bag .

Figure 10.2 Components of a manual resuscitator. The nonrebreathing valve directs the gas from the bag to the patient during inspiration. During expiration, the nonrebreathing valve directs exhaled gases from the patient to atmosphere through the expiratory port, and the bag inlet valve opens to allow the bag to fill.
View Figure

P .284

Spring-disc or Spring-ball Valve

Spri ng-dis c v alv es are s ho wn i n Fi gures 10.4 and 10 .5. In Fi gure 10.4, a s pring holds the disc aga ins t the seat. W hen the press ure on the disc is g rea t enough to ov erc ome the forc e of the spring, the v alv e opens . A s the press ure drops , the sp ri ng caus es the disc to c los e the v alv e. Some unidi rec tional v alv es hav e a ball in place of the d isc . The ball or disc may be he ld in place by grav i ty rather than a sp ri ng. Fi gure 10.5 shows a T-s haped v alv e wi th a sp ri ng disc that al ternate ly bloc ks th e gas inlet o r outle t. W he n the bag is comp res sed, the disc is pus hed ac ros s the v alv e, connec ting the ins piratory port with the patient port P .285 whi l e, at the sa me time oc cludi ng the expi rato ry port. When the bag is rel eased, the disc mov es bac k towa rd th e bag and all ows exh aled gas pas s through the ex piratory port. A guide pi n keeps the disc c entered. If the patien t is b rea thi ng spontaneous l y, the disc wi ll not cl os e the ex halation port, and room ai r wil l b e i nhaled.

Figure 10.3 The exhalation port may have a means to deflect the exhaled gas away from the operator.

View Figure

Figure 10.4 Spring-disc unidirectional valve. In the closed position, the spring holds the disc against the seat. When the pressure to the left of the disc increases above the pressure of the spring, the disc is forced away from the seat. When the pressure to the left of the disc drops, the valve closes.

View Figure

Figure 10.5 Spring-disc nonrebreathing valve. The disc is held on the seat by the spring. When the bag is squeezed, the disc moves to the left, closing the expiratory port. At the end of inspiration, the spring forces the disc to the right so that the patient exhales to atmosphere and not into the bag. A guide pin keeps the disc in the center. A spontaneously breathing patient can inhale room air unless a valve is placed over the expiratory port to prevent air entrainment.

View Figure

Figure 10.6 Edge-mounted flap unidirectional valve. Increased pressure upstream of the flap pushes the flap away from the seat, opening the valve. When the pressure downstream of the flap increases above the pressure upstream, the flap is forced back against the seat, blocking the flow of gas.

View Figure

Flap Valve
The f la p (leaf ) v alv e has a rigid or f lexi bl e flap that mov es. Th e f lap may be fixe d to the hous in g a t the e dge (F ig. 10.6) or the ce nte r (Fi g. 1 0.7 ). Fi gure 10.8 shows a nonrebreathing v alv e tha t i ncorporates two f la p v alv es. Duri ng i nspi rati on , the c enter-moun ted P .286 f lap v alv e mov es to the right. The peripheral f lap v alv e cov ers the exhalation po rt. Durin g exha lation, the flaps mov e to the left, prev enting ex haled gas f rom re enterin g the bag, an d the ex halation po rts are unc ov ered. The pe riphe ral fl ap v alv e prev ents i nha la tion of room ai r during s pontaneous breathing.

Figure 10.7 Center-mounted flap unidirectional valve. The flap valve is secured by a tab at the center. The tab is secured by a retainer, which is attached to the valve body.

View Figure

Figure 10.8 Nonrebreathing valve with two flap valves. During inspiration, the center-mounted flap valve opens, and the peripheral flap closes over the exhalation ports. During exhalation, the central flap valve closes, and the peripheral flap falls away from the exhalation ports. This valve has an oxygen inlet and two bag inlet valves, which open if the oxygen flow is not sufficient to prevent a negative pressure from developing in the space to the left.

View Figure

Fishmouth Valve
The f is hmouth (duck -bi ll ) v alv e (Fig. 10 .9 ) opens and cl oses l ike a fish's mouth. As press ure upstream of the v alv e inc reases , it o pens at the s li t in the cente r. A n i nc reas e in pressu re downs tream pushes the leafle ts together, c los ing the v alv e.

Diaphragm-flap Valve

A diaphragm-flap v alv e is sho wn in Figure 10.10. The diaphragm is attached a t its periphery. W hen the bag is squeezed, the di aphragm is pushed to the lef t an d oc c ludes the ex piratory po rt. Flap v alv es a t th e s ide of the diaphragm open, al lowin g gas from the bag to f low to the pa tient. W hen insp iration ends , the diaph ragm retu rns to its res ting pos i tion and the flap v alv es close, all owi ng the pati ent to exhale through the expirato ry po rt. A s pon taneous ly breathing patient may i nhale room a ir through the exhalation port if there is no flap v alv e to block ambien t ai r from enteri ng the v alv e.

Figure 10.9 Fishmouth unidirectional valve. As pressure to the left increases, the leaflets open, allowing gas to flow through the valve. An increase in pressure to the right pushes the leaflets together, closing the valve and preventing backflow of gas.

View Figure

Figure 10.10 Diaphragm-flap nonrebreathing valve. During inspiration, when the bag is squeezed, the pressure to the right increases and the diaphragm is pushed to the left, closing the exhalation channel. At the same time, the flaps at the edge of the diaphragm open, allowing gas from the bag to flow to the patient connector. When inspiration ends, the diaphragm moves away from the exhalation channel and the flaps close, blocking the inspiratory port.

View Figure

Figure 10.11 Mushroom-flap valve. This valve contains a mushroom-style diaphragm that is inflated when the pressure in the pressure channel increases. This occurs during inspiration. When the mushroom is inflated, it blocks the exhalation channel, allowing the lungs to be inflated. When the pressure inside the mushroom drops at the end of inspiration, it opens the channel and allows the exhaled gases to pass out of the exhalation channel. The flap valve prevents backflow of exhaled gases into the bag.

View Figure

P .287

Mushroom-flap Valve
The v alv e illus trated in F igure 10 .11 c ombines one mus hroom and two f lap v alv es . The ins ide of the mus hro om is con nec ted to a p res sure c hannel . During ins piration,

the mus hroom is i nf la te d agains t the se at, prev enting fl ow of gas through the ex piratory port and th e i nhalationa l flap opens . Duri ng ex hal ation , the ins pi ratory f lap v alv e prev ents flow bac k into the bag. T he mushroom coll apses and opens th e ex hal ation c hannel. A flap v alv e ov e r the expi ratory port prev en ts room air from being inha led duri ng sp ontaneous breathing.

Figure 10.12 Fishmouth-flap nonrebreathing valve. The circular flap and fishmouth valves are attached, around the periphery. When the bag is squeezed, the flap valve is seated against the exhalation ports, and the fishmouth portion of the valve opens. During expiration, the fishmouth closes and the flap falls away from the exhalation channel. A second flap valve over the exhalation ports prevents air from being inspired during spontaneous respiration.

View Figure

Fishmouth-flap Valve
The v alv e diagrammed in Figure 10.12 and pic tured disass embled in F igu re 10.13 has one fishmouth and two f lap v alv es. The fishmouth and one c i rc ul ar flap v alv e are combined i nto one piece . The flap v alv es surro und the centra l fish mouth. Outs ide the ma in v alv e b ody is another c ircular f lap v alv e. Duri ng inspi ration , the f is hmouth opens and the c ircular f lap v alv e c loses the ex halatio n port. The outs ide f lap v alv e prev ents room a ir f ro m en tering the v alv e during s pontaneous breathing. Durin g exha lation, the fishmouth s ec tion c loses . The c i rc ul ar f lap v alv e attac hed to i t is l ifted off the ex pi ra tory apertures, allowing exha led gas to es cape to atmosphere.

View Figure

Figure 10.13 Components of the fishmouth-flap nonrebreathing valve. Left: The patient connection with the expiratory flap. Center: The fishmouth with its concentric flap. Right: The part of the housing closest to the bag.

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Bag Inlet Valve

The bag inlet (refil l) v alv e is a one -way v alve that is opene d b y nega tiv e press ure i nsi de the bag. W hen the bag is squeez ed, the v alv e clos es . T his p rev ents escape of gas th rough the inlet. A s imple f lap (Figs . 1 0.2 , 10.7) or s pring -disc v alv e (Fig. 10.4) is mos t commonl y use d. Th is v alv e is usu al ly loca ted at the oppos i te end of the bag f rom the n onrebreathing v alv e but may be at the s ame end and may be co mbined with th e n onrebreathing v alv e.

Pressure-limiting Device
The pres sure-l imitin g dev ice (pressure rel ief dev ice, v alv e, or sys tem; ov erpressure l imi ting s ystem; ov erpres sure v alv e; pop-off v alv e; p res sure limiti ng s ys tem) protec ts agains t barotrauma and ma y prev ent gases f rom ente ring the s to mach during manua l v enti la tion (4 ). A v arie ty of dev ices hav e been used . One is a sp ri ng-loaded disc , wi th the tens ion on the s pring adjus ted so th at i t opens at the des ired pressu re. Another is a magn etic dev ic e, wi th the fo rce of the magnet adjus ted to open at the des i red press ure . Some s ys te ms p rov id e a s mall hol e. The max imu m press ure depen ds on the si ze of the hole and how f irmly the bag is compres sed. In order to ov erride the

dev ic e, i t is usual l y nec essa ry to plac e a f inger ov er the outl et (Fig . 10.1). An ov errid e mec hanis m may c ause c onfus ion (5 ). For adul t resus c i tators , the AS TM s tanda rd re qui res that if there is a dev ice that l imi ts the press ure to below 60 c m H 2 O, there mus t be an ov erride mechanism (2). If the ov erri de mechanism can be locke d, i t mus t be desi gne d so tha t th e operating mode (ON o r OFF) is readil y ap parent to the us er. It recommends that if a resus ci tator is equ ipp ed with a pressure-limi ti ng dev ic e, there s hould be an audib le or v is ible warni ng to the operator whe n the press ure li mi tin g dev ice is operati ng . It also requi res tha t with a pressure li mi ting dev ic e s et at a f ixed press ure , that press ure mus t be mark ed on the res usc itator. The A ST M s tan dard (2) requi res a pressure-li miting s ys tem for infant and c hild resus ci tators , wi th an o pening press ure of 45 c m H 2 O and an option for an ov erride . The mea ns that to c rea te a higher inf lation pres sure is espec ially important in a resus ci tator des igned for i nfants , bec aus e the firs t few breaths may re qui re press ures as high as 50 to 70 c m H 2 O. The press ure needed to ov ercome f lo w resis tance in a narrow tracheal tube and to ex pand the s tiff lungs of a p rema ture i nfa nt may ex ceed 30 to 40 cm H 2 O. It is rec ommended tha t a ma nometer be used wi th ne onatal resusc i ta tion dev ic es , because using these resusci ta ti on dev ic es can be as soc iated wi th ex tremely high ins pi ratory pressures (6).

Oxygen-enrichment Device
Mechanisms to i nc rease the i ns pired ox ygen c oncentration abov e that of room a ir are present on nearly a ll res usc i tation dev ices .

Oxygen Delivered Near the Bag Inlet Valve

Tub ing f rom an ox yge n fl owmeter attached near the bag inlet v alv e is a s imple means of i nc reasing the c oncentra tion of oxyge n in the bag. The ox ygen does not enter the bag direc tly . The inc reas e in oxy gen concen tration is limi ted because ai r can be d rawn i nto the bag. The deliv ered ox yge n c onc entrati on can be inc reas ed by i nc reas ing the ox ygen f low, but this is of limited v alue . The hi ghe r th e minute v olume an d the greater the inspi rato ry:ex piratory (I:E ) ratio, the l ower the de liv ered ox ygen c once ntration.

Oxygen Delivered Directly into the Bag

Ox ygen c an b e deliv ered di rec tly into the resusci ta tion bag . This method wil l resu lt i n h ig h del iv e red ox yge n c onc entrati ons wi thout mak ing the resus citator cu mbers ome. Ho wev e r, prov isi on mus t be made f or v en ting ex cess oxygen to

minimi ze the danger of the nonrebre ath ing v alv e locki ng in the inspi rato ry pos ition. If the ox ygen flow is less than the bag f il ling rate, th e bag inle t v alv e wi ll open an d admi t ai r.

Reservoir
Mos t uni ts hav e a res erv oi r (ac cumulator) in wh ich ox ygen is s tored when the bag i s not fil ling. It may be a tube o r a bag. W hen the resusci ta tion bag inlet v alv e opens , ox yg en from the reserv oi r en ters the bag. In gene ral , resusc i ta tors wi th reserv oi r ba gs prov ide a higher f rac ti on of del iv ered ox ygen than res usci tato rs wi th tubi ng reserv oi rs (7). The si ze of the res ervoi r may l imi t the ox ygen c oncentration deliv ered. If the v ol ume of the res erv oi r is less than tha t of the bag , the inf lo win g ox ygen may no t be suff ic ien t to mak e up the dif ferenc e, and room ai r wi ll b e dra wn i n. On the o ther hand, a la rge rese rv oir makes a res usc itator more cumbers ome .

Open Reservoir
Open rese rv oirs are s hown i n F igu res 1 0.14 (l eft) and 10.1 5. A piece of c orruga ted tubi ng or other ma terial op en to atmosphere i s placed l ike a s leev e aroun d the bag i nlet v alv e. If the ox ygen f low i s high, oxygen wil l f lo w i nto a tmos phere at the open end of the rese rv o ir. If the oxygen flow is l ow or the res erv oi r is sma ller than the tida l v olume , ai r wil l be drawn i nto the bag a long with the ox ygen. The high es t possible c onc entration of ox ygen wi l l be adminis tered if the reserv oi r i s l arge and the ox ygen fl ow i s g rea ter than the mi nute volume.

Figure 10.14 Left: A resuscitator with an open reservoir. Right: One with a closed reservoir.

View Figure

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Closed Reservoir
Cl osed rese rv oirs are s hown i n F igu res 1 0.1 , 10.14 (ri ght), and 10.16. Each has an ov erf low v alv e that v en ts ex ces s g ases and an ai r in tak e v alv e th at al lows in tak e of ambien t ai r if there is ins uff ic ient ox ygen f low. A bag prov ides a v isual indication of whe the r the rese rv oir i s receiv ing s uff ic ien t ox ygen. A deflated bag means tha t there is a problem wi th the ox ygen s uppl y or a hol e i n the bag .

Demand Valve
A demand v alv e connec ting a c ompress ed gas sou rc e to a self-expanding bag wil l cons is tently prov ide a high ins pi red oxygen conc entra tion (8). A negativ e p res sure i n the ba g triggers the flow of oxygen, whi ch s tops a t a preset p res sure. The dema nd v alv e may be man ual ly ac tiv ated wi th a pus h button.

Positive End-expiratory Pressure Device

A P EEP v alv e is av ail able on s ome resus c itators and can be added to the ex piratory port on oth ers .

Scavenging Mechanism
A means for sc av enging exp ired gas es (Chapter 13) c an be moun ted on the ex piratory port of s ome resusc i ta tors .

Carbon Dioxide Detector

A manual resusc itator may hav e a bui lt-i n colorime tric c arbon diox ide detec tor (7,9 ,10 ) (Chapter 22). A detec tor may als o b e a ttac hed.

Pressure Monitoring Port

A port fo r moni to ring ai rway p res sure is av ai lab le on some ma nual res usci tators (11).

Functional Analysis Respiratory Volumes

The mi nute v ol ume wi ll b e determi ned by the tidal v ol ume and resp iratory rate. These wi ll d epend n ot on ly on res us ci tator p erformance bu t also on the operator's sk il l . The v olume deliv ered whe n the bag is comp res sed wi ll v ary with the si ze of the user's hand and wh ether one o r two hands are used (12,13,14,15,16,17,18,19,20).

Ti dal v olume wil l be inc reas ed when a two-h ande d tec hni que is used . Grip s tren gth i s the bes t predic tor of deliv ere d v olumes and is more importa nt when the tidal v olume is deliv ered by a one-hand tech ni que (20). Tidal v olume may be inc reased by co mpressing the bag aga ins t a soli d s urfac e s uch as a thigh or the operating room tab le. Another method to inc rease the ti dal v olume is to compres s the bag between the open pal m and body (21). The resp iratory rate may be l imited by how fas t the bag re-expa nds , which depends on the bag c ons truc tion an d the si ze of the bag ref il l v alv e inlet. The max imum co mp res sion ra te may be reduc ed at l ow tempera tures (13,22,23).

Delivered Oxygen Concentration

The A ST M s tan dard (2) requi res th at a res usc itator for adults be cap able of deliv ering an ins pi red ox ygen c onc entration of at leas t 40% when c onnec ted to an ox ygen P .290 sourc e s upplying no t more than 15 L/mi nute a nd at l eas t 85% with an ox ygenenrichmen t dev ic e s uppli ed by the manuf ac turer.

Figure 10.15 Open reservoir. A: The bag is filling. Oxygen from the delivery tubing as well as that in the reservoir flows into the bag. If the volume entering the bag exceeds that in the reservoir and flowing through the delivery tubing, room air will make up the difference. The size of the reservoir is, therefore, important. B: The bag inlet valve is closed. Oxygen from the delivery tubing flows into the reservoir. Because the reservoir is open to atmosphere, some oxygen will be lost if the flow is high.

View Figure

The deliv e red ox ygen c oncentratio n is l imi te d b y res erv oi r si ze and the oxygen flow (7). If the v olume of the reserv oi r is gre ate r th an the v olume of the b ag and the ox ygen f lo w i s greater than the minute v olume, the de liv e red ox ygen c once ntration may appro ach 100 %. If the tida l v olume is gre ate r th an the rese rv oir v olume plus the v olume of ox ygen d el iv e red during i nspirati on, ai r wil l be drawn i nto the uni t and reduce the deliv e red ox ygen perc entage (24).

Controlled Ventilation
The deliv e red ox ygen c oncentratio n wil l be de termined by the minu te v olume , the s ize of the reserv oi r (if p res ent), the ox ygen f low, and the technique us ed to squeeze a nd release the bag (25 ). If the bag is a llowe d to fi l l at i ts mos t rapid rate, al l of the ox ygen in th e rese rv oir ma y be exhaus ted and ai r drawn i n. If bag fil li ng is manu al ly reta rded, the deliv ere d ox ygen c oncentra ti on wi ll be higher (8). This ma y be us efu l when l ow oxy gen f lows mus t be us ed or when the reserv oi r is smal l or no t present, but i t l imi ts the respi ra tory rate that ca n be achi ev ed. Fu rthermore , it ma y caus e the nonrebreathing v alv e to jam in the inspi rato ry pos ition. Ac tiv ating the press ure -l imi ting dev ice may cause the del iv e red oxygen conc entration to dec reas e (26).

Spontaneous Ventilation
W ith s pontaneous v entilation, insp ired gas may c ome from the ex halation port as wel l as the bag . The i nspi red ox ygen concentration can v ary f rom 25 % to 100% (24,27). Bags wi th f is hmouth v alv es a re as soc iated wi th l ow ins pi red ox ygen conc en trations (24 ,28 ,29 ).

Rebreathing
If the n onrebreathi ng v alv e is c ompetent, i nhaled and exhaled g ases s hould not mix . If the v alv e is incompetent, a back l eak wi l l allo w ex haled gas es to pass back i nto the resus c itator.

Use
A bag and mas k that are the appropri ate s i ze for the pa tient shou ld be se lec ted. For adul ts , an ox ygen f lo w of 10 to 15 L/minute is mos t commonl y used. Fo r ch il dren and infa nts , l ower f lo ws are recommended . Higher f lo ws than those recommen ded by the manufac turer c an res ult in si gnif ic ant lev els of auto-P EEP (30). If anes th etic gas es are to be adminis tered, the trans fer tube (Chap ter 13) f rom a sc av engi ng s ys tem should b e a ttached to the expirato ry po rt.

A manual resusc itator ca n be adapted f or manual v entilation duri ng MRI by i nserting an ex te nsion tube that is long e nough to c ov er the dis ta nce be twee n the pati ent a nd the pers on s queezing the bag between the non reb rea thing v alv e and the bag (1 ). A n ex te nsion must not be plac ed between the patient and the nonrebreath ing v alv e, as this wil l cause the dead s pace to be inc reased .

Hazards High Airway Pressure

Hi gh ai rway p res sure is a hazard mainl y if the pa tient is intubated. A dangerous ly high press ure is less like ly when a mas k or supraglo ttic dev ice is us ed.

Figure 10.16 Closed reservoir. Top: The reservoir is full, and the pressure increases. Oxygen flows through the overflow valve. B: The resuscitator bag is filling. Because there is insufficient gas in the reservoir, air enters through the intake valve.

View Figure

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Nonrebreathing Valve Sticking in the Inspiratory Position

If the n onrebreathi ng v alv e s tic ks (l oc ks up, j ams ) in the inspi ra tory pos itio n, the pati ent wi l l be atte mp ting to exhal e against a c lose d outlet, and c ontinued inflow wi ll quickl y cause a conti nuous and dangero us inc reas e i n pressu re. A v a ri ety of other c ondi tions can cause this , inc ludi ng inte rrupting manual v entilation for observ atio n of sponta neous res piratory eff orts , ma nual ly res tric ting bag refil l, the v alv e b ecoming c onta mina ted wi th forei gn mate ri al , a smal l squ eeze o r bump on the bag c aus ing the v alv e to loc k up, c oughing , imp rop er ass embl y, attaching an ox ygen inlet nippl e wi thout v ent holes di rec tly to the resusci ta tor, failure of the

ex piratory f lap v alv e to open, and a k ink in the res erv oi r ta il (31,32,33,34,35,36,37,38,39,40 ,41 ).

High Oxygen Inflow

The A ST M res us ci ta tor s tandard (2) requ ires that the v alv e no t ja m at an inp ut f lo w of up to 30 L/minute . In fan t resusc itators a re espec ially p rone to obs truc tion with high flows b ecause the b ag is s o s mall . A case has been rep orted in wh ic h the press ure mon itoring port wa s connec ted to an ox ygen s ourc e (11). This d is torted the inspi ratory v alv e and resu lted i n exces siv e pressu re.

Asynchrony between Patient Exhalation and the Demand Valve

Manu al ly ac tiv ating a demand v alv e while th e patien t is exhali ng can cause dangerous ly high press ures (8).

Pressure-limiting Device Failure

P ress ure-l imi ti ng dev ices of ten ma lfunc tion, o pening wel l abov e an ac cep tab le press ure (26,42,43).

Excessive Resistance
Res usci tators wi th hi gh resis tanc e c an expose the patien t wi th high exp iratory f lows to acute airway press ure e lev ations (44 ).

Rebreathing
Reb rea thi ng ex hal ed gas es can oc cur i f the v alv e on the inspi ra tory li mb from the bag is not c ompetent or is imprope rl y assembled (45 ,46 ). The fishmou th v alv e c an become uns eated, allowi ng rebreathing a nd/or i nsuff ic ien t pressu re during i nspi rati on (47). Ex tens ion tubing should not be ad ded be twee n the pa tient and the v alv e.

Hypoventilation
Studi es show that it is more d ifficult to ac hiev e satis fac to ry v entilati on wi th a resus ci tati on bag and fac e mas k P .292 than wi th a sup raglottic ai rway dev ice or Combi tube (48 ,49 ). A defec tiv e nonrebreathing v alv e may hav e fo rwa rd le ak , s o during i nspiratio n part of the v olume ex pelled from the bag escapes th rou gh the expi ra tory port (4 5,5 0,51). Unrecogni zed v enting through the pressu re re lief dev ice may res ul t in

hypov enti lation (52,53). If the f is hmouth v alv e s ticks or is abs ent, v enti lation is not possible (53,54 ). The s eal a t th e rear of th e bag may not s eat, al lowin g gas to ex it (55). Hypov enti lation c an be c aused b y a disc onnec tion o r broken pieces on the resus ci tator (56). Pediatric ba gs wil l no t prov ide ade quate v olumes wh en used wi th a dul ts (57,58). Us ing an intermedia te si ze bag ma y res ult in ade quate v en tila tion wi th reduc ed risk of gas tric inflatio n wh en us ing a fac e mask (59). The operato r is an important fac tor i n determining the effec tiv eness of v entilation (60). Squeezing the b ag may re qui re cons iderable phys ic al effort, and performance may de teriorate as the operator becomes fatigu ed. Op erators with smal l hands may hav e diff ic ulty deliv ering adequate ti dal v olu mes . Sq ueez ing the bag by usi ng one hand ins te ad of two ten ds to lower the delivered v ol ume (12,17,18). Adequate ti dal v olumes are f requentl y not de liv ered when a mas k is us ed unless two persons partic ipa te, one holding the mask and one squeezing the bag (15). Bec ause resusci ta tors are used awa y from the hos pi tal , i t is poss ib le that they wi ll be subjec ted to low tempera tures . In this s ituati on, the maxi mum c yc ling ra te is of ten reduced, and the uni ts may bec ome inope rab le or i nc apab le of deliv e ring sa tisfac tory v entilation (61 ,62 ). It may be pos s ible to mis assemble the resus citator so that when the bag is squeezed, the con ten ts are exhaus ted to a tmos phere (45,63,6 4). The bag may become detac hed from the nonrebre ath ing v alv e (65). If the p res sure reli ef dev ic e is se t incorrec tly, i t may open at a l ow p res sure, caus ing hypov en ti lation (66,67). If a p ediatri c adaptor wi th a pres sure rel ief dev ic e i s present on an adul t resus c i tator, i t wil l not al lo w a dequ ate v entilation (53). Dec reased tidal v olume may be s een wi th i nc reased res is tance or dec reased co mpliance (12 ,18 ,68).

Low Delivered Oxygen Concentrations

Low deliv ered ox ygen c oncentrations may be the res ult of ins uffic ien t ox ygen fl ow, a detach ed or defec tiv e ox ygen tubing, or problems wi th th e ox ygen-enric hment dev ic e (7,25,69,70 ). A defec t in the nonrebreathing v alv e may resu lt i n ox ygen no t f lowing to the pa tient (71 ). Th e res erv oir ma y be too s mall for the tidal v olume . Low temperatures ma y res ult in low ins pi red ox ygen c once ntrations bei ng de liv ered (61).

Durin g spon taneous v entilation, the patient may i nhale room a ir f ro m the exp irato ry port as we ll as ox yg en-enric hed gas f ro m the bag. The inspi re d ox ygen conc en tration c an v ary from 25% to 100% (2 4,27).

High Resistance
Some nonrebreathing v alv es offe r hi gh res is tance to f lo w s o that high nega tiv e press ures mus t be generated during s pontaneous v enti lation (24,27,44). The work of b rea thing may be q uite high.

Contamination
Bec ause thes e dev ices a re of ten used on pa tients who hav e res piratory infec tions, they f requently become contaminated (72,73,74 ). Oxy gen f lo win g through the v alv e may ae ros olize bac teri a and sp rea d the m into the su rrounding ai r. For thes e reasons and becaus e these dev ices a re diffi cul t to c lean, disposable un its hav e become pop ula r. B ac terial /v iral f il ters (Chap ter 7) may be us ed.

Inhalation of Foreign Bodies

Part of the ins ide of the bag or parts of the nonrebreath ing v alv e may break off and be i nhaled (75,76).

Checking Manual Resuscitators

Before use, the resus ci tation bag sh ould be v isuall y ins pec ted f or s igns of wear such as c rack s o r tears . After the bag has been inspec ted, i t shoul d be c hecked f or l eaks . The pa tient port should be oc cluded and the ba g s que ezed . P ressure should build up rap id ly to a poin t at which the bag can no lon ger be c ompressed. If there is a pressu re l imi ting dev ice, i t c an b e c hec ked by connec ting a pressu re mano mete r between the pa ti ent p ort and the bag by using a T-fi tting. If there is an ov errid e mechanism on th e p res sure li miting dev ice , th is shoul d be c hec ked . This check also determines th at the refi ll v alv e wil l c los e when the bag is s quee zed. To check that the bag refil l v alv e o pens , the b ag should be s quee zed, then the pati ent p ort occluded and the b ag re leased. The bag s hould ex pand ra pidly . If the resusci ta to r has a cl osed rese rv oir, i ts func ti on can be c heck ed by perfo rming sev eral compress ion-re lease c yc les with no ox ygen flow i nto the reserv oi r. T he reserv oi r shoul d def la te, but the resusc itatio n bag should c ontinue to exp and. A res erv oi r bag f rom a breathing s ys tem is plac ed ov e r the patient port. S queez in g the res usc itation bag should cause the res erv oi r bag to inf late . After the reserv oi r bag h as bec ome ful l y i nfl ated and the resusc i ta tion bag has been release d, the bag shoul d def late eas ily. T his

P .293 tes ts the insp iration a nd exhala ti on parts of the v alv e and th e exha lation pathway for patenc y. The res erv oir bag should d efl ate easi l y.

Advantages

The equipment is inexp ensiv e , compac t, li gh twei gh t, an d portable ye t rugged. The equipment is eas y to us e. The equipment is si mple with a s mall numbe r of pa rts . Disas sembl y and reass embl y are us ual ly eas ily p erf ormed. Dead s pac e a nd reb rea thi ng are minimal if the non reb rea thing v alv e func ti ons properl y. W ith proper a ttention to the ox ygen-enric hment dev ice, ox yg en flow, a nd v enti lation techniq ue, i t is poss ib le to adminis ter c lose to 1 00% ox ygen with mos t res usc itators .

Durin g emerg enc y s ituations in whic h a c onnec tion to a gas sou rce is not readi l y av ailable, the res usc itator c an b e used wi th room air until a s ource of ox ygen bec omes av ai la ble .

The operato r has some feel for p res sures and v olumes deliv ered. Ba rotrauma may be less lik el y with these dev ic es than with gas -powere d resusc i ta to rs , whi c h do no t al lo w the ope rator to sens e when the patien t's lungs are full y i nflated.

Disadvantages

Some of the v alv es are nois y and s tic k , pa rtic ul arl y when we t. The re may be c onsi derable hea t and humidity l os s f rom the pati ent wi th prolonged use. Cons ideration s hould be given to us ing a heat and mois ture ex changer wi th prolong ed trans port.

feel of the bag is dif ferent from that in other b rea thing s ys tems. The user's hand mus t be re-educ ate d. The v alv e mus t be l oca te d a t the p ati en t's head . Its bulk may be troubles ome, and i ts wei ght ma y caus e the trac heal tube to ki nk or be displac ed down ward .

Durin g infant res usc itation , manua l resus citators are un rel iabl e as freef lowing ox yge n del iv ery dev ices (7 7)

References
1. Taylor W F, Pa ngbu rn PD, Pascha ll A . Manua l v en ti la tion during magne tic resonance imagi ng. Respi r Care 1991 ;36 :1 2071210. [Med li ne Link ] 2. A me ric an Soc iety f or Tes ting and Ma terials . S tanda rd spec ification for mi ni mum performance and s afe ty requi rements for resusci tato rs i ntended f or us e with huma ns (AS TM F-920 ). W es t Cons hohocken, PA : Au tho r, 1993 (Reapprov ed 1999). 3. International S tandards Organ ization . Lung v entilatorsP art 4: Parti cular requi rements for operato r-powered res us ci tators (IS O 1 0651 -4). Genev a, S wi tz erl an d: Author, 20 00. 4. W en zel V , Idris A H, Banner MJ , e t al . In fluence of tidal v olume on the dis tributi on of gas b etween the lun gs and s tomac h in the nonintubated pa tient receiv ing pos itiv e-pressu re v en ti lation. Cri t Care Me d 1998;26 :36 436 8. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 5. A nony mous . A mbu/Me dicotes tInfant/c hild s ing le -us e manual res usc i tators : risk of ov er p res sure. Health Dev ices A lerts 2002;26(30):2 . 6. Husse y S G, Ryan CA , Mu rph y B P . Compa ris on of three manu al v entil ati on dev ic es us ing an intubated mann equin. A rch Dis Chi ld 2004;89:490493. 7. Ma zzoli ni DGJ , Mars hal l NA . Ev aluation of 16 adu lt d is posa ble manual resus ci tators . Res pi r Care 2004;49:150 915 14. [Med li ne Link ] 8. Ca mpbel l TP , S te wart RD, Kaplan RM, et al. Ox ygen enrichment of bag-v alv e mask units duri ng posi tiv e-p res sure v enti lati on: a comparis on of v ari ous tec hniques . A nn E merg Med 1988;17:232235 . [Cross Ref] [Med li ne Link ] 9. Gonzalez del Ray JA , Poi ri er MP , Digiulio GA . E v aluatio n of an ambu -ba g v alv e wi th a self -c ontain ed, c olori metric CO 2 s ys tem i n the de tec ti on of airway mis haps : an an imal tria l. Pe di atr E me rg Care 2000 ;16 :121123.

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18. Hess D, S immons M, B laukov i tch S , et a l. A n ev aluation of the effec ts of fatigue, impedance, a nd use of two hands on v olumes d eliv e red du ring bag -v alv e v enti lation . Respir Ca re 1993;3 8:271275. 19. Hess D, S pahr C. A n ev aluation of v olumes del iv ere d b y s elec ted adult disposable resus ci tators : the effec ts of hand s i ze , numbe r of ha nds us ed, an d use of dis posable medic al glov es. Respi r Care 1 990;35 :800805. [Med li ne Link ] 20. Mc Cabe S M, S me ltzer SC. Compa ris on of ti dal v ol umes obtained by o nehanded an d two-handed v en ti la tion techn iqu es . A m J Cri t Ca re 1993;2 :46747 3. [Med li ne Link ] 21. Thomas AN , Dang P T, Hyatt J , et al. A n ew tec hnique for two-h and bag v alv e mask v entil ation. B r Med J 1993;70:397398. 22. Anonymous . Manua l resusc itators . Health Dev ices 19 79;8:133146. 23. LeB ouef LL . Assessment of e igh t adu lt manual res usc i tato rs . Respi r Care 1980;25:1136114 2. [Med li ne Link ] 24. Mills P J , B ap tis te J , P res ton J , et al. Manual res usc itators a nd spon tan eous v enti lationa n ev aluati on. Crit Care Med 19 91;19:14251431. [Cross Ref] [Med li ne Link ] 25. Corley M, Ledwi dge MK , Glass C, e t al . The myth of 100% oxygen deliv e ry through manu al resus c i tation bags . J Emerg Nu rs 1993;19:454 9. [Med li ne Link ] 26. Fin er NN, Ba rrington K J , A l -Fadley F, et a l. Limi ta tions of s elf-i nflating resus ci tators . Pedia tric s 1986 ;77 :417420. [Med li ne Link ] 27. Hess D, Hi rsch C, Marquis -D'Amico C, et al . Impos ed wo rk and oxygen d el iv e ry during s pontaneous b rea thing wi th adul t dispos able manual v en tila to rs . Anes thes iology 1994;81:12561263. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 28. Nimmag adda U, Ra mez Salem M, Jos eph NJ , et al. Eff icacy of preox ygena tion wi th tid al v olume breathing. Comparis on of breathi ng s ys tems . Anes th esiology 2000;93:693698. [Fu ll tex t Link ]

[Cross Ref] [Med li ne Link ] 29. Tib balls J , Carter B , W hitting ton N. A disadv an tage of se lf -i nf la ting resus ci tati on bags . Anaes th Intens Care 2000 ;28:587. [Med li ne Link ] 30. Reick CW J r. Auto-PEEP ass oci ated wi th exc ess iv e ox ygen flow through fiv e manu al resus c i tators . Respi r Care 1 996;41:10091012. 31. Anonymous . Manua l reusab le pu lmonary resusci ta tors . T echnol Anes th 1 994; 14,8:56 . 32. Tuck er J , Hanson CW , Chen L. Pneumothorax re exac erbated by a self-infl ating bag-v alv e dev ice . Anes thes iol ogy 1992;76:10671068. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 33. Hunter W A H, Duthie RA . Malfunc tio n of a Laerdal res usc itation v alv e. Anaes thes ia 1991;46:505 506. [Cross Ref] [Med li ne Link ] 34. K li ec k J M, Bus hnell LS , Banc rof t ML. Ba rotrauma, a po ten tial hazard of manual resus ci tators . Anes thesi ol ogy 1978;49:363365 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 35. Anonymous . New c omponent desi gned for resusci ta to r v alv e s tic k ing probl em. B iomed S afe S tand 1991 ;21:123. 36. Ho A M-H, Sh ragge W, Tittley J G, et al . Ex halation o bstruc tion due to Laerdal v alv e misas sembly. Cri t Care Med 1996;24 :362364. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 37. Anonymous . Res usci ta tors , pulmonary manual reus abl e. Techn ol Anes th 1991;12:9. 38. Cul len P . Self-infl ating v entilatio n bags . A naes th Inte ns Care 2 001;29:203. [Med li ne Link ] 39. Myers DP , de Leon-Casas ola OA , B acon DR, e t al . Bi la teral p neumothorac es f rom a malf unc ti on ing resusc i ta tion v alv e . J Clin Anes th 1993;5:4 33435.

[Cross Ref] [Med li ne Link ] 40. Anonymous . Imprope rl y cl eaned resuscitato r v alv es may s tick & bl ock ai rway. B iomed S afe S tand 1991 ;21:105107. 41. Jumpe r A , Des ai S , L iu P , et al. P ul monary barotraumas res ulti ng from a faul ty Hope II res us ci tati on bag. Anes thes iology 1983;5 8:572574. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 42. K is soon N, Conno rs R, Tiffin N, et al . An ev aluation of the phys ica l and func ti onal charac teris tics of res usc i tato rs for us e in ped iatrics . Cri t Care Med 1992;20: 292296. [Cross Ref] [Med li ne Link ] 43. Barnes TA , Mc Garry WP . Ev al ua tion of ten disposable manua l resusc itators . Res pir Care 1990;35:960968 . [Med li ne Link ] 44. Hess D, S immons M. An ev aluation of th e res is tance to f lo w through the patient v alv es of twelv e adul t manual resusc i ta tors . Respi r Care 1992 ;37 :432438. [Med li ne Link ] 45. Munford BJ , W is haw KJ . Critical inc idents wi th nonrebreathing v alv es . Ana esth Intens Care 1990;18:56056 3. [Med li ne Link ] 46. Day CJE , Nolan J P . A reb rea thing no n-rebreathing v alv e. Anaesthes ia 1994;49:456. [Med li ne Link ] 47. Anonymous . Manua l resusc itators . Bi omed Safe S tand 1998 ;28 :126. 48. Doerges V M, Sauer C, Oc ker H, e t al . Ai rway manageme nt du ring ca rdiopu lmonary res usci tati ona comparativ e s tudy of bag-v alv e -mas k, l aryngeal mask airway and Comb itube in a benc h model . Resusci ta tion 1999;41:636 9. [Cross Ref] [Med li ne Link ] P .294

49. Cla yton TJ , Pi ttman JAL , Gabbott DA . A comparis on of two te chniques fo r manu al v entilation of the lungs by non-anaes thetis ts : the b ag-v alv e-facemask and the cuffe d o ropharyngeal ai rway (COP A ). Anaes thes ia 2001;56:756 759. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 50. Anonymous . Valv e component on res usc itation k its may leak . B iomed Sa fe S tand 1989;19:353 6. 51. Anonymous . Pulmonary res usc itators . Heal th Dev ices 1989;18:333 352. [Med li ne Link ] 52. Hirsch man A M, K rav ath RE . Ven ti ng v s v enti lating . A d ange r of manual resus ci tati on. Ches t 1982;82:369370 . [Cross Ref] [Med li ne Link ] 53. Smith G. P roblems with mis -as sembl y of adul t manual resus c itators . Res usci tation 2002;53:109111 . [Cross Ref] [Med li ne Link ] 54. Anonymous . Manua l resusc itators s ubjec t of s afety alert a nd recall. Biome d Safe S ta nd 1998;28:8 183 . 55. Anonymous . Manua l pul mona ry re sus ci tators . Techno l Anes th 20 02:10. 56. Conno rs R, K iss on N, Tiff in N, et al . An ev alu ati on of the ph ysical and func ti onal charac teris tics of infant res usc i tators . Pedi atr Emerg Ca re 19 93;9:104 107. [Cross Ref] [Med li ne Link ] 57. Doerges V , S auter C, Ock er H, et al. Smaller ti dal v olumes during ca rdiopu lmonary res usci tati on: compa rison of adul t and paediatric s elf -i nflatabl e bags with th ree different v entilatory dev ices. Res usc i tation 1999;43:3137. [Cross Ref] [Med li ne Link ] 58. Dorg es V , Ock er H, Hagel berg S , et al . S mal ler tida l v olumes wi th room ai r are not suffici ent to ens ure a dequate ox ygenation duri ng bag -v alv e-mask v en til ati on. Res usci tation 2000;44:3741. [Cross Ref] [Med li ne Link ]

59. Dorg es V , Ock er H, Hagel berg S , et al . Optimi za tion of tidal v olu mes giv en wi th se lf -inf la tab le bags without add itional oxygen during s imulated bas ic l ife support. Res usci tation 2000;43:195198 . [Cross Ref] [Med li ne Link ] 60. Dev i tt J H, B rook s DA , Oak ley PA , e t al . Mask lung v enti lation b y a mbulanc e personnel : a perfo rmance ass essment. Can J Anaes th 1994;41:111115 . [Med li ne Link ] 61. Barnes TA , S toc k wel l DL. E v aluatio n of ten ma nual res usc itators ac ross an operati onal tempera ture ra nge of -18C to 50C. Resp ir Ca re 199 1;36:161172. [Med li ne Link ] 62. Conno rs R, K iss on N, Tiff in N, et al . An ev alu ati on of the ph ysical and func ti onal charac teris tics of infant res usc i tators . Pedi atr Emerg Care 19 93;9:104 107. [Cross Ref] [Med li ne Link ] 63. Oliv er JJ , Pope R. Potential hazard, wi th s i lic one resusc itators . Ana es thes ia 1984;39:933934. [Cross Ref] [Med li ne Link ] 64. Anonymous . Mis ma ting of L aerdal exhalatio n div erters and Inte rtech mas ks. Tec hnol Anes th 1988;8:1 2. 65. Anonymous . Inspi ron disposable ad ul t manual pulmona ry resus c i tators . Technol Anes th 1 987;8:23. 66. Fre eman G, Hann al lah M. S ev ere hypoventi la tion resul ting f rom imp roper us e o f a disposable manual resus c itator. J Clin Anes th 1995;7:267. [Cross Ref] [Med li ne Link ] 67. Kain Z N, Berde CB , B en jamin PK , e t al . P erformanc e o f pediatric resus ci tation bags ass essed with an infan t lung s imu la tor. A nes th A nalg 1 993;77:261264. [Med li ne Link ] 68. Joha nnigman JA , B ranson RD, Dav is K , et al . Techniques of emergenc y v enti lation : a model to ev aluate tidal v olume , ai rway p res sure, an d gas tric i nsuff lation. J Trauma 1991;31:939 8. [Cross Ref] [Med li ne Link ]

69. Anonymous . Occluded tub ing c oul d l imit res usci tato r's ox ygen flow. B iome d Safe S ta nd 1994;24:1 711 72. 70. Anonymous . Damage to oxygen tubing leads to recal l of hyperinf la ti on sets , resus ci tator. B iomed Saf e S ta nd 1999 ;29 :77 . 71. Anonymous . Res usci ta tors , pulmonary, manual , dis pos able. Technol Anesth 1990;11:910 . 72. Thomps on A C, W i lde r BJ , P o wner DJ . Beds id e res usci tation ba gs : a so urc e of bac te rial c ontamin ati on . In fec t Contro l 1985;6 :23123 2. [Med li ne Link ] 73. Harts tein A I, Rasha d AL , Li ebler J M, et al . Mul ti pl e in tens iv e care uni t outbreak of A cin etobac ter c olcoac etic us subspec ies a nitratus res piratory i nfec tion and co lon ization as soc iated wi th co ntamin ated, reusable v entil ator ci rcui ts and resus ci tati on bags . A m J Me d 1988;85:624 631 . [Cross Ref] [Med li ne Link ] 74. Weber DJ , W ilson MB , Ru tala W A , et al. Ma nual v entilati on bags as a s ourc e for bac te rial co lonization of in tubated p atien ts . Am Rev R esp Dis 1 990;142:892 894. [Med li ne Link ] 75. Anonymous . Res usci ta tors , pulmonary manual . Tec hno l Anes th 19 85;7:11. 76. Anonymous . Reus able manual pulmonary re susc itators . Tec hnol Anes th 1998;19:6. 77. Martel l RJ , Soder CM. Laerdal infant res usc itators are unrel iab le as f re e-f low ox ygen de liv ery dev ic es . Am J P erinatol 199 7;14:347351. [Med li ne Link ] P .295

Questions
For the fol lowing ques tion, s elec t the c orrec t ans wer. 1. Wha t determines the maximum minu te volume delivere d from a res uscita tion device? The rate of ox ygen f low i nto the bag The rate a t whi ch th e bag re infl ates The s ize of the oxygen res erv oi r

The rate a t whi ch th e bag is s quee zed V iew A ns we rFo r the follo win g questions , ans we r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

2. Measures tha t can increase the concentration of oxygen de livered from a re susc itation bag include Inc reas ing the oxy gen f low Low mi nute v olume Additio n of a res erv oi r to the in le t A lo wer I:E ra ti o V iew A ns we r3. P roblems w ith delivering oxyg en directly into the re susc itation bag include Diff ic ul ty attaining h igh ox yge n c onc entrations Non reb rea thi ng v alv e loc ki ng in the inspi ratory pos i tion Exc ess iv e p res sure Inabil ity to de liv er adequate ti dal v olume becaus e the flowmeter can only deliv e r up to 15 L /minute V iew A ns we r4. Characte ristics of a n o pen reservoir include Ox ygen flows into the rese rv o ir during i nspirati on If the tidal v olu me is high, air ma y be added to the gases e nte ring th e res usci tation bag Ox ygen enters the bag from the resev oir during exhal ation A mbi ent air can make up defic ienc ies in ox ygen v olume duri ng inhal ation V iew A ns we r5. Characte ristics of the closed reservoir inc lude A v alv e to l et in ambient air A v alv e to v ent exces s gases from the reserv oi r The pres ence of a b ag A v alv e to p rov ide wa rni ng of excess oxy gen press ure V iew A ns we r6. Wh at minimum o xyge n c oncen tration must a re susc itation bag be ca pable of delivering? Forty perc ent wi th u p to 15 L/minute ox ygen f low

One hu ndred percent if the reserv oi r is smal le r than the tidal v olume E ighty-fiv e percent wi th the addi tion of a res erv oir Ni nety percent if the reserv oi r i s larger than the tidal v olume V iew A ns we r7. Benefits of manua lly res trictin g refill of the resuscitation bag include A lo wer f low of ox ygen may be us ed A res erv oi r may not be need ed to deliv er high ox ygen c onc entrations Hi gher ox ygen concentra tion wi ll be d el iv ere d Hi gher minu te v olume can be achiev ed V iew A ns we r8. S ituations that c an res ult in hig h a irw ay pressure include Non reb rea thi ng v alv e s tick ing i n the expi ratory pos i tion Hi gh ox ygen i nflow K ink ing of the res erv oi r tail Us e of a demand v alv e as the pa tient exha les V iew A ns we r9. Causes of hypoventilation w hen us ing a manua l re susc itato r inc lude Inc omp lete clos u re of the exp iratory port Low temperature Ven ti ng th rough the p res sure reli ef dev ic e No aux ili ary ai r i ntake V iew A ns we r10 . T he ASTM standard on resuscitators includes the follow ing provisions concernin g p ress ure limiting devices : In adul ts , if the ov erride mechanism c an be locked, i t mus t b e des igned s o tha t the operati ng mode is readil y apparent to the us er For infant and c hi ld res usc i tators , a dev ice wi th an openi ng press ure of 45 cm H 2 O Optio nal ov erride fo r in fant and c hild resusc itators For adul ts , a dev ice wi th an openi ng press ure of 50 cm H 2 O V iew A ns we r11 . Haza rds associated w ith u se of a manual resu scitator include Barotrau ma Inhalation of fo reign s ubs tanc es Deliv ery of low o x ygen conc entrati ons Hyperv entil ation V iew A ns we r12 . What techniques a re use ful to inc rease the tida l volume delivered fro m a manua l res uscita tor? Two -handed technique

S lowed bag expans ion Compres s ion agains t a s ol id s u rf ace Us ing the res usc itator at l ow te mperatu res V iew A ns we r13 . Whic h of the follow ing are associated w ith retarding re susc itating bag ex pansion? Inc rease d minu te v olume Dec reased respi ra tory ra te Ac tiv ation of th e p res sure limiting dev ic e ma y inc rease the ins pired ox ygen conc en tration The nonrebreathing v alv e may j am V iew A ns we r14 . Conce rning spon taneous re spiratio n through a ma nual re susc itato r, A wid e v ariation in ox ygen c oncentration ma y occu r Fishmouth v alv es are assoc ia te d wi th a high er inspi red ox yg en conc entra tion Roo m ai r may be ins pired th rough the exhalatio n port The bag inlet v alv e wi ll j am V iew A ns we r15 . A d ecreased inspire d oxyge n c oncen tration may be caused by A smal l reserv oi r Low temperature A v alv e defec t Sponta neous v entilati on V iew A ns we r

Chapter 11 Humidification Equipment

General Considerations Terminology
Humidi ty is a general term used to desc ribe the amount of water v ap or in a gas . It may be ex pressed s ev eral ways .

Absolute Humidity
Abs olute humidi ty is the mass of wate r v apo r presen t in a v olume of gas . It is co mmonl y express ed in mill igrams of water per li te r of gas .

Humidity at Saturation
The max imu m amount of wate r v apo r that a v olume of gas can ho ld is the humid ity at s atura tion. This wi l l v ary P .297 wi th the tempera tu re. The warme r the tempe rature, the more water v apor c an be held i n a gas . Table 1 1.1 s hows the abso lute humidi ty of s aturate d gas at v a rious temperatures . A t a body te mpera ture of 37 C, i t is 44 mg H 2 O/L.

TABLE 11.1 Water Vapor Pressure and Absolute Humidity in Moisture-saturated Gas Temperature Cmg H2O/L mm Hg 0 4.84 4.58

1 2

5.19 5.56

4.93 5.29

3 4

5.95 6.36

5.69 6.10

5 6 7 8 9

6.80 7.26 7.75 8.27 8.81

6.54 7.01 7.51 8.05 8.61

10 11

9.40 10.01

9.21 9.84

12 13 14 15 16

10.66 11.33 12.07 12.82 13.62

10.52 11.23 11.99 12.79 13.63

17 18

14.47 15.35

14.53 15.48

19

16.30

16.48

20 21 22 23 24

17.28 18.33 19.41 20.57 21.76

17.54 18.65 19.83 21.07 22.38

25 26

23.04 24.35

23.76 25.21

27 28 29 30 31

25.75 27.19 28.74 30.32 32.01

26.74 28.35 30.04 31.82 33.70

32 33

33.79 35.59

35.66 37.73

34

37.54

39.90

35 36 37 38 39

39.57 41.53 43.85 46.16 48.58

42.18 44.56 47.07 49.69 52.44

40 41

51.03 53.66

55.32 58.34

42

56.40

61.50

Relative Humidity
Relativ e humi dity, or perc en t saturati on , is the amount of wa ter v apo r at a partic ula r tempera tu re exp res sed as a pe rce ntage of the amoun t that wou ld be he ld i f th e gas were s atura ted .

Water Vapor Pressure

Humidi ty may als o be expressed as the p res sure exerted b y wate r v apor i n a gas mix tu re. Tabl e 11.1 shows the v apor press ure of water i n s atu rated gas a t v arious temperatures .

Inter-relationships
If a gas saturated with water v apor is heated, its capaci ty to h ol d mo is ture i nc reas es and i t bec omes uns atu rated (has <100% relativ e h umid ity). Its abs olu te humidi ty remains unchan ged. Gas tha t is 1 00% satura ted at room temperature and warmed to body te mperatu re wi thout additional humidi ty wi ll abso rb water by

ev aporation f ro m the s urface of the respi ratory trac t muc osa unti l i t becomes sa turated. If gas sa turated wi th water v apor is c oo led , it wil l c ondense (rain out) water. T he absol ute h umid ity wil l fall, but the relativ e humi di ty wi ll remain at 1 00%. If inspi red gas is to hav e a rela tiv e hu midi ty o f 100 % at b ody temperature , it mus t be maintai ned at body temperatu re af te r leav ing the h umidifi er or heated abov e body tempera ture at the humi difier an d all owe d to coo l as i t flows to the pa ti ent. Coo li ng wi ll res ult in condensation (ra in out) i n the breathing sys tem. The s pecif ic heat of gas is l ow. As a consequenc e, i t quick ly as sumes the temperature of the su rround ing env i ro nment. Inhaled gas es quick ly ap pro ach bo dy temperature , and gases in c orruga ted tubes rap idl y app roach room temperature. The heat of v apo ri zation of water is relativ el y high. Ev aporation of wate r, therefore , requi res cons iderably more hea t tha n warming of g ases . Likewi se , c ond ens ation of water y iel ds more heat than c ool in g of gas es .

Considerations for Anesthesia

W ater is intentional l y remov ed from medical g ases s o tha t gas es deliv ere d f rom the anes thes ia mach ine a re dry and at room tempera ture. A s gases f low to th e a lv eol i, i nspi red gas is brought to body tempe rature (ei ther by heating or cool ing) and 100% rela tiv e humi di ty (ei th er by ev aporatio n o r condens ati on). In the unintubated pati ent, the uppe r res pi ratory trac t (espec ial ly the nos e) func tions as the princ ipa l heat and mois ture exchange r (HME ). Durin g n orma l nas al breathing, the temperature in the upper tra chea is between 30 C and 33C, wi th a P .298 rela tiv e humi di ty of approx imatel y 98%, prov idi ng a water c ontent of 33 mg /L (1). Trac heal tubes and supraglottic ai rway dev ices bypass the upper a irway, modifying the patte rn of heat and mo is ture exc hange s o tha t the tracheobronchial muc os a mus t ass ume a g rea ter role in heating an d h umid if yi ng gas es .

Effects of Inhaling Dry Gases

The importance of h umid ification in anes thes ia rema ins uncertain . It is of g rea tes t benef it in ped iatric patients , pa tients at inc reas ed risk for dev el oping pulmona ry co mplica tions , and l ong proce dures .

Damage to the Respiratory Tract

As the res pi ratory mucos a d ri es and i ts tempe rature d rops , sec retions thicken, c il iary func tion is reduc ed, s urfac tant ac tiv ity is i mpai red, and the muc osa bec omes more s usc eptib le to i nj ury (2,3). If sec retions are n ot cl eared, ate lec tas is o r ai rway obs truc tion can resul t. Thickened plugs may p rov ide loc i for infec tion. Dry gas es can c aus e b ronchoc ons tric tion, furthe r compromis ing respi ratory func tion. Humidifying g ases may dec rease the inci denc e of respi ra tory comp lic ati ons (c oughin g and breath holding) as soc iated wi th an inhalation induc tion (4,5). The re is no agreement abou t the minimum humi dity nec ess ary to prev ent patho log ic al changes . Rec ommendations hav e ranged f ro m 12 to 44 mg H 2 O/L absol ute h umid ity (2,3,6,7,8 ,9 ). Th e dura tion of expos ure is important. It is unlike ly that a brief exposure to dry gas es wil l da mage the trac heobronc hial tree. As time i nc reas es , the like lihood tha t si gnifica nt trac heob ronchial da mage wi ll become greater.

Body Heat Loss

Bod y tempe rature is l owered as the ai rway s bri ng the ins pi red gas into th erma l equil ibri um and sa turate it wi th wate r. Th e use of a humidif ica tion dev ic e can dec reas e the heat l os s tha t occ urs du ri ng anes thes ia and may prov ide some heat i nput (10 ,11 ,12 ,13 ,1 4,15,16,1 7). Contro lling i ns pi red gas tempe rature and humidi ty i s not an ef fic ien t method of maintaining body temperature. Means to inc reas e body temperature are discus sed in Chapter 31.

Absorbent Desiccation
The effec ts of dry abso rbent on the composi ti on of i ns pired gases are dis cus sed i n Chapte r 9. W hi le HMEs prese rv e p atien t heat and humidi ty , they also may contri bute to abs orbent des icca ti on (18).

Tracheal Tube Obstruction

Thick ened s ec retions i n a tracheal tube inc reas e i ts res is tance and c an res ult in co mple te obs truc tion (19 ,2 0,21,22,2 3,24).

Consequences of Excessive Humidity

An inc reas ed wate r load c an cause c i liary degeneration and paralysis , pulmonary edema, al tered alv eol ar-arterial ox ygen gradien t, dec rease d v ital c apac ity and co mpliance, and a dec rease in hematoc ri t and se rum sodiu m (25).

Sources of Humidity Carbon Dioxide Absorbent

The reac tion of absorben t with carbon diox ide l iberates wate r (Cha pter 9). Wa te r is also co nta ined in the abso rbe nt granu les . Si nce the reac tion is exo the rmic , he at is produced. If the abs orbent granu les desicc ate , they may reac t wi th c ertai n anes thetic s and produc e ex treme heat. This i s discussed in detail in Chapter 9.

Exhaled Gases
The re is some rebreath in g i n the trac heal tube, the s upraglottic a irway dev ic e, and the conn ec tions to the breathing s ys tem. A lmos t half of the humidi ty in expired gas i s preserv ed in this manne r (2 6). In s ys tems that all ow reb rea thi ng of exhaled gases (Chapter 8 ), the humi di ty and temperature of the i nsp ired gas es depend on the relativ e p rop ortions of f resh and ex pired gases . This wil l depend on the s ys tem and the fres h gas flow. A s the f res h gas fl ow i s inc reased, the inspi red tempe rature and humidi ty are reduc ed. Use of the sys tem by a prev ious pa ti ent wil l i nc reas e the humidi ty .

Moistening the Breathing Tubes and Reservoir Bag

Ri nsing the ins id e of the breathing tubes a nd reserv oi r bag wi th wa ter befo re us e i nc reas es the i nspired humi di ty (27).

Low Fresh Gas Flows

Us ing l ow fresh gas f lows wi th a ci rcl e breathing sys tem wi ll c ons erv e mois ture. This is d is cus sed in mo re detail i n Chapter 9.

Coaxial Breathing Circuits

Coax ial ci rc le sys tems , wh en c ombined wi th l ow fl ows , wi ll i nc rease the h umid ity more quickl y than a s ys tem with two s eparate l imbs (2), bu t th is is not v ery eff ic ien t i n terms of hea t or hu midi ty improv ement (28). The B ain s ystem (see Chapter 8) is a coax ial v ersi on of the Mapleso n D . It does not meet optimal P .299 humidific a ti on requi rements bec ause of the high fresh gas flow re qui red (26).

Heat and Moisture Exchangers

An HME cons erv es some ex haled water and h eat a nd returns them to the patien t in the inspi red gas . Man y HMEs als o perform b ac terial /v iral f i ltra ti on and prev ent i nhalation of s mall pa rtic les . The HME is als o known as a co ndens er h umid if ie r, S wed is h n ose, arti fic ial nose, nos e humi difier, passiv e humidifier, re gene rativ e

humidifier, mois ture excha nger, and v apor c ondens e r. W hen c ombined wi th a fi l te r for bac te ria and v i rus es , i t is cal led a heat a nd mois tu re ex chan ging filter (HME F). Two i nternational s tand ards on HME s h av e been publis hed (29,30).

Description
HMEs are dis pos able dev ices wi th the ex changing medium enc losed in a plas tic housi ng. They v ary in s iz e and shap e. Ty pic al ones are s hown i n Figure 11 .1. Each has a 15 -mm fema le connec tion port at the pa ti ent e nd and a 15-mm male port at the oth er end. The pa tient port may also hav e a concen tric 22-mm male fi ttin g (Fig .11 .1C,D). There may be a port to attach the gas sampling l ine for a respi rato ry gas monitor (Fig. 11 .1B ,D) or an ox ygen line. One type uti lizes a ceramic heating elemen t with a wate r in put p ort, a membrane, and an alumi num grid that v aporizes the water (3 1). The dead space of HMEs v aries . Pediatric and neonatal HMEs wi th l ow dead s pace are av ai lable (32 ,33 ). Mos t mode rn HMEs are one of two ty pes , as shown i n Table 11.2.

Hydrophobic
Hyd rophobic HMEs hav e a h ydrophobic memb rane with smal l pores . The membrane i s pleated to inc rease the surface area. A pleated hy drophobic membrane prov ides mode ratel y good ins pired humidi ty . The pe rformance of this type of HME may be i mpai red by h igh ambie nt temperatures (1,21). Hyd rophobic HMEs are eff ic ie nt bacte rial and v iral f ilters (34,35 ,36 ,37 ,38 ,3 9). A pleated hy drophobic f il te r wi ll c onsis tentl y prev ent the hepatitis C v i rus from passing whi le a hygroscop ic fil ter may be inef fec tiv e (40). The y a ll ow th e p ass age of wa te r v apo r but not l iquid wa ter a t usual v enti lato ry press ures (34 ,36 ). They are as soc iated wi th s mall inc reas es in res is tance ev en wh en wet (12,41,42).

Hygroscopic
Hyg ros copic HMEs co nta in a wool , foam, o r pape rl ik e ma teri al coate d with mois ture -retain ing c hemicals . T he medium ma y be impregnated with a bac teric ide (43). Compos ite hygros copic HMEs cons is t of a hygroscopic layer plus a la yer of thin , non wov en f iber membrane that has been s ubjec ted to a n e lec trical f ield to i nc reas e i ts polari ty. This imp rov es fi l tration e ffic ienc y and h ydrophobic ity. Mos t s tudies hav e s hown that c ompos ite hygrosc opic HMEs are more effici ent a t mois ture and tempera ture conserv ation than hydropho bic ones (1,22,44,45,46,47,48,49,50,51,52,53). They wil l l ose thei r ai rborne f i ltra ti on

ef fic ienc y if they become wet, and mic roorganis ms held b y the f il te r medium can be was hed through the dev ice. Thei r res is tance c an inc rease greatly whe n the y become wet (42).

Indications
An HME can be us ed to inc reas e ins pired hea t and hu midi ty during both short- and l ong-term v en tila ti on. HME s ma y be espec iall y usefu l when transporting intubated pati ents , because trans port v entila tors frequ ently hav e no means f or humid if ying i nspi red gases . An HME can be us ed to su pply s upp le mental ox ygen to an intubated patien t or pati ent wi th a s upragl ottic airway by c onnecti ng ox ygen tubing to the gas s ampling port (54,55,56).

Contraindications
Con traindications inc lude patients with thick , cop io us , or bloody s ec re tions and pati ents with a leak tha t prev en ts ex haled gas f rom trav ers ing the pas siv e humidifier (e.g., bronch opleuralcutaneous fis tula or leak ing or absen t tracheal tube cuff ). HMEs s houl d be used with cauti on when weaning a patient from res piratory support (5 7,58).

Factors Affecting Moisture Output Heat and Moisture Exchanger Type

Composi te hygroscop ic HMEs hav e bette r heat and mois ture ex changing properti es than do hydrophobic ones .

Initial Humidity
Inc reas ing the humidi ty in the gas enteri ng the HME f rom the breathing s ys tem wi ll i nc reas e the inspi red humidi ty (59).

Inspiratory and Expiratory Flows

The f as ter that gas pas ses through the HME , the les s time the re is to ev aporate or depos i t mois ture, s o a la rge tidal v olu me ma y c aus e the humi di ty of the i ns pired gas to fa ll (45,48,59 ,60 ,61 ).

System Continuity
A leak around the trach eal tube wi ll res ul t in dec reased ins pired humidi ty (32,62).

Use
The HME s el ec ted s hould be of an appropriate si ze fo r the patien t's ti dal v olume. If a s mall HME is us ed in a large patie nt, the HME wi ll be i neff ic ie nt (63). Connecting

more tha n one HME in series wil l i mprov e perfo rmance (64 ,6 5). Ca re mus t be taken that the uni ts a re pus hed firmly toge the r and that the inc rease in dead s pace is not P .300 ex cess iv e for that partic ul ar patien t. Added dead s pac e is espec ially important in smal l p ati en ts .

Figure 11.1 Heat and moisture exchangers. A,E: Straight variety. B: Right angle HME with port for aspiration of respiratory gases on the breathing system side. C: The flexible tube attached to the HME extends the distance between the patient and the breathing system and allows the angle between the breathing system and the patient to be altered. Because this HME has significant dead space, it should be used only with high tidal volumes and controlled ventilation with monitoring of inspired and exhaled carbon dioxide. D: Hydrophobic HME with respiratory gas aspiration port. (Pictures C, D, and E courtesy of Gibeck Respiration, Pall Biomedical Products Corp. and ARC Medical Inc.)
View Figure

An HME shou ld be v isible and ac cess ib le at all times in o rde r to de tec t contamina ti on or d isc onn ec tio n. The greates t inspi red rel ativ e humidity occ urs wi th the HME p osi tioned nex t to the trache al tube, mask , o r sup rag lottic ai rway dev ice . Some gas mo ni tors (Chapter 22) a re pa rtic ula rl y sensitiv e to wa ter. If the s ampl ing l ine is on the machine s ide of the HME , the amou nt of mois ture to whi ch the moni tor is exposed wi ll b e reduced . An HME can be us ed with any breathi ng s ys te m. Wi th the Map les on sys tems , dead spac e can b e reduced by P .301 utili zing the gas sampl ing port as the fresh gas inlet (66). Ox ygen ca n be adminis tered through the gas sample port on the HME (55,56). An HME ma y be us ed for patien ts who h av e a trach eos tomy (67).

TABLE 11.2 Comparison of Hygroscopic and Hydrophobic Heat and Moisture Exchangers

Type Heat and moisture exchanging efficiency

Hygroscopic Excellent

Hydrophobic Good

Effect of increased tidal volume on heat and moisture exchange

Slight decrease

Significant decrease

Filtration efficiency when dry Filtration efficiency when wet

Good Poor

Excellent Excellent

Resistance when dry Resistance when wet

Low Significantly increased Greatly increased resistance

Low Slightly increased Little effect

Effect of nebulized medications

An HME may be use d as the so le sourc e of humidi ty o r may be combi ned wi th anoth er sou rc e s uc h as an unheated hu mi dif ier (68 ) but s hould not be used wi th a heate d humidif ier. If a nebu li zer o r mete red -dose in haler (Chapter 7 ) is us ed to deliv er medic ation, i t shoul d be ins erted be twe en the HME and the patient or the HME re mov ed f rom th e c i rc ui t during aerosol treatment. An HME shou ld be replace d i f c ontaminate d with sec retions .

Advantages
HMEs are inex pens iv e, e asy to use, s mall, li ghtwei ght, re liable, s imple in d esign, and s ilent in ope rati on. They hav e low res istance when dry . They do n ot requi re water, an ex ternal s ource of en erg y, a temperature mon itor, or alarms . The re is n o danger of ov erhydra ti on, hyperthermia, s k in or re spi ra tory trac t burns , or elec trical shock . Thei r us e may inc rease th e c orrelation betwe en eso phag eal an d core

temperatures (69). They ac t as a barrie r to large partic les , a nd some are effic ient bac te rial and v iral f i lters , al though thei r role in reduci ng nos ocomial infec tions remains c ontrov ers ial . The y ma y reduce problems caused by hu mi di ty in the breathi ng s ys tem s uch as obs truc tio n of l ines and v en ti lato r mal-f unc tion (70 ).

Disadvantages
The main disadv antage of HMEs is the li mi ted hu midity tha t these dev ic es can deliv er. The ir c ontributi on to temperature prese rv ation is not si gn ific ant. Tempera ture management is discussed in Chap ter 31. Ac tiv e hea ti ng and humidific a ti on are mo re effec tiv e than an HME i n retaining body heat, allev ia ting thic k sec retions , a nd prev en ti ng tracheal tube bloc kage (19,21,22,23,71,72,73,74,75). Th e d iffe rence is more app arent af te r intubation l as ting f or s ev eral d ays . P lac ing an HME between the breathing s ys tem and the patient i nc reas es dead spac e. This ma y necessi ta te an i nc reas e i n ti da l v olume and c an lead to dan gerous rebreathing (76 ). It also inc reases the work of breathing duri ng both ins pi ration and ex hal ation (77).

Hazards Excessive Resistance

The use of an HME inc reases res istanc e, althoug h usual l y it is not a ma jor co mponen t of the to ta l work of breathing (78 ). Res is tance inc reases with use (9,33,35,38,58,78,79,80,81,82,83,84,85,86 ). Heav y v isc ous sec reti ons can g rea tly i nc reas e resis tanc e. A n HME should no t be use d with a heated humidifier, as this can c aus e a dangerous inc reas e in resis tance . Nebuli zed medic ation inc reas es the resis tance of hygrosc opic HMEs (3 4,38). W ith a Mapl eson s ys tem, i nc reas ed res is tance may cause div ers ion of f resh gas down the ex piratory li mb (87,88,89 ). Hi gh resis ta nce may res ul t in s uffic ient back press ure to prev en t the low ai rway press ure alarm f ro m be ing ac tiv a ted if there i s a disconnec ti on between the patient and the HME (90 ,91 ). If inc reased resis tanc e is s uspec ted duri ng control led v entil ati on, the peak p res sure shoul d be meas u red wi th and without the HME i n p lace. S pontaneousl y bre athing pati ents should be observ ed f or s igns o f incre ased wo rk of b rea thing .

Airway Obstruction

An HME can bec ome obs truc ted by f luid, b lo od, s ec retions , a manufac turing defec t, or nebuli zed drugs (18,92,93,94,95,96,97,98 ,99 ,100,1 01,102). Parts ma y become detac hed and bloc k the breathing sys tem (103). The HME 's wei ght ma y caus e the trac heal tube to ki nk . If an HME is us ed for l ong-term v entilation , trac heal tube occlus ion may oc cur (20,21,22,23,24,73).

Inefficient Filtration
Liquid c an break through a hygroscop ic HME , res ulting in poor fil tratio n (34,36). P .302

Foreign Particle Aspiration

Parts of the HME may become detached (64,1 04,105,106 ,1 07). The parts ma y then be i nhaled by the patient.

Rebreathing
The HME dea d s pac e ma y c aus e excessiv e re breathing, es peci al ly wi th s mall ti dal v olumes . Special low-v olume dev ices are av ailab le f or pedia tric s . Ev en thes e smal l dev ic es may be too la rge for infants u nder 1 5 kg (108). HME s s hould not be used for mask v entil ation in smal l infants (109).

Leaks and Disconnections

Adding a n HME to a breathi ng s ys tem inc reas es the potentia l fo r discon nec tions and leak s (18 ,92 ,110,111,112 ).

Hypothermia
Patient wa rmi ng is disc uss ed in Chapte r 31. HMEs a re a means to c ons erv e temperature , but the amou nt of heat p res erv ed by th is method is smal l (15,113,114 ,115).

Dry Carbon Dioxide Absorbent

HMEs wi ll dec reas e the amount of humidity av ailable to the abs orbent. The ex tent to wh ic h HME s wil l l ead to a bsorben t des icc ation is unc lear. T he effec t of dry ca rbon d ioxide abso rbents o n the produc tion of Compoun d A an d c arbon monox ide i s dis cus sed in Chapter 9. In add ition, dry abs orbent wi ll abs orb so me v olati le agents . This can imped e anes the tic induc tion with these agents (18).

Humidifiers

A humidifier (v apo ri zer o r v apori zing humi dif ier) pas ses a s tream of gas ov er water (pass -ov er), ac ros s wic ks di pped i n water (b lo w-by ), o r through wate r (bu bbl e or cascad e). Humidif iers may be h eated or unh eated.

Unheated
Mos t unheated humidifi ers a re disposable, b ubble-th rough dev ices that are us ed to i nc reas e the humidi ty i n ox ygen s uppl ied to patients v ia a f ace mask or nasa l cannula. They cannot deliv e r more than ab out 9 mg H 2 O/L.

Heated
Hea ted hu midifie rs incorporate a d ev ice to wa rm the wa ter i n the humidif ier. Some also heat the ins pi ratory tube.

Description
Humidification Chamber
The humid if ic ation c hamber contains th e liquid water. It may be d is posa ble o r reusable . A clear c hamber makes i t eas y to check the wa te r lev el . Some humidifi ers hav e an in teg ral or re mote res e rv oir that s upplies liqu id water to the humid if ication chamber (Fi g. 11.2).

Heat Source
Hea t may be supplied by heated rods immersed in the wa ter o r a pla te at the bottom of th e humidificatio n c hambe r (Fi g. 1 1.3 ).

Inspiratory Tube
The insp iratory tube conv eys humidified gas f rom the humidifier ou tlet to the pati ent. If it is not heated, the gas wil l c ool and los e s ome of i ts mois ture as i t trav els to the p ati en t. This wa ter wil l co llec t in the ins pi ratory tub ing. A water trap wi ll be necessa ry to c oll ec t the c ondensed wa te r. Hea ting or ins ulati ng th e i ns piratory tube allows more p rec is e control of the temperature and humidity del iv ered to the patie nt an d av oids mois ture rainout (116,117 ). A hea ted wi re i ns ide the inspi ra tory tubing is mos t of ten us ed (Fig. 11.3). It should ex te nd as c lose to the pa tient c onnec tion as p ossible. Disposab le wi res in preass embled dispos able bre athing s ys tems are av ail able. A reusable wi re mus t be inserted manual ly i nto the insp iratory tube by us ing a d raw wi re (118). If the gas temperature de liv ered to the pa tient i s set abov e the temperature of the humidific a ti on chamber o utl et, less than 100 % rela tiv e humidi ty wi l l be del iv ered (119,120 ,121,122).

Temperature Monitor(s)
Mos t heated humidifiers hav e a means to measure the gas tempe rature at the pati ent e nd of the breath ing s ys tem. Us ually , th ere are te mperatu re sensors in the water res erv oir o r in contact wi th the hea ter pla te to ac tiv ate alarms and shu t off heate r power when nec ess ary .

Thermostat Servo-controlled Units

A serv o-c on trolled unit automatic all y regul ates powe r to the heati ng element in the humidifier in response to the temperatu re se nsed by a probe near the patie nt connec tion or the humidifi er outlet (123 ,12 4,125). These dev ices are equipped wi th alarms to warn of high temperatu re. Often, there are two the rmos ta ts so that if one fails , the other wil l cu t off th e power b efo re a dangerous te mperatu re is reac hed.

Nonservo-controlled Units
A nons erv o-controlled un it p rov ides power to the heating element ac cording to the se ttin g of a c ontro l, irres pec tiv e of the delivered tempera tu re. It may inc lude a se rv o -co ntrol led ci rc uit, but the s erv o-c ontrol led uni t controls the heater rather than the del iv ered tempera ture (123,1 25).

Controls
Mos t humi difiers a llow te mperatu re selec tion at the end of the d eliv e ry tube or at the humi di fication chamber outlet. Some al low l ess than 100% relativ e humidi ty to be de liv ered. Some models genera te s aturated v apo r onl y at a prese t tempera tu re (8).

Alar ms
A larms may wa rn whe n the temperature at the pa tient end of the c i rc uit dev iates f rom the s et temperature b y a fix ed amoun t, wh en the tempe rature probe is no t in place , when the hea ter wi re is not connec ted, when th e wa te r lev el i n the humidific a ti on chamber is lo w, or whe n the ai rway te mp era tu re probe does not sens e an inc reas e in temperatu re wi thi n a certa in time af te r the h umid ifie r is turned ON. A low tempe rature a la rm wil l help to detec t problems wi th the hea ter element. It P .303 also may be the means of detec ting lac k of gas fl ow in the c i rcu it (126 ).

Figure 11.2 Heated humidifier with separate water reservoir. (Picture courtesy of Hudson RCI.)

View Figure

Action
Some humidif iers hea t the gas to a temperature ex ceed ing the desired pa tient ai rwa y temp era ture (s uperheating) s o that the c ooling that occu rs as i t f lows to th e pati ent wi l l res ul t i n the des ired temperature at the pa tient connec tion. Coo ling in the tub e wil l resul t in wate r ra ining ou t in the tube. In other hu mi dif iers , temperature inc reas es as i t pass es th rou gh th e i ns piratory tube s o tha t gas wi th l ess than 100 % relativ e humidi ty is del iv ered.

Figure 11.3 Heated humidifier. Heat is supplied from a heated plate below the humidification chamber. The heating wire at the left fits inside the delivery tube.

View Figure

If the d eliv e ry tube is not heate d, the tempera ture wil l d rop as i t flows to the pati ent. The magnitud e of the d rop depends on many fac tors , incl uding ambient temperature ; gas f lo w; and the length, diameter, and thermal mass of th e b rea thi ng s ys tem. Cool ing can be reduc ed by sho rtening or i nsula ti ng the del iv ery tube or b y us ing higher i nspi rato ry f lows . If the g as is s atu rated at the humidifier outlet, the temperature drop wi ll c aus e wa te r v apo r c on dens ation (rainou t) to occ ur. A water trap wi ll be nec essa ry to c ol lec t the condensed wate r.

Standard Requirements
An inte rna tional and a U.S . s tanda rd on humidif iers hav e been pub lished (127,1 28). The y contain the fol lo win g p rov is ions . P .304

Humidifiers mus t be c apable of p roduc ing an output of at leas t 10 mg H 2 O/L. Those in tended for us e wi th patien ts whos e supraglottic ai rways hav e been bypass ed mus t be c apab le of producing an ou tpu t of at leas t 33 mg H 2 O/L.

The av erage temperatu re at the deliv ery tube outle t shal l n ot f luc tuate by more tha n 2 C from the se t temperatu re af te r a s ta te of thermal equilibrium has been es tablishe d foll owin g a c hange in gas flo w o r set tempe rature. If the measu red gas tempera ture diff ers f rom the set tempe rature by more than the range s pecifi ed by the manuf ac turer, an ala rm mus t b e ac tiv ated.

The v olu me of liquid ex iting the hu midif ie r shal l no t exc eed 1 mL/minu te or 20 mL/hou r for humidifi ers intende d for use wi th neonates or 5 mL/minute or 20 mL/hou r for all oth er humidifiers .

If the h umid if ie r is h eated, the gas tempe rature a t the deliv e ry tube outl et shall not exceed 41C or the gas tempe rature a t the humidif ier outlet s hall be i ndicated continuous ly and the temp era tu re-meas uri ng dev ic e shal l ac tiv ate an alarm wh en the temperature excee ds 41C. The hu midif ie r shal l i nterrupt heating whe n the meas ured gas temperatu re ex ceeds 41C.

The acces sible s urfac e tempe rature of the d el iv ery tube mus t not exceed 44C within 25 cm of th e patien t con nec ti on port. W hen the humidifi er is til ted 20 from its normal ope rati ng pos itio n, there shall be no water sp illed into the b rea thing s ys tem.

A ll c alibrated c ontro ls an d ind ica to rs sha ll be accu rate to wi thin 5% of thei r full -scale v alues , ex cept for tempe rature dis plays and c ontro ls . The meas ured gas temperatu re sh all be acc ura te to 2C.

The direc tion of flow mus t be mark ed on humidifiers with flow-di rec tion sens i tiv e components .

Use
In the c i rc le s ys tem, a hea ted humidif ie r is plac ed in the inspi ra tory li mb downs trea m of the unidirec tional v alv e by us ing an ac ces sory breath ing tube . A heate d humidif ier mus t not be plac ed in the exp iratory l imb (129,130 ). If a fi l ter is us ed in the breathin g s ys tem, i t mus t be placed ups trea m of the hu midifie r to prev ent i t from becoming c logged. In Maples on s ys tems (Chapter 8), the h umid if ie r is usuall y placed in the f res h gas suppl y tube (131 ,132). Us ing a large-diameter tubi ng and plac ing the humidifier near the end of the tube wil l dec rease condensation. The deliv e ry tube temperatu re probe may be plac ed ei the r between the fresh gas supp ly tube and the T-piece or between the T-piec e an d the patient. The humid if ie r mus t be lowe r than the pa tient to av oid the risk of wate r running down the tubing in to the patie nt. The condens ate mus t be drained periodical ly o r a water tra p i ns erted i n the mos t depe nden t part of the tubing to prev ent block age or as piration. The heater wi re i n the deliv ery tube should no t be bunched , but s trung ev enl y along the length of the tube . The de liv ery tube should no t res t on other s urfac es or be cov ered with sheets , blank ets , or other ma teri als . A boom arm or tube tre e ma y be us ed for support (133 ).

Advantages
Mos t heated humidifiers are c apable of deliv eri ng sa turated gas at body temperature or abov e, ev en with hig h flow rates . A h eated humi difier can produce more effec tiv e humidification than an HME (74,134 ). S ome (but not all ) can be us ed for spo ntaneous l y breath in g and tracheotomiz ed patients (67).

Disadvantages
Humidifiers are bu lk y and s ome what c omplex . These dev ices i nv olv e high mai ntenance cos ts , elec tric al haza rds , and inc reas ed work (temperatu re control , refil ling the res erv oi r, draining c ondens ate , c lean ing , and s teril ization). Thei r use is as soc iated wi th highe r cos ts than HMEs .

Compa red wi th c irculating wate r and f orc ed-ai r warmi ng (Chapter 3 1), the heated humidifier offers relativ ely li ttle protec tion agai ns t heat los s durin g anes thes ia (135).

Hazards
Infection
Bac terial growth can occ ur in wate r s tore d in a res erv oi r or the condens ate in the deliv ery tube. The use of a hea ted c ircui t reduc es the amount of condens ate, whi ch may reduc e the infec tio n ris k .

Breathing Sys tem Problems

Reported breathing s ys tem probl ems incl ude s ticki ng v alv es, leaks , disconnec ti ons , i ncorrec t c onnec tions , obs truc ted f res h gas li ne or i ns pi ratory l imb, no is e, and c logg ed fi l ters and HMEs (136,137 ,13 8,139,140 ,141). The deliv e ry tubi ng may mel t, resu lting in an obs truc ti on or l eak (118,142 ,143,144,145,146,147,148,149 ,150). Fires hav e been repo rted (123,151 ,152). A c harred breathing s ys te m may res ul t in fumes enteri ng the pati ent's lungs . Ov erheating of bre ath ing c ircui ts with me lting may be caused by defec ts in or damage to the heated wi re; bunc hin g of the heated-wi re coi ls within the breathing s ys tem; el ec tric al i ncompatibil ity between the hea ted -wi re breathing c i rc ui t and the humi di fier (153); opera ting th e dev ice ou tside the spec ifi ed range of f lows o r minute v olumes ; or cov e ring the del iv ery tube wi th sheets , blankets , or other ma terials (133 ,144,147). P roblems may occ ur if a c ircui t that is not from the humidifier manufac turer is used. E lec tric al c onnec tors for he ated-wi re c ircui ts tha t are phys ic al ly c ompatibl e may not be elec tricall y interchangeable (133). W hen v enti lation is in terrupted, as wh en cardi ac bypass is begun , the humid if ier s hould be turned OFF. W i thout a gas a ir f lo w, th e temperature at the patie nt end wi l l drop and the hea ti ng element may inc rease i ts ou tpu t, c ausing the attac hed breathing c i rc ui t to mel t. P .305

Adding a humidif ie r may c hange the b rea thing sys tem v olume and complianc e s ignif ic antly (154). This ca n result i n l ess ac curate s mall tidal v olume del iv ery . Ven ti la to rs that ca lc ulate the s ys te m complianc e and gas c ompression mus t perform thei r c hec kou t proc edu re wi th the humi difier i n place s ince the humidifier can affec t v entil ator accuracy .

Water Aspira tion

The re is danger of l iquid wate r enteri ng the trachea and drowni ng the patie nt or caus ing a burn in the res piratory trac t. Thes e risks c an be dec reas ed by i ns tal ling a water tra p i n both the ins piratory and exha la tion si des i n the mos t dep ende nt portion of the b rea thi ng tube, draining c ondensate frequentl y, and plac ing the humidifier and breathing tubes below th e pati en t.

Overhydration
A heated hu midi fier can produc e a p osi tiv e water b ala nce an d ev en ov erh ydration . A l though mos t anes th etics a re of s uff iciently short durati on that this is no t a s ignif ic ant probl em, i t c an be a p rob lem wi th inf ants .

Thermal Injury
Deliv ering ov erheated gases into the trachea c an cause hyperthe rmia or damage to the tissues lining the trac heobronc hial tree. Sk in burns hav e been re ported f ro m adminis tering heated oxy gen nas ally and wh en continuous posi tiv e airway press ure was de liv ered (125,155 ,156). Burns can also oc cur whe n tissue is in c ontac t with heate d b rea thing ci rcui ts (157,158). Ov e rheati ng inspi red gas may be c ause d b y omitti ng , mis plac ing, d islodging, or not full y i nserting the ai rwa y tempe rature pro be or by turn ing the humi difier ON wi th a l ow gas flow (123,155 ,156,159). A tempo rary inc rease in ins pi red gas tempera ture may oc cur follo wing a pe ri od of i nterrupted f low or a n inc reased f lo w rate (160 ).

Increased Work of Breathing

A heated hu midi fier inc reases resis tanc e (26,161 ,162). Mos t c anno t be used wi th spontaneous l y breathin g patien ts .

Monitoring Interference
A humidifier may add enough res is tance to prev ent a low a ir way press ure alarm f rom being ac tiv ated if th e s ens or is ups trea m of the humidifie r (91 ). S ome fl ow sens ors are a ffec ted by condensatio n, produc ing a false pos itiv e alarm (1 63). P ress ure an d f low monitoring are disc ussed in Cha pte r 23. Hi gh humidi ty c an caus e p rob lems wi th s ides tream (asp irating ) res pi ratory gas moni tors (Chap ter 22).

Altered Anesthetic Agents

Halothane may be altered if i t passes throug h a humidifie r whos e heating e lement i s in di rec t c ontac t wi th the gas at a tempe rature of 68C or higher (16 4).

Equipment Damage or Malfunction

Ven ti la to rs are s ens itiv e to rainout c aused b y wate r con dens ati on. S igns inc lude i nc reas ed res is tance to ex hal ation, inacc ura te press ure and v olume measu rements , autoc ycl ing, and v entil ator s hutdown (70,165). In o rde r to prev ent thes e problems , a water trap s hould be use d i f water is likely to c ondense in the b rea thi ng s ys tem. These nee d to be inspec ted regu la rl y and empti ed as needed. The humi difier needs to be lowe r th an the pa tient and v en til ato r.

Nebulizers
Description
A nebu li zer (ae ros ol generato r, a tomi zer, ne buliz ing humid if ier) e mits water in the form of an aerosol mis t (water v apor plus pa rtic ul ate water) (1 66). The mos t co mmonl y used are the pneumatic al ly d riv en (gas -driv en, jet, high pressu re, co mp res sed gas ) and u ltrasonic nebulize rs . B oth c an be hea ted . In addi tion to prov iding humidifica tion, nebul i zers may be use d to deliv er drugs to the b rea thing s ys tem. A pneu matic nebulizer works by pus hing a jet of high-pressu re gas i nto a l iquid, i nduc in g s heari ng forces and bre aking the wate r up in to f ine partic les . A n ul tras onic nebuliz er produc es a fine mis t by su bjecting the liqu id to a h igh-f requenc y, elec tric all y driv en ultrason ic res onator. The frequenc y of osci lla ti on determines the s ize of the droplets . Th ere is no need f or a driv in g gas . Ul tras onic nebuli ze rs c reate a denser mis t than pneumatic ones (1 24).

Use
Bec ause a hi gh f lo w of gas must be used wi th a pn eumatic nebul i zer, it shou ld be place d in the fresh gas l ine. An ul tras onic nebuli ze r can be us ed in the fresh gas l ine o r the i nspiratory l imb.

Hazards
Nebuli zed d rugs may obs truct an HME or f ilter i n the breathi ng s ys tem (95,96,167). Ov e rhydatio n c an occ ur. If the dropl ets a re not warmed, hy pothermia may resul t. Infec tion c an be trans mi tted because mic roo rga nis ms can be suspen ded in the water droplets . The re are rep orted cases where a nebuli zer was connec ted di rec tl y to a trac hea l tube wi thout prov is ion f or exhalation (168). In one c ase , th is resu lted in a pneumothorax .

Advantages

Nebuli ze rs ca n del iv er gas es saturated with wate r withou t hea t and, if des i re d, can produce gas es carrying more water.

Disadvantages
Nebuli ze rs are s omewh at cos tl y. Pneuma tic nebu lizers requi re high gas f lows . Ul traso nic n ebul izers req uire a s ourc e of elec tric ity and may p res ent el ec tric al hazards . There may be c ons ide rable water depos i tion in the tubings , requi ring f requent d raining, wate r traps i n both the i nsp iratory and exha lation tubes, and posin g the dangers of water d raining into the patient or blocking the tub ing. P .306

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68. Suzukawa M, Us uda Y, Numata K . The effec ts on spu tum cha rac te ris tic s of co mbining a n unhea ted humid ifie r with a heat-mois ture exc hanging f il ter. Respi r Care 1989 ;34 :97698 4. 69. S iegel MN, Grav ens tein N. Pass iv e warming of airway gas es (a rtif ic ia l nos e) i mprov es ac curac y of esophageal temperature moni toring . J Clin Moni t 1990;6 :89 92. [Med li ne Link ] 70. Cantil lo J , Domsk y R, Gra tz I, et al . Ve nti l ato ry failures wi th the Datex -Ohmeda 7900 S martVen t. Anes thes iol og y 2 002;96:76 676 8. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 71. B is sonnette B , Sessler DI, LaF lamme P . P assiv e and ac tiv e ins pired gas humidific a ti on in infants and children. Anes thes io logy 1989;71 :350354. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 72. B is sonnette B , Sessler DI. Pas s iv e or ac tiv e inspi re d gas humidifica tion i nc reas es the rmal s teady -s tate temperatures in a nes the ti zed i nfants . Anes thes iology 1989;69:783787 . 73. Mis set B , E scudie r B , Riv ara D , et al . Hea t and mois ture exchanger v s heated humidifier during l ong -term mechanical v entil ati on. A prospec tiv e randomiz ed s tudy . Ches t 1991;1 00:160163. [Cross Ref] [Med li ne Link ] 74. Edwards EA , B y rnes CA . Humidification diff ic ul ties i n two tracheostomi zed ch il dren. An aes th In tens Care 1999;27:656658. [Med li ne Link ] 75. Nakagawa NK , Mac chi one M, Pe trol ino HM, e t al . Effec ts of a heat and mo is ture ex changer and a heated humidifi er on respirato ry muc us in pa tients und erg oing mechanical v enti la tion. Cri t Care Med 2000;28:312317 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 76. Mas on DG, E dmonds on L, McHu gh P . Humi difier-i nduced hyperc arbia . Anaes thes ia 1987;42:672 673.

[Cross Ref] 77. Nis himu ra M, Mi shi ji ma MK , Okada T, et a l. Co mparis on of f low-res is tiv e wo rk l oad due to humidifyi ng dev ices . Ches t 1990 ;97 :600604. [Cross Ref] [Med li ne Link ] P .307

78. Johns on PA , Raper RF , Fisher MM. T he impac t of heat and mois tu re ex changing humidifiers on wo rk of b rea th ing . Anaes th Intens Care 1995 ;23:697 701. [Med li ne Link ] 79. P lo ysongs ang Y, B ranson R, Rashk in MC, e t al . P ressure flow c ha rac te ris tic s of co mmonl y used he at-mois ture ex changers . A m Rev Res pir Dis 19 88;138:675678 . [Med li ne Link ] 80. P lo ysongs ang Y, B ranson RD, Ras hk in MC, e t al . Effec t of f lo wrate and duratio n of use on the press ure drop ac ros s s ix a rtif ic ial nos es . Respi r Care 1989;34:902907. 81. Manthous CA , Schmidt GA . Resis tiv e p res sure of a con dens er humidifi er in mechanical ly v entilated pa tients . Crit Care Med 1994;22:17921795. [Med li ne Link ] 82. Cos tigan S N, S no wdon S L. B rea thi ng s ys tem f ilters c an affec t the performanc e of anaes thetic moni to rs . Anaes thes ia 1993 ;48 :10151016. [Med li ne Link ] 83. Chi ara nda M, Verona L, Pin amonti O, et a l. Use of heat and mois ture ex changing (HME ) fil ters in mechanical ly v entilated ICU pa ti ents : inf lu ence on ai rwa y flow- res is tance. Intens iv e Ca re Med 1993;19:462466. [Cross Ref] [Med li ne Link ] 84. Marti nez FJ , P ie tch el S , W ise C, et al. Inc reased resis tance of hygros copic condenser humidifie rs when usi ng a c losed c i rc ui t suc tion s ys te m. Cri t Care Med 1994;22:1668167 3. [Med li ne Link ] 85. Schu mann W , Schumann CM, Fuc hs J , e t al . Sudden uppe r ai rway o bs truc ti on due to inv isible rai n-o ut in the he at and mois ture exch ange fil ter. B r J Anaes th 2002;89:335336.

[Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 86. Wilk es AR. The abi li ty of breathi ng s ys tem fil te rs to p rev ent l iquid contamina ti on of b rea thing s ys tems : a laboratory s tudy. Anaes thes ia 2002;57:33 39. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 87. Da Fons eca J MG, W heele r DW , Pook J A R. The effec t of a h eat and mois ture ex changer on gas flow in a Maples on F b rea thi ng s ys tem during inhalational i nduc tion. Anaes thes ia 2000 ;55 :571573. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 88. Godda rd J M, B ennett HR. F il te rs and A yre 's T-pi ece. Anaes thes ia 1996;51:605. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 89. Marc us R, W andles s J , Thompson J . Filters and A yre's T -piec e. Pae dia tr Anaes th 1999 ;9:93. [Cross Ref] [Med li ne Link ] 90. Milliga n K A . Disablemen t of a v enti lato r disconnec t alarm by a heat and mois ture exchanger. Ana es thes ia 1992;47:279. [Cross Ref] [Med li ne Link ] 91. S lee TA , P av lin E G. Fai lure of low press ure alarm assoc ia ted wi th the us e o f a humidifier. Anes thesiology 1988;69:791 793 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 92. P rasad K K , Chen L. Compl ications re lated to the us e of a heat and mois ture ex changer. A nes thes iology 1990;72:958. [Med li ne Link ]

93. Anonymous . Heat & mois ture excha ngers block breathi ng c i rc uit ai rway . B i omed Safe S ta nd 1996;28:4 3. 94. P rados W . A dangerous defec t in a heat and mois ture ex chan ger. Anes thes iology 1989;71:804 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 95. Anonymous . Heat/mois ture exchange h umid if ie rs . Technol A nes th 1991;11(8):5. 96. Anonymous . Humidifi ers , hea t/mois tu re ex change. Techno l Anes th 1991;12:5. 97. Anonymous . Haza rd notice. A naes thes ia 1994;49:563 . [Cross Ref] 98. S tacey MRW , Asa i T, W ilk es A , et al. Obs truc tion of a breathing s ys tem f il te r. Can J A naes th 1996 ;43 :1276. [Med li ne Link ] 99. Walton JS , Fears R, Burt N, et a l. Intra operativ e b rea thing c i rc ui t obs truc tion caus ed by a lbu terol nebul i zatio n. Anesth A nalg 1999;89 :650651. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 100. Peady CJ. Another re port of obs truc tion of a heat and mois ture exchange f il te r. Ca n J Anes th 2002 ;49 :10 01. 101. W armington A , P eck D. HME plus hea ted hu midif ie r danger. A naes th Inte ns Care 1995 ;23 :125. [Med li ne Link ] 102. W ill iams DJ , S tacey MRW . Rap id and c ompl ete occlus ion of a heat and mois ture exchange fil te r by pulmona ry edema (c li nic al report). Can J A naes th 2002;49:126131. [Med li ne Link ] 103. Anonymous . Heat and mois ture ex cha ngers and fil te rs : c omponents may enter breathi ng s ys tems and caus e blockages . Heal th Dev ic es A le rts 2004 ; 28(36):5 6. 104. Anonymous . Humidifiers , heat/mois ture ex change. Techn ol Anes th 1985;6:8. 105. James PD, Gothard J W W. P ossible haz ard f rom the ins erts of c onde nser humidifiers . A naes thesi a 1984;39:70. [Cross Ref] [Med li ne Link ]

106. Cas ta A , Houck CS . Ac ute intrao perativ e endotrachea l tube obs truc tion as soc iated wi th a hea t and mois ture exchanger in an infa nt. Anes th Analg 1997;84:939940. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 107. Anonymous . Heat/mois tu re exc hange humi dif iers . Tec hnol Anes th 200 4;25(3 4):11. 108. Booker PD. E quipment and moni to ri ng i n p aediatric ana es thes ia. B r J Anaes th 1999;82:7890. [Med li ne Link ] 109. Lel louche F, Maggiore S M, Deye N, et al . Ef fec t of the humidifica ti on dev ic e on the work of breathing during no ni nv as iv e v entilation. Intensiv e Care Med 2002;28:1582158 9. [Cross Ref] [Med li ne Link ] 110. Bengts son M, Jo hnson A . Fai lu re of a heat and mois ture exc hanger as a cause of dis connec tion duri ng anaes thesia . Ac ta Anaes thes iol Sc and 19 89;33:522523. [Med li ne Link ] 111. Mans or M, Chan L . Cri tica l inci dent involv ing a heat and mois tu re ex changer wi th attac hed f lex ible c onnec tor. A naes th Inte ns Care 1999;27:114115. [Med li ne Link ] 112. W ilkes A R, Hampso n MA , Meck lenburgh JS . A method of tes ting the co mpliance of 15 and 2 2 mm con ic al connec tors on hea t and mois ture excha ngers to IS O 5356 -1:1987. J Med E ng Technol 199 7;21:147150. [Med li ne Link ] 113. Eck erbom B , Lindho lm CE . Heat and mois ture ex changers and the body temperature : a preoperativ e s tud y. Ac ta Ana es thes iol Scand 1990;34:538 542 . [Med li ne Link ] 114. Goldbe rg ME , J an R, Gregg CE , et al . The heat and mo is ture exc hanger does not preserv e body tempe rature or re duce recov ery ti me in outpati ents unde rgo ing su rge ry and anes thes ia . Anes thes iology 198 8;68:122123. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

115. B ickl er PE , Sess ler DI. Ef fic ienc y of air way heat and mois ture ex cha ngers in anes thetized humans . A nes th A nalg 1 990;71:415418. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 116. B ranso n R. Humidificatio n for pa tients wi th arti fic ial airway s . Res pir Care 1999;44:630641. 117. Mizutani AR, Ozaki G, Rusk R. Ins ulate d c ircui t hose imp rov es heated humidifier performanc e in anes thesi a v enti la tion ci rc uits . A nes th Analg 1991;72:566567. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 118. Anonymous . Heated wi re s c an mel t dispos able breathing c ircui ts . Technol Anes th 1 989;9:23. 119. Miyao H, Mi yasaka K , Hi rokawa T, e t al . Cons ide ration of the in ternational s tandard for ai rway humidification using si mulated sec retions in an artific ia l ai rway . Res pir Care 1996;41:4349. 120. Lev y H, S impson S Q, Duv al D. Hazards of humid if iers wi th h eated wires . Cri t Care Med 1993 ;21 :47 747 8. [Cross Ref] [Med li ne Link ] 121. Gilmou r IJ , B oyle MJ , Rozenb erg A , e t al . The effec t of heated wi re ci rc uits on humidific a ti on of ins pired gases . A nes th A nalg 1994;79:160164. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 122. W ilkes A R. Low re lativ e humi di ty de livered by a humidifier with a heatin g wi re. Crit Ca re Med 1993;21:948. [Cross Ref] [Med li ne Link ] 123. Anonymous . Heated hu midi fiers . Techn ol A nes th 1987;8:15 . 124. Anonymous . Heated hu midi fiers . Heal th Dev ic es 1987 ;16 :223250. 125. Anonymous . An ov erv iew of heated humidifiers . Tec hno l A nes th 1994;15(6):1 5.

126. Rus sell W J , W ebb RK , v an der Wa lt J H, et al . P robl ems wi th v enti lation : an analys is of 2000 i nc id ent reports . A naes th Intens Ca re 1993;21:617620. [Med li ne Link ] 127. Inte rna tional S tandards Organizati on. Humidif iers fo r medical usegeneral requi rements for humid ificatio n s ystems (ISO 8185 ). Ge nev a, S wi tze rl and : Author, 1997. 128. A meric an Soc iety fo r Tes ti ng and Materi als . S tandard s peci fic ation for humidifiers fo r medical usePart 1: General requi rements for ac tiv e humidificatio n s ys tems (AS TM F-1690 ). W es t Cons hohocken , PA : A u tho r, 2 004. 129. Hawk ins C, Ross A . Unexplained hu mid if ie r fail ure. Ana es th Intens Care 1994;22: 739740. [Med li ne Link ] 130. Spencer M. U nexplai ned humid if ier fa ilure. A naes th Intens Ca re 1994;22:740. 131. Hann al lah RS , Mc Gil l W A . A prac tical wa y of using he ated humidif iers wi th pedia tric T-pi ece sys tems . An es thes iolog y 1 983;59 :156157. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 132. Kov ac AL, Fil ard i JP , Go to H. W ater trap for f resh gas f low l in e o f Bain or CPRA M ci rc uit. Can J A naes th 1987 ;34:102103. [Med li ne Link ] 133. Burli ng ton DB . F DA s af ety alert. Hazards of heated-wi re breathing c ircu its . Roc kv i lle, MD: Food an d Drug Adminis trati on, 1993. 134. Yam P C, Carl i F. Maintenance of body te mperatu re in e lde rl y patients wh o hav e joint rep lac ement surgery. A compa rison be twe en the heat an d mo is ture ex changer and heated humi difier. Anaes thes ia 1990;4 5:5635 65. [Cross Ref] [Med li ne Link ] 135. Hynson J M, Sessl er DI. Intraopera tiv e warmin g therapies : a compa ris on of three dev ices . J Clin Anes th 1992;4:194199. [Cross Ref] [Med li ne Link ] 136. Mc Nul ty S , B arri nge r L, B rowder J . Carbon diox ide retention assoc ia ted wi th a humidifier defec t. Can J Anaes th 1 987;34:519521 . [Med li ne Link ]

137. Shrof f PK , Sk erman J H. Humi difi er malfu nc tiona c aus e of anes thes ia c i rc uit oc c lusi on. A nes th A nalg 1988 ;67:7 107 11. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 138. Shamp ai ne E L, Helf aer M. A modes t proposal for i mprov ed humidif ier des ign. Anes th An al g 1991;72:130131 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 139. W ang J , Hung W , Li n C. Leak age of d is pos able b rea thi ng c i rcui ts . J Clin Anes th 1 992;4:111115. [Cross Ref] [Med li ne Link ] 140. W armington A , P eck D. Ano ther complication of heate d hose hu midif ic ation. Anaes th Intens Ca re 1994;22:740741. [Med li ne Link ] 141. Beards SC, P ayne T. A n unexpec ted comp licati on of heated h ose humidific a ti on. A naes th Intens Care 1 994;22 :232. [Med li ne Link ] 142. Patil A R. Mel ting of anes thesia c irc ui t by humidif ie r. Another c ause of v entilator d isc onnec t. A nes th P rog 1989;36:63 65. [Med li ne Link ] 143. W ong DHW . Mel ted d el iv ery hosea complicati on of a hea ted humidif ie r. Can J Anaes th 1988;35:183186. [Med li ne Link ] 144. W ood D, Bo yd M, Campbe ll C. Insulation of heated wi re ci rc ui ts . Anes th Analg 1992;74:471. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 145. Sprague DH, Macc ioli GA . Disposable c i rcui t tu bi ng melted by heated humidifier. Anes th Analg 1986;65:1247. [Cross Ref] [Med li ne Link ] 146. Anonymous . Anes thes ia breathing c ircui ts . Technol Anes th 1992;13:8.

147. Anonymous . Incompa tibi li ty of dispos able hea ted -wi re breathing ci rc ui ts and heate d-wi re h umid if ie rs . Tec hnol An es th 1993 ;14 (2):45. 148. W ebb RK , Russell W J , K lepper I, et a l. E qui pment fai lure : an analys is of 2000 i nci den t reports . A naes th Intens Care 1993;21:67 367 7. [Med li ne Link ] 149. Anonymous . Inappropri ate Fisher & Payk el he ate r- wire adap ter me lts A llegiance breathing ci rc ui t. Health Dev ices 2000;29 (23):8687. [Med li ne Link ] 150. Anonymous . Anes thes ia breathing c ircui ts ma y ov erhea t & melt tubing . Biomed Safe S ta nd 1994;24:8 5. 151. Anonymous . B reathing circu it h eating c ompon ent c oul d s hort and c ause f ire. B iomed S afe S tand 1990 ;20:6768 . 152. Anonymous . Fishe r & Pa ykeldua l-hea ted adul t breathing c ircui ts : ris k of fi re. Hea lth Dev ices A lerts 2006;30:45 . 153. Anonymous . Ven ti la tor bre ath ing c irc uits . Tec hnol Anes th 200 0;21:7 154. Cote CJ , Petk au A J , Ryan J F, et al. W as ted v entilation meas u red i n v itro with eight anes the tic ci rcu its wi th and wi th out inli ne humidification. Anes thesiology 1983;59:442446. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 155. Anonymous . Heated hu midi fiers can burn i nfants duri ng CPAP . Heal th Dev ic es 1987;16:404406. 156. Anonymous . Heated hu midi fiers can burn i nfants duri ng CPAP . Tech nol Anes th 1988;8:79. 157. Anonymous . Pos s ible bu rn f rom hea ted breathing c i rc ui t. Bi ome d Safe S tand 1991;21:147. 158. W hi tel ey S M. A hazard o f heated humidif iers . A naes thes ia 1 992;47:909. [Cross Ref] [Med li ne Link ] 159. Anonymous . Saf ety ac tion bulleti n. Ana es thes ia 1992;47:547. [Cross Ref] 160. S mi th HS , A llen R. Ano the r haza rd of h eated water humidifiers . Anaes thes ia 1986;41:215216. [Cross Ref] [Med li ne Link ]

161. Oh TE , Li n ES , B hatt S . Resis tanc e of humidifi ers , and ins pi ratory work i mposed b y a v entilator-humidif ier circuit. Br J Ana es th 1991;66 :25 8263. [Cross Ref] [Med li ne Link ] 162. Rathgeber J , K azmaier S , Penac k O, et al . Ev aluation of heated humidif iers fo r us e on intuba ted pati ents : a c omparativ e s tudy of humidifying eff ic ienc y , flow resis tance , and alarm func tions us in g a lung mod el . Intensiv e Care Med 2002;28:731739. [Cross Ref] [Med li ne Link ] 163. Anonymous . Rai nou t from a F isher & Payk el heated humi dificatio n sys tem can shut down c ertain v enti la tors . Technol Anesth 2002;22(9):1 2. 164. Karis J H. A l teratio n of hal othane in heated humidifiers . A nes th Analg 1980;59:518. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 165. Anonymous . Rai nou t puts v enti la tor-dependent patien ts at risk . Tec hnol Anes th 2 003;23:12 . 166. Peters on B D. Heate d humidif iers . S truc ture and f unc ti on. Res pi r Care Cl in N A mer 1998;4:243 259. 167. Barto n RM. Detec tion of expi rato ry anti bac teria l fil te r occlus ion. Anes th Analg 1993;77:197. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 168. Anonymous . Nebulize rs . Tech nol Anesth 2002;22 :10 . P .308

Questions
For the fol low ing ques tions , s elec t the co rrec t answer. 1. Which is not an effec t of in haling dry gases ? Dryi ng of the mucos a Dec reased co mp li anc e

Dev elopment of loci for infec tion Impai rmen t of su rfac tant ac tiv ity Dec reased alv eola r-arteria l ox ygen differenc e V iew A ns we r2. Wh ere sho uld a hea ted humidifier be located in the circle system? Between the ex halati on tubi ng and the carbon diox ide a bsorber Between the Y-piece and trac heal tube Between the inspi rato ry tubing and the Y-p iec e Between the abs orber and the inspi rato ry tubing Between the Y-piece and the mask V iew A ns we r3. If a bac teria l filter is used in a circ le syste m th at has a hea ted hu midifier, w here should the filter b e placed? Between the Y-piece and the tracheal tube Between the Y-piece and the inhalational tubing Between the inhalatio nal tubing an d the humidif ier Between the inhalatio nal unid irec ti onal v alve and the humidifier Between the Y-piece and the exhala tion tubi ng V iew A ns we r4. Wh ich is the defin ition of a bsolute h umidity? The pres sure exerted b y wate r v apo r in a gas mix ture The amo unt o f water v apor at a pa rtic ul ar temperatu re as a percentage of the amou nt that wo uld be held if the gas were saturated The max imu m amount of wate r v apo r that a v olume of gas can ho ld The mas s of water v apor p res ent in a v olume of gas . The humid ity of gases at body temperature V iew A ns we r5. Wh at w ill cause w ater to rain out in th e b reathing hose ? Us ing coax ial tubes i n the breath ing s ys tem Hea ted hu midified g as that c ools in the b rea thi ng tube W arming cooled humidified gas es in the breathi ng tube Mai ntaining the temperature of heated gas in the b rea thing tubes Us ing an ex tra-lon g b rea th ing tube V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t

i f A , B , C, and D a re co rrec t.

6. Which of the follow ing statements about h umidity and ambie nt cond itions are true? If a gas saturated with water is heated, i t c an hold mo re water Gas that is 100% s a turated at room tempera ture and warmed to body temperatu re wi ll be abou t 60% saturated If a gas saturated with water is heated, the absol ute h umid ity rema ins the sa me If a gas saturated with water is heated, the rela tiv e humi di ty inc reases V iew A ns we r7. A result of the low specific h eat of g ases is Inhaled gas wi l l quick ly as sume body tempera ture W ater wi ll c ondense i n the ex halatio n s id e of a ci rcl e sys tem Gas in bre ath ing tubes wil l quic k ly assume room tempera ture Gas has a tendency to change temperatu re s lowl y V iew A ns we r8. Heat and moisture are norma lly lost during anesthe sia bec ause Dry g ases a re suppl ied f ro m the anes thes ia machine Gas es are heated by the b ody Trac heal intubation bypasses normal humidifica tion mechanis ms The trachea l tube does not ac t to co nserv e heat or mois ture V iew A ns we r9. S ources of humidity in the breathing sys tem include Carbon di ox ide absorben t Exh aled water from a p rev ious patie nt Reb rea thi ng of p rev io usl y exh aled g ases Fres h gas V iew A ns we r10 . Advan tages of a hydropho bic HME over a co mposite hyg rosc opic HME include Better fi l tration Less res is tance when we t Nebuli zed d rugs hav e l ittle ef fec t on res is tanc e Better humidifica tion V iew A ns we r11 . Using a heated brea thing tu be w ith a heate d humidifier w ill result in Rainou t in the deliv ery tube A higher tempe rature at the Y-piec e Dryi ng of sec re ti ons

A del iv ered relativ e humidity of 100% V iew A ns we r12 . Haza rds of heated h umidifiers inc lude S tic ki ng v alv es Ov e rhydra tion A l te ration of anes thetic agents Obs truc tion of si des tream gas moni tors V iew A ns we r13 . Advan tages of HMEs in clu de Fl uc tuating tempera tu re and humidi ty Dec rease in dead space Low co mpli ance Dec reased res is tance to breathing V iew A ns we r14 . Contraindicatio ns to use of a n HME include B loody s ec retions Patient temperature of less than 35C B ronch opleurocu taneous fis tula Unc uffed trac heal tube V iew A ns we r15 . When using an HME , th e insp ired humid ity can be increase d by Us e of an uncuffed tube Inc reas ing the minute v olume Loweri ng the humidi ty of gas entering the HME Us e of a h ygrosc opic rather than a hy drophobic HME V iew A ns we rP .309

16. Wh ich pa tients o r conditions de rive the greatest b enefit fro m humidification of insp ired gases? Long anes the tics Patients who are l ik el y to dev elop pul monary complications Pediatric pa ti ents E lderly patients V iew A ns we r17 . Whic h of the follow ing are respiratory c omplications of dry resp iratory mucosa ? B ronch ocons tric tion A i rwa y o bs truc tion Infec tion

A telec tasis V iew A ns we r18 . Consequenc es of excessive humidity include w hich o f the follow ing? Pulmona ry ed ema An inc reas ed serum s odi um Ci liary dege neration Inc rease d pulmonary compl iance V iew A ns we r19 . Haza rds associated w ith u sing a ne buliz e r inc lud e Ov e rhydra tion Fi lter o bs truc tion Bac teria inf ec tion Hypoth ermi a V iew A ns we r

Chapter 12 Anesthesia Ventilators

A v enti la tor (breathi ng machine ) is an au toma tic dev ic e des igned to prov ide or augment p ati ent v enti la tion. Ne wer anes thes ia v enti lato rs are an integ ral part of the anes thes ia works tation. They are des igned wi th more fea tu res and v entilatory modes than earl ier mode ls and hav e the abil ity to v enti late more diff ic ul t patients and to al low v enti lation to be ta ilored to the patient's nee ds. Tradi ti onal anes thes ia v en ti lato rs could no t prov ide as hi gh inspi ra to ry press ures o r f lows as the ir i ntens iv e c are unit (ICU) cou nte rpa rts (1,2,3,4 ). A s a resul t, some ICU v entilators needed to be adapted f or use durin g s urgery in order to care f or pati ents who were d ifficu lt to v en tila te. If pos i tiv e end-expi ra tory pressu re (P E EP ) were needed, often th e anesthes ia prov ide r had to add a PEEP v alv e to the anes thes ia breathing s ys tem. S ome of these v alv es were i mprec ise, not v ariabl e, and c ould be mis connec ted (Chapter 7). On some older v entilators , the user had to manu al ly en able the low pressu re al arm when the v en til ato r was tu rned ON. A ls o, i t may hav e been neces sary to c lose the adj us table press ure l imi ting (AP L) v alv e and/o r turn the b ag/v enti la tor s wi tch wh en turning on the v enti lator. A nothe r drawback of ol der v enti lators was that se parate mod els o r diff erent be llows as sembli es were required fo r adul t and pediatric patients . The deliv ered tidal v olume was affec ted by f res h gas flow and b rea thi ng s ys tem c ompl iance. F in all y, older v entilators offered onl y v olume con trol v entilation. The demand f or perfo rmance equiv alent to ICU v enti lators has l ed to a numb er of i mprov emen ts in anes thesia v entilators . High inspi ra tory pressu res and fl ows ca n be de liv ered. Newer anes thes ia v entil ators hav e an in tegra l PEEP v alv e, and many hav e sev e ral v entila tory modes . Anothe r improv ement is imp rov ed fl ex ibi l ity so th at the v enti la tor c an deliv er v olu mes for a wi de range of patie nts f rom the smal les t ch il d to the la rges t adult. The new v entilators are des igned to ov erc ome the effec ts of f res h gas , breathing s ys tem complianc e a nd gas c ompressi on on tida l v olume. Turni ng the v enti lator ON i nv olv es fewe r s teps and au toma tical l y enab les the low ai rwa y pressure alarm. Ven ti la to rs used in anes thesia are c ov ered by intern ational and U.S . s tandards (5,6 ,7). This chapter wi ll c ov er a number of v enti la tors av ailable at the ti me of this wri ti ng. It is impos sible to prov ide al l of the details that need to be mas te red to safel y use a partic ula r v en tila tor. Sof tware updates and upgrades oc cur f requen tl y. It is

i mportan t th at the user ma nual be s tudied bef ore usi ng a v entil ator that is unfami liar to the anes thesi a p rov ider.

Definitions

Barotrau ma: Inju ry resul ting f ro m high ai rwa y pressure. P .312

Compl ianc e: Ratio of a c han ge in v olume to a c hang e in press ure . It is a meas ure of dis tensi bi li ty and is usuall y express ed in mill ili ters pe r cen ti mete r of wa te r (L or mL/cm H 2 O). Mos t c ommonl y, compli ance is used in ref erenc e to the lungs and ches t wal l. B rea thing s ys tem c omponents , es pec iall y breathi ng tubes and the reserv oi r bag , also hav e compl iance .

Con tinuous Pos i tive A i rway P ressure (CPA P ): A i rway pressu re mai ntained abov e ambient. This term is c ommonl y used i n referenc e to sp ontaneous v enti lation .

Exh aus t Valve: V alv e i n a v enti la tor with a b el lows that when open allows driv in g gas to ex it the be ll ows hous ing. Exp iratory Flow Ti me: Time between the beginning and end of expi ratory f low. Exp iratory Pause Ti me: Ti me from the end of exp iratory f lo w to th e s tart of i nspi rato ry flow. Exp iratory Phase Ti me: Ti me between the start of exp iratory flo w a nd the s tart of ins piratory f lo w. It is the s um of the exp iratory f lo w a nd expi rato ry pause times .

Fres h Gas Comp ensa tion: A means to preve nt the fresh gas flow from af fec ting the tida l v olume by meas uring the ac tual ti dal v olume and us ing this i nfo rmati on to c hange the v olume of g as deliv ered by the v entilator.

Fres h Gas Dec oup ling: A means to prev ent the fresh gas fl ow from affec tin g the tidal v olume by is ol ating the fresh g as flow s o that i t doesn't enter the breathi ng s ys tem duri ng inspi ra ti on.

Ins pi rato ry Flow Time : Perio d between th e b eginning and end of inspi rato ry f low.

Ins pi rato ry Pause Ti me : That porti on of the i nspi ra to ry phase ti me during whi c h the lu ngs are hel d inf late d a t a fixed pres sure o r v olume (i .e., the time during whi ch the ins piratory phas e has zero flow). It i s also c alled the i nspi rato ry ho ld, inflation ho ld , and inspi rato ry plateau. The inspi ra tory pause time may be ex pressed as a pe rc entage of the i nspi rato ry phase time.

Ins pi rato ry Phase Ti me : Ti me b etween the s ta rt of inspi ratory flow and the beginning of ex piratory fl ow. It is the sum of the inspi rato ry f low an d i nspi rato ry pause ti mes .

Ins pi rato ry : Expi ra tory Phas e Time Rati o (I:E ra tio): Ratio of the inspi rato ry phase time to the exp iratory ph ase time. Ins pi rato ry Flow Rate: Rate at whi ch gas fl ows to the patient ex pressed as v olume pe r uni t of time. Inv erse Ratio V entil ation : V entila tion in wh ic h the inspi rato ry phase ti me is l onge r than the ex pi ratory phas e time. Minute V olu me: Sum of al l ti dal v olumes wit hin one mi nute. Peak P res sure: Max imum press ure du ri ng th e i ns piratory p has e time . P lateau P ressu re: Res ting p res sure during the i nspi ra to ry pause. A i rway press ure us ual l y fal ls wh en there is an inspira tory paus e. Th is lower press ure is cal led the pl ateau pres sure.

Pos itive End-ex piratory P ress ure (P EEP ): Ai rway p res sure a bov e a mbient at the end of exhalation. Th is term is c ommonly use d i n referenc e to control led v enti lation .

Res is tance: Ra tio of the c hange in driv ing pre ssure to the cha nge in flow rate . It is commonly express ed as centi mete rs of wate r per l iter per second (c m H 2 O/L /s econd).

S igh: De liberate inc re ase i n tidal v olume for o ne or more b rea ths . Solenoid : A c omponent that c ontrols pneumatic f low b y means of an elec tronic signal . Spi ll Valve: The v alv e in an anes thes ia v enti lator that a llows ex ces s g ases i n the breathing s ys tem to be s ent to the sc avenging s ys tem af te r the bellows or p is ton has become fully f ill ed during exha lation.

Ti dal Volume: Volume of gas entering o r leav ing the p ati en t during the i nspi rato ry or expi ra tory phase time. Ven ti la to ry (Respi ra tory ) Ra te or F requenc y: Number of resp iratory c yc les per minu te.

Volutra uma: Injury due to ov e rdis tention of the lungs . W ork o f B re athing: Ene rgy expended by the patient and /o r v enti lator to mov e gas in and ou t of the lungs . It is ex p res sed as the ra tio of work to v olu me mov ed, co mmonl y as joules per l iter. It inc lu des the work neede d to ov erc ome the elas tic and flo w-res is tiv e forces of the bo th the res pi ratory s ys tem and appa ratus .

Relationship of the Ventilator to the Breathing System

A v enti la tor replac es the res erv oir bag in the breathing s ys tem. It may be connec ted to the b rea thi ng s ys tem by a bag/v enti lator s elec tor v alv e (Chap ter 9 ). On some ne wer works tations , turning the bag/v entilator s el ec tor s wi tc h to the v enti lato r pos itio n or a mode s elec tion s wi tc h turns ON the v entilator. On o the r v enti lato rs , the re is an ON-OFF s wi tc h. Mos t anes thes ia v enti lators hav e a bellows i n a box (bag in a bottl e, double c i rc uit) desig n (Fig. 12 .1 ). The b el lows is housed in a pres sure c hambe r, and the ins ide of the bel lo ws is co nnec te d to the b rea thi ng s ys tem. The bellows ac ts as an interfac e between the breathi ng s ys tem and the v entil ato r driv ing gas , jus t as the rese rv o ir bag ac ts as an interface between the breathing s ys tem and the anes thesi a prov ider's hand. It s eparates P .313 breathi ng s ys tem gas f rom driv ing gas . The pressu re of the anes thesia prov ider's hand is replaced b y the driv ing gas pressu re that c ompresses the be llows .

View Figure

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

Durin g ins pi ration, driv ing gas is del iv ere d into the s pace be twe en the bellows an d i ts ho using. This c auses the be llows to be compress ed so that gas flows into the breathi ng s ys tem. A t th e s ame ti me, the spi ll v alv e (whi ch v en ts ex ces s gases to the scav enging s ys tem) and exhaus t v alv e (whi c h v ents driv ing gas ) a re c los ed. Durin g exha lation, the bel lows re -ex pands as breathing s ys tem gases and fres h g as f low i nto i t. Driv ing gas is v en ted to atmosphe re through the exhaus t v alv e. Af te r the bel lo ws is ful ly ex panded, exces s gas from the b rea thing sys tem is v ented to the scav enging s ys tem through the sp ill v alv e. Ins tead of a bellows i n a box , s ome v enti la tors hav e an elec tric al ly d riv en pis ton. B y el imina ting th e need for a driv e gas ci rcu it (an add itional source of c ompressible v olume ), a s table fl ow del iv ery can be prov ided. In p is ton v entilator s ys te ms tha t are presentl y av ailabl e, the res erv oi r bag is not isol ated from th e b rea thing sys tem

during the exhalation phas e of automatic v entilation and ac ts to modulate press ure i nc reas es in the sys tem. Duri ng inspi rati on , when the pis ton forces g ases i nto the breathi ng s ys tem, the bag is isol ated from the breathing sys tem and col lec ts the f res h g as fl ow entering the breathi ng s ys tem. On s ome v enti la tors , the ba g c an be seen to ex pand an d c ontrac t wi th res pi ration ev en though the pis ton is ac tuall y v enti lating the patient. A p rob le m wi th pis ton v en til ato rs may be ai r en trai nment wi th a disconnec tion P .314 (8,9 ). In this c ase, the mac hine may not al arm and the pa tient wi l l c on tinued to be v enti lated, bu t ai r wil l be entrained, res ul ti ng in lower c onc entrati ons of oxygen and anes thetic agents .

Factors That Affect the Delivered Tidal Volume Fresh Gas Flow
W ith ol der v entil ators , the deliv ere d tidal and minu te v olumes changed when the f res h g as fl ow, I:E ratio, or respi ra tory ra te was al tered despi te the bellows ex cursi on rema ining unchanged. If the fres h g as fl ow inc rease d, the ti dal and minute v olumes inc reased (10,11 ,12 ,13 ). If the fresh gas fl ow dec reas ed, the tida l and minute v olumes dec rease d. S ince f res h gas was added to the inspi red tidal v olume on ly du ring ins pi ra tion, v enti lator s etti ngs that prolonged the ins piratory time (a nd th ereby inc re ased the I:E ratio) would cause an inc reased tidal v ol ume. Lower I:E ratios dec rease th e tidal v olume. As respi ra tory ra te i nc reas ed, the i nc reas e in tidal v olume from fresh gas flow was less , a lthough the e ffec t o n minute v olume remained the same. S lo wing the respi ra tory ra te had the opposi te eff ec t. Manufac tu rers hav e re-engine ere d thei r v entil ators to eliminate the f resh gas effec t on the ins pi red v ol ume. One method is to measure the inspi red fresh gas flow and co mpens ate for i t by al te ri ng the bel lo ws excu rs ion (fresh gas c ompensation). Ano the r method is to prev ent the f resh gas f rom entering the breathing s ys tem during ins pi ra tion by usi ng a v alv e that div erts the fresh gas into a res erv oir bag during ins pi ra tion (f resh gas decoup li ng).

Compliance and Compression Volumes

Dec reases i n compl iance in the breathing sy s tem c an be acc ompanied by dec reas es i n ti dal v olume as more of th e i ns piratory fl ow is ex pended by exp anding the components . Gas compress ion l oss es depend on the v olume of the breathing

s ys tem and the pres sure d uring i nspiration . Adv anced technology no w a ll ows the v enti lato r to compens ate for c hanges in breathi ng s ys tem c ompliance by al te ring the v olume del iv ered. B reathi ng s ys tem c ompliance is dete rmined during the checko ut procedure befo re us e. For accu rate c ompl ianc e c ompensation, the breathi ng s ys tem mus t be in the configuration that is to be used whe n the c heck out procedure is perfo rmed . Changes in the c i rcui t confi guration (suc h as le ngtheni ng the breathing tubes or adding c ompon ents ) wi ll c aus e the co mpens ati on to be i nacc urate (14). Other v entilators measure ins pi red v olu mes at the patient c onnec tion and ad jus t the v enti lato r exc urs ions acc ord ing ly .

Leaks
A leak around the trach eal tube or s upraglotti c dev ic e wi l l cause a dec reas e in tida l v olume that is not tak en in to ac coun t by the v enti lator. Sides tream gas moni to rs may dec rease the v olume del iv ered to the patie nt.

Components Driving Gas Supply

Mos t curren tl y av ailable anes thesi a v enti la tors are p neumatical ly p owered but elec tric all y con trolled. The driv ing (driv e, po wer) gas is either ox ygen, ai r, or a mix tu re of a ir and oxy gen. It is usua ll y less exp ens iv e to power the v entilator wi th ai r. Some v enti la tors can s witc h between driv ing gas es s o tha t if the re is a los s of press ure in the p ri mary driv ing gas suppl y, the other gas can be us ed. Some v enti lators us e a d ev ice c alled an injec tor (Venturi mechan is m) to inc reas e the driv ing gas f low. A n injec tor i s s hown i n Figure 12 .2 . As the g as fl ow meets a res tric tion, i ts latera l pressu re drops (Bernoul li princ iple). W hen the la teral press ure drops belo w a tmos pheric , ai r wi ll b e entrained . The resul t is an inc rease i n the total gas f low l eav ing the injec tor, and a dec reased consump tion of driv ing gas . A s ignificant flow of gas is neces sary to driv e a bellows (15,16,17). The amount wi l l v a ry, depending on the v entilator and the se ttin gs . T he us e of a gas c yl in der to power a v entila tor ma y quick l y deplete th e g as supply .

Controls
The v entil ator c ontrols regulate the flow, v ol ume, timing, and press ure of the bellows comp res s ion or pis ton mov ement.

Alarms
The v entil ator and wo rk s ta tion s tanda rds (6,7) group alarms into th ree ca te gories : high, me di um, and low pri ority, depen di ng on whether the condi tion re qui res P .315 i mmediate ac ti on, pro mpt ac tion, o r operator awa ren ess bu t not neces saril y ac tion (Chapter 26 ).

View Figure

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

The v entil ator s tand ard (6) mand ates an alarm th at indicates that the press ure in the breathing s ys tem has ex ceeded a set limi t (high-pressure alarm). On modern v enti lato rs , this threshol d is adjus table by the user, usu all y wi th a defaul t around 50 cm H 2 O. There mus t be an a larm to indicate tha t the p res sure in the bre ath ing s ys tem has not reac hed a minimum v alue wi th in a certa in time pe ri od (low ai rwa y press ure alarm).

Pressure-limiting Mechanism
A pressu re-limi ting mech anism (press ure -l imi ting v alv e, max imum limi ted p res sure mechanism, driv ing gas press ure rel ief v alve, p res sure limitation mec hanis m, maxi mum work i ng pressure con trol , pressu re limi t con trol ler, i nspiratory press ure l imi t, adjus tabl e pressu re relief v alv e, high pres sure s afety rel ief v alv e, ov erp res sure rel eas e) is desi gne d to limi t th e ins pi ratory pressure. The anes thesi a work s tatio n s tandard (7) mandates that this be adjus table. An adjus tabl e mechanism carri es the haza rd of operato r error. If s et too l ow, i nsuffic ien t pressu re

for v en ti lation may be generate d; i f set too high , exc essiv e ai rway pressu re may oc cur. Setti ng the pressure limi t 10 cm H 2 O abov e the peak pressu re ac hiev ed wi th the des i red tidal v olume and f low rate wi l l av oid mos t barotrauma (18). P ress ure-l imi ti ng dev ices work in one of two wa ys . W hen the max imum pressu re is reached, one type holds th e p res sure at that l ev el until the s tart of exhalation, at whi c h time the pressu re dec reases . The other type termina tes ins piration wh en th e press ure limi t is reached s o that the p res sure d rops immed iatel y.

Bellows Assembly
Bellows
The bell ows is an acc ord io nlike dev ice that i s a ttac hed at ei ther the top o r bottom of the be ll ows as sembly. Latex -f ree bello ws are av ai lable . There are two ty pes of bellows , dis ti ngu is hed by thei r motion du ring ex halation : asc ending (s tanding, upright, fl oa ting) a nd desc ending (hang ing, i nv erted). Ventilators with desc ending bellows were c ommon un ti l the mid 198 0s . A fter that, mos t n ew v entilators had as cending b ellows , but desc ending bellows are us ed by a nu mber of mo re recent v enti lato rs . W ith an asc ending be llows (Figs . 12 .36 , 12.44), the bel lo ws is attached a t the base of the as sembl y, a nd th e bellows is comp res sed downward d uri ng inspi rati on . Durin g exha lation, the bel lows expands upward. These v enti la tors impos e a s light resis tance at the end of exh alati on , at whi ch time the pressu re i n the bel lows ris es enough (2 to 4 cm H 2 O) to open the spill v alv e. The ti dal v olume may be set direc tl y by adjus ti ng the inspi ra tory time and f low or b y a p late that l imi ts upward excu rsi on of the be ll ows . Wi th a disc onnec tion or leak in the breathing s ys tem, the bell ows wi ll c ol la pse to the bottom o r fa il to ex pand fu ll y. T he v enti la tor ma y c ontin ue to deliv er s mal l ti dal v olumes (19). To deliv er the en ti re tidal v olume , th e bellows mus t des cend to th e p roper l ev el or, dependi ng on the v en til ato r, be fully c ompressed a t th e end of the inspi ra tory phase. If the inspi ra tory flow i s ins uff ic ient to ful l y compress the bel lows or ac hiev e the des i red tidal v olume, a l ower ti dal v olume wil l be deliv ered. W ith a desc ending be llows (Fig . 12.50), the bel lo ws is attached a t its top and is co mp res sed up ward during i nspi ration. There is us ual ly a wei gh t in the dep endent portion of the bellows that fac il itates downward re-expa nsion duri ng ex ha la tion. A s the wei ght descends , it c an caus e a s mal l nega tiv e press ure in the bellows and breathi ng s ys tem. W i th a leak or dis connec ti on in the bre athing s ys tem, the weight i n the be llows wi ll caus e the be llows to expa nd, and room ai r wi ll ente r the

breathi ng s ys tem. All or part of the nex t inspi ration wi ll then b e los t in to the room. Newe r v enti la tors with hanging bello ws empl oy sophis ticated software to detec t disc onnec ti ons o r leaks (20,21). The software anal yzes s ens or outputs and trigge rs appropriate ala rms . A negativ e pressure rel ief v alv e p rev ents th e pati ent from being ex posed to negativ e press ure.

Housing
The bell ows is surrounde d b y a c lea r plas tic c yl inder (canis ter, bel lows chamber or c ylinde r, p res sure dome) that allows the bell ows mov ement to b e observ ed. A scal e on the s ide of the hous ing p rov ides a rough approxi mation of the tidal v olume being deliv ered. The hous in g for p is ton v entil ators usual l y has a scale that c an be observ ed.

Exhaust Valve
The exhaus t v alv e (exh al ati on v alv e, v en ti lato r rel ief v alv e, comp ressed gas ex haus t, b ellows c ontrol v alv e) c ommunica tes wi th the i nside of the bel lows housi ng on pneumatic all y powe red v entilators . It is c los ed during ins piration. Durin g exha lation, i t op ens to allow driv ing gas ins id e the hous ing to be ex haus ted to a tmos phere. W i th a pis ton v enti la tor, there is no need for an ex haus t v alv e.

Spill Valve
Bec ause the APL v alv e is is olate d from the breathi ng s ys tem duri ng v enti la tor operati on, a spil l v alv e (v ent v alv e, dump va lv e, ov erf low v alv e, expi red gas outle t, ex piratory v alv e or po rt, saf ety dump v alv e, pop-off v alv e, re li ef v alv e, f lapper v alv e, press ure reli ef v alv e, ov erspil l P .316 v alv e, gas ev acuati on ou tl et v alv e, ex haus t gas v alv e, gas ev ac uation o r ev acuator v alv e, ex piratory p res sure rel ief v alv e ) is us ed to di rec t exces s res pi red gases into the scav enging s ys tem. This v alv e is c lose d d uring i nspiration . During exhalation, i t remains c losed unti l the bel lows or pis ton is f ul ly expanded, then opens to v ent ex cess b rea thi ng s ys tem gases . The sc av enging trans fer tub ing c onnec ts the ex hal ation po rt of th e s pill v alv e to the scaveng ing s ys tem interface (Ch apter 13). W ith an asc ending be llows , th e s pill v alv e has a min imum opening pressu re of 2 to 4 c m H 2 O (22 ). This e nables the bel lo ws to f il l during exhala tion. This amount of PEE P is appli ed to the breathing s ys tem. It i s not applied wi th a pis ton or a hanging bellows v enti lato r.

W ith a pis ton v entil ator, exc ess gas is v ente d throug h a sp ill v alv e, which may no t i n the v enti lator, o r th rough an elec tron ic ally control led A PL v alv e, whic h ac ts as a sp il l v alv e.

Ventilator Hose Connection

The v entil ator s tand ard (6) requi res tha t the f i tting on the tubi ng con nec ting the v enti lato r to the breathing sys tem be a s tanda rd 22-mm male conic al f itting . A f ilter may be us ed on the tubing to les sen transmi ssion of p athogens and partic les . In mos t newer v enti lators , a se parate hose is n ot present, and the c onnec tions between the v enti lator and the breathing s ys tem are internal . This reduces the l ik eliho od of misconnec tions , disconnec tions , or ki nked hoses (23).

Positive End-expiratory Pressure Valve

PEE P v alv es are disc uss ed in Chapte r 7. Modern v entilators hav e i ntegra l elec tric all y ope rated P EEP v alv es. So me v entilators appl y P EEP to the entire s ys tem, whi le othe rs app ly i t onl y to the ex piratory hose (23). A s tanding c auses a small amount (2 to 4 cm H 2 O) of P EEP . There is no uns et PEE P wi th hanging bel lows or pis ton-driv en v enti lators .

Ventilation Modes
Anes thes ia v en ti la tors offer one or more v enti la tion modes (18). Many offer du al modes to gain the adv antages of both . Venti lator s ettings mus t be c arefully i ndiv idual ized in each mode to av oid hy pove nti lation , hyp erv entilatio n, v olu trauma, or baro trauma. It is impo rtant when s wi tc hing from one mode to another to ensu re that the ti da l v olume, peak press ure, and alarm s etti ngs are appropria te. A v enti la tor c an del iv er gas by generating flow or press ure. W ith flow generators , the flow patte rn c an b e c ons tan t (s quare wav e) o r noncons tan t (accelerativ e o r decel era tiv e). P ress ure ge nerato rs produc e a c ons tan t or nonc ons tant pres sure. Ins pi rato ry f low rate v ari es ac cording to the preset p res sure and the patien t's resis tance and compl iance . The c harac teris tics of insp iration and exhala tion related to the v entil ator settings , co mpliance, and res is tance are ref lec te d i n th e pressure and f low-v o lume l oops . These are d is cuss ed in d eta il in Chap ter 23. Fea tures of some common ly us ed v enti la to ry modes a re sh own in Table 1 2.1 . The terminol ogy used to d esc ri be the wa y a v entil ator op era tes has not b een univ e rsa ll y agreed o n, and s ome ma nufac turers hav e coined new terms for the ir v entil ators .

Volume Control

The mos t commo nly us ed mode in the opera ting room is v olume control (v olume control led o r v olume) v entilation, in whi ch a preset tidal v olume is del iv ered. Th e tida l or minute v olume and respi rato ry rate are set b y the anes thes ia prov ide r and deliv ered by the v enti la tor, i ndep endent of p ati en t effort. It i s time in itia te d, v olume l imi ted, and c ycl ed by v olu me o r time. Fl ow rate is f ixed at a c ons tant v al ue during i ns piration. If the ins piratory f low is too l ow to prov ide the set tidal v olume, the bello ws or pis ton wil l no t complete its ex cursi on. If the flow is s e t at a fas ter rate than is needed to prov ide the tidal v olume , th ere wi ll be an P .317 i nspi rato ry pause. A n excess iv ely hi gh peak i ns piratory p res sure may res ul t from se ttin g the ins pirato ry f lo w rate too high (24). The inspi ra tory phase may be terminated before the tidal v olu me h as been deliv e red if the peak ai rway pressu re reaches the s et press ure l imi t.

TABLE 12.1 Ventilatory Modes Mode Volume control ventilation Pressure control ventilation Intermittent mandatory ventilation Initiation Time Time Time Limit Volume Pressure Volume Cycle Volume/Time Time Volume/Time

Synchronized intermittent mandatory ventilation

Time/Pressure

Volume

Volume/Time

Pressure support ventilation

Pressure/Flow

Pressure

Flow/Time

Ty pic al ly , a v olume control wav efo rm shows s te adily inc reas ing p res sure during i nspi rati on . Changes in c ompliance or resis tanc e a re reflec ted in c han ges i n peak i nspi rato ry press ure and the differenc e between peak and pl ateau press ure (25). For a g iv en s et tidal v olume, the pressure in the breathing s ys tem is dete rmined by

the res is tance and compl iance of the breathing s ys tem and the patient. P la teau press ure is a ref lec tion o f compl ianc e. Peak p res sure is also inf luenc ed b y resis tance . The press ure -v o lume and flow-v olume loops as soci ated wi th v o lume control v entilatio n are seen in Figures 23 .22 and 23.23. Adding PE E P dec reases the tidal v olu me d eliv e red , with the effec t gre ate r with smal l tidal v olu mes (26 ,2 7). On newer v enti lators wi th i ntegral PE E P , v enti la tion may be be tter mai ntained (4 ). If c losed s ys tem suc tioning is performed during v olume c ontro l v enti la tion, the re wi ll be a s ignificant rise in airway press ure whe n the ca the te r is i nse rted and low ai rwa y pressure durin g s uc ti oning (28 ,29,30).

Pressure Control
P ress ure control (press ure -l imi ted, press ure -c ontroll ed, pres sure-p res et control , l ung protec tiv e, or p res sure) v entil ati on is av ail able on many an esthes ia v enti lato rs (2,31,32,33). W i th this mode, the opera to r sets the insp iratory pres sure a t a lev el abov e PEE P . The v en ti la tor quickl y inc reases the press ure to the s et l ev el at the s tart of ins piration and main tains this pressure until exha la tion beg ins . Ins pi rato ry gas f low i s highest at the be ginni ng of inspi ration, then dec reas es . Inc rease d res is tance may c hange th e shap e o f the flow-v ers us -ti me wav eform to a f latter, mo re square-s haped pattern as ti dal v olume del iv ery s hifts in to the latter part of the i nspiration (25). This al lo ws the v entilator to p res erv e ti dal v olume with i nc reas ed res is tance until res is tanc e bec omes sev ere. The pres sure-v olume and f low-v o lume loops s how s peci al c harac teris tic s s een wi th p res sure-c ontrolled v enti lation (Figs . 23 .29 , 23.30). W hen press ure c ontrol v enti la tion is used, ti dal v olume is de termin ed by the rise time and s et press ure . Ti dal v olume is not set or c ons tant but fluc tuates wi th changes in res is tance and c ompliance and wi th p atien t-v enti la tor asynchrony (25). If res is tance inc reases or comp li anc e dec reas es , the tidal v olume wi ll dec reas e. It has been pos tulated that a dec rease in tidal v olume with pressure con trol v enti lation would de tec t a partial ly occl uded trache al tube, but i t was f ound that tida l v olume was not dec reased un ti l the occ lus ion wa s nearly c ompl ete (25). Unlike mos t ICU v entilators , an anes thes ia v entilator in the press ure c ontrol mode operates wi th a prese t I:E ratio, so inc reas ing the respi ra tory ra te shortens i nspi rato ry time and lowers tidal v olume (2 ). A n i nc reas e in PEEP c auses a reduc tion in tidal v olume. Ti dal v ol ume is no t affec ted b y fresh gas f low b ecause ex cess g as is v ented through the sp ill v alv e.

On some v enti lators , the ins piratory fl ow is adjus table (Fig. 12.48). Th ere may also be a setting that c ontro ls the inspi ra tory ri se time. For pa tients with goo d co mpliance, insp iratory flo w s hould be high to ensure tha t th e i ns piratory p res sure i s rapidl y atta ine d. Limiting the maxi mum insp iratory flo w i s useful to av oid ov ers hooti ng the target pres sure, es pec ially wh en compl ianc e is low. In patien ts wi th l ung inj ury or during s ingle -l ung v enti lation , pressu re con trol v enti lation may improv e ox ygen ation and p roduce greater tidal v olumes than v olume c ontrol v enti lation beca use of the decelerating flo w pa ttern that deliv ers gas to the alv eoli early du ri ng inspi ra tion (31). It i s of ten us ed with s up rag lo ttic dev ices and p ati ents wi th na rrow o r parti al ly obs truc te d tracheal tubes to prov ide v enti lation at relativ ely l ow pressu res (34,35). It may be useful if there is a n a irway l eak (e .g ., uncuffed tube , sup rag lottic ai rway dev ice , bronchopl eural fis tul a). Howev er, if the re i s a large leak , the c ycl ing p res sure l imit ma y not be reached, c aus ing a prol onged i nspi rati on (18). Durin g closed s ys tem s uctio ni ng (Chapte r 3), pre ssu re con trol v entilation resu lts in l ess i ntrins ic PEEP durin g c atheter i nsertion and les s suba tmos pheric p res sure during s uc tioni ng than durin g v ol ume c on trol v enti lation (28,29).

Intermittent Mandatory
W ith in te rmi ttent mandatory v entilation (IMV ), the v entil ato r del iv ers mechanic al (mandatory, au toma tic ) b rea ths at a p res et rate and permi ts s pon taneous , unassis ted breaths of a c ontrol labl e i ns pi ratory gas mix tu re between mec hanica l breaths . The v en ti la tor has a sec onda ry sourc e of gas f lo w f or s pontaneous breaths . This u ti l izes eithe r conti nuous gas flow wi thi n the c ircu it o r a demand v alv e that opens to al lo w gas to flow f rom a res erv oi r. Continuous gas flo w a t a rate greater than peak inspi ratory fl ow inv olv es n o addi tiona l work of breathing but requi res a large v olume of f resh gas . The demand v alv e sys tem, al though more ef fic ient in f res h gas us e , can impos e s ignifi cant work of breathing on the pa tient. This mode is of ten us ed fo r weaning pa tients from mecha nic al v entilation. The IMV rate is graduall y P .318 reduc ed, al lowi ng inc re ased time for the patient's s pontaneous breaths.

Synchronized Intermittent Mandatory

S ynchroni zed i ntermi tten t manda tory v en ti lati on (S IMV ) s ync hro nizes v en ti lato rdeliv ered breaths wi th the patient's spontaneous breaths . If pati ent insp iratory

ac tiv i ty is detec ted, the v entil ator sy nchronizes i ts ma ndatory bre aths so that th e se t res pi ratory freque ncy is achiev ed. Pos i tiv e press ure (mandatory) breaths may oc cur at irregular i nte rv als . The time be twe en the end of eac h mandatory breath and the beginni ng of the nex t i s subd iv ided into a spon taneous b rea thing time and a tri gge r ti me. Duri ng the tri gger ti me, the v enti la tor c hec ks whether the ai rway pressu re has dropped a minimum amount belo w the pressu re meas ure d at the end of the exp iratory phase . If a drop is not s ens ed, the v en til ato r del iv ers a breath. The trigger wi ndo w may be adjus table (Fig. 12.49). A manda tory ti dal v olume and a minimum mec hanical v en tila ti on ra te mus t be se lec te d. This determin es the mi ni mum minute v enti la tion. When setting the v enti lato r ra te, the pa tient's s pontaneous rate mus t be cons idered. If the S IMV rate i s set too high, the pa tient ma y b ecome apneic . Se tting a n I:E ratio is not requ ired i n S IMV . The I:E ratio wi l l c hange as the patient's respi ra tory ra te and rhythm changes . S IMV is used to fac ili ta te emergence from anes thes ia as the p ati ent trans itions f rom c on trol led to sponta neous v entil ati on. It ens ures a mi ni mal amount of v enti lation whi le freeing the anes thesi a p rov ider from periodic al ly v entil ating the pati ent b y hand. It reduc es the inc idence of patient-v enti lato r disharmony wh ere the pati ent tri es to fight the v entil ator and the need for s edation or narcos is for the pati ent to to lerate mecha nic al v entilatio n. During a nes thesia , S IMV may be used to prov ide backup mec hanica l v en ti la tion for sponta neous l y breathing p ati ents . S IMV can be c ombined wi th pres sure s uppo rt v entil ation (PSV ).

Mandatory Minute
Mand ato ry mi nute v entilati on (MMV ) i s a meth od of mec hanical v entila ti on in wh ich the amoun t of v enti latory support is automatic ally adjus ted to fluc tua ti ons i n spontaneous v en ti la tion so that a pres e t min ute v entilatio n is deliv ered. The v enti lato r c i rc uitry mo nitors spon taneous expi red v olume and, if i t falls below a predetermined lev el , prov ides the di fference be twe en the s elec ted and ac tua l minute v olume.

Pressure Support
PSV (p res sure-assis ted or assis ted spontaneous v enti lation) has been a feature of ICU v entilators f or years and is now o n ma ny anes thes ia v enti lators (36 ,37,3 8,39). It is designed to augme nt th e patien t's spo nta neous breath in g b y appl ying pos itiv e press ure to the ai rway in res ponse to patient-in itiated b rea ths . A disadv antage of

this mode of v enti lation is tha t if the patient fai ls to make an y res pi ratory eff ort, no press ure -su pported breaths wil l be i ni tiated. To av oi d this potentially disas trous s i tuation , mos t v entil ators hav e a backup or apneic S IMV rate in cas e tha t the pati ent's s pontaneous respi ration ce ases (ass is t/control v entil ation ). A supported breath may be pressu re or fl ow i ni tiated. Flo w t ri ggeri ng imposes l es s i nspi rato ry work l oad than press ure tri gge ri ng and is used more frequently (40). W hen the use r-s el ected f low or s ub-base line press ure c aused by a s pontaneous breath is reached, fl ow f rom the v en til ato r begi ns and the se t pressu re is quick l y reached. The v entil ator then modula tes the f low to ma intain that press ure . The flow dec reas es unti l i t falls below a predetermine d f rac tion of the ini tial rate (us ual ly 5 % or 25%) or a fixed fl ow (us ual ly 5 L/minute) or af ter a spec ific duration as a bac kup (41). A t this p oin t, f low i s termi nated and exhal ation b egins . Because th e P SV lev el i s reached ea rl y in insp iration and is mai ntai ned th roughou t the ins pi ratory phas e, the pressure wav eform has a squa re, flat-topped shape. PEEP may be added if needed. The anes thes ia prov ide r mus t s et the trigger s ens i tiv i ty and th e i ns piratory p res sure (usua lly from 5 to 10 c m H 2 O). The triggering s ens itiv i ty should be set s o that it wi l l respond to inspi rato ry effo rt wi thout auto-c yc lin g in respons e to a rtifac tual c hanges i n a irway press ures . The i ni tial ins pi ratory flow is us ual ly nonad jus table but can be change d on s ome v en ti la tors by adjus ting th e ins pi ratory rise ti me (Fig. 12.48). The opti mal ini ti al insp iratory f lo w i s highes t in p ati en ts wi th l ow compli ance , hi gh resis tance , and mos t ac tiv e v enti latory drive . On some v enti lato rs , the trigge r wi ndow c an be changed (F ig. 12.49). Ti dal v olume is de te rmined by the pressu re sup port lev el , l ung cha rac te ris tic s, and pati ent e ffort. The d esi red ti dal v ol ume s hou ld be ca lc ula te d and the p res sure support l ev el adjus ted so that the des ired volume is del iv ered. If the ex hal ed v olume is in adequate, the inspi ratory pressu re should b e i nc reased or i ns piratory rise time dec reas ed (if adjus table). PE EP may ca use an inc reas e i n tidal v olume (42). Very h igh ins piratory f low (due to a hig h s et press ure) may dec rease tidal v olume by p rematurel y terminating i nspiration (37). As the patient's effo rt i nc reas es , the lev el of inspi ra to ry press ure can be red uced . Undes ired hyperv enti lation can be treated b y adj us ting the trigge r sens itiv ity, pressure lev el , or tri gger wi ndow or, if these seem adequa te, addi tion al s edatio n. PSV c an b e used to reduc e the patien t's work of spo ntaneous b rea th ing (38,43,44). In addi tion, it c an inc rease the fu nc tional res idua l capaci ty . It may be us eful for preox ygenating ob ese patients by imp rov ing the effic ienc y

P .319 of s pontaneous v entilation and during we ani ng from mec hanic al v entilation. It can be us efu l wi th a s up rag lottic ai rway dev ice to k eep the ai rwa y p res sure lo wer than the supraglottic dev ic e leak pressure (3 8,42,4 5). If there is a leak around the dev ic e, PSV wi ll be able to c omp ens ate for the leak to s ome ex tent, as the air way press ure is maintained irres pec tiv e of the volume. An adv antage of PSV is the s ync hrony between the patient and the v entilator. The pati ent c ontrols ra te , v ol ume, and ins pi ra tory ti me. This may inc reas e patient co mfort. B rea th s tack in g and f ighting the ven ti lato r are dec reased. E v en patients who are in itia ll y tachy-pneic may be s ucc essful ly manage d i n th is mode, as the press ure s upport can be set s uffic iently high to augmen t tidal v olume and he nce reduc e the respi ra to ry ra te. P eak an d me an ai rway pres sures are lower tha n wi th v olume c ontrol v enti lation, reduc ing the ris k of barotrau ma (42). Too high an i nspiratory f lo w ma y c aus e p atien t discomfort (3 3). PSV wil l deliv er a v a ri able minu te v olu me in a patien t wi th a changing respi ratory driv e. Inappropria te v enti lato r tri ggering c an occ ur wi th P SV (40,46,47). This may be caus ed by a leak or a dec rease in airway press ure c aused by cardiac contrac tions . W ith c lose d s ys tem suc tioning, P SV resu lts in a lower a ir way press ure du ring ca the ter ins ertion and highe r end-ex piratory p res sure during s uc tioning than either v olume c ontrol or pressu re control v entilatio n (28,48 ).

Specific Ventilators Drager AV2+

The A V2+ is the suc cess or to the AVE and AV 2 v en-ti lato rs .

Description
The A V2+ is sh own in Figures 12 .3 and 12.4 . It has an asc ending bellows . Ti dal v olume is adjus ted by us ing the kn ob abov e the be llows as sembl y, whic h rais es o r l owers a p la te at the top of the bel lo ws . A sca le on the bel lows hous ing p rov id es a rough i ndication of the ti dal v olume del iv ered. Mos t v enti la tor c ontro ls are located ac ross the top of th e v entilator. To the lef t of the tidal v olume con trol an d abov e the bel lows is the inspi rato ry press ure l imi t control . On the lef t abov e the p res sure limit and tida l v olume controls is the f requenc y contro l wi th a digital P .320

readout to the left. To the right of the freque ncy co ntrol a re the c ontrol and dis play for th e I:E ratio . In order to s et an inv erse ratio, an ex tended range button below the display and control must be depressed.

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

View Figure

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

View Figure

To the right of the I:E ratio control a re the ins pi ratory flow c ontrol and gauge . The sc ale o n the gauge is d iv ided into lo w, medium, an d high fl ow. To the right is the v enti lator ON/OFF s wi tc h. A green l igh t nex t to the s wi tc h i ndicates that the v en ti lato r is turned ON. The v entilator may be turn ed ON a t this s wi tch or by turning the Manual /A u tomatic swi tc h on the absorber to the au toma tic

position. The v enti lator c ontrol s wi tc h c an onl y be tu rned ON wi th the Manu al /A utomatic s wi tch in th e Au toma tic pos ition. If the ON/OFF s wi tc h is turned ON with th e b ag/v ent selec tor s witch in the bag p osi tion, a faul t l ight to the lef t of the ON/OFF s witch wi ll b e i l lumina ted . The s pil l v alv e (Fig. 1 2.5 ) is at the base of the bel lows ass embl y. A pi lo t line f rom the canis ter c onnec ts through the top of th e spi ll v alv e to a ba lloon diaph ragm. P ress ure i n the canis te r c auses the bal loon diaphragm to be i nfla ted , c los ing the opening to the scav engin g s ys tem. Th e ball in the spil l v alv e ensures that a certa in press ure mus t be pres en t to all ow gas flow through the spill v alv e, ev en if th e balloon diaph ragm is defla ted . This resul ts in approx imatel y 2 c m H 2 O PE EP in the breathi ng s ys tem. The internal c ons truc ti on is shown i n Fi gures 12.6 to 12.9. T he inspi ratory pressu re regulator reduc es the gas from approx imatel y 50 psig to the v alue in dicated on the i nspi rato ry flow ga uge. A so lenoi d in the oxy gen line links the p neuma tic and elec tronic porti ons of the v entil ator. Wh en the s olenoid is energized, i t al lo ws gas to fl ow through the co ntrol v alv e in the ox ygen l ine to the Ve ntu ri mechanis m. A smal l-diameter tube ca rries ox yge n from the i nspi rato ry f low regulator to the top of the au to-ra nging v alv e, which c on trols the amount of ambient ai r en trained at an y giv en ins piratory s etting. The auto-rang ing v alv e contai ns a diaphragm that is depressed when pressure is applied. The plunger mov es downward , c ontroll ing the opening through which ambient a ir is entrained during insp iration.

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

View Figure

P .321

The c ontrol v alv e al lo ws gas to f low through i t when p res sure is applied . The Ven turi receiv es ox yg en from the co ntrol v alv e and ai r f rom th e auto-ranging v alv e and c ombi nes them to form th e d riv e gas that pushes the b ellows down ward during i nspi rati on . The pilot ac tuato r, wh ich c ontrols the open ing of the exhaus t v alv e, ope rates in respons e to oxygen pressure th at enters at the top . W hen suff ic ien t pressu re is applied, the v alv e mov es do wnward agai ns t th e s pri ng , whic h cl oses the v alv e wh en no press ure is app li ed. Du ri ng inspi ra ti on, the pres sure of the d riv ing gas ins ide the bellows housing pus hes the bellows d ownwa rd. W hen no pressure is appl ie d to the pi lot ac tua tor, the exhaus t v alv e opens , and the driv ing gas flows to atmosphe re through the exhaus t v alv e.

Controls
The v entil ator c an d el iv e r tidal v olumes f rom 20 to 1500 mL. Respi ra tory rate c an be se t from 1 to 99 breaths per minute (bpm). Ins piratory f low c an be set between 10 an d 100 L/minu te. The I:E ratio c an be set f rom 1 :4.5 to 4:1. The ins pi ratory press ure limi t range is 15 to 120 cm H 2 O.

Alarms

The A V2+ ala rms are assoc iate d with the an es thes ia mac hine a nd are not part of the v enti la tor. A larm mess ages a re displ ay ed on th e anes thes ia mac hine moni to ri ng sc reen. W arnings are accompanied by a th ree -puls e pattern tha t is ini tial l y repeated ev ery f ew sec onds in a s eries o f des cending v olu me a nd th en cons tantl y at full v olume un til the alarm c ondi tion is reso lv ed. Ca uti ons a re ac companie d b y a three-p uls e tone pattern tha t is repe ated every 30 s ec onds . A dv iso ries util i ze a s ingle tone or no sound, dependi ng on the a dv isory. T he highes t priori ty cu rrently ac tiv e alarm c ondi tion is annunc iated. Audio s ign als f or lower-pri ority al arm condi tions a re te mporari l y s upp res sed to minimize confus ion ca used b y s imul ta neous ala rms.

Ventilation Modes
Volume co ntrol is th e onl y v entilatory mode on th is v entilator. The v en tila tor is time c ycled and v olume prese t.

Inspiration
Durin g ins pi ration (Fig. 1 2.6 ), the con trolle r energi zes the soleno id and pressurizes the control v alv e, caus ing it to open. This allo ws oxygen from the pres sure regulator to f low to th e bel lo ws assembly . A smal l portion of the ox yge n is div erte d to the pi lot ac tua tor. This causes the pi lo t ac tuator to mov e down ward, sealing the ex haus t v alv e and p rev enting d riv e gas f rom es cap ing to atmosphe re. A s ma ll portion of the regu lated ox ygen also f lo ws to the auto-rang ing v alv e and opens i t in proportion to the s etting on the ins piratory fl ow regu la tor. Ox ygen flows through the V enturi, entraining room a ir. The driv e gas , c ons is ting of ox ygen an d entrained ai r, then pressu ri zes the space between the bello ws and the canis te r. Th is causes the be llows to b e c ompress ed and gas es insi de the b ellows f low to the breathi ng s ys tem. The s pil l v alv e prev ents gas es from enteri ng the scav enging s ys tem during i nspi rati on . Driv e gas fl ows th rough the p ilot l ine and inflates a bal loon diaphragm that bloc ks the outlet between the ins ide of th e bel lo ws and the s cav enging s ys tem. This v alv e remains cl osed until the bellows has reac hed i ts limi t of expans ion during exhala tion.

Inspiratory Pause
Durin g the ins piratory pa use (Fig . 12.7), the c ontrol ler continu es to energ ize the so len oi d. As long as ox ygen flo ws to the bello ws assembly , press ure on the pi lo t ac tua tor is maintained, and the exhaus t v alv e remai ns clos ed. S inc e the bel lows is

co mple tel y comp res sed , no addi tional gas can enter the bellows housing, and no more air is entrain ed by the Venturi . Ex cess ox ygen is v ente d to atmos phere through the air entrainmen t port. T he pi lot line and the ball oon di aph rag m P .322 i n the sp il l v alv e remai n pressu ri zed , s o gas f lo w to th e s cav engi ng s ys tem remains block ed.

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

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Exhalation
Durin g exha lation (Fig. 1 2.8 ), the controlle r de-energi zes the so lenoid, whic h s tops the flow of ox ygen through i t. The oxy gen in the tubi ng between the solen oid an d the supp ly v alv e is v ented to atmosphere v ia a smal l ex haus t tube at the top of the so len oi d. Onc e this oxy gen is v ented, the co ntrol v alv e c loses and s to ps the f low of ox ygen to the V entu ri . This also al lo ws the pi lot ac tua to r to dep res surize. W i th the pi lot ac tua tor d epress uri zed , the spring f orces the plunge r upward, o pening the ex haus t port. E xhaled gases push the bell ows up ward. Driv e gas v ents to atmosphere through the exhaus t port. As the press ure in the c anis ter dec reases , the pressure wi thin the pilot l ine for the s pill v alv e als o dec reas es , and the ball oon diaph ragm deflates . The bal l check v alv e be lo w the bal loon diaph rag m prese nts more res is tanc e to the flow of ex haled gas than does the bellows , so ex haled gas es

P .323

P .324 continue to fi l l th e bel lows . Expiratory f lo w ends when the bel lows re aches the plate at the top.

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

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

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Expiratory Pause
Af ter the bellows has reached max imum expans ion (Fig. 12.9), th e expi ra tory pause time beg ins . The s olenoid and the supp ly va lv e remai n cl osed. The pres sure in the pi lot line to the s pil l v alv e dec reas es to atmos pheric , and the bal loon diaphragm defl ates . W hen p res sure from gas in the bell ows exc eeds the resis tance c reated by the wei ght of the ba ll in the spi ll v alv e, the ball is l if ted, and g ases c an flow in to the sc av engi ng s ys tem.

Special Features
A saf ety rel ief v alv e v ents driv e gas to atmosph ere if the driv e gas p res sure ex ceeds 120 cm H 2 O. In the ev ent of mains power f ai lure, a ful ly c harged ba ttery wi l l powe r th e v entilator for app rox imatel y 20 minutes . There are yell ow ind ic ato rs to s ignif y that there is al te rna ti ng cu rrent (AC) power fa ilure and th at the battery powe r is l ow. If the machine h as s wi tc hed to P .325 battery power, a three-pulse tone sounds ev ery 30 s econds . A ba ttery tes t butto n is present on the machine. A g reen battery tes t i ndicator s ign if ies tha t th e battery power i s s atisfac tory. Ba ttery messages are dis played on the moni tor sc reen .

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

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Hazards
The problems disc uss ed below were reported with the p red eces sor A V -E v entila tor. S ince the two v entilators a re s imilar i n construc tion, there is a possibili ty that s imilar p roblems c ould occ ur wi th the AV2+ v en ti la tor. A cas e has been repo rted in whic h the muf fler plac ed ov er the driv ing gas exhaus t became s aturated with water and obs truc ted the flow from the b ellows c hamber (49). This res ul ted i n high air way press ures as gas continued to f lo w i nto the v enti lato r. In another repo rted cas e, th e contro l v alv e malf unc tioned , res ul ti ng in c ontinuous driv in g gas flow to the bel lows (5 0). High air way pressu res resu lted. P .326

P rolongation of the ins pi ra tory phase owi ng to i nsuff ic ien t parts lubric ation h as been rep orted (51). Ven ti la to ry i rregularities res ul ti ng from imprope r s ea ting between the bell ows and i ts mount hav e been reported (52). The re has been a report of the spill v alv e becomi ng incompe ten t, resu lting in hypov enti lation (53). In othe r rep orted cases , the pil ot line c onnec ting the bel lows

chamber to the s pi ll v alv e beca me k inked so that i t was occ lude d (54,55). If the pi lot line becomes occluded during i nsp iration , hypov en tila ti on wi ll res ult beca use the spill v alv e wi ll be open . If the oc c lusi on occ urs duri ng ex halation , gas wi ll be unable to ex i t the c i rc uit, an d the press ure ins ide the c i rc uit wil l i nc reas e. PEE P can resu lt under certai n ci rc ums tanc es . Th is was repo rted when some hoses were dra ped ov er th e s pi ll v alv e, p artially obs truc ting the p ilot l ine (56 ,57 ).

Cleaning and Ster ilization

Cl eaning and dis infec tion or s teril izati on are c ompl ica ted ma tters b eyond the sc ope of this tex t. They are explained in detai l in the ope rator's manual .

Drager Divan
The Div an v entilator (dig ital v entilator for an es thes ia) is a c omp onent of the North A meric an Drager 6000 series machi nes .

Description
The v entil ator c ontrol panel (Fi g. 1 2.10) is s ituated at the f ron t of the anes th esia machine b el ow the desktop. To alter a func ti on, the key f or that f unc tion is pressed . Changes are made by us ing the ro ta ry k nob at the ri ght of th e c ontro l pane l and the change co nfi rmed by press ing the knob. If the al tered v alue or mode is not confi rme d within 10 seco nds , the v entilator retu rns to the prev ious v alue. A t the left s id e of the contro l panel is a Manual / Spontaneous key. After pres s ing this k ey and confi rming the setting , th e patien t can breathe s pontaneo usl y or be v enti lated manual l y by adj usting the AP L v alv e. Below th e Ma nual /S pontaneous ke y is the Volume Mode k ey. W hen i t is p res sed and i ts func tion confi rmed, the v en tila tor goes into the v olume c ontrol mode. Be lo w the v olume mode ke y is the S IMV key . To the ri ght of th is ke y is the key for press ure c ontrol v enti lation (P res Mode ). To the right of the Manual /Spontane ous ke y is a wi ndow wi th a bar g raph that i ndicates pis ton mov ement and d is plays the percent of the set tidal v olume (0% represen ts f ull ex ha la tion, whil e 100 % indicates i nspi ration to the se t tidal v ol ume). Below th e bar graph wi ndo w i s a numeric disp la y wi ndow tha t displ ays the v alues for th e keys belo w i t. A t th e lef t is the s etting for max imum a ll owab le press ure (P max ) i n the v olume and S IMV modes or preset airway pres sure (Pse t) i n the press ure c ontrol mode. In th e middle is the se ttin g for tidal v olume i n the S IMV and v olume c ontrol modes . A t the ri ght is th e res piratory rate setting. T o a lter a parameter, th e key under i t is p res sed and the ro tary knob rotated to i nc reas e o r

dec reas e the s etting. The new v alue is displaye d i n th e wind ow abov e the ke y. W hen the proper P .327 v alue is displaye d, i t is c onfirmed by pus hing the rotary k nob.

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

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To the right of the n umeric display is an alphanumeric disp la y. This prompts the operator to take certa in ac tions du ring the chec kout procedu re and updates the progress of the c heck out. Af ter a c hange in v en ti la tory mode or paramete r is made, there wi l l be a prompt to conf irm the change . Other mess ages repo rting s tatus an d faul ts are displ ayed h ere . Under th e alphanu meric display are addi tion al ke ys . The I:E key sets the I:E ratio . The % I.P ./Fl ow key s ets the ra tio of i nspi rato ry pa use time to insp iration p hase time i n the v olume c ontrol and S IMV mod es and the inspi ratory flow ra te in the press ure c ontrol mode. T he PEEP k ey is used to set the P EEP in a ll mo des . The S IMV Ra te ke y s ets the mi ni mum v entil atory rate in the S IMV mode. A t the ri gh t s ide of the control pa nel is a s ta ndby k ey. In this mode , driv e g as use is minimi ze d, and i nspec tion or repai rs can be performed. Abov e th e s tandby ke y is a tes t ke y. Th is ca uses the v entil ato r to measure s ys tem co mpliance and leaka ge. Th is c an onl y be in itia ted wh en the v entilator is in the s tandby mode. Below th e tabletop is an elec tricall y powered pis ton (Fig. 12.1 1). The manufac turer of fe rs an op ti ona l to p c ov er with a transpare nt wi ndow that al lows th e user to see

pis ton mov ement. If there is inadequa te gas i n the breathing s ys tem to al lo w the pis ton to retrac t fu lly, the pis ton wil l s top an d ale rt the anes thesi a prov ider. This wi ll prev ent a negativ e pressure from being exe rted (23). A heater i s incorporated in to the abso rbe r head to minimize mois tu re co ndensation. The internal c ons truc ti on of the v entilator and b rea thing sys tem is sho wn i n Figures 12.12 to 12.17. V 1 is the f resh gas decoup ling v alv e. V2 is the su rpl us gas v alv e. V3 is the v alv e that controls gas flow to the AP L and gas relief v alv es . Gas is as pirated from near the pa tient port, anal yzed , and retu rned to th e c ircui t downs trea m of the ex pi ratory uni di rec tiona l v alv e. A n ultrason ic flo w s enso r (Chapter 23 ) and PE EP v alv e a re located in the ex pi ratory limb.

Controls
The v entil ator c annot be s et to v alues resulting in an inspi ra to ry flow greater than 75 L/min ute, a minute v olume g rea ter than 2 5 L /minute, or an expi rato ry time of l ess than 400 ms . PEE P can b e s et f rom 0 to 20 (def aul t 0) c m H 2 O. PEEP is not av ail able in the Man/Spont or S IMV modes . The peak ai rwa y p res sure (Pmax /Ps et) c an be se t from 10 to 80 (defaul t 25) cm H 2 O i n the v olume c ontrol and S IMV mod es and 10 to 70 (default 10) cm H 2 O in the press ure c ontrol mode. W he n the max imum al lo wable pressure is reac hed, fl ow is adjus ted s o tha t the p res sure remains c ons tant through the end of inspi ration. In this s ituation, the fu ll ti dal v ol ume may not b e deliv e red .

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

View Figure

The mi ni mum d iffe rence between Pmax and PE EP is 5 cm H 2 O. If the pressu re i nc reas es by more than 5 cm H 2 O abov e Pmax , ins pi ration is immediate ly s topped and expi ration beg ins . The % inspi ratory paus e/flow (% I.P ./Fl ow) s ets the length of the inspi ratory paus e i n the v olume c ontrol and S IMV modes or the inspi ra tory flow in the press ure control mode. The p ause range is 0% to 60% (d efa ult 10%). During press ure c ontrol v enti lation , the ins piratory f low rate can be se t from 5 to 75 (defaul t 50) L/minute. The av ai la ble tidal v olumes are 10 to 19 mL, 20 to 100 mL, and 110 to 14 00 (defaul t 600 ) mL. The resp iratory rate rang e is 6 to 80 (default 12) bpm in the v olume and press ure control modes and 3 to 8 0 (default 12) bpm in the S IMV mode. The range o f av ail able I:E ratios is 1:3 to 2:1 (default 1:2 ). If an inv e rse I:E rati o is se t and co nfi rmed, a mess age is dis pl ayed .

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

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P .328

Alarms
A larm limi ts , which dep end on the v enti la tory mode and the pati ent, are p res ented i n a n ala rm win dow on the machine moni to r sc reen . If an ala rm limit is ex cee ded or not reached , the a la rm li mits menu is displayed, and the v alue is highligh te d. Related alarms are combined. A mess age th at i ndicates the compu ter analys is of the problem wi l l appear. The alarm s ilenc e key i n the al arm wi ndo w a llows the ala rms to be audio paus ed (s ilenced) f or 60 s eco nds i f pressed o nce and for 12 0 seconds if presse d twi ce. A larms c an be sus pend ed by press ing a key o n the bo ttom o f the s c reen. W arnin gs are announc ed by a three-ton e s equence of h igh, high, low. The tones are als o in a seq uenc e of different v ol umes wi th the fi rs t and fourth s equence bei ng at full v olume . A larm mess ages are displaye d on a f lashing red back ground wi th whi te tex t. The f lashing s tops wh en the alarm s ilence button is dep res sed . Flashing resumes wh en th e audi o paus e (s i lence ) perio d has ended.

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

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P .329

Cau tions are displ ayed o n a f lashing ye ll ow back ground in black tex t. The mess ages a re announc ed by a th ree -tone burs t of lo w, l o w, hi gh. A nnouncements oc cur ev ery 30 s econds . Adv is ori es are displ ayed on a wh ite back gro und wi th blac k tex t tha t does not f lash. A s ingle tone ma y sound. An al arm l og can be ac ces sed. It wi l l al lo w t he cl in ic ian to obse rv e a ll a la rm ev en ts that hav e occ urred du ri ng the c ase. It c an store up to 500 ev ents .

Ventilation Modes
The desi red mode (Volume or P ress ure Co ntrol o r S IMV ) is selec ted by push ing the ke y for that mode and co nfi rming that c hoice. In the press ure c ontrol mode, ins piratory f low rate can be se t in dependen t of ai rway press ure (Pset). Howev er, P set may no t be ach iev ed if the i ns piratory f low rate is too lo w. In this c ase , an alarm mess age wi ll be dis played .

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

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P .330

Durin g S IMV , the time between each mand ato ry res pi ration an d the begin ning of the nex t is subdiv ided into a spontaneous breathing time (Ts pont) and a tri gger time (T trig ger). Du ri ng th e trigger ti me, the s ys tem c heck s whether the ai rwa y press ure has dropped at leas t 0.5 c m H 2 O below the pres sure me asured at the end of expi ra tion. If this has not occu rred, the ven ti lato r deliv ers a breath.

Spontaneous Breathing
To al low s pontaneous breathi ng, the MA NUAL /SP ONTA NE OUS k ey is pressed and the APL v alv e s e t to S P ONT . Valv es V 1 an d V 3 a re open, whi l e V2 is cl osed. W hen the patie nt inspi res (Fi g. 12.12), the i nspiratory v alv e opens , and g as fl ows f rom the res erv oi r bag. During ex halation (Fi g. 12 .13 ), the exp iratory v alv e opens , and ex hal ed gas es pas s through the abs orb er and i nto the bag. During late ex halation, the pressure rises , P .331 and exces s gas flows through V 3 an d the gas reli ef v alv e to the s cav enging s ys tem.

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

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Manual
For ma nual v enti la tion, the Manual /Spo ntaneous key is pressed , and the APL v alv e i s set to MA N. The press ure d uring ins pi ration wi ll be li mited by the A PL v alv e se ttin g. W hen the pressu re l imi t is reac hed, excess gas wi l l flow th rou gh V 3 and the AP L v alv e to the s cav engi ng s ys tem through the gas rel ief v alv e (F ig. 12.14). Durin g exha lation, exhal ed gases flow thro ugh the abso rbe r in to the res erv oi r bag.

Mechanical
W hen mec hanica l v en ti la tion is s elec ted, the APL v alv e is clos ed. The bag func ti ons as a reserv oi r f or fres h gas . Durin g ins pi ration (Fig. 1 2.15), v alv es V1, V2, and V 3 a re c losed. Pis ton mov ement produces gas f low through the inspi ra to ry valv e to the patient port. Fres h gas P .332 continues to en ter the reserv oi r ba g but does not aff ect the tidal v olume , bec aus e v alv e V1 is c losed (fres h g as dec oupli ng).

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

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W hen ex halation begins , the ex piratory v alve opens, all owi ng exha led gases to fl ow through the abso rbe r and into the re trac tin g pis ton and to the res erv oi r bag through V1, whic h opens. Valv es V 2 and V 3 rema in c los ed. Fresh gas fl owi ng in to the s ys tem mix es wi th s ome of the exha led gases in the p is ton v entilator. Mid ex hal ation is depic ted in Figure 12 .16 . The pis ton re trac ts , allowi ng the c yl in der to f il l wi th gas from the reserv oi r bag and fresh gas . During the later part of exha lation (Fig . 12.17), V2 opens , a nd gases are v ente d to the scav engi ng s ys tem through the gas rel ief (s pil l ) v alv e.

Special Features
The Div an v entilator decouples f resh gas f lo w f ro m tid al v olume . Fresh gas en tering the ci rcu it duri ng insp iration P .333 i s iso la ted f rom the patient c i rc ui t and ac cumul ates in the reserv oi r ba g. If the ox ygen f lush is ac tiv ated du ri ng inspi rati on, the gas wil l no t be add ed to the tidal v olume bu t wi ll e nte r th e rese rv oir bag (2 3). T he res erv oi r bag wi ll inf late and defl ate d uring mec hanical v entila ti on.

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

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This v entil ato r compensates for breathing sys tem c ompliance and gas c ompression so that the pati ent rece iv es the s et tida l v olume . Information that makes tidal v olume c ompens ation poss ible is ga thered d uring the automated checkou t. T he Ypiece mus t be oc c luded and f resh gas f lo w s et at a mi ni mum to perform thes e meas urements . S mal l -diameter b rea thing tubes are recommended fo r pediatri c patients where ti dal v olumes are less than 20 0 mL. After s witching to the pedia tric tubes , the leak and co mpliance tes t s hould b e performed before the pati ent is connec ted to the v enti lato r. If a low-c omplia nce ci rc ui t suc h as a pediatri c ci rcu it we re added wi thout P .334 conduc ting a compl ianc e tes t, the v enti la tor could del iv er ex ces siv e v olumes . To prev ent this f rom oc curri ng when a tidal v olume of les s than 200 mL is se lec ted, the v enti lato r wi ll use the measured c i rc ui t c ompl iance only if i t is 0 .8 mL/cm H 2 O or l ess (58). If the measured ci rcu it c ompl ia nce is hig her, a defaul t v alue of 0.6 mL/cm H 2 O is used . The breathing s ys tem and pis ton assemb ly are des igned to minimize c irc ui t v olume and the time that i t takes the s ys te m to resp ond to c hanges in f resh gas co mpos i tion . A low-f low wi zard helps th e c linici an to asses s the f resh gas su rplus . It prov ides graph ica l i nfo rmation of f res h gas surplus , a mes sage repo rt, and a hel p

ke y. The mes sag e a rea giv es rec ommenda tions for us e with low f lo ws , i nc luding bag s iz e and v enti la tor s ettings . W hen the anes thes ia machine is turned ON, a n automated chec kout process that requi res about 5 minu tes is set in motion . Oth er than a fe w prompts re mind ing the anes thes ia prov ider to s et a p res sure a t the AP L v alv e and to occlud e the Y-pi ece on the breathing s ys tem, this chec kou t is ful ly au toma tic . The chec kout allows the co mputer to dete rmine informatio n about gas comp res sion, l eak s , an d c ompl ianc e of the breathing s ys te m. If the v entilator de tec ts an internal faul t that mi ght affec t patien t saf ety during mechanical v enti la tion, i t i ni tiates a saf e s ta te i n whic h v entilation can be c ontinued i n the Manual /S pontaneo us mode. When the v entil ator en ters th e s afe s tate, the c linic ian is alerted by a disp la y read in g Equipment Fault, a nd an audibl e tone sounds . The v entil ato r now perfo rms as if i t were i n th e ma nual /spon tan eous mode. The v entil ator ov erride button is on the machine nea r th e abs orber head. It i s prov ided i n the ev ent the re is an unforeseen c ondi tion that the software d oes not recognize. Ac tiv ating this ov e rrid e remov es powe r from the v entilator and al lows manu al or s pontaneous v entil ation. The Na rkomed 6000 has battery bac kup that wi ll power the mac hine and v enti lato r for at leas t 30 minutes. An alarm indica tes wh en the battery has only ano ther 10 minutes . Af ter the batteri es are exhaus ted, the mac hi ne can c ontinue to be used wi th manual v entilatio n o r s pon taneous b rea thi ng . Res piton e is an opti on on the 6400 anes thes ia machine . It is a v en til ati on so und co mposed of two dis tinc t tones . One tone annunc iates whe n the press ure wav eform c ross es the apnea thresho ld du ri ng inhalation . Anothe r ton e annunc iates on the ris ing edge of a c arbon d iox ide wav eform co rres pondi ng to exhalation.

Evaluation
A compa ris on be twe en a Div an and an AV 2+ v entil ator was made duri ng s imul ated v enti lation of pediatric patients (59). The Div an offered adv antages in the low ti dal v olume range duri ng v olume control v entilati on. The Div an a nd an ICU v en ti lato r were c ompared by us ing b oth an infant l ung mod el and infants with c ongeni tal hea rt d is eas e (60,61). Both v enti lators prov ided adequate v en ti lation in the v olume c ontrol mode. In c omparison wi th an ICU v entilator and a n a nes thes ia v entil ator wi th a gas powered bellows during press ure c ontrol v enti lation, the Div an mai ntained tidal

v olume wi th i nc reas in g res piratory rates bette r th an the o the r anes thesi a v enti lator but not as we ll as the ICU v entilator (2).

Hazards
A high nega tiv e press ure applied to the ai rway c an ex ceed the abi l ity of the v enti lato r's negativ e press ure rel ief v alv e, caus in g the piston to l ock (62,63). The problem can be remedi ed by openi ng th e v entilator cov er and remov ing the pis ton to b reak the negativ e s eal . The v entil ator ov erride button is in a rather i nconspicuous place (64). A cas e of powe r supply failu re that interrupted v enti lation has been reporte d (64,65). The link age to the backup batteries p rev ented them f rom k ick ing in.

Cleaning and Disinfection

Mos t of the v enti la tor p arts , inc lu din g those ex posed to b rea thing gases , can be s team autoc lav ed. See the opera ti on manu al for spec ific dis ass embl y and s teril i zing ins truc ti ons .

Drager Fabius GS
Description
On the Fabius mach ine, the v entilatory module, wh ic h inc lud es a pis ton, is loc ated behind a door on the left s ide of the machine (F ig. 12.18). The pis ton is ins ide a metal c ase that wi ll s wi ng out wh en the door i s open ed (Fig. 12.1 9). A wi nd ow al lows the o perato r to v iew pi s ton mov ement. The pis ton as sembly is s hown i n Figures 1 2.20 and 12.21. E lec tric al power i s use d to raise and lower the pis ton. The moto r is n ear the botto m of the c y linder that holds the pis ton. There a re two rol li ng diaph rag ms tha t s eal the p iston and p rev ent mix ing of ambi ent and respi red gases . The upper d iap hra gm is attached at the top and f i ts ov er th e upper end of the pis ton. Th e lowe r part of u pper d iap hra gm rolls upward and downwa rd as the pis ton mov es upward and downwa rd (F ig. 12.20). The l ower d iaphragm is c onnec ted be tween the pis ton wal l an d the i nside of the c ylinde r. As the pis ton mov es down ward, the s pace abov e th e upper d iaphragm i nc reas es , al lowi ng exh aled gas es to enter that s pace . The re are h igh p res sure and negativ e p res sure reli ef v alv es on the top of the pis ton, c onnec ti ng wi th the s pace for re spi re d gas es .

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

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P .335

The disp la y s c reen is s hown in Figure 12 .22 (see page 338). A t the left si de are ke ys th at determine the v enti latory mode (v olume control , press ure co ntrol , manu al /sp ontaneo us ). A rotary mouse is at the bottom righ t of the sc reen . Once a parameter i s sel ec ted , the v alue is al tered b y turning the rotary mouse and is confi rme d by depress in g i t. The S tandb y k ey is to th e right of the rotary mouse. To the right of the rotary mo use and abov e the S tandby k ey is the Mains Power li ghtemi tti ng diode (LED), wh ic h, when l i t, c onfirms that the machine is c onn ec ted to a func ti oning elec tric al s ys tem. To the right of the s c reen are three keys . Th e bottom one is the Home k ey. It caus es the main sc reen to be dis pla yed. The Setup k ey is abov e the Home k ey. W hen press ed, the displ ay ed win dow enab les the opera tor to v iew and change v enti lation and to rev iew s etti ngs . P .336 Abov e th e S etup k ey is the Alarms k ey. W he n p res sed, alarm limi ts are shown on the right s ide of the s c reen. To the righ t of the Al arms ke y is the A larm S i lence k ey . Pus hing this causes ac tiv e al arms to be aud io paused for 2 mi nutes .

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

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

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To the right of the A larms key are two LE D lamps that i ndica te the urg ency of th e alarm mes sage . A s ta tus bar nea r the top of the sc reen d is plays the v enti latory mode be ing used. It als o d is pla ys al arm si lence s tatus , battery powe r lev el , and the time. To the left s ide of the s c reen are v irtu al flowme ters fo r ai r, ox yge n, and n itrous ox ide . To the ri ght of the f lo wmeters in the upper thi rd of the sc reen is an al arm wi ndow. This dis plays up to fou r of the highes t priori ty

P .337 alarms . To the ri ght of th is wi ndo w, th e ins pired ox ygen c once ntration a nd alarm l imi ts for ox ygen c oncentration are disp layed. The res pi ratory v olume moni to r wi ndow i s the mi ddl e win dow to the right of the flowmeter wi ndo w. It dis plays respi ra to ry ra te and ti dal and minu te v olumes . B el ow the res piratory v ol ume win dow i s the breathing press ure mon itor wi ndow. It d is pla ys PEEP v al ues and peak and mean insp iratory p res sures . Be lo w the fl owmeters and the bre ath ing p res sure wi ndow i s the breathing press ure wav ef orm wi ndow. B elo w thi s are s ix wi ndows as soc iated wi th v entil ato r parameters . Below th ese wi ndows a re ke ys fo r the as soc iated parameters .

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

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Controls
The range f or the maxi mum v entila ti on pressu re (P MA X ) is 10 to 70 (defa ult 40) cm H 2 O. Othe r con trols a re disc usse d under the indiv idual v en tila ti on modes . W ith v ol ume co ntrol v entil ation frequenc y ca n be s et f rom 4 to 60 (defaul t 12 ) bpm. The time ratio between the inspi rato ry and expi ra tory ti me phas es (T i:Te) range is 4:1 to 1:4 (defau lt 1:2 ). The i ns pi ratory p aus e c an be s et f rom 0 % to 5 0% (defaul t 10%). PE EP can be s et f rom 0 to 20 (default 0) c m H 2 O. The range for tidal v olume i s 20 to 1400 (defau lt 600) mL. In the press ure c ontrol mode, the i nspi rato ry press ure (P I N S P ) can be se t from 5 to 60 (defaul t 15) c m H 2 O, P .338

and the i nspi rato ry f low c an be set f ro m 10 to 75 (defau lt 30) L/minute . PEEP can be se t from 2 to 20 (defaul t 0) c m H 2 O. V entil ation f requenc y can be s et f rom 4 to 60 (defaul t 12) bpm.

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

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Alarms
A larms a re automatical ly e nabled whe n the v enti lato r is s witche d to a v enti la tion mode . Al arm mess ages are displayed in the ala rm box in the center of the top of the data sc reen. The tex t displays are fol lowed by exc lama tion marks (! ). T here a re three ma rks (!!! ) for warn ings , two (! !) for ca ution , and one (! ) for adv isories . The LE Ds to the right of the al arm s ilenc e k ey i ndicate the urgenc y of the alarm condi tion. A wa rni ng is s ignaled by a bl ink ing red LE D . A c aution is ex pressed by a bl inki ng yel low LED. An adv is ory is indic ated by a con tinuous yel lo w L E D. W arn ing tones are con ti nuous . Ca uti on tones enunc iate ev e ry 30 sec onds . A n adv is ory has a s ingle or no tone.

Ventilation Modes
The Fa bi us offers v olume con trol an d pressure con trol v enti lation . PSV c an be added. W he n the v entilation mod e is ch ange d, the func tion is displaye d ac ross the bottom of th e data s c re en and abov e the appropria te ke y.

Standby
In the S tandb y mode, the v enti lato r s tops , and the moni toring and al arms a re turned OFF. If gas f lo w i s detec ted, a Gas S till Flowi ng message appears i n the

alarm wi ndo w. If the mac hine is in the S tand by mode fo r 5 minu tes and the re is no us er i nput, the machine go es in to the S leep mode, and a sc reen sav er appears .

Manual/Spontaneous
In Man/S pon mode, the pis ton in the v entil ator i s mov ed to i ts topmos t pos i ti on to minimi ze s ys tem c ompl ianc e. The AP L bypass v alv e is c lose d, di rec ting exces s gas through the AP L v alv e. For s pon taneous v entilation, the A PL v alv e i s put in the S P ONT pos i tion, in whi ch i t i s full y open. Duri ng insp iration (Fi g. 12.23), gas from the bag f lo ws throug h the f res h g as dec oupli ng v alv e and the i nspi rato ry unidi rec tional v alv e to the Y-piec e. Durin g exha lation (Fig. 1 2.24), ex ha led gases f low through the exp iratory unidi rec tional v alv e and the abso rbe r. The res erv oir bag fi lls wi th a c ombin ation of f res h g as and gas tha t has passed through the abs orb er. Exces s gas ex its through the APL v alv e. Durin g ma nual v enti la tion, the APL v alv e is set to the MA N pos i tion. The opening press ure c an be adj us ted f rom 5 to 70 c m H 2 O. As the bag is comp res sed (Fig . 12.25 , s ee page 341), the gas in the bag f lows th rough the f resh gas decoup ling v alv e, the ins pi ratory unidi rec tiona l v alv e, and the Y-p iec e. Some gas fl ows retrograde through the abso rbe r and the APL v alv e, whi ch is ad jus ted to prov ide the proper pres sure. Durin g exhalati on, ex haled gas es flow thro ugh the expi ra tory unidi rec tional v alv e and the a bso rbe r. The res erv oir bag fi lls wi th a c ombin ati on of f res h g as and gas tha t has passed through the abs orb er.

Mechanical
W hen the Fabius is in au toma tic mode, the AP L bypas s v alv e is held open. F res h gas decou pl ing is acc ompl is hed by us ing a decoup ling v alv e betwe en the f resh gas i nlet and the breathi ng s ys tem. T he res erv oi r bag wi ll inf late and def la te duri ng mechanical v enti la tion. If the ox ygen fl us h is ac tiv ated duri ng inspi ration, the gas wi ll not be added to the tidal v olume bu t wil l e nte r the rese rv o ir bag (23 ). Durin g ins pi ration (Fig. 1 2.26, s ee p age 342 ), the press ure ge nerated b y the piston c los es the f resh gas decoupling v alv e . Fresh gas f lows retrograde th rou gh the P .339 absorber and enters the res erv oi r bag . The pis ton pus hes gas through the i nspi rato ry un idi rec tio nal v alv e and the ins pi ratory hose to the Y-piece . If the press ure ex cee ds the p res sure limit, the Pmax v alv e opens .

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

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Durin g exha lation (Fig. 1 2.27, see page 343), e xhaled gas flows through th e ex piratory unidirec ti onal v alv e and into the reserv oir bag, whe re f res h g as has been co ll ec ti ng during ins piration. The p is ton retrac ts , d rawing in gas . Excess gas f lo ws through the AP L bypass v alv e and the ex haus t v alv e to the sc av enging sys tem.

Special Features
A high pressure and a negativ e pres sure relief v alv e are located at the top of th e v enti lato r pis ton (Figs . 12.20, 12.2 1). The hi gh pressu re re li ef v alv e opens a t 75 5 cm H 2 O. The nega tiv e press ure s afe ty reli ef v alv e le ts in air at -2 to -5 cm H 2 O. If a fau lt in the v entilator is not c orrec ted an d the anes thes ia prov ider c ann ot s wi tc h to manual v enti lation by usi ng the Man/Spon t mode, manual v enti lati on is s ti ll possible. To do this , the ON/OFF s ys tem power s witc h on the rea r pane l is s witched OFF, the n ON. The Fa bi us GS has batte ry backup that wil l power th e machi ne and v entilator f or at l eas t 45 minu tes if the batte ries are ful l y charged . If the power fa ils , the mains LED wi ll go out, a messa ge wil l appear, an d a battery s ymbol wil l a ppea r in the s tatus bar. A f te r the battery is ex haus ted, the patie nt can be v entilated in the manu al /sp ontaneo us mode. B reathi ng s ys tem comp lianc e is determined during the ch eckout proce dure. For ac curate c ompl iance c omp ensa tion, the breathi ng s ys tem mus t be in the configuration in whic h i t is to be used f or the patient wh en the c heck out p roc edure i s performed.

The Fa bi us GS is equ ipped wi th fres h g as dec oupli ng. During mechanical i nspi rati on , the f resh gas decoup ling v alv e c loses . This direc ts the fresh gas to the reserv oi r ba g, thereby s topp ing i t f rom bei ng added to the inspi red tidal v olume. Durin g exha lation, the dec oupli ng v alv e P .340 opens , a llowi ng ex hal ed gas and the ac cumulated fresh g as to f ill the pis to n.

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

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Hazards
A i r c an be entrained du ri ng mecha nical v entil ation if there is a disc onnec tion or l eak or the f res h g as fl ow i s d irec ted to the wrong c i rc uit (9,66,67). Th is could lead to patien t awareness and hypoxia. S uch a pro blem s hould be discov ered durin g the checko ut procedure but co ul d occur later. Ven ti la to r fail ure resu lting f rom wo rn parts of the mo tor that driv es the bellows has been rep orted (68,69). A v entilator fai lure warning was pos ted and manual v enti lation was possi bl e af ter the v entilator was plac ed in the s tandb y mode.

Cleaning and Ster ilization

Ex ternal parts of the v enti lato r may be c lean ed with deterg ents and dis infec tants . The parts that are exposed to resp iratory gases ca n be remov ed from the v entilator. The v entil ator di aph rag m, cov er, a nd hos es can be s team autoc lav ed.

Drager Apollo

Description
The main sc reen of the Drage r A pollo machine is s hown i n F ig ure 12 .28 (s ee page 344). A t the l ef t on the bottom are v irtual f lo wmete rs . Abov e this is gas -moni toring i nfo rmati on. To the right of this is the carbon di oxide wav efo rm and press ure - and f low-v o lume loops. Below the pressure-v olume loop are bar graphs for tidal v olume and a irway press ure. To the right of the c a rbon d iox ide wav ef orm and flow-v olume l oop are the v alues fo r v enti latory parameters . Below th is are the p ipe line and c ylinde r pressu res . A t the ri ght a re soft k eys for v a ri ous other func tions . Ven ti la to ry func tions are c ontrolled by us ing two s ets of ke ys bel ow th e b ottom of the sc reen (Fig . 12.29, see page 345). The ke ys in the bottom row are us ed to P .341 se t the v entilatory mode (manual /s pontaneous , v olume mode, pressure mode, or press ure s upport). To s elec t a mode , the k ey is p res sed, and th e knob to the rig ht i s pressed to c onf i rm the c hange. The right key is used to selec t th e aux i liary co mmon gas outl et, whic h is an op ti ona l featu re.

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

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Abov e th is row o f keys is another row that is us ed to se t the v entil ation parameters . To al te r th e s etting, the k ey is press ed, an d the knob is rotated to inc rease or dec reas e the v al ue sho wn abov e the soft k ey until the des i red v alu e is reach ed. The n, the k nob is pressed to confi rm that se ttin g. To the right of the k nob (not s hown in F ig. 12.29) is the s tandby ke y, whi ch is used to s witc h be twee n operating and s ta ndby modes .

The internal c ons truc ti on of the A poll o v entil ato r is s hown in Fi gu res 12 .30 to 12.35 (s ee pages 345,346,3 47,348,349,3 50,351). Fres h gas enters the breathing s ys tem and p asses through the f res h gas dec oupler v alv e. The v entilator, whi c h has a n elec tric all y driv en pis ton, is connec ted to the inspi ra tory si de of the c i rc uit downs trea m of the f resh gas dec oup ler v alve. A f lo w s enso r jus t downs tream of the unidi rec tional v alv e moni tors the i ns pi ratory f low. On the ex halation s ide of the ci rcu it another f low s ens or, a pres sure gauge and a PEE P v alv e a re located ups tream of the exp iratory unid irec ti onal v alv e. The reserv oi r ba g and APL v alv e as we ll as an AP L bypass v alv e leading to the ex haus t v alv e f rom the v en ti la tor are be twe en the ex pi ratory unidi rec ti ona l v alv e an d the absorber.

Controls
The range f or pres sure li mitation (P M A X ) is 10 to 70 (defaul t 40) c m H 2 O, wi th a minimum of PEEP +10 c m H 2 O. The ran ge for ti dal v olume is 20 to 1400 (defaul t 600) mL. W i th PSV , the tid al v olume range is 10 to 1400 mL. Res pi ratory f reque ncy can be s et f rom 3 to 80 (defaul t 12 ) bpm in v olume c ontrol and pressu re control v enti lation . During PSV , th e f requenc y is Off or 3 to 20 (default 3) bpm. Ins piratory time (T I N S P ) can be s et from 0 .2 to 6 .7 (defaul t P .342 1.7) sec onds . Inspiratory pause time can b e s et f rom 0% to 60% (defaul t 10%) of i nspi rato ry time. PE EP can be se t from 0 to 20 (d efault 0) c m H 2 O, with a max imum of P max -10 c m H 2 O. Tri gge r sens itiv ity ca n b e set f rom 0.3 to 15 (defaul t 3) L/minute i n pressu re s upport mode. Ris e time (T S L O P E ) can b e set f ro m 0.0 to 2.0 (defaul t 0.0) seconds . The p res sure s upport rang e (Pps ) is 3 to 50 (defau lt 5 ) cm H 2 O. The inspi ra to ry press ure i n the pres sure mode is PEEP +5 c m H 2 O, up to 70 cm H 2 O. P ati en t age ca n be s et f rom <1 to 1 20 (default 40) years .

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

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Alarms
A larms a re indicated on the s ta tus f ield a t the top of the sc reen (Fig. 12 .28 ). W arnin g messa ges flas h ON an d OF F o n a red bac kground , and a con tinuous tone sounds . Caution messa ges f las h ON an d OF F on a y ellow bac kground, and an i nte rmi ttent tone s ounds ev ery 30 s ec onds . Adv is ory mes sages appear on a whi te background, and depending on the adv isory, a s ingl e tone may s ound.

Ventilation Modes
Volume co ntrol (wi th or wi thout s ync hronization and optional press ure s uppo rt) and press ure c ontrol (wi th or without s ync hroni zatio n and optional p res sure supp ort) v enti lation are s tanda rd features . The re is a 1 5-s econd timeout period for mak ing v enti lation mode c hanges , wi th a n audi ble tone after the fi rs t 10 seconds . If the new se tting is no t conf i rmed wi th in this time, the prev ious v en ti lato ry mode remains i n effec t.

Manual/Spontaneous
To us e the manual /spontaneous v enti lation mode , the user mus t f irs t s e t the A PL v alv e to the appropriate mode (manual or sp ontaneous ), th en selec t the mode on the front dis pla y pane l. The fresh gas decou pl er v alv e s tays open. Durin g spon taneous respiration (Fig. 12.30), the patient inhal es gas from the reserv oi r ba g and fresh gas. Duri ng exha la tion (Fig. 12.31), gas flows into the reserv oi r ba g. Fres h gas wi l l also f low to ward the reserv oi r P .343

bag. Exc ess gas wil l ex it v ia the APL v alv e, whic h should be f ul ly open.

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

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Durin g ma nual inspi rati on (Fig. 12.3 2), the AP L v alv e is turned to the des ired press ure . W hen the bag is s queezed, gas flows through the abs orb er and pas t the f res h g as inle t. The pressure wil l be l imited to that s et on the AP L v alv e. Pul li ng up on the APL v alv e kn ob wil l temporaril y re liev e exces siv e pressu re. During ex hal ation , the rese rv oir bag fil ls wi th ex haled gas a nd fresh gas f lowi ng retrograde through the abso rbe r.

Mechanical
Durin g mec han ic al v enti lation , the fresh gas d ecouple r v alv e cl os es during i nspi rati on (Fig . 12.33). This caus es f resh gas to f low retro gra de through the absorber. Durin g early ex halation (Fi g. 12.34), ex hal ed gas f lo ws throug h the absorber and i nto the re trac ting pis to n v entilator. Fres h gas also flo ws into the v entilator. After the pis ton has fu lly re trac ted (F ig. 12.35), exc ess gas f lows th rou gh th e exhaus t v alv e to the s cav enge r s ys tem. S ome fres h gas wi l l flow re trograde through the absorber.

Volume Control
The parame ters fo r v olume-c on trolled resp iration c an be preset before the v olume mode is ac tiv ated. Compliance c ompensation is applied duri ng v olume -c ontrolled v enti lation . Compl iance is determined duri ng the leak tes t performed in the s tan dby

mode . For c ompliance compensa ti on to wo rk ac curate ly , it is i mportan t that the hoses us ed during the tes t match those us ed durin g the procedure. Ac tiv ating s ync hroni zatio n is optional . It is ac tiv ated b y e nte ring a v alue for tri gger sens i tiv ity . A breath tri gge red b y the pa ti ent i s represented by a v e rtic al black l ine on the pressu re and flo w c urv es . The ac tiv e window for a breath tri ggered by the pati ent is the l as t 25% of the expiratory time . In order to maintain a cons tant f requenc y, a breath triggered prema tu rel y is c ompens ated fo r in the nex t c yc le.

Figure 12.28. Main screen of the Apollo anesthesia machine.

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P .344

Pressure Control
P ress ure control v entilation is a s tand ard feature on the Apollo v entila tor. The rate at wh ic h the press ure ris es is s et v ia th e rise ti me (T S LO P E ). The max imum ti me fo r control led v entil ati on is se t v ia the f requency. In the p res sure control mode, the maxi mum inspi ra tory flow i s 1 50 L/minu te. The v enti la tor can be confi gured so that the inspi ratory pressu re wi ll be automatica lly cha nged wh en PE EP is ch anged in the pressure con trol mode. S ynchroni zation with s pontaneous breath ing c an be ac tiv ated in this mode by enterin g a v alue for trigger s ensi tiv i ty . A v enti la tion s trok e triggered by th e pati ent i s rep res ented by a v ertical black l in e i n the p res sure and flow c u rv es (tri gger i ndicator). T he window for P .345

tri ggeri ng by the p ati en t is the l as t 25 % of the ex pi ratory phas e ti me. In o rde r to mai ntain a c ons tant f reque ncy, a b rea th triggered prematurely is compensa ted f or i n the nex t c yc le.

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

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

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Pressure Support
P ress ure-as sis ted s pon taneous breathing, if p res ent, is optional i n the press ure control a nd v olume con trol modes . It can b e us ed as a s eparate mod e. It is ac tiv ated by en tering a v alue for the l ev el of s uppo rt (Pps ). If th e patien t is being

v enti lated without s ynchroni zatio n when press ure support is turned ON, s ynchroni za tion wi ll b e automatica ll y ac tiv ated. S ynch ron ization wi ll be main ta ined whe n p res sure s upport is de ac tiv ated. The rate a t whi ch th e p res sure rises is set b y using the ri se time (T S L O P E ). The manufac tu rer rec ommends that the ris e time be s et s o that the pl ateau press ure is reached within one th ird of the inspi ra tory time. Insp iration ends as s oon as the i nspi rato ry flow drops be lo w 25 % of the insp iratory peak flow. The insp iratory time f or s pontaneo us breathi ng cannot be greater than 1.5 s ec onds i n p atien ts under 4 ye ars of age or more than 4 s econ ds in patients ov e r that age.

Special Features
The mac hine has an au toma ted c heck out p roc edure tha t incl udes a c ompliance meas urement. Enterin g the pa tient's body wei ght and age caus es the v enti lato r to produce defaul t se ttin gs bas ed on the g iv en information . Thes e s ettings need to be c onf irmed. The insp iratory p res sure c an be automatically c hanged when PEEP is altered in the press ure c ontrol mode. T his f eature can be disab le d. The insp iratory time ca n be automatic al l y a ltered in the v olume-c on trolle d o r pressu re-con trol led v entilation modes withou t s ynchroni zati on so that the res ultan t I:E ratio remains cons tant. P .346 If this se tting is disab led, the ins pi ratory time wil l be independent of the change in f requenc y, and the I:E ra tio wil l change accordingl y.

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

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The A pollo has f resh gas decoup ling. Duri ng insp iration wi th mec hanica l v en ti lation, the fresh gas decoupl er v alv e c loses . This d irec ts the f resh gas that enters the s ys tem to the res e rv oir bag, thereby s toppin g i t f ro m being a dded to the i nsp ired tida l v olume . During ex halation, the fresh gas decoupler v alv e opens , al lowi ng ex hal ed gas and the ac cumulated fres h g as to fil l the v en ti la tor.

Cleaning and Ster ilization

The breathing s ys tem and v enti lator may be d is ass embl ed for c leani ng and s teril i zation. Al l parts o f the b rea thing sys tem excep t the Spirolog f low s ens or c an be thermall y disi nfec ted in an auto matic cl eaning and dis infec ting mac hine a t 93C for 10 minutes . On ly ne utral c leani ng agen ts and ful ly deminerali zed wa ter ma y be us ed. Chemic al disi nfec tants should not be added fo r the rmal dis infec tion, as th ey may cause co rrosion. The in ternal parts of the v enti lato r can be s team s teril i zed at 134C fo r 8 mi nu tes . The Spi rolog sens or also ca n be immersed in 70% a lc ohol for approxima tel y 1 hour and allo wed to dry fo r 30 minutes .

General Electric Datex-Ohmeda 7900 Series

Description
The 7900 (S ma rtVent) v enti lato r is an integral pa rt of a number of Datex -Ohmeda anes thes ia mach ines (4,12). The re are a v ariety of s oftware v ersi ons i n use, and a partic ula r v en tila tor ma y hav e added features such as addi tiona l v enti la to ry modes . S ince there are so man y v ariations in use, it i s not poss ibl e to disc uss each v a ri ation . The ins truc tions f or the v ersi on that the use r has should be consul ted.

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

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The bell ows as sembly (Fig . 12.36, s ee page 3 51), whi ch has an as cendin g bel lows , i s sepa rate from the control portion. On newer mach in es, the B ag /V en t selec tor s wi tch on th e top of the ca rbon d ioxide abso rbe r serv es as the ON-OFF c ontrol fo r the v enti la tor. P lac ing the s wi tc h i n the V ent posi tion tu rns the v enti lato r ON. Ol der mode ls hav e an ON-OF F s witch on the v entila tor (Fi g. 12 .3 7, see page 352 ). The v entil ator c an b e powered by ai r or ox ygen a nd has a peak ins pi ratory flow of 70 L/min ute. Inspi re d and exhale d v olumes are measu red us ing v ari ab le orifice flow sens ors at the outle t and inlet on the abs orb er (Chapter 23 ). Informa ti on from the i nspi rato ry s ensor is us ed to regulate the be llows c ompressi on during ins pi ration. Sev era l breaths are n eede d to al lo w eq ui librati on so that the v enti lator deliv ers the se t tidal v ol ume. The v enti lator c an c ompensa te fo r fresh gas flows f rom 15 to 200 mL/minute and moderate b rea thing sys tem leak s. Th is el imina tes the effec t of f resh gas fl ow o n the de liv ered tidal v olume bu t does not protec t c ompl ete ly f rom added v olume if the ox ygen fl us h is ac tiv ated durin g ins pi ration (23 ). The flow s ens or i n the expi rato ry l imb meas ures exha led v ol ume, whi ch is th en dis played on the sc reen. B ec aus e the f low s ensors are a t the a bsorber, c hanges in tida l v olume resul ting f rom gas c ompression and c irc uit c ompl ia nce can not b e c ompensated fo r. The f ro nt panel on ol de r models (F ig. 12.37) has the controls fo r th e v entilator func ti ons and a disp lay s c reen. Th e ON-OFF ke y, whic h has a bellows icon , is to

the left of the s c reen. On so me machi nes , this ke y is re pl aced by an E nd Case ke y that pu ts the apnea and v olume alarms into s tandb y and caus es us er s elec tions to be retu rned to defaul t se ttings . A bov e the ON-OF F k ey is a k e y to aud io pause (s ilence) alarms . On the ri ght is a k ey to dis abl e/enable the apnea and v olume alarms . B el ow th is is th e me nu access key . Below th e menu key is a rotary mouse (ComW heel ) that is used to selec t menus an d c hange settings .

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

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The s c reen dis pl ays al arm messages , a larm s ta tus , v enti la to ry modes , v enti lato ry control v alues , v arious measu red v alues , an d wav eforms . Abov e th e wav eform, the s tatus of the apnea al arm and v olume mon itor are displaye d. Inspi red ox ygen conc en tration ; exhaled tidal and minute v olu mes ; resp iratory rate ; and pe ak, me an, and p lateau airway press ures a re s hown on th e lef t s ide of the sc ree n. A larm limi ts can be d is played to the right of s ome v al ues . A larm mess ages are dis pl ayed a bov e this a rea (Fig . 12.38, see page 352). Below th e sc reen are selec tion k eys . W hen a k ey is pressed, the box around the display wi ndo w a bov e that k ey flas hes . The setting can be adj usted by turning the rota ry mous e. P ress ing the key o r the rotary mouse confi rms the selec ted v alue. If the setting is not c onf irmed in 8 seconds , the s etti ng remai ns unc hanged. Onc e a change in a para mete r is c onf irmed, i t us ually takes sev e ral breaths for the v enti lato r to ad jus t to the ne w s e tting.

Menus (Fig. 12.39, see page 353 ) are acces sed by press in g the bu tton abov e th e rota ry mous e. These are used for s ettings tha t are c hanged less frequently . The content of the menus depends on the sof twa re in place. The c ontrol panel fo r a newer mo del is shown i n Fi gure 12.40 (see page 353). On the left are con trols f or the timer. On the ri ght at the top is the S ilence A larms (audio paus e) ke y. B el ow this is th e k ey fo r th e a la rm setup, wh ic h wh en presse d wi ll bri ng up an alarm men u. Below this is a Help k ey. B elo w that is a key f or Trends . The nex t ke y is for the Ma in Men u. Below th is is the Ch eckout ke y. B el ow this is the S tart/End Case k ey . A t the bottom l ef t is the Gas Setup ke y. Abov e this are th ree ke ys th at control the parameters in the box es abov e the m (O 2 %, total fl ow, and v apori ze r setting). To the righ t of this is the Ventilator Se tup k ey. Abov e this a re th ree k eys that c ontrol parameters rel ating to the s el ected v en ti lation mode. To the ri ght is the S pirometry ke y. To the ri ght is a key to P .349 bring u p the Normal Sc re en. To i ts rig ht is the rota ry mouse.

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

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Fi gure 12.42 (s ee page 355) shows th e V entil ator Setup sc reen. To the left are the choic es fo r v en ti la tion mode . On the right are v enti latory parameters . Some of these pa rame ters can also be s et by us ing the ke ys at the bottom c enter of the control p anel (Fig. 12 .4 0).

Controls

The c ontrols and thei r arrangemen t wil l depend o n wh ic h v ers ion of the 7900 v enti lato r is bein g used . Earlier models had all of the con trols o n the v entil ator i ts elf , whi le the later models hav e th em o n the sc ree n. The c ontrols fo r tidal v ol ume (20 to 1500 mL ), P ins pired (the press ure deliv e red wi th each pressu re c on trol le d b rea th) (5 to 60 c m H 2 O), respi rato ry rate (4 to 100 bpm in v olume control or p res sure c ontro l ven ti la tion, 2 to 60 bpm in PSV or S IMV ), I:E ra tio (2:1 to 1:8), ai rwa y p res sure li mit (P limi t, 12 to 100 cm H 2 O), and PEEP (OFF o r 4 to 30 c m H 2 O) a re se t by us ing the s elec tion keys . The f ol lo win g a re s et through menus : ins pi ratory paus e (0% to 60 % of the i nspi rato ry time), Psupport (inspi ratory pressu re del iv ered durin g P SV o r S IMV ) (2 to 40 c m H 2 O), trigger wi ndow ( whic h contro ls the percen t of the exhalation phase wi th in whi ch the patient may tri gger the next mec hanica l breath in S IMV and P SV ) (0% to 80% in inc rements of 5%), i nspi ra to ry time in S IMV and PSV (0 .2 to 5 .0 seconds ), the f lo w t ri gge r lev el ( whic h se ts the minimum flow th at tri ggers the v enti lato r to de liv er a mec han ic al breath durin g S IMV or PSV (0 .2 to P .350 10 L/min ute), and th e i ns piratory terminal lev el (whi ch se ts the percen tag e of the peak inspi ratory flow where the v entilator s tops a press ure -s upported breath in S IMV o r PSV ) (5% to 50%).

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

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A normal sc reen is shown in Fi gure 12.41 (s ee pag e 354). V irtual f lo wmete rs are displayed on the lef t. In the midd le are waveforms . To the ri ght are measured parameters .

Alarms
The re are v aria tions in the alarms offered, d epen di ng on the s oftware ins talled. In l ate r v ers ions , the a larms are c ategorized in to high, me dium, and low priori ty. A high prio ri ty c ons is ts of ten tones and a 10-second pa use. The c ause of the al arm i s shown i n rev ers e col ors on the sc reen. Th e me dium pri ori ty a larm c ons is ts of three tones with a 25-s econd paus e. A lo w pri ori ty a la rm has a s ingle tone. A larm limi ts may be d is pla yed on the sc reen nex t to the pa rame ters wi th whic h they are assoc iated. They are ac ces sed f rom the a la rm menu. The v alue to b e a ltered is se lec te d, then set and confi rmed b y us ing th e rotary mouse. A larm mess ages a re dis pl ay ed at the top o f th e s c re en (Fig. 12.40). Ala rms c an be audio pa used (si le nced ) fo r 120 s econds by us ing the button at the upper l ef t of the sc reen. This time wi ll b e coun ted do wn on the s c reen jus t under the bell wi th an X through i t.

Ventilation Modes
Volume co ntrol and pressure con trol v entilation a re s tand ard an d hav e been av ailab le s inc e this v entila tor was fi rs t in troduc ed. S IMV and PSV wi th apnea backup (PSVP ro) are optional . PEEP is av ailable in al l modes . Af ter a mode is se lec te d, the highligh te d c ontrol parameters mus t be s e t.

Special Features
Battery backup permi ts approx imately 30 minutes of mechanic al v entil ation and operati on of monitors d uring a powe r fa ilure. A hel iox mode may be av ailable. This a utomatic all y correc ts f or the lower dens i ty of heliox .

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

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A minimum moni to ring mode shows patient da ta bu t does not permit mechanic al v enti lation . The c ard iac b ypas s mode tu rns OFF the v olume and a pnea alarms . A c i rcu it leak ala rm is ac tiv ated if less than half of the i nsp ired v olume is s ens ed at the exha la ti on sensor. It c an be turned off to prev ent nuisa nce alarms f rom a known l eak (e.g ., an uncuff ed tracheal tube). The 7900 v en tila to r has f res h gas compensa tion. The bel lo ws excu rs ion is al tered to deliv e r the c orrec t ti dal v ol ume by sub trac ting the f resh gas i nput during i nspi rati on f rom the v olume that the v enti lator deliv ers . This is mediated by meas uri ng the inspi re d and exhale d tidal v ol umes th rough use of the flo w s enso rs l ocated in the ci rcl e s ys tem.

Evaluation
The 7900 v en tila to r has improv ed press ure and f low c apa bil i ti es and p rov ides a more s table tidal v olu me wi th a ltered fres h gas fl ow than older model v en tila to rs f rom the s ame manuf ac turer (4,12).

W hen the Aes tiv a 5 v ers ion of the 7900 v entil ator is in the pressure con trol mod e, i nc reas ing resp irato ry rate dec reases the de liv ered tida l v olume more tha n with an ICU v entilator or the Nark ome d 6000 v en ti lato r (2). The v ariable orif ic e flow s ensors a re sens i tiv e to mo is ture bui ldup. Heated humidifiers can also contri bute to mois ture buildup and probabl y s hould n ot be us ed wi th thi s v entilator (70,71). W ater can migrate into the sensor i nterfac e board in the v enti lato r. The fi rs t warning tha t th ere is a p rob le m may be a rev erse flow warni ng (72,73). A f low s ens or des igned to minimiz e mois ture bui ldup has been desi gned. A s imilar p roblem has been no ted in operating rooms that a re partic ula rl y cold (70 ). S tres s frac tures where the pneumatic tube e nte rs the sens or hav e been repo rted (74,75,76). The s ensor o r the tubing to it c an bec ome frac tured and leak (77,78).

Cleaning and Ster ilization

W hen us ed with the A es tiv a mac hi ne and breathing s ys te m, nearl y all parts ex cept the flow s ensors and oxy gen se nsor that are ex pos ed to respi ra tory gas es are s team autoc lav able. Th e f low s ens ors c an be dis infected by using glutara ldehyde. Autoc lav able flow s ensors a re av ailab le.

General Electric Datex-Ohmeda 7100

The 7100 v en tila to r is s imi lar to the 7900 ve ntilator. The main d iffe rence between them is that the 710 0 has fe wer f eatures .

Description
The 7100 v en tila to r is turned ON b y s etting th e Bag/Vent s el ec tor s wi tc h to the Ven t pos ition. Volume meas urements are made b y us ing two v ariabl e orif ic e sens ors (Ch apter 23) at the abso rbe r ass embl y. The d isp la yed moni tored v ol ume is obtained f rom the exh ala ti on sensor. Info rmatio n f rom the inspi rato ry s ensor is us ed to adjus t th e del iv ered tidal v olu me. This method eli mi na tes the ef fec t of f resh gas on the deliv ered tidal v olume bu t does n ot protec t f ro m the effec t of ad ded v olume if the ox ygen fl us h is ac tiv ated durin g ins pi ration (23 ). This mec hanism does not c ompens ate for gas compress io n or c i rc uit compl ianc e i n the b rea thing s ys tem. The disp la y s c reen is s hown in Figure 12 .43 (see page 355). To the left of th e sc reen a re two k eys . The top k ey is for audio paus ing (si lenci ng) ala rms up to 120 seconds . The s c reen sho ws the time remaining in the s ilenci ng perio d. P ressing and h old in g the ke y for one sec ond when no alarms are ac tiv e suspe nds audio tones for medium and low pri ority alarms for 9 0 s ec onds . W hen the alarms

P .352 are audio paused, a large X c ov e rs the li mits . B elo w thi s key is an E nd of Cas e ke y.

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

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To the right of the s c reen are two k eys. The top on e turns th e v olume ala rms ON or OFF. Below this is a menu k ey th at al lo ws the operato r to ac cess a number of sc reens use d to adjus t functions associ ated with the v entil ator. Below thi s key is a rota ry mous e tha t is us ed to al ter and c onf irm v alues on the sc reen. The re are fiv e k eys below the s c reen. Th ese al low the tidal v olume , respi ratory rate , I:E rati o, maxi mum ai rway pres sure, and PE EP to be adjus ted . The set v al ues are dis played on the sc reen abov e each key. If pressure c on trol v entil ation is use d, the left-hand box wi ll indic ate the inspi rato ry press ure . Abov e th e func tion v alues on the s c reen is a s pace that indicates the mechanical v enti lation s tatus (ON or OF F), the v enti lation mode (v olume or p res sure control), and the breathing s ys tem being us ed. A bove this on the lef t are the meas ured v alues for tidal v ol ume, minute v ol ume, resp iratory rate, and ox ygen p erc entage . To the right a re v alues for peak inspi rato ry and mean ai rway pres sure and PEEP . Abov e is a press ure bar graph or P .353 wav efo rm. Th e ala rm s tatus message dis play is at the top of the sc reen.

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

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

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Controls
The c ontrols fo r tidal v ol ume (20 to 1500 mL ), P ins pired (the amo unt of pressure deliv ered during pressure-con trolled v entil ation) (5 to 60 cm H 2 O), res piratory rate (4 to 100 bpm in v ol ume c ontrol or p res sure contro l v en ti la tion, 2 to 60 bpm in PSV or S IMV ), I:E ratio (2:1 to 1:8), hig h a irway press ure (P l im it , 12 to 100 cm H 2 O), and PEE P (OFF o r 4 to 30 cm H 2 O) a re se t by us ing the selec tion keys at the bottom. The insp iratory pause (0% to 60% of inspi rato ry time) is s e t th rou gh a menu.

Alarms

The alarm s ettings are controlled through a menu. The alarm to be altered selec ted and a djus ted by using the c ontrol knob, then c onfi rmed by push ing the kn ob. A larm l imi ts c an be displ ayed o n the sc reen bes ide each measu red v ariable.

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

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

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A high pri ority alarm inc ludes two burs ts of f iv e tones , af ter whi ch there is a paus e and then the audibl e alarm is repeated. A medi um pri ority alarm so unds three tones

followe d by a 25-s econd paus e, and the alarm i s the n repeated. A lo w p ri ority ala rm has a s ing le sound that is not repeated.

Ventilation Modes
The v entil ation modes are accessed f rom the main menu. Vo lume c ontrol is s tandard , whi le press ure c ontrol is op tional.

Special Features
The 7100 v en tila to r has a batte ry backup , which wi ll s uppl y power fo r 90 min utes whe n fully c harged. Under s ome c i rcu ms tances , this p ower wi l l be av ail able fo r onl y 30 minutes . The v entil ator ad jus ts gas fl ow to the bellows based on the insp iratory v olume meas ured by the v ariable orif ice sens or on the inspi ra tory breathing s ys tem limb (fres h gas c ompensation). T his elimin ates the effec t of cha nges in fresh gas f low on tida l v olume . During some ma lfunc ti ons , th e v entilator au toma ticall y turns OFF v olume c ompens ation . If the a nes thes ia mac hine is equipped to use heli um, the hel iox mode c an be se lec te d through a menu . This automatically c orrec ts fo r helium's lower d ens i ty. The re is an ala rm fo r ci rcu it l eak that is ac tiv ated when les s than hal f of the i nspi red v olume re turns through th e expi ra to ry flow s ensor duri ng mec hanica l v enti lation .

Evaluation
A pro bl em wi th the 7100 v enti lator h as been repo rted (79 ). The v enti lator wo ul d periodicall y s hut d own and the sus tai ned p res sure ala rm woul d be ac tiv ated. It was determined that if the f low to th e s cav engi ng s ys tem was l ow, was te gas would ac cumulate in the bag. When the pres sure woul d reac h 9 c m H 2 O, the v entilator wou ld sh ut OFF. The manufac turer of fe rs a conv ers ion to full fl ow fo r the sc av engi ng s ys tem to remedy this problem. Ano the r re ported problem was inabil ity to us e v olume contro l v en ti lation when the f low s ensor was s ubjec t to s ignif icant amounts of mois ture (80).

Cleaning and Ster ilization

Mos t of the parts of the 7100 v enti la tor that hav e been ex posed to the res pired gases can b e d is assembled and s team autoc lav ed. Pa rts tha t cannot be s team autoc lav ed can be c hemicall y dis infec ted .

General Electric Datex-Ohmeda AS/3 Anesthesia Delivery Unit

Description
This v entil ato r is an integral part of the Da tex -Ohmeda A nes thes ia Deliv e ry Uni t (A DU). It is s hown i n Fi gure 12.44. The bellows assembly, with an asc endi ng bellows , is located to the l ef t of the display wi ndow. The P .355 A UTO/MA N s wi tch is below th e bel lows . Turning it to the A UTO posi tion turns on the v enti la tor.

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

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Figure 12.43. Screen for the 7100 ventilator.

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E i ther ai r or ox ygen c an be used as the drive gas . If the prima ry driv e gas pressu re i s los t, the v entil ator wi ll a uto matica ll y s wi tc h to the o ther gas . The max imum i nspi rato ry flow i s 80 L/minu te. V olume is meas ured between the breathing s ys tem and the patient wi th a D-li te s ens or (Ch apter 23 ). A diagram of the bell ows b loc k is shown in Fi gu re 12.45. Duri ng inspi rati on (Fig . 12.45 , top), the control uni t di rec ts driv ing g as in to the block . The bellows can is ter i s pressuri zed, d riv ing the bel lo ws down wa rd. A t th e s ame ti me, the pressu re in the ov erf low (s pi ll) v alv e housing inc reases , pus hing downwa rd on the rubber membrane an d me tal lid in the ov e rf lo w v alv e. Th is cl os es the v alv e, prev enting gas that is ins ide the bell ows f rom being los t. A t the end of the ins piratory phas e , the press ure in the oute r c anister returns to zero. Fi gure 12.45, bottom, d epicts the v enti lator during late exh ala ti on. Exhaled gases caus e the bello ws to re turn to i ts u ppermos t p osi tion. The press ure in the ov erf low v alv e h ousi ng retu rns to zero, all owi ng the rubber membrane and metal l id to rise f rom the s eat s o tha t exc ess gas c an esc ape to the sc av enging sys tem. The v entil ator panel is sho wn i n Figure 12.46. Th e k eys v ary in posi tion for different v ers ions of this machi ne. To the rig ht of the sc reen a re k eys for v entilatory mode , respi ratory rate, I:E ratio, and PEEP . B elow the sc reen is a handwheel. W hen a parameter is selec ted , it is adjus ted b y rotating the handwhee l. The new se ttin g is confi rmed b y push ing the wheel or k ey or by pus hing ano the r key on the display unit. The re is als o a k ey to bring up other sc reens .

A t the lower rig ht of the sc reen, the set tidal v o lume, minute v olume, insp iratory pause, res piratory rate, I:E ra tio, I:E times , v en ti lato ry mode , and PEEP are displayed. To the left of the v entil ator s e ttings on th e sc reen is a mi ddle field with gas - and v olume -mon itori ng inf orma tion or tren ds . T o the left of the midd le f ie ld is the f resh gas dis play where fl ows of ox ygen, ai r, and N 2 O are d is played as v irtu al f lowme ters and n umeric al v alues . The a nes thetic a gent setting is dis played in a box to the ri gh t of the f lowme te r numeric al disp lay . Abov e th e v entilatory s ettings , two wav ef orms c an be dis pl ayed . One is alwa ys c i rc ui t pressu re. E nd-tidal and ins pi red c arbon dioxi de may be disp lay ed if the ca rbon d ioxide wav eform is sho wn. A n alarm mess age f ie ld is a t th e top . P ress ing the v enti la to r key to the righ t of the PEEP key b ri ngs up a menu that al lows the v entilatory mode (v o lu me, press ure , or S IMV ) to be s elec ted. Tida l v olume , set p res sure, resp irato ry rate , I:E ratio, and PE EP a ls o ma y b e a ltered f rom this men u.

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

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P .356

The options wi ndow i s acc ess ed through the v entil ator menu . Subheadings inc lude the trig ger wi ndo w ( whi ch is us ed in S IMV and PSV ), i nspi rato ry pause (wh ic h c an be us ed in the v olume and S IMV modes ), i nsp iratory ris e time ( whic h is used in the press ure c ontrol mode), and s igh (whi ch c an be us ed in the v olume c ontrol mo de).

Controls
The re are a number of di fferent software v ers ions av ail able, s o the re may be so me disc repanc y be twe en the user's mac hine and the inf ormation prese nted here. Ti dal v olume (20 to 1400 mL), mi nu te v olume , inspi ra tory paus e (0% to 60% of i nspi rato ry time) (Fi gs . 12.47, 12 .48, see p ages 358, 359), res piratory rate (2 to 60 bpm), I:E ra tio (1:4.5 to 2:1, defa ult 1:2 ), I:E times (inspi ra tory ti me 0.35 to 20 seconds ), the v entilatory mode (Volume Con trol , P ressure Contro l, P res sure Support, o r S IMV ) and PEEP (OFF or 5 to 20 c m H 2 O) are set b y us ing the k eys below the sc reen. P EEP is l imi ted to 10 cm H 2 O i f the ti dal v ol ume is less than 100 mL. In pressu re con trol v entil ation, the pressure (5 to 40 cm H 2 O abov e PE EP ) c an be se t by using a ke y. Cha nges are made by the v enti la tor ov er s ev eral respiratory c ycles . The f ol lo win g a re s et through menus : trigger s ens i tiv i ty (-5.0 to -0.5 c m H 2 O), tri gger wind ow (5% to 95 % of the ex pi ratory ti me, defau lt 9 5%) (Fi g. 12.49, s ee page 359), i nspi rato ry time (0 .35 to 20 sec onds ), ins piratory ris e time (s low, medium, o r fas t) (Fi g. 12 .48 ), and inspi ra tory paus e (0% to 60 % of ins pi ratory ti me) (Fig . 12.47). A fas t rise time reach es the targeted press ure in the f irs t 10% of the i nspi rato ry time, medium i n 50%, and s low i n 90%. W hen the s igh is used , the v enti lato r del iv ers a tidal v olu me that is 1.5 ti mes larger than the n ormal ti da l v olume ev ery 100th breath . It is limi ted to 1400 mL. The re is an adjus table (5 to 40 cm H 2 O abov e PE EP ) max imum airway press ure release. The v enti la to r automatic all y s wi tches to expi rati on when the press ure is reached.

Alarms
A larms a re acc ess ed through the A larm Se tup k ey to the uppe r ri ght of the sc reen and s et by us ing the wheel below the sc reen . Ala rms are arranged by pri ority. A high-prio ri ty alarm is red a nd is an nunc ia ted by fiv e beeps foll owed by a 1-s ec ond delay and then fiv e more b eeps f ol lowed by a 5-s ec ond del ay. This is repeated. A medium priori ty al arm is yel low a nd is annunc ia ted wi th three P .357

P .358

beeps and a 19-s econd pause, the n repeated. An adv isory note is whi te , and a beep sounds ev e ry 60 seconds.

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

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Figure 12.46. Panel for Datex ventilator.

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Ventilation Modes
Volume co ntrol , press ure co ntrol , and S MIV are s tandard. PSV is option al. B rea ths that are pressu re supported a re c olored red on the pres sure wav eform.

Special Features
The re is an ov erpress ure releas e v alv e that is se t at 80 c m H 2 O. During spontaneous breathing, s ubatmosph eric press ure is limited to -3 cm H 2 O. This mach in e has batte ry backup for the entire machine as we ll as the v entilator for at leas t 20 minutes wi th full y cha rge d batteries . There is a battery cha rge P .359 i ndicator. W hen abo ut 30 s econds remai n i n the battery , a red alarm messag e i ndicates Battery E mpty, Go Manua l.

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

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

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The re is an automatic check out proc edure tha t can be pe rformed before the patie nt i s conn ec ted to the uni t. The fu ll chec kout is recommended on eac h machine power-up but can be bypass ed. B reathing sy s tem c ompliance, c ompress ion v olu me , and leak age are measu red . If the bypass c ommand is selec ted, the defau lt v alue fo r co mp res sible v olume is 2 mL/cm H 2 O. The d el iv e red tidal v olu me ma y not be co rrec t if the compress ib le v olume dif fe rs f rom th is v alue. The amo unts of f res h gas and liquid a nes thetic agen t used s inc e power-u p a re ca lc ula ted and can be displayed. Gas usage c an be displ ayed. If the p ati en t's wei ght is entered, the v en tila to r automatic all y ca lc ula tes and sugges ts se ttings fo r tidal v ol ume, resp iratory rate, and minute v olume. The defaul t P .360 wei ght is 60 k g and corres ponds to a tidal volume of 500 mL and a res piratory rate of 10.

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

View Figure

The v entil ator has c ompens ation for f resh gas f lo w a nd ci rcu it c ompl ia nce. The A DU meas ures the f resh gas f lo w c ontinuous ly. The del iv ered v olume is ca lc ula ted f rom these v alues . This d oes not pro tec t the patien t from an inc re ased tida l v olume if th e ox ygen fl ush is ac tiv ated during ins piration (23).

Hazards
W ith a v ery high fresh gas fl ow, the fresh gas f low c ompensation may c aus e v enti lato r s tands til l (81).

Cleaning and Ster ilization

Mos t of the parts of the v entil ator and breathing sys tem c an be s team autoc lav ed a t a max imum of 121 C. Refer to the user ma nual for c leani ng, dis asse mbly , and disi nfec tion of indiv idual components .

Datascope Anestar
This v entil ato r is an integral pa rt of the A nes tar an es thes ia s ys tem (20,23). The Anes tar S is a scaled-down v ersion with s ome func tional differences .

Description
The A nes tar breathi ng s ys tem is posi tioned at the front lef t of the mac hine (Fi g. 12.50 ). A hea ted a luminum bl ock engages with a mo to ri zed dock ing s tation . W hen attached to the dock ing s tation, the breathin g s ys tem's pneu matic and elec tronic connec tions are sec ure d. The h anging bel lows and hous ing are loc ated below the alumi num bl ock. The breathi ng s ys tem c on tains a negativ e

P .361 press ure rel ief (room air, eme rgency ai r) v alv e. It opens to a tmos phere whenev er the pressure fa lls 3 cm H 2 O o r more belo w a mb ient press ure .

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

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Figure 12.51. Anestar anesthesia machine screen. Manual ventilation.

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E i ther ai r or ox ygen c an be used as the drivi ng gas for th e v entilator. If line press ure is unav ai lable , the machine wi ll a uto matica ll y s wi tc h to c yl inders fo r driv in g gas if the c ylind ers are ope n.

A i rwa y p res sure is measured in the inspi ra tory limb. E xpi red v olu me is meas ured in the expi rato ry l imb by us ing a hot- wi re anemomete r (Chapter 23). During mechanical v enti la tion, the deliv ered ti da l volume is c onf irmed by us ing a n i nternal f low s ensor. The touc h s c reen is s hown i n Figures 12.51, 12 .52, and 12 .53 . V entila tor func tions are adj us ted using the keys surrou ndi ng the s c reen. W hen the pa rame ter to be change d is touched, the sc reen v alue is highl ighted. The up and down k eys to the righ t of the sc reen are used to inc rease or d ec reas e the s elec ted p aramete r. Th e change is conf i rmed by p ushi ng the E NTE R key at the lower ri ght. The V IEW SE TT INGS k ey a t th e lowe r left c orner c an be used to v iew the setti ngs a long the bottom of th e s c reen. A c ross the top of the sc reen are meas ured v al ues for peak press ure , mean press ure , minute v olume, i nspi red ox yg en concentra ti on, and v enti lato ry mode. The v ent mod e k ey is a t the top ri gh t of the sc reen .

Figure 12.52. Anestar anesthesia machine. Volume control ventilation.

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Figure 12.53. Anestar anesthesia machine. Pressure control ventilation.

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In the mi ddle of the sc reen is a p res sure v ers us time graph. Below thi s is a box whe re alarm co ndi ti ons are displaye d. During the s tart-up f or the machine, perti nent i nfo rmati on and ins truc ti ons that are needed to compl ete the s tart-up are dis played on the data sc reen. The OP T IONS key to the lef t of the sc reen a t the top prov ides acces s to the util ities that are av ailable when the v enti la tion mode di al is in the s tandby pos ition. These i ncl ude c ompliance, oxygen c al ib ration, leak tes ting, running hours , breathing s ys tem temperature, breathi ng s ys tem ej ec ti on control (A nes tar only ), and display sc reen c ontras t. The A LARM L IMITS k ey ac tiv ates and deac tiv ates the a larm sc reen.

Controls
In v ol ume control v en til ati on, tidal v olume can be v a ried from 40 to 400 (default 200) mL in the chi ld mode and 300 to 1400 (defaul t 500 ) mL in the adul t mode . The tida l v olume /f lo w k e y, whic h is only on the A nes tar, allo ws the op era tor to adj us t the inspi ratory flow ra te, whic h can be v aried from 10 to 60 (defaul t 40) L /minute. P lateau press ure ca n be set to OFF, 20 % or 3 0% (defaul t OFF) of i nspi ra to ry time. The resp iratory rate c an be v aried from 10 to 60 (defaul t 20) bpm in the c hild mode and 4 to 30 (defau lt 10) bpm in the adultmode . The I:E ra tio range P .362 i s 4:1 to 1:5 (defaul t 1:2). PEEP is a djus tabl e from 3 to 15 c m H 2 O (defaul t OFF ).

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

The plateau pres sure k ey is used during pressu re con trol v entilatio n to set the i nspi rato ry (pla teau) press ure , which c an be v ari ed f rom 10 to 60 (defaul t 20 ) c m H 2 O i n both a dul t and c hild modes .

Alarms
The alarm l imits key is to the left of the data sc reen. P ress in g i t opens a win dow on whi c h alarm s ettings and al arm v olume can be al te red . A larms are acc essed b y touching the sc reen a nd are s et by us ing the up and d own k eys. The re is a MUTE abov e th e up and down arrow k eys , whi ch audi o paus es alarms for 2 minutes . The alarms v ary wi th the mode of v enti la tion.

Ventilation Modes
The A nes tar has both v ol ume control and press ure c ontrol v enti la tion. W hen s wi tching between modes , s ettings are sav ed and wi ll resume when re turning to a mode . The Anestar S has onl y v olume co ntrol v entilation. The A nes tar breathi ng s ys tem is shown i n Fi gures 12.54 to 12 .60 (see pages 362,3 63,364,365 ,366,367,368 ). Th e res erv oi r bag serv es to hold fresh gas . During mechanical v enti la tion, the bag is fu ll and appears to pulsate, inf lating s l ightly during ins pi ra tion. T he bag, rather than the bel lows , p rov ides a v is ual ind ic ation of a disco nnec tion. If a leak oc curs and the v ol ume of gas l os t is less than the fresh gas fl ow, the bag wi ll pulsate more deepl y. In c ase of a d is conn ectio n o r major l eak , the rese rv oir b ag wil l deflate after a few b rea ths .

The A PL v alv e should al ways be set to the OPE N pos i tion whi le in the CV M or P CV modes .

Spontaneous Breathing
Durin g spon taneous breathi ng, the be llows remains full y exp anded. Durin g i nspi rati on (Fig . 12.54), gas f lows from the rese rv o ir bag. If the bag empties, the subatmos pheric press ure reli ef v alv e opens, and air is drawn i nto the sys tem. Durin g exha lation (Fig. 1 2.55), ex ha led gases pass through the abso rbe r and mix wi th f res h gas in the reserv oi r bag. Exc ess gas is v ented to th e s cav enging s ys tem through the AP L v alv e.

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

View Figure

P .363

Manual
W ith manua l v enti lation , the bellows s tays ful ly expa nded . During insp iration (Fi g. 12.56 ), the reserv oi r bag is squeeze d s o tha t gas es flow to the patient. Thes e i ncl ude f res h gas and g as tha t has passed through the abs orb er. Duri ng the la tter part of ins pi ration, s ome gas may be v ente d through the partl y open AP L v alv e. Durin g exha lation (Fig. 1 2.57), the insp iratory u nid irec tional v alv e cl oses . Fresh gas fl ows in to the res erv oi r bag. Ex haled gas pass es th rough the absorber and mixes wi th f res h gas in the reserv oi r bag.

Mechanical

Durin g ins pi ration (Fig. 1 2.58), the f res h gas dec oupl ing, expi ra tory con trol , and bellows control v alv es clos e . Fresh gas f lo ws into the res erv oi r bag. Onc e the bag i s fi lled, exc ess gas f lows to the scav enging s ys tem throug h the APL v alv e. Durin g exha lation (Figs . 12.59, 12.6 0), the fre sh gas decoupling v alv e is ope n s o that f resh gas flows into the bell ows a nd ins pi ratory limb. Ex haled gas es pas s through the expi ra to ry unidi rec tional v alv e a nd th e absorber. Th e open bel lows control v alv e v ents the driv e gas to atmosph ere , allowing the bel lows to ref ill. Firs t f res h g as , then the exhaled gas , then poss ibl y gas in the res erv oir bag fi lls the descending bello ws . In the ev ent that fresh gas flo w i s los t, th e s ubatmos pheric press ure rel ief v alv e prev ents a negativ e p res sure in the c ircu it b y allowi ng ambien t ai r to e nte r the s ys tem. Af te r the b el lows has fil led (Fig. 12.60 ), the pressu re in the breathi ng s ys tem inc reas es. W hen i t reaches approx imatel y 2 cm H 2 O, ex cess gas passes through the APL v alv e to the sc av enging sys tem. PEE P is c reated by adj us ti ng the ex pi ratory control v alv e. Closi ng th e v alv e before the s tart of the n ex t i ns piratio n traps v olume retu rning f rom the patient. The ti mi ng i s fi ne tu ned ov er s ev eral breaths to tra p the app rop ri ate v olume in the exp iratory l imb in o rde r to maintai n the des i red lev el of PE E P .

Special Features
Durin g mec han ic al v enti lation , tidal v ol ume i s unaffec ted by sys tem comp li anc e. The c omputer c ompiles the nec ess ary i nforma ti on during the s tartup p roc edure. P .364 This task , whic h tak es 30 sec onds, c an b e b ypas sed and the prev ious measuremen t reta ine d for e mergenc y c ases . Tidal v olume is un affec ted by f resh gas flow.

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

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The max imu m i nspi rato ry press ure li mi t is 80 c m H 2 O. The breathing s ys tem is hea ted to 35C (97F). T his wa rms inspi red gases and el imina tes mois ture condensa ti on wi thi n the breath ing s ys tem, ev en with lo w f re sh gas fl ows . In the ev ent of power fail ure , a ful l y c harged ba ttery wi l l powe r th e v entil ator and i ts i ntegrated monitor for 30 mi nutes . After 30 minutes , manual and as s is ted v enti lation is poss ib le , and moni toring c ontinues until the battery is de ple ted . A subatmos phe ric pressure (room ai r) v alv e prev ents negativ e press ure b y entrain in g room ai r if the pres sure i n the bre ath ing s ys tem falls 3 c m H 2 O or mo re below ambien t pressu re. A n ala rm is ac tiv ated and a sc reen message appears if there is ambient air intak e. The A nes tar has a pres sure rel ief button tha t ra pidly disc harges ai rway pre ssure if depressed . This red button is loc ated on the breathing s ys tem near the AP L v alv e.

Cleaning and Ster ilization

Di rec tions f or assemb ly an d d is assembly of th e b rea thi ng s ys tem a re giv en in the operati ng manual. Mos t of the pa rts of the bre ath in g s ystem tha t are expos ed to respi ra to ry gas c an be s team autocl av ed a t 124 C.

Pediatric Ventilation
In the pas t, pediatric v en ti la tion has c aused u neas iness among anes thes ia prov iders bec ause the l arg e amount of space in the abs orber, tub ings , an d v enti lato r resul ted i n re lativ el y la rge loss of v olume from gas comp res sion and

co mpliance of these c omponents (82,83). Experi ence has shown th at v olume control v entilatio n of infants wi th newer v entil ators is saf e and effec tiv e, al though the del iv ered tidal v olume may be somewhat i mprec ise (60,61). P res sure c ontrol v enti lation can als o be used wi th pediatric patien ts (27,28,59,83,84). S ome v enti lato rs hav e a pediatric mode that is tailored to smal l infants and children.

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

View Figure

P .365

Magnetic Resonance Imaging Ventilators

Cons iderations f or prac tic ing anes th esia in the magne tic res onance ima gi ng (MRI) unit a re discussed in Chap ter 30. S tanda rd v enti lato rs wi th ferrous ma terial cannot be us ed, because the e lec tromagnetic env ironme nt wi ll interfe re wi th the controls and the v enti lato r can interf ere with the radiof req uenc ies of the MRI. Anes thesi a v enti lato rs su itable fo r use in an MRI uni t are av ailabl e. ICU v entilators c an be modified s o tha t the y are su itable fo r s uc h use (8 5). The re is a repo rt of a p atien t death due to an oxy gen c yli nder emptying whil e a pneumatic al ly driv en v en ti la to r was being us ed in an MRI s uite (86). A lthou gh the re was an alarm, i t was not notic ed by pers onnel . In un usua l si tuations such as an MRI su ite, the v en til ato r s hould be attached to the c entral pi peli ne s ys tem when the v enti lato r is bein g used . If this is not av ailable, ex tra non ferrous c y li nde rs need to be present and the mach ine, v entil ato r, and patient caref ul ly wa tched.

General Hazards Hypoventilation

Ventilator Failure
Mos t anes thes ia v enti lators perform rel iabl y f or long peri ods of ti me. Nev erthe less , one may occas ional ly fail to wo rk properl y. Some probl ems are ins idious and resul t i n les s -than-total f ai lure. Malfunc tion may not be rea dil y apparent, and a fa lse sens e of s ecuri ty may be ge nerate d by the s ound that the v enti lato r makes . Causes of v entilator fai lu re incl ude disc onnec tion f rom or fai lu re of the powe r sourc e (elec tric i ty or driv ing gas ) and internal d ysfunc ti ons . An in termediate f requenc y setting may ca use cyc ling f ai lure (8 7). On s ome v enti lators , wi th f resh gas fl ow c ompensation, a v ery hi gh fresh gas flow c an c ause v enti lato r s tands til l (81). P roblems with the elec tric motor o r power s upp ly may c ause the v enti la tor to s top func tioning (64 ,6 5,68,88). Flu id en teri ng the elec tronic c i rc uitry ma y c aus e the v enti lato r to s top work ing (89).

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

View Figure

P .366

If the b ellows housing is not tig htl y sec ured, driv ing gas c an leak , causing a reduc tion in tidal v olume (90). The housi ng may disloca ted by hitti ng ce iling co lumns or other objec ts as the v enti lator is mov ed. Operating room personnel may

attempt to mov e a v entil ator by g rab bing the hous ing, loosening i t, o r c ausi ng it to break . A malfunc tion i n a c omputer-c ontroll ed v enti la tor ma y interrup t c yc li ng . It is good prac tice to turn the anes thesi a machi ne OFF an d res tart i t by usi ng the elec tron ic checko ut procedure a t leas t daily so that the c omputer has f resh information in its data bank . A c yc ling fail ure may sometimes be solv ed b y turning th e anesthes ia machine OFF and the n ON bu t usu all y require s reference to the opera tion manual or a ca ll to the manufac turer. Low max imum fl ow rates and v ariabi li ty in flow ra tes wi th i nc reased ai rwa y p res s ure wi th ol der anes thes ia v entilators can re duce the tidal v olume that ca n be deliv ered. A l though this is us ual ly no t a pro bl em in patients wi th n ormal lungs , it c an bec ome i mportan t in pa ti ents wi th ex piratory a irflow obs truc tio n, for who m a prolonged ex piratory phase may be n eces sary to av oid a utoPEE P .

Loss of Breathing System Gas

Ol der an es thes ia v enti lators hav e no means o f comp ensa ting fo r gas loss in the breathi ng s ys tem. New c omputer-c ontroll ed v en ti la tors can c ompens ate for s mall l eaks . A v entilator ma y c ycl e but fail to occ lude the ex i t port of the s pi ll v alv e, blowi ng part or all o f the ti dal v ol ume into th e s cav enging sys tem (53,54,91). If there is loss of breathi ng s ys tem gas and an asc ending be llows v entil ator is in us e, the bello ws ma y not return to i ts ful ly expa nded pos i tion. This usual l y wil l be obv io us . Ho wev e r, wi th the i ntroduc tion of cl osed sc av enging s ys tems , the bel lows may remain ex panded if th ere is a dis connec tion (92 ). A des cendin g bel lows v enti lato r may appear to func tion no rmall y in the fac e of loss of b rea thing sys tem gas .

Incorrect Settings
In a c rowd ed anes theti zing area, v entilator s witches o r di als ma y be i nadv ertently change d as personnel mov e about. A n ope rator may fai l to adjus t s ettings fo r a new case (93 ). F or v en ti lato rs that prov ide a co ntrol for l imi ting the peak ins pi ratory press ure , setting that p res sure P .367 too lo w may resul t in an inadequate tidal v ol ume being del iv ered.

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

View Figure

If an anes thes ia machine is turned OFF and then turned bac k ON, the v entilator may defau lt to diff erent s ettings than were b ei ng used (94). It is essen ti al that the re be s uff ic ien t inspi ra tory time fo r the des i re d tidal v olume to be de liv ered. Ins uffic ient i nspiratory time may be indica ted b y a be ll ows that d oes not mak e a fu ll excu rsion, caus ing a d ec rease in the tidal v olu me.

Ventilator Turned OFF

The re are ti mes during anes thesia wh en th e v entilator mus t be tu rned OF F, such as during radiologic al proc edures where mov ement would comp romise the ima ge quali ty. The operato r may fo rge t to turn i t bac k ON.

Flow Obstruction
As wi ll be pointed out i n Chapter 1 4, res tricted or oc cl uded gas f low c an occ ur at a v a ri ety of s i tes a nd be caused by a v ari ety of mechanisms . incl ud ing f ai lu re to change the pos itio n of the b ag-v en tila tor s el ec tor v a lv e when conv erting to automatic v entilati on. If the v alv e is lef t in the ba g pos i tion , the v entilator wi l l operate aga ins t a dea d end. W ith obs truc tion to fl ow, the ex cursi on of the bell ows wil l be reduced but not total ly el imina ted . The press ure s hown on the s ys tem pressu re gauge wi ll v ary , depending on the loc ations of the obs truc tio n and the g auge .

Positive End-expirator y Pressure

Additio n of P EEP may dec rease the tidal v ol ume del iv ered with some v en til ato rs (21,22). The effec t is mo re pronounce d wi th l ow tida l v olumes but less if lung co mpliance is l ow.

Hyperventilation
In one reported case, v entil ator se ttings fo r a patient wi th l ow c ompl ia nce were not modified p ri or to the nex t c ase, a pa tient wi th norma l lung complianc e (93). The resul t was exces siv e tidal v ol ume. W ith a hole in the bello ws or a lo ose connec tion between the bellows and i ts base as sembly, d riv ing gas f rom the hous ing c an enter the bell ows , c ausi ng an unexpec te dl y high tidal v olu me (95). Th is ca n be P .368 ac centuated by a high inspi rato ry flow rate . A s mal l hol e in the bel lows may not caus e a cha nge in the tidal v olume (96).

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

View Figure

Hyperoxia
A hol e or tear i n the bellows wi th ox ygen as the driv ing gas can res ult in an i nc reas e in the ins pired ox ygen c once ntratio n and lo wer-than-exp ec ted anes th etic conc en trations (95 ,97 ,98 ). Ho wev er, wi th a smal l tear, there ma y be no eff ec t (96 ).

Excessive Airway Pressure

Exc ess iv e a irway press ure can dev elop v ery rapidl y, es pec ial ly if high f resh gas f lows a re being us ed. Qu ic k ac tion may be requ ired to prev ent pa ti ent injury. Bec ause the v enti lato r spil l v alv e is cl osed du ring ins pi ra tion and the A PL v alv e in the breathing s ys tem is cl os ed or isolated, ac tiv ating the oxygen flush duri ng the i nspi rato ry phase c an resu lt in barotrau ma. Fres h gas decoupl ing reduces this danger b y div erting the ox ygen to the res erv oir bag. V entilators that compensate by al te ri ng the bel lo ws excu rs ion may no t al ways be ab le to prev ent excessiv e ai rwa y press ure if the ox ygen fl us h is used during insp iration . A hol e in the bel lo ws or a loose co nnec tion between the bel lows and i ts base may al low d riv ing gas to enter the bel lo ws , resulting in a higher-than-ex pec ted press ure during ins pi ra tion. P res sure on the v enti lator s pi l l v alv e c an res ul t in ex ces s press ure (54,56,57). In one cas e, a muffler desig ned to s ilenc e the ex haus t of driv in g gas from the v entil ator became saturated with water and prev ented gas from ex iting the bellows ho using (49). Suffic ien t ti me to all ow f ul l ex hal ation mus t be allo wed. Ins uffic ient ex pi ratory ti me may be indicated by a be llows that does not ex pand full y and carri es the risk of air trappin g and auto (oc cul t, in trins ic ) PE EP (9 9). A pro perly s et press ure l imi ting mec hanis m sho ul d reduce the risk of ba rotrauma. Some v enti lators hav e adj us tab le high-press ure alarms . On others , the alarms are prese t. Such an alarm may giv e warni ng of a probl em in time to p rev ent h arm to the pati ent. The ris k of P .369 barotra uma and v olutra uma are reduc ed wi th fres h gas decoupl ing (10 0). W hen there is hi gh ai rwa y pressure, a disc onnec ti on sh ould be made immediate ly at the trac heal tub e and manua l v en ti lation i ns tituted. Taki ng time to f ind the sourc e o f the p rob lem may resul t i n harm to the pa ti ent.

Negative Pressure during Expiration

Negativ e press ure is cons idered undesi rab le under mos t ci rcums tances b ecause of adv erse effec ts on pu lmonary func tion and inc reas ed risk of air embolis m. A v enti lato r wi th a wei ghted hang in g bel lows c an gene rate sub atmos phe ric pressu re during the earl y part of expi ra ti on if expi rato ry f low i s not impeded. This wi ll be ac centuated if th e f resh gas f low i s l ow. Newe r v entila tors with a hanging b ellows hav e a n egativ e pressu re v alv e to admi t ai r if nega tiv e press ure dev el ops .

Alarm Failure

A l though low-pre ss ure al arms hav e s ignifica ntl y adv anc ed patie nt safety, they c an fail . W hen the low air way press ure alarm threshold is adjus table, i t s houl d be s et j us t b elo w the peak ins pi ratory pressure. Cases hav e been repo rted where resis tance (from trache al tube c onnec tors , Y -pi eces , f il ters , and other c ompon ents or f rom the patient po rt of the breathi ng s ystem bein g p res sed agains t the pati ent or a pi l lo w) c oupled with high ins pi ratory f low rates c reated s uff ic ien t bac k pressure to generate a f als e-pos itiv e s ignal a t the s ens ing s ite when the thres hold was set too lo w. The use of a PEEP v alv e in the breathing sy s tem may c ause a low-pre ssure alarm not to be ac tiv ated i f the P EEP v alv e ra is es the pres sure abov e the alarm threshol d.

Electromagnetic Interference
Ul tra-high-f requency (UHF ) ra dios and GS M c el l phones may i nte rfere elec tromagne tical l y with ICU and op era ting room v entil ators (101). E ffec ts inc lude faul ty readi ngs , mis leading alarm mes sages, modif ic ation of v entilation parameters , and o utput inte rruptio n and were tempo rary.

Loss of Electrical Power

Mos t v enti la tors in us e today are elec tric ally po wered. If th ere is a power f ailu re, there mus t be a battery backup for at leas t 30 minutes (6). T he sc reen wi ll note the change ov er to batte ry po wer and giv e an indica tion of b attery life . W hen all elec tric al ene rgy is los t, mos t anes thes ia mac hines wi ll defaul t to a manu al /sp ontaneo us breathing mode. The anes thes ia prov ider may need to ini tiate this mov e. W i thout the v enti la tor or mach ine mon itors , mos t mac hines wi l l prov ide ox ygen to the breathing s ys te m, and sometimes v olati le agent. S ince mach ines handle this probl em in diff erent wa ys , the us er needs to de termine how a p articular machine wil l re ac t to a power outage and dev elop a plan of ac tion if this problem oc curs .

Advantages

Us e of a v entilator all ows the anes thes ia p rov ider to dev ote ti me and ene rgy to o the r tasks and e liminates the fatigue res ul ting from sque ezing a bag (102).

A v enti la tor p roduces mo re regular v enti lation wi th resp ec t to rate, rhythm, and tidal v olu me than manual v entil ation.

Disadvantages

P robably the greates t d isadv antage to the use of a v entilator is the l oss of contac t be twee n the an es thes ia prov ider and the p atien t. The fee l of the bag can rev eal s uch th ings as disconnec tions , changes in res is tance or co mpliance, c ontinuous posi tiv e pressu re, and spontaneous res pi ratory mov ements . W i th mechanic al v enti lati on, thes e ma y go unde tec ted for a cons iderabl e period of ti me.

A v enti la tor ma y ind uce a fals e s ens e o f sec uri ty in the user if i t conti nues to make the app rop riate s ounds ev en wh en it malf unc tions . Some anes thes ia v entil ato rs do no t incl ude al l the newer mo des of v enti lation , and some c anno t dev elo p high e noug h ins pi ratory pressures or f lows to v en ti la te ce rtai n patien ts (1,103). It ma y be necessary to tak e a c ritical c are v entilator i nto the ope rating room to prov ide adeq uate v entilati on for c ritically i ll patients .

Components that are subjec t to c ontamination may no t be eas y to re mov e or c lean , espec ially thos e on o lder v en ti lato rs . Some v enti lators lack user-f ri endlines s . There is room f or imp rov ement in the desig n and grouping of c ontrols . Some v enti lators are dis turb ingly no is y o r to o quiet. Some v enti lators requi re relativ ely high f lo ws of driv ing g as (1 5). Gas cons ump tion inc reases with inc reased minute v ol ume and wi th so me v enti lato rs , an inc re ased I:E rati o. A v entilator wi th a pis ton wil l no t consume driv in g gas .

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74. K rock J, Padda G, Moore J . Ohmeda 7900 ventilator flow sensor. Anesth An al g 1998; 86 :231232. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 75. Shogase A , Mi zutani K , Toy oda Y . P rotec ting Oh meda 7900 v entilator flow sens or. A nes th A nalg 1 999;88:234 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 76. Hari MS , Jennings M. Flow s ens or faul t caus ing v en tila tor ma lfunc ti on. Anaes thes ia 2005;60:1049 1050. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 77. A ld ridge J . Leak on Da tex Aes tiva /5 anaes thetic machine. A naes thes ia 2005;60:420421. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 78. Hari MS , Jennings M. Flow s ens or faul t caus ing v en tila tor ma lfunc ti on. Anaes thes ia 2005;60:1049 1050. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 79. Mychask iw G, Morri s S . Dange rous design flaw in the Ohme da Aesp ire anes thes ia sy s te m. Anes th Analg 2005;100:15431544. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 80. Snyd ers S . Fai lure of a flow sensor o f a Datex Ohmeda S /5 Aespi re. Anaes thes ia 2005;60:941. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 81. Wo ng DT, Li A Q. Venti la tor bellows s tan ds til l . Can J Anes th 2005;52:774775 .

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83. S tevens on G, Tobin M, Jo rn B , et al. The effec t of c ircui t co mpliance on delivered ven ti lation wi th us e of an adu lt c irc le sys tem fo r ti me cyc le d v olume control led v entil ati on us ing an infa nt lung mode l. P aedi atr Anaes th 1998;8:139 144. [Cross Ref] [Med li ne Link ] 84. Tobin MJ, S tevens on GW , Babette JH, et al . A compa rison of three modes o f venti lation wi th the us e of an adul t c irc le s ys tem in an infant lung model. A nes th Analg 19 98;87:766771. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 85. Wil liams EJ , J ones NS , Carpenter TA , et al . Tes ting of adul t an d paediatric venti lato rs for us e i n a magne tic res onance ima ging uni t. A naes thes ia 1999;54:969974. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 86. Anony mous . Anes thesi a v entilators with desc ending be ll ows : the n eed fo r appropriate moni toring. Technol Anes th 1996;17:13 . 87. Sos is MB . Drager v entilator fai lure on changing the res piratory rate setting. Anes th An al g 1993;76:453454 . [Med li ne Link ] 88. Usher AG, Cave DA , Fin egan BA . Cri tica l inc ident w i th Nark omed 6000 anes thes ia mach ine. Anes th esi ology 20 03;99:762. [Fu ll tex t Link ] [Cross Ref]

[Med li ne Link ] 89. Cowl ing M. Ca to mac hine fai lure . Anaesth Intens Care 1998 ;26 :3 29330. [Med li ne Link ] 90. Lee K . Leak of drivi ng gas from A i r-Shields venti lator. Can Anaes th Soc J 1986;33:263264. [Med li ne Link ] 91. Wa gner K , Loy J . A s trange plac e to fi nd a cab le tie . Anes th Ana lg 2006;102:655656 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 92. B lacks toc k D. A dvantages of s tanding bel lows v en tila tors and low -flow tec hniques . A nes thes io lo gy 1984 ;60 :167. [Fu ll tex t Link ] [Cross Ref] 93. Wo ng DT, Shi rzad T. Un usua l cas e of vo lutrauma. Can J Anaesth 2000;47:1046104 7. [Med li ne Link ] 94. We in berg L , S awhney S , Skewes D. S afety warning w ith Datex -Oh meda S /5 anaes thetic deliv ery un it desi gn. A naes th Inte ns Care 2004;32:719720. [Med li ne Link ] 95. Rig g D, J oseph M. Spl it venti lator b el lows . Ana es th Intens Care 1985;1 3:213. [Med li ne Link ] 96. Lampo tang S , Sanc hez J C, Chen B , et al. The effec t of a bellows l eak in a n Ohmed a 7810 venti lator on room c ontamination . Inspi red oxygen, ai rway pressu re and tidal v olu me. A nes th A nalg 2005;101 :15 115 4. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 97. Rip p CH, Chapin J W . A bel low 's leak in an Ohio anes thes ia venti lator. Anes th Analg 19 85;64:942. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 98. We bb RK , Rus sel l WJ , Kl epper I, et al . Eq uip ment fai lu re: an analys is of 2000 i nci den t reports . A naes th Intens Care 1993;21:67 367 7.

[Med li ne Link ] 99. B iddle C. Adv ances in venti lating the pati en t w ith sev ere lung diseas e. AA NA J 1993;61:170175. [Med li ne Link ] 100. B rockwell RC. Unde rs tand ing y our anes thes ia mac hine (ASA Refresher Course #506). Park Ridge, IL: ASA , 2005. 101. Barbaro V , Barto lini P , Benas si M, et al . E lec tromagnetic interferenc e by GSM ce ll ul ar phones an d U HF radi os wi th intensive -c a re and operating-room v entilators . B iomed Ins trum Tec hnol 2002 ;XX :361369 . 102. A maranath L, B outros A R. Ci rc le absorber a nd soda li me c ontamination . Anes th An al g 1980;59:711712 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 103. Del V all e RM, Hec ker RB . A rev iew of v entilatory modal ities used in the i nte nsive ca re uni t. A m J Anes th 1995 ;22 :23 30. P .372

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. A hole or tear in the bellow s may result in Hyperv entil ation Hyperoxi a Barotrau ma Patient aware ness V iew Answe r2. E xcessive a irw ay pressure ma y b e caused by Ac tiv ating the ox ygen f lush during ins pi ration A hol e in the bel lo ws hous ing

A s tuck sp ill v alv e Asc ens ion of the bellows V iew Answe r3. A standing bellow s Is a ttached at the to p Exp ands d uring ex halation Imposes n o pressure during exhalation Makes it eas y to detec t disc onnec tions V iew Answe r4. Whe n a ventilato r w ith a piston is use d, PEE P of 2 to 4 c m H 2 O is usual A i r entra inment may oc cur The rese rv o ir bag is is ol ated from the b rea thing sys tem d uring ex halation The rese rv o ir bag may expand and co ntrac t with mechanical v entilation V iew Answe r5. R egardin g press ure co ntrol ve ntila tion, Fl ow is high es t a t the b eginning of insp iratio n Ti dal v olume is no t cons tant It is often us ed wi th s upraglottic dev ices It is usef ul for detec ting a partial ly occl uded tra cheal tube V iew Answe r6. R egardin g S IMV , The v entil ator has a s econdary s ource of gas flow fo r spon taneous b rea ths It is often us ed for we aning patie nts f rom mec hanical v en tila ti on A manda tory ti dal v olume and minimum mechan ical v en til ati on rate mus t be se lec te d Pos itiv e pressu re (mandatory) breaths occ ur at regula r in terv als V iew Answe r7. R egardin g PS V , Mos t v enti la tors hav e a backup o r apneic rate The optimal ini tial ins pi ratory flow is hi ghest i n patients wi th h igh c ompl iance The pres sure wav ef orm has a s quare, f la t-to pped s hape It is assoc ia ted wi th a dec rease i n func tional res idual capac i ty V iew Answe r

Chapter 13 Controlling Trace Gas Levels

Introduction
Before scav enging was ins ti tu ted , exc ess an es thetic gases and v apors were disc harged in to room air. As a consequenc e, ope rating roo m pe rs onnel were ex posed to lo w c oncentrations of thes e d rugs with li ttle c onc ern about any detrimen tal effec ts that c ould poss ibl y result f rom suc h exposure. Ques tions hav e been raised about poss ibl e haz ards from expos ure to trace amo unts of anes thetic gases and v apors (1). (For the remainder of this chapte r, a nes thetic gases and v apors wil l be refe rred to as gases , bec ause mos t v apors behav e as gas es .) A trace lev el of an anes thetic gas is a conce ntration far belo w that n eeded for c linic al anes thes ia or that can be de tec ted b y s mel l (2 ). Trace gas lev els are us ual ly ex pressed in parts per mill io n (ppm), whi ch is v ol ume/v ol ume (100% of a gas is 1,000,000 ppm; 1% is 10 ,000 p pm). Reported trac e gas concentra tions in operating rooms v ary greatly, depend ing on the fresh gas fl ow, the v en ti la tion sys tem, th e l eng th of time tha t anes thes ia has been adminis te red , the measuremen t s i te, anes the tic techni que, and othe r v a ri ables . Trace gas lev els tend to be h igher wi th pedia tric anes thes ia (3,4 ), i n denta l operatories (1,5), and in poorly v entilated pos tanes thetic c are un its (rec ov ery rooms ) (6,7 ,8,9,10).

Methods of Study
Des pite many s tudies and much discuss ion, opi ni ons differ o n wh ether or n ot a problem ex is ts and what lev els shou ld be all owed in the work ing env ironmen t (11). To inte rpret the data, i t is fi rs t nec ess ary to unde rs tand how i t was c ol lec ted. Fou r basic metho ds of s tudy hav e been used . All hav e maj or l imitations and disadv antag es .

Animal Investigations
Durin g animal s tudies , laborato ry animals are expos ed to v ary ing lev els o f gases for v arying peri ods of ti me and are s tud ied to determine the effec ts . These s tudies shoul d be interpre ted wa ri ly . Large numbers of animals need to be s tudied to achi ev e s tatis tical s ignif icanc e . In an imals , d ie t affec ts tumor suscep tibi li ty, and s tress af fec ts rep roduc tio n (12). Tox ic ity usual ly depends o n both exp osure time and co ncen tration , and it i s d ifficult to corre late ex posure time i n a ni mals wi th that in humans bec ause their l ife s pans are so d iffe ren t. Fina ll y,

v a ri ations in drug effec ts among spec ies c re ate uncertainty about the rel ev ance of these f indings to h umans .

Human Volunteer Studies

Human v olunteers hav e been used to s tudy th e eff ec ts of trace gas es on sk il le d performance, immune responses , and d rug metabolism.

Epidemiologic Studies of Exposed Humans

A numbe r of ep idemiolog ic s tud ies of exposed pe rsonnel hav e been perfo rmed. Mos t were retros pec tiv e and us ed ques tionn ai res . They s uffer f ro m low res pons e rates , inapp rop ri ate c ontro l groups , poor rec oll ec ti ons an d biases on the part of the responden ts , poor wo rdi ng , failure to include s ignif icant po ints in the ques tionnai res , P .375 and mis interp retatio ns due to differe nces i n educ ation and expe ri enc e o n the part of the responden ts (12,13,14,15,16). Data interpreta ti on is hampered by a lack of agreeme nt as to what l ev el of s ign if icanc e to acc ept (12,17). Final l y, many of the s tudies hav e not b een des igned to tes t the c aus e -and-effec t relations hip between trac e g ases and problems in ex pose d personnel. Some s tudies sho w i nc reas ed risk for spec ific groups bu t not for o the r equall y exp osed groups (18 ). Others hav e shown pro bl ems in groups with and wi tho ut ex posu re to trace gas es , s ugges ting that the risk may be rel ated to some othe r fac to r. Fina lly, many of the s tudies were performed b efo re sc av enging and other methods to co ntrol trace gas lev els were i mple mented.

Mortality Studies
S tudi es on the caus es of d eath and the age at whi ch death oc curre d among anes thes iologis ts hav e p rov ided in teres ting data. One s tud y found tha t anes thes iologis ts do not hav e an inc reas ed ri sk of death from c anc er or heart disease but do hav e high er ra tes of death due to s uici de, s ubs tanc e abus e, other ex ternal c aus es and ce reb rov asc ular dis ease than internis ts (19). The re was also an i nc reas ed rate of de ath f ro m HIV and v i ral hepa ti tis i n ma le anes thesi ol ogis ts . Ano the r s tudy found that wh ile anes th esiologis ts hav e a s ignif ic antly younge r mean age of death, there was no s tatis tical di ffere nce i n age-specif ic mo rtal ity (20).

Problems Attributed to Trace Gases

Spontaneous Abortion
Epidemiologic Studies
Epidemiologic s tudies f rom sev eral c ountri es hav e s hown higher ra tes of spontaneous abortion in operating room and dental opera tory person nel than in women in different env i ronments (21,22,23 ,24 ,25 ,26,2 7,28,29,30,31,32,33). Other s tudies hav e failed to f ind significan t inc reases in spontaneous aborti ons in ex posed p ers onne l (34,35,36,37,38,39,40). One s tudy f ound that the f requenc y of miscarri ag es among nu rs es work in g in inte ns iv e care uni ts wa s approximatel y equal to that of nurses in the operating room, s ugges ting that o the r fac to rs s uch as s tress may play a ro le (27,41). A s tudy of midwiv es who were of ten ex pos ed to ni trous ox ide foun d that the ris k of spontaneous aborti on was n ot inc reased with nitrous ox ide expos ure bu t was i nc reas ed with night work and hi gh work load (42).

Animal Studies Halogenated Agents

Inv es tigati ons hav e fou nd no ev idenc e of inc reas ed s pontaneous aborti on in mice ex posed to high lev els of isof lurane, enfl urane, o r halothane (43,44,45,46,47,48,49).

Nitrous Oxide
One s tudy f ound that pro lo nged ex posu re to 1 ,000 ppm n itro us oxi de ca used fetal death , but no eff ec t was s een wh en 500 ppm was us ed (50). A later s tudy found that the th res hold for fetal d eath was higher (betwee n 1 ,000 a nd 5,000 ppm) wi th i nte rmi ttent exposure (51).

Mixtures
Inv es tigati ons us ing mixtures of hal othane a nd ni trous ox ide found no effec t with conc en trations as high as 1,600 ppm halothane p lus 1 00,000 ppm ni trous oxid e (49). Nitrous ox ide 50 0,000 ppm plus is ofl urane 3,500 ppm also had no effec t on spontaneous abortions (52 ).

Spontaneous Abortion in Spouses

A l though s ev eral s tudies hav e s hown an incre ased s pontane ous abo rtio n rate in wi v es of expos ed mal es (2 3,53,54), the majority s ugges t tha t there is no inc rease (16,21,25,40). One s tudy found no c hanges in s perm c oncen tration or mo rph ol ogy i n male an es thes iolog is ts work ing in heal th care fac i li ties wi th s cav engi ng equipment (55). S tudi es hav e f ai le d to sho w a ny adv ers e effec t on rep roduc tiv e

processes of male anima ls ex posed to up to 5 ,000 ppm enf lurane (44,56) o r 10 ppm halothan e plus 500 ppm ni trous ox id e (57).

Infertility
Epidemiologic Studies
Sev era l s tudi es hav e found higher-than -ex pec ted rates of i nv ol un tary infertil ity amon g exposed person nel (24,53,58 ). A more recent s tudy found n o ev idenc e tha t female a nes the tis ts hav e inc reas ed risk of inf erti li ty (59 ). One s tud y found dec reas ed ferti li ty in den tal operatory s taffs who were ex pos ed to cons iderabl y highe r lev els of ni trous ox ide than those who were o perating room personnel (5). One s tudy f ound no effec t from pate rna l exp osu re (2 5), and no cha nges in spe rm count or mo rphology were found in male anes thesi ol ogists work ing in scav enged operati ng rooms (55 ).

Animal Studies Halogenated Agents

Numerous s tud ies of animals exposed to hig h c onc entrations of isoflurane, enfl ura ne, o r hal othane showed l ittle or no effec t on ferti l ity (43 ,45,56,6 0,61,62,63).

Nitrous Oxide
No cha nges in male ferti l ity and no sperm abnormali ties were found in mice af te r ex posu re to up to 800 ,000 ppm (60,64). Howe v er, prolonged expos ure of male rats to 200,000 ppm resul ted in abnorma li ties i n spe rmatogenic c ells (65). Exposure to up to 8 00,000 ppm ca used no c hanges in ferti li ty i n male or female flies (61). P .376

Mixtures
Dec reased f erti li ty wa s s een in female ra ts ex posed to halothane 10 ppm plus ni trous ox ide 500 ppm bef ore ma ting (5 7). Male rats exposed to thes e conc en trations showe d g rea ter frequenc y of c hromosomal abe rrati ons i n spermatog enic c el ls , but the aberrations were p rob ably too inf req uent to caus e dec reas ed ferti li ty (61).

Birth Defects
Epidemiologic Studies

Sev era l s tudi es i n humans h av e fo und an inc reas e in congeni tal abnormali ties in ch il dren of ex pose d pers onn el (2 1,23,24,28,34,37,53,54,66,67). Interp retations of the data hav e be en ques ti one d (12,17 ,18 ,68 ). Sev eral inv estiga tors hav e found no i nc reas e in bi rth defec ts among the offsp ri ng of expos ed parents (16,25,26,27,29,36,40). No inc rease in chromosomal abnormali ties in exp osed nurses o r cha nges in sperm mo rphology hav e been found in male an esthes iolog is ts work i ng in operating rooms (55,69).

Animal Studies
S tudi es of labo ratory animals exposed to c once ntrations of inha lational agen ts wel l abov e th ose found in ev en unscav enged operating rooms h av e fa iled to f ind any s ignif ic ant teratogenic effec ts (44,45,47,48,49,50 ,52 ,57 ,60,64,7 0,71,72).

Impaired Performance
Operatin g room pers onnel a re s ubjec ted to many s timul i that requi re p rec is e, ra pi d, and c ompl ic ated res pons es . Becaus e the pati ent's surv iv al depends on th e alertness and pe rf ormance of the profess ion al team, an ythin g tha t in terferes wi th i ts ab ility to perc eiv e changes and reac t quick ly and appropriatel y may resul t in harm to a patient. A l though a few s tudies hav e f ound that v olunteer expos ure to trace gas conc en trations caus ed si gnific ant dec reases in performanc e (73,74 ,75 ,76 ), e fforts to dupl ic ate thes e res ults hav e fail ed (41 ,77,7 8,79,80,81,82,83,84,85,86). These s tudies found that the c oncen trations needed to dec reas e performance were hundreds of times greate r than the av erage lev els found in u nscav eng ed ope rating rooms . In anothe r s tudy, neuropsyc holog ic al sy mptoms and ti redness were repo rted more by indiv iduals in op era ti ng rooms where s cav engi ng was used less of ten (87). One s tudy d ete rmined that pe rs onnel exposed to 51 to 54 ppm of n itrous ox ide had s lowe d reac tion ti mes compared with work ers not ex pos ed to trac e g ases (88).

Cancer
Epidemiologic Studies
A la rge s tud y found no inc rease in c anc e r in ex pos ed males but indica ted that females in the ope rati ng room were at highe r ri sk for cancer than n onex posed females (21). T he s ignificance of thes e data h as been ques ti oned (17,18). S imi lar resul ts hav e been reported for female dental op era tory ass is tan ts (23). Two s tudies of dentis ts hav e sho wn that the inci dence of c ance r is not s igni fica ntly dif ferent amon g those exposed an d thos e not ex pos ed to trac e c onc entrations of anes thetics

(23,54). One s tudy found a hi ghe r rate of melanoma among anes thesiologis ts (89). A rev ie w o f combi ned data f ro m six s tudies found an inc reas ed c ancer ris k among women but not men (41 ,90 ).

Mortality Studies
The re is no inc reased de ath rate f rom c ance r in mal e anes thes iologis ts (19,91,92,93,94,95,96). The death rate from c ance r among female anes thes iologis ts is h igher when c ompared wi th male anes thesi ol ogis ts and c on trol groups (93), but the n umbers are too smal l to permi t an y s trong c onc lus ions . Vari ous therapeutic modal ities hav e res ulted in higher cancer cure rates , s o the i nci dence of canc er cannot be infe rred by us ing only morta li ty data .

Animal Studies
S tudi es hav e found no ev idence of inc reas ed c arc inog enici ty in animals expos ed to up to 5 ,000 ppm halothane or 10,0 00 ppm enf lu ran e (97,98 ,99 ). On e s tud y found hepatic ne oplasms in mice ex pos ed during g es tation and early lif e to 1,000 to 5,000 ppm isof lu rane (100 ), but the v al id ity of this s tu dy has been ques tioned, and i t appears tha t the i nc reas ed inci dence of tumors ma y hav e been the resu lt of other fac tors . In l ater s tudies , no ev ide nce of inc reas ed carci nogenic i ty was found in animals exposed to up to 6,000 pp m isofl ura ne (98 ,101). No ev idenc e of inc reased ca rc inogenic i ty i n mic e h as been found with ex posure to up to 800,000 ppm ni trous ox ide (98,102 ). No inc reas e in neo plasms was f ound i n rats exposed to 10 ppm halothan e plus 500 ppm ni trous ox id e (103 ).

Mutagenicity Testing Human Studies

Cytoge netic methods are inc reas ingly used for ev alu ati ng the effec ts of ex posure to poten tial mutagens in the env ironment (105,106 ,107,108,109,110,111,112,113 ,114,115). Some s tudies f oun d no as soc iation between oc cupa ti ona l exp osure to was te an es thetic gas es and c y tog enetic damage (104,108,110,113,116 ,1 17,118,119 ,12 0). Othe rs sugges t that there ma y be an associ ati on (105,106 ,107,111,112 ,11 4,115,121 ,122,123). One s tudy foun d that the wa s te gas lev els rec ommended by the Na tiona l Ins ti tute f or Occ upati onal Safe ty an d Heal th (NIOS H) appea r to be safe , whereas ex posu re to highe r lev els were assoc ia ted wi th an inc rease in c h romosome dama ge (109).

Animal Studies

Sev era l s tudi es hav e found that halothane a nd its metabol i tes a re not mu tagenic (124,125 ,126,127,128,129). Others hav e fou nd tha t halothan e and/or i ts P .377 metabol i tes a re weak l y mu tag enic (130,1 31,132,133). Inv estigato rs hav e been unable to demons trate mutagenic ef fec ts f ro m enflurane (125,134 ,135) or is ofl ura ne (125,127 ,135). Inv es tig ations h av e found that nitro us oxi de is not mutagenic (125,136 ). One i nv estigation found that halo thane plus ni trous ox ide did no t i nc reas e mutag enes is (128). Ano the r fo und th at ni trous ox ide had no effec t on the mutagen ic ity of ha lo thane (130). The same s tudy foun d tha t there was no mutagen ic ity with mix tu res of nitrous oxi de and e nflurane or isoflurane.

Liver Disease
Epidemiologic Studies
S tudi es hav e found th at ope rati ng room and d ental opera to ry personnel hav e highe r-than-expec te d rates of hepatic d is ease (11,19,21,23,54,89,90 ,137). Inte rpretation of thes e data has been ques tioned (17). Rec urrent hepati tis fo llowi ng exposure to ha lo thane has been demons trated in a few i nd iv iduals (138 ,139,140,141 ,142), and exp osure to trace anes the tic age nts enhanc es hepa tic metabolis m of some drugs (143,144 ). E lev ated serum autoa nti bodies tha t reac t wi th s pec if ic hepatic proteins hav e been found in anes thes ia personnel , es peci al ly females an d pediatri c anes thes iologis ts (145 ). The relev ance of thes e f ac ts to the effects of trac e c oncentratio ns is no t c lear.

Animal Studies
Halothane ex pos ure in concentra ti ons as low as 20 pp m may be as soc iated wi th mi ld toxic effec ts to the liv er in rats (146,147,148). No ev ide nce of s uc h effec ts has been found from exposure to enf lurane or isof lu ran e (146 ,148).

Renal Disease
One s tudy f ound that fema le opera ting ro om n urs es , technici ans , a nd anes thes iologis ts had a hi ghe r ri sk of k idney disease than did c omparable groups outside the operatin g room (21). Thes e results hav e been ques tioned (17). A nother s tudy faile d to find an y inc rease in k idney di seas e in male anes thes iologis ts (11). A s tudy showed an inc rease in ren al dise ase in expos ed den tis ts and female c hai rs ide as s is tants (23). No inc rease in deaths caus ed by renal diseas e has bee n fou nd amon g anes thes iologis ts (93).

Hematologic Studies
Epidemiologic Studies
In one s tudy, a higher-than-expec ted ra te of l euk emia wa s fou nd in f emale anes thes iologis ts , b ut the smal l database made any v al id co ncl usions d iffic ult (21). Other s tudies found n o s ignifican t al terations in hematologic func tion in expos ed i ndiv iduals (149,150 ,151,152). Howev er, 3 of 20 den tis ts expos ed to c onc entrations of nitro us oxi de highe r than those normal ly found in operating rooms s howed abnorma li ties i n their bone marrow, and two h ad abno rmal i ties i n thei r pe ri phe ral blood (153).

Animal Studies
In mice, no hematologic effec ts we re found f rom exposure to 50 0 ppm halothane (97). Exposure to 3,000 ppm enf lurane had no effec t on h ematopoies is in mice (154). Exp osure to 10 ,00 0 ppm n itrous ox ide c aused no c hanges in hematopoies is i n rats (155). Cytogene tic damag e to bone ma rrow was found in rats expos ed to 10 ppm hal othane plus 500 ppm ni trous ox id e (56).

Neurologic Symptoms
A nons pec if ic polyneuropa th y f ol lo win g c hronic exposure to ni trous ox id e has been desc ribed (15 6,157). Two s tudi es found an inc reas e in neu rolog ic s ymptoms (numbness , tingl in g, an d/o r musc le weak nes s ) in dentis ts an d female cha ir-s ide as s is tants wh o a re ex pose d to anes th etic gases (23,158). A no the r s tudy sho wed no differenc e i n neu rologic s ympto ms o r s igns , sens ory p erc eption, or n erv e conduc tion between dentis ts who us e nitrous ox ide ex tens iv ely and those wh o use i t spa ri ngl y or no t at al l (159). High lev els of ni trous oxide hav e not bee n shown to caus e neu romuscular o r neurologic abnorma li ti es i n animals (159 ).

Alterations in Immune Response

Sev era l s tudi es hav e found that work in opera ti ng rooms does not change the i mmunologic profi le of i ndiv iduals (1 60,161,162,1 63,164). A s tudy of people work i ng in unscav enged rooms with trac e gas c onc entrations sev eral times the recommen ded lev els had c hanges tha t rev ers ed when they we re re mov ed f rom that env ironment (165).

Cardiac Disease
S tudi es hav e shown a greater-than-ex pec ted f requenc y of hypertens io n and dys rh ythmias (11,166), a nd th ere is one case rep ort of atri al fi bri llati on sec onda ry

to haloth ane exposure (167). Howev er, mo rtal ity s tudies giv e no ev ide nce that anes thes iologis ts hav e a h igher-th an-expected risk of dying from heart disease (91,92,93,94,95,96).

Miscellaneous
Vari ous s tudi es hav e rep orted highe r-than-expec ted inc idences of bone and jo int disease (1 1), ulc ers (11,166 ), ulce rativ e coli tis (16 6), gallbladder d ise ase (11), migra ine (166), an d headache and fatigue (168) in exposed personnel . Cas e reports of exposed pe rsonnel who dev elo ped as thmatic s ymptoms (169), la ry ngi tis (170), oph thalmic P .378 hypersens itiv ity (1 71), c on junc tiv itis (172 ), ex ac e rba ti on of myas thenia grav is (173), and s kin e rup tions (174,175 ) hav e been publishe d. Morta li ty s tatis tic s s how a high i ncidence of suic ide an d subs tance abuserelated deaths amo ng anes thes iologis ts (19,9 1,93).

Summary
The ev id enc e that trace anes thetic gases are harmful is at present s ugges tiv e rather th an conclus iv e (176). The hazard, if it ex is ts , is not great and is mo re properl y regarded as disquietin g tha n a la rmi ng. Researche rs who hav e s ys tematica ll y exa mined the publish ed data hav e c onc luded tha t reproduc tiv e problems i n wo men were the onl y hea lth effec ts f or whi ch there is reasonabl y conv inc ing ev idence (14). W hile it is reass uring to note tha t s tudies hav e s hown that an es thes io log is ts hav e a mo rtal ity rate less than that ex pec ted for phys ici ans or the general pop ul ati on (92,93,94), re produc tiv e pro blems are no t refl ec ted in mortali ty da ta , and high cure ra tes may be resp onsi bl e fo r the l ow mortali ty. One s tudy s howed an i nc reas ed ra te of e arl y re tire ment as a res ul t of permanent il l health and a hi gh ra te of deaths whi le work ing among anes thesia pers onnel (1 77). A cause-and-effec t re la tions hip betwe en occ upational ex pos ure and the p rob lems desc ribed has not been f irmly establis hed. If there is an inc reas ed ri sk, it may b e rela ted to other fac tors s uch as men tal and phys ical s tress ; s trenuous physica l dema nds ; dis tu rbed n ight res t; need for c ons tant a le rtnes s ; long and i nconv enie nt work i ng hou rs that of ten in terfe re wi th do mes tic lif e; i rregu la r rou tine; exposure to transmis si bl e i nfec tions , s olv en ts , propel lants , c leaning s ubs tanc es , las ers , methylmethac rylate, radi ation , or ul trav io let li ght; pre-ex is ting h eal th and reproduc tiv e probl ems ; h ormonal or die ta ry dis turbances ; the physic al o r emotio nal

makeup of thos e wh o choose to work in op era ti ng rooms ; s oci o-economic f ac tors ; or s ome other as ye t undefine d fac tor (178 ). The Co mmi ttee on Oc cupa tiona l Heal th of Operating Room Pe rs onnel sugges ts th at health care ins ti tutions b ring to the attention of operati ng and rec ov ery room personnel perti nent information on the c laimed risk s of exc ess anes thetic gases and wa ys by which these ris ks can be mi nimized (179). A s ampl e l ette r is av ailable (180).

Control Measures
Complete el imination of al l anes thetic mol ec ules from the ambien t atmosphere is i mposs ib le. The goal s hould b e to reduce co ncen trations to the lo wes t lev el cons is tent wi th a reasonable exp endi ture of effort and money. To achiev e this , attention s hould be focus ed o n fou r areas : s cav engi ng, equipmen t leaks , work tec hniques , and the room v enti lation s ys tem.

Scavenging Systems
Scav eng ing is the col lec tion of excess gas es from equipmen t used to admi nis ter anes thes ia or ex haled by the patient and the re mov al of these gases to an appropriate place of disc harge outs ide the work env i ron ment. Scav engi ng s ys tems are als o ref erred to as ev acuation s ys tems , was te anes th etic gas d isposa l s ys tems , anes thes ia was te exhaus t, and excess anesth etic gas -s cav enging s ys te ms . Ins tal lation of an eff ic ien t scav eng ing s ys tem is the mos t i mportant s tep in reduci ng trac e g as lev els , lowe ri ng ambient c onc entrations by up to 90% (181,182 ,183,184,185,186,187,188,189 ,190,191). A scav eng ing s ys tem cons is ts of f iv e bas ic pa rts (Fig. 13.1 ): a gas -c ol lec ting as sembly, wh ic h c aptures gas es at the si te of emiss io n; a trans fe r tub ing, whi ch conv eys col lec ted gases to the interface; the inte rf ace, whic h prov ides pos itiv e (and s ome times negativ e ) pressure re li ef an d ma y prov ide res erv oi r c apac i ty ; the gas -d is posa l tubing, whi ch conduc ts the gas es from the interf ac e to the g as disposal s ys tem; and the gas dis pos al s ys tem, whi ch conv eys the gases to a poin t whe re th ey are d is charged . Frequen tl y, s ome or al l of these c omponents are co mbined. A U.S . s ta ndard (192) and an internatio nal s tandard (193 ) fo r scav enging s ys tems hav e been publis hed. The in ternational s tandard di ffers f ro m the U.S . s tandard in that s ome fi ttings are ma le rather than female a nd v ice v ers a.

Gas-collecting Assembly

The gas -col lec ting as semb ly (scav enge r adap te r; gas -c apturing assemb ly , dev ice , or v alv e; s cav engi ng trap or v alv e; c ollec ting or co llec tion v alv e; scav eng ing exhale v alv e; ev acuator; anti pollu ti on v alv e; duc ted expi ratory v alv e; col lec ting s ys tem ex haus t v alv e; scav enging trap, c ollec ting sys tem) c ol lec ts ex ces s gases and deliv ers them to the transfer means . It may attach to , or be an integral part of , a sourc e. Frequentl y, the ou tlets of two o r more s ources are joine d toge ther. T he A meric an Soci ety of Tes ting and Ma terials (AS TM) s tan dard and in te rna tional s tandards (192,193) spec ify that the ou tlet c onnec tion mus t be a 30-mm mal e f itting. In the pas t, 19 -mm fi ttings were permi tted , but they a re being phas ed o ut. The s ize is important, bec aus e it s houl d not be poss ib le to c onnect c ompone nts of the breathing s ys tem to the outle t. Some earl y as semblies had 22-mm fi ttings , and cases of misc onnection wi th breathing sys te m tubes occu rred (194,1 95).

Breathing Systems
Systems Containing an Adjustable Pressure-Limiting Valve
S ys te ms wi th an adjus table pressu re-limi ting P .379 (A PL) v a lv e (Chap te r 7) i nclude the ci rcl e sy s tem and the Maples on A , B , C, and D s ys tems . Th e A PL v alv e is essen ti al ly f itted with a shroud (F ig. 13.2). W i th the c i rc le , Bain, and Lack v a ri ant of the Mapleson D s ys te ms , the wei ght of the as sembly c an be s uppo rted by the a nes thesi a mac hine, and the transf er means can be qu ite s hort. Smal ler and ligh ter A PL v alves wi th gas -collec ti ng as semblies are av ailab le for the other Mapl es on s ys tems .

Figure 13.1 Complete scavenging system. The gascollecting assembly may be an integral part of the breathing system, ventilator, gas monitor, or extracorporeal pump oxygenator. The interface may be an integral part of the gas-collecting assembly or some other portion of the scavenging system.
View Figure

An APL v alv e may hav e a bui l t-in mec hanism that prev ents posi tiv e or n egativ e press ure f rom the scav enging s ys tem being trans mitted to the b rea thing s ys tem (196).

Figure 13.2 Gas-collecting assembly attached to an APL valve.

View Figure

T -piece Sys tems without a n Adjustable Pressure-Limiting Valve

Numerous dev ices for remov ing gases f rom th e bag hav e been des c ribed (197,198 ,199,200,201,202,203,204,205 ,206,207,208 ,209,210,211 ,212,213,214). Other methods use a contai ner tha t is attached to s uc tion (215,216 ). Other methods

attach th e gas -collec tin g assembly be twe en the ba g and its attachmen t to the tubi ng (217,218,219 ,220).

Resuscitation Equipment
Non reb rea thi ng v alv es with a scav enging ad apter are commerci al ly av ai lab le . It is fairl y s imp le to a ttach a c ollec tion ass embl y to the exha lation port of s ome exis ting nonrebreath ing v alv es wi thout af fec ting v alv e func tion .

Masks or Nasal Cannulae

It is c ommon prac tic e in s ome ins titutions to admin is ter anes the tic gases to pati ents through a nasal cannula o r face mask for sedation . P lac ing a ten t or hood around the patient's h ead and attaching a suc tion s ourc e c an reduce the ambi ent conc en trations of gas es (221,222,223 ). A do uble mask consis ting of a s mall er inner mask s eparated from a l arger oute r mask by a sp ace connec ted to a s cav enging dev ic e wil l reduc e ambi ent conc entrations (224,2 25).

Ventilators
Anes thes ia v en ti la tors are now equipped wi th gas -c ol lec ting assemblies . The was te gas is di rec ted to th e same in terface that is us ed by the breathi ng s ys tem. In mos t cases , the driv e gas whi ch is composed of ox yg en, ai r, or a comb ina tion of the two, i s expe lled into the ro om. P .380

On some ol der v entilators , the exhaus t inc lu des no t onl y exc ess breathi ng s ys tem gases but also the driv ing gas for the v entilator. In this si tua tion, a d ispos al s ys tem that is capable of handling high gas flows is requ ired. A sc av enging sys tem that func ti ons effici entl y with s pon taneous ly b rea thi ng or manual l y v entilated patients may fail to do so wh en used wi th v entilators that discha rge the driv ing gas into th e sc av engi ng s ys tem (226).

Extracor poreal Pump Oxygenators

The outlet port of an ex tracorporeal pump ox ygena tor is a potential sourc e of anes thetic pollutio n (227 ,228). Gas -c ol lec tin g assemblies f or these are av ailabl e (229). It is important to p rov ide a n effec tiv e in terfac e with these dev ic es bec aus e s ignif ic ant posi tiv e or n egativ e pressure al te rations at the outflow port c an markedl y al te r ox ygena tor func tion ing (230 ).

Respiratory Gas Monitors

A div erting gas monitor (Chap ter 22) wi th draws gas from the breathing sys tem and transports i t into the moni tor. The gas then needs to be either returned to the breathi ng s ys tem or div erted into the scav enging s ys tem. Th is s ource of contamina ti on is often i gnored (2 31,232,233 ,234). Moni to rs manufac tu red i n rec ent years are equipped with an outlet to fac il itate scav enging (235) (Fi g. 13 .3).

Figure 13.3 A: Gas monitor with sample gas outlet (at upper right). B: Connection of transfer tubing near the interface.

View Figure

Cryosurgical Units
Some c ryos urgic al units use ni trous ox ide. These c an c ontri bute to opera ting room contamina ti on (236). These uni ts s hould be fi tted wi th s cav engers , o r carbon diox ide s hould be use d i ns tead of ni trous ox ide (237 ).

Leak Sites
W hen there is a definite leak si te (suc h as when a fac e mask is used or a v aporiz er i s fi lled), or i n the pos tanes thesi a care uni t, c lose (l oc al) scav engi ng of contamina ted air through a s eparate sc av enging dev ic e o r a low negativ e p res sure hood can be us ed to l ower a mb ient c oncen trati ons (210 ,238,239,240 ,241). A f ace mask that has the abi li ty to reduce the concentrati on of anes the tic gases in the recov ery room has been des c ri bed (8).

Transfer Tubing

The tra nsfer tubing (exhaus t tubi ng or hose, tra nsf er means , tra nsfer s ys te m) conv eys gas from the c ollec ti ng as sembly to the in terfac e when the inte rface is not an i ntegral part of the gas -c ol lec ting as sembl y. The tra nsfer tubing is mos t commonly a leng th of tubing wi th a c onnec tor a t ei ther end. The inlet and outlet fi ttin gs should be e ither 19 o r 30 mm. It should be as s hort as possible (this is fac ili tated b y mounting the i nterface o n the anesthes ia machine ) and wi de en ough to carry a high flow of gas withou t a signific an t inc rease in press ure . It s hou ld be resis tant to k ink ing. It sh ould not touc h the floor, but if it does , i t should be desi gned to prev en t occ lus ion. It sho ul d be easi l y s een an d eas y to dis connec t f ro m the gas -c ollec ting ass embl y in the ev en t of malfunc tion or sc av engi ng s ys tem occ lus ion. To disc ourage misconnec tions , it is recommen ded that the trans fe r tub in g be diffe ren t (b y c olor and /o r c onf iguration ) from the breathi ng s ys tem tubing (Fi g. 1 3.6).

Interface
The interf ac e (balanc ing v alv e or dev ice, p res sure bal anci ng v alv e o r dev ic e, i nte rface s ys tem o r block , intermedi ate s ite, s af ety bloc k , ai r break receiv e r, receiv er uni t, a ir b reak , receiv ing sys tem, inte rface v alv e, sc av engin g v alv e, reserv oi r) s erv es to p rev ent p res sure inc reases or dec reas es in the sc av enging s ys tem f ro m be ing transmi tted to the breathi ng s ys tem, v entilator, or ex traco rpo rea l ox ygenato r. T he U.S . and in ternational s tandards (192,193 ) requi re that the press ure immediately d owns tream of the gas -col lec ting assembly be l imited to between -0.5 and +3.5 cm H 2 O during normal operating c ondi tions and up to +15 cm H 2 O wi th obs truc tion of the scav engin g s ys tem. The interf ac e inl et mus t hav e a 1 9- or 30 -mm (pref erred) ma le c onnec to r. Th e s ize of the ou tlet is optio nal but s hould be d ifferen t from bre athing s ys tem connec tors and f rom the in le t connec tor if the dev ice is sens itiv e to the di rec tion of f low. P .381

The interf ac e s houl d be s i tuated as close to the gas -c ollec ting as sembl y as possible, whe re i t can be readil y obse rv ed a nd reache d b y a nes thes ia pers onne l. The re are three bas ic e lements to an in terface: posi tiv e pres sure rel ief, n egativ e press ure rel ief , an d res erv oir c apac i ty. Irres pec tiv e of wh at type of disp osal sys tem i s used , pos itiv e p res sure rel ief mus t be prov ided to p rotec t the equipment and pati ent if oc c lusi on of the sc av enging s ys tem occ urs . If an ac tiv e dis posa l sys tem is

us ed, ne gativ e pressure relief is need ed to l imi t s ubatmospheric press ure. A reserv oi r is necessa ry to match the in termi ttent f low f ro m the gas -co ll ec ting as sembly to the con tinuous flow of the disposal s ys tem. A dev ic e that giv es an audible si gnal may be f itted to the interface to i ndicate operation of the pos i tiv e o r negativ e p res sure reli ef dev ic e. A fl ow indicator may be prov ided to moni to r flow f rom the interfac e to the gas -disposal s ys tem (Fi gs . 13.4, 13 .5). The rese rv o ir may be a rig id c onta in er, wide tubing, a b ag, o r a c ombinatio n of these . A dis tensi ble bag allows g as remov al b y the sc av engi ng s ys tem to b e moni tored. It should on ly be used wi th ac tive disposal s ys tems and should be of a different c olor from, a nd s i tua ted a way from, the res erv oi r bag in the breathing s ys tem. The connec ti on between the bag a nd the interfac e s hould be a di fferent s ize f rom the mount for the reserv oi r bag in th e b rea thi ng s ys tem. Inte rf aces c an be div ided into two ty pes : open an d c los ed, depen di ng on the me ans to p rov id e pos i tiv e an d negativ e pressu re reli ef .

Open Interface
An ope n interface (ai r break receiv e r uni t) (242,2 43,244) (Fi g. 13 .4A) has one o r more openi ngs to atmosphere (allowing posi tiv e an d negativ e pressure relief ) and contains no v alv es . It s hould be us ed onl y with an ac tiv e dis pos al sys tem. The i nlet, the dispos al s ys tem connec ti on, and the op eni ng(s ) to atmosphe re sh ould b e arra nged so that wa s te g ases a re remov ed before room air i s entra ine d. Bec ause the discharge of was te gas es is usual l y intermitte nt an d f low throug h an ac tiv e dispos al assemb ly is continuous , a reserv oi r is needed to hold th e surges of gas that enter the interface until the disp osa l s ys tem remov es them. The res erv oi r al lows the f low rate in the dispos al s ys tem to be kep t jus t ab ov e the av erage flo w rate of gas es f rom the gas -c ollec ting ass embl y. It is important that the reserv oi r hav e adequate c apac ity, es pec iall y if a v entilator in whi c h the driv ing gas mixes with was te gases is us ed or if hi gh tidal v olumes or high ni trous ox ide flows are used (245). The s afe ty affo rded by an open s ys tem depends on the patency of the v ents to atmosphere, so i t is i mportant to h av e redun danc y in case some are accidenta lly block ed (2 46,247). The v ents s hou ld be check ed P .382 and c leaned regularly . Pl as tic bags and su rgica l drapes s hould be kep t away f rom the v ents .

Figure 13.4 A: An open interface. Note the escape-inlet ports at the top of the reservoir. These provide positive and negative pressure relief. B,C: are closed interfaces. (A) and (B) are active systems. (C) is a passive system.

View Figure

View Figure

Figure 13.5 Open interfaces. The open ports at the top of the canister provide positive and negative pressure relief. The flow control valve is used to regulate the scavenging flow. The flowmeter indicates whether or not the flow is within the range recommended by the manufacturer. The float should be between the two markings on the flowmeter. Inside the canister, one tube conducts waste gases to the bottom. The other tube conducts gases from the bottom to the disposal system.

Open interfac e a re shown in Fi gs . 13.4A , and 13.5. Anes thetic gases f rom th e transfe r means ente r at the top a nd are c onduc ted to the base whe re they are dispe rs ed. A parallel tube is c onnec te d a t th e top to the reserv oi r. The sp ace around b oth tubes ac ts as a rese rv oir. The holes a t th e top are open to atmosphere. A flowmeter measures the a mount of v ac uum that is appl ie d to the i nte rface by the ac tiv e disposal s ys tem. It al so prov ides a v isua l indication tha t the v acuum is turned ON. Us ual ly , there are two marks be tween whic h the indicator shoul d be loc ated.

The open in terface is s imp le bu t may pollu te the atmosphere if the res erv oi r does not hav e s uff icient v olume to con tain the b ol uses of was te gases . Th e ac tiv e disposal s ys tem mus t s uppl y adequate flow to remov e the sc av enged gas es from the in terface. Turbule nce wi ll inc rease the volume of ai r co ntamina ted wi th anes thetic gases (242). Turbulence is greates t when gas es f rom th e breath ing s ys tem flo w a gains t the disposal s ys tem fl ow and l eas t when flow i s in the same di rec tion .

Closed Interfaces
A c losed i nterfac e (Fig. 13 .4B ,C) mak es its connec tion(s ) to atmosphe re th rough v alv e(s ). A pos itiv e pressu re re li ef v alv e is al ways requ ired to allow gas es to be released i nto the room if there is obs truc ti on of the sc av enging sys tem downs tream of the inte rf ace . If an ac tiv e d is pos al s ys tem is to be us ed, a negativ e p res sure relief (pop -i n, i nl et relief ) v a lv e is nec ess ary to allow ai r to b e entrained when the press ure in the rese rv oir falls belo w a tmos pheric . A res erv oi r is not re qui re d wi th a c los ed in te rface and s hould not b e used un les s an ac tiv e dispos al s ys tem is us ed. If an ac tiv e disposabl e sys tem is used , a dis tens ible bag is useful for monitoring scav engi ng s ys tem func tion.

Positive Pressure Relief Only

A c losed i nterfac e wi th onl y posi tiv e p res sure rel ief s hould be used on ly wi th a passiv e dispos al s ys tem. An ex ample is sh own in Fi gure 13.4C. The p osi tiv e press ure rel ief v alv e re mains c losed un less th ere is a p rob lem do wns tream of the i nte rface . The relief dev ice may be sp ri ng lo aded or work by g rav ity.

Positive and Negative Pressure Relief

If an ac tiv e dispos al s ys tem is used, a negativ e pres sure rel ie f v alv e mus t also be present. Subatmospheric pres sures gre ater th an -0.5 c m H 2 O c an rais e or l ower the opening pressu re of s ome APL v alv es (248). Exa mples of the c losed interf ac es are s hown in F igu res 1 3.4B and C and Figure 13.6. W hen a pass iv e disposal s ys tem is used, the negativ e pressure relief wi l l P .383 remain c losed at all times . If an ac tiv e disposal s ys tem is us ed, i t shoul d cl ose during hi gh peak f lo w rates from the gas -collec ting as semb ly an d open when the gas -d is posa l ass embl y fl ow is greater than the fl ow of gas es en tering the g as co ll ec ti ng ass embly f rom the breathi ng s ys tem.

Figure 13.6 Closed interfaces. Note the wide-bore flexible transfer tubing that is different in appearance from the breathing system tubes.

View Figure

The rate of flow i nto the gas -dispos al assembly s hould be adjus ted to the op timal l ev el by obs erv ing the bag (if present) an d the pos itiv e and ne gativ e rel ief v alv es. In an o ptimal ly adjus ted sys tem, the bag expands and d efl ates but nev e r becomes ov erex te nded or c ompletel y def lated (249,250 ,25 1). If the bag is con tinuall y co ll aps ed or the nega tiv e press ure rel ief v alv e opens frequently , the f low s hould be l owered. If the bag becomes dis tend ed or the posi tiv e p res sure rel ief v alv e o pens f requentl y, f low s hould be inc reased . A c losed i nterfac e c an be used with any ty pe of disposal s ys tem, but v alv es add to the compl ex ity. They mus t b e des igned s o tha t they do not s tick or leak . Inte rfaces wi th t wo negativ e pressu re relief v alv es are av ai lable and add a margin of safety.

Gas-disposal Tubing
The gas -dispos al tubing (rece iv ing hos e, d is pos al tubing) connec ts the inte rf ace to the dispos al s ys tem (Fi g. 13 .1). To av oid misconnec ti ons , i t should be dif ferent in s ize an d appea rance from the breathing system hos es . It s houl d be res is tant to co ll aps e and free of leak s . W i th a pas siv e gas -disposal s ystem, i t is impo rtant that the hose be as s hort and wi de as prac tic al to minimize resis ta nce. Ideall y, the gas -dispos al tub ing s hould be ru n ov erhead to mini mi ze the ri sk of oc c lusi on and to av oid th e dange rs of pers onne l tripping ov e r it o r other apparatus becoming entangled in it. It may be hidden in a false ce ili ng. If the tub ing mus t be run ac ross the fl oor, i t should be routed whe re it is l eas t like ly to be s tepped on o r hav e equi pmen t rolled ov e r it. If it mus t pass a doorway , it s hou ld f ollow the door f rame.

Gas-disposal System
The gas -dispos al s ys tem (el imination s ys tem or route, disp osal -exhaus t route, disposal assembly ) re mov es was te gases f rom the anes the ti zi ng location. The gases mus t be v ented at a p oin t th at is iso la ted f rom pers onnel and any ai r intakes . Gas -disposal s ystems are of two types : ac tiv e, in wh ich a flo w-i nduc ing dev ice mov es the gases , and passiv e, in whi ch the pressu re is raised ab ov e atmospheric by the patient ex halin g, by manual ly s quee zing the reserv oir bag, or b y a v entilator. W ith an ac tiv e s ys te m, the re P .384 wi ll be nega tiv e press ure in the gas -dis posal tubing. W i th a pas s iv e s ys tem, the press ure wi l l be pos itiv e. Ac tiv e s ys tems a re usually more eff ec tiv e at k eeping pollution lev els l ow, b ecause mos t leaks wi ll be inward (182,252 ,253). They al low s mal l-bore tub in g to be use d, and exces s iv e resis ta nce is not a problem. They also ai d room ai r exc hange. Th ey are, ho wev er, ex pens iv e in terms of e nergy cos ts . They a re not automatic an d mus t be turned ON a nd OFF. If th ey are not turned ON, ai r pol lu tion wi ll occu r; i f they are not turned OFF, there wil l be needl ess wa s te o f energy . Activ e s ys tems are more c omplex than pas siv e ones . Their use requi res that the i nterface hav e negativ e p res sure reli ef. Pas s iv e s ys tems a re s impl er but may not be as effec tiv e in loweri ng trace gas l ev els , beca use the pos i tiv e p res sure enc oura ges outward leaks . They are less ex pens iv e to operate than ac tiv e s ys tems .

Passive Systems
Room Ventilation System
Ven ti la ti on s ys tems in ope rating rooms are of two types : nonrec irculating (one pass, s ingle pass , 1 00% fresh ai r) and recircu lating (187). A nonreci rc ula ti ng s ys tem takes in ex terio r ai r and processes it by fil teri ng and a dj us ting the hu mi di ty and tempe rature. The proc essed air i s ci rc ul ate d through the room and then al l of i t i s exha us ted to atmosphere. Th is type of v entilation s ys tem can be us ed fo r was te gas dis posa l by securing the disposal tubing to a c onv enient ex haus t grill e. A i r f lowing into the grille wil l remov e the gas es from the room. Eco nomic conc erns has l ed to inc reas ed use of v entilation s ys tems that rec i rc ul ate ai r. W i th this type of s ys tem, a smal l amou nt of a ir is taken in from the atmosphere , whi l e the remaining air is rec i rc ula ted . Mos t o f the gases exhaus ted from the room

are shun ted back into the in take and reci rc ula ted , whi le a v olume eq ual to the f resh ai r admi tted is exhaus ted. Wi th this type of s ys tem, was te gas es mus t b e v ented beyond the poi nt of rec irculation. The heal th c a re faci li ty engi neer shou ld k now whic h type of v en til ati on s ys tem is present. If no t, a bsence of reci rc ul ati on ca n be determi ned by s ampl ing the room ai r i nle t to s ee if i t is free of trace gases after they hav e been releas ed in anoth er room. An i mportan t c ons idera tion whe n us ing the room v entila tion s ys tem for was te gas disposal is the nega tiv e press ure i n the ex haus t duc t. If was te gas es are in troduc ed at the gril le, the nega tiv e press ure is us ually minimal and i ts effec t negligible (2 46). If they are introd uced a t a dis tanc e down s tream in the duct (as they mus t be wi th a reci rc ula ting s ys te m), negativ e pressure rel ief mus t be prov ided in the interf ace . In many operating rooms , th e exhaus t gri lles are not loca ted c los e to the anes thes ia mach ine, pos ing p roblems wi th tubi ng on the floo r where i t may b e oc c luded. In s ome c ases , the dis pos al tubing c an be ex tended to a wa ll - or c eil ingmoun ted c onnec tion that lea ds to a pipe in the wal l (187). The pi pe then co nnec ts to the ex haus t duc t.

Piping Direct to Atmosphe re

P iping di rec t to the atmosphere is also known a s a d irec t duc t o r v ent, s pec ialized duc t sys tem, di rec t disposal l ine, or through-the-wal l s ys tem (252 ,25 3,254,255). Exc ess gas es are v ented through the wal l, wi nd ow, c e il in g, or fl oor to the ou ts ide , us ing only the s l ight press ure of th e gases a nd leav ing the g as -col lec ting assemb ly to p rov id e the flow. This type of s ys tem is not s ui tab le for an op era ti ng room that is far from an outsi de wal l (246). To prev ent c ross f lo w b etwe en roo ms , each roo m s hould hav e i ts o wn duc t. The i nlet to the duc t sho ul d be c lose to the anesth esia machine. There should be a means to cap the opening to the duc t when i t is not connec ted to the gas -d is pos al tubi ng. The duc t should be s hort with a l arge di ameter to av oid exc essiv e back press ure . A unidirec tional v alv e may be plac ed in the duc t to prev ent outsi de ai r f rom entering the ope rating room an d to minimi ze the ef fec ts of wind pres sure o n the dispos al s ys tem (254 ). The disc harge point on the outside should be s elec ted so that i t is away f rom wi nd press ures , igni tion ha zards , wi ndows , and the i nl ets for the v entil ati on s ys tem. It may be adv antage ous to a ttach a short T-piec e as a termin al (2 56). The open

end(s ) should po in t downward to p rev ent wa ter and di rt f rom en te ri ng and be f itted wi th ne ttin g to prev en t insec ts , rod ents , and f oreign matter f ro m en tering the pipe . The direc t p iping disposal s ys tem is e asy to us e but requires a spec ial i nstal lation. In redesi gning an ex is ti ng operating room or des igning a new ro om, cons truc tion of such a sys tem should be c onsi de red . If the opera ti ng rooms are no t nea r the outside of the building, this type of disposal asse mbly may not be prac tic al . P roblems that c an occur with the direc t d is posa l s ys tem i nclude bo th posi tiv e and negativ e p res sure caus ed by wi nd curren ts , obs truc tio n f rom ice bui ldup, and ac cumulation of fo reign matte r at the outle t (2 55,257). The re needs to be a means to dete rmine sys tem pa tenc y. It is impo rtant to do trace gas moni to ring with the s ys tem in use in order to mak e c ertain a flow-in ducing dev ice is no t nee ded. A s tudy of this type of s ys tem found tha t i t work ed ef fic ientl y a nd had low mai ntenance cos ts (258).

Adsorption Device
An ads orption dev ic e remov es some or all exc ess anes thetic ag ents by ads orbing them or conv erting them to harml ess subs tances (185,255 ,259,260,261,262,263,264). Can is ters of v a rying s hape and c apac ity that are fi ll ed wi th ac tiv ated c harc oal hav e been us ed for was te gas dis pos al. Some can be regen era ted by autoc lav ing (265). Differe nt v olatile agents a re ads orbed wi th v a rying effic ienc y. The eff iciency of ads o rpti on also P .385 depends on the f lo w rate through the canis ter (266 ). Mois ture ma y red uce the ef fic ienc y (267). Ads orp tion dev ic es are s imp le and portable and do no t re qui re ex pens iv e i ns tal la tion or maintenance. A n a ddi ti ona l adv antage is tha t haloge nated anes thetic v apors a re not released to the ozo ne la yer (266 ). An ac tiv ated charc oal f i lter has been used s uccessful ly to scav enge n itric ox ide and n itrogen diox ide (268). Ads orp tion dev ic es hav e a n umber of disadv antages . A t present, the re is no adsorpti on dev ice for nitrous oxide . They are fairly expensiv e and are effec tiv e fo r only sh ort periods of time. T hey mus t be rep laced regularly and p ose s torage and disposal p roblems . In o rde r to de termine whether or not the ads orber is s atu rated requi res mo ni toring or wei ghi ng. Finally, a large c an is ter ma y impose si gnific ant resis tance (259). It is recommended that adso rption dev ices be l imited to s ituations

whe re ni trous ox id e is not bei ng employed a nd no other mea ns of el imina ting was te gases is av ai labl e. Concerns about the releas e of anes thetic was te gases into the atmosphere a nd thei r con tribution to glo bal wa rmi ng and ozone depleti on hav e been v oiced (255,269 ,270,271). Zeol i tes may be used to adso rb halogenated agents f ro m the outl et of the sc av engi ng s ys tem, the reb y reducing atmosph eric pol lution (269,272 ,273).

Catalytic Decomposition
Catal ytic decompos i ti on can be used to c onv e rt n itrous ox ide to ni trogen and ox ygen , reduc ing i ts co ntribution to the g ree nhous e effec t (2 74,275).

Active Systems
Piped Vacuum
The c entral v acuum s ys tem is a po pular method of gas dispos al (276,27 7,278). The s ys tem s hould be cap abl e of prov iding high v olume (30 L/minute) f low, but onl y s light negativ e pressure is needed . The re should be a means to all ow the us er to control the f low. This wil l cons erv e energ y, reduc e the load on the c entral pumps , and reduce the nois e lev el . For s ome uni ts , th is is done by o bserv ing the bag and the pos i tiv e and nega tiv e press ure rel ief v alv es . Others hav e a means to al low the us er to adjus t the flow to that recommended b y the manufac tu rer (Fi gs . 13.5, 13 .6). A res tric tiv e ori fice may be placed i n the v acuum n ipple to li mit the flo w (279). The re are a number of problems ass oc iated with us ing a cen tral piped v acuum s ys tem for sc av enging.

Inadequate Number of Vacuum Outlets

Many operati ng rooms hav e only two v ac uum outle ts . This is ba rely eno ugh f or so me s urg ic al procedures , let alone a nes thes ia us e. Ideall y, a nes thes ia pe rs onnel shoul d hav e two v acuum outlets av ailabl e, o ne fo r suc tioning the airway an d one for sc av enging was te gases . If there are not e noug h outlets , a Y may be i nserted into th e v acuum l ine to c reate t wo l i nes . Unfortuna tel y, this may re duce the flow s o that i t becomes inadequate fo r ei th er pu rpose. Some anes thes ia prov iders us e a s ingle v acuum li ne f or sc av engi ng and pati ent suc tion ing . The v acuum l ine remai ns attached to the interfac e mos t of the time and i s detached when needed fo r patie nt suc tion in g. If the f lo w o f anes thes ia gases is not turned OFF , there wi ll be esc ape of anes thetic gases into the room ai r.

Inconvenient Outlets
If a suc ti on outle t is not nea r th e anesthes ia mac hine, l ong tubings mus t reach ac ros s the floor, with the ha zards of occ lusion, trip ping, and e ntangl ement with other apparatus .

System Overload
Bec ause s cav engi ng requi res h igh fl ows , the c entral v acuum s ys tem may become ov erload ed if too man y dev ices a re in us e at the same time. Ov ercomi ng th is problem may requi re a major re nov a ti on of the sys tem. S ys tem ov e rl oad c an b e reduc ed if anes thes ia p ers onne l adjus t the flo w to th at nec ess ary to prev ent gases f rom being sp illed into ro om air and turn off the f lo w a fter us e.

Damage to the Vacuum System

W ear and tear on the v acuum pump c an be ex pec ted to i nc rease if the central v acuum s ys tem is used for disposal of was te gas es . V acuum pump fai lu re an d pump f ires hav e been reported (280).

Personnel Exposure
If the ex haus t f rom the central v ac uum pump goes to an area frequ ented by personnel or is s ituated nea r an ai r in tak e, open win dow, o r door, this wi l l resul t in additi onal exposure of personnel to was te gas es . It may be necess ary to reloc ate the pump ex haus t.

Inconvenience
To cons erv e energ y, the v acuum s ystem sho uld be turned ON jus t before anes thes ia is begun and turned OFF at the terminati on of a proced ure . For f urther energy c ons erv ation, the a nes thes ia prov ide r should ad jus t the v acuum f low ac cording to the v olume of was te gases . If thes e duties a re neg lec ted, there wil l be ei th er was ted energy or ope rating roo m pollutio n.

Active Duct System

The othe r ty pe of ac tiv e disposal assemb ly is a dedicated ev acua ti on s ys tem that l eads to the outs id e and empl oys f lo w-i nducing dev ices (fans , pumps , blo wers , etc .) that c an mov e large v ol umes of gas at l ow p res sures (246,252 ,278,281,282,283,284) (Fi g. 13.7). It has been rec ommended tha t two f lo wi nduc in g dev ices be p rov id ed and arranged so that if one fai ls , the s econd one wi ll run. S ev eral duc ts may be c onnec ted tog ether to a c ommon duc t th at leads ou ts ide . The f lo w-i nduc ing dev ice is located in the commo n duc t and prov ides mov ement of gases at a low nega tiv e press ure . Bal anc ing dampers s hou ld be prov ided to prev ent

press ure imbal anc es from dev elopin g between the operating rooms that a re connec ted to the s ystem (24 8,278). The P .386 negativ e p res sure hel ps to ensure tha t c ross contamina tion betwee n o perati ng rooms wi ll n ot oc cur an d p rev ents atmospheri c conditi ons f rom affec ting the outflow f rom the s ys tem. The outlet to atmosphere s houl d be away f ro m wi ndo ws and v enti lation i ntakes . A means to adj us t the flow may be inco rpo rated into the co mmon duc t.

Figure 13.7 Part of a piped anesthetic gas evacuation system with a shut-off valve. The gauge is at the right.

View Figure

Eac h operating room is s uppl ied with an evacuati on in let (Fig. 13.8 ). It should not be i nterc hangeable with other s ys tems , inc luding the piped v acuu m sys tem. It is recommen ded that there be a means to indica te to the us er that the scav eng in g s ys tem is operational . The adv antages of the ac tiv e duc t s ys tem are that res is tance is not a problem, and wi nd curre nts do not affec t the sys tem. D isadv antages i nclude those of any ac tiv e s ys tem: add ed complex ity and the need f or negativ e p res sure reli ef and rese rv oir capaci ty in the interface. It requi res a s pecial ins ta llation, whi ch sh ould b e cons idered during ren ov ati on or when a new an estheti zing loc ation is bei ng desig ned. The flow-in duc ing dev ice means a dded energ y c ons umption and requires regular mai ntenance.

Alterations in Work Practices

A numbe r of work prac tic es al low anes thetic gases to enter ro om air (285,286 ,287,288). Adhe ri ng to the followi ng prac tic es wi ll s ignifican tly reduce contamina ti on. Mos t can be fol lowed wi th out co mpromis ing s afe ty, and some of them are benefic ia l to the patient. Trace gas moni toring can be used to demo nstra te to pers onne l the tec hni ques n eeded to av oid polluting room ai r. Adhering to good work prac tic es shou ld no t dis trac t from patient comfort and safety. F or example, in pediatri c anes thes ia, us e of unc uffed trac heal tubes may necess ary , and holding the mask tig htly agains t the face may be frightening to a ch il d.

Checking Equipment Before Use

Before s ta rting a n anes the tic , all c omponents of the scav enging s ys tem s hould be securely c onnec ted and patent. P .387 If an ac tiv e gas disposal asse mbly is to be used, the flo w s hould be tu rne d ON.

Figure 13.8 Inlet for anesthetic gas evacuation (at right). A probe attached to the gas transfer disposal tubing is inserted into this.

View Figure

Leaks i n the anes thesi a mac hine and breath in g s ys tem can c ontri bute to ope rating room c ontami nation. The preuse c hec kou t (Chapter 33) s hould rev eal these leaks so that they c an be correc ted (289 ). Ni trous ox id e s hould be turn ed ON on ly momenta ri ly d uring the preuse equ ipment checko ut. Mos t tes ts sho ul d be c onduc ted by us ing ox ygen or air.

Using Scavenging Equipment

Fail ure to use av ail ab le sc av engi ng equi pmen t correc tly is c ommon (290,291 ). In so me c ases , the reasons relate to equipmen t des ign and spec if ic c ircums tances . More freque ntl y, howev er, l ac k of conc ern is the problem.

Proper Mask Fit

Obtai ni ng a good mas k f i t requi res s kil l but i s c ri tic al to maintain the l owes t possible lev els of anes thetic gases in the room. Mas k f i t is espec ia ll y important during ass is ted or c ontro ll ed v enti lation , wh en highe r pressu res wi l l magnify the l eak between the pa tient and the mask . Anes thes ia by face mas k c aus es the highes t lev els of p ol lution (234,240,289 ,292,2 93,294,295). P oll uti on is also a problem with s upraglottic ai rway dev ices, although l ower lev els of anes thetic gases are found with th ese dev ic es than with face mask s (234 ,29 2,293,296 ,29 7). A n ac tiv e sc av enging dev ice near th e mask (210,241,298) or the use of a d ouble mask can reduce room pollution from a poor mask f i t (299,300).

Preventing Anesthetic Gas Flow Directly into the Room

Ni trous ox id e and other agents shou ld no t be tu rned ON unti l th e mask is f i tted to the patie nt's fac e. T urning the gas f low (but not the v aporize r) OFF du ring i ntu bation is also good practice (301,30 2,303,304,305 ,306). This main tai ns pos tintuba ti on concentrati ons c lose to prei ntubation lev els a nd dec reases operating room pol lution. The patient c onnec tio n port on the b rea thing s ys tem c an be blocked during i ntu bation (307 ,308,309,310 ), but care should b e take n tha t part of the block ing dev ic e does no t bec ome dis lodged and enter the breath ing s ys tem (311). The fresh gas fl ow s hould be turned OFF or th e APL valv e opened to p rev ent the bag f rom ov erf ill ing. Disconnec tions c an be prev ented by mak in g c ertain that al l connec ti ons are tight before use. Dis conn ectio ns fo r ac tiv ities suc h as tap ing the trac heal tub e o r positioning the patien t should be k ept to a minimum. If i t is neces sary to mak e a disc onnec ti on, release of anes thetic g ases into the room can be mi nimi zed if the reserv oi r ba g is fi rs t gradu all y emptied in to the scav enging sys tem a nd the f resh gas fl ow i s turned OFF. A l te rna tel y, the pa tient port can be oc cluded and the APL v alv e o pene d s o tha t th e gases wi l l enter the scav eng ing s ys tem. If a v en tila tor ( whic h has i ts own sp il l v alv e) is bei ng use d, th e AP L v alv e does not need to be opened.

Washout of Anesthetic Gases at the End of a Case

A t the end of a c ase , 100% oxy gen sh ould be adminis te red befo re ex tuba tion or the fac e mask o r supraglottic dev ic e is remov ed to fl us h mos t of the anes thetic gases i nto the sc av enging s ys tem.

Preventing Liquid Agent Spills

It is easy to s pill li quid agen t when f il l ing a v aporizer, s o care s houl d be ex erc is ed. The use of an agent-spec ific fil li ng dev ice (Chapter 6) wi l l reduc e spil lage. Dev ices that reduc e s pi llag e wh en us ing funne l-fi ll vapo ri zers are av ai lable. Us ing l ocal sc av eng ing wi l l re duce c ontamin ati on as soc iated wi th fil ling a nd draining v apo ri zers (176,240). A portab le va porizer may be f illed in a hoo d wi th gas ex trac tion. The c onnec tions for fi lling and drain ing a v aporizer s hould be kept ti ght. If one of these c onnec ti ons is l oose , agen t may esc ape (312).

Avoiding Certain Techniques

Ins ufflati on tec hniques in whi ch an an es thetic mix ture is introduced into the pati ent's resp iratory s ys tem d uring inha lation are s ometimes us ed fo r la ryn gosc opy and b ronchos copy . These techniques res ul t in f lo oding the a ir a round the face wi th anes thetic agents . High f low rates are require d to av oid di lution wi th room ai r and resul t i n a c loud of anes thetic gases es caping i nto the room air. Local s cav enging shoul d be used to remov e the anes thetic gases if an i nsuff la tion techn iqu e is us ed.

Proper Use of Airway Devices

The use of cu ffed trach eal tubes wil l reduc e e nv i ronmental c ontamination f ro m was te anes thetic gases (313). Onl y smal l leak s s houl d be permi tted around uncuffed tubes in ped ia tric pa tients . W hen us ing an unc uffed tube, c ontaminatio n can be reduced by pl ac in g a suc tion c athete r in the mouth (31 4) and using a throat pack (17 6). Sup raglottic ai rway dev ices usuall y hav e a greater leak than c uffed trac heal tubes but contribu te l ess to trace gas c ontamination than an es thes ia conduc ted wi th a mask (234 ,292,293,296 ,29 7). W here it is not poss ib le to use a leak -tight d ev ice, a hood can be plac ed around the head and suc tion us ed to remov e the trace gases (313,315 ,316).

Disconnecting Nitrous Oxide Sources

Ni trous ox id e and ox ygen pipel ine hoses lea di ng to the machine sh ould be disc onnec ted a t th e end of the ope rating schedule. Th e d is connec tio n s hou ld be made as

P .388 c los e to the termina l uni t as possi bl e and no t at the bac k o f the anes thesia mac hine so that if there is a leak in the hos e, no gases wi ll esc ape to room ai r whi le the hose is disc onnec ted. Th is wi ll res ul t in lower l ev els of ni trous ox id e i n the operati ng room and cons erv e gases . W hen c y li nders are used, the c ylinder v alv e should be c los ed at the end of the operati ng schedule. Gas remai ni ng in the mac hin e shou ld be bled out and ev acua ted through the sc av eng ing s ys tem.

Using Low Fresh Gas Flows

Us ing l ow fresh gas f lows wi ll reduce the poll uti on res ul ti ng from disconnec tions in the breathing s ys tem and f rom ineff ici ent s cav enging (317,318,319 ). It also al lows l ow remov al f lo ws to be us ed with ac tiv e dispos al as sembl ies , resu lting in ene rgy cons erv ation and reduc ed wear a nd tea r on th e d is posa l dev ic e. The use of a trace gas monitor may l ead to use of lowe r fresh gas fl ows (320). Usi ng low g as flows does not mak e scav enging unnecessa ry, becaus e high flows mus t s til l be used at times .

Using Intravenous Agents and Regional Anesthesia

Us ing i ntrav enous induc tion tec hniques s ign if icantl y reduces trac e gas ex posu re (321).

Keeping Scavenging Hoses off the Floor

A scav eng ing hose on the fl oor c an be obs truc ted or damaged by equi pment rol l ing ov er i t, reduc ing sc av enging .

Leak Control
Some leak s a re unav oidab le , but they s hould be min imi zed (14,25,198,287 ,288,322,323 ). Leak con trol may requ ire repl ac ement of equ ipment that c annot be made gas ti ght. Mos t anes thes ia machi nes are serv iced at regula r in terv als . Unfortuna tel y, this se rv ic ing does not a lways id entif y or co rrect a ll leak p oin ts . In addi tion, leak s in so me equi pment dev elop fai rl y frequently, so quarterl y serv ic ing is not suff ic ient. In-house mon itoring and main tenance a re nec ess ary to mi ni mi ze leakag e.

Pressure Terminology
Some l iterature on sc av enging has refe rred to al l equipment ups tream of the fl ow control v alv es as the high-pressure s ys tem and a ll equi pmen t between the fl ow

control v alv es and the patient plus the sc avenging equipmen t as the low-pressu re s ys tem (287). In this book , the high-pressure s ys te m refe rs to thos e components that c ontain gas whos e p res sure is no rmally a bov e 50 ps ig (340 k P a). T his inc ludes the components between the cyl inder and th e regula tor. The intermediate -press ure s ys tem inc lud es components normal ly subjec ted to a press ure be twe en 50 and 55 ps ig. This inc ludes the pipel ine hoses and the c ompone nts of the machi ne between the pressure regulators or p ipeline inlets and the f low c ontro l v alv es . The lowpress ure s ys tem c ons is ts of c omponents downs tream of the fl ow c on trol v alv es to the patie nt, plus the s cav engi ng s ys tem.

Identifying Leak Sites

The re are sev e ral tec hniques for loc ati ng leak s i tes (234). A c ontinuous i nf rared ni trous ox ide anal yzer can b e used. The equ ipment und er tes t is pressu ri zed wi th ni trous ox ide and the sampli ng pro be di rec ted at susp ec ted leak si tes . Th e me ter reading i ndicates the presenc e or abs ence of le aks . This wil l i dentify mos t leaks . An ex ception woul d be le akage into a v apo ri zer. Some leak s i tes can be iden tified by appl icati on of a s olu ti on of 50% liquid s oap and 5 0% wa ter o r a commerc ial leak test s ol ution . Another me thod is to put alcohol on on e's hands an d mov e the hands ov er the equ ipment. A l eak wi l l c ause cooling. Leakag e c an be ass ess ed by tes ting the cap aci ty of the equipment to sus tain press uri za tion. The total leak rate is de termi ned, after whi ch a co mponen t is ex c luded an d the l eak rate de termined again. The differenc e is the leak rate for tha t co mponen t.

High-pressure System
To tes t for l eak s i n the high-p res sure s ys tem, the pi peli ne hos es should be disc onnec ted and the f low c ontro l v alv es c losed. The v alv e on a ni trous oxi de c ylinde r s hould be o pene d ful ly , the p ressure rec orded, and th e c yl ind er v alv e c los ed. Th e p res sure shou ld be recorded again 1 hour later. If l ittle or no p res sure drop has oc curre d, there is no si gnif ic ant leak age. If i t falls , the high-press ure s ys tem is not tight. The tes t s hould be repeated wi th the other ni trous oxide c ylinde r if the re is a double yok e. If a signi fican t leak is found, the mos t c ommon s i te is the yoke, a nd appl ication of a l eak tes t s olu ti on wi ll demons trate a p oor se al . Tightening the c ylinder i n its yoke wi ll often seal the leak . Other eas ily c orrec tabl e causes inc lude doubl e, abs en t, o r deformed was hers . If damaged parts are fou nd, they s hould be replaced. If f ixing

these problems does not c ause the press ure to hold, the le ak is ins ide the machine and mus t be co rrec ted by the manufac turer's serv ice represen tativ e. Bec ause leak age in this area does not occ ur of ten, check ing ev ery 2 to 4 months as wel l as after a c yli nder has been c hanged should be s uff icient (202 ,285,287).

Intermediate-pressure System
Leaks i n the inte rmed ia te-pressu re s ys tem c omponents c an be determine d by meas uri ng the ni trous ox ide c onc entrations i n the ope rati ng room wh en no anes thes ia is being admi nis te red (287). The s urv ey should begin at leas t 1 hour af te r adminis tration of anes thes ia has been discon tinued. If a P .389 reci rc ula ting ai r con di tioni ng s ys tem is in us e, a longe r perio d may be requ ired. The earl y mo rning is an exc ell en t time to pe rform th is tes t. Fl ow control v alv es shou ld be c los ed, p ipeline hoses co nnec ted , and c ylinde r v alv es cl osed . Room ai r s hould be s ampl ed at the anes th esia breath in g zone (4 to 5 feet abov e the floor wi thin 3 f eet o f the f ro nt of the anes thes ia mach ine) and the room air intake and outle t. Ni trous ox ide c onc entra ti ons shoul d be less th an 5 ppm (153,230 ). If a higher lev el is fou nd, the pipel ine hoses should be disc onnec te d and the measu reme nts repea ted a fter a period of time. If a high lev el is s ti ll p res ent, this indica tes a l eak in the n itrous ox ide pi pe le ading into the ro om or the s tation outl et an d s hould be reported to the heal th ca re fac i li ty enginee r. If the lev el falls , this indica tes a l eak in the p ipe line hos e or the anes thes ia machine. Common probl ems wi th pipe line hos es incl ude worn or leaking connec ti ons (espec iall y quick c onnec ts ), defo rmed co mpre ssion f ittings , and holes . These shoul d be c orrec ted o r the hoses replaced. Leaks i nside the anes thesi a machi ne requi re c orrec tion by a serv ic e rep res entativ e. Onc e leaks are c orrec ted, it is s ugges ted that tes ting of the in termediate sys tem be performed ev ery 2 to 4 months (198,2 30,285,287).

Low-pressure System
The low-pressu re porti on of the s ys tem develops leaks more f requen tl y th an other parts . The p reuse tes t fo r leaks i n the breathing sys tem (Chapter 3 3) is s uffici ent for th e safe c onduc t of anes thes ia, ye t can miss leaks that emit large amoun ts of anes thetic gases i nto room ai r. One way to quan tify leak age in mos t of the low-pre ssure s ys tem is shown i n Fig ure 13.9. The breathin g s ys tem is as sembl ed for us e. A l l componen ts that a re normal ly

us ed shou ld be pres ent in their usual pos i tio ns . The p atien t port is occ luded. The bag is re mov ed and the bag mount oc cl uded . This is neces sary beca use the bag's co mpliance makes i t hard to quantitate low l eak rates . The b ag should be tes ted separate ly for leaks . A v apo ri zer on the anes thes ia mach ine s hould be turned ON. The A PL v alv e should be fully open and the scav enging s ys tem occluded ups tream of the inte rf ace . The ox ygen f lo w c ontrol v alv e is now opened suffici entl y to es tablish and maintain a s teady press ure of 30 cm H 2 O o n the press ure gauge in the breathing s ys tem. Th e f low on the ox yge n fl owmeter i s the leak rate and should be l ess than 1,000 mL/minute . Leakage of 1,0 00 mL/minu te of nitro us oxi de would resul t i n a mean conc entra tion of on ly 30 ppm in a 4,000 cubic f oot room with 15 ai r changes p er hour (2 48). The leakage tes t should be repeated with the o the r v aporizers turned ON.

View Figure

Figure 13.9 Test for quantifying low-pressure leakage. (1) The reservoir bag is removed, and the bag mount is occluded. (2) The patient port is occluded. (3) The APL valve is opened fully. (4) The transfer means is occluded just upstream of the interface. (5) Oxygen flow is turned on and adjusted to maintain a pressure of 30 cm H2O on the pressure gauge in the breathing system.

If the leak rate exceeds 1,000 mL/minute , th e A PL v alv e should b e c losed and the l eak rate again dete rmined. The di fference is th e l eak rate in the scav enging s ys tem. The remaining leakage c an be div ided i nto that assoc ia ted wi th the machine a nd that as soc iated wi th the bre ath in g s ys tem by attac hing a sphygmo manometer b ulb to the anes thes ia mac hine common gas outlet a nd determin ing the ox ygen f lo w neces sary to ach iev e and maintain a press ure of 22 mm Hg . This is the portion of the l ow-pre ssu re leak age associated with the machine. The mac hine leak si te can be f urth er refined by turning the v aporizer OFF and a gai n determi ni ng th e leak rate.

P roblems in the sc av enging s ys tem may be as s imple as a c rack in a tubi ng (espec iall y where it becomes kinked ) or a poo r connec tion. The breathing s ys tem is the mos t co mmo n loc ation for si gnific ant low-pressu re l eaks , and the mos t c ommon s i te is th e absorber. Common p roblems inc lude defec tiv e gas kets or se als , improper cl os ure , in adequate ti ghteni ng, and open o r l eak ing drain c ock s. Absorbent granules on th e gask ets c an prev ent a tight s eal . Disposable can is ters may be c rack ed during tra nsi t and leak af ter being ins talled. Mos t of these problems are eas il y correc te d. Compl icated repai rs s hould be done only by the serv ice re pres entativ e. The abov e tes t does no t c hec k for leaks in the v enti lato r. The v entilator and the l ow-p res sure s ys tem can be tes ted by us ing a n inf ra red n itrous ox ide ana ly zer. The anes thes ia mach ine and bre ath ing s ys tem are s et up for cl in ic al us e. The pa ti ent port ou tlet is occ luded and the bag/v entil ator s el ec tor s witc h pu t in the bag mode. The A PL v alv e is clos ed. Us in g the flowme ters , the breathing sys tem is pressuri zed to 30 c m H 2 O wi th a 50 % mix ture of nitrous ox ide and oxygen. Th e machi ne and breathi ng s ys tem are scanned for ni trous ox ide leaks. The selec tor v alv e is then put i n the v enti lator mode and the f lowme te rs set to deliv er 2 L/minute ox ygen and 2 L/minute ni trous oxi de. The v entila tor is turn ed ON and s et to a P .390 tida l v olume such that a peak p res sure of 30 c m H 2 O is reac hed . The sc av enger s ys tem is ac tiv ated. The machine, v entilator, breathing s ys tem, and scav engin g s ys tem are sc anned . Read ings s hou ld no t be greater than 25 ppm ni trous ox ide. A v enti la tor with a s tanding bel lo ws c an be checke d for l eaks by fil ling the bello ws wi th gas , then s wi tc hi ng th e bag/v enti la tor s elec tor s wi tch to the bag pos i tion. The bellows should remain fu ll y infl ated. A ha ngi ng bello ws can be tes ted fo r le aks by s topping i t du ring ins pi ra tion and pl ac ing the bag /v entil ator s elec to r s wi tc h in th e bag p osi tion. The bel lows should remain compress ed. It is c ontrov ers ial as to how o ften the low-pr ess ure s ys tem s hould be tes ted fo r l eaka ge. S ugges ted interv als v ary from dai ly (230,285 ) to ev ery othe r week (287) to monthl y (198). It s hould be repeated wi th ne w e qui pment a nd when the abs orbent is change d.

Room Ventilation System

The room v enti la tion s ys te m se rv es as an important adjunc t to trac e gas c on trol by di luting and remov ing a nes thetic g ases resu lting from leaks , e rrors in tec hnique ,

and s cav engi ng s ys tem malfunc tions (3 24,325,32 6,327,328). Rec irculatin g sys tems are les s eff ec tiv e at remov ing trace gas es than n onreci rc ul ating s ys tems . A downward d is placemen t v en tila ti on s ys tem is more effec tiv e than a turbulent fl ow s ys tem (183). A tu rnov er rate of 20 exc hang es per hour is cons idered necessary to prev ent bac te ria from s ettling (329 ). The anes thes ia mac hine shou ld be plac ed as cl ose to the ex haus t gril le as possible. This wi ll ensu re maxi mum gas remov al by the v entil ation s ys tem and make i t eas y to us e the v entilation s ys tem as th e gas -dispos al s ys tem. This sho ul d be taken i nto cons id era tion when co ns truc ting a new opera ting ro om o r renov ati ng an older one. Onl ine ambient ai r c ontrol has been p ropose d (10,330 ). Th is wo uld pe rmi t the room v enti lation to be matc hed to the ac tua l con tami nation lev el .

Hazards of Scavenging Equipment Misassembly

Mi scon nec ti ons inv olv ing the scav engin g s ys tem are no t unc ommon (331,332). Mos t sc av engi ng components hav e 19- or 30-mm connec tions ra the r than the 1 5- and 22 mm s iz es found in b rea thi ng s ys tems . Th is wi l l not c ompletely p rev ent miscon nec ti ons , because there may be other app ara tus in th e room that wi l l acc ept 19- or 30-mm c onnec tions (32 5,325A ), and so metimes a 19- or 30-mm c onnec to r can be f i tted onto a 22-mm one (333,33 4). T he safety prov ided by 19- and 30-mm connec tors can be bypas sed by us ing c heater adapters or ta pe fo r making connec tions . A c i rc le s ys tem hose may be connec ted to the ou tlet of the APL v alv e col lec ting as sembly (1 94,195,335 ,3 36). Measu res to prev ent this inc lude turn ing the exhaus t port of the gas -c ol lec ting as sembl y so that it points i n the opposi te d irec tio n from the breathing s ys tem ports , use of transfer and gas -disposal tubings of di fferent co lors and /or c onf igura tions f ro m breathing s ys tem tubes , and us in g 30-mm connec tions in the s cav engi ng s ys tem.

Pressure Alterations in the Breathing System

The s cav enging s ys te m ex tends the b rea th ing s ys tem a ll the way to th e gas disposal point. When a s cav enging sys tem malf unc tions or i s mis used, pos itiv e or negativ e p res sure can be transmitted to the breath ing s ys tem. This is more l ik el y to oc cur wi th c los ed in te rfaces .

Meas ures to prev ent these un toward i nciden ts inc lude emplo yin g collapse-res is tant material in al l disp osal lines , mak ing the transf er means eas y to disconnec t, us ing sc av engi ng tubing that has a dis tinc tiv e appearanc e, incorporating pos i tiv e and negativ e p res sure reli ef v alv es in the in terface, regu larl y chec king the v alv es fo r proper func tion ing, usi ng an op en in terface, and us ing ai rway pressure moni to rs (Chapter 23 ).

Positive Pressure
Pos itiv e pressu re in the sc av engin g sys tem can resul t f ro m an oc cluded transfer or gas -d is posa l tubing. Th is can be caus ed by th e wheel of an anes thesia machine or other equipment rol ling o nto the tu bing (195,3 37,338,339,3 40), ic e (257 ), i ns ec ts , water, or other forei gn matter. Ano the r caus e is defec tiv e compone nts (341). Mi sass embl y of the connec ti on to the exhaus t g ri lle (342) and f ai lure to i nc lu de an opening between the in ner an d outer tubes of a tube -wi th in-a-tube interface (343) hav e been reported. These malfunctions may not resu lt in a pressure bui ldup when a pos itiv e pressu re relief mechan is m is inc orporated into the i nterfac e. The pos i tiv e press ure rel ief mechanism may be incorrec tl y ass embl ed, ma y not open at a lo w e nough p res sure, or may be blocked (344). Obs truc tion or mis con nec tion of the trans fer tubing may oc cur (334,345,346,347,348 ,349). Beca use these problems are on the patient s ide of the inte rf ace , disconnec ti ng th e transfer means from the gas -col lec ting as sembl y may be necess ary to prev en t a dangero us inc rease in p res sure. In one reported case, the trans fe r tub ing was k inked , c ausing back pres sure to dev elop in the gas j ack et of an ex trac orp ore al ox ygen ato r. This resu lted in gas being fo rced into the blood (350). A l l tubings that c onduc t sc av enged gas s hould be off the floor o r protec ted so that they cannot b ecome obs truc ted (339 ). W ith s ome ol der APL v alv es , subatmosphe ric pressu re can resu lt in obs truc tion and a buil dup of pos i tiv e P .391 press ure in the b rea thi ng s ys tem (343 ,35 1). In one reported cas e , subatmosphe ric press ure in the s cav enging sys tem drew a v enti lator rel ief v alv e diaph ragm on to i ts seat and c los ed th e v alv e, resulting in a pressu re inc reas e in th e s ys tem (35 2). In another repo rted cas e, low s cav enging flow res ul ted in an inc reas e in press ure in the bag at the inte rface . This caus ed the v entilator to fail , and there was sus taine d

positiv e pressu re in the pa ti ent c ircui t (353). On newe r models , onl y ful l flo w c an be us ed for scav enging .

Negative Pressure
If an ac tiv e dispos al s ys tem is in use and the APL v alv e is full y open, the re is danger that subambie nt press ure wi l l be app lied to the breathing sys tem. Moni tori ng ex pi red v olu me (but not ai rway pre ssure) may fai l to d etec t a disc onnec ti on in the breathi ng s ys tem becaus e the s cav enging s ys te m may draw a cons iderabl e fl ow of room ai r through the ex pi ratory pathway (354,355 ,36 7). Gas may be ev acuated f rom the breathing sys tem if the A P L v alv e al lows gas to be drawn th rough it and in to the scav eng ing s ys tem at a pressu re l ess than that needed to open the nega tiv e press ure v alv e o n the i nterface (356 ,357). This problem can be co rrec ted by partial l y closing the A P L v alv e (358), inc reasi ng th e f res h g as fl ow, or lo wering the flow i n the gas dis posal s ys te m. The negativ e pressure re lief mec hanism may malfunc tion (344,359 ,360,361,362,363). A nother problem is us ing an in terface des ign ed fo r a passiv e s ys tem ( whic h has no means to prev ent a sub atmos phe ric pressu re) i n an ac tiv e sc av enging s ys tem (3 46). In so me s cav enging s ys te ms tha t use the central v acuum s ys tem, a res tric tiv e orif ice is i nco rpo rated into the v ac uum hos e f i ttin g to l imi t gas ev acuation , re gardless of the press ure appli ed by the cen tral v acuum sourc e (279 ). If this o rifice is omitted or bec omes da maged, excessiv e v acuum wi ll be ap plied to the interfac e and the c apac ity of the nega tiv e press ure rel ief mechanism may be exc eeded. W ays to prev ent nega tiv e press ure f rom being transmi tted to the breathing s ys tem i ncl ude prov is ion of one or more nega tiv e re lief mechanis ms in the interfac e with an ac tiv e dispos al s ys tem (364), adjus tin g the f lo w thro ugh the gas disposal s ys tem to the minimum nec essa ry, and protec ting the openings to a tmos phere from acc idental oc c lusi on.

Loss of Monitoring Input

A scav eng ing s ys tem ma y mask the s trong o dor of a v olati le anes thetic agen t, delay in g recogni tion of an ov erdos e (345 ,365). Us e of anes thetic agent moni toring (Chapter 22 ) should largely elimi nate this problem.

Alarm Failure
A cas e has been repo rted in whic h ne gativ e pressure from the sc av enging s ys te m i nte rface prev ented the v entil ator bel lows from coll apsi ng when a d isc onn ec tion in

the breathing s ys tem occ urred (366). The l ow a ir way press ure alarm in the v enti lato r was not ac tiv ated. In another c ase , room ai r was d rawn into the breathi ng s ys tem through a disconnec ti on, prev enti ng the low minute v olume a la rm from sounding (367).

Monitoring Trace Gases Rationale

A i r moni to ri ng is the bes t indicator of the s uccess of a was te gas c ontrol program. It ref lec ts how wel l l eaks and errors i n techn ique a re being c ontrol led as wel l as the ef fic ienc y of the scav eng ing and roo m v enti lation s ys tems and documen ts that l ow trac e lev els a re bei ng mai ntained. Some anes thetic dep artments do not mo ni tor trac e g as lev els in the bel ief that s cav enging dev ic es hav e s olv ed the problem (368). Moni tori ng is necessa ry bec aus e a sc av engi ng s ys te m that ap pears ade quate in desig n ma y perform ineff ic ien tl y in use. Si tes where gas c an leak a re div erse, f requentl y obsc ure , and so me times inacc ess ibl e. E v en re la tiv el y la rge leak s may be i naudible. Nitrous oxide is odorless , and the thresho ld for smel l ing halogenate d agents ma y be as high as 300 pp m (369). W ithou t moni to ring, operating room personnel may be unawa re that atmospheric c ontamination is at unacceptabl e l ev els . A prope rl y con duc ted moni tori ng program c an prov ide a cons truc tiv e method of remi nding anes thesia personnel to av oid careless wo rk habits . A nother adv antage of moni toring is that i t can detect p roblems wi th gas del iv ery to equipment (370). A l though s uch a pro gra m wi ll inc reas e a hea lth c are fac il ity's ope rati ng expense, it wi ll help to reduce the ins titutio n's l iabi li ty to c laims b y employees all eg ing that ex posu re to wa s te gases c ontri buted to a sp ontaneous abo rtion o r other medica l problems . Correc ting certa in leaks s uc h as those assoc ia ted wi th the pipel ine or pipel ine hos e c an res ul t in a sav ings to the fac i li ty.

In-house versus Commercial Laboratory

The mon itoring p rog ram sho uld be direc ted by an interes te d and qualified pe rs on, prefera bly f ro m the anes thesi a depa rtment. Samples may be anal yzed b y either fac i li ty-base d pers onne l or ou ts ide c ommerc ial laborato ri es . The us e of an outs ide l aboratory av oi ds the cos t of purchas ing, operating , main taini ng , and ca librati ng a gas anal yze r. The res pons ib ility fo r record k eepi ng is shared. P .392

The c hie f disadv antage is the dela y in reporti ng resul ts . The p rec is e c irc ums tanc es at the time the samples were tak en are l ikely to hav e been forgotte n, and the effect of c orrec tiv e meas ures c ann ot be i mme di ate ly as ses sed. In add ition, analysis of a l arge n umber of samples is ex pens iv e . Adv antages of in -ho use an alys is inc lu de a virtually unlimited number of anal yses at modes t cos t and i mmediate on-s i te reporti ng. Leak s can be f ound qu ic kly a nd the ef fec tiv enes s of the c orrec ti on ass ess ed immed iatel y. An on-s ite continuous moni tor is useful for de mons tra ting the effec ts of tec hnique errors on trac e gas l ev els and the resul ts of c orrec tions . A smal l f aci li ty migh t perio dic al ly l eas e an ins trument or sha re one wi th o the r health care fac ili ties in the area ra the r th an purchas e its own.

Equipment for Determining Trace Gas Concentrations

Infrared Anal yzers
Infrared gas analy zers were d is cuss ed in Ch apter 22. Thes e monitors are the mos t prac tical for the av erage heal th c are ins tituti on because they are rel iable, rela tiv ely i nexp ens iv e , and eas y to us e (371). They are useful for l oc ating l eak s , es pec ial ly those in unus ual loc ations . The y giv e continuous me asuremen ts so that expos ed personnel and th ose respons ible for a ir mon itoring a re giv en an i mmedi ate readin g. W hen opera ted on battery power, a numbe r of loc a ti ons c an be sampled quic k ly . A recordi ng attac hment ma y be helpful. These ins truments are mos t o ften used f or monitoring n itrous ox ide. Unfo rtunatel y, ca rbon d ioxide and water v apor in high conc entrations wi ll interfe re wi th the analys is . Th is c an b e av oided by s ampl in g a t le as t 6 to 10 inches away from personnel . Analy zers capa bl e of measu ri ng hal ogenated anes thetic s a re av ail ab le but hav e many tec hnical diff ic ulti es ; a lc ohols and other s ubs tanc es in the opera ting room c aus e interferenc e (66 ,371,3 72).

Proton Transfer Reaction Mass Spectrometry

P roto n transfer reac tion mass s pec trometry al lo ws measuremen t of trac e gases in parts p er bi l li on (373). It h as been used to measure trace gases bo th in a mbient ai r and exhal ed gases (10,296,374 ). Th is tech nology is not av ai lable f or in-hous e use.

Dosimeters

Pas s iv e dos imeters me asu re the amount of ni trous ox ide tha t di ffuses into a mol ecular s iev e (375). Anal ys is (usua ll y by the manufac turer) req uires ex trac tio n of the ni trous ox ide . Pas s iv e dos imeters hav e man y adv antages . They ca n g iv e a time -wei gh ted av erage (TW A ) conc entra tion fo r as l ong as a month. They are c onv enient to use. They ca n be made li ghtwei ght and compac t s o that they c an be worn f or pe rso nal s ampl ing. A v ariant of the pass iv e dos ime ter is the gas cartri dge sample r, wh ic h is a smal l container that is fi ll ed wi th a sa mp le of operating room ai r and then sen t to the l aboratory f or anal ysis . Ac tiv e dos imeters depend on energy ou ts ide of the absorbing medium to obtain the sa mple . A pump is us ed to take in gases tha t are then s tored in a gas -ti ght b ag in an absorbing medium. The s amples are as pi rated into an anal yze r.

Ionizing Leak Detector

The ioni zing leak de tec tor (l eak meter) c ons is ts of three comp onen ts : an el ec tron captu re detec tor hous ed within a h and piece and f i tted wi th a probe, a c ontrol uni t that proc esses the si gnal f rom the detec tor and d is pla ys the output on a meter, and a c arri er g as supply (198 ,376). The ins trumen t is c ompac t, relativ ely inex pens iv e, portabl e, and c an be ope rated on batteri es . The ioni zing leak de tec tor is su itabl e fo r measu ri ng lo w c once ntrations of halogenated agents . Howev er, there may be i nterferenc e f rom o the r halogenated agents in the area, i ncludi ng anti bi otic and sk in -protec ti on sprays . It is not useful for ni trous ox ide detec tio n. It is somewhat uns tabl e in use, requ iring f re quen t ze roing and reca librati on (198,324 ).

Oxygen Analyzer
An ox ygen mon itor ca n be used to c hec k the sc av enging s ys tem. Us ing 100% ox ygen , th e s ens or is pos i ti one d at the interfac e where ov erfl ow wou ld ex it into the room. Any inc rease in ox ygen indica tes that anes the tic gas wi ll be released duri ng normal use.

Carbon Dioxide Analyzer

The eff ic acy of s cav engi ng wi th an open in terface c an be c heck ed by ana ly zi ng the open end of the reserv oi r for c arbon diox ide (243 ). If any of the patien t's expi red gases ov e rflo w, c arbon d iox ide wi l l be detec ted .

Sampling Methods
Instantaneous Sampling

Ins tantaneous (g rab , s ingl e-shot, pe ri odic , s natc h) s ampling is perfo rmed by drawi ng a s ample of ai r into a c ontainer and s ubsequen tly meas u ring the trace gas conc en tration . The conta in er mus t n ot ads orb o r abs orb the con taminan t or l eak . Nylon ba gs are the prefe rred s torage c on tainer when ni trous ox ide lev els a re meas ured (17 6,377). W hen an ins tantaneous sample is taken, it is imp ortant to record the d ate and time of c ol lec tion, the wo rk prac tic es , anes thes ia machine, b rea thing s ys tem, fres h P .393 gas fl ow, ai rway dev ice (fac e mask , supraglottic ai rwa y d ev ice or trac hea l tu be), type of v entilatio n, v enti lator, a nes the tic agen ts us ed, loc a ti on of s ampl ing s ite, and the person adminis tering a nes thes ia . This method is rel ativ el y inex pens iv e, q uic k, and s imp le to p erform and does no t i nv olv e tak ing bu lky equipment into th e operati ng room. There are some se ri ous disadv antag es . A long i nte rv al between s ampl ing and rep orting makes i t difficul t to remember the precis e ci rcums tanc es under whi c h the s ample was taken . The effec t of c orrec tiv e meas ures c ann ot be i mme di ate ly as ses sed. It is of limi ted v alue in determin ing leak s ites and asses s ing le ak correc ti on . Another s erious dis adv antage i s tha t eac h s ample rep res ents the lev el at one loc ation in a rel ativ ely s mall v olume and ov er a v e ry short ti me peri od. Fai lu re to s ample in the ri ght p lac e at the right time c an p rod uce resul ts that are misl eading (14). One inv estigatio n c onc luded that gradients in operating rooms were s uffic iently l arge to inv alidate es tima tion of personnel exposure f rom ins tan taneous s ampl es (378). This dis adv antage can be dec reas ed by taking mul tiple samp les , but this inc reases the ex pens e. The ins tantaneous s ample is probably bes t employed fo r anal ys is of s teady-s tate contamina ti on, tha t is , samp ling before s ta rting anes thesia for i nterme dia te press ure leak s or when equi li brium has b een achiev ed. If go od techni ques are employed and leaks hav e been c orrec ted , trace gas lev els ten d to ris e i n a f luc tu ati ng pa ttern d uring the early pa rt of an anes th etic and then rough ly equil ibra te, reachi ng a lev el that repres ents the ne t effec ts of leaks , a ir condi tioni ng , inflowi ng gas , scav enging eff ic ienc y, and person nel mov ement (378). Under th ese ci rcums tanc es , a n ins tan taneous s ample 30 to 45 minutes af ter i nduc tion is p robabl y a good i ndex o f the average trac e gas lev els (230,378). If poor techniques are e mp lo yed and /or no attempt has been made to eli mina te l eak s , pollution l ev els wi l l v ary mark edl y and i ns tantane ous samples ma y be qui te

mis leading. If unacc eptabl y high lev els are found , one c annot be sure whether the caus e is a l eak , poo r tec hnique , or a f aul t in the scav enging s ys tem.

Sampling at the Air Conditioning Exhaust

Samp les may be tak en at the ai r conditioning exhaus t g ri ll e (2 89,379). This location giv es a general indication of the ov eral l l eak age in to the roo m bu t not of i ndiv iduals ' ex posure to trac e gases .

Time-weighted Average Sampling

The toxic i ty of anes th etics is probably a fu nc tion of both dos e and exposure ti me. Hence, a method that giv es an av e rage ex pos ure lev el during a p eriod of time (an i nte gra ted s ample) is of i nte res t. TWA sa mpli ng is also known as integrated or time-i nte gra ted s ampling . TW A samples can be obtained by us ing ac tiv e dosi me try in which gases are pump ed con tinuous l y ov er a pe riod of time into an ine rt c ontainer (372,380,381) or a dev ic e c ontaining an adso rbe nt material (176,3 82,383,38 4,385,386). Pas s iv e dos imetry , whi ch depends on gas di ffus ion into a molecu la r s iev e, can be us ed to obtain TW As (387). Smal l, rugg ed, lightweight dos ime te rs (d iffus iv e sa mple rs ) are av ai lab le (318,387 ,38 8,389). The y a re unobtrus iv e, eas il y attached , and requ ire a mi ni mum of mai ntenanc e (18 2). T hey can be us ed ei th er as pe rs onal or a rea mon itors for u p to 40 hou rs (388). They hav e been fou nd to be quite ac curate (387,388). S eparate s ampl in g me di a h av e to be used for ni trous ox ide and the halogenated agen ts (2). Howev e r, more th an one hal ogenated age nt can be meas ured from one sampler. Other way s of obtaining a TW A a re to av erage the res ul ts of ma ny ins tantaneous sa mples , av erage the c oncentratio ns meas ure d a t equa l time inte rv als throughout the rec orded trac ing of a c ontinuous anal yzer, or i ntegrate the ou tpu t of a continuous ana lyzer (390). B y el imina ting errors due to tempo ral fluc tuations , TW A s ampl ing reflec ts pers onnel ex posu re better than ins tantaneo us s ampl ing. It requi res onl y a modes t c api tal i nv es tment, and there is c ons iderable time a nd labor sav ings compared with tak in g and a nal yzing mul tiple ins tantaneous samples . The re are sev e ral disadv antages to ti me-wei ghted sampling. It does not help wi th detec ting leaks or improv ing work techni ques . De layed resul ts mak e i t difficul t to co rrela te wi th ac tiv i ties at the time of c ol lection . If conc entrati ons in excess of those recommended are found, one cannot tel l whether the problem is technique erro rs , leaks , o r inadeq uate s cav enging.

Continuous Sampling
Con tinuous (di rec t-reading , real ti me) monitoring is carri ed ou t by using an inf rared analy zer, l eak meter, or proton transfer reac tion mass s pec trometry. The use of a battery -po wered ins trument al lows for eas y mov ement wi th in an d between rooms . If a wri ter i s a ttached and the analyz er is run ov er a perio d of ti me, a TW A samp le is obtained (176,390). Con tinuous moni tori ng can be us ed to de tec t l eaks and to determine if a leak has been red uced or eliminated. A c ontinuous analy zer op era ted wh il e anes thes ia is being ad ministered can be us ed to demons trate the effec ts of imprope r work prac tices on trac e l ev els and the improv eme nt f rom modifying those prac tices . The c onv enienc e and i mmedi ate feedbac k of co nti nuous moni toring are dis tinc t adv antages ov er ins tan taneous o r TW A s ampl ing. W hen high readi ngs are obtained, the caus es can usual l y be determined immediately and corre c tiv e meas ures taken. A disadv antage of c ontinuous mon itors is that the time and ex pens e required to mai ntain the ins trume nt P .394 may mak e i t unsatis fac to ry for a smal l f aci lity. In s uch c i rcumstances , sev e ral fac i li ties mi ght cons id er sha ring an ins trume nt, or a manufac turer's se rv ice represen tativ e might use o ne during routine quarte rl y main tenanc e c al ls . This method tends to dis rupt the operating room ro utine more than ins tan taneous o r TW A sampli ng. Fi na ll y, rapidl y changing c oncentra ti ons are diff ic ul t to interp ret in terms of personnel ex posu re unles s integration ov er ti me is empl oyed.

Personnel Sampling
End -tid al sa mples of gas es may be taken f rom ex pos ed p ers onne l af ter a peri od of ex posu re (8 ,186,374,378 ,391,392,393 ,394,3 95,396). This method is mos t s uitable for potent halogenated agen ts . Nitro us oxi de is so rap idl y abs orbed and ex c reted that i ts l ev el in end-ti dal gas re flec ts only th e mos t recen t exp osure. B lood samples c an be drawn from personnel at the end of an ex posu re period and analy zed (183,391 ,393,397). Uri na ry concen trations of anes thetic agents s how a s ignif ic ant c orrel ation wi th env i ronmental ex pos ure (395,398 ,399,400,401,402,403,404).

Agents to Be Monitored

Ideall y, al l gases empl oy ed in the con duc t of anes thesia wi th the exce pti on of ox ygen s houl d be measu red . Anal yzers that can sc an the i nf rared spec trum and c an be programmed to d is ti nguish indiv idua l inhalatio nal agents are av ai lable. Likewi se , mass s pec trometry and gas chromatography c an meas u re al l agents . Howev er, it is s impler to moni tor a s ing le gas . The NIOS H c ri teria doc ument (285 ) does not recommen d mo ni toring of al l an es thetic agents but o nly the one mos t frequ ently us ed.

Nitrous Oxide
Many people bel iev e that ni trous oxi de is the mos t log ic al agent to moni tor becaus e i t is admin is tered i n h igher conc en trations than o ther age nts , is eas y to measure, and is more l ikel y to be s ubjec t to occ ult leakage than v ola ti le li quid a gents . Bec ause n itrous ox ide and other agen ts are not s eparated by buo yanc y effec ts (198,324 ), they wi l l be presen t in a room in the same ra ti o in which they are i ntroduc ed. Bec ause of this , man y people co ntend tha t ni trous ox ide c an serv e as a trac er for other agents adminis tered wi th i t to a degree of ac curac y suffic ient to as sess occupational ex posu re. This tracer c onc ept wo rks bes t under s tea dy-s tate condi tions and low equipment leak age. It does not work we ll wh en a v apo ri zer is being f il led or drai ned, during c ard iopulmonary bypass , during i nduc tion or recov ery f rom anes thesi a, o r when there is a la rge nitrous ox ide leak or a leak in a v aporizer.

Volatile Agents
Moni tori ng ag ents other than ni trous ox ide c an be worthwhil e (4 05,406). Volatil e agents c an leak independen tl y of ni trous oxi de. Anal yzers that meas ure p otent agents a re more expensiv e than thos e that measure o nl y n itrous oxide.

Sites to Be Monitored
Moni tori ng shoul d be sch eduled s o that the work of each anes thesi a p rov ider and of each operating room is c heck ed whi le using a mask , s upragl ottic dev ice , and trac heal tube. Moni toring s hould be performed duri ng spon ta neous , manually as s is ted, and manuall y c ontro lled and au toma tic v en tila ti on. The res ul ts of the moni tori ng shoul d be anal yzed and disc usse d with all parties concerned .

Personal Monitoring
W hen mon itori ng work e r exposure to was te anes thetic gas l ev els , the Occupational and Safety Heal th Organization (OS HA ) mandates tha t samp li ng be performed i n the work er's breathi ng zone (407 ). A nes thes ia pe rsonnel are cons idered the mos t

i mportan t to monitor, because they us ually are ex posed to higher c oncentrations than other operating room pers onnel (389) a nd are more like ly to remain in the room for the en ti re du ration of anes thes ia admi nis tration. Pas s iv e dos imeters c an be attached to the p ers on's cl oth ing and worn for prolonged periods . Sampling di rec tl y in the subjec t's ex pi ratory pathway mus t be av oid ed if measuremen t of ni trous oxi de by i nfrared analys is is used.

Area (Room) Sampling

The exhaus t grill e of the air c ondi tioning s ys tem or the open door wi ll be represen tativ e of av era ge personnel ex pos ure i f gas es are ev enl y dis tributed in the room. Fifteen o r more ai r ex changes pe r hour a re suff ic ient to p rod uce nea r homo gene ity of anes thetic c once ntrations in all loc ations except those c los e to the l eak (66,82,324). W ith lower ex change ra tes , mix ing ma y n ot be c omplete , and l ocali zed areas of high (ho t spots ) o r lo w (c old spo ts ) conc entration may occ ur. A rea sampli ng may be less dis ruptiv e to the operating room rou tine than pers onal moni tori ng.

Monitoring Frequency
A t the initiation of a wa s te gas con trol program, f requent moni tori ng unde r ac tual work i ng c onditions wi ll be necessa ry. As expe rienc e is gai ned and equipmen t is mai ntained leak tigh t, the frequenc y c an be dec reas ed. Whenev er highe r-thanac ceptable concentrations a re found, P .395 new equipment is ins tall ed , or old equipment i s modifi ed, monitoring s houl d be repeated . The f ol lo win g s chedule h as been s ugges ted (14 ):

An ann ual c omprehens iv e surv ey i n which expos ure lev els are measured, l eaks d etec ted and c orrec ted, an d TW A ex pos ure lev els are calculated or meas ured.

Quarterl y fo ll ow-up wi th a less -detai le d s urv ey; if there appears to be a problem, a co mprehens iv e s urv ey should b e p erf ormed to de termine caus es and asses s correc tiv e ac tions .

A rep eat c omprehensiv e surv ey in the ev ent o f major cha nges to the v enti lation sys tem, anes thes ia equ ipment, or sc av engin g sys tems .

TW A moni to ri ng of each member of the s taff f or a short peri od , suc h as a wee k , repeated on a 6-month basis also has b een sugges ted (372).

Role of the Federal Government

In 1970, the U.S . Congress pas sed the Occupational S afety and Hea lth (OS HA ) A ct (14,408,409 ). It c reated two s eparate exec utiv e -branc h agenc ies to c a rry out the prov isions of the ac t: the National Ins ti tute of Safety and Heal th (NIOSH), an agenc y wi th the Centers for Dis ease Con trol an d P rev ention under the Dep artment of He al th and Human Serv ic es , and OS HA , under the Depa rtment of Labo r (176). NIOSH is responsible for c onduc ting an d funding researc h and education and fo r preparing c riteria doc uments to be used to d ev el op s tandards . Criteria documen ts prepared by NIOSH are transmi tted to the sec retary of labor for rev iew by the OS HA s taff. OS HA is resp ons ibl e fo r enac ti ng job s afety and hea lth s tandards , es tablishing reporti ng and reco rdk eepi ng proce dures , i ns pec ting work places , and enfo rci ng the requi rements of the ac t by us ing c i tations and fines (176). A c riteria doc ument on trace gases was publ is hed and trans mi tted to OSHA i n 1977 (285). It inc luded the fol lowi ng prov isions .

A l though a safe lev el of exp osu re to trace anes thetic gas es c ou ld no t be defi ned, max imum c once ntrations to wh ic h a work er in the operating room shoul d be exposed were rec ommended. Fo r ni trous ox ide alon e, a TW A ex posu re l imi t of 25 ppm was rec ommende d. For halogenated agen ts us ed alone , th e li mit wa s 2 ppm TWA . When hal ogenated agen ts are used in co mbination wi th ni trous oxide, the recommended l imi ts we re 25 ppm ni trous ox ide and 0.5 ppm of the ha logena ted agent. For dental fac il ities , a l ev el of 50 pp m ni trous ox ide was recommended. These were arbitra ry lev els and were not based on toxic effec ts . Is oflurane , des flurane, a nd sev oflurane were not included in the recomme nded ex posu re l imi ts becaus e they were no t in c linic al use in 1977. Highe r limi ts are rec ommended in other c ountri es (255,294 ,410,411). Isof lu ran e and des flurane lev els c an be k ept below the NIOS H l ev els rela tiv el y eas il y (409,410,412,413,414). Exc ept duri ng a mask induc ti on , l ev els of s ev oflura ne can als o be k ept under 2 ppm (415,416 ,417,418). Howev er, it may be diff ic ul t to ac hiev e th is lev el when us ing a face mas k

(418,419 ). One s tud y determined that s ev ofl urane in c ombination wi th n itrous ox ide c ommonly exc eeded the recommended l imi t (416).

Moni tori ng ex posu re l ev els is rec ommended i n al l areas wi th po ten tial for work er ex posure on a quarterly bas is and foll owi ng c hanges to v en ti lation s ys tems , anes thetic equipment, or s cav enging techn iq ues . B rea thi ng zone or work are a sampl es are mos t desi rable. Resu lts of moni toring and c orrec tiv e meas ures are to be main tained and retained for 20 years (176 ).

Rec ommenda tions we re made regarding scav enging, v entil ati on s ys tems , l eak tes tin g, and wo rk prac tices aimed at minimizing emp loyee exposure (176).

Medical s urv ei llance, inc luding comprehensiv e employee pre placemen t medical and oc cupationa l his tories , annual updating of employee me dical his tories , and preplac ement and annu al ph ys ical examina ti ons of employees ex posed to was te anes thetic gases were rec ommended.

E mpl oyees were to be info rmed on as si gnmen t and at least yearl y th ereafter of the possible heal th effec ts of ex pos u re to tra ce anes th etics , especi al ly possible effec ts on re produc tion. Appropri ate s igns and labe li ng were recommen ded.

NIOSH partic ipation c ame to a hal t af te r th is c ri teria d ocume nt on trac e gases wa s transmitted to OSHA . To p romu lga te this as a s tandard, OSHA wou ld hav e to go through an ex tensiv e rule-mak ing procedure, i nc luding a public comment period. This has n ot oc curred to date.

Medicolegal Considerations
Bec ause the NIOSH document does not cons titute a p romulgate d OS HA s tandard, employers are not obliga te d to compl y wi th i ts recommendations . Ho wev e r, the general duty c laus e of the 1970 ac t giv es OS HA th e authority to i nspec t wo rk plac es to dete rmine whether employers are p rov iding a work pl ac e f ree from hazards , ev en i n the abs enc e of a rel ev ant s tandard. The ac t giv es each employee the rig ht to reques t an OSHA ins pec tion if an employee believ es that he o r she is in imminent danger f rom a haz ard o r if OS HA s tandards are being v iol ated. Sev eral i ns pec tions in res pons e to employe e co mplaints were c arri ed out in the 1970s . Fines and c itatio ns were iss ued becaus e employees were exposed to c onc entrati ons of nitrous oxi de in exces s

P .396 of the NIOS H recommended lev els o r beca use ex posu re was no t re duced to th e l owes t feasible lev el (406,409 ). The A me rican Soc ie ty of A nes thes iologis ts (A SA ) l egal counsel has adv is ed tha t it i s within the right of an emplo yer to ref us e to permit an OS HA represe nta tiv e to enter the faci li ty unless that indiv idua l has e ither a searc h warrant or a court order co mpelling the ins pec tion. OS HA wo uld need to s eek a searc h warra nt f rom a federal c ourt and show p robabl e caus e for making an inspec tion (406). If fac ed wi th a v isi t from an OSHA rep res entativ e, obtaini ng le gal c ouns el is adv isable. Fai lure to demand a searc h wa rrant o r c ourt order n ormall y would cons ti tute a waiv e r of any later right to o bject to the v ali di ty of an inspec tion. A ll s tates hav e wo rk ers ' compensa ti on laws so that indiv iduals suff ering f rom oc cupa tiona l diseas es can c ollec t benefi ts , i rrespec tiv e of whether o r not the employer's negligence caused the dis eas e. It is possible tha t a work ers ' co mpens ati on case could aris e from an operati ng room employee s ufferin g f rom one of the p roblems d esc ri bed in the fi rs t sec tion of this ch apter, p rov ided the employee c ould show that the i llness was work conn ec ted and that e mplo yment in the operating room s ub jec ted him or he r to spec ial risk in ex ces s of those ex perienc ed by the genera l public . In mos t s tates , wo rk ers ' compensa ti on laws prec lude priv ate l aws uits by an employee agains t his or her emplo yer. Howev er, in addition to mak ing a cl ai m for work ers ' c ompensation, an emp loyee c an bri ng a c iv il s ui t fo r damages agains t a third party (s uc h as an anes thes ia p rov ider) whom the emp loy ee cl ai ms c aus ed i njury .

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[Med li ne Link ] 361. S iv alingam P , Hyde RA , Eas y W R. A n unpredic table a nd poss ib ly dangerous hazard of an anaes thetic s cav engi ng s ys tem. Anaes thes ia 1997 ;52 :6 096 10. [Fu ll tex t Link ] [Med li ne Link ] 362. Sey mour A . P ossible haza rds wi th an a naes th etic gas s cav enging s ystem. Anaes thes ia 1982;37:1218 1219. [Cross Ref] [Med li ne Link ] 363. Gra y JS , Ev ans GA . Sc av engi ng malfunc tion. Anaes thes ia 2003 ;58 :1144 1145. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 364. Mil lik en RA . Haz ards of sc av enging sys tems . Anes th Ana lg 1980;59:162. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 365. Sharrock NE , Gabel RA . Inadv erte nt an es thetic ov erdose obscu red by sc av engi ng. A nes thes iology 1978;49:137138 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 366. Heard S O, Muns on ES . Venti lato r alarm nonfunc tion assoc ia ted wi th a sc av engi ng s ys tem fo r was te gas es . A nes th A nal g 1983 ;62 :23 0232. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 367. Oliv e r W C, A bens tein J P , Nuttall GA . Ventilator al arm fai lu re due to modific ati on of the sc av enging s ys tem. Anes thesio lo gy 2000 ;93:13511352 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 368. Halsey MJ . Occupational heal th and po llution for anaes thetics . A repo rt o f a se mina r. Anaes thes ia 1991;46:486488 . [Cross Ref]

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378. Bey nen FM, Kno pp TJ , Rehder K . Nitrous oxide ex pos ure in the opera ting room. Anes th A nalg 1978;57:216223. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 379. B yh ahn C, W es tpha l CK . Causes of nitrous ox ide c ontamination in operating rooms . A nes thes iolog y 1999 ;91 :19 601 961. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 380. Gra y WM, B urnside GW. The ev ac uated c anis ter me th od of personal s ampling . An as sess ment of its sui tabi li ty f or routine moni toring of ope rating theatre poll ution . Anaes thes ia 1985;40:288 294. [Med li ne Link ] 381. Aus tin J C, S ha w R, Mo yes D, e t al . A s imp le ai r sampling techn ique for moni tori ng ni trous ox ide pollu ti on. B r J Anaes th 1981;53:9971003 . [Cross Ref] [Med li ne Link ] 382. Burm A G, Spierdijk J . A method fo r s ampl ing halothane and enf lurane p res ent i n trace amou nts i n ambient air. Anes thes iology 1979;50:230233. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 383. Carte r KB , Hal l ida y MM. A pe rs onal air s ampling pump fo r hosp ital operati ng s taff. J . Med Eng Tec hno l 1978 ;2:31 031 2. 384. Dupres soi r CAJ . A prac tical apparatus fo r measu ri ng av e rag e exposure of operati ng theatre perso nnel to halothane. Anaes th Intens Ca re 1975;3 :34534 7. [Med li ne Link ] 385. Choi -Lao A T. T rac e a nes the tic v apo rs i n hospital opera ting-room env ironments . Nurs Res 1981 ;30:156161. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 386. Halliday MM, Carter KB . A c hemical a dsorption s ys tem for the s ampl ing of gaseous o rganic pollutan ts in operating theatre a tmos pheres . B r J Anaes th 1978;50:1013101 8.

[Cross Ref] [Med li ne Link ] 387. B ishop EC, Hoss ain MA . F ield comparison between two ni trous ox ide (N 2 O) passiv e moni tors and c onv entio nal s ampl ing methods . A m Ind Hyg Assoc J 1984;45:812816. [Cross Ref] [Med li ne Link ] 388. W ard B G. Dev elopment and a pplic ati on of a long d ynamic ra nge ni trous ox ide moni tori ng s ys tem. An In d H yg Assoc J 1985;46:697703 . 389. Gra y WM. Oc c upational exposure to nitrous ox ide in four h ospi tals . Anaes thes ia 1989;44:511 514. [Cross Ref] [Med li ne Link ] 390. Mc Gi ll WA , Riv era O, Ho ward R. T ime-wei ghted av erage for nitrous ox ide : an automated method . A nes thesiology 198 0;53:424 426. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 391. Kortti la K , P faffli P , E rtama P . Resi dual ni trous ox ide in opera ting ro om personnel . Ac ta Anaes thesi ol Scand 1978;22:635 639 . [Med li ne Link ] 392. Anonymous . W ork shop on anes the tic pol lu tion. A nes thes iol Rev 1977;4:25 34. 393. Nikk i P , Pfaff li P , Ahlman K . E nd -tid al and b lood halothane an d n itrous ox ide i n s urgic al pe rs onnel . Lanc e t 1972 ;2:49049 1. [Cross Ref] [Med li ne Link ] 394. P rado C, Tortosa J A , Iba rra I, et a l. B iologic al moni tori ng of occupational ex posu re to isoflurane by meas urement of is oflurane ex haled breath. J Appl Tox icol 1997;17:179183. [Cross Ref] [Med li ne Link ] 395. Trefisa n A , Gori GP . B iological monitoring of ni trous ox ide expos ure in su rgical areas . A m J Ind Med 1990;17 :357362. [Cross Ref] [Med li ne Link ]

396. Cope KA , Merritt W T, K renz is chek DA , et al . Phase II. Coll aborativ e p ilot s tudy : preliminary analys is of c entral neu ral e ffec ts from ex posure to v olati le anes thetic s in the PA CU. J P eria nes th Nurs 2002 ;17 :240250. [Cross Ref] [Med li ne Link ] 397. Hi llman K M, Saloo jee Y, B rett II, e t al . Nitrous oxide conce ntrations in denta l su rge ry. A tmos pheric and bl ood c oncen trations of personnel . Anaes thes ia 1981;36:257262. [Cross Ref] [Med li ne Link ] 398. Imb riani M, Ghittori S , P ezz agno G, e t. a l. A nes thetic in urine as bio logic al i ndex of exposure in op era ti ng-roo m pe rs onnel. J Tox E nv i ron He al th 1995;4 6:249 260. 399. Sonander H, S tenqv is t O, Nilss on K . Expos ure to trac e amounts of n itrous ox ide . B r J A naes th 1983;55 :12251 229. [Cross Ref] [Med li ne Link ] 400. Sonander H, S tenqv is t O, Nilss on K . Urina ry N 2 O as a meas ure of biologic ex posu re to nitrous oxide anaes thetic c ontamination . A nn Occ up Hyg 1983;27:73 79. [Cross Ref] [Med li ne Link ] P .401

401. Imb riani M, Ghittori S , P ezz agno G, e t al . B iological monitoring of oc cupa tiona l exposure to enflurane (E thrane ) in opera ti ng room pers onnel. A rch Env iron Heal th 1994;49:135140. [Med li ne Link ] 402. Imb riani M, Ghittori S , Zadra P , et a l. B iolog ica l moni toring of the oc cupa tional ex posu re to halo thane (F luo tha ne) in operating room personnel . Am J Ind Med 1991;20:103112. [Cross Ref] [Med li ne Link ]

403. Imb riani M, Ghittori S , P ezz agno G, e t al . Ni trous ox ide (N 2 O) i n uri ne as biological index of expos ure i n operating room person nel . App l Ind Hy g 1988;3:223226. 404. Imb riani M, Ghittori S , P ezz agno G, e t al . Ev alua ti on of expos ure to is ofl urane (Fora ne): env ironmen tal and biological measu rements in operating room personnel . J Tox ic ol E nv iron Heal th 1988;25:39 340 2. [Med li ne Link ] 405. Mil lik en RA . A plea for moni toring both hal ogen ated and non -ha logenated anes thetic agents in the operating room. Anes thesiol Rev 1976;3:2931 . 406. Anonymous . OS HA inspec tions of hos pital operati ng rooms . ASA News lett 1980;44:7. 407. Moore BL. Ex posu re of pos toperativ e nurses to wa s te-a nes thetic g ases and fac tors inf luencing ex pos ure . Ac ta A naes thes iol Sc and 1997;4 1[S uppl 111]:239 241. 408. Gerac i CL J r. Ope rati ng room po llution: gov ernmental pers pec tiv es and guidelines . Anes th An alg 1977;56:775 777 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 409. Mazz e RI. W as te anes thetic gases and the regulatory a genc ies . Anes thes iology 1980;52:248256 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 410. W es tpha l K , W ilke HJ , S trouhal U. Ex posu re of s urgeon to desflu rane and ni trous ox ide in i ntraoral operativ e p roc edures . Ac ta An aes thes iol Scand 1998;42:745. [Med li ne Link ] 411. Hend ers on KA , Matthews IP . An env i ronmen tal s urv ey of c ompl iance wi th Occ upati onal Expos ure S tandards (OES ) for a naes the tic gas es . A naes thes ia 1999;54:941947. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 412. B yh ahn C, W ilke H-J , S trouhal U, et al. Oc cupa tiona l ex posure to ni trous oxi de and d esflu rane d uring ea r-nose -throat-su rge ry. Can J Anaes th 2000;47:984 988.

[Med li ne Link ] 413. B yh ahn C, Kes s ler P , L isc hke V , e t al . Occupational expos ure to nitrous ox ide and d esflu rane d uring pedia tric s trabismus su rge ry . Anes thes iology 2002;96: A1256. 414. Hobb hahn J , Hoerauf K , Wi es ner G, e t al . W as te g as exposure durin g desflurane and isoflurane anaes thes ia. Ac ta A naes thesiol Sca nd 1998 ;42:8 64 867. [Med li ne Link ] 415. B yh ahn C, Lisc hke V , Mi erdl S , et al. Occupational ex posu re to s ev oflurane and n itrous ox ide duri ng pediatric anes thes ia and mask i nduc tion . Pos ter presenta tion, A SA Meeting, San Franc isc o, 2000. 416. Hoerauf K , Kol le r CH, W iesne r G, et al. Occ upational ex posure to sev oflurane and n itrous ox ide i n operating room pers onn el . Anes thesiolo gy 1994;81:A 553. 417. Hoerauf KH, W allne r T, Akc a O, et al . Ex posu re to s ev oflurane and ni trous ox ide duri ng four different me thods of anes thetic induc tion. A nes th A nalg 1999;88:925929. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 418. Hoerauf KH, Koller C, Taeger K , et al . Occ upati onal exposure to sev oflurane and n itrous ox ide i n operating room pers onn el . Int A rc h Oc cup E nv iron Heal th 1997;69:134138. [Cross Ref] [Med li ne Link ] 419. Hall JE , Hende rson K A , Ol dham TA , et al. E nv i ronmental monitoring during gaseous ind uc tion wi th s ev oflurane. B r J A naes th 19 97;79:342345. [Med li ne Link ] P .402

Questions
For the fol low ing ques tions , s elec t the co rrec t answer 1. T race a mo unts of the follow ing anesthetic agent ha ve been show n to have an effe ct on anes thesia pe rsonnel pe rformance in th e operating roo m? Halothane

Ni trous ox id e Enflura ne Isof lu ran e None of th ese V iew A ns we r2. Wh ich of the fo llow ing a nesthetic agents is most like ly to be associated with spontaneous a bortions in an imals? Halothane Ni trous ox id e Enflura ne Isof lu ran e Sev oflurane V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

3. T he follow ing measures a re necessa ry to minimize trace gas c oncen trations in the operating room: A scav eng ing s ys tem Changi ng work tec hniques E limination of leak s The room ai r c onditioning sys tem V iew A ns we r4. Gas-c ollecting devices need to be attac hed to Anes thes ia breathing s ys tems Pump ox ygenators Anes thes ia agent moni to rs Ven ti la to rs V iew A ns we r5. Parts of th e s cavenging system c onnec ted by the transfer tubin g include The interf ac e and an ads orp tion dev ic e The interf ac e and v enti la tor The interf ac e and th e room v en ti la tion sys tem The interf ac e and th e AP L v alv e

V iew A ns we r6. Passive dispos al assemblies include The room v enti la tion s ys te m. P iped v acuum sys tem P iping di rec tl y to atmosp here Duc t s ys tem wi th a fan V iew A ns we r7. P ossible p roblems ass ociate d w ith the use of piped suc tion systems fo r gas disposa l inclu de Inade quate numbe r of ou tlets Damage to the s uc ti on pump Vac uum s ys tem ov e rl oad Exp osure of pe rs onnel in other parts of the fac i li ty V iew A ns we r8. Componen ts con nected by the gas d isposal tubing include The interf ac e and an ads orp tion dev ic e The interf ac e and th e s uc tion s ys tem The interf ac e and th e v entil ation s ys tem The interf ac e and th e AP L v alv e V iew A ns we r9. The follow ing w ill redu ce expos ure of o pera ting room personn el to trace anesthetic gases: Us e of cuffed trachea l tubes Us e of high fresh gas fl ows Disconnec tion of the ni trous ox ide pip eline hose when the mach ine is not i n use Us e of ins uf fl ation tec hni ques V iew A ns we r10 . T he maximum time-w eighted average concentra tions to w hich a w orke r in the operating roo m sho uld be ex posed according to the Occu pational Safety a nd Health Adminis tration inclu de 5 ppm fo r halogenated agen ts 2 ppm fo r halogenated agen ts 180 p pm for ni trous ox ide 25 pp m for ni trous ox ide V iew A ns we r11 . Haza rds associated w ith s cave nging equipment include Negativ e press ure in the b rea thing s ys tem Mi scon nec ti ons Barotrau ma Ven ti la to r malfunc tion

V iew A ns we r12 . S ampling methods for determining trace gas concentrations include S ingle s hot Ti me-weig hted av erage End -tid al sa mp ling Urine s ampl ing V iew A ns we r13 . S iz e(s) of the inlet and o utlet fittings of the transfer tubin g include 15 mm 19 mm 22 mm 30 mm V iew A ns we r14 . Ways in w hich leak sites can be iden tified in clu de Application of a 50% soa p s olution to a c omponent Tes ting the capaci ty of the mac hin e to sus ta in press ure Us ing a ni trous ox id e anal yze r to c heck s uspec ted s ites Open ing the ni trous ox ide c yl inder a nd watching the p res sure dro p V iew A ns we r15 . When the low pressure s ystem is checked fo r lea ks, The preuse machi ne ch eckout wi ll rev eal even smal l l eak s The bag port and the Y-p iec e s hou ld be oc cl uded The v aporizers s hould be in the OFF pos iti on The leak rate s houl d be less than 1 L/minu te V iew A ns we r16 . Conce rning the room air c onditioning system, A i r exc hanges should be 2 5 to 35 per hour Rec irculating s ys tems are les s effec tiv e than non rec irculatin g s ys tems The f lo w s houl d be upwa rd rather th an down ward The anes thes ia mac hine shou ld be plac ed near the ex haus t gril le V iew A ns we r17 . P rob lems that co uld ca use positive press ure in the breathin g s ystem include Occ lusio n of the gas disposal assembly Mi ssas sembl y of the c onnec tion to the gas -disposal s ys tem Inc orrec t as sembl y of the pos itiv e pressu re re lief v alv e Application of su bambient pressure to the APL v alv e V iew A ns we rP .403

18. Conce rning monitors that can be used for detection of tra ce gases, Infrared anal yzers a re mos t often us ed to meas ure v ola ti le agents A carbon diox ide anal yzer c an be us ed to ch eck the effic ienc y o f scav eng ing wi th an op en interface The ioni zing leak de tec tor is bes t su ited to measure nitrous ox ide An ox ygen analy zer c an be used to moni tor th e s cav enging sys tem interfac e V iew A ns we r19 . Whic h factor(s) a ffect trac e g as conce ntrations in the ope ratin g room? Roo m v entil ation s ys tem Duration o f the anes thetic Fres h gas f low The type of s urgery bei ng perfo rmed V iew A ns we r

Chapter 14 Hazards of Anesthesia Machines and Breathing Systems

A l though enormous s trides hav e been mad e i n imp rov ing the sa fety of anes thes ia apparatus , probl ems conti nue to be reported . S tudies show that human error i s more freque nt than equipme nt failure (1,2,3,4,5 ,6,7,8,9,10,11). This chapter wi ll exami ne hazards of anes thes ia mach ines and breathing s ys tems f rom the pers pec tiv e of thei r ef fec t on the patient. Many ex amples are g iv en, bu t these s houl d not be c ons ide red a co mple te l is ting of a ll poss ible dangers . Many hazards inv olv e ol der apparatus th at may hav e been modifie d and is no lon ger s old or s erv ic ed by the ma nufac turer. A disc uss ion of anes thesia machine obs olescenc e i s fou nd in Chapte r 5.

Hypoxia Hypoxic Inspired Gas Mixture

Incorrect Gas Supplied Piping System
The wrong gas may be supp li ed to the ce ntral ox ygen supply (12,13,14,15,16,17,18,19). Crossov ers between ox ygen and other gas es may oc cur i n the piping s ys te m (20,21,22,23). During or fo ll owi ng c ons truc ti on or repai r, a pipel ine may be fil le d wi th air o r ni trogen rather than ox ygen (24,25). A gas mixer, anesthes ia machi ne , or v enti lator may allo w a c ross ov e r and contamina te one p ipeline gas with the c ontents of th e oth er (26,27,28,29,30,31,32,33,34). If the oxygen pressu re is l owe r than the other gas , that gas may enter the oxy gen pi peline. Ins ide the operating room, inco rrec t outlets may be ins tal led (35,36,37,38,39,40,41,42). A te rminal u nit may acc ept an inco rrec t c onnec tor (43,44,45,46,47,48). A n i ncorrec t co nnec tor ma y be pl aced on a hose (49,50,51,52,53,54,55) o r the pipeli ne inlet of the anes thesia mach in e (40). It may be poss ible to attach an ox ygen tu bi ng or hose to the outle t from an air flowmeter (56,57,58,59). If it is suspec ted that the pipe line oxygen sy s tem is del iv ering les s than 100% ox ygen , it is i mportan t to open an ox ygen cy linde r AND to disco nnec t the ox yg en pipel ine hos e. If the pipe li ne hos e is no t discon nec ted , gas f rom the piping s ys tem

wi ll s ti l l be deliv ered. If the cause of a low ox yg en conc entrati on is not obv ious and the si tua tion is n ot co rrec ted by disconnec ting the oxy gen pi peline hose an d opening an ox ygen c ylinde r, the patient s hould be v en ti la ted wi th room ai r by us ing a manua l resus citation bag (Chapter 10 ).

Cylinders
It is possible for a c yl inder label ed ox ygen to c on tain ano the r gas (60,61,62,63,64,65). A c yl inder may be painte d a c olo r other than that normal ly us ed for a particular gas . Care shou ld be taken wh en us ing c y linde rs in o ther countries , because four different c ol ors (green, wh ite, b lue , and blac k ) are used around the world f or ox ygen (66). In a c ylind er con taining a mix tu re of two gas es , i ncomplete mix ing ma y res ult in a hypox ic mix ture bei ng del iv ered (67,68). Such a c ylinde r may requi re 45 minutes of rotati ng before mix ing is compl ete. Des pite almos t univ ersal use of the Pin Index S afe ty S ys te m, reports of inc orrec t c ylinde rs be ing c onnec te d to yok es con tinue to appear (69,70,71,72,73,74,75,76,77,78 ,79 ,80 ,81,82). A n inc orrec t yoke bloc k ma y be i nserted (83 ,84 ). A pin may bec ome unsc rewe d from the yoke (85 ).

Crossovers in the Anesthesia Machine

Crossov ers between ox ygen and other gas es can oc cur ins ide the anes thesia machine a nd are espec iall y lik ely if th e machine piping has be en al tered (4 9,86).

Hypoxic Mixture Set Flow Control Valve Malfunction

A flow c on trol v alv e malfunc tion may resul t i n mo re or l ess gas being del iv ered. If the ox ygen fl ow c on trol v alv e is dama ged an d the flow i s dec reas ed, h ypox ia c an resul t (87,88,89). If the f lo w c ontrol v alv e for ano the r gas malfunc tio ns in s uch a way that excessiv e gas is del iv ered, hypox ia c oul d a ls o resu lt.

Incorrect Flowmeter Setting

Some older anes thesi a machines do no t hav e a minimum ox ygen rati o dev ice th at prev ents the use r from dia li ng a hypox ic fresh gas mix ture. On these mac hines , a hypoxic mix tu re can be c aused by partl y or full y clos ing the oxy gen f low c ontrol v alv e, whi le a ll owi ng the nitrous oxi de f low to c ontinue (9 0,91,92,93). Absence of a minimum ox ygen ratio dev ic e is one of the c ri teri a fo r machine obsolesc ence (Chapter 5). Unfortunately , many anes thes ia mac hines in s erv ic e s ti l l lack th is dev ic e (94 ). There may b e p rob lems wi th the mi nimu m ox ygen ratio dev ic e

(95,96,97,98,99,100 ,10 1,102,103,10 4,105), or the mac hine may hav e add itional gases that are not inc orp ora ted into the mini mu m ox yge n ratio dev ice. Ox ygen flow ca n be inadv ertently lowered (o r the flo w o f another gas i nc reased) if the flow c on trol knob is inadv erten tl y ro tated by an i te m on the surfac e below (1 06) or b y a hose or wi re al lowed to drape around it. W i th some f lowmeters , in and out mov ement of the f low c ontro l v alv e ca n c hange the f lo w s ignif icantl y (107 ). Someone hel pi ng to mov e the mac hine could grab a flow c ontrol v alv e k nob and change the flow (F ig. 14.1). Mos t ne w mac hi nes hav e a guard ov er o r around the f low c ontrol v alv es to p rev ent this problem. The abil i ty to deliv er 100 % ni trous ox ide was fo und in an a nes thes ia machine where the tub in g to the c ommon gas outlet b ecame k ink ed (108,109). In this cas e , P .406 the ni trous ox ide regul ator wa s s et at a h igh er press ure than the ox ygen regulator, whi c h caused ni trous ox ide to preferential l y pass through the tubing.

Figure 14.1 A dangerous practice. The flow control knob may look like a good thing to grab to someone moving an anesthesia machine. Flows may be altered in the process.

View Figure

Incorrect Flowmeter Reading

On some ol der machines , the flowmeter i ndicator c an disapp ear f rom v iew at the top of the tube when the fl ow of gas exceeds th e max imum s cale cal ib rati on. S uch a flowme ter is v ery si milar i n appearance to one wi th the ind ic ato r res ting at the bottom. If the f lowmeter carri es a gas o the r th an ox ygen, a hypox ic mix ture may resul t.

If an ai r fl owmeter is presen t on a machine, dialing ai r i ns tead of oxygen can resul t i n a h ypox ic mix ture (110). To prev ent this , mos t mo dern anes thes ia machines do not allow adminis tra tion of ai r and nitrous ox ide wi th out addi tional ox ygen fl ow.

Inaccurate Flowmeter
Causes of fl owmeter i nacc urac y i ncl ude di rt, greas e, or o il on the indicator o r tu be; a s tuck or damaged indic ato r; misali gnmen t of the tube; s tatic e lec tricity; i mprope r ca li brati on ; the s top at the top of the tube fa lli ng down onto the indic ato r (Fi g. 14.2); and transpos i tion of i ndica tor, sc ale, or tube (111,112 ,113,114,115 ,116,117).

Oxygen Lost to Atmosphere

If there is a leak a t the top of the ox ygen fl owmeter tu be, oxygen wil l be prefere nti al l y los t, ev en if the ox ygen fl owmeter is downs tream of the other f lowme ters (118,119,120,121,122,123 ). The posi tion of the indica tor ma y not be af fec ted. Of ten, the defec t c anno t be seen u ntil the tube is d is assemble d. Other leak s in the anes thesia machine c an resu lt i n hyp oxia, the magni tude of whi c h wi ll depend on th e s ize of th e l eak a nd its locatio n (121,122 ,124,125,126,127,128,129). It is importa nt to use a yoke p lug in any yoke not contai ni ng a P .407 c ylinde r s o that gas wi l l not leak out of the y oke if the f low c ontrol v alv e to that yoke is open.

Figure 14.2 The stop at the top of the flowmeter tube has broken off and fallen onto the indicator. The flowmeter will read less than the actual flow.

View Figure

Air Entrainment
If the p res sure in the breathing s ys tem falls bel ow atmosphe ric , ai r may be d rawn i nto the s ys te m through a leak or disc onnection . Suba tmos pheric p res sure may be caus ed by the pati ent's insp iratory effort; suc tion appl ied to an enteric tube i nadv ertently placed in the tracheobronchial tree or to the work ing channel of a f ibe rs cope in the ai rway; a problem wi th a cl osed s cav enging s ys te m interface ; a v enti lato r wi th a hang in g bellows ; a pis ton venti lator; or a si des tream gas an al yzer wi th a l ow f res h gas flo w (130 ,131,132,133,134,1 35,136,137 ). Ai r can enter th e breathi ng s ys tem if the v entilator be ll ows is imprope rl y con nec ted or has a hole (138,139 ,140,141,142,143,144) or the f res h gas flow i s direc ted to the wrong ci rc ui t (145). In many c as es , ai r en trai nment is manif es ted by a dec rease in an es thetic agent as wel l as oxygen c onc entrations (1 35,146).

Hypoventilation Causes
Insufficient Gas in the Breathing System Low Inflow
Pipeline Problems
Loss of pipel ine oxy gen press ure was d is cuss ed in Ch apter 2. Caus es inc lude dama ge during c ons tructio n, debris in the line follo wing i ns tal lati on, unannounced

s ys tem s hutdown, press ure regulato r malfunc tion , cen tral suppl y s ys tem malfunc tion, a dis rupted line betwee n the ce ntral s upply and the pi pi ng s ys tem, co mp res sor f ai lure resul ting f ro m an el ec tric al s torm, fi res , an d a c losed isolation v alv e (51,147 ,148,149,150 ,151,1 52,153,154,1 55,156,157 ,1 58,159). A s tation ou tlet may become block ed or not accept a quick c onnec to r (1 59,160). A hos e may dev elop a leak , become b loc ked , or dev elop a ki nk tha t obs truc ts gas f low (152,161 ,162,163,164 ,165,1 66,167). Th e anesthes ia mac hi ne may rol l ov er a hose, oc c luding gas f lo w (164 ). The chec k valv e at the pi peline inlet o f the anes thes ia mach ine may malfunc tion (168), or the filter ma y b ecome c log ged, reduc ing gas flow (1 69). If pi ped oxygen press ure is los t, an oxy gen c ylinde r s hou ld be opened and the pipel ine hos e dis connec ted from the wa ll to prev en t flow from the c ylind er into the pipel ine. To minimize ox yg en use, a g as -powered v enti lato r should b e turned OFF (this is n ot nec ess ary if an elec tric all y powere d p is ton v entilator is being used ), manu al or s pontaneous v entil ation ins ti tu ted , and the fresh gas flow lowere d as much as p oss ible. If open in g an oxygen c yli nder does not rep res suriz e the anes thes ia mac hin e, then there is a problem in the machine's high or intermed ia te press ure s ys tem o r th e c ylinde r is emp ty or n ot prope rl y conn ec ted (1 64). A resusc i tation bag s hould be us ed to v enti late the patient unti l anoth er mac hin e c an be obtained .

Figure 14.3 Failure to remove the dust protection cap from a cylinder before installing it on a machine caused a portion of the cap to be pushed into the cylinder valve port, and this blocked the exit of gas from the cylinder.

View Figure

Cylinder Problems

A c yli nder ma y be empty a t deliv ery o r af ter us e. T he c yl inder v alv e may be i nope rab le, or the v alv e outlet may be bloc ked (1 70,171,172,1 73). Before a c yl inder c an b e used, it mus t be co rrec tly ins tal led on th e machi ne. Of ten, the mos t inex perienced pe rs on in the operating room is told, wi thout s ufficient i ns truc ti ons , to repl ac e an empty c ylinder. He o r she may fai l to c rac k the v alv e; i ns tal l the c ylinder wi thout a was her, wi th a damaged washer, or wi th two wa s hers ; fail to remov e the dus t pro tec tion ca p (Fig. 14 .3); or fail to chec k tha t th e c yl ind er i s full . Another error is to penetrate the s afe ty relief v alv e on the c yl inder v alv e with the retaining sc rew on the yoke (174). It is s ometimes possible to spot an i ncorrec tly plac ed cyl inder s impl y by look ing at it. An i mp roperl y ins tal led c yl inder may hang at an angle ins tea d of paral lel to the mac hi ne and perp endicu lar to the f loo r (F ig. 14.4). The f ac t tha t a ful l c ylinder is p res ent on an anes thes ia machine does not mean that there wil l be ox yge n av ai lable wh en needed. F irs t, there mus t be a means of opening the c ylinder. A g ood prac tic e is to c hain a handle to each mach ine s o tha t i t wi ll a lwa ys be th ere whe n neede d. A c yli nder ma y be empty , and there may not b e another one av ai lable to replace i t. This should be determined du ri ng th e preuse c heckout (C hapter 33 ). Th e amount of ox ygen that needs to be in the c yl inder depends on the c linic al s i tuati on. If there is a s ingle yok e for ox yge n on the mac hine and the c ylin der is to be the P .408 prima ry s ourc e of oxy gen f or the a nes the tic, the c ylinder needs to be fu ll and the numb er of addi tiona l cy linde rs immediate ly av ai lab le needs to b e dete rmi ned (175). If the p ipeline is to be the primary ox ygen supply , the oxygen c yli nder is the back up for th is s ource. In this case, i t is likel y th at a qua rter- to half -full c yl inder i s adequate. The anes thes ia prov ider mus t be watc hful of the c ylinder press ure gauge whe n c heck ing or us ing the c yl inder as the pri ma ry ox ygen s ourc e to de termine how much ox yge n remains in the c yl inder.

Figure 14.4 A sure sign that a cylinder is not correctly fitted in its yoke is that it hangs at an angle to the machine rather than perpendicular to the floor.

View Figure

Anes thes ia machines hav e a number of wa ys th at warn the anes thes ia prov ide r tha t the ox ygen cyl inder has bec ome ex haus ted. Ma ny anes thes ia prov iders do not recognize when this occurs and furthermore do not k now how to reac t to the problem (176). This has been a ttributed in part to the fac t that an esthes ia tec hnic ians usua lly maintain the c yli nders on the machine and that many anes thes ia prov iders do not hav e ex perience wi th changing c y li nde rs . This s lo ws thei r re ac tion during an eme rgenc y si tuation .

Machine Problems Obstruc tion

Obs truc tion to gas f lo w i n th e anes thes ia mac hine may be caus ed by probl ems in the ox ygen fl us h v alv e, f low c ontrol v alv e, yoke , or v aporiz er co nnec tions (117,177 ,178,179,180,181,182,183,184 ).

Leaks
If the c heck v alv e in the pipel in e i nl et of the a nes thes ia mac hine fa ils , gas may fl ow i nto the room (if the p ipeline hose is disc onnec ted) or i nto the p iping s ys tem (if the hose is c onnec ted) (1 85,186,187). Gas can be l os t through a broke n f lowmeter tube or an open f low c ontrol v alv e with an openin g to atmosphere ups trea m of the f lowme ter (12 1). Leaks can occur in the machi ne piping (1 88,189); at a l oos e or defec tiv e v apori ze r connec tion (190,191 ,192,193,194,195,196,197,198 ,199,200,201 ,202,203,204 ,205,206); a

l oose , def ectiv e, o r absent v aporiz er f ille r cap or d rai n sc rew (2 07,208,209) (F ig. 14.5); or a defec t in the v apori ze r itse lf (210 ). Va porizer l eaks do not manifes t themse lv es until the v aporizer is turned ON. These c an b e P .409 disc ov ered if the v aporizer is turned ON duri ng the c heck out proc ess (Chapter 33 ). Some mac hines are desi gne d s o tha t when a v apori ze r is remov ed, a manifold c ap mus t be pl aced wh ere the v apo ri zer was s i tua ted. Fai lure to do so wil l resu lt in a maj or leak . The press ure rel ief dev ice on the mach ine may v ent f resh gas if downs trea m resis tanc e c aus es the pres sure to ri se (211,212 ).

Figure 14.5 When the block on the filling block is not in place, there will be a leak when the vaporizer is turned on.

View Figure

Gas Supply Switched OFF

The main ON-OF F s witch on the machine may be acc iden tal l y turned to the OFF position (213,214,215 ,216,2 17). Some mach in es hav e a two-posi tion s witch to turn i t ON. One position places the machine in standb y, whi ch enables onl y the elec tric al portion of the mac hine, wh il e the othe r ac tiv ates both the elec tric al and pneumatic portions of the mach ine . If it is not noticed tha t the s witch is in the

s tandby pos ition, f res h gas wi ll n ot be de livered. Newer mac hi nes hav e a s imp le s wi tch that enables al l fu nc tions .

Problems with the Fresh Gas Supply

The f resh gas hose can be de tac hed, occ lud ed, dev el op a le ak , o r be attac hed to the wron g pos i tion (131,150 ,172,218,219,220,221,222,223 ,224,225,226 ,227,228,229 ,230,231). The i nner tube of the Ba in or Lack s ys tem, which c a rries the f res h gas flow, c an bec ome obs truc ted (232,233 ,234). W hi le mos t anes thes ia machines hav e one fre sh gas ou tlet that s uppli es gas to the breathi ng (usual l y c irc le) s ys tem, s ome have a sec ond outlet that c an be used wi th other types of breathing sys tems . A haza rd of this des ign is th at gas may f low through the auxi liary outl et when i t is not intende d to be in use (2 35). Hav ing an i nte rl ock to c lose this s econdary outle t is on e s ol ution to this problem (236).

Excessive Outflow
Breathing Sys tem Leaks
Mos t breathin g s ystem le aks are too small to be of c linical significance, but some are large enough that the pati ent c anno t be adequatel y v enti lated, espec ially if lo w f res h g as fl ows are used. Leaks also cause pol lution of operating room ai r (Chapter 13). A common loca tion fo r le aks in the c i rc le s ys tem is the abs orber. If the can is ters do not fi t together p rop erl y, a large leak can resul t (237,238,239,240,241 ,242,243). A canis te r may bec ome dis engaged f rom the a bsorber (150,244,245,246 ). Leaks h av e been rep orted in h umid ifi ers , respi ratory v olume meters , breathin g tubes , e lbo w adapters , bags , temperature probe s i tes , c onnec tors for res pi rato ry gas anal yze rs or p res sure moni tors , bag/v entila tor s el ec tor v alv es, fil ters , hea t and mois ture ex changers (HMEs ), ox ygen an al yzer adap tors , adjus table pressure li mi ting (A P L) v alv es, the reserv oi r bag mount, and Y-pieces (150,247 ,248,249,250,251,252,253,254 ,255,256,257 ,258,259,260 ,261,262,263,26 4, 265,2 66,267,268 ,269,270,271 ,27 2,273,274,275,2 76,277,27 8,279,280,281 ,28 2,283,2 84,28 5,286,287,288,289,290,291 ,292,293,294 ,29 5,296) (Fig. 14.6). The c ap for the gas s ampl ing l ine to a s ides tream gas anal yzer a ttachment may become los t (297,298 ). A hea ted h umid ifie r may mel t a hole in a breathing tube (299,300 ,301,302). The A PL v alv e may fail to c lose (303,304 ,30 5,306,307,308). This l eak may not be easil y found , because the ex haus ted gas wi l l fl ow i nto the scav enging s ys tem. The

transfe r tu bing ma y need to be remov ed from the A P L v alv e to de tec t the p roblem (308,309 ). Mos t presen t bag /v entil ator sel ec tor v alv es cause the AP L v alv e to be ex c luded f rom the s ys tem when s wi tched to the automatic mode or when th e v enti lato r is turned ON. W i th older machi nes whe re the APL v alv e is not ex cl uded , the user may forget to clos e i t whe n s witching to automatic v entil ation .

Figure 14.6 Parts of the breathing system may have holes in them when they are received from the manufacturer.

View Figure

A leak may occ ur i n a v entil ator (310,311 ) or i n i ts a ttach ment to the breathi ng s ys tem (312,31 3,314). If the pilot l in e becomes d is connec ted or k ink ed durin g ex piration, the spi ll v alv e ruptures o r bec omes s tuck in the o pen pos ition, or the ex haus t v alv e mal func tions , gas can be los t (315,316,317,318 ,319). A large le ak wi ll occu r if the bag/v entilator s witc h is placed i n the v entil ator pos ition with no connec tion to the v en til ato r (320). A defec tiv e nonrebreathing v alv e or misasse mb ly of a manual res usci tato r c an resul t i n part or al l of the gas v olume leav ing the b ag during i ns piratio n and es caping to a tmos phere (321,322,323 ). Mos t leaks can be d etec ted by the p reuse check. Many rep orted leaks inv olv e equipment that wa s added after the c heckou t was perf ormed (287,32 4). It is i mportan t th at al l eq uipment that is to be used duri ng a c ase be i n place before the preus e c hec kout is perf ormed . Chec k ing is disc uss ed in more detail in Ch apter 33. Leaks may oc cur du ring an anes thetic (252). S uc h a leak may b e ev ident by a low ex pired v olume or an inc re ase in e nd-tidal carbon diox ide. Wi th a s tanding bello ws v enti lato r, the bel lows may not return to i ts full y expande d pos i tion (325), and the re may be a change in the v entilator sound. An airway pressu re moni tor

P .410 may alarm wi th a leak bu t can not be rel ied o n, espec ial ly if the leak is no t large o r the alarm li mi t is s et l ow (258 ,326). W hen a l eak is s uspec ted, a s ys tematic se arc h of the anes thes ia machine and breathi ng s ys tem s hould be made, follo win g the route of gas trav el . It may be easie r to de tec t a leak if glov es are not wo rn (279). A l eak c an s ome times be l ocated by plac ing alc ohol o n the hands and mov ing the ha nds ov er componen ts whi l e gas flow i s occurri ng . The l eaki ng gas ev apora tes the alcoh ol and c ools the sk in.

Disconnections
A discon nec tion is an unin tended separation of components (327). Dis connec tions i n b rea th ing c ircui ts a re among the mos t c ommon type of p rev entabl e anes thetic mishap inv olv ing equi pment (1,2,11,238,328 ,329). Mos t b rea thing s ystem connec tors are s lip fi ttings that rel y on fric tion to h old them to gether. They wil l co me apart if s uffic ient tens ion is app li ed. If the connec ti on is under a drape , th is wi ll make it diffic ult to spot the dis con nec tion (32 9,330). Disconnec tions c an occu r any where in th e bre ath ing s ystem. Th e mos t c ommon s ite i s between the breath in g s ys tem and trac heal tube c onnec tor or HME (1 ,331,3 32). Disconnec tions are of ten as soc iated wi th a third party interfering with the breathi ng s ys tem and with surgery on the head and neck (238). Disconnec tions c an be made l ess f requent b y maki ng sec ure co nnec tions . Connec tors with lugs or other features that mak e them eas y to grip may be e asier to ti ghten. Push and twis t (wrung ) connec tions are much s tron ger than those made wi th a s tra igh t pus h (333 ). Metal -to-metal or p las tic -to -plas tic joints are s tronge r than metal-to-plas tic join ts (334). Antidis con nec t dev ices f or b rea thing s ys tem c omponents hav e been desc ribed (327,335 ,336). Lock ing c onnec to rs us e a mechan ic al means to ens ure that the connec tors do not sepa rate unde r any forc e tha t is c ommon durin g use. Many believ e that they s houl d not be us ed at the connec tion between the trac heal tub e connec tor and the b rea th ing s ys tem, reaso ning tha t it is safer for s uch a union to co me apart unde r tensi on than for the tracheal tube to be pu lled out of the patient (337). It may be nec essa ry to make a dis con nec ti on rap idl y at this point for suc tion ing o r to re li ev e a high press ure i n th e b rea thing sys tem. Latch ing connec tors are s imi lar but a re designed to break awa y wi th a certain

disc onnec ti on forc e (32 7). A dhes iv e tape is sometimes us ed to prev en t disc onnec ti ons . Unfortun ate ly , ta pe can prev ent the disconnec tion from being seen , i nhibi t reconnec tion, and c ause an obs truc tion (327). The anes thes ia works tation s tandard (3 38) requi res tha t the work s ta tion be prov ided wi th a n a la rm tha t is ac tiv ated i n the ev ent of a c omplete disconnection in the breathing s ys tem. Al arms cons idered to comply wi th this requirement inc lude a l ow air way press ure a larm, a lo w ex haled ca rbo n d iox ide ala rm, and a low v ol ume alarm. Thes e dev ices a re discussed in Chap ters 22 and 23 . W ith spon tan eous breathi ng, no mov emen t of the res erv oi r bag wi ll be seen if a disconnec ti on oc curs (339).

Negative Pressure Applied to the Breathing System

If the a ir i nl et v alv e of a cl osed s cav engi ng i nte rface or the opening to atmosp here of an o pen inte rf ace becomes bloc ked or the inte rf ace is omitted, a su batmospheric press ure may be trans mi tted ac ros s a n open APL v alv e to the b rea thing s ys tem (339,340 ,341,342,343,344). If suc tion is appl ied to the work ing c hannel of a f ibers cope passed into the a irway or to an enteric tube that has entere d the trac hea rath er than the esophagus , respi ra to ry gas es wi ll be remov ed rap id ly f rom the lungs and breathi ng s ys tem (132,345 ,346,347).

Improper APL Valve Ad justment

W hen manual ly control led or as sis ted v entilation is us ed, gas is v ented from the s ys tem during inspi ration (unless a c losed sys tem technique is used). Part of the gas dis placed f rom the bag goes to the patien t, and the res t is disc harged from the breathi ng s ys tem. The person s queez in g the bag ma y find it dif fic ult to es timate how muc h g as is ente ri ng the patien t and ho w muc h is es caping to a tmos phere. Hypov enti lation c an occu r if too much gas esc apes through the v alv e.

Blocked Inspiratory and/or Expiratory Pathway

A partial o r complete bl ock in the breathing s ys tem c an res ult in hypov entil ation . In mos t cas es , the problem c an be detec ted before the c ase has begun by h av ing the anes thes ia prov ider o r th e patien t breathe through the s ystem (348 ). Lack of obs truc tion to breathing, a s atisfac tory c apn ogram, and rese rv oir b ag mov ement shoul d be s een . It is importan t that al l equip ment that is planned to be us ed for the case is in place in the s ys tem wh en the preuse c hec ki ng is performed, as added equipment may c ause an obstruc tion (3 49,350,35 1,352).

Causes of b rea thing sys tem o bs truction i nclude manufac turing defec ts ; foreign bodies (e.g., caps , plas tic wraps , tape); miscon nec tions ; blood; s ec retions ; or o ther problems (260,267 ,297,349,350,351,352,353,354 ,355,356,357 ,358,359,360 ,361,362,363,36 4, 365,3 66,367,368 ,369,370,371 ,37 2,373,374,375,3 76,377,37 8,379,380,381 ,38 2,383,3 84,38 5,386,387,388,389,390,391 ,392,393,394 ,39 5,396,397,398,399,400,401 ,402,40 3,404 ,405,406,407,408,409,410). Obs truc tio n can resul t if th e s eals on a disposable abs orbent p ackage are not remov ed , from occ lus ions in the holes in the top and bottom panels , o r from c ompac ted a bsorbent (150,411,41 2,413,414,415 ) (Fig . 14.7). A pos itiv e end-exp irato ry press ure (PEEP ) v alv e may s tic k in th e closed position (351,383 ,410). Connec ti ng a fl ow-di rec tion -sens i tiv e component such as a PEE P v alv e o r humidifi er in rev ers e wil l res ul t in littl e o r no flow (4 16,417,418). If the bag/v entilator se lec to r v alv e is lef t in the wr ong posi tion when au toma tic v en tila ti on i s ini tiated , complete obs truc tion to gas f low wi l l re sul t. A n HME or f ilter c an become obs truc ted (3 32,419,42 0,421,422,423 ). B reathi ng tubes can become obs truc ted f rom k ink ing or twi s ting (424) (Fi g. 14.8 ), as ca n the reserv oi r bag neck P .411 (425,426 ) (Fi g. 14.9 ). A hea ted h umid ifie r may cause th e tubing to me lt and bec ome obs truc ted (427) (Fi g. 14 .10 ).

Figure 14.7 Prepacked absorbent container. Failure to remove the label from the top and/or bottom will result in obstruction to flow through the absorber.

View Figure

Ventilator Problems
Hypov enti lation s econd ary to v entila tor p rob le ms is discussed in Chap ter 1 2. Causes inc lude c yc ling f ai lu re, leaks of d rivi ng or breathing s ys te m gas , i napp rop riate s ettings , and the v enti la tor bei ng turned OFF . If a n anes thes ia machine is turned OFF and th en turned ON aga in , the v entilator may defau lt to se ttin gs that are d ifferent from th ose origina lly s et (428).

Figure 14.8 Kinking of a breathing tube.

View Figure

Detection
Vigilance aids used to detec t hypov en tila ti on inc lude ai rwa y pressure, resp iratory v olume , and ca rbon d ioxi de moni tors . T hese are discussed in Chapters 22 and 23. An ox ygen analy zer ma y detec t s ome dis con nec ti ons (238,429,430) but shou ld not be relied on , bec ause i t is effec tiv e in on ly a l imi te d set of c i rc ums ta nces . The low temperature al arm on a he ated humidif ier may s ignal loss of gas flow in the breathi ng s ys tem (238). Bec aus e an y s ingle monitoring modal ity may f ail to detec t a probl em, i t is adv isab le to use more than one (428 ,431,432,433 ). As s tated prev ious ly, obs truc tions in the bre athing s ys tem are bes t de tected b y breathi ng th rough the s ys tem before i t is used bu t af ter a ll components tha t wi ll b e us ed are in place. T he checkou t proced ure is discus sed in Chapter 33 .

Response to Hypoventilation

W hen hy pov entilation occurs durin g mechanic al v entil ation, the fi rs t s tep should be to s witc h to manual v enti lation (434,435,436 ,437). The anes th esi a prov ider c an then determine wh ether or not breathing s ys tem resis tance an d compl ianc e is normal and if the re is adequate gas in the bre athin g s ystem. If manual v enti lation can be us ed to v entil ate the p ati en t satis facto ri ly , the proble m probably l ies wi th the v enti la tor o r v en ti la tor c ircu it. If the problem cannot b e d iagnos ed or correc ted quick ly , manual v enti lation c an be continued or a backu p anes thesia mac hi ne brought in. If manua l v en ti la tion sh ows obs truc tio n to ven ti la tion, the nex t s tep is to attach a resus ci tati on bag to the ai rwa y dev ice (mask , trache al tube, or s upraglo ttic dev ice). If it remai ns diffic ul t to v enti late the patien t, the problem is probably wi th the ai rway dev ic e or wi th the patie nt. Compl ic ations related to s upraglo ttic a irways and trac heal tubes are dis cuss ed in Chapters 17 and 19. If manua l v en ti la tion sh ows that there is gas f lo w i nto the breathi ng s ys tem, but i t is not adequate to v en til ate the pati ent prope rly, the fres h g as fl ow should b e i nc reas ed. If inc reasi ng the fresh f lo w does not a ll ow ade quate v en tila tion, a resus ci tati on bag shoul d be used . If adeq uate v entilati on can be ac hi ev ed by us ing a res usci tati on bag, the tubing to the bag should be connec ted to the anes thes ia machi ne ou tl et, if poss ib le. Ins pi red gas monitoring s hould be continued, if pos si ble. This wi ll dete rmine if the resus ci tati on bag is being supp lied f rom the anes thes ia machine or room air. If th e resus ci tati on bag cannot be c onnec ted to the machine ou tlet or the re is no flow f rom the anes thesia machine, a so urc e of ox ygen should be con nec ted to the P .412 resus ci tati on bag and a nes thes ia maintained by us ing intrav enous agen ts .

Figure 14.9 Twisting has caused this bag to become obstructed. Many bags have a guard in the neck to prevent this.

View Figure

Af ter adeq uate v entil ati on and anes thes ia lev el h av e been established , the c aus e of the problem c an be inv estigated. A second k nowl edgeable pers on shoul d be s ought and s eri ous c ons ide ration giv en to b ringi ng i n a s econd anes thes ia mac hine, if this has not al ready been done . Ev en if the problem c an be fou nd, i t may no t be possible to correc t i t quick ly .

Figure 14.10 Contact with a heated humidifier can cause a breathing tube to melt and become obstructed.

View Figure

Hypercapnia

Hypoventilation
Hyperc apnia can be the resul t of h ypov entilation, wh ich wa s dis cus sed prev ious ly . Ins pi red c arbon diox ide wi ll be zero if h ypov entilation is the sole cause of hypercarbia. Other c auses of hype rc apnia mentioned bel ow are associated wi th a n i nc reas ed ins pi red c arb on diox ide c oncentra tion.

Inadvertent Carbon Dioxide Administration

A few anes thes ia mac hin es are equi pped wi th a ca rbon dioxi de c yl inder and f lowme ter (43 8). This f lowmeter may be ac ci dentally turned ON but no t notic ed, es pecial l y wh en the ind ica to r is at the top of the tu be (439). A n apparentl y OFF f lowme ter may leak carbon dioxi de into the breathi ng s ys tem (440). In one reported case, a ni trous ox ide hos e wa s conn ec ted to the carbon di ox ide s tatio n outlet (441). A c ylinde r may be mis takenl y fi lled with carbon di oxide (65).

Rebreathing without Carbon Dioxide Removal

Absorbent Failure or Bypassed Absorbent
It is important to wa tc h for the app earance of c arbon diox ide i n the insp ired gas . The s mall er c anis ters on s ome new mac hines hav e a s horter l ife span than the l arger ones on older mac hines . Hypercarbia can occ ur if channel ing allows g ases to bypass the abs orbent (150 ,442).

Bypassed Absorber
An abs orber bypass allows some o r all of the exhaled gases to bypass the absorbent. Unintentional ac tiv ation P .413 of this bypass can lead to hyperc arbia. The abs orb er may be defec tiv e so that gas f low i s not di rec ted th rough the absorben t (4 43). Mos t new a nes thes ia breathi ng s ys tems tha t hav e s mall abs orb ers al low the c anis te r(s ) to be c hanged wi thout the breathi ng s ys tem integri ty being in terrupted. It i s p ossible that the anes thes ia prov ider ma y not no tice that a ca nis te r is l oos e o r mis sing. Some anes thes ia prov iders in tentiona ll y remov e the canis ter to allow c a rbon d iox ide to inc reas e i n the breathing s ys tem at the end of a c ase. T his ma y n ot be no ticed by the nex t anes thes ia prov ider.

Figure 14.11 Damaged unidirectional valve leaflet.

View Figure

Unidirectional Valve Problems

Correc t mov ement o f gas es in a ci rc le sys tem depends on properly func tioning unidi rec tional v alv es. If they do no t c los e prope rl y, rebreathi ng wil l oc cur. The disc may become displace d, wet, s ticky , or dama ged so that i t wi ll not s eat prope rl y (150,444 ,445,446,447,448,449,450,451 ,452,453,454 ,455,456,457 ,458,459) (Fi g. 14.11 ). The dis c ma y not be replac ed after remov al for cl ean ing or s erv icing. The cage holding the dis c ma y bec ome dis lod ged (460,461). Unidi rec tion al v alv e p rob lems c an be discov ered preoperativ ely duri ng the breathi ng s ys tem c heckout (Chapter 33). P roblems wi th the unidi rec tional v alv es may be indicated by a respi ro mete r indicatin g rev e rse d fl ow (Chapte r 23), a rise in the inspi red c arbon di oxide abov e zero (Cha pte r 22) o r a c apnogra m wi th a sl an ting downs trok e (Fi g. 22.32). P res sure-v olume lo ops (Chapter 23 ) may also indicate this problem.

View Figure

Figure 14.12 Possible problems with the inner tube of the Bain system that can result in hypercarbia. The fresh gas supply tube can become detached (A), the inner tube can become kinked or develop a leak (B), and the inner tube may not extend to the patient port (C).

Problems with Nonrebreathing Valves

Improperly as sembled or s tick y nonrebreathi ng v alv es c an res ul t in pa rtial or total rebreathing. Th is is dis cus sed more ful l y i n Chap ter 9.

Inadequate Fresh Gas Flow to a Mapleson System

In s ys tems wi thout ca rbo n d ioxi de abso rpti on, a low fres h gas f low c an resul t in dangerous rebreathing (Chapter 8). Reported c aus es incl ude the fresh gas f low being s et too low; a l eak o r obs truc tion in the machine, c ommon gas outlet, f res h gas s uppl y l ine , or a v aporizer; o r an empty c yl inder (263 ,462,4 63,464,465).

Problems with Coaxial Systems

In Maples on s ys tems in whi ch the fresh gases are deliv ered to the dis ta l end of the s ys tem by an inner tube, rebreathing wi ll occur if the inner tube is av uls ed, dama ged, k inked , or omi tted; has a leak at the mach ine en d; or does no t ex tend to the patie nt port (233,466 ,46 7,468,469 ,470,4 71,472,473,474,475,47 6) (F ig. 14.12). If the inne r tube of a coaxial c i rc le s ys tem is displac ed or dev elops a l eak , an i nc reas e in inspi red c arbon dioxi de wi ll be seen , as prev ious ly ex hal ed gas wi l l be reinhaled wi thout ca rbo n d iox ide h av ing bee n remov ed (4 77).

Excessive Dead Space

An inc reas e i n dead s pace wi l l inc rease rebreathing. Th is inc reas e is especi al ly i mportan t in s mall patien ts (478). A n HME is plac ed between the patie nt po rt and the breathing s ys tem. Th ese come i n a v arie ty of s izes , and if a l arge one is used on a pati ent wi th a s ma ll tidal v ol ume, dangerous rebreathing may occ ur (4 79).

Of ten , a c onnec tor is added between the patien t port of the breathing s ys tem and the patie nt to mov e the b rea thing s ys tem away from the su rgical fi el d P .414 (Fig . 14.13). These inc re ase dead spac e and mus t be used wi th c aution.

Figure 14.13 Increased dead space between the breathing system and the patient can result in serious hypercarbia in pediatric patients and spontaneously breathing adults.

View Figure

If a dis connec tion occu rs in a c losed space, s uch as under a plas tic drape ov er the fac e duri ng spon taneous b rea thing , exhaled g as con taining ca rbon dioxid e can ac cumulate in that s pace and the i nspired carbon diox ide lev el wi ll ri se (33 9). Hyperc arb ia is bes t detec ted using capnome try. Inspi red carbon diox ide wi l l be zero i f a c i rc le s ys te m wi th prope rl y func tion ing a bsorben t and un idirec tional v alv es is us ed and hypov entil ati on is the s ole c ause of the hyperc arbia. If th e h ype rca rbia is not caus ed by added c arbon diox ide and is the res ul t of hy pov entilation, inc reas ing the minu te v olume wi l l re duce the carbon diox ide in the b rea thing s ys tem. If the ca rbon d ioxide abso rbent or a un idi rec tional v alv e is no t work i ng properly , i nc reas ing the fresh g as fl ow wil l l ower the ca rbon dioxi de lev els in the c i rc le s ys tem. Hype rc arbia when using a Mapleson s ys tem is usually the res ul t of low f res h g as fl ow, s o inc re asing the f resh gas flo w wi l l l ower the ins pi red c arb on diox ide lev el. Ch apters 8 and 9 dis cuss the Mapleson s ys tems an d c irc le s ys tems . Chapte r 22 offers a ful ler disc uss ion of c arbon dioxi de moni tori ng.

Hyperventilation
A hol e or tear i n the v entilator bel lows can c aus e i nadv erten t hyperv entilation (138,139 ,480). This c an be detec ted by an inc reased ox ygen concen tration , if

ox ygen is the d riv ing gas (or a dec reased concen tration if ai r is used); i nc reas ed v enti lation as indica ted by a s pirometer; or dec reas ed end-tidal c arb on diox ide. These moni to rs are discus sed in Chapters 22 and 23.

Excessive Airway Pressure

In addi tion to interferi ng with v en ti la tion, a h igh pres sure c an cause barotrauma and a dv erse effec ts o n the c a rdiov ascula r sys tem. N eurologic c hang es and otorrha gia hav e bee n repo rted (481,482). A hype rinf la ted lung may interf ere with su rge ry (4 83).

Modifying Factors
The rate and ex tent of the p res sure rise are impo rtant a nd wil l be affec ted by a numb er of fac tors , incl ud ing the reserv oi r ba g; the v ol ume and c ompliance of the s ys tem; the f resh gas f lo w; and us e of a cuffed or unc uffed trac hea l tube, face mask , or s upraglottic airway dev ice. The pres sure in the bre ath ing s ys tem is no rmal ly li mited to 50 c m H 2 O by the reserv oi r ba g. Non -l atex bags may allow s l igh tl y hi gher pressures (484). W hen an automatic v entilator is in use, the bel lows buf fe rs inc reas es in pres sure. If the bag or bellows is exc luded from the s ys tem, this b uffering capaci ty is remov ed and dangerous ly high press ures ma y be reached rapidl y if there is c oinc idental obs truc tion to the outfl ow of gas es f rom, or high infl ow in to, the s ys tem. B ag ex c lusi on is mos t c ommonly c aused b y an obs truc ted exp iratory l imb ups trea m of the bag. The bag may bec ome obs truc ted at i ts neck (485) (Fig. 14 .9). Unfortun ately , an anes thesi a prov ider wh o fi nds a res erv oi r bag that is not filled may i ncorrec tly as sume that there is a leak i n the s ystem and operate the ox ygen f lus h in an attempt to c ompensate (48 6). The hi gh gas flo w f rom the oxygen flus h can raise the pressure in the breathing s ys tem to dangerous l ev els v ery rapidl y whe n the bag is exc luded.

Protective Devices
The anes thes ia works tation s tandard re qui res that the re be a dev ic e to limi t the press ure in the b rea thi ng s ys tem to 125 cm H 2 O (3 38). Thes e dev ices ma y malfunc tion (487 ). In addi tion, there mus t be a means to c on tinuousl y dis play the press ure in the b rea thi ng s ys tem and a p res sure moni tor tha t ac tiv ates a hig h prio ri ty alarm wh en the p res sure in the breath in g s ys tem exc eeds the operatoradjus table li mi t for high press ure .

Some of the ne wer v entil ato rs hav e pressu re-con trolled v entilatio n i n which peak ai rwa y pressure is lower than when v olume control v entilatio n is us ed. S ome of these v entilators automatica ll y s wi tc h f rom the inspi ra tory to the expiratory phase whe n the peak pressure th res hol d is ex ceeded (4 88). Ano the r fac to r that ca n reduce the a irway press ure ris e is an unc uffed tracheal tube or a trac hea l tube in which the cuff is not inf lated to a h igh p res sure. Adjus ti ng cuff press ure to 34 cm H 2 O or less wi ll a ll ow it to ac t as a safety v alv e fo r exc ess iv e press ure in the a irway. T he use P .415 of a mas k or sup raglo ttic ai rway dev ic e wi l l also prov ide a means of pressure re lief . Automatic dis connec tion of breathi ng s ys tem c omp onen ts c annot be rel ied on to prov ide press ure relief, because the p res sures requi red for disc onnec ti on are fa r in ex cess of those that ca use lung i nju ry (334).

Causes of Excessive Airway Pressure

High Inflow
If the ox ygen flush v alv e s tick s i n the ON pos i tion, 35 to 75 L/minute of oxygen wil l be de liv ered. Ox yge n fl ush v alv es on newe r machines a re des igned to c los e automatic al l y but c an f ai l (489,490 ,491). It i s pos sible f or pe rso nnel to ac cidental ly ac tua te so me ox ygen flush v alv es. Other equipment may caus e the flush v alv e to s tick in the ON pos i tion (492,493 ,494,495). If the ox ygen f lush v alv e is ac tiv ated during ins pi ra tion when a mechanic al v entilator is being us ed, a large v olume of gas wi l l be added to the inspi re d ti dal v olume, resul ting in a greatly i nc reas ed press ure wi th c ertai n breathing s ys tem confi gurations (496 ,497). A v entilator control v alv e can malfu nc tion, resul ting in a cons tan t flow of d riv ing gas (498).

Low Outflow Obstruction in the Expiratory Limb

As noted prev iousl y, ex c luding the bag from the breathi ng s ys tem resul ts in loss of bufferi ng capaci ty. Th us, breathing sys tem obs truc tion i n the ex piratory l imb is partic ula rl y haza rdous if it occu rs ups tream of the reserv oi r bag . The ex piratory pathwa y can be obs truc ted by fore ig n bodies (inc ludin g a mpules , c oins , plas tic wraps , dis cs, tape, and c aps ) (361 ,49 9,500,501 ,502), wate r (5 03), or equ ip ment defec ts or misassembly

(383,410 ,497,504,505,506,507,508,509 ,510,511,512 ,513,514,515 ,516,517,518). A PEE P v alv e ma y s tick or be placed back ward (383,410,519 ,52 0,521,522,52 3). The expi ratory li mb of a T-piece sys tem ca n b ecome obs truc ted by the us er's f ing er, k ink ing, ex ternal comp res s ion, misas sembl y, or adh esiv e tape (524,525 ,526). If a pedi atric breathing s ys tem with an adapte r th at has the f res h gas in le t protrud ing near the end is used wi th a low dead spac e trac heal tub e connec tor, the fresh gas s upp ly tube may c lose ly approx imate or ev en press agains t the end o f the conn ec tor, caus ing partial or complete obs truc tion of the ex halatio n path way (527,528 ,529). The s ame probl em has be en reported wi th a bronch osc ope (530).

Obstruction at the Ventilator

If the v entilator sp ill v alv e beco mes s tuck , the press ure i n the b rea thing sys tem wi l l rise (317 ,53 1,532,533,53 4). The ex i t of d rivi ng gas f rom the bel lo ws hous ing may be bloc ked (535).

Obstruction at the Adjustable Pressure-Limiting Valve

AP L v alv e omis sion, malfunc tion, or blockag e ma y occu r (485,486 ,536,537,538,539,540,541). The user may fail to open the v alv e when s wi tching from automatic to spon tan eous v entilation if the AP L v alv e is not automatic al l y excl ude d f rom the breathi ng sys tem duri ng mechanic al v entilation and automatic al l y inc luded during manual or spontaneous v enti la tion. W i th s ome AP L v alv es, s ubambien t pressu re from an ac tiv e scav enging s ys tem wil l ca use the v alv e to c lose, p rev enting exces s gas f rom leav ing the bre ath ing s ys tem (542,543 ,544,545).

Obstruction in the Scavenging System

The s cav enging s ys te m is essentiall y an ex tens ion of the b rea thing s ys tem. If malfunc tions in the scav enging s ys tem occ ur, the press ure in the b rea thing s ys tem may be affec ted. Obs truc ti on in the trans fer tubing b etwe en the A P L v alv e in the breathi ng s ys tem or betwe en the s pi ll v alv e in the v enti la to r and th e interface can prev ent gas f ro m l eav ing the breathi ng s ys tem (544,545,546,547,548,549 ,5 50,551). The tra nsfer tubing may be connec ted to an incorrec t s i te (552,553 ,554). If the p res sure reli ef v alv e i n a c losed ac tive sc av enging interface (Ch apter 13) fails to o pen, s us tained pos i tiv e press ure i n the breathi ng s ys tem c an res ult. In one reporte d c ase, a v alv e in tended f or negative pres sure rel ief ra the r than one fo r positiv e pressu re re lief was accidenta ll y installed (555).

Problems with Nonrebreathing Valves in Resuscitators

A sudden high inflow of gas o r a quick squeeze o r bump on the self-re fi lli ng bag of a resusc itator may ge nerate s uff ic ient pressure to lock the nonrebreathi ng v alv e in the inspi ratory posi tio n (556 ). Continuing i nf lo w wi ll c aus e a ris e in press ure. Inc orrec t no nrebreath in g v alv e ass embl y o r malfunc tion may resu lt i n obs truc tion to ex hal ation (557,558,559,560).

Misconnected Oxygen Tubing

Mi scon nec ti on of ox ygen tubing di rec tly to an ind wel ling trac heal or trac heos tomy tube or s upraglottic airway dev ice withou t prov is ion fo r v enting has oc curred , of ten wi th di sas trous results (561,562,563 ,56 4,565,566,567,568,569) (Fi g. 14 .14). Ano the r caus e of inc reas ed pressure is c onnec tion to a T -piec e wi th a c los ed ex piratory l imb (570 ).

Unintentional Positive End-expiratory Pressure

An ex ternal PEEP v alv e may remain i n th e c ircui t and n ot be remov ed, or an i nte gra l P EEP v alv e may be lef t in the ON pos i tion a t the end of a c as e and not noticed by the nex t use r (523,5 71) (Fi g. 14 .15 ). W i th older b rea thing s ys tems , the ai rwa y pressure gauge is loca ted on the abs orber si de of the unidi rec tio nal v alv es, and PE E P c anno t be obs erv ed on th e gauge (483,52 3,572). Newer b rea thing s ys tems measu re the pressure on the patien t s ide of the uni di rec tional v alv e. Inadv ertent PEEP may be c aused by water t hat is c ondens ed in the tubi ng connec ting the v enti lator to the P .416 breathi ng s ys tem (573) o r an inadeq uate openi ng in the ba g of a Mapl eson F s ys tem (574).

Figure 14.14 A: The oxygen tubing is attached to the mask. B: The adapter has become detached from the mask and is attached to the tracheal tube connector. There is no way for the gas to escape.

View Figure

Detection
W hen an au toma tic v en ti la tor is us ed, i t is essential tha t th e c hes t wal l motion , defl ec tions on the bre ath ing s ys tem pressure gauge, tidal and mi nute v olumes regis tered o n a resp irometer, and breath sounds be c arefull y moni tored. Obs erv ing the ai rway pres sure wav eform, if av ailabl e, can detec t s ome p roblems . P ressu rev olume loops (Chapte r 23) are also useful . The v entil ator may c hange s ound wi th s tack ed breaths . A continu ing or high airwa y press ure alarm ma y a le rt the ope rator to this hazard . The c apnograph (Chap ter 22) may sh ow an asce ndi ng limb wi th a prolonged ris e time and no plateau. Obs truc tions to the breathing s ys tem can be de tec ted b y performing a thoroug h anes thes ia mach ine P .417 and b rea thi ng s ys tem c heck , i ncl udi ng hav in g s omeone b rea th e through the s ys te m prio r to us e (383). T he procedu re for preuse c heck in g is discusse d i n Chap ter 3 3.

Figure 14.15 A: PEEP valve with 0 PEEP. B: Same valve with PEEP. Note the similarity in appearance.

View Figure

Response
If there is a p res sure bui ldup in the sys tem, a dis connec tion s hou ld be made IMME DIA TE LY at the trac heal tube connec tor (575). T ime spent look ing for the caus e of the problem may res ul t in ev er-i ncreas ing press ure. Ven ti la ti on shoul d be continued by us ing a resusc i ta tion bag unti l the problem is diagnosed and c orrec ted .

Inhalation of Foreign Substances

A foreign body in the breath ing s ys tem can of fe r more ris k than o bs truc tion . In so me c ases , it could mig rate in to the patient's respi rato ry trac t (5 76,577).

Absorbent Dust
Inhali ng abso rbent dus t can c aus e b ronc hos pas m, laryngospas m, cough, dec reas ed co mpliance, and burns to the patie nt's face (5 78,579). Th is can b e av oided by us ing a fi l ter at the patient port, rel easing breathing s ys tem pressure at the A PL v alv e whe n c heck ing for l eaks , tapp ing each canis ter to re mov e dus t bef ore it is put into the abso rbe r, and not ov erfill ing c an is ters (581,582).

Medical Gases Contaminants

Reported contaminants in medical gases inc lude water, o il , hy drocarbons , higher ox ides of ni troge n, an d me tal l ic f ragments (35,53,170,582 ,583,584,585 ,58 6,587,588 ,58 9,590,591). B ac te ria ma y be fou nd, es pecial l y i n comp res sed ai r (592,593 ,59 4,5 95).

Parts of Breathing System Components

Part of a breathing s ys tem c ompone nt may break and become detached . Repo rted cases hav e inv olv ed pa rts of th e sampl ing si te fo r an asp irating resp iratory gas moni tor, an APL v alv e, an ox ygen sensor, and HMEs (297,388 ,596,597,598,599,600,601,602 ,603). S ome manuf ac turers pla te the insid e su rfaces of c omponents wi th materi als that may flake off (604,6 05).

Other Foreign Bodies

A numbe r of other forei gn bodies hav e bee n f ound in breathing sys tems (377,378 ,379,381,396,400,499,500,501 ,502,577,606 ,607,608,609 ). Of ten, these enter duri ng c leanin g.

Carbon Monoxide
Dry a bsorbents c ontain ing s odi um or potas sium hydroxide can resul t in carbon monox ide formation when P .418 ex posed to v olatil e anes thetic ag ents . Th is i s dis cus sed in d etail in Chapte r 9.

Anesthetic Agent Overdose

An anes thetic agent ov erdos e can res ult in sev ere cardiov as cular de press ion. Chapte r 6 off ers a more comp lete discuss ion of ov erdos e c aused b y v apo rizer malfunc tion.

Tipped Vaporizer
If a v apo rizer c harged wi th l iquid is ti ppe d or agi tated, a v ery high concentra ti on may be de liv ered whe n the v aporizer is turned ON (61 0). Some newer v apo ri zers hav e a trav el setting that isolates the v apo ri zing chamber f rom th e res t of the v aporizer when the v apori ze r is remov ed f rom the anes thesia mach ine .

Vaporizer or Nitrous Oxide Inadvertently Turned ON

P rev ious v aporizer s e ttings by a colleague o r serv ice technici an can resu lt in the v aporizer c on trol dial being left in th e ON pos ition (61 1,612,613 ). S omeone he lping to mov e the machine may grasp a con trol dial , inadv ertentl y turning it ON. Inadv ertent adminis tration of ni trous ox ide ma y occu r if gas from the mai n f lowme ters is used to s uppl y su pplementary ox yg en (614).

Incorrect Agent in the Vaporizer

If an agent is inc orrec tl y placed i n a v aporizer des igned f or an agent wi th a lower v apor press ure and/or a higher minimum alv eol ar c oncentration (MA C) v alue, a hazardous ly hi gh co ncen tration may b e deliv e red (615,61 6,617,618). A n ex ample is plac ing isof lurane or halothane i n a v apo ri zer des igned for enflurane .

Improper Vaporizer Installation

If a v apo rizer not designed to b e exposed to high gas fl ows is p laced in the f res h gas s uppl y tube between the anes thes ia machine and the breathing s ys te m, the re wi ll be a h igher-than-us ual flo w of gas through the v apo ri zer wh en the oxygen f lus h i s ac tiv ated (619). S ome v apo rizers del iv er a c onsi derably higher-than -ex pec ted v apor ou tpu t if conn ec ted so that gas flow is rev ers ed, al th ough some wil l del iv er a normal c onc entration (620,621).

Overfilled Vaporizer
Mos t v apo rizers are now d es igned s o tha t th ey c annot be ov erfi ll ed. Many agentspec ific fi l li ng dev ic es prev en t ov e rf il l ing b y c onnec ting the ai r i ntake in the bottle to the ins ide of the v aporizing chamber. This safety featu re c an often be ov e rrid den by s li ghtly unsc rewi ng the bottle adap ter and tu rni ng the concentra ti on dial ON during fi l li ng (622,623,624). A drain has bee n added to some fi l li ng dev ices to help prev ent ov e rfil ling.

Vaporizer Interlock System Failure

If the v apori zer i nterl oc k s ys tem fa ils, i t is poss ib le to turn on more than one v aporizer at a time (625,626 ). An age nt moni tor (Chapter 22 ) wil l measure the c once ntration of v ol atile age nt in the breathing s ys tem. W hen an ov erdose of anes thetic agent is susp ec ted, the pati ent s hould be disconnec ted f rom the breathing s ys tem and v entil ated by usi ng a resus ci tati on bag and g as from a s ource other than the anes thes ia machine outlet.

Inadequate Anesthetic Agent Delivery

Inade quate anes thetic agent deliv ery c an ca use se rious morbidi ty and result i n pati ent a ware ness during the surgical p roc edure (6 27,628,629 ,63 0).

Decreased Nitrous Oxide Flow

P ipel ine nitrous oxi de may be los t as a res ul t of leaks , a frozen regula tor, i mproper mai ntenance, depletion of the s ys tem supp ly, and del iberate tampe ri ng with the equipment (51,631,632,6 33). Cylinder s uppli es also can fail . An obs truc tion or l eak

i n the an es thes ia mach ine ma y c aus e dec reas ed nitrous ox ide f lo w (634). A no th er poten tial problem is i nadv ertentl y us ing ai r ins tead of nitrous ox ide (635).

Unexpectedly High Oxygen Concentration

If a conn ec tion b etween the n itrous ox ide an d ox ygen s ourc es occurs in the pipel ine s ys tem, a mixer, or the anes thes ia machine, and the ox ygen press ure is highe r than tha t of ni trous ox ide, ox ygen wil l f low i nto the ni trous ox ide line (636,637 ). Acc idental ac tiv ati on of the oxy gen flus h ma y occu r (490,493,638 ,639,640,641 ). Repeatedl y us ing the oxyg en flush to keep the res erv oi r bag fil led can lead to pati ent a ware ness (491 ,64 2,643). Damag e to the ox ygen flush v alv e c an cause it to l eak ox ygen into the f res h gas (644). On some el ec tronic machines , a machine probl em wil l c ause i t to s witch into a s afe mode where onl y ox ygen is deliv e red (645).

Air Entrainment
As disc ussed earl ier i n this chapte r, a ir e ntrainment c an cause dilu ti on of inha led anes thetic agents . P .419

Faulty Vaporizer
Vapori ze r leaks and p rob lems wi th the moun ting or i nterl oc k dev ice are rel ativ el y co mmon (630,646 ,647,648,649,650,651,652,653 ,654,655,656 ,657,658,659 ,660,661,662,66 3, 664). S uch a leak of ten does not occur until the v aporizer is turned ON. Therefore, i t is essen tial that the preus e chec king procedu re for l eaks be performed with the v aporizers turned ON (Chap te r 33). W hi le the ov e rf il led v apo ri zer has usu all y be en assoc iate d with a h igher-thanex pec ted v apor ou tpu t, there is one rep orted c ase where it wa s associated with no v apor ou tpu t (665).

Empty Vaporizer
Ano the r caus e of underdos age is a v aporizer th at runs empty (6 27). Cases hav e been rep orted in wh ic h a l iquid lev el was v is ibl e in the v aporize r s ight g lass al th ough the v apori ze r was empty (666). In one repo rt, a fragmen t of rubbe r obs truc ted the channel f rom the lower end of the l iquid lev el indica tor, sh owi ng a

l iquid lev el des pi te the v apo ri zer b ei ng empty (667 ). S ome elec tronic v aporize rs wi ll ac tiv ate an alarm when the l iquid l ev el re aches a c ertain poi nt.

Incorrect Agent in Vaporizer

If a v apo rizer that is des igned f or us e wi th a hi gh ly v ola ti le agent is fi l led wi th a n agent of low v olati li ty , the patie nt wi ll fail to rec eiv e the c once ntration expec ted (615,616 ). A n ex ampl e is pl ac ing enflurane i n a v aporizer that is des ign ed fo r i sof lu rane.

Incorrect Vaporizer Setting

An inc orrec t v aporizer s etting c an be a caus e of anes thetic un derdosage. It is i mportan t to c heck se ttings frequently du ring a cas e b ecause they can be al tere d wi th out the ope rator's knowl edge . It is not unco mmon to f orget to turn ON a v aporizer af ter fi ll ing it duri ng us e. If an anes thesi a mach ine is tu rned OF F and then tu rned ON again, the v apo ri zer s etting may def aul t to zero (428 ).

Anesthetic Agent Breakdown

The reac tion between s ome des icc ate d abso rbe nts an d sev oflurane (C hapter 9) c an be so rapid and ex tensiv e tha t it is difficul t to ma in tai n a satis fac to ry i nspi red conc en tration . If the re is a large disc repancy between the v apori ze r s etting and the agent lev el in the breathing s ys tem, anes the tic break do wn shou ld be co nsidered.

Inadvertent Exposure to Volatile Agents

It is possible that hal othane-related hepa ti tis or mal ignan t hyperthermia may be tri ggered by s ma ll amounts of ag ent p res ent i n a machine and b rea thi ng s ys tem ev en if the v aporizers are tu rned OFF (661 ,668,6 69,670,67 1,672,673,674 ). W he n a pati ent wi th a his tory or suspici on of one of th ese enti ties mus t be anes theti zed, the anes thes ia machine should b e prepared for us e by remov ing all v aporize rs i f possible (673 ). Other necessary ac tions inc lude changing the abso rbent, replacing the fresh gas s upp ly hose, us ing n ew tub ings and bag , and f lushing wi th a high flow of oxygen for a p rolong ed time (675,676,677 ,678,679,680). Should a n episode of ma li gnant hyperthe rmia occu r durin g admi nis tration of anes thes ia and the department h as a machine f rom whic h v apori ze rs hav e been remov ed a nd tha t has been thoroughly fl us hed of v ola ti le a gents , i t sh ould be subs tituted fo r the mac hi ne in us e. A fresh b rea thi ng s ys tem s hould be use d. If the department does not hav e suc h a mach ine, the fol lowi ng measu res s hould be tak en to reduce the inhale d c onc entrati on of v olati le an es thetic (675 ,677):

Change th e breathing s ys tem hoses a nd bag. Change th e fresh gas s uppl y hos e. Change th e abs o rbent. Us e v ery hi gh ox ygen f lo ws . Ins ert a cha rc oal f il ter on the ins pi ratory port of the abs orber. Av oid us in g a c ontamin ated v entilator. Remov e v apo rizers from the mac hine if poss ibl e.

Inadv ertent anes the tic age nt exp osure can oc cur i f the anes thesi a machi ne is used to deliv e r ox ygen to a pa ti ent undergoing l oca l or MA C anes thes ia if the f res h gas deliv ery port or the patient po rt of the b rea thing sys tem is used to del iv er ox ygen to a nas al cannula. If a v aporize r is inadv ertentl y tu rne d ON , the p atient may bec ome deepl y seda ted or anes the ti zed wi th the age nt (681,682 ). These probl ems can be av oid ed by using the aux il ia ry flo wmete r on th e anes thes ia mac hine, an ox ygen f lowme ter attac hed to the pipel ine sys tem, o r a c ylinder as the ox ygen sourc e.

Physical Damage
Ol der an es thes ia mac hines of ten hav e equ ipment added to the top of the machine. This may resul t in the mac hi ne becoming top heav y. If the equipment con tac ts a ce il in g column or other s truc ture, equipment may be k nock ed onto the f loor or personnel . W hi le ne wer anes thesia mach in es hav e a generall y lower p rof il e and tend to i nclude many of the moni to ri ng dev ic es tha t are o ften pl aced o n the top of older machines , it is s ti ll poss ible to do phys ical damage to the machine. Ano the r haz ard to anes thesia equipment is the presence of wi res a nd tubings on the floor. These make i t more l ikel y th at the machine wi ll ti p during mov ement, spewi ng equipmen t to the fl oor. Many machines come P .420 wi th op tiona l arms that hold b rea thing s ys tem hoses , tubings , and wi res off the f loo r. A number of d ev ices h av e been manufac tured to mov e the impediments from the mac hi ne wheels (683 ,684,685,686 ) (Fi g. 1 4.16). The c as tors on a machine c an break , c ausing the an es thes ia mac hine to tip ov er (687).

View Figure

Figure 14.16 A: If the machine's wheels go over the hose, the machine will be tipped and the line blocked. B: This device allows easier movement of the machine by pushing hose out of the way. (Picture courtesy of CASTrGard.)

Electromagnetic Interference
Ov e r the pas t f ew decades , the number of wi rel ess radio frequenc y (RF) transmitters in medical fac il i ties has inc reas ed dramatica ll y (6 88,689,690,6 91). W irel ess c omputer ne two rks , paging s ys tems , h andh eld radios , cellula r tel ephones , and o the r RF transmi tters , wh ic h a re sou rc es of el ec tromagne tic ene rgy , hav e become prev al ent in c li nical env i ronments . In the f uture , it is l ik ely that moni tors and o the r dev ices wil l be connec te d to the d ata management s ys tem through a wi rel es s conn ec tion. Thes e produc e elec tromagnetic radiation ev en when the dev ic e is in s tandby mode, as they co ns tantl y s end s ignals to the base s tation . It has long been rec ogni zed that equipmen t th at emi ts radio wav es c an in terfere wi th the operatio n of elec tronic medic al equi pment (elec tromagne tic in terfe rence or E MI). Th e ex tent of the p rob lem is unkno wn. Av ailab le c l inical data i ndicate that se ri ous malfunc tions are rare (689 ). E qui pment repo rted being affec ted inc ludes moni tors , v en tila to rs , and infus ion pumps . The risk of interfe rence depends on transmis si on powe r and f req uenc y, dis tanc e to the tra nsmi tter, and i mmuni ty (c ons truc tion) of the medic al dev ic e. The wi de v a riety of RF transmi tters and med ica l dev ic es use d i n and aroun d heal th ca re fac i li ties mak es inte rac tions dif ficul t to predic t. A reas s uch as the ope rati ng room and c ritic al c are areas , which hav e a h igh c oncentratio n of el ec tro nic medic al dev ic es , a re mos t likel y to be affec ted by EMI. Di agnos tic , mo ni toring, an d therapeu tic equipmen t th at is direc tl y attac hed to pa tients is partic ul arly suscep tible to E MI.

To help prev ent E MI, newer medical dev ices are manufac tured to enhance their i mmuni ty to, or c ompatibili ty wi th , ex ternal s ources of elec tromag netic en erg y. Newe r cel l ph ones and newer e quipment offer better s hielding to mitigate or prev ent elec tromec hanical i nterferenc e. Older med ic al equip ment is of more conc ern bec aus e i t may not hav e be en des igned to be i mmune to the inc reas ing ly co mplex elec tromagnetic env i ron ment that c an be found i n heal th c are fac ili ties . For mos t RF transmitters , th e fi eld s trength dec reas es wi th dis tanc e. It follows that i n g eneral , the greate r th e s eparatio n between a RF transmi tter and a medical dev ic e, the lo wer the RF expos ure to th e dev ice, and the lowe r th e potential for E MI. Careful cons ideration mus t be giv en to wei ghing the risks and b enef i ts of wi reless equipment us ed in and around health care fac il i ties to dete rmi ne whether i t ca n be us ed safel y and effec tiv ely. Unless each medical dev ice is tes ted for i mmuni ty to each RF trans mi tter, i t is difficul t to identif y whic h dev ices may be affec ted by a partic ula r trans mitte r and what trans miss ion c ondi tions are likel y to c ause i nte rference . S ince the time that c el lular tele phon es were i ntroduced, health care org anizations hav e s truggled to determine a prude nt pol icy fo r th eir use in c linical s ettings . S ome fac i li ties hav e banned the use of c el lu lar telephones on thei r premis es . Othe rs al low them to be used f ree ly , whereas others hav e banned the ir us e in ce rtain areas or withi n a c ertain dis tance of medic al eq ui pment (688 ). A l though appropri ate medical d ev ice design and tes ting for elec tromagnetic co mpatibi lity (E MC) c an P .421 reduc e potential E MI risk s in the c li nica l env ironmen t, they c anno t ensu re that a dev ic e wil l no t experi enc e problems . Und er certain c ircums tances , E MI can s ti ll oc cur, ev en i f the dev ic e c onf orms to current E MC s tandards . Therefore , di rec t or c los e c ontac t between th e medic al dev ice and wi re les s c ommun ica ti on dev ic es shoul d be av oided. W ireless phones in publi c areas do not appea r to cause problems (6 90). Periodic al tes ting of wi rel es s transmi tting dev ic es and medica l equipment wi l l be requi red to ensu re a saf e env ironmen t.

Accident Investigation

Any time a patient has an unexpl ai ned problem, eq uipment malf unc tion or misuse shoul d be s uspec ted, and the apparatus sho uld not us ed again until this has been disprov ed (69 2,693,694,69 5,696). W hen there has been a pa ti ent injury, the health care fac il i ty safety officer (or ri sk mana ger) sho uld be c ontac ted at once to s uperv ise inv es tigation of the incident. An es tablished pro toc ol sh ould be des ign ed and followe d s o tha t all important areas are s ys tematical l y c ov ered . All indiv iduals inv olv ed i n the inc iden t sho uld document thei r obs erv ations s oon af te r th e ev ent whi le detai ls a re s ti ll f resh in thei r mi nds . This should be a s impl e s tatement of fac ts , wi tho ut judgments a bout c aus ali ty or respons ibi li ty . The f ol lo win g ques tions need to be as ked:

W hat was the date an d ti me of the p rob lem? In wh at area di d the problem occ ur? W hat monitors were b eing used? W hat were the s et a larm l imits? W hat was the firs t ind ica tion that there was a pro blem? A t wh at time di d the probl em occ ur? W ho fi rs t no ted the probl em? W hat c hanges attracted attention? W ere any alarms ac tiv ate d? W hat s igns or s ymptoms did the patient ex hi bit? Had there been any rec ent mod ific ations to the elec trical s ys tem or gas pipel ines in tha t are a? W as any th ing al tered shortl y before the inc iden t? W as this the fi rs t c ase perfo rmed in tha t are a on tha t day? W ere there any problems du ring prev ious cases pe rformed in that area on that da y or on the prev ious day ? W ere there any unus ual occ urrenc es in o the r areas on that da y or on the prev ious d ay? Had an y equi pmen t been mov ed in to that area rec en tl y? W ere there any problems noted in the room where it wa s p rev ious l y used? W hat p reus e anes thes ia equi pmen t checks were made? W ho las t f il led the v apori zers on the anes thes ia mac hine? If a v apo rizer wa s rec ently attache d to the machi ne, were preca uti ons tak en to p rev ent l iquid from being s pi lled into the outflow trac t?

Af ter the ini ti al i ndic a ti on that a probl em had occ urred , what wa s the sequence of ev ents?

An i mportan t s tep inv olv es cons truc tion of a ti me l ine, on wh ic h all ev ents are lis ted i n c hronol ogic al order (692). This wi ll help to s ort out ev en ts an d ma y lead to i dentification of miss ing data. T ren d data f ro m moni tors o r a data management s ys tem c an help. Numerous photographs s hould be taken of the area from v arious angles , wi th al l equipment s i tuated where it was at the time of the inc ident. Eac h p iece of equipment s houl d be photog raphed sep ara tel y. Af ter pic tu res hav e been tak en, al l s uppl ies and equipment as soc iated wi th the case should be s av ed and seques tere d i n a sec ure loca tion and l abe led DO NOT DISTURB . Settings s hould not be c hanged. Re lev ant identif yi ng information s uch as the manuf ac turer and lot and/or s eri al numbers s hou ld be recorded. If af ter a ll this has been done i t appears pos sible that the equip ment may be i mplica ted i n caus ing the problem, a thorough i nspec tion of the equipmen t by an uninv olv ed third party i n the pres ence of the primary anes thes ia pe rs onnel , i nsuranc e c arri er, heal th c are f aci l ity safety officer, patient represen ta tiv e, a nd equipment manufac ture rs should be c ond ucted. The inv estigation s houl d cons is t of an i n-d epth examinati on of the equipment s imilar to the c hec k ing proc edu res desc ribed earlier i n this chapter. V aporizers s houl d be c alibrated and checked to determine if v apor is del iv ered in the OFF pos ition. An analys is s hou ld be made of the v apo ri zers ' c ontents , i f necess ary. Foll owi ng the i nv es tigation, a repo rt s houl d be made , detailing all fac ts , a nal yses , and c onc lus ions . If a problem wi th the equ ipment is fou nd, an a ttempt s hould be made to recons truc t the acc ident, if this can be do ne withou t dan ger to anyone, and the equipment shoul d agai n be locke d up until any li tiga ti on is s ettled. If the inv estigatio n rev eals no problems , the equipment c an be re turned to serv ice with th e c ons ent of all parties .

Problem Reporting
In the Uni ted S ta tes , the Center fo r Dev ice and Radiological Heal th (C DRH) of the Foo d and Drug A dmin is trati on (FDA ) receives pos tmark et adv ers e ev ent reports submitted by manufac turers , us er fac ili ties , hea lth care P .422

profess ion als , and c onsume rs inv olv ing death, s erious injury , or i llnes s and produc t malfunc tions (698,699). The FDA analy zes the re ports to d etermine the impac t on the publ ic heal th a nd makes rec ommendati ons to manufac ture rs , heal th c are profess ion als , and c onsume rs . MedW atch is the FDA 's name for i ts medic al produc ts reporting p rog ram. It is a b roa d p rog ram that encompasses both v olu nta ry and mandatory repo rtin g for medic al products . Us e r facil i ti es are required to repo rt to the F DA med ic al dev ice pro bl ems tha t hav e or may hav e ca used or contribu ted to death, s eri ous il lness, o r s erious in ju ry. Seri ous illnes s o r in ju ry is def ine d as life -threateni ng or resul ting in permanen t i mpai rmen t of a bod y func tion or perma nent damage to a body s truc ture or tha t necess itates immedia te medica l or s urgica l i nte rv ention to prev ent damages to the body. Us e r facil i ti es mus t rep ort a p rob le m no later th an 10 days after becoming aware of i t. F ail ure to report acc urately and in a ti mel y manner can lead to c iv il o r ev en c riminal penalties . P robl ems resul ting in patient deaths a re to be s ent to the FDA and to the equipment manufac turer. Seri ous i l ln ess or injury ev ents are reported to the manufac turer or, i f th e manufac ture r is n ot known, to the FDA . The manufac tu rer has th e res pons ibil ity to inv estiga te the incident a nd, if appropri ate, report th e inc ident to the FDA . A dv ers e ev ents , inc lud in g thos e in which a dev ic e failed to performed as intended bu t did not resul t i n a death or s e rious injury may also be reported v ol untari l y through the FDA 's MedW atch program. Reports sha ll not be admitte d into ev idence or otherwi s e used i n a c iv il ac tio n unles s the fac i lity or pers onnel maki ng th e repo rt k new th at the inf ormation was fals e. Th ere are a number of ways that the inf orma tion could bec ome av ailabl e, i ncl uding the Freedom of Informati on Ac t. It is theref ore possi bl e tha t th is i nfo rmati on could be av ailable for a c iv i l suit (698). The user faci l ity shou ld s e t up a pro tocol f or handl in g adv erse inc iden ts i n order that they wi l l be properly reported in a timely fashion. Medic al pers onnel need to know who (the heal th c are fac il ity safety offi cer, ri sk man agement, b iomedical department, or other des ignated pers onnel ) should receiv e the re port.

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613. Curri e M, Mack ay P , Morgan C, et a l. T he wrong drug p rob le m i n anaes thes ia : an anal ys is o f 2000 inci dent re ports . Anaesth Intens Care 1993 : 21:59 660 1. [Med li ne Link ] 614. W oehl ick HJ . Ha zards of s uppl ying supplemental oxygen through ma in gas f lowme ters . A nes thes io lo gy 1993 ;78 :401402. 615. B ruce DL, Linde HW. V aporiz ation of mix ed anes the tic liquids . Anes thesi ol ogy 1984;342 346. 616. Chilcoat RT . Haza rds of mis -f il led v apo ri zers . S umma ry tabl es . Anesthes io logy 1985;63:726727. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 617. Martin S . Haza rds of agen t-spec ific v apo ri zers . A case report of succes sful resus ci tati on after mass iv e is oflu rane ov erdos e. Anes thesi ol ogy 19 85;62:830 831. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 618. B lock FE , Schul te GT . Obse rv a ti ons on use of wrong age nt i n an anes thesi a agent v aporizer. J Cl in Moni t 1999 ;15:5 761 . 619. Kel l y DA . Free-s tandi ng v apori zers . A naes thes ia 1 985;40:66 1663. [Cross Ref] [Med li ne Link ] 620. Railton R, Ingl is MD. Hig h halothane concentrations f ro m rev ersed fl ow i n a v aporizer. A naes thes ia 1 986;41:672673 . [Cross Ref] [Med li ne Link ] 621. Yee S , Old S . Any wh ic h wa y but loos e: the s ignificance of gas flow di rec ti on through a v apori zer. A naes thes ia 20 00;55:598600. 622. S inc lai r A , Van Be rgeb H. V apori zer ov erfill ing. Ca n J Anaes th 1993;4 0:77 78. [Med li ne Link ] 623. Cra ig DB . V aporiz er ov erf i ll ing. Can An aes th S oc J 199 3;40:10051006. 624. Daniels D. Ov e rf ill ing of v apo ri zers . An aes thes ia 2002;57:288 . [Fu ll tex t Link ]

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[Med li ne Link ] 636. Cra ig DB , Longmu ir J . An unus ual f ai lure of an ox yg en fa il -s afe dev ice. Can Anaes th S oc J 1971 ;18:576577. [Med li ne Link ] 637. Puri GD, Geo rge MA , S ing h H, et al . Awareness under anaes thes ia due to a defec tiv e gas -l oad ed regulato r. Anaes thesia 1987;42:539540 . [Cross Ref] [Med li ne Link ] 638. B rahams D. Anaes thes ia and the law. A wa reness and p ai n duri ng anaes thes ia . Anaes thes ia 1989;44:352. [Cross Ref] [Med li ne Link ] 639. Judk ins K C. B OC Boyle M anaes thetic machinea mod if ication. A naes thesi a 1983;38:387388. [Cross Ref] [Med li ne Link ] 640. Pay mas ter NJ . Inadv erte nt adminis tra tion of 100% ox yg en during anaes thes ia. B r J Ana es th 1978 ;50 :1268. [Cross Ref] [Med li ne Link ] 641. Dodd KW . Inadv ertent admi nis tration of 100% ox ygen d uring anaesthes ia . B r J Anaes th 1979 ;51 :573. [Cross Ref] 642. Longmui r J , Crai g DB . Mis adv enture wi th a Boy le 's gas machi ne. Can A naes th Soc J 1976;23:671673. [Med li ne Link ] 643. Peters K R, W ingard DW . An es thes ia mach in e l eakage du e to mis al igned v aporizers . Anes th Rev 1987;14:3639. 644. Mann DP , Der Ananian J , A ls to n TA . Ox ygen fl us h v alv e booby trap. Anes thes iology 2004;101:558. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 645. A zi z E , Sanders GM. Fai lu re of Da tex AS /3 anaes thes ia deliv ery uni t. Anaes thes ia 2000;55:1214 1215. [Fu ll tex t Link ]

[Cross Ref] [Med li ne Link ] 646. Ghai B , Makk ar JK . A n unus ual c ause of fau lty Tec 7 v apori ze r. An es th Anal g 2005;101:189018 91. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 647. Orme R, Grange C. Vapori zer failu re. A naes thesia 1999;54:111112 . 648. Green M, B ugg N, Ho lt P . Failed inh alationa l i nduc tiona faul ty v apori ze r. Anaes thes ia 1995;50:858 6. [Cross Ref] [Med li ne Link ] 649. Lewi s SE , A ndre ws JJ , L ong GW . An unexpec ted Penlon Sigma El i te v aporiz er l eak . A nes thesiolo gy 199 9;90:12211224 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 650. Ngan J , Cas hen D, Nichols G. Sev oflurane v aporizers . Can J Anes th 1999;46:200. 651. Cartwri ght DP , F reeman MF. V apo ri zers . An aes thesia 1999;54:519 520 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 652. Cudmo re J , K eogh J . A nother S elec ta tec s witc h malfu nc tion. Anaes thes ia 1990;45:754756. [Cross Ref] [Med li ne Link ] 653. Lamb erty J M, Le rman J . Intraoperativ e fai lure of a f luotec Mark II v apourizer. Can A naes th Soc J 1984;3 1:687689. [Med li ne Link ] 654. Mal tb y J R. In traop era tiv e failure of a Fl uotec Mark II v apourizer. Can A naes th Soc J 1985;32:200. [Med li ne Link ] 655. Anonymous . Anes thes ia uni t v apori ze rs . Technol Anes th 1997 ;17 (10 ):9. 656. Duff PJ , Rollison RA , Lee TW . Selec tatec probl ems : a gain and aga in. Anaes th Intens Care 1994;22:622 .

[Med li ne Link ] 657. Dwye r M, Hol land R, Shep herd L , et al. V aporiz er and S elec ta tec leak s . Anaes th Intens Ca re 1994;22:739. [Med li ne Link ] 658. Chambers J C, Hough MB . A ware ness h azard usi ng a Tec 6 v aporise r. Anaes thes ia 2005;60:942. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 659. Mitton M. A warenes ss hazard usin g a T ec 6 v apo riser. A rep ly. A naes th esia 2005;60:942. [Fu ll tex t Link ] 660. Gars tang JS . Gas leak from T ec 5 isoflurane v aporize r. Anaesthes ia 2000;55:915. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 661. Dunc an JAT. Selec t-a-tec s wi tc h malf unc tion. A naes thes ia 1 985;40:911912 . [Cross Ref] [Med li ne Link ] 662. Chum NL. A po ten tial c ircui t leak wi th Tec 5 v aporizers . Anes thes iology 1997;87:1599 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 663. Vohra SB . Leak ing v apori ze r. An aes thes ia 2 000;55:606607 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 664. MacLeod DM, Ec Ev oy L, W alke r D. Repo rt of v apori zer malfunc tion. Anaes thes ia 2002;57:299 300. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 665. Fernan do P M, Pec k DJ . An unc ommon caus e of v aporizer failure. An aes thes ia 2001;56:1009101 0.

[Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 666. Barc roft JP . Is the re liquid i n the v aporiz er? Anaes thes ia 1 989;44:939 . 667. Fou nd P , Forres t AP . V aporiz er lev el obs truc tion detec ted by anes th etic v apor analys is . Anes th A nal g 1999;88:46 9. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 668. Varma RR, W hites ell RC, Is kandarani MM. Ha lothane hepa ti tis wi thout halothan e. Role of inapparent c ircui t contamina ti on and i ts p rev entio n. Hepatolog y 1985;5:11591162 . [Cross Ref] [Med li ne Link ] 669. E l lis FR, Clarks IMC, Mo dgill E M, et al. Ne w c auses o f mal ign ant hyperpyrex ia. B r Me d J 1975;1:575. [Med li ne Link ] 670. B ridges RT. Vapori ze rs s erv ic ed and checke d? Anaes th esia 1991 ;46 :695 697. 671. Cook TL, E ge r E I, B ehl RS . Is your v ap ori ze r off? Anes th Analg 1977;56:793 800. 672. Robins on JS , Thompson J M, Barratt RS . Inadv erte nt contamination of anaes thetic c irc ui ts with hal othane . B r J Anaes th 1977;49:745753 . [Cross Ref] [Med li ne Link ] 673. Ri tc hie PA , Chesh ire MA , Pearce NH. Decontaminatio n of hal othane f rom anaes thetic machines ac hi ev ed by c ontinuous f lushing wi th ox ygen . B r J A naes th 1988;60:859863. [Cross Ref] [Med li ne Link ] 674. S tree ts C, Dav ies P . S hou ld we perf orm a sniff tes t? Ana es thes ia 2000;55:509510. 675. Beebe JJ , S essler K I. P reparation of anes thes ia machi nes for p ati en ts suscep tible to mal ig nant hype rthermia. Anes thesiolo gy 198 8;69:395400. [Fu ll tex t Link ] [Cross Ref]

[Med li ne Link ] 676. Mc Graw TT, K eon TP . Malignant h yperthermi a and the c lean mac hine. Can J Anaes th 1989 ;36 :530532. [Med li ne Link ] 677. Coop er JB , Philip J H. More on anes th es ia machi nes and malign ant hyperpyrex ia. A nes thes iolog y 1989;70:561562. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 678. Samulks a HM, Ramai ah S , Nob le W H. Unintended exposure to halothane i n su rgical patients . Halothane was hou t s tudies . Can A naes th Soc J 19 72;19:3541. [Med li ne Link ] 679. Gill y H, W eindl mayr-Goe ttel M, K oberl H, et al. A naes the tic uptake an d was hout charac teris tics of patien t c i rc uit tub ing wi th s peci al reg ard to curren t decontami nation tec hniques . Ac ta A naes thes iol Sc and 1992;36:621627. [Med li ne Link ] 680. Petro z GC, Lerman J . P reparation o f th e S ieme ns K ION anes thetic mac hine for pati ents susc eptib le to malignant hyperthe rmia. Anes thesi ol ogy 2002;96: 941 946. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 681. S mi th W Q. Inadv e rtent i nhala tion anaes thes ia du ring surgery unde r retrobu lba r eye bloc k . B r J Ana esth 1998 ;81 :793794. [Med li ne Link ] 682. S tone A GH. S upplementary ox ygen durin g Caesa rean s ec tion. A naes thes ia 2006;61:298. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 683. Sak ai T, Mc Intyre JW R, Baba S , et al . Pus h and pul l: mov e your anesthes ia machine mo re eas ily. A nes th Analg 199 4;79:1 96197. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

684. Sak ai T. P rotec ti ng anaes th etic tubing from occlus ion. B r J A naes th 2001;87:324. [Med li ne Link ] 685. Dell R, Cochrane D. P rotec ting a naes the tic tubing from occl usion . B r J Anaes th 2000 ;84 :698. [Med li ne Link ] 686. A yll on IR, Mi lls GH. P rotec ting anaes th etic tubing from occl us io n: an i nbui l t so lution. B r J A naes th 2000;8 5:498. [Med li ne Link ] 687. Catto DD. Medic al dev ice safety alert. Drager Se rv ice , Telford, PA ., Feburary, 2001. 688. Tri JL, Sev ers on RP , Firi AR, e t al . Cellu lar telephone interf erence wi th medical equ ipment. Mayo Clin P roc 2005 ;8 0:1 2861290 . [Med li ne Link ] 689. Lyznicki J M, A l tman RD, W i ll iams , MA . Report of the Americ an Medical Ass oc iation (A MA ) Counci l on Sc ie ntific A ffa irs and A MA rec ommenda tions to medical professi ona l s taff on the use of wi re les s rad io -f requenc y equipmen t in hospi tals . Biomed Ins trum Tech nol 20 01;35:189195 . [Med li ne Link ] 690. W al lin MKE , Marv e T, Hak ans son PK . Modern wi re less te lec ommunic ati on tec hnologies and thei r elec tro magnetic c ompa ti bi li ty wi th l ife -supporting eq uipment. Anes th An al g 2005;101 :13931400. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] P .429

691. Lauder P G. Mobile phone use in hosp itals . An aes thes ia 2006;61:616. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 692. A rms trong J N, Dav ies J M. A s ys tematic method for the inv es tigation of anaes thetic inc idents . Can J Anaes th 1991 ;38 :10 331 035. [Med li ne Link ]

693. Eagle CJ , Dav ies J M, Reason J . Acc iden t analys is of la rge -sc al e tec hnol ogical disas te rs applied to a n anaes thetic comp lication. Can J An aes th 199 2;39: 118 122. [Med li ne Link ] 694. Coop er JB , Cul len DJ , E ic hhorn J H, e t al . A dminis trativ e guidel ines fo r respons e to an adv erse anes thesi a ev ent. J Clin Anes th 1993;5:7 984 . [Cross Ref] [Med li ne Link ] 695. Fors el l RD. The cl in ic al engineer's role i n inc ident i nv estigation . Bi omed Ins t Tec h 1993 ;27 :378383. 696. Lee RB . Repl y to gui de li nes and tec hniques for the i nv es ti gation of an es thetic ac c idents . J Clin An es th 1994 ;6:171 172 . [Cross Ref] [Med li ne Link ] 697. Marders J . FDA enc ourages the reporti ng of med ic al dev ice adv e rs e ev ents : f ree -hos ing haza rds . APS F News lett 20 02;17:41. 698. Anonymous . Medical dev ice repo rting u nder the Safe Medical Dev ices Ac t: A guide for healthc are fac il ities . E CRI, P lymou th Meeting, P A ., 1991. P .430

Questions
For the fol low ing ques tions , answe r

f A , B , and C are co rrec t i f A a nd C a re co rrec t i f B and D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. Hy percarb ia due to an inco mpetent unidirec tional valve can be distingu ished from that due to exhausted absorbent by A . Th e shap e of the c arbon dioxi de wav efo rm B . A n inc reas e in inspi red carbon dioxi de C. Inc reas ing the f res h g as flow D. Absenc e of hea t in the abs orber

V iew A ns we r2. Causes of air e ntrainment include A . S uc tion applied to an nas ogas tric tube cu rl ed in the eso phagus B . Malfunc tion of the in terface of a c los ed scav enging s ys tem C. Us e of a mains trea m gas a nal yze r D. A leak in the v enti lato r bel lows V iew A ns we r3. Wh at course of ac tion should be ta ken if a gas c rossove r in the pipeline syste m is s uspecte d? A . Us e the ox ygen f lush on the machine to p urg e the c ross ed gas B . Disc onnec t the pipel in e, and op en an oxy gen cy linde r C. Tu rn up the flowmeter for the c rossed gas , a nd tu rn off th e ox ygen fl owmeter D. Us e a resusci ta ti on bag to v entilate wi th ro om a ir V iew A ns we r4. Color(s ) w hich an oxyge n c ylinde r may be painted include A . B lac k B . W hi te C. B lue D. Green V iew A ns we r5. Safe ty mechanism(s) that p revent a hypoxic mixtu re being delivered because the flow me ters are incorrec tly set include A . Th e ox ygen fail ure s afe ty v alv e B . A n ox yge n anal yze r C. The ox yg en pressure fa ilure a la rm D. P ropo rtioning s ys tem V iew A ns we r6. A low er-than-expe cte d a nesthetic level may be cause d by A . S ev oflu rane b reakdown b y desicc ated a bsorben t B . A l eak i n a v entilator bell ows C. Vaporizer leak D. A i r f rom a li ght source V iew A ns we r7. Wh ich measures s hould be take n in the e vent that the oxy gen pipeline su pply is lost? A . Us e low f res h gas flows B . Open an ox ygen c yl inder C. Disc onnec t the machine f rom the c entra l sup ply D. Tu rn the pis ton v entilator OFF V iew A ns we r8. A leak in the breath ing syste m should be suspec ted if A . Th e end-tidal carbon diox ide begins to i nc reas e B . Th ere is a c han ge in the v enti la tor sound

C. A s tanding v entilator bell ows fails to return to the top of i ts hous ing D. The FiO 2 dec reases during c ontroll ed v enti la tion V iew A ns we r9. Wh ich situ ations w ould res ult in a negative pressure in the brea thing sys tem? A . Nasogas tric tube p laced i n the trac hea B . S uc tion applied to a work ing c hann el of a fib ers cope C. Malf unc ti on of v alv es in a cl osed scav enging i nterface D. Loss of ox ygen p res sure to the mac hi ne. V iew A ns we r10 . An obstruc tion in th e b rea thing system may cause A . A n inc reas e in the peak breathing sys tem pres sure B . Ac tiv ation of the high pressu re alarm C. Hypov enti lation D. Dec re ased mov ement of the v entilator bell ows V iew A ns we r11 . Whic h mon itors are reliable de tec tors of a breathing system discon nection? A . Ca rbo n d ioxide B . A i rway press u re C. Respi rome ter D. Ox ygen analy zer V iew A ns we r12 . Causes of carbon dioxide in th e insp irato ry gas include A . A bsorbent being bypassed B . Inad equa te f res h g as fl ow to a c i rc le b rea thi ng s ys tem C. An inco mpetent unidirec tional v alv e D. Ex ces s c arbon diox ide produc tion V iew A ns we r13 . E xcessive airw ay pressu re may be caused by A . Malfunc tion of the AP L v alv e B . Us e o f the oxygen flus h du ri ng inspi ra ti on wi th ce rtain mechanic al v enti lators C. Obs truc ti on in the scav enging s ys tem D. A uni di rec tion al P EEP v alv e p laced i n the ex piratory li mb V iew A ns we r14 . Anesthetic agent overd osage may be caused by A . Is ofl ura ne in a halothane v apori zer B . Rev ersed f low thro ugh a v apori zer C. Enflurane in an isoflurane v apori ze r D. Ov erfil led v apori ze r V iew A ns we r

Chapter 15 Latex Allergy

Concern a bout latex all ergy in the medical c ommuni ty has inc re ased as heal th c are personnel hav e seen an inc rease in reac tions among both pati ents a nd th emselv es . Latex is the s ec ond mos t common c aus e of i ntraop era tiv e ana phyl ax is , prec eded only by mus cl e rel axants (1).

Origin of Sensitivity
Natural latex is ob tai ned f rom the s ap of a rubber tree . During the manufac turing process , many chemic als are added to the latex , depending on the desi gn and tec hnic al requi re ments of the fi nished produc t. Thes e subs tances may also be al lergenic . There may be as ma ny as 240 po ten tially al lergenic subs tances in processed l atex produc ts (2). The inc reas ed inci denc e of l atex a llergy is b el iev ed to be du e both to c hanges i n the manufac turing p roc ess es and i nc reas ed us e of latex -con taini ng produc ts . Adoption of univ ersal and s tanda rd precautions (Chap ter 34) has grea tl y inc rease d l atex exposure. Latex s ens i tiza ti on ca n occur as a res ult of contac t v ia the s k in o r mucous membranes , i nhalation, inges tion, parentera l injec tion , or wou nd inoculati on.

Latex-containing Products
Latex is ubiqui tous i n the home , workplac e , and health care setting bu t is no t al ways obv ious . In the ope ratin g room su ite, i t i s fou nd in glov es; trac hea l tu bes ; Combi tubes ; face mask s; mas k s traps ; ai rways ; wrappers on tra ys ; laryngosco pe bulb gas kets ; s k in tempe rature mo ni tors ; rubber s uc ti on ca the ters ; a rm boards ; bite block s ; teeth pro tec to rs ; breath ing tubes; ox ygen tubing; res erv oi r bags ; v en tila to r hoses and bellows ; resusc itation bags (black or blue , reusab le); blood pres sure cuffs and tubing; s tethos cope tubi ng ; in travenous tubi ng in jec tion po rts ; tourniq uets ; s yringe p lungers ; rubbe r-s hod c lamps ; intrav enous bag and tubing ports ; medica tion v ial n eedle ports ; tape and other a dhes iv es (e.g., Es ma rc h bandages , adhes iv e bandages ); den tal dams ; elas tic ba ndages (Ac e wraps ); dress ings (e.g., Coban, Molesk in , Mic ropore ); rubb er pads ; protec tiv e shee ts ; drains ; e lec trode pa ds ; rubber aprons ; ci rc ul ating fluid warmin g b lankets ; s ome c ast material ; goggl es ; pulmonary artery catheter ba lloons ; ep idu ral catheter ad apters ; i ntrav enous (IV ) medication pump cas settes; elec trocardiogram (E CG) el ec trodes and p ads ; finger cots ; os tomy bags ; intestinal a nd s tomach tubes ; rubber bands ;

ches t tube drai nage s ys tem tubing; con dom uri na ls ; uri na ry and nephros tomy ca the ters ; gas tros to my tub es ; bu lb s y ringes; adhes iv e drapes ; nipples ; ins trument mats ; s pec imen traps ; ca the ter bag s traps ; di lating c a thete rs ; and P .432 the elas tic i n items ranging from surgical masks , head cov erings , hats , and booties to diapers . A lle rgic reac tions hav e b een attributed to drugs that had been prepa red i n a latex -con taining s y ringe f or a c onsi derable ti me b efo re us e o r a bottle with a l atex s topper between the drug and the diluen t (3,4). P roduc ts mad e of dry , mol ded, or ex truded rubbe r suc h as wheelchair ti res , tool handles , rubber s ea ls , v ial s toppers , an d s yringe p lu ngers contain much less al lergen than do items suc h as glov es , c ondoms , and bal loons that a re fo rmed by dipping forms into l iquid la tex (5). W el l-wash ed rubber p roduc ts such as v entilator be ll ows pose less risk than ne w i tems (2). There is a dec re ase in latex proteins in glov es tha t are autoc lav ed (6). P roduc ts that a re s terilized by us ing ethy len e oxi de may inc rease the risk of latex sens i ti za tion (7 ). Gl ov es h av e v ery hi gh al le rgen lev els c ompared wi th mos t other l atex -containing medical produc ts . Latex glov es a re the bigges t contribu tors to the aeroal lergens i nsi de the operating room. Ma ny glov es c ontain powder. Latex proteins from the glov es bond wi th this powde r. W hen a gl ov e i s put on or re mov ed , the p owder ma y sp ray into the ai r. It c an then be in haled by person nel , inocu late an ope n wound , and c ontaminate the i ns tru ments on the su rgica l field (8). The h igh es t l ev els of ai rborne latex allerg en are f ound i n the operati ng rooms where powd ere d l atex glov es are f requentl y donn ed and remov ed (9,10,11). The powd er c an remai n suspended i n the ai r f or hou rs . Ev en in operating rooms whe re laminar ai rf low dev ic es are used, la tex ae roa llergens a re presen t in high quantities . A l lergens are ca rried throughout the env ironmen t by v entil ation ai r ex change s ys tems as well as by se ttling on c lothing and equi pment. S wi tc hing to low-a ll ergen gl ov es has been found to reduce the lev els of these ae roa ll ergens (12). Latex is found in man y products outs ide the heal th c are s etting. These inc lude toys ; condoms ; expandab le f abric s (wai s tbands ); diaphragms ; ball oons ; hot wa ter bottles ; erase rs ; rubber ba nds ; shoe so les ; motorc yc le and bic ycl e handg ri ps ; bathing su its , c aps , and goggles ; racquet ha ndles ; pac ifiers ; baby bottle nippl es ; bungee co rds ; che win g g um; cos metic applica tor sponges ; fish tanks ; bike hel mets ;

automob il e ti res ; raincoa ts ; c ompu ter mo use pads ; earphones ; household rubbe r glov es; and c arpet pa dding to na me b ut a fe w (8,13).

Clinical Signs and Symptoms

Reac tions to la tex inc lude a s pec trum of non-i mmune and immune-mediated respons es . Si gns and s ymptoms may be local o r s ys temic and v ary wi del y in sev erity and the time of oc currence. Mos t adv ers e reac tions to latex occu r 30 to 60 minutes af ter induc tion (14,15). S ymp toms c an progress quick ly f rom mi ld to sev ere. In s ome cas es , life-th rea ten in g reac ti ons a re the fi rs t to appear. The re are three types of reac tions to l atex : i rritant contac t dermati tis , Type IV delay ed hyp ers ensi tiv ity, and Type 1 immedi ate hypersens itiv i ty (2,8 ,16 ).

Irritant Contact Dermatitis

This is the mos t common type of glov e-related reac ti on. It resul ts f rom the di rec t ac tion of latex and other irri ta nt ch emic als a nd cons is ts of itching , rednes s , sc ali ng , dryi ng, a nd ski n c rack ing . The rash is usuall y limited to the ex posed s k in area. Soaps , mec han ica l i rritation f ro m sc rubbi ng, and excess iv e s we ating of ten ex ac erbate it. W hi le this is no t a true al lergy , dis ruption in sk in integ ri ty may enhanc e absorptio n of la tex allergens and acce le rate the o nset of al le rgic reac tions .

Type IV Delayed Hypersensitivity

Hy pers ensi tiv ity is an immune response that l eads to tiss ue damage. Onc e sens i ti zed, an indiv idual 's ex posure to an antigen can c ause a reac ti on. It may tak e sev eral years for l atex sens itiv ity to dev elop . W hen i t does , mos t dev elop as a Ty pe IV (delayed) reaction. A Type IV reac ti on (all ergic contac t dermatitis , delaye d h ype rsens i tiv ity) is a Tce ll mediated response cha rac te ri zed by a sk in rash that appears up to 72 hours af te r in itia l con tac t and may p rog res s to ooz ing s k in b listers . Unl ike irri tant c ontac t dermatitis , al lerg ic contact de rmati tis often sp reads beyond the a rea of c ontac t with the allergen . Flushing , itching , rhi ni tis , di zzines s, s inus s ymptoms , c onjunc tiv i tis , and e yel id edema may also be presen t. Not a ll ind iv iduals who dev elop Type IV hypersens itiv i ty progress to Type I, but mos t indiv id uals with Type I s ens i tiv ity hav e p rev ious l y had Typ e IV s ymptoms (2,16,17).

Type I Immediate Hypersensitivity

This is the mos t sev ere reac tion and may lead to s ignificant morb idi ty and mortali ty (18). S ymptoms usually appear s hortl y af ter ex posure but c an occu r hours la ter. The y run the entire s pec trum from mil d (sk in redness , h iv es, i tc hing, rhini tis , sc ratc hy throat, i tch y or s wo ll en eyes ) to mo re sev ere (fac ial ed ema, faintn ess, nausea , abdomina l c ramps , dia rrhea, coug h, hoars e v oice, c hes t tightnes s ) to l ife threatening (l ary nge al ede ma, bronc hospasm, anaphy laxis ). A s urv ey of anaphy lax is duri ng anes thes ia sho wed th at cardiov ascular s ymptoms , cutaneous s ymptoms , and b ronchos pas m were the mos t common c linical fea tures (19). Anaphylax is is an immed ia te, s ev e re, life -threateni ng al lergic response. Th ere are a numb er of repo rts in the li terature of an aphy lac tic reac tio ns to latex (1,2 ,4,7,20,21,22,23,24 ,25 ,26 ,27 ,28,29,30,3 1,32,33,34). P .433 Latex al lergy s hou ld be high on the lis t of pos s ibili ties when anaph yl axis occ urs during anes thesi a and surgery. It may no t be app are nt that l atex is the c ausativ e fac tor. If medic ati ons hav e been injec ted in c lose prox imi ty to the anaphy lac tic reac tion, the anes th esia prov ider may s uspec t that med ic ation c aused the reac tion (32). Fai lu re to recogni ze latex a llergy can delay remov al of latex -conta in ing produc ts and delay effec tiv e trea tmen t.

Individuals at Risk
Identifyi ng pa ti ents at hi gh ris k f or h av ing an al le rgic l atex reac tion al lows prev entiv e meas ures to be targeted (17 ). High-risk g rou ps can be identified by knowi ng the ris k fac tors and appropri ate ques tioning . Latex anaphylax is may be dec reas ed by iden tify in g at-ri sk pa tients (19). The reported prev alenc e of la tex a llergy v ari es greatl y dependi ng on the pop ula ti on s tudied an d the methods used to detec t s ens i ti za tion. Anyone with frequent ex posu re to latex -con tai ni ng materials is a t inc reased risk of dev el opi ng latex al lerg y. The greater the ex posu re to l atex in a popul ation , the g rea te r the number of sens i ti zed indiv iduals . Ex tended or mass iv e ex posure in and of itself is nei th er necess ary n or suffic ien t to c ause sens i ti za tion if the pers on is no t gen etica ll y predispos ed (35). Childre n and younger adul ts are more lik el y to bec ome la tex s ensi tiv e than the general population . Some but not al l s tudies hav e found that wo men and members of non-Cauc as ian races are mo re lik ely to hav e latex alle rgi es (17,35,36,37,38).

The majority of l atex -s ensi tiv e indiv iduals hav e a h is tory of atopy (predispos iti on to mul tiple al lergic con ditions ) or pos itiv e tes ts in atopy sc reen ing (2,17,25,27,35,39,40,41,42,43). Many hav e a his to ry of an anap hylac tic reac tion in the pas t (8,36,43). S ome s tud ies h av e found a connec ti on between an al lergy to an anes thes ia-re lated agent and latex (43,44). Many pati ents wi th Type I la tex allergy hav e a his tory of alle rgy to certa in foods , i ncl uding bananas , mang oes , wate rmelons , av ocados , peaches , figs, apples , ches tnuts , pineapples , k i wi, p ass ion f ru it, apric ots , nec ta rines , pap aya, celery , peanuts , c herri es , s trawbe rries , plums , potato es , and toma toes (2,5 ,25 ,35 ,37,45,4 6). There ma y be c ross sensi tiv ity be twe en la tex an d ficus , grass es , a nd rag weed (47). Patien ts wi th milk p rotein allergies may exh ibit a ll ergic reac tions to l atex produc ts contain ing c asein (48). Indiv iduals wi th hand derma ti tis who wea r la tex g lov es are a t inc reased risk (35 ). A his tory of glov e-re la ted s ymptoms does not re liabl y indicate la tex al lergy; conv ersel y, abs ence of s ymptoms does not rule ou t sens i ti zati on (42 ). Many latex -s ens i tiv e indiv iduals re port s wel l ing o r itching on the hands or other areas af ter con tac t wi th rubber glov es , condoms , d iap hra gms , toys , or othe r rubber produc ts . Other s ymptoms inc lude s wel ling or i tchi ng at the l ips o r mouth f ro m blowi ng up bal loons o r after dental ex aminations (2). Latex al lergy inc id ence is highes t fo r patie nts requ iring multiple opera tions along wi th repeti tiv e urinary c a thete ri zation. Th is i ncl udes patien ts wi th mye lo dysplasia, congen ital orthopedic d efec ts , and c ongenital g eni touri nary trac t abno rmali ties (49). Spina bifi da pati ents hav e a particu la rly high inc id ence . Howev er, adul ts with sp ina l cord in ju ri es hav e a l ow ri sk of l atex sens i ti za tion (50). Othe r high risk groups i nc lude patien ts who undergo re peated es ophageal d il ations , pati en ts who hav e frequent v aginal ex ams (partic ul arl y those go ing through an in v i tro ferti li zation program) and are examined wi th a l atex -c ov e red ul tras ound p rob e (51), and p ati ents undergoing barium enema p roc edu res wi th a l atex bal lo on tip (17 ). Other at-risk patients f or latex al le rgy inc lud e those who use gl ov es in thei r dai ly ac tiv i ties : farmers , food-serv ice work ers , gard eners , pain ters , mo rtuary work ers , auto tec hnicians , l aw enforc ement p ers onnel, was te remov al wo rk e rs , hai rdres sers , i ndiv iduals inv olv ed in the manuf ac ture of la tex p roduc ts , and those with prior reac tions to l atex -c on taining dev ic es . App rox imatel y 70 perc en t of adv erse ev ents to la tex repo rted to the Food and Drug Admi nis tration (FDA ) inv olv e hea lth care work ers . W ithin the med ic al profess ion , i ndiv iduals who f req uentl y use dis posable gl ov es , inc luding s urgeons ; anes thesia

prov iders ; operating room, pos tanes thes ia c are u nit (PA CU), and emergency room personnel ; dentis ts and dental ass is tan ts ; and l aboratory tec hnic ians are mo re l ik ely to bec ome latex se nsi tiv e than other h eal th c are work ers . A dul t anes thes iologis ts cha nge gl ov es mo re of ten than p ediatric anes thesiologis ts and hav e an inc reased prev alence of latex se nsiti za tion (52).

Diagnosing Latex Allergy

Latex al lergy is diagnose d b y h is tory and conf irmato ry tests (53 ).

History
S tanda rd ques tions to sc reen for l atex al le rgy s hould be dev eloped . There are ex amples of sc reening to ols f or pa tients in the l iteratu re that c an b e of ass is tance i n d ev elop ing a qu es tionnai re (46,54). The h is tory s hould inc lud e the risk fac tors and occup ations where latex ex posu re is c ommon, as dis cus sed prev ious ly i n this chapter. P .434

Confirmatory Tests
A patient wi th a his tory s uspic ious for l atex al le rgy may be a c andidate fo r confi rma tory tes ting . Immunol ogic tes ting is not foolproof , partic ula rl y in the cas e of la tex , bec aus e of the numerous different latex protei ns . T es tin g requ ires a v arie ty of latex an tigens , and there c an be no c ertainty that a partic ular an ti gen wi l l be included in the tes t so lution (17 ). B ecause false negativ es can occur, pati ents with a s trong s uspic ion of latex alle rgy s hould be managed in a l atex -safe env i ronment ev en if immunologic tes tin g i nd ica tes a negativ e reac ti on (17).

Skin-prick Test
The s k in-p rick tes t (SP T) is used to detec t T ype I latex allergy (38). A dilute so lution of latex al lergen is pl aced o n the sk in, and the skin is prick ed or sc ratc hed . A wheal -and-flare reac tion is considered pos i tiv e for l atex sens i tiv i ty . This tes t is i nexp ens iv e and eas y to adminis te r and interp ret. It offers reasonabl y good sens i tiv ity and spec if ici ty. Retros pec tiv e s tudies sho w that p atien ts wi th i ntraop era tiv e l atex anaphylax is are a lmos t i nv ari ably latex -SP T positiv e (42).

Drawbac ks to the SPT inc lude abs enc e of an acc epted tes t so lu tion (2 ,5,9,17,55). The ris k of a s ys te mic anaphy lac tic reac tion ex is ts , but it is less th an with i ntrade rmal tes ti ng.

Intradermal Test
W ith in trade rmal tes ting, a s mall amount of a s us pens ion o r al lergen is in jec te d into the skin. This method is more s ensi tiv e than s k in p rick ing, but the chance of anaphy lax is is greater (1 7,56).

Patch Test
The patc h tes t is av ai la ble for diag nosis of Ty pe IV de layed hypers ens i tiv ity (8,38). A s tanda rdi zed patc h or a fragmen t of the la tex p roduc t is applied to the sk in and checke d ov er s ev eral days . A posi tiv e reac ti on inc ludes i tc hing, redness, s wel li ng, or b listering whe re the patch c ov ers the sk in.

In Vitr o Measurement of Antibodies

In v itro tes ts are used to measure spec if ic antibodies agai ns t la tex a llergens in blood s ampl es (57 ). These tes ts are expensiv e, and the cl inical s ignificanc e of a positiv e serologic tes t is unclear. S ub jec ts wi th a nti latex antibodi es are termed l atex sens itive, al though many are n ot sy mpto matic and may nev er become so .

Challenge Tests
Cha ll eng e (prov oc ation , us e , wear) tes ts ma y be used if the res ul ts of o the r tests are equiv oc al o r if the pers on h as a cl inica l his tory high ly cons is tent wi th l atex al lerg y but resul ts o f other tes ts are negative (5,35,58 ). Th e potentiall y allergic person handl es , wears , or inhales la tex proteins and is obse rv ed for reac ti ons . Howev er, there may be dis c repanc ies in c ha lleng e tes t res ul ts , and no chall enge method has become broad ly ac cep ted by c linici ans .

Preventing Reactions
Suc ces sfu l prev en ti on of l atex reac tions requi res a f aci lity-wid e s trategy. Heal th ca re fac i li ties s hould appoin t a multidis ci pl ina ry task f orc e tha t inc ludes represen tativ es f rom ev e ry profess ion al component of the ins titutio n. It shou ld i ncl ude an al lerg is t or i mmunol ogis t as consul ta nt. It may be a good id ea to hav e a l atex -sens itiv e empl oyee o n the team (9). Among the duties of this tas k force shoul d be glov e selec tion, a mec hanism fo r re porti ng la tex reac ti ons , fo rmul ating polici es and protoco ls for management of the la tex -s ensi tiv e p ati ent, and heal th ca re work er a nd educ ation al programs (2 ,59 ,60).

Medical produc ts that c ontai n latex wi ll need to be i dentif ied and alternativ es es tablished before an eme rgenc y aris es . Ma nufac turers hav e made great s trides in dec reas ing la tex in a v arie ty of p roduc ts (57 ). If i t is not poss ible to re mov e a la tex produc t, barri ers s houl d be pl aced b etwe en th e l atex i tem and the patient. Suc ces sfu l prev en ti on of a ll ergic reac tions wi l l occ ur onl y when ins ti tu tions adopt s tric t pol ic ies to pro tec t at-ris k patie nts f rom unnecessary la tex expos ure. A t-ris k ch il dren in a latex -c ontaining env i ronment are more like ly to h av e an all erg ic reac tion than those in an env i ron ment whe re latex -containing articl es hav e been remov ed (3,61). It is impos sible to total l y e liminate l atex ex posu re. The goal is to c reate a latex safe env ironme nt, tha t is , one i n which the p res enc e of latex an tigens is mi nimi zed. The need fo r educ ation c anno t be ov e remphas i zed . The majority of latex reac tions i n a c enter wi th an es tab lis hed pro toc ol were attrib uted to huma n e rror (6 1). Us ing po wderless glov es s houl d be a high pri ority (5 ,62 ,63 ). It helps to minimi ze reac tions to l atex at l i ttle added expens e and dec reas es th e amount of aeroallergens i n the wo rk i ng env ironment. Oil -bas ed hand c reams or lotio ns shou ld be av oided. They can b reak down la tex and make the pro tein more likel y to s tick to the hands . W hen glov es are powdered, pul ling them on and off gen tl y wil l mi ni mize aeros oli zi ng the la tex p rotei ns . Patients with k nown o r suspec ted latex allergy should h av e thei r rec ords fl agged and we ar l atex -allergy wri s tbands . Drug prophy lax is is s ometimes undertak en (56 ). A lle rgic reac tions , inc luding anaph ylax is , may occur ev en when p rophylac tic agents are us ed (3,64). W hile hav ing thes e drugs alread y on board may lessen the P .435 sev erity of a reac tio n, they may mas k the ea rl y s igns of a naphy lax is , de lay ing recognition and i mplementation of more ag gre ssiv e treatment (17 ). Us ing H 2 block ers ma y inc rease the risk of he art block fo r patients wh o d ev elop anaphy lax is (65). If patients requiring s urgery hav e confi rmed latex s ensi tiv i ty o r c onv inci ng his tori es of latex reac tions , av oiding la tex -c ontainin g produc ts is the onl y effec tiv e therapy . This is not al ways eas y , as latex allergens p ermeate the hos pital . Ev en in the absenc e o f kno wn latex al lerg y, so me p roc edures inv olv ing pa tients with s yndromes such as spi na bif ida s hould be perfo rmed in a latex -saf e area (66 ). Fo r high-ri sk pati ent g roups , av oiding la tex products s hou ld beg in at birth (67).

The FDA requi res that al l medica l produc ts that c ontai n l atex th at may di rec tly or i ndi rec tl y come into c ontac t with the b ody duri ng us e to b ear l abe ls s tating that the produc t contains latex and that l atex may ca use all ergic reac tions in s ome i ndiv iduals (68) (Fig . 15.1). Gov ernmen tal agenci es in many o th er countries hav e s imilar requiremen ts (68). If a produc t does not hav e this wa rning, it is l ikely that the produc t is latex -free unl ess i t is a pharmaceu tical or is not regulated by the FDA . Drug man ufac tu rers are exempt from the l abel ing req ui remen t (69). Manufac tu rers frequently labe l dev ices as la tex -f ree (Fi g. 15 .2). The term hy poal lergenic is no l ong er us ed for dev ices that contai n latex . A t present, the re is n o tes t that can adequately de termine the lev el of latex prote ins in a produc t, and the re is no manuf ac turin g p roc ess that c an reduce the lev el below the minimum requi red to produc e a reac tion in so me p eople. Also , the total p rotein content is not an al ogous to alle rgic risk . The latex -sens i tiv e pati ent s houl d be sc heduled as the fi rs t case of the day wi th al l l atex -containing mate rials remov ed th e precedi ng night to minimi ze ex posu re to ai rborne latex -laden pa rtic les (2). No one sh ould enter that opera ting ro om wi th l atex glov es wi th out s c ru bbing af ter tak ing off l atex glov es or whi le we aring cl othing f rom prev ious latex exp osure.

Figure 15.1 Thermodilution catheter clearly marked as containing latex.

View Figure

S igns sa ying La tex A llergy or Latex Al ert (fo r patie nts wi th s ignifican t ri sk fac tors for l atex al le rgy bu t no ov ert s ig ns or s y mpto ms ) should b e pos ted insi de and o uts id e the opera ting room as we ll as in pe rioperativ e care a reas (Fig. 15.3 ).

Figure 15.2 Device labeled latex-free.

View Figure

P .436

Figure 15.3 A sign indicating possible latex allergy should be placed outside the operating room door.

View Figure

Latex produc ts s hould be limi ted to si tuations where i t is tho ught tha t they are superior to non la tex -containing p rod uc ts . La tex -f ree glov es wi th improv ed f it a nd feel a re av ail able (70). A k i t/cart containi ng latex -free produc ts should accompany the patient throughout his or he r s tay. La tex p rec aution s tick ers s houl d be pl aced o n doc tors ' order s heets and the l ik e. Si gns s tating Latex P recautions or Latex A l le rgy shou ld be plac ed on the wal ls and doors of the patient's ro om. A ny departmen t that is to receiv e a pati ent wi th l atex al lergy o r sens itiv i ty should be notifi ed pri or to trans fer to that department. Peri operativ e c are areas wh ere mul tiple pati ents are man aged i n proximi ty (e.g., preoperativ e holding areas and PA CUs ) should be re-ev aluate d. If powd ered g lov es are us ed in these areas , patien ts may be admitted direc tl y to the operatin g room and remain there du ring their rec ov ery from anes thes ia. If PA CUs hav e is ola ti on rooms , they may be c onv erted to l atex -s afe env ironmen ts f or patients rec ov eri ng f rom s urgery (71). Some health care facil i ti es hav e es tablis hed a spec ific ope rating room whe re al l l atex -containing mate rials are banned . S igns sho ul d be pos ted on al l en trances to that op era ti ng room, reminding me dical p ers onne l of the s i tuation (72). Traff ic in the room s hould be kept to a minimum (2 ). No latex -c ontaining items (i .e., gowns , hats, boots , and c ompression s toc ki ngs ) shoul d be placed on the patie nt. Cords and tubes for al l monitoring dev ices should be plac ed in s tock in ettes and s ecu red wi th non-latex tape (73). Latex -f ree i ntrav enous s tart k its con tai ni ng tourniq uet, bandages , dress ings , tapes , and g lov es are av ail abl e. Intrav enous tubing wi th out l atex in jec tion po rts s hou ld be us ed or all latex injec ti on ports s houl d be taped to p rev ent ina dv ertent punc ture . S topc ocks or one-way v alv es s hou ld be us ed fo r pus h and piggyback medica ti ons . Intrav enous f luid or commerc ial ly prepa red med ica tion bags should be pi erced through the intrav enous tubing port, n ot the latex injec tio n port. A l though reactions to rubber s y ri nge pl ungers hav e been repo rted, no proble ms hav e so fa r been desc ribed in medic ati ons freshly drawn and i mme di ate ly adminis tered (74 ). If latex -contai ni ng s yringes are used , drugs should be freshl y prepared in the sy ri nge i mmedi ately befo re us e. Gl ass s y ringes off er an attrac tiv e al te rna tiv e, and to ta ll y plas tic s yri nges and spec ial needles are av ai labl e (75,76,77). It is bes t to use medic ati on from g lass ampules , if av ai labl e. A l though i t has been adv oca ted that the contents o f a via l should be drawn u p after the rubber s topper has been re mov ed (17,47,78), this may not be benef ic ial and may resul t in

i nc reas ed mic robial contamination a nd was te (79). L yoph ili zed drugs in containers wi th l atex should be reco ns tituted by usi ng a s y ri nge, not s haken in a multidose v ial and wi thdrawn by us ing a fil te r. V ials sho uld be k ept up ri ght and not s hak en (4). A fi l ter s hould be us ed at the bre ath ing s ys tem patie nt port to p rotec t agains t ai rborne latex allerg ens (80,81). It may not be poss ibl e to e nti rely av oid s ome rubber-c ontaining anes the tic equipment-rubber bellows , diaph rag ms , valv es, and tubings (82). Howev er, when these pa rts of equip ment do not come into contac t with the patient and hav e been prev ious ly was hed , no comp lications hav e res ul ted (83). Latex -f ree equipment i nc lu ding fac e masks , ai rway s , mas k s traps , tracheal tubes , bag-v alv e-mask uni ts , res erv oi r bags , ECG elec trodes and pads , s tethosco pes (tub ing o r diaphragm), pulse ox imetry s enso rs , esophageal s tethos copes , nasogas tric and suc tion tubes , tap e, gas hoses , and b rea thing tubes s hould be us ed. Unfortunatel y, some l atex -free res ervoi r bags hav e s uch poo r dis tens ibi li ty that thei r us e ma y c ompromis e patient saf ety (8 4). If an epi dural c atheter adapto r c on tains latex , i t shoul d be rep lac ed wi th a blunt, l atex -free adap tor. Latex -f ree reus able blo od pressu re ins trume nts and accesso ries are av ailabl e i n a v a ri ety of s izes an d mo dels . These inc lude inf la ting tu bin g, co il ed tubi ng, sphygmo manometers , and inf lation bladd ers . W rapping the area under the cuff wi th soft c otton c an p rev ent c ontac t with any l atex in these dev ices. In s ome c as es , s ome improv ising may be neces sary, as wi th a pu lmon ary artery ca the ter (85 ,86 ). From the su rgic al point of v iew, us ing non-latex glov es, d rains , and cathe ters is mand ato ry . Spec ial precautions should be unde rtaken to av oid latex -b ased equipment s uch as i nstru ment mats , rubber-sho d c lamps , v ascula r tags , bu lb s y ringes , rubber bands , and adhes iv e b anda ges . A non-latex glov e c an be used as a P .437 Pen ros e drain, whic h can be a sou rce of la tex hy pers ensi tiv i ty (86A ). W hen latex -sens itiv e patie nts o r s taff hav e been identified, i t is i mportant to prov ide latex -free items . These s hould be col lec ted in to a c art that c an be cal led i nto ac ti on as the need a rises . The A merican Soc iety of A nes thes iolog is ts and others hav e made rec ommenda ti ons for the con ten ts of a latex -safe cart (2,5 9,86). Sugges ted i tems a re l is ted in Tabl e 15.1. Each item should giv e informati on on

l atex content and s hould be rev iewe d for this information p ri or to addi ng the item to the la tex -s afe ca rt o r before use.

TABLE 15.1 Suggested Contents of a Latex-safe Cart Latex-free or glass syringes Syringe needles Intravenous catheters Intravenous tubing and extensions made from polyvinylchloride Stopcocks (in-line, three-way, and single) Latex-free heparin lock caps and T-pieces with side port Alcohol wipes in a new box Latex-safe adhesive tape from a new box Latex-free intravenous tourniquets Sterile gauze pads Esophageal thermometer Disposable blood pressure cuffs of various sizes Isolation stethoscope Sterile case padding Latex-free disposable pulse oximetry finger sensors Latex-free ECG electrodes Latex-free resuscitation bags sized for infants, children, and adults Nasal oxygen cannula Oxygen extension tubing Latex-free tracheal tubes, double-lumen tubes, and stylets Latex-free oral and nasal airways Silicone supraglottic device Plastic face masks and head straps (elastic strap may have latex) Medications for cardiac arrest and emergency situations Vinyl gloves for any size staff Sterile nonlatex gloves, sizes 6 to 9 Silicone urinary catheter in assorted sizes Urimeter Epidural and spinal trays Polyvinylchloride suction catheters, sizes 8 to 14 French Anesthesia breathing circuits without latex components Anesthesia medications in vials In-line high efficiency particulate gas filter Policy binder with all latex policies and protocols Reference guide for latex-containing materials Brightly colored signs that warn of latex allergy

Treating Latex Reactions

The s ymptoms of i rritant contac t dermati tis can often be co ntrol le d b y remov in g the i rritant. Measures inc lude wearing a s oft gl ov e l ine r and reduc ing expos ure to oth er i rritants (e .g., s oaps ). Treatment wi th top ical cortic o-s teroids may be helpful . Us e of p rotec tiv e hand c reams , ho wev er, is contraindic ated (2). For all ergic reac tions , the mos t i mporta nt s tep is to s top adminis tration and/or reduc e absorption of th e off end ing agent. A ll potential routes of ex pos ure , includi ng mucosal and inhalatio nal , mus t be c ons ide red . Top ic al co rtic os teroids can be us ed for a rash or hiv es. Topical n asal s teroids ma y be us ed for rhini tis (2 ). A n ti his tamines and s ys temic s teroids can be used to treat other mil d reac ti ons (2). If the sy mpto ms a re more sev e re, mo re agg res siv e trea tmen t is indica ted , inc luding antih is tamines , sys temic steroi ds, H 2 blockers , ox ygen , in trav enous f lu ids , bronch odila to rs , and epi nephri ne (2,36,87). If anaphy lax is occurs , a rtif icial ai rwa y s upp ort ma y be needed as wel l as i ntrav ascula r v ol ume expans ion , admi nis tration of v as oac tiv e medications , and other l ife-support techn iques . The c rash cart mus t not c ontai n l atex -con taining i tems (2). Latex prec autions shou ld ac company th e pati en t th roughout the remai nde r of the pos toperativ e pe riod (P A CU, i ntens iv e care uni t, and discharge uni t). The deta ils of an y a ll ergic reac tion sh ould be c learly documen ted in the pati ent's chart. This should i nc lu de a desc ription of the an esthetic agents and tech niques , su rgical produc ts us ed, resus ci ta tiv e meas ure s requ ired, lab ora tory ev aluation, and the perioperativ e co urs e. Th e pati en t should be referred to an a llergis t and the pati ent's reco rd f lag ged to a lert subsequent caretak ers . Des ens i tiz ati on by us in g p rog res siv e con tac t has been des c ri bed (88). It c onsis ts of i nc reas ing ex pos ure to latex by we aring l atex glov es da il y fo r inc reas ing periods . Sublingual desens iti zatio n may resu lt in s ignif ic ant improv emen t in s ymptoms (89 ).

Latex Allergy and Medical Personnel

Numerous s tud ies show a hi gh inc idenc e of la tex allergy in heal th care work ers (2,8 ,9,10,11 ,35 ,40 ,41 ,4 2,56,90,9 1,92,93,94,95). Medical personnel who we ar l atex glov es on a regula r basis (s urgeons , anes thes ia prov iders , opera ti ng room s taff , radiologis ts , housek eepi ng s taff, and laborato ry pe rsonnel ) are at highe r risk f or dev el oping latex a ll ergies than are other heal th c are wo rk e rs (4 1,42,72). Occ upati onal as thma has been reported i n a n adminis trativ e e mplo yee who was ex posed to ai rbo rne latex al le rge ns (9 6). P .438

Health Care Institution Responsibilities

Ins titutio ns should prov ide educa tion programs and training materials abou t la tex al lerg y (71). This inc ludes educ ating all s taff membe rs , not jus t p rof es sio nal heal th ca re prov iders . Fo r example , env ironmen tal and nutritional s erv ic e work ers are requi red to wear glov es; the refore, they s hould be knowled geab le about thei r glov e choic es . S taff should be encou rag ed to re port alle rgic s ymp toms a nd be periodic al ly sc reened for la tex -allergy s ymp toms . Detecting s ymptoms early a nd pro tec ting s ymptomatic work ers from latex ex pos u re are essenti al for p rev enting long-term health ef fec ts . P rev ention s trategies shoul d be re-ev alu ated whenev er a work er is diagnosed wi th latex alle rgy . S tudies hav e s hown that econo mic all y fe asible i nte rv entions to reduc e l atex ex posu re can s uccessfully allow la tex -all erg ic i ndiv iduals to c ontinue work ing as wel l as dec rease the number of new c ases of oc cupa tiona l la tex allergy (5). The use of powderles s gl ov es (Fi g. 15.4) s houl d be enc ouraged . In a s tudy in whi ch health care work ers used both powd ere d and powd er-free gl ov es, the ra te of conv ers ion to l atex sens i tiv ity wa s the same i n eac h g rou p, but the c onv erters using powdered glov es were s ymp toma tic whereas the ones usi ng powde rless glov es showed no s ymptoms (92). Us ing no n-latex gl ov es for ac tiv i ties that are no t likely to inv olv e con tac t wi th i nfec tious mate rials (f ood handling , hous eke eping, tra nsport) should b e encourage d. This c an greatl y reduc e the lev els of latex antigens in the env ironment. W earin g non-la tex glov es or us ing s ome type of ba rrier between the la tex gl ov es and the sk in s hould be enc ouraged. Non-latex glov es are usual l y mo re ex pens iv e than glov es c ontaining la tex (97). It is l ik el y, howev er, that the pric e d iffe ren ti al c an be dec reased if the fac il i ty were to choos e a s ing le v endor o f la tex -f re e g lov es. If a work er mus t mov e to ano the r jo b to av oid l atex -c ontai ning mate rials and th e new j ob pays l es s, that wo rk e r may be eligibl e fo r work ers ' c ompens ation . It is also possible tha t work ers c ould beco me s o sens iti zed that employ ment is not p oss ible. Very lo w l ev els of permanen t disabil ity are n eeded to make the conv ers ion to l atex f ree gl ov es cos t effec tiv e (97).

Figure 15.4 Gloves that are both powderless and latex-free will help to prevent latex allergy.

View Figure

Fac il i ties should ensu re that good hous ekeepi ng prac tic es are pe rformed to re mov e l atex -containing dus t from the workplac e. This can be acco mp lish ed by id entif yi ng areas that a re c on ta mi na ted wi th latex dus t (c arp ets , uphols te ry, and v en til ati on duc ts ) fo r frequent c lea ning a nd cha nging ven ti la tion fil te rs and v acuum bags f requentl y. Some health care ins titutions require that bal loons that often ac company flower arra ngemen ts be non-l atex (98). For s ens itized health care work ers , th e A me ric ans with Dis abi li ties Ac t gua ran tees work ers reas onable modif ic ation of the work pl ace to accommodate the dis abil i ty . The Oc cupa tiona l S afety a nd Heal th Adminis tra tion (OS HA ) ru les s tate that in additi on to gl ov es tha t are normall y prov ided, non-la tex g lov es, g lov e li ners , powderles s glov es , or other s imi lar al te rna tiv es s hal l be readil y accessible to those employees who are allergic to l atex glov es (9).

Health Care Worker Responsibilities

W orkers in health care need to tak e a dv anta ge of latex allergy education and trai ning to become f amil iar wi th way s to prev ent l atex allergy and to learn to recognize the s ymptoms . W orkers shou ld protec t thems elv es from la tex expos ure insi de and o utside the work plac e. Non-latex glov es shoul d be used f or ac tiv i ties that a re no t like ly to i nv olv e c ontac t wi th i nfec tious materi als . Intac t sk in is an effec tiv e b arri er, and it is i mportan t to maintai n good hand care. Cuts and open sores sho ul d be c ov ered wi th a pl as tic b arrie r dressing prior to we ari ng latex glov es (99). Oil -based hand c reams

or l otions should b e av oided , as th ey may enhance the re lease of latex proteins f rom the glov es (54). A fter remov ing latex gl ov es , hands should b e was hed wi th a mi ld so ap and dried thoroughl y. This wi ll dec reas e the load of a llergen. Hea lth care work ers s hould av oid wea ri ng work c lo thes (sc rubs ) ho me after work i ng i n the op era ti ng room (99). Indi rec t exposu res hav e caus ed latex allergy in c hildren and s pous es . If s igns and s ymptoms of latex al lergy dev elop, the pe rson s hould av oid c ontac t wi th l atex -c ontaining produc ts un ti l he or s he c an be s een by a phys ic ian who is ex perienc ed in dia gnos ing and treating latex al lerg y. A diary of s ymptoms sh ould be kept. Delay and P .439 se lf -tre atme nt can dela y diagnos is , allo win g the problem to become more s eri ous .

The Health Care Worker with Latex Sensitivity

Depending on the sev eri ty of the reac ti on, latex sens i tiv i ty in health care work ers can be a n inc onv eni ence or a l ife-threatening haza rd. It c an mean the e nd of a ca ree r (100,101). Often, heal th c are p ers onnel are unaware of thei r sens i ti zati on, as the s ymp toms c an be nons pecif ic (99). The on ly cl ue might be the temporal rela tions hip wi th work ing . Deni al c an be a pro blem. Latex -al lerg ic an esthes ia prov iders s hould b e c ounseled on the risks of c ontinued work in env i ronments with high latex us e and on s trategies to li mit exposure. Th ey shoul d hav e prope r allergy identification, inc lud ing a medic al al ert dev ice , and shoul d inform thei r hea lth care prov iders (inc luding den tis t a nd local h ospi tal). They may wan t to c a rry an al lergy ki t, incl udi ng an epinep hrine au to-injec tor dev ic e, nonl atex glov es to wear or g iv e to others to wear if they mus t care fo r them, and a co mple te l is t of med ica tions taken. Frie nds and fami ly s houl d be giv en info rmati on about latex allergy . The i ndiv idual must be o n the lookout f or hi dden l atex . Cons ideration s hould be giv en to av oiding foods that may co nta in protei ns similar to thos e in latex . Onc e latex alle rgy is diagnosed , the only opti on is to av oid c ontac t wi th l atex and to try to c ontrol the s ymptoms . A lmos t all the p rod uc ts tha t hea lth c are work ers encoun ter in thei r daily wo rk c an b e ma de la tex -f ree. A latex -s afe env ironment also prev ents expos ure of oth er work ers . The re are many non -l atex glov es av ai la ble , both s teri le and nons te rile . Thes e i ncl ude v iny l, n itri le, s tyrene bu tad iene, an d n eoprene (2,53,97,102). Unfortunately ,

these may not match the p hysica l cha rac te ri s tic s of la tex g lov es such as high elas tici ty, s trength , fl exibi lity, tear res is tance, tac tile s ensation, an d barri er i nte gri ty (5,53,103 ). L atex glov es are bi odegradable a nd do not p roduce ha zardous and tox ic emissi ons wh en inc inerated, as do s ynthetic glov es. Non-l atex glov e l iners and latex glov es with in teg ral non-la tex layers are av ailable (9 ). Co -work ers shoul d wear po wderless, l ow-la tex a llergen glov es. This reduc es the expos ure to l atex by those who are not y et sens i ti zed and ma y dec reas e symptoms i n s ens i tiz ed pati ents (2,10,12 ,16 ,96 ,104,105). Hea lth care work ers wi th l atex sensi tiv i ty are not a t inc reased risk when i nci den tal l y exposed to d ry, mo ld ed, or ex truded rubber p roduc ts in the heal th c are env ironment; howev er, if d irec t c ontac t with such objec ts is ro uti ne , ex posure shoul d be mini mized by cov ering the objec t or ex pos ed body pa rt (5). Bec aus e of the many fac to rs that diss eminate latex alle rgens and becaus e latex al lergens are s o prev alent in s ome areas , it may not be p ossible to c ompl ete ly i sol ate work ers f ro m these al lergens . In this c ase , job reas si gnmen t may be necess ary . In the s ev erely a llergic wo rke r, it may no t be pos si ble to find an area in the heal th c are fac il ity that wi ll be s afe.

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42. A rellano R, B radley J , Suss man G. P revalenc e of la tex s ensi tization among hospi tal physic ia ns occ upationall y ex posed to latex glov es. A nes thes iology 1992;77:905908. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 43. Tan BB , Lear J T , Wa tts J, et al. P eriop era tiv e coll aps e: prev alence of latex al lerg y i n patients sens itiv e to anaes thetic a gents . Contac t Dermatitis 1997;36 :47 50. [Cross Ref] [Med li ne Link ] 44. Watts J . La tex allergy. A naes thesia 1997;52:1019. [Fu ll tex t Link ] [Med li ne Link ] 45. Hamid RKA . Latex al le rgy . Diagnos is , managemen t and s afe equ ipment(ASA Ref resher Cours es ). A tla nta : AS A , 1995. 46. Haebe rl e HA , Lup ic D, Mi doro-Horiuti T, et al . Rol e of c ross -al lergies to latex in c linic al routine of anes thes ia. J Cli n Anaes th 200 3;15:495504. 47. Kam PCA , Lee MS M, T hompson J F. La tex allergy: a n emerg ing c linical and oc cupa tiona l heal th pro blem. A naes th esi a 1997 ;52 :570575. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 48. Pask awi c z J , Chatwa ni A . Latex all ergy: a c once rn for anes thes ia personnel . A m J Anaes thes iol 20 01;28:435441. 49. Porri F, P radal M, Le miere C, et a l. A ssoc ia tion between l atex sens i ti zation and repeated latex expos ure in c hildren. Anes thes iolog y 1997;86 :599602. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 50. Merttes P M, Mouton C, Fremont S , et al. La tex h ypersensi tiv i ty i n spi nal cord i njured a dul t pati ents . Anaes th Intens Ca re 2001;29:393399. [Med li ne Link ] 51. Bal lantyne JC, B rown E . La tex anaph yl ax is: another case, a nother c ause . Anes th An al g 1995;81:13031304. [Fu ll tex t Link ]

[Cross Ref] [Med li ne Link ] 52. Greenberg RS , Hami l ton RG, B rown RH. Di fferential latex allergy prev alence in anes thes iology s ubspec ial ti es . Anes thesi olo gy 199 9;90:1238. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 53. Rin aldi P A . Pe ri ope rativ e management of the patien t with la tex allergy (ASA Ref resher Cours e #532 ). Orlando: ASA , 19 98. 54. B rown M-M, Hess R. Ma naging latex alle rgy in the c ardiac s urgic al patient. Cri t Care Nurs Q 1998;21:815. [Med li ne Link ] 55. Beez hold DH, S uss man GL. Determin ing the al le rgenic p otential of l atex glov es . Surgical Serv ic es Mgt 1997;3:3541 . 56. Thomas LC, Skerman J H. L atex al lergy: another c omplic ation for anes thes iology . Part 2. AS A Ne ws l ett 1 999;63:17 20. 57. Hepne r DL, Cas te lls MC. Latex all erg y: an up date. Anes th Analg 2003;96:1219 1229. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 58 . Palc zy nski C, W alus iak J , Ru ta U, et al. Occup ati onal al lerg y to la tex . Life threatening reac ti ons i n health care work ers : re port of three c ases . Int J Occ up Med Env iron Heal th 1997;10:297301. [Med li ne Link ] 59. Bai le y DA , Rei lly ME , A tk ins P M, et al. Impl ementi ng a s ys tem for care of pati ents with la tex a llergy. Inf ec tio n C ontrol and S teril ization Tec h 1998 ;4:27 36. 60. Sens t BL, J ohns on RA . Latex al lerg y. Am J Heal th -S ys t P ha rm 1997 ;54 :10 71 1075. [Fu ll tex t Link ] [Med li ne Link ] 61. B irmin gham PK , Ds ida RM, Grayhack J J, et a l. Do latex precau ti ons in child ren wi th mye lod ysp las ia reduc e intraoperativ e all ergic reac tions . J P ed Ortho paed ic s 1996;16:799802. 62. Mos er D . How our hospi ta l tackled l atex sens itiv ity. Ou tpatient Surgery Maga zine 2001 ;11 :6272 .

63 . Lee J . W ha t's new i n latex -and po wder-fre e g lov es . Outp ati en t S urgery Maga zine 2003 ;4:5660. 64. Setloc k MA , Cotte r TP , Ros ner D. Latex allergy: fai lure of pro phylax is to prev ent sev ere reac tion. Anes th Analg 1993;7 6:650652. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 65. Patterson LJ , Mi lne B . Latex anaphylax is caus ing heart bloc k : role of ranitid in e. Can J A naes th 1999 ;46 :776778. [Med li ne Link ] 66. Land wehr LP , B ogu nie wic z M. Current perspec tiv es on l atex all ergy. J Pediatric s 1996;128 :3 053 12. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 67. S wartz J , Leona rd M. P rev enti on of l atex al lergy . Anes th Analg 1993;77:108 0. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 68. Anonymous . FDA fol lows other gov ernments re qui ring l atex product labeling . B iomed S afe S tand 1997 ;18:150151. 69. Royer K . Choos ing la tex -f ree s uppli es . Ou tpa tient S urgery Mag azi ne 2004; 5(10)(s uppl ):2224. 70. Wasek S . W ha t's new i n s urg ic al glov es. Outpatient Su rge ry Maga zi ne 2006;7(2 ):7276. 71. Shoup AJ . Gui deli nes fo r the ma nage ment of latex al lerg ies a nd safe use of l atex in pe rioperativ e prac tice se ttings . A ORN J 1997;66:726 730. [Cross Ref] [Med li ne Link ] 72. Anonymous . FDA proposes new la bel in g regu lati on fo r latex -c ontain in g produc ts . Tec hnol A nes th 1996;17:1 3. 73. Redmond MC. Latex al lergy : rec ogni tio n a nd perioperativ e man agemen t. J Pos t Anes th Nu rs 1996;11:612 . [Med li ne Link ] 74. A rms trong TS H, B arr J M. Latex alle rgys trategies for management. Anaes thes ia 1998;53:1236 .

[Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 75. Kubasie wic z MK . Latex al le rgy and nonlatex sy ri nges . Anes th Analg 1996;83:1352 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 76. Mos tel lo LA . The c l in ic al s ignif ic anc e an d ma nagement of la tex al lerg y (ASA Annual Refresher Cours es ). Ne w Orle ans : ASA , 1996. 77. Nyabadza M. P rev enti ng latex sensitisation and fo reign bo dy mic ro-embol i . Anaes thes ia 2001;56:705. [Fu ll tex t Link ] [Med li ne Link ] 78. Anonymous . Americ an A ssoc ia tion of Nu rse An es thetis ts latex al le rgy protoco l. J Am A ssoc Nu rse A nes th 1993 ;61 :223224. 79. Thoms en DJ , Burk e TG. Lack of latex all ergen c ontami nation of so lutions wi th dra wn f ro m v ials wi th natural rubber s toppe rs . Am J Hea lth S ys t P harm 2000;57:4447. [Fu ll tex t Link ] [Med li ne Link ] 80. Barbara J , Chabane MH, Leynad ier F, et al . Re ten tion of ai rborne la tex partic les b y a bac teri al and v i ral fi lter used i n a naes th esi a. Anaes thes ia 2001;56:231234. [Full tex t Link ] [Cross Ref] [Med li ne Link ] 81. Barbara J , S antais MC, Lev y DA , et al . P rev ention of latex sens i ti za tion in guinea p igs b y a b ac terial and v i ra l fi l ter used i n anaes thes ia. B r J A naes th 2005;95:349354. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 82. Watts J . La tex allergy. A naes thesia 1997;52:1019. [Fu ll tex t Link ] [Med li ne Link ]

83. Hol zman RS . La tex a llergy: an emerg ing OR problem. Anes th A nal g 1993;76:635641. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 84. B lansha rd HJ , Mi lne MR. Latex -f ree reserv o ir bags : exch anging one potential hazard for another. Anaes thes ia 2004 ;59:177179. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 85. Wakak uwa JS , Shulman MS . Latex alle rgy and cardiac surgery. Anesth A nal g 2003;97:1545 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 86. Berns tein ML. Latex -s afe emergenc y cart produc ts l is t. J Emerg Nurs 1998;24:5861. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 86A . Bai le y P D, Bas tien J L. Intraoperativ e latex hypersens itiv ity: do not ov erlook Pen ros e drains . J Clin A nes th 2005;17:485487. [Cross Ref] [Med li ne Link ] 87. Opsome r O, Van Bov en M, Pendev i lle P, et al. An unus ual p res entation of latex al lerg y. Can J Anaes th 1993 ;40 :1000. [Med li ne Link ] 88. Patri arc a G, Nuce ra E , Bu onomo A , et al . Latex alle rgy desens iti zation by ex posu re protocol ; f iv e c ase reports . Anes th Analg 2002;94:754758 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 89. Patri arc a G, Nuce ra E , Po llas trini E , et al . S ubli ngual desens iti zation: a new approach to l atex al le rgy problem. A nes th Anal g 200 2;95:956960. [Fu ll tex t Link ] [Cross Ref]

[Med li ne Link ] 90. Hees e A , Hintze nstern J V , Peters K -P , e t al . Al lergic and i rritant reac tions to rubber glov es i n medical heal th se rv ic es. J A m Acad Dermatol 1991;25:831839 . [Med li ne Link ] 91. Hunt LW , F rans way A F, Reed CE , e t al . A n epidemic of oc cupa tiona l al le rgy to l atex inv olv ing heal th c are wo rk e rs . J OE M 1995 ;37 :12 041 209. 92. Suss man GL, Liss GM, Dea l K , et al. Inc idence of latex s ensi ti za tion among l atex glov e use rs . J A llergy Clin Immumo l 1998;101:171178. 93. Zuck er-P inchoff B . Latex alle rgy : a personal perspec tiv e. ASA News lett 1999;63:1213. 94. Hack M. The p rev al ence of latex all ergy in opera ting theatre s taff. A naes th Intens Care 2001;29:4347. [Med li ne Link ] 95. Kac zmarek RG, S ilv e rman B G, Gross TP , et al . P rev alence of latex -spec ific IgE anti bodies in hosp ital pers onnel. A llergy Asthma Immunol 19 96;76:5156. 96. Vandenpl as O, Del wi c he J -P , S ibi lle Y. Occ upa ti onal as thma due to l atex in a hospi tal adminis trativ e employee . Thorax 19 96;51:452453. [Fu ll tex t Link ] [Med li ne Link ] 97. Phi ll ips V L, Goo drich MA , Su lliv an TJ . Heal th c are work er dis abi li ty due to latex al lerg y and as thma: a c os t anal ysis . Am J Publ ic Heal th 1999;89:1024 102 7. [Med li ne Link ] 98. Anonymous . Latex al le rgies : what y ou should k now. S a me Da y S urg 1999;23:7376. 99. Rande l GI. Latex al le rgy : who is n ex t? ASA News l ett 1997 ;61(5 ):141 7. 100. Baur X , Ammon J , Ch en Z, et al. He al th risk in hos pitals th rou gh ai rbo rne al lergens fo r patients p re-sens i tized to la tex . Lancet 1993;342 :11481149. [Cross Ref] [Med li ne Link ] 101. Lee J . S ev en wa ys to tel l if your s taff is a risk f or latex all ergy. Outpatient Surgery Magaz ine 2003;4:6672. 102. Zuc ker-P inc hoff B . Latex -al lerg y organi zation rec ommends man y new nonl atex glov es as safety tools . APS F News lett 1999;14:49. 103. Olsen RJ , L ync h P , Coyle MB , et al . Ex amination glov es as barri ers to hand contamina ti on in c linical prac tice . JA MA 199 3;270:350353. [Cross Ref]

[Med li ne Link ] 104. Lev y DA , A l louache S , Chaba ne MH, et al . Po wder-f ree p rotei n-poor natu ral rubber latex glov es and latex sens iti zation. JA MA 1999;281:988 . [Cross Ref] [Med li ne Link ] 105. Hunt LW , B oone-Ork e JL , Frans way AF , et al . A medic al -center-wi de mul tidisc ipl inary approac h to the p rob lem of n atural rubber l atex al le rgy . J OE M 1996;38: 765770. P .441

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. Wha t fac tors contribute to the increasing in cid ence of latex allergy? A . Inc reas ed length of surgical procedu res B . Changes in the manuf ac turin g p roc ess C. Younge r peop le en teri ng the he al th ca re indus try D. Inc reas ed use of l atex produc ts becaus e of un iv ers al prec autions V iew A ns we r2. Wh ich are likely routes of sensitizatio n to latex? A . Sk in c ontac t B . Inha lation C. Inges ti on D. Pa ren teral injec tion V iew A ns we r3. Wh ich item(s) listed below is unlikely to cause latex alle rgy? A . W heelc hai r tires B . W as hed v enti lato r bel lo ws C. S y ringe plungers D. P roduc ts s teri li zed wi th e thylene oxide

V iew A ns we r4. P ow dered glo ves pose a greater threa t tha n thos e w ith out pow der beca use A . Latex p rotei ns bind to the powder B . Th e powde r contains all erg ens C. Po wder may s pra y into the operating room when th ey are donne d o r re mov ed D. Fi l ters in the v entil ati on s ys tem ma y b ecome c logged V iew A ns we r5. Wh at are the symptoms of irritant con tac t derma titis? A . Sk in c rac king B . Itc hi ng C. Sc aling D. Dryness V iew A ns we r6. Wh at are the characteristics of T ype IV hypersens itivity? A . De layed hypers ens i tiv ity B . A l way s s ta ys wi thin the a rea of the an ti gen C. May be assoc ia ted wi th d iz ziness D. Sk in rash is s een wi th in 5 hou rs V iew A ns we r7. Characte ristics of T ype I hypersensitivity in clude A . Reac tio ns may lead to morta li ty o r morbidi ty B . S y mpto ms c an occ ur da ys la ter C. Reac tions range from mi ld to sev ere D. They are media ted b y IgF antibodies V iew A ns we r8. P rimary clin ica l fe atures of T ype I hype rse nsitivity include A . B ronc hos pas m B . Cu taneous s ymptoms C. Cardiov ascular s ymptoms D. Neurolog ic sy mptoms V iew A ns we r9. Wh at are the impo rtant points to lo ok for w he n taking a history in a n a ttempt to de termine the pre sence of latex alle rgy? A . Hand dermati tis in conj unc ti on wi th wea ri ng l atex g lov es B . S ens i tiv i ty to ra gweed C. Food al lergy to wate rmelons , pi neap pl es, s trawberri es , and tomatoes D. P redispos i ti on to mu ltip le al lergic c ondi tions V iew A ns we r10 . Whic h conditions are assoc iated w ith a high incidence o f latex a llergy? A . Genitouri nary trac t abnormal ities

B . Congen ital orthope dic d efec ts C. Es ophageal s tric tu res D. Sp ina l cord in ju ry V iew A ns we r11 . Impo rtant features of the SPT include A . High inc idence of anaphylaxis B . Reas onabl y good s ensi tiv i ty and s peci fic ity C. Av ailab il i ty of a go od tes t soluti on D. Pa tients with anaphyl ax is du ring s urgery are al mos t inv ariably s k in-p rick pos itiv e V iew A ns we r12 . P re ventive measures for latex allergy inclu de A . De termin in g the produc ts that contain latex B . Us ing o il -based hand c reams or l otions C. Us ing powderless gl ov es D. To tall y eliminating latex ex posu re V iew A ns we r13 . Considerations for drug prop hylaxis include A . H 2 b lockers may inc rease the risk f or pati ents with heart bloc k B . It may mas k the s igns of anap hylax is C. It may delay impl ementation of treatment, i f anaphylax is oc curs D. It wi ll p rev ent anaph yl axis V iew A ns we r14 . Regarding lab eling fo r latex con ten t, A . If the label do es not indic ate that i t contains latex , it is l atexf ree B . P roduc ts not regulated by th e FDA mus t be l abe led if they conta in latex C. Drug manufac turers mus t labe l produc ts regarding la tex D. The FDA requ ires that al l med ic al produc ts that may d irec tl y or indi rec tl y con tac t the body be labeled if they contain l atex V iew A ns we r15 . S urg ical precautions tha t need to be take n if a patient is know n to be latex sensitive inc lude A . No one s hould enter the ope rating room we ari ng latex glov es B . Th e case s houl d be pos ted for the fi rs t cas e of the day C. Clothes that hav e not been ex pose d to latex shou ld be worn D. La tex a le rt s igns s hou ld be pos ted ins ide a nd outsi de th e room V iew A ns we r16 . Whic h s teps can be taken to limit the like lihood of latex alle rgy resulting from intravenous or p aren teral injec-tions? A . Us ing medic ations supp lied in a mpules B . Us ing g las s s yrin ges C. P repa ri ng drugs jus t befo re use D. Us ing rubber syri nge plung ers

V iew A ns we rP .442

17. Methods to treat irritant c ontact de rmatitis include A . Reduce ex pos ure to the i rritant B . Us e o f a plas tic glov e l iner C. Topical c orticos teroids D. P rotec tiv e hand c ream V iew A ns we r18 . S te ps tha t health ca re w orkers can take to protect themselves against latex exposu re include A . W as hing hands after l atex glov es a re remov ed B . Us ing n on-latex glov es where infec tious material wil l no t be enc ountered C. Cov ering breaks in the skin wi th a pl as tic b arrie r D. Us ing oil -based c reams or lotions V iew A ns we r

Chapter 16 Face Masks and Airways

P .444

Face Masks
The f ace mas k allows gas adminis tration to th e patien t from the breathing s ys tem wi th out introduci ng any apparatus in to the patie nt's mouth. The abi li ty to hol d the mask and to ad minister posi tiv e press ure v entilatio n through the mask is a basic sk il l that a ll anes thesia p rov ide rs mus t mas ter. In the pas t, the face mask was often been used to adminis te r an entire anes thetic . Mo re rec en tly, the introduc tion of supraglo ttic airway dev ic es (Chapter 17) has led to a dec rease in this prac tice . W hi le so me s upragl ottic ai rway dev ices have the word mas k in thei r ti tles , they are v e ry different f ro m face mas ks and are dealt wi th s eparately in Chap ter 17. The f ace mas k is also us ed to ad minis ter no ni nv as iv e posi tiv e pres sure v entil ati on (NPPV ) f or treatment of respi ra tory failure (1,2).

Description
A face mask may be cons truc ted of a numbe r of s ubs tanc es , inc luding blac k rubber, c lear plas tic , an el astomeric material , o r a c ombinatio n of these . The majori ty of anes thetic s today empl oy a dispos able plastic mas k . Th ese mask s are desi gned to f it a wi de v ariety of patients and are no t as eas y to us e as ma ny ol der mas ks that were s i zed and anatomic al ly des igned to f i t a narrowe r ra nge of pa ti ents .

Body
The body (s hell, dome) c ons ti tutes the mai n p art of the mask (3 ). A transparent body allows o bserv ati on fo r v omi tus , sec re tions , blood, lip c olor, and ex haled mois ture . A transpare nt mas k ma y be better acce pted b y a c ons c ious patient (4).

Seal
The s eal (ri m, f lap , edg e) is the pa rt of the mas k tha t comes in con tac t wi th the fac e. Two gene ral typ es are av ailable. One i s a p ad (c ushi on) that is inf lated wi th ai r or fil led wi th a mate rial that wil l c onfo rm to the fac e when press ure is appli ed. The s ec ond typ e is a flap that is a flex ible ex tens ion of the body that confo rms to the contour of the fac e. It is p res sed on to the fac e to c reate a s eal .

Connector

The c onnec to r (orifice, col la r, mount) is at the op posi te s ide f rom the seal. It cons is ts of a th ick ene d fi tting wi th a 2 2-mm in ternal diamete r. A ring wi th h ooks (Fig . 16.1) may be pl ac ed around the connec tor to allow a mask s trap to be attached .

Specific Masks
Mask s come in a v ariety of si zes and shapes (F igs . 16.1, 16.2 ). An as sortment shoul d be k ept readil y av ail able, because no one wi l l fi t ev ery face we ll .

Figure 16.1 Clear, disposable masks. (A, Picture courtesy of Kendall; B, Courtesy of Rusch, Inc.)
View Figure

P .445

Figure 16.2 Black rubber masks. (Courtesy of Sun Med.)

View Figure

Rendell-Baker-Soucek Mask
The Rendell -Bak er-S oucek (RB S ) mask (Fig. 16.3), whi c h is desi gne d for the pedia tric pa ti ent, has a tri angul ar bod y. It has a l ow dead s pace (5,6 ). So me of these mas ks are s cen ted and ma y hav e a pac if ier (F ig. 16.3B). This mask has been us ed for the pa tient with a tracheostomy (7,8,9) and a pa tient with ac romegaly (10). It may also be useful when a mask to cov e r onl y the n ose is needed (11 ).

Endoscopic Masks
An end osc opic mask is des igned to al lo w mas k v enti lation whi le an endosc ope is being us ed (12,1 3,14,15). One is s hown i n F igu re 16.4. A po rt/diaphra gm in th e mask body al lows a fiberscope to be i nse rted in to the nose or mouth. A lighted s tyl et (Chapter 19) may also be us ed (16 ). A trac heal tub e prev iousl y lo aded ov er the fiberscope or l ighted s tyle t can then be adv anc ed, if des ired.

Scented Masks
S ince f ace mas ks are often used for an inha la tion anes thes ia induction or for preox ygenation prior to i nduc tion , efforts hav e been made to mak e this experienc e more acceptabl e b y us ing sc ents to camou flage the odo rs of i nha la tional agen ts (17,18,19,20,21,22,23,24). The s cent ma y be incorporated into the mask by the manufac tu rer o r app li ed to the mask by the anes thes ia prov ider (Fi g. 16 .5). S ome mask s are c olo r coded acco rding to the s cent. The e thy l alcohol i n s ome appl ied f rui t f lav ors ma y affec t the accuracy of some gas monitors (25 ,26 ). P re-sce nted mask s from the man ufac turer do not pres ent this pro blem (25).

Techniques of Use
The f ace mas k s hou ld f orm a tight s eal on the pa tient's fac e whil e fi tting co mfortably i n the user's hand. A prope r seal is es sen tial ly for preox ygen ation (27,28). A poor f it req uires the anes thes ia prov i der to main tain s teady p res sure. This may lead to c ramped hands and ti red muscles and l imits the user's ab ili ty to perform other task s . W i th spontaneous res pi rati on, a loose s eal wi l l res ul t in P .446 ai r dilu ti on. Wi th assis ted or controll ed v enti lati on, adequate gas exchange may b e i mposs ib le wi th a poo r mask fit. An inadequate seal can be co mpens ated for s ome ex ten t by inc reas ing the fresh gas flow, bu t th is is was teful an d c ontaminates the room with anes the tic gas es and v apors .

Figure 16.3 Rendell-Baker-Soucek masks. A: Clear plastic version. (Courtesy of Rusch, Inc.) B: With pacifier. (Courtesy of Ohio Medical Products, a division of Airco, Inc.) C: They are also available in black rubber.

View Figure

Figure 16.4 Endoscopic masks. (Pictures courtesy of VBM Medical, Inc.)

View Figure

Correc t mas k use s tarts wi th sel ec ti on of the app rop ri ate s ize and sha pe. Th is may requi re s ome trial and error. The s malles t mask that wi l l do the job is th e mos t desirable bec aus e i t wi ll caus e the leas t incre ase in dead space, usua ll y be eas ies t to hold, and wi l l be less l ikely to res ul t in press ure o n the eyes . If a sea l is d iffic ult to es tabl is h, reshapin g the mark 's malleable peri meter, altering the amount of air i n the seal or se lec ting a different mas k may be helpful. If there is a leak , the mas k shoul d be c hec ked to make c ertain there is an ad equa te sea l between the breathing s ys tem c onnec to r and the mask (29).

One-hand Method
The re are sev e ral meth ods of holding a mas k to maintain an open ai rwa y and a tigh t s ea l. A co mmonl y us ed method is shown i n Fi gure 16.6. The thumb and index f ing er on the left h and are placed on the mask body on oppos i te s ides of th e connec tor. These fingers push down ward to hol d the mas k to the fac e and prev ent l eaks . A ddi tional d ownward pressu re, if requi red, c an be exerted by the a nes thesia prov ider's chin pushing d own on the mas k el bow. Th e remaining thre e f ingers are place d on the mandible or the inf erior part of the mask . It is impo rtant that the applied press ure does not dec reas e a irway patenc y. Ca re shoul d be tak en to prev ent press ure on the eyes. In s ome cas es , i t may be neces sary to ex tend the f ing ers to the ri ght s ide of the mas k to get a g ood seal. It may be benefic ia l to gathe r part of the le ft c heek a round the lef t bas e of the mask wi th the pal m of the l eft hand .

Figure 16.5 Adding scent to the face mask may make inhalational inductions more pleasant.

View Figure

P .447

Figure 16.6 Holding the mask with one hand.

View Figure

Two-handed Method
A sec ond method can be us ed to open any b ut the mos t difficul t ai rway and ob tain a tigh t fi t (Fi g. 16.7). It requires two hands , so a sec ond pe rson is nec ess ary if as s is ted o r con trol led resp iration is needed. T he thu mbs are plac ed on ei ther side of the mas k body. The index fingers a re placed under the angles of the ja w. The

mand ib le is lifted and the head ex tended. If a leak is pres ent, downwa rd press ure on the mask can be inc reased by pres sin g down on the mask wi th the anes thes ia prov ider's chin on the mas k elb ow (Fi g.16.7B ). If a s econd pers on is not av ail ab le, the anes thes ia v enti lator c an be used to sup ply p osi tiv e press ure wh il e the ai rway i s held open by bo th ha nds (30).

Two-handed Jaw Thrust

Ano the r method to open the airway i s to hav e one person s tan d a t the h ead of the pati ent a nd perform a jaw th rus t at the ang le of the l eft mandible whi le the right hand compress es the res erv oir bag (31). The s ec ond pers on s tan ds at the patient's shoul der, fac ing the f irs t pers on. This s econ d person's ri ght hand c ov ers the lef t hand of the fi rs t person , and the left ha nd ach iev es ri gh t-s ided jaw thrus t and mask seal.

Claw Hand Technique

The c law ha nd tec hnique is us eful for c hildren un dergoing sho rt-du ration ophth almic procedures (32 ). The a nes thes ia p rov ider s tands a t the s ide o f the bed, P .448 fac ing the c hi ld . The face mask is appl ied to the face by us ing the ri ght hand wi th the palmer su rfac e fac ing upwa rd. The ring f ing er goes unde r the angle of th e jaw, and the middle fi nger is pl aced under the an gl e of the jaw on the left. The i ndex f ing er and thumb enc i rc le the b ody of the mas k . The anes thes ia prov ide r the n tigh tens the g ri p on the mas k to ac hiev e a good f it. The l i ttle f inger is kept free.

View Figure

Figure 16.7 A: Holding the mask with two hands. Also shown is the Esmarch-Heiberg maneuver, which involves dorsiflexion at the atlanto-occipital joint and protrusion of the mandible anteriorly by exerting a forward thrust on the rami. B: The anesthesiologist's chin on the mask elbow helps to create a better seal between the mask and the patient's face.

Bearded Patient Techniques

Ach iev ing a s atisfac tory mask f it is of te n d iff icu lt when the patien t has a beard. One so lution is to shav e the beard (33). This is usual l y not ac cep tab le to the pa tient. Ano the r solution is to use a s upraglottic ai rwa y dev ice (34). In s ome c as es , i t may be poss ible to place the ro und end of the mas k between the l ower l i p a nd the a lv eolar ri dge (35). The beard ma y be c ov e red wi th a c lear adhes iv e drape , a def ibri ll ator pad wi th a ho le cu t in the middle, pl as tic c li ng wrap, or gel and gauze (36,37,38,39,40,41,42 ,43 ). A s mall mas k can be plac ed ov er the nose and the mouth h eld s hut (44).

Mask Ventilation of the Tracheostomy Stoma

A Rende ll -Baker-S oucek mask can be used ov e r a tracheotomy s toma to achiev e control led o r ass is ted v entil ation (8,9). It i s place d a round the s toma wi th the nas al portion poin ting i n a c audal di rec tion so that the mand ibula r curv e res ts on the trac heal reg ion and the apex on th e supras ternal n otc h.

Difficult Face Mask Ventilation

Diff ic ul t mask v entil ation is reported to occur in 5% to 6 % of anes thetics (45,46,47). A v arie ty of fac ial charac teris tics (fa t, emaci ate d, an d edentulous faces as wel l as those wi th p rominen t nares , burns , f la t noses , recedin g j aws ) or other p rob le ms (dra inage tubes in the nos e) wi ll be encountered in c l inical p rac tice. P red ic tors of diff icul t mask v entilation inc lude male g ende r, a bea rd, lack of teeth, ag e ov er 55

years , mac rogl oss ia , hi gh body mass in dex , a his tory of snori ng , inc reased Mal la mpati sc ore, and low thy rome nta l dis tance (46,47). A his to ry of s leep apnea does no t see m to b e a p red ic tiv e si gn of d ifficul t mas k v enti lation (48). The ai rway in these p ati ents may be improv ed by plac ing the hea d i n the sn iffing posi tion (49). The edentulous pa ti ent p res ents the mos t commo n p rob lem. There is loss of bone of the alv eola r ri dge , c ausing a los s of dis tance be twe en the po in ts whe re the mask res ts on the mandible and the nose. Furthermore, the bucc inato r muscle loses i ts tone in thes e patien ts . The c heeks s ag, c reating gaps between them a nd the mas k . A lv eolar process reso rpti on res ul ts i n s hrink ing a t the c orners o f the mouth . Means to i mprov e mas k f i t inc lude i nserting an oral a irway, leav ing the patient's dentures i n p lace, pack ing the che eks wi th gauze spo nges , and inse rting the inferi or margin of the mas k between th e g ingiv a of the mandible and the lower li p (50,51). Patients with fac ial deformities are pa rtic ularl y challenging . Mask ap pl ic ation wi th the nasa l projec tio n poin ted inferiorl y has been used for chil dre n with c ertain faci al deformiti es (3) and fo r patients wi th ac romegal y (10). If the mask is too smal l wi th an o ral airway i n place, the oral ai rway sho uld be remov ed a nd a nasal ai rway used. If a mask i s too long, the mouth c an be elongate d by inserti ng an oral ai rway. If mask v enti lation is nec essa ry f or the patie nt who has a nas ogas tric tube in pl ace , there is usually a l eak around the tube as i t ex i ts the si de of the mask . This leak can be improv ed b y adding den ture adh esive around the tube at the point wh ere i t ex its the mas k (52 ).

Dead Space
The f ace mas k and its adaptor normally co ns titute the major part of the mecha nic al dead spac e. Dead s pac e ma y be dec reas ed by inc reas ing the pressure on th e mask , c hanging the v olume of the cus hion, us ing a s ma ller mas k , ex tending the separati on be tween the insp iratory and expira tory c hannels close to or i nto the mask , or blowi ng a jet of f resh gas into the mas k. The leak induced wi th a poo rl y f itting f ace mask wi l l re duce the dea d s pac e o f the b rea thing s ys tem d uring spontaneous v en ti la tion (53).

Mask Straps
A mask s tra p (mas k holder, in haler re taine r, h ead s trap, hea d harn ess , mask harness, mas k retainer, headband, he ad-res trai ni ng s trap) is us ed to ho ld the mask f irmly on the face. Pa rtic ular ca re needs to be pa id to main taining the airway whe n

us ing a mas k s trap bec aus e obs truc tion is mo re l ik ely to go unreco gnized than whe n the mask is being he ld by the anes thes ia prov ider's ha nd. A typic al mas k s trap (Fig . 16.8) c ons ists of thin s trips a rrange d i n a c i rc le wi th two or four p rojec tions . The he ad res ts in the c irc le, and the s traps attac h a round the mask c onnec tor. The s traps a t the jaw may tend to pull the jaw pos teriorl y. Cross ing the two l ower s traps under the chin may resul t in a better f it and counterac t the pul l f rom the u pper s traps s o that the re is les s tendenc y for the mask to c reep up abov e th e b ri dge of the nose (5 4). The bes t s trap applica tion is a matte r of indiv idual pre ference and may be the bes t res ul t of a tri al -and-e rror process (55). Care mus t be taken tha t th e s traps are no tighter than neces sary to achiev e a seal i n o rde r to av oid p res sure damage f rom the mask or the s traps . They s hould be released peri odicall y and the mask mov ed sl igh tl y. Gauze P .449 sponges p lac ed between the s traps and the ski n wil l help to pro tec t the fac e f rom ex cess iv e pressure. An other risk of using a mask s trap is that i t wi ll tak e longer to remov e the mask if v omi ting or regurgitation oc curs .

Figure 16.8 Mask straps.

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Advantages
Us ing a face mask is ass oc iated with a lower inci denc e of sore th roa t and requi res l ess an es thetic depth than usin g a s upragl otti c dev ice or a tracheal tube. Muscle

relaxants do not need to be us ed to tolerate the mas k. The face mas k may be the mos t cos t-effic ient method to manage the airwa y for s hort c as es (5 6).

Disadvantages
W ith a fac e mask , one or more of the anes th esia prov id er's hands are i n con tinuous us e, and higher f res h g as fl ows are of ten ne eded . During remote anes thesi a (magnetic res onance imagin g and compu te ri zed tomography s cannin g) ai rwa y ac cess is diffic ul t. Co mpared with patients who are man aged wi th a supraglo ttic ai rwa y dev ice , patie nts wh o a re mana ged wi th a face mask hav e more e pis odes of ox ygen des aturation, req ui re more intraoperativ e airway manipul ations , and presen t more diffic ulties in maintaining an ai rway (57,58). In s pontaneous l y breathi ng pati ents , the work of breathing is hi gher wi th a face mask than wi th a sup raglo ttic ai rwa y dev ice or a trachea l tube (59). Us ing a n a irway and/o r continuous posi tiv e press ure wi l l reduce the work of breathing.

Complications
Skin Problems
Dermatitis may occur if the patient is al le rgic to the materi al f rom wh ic h the mask is made (60). The pa ttern of th e dermati tis follows the area of c on tac t between the mask and sk in. Chemic al or gas s teril iz ation of reusable mask s can leav e a resi due that c an c aus e a s k in reac tion (61,62). P ressure nec ros is un der the face mask has been rep orted followi ng prolonged mask app lication in the presence of hy potension (1).

Nerve Injury
P ress ure f rom a mask or mask s trap may resu lt in pressu re inju ry to underl ying nerv es. Forward jaw di splac ement ma y caus e a s tretc hi ng nerv e inju ry. Fortunately , the sens ory and moto r dys func tions rep orted hav e been transient (63,64,65,66,67,68). If exc essiv e press ure o n the face or ex treme forwa rd j aw displac ement mus t be ex erted, trac heal intubati on or a sup rag lo ttic ai rway dev ic e shoul d be c ons idered. The mas k should be remov ed f rom the face periodically and readjus ted to make certa in that c ontinuous press ure is not appl ied to one area.

Foreign Body Aspiration

The diaphragm of an endoscopic mask may ru ptu re during tracheal tube inse rtion, and a pi ec e may be pushed into th e patien t's tracheobronc hial tree (69,70,71,72). Other pa rts of a mask or mask s trap may b e as pi ra ted (73,74).

Gastric Inflation
W hen posi tiv e press ure v enti lation is used wi th a f ace mas k , gases are lik el y to enter the s tomac h (75,76 ). It i s recommended that ins pi ratory pressure be kep t below 20 cm H 2 O (75).

Eye Injury
A corneal abrasi on may be c aused by a face mas k inadv ertently pl ac ed on an open eye (77). Che micals that e nte r the mask cus hion during c leaning and disinf ec tion can be ex pell ed from c racks i n the c ushi on and c ome in to co ntac t wi th the eye whe n the mask is app lied to the face (78,79,80,81). P ressure on the medial ang les of the ey es and s upraorb ital margins may resul t in eyel id edema, c hemos is of the conju nc tiv a, press ure on the supra orb ital or supratroc hlear ne rv e, cornea l inju ry, and tempo rary blindnes s f rom c entral retinal artery oc clus ion (8 2).

Mask Defects
A mask wi th a plas tic me mbrane tha t occ lu ded the c onnec tor has been reported (83). Another mask had a metal P .450 wi re s ticking out of it (84 ). Inco rrec t assemb ly of a fac e mask has been reported (85).

Cervical Spine Movement

Mos t but not al l s tudi es s how tha t mask v entil ation mov es th e c erv ical s pine mo re than commo nly us ed methods of tracheal intubation (86 ,87,88,8 9). This may be of s ignif ic ance in the p ati ent with an uns table ce rv ica l spine injury .

Latex Allergy
If rub ber is a component of a face mask , a s eri ous reac tion ca n occur in the patient wi th l atex al lergy (90,91). This is disc uss ed more fully in Chapter 15. Bec ause of the serio usness of this pro blem, non-l atex masks are recommended wherev e r possible.

Lack of Correlation between Arterial and End-tidal Carbon Dioxide

The dif fe rence between arte rial an d end-tidal carbon diox ide lev els is hi gher wi th fac e mask v entilatio n tha n wi th a trachea l tu be or supraglo ttic d ev ice, partic ul arly wi th s ma ll ti dal v olumes (9 2).

Environmental Pollution
S tudi es show that usi ng a face mask is assoc iate d with greate r operating room pollution wi th anes thetic gases and v apors than when a trachea l tube or supraglo ttic airway dev ic e is us ed (93 ,94 ). Po llution c an be reduced by us ing a c los e ac tiv e s cav engi ng dev ic e (95,96).

User Fatigue
Holdi ng a mask securel y onto the face and at the s ame time ma in tai ni ng the correc t j aw pos i tion c an be diffic ult and may resul t in operator fati gue . Fai lure to ma in tain the correc t jaw p os i tion may resul t in loss of ai rway patenc y o r gas tric dis tenti on.

Jaw Pain
Pos toperativ e jaw pain is more c ommon af te r mask anes thesi a than when a supraglo ttic airway dev ic e is us ed (97 ).

Airways Purpose
A fundamen tal res pons ib il i ty of the anes thes ia prov ider is to maintain a patent ai rwa y. Unl ike other man euv e rs to maintain a patent a irway, s uch as c hin lift, ja w thrus t, and trac heal i ntuba ti on, cerv ical s pine mov emen t does n ot oc cur wh en an ai rwa y is inse rted (98 ). Fi gure 16.9A shows the normal unobs truc ted ai rwa y in a supine pati ent. The air way passage h as a ri gi d pos terior wall , s uppo rted by the c erv ic al v e rtebrae, a nd a co ll aps ib le anterio r wal l, c ons is ting of the to ngue and epiglo ttis . Fi gure 16.9B shows th e mos t c ommon c aus e of ai rway o bs truc ti on. Under anes thesia, the musc les in the floor of the mouth and pharynx s uppo rting the tongue relax , and the tongu e and epiglottis fal l back into the pos teri or pha rynx , oc c luding the airway . The purpose of an ai rway is to lift the tongue and epiglottis away f rom the pos terio r pharyngea l wal l and prev ent them from obs tru c ting the space abov e the larynx . Us ing maneuv e rs suc h as dors iflex ion at the atl anto-occ ipi ta l join t and protrus ion of the mandible anteri orly ma y s ti ll be nec essary to ensu re a patent airway (99). A n oral or nasa l ai rwa y d ec reases the wo rk of b rea thi ng du ring s pontaneous b rea thing us ing a face mas k (59).

Figure 16.9 A: The normal airway. The tongue and other soft tissues are forward, allowing an unobstructed air passage. B: The obstructed airway. The tongue and epiglottis fall back to the posterior pharyngeal wall, occluding the airway. (Courtesy of V. Robideaux, M.D.)

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Types
Oropharyngeal Airways
Fi gure 16.10 sho ws an oropharyngeal (oral) airway i n place. The bi te porti on is between the teeth and li ps , and the fl ang e is outside the lips . The pha ryngeal end res ts between the pos terio r wal l of the pha rynx and th e P .451 base of the tongue an d, by ex erti ng pressure al ong the base of the tongue, also pulls the epig lo ttis forward .

Figure 16.10 Oropharyngeal airway in place. The airway follows the curvature of the tongue, pulling it and the epiglottis away from the posterior pharyngeal wall and providing a channel for air passage. (Courtesy of V. Robideaux, M.D.)

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In addi tion to h el ping to maintain an o pen ai rwa y, an oropha ryngea l ai rway may be us ed to prev ent a patient f rom bi ting and occ luding an oral tracheal tube, p rotec t the ton gue f rom bi ting, fac il i tate oropharyngeal suc tioni ng, o bta in a better mask f it, or p rov ide a pa thway for ins erti ng dev ices in to the esop hagus o r pharynx (100 ). Oral ai rwa ys hav e not been ass oci ated with an inc re ased inc ide nce of s ore throat or o the r s ymptoms (101,102 ) or bac te remia (1 03).

Description
An oropha ry ngeal ai rway (Fi g. 16.11) ma y be made of elas tome ric mate rial o r plas tic . It has a f lange at the buc cal end to prev ent i t from mov ing deeper i nto the mouth. T he flange may a ls o s erv e as a means to fix the ai rway in plac e. The bite portion is s traigh t and f its between the teeth or gums . It mus t be fi rm enough that the patie nt cannot c lose the lumen by b itin g. The c urv ed porti on ex tends bac k ward to c orres pond to the sh ape of the tongue and palate.

Figure 16.11 Oropharyngeal airway. All oral airways have a flange to prevent overinsertion, a straight bite block portion, and a curved section.

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The A me rican na ti onal s tanda rd (104) spec ifies that the si ze of ora l ai rway s be desig nated by a numbe r that is the length in c entimeters (Fig. 16.11).

Specific Airways
Guedel Airway
The Guedel airway (Fig . 16.12) has a large f lan ge, a reinfo rce d b ite portion, and a tubular c hannel. Modifications to a id flex ib le fib eroptic i ntubation h av e be en desc ribed (10 5,106,107,10 8).

Berman Airway
The B e rman ai rway (Fi gs . 16.10, 16.1 1) has a c enter sup port and open si des . The cente r s upport may hav e openi ngs . The re is a flange at the buc cal end. The s ide opening c an be op ened wi der to eng age or disengag e a tracheal tube.

Patil-Syracuse Endoscopic Airway

The P a til-S yracuse endoscopic a irway was designed to aid f iberoptic intubatio n (109). It has late ral channels and a cen tral groov e on the li ngual surfac e to al low a f ibe rs cope wi th a trac heal tube to pas s . A s lit in the dis ta l end all ows the f iberscope to be manipulated in the anteropos terio r di rec tion but P .452 l imi ts lateral mov ement (110). It is made from aluminu m. The ai rwa y mus t be remov ed f rom the oropharynx befo re a trac heal tube c an be adv anced ov er the f ibe rs cope and into th e g lottis .

Figure 16.12 Guedel airways. The bite portions are color coded to provide easy identification of size. (Courtesy of Mercury Medical.)

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Figure 16.13 Williams airway intubators. (Courtesy of Mercury Medical.)

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Willia ms Airway In tubator

The W i lli ams ai rway i ntubator wa s des igned f or b lind orotrac heal intuba tions (111,112 ,113). It c an als o be used to aid fi beroptic intubations or as an o ral airway (114). The airway, s hown i n Figure 16 .13 , is p las tic and av ai lable in two s i zes , #9 an d #10, whic h wi ll admi t up to an 8.0 or 8.5 in ternal diameter (ID) t rac heal tube, respec tiv ely . The trac heal tube c onnec tor should be remov ed during intuba tion,

becaus e i t wi l l not pass through the airway unless the a irway i s modifi ed (115). The prox imal h alf is c ylindrical , whi le the dis tal half is open on its lingual su rface . A compa ris on of the W i lli ams airway i ntubator wi th the Ov as sapian f iberoptic i ntu bating airway f ound that the W il l iams airway i ntubator prov ided a be tter v iew of the glottis in a s ignificant number of p atients (116).

Ovassapian Fibe roptic Intubating Airway

The Ov as -sapian fiberoptic i ntubating a irway (F ig. 16.14) wa s d esigned to del iv er a f ibe rs cope as c los e to the larynx as poss ib le (110). It has a flat li ngual surface that graduall y wi dens at the distal end. A t the bucca l end are two v e rtic al s ide walls . Between the si dewa lls is a pair of guide wal l s that c urv e to ward each other. The guide wa lls are f lex ible a nd permit the ai rwa y to be re mov ed f ro m around the trac heal tube. The p rox imal half is tubu la r so that i t can func tion as a bi te block . The dis tal half is open pos teri orl y. It wi ll acc ommodate a tracheal tube up to 9 .0 mm ID. P lac ing a bl ack l ine al ong the mi dd le of the ai rwa y helps to iden tify the midline and f ac il itates adv anc ing the f lex ib le endosc ope (117,118,119).

Figure 16.14 Ovassapian fiberoptic intubating airway. (Courtesy of A. Ovassapian, M.D.)

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Figure 16.15 Berman intubation pharyngeal airways.

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A compa ris on of this ai rwa y with the W i lli ams airway i ntubator and the B e rman i ntu bating airway (s ee below) f oun d tha t both other ai rwa ys prov ided a good v ie w o f the glottis (116 ,120).

Berman Intubating/Pharyngeal Airway

The B e rman intubating/pharyngeal a irway (B erman II) (Fi g. 16 .15 ) is tubular along i ts en ti re length. It is open on o ne s ide so th at i t can be sp li t and remov ed from around a trac heal tu be. It can be used as an oral airway or as an aid to f iberoptic or b lind orotrac heal i ntuba ti on (121). W hen the fiberscope is in the a irway, the tip cannot b e bent, limi ti ng sc ope maneuv erabil ity. Pa rtiall y wi thd rawi ng the ai rway wi l l i mprov e maneuv erabili ty (11 0). One s tudy f ound that the B e rman ai rway offered an adv antage ov er tongue retrac ti on for fiberoptic intuba tion (1 22). Comparison wi th the Ov ass apian i ntu bating airway f ound that the Berman ai rwa y o ff ers s omewha t eas ie r v isuali za tion of the cords (120). Howev er, if the trac heal tube impi nges on th e ai rwa y, i t i s mo re di fficul t to c ompl ete the intu bation wi th the Berman ai rwa y. Manipu lating the Be rman ai rway in plac e c an le ad to s uccessful trachea l in tubation (120).

Use
Pha ryn geal and lary ngea l reflexes s hould be depressed befo re an oral ai rway is i nserted to av oid c ough ing or laryngospasm.

Selec ting the c orrec t si ze is important. Too smal l an a irway may c ause the tongue to k ink and fo rce pa rt of P .453 i t agains t the roof of the mouth, caus ing obs truc tion. Too large an ai rwa y ma y caus e obs truc tion by dis pl acing the epiglottis posterio rl y and may trau matize the l ary nx . T he correc t s i ze ca n be es timated by holding the ai rwa y nex t to th e patien t's mouth. T he tip should res t c ephalad to the a ngle of the mandible. The b est c ri te ri a for proper s ize and pos ition are un obs truc ted gas ex change. If the airway repeated ly comes out of th e mo uth , it shou ld be remov ed a nd a s maller s ize tried.

Figure 16.16 Insertion of oral airway. The airway is inserted 180 from the final resting position.

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W etti ng or l ubric ating the ai rwa y ma y fac il i tate insertion. The ja w i s ope ned wi th the left hand. The tee th or gums are s eparated by pressi ng the th umb agains t the l ower teeth or gu m and the index or thi rd f inger a gains t the up per teeth or gum. One method to ins ert an ai rway i s sho wn i n Fi gure 16.16. Th e a irway is ins erted wi th i ts c oncav e s ide fac ing the up per l ip . W hen the junc tion of the b ite portion and the curv ed sec tion is near the inc iso rs , the ai rway is rotate d 180 and s li pped behind the tongu e i nto the f inal posi tion. If res is tanc e is met du ring ins ertion , it c an us ual ly be ov ercome by a ja w thrus t. An al te rna te method of i ns ertion is s hown in F igu re 16.17. A tongue bl ade is used to push f orwa rd and d epress the tongue. The ai rway i s inserte d wi th the co ncav e s ide toward the tongu e. As i t is adv anced, it i s ro tated to s li de around b ehind the tongu e.

If the a irway has been us ed to faci li ta te fibero ptic i ntubation, i t may be bette r to remov e the ai rway after the fiberscope has en tered the trachea beca use the airway might prev ent the trach eal tube f rom passing into the trachea (12 3).

Bite Block
A bi te block (gag , mouth p rop , bi te protec tor) is plac ed between the molar teeth o r gums but not the inc iso rs (124). It is intende d to prev en t th e teeth from biting on a trac heal tube, s upraglo ttic a irway dev ic e, fib ers cope , or other dev ice. Not on ly wi ll i t protec t these dev ices , but i t may also av oi d d ental injury (125 ). A bi te bl oc k is also us ed during elec troc onv ulsiv e therapy and in unc onsc ious indiv iduals to protec t the tongue a nd li ps . An oral ai rway s houl d not be used for these pu rposes (124,126 ,127). It i s ineff ec tiv e and may be h armful to the pa ti ent in this role becaus e a ll the po wer of the bi te is concentrated on the inc isors , whic h a re no t desig ned f or this pres sure and are l iable to break or loos en. B ecause a bite block does not ex tend in to the pharynx , it is us ually l es s i rri ta ting than an oral ai rwa y.

Figure 16.17 Alternative method of inserting an oral airway. A tongue blade is used to displace the tongue forward.

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A v arie ty of bite block s hav e been dev eloped (Fi gs . 16.18,16.19,16 .20 ). S ome hav e a c hannel for gas to pass . Many hav e an a ttach ed s tri ng th at can be p in ned to the P .454 pati ent's gown or taped to the sk in s o that it c an be eas il y retriev ed. The curv ed portion of an ora l ai rwa y can be remov ed , le av ing the remaining po rtion as a bi te block (128 ,129). A gauze roll is s oft and allo ws pressure to be dis tribu ted ov er

sev eral teeth (127). A bi te b lock may be part of a dev ice used to sec ure a trac heal tube.

Figure 16.18 Bite block. This is placed between the teeth or gums (preferably in the molar area) to prevent occlusion of a tracheal tube or damage to a fiberoptic endoscope or to keep the mouth open for suctioning.

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Figure 16.19 This bite block is designed to be placed between the molar teeth with the flat portion extending toward the side of the face. The flat portion is used to grip for insertion and removal. (Picture courtesy of Hudson RCI.)

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A bi te block may become de formed s o that it does not p rev ent bi ting (130 ). A bi te block may be aspi ra ted (130 ).

Nasopharyngeal Airways
A nas opharyn geal airway (nas al ai rwa y, nas al trumpet) is sh own in pos i tion in Fi gure 16.21. W hen full y ins erted, the phary ngeal end s houl d be below th e base of the ton gue but abov e the epiglottis (131).

A nas al ai rwa y is be tter tole rated than an oral ai rway if the pa ti ent has i ntac t ai rway reflex es . It is p referabl e to us e a n asal air way if the patien t's teeth are loose or i n poor c ondition or there is trauma o r pathol ogy of the oral c av i ty . It c an be us ed whe n the mouth cannot be opened.

Figure 16.20 Oberto mouth prop, which is used for protecting the teeth during electroconvulsive therapy. (Courtesy of Rusch, Inc.)

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Figure 16.21 The nasopharyngeal airway in place. The airway passes through the nose and extends to just above the epiglottis. (Courtesy of V. Robideaux, M.D.)

View Figure

Con traindications to us ing a nasopharynge al ai rwa y inc lude antic oagula tion; a basilar s kul l f rac tu re; pathology, seps is , or deformity of the nos e or nas opha rynx ; or a his tory of nos ebleeds requ iring medic al tre atment. There is no ev id ence that nasal air ways c ause s ign if ic ant bac teremia (103,132 ).

Nas opha ryn geal airway s hav e been used d uri ng and after pha ry ngeal s urgery (133,134 ), i n infan ts wi th Pi erre Rob in s yndrome (135), to app ly continu ous pos itiv e ai rwa y pressure (CP A P ) (136), to fac i li tate s uc tionin g (137), as a guide for a f ibe rs cope (137), to treat s ingultus (hiccups), as a guide fo r a naso gas tric tube (138,139 ), to dilate th e nas al pass ages in preparatio n for nasotrachea l i ntubation (138) a nd as a means to ma in tain the airwa y and admin is ter anes thesi a duri ng denta l surgery (140). A nas opharyn geal airway ca n be fi tted wi th a trach eal tube c onnec to r and us ed with an an esthes ia breathi ng s ys tem (1 41,142,14 3,144,145,146,147,148). Thes e dev ic es hav e been us ed to maintain v entilati on durin g o ral fi beroptic endos copy (109 ) and to admin is ter continuous posi tiv e pres sure (136 ). Env i ronmental gas c ontamination may be a problem with this techn iqu e (149).

Description
A nas opharyn geal airway resemb les a sh ortened tracheal tube wi th a flange at the outer end to prev ent i t from completel y pass ing into the naris . S ome air ways c ome wi th a saf ety pin that can be inserted in to the flange o r ai rway wa ll (150 ). The f lan ge is mov abl e on s ome models . The Americ an s tanda rd (104) requ ires th at the s ize of a nasopharynge al ai rway be des ignate d by the i nsi de diameter i n mi ll ime ters . P .455

Figure 16.22 Nasopharyngeal airways. The one on the right does not contain latex.

View Figure

Specific Airways
A v arie ty of nasopharyngeal airways are ava ilable. Some a re shown in Figure 16.22 .

Linder Nasopharyngeal Airway

The Linder nas ophary ngea l (bubble-ti p) ai rway is s hown i n F igu re 16.23 . It is plas tic with a large flan ge (15 1,152). The dis tal e nd has no bev el . The ai rway is suppl ie d wi th an introduc er, whic h has a balloon on its tip. The bal loon c an be i nflated and deflated by attaching a s yrin ge to the one -way v alv e at th e oth er end of the in troduc er.

Figure 16.23 Linder nasopharyngeal airway. (Courtesy of Polamedco, Inc.)

View Figure

Before ins ertion, the i ntroducer is ins erted into the ai rway until the tip of the balloon is jus t pas t the end. A i r is in jec te d u nti l the bal loon tip is infl ated to approxima tel y the outs ide di ameter of the tu be. The c omplete assembly is l ubric ated and then inserted through the nos tril . Af te r it is in p lace, the balloon is defl ated and the introduc er re mov ed.

Cuffed Nasopharyngeal Air way

The c uffed nasophary ngea l (pharyngeal) airway i s s imilar to a s hort c uffe d tracheal tube (147,148,153). It i s inserted through the nos e into the pharynx , the cuff is i nflated, and th en is pulled back until res is tance is fel t.

Binasal Airway
The binasal a irway (F ig. 16.24) c onsis ts of two nas al ai rwa ys jo in ed togeth er by an adaptor fo r attac hment to the breath in g s ys tem (154,155 ,156,157,158,159,160,161). It can be us ed to adminis ter anes thes ia or to prov ide CPAP to babi es .

Insertion
The diame ter of th e nasa l ai rway s hould be th e s ame as needed to ins ert a trac hea l tube (0 .5 to 1 mm smal le r th an for an ora l trach eal tube ).

Figure 16.24 Binasal airway. (Courtesy of Rusch, Inc.)

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P .456

Figure 16.25 Insertion of a nasal airway. A: Correct method. The airway is inserted perpendicularly, in line with the nasal passage. B: Incorrect method. The airway is being pushed away from the air passage and into the turbinates.

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Before ins ertion, the nas al ai rway s hould b e l ubric ated thoroughl y al ong i ts en ti re l ength. E ach si de of the nos e s hould be inspec ted for s ize, pa tenc y, and the

presenc e of poly ps . A v asoc onstric tor may b e appl ied bef ore ins e rtion to reduc e trau ma. The nasop haryngeal ai rway s hou ld be inse rted as sho wn in Figure 16.25A. The ai rwa y is he ld wi th the bev el agains t the sep tum and gentl y adv anc ed pos terio rl y whi l e being rotated bac k and fo rth. If res is ta nce is encountered during i nse rtion , the oth er nos tri l or a smal ler si ze ai rway should be us ed. F igu re 16.25B s hows an i ncorrec t method f or inse rting the ai rwa y. Th e a irway is being pushed to ward the roof of the nose. The airway may be adjus ted to fi t the pharynx by s liding i t in or out. If the tube is i nserted too deepl y, larynge al reflex es may be s timu lated ; if too s hort, ai rway obs truc tion wil l not be reliev ed. A l though the c orrec t nas al airway l ength fo r a pati ent c orrel ates with s i mpl e ex ternal meas urements of the fac e and nec k , s tudi es i ndicate a correlatio n onl y with the pa tient's hei ght (131).

Complications
Airway Obstruction
The tip of an ai rway c an press the epi glo ttis o r to ngue ag ains t the pos teri or pharyngea l wal l and c ov er the lary ngeal ape rture (162 ,163). W i th a nasoph aryngea l ai rwa y, neck mov ement i n rotation o r anteropos teriorl y may resul t in the l umen becoming obs truc ted (164). The use of a f en es trated ai rway may ov ercome this problem. The nasopharyngeal ai rway lu men may be c omp res sed ins ide the nose (131). A foreign body c an enter an airway and c ause c omplete or parti al obs truc ti on (165,166 ). In one c ase, the plas tic packaging became s tretched ov er the end of the ai rwa y, ca usi ng obs truc tion (167). If a naso pharyngeal a irway perfo rates the re tropha ryngeal spac e, the space may ex pand and c aus e a irway obs truction (168).

Trauma
Inju ry to the nose and pos te rior ph arynx is a po ten ti al c ompl ic ation of nasa l ai rwa ys . E pis taxis is usual ly s elf -l i mitin g but ca n present a s erious p rob lem in s ome pati ents . To c ontrol sev e re nas al and nas opharyng eal b lee di ng, an epis tax is a irway (Fig . 16.26) c an be used. Pha ryngeal perforatio n and retropha ryngeal absc ess formati on can oc cur (168 ). The li p or tongue may b e c augh t between the te eth a nd an oral a irway.

Tissue Edema

Fac ial, neck , or tongu e edema, either uni lateral or bil ateral, can oc cur f ol lo wing su rge ry, espec ially i n the s i tting pos ition, an d c an resul t in a irway obs truc tion (169,170 ,171,172,173). P ress ure f rom an oral ai rway may be a P .457 contri buting fac tor. To prev en t th is compl ica tion, the oral air way should not be lef t i n p lace fo r an extend ed period . A bite bl ock shoul d be used ins tead. Exc ess iv e head or nec k fl exion should be av oi ded, and the head and nec k s hould be ch ecked f requentl y duri ng long cases for edema o r ecc hymos es . Uv ular edema possi bl y caus ed by the uv ula becoming entra pped betwe en the hard pa late and an orophary ngea l ai rway h as been reported (17 4). A nother patient dev eloped temporary deafnes s s econdary to edema of th e uv ula and soft pala te followi ng prolonged nasopharyngeal ai rway use (175). Trans ien t sal iv ary gland s wel l in g ma y oc cur wi th o ral air way us e (176 ,17 7).

Figure 16.26 Epistaxis airway. This is inserted into the nose and inflated to provide local pressure on the bleeding site. It is available in several sizes. (Courtesy of Rusch, Inc.)

View Figure

Ulceration and Necrosis

Ulceration of the nos e or tongue can oc cur if an ai rwa y remains i n place for a lo ng period of time (178).

Central Nervous S ystem Trauma

The use of a nas al ai rway in a pati ent wi th a basi lar skull f rac tu re c an resu lt in i ts enterin g the an terior c rani al foss a (179,180).

Dental Damage

Tee th can be damaged o r av uls ed if the pati ent bites down h ard on an oral a irway (181,182 ,183). An o ral ai rway s hould be avo ided if there is ev idence of perio dontal disease, teeth weak ened by c ari es or res toratio ns , c rown s , f ix ed parti al dentures, pronounce d p roc linati on (the front tee th having a forward i nc l ination and ov erlapp in g the l ower f ront teeth), or is olated tee th. In these cases , the us e of a nasoph aryngea l ai rwa y a nd/or a bi te bloc k b etween the b ack teeth may be prefera ble .

Laryngospasm and Coughing

Ins erting an ai rway before adequate anes thetic d epth is es tablish ed may c aus e coughing or laryngos pasm, especi al ly if the ai rway c ontac ts the epig lo ttis or v oca l co rds .

Retention, Aspiration, or Swallowing

Part or a ll of an ai rwa y ma y bec ome disp laced i nto the pha rynx , trac heobronc hi al tree , or es ophagus (184,185 ,186,187,188,18 9,190,191). P lac ing a safety pi n through the nasal ai rway f l ange may prev ent i t from s l ippin g i nto the nos e (192).

Devices Caught in Airway

In one c as e, a cuff became detach ed when an es ophageal s tethosco pe was remov ed f rom a patient wi th an o ral airway i n pl ace (193). It was pos tulated that the cuff became caught in the si de gro ov es of the a irway. A nother c ase was reporte d whe re a fi bersc ope inadv ertently trav ersed a fenes trated ora l ai rway , maki ng i t i mposs ib le to pass a trac heal tube (194 ).

Equipment Failure
An oral ai rway may frac ture at the conn ec tio n between th e b ite portion an d the cu rv ed s ec tion (195,1 96,197). A defec t in the Wi l li ams intu bating airway that c ould tear the tracheal tube c uff has bee n repo rted (198).

Latex Allergy
If an ai rway c ontains la tex , a sev ere reac tion may occ ur i f the patien t is s ensi tiv e to l atex (90 ). Non-l atex oral and nas al airway s are readi l y ide ntif ied and av ail able. Chapte r 15 prov ides more details on l atex al lergy.

Gastric Distention
A nas opharyn geal airway that is to o l ong ma y ente r th e esophagus wi th resu ltant gas tric d is ten tion (1 31).

References

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[Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 178. Moore MW , Rausc her L. A c ompl ic ation of oropharyngeal a irway pl aceme nt. Anes thes iology 1977;47:526 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 179. Muzz i DA , Losas so TJ, Cucchiara RF. Compl ication from a nasop haryngeal ai rwa y in a patient wi th a basilar s kul l f rac tu re. A nes thes io lo gy 1991 ;74:366368. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 180. Sch ade K , Borzo tta A , Mic haels A . Intrac ran ial malposi tion of nasopharyngeal ai rwa y. J Trauma 2000;49:967968. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 181. Pol lard BJ , O'Leary J . Guedel ai rway and tooth damage . Anaes th Intens Care 1981;9:395. [Med li ne Link ] 182. Cl okie C, Metcalf I, Holland A . Dental tra uma in anaes thes ia . Can J Anaes th 1989;36:675680. [Med li ne Link ] 183. Burto n J F, Bak er AB . Dental damage during a naes thesi a and surgery. Anaes th Intens Care 1987;15:26226 8. [Med li ne Link ] 184. Anonymous . Nas opharyn geal airway . B iomed Safe S tand 1 984;14:111112 . 185. Daly S M, W ei nberg B , Murphy RJC, et al . Unrecogni zed as piration of an orophary ngea l ai rway . P ediatr Rad iol 1983 ;13 :227228. [Cross Ref] [Med li ne Link ] 186. Howa t DDC. Dispos able nas opharyngeal a irways a p otential haza rd. Anaes thes ia 1982;37:101. [Cross Ref] [Med li ne Link ]

187. Hayes JD, Lock rem JD. Asp iration of a nasal ai rway . A case repo rt an d princi ples of mana gemen t. A nes thes iolog y 1 985;62:534535. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 188. Ho G, W ei nger MB . Unusual complica tion of n asotracheal suc tioning . Anes thes iology 1993;79:630 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 189. Milam MG, Mil ler KS . A spi ration of an artific ia l nas opha ryngeal airway . Ches t 1988;93:223224. [Med li ne Link ] 190. Zal tzman J , Fe rman A . A n acute li fe -threateni ng complication caus ed by a Guedel ai rway. Cri t Care Med 1 987;15:1074. [Cross Ref] [Med li ne Link ] 191. S mi th BL. Retained nasopharyngeal a ir way. A naes thesi a 1989;44:44 7. [Cross Ref] [Med li ne Link ] 192. S toneh am MD. Nasopharynge al ai rwa ys and nas otrachea l suc tion. Anes thes iology 1994;80:480 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 193. Gandhi S , Dhamee MS . Detachment of an esophag eal s tethos cope c uff possible role of an oral a irway. A nes thes iolo gy 1983 ;58 :202. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 194. Topf A I. Compl ic ation as soc iated wi th the use of an oral ai rway . Anes thes iology 1996;84:485 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 195. Lloyd -W ill ia ms R. Frac tu red airways . Anaes th Intens Care 1985 ;13 :3353 36.

[Med li ne Link ] 196. Anonymous . Univ ersal hospital s uppl ies . S izes 2 and 3 Guedel ai rway s : bi te block may d is lodge. He al th Dev ices A le rts 2004 ;28 :5. 197. Nand al an SP , Hi rema th A . Critical i nc id ent due to a Guede l ai rwa y. Anaes thes ia 2004;59:832. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 198. Mic helsen L G, V al des -Murau H. An in tu bating airway wi th teeth. Anes thes iology 2001;94:938 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] P .460

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. Co mp licatio ns assoc ia ted w ith use of a face mask include A . Mov ement of the cerv ical s pi ne B . Fac ial ne rv e injury C. Chemic al i rritation o f the e yes D. S inus itis V iew A ns we r2. Wh ich mane uvers can be used to secure a patent airw ay ? A . J aw thrus t B . P os terior protrus ion of the mandible C. Chin l if t D. Pos te ri or flexion of the atlan to-occ ipital joint V iew A ns we r3. Airw ays developed to aid in fiberoptic intubation include

A . P a til-S yracuse B . W i lli ams C. Ov assapian D. Gue del a irway V iew A ns we r4. Contraindications to nasa l airw ays include A . He mo rrhagic disorders B . S eps is C. Bas ilar s kul l f rac tu re D. Se izure diso rde rs V iew A ns we r5. Wh ich ex ternal measurements c orrelate w ith th e p rope r length o f a nasal airw ay? A . Tip of nose to 2 c m abov e the thy roi d carti l age B . Th e dis tance from th e ti p of the thumb to the tip of the index finger measured to the hand and back C. Tip of the earlobe to c ricoid carti l age D. The p atien t's height V iew A ns we r6. Complicatio ns asso cia ted w ith th e use of oral airw ays include A . S we ll i ng of the tongue B . E dema of the uv ul a C. Ulceration of th e ton gue D. S wa llowi ng of the ai rwa y V iew A ns we r7. P redictors of difficult mask ve ntila tion inc lud e A . High body mass index B . A ge ov er 6 5 years C. His tory of sno ring D. His tory of s leep ap nea V iew A ns we r8. Techn iques to improve mask fit in the edentulo us patient include A . P acking the c heeks wi th gauze spo nges B . No t remov ing the dentures C. Inse rting the infe ri or margin of the mask between the gingiv a of the mandib le and the l ower l ip D. Us ing a nas al airway V iew A ns we r

Chapter 17 Supraglottic Airway Devices

P .462

Sup raglottic ai rway dev ices hav e become a s tanda rd f ix ture in ai rway management, f il ling a niche betwe en the f ace mas k and trac heal tub e in te rms of both an atomic al position and degree of inv asiv eness . Thes e dev ices s i t outside th e trachea but prov ide a handsf ree means of ac hiev ing a gas -tigh t ai rwa y. The f irs t s ucc essful s upraglottic ai rwa y d ev ice, the La ryn geal Mask Ai rwa y (LMA )Cl ass ic , bec ame av ai labl e i n 1989. As time wen t on, a ddi ti ona l dev ic es were a dded to the LMA famil y to sa tisfy s pec ific needs , and a number of o ther dev ic es were dev el oped (1,2). T here a re a la rge number of s upraglottic ai rwa y dev ices , so me o f whi c h ap pear s imi lar to the LMA famil y and others tha t work under a d iffe ren t conc ep t. It is not poss ible to disc uss al l of thes e dev ices , becaus e the y a re bei ng i ntroduc ed at a rapid rate whi le o the rs are dis appearing . Thos e tha t seem to be gaining ac ceptance and longev ity at the time this writi ng wil l be d is cuss ed.

Laryngeal Mask Airway Family Types

LMA-Classic Description
The LMA -Class ic (s ta ndard LMA , Cl ass ic LMA , LMA -C, cLMA ) c ons is ts of a cu rv ed tube (s haf t) c onnec ted to an ell iptical s poon-s hape d mask (c up) at a 30 angle (Fig . 17.1). The re are two f lex ib le v e rtic al ba rs where the tube ente rs the mask to prev ent the tube f rom b eing o bstruc te d by the epig lo ttis . A n infl atable c uff su rrounds the inner ri m of the mas k . An inf lation tub e and self -se al ing pil ot ba lloon are attac hed to the prox imal wi der end of the mask . A b lack line runs longi tudinal ly along the pos terior aspec t of th e tube . A t the machine end of th e tub e is a 15-mm connec tor. The L MA is made from si lic one and con ta ins no latex .

Figure 17.1 LMA-Classic. Note the bars at the junction of the tube and mask. (Courtesy of LMA North America.)

View Figure

P .463

TABLE 17.1 Available LMA-Classics LMA Size 1 1.5 Patient Size Neonates/infants up to 5 kg Infants between 5 and 10 kg

2 2.5

Infants/children between 10 and 20 kg* Children between 20 and 30 kg

3 4

Children 30 to 50 kg Adults 50 to 70 kg

5 6

Adults 70 to 100 kg Adults over 100 kg

LMA, Laryngeal Mask Airway. *Size 2.5 may be more suitable for children of this size (16).

The c las sic laryngeal mask is av ailable in ei ght s izes , as s hown i n Table 17.1. More than one s ize s hould al ways be av ai lable , bec ause the correc t s i ze c annot always be predic ted. W hen the re is doubt, a l arger ra ther th an a s malle r s i ze should be chos en for the fi rs t attemp t (3 ). Some s tudi es hav e indicated that the appropri ate s i ze for mos t adul t femal e pati ents is nu mber 4 whi l e the mos t appropria te s i ze f or adult males is 5 (4,5 ,6,7,8,9,10,11,12,13). Other s tudies found that both the s i ze four and fiv e may be suitable fo r fema les (11,14). It may be more a ppropria te to use a s ize 5 for l arge adults and a si ze 4 fo r normal ad ults , reg ard les s of gen der (12,15). A l te rna tiv e fo rmulas bas ed on wei ght hav e b een propos ed (17 ). A method to c hoos e the correc t s i ze lary ngea l mask for ch ildren is to matc h the wi des t part of the mask to the wi dth of th e s econd to fourth fingers (18). Too s ma ll an LMA wil l predispose to gas leaks during pos i tiv e p res sure v entilati on. Too large an LMA may tend to come up wi thin the mouth, may interfere with procedures in the mouth (5), and may a ls o b e associa ted wi th a higher i nc idenc e of so re th roa t and other s ymptoms and a greater poss ibili ty of press ure on the li ngual nerv e.

Insertion
Standard T echnique
The s tandard ins erti on tec hnique us es a mid line or s li ghtly d iag onal approac h with the cuff full y defl ated (19,20 ,21 ,22 ). The head should be ex tended and th e neck

f lex ed (s niff ing pos i ti on) (23 ). Th is posi tion i s bes t ma intained du ri ng inserti on by us ing the non inserti ng hand to s tabi li ze the occ iput (F ig. 17.2). The LMA can be i nserted withou t plac ing the head in this pos ition (24 ). The n eutral pos i tion ma y caus e a smal l dec reas e i n s ucc ess ful placemen t compared wi th the sn iffing positi on (25,26,27). The j aw ma y be pulled down by an as sis tant to mo re full y open the mouth. The tube po rtion is grasped as if i t we re a pen, with the index f inger pressi ng on the point whe re the tube joins the mask (Fig. 17.2). W ith the a perture fac ing forwa rd (and the b lack li ne fac ing the patien t's upper l ip), the ti p of the cuff is place d agai ns t the inne r s urface P .464 of the upper i nc isors or gums . A t this point, th e tube s houl d be paral le l to the floor (23). If the mouth is b eing hel d open, the j aw s hould be release d during f urthe r i nsertion . In the patient wi th a res tri c ted mouth open ing an a lternativ e method is to pass the L MA behind the mol ar teeth into the pharynx . The tubu lar part is then mane uv ered toward the midl ine (28).

Figure 17.2 Initial insertion of the laryngeal mask. Under direct vision, the mask tip is pressed upward against the hard palate. The middle finger may be used to push the lower jaw downward. The mask is pressed upward as it is advanced into the pharynx to ensure that the tip remains flattened and avoids the tongue. The jaw should not be held open once the mask is inside the mouth. The nonintubating hand can be used to stabilize the occiput. (Courtesy of Gensia Pharmaceuticals, Inc.)
View Figure

Figure 17.3 By withdrawing the other fingers and with a slight pronation of the forearm, it is usually possible to push the mask fully into position in one fluid movement. Note that the neck is kept flexed and the head extended. (Courtesy of Gensia Pharmaceuticals, Inc.)

View Figure

As the LMA is adv anc ed, the mask po rtio n is press ed agains t the h ard pa la te by us ing the index f inger. This means that the di rec tion of appl ied pressu re is d iffe ren t f rom the direc tion in whi ch the mask mov es (2 9). If resis tanc e is fe lt, the tip may hav e folde d on i tself or impac ted on a n i rreg ula ri ty o r the pos teri or pharynx . In this case, a diagonal s hift in di rec tion is often helpf ul , or a glov ed fi nger may be i nserted behind the mask to l ift i t ov er the obs truc tion (30). If at any ti me d uring i nsertion the mask f ai ls to s ta y fl attened or s tarts to fol d bac k , i t shoul d be wi th dra wn a nd reins erted. A change of di rec tion c an be sensed as the mask tip encoun te rs the pos terio r pharyngea l wal l and fol lo ws i t down ward. By wi thdrawin g the other fingers as the i ndex finger is adv anced and sl ig htl y pronati ng the f orearm, it is of ten poss ibl e to i nsert the mask ful ly i nto posi tion wi th a si ngle mov ement (Fig . 17.3). If this mane uv er is no t suc cess ful, hand pos ition mus t be c hang ed for the nex t mov ement. The tube is grasped wi th the other h and, s traightene d s lightl y, and then p res sed down wi th a s ingle qu ic k but gentl e mov ement un ti l a defi nite resis ta nce is fel t (Fig . 17.4). This may co inc ide wi th anterior l aryngeal displac ement (30 ). The lon gitudina l black li ne on the s haf t should li e i n th e midli ne fac ing the up per l ip . Any dev iation may i ndicate that the cuff is misplac ed. If the p ati en t has a high, a rched palate, a s lightly lateral approac h ma y be needed. The opera to r should check that the cuff tip is correc tl y f lattened agains t the pal ate before proceeding (30). Diff icul ty enc oun te red i n nego tiating the ang le at the back

of the tongue is mos t commonl y the res ul t of an inco rrec t angle of app roach. The i nserting f inger mus t press agains t the palate throug hout ins erti on. The rate of suc ces sfu l place ment may be reduc ed if c rico id press ure (espec ial ly one h ande d) is a ppl ie d (25,31,32 ,33 ,34 ,35,3 6,37,38). If the f irs t inse rtion a ttempt is unsucc ess ful , c ric oi d pressure should be tra nsientl y releas ed whi le the mask is mov ing do wn ward during a second a ttempt (39). W hen ini tial i nse rtio n is unsucc ess ful , a number of maneuv ers alone o r in co mbination may be helpful . These inc lude inse rting the LMA from the s ide of th e mouth; pulling th e ton gue fo rward; a jaw th rus t; repositioni ng th e head; inserti on wi th the lu men fac ing b ack wards then rotating i t 180 as it enters the pha rynx (se e below); ap ply ing c ontinuous pos i tiv e ai rway pressu re (CP A P ); s li gh t la teral rotation ; partial cuff inflation; inse rting a finger be hi nd the mas k to ac t as a gui de; us ing a l ary ngos cop e; plac ing a s tylet i n the LMA ; us ing a forc eps ; p res si ng the tip anterio rl y to ward the bowl whil e the cuff is d efl ated; and usi ng a th read to til t the tip f orwa rd (22,30,40,41,42,43,44,45,46,47 ,48 ,49 ,50,51,5 2,53,54,55,56,57,58,59,60,61,62,63 ,6 4,65,66,67,68,69 ,70 ,71 ). W hen prope rl y placed , th e mask res ts on the floo r of the hypopharynx . The s ides fac e the pyriform f oss ae, P .465 and the upper border of the cuff is b ehind th e base of the tongue (Fi gs . 17.5, 17.6). The tip of the epig lo ttis may res t e ither with i n the bo wl of the mask or under the prox imal c uff at an an gle de te rmined by the ex tent to which the mask has defl ec ted i t down ward (19,63,72). In s ome cas es , the upper part of the es ophagus l ies wi thin the rim of the mas k . S tudies hav e sho wn tha t s atis fac to ry f unc tion may be ach iev ed ev en when pos itioni ng is not ideal (73 ,74 ,75 ,76 ,7 7,78,79,80).

Figure 17.4 The laryngeal mask is grasped with the other hand and the index finger withdrawn. The hand that is holding the tube presses gently downward until resistance is encountered. (Courtesy of Gensia Pharmaceuticals, Inc.)

View Figure

180-degree Technique
Ano the r tec hni que is to i nse rt the LMA wi th th e laryngeal a perture pointin g cephalad and rotate i t 18 0 degrees as i t enters the hypophary nx (4 5,81,82,83). A dis tinc t po p may be fel t by the introduci ng hand (81). This method may be as sa tisfac tory as the s tan dard tec hni que, espec ia ll y in pediatric patients . It has bee n pos tulated that rotati on of the bu lk y LMA c uff in the c lose prox imi ty of the hypoph arynx could disloca te the ary tenoid c arti lages (84).

Partial Inflation T echnique

Yet another tec hni que is to parti al l y o r fu lly inflate the cu ff befo re i nsertion (85,86,87,88,89,90). A l th ough this tec hnique may of fe r s ome adv antages for an i nexp erienc ed us er, the dev ic e may frequently be malpos itioned (73,91). The i nci dence of so re thro at may be reduc ed with the p artial inflation method (89 ).

Thumb Inse rtion Technique

The thumb insertion tech ni que is more s ui table for patien ts whe re acc ess to the head from behind is difficu lt o r impossi bl e. Inse rtion is s imil ar to the s tandard tec hnique except that the LMA P .466 i s held with the thumb in the position occ upied by the index finger in that tec hnique. As the thumb nears the mou th, the f ingers are s tre tc hed forwa rd ov e r the p ati en t's

fac e. The th umb is adv anc ed to i ts ful les t ex ten t. Before re mov ing the thumb , the tube is pushed into its final pos ition b y us ing the other hand.

Figure 17.5 The laryngeal mask in place. (Courtesy of Gensia Pharmaceuticals, Inc.)

View Figure

Figure 17.6 Laryngeal mask airway in place. The tip of the mask rests against the upper esophageal sphincter while the sides face the puriform fossae.

View Figure

Tracheal Intubation with the LMA-Classic

The LMA ca n s erv e as a condui t through whi ch a tracheal tube, s tyle t, or fiberscope i s pass ed (92 ,93,94,9 5,96,97,98,99,100). It ac ts to pos i tion the dev ice ov er the l ary ngea l ape rture . The 30 angle between the tube and cuff wa s c hos en bec ause i t was found to be optima l fo r in tubation through the LMA (10 1).

Trac heal tube or f iberscope pass age may be ai ded by remov ing the bars at the j unc tion of the tu be and mask (102 ,10 3). Thi s is not rec ommended by the manufac tu rer. A tracheal tube wi th the bev el po int (Chapter 19) i n the midli ne may fac i li tate the pas sage b etwe en the b ars . It is important to unders tand the rel ativ e dimensi ons of the trachea l tube, f ibe rs cope , and LMA s o that the proper s ize tube o r fibersc ope can be s elec ted. These are g iv en in Table 17 .2.

Techniques Blind
B lind intuba tion th rough the L MA has been pe rformed in both adu lts and ch il dren (106,107 ,108). The s uc cess rate is v a ri able and depends on tec hnique, time av ailab le, manipul ation o f the patient's head and neck , operator ex perience, numb er of a ttempts , and tracheal tube us ed (38 ,109,110,111 ). The s ucc ess rate in pati ents with limi ted neck motion is lo wer than i n thos e with normal anato my. Bec ause a do wnfo lded epiglottis can i mpai r bl ind intubation, i t has been recommen ded that intubation throug h the LMA be prec eded by f ibe rop tic as sess ment of epiglottic pos i tion (112 ). If the epiglottis has down folde d, mov ing the LMA up and do wn withou t def la ting the c uff may help. A nother man euv e r is to wi th dra w the mask about 5 c m and reins ert i t whi le ex ecu ting a jaw thru s t (113).

TABLE 17.2 Maximum Size of Tracheal Tubes and Fiberscopes That Can Fit through the LMA-Classic Mask Size Largest Tracheal Largest Fiberscope Tube That Can Fit the LMA-Classic That Can Fit into a Tracheal Tube (ID in mm)a (OD in mm)b 3.5 2.7

1.5 2

4.0 4.5

3.0 3.5

2.5

5.0

4.0

3 4 5 6

6.0 cuffed 6.0 cuffed 7.0 cuffed 7.0 cuffed

5.0 5.0 5.0 5.0

LMA, Laryngeal Mask Airway; ID, internal diameter; OD, outer diameter. a If the connector is removed, a larger tracheal tube can be inserted (104). b A larger fiberscope may be accommodated if the aperture bars are removed (105).

Af ter the LMA is ins erted and fixed into pos iti on, the trachea l tube is we ll l ubricated and ins erted into the tube. Auscul tating the end of the tube may be us eful during spontaneous breathing. The trachea l tube should be rotated 15 to 90 counterc lock wi se as i t is adv anced to p rev ent the bev el f rom ca tc hin g on the ba rs at the junction of the tube and mask . A tracheal tube wi th a mid line bev el poin t may make this maneuv er unnecessa ry. Once th rough the b ars , the trache al tube is rota ted c loc k wis e, a nd th e neck is ex tended to ena ble the tip to pass an terio r to the arytenoi ds . The trac heal tube is then adv anced until res is tanc e is f el t. The head is then flex ed, permi tting the tube to adv ance i nto the trac hea. An al te rna te method of tracheal intubation inc ludes l oading the lu bricated trac heal tube wi th the ti p placed at the lev el of the bars in the LMA s o that whe n p ushed down, i t wil l pass smoo thl y through the mi dd le ape rture (114 ). If the trachea is not entered ini tiall y, i t is p ossi bl e that the LMA is not wel l s i tua ted ov er th e laryngeal a perture or the epiglottis is bloc ki ng the aperture. Va rying degrees of neck flexi on and ex tensi on at the atl anto-occ ipi ta l join t may be hel pful (111). If the tube s ti ll does no t enter the trachea, i t should be withdrawn unti l th e bev el is jus t behind the aperture bars . The L MA cuff s hould be P .467 defl ated and the LMA p ushed a li ttle farthe r in to the hypopharynx . This maneuv er

may cause elev a ti on of the downfo lde d epigl ottis . The trachea l tube is then pushed downward. S mal ler trac heal tubes are eas ier to p lace than larger ones (115). If the tube is not l arge e nough, i t may be replaced by a larger tube by us ing a tube ex changer (Chapter 19 ). The LMA ca n be used to guide a s ty le t, b ougie, o r exc hang e c ath eter in to the trac hea (42,95,99,116,117 ,118,119,120 ,121,122,123 ,124,1 25). It may be easi er to pass a s tyle t if its angu lated end is made to poi nt an teriorl y until it pass es through the gri l l of the mask and then rotated 180 (126 ). Monitoring c arb on diox ide th rough a c hannel in the exc hang e c ath eter is a us eful way of determining that the tip is in the trachea (127). After ca the te r placemen t is c onf irmed, the LMA can be wi thdrawn and the trac heal tube ins erted ov er the c atheter.

Fibe rscope Guided

The LMA -Class ic c an b e used to aid f ib eroptic -gui ded intuba tion. The LMA is i nserted in the usua l manner. T he fibersc ope, with a we ll -l ubricated tracheal tube and a f ul ly defl ated c uff threaded ov er i ts sh aft, is adv anced through the LMA . The f ibe rs cope is adv anced i nto the trachea , and the trach eal tube is adv anced ov er the f ibe rs cope into the trac hea. The tu be should be rotated as it is adv anced. It may be us eful to posi tion the tracheal tube in the LMA , jus t proxi mal to the aperture bars , before inserti ng th e f ibersc ope. A ri gh t angle bronchosc opic trache al tube connec tor with a s eal is attached to the trachea l tube. This al lows th e fi beroptic sc ope to b e i ns erted thro ugh the trache al tube whi le the pati ent is being v enti late d. W ith this , pos itiv e end-exp iratory press ure (PEE P ) c an be app lied, whic h often dramatic al ly improv es the v iew by s tenting the col laps ed uppe r ai rway (128) Fi bersco pe s ize is important, espec ially in smal l patients . The max imu m diameters of s copes for v arious si ze trac heal tubes a re giv en in Table 17.2. The laryngeal mas k has prov ed equal o r sup erior to other dev ic es des ig ned to a id wi th i ntubation us ing a fiberscope (1 29,130). This i ntubation me thod h as bee n used i n infants as smal l as 3 .6 kg (131). This method has a high er succes s rate than the bl ind meth od and is associ ated wi th l es s risk of tra uma or esophageal intuba tion (96,132,133 ,134). An ins pec ti on of the trach eobronc hial tree c an be made. It is us eful fo r patie nts i n whom nec k mov emen t needs to be av oi ded (135). A fibersc ope may be us ed to insert a bou gie o r other guide into the trac hea through an LMA (97,119,125 ,126,127,128 ,129,1 30,131,132,1 33,134,135 ,136,137,138 ,13 9,140,141 ,1

42,14 3,144,145,146,147,148). The LMA c an then b e remov ed and a trach eal tube i nserted ov er the guide . This techni que allows a l arger trac heal tube to be plac ed and av oids the dange r of ac ci dental ex tubati on when the LMA is remov ed (97,143 ).

Retrograde
The LMA ca n be used to fac il i tate tracheal intuba tion by us ing a retrograde wi re tec hnique (149,1 50,151) (Chapte r 21). The guide wi re i s inserted through the c ric othyroid memb rane and pas sed cephalad. A gu id e c atheter is then threade d anteg rad e ov er the wi re. The LMA is then re mov ed and a tracheal tube pas sed ov er the catheter.

Lighted Stylet Guided

Trac heal intubation by usi ng a ligh ted s tylet p laced through a trach eal tube that is i nserted through an LMA -Clas sic has been d esc ri bed (152,153,15 4,155). The s tyl et tip is pos i tion ed at the patient end of th e trache al tube and is adv anced through the LMA . If a central poin t of light in the an teri or nec k is observ ed, the L MA cuff is su itabl y placed a rou nd the l aryngeal inlet. If tra ns illumination is no t see n, the LMA i s repos i ti oned i n the pharynx according to the location of the light. Trach eal i ntu bation is ac complished by adv ancing the l ighted s ty le t unti l the s upras ternal notch is trans il lumin ated. The s uccess of intubation with th is method is compa rable to blind intubation (155 ,156).

Nasotracheal Intubation
The LMA has been us ed to f aci li tate nasotrachea l i ntubation (157 ). Th e LMA is i nserted and a catheter plac ed in the trach ea. Another c a the ter is inse rted in to the nose and brough t out through the mouth. The LMA is remov ed wi th the c athe ters in place . The ca the te rs are s utured toge ther and trac ti on ap plied to the nasal c atheter so that the cu rv e i n the mou th is remov ed. T he trach eal tube is then ins erted ov er the catheters into th e l arynx . Ano the r method to pe rf orm nasotrac heal intubation is to c u t a window in the pos te rior as pec t of the LMA 's tube n ear the mask and remov e the ap erture bars (158). A fiberscope mounted wi th a trac heal tube is i nserted v ia the nos e throug h the win dow in the LMA and into the trac hea. Ano the r method is to insert the L MA and the n parti ally wi th dra w the cuff i nto the orophary nx , wh ere i t c an s uppl y fres h gas to the sponta neous ly b rea thi ng pa ti ent (159). Nas otracheal intuba tion is then ac compl ishe d b y us ing a fiberscope.

Problems Associated with T racheal Intubation through the LMA-C lassic

Some s tandard tracheal tubes may no t be lo ng enough to inse rt through the LMA Cl ass ic (160). Deeper plac ement c an be ach iev ed by us ing a longe r trach eal tube (134,161 ,162,163,164,165,166,167,168 ,169,170,171 ,172,173,174 ), s horten ing the LMA tu be (139,175,176 ), remov ing the c onnec tor f rom the LMA , deflating the LMA cuff (160 ) usi ng a spl i t LMA (92,102), o r using a dev ic e s uc h as a s tylet to adv ance the tracheal tube f arther (108). Consi deratio n s hou ld be giv en to us ing an ai rwa y ex change c atheter (177). As the tracheal tube is pass ed th rou gh th e L MA -Class ic , the p ilot tube may bec ome k ink ed (17 8). P .468

W hen intubating a p ediatric patient wi th an uncuffed trac hea l tu be th rough an LMA Cl ass ic , the l arges t tub e tha t wil l pass th rough the L MA may b e too s mall to al low a good seal during pos i tiv e press ure v entilatio n. Leav ing th e L MA i n place wi th the cuff infla ted wi l l re duce the le ak (1 79). If a c uff ed tube is used, it ma y b e i mposs ib le to remov e the LMA wi thout da maging the infla ti ng dev ic e (180 ). Cric oid pres sure may make it mo re diff icul t to pass a trac heal tub e (38,181,182 ,183). If intubation is ini tial ly u nsuc ces sfu l and intubation is de emed v i tal, a s econd attempt s hou ld be made wi th tra ns ient releas e of c ric oi d p res sure. Changi ng from one-handed to b imanual c ricoid pressu re app licati on may be helpful .

LMA-C lassic Removal after Tracheal Intubation

The decis ion to remov e the LMA -Class ic after tra cheal intubatio n o r to leav e i t in place depends on the c irc ums tances . Reasons to remov e the LMA inc lude c oncern about press ure on the soft tissues , the need to keep i t awa y f rom the surgic al field, a pos si ble i nc reas e in gas troes opha geal refl ux , a nd diff ic ulty i n p lac ing a gas tric tube (184). Many users prefer to le av e the LMA -C las sic in plac e af ter i ntu bation to prov ide an al te rna tiv e ai rway at the conc lus ion of the anes thetic (185,186,187 ). If this is done, the pro truding end of the trachea l tube should be f irml y s ecu red . The re is no s imple way to remov e the L MA wi thout dis turbing the trac hea tube. An LMA may be modif ied by s pl itting the tube and cuff so that i t c an be more easi ly remov ed ov er the tracheal tube (102,18 8). A small tracheal tube or othe r dev ice

may be pl ac ed in the end of the trac heal tub e to ac t as a pusher (ex tender) to prev ent ex tubation as the LMA is wi th dra wn (94 ,189,190,191 ,192). A f ibers cope, bougie, jet s tylet, or tube c hange r may be pas sed through the trac heal tube to fac i li tate reintu bation if ex tubatio n occurs as the LMA is being remov ed (193 ).

LMA-Unique
The s ing le -us e L MA -Unique (disposable l ary ngea l mask ai rway, DL MA ) is s hown in Fi gure 17.7. S i zes a re giv en i n Table 17.3. It is made of pol yv in ylchloride and cos ts l ess than a reusable LMA . W hi le the dimensions are identica l to the s tanda rd LMA , the tub e is s tiff er and the cuff less c ompliant. It may be h elp ful to warm i t pri or to i nsertion to make i t sof te r and more compliant. Indications are the same as for the LMA -Class ic . It may be a be tter c hoic e for outof -hos pi tal or wa rd us e, where it woul d be di ff ic ult to c lean and s te ri li ze a reusable LMA af ter use. Ins erti on and pl acement of the LMA -Unique is s imil ar to the LMA Cl ass ic . If i t is used for fiberoptic i ntubation, sh ortening the tube ma y be helpful (176). Compa risons of the LMA -Unique with th e LMA -Cl ass ic show li ttl e d iffe rence in ease of ins ertion or performanc e (194,195,196 ), a lthough the LMA -Uni que may be so me what mo re diff icul t to inse rt (197 ). The intracuff press ure inc reas es s ignif ic antly l ess in the L MA -Unique wh en ni trous ox ide is use d (198 ,1 99).

Figure 17.7 LMA-Unique.

View Figure

One s tudy f ound that a 3 -mm or 4-mm intern al di ameter (ID) trache al tube c ou ld no t be i nserted through the LMA -Unique (200). A s truc tural p rob le m res ul ting i n a leak has been reported (201 ).

LMA-Flexible Description
The LMA -Flex ible (wi re -rei nfo rced, reinfo rce d L MA , RLMA , FLMA , flex ib le LMA ) (Fig . 17.8) differs from the LMA -Class ic in tha t it has a fl exible, wi re-rei nforc ed tube (202,203,204). T his tube is lo nger and narro wer th an the tube on the LMA Cl ass ic . It is av ailable in the s izes s hown i n Table 17.4. The c uff s izes are the sa me as f or the LMA -Classic . A s ingle-use v ers io n is als o av ail able. The s i zes for the si ngle-use v ersion are the same as for the mul tius e one.

TABLE 17.3 Sizes of the LMA-Unique Mask Patient Size Maximum Cuff Size (kg) Volume (mL of air) 1 Up to 5 4 Largest Tracheal Largest Flexible Tube (ID in mm)a Endoscope (ID in mm)b 3.5 2.7

1.5 2

5 to 10 10 to 20 20 to 30 30 to 50 50 to 70 70 to 100

7 10

4.0 4.5

3.0 3.5

2.5

14

5.0

4.0

20

6.0

5.0

30

6.0

5.0

40

7.0

5.5

ID, internal diameter. a If the connector is removed, a larger tracheal tube can be inserted (104). b A larger fiberscope may be accommodated if the aperture bars are removed (105).

P .469

Figure 17.8 LMA-Flexible. The wire-reinforced tube is longer and has a smaller diameter than the standard LMA.

View Figure

The f lex ible tube c an be bent to any angle without k ink ing. This a llows i t to be positioned away from the s u rgica l field withou t occ luding the lumen or l os ing the seal agains t the la rynx . It is les s l ikel y to be disp lac ed during head rota tion or tube repos itioning tha n the LMA -Class ic .

Insertion

The LMA -Flex ible is more diffic ul t to i nse rt than the LMA -Clas sic . A s tylet, s mal l trac heal tube, or o the r dev ice may b e i ns erted i nto the tu be to s tiff en i t (205,206 ,207,208,209,210,211,212,213 ,214,215). The manufac ture r rec ommends that i t be he ld between the thumb and i ndex f inger a t th e j unc tion of the tube and cuff and posi tioned by i nserting the index f inger to i ts full es t ex te nt into the oral cav ity unti l resis ta nce is encountered. It may be nec ess ary to use the other hand to ac hiev e fu ll ins ertion. It may be easi er to i nse rt b y us ing the thumb , index , and middl e fingers at the junc tion of the tube a nd bowl , then us ing the index and mi ddle f ing er to adv ance it into the hypopharynx (216). A modified Magil l forc eps or o the r dev ic e may be useful (59 ,212,217). Oth er methods f or inse rtion hav e been desc ribed (21 8). S ome tec hniques s uch as the 180 -degree tec hnique may no t work wi th thi s L MA (202 ). Af te r inserti on, the tube may be broug ht ou t through the nose (219).

Use
The LMA -Flex ible is des igned f or us e with surgery on the head, neck , and upper tors o where the LMA -Classic would be in the way . A throat pack should be used i f there is a risk of d ental f ragments becomin g we dged behind the c uff (202). If mal occ lus ion tes ti ng is needed, the tubing can be coi led ins ide the mouth (220). Compa risons between the LMA -Clas s ic and LMA -Flexi ble rev eal that both are s imilar in te rms of mask pos ition, c li nical p erf ormanc e , and ph aryngea l mucosal press ures (221,222).

Problems
The wi re rei nfo rc ement makes the LMA -F lex ib le more res is tan t to k ink ing a nd co mp res sion than the L MA -Class ic bu t does n ot prev ent obs truc tion from biti ng. A i rwa y o bs truc tion an d l os s of sea l hav e been reported when a B oyle Dav is gag was us ed (2 23,224,225 ). This c an usua ll y be c orrec ted by repos i tion ing the gag . The s piral rei nforc in g wi re i n th e L MA -Fl ex ib le may become dis rupted. S ometi mes , the dis ru pti on is internal and can on ly be disc ov e red by look ing c arefu lly down the shaft (226). Defec ts in th e wi re may c aus e o bs truc tion if the tube is ben t, o r pieces of wi re c ould bre ak off and migra te i nto the trac heobronchial tree (226 ,22 7). The s ma ll diamete r of the tube limits the si ze endoscope or trac heal tube that c an be passed through the LMA -Flexible (105). It has be en recommended that prolonged s pontaneous v entil ation b e av oided becaus e the s ma ller tube c auses i nc reas ed res is tance (2 02,228).

The LMA -Flex ible is uns ui table for magnetic resonanc e imaging (MRI) s canning if i mage qua li ty in the region of the LMA is impo rtant (229). The me tal l ic rings wil l caus e i mage dis tortion (229). Mal pos ition is less easi ly diagnosed wi th the LMA -Flex ible than wi th the LMA Cl ass ic becaus e the tube giv es no c le ar indi cation of cuff ori entati on (230).

TABLE 17.4 Size Comparison between Standard and Flexible Laryngeal Mask Airways LMA Patient Size LMA-Flexible LMA-Classic Size (kg) (ID in mm) (ID in mm) LMA-Flexible Tube Length (cm) 21.5 Maximum Cuff Inflation Volume (mL) Up to 10

10 to 20 20 to 30

5.1

7.0

2.5

6.1

8.4

23.0

Up to 14

30 to 50

7.6

10.0

25.5

Up to 20

50 to 70 70 to 100

7.6

10.0

25.5

Up to 30

8.7

11.5

28.5

Up to 40

>100

8.7

28.5

23.5

Up to 50

LMA, Laryngeal Mask Airway; ID, internal diameter.

P .470

LMA-Fastrach

The LMA -Fas trac h (in tubating LMA , ILMA , ILM, intuba ting lary ngeal mask ai rway) was des igned to ov ercome s ome of th e l imitatio ns of the LMA -Clas sic during trac heal intubation (231,232 ,233,2 34,235 ,23 6,237,238). The L MA -Class ic was too f lop py to op ti miz e ali gnment wi th the glottis, and the long na rrow tub e c oul d not ac commoda te a s tandard trac heal tube. A noth er objec tiv e was to e liminate the need to dis tort the an te ri or phary ngea l anatomy i n order to v is ualiz e the lary ngea l i nlet, maki ng the dev ice app lic able to patien ts wi th a his tory o f diffic ul t in tubation and a high or anterio r l arynx (234).

Description
The LMA -Fas trac h (Fig. 17.9) has a s hort, curv ed s tai nless s teel s haf t wi th a s tandard 15 -mm connec tor. The tube is of suf fic ient di amete r that a cuffed 9-mm trac heal tube c an be i nserted a nd sho rt enough to al low a s tanda rd trac heal tube cuff to pass beyon d the v ocal c ords . Th e me tal handle is sec u rel y bonded to the shaft near the connec tor end to f aci l itate one-handed insertion, pos i tion adjus tmen t, and maintain the dev ice in a s te ady pos ition durin g tracheal tube i nsertion and remov al . There is a si ngle, mov able epiglottic elev ator b ar in place of the two v e rtic al ba rs (Fig . 17.10A). A V -s haped g uidin g ramp is bui lt into the fl oor of the mas k aperture to di rec t the trac heal tube toward th e g lo ttis . The tip is s li gh tl y cu rv ed to permit atrauma tic ins erti on. Figu re 17 .10B s hows trac heal tube p rotrudi ng through the LMA tube and into the b owl . The LMA -Fas trac h does not contain latex . It i s av ail able in s izes 3, 4, and 5. Thes e f it the same s ize patien ts as the LMA -Class ic . Bo th reusable and dis pos able v e rsions a re av ailab le.

Insertion
The LMA -Fas trac h was desi gne d for use wit h the p atien t in the neutral pos ition (231). This i ncludes us ing a head support, s uch as a pi llow, but no h ead extens ion. The inse rtion tec hnique cons is ts of one -hand mov ements in the s agi ttal plane. It does not requi re p laci ng finge rs into the pati ent's mou th, thus minimizing the ris k of i njury or inf ec ti on trans mis sion as wel l as allo win g ins erti on from almos t any position (234,239).

Figure 17.9 LMA-Fastrach with tracheal tube. The tube on the LMA is shorter and wider than on the LMA-Classic and has a metal handle. Note that the tracheal tube connector has been removed. (Courtesy of LMA North America.)

View Figure

The LMA -Fas trac h s hould be defla ted and lu bricated i n a manner s imi lar to the LMA -Classic . It is hel d by th e handle, wh ic h s houl d be app rox ima tel y paral le l to the pati ent's c hes t. The mask ti p is pos i ti oned fl at agains t the hard palate immediatel y pos te rior to the upper P .471 i ncis ors , then s li d back a nd forth ov er the palate to dis tri bute the lub ri cant. Af te r the mask is flattened agains t the h ard pa la te, it is inserted wi th a rotational mov ement a long the ha rd pal ate and the pos terio r pharyngeal wall . The mouth opening may need to be inc reas ed mome nta ri ly to permit the wi des t part of the mask to enter the oral cav ity. The handle s houl d not be us ed as a lev er to fo rce the mouth ope n. As the mask mov es towa rd the pharynx , it s hou ld be f irmly p res sed to the sof t pal ate and pos te ri or phary ngeal wal l to k eep the tip from folding. The cu rv ed p art of the meta l tube shou ld be advanced wi thout rota ti on until it contac ts the patie nt's ch in, then k ept in con tac t wi th the chin as the d ev ice is rotated in ward . The handle s hould no t be used to lev er upward during i nse rtio n, bec aus e this wil l caus e the mask to p res s into the tong ue.

View Figure

Figure 17.10 LMA-Fastrach. A: Note the single, movable epiglottic elevator bar and the V-shaped guiding ramp built into the floor of the mask aperture to direct the tracheal tube toward the glottis. B: Tracheal tube emerging from the LMA.

W hen prope rl y inserted , the tube s hould emerge from the mou th di rec ted s omewh at caudall y. Al igning the i nternal LMA -Fas trach aperture a nd th e g lo ttic opening by f ind in g the pos iti on th at produc es optimal ve nti lation an d then appl ying a sligh t anterio r li f t with the L MA -Fas trac h handl e fac ili ta tes c orrec t pos itioning and bl ind i ntu bation (240 ). The LMA -Fas trac h c an be inserted wi th a 18 0 ro tation techni que (241).

Use
A l though the LMA -Fastrach has been des ign ed to faci li tate trachea l intu bation, i t can als o be used as a prima ry ai rwa y dev ice . It is espec ially useful for the antic ipated or unexpec ted diff ic ult airway (231,240 ,242,243,244,245,246,247,248 ,249,250,251 ,252,253,254 ,255,256,257,25 8, 259,2 60,261,262 ,263,264,265 ,26 6,267,268,269). S tudi es i ndicate tha t mos t ins erti on attempts wi th the LMA -F as trach are s uccessful , and a pa ten t ai rwa y i s sec ured in nearl y al l pati ents (231,237 ,240,245,247,250,253,258,265 ,270,271,272 ,273,274,275 ). It has been us ed suc cess full y in ch ildren (276), morb idly obese pati ents (277 ,278,279), and ac romegal ic pa tients (2 80). The LMA -Fas trac h c an be inserted wi th the same or better s ucc ess than the LMA Cl ass ic (281,282 ,283,284). It is eas ier to plac e than the LMA -Class ic when manual i n-l ine s tabili za tion is used (285). Howev er, in pa tients with li mi ted n eck mov ement, i ntu bation ma y be les s likely to b e s ucc essful and tak e longer than if a l igh ted i ntu bation s ty le t is us ed (286).

The LMA -Fas trac h has been us ed suc ces sfu lly in the emergency depa rtment and prehospi tal care (265,2 82,287,288,2 89,290). It c an be us ed wi th th e patien t in the l ate ral posi tion (291 ,292,293,294 ).

Tracheal Intubation
Musc le relaxan ts are not neces sary for intuba ti on thro ugh the LMA -Fas trac h but may i nc reas e the s ucces s rate (2 95,296,297 ,298,299). Cri co id press ure wi l l dec reas e the likeli hood of succ ess an d may need to be releas ed to all ow intubation (182). The trachea l tube rec ommend ed by the manuf ac turer fo r use wi th the LMA -Fas trac h i s a s il icone , wire-rei nforced, c uffe d tube wi th a tapered pati ent end and a blunt tip (236,300 ,301) (C hapter 19 ). Th is tube is fl ex ibl e, wh ic h a ll ows negotiation around the anatomical curv es of the ai rway. It has a hi gh-press ure , lo w-v olume c uff tha t reduc es res is tance duri ng intubation and makes cu ff pe rforation as the tube pas ses through the LMA les s l ikel y. T here is a s tabi li i zer that allows the LMA to be remov ed wi thout ex tubati ng the pa tient. W hen us in g the LMA -Fas trach, s tandard curv ed pl as tic trach eal tubes a re as soc iated wi th a greater l ik elihood of lary ngea l trauma (302,303). W arming a plas tic tub e wi l l resul t in s ucc ess and c omplic ation rates s imilar to tha t of the tube f rom the L MA -Fastrac h manufac turer (3 01). A s pi ral -embedded tube shou ld no t be us ed. If a curv ed plas tic tracheal tube is used , it may be hel pful to ori ent the c urv e oppos i te the LMA curv e (265,272 ,303). W hatev e r tracheal tube is use d, i t is es sen tial that i t is pos sible to remov e the connec tor (304). It i s impo rtant to lu brica te the tracheal tube wel l and pass i t through the LMA s ev eral times before use (305).

Blind Intubation
The patient's head is main tained in the neutra l pos ition. The trac hea l tu be connec tor should be loos ely f itted for easy remov al. The trach eal tube s hould be l ubric ated with a wa ter-s oluble lubric an t and passed into the metal s haf t of the LMA -Fas trach until the tube tip is about to e nter the mask ape rture . W ith the s il ic one tracheal tube s pecial ly des igned for the LMA -Fas trach, the longitudinal li ne shoul d fac e the handle of th e LMA , and the trac heal tube s hould not be pass ed beyond the poi nt wh ere the trans v ers e line on the tube is lev el wi th the outer ri m of the LMA -Fas trac h airway tube. The LMA -Fas trac h handl e is grasped with one ha nd to s tead y it wh il e the tracheal tube is being ins erted , then lifted l ik e a laryngoscope (no t lev ered) to dra w the

l ary nx fo rward a few mi ll ime ters . This inc reases the seal pressu re and helps to al ign the ax es of the trac hea and the trach eal tube . It als o correc ts the te ndenc y fo r the mask to f lex . As i t is adv anced into the LMA -Fas trach, the tube s hould be rotated and mov ed up and d own to dis tribute the lub ric an t. V entil ation and c arbon diox ide moni toring c an be pe rforme d duri ng trac heal tub e ins ertion by connec ting the trachea l tube to the anes thes ia breathing s ys tem. The trachea l tube sho uld be adv anced gen tly. T he LMA -F as trac h hand le shoul d not be press ed down ward . If no res is tance if felt, it i s lik ely that the ep iglottic elev ating bar is l if ting the epiglottis upwa rd, a llowi ng the tracheal tube to pass into the trac hea. When the trachea l tube is thought to be in the trachea, the c uff shoul d be i nflated and i ts pos i ti on in the trac hea confirmed (Cha pte r 19). If the tracheal tube fa ils to en ter the trachea , a number of problems may hav e contri buted to the lack of P .472 succes s (234,270). The ep igl ottis may hav e folded d ownwa rd, o r th e tube may hav e i mpac ted on the periglottic s truc tures . Th e L MA -Fas trach may be too s mall o r too l arge f or the pati ent. The l arynx may hav e been pushed downward during ins erti on. The re may hav e been inad equa te anes thes ia or mus cl e relax a ti on so that the v oc al co rds we re c los ed. Durin g bli nd trac heal in tubation , th e operato r rel ies on tac tile percepti ons , es pecial l y a f eeling of res is tance , whi le advanc in g the trac heal tube (234). If the mask is not ali gned with the glottic opening or the si ze of the LMA -Fas trach is i napp rop riate, resis tance wi l l be enc ountered as the tracheal tube tip pus hes agains t glottic or pe ri glottic s truc tures, s uch as the downfo lded epiglottis , v all ecu lae, arytenoids , or aryepiglottic fo lds. If res is tance is fel t af te r the trac heal tube le av es the LMA -Fas trac h, the re are a numb er of ma neuv ers that c an be taken to rel iev e the s ituation. If resis tance is fe lt at 2 c m beyond the 15-c m ma rk on the trach eal tube , it is l ik el y tha t the tube has i mpac ted on the v es ti bular wa ll . Rotating the trac heal bev el may ov e rcome the i mpac ti on. An other problem at this lev el may be a down fol ded epiglo ttis . W ithou t defl ating the cuff , the dev ice should be s wung ou tward fo r 6 c m and rei ns erted (234). If res is tance is e ncounte red 3 c m bey ond 15 c m, the ep iglottis may be ou t of the reach of the el ev ating bar, and a larger LMA sho uld be used. If res is tanc e oc curs immedi atel y af ter the trac heal tube leav es the LMA -F as trac h, the LMA may

be too la rge and s hou ld be replaced wi th a smaller on e (270). If res istanc e is fe lt a t 15 plus 4 cm, the LMA may be too large, and a smal le r s i ze should b e used (239). Other man euv ers that c an be tried inc lude sli gh tl y rotating the LMA -Fas trach in the sagittal pl ane by usi ng the metal handl e unti l the least res is tance to manual v enti lation is achi ev ed, remov ing the head s uppo rt, pul l ing the metal handle toward the user (ex tens ion), or pus hi ng it away f rom the user (flex ion ) (2 37,240,258 ,265). The LMA -Fas trac h c an be used to place an ai rwa y exch ange c ath ete r, wh ic h c an then be us ed to di rec t a trac heal tube i nto the trachea (306). B lind intuba tion usi ng the LMA -Fas trach is fas ter than f ib ero ptic -guided intuba tion or i ntuba tion using di rect l aryngoscop y (272,3 07). It c an be perfo rmed awak e (2 48). W hen co mpared with awak e fi beroptic i ntubation for patien ts wi th k nown diff icul t ai rwa ys , p atien t satisfac tion was g rea ter with the L MA -Fas trach (250). The s uccess ra te of b lind intubatio n v aries fro m 40 % to 100% (231,235 ,237,240,243,245,248,256,258 ,265,270,271 ,272,275,276 ,280,300,307,30 8, 309,3 10,311,312 ,313,314,315 ,31 6,317,318), depend ing on the number of a ttempts and the ex perience of the operator. The blind technique c an be time consumi ng and may res ul t in trauma or esoph ageal i ntu bation (237 ,245,271,309 ,31 0,312,319 ,32 0,321,322,323). If diffic ul ty is encoun tered, the us e of an LMA -CTrach sho ul d be c ons ide red .

Blind Nasal Intubation

B lind n asal in tub ati on can be accomplis hed (3 24). A f lex ible tracheal tube is i nserted into th e trachea through the LMA , wh ic h is then re mov ed. A F ole y catheter i s introduc ed into th e nos e and withdrawn from the mou th. The Foley c a the ter is i nserted into th e end of the tracheal tube and inf lated with saline to grip the in ner wal l s . The Foley c atheter is then wi thdrawn until the mac hi ne end of the trac heal tube ex i ts through the nos e.

Fibe rscopic-guided Intubation

The LMA -Fas trac h is useful for f iberoptic intubation in the diff ic ul t-to -intubate pati ent (263 ). Th e fi bersco pe is us ed to observ e correc t trac heal tu be pass age through the LMA . The ep ig lottic elev ating ba r is too s tiff to be elev ated by a f ibe rs cope wi th out ris k of damaging the tip o r direc ti ng it down wa rd (239,325 ,326). It should be l ifted by the dis ta l end of the trac heal tub e (327). The trachea l tube is adv anced app rox imately 1.5 c m p as t the mask aperture whi le the in tub ating metal h andle of the LMA -Fas tra ch is he ld to s tabi li ze i t. The tip of the trac heal tube s hou ld now hav e lif ted the fibe rsc ope away f ro m the bowl of the

mask , ex pos ing the glottic s truc tures . The fiberoptic s cope is inserted a nd adv anc ed to, but not beyond, the dis tal end of the trach eal tube . The trac heal tub e i s adv anced un ti l the glottis is broug ht into v iew. The tracheal tube is th en adv anc ed in to the trachea. If diffic ul ties are e ncountered, the patient's head and nec k ma y be maneuv ered or the LMA -Fas trac h posi tion adjus ted by us ing the meta l handle (228 ). Fi beroptic i ntuba ti on has a high succes s rate (134,240,272 ,31 1,328). It can be performed a wake (257,261 ,32 9,330,331). It has been used i n patients with uns table necks (261,328 ,330). It i s eas ier than intuba tion wi th a rigid laryng osc ope or us in g only a fi be rsc ope in p atien ts wi th manual in-li ne s tabil ization (259,328 ). It al lo ws an ex amination of the l ower a irway. It c an be perfo rmed eas ie r and i n les s ti me if the recommen ded trac heal tub e is used (33 2). Durin g fiberoptic intubation with a s i ze 3 or 4 LMA -F as trac h, v entilation ma y b e i nadequate (333). Wi th a s iz e 5 LMA , v enti lation is general ly ac cep table. The LMA -Fas trac h c an be used wi th an o ptica l s tyl et (334).

Light-guided Intubation
An i lluminated flex ible fibe r or a ligh ted intubati on s tyle t inserted through the trac heal tube ex tendi ng jus t beyond the trac heal tube tip can be us ed to gu ide a trac heal tube into th e g lottic op ening (247,270 ,291,292,308,310,312,322,335 ,336,337,338 ,339,340,341 ,342,343,344). A dis tinc t central p oi nt of l ight wi thout a halo in the mi dl ine i ndica tes c orrec t place ment. Once c orrec t pos i tion is achiev ed, the trac heal tub e is adv anc ed. If res is tance is fel t, c orrec t trans il lumination is not observ ed o r the l ight po in t is seen mov ing la terall y, the tracheal tube s hould be withdrawn 1 cm beyond P .473 the epiglottic elev ator ba r and one o r more of the f ol lowing adjus ti ng maneuv e rs applied, dependi ng on the c aus e o f res is ta nce and o bserv ati on of the light before each addi tional i ntubati on attempt: f lex ion or ex tens io n of the hand le, withdrawi ng the LMA -Fas trac h by 5 cm fol lo wed by re inserti on, performing manual v entilati on and a djus ting the LMA -Fas trach pos ition until the op timal s eal is obtained, fl exi ng the neck a nd ex tending the head, us ing a smaller trac heal tube, us ing a larger or smal ler LMA -Fas trach, or twis ting the L MA h andle (27 0,322,335 ,336,338,340 ,345).

Light-g ui ded intubatio n c an dec rease the time to succ ess ful in tubation and the numb er of a ttempts and f ailures when ins e rting a trachea l tube th rough the L MA Fas trach c ompared with bl ind intuba tion (3 08,310,312 ,336,339,340 ).

Removing the LMA-Fastrach after Intubation

Af ter the trachea has been i ntubated, the dec isi on needs to be made whe the r to remov e the LMA -F as trach or to leav e it i n place . It is usual ly recommended that the LMA -Fas trach be remov ed (346 ,347,348). Al ternatel y, the cuff c an be def la ted to 20 to 30 c m H 2 O and the L MA -Fas trach lef t in s itu (349). The LMA -Fas trach may exe rt mucosal pressures in excess of capi ll ary perfus ion p res sure (348). P a ti ents in who m the LMA -F as trac h is retain ed hav e a highe r inc idenc e of hoa rseness , s ore throat, and dys phag ia (246,346 ). Remov in g the LMA is assoc iate d with a h emody namic res pons e (350 ). Delay in g remov al for a few min utes may s l igh tl y dec rease the assoc ia ted p res sor response (273,351 ). The trachea l tube needs to be s tabi l iz ed to prev ent ex tubation du ring LMA -Fas trach remov al . Th e tube c onnec tor needs to be remov ed. A s tabili ze r rod (ex tender) that i s placed in the end o f the trac heal tube is av ai lable f rom the manufac turer (Fi g. 17.11 ). Ins e rting the tip of a s ma ll er trachea l tube in to the end of the i nserted trac heal tube wil l al low v entilation whil e the LMA -Fas trac h is being remov ed (352).

Figure 17.11 To stabilize the tracheal tube and to prevent extubation during LMA-Fastrach removal, a stabilizer rod (extender) is placed in the end of the tracheal tube.

View Figure

The LMA -Fas trac h c uff is deflated, and the LMA -Fas trach is s wung out of the pharynx in to the oral c av ity whi le ap pl ying coun terpress ure to the trac heal tube (239). The s tab il iz ing rod is remov ed when the LMA -Fas trach cuff is c lear of the

mouth. T he tracheal tube is then f i rml y grasped wh ile unthre ading the inf lation tube and p ilot balloon f rom the LMA -Fastrach. Finall y, the trac heal tube c onnec tor i s replaced .

Problems with Intubation

Pha ryn geal pathology may mak e intuba tion through the LMA -Fas trac h impossi ble (311,331 ,353). Currentl y, the smalles t s ize av ai lable of the LMA -Fas trach is the numbe r 3. Th is has been found to work wel l f or intubation of patients ov er 30 kg, but for pati ents under this we ight, succ ess ful intubation thro ugh this dev ice is les s c ertain (313). The LMA -Fas trac h trachea l tu be is ex pens iv e and should n ot remain in place for l ong peri ods of ti me b ecause it has a high-pre ssure cuff. The LMA -Fas trac h requi res more time for i ntubation and resul ts in more es ophageal i ntu bations and muc osal trauma th an rigid laryngosc opy (309). B lind intuba tion through the LMA -Fas trac h generates cardiov ascular res pons es s imil ar to tracheal i ntu bation using di rec t la ryngos copy (309,35 0,354). W hen the LMA -Fas trach is remov ed, the tracheal tube may be d isp laced downward or d is lodged (276).

Problems
The rig id LMA -Fas trach sh aft cannot easil y adapt to a c hang e i n the pos i tion of the pati ent's neck . It is more l ikel y to be dislodg ed th an the LMA -Cl ass ic if head o r neck manipul ation is re qui re d. It shou ld no t be used in c as es where the patien t wil l be i n the prone posi tion. The LMA -Fas trac h is uns uitable fo r use in the MRI uni t. A cas e of obs truc tio n after the LMA -Fas trach was inserted has been repo rted (355). Fi berosc opy rev ealed that the epiglottic el ev ating bar was in the la ry ngea l aperture , and though it l ifted the epiglottis , the ary tenoid carti lage was press ed anteriorly by the LMA -Fas trac h cuff, parti al ly obs truc ting th e l aryngeal aperture. Despi te the obs truc tion, the trac hea was intubated suc ces sfu ll y. The large di ameter of the LMA -Fas trach ai rwa y tub e c an cause diff ic ulty duri ng i nsertion in the p ati ent with a limited mouth opening and may put dentiti on at ris k (356,357 ). Compared with the LMA -Class ic , the L MA -Fas trach c auses an inc reased i nci dence of so re thro at, sore mouth , and difficul ty s wal lowing (358). W hi le LMA -Fas trach is easi er to place than the LMA -Cl as sic and placement is mo re l ik ely to be suc ces sfu l in P .474

pati ents with immobil i zed ce rv ic al spines (240 ,28 5,329), the L MA -Fas trac h ma y ex ert p res sure on the c erv ic al spine (348 ,35 9). Intuba ti on thro ugh the L MA Fas trach may c ause s ign if ic ant mo tion of the c erv ical s pi ne. It may be d ifficult to i nsert i n the pa tient with a c erv ic al co ll ar, espec ial ly if c ric oid pressure is us ed (256). Anes thes ia prov iders who hav e l i mited use of the lef t arm wi ll fi nd th e L MA Fas trach difficul t to use (360).

LMA-CTrach Description
The LMA -CTrach (Fig . 17.12) is si mi lar i n cons truc tion to the LMA -Fas trach (361,362 ). It has two bui l t-in fiberoptic channels , one to conv ey l ight f ro m an d the other to conv ey the image to th e v ie wer. Thes e emerg e a t the d is tal end of the ai rwa y tube under the ep ig lottic elev a ti ng ba r, whic h l ifts the epiglottis as the trac heal tube pass es th rou gh the LMA -CTrach into the lary nx . The fi beroptic s ys tem i s sealed and robus t, so the L MA -CTrach c an be autoc lav ed. The mon itor (v iewer) is a ttached to the LMA-CT rac h v ia a magn etic latc h conn ec tor. It has controls fo r foc us ing and i mage ad justment. The v iewer i s battery opera ted . The battery prov ides up to 3 0 minutes of continuous us e and can b e rec harged. The LMA -CTrach is av ail able in s izes 3, 4, a nd 5 and is reus able up to 20 times (361).

Figure 17.12 The LMA-CTrach. It has two built-in fiberoptic channels, one to convey light from and the other to convey the image to the viewer. The monitor (viewer) is attached to the LMA-CTrach via a magnetic latch connector.

View Figure

Use
The LMA -CTrach is lubricated an d ins erted s imilar to the L MA -Fas trac h without the v iewe r attac hed (361). An antifogg ing s olution should be appli ed to the optic al l ens . Af ter the LMA has been i nserted, the ai rway s ecured, and the patient v en til ated, the v iewe r is s wi tched ON and attached. A rea l-ti me image of the la rynx is then displayed. If pos itioning is not sa tisfac tory , v ari ous maneuv ers can be p erf ormed to i mprov e the v ie w (361). Af te r a s atis fac tory glottic apertu re i mage is achiev ed, the trac heal tube is adv anc ed and v iewed as i t en ters the trachea. Onc e the patient is i ntu bated, the v iewe r is de tac hed and the lary ngea l mask remov ed, leav ing the trac heal tube in place .

Evaluation
The LMA -CTrach has poorer i mage quali ty than a f lex ible f ib ero ptic end osc ope. In contras t to the v iew through a l aryngoscope, the v iewer p rov ides v isual ization f rom the unde rs ide of the trac heal tube. Its adv an tages inc lude the abili ty to align the LMA outl et wi th the la rynx and a high fi rs t in tubation attempt s uccess rate wi th minimal nec k mov emen t. As wi th the LMA -Fas trach, the LMA -CTrach cannot be us ed eas i ly in the patient wi th a l imi te d mouth openi ng. Trac heal intubation was suc ces sfu l at the firs t or s econd attempt in more tha n 96% of patien ts , higher than bl ind in tubation v ia the LMA -Fas trac h (361,362). The v iew may be obs truc ted by s ec retions , l ubric ant, or bloo d. It has prov ed useful du ring awa ke in tubation i n the pres ence of an uns tabl e cerv ical spi ne (363).

LMA-ProSeal Description
The LMA -P roSeal (LMA -P ROSEA L, PLM) (Fi g. 17.13 ) has four mai n parts : th e c uff, i nflation line wi th pi lot ball oon, airway tube, and drain (gas tric ac ces s ) tube (364,365 ,366,367). A l l components are ma de from sil icone and are l atex -free. It is av ailab le in s ix s iz es (Table 17.5 ). S tudies indica te that the s i ze 4 is preferable for P .475 mos t adul t women and the s iz e 5 f or mos t adult men (368 ,369).

Figure 17.13 LMA-ProSeal. Note the integral bite block.

View Figure

TABLE 17.5 LMA-ProSeal LMA Patient Maximu Maximu Maximu Length Largest Size Size (kg) m Cuff m Gastric m of Drain Tracheal Inflation Tube Size Fiberopti Tube Tube (ID in Volume (French) c Scope (cm) mm) (mL) Size (mm) 1. 5 5 to 10 7 10 18. 2 4.0 uncuffe d

10 to 20 20 to 30

10

10

19. 0

4.0 uncuffe d 4.5 uncuffe d

2. 5

14

14

23. 0

30 to 50

20

16

26. 5

5.0 uncuffe d

50 to 70 70 to 10 0

30

16

27. 5

5.0 uncuffe d 6.0 cuffed

40

18

28. 5

ID, internal diameter.

The airway (b rea thing , v entila ti on) tube of the LMA -P roSeal is s horter a nd smal le r i n d ia mete r than tha t of the LMA -Clas sic and is wire rei nforc ed, wh ic h makes i t more fl exible. There is a loc ating s trap on th e ante rior dis tal tube to prev ent the f ing er s li pping off th e tube and to prov ide an insertion s lot for the introd ucer tool . An ac cess ory v ent under the drainage tube i n the bo wl prev en ts sec re tions f ro m pooling an d ac ts as an accesso ry v entil ati on po rt. The LMA -P ro Seal has a deeper bowl th an the L MA -Cl ass ic an d does no t hav e aperture bars . There is a bite block between the tubi ngs at the lev el where the teeth would con tac t the dev ice. The drain (drainage, es opha geal d rain) tube is paral le l and l atera l to the ai rway tube unti l it enters the cuff bo wl, where i t co nti nues to an opening in the tip that is s lope d anteriorly (Fi g. 17.14). W hen the LMA -P roSeal is correc tly pos itioned , th e cuff tip l ies behind the c ric oid c artilage a t th e o rigin of the esophagus . It al lo ws l iquids and gas es to es cap e f rom the s tomach , reduces the ris ks of gas tric i nsuff lation and pu lmonary as pi rati on, al lows dev ic es to pass into the es ophagus , and p rov ides information a bout the LMA -P roS eal pos i tion . The drain tube is desig ned to p rev ent the epiglottis from occ luding the ai rwa y tube, el imina ti ng th e need for airway ba rs (3 68). A gastric tube, Doppler probe , th ermome ter, s tethos cope , or medica tion can be p assed into the esophagus through the drain age port (370,371 ,372,373,374 ). A plas tic supporti ng ring around the dis ta l drai n tube prev ents the tube from collapsi ng when the cuff is inflated.

Figure 17.14 Patient end of LMA-ProSeal. The drain tube continues to an opening in the tip.

View Figure

The LMA -P roSeal has a sec ond do rsa l cuff (Fig . 17.15). This pushes the mask anterio rl y to prov ide a better s ea l around the gl ottic apertu re and h elps to anc hor the dev ice in plac e (3 67). The do rsa l cuff is not pres ent on s izes 1 1 / 2 to 2 1 / 2 . The cuff is sof te r than that on an LMA -Classic . T he v entral c uff is la rge r prox imall y to i mprov e the s eal . A s ilicone-c oated mal leable me tal in troduc er to f ac ilitate pl acemen t of the LMA P roSeal is av ai lable (Fi g. 17.16). It has a cu rv ed, malleable s i licone-c oated blade P .476 wi th a gui di ng handle. The dis tal end fi ts into the loc ating s tra p, and the proxi mal end f i ts i nto the ai rwa y tube.

Figure 17.15 Posterior of the LMA-ProSeal, showing the dorsal cuff.

View Figure

Figure 17.16 Metal introducer used to facilitate placement of the LMA-ProSeal.

View Figure

Insertion
Insertion Methods
It is recommended that the LMA -P roS eal cuff be defl ated into a wedge sh ape, as wi th the LMA -Clas s ic . The p ati en t should be in the sniffi ng pos i tion (lo wer nec k f lex ion and head ex tens ion). It may be nec ess ary to bri efly releas e c ricoid pressu re to allow th e L MA -P roS ea l to p ass (3 75).

Introducer Technique

The tip of the metal i ntroduc er is ins erted into the s trap at the top of the cuff . The ai rwa y and drainage tubes a re folded aro und the introduc er bl ade and into matc hi ng s lots on ei the r si de of the in troduc er. Lubricant shou ld be plac ed on the pos teri or tip. The ti p is then pres sed agains t the hard p al ate and maneuv ered to s pread the l ubric ant along the ha rd palate. If the palate i s high, a sl ightly lateral app roach may be ne eded . The cuff is th en s lid i nward, k eeping pressu re agains t the palate. As the LMA -P roS eal is inserted , the i ntro duce r is k ept c los e to the chin. The c uff shoul d be obse rv ed to make c e rtai n tha t it has not folded ov er. The i ntroducer is s wu ng in ward i n a s mooth ci rcu lar mov emen t. T he jaw c an be pul led downwa rd by an as sis tant or p ushed downwa rd wi th the middle f inger un ti l the cuff has passe d the tee th , but the j aw s hould not be held wid ely o pen, because th is may c ause the tongu e and epiglottis to drop down ward , block ing the mask 's passs age. The LMA P roSeal is adv anced unti l res is ta nce is fel t. The non dominant hand sh ould be used to s tabil i ze the a irway tube as the in troduc er i s remov ed by fo ll owi ng the curv ature back ward out of the mouth , tak ing care to av oid damage to the teeth (367 ). The b ite block s houl d be at the teeth (376 ). Ins ertion in patie nts wi th a s tereotac tic f rame or nec k col la r is proba bl y bes t performed wi thout the introd ucer to inc rease man euv e rab il ity (366).

Digital Method
The digi tal method f or insertion is si milar to the introducer me thod except that the tip of the index f inger is placed a t the junc tion of the cuff and the two tu bes . As the i ndex finger passes into the mouth , th e f inger j oint is ex tended and the LMA P roSeal is pres sed bac k ward toward the other ha nd tha t exe rts coun terpress ure to mai ntain the sn iffing pos ition (377). Dependi ng on patient and us er f in ger s ize , the f ing er may ne ed to be inse rted to i ts ful les t ex ten t before resis tanc e is encoun tered. The nondominant hand sh ould b e used to s ta bi lize the LMA as the f ing er is withdrawn. The thumb may be us ed to ai d i nsertion whe n i t is diff ic ul t to ge t acc ess to the pati ent f rom behind. The thumb is inserted into the s trap. As the thumb enters the mouth, the f ingers a re s tre tc hed fo rward over the pa tient's fac e. The thumb is adv anc ed to i ts fulles t ex ten t. The push ing ac tion ex erted by the thumb agai ns t the hard palate s erv es to p res s the head in to ex tension (377). A lateral app roach is requi red mo re f requently wi th this method (3 66).

Guided Method

W ith this technique, a lubric ated s tyle t, bougie, fi beroptic en dosc ope, s uc ti on ca the ter, l ightwa nd, o r gas tric tube is f i rs t placed through the drain tube (366,378 ,379,380,381,382,383,384,385 ,386,387,388 ,389,390,391 ). The p atien t end of the dev ic e is then inserted into the esophagus under l aryng oscopic or fi be rsc opic guidance. The bougie s houl d be pointing pos teriorl y, oppos i te to when i t is used for i ntu bation. The L MA -P roS ea l is then adv anced in to plac e ov er the dev ic e. This method av oids folding the ti p back ward. It is more s uc cess ful and less trau matic than us ing the in troduc er tool o r digital me thods (381,385,388 ,392). This meth od has been us ed for patien ts wi th kn own diff icul t ai rwa ys (39 3,394), af te r fai led positioning of an L MA -Flexi bl e (395), and to exchange an LMA -P roSeal (396).

Cuff Inflation
Af ter the LMA -P roS eal has been inserted , th e c uff should be i nfla ted wi th e nough ai r to ac hiev e an intrac uf f pressu re of u p to 60 cm H 2 O. Du ring insertion and c uff i nflation, the front of the neck s hould be obs erv ed to see if the c ric oid c arti lage mov es forward, i ndic ati ng th at the mask has c orrec tl y pass ed behi nd i t. The c uff v olume requi red for the LMA -P roS eal to f orm an effec tiv e seal wi th the respi ra tory trac t is l ower than for the LMA -Classic (397). In f ac t, an adequate sea l can be obtained i n mos t patien ts wi th no ai r in the cuff ; howev er, the cuff sho ul d be i nflated wi th at leas t 25% of the maxi mum recommended v olume to ensure an ef fec tiv e s eal wi th the gas troi ntes tinal trac t (3 98).

Tests after Insertion

A smal l amou nt (1 to 2 mL) of wa ter-bas ed gel or a soap bubble should be placed on the end of the drainage tube that p rotrudes f rom the mouth and pos i tiv e press ure appl ied to the a irway tu be (3 99,400,401 ,402,403). If the LMA -P roS eal is prope rl y placed, the re sh ould P .477 be a s light up /do wn mov emen t of the lu brica nt/soap. The s oap bu bble ma y mov e whe n the lubric ant ge l does not (404). If there is no mov ement or the bolus is ejec ted, the mas k may not be c orrec tl y placed . The drainage tube s hould be tes ted for patenc y . This can be done by pas si ng a gas tric tube , a flex ible endosco pe, or a l ighted s tylet through the drainage tube (405,406 ). E asy pas sage indic a tes c orrec t posi tion in g; diff icul ty s ugges ts that the mask s hould be repos i tioned, ev en i f v en tilati on is satis fac to ry.

The s upras ternal no tc h tap tes t i nv olv es tapping the s upras ternal notc h o r c ric oid ca rtilage and obse rv ing s imul taneous mov emen t of the s oap bubble at the proxi mal end of the d rainage tube (366 ,40 0). Howev er, thi s can produce both false pos i tiv e and false negativ e resu lts (407). P roper L MA -P ros eal pos i ti oning c an a lso b e d etec ted by inserti ng a ligh ted s tylet (406). If the tip is fo ld ed ov er, the s tyle t wi ll meet res is tance 1 to 2 cm f rom the tip of the drain tube.

Insertion Problems
Sev era l mal pos i tions fo r the LMA -P roSeal hav e been des c ribed, inc luding i nsuff ic ien t dep th, the tip i nse rted in to the gl ottis , the ti p folded back ward , and sev ere e pi glo ttic downfolding (408,4 09). If the L MA -P roSea l is ins erted to an ins uff ici ent depth , th ere wi l l be a poor s eal . If a bub ble of ai r is se en or the bolus of gel is ejec ted when the lungs are inf late d wi th l ess than 20 cm H 2 O, the respi rato ry an d gas trointes tinal trac ts are no t i sol ated from one ano the r. If adv anc ing the LMA -P roS eal does not correc t th e problem, i t shoul d be remov ed and reinserte d. If the L MA -P roSea l has en te red the v es tibule of the la rynx , v entilation may be obs truc ted and gas may leak up th e drainage tube or c ause th e gel in the drain tube to mov e up and down wi th the ca rdiac rhythm (401 ,4 03). P ressure on the c hes t l eading to bubble fo rmation conf i rms that the la ry ngeal v es ti bule has been entered (409). A dv anci ng the mask deeper wi l l ex acerbate the obs truc tion. The mask s hould be remov ed and reins erted (377). If the L MA -P roSea l tip fo lds back ward , the d rain tube wil l be p inc hed off, leav ing the uppe r esophageal s phinc ter op en (410,4 11,412,413). A spi ra tion of gas tric contents s econdary to this malpos i ti on has been rep orted (414). The lubricant/s oap bubble a t the end of the drain tube wi ll not mov e, ev en with gen tle tap pi ng on the supras te rnal notch (399,400 ). Th is mal positi on may be ass oci ated wi th re s istance to ins ertion, un expec tedl y high infl ation press ures , an d the bi te b lock portion protrud ing f rom the mouth. Inabi lity to pass a gas tric tube freel y to the tip of the drain tube c onfirms the mal pos i ti on. S ev eral tech ni ques may be us ed to c orrec t the s i tuation , incl udi ng re inserti on wi th a la teral a pproach ; re ins erti on with th e d rainage tube s tiffened by a gas tric tube, bou gi e, or s tyl et; bougie-guided reins ertion; and s we eping a finge r behind the cuf f (366). Sev ere epig lottic do wnf olding occurs when the epiglottis is d ragged infe ri orl y and co mple tel y cov ers the gl ottic inle t. T o c orrec t this problem, the LMA -P roS eal s hould

be reins erte d wi th the head and nec k in a more ex treme sn iffing positi on, wi th a jaw thrus t appli ed or with the ep iglottis elev ated b y using a laryngosc ope (366).

Inserting a Device through the Drain Tube

The dev ice to be inse rted th rough the d rain tu be should be we ll l ub ricated and passed s lowl y and c areful ly, no t fo rce d. W armi ng the dev ic e ma y fac ilitate pass age (415). S ome res is tance may b e fel t where th e d rai n tu be angu la tes (416 ). It may be helpful to use back -and -forth motions whil e inserti ng a gas tric tube to adv ance l ubric ant into the cu rv ed s egment and to ease passage through this porti on of the drain tube (417 ). Inab ility to pass a gas tric tube indicates mas k misp lac ement (407). Suc tion should not be appl ied to the end of the dra in tube as the LMA is being i nserted, becaus e this may ca use th e dra in tube to c ollapse and i nj ure the uppe r es opha geal sphinc ter. S uc ti on sho ul d not be applied to a g as tric tu be until it h as reached the s tomach. The gas tric tu be may be used to reinsert the L MA -P roSea l if i t bec omes displac ed (380). The drain tube shoul d not be c lamped. A gas tric tube inserted through the LMA -P roS eal can be conv erte d to a naso gas tric tube (418).

Tracheal Intubation through the LMA-Pr oSeal

Trac heal intubation through the LMA -P roSeal requi res a long narro w tra c hea l tu be or an a irway ex change catheter (419). A f te r the LMA -P roS ea l is remov ed, a l arger tube can be s ubs ti tuted , if necessary.

Use
The LMA -P roSeal can be us ed fo r both spon taneous and contro ll ed v enti lation , but i s mo re su ited to c ontrol led v enti la tion (409,420). The s eal ing p res sure is higher than wi th the LMA -Clas s ic i n adult and pediatric patients , mak ing i t a better c ho ic e for s i tuations where h igher ai rway pressures are req ui red , where better airway protec tio n is des irabl e, and for surgical p roc edures in whic h intraoperativ e gas tric drainage or decompressi on is needed (364,365 ,397,398,411,413,421,422,423 ,424,425,426 ,427,428,429 ,430,431,432,43 3, 434,4 35,436,437 ,438,439,440 ,44 1,442). Cas e repo rts show no as piration of gas tric contents d espi te regu rgi tation or v omi ting unles s the LMA -P roS eal is malpos itioned (414,436 ,443,444,445,446,447,448,449 ,450,451,452 ,453,454). Howev er, as pi ration has been reported wi th ma lpos i ti oning (455).

It may be eas ie r to place the LMA -P roSeal than the LMA -Classic during manual inl ine n eck s tabil ization (424). It has been used i n cas es of k nown diff ic ul t ai rway (428) a nd has been succ ess full y us ed af ter failure with an LMA -Clas s ic (375,4 27). The LMA -P roSeal may be useful in cases whe re i t is important to av oid ai rway trau ma, as i t exe rts lower pressu res agains t the ph aryngea l mucos a than the LMA Cl ass ic (397). Howev er, ai rwa y tra uma as ev idenced by P .478 blood on the dev ic e after remov al is h igher for the LMA -P roS eal than for the L MA Cl ass ic (409). The LMA -P roSeal has be en found to be s afe for us e in an MRI un it, but imag ing quali ty ma y be c ompromised, dependi ng on th e pulse sequenc e that is us ed and whe the r the a rea of interes t is nea r the L MA (456).

Problems with the LMA-ProSeal

The LMA -P roSeal is l ess s uitab le as an intubati on dev ice than the LMA -Fastrach becaus e o f the narrowe r air way tube. The fibe rsc ope and trachea l tu be s izes that can be acco mmo dated by th e LMA -P roS eal are giv en in Table 1 7.5 . The high resis tance as soc ia ted wi th the s mall er lumen may make i t l ess suitable fo r us e wi th spontaneous l y breathin g patien ts than other d ev ices (457). The LMA -P roSeal may be s ome what more di ff ic ul t and take s li ghtly l onger to i nse rt than th e LMA -Cl as sic in adu lts , al though overall s uc ces s is equ iv al ent (364,365 ,397,408,411,413,421,422,432 ,433,458). The inc idenc e of intraoperativ e co mplica tions and pos tope rativ e sore throat are s imi lar. In chi ld ren , the e ase of i nsertion is si milar to the LMA -Class ic (434,435 ,437,459). The LMA -P roS eal requi res a g rea ter depth of anes thesi a fo r inserti on than does the LMA -Classic (460). The LMA -P roSeal can cause ai rwa y obs truction after i nserti on , ei the r by co mp res sing the s upraglottic and glottic s truc tu res or by c uff info ld ing (462,463). Remov in g a ir f rom the c uff or p lac ing the pati ent in the s niff ing pos i tion ma y rel iev e the obs truc tion. Parti al uppe r airway obs truc tion duri ng spon taneous v entilation ma y res ult in as pirating air through the drain tube into the es ophagus (404,463 ). Es opha geal i nsuff lation can oc cur s imul taneo usl y with v en ti ng from the drainage tube during positiv e pressu re v enti lation wi th malpos ition (46 4,465). This may res ul t in i nadequate v en ti la tion.

It may not be poss ibl e to ins ert a gas tric tub e i n some pa tients (4 66,467). This may be du e to selec tion of too la rge a tube, inadequate l ubricatio n, us ing a cooled gas tric tube , cuff ov erinf lation, or malpos itio n (415 ). The LMA -P roSeal is rel ativ ely contraindica ted for i ntrao ral s urgery b ecause it cannot b e mov ed easil y around the mouth, the drai nage tube is v ulnerable to oc c lusi on, a nd the larger prox imal cuff could interf ere with the su rgica l fi el d (365). The LMA -P roSeal has a sho rter l if e spa n than the LMA -Class ic (4 68)

Using the LMA Family

An LMA of the chosen si ze pl us one s ize smal ler and larger s hould alwa ys be i mmediate ly av ai lable . The s y ringe us ed to inf late th e L MA s hould con tain onl y ai r. Injec ting o rganic s ubs tanc es suc h as propofol f rom a prev ious ly us ed s yringe may dama ge th e L MA (469).

Preuse Inspection Visual Inspection

The f irs t s tep is to examine the tube . The airwa y tube s hould not be discolored, as this wo uld p rev ent s eeing fl ui ds that may ente r the tube . There should be no c uts o r tears in the tube, and the spi ral wi re s s hould not be ki nked . The res t of the LMA 's ex ternal s urfac e shou ld be ex amined fo r damage suc h as c uts , tears , sc ratches , or fore ign partic les . The interior s hould be f ree f rom obs truc tion or fore ign pa rtic les . The L MA -Fl exible shoul d be examined to make certain that the reinfo rc ing wi re i s whol ly c ontained wi th in the wal l of the tu be. The tube s hould be flexed up to, but no t bey ond, 180. Ki nking should not occ ur. Bending the tube be yond 180 cou ld c ause pe rmanent da mage. The nex t tes t is to examine the mask ape rture . The bars s hould b e gently probed to make c ertain tha t th ey are not damaged and the space between them is f ree f rom partic ula te matte r. If the drain tube i n the LMA -P roSeal bowl i s to rn or pe rf ora ted, the LMA shou ld not be used . The c onnec to r should f it tightly into the oute r end of the ai rwa y tube. It should no t be poss ible to re mov e i t eas il y. The connector shoul d not be twis ted. If the connec tor has c rack s o r s urface irre gularities , i t should n ot be us ed.

Deflation/Inflation
The nex t s tep is to wi th dra w ai r f rom the cuff so that the wal ls a re fl attened agains t each oth er. Excessiv e f orc e s hould be av oid ed. The c uff sho uld not re inflate. The

s y ringe should be remov ed f rom the infla ti on v alv e and the c uff chec ked to make ce rtain that it remains deflated. If it reinf la tes , there is a fa ulty v alv e or leaking cuff . An LMA cuff wi th a hole may not reinfla te af te r the ai r had been remov ed (470). The nex t s tep is to i nflate the c uff with 50% more ai r than the rec ommended maxi mum inflatio n v olume (Ta ble 17 .6). The c uff shou ld ho ld the pressure fo r at leas t 2 minutes . Any he rniatio n, wal l thin ni ng, or as ymmetry is an indication to disc ard the LMA . The b al loon s hould be el liptical , not sphe rical or irregularly s haped . Exc essiv e pi lot ba lloon wi dth i ndicates weak nes s and i mminen t ruptu re. Fai lu re to pe rform this tes t may mis s problems wi th the cuf f (4 67,471).

Mask Preparation
The c uff shou ld be f ul ly defl ated with a dry s y ringe to form a f la t ov al disc (F ig. 17.17 ) This c an be do ne by press ing the hollo w s ide down agains t a c le an, h ard , f lat surface. The d efl ated c uff s houl d be wri nk le-f ree . A cuf f-defl ating tool is av ailabl e from the ma nufac ture r (F ig. 17.18). This dev ice wi l l prov ide a superi or and more cons is tent s hape than ei ther hand manipulation o r free defl ation bu t does not offer any benefits in P .479 terms of res idual v olume (472 ). The use of this dev ice wi l l lengthen the cuff life (473).

TABLE 17.6 Maximum Test Cuff Inflation Volumes

Size

LMA-Classic or LMAUnique (mL) 6

LMA-Flexible (mL)

LMA-Fastrach (mL)

LMA-ProSeal (mL)

1.5 2

10 15

15

2.5 3

21 30

21 30

30

4 5

45 60

45 60

45 60

45 60

75

75

Lubrication should be a pplied to the pos terior c uff surfac e cuff jus t b efo re inserti on , tak ing c are to av oid getting lubrica nt on the anteri or (bowl ) s u rface . The manufac tu rer rec ommends wa ter-s oluble j ell y and does not recommen d the us e of analges ic -contai ni ng gels or sp rays , because this may delay the re turn of protec tiv e reflex es and may prov oke an allergic reac tio n. W hi le so me s tud ies s how that l ubric ati on wi th l id ocaine gel or s pra y wi l l resul t in a l ower inc idence of retching and c ough ing on e mergence (87,474), anoth er s tudy s howed inc reas ed in tra- and pos toperativ e probl ems (475). Lubricants or sprays that c ontain s ilic one may cause the mask to s of ten an d s wel l.

Figure 17.17 The laryngeal mask ready for insertion. The cuff should be deflated as tightly as possible, with the rim facing away from the mask aperture. There should be no folds near the tip. (Courtesy of Gensia Pharmaceuticals, Inc.)

View Figure

Anesthetic Induction
Ins ertion of the LMA requi res sufficient general o r topic al anes thes ia to obtund the ai rwa y ref lexes . A depth si mi lar to tha t necessa ry for inserting an orophary ngea l ai rwa y but no t as deep as is needed for trac heal in tub ati on is requi red (476). Abs ence of a mo tor res pons e to a ja w thrust i s a reli able me thod for assessi ng the adequac y of anes thes ia f or LMA inserti on (4 77). Grea te r depth is needed for i nserting the LMA -P roS eal than for the LMA-Classic (46 0).

Awake Placement
The laryngeal mas k can be inserte d in an awa k e patient f ollowi ng topical anes thes ia of the upp er ai rwa y and/or ne rve bloc ks (99,100,135 ,248,478,479 ,480,4 81,482,483). Ma sk insertion should be coordinated

wi th s wa ll owi ng. It may b e helpful to pa rtia lly inflate the cuff to s imulate a bolus of food (484).

Cuff Inflation and Assessing Position and Function

The c uff shou ld be inf lated to a pres sure of app rox imatel y 60 c m H 2 O (485,486). A cuff p res sure gauge is recommended fo r pro per inflati on pressu re. Cuff pressure can be es timated by feel ing the tens ion in th e p il ot ba lloon . A sphe rical pil ot balloon is an indic ation that the re is too much gas in the c uff. The c uff shou ld be inf lated ov er 3 to 5 s econds wi thout holding the tube un less th e position is obv iousl y uns table (e.g., in edentulo us patients with s lack tiss ues ). Th is us ual ly c auses s ligh t upward mov ement of the ai rway tube, and a s light bulging at the front of the neck is c ommonly s een. Th ere shoul d be a smooth ov al s wel l ing i n the neck a nd no cuff v isi ble in the oral cav ity. The reco mme nded max imum inflation v ol umes are giv en in Table 17.7. In p rac tice, i t is rarely neces sary to P .480 us e the f ull v olume (30,485,487,488). Us ing greate r-than-reco mmende d v olumes wi ll not i mprov e th e s eal agai ns t the larynx and may wo rs en it (194 ). A ra ti ona l approach is to inflate the mas k with half the maxi mum infla ti on v olume an d to determine the orophary ngea l le ak pressu re, adding more air if neces sary. Cuff si ze i s probabl y more i mporta nt than inflating v ol ume in de termining the seal, so upsiz ing the LMA may prov ide a bette r sea l th an adding more air to the cuff of a smal ler LMA (10,16,489,490 ).

View Figure

Figure 17.18 Cuff-deflating device for the Laryngeal Mask Airway. A: The laryngeal mask is inserted into the device. The cuff is deflated by using a syringe. At the same time, the device is compressed. B: After cuff deflation, the LMA is ready for insertion.

If pos itiv e-p res sure v enti la tion is to be us ed, the leak pressure should be g rea ter than 20 cm H 2 O (30 c m H 2 O wi th the LMA -Pro Seal ). If s pontaneous respi ra tion is to be us ed, the leak press ure s hould be greate r th an 10 cm H 2 O. Th is is the approxima te press ure of fluid a t the pos terio r pharyngeal wa ll if the oral cav i ty is f loo ded (491). Until spon tan eous resp iration h as res umed, it may be h elpfu l to oc c lude the nose and s eal the mouth around the tube to all ow p osi tiv e -press ure v enti lation (492). The airway s ea li ng press ure is determined b y obse rv ing the pressu re gau ge in the breathi ng s ys tem as the bag is squeezed and the pres sure inc reases . S ev e ral methods c an be used to determine the leak press ure (493,494 ). A s tethos cope can be plac ed jus t late ral to the thy roi d cartilage . Another me thod is to l is ten ov er the mouth fo r a noise when the bag is squeezed . Carbon diox ide may be de tected b y plac ing the sample line in the o ral cav i ty. Ano ther method is determining a s teady ai rwa y pressure af ter c los ing the adjus table pressure li mi ti ng (AP L) v alv e i n the c i rc le s ys tem. It may be pos s ible to improv e the s eal by ad ding mo re ai r to the c uff (if the maxi mum recommended v ol ume has n ot bee n i nj ec ted ) or by f lexi ng or rota ting the head and nec k sligh tl y (222,495,496 ). The leak pressure wil l be h igh er if the h ead and n eck are fl exed o r ro tated (222,433,497,4 98). Hig her pres sures may be ac hiev ed by applying pressure on the f ront and/o r si de of the nec k , by applying continuous fo rwa rd pressu re on the LMA , or b y lifting the h andle of the LMA Fas trach (499,500,501,502,503 ,504).

Indications that the LMA is prope rl y pos i tion ed incl ude normal b rea th sou nds , ches t mov ements , press ure-v olume loo ps and v olu me mon itoring n ot sho win g a leak , and ca rbon d ioxide wav eforms with posi tiv e-p res sure v entilation. If th e patien t is breathi ng sponta neous l y, no rmal rese rv oir b ag exc urs ions and absenc e of s igns of obs truc tion are i ndica tions of proper P .481 place ment (506). A fibe rsc ope or rig id en dosc ope can b e i ns erted thro ugh the LMA to c onf irm i ts pos i tion and rul e out a irway obs truc tion (73 ,79 ,109,506,507 ). X -ra y o r MRI ca n als o be used to conf i rm the pos i tion (75,508). A n esophag eal detec to r dev ic e can be us ed (50 9,510), al though i ts uti li ty has been ques tioned (511).

TABLE 17.7 Maximum Cuff Dimensions Mask Air Volume Maximum Bulge of Maximum Bulge of Maximum Transverse Size (mL) Cuff Tip (mm) Wide End of Cuff (mm) Diameter of Cuff (mm) 1 1.5 2 6 10 15 7.8 9.5 11.5 8.6 10.2 13.0 26.3 32.6 39.0

2.5 3

21 30

13.0 14.8

14.5 16.6

45.0 51.2

4 5

45 60

17.0 21.1

19.0 22.4

58.5 68.3

If the a irway i s o bs truc ted, the cause may be incorrec t mask posi tion, a downfolded epiglottis , a c losed glottic sphi nc ter, or an ov erinfl ated c uff. In mos t cas es , remov ing and reins erting the mask wi l l el iminate th e obs truc tion. Another technique i s to lif t the anterior neck s truc tures b y us ing a glov ed hand inserted into the

mouth, deflate the c uff , and rotate the mas k 3 60 (512). In s ome cas es , the epiglottis may be s tra ig htened digi tal ly (513). J aw manipul ation o r repos i tion ing the head usua ll y does n ot reliev e air way obs truc tion. Re mov ing ai r from the cuff ma y be he lpf ul (514 ). If des pi te thes e efforts sati sfac tory v entil ation cannot be ac hiev ed, the dev ice s houl d be withd rawn and reinse rted or a diff erent s iz e L MA or trac heal tube sho ul d be used.

Fixation
A bi te block o r rol l of gauze s hould be inserted into the mouth bes ide the tube to prev ent the patient from bi ting the tube and to i mprov e s tabi li ty. This is not necess ary wi th the LMA -P roSeal . Various other d ev ices hav e been used (515,516 ,517,518). An oropharyngeal airway shoul d not be us ed, b ecause both it and the LMA are des igned to be pl aced in th e midline, and the ai rway ti p migh t co mp romise the LMA cuff or c aus e tube compress ion (5 19). Als o, an oropharyngeal ai rwa y may not prev ent the tube from being bi tten (121,520). The tube s hould be sec ured wi th tape, taking c are tha t it does no t bec ome twi s ted. This can b e accomplished by affix ing the tape firs t to the max illa, wi nding ov er the cephalad s ide of the tube, a nd down around the caudal side to f ix the tu be and bi te block f i rml y to eac h o th er and to the opposite max illa (521). Furthe r sec uri ty c an be prov ided by taping f rom zygoma to zygoma under the mandi bl e (522) or a round the neck (52 3,524). A tracheal tube holde r may be used (525 ). Other fixation me th ods hav e been desc ribed (5 26,527). The f ix ation method s hould not obs truc t the su rge ry. A s utu re around a tooth ma y be used if tape wi ll be in th e way. Bending the tube agains t i ts na tu ral curv ature may c ause i t to become dis lodged or k ink , unless the LMA -Flexi bl e is used. Trac ti on from the breathing sys tem sh oul d be av oided, and sev era l methods to achiev e this hav e been sugges ted (527,529 ).

Intraoperative Management
Durin g surgery, ai rwa y patenc y and correc t LMA orien tation sho uld be v erified at regular i nterv als . The p ati ent's uppe r abdomen should be pe ri odicall y obse rv ed for s igns of dis tention and epigas tric auscul tation pe rforme d. A li ghter l ev el of anes thes ia than would be requi red if a tracheal tube we re us ed is us ual ly possi bl e. If la ryngospasm, wh eezi ng , s wal lowi ng, co ughi ng , s trai ni ng, o r breath h ol ding oc curs , an es thes ia shoul d be deepened or muscle relax ants admi nis te red . An aeros ol ca n be adminis te red by us ing a n LMA (530 ). Ni trous ox id e and carbon di ox ide c an dif fuse into the cuff , inc reas ing intracuff press ure and v olume

(198,199 ,531,532,533,534,535,536,537 ,538,539,540 ,541,542,543 ,544). Cuff v olume i nc reas es less with the L MA -Un ique than wi th the LMA -Classic (1 98). The inc reas e i n v olume may c ause airway obs truc ti on (514). In flating the cuff wi th n itrous ox ide wi ll av oid this inc reas e (545 ,546). The man ufac ture r rec ommends tha t cuff press ure be c heck ed perio dic al ly wi th a press ure gauge, transducer, or o ther dev ic e (Fi g. 19 .29 ) and ad jus ted to kee p i t at approxima tel y 60 c m H 2 O. T he pi lot balloon should feel c ompliant. If the ball oon feels s tiff or ol iv e sha ped, the press ure may b e excessiv e. Othe rs hav e sugg es ted that the logical me thod of con trolling cuff press ures during nitro us oxi de anes thes ia may be to tak e the jus t sea l p res sure as a contro l v alue an d withdrawn v olume to mai ntain v alues c lose to this press ure (546). The LMA ca n be used wi th c ontrol led (i ncl ud ing mec hanical) o r spon taneous v enti lation . Patie nt outc ome has been found to be s imilar in nonparaly zed pa tients wi th pos i tiv e-pressu re v enti lation or s pon tan eous breathing (547). If contro ll ed v enti lation is used , the peak i nspiratory press ure s houl d be kep t below 20 cm H 2 O (30 cm H 2 O with the P roSeal). Higher p res sures may res ul t in a leak a round the mask , gas tric d is ten ti on, and operating room poll ution (15,548 ,549,550,551,552). Changes in the v entilatory pattern to reduce ti dal v olu me a nd us ing musc le relaxants may resul t i n a lower peak pres sure. If hi gher p res sures are requ ired, cons ideration s hould be giv en to exch anging the LMA for a trac hea l tu be. If c ric oi d press ure is appl ied, the ai rwa y pre ssures at whic h the pa tient is v entil ated can of ten b e inc reased to ov er 30 c m H 2 O wi thout gas tric insufflatio n occu rring (553 ). P ress ure control v entilation (Chapte r 12), wi th or wi thout P EEP , whi ch is av ail able on ne wer anes thes ia v enti la tors , ma y be the mod e of choic e for c ontroll ed v enti lation wi th the lary ngeal mask bec aus e it a llows a lo wer peak pressu re fo r th e sa me tidal v olu me wi th l es s leak around the LMA (439 ,554,555). For patien ts breathi ng sponta neous l y, press ure -su pport v enti lation i mprov es gas exchange and reduc es the wo rk of b rea thi ng (556,557 ). The work of bre ath ing c an also be reduc ed by us ing CPA P (558). A sudden inc reas e i n leakag e, sno ri ng, o r other s ounds often s ignals the need for more musc le relax ation , al though other c aus es suc h as L MA d is placemen t, li ght anes thes ia causing glottic c losure, ai rway obs truc tion, a leak ing cuff , and a dec reas e i n l ung c ompl iance re la ted to the s urg ical procedure a re other p ossible caus es P .482

(559). A dd ing ai r to the c uff wil l not al ways co rrec t a leak and ma y make it wors e by inc reas ing tens ion in the cuff and pushing it away f rom the l arynx (560 ). Some times , remov ing s ome air from the cuff wi l l help. If reg urgitation occu rs , the firs t s ign may be the ap pearanc e of fluid trav eling up the LMA tu be. B reath holding or c oughing may occur. The pa tient s hou ld be plac ed in the head -do wn posi tion , the b rea thing c i rc uit disconnec ted, and the ai rwa y tub e suc tion ed. It may not be necessa ry to remov e the LMA , a lthough preparations for trac heal intubation should be made and the patient intubated, if indica ted . Ins erting a nas ogas tric tube behind a non-Pro Seal LMA c an be ai ded by us ing a nasal air way or a f lex ib le endosc ope to dis place the L MA forward (561).

Emer gence from Anesthesia

It is important that the bi te bloc k o r ro ll of gauz e be le ft i n place until the L MA is remov ed to maintain patenc y and prev ent damage to the LMA (562,563). Cuff defl ation s houl d be perfo rmed on ly when the LMA is remov ed (564,565). If the c uff remains inflated as the L MA is remov ed, a g rea te r mass of s ec retions wil l also be remov ed (566 ), bu t th is tech nique inc reases the inci dence of blood s taining (b ut no t so re th roa t) (567 ). Tak ing off a g lov e th at was worn when the LMA was remov ed and inv e rting it ov er the dev ic e wi l l min imi ze the spread of c ontamination (568 ). Keeping the LMA in place during transfer to the pos tanes thesi a c are unit (PA CU) wi ll ma in tai n a patent a irway, whil e l eav ing the anes thes ia prov ider's hands free for other tas ks . Du ring recov e ry, suppleme ntary ox yge n c an be del iv ered with th e L MA i n p lace by us ing a T-piece or other dev ice (569,570 ,571,572,573,574,575,576,577 ,578,579,580 ). W i th the T-p iece, res piration may be as sis ted manuall y by in termittently occ luding the expi rato ry limb (19). The re is controv ersy re gardi ng the op ti mal ti me for LMA remov al . It should e ither be remov ed wi th the pa tient in a deep lev el of anes thes ia or when full rec ov ery of ai rwa y ref lexes has occu rred. Leav ing the LMA in pos ition until ai rway ref lex es hav e rec ov ered and the patient c an phonate o r open his or h er mouth on c ommand, as recomme nded by the manufac turer, wi ll e nsure maintenanc e of a sec ure ai rway. The onset of s wal lowi ng is a us eful predic tor that s uch a lev el o f wak efulnes s is i mminent. The LMA sh ould not be remov ed during a l ig ht l ev el of anes thesia. If s wallowi ng and c ough reflex es are n ot present, sec retio ns in the upp er pha rynx may flood into the la rynx , prov oking laryn gospas m, c oughing , or ga gging. Re mov ing th e L MA wh ile

the patie nt is anes the ti zed or coinc iden t with s igns of rej ec ti on (s wal lowi ng , s truggl ing, and res tless ness ) but befo re the patient responds to c ommands c an i nc reas e the inci dence of gastroes ophageal ref lux (581,582). Remov in g the LMA whi l e the patient is und er dee p anes thes ia wi l l dec rease the i nci dence of coughing , breath hold ing, and bronchos pasm. It may be highly desirable in s ome s i tua tions , suc h as after intraoc ul ar s urgery . It shou ld no t be performed in a patient kno wn to be difficul t to intuba te. Deep ex tub ati on has been as soc iated wi th ai rwa y obs truc tion , re gurgitation, an d laryngospas m (563 ,583). Damage to the LMA is less f requent when th e L MA is remov ed under deep anes thes ia (563). Mos t s tudies sho w that in chi ldren, remov al when awak e may resul t in a high er i nci dence of ai rway pro bl ems (laryngospas m, c oughi ng, b rea th holding, bronc hospasm) co mpared with re mov al whil e dee p (584,585 ,586,587,588,589,590,591). However, a s imilar or higher i nci dence of ai rwa y pro blems in ch il dren with deep remov al has been re ported by s ome i nv es tigators (58 9,592,593 ,594). The patient s hou ld be lef t undis turbed, except to adminis te r oxy gen and pe rform moni tori ng, and shoul d not be turn ed onto hi s o r her s ide unless there is an i ndication (such as re gurgi tation or v omi ting) bec ause this may c aus e pre matu re rejec tion of the LMA . It is not necessary to remov e s ec retions in the uppe r pharynx , as they do no t enter the la rynx prov ided th e cuff is n ot defl ated p rior to remov al , and the LMA is not remov ed befo re th e patien t is able to s wal l ow e ffec tiv el y. Suc tioni ng through the LMA s houl d not be performed unles s the re is ev idenc e o f gas tric c ontents in the tube.

Care and Cleaning

As soon as pos sible af ter use , the reusabl e LMA should be gentl y cl ean ed with warm wa ter and a di lute (8 % to 10%) sod ium bic arbonate s olu tion until al l v isible material has been remov ed. The s ol ution o f bicarbona te wi ll hel p to disso lv e sec re tions (23,239 ). If a mil d detergent is us ed, i t s hould be o ne th at contains no mucous membrane i rritants . A pi pe c lean er ty pe brush should b e i ns erted through the dis ta l ape rture to cl ean out the shaf t, tak ing ca re not to damage the bars . The drain tube of the L MA -P roSeal should b e c le aned c a refull y, bec aus e i t c oul d be dama ged by a s tiff brush (417 ). The i nfl ati on v alv e s hould not b e exposed to any c lean in g s olution , because this ma y c aus e v alv e fa ilure (30). The LMA shoul d be

rins ed with tap wate r to remov e res idue an d then d ri ed and pl ac ed in a pouc h (239). W ater s hould not be all owed to ente r th e c uff. Au toc lav ing an LMA with water in the cuff may c aus e i rrev e rs ible dama ge (59 5). T o remov e fluid f rom the cuff wi th out dama ging the LMA , the c uff should be emp tied wi th the cuf f uppermos t and manu al ly squeezed. A sy ri nge wi th out a pl unger s hould be ins erted into the i nfl ati on v alv e a nd the L MA plac ed in a warming c loset for 12 hours a t 60C (596,597). As much a ir as poss ible sho ul d be remov ed from the cu ff s hortl y before autoc lav ing (598,599 ). Residual a ir P .483 wi ll expa nd in the heat and may damage the c uff , v alv e, or p il ot balloo n (599,600 ,601,602). If desi re d, an LMA ca n b e p reformed in to a more desi rable shape by bending it when it is packed for au toc lav ing (603). A red plug is s uppl ied wi th the LMA -P roS eal (604). Leav ing the v alv e open lets ai r escape to the atmosphere.

TABLE 17.8 Minimum Exposure Time for Steam Autoclaving of Reusable Laryngeal Mask Airways Autoclave Gravity displacement Wrapped 10 to 15 minutes Unwrapped (flash) 10 minutes

Prevacuum

3 to 4 minutes

4 minutes

The LMA ca n be autoc lav ed a t temperatu res up to 135C (275 F) (23,30) (Tab le 17.8). Higher tempe rature can c ause th e tub e to bec ome bri ttle and fragme nt. The LMA sho ul d be allowe d to coo l to room temp era ture af ter s te ri li za tion. Au toc lav ing i mpai rs the bond betwe en th e c onnec tor and the tube but n ot i ts ai r tigh tness (605).

The W orld He alth Organi zation guidel ines and pu blished li tera ture indic ate that the LMA cl ean ing and s te ri li za ti on proced ures dis cus sed prev ious ly a re suff ici en t fo r i nac tiv ation of conv entional pathogens suc h as bac teria , fu ngi , and v i ruses . In pati ents known o r sus pec ted to hav e a trans mis sible s pongif orm enc epha lopathy, i t i s rec ommende d tha t the L MA be des troy ed af ter use. A n L MA -Uni que s hould be us ed in these c ases . Liquid c hemic al agents s uch as glutaraldehy de, phenol -based c leaners , i odi ne containing c leaners , or quatern ary a mmo ni um c ompounds or ethylene oxi de sho uld not be used to cl ean or s teri li ze the LMA . They are adsorbed onto th e sil icone and can c aus e p haryngi tis and laryng itis as well as shorten the L MA l if e (23,30,239,606 ).

Life Span
W ith c aref ul us e and s tric t a dherenc e to c leani ng an d s te ri li za tion procedures , a l ary ngea l mask ai rway wi ll l as t for a lon g time . The recommended max imum numbe r of uses by the manufac turer f or the LMA -Class ic is 40 , but up to 200 us es hav e been rep orted (239,469,607,608,609). W ith re peated us e, there is a dec reas e in elas tance, an i nc reas e in cuff permea bi li ty , and a loss in s treng th of the ai rway tube (468,608,610). It may be poss ible to ex change a malfunc ti oni ng inf lation v alv e on an LMA (611). The LMA -P roSeal has a sho rter l ife span than the LMA -Class ic (468).

Dead Space
The dead space ass ociated with the L MA is less than with a fac e mask but is greater than wi th a trac heal tube. The c o rrel ation be twe en end-ti da l and arte ri al ca rbon d ioxide is be tter wi th the la ryn geal mask than wi th th e fac e mask (612,613) and as accu rate as wi th a tracheal tube (614,615 ,616,617). The pref erred s i te for meas uri ng end-tidal c arb on diox ide in c hildren is the lary ngeal end of the s haf t (618).

Flow Resistance and Work of Breathing

Res is tance to breathing is an impo rtant c ons ideration with the LMA becaus e i t is f requentl y used wi th sp ontaneo us breathing. W hi le the LMA itse lf offers les s resis tance than a trac heal tube, to ta l res pi ratory res is tance and work of breathi ng hav e been found to be s i milar because the larynx is not bypas sed (619,620 ,621,622,623,624). T he work of breathing through the LMA is s imi lar to that wi th a fac e mas k u nl ess there is diffic ulty i n main taining a patent airway . The

LMA -Flexi bl e has a smal le r ID and impos es s ignificantl y greater resis tance than other L MAs (10 5,228).

Useful Situations
The LMA has been us ed for a wi de v a ri ety of procedures , bu t it is probably bes t su ited to s hort cas es , mak ing i t es pec ial l y usef ul f or outp ati en t surgery. It has prov ed useful f or pa tients who nee d mu ltip le anes thetic s ov er a s hort period of time. The maxi mum duration f or whi ch the LMA c an be safel y use d is not known . It has been us ed for s urgic al proce dures las ting up to 8 hours (625,626). The l ary ngea l mask has been us ed wi th l ow-f l ow a nd c losed s ys tem anes thes ia (627,628 ,629,630).

Difficult Face Mask Technique

For patien ts i n whom mask v enti lation is or could be d ifficu lt, suc h as eden tulous pati ents or those wi th faci al injuries o r a fragi le n ose, those with facial c onto urs that are not s ui ted to a f ac e mask or beards, and p atients undergoing laser trea tmen t of the face, i t may be eas ier to maintai n a s atisfac tory ai rwa y wi th the LMA (631). S tudies compa ring LMA use wi th a face mask s how fe wer episodes of desatura tion and less d ifficul ty in maintainin g an airway wi th the LMA (632,633 ,634,635,636). The LMA may prov e useful for patients with facial burns who of ten require mul tiple anes thetic s (638). Ho wev e r, i t is not ap propri ate to us e the LMA to s ecure the ai rwa y in a patient wi th upper airway burns .

Difficult or Failed Intubation

Laryngeal masks hav e con tributed g rea tl y to s olv ing the diff icul t intu bation p roblem. The LMA is part of the Americ an Soc iety of Anes thes iologis ts ' d ifficu lt a irway algori thm, the Americ an Heart Ass oc iation a dv anced c a rdiac l ife support cou rse , and v ari ous i nternatio nal gu idelines (63 8,639,640,641 ,642,643). In s ituati ons whe re th e patien t can not be intubated , the L MA may be usef ul and ev en lifesav ing b y us ing it either as the primary means of maintaining P .484 an ai rway or to f aci l itate pass age of a tracheal tube (254,374 ,426,427,430,636,644,645,646 ,647,648,649 ,650,651,652 ,653,654,655,65 6, 657,6 58,659,660 ,661,662,663 ,66 4,665,666,667,6 68,669,67 0,671,672,673 ,67 4,675). For this re ason , it is recommended that an L MA be i mmedi ately av ailable wh enev er

a c anno t in tubate/c anno t v enti la te scenari o is p ossible. In th e patien t whos e trac hea cannot be i ntuba ted because of unfav orable anatomy (but not periglottic patho log y), the L MA should be consid ered as the f irs t treatment op tion (1 10). The LMA may be us eful in patien ts wi th ai rway di s torti on secondary to tumor (676,677 ), l arynge al f rac tu re (679), c ongenital probl ems (42,103,479 ,648,679,680 ,681,6 82,683,684,6 85,686), faci al i njuries (644 ,687), hema toma or absc ess (688,689 ), l aryngeal polyposis (691), l ary ngeal in ju ri es (683), supraglo ttic edema (657), to nsi llar h ypertrophy (691,6 92), os teogenes is imperfecta (694), l imi ted mouth op ening (28,118,267,69 4,695), nec k mass (267), poor neck mobil ity, a nd presenc e of a cerv ical colla r (24,95,241,246 ,255,306,318 ,69 4,695,696 ,69 7,698,699,700). The laryngeal mas k has bee n used bo th as the pri mary ai rway an d to faci li ta te i ntu bation for patien ts wi th P ierre-Robin (42,1 03,480,679,6 81,682,684 ,685,701,702 ) and Treacher Coll ins s yndromes (650,7 04,705,70 6,707), and other c ongeni tal condi tions that make in tubation difficul t (707). If the tracheal tube c uff in a difficu lt-to-intub ate pa ti ent dev elops a leak , i t may be possible to elimi nate the leak b y ins erting a laryngeal mask ov e r th e tube , inflating the cuff, and then s eal ing th e p rox ima l orif ic e (714 ).

Ophthalmic Surger y
The LMA has been us ed for procedu res on the eye (232 ,71 5,716,717,718,719). Mos t s tudies hav e s hown that intraocular pres sure is l ower af ter i nserting an LMA than a trac heal tube (720,721 ,722,723,724 ,725,726,727 ,72 8,729,730,73 1). Intraoc ul ar press ure du ring emergenc e is us ual ly l ower with an LMA (729,7 32). Res erv ations hav e be en expres sed abo ut us e of the L MA in ocu lar s urgery (733,734 ). The L MA ma y b e d is lo dged du ri ng in traoc ula r surgery (728,735,736). This can b e p rev ented by ca ref ul fixatio n and main te nanc e of an adequate depth of anes thes ia and mus cl e relax a ti on (737). The us e of an LMA -Flex ible h as been recommen ded.

Tracheal Procedures
Some pa tients with tracheal s tenos is may be managed by us ing the lary ngeal mask (689,739 ,740,741,742,743,744,745,746 ,747,748,749 ,750), altho ugh failure in this s i tuation has been reported (751). The LMA has bee n used as a bl oc ker to prev ent gas los s f rom the trac hea durin g a tracheopl as ty (752). Compres s ion of the trachea by a medias tinal mass c an cause pro bl ems s imil ar to trac heal s tenos is . Both me dias tinoscopy and thoracotomy hav e been pe rforme d in

this s ituation with the L MA and spon tan eous v entilation (753 ,754,755). Howev er, us ing the LMA in a pa tient wi th a med ias ti na l mass has b een ques tioned (756). The laryngeal mas k has bee n used to d ia gnos e laryng omalac ia and trac heob ronchoma lac ia in adul ts and c hi ldre n (758 ,7 59,760,761 ). Ho wev er, i ts us e for pati ents with colla psi bl e airway s has bee n questioned (756).

Endoscopy
The LMA has been us ed to ai d diagnos tic and therapeutic fibe rop tic l ary ngotrache oscopy and bronc hosc opy in adul ts and chi ldren by direc ting the f ibe rs cope to the glottis (72,728,740 ,761,762,763 ,764,7 65,766,767,7 68,769,770 ,771,772,773 ,77 4,775,776 ,7 77,77 8,779,780,781,782,783,784 ). The LMA h as also been used to f aci l itate bronc hoalv eola r lav age (765,785,7 86) and to pl ace a bronchial s tent (787 ). A la rge r fiberoptic b ronc hos cope ma y b e used wi th the la ry ngeal mask compared wi th the nos e o r trach eal tube . The LMA -Flex ibl e is not sui ta ble for f iberoptic ex aminations because of the narro w tube an d because th e i nternally s eated wire may be damaged (105). Ven ti la tion c an b e maintained by us ing a c onnec tor that i ncorporates a diaphragm openin g for the bronc hosc ope (see (4 ) in Fig. 7 .2). This al lows the PE EP appl ic ation , which may imp rov e the bronc hos copic v iew of the upper ai rways (128). The LMA may be he lpful whi le plac ing a bronc hia l block er (7 88,789). The bloc ker is place d in the trachea prior to plac ing the laryng eal mas k . A bronchosc ope is p laced through the LMA to ass is t in plac ing the bl ock er. After this h as bee n accomplished, an ap pro priate tracheal tube is placed through the LMA into the trachea , and the LMA is wi thdrawn. A l tern ate ly , the L MA may b e p laced fi rs t an d then the block er positioned through i t.

Tracheal Tube Exchange

The laryngeal mas k can be used to faci li tate trachea l tube exc hange (790 ,79 1,792). The LMA is inserted nex t to the tracheal tube. A fibe rsc ope wi th a trac heal tub e moun ted o n the fibe rop tic porti on is ins erted into the LMA . T he fiberoptic scop e is i nserted into th e trachea nex t to the o riginal tube . W hen pl acement in the trachea is v e rified, the old tu be is remov ed and the new one adv anc ed ov er the sc ope i nto the trac hea.

Transesophageal Echocardiography

The LMA has been us ed in pa ti ents unde rgoing transesoph ageal echocardiography (793,794 ,795,796).

Ventilator y Support without Tr acheal Intubation

The LMA ca n be used f or sh ort-term airway mai ntenanc e (79 7,798,799,800 ,801), applica tion of CPA P or P EEP (128,802,803,804), o r pressu re-sup port v en tila tion (556,805 ,806). The la ryngeal mask ca n be used to aid trac heal suc tioning wi thout resorti ng to intuba tion or trac heos tomy (807).

Head and Neck Procedures

The LMA has been us ed for a v ariety of head and neck procedures , inc luding l ary ngos cop y and P .485 mic rosurgical p roc edures on the la rynx (740,7 57,807,809 ), nasal and pharyngop las tic surgery (8 11,812,813 ,814,815,816 ), myringotomies (633,635), adenoidec tomy and tonsi llec tomy (31,203,223 ,224,225,635 ,740,8 16,817,818,8 19,820), and dental procedures (66,219,816 ,821,822,823 ,824,8 25,826,827,8 28,829). The L MA has been us ed in conju nc tion with a f iberoptic bronc hos cope to assis t in thyroplas ty (83 0). The LMA -Flex ible is partic ul arl y useful fo r pro cedu res inv olv ing the head and nec k area bec aus e the tubing c an be mov ed abou t to fac i litate the su rge ry, and the wire reinforceme nt mak es the tube more res is tant to k ink in g and comp res s ion than the LMA -Classic . Ca re mus t be taken not to displac e the LMA or al low it to ro tate when mov ing the ai rwa y tube . The LMA cu ff ac ts to prev en t as piration of blood, teeth, a nd sec retions from abov e the mask (114,224 ,22 5,811,831,832,833,834). Further protec tio n ma y be obtained by inse rting an o rop haryngeal pack or by pos i ti oning a suc ti on ca the te r in the groov e between the mask and the LMA tub e (835). The LMA has been us ed for thy roid surgery. T he c uff displac es the g lan d anteriorly , fac i li tati ng su rgica l acc ess (30,740). Bec aus e damage to the recurre nt lary ngeal nerv e is a c omplic ation of thy roid su rge ry, it may be desi ra ble to s timulate tha t nerv e du ring and af ter surgery and observ e th e mo ti on of the v oc al c ords b y using a fibe rsc ope through th e L MA (23,728,767 ,768,769,770 ,771,7 72,773,774,7 75,776,777 ,778,779,780 ,78 1,782,783 ,7 84,78 5,786,787,788,789,790,791 ,792,793,794 ,79 5,796,797,798,799,800,801 ,802,80 3,804 ,805,806,807,808,809,810,811,8 12,813,814 ,815,816,817 ,818,819,820,821,8 22

,823,824 ,825,826,827 ,828,829,830,83 1,832,833,834 ,8 35,836,837 ,838,839,840 ,84 1) . A n LMA can a ls o be used to c ontrol the tens ion and pos ition of the pharyngeal wal l to fac il i tate surgical c ond itions (842). Tra chea l dev iati on and na rrowi ng should be cons idered re la tiv e con traindic ations to us ing the LMA in thy roid surgery. Ear p roc edures are wel l sui ted to the LMA (740,8 43,844). A t the end of the s urg ic al procedure, i t is important that the pati ent do es not c ough or s train. Thes e problems are les s likel y wi th the la ryngeal mask . A pe rc eiv ed drawbac k to usi ng the la ryn geal mask in ear c ases is that of ten the anes thes ia prov ider is loca ted at the foot of th e pati ent. S ome c l inic ia ns feel uncomf ortabl e wi th this pos i tion whe n an L MA is in place . The LMA has been us ed for s tandard (650,655,682 ,72 8,845,846 ) and percutaneous di lata tiona l tracheos tomy (667,847 ,848,849,850,851,852,853,854 ,855,856,857 ,858,859) (Chap ter 21) an d for i nserting a needl e i nto the trachea for j et v entilation (689 ). Us ing the LMA el imina tes the nee d to sha re the trachea with the s urgeon and av oids the p oss ibi lity of c uff punc tu re, tube transec tion, or acc idental ex tubation . It als o all ows the trac hea to be v is ual ized th rough a fiberscope durin g the procedure. The LMA may be us ed fo r c arotid endarterec tomy (860,861 ,862,863). Ai rway mana gemen t with the L MA is ass oc iated with dec reased hemodyna mic and s tress respons es . The su rge on should be wa rne d that neck anatomy may be al tered and that ex ces siv e nec k p res sure migh t displace the cuf f (863). Cuff inflation and def lation has been found to dec reas e and inc rease blood f low through the carotid artery (8 64). The c li nic al si gn ific anc e of th is finding is not c lear, but cuff inflatio n v olume and press ure s hould be kep t as lo w a s p rac tic al. P lace ment is sometimes diff ic ult in pa tients with la rge tons ils (50,8 65). The LMA tube may bec ome compres sed between the l ower teeth and the Boyl e Dav is gag blade (114,223,224,866,867 ).

Pediatric Patients
The LMA ca n be used in chi ld ren , inc luding smal l infants (50,63,276,436 ,442,454,588 ,70 5,783,868 ,86 9,870,871,872,873,874,875 ,876,877,87 8,879 ,880,881,882). It may be partic ula rl y helpf ul wi th ch ildren in who m un usual anato my makes trac heal intuba ti on diff icul t (108,884 ,885,886,887). The L MA has been used in Treache r Col lins , Dandy -W alker, P ierre-Robin, Goldenhar, Freeman Sheldon, Beck wi th -W iedeman n, an d S till 's synd romes ; congen ital epulis ; and mucopol ysacchari dos es

(98,103,143 ,479,649,679 ,681,6 82,685,701,7 03,704,705 ,706,846,884 ,88 7,888,889 ,8 90,89 1). Howev e r, i t may no t be useful in so me p ati en ts wi th Hun ter's s ynd rome (892). The laryngeal mas k airway prov ides a us ef ul al te rna tiv e to the trac heal tube when i t i s necessary to admin is ter anesthes ia to c hild ren wi th an upper res piratory i nfec tion (893). In c hi ldren wi th bronc hopulmon ary dysplas ia, the LMA can ma intain a sa tisfac tory a irway wi th fewer a dv erse respira tory effec ts than a trac heal tube (894,895 ,896). Chil dren wi th s ubglottic s tenos is may hav e res pi ratory problems if this a rea is irri tate d b y a trachea l tube. The laryngeal mask has been used f or ch il dren with th is problem who are u ndergoing su rge ry that is not related to the ai rwa y (89 7,898). The l aryngea l mask has been us ed fo r high-frequenc y os ci llation for a prematu re infant (899). The LMA has been us ed for child ren who h av e anes thesia fo r radio the rap y and MRI ex aminations and fo r those who re qui re multiple anes th etics ov er a s hort period of time (9 00,901,902,9 03,904,905). T he LMA has been s ucc essful l y used for pedia tric pati ents who hav e ex trac orporeal sh ock wav e l i thotri ps y (9 06). A l tho ugh diff icul t to i nsert, the L MA -Fl exible has been used s ucc essful ly for pediatric dental s urgery (907,908 ). The L MA has been us ed fo r ped iatric c a rdiac ca the ri zati on (759). Some s tudi es s how fewer hypox ic episod es and improv ed su rgica l conditi ons i n ch il dren who are v entil ated wi th the LMA as compa red wi th a face mask (633 ). Other s tudies hav e found that there were more complications suc h as bre ath holding, coughing, laryngospas m, s ec retions , obs truc tion , and ox yge n desaturation wi th the LMA when compared with the face mas k and oral ai rwa y (90 9). S ome s tudies found a tende ncy for the LMA posi tion to deteri orate after ini tial s atisfac tory place ment i n infan ts (63,77). P .486

Bec ause the epiglottis in c hildren is rel ativ el y l arge and f loppy, the l ik el ih ood of i ts being wi th in the mask is greate r th an in adul ts (50,75,79,910). This may mak e b lind i ntu bation o r in tubation ov er a bougie o r guide wi re pas sed through the LMA diff icul t (64). S mal ler chi ldren are more likel y to hav e ai rwa y obs truc tion , greater i nspi rato ry l eak , and more c ompl ic ations and requi re highe r v en tila tory pressu res than ol de r ch il dren (877,882). The inc idence of tra uma ma y be higher than ex pec ted (911).

Professional Singers
The laryngeal mas k ma y be espec iall y us efu l fo r professional s ingers and sp eake rs i n whom the laryngeal complica tions of intuba ti on wou ld be mos t serio us (9 12,913). The LMA ca uses l es s c hang e in v ocal func tion than tracheal intuba tion (9 14).

Remote Anesthesia
S i tuati ons i n which the anes thesi a p rov ider mus t be away f rom th e patien t, i ncl uding di agnos tic imagi ng and radiotherapy proce dures , c an of ten be managed by us in g a larynge al mas k (208 ,229,900,903 ,905,915,916 ). These procedures are us ual ly as soc ia ted wi th minimal or n o pain b ut requi re the patient to remai n s til l for a perio d of ti me. If the patient mus t be placed i n an awk wa rd pos ition and the are a of interes t is not n ear the LMA , the LMA -Flex ibl e may be the best c hoice. MRI poses some s pec ial problems (Chapte r 30). Bec ause s ome of th e i nfl ati on v alv es contai n metall ic ma terial, it ma y be necessary to remov e the v alv e an d knot the pilot tube (917 ). If a nonferro us v alv e is not av ai lable , the v alv e can be positioned away from the area of interest (23). If the LMA -Flex ible, LMA -Fas trach , or L MA -P roS ea l is used, the metal c oil produc es a l arge black ho le i n the image in the area s urroundi ng th e a irway as wel l as d is torti on of the i mage in the area su rround ing the ai rwa y (229 ). A n L MA may no t be s ui table if magnetic resonanc e spec tros cop y is performed , bec ause the resonance of s ome si licone-contai ni ng materials comp romises interpre tation of the scans (91 8). The LMA -Unique c an be us ed in this c ircums tance.

Supplementing Regional Block

In c ases wh ere s urgery ou tlas ts a reg io nal b loc k or onl y a parti al block is pres ent, suppl ementation with li ght general a nes thes ia may be desi ra ble . In addi tion, many pati ents become res tless and c anno t to le rate pro lo nged su rge ry under regional anes thes ia. The LMA can be us ed in thes e s ituatio ns, as it requ ires a li ghter l ev el of anes thesia than wou ld be requi red with a trache al tube (626,919 ).

Resuscitation
Suc ces sfu l us e of the L MA -Class ic and L MA-Fas trac h duri ng ca rdiac arres t has been rep orted (553,920,921,922,923,924 ,925,926). The pres ence of an LMA d oes not in terfe re wi th pa lpa ti on of the ca rotid puls e (927). S inc e the LMA can be i nserted from the f ron t, s ide, or head of the patient, it is us eful in entrapmen t s i tuations. The h ead ca n be ma intained in the neutral posi tion i f ce rv ica l trauma is suspec ted. B ette r v en ti la tion c an be achieve d than wi th a face mas k (928 ,929,930).

The LMA has been us ed for neonatal resusc itation i n i nfants as s mall as 1.0 k g and i n n eona tes wi th abnormal a irways (501,682 ,931,932,933,934,935,936,937 ,938,939). Disadv antages i nc lu de the i nabi l ity to remov e mec onium or to ad minis ter h igh p res sures (940). This may make i t uns uitab le for re sus citation of premature ne wborns or ones who requi re hi gh ai rwa y pressures (936). Nonanes thes ia pers onne l can l earn th e L MA inse rtion tec hnique eas ily (846,941 ,942,943). The LMA -Fas trac h may be superio r to the LMA -Clas sic for i nexp erienc ed personnel (944 ). Intubation with this dev ice c an be l earned more easil y and rapi dl y than tracheal i ntubation us ing la ry ngos copy (945 ,946). It is preferred by pe rs onnel who use an ov er-the-p ock et f ace mask or mouth-to-mouth contac t for ex hal ed ai r v entila ti on (947,948). The LMA sh ould not be c onsi de red a s ubs titute for a trac hea l tube if s omeone present has the abi l ity to plac e a tracheal tu be. The LMA ca nnot offer ful l protec tion f ro m as pi rati on. Reg urg itation is l ess wi th the LMA th an with a bag-v alv e -mas k dev ice (949). The LMA does offer p rotec tion from as piration f rom abov e the la rynx , inc luding blood f rom tra uma (80 5). The LMA sh ould not be used if the p ati en t is no t profo undl y unc onsc io us or res is ts i nsertion . It ma y not be poss ibl e to adequa tel y v enti late pa tients who re qui re positiv e-pressu re v en til ati on and wh o hav e poorl y compliant lungs with pul mona ry edema, as piration, or o bs truc tiv e pu lmonary d is eas e .

Out-of-hospital Use
The LMA has been us ed in ou t-of-hospi tal si tua tions , incl udi ng ai r trans fe rs (950,951 ,952,953). It has prov en useful in patien ts wi th c erv ic al s pine injury and in those trapped in posi tions tha t do not lend thems elv es to trachea l i ntubation (954,955 ). Its ease of i nse rtio n ma y make it us eful i n the s c enari o of a toxic mass casual ty ev ent (95 6). Paramed ics and res pi ratory the rapis ts ca n acqui re s k ills more rapi dl y and hav e a highe r rate of s uccessful p lac ement with the LMA than wi th a trac heal tube (846,957 ,958,959,960,961,962). Howev er, whi le LMA pl acement by pa rame dic s is us ual ly s uccessful , bl ind tracheal i ntubation through i t is not assoc ia ted wi th a hi gh succes s rate (963).

Obstetrics
Bec ause the risk of aspi ration of gas tric con tents is high in the obs tetrica l patient, the use of an L MA is usu al ly no t rec ommend ed (964). Howev e r, i t has b een

P .487 us ed in he althy pa rturi en ts for elec tiv e Cesa rea n s ec tion (67 1,965). If i ntuba ti on cannot b e performed, the LMA may be lifesav ing (652,657 ,661,669,670,966,967,968,969 ,970,971,972 ). Fo r this reaso n, and b ecause the incidenc e of fa iled intubatio n i n the obs tetric populati on is h igh er than in the general population , la ryngeal masks s houl d be kep t in ev ery obs tetric al operating room. The L MA -P roS ea l is p robabl y a better c hoice than the L MA -Class ic for this us e. In the obs te tric pa tient who can be v enti lated by usi ng a face mask whi le c rico id press ure is con tinuousl y appl ied, pl ac ing the LMA may hav e l i ttle benefi t and might i nduc e v omi ting and as pi ration. S inc e c ricoid pressu re of ten i nhibi ts LMA place ment, c ric oid p res sure may need to be momentari l y rel eas ed to al low the LMA to be s ucc ess ful ly i ns erted. The lary ngea l mask may no t al ways be effec tiv e in the obs te tric pa ti ent (97 3). The laryngeal mas k has bee n i ns erted by us ing topical anes thesi a and has b een us ed to f aci li tate trachea l in tubation in a parturi ent (974).

Laser Surgery
The LMA has been us ed for las er s u rge ry on the face (975,976), pha rynx (81 2,977) and s ubgl ottic areas (72,742,978 ,97 9). The manufac turer does not rec ommend that these dev ices be us ed with lasers . A l though L MAs , wi th the exc eption of th e L MA Unique and the LMA -Fas trach , are more resis tant to perforation by las ers than polyv in ylchloride or wire-rei nforc ed tracheal tubes , they can be ign ited at c li nical l y us ed power dens ities (98 0,981,982). Operating roo m f ires are d is cuss ed in Chapter 32. The cuff and the bl ac k ma rk e rs on the tu be are the mos t v ulnerable are as (204). The LMA tube s haft s hould be wrappe d i n a las er-res is tant materia l and the cuff p rotec ted wi th wet gauze and fi l led wi th s al ine (596,97 7,982,983). A gauz e bite block s houl d not be used (976). It is importa nt that res idua l fl ui d in the cuff be remov ed a nd dri ed wi th the infl ation v alv e open (596). A n i mportan t adv antage of us ing the LMA fo r laser trea tmen t v ia the f lex ible e ndos cope in patients wi th trac heal tumo rs is the gas f low- res is tance charac teris tics through the LMA co mpared with a tracheal tube (105). An intubating laryngeal mas k can be us ed to faci li tate l as er-res is ta nt trac heal tube place ment (984).

Laparoscopy

Us e of the LMA for l aparosc opic procedures i s con trov e rsial , becaus e i t does not of fe r def in itiv e pro tec tion f rom pul mona ry as piration of gas tric c ontents (986,987 ,988,989,990). S tudi es sugges t that the LMA is safe f or gynecolog ic l aparosc opy (662,990 ,9 91,992,993 ,99 4,995,996 ). It has als o been use d succes sfully for laparosc opic cholec ys tec tomy (31,423,432 ,448,997,998 ,999), but a case of as pi ration has been repo rted (1 000). The LMA -P roSeal is recommended f or these proc edures (4 32,1001 ,1 002).

Lower Abdominal Surger y

A numbe r of s tudies indica te th at the LMA is safe for l ower abdomi nal p roc edu res such as hys terec tomy and retropubic prostatec tomy. Ad equa te anes thesia dep th to prev ent coughi ng during peritone al s timula tion needs to be mai ntained (31).

Neurosurgery
The LMA has been us ed for patien ts un dergoing v en tric uloperitoneal s hunts (1003) and intrac ra nial s urgery (1004,1005,1006,10 07,1008 ,1009,1010 ). He modyn amic s tabi l ity ass oci ated with th e L MA may be espec ia ll y beneficial in patients undergoing procedures wh ere hy pertens ion mus t be av oided , s uc h as rep ai r of an i ntrac ranial aneu rys m, and in patients wi th i nc reas ed in trac ranial p res sure. Th e LMA can be us ed to p rov ide a smooth er emergence from anes thesia after i ntrac ranial or s pi na l surgery (1011). Cerv ical spine diseas e is of ten associ ated with head and n eck immobi li ty, whi ch can be assoc iated wi th d ifficult trac heal intubation. Use of the LMA -Fas trach may enable tracheal i ntubation without the need to man ip ula te the head and neck (246,261 ,1012).

Unstable Cervical Spine

The optimal a irway management for the pa tient with an uns table cerv ical s pine is controv e rs ial . W hi le the LMA re qui res les s c erv ic al man ipu la tion during intuba tion than di rec t laryngos cop y, i t produc es flex ion and pos terior cerv ic al s pine displac ement despi te manual s tabili zation (2 60,359,1013,1 014). This motio n is in the opposi te di rec ti on of laryngosc opy. Some inv estigators feel tha t th e L MA s hould not be used f or the pati ent wi th an uns tabl e cerv ical s pine unless intubation by s tandard tec hniques is uns uccessful (359,1015).

Extubation
The LMA ca n be s ubs ti tu ted for the trac heal tube wh il e the patient is s ti ll in a deep plane of anes thesi a o r bef ore anta gonism of neuromusc ula r block ade to faci l itate a

smoo ther emergenc e from a nes thes ia (781,798 ,1011,1016 ,1 017,1018,1019,1020,1 021,1022,1023 ,10 24,1025 ,1026,102 7). The LMA is placed be hind the trachea l tu be, and the cuff is inflated. Correc t l ary ngea l mask pos i tion ca n be c onf irmed by us ing a f ibers cope or a c apnograph. The trachea l tube cuff is then d efl ated, and th e tracheal tube is remov ed as soon as the patie nt resumes s pontaneous breathing. A n exchange ca the ter or bougie may be us ed to fac i li tate reinsertion of the tracheal tube, if this is needed (984). The LMA may be us ed to mai ntain an airway wh en accidenta l ex tuba tion occ urs and rein tub ation wo uld be d ifficul t (102 8). P .488

The LMA ca n be used to aid diagnos is of laryngeal edema before ex tubation by us ing a f ibers cope (1029 ).

Access to the Upper Gastrointestinal Tract

The LMA ca n be used to direct a g as troscop e or nas ogas tric tube into the es opha gus (1030,103 1). The LMA -P roSeal is spec iall y des igned to f aci l itate the passing of an ente ral tube.

Extracor poreal Shock Wave Lithotripsy

Ex tracorporeal shoc k wav e l ithotri ps y requ ires v ery l imi ted d iaphragmatic motion to l ocali ze the u reteral s tone. The LMA in combinati on with high-frequenc y j et v enti lation can red uce motio n and make this p roc edure more effic ien t (1032).

Complications
Aspiration of Gastric Contents
The LMA does not form a waterti ght s eal a round the larynx and c ann ot be relied on to p rotec t the tracheo bronchial tree from the c ontents of th e gas tro intes tinal trac t as reliab ly as c an a tracheal tube (686,100 0,1033,1034,1035,1036,1037 ,1038,1039 ,1040,104 1,1042,1043,1044,1045, 1046,1047 ,1048,1049 ,1050). The ov era ll inc idence of gas tric content as piration is l ow and has been reported as 2.3 per 10,000 to 10 .2 pe r 10,000 in adul ts (1033). Many repo rted c as es of as pi ratio n with the LMA are ass oc iated with patie nts wh o are cons id ere d inappropriate fo r the L MA -Class ic (gas troin tes ti nal pathology , obesi ty , ai rway p rob lems , dep res sed l ev els of c onsc iousness , T rendelenbu rg or l ithotomy pos ition, his tory of reflux or emerg enc y s urgery , and trauma), b ut cases

of aspi ra tion in fas ted pa ti ents with no predispos ing fac to rs duri ng elec tiv e procedures hav e been re ported (1033). A spi rati on is l ess l ikel y with th e L MA P roSeal , al though as pi ra tion may resul t if th e tub e is not correc tl y plac ed (414). Gas troeso phageal ref lux ma y be a p rec urs or to as pi ra ting gas tric c ontents . No co rrela tion has been found between p res sure and v olume ins ide the cuf f and v a ri ations in es opha geal p H (1050). The inci denc e of reflux is the s ame wi th spontaneous and positiv e-pressu re v entil ation (19,1036 ,1051). The ris k of refl ux is i nc reas ed if the LMA remains in pl ace un ti l the patie nt can open the mouth o n co mmand as opposed to remov al on the f irst s ign of rej ec ti on (581,582,105 2). Regurg itation usual l y occu rs wi tho ut warning. It is often as soc iated wi th l ight general anes thes ia. The fi rs t indication is ofte n the appearanc e of gas tric sec re tions in the tube . Fortunately , mos t of th e reported c as es hav e had fav orable outcomes becaus e the regurgitated material wa s not as pi rated or the as piration was rela tiv el y mild. S tudi es sugges t an inc idenc e of asp iration of 1 in 5000 to 12,000 patients wi th the LMA -Classic (662,1046 ,1053). The inc idence app ears to be fa r lo wer wi th the LMA P roSeal (409). A red uc tion in lower es oph ageal sphinc te r tone may occu r when a lary ngeal mask is us ed (1054,1055 ). Ho wev er, the uppe r esophageal s phi nc ter remains compete nt and c an prev ent reg urg itation in th e absence of ne uromusc ula r block (1056 ). Duri ng general anes thes ia wi th the LMA , the pharyngeal ref lex is bl ock ed or minimal and does not affec t esoph ageal motil ity (1057). A s tudy i n c adav ers found tha t corre c tl y place d LMAs attenuated li quid flow betwee n the es ophagus and phary nx (1058). The re is significan t imp airment of the cough ref lex fol lowi ng LMA use (1059). Vomi ting is rare whi le the la ryngeal mask is in us e. An inc idenc e of 0.4% was reporte d i n a la rge retros pec tiv e s tudy (1060). The re was no aspi rati on in this s tudy . In the ev ent of a f ai led intubati on in a patient for whom the re is a s ign ificant risk of as piration and in wh om v entilatio n c an be maintained with a fac e mask whi le c ricoid press ure is appl ied, i t may be s afe r to c ontinue wi th the face mas k and c ric oid press ure rather than try to ins ert the LMA (1 061). Apply ing c ric oi d pressu re may make pos i tioning the LMA more difficul t an d ma y dec reas e the succes s of v enti lation (25,32,34,35,38,106 2). It is probably a goo d idea to momentaril y relax c ric oid p res sure whi le the LMA is inserted. The L MA does not dec reas e c ric oi d press ure eff ec tiv enes s , so c ricoid pressu re shoul d be reapplied a nd main taine d af te r the L MA is inserted u nless i t in terfe res wi th v entilation (1063,1064 ).

The inc ide nce of aspi ra tion can be reduc ed by l imi ti ng the elec tiv e use of the LMA to fas ting patients who are no t at inc reas ed ri sk for gas troes ophageal ref lux . Gas tric dis tention can be minimized b y using the correc t si ze mask , av oiding un deror ov erinflating the cuff , careful pos itioning and f ix ation , mainta in ing adequa te anes thetic depth and relax ation throughout su rge ry, and lo w i nf la tion press ures . The use of low ti dal v olumes and l ow inspi ra tory flow ra tes wi l l help to keep peak ai rwa y pressure lo w. The mean p res sure a t whi c h gas tric ins uffl ati on oc curs is 28 cm H 2 O wi th a range of 19 to 41 c m H 2 O when us ing s ize 4 and 5 LMA s (1065). Epigas tric ausc ultatio n s hou ld be pe rf ormed to ens ure that g as tric insufflation is not occ urring. A nas ogas tric tube may be us ed but ma y not al ways be helpfu l (895,109 6). The use of p res sure-contro lled rather than v olume-c ontrol le d v enti lation (Chapter 12) may resul t in lowe r inflation p res sures (1067). Durin g spon taneous respiration , it is importan t to maintain an adeq uate lev el of anes thes ia bec aus e gas tric dis te ntion resu lting f rom recu rrent s wall owi ng can occu r whe n anes thes ia is too l ight (1068,1 069). Degluti on frequenc y may be inc reas ed by the LMA (1070). Ev en i n the pres ence of deep an esthes ia and in th e absence of risk fac tors , as pi ration c an oc cur. If gas tric contents a re se en in the la ryngeal mask , the pa tient s hou ld be plac ed in the 30 he ad-down position, the LMA le ft i n s i tu , anes thes ia deepened , and P .489 the breathing s ys tem disconnec ted temporaril y to al low drai na ge. The lateral position has no ap parent a dv antage, as regurgi ta ted f lu id is prev ented f rom es caping v ia the pharynx . Ox ygen shou ld be s uppli ed. Fo rceful v enti la tion attemp ts shoul d be av oided and s mall tidal v ol umes d eliv e red . S uc ti oning should b e performed v ia the LMA , preferabl y b y using a fibersco pe. The LMA s hould be replaced wi th a trac hea l tu be if aspi ra tion has oc curred. If the L MA -P roSea l is being used and u nex pec ted regurgi tation occ urs , fl uid wil l emerge f rom the d rain tube. It has been shown in cadav ers that f luids ex i t v ia the drain tube wi thout l aryngeal c ontamination wh en the mas k has been c orrec tly place d. In this s i tu ati on, it is not necessary to remov e the LMA -P roS eal i f the ox ygen s atu ration remains a t acc eptabl e lev els (377 ).

Gastric Distention
Gas tric dis tention, wh ich h as been impl ic ate d as a f ac tor i n asp iration, can occur wi th pos i tiv e-pressu re v enti lation

(15,50,109,549 ,551,552,873 ,87 4,1071,1072,1073 ). The inc idence of gas tric dis tention inc reases wi th i nc reas in g a irway press ure and tidal v olume but is unlikel y to occur a t ai rwa y p res sures of less than 20 c m H 2 O (30 cm H 2 O for the LMA -P roS eal ) if the L MA is properly posi tioned. The use of press ure -l imi ted rather than v olume-l imi ted v entilation may help to av oid gas tric di latation (1074). The risk of gas tric insufflatio n is inc reas ed if the LMA is not prope rl y pos i tioned (1 075). Epigas tric ausc ultatio n is a fa irly relia ble technique fo r detec ting gas tric inflation (1076).

Foreign Body Aspiration

A foreign body may become entrapped in the LMA tube (1077,10 78,1079 ,1080,1081 ,1082,1083). Such an ob jec t may be subsequentl y as pirated or c ause ai rway obs truc tion. Chewing gu m has been found o n the upp er su rface of an L MA upon re mov al (1084).

Airway Obstruction
Reported causes of complete or parti al airway obs truc tion whi le us in g a larynge al mask inc lud e malposi tioni ng , dis ta l cuff backfolding, epig lo ttic backfol di ng, for ward displac ement of th e pos tc ric oid a rea , ary epiglottic fold i nfo lding , aryte noid carti lage disl oca tion, laryng eal opening obs truction by th e cuff, tube k ink ing, inc reas ed cuff v olume , cuff he rni ation, lubric ant appl ied to the mas k apertu re, the LMA -P roS eal bowl fo lding i nward, a faul ty LMA , foreign body presenc e, a sup rag lottic tumor or l ingual tonsil lar hypertrophy , app lication of c ricoid pressure, f i ri ng from a v agal nerv e s imulator, and l aryngos pasm (30,33,63,66,78,208 ,46 2,514,536,56 0,663,904,1063,1069 ,1085,1086 ,10 87,1088,1 08 9,109 0,1091,1092,1093,1094,1095 ,10 96,1097 ,1098,1099,1 100,110 1,1102,1103,110 4,110 5,1106,1107). The reported inc idenc e of la ryngosp asm is 1 % to 3 % and may occur anytime during the perioperativ e pe riod (63,1108,1109,1110,1111,1112 ). La ry ngos pasm usu al ly resul ts f rom inadequa te anes thetic depth o r lub ric an t on th e anterior s urf ace of the mask . S tridor h as been repo rted for as long as 2 days fol lo win g u nev entf ul use of an LMA (1 113,111 4). B i ting the tube can cause obs truc tion and damage the LMA (562). This can be av oid ed by inserti ng a bi te bloc k o r gau ze rol l and leav ing it in place un ti l the LMA i s remov ed. Ho wev e r, a bi te b loc k may be def ormed (11 15). The LMA -P roS eal has a buil t-in bi te bloc k between the two tubes , whi c h may prev ent this p rob lem. Mouth gags used for s u rge ry may cause obs truc ti on of the LMA tub e (223,8 20).

A i rwa y o bs truc tion may be c aus ed b y the LMA rota ting in s uch a way that the c uff oc c ludes the la rynx (230,1116,111 7). Rota tion can b e detec ted by checki ng fo r th e black li ne, wh ic h s houl d face the u pper l ip. Apply ing c ric oi d pressu re or do wn ward pressure on the mandi bl e by the s urgeon may cause ai rwa y obs truc tion wi th the l aryngea l mask in plac e (8 25,1062). Changi ng from s ingl e-h ande d to bi manua l cric oid p res sure appl ic ation may resolv e the problem (663). If ai rway o bs truc tion dev elops , rap id f ib eropti c endoscopy may help to differentiate the v ario us causes and g uide a ppropria te managemen t (1086,1118 ,1119,1120). Mane uv ers that may he lp to rel iev e obs truc tion inc lude mino r ja w o r LMA adjus tmen ts , mandibular p rotrusi on, h ead ex tens io n, an d unk ink ing of the LMA tube (63,1102 ). In mos t c as es , the L MA s hould be re mov ed and reinse rted or a different s ize LMA us ed.

Trauma
A numbe r or traumatic in ju ries hav e b een reporte d. These inc lude inju ries to the epiglottis , pos terior pharyngeal wa ll , uv ula , sof t pa late, ton gue and tons ils (865,104 5,1110,1121,1122,1123,1124 ,1125,1126 ,1127,112 8); a hematoma abov e the v ocal co rds i n a p ati en t with a bl eeding diathesis (1129); es ophageal perfora tion af ter blind intubati on through the intubating LMA i n a patient wi th a hi gh es opha geal pouc h (319 ); arytenoid an d tempo romandi bular joint disloca ti on (1094,11 30,1131 ); tongue c yanos is (1 132,1133); and c omp lete dis ruption o f a c left soft pala te repai r (1134). The inc ide nce of s ore throat f ol lowing use of the LMA has bee n repo rted to be between 0 % and 70% (73,199,234 ,248,475,506 ,519,6 30,634,716,9 46,965,993 ,1069,1110,1111,1135,1136, 1137,1138 ,1139,1140 ,1141,1142,1143,1144,1 145,114 6,1147 ,11 48,1149 ,1150). The i nci dence is less than wi th a trac heal tube but more than when a fac e mask is used (1151,11 52). The us e of an insertion aid and c uff de flator may lower the inc idence (1138,11 53). Inserti ng the L MA ful ly o r partial ly i nfla ted wi l l reduc e the inc idenc e (89). Us e of larger LMAs is ass oc iated wi th a hi gher i nc idence of s ore throat (5,1154,1155). The inc idenc e of s ore P .490 throat i nc reases with use an d leav ing the LMA i n s itu af ter intuba tion (346,348 ,358,1156).

S tudi es differ on the effec t of i ntracuff press ure on the inc idenc e of s ore th roa t (1143,11 45,1148 ). So me s tudies hav e sh own that lowerin g c uff pressure may dec reas e the inc id ence of s ore throat and dys phagia, especial ly i n women (1069,11 44,1151 ,1157). Oth er s tudies hav e found no corre la ti on between s ore throat and c uff pressure (234). The pressu re on the mucos a beneath the fu ll y i nflated cuff may be g rea ter than c api ll ary pre ssu re (5 35,537,538), rais ing c oncerns about ischemic damage to the muc osa or ref lex rel axa tion of the lo wer es opha geal sphinc ter (1158,1159). P rov ided the intracuff pressu re is kept at 60 cm H 2 O, mucosal pressures wi ll be les s tha n those considered safe for p rol onged tracheal i ntu bation (1160). There is ev idence that the phary nx may adap t to the LMA cuff (538). B lood on the la ryngeal mask oc curs les s often if the laryng eal mask is remov ed defl ated than if i t is remov ed wi th the c uff parti all y inf lated. Dys phag ia is seen more frequently af ter LMA use than when a trac hea l tube or a fac e mask is used (1143,1151). The inc idence of d ysphagi a may or may no t be rela ted to cuff press ure (234,1144,1151).

Posterior Spinal Ligament Rupture

A cas e of pos terior spina l ligament rupture wi th qu adrip legia following l aryngeal mask ins ertion in a pati ent wi th an uns tabl e cerv ical s pine has been rep orted (1161).

Dislodgment
Acc idental dis lodgment c an occ ur (728,735,736 ,8 25,874). A correc tl y placed L MA may be f orc ed upwa rd out of the hypopharynx if c ricophary ngeal musc le tone is permi tted to i nc reas e o r if the c uff beco mes ov erinflated. The LMA ma y get c aught i n the groov e of a tongue blade , whic h can lead to prema tu re re mov al (635). T his can be av oi ded by c oating the groov e wi th lub rican t je ll y. If the L MA has come out only a s hort dis tance , it can of ten b e pushed back into place (30). P ers is tent di fficul ty in ke eping th e L MA i n pos i tion ma y be s olv ed by us ing a different s ize mask , reduc ing the c uff v olume, elev ating the mand ib le, or us ing a different head pos ition.

Damage to the Device

The LMA may break apart (520,1069,1162,1163 ,1164,1165 ,1166,1167) (F ig. 17.19). This is us ua ll y occ urs when the LMA is beyo nd its useful life s pan. The tube c an be transec ted by the pati ent bi ting i t (562,1168,1 169,1170,1171 ,11 72). The cuff or

pi lot tube may be to rn on a tooth o r denture, damaged by s urgery or by ins ertion of an i ntrav enous c atheter or nerv e b lock need le (396,469 ,470,1173,11 74,1175 ,1176,1177 ,11 78,1179,1180,118 1,1182). The d ev ice may be damaged du ri ng remov al (1183,1184 ).

Figure 17.19 This LMA came apart during autoclaving. It had been used more than the recommended number of times.

View Figure

To prev ent the problem of pilot bal loon tubin g being c aug ht i n the snare us ed fo r tonsi l lec tomy, the tub ing s hould be ca refully taped (1185,1 186). The wi ri ng in a f lex ibl e LMA ma y become defec tiv e (226,227 ). T his may result i n ai rwa y obs truc tion , or the wi res could b reak off and mig rate in to the trac heob ronchial tree. The 15-mm connec tor may l oos en af ter a few autoclav e c yc les (1187). A cas e has been rep orted where th e c onnec tor was remov ed and rev ersed (1188). If the L MA leak s in s i tu, of ten the patient c an be v enti la ted by using a f ac e mask ov er i t (19 ,1 189).

Failure of the Cuff to Inflate or Deflate

In one reported case, the pi lot tube bec ame s tuck between the pati ent's teeth, s o the cuff could no t be inflated (1191). In another c as e, the pilot tube bec ame lo oped around the mask aperture bars (1191). In ye t ano the r cas e, the pilot tube b ecame wed ged between two te eth , and the c uff could no t be def lated (119 2).

Nerve Injury
Pals ies of the hy poglos sal (1193,1194,1195,1196,1197,1198 ), recu rrent larynge al (484,113 0,1199,1200,1201,1202,1203 ,1204,1205 ,1206,120 7,1208,1209,1210,1211),

and li ngua l (1212,1213,1214,121 5,1216,1217) ne rv es hav e be en reported af te r us ing an L MA . Loc al anesthes ia applied to the LMA c an mi mic ne rv e injury and caus e v oc al c ord pa ral ys is (1201 ).

Bronchospasm
B ronch ospasm associated with the l aryngeal mas k has been repo rted (530,110 9,1218). A bronchodilator aerosol c an be adminis tered through the LMA (530).

Pulmonary Edema
Pulmona ry ed ema has been repo rted af ter a l aryngeal mas k was inserted (1219,12 20,1221 ,1222). In each c as e, there was P .491 precedin g airway obs truc tion with s pontaneous v entilati on. The LMA -P roSe al drain tube may l imi t negativ e intrathorac ic press ure and pro tec t aga ins t this c omplic ati on (420).

Other
Trans ien t sal iv ary gla nds an d tongue s wel l ing and siala denopathy hav e been desc ribed in as sociati on with the laryng eal mas k airway (1223,12 24,1225 ,1226,1227 ,1228,1229). Hic cups c an occu r (1230). Uni la teral supraglo ttic and v oc al co rd ede ma h av e bee n reported af te r us ing an LMA (1231,12 32). An LMA may dis tort the an atomy and displace mob ile landmarks us ed to cannul ate the in ternal jug ul ar v ein or othe r neck s truc tures (1233,1234 ,1 235,1236), caus e spuri ous d iagnos is of a c erv ic al mass (123 7), or c ause the s urgeon to damage loca l s truc tures (1238). Ultrasound guidanc e is sugges ted to av oi d problems with cannulation of th e j ugula r v ein. LMA cuff inf lation and de flation has been found to dec reas e and inc rease bl ood f low thro ugh the caroti d artery (8 64). Venous con ges tion in the neck c an be c aused by an ov erinf late d c uff (1239). The pilot tube of a trac hea l tu be may bec ome kinked when i ns erted through a l ary ngea l mask (1240).

Advantages
Ease of Insertion

An outs tand ing f eature of th e LMA is that i t ra pidly p rov ides a c lear ai rwa y in the v ast majority of pa tients and is fas ter and eas ie r to insert than a trac heal tube (1241). Th e wo rk load associa ted wi th L MA ins ertion is lower than for other me thods of air way managemen t (1242). The i nsertion technique is s impl e, and ev en thos e wi th l ittle or no p ri or ex perience are usuall y suc cess ful at ins erting i t c o rrec tly . Trainin g for p rop er insertion is nei th er lengthy no r el aborate. Peo ple wh o a re not sk il led at intu bation hav e a hi gh suc ces s rate with the laryngeal mas k (924,945 ,961,1243,12 44). Reported fi rs t-time inserti on rates in adults v ary from 76% to 96% i n adul ts (588,959 ,961,1110,11 11,1135 ,1140,1142 ,12 45,1246,1247). S l ightl y lower f irs t-time i nsertion rates may occ ur wi th ped ia tric pa tients (50,75,77,588,633,876,900,110 9,1112,1248). S tu dies s how that an u nobs truc ted ai rwa y can be ac hiev ed in gre ate r than 90% of cas es (50,63,79,588,633,900,1110 ,11 11,1135,1246,124 7,1248,1249,1250,1251). Wi th ex perienc e, the s ucces s rate inc re ases and may exc eed 99% (109,662,874 ). The LMA ca n be ins erted wi th the patient i n almos t an y posi tion whe re ac cess to the mouth is pos s ible (1252,1253,1254,1255 ,1256). This makes i t us efu l for mai ntaining the ai rway after acci den tal ex tubati on when the patient is not s upine (1256,12 57,1258 ). The LMA has been us ed in ou t-of-hospi tal care when ac cess to the p ati ent was so l imi ted tha t it was imposs ible to i nsert a trac heal tube (954 ). A cerv ica l coll ar or manu al in-line s tabi liza ti on does not appear to i nte rfere wi th s uccessful placement (24,26).

Smooth Awakening
The LMA al lows a smoother awake ning than a trac hea l tu be with fe wer episodes of desatura tion, b rea th ho lding , coughing, l aryngospasm, and hyperte nsion (50,224,723 ,1139). Patients wi th an L MA h av e better ox ygen sa turatio ns and less coughing than patients who hav e an o ral airway i n place durin g emergenc e (1019,10 22). Patients wh o hav e had an L MA requi re les s a nal ges ia du ring recov e ry than th ose who hav e been intuba ted (506).

Low Operating Room Pollution

The re is les s operatin g room pol luti on wi th an LMA than wi th a face mask (550,111 1,1259,1260,1261,1262,1263 ,1264,1265 ). Du ring spontaneous v enti lation, trac e g as concentrations a re comparable to th ose wi th a tracheal tube (1262).

Us ing a c lose (local ) scav enging d ev ice wi ll lower th e lev els of trac e anesthetic gases to thos e assoc iate d with trac heal intubati on during pos i tiv e v entil ation .

Avoiding the Complications of Intubation

W hi le bl ood p res sure and hea rt rate usual l y inc rease af ter a laryngeal mas k is i nserted, thes e inc reases are s imi lar to thos e s een af ter i nsertion of an ora l ai rway and a re less marked and of sho rter duration than thos e assoc iated wi th trac heal i ntu bation o r if a Co mbitub e is used (506,722 ,723,861,113 9,1266,1267,1 268,126 9,1270,1271,1272 ,1273,1274 ,1 275,127 6,127 7). There is minimal inc reas e i n intraocu lar pressure fo ll owi ng insertion. The s tress an d anx iety associated with fai lure to intubate are dec reased. The ti me needed for i nserti on is usua lly less than that needed for trac heal intubation (958,959 ,961). Inadv ertent bronc hial or esophageal in tubation c annot occ ur. Less anes th esia is needed to tolerate a l aryngeal mas k than a trac heal tube (476,115 2,1278). Nei ther lary ngoscop y nor a neu romuscul ar blocking age nt is requi red, thus prev enti ng as soc iated problems suc h as musc le pains an d trauma to the lips , gums , and teeth . S ince musc le relaxan ts are not needed, comp licati ons as soc iated wi th them are av oided. This is adv antageous fo r patients with myas thenia grav is (127 9). For LMAs other than the LMA -Fl exi ble, the LMA prov ides l ess resis tance to flow th an the c orresp onding si ze trac heal tube; pa radoxic al i nspi rato ry mov ement is s ignificantl y l ess when b rea thing through an LMA than a trac heal tube (1280). E mergence and recov ery times a re s horter wi th the LMA (6 34,1281 ,1282). E mergence is s mooth er wi th l ess coughi ng , s trai ni ng, bre ath holding , fe wer P .492 ca rdiov ascular c han ges , and i mp rov ed oxy gen sa turation (423,716 ,722,996,113 9,1241,1283,1 284,128 5). There is a lower i nci dence of trau ma, sore th roa t, d ysph onia, and d ysp hagia (234,506 ,630,722,723,1137,1143 ,11 46). S ince the LMA is no t in troduc ed in to the la rynx or trac hea, l aryngeal o r subglo ttic edema o r trauma s hould not occur. Howev er, la ry ngea l ref lexes may be depress ed (1059). Muc oc iliary trans port v eloc i ty is less in patients wh o hav e a trach eal tube in place c ompared wi th those who hav e the LMA (1286). T his ma y hav e implica tions for re duc ing the risk of retained sec re ti ons , atelec tasis , and pulmonary infec ti on. The inc ide nce of bac teremia is low whe n the lary ngeal mask is used (1287,1288 ).

The LMA ca n be used in patients wi th tra cheal abnormali ties wh ere a trac heal tube might c ause trauma (743 ,1 289,1290,1291). The use of an LMA av oids dis tu rbing a trac heal s tent (1292 ,12 93,1294 ). As thmatics and other patien ts wi th reac tiv e ai rwa y d is ease are at i nc reas ed risk of bronc hospasm during manipulations of th eir airway . B ecause the LMA is less i nv as iv e tha n a trachea l tube, the risk of bro nchospas m is reduced (1295,1 296). Howev er, the L MA may be unsui tabl e for the pa tient with ac ute as thma who requi res high airway press ures.

Ease of Use
Bec ause there is no n eed to s upport the jaw o r hold a fac e mask , the c l in ic ian's hands are f ree for o th er tasks . A irway de teri ora tion from use r fatigue is eliminated. Intraopera tiv e ai rwa y manipulations , difficulty i n mai ntain ing a pa ten t ai rwa y, and hypoxemia are les s common wi th the LMA than with a fac e mask (225,633 ,634,1297).

Avoiding Face Mask Complications

The LMA av oi ds many of the complica tions as soc iated wi th a face mask (Chap ter 16) inc luding dermati tis an d inj ury to the nose , eyes , teeth, and n erv es of the face (975,129 8,1359). The inci dence of a s o re jaw is less than when a fac e mas k is us ed (1151). It prov ides protec tion from aspi ra tion of nas al and oral sec re tions . The anes thes ia prov ider's h ands are free, minimi zin g fatigue and po ten tial a irway deterio ration and all owing the prov ide r to pe rform other task s . There are fe wer episo des of oxygen desa turatio n (1111). Gas tric inflation is less lik ely to occ ur.

Protection from Barotrauma

Barotrau ma is a potenti al probl em with trach eal tubes because of the tigh t s eal i nsi de the trache a. It is l ess l ikely to oc cur wi th a l arynge al mas k (1300).

Cost-effectiveness
W hi le the in itial pric e of a reusabl e LMA is h igh c ompared with a dispos abl e fac e mask o r trach eal tube , it may be a c os t-e ffec tiv e choice if i t is reus ed enou gh times (1301,13 02). Some hav e reported 20 0 to 250 us es (6 00,1303 ). The manuf ac turer does not recommen d i t being used more than 4 0 ti mes . Its l ife span is prol onged by careful us e, s tri c t adherenc e to cl ean ing, c hecki ng and s teri li zation proc edu res , and av oid in g forc eful remov al through parti al l y c lenched tee th (19). There may be sav ings from reduced use of mus cl e rel axants , v olatile anes thetic s , narco tics ,

ai rwa ys , a nd suc tion equ ip ment; inc re ased pa ti ent turnov er; and re duced pos toperativ e morbi di ty . It c an be use d wi th low f res h gas flows . Unexpec ted a irway management problems , es pecial l y the i nabil ity to i ntubate, often was te co nsiderabl e operating room time at s ign if icant ex pense. The use of an LMA may shorten the time spen t es tabl ishing a rel iable ai rway . Howev er, the reduced anes thes ia induc ti on time in mos t c as es is s mall (1304). Acc idental dis posal of reusa ble LMA s c an be c os tl y (1305). This can be mi ni mized wi th i n-s erv ic e educ ati on of the s taff. Some form of acc ountabil ity may be desirable.

Disadvantages
Unsuitable Situations
Relativ e contra indic ations to us e of th e L MA inc lud e s ituations as soc iated wi th an i nc reas ed risk of aspi ration (full s tomac h, prev i ous gas tric s urgery, gas troes ophageal ref lux , d iabetic gas tropa res is , ov e r 14 week s p regnant, dementia, trau ma, opi ate medications , inc reased i ntestina l press ure) unless other tec hniques for sec uring the ai rwa y h av e failed . Hia ta l hernia is a relativ e contrain dicatio n to LMA use un less effec tiv e measures to empty the s tomach hav e been take n. Patients with obes ity may be candidates fo r the LMA (15,279,1250,1306 ). The re is dis agreemen t abou t the s afety o f th e l aryngeal mas k for p roc edu res such as laparos copic s urgery, wh ere intra-abd omi nal pres sure is high (985,986). Suc ces sfu l us e of the L MA in this s i tuation has been reported (31,662,991 ,993,997,998 ,1307). The patient with glottic o r subglo ttic a irway obs truc tion, such as trac heomalac ia or ex ternal tracheal compress ion, s hou ld no t be managed with a laryn geal mask, becaus e i t c annot prev ent trache al c ollaps e (756,1308). Sup raglottic pa tho logy suc h as a c ys t, absces s , hematoma, or tis sue dis rupti on can make p rop er pos itioni ng diff ic ul t or i mposs ib le (1309), al though the LMA has prov en us eful in upper airway obs truc tion caus ed by sup rag lo ttic edema, a thyrogl oss al tumor, and tons i llar hype rtrophy (147,430,655 ,65 6). A v al lec ular c ys t has b een reporte d to cause obs truc tion after the la ryn geal mask was inse rted (1 310). If the mask is pus hed behin d the ep iglottis , v enti lation may be pos sible . It ma y P .493 be more appropria te to use al te rna tiv e inserti on techn iq ues , dependi ng on the nature of the pathology (19).

Maj or ce rv ic al pathol og y s uch as a l arge goi ter, s well ing in the hyp opha rynx , neck f ibros is , laryngeal canc er, or a dev iated trac hea may obs truc t the ai rway and mak e i ntu bation through an L MA d ifficul t (331,353,1 311,131 2). The LMA -Fas trach may hav e a h ig her s uccess ra te than th e L MA -Class ic i n these patients (1313). The LMA may be diffic ul t or impossi bl e to insert i n p atien ts wi th an angle between the ora l and phary ngea l axes of l ess than 90 a t the b ack of the tongue, a limi ted mouth ope ning, palatal defec ts , oroph aryngeal mass es , a ha rd palate c rib f or thumb sucki ng, and sha rp edg es in the mouth (19 ,28 ,243,1314 ). In patients wh o hav e had ce rv ica l radio the rap y, LMA insertion an d subs eque nt v enti lation may be ex tremel y diff icul t (311,131 5). W hile it has been s tated that an interdental d is tance of 20 mm of les s p rec ludes us e o f the L MA -Fas trac h, i t has been used wi th s maller o penings (28). In patien ts who requi re h igh inf la tion press ure s , that is , thos e with low c omplianc e or h igh res is tanc e, on ly the LMA -P roSe al sh ould be used. P resence of a bl eed in g d is order is c ons ide red a re la tiv e contraindication to us ing an LMA (7 40,1129,1316). Some f eel that the LMA is rel ativ el y contrain dic ated in s i tuations where the re is res tric ted acc ess to the ai rway, es pec ial l y if there is no g uarantee that the LMA c an be repl aced if i t bec omes dis lodged or if in tubation becomes neces sary. The L MA has been us ed in the la teral and pro ne positions (29 1,1028,1252,1317 ,1318). Anes thes ia in the prone pos ition is highl y co ntrov e rs ial . Regurg itation is more l ik ely , and higher ai rwa y pres sures may be needed . The LMA may be more e asi ly displac ed in this pos i tion . W hi le so me a nes thesia p rov ide rs cons ider p rolon ged proc edures a c ontraindic ati on to the LMA , ti me a lone has not been s hown to be a l imi ting fac tor.

Requirement for Paralysis or Obtunded Airway Reflexes in Some Situations

The LMA ca nnot be inserted un less th e j aw and pharynx are full y relaxed. Coughi ng, g agging, v omi ting, biti ng, laryngospas m, and bronc hos pas m can oc cur i n i nadequatel y anes theti zed patien ts , espec iall y those wi th c hronic respiratory diseases and heav y s mokers .

Lost Airway Management Skills

The abil i ty to ma in tai n an adequate ai rway b y using a fac e mask is one of the funda mental sk il ls of anes thetic prac tice. Inc reas ing d ependenc y on the LMA may

resul t i n a lac k of experi ence and sk il l in usi ng a fac e mask fo r prolonged pe riods or wi th a difficul t ai rway (1 320). Intu bation s ki lls may be comp romised b y the i nc reas ing popularity of the LMA (1320,1321 ).

Loss of Tactile Monitoring

W hi le the la ryngeal mask f rees the an esthes ia prov ider's hands , i t dis tanc es the prov ider from the pati ent a nd may caus e del ay in d iagnos ing a dec rement in airway quali ty.

Less Reliable Airway

The LMA does not s ecure a c lear ai rway as ef fec tiv ely as a trac heal tube and does not prev ent air way obs truc tion at the glottic and subgl ottic lev els . The L MA can be more readil y displac ed than a trachea l tube. Mov ements of the head, neck , o r drapes ; i nsertion of a pack ; and the like that wou ld be ac cep tab le wi th a trac heal tube in p lac e may caus e LMA d is placemen t.

Unreliable Drug Administration

Durin g res usci tation , th e tracheal tube is s ometimes used for drug adminis tration. The LMA is not as rel ia bl e a route for adminis tering drugs as is the trac heal tube (1322,13 23).

Other Supraglottic Airways Similar to the Laryngeal Mask

The s uccess of the lary ngea l mask has caus ed a bewi ld ering v ariety of other supraglo ttic dev ices to be produce d (2,1324). S ome are s imila r to the LMA , whi l e others are d is tinc t. Some of these dev ices hav e undergone mod if ic ations either in materials or design si nce thei r in iti al introduc tion , so the reader shoul d mak e ce rtain that performanc e s tu dies of a particu lar dev ice do no t relate to an olde r v e rsion of tha t dev ice .

Soft Seal Laryngeal Mask

Description
The P o rtex Sof t Seal Laryng eal Mas k (Figs . 17.20, 17.21) is a c lea r, dis posable mask made from pol yv inylchloride. P .494 The ov al c uff does no t taper at the tip . The i nflation tube is attached to the a irway tube. There is a bl ue li ne on the c onv ex su rfac e. It h as no epigl ottic bars . It is

av ailab le in a number of s i zes , as s ho wn i n Tab le 17.9. The maximum recommen ded cuff v olume is mark ed on the pi lot ballo on. S ome inv estiga to rs recommen d tha t a siz e 3 b e used for adu lt females an d a s ize 4 f or adult males (1326). Others hav e recomme nded s i ze 4 for adu lt f emales and s ize 5 for adul t mal es (1 326).

Figure 17.20 Back of the Soft Seal Laryngeal Mask.

View Figure

Figure 17.21 Front of the Soft Seal Laryngeal Mask. Note the absence of bars between the tube and bowl.

View Figure

Insertion
Ins erting the S of t Seal with a parti ally inf la ted cuff h as bee n found to be eas ie r and l ess traumatic that inse rting the dev ic e with the c uff ful l y d eflated

(541,542 ,1325,1327 ,1 328,1329,1330). The inse rtion p roc edure is s imi la r to that of an LMA .

Evaluation
Mos t s tudies sho w that the Sof t Sea l mask offers easy i nsertion an d good cl inical performance in mos t adu lts and c hildren (541,542 ,543,544,115 1,1330,1331,1 332,133 3,1334,1335). The c uff is less pe rmeable to nitrous ox ide than si l ic one mask s , so the inc rease in cuff p res sure res ulting from nitrous ox ide diffus io n is less than wi th th ose dev ices (198,199 ,540,541,544,1331,1336 ,13 37). In tracuff pres sure s hould be moni tored and adjus ted to keep i t at 60 c m H 2 O (540 ). In one reported case, c omplete a irway obs truc tion occu rred when a Sof t S ea l Laryngeal Mask was inserted becaus e the epiglottis entered the tube shaft (1338). No obs truc tion occu rred when an LMA -Unique was ins erted.

Comparison with Other Supraglottic Air way Devices

Compa risons between the S of t Seal and LMAs show c onflic ting res ul ts , poss ib ly becaus e in some s tudies , the Soft S eal was ins erted wi th the cuff fully deflated (1150,13 32,1333 ,1334,1335 ). Mos t s tudies compari ng the LMA -Cl as sic a nd Sof t S eal fou nd s imil ar f irs t ti me i nsertion rates and eas y ins ertion (5 41,544,1150,1331 ,1336). Leak p res sures were co mparable, wi th so me s tudies reportin g sligh tl y hi gher p res sures wi th the Soft Seal (1 150) and others wi th the LMA -Cl assic (544). The Sof t S eal Laryngeal Mask was be en fo und to hav e a lo wer or e qual inc idence of sore throat in th e i mmedi ate pos toperativ e pe riod i n s ome but not al l s tudies (541,115 0,1325,1328,1330,1331,1332 ,1339). W hen trac heal intuba tion through an LMA -Classic and a Sof t S ea l Laryng eal Mask were c ompared, n o significan t differenc e i n time to intubate or the suc cess rate were f ound (1340 ). W hen the Sof t Seal was compared wi th the LMA -Unique, some s tudies sh owed co mparable ins erti on rates and ti mes (1150,1337 ), wh ile one s howed that shorter times and fewe r attemp ts at ins erti on were needed wi th the LMA -Unique (1333). The airway le ak pressu re was equal o r hi gher with the Sof t S eal (1150,13 33,1335 ,1336,1341 ). P os toperativ e s ore throat and mucos al trauma wa s more c ommon in the Sof t Seal P .495

(1151,13 34,1336 ,1338), al though the Sof t Seal and the LMA -Un iq ue were found to ex ert e qual pressu re on the mucos a (1343).

TABLE 17.9 Soft Seal Laryngeal Mask Sizes Size Description Tube (ID in Tube (OD in mm) mm) Maximum Cuff Volume (mL)

Neonates up to 5 kg

1.5 2

Infants 5 to 10 kg Infant/child 10 to 20 kg

2.5 3

Child 20 to 30 kg Child 30 to 50 kg

10.1

15.5

25

4 5

Adult 50 to 70 kg Adult over 70 kg

11.0 12.0

17.6 19.8

35 55

ID, internal diameter; OD, outer diameter.

Figure 17.22 Ambu Laryngeal Mask.

View Figure

Ambu Laryngeal Mask

Description
The A mbu Lary ngeal Mask (Figs . 17 .22, 17.23) is a disposable dev ic e that has a cuff that is tapered at the tube. T he airway tube is larger and more rig id than that of the LMA and is p rec urv ed. It has no a pertu re bars . The inf lation l ine is attached to the ai rway tube . It has a reinf orced ti p. It is av ailable in s ev en s i zes , as s hown i n Tab le 17 .10 . A reusable v ers ion is a ls o av ailable in ei ght s iz es , f rom 1 to 6 .

Use
Ni trous ox id e wi l l di ffus e through the cuf f , but the inc rease is re lativ el y s mal l (198).

Figure 17.23 View of bowl of the Ambu Laryngeal Mask.

View Figure

TABLE 17.10 Ambu Laryngeal Mask Size Patient Weight (kg) Up to 5 5 to 10 Maximum Cuff Inflation Volume (mL) 4 7

1 1.5

2 2.5

10 to 20 20 to 30

10 14

3 4

30 to 50 50 to 70

20 30

5 6

70100 >100

40 50

If in tubation becomes n eces sary, the manufac turer recommends that i t be performed ov er an ai rway exc hange c atheter.

Intubating Laryngeal Airway

Description
The Intubating Laryngeal A i rwa y (ILA ) (Figs. 17 .24 , 17.25) is a re usab le dev ic e made f ro m si l ic one wi th a c lear, c urv ed tube and a dark blue , ov al bowl . The b owl has a do wn ward ti lt at the tip to fac ili tate i t s lippi ng bel ow th e e pi glo ttis . The opening in to the bowl h as ri dges o n the top and si des to prev en t the e pi glo ttis f ro m being trapped, res ul ting in a ke yhole-shaped outlet. There are rid ges i n the bo wl below the outle t. These are des ign ed to i mprov e th e s eal a nd to he lp isolate the es opha gus . The ILA is av ailable in th ree si zes (Tab le 17 .11 ) and allows use of s ta ndard trac heal tubes of ID 5 .0 to 8 .5. It c an be autoc lav ed up to 40 times . A reusable remov al s tyle t fo r s tabi li zi ng the tracheal tube whi l e the ILA is being remov ed fol lo win g intuba tion is av ai lable f ro m the manufac turer (Fi g. 17.26).

Figure 17.24 Intubating Laryngeal Airway.

View Figure

P .496

Figure 17.25 Bowl of the Intubating Laryngeal Airway.

View Figure

Use
A ja w l if t is rec ommended when the dev ice is inserted . Fiberoptic g uidance for trac heal intubation produc es the bes t res ults .

Other Supraglottic Airway Devices

Laryngeal Tube Airway

Description
The Lary ngea l Tube A i rway (l aryngeal tube, LT) (Fig . 17.27) is a reusable s i lic one dev ic e tha t has a s ingle lumen that is c losed at the tip (1343 ,13 44). Si ngle-use v e rsions (LT-D) made of pol yv iny lch lo ri de are av ai lable. The La ry ngeal Tube Suc tion (LTS , Sonda la ry ngeal tube, SLT) (Fi g. 17.28) has an addi ti onal (esophage al) lumen p osterior to the res piratory l umen that ends jus t dis tal to the es opha geal cuff fo r suc tioni ng and gas tric tube placemen t (1 345,1346,1347). The LT has a s mall (esophagea l, d is tal ) cu ff n ear the bl in d d is tal ti p and a la rge r (oro pharyng eal , pha ryn geal ) c uff n ear the mid dle of the tube wi th one inf lation tube to infla te bo th light bl ue cuffs . Gas ex chan ge is through two anteri or-fac ing , ov al shaped openings (v enti la tion holes ) between the two cuffs . These al lo w s uc tioning or f iberscope pass age. In add ition, there a re s ide holes latera l to the top of the dis tal opening (1 348). A ramp l eads from the pos te ri or wal l toward the main v enti lato ry ou tl et (1349 ).

TABLE 17.11 Available Intubating Laryngeal Airways Size Patient Weight (kg)Maximum Tracheal Tube Size 2.5 20 to 50 6.5

3.5 4.5

50 to 70 70 to 100

7.5 8.5

The airway tu be is relativ ely wi de and c u rv ed. Th ere are th ree marks on the tu be j us t b elo w the connec tor to the brea th ing s ys tem. These indicate the range for proper depth placement. The tube si ze is c olo r c oded on the c onnec to r, wi th eac h s ize hav ing a d iffe ren t c ol or. Table 17 .12 giv es the si zes of av ailable lary ngeal tubes .

Use
For ins ertion, the patient's he ad is p lac ed in the neu tral or s ni ffing posi tion . A jaw thrus t may be he lpful (13 50). Both c uffs should be defla ted and a wa ter-b ased l ubric ant applied . Af ter the tube is introduced into th e mo uth , the f lat edge of the tip i s placed agains t the hard palate, keeping the tube cente red . The tube is then s lid along the palate and i nto the hyp opha rynx until res is tance is fel t. A malpos itioned LT wi ll often bounce back from the intended posi tion (1351 ). Af ter inserti on , the marks on the s haf t sh ould be aligned with th e teeth. If difficul ty is enc oun tered, a l ate ral inserti on or a lary ngos cope ma y be helpful. The c uffs should be inf la ted to a pressure 60 c m H 2 O (1352). The prox imal c uff wil l f il l f irs t. The v olume requi red wil l de pend on the pati ent (135 3). The manufac turer's maxi mum recommended v ol umes are s ho wn i n Tab le 17 .12 (s ee pa ge 498). If a mano mete r is not av ailabl e, c uff v olume sho ul d be adjus ted s o that there is a s light orophary ngea l leak at the requi red v entilatory s etti ng and then ai r should be added unti l the leak jus t P .497 disap pears . A fter i nserti on and cuff infl ation, the airway l eak press ure s hould be meas ured and epigas tric a uscultation p erf ormed (1354). If gas tric infl ati on is oc curri ng, the c uffs shou ld be inf la ted more. The dev ice may need to be mov ed up or down to ac hiev e effec tiv e v entilatio n.

Figure 17.26 Removal stylet for stabilizing the tracheal tube during removal of the Intubating Laryngeal Airway following intubation.
View Figure

Figure 17.27 Laryngeal Tube Airway. The distal cuff blocks the esophagus. (Courtesy of King Systems Corporation.)

View Figure

The LT c an be used wi th e ither s pontaneous breathi ng or posi tiv e-press ure v enti lation (1355 ,1356,1357). Cuff p res sure should be monitored continuous ly. If ni trous ox ide is us ed, c uff pressure wil l n eed to be read jus ted duri ng the cas e (1358,13 59,1360 ). For trac heal intubation, an ai rway exc hange c atheter or tra chea l tube mounted on a f ibe rs cope is inserted through the la ryngeal tube and in to the trach ea (13 61). If the v iew th rough the fiberscope is not satis fac to ry, the l aryngeal tube may need to be rota ted . A jaw thru s t may be he lpful . For naso tracheal i ntubati on, the la ryngeal tu be is i nse rted and a fibersc ope wi th a trac heal tube adv anced through the nos e (1362,1 363,1364). The dis tal c uff of the l ary ngea l tube helps to identif y the gl ottis , whic h s hou ld be jus t in front of i t. Af ter the tracheal tube has entered the trac hea, the l aryngeal tube is remov ed. The L T has been us ed to smoo th emergence in a pa tient with a n asal intubation by subs titutin g the LT for the trac heal tube (1365).

Figure 17.28 Laryngeal Tube Suction. There is an additional (esophageal) lumen posterior to the respiratory lumen that is open distal to the esophageal cuff. (Courtesy of King Systems Corporation.)

View Figure

The reus able laryngeal tube mus t be cleaned and s teril i zed betwee n uses . It is fi rs t was hed i n wa rm water wi th so ap or a mild detergent. Tube brushes mus t be use d to c lean the v en ti lation channe l and ai rway openings . The tube s hould be i nspec te d to determine that al l v isible f oreign matter has been remov ed. P rio r to s teril i zation, the cuffs mus t be ev acuated of any ai r. T he LT shou ld be au toclav ed at 134C (273F) and 2.4 bar (35 ps i) for 10 minutes . Thes e dev ices mus t not be s te ri li zed P .498 by us in g formaldehyde, gl utaraldehy de, ethy lene oxi de, o r plasma s teri l iz ation . The manufac tu rer rec ommends up to 50 uses for the reusable dev ice (1366).

TABLE 17.12 Sizes of Laryngeal Tubes

Size 0 1

Patient Neonate Infant

Weight (kg) Color of ConnectorMaximum Cuff Vol (mL) <6 6 to 15 Transparent White 15 40

2 3

Child Small adult

15 to 30 30 to 60

Green Yellow

60 120

4 5

Medium adult Large adult

50 to 90 >90

Red Violet

130 150

Evaluation
The LT is re lativ el y eas y to insert, ev en for c linic ians who hav e l i ttle o r no ex perienc e. T he inserti on time is s hort, and the s uccess ra te for fi rs t-time ins ertion i s high (431,135 2,1355,1356,1367,1368,1369 ,1370,1371 ,1372,137 3,1374,1375,1376). It is wel l tol era ted du ring emergence (13 67). Bec aus e the dis tal c uff f its ov e r the es opha geal inlet, the risk of gas tric inflation i s lo w (1377). Satisfac tory v entilatio n wi th both s pontaneous and c ontrolled v en til ati on ca n be ac hiev ed in mos t pa tients (2 3,1352,1356,1367,13 68,1373 ,1378). Hi gh v enti la tion press ures c an be used, and the dis tal c uff s hou ld seal the es opha geal inlet. This dev ic e ma y be especi all y us efu l fo r res usc itation (1352,13 56,1366 ,1375,1377 ,1379,1380,1381). It has be en us ed in th e cannot i ntu bate, c annot v enti late s ituation (1382) and in obs te tric s after f ai le d i ntuba ti on (1383). It has prov ed usef ul in ede ntu lous patie nts i n whom v en tila ti on wi th a face mask wa s diff ic ult (1384). A l though a s tudy f oun d that the pa tient's head an d neck s tabi l iz ati on by man ual i nl ine metho d often made the la ryngeal tube e ither diff icu lt or imp ossible to inse rt

(1385), i t has been use d with ma nual in -l ine s tabil ization and a high cerv ical c ollar (1347,13 64,1386 ). The inc ide nce of c ompl ic ati ons s uch as s ore throat, mouth pain, or dys phagia as soc iated wi th i ts us e is low (1357,1367 ,13 69,1370 ). Cuff rupture has been reported when a manometer wa s not us ed to ev aluate cuff press ure (1387 ). In c omparison wi th the LMA -Cl as sic , inserting the LT was easi er fo r in expe rienc ed personnel (1374,1388 ). Cases hav e been reporte d where the l aryngea l mask i nsertion fai led but the LT was suc ces sfu ll y inserted (1363,1 382,1389). Duri ng control led v entil ati on, the LT prov ides higher s ea li ng press ures and tidal v olumes than th e LMA -Cl as sic in adu lts and children, and g as tric inflation occu rs less f requentl y (432 ,1352,136 8,1374,1378,1390,1391,1392 ,1393). When used for spontaneous breathing, the la ryngeal mask prov ided s uccessful airway mai ntenance in more patie nts than did the LT (1393,1394 ). Th e inc idence of co mplica tions is s imil ar, al though the LT may require more pos i ti on readjus tments to obta in a cl ear a irway (1343 ,13 91). The LMA has a s ma ll er s torage capaci ty than the LT, s o regu rgi tated l iquid is less l ikel y to be as pirated wi th the LT (13 95). In c omparison wi th the LT, the LMA -P roS eal wa s found to be easie r to i nse rt, i nserted s ucc ess ful l y on the f irs t a ttempt mo re of ten, and gav e a signi fican tl y bette r v iew of the glottis (466,1396). During contro lled v entilati on , th e two dev ic es performed e qual ly well in terms of seal pressure (1396). During s pontaneous breathi ng, the LMA -P roS eal was s uc cess ful more of ten (466). W hen the LT-Suc tion and the LMA -P roS eal were c ompa red , both dev ices performed equally wel l i n te rms of s eal pres sure and suc cess fu l inserti on, but the LMA P roSeal c aused less hemo dynamic s tress , was ass oc iated with bette r v enti la tion, and a llowed a better v iew of the la rynx with a fi bersco pe (1396,1397 ,1 398,1399). In c omparing the intubating LMA and LT during manual in-l ine n eck stabil ization , place ment wa s easi er and quicker and tida l v olume greater wi th the LMA -Fas trach (1400).

Perilaryngeal Airway
Description
The P e ri la ryngeal A irway (CobraPLA T M , CPLA TM , Cobra P LA TM ) (Fi gs . 17.29 ,17 .30 ,17.31) is a s ingle -us e p las tic dev ic e with a wi de , tapered patient end that has a s eries of sl ots . It has a high-v olume, low-pressu re, ov al cuf f that is

shaped to fi t in the hypopha ry nx at the base o f the tong ue. It is av ai lable in eight s izes (Tab le 17 .13 ).

Use
Before use, the tube sh ould b e chec ked for defec ts and the c uff for l eak s . Lub rican t shoul d be appl ied to the entire cuff and the bac k and s ide of the patient end. The cuff s hould be defl ated and folded back ag ai ns t the tube. P .499

Figure 17.29 Perilaryngeal Airway. It has a high-volume, low-pressure oval cuff that is shaped to fit in the hypopharynx at the base of the tongue. It is available in eight sizes (Table 17.13).
View Figure

The patient s hou ld be plac ed in a sniffing pos ition. A j aw thrus t ma y f ac ili tate i nsertion (1401 ). The dev ice is inserted s trai ght back in to the mouth, no t di rec te d toward the ha rd palate. The tube is adv ance d bli nd ly in the mi dl ine unti l resis tanc e i s fel t. The c uff shou ld be inf lated wi th j us t enoug h air to obtain an appropriate seal . Cuff press ure s houl d be less than 25 cm H 2 O. If there is a leak , the dev ic e s hould be pushed in s l igh tl y and ai r added to the cuff or the un it remov ed and replaced wi th a l arger si ze. It may be n eces sary to mov e the dev ic e up or down to obtain sa tisfac tory v entilation (1402). Durin g use, airway press ure s hould be li mi ted to less than 20 cm H 2 O. A trach eal tube can be ins erted through the Cobra P LA . Up to an 8 -mm ID tube can be us ed with a Cobra 4 , 5, or 6. For s izes 2 and 3, a 6.5-mm trac heal tube wil l f it.

Evaluation
The Cobra is easy to insert and is associated with a highly s ucc essful fi rs t ins erti on rate wi th a low inc idence of sore throat in adults and pedia tric patients (1043,14 01,1402 ,1403,1404 ,1405,1406).

Figure 17.30 Side view of the Perilaryngeal Airway.

View Figure

The large lu men makes i t us efu l fo r pass ing a relativ ely l arge tracheal tube or f ibe rs cope , mak ing i t useful for assess ing th e a irway (1407,14 08,1409 ). The short breathi ng tube al lows a s tandard leng th trac heal tube with its cuf f to p ass wel l pas t the v ocal co rds . The Cob ra does n ot ne ed to be remov ed after intubation. The airway s ea li ng press ure has been found to be higher a nd the l aryngoscopic v iew s uperi or wi th the Cob ra compared with the LMA -Cl ass ic (1403,14 07,1410 ,1411,1412 ). The seal ing pressu re is als o higher than wi th the LMA -Unique (1413 ). It has be en used for pe rcu taneous d il atation al c ric othyroidotomy (1 414), i n the diffic ult to intu bate/dif ficu lt to v enti la te scenario (1 415), i n two cases of face and neck contrac tures when an LMA -Classic fa iled (1416), and after LMA -Fas trach failure (1417). The Cobra PLA does not p rotec t agains t asp iration (1418 ,1 419,1420). A irway obs truc tion has been rep orted when the Cob ra apparentl y mov ed upward, ca tc hing the P .500 epiglottis between the bars (1421). Cuff leaks hav e bee n reported (1 422).

Figure 17.31 Patient end of the Perilaryngeal Airway.

View Figure

Figure 17.32 Streamlined Pharynx Airway Liner. T, toe; B, bridge; H, heel. (Courtesy of ARC Medical, Inc.)
View Figure

Streamlined Pharynx Airway Liner

Description
The S tre amlined P harynx A i rwa y L iner (S LIPA TM ) (Fi gs . 1 7.32, 17 .33 ) is a pl as tic , disposable, uncuffed dev ic e that is anatomica ll y preshaped to l ine the p harynx . It forms a seal wi th the pharynx a t the b ase of the tongue and the entranc e to th e es opha gus by v i rtue of the resi lience of i ts wa ll s . The dis tal part of the SLIPA is s haped lik e a ho ll ow boo t with a toe , bridg e, and heel. There is an an teri or opening for v entilation. The end of the toe res ts in the

es opha geal entrance. The bridge f its i nto the pyriform f oss ae at the bas e of the tongu e, which i t displac es from the pos te ri or phary ngea l wal l. The hee l connec ts to the ai rway tube , whi ch is rec tangular in s hape an d has a c ol or-coded connec tor. The heel s erv es to anchor the SLIPA in a s tabl e pos ition. Ac cording to the manufac tu rer, i t usuall y does not need to be fix ed in p lac e. Th e SL IP A has a largecapaci ty c hambe r fo r s tori ng regurgi tated l iq uids. Toward the toe s ide of th e l ateral bulges of th e bri dge are s mall er sec onda ry l atera l bulges . This feature is meant to re liev e p res sure at this s ite and to prev ent da mage to the hy poglos sal a nd rec urrent laryngeal n erv es.

TABLE 17.13 Perilaryngeal Airways Size 0.5 1 Tube (ID in mm) 5.0 6.0 Patient Weight (kg) >2.5 >5 Cuff Volume (mL) <6 <10

1.5 2 3 4

6.0 10.5 10.5 12.5

>10 >15 <35a <70a

<22 <40 <50 <60

5 6

12.5 12.5

<100a >130

<60 <85

ID, internal diameter. a Another source suggests size 3 for patients <60 kg; size 4 between 60 and 80 kg; and size 5 >80 kg (1402).

The S L IPA is av ai lable in s ix adult s izes that re la te to the dimens ion ac ross the bridge: 47, 49, 51, 52 , 55, and 57 mm. To choose the correc t s i ze, this di mens ion shoul d be matc hed to the wi dth of the patient's thy roi d cartilage .

Use
The S L IPA sh ould be examined f or defec ts and wate r-solubl e lubrica nt applied. It shoul d be c ol laps ed in th e ante rior-pos te ri or pl ane befo re ins ertion . After i ns ertion, i t spo ntaneous ly returns to i ts preinse rtion s hape . The head is extended and the dev ice inserte d toward th e back of the mou th unti l the heel loc ates itsel f i n the pharynx . It is helpf ul if the jaw i s lifted forward du ring i nsertion . A laryng osc ope or glov ed finge rs can be us ed to c reate a sp ace in the pharynx (1049). A i rwa y s eal p res sure shou ld be c heck ed after i ns erti on. If i t is too lo w, a la rge r s i ze SLIPA sho uld be tri ed . If pos i tiv e -press ure v entilatio n is used, the epigas triu m shoul d be ausc ul tated to make certa in that gas tric infl ation is not occurring (1049 ). If obs truc tion is enc ountered immedia tely afte r inserti on, a downfolded epi gl ottis may be the caus e. The head s hould be ex tended and the jaw pul led fo rward. If this does not c orrec t the problem, the SLIPA s ho uld be remov ed and re inserted wi th a n ac centuated jaw li ft. P .501 Ano the r maneuv er is to momenta ri ly inse rt the SLIPA deeper s o that i t wi ll free up the epiglottis . If th is does not reliev e th e obs truc ti on , the likel y caus e is l ary ngos pas m.

Figure 17.33 Streamlined Pharynx Airway Liner in place. T, toe; B, bridge; H, heel. (Courtesy of ARC Medical, Inc.)

View Figure

If reg urgitation is suspec ted , a suc tion catheter wi th the cu rv e to one s ide should be i nserted so that i t does not touch the v oc al co rds . It is recommended that the SLIPA be used with the head in the neu tral position becaus e twi s ting the hea d to one s ide may disl odge the s eal . Parti al obs truc tion during s pontaneous v entil ation wil l us ual ly b e rel iev ed by ex te nsion of the head o r s impl y by ins titutiv e p osi tiv e-press ure v entilatio n.

Evaluation
The S L IPA is eas y to ins ert and is assoc iate d with a h igh firs t i ns ertion suc cess rate ev en in inex perie nced hands (1423,1424). Desp ite its irregular shape, i t i mposes no mo re resis tance than s imilar supraglottic dev ic es (1425). It can be us ed wi th bo th spontaneous breathing a nd con trol led v entilatio n. It is tolera ted we ll during rec ov e ry (1424). The a irway sea ling press ure is greater th an with the L MA Cl ass ic (1049 ). B ecaus e the re is no cuff, n itro us ox ide has n o effec t on seal ing press ure . Both th e S LIP A and the LMA -P roSeal but no t the L MA -Class ic p rov ide effec tiv e protec tio n agai ns t aspi ra ti on during pos i tiv e-p res s ure v entilati on (1049). Howev er, i t is possi bl e that the s to rage capaci ty of the SLIPA may not be adequate for no nfas ted patients . The man ufac ture r sugg es ts th at i t may be saf e to suc tion wi thin the dev ic e if regu rgi tated l iquid is present wi th negligible ri sk of prec ip itating l ary ngos pas m. The S L IPA is contra indic ated if u pper a irway ana to my is abnorma l or dis torted (1).

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1403. Ak ca OW , Wadhwa A , Sengup ta P , et al . The new pe ri la ryn geal airway (CobraPLA ) is as efficient as the laryngeal mas k ai rway (LMA ) bu t prov ides be tter ai rwa y seal ing pressu res . Anes th Ana lg 2004;99:272278 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 1404. Gai tini LA , Va ida SJ , Somri M, et a l. A co mparis on of the Cobra, Peri laryngeal A irway and La ryngeal Mask A irwa y U nique in spontaneous ly breathi ng adul t pati ents . Anes thes io logy 2004 ;101:A518. 1405. Lee J M, Chang C, K im M, et a l. Eff ic ac y of the Cob ra P LA duri ng in termittent positiv e pressu re v enti lation . Anes thesi ol ogy 2005;1 03:A 844 . 1406. S z muk P , Matus zc zak M, Ca rls on RF, et al . Use of CobraPLA fo r ai rway mana gemen t in a neo nate with Desbuquo is s yndrome. Case report and anes thetic i mplica tions . P ed Anes th 2 005;15:602605 . 1407. S z muk P , Ghelber O, Akca O, e t al . CobraPLA as a condui t for flex ib le bronc hosc opy in a c hi ld under general anaes thes ia . B r J A naes th 2005;94:548 549. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 1408. P olaner DM, A huja D, Z uk J , et al. V id eo assessmen t of s upraglottic airway orienta ti on through th e P eri lary ngea l A i rway i n pediatric patients . A nes th A nalg 2006;102:168516 88. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 1409. A gro F, Caras s iti M, B a rzo i G, et a l. A f irs t repo rt on the diagnos is and trea tmen t of ac ute pos toperativ e a irway obstruc tion with th e CobraPLA . Ca n J Anes th 2 004;51:640641 . 1410. K anaya N, K a zui K , Hirata N, et al . A comparison of the n ew p eri lary nge al ai rwa y (Cob raP LA ) wi th the la ryngeal mask ai rwa y (LMA ) b y an anes thesia beginner. A nes thes iology 2005;103:A1169. 1411. Gai tini LA , Sa mri MJ , Kers h K , et al . A comparis on of the laryng eal mas k ai rwa y Unique, pharyngeal ai rway X press and peri lary ngea l ai rwa y Cobra in paral yzed anes the tized a dul t patie nts . Anesthesiology 20 03;99:A1495.

1412. A gro F, Baroi G, Gall i B . The CobraPLA in 110 ana es thetized and pa ralys ed pati ents : wh at s i ze to c hoos e? B r J Anaes th 2 004;92:777778. 1413. Gai tini L, Yan ov s ki B , S omri M, e t al . A c omparis on between the PLA Cob ra T M and th e Laryngeal Mask A i rway Uni que T M during s pontan eous v entilation : a randomi zed p ros pec tiv e s tudy . A nes th A na lg 2006;102:631 636 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 1414. A gro F, Caras s iti M, Magnani C. Percutane ous dila ti ona l c ric othyroid otomy: ai rwa y control v ia the CobraPLA . Anes th Analg 2004 ;99 :628. [Fu ll tex t Link ] [Med li ne Link ] 1415. S z muk P , E zri T, Ak ca O, et al. Us e of a new s up rag lo ttic ai rway dev ic ethe Cob raPLA i n a difficul t to in tubate /diffic ul t to v entilate s cenari o. A c ta Anaes thes iol Sca nd 2005 ;4 9:4214 23. [Cross Ref] [Med li ne Link ] 1416. K han RM, Maroof M, Jo hri A , et al . Co bra PLA ca n ov ercome LMA failure in pati ents with face and nec k contrac tures . Can J Ana es th 2005 ;53 :340. [Med li ne Link ] 1417. Dimitriou V , B ri macombe J , Zogogiannis I, et al . Suc ces s of the Cobra after failure of the Fas trach in the diff icul t ai rwa y. Can J Anes th 2005;52:992 . 1418. Cook TM, Lowe J M. An ev al uation of the Cobra Peri lary ngeal A i rwa y s tudy halted af ter two c as es of p ulmonary as pi ra tion. Anaes thes ia 2005;60 :791796. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 1419. Fa rrow C, Cook T. P ulmonary aspi ra tion th rough a Cobra P LA . Anaes thes ia 2004;59:1140114 1. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 1420. Qui nn B . The CobraPLA a response from the manufac ture r. Anaes thes ia 2005;60:817818. [Fu ll tex t Link ] [Cross Ref]

[Med li ne Link ] 1421. Yama guc hi S , Urabe K , Ikeda T, et al. A i rway obs truc tion d ue to i ncarc eration of the epigl ottis i nto th e epiglo ttic b ars du ring gen eral anes th esi a with a new peri laryngeal a irway (Cobra P LA ). Anes th Analg 200 6;102:973. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 1422. V an Zundert AAJ , Baha AS , B rimacombe J , et a l. V alv e leaks wi th new disposable ex traglottic airway dev ices. Anes thesiolo gy 200 5;103:213. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 1423. Mi ller DM, Camporota L . Adv antages of P roSeal and S LIPA ai rways ov er trac heal tubes fo r gynecologica l laparosc opi es . Can J A nes th 2006 ;53 :1 88193. 1424. Hein C, P lummer J , Owen H. Ev aluation of the SLIPS (S treaml ined Liner of the Pharynx A i rway), a s ingle use sup rag lottic ai rway dev ice , in 60 a naes the tized pa ti ents unde rgo ing minor s urgic al proc edures . A naes th Intens Care 2 005;33:756 761. [Med li ne Link ] 1425. Coe tz ee GJ . Fl ow th rough dispos able alternativ es to the l aryngea l mask . Anaes thes ia 2003;58:280 281. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] P .519

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. Us es for the flex ible LMA include A . Intubations thro ugh the L MA B . W hen a mou th gag is in p lac e C. S i tuations where l ow res istance to flow is needed D. Su rgical procedures a rou nd the h ead and neck V iew A ns we r2. Checking the LMA be fore use shou ld include the follow ing: A . Th e infl ated c uff sho uld hold pres sure f or a t leas t 2 minutes B . A i r should be withdrawn to rev eal leak s in the cuf f C. The b ars s hould be probed to be certa in that they are in tac t D. The tube s hould be fl ex ed more than 18 0 d egrees V iew A ns we r3. To p repare the LMA for use , A . B o th s ides of the c uff should be lubric ated B . Th e cuff should be wri nk le-f ree C. Lu bricants that contain s ilicon e a re recommen ded D. The c uff s hould f orm a s tiff wed ge V iew A ns we r4. If there is difficulty in inserting the LMA, he lpful mane uvers include A . Inse rtin g the LMA bac k ward B . P osi tiv e-pressu re v enti lation C. Inse rtion f ro m the s ide of the mouth D. Cric oi d p res sure V iew A ns we r5. Wh en cleaning and ste rilizing the LMA, A . It should fi rs t be wash ed with detergent a nd water B . Th e LMA c an be s teri l iz ed by using the steam autoc lav e C. E thylen e ox ide shou ld no t be used to s teri l iz e the LMA D. The L MA c an be soaked in l iquid chemical agen ts f or up to 30 mi nu tes V iew A ns we r6. Wh ich statements a re correc t? A . Dead spac e is greater wi th the LMA th an with th e face mas k B . Th e pharynx adapts to the shap e of the LMA c uff C. The reinforc ed LMA offers less res is tance to b rea thi ng than the s tandard v ersion D. The work of breathing wi th the LMA is s imi la r to that assoc ia te d wi th a tracheal tube V iew A ns we r7. Indica tions for u se of th e laryngeal mask include A . Fa iled intubatio n B . Fac ial bu rns

C. P rofess ional s inger D. Limi ted mou th opening V iew A ns we r8. If the LM A is used for ophthalmologic s urge ry, A . Intraocular press ure is less during in duc ti on and emergence with the L MA than wi th a trac heal tube B . Th e LMA is more likel y to be dis lodged during surgery than a trac heal tube C. There is less likelihood of cou ghing durin g the s u rgica l proced ure D. The s ta ndard LMA should be us ed V iew A ns we r9. P rocedures to be performed if g astric c ontents appear in the LMA include A . A 30-deg ree head-down posi tion B . Re mov al of the LMA for s uc tionin g C. Inse rtion of a trache al tube if asp iration has occu rred D. P lac ement o f the patien t in the la teral pos i ti on V iew A ns we r10 . What measures c an be tak en to minimiz e the incidenc e of a spiration ? A . Ov erinf la ting the LMA c uf f by 10 cc B . Us ing low ti da l v olumes C. Keepi ng peak a irway press ure less than 41 cm H 2 O D. A lev el of anes thesi a adequate to prev ent s wa ll owi ng V iew A ns we r11 . Causes of airw ay obs truction associated w ith the LMA include A . B ackfoldi ng of the dis tal c uff B . Lary ngos pasm C. Obs truc ti on of the la ryngeal opening by the dis tal c uff D. Ov erdis tension of the cuff V iew A ns we r

Chapter 18 Laryngoscopes
P .521

Laryngosc opes a re used to v iew th e larynx and a djac en t s truc tu res , mos t c ommonl y for th e purpos e of ins erti ng a tub e i nto the tra cheo bronch ial tree. Other purposes i ncl ude pl ac ing a gas tric tube o r trans esophageal ec hoca rdiac probe , fo reign bo dy remov al , and v isual i zi ng and ass ess ing the upper ai rway. They ran ge from s imple rigid sc opes wi th a light bulb to c omplex fiberoptic v ideo dev ices . The wide range of av ailab le dev ic es attes ts to the div ers e dif ficu lties enco untere d in thei r use .

Rigid Laryngoscopes Description

Ri gid l aryng oscopes are manufac tured ei ther as a s ingle-piece or a s eparate detac habl e blade and handl e. In the latte r cas e, the light s ourc e is either a lamp attached to the b lad e o r a lamp in the handle with a light guide in the bl ade. For a detac habl e handle and blade, the l igh t sou rce is ene rgi zed wh en the b lade and handle a re lock ed in the operatin g pos i tion . A hook -on (hinged, folding) c onnec tion between the handle and blade is mos t c ommonly used . The handle is fitted wi th a hinge pin that f its in to a sl ot on the bas e of th e blade. This al lows th e blade to be quick ly and eas il y attached or de tac hed. A s ing le -piec e laryngoscope has a s wi tc h on the handle that c ontrols power to the lamp. S tanda rds c ov eri ng ri gi d l ary ngos cop es include th e A me rican Soci ety for Tes ting and Ma teri als (AS TM) F965 a nd F-1 195 and the In ternational S tandards Organi zation (IS O) 7376 (1,2,3).

Handle
The handle is the part held in the hand during use. It prov ides the powe r fo r the l ight. Mos t of ten, disp osab le ba tteri es are th e power s ourc e. Handles wi th recha rge able batteri es are av ailable (4). Fib ero ptic -i lluminated la ryngos copes ma y us e a remote elec trical ly operated l ight s ourc e. Most handl es are des igned to ac cept either fiberoptic -i l luminated or lamp-i n-bulb b lades , b ut some c an acc ept ei th er one. Handles desi gned to ac cept b lades that have a light b ulb hav e a metall ic contac t, whi c h comple tes an elec trical c ircui t when the ha ndl e and blade are in the work ing position. Ha ndles con tai ni ng ba tteri es and us ing fiberoptic illumina tion contain a

halogen la mp bulb . W hen the hand le and b lade are lock ed in the work in g pos i tion , an ac tiv ator s witch is depress ed. This prov ides a c onnec ti on be twe en the bulb an d the batte ries . A ha log en la mp bulb has a lon ger l ife than other l ight bulbs . S tudi es hav e shown that the illumi nation is be tter wi th lamp-in -blade than f ib ero ptic s ys tems (5,6,7,8). Handles are av ailab le in sev e ral si zes (Fig . 18.1). The surface is usuall y rough fo r i mprov ed grip . Short handles may be adv antageo us fo r patients in whom the c hes t and/o r breas ts contac t th e handle during use, when c ric oid pres sure is being applied, or whe n the patient is in a body cas t (9). Ano ther technique for h andl ing this s ituation is to ins ert the bl ade lateral ly i nto the mouth, P .522 then to adv ance and rota te i t until it is in a midl ine posi ti on (10,11).Th e b lade can be de tac hed f rom th e handl e before it is inserted i nto the mou th and then c an be attached to the handle af ter i t is placed (12).

Figure 18.1 Laryngoscope handles. (Courtesy of Rusch, Inc.)

View Figure

A l though mos t blades form a right angl e wi th the hand le whe n read y f or use, the angle may also be acute or obtuse . An adapte r may be fi tted be twe en the handle and the blade to allow the angle to be al tere d (13,14,15 ) (Fi g. 1 8.1 ). The P ati l S yrac use handle (Fig. 18 .2) c an be pos itioned and l oc ked in four dif fe ren t pos itions (16). Some handles al lo w the bulb and ba ttery porti on to be remov ed as a unit. Th is al lows the o ute r part of the han dle to be cl eaned and dis infec ted or s teril ized.

Blade
The blade is the component that is inse rted in to the mouth. W hen a bl ade is av ailab le in mo re than one s ize , th e b lades are numbered, with the nu mber i nc reas ing wi th s ize. Tab le 18 .1 shows the a ppropriate si ze marki ngs acc ording to the IS O s tandard (3). Dis posa ble blad es are av aila bl e (Fig. 18 .3). The blade is composed of sev era l parts , incl uding the base, heel , tongu e, f lange, web , ti p, and light sourc e (F ig . 18.4).

Figure 18.2 Patil-Syracuse handle. With this handle, the blade can be adjusted and locked in four different positions (45, 90,135, or 180). (Courtesy of Mercury Medical.)

View Figure

The base is the pa rt that a ttaches to the handle . It h as a sl ot for engaging th e hinge pin of the han dl e. The end of the base is called the heel . The tong ue (s patula ) is the main s haf t. It s erv es to co mpress and man ipula te the soft tissues (es pecial ly the tongue) and l ower j aw. The long axis of the tongue may be s tra ig ht or c urv ed in pa rt o r al l of i ts leng th. B lades are c ommonl y referre d to as cu rv ed o r s trai gh t, depend ing on the predominant sh ape of the tongue . In ge neral , P .523

P .524 s traight blades p rov ide better l aryngeal v is ual iz ation , whi le cu rv ed bla des mak e i ntu bation easi er (17). W hen a satisfac tory v iew i s obtained but intuba tion is diff icul t, the us e of a bougie or a s ty let (Cha pte r 19) may be h el pfu l (18).

TABLE 18.1 Size Markings for Laryngoscopes Marking 000 Intended Use Small premature infant

00 0 1 2 3

Premature infant Neonate Small child Child Adult

4 5

Large adult Extra-large adult

From International Standards Organization. Anaesthetic and respiratory equipmentlaryngoscopes for tracheal intubation (ISO 7376). Geneva, Switzerland: Author, 2003.

Figure 18.3 A: Reusable handle with curved (Macintosh) and straight (Miller) disposable blades. B: Disposable handle and blade. (Courtesy of Rusch, Inc. and Vital Signs.)
View Figure

Figure 18.4 The parts of the Macintosh (top) and the Miller (bottom) blades are illustrated. The tip is the distal end of the blade intended for insertion into the patient. The proximal end is the part closest to the handle. (Redrawn from a drawing in Committee, American National Standards Institute. Draft standard, laryngoscopes for tracheal intubation (Z-79). Philadelphia: ASTM.)

View Figure

Figure 18.5 Left-handed Macintosh blade. (Courtesy of Penlon Ltd.)

View Figure

The f la nge projec ts off the s ide of the tongue and is c onnec ted to i t by the web. It se rv es to gui de ins trumentation an d deflec t ti ss ues f rom the l ine of v ision . The f lan ge determines the c ros s -s ec tional s hape of the blad e. The v ertical height of the c ross -s ec tional s hape of a b lade is some ti mes refe rred to as the s tep (19 ). The tip (beak ) c on tac ts e ither the epi gl ottis or the v allec ul a and di rec tly or i ndi rec tl y el ev a tes the epiglottis . It is us ua lly blunt and thick ened to dec reas e trau ma. The blade ma y hav e a lamp (bu lb) (Fi g. 18 .5 ) or a fiberoptic bundle that transmi ts l ight from a source in the handle (Fig. 18 .6). The l amp sc rews into a s ock et that has a metallic contac t. On mos t blades , the soc ket is located nea r the tip. W hen the blade is in the work i ng posi tion, elec trica l con tac t wi th the power s ourc e i n the handle is made . The socket is subjec t to s oili ng by f lu ids tha t can affec t the elec tric al con tac ts , caus ing the l ight to fai l . A fiberoptic -i l lu mi na ted blade has an enc ased fiberoptic bu ndle tha t trans mi ts li ght f rom a source in the ha ndle or the base of the blade. Bec ause there is no bu lb or elec tric al con tac t in the blade , c lean ing an d s te ri li za tion are eas ier. The IS O s tandard (3) requi res fiberoptic -i l lumi nated blades to hav e a g reen ma rk on the heel.

Figure 18.6 English Macintosh blade. (Courtesy of Welch Allyn, Inc.)

View Figure

In mos t cases , usi ng a la ryngosc ope prese nts li ttle or no diff icu lty to the ex perienc ed opera tor, an d s ki ll is of more importanc e than the type of blade employed. There are, h owev e r, s ituati ons i n wh ic h a c ertain blade may be partic ula rl y adv antageo us (20 ). These si tuations hav e led to the dev elopmen t of a numb er of d iffe ren t bl ades . The blades discus sed he re are all av ai lable co mme rci al l y in the Uni ted S tates at the time of this wri ti ng. A number of other blades hav e been des c ri bed in the li terature.

Macintosh Blade
The Mac in tos h (Fi gs . 18.3, 18 .4, 1 8.14, 18 .15 ) is one of the mos t popular blades (21,22,23). The tongue h as a gentle c urv e tha t ex tends to the tip. In c ross sec tion, the ton gue, web, and flange form a rev erse Z. Nume rous modifications hav e been sugges ted (24,25,26,27,28,29 ,30 ,31 ,32,33,3 4,35,36,37). The no. 4 b lade may be more useful than the no. 3 in normal an d large-s ized adults (38). Cerv ical spine mov ement is greate r with th e Ma ci ntosh blade compared with the Mi ll er bl ade, a lightwand, or the GlideScope (39,40,41 ,42 ).

Left-handed Macintosh Blade

The lef t-handed (rev e rsed) Mac intos h b lade (Fi g. 18 .5 ) has the flange on the oppos i te s ide f ro m the usual Mac intos h b lad e (43 ). Th is blade may be useful for abnorma li ties of the rig ht s ide of the face or o rop harynx , left-handed intubators , i ndiv iduals wi th l imi te d use of the l eft arm, intubating in the ri ght lateral pos i ti on, or positioning a trach eal tube di rec tly on the left s ide of th e mo uth (44,45,46,47,48 ).

English Macintosh
The E nglis h Mac in tos h (Fig. 1 8.6 ) is s imi la r to the c onv entional Mac intosh exc ept the flang e is c urv ed and lo wer at the handle e nd. Two s tud ies hav e found that this blade prov ided better resu lts th an other c ommonl y used blades (49 ,50 ). A modification is s hown i n F igu re 18 .7. It has a reduced flange to dec re ase press ure on the max il la ry i ncisors .

Figure 18.7 English Macintosh blade with reduced flange.

View Figure

P .525

Figure 18.8 The polio blade. (Courtesy of Sun Med.)

View Figure

Polio Blade
The poli o blade (Fig . 18.8) is also a mo di ficatio n of the Maci ntosh. The blade is of fs et f rom the hand le at an obtus e angle to a llow in tubation in iron lung res pi ra tors or body j acke ts ; af ter the anes thes ia sc reen i s i n p lac e; and of patients with obesi ty , breas t h ypertrop hy, k yphos is with sev e re barre l ches t deformi ty, a s hort neck, or res tric ted n eck mobi lity (51,52). Dis adv antages of this blade are tha t li ttle forc e c an be app lied, and con trol is minimal (12 ).

Figure 18.9 A: The improved vision (IV) Macintosh blade (left) and the conventional Macintosh blade (right). Note the improved vision when the blade is viewed from the proximal end. B: Conventional Macintosh blade (top) and the IV Macintosh blade (bottom). On the IV Macintosh, the midportion of the spatula is concave. (Courtesy of Gabor B. Racz, M.D.)

View Figure

Figure 18.10 The oxiport Macintosh blade. (Courtesy of Mercury Medical.)

View Figure

Improved Vision Macintosh Blade

The improv ed v ision (IV ) Ma ci ntosh blade (F ig. 18.9) is s imil ar to the s tand ard v e rsion ex cept tha t the mi dpo rtion of the ton gue is c onc av e (3 6,53).

Oxiport Macintosh (Mac/Port)

The Ox ipo rt Ma cin tosh bl ade (F ig. 18.10) is a Mac intosh blade wi th a tube added to deliv er ox ygen.

Tull Macintosh
The Tu ll (suc tion ) blade (F ig. 18.11) is a mo dified Mac intosh that has a suc ti on port near the tip. The s uc tion c hann el ex tends nex t to the han dle and has a fingercontrol led v alv e so that s uc tion c an be controlled by the laryngos copis t.

Fink Blade
The Fink blad e (Fig. 18 .12 ) is another mod ific ation of the Mac in tos h. The tongue is wi der a nd has a sha rpe r c urv e at the distal end. The he ight of the f lange is reduc ed, es pec ial l y at the prox ima l end . The l ight bulb is p laced farther forward than on the c onv entio nal Mac in tosh blade.

Figure 18.11 Tull (suction) Macintosh and Miller blades. The finger-controlled valve allows suction to be regulated by the laryngoscopist. (Courtesy of Mercury Medical.)

View Figure

P .526

Figure 18.12 The Fink blade. Note that the tongue is more curved at the tip, and the flange is reduced at the proximal end compared with the Macintosh blade. The light bulb is placed nearer the distal end. (Courtesy of Puritan-Bennett Corp.)
View Figure

Bizzarri-Giuffrida Blade
The B i zzarri -Gi uff rida bl ade (flan gel ess Mac in tos h) (Fig . 18.13) is a modified Macintos h o n wh ic h the f la nge is remov ed, ex cep t fo r a s mal l part that encases the l ight bul b (20,3 6,54). This modification was made to li mit damage to the up per

teeth. The b lade is des igned for patients wit h a l i mited mouth opening, prominent i ncis ors , receding mandible, sh ort and thic k neck , or an teri or l arynx .

Upsher Low Profile

The Upsher low profil e (ULP ) blade (Fig. 18.14) is a modified Mac intosh wi th a l ow f lan ge and a fairly s traight p rox imal sec tion th at leads to a tip with a s ignif icant cu rv e . It is des ig ned f or inserti on into a s ma ll mo uth.

Upsher ULX Macintosh Blade

The ULX bl ade (Fi g. 18 .15 ) has a l ittle more c urv e than the s tandard Mac in tos h blade .

Miller Blade
The Mi ller (Fi gs . 18.3, 18.4, 18.1 6) is one of the mos t popular blades (55). The tongu e is s tra igh t wi th a s l ight upwa rd cu rve near the ti p. In c ross sec tion, the f lan ge, we b, and tong ue fo rm a C wi th the to p fattened. S ome v ersions of the blade hav e the l amp soc ket on the tongu e, whi le o thers hav e it on the we b. The lamp may be on ei ther the ri ght or left s id e of the bla de. If the bulb is on the left s id e, the bulb is easi er to chan ge but c an be cov ered b y the tongue. P laci ng the bulb on the righ t si de al lo ws i t to be pro tec te d b y the f la nge (56). S ev e ral modifications hav e been desc ribed (57,58,59,60,61).

Figure 18.13 The Bizzarri-Giuffrida blade. (Courtesy of Puritan-Bennett Corp.)

View Figure

Figure 18.14 Upsher low profile blade. Top: A standard Macintosh blade. Bottom: A ULP blade.

View Figure

In c omparing the Mac in tos h and Mil ler blades , i t was found that f orce, head ex tensi on, and cerv ical s pine mov emen t were l es s with the Mi ller (39,40,41).

Oxiport Miller Blade

The Ox ipo rt Mi l ler (Mi ll er/po rt, ox yscope) blade (Fig. 18 .17 ) has a bui l t-in tube that al lows deliv ery of oxy gen during in tub ati on (62,63,64). It may also be use d for suc tion ing . W hen us ing this blade, oxygen ins uffl ation du ring intubation has been found to les sen ox ygen d esaturation in s pon taneous ly breathing anes thetiz ed pati ents (65 ,66 ).

Tull Miller Blade

The Tu ll (suc tion ) Mil ler blade is a s tandard Mil le r bl ade wi th a s uc ti on tube whos e port ends near the bl ade tip (Fi g. 18 .11 ). Ne ar the hand le is a f inger-c ontrol led port that al lows suc tion to be contro lled.

Mathews Blade
The Mathews b la de (Fig. 18.1 8) is s trai ght wi th a wi de and f lattened petalloid configuration at the tip. It is des igned for difficul t nas otrachea l intu bations .

Wisconsin Blade
Unlike the Mi l ler b lade, the W is cons in bl ade's tong ue has no cu rv e (Fig. 18 .19 ). The f la nge is curv ed to form two thi rds of a c i rc le in c ross s ec tion P .527

(20). The flange depth is narrow at the proxi mal end a nd is wi der i n the dis ta l portion .

Figure 18.15 ULX blade. The ULX blade is at the top. A standard Macintosh blade is at the bottom. (Picture courtesy of Mercury Medical.)

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The W hi tehead mod if ication of the W isco nsin bl ade (F igs . 18.20, 18.40) has a reduc ed flange a nd is open proxi mally and d is tal ly.

Wis-Foregger Blade
The W is -Fore gger blade (Fig. 1 8.21) i s a mo dif icatio n of the W isc ons in blade, with a s traigh t tongue and a flange that ex pands s ligh tly to ward the dis tal end (67). The dis tal po rtion of th e blade is wi der and fo rmed sl ightly to the right.

Figure 18.16 Miller blades. (Courtesy of Sun Med.)

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Wis-Hipple Blade
The W is -Hipp le bl ade (Fi g. 18 .22 ) is a modif ied W isco nsin bl ade. T he tongue is s traight, and P .528 the flang e is larg e and c i rc ula r. Co mpared with the W isco nsin blade, the flange is s traighte r and runs paral le l to the tongue an d the tip is wid er. It i s des ign ed prima ri ly for us e in i nfants .

Figure 18.17 Oxiport Miller blades. (Courtesy of Rusch, Inc.)

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Figure 18.18 The Mathews blade. (Courtesy of Mercury Medical.)

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Schapira Blade
The Sc hapi ra b lade (Fig. 1 8.23) is a s trai ght blade wi th a tip that c urv es upward (68). The v ertic al c omp onen t is mi ni mal .

Alberts Blade
The A lberts blade (Fig. 18.24) c omb in es c harac teris tics of the Mi ller and W is -Hippl e blades with a c ut-awa y fl ange to inc rease v is ibi li ty. The re is a recess to f aci l itate trac heal tube ins ertion. The bla de forms a 67-degree angle wi th the handle . It is us ed for pedi atric patients .

Michaels Blade
The Mic haels b lade (Fig. 1 8.24) differs from the A lberts blad e onl y in th at i t fo rms a 93-degree a ngle with the handl e.

Soper Blade
The S oper blade (Fig. 18 .25 ) combines the Z shape on the f lange of the Mac in tos h blade wi th a s traight bl ade (20,69). It has a s lot buil t into the tip, whic h is intende d to p rev ent the epi gl ottis from sl ip pin g off the bl ade .

Heine Blade
The He ine blade (Fi g. 18 .26 ) is s traight wi th a sl ight upward c urv e at the tip. The f lat flange is curv ed a way from the bl ade. It is us ef ul f or chi ldren with large tongu es.

Figure 18.19 The Wisconsin blade. (Courtesy of Ohio Medical Products, a division of Airco, Inc.)
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Figure 18.20 Whitehead modification of Wisconsin blade. (Courtesy of Sun Med.)

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Snow Blade
The S now blade (Fig. 1 8.27) is a h ybrid blade c ons is ting of a Miller tongu e and a W is -Fo reg ger flange (70). It is curv ed 1 inch f rom the ti p.

Flagg Blade
The Flag g b lade (Fi g. 1 8.28) has a s traig ht tongu e. The f lange has a C shape tha t graduall y dec reases i n si ze as it approac hes the dis ta l end .

Guedel Blade

The Guedel blade (Fig. 18.29) is a s traight blade on whic h the tongu e is s e t at a 72 angle to the handle . The f lan ge has the sha pe of a U on its s ide. Th e l ight is c los e to the tip, whi ch has an upti l t of 10.

Bennett Blade
The B ennett blade (Fig. 18.30) is a modif icati on of the Guedel blade. It also forms an ac ute angle with the handle. Th e upper p art of the fl ang e has been omi tte d.

Eversole Blade
The Ev ers ole blade (Fig. 18.31) has a s traig ht tongue. The f lange forms a C with the ton gue and we b near the prox imal end. Mi dway to the tip , the upper f lange tapers .

Seward Blade
The S e ward bl ade (Fi g. 18 .32 ) has a s tra igh t tongue wi th a cu rv e n ear the ti p (7 1). It has a smal l rev e rse Z-sha ped flange. T he bla de is useful f or nas otrac heal i ntu bation because i ts sh ape al lo ws a Magill forceps to be in troduc ed with min imum l oss of v ie w. It is i ntended f or us e in ch il dren younger than 5 years old.

Figure 18.21 The Wis-Foregger blade. (Courtesy of Puritan-Bennett Corp.)

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Figure 18.22 The Wis-Hipple blade. (Courtesy of PuritanBennett Corp.)

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Figure 18.23 The Schapira blade. (Courtesy of PuritanBennett Corp.)

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Figure 18.24 The Alberts (top) and Michaels (bottom) blades. The Alberts blade offers a sharp 67 angle, whereas the Michaels blade has a slight 93 angle. (Courtesy of North American Drager.)

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Figure 18.25 The Soper blade. (Courtesy of Penlon Ltd.)

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Figure 18.26 Heine blades. (Courtesy of Heine Ototechnic Manufacturing Co., Inc.)

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Figure 18.27 The Snow blade. (Courtesy of Air Products and Chemicals, Inc.)
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Figure 18.28 The Flagg blade. (Courtesy of Ohio Medical Products, a division of Airco, Inc.)
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Figure 18.29 The Guedel blade. (Courtesy of Penlon Ltd.)

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Figure 18.30 The Bennett blade. (Courtesy of PuritanBennett Corp.)

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P .530

Figure 18.31 The Eversole blade. (Courtesy PuritanBennett Corp.)

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Phillips Blade
The P hil lips b lad e (Fig. 18 .33) is s traight wi th a low fl ange and a curv ed tip s imilar to a Mi ll er bla de (72 ). The l ight bulb is on th e l ef t si de of the bl ade .

Racz-Allen Blade

The Rac z-Allen blade is s traigh t with a c urved tip (73). The prox imal p ortion of the blade f lexes to rel iev e press ure on the teeth . The v e rtic al po rtio n is hi nged and held i n pos i tion by a sp ring. The spring allows l ateral def lec tion of the v ertical portion wi thout occ luding the v iew. E x pos u re is improv ed b y tilting the l aryngoscope handle to the lef t. The hi nged porti on is concav e along its length. The tongue su rface is rough and unp ol ish ed to reduc e sli ppage.

Robertshaw Blade
The Roberts haw blade (Fi g. 18.34) has a s trai ght tongue with a g entle c urv e n ear the tip (74 ). It i s des igned to l if t the epi gl otti s i nd irec tly . The f la nge is ex tende d to the left. The blade wa s desi gned for i nfants and ch ildren. It may be us eful fo r nasotrac heal in tubation , beca use i t allo ws a Ma gil l f orceps to be in troduc ed with a minimum loss of v iew.

Oxford Infant Blade

The Ox ford in fan t bl ade (F ig . 18.35) has a strai ght tong ue th at cu rv es up s li gh tl y at the tip. It has a U sha pe at the prox imal end , wi th the bottom l imb of the U dec reas ing to ward the ti p so that the dis tal pa rt is open . It tap ers f rom a maximum wi dth a t the p rox imal end to the tip. A lthough in tended prima ri ly for ne wborns, i t can be us ed for ch il dren up to 4 yea rs of a ge.

Figure 18.32 The Seward blade. (Courtesy of Penlon Ltd.)

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Figure 18.33 Phillips blades. (Courtesy of Mercury Medical.)

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Bainton Blade
The B ainton bl ade (Fi g. 18 .36 ) has a s tra igh t tongue (20,75). The dis tal 7 -cm sec tion is tubular s o that i t is pro tec ted f rom obs truc ti on by ede mato us tiss ue, blood , sec retions , intraora l mass es , and sca r ti ss ue and has an intra luminal light sourc e. The tip is bev eled at a 60 angle to c reate an ov al open ing at the d is tal end of the tube. A trac hea l tube of 8 mm or les s can be inserted throug h the tubul ar l umen wi thout s ignif ic antly obs truc ting v ision. The B ainton bl ade is des ig ned fo r patients wi th ri ght-s ided o r c i rc umferenti al pharyngea l les ions . The tubul ar po rtion c an displace tis sues c ircumferentia ll y and thus ov e rc ome this problem. A modified two-p iece tubular pha ryn golaryngoscope is also av ai lab le . The two parts of the bl ade are held to gether by a sc rew du ri ng in tubation . A trache al tube is place d intralumina lly in to the glottis and th en the two piec es a re dismantl ed and remov ed f rom around the tube.

Double-angle Blade
The s patula of the doubl e-angle (Ch oi ) blade (F ig. 18.37) has two angulations , 20 and 3 0 degrees , to improv e lifting of the epiglottis . The s patula and tip fo rm a wide , f lat surface. The b ul b is located on the left edge of the blade betwee n the two cu rv a tures . The flange has be en eliminated. T he blade may be P .531

es pecial l y usef ul f or the patient wi th an an te ri or lary nx . The absenc e of the f lange l eav es more room to pas s the tracheal tube th an with a s traight blade.

Figure 18.34 The Robertshaw blade. (Courtesy of Penlon Ltd.)

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Figure 18.35 The Oxford infant blade. (Courtesy of Penlon Ltd.)

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Blechman Blade
The B lec hman blade (Fig . 18.38) is a modification of the Macintosh blade , wi th the tip angled s harpl y to elev ate the epiglottis . The f lange has been remov ed n ear the handle e nd of the bl ade.

Belscope Blade

The B els cope blade (Fig. 18 .39 ) is a s tra ight blade bent f orwa rd 45 degrees near i ts midpoi nt (78). The tip is beaded on the unde rs ide , and the handle is offset. The blade is des igned to be us ed like a s traight blade, with the ti p l iftin g the ep iglottis . It is av ai lable in s ev era l lengths . W hen a s atisfac tory v ie w of the larynx cannot be obtained, a prism o f trans parent ac ryl ic can be attached to the blad e j us t prox imal to the angle (Fig. 18.39B). Mois ture c onde nsation on th e p ris m can be prev en ted by appl ying an antifog preparation to the prism and/or wa rmi ng it bef ore us e. A noth er meas ure to prev ent fogging is to di rec t a con tinuous flow of ox ygen ov er the pris m through a suc tion ca the ter taped to the bl ade (7 9). B ecause th e i mage of the larynx is rotated, the us er's head mus t be mov ed higher and farther forward than when the pris m is omi tted.

Figure 18.36 The Bainton blade. Note the distal tubular section. (Courtesy of Mercury Medical.)

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Sev era l s tudi es hav e shown that an improve d v ie w o f the larynx can often be obtained wi th the B elsc ope compared with oth er bl ades (80,81,82,83 ). The Belsc ope prov ides a greater dis tanc e between the pos terio r end of the blade and the uppe r teeth , making i t less like ly to c ontri bute to dental da mage than other blades (82). This blade f eels different f ro m other b lades , s o prac tic e is nec essa ry to acqui re p rof iciency (77,84). Intubatio n may tak e long er and be les s s ucc ess ful whe n the pris m is used (85).

Cranwall Blade

The Cranwa ll blade (Fig. 18.40, top) has a c urv ed tip like a Mi ller blade. The re is a reduc ed flange to dec rease the p otential for d amage to the upper teeth. It may be us eful fo r an anes th esia prov ider who has limited us e of th e lef t arm (48).

Figure 18.37 The double-angle blade. (Courtesy of Jay J. Choi, M.D.)

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Figure 18.38 Blechman blade. (Courtesy of Mercury Medical.)

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CW Blade

The CW bl ade is s hown i n F igure 18 .41 . It is desig ned to be ins erted an d remov ed wi th the horizontal f lange almost para ll el to th e teeth.

Flexible-tip Blades
The re are a number of fl ex ible tip blades that hav e a hinged tip tha t is controll ed by a lev er a ttached to the prox ima l end of the b lade (86,87) (Fi g. 18.42). Wh en the l ev er is pushed toward the handl e, the tip of the blade is fl exed (Fig. 18 .42B ). Fl exible-ti p blades are av ailable und er v arious names , inc ludi ng Mc Co y, Fl ip per, Fl ex Tip, lev e ring la ry ngos cope blade, and artic ula ti ng lary ngos cope b lad e. Vari ous blades hav ing a flex ibl e tip are av ai labl e, i nc luding pedia tric blades , and Mil ler (Fig . 18.43) and Maci ntosh (F ig . 18.42) b lad es are av ailable. The tip is less rounded than on the us ual Mac intosh bl ade (8 8). It may be helpfu l to us e a narrow handle with these blades (89).

Figure 18.39 The Belscope blade. A: Blade without prism. B: Blade with prism attached. (Courtesy of Dr. Paul Bellhouse.)

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Figure 18.40 Cranwall (top) and Whitehead (bottom) blades. (Courtesy of Bay Medical, Inc.)

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The f lex ible tip blade ma y be helpf ul whe n a dif ficul t intubation is encoun te red (88,90,91,92,93,94,95,96,97,98 ,99 ). Ev en if the blad e does not improv e the v iew of the la rynx , i t may imp rov e the lik el ih ood of s uccessful intubation by el ev ating the epiglottis (100,101,10 2). It may be espec ially usef ul in patients with mini mal neck mov ement (97,103 ,104,1 05,106 ). Ex ternal la ryngeal pressure may fu rther improv e the v iew b ut also may worse n i t (96,105,107 ,108,109). In s ome patients in whom the v iew i s sa tisfac tory wi th the Mac intos h b la de, us ing the lev ering bl ade may make the v iew wors e (49 ,8 8,110,111). S tudi es hav e shown that us ing the f lex ible ti p b la de res ul ts i n s igni fican tl y less forc e b ei ng appli ed and a reduc ti on in the stres s res pons e c ompared wi th the Macintos h b lade (112,113). P roblems hav e been reported wi th the f lexib le tip blades (11 4,115). In one case , the conn ec tion of the lev er mec hanism was broken , so the tip of the blade would not flex . The hi nged tip f rom the blade has b ecome de tac hed (116). A ry te noi d disl oca tion has been reported wi th i ts use (1 17). P .533

Figure 18.41 CW blade.

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Flexiblade
The Flex iblade is a s tai nless s teel b lade wit h s ix slo ts an d s ev en windows on the f lan ge (118,119). The bl ade c ons is ts of a rig id rear po rtio n, a flex ible in te rmediate portion , and a ri gid front portion. A lev er (co ntrol tri gger) i s attached at the prox imal e nd of the bl ade. S queezin g the trigge r c aus es the intermedi ate p ortion to become more c urv ed. Th e blade is inse rted wi th th e c ontro l trigger releas ed. The Flex iblade c an be used for both routine and diff icul t in tu bations (49 ). In mos t cases , the v iew i mprov es when the blade is flex ed (120,1 21,122,123,1 24). The Flex iblade has been repo rted to hav e broken af ter onl y fiv e us es (120). It is i mportan t th at the blade is not manu all y f lex ed and that i t is disengaged f rom the blade by rotating in the hori zon tal and not the v ertical d irec tion (125). A nother problem inv olv ed inco rrec t as semb ly (126). The l ight bundl e was on the wrong s ide of the bl ade and poi nting away from the lary nx . The re hav e been reports o f damag e to the tee th and g ums (127,128). A tongue l aceration was noted af ter an attempt a t i ntu bation wi th a n i nc orrec tl y assembled blade (125).

Vital View Blade

The V i tal V iew la ryn gosc ope blade is a dis pos abl e p las tic blade that c ontains a f ibe r li gh t. One s tud y showe d n o signi fican t difference i n the v iew of the gl ottis or the suc cess rate of trach eal intuba tion wi th th e V ital V iew c omp are d with a reus able metal blad e (129 ).

Henderson Blade
The Henders on blade is a la rge , s traight blade with a s trai ght tip tha t ex tends well beyond the main part of the blade (130). In c ross s ectio n, the blade is s emitubula r. It can ac commod ate an 8-mm tracheal tube (1 31). W hen used with the pa rag lossal tec hnique, a better v iew is obtained by optimi zing con trol of the s oft tissues and i mprov ing the line of sight.

Cardiff Blade
The Ca rdiff blade is des igne d for use in c hildren from birth to adoles cenc e (132,133 ). S ev eral s i zes are av ai lab le (133). The distal part is c u rv ed at an angle of 85 d egrees . P rox ima ll y, the bl ade has a Z -sh ape. The P .534 web and f lange are attenuated dis tall y so that the te rmi nal part continues as a cu rv ed s patula, na rrowi ng at the tip. It te rminates wi th a th ic kened, transv erse bead.

Figure 18.42 Curved flexible tip blades. A: Unflexed. B: Pushing the lever toward the blade causes the tip to be flexed. (Courtesy of Heine USA Ltd.)

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Figure 18.43 Straight blades with flexible tips.

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Viewmax Blade
The V iewmax l aryngoscope (Fi g. 18.44) has a n optic s ide po rt on a s tand ard Macintos h b lade tha t ref rac ts the image appro xima tel y 20 de gre es from the hori zontal . This modific ati on al lows fo r a mo re anterio r v iew from a pos i ti on 1 c m behind the lef t tip of the blade whi le a t the s ame time allowi ng the s tanda rd di rec t v iew.

Dorges Blade
The Do rges laryngosc ope blade combines fe atu res of both the Mi ller and Mac intosh blades (133). Compared with the Mac intosh, the f lan ge has a lower he ight, and the cu rv e of the blade is l ess. It is av ail abl e in o nly o ne s ize and can be used in pati ents >10 kg. It has 10- and 20-k g mark in gs on the b lade. S tudies hav e found that the Dorges did not perform an y better than the s tandard Mac in tos h b lade in easy or diff icul t intu bation s cenari os (111,133 ).

Figure 18.44 Viewmax blade. (Courtesy of Rusch, Inc.)

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Truview Blade
The Truv iew bl ade is a s ta ndard Maci ntosh blade that inc orpora tes a n unmagnif ie d optic s ide (pris m). Adul t and pedia tric s iz es are av ai la ble . The pris m c aus es a 20degree a ngle of refrac tion. It can be us ed as a s traigh t or c u rv ed b lade.

Prisms
P ris ms that c an be attac hed a nd detached from the lary ngos cope b lad e are av ailab le in v arious s izes (F ig . 18.45). The y a re attached to a l aryngosc ope blade by us in g a c li p. A refrac tion is prov ided in th e l ine of s igh t, thereby bringing in to v iew s truc tu res wi thin a f ew mi l li meters of the tip of the b lade. The i mage is ri ght s ide up. It is imp ortant to warm the pris m before use to prev ent condensa ti on. The Huff man prism (134,135,13 6) is a bl oc k o f Pl exi glas s haped to f i t on th e prox imal e nd of a no. 3 Mac in tos h bla de (Fig. 18.46). The Huffman p ris m l ary ngos cop e b lade has the pris m bui l t in to the blade. An addi tional 20 ref rac tion f rom ri ght to left is ad ded bec aus e the pris m is to the left of the midl ine. The pris m l ary ngos cop e b lade all ows e ither c onv ention al di rec t larynge al ex posu re or i ndi rec t v iewi ng through th e p rism.

Techniques of Use
The optimal p osi tion for l aryngos copy for mos t adu lt p ati en ts is approx imately 35degree f lex ion of the lo wer P .535

ce rv ica l spine and an 8 5-degree to 90 -de gre e head ex tensi on at the atl an tooc c ipital l ev el, the s o-c al led s niff ing pos i tion (137). El ev ation beyond the s niff in g position may imp rov e the v iew i n c ases of di ff ic ul t la ryngosc opy (138). The lower ce rv ica l spine po rtion c an be mainta ined in a flex ed posi tion b y us ing a pil low unde r the head . A tlan to-occ ip ital joint ex tens ion is ac hiev ed b y pressure on th e top of the head and/or up ward trac tion on the upper teeth o r gums . In obese patients , cons iderabl e should ers a nd head el ev ati on may be neces sary s o tha t an imaginary hori zontal l ine c onnec ts the patien t's s tern al no tc h wi th the ex ternal audi tory meatus (139). A cus hion desi gned to prov ide the bes t poss ible pos ition has been dev el oped (Fi g. 18.47 ). In c hi ld ren , it ma y be unneces sary to fl ex the lo wer c e rv ica l v e rtebrae. In neon ates , i t may be necess ary to elev ate the s houlde rs becaus e the head is rela tiv el y large.

Figure 18.45 Prisms for attachment to laryngoscope blades. (Courtesy of Anesthesia Asssociates, Inc. San Marcos, CA.)

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A mbi ent light s hou ld not be ov erl y bri ght (14 0). The operatin g l ight s houl d not s hi ne on the face.

Figure 18.46 The Huffman prism. (Courtesy of Penlon Ltd.)

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The laryngoscope hand le is hel d in the gloved l ef t hand . Mois tening or lubric ating the blade wi ll faci l itate ins ertion if the mou th is dry . In so me s ituati ons , the c hes t wi ll impinge on the handle, mak ing i t diff icult to i ns ert the bl ade . In thes e c ases , a short h andle may be us ed, the bl ade may be inse rted si deways (10 ), or the blade may be inse rted and then attached to the ha ndle (12 ,141). The f in gers of the right hand are used to open the mouth and spread the lips . In pati ents with denti tion, the op timum opening of the mou th is often ac hiev ed wi th a thumb-ov e r-index -finge r app roac h, wi th the i ndex P .536 f ing er on the max i ll ary te eth and the thumb place d on the lower teeth.

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Figure 18.47 Troop elevation pillow. A standard pillow should be used with this. The elevation pillow helps to achieve a better position for ventilation and laryngoscopy in large-framed and obese patients. The head and neck are elevated above the level of the chest and abdomen. The upper airway is more isolated, and the weight of the abdomen is moved away from the diaphragm. This pillow is easier and quicker to use and more stable than a stack of blankets. (Courtesy of Mercury Medical.)

Figure 18.48 A: Intubation with a straight laryngoscope blade. The tip of the blade picks up the epiglottis. B: Intubation with the curved laryngoscope blade. The epiglottis is below the tip of the blade. A small pillow under the head allows better visualization of the larynx. (Courtesy of Vance Robideaux, M.D.)
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The blade is inserted at the ri ght s id e of the mouth . This red uces the l ik eli hood tha t the incis or teeth wil l be da maged an d helps to push the tongue to the left. The blade is adv anced a lo ng the s ide of the tong ue toward the right tonsill ar f ossa s o that the tongue l ies on the lef t side of the blade . The ri gh t hand k eeps the li ps f rom getting c augh t between the teeth o r gums and the bl ade. If the tongue is sl ip pery, plac ing tape on the li ngual bl ade s urfac e ma y be helpfu l (1 42). W hen th e right tonsi l la r fos sa is v is ual ized, the blade tip is mov ed toward the mi dl in e. The b lade is then adv anc ed behind the base of the tongue, el ev ating i t, until the ep igl ottis co mes into v iew.

The re are two methods for e lev ating the epiglottis , d epending on whether a s traig ht or c urv ed blade is being used .

Straight Blade Technique

The s traight blade is sho wn in pos iti on fo r intubation i n F ig ure 18 .48A . The blade is made to scoop unde r the epiglottis and l ift it an te ri orl y. The v oc al co rds s hould be i dentified. If the blade is adv anced too fa r, i t wi ll elev ate the l arynx as a who le rather th an ex pose the v ocal cords . Occasio nally , the bla de wil l expos e the es opha gus . It s hould th en be withdrawn s lowl y. If i t is wi thdrawn too far, the ti p of the epiglottis wil l be released a nd fli p ov er the glottis . A s traight blade c an also be i nse rted in to the v al lecula (the angle made b y the epiglottis wi th the bas e of the tongue) and used i n the same ma nner as a c urv ed blade (s ee below). Ano the r tec hni que usi ng a s traight b lade has been repo rted to s ucceed after failu re wi th a Maci ntosh blade (143 ). Th e blade is passed f rom the ri ght corner of the mouth in to the groov e be tween the tongue and the tons il , displacing the tongue to the left. The blade is adv anced, the epiglotti s identif ied, and the bl ade tip passed pos te rior to the epigl ottis . Nex t, the blade is lifted anteriorl y, elev ating the epiglottis di rec tl y so that the glottis is ex pos ed. The b la de is then mov ed towa rd the midline , pus hing the tongue to the lef t. W i th this app roach, an ass is tant may b e needed to retrac t the corner of the mou th so that the trac heal tube c an be manipu lated into plac e. The use of a bougie o r s tyl et in the trac heal tube ma y be helpful (144 ). A l ternately , the laryngoscope handle may be s witc hed from lef t to righ t and the tracheal tube introd uced f ro m the left s ide of the mou th (145).

Curved Blade Technique

Fi gure 18.48B sho ws the c urv ed blade in p os i ti on. After the epi gl ottis is v isualized, the P .537 blade is adv anced u nti l the tip f its into the val lecula. Trac ti on is then ap plied along the hand le at ri ght angles to the blade to mov e the base of the tongue a nd the epiglottis fo rwa rd. T he gl ottis s hou ld co me into v ie w. It is important that the end of the hand le oppos i te the blade is not pulled back wa rd. This wil l ca use th e tip to push the l arynx up ward and out of sight and c ould c aus e damage to the teeth or gums (146 ,147).

A curv ed bl ade c an also be used as a s traight bl ade, l if ting the epigl ottis direc tl y, if i t is long enough (148 ). In c ases of diff ic ul t la ryngos copy , a lef t-molar or ri ght-molar approac h often i mprov es the la ryngeal v ie w (149 ). The lef t-mol ar approach is ma y be espec ially helpful and may spa re the inc is or teeth (150 ,151).

Other Maneuvers
Ev en with correc t techni que, the larynx wil l not always be v isuali ze d. Displac ing the l ary nx by ex ternal back ward , upwa rd, and rightward pressure (B URP ) on the thy roid ca rtilage may i mprov e v isua li za ti on of the gl ottis (149,152,153,154,1 55,156,157 ). Mand ibula r adv ance ment may also improv e th e v ie w (158 ). Inf la ting a Foga rty ca the ter attached to the bac k of the tongue blade po rtion may improv e v isuali za tion i n s ome cas es (99,159,160,161 ,162,163,164 ,165).

Figure 18.49 Disposable laryngoscope covers. A: The cover ensheaths both the blade and the handle. B: Only the blade is covered. (Courtesy of Blue Ridge Products.)

View Figure

Cleaning
The c lea ni ng of l aryngos copes has be en a s ubj ect of debate for s ev eral y ears . S ince bl ades are inse rted in to the mouth and of ten c ause bleeding, there is poten tial f or c ross i nfec tion among pa tients . T he handle, whi le not in di rec t contac t wi th the patient, may be con taminated wi th blood o r sec retions from the anes thes ia prov ider's hands . Rec ommended c leani ng proced ures , i ncluding was hi ng th e b lad e and liquid chemic al s teril i zatio n, are discus sed in detail in Chapter 34. S ome bla des can be

s team autoc lav ed. S tea m autoc lav in g ma y reduce the luminance of fiberoptic blades ov er time (166 ,16 7). Disposable la ryngos cope blades and han dl es are av ai lable Fig. 18.3). W hen the enti re bl ade and hand le are dis pos able, the batte ry and /or light s ourc e are usuall y reusable . W hile some s tud ies s how th at some s ingle -us e plas tic blades perform l ess sa tisfac toril y th an reusable blades (168 ,169,170,171 ), s ome single-use blades were rated hi ghly by an es thes ia prov iders (1 69,172,173 ). Disposable metal bl ades may break more eas il y than reus abl e ones (174 ). Pl as tic la ryngosc opes hav e l ess poten tial f or denta l frac ture than me ta l blades (175). Disposable c ov ers a re av ailab le for the bla de or the entire blade and ha ndl e (Fig. 18.4 9). Howev e r, they reduc e i l lumina ti on (176,177). P .538

Flexible Fiberoptic Endoscopes

The f lex ible f iberoptic endosc ope (fibersc ope) is used to place and ev al uate place ment of tracheal , dou ble -lumen, tracheos tomy, and gas tric tubes and bronc hia l block ers ; check tube patenc y; ev aluate the ai rwa y; an d loc ate and remov e sec re tions (178,179,180,181,182 ,183). The flex ib le f ibe rop tic endoscope can be us ed with a v ideo c amera and sc reen.

Description
The f ib ers cop e (Fig. 18 .50 ) is c ompos ed of sev eral pa rts , whic h i ncl ude the ligh t sourc e, handle, and fl exible ins ertion porti on (184,185,18 6).

Light Source Handle with Batteries

A hand le wi th ba tteries that uses a ha logen li ght bul b is c ompac t, c onv enie nt, and i nexp ens iv e . Howev er, the il lumi nation wil l usual l y b e weake r than tha t from a separate s ource.

Separate Light Source

The l ight s ourc e is co nta ined in a separa te box , us es mai ns power, an d is connec ted to the s cope by a univ ers al (light trans miss ion ) cord. A bright l igh t wi th out muc h heat is produc ed. Ul trav iolet l ight is fi l te red in the f ib ers cop e but not i n the light sourc e o r trans mis s ion cord. W hen the c ord is attache d to an ac tiv e

l ight sou rc e and the o pen end ca n foc us the l i ght onto a f lammable material, a f ire can resu lt. Fi res a re disc ussed in detail in Chapter 32 .

Handle
The handle (c ontrol body , body ) (F ig. 18.51) i s the p art held in th e hand during use . It hous es the batteri es , if they are used as the powe r s ou rc e , or there ma y be a connec tor for a s eparate l ight s ource. Other p arts of the han dl e i nc lude the eyepi ece, foc us ing ring , work i ng channel port, an d the tip control lev er or k nob. By turn ing the focus ing (adjus ting) rin g, the image can be brough t in to focus . A c amera can be a ttached to the eye piece fo r remo te v iewi ng.

Figure 18.50 Flexible fiberoptic laryngoscope. Light is supplied from a separate source. The lever on the handle controls deflection of the tip in two directions. Two ports attach to the working channel. One is for insufflation or injection, and one is for suctioning. (Courtesy of Olympus Corp.)

View Figure

The tip (bending, an gul ation ) control lev er or k nob ma y be on the s ide of the body or a thumb-con trol led l ev er s ys te m on the bac k of the handle. B y turning this lev e r, the insertion cord tip can be f lexed or ex te nded in one plane . A f ul l range of mo tion can be ac hi ev ed by rotating the en ti re ins tru ment. Many fibers copes hav e a tipl ock ing lev e r that l ocks the tip in a des i red posi tion.

View Figure

Figure 18.51 Handle of flexible fiberscope. The syringe is attached to the working channel. At the bottom is the lever for controlling the tip. Above it to the left is the connection for the light source. At the top is the connection for suction tubing and the suction control. The eyepiece, to which a camera may be attached, is to the right.

P .539

Insertion Cord
The inse rtion c ord (shaft, tube) is th e porti on of the fi bersc ope that is ins erted into the patie nt and ov er whic h the trac heal tube c an be pas sed. It c ontains an imagetransmitting bundle, o ne or two l i ght-c onducti ng bundl es , two angula tion wi res , and so me times a work i ng channel . These are s urrounded by a protec tiv e wi re mesh and v inyl c ov ering. Circular d epth ma rks a re usu al ly present. This portion is fully submers ib le , whi ch faci li ta tes c leani ng. The outs ide diame ter of the ins ertion c ord determi nes the s mall es t s ize trac heal tube th at the cord can pas s throug h. The ins ide diame ter o f the tracheal tube shoul d be at leas t 1 mm la rge r than the inse rtion c ord outs ide d ia me ter. The connec tion of the han dl e to the ins erti on porti on is usual ly tap ere d to hold th e trac heal tube. The inse rtion c ord leng th v a ries . For trac heal intubation in adul ts , a 50-cm ins erti on co rd is usual l y sufficient. Double-l umen bronc hial and n asotracheal tube inserti on may requi re a length of 55 to 60 c m.

Image-conducting Bundle
The image -conduc ti ng (optic f iber, i mage tra nsmiss ion, imag e guide) bundle transmits the image f rom the dis tal lens to the eyepiece . The f ibe rs are arrang ed so

that the relati onsh ip of one fi be r to the other i s the s ame at eac h end of the bun dle . Suc h a b undle is c alled coherent a nd al lows a c lea r image to be transmitted. A l ens at the us er's end al lows th e imag e transmi tted by the fi bers to b e focused. Except at the ends where the f ibers are fused for s tre ngth, the bund le is fl exible but delicate. W he n b rok en, a f iber wi ll no longer pass i ts i mage, and the v ie wer wi ll s ee a bl ack do t in that f iber's loca tion.

Light-conducting Fiber Bundle

The l ight-conduc ting f ibe r (l ight gu id e, ligh t trans mis sion, i ll umination) bundle transmits l igh t from a p owerfu l sou rce wi th out p roduc ing dan gerous hea ti ng. Unlik e the imag e-c onduc ting bundl e, the fibe rs are not arranged i n a prec ise manne r. Th is i s known as a n inc oherent bundle.

Working Channel
Mos t scopes hav e a wo rk i ng (ins trumen t) c hannel that ex te nds th e length of the sc ope. This c an be used for s uc tio ni ng, injec ting sal ine o r medications , ins ufflating gases , or pas s ing ins trumen ts (s uch as forceps , brush, gui dewi re , or s tyl et).

Tip Flexion Cables

Two tip f lexion cables (angu lation wires , c ontrol wi res , tip-bending contro l wi res ) connec ting the tip to the bending k nob on the handle are placed along the s ides of the insertion cord.

Endoscopic Accessories
Acc ess ory dev ices to pro tec t the fi berscope from the teeth, k eep it in the mi dl ine, and d irec t i t to the v icini ty of the larynx a re of ten us ed. Thes e a re discussed in Chapte r 16. A ni pple from a baby bo ttle may be used in an a wake infant (187). Endoscopy us ing a supralaryngeal air way dev ic e is disc ussed in Chap ter 17. Ano the r use ful item is a dev ic e to sup port th e j aw (1 88,189). It is usef ul to h av e a cart for f ibe rop tic endoscopes (Fig . 18.52). This c art wi ll contain the v ideo ca me ra an d acces sories such as a v ideo rec ord er, l ight s ourc e, and a disp lay s c reen. A cabinet to s to re the fiberoptic s cope in suc h a wa y that it wi ll not be damaged is also an imp ortant part.

Techniques of Use
Intubation
W hen us in g a f lex ible f iberoptic sc ope for i ntu bation, the choic e of trache al tube is i mportan t (182,190,191 ,192,193,194 ). The tracheal tube wi ll b e mo re l ik ely to

adv anc e into the trachea if the la rges t sc ope that f its eas il y insi de the trachea l tube i s used (195,196 ). A tube wi th a tip des igned to minimize the dis tanc e betwe en th e f ibe rs cope and the tube's leading edge may pass more eas il y than a s ta ndard tube (197,198 ,199,200,201,202,203,204). A spi ra l embe dded tube may pass more easi ly than a tube with a p reformed curv e (2 05,206 ,207,208). W arming a s tanda rd trac heal tube ma y fac ili tate pas sage . A s leev e may be pl ac ed on the f ibersc ope to i nc reas e i ts d iame te r (209,210). An ai rwa y exchange c athete r th at fi ts ov er the en dosc ope may be us ed (211,212). A fibersc ope can be inse rted ei ther nas al ly or o rall y in awak e or anes thetized pati ents who are either b rea thing spontaneo usl y or being v entilated (213). A ltho ugh f ibe rop tic in tubation c an be performed in u nconsc ious indiv idu als , mos t authors recommen d tha t when possible i t be p erformed in the awak e patien t usi ng sedation and topica l anes th esia. Loss of c onsc io usness is assoc ia ted wi th a l oss of tone in the submandibul ar mus cl es that di rec tl y support the tongue and i ndi rec tly support the epiglottis . Bec ause this ins trumen t is ex pensiv e and del icate, great care mus t be taken to prev ent damage. A minor bl ow can break g las s fibers . As we ll , c a re mus t be tak en to av oid forceful bend ing alon g the c o rd. The inserti on portion s houl d not be wi th dra wn o r adv anced wi th the tip an gulated. Before use, the l ight sh ould be tes ted . The tip sh ould be treated wi th antifoggi ng so lution or be plac ed in warm wa ter (no t sali ne) for sev eral minutes bef ore use. A l te rna tiv el y, the tip can be bri ef ly he ld agai ns t the buc cal mucosa to warm the l ens . Hot ai r f rom a conv ectiv e warmi ng devic e (Chapte r 31) ma y be direc ted ov er the tip. The foc usi ng ri ng shoul d be adjus ted by v iewi ng s mall p rint at a d is tance of 2 to 3 c m. T he flex ible portion s hould be coated wi th a lubric a ting gel , but the l ubric ant s houl d not c ontac t the lens. Tubi ng for s uc tion or ox yge n ins ufflation shoul d be attac hed to the app rop ri ate port. P .540 Ox ygen s uppl ied through the work ing channel wi l l support patient ox ygenation , c lear sec retions , and defog the o ptics . Contro l l ev er f unc tion sh ould be assessed. The trachea l tube sho uld be adv anced up the sco pe and anc hored fi rmly on the wi der p ortion of the ins erti on cord.

Figure 18.52 Cart for endoscopic equipment. A: Front view. The monitor can be used to view the image at the end of the fiberscope. The light source is placed on the shelf. The cabinet at the right is used to store flexible endoscopes. B: Side view showing cabinet.

View Figure

The prox imal c ontrol s ec ti on is held in one h and wi th th e index finge r on the suc tion /insu ffla ti on port and the thumb on th e l ev er that c ontrols angula tion of the dis tal tip . The other hand holds the shaft of th e s cope and guides i ts adv ance. Optimal pos itioning for fiberoptic laryng osco py inc ludes ex te nding the c erv ic al sp ine rather than flex ion as rec ommended for d irec t laryngosc opy (214,215 ). Bec aus e the cables are no t s trong enough to lif t or disl odg e tissues , i t is impo rtant to hav e an ai r s pace at the end of the tip. In the anes thetized patient, v is ual i zatio n i s often diff icul t or i mpos s ible unless some means to ex pand the pha rynx is us ed. This may be ac compl ished by h av ing a sec ond person pu ll the tongue anteriorly o r elev ate the ja w (216,21 7,218,219,220 ). Oc cas ion all y, it may be necessary to lif t the l ary nx by grasp ing i t ex ternall y. A l te rna tely, a tong ue retrac tor or a rigid l ary ngos cop e c an be use d to pus h the tongu e forward (101,151 ,218,219,221,222,223,224,225 ,226). The awak e patient c an b e asked to s tick out h is or h er tongu e, whic h is then hel d g ently be twe en gauze b y an as s is tant. Spec ial airway s hav e been dev elo ped to a id f ibe rop tic in tubation . Thes e are dis cus sed in Chapter 16 . Disorienta ti on in the ai rway is bes t resolv ed b y s lo wly wi thdrawi ng the tip an d ex amining the area with gen tle up and down ti p deflec tion, by rotating the sc ope as a uni t, or by al tern ate ly adv anc in g the tip an d wi thdrawi ng it s li gh tl y. If the v ie w i s cons is tently f ogg y o r haz y, i rrigation wi th sa line and s uc tio n wil l us ually resolv e this p rob lem. Adherent sec retions may requi re the ins trumen t to be wi th dra wn and

the tip mechanically c lea ned wi th a mois t ga uze. If s uc tio n is being applied , it ma y draw ti ssu e ov er the sc ope tip. If bl ood or s ec retions a re present, the glottic opening may be located by us ing capnog rap hy (227,228) o r by placi ng a guide wi re pas sed retrograde through the work i ng c hannel (229,2 30). Retrog rade intuba ti on is d is cuss ed in Chapter 21. Pas s ing the trachea l tube ov e r the fiberscop e f reque ntly meets res is tance. Rota ting the tracheal tube 90 c oun terc lock wis e may be helpf ul (231,232 ,233,234,235 ,23 6). Other he lpful maneuv ers inc lude appl ying a ja w thrus t, app lying ex te rna l pressu re on the la rynx , and e lev ating the epiglottis by us ing a rigid lary ngos cope o r the f ing ers (102 ,237,238,239 ). A noth er method to ov erc ome res is tance is to ins ert a smal ler trac heal tube beyond the trachea l tu be tip P .541 (240,241 ). S ti ll another technique is to pas s a n airway ex change c atheter v ia the trac heal tube bes ide the flex ible scope until the tip of the c athete r is v isual ized near the c arina (242). If the tip of the fi berscope pro trudes through the trach eal tube 's Murphy eye, i t may not be pos sible to s li p the tub e off the endosc ope or to withdraw th e f iberscop e f rom the tracheal tube (2 43,244). The f iberscop e and tracheal tube may need to be wi th dra wn a s a unit. To av oid this probl em, the tracheal tube sh ould be thread ed onto th e fiberscope before endos copy , or the fibersc ope sho ul d be adv anced through the tube u nder d irec t v is ion, identify ing bo th the s ide and dis tal o penings and tak ing c a re to p ass the fibersc ope th rou gh th e d is tal one. T he endosco pe tip shoul d be in the neutra l pos ition as the tracheal tube is adv anced an d the f ibe rs cope is withdrawn. A v arie ty of tec hniques a re av ailable. The firs t is to th read a tracheal or doublel umen tu be with th e l ume n l ubricated ov e r the c ord un ti l i t abu ts the handle , adv anc e the f lex ib le po rtion unti l the tip enters the trac hea or bro nchus , then thread the tube ov er the endoscope. W i th the s econd techniqu e, th e tracheal tube i s fi rs t adv anced into the pharynx so that i t ac ts as a guide to bring the tip of the sc ope clos e to the e ntranc e of the larynx . The fibers c ope is pas sed through th e tube and into the trac hea, then the tube is threaded ov er it. A thi rd technique is to us e the f ibe rs cope to place a gui de wire or s tyl et into the trachea (245,246 ,247,248). The f ib ers cope is withdrawn , and a tracheal tube is pas sed ov e r the guide and i nto the trac hea. This ma y be es peci all y us eful in s mall patients . A

s tyl et may be ins erted alongs id e the fibers cope in th e tracheal tube, but this wi l l mean that the shape of the trac heal tube c anno t be al te red .

Oral Intubation
Oral i ntubation is consi dered more difficul t than nasal intuba tion. The tip enters the l ary nx at an acute angle to the glottis whereas v ia the nas al rou te, i t is at an oblique an gle . In tubation may be e asier i f used with an acc esso ry that wi l l protec t the ins trumen t from the pa ti ent's tee th, guide it into the midline, and k eep the tongu e f rom fal li ng bac k ward. Th ese methods a re disc usse d i n Chap ter 16. The i nsertion c ord is placed in the mi dl in e and adv anced u nder d irec t v is ion, c u rv ing downward a t the pos terior pharyngeal wa ll , seek ing the epiglo ttis . It is i mportan t that the ti p be k ep t in the midline as i t is adv anced . W hen the e pi glo ttis has been l ocated, the f ibersc ope tip is ro ta ted do wnward so that i t pass es beneath the epiglottis and is th en turned upward u ntil the v oc al c ords a re s een. Th e tip is then passed be twe en the c ords and adv anced s ev eral c entime ters into the trachea. Fo r bronc hia l intubatio n, the ti p is adv anc ed in to the desi red mains tem b ronchus . W ith the f iberscope tip in plac e, the lub ricated tube is adv anced ov er th e scope, whi c h func tions as a s tylet. The bev el s hould face pos terio rl y (2 49). The fibe rsc ope shoul d be used to v erif y that the tub e tip is co rrec tly posi tioned a nd th en wi th dra wn, l eav ing the tu be in plac e .

Nasal Intubation
Fi beroptic nasotracheal i ntubation is us ual ly easier than orotracheal intuba ti on becaus e mi dl ine pos i tion ing is eas ie r to maintai n, the patie nt cannot b ite the s cope , and the nas ophary ngeal anatomy na turally d irec ts the tube into the trac hea. It is as soc iated wi th l ess ce rv ic al spine motion than d irec t laryngosc opy or o the r methods of ai rway management (250). A nasopharyngeal airway may be us ed to l ubric ate and dilate the nasal pass ages , th en remov ed. The fibe rsc ope sh ould b e adv anc ed through the trachea l tu be before inse rtion, becaus e i t may not be possible to i nsert a tu be loaded ov er a fi bersc ope th rough a narrowe d nasal passage a fter s uccessful ins e rtion of th e f iberscope into th e trachea (251 ).

Tracheal Tube Exchange

To ex change a trache al tube, the ne w tube is threaded ov er the f iberscop e. In one tec hnique, the inserti on portion of the f ib ers cop e is adv anc ed into the tube to be replaced (252). As the old tube is pul led out, i t is cu t and remov ed f rom a round the f ibe rs cope . The new tube is then a dv anced i nto plac e ov er the f ibers c ope .

In an a lternativ e tec hnique, the ex is ti ng tube is v is ualized in the pha rynx by using the fiberscope and is fol lowed do wn to the lev el of the v ocal c ords (25 3). It may be adv is able to inse rt an ai rway exc hange c atheter through the old trachea l tu be before remov ing it to al low f or v entil ation or rei ntubation ov er it if the new trac heal tube can not be p assed into the trache a (252 ). The c uff on the exis ting tube is then defl ated, and the f ib ers cope is adv anced through the spac e around the tube pas t the cords . T he old tube is remov ed, and the new one is adv anced ov er the f ibe rs cope into p osi tion .

Extubation
The f ib ers cop e c an be use d to ev aluate a diff icul t ex tubation (254), es pec ially in a pati ent wh o would be diff icu lt to re in tubate . The f ibe rs cope is ins erted through the tube and the tu be withdrawn f rom th e larynx . The work i ng ch anne l can be us ed to i nsuff late ox ygen. If n eces sary, the tube can be reinserted ov er the f ibe rs cope .

Advantages
Fl exible fi beroptic endos cop y is a v ery rel iable approac h to diff icul t ai rwa y mana gemen t. It c an b e used oral ly or nasa lly and when access to the ai rway is l imi ted. It c an be us ed in patients of a ny age and in any posi tion. The f lex ible f iberscop e c an be use d to intubate patien ts who are diff ic ul t or i mposs ib le to intuba te wi th a ri gid la ryngosc ope (178,246 ,255,256,257,258,259,260,261 ). It i s espec iall y us efu l fo r patients wi th uns table c erv ic al sp in es and for those at h ig h risk fo r dental damage (262,263 ,264). It can be P .542 us ed in cases whe re the patient can not b e p laced i n the supine posi ti on (265). It can be us ed by an anes thes ia prov ide r who has l imi ted use of the left arm (48). Ins ufflati ng ox ygen or j et v entilatio n through the suc tion c hanne l may prov ide additi onal time when diff icul ty i n pass ing the trac heal tub e into the trache a is encoun tered.

Disadvantages
The f lex ible f iberoptic endosc ope is mo re ex pens iv e, f ragile, and diffic ult to use and c lean than a rig id laryngoscope (266 ). F ibe rop tic in tubation requi res more time than intu bation wi th a rig id lary ngoscope, so i t is of limi ted use in eme rge ncy

s i tuations or during a rapid s equenc e induc tion. It re qui res c ons ide rab le ex perience and s ki ll ma intenance . It does no t al low di rec t man ipula ti on of ai r way s truc tu res . Intubatio n wi th the f lex ible f ib ero ptic sc ope may be difficul t or i mpos sible wi th ce rtain p ati en ts (267,268 ). A major i mpedi ment to its succes sful us e is th e presenc e of s ignif icant amounts of blood and/or sec retions . If alumin um h ydrox ide or magnes ium tris ilicatebase d antaci ds are used, the re may be a whi ti sh f ilm o n the end of the sc ope that i mpedes v is ion (26 9). Gas tric dis tens ion a nd rup tu re, tens ion pneumo -thorax , a nd subc utaneous emph yse ma h av e all oc curred af ter ox ygen i nsuff lation th rou gh the wo rk ing ch anne l (270,271 ,272,273). Laryngeal trauma may occ ur wi th f ibero ptic i ntu bation (274 ). Th is is frequently as soc iated wi th diffic ul ty in pas si ng the trachea l tube in to the trachea ov er the f ibe rs cope .

Cleaning
Cl eaning procedures wi ll v ary wi th the partic ula r scope being used. It is important to read the ins truc tion manual ca reful ly , bec aus e i mproper c are c an c ause ex tensiv e and ex pens iv e d amage to the sc ope. Cle aning methods are discus sed in more detail in Cha pte r 34.

Indirect Rigid Fiberoptic Laryngoscopes Bullard Laryngoscope

Description
The B ullard laryng osc ope (F ig. 18.53) has a ri gid metal blade s pec iall y sha ped to follow the c ontour of the P .543 orophary nx and res t beneath the e pi glo ttis . Fi beroptic bundles for i llumination and operator v ie win g a re hous ed in a s heath on th e pos terior aspec t of the blade . A v iewi ng arm wi th e yepiec e ex tends at a 45-d egree angle from the handle. A snapon diopter f or us ers with unc o rrec ted v is ion is av ailable . Later v ers ions hav e an eyepi ece that c an be focus ed. A v ideo came ra ca n be a ttach ed to the eyepiece fo r remote v iewing .

Figure 18.53 A: Bullard laryngoscope with a battery handle and a introducing stylet. Between the handle and the stylet is a port for attaching a syringe or inserting a wire. B: Patient end. At left is the light channel. In the middle is the working channel. The image-transmitting bundle is at the right. If an extender is used, it is slipped over the tip.
View Figure

The power s ourc e ma y be batte ries and a halogen bul b in the hand le or an adaptor for a flex ible fiberoptic cable th at is conn ected to a high-i ntens i ty light sourc e. A work in g chan nel ex te nds f rom the s cop e b ody to the point where the l ig ht bundles end a t the tip. It can be us ed fo r suc tion, oxyge n i ns uff lation , admi nis tration of local anes thetic s or sali ne, o r pass age of an airway ex change or j et v enti lation c athete r (275,276 ). The end nea res t the handle has a Lue r lock connec tor for attaching a medica tion s yringe. Three s i zes a re av ailab le: pediatric , pediatri c long, and adul t (F ig. 18.54). The pedia tric v ers ion is used f or babies . The pediatric long v ersi on is used f or patients up to 8 to 10 yea rs of a ge. The adul t v ersi on is intended fo r adul ts and chi ldren ov er 8 to 10 years but may be us efu l in younger patients (277,2 78). A plas tic blade ex tender i s av ail able and may be es pec ial l y us eful i n ta ller pa tients (2 79). The ex tender i s also useful when intu bating ma le patients but is of ten no t helpf ul or ev en a h in drance when i ntubati ng fe males . The pediatric handle may be us ed with the adul t blade to dec reas e the we igh t.

Figure 18.54 Bullard laryngoscopes. The handle contains batteries that power a halogen light bulb. Note that the curve of the adult blade differs from the other two. (Courtesy of Circon ACMI, a division of Circon Corp.)

View Figure

Figure 18.55 Introducing stylets for Bullard laryngoscope. The adult version is on the left and the pediatric version on the right. (Courtesy of Circon ACMI, a division of Circon Corp.)

View Figure

Two s tylets are av ailab le . They a re des igned to fol lo w the c on tou r of the l ary ngos cop e b lade and attac h to the body of the laryngosco pe.

Introducing (Intubating) Stylet

The introduci ng s tyl et (Fig . 18.55) has a curv e of approx imate ly 20 degrees to the l eft near the tip to b ring the end of the s tylet i nto the fiel d of v is ion an d to faci li tate passage o f the trac heal tube into the la ry ngeal in let. It attac hes near the base of the v iewi ng arm wi th a spring-loaded, l oc king mecha nis m.

Multifunctional Stylet

The mul tifunc tional s tylet (Fig . 18.56) c ons is ts of a l ong, hollo w tube that is curv ed at the tip to d irec t the tube i nto the field of v ision . It ma y attach to the v iewing arm by us in g a s c re w c lamp . Its hol low c ore c an serv e as a guide for a flex ibl e f ibe rs cope , trac heal tube ex changer, or s ma ll catheter. It c an als o be used to ins til l l ocal anes thetic in to the trach ea.

Techniques of Use
Bul lard laryngoscopy can be pe rformed i n th e a wake pa ti ent with topic al anes thesia or i n an anesthetized P .544 pati ent wh o is ei th er paral yzed or breathing spon taneous ly (280 ,281). For patients who are breathing s pontaneous ly , oxy gen can be ins uffl ated through the work i ng channe l (282,283,284 ). Th is wi l l help to bl ow s ec retions awa y f rom the v ision bundles and prev ent foggi ng (285). Jet v enti lati on can be admin is tered by us ing the work i ng c hannel (286,2 87,288). Suc tion ca n a ls o be a pplie d to the channel , but this may pu ll tissue agai ns t the end of the fi beroptic bundle and impede v is ion.

Figure 18.56 Multifunctional stylets with screw clamps. The adult version is at the top. The pediatric version is at the bottom. Note the end of the lumen through which a wire can be inserted. (Courtesy of Circon ACMI, a division of Circon Corp.)

View Figure

Before use, the image bundle wi ndow a t th e d is tal end of the sh eath s hould be wi ped c lean . In tubation c an be acc ompl is hed wi th a s tyleted trache al tube, a trac heal tube with a d irec tional ti p, or one of the Bul la rd s tyl ets . A P arker or spi ral embe dded tube is a good choic e (27 9). If the ped iatric introduci ng s tylet or the mul tif unc ti onal s ty le t is used, the trac heal tube connec tor mus t be remov ed before i t is backl oaded ov e r th e s tylet.

Before the trac hea l tu be is plac ed on the s ty let, a s mall amo unt of lubrican t sho uld be ap plied to the s tyl et and the tube . W arming the tube ma y make pas sage into the trac hea eas ie r. The tracheal tube is threaded ov er the lubric ated s ty le t s o that the tip of the s tylet protru des through the Mu rph y eye. The pediatric and mul tipu rpose s tyl ets shou ld be posi tioned near the tracheal tube tip bu t not p rotruding th rough the end. The s tylettrac hea l tu be combi nation is fas tened to the laryng osc ope. This b ri ngs the v ertical part of the s tylet be hind and to the right of the laryngosc ope i n the groov e formed by th e b lade anteriorly a nd the l ens housi ng in the middle. W hen properl y loaded, the tip of the introduci ng s tyl et shoul d be v isi ble a t the f our o 'c lock position. The multipurpose s tyl et tip ma y not be v isible. If the p ati en t is large, i t may be he lpful to add the pl as tic tip ex tender to the tip of the scope. An attempt should be made to remov e the blade ex ten der after i t cl ic ks i nto plac e (289). It may c ome off i n the mouth if inco rrec tly attached (290 ). Antifog s olu tion s hould be a dded to the tip of the f iberoptic bundl e (279). A n al te rna tiv e is to place the la ryngos cope at the en d of the tubing f rom a conv ec tiv e warmin g d ev ice (Chapter 31 ) fo r a few min utes prior to in tubation (291). This wi ll warm the blade and p rev ent f ogg ing. The user is posi tioned at pa tient's head and the sc ope held in the left hand wi th the handle h ori zontal. T he patient's head is ke pt i n the neutral pos i tion .

Oral Intubation
E i ther by manually opening the mouth or wit h the aid of a tongue bla de, the Bul lard blade is inserted in th e midl ine of the oral cav ity, wi th the han dl e hori zonta l. The handle s ometimes impi nges upon the ches t during ins ertion, espec ia ll y in obese pati ents . In these c as es , i t can be remov ed prior to inserti on and then reconnec ted or a sh ort handle us ed (279,2 92). W hen us in g the introduci ng s tylet, i t c an be pos itio ned to the ri gh t of the blade as i t i s ins erted into the mouth. The finge rs of the left hand that holds the s cope can mane uv er the s tylet b ehind the b la de once it i s in the mouth. One mis take that many users mak e is try ing to look th rou gh the e yepiec e as the blade is bei ng i nserted. W hen doin g this , the sc ope of ten g ets turned to o ne si de or the other, and the cl inici an is unab le to identif y where the tip is placed. It i s rec ommended th at the blade be i nse rted wi thout looking through the eyep iece but wa tc hing that the s cope remains in the midline duri ng inserti on. A s the blade is adv anced, the handle is rota ted to the v ertical pos i ti on so that the blade sl ides ov er the tongue. Once the

blade has been rota te d a round the tongue and i t feels that it has seated in the pharynx , upward mov ement along the axis of the hand le is exerted to v isua li ze the l ary nx . T his is th e fi rs t time tha t the c li nic ian s hould look through the eyepiece. If properl y placed, eithe r the epig lottis or the glottis sho ul d c ome in to v iew th rough the eyep iec e. The bla de can be us ed to l if t the epiglottis di rec tly or indi rec tl y. Occ asi ona lly, i t may be nec es sary to dis pl ace the blade sl ightly pos teri orly and then lif t v ertica lly to op ti miz e v isual i zation. P .545

Onc e the lary nx is v is ual ized, the s tylet tip is manipulated with the lef t ha nd until i t points between the c ords . Under v is ual i zatio n, the tub e is adv anc ed off the s tylet unti l the cuff pas ses the v oc al co rds . The lary ngos cop e and s tyl et are then remov ed . If the tube does not ente r the trachea , th e tube a nd s tyl et must be wi th dra wn a nd the s ty let placed thro ugh the Mu rph y eye before another a ttempt a t i ntu bation is made . In so me c ases , the tip of the tracheal tube wi l l impac t on the righ t arytenoi d or aryepi gl ottic fo ld (293). If th is oc curs , the sc ope and s tylet s hould be repos itioned to the left. If th is does not work , anothe r maneuv er is to rota te the tube 180 degrees , p osi tion ing the end of the bev el near the blade and h av ing the tip of the s tylet protru de through the trac hea l tu be. If the tube pass es through the v ocal c ords but cannot be adv anced p as t the lev el of the c ric oid ca rtilage , th e l ary ngos cop e s hould be ang led forward s li ghtl y. If the multif unc tiona l sc ope is used, the tip may no t be v isible when th e scope is properl y placed. An intuba tion c a the ter c an be adv anc ed s ligh tl y until it is v isuali ze d. The c athete r is then plac ed through the v ocal c ords and the tracheal tube adv anc ed ov er the c a the ter. Th e mu ltifunc tiona l s tyl et do es not hav e the mane uv erabi l ity th at the in troduc ing s ty let aff ords .

Nasotracheal Intubation
A s tylet is not us ed for naso tracheal intubati on. A di rec tional tip trac heal tube ma y be us efu l in this s i tua ti on (294,295 ,296). The la rynx is v isuali zed by usi ng th e Bul lard laryngoscope ins erted through the mouth, and the patient's head pos ition and thyroid carti lage are manip ul ated to allo w the trac heal tube to be adv anced between the v ocal c ords unde r direc t v isi on. Ano the r method used for nasal intubation was desc ribed fo r an infan t wi th Treacher Coll ins s yndrome (297). The pa tient was fi rs t in tubated ora ll y. A s mall tube

changing ca the ter was placed though the nose and under di rec t v is ion manipula ted alongsi de the o rotrachea l tube. Th e ora l tube was remov ed , and a nas al tube was passed ov er the catheter i nto the larynx .

Advantages
The B ullard laryng osc ope is usef ul in patients wh o a re di fficul t to intubate, i ncl uding those in whom head and neck mov ement is limi ted or undes i rable ; those wi th l imi ted mouth openi ng, poor dentition, pharyngea l or l arynge al pa thology, o r fac ial f rac tu res ; and the morbid ly ob ese (276,282 ,285,298,299,300,301,302,303 ,304,305,306 ,307,308,309 ). It has p rov ed us eful in c hildren wi th Treac her Coll ins and P ie rre-R obin s ynd romes (297 ,310,311). It causes l ess ce rv ical s pi ne mov ement than c onv entional l aryngos cop y (41,312 ). Compared wi th f lexi bl e fi beroptic intubation, the Bul lard laryngoscop e prov ides quick er i ntubations (281,313). Other adv antages inc lude ra pidity of intubati on, low ri sk of failed intuba tion or trau ma to lips and teeth, and less discomfort i n the awa ke patient than di rec t l ary ngos cop y (287 ). It is mo re resis tant to pro blems with sec retions and more rugged than a flex ib le fibers cope . W hile there is a learning c urv e, this laryngoscope can s oon be us ed quickl y and effic ien tl y. A sk il led ass is tan t is no t needed to perform a ja w thru s t or to hol d an ai rwa y i n place . It requ ires a mouth opening of only 7 mm. Later v ers ions are ful ly i mmers ib le f or c leaning .

Disadvantages
Us e of the Bu llard s cop e requ ires experi ence and maintenance of sk il ls . The equipment is somewhat ex pens iv e. Cleani ng is somewh at inv olv ed. Intubation ma y tak e sl ightly longe r than with a rigid laryngoscope (3 14). It c anno t be use d by an anes thes ia prov ider wh o has l imi ted use of the left a rm (48 ). Us ing a trac heal tube l arger than 7.5 mm may c ause the in troduc ing s ty le t to be displac ed pos terio rl y, wh ic h ma y make in tub ati on more diffic ult (315). Certain trac heal tubes (e .g., the metall ic l as er tube) (Chap ter 19) wi ll not f it ov er the s tylet. Double -l umen tubes wi l l not f i t the s ty lets . In these cas es, another tub e c an be i nserted by usi ng the Bul lard, a nd a tube excha nger can be us ed to insert the desired tube. The re are rep orted cases where the b la de ex tender was ac cidental ly dislodged becaus e i t wa s not s ecurel y a ttach ed (290,3 16,317 ).

WuScope

Description
The W uSc ope (Fig . 18.57) c ombines a ri gid, tubu lar blade and a flex ib le f ibe rs cope . It can be ba ttery p owered or us ed with a fi beroptic li ght s ource (31 8).

Flexible Fiberscope Portion

The f ib ers cop e has sho rt l ight- and image-trans mitti ng f ibe rop tic bundles and tip defl ec tion contro l. The uppe r segme nt of the inse rtion c ord has the s ame configuration as the c one-shaped W uScope hand le .

Blade Portion
The blade portion has three d etacha ble metal p arts : handle, ma in bl ade, and biv alv e element. The biv alv e element can be attached o r rel eas ed from the handle and the dis tal main bl ade by separate i nterloc k ing mecha nis ms . The handle is a c one-shap ed tube tha t receiv es the fi bersc ope at the top and connec ts to the main blade at the bas e. The h andle-to -blade angle is 110 degrees . An ex ten der ad jus ts the l ength of the fibersc ope insertion po rtion for the adu lt blade . The main blade and b iv alv e ele ment are ana tomicall y shaped. W he n pos i tion ed together, they form two passageways : a l arg er one f or a s uc ti on ca the ter or trac heal tube and a smal le r one for the fibersco pe (Fig. 18.58). An ox yg en channel i s alongs ide the s lot for the fiberscope. P .546

Figure 18.57 WuScope. Shown from left to right are the fiberscope, the large-adult bivalve element, the large-adult main blade, the adult bivalve element, the adult main blade, the extender, and the handle. (Picture courtesy of ACHI Corporation.)

View Figure

Figure 18.58 Three channels of the WuBlade for the suction catheter and tracheal tube, fiberscope, and oxygen.

View Figure

Diff erent s izes of blades and biv alv e elemen ts ca n be used wi th the hand le . The adult blade can ac commodate a trac heal tub e of up to 8.5 mm, whi le the l arg e-a dul t blade c an c ontain a 9 .0 -mm tube .

Techniques of Use
The W uSc ope can be used to f ac il itate in tub ati on in the awake or anes theti zed pati ent. The pa tient's head sh ould be in the neutra l pos ition.

The c omponents a re as sembled (F igs . 18.59 , 18.60). If the adul t bl ade is used, the ex tender s houl d be attac hed to the handle. The trachea l tube sho uld be lubricated and ins erted until the Mu rph y eye is jus t bey ond the P .547 dis tal edge of the biv alv e el emen t. Us e of th e tracheal tube that is des ign ed for use wi th the Fas trach intubatin g laryngeal mas k may fac il i ta te pas sage through the glottis (204). The s uc ti on or a irway ex change c atheter sh ould also be lubrica ted . Ox ygen tubing should be c onnec te d to the ox ygen channel . Antifogging solution shoul d be appl ied to the lens .

Figure 18.59 WuScope, partially assembled, showing fiberscope and assembled handle, blade, and bivalve element.

View Figure

Figure 18.60 Fully assembled WuScope with a tracheal tube in the tracheal tube passage, a suction catheter in the tracheal tube lumen, and oxygen tubing connected to the oxygen port.

View Figure

Orotracheal Intubation
Holdi ng the me tal porti on of the handl e, the scope is inse rted in to the patien t's mouth in the midline muc h l ike an oropha ryn geal airway . The handl e is gradua ll y rota ted toward the o perato r as th e b lade adv ances ov er the tongue . The opera tor l ooks through the eye pi ece and i den tifies the pos terio r pha ryngeal wal l and epiglottis as the sco pe is adv anc ed. If the epiglottis blocks the v iew, the dev ic e may be wi th dra wn sligh tl y and re adv anced to lif t it up. A suc tion c a the ter in the trac heal tube pass agewa y can be used to re mov e ex cess iv e blo od or sec re ti ons . W hen the la rynx comes into v ie w, th e d is tal main b lad e is adjus ted, if necessa ry, to al ign the tracheal tube with th e g lo ttic opening. Once the trache al tube is p roperl y positioned , it is adv anc ed in to the trac hea. A l te rna tiv el y, a s uc tio n catheter or ai rwa y exch ange c ath ete r may be adv anced through the trac heal tube into th e trac hea. An intuba tion guide that c an be maneuv ered may be usefu l (319). This then serv es to di rec t th e tracheal tube through the glo ttis . The biv alv e element is remov ed f irs t. The handle, main blade , and f ibe rsc ope are then remov ed as a uni t, l eav ing the trach eal tube i n place.

Nasotracheal Intubation
For naso tracheal i ntubati on, the biv alv e elemen t is no t attac hed to the sc ope. After a trach eal tube is pas sed into the oropha rynx through the nos tri l, the sc ope is positioned ins ide the mouth in a manne r s imilar to ora l in tu bation . The concav e unders urfac e of the dis ta l main b lad e is di rec ted to s traddl e the trac hea l tu be and

to guide it toward the glo ttis . The trac heal tube is adv anc ed in to the trachea, and the dev ice is remov ed f rom the mouth .

Tracheal Tube Exchange

The W uSc ope can be used to exchange a trac heal tub e (320 ). A new trac heal tube moun ted in the W uS cope is adv anced into the oropharynx and posi tioned anteri or to the ex is ting tube. A cathe ter is pas sed thro ugh the trac heal tube and into the l ary nx bes ide the old tube. The ex is ti ng tube is withdrawn, and the new tub e is adv anc ed in to the trachea ov er the ca the ter.

Advantages
The W uSc ope has been us ed succ ess ful l y to pl ace bo th trac heal and double-l umen bronc hia l tubes in diff ic ult-to-in tubate pati en ts (318,321 ,32 2,323,324,32 5,326). Its tubular s truc ture p rotec ts the fi beroptic l ens f rom bl ood, s ec re tions , and redun dant soft tissue . This may make i t espec ial ly us eful in the pa ti ent with airway obs truc tion resul ting f rom hema to ma or edema. No forceps or s tylet is needed, so the risk of ai rwa y injury is low. S uc tioning a nd ox ygen adminis tration can be pe rf ormed s imul ta neous ly . Unl ike flex ible fiberoptic endoscop y, on e c an v iew the trac hea l tu be as i t adv anc es through the glottic opening in to the trac hea. The handle-to-blade an gl e fac il itates entry i n obese patients and in those wi th barrel ches ts , short neck s, or large breas ts . T here is no need for head ex tensi on or tongu e l ifting. Mi nima l jaw o pening is nec essary. P .548

Figure 18.61 UpsherScope. The larger photograph shows the delivery slot for the tracheal tube. The blade is attached to a conventional Upsher handle. The inset shows the opposite site of the blade with the eyepiece. A fiberoptic cable from the light source is attached to the handle. (Courtesy of Mercury Medical.)
View Figure

Disadvantages
Limitations include a high in itia l cos t, the ne ed for new c leani ng and d is infec ting routines , the need to learn and mas ter new sk il ls , and the ti me requi red to as semble and disassemble the dev ice . The f lex ib le f ibers cope may b e damaged . It may no t be use ful in a patient wi th a s ev erel y l imited mouth open in g. Application of c ric oid p res sure dec reas es the ease of intuba ti on when usi ng this dev ic e (32 7).

UpsherScope
Description
The UpsherSco pe (Fig. 18.6 1) consis ts of a C-s haped metal blade, s hape d to approxima te the curv e of the oropha rynx (32 8). The open pa rt o f the C to the righ t ends abou t 1 inc h from the end of the blade. The d is tal part of the blade has an upward cu rv e. To the lef t are two tubes that carry f ibe rop tic bundles . Both bun dles end wh ere the semici rc ular channel ends . Pro xi mall y, the v iewi ng bu ndle termin ates i n a n eyep iec e with a foc us ing ri ng whi l e the l ight bun dl e mak es c ontac t wi th the f ibe rop tic ligh t source at the ha ndle. A n Ups her h andle mus t b e used. A remote l ight sou rc e c an be used. A camera can be attached for remote v iewin g. It is presentl y av ailabl e onl y i n an adul t s i ze. A p ediatric v ersion is said to be in dev el opmen t.

Techniques of Use

P rior to i ntubation, the v iewi ng fiberoptic b undl e should be treated with an antifogging sol ution. The trachea l tu be should be l ubricated and place d in the deliv ery s lot wi th the tip not q ui te protruding f rom the dis tal end of the channe l (F ig. 18.62 ). Ins e rting a bo ugie through the trac heal tube s ignifican tl y imp rov es the chances of suc ces sful intubation (329 ). The bla de is c lipped to the handle and the v iewi ng l ens focus ed. Head and nec k flexi on wi ll inc rease the probabil ity of succes s . The s cope s houl d be in troduc ed c en tral ly into the mouth. A jaw li ft is us ual ly helpful . Occ asi ona ll y, c hes t impedanc e ma y make it nec essary to introduce the sc ope sidewa ys , then rotate i t to a c entral pos i tion . It is then adv anc ed along the orophary ngea l curv e. When the larynx comes in to v iew, the sc ope tip is p osi tioned under the epiglottis , and the sc ope is elev ated to a lign P .549 the lo wer part of the blade wi th the arytenoid c artil ages . The trac heal tube, bougie, or a irway exc hange catheter is then adv anced un der di rec t v is ion be twe en the v ocal co rds . The sc ope is the n remov ed from the tube and rotated o ut of the mou th.

Figure 18.62 UpsherScope with tracheal tube loaded onto it.

View Figure

Figure 18.63 Shikani optical stylet. Both the adult and pediatric stylets can be attached to the same handle. Note the tube stop and the connection for oxygen tubing.

View Figure

If the tube is diff ic ul t to adv anc e, this c an of ten be c orrec ted by rotating the trac heal tube 90, further f lex ion o f the head on the nec k , modif ic ation of the v ec tor of l ift, ro tati ng th e tip of the s cop e to the left or rig ht, or pas sing a gui de wi th subs equent pass age of the trac heal tub e over i t (328,329 ). The blade sometimes rolls of f the tongue to the s ide. W hen this occ urs , a paramedian appro ach should be atte mpted.

Advantages
The UpsherSco pe is us eful to i ntubate patients with diff ic ult airway s withi n a reasonable time (328). It c an be used wi th a ll sizes of adul t trac heal tubes . It can be cleaned by us ing the S teris s ys tem.

Disadvantages
In routi ne in tubation , the UpsherSco pe has demo nstra ted no adv an tag es ov e r conv en tiona l la ryngos copy . The time nee ded to perform intubation and the number of a ttempts hav e been s ignificantl y l onge r and highe r with th e Ups herScope (330). The UpsherSco pe is no t s ui table for n asotracheal i ntubation. S ec retions can obscure the v ie w (328,329 ).

Optical Intubating Stylets

A numbe r of dev ices that combi ne fiberoptic i magi ng wi th an intubati on s tyl et hav e been desc ribed (331,332 ,3 33,334,335 ,336,337,338 ,33 9,340,341,342,343,344). These are referred to as optic al i ntubating s ty le ts , optic al s tylets , intubating f ibe rop tic s tylets , s tylet lary ngoscop es , o r v i sual scopes . S ome hav e a mechanism

to alter the shape of the s tylet duri ng use. Mo s t can be attac hed to a v ideo transmis si on s ys tem s o that i ntuba ti on can be observ ed on a moni tor. S ome hav e a port f or ox ygen insuffla ti on, drug adminis trati on , or s uc ti on . Some are battery operated . Others requi re a separate li ght s ource, a nd some can be us ed ei th er way . Some ca n be used wi th a f ib ero ptic han dle for a ri gi d blade.

Description
Shikani Optical Stylet
The S hik ani optica l s tyl et (S eeing Optic al Styl et, S OS ) (F ig. 18.63) is a s tainles s s teel mall eable s tylet (336 ,337,345,346 ,347). It c omes i n a pref ormed J -s hape bu t can be b ent a t the ti p. It has a handle , eyepi ece, adjus table tube s top, and integral port f or insufflati ng ox ygen through the tracheal tube. The eyepiece has a f ixed foc us on the area around the tip of the fiberoptic bund le. It c an be us ed wi th sev eral lig ht sourc es . The re is both an adul t and a pe dia tric s ize. The adul t s ize wil l fi t a trache al tube of 5.5 mm or l arger. The pe di atric s ize wil l f it a tube of 3 mm or larger.

Bonfils Retr omolar Intubation Fiberscope

The B onfi ls intubation f ibers cope (Fi g. 18.64) is a nonma lleable s tylet l aryngoscope wi th a 40 dis tal curv e (348). It h as a 5-mm outside diameter an d a leng th of 40 c m. A 6.0 mm or l arger trac heal tube can be inserted ov er i t. It h as a mov ab le eyepi ece as wel l as a s li de adapte r fo r s tabi li zi ng the trache al tube. The adapto r has a connec tor to adminis ter ox ygen du ri ng intubatio n. It can be us ed with batte ries or a separate f iberoptic l ight sou rc e.

Techniques of Use
P rior to i ntubation, antifoggi ng agen t is p lac ed on the lens or the s tyle t is wa rmed i n wate r or sa li ne. It s hould P .550 be i nserted in to the tracheal tube wi th out i ts tip protrudin g pas t the tip and then f ix ed to the tub e. W ith a pediatri c trac heal tube, i t may be nec ess ary to remov e the connec tor.

Figure 18.64 Bonfils intubating fiberscope.

View Figure

The patient is plac ed in the neutral pos ition or wi th a pi ll ow und er the head . If sec re tions are presen t, they s hould be remov ed before proceedin g further. A rig id l ary ngos cop e o r ja w thrus t s hould be use d to lif t th e epiglo ttis (336 ,34 4,347,349). It may also be he lpful to grasp the tongue and d raw i t out of th e mouth . The ha ndle is held i n the righ t han d and the s tylet ins erted into the mouth in the mid line and adv anc ed in to the hypo pharynx jus t beyond th e tip of the epiglo ttis . The s tylet is then adv anc ed unde r direc t v ision through the v ocal c ords . Fo r some pa tients , i t may be necess ary to apply ex ternal pressure on th e larynx . If sec retions are a problem, insuff la ting ox ygen may improv e th e v ie w. If orientation is los t, the scop e shoul d be withdrawn unti l orien ta ti on is re-es tabl is hed . W hen an intratracheal pos ition is ac hi ev ed, th e tub e s houl d be adv anced into the trac hea. The s tylet is remov ed by roll ing the handle to ward the patient's ches t, followi ng the curv e. It s houl d not be pulled s traight ou t. A retromol ar app roach is s ometimes used (3 50). The sc ope is ins erted be twee n the cheek and the molars on the pati ent's right s ide wi th the end of the sc ope po inting toward the midl ine . An optical s tylet can be us ed v ia a Fas trac h Intuba ti ng Laryng eal Mask A irway (ILMA ) (351 ). It c an a ls o be used as a l ightwand. It can be us ed to c hec k tracheal tube pos ition. It may be us ed to place a double-l ume n endob ronchial tube (352) o r to direc t a s uc tion c atheter i nto a mains tem bronc hus .

Advantages

Optic al s tyl ets are rel ativ ely easy to use for rou tine and diffic ul t intubations , al th ough prac tice wi ll b e required to achieve and ma intain profic ienc y (307,332 ,334,335,336,337,340,343,344 ,346,347,353 ,354). Intubation wi th this dev ic e may be s uc cess ful af ter fai led direc t la ryngosc opy (350). Si nce the trachea can be v is ualiz ed, esophagea l intu bation s houl d not occu r. Th e inc idence of sore throat and the inc rease i n heart rate are less th an with conv enti onal laryngosc opy (332,340 ,355,356). The ris ks of de nta l trauma an d s of t tiss ue damage wi l l be reduc ed if a c onv ention al lary ngos cope is not used in conj unc tion wi th the optic al s tyl et. The us e of an optic al s ty let ma y res ul t in less c erv ic al sp ine mov ement than whe n c onv entional l aryngoscop y is us ed (35 7). The optical s tylet is mo re portabl e, rigid, and rugged and c osts less than a f ibe rs cope . Howev er, bending may damage the fiberoptic f ibers . It may be a useful al te rna tiv e whe n a f ib eroptic endosc ope is n ot av ailab le.

Disadvantages
Intubatio n time ma y b e l onger than wi th conv en tiona l la ryngos copy (335 ). Intubatio n is fas ter than wi th the intuba ting LMA -Fas trach, but the time to v enti lation is shorter wi th the ILMA -Fas trach (342). The ini ti al c os t of th e moni tor, l ight sou rc e, and as soc ia ted equipment is high. Sec retions o n the l ens may c ause i ntu bation fai lure (334,340 ). The majo r li mitation is that i t ca nnot be ori ented in a prec ise di rec tion . Nasa l i ntubation c anno t be perfo rmed wi th s ome of these dev ic es .

Video Laryngoscopes
A v ideo l aryngos cope c an be c reated by attac hing a v ideo sys tem to a f lexi bl e f ibe rs cope or an optic al s tylet. Sev eral la ryn gosc opes that are s peci al ly des igned to work with a v ideo s ys tem are c ommerc ially av ai lab le (Fi g. 18.65). V ideo l aryngoscop y has many adv antages . The dis played an ato my is magn if ied, and a larger v iewi ng an gle is prov ided. The ope rator an d assis tant can c oo rdi na te thei r mov ements because eac h s ees the same i mage on the moni tor (358). T he abil ity to projec t the image seen th rou gh the laryngoscope makes i t a good teac hing tool , P .551 al lowin g the superv isor to moni to r the intubation proces s mo re effec tiv ely (359,360 ,361). Pos i tioning the moni to r ov e r the pati ent's ches t allo ws the intubator to wo rk an d observ e in one axis (359).

Figure 18.65 Video laryngoscope stand. The whole unit is portable. (Courtesy of Saturn Biomedical.)

View Figure

Us ing a v ideo l aryngoscope ma y res ult in less neck mov ement than whe n usi ng a conv en tiona l la ryngos cope , depe nding on the particular l aryngoscope (362). It al lows the a nes thes ia prov ide r to maintai n a dis tance from the pa tient duri ng i ntu bation, and this c ould make i t us eful in p ati ents who hav e infec tious dis eases (363). In one c ase , th e rec orded intubation was us ef ul in demons trating to the pati ent that the intubation had been performed properly and was not respons ible fo r the dislocation of the ary tenoid c arti la ge (36 4). In addi tion to a llowi ng laryngos copy a nd in tubation to be v isual i zed, it c an be used to observ e bougie plac emen t (3 65,366), mov ement of the v ocal cords af ter thy roid su rge ry (3 67,368,369,3 70), v erif y trac heal tube p osi tion, and aid in trac heal tube ex change. A limi tation of these dev ices is the need fo r a v id eo-endoscopy moni to ring sys tem, so i t may not be sui ta bl e for use outsi de a heal th c are fac il ity. Howev er, mos t operati ng sui tes are equipped wi th v ideo-endos copy mo nitorin g s ys tems to wh ic h these dev ices can be connec ted.

Figure 18.66 GlideScope. Note the 60-degree angulation of the blade. (Courtesy of Saturn Biomedical.)

View Figure

GlideScope
Description
The Gl ideSc ope (Fig. 18.66) has a mi ni ature di gi tal c ame ra on the unde rs ide of a plas tic blade. A light-emi tting dev ice (LED) moun ted b eside the c amera p rov ides i llumi nation. The b lad e has an embe dded an tifo gging mechanis m and a 60 bend at the midp oi nt. As a resu lt, the v iew f rom the came ra is dif fe ren t from the one seen whe n looking into the mouth . The image is transmi tted v ia a cabl e to a monitor sc reen. A portable Gl ideSc ope that can operate on ba ttery power a nd one s uppl yi ng a c olor i mage are av ailabl e (371). The Gl ideSc ope is av ailable in adul t and pedia tric s izes (neonate, inf ant, and c hild).

Use
Imme rsi ng the blade i n l uk ewarm wa ter f or a few mi nu tes befo re using i t may i mprov e v isi on (372). It c an be used as a c urv ed or s traight blade . The use of a s tyl et i n the trac heal or do uble-l umen tube is rec ommended. The a ngle on the s tylet s hould b e a t leas t 50 to 60 deg rees (37 3,374,375,37 6,377). A mal le able s tyle t whos e shape c an be c hanged du ri ng us e may be h elp fu l (3 78). W ith the head in a n eutral pos i tion , the Gli deSc ope is ins erted in the midl ine . In pati ents with limi ted mou th ope ni ng or l imi te d head/neck mov ement, it may be helpful to insert th e laryngosc ope ups ide down and then ro tate i t c oun te rc loc k wi se (372). It is helpful to identify the uv ula and ensure tha t it is cente red on the moni tor before adv anci ng the scope around the tongue (3 79). The blade shoul d be

adv anc ed anterior to th e epiglo ttis . A f ter the tip is in the v al lecula, the sc ope is gently elev ated . Intubatio n occas ional ly fails despi te an exce llent laryng eal v ie w (378,379 ,380). This may be ov erc ome by inserti ng the trach eal tube upside down, rotating i t wh ile it is P .552 i nserted, us ing a trachea l tube with a blunt tip , changing the s tylet's c urv e, s light wi th dra wal of the l aryngos cope, wi thd rawing the s tylet, relax ing the lary ngos cope elev ation, appl ying ex ternal laryngeal p res sure, inse rting a tube nas al ly , or i nserting a bougi e foll owed by rail roadi ng the trach eal tube ov er i t (363,369 ,372,379,382).

Figure 18.67 Video Macintosh. The fiberoptic bundle is inserted into the blade. The blade can be removed for cleaning.

View Figure

If the Gli deSc ope is l ef t insi de a patient for an ex ten ded period of time, there is a theoretic al ris k of damag e to the tissues , as the glas s wi ndow wil l be hotter than 41C (106F). The refore, the GlideScope mus t be remov ed after intubatio n is co mple te.

Evaluation
S tudi es show that the Gl ideScope yields a c omparable or s uperio r glottic v ie w co mpared with direc t la ryn gosc opy (363,371 ,377,379,383 ,384,385,386 ,387). It has been used s uccessful ly in both anes the ti zed and awak e pa tients wi th difficul t ai rwa ys , inc luding foll owi ng fail ed fiberoptic intuba tion (3 83,388,389,3 90,391). It caus es less c erv ic al sp in e mov ement tha n the Mac intos h b lade (42 ). The lea rning cu rv e ap pears to be rapid (379,385,392 ). Ho wev er, i t may not be sui table for us e

wi th ne onates (393). In s ome cases , i t may be diff icul t or i mpos si bl e to pas s the trac heal tube desp ite a good v iew of the glotti s (61 ,382).

Video Macintosh Intubating Laryngoscope

The V ideo Mac in tosh intubating l aryngoscop e (Fig. 18 .67) has a Macintosh b lad e attached to the handle and the image-l ight b undle th readed through a smal l metal guide in the b lad e and adv anced two th irds of the length of the blade (3 59). Antifog so lution s hould be p lac ed on the tip of th e image-l ight bundle. It may prov ide a better v i ew th an a tradi ti ona l Macintosh laryngoscope (394).

Angulated Video-intubation Laryngoscope

The angled v ideo intu bation laryng oscope (AV IL) has a plas tic blade wh ose tip is angulate d at app rox imatel y 25 deg rees (344). T he v ertical fl ange is f lattened . A thin channe l leads f rom th e handle to the blade tip and p ermi ts f lex ible fiberscope i nsertion . It has prov en useful in chi ld ren requi ring manual in-li ne neck s tabi li za tion (362,395 ).

Tooth Protectors
A tooth protec tor (mouth guard, mouth protec tor, dentgua rd) (Fi g. 18 .68 ) is plac ed ov er th e upper tee th to p rotec t them f rom the la ryngosc ope blade . It ma y als o prev ent the blade from getti ng cau ght in a gap betwee n the teeth. Use of a protec tor does not g uarantee safety f rom dental trauma (396 ,397). Althou gh it wil l prev ent di rec t trauma to th e s urfac e of the teeth, i t cannot prev ent transmiss ion o f press ure to the roots . Too th protec tors a re av ailab le in d iffe ren t des igns (Fig. 18.57) and a re fashioned f rom a v arie ty of ma teri als . A c us tom tooth protec tor, professi ona ll y made f rom an i mpress ion of the patient's teeth, c an prov ide s ignifican t protec tion (398). A tooth protec tio n dev ice may be attached to the laryng oscope bl ade (399,400,40 1). These dev ic es may make i t harder to v isualize the larynx and may make trac heal tube inserti on more diff ic ult beca use of lac k o f space (396). They s lightl y inc rease the in tub ation time (402). Cutting off pa rt of the rig ht si de of the protec tor or usi ng a trans parent p rotec tor ma y dec reas e thes e proble ms . It may be nec ess ary to remov e the pro tec to r before i ntuba ti on can be accomplishe d. P .553

Figure 18.68 Tooth protectors. (Courtesy of Sun Med.)

View Figure

Complications of Laryngoscopy Dental Injury

Damage to teeth, gums , or denta l pros thes es is the mos t f requent anes thesi arela ted i nsu rance cl ai m (403,404 ,405,406,407 ). In addi tion to cos me tic disf igurement and dis comfort, there may be pul monary comp lications if the disl odg ed too th or f ragment is as pirated. P rof use blee ding ma y res ul t (408). A tooth or p ros thetic dev ic e may be chipped, broken , loose ned, o r av uls ed. The teeth mos t lik el y to be dama ged are thos e tha t hav e been res tored o r weak ened through periodontal dis eas e, but soun d teeth may also be affec ted (40 9). The uppe r i ncis ors are mos t f requently i nv olv ed (405,410). This is mos t of ten c aus ed by usi ng the tee th as a fulc ru m po int for the lary ngoscop e while el ev a ting the e pi glo ttis . The c ondi tion of each pa tient's tee th shoul d b e carefu ll y ass ess ed preoperativ ely to i dentify possi bl e p rob lems . Inqui ry s hould be made concerning v ul ne rab le denta l repai r work or l oose or carious tee th . Anatomical c ondi tio ns in the mouth and pharynx that can c ause di fficul ty shou ld be no ted . The patient s houl d be adv is ed beforeha nd if there is lik el y to be a problem. A s uture may be plac ed around a l oose tooth to prev ent i t from enteri ng the ai rway i n th e ev ent it becomes dis lodged . In patien ts 4 to 11 years old , the d eci duous te eth may be eas ily dis lod ged. If such teeth a re loose , remov al before or during an es thes ia may be indicated . W hen there are gaps between the uppe r front tee th, a p ortion of a tracheal tube or other dev ice may be us ed to brid ge th e gap, o r a tooth protec tor may be us ed.

Keeping a parti al up per dentu re i n p lace may prev ent the laryngoscope from s lippi ng in to gaps between teeth. If a too th, fragmen t, or dental appl iance is dis lo dged , foreign bod y as pi ration shoul d be a major conc ern . An immed ia te sea rc h s hould be conduc ted , s tarting with an ex amin ation of the oral c av i ty a nd the a rea su rround ing the pati ent's head. Ches t and n eck radi ographs mus t be taken if the fragmen t is no t recov ered . Diff erent types of to oth d amage may oc cur (403 ). These requi re different trea tmen ts . A qual if ied dentis t or o ral s urgeon should be cons ul ted . If a tooth is av uls ed, i mmedi ate rep lacement in i ts origin al posi ti on and s tab iliz ation wi l l i nc reas e the chances of suc ces sfu l re implan tati on (41 1). Too th protec tors may p rev ent dental damage. P lac in g adhes iv e tap e o r other materials on the fl ang e of the b lade has also bee n reported to be effec tiv e (401,412 ). Ins e rting the lary ngos cope b la de from the left c orner of the mou th may spare the inc isor teeth (150).

Cervical Spinal Cord Injury

Agg res siv e head posi tioni ng du ring in tubation , espec ial ly head or neck ex tens ion, has the poten ti al to caus e damage in the pati en t with an uns tab le ce rv ica l spine (413). A n uns table ce rv ic al spine c an be ass oc iated with a c ongeni tal weak ness , malfo rmation, f rac tu re, o r disloc ati on of a cerv ical v erte bra or o ther con di tions such as os teoporos is , c onnec tiv e tissue disease, or tumor (312,414 ,415). Case reports that desc ribe neurol ogic deterioration after intubation ex ist (416,417,4 18), al tho ugh the contribu tion of laryngoscopy to these i njuries remains debatable and th e ov erall risk a ppea rs to be low (4 18,419,420,4 21). It ma y be adv isable to inv olv e the neurosurgeon to witnes s the intubation so tha t a maneuv er that c oul d cause harm can be av oi ded . The re are no data to sugges t tha t any mode o f ai rwa y i nterv ention is s uperio r in dec reas ing sec onda ry injury or improv ing ou tc ome (312 ,422). Manua l in -l ine i mmobili zation reduces s pinal mov ement and the l ikel ihood of secondary in ju ry (39,312,422 ,423,424,425 ,426,4 27,428,429). A ce rv ic al c ol lar should be not b e relied on for this purpose.

Damage to Other Structures

Reported i nju ries to the upp er ai rway inc lude abrasi on; hematoma; and lips , tongu e, palate, pharynx , hypopharynx , la rynx , and esophagus l ac era ti ons . A co mmon occu rrenc e is roll in g the upper or lowe r li p between the teeth and the l ary ngos cop e b lade as th e b lad e is inserted. Os teomyel itis of the ma ndibl e has

been rep orted (430). The l ingual and/or hypogl os sal nerv e may be in jured (431,432 ,433,434,435). A rytenoid s ub luxation may occur (43 6). A nte ri or temporomanidibular j oint (TMJ ) d is loc ation may oc cur (437 ,4 38). Patien ts wi th TMJ derangements P .554 of ten s ta te that thei r problem began f ol lo win g general anes thesia (439 ). The re is a s ignif icant inc rease in the ra te of airway -rela ted c omplic ati ons as the numb er of l aryngoscopic a ttempts inc reases (440 ). The A meric an S ociety of Anes thes iologis ts (A SA ) Task Fo rc e on the Mana gemen t of the Diffic ult Airway has recommen ded l imi ti ng to three attemp ts (441,442 ).

Shock or Burn
If a laryngosc ope l igh t that is lef t ON con tac ts the patie nt, a burn may resu lt (443,444 ). A sho rt c irc ui t c an res ult in the hand le an d b lade rap id ly heating (445,446 ). The ti p of a fi bersc ope app li ed dire c tl y to the sk in may produce a burn (447).

Swallowing or Aspirating a Foreign Body

Cas es hav e been reported i n which the bul b o r other pa rt of a laryngoscope was as pirated or s wall owe d (448 ,449,450,451 ,45 2,453). It is importan t to mak e ev ery ef fo rt to find these foreign b odies . If they ca nnot be found in the oral cav i ty or around the patient's h ead, x -rays of the ches t a nd nec k s hould be taken . Part of a tumor may be disl odged in to the ai rway a nd may beco me impl anted (454).

Laryngoscope Malfunction
The mos t commo n l aryngoscope malfunction is li ght fai lure . This may be th e res ult of a de fec tiv e po wer s ourc e, lamp, or sock et; incorrec t ass embl y; or poor c ontac t between the blade and hand le. Fiberoptic lary ngos cop es are more rel iable because the halogen lamp's us efu l lif e is longe r tha n an ord ina ry l ig ht bulb, and the lamp is us ual ly in the handle rathe r than in the bla de. Va rious pa rts of the blade and handle may break (452,455,456,457,458 ,459,460,461 ,46 2,463,464,465,466,467,468 ). Mi sass embl y may res ul t in fai lu re (469). A pre use check wi ll detec t mos t malfunc tio ns . An ex tra hand le and b lade should al ways be immediatel y av ai labl e. Neglec ting to obs e rv e thes e p rec autions cou ld spell disas ter, esp ecial ly wh en a rapi d sequenc e induc tio n is to be performed (470,471 ).

Circulatory Changes
Laryngosc opy may resul t in s ignifican t inc reases in bl ood press ure and heart rate , al th ough thes e c hanges are les s tha n thos e assoc iated with trac heal intubation (219,472 ,473,474,475,476).

Disease Transmission
The ris k of infec tion tra nsmission, partic ul arly Creutzf el dt-Jakob disease, v ia l ary ngos cop es , is unk nown but is a matter of concern to anes thesia prov iders (177,477 ,478). The use of a d is posa ble blad e c ov er or dis posable lary ngos cope blade has been encouraged (172,1 76,479).

References
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432. S i lv a DA , Col ingo KA , Mi ller R. Lingual n erv e injury fol lowi ng la ryn gosc opy . Anes thes iology 1992;76:650651 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 433. Mirenda J . Lingual ne rv e injury . Anes th esiology 1992;77:220221. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 434. Ev e rs KA , E indhov en GB , Wierda J MKH. T ransient ne rv e d amage followi ng i ntu bation for tra ns -sph enoidal hypophysec tomy. Can J Anes th 1999;4 6:1143 1145. 435. Lang MS , Waite PD. B ila teral l ingua l nerv e injury af ter la ryngos copy f or i ntubation. J Ora l Maxi l lofac S u rg 200 1;59:14971499 . [Cross Ref] [Med li ne Link ] 436. Jens en NF. A ryteno id injury and subl ux ation i n anes the tic prac tic e. Am J Anes thes iol 1995;22:14514 8. 437. Ras tog i NK , V ak haria N, Hung OR. Perioperativ e ante ri or dis loca tion of the temporomand ic ular join t. An es th A nal g 1997 ;84 :9 24926. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 438. Sch wartz A S . Dis loca tion of the mand ible: a c ase report. A ANA J 2000;68:507513. [Med li ne Link ] 439. Upton LG. Oral an d max i ll ofaci al s urg ic al cons iderations in the diffic ul t ai rway . In: Norto n ML , B ro wn A CD, eds . A tlas of the dif ficul t ai rway. A sourc e b ook . S t. Louis : Mosb yYea r Book , 199 1:1291 44. 440. Mort TC. Emergenc y tracheal intuba tion: c ompl ic ations assoc iate d with repeated laryngoscop ic attempts . A nes th An al g 2004;99:60761 3. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

441. A meric an Soc iety of Anes thesiologis ts Tas k F orc e on Management o f the Diff ic ul t A i rway . P rac tic e g uidelines for management of the dif ficul t ai rway. Anes thes iology 1993;78:597602 . [Fu ll tex t Link ] [Cross Ref] 442. Anonymous . P rac tic e guidel ines for management of the d iffic ult air way. Anes thes iology 2003;98:269277 . 443. Koh THHG, Coleman R. Oro pharyngeal b urn i n a n ewborn baby: new co mplica tion of l ight-bu lb lary ngos copes . An es thes iolog y 2 000;92:277279. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 444. Tou ng TJK , Donham RT, Sh ip ley R. Thermal bu rn caused by a lary ngos cope. Anes thes iology 1981;55:184185 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 445. S iegel LC, Garman JK . Too hot to hand le. A l aryngoscope malfunction. Anes thes iology 1990;72:10881089. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 446. A lexander PD, Meurer-Laban M. Rec ha rge able optima lary ngoscopes . B r J Anaes th 1995 ;74 :724725. [Cross Ref] [Med li ne Link ] 447. v an der W alt J H, Gas smanis K . Sk in bu rns f rom a cold li gh t sou rce . Anaes th Intens Care 1990;18:11311 5. [Med li ne Link ] 448. Joh nson J D, Lov e J D. Li ghts out! A prev entab le c omp licati on of en dotrac hea l i ntu bation. Ches t 19 85;87:701702. [Med li ne Link ] 449. Perel A , K atz E , Dav idson J T. Fi berbronch osc opic retri ev al of an aspi ra ted l ary ngos cop e bulb. In te nsiv e Care Med 1 981;7:143144 . [Cross Ref] [Med li ne Link ]

450. Inc e Z, Tugcu D, Coban A . An unusual complicatio n of endotrac heal i ntu bation; inges tion of a laryngoscope bul b. P ed E me rg Care 1998;14 :275276. 451. Naumov sk i L, Sc haffer K , Fleisher B . Inges tion of a la ryngosc ope lig ht bul b during deliv ery room resus c itation. Pedia tric s 1991;87 :58 158 2. [Med li ne Link ] 452. Babb S , Mann S . Dis posable la ry ngos cope blad es . An aes thes ia 2002;57:286 287. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 453. S mi th TE , d 'Hu ls t D, Ri rie DG. A we ll -ferti l ized bulb should blos som. Anes th Analg 20 04;99:622. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 454. E ipe N, Dildeep A , Samuel T. En dobronc hial metas tas is : an anes thetic co mplica tion? Can J A nes th 2005;52:550551 . 455. Daley H, Amoros o P . Dange rous repairs . An aes thesia 1991;46:997 . [Cross Ref] [Med li ne Link ] 456. Des me ul es H, Trembl ay P . La ryngosc ope blade break age du ri ng in tubation . Can J A naes th 1988 ;35 :202203. [Med li ne Link ] 457. S mi th MB , Camp P . B rok en la ryngosc ope. Anaes thes ia 1989 ;44 :179. [Cross Ref] [Med li ne Link ] 458. Roc co M, Chatwani A , Shupak R. Laryn gosc ope han dl e ma lfunc ti on. Anes thes iology 1986;65:107 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 459. Vernon J M. A broken laryngosc ope. A naes thes ia 1 990;43:69 7. [Cross Ref] [Med li ne Link ] 460. Anonymous . Dispos able la ryngosc ope blades ma y bre ak during us e. B iomed Safe S ta nd 1994;24:1 011 02.

461. Gibson S , K elly K . Pa ediatric laryngosc ope blade failure. Anaes th In tens Care 1996;24:724725. [Med li ne Link ] 462. Hodg es UM. Damage to a la ryngosc ope. Anaes thes ia 1988 ;43 :71 1. [Cross Ref] [Med li ne Link ] 463. K ris hna M. A potentia l complication assoc iate d with laryngosc ope. A nes th Analg 19 97;84:938939. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 464. Paters on J G. L aryngos cope b reakage . Can J A naes th 2000;47:927 . [Med li ne Link ] 465. Jol ly DT, Hawthorn G, W an T. Fi beropti c l aryngoscope bl ade. Can J Anaes th 1998;45:382. [Med li ne Link ] 466. Jol ly DT, Germsheid R, Gal lant B , e t al. Unex pec ted laryngoscope fai lure . Can J Anes th 2002;49:637 . 467. Jeff ers on P , P erk ins V , E d wards V A , et al . P robl ems wi th disposab le l ary ngos cop e b lades . A naes thes ia 2 003;58:385386. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 468. S tokan M. Mec hanica l fa il ure of a la ryn gosc ope handl e. Anaes th Intens Ca re 2004;32:439440. [Med li ne Link ] 469. B risk in A , Hoffman B , Iosc ov ich A . Le t th ere be l ight (preferabl y on the inside): misass embl ed lary ngos cope blad e as caus e o f fa il ed intu bation. Anes thesi ol ogy 2005;103:1103. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 470. Anonymous . Laryng osc opes . Tec hnol A nes th 1982;3 :4. 471. Anonymous . Fail ing batteries caus e b rain damage: $2 .4 mill ion awarded. B iomed S afe S tand 1982 ;12:91.

472. Sch rad er S , Ov assapian A , Dykes MH , et al . Cardiov ascular c hanges durin g awa ke ri gid and fibe rop tic laryngosc opy. Anes thesi ology 1987;6 7:A 28. [Fu ll tex t Link ] [Cross Ref] 473. Norris TJ , B a ysinge r CL. He art rate and bl ood press ure response to l ary ngos cop y. The i nf luenc e of laryngosc opic techni que . Anes th esiology 1985;63:560. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 474. Buc x MJ L, Van Gee l RTM, Sc heck P A E , et al . Ca rdi ov ascular effec ts of forc es applied du ri ng la ryngos copy . The importance of trac heal in tubation . Anaes thes ia 1992;47:1029103 3. [Cross Ref] [Med li ne Link ] 475. Barak M, Ziser A , Gree nberg A , et a l. Hemodynamic a nd catecholamine respons e to trachea l i ntubation: di rec t lary ngos cop y c ompared wi th f iberoptic i ntu bation. J Clin Anes th 2003;15:132136 . [Cross Ref] [Med li ne Link ] 476. Xue FS , Zhang H, S un HY, et a l. B loo d p res sure and hea rt rate c hanges during in tubation : a compa ris on of d irec t laryng osc opy and a f ibreop tic method. Anaes thes ia 2006;61:444 448. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 477. B i rks RJ S . Saf ety matters . Ana esthes ia 2001;56:823 824. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 478. A rns tein F . New v aria nt Creutzfeld t-J akob dis eas eis ou r prac tice s afe? Anaes thes ia 2001;56:585. 479. So EC. Us e of a condom as a bl ade c ov e r for laryngosc ope. A nes thes iology 2000;93:906. [Fu ll tex t Link ] [Cross Ref]

[Med li ne Link ] P .560

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. T he best position for intu bating an adult p atient w h en using a rigid laryngosc ope is A . S houlders elev ated B . Flex ion o f the lowe r c erv ical s pine and ex tension of the head C. Flat on the bed D. P ress ure exerted on the top of the head V iew A ns we r2. Techn iques for inserting a tracheal tube w ith a flexib le fibe roptic en doscope inc lude A . V isu ali zi ng the la rynx with the f iberoptic endosc ope, plac ing the e ndos cope into the la rynx , and s liding the trache al tube ov er th e endos cope B . P lac ing a bougie in the trachea unde r direc t v isi on by using the fi beroptic endosc ope and then i nse rtin g the tube ov e r th e bougie C. P lac ing the tracheal tube into the phary nx as a guide for pl acement of the f ibe rop tic endosco pe and then adv anc ing the end oscope and then the tube into the l ary nx D. P lac ing the tracheal tube into the l arynx wi th a bl ind tec hnique an d c heck ing i ts position with th e f iberscope V iew A ns we r3. If the trache al tu be canno t be advanced over a flexible endoscop e into the trachea, w hich of the follow ing man euvers may be helpful? A . W i thdrawing the tube and rota ting i t 90 degrees B . E lev ati ng the mandible C. Apply ing ex ternal press ure on the lary nx D. Us ing a rigid lary ngos cope to elev ate the e pi glo ttis

V iew A ns we r4. Reported comp lications assoc iated w ith la ryngoscopy include A . To oth d amage B . Th e fiberoptic s cope protruding through the Murphy eye C. Dama ge to the cerv ic al spinal c ord D. Dama ge to the recurren t la ryngeal nerv e V iew A ns we r5. Wh ich mane uvers are use ful for nasal intubation w ith a fibe roptic scope? A . Us ing a nasophary nge al ai rwa y to di la te the nos e B . Introduc ing the tube through a spec ially d esigned mas k C. Us ing a sl i t nas opha ryn geal airway to introduc e the tube D. Introd ucing th e fi bersco pe ora lly and us in g i t to gui de the tube f rom the nose V iew A ns we r6. In w hich situatio ns w ould it be advantageous to use a sho rt rigid laryng oscope handle? A . W hen c ric oi d pressu re is being appli ed B . W hen the patient is in a body c as t C. W hen the patient has la rge breas ts D. W hen the nec k is f roz en in the flex ed pos ition V iew A ns we r7. Techn iques that may be helpful to in tuba te a patient w hen it is diffic ult to place a conventiona l la ryng oscope b lade in the mouth beca use of a n anato mic abnormality inc lud e A . Inse rtin g the blade i nto the mou th wi tho ut the hand le attache d and then attaching the hand le B . Inse rtin g the blade i nto the mou th late rall y and mov ing i t to the in tubating position C. Inse rting the blade wi th a 90 -degree turn and th en tu rning i t to the in tubating position D. Inse rting the blade 180 d egrees f rom normal and rotating i t to the no rmal i ntu bating posi ti on as i t is being inserted V iew A ns we r8. Wh en intubatin g c hildren, A . Ce rv ica l flex ion is frequ ently no t nec essa ry B . Th e head shoul d be ex tended 70 to 85 C. The s houlde rs f requentl y need to b e e levated D. It wi ll often be nec ess ary to extend the head ov er the end of the bed V iew A ns we r9. Wh ich of the state me nts be low are a dvantages o f fibe roptic intu bation ?

A . It is easi er than rig id lary ngos cop e i ntuba tion B . Th ere is less cerv ical spine mov ement C. Ins truments used are robus t D. It i s usef ul f or dif ficul t intubations V iew A ns we r10 . P rob lems associated w ith flexible fibe roptic intubatio n include A . Ca rdiac dys rhythmias B . Greater leng th of time to perform C. Hypertensi on D. The p res enc e of bl ood and s ec retions V iew A ns we r11 . Complica tions ass ociate d w ith insufflatin g oxygen throu gh the w orkin g c hanne l inc lude A . Gas tric rupture B . Te nsion pneumothorax C. Subc utaneous emph yse ma D. A i r embo lism V iew A ns we r12 . S ituatio ns in w hich the Bullard laryngosc ope w ould be helpful include A . Limi ted mouth op eni ng B . Treac her Co ll ins s yndro me C. Morbid obes ity D. Cerv ical s pi ne f rac tures V iew A ns we r

Chapter 19 Tracheal Tubes and Associated Equipment

P .562

The trachea l tube (endotrac hea l tu be, intratracheal tube, trac heal ca the ter) i s a dev ic e tha t is i nse rted th rough the larynx i nto the trac hea to c onv ey gases and v apors to and f rom the lungs . P .563

General Principles Resistance and Work of Breathing

A trach eal tube plac es a mecha nic al bu rden o n the s pontane ousl y breathing patient (1,2 ,3). It adds res is tanc e and is us ual l y a mo re i mportan t fac to r in de termining the work of breathi ng th an th e b rea thi ng s ys tem (4). This is pa rtic ularl y imp ortant in pedia tric pa ti ents (5 ). Sev eral fac tors help to determine the res is tance to g as fl ow i mposed b y a tracheal tube.

Internal Diameter
The s ing le mos t important fac tor in determin ing the res is tance to gas fl ow i s the i nte rna l diameter (ID) of the tube and its connec tor. A tube wi th a thick wal l wi ll of fe r more resis tanc e than a thin-wa ll ed tube wi th th e same outer di ameter (OD). The wa ll thickness to tube diame te r ratio is greater in s mall tubes , leading to a greater inc reas e in res is tanc e (6). Res istance wi l l be inc reas ed if a suc tion ca the ter, f ibers cope , or other dev ice is pass ed th rough the tube or if s ec retions l ine the inner wal l .

Length
Dec reasi ng tube len gth lowers its resis tance , but the dec rease is much less th an could be accomp lis hed by inc reas ing the ID (5,7,8). Mos t d is posable tubes a re suppl ie d l onger than nec ess ary and may be cut to a more su itable le ngth to reduc e resis tance .

Configuration

Curv es in the tube or connec tor i nc reas e res istanc e, bu t if the cu rv e is gen tle, the i nc reas e is smal l (5,6 ). K ink ing inc reases res istance . The resis tance of s wiv el connec tors is s imi la r to that of curv ed c onnec to rs (9).

Dead Space
The trachea l tube and connec tor c ons ti tu te mec hanical dead s pace , whic h was disc ussed in Chap te r 7. B ec ause the v olume of a trachea l tube and i ts c onnec to r is us ual ly less than that of the n atu ral pass ages , dead s pac e is normal ly reduced by i ntu bation. In p ediatric patients , howev er, long tubes and c onnecto rs may inc reas e the dead s pac e . Spec ial lo w-v o lu me p edi atri c conn ec tors a re av ail able.

Tracheal Tube System Tube

Materials
The materia l from whic h a tracheal tube is manuf ac tured should hav e the fol lowin g charac te ris tic s (10 ,11 ):

Low cos t Lack of tis sue tox ici ty Trans parenc y Eas y s te ri li za tion and du rab ili ty wi th repea ted s teri li zati ons (unless disposable) Nonflammabi l ity A smooth, nonwettable surfac e ins id e and outs ide to prev ent sec re ti on buildup, al low eas y pas sage of a s uc tion c atheter or b ronchos cope , and prev ent trauma

Suffic ien t body to mai nta in i ts shape duri ng inserti on and to prev ent oc c lusi on by to rs ion , k ink ing, or c omp res si on by the c uff or ex ternal pressure Suffic ien t s trength to allow thin wa ll c ons truc tion The rmoplas tic i ty to conform to the patien t's anatomy whe n in plac e Lack of reac tion with lubric ants and anes the tic agen ts Latex -f ree

To date no subs tance wi th a ll of th e abov e tra its has been found. Red rubbe r tubes are s ti l l av ail able. Thes e c an be c leaned, s teril ized, and reused mul tiple ti mes . Howev e r, they a re not transp are nt, the y harden and become s tic ky

wi th ag e, hav e poor resis tanc e to kink ing , bec ome c logged by d ried sec retions more eas il y than plas tic tubes , and do not sof ten a ppreci ably at body te mperatu re. Latex al lergy is anoth er pos si bl e p rob lem (Chapter 15). Pol yv inyl ch lori de (PV C) is the subs ta nce mos t wid ely used i n d is posable trachea l tubes . It is rela tiv el y inex pens iv e an d is c ompatible wi th tiss ues . Tubes made from PV C are les s likel y to k ink than rubbe r tubes . They are s tiff eno ugh fo r in tubation at room tempe rature but s often at body temperature , so th ey tend to co nfo rm to the pati ent's upper a irway. P ri or to us e, a PV C tube may be co ol ed to make i t more fi rm during in tubation or warmed to fac il i ta te place ment ov er a fibe rsc ope (12). PV C tubes hav e a smooth s urfac e that faci li tates pass age of a suc tion c athete r or bronc hosc ope. Thei r transparenc y permi ts obse rv a tion of the tida l mov eme nt of respi ra to ry mois ture as we ll as ma te rials i n th e lume n. S ilico ne is us ed in s ome tracheal tubes . A l though more ex pens iv e th an PV C, tubes made f ro m i t can be s teri lized and reused.

Tube Design
The international /U.S . s tandard (11) c ontains requiremen ts an d recommenda ti ons for trac heal tubes , inc lud ing the material f rom wh ic h the tube is c ons truc ted, the i nsi de diameter, length, inflation s ys tem, c uff, radius of c urv ature , mark ings , packaging, and labeling (10). A typic al tracheal tube is s hown in F igu re 19.1. The internal and ex ternal wa lls shoul d be c i rc ular. A tube P .564 who se lu men is ov al or e lli ptic al in s hape is more prone to k inki ng th an one that is round.

Figure 19.1 Cuffed Murphy tracheal tube.

View Figure

The mac hine (prox imal ) end rec eiv es the c onnec tor and proj ec ts from the pa tient. It may be possible to shorten the tub e a t this end. The patient (trac heal or dis tal ) end (ti p) i s ins erted into the trac hea. It usual l y h as a sl anted porti on ca lled the beve l. The angle of the bev el is the acu te angle betwe en the bev el and th e l ongitudinal ax is of the trac heal tube (Fi g. 19.1 ). Mos t commo nly , the opening of the bev el fac es to the left when v iewi ng the tub e f rom i ts c oncav e aspec t. This is because th e tube i s usua lly in troduc ed from the rig ht, and th e larynx is eas ie r to v isuali ze wi th the bev el faci ng to the lef t. The desi gn or orientati on of the pa tient end is i mporta nt when the tube is adv anced ov er a fi bersc ope or i ntroduc ing c atheter. Inserti on is eas ier i f the bev el faces back ward or the ti p is s peci al ly d esigned to min imi ze the dis ta nce betwee n the sc ope and the tube's leading edg e (13,14,15,16 ,17 ,18 ,19 ,2 0,21,22,23,24). A hemispheric al bev el reduces nas al morbidi ty du ring nas otracheal intuba tion (25). Durin g nasa l in tubation , tu rning the tracheal tube so that the bev el f aces up may av oid the tip from bec oming impi nged on the ep iglottis (23). Fi gure 19.1 shows a hole through the tub e wall on the s ide o ppos ite to the bev el. This is k nown as a Murphy eye, and a tube wi th thi s fea ture is c alled a Murphy or Murphy -type tube. The purpose of the eye is to prov id e an alternate pathway f or gas fl ow i f the bev el becomes oc cl uded (26,27). Forceps , tube ch ange rs , and f ibe rs copes ma y inadv ertently adv anc e through a Murphy eye and bec ome cau ght (28,29,30,31). Us ing a tu be with a Mu rph y eye wi ll reduce trauma du ri ng nas al i ntu bation (32). A theoretica l disadv antage is th at sec re ti ons may ac cumulate in the

eye. Some tubes hav e an add itional e ye abov e the bev el . Th is may prov ide an additi onal measure of s afe ty if th e tub e acciden tal ly adv ances i nto a ma ins te m bronc hus . Trac heal tubes lac king the Murphy eye are k nown as Magi l l or Magil l -type tubes . If a Murphy eye is not p res ent, th e cuff can be pl ac ed c loser to the tip. Th is may dec reas e the ri sk of inadv ertent bronc hial in tubation . The A me rican Soc ie ty f or Tes ting and Materia ls /Internati ona l S tanda rds Organi zation s tanda rd (1 1) requi res that a radi opaque marker is placed at th e pati ent e nd or along the entire length of the tube to aid in determination of tube position af ter i ntuba tion.

Special Tubes Cole Tube

The Co le tube is s hown i n Figure 19 .2. It is an unc uf fed tube. The patient end has a smal ler diameter than the res t of the shaft. Th is prov ides s ome pro tec tion agains t i nadv ertent bronc hi al intuba tion. Cole tubes are s i zed according to the ID of the trac heal porti on. The tube s hou ld no t be inserted far enough for the shoulder to contac t the la rynx , as this could damage the larynx (33). It h as bee n recommended that this tube is used for neona tal res usc itation but not for lon g-term i ntubati on (33). The res istance offered by the Cole tube is less than that of a compa rable tube of c ons tan t lumen (8). A dis adv antage is tha t it c annot be inserted throug h the nose.

Preformed Tubes
Some trac heal tubes are p reformed to f aci l itate s urgery about the head and nec k (34). One of these is the Ring -Ada ir-E l wi n (RAE ) tube (Fi g. 19 .3), whi ch has a preformed b end that may be temporarily P .565 s traighte ned during ins ertion. F requently , there is a mark at the be nd. The ex ternal portion of the o ral v ers ion is bent at an acute angle so that whe n in place , it res ts on the patient's ch in wi th the c onnec tor ov er the patient's ches t. The nasal v ers ion has an o ppos ite curv e f rom the o ral tube s o tha t when in place th e outer porti on of the tub e is di rec ted ov er the pa tient's forehe ad. Th is he lps to reduce press ure o n the nares . The oral tubes are s horte r than nasa l tubes .

Figure 19.2 Uncuffed pediatric tracheal tubes. The top tube is a Cole tube, which is sized by the French scale, according to the intratracheal portion. The middle tube is a Magill tube, while the bottom tube has a Murphy eye. The dark color is the part of the tube that the manufacturer recommends to be below the vocal cords. (Courtesy of Rusch, Inc.)
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The nasal and oral v ers ions a re av ail ab le in v arious siz es and in c uffed and uncuffed v ers ions . Uncuf fed RAE tubes a re sho rter than cuff ed RAE tubes (35). A s the diameter inc reases , the length and dis tance f rom the dis ta l ti p to the curv e also i nc reas es . In the majority of c ases , when thi s ma rk is at the tee th or nares , the tube wi ll be s atis fac tori ly pos i ti one d i n the trachea if the proper s ize tube for the pati ent wa s selec ted. T his is onl y a guide and s hould not be used as the sole c riterion for judging c orrec t tube pos i tion . Unf ortunately , the leng th f rom the angle to the tip of the tube v aries (36,37). These tubes are eas y to s ec ure and ma y reduce the ri sk of unin ten ded extubation. The c urv e allows the breathing s ys tem con nec tion to be plac ed away f rom th e su rgical fi el d during s urgery around the head witho ut use of spec ia l connec tors (38). The long length may make them useful f or inse rtion through a supraglottic ai rwa y dev ice (39,40,41) (Chap ter 17). The nas al tube may be us ef ul for oral i ntu bation of pati ents who are to be in the prone pos ition (42) or who are undergoing otola ryngology proc edures (43). A disadv antage of p reformed tubes is the difficul ty i n pas s ing a s uc tion catheter through them. In c ri tica l si tuations , suc tioning c an be acc ompl is hed by cu ttin g the tube at the curv a ture and then re inserti ng th e c onn ec tor into the cut end (43). These tubes offe r more res is tanc e than c omparabl y s i zed co nv entional tubes (6). S ince they are desi gned to f it the av erage patie nt, a tube may b e e ither too l ong or too short for a giv en pa tient (35,44). W hen se lec ting tube s i ze , referenc e to height

and we ight may be more us eful than ag e in years , and the user shou ld al way s b e alert to the pos sibil i ty of bronc hi al intuba tion or ac cidental ex tubation.

Spiral Embedded Tubes

The s piral embedded (f lexometallic , a rmored, reinf orced, anode , metal sp iral , wov en, wi re -rei nfo rced) tube has a metal o r nylon s pi ral-wou nd reinforcing wire cov ered in ternall y and ex ternal ly P .566 by rubbe r, PV C, or s i lic one (F ig. 19.4). The spi ral may not ex tend into the dis tal and p rox imal ends . The co nnec to r is f requentl y b onde d to the tube.

Figure 19.3 Preformed tubes. At left are two nasal tubes, one cuffed and one uncuffed; at right are two oral tubes. (Courtesy of Rusch, Inc.)

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Figure 19.4 Spiral embedded tracheal tubes. A: Note the reference marks near the patient end of the tube to aid in positioning with respect to the vocal cords. (Courtesy of Mallinkrodt Medical, Inc.) B: Note that the tube on the left has a single reference mark. (Courtesy of Rusch, Inc.) C: The middle tube has a reinforcing covering over the bite area. Note again the referencing marks. (Courtesy of Kendall Healthcare Products Co.)

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Spi ral embedded tubes a re especi al ly useful i n si tua tions wh ere the tube is lik el y to be be nt or c ompresse d, as in head and neck su rge ry. Another use is for su rge ry on the trachea. The tube c an be plac ed by the su rgeon. The primary adv antage of these tubes is res is tance to k ink in g and compres s ion. The portion of the tube outs ide the pa ti ent c an be ang led a way from the s urgic al f ield wi thout k ink ing . This makes them us efu l fo r P .567 i nsertion into the pa tient with a trac heos tomy (45 ), for s ubmental intuba tion (46,47,48,49,50), and retromolar pos i ti on ing (51). A s pi ral embed ded tube may pass more easi ly ov er a fibe rsc ope than a conv entional tube (52,53,54,55). The re are a number of problems with th ese tubes . A f orceps and/or a s tyl et wi ll of ten b e needed for i ntuba ti on. The tube may rotate on the s tylet during ins e rtion. It i s diffic ult and s ome times imposs ible to pass th e tub e through the nos e. Bec aus e of the spi ra l, thes e tubes cannot be s hortened. The e las tic recoi l forc e may inc reas e the ten denc y to un intentional extubation. They are difficu lt to insert th rough the i ntu bating laryng eal mask ai rway (56). S pi ra l embe dded tubes that hav e been

res teri l iz ed hav e a hi gh inci dence of problems (57,58,59). For this reason, reuse is not rec ommend ed. Ev en si ngle-use tu bes may dev elop probl ems (60). Cases hav e been rep orted where a patient bi t the tube, caus ing it to be sev ered or pe rmanently deformed (6 1,62,63,64,65,66,67,68). A bite block be twe en the mol ar teeth, not an oral ai rway, s hould be used to prev en t th is . Some spi ral embedded tubes h av e an ex ternal reinf orced c ov ering ov er the bi te po rtion (Fig. 19.4C). K ink ing as a resul t of c ompress ion be twe en a retrac to r and the tee th has been reporte d (69). The absenc e o f a Murphy eye may resul t i n obs truc tion if the bev el abuts the wal l of the trac hea (70).

Hunsaker Mon-Jet Ventilation Tube

The Huns ak er tube (F ig. 19.5) is las er-re sistant an d des igned f or s ubglottic j et v enti lation . It is comp atible wi th c arbon diox ide, neodymium-yttrium aluminumgarnet (Nd-YA G), and argon las e rs . The OD i s 3 mm, and i t has an integral lumen for moni tori ng ai rwa y pressure and respi ra to ry gas es . The patie nt end h as a basket-s haped dis tal ex tens ion des igne d to cen ter the tube. This tube h as been us ed to adminis ter on e-lun g v entilation (71).

Laryngectomy Tube
Laryngec tomy tubes hav e a J c onf iguration at the pa tient end (73 ) (Fi g. 19.6, l eft). They are des igned to be inse rted in to a trac heotomy. This allows the part of the tub e ex ternal to the pa tient to be di rec te d a way from the s urg ic al field. The tip may be sh ort and/or wi th out a bev el to av oid adv anc ement i nto a bronchus .

Figure 19.5 Hunsaker Mon-Jet ventilation tube.

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Figure 19.6 Left: Laryngectomy tube. Middle: Injectoflex tube, which is used for procedures on the larynx. The tube has an embedded metal spiral. The insufflation lumen and cuff inflation tube are combined in one sheath with the malleable introducer. Right: Spiral embedded tube. (Courtesy of Rusch, Inc.)

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The c urv e ma y need to be s traightene d to fac ili ta te insertion . The tube can b e secured by suturing o r ta ping i t to the c hes t wall (72 ). A cas e of obs truc tio n of this tube has been reporte d (73). The s oft cuff and short dis tanc e between th e c uff and dis tal tip of the tube may c ause the bev el to abut the trac heal wal l.

Microlaryngeal Tracheal Sur gery Tube

The mic rolary ngeal trach eal s urgery (LTS or MLT ) trac heal tube (Fig . 19.7) i s av ailab le wi th an ID of 4, 5, or 6 mm (74). The l arg e c uff di ameter is the same as that found on a s tandard 8 -mm-ID tube. Th is helps to kee p the tube c en te red i n the trac hea. One v ers ion has a yel low-c olored cuf f. This tube is desi gned for mic rolary ngeal s urgery or for pati ents whose ai rway has been narrowe d to suc h an ex tent that a normal-si zed trac heal tube c anno t be i nserted. Th e s mal l tu be dia mete r prov ides be tter v is ibili ty and acc ess to the su rgical fi el d. Its leng th al lo ws it to be used for intuba tion v ia a laryngeal mask ai rwa y (LMA ) o r other supraglottic airway dev ic e (76 ). Poss ible proble ms with a tube hav in g s uch a s mall bo re inc lude inc omple te ex halation and occlus ion . This type of tube is not s afe f or us e with las ers . It can be us ed fo r selec tiv e bronchial i ntu bation (75) (Chapte r 20).

Endotrol Tube

The E ndotrol (tri gge r) tube (Fig . 19.8) has a p ull ri ng loop (tri gger) that is connec ted to the tip of the tube wi th a c able e mbedde d in the tube wall . Pu lling on the ring dec reases the tu be's ins ide radius and mov es P .568 the tip anteriorl y. W hen us ed with a s tyle t, the tip alone c an be controlled (77). The Endotrol tube has been us ed fo r bl ind i ntubations , inclu di ng bl ind nasal intuba tion; i ntu bation u ti l izing a l ighted intuba tion s tylet; and intubatio n usi ng a l aryng osc ope (78,79,80,81,82,83,84,85,86).

Figure 19.7 Tubes for microlaryngeal tracheal surgery. Top: The cuff on this tube is colored yellow for greater visibility. (Courtesy of Sheridan Catheter Corp.) Bottom: Similar tube with an uncolored cuff.

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In one reported case, obs truc tion to gas flow was no ted af ter the tube wa s ins erted nasal ly (87). The pull ri ng exerted tens ion on the p ull wire, c ausi ng the tip of the tube to abut the trach eal wa ll . Cutting the pul l rin g a ll ev iated the tension and the obs truc tion. K ink ing d uring prol onge d i ntuba tion has been re ported (88).

EndoFlex
The E ndoFlex tube is des igned to ai d intuba tion when the pati ent h as an anterior l ary nx . P ull ing the wh ite bar toward th e c onnec tor c auses the tube to f lex a t the cuff and the tip to mov e anterio rl y.

Parker Flex-Tip Tube

The P a rke r Fl ex -Tip tube (Fig . 19.9) has a hooded curv ed, fl exible tap ere d tip tha t points P .569

toward the cente r of the dis tal l umen on the conc av e su rface of the tube s o that the bev el faces pos terio rl y during i nse rtio n. The re are Murphy eyes on the righ t and lef t s ides of the tube . This tu be is f itted with a v ery thin cuf f. This tube is eas ie r to adv anc e ov er an intuba ting catheter o r flex ible endosco pe than a c onv entional tube (13,19,89,90,91). It is als o l ess l ik ely to impinge on the s ide of the ri ght v ocal c ord than is a tube wi th the point of th e bev el on the rig ht. The tube is av ai lable in a v a ri ety of shapes wi th an d wi thout a c uff .

Figure 19.8 Endotrol tracheal tube. The ring is attached to the tip by a cablelike mechanism that allows the tip to be maneuvered. (Courtesy of Mallinckrodt Anesthesiology Division, Mallinckrodt Medical, Inc.)

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Figure 19.9 Parker Flex-Tip tracheal tube. Note the two eyes and the hooded curved, flexible tapered tip that points toward the center of the distal lumen on the concave surface of the tube so that the bevel faces posteriorly during insertion.
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Tubes with Extra Lumen(s)

Tub es wi th one or mo re separate l umens terminating near th e tip a re av ailable (Fig . 19.10 ). They are useful for respi rato ry gas s ampl in g, suc tion ing , ai rwa y p res sure moni tori ng , fluid and drug injec tion, and jet v enti lation . A n umber o f problems are as soc iated wi th these tubes (92). S ec retions , blood, o r mois tu re c an o bs truc t the ex tra lumen. The sampling tube mus t be sec ure ly s tab il ized to mini mize tens ion on the tub e. Mois ture ma y e nte r the gas lumen and caus e problems wi th the gas moni tor (C hapter 22 ). The LITA (laryngotrac heal i ns ti llation of topical anes thes ia) (F ig. 19.11) has an additi onal smal l-bore channel inc orpora ted wi th in the c oncav e s urface of the tube . Ten s ma ll holes at the dis tal 13 cm of the tube allo w the in jec ted me dicatio n to be sp rayed both abov e and below th e c uff. S tudies sh ow tha t this ca n p rov ide a smoo th eme rge nce from anes th esia withou t cou ghing in mos t cas es (93).

Tubes with Embedded Fiberoptics

Tub es wi th fibe rop tic channels embedded i nto the tube wal l are av ai lable. W hen connec ted to a v id eo s ys tem, the f ib ero ptic channel al lows the lary nx and trac hea to be v is ualiz ed. This type of tube can be us ed to confi rm trac heal intub ati on and rule ou t bronch ia l in tubation . Thes e tubes may be useful for diff ic ult intuba tions .

Laser-resistant Tubes
A numbe r of trac heal tubes hav e b een desig ned to be used whe n l as er s urgery is performed. The manufac turer's ins truc ti ons shoul d be c ons ulted to determi ne whi ch tubes s houl d or s hould not be us ed wi th a partic ul ar las er. It i s imp ortant to unders tand that these tubes are las er-res is tant but may ca tc h fi re if the las er powe r i s too great or th e las er applica tion too lon g. Las ers and fi res are disc uss ed in more detail in Cha pte r 32.

Laser-Shield II Tube
The Laser-S hie ld II (Fi g. 19.12) is made from s i licone with an inner aluminum wra p and a n oute r Tef lo n c oating (94 ). It is desi gned for use with CO 2 and po tas si umtitany l-phos phate (K TP ) l asers . Th e cuff is n ot l aser-resis tant and con tains methylene -blue c rys tals . It s houl d be in fl ated with water or a sa line s oluti on. There i s 1 c m of unprotec ted s i lic one tub ing above the cuf f . The part of the tube dis tal to the cuff is a ls o u nprotec ted. Co ttonoi ds for wrapping around the cuff a re suppl ied wi th each tube. These mus t be mois tened and kept mois t duri ng the entire procedure.

S tudi es show that the wrapp ed portion of the s haft is not penetrated b y a CO 2 o r Nd-YA G laser, but the ov erl yi ng Tef lon may be v apori zed (95). Exp osure of the unprotec ted parts of the tube prox ima l and dis tal to the c uf f can resul t in rap id co mbus tion. Th e me thylene-blue c rys tals may not full y dissolv e and may obs truc t the pilot tube, maki ng i t imposs ible to deflate (96 ).

Laser-Flex Tracheal Tube

The Laser-F lex tube (Fig . 19.13) i s a s tainless s teel tube wi th a s mooth p las tic su rface and a matte f in is h to reflec t a l as er beam. It is des igned fo r use wi th CO 2 and K TP las ers . The wal l of the tube is thick er than th at of mos t other tubes (97 ). The adul t v ersi on has two P VC c uffs an d a PV C tip wi th a Murphy eye. The two cuffs are inflated by using sepa rate inflation tubes tha t run a long the insi de of the tube. The distal c uff c an be P .570 us ed if the proximal one is damaged by the l aser. Smal l uncuffe d tubes are av ailab le.

Figure 19.10 Tubes with additional lumen(s). These tubes have a main lumen for ventilation of the patient and one or more additional lumens for monitoring, irrigation, pressure monitoring, suctioning, and/or ventilation. A: These tubes have two additional lumens. The clear lumen is used for jet ventilation and administration of oxygen during suctioning and bronchoscopy. The opaque lumen can be used for irrigation and sampling of gases from the trachea. (Courtesy of Mallinckrodt Anesthesiology Division, Mallinckrodt Medical, Inc.) B: Pediatric tubes with monitoring lumens. (Courtesy of Kendall Healthcare Products Co.) C: Tube with lumen designed for subglottic suctioning. (Courtesy of Mallinkrodt Medical, Inc.)

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The c uffs should be f i lled wi th s aline colored wi th methylene blue (98). The dis tal cuff s hould be fil le d fi rs t until s eal ing occu rs , then the prox imal cuff s hould b e f il led. S tudi es show that the s haf t hol ds up wel l when exposed to a CO 2 or K TP las er bu t not the Nd -YA G laser (97,99,10 0,101,102). B lood on the outsi de of the tube renders i t less res is tant to c ombus tion wi th the CO 2 laser (103 ). The c uf f and tip are v ulne rab le to all lasers . This tube is l es s l ikel y to reflec t CO 2 laser radiation than are other tubes (104). The Laser-F lex tube is somewh at s tiff and has a ro ugh s urfac e. T he doub le cu ff adds to the time of intubation and ex tuba ti on. The la rge ex ternal di ameter can be a P .571 problem in sma ll pati en ts . In one repo rted cas e, great difficu lty was experi enced in remov ing the tube because of a subglottic mass (105). In a nother c ase, d ifficulty i nserting an a irway exc hange c atheter (AE C) occ urred (106). The Laser-Flex tube wi ll not fit ov er either of the B ullard s tyle ts (Chapter 1 8), so this lary ngos cope cannot b e used wi th this tube. The tube wi ll fi t thro ugh the Upshe r Scop e (Chap te r 18).

Figure 19.11 LITA (laryngotracheal instillation of topical anesthesia) tube. Small holes at the distal 13 cm of the tube allow the injected medication to be sprayed both above and below the cuff. The black reference bar indicates the position of the uppermost opening. (Picture courtesy of Kendall Healthcare Products Company).
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Sheridan Laser Tracheal T ube

The S heri dan las er tu be (Fig. 19.1 4) is a red rubber tub e wrapped with copper foil tape. This is ov e rwrapp ed with water-abs orb ent fabric that shou ld be sa turated wi th water pri or to use. Th ere is a c opp er band at th e cuff-tu be junc tion . Radi opaque

pledgets that are desi gned to b e mo is tened and plac ed abov e the c uff a re prov ided wi th each tube. It i s des igned for use with a CO 2 or K TP laser. A disadv antage is that i t has a thick wal l (107). It has a high-pre ssure cuff .

Figure 19.12 Laser-Shield II tracheal tube. (Courtesy of Xomed-Trease.)

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Norton Tube
The No rton tube is a re usab le , flex ible, s pi ral -wound metal tube wi th a s tai nl ess s teel connec tor and thick wal ls (108). T he ex teri or of th e tub e has a ma tte finish to dec reas e refl ec ti on of the laser beam. It has no c uff . A s epara te c uff may be attached , or pack ing around the tu be can be us ed to ac hiev e a sea l. S tudies s how this tube is acc eptable for use wi th K TP , Nd-YA G, and CO 2 l asers (102). The re are a number of problems with th is tube. Its flex ibl e coils a re not airtigh t, and angulation c an res ult in a large leak (109 ). The tube's ex te ri or is somewhat rough and may hav e sh arp ed ges that could c aus e ti ssue damage (110). The l arge ex ternal diamete r and s tiffnes s c an make su rgica l exposure diffic ul t (11 1). The tube tends to twi s t on a s tyl et duri ng intubation (102). It requi res spec ia l v enti lating tec hniques when used wi tho ut a c uff. If i t is us ed wi th a cuff , the cuff and i ts i nflating tube c an be i gni ted and may or may no t rema in attached to the tube .

Figure 19.13 Laser-Flex tracheal tubes. The adult tube has two cuffs. The distal cuff can be used if the proximal one is damaged. (Courtesy of Mallinckrodt Medical, Inc.)

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P .572

Figure 19.14 Sheridan Laser tracheal tube. The outer fabric should be saturated before use. (Courtesy of Kendall Healthcare Products Co.)

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Bivona Fome-Cuf Laser T ube

The B iv ona Fome-Cuf lase r tube (Fig. 19.1 5) has a n a luminum and s il icone sp iral wi th a s ilicone cov ering. It has a self-infl atin g c uff tha t cons is ts of a pol yurethane foam sponge with a si licone env elop e. The c uff mus t be de fl ated before intuba tion or ex tu bation (112 ). T he cuff s hould b e f illed wi th sa line during use. The cuff

reta ins i ts s hape and keeps a s eal wh en it is punc tured, but it c an no longer be defl ated for remov al (77,102). The inf la tion tube runs along th e ex teri or of th e tube and is col ored black so that i t c an be pos itio ned away f ro m whe re the laser wi ll be us ed (113). It i s mark eted for use wi th the CO 2 laser. The tube is poorl y resis tant to all lase rs (99,100,102 ). W hen burn ed, the si licone cov ering f orms an ash that s loughs of f and is left in the trachea , but mos t of the tube s tays intac t (102 ). A high inc idenc e of so re th roa t has been noted wi th th is tube (114).

Lasertubus
This tube (F ig. 19.16) is made of wh ite rubber an d has a cuff-wi thi n-a-c uff des ig n. If the o ute r cuff is perforated by the las er beam, the trache a wi l l s till be s eal ed by the inner cuff . The manufacture r rec ommends that the inne r cuff be f illed with air and the outer c uff with water or s aline . The sha ft abov e the c uff is cov ered b y a co rrugated si lv er foil, wh ic h is cov ered by a Meroc el s pong e that shou ld be mois tened wi th s al ine befo re use . This tube is recommended for us e wi th a rgon, Nd-YA G, an d CO 2 las ers (115 ). B ending the tube in the a rea abov e the s ponge cov ering c an predispos e the tube to k ink ing (116,117).

EMG Reinforced Tracheal Tube

This tube (F ig. 19.17) is des igned to moni tor rec urrent lary ngea l nerv e elec tromyogram (E MG) ac tiv ity during s urgery (118). The tube is wire-rei nforced and h as four s tainless s teel elec trodes abov e the cuff . The elec trodes a re connec ted to a monitor (Fig. 19 .18 ). Manufac tu ring def ec ts wi th this tube hav e been repo rted (119,120,121 ). It shoul d be check ed c arefull y fo r defec ts before use.

Intubating Laryngeal Mask Tracheal Tube and Tube Stabiliz er

The intubating la ryn geal mask (ILMA , ILM, L MA -Fas trac h) tracheal tube (Fig. 19.19 ) i s des igned to be inserted throug h the intubatin g laryngeal mask (Chapter 17) but can be p urc has ed sepa ratel y. It is a s traight, wi re-re inforc ed s il ic one tube wi th a tapered patient end, bl unt tip, s hort bev el, and Murphy eye . It has a hi gh-pressure, l ow-v olume cuff (122,123) (Fig. 19 .20). It i s reusabl e and c an be autocl av ed. It is av ailab le in s izes 6, 6.5, 7 , 7.5, an d 8 . Fi gure 19.21 sho ws the tube s tabi l iz er. It is use d to s tabi li ze the tu be whi le the LMA is being remov ed.

This tube has been found to be e asier to adv ance ov e r a fiberscope than a p las tic tube during both o ral and nas al intubation (14 ,15,20,2 1,24). It h as been us ed fo r submental i ntubati on (124) and tracheal resec tion and recons truc tion af te r the tip has been remov ed (125). P roblems re ported wi th this tube inc lude eccentri c cuff inflation, i nte rna l deformiti es , and the tip folding durin g i ns ertion (12 6,127,128,129 ). As wi th o the r sp iral wi re -rei nfo rc ed tubes , bi ting c an deform the spi ra ls or c aus e P .573 a le ak (1 30). This tube shou ld be us ed with cau tion if pro longed intubation is antic ipated bec ause of the high -press ure c harac teris tics of the cuf f (122,123 ,125,131). Cuff inflatio n s hould be l imi ted to the minimum v olume that seals the trac hea. When exposed to the magnetic res onance i maging (MRI) env ironment, the tube poses no di rec t ris k to the patien t or other personnel. Howev er, MRI quali ty may be compromised.

Figure 19.15 Bivona Fom-Cuf laser tube.

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Figure 19.16 Lasertubus. The inflation tubes have stopcocks.

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Hi-Lo Evac Tube

The Hi -L o Ev ac tube (F ig . 19.22) inc orporates a dedic ated channel that can be us ed to c lear sec retions bel ow th e v ocal cords but abov e the cuff . Resu lts were mixed when us ing this tube to prev ent or del ay pneumonia (132,133 ,134,135,136,137,138). The lumen may bec ome blocke d by sec retions (139).

Figure 19.17 Electromyogram reinforced tube. Note the surface electrodes and electrode leads. (Courtesy of Xomed Surgical Products, Inc.)

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Hi-Lo Jet Tube

The Hi -L o Jet tube is an uncuff ed tube wi th an additional l ume n that c an be us ed for j et v en ti lation, moni to ring ai rway p res sure, sa mpling respi rato ry gases , adminis tering l ocal anes thetic s, or i rri gating the ai rwa y (77 ,140). On e problem wi th the tub e is that a suc tion c athete r may bind in the smal l trac heal tube lumen (141 ).

Tube Siz e
Current s tand ards des igna te trac heal tube s iz e by the ID in mill ime ters . The Fre nch sc ale s iz e (th re e times the ex te rnal di ameter i n mil limeters ) may s till be l is ted in ca talogs and on pac kages and is used on so me tubes (Figs . 19.2, 19.23). Becaus e of v ariations in wa ll thick ness , tu bes hav in g the same ID may hav e d iffe ren t ex ternal diamete rs (142,143 ,144). The s tanda rds als o s peci fy tha t tubes s i ze 6 and smal ler show the ex te rna l diameter i n mi lli meters (Fig. 19.3B ). Many man ufac ture rs also mark this on larger tubes . The A ST M/IS O s ta ndard (11 ) requi res tube s ize to be mark ed between the cuff and the tak e-off point of the infl ati on tube for c uffed tubes . For uncuff ed tubes , the si ze mark ing s hould be toward th e patient end. Some manufac turers als o put the tube s ize on the pi lo t balloon so that the s ize can be de te rmined when the tu be is i n place (Fi g. 19.24 ).

Tube Length
The A ST M/IS O s ta ndard (11 ) spec if ies min imum tube le ngth, whi ch inc reas es as ID i nc reas es . Mos t manufac turers supply tubes l onger than the mini mum required by the s tandard. Mos t tubes c an be shortened. The length of a tube may v ary (1 45).

Tube Markings
Ty pic al trac hea l tube mark ings , sh own in Figu re 19.23, are s i tuated on th e bev eled s ide of the tube abov e the c uff and are read f rom the patient to the mac hi ne end. The f ol lo win g a re re qui re d b y the AS T M/ISO s tandard (11):

The wo rd oral or nas al or oral /nasal . Tub e size in ID in mil limeters . This may also be marked on the pi lo t ball oon (Fig . 19.24). The OD fo r tu bes si ze 6 and smaller. The name o r trade mark of the manufac ture r or suppl ie r. P .574

Figure 19.18 Monitor for use with EMG reinforced tube. (Courtesy of Xomed Surgical Products, Inc.)

View Figure

Graduated mark ings showi ng the d is tance in c entimeters from the patient end. These allow the depth of i nse rtio n to be determined and moni to red . On so me tubes , the name of the manufac tu rer ma y repl ac e the l ength markings (146). This can lead to pro blems with correc t place ment.

A cauti onary note suc h as Do not reuse or S i ngle use on ly if the tube is disposable. A rad io paqu e ma rke r at the patient end o r al ong the full leng th.

Other mark ings no t in c onf lic t wi th thos e mentioned in the list ma y be appl ied. Some tubes h av e mark ings (guide mark s ) to h el p pos i tion the tube with res pec t to the v ocal co rds (147,148 ,1 49,150,151 ,152,153,154 ) (Figs . 19.2, 19 .4, 19.23).

Figure 19.19 ILM-ETT. The black circle near the middle of the tube will be at the end of the connector when the tip of the tube is at the entrance to the bowl of the mask. (Courtesy of LMA North America.)

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Cuff Systems
A cuf f sys tem c ons is ts of the cuf f plus an inf lation s ys tem, whic h inc ludes an i nflation tube, a pi lo t bal loon, and an inflatio n v alv e (Fig. 1 9.1 ). A n inf la tion lumen i n the tube wal l may also be pres ent. The purpose of the cuff s ys te m is to prov ide a seal between the tube and trachea l wal l to p rev ent passa ge of phary ngeal c on ten ts i nto the trac hea and ensure tha t no gas l eak s pas t the cuff duri ng positiv e-pressu re v enti lation . The cuff als o s erv es to center th e tub e i n th e trachea.

Cuff
The c uff is an inf latable sl eev e near the pati ent end of the tub e. The c uff mate rial shoul d be s trong and tea r-res is tan t as wel l as thi n, soft, and pl iable. Cuff materia ls are subj ec t to the same tis sue-tes ting requirements as th e tube i tsel f.

Figure 19.20 Tip of ILM-ETT. Note how the high-pressure cuff lies flat against the tube.

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P .575

Figure 19.21 ILM-ETT with Stabilizer.

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The A ST M/IS O s ta ndard (11 ) spec if ies the maximum dis tanc e from the tip of the tube to the patient end of the cuff. This v aries wi th tube s ize . It a ls o requires that the bonded edge of the c uff does no t enc roach on the Mu rph y e ye, if pres ent; th at the cuff does not he rniate ov er the tube tip under no rmal cond itions of us e; and that the cuff inflates sy mme tric al ly .

Cuff Types
The c uff type depends on i ts c ons truc ti on. The cons truc ti on la rge ly de termi nes if the pressure needed to inf la te the c uff is hig h o r lo w.

Low-volume, High-pressure Cuff Description

The low-v olume, high-p res sure (sma ll res ti ng di ameter, low re si dual v olume, low v olume , smal l, s tanda rd, c onv ention al , lo w-co mpl iance, h igh -pres sure) c uff has a smal l d iame ter at res t and a l ow re s idual v ol ume (the amoun t of ai r that c an be wi th dra wn f ro m the cuff af te r it has been allowe d to ass ume its shape with the i nflation tube exposed to a tmos pheric p res sure). It requires a hi gh intracuff press ure to achiev e a s eal wi th the trac hea. It has a s mall are a of con tac t wi th the trac heal wal l and dis tends and deforms the trac hea to a ci rc ul ar sh ape (F ig. 19.25).

Figure 19.22 Hi-Lo Evac tube. (Picture courtesy of Tyco Healthcare.)

View Figure

Mos t of the pressu re insi de this type of c uff is us ed to ov erc ome cuff wal l co mpliance. The p res sure exerted lateral ly on the trac heal wall wil l be less than the i ntrac uff p ressure. Th e i ntracuff press ure do es not c hang e when the trache al wal l is contac ted and does not bear a cons is tent rela tions hip to tracheal wa ll p res sure.

Advantages
These c uffs off er be tter protec tio n agains t aspi ra ti on and b etter v is ibil ity during i ntu bation than low-press u re c uffs . They may be ass oci ated with a lower i nci denc e of s ore throat (114,15 5). B ecause they are usual l y reus able, they are less ex pens iv e. The y hav e be en rec ommended for use in adolesc ent pa tients (156).

Disadva ntages
The pres sure on the trac hea l wal l exe rted by such a c uff is difficul t to determine bu t wi ll li kel y be wel l ab ov e mucosal perfus ion p res sure (157 ). Intrac uff pressu re and the la teral p res sure on the tracheal wal l i ncrease s harply as inc rements of air are added to the cuff . If the larg es t trachea l tube pos si ble is used, the cuff wi ll b e minimall y inflated when a sea l is c reated. The mos t seri ous risk assoc ia ted wi th high -pres sure c uffs is isc hemic damag e to the tracheal wa ll mucosa follo wing p rolonged use . Whether they should be us ed for short p eriods of genera l anesthes ia is more controv ers ial . If a tube wi th a highpress ure c uff is us ed intraope rativ el y and th e tub e mus t be lef t in pl ac e fol lo win g su rge ry or the s urgery is expec ted to las t more than a few hours , i t shoul d be replaced wi th a tube wi th a low-p res sure cuff. P .576

View Figure

Figure 19.23 Typical tracheal tube markings. The dark marking at the patient end of the bottom tube and the mark above the cuff on the top tube are to aid in proper placement with respect to the vocal cords.The internal and external diameters as well as the size in French scale are shown. For example, on the top tube, the ID is 5.0, the external diameter is 6.7, and the French scale size is 20). Z-79 and IT both indicate that the tube material has passed the tissue toxicity test. Length from the patient tip is marked in centimeters. (Picture courtesy of Rusch, Inc.)

Figure 19.24 The tracheal tube size is marked on the pilot balloon.

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High-volume, Low-pressure Cuff Description

A high-v olume, low-pressu re (l arge res ting d iame ter; l arge res idual v olu me ; large; high-v olume; high-compli ance , lo w-press ure; floppy; low-pressu re, HVLP ) cuff h as a la rge res ting v ol ume and di ameter. A thin compliant wall allows a seal wi th the trac hea to be achiev ed without s tretching the trach eal wa ll . As the cuff is inf la ted, i t f irs t touc hes the trache a at the wides t pa rt of the c uff or the narrowe s t point in the trac hea under the cuff. A s the cuff c ontinues to inflate , th e a rea of contac t beco mes l arger and the c uff ad apts itself to the tracheal surfac e (Fi g. 19.25). If c uff inflation i s continued , the a rea in c ontac t with th e c uff wil l be s ubjec t to inc re asing press ure , and the trac hea wi ll b e d is torted. Diff erent s hapes h av e be en used for the low-press ure c uff (158). A c uff with a s hort trac heal c ontac t are a ma y hav e f ewer folds and wrin k les when inf lated and ma y be as soc iated wi th a lo wer i nc idence of pos toperativ e s ore throat. W hen high ai rwa y press ures mus t be us ed, a s hort c uff requi res hig her i ntrac uff pressures than a cuf f wi th a l arger v olume. The la rge r v olume prov ides a greater res e rv oir of gas wi th in the cuff, allowi ng add iti onal gas to b e milke d into the proximal end of th e c uff wi th out inc reas ing the res ting c uff pressure (1 58). The intrac uf f pressu re v aries durin g the v enti l atory c yc le. Duri ng spon taneous breathi ng, airway (a nd cuff) pressure wil l be negativ e during insp iration a nd positiv e during exha lation. W i th co ntrol led venti lation, wh en airway press ure

ex ceeds intracuff press ure , pos itiv e p ressure wil l be appl ie d to the lowe r fac e of the cuff. If the c uff wal l is pliable , it wil l be unable to resis t this p res sure and wi ll be deformed into a co ne shape as the dis tal P .577 portion is comp res sed and the proxi mal po rtion is dis tended (158). T he ai r in the cuff wi l l be comp res sed un ti l intracuff p res sure equa ls ai rway pressu re. Duri ng ex hal ation , the intracuff press ure wi ll dec reas e until i ts res ting pressu re is reached . A leak wil l dev elop if th e d iame ter of the expanded trachea becomes greater than the diameter of the prox imal end of the cuff. A t tha t point, more gas mus t b e added to the cu ff to abolis h the leak . Unfortunately, th is addi tiona l cuf f i nfl ati on wil l elev ate the bas eline cu ff p res sure.

View Figure

Figure 19.25 Relation of different types of cuffs to the trachea. A: Side view. At the left, the high-volume, lowpressure cuff has a large area of contact with the trachea. The cuff adapts itself to the irregular tracheal wall. At the right, the low-volume, high-pressure cuff has a small area of contact with the trachea. It distends the trachea and distorts it to a circular shape. B: Cross-sectional view. At the left is the normal trachea. At the top, the low-volume, high-pressure cuff distorts the trachea and makes the tracheal contour the same as the shape of the cuff. At the bottom, the soft high-volume, low-pressure cuff conforms to the normal tracheal lumen.

Ins erting a gas tric tube or esop hage al s tethos cope may inc reas e intracuff press ure (159,160 ). It is desi rab le that c uff c i rc umferenc e a t resi dual v olume be at leas t equal to the c i rc umference of the trac hea (161,162). If th e c uff is s ma ller, it mus t be s tretc hed beyond i ts resi dua l v olume to c rea te a seal. A t th is po int, i t wi ll ac t l ik e a hig hpress ure c uff (158 ). On the other hand, if the res idual c uff diameter is much gre ate r than th e dia mete r of the trachea, c uff inf ol ding may occ ur, with the poss ibil ity of as piration along the folds .

Advantages

A s ignificant adv antage of h igh-v olume, low-press ure c uffs is that prov ided the cuff wal l i s not s tretc hed , the intracuff pressu re c lose ly approx imates the press ure on the tracheal wa ll (162 ). Thus , i t is poss ible to meas ure and regulate the pres sure ex erted on the trach eal muc osa. W i th p roper us e, the risk of s ignif icant cuffi nduc ed complications fo ll owi ng prol onge d intuba tion is reduced.

Disadva ntages
Tub es wi th th ese cuffs may be more difficult to insert, as the cuff may obscu re the v iew of the tube tip and lary nx . T he cuff is mo re l ik ely to be to rn during intub ati on, es pecial l y i f forc eps are us ed. The re may be a greater l ik elihood tha t the trache al tube wi th this type of cuff wi ll b e d is lodged (163). The inc ide nce of s ore throat may be g rea ter wi th l ow-press ure than wi th highpress ure c uffs , unless the c uff is s peci al l y des igned s o tha t the trache al co ntac t area is s mall (114,155). A major drawbac k of this type of cuff is that it ma y not effec tiv ely p rev ent f lu id f rom l eak ing into the l ower a irway ev en at cuff press ures as high as 60 cm H 2 O (157,164 ,165,166,167,168,169). Fl uid l eak age is inc reased wi th s pontaneous respi ra tion and is re duced with conti nuous p osi tiv e ai rway pressu re, posi tiv e endex piratory p res sure (PE EP ), and pressure-supported v entil ation (166). Intermi ttent positiv e-pressu re v en til ati on adds some protec tio n. Lub rication with a wate r-s oluble gel wil l reduc e fl ui d leak for a l imi ted period o f ti me (16 6,170,171 ,172). It h as been shown th at a si lic one cuff wi thout f olds prevents the leakage of fluid when used wi th a constant-press ure i nfla ti on s ys tem (168,16 9,173,174,175 ). It is rel ativ ely easy to pass dev ic es suc h as es ophageal s tethos copes , temperature probes , and ente ric tub es around l ow-pre ssure cuf fs (176 ,177,1 78,179,18 0). Suc tion applied to the gas tric tube wi l l result i n negativ e pressu re in the lungs . P .578

Figure 19.26 Tube with deflated foam cuff.

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A pro bl em wi th l ow-pressu re cuffs is the belief that s impl y us ing this type of c uff wi ll prev ent high p res sures from being ex e rted on the trache al wal l . Any cu ff c an be ov erf illed or the v ol ume and p res sure can inc rease du ring use , resul ting in high i ntrac uff and trach eal wa ll pressures . Indeed, trac heal injury c an occu r ev en when these c uffs are used properl y. W hen ni trous ox ide is us ed, i t wi l l diffuse into the cuff . This added v olume wil l i nc rease the pres sure o n the trac heal mucos a (181,182 ,183,184,185,186,187).

Foam Cuff
The f oam (s ponge, Fome , Kamen-W ilki ns on) c uff h as a large diameter, re s idual v olume , and su rface area (182,188) (Fi gs . 19.15, 1 9.26). It i s fi ll ed wi th polyu rethane foa m that is cov ere d with a s heath. A pplying suc ti on to the in flation tube caus es the foam to shrink . W hen the negativ e press ure is re leas ed , the c uff ex pands . The tube is supplied wi th a T-piece to f it bet ween the c onnec tor and the breathi ng s ys tem (Fi g. 19.27 ). W hen the i nflation tube i s connec ted to this T-piece, the press ure insi de the cuff wi ll fol low prox ima l ai rway p res sure during the v en til ato ry c ycle (182 ,188). Before ex tubation , th e c uff should be c ollapsed by as pi rating and then c lampi ng the infl ation tube. W hen in place in the trac hea, the amou nt that the f oam expands determines the press ure ex erted l atera ll y on the trac heal wal l . The more the foam expa nds , the l ower the press ure (188). Thus, the pressu re on the tracheal wal l depends on th e rela tions hip betwe en c uff diameter at res idual v olu me a nd th e d iame ter of the

trac hea. If too large a c uff is used, the cuff:trac heal wal l pressu re ra ti o wil l be h igh . If too s mall a c uff is used, the re wi ll not be a s eal. T he risk of fl ui d l eak ing p as t the cuff is s imil ar to tha t wi th mos t hig h-v olume, l ow-pre ssure cuf fs (166 ). Diff usi on of anes the tic agen ts i nto the cuff c an occ ur but wil l no t c aus e an inc rease i n p res sure if the i nflating channel is open to atmos phere (182,189). It i s not necess ary to moni to r cuf f press ure wi th this dev ice. It c an prov ide a seal at a lo w trac heal wal l pressu re, p rov ided the relationship between the c uff an d trachea l diameters is op timal (112,188 ). A reduc ed inc idenc e of trach eal d il atation has been reporte d wi th i ts us e (1 90). One s tudy f ound a high inc idence of s ore throat as soc iated wi th i ts us e (114), whil e anoth er found a lo w i nc idence co mpared wit h ai r-fi lled cuffs (191). In two repo rted cases , the inf la tion tube was acc id ental ly pu lled out at the point of i ns ertion on the tube, maki ng cuff def lation i mposs ib le (192,193 ).

Lanz Cuff
The Lanz press ure-regulating v alv e (Mc Ginn is ba lloon sys tem) (1 94,195,196) cons is ts of a P .579 v e ry c omp liant latex pil ot balloon insi de a trans parent plas tic she ath wi th a n automatic pressure-regulating v alv e between the bal loon and th e cuff (Fig. 19.28). The pilot ba ll oon has three func tions : (a) an i nd ica tion of c uff infl ation , (b ) an ex ternal res erv oi r for the c uff , an d (c ) a press ure limi tin g dev ice. It is designed to mai ntain a n i ntracuff pressu re of 20 to 25 torr a t end ex piration while prev en ting ov erinf la tion of the cuff .

Figure 19.27 Tube with inflated foam cuff and a T-piece.

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Figure 19.28 Lanz pressure-regulating valve. The pilot balloon is confined inside a transparent plastic sheath. There is a pressure-regulating valve between the pilot balloon and the cuff. Air should be injected into the cuff until the pilot balloon is stretched, but it should be smaller than the confining sheath.
View Figure

The pres sure-regu la ting v alv e pe rmi ts rapid gas flow f rom the balloon to th e cuff but onl y sl ow f low from the cu ff to the b alloo n. This prev en ts gas f rom bein g squeezed back i nto the b alloon wh en the air way press ure ris es rapidly, so there is no gas leak a round the c uf f during p osi tiv e -press ure v entilation. It also prev ents i nc reas es in cuff v ol ume and pressu re ca used by d iffus ion of ni trous ox ide and other gases into the c uff . As ai r is injec ted , th e c uff and bal loon are inflated in paral lel. When the b alloon h as a s tretch ed appeara nce, a p res sure of app rox ima tely 26 to 33 c m H 2 O wi l l be present i n the c uff . As injec tion c ontinues , the pil ot bal loon f il ls p referentia ll y. The

i ntraba lloon p res sure remains co nstant and wi ll n ot inc rease unti l i t s tri kes the confining sheath. S hould the trac hea expand, air wil l sl owl y flow from the balloon i nto the cuf f . The press ure -regulating v alv e protec ts agains t rapid loss of c uff v olume into the balloon du ring ins pi ra tion. This v alv e has been f oun d b y s ev e ral inv estigators to be effec tiv e in k eepi ng latera l trac heal wal l pressu re l ow a nd prev en ting inc reases in cuff press ure due to ni trous ox ide (189,194). It el imina tes the need to meas ure c uff pressure. For patien ts requi ring hi gh ai rway pressu res , th is s ys tem ma y fai l to form a se al (197). The c uff may l eak , pa rtic ula rl y af ter p rolon ged use (198). If the b al loon is co mp res sed or ov erinflated, the intrac uff p res sure wil l ris e.

Cuff Pressures
Intracuff Pressure
A high cuff press ure prev ents aspi ra tion, v entilatory l eaks , a nd ecc entric tub e positioning in the trac hea but can cause damage to th e trachea. A lo w c uff pressure minimi zes trache al da mage and c an ac t to rel iev e exc ess iv e a irway press ure bu t may res ul t in aspi ration, leaks , and ecc entric tu be posi tionin g. It is desi rab le that the cuff s eal the ai rwa y without exerting so muc h pressure on the trachea tha t its c i rc ulation is compromised or the trac hea is d il ated. Mos t autho rs recommend that the pres sure o n the lateral trach eal wa ll measured at end ex piration is between 2 5 and 34 c m H 2 O (18 to 25 mm Hg) in normotens iv e adul ts (77,157,199 ,200,201,202 ). A pati ent wh o requires high peak inflati on press ures wil l need a h igher cuff p res sure to prev en t leaks (mini mum occ lusiv e pressure), i nc reas ing the risk of is chemic trach eal i nj ury (202 ). For c hi ld ren , no fi rm recommen dations fo r cuf f pressu re hav e been reported, bu t it seems logic al that lowe r pre ssure sho uld be us ed bec aus e of their lower arteri al press ures (203). P .580

Changes in Intracuff Pressure

The intrac uf f pressu re and v olume of a cuff i nflated wi th ai r rise whe n nitrous ox ide i s admi nis te red (181,182 ,1 83,184,185 ,186,187). The i nc reas e v aries direc tly wi th the parti al p res sure of the nitrous ox ide , the p ermeabi li ty of th e c uff wal l, and ti me. Hea ted hu midific ation sl ows d iffusion of ni trous oxide into the c uf f (204). Wh en

ni trous ox ide admi nis tration is discontinued, the press ure in the cuff dec reas es rapidl y (205 ). The re are a number of other reaso ns why cuff p res sure wil l v a ry. Cuff pressures are lower during hypo the rmic bypass (2 06,207). Inc reases in cuff p res sure ma y resul t f rom press ure f rom nea rby s urg ic al proce dures (208), inc re ases i n al ti tude (209), diff us ion of oxygen in to the c uff (210), and changes in head posi tion away f rom the neutra l pos ition (211 ). Cuff p res sure wil l als o be affec ted by coughing, s training , and ch anges in the muscl e tone. Foam-f i ll ed cuffs do not ex hibit these f luc tu ati ons (191 ). Du ring aeromedica l trans port, c uff pressu re rises when al ti tude i nc reas es (212). Certai n topic al anes thetic s can i nc rease the c uff pres sure wi th so me tracheal tubes (213).

Means to Limit Cuff Pressure

Cuff press ure c an be measu red c ontinu ously or a t frequent i nterv als and al te red b y i nf la ting or d eflating the cuff as needed. This is the only wa y to ensure adequate protec tion from the threats o f asp iration and trache al i schemia (214). Meas urement is eas y, an d c uff moni tors are inex pens iv e. P ress ures h igher or l owe r than rec ommende d a re common when th e cuff press ure is not measured. Fou r hours may be needed to s tabili ze c uff press ure wh en usi ng ni trous ox ide (215,216). If the tracheal tube is to be lef t in plac e and ni trous ox id e has been i n use, the cuff s hould be ev acuated an d fi lled wi th ai r to av oi d a l eak in the pos toperativ e period (217). Sev era l methods hav e bee n used to monitor i ntracuff pressu res c ontinuous ly or i ntermi tten tl y (197,198 ,199,200,201,202,203,204,205 ,206,207,208 ,209,210,211 ,212,213,21 4,215 ,216,217,218,219). Dev ices f or this purp ose are av ail able commerc ial ly (Fig . 19.29). Cuff press ure c an be measu red by c onnec ting the infl ation tube to the press ure c hann el of a mon itor by us in g an air-f i lled press ure transduc er (220,221 ,22 2,223) or direc tly to a manome ter (22 4). P .581

Figure 19.29 Device to measure intracuff pressure. A: Frontal view. B: Side view showing valve used to reduce the pressure. (Courtesy of Rusch, Inc.)

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The c uff can be f il le d with a g as mix ture con tai ni ng ox ygen an d n itrous ox ide or n itrous ox ide al one (183,225 ,22 6,227,228 ). Th is is awk wa rd to p erf orm. A cuff infla ted wi th n itrous ox ide wi ll l os e v ol ume and may al low a l eak when ni trous ox ide admi nis tration is discontinued or during ex tracorporeal c i rc ulation (205,217,2 29).

The c uff can be f il le d with wate r or sa line (184,209 ,22 9,230,231,232). T his resul ts i n a more s tab le press ure . Howev er, the ini ti al adjus tment of c uff press ure is more difficul t. Fluid -f ill ed cuffs c anno t be defl ated rapidl y.

The s yri nge may be lef t attached to the i nfla tion tubing. Th is has not be en found to be effec tiv e in l imi ting p res sure inc re ases in the c uff (233,2 34,235). Us ing a cuff des igned to reduce diffus ion of nitrous oxide , a cuf f wi th a high co mpliance, or a c uff with a large thin -wal led pi lo t balloon has been recommen ded (185,186,23 6,237,238,239,240,241,242 ).

Speciali zed balloon s ys tems s uch as th e Lanz press ure-regu lating v alv e (see abov e) and v arious other dev ices f or con trol ling cuff p res sure h av e be en dev el oped (199,219,2 42,243,244,2 45,246,247 ,24 8).

P ress ure may be as ses sed by manual palpati on and pinchi ng the p ilot balloon. Thes e me thods do not giv e cons is ten tl y acc ura te as sess ments of cuff p res sure (249 ,250,251,252 ).

Us ing a min imal leak v olume, minimal occlus iv e v olume , or a predetermined v olume to inf late the cuff has been found to be uns atisfac tory (25 2).

Inflation S ystem (Fig. 19.1) Inflation Lumen

The inf la tion lumen, wh ic h c onnec ts the inflation tub e to the cuff, is located wi thi n the wal l of the trach eal tube . The A STM/ISO s tandard (11) requ ires that i t does not enc roac h on the trach eal tube l umen and reco mmends that i t does not b ulge outward.

External Inflation Tube

The ex te rna l infl ation tube (cuff tube, pilot tube o r li ne, pilot b al loon li ne, inf lating tube, tai l ) is ex ternal to the tu be. The A STM/IS O s tandard (1 1) requi res that its ex ternal diamete r does n ot ex ceed 2.5 mm and rec ommends that it be a ttached to the tub e at a smal l an gle . The s tandard also s pecif ies the dis tanc e f rom the tip of the tub e to where the inf lation tube is a ttach ed and requi res tha t there is at leas t 3 cm between the mach ine end of the infl ation tube and the pi lot ball oon or inf la tion v alv e. The inf la tion tu be can become obs truc ted by ki nk ing , c rushi ng f rom a cl amp or ex ternal fixation dev ice , methylene-blue c rys tals , or the trachea l tu be connec tor (96,253,254 ,255).

Pilot Balloon
The pilot ba ll oon (bulb, ex te rna l reserv oi r, ex ternal balloon ) may be located nea r the midp oi nt of the inflating tub e o r adjace nt to the inflati on v alv e. Its func tion is to i ndicate c uff inflation.

Inflation Valve
The inf la tion v alv e is des igned so th at when the tip of a s yringe is ins erte d, a plunger is dis plac ed f rom i ts seat and gas can be injec ted in to the cuf f. Upon remov ing the s yringe, the v alv e se als so tha t gas c annot esc ape from the c uff . Some tubes may l ac k an inf lation v alv e. If a v alv e is not present, cuff inflation is mai ntained by apply in g a c lamp to the ex ternal inflation tube or b y plac ing a plug i n i ts f ree end.

Tracheal Tube Connector

The trachea l tube con nec tor (uni on) s erv es to a ttach the tube to the breath in g s ys tem. It may be made of p las tic or metal . The di mens ions of the c onnec tor are se t by an A STM/IS O s tandard (11). The end tha t fi ts into the tube is call ed the p ati ent end, and the s iz e of the connec tor is des ignated by the ID of this end in mill imete rs . The end that c onnec ts to the breathing s ys te m is c al led the mac hin e end and has a 15-mm male f i ttin g. The c onnec to r should be the s ame s ize as the tube wi th whi ch i t is i ntended to be us ed. Th is wi ll res ul t in minimal reduc tion of the lumen and make s eparatio n unlikel y. The mos t commo nly us ed con nec tors are the s tra igh t and 90 curv ed (ri ght angle). Acu te an gle c onnec to rs wi th l ess than a 90 c urv e (Fig. 19.3 0) and f lex ible connec tors are av ai lable. A curv ed or fl exi bl e connec tor may faci li tate pos i tioning the breathing s ys tem away f rom the s urgic al f ie ld bu t inc re ases res is tanc e and mus t be remov ed f rom th e tube wh en it is des ired to ins ert a s tylet o r s uc ti on ca the ter. The c onnec to r may hav e p rotrusions , lugs , or other features to which elas tic bands or o the r dev ices may be attac hed to p rev ent acc idental dis connec ti on from the breathi ng s ys tem. There is c ontrov ers y as to thei r des irabi li ty, as they may i nc reas e the risk of acc idental ex tubation . Some con nec tors hav e a port f or respi ra tory gas s ampl ing. Some hav e flang es to ai d in ho ld ing the c onnec tor. Many d is posa ble trachea l tubes co me wi th the connec tor onl y partl y ins erted . This i s done by the manufac turer to prev ent the tube f rom di la ting and the c onnec tor f rom fall ing out. Before us e, the c onnec tor s houl d be full y inserted. Remov ing it f rom the tube and wip ing the tu be end wi th alcohol wi l l faci li ta te f ul l inserti on and bond the c onnec to r with th e tube . A towe l clip may be used to remov e a c onnec to r f rom the tracheal tube (2 56). Occ asi ona lly, wh en the c onnec to r is firml y s eated, the pi lot tube may be oc cluded, block ing the inf lation tube (253). T his only occurs when the pi lo t tube enters the trac heal tube a t th e end where the c onnecto r is ins erted. P .582

Figure 19.30 Method of securing a nasotracheal tube. A: A skull cap is placed around the head. An acute-angle connector is used and taped so that it does not exert pressure on the nasal ala. B: Foam padding is used to keep the breathing system from exerting pull on the tracheal tube. C: Tape is added to keep the breathing system firmly in place.

View Figure

Laser-resistant Tracheal Tube Wraps

The only produc t approv ed by the Food a nd Drug Ad minis tra tion (F DA ) fo r laser protec tio n is a two -l aye red s heet of s yn the tic surgical s pong e and adhesiv e-bac ked co rrugated si lv er foil (Me roc el Laser-Gua rd), whi ch is av ail able in sev eral si zes . It can be us ed on rubbe r or PV C tubes bu t s hould no t be us ed on a s il icone tube. Before use, the tube wi th wrap is s atu rated wi th s a line. W hen wet, the s ponge and reflec tiv e fo il ac t as a heat s ink and dis perse argon, CO 2 , Nd-YA G, and K TP las er beams (10 2,104,247,248 ,249,250,251 ,252,253,254 ,25 5,256,257,258,259). The wrapped tube s hould not be used wi th Nd-YA G con tac t fibe r ti ps , whic h may punc ture and damage the wra p. Bl ood on the c oa ting does not reduc e its pro tec tiv e ef fec t (103). It is importa nt that the wra ppi ng proc edure recommended by the manufac tu rer is followe d c arefull y and that the sponge materi al is kept mois t du ring us e. The c uff and the a rea be lo w the c uff are not p rotec ted by the wra p. The c uff shoul d be inflated with wate r or sa li ne an d methy lene blue and protec ted by mois tened c otton patties s uppli ed with the tube. B reaks in the s ilv er foi l wrap when the tub e was mani pulated hav e been re ported (260 ). Other produc ts inc lud ing alu minu m foil and tape and c oppe r tap e hav e been used to wrap tracheal tubes . Thes e produc ts are not approv ed for protec ting tracheal tubes f rom las ers . These wraps hav e a number of disadv antages . The y reduce tube f lex ib il i ty, can predispose to ki nk in g, and may c rea te a rough surface (102,261 ,262). The OD of the tube is inc reased. Reflection of the lase r beam f rom metallic ta pe may cause damage to non-targ eted tissues (10 4). The wra ppi ng

material may come off and obs truc t th e a irway (263). E rrors in wrapping or s harp bends cou ld ex pos e the tube to the laser beam (102,264,265). Tub e wrap ping, f ires , and lasers are disc uss ed in more detail in Chapter 32.

Use of the Tracheal Tube Tube Choice

Cuffed versus Uncuffed
Cuffe d tub es are routinel y used i n adul ts (266 ,26 7,268,269 ,270,271). Tradi ti ona lly, uncuffed trac hea l tu bes were rou tinel y used in P .583 young chi ldren, wi th the prac tic e of add ing a c uff begi nning at 6 to 10 years of ag e (156). In rec ent years , cuffed trache al tubes h av e been used more often i n s mal l ch il dren. Adv antages of cuf fed tubes inc lude imp rov ed acc urac y of monitoring end-ti dal gases , tidal v olume, compl iance, and ox ygen c onsumpti on; dec reased risk of as piration; ab il ity to use high inf lation pres sures and low fres h gas f lows ; l ess operati ng room (OR) poll uti on ; dec reased risk of fi re ; and fewer tube changes (269,272 ,273,274,275,276). T here is a theoretic al ri sk that inf ec ti ous droplets wil l be dispers ed when v entil ating wi th an uncuffed tub e (271 ). Drawbac ks of using a c uffed tube i n c hi ldren inc lude the nee d to choose a sl ightl y smal ler tube (whic h makes suc tion ing mo re diff icul t and tube obs truc tion more lik el y and inc reases resis tance and work of breath ing ); the risk that ov erinflation of th e cuff wi l l re sul t in exces s iv e pressu re ag ainst the mucos a; the risk of injury to the v ocal c ords ; and a reduc ed margin of safety (the need to av oi d the c uff impinging on the gl ottis , ye t av oiding bronc hial intu bation) (272,277 ,278,279,280). Rel ativ el y smal l a mounts of inf lated ai r lead to rapi d inc reases in cuff press ure and v olume (280). The larger ex ternal diameter of the cuf fed tube ma y lead to problems wi th ex tubation (281). If a c uffed tube is inserted through a pedia tric s upraglottic dev ice such as an LMA , i t may be i mpos si ble to remov e the s upraglottic dev ice af ter i ntu bation (282 ). S tudi es i ndicate tha t us ing cuffed tubes i n chi ld ren is not assoc ia ted wi th i nc reased co mplica tions (273,283 ,2 84,285,286 ,28 7,288). A cuffed tube may be used to oc c lude a tracheo-es ophageal f is tula (288,289,290 ).

S tudi es i ndicate tha t an ul trathin h ig h-v olume, low-pre ssure pol yurethane c uff resul ts i n lo wer se al ing pres sures than c onv entional c uffs (203,291,29 2).

Size
S mal ler-di ameter tubes are eas ier to insert and requ ire les s res haping forc e to adapt to the pa tient's a irway bu t are assoc ia ted wi th high er res is tance , diffic ul ty passing a fiberscope or s uction c ath ete r, and inc reased ris k of occ lus ion and k ink ing (293). La rge r tubes are associa ted wi th l es s risk of occ lusi on and lower resis tance bu t are li nked wi th a hi gher i nci denc e of pos toperativ e s o re throat and are more difficul t to ins ert. Bec ause n o s ys tem of choos ing the corre c t s ize tube is foolproof , the user shou ld al ways hav e readi l y av ai lable tubes tha t are l arger and smal le r than the tube chos en . A s mal ler tube s houl d be us ed when a diff ic ul t in tub ation is antic ipated.

Cuffed Tubes
W ith c uffed tubes , the cuff c ircumf erence sh ould equa l th at of the trac heal lumen. If the tub e is too s mal l, a h igh c uff pressure wil l b e neede d to ac hiev e a s eal , i nc reas ing pres sure o n the muc osa. If the cuf f is too large in relation to the trac heal l umen, i t wi l l hav e folds when inf la ted to occ lus ion. Asp iration may occur along those folds .

TABLE 19.1 Recommended Tube Sizes for Children Age 14 y Normal Size 7.58

1213 y 1011 y

77.5 6.57

810 y 67 y

66.5 5.56

45 y 1.54 y 918 mo Full term to 9 mo Premature

55.5 4.55 44.5 3.54 2.53

One s tudy f ound tha t the ideal tube in the av e rage adul t is a 7 .5-mm-ID tube for females and an 8.5-mm-ID tube for mal es (2 94). Howev er, the re is gre at v ari ati on i n s iz es and s hapes of tracheas i n adul ts . The transv erse dimens io ns inc reas e wi th age, but in genera l, the c o rrelation be twee n age, race , height, wei gh t, body surf ace area, and trac heal s hape or s iz e is poor. T here is cons iderable v aria tion in the c uff c i rc umference of trachea l tubes wi th i dentical IDs . Age is rec ognized as the mos t reliabl e indicator of the appro priate trac heal tube s ize for ch il dren (Table 19 .1 ). For c uffed tubes in c hi ldren, the fo llowi ng fo rmula may be use d: ID i n mm = age /4 + 3 (273). Alternatel y, a tube 0.5 to 1 mm sma ller than that c alc ulated for an unc uffed tube may be us ed. Howev er, there a re consi derable differences in outer tube diameters for a giv en ID c uffed tube f ro m different manufac turers (278 ). A chi ld wi th Do wn s ynd rome has a s maller trachea, so a trac heal tub e a t le as t two s izes s maller than usual should be us ed (295). P rema tu re bab ies hav e re la tiv el y elas tic laryngeal s truc tures that may al low a large tube to be inserted (29 6). This may res ul t in injury to the pos terior part of the glottis .

Uncuffed Tubes
W ith unc uff ed tubes , th e s ize s hou ld be large enough to prov ide ef fec tiv e v enti lation bu t not s o large as to caus e p res sure on the mucosa . This is c ommonl y ac hiev ed by al lowi ng a leak between the tub e and the wa ll of the trache a at hi gh peak airway pres sures (20 to 25 cm H 2 O) (143,297 ,29 8,299,300 ). Man y fac tors i nflue nce the leak pressure, and these shoul d b e borne in mind when performing

the leak tes t (2 68). Meas uring the le ak when the chi ld 's head is turned to one s ide or wh en he is not paralyzed inc reases the pressu re re qui red to c ause th e P .584 l eak . The importanc e of the presenc e of a le ak has been chal lenged (301). The f ol lo win g hav e been used as general gu id elines for s el ectin g the proper si ze tube in c hi ldren. There is cons iderabl e v aria tion i n s ubglottic s i ze in chi ld ren and in the ex ternal diame ters of pedia tric trac hea l tu bes (143,302 ,303).

For c hi ld ren be lo w 6 ye ars : age in years /3 + 3 .75 For c hi ld ren olde r tha n 6 years : age in yea rs /4 + 4.5 (277,304),

ID = age in yea rs /4 + 4 o r 3.5 (153 ,27 3) ID = 3 mm for thos e 3 mon ths of age and younger = 3.5 mm fo r those from 3 to 9 months of age = (a ge in ye ars + 16 )/4 ov er 9 mon ths of age (298,305)

(age in y ears + 1 6)/4 (306) Us e of a me asure base d on body leng th (305,307 ,308,309). Choos ing a tube whose ex te rna l diameter is the same wi dth as th e d is tal phalanx of the li ttle or i ndex f in ger. S tudi es indicate this may be less ac curate than other me th ods (298,304) but may be useful when the ch ild's age is unk nown.

ID = 2.44 + (age 0.1) + (height i n cm 0 .0 2) + (wei gh t in kg 0.016 ) (310).

Checking the Tube

Before ins ertion, the tube should be examined for def ec ts such as spl i tting, ho les , and miss ing s ec tions (31 1,312,313,31 4). The tube s hou ld also be check ed for obs truc tions. Wi th transp are nt tubes , si mple observ ation wil l suff ic e (315). W i th other tubes , the use r s hou ld look into both e nds and /or ins ert a s tyle t. The c uff , if presen t, s hould be inflated and the syri nge re mov ed to chec k for leaks i n the inf lation v alv e. If the sy ri nge remains in the v alv e, the v alv e hous ing may c rack and leak (316). The cuff s hould be ins pec ted to make c ertain that i t inflates

ev enl y and does not cause the tube lumen to be reduc ed. It s hould b e lef t inflated for at leas t 1 minu te to chec k for a s low l eak . If the tube has a s ponge c uff, a ll the ai r sh ould be aspi rate d. The inf la tion tube shoul d the n be c losed or c lamped. The cuff sho ul d remain col lapse d. If it f i lls , there i s a leak , and the tu be should be d isc arded.

Preparing the Tube

Af ter the s terile wrapping is opened, the tube s hou ld be ha ndled only at the connec tor end. The connec tor shoul d be inserted as far as p oss ible. Remov ing the connec tor from the tube and wi pi ng th e tube end with alcohol wi ll make it e asier to i nsert the connec tor into the tube and wi l l allo w i t to b ond to the tube. Us ing s te ri le l ubric ant jelly on a low-pre ssure, high -v olume c uff may dec reas e aspi rati on by f il ling in the f ol ds (1 66,170). For ora l in tubation , onl y the c uff sho uld be lubricated. If nas al i ntubation is planned, lubric ant s hould be place d a long the enti re l eng th of the tub e. If a fiberoptic intubation or nasal i ntuba ti on us ing a s tandard tube is i ntend ed, the tube sho ul d be warmed to inc rease flex ib ility (3 17).

Inserting the Tube

Techniques Oral Intubation
Direct Laryngoscopy
Oral i ntubation is gen erall y prefe rred fo r gene ral anes thesia and in eme rgenci es becaus e i t c an be performed more q uick ly and eas il y than nas al intubation. It al lows use of a wi der and sho rter tube than can be us ed fo r nas al intubatio n. Disadv antages inc lude the p ossibi lity of oropha ryngea l complications . Oral i ntu bation is us ual ly no t wel l tole rated by the c onscious pa tient. The patien t with an oral tube has difficu lty s wal lowi ng. Si gnific ant c erv ic al s pine moti on may be as soc iated wi th di rec t laryngoscop y (318,3 19). Obs truc tion f rom b iting c an occ ur wi th oral intubation. A bi te bloc k , rol led gauze , or oral ai rway should be p lac ed between the te eth to prev ent the p ati ent from b iti ng the tub e and occ luding the lumen. Ins erting the tube is us ual ly e asy once th e v ocal cords are expos ed. The tub e shoul d be introduc ed in to th e right c orner of the mouth and di rec ted toward the glottis wi th the bev el paral le l to the v oc al co rds . If the re is c ord mov ement, the tube shoul d be ins erted du ri ng maxi mum abduc tion . Grippi ng the tube as sho wn i n

Fi gure 19.31 may fac ili ta te an terior mov ement of the pa ti ent end of the tube during i nsertion (320).

Blind Oral Intubation

A bl ind o ral tec hnique is performed wi th the head f la t, then til ted back in max imum ex tensi on (321,322). A s ty le t with a bend is inserted into the trac hea l tube. Th e i ntu bator applies pres sure to th e c ricoi d cartil age wi th one h and whi l e the trac heal tube is i ntroduce d i nto the mouth wi th the other, followi ng the curv e of the tube. The tube is adv anced unti l the intubator feel s the tip or fee ls the tube adv ance into the trachea. It may be nec ess ary to mani pulate the l arynx to the ri gh t or left to adv anc e the tube into the trach ea. The Endotrol tube may be us efu l in bl ind oral i ntu bations (82,83). If the pati ent is breathin g s pontaneous ly , bl ind i ntubati on may be pe rforme d b y us ing c apnograph y to obtain the op timal CO 2 wav eform (323,324 ) or a whi s tl e-type dev ice suc h as the Beck Ai rway A i rflow Moni tor (B AA M) ma y as s is t placement (83). The trac heal tube with dispos able whi s tl e attac hed is pass ed bl indl y into the o rop harynx and adv anced s lowl y. W he n the whi s tle s ounds lou des t, the tracheal tube is adv anced . As wi th any b lind techniqu e, bleeding may occur. This wi ll make P .585 f ibe rop tic techniqu es more difficul t if the blind i ntubati on is no t s uc cess ful.

Figure 19.31 A: The tracheal tube is gripped as shown in the picture with the thumb on the shaft near the connector and two fingers around the tube. B: Pushing forward with the thumb will cause the tip to move forward.

View Figure

Digital T echnique

In a digi tal (tac tile ) technique, one ha nd is p lac ed in the patient's mou th, and the f ing ers a re s lid pos teriorly along the tongu e. The o the r hand introduces the trac heal tube into the mouth, an d the i ntrao ral hand i s used to guide th e tracheal tube tip. Sev era l v ari ations of th is techniq ue hav e been des c ribed (325,326 ,327,328,329,330,331).

Nasal Intubation
The nasal route is c ommonl y us ed for s urg ic al procedures inv olv ing the o ral cav i ty, orophary nx , and fac e where an o ral tube would hinder the s urgeon's access to the operativ e fi el d (332,333). Other indications may i nclude a frac tured mand ible, l imi ta tion of mov ement at the temporo mandibul ar joints , a patient wi th a neck in ju ry or c erv ic al sp ine dis ease , in tra-o ral pathol ogy inc lud ing mec hanical obs truc tion, and p ati ents who wi ll not tolera te di rec t laryngoscop y. Intubatio n b y the nas al route has man y adva ntages. Securi ng the tube is eas ier. The nasal route el iminates the pos s ibil i ty of the tube being oc c luded by b iting. Nas al i ntubation ma y caus e les s cerv ical s pi ne mov ement than oral intubatio n (318,334 ,335). Dis adv anta ges incl ude the fac t that a sma ll er tube mus t be used , resul ting in inc reased res is tanc e and diffic ul ty i n s uc tioning or endosc opy. Intubatio n usual l y tak es longer. Sev ere bleeding may occ ur (336). Nasa l intu bation has been shown to res ul t in a h igh i ncidence of bac teremia , s inus i tis , and otitis (337,338 ,339,340,341,342,343). Con traindications to nas otrac hea l in tubation inc lud e c oagulopathy and an y mechanical impedime nt of the nasotrachea l ro ute , includi ng pol yps , abs ces ses , fore ign bodies , and poss ibly epiglottitis (344 ). A frac ture at the base of the s kul l is us ual ly c ons idered a con traindication to nas otrac heal intub ati on (345), al though i t has been safel y use d i n th is s ituation (346,3 47,348,349 ). Fibe rop tic -guided i ntu bation s hou ld be us ed (350). Pneumoc ephalus has been reported af te r nasa l i ntu bation in a patient who had had a repair of the c ri bi fo rm plate (351). Trans spheno idal surgery can leav e a bony defec t in the sku ll that is susceptible to perfora tion by a nas al tube (352). A trach eal tube on e s ize s malle r than would be cons idered optimal f or o ral i ntu bation is pref era ble to mini mi ze trauma. It s hould be th oro ughl y lubric ated a lo ng i ts en ti re length wi th a s teri l e, water-s oluble l ubric ant. Th e c uff should be fully defl ated. If pos sible , a fiberscope s hould be passed through the nos trils to dete rmi ne th e presenc e of abnormal ities (349,353,354). Clin ic al tes ts suc h as es timating the rate

of airflow by palpa tion when the c on tralate ral nos tril is occ luded or ask ing fo r the pati ent's asses sment of ai rf low through the nos trils does not c orrelate wi th nasal abnorma li ties (355 ). Inse rting p rog res siv ely la rge r lubricated nasal a irways wi l l tes t the patenc y of the n os tril and d ilate it. Other methods to dec rease trauma inc lude apply in g a v asoc ons tric tor; us ing a Magi l l-tipped tube; us ing a s il ic one tube wi th a hemispheric al bev el ; th ermosof tening the tube; pass ing the tube th rough a nas al ai rwa y; us in g an intra lu mi na l bal loon or es ophageal s tethosc ope; s li pping the end of a c ath ete r or glov e f inger ov er the tip of the trac heal tube; and inse rting the tube ov er a bougie , s tylet, or catheter (25,32,356,357 ,358,359,360 ,36 1,362,363 ,36 4,365,366,367,368,369,370 ,371,372). Us ing a bougie o r s tyle t wi th an anterio r curv e wi ll fac il i tate in tubation . Nas al trea tmen t with mupi rocin is effec tiv e in preventi ng bac teria f ro m be ing c arried into the trachea (373). W hen the tu be is i nse rted, the bev el openi ng s hould f ace l atera ll y (374,375). It shoul d be adv anced alon g to the f loor of the nose whi le s lightl y l ifting the tip of the nose (375,376). The tube should b e pul led c epha lad as i t is pas sed pos te riorl y until i t con tac ts the pos teri or pha ryngeal wal l. F rom th is po int, the natural cu rv e of the tube and the anterio r body of the c erv ic al sp ine wi l l usuall y di rec t i t anterio rl y. Only gentle pressu re shoul d be used . If excessive res is tance is encountered, the other nos tril or a smal ler tube should be tri ed (376). Some times , the tube wi ll i mpac t th e pos terio r pharyngeal wa ll and res is t atte mpts to adv anc e i t farthe r. Th e tub e s houl d be pull ed bac k a s hort dis ta nce and the pati ent's head ex tended to fac il itate p ass age beyond this poin t. It may be us eful to wi th dra w the tu be and plac e a s tylet wi th an ac ute bend in the dis tal 1 .5 cm into the P .586 tube. The tube is then inserted until i t passes the pos te rior nasophary nx , then the s tyl et is withdrawn . A nother tec hnique is to pas s a s uc tion catheter through the tube and into the orophary nx . The tip of the catheter can be bro ught out thro ugh the mouth. A forwa rd pull on the ca the ter wil l us ual ly bring th e ti p of the tracheal tube forwa rd. A nticl oc k wis e rotation ma y ass is t pass age at this point (332,37 7). If the tube dev ia tes l atera ll y, i t s hould be withd rawn to the upper pa rt of th e o ropharynx and redi rected after a rotation of 3 0 or more (33 3). Til ting (not rotating) the pati ent's head to ward the s ide of the intu bation ma y a ls o be helpful (3 78).

Direct Laryngoscopy

Af ter the tube is in the pharynx , the larynx is ex posed b y using a ri gi d l ary ngos cop e. If the tube impinges on the anterio r commissu re, i t s hould be twi s ted whi l e appl ying gen tle downwa rd press ure (379). The pos i tion of the lary nx re lativ e to the tube tip may be al tered b y fl exi ng or ex tending the neck and/o r ex ternal press ure on the lary nx . If these man ipula ti ons do not align the tube and laryngeal opening, forc eps c an be use d to gras p the ti p a nd di rec t it through the v ocal c ords . The c uff shou ld no t be grasped, as i t may be damaged by the forc eps . An al te rna tiv e to g rabbing the tube wi th a forc eps is to add 10 to 15 mL of ai r to the trac heal tube c uff (380). This may caus e the tip to align i ts elf with th e v ocal cords . The tube tip is then pushed in to the trache a until the cuff c ontac ts the v ocal cords , at wh ic h poi nt the cuff is deflated and the tube is ins erted i nto the trachea. If the tip passes through the v ocal c ords but then encoun ters res is tance , it is lik ely that the curv e of the tube is d irec ting the tip i nto the an te ri or wal l of the larynx . W ithdrawi ng the tube s li gh tl y and flex in g the neck wil l usuall y allow th e tub e to adv anc e into the trachea . Other techn iques incl ude ro ta ti ng the tube 1 80, pass ing a s uc tion ca the ter o r bou gie through the tube in to th e larynx as a guid e, an d i nserting a s tylet wi th a n ante rior be nd near the tip .

Flexible Fiberoptic Laryngoscopy

This method is often pref erred. B lind nas al intubation may s tir up bleeding and ru in the chanc e to v iew the la rynx through a fibers cope . The techniq ue is desc rib ed in Chapte r 18. A wi re- re inforced , P arker F lex -Ti p, o r warmed s ta ndard trach eal tube may fac ili tate i ntubati on with a fiberscope (1 3,19,52,5 3,54,55,317). Pas sag e beyond the epi gl ottis may be fac ili ta ted if the tube is rota ted s o that the bev el is fac ing up (23).

Blind Nasal Intubation

The blind technique ma y be useful wh en di rec t la ryngos copy or fi beroptic i ntubati on wou ld be difficul t. There are ins tanc es where bl in d nasal intubation may prov e l ife sav ing, and the techn ique is wel l wo rth lea rning (381,382 ,383). B lind n asal in tub ati on may be performed unde r gene ral or l ocal anes thes ia. A trac heal tube with direc tional tip c ontrol may i mprov e the s ucc ess ra te (84,86). The c las sic al tec hnique of bl ind nas al i ntubation requ ires a sponta neousl y b rea thing pati ent a nd us es b rea th so unds to guide placement. The patient is pl aced in the c las sic al intubating posi tion wi th the neck flex ed and the head ex tended. After the tube is i ns erted thro ugh the nos tril , it is advanc ed bl indly . If the pa ti ent is breathi ng spontaneous l y, breath sounds can b e heard as the tip approach es the larynx . W hen

the soun ds are a t max imal intens ity, the tube is gently bu t s wi ftly adv anced duri ng i nspi rati on . If the so unds s uddenly c eas e bu t the patien t c on tinues to breathe, the tube has passed into a loc ation othe r than the trac hea . Vari ous modifica ti ons of this techn ique have been des c ribed (384,385 ,386,387,388,389,390,391,392 ). T he BAA M and other whi s tle dev ices hav e been used to fac il i tate detec ti ng ai rflo w du ring in tubation (330,393 ,394,395,396,397). T hese dev ices are attac hed to the mach ine end of the trac heal tube and make a sound as ai r pas ses thro ugh the tube. The pres ence of end-ti da l CO 2 can als o be used as a guide to b li nd intubation (398,399 ,400,401). If CO 2 ceas es to be detec ted, the tube has entered the es opha gus . If the p ati en t is no t breathing, ce rtain lan dmarks on the f ront of the neck (h yoid bone, no tc h of the thyroi d carti lage, and th e c ricoid carti l age) can be obs erv ed. As the tub e mov es an teriorl y, the tip mov es these landmarks . The obj ec t is to mov e the tip to the midl ine at the th yro id angle, where it s hou ld en ter the l arynx . If the tip i s abov e the thyroid c arti lage, f lexi ng the head wil l mov e the tip c auda lly. If the tip i s below the thyroi d c arti lage, neck ex tens ion wil l mov e i t c ephalad . If the tip is observ ed l ate rall y, the tu be shou ld be wi th dra wn and twi s ted to d irec t it toward th e midline . If the tube tip pas ses the la ry ngeal in let but impinges on the anterio r trac hea, inc reasi ng cerv ical flex ion or rotating the tube throug h 180 may a ll ow it to pass in to the trac hea. Other man euv ers may be employ ed to aid blind nasal in tub ation . Flexi on or ex tensi on of the head or manipul ating the lary nx by ex ternal p res sure ma y line up the tub e and la rynx (40 2). Rota ting the tube ma y be helpful (332,403). A s tylet c an be i nserted in to the tube to help to adv anc e the tip through the v oc al co rds . The cuff may b e parti ally inflated in the orophary nx to elev ate the tip from the pos teri or pharyngea l wal l and c enter i t (380,402,404 ,405,4 06,407,40 8). The cuff is deflated before the tube is adv anced into the trachea . A s uc ti on catheter or nas ogas tric tube that is ins erted through the tu be may faci li ta te passage through the lary nx (409,410 ,411). A bougie c an be us ed (412). B lind nasotrac heal in tubation fac ili tated by co ntinuous fluo ros cop y has been desc ribed (4 13).

Depth of Insertion
In adul ts , the tube s houl d be ins erted until the cuff is 2.25 to 2.50 c m below th e v ocal c ords (147,414). This should be regarded as a s tarting pos i tion, as the re is great v ariation in the le ngth of th e trachea. Some manufac tu rers

P .587 place a mark abov e the proxi mal e nd of the cuff and reco mmend th at the tub e is adv anc ed until this mark lies at the v oc al c ord s . If no cuff is present, the tube ti p shoul d be ins erted no t more than 1 cm pas t th e c ords in ch il dren unde r 6 months , not more than 2 cm pas t the c ords for patients up to 1 year, and not more than 3 to 4 c m pas t the c ords in larger patients . In av erage-si ze adult patients , sec uring the tu be at the anteri or i nc is ors at 23 cm in mal es and 21 c m i n females has been s hown to be a reas onable s tarti ng point for tube place ment (415,416 ). Fo r nas al i ntubations , 5 c m shoul d be added to these l engths for pos itioning at the nares (417). Howev er, caution should be exerc ised in us ing routine depth of insertion , as trac heas v ary in length (418 ,419,4 20,421 ). Formulas bas ed on th e s ubjec t's hei ght o r oth er meas urements may be used (422,423 ,424), or th e c orrec t le ngth c an be es timated by ali gning the prox imal end of the cu ff ex te rna ll y at the lev el of the c rico id ca rtil age and angl ing the tube anterio rl y to ward the lev el of th e upper inc is ors o r gums (4 25).

Checking Tube Position

Af ter the tube has been inserted, i ts p osi tion s hould b e chec ked to b e c ertai n th at i t i s in the trac heobronc hial tree and that it is nei ther too deep nor too s hall ow. Methods to detec t bronc hi al o r esophageal intubation are disc uss ed in the Peri operativ e Co mplica tions s ec tion later i n this chapter. A fter co rrec t plac ement is confi rme d, the porti on of the tube ex ternal to the p atien t may be sho rtened to prev ent ki nking (426).

Inflating the Cuff

Low-volume, High-pressure Cuff
A high-pressure cuf f should be inflated with the minimal amo unt of gas that wi ll caus e i t to seal agains t the trachea at peak inspi ra tory pressu re. Lis tening with the unaided ear wi l l of ten miss s mall leak s. Th ese ca n be detec ted by pal pation or auscul tati on of the pretrac heal area. Inflation until the pi lot ba ll oon is tense and /or i nflating beyond sea l wil l res ult i n unn eces saril y high cuff v olume and pressure.

Low-pressure, High-volume Cuff

W ith a lo w-press ure , high-v olume cuff , the c uff s hou ld be inf la ted to a p res sure of 25 to 3 4 cm H 2 O (18 to 25 mm Hg) at end-exp iration in adul ts (77,157,197 ,200,201,202 ). No da ta ex is t in ch il dren abou t cuff press ure l imi ts , bu t

l ower c uff pressures are preferable. T he pressu re should be me asured (F ig . 19.29) and a djus ted approxi matel y 10 minu tes after the tube has been ins erted . This delay i s necessary to al low for sof tening of the c uff mate ri al at body temperature and for the patie nt to become se ttle d, becaus e the v olume nec es sary for occ lus ion wi l l v ary wi th mus c le tone . Not measuring the press ure wi l l usually res ul t in a p res sure well abov e th at recommen ded (139). Af ter cuff pressu re has b een adjus ted , a check should be mad e to make ce rtain tha t there is no leak at peak ai rwa y pre ssure. A l eak ca n be detec ted by a difference between inh aled and exh aled v olumes , a noi se heard with a s teth oscope around the cuff , or by monitorin g for CO 2 in the upper air way (139). Cuff press ure s houl d be measu red and adjus ted frequently . Changes in musc le to ne i n the trac hea and d iffus ion of gases ac ros s the cuff may resu lt i n large c uff press ure c hanges . Th e peak inspi rato ry press ure may als o c hange, so f requent checks for l eak s should also be pe rforme d. W hen a trac heal tube wi th a L anz press ure-regulatin g v alv e is us ed, the cuff s hould be i nflated un ti l a sea l is achiev ed duri ng pe ak ins pi ration. T he pilot b al loon should be dis tend ed but s maller than the c onfining she ath .

Sponge Cuff
Af ter intubation, the i nfla ti on tu be should be o pened to atmosphere and the cuff al lowed to fil l wi th a ir. The amount of air in the cuff should b e determi ned by wi th dra wing the ai r wi th a s yringe. The ability to re mov e 2 to 3 mL from the smal les t c uf f or 5 to 6 mL or more from the l arges t c uff usua lly s ignif ies that the cuff :trachea l wal l press ure ratio wi ll a ll ow adequate mucos al pe rfus ion. If l i ttle or no ai r ca n be aspi ra ted , the cuff may be too large. If a leak is present af te r the c uff has bee n all owe d to expand, wri nkl es i n the c uff may be pres ent and may be s traightene d out by injec tin g 2 o r 3 mL of air into the cuff and then allowi ng i t to deflate. If the leak pers is ts , a larger tube may be needed.

Securing the Tube

A sec ure ly pos i tioned tracheal tube is essen tial f or safe an es thes ia. If the tube is not wel l fixed, there is danger of accide nta l ex tuba tion, o r the tube may a dv ance i nto a bronc hus . The tec hnique used to f ix the tube mus t be appropri ate f or the nature of the surgery and allo w a cces s to the tube. Gen tl y pressi ng the chin toward the max i ll a wi ll help to k eep the tube in positi on whi l e i t is being s ec ured (427).

Adhesiv e tape is mos t co mmo nly used to ma intai n the tube i n the des i red pos i tion. A v arie ty of tap ing methods hav e be en use d (428 ,429,430,431 ,432,433). The pa rt of the tube to wh ic h the tape is to be app li ed s hould b e thoroughl y dri ed. A ll tap es do no t adhe re to a ll tracheal tubes equal ly we ll (429 ,433), s o it is adv isabl e to tes t av ailab le tapes to determi ne whic h works bes t f or the chos en tu be. A dhes ion to both th e patien t and the tube may be P .588 i mprov ed by us ing a transpa ren t adhesiv e dre ssing (434,435 ,436) or an adhes iv e such as ti nc ture of benzoin (434,437). If pos si ble , the tape s hould not be placed ac ros s the c onnec to r, becaus e it ma y o bsc ure a disco nnec tion and hinder rapid reconnec ti on (438,439). S ec uring the edges of the tape wi th tape a t a ri ght a ngle wi ll prev ent loosening at the ed ges (437). A c lear ad hesiv e dress in g p laced ov er the tap e wil l protec t i t f rom oral sec re tions , blood, or prep s ol utions (440). A g auze pad may be used to p rotec t the pati en t's face from the connec tor, es pec iall y when the patie nt is i n the prone or l ate ral posi tion (441 ). Many pati ents hav e beards or mus taches , mak ing i t diffic ul t to attach the tap e. For pati ents with suffici ently long mus tache ha ir, this c an be taped to the trac heal tube (442). If a mustache interf eres with proper fi xation, the patient sh ould be informed preoperativ el y that tri mming or ev en s hav ing may be necess ary. Bec ause h air is an i nsec ure medium for fix ing a tube, a c lose-fitti ng sk ul l c ap, e las tic net, or a towel taped around the head may be used to provi de a s truc ture to attach tape or ties (Fig . 19.30). Ano the r meth od is to use do ubl e-s id ed tape to attach an elas tic s trap (443). Some pa tients hav e c utaneous res pons es to adhes iv e tape (444,44 5,446). Fragile sk in is commonly present wi th prematurity, c hronic s teroid treatment, zinc defic ienc y , amyl oi dos is , epidermol ys is bull osa and p atients receiv ing cos metic sk in ex fol iants . In these patients , other ma teria ls s uch as a tie sho ul d be used to anc ho r the tub e (428,447,448,449 ,450,451,452 ). Special dev ic es (tube h olders , fixa tion dev ic es ) for s ecurin g tracheal tubes wi thout us e of adhes iv es or ti es are av ai lable c ommerciall y (453,454,455,456). A tube holde r may be combined with a bite block and /o r naso gas tric tube hol de r (457,4 58). Special methods for s ecuri ng the trachea l tu be in pa ti ents with trauma or fac ial burns hav e been desc ribed (448,459,460 ,4 61,462,463 ,464,465,466 ,467,4 68). Compl icated c rani ofac ial p roc edures and recons truc tiv e su rge ry may requi re securing the trac heal tube to a s tabl e tooth by us ing a wi re , suture, or dental f los s

(448). The tube may also be su tu red to the tongu e, be twee n the teeth, to a mand ibula r s truc tu re, o r to the nas al septum (469,470 ,471). A nas al brid le may be us ed fo r fix ati on of a nas otrac heal tube (472 ,47 3,474,475 ). A sec tion of ma te rial (e.g ., feeding tube o r umbi lical tape) is looped around the nas al septum. The three tubes (nasotrac heal and t wo e nds of the f ix ation material ) are then sec ured together cl os e to the ex te rnal nas al s eptum. This may be espec ial ly us eful in patients wi th tape al le rgies or excess iv e sec re ti ons .

Changing the Tube

Rep lac ing a trachea l tu be may be nec ess ary i f th e tub e is damaged or obs truc ted o r a la rge r tu be is requi red (476,477). It ma y be necessa ry to c hange f rom an o ral to a nasal tube or v ic e v ersa. There a re s ev eral tec hniques : direc t laryngosc opy, usi ng a flex ible endosc ope, us ing a laryngeal mask , a nd us ing a tube changer (discus sed l ate r in this chap ter). Combining these methods may c onfer add itional s afety (478,479 ,480,481,482). Changi ng an oral tube to a nasal tube by usi ng an AE C is disc ussed later i n th is chapter. Another tech ni que is to insert a fi berscope lo aded wi th a trac heal tube through the nostri l and then ins ert the tip into the trac hea besid e the oral tube . The oral tube is the n withdrawn and the nas al tube adv anc ed into the trachea. A l te rna tel y, a f iberscope ma y b e ins erted thro ugh the nos tril , re triev ed oral ly , then passed through the ex is tent o ral tracheal tube (483). The f ib ers cope and tub e are then wi thd rawn retrog rade through the nas al passa ge.

Removing the Tube

The oral airway or b ite block shoul d be lef t in place until af ter ex tubation to av oid bi ting on the tu be (67 ,4 84,485,486 ,487). Lidoca ine s pra yed down the trac heal tube wi ll attenuate the ai rwa y and ci rc ula to ry re ac tions during emerg ence a nd ex tubation (488,489 ). Respi ratory and ca rdiov ascular complications that are c ommonl y as soc iated wi th ex tub ati on can be dec reas ed by i nserting a sup raglo ttic airway dev ic e (Chapte r 17) befo re or jus t after remov al of the trac heal tube (490,491 ,492,493,494,495,496,497,498 ,499,500,501 ,502). Ex tubating a patient in whom it ma y b e diff ic ult to re -es ta blish an ai rway is bes t ca rried out in a s tag ed or rev ers ibl e manner, permittin g rei ntubation while al lowin g ox ygen admi nis tration by insufflatio n o r je t v enti la tion whi le the ai rwa y is being s ecured (503,504,50 5,506,507,508 ,509,510). An AEC that can be c onnected to the breathing s ys te m or o the r oxy gen sou rc e ma y be useful for this purpose . In the v ery s mall patient, a gui de wi re may be us ed (509).

Before ex tubation, the mouth and pha ry nx shou ld be s uc tioned and the tape or other fix ation d ev ice remov ed. W ithdrawi ng th e tub e unti l resis tanc e is met befo re defl ating the cuff may push material that has ac cumulated abov e the c uff into the pharynx , wh ere i t c an b e remov ed by suc tioning. A large sus tained inf la tion should be ad mi nis tered (504,511). A l ternatel y, the adj us tab le press ure li miting (APL) v alv e can be c losed and airway press ure all owed to ris e to 5 to 10 c m H 2 O (512). W hile the lung is near to ta l capaci ty , the c uf f should be deflated and the tu be remov ed. If a s yri nge cannot be loc ated, the tip of a pen c an be inserted into the v alv e as sembly to defl ate the cuff (513 ). The practi ce of pulling the pilot bal loon and i nflation v alv e from th e i nfla tion tube to deflate the c uff s hould be disc ouraged , as this c an c ause the inf la tion tube to seal (514,515 ,516). Suc tion shou ld no t be applied to the tube during ex tuba tion, as this wi ll c ause oxygen d esaturation (511,517 ). If the tube c anno t be eas il y remov ed, the i nf lating tube shou ld be c heck ed fo r obs truc tion, espec ia lly at the P .589 point where tape wa s used to h old the tube i n p lace. If th e surgery has inv olv ed the mouth, neck , or thorax , a su ture may hav e b een plac ed through o r around the tube. If the tube is fo rci bl y remov ed in these c i rcums tances , the surgic al s ite may be dis rupted.

Using Open but Unused Tubes

Many c linic ians feel that it is nec ess ary to open one o r more tubes of different s izes . This ra is es the ques tion as to wh ether i t is s afe to s to re these tubes f or anoth er day . S tudi es in dic ate tha t tracheal tubes c an be use d up to 14 da ys af ter being op ened (518,519). Ho wev e r, if a lubricant has b een us ed, i t may dry out and form flak es (520).

Perioperative Complications Failure of the Tube to Pass into the Trachea over an Intubating Device
It is s ometimes difficul t to pass (ra il ro ad) a trac heal tube ov er a f ibers cope , ligh ted s tyl et, bougie , or ai rway exc hange c atheter (A E C) and through the glo ttic o pening. W hen us in g a f lex ible e ndos cope , th is can often be prev ented b y using th e l arges t sc ope that fits eas il y ins ide an appropriate s ize of trach eal tube an d k eeping the

f ibe rs cope in the mi dl in e (521 ,522,523,524 ,525,5 26,527). A tube with a tip desig ned to minimize the dis tanc e between the fiberscope and the leadi ng edge o f the tub e may pass more eas il y than a s tandard tube (14,15,18,19,20,21,24,90,91,52 8). A s piral e mbedded tube ma y p ass more easi l y ov er a fi bersc ope th an a tube with a p reformed curv e (53,5 4,55,529,530 ). W armin g a s tanda rd trac heal tub e may fac il i tate its pas sage (55,317 ). The tube may pass more eas il y if i t is rev ers e loaded (u pside down f ro m i ts na tural c urv ature ) (527,531 ). Other man euv ers c an be tak en to fac i li tate passing a trac heal tube into the trachea (532). A supraglottic dev ic e such as an L MA may fac il itate intuba tion (5 33). Rotatin g the trac heal tube 9 0 counterc lockwi s e may be he lpf ul (18,277,505 ,524,526,534 ,535,5 36,537). Other help ful maneuv ers are neck ex tensi on, us ing a rig id laryngoscope to ope n up the ai rway, a ppl ying a j aw thrus t, and a ppl ying ex ternal p res sure to the larynx (521 ,538,539,540,541). A nother method is to insert a smal ler trac heal tube b eyond the tip of the trac hea l tu be (529,533 ,542,543). A s ty le t may be pl aced wi thin the tube wi th th e fiberscope (544). S till another techn ique is to pass an AE C v ia th e tracheal tube bes id e the f lex ib le sc ope un ti l the ti p of the catheter is v isuali zed ne ar the carina (545). A s leev e may be placed on the fibe rsc ope to inc rease its diameter (522,546 ). If the pati ent is awak e, he can be aske d to take a deep breath or in the s itti ng pa ti ent to l ook upward (547).

Trauma
Intubatio n is of te n assoc ia ted wi th tra uma to the s truc tures in the up per and lower ai rwa ys . On e s tudy found that 86 % of patien ts had occul t or v isible bloo d after ex tubation (548). Ai rwa y inj ury forms a majo r subg roup of malprac tic e c laims (549,550 ). Trauma is often as soc iated wi th us e of exc ess iv e force or repea ted attempts at in tubation . It v aries wi th the sk ill of the opera tor, the diff ic ulty of the i ntu bation, and the amount of musc le rel ax ati on . Damage may be inc reased if the s tyl et protrudes beyond the end of the tube or through the Murp hy eye . Mucos a can be torn wh en a me tal or fo il -wrap ped tube is used. A defec tiv e tube may hav e a barb. Reported i nju ries to the lary nx incl ude hema tomas , c ontus ions , lac erations , punc ture wo unds , cord av ulsi ons , and f rac tu res (550 ,551). A rytenoid ca rtilag e disl oca tion may oc cur (550,552 ,553,554,555 ,556,557,558 ,559).

W ith nas otrac heal intuba ti on, a bras ion or laceration of th e nasa l mucosa is common (560). The nasal s eptum ma y be dislocated or perforated. Fragmen ts of adeno id tis sue, nasa l pol yps , or turbinates may be di slodge d (375,561 ,562,563,564,565,566). B lood clots f rom epis tax is ma y e nte r the trac hea and b loc k a b ronchus (567 ,558). Cas es of trac heal , b ronchial , pharyngeal , nasal f oss a, hypophary ngeal, p yriform s inus , es ophageal , and larynge al pe rfora ti on hav e been reported, so metimes wi th fatal c onsequenc es (550,569 ,570,571,572,573,574,575,576 ,577,578,579 ,580,581,582 ,583,584,585,58 6, 587,5 88,589,590 ,591,592,593 ,59 4,595). Eso phag eal perforation c an occu r (550,596 ,597,598,599,600,601,602,603 ,604). The bes t wa y to av oid trauma is to nev er use more than gentle pressu re. A s tylet shoul d be fl exible and not ex tend be yond the tip of the tu be. Metho ds to dec re ase trau ma to the nose were dis cus sed in the Nas al Intubation sec tion.

Esophageal Intubation
Eso phag eal i ntuba ti on can oc cur ev en wi th an ex perienced an esthes ia prov ider (605,606 ,607,608,609,610). Recognition and prompt c orrec ti on are neces sary to prev ent di re c onsequences . In mos t patien ts , rec ognizing es ophageal in tubation is not diff ic ult. Bu t in s ome, the s igns so c los el y res emble trachea l placement that they can d eceiv e ev en a carefu l, ex pe rience d ind iv idual . In man y of the repo rted cases of esophageal i ntubation, one or mo re of the followi ng tes ts were performed and we re misleading.

Direct Visualization
Di rec tly v isua li zi ng th e tube pass ing be twe en the v ocal cords is one of the mos t reliable methods . Unf ortunately , the g lottis of ten cannot be seen wel l. The tracheal tube may be pos te ri orly displac ed with th e laryngosco pe blade s til l in the mouth , bringing the larynx i nto v iew (611). Howev er, ev en after the tube is P .590 v isuali ze d between th e c ords , i t may s li p out as the la ry ngos cope or s tyle t is remov ed o r the tube is s ec ure d.

Feel of the Reservoir Bag

Normal reserv oir bag compl iance and ref il lin g wi th manual v enti lation is a nother method to determine c orrec t trac heal tube placemen t. This tes t is un rel iable (605,606 ,612). It may be more re li able if performed wi th no f res h g as fl ow (6 13). A related tes t is see ing mov ement of the res erv oi r bag in time wi th the pa tient's spontaneous respi ratory efforts . Howev er, tidal v olumes hav e been no ted wi th the tube in the es ophagus (605,614).

Chest Wall Motion

Some us ers rely on v isual and/or manual evi denc e of ches t wal l mov ement d uring v enti lation . Unfortuna tely, mov emen t of the ches t wal l s imulating lung v entilation can occur with the tube in the esophagus , espec ial ly in patients wh os e respi ra tion i s primarily abdominal (606,614 ,615,616). Ches t wal l mov ement may be d ifficu lt to as sess in th e obese p ati ent or i n the pati ent wi th l arge breas ts . Low lung o r ches t wal l co mpliance may resul t i n l i ttle c hes t mov emen t, ev en when the tube is in the trac hea. Lis tenin g throug h the ope n end of the trac heal tube wh il e the s ternum is abruptl y depress ed c an also be misl eading (606).

Auscultation
Aus cul ta ti on shoul d be performed hi gh in each midax illary area, no t jus t the anterio r ches t regi on. The qual i ty of the sounds is imp ortant. A gurgling s ound (death rattle) s ugges ts esophageal pl acement. This tes t is not al way s rel iable (605,606 ,614,615,617,618,619). Ausc ul tating the u pper a bdomen as well as th e l ungs may inc rease the rel ia bil i ty of ausc ultation (615,620). These sounds may be confused wi th breath sou nds th at are often heard i n the epigas tric area in thin i ndiv iduals and pedi atric patien ts (605,618 ). Ano the r method of de termining trac heal tube locati on is breathing sys tem auscul tati on (621). A s tethosc ope is a ttach ed to an adaptor i n the breathing sys tem adjac ent to the trachea l tube. If the tube is in the trachea , loud breath s ounds a re heard. If the tube is i n the esop hagus , s queak s o r flatus -like s ounds a re hea rd. This tes t is not total ly rel iab le .

Epigastric Distention
The abdomen c an be obse rv ed for gas tric dis tention. Unfortunate ly , th e abdomen does not al ways dis te nd with in termi ttent gas tric inflation, and gas tric dis te ntion can resu lt f rom mas k v enti la tion before i ntuba ti on is a ttempted (606). The presence of a hiatal hernia or i ntra tho rac ic gas trointes tinal c ontents may res ul t in the absenc e o f abdominal dis tention with esophageal intubation (61 4). The presence of

a nas ogas tric tube may mak e gas tric fil ling difficul t to dis tinguis h f rom no rmal abdominal mov ements durin g v enti lation.

Moisture Condensation in the Tracheal Tube

Mois ture c onde nsation in a trans parent tracheal tube is not reli ab le, because mois ture c an appear wi th es ophageal intuba tion (605,606 ,615,6 22,623). But if no condensatio n is s een, the tube is almos t always i n the es ophagus .

Gastric Contents in Tracheal Tube

Gas tric co ntents in the tube lumen may indica te mispl acement. Howev er, gas tric f luid may not appear wi th es ophageal plac emen t and/or may be dif ficu lt to dis tinguish from sec reti ons f rom the trache a (605 ,606).

Oxygenation
Good p ati ent color or s atis fac tory pulse ox imeter read ings hav e b een adv ocated as a means to con fi rm trach eal p lac ement. Howev er, hypoxe mia may be de layed a numb er of minutes wi th es ophageal in tubation if preox ygen ation has been performed. Later onset of hypoxemia may occ ur f rom other c auses beside es opha geal intuba tion and mus t be ru le d out. B y tha t time, esophagea l in tubation may no t be sus pec ted. If ox ygen s atura tion i mp rov es af te r intub ati on, it is l ik ely that the tube is in the tracheobronchial tree (6 24). The patient c an be v enti la ted by us ing a mas k placed ov e r the open tube and mou th. Cyanos is rel iev ed by this mane uv er is ev idence of tube mis plac ement.

Chest X-ray
Ches t radiography is ti me cons uming and ex pens iv e and may not be defini tiv e i n determin ing if the tu be is i n the es oph agus (605,606 ,625,626,627 ).

Palpation
Durin g intuba ti on, a was hboard like sensation c an of ten be fel t by the indiv idual who i s ma ni pulating the tu be or apply in g c ricoid press ure as the tu be pas ses ov er the trac heal ri ngs . After tube plac ement, mane uv ers suc h as inf lating an d def lating the cuff rapi dl y, s quee zing the pi lot ba ll oon , or mov ing the tube in an d out may be fel t whe n the neck is pa lpate d a t the s upras ternal n otc h (628). T he rol l tes t inv olv es gentle bac k ward pressure on the c ric oi d cartil age and s imul taneous si de to s ide displac ement of th e c arti lage in an attempt to detec t a trac heal tube lying behind in the esop hagus (629). None of thes e tes ts is alwa ys re liable (6 05,629,630 ).

Cuff Inflation Needed to Produce a Seal

Ano the r method is to note the amount of ai r required to c aus e the cu ff to form a seal. A n excessiv e amount may indicate eso phag eal p lac ement. If the c uff is at or P .591 j us t a bov e the v oc al co rds o r is torn o r fails to ex pand unif ormly, the re wi ll als o be a nee d for h igh v olu mes of ai r to be added to the tracheal tube cuff.

Figure 19.32 Adaptor to allow a fiberscope to be inserted without interrupting ventilation.

View Figure

Fiberscopic View
The trachea l rings c an be v isuali zed by using a f iberscope o r an optical s ty let. A spec ial adaptor (Fig . 19.32) with a port wil l al low v entil ation whil e the examinati on i s carri ed out. Thin optic al f ibers p ass ed through o r incorporated in to a tracheal tube can be used to c onf irm the proper placemen t of the tracheal tube wh en a f ibe rop tic scope is too large to pas s through the tube (631,632,633 ). This is a rel iable method b ut requi res s pec ial ins trumen tation, s kill , and time . If the tip of the tube han gs up on the anterior c ommis sure, i t may be possible to v isua li ze the trachea, ev en though the tu be is no t in the trachea (634,635).

Tactile Confirmation
Tac til e c onf irmation inv olv es pl acing one hand inside th e patien t's mouth and the other hand on the neck and conf i rmi ng th at the tub e li es i mmediate ly an teri or to the i nte raryteno id groov e. This tes t is not total ly rel iable (636,637 ).

Intentional Bronchial Intubation

The trachea l tube may in ten tionall y be adv ance d into a mains tem b ronc hus (638,639 ). The c hes t is then auscul tated during pos i tiv e-press ure v entilation . If breath sounds can be heard on only one s ide, b ronchial i ntubati on has been ac hiev ed. Wi th esophageal intubatio n, the bre ath s ounds a re ei ther equal bi laterall y or equall y dimi nished o r abs ent on bo th s ides of the c hes t. Th is tes t is not foo lp roof (638).

Passing a Device through the Tracheal Tube

A nas ogas tric tube, introduc er, or other devi ce can be passed d own the trachea l tube (605,640). If the tube is in the trac hea, i t wi l l abut the c arina at 2 8 to 32 cm in adults . If the tube is in the es oph agus , this resis tance wi l l not be f el t. Othe r c riteria i ndicating trac heal intubation inc lude the abi li ty to main tain ai r entrainment through the open end of the tracheal tube whi le s uc tion is applied to the tube, the ease of wi th dra wing the tube with suc tion, and the abse nce of bile or gas tric c ontents in the as pirate.

Tracheal Illumination
A lighted intubation s ty le t, dis cuss ed la ter in this c hapter, can be passed through the tub e and th e i ntens ity of the il lumination us ed to dif fe ren tiate trac heal f rom es opha geal intuba tion (641). Obes ity and swe ll i ng of the neck mak e use of this tec hnique diffic ult, and i t c an onl y be used wi th tubes larger than 6 .5 mm ID (642). This tes t has limited reliab il ity (6 19,643).

Pressure- and Flow-volume Loops

P ress ure- and flow-v ol ume loops a re discussed in Chap ter 2 3. If the trache al tube i s in the esophagus , the loops wi ll not hav e th eir charac teris tic shapes . The loop wi ll pro babl y be open. A l though i t wi ll n ot de tec t all esophageal intuba tions , th is tes t has a high likel ihood of s ucc ess.

Esophageal Detector Device

The esoph agea l detec tor dev ice (E DD ) (Fi g. 1 9.33) cons is ts of an as pirating co mponen t (a large s yrin ge or se lf -inf la ti ng comp res sible bulb ) attac hed to the trac heal tube usi ng an ada pto r (642,644,645 ,646,647,648,649). T he pl unge r is wi th dra wn, or the c omp res sed bu lb is releas ed. If the tube is in the trachea and a n ai rti ght s eal has been ac hiev ed , P .592 gas wi l l be as pirated from the patient's lun gs wi thout res is tance . Howev er, if the

tube is i n the esop hagus , app osi tion of the es ophageal wal ls around the tube tip wi ll occl ude the lumen and caus e a negative pres sure o r res is tance. A s a confi rma tory tes t, the dev ice can be used to i njec t a bolus of ai r i nto the tube whi le l is ten ing ov er the epi gas trium. This tes t wi ll als o detec t a bloc ked trac heal tub e (646). The EDD should be used immediately a fter tube placement, prior to deliv ering the firs t b rea th (608).

Figure 19.33 Esophageal detector device attached to a tracheal tube.

View Figure

Mos t s tudies sho w that this test has a hi gh degree of acc uracy in iden tifying es opha geal intuba tion ev en with inexpe ri enc ed users (619,642 ,646,650,651,652,653,654,655 ,656,657,658 ,659,660,661 ,662,663,664,66 5) , bu t one showed poor sensi tiv ity (666). It can be us ed to de tec t the pos i tion of the Combi tube (667). The presence of a nasog as tric tube or trac heal tube c uff defla ti on does not l imi t i ts eff ic ac y (668). Its ac curacy is not affec ted by lack of pul monary perfus ion. It is fas te r than mos t other me th ods . This dev ice may be be tter than ex hal ed CO 2 in the cardi ac arres t patient (663,66 9). The re are a number of fa ls e-n egativ e res ul ts in whic h the tube is in the trache a but the bulb expands too s lowl y o r not a t all (670,671). Some inv estiga tors found that there we re f ewer f alse-nega tiv e resul ts i f 10 s econds were a llowed for rei nflation (656). The re are s ituati ons whe re this d ev ice may not conf i rm placemen t in the trac hea (646,672). The b ulb wi l l not re-expand ra pi dly in patients wi th d ec reas ed ex piratory res e rv e v olume as with the mo rbidl y obes e or pregnant patient, patients wi th bronc hospas tic dis ease , tracheomalac ia, pulmonary edema , bro nchial i ntu bation, and upper o r lo wer ai rwa y obs truc tion

(642,656 ,659,673,674,675,676,677,678 ,679,680). Patients hav ing ces arean sec tions hav e been inv estigated by usi ng thi s tes t, a nd a high n umber of fa lse positiv e and false-nega tiv e resul ts we re found. The inc idenc e of f als e negativ es is reduc ed if the bu lb is compress ed after c onnec tion to the tracheal tube. Another sourc e o f a false negativ e is the bev el l ying agains t the trachea l wal l. This dev ice is unrel iable in patients unde r 1 y ear of age (681). If the tip of the tracheal tube is abov e th e cords , a f alse-nega tiv e test c an occu r (6 63). False pos i tiv es hav e bee n repo rted where th e trachea l tu be was not in the trac hea but the dev ice sug ges ted that i t was (656,67 6,679,682,683 ). T hes e may be rel ated to an inc ompetent gas tro esophage al junc ti on (obesi ty, pregnancy ) or gas tric i nflation.

Ultrasound
Ul traso und imaging of the di aphragm jus t be neath the x ip hoi d p roc ess c an identif y mos t esop hageal i ntubati ons (684).

Exhaled Car bon Dioxide

In mos t cases , an es ophageal intubation c an be rapidl y and rel iabl y determined if CO 2 is not pres ent in the exhaled gas es (6 05,606,619,685). Carbon di oxide moni tori ng is discus sed i n detail in Cha pte r 22. A l though not fool proof , this is generall y considered th e mos t re liable method of d etec ting esoph ageal in tubation . The A me rican Soc ie ty of A nes thes iolog is ts (A SA ) S tanda rds for Bas ic A nes thetic Moni tori ng an d the Americ an Ass oc iation of Nurs e Anes the tis ts (AA NA ) require that whe n a tracheal tube is inse rted, i ts c orrec t posi tio ning mus t be v e rifi ed by i dentification of CO 2 in the ex pi red gas (686). It has been found to be rel iable in c i rc umstanc es where the esophagea l detec tor dev ice was unrel iable (687 ). Carbon di ox ide may not be detec ted despi te c orrec t placemen t wi th sev ere bronc hospasm, c ardiac a rres t, no pul mona ry blood f lo w f ro m problems such as pulmonary embolism, or a one-way obs truc ti on in the trach eal tube (612,660 ,688,689,690). The E D D may be a more rel iable dev ice i n thes e c i rc umstanc es (669). In the prehos pital s etti ng, c ol orimetri c end-tida l CO 2 (Ch apter 22) ma y be di ffic ul t to us e because of inadequa te l ight. Carbon diox ide may be detec ted wh en the tube tip is abov e the v ocal c ords (691,692,693 ). The re are some c i rc ums tanc es in whi ch CO 2 may be detected if the tube is i n the es opha gus (694,695). Ex haled gas es may hav e been fo rc ed into the s tomach duri ng mask v entil ation before intubation (66 0,696). Carbon diox ide c an b e i n the s tomac h as a by-produc t of antac ids that hav e reac te d with gas tric ac id or f rom i nges tion of

ca rbonated bev e rages . In these cases , the end-tidal CO 2 wi l l be l ow. The capnog ram (Chapter 22) wil l hav e an abnormal c onf iguration and be i rreg ul ar. In this s ituation, the CO 2 lev els wi ll rapidl y diminish wi th repe ated v entil ati on (697).

Inadvertent Bronchial Intubation

Bronch ia l in tubation is a relativ el y c ommon problem (618,698,699). It occ urs more f requentl y wi th emerg enc y i ntubati ons an d in ped iatric and female patients (700,701 ). A sho rt trac hea is ass oc iated with a numbe r of pedia tric s yndromes (702). One s tudy s howed that RA E tubes (discussed p rev ious l y in this c hapter) were too l ong in 32% of ch ildren, and b ronchial intuba tion occ urred in 20% (44). B ronch ia l placement c an lea d to atelec tas is in the nonv entilated l ung (7 03). The l ung that is v enti la ted may become hy perinfl ated, lead ing to barotrauma and hypotens ion . If the tip impinges on the cari na, pe rs is tent coughi ng and buc king may oc cur. Us ually, the tube wi ll enter the ri ght ma ins te m bronc hus , eithe r bec ause of the anato my of th e c arina an d the trac heal bifurcation or the ri ght-s id ed bev el of the trac heal tube (704 ,7 05,706). Tubes without bev els als o tend to enter the ri ght bronc hus (707). B ronch ia l in tubation c an occu r af ter correc t in itial pl acement. A tracheal tube may descend into a bronc hus P .593 as a res ul t of the wei ght of the attac hments, s uc tio nin g, mov ement of the patien t's head, and/o r nec k o r patient repos itioning. It i s impo rtant that the c o rrec t tube position is c onfirmed af ter the pa tient's pos iti on has b een al te red . The tube wi ll us ual ly mov e caudall y wi th neck flex ion , mouth open ing , and ch ange i n pos i tion f rom erect to rec umben t (148,154 ,421,708,709,710,711,712,713 ,714,715,716 ,717,718). The dis tanc e from the cords to the cari na is dec reased duri ng l aparosc opy and with the Trendele nburg position (719,720,721 ,722,7 23,724,72 5,726). Mani pulation of an instrument i ntroduc ed into the mouth suc h as a transesophagea l echoc ardiography p rob e, gas trosc ope, or tongu e depresso r can result i n trach eal tube mov ement (713,714 ,727). A numbe r of techniques and tests hav e been recommended to av oi d or detec t bronc hia l intubatio n. These should be made after intubati on and at interv als during

an an esthetic , esp ecial ly af ter the patient is repos i tioned o r th e head and neck are mov ed.

Lung Auscultation
Lung ausc ul tation is the mos t c ommonly use d me thod to detec t bronchial i ntu bation. Aus cul ta tion s hould be performed bi la teral ly i n th e midax illary a reas . If su rge ry has b egun an d ausc ultatio n would dis tu rb th e surgic al f ie ld , the e nd of the s tethos cope c an be put in a s te ri le bag and pos itioned in e ach ax il la b y a member of the su rgica l team (728 ). A uscul tati on may be misleading , as breath soun ds can be transmitted to the oppos i te s ide of the ch es t i n the p res enc e o f bronch ial i ntu bation, un les s the tube is wedged fi rml y in a bronchus (700,729 ,730,731,732,733,734). The prese nce of a Murphy eye ma y reduce the reliabil ity of c hes t ausc ul tation in de tec ti ng bronc hia l in tubation .

Symmetrical Chest Expansion

V isua lizati on of sy mmetric al c hes t expans ion is e asi ly performed but is not rel ia ble . The c hes t is no t al ways av ailab le f or inspection .

Chest X-ray
Ches t x -ra ys are reliable b ut time c onsuming and ex pens iv e. The trac heal tube s tandard (11) requ ires a rad iopaque marke r at the patient end o r along the f ul l l ength of the tube. Th e tip of the tube s hould be in the middl e thi rd of the trachea , wi th the head i n a neutra l pos ition (midway between f ul l ex tensi on and full flexi on ). In adul ts , the tube tip s hould be 3, 5 , or 7 cm abov e the ca ri na wi th the neck f lexed, neutral , or ex tended , res pec tiv el y (702). The tip s hould l ie ov er the second to fourth thorac ic v erteb rae in the n eutral pos ition (612 ,729) or a t th e l ev el of the c lav icle (724). In the neonate, inf ant, and young ch ild, the ti p should b e 2 c m abov e the carina wi th the nec k in th e neutral pos itio n (735 ). In c hi ldren approach in g 5 to 6 years of age, th is dis tanc e shou ld be inc reas ed to 3 cm.

Tube Position at the Lips/Nostril Adult Patients

It has be en rec ommended tha t oral tubes be posi ti oned a t th e 21-c m mark on th e tube at the teeth (or upper ante rior ed ge of the gums i n edentulous pa tients ) i n normal -s iz e femal es an d 22 to 23 c m in no rmal -siz e males and that for nas al i ntu bation, 2 or 3 cm be added to these leng ths for pos i tioning at the nos tri l (415,736 ,737). S tud ies s how th at this is a bette r method of prev enting bronc hial

i ntu bation than c hes t ausc ul tati on. Ho wev er, i t wi ll res ult i n malposi tionin g in some pati ents (419,423,700 ,701,738). The re is a c orrel ation b etwe en ai rway l eng th and body hei gh t (419,423). For pati ents whos e body lengths lie ou ts ide the normal range , the tube c an be pl aced alongsi de the patient's fac e and nec k . The ti p of the tube is al igned to the supras te rnal notch , and the tube is ali gned to c onform to the pos iti on of a nas al or oral trachea l tube. Th e p lace on th e tube a t whic h th e tube i nters ec ts with the tee th or gums (oral intuba tion) o r the nares (nas al i ntubation) is noted, and the tube is secured at that poin t.

Pediatric Patients
The margin of s afety in c hildren is l es s than i n adu lts . A numb er of formulas hav e been dev eloped, inc lud ing the f ollowi ng :

Oral Intubation

Length i n cen timeters = age /2 + 12 cm (700). Length i n cen timeters = wei ght in k i lograms/5 + 1 2 c m. Length i n cen timeters = hei gh t in c entimeters /10 + 5 c m. Rule of 7-8-9: infants weighin g 1 k g a re intubated to a depth of 7 c m at the l ips , 2-k g i nfants to a depth of 8 c m, and 3-k g inf ants to a l ength of 9 cm. Equations based on the c rown-ru mp and c rown-heel len gth hav e been dev el oped (710).

Nasotracheal Intubation

L = (S 3) + 2, whe re L is the length in c entimeters , and S is the ID of the tube in mi l li meters (739). Mul tipl ying c rown-heel length b y 0.21. For total tube leng th, 0.16 height in c entime ters + 4.5 c m, then leav e 2 c m of tube outs ide the nos tril of an infant an d 3 c m ou ts ide f or an olde r chi ld (740).

W hi le us e of special f ormu las ma y dec reas e the inci dence of bronc hia l intubation, they are bas ed on av erages and shou ld no t be cons idered total ly rel iable. Furthermo re, tube length marki ngs are not a lwa ys acc ura te (741).

Placing the Cuff Just Below the Vocal Cor ds

P lac ing the cuff onl y a fe w c entimeters pas t the v ocal c ords shou ld av oid b ronc hial i ntu bation in adu lts . P .594

Guide Marks on the Tracheal Tube

Many tubes hav e l in es or rings to help pos iti on the tube wi th respec t to the v ocal co rds (Figs . 19 .2 , 19.4), and the dis ta l porti on of s ome pediatric tubes are colored (Fig . 19.23) (147 ,14 9,153,154,74 2,743). Gui de (de pth) marks v ary in thei r pos iti on rela tiv e to the cuff and ti p of the tube (148,1 50,151,152 ,15 3,744,745 ).

Intentional Bronchial Intubation

The tube c an be adv anced un ti l un ilateral breath s oun ds and c hes t mov ement are observ ed. The tube is then sl owl y wi thd rawn , noting the tube length at na res or gum at wh ic h s ymmetrical bre ath s ounds a nd c hes t mov ement return . The tube is then wi thd rawn an addi tional 2 cm in chi ldren (73 5). The tu be should be wi th dra wn further in adu lts .

Fiberscopic Observation through the Tube

Pas s ing a fiberscope through the tube is equal in ac curac y and fas ter than a c hes t x -ra y for d ete rmining tube posi tion in both adul ts and pediatric patients and is mo re ac curate than auscul tation (632,734,7 46). The ready av ai lab ili ty of f iberscopes in mos t OR s uites mak es this a prac tic al method of chec king tube pos i tion. Howev er, head and nec k mov emen t during the ex ami nation may c ause the tube to mov e (726).

Palpation of the Anterior Neck

Ano the r method to de termine trac heal tube l oca tion inv olv es inf la ting and deflating the cuff whi le palp ati ng the anterio r neck (736). Th e l owe r border of the c uff shou ld be fel t jus t abov e th e supras ternal n otc h. Th is method is not totally reli ab le (700). W ith unc uff ed tubes , th e tip of the tube c an be fe lt d uring ins e rtion and adv anc ement s to pped when the tip has j us t pas sed the supras ternal notch.

Monitoring Expired Carbon Dioxide

Moni tori ng ex pi red CO 2 may l ead to the disc ov ery of b ronchi al intubation, bu t it is not a reliable means to detec t this p rob lem (698,724 ,747). E ither a n inc rease or dec reas e i n end-tidal CO 2 may be s een.

Lighted Intubation St ylet

Ins erting a ligh te d i ntuba ti on s tyl et so that the l ig ht is a t th e tip of the tube and positioning the tub e s o tha t the max imu m transi ll uminated glow is at the s ternal notch an d then a dv anci ng the tube 2 to 3 c m c an b e used to p lace the tube tip at a sa tisfac tory l ev el (748).

Pressure- and Flow-volume Loops

Peak ins pi ratory pressure wil l us ual l y i nc rease with bronchial in tubation . P ressurev olume an d flow-v olume loops (C hapter 23 ) can of te n be used to detec t b ronchial i ntu bation. The p res sure-v olume loo p wil l sh ow low c omplianc e when the trache al tube enters a mains tem bronc hus . As the tube is withdrawn, the re wi ll be a mark ed sudden improv emen t in c ompl iance as the tube leav es the bronc hus . If peak i nflation pressure is mon itored whi le de liv eri ng a c ons tan t min ute v olu me, bronc hia l i ntu bation wil l caus e an immediate inc reas e in peak inflation pres sure (749 ).

Ultrasound
Ul traso nic imagi ng of the di aph rag m be neath the x iphoi d process c an detec t bronc hia l intubatio n (684 ).

Other
Dec reases i n satura tion of p uls e oxi metry (S pO 2 ) a nd transc utaneous ox ygen are of ten s een wi th bronc hial intubation (61 8,698,747). Howev er, des atu ration wil l no t al ways be s een, ev en wi th mass iv e atel ec tas is. If the patie nt is rec eiv ing a h igh ox ygen c once ntration, the ox yg en saturation may no t fa ll . Aco ustic ref lec trometry h as been us ed to de tec t bronc hia l intu bation in the presenc e of equal bilateral breath sounds (7 30). W hen a trac heal tube is bel iev ed to be in a bronc hus , the cuff s houl d be def lated and the tube gen tl y withdrawn, the c uff re-inflated, and the p osi tion rechecked . If rein tub ation wo uld be d ifficul t b ecause of the patient's pos ition or becaus e the i ni ti al intubation was diff ic ul t, c ons ide ration should be giv en to adv ancing a f ibe rs cope or v entil ati on catheter (s ee below) into the tube befo re wi thd rawing i t. If ex tubation s hould occ ur, the trac heal tube can be quick ly rei nserted.

Swallowed Tracheal Tube

The re are a number of c as e repo rts of a tracheal tube being los t in the esophagus , us ual ly du ring newb orn resusci ta ti on (750,751,75 2,753) and in an adult foll owing emergenc y intu bation (754 ). The use of a co nnec tor tha t fi ts f i rml y into the tube c an prev ent this c ompl ic ation . Bonding be twe en the c onnec to r and the tube wil l be

i nc reas ed if the connec tor is wi ped wi th alco hol before being ins erted into the tube. The tube s hould be long enough that i t pro trudes f rom the mouth when co rrec tly place d and fi rml y secured. To s ecure the tube , tape should be attached to the tube i ns tead of to th e c onn ec tor. If this compl ication occu rs , the tube does not need to be remov ed i mmedi atel y.

Foreign Body Aspiration

Durin g intuba ti on, a v ariety of materia ls that c an caus e blockage or check -v alv e obs truc tion can be as pi rated into the trac hea. The tracheal tube may disl odg e f rag ments of tiss ue, incl ud ing teeth, f rom the oral cav ity, pharynx , or lary nx . A tube i nserted nasa ll y may disl odge ad enoid or nasal tissue during i ts passage. P .595

A portion of a cuff o r sha ft of the tube inc luding the punched -ou t are a from the Murphy eye s ti ll in s itu may be left in th e a irway (7 55,756,757,7 58,759,760,7 61). A trac heal tube c an sep ara te f rom its connec tor and sl ip be low the c ords . Other f oreig n bodi es that hav e been found in trach eal tubes inc lu de cottonoids or pieces of aluminum us ed to pro tec t th e cuff or shaf t from a las e r beam, the dis tal portion of a trac heal tube, a c ap li ner from a tube of a nes the tic ointment, and parts of s pra ys and laryngosco pes (261,628,762,7 63). Careful inspec tion of equipme nt before use wi ll h elp to av oid introduc tion of forei gn bodies . The c onnec tor sho ul d f i t fi rml y in the trac heal tub e, and the tape or securing d ev ice s hould b e a ttached to the tu be, no t th e c onnec tor. When a c uf f l eaks , i t should be c areful l y examined for mi ssing portions after i t is remov ed from the patie nt. Forei gn bod y aspi ra tion sh ould b e suspec ted whenev er obs truc tiv e s igns or s ymptoms a ppea r. The patien t's ai rwa y s hould be searc hed i mmedi ate ly an d s hould i ncl ude bronc hos copy if ex amination ab ov e the lev el of the larynx prov es fruitless . If the f oreign body is abov e the c uff , i t might be poss ible to blow it out of the trac hea by defl ating the cuff and forc ibly c ompress ing the reserv oi r bag in the breathi ng s ys tem (764).

Leaks
A leak may make i t diff ic ul t to maintain adeq uate v entil ation, fai l to protec t a gains t as piration, and inc rease the dif ficu lty of s u rge ry inv olv ing the ora l cav ity (765).

Durin g ins ertion, the cuff , inflatio n tube , or the tube itsel f may be torn by a tooth, turb ina te , implan t, laryngoscope blade, forceps , or s ty let (766). A problem with the i nflation s ys tem (254,316,765 ,767,768,769 ,770,771,772 ,77 3,774,775,77 6) or the s y ringe us ed to inf late the c uff (777,778) ma y make it impossible to inflate the c uff . A defec t in the tube o r ecc entric cuff inflation c an cause a leak (126,312 ,779,780,781,782,783). The trac heal tube c onnec tor may be the source of a le ak (4 38,618,693 ,7 84,785,786 ,78 7). P rotrus ion of the c uff abov e the v ocal c ords can res ul t in a leak despi te a large amou nt of air being inj ec ted into the c uff (788 ,789,790,791 ,792,793). The c uff can dev elop a l eak while the tube is in p lace (794). Appl ic ation of loc al anes thetic s pra y h as bee n assoc ia ted wi th c uff le aks (7 95,796). The c uff or other parts o f the tube ma y b e damaged d uring ca nnulation of the internal jug ula r or subc lav ian v eins , duri ng percutaneo us dila tational tracheos tomy (Ch apter 21 ), or by other nearby procedures (755,797 ,798,799,800,801,802,803,804 ,805,806,807 ,808,809,810 ,811,812,813). A l aser beam can pe rfora te the cuf f. A tube may be damaged by bitin g (61,66,814,815 ,816,817). Chewing gum attache d to a cuff can c ause an unsatis fac to ry s eal (8 18). If a leak bec omes ev iden t af ter a gas tric tub e or other dev ice has been pl aced , the possibi li ty that tha t dev ic e has pas sed i nto the trachea al ongs ide the trac heal tub e i ns tead of into th e esophagus s hould be cons idered (176,177 ,178,179,180,819,820). W hen a l eak is p res ent, lary ngos copy s hould be perf ormed . If the c uff is abov e the v ocal c ords , i t sho ul d be deflated and the tube adv anced before the cuff is reinflated. Consi deration s hould be giv en to us ing a tube c hanger or f iberscope during th is procedure, es peci al ly if intubation was diff ic ul t. If the p roblem is i n the inflati on s ys tem, i t may be pos sible to repai r the damage, or the leak can be by pass ed by inserti ng a s topc ock , s mal l ca the ter, or a needl e in to the line below the def ec t (821 ,822,823,824 ,825,8 26,827). It may be pos sible to sea l a c ut in the tub e i ts elf by us ing g lu e (828 ). Temporary approxi mation of the cu t edges and c i rcumferential pack ing ma y b e helpful (7 99). If the c uff is leak ing , sev eral al te rna tiv es are av ailabl e:

Us e ph aryngea l pac k ing to control the leak . It ma y b e necessary to inc reas e the fresh gas fl ow to comp ensa te for the leak .

Fi ll the c uff with a mix ture of li docaine and s ali ne (829) o r use a sali ne i nfus ion (830). A ttach a mechanis m for maintai ning a c ontin uous gas infus ion into the i nflation tube. Methods desc ribed i nclude tubing connec ted to an air-f i lled plas tic contai ner to whic h cons tant ex ternal pressu re is appl ied (831,8 32), a f lowme ter (83 3,834,835), and a s ys tem f or maintaining in traoc ula r pressu re (836).

P lace a supraglo ttic d ev ice suc h as an LMA ov er the tube, and sea l the prox imal e nd (837). Rep lac e the tracheal tube. If this c ourse of ac tion is s elec ted, c ons ide ration shoul d be giv en to us in g a tube ex changer.

W hen a damaged tu be is remov ed, i t s hould b e carefu ll y examine d to make ce rtain that there are no miss ing po rtions .

Intubating Device Trapped inside the Tracheal Tube

W henev er a ny dev ic e is placed through a trac heal tub e, there is a ri sk that i t co ul d become entrapped in the tube . A nything pas sed do wn the trac heal tube such as a suc tion c a thete r, tube ex chan ger, or fibers cope c an pass through a Murphy ey e and become c aught (Fi g. 19.34). It may be i mposs ible to remov e the dev ic e withou t also remov ing the trac heal tube (838). The needle or wi re of a pe rc u taneous trac heos tomy s et (Chapter 21 ) may trav e rse the Murphy eye (839 ,840,841). A flex ible scope or other dev ice i nserted into a tracheal tube may bec ome s tuck on remov al (84 2). It may be p oss ible to f ree i t by injec ting s al ine into th e tracheal tube. P .596

Figure 19.34 The tube changer has become caught in the Murphy eye.

View Figure

Tracheal Tube Fires

Fi res in trac heal tub es hav e a high l ik el ihood of caus ing s erious harm. Fi res are disc ussed in Chap te r 32.

Tracheal Tube Obstruction

One reason f or ins erting a trachea l tube is to prov ide a patent ai rway (6 18). Unfortun ately , th e tub e i ts elf may bec ome th e c ause of obs truc tion. This is es pecial l y a probl em wi th i nfants and c hi ld ren (843,844). Obs truc ti on can be partial or c ompl ete. It is possible to hav e an obs truc tion s uc h that i nspiration is uni mpeded but res is tance to ex pi ration is inc reas ed and v ice v e rs a (845 ,846).

Causes Biting
Unles s p rotec tion in the fo rm of a bi te bloc k o r oral ai rwa y is prov ided, the patien t may bi te a nd obs truc t the tube (62 ,64,6 5,847,848,849,850). Many of the reporte d cases inv olv e s piral embedd ed tubes th at were permanently def ormed a fter the bi te was rel eased (63,67,68 ,13 0,848,851,85 2,853,854,855 ) (F ig. 19.35). A n ora l ai rwa y may no t prev ent obs truc tio n, as i t can on ly be plac ed in the midline (68,856,857 ).

Kinking
K ink ing is a f requen t c ause of trac heal tu be obs truc tion . Spi ral embedded tubes hav e been us ed in the OR to ov e rc ome this problem, but ki nking can s ti ll occu r at the patie nt end if the c onnec tor is not ins erted i nside th e s pi rals . K ink ing

so me times oc curs when the patien t's hea d p osi tion is changed, especiall y when the neck is f lexed (858,859 ) (Fi g. 19.36). It c an also occ ur when a tube is mov ed f rom one s ide o f the mouth to other (8 60). S ome tubes may k ink in the p harynx af te r th ey hav e been in place fo r s ev eral hou rs . K inking c an be c aused by o the r equipmen t in the mouth (69,861,862). Adv anci ng th e tube wi th a dril li ng mov ement may i ntroduc e some torque in to the tub e (863). Tub es v ary in thei r resis tance to kink ing. Smaller tubes k ink mo re readi ly than l arger ones. A s truc tu ral fau lt in th e tube s uch as the poi nt wh ere the inflating tube enters the wa ll of th e tub e (864 ,865,866) o r the intrac uff are a (867) can predisp ose to k ink ing. A t times , tubes a re made wi th thin s idewal ls . K inki ng sometimes oc curs at the dis tal pa rt of th e c onnec tor (8 68). The Endotrol tube may k ink a t th e l ev el of the glottis (88). The tip of a tube ma y fold, c aus ing obs truc tion (128). The Lasertubus can kink at the j unc tion of the plas tic and outer laye rs (117).

Material in the Lumen of the Tube

A trach eal tube may be o bs truc ted b y d ri ed sec re tions , blood, p us , tumor, or o the r tis sue (618,869,870,871,872,873 ,874,875,876 ,87 7). Lubric ant that is us ed to he lp put the c onnecto r in to the tube ma y dry and form a f il m (878). A v a riety of fo rei gn bodies hav e been found in trachea l tubes , inc luding a tooth, foam rubber from P .597 a mask , an infl ation v alv e, a cleaning brus h, an adaptor f rom an intrav enous s et, an i ntrav enous needle, a s top f rom a s tyl et, a c ork , a glass ampo ul e, pieces of plas tic , part of a nasogas tric tube, an o ral medicatio n tablet, a smal ler trac heal tube, part of a pa per towel , pa rt o f a sampl ing tube, ca ps from s yringes , and dead o rga nis ms (618,879 ,880,881,882,883,884). Part of a s tyl et c an be detached and remain in the l umen (885,886,887). A manufac tu ri ng defec t can c ause obs truction (888).

Figure 19.35 Spiral embedded tube permanently deformed by patient biting down on it.

View Figure

Figure 19.36 This tube kinked in the back of the mouth. The pen points to the site of the kink.

View Figure

Spiral Embedded Tubes

Mos t spi ra l embedded tubes do no t hav e a Murphy e ye. A n ything tha t blocks the bev el c an caus e obs truc tion (889). In some spi ral embedded tubes , the part of the tube dis tal to the cu ff has no spi rals . This part may be so ft and eas il y occluded. Pha ryn geal obstruc tion of a s pi ral embed ded tube in a pa ti ent wi th edema of the tongu e has been repo rted (890). Reus ing s piral embedded tubes predispos es to problems . Ev en s ingle use tubes ma y hav e ai r bubbl es in the wal l that en la rge wi th ni trous ox ide exposure and cause obs truc tio n (60).

Cuff Problems
If the tracheal tube c uff he rniates or i nfla tes eccen tric ally, it ma y d is place th e bev el f rom the c enter of the trachea (Fig . 19.37). Ecc entri c cuff ex pans ion f rom diffused anes thetic gases can caus e i t to expand in one d irec ti on and al low the bev el to i mpin ge agains t th e tracheal wal l (Fi gs. 19 .3 7, 19.38) (618,8 91,892,893 ,8 94,895). An infl ated cuff may ba ll oon ov er the tube tip (61 8,896) (Fi g. 19 .37 ). Inf la ting the cuff may c aus e c ompress ion of the tube l umen (8 97,898,899 ) (Fi g. 1 9.39). Obs truc tion f rom thes e c aus es may not occu r until some time af ter i ni tial c uff i nflation. Defl ating the cuff us ually reliev es the obs truc tion. Cas es hav e been reported for wh ich a feeding tube or o the r dev ice was c onnec ted to the cu ff i nfla tion s ys te m (900,901 ). This c an c aus e the c uff to ov e ri nf late and obs truc t the tube .

External Compression or Displacement

The trachea may be dis plac ed by the aorta , or the thy ro id gland may c ause the bev el to li e agai ns t the tracheal wal l or c ompress the tube. A nas ogas tric tube or suc tion c a thete r knotted around the tube o r a nearby su rgical retrac tor can c ause co mp res sion (9 02,903,904 ). Ex te rna l tracheal tube c ompression has been re ported as soc iated wi th Ludwig 's A ngina, Fo res tier's disease, or s aber-s heath trac hea (52,905,906 ,907,908,909 ,910). Bony f rag ments f rom a LeFort frac ture c an caus e ex ternal c ompress ion of the tube (911 ).

Defective Connector
If the c onnec tor is defectiv e o r damaged during ins ertion, i t can pa rtiall y or co mple tel y obs truc t the lumen (912,913 ,914,9 15). To av oid probl ems wi th reinserting the conn ec tor af ter sho rtening th e tracheal tube, the tube sh oul d be c ut diagonal ly , mak ing a sho rt b ev el P .598 (916). The c onnec to r shou ld be l ubricated sl ightl y wi th alcohol, brought into the l ongi tudinal ax is of the tube, and then gently sl id into the tube .

Figure 19.37 Two causes of tracheal tube obstruction. A: The bevel is pushed against the wall of the trachea by an eccentrically inflated cuff. B: The cuff has ballooned over the end of the tube.

View Figure

Figure 19.38 Tracheal tube obstruction secondary to eccentric cuff inflation. A: The cuff as removed from the patient. B: When placed in a glass tube, the inflated cuff pushes the bevel toward the wall of the tube.
View Figure

Change in Body Position

A shift in body posi tio n ma y c aus e the trac heal tube to bec ome obs truc ted (917,918 ,919). W hen the tube orific e faces in one di rec tion and the head is turn ed to the other, the orif ic e may fac e the trac heal wall (92 0).

Prevention
P rev enting trac heal tube obs truc ti on s tarts wi th the c ho ic e of tube. Transparent tubes fac il itate ide ntif ying mate rial or objec ts block ing the lumen. The use of a fenes trated (Murphy ) tube ma y av oid s ome cases of obs truc tion . A s pi ral embedded

tube may be us efu l if an operatio n i nv olv es turn ing the head o r other maneuv e rs that may c ause k ink ing. S pi ra l embedded tubes s hould not b e reused. S olu tions o r l ubric ants tha t can f orm a fi lm ba rrier shou ld be prev ented from ente ring the tube l umen (921). The trachea l tube sho uld be examined careful ly before use and the pa tenc y of the l umen v erified. Foreign b odies and other p roblems ins ide the l umen can be detec ted by i ns erting a s ty let. Th e c uff should be exami ned to make c ertain that i t i s secu rel y attached an d inf lates s ymmetrical ly. The lumen s houl d not be red uced whe n the cu ff is inflated. Inse rtin g a metal c onnec tor i nto the tube may prev en t ex ternal c ompress ion (922 ). If the tube has a s of t f lex ible tip , a s ty le t s hould be us ed during ins ertion. Af te r insertion, the cuff s hould be inflated as desc ribed earlie r in this c hapter. Cuff press ure s hould be readjus ted frequ ently , espec ially if ni trous ox ide is us ed. W hen an x -ray is tak en, the pos itio n of the ori fic e and the configuration of the cuff should be examined. Once inserted, the tube shou ld no t be wi th dra wn wh il e the c uff is inf la ted , as this may c ause the cuff to b al loo n ov er the end of the tube .

Figure 19.39 Reduction of tube lumen by cuff. Inflation of the cuff caused narrowing of the tube lumen.
View Figure

P lac ing a bi te bloc k s ecu rel y between the molar teeth a nd mai nta ining an adequa te l ev el of anes thesi a wi ll p rev ent b iting on the tube . Various me thods hav e been desc ribed to av oid k ink ing of th e tube f rom trac tion on i t (923,924,925 ,926,927). Af ter surgery, a s pi ral embedded tube s hould be cha nged to a c onv enti onal on e if pos toperativ e intubation is requi red (890,9 28).

Diagnosis and Treatment

Parti al tracheal tube obs truc tion may presen t as a dec reas e in complianc e or ex piratory f low, hi gh inspi rato ry press ures and an inc rease in the dif fe rence between p eak and p lateau airway press ures with v olume-controlled v entil ation , reduc ed tidal v olume during p res sure-contro lled v entilati on , or wheezing (929,930 ,931,932). P ressu re-v olume loops (Chap ter 23) are helpf ul i n d iagnos ing an obs truc tion. Pa radox ical ches t mov ements ma y be seen in spon ta neous ly breathi ng patients . The c apnograph (Chapte r 22) ma y s how an inc rease d s lope in Phase III and a l arger angle (933,934 ,935). Rel ying on the anes thes ia prov ide r's educ ated hand is no t rel iable (93 6). A high negativ e i ntra tho rac ic p res sure ma y resul t i n pul monary edema (937,938,9 39). A p rob lem that pe rmi ts inhalati on but prev ents exhalatio n (bal l -v alv e obs truc tion ) may presen t as ci rc ul ato ry c ollaps e o r barotra uma (84 5,940). P .599

Pas s ing a fiberscope down the tub e ma y fac il i tate diagnosis . Al te ring the patien t's head posi tion o r def la tion of the cuff may rel iev e the obs truc tion. The tube can be checke d for k inking eithe r by examina tion wi th a glov ed f in ger o r by di rec t v is ion us ing a laryngoscop e. Pas s ing a s uc ti on catheter or s ty le t down the tube may be helpful . Di gi tal pressure at the si te of the k ink may rel iev e the o bstruc tion. A k ink i n a smal l tube can s ometimes be remedied by p lac ing a larger tube ov er the smal l tube (927,941 ). If a la rge tube k ink s , i t may be pos s ible to pas s a s maller tube through i t. A hemostat applied at 90 degrees to the oc c lusi on may reliev e obs truc ti on secondary to bi ting (8 48,854). If th e obs truc ti on is caus ed by c lotted b loo d o r i nspiss ated mucus , it ma y be poss ible to remov e this by us ing an emb ol ectomy (Fogarty) cathe ter (942 ,943,944,945 ). In s ome cas es , rotatin g the tube ov e r a f ibe rs cope or tube exchanger ma y reli ev e the obs truc tion. A new dev ice that is spec ial ly des igned to remov e sec retions within a tracheal tube has been dev is ed (946). Equipme nt plac ed between the breath in g s ys tem and the trac heal tube may be the sourc e o f the obs truc ti on . Thes e components should be c onsi dered in the differential di agn osis of obs truc ti on, es pec ia lly if the y a re added af ter the ini ti al equipment c heck or jus t before the obs truc tion was detec ted (947).

Aspirating Fluid from above the Cuff

A l though i t is g enerally assumed that a tracheal tube wi ll p rev ent f oreign mate rial f rom entering the lungs , asp iration c an occ ur around the c uff (948). In one s tudy of l ong-term in tubation , sec retions leak ing around the trac heal tube c uf f were the mos t i mportan t risk for pneumonia in the fi rs t 8 days of i ntubation (949 ). The inc ide nce of aspi ra tion is inc reased by the use of l ow-pressu re cuffs , spontaneous v en ti la tion, and fluid acc umulati on abov e the cuff.

Use of Low-pressure Cuffs

Low cuff p res sure (below 20 mm Hg) is assoc iate d wi th an inc reased ris k of pneumonia in patients wi th l ong-te rm in tubati on (165,166,949,950). Many lowpress ure c uffs wri nk le des pi te prope r inflation an d all ow fluid to pass along the folds . Infold ing c an be dec reased by inc reas ing the press ure in the c uff , us ing a thin -wa ll ed cuff , and us ing a tube in wh ic h c uf f diameter at resi dua l v olume approxima tes the inte rna l trach eal d iame te r (157,164). A pplying l ubric ant jel ly to the cuff may f il l in the folds and prev ent aspiration (166 ,170). W hen ni trous ox ide adminis tra tion is dis conti nued , there wi ll be an outfl ow of that gas from the c uff . This can c aus e the c uff to los e v ol ume and dec reas e the s eal (205). The ultrathi n pol yurethane c uff ma y prev ent as pi ra tion better than other c uffs (951).

Spontaneous Ventilation
Durin g spon taneous v entilation, there wi l l be neg ativ e p res sure in the airway du ri ng i nspi rati on (952). In addi tion, the trac hea tends to di late duri ng spon tan eous i nspi rati on . Wi th thin-wal led c uffs , the negativ e a irway press ure wi l l be trans mitted to the cu ff . W ith an unc uffed tube, the negativ e p res sure wil l be appl ied around the tube. If the negativ e press ure exceeds the leak p res sure around the tube, bl ood or sec re tions may be d rawn i nto the trac hea (953). Inte rmi ttent pos i tiv e pres sure, PEE P , and press ure -supported v entilati on wil l l ower the i nci dence of as pi ration but not total l y p rev ent i t (166,952 ).

Fluid Accumulation above the Cuff

Suc tioni ng to ma in tain a cl ear oroph arynx wil l d ec rease the press ure ex erted by f luid abov e the c uff. It has been sugges ted that the cuff be p lac ed just be low the v ocal c ords to reduce the v olume of f luid that c annot be remov ed by s uc ti oning. Howev er, if the c uff is jus t belo w the co rds , head mov ement ma y caus e the tube to mov e upward, ca usi ng th e c uff to ex ert pressure on the c ords and inc reas ing the risk of in adv e rtent ex tubation. Furthermo re, a c uff placed j us t below the co rds ma y co mp res s nerv e endings agai nst the thyroid carti lage, resu lting in v ocal c ord

paral ys is . If the patient is in a he ad-up position, the hydros tatic p res sure exerted by the fluid wil l be higher than if the patient is supine. B lood f rom the pharynx c an dra in below the v oc al co rds and accu mula te abov e the cuff . If suffici ent time e lapses f or this blood to c lot, i t c an f orm a shea th be tween the tub e and th e tracheal wal l . During ex tubatio n, this s heath may fa ll i nto th e trac hea, caus ing c omplete o r parti al obs truc ti on. A trach eal tube that i nc orpora tes a dedic ated s uction lumen and channel can be us ed to c lear sec retions abov e the c uff . S tudies sh ow that us ing th is tube may reduc e the inc idence of v entil ator-ass oc iated pne umonia during long -term i ntu bation (132 ,133,134,135 ,13 6,137,138 ). Asp iration c an occ ur on ex tubation . Pharyng eal s uc tion ma y not remov e al l of the f luid abov e the tube , and i t can fi nd its way in to the lu ngs when the tube is remov ed . Recommenda tions to av oid this inc lude wi thdrawin g the inf lated cuff u ntil i t imp inges on the lower s urface of the v oc al co rds , plac ing the patient in a head down and la teral pos i ti on before cuff def lation , and deflating the cuff du ring applica tion of posi tiv e ai rwa y pre ssure to blow materi al c ol lec te d abov e the c uff i nto the pha rynx , whe re i t can be remov ed by suc tioning (4 84).

Misplacement of Other Equipment into the Trachea

A trach eal tube keeps the glottis open, mak ing it eas ier to pas s o the r equ ipment i nto the trac heob ronchial tree P .600 (176,177 ,178,179,180,819,820,954). Mi splaced i tems hav e i ncluded gas tric tubes , es opha geal s te thoscopes , tempe rature probes , and el ectrocardiogram (E CG) l eads .

Scan Artifacts
W ork ing in the MRI env ironmen t is disc uss ed in Chapter 30. A rtif acts may be seen on a computed tomog rap hy (CT ) scan wh en rad iopaqu e ma rke rs are present on a trac heal tube. Tubes wi thout these mark ers are av ai la ble and s hou ld be used fo r this a pplic ation (955,956 ). T he meta llic s pri ng i n the i nfla ti on dev ic e of a plas tic tube can c ause an artifac t o n an MRI sca n (957 ,958,959). Reposi ti oni ng i t away f rom the patien t wi ll usual l y solv e th e proble m. Wi re-reinforc ed trach eal tubes wil l caus e i mage dis tortion when us ed in an MRI unit. Nylon -reinforc ed tubes are recommen ded f or this appl ic ati on (960).

Unintended Extubation

Acc idental (spon taneous ) disloc ati on of a trac heal tub e f rom the trac hea is a t bes t a nuisance and at wors t a life -threatening emergenc y. It oc curs mo re c ommonly i n smal ler pa tients and i n patien ts wi th bu rns (459 ,843). Nec k ex tens ion or lateral head rotation head c an c aus e c ephala d tube mov ement (154,421 ,711,713,716,717). T his mov emen t is i nc reas ed with nas al intubatio n (961). The prone posi tion (962) or uppe r ai rway s well i ng can cause the tu be to mov e c epha lad (789 ). Remov in g a g as tric tube entwin ed around the tracheal tube can c aus e ex tubation (963). Acc idental ex tubation c an occ ur when the cuf f is posi tio ned between or jus t below the cords . If the cuff is dis tended as a result of ov erinfl ation o r ni trous ox ide diffus ion , it may herni ate up ward. This may re sul t i n a leak . A c ommon response is to injec t more ai r i nto the cuff . If the cuff is at o r jus t abov e the v ocal cords , this may cause the tube to mov e farthe r out of the trachea . Remov in g an adhesiv e surgical d rape that is posi tioned ov er the tracheal tube may resul t i n unintended remov al of the tube (964,965). This can b e av oided by p lac ing so me th ing ov er the part of the adhes iv e s trip that is to c ome into c ontac t with the ai rwa y dev ice (966). Antidis con nec t dev ices ma y i nc rease th e risk of inadv erten t ex tuba ti on. It may be prefera ble for the c onnec tion between the tu be and th e breathing s ystem to giv e way un der s train than to permit the tube to be pulled ou t. To prev ent i nadv ertent ex tubation, the tube sho ul d be pos i ti oned with the tip in the middl e thi rd of the trachea wi th the nec k in a neu tral posi tion. A cuff that req uires f requent inf lation should s ugg est that it may b e s ituated be twee n the v ocal c ords . The tube s hould be wel l sec ured. If th e s ecu ri ng tape becomes wet, it s hou ld be replaced . Pulling on the tube should be av oided. Care s hould be taken to av oid ex tubation whe nev e r th e patien t is pos i ti one d. Us ing an RAE tube may dec rease the incidenc e of acc idental ex tub ati on . If unplan ned ex tubati on oc curs in the lateral pos i tion, usi ng a supragl ottic dev ic e (Chapter 17 ) may resul t i n mo re re li able ai rwa y c ontrol compa red wi th tra cheal i ntu bation in the lateral posi tion (967).

Infection
A high incidenc e of si nus i tis and oti tis du ring and f ol lowi ng nasotracheal in tubation has been reported (337 ,338,339,340,34 1,342,343,968 ,969). During l ong -term

i ntu bation, the rates of nosocomial si nusi tis and pneumonia do not d iffe r s ignif ic antly be twe en ora l and nasal intuba tion (9 70).

Difficult Extubation
A diff ic ul t ex tuba tion is a rare bu t dangerous problem (971). A c ommon caus e is failure of the cuf f to d eflate. Th is may be due to obs truc tion of the inflation tube . If the obs truc tion is dis tal to the pi lot ball oon, the balloo n wi l l offe r no c lue tha t the cuff has not deflated (972). Heat f rom a lase r or a dril l may mel t the inf lating tube, caus ing it to oc c lude (9 73). The pati ent may b ite the inf la ting tu be, c aus ing i t to become occ lu ded. S ome users pull the pi lot bal lo on and inflation v alv e from th e i nflation tube to defl ate the cuff . This can ca use the infl ati on tube to s eal (514,515 ,516). The c onnec tor may occl ude the inflation tube if i t fi ts b el ow the point where the tube l eav es the trac heal tube wall (253). A retain ing bandage may k ink the pi lot tub e. The inf la ting tube may bec ome entangl ed wi th a nasogas tric tube or turbinate (974 ). W i th a spo nge cuff , defla ti on wi ll be diffic ult if the inflation tube is c ut or d etache d (192 ,193). A fold or flan ge in the cuff may impede ex tubation (975,976 ,9 77). Edema of the lary nx may make ex tubation d ifficu lt (281 ). If the tracheal or infla ti on tu be is transfix ed to ad jac ent tissues , ex tu bation wi l l be diff icul t (839,978 ,979,980,981). Th is probl em is c ommonl y associated with surgical procedures near the tube. A s utu re may ca tch a po rtion o f the tube wa ll o r be ti ed around i t. Forc ibly remov ing the tube may cause tiss ue dis ruption and lead to fatal cons equenc es . W hen i t is i mpos s ible to def late the c uff, a c ut in the inf la tion tu be may rel iev e the press ure in the c uff (51 6). It may be p ossible to inse rt a s y ringe and needle in to the s tump of the pi lo t tube and def late the c uff . If the cuff s ti l l rema ins inf late d, the tube sho ul d be pulled o ut unti l th e c uff is c los e to the unde rs u rf ace of the v ocal co rds . A needle c an then be i nse rted th rough the c ricothyroid membrane, punc turi ng the cuff (982). A l ternatel y, the tube can be wi thdrawn s o that the c uff is seen below the c ords and punc tu red f rom abov e wi th a sha rp obj ec t (983,984). Remov al may b e a ide d by rel ax ing the v ocal P .601 co rds an d/or tube rotation (971,9 83). If the tube is s urgic al ly fix ed to ad jac ent tis sues , surgical re-exp loration ma y be required.

Emergence Phenomena

Undes i rable phenomena during emergence and ex tubation inc lu de cou ghing, bucking, res tless ness , inc reas es in arterial blood pres sure, tac hycardia, and i nc reas es in intraocular press ure . The inc idence of mos t of thes e p rob lems c an be dec reas ed by f i ll in g the trac heal tu be cuff wi th a lidoc ai ne solution (985,986 ,987,988,989). Lidocai ne wil l d iffuse through the trachea l tube cuff (990). The addi tion of s odium b ic arbonate inc reases the diffus ion rate (991 ,992). S praying the trachea with li doc aine bef ore intubati on wil l d ec rease the inc idenc e of coughing on emergence af ter cases of less than 2 hours ' durati on (993).

Postoperative Sore Throat

Sore throat is a co mmo n pos tope rativ e complaint (228,231 ,238,994,995,996,997,998,999 ). It i s more co mmon in females , fol lo win g operati ons inv olv ing the head a nd neck , wi th us e of la rge r tu bes , a nd when the pati ent is in the prone positi on. Cuff desi gn may be a con tribu ting fac tor (1000). Limiting in tracuff pres sure ma y dec reas e the inc idence (1000,1001 ,1 002). The i nci dence of so re thro at is high wi th the s ponge c uff (114 ). S tudi es as soci ating the inci dence of s ore thro at wi th the effec t of topical lidocaine, s teroids , and lub ric an ts on the cuff offe r confl ic ti ng resul ts (994,100 3,1004,1005,1006). S ome s tud ies h av e found that inf la ting the cuff with a l idocaine or s al ine s olu ti on wi ll dec reas e the inc idence and sev erity of so re throat (986,987 ,992,1007,10 08,1009 ,1010,1011 ). So di um b ica rbo nate may enhanc e the l idocaine effec t (1008 ). P reopera tiv e inhal ation of a s tero id or gargling wi th s od ium azule ne sulfonate may help (1012,1013 ).

Hoarseness
Hoa rs eness is common ly s een af ter intuba tion. Its inc idence may b e dec reas ed by us ing tubes with low-press ure cuffs , s mall er tubes , and lub ric ation with lidoc aine j elly (1014 ,1015). Hoars eness inc reas es with diffic ul t and long intu bation but no t wi th i nc reas ed in tracuff press ure (231 ,99 8). Hoarseness that is persis tent or that dev el ops later in the pos toperativ e pe ri od should be i nv es tigate d.

Neurologic Injuries
Trigeminal, li ngual , bucc al , and hypogl os sal n erv e palsies hav e b een re ported followi ng short-term i ntubation (965,1016 ,10 17,1018 ,1019,102 0). Mental nerv e neuropraxia has been reported after use of an oral RAE tube (1021 ).

Upper Airway Edema

Edema ma y occu r anywh ere along the pa th of the tube, inc ludin g the tongue, l ingual f ol l ic les , uv ula , epi gl ottis, aryepiglottic folds , v entricular folds , v ocal cords , and the re troarytenoid and su bgl ottic spaces (971,102 2,1023,1024,1025,1026,1027 ,1028,1029 ,1030,103 1,1032). The mou th floor can s wel l due to s ia ladeni tis f rom a submandibular duc t obs truc ted by a trachea l tube (1032). Laryngeal edema (pos tintubation c roup o r inflammation, ac ute ed ematous s tenosis , s trido r, and s ubg lottic ed ema) enc ro aches on the a irway lu men, espec iall y in the young chi ld, in whom a mi ld degree of ed ema may produce a s ignif ic ant reduc ti on i n the internal c ross -s ec tional area. Beca use the c rico id c a rtilage c ompletely su rrounds the subgl ottic region, no ex ternal ex pans ion of the s wo ll en tiss ues may oc cur at this locati on. Laryngeal edema has a peak inc idenc e between 1 and 4 yea rs of age. It is mos t co mmonl y s een af te r surgery inv olv ing th e h ead and neck and wi th i nc reased duratio n of intubatio n. It is more c ommon in adul t females th an in adul t males (1033). Th e p res enc e o r absence of a leak or the his tory of a recent res piratory i nfec tion does not correl ate with th e i nc idence of c roup (301). Inflammation, mechanical trauma, a tube that is too large, mo tion, and al le rgic re ac tions to the tube i tse lf o r mate rials used i n lubrica tion or s terili zation hav e be en pos tulated as mechanisms of l aryngeal edema. Edema ma y manifes t itself a ny ti me during the fi rs t 48 ho urs after ex tub ati on . Us ually, the f irs t s ig ns are ev ident 1 to 2 hours pos tope rativ ely. In its mildes t fo rm, there is hoa rs enes s o r c roupy co ugh. In the mos t s ev ere cas es , resp iratory obs truc tion wil l oc cur. Dec ompens ation c an be rapid . P rev enting l aryngea l edema begi ns wi th avo id ing i rri tan t s timul i . If the re is an upper res pi rato ry infec tion , the use of a face mask o r la ryn geal mask s hould be s trongl y cons idere d. Tubes , s pra ys , a nd lubri ca nts that are us ed on the tubes shoul d be s te ri le . In tubation s houl d be atrau matic , and adequate anes the tic dep th and/o r good mus cle relaxa ti on sho ul d be ma intai ned to prev ent tube mov emen t. Head mov emen t s hou ld be k ept to a mini mum.

Vocal Cord Dysfunction

Voc al co rd paral ys is an d pares is hav e been reported af te r trach eal i ntubati on despi te the in tub ati on being a traumatic and th e s ite of the surgery remo te f rom the head and nec k (550,1 034,1035,1036,10 37). Mos t c ases reso lv e s pontane ous ly, us ual ly wi th in da ys or we eks , but i t may be l ong term (1038). Pos itio ni ng the tube

wi th the c uff jus t b elo w the cords an d h igh c uff pressu re may inc rease the i nci dence of this p rob le m. Bec ause a tube mov es c ephal ad wi th head or neck ex tensi on, the cuff may P .602 become pos itioned i n the s ubglottic reg ion a nd should be readj us ted wh en the pati ent remai ns i n this pos ition for a l ong time (154).

Ulcerations
Ulcerations (eros ions ) of the lary nx and trac hea are common, ev en wh en a tube has been in pl ace for on ly a s hort ti me. The i ncidence and s ev erity inc reas e wi th the duratio n of intubatio n. Ulcers v ary from s uperficial les ions inv olv ing onl y the mucosa to deep lesi ons i n whic h the underly ing c arti lage is ex posed. The end res ult wi ll depend on the loca tion and s ev eri ty as wel l as o the r facto rs , suc h as infec tion, that aff ec t the hea ling process. If the ulcer is supe rf ic ial, regeneration to norma l epithelium oc curs rel ativ el y quick ly. W hen the da mage is deepe r, the regene ration follows the same pa ttern as for the su perfic ial damage but is more pro trac ted. If the ulcer is v e ry deep, sc ar tis s ue may form. Cas es of uv ular nec ros is fol lo win g intuba tion hav e b een reported (1039,1040).

Vocal Cord Granuloma

The inc ide nce of v ocal c ord granuloma fol lowi ng in tubation (in tub ation or pos tanes thesia g ranulo ma) is repo rted to be be twe en 1 in 800 and 1 in 20,000 (1041,10 42). Mos t occur in adu lts , a nd the y are more common in women. A nu mber of poss ibl e etio log ies hav e been pro posed, i ncl uding trauma, infec tion , too large a trac heal tube, ex cess iv e cuff pressu re, durati on of intuba tion, and the tube position. S ymp toms inc lud e pers is ten t hoa rs eness , inte rmi ttent v oice loss , pain o r discomfort i n the throat, a feeling of f ul ln ess or tens ion i n the throat, ch ron ic cough, hemo ptys is , and pai n ex tendi ng to the ea r. So me c ases are s ymp toml es s. Occ asi ona lly, res piratory obstruc tion is s een. Symptoms may s tart after ex tu bation or may not dev elop fo r as long as sev eral months . Persis tent h oars eness af ter intuba tion warra nts l aryngeal ex amination . If the ex amination rev eals ulce ration ov er the v ocal process es , s tric t v oice res t to allo w healing to tak e p lace may prev ent the dev elopme nt of a granu lo ma.

Latex Allergy

W hi le mos t tracheal tubes are mad e f rom PV C, some l aser tubes are made f rom l atex -containing rubber. A c areful history s houl d be taken and p roper precau tions undertak en if these tubes are used. Latex al le rgy is discus sed in Chapter 15.

Gastric Tube Knotted around the Tracheal Tube

A gas tric tube may form a k not around th e tracheal tube (902,963 ,10 43,1044 ,1045). Tan dem mov ement of both the nas ogas tric tube and the trac heal tube shou ld sugges t th is problem. Op tions for dea ling wi th this inc lu de cutting the k not unde r di rec t v ision, leav ing th e k notted tube in pl ace until trac heal ex tubation is performed, and reintu bation.

Macroglossia
Mac rogl os sia c an be a serio us problem resu lting in ai rway obs truc tion after ex tubation . Patients in the p rone p osi tion, espec ial ly for prol onge d peri ods of ti me, us ual ly hav e edema in the dependent fac ial s truc tures (1046 ,1047). Mac rogloss ia has als o been reporte d i n patie nts i n the s itting pos i ti on (1048). Hemo rrhage into the ton gue c an occur in an an ticoa gulated patie nt (1049). Li ngual ischemia c an also oc cur (1050 ).

Tracheal Stenosis
Trac heal s ten osis fol lowi ng bri ef intuba tion has been reported (1051,1052). Howev er, th is problem is more c ommon wi th l ong -term i ntubation.

Cuff Inflated with Medication

Cas es hav e been reported wh ere a s y ringe or i ntrav enous line was c onnec ted to the cuff inflatio n sys tem. Medic ation or fluid was then injec ted (1053 ).

Airway Management Adjuncts Stylets

A s tylet (i ntroduce r, i ntubating or mall eable s tyl et) is des ig ned to f i t insi de a trac heal tube and c hange the s hap e of the tracheal tube to fac il itate intuba tion. A s tyl et is also useful to check the patenc y of a tracheal tube. A s tylet s hou ld al ways be i mmedi ately av ailable wh en intub ati on is performed. Many anes th esia prov iders routine ly us e a s tylet, wh il e oth ers rese rv e its use for diffic ult intubations .

Description
A v arie ty of s ty le ts are av ailabl e. So me h ave s peci al nons tic k surfac es . T here shoul d be a means to l imit the dep th that the s tylet is ins erted into the trac heal

tube (F ig. 19.40). If a s ecuri ng dev ice is not p res ent, th e s ty le t should be b ent ac utely at the mac hine end (F ig. 19.41). The mac hine end of the s tyl et may hav e a means to prev ent the tube f ro m rotating on the s tyl et. A s tylet P .603 shoul d hav e enough mall eabi lity so that i ts shape can be c hang ed eas il y and wi ll yi el d if p res sed agains t s oft tissu es, y et eno ugh ri gi di ty to mai nta in i ts shape duri ng i ntu bation. It sho uld be res is tant to chipp ing a nd break ing. It shoul d hav e a smooth su rface dev oid of s ha rp ed ges . S ome s ty le ts al low the us er to c hange the ir s hape i n s itu (1054,1055) (F ig. 19.42). These may be espec ial ly us eful in the pati ent wi th a c erv ical s pi ne in ju ry. The s tylet may hav e a light a t the e nd to as sis t in v isuali za tion during and af ter placemen t.

View Figure

Figure 19.40 Malleable stylets with adjustable stops. The stop fits into the tracheal tube and prevents the stylet from protruding beyond the distal tip of the tube. (Courtesy of Rusch, Inc.)

Techniques of Use
Unles s the s tylet has a n on-s tic k c oatin g, a th in film of lubric ant shoul d be s pread ov er i ts l ength bef ore i ns ertion (1056,1057 ). The s ty le t s hould be inse rted into the tube unti l the d is tal end reaches the b ev el and should be f ixed s o that i t c annot adv anc e. Occ as ionall y, the patient's ai rway may re qui re ex ten di ng the s tyl et tip beyond the tracheal tube bev el , bu t this is bes t av oi ded (1057 ). Remov ing the connec tor from the tube before ins erti ng the s tylet ma y make it eas ier to withd raw the s tyle t and dec rease the likelihood of damage to th e s ty le t, espec ia lly if the tube has a s ma ll dia mete r. If the connec tor is le ft i n pl ace, the flanges , if present,

shoul d be loc ated at the 2 a nd 8 o'clock pos iti ons when v iewing the tracheal tube along the cen tral ax is (1057). The tube and s ty le t shou ld then be be nt to the des ired shape. For ro utine i ntu bations , a s traig ht or s lightl y curv ed c onfiguratio n is us ually bes t. W hen dea li ng wi th an an teri or lary nx , a J or hoc key s tick c onf igura tion, wi th the pa ti ent end of the tub e bent a nte riorly at an angl e of 70 to 80 , is mos t c ommonl y used . Bend ing the midp oi nt of the tube to the ri gh t or left ma y res ul t in a better v iew of the la rynx (1058). Remov ing the s tyl et in si tu c an be di ff ic ul t and may resul t in acc ide nt ex tubation (1059 ,1060,106 1). If ex ces siv e force is needed, the s tylet is kinked or too sharpl y bent and should be reformed or disca rded.

Figure 19.41 Malleable stylets. The proximal end must be bent to prevent it from protruding past the patient end of the tracheal tube.

View Figure

P .604

Figure 19.42 Schroeder stylet. By pushing on the proximal part, the angle of the tube is increased.

View Figure

The trachea l tube is he ld so that the thumb re s ts on the co nnec to r. The larynx is ex posed a nd the tracheal tube ins erte d. In mos t cases , uni mpeded p ass age is ac hiev ed by introd ucing the uni t th rou gh the rig ht s ide of the mouth whi le poin ting the tracheal tube tip toward the larynx an d s imul taneous l y supina ti ng th e hand 30 to 40 from th e v ertical (1057). Adjus tments to the angle of en try are easi ly made by mov ing the connec tor and/or s upinating o r pronating the hand. The thumb is us ed to adv anc e the trac heal tub e. W hen the dis tal pa rt of the tube is bel iev ed to hav e pass ed the v ocal c ords , the s tylet is careful ly wi th dra wn from the tube. Counte rpress ure on the tube in the opposi te direc tion from the pul l on the s tylet may be necess ary to prev en t the tracheal tube from bei ng remov ed . As the s tylet is wi th dra wn, the ti p of the tube typ ic all y moves anteri orly (1056). If this anterior mov ement is ti med wi th passage under the epiglottis , it ma y help to di rec t th e tub e through an anterio rl y pos i tioned glottis . A s lightl y different technique inv olv es i ns erti ng the s tylet into the tube , angl ing the dis tal po rtion anteriorly , and then remov ing th e s tyle t from the tube (1062 ). Th e s tyl et is placed in a readily acc ess ib le locati on. Th e tube is adv anced to the v icinity of the lary nx and the s tylet reinserte d. This wi ll reduce the p res sure on tissues as the tracheal tube is inserted . B lind s ty le ted trac hea l in tubation may be perf ormed (1063).

Problems
The use of a s tyl et may be as soc iated wi th trauma to the airway or es oph agus (574,106 4,1065). The ris k is i nc reas ed if the tip of the s tyl et p rotrudes f rom the

pati ent e nd of the tube. If th e tub e is adv anced into th e a irway wi th an ac ute angle on the s tylet, the tube tip may be forc ed in to the anterior larynx . The s tylet s hould be retrac ted as the tu be is adv anced beyond the glottis . Part of the s tylet may b e s heared off (885,886 ,887,1066,10 67,1068 ,1069,1070 ,10 71,1072,1073,107 4,1075,1076). The s tyl et may damage the trach eal tube. The inflation tub e c an bec ome entangled in the s tyle t (1077). The trac hea l tu be may not a dv ance ov e r the s tylet after intubati on (1059,10 60,1061 ).

Bougies
Description
The c las sic bougie (intuba ting or intubation catheter o r introduc er, gui de, i ntroduc er o r s tyle t; E schmann tracheal introducer) i s shown i n Figure 1 9.43. It is fabric ate d f rom a brai ded polyes ter bas e wit h a resin c oa ting. Its col or is gol den brown, a nd it is reusable . It is ho llow exc ept at its ends , but the ends may be cut awa y s o tha t it can be pas sed ov er a small er guide or used to mo nitor CO 2 (1078,10 79,1080 ,1081). P lac ing twi s ted wi res in the h ol low l umen al lo ws the bougie to be s haped (1082). Some bougies hav e length mark ings .

Figure 19.43 Bougie.

View Figure

P .605

Figure 19.44 Tip of bougie.

View Figure

The dis tal end may be ang le d 30 degrees to 4 5 degrees (1083 ,1084) (Fig. 19.44). This makes it e asi er to pass the dev ic e through the l aryngea l in le t and prev ents the bougie f rom adv ancing too far (1085 ). A bou gi e wi th a s traight tip may be useful for trac heal tube exchange (510,108 6), but is less adv antageo us than an A EC (1087,10 88). A boug ie c an be cons truc ted from other materials (1089 ,1090,1091 ,10 92). The plas tic cann ula f rom a Laryngeal T rac heal Anes thes ia (LTA ) k it ma y be used as a bougie (1093,1094,1095,1096 ). Single-use bougies are av ai labl e but may no t work as wel l as reus able ones a nd/or may hav e gre ate r potentia l fo r trauma (1097,10 98,1099 ,1100,1101 ,1102,1103,1104,110 5,1106,11 07,1108 ). A hollow bougie a llows v e rifica tion of c orrec t posi tion by i ns erting a f ine fi beroptic endosc ope through it or by us ing c apno graphy (1092) o r the esophagea l detec tor dev ic e (11 09). A boug ie wi th an angl ed tip is espec ial l y usef ul when th e operato r recogn iz es some anato mica l landmarks bu t c annot di rec t the tip of the trac heal tube into the l ary ngea l inle t or whe n mov emen t of the hea d and/or nec k is undesi rable (536,111 0,1111,1112,1113,1114,1115 ,1116,1117 ,1118,111 9,1120,1121,1122,1123, 1124,1125 ,1126,1127 ,1128,1129,1130,1131,1 132). In these s i tua ti ons , it is of te n possible to i ntubate the trac hea wi th the thinner and more maneuv erabl e boug ie and then guide the trac heal tube into the trachea ov er i t.

Techniques of Use as an Aid to Intubation

It is important to hav e bougies of v a rious diameters av ai lable.

Before use, a bougie sho uld be c areful l y ins pec ted f or f rac tu res and tes ted for rigidi ty (1076,1 133). It should be we ll l ub ricated. It c an be placed firs t in th e trac heal tube with the tip protrudin g, or i t ca n be placed into the gl ottis and the trac heal tube then adv anced ov er i t. A boug ie c an be placed in the trac hea by internal pa lpation of p os terior pharyngeal and g lottic s truc tures or wi th th e aid of a ri gid laryngoscope or bronc hosc ope, a f lex ib le endosc ope, or a sup raglottic ai rway dev ice (1121,11 34,1135 ,1136,1137 ,1138,1139). It i s bette r to pre-pos i tion the bougie in the la ryn geal mask s o that i t ex its through the middle, rather than pass it b lindl y (1140). Bec ause the tip is angled, the tip shoul d be in troduc ed poi nting a nte ri orly . If the tip becomes s tuc k a t the anterior c ommis sure, i t sho uld be rotated 180 and the n adv anc ed (367). If the ai rwa y c urv ature is ex treme, the ti p can be di rec ted ev en more anteriorly by l ifting i t wi th forceps (536 ). The fai lure rate f rom us ing the s traight bougie ma y b e dec reas ed by us ing a la ry ngea l (dental) mi rror (1141,1142). The bougie s hould be adv anced gen tl y. The fi rs t s ign that the tip is trav ersing the l ary nx may be a faint upward pressu re fe lt by the pers on who is appl yi ng c rico id press ure (1125 ). As the bougie adv ances ov er the trac heal rin gs , i t wi ll often produce a c lick ing s ensa tion. The bougie may rotate as i t en ters a main bronchus and c ome to a s top when i t reaches a s maller b ronchus (1111,1118,11 21,1143 ). In the lightly anes the tized , nonparaly zed pa tient, a cou gh sugges ts tracheal rather than eso phageal p lacement (1144). If the bo ugie is ho ll ow, the prox imal end ma y be attached to a c apnograph to c onf irm intratrache al pl acement (1144 ,1145). Howev er, CO 2 may no t be detec ted if the openings a re bl oc ked by sec re tions or the tip is passed too fa r. Ph aryngea l place ment of the tip c ould y ie ld false-pos i tiv e results . If c licks are not e lic i te d, the bougie should be gentl y adv anced to a max imum dis tanc e of 45 cm (11 46). Durin g nasa l in tubation , the bougi e is adv anced through the nos tri l and into the l ary nx . It is the n obse rv ed b y usi ng a la ryngosc ope (367). The bougie is di rec ted toward the v ocal c ords unde r di rec t v isi on. W hen the tip is ins ide the l aryngeal i nlet, the bougie is rota ted s o that the tip poin ts pos te riorly . It wi l l usual ly then adv anc e into the trachea . In the patient wi th a l imi ted mouth openi ng, it may be possible to blindly pass the boug ie through a nos tril and into the trachea (412). Onc e the bougie is bel iev ed to be in the trac hea, the trac heal tube with its lume n l ubric ated with a wa ter-s oluble gel is gen tl y adv anced (ra il roaded ) ov er the bo ugie by us in g a rotary moti on. A trac heal tube that is desig ned to minimize the gap

between the leading ed ge of the tube and th e intuba ti on ca the ter may fac il i tate i nsertion (13,89). Intu bation may b e fac il itated by leav ing the la ry ngos cope in the mouth, a jaw th rus t, o r rotating the trac heal tube coun tercl ock wis e 90 degrees (357,535 ,536,1125,11 31,1147 ,1148,1149 ). A bronc hosc opic adap ter (Fi g. 19.3 2) can be us ed to c hec k for i ntra trac heal plac ement o f the trac heal tube wi thout remov ing the bougie (1150). The bougi e is then wi thdra wn. If th e bougie is i nadv ertently placed in the es opha gus , it ma y be used as a gu ide f or inse rting the LMA P roSeal (11 51). A sec ond technique is to p rei ns ert the bougi e into the tracheal tube so that i ts tip protrud es approx imatel y 5 c m b eyond that of the tube (112 5). This may sav e a few seconds but may mak e s te ering the tip to the left o r ri ght mo re diff icul t. P .606

Other Uses
A useful tec hni que f or ex changin g a trachea l tube is to insert a bougie alongside the ex is tin g tube (115 2). The ex istin g tub e is th en remov ed, and a new tu be is i nserted ov er the bougie. A boug ie c an be used to improv e the util i ty of the Ups herScope (Chap te r 18) by di rec ting the tracheal tube tip ante ri orly (1153 ). A boug ie c an be used to direc t the P roSeal LMA in to the es ophagus (1154) or to change a P roSeal LMA (1155).

Evaluation
As an aid to the diffic ul t in tubation , the bougie may be superior to a s tylet (1110,11 14,1146 ,1156,1157 ,1158). It may be the f i rs t item tha t sho uld be tri ed whe n laryng oscope-ass is ted trac heal in tubati on is not s uccessful (1159). A boug ie may be espec ial ly useful in the patien t wi th a sev erely co mpromised uppe r ai rwa y, an teri or lary nx , o r li mited mou th ope ni ng (1160). If g lo ttic ex pos ure is i mposs ib le, the bougie may be inserted b lindl y to ward the presumed laryngeal inlet and a dv anced until res is tanc e is encountere d. The tracheal tube is then threade d ov er th e bougie. Us ing a bougie may resu lt i n trauma to the ai rway (1 125,1161,1162,116 3,1164). The f orce exerted by the tip is inc reased when the bougi e is held n ear the tip (1097). Th e tip of the bougie may bec ome detached, and the ou ter layer may

become frac tured (1133,116 5). The boug ie c an be a s ourc e of c ontamin ation (1166,11 67).

Airway Exchange Catheters

Description
An AEC (g uidin g c atheter, d irec tor, s tylet ca the te r, c athete r guide, e las tic s tyl et, trac heal tube repl ac ement obturator, tube changer o r exc hanger, v enti lation or ex change bougie , je t-s tyle c athete r, j et s ty let, i ntubati on catheter, in tubating i ntroduc er) (F igs . 19.45, 19.46) c an be used for a number of purposes (486,505 ,1168). Numerous on es in differi ng s izes are on the mark e t. So me h av e an angular dis tal tip s imi la r to a bougie . S ome hav e a s tiffening c annu la. A n A EC is more fl exible and longe r than a bougi e.

Figure 19.45 A: Airway exchange catheter. Note the marks showing the distance from the tip and the holes near the tip. B: The proximal connections allow administration of oxygen, jet ventilation, connection to a CO2 analyzer, or suctioning. (Courtesy of Cook Critical Care, a division of Cook, Inc.)

View Figure

P .607

Figure 19.46 Tube changer in place. (Picture courtesy of Kendall Healthcare Products, Inc.)

View Figure

W hen us ed as a tube chan ger, the c atheter mus t be long enough so that th e tub e can be c ompletely remov ed withou t the c atheter being pulled f rom the trache a. Its l ength mus t be g rea te r than d ouble that of the tube being ex changed . It s houl d be s tiff enough that i t wi l l not k ink as the tube is remov ed or rei nserted. Dep th mark ings that are la rge , c i rc umfe ren ti al , and bo ld are hel pful as they all ow a n es timation of how fa r the c athete r has been inserted into the ai rway. A ca the ter wi th mul tiple dis tal s ide holes may dec rease the press ure deliv ered at the dis tal end, min imi ze c a the ter whipping, an d center the c atheter wi thin the trac hea duri ng j et v enti lation (1169 ). Vari ous dev ic es hav e s erv ed as AECs , inc luding suc ti on catheters , bo ugies , urethra l catheters , embolec tomy catheters , gas tric tub es , plas tic s heaths, gu ide wi res , and f lex ible -tip ped s tylets (1137,11 70,1171 ,1172,1173 ,1174,1175,1176,117 7,1178,11 79,1180 ). Hollow d ev ices allow ox ygen admi nis tration by insuffl ati on or j et v en ti lation an d CO 2 measurement. Adapto rs for th ese pu rposes are often furn is hed wi th the AE C. Je t v entila ti on th rou gh an AE C can prov ide sa tisfac tory gas exc hang e i n mos t cases (1181). The length and s mal l ID make man ual v entilation with a resusc i tation bag imprac tic al .

Uses
The c hoic e of an appropriatel y s i zed tube changer can be v i tal. The bes t cha nce of a trach eal tube pass ing eas ily ov er a c atheter i nto the trachea oc curs when the ca the ter has a rel ativ el y large OD and the tube has a rel ativ el y smal l ID

(1182,11 83). The AE C may be label ed wi th the rec ommend ed diameter tu be to be us ed with it. Ai rwa y exchange rs s uitable for pediatric tracheal tubes are av ailab le . A s ilicone spray or water-s o luble lubricant shou ld be applied to the ou ts ide of the AE C. The mark ing on the catheter shoul d be matc hed wi th the c en timeter mark in gs on the tracheal tube to av oid adv ancing the AEC too deepl y. Th e user mus t al ways b e cogni zant of the depth that the catheter is inserted , bec ause deep inserti on i nc reas es the ris k of perf ora ti on and ba rotra uma with je t v en ti la tion. The A EC shoul d nev e r be inserted a gains t a res is tanc e. If the AE C is pas sed th rough the s elf-sea ling di aphragm on a bronch oscopy adapto r (Fig . 19.32), v entil ati on can tak e p lace around the c atheter. This allows the us e of capnog rap hy to confi rm intratracheal location of the tub e without remov ing the ca the ter (1184). A la ryngosc ope shoul d be used wh en pass in g a tracheal tube ov er an A EC to fac i li tate passage pas t the s upraglottic tissu es (1 182,1183). Twis ti ng the tube ma y aid its adv ance ment. If res is tance is encounte red , the tube s hould be tu rned 90 degrees coun terc loc k wi se. A je t v en tila tor s hou ld be immediately av ai la ble i n cas e the ne w tube does not follow the AEC into th e trachea , and the je t v en ti la to r shou ld be prese t at 25 pounds pe r s quare inch (ps i ) (1183). A short i nsp iratory time and lon g expi ra tory time s hould be used i ni ti al ly .

Tracheal Tube or Supraglottic Device Exchange

An AEC is espec iall y useful for exchanging a trach eal tube in a patien t who was diff icul t to intuba te. It may a lso d ec rease the risk of airway difficul ties i n patients wi th an uncompromised lary ngeal v iew durin g d irec t laryng osc opy (1185). Duri ng tube exc hange, v entilation c an be maintained by inserti ng th e tub e c hanger v i a a f ibe rop tic adapto r (Fi g. 19.32). Oxygen ins ufflation is achiev ed by connec ting the ex change c atheter to an oxy gen flowmeter.

Replacing an Existing Tube

The lubricated tube chan ger is inserted i nto the tracheal tube and adv anc ed until it has reac hed the end of the tube as i ndicated by depth mark ings . A lternatel y, the tube cha nger may be placed alongsi de th e tube (118 6,1187). W hi le the tube P .608 change r is he ld s tead y, the ex is ting tube is wi thd rawn. A new trach eal tube is then

threaded ov er the tube changer and adv anced un ti l i t is a t th e p roper dep th. Trac heal plac ement s hould be confi rme d by us ing CO 2 moni tori ng, the E DD, or a f lex ib le endosc ope. The tube changer is then withdrawn . This tec hni que has been us ed to ex change a tracheal tube placed s ubmen tal l y (1188), a naso trach eal tube (1086), a double-lumen for a conv en ti onal si ngle-l ume n tube (1189 ,1190), a Univ ent tube fo r a s ingl e-lumen tube (1191 ), and to replace a tracheos tomy tube (1192).

Changing a T racheal T ube from Oral to Nasal

To change an oral tube to a nasal tube, the tu be cha nger may be pass ed through the ora l tube and a tracheal tube passed through the nos e into the pharynx . The oral tube is remov ed, l eav ing the tube change r in the trachea. The nasa l tube is i nserted into th e trachea nex t to the c hang er. An al te rna te method is to adv anc e the tube cha nger through the nos e, then plac e i t alongsi de the ex is ting trac heal tube. The exi s ti ng tube is the n remov ed and a trac heal tube adv anced ov er the exc hanger in to the trach ea. In another technique, the ex change c atheter i s adv anced i nto one of the nares an d then brough t out through the mouth (1193). The ca the te r is then adv anc ed in to the oral trachea l tube. Th e o rotrache al tube is then s lo wly wi th dra wn, c u tting i t l ongi tudinally until i t is remov ed from the excha nge ca the ter. A trac heal tube is then adv anc ed ov er the ex change catheter. Ano the r tec hni que has been desc ribed (1 168,119 4). A s uc tion c ath eter or other dev ic e is inse rted through the na res , and the other end is retriev ed through the mouth. T he AE C is ins erted into the o ral tube, and the oral tube is remov ed. The ca the ter is attached to the nasal part, a nd the nasal end is pulled ou t until the upper en d of the c atheter appears . Th is then s erv es as a guide for a tracheal tube, whi c h is adv anced through the nos e i nto the trachea .

Changing a T racheal T ube from N asal to Oral

W ith one technique, a tube c hanger is plac ed ora ll y alongs id e the trac heal tube (by us ing direc t laryngosco py or a flex ible en dosc ope) (1195,1196). A l te rna tely, a f ibe rs cope loaded with a tracheal tube can b e p lac ed al ongs ide the trac heal tube (478,119 7). A tube change r is passed through the nas al tube, whic h is then wi th dra wn i nto the pharynx . A trachea l tu be is adv anc ed ov e r the f i rs t tube c hang er (or th e f iberscope) un til i t is in th e trachea. The nasal tube and tube exchange r are then remov ed . If i t is not poss ible to adv ance the o ral tube, the nasal tube c an be passed back into the trac hea ov er the tube change r.

W ith ano the r technique , a tub e chan ger is pass ed th rough the nasal tube, then the nasal tube is completel y withdrawn (1 168,11 98,1199 ). The tube exchanger is l ocated in the ph arynx and pulled out throug h the mou th. A trac hea l tube is then adv anc ed ov er the tube c hange r in to the trache a.

Intubation
The A EC ca n be used s imi la rl y to a bougie to fac il i tate in tubation wi th a s ing lel umen or double-lume n tub e (1200,1201,120 2,1203,1204,1205 ,1206). A gui de wi re may be i nserted into the trache a and the tube c hang er then ins erte d ov er th e guide wire (1 207,1208). S ome catheters c an be pl aced ov er a fibe rs cope (1209). A sup rag lottic ai rway dev ice c an be use d to pl ace the c atheter, al though the succes s rate is not high wi th bl ind ins erti on (1 210,1211,1 212). It is be tter to place the AE C by us ing a flexi bl e endoscope (1206,121 3,1214) o r pre lo ad it s o tha t it passes through the midline sl it in the sup rag lottic dev ice (11 40).

Extubation
Des pite es tablished ex tubatio n c ri teri a, i t is diff ic ult to reliab ly predic t s ubse quen t respi ra to ry dis tres s (485,505,797,1215,1216 ,1217,1218 ,1219). An ex tuba tion trial shoul d be c ons idered, es peci al ly for a pa tient wh o migh t be diff ic ul t to reintubate. The airway exc hange catheter is ins erted into the trac heal tub e, whic h is then remov ed . The c a thete r forms a bri dge that wil l al l ow rei ntubation, ad minis tration of suppl emental ox ygen, v enti lation , or meas urement of end -tidal CO 2 f rom the trac hea. If the pati ent is able to v enti late adequately , the c atheter is remov ed. The us e of an AE C might produc e cos t s av ings b y demons trating that patien ts wi l l tole rate ex tuba tion earl ier. AE Cs hav e bee n l ef t in p lac e for long periods of time and are wel l to le rated by mos t pati ents (1187,1216 ,1 217,1220,1221). Lubricating the dis tal end of the changer wi th l id ocai ne jelly may help the patient tolera te i t bette r (1222). The patient c an v ocal iz e while the catheter remains in the trach ea (1217). Manipul ati on of the tube change r may be us ed to s timul ate the c ough ref lex (1220). Ox ygen admin is tration through the exchange c a thete r may obv iate th e need for fac emas k or nas al c annula followi ng ex tubation . It is possi bl e to enrich the ox yge n c ontent o f the gas del iv ered through the catheter by us ing a face mask .

Other Uses
An AEC may be used to prov ide v en tilati on du ring mic rolaryngeal s urg ery (1168 ). It can p rov id e a us eful gu ide to the trachea du ri ng flex ib le endosc opy.

W hi le a trac heos tomy is being performed , it may be useful to re -es ta blish an a irway i f a pro blem oc curs and may gu ide the surgeon to the tracheal l umen (807,122 3,1224,1225,1226). Ano the r use for the A EC is duri ng retrograde in tubation (Chap ter 21). The ex change c atheter is pas sed ov e r a guide inserte d transl aryngeal ly and passed retrograde to the oroph arynx or nasopharynx (1078,1227,1228). Other us es fo r the AE C inc lud e d is ti nguish in g esophageal from tracheal intubation (605), v en ti lating P .609 the patie nt during management of in traope rativ e trach eal i nj ury (1229), fac il i tating passage o f a tracheal tube ov er a fibersc ope (1230), fac ili tati ng submental i ntu bation (1231), and v enti lation of part of the lung during thoraco tomy (1232).

Complications
A i rwa y p erf oration has been reported as a complication of an AE C (505,121 5,1233,1234,1235). The ri sk of pe rfora tion is related to the depth of i nsertion . The ex chan ge catheter s hould nev er be ins erte d agai ns t a resis tanc e. The use of jet v entil ation through the AE C ma y res ul t in ba rotrauma (1169,11 81,1216 ,1236,1237 ,1238). The us e of s tand ard v entil ation through a 15mm c onnec tor is les s dange rous , s o jet v entil ation shou ld be us ed onl y if s tandard v enti lation fails to prov ide adeq uate gas exc hange. The ris k of barotrauma with jet v enti lation may be dec reas ed b y loweri ng the gas press ure , us ing a sho rt i nspi rato ry time, prov iding a l ong ex pi ratory ti me, an d s elec ting a properl y s i zed ex change c atheter (1215 ,1 233,1239). It i s impo rtant to kee p the dis tal tip of the ai rwa y exch ange r abov e the c ari na. If i ncompl ete ch est deflation occu rs , je t v enti lation should be discon tinued (12 40). The re are a number of other co mplica tions assoc ia ted wi th the A EC. The catheter may no t s l ip off the flex ible endosco pe if the fit is too tight (1241). The tracheal tube may fail to pas s ov er the AE C. P art of the catheter may break off a nd be as pirated (1 133,124 2,1243). The excha nge ca the ter may be inadv e rtently remov ed (1217). Th e replac ement tracheal tube may not end up in the trac hea (1244). The channe l in the exc hange c atheter tube changer ma y bec ome occluded b y sec re tions , incorrec tl y imp ly ing esoph agea l placement (1245 ). The c atheter may disl odg e a muc ous plug, caus ing air way obs truc tion (12 46). The ca the ter may exi t through a s ide hole in the trach eal tube (817). Gas tric pe rforati on secondary to

ox ygen insuff la ted through a c a the ter in the es ophagus has bee n repo rted (1247). The c athete r may shear (1 248).

Lighted Intubation Stylets

A lighted intubation s ty le t (l ightwand, [flexible ] ligh ted s tyl et, Trac hl ight T M , i llumi nating o r ligh ted intubating or intubatio n s ty le t) us es trans il lumination of the soft tissues in the anteri or neck to g ui de the tip of the trachea l tube in to the trac hea or to determine the pos itio n of the tracheal tube or othe r airway dev ice (1249,12 50,1251 ,1252,1253 ,1254,1255,1256,125 7,1258,12 59,1260 ,1261). During di rec t l aryngoscop y, the li ghted s tyl et c an be used to imp rov e the v iew i n the hypoph arynx . The l ighted s tyle t is espec ia ll y useful in s i tuatio ns where a f iberscope is unav ail able or endoscopy is d ifficult to perfo rm (e.g., when an a irway is obscu red by blood o r sec retions or when a p ati en t's head c annot be flexed or ex tend ed).

Description
Sev era l diff erent li ghted s tylets are av ail able c ommerc ially . E ac h h as a reusable handle c ontaining the p ower so urc e and a mal leable wa nd with a light at the end. The wa nd sec tion may be detachable from the ha ndl e and may be disposable. Dep th marki ngs should be p resent. Lighted s tyl ets differ from s tylet lary ngos copes i n tha t they do not h av e a means to see thro ugh the s tyle t. There is onl y a light transmis si on bundle . S tyle t la ryngos copes a re disc ussed in Chapte r 18. Some hav e a means to s ecu re the li ghted s tyl et to the trachea l tube. It may hav e a tip that c an be manipulated durin g i ns ertion. On s ome dev ices , it is possible to v ary the length of the wand sec ti on to accommodate tracheal tubes of v arious lengths . Some hav e a retrac tabl e i nner s tyl et that a llows the distal porti on to be made se mi rigid. Some of the dev ices us e f iberoptic l ight. The ligh t blinks af ter being c ontinuousl y ON for 30 sec onds (1260 ). Pedia tric l ighted s tylets that c an acc ommodate tubes as smal l as 2 .5 mm are av ai lab le (1257 ,1260).

Techniques of Use
A lighted intubation s ty le t that is lub ricated wi th a s ilicone spray or a water-based l ubric ant is pas sed th rough a tracheal tube so that the light is j us t sho rt of the end of the tube (1262). If the bulb p rotrudes past the tube, trau ma ma y result. Adu lts ized tubes mus t be tri mmed when us ed wi th s ho rter s tylets . The s ty let s hou ld be f irmly attached to the tube.

The s tylet is ben t to the des ired s hape. F or oral intubation, a 75- to 120 -de gree bend jus t prox imal to the c uff is recommended (1255,1260,1263 ). Ca re should b e tak en no t to bend the s ty let at the point at whic h the bu lb mee ts the shaf t (1254 ). It may be us eful to measure the mandibul ar-hy oid dis tanc e (1251). A nother s tudy found good suc cess wi th a bent l ength of 6.5 c m (1264). If the pa tient has protrud ing upper teeth, another be nd to coinc ide with th e teeth should b e ma de (1265). If des ired, a c athete r may be th readed under the hous ing and used to adminis ter topical anes thes ia (126 6). Sof tening the trachea l tube (by i mmersi on in warm s al ine s olu ti on or b y p lac ing it i nsi de the hose f rom a fo rc ed-air wa rmi ng dev ic e) and rev ersi ng loadi ng the tu be (ups ide down f rom the usu al pos iti on) may fac il itate pass in g the tube into the trac hea (531). A relativ ely ex tended posi tion wi l l make i t eas ie r to obs erv e the neck . In obese or pedia tric pa ti ents or i n patients wi th ex tremel y sho rt n ecks , pl acing a pi ll ow und er the shou ld ers and neck may be usef ul . It hel ps if an assis tant retrac ts the breas t or ches t wa ll tissues P .610 and inde nts the tis sues aroun d the trachea . Thes e ma neuv ers enhance trans illumi nation in the anteri or neck . The room lights s houl d be di mmed or the anterio r nec k s haded in ob ese pati ents or in thos e with thick necks (1267 ,1268). The operato r may s tand at the head o r to the s ide of the pati ent's head. Lowering the bed may ai d in observ ing the n eck. The mouth is opened , and the tongue and mand ib le are pulled for ward. A bite block may be neede d to prev en t the patient f rom bi ting the tub e-s ty le t. The tub e s hould be i nserted from the s ide, the n b rought i nto the midline of the orophary nx. It is the n rotated towa rd the tip of the c hi n and rocked (1267). The li gh ted s tylet ma y b e ins erted through the intubati ng po rt of a mask (1269). As the tube and s tyl et are adv anced , the l ight tra ns -il lumi nates the tissues and can be seen through the an te ri or nec k . A properl y adv ancing lighted s tylet p roduces a wel l -defined bright gl ow in the mid line . A faint gl ow abov e the laryngeal p rominence i ndicates that the tip is in th e v allec ul a. A wi desp rea d g low to either s id e of the midline s ign als entry in to a pyri form f os sa. A v ery diffuse , fu zzy , or absent light means tha t th e esophagus has been en te red . This can be co rrec ted by re trac ting and lifting the s tylet to bri ng the tip more ante ri or (1251 ).

Apply ing c ric oi d pressu re may inc rease the i nte nsi ty o f the i l luminati on but ma y prolong the intubati on attempt and i nc reas e the fai lu re ra te (1270). If resis ta nce is felt, the ligh ted s tyl et-tube s hould be rocked back wa rd and the tip redi rec ted by us ing the gl ow from the l ight as a gui de . A loss of res is tanc e and/or c l ick may be fe lt when the l ightwand is adv anced u nder the epiglottis and th rough the c ords (1261,1267 ). W he n the l arynx is s harply trans i llumi nated, the trac heal tube should be advanc ed in to the trach ea. The loc k ing dev ic e is then released and the l ightwand wi thd rawn f rom the trach eal tube . A modification to this tec hni que has been desc ribed (1271). Rather than retrac ting the s tyle t on the Trac hl ig ht, the thumb is used to p ush the hand le v e rtic al ly do wn whi l e the f inger ho lding the s tylet maintains its pos i tion. This re trac ts the s ty let dis tal ly whi l e conv erting s ome of the v ertic al he igh t of the s tylet into hori zon ta l dis tanc e. Ano the r tec hni que for oral intuba tion has been des c ribed. This techni que u ti l izes the Bul la rd Laryng osc ope (Chapter 18) to v isua ll y ass is t in tubation wi th the l ighted i ntu bation s ty le t. Th e Bullard s tyl et is remov ed. The cords are iden tified , and the Bul lard s cope is mov ed to the l ef t. A trac heal tube ov er a l ig hted s ty le t is used to i ntu bate the larynx . This is guided into pos ition under direc t v ision from the Bul lard sc ope (1 272). If v en tila ti on is needed during intubation, the trach eal tube ov er the lighted s tylet can be ins erted through the diaphragm of a v en ti la ting mask (127 3) or through a supraglo ttic airway dev ic e (127 4,1275 ,12 76,1277 ,1278,127 9,1280,1281,1282). The patient with a c le nched jaw c a n be intuba ted by retrac ting the c heek and i nserting the ligh twand from the side l ate ral to the tee th . Nas al i ntubation can be performed by usi ng a l ighted intubation s ty let (372,402 ,1252,1255 ,1 256,1257,1258,1283,1 284,1285,1286 ,12 87). The shape of the s tyl et s houl d be prepared aga ins t the patient profi le. Th e l ighted s tylet wi th trac heal tube is i ns erted thro ugh the nos tril and gently adv anced. When the l ight is see n i n the oropharynx , the hand le is rotated and the tip di rec ted toward the thyroid prominenc e, us ing the glow of the light as a gui de. Flex ing the patient's n eck, apply in g p res sure to the larynx , or i nfla ti ng the tracheal tube cuff may help to al ign the tracheal tube tip wi th the glottis . The E ndotro l tube (disc uss ed earlier) may be us eful fo r nas al intu bation with a l ighted s tyl et. The l ighted in tubation s tylet c an be used to aid direc t laryngosc opy (1 288). P lac ing the lighted s tylet in the trachea l tube wil l i mprov e the v iew i n the hypopharynx , and trans illumi nation c an ass is t in gu id ing the trach eal tube into the trachea . In another

tec hnique, the ligh ted intubation s tyle t is p laced th rou gh th e Mu rphy e ye of the trac heal tube and adv anced beyond the end of the tube (1289). Once the tip of th e l ighte d s ty let is in the trachea , th e tracheal tube is threaded ov er i t. Rotating the trac heal tube ma y aid in adv ancing i t.

Useful Situations
S tudi es sugges t that the lighted intubation s tylet can pl ay a maj or ro le in tracheal i ntu bation, es pec iall y in patients whos e l arynx ca nnot be v is uali zed wi th conv en tiona l di rec t la ry ngos copy (1256,12 60,1290 ,1291,1292 ,1293,1294,1295,129 6,1297,12 98,1299 ,1300,1301 ,1302 ,1303 ). These inc lude pa ti ents wi th a li mi ted mou th opening, mic ro-gnathia, prominent upper inc is ors , res tric ted cerv ical s pine mov emen t or s pinal i mmobili zation, g los sop tos is or glossomegaly, or res tric ted acces s to the airway (halo trac tion, s tereotax ic frame). It ma y be es peci al ly us eful in s ituations in wh ic h a flex ible endosc ope is unav ailabl e (e .g., ambulances o r emergenc y depa rtments ) or endos copy is diff ic ul t to pe rf orm (e.g ., wh en the a irway is obscu red by b lood or sec re tions or when a patient's head c annot be flexed or ex tended ) (1303,1304 ). It may also be adv antageous wi th ex tens iv e den tal work o r poor tee th (1 256). The l ighte d i ntuba ti on s tylet is useful when the a nes thes ia prov ide r has l imi ted use of the left arm (13 05). It h as been incl uded on th e AS A P rac tice Guidel in es fo r Mana gemen t of the Diffic ult Airway on the nonemergenc y pathway (5 06). Other s i tuations where the l ighted intubation s tylet may b e useful inc lud e patien ts i n h ead f rames and where head ex tensi on is no t pos s ible. In this si tua tion, the succes s rate was not as high and took longe r than d irec t laryngosc opy (1306). P .611

The l ighted in tubation s tylet may b e espec ia lly useful in eme rge ncy se ttings (1254). It is possible to us e the dev ice from the f ron t or s ide of the pa ti ent, so the tec hnique c an be us ed in c ramped quarters suc h as hallwa ys and helicopte rs (1291,12 57). It i s espec ially s uited to low-l ig ht settings . The l ighted s tyle t can be used to c heck that the trac heal tube has entered th e trac hea and not the esophagus (128 0,1307,1308) as we ll as to check fo r proper depth of the trac hea l tu be (74 8,1309). It has been us ed to id entif y th e trachea during trach eos tomy (1310).

A lighted s tyl et c an be us ed to ai d retro grade intubation (1311 ,1312) and to place a double-l umen bronchial tube (1313,13 14). It ma y be useful in th e pati en t with a c lenc hed jaw in who m nasal i ntubati on is c ontraind ica ted (131 5), the pa tient with ce rv ica l ins tabi li ty (1316,1317), and tracheos tomy (1318). A lighted s tyl et may be us ed to aid intubation through a laryngeal mas k (1279,12 80,1282 ,1319,1320 ,1321,1322,1323,132 4,1325,13 26,1327 ,1328,1329 ,1330 ,1331 ,1332). It c an be used in ped ia tric pa tients (1 291,129 4,1297,13 33,1334 ). It can be us ed wi th the patient i n the lateral pos ition (13 35).

Contraindications
Con traindications to us e of the lighted intubatio n s tylet inclu de patients wi th tumors , i nfec tion , trauma , or foreign b odies in the upper ai rwa y; anything that i nte rferes with trans miss io n of the light f rom the nec k (an teri or nec k scarri ng , f lex ion c ontrac tions , a bea rd, excess iv e adipose tiss ue, midl ine neck tumors o r s we ll ings , c ov e ring of the bulb with blood an d/o r s ec retio ns ); and po te nti al c erv ic al sp ine ins tab il ity. This is n ot an eme rgenc y ai rwa y tec hnique . The procedure c an take a s ig ni fican t amou nt of time and may need to be perfo rmed i n the da rk (1336 ). Fo r c an't i ntu batec an't v en til ate si tua tions , a supraglottic ai rwa y dev ice (Chapter 17) may be more appropria te. It is more diffic ul t to us e the l ighted intuba tion s tylet i n chi ld ren and infan ts than in adults and s hould not b e undertaken in s mal l patients without expe rienc e in older ones (1302).

Advantages
The l ighted in tubation s tylet is s imple, inexp ensiv e , ligh twei gh t, reus abl e, reliable, co mpac t, easil y cl ean ed, p ortable, a nd reasonabl y durable. Intu bation c an be ac complished rapidl y after f aci lity with th e tec hni que has been atta ined (1259,12 60,1331 ,1337,1338 ). It can be performed wi th c ric oi d p res sure and i n uncoop era tiv e patients (13 03). The presence of bloo d o r sec reti ons is not a s tro ng i mpediment to suc ces s . It c an be us ed when ac ces s to th e head and a irway are l imi ted. Hea d and nec k manipulation can be kept to a minimum. A wi de mouth opening is no t requi red . Intubatio n b y us ing the l ighted s tyl et is assoc iate d with a low i nc idenc e of mucos al i njury , dys phagia, sore throat, and dental trauma c ompared wi th di rec t l ary ngos cop y (1259,1261,1339,1340 ), but one s tud y f ound a g rea ter inc idence of hoars enes s with the l ighted s ty le t (1341).

The c irc ulatory resp onses and effec ts on intra ocular p res sures are s imi lar to direc t l ary ngos cop y (1339,1341,1342,1343 ,13 44,1345 ,1 346,1347,1348,1349). In awa ke pa ti ents , the magn itude of s tress is less than with a la ryngosc ope (1350). The intubation techni que wi th the l igh ted s ty let is eas ily learned, although there is a le arn in g c urv e (1340). Compa red wi th b li nd nas al intubati on, nasal intuba tion wi th a ligh ted s tylet has been shown to require less time and f ewer a ttempts (1252). In pa tients with cerv ical sp ine dis o rde rs , in tubation wi th a l igh ted s ty let is fas ter an d assoc iate d wi th a highe r s uc cess rate tha n i ntuba ti on th rough an in tub ating larynge al mas k (129 8). It caus es less c erv ic al sp in e mov ement tha n intuba tion wi th a Macintosh l ary ngos cop e and is f as ter than us ing a Bu llard laryngosco pe or f ibers cope (1317 ).

Disadvantages
This is a b li nd app roach and prof ic ienc y i n use requi res prac tice. The time to i ntu bation and numbe r of attempts a re greater than wi th the patients intuba ted wi th a ri gid la ryngosc ope (1250 ,1251,1256 ,1341,1351).

Complications
The bulb or lens ma y beco me d etached (125 0,1254,1290,1 352,1353). The dev ic e may f rac ture nea r the h andle (13 54). The re is the po ten tial for tra uma in the uppe r ai rway assoc ia ted wi th i ts use. Cases of a rytenoid dis loc ation and epiglo ttis ma lpos i tion hav e b een reported (1355,13 56,1357 ). A case has been rep orted where the epi glo ttis was partial ly pushed into the l aryngea l inle t (1355). It is no t unc ommon to c ause so me b leedi ng with th is tech niq ue. If this technique fails , the presence of blood mak es fiberoptic techniques more d ifficult. W ith re peated us e and s teril iza tion, the s tylet ma y b ecome i rregu la r and diff icul t to retrac t (1358). A s mall amoun t of l ubric ant may help the problem. The elec trical contac t be twee n the s tyl et and the handl e may fa il , c ausi ng in termi ttent li ght. W hi le there is c oncern th at the bulb coul d cause a burn i n the trac hea, this has not been rep orted. The abs enc e of injury may be a res ul t of co ntinuous mov ement of the light bulb (1359). P .612

Figure 19.47 Magill's forceps. (Picture courtesy of Sun Med.)

View Figure

Forceps
Forc eps can be us ed to di rec t a trac heal tub e i nto the larynx or a gas tric tube or other dev ice into the es ophagus . It may also be us ed to inse rt o r remov e pharyngea l pac king and to remov e foreign bodi es f rom th e upper air way or es opha gus (1360,136 1). Forceps s hould be immedia tel y av ailab le whe nev e r an i ntu bation is perf ormed .

Description
A popu la r ty pe is Mag ill's forc eps (F ig . 19.47). These are des igned s o that when the grasping ends are in the ax is of the trachea l tube, the han dl e is to the right. W hen the la rynx is ex posed, mos t of the fo rceps is ou t of the line of s ight. Modific ati ons of Magi ll 's forc eps and us e of other dev ices hav e been desc rib ed (1362,13 63,1364 ,1365,1366 ,1367,1368).

Problems
The trachea l tube cuff may bec ome damaged, espec ia ll y when forc eps are used wi th hi gh-v o lume , lo w-press ure c uffs . The tu be should no t be grasped a t the c uff. Ano the r way to av oi d cuff dama ge is to s mooth the ridges on the fo rceps (13 62). The f orceps may c ause damage to the ai rwa y mucos a. A no the r pro bl em is th at on e arm of the forc eps may become lodged in a Murphy eye (28). A forceps ma y bre ak (1369,13 70).

References

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Questions
For the fol low ing ques tion, s elec t the c orrec t ans wer 1. T he best w ay to detect an es ophag eal intubation is A . S eeing the tube pass th rough the v ocal cords B . Observ ing c hes t wal l mov ement du ring i nspi rati on and exhal ation C. Hearing breath soun ds during c ontro lled v en ti lation D. Monitoring CO 2 in exhaled gases E . S eeing a d rop in oxy gen saturation as me asured by pulse oxime ter V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t

i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

2. Factors that help to determine the resistance to brea thing that result from the use of a tracheal tube in clu de A . Tu be length B . ID o f the tube C. Tube c onfiguration D. Gas v is cosi ty V iew A ns we r3. Wh ich statements a bout de ad space a re accura te? A . P ediatric tubes and connec tors can inc reas e dead space abov e normal B . Th e use of a sh orter tra cheal tube wil l d ec rease dead s pace C. Mec hanica l v enti la tion ca n ov ercome the effec ts of inc reased dead spac e D. The d ead sp ace of the tube pl us connector is greater than natural dead space in adults V iew A ns we r4. Ma teria ls co mmon ly use d in tracheal tu bes to day in clu de A. PVC B . Rubber C. S il ic one D. Po lyeth ylene V iew A ns we r5. Concerning the Murphy eye, A . It may reduc e trauma during nasal in tub ati on B . A fibe rop tic scope may bec ome trappe d in it C. It may mask a right mains tem bronchial intuba tion D. Sec re tions may tend to accumula te there V iew A ns we r6. Advantages o f a spiral e mb edded trac heal tube include A . E ase of ins e rtion ov er a f ibers cope B . Res is tance to k inki ng C. Flex ible enough to be placed in tracheostomies D. Unlikel y to be the cause of obs truc tion V iew A ns we r7. Wi th respect to trac heal tube siz e, A . P ediatric tubes are s i zed b y the OD B . Tu bes larger than s i ze 6.0 mus t hav e the OD marked on them C. The F rench sca le is required to be ma rke d on the tube D. S ize is often displ ay ed on th e p il ot balloo n

V iew A ns we r8. Wi th trac heal tube s, A . Cuff p res sure s hou ld be kept betwee n 25 a nd 34 cm H 2 O B . Measuring the intrac uff pressure in hi gh -press ure c uffs giv es an indication of the press ure appl ied to the tracheal wal l C. Ni trous ox ide c an ca use the c uff pressu re to inc rease D. Intrac uff pressure in l ow-pre ssu re c uffs d oes no t v ary durin g c ontroll ed v enti lation V iew A ns we r9. Advantages o f the foam cuff tube include A . Measuring intracuf f press ure is not neces sary B . Ev en la rge c uffs do not p res ent excessive press ure to the trac heal wal l C. Diffus ion of anes th etic agents wi l l not affec t cuff pressu re D. A sea l suf fic ien t to prev ent as pi rati on wil l be ac hiev ed regardless of the relativ e s ize of the tube and trachea V iew A ns we r10 . Features of th e Lanz pressure-regu lating valve inc lude A . It giv es an indica tion of c uff inf lation B . It has a n ex ternal reserv oi r f or cuff ai r C. It l imi ts the pressu re in the cuff D. Intrac uff pressure is mai ntained at 26 to 33 torr V iew A ns we r11 . P roducts appro ved fo r use as a laser-resis tan t w rap for tracheal tubes include A . Copper foil B . A luminum tape C. A luminum fo il D. Sponge and adhes iv e-back ed c orrug ated s ilv e r fo il V iew A ns we r12 . Disadvantages of w ra pping trachea l tubes inc lud e A . Th e OD of the tube is inc reased B . A ro ugh su rfac e may be c reated C. A reflec ted beam c ould damage othe r ti ssues D. The a irway c ould bec ome obs truc ted V iew A ns we r13 . P rob lems associated w ith a tracheal tube cu ff that is too large include A . P ress ure o n the trac heal wal l wil l b e i nc reased B . Trauma to the v ocal cords is more likely C. Intrac uff pressure wi ll b e inc reased D. As piration is more likel y to occur

V iew A ns we r14 . In de termining pro per inflation of a low -p ressure , highvolume cuff, A . Th e v olume of ai r j us t needed to abo lish ai r l eak may not be enough to prev ent as piration B . Th e fee l of the in fl ation b al loo n is a good i ndica tion of the cuff pres sure C. Measurement of cuff press ure is nee ded to dete rmine proper i nf la tion D. Cuff pres sure needs to be checked du ri ng the ins pi ratory phas e of v en ti la tion V iew A ns we r15 . P oss ible complications of n asotracheal intubatio n include A . Re mov al of segments of turb ina tes B . Es opha geal perforatio n C. Pe rfora tion of the nas al s eptum D. Pe rfora tion into the re tropha ryngeal s pac e V iew A ns we r16 . Ways to minimiz e trauma w hen a nas al intubation is perfo rmed inclu de A . Av oi ding lub rican ts B . W arming the trac heal tube C. Vasodi lating the nas al muc osa D. Us ing s mall er tubes than thos e tha t would be use d for o ral intub ation V iew A ns we rP .630

17. If there is a leak arou nd the tracheal tube that recurs despite ad ded air, A . Th e tub e ma y be s li di ng in a nd out of a bro nchus B . Th e cuff may be abov e the c ords C. Gas may be diffusi ng out of the c uff D. There may be a l eak i n the c uff V iew A ns we r18 . Factors that tend to p romote inad verten t bronchial intub ation inclu de A . Trend el enbu rg pos iti on B . Neck flex ion C. La parosc opy D. Us e of RAE tubes fo r chil dre n V iew A ns we r19 . Reliab le methods fo r determinin g the presenc e o f an inadve rtent bronch ial intubatio n include A . A uscultation of the l ungs

B . P uls e oxi metry C. End-ti dal CO 2 mon itorin g D. Fibersc opic v isuali zation through the tube V iew A ns we r20 . Ways to handle a cu ff leak include A . Re intubation B . P acking the pharynx C. A ttac hing a mechanis m for c ontinuous air i nfusi on to the c uff inf lation s ys tem D. Fi ll the cuff with lidoc ane and sal ine V iew A ns we r21 . Ways of preven ting trache al tu be obstruc tion inc lude A . Check ing the cuff for ev en infl ati on B . No t withdrawi ng the tube with the c uff infl ate d C. Us ing an o ral airway or b ite block D. Pu ttin g trac tion o n the trac heal tube V iew A ns we r22 . Factors increas ing the inc ide nce of aspiration of gastric con ten ts inclu de A . Head-up posi tion B . Control led v entil ati on C. Ac cumulation of fl uid abov e the c uff D. High-press ure cuffs V iew A ns we r23 . Factors that increase the likelihood of accidental extuba tion inc lud e A . Re mov ing an adhesiv e plas tic d rape B . Us ing a nti disc onnec t dev ic es C. Remov ing a nas ogas tric tube before ex tubati on D. P lac ing the tu be at the carina V iew A ns we r24 . P oss ible caus es of diffic ult e xtu bation include A . Obs truc tion of the inflating mechan ism B . P ull ing the pi lot ba ll oon and inf lation devi ce from the inf lating mechanism C. Su rgical trans fix ion D. S we ll ing in the ai rway V iew A ns we r25 . P ostoperative so re th roat A . Is more c ommon in males than f emales B . Is inc reased i f the patient is in the pro ne posi tio n C. Is rel ated to both du ration of anes thes ia and age of the patient D. Is ass oc iated with use of larger tubes V iew A ns we r26 . Conce rning hoarseness fo llow in g intubation ,

A . Th e inc id ence is dec reased wi th the use of low-press u re c uffs B . Lubric a ti on of the tube wi th l idocaine jelly does not dec rease the inc idenc e C. Smal ler tubes a re ass oc iated with a dec reas ed inc i -dence D. The inc idenc e is not inc reas ed if the intubati on was trauma tic V iew A ns we r27 . Laryngeal ede ma A . May b e c aus ed by pre -ex is ting infl ammati on, bac teri al c ontami nation, or chemic als B . May b e c aus ed by inadequate muscle relax ation or too l arg e a tube C. May be c aus ed by an al lergic reac tion to the tube or lub rican ts D. Can occur anytime duri ng the fi rs t 48 hou rs af te r ex tu-bation V iew A ns we r28 . Gran ulomas o f the vocal c ords A . A re found mos t c ommonly in males B . May n ot bec ome s ymp tomatic for s ev e ral months C. A re most c ommon in c hildren D. May be s ymptomless V iew A ns we r29 . Disadvantages of prefo rmed RAE tubes inc lude A . Th e tub e ma y not be cu t B . Inc reas ed res is tance C. Heigh t and wei ght are no t useful to de termin e the prope r si ze tube D. Age i n yea rs is not us ef ul to d ete rmine th e p roper si ze tube V iew A ns we r30 . Advan tages of th e microla ryngeal tracheal surgery tube include A . S ma ll d iame ter prov idin g better v is ib il ity for th e s urgeon B . Lower res is tanc e to both inh al ati on and exhal ati on C. Can b e used for patients with a narrowe d airway D. Can b e used wi th l ase rs V iew A ns we r31 . Whic h tube(s) ha ve a high-pressure cuff? A . No rton trac heal tube B . S heri dan Laser trac heal tube C. Lasertu bus D. Intubating laryngeal mask trach eal tube V iew A ns we r32 . Disadvantage(s ) of using a trache al tube w ith a low pressu re cuff in clude A . As pi ration of f luid from the upper a irway i nto the trac hea B . It may be torn easi ly C. A greater inc idence of s o re throat compare d with the high -press ure c uff

D. More diffic ul ty during ins ertion V iew A ns we r33 . S ituatio n(s ) tha t w ill cause trache al tu be cuff pressure to va ry include A . Heated humidif ication B . Ox ygen diffus io n i nto th e c uff C. Changes i n head p osi tion awa y from the neu tral pos i ti on D. Inc reas es in al titude V iew A ns we r34 . What are some w ays to limit cha nges in the in tracuff pressu re in the low -pressure cuffs? A . Mon itoring c uff pressure B . Fil ling the cuf f wi th a mix tu re of ox ygen a nd ni trous ox ide C. Fi lling the cuff wi th water or s al in e D. Le av ing a s yringe attac hed to the inf lation tube V iew A ns we r35 . Advan tages of cuffe d tracheal tubes inc lude A . Less ope rating room po ll ution with anes the tic gas es B . Dec reased aspi rati on risk C. Improv ed moni toring of res piratory gases D. Greater margin of safety V iew A ns we r36 . Drawbacks of usin g c uffed tu bes in ch ildre n include A . P ossible obs truc tion b y the cuff B . Highe r gas flo ws mus t be us ed C. Suc tion ing through the tube is more diff ic ult D. Lo wer i nf lation pressu re mus t b e used V iew A ns we rP .631

37. Advan tages of ora l in tuba tion inc lude A . Can be perf ormed quickl y B . Mi ni mal ce rv ica l spine motion C. Can use a trache al tube wi th a large r diameter D. W el l tolera ted i n the c onsc ious patie nt V iew A ns we r38 . In dications for naso trachea l in tuba tion inc lud e A . Te mporomand ibula r joint mov emen t limi tation B . Intrao ral pathol ogy C. Cerv ical s pi ne inju ry D. Frac tured max i lla

V iew A ns we r39 . Advan tages of nas otrache al intub ation include A . A l arg er tube can be used B . Tu be wil l not be oc c luded by bi ting C. Lo wer i nci dence of bac tere mia D. Less cerv ical spine mov ement than oral intubation V iew A ns we r40 . Relative con train dications to n asotracheal intubatio n include A . Coagulopa thies B . P rev ious repair of the c ri bifo rm pla te C. Absces ses D. Trans -s phenoidal su rge ry V iew A ns we r41 . Whic h techn ique(s ) w ill fa cilitate pass ing a tracheal tube throu gh the vocal cords ove r a flexible en dosco pe, bou gie , or exchange catheter? A . W arming the trac heal tube B . Ro tati ng the tube counterc lock wi se 180 d egrees C. Apply ing a j aw th rus t D. Us ing a sma ller en dosc ope, bougie, or ex change catheter V iew A ns we r42 . Way(s) to avoid trau ma as sociated w ith trachea l intub ation inclu de A . Th ermosof te ning the tube B . Us e o nl y gentle pres sure C. Do no t le t a dev ice in the trachea l tube pro trude f rom th e ti p D. Apply ing a v asoc onstric tor to th e nose V iew A ns we r43 . While obse rving ches t w all motion as a tes t of tracheal intub ation, w h ich co nditions may simu late trache al intubation during an esophageal intu bation? A . P a tients with a lo w l ung v olume B . Obese pati ents C. Lo w c hes t wal l compl ianc e D. Abdominal resp iration V iew A ns we r44 . Whic h auscultatory tec hnique(s) give the mos t reliable indication that the trachea l tub e is in the trachea? A . A uscultation of the upper abdomen and lungs B . Gurgl ing s ounds with v en ti la tion C. A i rway ausc ul tati on

D. Auscul tation of hig h mid-axi l lary area V iew A ns we r45 . S ituatio ns w here e nd-tid al CO 2 de tec tion ma y not indicate that the trachea has been intu bated inc lude A . Ca rdiac arres t B . Ex haled gas es in the s tomac h C. Pu lmonary embolis m D. B ronc hos pasm V iew A ns we r46 . S ituatio ns w here the esophageal detector device w ill be more accurate in detecting trach eal intu bation than CO 2 monitoring include A . S ev ere bronchospas m B . Ca rdiac arres t C. Pu lmonary embolis m D. One -wa y trac heal tube obs truc tio n V iew A ns we r47 . S ituatio ns w here CO 2 mon itoring may cause a falsepos itive reading about tracheal tube placemen t inc lud e A . Ex haled gas es fo rced into the s tomac h during prev ious mask v entilation B . Intrav enous lac ta ted Ringe r's s olution C. An tac ids tha t hav e reac ted wi th gas tric ac id to form CO 2 D. B ronc hos pasm V iew A ns we r48 . Complica tions th at can oc cur w ith th e lighted s tylet include A . B u rns f ro m the hot l ight bulb B . A rytenoid disl oca tion C. Takes more ti me and more a ttempts than b lind nasal intubation D. Ep iglottis mal pos itio n V iew A ns we r49 . Ways to avoid trac heal tube obs truction include A . Us ing transpa ren t tracheal tubes B . Deflating the c uff before wi thd rawi ng the tu be C. Cutting the machine e nd of the tube at a bev el before the c onnec tor is i ns erted D. P lac ing a bi te b loc k between the incisor teeth V iew A ns we r50 . In dications that a partial trac heal tube obstruction is presen t may inc lude w hich of the follow in g? A . W heezing B . A n al tera tion in the press ure -v o lume l oop C. Pa rad oxical ches t mov ements during spontaneous breathing D. A dec reased s lope in Phas e III and a s mal ler angle on the capnogram

V iew A ns we r51 . A p artia l tracheal tu be obstruc tion can be diagnosed by w hich of the following maneuvers? A . Deflating the trac heal tube c uff B . Digi ta l exa mina tion C. Fibersc opic examination D. Inse rting a s tylet o r s uc ti on catheter V iew A ns we r52 . Ways to relieve a pa rtially obstructed tracheal tu be include A . Us ing a hemos tat or c lamp to reli ev e the k ink B . P assing a smal ler tu be th rough the tracheal tube C. Us ing an e mbolec tomy catheter D. P lac ing a larg er trac heal tube ov er the k inke d tracheal tube V iew A ns we r53 . Whic h of these tec hniq ues may avo id pulmonary aspiration w hen the tracheal tu be is re mo ved? A . W i thdrawing the tube with th e c uff in fl ated until the c uff is jus t abov e the v oc al co rds B . P lac ing the patient i n the head down l atera l pos iti on C. W i thd rawing the tracheal tube during sucti on ing D. W i thd rawing the tu be unde r pos itiv e pressure in the trachea V iew A ns we rP .632

54. S ituatio ns that can contribute to macroglossia inc lude A . S i tting pos ition B . A n ticoagulation C. P rone posi ti on D. Hemo rrhage i n the pharynx V iew A ns we r55 . In dication(s) that a boug ie has en tered th e trachea include A . Ro tati on, if the boug ie en ters a mainstem bronc hus B . A c l icking sensatio n as it pass es ov er trache al rings C. Resis ta nce as i t enters s malle r bro nchi D. A dec rease in force needed to adv anc e the bo ugi e V iew A ns we r56 . S ituatio ns w here the lighted in tuba tion sty le t is particularly use ful inc lude A . Limi ted mouth op eni ng

B . Mic rogna thia C. W hen a f lex ible endos cope is not av ailable D. W hen the anes thes ia prov ider has limi ted us e of the lef t arm V iew A ns we r57 . Contraindicatio ns to th e lighte d s tylet techn ique o f intub ation inclu de A . Fo reign bodies in the uppe r ai rway B . P lac ing doubl e-lu men or bronchial tubes C. Inf ec tio n D. Cerv ical ins tabili ty V iew A ns we r

Chapter 20 Lung Isolation Devices

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Indications for Lung Isolation Thoracic Procedures

A deflated lung provides better operating conditions and reduced trauma during thoracic procedures.

Control of Contamination or Hemorrhage

A lung isolation device can prevent infected material from one lung from contaminating the other lung (1). W hen hemorrhage occurs in one lung, an isolation device allows the unaffected lung to be ventilated (2,3,4,5,6,7,8,9,10,11).

Unilateral Pathology
A bronchopleural or bronchocutaneous fistula may have such a low resistance to gas flow that most of the tidal volume passes through it, making it impossible to adequately ventilate the other lung (12,13,14). Large cysts or bullae may rupture under positive pressure, making it mandatory that they be excluded from ventilation. Another indication for lung sep aration is when lu ngs have markedly different compliance or airway resistance such as that which occurs follo wing single-lung transplantation or unilateral injur y (15).

The best method of producing lung isolation in a given situation will depend on several factors, including the indication for lung isolation, patient variables, available equipment, and the skill and training of the anesthesia provider.

Anatomical Considerations
The right mainstem bronchus is shorter, straighter, and has a larger diameter than the left. It takes off from the trachea at an angle of 25 degrees in adults. The left mainstem bronchus diverges from the median plane at a 45-degree angle. These angles are slightly larger in childr en (16). The right upper lobe bronchus takeoff is v ery close to the origin of the right mainstem bronchus. These anatomical features mean that it is us ually easier to intubate the right mainstem bronchus than the left, but it is more difficult to place a tube in the right mainstem bronchus without obstructing the upper lobe orifice.

Double-lumen Tubes
The double- lumen tube ( DLT, DLET) is the device most commonly used to provide lung isolation.

Description
A DLT is essentially two single-lumen tubes bonded together and designated either as right- or left-sided, depending on which mainstem bronchus the tube is designed to fit. The tracheal lumen is designed to terminate above the carina. The distal portion of the bronchial lumen is angled to fit into the appropriate mainstem bronchus.

The internal lumen of each tube is D-shaped with the straight side of the D in the middle of the tube. The resistance of each lumen of a 35 to 41 French (Fr) DLT has been found to be comparable to the resistance of a size 6 to 7 mm internal diameter single-lumen tracheal tube (17). The bronchial cuff for right-sided tubes varies in shape, depending on the manufacturer. On some tubes, the cuff has a slot to allow ventilation of the right upper lobe. Some right-sided DLTs hav e two bronchial cuffs with an opening for the right upper lobe between them. The resting volume and compliance of bronchial cuffs varies between different sizes and brands of DLTs (18,19). Most manufacturers color the bronchial cuff blue. They also use blue markings on the pilot balloon and/or the inflation device for the bronchial cuff. A few DLTs hav e a carinal hook to aid in proper placement and minimize tube movement after placement. Potential problems with carinal ho oks include increased difficulty during intubation, trauma to the airway, malposition of the tube becaus e of the hook, and interference with bronc hial closure during pneumonectomy. The hook can break off and become lost in the bronchial tree. Most manufacturers place a radiopaque marker at the bottom of the tracheal cuff or at the end of the tracheal lumen. Other marks may be placed above and/or below the bronchial cuff. Some have a radiopaque line running the length of the tube. Disposable DLTs are supplied in sterile packages, which include a stylet, connectors, and suction catheter(s). A means to supply

continuous positive airway pressure (CPAP) may be included with the tube or can be purchased separately. The connector (20) allo ws both lumens to attach to a breathing system at the same time.

Sizing
Adult DLTs commonly come in sizes 35, 37, 39, and 41 Fr. The French scale is the external diameter of the tracheal segment times three. Some manufacturers also provide 26, 28, and 32 Fr tubes for younger patients. Unfortunately, the French gauge markings are of limited v alue in determining the most important measurement-the diameter of the bronchial segment. There are major variations between manufacturers in the dimensions of the bronchial segment of DLTs of the same nominal size and even among tubes of the P.635

same size from the s ame manufacturer (21,22,23,24). An International Technical Specification has recommended that outside circumferenc e of the bronchial segment be designated in millimeters (25). The diameter of the bronchial segment with the cuff inflated may not increase with tube size (26).

Margin of Safety
The margin of safety for a DLT is the length of the tracheobronchial tree between the most distal and proximal acceptable positions (27,28). The margin of safety will depend on the length of the lumen into which the cuff is placed and the

length of the cuff. If the cuff is short or the mainstem bronchus long, the margin of safety will be greater.

Left-sided Tubes
The outermost acceptable position for a left-sided DLT is when the bronchial cuff is just belo w the carina. If the tube were more proximal, the bronchial cuff could obstruct the trachea and/or the contralateral (right) mainstem bronchus. In this case, the seal between the two lungs would be lost. The most acceptable distal position is when the the bronchial segment tip is at the proximal edge of the upper lobe bronchial orifice. More distal insertion would result in obstruction of the upper lobe bronchus. The average length of the left bronchus from the carina to the takeoff of the upper lobe bronchus is 5.6 cm. This leaves a relatively small margin for placement, as there could be up to 3.5 cm of movement with neck flexion and extension (29). There is great v ariability in the length of the bronchial segment of leftsided DLTs currently available (30).

Right-sided Tubes
The margin of safety is defined differently for right-sided tubes. A right-sided DLT is acceptably positioned if the right upper lobe ventilation opening or the space betwee n the two cuffs is aligned with the right upper lobe orifice. T hus, the margin of safety is the length of the ventilation opening minus the diameter of the orifice. The margin of safety for right-sided tubes is considerably less than for left-sided tubes.

Specific Tubes

Carlens Double-lumen Tube

The Car lens DLT (Figs. 20.1, 20.2) is intended to be inserted into the left mainstem bronchus. It has a carinal hook (spur). This tube may be especially useful with massive hemoptysis when verification of tube placement is especially difficult (31).
Figure 20.1 Carlens double-lumen tube. A: The connector has ports for fiberscope insertion or suctioning and areas where a clamp can be applied to occlude gas flow. B: Note the carinal hook and the blue bronchial cuff.

View Figure

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Figure 20.2 Carlens tube in place.

View Figure

White Double-lumen Tube

The W hite DLT (Fig. 20.3) is designed to fit the right mainstem bronchus. It has a carinal hook. The cuff for the right mainstem bronchus is circumferential superior to the opening to the upper lobe bronchus and continues distally behind the opening.

Robertshaw Right Double-lumen Tube

The bronchial portion of the Rober tshaw right DLT (Fig. 20.4) is angled at 20 degrees (32). The bronchial cuff has a slotted opening in its lateral aspect (Fig. 20.5). The bronchial cuff is proximal to the slot on the lateral surface and extends tangentially toward the medial surface.

Robertshaw Left Double-lumen Tube

The Robertshaw left DLT is shown in Figures 20.6 and 20.7. The angle of the bronchial portion is 40 degrees (32). The average length of the bronchial segment is 23 mm for sizes 35/37 and 25 mm for sizes 39/41 (30).

Broncho-Cath Right-sided Tube

The Broncho-Cath right-sided tube has a bronchial cuff that is roughly the shape of an S, or s lanted doughnut. The cuff edge nearest the right upper lobe bronchus is closer to the trachea than the part of the cuff touching the medial bronchial wa ll ( Figs. 20.8, 20.9). A slot in the tube just beyond the cuff corresponds to the opening of the upper lobe bronchus (27). The end of the bronchial segment has no bevel (33). The shape of the right bronchial cuff allo ws the ventilation slot to ride off the right upper lobe orifice, increasing the margin of safety. One study found that when this tube was inserted blindly, right upper lob e obstruction occurred in 89% of cases (34). Plac ement using fiberoptic endoscopy resulted in much better positioning (35).

Figure 20.3 White double-lumen tube. (Picture courtesy of Teleflex Medical.)

View Figure

Broncho-Cath Left-sided Tube

On the Broncho-Cath left-sided DLT (Fig. 20.10), the bronchial portion of the tube is at an angle of approximately 45 degrees (33,36,37). The bronchial p ortion has a curved tip. The bevel was removed in 1994 but reintroduced in 2001 (33,38). The average length of the bronchial segment is 30 to 31 mm (30). The tube is available with or without a carinal hook.

Sher-I-Bronch Right-sided Double-lumen Tube

The Sher-I-Bronch right-sided DLT has two cuffs on the bronchial segment, one proximal and one distal to the upper lobe

ventilation slot. The slot is 13 to 14 mm long (Figs. 20.11, 20.12). One study found that poor lung isolation was more common when this tube was used (39). A case has been reported in which the tube tip became trapped in the right upper lobe bronchus (40).
Figure 20.4 Robertshaw right double-lumen tube in place.
View Figure

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Figure 20.5 Robertshaw right double-lumen tube in place.

View Figure

Sher-I-Bronch Left-sided Double-lumen Tube

The bronchial segment of the Sher-I-Bronch left-sided DLT diverges from the main tube at an angle of 34 degrees. The average length of the bronchial segment is 35 mm (30). The bronchial segment has a bevel (30). One study found that the bronchial cuff on this tube required significantly higher pressures to achieve one- lung is olation than cuffs on other DLTs (41).

Silbroncho Double-lumen Tube

The Silbroncho DLT (Fig. 20.13) is made of silicone, which is softer than polyvinylchloride (PVC). The tube does not contain latex. The bronchial segment is wire-reinforced distal to the tracheal cuff. This allows it to be flexible and prev ents kinking.

The wire reinforcement also makes tube position easy to determine on x-ray. The bronchial cuff is s mall and near the end of the tube. It is available in sizes 33, 35, 37, and 39 Fr.
Figure 20.6 Robertshaw left double-lumen tube. (Courtesy of Rusch, Inc.)

View Figure

Figure 20.7 Robertshaw left double-lumen tube.

View Figure

Techniques
Tube Choice Right versus Left
W hen surgery is performed on the right lung, a left-sided DLT should be used (42,43,44). Because the margin of safety in positioning a right-sided DLT is so small, some prefer to use a left-sided DLT whenever possible for left lung surgery (28,45). During left pneumonectomy, immediately before the left mainstem bronchus is clamped, the DLT can be pulled from the bronchus and used for ventilating the right lung. A disadv antage of this technique is the risk of b lood and secretions moving from the

operative (left) bronchus to the nonoperative bronchus. Other possible problems include the tube becoming dis lodged or sutured in place during surgery. A ball-valve obstruction may occur as a result of secretions or mediastinal press ure pushing the tracheal lumen against the tracheal wa ll (46). A left DLT may not prov ide optimum conditions for ventilating the resid ual lung after left upper lobectomy (47). A right-sided DLT should be us ed when it is important to avoid manipulation/intubation of the left main bronchus (e.g., an exophytic lesion), when the left main bronchus is narrowe d or the left mainstem bronchus is so cephalad that the bronchial lumen will not enter the P.638

left mainstem bronchus, left pneumonectomy, left lung transplantation, left mainstem bronchus stent in plac e or when there is trac heobronchial disruption on the left (43,48,49,50,51).

Figure 20.8 Broncho-Cath right double-lumen tube. Newer versions have no bevel at the end of the bronchial segment. (Courtesy of Mallinckrodt Medical, Inc.)

View Figure

Before placing a right DLT, the patient's chest x-ray or computed tomography scan can be closely examined to identify a right upper lobe bronchus takeoff, which would make it diffic ult to use a right DLT. A left DLT should be placed in the right mainstem bronchus in Kartagener's syndrome, which includes complete situs inversus and a longer-than-normal right mainstem bronchus (52).

Figure 20.9 Broncho-Cath right double-lumen tube. The bronchial cuff has the shape of an S or a slanted doughnut, with the edge of the cuff nearest the right upper lobe bronchus closer to the trachea than the part of the cuff touching the medial bronchial wall. A slot in the tube beyond the cuff corresponds to the opening of the right upper lobe bronchus. Newer versions have no bevel on the bronchial segment.

View Figure

Size
Sele cting an appropriately sized DLT for a given patient is critical to minimize the frequenc y of complications (53). A DLT that is too small may fail to provide lung isolation or may require bronchial cuff volumes and pressures that could produce mucosal ischemia or bronchia l rupture. Using too small a DLT can result in the tube advancing too far into the bronchus, a higher level of autoPEEP (positive end-expiratory pressure), or barotrauma (54,55). An undersized tube may be more likely to be displaced. Ventilation and suctioning are more difficult with a small tube.

Using a large DLT will res ult in less resistance to gas flow, facilitate suctioning and passage of a fiberscope, and reduce the risk of advancing the DLT too far into the bronchus but may result in trauma (56). Inability to insert a larger tube through the larynx or past the carina or intrinsic or extrinsic obstruction in the mainstem bronchus to be intubated may necessitate use of a smaller tube. A tube is oversized if the bronchial lumen will not fit into the bronchus or there is no air leak with the bronchial cuff deflated (22,38,57,58,59,60). It is too small if the bronchial cuff inflation volume is greater than the resting cuff vo lume. Not more than 3 cc of air in the bronchial cuff should be required to create a seal. W hen there is a high risk that fluids will seep past the bronchial cuff, a smaller DLT should be used (61). In adults, the dimensions of the cricoid ring best define thos e of the main bronchi (23). In children, age but P.639

P.640

not weight is a predictor of bronchial diameter, and the right main bronchial diameter is significantly larger than the left (62). Suggested sizes for DLTs in childr en are shown in Table 20.1. Tubes fro m different manufacturers vary in size and may not fit this table.

Figure 20.10 Broncho-Cath left double-lumen tube. (Courtesy of Mallinckrodt Medical, Inc.)

View Figure

Figure 20.11 Sher-I-Bronch double-lumen tubes. A: Left-sided tube (top). Right-sided tube (bottom). B: Close-up of right bronchial segment, showing opening to the right upper lobe. (Courtesy of Sheridan, Inc.)

View Figure

Figure 20.12 Sher-I-Bronch right double-lumen tube. Note the two cuffs proximal and distal to the opening to the right upper lobe.

View Figure

The optimal size of DLT is easily selected if the diameters of the patient's main bronchus and the DLT tip are known. The diameter of the DLT bronchial lumen should be 1 to 2 mm s maller than the intubated bronchus (22). The diameter of the mainstem bronchus in any given patient can be difficult to determine. There are considerable v ariations in mainstem bronchial diameters. Age, sex, gender, weight, and height have relatively weak predictive value when selecting the proper DLT (22,60).
TABLE 20.1 Sizes of Double-lumen Tubes for Children

Age (years) 8 to 10

Double-lumen Tube (French) 26

10 to 12

26 to 28

12 to 14

32

14 to 16

35

From Hammer GB, Fitzmaurice BG, Brodsky JB. Methods for single-lung ventilation in pediatric patients. Anesth Analg 1999;89:14261429.

The size of the mainstem bronchus may be determined by measuring the width of the patient's bronchus from a chest x-ray or computed tomographic scan (22,54,60,63,64,65,66,67,68). Unfortunately, it is not possible to accurately measure bronchial width on many chest x-rays, and the correlation between the tracheal and bronchial size may not be reliable enough to determine the proper size DLT from the size of the trachea (56,59,63,69,70,71,72). Reliability may be increased by measuring the tracheal diameter both anteropostally and mediolaterally (73). The lung transplant patient may have a significantly different sized bronchus than would hav e been predicted from the size of the trachea (56).

Preparing the Double-lumen Tube

The tracheal and bronchial cuffs should be inflated and checked for leaks and symmetrical cuff inflation, making certain that each inflation tube is associated with the proper cuff. The cuffs and stylet should b e lubricated with a water-soluble lubricant and the stylet placed P.641

inside the bronchial lumen, making certain that it does not extend beyond the tip. The connector should be assembled so that it can be quickly fitted to the tube and breathing system after intubation.
Figure 20.13 A: The Silbroncho double-lumen tube. B: The bronchial segment is wire-reinforced distal to the tracheal cuff.
View Figure

Insertion
The DLT is advanced through the larynx with the angled tip directed anteriorly. After the bronchial cuff has passed the cords, the tube is turned 90 degrees so that the bronchial portion points to ward the appropriate bronchus. If the tube is to be placed in the left mainstem bronchus, the head and neck should be rotated to the right before rotating and adv ancing the tube (74). Leaving the stylet in place for the entire intubation procedure rather than removing it once the bronchial cuff has passed the vocal cords may result in more rapid and accurate p lacement (75). However, some recommend that th e stylet be removed just after the tube passes the vocal cords to prevent trauma (76). A DLT is most accurately placed by inserting a fiberscope into the bronchial lumen and directing it into the appropriate bronchus under direct vision (77,78,79,80,81,82). Concurrent direct laryngoscopy may be required to elevate the supraglottic tissues to facilitate passing the DLT through the glottic opening after the fiberscope is in the trachea (83). This ensures that the correct bronchus is intubated on th e first attempt and avoids inserting the tube too deeply or the tube becomin g kinked in the upper lobe bronchus (40). A DLT with a carinal hook should be inserted with the bronchial segment concave anterior ly until the bronchial cuff passes the cords. It should then be rotated 180 degrees so that the hook is anterior and advanced until the hook passes the v ocal cords. The tube is then advanced until the hook engages the carina. The

hook can be tied closely to the tube with a slip knot to facilitate passage through the larynx and then untied. Inserting the bronchial portion into the bronchus c an be performed blindly after insertion through the vocal cords. In some cases (e.g., bronchorrhea, bleeding), blind placement may succeed where the fiberoptic technique does not (79). W ith blind insertion, the correct depth of insertion may be difficult to determine. Ho wever, this method may be useful where rapid lung isolation or collapse is necessary. In adults, there is a correlation between the ide al depth of insertion of left DLTs and patient height but not weight or age (24,84,85,86,87). The ideal depth of insertion can be estimated from the chest x-ray (84,85,86). Advancing the tube with the bronchial cuff partially inflated until an increase in resistance is felt (or only one side of the chest moves and compliance is reduced) may prevent inserting the tube too deeply (88,89,90,91). The bronchial cuff is then deflated and the tube advanced a distance equal to the length of the bronchial cuff plus 1 to 1.5 cm to place it just beyond the carina (92,93). Depth of insertion may be estimated by monitoring bronchial cuff pressure (94). Sinc e the tube usually moves upward with positioning, some clinicians recommend that the tube should initially be inserted more deeply than would be the ideal position (36,38,95,96). Others believe that the dan ger of trauma is increased if the tube is intentionally placed too deeply (97). If the patient is anatomically difficult to intubate, a single-lumen tracheal tube may be placed by any of the means that facilitate

difficult intubations (98). An exchange c atheter can then be inserted into the single-lumen tube and the DLT inserted over the catheter after the single- lumen tube has been withdrawn (99). The W uScope (Chapter 18) has been successfully employed to place a DLT in a patient who was difficult to intubate (100). A DLT can be placed by using a lighted stylet ( Cha pter 19) in the bronchial lumen (101) or a retrograde intubation technique (102). Awake fiberoptic bronchial intubation with a DLT has been reported (103). A DLT may be introduc ed over a gum elastic bougie (45,104,105,106). It may be helpful to pass the bougie through the opening for the right upper lobe orifice on right DLTs (105). A DLT may be inserted through a tracheostomy (107,108).

Cuff Inflation
Once the tip is thought to be in a mainstem bronchus, the tracheal cuff should be inflated in a manner similar to that of a tracheal tube (109,110). It is more difficult to inflate the bronchial cuff correctly. An overinflated bronchial cuff is more likely to herniate into the trachea, cause the carina to be pushed toward the opposite side, or result in narrowing of the bronchial segment lumen. Inflating the bronchial cuff beyond its resting volume may result in dangerously high pressure (18,111). The bronchial cuff should b e inflated with small incremental volumes until an airtight seal is just attained (109,112). The total volume should be less than 3 mL (41). One technique is to immerse the proximal tracheal lumen in water d uring ventilation

via the bronchial lumen. Th e bronchial cuff is inflated until no bubbles are seen escaping during positive-pressure inspiration (110,111) (Fig. 20.14). Variations of this are to connect a balloon (113) or a capnograph (111) to the tracheal lumen. Another method is to apply suction to the tracheal lumen (110). Absence of bronc hial seal will caus e the reservoir bag in a breathing system that is connected to the bronchial lumen to collapse. Inflating the bronchial cuff to an airtight seal may not prevent the spread of blood or secretions (61). The bronchial cuff may also be inflated with water (114).

Confirming Position
Confirming proper tube position is essential because the tube may not perform properly if incorrectly P.642

positioned. Position should be checked after insertion, after repositioning the patient, and before beginning one-lung ventilation, as these tubes often move during patient positioning or surgical manipulations (97,115,116,117,118,119,120,121,122,123). The most frequent DLT movement is during lateral decubitus positioning. W hile movement is usually outward, distal migration may also occur. DLT position should be confirmed whenever there is evidence of malfunction.

Figure 20.14 Inflating the bronchial cuff. With the tracheal cuff inflated, the bronchial cuff is slowly inflated. Right: A bronchial cuff leak is indicated by bubbles when the end of the tracheal lumen is placed under water. Left: With a seal, no bubbles appear.

View Figure

Auscultatory Techniques
Unfortunately, auscultation detects DLT malposition only part of the time because breath sounds can be transmitted from one region of the lung to adjacent areas (124,125,126,127). Studies have shown that a significa nt percentage of DLTs thought to be positioned satisfactorily by auscultation were foun d to be inappropriately positioned on subsequent fiberoptic examination (116,120,128). A DLT may function satisfactorily although not in an ideal position. Another problem with auscultation is that once the patient is prepped and draped, the chest is no longer available for auscultation. One study found that auscultatory

placement was not associated with an increased incidence of complications during one- lung ventilation (39).

Clamping Method Left-sided Tubes

W ith only the tracheal cuff inflated and the tracheal lumen connected to the breathing system, both lungs should be auscultated in the axillar y regions and upper lung fields to detect differences. The bronchial cuff s hould then be inflated and both lumens connected to the breathing system. Auscultation should then be repeated. Next, the attachment bet ween the breathing system and the tracheal lumen should be occluded and the tracheal lumen opened to atmosphere. Breath sounds should be heard only over the left lung. If breath sounds are heard bilaterally, the tube is too high in the trachea. Both cuffs should be deflated and the tube advanced. If breath sounds are heard only over the right lung, the bronchial lumen is on the right side. If this is the case, both cuffs should deflated, the tube withdrawn until its distal end is above the carina, rotated, then reinserted. The steps outlined should be repeated. The attachment between the breathing system and the bronchial lumen should then be clamped and the patient ventilated through the tracheal lumen. The bronchial lumen should be opened to atmosphere. Breath sounds should be heard only over the right lung. If there is marked resistance to v entilation, the tube is either too far into the left bronchus or is not deep enough. The

position can be determined by deflating the bronchial cuff while continuing to ventilate through the tracheal lumen with the bronchial lumen clamped. If the tip is too deep in the left bronchus, breath sounds will be heard only on th e left side. If the tube is not deep enough in the bronchus, breath sounds will be present bilaterally. The tracheal cuff als o should be deflated and, depending on where breath sounds were heard, the tube pulled back or advanced. Both cuffs should be reinflated and the auscultatory sequence repeated.

Right-sided Tubes
Auscultation of a right-sided DLT is similar to that of a left-sided tube. It is especially important to confirm ventilation of the right upper lobe. P.643

Single Connector Method

An alternative technique is the single connector technique in which a single connector is used to ventilate eac h lung in turn by simply transferring the distal end of the DLT from one lumen to the other, eliminating the need for repeated clamping and unclamping (126). This has the advantage of being simpler and requiring fewer steps and may result in reduced risk of creating a potentially harmful ball-va lve effect in a partially obstructed lobe or lung by detecting it ear lier.

After the DLT is advanced to the desired depth, a single connector from the breathing system is attached to the bronchial lumen. W hile performing manual v entilation, the bronchial cuff is inflated to create an airtight seal. Auscultation is used to confirm that the intended lung is being v entilated. The connector is then transferred from the bronchial lumen to the tracheal lumen. The tracheal cuff is inflated to create an airtight seal, and it is confirmed that the proper lung is ventilated. The c onnector is then transferred to the bronchial lumen and short ventilations performed while listening over the apex of the lung for vesicular breath s ounds. If these are not heard, the single connector is detached from the bronchial lumen and a double connector is connected to the two lumens.

Flexible Endoscopic Techniques

Flexible endos copy is the most accurate method for determining DLT position (120,129,130,131,132). Many recommend that this should be the standard of care (81,131,133,134,135,136). Others believe that the fiberoptic scope is helpful but not essential (95,124,137,138,139). There is general agreement that fiberoptic endoscopy is always needed for right-sided DLTs. Fiberoptic methods to confirm the position of the DLT may not work in the presence of blood or secretions (140). W henever there is any doubt, this method should be used to check the position. A further advantage is that it can be used to remove blood or secretions. It can also be used after the patient is prepped and draped if a question arises with regard to proper tube placement.

Left-sided Tubes
A fiberscope is placed in the tracheal lumen through the open end of the tube or through a port in the connector that is specially designed for this purpose. As the fiberscope is advanced, the carina should come into view. The top surface of the blue bronchial cuff should be seen belo w the carina in the left mainstem bronchus. The bronchial cuff should not herniate over the carina, neither should the carina be pushed to the right. An unobstructed view of the nonintubated right mainstem bronchus should be obtained. The fiberscope should then be advanced through the bronchial lumen to check for narrowing of the lumen at the level of the cuff and an unobstructed view of the distal bronchial tree.

Right-sided Tubes
Looking down the tracheal lumen, the bronchial cuff's upper surface should be seen below the carina in the right mainstem bronchus. The fiberscope is then placed in the bronchial lumen. The right middle lower lobe bronc hial carina should be seen below the end of the tube. The endoscopist should be able to look into the right upper lobe orifice by flexing the tip of the fiberscope superior ly.

Bronchospirometry
Pressure-volume and flow-volume loops are discussed in Chapter 23. Changes in complianc e or resistance may mean that the DLT is not correctly plac ed (141,142,143,144,145,146,147,148,149,150). If a DLT is

advanced into the trachea with the bronchial cuff partially inflated, compliance is reduced when the tube impacts the bronchus (92).

Chest X-ray
Chest x-ray may be useful to confirm tube position when a fiberscope is not av ailable or cannot be used. However, it is less precise than the fiberoptic bronchoscopy and is costly, time consuming, and awkward to perform.

Stabilizing the Tube

Once correct tube position is confirmed, the tube should be secured in place. Special fixation methods have been recommended (151). During positioning, the tube should be held at the level of the incisors and the head immobilized in a neutral or slightly flexed position to prevent the tube from migrating into an incorrect position.

Intraoperative Care
The bronchial cuff should b e kept deflated (unless the lung needs to be isolated to prevent spread of blood or infection) until the lung needs to be collapsed to minimize damage to the bronchial mucosa (38). Lung collapse will be most rapid if lung separation is initiated at end-expiration. Suction is of limited utility because the gas trapped in the lung is distal to collapsib le airways. If despite best efforts complete lung separation cannot be accomplished and gas is introduced into the ipsilateral lung with each breath, then continuous suction may be helpful to evacuate

the gas as it enters the lung (38). Bronchial cuff pressure should be monitored and adjusted to the minimum necessar y to achieve an airtight seal. A useful technique when the bronchial lumen is in the surgically operated lung is to pass a suction catheter through the bronchial lumen when the lung is deflated and to leav e it until ready for reinflation (152). This may prevent the bronchial lumen from becoming obstructed by blood or mucus. P.644

Replacing a Double-lumen Tube with a Single-lumen Tube

If mechanical ventilation needs to be continued at the conclusion of a case in which a DLT was used, it is usually desirable to replace the DLT with a standard tracheal tube. Personnel who are caring for the patient in the postoperative period are not usually familiar with a DLT. After pneumonec tomy, when all of the patient's ventilation is conducted through one lumen of the DLT, the small diameter of the lumen may make if difficult for the patient to breathe spontaneously. W ith high minute ventilation, this can lead to auto-PEEP (17). Pressure-support ventilation (Chapter 12) can be used to decrease the imposed work of breathing during spontaneous ventilation if replacing the DLT cannot be performed. Suctioning through a DLT is difficult.

In most cases, the procedure is simply to remove the DLT and insert a single-lumen tube in its place. If the patient was difficult to intubate or circumstances make visualizing the larynx difficult, other techniques shou ld be considered. One technique would be to insert an airway exchange catheter into the tracheal lumen before the DLT is removed. Special extra-long exchange catheters are needed for th e exchange. After the DLT has been removed, the single- lumen tube is then advanced over the catheter (153,154). Oxygen insufflation via the catheter will reduce the incidence of hypoxemia. Another technique has been described (155). At the conclusion of the case, both cuffs are deflated and the DLT withdrawn until the bronchial lumen is above the carina. The bronchial cuff is then inflated and the lungs ventilated through the bronchial lumen. The tracheal lumen is c lamped, and an opening is created in the wall of the tracheal lumen. A single- lumen tube is then s lipped over a fiberscope, and the fiberscope is advanced through the hole in the tracheal lumen and into th e trachea. The opening in the DLT is extended, and the DLT is slowly removed. The fiberscope is then remov ed.

Hazards Associated with Double-lumen Tubes

Many of the hazards associated with single-lumen tracheal tubes (Chapter 19) can also occur with DLTs.

Difficulty with Insertion and Positioning

Inserting a DLT may be time consuming. W hen there is severe hemorrhage, this can be a major problem. Multiple insertions and repositionings increase the risk of trauma. W hile they are very useful in adults and older children, they are often too large for small children. They are often difficult to position and us ually must be replaced with a single-lumen tube at the end of surgery. The rigidity and width of the DLT can make intubation complicated. The tube does not allow preshaping before intubation, and the large width makes it difficult to pass the DLT through a tracheostomy stoma, small airway, or nasal passa ge.

Tube Malposition
Certain physical conditions may make it difficult or impossible for a DLT to be correctly plac ed (156,157). Preoperative fiberoptic endoscopy may detect many of these problems. Even if a correct position is achieved initially, head movement, a change in body positioning, or surgical manipulation may result in tube malposition. Displacement during positioning can be decreased by using a neck brace (123,158). Malpositioning is increased when anesthesia providers hav e limited experience in lung isolation (159). If DLT malposition is suspected, fiberoptic techniques are clearly advantageous in defining the problem and afford a means of visual correction. W hile some have reported that monitoring carbon dioxide waveforms helps to detect DLT displacement (160,161), capnography does not reliably indicate DLT misplacement (142,148,149,162).

Consequences
Functional indications of misplacement include the following:

Unsatisfactory Lung Collapse

An obstruc tion in the unventilated lumen can prevent the unventilated lung from deflating. If the lung cannot be collapsed, operating time will be increased, and the surgical result may be compromise d. Another cause may be a tumor fragment in the airway (163).

Obstruction to Lung Inflation

If the bronchial cuff is not belo w the carina, it may obstruct the trachea and right mainstem bronchus. W ith right-sided tubes, misalignment of the port for the right upper lobe can result in obstruction. If the bronchial cuff on a left-sided DLT is too deep, it may obstruct the upper lobe bronchus.

Gas Trapping
Gas trapping or expiratory obstruction may be the result of a oneway v alve effect that allows inflation but not deflation. If unrecognized, it can result in cardiorespiratory embarrassment and/or lung parenchymal damage.

Failure of Lung Separation

If the airway to a bronchopleural fistula cannot be isolated from that to the normal lung, barotrauma may develop with positivepressure ventilation, or the air leak through the fistula may be so large that ventilation of the normal lung is compromised. An

incompletely protected dependent lung ma y be flooded with blood or secretions.

Possible Malpositions
Bronchial Lumen in the Wrong Mainstem Bronchus
In some cases, the bronchial portion will enter the opposite P.645

lung. This is usually easy to detect and correct by using fiberoptic endoscopy (115). In some cases, it may be best to leave the bronchial lumen in the operative bronchus and isolate the operative lung by clamping the bronchial limb and using the tracheal lumen for ventilation (118,122). This may be appropriate for right lung surgery but not for surgery on the left lung, since the right upper lobe bronchus would almost certainly be occluded. An alternative option is to withdraw the tube until it is intratracheal and to use a bronchial blocker (see below) to block the operative lung. It may be possible for the surgeon to as sist in correctly placing the tube once the chest is open (164). If it is determine d that the tube is in the wrong bronch us, both cuffs are deflated, and the tube is withdrawn into the trachea. The surgeon then compresses the bronchus, and the anesthesia provider advances the tube into the correct side with surgical guidance. The cuffs are then reinflated.

Bronchial Portion Inserted too Far into the Appropriate Bronchus

If a left-sided DLT is inserted too dee ply, the problem may be that the tube is too small (156,165,166,167). It will result in obstruction of the upper lobe. In some patients, a left-sided DLT placed so that the bronchia l cuff is just dis tal to the carina still may caus e left upper lobe obstruction. A high peak airway pressure during one- lung ventilation should suggest this malposition (135).

Tube too Proximal in the Airway

If the tube is not sufficiently advanced into the bronchus, the bronchial cuff may protrude into the trachea. The need to inject more than 3 mL of air into the bronchial cuff to achiev e a seal should alert the user that the tube may be malpositioned. The bronchial segment may slip out of its bronchus, especially during changes in the patient's position. In many cases, no un toward sequelae will occur. Howev er, ther e may be obstruction of gas flo w to the other lung and inability to isolate the surgical lung.

Tip of Bronchial Lumen above the Carina

The tip of the bronchial lumen may be above the carina because of a tracheal lesion that prevents the tube from being a dvanced farther. W ith this malposition, there will be unsatisfactor y lung deflation and failure of lung separation.

Incorrect Placement with Respect to the Upper Lobe Bronchus

Malposition with respect to the upper lobe bronchus is particular ly a problem with right-sided tubes (34). Even with a left-sided tube, it is possible to obstruct the upper lobe bronchus (129,168). The result of such a malposition is usually hypoxemia and failure of the upper lobe to deflate satisfactorily. A cas e has been reported where the bronchial lumen entered the right upper lobe bronchus (40).

Asymmetric Bronchial Cuff Inflation

The inflated bronchial cuff can cause the tip of the bronchial lumen to face into the bronchial wall, producing one-way valvular obstruction that allo ws lung inflation but not deflation (169,170).

Hypoxemia
In many instances, hypoxemia during one- lung ventilation is at least partly the result of a malpositioned DLT (171). For this reason, whenev er hypoxemia oc curs, tube position should be reassessed and adjusted if neces sary. Even with correct positioning, hypoxemia can result from blood continuing to flow through the unventilated lung (shunting) after one-lung ventilation has begun. Another cause of hypoxemia is the presence of a tracheal bronchus arising from the lateral tracheal wa ll (166,172,173,174). If a DLT is used, the tracheal bronchial opening mus t b e checked after the tube is placed. In some of these cases, a bronchial blocker may be a better choice for one-lung ventilation. Another mechanism that can produce hypoxemia is ambient pressure ventilation of the nonventilated lung. Attaching an

oxygen source at ambient pressure to the opening to the nonventilated lung may help to pr event hypoxia (175,176,177,178). This may also enhance collapse of the nonventilated lung. If hypoxemia is a problem despite proper tube position, CPAP can be applied to the nondependent lung (179). Some DLT manufacturers include a CPAP device with each DLT, or they may be purchased separately (Fig. 20.15). Other measures to improve oxygenation include dependent lung PEEP, occasional ventilation of the nondepen dent lung (one breath every 5 to 10 minutes), insufflation of 2 to 3 L/minute of ox ygen to the nonventilated lung, and clamping of the pulmonary arter y before clamping the bronchus. Jet ventilation o f the nondependent lobes that are not being removed by using an airway exchange catheter may be used to improve oxygenation (180).

Obstructed Ventilation
Many cas es of obstruction are the result of a malpositioned tube. In addition, inflating the bronchial cuff can cause narrowing of the bronchial lumen (129,156) or may cause the carina to be displaced laterally, producing obstruction of the other mainstem bronchus (181). A defective tube or connector may c ause obstruction (182,183). Other causes of bronchial obstruction have been reported. In one case, the bronchial cuff was left deflated until o ne-lung ventilation was to begin, and necrotic tumor migrated into the bronchus of the dependent lung, causing obstruction when one-

lung ventilation was begun (184). The bronchial lumen can become twisted (185). A carinal hook may obstruct the opening of the tracheal lumen (186). P.646

Figure 20.15 Device for applying continuous positive airway pressure to a nonventilated lung. The adjustable valve supplies pressures from 1 to 10 cm H2O.

View Figure

A relative contraindication to using a DLT is a lesion (airway narrowing or endoluminal tumor) somewhere along the pathway where the tube will reside. An aberrant tracheal bronchus may be a contraindication for using a DLT (172,173).

Trauma

Trauma to the respirator y tract can occur whenever intubation with a DLT is performed (187,188). Tears in the trachea and mainstem bronchus have been reported (76,187,188,189,190,191,192,193,194,195,196,197,198,199,200, 201,202,203). Tube size is a factor. Large tubes have been involv ed more often in injur y than smaller ones (188). A tube that is too small and requires excessive cuff inflation may cause ischemic injury. In one reported case, an endobronchial polyp that developed a t the bronchial cuff site ended in a fatal hemorrhage (204). Measures to reduce air way trauma include removing the stylet after the tip of the tube has passed the vocal cords, avoiding cuff overinflation, deflating the tracheal and bronchial cuffs when repositioning the patient or the tube, and not advancing the tube when resis tance is encountered. Some bronchial cuffs can prov ide one-lung isolation with significantly lower pressures than others (41). It has been recommended that the bronchial cuff be kept deflated until needed to minimize pressure on the bronchial mucosa. This may not be prudent if there is a bronchial tumor, as necrotic tumor may migrate into the other lung (184).

Tube Problems
Reported problems with DLTs include mislabeling, tracheal lumen distortion that prevented a suction catheter from passing, a slit in the septum, a defect that made the bronchial lumen kink on itself, a split in the tubing to the bronchial cuff, a kink in the inflating tube to the tracheal cuff, a protuberance in the wall of the tube

with resultant tracheal lumen obstruction, and foreign bodies in the DLT (205,206,207,208,209,210,211,212). The carinal hook may bend backward, obstructing the opening of the tracheal lumen (213). Tracheal or bronchial cuff rupture can occur. This most commonly results from contact between the tube and the teeth or laryngoscope during insertion. Proposed methods to avoid this problem include the use of a retractable protective sheath (214), a lubricated Penrose drain (215), and lu bricated teeth guards (216) and increasing the curve of the bronchial portion of the DLT with the stylet (217). Another possible cause of cuff rupture is movement during repositioning (218).

Surgical Complications
The bronchial cuff may be punctured by the surgeon (219,220). A suture or staple may be plac ed through the DLT, or the surgical procedure may result in a tight stenosis, which could entrap the bronchial segment (221).

Failure to Seal
One of the reasons to use a DLT is to prevent material from passing from one lung to the other during the surgical procedure. Failure to prev ent fluids from traversing the bronchial c uff could result from malposition or from improper cuff inflation. Neither an airtight bronchial seal nor a cuff pressure of 25 cm H 2 O guarantees protection against aspiration (61). Lubricating the cuff with a gel will reduce the risk that fluid will leak past the cuff (222,223).

Difficult Extubation
Difficulty in removing a DLT may be due to anatomical abnormalities, surgical fixation, or entanglement by other surgical or anesthetic hardware (220,224). P.647

Single-lumen Bronchial Tubes

Another option for achieving lung separation is to use a singlelumen tube to intubate a mainstem bronchus. T wo bron chial tubes may be used in situations where dual lung ventilation is needed but circumstances bode against having one tube in the trachea (225,226,227). Single-lumen bronchial tubes are sometimes us ed in pediatric patients whose air ways are too small for DLTs or in whom a bronchial blocker cannot be used (1,165,226,228,229,230,231,232,233,234,235,236,237). In the patient with massive hemoptysis, bronchial intubation with a single- lumen tube is often the easiest and quickest method of separating the lungs (5,10).

Equipment
Bronchial intubation is most ofte n carried out with a conventional tracheal tube. A cuffed tube will prevent re-expansion of the collapsed lung. The distance from the tip of the tube to the cephalad edge of the cuff must be shorter than the length of th e

mainstem bronchus to ensure that the cuff can lie entirely inside the bronchus and the upper lobe bronchus is not obstructed (238). Special tubes with a single lumen, an angulated distal (bronchial) tip, and cuffs at both the tracheal and bronchial positions are available (239,240). They are longer than conventional singlelumen tracheal tubes.

Techniques
Before insertion, the correct length and size of the tube should be estimated from a chest x-ray or computed tomography (CT) scan (238). If the nasotracheal route is used, most conventional single- lumen tubes will not be long enough to provide a reliable mainstem intubation. It is recommended that the tube should be one half to one size smaller than the usual size selected for tracheal intubation (237). For bronchial intubation in children, a tracheal tube 0.5 to 2.0 mm smaller than recommended for the particular patient should be used (229,231). Right-sided intubation can usually be performed blindly, but the tube is more reliably placed by using a bronc hoscope. It may be possible to align the Murphy eye with the right upper lobe bronchus. It may be possible to rotate the tube so that the bevel faces the upper lobe bronchial orifice. Left mainstem intubation may be achieved blindly by using a stylet to curve the distal end of the tracheal tube to the left (231) but often requires bronchoscopic guidance. If blood or secretions prec lude fiberoptic visualization, fluoroscopy is another option.

The chance of intubating the left bronchus will be increased if the tube is rotated 180 degrees from its usual position before advancing it beyond the vocal cords and the patient's head is turned to the right (228,229,241,242,243). A gum elastic bougie can be inserted into the chosen bronchus by using a bronchoscope. The bronchial tube can then be railroaded over the bougie into position (244). Correct positioning can be confirmed by auscultation, x-rays, and/or flexible bronchoscopy. The tube should be withdra wn into the trachea when one- lung ventilation is no longer needed.

Evaluation
Advantages of using a single- lumen tube for lung separation include simplicity and the rapidity with which lung s eparation can often be achieved, particularly when the right lung must be ventilated. Disadvantages inc lude frequent lack of ventilation of the right upper lobe with right mainstem intubation (38,236). Left upper lobe ventilation may also be exclu ded when the left mainstem bronchus is relative ly short (238). Neither suctioning nor application of CPAP to the nonventilated lung is possible. There may be failure to achieve an adequate seal, especially if an uncuffed tracheal tube is used or if the c uff is not inside the bronchus (226,236,238,245). Lung collapse will be incomplete, and the healthy ventilated lung will not be protected from contamination. Both lungs cannot be ventilated at the beginning

of anesthesia, and the collapsed lung cannot be re-expanded and ventilated until the tube is withdrawn into the trachea (236).

Bronchial-blocking Devices Indications and Use

Indications for bronchial blockers are similar to those for a DLT, with the exc eption of independent lung ventilation (44,226,246). They are often used in patients in whom using a DLT is not possible or advisable (nasal intubation, small patient, difficult intubation, patient with a tracheostomy, subg lottic stenosis, thick and excessive secretions, need for continued postoperative intubation) (240,247,248,249,250,251,252,253,254,255,256,257,258,259,260 ,261). A blocker may be especially useful for providing lung separation in a critically ill patient with a single-lumen tracheal tube already in place. Another indication may be the patient on anticoagulants, since placing a blocker is usually less traumatic than inserting a DLT (8). A blocker may allow a larger fiberoptic endoscope to be us ed and provide better suctioning than a DLT (262). A modified bronchial blocker can be used for tracheal gas insufflation to reduce carbon dio xide within the dead space by delivering fresh gas near the end of the tracheal tube (263). P.648

Another indication for a blocker is the need to block a segment of a lung rather than the entire lung

(9,14,258,259,264,265,266,267,268,269,270). This ca nnot be done with a DLT. A blocker may be used to sequentially block different parts of the lung (270). A blocker may be used to achieve lung is olation in the patient with an improper ly positioned double-lumen or bronchial tube (53,122,238,271,272,273). A bloc ker may be useful if both lungs require sequential blockage (274). The blocker can be shifted to the opposite lung when needed. If one blocker does not provide complete one- lung is olation, a second blocker may be used (173,275,276,277). Finally, there is no need to change the tu be at the end of the operation if postoperative mechanical ventilation is needed if a bronchial blocker is used.

Devices
Univent Bronchial-blocking Tube Description
The Univent tube is a cuffed silicone tracheal tube with a s mall additional internal lumen along its concave side (7,11,226,236,278,279,280,281,282,283,284) (Figs. 20.16, 20.17). The s mall channel contains a movable tubular blocker that has a blue high-pressure, low-v olume cuff. The blocker can be advanced sufficiently beyond the tip of the tube to block airways smaller than a mainstem bronchus (246,260,264,265).

Figure 20.16 Univent bronchial blocker. The cuffed tracheal tube has a small lumen along its concave side, which contains a tubular cuffed bronchial blocker. The blocker can be advanced into a mainstem bronchus or smaller airway.

View Figure

The blocker has external depth markings to help determine the blocker positio n in relation to the tube. There is a s light bend in the blocker above the cuff. The blocker tip is radiopaque. A grip allo ws the user to rotate the blocker. A locking clamp fixes its depth below the tip of the tube. As s hown in Table 20.2, the Univent tube is available in several sizes. It has a s lightly larger-than-usual external diameter for its internal diameter because of the space required by the blocker. Univ ent tubes that are 5 mm and larger have a lumen that can be used for suctioning, CPAP, or oxygen insufflation (285). Adult versions of the Univent blocker are hollo w. The Univent blocker (Uniblocker) can be purchased separate from the tracheal tube and used with other tracheal tubes

coaxially or in paralle l (265,286) (Fig. 20.18). It is supplied with a swiv el adaptor that fits onto the tracheal tube connector. This adaptor a llows connection to the breathing system and has a port for a fiberoptic scope in addition to a port for the blocker.

Use
Before use, the bronchial blocker and tube cuffs should be inflated and checked for leaks. Both the tube and the blocker should be well lubricated. After the cuffs have been deflated, the blocker should be pushed back and forth in the tube to ensure free movement. The block er should then be fully retracted into the tube lumen and fixed in place by using the clamp. If there is an unobstructed view of the larynx, the Univent tube is inserted in the same way as a conventional tracheal tube. If the patient has a difficult air way, it can be inserted ov er an airway exchange catheter or other device (287). The blocker can be extended and used as an introducer (288,289). After the blocker has passed the v ocal cords, the tube is threaded over it and into place. After the Univent tube is inserted, the tracheal tube cuff is inflated, and the patient is ventilated. The blocker is visualized by using a flexible fiberoptic endoscope through an airway adaptor with a port for the scope and is maneuvered into the appropriate bronchus. The blocker tip directio n can be changed by twisting the shaft (290). It may be useful to deflate the tracheal tube cuff and rotate the tube s o that the b lo cker is directed toward the side to be occluded.

A guide wire can be inserted through the blocker's lumen and be used to direct the blocker into pla ce, especially when it is necessary to block an airway smaller than a mainstem bronchus (258). Another method of placing the blocker in the right or left main bronchus is to insert a fiberscope through the trachea tube into the bronchus to be block ed and then to advance the tube into that bronchus. The blocker is then advanced into the bronchus and the tube withdrawn into the trachea, leaving the blocker in the bronchus. This technique may result in trauma to the air way (291). P.649

Figure 20.17 Univent bronchial-blocking tubes. Top: The bronchial blocker is retracted. Bottom: The bronchial blocker is advanced, and the cuff is inflated. (Courtesy of Vitaid.)

View Figure

TABLE 20.2 Univent Tubes

Internal Diameter (millimeters) 3.5 (uncuffed)

Outer Diameter (millimeters)a 7.5/8.0

Age (years)

6 to 10

4.5

8.5/9.0

10 to 14

6.0

9.7/11.0

14 to 16

6.5

10.2/12.0

16 to 18

7.0

11.6/12.5

Adult

7.5

11.2/13.0

Adult

8.0

11.7/13.5

Adult

8.0

12.2/14.0

Adult

9.0

12.7/14.5

Adult

Values are sagittal/transverse. From Hammer GB, Fitzmaurice BG, Brodsky JB. Methods for single-lung ventilation in pediatric patients. Anesth Analg 1999;89:14261429; Frolich

MA. Postoperative atelectasis after one-lung ventilation with a Univent tube in a child. J Clin Anesth 2003;15:159163; Hammer GB, Brodsky JB, Redpath JH, et al. The Univent tube for single-lung ventilation in paediatric patients. Paed Anaesth 1998;8:5557; Tobias JD. Variations of one-lung ventilation. J Clin Anesth 2001;13:3539.

The bronchial blocker can be inserted blindly. The whole tube is turned s o that its concav ity faces the side to be blocked. The blocker is advanced into the mainstem bronchus and the cuff inflated. This method has n ot proved very successful and may be associated with airway trau ma (282,292). The blocker position s hould be checked by using a fiberscope. The cephalad tip of the bronchial cuff should be below the carina. The blocker should then be fixed to the tracheal tube by using the cap stopper and blocker grip. W hen the bronc hus needs to be blocked, the lung is deflated with the blocker open to atmosphere. T he bronchial blocker cuff should be inflated by using the least amount of air that will prov ide a seal. This can be achieved by attaching the sample line

from a c arbon dioxide analyzer to the proximal end of the blocker and noting when the waveform disappears (293). Another method is the bubble test, in which the end of the bronchial lumen is placed into water in a beaker (294). W hen the bronchus is sealed, no bubbles will be observed passing through the water. The typical cuff inflation volume is 5 to 6 cc (112). The blocker from a Univent tube can be removed from the tube and inserted alongside a tracheal or tracheostomy tube (265,295,296). The blocker is then P.650

guided into place with a fiberscope inserted through the tube.

Figure 20.18 The Univent bronchial blocker can be purchased separately from the tube. The connector has ports for attachment to the tracheal tube and breathing system, for introducing the blocker, and for a fiberscope. Note the cap that fits over the end of the blocker.

View Figure

W hen the blocker is no longer needed, the cuff is deflated and withdrawn into the main tube. If the Univent is to be used for postoperative ventilation, the blocker should be fu lly retracted and disabled to avoid inappropriate use by caregivers who are unfamiliar with the device (297).

Evaluation
Most studies show that the Univent provides lung isolation equivalent to that of a DLT (11,280,298,299,300,301). The Univent may be easier to insert and position correctly than a DLT and may be especially useful for the difficult-to-intubate patient (287,288,289,302,303,304,305). It can be used in the patient with a tracheostomy (254,253,296) and for nasal intubation (247). It can be used for postoperative ventilation without having to reintubate the patient. It is possible to use suction, apply CPAP, or insufflate oxygen through the blocker lumen (278,306). The blocker with the cuff deflated has been used for jet ventilation during carinal resection (307,308). Reports of problems with the Univent include the cap becoming dislodged from the tip of the blocker (309,310) and fragmentation of the tube inner wall and connector (311,312). The Univent's curved shape is fixed, and this may be a disadvantage when sliding it over a bronchoscope. It will not soften in a warm water bath (38). It may distort the neck anatomy sufficiently to make internal jugula r vein cannulation difficult (313). Bronchial perforation by the blocker during blind insertion

has been reported (292). A case has been reported of prolonged postoperative atelectasis after using a Univent tube (262). It is not recommended for use in c hildren below the age of six years. W hen comparing the Univent with a left DLT, there was a greater incidence of malposition with the Univent (119), but comparison of the Univent and a right DLT failed to demonstrate a cle ar advantage (35). The Univent is more expensive than a DLT or other blockers (79,119,310). A disadvantage of the Univent tube is the large amount of crosssectional area occupied by the blocker channel, especially in the smaller tubes (236). It is not available in a size that would fit an infant or small child. Another problem is that the small lumen is re latively easily blocked by blood or pus (285). As a result, blood or pus may accumulate and contaminate the dependent lung when the blocker is deflated. The blocker's low-volume, hig h pressure cuff may caus e in mucosal injury (314,315). The larger external diameter may make it difficult to pass the Univ ent between the vocal cords.

Arndt Bronchial Blocker Description

The Arndt bronchial blocker assembly (wire-guided bronchial blocker, W EB, FW EB) is designed to be used for a patient with a single- lumen tracheal tube already in place (44,111,246,253,316,317,318,319,320,321,322,323). It consists

of two parts: A blocking catheter and a special air way adaptor. Either may be purchased and used separately.

Blocking Catheter
The Arndt blocking catheter (Fig. 20.19) has a low-pressure, high-volume balloon that has either an elliptical or spherical shape. The spherical balloon is relatively compliant unless overinflated and takes an e lliptical form when inflated in a small bronchus. The 9 Fr catheter is available with an elliptic al balloon that provides a longer sealing profile. It is recommended that the elliptical cuff be limited to left mainstem intubation (236,246). P.651

Figure 20.19 Arndt bronchial blocker with multiport adaptor. The wire loop can be cinched around the tip of the fiberscope, or the fiberscope is passed through the loop. The adaptor has ports for attachment to the tracheal tube and breathing system, for introducing the blocker, and for a fiberscope.

View Figure

A flexible nylon wire passes through the proximal end of the catheter and extends to the distal end, then exits as a small loop (Fig. 20.19). The size of the loop may be increased or decreased by advancing or retracting the wir e assembly. There are three sizes: 9, 7, and 5 Fr. Characteristics of the blockers are shown in Table 20.3. Near the distal end of the 9 Fr catheter are side holes to facilitate lung deflation.

Airway Adaptor
The multiport adaptor (Fig. 20.19) allo ws simultaneous introduction of a bronchosc ope and the blocker while maintaining mechanic al ventilation. It has four ports:

A 15-mm female connector that attaches to the tracheal tube;

A side port with a 15-mm male connector that attaches to the anesthesia breathing system;

A port angled approximately 30 degrees for the bronchial blocker; and

A port for the flexible endoscope.

The blocker port has a Tuohy-Borst type connector to maintain an airtight seal and lock the blocker in place (by tightening the connector around the block er) or to allow free movement of the blocker (by loosening the connector). The bronchoscopy port has a plastic sealing cap.

Use
Before use, the inside of the tracheal tube and the outside of the blocker and the bronchoscope should be well lubricated with a silicone s pray. The loop should be adjusted so that it loosely approximates the outside diameter of the bronchoscope. The blocker balloon should be inflated to test for leaks and then fully deflated. For each size W eb, there is a tracheal tube size for which coaxial placement is limited by the diameters of the blocker and fiberscope used during placement. W hen these limits are exceeded, paralle l placement may be required. Either the web is passed outside the tracheal tube with guide loop inoperable, or a fiberscope is also placed in parallel with the tracheal tube before or after intubation.

TABLE 20.3 Arndt Endobronchial Blockers Size Smallest Single-lumen Length Cuff Shape (French) Tube Internal Diameter (centimeters) for Coaxial Use (millimeters) 9 7.5 78 and 65 Elliptical Average Cuff Inflation Volume (cubic centimeters)

6 to 12

Spherical

4 to 8

6.0

65

Spherical

2 to 6

4.5

65 and 50

Spherical

0.5 to 2.0

From Klafta JM. One-lung anesthesia; making it work (ASA Refresher Course #509). Park Ridge, IL: ASA, 2004.

P.652

The wire in the blocker lumen is used in either of two ways: (i) when cinched tightly around the tip of the fibersco pe, the fiberscope carries the blocker into its desired location, and (ii) when the fiberscope is passed through the loop, it prov ides a track for blocker to pass through after the fiberscope is placed into the bronchus.

After the patient is intubated and v entilation has begun, the multiport adaptor is connected between the breathing system and the tracheal tube. The bronchoscope is advanced through the guide loop. This allo ws the blocker to follow the bronchoscope. Alternately, the wire loop may be placed over the end of the blocker prior to attaching the air way adaptor to the tracheal tube (324). The bronchoscope is advanced into the airway to be blocked and then the guide loop is slid over the end of the bronchoscope. The bronchoscope is withdrawn slightly to visualize the blocker. The blocker is then advanced or withdrawn into position (324,325). It may be advisable to advance the blocker approximately 1 cm beyond the optimal position when the patient is in the supine position to avoid dislodging the blocker toward the trachea while the patient's position is changed to the lateral dec ubitus position (246). The balloo n is then inflated under direct vision. The balloon should fill the entire bronchial lumen and not herniate into the trac hea. Fo llowing placement, the balloon may be deflated until one- lung ventilation is required. Remov ing the wire loop will result in an open channel, which allo ws CPAP application, oxygen insufflation, suctioning, or intermittent inflation. Leaving the wire loop during the operation might damage the airway and entails the risk that the loop may accidentally be stapled into the bronchial closure (326). However, leaving the loop in place allo ws the blocker to be repositioned (327). It may be possible to reposition the blocker by using fiberoptic endoscopy (326). Excessive force should not be used

when remov ing the wire guide, because this may displace the blocker. Lung collapse can be expedited by attaching a syringe or applying suction to the blocker channel (44,328). However, some clinicians do not recommend using suction through this channel because of the risk of dev eloping negativ e pressure pulmonary edema (326). W hen no longer needed, the blocker cuff shou ld be fu lly deflated and the blocker removed.

Evaluation
The Arndt blocker s ystem can be used in the patient who is already intubated (316,317,329), in the patient with a tracheostomy (318,324,325), or with a nas al intubation (253,318). It has been used to provide single -lung ventilation in children as young as 17 months (245). It may be especially useful for the patient in whom a DLT would be difficult to use (260,316,318,319,320,321,330). It has been used in a newborn (322). It allows a larger internal cross-sectional area than a DLT or Univent tube of similar outside diameter (331). It may require fe wer insertion attempts than a DLT (332). If the wire is removed, the lumen can be used for suctioning or administering oxygen or CPAP.

Problems
A disadvantage is that once the wire loop is removed, it cannot be reinserted through the channel to allow re positioning of the blocker. Placement requires the availability of fiberoptic equipment and someone able to use it. It takes longer to position

and to achieve complete lung collapse compared with the Univent tube or a DLT (328,332). The balloon may be sheared when it is removed from the blocker port (333).

Cohen Tip-deflecting Bronchial Blocker

The Cohen tip-deflecting bronchial blocker (Fig. 20.20) has a 9 Fr external diameter and a central lumen with a 1.6 mm diameter (334). The high-volume, lo w-pressure blue balloon at the tip is spherical in shape. The average inflation volume is 5 to 8 mL. There are side holes between the tip and the balloon to evacuate gas from the distal lung or to insufflate oxygen. A proximal control wheel that can be operated with the thumb and forefinger is used to adjust tip deflection (Fig. 20.21). The catheter has depth markings and an indicator arrow that shows the direction in which the tip d eflects.

Figure 20.20 Cohen tip-deflecting bronchial blocker. The proximal control wheel is used to adjust tip deflection. An arrow on the wheel indicates the direction to which the tip deflects. (Courtesy of Cook Critical Care.)
View Figure

P.653

Figure 20.21 The tip of the Cohen bronchial blocker can be manipulated to fit into either bronchus.

View Figure

In most cases, the blocker and a fiberscope are ins erted through an appropriate ly sized tracheal tube. The blocker can also be placed outside the tracheal tube and guided into place with a bronchoscope placed through the tracheal tube. A multiport air way adaptor like the Arndt is attached to the breathing system end of the tracheal tube. Alternatively, a standard swivel adaptor can be used for insertion. An assistant with or without video flexible fiberoptic scope may be necessary because it may require two hands to manipulate the blocker into position, one to deflect the tip and the other to rotate and advance the catheter.

Embolectomy Catheter

Description
An embolectomy (Fogarty) catheter can be used a s a bronchial or segmental blocker (1,14,53,62,226,248,251,256,257,267,268,269,275,324,335,336,3 37,338,339,340,341,342,343,344). This catheter is readily available in most operating suites where vascular surgery is performed or can be purchased for this purpose. It comes with a stylet in place so that it is possible to place a curvature in the distal tip to facilitate guidance to the target bronchus. The occlusion balloon has a hig h-pressure, low-volume cuff (246). It comes in a variety of sizes. Adult bronchi can be blocked with 7 Fr catheters, whereas 2 Fr to 5 Fr catheters are suitable for segmental or pediatric blockade.

Use
Prior to use, the blocker s hould be lubricated with jelly or silicone spray to facilitate passage. The balloon shou ld be tested for leaks and then fully deflated. A catheter with a faulty or eccentric balloon should be discarded. The embolectomy catheter may be placed before or after intubation with a single-lumen tracheal or tracheostomy tube and can be passed either through or alongside the tube. Placing the catheter alongside the tube allows the tube to splint the blocker in position. An alternative method is to insert the catheter through a hole made in the side of the tracheal tube (345). If the patient is alr eady intubated, the catheter containing a stylet may be passed through a fiberoptic endoscope adaptor

(335,341,342). This allo ws uninterrupted v entilation. The Arndt multiport air way adaptor (previously mentioned) or similar device (346) may also be used to prevent an air leak. An annular space around the fiberoptic endoscope and embolectomy catheter equivalent to a sin gle-lumen tube with an inner diameter of 4 to 5 mm will be necessary to allow exhalation in a reasonable period of time (347). A fiberoptic en doscope is p assed down the tracheal tube, and the embolectomy catheter is guided into the appropriate bronchus under direct vision. T wirling the catheter between the fingers at the proximal end or rotating the tracheal tube will impart lateral direction to the tip (98). Additional lateral direction may be gained by rotating the tracheal tube to one side or the other. After the tip is advanced into the proper position, the stylet is removed, the catheter balloon is inflated under direct vision, and then the fiberscope withdra wn. A modification of this technique is to deliberately intubate a mainstem bronchus with a tracheal tube one size smaller than would be appropriate for the trachea, advance the blocker through the tracheal tube, then withdraw the tracheal tube into the trachea (348,349,350,351). It may be helpful to preshape the tracheal tube by using a stylet (351). Once the catheter is in the targeted bronchus, the stylet is removed. Removing the tracheal tube followed by insertion of a larger tracheal tube beside the Fogarty catheter will securely fix the catheter in place. The catheter balloon is inflated s lowly until no air enters the blocked lung, as detected by using auscultation. The Fogarty catheter

should be securely taped to the tracheal tube to prevent it from being dislodged. A fiberoptic endoscope should be used to check the position of the blocker. The catheter ballooon should be deflated and the lung collapsed by using pressure on the chest and/or suction through the tracheal tube (351). The catheter balloon should then be reinflated to the same volume as prev iously used.

Evaluation
The use of an embolectomy catheter has many advantages. It can be passed through a single- lumen tracheal tube in an already intubated patient, and there is no need for reintubation if postoperative mechanical ven tilation is needed. It may be useful in P.654

pediatric patients (62,236,267,268,324,337,338,340,345,352), the patient with a tracheostomy (252,336,351,353), or for a nasal intubation. The embolectomy catheter is less expensive than a DLT, Univent tube, or Arndt block er (326,339). Fogarty catheters are relatively thinner for a given balloon volume when compared with other bronchial blockers and thus will allo w the use of larger tracheal tubes, especially in pediatric patients when they are placed side by side in the trachea (351).

Problems
A significant disadvantage is the lack of a hollow center. Suctioning, oxygen insufflation, or applying CPAP to the blocked

lung is not possible, and lung collapse takes longer and may not be as complete as with a DLT or a blocker with a hollow lumen (62). The obstructed lung segment cannot be re-expanded until the blocker is removed. Another disadvantage is that it is made of latex, so it cannot be used in the patient with potential latex allergy (Chapter 15). Most of these devices have low-volume, high-pressure cuffs and can damage the air way, although the pressure may be less than that exerted by the cuff on a DLT (109,236). There are no reported complications with the embolectomy catheter in adults (246). Bronchial rupture has been reported with an overinflated balloon in a child (337).

Other
Balloon atrioseptostomy, Foley urinary, and Swan Ganz pulmonar y arter y catheters have been used as bronchial blockers. They have a central lumen for suction or administration of oxygen to the block ed lung.

Problems with Bronchial Blockers

A blocker may not be suitable for the patient with a high right upper lobe bronchus takeoff or a tracheal bronchus (173,354). It may be necessar y to either use a second blocker or a DLT under these conditions. If the distance between the carina and the tracheal bronchus is s mall, it may be possible to herniate the balloon on the bronchial blocker so that it blocks the upper lobe bronchus (355). It may be possible to use the tracheal cuff of the Univ ent tube to block a tracheal bronchus (356).

A blocker may be dislodged into the trachea (357). The inflated balloon may then block ventilation to both lungs, prevent collapse of the operated lung, and/or cause air trapping. Other complications reported include fixation by surgical stap les (358); perforation of the blocker balloon by a surgical needle (359); and accidental inflation of the blocker cuff when it was just below the tip of the tube, resu lting in obstruction to gas flow (360). The narrow blocker lumen may result in ineffective removal of secretions and pulmonar y soiling after the cuff is deflated (361). Lung deflation may not be as satisfactory or achieved as rapidly with a bronchial blocker as with a DLT (332). Development of severe hypoxemia has been reported after continuous suctioning of the nondependent lung through a bronchial blocker (362). If suction is used to facilitate lung collapse, it should be applied for only a few seconds, intermittently and with lo w press ure (246).

References
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[CrossRef] [Medline Link] 289. Takenaka I, Aoyama K, Kadoya T. Use of the Univent bronchial-blocker tube for unanticipated difficult endotracheal intubation. Anesthesiology 2000;93:590591. [Fulltext Link] [CrossRef] [Medline Link] 290. Baraka A. The Univent tube can facilitate difficult intubation in a patient undergoing thoracosc opy. J Cardiothorac Vas c Anesth 1996:693694. 291. Doyle DJ. A simple technique for placement of the Univent bronchial blocker. Anesthesiology 1993;79:399. [Fulltext Link] [CrossRef] [Medline Link] 292. Hannallah MS. Pneumothorax complicating the use of a Univ ent endotrac heal tube: a different mechanism. Anesth Analg 1993;77:200. [Fulltext Link] [CrossRef] [Medline Link] 293. Schwartz DE, Yost CS, Larson MD. Pneumothorax complicating the case of a Univent endotracheal tube. Anesth Analg 1993;76:443445. [Medline Link]

294. Essig K, Freeman JA. Alternative bronchial cuff inflation technique for the Univ ent tube. Anesthesiology 1992;76:478 479. [Fulltext Link] [CrossRef] [Medline Link] 295. Hannallah MS, Benumof JL. Comparison of two techniques to inflate the bronchial cuff of the Univent tube. Anesth Analg 1992;75:784787. [Fulltext Link] [CrossRef] [Medline Link] 296. Asai T, Shingu K. One- lung ventilation in the patient with laryngeal or tracheal stenosis. Anesth Analg 2000;90:1000 1001. [Fulltext Link] [CrossRef] [Medline Link] 297. Dhame e MS. One-lung ventilation in a patient with a fresh tracheostomy using the tracheostomy tube and a Univent endobronchial blocker. J Cardiothorac Vasc Anesth 1997;11:124 125. [CrossRef] [Medline Link] 298. Schwartz RE, Stayer SA, Pasquariello CA. Univent tube: a simple method for avoiding a potentially disastrous complication. Anesth Analg 1993;77:10771078.

[Fulltext Link] [CrossRef] [Medline Link] 299. Hammer GB, Brodsky JB, Redpath JH, et al. The Univent tube for single-lung ventilation in paediatric patients. Paed Anaesth 1998;8:5557. 300. Kamaya H, Krishna PR. New endobronchial tube (Univent tube) for selective blockade of one lung. Anesthesiology 1985;63:342343. [Fulltext Link] [CrossRef] [Medline Link] 301. Campos JH, Massa FC. Is there a better right-sided tube for one-lung ventilation? A comparison of the right-sided doublelumen tube with the single- lumen tube with right-sided enclos ed bronchial blocker. Anesth Analg 1998;86:696700. [Fulltext Link] [CrossRef] [Medline Link] 302. Bauer C, W inter C, Hentz JG, et al. Bronchial blocker compared to double- lumen tube for one-lung ventilation during thoracoscopy. Acta Anaesthesiol Scand 2001;45:250254. [CrossRef] [Medline Link] 303. Ransom ES, Carter SL, Mund GD. Univent tube: a useful device in patie nts with difficult airways. J Cardiothorac Vasc Surg 1995;9:725727.

304. Campos JH. Difficult airway and one- lung ventila tion. Curr Rev Clin Anesth 2002;22:197208. 305. Garcia-Aguado R, Mateo EM, Onrubia VJ, et al. Use of the Univ ent s ystem tube for difficult intubation and for achieving onelung anaesthesia. Acta Anaesthesiol Scand 1996;40:765767. [Medline Link] 306. Garcia-Aguado R, Mateo EM, Tommasi-Rosso M, et al. Thoracic surger y and difficult intubation: another application of Univ ent tube for one-lung v entilation. J Cardiothorac Vasc Anesth 1997;11:925926. [CrossRef] [Medline Link] 307. Foroughi V, Krucylak PE, W yatt J, et al. A technically simple means for administration of continuous positive airway pressure during one-lung ventilation using a Univ ent tube. Anesth Analg 1995;81:656. [Fulltext Link] [CrossRef] [Medline Link] 308. Ransom E, Detterbeck F, Kle in JI, et al. Univ ent tube prov ides a new technique for jet ventilation. Anesthesiology 1996;84:724726. [Fulltext Link] [CrossRef] [Medline Link] 309. W illiams H, Gothard J. Jet ventilation in a Univent tube for sleeve pneumonectomy. Eur J Anaesthesiol 2001;18:407409.

[CrossRef] [Medline Link] 310. Arai T, Hatano Y. Yet another reason to use a fiberoptic bronchoscope to properly site a double lumen tube. Anesthesiology 1987;66:581582. [Fulltext Link] [CrossRef] [Medline Link] 311. Campos JH, Kernstine KH. A structural comp lication in the torque c ontrol blocker Univent: fracture of the blocker cap connector. Anesth Analg 2003;96:630631. [Fulltext Link] [CrossRef] [Medline Link] 312. Harioka T, Hosoi S, Nomura K. Foreign body in the trachea originated from the inner wall of the Univent tube. Anesthesiology 1998;89:1596. [Fulltext Link] [CrossRef] [Medline Link] 313. Doi Y, Uda R, Akatsuka M, et al. Damaged Univent tubes. Anesth Analg 1998;87:732733. [Fulltext Link] [CrossRef] [Medline Link]

314. Schummer W , Schu mmer C, Frober R, et al. The influence of the Univent endotracheal tube on internal jugular vein cannulation. Anaesth Intens Care 2005;33:8286. [Medline Link] 315. Kelley J, Gaba D, Brodsky J. Bronchial cuff pressures of two tubes used in thoracic surgery. J Cardiothorac Vasc Anesth 1992;6:190192. [CrossRef] [Medline Link] 316. Benumof J, Gaughan S, Ozaki G. The relationship among bronchial blocker cuff inflation volume, proximal air way pressure, and seal of the bronchial blocker cuff. J Cardiothorac Vasc Anesth 1992;6:404408. [CrossRef] [Medline Link] 317. Arndt GA, DeLessio ST, Kranner PW , et al. One- lung ventilation when intubation is difficultpres entation of a new endobronchial blocker. Acta Anaesthesiol Scand 1999;43:356 358. [CrossRef] [Medline Link] 318. Arndt GA, Krammer PW , Rusy DA, et al. Single-lung ventilation in a critically ill patient using a fiberoptically directed wire-guided endobronchial blocker. Anesthesiology 1999;90:14841486. [Fulltext Link] [CrossRef]

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324. Bastien JL, O'Brien JG, Frantz FW . Extraluminal use of the Arndt pediatric endobronchial blocker in an infant: a case report. Can J Anesth 2006;53:159161. 325. Tobias JD. Variations of one-lung ventilation. J Clin Anesth 2001;13:3539. [CrossRef] [Medline Link] 326. Matthews AJ, Sanders DJ. Single-lung ventilation v ia a tracheostomy using a fibreoptically-directed steerable endobronchial blocker. Anaesthesia 2001;56:492493. [Fulltext Link] [CrossRef] [Medline Link] 327. Campos JH. An alternative way to use Fogarty balloon catheter for perioperative lung isolation. In reply. Anesthesiology 2003;99:241. [Fulltext Link] [CrossRef] 328. Karzai W . Alternative method to deflate the operated lung when using wire-guided endobronchial blockade. Anesthesiology 2003;99:239240. [Fulltext Link] [CrossRef] [Medline Link] 329. Campos JH, Kernstine KH. A comparison of a left-sided Broncho-Cath with the torque control blocker Univ ent and the wire-guided blocker. Anesth Analg 2003;96:283289.

[Fulltext Link] [CrossRef] [Medline Link] 330. Arndt GA, Kranner PW , Valdes-Mura H. Reversal of hypoxemia using insufflation of oxygen during one- lung ventilation with a wire-guided endobronchial blocker. J Cardiothorac Vasc Anesth 2001;15:144. [Medline Link] 331. W ald SH, Mahajan A, Kaplan MB, et al. Experience with the Arndt paediatric bronchial blocker. Br J Anaesth 2004;94:9294. [Fulltext Link] [CrossRef] [Medline Link] 332. Arndt GA. Endobronchial blo cker response. Anesthesiology 2003;99:240. [Fulltext Link] [CrossRef] [Medline Link] 333. Grocott HP, Darrow TR, W hiteheart DL, et al. Lung isolation during port-access cardiac surgery: double- lumen endotrachea l tube versus single-lumen endotracheal tube with a bronchial blocker. J Cardiothorac Vasc Anesth 2003;17:725727. [CrossRef] [Medline Link] 334. Prabhu MR, Smith JH. Use of the Arndt wire-guided endobronchial blocker. Anesthesiology 2002;97:1325. [Fulltext Link]

[CrossRef] [Medline Link] 335. Cohen E. The Cohe n Flextip endobronchial blocker: an alternative to a double lumen tube. Anesth Analg 2005;101:1877 1879. [Fulltext Link] [CrossRef] [Medline Link] 336. Ransom ES, Norfleet EA. Syringe cap prevents leaks during one-lung ventilation. Anesthesiolo gy 1995;82:1538. [Fulltext Link] [CrossRef] [Medline Link] 337. Oxorn D, Pagliarello G. Traumatic rupture of the thoracic aorta: diagnosis on fibreoptic bronchoscopy. Can J Anaesth 1992;39:296298. [Medline Link] 338. Borchardt RA, LaQuaglia MP, McDo wall RH, et al. Bronchial injury during lung isolation in a pediatric patient. Anesth Analg 1998;87:324325. [Fulltext Link] [CrossRef] [Medline Link] 339. Turner MW , Buchanan CC, Brown SW . Paediatric one lung ventilation in the prone position. Paediatr Anaesth 1997;7:427 429. [CrossRef]

[Medline Link] 340. Munir MA, Albataineh JI, Jaffar M. An alternative way to use Fogarty balloon catheter for perioperative lung isolation. Anesthesiology 2003;99:240. [Fulltext Link] [CrossRef] [Medline Link] 341. Cooper MG. Bronchial blocker placement in infanta technique and some considerations. Paediatr Anaesth 1994;4:7374. [CrossRef] 342. Larson CE, Gasior TA. A device for endobronchial blocker placement during one-lung anesthesia. Anesth Analg 1990;71:311312. [Fulltext Link] [CrossRef] [Medline Link] 343. Oxorn D. Use of fiberoptic bronchoscope to assist placement of a Fogarty catheter as a bronchial blocker. Can J Anaesth 1987;34:427428. [Medline Link] 344. Kinouchi K, Kagawa K, Iura A, et al. One-lung ventilation using a 2 Fr Fogarty c atheter as a bronchial blocker in 3 neonates. Anesthesiology 2005;103:A1386. 345. Vretzakis G, Dragoumanis C, Papaziogas B, et al. Improved oxygenation during one-lung ventilation achieved with an

embolectomy catheter acting as a selective lobar endobronchial blocker. J Cardiothorac Vasc Anesth 2005;19:270272. [CrossRef] [Medline Link] 346. Asai T, Ikeda S, Shingu K. Insertion of a Fogarty catheter through an endotracheal tube for one-lung ventilation: a new method. Anesthesiology 2000;93:909. [Fulltext Link] [CrossRef] [Medline Link] 347. Rajan GRC. An improved technique of placing a coaxial endobronchial blocker for one-lung ventilation. Anesthesiology 2000;93:15631564. [Fulltext Link] [CrossRef] [Medline Link] 348. Cohen E, Benumof JL. Lung separation in the patient with a difficult air way. Curr Opin Anesthesio l 1999;12:2935. [Fulltext Link] [CrossRef] [Medline Link] 349. Arndt GA, Kranner PW , Lorenz D. Co-axial placement of endobronchial blocker. Can J Anaesth 199 4;41:11261127. [Medline Link] 350. Kaplan R, Guzzi L. An aid in the placement of right sided bronchial blocker in small children. Paediatr Anaesth 1993;3:263266.

[CrossRef] 351. Seal RF. An aid in the placement of bronchia l blockers in small children. Pediatr Anaesth 1994;4:74. 352. Chengod S, Chandrasekharan AP, Manoj P. Selectiv e left bronchial intubation and left-lung isolation in infants and toddlers: analysis of a n ew technique. J Car diothorac Vasc Anesth 2005;19:636641. [CrossRef] [Medline Link] 353. Lin Y-C, Hackel A. Paediatric selective bronchial blocker. Pediatr Anaesth 1994;4:391392. [CrossRef] 354. Veit AM, Allen RB. Single-lung ventilation in a patient with a freshly placed percutaneous tracheostomy. Anesth Analg 1996;82:12921293. [Fulltext Link] [CrossRef] [Medline Link] 355. Peragallo RA, Swenson JD. Congenital tracheal bronchus: the inability to isolate the right lung with a Univent bronchial blocker tube. Anesth Analg 2000;91:300301. [Fulltext Link] [CrossRef] [Medline Link] 356. Kin N, Tarui K, Hanaoka K. Successful lung isolation with one bronchial blocker in a patient with tracheal bronchus. Anesth Analg 2004;98:270.

[Fulltext Link] [CrossRef] [Medline Link] 357. Toyoyama H, Minami W , Toyoda Y. Possible right lung isolation by blocking the tracheal bronchus with only a Univent tube for some patients. Anesth Analg 2003;96:1239. [Fulltext Link] [CrossRef] [Medline Link] 358. Sandberg W S. Endobronchial blocker dislodgement lea ding to pulseless electrical activ ity. Anesth Ana lg 2005;100:1728 1730. [Fulltext Link] [CrossRef] [Medline Link] 359. Thielmeier KA, Anwar M. Complication of the Univent tube. Anesthesiology 1996;84:491. [Fulltext Link] [CrossRef] [Medline Link] 360. Gayes J M. Management of Univent bronchial blocking balloon perforation during one- lung ventilation. Anesth Analg 1994;79:1210. [Fulltext Link] [CrossRef] [Medline Link]

361. Dougherty P, Hannallah M. A potentially serious complication that resulted from improper use of the Univ ent tube. Anes thesiology 1992;77:835836. [Fulltext Link] [CrossRef] [Medline Link] 362. Park H-P, Bahk J- H, Oh Y-S, et al. Case report: pulmonary soiling after one- lung ventilation with a bronchial blocker. Can J Anesth 2002;49:874876. 363. Baraka A, Nawfal M, Kawkabani N. Severe hypoxemia after suction of the nonventilated lung via the bronchial blocker lumen of the Univent tube. J Cardiothorac Vasc Anesth 1996;10:694 695. [CrossRef] [Medline Link] P.659

Questions
Each question below contains four suggested answers of which one or more is correct. Choose the answer:

if A, B, and C are correct if A and C are correct if B and D are correct if D is correct if A, B, C, and D are correct.

1. Indications for a double-lumen tube include A. Patient with hemorrhage B. Patient having one-lung surgery C. Control of infection from one lung D. Patient with a lesion in the trachea View Answer2. When placing a left-sided double-lumen tube, A. The outermost acceptable position for the bronchial cuff is just below the carina B. The average length from the left upper bronchus to th e carina is 3 cm C. The tip of the bronchial lumen should be at the proximal edge of the left upper lob e bronchus D. The margin of safety is less than for right-sided tubes View Answer3. Which of the following statements are correct? A. A left double-lumen tube can usually be used for right lung surgery B. A left double-lumen tube can be used for left pneumonectomy C. A right double-lumen tube must be used for left lung surgery if there is rupture of the left mainstem bronchus D. Manipulation during surger y is like ly to alter the position of a tube in the contralateral bronchus. View Answer4. Which of the following apply to inserting a double-lumen tube? A. A stylet needs to be used for all intubations

B. The tube should be inserted at a 90-degree angle from where it will ev entually rest C. If the tube is to be placed in the left mainstem bronchus, the head and neck should be rotated to the right before rotating and advancing the tube D. Removing the stylet after passing the cords may prev ent trauma View Answer5. Techniques useful in confirming the position of a double-lumen tube include A. Auscultation of the chest B. Fiberoptic examination C. Chest x-ray D. Capnography View Answer6. Possible consequences of bronchial tube malposition include A. Unsatisfactory lung deflation B. Air trapping C. Airway obstruction D. Trauma View Answer7. Possible double-lumen tube malpositions include A. Obstruction of the upper lobe bronchus B. Bronchial tip abov e the carina C. Bronchial tip inadequate ly advanced into the bronchus D. Insertion into the wrong mainstem bronchus View Answer8. Possible causes of obstruction to ventilation when a double-lumen tube is in use include

A. Tube malposition B. Foreign body migration into the dependent lung C. Ov erinflation of the bronchial cuff D. T wisting of the bronchial lumen View Answer9. Possible consequences of trauma resulting from double-lumen tubes include A. Vocal cord paralysis B. Rupture of a mainstem bronchus or the trachea C. Mediastinal emphysema D. Hemorrhage View Answer10. Uses of bronchial-blocking devices include A. Patient on anticoagulants B. Bronchopleural fistula C. Pulmonary hemorrhage D. Differential lung ventilation View Answer11. Problems associated with a carinal hook on a double-lumen tube include A. Hook fracture B. Trauma to the airway C. Interference with bronchial closure during pneumonectomy D. Malposition of the tube View Answer12. Which problems can be attributed to using too small a double-lumen tube? A. High cuff volume with high pressure on the mucosa B. Displacement may be more likely C. The tube may advance too far into a bronchus

D. Hemorrhage View Answer13. Indications that the bronchial lumen is not the correct size include A. No air leak with the bronc hial cuff deflated B. The tube will not fit into the bronchus C. More than 3 mL of air in the bronchial cuff is needed to make a seal D. There is obstruction of the bronchus View Answer14. In determing the proper size doublelumen tube for a patient, A. The left bronchus is lar ger than the right B. The size of a mainstem bronchus may be reliably determined by measuring the width from a chest x-ray C. W eight is the best predictor of bronchial diameter in children D. In adults, the dimension of the cricoid ring best defines those of the main bronchi View Answer15. How is the proper depth of insertion for blind insertion of a left double-lumen tube determined? A. Patient sex B. Patient weight C. Patient age D. Patient height View AnswerP.660

16. Insertion techniques that can be used to attain the proper insertion depth include

A. Monitoring the bronchial cuff pressure B. Looking for one side of the chest to inflate C. Advancing the tube with the br onchial cuff inflated until it wedges into the bronchus and then deflating the cuff and inserting the tube an additional 1 to 1-1/2 cm D. Inserting the bronchial portion und er direct v ision with a flexible endoscope View Answer17. What are the possible consequences of overinflating the bronchial cuff on a DLT? A. Shifting the carina toward the opposite side B. Herniation into the trachea C. Narrowing the bronchial segment lumen D. Obstructing the opposite mainstem bronchus View Answer18. When should the position of a DLT be checked? A. After it is initially placed B. At the beginning of one- lung ventilation C. After the patient is positioned for surgery D. Before the chest is closed View Answer19. Possible causes of hypoxia associated with using a double-lumen tube include A. Bronchial tube in the wrong bronchus B. Presence of a tracheal bronchus C. DLT blockage D. Shunting, even with a properly placed tube View Answer20. Possible measures to combat hypoxemia during double-lumen tube use include

A. CPAP to the nonventilated lung B. Occasional ventilation of the operative lung C. PEEP applied to the dependent lung D. Clamping the pulmonary artery before clamping the bronchus View Answer21. Problems associated with a single-lumen bronchial tube include A. Inability to ventilate the right upper lobe bronchus B. Inability to administer CPAP to the nonventilated side C. Inability to ventilate the left upper lobe bronchus D. Incomplete lung collapse View Answer

Chapter 21 Devices for Managing the Difficult Airway

Ens uring a patent ai rway wi th a dequate v entil ation and ox yg enation is a prima ry goal i n anes thes ia a nd res usc itation . A l though dea th and b rain damage from the diff icul t ai rwa y hav e dec l ined, i ts man ageme nt remains a s ig nificant problem (1). The A me rican Soc ie ty of A nes thes iologis ts (A SA ) has d ev eloped an al gorithm to help the anes thesi a p rov ider recognize and dea l with patients who hav e, or are l ik ely to hav e, a diff ic ul t ai rway (2,3). If a diff icul t ai rwa y is recogni zed beforehand, the course is likel y to b e d iffe ren t from tha t whi c h occ urs if that p roblem goes unrec ogni zed. Vari ous as pec ts of ai rway pres erv ation are dealt with in other chap ters , i nc lud ing mask s and ai rwa ys (Chapter 16 ), trac hea l in tubation (Chapter 19), and use of the supraglo ttic airway dev ic es (Chapter 17). W hen thes e tec hni ques a re uns ucc essful , other me asures need to be cons idered.

Combitube Description
The Co mb itube (E TC, esophagea l-tracheal double lu men airway , E TLDA , es opha geal trache al Combitube) (Fi g. 21.1 ) has two s epa rate lume ns that are fus ed P .662 l ongi tudinally and two i nflatable cuffs (4,5,6). E ach lumen is li nked b y a s hort tu be to a s tan dard 15-mm con nec tor a t the b rea thing sys tem e nd. The pharyngeal l umen has an occ luded dis ta l end and e igh t ov al-shaped perforations (v enti lating eyes ) between the cuffs . Th e tub e and conn ec tor as soc iated wi th the pha ryngeal lumen may be co lo red blue. The other (tracheoes ophageal , trac hea l) lumen has a pate nt dis tal end and a c lear tube. The s mall er distal cuff s erv es to s eal e ither the es opha gus or trac hea , depending on i ts plac ement. The l arger (pharyngeal ) c uff (balloon) is abov e the pe rfora tions . It s erv es to s eal the phary nx by fi lling the spac e between the base of the to ngue an d s oft palate s o tha t gas c annot escape th rough the mouth o r nos e. The pi lot ba lloon for the pharyngeal c uf f is c olo red blue . If the tip is ins erted into the trac hea, the dis tal c uff is inf lated an d the tube is used as a conv en tiona l trach eal tube . If the tip is inserted into the es ophagus , both c uffs are i nflated and v entilation occu rs thro ugh the h ol es abov e the dis tal c uff.

Figure 21.1 Combitube. Note the ventilating eyes between the two cuffs. (Courtesy of Sherican Cather Corp.)

View Figure

The Co mb itube has a p ronounc ed anterior curv e to ward the pati ent end. It is marked wi th two black rings a t the machine end that help to indic ate the insertion depth . The Co mb itube is av ailabl e in two si zes : the regul ar (41 Frenc h [Fr]) f or ad ult mal es and the s mall adul t (SA , 37 Fr) f or femal es and s mall adul ts . The Co mbitub e i s rec ommende d for pati en ts wi th a hei gh t gre ater th an 5 fee t (152 cm). T he Combi tube S A is reco mme nded for us e in patients 4 to 6 fee t ta ll (120 to 180 cm) but has been used in patients up to 6-1 /2 f eet tall (198 cm) (7,8 ,9). The Co mbitub e i s not recomme nded for patients youn ger than 12 years of age.

Use
It is important to p rac tice ins erting the Combi tube under con trolled c ondi tions before attempting to us e i t on a difficul t ai rway. If a c erv ical col la r is i n place, i t shoul d be remov ed and the cerv ical spine immobili zed manual ly whi le the Combi tube is ins erted (10,11,12). Once the E TC has been inserted s uccessful ly , the anterior porti on of the collar shoul d be reapplied befo re re leas ing the manual s tabi l iz ati on (6). The Co mb itube c an be inserted f ro m an y p os i ti on . For bli nd inserti on, the head shoul d be in a neu tral pos i ti on wi th the occiput on the f lat s urf ace on whi ch the pati ent is pos itioned, not the s nif fi ng pos ition tha t is usual l y used for trac heal i ntu bation. Bending the Co mb itube in the porti on between the bal loons for a few seconds ma y fac il i tate ins ertion (6,13,1 4,15,16). Suc ti oning is no t nec ess ary , ev en i n the presence of b lo od or v omi tus (4).

The Co mb itube is inserte d wi th one hand , whi le the other hand pul ls the tongue forwa rd and l ifts the jaw (4,17,18 ). It sho uld b e pass ed along the s urfac e of the tongu e, not the pa la te. It is important to keep the Combitube midl ine duri ng i nsertion to av oid bl ind pock ets s uch as the v al lecula. The Combi tube is adv anc ed unti l the spac e between the two bl ack rings li es be twe en the patient's tee th or g ums or unti l resis tanc e is felt. Tempora ry release of c ricoid press ure (if used) may be requi red (19). If there is diff ic ul ty adv anc ing the E TC, rotating the tube may be helpful i n some pa tients (1 6). The use of a laryngosco pe may fac il i ta te suc ces sful place ment and lower th e number of c omp lications (7 ,20,2 1,22). The pharynge al ball oon is inf lated with 100 mL (85 c c for the Combi tube SA ) of air. The Co mb itube of ten mov es outwa rd about 1 c m during inf lation (5). T he dis tal c uff shoul d be inflated with 5 to 12 mL of ai r (C ombi tube 37 F r) o r 5 to 15 cc of a ir (Combi tub e 41 Fr). It may be prefe rable to inf la te the dis ta l cuff f irs t if the patient is at ri sk fo r aspi ration (23). The blue bal loon shoul d not be v isi ble when look ing i nto the patie nt's oral cav i ty (16). Af ter ins erti on and ba ll oon inf la tion, v entilation is begun in o rde r to determine whe the r the dis tal lumen is in the es ophagus or tra chea . Since mos t i ns ertions resul t i n esophageal place ment, v en tila ti on shoul d be attempted firs t v ia th e blue l umen. Gas trav els down the tube, through the l ate ral wall perfo ratio ns , i nto the pharynx , and on in to the trachea. It is prev ented from enteri ng the s tomach by the dis tal c uff in the esophagus and from escapi ng through the mou th and nose by the pharyngea l cuff. If n o ev idenc e of v en ti la tion is detec ted, a s witch s hould be made to the c lear lumen wi thout alterin g the Comb itube's position. If v enti lation is sa tisfac tory, the dev ice is then used as a trac heal tube. If v en ti lation continues to be i nade quate, the Combi tube shoul d be P .663 wi th dra wn 1 to 3 c m af ter def lating the cuffs a nd v enti la tion attemp ted agai n wi th the blue lumen (24). If th is thi rd atte mp t at v entilatio n is uns atisfac tory, the Combi tube sh ould be remov ed and v entilation es tabl is hed by us ing another tec hnique.

Figure 21.2 Combitube in place in the esophagus. (Courtesy of Sherican Cather Corp.)

View Figure

The esoph agea l detec tor dev ice and the colorimetric c a rbon d iox ide detec tor (Chapter 22 ) hav e b een us ed to v erify co rrec t p osi tion (24,25,26,27,28,29,30,31 ). In anes thesia s ettings , c apnography c an be us ed . Af ter s tabi li zi ng th e tub e, the amount of ai r i n the cuffs shou ld be reduc ed. If the Combi tube is ins erted into the trac hea, inf lati on s hould be to jus t s ealing v olume (32). The v olume in the pharyngea l bal loon shoul d be reduced to the minimum requi red to fo rm an effec tiv e seal (7,22,33,3 4,35,36). If v entilation is co ntrol led, a s light posi tiv e end -ex pi ratory pressure may be presen t (21,37,38,39). In the es ophageal posi tion (Fig. 21.2), th e unus ed tracheal lumen c an b e c onn ec ted to s uc tion to asp irate fluids or a gas tric tube c an be ins erted (22). Epinephri ne can be i ns til led th rough the esoph agea l lu men (40 ). The dose s hould be te n ti mes tha t adminis tered through a trac hea l tu be. The Co mb itube i n the esoph ageal pos ition ma y be exc hanged for a s tandard trac heal tube b y usi ng a fl exible fi bersc ope, ri gid l aryngoscope, or retro gra de i ntu bation a round the Combi tube (5,7,9,41,4 2,43,44).

Indications
The Co mb itube is useful for a irway mana gemen t in the diff ic ul t-to -intubate patie nt (6,25,45,46,47,48,49,50,51,52,53,54,55,56 ,57 ). B ecaus e it c an be pl aced wi thout hav in g to v isua lize the la rynx , i t may be es pec ially useful for pa ti ents with mass iv e ai rwa y bleeding or regurgi ta ti on. It c an be used in patie nts wi th l imited acc ess to the ai rway and li mited mouth opening a nd fo r patients in whom nec k mov emen t is contraindicated . It has been used suc ces sfull y in patien ts in a halo head frame

(58,59), a patien t wi th exc ess iv e pharyngeal blee ding (60), a hema toma caus ing upper ai rway obs truc tio n (61), a pati ent who had a wo oden s pli nter through the mouth parti al l y b lock ing the pharynx (62), respi ra tory arres t s ec onda ry to an ac ute as thma tic exac erbation (63), a patient wi th fac ial b urns (64), and a pa tient trappe d i n a c ar (65). It may b e useful in entertainers in wh om i t is impo rtant to av oid v ocal co rd dama ge (18 ). It has been use d for Cesarean sec tion (66). The ETC has been us ed suc cess full y after failu re wi th a l aryngeal mask ai rway (LMA ) (54 ,59 ). The E T C has an es tabl ished rol e in cardiopulmonary res us ci ta tion in both prehospi tal and i n-h ospi tal se ttings (56,67,6 8,69,70,71,72,73). It is i ncluded in the Guidel ines f or Adv anced Ca rdiac Lif e Suppo rt of the A me rican Hea rt As soc iati on, P rac tic e Guidel ines for Management of the Diff icul t A i rwa y o f the A SA , the Canadi an A irway Focus Group, and guidel ines f or resus c itation of the European Res usci tation Counci l as a s uitable al ternativ e ai rwa y to trac heal intuba tion, es pecial l y i n th e ca nnot v entilate, c anno t in tubate s i tuati on (2,45,74). The Co mb itube has been us ed suc ces sfu lly fo r anes thes ia las ting up to 6 h ours , i ncl uding gyneco logic lapa ros copic su rge ry (5,21,22,38,4 1,75). Rel ativ ely hi gh ai rwa y pressures can be used (4,2 1,22). Wh ile it is no t recommended for rou tine anes thes ia, i t may be a v iab le op ti on fo r patients in whom it has bee n placed to secure a diffic ul t airway (7 6,77). Usi ng it in elec tiv e cases may P .664 i nc reas e the anes thes ia prov ider's c omfo rt wi th the dev ic e. It has be en use d in th e es opha geal pos i tion wi th mec hanica l v en ti lati on for up to 8 hours (38). The Co mb itube has been us ed durin g perc utaneo us di latational tracheos tomy (s ee below) (78 ) but may not be the bes t choice for ai rwa y manage ment during this procedure (79). The trachea is free of any appl ianc e , but i t does not a llow a f ibe rs cope to be used du ri ng th e procedu re (8 0). It h as also been us ed fo r v enti lation du ri ng trac heotomy (8 1).

Contraindications
Con traindications to us ing the Combitube inc lude ac tiv e phary ngea l or l aryngeal reflex es ; k nown esophageal trauma or patho logy; i nges tion of corros iv e a gents ; and orophary ngea l, pharynge al, or hypophary ngeal mass . It s hould not be used in pati ents younger than 12 y ears of age or i n th ose un der 4 feet tal l.

Advantages

Compa red wi th a tracheal tube, the ti me nee ded fo r inserti on is s ignifican tl y shorter, and less sk ill is requi red (82). B ec ause s uccessful us e does no t re qui re di rec t v isuali za tion, the presence of b lood and/or v omitus does not p rev ent succes sful plac ement. Once in place, the Comb itube prov ides c omparable v enti lation and i mprov ed oxyg enatio n compared wi th trac heal in tub ati on (37,38,41,48,67,68,71,83). It can be us ed by an anes thesi a prov ider who has l imi ted use of the left a rm (84 ). Mi nimal training is needed b efo re use . The sk il ls required to ins ert a Co mb itube do not need to be reinforced as of ten as the y do for tracheal i ntubation. Th e Combi tube ca n be used succes sful ly by no n-a nes thesia pers onne l both as a fi rs tl ine treatment and after failed trachea l in tubation (71,72,73,83,85,86 ,87 ,88 ). It is of ten us ed by pa rame dics . The Co mb itube i n the esoph ageal pos ition is wel l tol era ted by the patient during emergence from anes thes ia (4). Its use is not associa ted wi th h ig h l ev els of trace gases (8 9). There is no danger of bronch ia l in tubation in the esoph agea l pos itio n. The pharynge al ball oon anchors th e dev ice i n p lace, l ess ening the risk of ac c idental ex tubation. The Co mb itube prov ides good bu t not c omplete p rotec tion from aspi ration (7,9 ,22 ,48 ,58,63,7 2,90,91,92). Gas tric dis tentio n c an occ ur wi th i ts us e (36).

Disadvantages
Trac heal s uc tionin g o r fi beroptic bronchoscopy is no t pos s ible through the Combi tube in the es opha geal posi tion unless th e C ombi tube is modif ied (93). If inserted i nto the trachea , the res ult is a tu be with a relativ el y large outer diameter bu t smal l i nternal lumen. The ai rf lo w res is tanc e wi th a s mall adul t Combi tube is greate r than tha t of a 7-mm trac heal tube but l ower than that of a 6mm tube (94,95). A cas e has been repo rted where the pa ti ent could not be v entilated af te r the Combi tube was plac ed (96 ). The tube was found to be s o deep th at the uppe r c uff obs truc ted the tracheal lumen . P ul ling the tu be back ward remedi ed the problem. In anoth er cas e where v entil ati on was diff ic ul t, f lex ible f iberosc opy sho wed a v alv el ike mechanism by the a ryepi glo ttic f ol ds ov er th e perforations in the tube (97 ). Ins ertion and remov al of the Combitube may be assoc ia ted wi th a highe r s tres s respons e than that wi th a trac heal tube o r supragl ottic ai rway dev ice (22,39). Ins ertion takes longer than wi th the LMA (72 ). The Co mbi tub e ma y be ins erted

wi th out mov ing the head or nec k , bu t there may be more cerv ical s pine motion during ai rway manageme nt wi th a Combi tube than with other dev ices (98,99). Trauma to the ai rwa y and eso phagus may occ ur wi th the Combi tube (12,21,36,71,100,101,1 02,103,104,1 05). It exerts rel ativ ely hi gh press ure on the trac heal mucos a (106 ). So re throat and dysphagia are c ommon after i ts us e (33,100). Trauma may be re duc ed by us ing the smal l adult Combi tub e when appropriate, gentle inserti on, hal ti ng further adv ancement in the prese nce of resis tance , us ing a la ry ngos cope to aid i nsertio n, adequa te anes thetic depth , sl ow cuff infla ti on, a nd regular as sess ment of both c uff pressu res . The prox imal c uff of the Combi tube is made of l atex , mak ing i t unsui table for us e in a patient wi th l atex alle rgy (Chapter 1 5). The Co mb itube is expens iv e compared to other s ingle use dev ices . Th is mak es it unecon omic al to use fo r ro uti ne anes thetic s.

Retrograde Intubation
Retrograde (tra ns lary nge al-guided, gui ded b lind) i ntuba tion is an elec tiv e or emergenc y technique for s ecuring a d ifficu lt a irway, eithe r alone or i n conjunc tion wi th other tec hniques (107 ,108,1 09). It shou ld be cons idered part of the armamentariu m of ev ery anes thesia p rov id er (2). Re trograde i ntubation is a us eful opti on in pa ti ents who ca nnot be intuba ted b y using tradi ti onal tec hniques (110,111 ,112,113,114,115,116,117,118 ,119). It ma y not be su itabl e fo r patie nts who requi re immediate intub ati on and v entilatio n, as the proced ure c an be expec ted to tak e 5 minutes or more fo r completion. A retrograde in tubation s et is shown i n Figure 21.3 . After s k in p rep ara ti on, a ca the ter-ov er-needle dev ice wi th a n a ttac hed s yringe is inse rted th rough the P .665 c ric othyroid memb rane in a c ephal ad di rec tion (F ig . 21.4). Entering the ai rway l ower i n the airway (b etween the c ricoid cartil age and the f irs t trac hea l ring or between the f irs t and sec ond trach eal rings ) a llows more room for adv anci ng the tube (107,117,120,121,122,123 ). Free ai r as piration c onfirms the loc ation . Loc al anes thes ia should b e i nj ec ted thro ugh the syrin ge. The needle and s yri nge a re remov ed , and a guide wi re i s inserted through the c atheter (124 ) (Fig. 21.5 ). Ano the r dev ic e s uc h as an ep idura l or central v enous catheter may be us ed as a guide .

Figure 21.3 Retrograde intubation set.

View Figure

The guide is adv anc ed cephalad until it eme rges at the oral c av ity or na res (Fi g. 21.5). It may be nec essa ry to use a spec ia l dev ic e to re triev e the guide wire (123,125 ,126). If nasotracheal in tubation is des ired, a c ath ete r c an be i nse rted nasal ly , brough t out through the mouth, and secu red to the gu id e wi re (127 ). The ca the ter is then pull ed out through the nos e, bringing the guide wire with it. The ca the ter at the c rico thy roid membrane is remov ed and the guide cl amped a t the sk in.

Figure 21.4 The catheter-over-needle with syringe attached is inserted through the cricothyroid membrane in a cephalad direction. Aspiration of air confirms placement within the airway.

View Figure

A la rge r dev ice s uch as an ep idu ral catheter or air way ex change catheter c an be s lid ov er the guide wi re and the trac heal tub e adv anced ov er the catheter (108,123 ,128,129,130,131,132) (Fi gs . 21 .6,21 .7,21.8). A l ternatel y, the trac heal tube can be threade d ov er the guide wi re , with the g ui de wire goi ng ei th er th rough the Murp hy eye or main l umen. The guide s hould then be put under s l igh t te nsion. The trach eal tube is adv anced unti l i t reaches the point where the gu ide wi re en te rs the airway . The guide wi re is remov ed f rom abov e and the trac heal tub e ins erted to the proper depth. If the trac heal tube c annot be adv anc ed, i t may be he lpful to ro tate it 90 degrees counterc lock wi se, exchange i t for a s malle r tu be, relax th e tens ion on the guide, or i nsert a fibe rsc ope through the tracheal tube (112,123 ,13 3). The tracheal tube may also be pu lled into the trachea by tying the retrograde gu ide to th e tracheal tube (108,117 ,122,131,134). A l te rna tel y, after the guide wi re i s retri ev ed through the mou th or nose, i t may be place d through the channe l of a flex ible fibers cope wi th a trac heal tube threaded ov er i t (108,109,111 ,114,123,135,136,137,138). The fibers c ope is adv anc ed ov er the guide and do wn to the point of ex i t of the guide wi re f rom th e trachea. A t this point, the guide wi re c an be loosened and the fi bersc ope a dv anced further (139). Af ter confi rmation tha t th e f iberscope is in the trac hea, the guide is remov ed v ia the prox imal p ort of th e fi bersc ope. Th e tracheal tube is then adv anced into the trac hea. Retrograde in tubati on is a s afe, eas y, and dependab le method of intuba tion (117). It may be espec ially us eful in patien ts wi th ai rway trauma or l imited nec k mo bi li ty and in th e p res enc e of oropharyngeal bleedi ng, wh ic h P .666 may obscure th e f ield of the f iberscop e (108 ,113,140). It has be en used in infan ts and c hildren (112,123 ,135). It has been us ed to plac e a do uble-lumen tube (141 ). This method may be a us efu l means for rei ntu bation wh en a tracheal tube is remov ed (142 ). It has b een used to in tubate a pa tient with a Combi tube in place (143). It is inc lude d in the ASA A lg ori thm for Man agemen t of the Diff ic ul t A irway (3).

Figure 21.5 A: Guide for retrograde intubation. B: The guide is inserted through the catheter and advanced cephalad until it emerges from the mouth.

View Figure

Compl ications of retrog rade intuba tion include so re th roa t, trauma, baro trauma, a nd pretrac heal absc ess (117,119 ,138,144,145 ). The trac heal tube may i nadv ertentl y s lip out as i t is a dv anced (146).

Cricothyrotomy
P lac ing a dev ic e through the c ric othyroid memb rane to gain c on trol of the ai rway is not a n ew proc edu re (147,148,149,150). In recen t yea rs , the technique has been refined and is no w c ommonly used by emerg enc y medic al se rv ices (15 1,152). It is part of the ASA and Dif ficul t A i rway S oci ety diff ic ult ai rway algo ri th ms (2,3). Cric oth yro tomy equipment s hou ld be on ev ery d ifficul t airway c art.

General Considerations
The thyroid c arti lage is p romi nen t and easily palpable in mos t ind iv iduals , es pecial l y i n males . It may be difficul t to pal pate in ob ese pati ents and infants . The rela tiv el y av ascular c rico thy roid membrane i s loc ated approx imatel y 2 to 3 cm below the thy ro id notch in adul ts . This area is usual ly the mos t acc ess ible part of the res pi ratory tree below th e glottis . Occasional ly , i t may be nec essa ry to choos e a s i te lower i n th e airway be tween the second and thi rd tracheal ri ngs (153 ,154). Cric oth yro tomy c an be perfo rmed by plac ing a sma ll needle or c ath ete r (needle c ric othyrotomy), a large cannula spec ia ll y des ign ed fo r this purpos e, or s urgic al ly i nserting a c uffed tube (147,155). If time allows , fiberoptic gui danc e may dec reas e the incidenc e of malposi tion (156).

Techniques

Needle Cricothyrotomy Technique

The patient's head is ex tended and the c rico thy roid membrane identifi ed. A needle or c ath eter-ov e r-needle un it wi th a s y ri nge a ttached is inserted in P .667 the midl ine poi nting b etween 30 deg rees and 45 deg rees in a c audal d irec tion. If ai r can be as pi ra ted f reely i nto the s yring e, th e needle is ins ide the ai rwa y. A th ree way s topcock c an be pl aced b etwe en the s yri nge a nd need le wi th one li mb of the s topc ock c onnec ted to a capnograph (1 54,157). As pirating c arbon diox ide c onfi rms ai rwa y placemen t. The cannula is th en s lip ped off the needle into the trac hea and the need le remov ed.

Figure 21.6 A: Airway exchange catheter. B: Airway exchange catheter has been advanced over the guide wire (after removal of the connection).

View Figure

S mal l intrav enous cannulae are us ual ly read ily av ail able but a re eas il y comp res sed and p ron e to k ink ing (158,159,16 0). P lac ing a s mall bend i n the end of the catheter may dec rease the inc idenc e of k inki ng (159). S ome P .668 i ntrav enous c atheters are not s ui tab le , because a s y ringe cannot be a ttac hed and many a re too short (1 61).

Figure 21.7 The tracheal tube is advanced over the airway exchange catheter.

View Figure

Figure 21.8 The guide wire and airway exchange catheter are removed, and the tracheal tube is advanced into the trachea.
View Figure

Large-gauge in trav enous ca thete rs hav e been us ed s uc ces sfull y (162). Mos t autho rs recommend a 14 -ga uge or larger c ath ete r fo r adul t pa tients (147,163 ,164,165). Us e of a c athete r with s ide holes may l ess en the ris k of trac heal dama ge (163). Catheter l eng th is impo rtant. If the c athete r is too s ho rt, i t may come out, and gas wi ll be injec ted into the s ubcu tan eous neck tiss ues . Howev er, the longer th e ca the ter, the greater the res is tance to flo w. For the adu lt p atien t, the cathe ter shoul d be at leas t 4 c m in length. For the pa tient wi th a thick nec k , a greater l ength may be necess ary (166 ).

Other dev ices us ed inc lude a Tuohy needl e (1 67,168), the v ess el dil ator of a n i ntrav enous i ntroduce r ki t (1 69,170), a tri ple -l umen central v enous catheter (171), and a suc tion c ath ete r (1 72). To connec t th e c ricothy rotomy dev ic e to a means of v enti lation, either a Luer l ock (Fig . 21.9) or a 15 -mm connec tor i s requi red . Many k i ts p rov ide both . Some hav e the Luer loc k attachment ins ide a 15-mm c onnec tor.

Ventilation Techniques
The c athete r diameter of ten does not al low an ad equa te tida l v olume to be deliv ered at the press ures p rov id ed by conventi onal v enti lators . A sou rc e of highpress ure ox yge n and robus t c onnec tions are requi red.

Jet Ventilation
Injec tion of high-v eloc i ty gas in to the ai rway through a narro w c annu la wi th out a seal is termed je t ven ti lation. It c an be perfo rmed au tomatical l y o r manua lly. J et v enti lation is conv entional ly c arri ed out a t rates up to 60 c yc les /minute. A bov e 60 c ycles / minute, the techn ique is refe rred to high-frequenc y jet v entilation (173).

View Figure

Figure 21.9 This device is designed to deliver oxygen at a high flow through a small tubing. The pressure tubing is attached to a 50-psi oxygen source, such as the outlet of a piped oxygen system. The pressure delivered can be adjusted by turning the knob. The pressure is measured by the pressure gauge at left. The flow is controlled by the toggle switch downstream of the knob. The tubing end at the top has a Luer lock connector and is attached to a largebore needle or catheter placed percutaneously through the cricothyroid membrane.

P .669

A means of jet v enti la tion should be av ai la bl e in ev e ry anes thetiz ing a rea (174). Unfortun ately , not a ll loc ations hav e the equ ipment readi l y av ai lable and ready fo r us e (175 ). Du ri ng an emergenc y is no t the ti me to ass emble these dev ices . A l l

connec tions mus t be c orrec t for the mode of v entilatio n antic ipa ted and robus t enough to withs tand the pressu res that wil l be us ed. In a s ma ll patien t, the pe ak pressu re should b e reduced to 5 pounds p er square i nch (ps i ) and then inc reased in i nc rements of 5 ps i until adequate ches t exc urs ions are obse rv ed (166,176,177). In adul ts , the jet v entil ati on dev ice s hould be preset a t 25 ps i, then i nc reas ed or dec re ased as indic ated b y the cl inical respons e (178 ). The upper a irway s hould b e made maxi mally pa ten t durin g jet v enti lation by putti ng the patie nt in a n optimal sn iff pos i tion , by us ing bi late ral ja w thrus t and orophary ngea l ai rway s , and by av oiding jet v enti lation du ri ng phonation. If c omplete ai rwa y obs truc tion pers is ts af te r je t v enti la tion is a ttempted, the ai rway needs to be conv erte d to a tracheos tomy as so on as pos si bl e. The pattern of je t v en ti lation is impo rtant (142 ,16 2,179). The i nspirato ry v olu me depends on the gas fl ow rate, i nj ec tion time, respi rato ry s ys tem c ompl iance, a nd ai rwa y res is tance. The expi rato ry v olume wi ll depend on th e exhalation time, elas tic recoil of the l ungs , and airway re s is tance . Care mus t al ways be take n not ini tiate i nspi rati on before th e end of ex halation . End-tida l carbon diox ide c an be moni to red by plac ing a sa mple li ne through the mou th or nos e (180). The inspi red ox ygen conc en tration wi l l depend on the a mount of ai r that is entrai ned, whi ch depends on the rati o of the c atheter to the trac hea and the s truc tu re of the cathe ter (numb er of s ide holes ). If too much gas es capes from the trac hea th rou gh th e mouth or nose du ring i nspi rati on , the p ati ent's mouth and nos e s houl d be c lose d o r the back fl ow blocked wi th a th roa t pac k (18 1).

Devices
A numbe r of jet v enti lation dev ices are commerc ially av ai lable . One is s hown i n Fi gure 21.9. They are c onnec ted to a piped ox ygen ou tl et or an oxygen c yli nder wi th a re gulator. S ome hav e a means to regulate the de liv ered press ure an d/o r an alarm. The jet may ac t as a V en turi and entrain adjace nt gas to inc rease the v olume deliv ered. The je t's ef fic ienc y d epen ds on a number of fac tors (173 ). The amount o f gas deliv e red i nc reas es as the driv ing press ure is ra ise d.

Automatic Ventilator
Automatic v entilators tha t can de liv er a j et of gas au toma tic al l y while moni tori ng both del iv ery pressure and ai rway pressu re are av ai la ble and c an be attached to the c rico thy ro tomy ca thete r (142,1 69,172 ,18 3,184,185,186). S ome automatic all y

pause v en ti lation when the end-expi ratory pre ssu re exc eeds a prese t limi t, e nabli ng detec tion of outlet obs truc tion (171).

Manual Jet Ventilation Device

A manuall y con trol led jet v entil ation dev ice may be attached to the c ricothyrotomy ca the ter and the patien t v enti la ted b y us ing an in termi ttent j et of oxy gen. T idal v olume , inspi red ox ygen conc entrati on, a nd ai rway pres sures are not eas il y moni tored. A c heck mus t be made for c omplete exha lati on af ter each deliv ered tidal v olume .

Flowmeter
Many anes thes ia mac hines hav e an aux il ia ry (c ourtesy) f lo wmeter. This o r a f lowme ter attac hed di rec tl y to a piping sys te m ou tlet c an be used as a s ource of ox ygen (186,187). Noncomp li ant tubing s hould be use d between th e flowmeter and the c rico thy ro tomy ca thete r. A three-wa y s to pcoc k or other d ev ice can be used at the patie nt end to c onv ert the c ontinuous f lo w o f gas to intermittent burs ts , or a hole can b e c ut in the tubi ng and the ope rator's f inger pl ac ed ov e r the hole to deliv er a jet of ox ygen.

Oxygen Flush
It may be pos s ible to s upp ly ox yge n f rom the anes thesi a machine by a ttaching noncompl iant tubing to the co mmon gas outl et and intermittentl y ac tiv ating the ox ygen f lush (188,189,190 ,191). A lternativ el y, i f there is a port near the pa tient e nd of the tubing, a secon d pers on can continuous l y dep res s the ox yge n f lush button whi l e the anes thesi a prov ider intermittentl y occ ludes the port (1 92). Not a ll anes thes ia machines hav e a common gas outlet tha t can be ac ces sed, and not all anes thesi a mac hi nes s uppl y ox ygen at a h igh enough pres sure to driv e the ox ygen through the nonc ompl iant tubing and a c ric othyroid c athete r (1 91,192). Before rel ying on this means of v entilation, the anes thes ia d epartment shoul d as certain what pressure wil l b e deliv ered .

Anesthesia Breathing System

The 15-mm connec tor f ro m a c i rc le breathi ng s ys te m can be c onnec ted to the c ric othyroid dev ice and the oxy gen f lush intermittently ac tiv ated. B ecause the reserv oi r ba g and tubin gs abs orb mos t of the pressu re, the lungs wil l probab ly no t be effec tiv ely v entilated by this metho d a lthough adeq uate oxygenation ma y be ac hiev ed (188). Applying press ure to th e rese rv oir b ag wil l i nc reas e the deliv e red press ure .

Manual Resuscitation Bag

A manual resusc itator (Chapter 1 0) or a Maples on sys tem (Chapter 8) ma y be attached to the c ricothyrotomy dev ic e. These c annot prov ide ad equa te v enti lation unles s a v ery large c annula is us ed (176,192,197 ).

Percutaneous Dilatational Cricothyrotom y

The eleme nts of a perc utaneous c rico thy ro tomy se t are s hown in Fig ure 21 .1 0. A numb er of c us tomi zed k i ts c ontaining the neces sary items are av aila bl e (164,175 ,198,199,200,201,202,203,204 ,205,206,207 ,208,209). A need le-ov ercannula or a s impl e needl e wi th an attached s yri nge is inserted through the c ric othyroid memb rane and ai r asp irated (Fig. 21.1 1). A gu id e wi re is then ins erted through the catheter. P .670

(Fig . 21.12), and the catheter is then re moved. The hol e in the skin around the guide wi re i s enlarged by us ing a sc al pel (Fi g. 21 .13 ). The trac t around the gu ide wi re ca n be enlarged by usi ng a s eries of progress iv ely larger d ilators (in troducers ) or a cu rv ed dilator (Fi g. 21.14). The a irway dev ic e is then inserted into th e trachea ov er th e wire gui de or dil ato r, wh ic h is then remov ed (Fig . 21.15). A c rico thy rotomy tube may hav e a c uff (Fi g. 21.16). The inserti on as sembl y may differ (Fi g. 21.17).

Figure 21.10 Elements of a cricothyrotomy set. At bottom is a syringe with needle. Next is the guide wire, which is advanced through the needle. The small scalpel is used to enlarge the hole in the skin at the site of the guide wire. The dilator is used to enlarge the opening into the airway. The tube is advanced over the dilator. The guide wire and dilator are then removed, and the tube is used to ventilate the patient.

View Figure

This techn ique is fas t a nd usuall y eas y to perfo rm, ev en in the pati ent wi th a s hort neck or sp inal inju ry. An adv antage is that mos t an es thes ia prov iders are ex perienc ed in wire-g uided techni ques (210). A dequate v entilation c an be ac hiev ed by us in g a c onv ention al breathing s ys tem if th e d iame ter of the dev ice is at leas t 4 mm (147 ,208). Howev er, i t may resu lt in more c ompl ic ations and less chance of co rrec t pos i ti oning than a catheter-ov er-needle tec hnique (211,212 ).

Surgical Cricothyrotom y
In s urg ic al c ricothyrotomy, a transv erse sk in inc isi on is ma de at the lev el o f the c ric othyroid memb rane (147,151,198,213 ,214,215,216 ). If the neck is edema tous and the l arynx cannot be p alpated, the incisi on shou ld be v ertic al and then deepened until the lary ngeal c a rtilages a re i dentified. A n inc is ion is then made in the c rico thy ro id membrane . A c atheter may be placed as a g ui de. The inc is ion in the membrane is then s pread, and a trachea l or tra cheos tomy tube is placed through the opening . A bougie may fac ili tate inse rtion of a tracheal tube (217). Surgical c rico thy rotomy is mo re time c onsuming than th e perc utaneous meth ods and requ ires an experi enced s urgeon but prov ides a more def initiv e ai rway P .671 than th e other methods . Howev er, if s peed is particu larl y impo rtant and/or when equipment for l ess i nv asiv e tec hniques is un av ai labl e, i t can b e performed qui te rapidl y.

Figure 21.11 The needle-over-catheter is inserted through the cricothyroid membrane in a caudal direction.

View Figure

Figure 21.12 A guide wire is inserted through the catheter.

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Indications
Upper Airway Obstruction with Inabilit y to Ventilate or Intubate
A prime in dic ation for c ricothyrotomy is the i nabi l ity to secure a patent ai rway by conv en tiona l techniqu es (154,1 70,194,21 8,2 19,220,221,222,223). These incl ude fore ign body aspiratio n and uppe r ai rway p ath ology or wh en a pers on sk il led a t i ntu bation is not av ai lable or ca nnot intuba te the patient and a supraglottic d ev ice cannot b e ins erted .

Anticipated Difficult Intubation

Cric oth yro tomy may be used as an ad junc t to fiberoptic o r other i ntubation tec hniques where it is an tic ipated th at intu batio n ma y be diff ic ult to perform (109,166 ,174,224,225,226,227). It p rov ides a means to v enti late the patien t if the i ntu bation p roc edu re is p rol ong ed. This may b e espec ia lly useful for patien ts who cannot tol erate an a wak e intu bation. J e t v en ti la tion may make s ubs equen t tracheal i ntu bation easi er because the high tracheal pressu re may open the c ollapsed P .672 glottis (154,228,229 ). L eav ing the c rico thyro tomy dev ice in pl ac e duri ng the recov ery peri od al lo ws emergenc y oxygenati on at a time when reintubation may b e diff icul t or c ontraind ic ated.

Figure 21.13 The hole in the skin around the guide wire is enlarged by using a scalpel.

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Figure 21.14 A: The tract around the guide wire is enlarged by using a curved dilator (introducer). B: The cricothyrotomy tube fits over the introducer and guide wire.

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Procedures Involving the Airway

Je t v entila ti on th rou gh a c ric o thy rotomy devi ce can be us ed during p roc edures i nv olv ing the uppe r ai rway (168 ,171,174,182 ,230). This l eav es the entire ai rway f rom the v ocal cords to the face ac cess ib le to the su rgeon. S inc e there is no trac heal tube, there is a reduced lik el ihood of fi re (231) (Chap ter 3 2). A disadv antag e is that the ai rway i s not p rotec ted f rom contamina ti on by blood a nd

su rgical debris . Howev er, th e c ontinuous e gre ss of gas from the ai rwa y hel ps to reduc e c ontami nation.

Cervical Spine Injury

If cerv ic al spine injury has occurre d o r has no t been ruled out, c ric othyrotomy ma y be a good way to es tab lish an ai rway. Other me tho ds of securing an a irway wi th minimal nec k mov emen t are d is cuss ed in Ch apters 17 and 19.

Contraindications
Intrathoracic Airway Obstruction
Cric oth yro tomy is onl y useful for obs truc tions abov e the c ric oid carti lage. Obs truc tions at or below thi s lev el ma y be push ed deep er. For obs truc tions at o r below the lev el of the c ricoid, trac heo to my wi l l be nec ess ary . P .673

Figure 21.15 The introducer and guide wire are removed, and the cricothyrotomy tube is left in place.

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Inability to Locate the Cricothyroid Membrane

This procedure s hould not be attempted i f th ere is unce rtai nty about the loca tion of the c rico thy ro id membrane .

Complete Airway Obstruction

If there is complete obs truc tion abov e the cric oth y-rotomy c atheter, there wi l l be no ex it p ath for ex hal ation. Howev er, if a f oreign body obs truc tion i n the mouth or

l ary nx is p rev enting resp iration, there is the poss ibi lity that this c oul d be bl own out and the obs truc tion rel iev ed. It may be pos sib le to adminis te r pressu ri zed ox ygen safel y to patients wi th co mp le te upper ai rwa y obstruc tion b y us ing a Y -adaptor attached to the c ath ete r hub (228). Oxy gen can be a dmin is tered thro ugh one l imb whi l e the other l i mb is us ed for pass iv e expira ti on.

Figure 21.16 Cuffed cricothyrotomy tube. (Courtesy of Cook Critical Care.)

View Figure

Pediatric Patients
Cric oth yro tomy is technica ll y diff ic ul t in the ped iatric population and s hou ld be performed wi th ex treme caution in c hi ld ren below 10 years of age (155). P ed iatric pati ents hav e a highe r incidenc e o f comp lications f rom c ric othyro tomy than do adults (2 32).

Laryngeal Pathology
Cric oth yro tomy s hould not b e used i n the prese nce of laryng eal i nflammation or i nfec tion .

Decreased Compliance
Patients with c ond itions suc h as emphysema and c hro nic b ronchi tis of ten hav e dimin is hed complianc e tha t may make v enti lation l ess effec tiv e.

Complications
Barotrauma
If pos itiv e p res sure is applied belo w the v oc al c ords , ai rwa y pressure may rise to a hazardous lev el wi th res ul tant ba rotra uma (175,1 82,183,22 8,230,233,234 ,235).

Carefully moni tori ng ch es t mov ements , l imiti ng ins pi ratory pressure and time, and al lowin g adequate time for ex pi rati on wil l dec rease the risk of baro trauma. A irway press ure mon itoring s houl d be perfo rmed , if feasible . Some jet v en ti lato rs automatic al l y pause wh en a p res et press ure i s reache d (171 ,2 29).

Trauma
P lac ing a c ric oth yro id dev ice can resul t i n in jury. B leeding, hematoma, lary ngea l ca rtilage injury , mucosal ulc era tion, and perfo ration of the posterio r trachea and es opha gus hav e been reported (175,2 05,213,220 ,236,237,238 ,239,240). P .674

Figure 21.17 Cricothyrotomy set with the guide wire attached to the needle and a side tubing through which air can be aspirated.

View Figure

If the c atheter is i nc orrec tly placed or s li ps out of the trachea or i f there is a hol e in the catheter near the surfac e of the neck , ox ygen may be injec ted into the tiss ues , resul ting in subc utaneous or medias tinal emphysema (183,228,241 ,2 42,243). Subcutaneous emphysema also may oc cur after decannulation (168,244 ). Th e c ric othyrotomy dev ice sh ould be fi rml y sec ure d to prev ent dis lodgme nt. Sutu ring the dev ice in plac e should be c ons ide red i f time permi ts . Neck mov ement s hould be l imi ted. Wh ipping of the cathe ter with each breath can be minimiz ing by k eepi ng a short l en gth wi thin the trachea and us ing a low driv ing press ure (171). Late comp lications i nclude granula ti on at the c uff si te, ex cess iv e p roc edu re ti me, trac heal s toma s tenos is , persis tent s toma, h emorrhage, s ubglottic s tenos is ,

as piration of blood, dysphonia, v ocal cord paral ysis or pares is , v oice changes , and wou nd infec tion (2 20,236,23 9,245,246).

Kinked Catheter
If the c atheter ki nks , v en tila tion may no t be pos sib le (158,16 8,247). A dding a smal l cu rv e to the tip may h elp prev ent k ink ing (159 ). P recu rv ed c atheters a re co mme rci al l y av ai lable (24 8). If kink in g occurs , i t may be p ossible to change the ca the ter for one more res is tant to ki nki ng by us ing a gu id e wi re (168 ).

Failure to Cannulate the Trachea

The reported fai lure rate f or s ucc essful ly p lac ing c atheters in the trachea v aries f rom 0% to 40% (151,200,213 ,2 14,219,220 ,236,2 38,239,24 0,249,250,25 1). P rac tice wi th the technique d uring el ec tiv e cas es or a s imul ato r inc reas es fami li arity wi th the method and faci li tates its use i n an emerg enc y s ituation (156,247,252 ,253).

Advantages and Disadvantages

Cric oth yro tomy is re lativ ely s imple , safe, eas y to lea rn, and quick . The suc ces s rate i s high ev en in inexperienced h ands (151 ,15 2,214,219,220,238,239,250). Percutaneous jet v entilation may fac i litate tracheal intubation by al lowing i dentification of the glottis o pening (154,228 ). The princ ipa l disadv antage is that i t does not es tabl ish a defini tiv e ai rwa y.

Percutaneous Dilatational Tracheostomy

Percutaneous di lata tiona l trach eos tomy en tai ls ins ertion of a full -si zed trac heos tomy tube in the s ubc ricoi d area (254 ). It is an alternativ e to trad itional su rgical trac heos tomy. It may be performed at the beds ide in a c ritic al c are un it. Many ins ti tu tions hav e adop ted i t as the techni que o f cho ic e in c ritically i ll patients who requi re a trac heos to my (255 ,256,257). It is mos t of ten pe rformed elec tiv ely but can be us ed in an emergenc y s ituation (258).

Technique
Ven ti la ti on can be maintained throughout the proc edure by usin g a tracheal tube place d abov e the si te of the p rop osed tracheos tomy, a sup rag lo ttic ai rway dev ic e, a Combi tube, a mic rolary ngea l tube, an a irway ex change c atheter, or a fl ex ible or rigid bronchosc ope (78,259,260 ,261,262,263 ,264,2 65,266,267,2 68,269,270 ,271,272,273 ,27 4,275,276 ). The Co mb itube may not be su itable if the longe r lu men is in the trachea (79).

Endoscopy is often use d duri ng the proced ure to av oid complications (261,265 ,275,277,278,279,280,281,282 ,283). A n optic al s tylet may a ls o be used (284). It al lows c onf irmation of the p osi tion of the trac heal tub e as wel l as correc t place ment of the needle (i .e ., wh ether i t is midl ine and P .675 at the co rrec t l ev el), guide wi re , di la tor, and f inal ly the trac heos tomy tube. Mo re sev ere c omplic ations occu r when endosc opic v isuali zation is no t us ed (285 ). It als o makes it relativ ely eas y to perform a therapeu tic or diagnos tic bronchos copy after the procedu re is completed (2 86,287). Disadv antages of fibe ros copy inc lud e an i nc reas e in the time needed f or the procedure, th e need for a s epara te sk ille d person, and the potential for hypov enti lation (288). A light wand may be us ed to guide the proced ure (289,29 0). A modification of this tec hni que is to util i ze endoscopic g ui danc e during gu ide wi re place ment and then to insert an ai rwa y exch ange r catheter (266,291). T his produces l ess ai rway res is tance, a llows v enti l ation and adminis tration of oxy gen, and fac i litates reintub ati on, if n eces sary. The patient is plac ed in the supine pos i ti on wi th the neck ex te nded un less th ere is known or suspec ted c erv ic al s pine ins tab ility. Ultrasound s canning c an be used to i dentify bl ood v essels and the co rrec t lev el (269,292 ,293,294,295,296). If the p ati en t is intubated, the trac hea l tu be should be wi thdrawn to a poi nt abov e the in ten ded s i te of the tracheos tomy. A bou gie or airway ex change catheter may be i nserted through the tracheal tube to fac ili tate reintu bation if the trac heal tube is disl odg ed (291,297). A short, s ha ll ow sk in incis ion is made ov er the trachea, betwe en the fi rs t and fo urth ca rtilages (259,298). If the s i tuatio n is urgent, the c ric o th yroid membrane may be punc tured (202 ). A l arg e gauge needle is then i ntroduced i nto the trac heal lumen between two ri ngs (Fig. 21 .18 ). P osi tion wi thin the trache a is c onfi rmed by as piration of ai r, d irec t b ronchoscop ic v isual iza ti on (p referre d), o r capnograph y (299,300 ). Local anes the tic can be inj ec ted in to the lu men of the trac hea. A guide i s introduc ed throug h the needl e into the trache a, and the needl e is then remov ed.

Figure 21.18 After the front of the trachea has been exposed, the needle with syringe attached is inserted into the trachea. Entry into the trachea is confirmed by the appearance of air bubbles on aspiration. A guide wire is then inserted through the needle, and the small dilator is inserted.

View Figure

Diff erent tec hniques are used to dilate the o pening in the an te ri or trac heal wall ov er th e guide (301,302,303 ,304). The fi rs t employs p rog res siv el y la rge r tap ered di lato rs (F ig . 21.19) o r one large tape red o r sc rewl ik e d il ator (Fig . 21.20) i ntroduc ed ov er the guide (305,306,307 ,308,309,310 ,311,3 12,313,314). S ome di lato rs hav e a h ydrophi l ic c oating that helps to en la rge the entra nce si te . A nother tec hnique uses a di lating forc eps (315,316 ,3 17). This tec hnique is fas te r and may be P .676 as soc iated wi th fewer c ompl ic ati ons than s equential d ilatation tech ni que (318,319). K i ts c ontaining the necess ary i tems for each method are av ailabl e (254,309 ,320,321,322).

Figure 21.19 Progressively larger dilators can be used to enlarge the hole.

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Figure 21.20 A large dilator is passed over the guiding catheter, which was passed over the guide wire.

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The lubricated tracheos tomy tube is i ns erted ov er the dilatin g dev ice or guide, whi c h is then remov ed (3 23) (Fig . 21.21). Special trac heal c ann ulas with obl iq uely cu t tips that f aci l itate ins erti on hav e been dev eloped (259). Capnograph y s hould be us ed to co nfi rm c o rrec t p lac ement (286,3 24).

Contraindications
Relativ e contra indic ations to percutaneous trac heos -tomy i nclude infec tio n a t the s i te, inabi l ity to ex tend the neck , anatomical features in terfering wi th identification of anatomic l andmark s , tracheomalacia, and s ev ere c oagulopathies . Its use in

ch il dren is controv ers ia l (259,325,326 ,327). Howev e r, perc uta neous dilatational trac heos tomy h as been pe rformed in al l of these subg roups (255).

Advantages and Disadvantages

A major adv antage of p erc utaneous tracheos tomy is the abil ity to p erf orm the tec hnique at the beds id e. This av oids delays , risks , and logis tic al probl ems of transfe r to the ope rating room. Compared wi th a s urgical trache os tomy, i t is less ex pens iv e, fas ter, easi er, and as soc iated wi th less blood los s and is les s l ikel y to resul t i n cosme tic deformi ty, infec tio n, or bac teri al c ontami nation of neighbori ng s truc tures (255 ,259,278,328 ,329,3 30,331,33 2,333,334,335,336,337,338 ). S hortterm c omp licati on rates are less than for operativ e tracheos tomy (316,329 ,331,334,339,340,341,342,343 ,344). It c an be perfo rmed in mos t pa tients who ca nnot unde rgo neck ex tens ion (345 ,346) an d in morbid ly obese pati ents (306,347 ,348,349,350).

Complications
S tudi es i ndicate tha t there is a lea rning cu rv e f or pe rc utaneous d ilatational trac heos tomy (351 ). Th e c ompl ic ation rate ma y be higher i n obes e patien ts (350). The use of ul tras ound sh ould reduc e the number of se ri ous complica tions (295,296 ).

Incorrect Placement
Some s tudi es s how th at a si gnificant numb er of tubes h av e be en placed in an i mproper loca ti on, usual l y higher in the airway than in tended (352,353 ). A tube may end u p mov ing c ephalad rather than c auda lly (3 54).

Figure 21.21 The tracheostomy tube is loaded over a small dilator, which is in turn loaded over a guiding catheter, which is then loaded onto a guide wire. After insertion into the trachea, the dilator, guiding catheter, and guide wire are removed.
View Figure

P .677

Trauma
Trauma resul ting f rom percu taneous tracheos tomy can inc lude formation of a fals e passage e ither anteri or to or bes id e the trac hea, injury to the pos teri or trac heal wal l or tracheal c a rtilages , he mato ma, hemo rrhage , esophag eal pe rforation, subc utane ous emph yse ma, medias tinal e mphys ema, pneumothorax , hemothorax , trac heoesophageal fis tula, an d tracheoinnominate fis tula hav e al l be en reported (286,287 ,302,303,310,322,333,334,353 ,355,356,357 ,358,359,360 ,361,362,363,36 4, 365,3 66,367,368 ,369,370,371 ,37 2,373,374,375,3 76,377,37 8,379,380,381 ,38 2).

Tracheal Tube Damage

Trac heal tube damage, inc lud ing punc turing the cuff , transfix ing the tube, and i nserting the guide wi re through the Mu rph y eye, ma y occu r durin g perc utaneous trac heos tomy (301 ,38 3,384,385,386,387). Damage to the e ndos cope may also oc cur.

Tracheal Stenosis
The inc ide nce of trachea l s tenosis as a l ong -term co mplica ti on v ari es from les s than 1% to 10% (259,286,32 5,329,339,342 ,388,389,390 ,39 1). Thicken in g of the l ate ral tracheal wa ll has been repo rted (392).

Hypoventilation

Hypov enti lation c an occu r when the tracheal l umen is obs truc ted from ex ternal press ure , a dilator, or the endosco pe (255,288). The tidal v olume an d/or respi ra tory rate ca n be inc reas ed to c ompe nsate for the leak c rea ted by the hole in the trac hea.

Foreign Body in Trachea

Cas es hav e been reported of a frac ture d gui de wire and the di lator lodged in the trac hea foll owi ng pe rcu taneous dilatati onal trac heos tomy (393 ,39 4,395). A c ase has been reported wh ere the bl ade of the forc eps broke awa y and entered the trac hea (396).

Other Complications
Other co mplic a ti ons repo rted with percutane ous trac heos tomy incl ude inadv ertent ex tubation , persis tent s toma, cel lu li tis , bac teremia, a cha nge in v oice, ai rway obs truc tion, d ysph agi a, ongoing s ev ere c ough , and sk in teth ering (301,321 ,342,388,397,398,399,400). Dama ge to the endoscope ma y occu r (4 01).

Translaryngeal Tracheostomy
This techn ique is un like others in this c hapter i n th at the tracheal c annula is i nserted from i ns ide the trac heal lumen to th e outs ide (402 ,4 03). A k it based on this tec hnique is av ai lab le . It may be adv antageous in patients who hav e s erious hypoxemia and in those who are cons idered d ifficu lt to in tubate o r who hav e ce rv ica l spine injuri es (177).

TABLE 21.1 Equipment for Difficult Airway Cart

Fiberscope Fiberoptic light source Video head VCR Defogging solution Swivel fiberoptic adaptors Local anesthetic spray Endoscopic mask Fiberoptic intubating airways (e.g., Ovassapian, Patil-Syracuse, Williams, Berman) Fiberoptic stylet laryngoscope Lighted intubation stylet Rigid indirect laryngoscope (e.g., Bullard, WuScope, Upsher Scope) Bougies

Flexible suction catheters Yankauer suction catheter Supraglottic devices (LMAs, etc.) and tracheal tubes suitable for insertion through the supraglottic device Cricothyrotomy device and device for jet ventilation Combitubes Retrograde intubation kit Percutaneous dilatational tracheostomy kit Binasal airway Magill forceps Water-soluble jelly and ointment Airway exchange catheters Difficult airway algorithm Elevation pillow (Fig. 18.47) Variety of face masks Variety of rigid laryngoscope blades and handles Nasal and oral airways Tracheal tubes Stylets

Under bronc hosc opic guidanc e, a guide wi re is pass ed v ia a perc utaneous need le i n the trac hea (pass ed retrograde into the mouth). The guide wi re i s attac hed to a spec ial ly des igned cone that is bonded to a tracheos tomy tube. The conal di lato r/tracheostomy tube is threaded ov er the guide wi re an d pul led through the oral c av i ty , la rynx , and trachea a nd out through the anterio r tracheal wal l . The cone i s the n detached f ro m the tracheos tomy tube, whic h is rota ted f rom a cephal ad to a caudal direction by us ing an ob turator, th en adv anced c audall y to i ts f inal position. Durin g the procedure, the patient is v enti lated v ia a thin trac heal tube, the end of whi c h is posi tioned dis tal to the trac heos tomy s ite. Th e tracheal tube is remov ed af te r or jus t befo re the tracheos tomy tube is rotated and sec ured (404,4 05). P .678

The mod if ied Fanc oni tech ni que inv olv es the us e of a fiberscope, ins e rtion of a J shaped wi re , and the use of a s ma ll -d ia mete r tracheal tube posi ti oned c oaxi al l y to the ori gi nal airway to v entilate th e patien t during introduc ti on of the trach eos tomy tube (177).

This techn ique can be perf ormed at the beds ide. B ecause di la tion is achi ev ed by the tracheal c annu la i tse lf , the can nula f i ts smugly wi th the trac heos tomy wo und edges . It has been us ed in pa tients wi th sev ere resp iratory failu re and coagulopa thy (177 ,406). This techn ique is techn ic ally more complicated than percutaneo us trac heos tomy . It requi res three peo pl e to perfo rm properly, one of wh om is c oncerned s olel y wi th mai ntaining the ai rway and the patient's v en ti lation. Complic ati ons inc lude bleeding, barotrauma, trauma, and misplac ement o f the trac heos tomy tub e (332,403 ,405,407,408). A s tudy comparing this tec hni que wi th forceps di latati onal percu taneous tracheos tomy found a h igher c ompl ic ation rate and mo re techn ic al diff icul ti es wi th the trans la ryngeal tec hnique (403). It takes longe r than a percu taneous tracheos tomy.

Difficult Airway Cart

A cart con ta ining equipment that is us eful when a difficul t ai rwa y is encoun tered shoul d be immed iately av ailabl e in ev ery l oc ation whe re anes thesi a is adminis tered. It is important that e ach ca rt be nearly i dentical ac ross all locations so that wh en faced wi th an emergenc y, the us er i s fami li ar with the loca tion and operati on of all the equ ipment. The equipme nt on this c art shou ld f it the sk il ls and prefere nces of the a nes thes ia prov ide r. The lis t in Table 20-1 is giv en only as an ex ample a nd should not be consi dered exh aus tiv e.

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386. Mpha nza T, J acobs S , Chav ez M. A potential c ompl ication associated with percu taneous tracheos tomy with an endo tracheal tube wi th a Murphy eye in si tu . Anes thes iology 1998;88:1418. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 387. Day C, Ra nki n N. Lac era tion of the cuff of an endo trac heal tube during percu taneous dil ational trac heos tomy. Chest 1994;105:644 . [Med li ne Link ] 388. Esc arme nt J , S uppini A , Sal lab erry M, et al. Pe rc utaneous tracheos tomy by forc eps di lation: report of 162 c as es . Anaesthesia 200 0;55:125130. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 389. Mc Fa rl ane C, Denholm S W , S udlow CLM, et a l. Lary ngotracheal s tenos is : a se ri ous complica tion of p erc utaneous trache os tomy. A naes thesi a 1994;49:3840. [Cross Ref] [Med li ne Link ] 390. W al z MK , Pei tgen K , Thurauf N, et al . Pe rcu taneous dilatational trac heos tomy earl y resul ts a nd long-term o utc ome of 326 c ri tica ll y ill patients . Intens iv e Care Med 1998 ;24 :68569 0.

[Cross Ref] [Med li ne Link ] 391. Koi ts chev A , Graumuelle r S , Zenner H-P , et a l. T rac heal s tenos is and obligeration abov e the tracheos toma af te r percutaneous di la tiona l trac heos tomy . Crit Ca re Med 2003;31:15741576. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 392. Mazz on D. Late modifica ti on of trachea l wal l af te r percutaneous trac heos tomy : a like ly ha zard due to a pa ramed ia n access. J Neu ros urg A nes th 1997 ;9:287 . 393. Kumar BN, W als h RM, Courtn ey-Harris R G. Laryngeal fore ign body: an unusua l complication of percu taneous tracheos tomy. J Laryn gol Otol 19 97;111:652 653. [Med li ne Link ] 394. P inder M, Cameron P , Lov egrov e A . Trach eal foreign body f ol lo win g tube change du ring percutaneous di lati onal trac heos tomy : a cautionary tale. Anaes th Intens Care 2000;28:44344 5. [Med li ne Link ] 395. Phukan DK , A ndrz ejo wski J . Perc utan eous trac heos to my: a gui de wi re co mplica tion. B r J A naes th 20 04;92:891893. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 396. Baines D, S is er J . Fa il ure of percutaneous trac heos to my forc eps . Anaes thes ia 2004;59:628. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 397. W hi ttet HB , Commins DJ , W aldmann CS . Sk in tethering af ter dila ti ona l percu taneous tracheos tomy. Anaes thes ia 19 95;50:892894. [Cross Ref] [Med li ne Link ] 398. Teo h N, Parr MJ A , Finf er S R. B ac teraemia following pe rc utaneous d ilational trac heos tomy . A naes th Intens Care 199 7;25:3 54357. [Med li ne Link ]

399. Ri gg CD, E dmondson L . Percutaneo us di la tional trach eos tomy. Malp osi tion l eading to delayed we aning. A naes thesia 1995;50:724 725 . [Cross Ref] [Med li ne Link ] 400. Sv i ri S , Samie R, Robe rts BL, et al. Long-term outcomes fol lowi ng percu taneous tracheos tomy us ing the Gri ggs technique. Anaes th Intens Ca re 2003;31:401407. [Med li ne Link ] 401. Jus te RN, Dakin M, S oni N. Perc utaneo us trac heos tomy: an expens iv e co mplica tion. A naes thes ia 1997;52:711712. [Fu ll tex t Link ] [Med li ne Link ] 402. Fan ton i A , Ri pamon ti D . A non-deriv ativ e, non-surgical tracheos tomy: the trans lary ngea l method. Intens iv e Ca re Med 1997;23:386392. [Cross Ref] [Med li ne Link ] 403. Cantais E , Kaise r E , Le-Goff Y, et al. Perc utaneous trac heos tomy: p ros pec tiv e co mpariso n of the trans laryngeal technique v ersus the forc eps -di la tional technique i n 1 00 c ritic ally i ll adul ts . Crit Ca re Med 200 2;30:815819. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 404. Mil lig an K R, Mc Co ll um J C. Trans laryng eal tracheos tomy in the high-ri sk pati ent. A naes thesi a 2000;55:1132. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 405. B yh ahn C, W ilke H-J , L isc hke V , e t al . Beds id e perc utaneo us trac heos tomy: c linic al c omparis on of Griggs and Fan ton i techni ques . W orld J S u rg 2001;25:296 301. [Cross Ref] [Med li ne Link ] 406. B yh ahn C, Lisc hke V , W es tphal K . Trans la ryngeal trach eos tomy in h ighly uns table p atien ts . A naes th esi a 2000;55 :676684.

407. Craske DA , Mo ll ick A , Nan dakumar CG. B ronc hosc opic conf i rmation of th e co rrec t plac ement of the tracheos tomy tube during transl aryngeal tracheos tomy. Anaes thes ia 2000;55:1035 1036. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 408. W es tpha l K , B yhahn C, W i lk e H-J , e t al . Percutaneous trac heos tomy : a c linica l co mpariso n of di la tati onal (Ciagl ia) and tra ns laryngeal (F antoni ) techniques . A nes th Analg 19 99;89:938943. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] P .684

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. Which statements concerning Combitube place me nt are true? A . Th e pharyng eal balloo n s hould be inflated fi rs t B . Th e use of a lary ngoscope may lowe r th e n umber of compl ications C. The tip of the tub e usual l y ends up in the tra chea D. The es ophagea l detec tor dev ice is usef ul i n v eri fying tube pos ition V iew A ns we r2. Contraindications to using a Co mb itube in clude A . Inges tion of corros iv e agents B . K nown eso phageal trauma C. Ac tiv e pha ryngeal and laryngea l reflexes D. Pa tients younger than 12 years o f age V iew A ns we r3. Advantages o f the Combitube inc lud e A . It can b e used by no n-anes thesia pers onnel

B . Neck mov eme nt is not neces sary C. The p haryngeal ba lloon a ncho rs i t in plac e D. There is no danger of b ronchial intuba tion V iew A ns we r4. Disa dvantages o f the Comb itube inclu de A . Fibe rop tic bronc hoscopy is no t pos si ble B . It is not us eful for patients with latex all erg y C. There is higher s tress resp onse than that f ro m a trac heal tube duri ng insertion or remov al D. The p res enc e of bl ood or v omitus i n the pharynx precludes i ts use V iew A ns we r5. S ituations that lend themselves to retrog rade intubation include A . Orophary ngea l bl eeding B . Infant and chi ld intubation C. Limi ted neck mobil ity D. P retrac heal absc ess V iew A ns we r6. Conditions w here cricothyroto my may be indicated include A . Ce rv ica l spine i nj ury B . S u rge ry inv olv ing the uppe r ai rway C. Diff icul t intu bation D. Fo rei gn bo dy aspi rati on V iew A ns we r7. Contraindications to cricothyroto my include A . Co mple te ai rway obs truc tion a bov e the cric oth yro id membrane in the larynx B . Dec reased c ompl iance C. La ry ngeal infl ammation o r infec tion D. Obs truc ti ons below the thy roid cartilage V iew A ns we r8. Complications of crico thy rotomy inc lude A . K ink ed catheter B . Trac heal s toma s tenos is C. Subc utaneous or medias tina l emph ysema D. Es ophageal perforation V iew A ns we r9. Barotra uma can be red uced by w hich mecha nis ms ? A . Limi ting inspi rato ry time B . Us ing a irway maneuv ers s uc h as sniff p os i ti on and jaw thru s t C. W atc hing ches t mov ements D. Limi ting the peak press ure to a max imum o f 35 psi in adu lts

V iew A ns we r10 . Relative con train dications to p ercu taneous tracheostomy include A . S ev ere coag ulopathi es B . Infec tion a t th e site C. Trach eomal ac ia D. Inabil ity to ex tend the neck V iew A ns we r11 . Advan tages of percutaneo us tracheo sto my include A . Fas ter than surgical tracheos tomy B . Can be perf ormed on pati ents who cannot ex tend thei r necks C. Lo wer i nci dence of infec tion D. Fe wer co mp lica ti ons than su rgic al trach eos tomy V iew A ns we r12 . Complica tions of pe rcutane ous tracheostomy include A . P neumothorax B . Trac heal tube damage C. A i rway obs truc tion D. Trach eal s tenosis in u p to 15% of pa tients V iew A ns we r

Chapter 22 Gas Monitoring

P .686

Reliabl e, affo rdable, and user-f riend ly monitors to measu re respi ra tory and anes thetic gas conc entra tions are now av a ilabl e. So me use more than one tec hnology to measure different gas es . S ome c ombine gas a nalys is wi th other types of monitoring s uch as e lec troca rdiograph , blood press ure , pulse ox imetry , or sp irometry (Fig . 22.1).

Definitions

Delay time (trans i t time , res ponse time, transpo rt de la y, time delay , lag ti me) i s the time to achiev e 1 0% of a s tep c hange in readi ng at the gas monitor. Rise ti me (resp onse time ) is the time requi red for a change f rom 10% to 90% of the tota l cha nge in a gas v alue wi th a cha nge in c oncentration at th e sa mpling si te.

Total s ys tem res ponse ti me is the sum of the delay an d ris e times . A fas t respons e time is nec es sary to ob tain acc ura te v alues and wav efo rms . The us e of an ins trument wi th a sl ow res pons e ma y res ul t in inc o rrec t e nd-tidal v alues during rapid v enti la tion (1 ).

The s enso r (measuring h ead or c hamber) is the pa rt o f a res piratory gas moni tor that is sens itiv e to the gas be in g me asured. P .687

View Figure

Figure 22.1 Multipurpose monitor. Most gas monitors are now part of a physiologic monitor that includes other monitoring such as electrocardiograph, blood pressure, pulse oximetry, and the like. A gas monitor may also be part of the anesthesia machine. Newer anesthesia machines have one or more screens to display monitored functions, and the gas concentrations and waveforms may also be displayed.

A nond iv erti ng (mains tream, di rec t probe , flow thro ugh, in-line , on ai rway , nonsampl ing moni to r) mon itor measures the g as concentration at the sa mpling si te.

A diverti ng (s ides tream, wi thd rawa l, s ampl in g, as pirating, sn iffe r, s ampled s ys tem mon itor) trans ports a portion of the gas being meas u red f rom the sa mpling si te through a s ampling tube to the s ensor, whi ch is remo te f rom the sampl ing si te.

The s ampl ing s ite (sens ing s i te) is the locati on from whic h gas is d iv erted for meas urement in a div erting moni to r or the locatio n of the s ens or in a nondiv erti ng moni tor.

The s ampl ing tube (inlet li ne, sample gas transport tube, sampl e capi lla ry tube, s ampling catheter or tube , trans port tu be, aspi rating tube, s ample l ine) i s the c ondui t f or transferring gas from th e s ampl in g s ite to the sensor in a div erting gas moni tor.

Gas leve l is the c oncen tration of a gas in a gas eous mix ture. It may be ex pressed ei ther as p artial press ure or v olumes pe rcent. The partial press ure of a g as is the pressu re that a gas in a gas mix ture wou ld ex ert if i t alone oc cupied the v olume of the mix tu re at the same temperature .

The v olu mes percen t (%, V /V , v ol %) of a gas is th e v ol ume of a gas in a mix tu re, express ed as a perc en tage of the total v ol ume.

Monitor Types
The re are two general types of moni tors in c linical use: d iv erting (s ides tream) o r nondiv erti ng (ma ins tream) (2,3). Thes e refer to the measurement s ite of the gases and n ot to the tec hnology being us ed. B o th can be integrated in to a s ingle modul e.

Nondiverting
A nond iv erti ng gas moni tor meas ures the gas by usi ng a sensor loc a ted direc tly i n the gas s tream. Onl y ox ygen and c arbon diox ide (CO 2 ) can be meas ured by nondiv erti ng moni tors . Carbon di ox ide is meas ured b y inf ra red tech nology wi th the s ensor l oca ted betwe en the breathing s ys tem and the patient (F igs . 22.2, 2 2.3 ). A nondiv erti ng moni tor is av ailab le for the non-in tub ated patient, in which the sens or attaches to a disposable oral an d nasa l adap tor. The mains tream oxy gen s ensor uses elec troche mic al techno lo gy. It is usua ll y place d in the breath in g s ys tem ins pi ratory limb. If the tec hnolog y is fas t enough to meas ure b oth insp ired and ex hal ed ox ygen, it s houl d be pl aced b etween the patien t and the breathing s ys tem. Chapter 9 disc usses poss ib le locations of the ox ygen moni tor sensor i n th e c ircl e breathin g s ys tem.

Advantages

Mai ns tre am CO 2 moni tors hav e f as t res pons e ti mes bec ause there is no delay time . The CO 2 wav ef orm generated has better f idel ity than one generate d b y a div erting moni tor.

Bec ause n o gas is remov ed from the breathi ng s ys tem, it is not necessary to sc av enge th ese dev ic es or to inc rease the fresh gas flo w to compensa te fo r gas remov ed from the breathing s ystem.

W ater and s ec retions a re se ldo m a problem with th is type of a nalyze r, al th ough s ec retions on the wi ndo ws of the cuv e tte used for mains tream CO 2 moni tori ng can c aus e e rroneous readings . Wa ter and s ec retions P .688

are gene ral ly not a problem with ox ygen sensors , as they are usu all y on the i nspi rato ry s ide of the breathi ng s ys tem.

View Figure

Figure 22.2 Nondiverting gas monitor. A: The sensor is in position over the cuvette, which is placed between the patient and the breathing system. The two clear tubings to the left are for spirometry loops (Chapter 23). B: The sensor is separated from the cuvette, which contains the window through which the infrared light passes. C: Calibration cells. For convenience, they are attached to the cable to the sensor. During calibration, the sensor is placed over each cell in sequence.

Samp le co ntamina ti on by f res h gas is l es s l ikel y than with a div erti ng moni tor. A s tanda rd gas is not required fo r c al ibra tion. Ox ygen s enso rs are usua ll y ca li brated by usi ng room a ir. These moni to rs us e fewe r dispos able items th an div erti ng moni tors .

Disadvantages

To obtain acc ura te en d-tidal CO 2 v alues , the ai rwa y adap tor must be plac ed near the patien t. T he sens or wi ll add weight to the b rea th ing s ys tem a nd may caus e trac tion on the airway dev ice or breathing tubes .

The use of an adaptor between the patient a nd the b rea thing s ystem wi l l i nc reas e d ead space. Ho wev e r, s tud ies s how th at end -tidal CO 2 v alues obtained by us ing a ma ins tream analy zer wi th a pe dia tric a dapter in heal thy neonates and i nfants are c los e to arteri al va lu es (4).

Leaks , dis connec tions , and ci rc uit obs truc tions can oc cur (5,6 ,7 ,8). W ith a mains tream CO 2 monitor, c ond ensed wate r, s ec retions , or b lo od on the win dows of the cuv ette wi ll interfe re wi th l ight transmis sion. W ith a mains tream CO 2 monitor, the s enso r may bec ome dis lodged f rom the cuv ette. If i t is compl etely dis lo dged , no wav efo rm wil l be seen. If i t is

s lightly dis lodged (F ig. 22.4), the readi ng may be inco rrec t although the wav efo rm wil l appear norma l (9 ,10 ,11).

The expens iv e optic al se nsor for CO 2 is v ulne rable to cos tl y damage . A t pres ent, mains tream mon itors c an meas ure on ly ox ygen a nd CO 2 . The adaptor for the CO 2 sensor mus t be cl eaned and dis infec ted between us es . Th ere is potenti al f or c ross contaminati on be twee n patien ts if th is is not done prope rl y. Disp osab le adaptors are av ailable but inc rease the c os t.

The rmal burns hav e been re ported wi th a mains tream CO 2 anal yzer des pi te us e of mul tiple lay ers of gauz e, which k ept the sensor f rom di rec t co ntac t wi th the sk in (12). T o p rev ent this , i t may be neces sary to in te rpos e a piece of aluminu m foi l between two pieces of sof t materi al to refl ec t the radi ant energy. P .689

Figure 22.3 Mainstream infrared analyzer. A: Side view. The light source and detector are housed in the sensor, which fits over the cuvette. The infrared light shines through the windows of the cuvette and is detected by the photosensor. B: Cross-sectional view. Gases pass through the airway adaptor (cuvette). The infrared light that is transmitted through the windows is filtered and then detected by the photodetector in the sensor.
View Figure

P rolonged c ontac t of the CO 2 sens or ass embl y with the patien t c ou ld caus e press ure injury .

Diverting

A div erting moni tor uses a pump to as pirate gas from th e s ampl in g s ite th rough a sa mpling tubing to the sensor that is located in the main uni t. Keepi ng the sampling tube as sh ort as poss ib le wi ll dec reas e the delay ti me a nd res ul t in more sa tisfac tory wav eforms . These ana lyzers a re us ually zeroed us ing ro om a ir and ca li brated using a gas of k nown c omp osi tion . A ma ins tream moni to r wi th div erting capabil ity is shown in Fi gu re 22.5. Gas is as pirated th rough a spec ia l cuv ette and is analy zed by the sensor. To av oid wa ter o r particu late con tamination in the moni to r, a number of dev ices hav e been us ed. These inc lude traps (Fig. 22.6) (wh ic h must be emp tied periodicall y), fi lters and hyd rophobic membranes (whi ch mus t be c hanged periodicall y), and spec ial tubi ng (wh ic h allows water to diffuse through i ts wal ls ) (13,14). W ater droplets and sec reti ons f rom the b rea thing s ys tem c an enter the samp li ng tube and inc reas e res is tance in the tu bing, af fec ting the ac curac y. Some i ns trume nts e ither i nc rease the s ampl in g f low or, to c lear the con ta minant f rom th e tube, rev ers e the flow (purge) whe n the y sens e a drop in pressure from a f low res tric tion (15). If this fails , the s ampl ing port a nd/or the tube mus t be replaced. P .690

Figure 22.4 Mainstream infrared CO2 analyzer with the sensor not completely covering the windows of the cuvette. This can result in falsely low CO2 readings.

View Figure

Acc urac y dec reases wi th i nc reas ing res piratory rate and longer s ampl ing lines (16). Mos t div erting capnometers are ac curate a t th ose respi ra tory ra tes that a re

normal ly e ncounte red in c lin ica l prac tic e (20 to 40 breaths per minute). A t higher respi ra tory ra tes , acc uracy is lowe r. The s ampl ing f low rate shou ld be propo rtional to the s ize of the patien t. It has been recommen ded that a flow rate l ess than 150 mL /minute should no t be used b ecause a lo w s ampl in g f low ma y res ult in an elev ate d basel ine, e rroneous l y lo w peak readings , and absenc e of an end-tidal plateau (Fig . 22.36), es peci al l y when the respi ra to ry ra te is fas t and tidal v olume is smal l (17). A high f low rate wil l dec rease the delay and ris e ti mes but may c aus e f resh gas to be entrai ned into the s ample l ine wi th s ome breathin g s ys tems . This wil l resul t i n incorrec t end-tida l readings and a ca pnog ram wi th a dec rease in CO 2 a t the end of the ex pi rato ry plateau (Fig . 22.37 ).

Figure 22.5 Mainstream infrared CO2 analyzer used as a diverting monitor. Gas is drawn through the cuvette by a pump.

View Figure

Devices Face Mask

A face mask has a relativ ely large dead space rela tiv e to ti dal v olume, mak ing i t more diffic ult to obtain acc urate end -tidal va lues. Figure 22.7 s hows a mas k with a sa mpling lin e for CO 2 . A sampling catheter can als o be attac hed to the upper l ip or place d in the patie nt's nares or the lumen of an o ral or nas opha ryngeal ai rway under the mask (18). W i th a b rea thing sys tem, the s ampl ing tube is mos t often attached to a c omponent betwe en th e mask and the breathin g s ystem (Fig. 22.8 ), o r the P .691

sa mpling tube may be inserted throug h the rig ht-ang le co nnec tor tha t attac hes to the mask (19,20).

Figure 22.6 Water trap. This should be emptied periodically to prevent water from entering the monitor.

View Figure

Figure 22.7 Face mask with lines for oxygen administration and gas sampling.

View Figure

Tracheal Tube
To meas ure b oth insp ired and ex hal ed gas es , the sampling si te mus t be be tween the patie nt and the breathing sys tem. Mos t disposable breathi ng s ys tems a nd heat and mois ture exchange rs (HMEs ) hav e bui lt-in s amp le po rts (Fi g. 2 2.8 ).

The s ampl ing s ite shou ld be away from the f res h gas port. W hen a Ma pl eson breathi ng s ys tem is us ed , con ti nuous inf low of fres h gas that is c lose to the sa mpling si te c an cause erroneous readings a nd an abno rmal wav eform (Fig. 22.37 ). Trac heal tubes that inc orporate a sampling l umen that ex te nds to the middle o r pati ent e nd of the tube are av ailab le (Chapter 19). Trac heal tube connec tors wi th an attac hmen t or ho le f or a sampling tube are av ai lable o r can be c reated (21). These may resul t in measuremen ts that more c losel y app rox ima te alv eolar v alues , es pecial l y i n smal l pa tients and wi th breathing sys tems in whic h the fres h gas f low can mix wi th exhaled gases (22 ,23 ,24 ,25,2 6).

Figure 22.8 Ports for gas sampling in breathing system components.

View Figure

Supraglottic Device
W ith a supraglottic ai rwa y dev ice , a sampling tube c an be inserted through the connec tor (27,28 ). Th e p referre d s ampl in g s ite is the dis tal end of th e s haf t (29,30), but in mos t patie nts , samp ling at the connec tion to the breathing sys tem wi ll res ult i n s atis fac tory re adings (31,32,33,34,35). A sampli ng tu bing ma y be inserted i nto a nasal airway (36,37,38).

Oxygen Supplementation Devices

A relativ ely new dev ice , the Ox yA rm, al lo ws s imu ltaneous adminis tration of ox ygen and c arbon dioxi de moni to ri ng (39,4 0). It c ons is ts of a headse t th at trav ers es ac ros s the top of the hea d, ox ygen suppl y and CO 2 s ampling l ines attac hed to an adjus table boom and a dis pos abl e arm diffuso r. It can be used to adminis ter ox yg en

and mon itor CO 2 in both nos e and mouth b rea the rs . A n asal c ann ula c an be modified to acc ept a sampling tubing (39,40,41,42,43,44,45,46,47,48 ,49 ,50 ,51,52,5 3,54,55,56,57,58,59,60,61,62,63,64 ,6 5,66,67). They are av ai lab le in sev e ral confi gurations (Fi gs. 22.9, 22.10 ). Mou th breathi ng, airway obs truc ti on, and ox yg en del iv ery through the ips ila teral nasal cannula can affec t ac curac y (68). Caution should be observ ed in adap ti ng a nas al cannula; a piec e ma y become dis lodged and pres ent a c hoki ng haz ard (69). A plas tic ox ygen mask may be fi tted wi th a sa mpl ing po rt (39,70) (Fi g. 22 .7). A l te rna tiv el y, the sampling tube may be connec ted to the mask outle t (71), i ns erted through a v ent hol e (42 ,57 ,72 ,73,7 4,75,76) or a s li t i n the mask (77), or s lipped under the mask and a ttached near the nos tri ls (37,78,79,80).

Jet Ventilation
Durin g jet v enti lation, an injec tor i nco rpo rati ng a sampl ing lume n (81,82 ,83 ,84 ) or a sa mpling tube place d i n the air way (85,86) may be used. The v en tila tory frequency may need to be lowered to measure the end-ti dal CO 2 (83,87,88).

Other
The end of a sampli ng li ne can be placed in front of or i nsi de the patien t's nos tril (89,90) or a nasopharynge al ai rway (91 ). If the patie nt is a mou th breather, the sa mple line can be place d in front of the mouth o r in the nas opha rynx (89 ,92 ) or hypoph arynx (93,94). A ca th ete r can be plac ed in the trach ea after ex tubation for CO 2 monitoring (95). A bite bl ock ca n be mo dified to ac commodate a sa mpling lin e (96). A s ampling li ne can be plac ed ov er a tracheos tomy s toma (97 ). Optimal pl acement shoul d be determined b y the CO 2 wav eform. Mucosa l i rritation , ca the ter blockage, an d mec han ic al i nterference s ometimes c ause probl ems . P .692

Figure 22.9 Devices for simultaneous administration of oxygen and gas sampling. A: This device is designed for patients who are predominantly mouth breathers. The longer oral sampling prongs can be cut and shaped to suit individual patients. (Courtesy of Biochem International, Inc.) B: One prong is used for administration of oxygen and one for gas sampling. There is a septum between the two prongs. C: With this device, the two prongs are divided so that oxygen is delivered and gas is sampled through each prong.

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Advantages

Calibra tion and ze roi ng are us uall y automati c . Occ asiona l cali bra tion is necess ary b ut is usua lly eas il y acc omplis hed. The added de ad spac e is mi nima l. The pote nti al for c ros s contamination between patients is low. Depending on the techno log y bei ng use d, sev eral gas es can b e me asured s imul ta neous ly . This al lo ws automatic co rrec tion for nitrous oxi de an d/o r ox ygen .

The s ampl ing p ort c an be used to adminis ter bronc hodi lato rs (98) (Chapter 7). These dev ic es can be us ed when the moni to r mus t be remote from the pati ent (e.g., during magnetic reso nanc e imaging [MRI]) (99,100).

P .693

Figure 22.10 This device is used for CO2 sampling in nonintubated patients who are either exhaling by mouth or nose.

View Figure

Disadvantages

P roblems wi th the sampling s ys tem (l eak s , s ampl ing tube obs truc tion, o r failure of the aspi rato r pump) can occ ur. Parti culate ma tter, blood, sec re tions , or water c an obs truc t the tubing (102). The s ampl ing line c an be connec ted to the wrong plac e (103 ,10 4). If there is a leak i n the s ample l ine, ai r wi ll be added to th e s ampl e. This wi ll dilute the s ample and re duce the v alues of end -tid al CO 2 and anes the tic agen ts (105,106 ,107) (Fig . 22.29). The s ampl ing tube c an ki nk , bu t this c an be prev ented by us ing a n e lbow connec tor near the attachmen t to the patient end (108 ).

The aspi rated gases mus t be ei the r rou ted to the s cav engi ng s ys tem or retu rne d to the b rea thi ng s ys tem. If scav eng ing is employe d, the fresh gas f low may need to be i nc reas ed to compens ate for the gas remov ed o r negativ e p res sure wil l be c reated in the breathi ng s ys tem (109).

In s ome div erting moni tors , roo m ai r us ed in the cal ibra tion process is ad ded to the gas ex i ti ng th e moni tor. If th is ai r is returned to the breathing s ys tem, i t wi ll c rea te problems duri ng c losed c irc ui t anes thes ia.

Some delay ti me is unav oidab le. A supply of cal ib rati on gas mus t be av ailable. A numbe r of disposable i tems (adapto rs and c athete rs ) mus t be used. The re may be deformation o f the wav ef orm and e rroneo usl y lo w CO 2 readings f ro m the fresh gas dilution (Fig. 22.3 7).

Compa red wi th ma ins tream moni to ring, s ides tream measurements produc e more v ariab le differenc es between arterial a nd end-tidal CO 2 lev els (110).

Technology
The re are a number of di fferent technologi es av ailable to measure res pi ratory and anes thetic gases .

Infrared Analysis
Infrared anal ys is is by fa r the mos t common tec hnology in use today (3,111,11 2).

Technology
Infrared (IR) ana ly zers are based on the pri nc iple that gases wi th two or more diss imi la r atoms in the molec ul e (ni trous oxi de, CO 2 , and the hal ogenated age nts ) hav e spec ific and unique i nf rared l igh t abs orp ti on spec tra. Since the amount of i nfrared li gh t abso rbed is propo rtio nal to the c oncentration of th e abs orbing mol ecules , the c onc entra tion can be de te rmi ned by comparing the infrared light absorbanc e in the sample with that of a k nown s tanda rd. The non polar molecu les of argon, ni trogen , hel ium, xenon, an d ox ygen do not absorb infrared light and c annot be meas ured us ing th is technology. The re are two general types of inf rared technol ogy av ai lable toda y.

Blackbody Radiation Technology

The mos t commo nly us ed infrared tec hno log y uti l iz es a heated element cal led a black body emitte r as the s ource of inf rared l ight (113). This produc es a b roa d i nfrared spec trum. The ma jo ri ty of the emi tted radi ation is redundant and mus t be remov ed . Fi lters block radia tion that is outside the des i re d range. This method cannot remov e the radi ation that f al ls between disc rete abso rbing l ines because of the continuous emis s ion nature of the b lac kbody. The optical detec tors mus t be ca li brated to recogn ize only inf ra red radi atio n that is modula ted at a c ertain f requenc y by us ing a spinning choppe r wheel . The anal yzer s el ects the appropria te infrared wav e length , usi ng an i ndiv idua l fil ter or a f il ter whee l to max imi ze absorpti on by the sel ec ted gas at i ts peak wav e length and to minimize abs orp tion by other gases a nd v apo rs that c ould interfe re wi th meas urement of the desi red c omponent. Some older i nf rared units are equipped wi th a dial or s wi tch to selec t the an es thetic a gent being measu red , whi le others requi re a different f i lter an d s cal e to measure eac h ag ent. Mos t uni ts in use today can reco gni ze the agen ts that c an be moni to red wi th this tec hnology . Af ter the

sens or d etec ts the transmi tted infrared energy, an elec tric al s ignal is produc ed and amplified, and th e c onc entration is dis pla yed. Moni tors that identif y and quantif y halogenate d agents use a separate c hamber to meas ure a bsorption a t s ev eral wav e lengths . T ypical l y, these are s ingle-chan nel , four-wav el ength infrare d f ilter photomete rs . There is a f il te r fo r eac h anes thetic agent and one to prov ide a P .694 basel in e for c omparis on. Each fi l ter transmits a s pecif ic wav elength of i nf rared l ight, and eac h g as abs orbs d ifferen tl y in the s elec ted wav elength bands (114).

View Figure

Figure 22.11 Sidestream optical infrared analyzer. A beam of infrared light is at one end, and a photodetection device is at the other. The chopper wheel contains several filters, which are divided into sections that will allow passage of only the frequencies most readily absorbed by the gases to be measured. The filtered and pulsatile infrared light is directed through both the sample chamber and a reference chamber with no absorption qualities. The amount of infrared light absorbed at each frequency depends on the gas level in the sample chamber.

Mos t infrare d i ns truments hav e an accu rac y of 0.2% for CO 2 conc entra tions ov er the range of 0% to 10 % and 2.0 % for ni trous oxide conc entra tions f rom 0% to 100%. For typic al haloge nated agents , th e accu rac y is 0.4% ov er a range of 0% to 5% (11 5). Mos t inv estiga tors bel iev e that thes e monitors are s uffic iently ac curate for c linic al pu rposes (116,117 ,118), altho ugh they te nd to underestimate the i nspi red lev el and ov eres timate en d-tidal v al ues at h igh resp iratory rates .

Diverting
Fi gure 22.11 sho ws a div erting (s ide-s tre am) i nfrared anal yzer. Inf ra red l ight is continuous l y focus ed on a s pinning (c hopper) wheel . The wh eel h as holes wi th f il te rs sp eci al ly s elec ted for the gases to be measured. The gas to be measu red is pump ed con tinuous l y throug h a measuring c hambe r. Th e fi ltered and pu ls ed light is passed through the sampl e cha mber an d a ls o through a refe rence chamber wi th no

absorpti on charac teris tic s . The l ight is then foc used o n an infrared photosensor. The amo unt o f light abso rbed b y the s ampl e g as is proportio nal to the p artial press ures of gas es whos e inf ra red l ight absorption patterns c orrespond to the wav elengths selec ted b y the fil ters on the chopper wheel . The c hanging li ght lev els on the photos enso r produce c hanges in the elec tric al curre nt that runs thro ugh i t. Rotatin g the whe el thous ands of times per minu te prov ides hundreds of readin gs fo r each res pi ratory c ycl e. F or prac tical p urp oses , the wav eform on the display is continuous . Monochromatic s ides tream op tical inf ra red a nalyze rs use one wav elength to meas ure p otent inhalational agents and are unab le to dis ti ngu is h b etween age nts o r to detec t a mix tu re of agents (119). Wh en suc h an anal yz er is used, the cl inici an mus t selec t whic h agen t is to be moni to red . If an inc orrec t agen t is s elec ted, i ncorrec t v alues wil l be repo rted (120,121,122 ). P olychromatic i nf rared analy zers us e mu ltip le wav elengths to both iden tify and quan tify the v ari ous agents (123 ). This elimi na tes the need f or the us er to s elec t the agen t to be monitored and al lows a mix ture of agents to be de tec ted. Mos t si des tream anal yze rs hav e a fixed sampling f lo w rate, al th ough s ome permi t se lec tion of the flow rate . The measuring c ell is ca librated to ze ro by us ing gas tha t i s free of the gases of inte res t (us ual l y room ai r) and to a s tand ard lev el by us ing a ca li brati on gas mix ture.

Nondiverting
W ith a nond iv erting (mains tream) CO 2 monitor, the gas s trea m pas ses through a chamber (c uv ette) wi th t wo wi ndows that a re transparent to infrared li ght (Fig. 22.2). The c uv ette is pl aced betwe en the b rea thing s ys tem and the patient. The sens or, whi ch houses both the ligh t source and d etec tor, fi ts ov er the c uv ette. To prev ent water c ondensation, the sensor is heated s l ightly ab ov e bo dy tempera ture. Infrared light s hi nes through the win dow on one si de of the adaptor, and the s ens or receiv es the l ight on the oppos i te s ide. A fter pass ing th rough the s ample chamber, the light goes through three ports i n a rota ting wheel, whic h contains (a) a seal ed ce ll with a k nown high CO 2 c oncen tration ,(b) a cha mber v ented to the s ens or's i nte rna l atmosphere , and (c ) a sealed c el l con taining only ni trogen (Fig. 22 .2B ). The radiatio n then p asses through a f il ter that sc reens the light to th e c orrec t wav elength to isolate C O 2 information f rom i nte rfering gases an d onto a photo detec tor. The s igna l is amp lified and sent to the dis play module.

Calibra tion is performed by usi ng two seal ed c ells in a pl astic uni t that attaches to the control uni t (Fi g. 22.2C). It is shaped s o that the s enso r can c l ip ov er e ither ce ll . The low c al ibra tion cel l c ontains 100% ni trogen , whi le the hi gh cell c ontains a known parti al p res sure of P .695 CO 2 . Correc tions f or ni trous oxide and/or ox yge n mus t be en tered manuall y. The s enso r may bec ome dis lo dged f rom the cuv ette. If i t is c ompl ete ly dislodged, no wav eform wil l be s een. If i t is s li gh tl y disl odged (Fig. 22 .4), the readings may be i ncorrec t al though the wav efo rm appe ars n ormal (9,10 ). Con dens ed water, sec re tions or blo od on the c uv e tte windows wi ll i nterfere with ligh t trans miss io n and caus e erroneous readings (124).

Microstream Technology
Mi c ros tream technology util i zes laser-based tec hnology to gene rate infrared emiss ion that p rec is ely ma tc hes the absorption spec trum of CO 2 (113). It u ti lizes a smal ler sample c ell and a lo w f low rate (50 mL/minute ). The emiss io n s ourc e is a glas s d is charge lamp withou t an elec trode that is c oupl ed wi th an inf rared trans mitting wi ndo w. E l ec trons tha t are generated by a rad io f requenc y v ol tage exci te n itrogen molecu les . Carbon dioxi de mol ec ules are then ex c ited by c oll isi on with the exci ted nitrogen molecu les . As the exc ited CO 2 mol ecules d rop back to thei r ground s tate th ey emi t th e s ignature wav elength of CO 2 . The emiss io n is spl i t so that one part is di rec ted to the mai n optica l detec tor v ia the gas s ample cel l whi le the other p art pass es th rou gh a ref erence de tec to r. Th is channe l is used as a con ti nuous ref erenc e d etec tor, c ompensatin g for c hanges in i nfrared output. The inf rared s ourc e is elec tronical ly modulate d so tha t meas ureme nts a re made ev ery 25 ms ec . Th is prov ides a rapid res ponse ti me. The ampli tude of the s ignals receiv ed b y the de tec to r depends on the amoun t of radi ation absorbed f rom the gas sa mple . The absorbed ra dia ti on is proporti onal to the CO 2 c oncentra tion. The airway ada pto r has three c hannels with narrow hy drophobic openi ngs , each fac ing a differe nt di rection . This permits the a daptor to be used in any ori entation and p rev ents the s ample l ine from being occ luded by water or s ec retions . The sa mple line has a hyd rop hobic fil ter. A water trap is not neces sary.

Bec ause of the low s ample f low and s mall sample cel l , th is tech nol ogy is useful f or meas uri ng CO 2 i n v ery s mall patients , hi gh respi rato ry rates , low-fl ow applic ations , and u nin tubated patients . Readings are no t af fec ted b y high conc entrations of ox ygen or anes the tic gas es .

Advantages of Infrared Anal ysis Multigas Capability

Infrared anal yzers a re capabl e of meas uring CO 2 , ni trous ox ide, and a ll of the co mmonl y used po ten t v olatile agents .

Volatile Agent Detection

A l though mon ochromatic a nalyze rs are unab le to identif y anes thetic agen ts and mix tu res of agen ts , most newer models p rov ide a gent detectio n and can de tec t and quantif y mix tures . A nalyze rs ha ndle mix tures of agents in different ways . They may giv e a displ ay s a ying tha t there is a mix ture of age nts o r may compe nsate fo r the additi onal agen t.

Figure 22.12 Microstream infrared analyzer. Small handheld device. (Picture courtesy of Oridion Medical.)

View Figure

No Need to Scavenge Gases

Af ter measu remen t, the gases can be returned to the breathi ng s ys tem, if des i red .

Portability
The units (F ig. 22.12) are smal l, compac t, and l igh twe igh t. They may be i ncorporated in to an an es thes ia mac hine o r phys iologic monitor and be used in remote a reas of th e fac il ity.

Quick Response Time

The resp onse time is fas t enough to measure both ins pi red and exha led conc en trations . Res pons e times fo r anes th eti c agents and ni trous ox ide are longer than fo r CO 2 (1 15).

Short Warm-up Time

The wa rm-up ti me is short. The ins truments do not need to be k ept i n a s ta ndby mode .

Convenience
A l though ea rl y uni ts requi red a complicated cal ibrati on with tes t gases wi th each us e, newer uni ts o nl y require periodic c alibratio n wi th a s tan dardiz ed gas mixture . P .696

Lack of Interference from Other Gases

A rgon or l ow concentra tions o f ni tric ox ide d o not interf ere with v olatile agen t moni tori ng by inf rared ana lyzers (12 5,126). In frared s pec trometry is accu rate in the presenc e of 5% CO 2 (127).

Detecting Anesthetic Breakdown

Agent-i dentifying inf rared ana ly zers ma y prov ide warn ing of des flura ne breakd own that produces ca rbon monox ide by d is pla yi ng wron g o r mix ed agen ts (128).

Disadvantages Oxygen and Nitrogen not Measured

Ox ygen and ni trogen c annot be measured by i nfrared tec hno log y.

Gas Interference
W hi le ox ygen is not abso rbe d b y inf ra red light, it c aus es broaden ing of th e CO 2 absorpti on spec tra , whi ch res ul ts i n lower CO 2 re adi ngs (115). In a typica l infrared CO 2 an aly zer, 95% ox ygen c auses a 0.5% dec li ne in measured CO 2 (101). Some units hav e a us er-ac tuated el ec tronic offse t for ox yg en. The re is some ov e rl ap of the CO 2 and ni trous oxide infrared abso rption peak s so that ni trous ox ide c an caus e falsel y hi gh CO 2 rea di ngs , with an inc rease of 0 .1 to 1.4 torr pe r 10% nitrous ox ide . Mos t inf ra red analy zers that meas ure bo th CO 2 and ni trous ox ide automatic all y c o rrec t for ni trous oxide's effec t on the C O 2 readin g. Some requi re the us er to indic a te when n itrous oxi de is p res ent.

If the a nalyze r is s et to measure a v olati le agent diff ere nt f rom that prese nt in the gas mix ture being anal yzed, CO 2 and nitrous ox ide as we ll as agen t readings wi ll be i ncorrec t (129). A mix ture of agents c an caus e erroneous readings (130). Des fl urane may dis turb the i nfrared CO 2 s ensor so that i t reads higher-thanex pec ted co ncen trations (13 1). Helium in th e gas mix ture may cause the i nfra red analyzer to und eres ti mate the conc en tration of CO 2 (132).

Inaccuracy from Other Substances

E thano l, me thanol , isopropanol , diethyl e the r, acetaldehyde, o r acetone in s ampled gases can c ause s puriousl y high v olati le agent readings (122,133 ,134,135,136,137,138). E th er that is use d to soak gauze that pack ed a pros thes is c an c aus e a monitor to incorrec tly identif y is of lurane (139). Pol yc hromatic ana lyzers are less affec ted, a nd some display a warni ng tha t the i nte rfering agent has been detec te d (118,123,140,141 ). S ome a nal yze rs de tec t halogenated propell ants as anes th etic gases (142,143 ,144,145,146). Methane , whic h can accumu late during low-f low an es thes ia, caus es inacc uracies wi th monitors that us e the 3.3 m wav elength range (14 7,148).

Interference from Water Vapor

W ater v apor abs orbs infrared light a t many wav elengths an d wi l l c ause inc reased CO 2 an d v olatil e agent readin gs (1 15). Monito rs us e s pec ial tub ing, water traps , f il te rs , and/or hydropho bic memb ranes to mi nimize this . W ater that gets into the moni tor can c ause expensiv e or i rrev ers ible damage (102 ).

Slow Response Time

W ith ra pid res piratory rates , the respons e time may be to o s lo w to measu re i nspi red and end -tid al lev els of v ol atile agen ts ac curately (149).

Radio Frequency Interference

Handheld two -way radios in use nea r an infrare d analyzer may cause CO 2 readi ngs to be inc reased (150).

Difficulty Adding New Volatile Agents

As new v o la ti le agents are added to the anes thetic armamen tari um, these moni tors need to be rev ised to accept the new agen ts . This rev is ion ma y requ ire anything f rom a sof twa re change to an expens iv e cha nge to the analy zi ng benc h. In some cases , a c orrec tion fac to r can be used to c onv e rt o ne channel o f a moni tor to

moni tor ano ther agent (151). In s ome cases, i t wi ll be necessary fo r the user to manu al ly se lec t the agen t bei ng use d (152,1 53).

Paramagnetic Oxygen Analysis

W hen introd uced into a magnetic f ie ld , s ome s ubs tanc es locate thems elv es in the s tronges t porti on of the field (154,155 ). These su bs tanc es are termed paramag netic . Oxygen is the onl y paramag netic gas tha t is important in a nes thesia . W hen a gas that contai ns ox ygen is pass ed th rou gh a s witc hed magne tic field, the gas wi l l ex pand and c ontrac t, c aus ing a press ure wav e th at is p roporti onal to the ox ygen pa rtia l pressu re. To obtain a high degree of ac curacy , it is neces sary to compare the pressu re in the gas s ample with a ref erence s ignal that is obtai ned by us ing a ir o r oxy gen. W he n ai r is us ed as a refe rence gas , ni trogen may accumu late in the breathing s ys tem during c losed -c i rcui t anes thesia if the refere nce gas es are redi rec ted to the anes thes ia c i rc ui t. If ox ygen is used as the refe rence gas , the accumu lation of ni troge n is s ignif ic antly reduc ed (156). A paramagnetic ox ygen an aly zer is s hown in Figure 22.13. Referenc e and samp le gases are pumped through the analyzer. The two g as paths are joined b y a differential press ure or f low s ens or. If the samp le and reference gases hav e different parti al press ures of ox ygen , th e ma gnet wi l l caus e thei r pressures to differ. This difference is detec ted by the trans duce r and c onv erted into an el ec trica l s igna l that is displ ayed as oxygen parti al pres sure o r v olumes perc ent. The s hort ri se time al lo ws both ins pi red and e nd-ti dal ox ygen lev els to be meas ured ev en at rapid res piratory rates . Many moni to rs combine inf ra red analys is of CO 2 , P .697 v olati le anes thetic a gents , and nitrous ox ide wi th p aramagnetic ox ygen anal ys is in the same moni tor using the same div erted gas (Fig . 22.1). This al lows mos t gas es of interes t to be moni to red by a si ng le monitor.

Figure 22.13 Paramagnetic oxygen analyzer. A reference gas of known or no oxygen content and the gas whose oxygen level is to be measured are pumped through the analyzer and converge into a tube at the outlet. The two gas paths are joined at their midpoints by a differential pressure or flow sensor. The magnet is switched on and off at a rapid rate. Because the reference and sample gases have different oxygen levels, the pressures in the paths will differ. The pressure difference is detected by the sensor.

View Figure

If the s ample gas from th e anal yze r is return ed to the bre ath ing s ys tem and ai r was us ed as a ref erence g as, i t wi ll dilute the o the r gases and cause an inc rease in ni troge n (101). T his is es peci al ly a probl em during c losed-c i rc ui t anes th esia. If ox ygen is used as the refe rence gas , the accumula tion of ni trogen is s ign if ic antly reduc ed (156). Desflu rane ma y d is turb th e p ara magne tic ox ygen s ensor s o that it reads hi gher than exp ected (13 1). Fai lu re of a pa ramagnetic oxygen a nal yze r has been rep orted (157).

Electrochemical Oxygen Analysis

An el ec trochemica l ox ygen analy zer c ons is ts of a sensor, whic h is exposed to the gas being anal yzed, and the analyzer box , whic h c ontains the elec tronic c i rc ui try, display , and alarms (Fig. 22 .14). T he sensor c ontains a c ath ode and a n anode su rround ed by elec tro lyte. The gel is held in plac e by a me mbrane tha t is nonpermeable to i ons , proteins, and o the r suc h materia ls , yet is permeab le to ox ygen . The membrane sh ould not be touc hed, beca use di rt and grease reduc e its us abl e area. In mos t c as es , the sensor is plac ed in the inspi ratory li mb of the breathi ng s ys tem. Mos t of these anal yzers respond s lo wly to changes in oxygen pressu re, s o the y cannot b e used to measure end -tida l concen trations . Some ne wer s ensors can analy ze ox ygen quick ly e nough to measu re i nspi red and ex hal ed concentra ti ons .

Technology Galvanic Cell (Fuel Cell, Microfuel Cell)

Ox ygen diffus es through the sens or membra ne and elec troly te to the ca thode, whe re i t is reduc ed, c ausi ng a c u rrent to flow (11 4,1 58,159,160). T he rate at wh ich ox ygen en ters the cel l and ge nerates current is p roportional to the partial pres sure of oxygen in the gas ou ts ide the membrane. F or conv enience, h owev e r, the display sc ale is usual ly marked in perc ent ox yg en. A gai n con trol al lows the anal yz er to be ca li brated with gas wi th a kno wn partial press ure of oxy gen (usual l y air). A galv an ic cell sens or is shown i n Figure 22.1 5. It cons is ts of an anod e and two ca thodes su rrounded by el ec trolyte. T he cathode acts as the s ensi ng elec trode and i s not c onsumed. The h ydroxyl ions fo rmed there reac t wi th the lead anode, fo rming l ead ox ide . The anode is g radual ly c onsu med. Cathode: O 2 + 2H 2 O + 4e - 4OH Anode: 4OH - + 2Pb 2Pb O + 2H 2 O + 4e P .698

View Figure

Figure 22.14 Electrochemical oxygen analyzer. The sensor is connected by a cable to the analyzer box, which contains the meter, alarms, and controls. A thermistor compensates for changes in oxygen diffusion caused by temperature. An amplifier is present in the polarographic analyzer. Those monitors with manual calibration require adjustment of a gain control until the correct reading is obtained for a standard oxygen concentration. Those with automatic calibration simply require a button to be pressed in the presence of a gas of standard concentration (usually air). This puts the monitor into calibration mode, and it returns to normal readings automatically when calibration is complete.

S ince there are two cathodes, two v ol tages are generated. These are compared, and if a certain amo unt o f difference is present, the operator is prompted to check the cell. Because the curren t is s trong enough to o perate the meter, a s eparate power sou rc e is not requ ired to operate the ana lyzer. A power s ourc e (ei ther battery o r mains curren t) is requi red to power the alarms .

The c hemical reac ti on is tempe rature depe nden t. In order to c ompensate for temperature di fferenc es , a temperature-dependent res is tor (th ermis tor) may be connec ted i n parallel with th e s ens o r.

Figure 22.15 Galvanic cell sensor. The membrane is permeable to gases but not to liquids. At the cathode, oxygen molecules are reduced to hydroxide ions. At the anode, hydroxide ions give up electrons. An electron flow between the anode and cathode is generated, which is directly proportional to the partial pressure of oxygen in the sample gas.
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P .699

Figure 22.16 The life of a galvanic (fuel cell) electrochemical oxygen analyzer can be prolonged by leaving it exposed to room air when not in use.

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The s enso r c omes packaged i n a s eal ed con tai ner tha t does not conta in ox ygen . Its l if e span begins when the pac kage is opened. Its useful l ife is c ited in p erc ent

hours , whi ch is the produc t of hours o f exposure and ox ygen pe rcentage. If i t is ex posed to a high ox ygen concentra tion, its li fe expec tanc y wi ll be dec reas ed. Sensor l ife can be p rol onged by remov ing it from the breathing s ys te m an d ex posing i t to ai r wh en not in use (Fig . 22.16). Galv anic sens ors requi re no membrane or e lec trol yte rep lac ement. Th e wh ol e s enso r cartri dge mus t be replac ed whe n i t becomes exhaus ted (Fig. 22 .17).

Polarographic Electrode
A pol arographic (Clark el ec trode) s ensor is shown in Figure 22.18. It cons is ts of an anode, a c athode, an elec trol yte, and a gas-permeable membrane. There is a powe r sourc e (battery or alternating curren t [A C] line) f or induci ng a potential between the anode and the cathod e. Ox ygen molecu les diffuse th rou gh the memb ran e and elec trol yte. W hen a po la ri zing v oltage is appl ied to the cathode, el ectro ns combine wi th the ox ygen molec ules and reduc e them to hydroxide i ons . A cu rrent that is propo rtio nal to the ox ygen p artial press ure in the s ampl e fl ows between the anode and ca thode. Polarographic s ensors may be ei ther preass embled disposable cartri dges or uni ts that c an be disass embl ed and reuse d by changing the memb ran e and/or elec troly te .

Use
Calibration
Calibra tion should be p erf ormed daily b efo re us e and at leas t ev ery 8 hours af ter that. Some ins truments remind the user whe n cal ib ration is needed and wil l not giv e a readi ng until cal ibration is performed (Fig. 2 2.19). The c al ibra tion c an be c heck ed by ex pos ing the sensor to room ai r an d v erif ying that i t indic ates approx imatel y 21% oxy gen .

Checking the Alar ms

The s enso r s hould be p ut i n room ai r and the lo w o x ygen a la rm set abov e 21 %. The v isual signa l sho uld fl ash, and th e audi bl e ala rm should sound. If the uni t has a high ox ygen alarm, th e s etting fo r that sh oul d b e mov ed below 21 %. Both v is ual and a udi bl e s ignals should be ac tiv ated . If the v isual s ignal fa ils or the audibl e s igna l is we ak , the ba tteries s hould be re placed an d the alarms rec heck ed. If th is fails to remed y the problem, the uni t shoul d not be used.

Figure 22.17 Galvanic cell sensor. The entire sensor must be replaced when it becomes exhausted.

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P .700

Figure 22.18 Polarographic sensor. Oxygen diffuses through the membrane and electrolyte to the cathode. When a polarizing voltage is applied to the cathode, the oxygen molecules are reduced to hydroxide ions. The current flow between cathode and anode will be proportional to the partial pressure of oxygen. (Redrawn from Bageant RA. Oxygen analyzers. Respir Care 1976;21:415 .)

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Placement in the Breathing System

S i tes f or p lac ing the s ensor in breathing sys te ms a re discussed in Chap ter 9 . The sens or s erv ic e life of some galv anic c el l ana lyzers is reduce d by ex posure to CO 2 , so loca ting the s ens or on the inspi ratory s ide of the sys tem may be preferable . The

sens or s hould be upri ght o r ti lted s l ightly to prev ent mois ture from accumul ati ng on the membrane. T he junc tion betwe en th e c able and the sens or sh ould not be under s train .

Setting Alarms Limits

The low ox ygen alarm sh ould be s et a l ittle bel ow the minimum and the high ox ygen l ev el alarm a li ttle a bov e the maxi mum acc eptable conc entrations . There shou ld be places on the anes thes ia record fo r rec ordin g the al arm s et poi nts and ox ygen percentage.

Advantages Easy to Use

E lec trochemica l oxygen ana ly zers are dependable, ac curate, and user-f ri endly. Galv anic anal yzers may be more rel ia ble than pola rog rap hic anal yze rs (161).

Low Cost
These ins truments c os t less than other me ans of ox ygen anal ys is .

Compact
Compa red wi th o the r techno logies for me asuri ng ox yg en, the elec troche mic al analy zer tak es up li ttl e spac e.

No Effect from Argon

A rgon does not affec t g alv anic cel l mon itoring (126).

Disadvantages Maintenance
W hi le maintenance on newe r models has been si mplif ied, some i ns truments nee d f requent membra ne and elec tro ly te ch anges. P ol arographic moni tors require mo re mai ntenance than the galv anic cel l monitors (161 ).

Figure 22.19 The display on the anesthesia machine provides a reminder that the oxygen analyzer needs to be calibrated.

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P .701

Calibration
These ins truments need to be c alibrated before use eac h day and at l eas t ev e ry 8 hours .

User Enabling
Ins truments that are no t an in tegral part of anes thes ia mac hines need to be tu rned on by the use r.

Slow Response Time

Mos t of these anal yzers can not be used to measure end-tidal oxy gen.

Piezoelectric Analysis
Technology
The piez oelec tric method us es v ibra ting c rys tals th at are c oated wi th a la yer of lipid to meas ure v ol atile anes thetic age nts (158 ,1 62,163,164 ) (Fi g. 22.20). Wh en ex posed to a v olatile anes thetic agent, the v apor is ads orb ed in to the lipid. The resul ting c hange in the mass of the li pi d al ters the v ib ration frequency . B y usi ng an elec tronic s ystem consis ting of two os c il lating c ircui ts , one of whic h has an uncoated (reference ) c rys tal and the other a c oated (de tec to r) c rys tal , an elec tric s igna l that is proporti ona l to the v apor concentrati on is gene rated. Piezoelec tric

analy zers are div e rting d ev ices . Some piezo el ectri c -based uni ts hav e a s epa rate nondispersiv e infrared s ensor to diff ere ntiate inspi ra tion and ex pi ration.

Advantages Accuracy
Inv es tigati ons show a n accu rac y of better th an 0.1% (162,163). W ater v apor and ni trous ox ide affec t the reading , but the wors t-c ase i nte rference is les s than 0.1%. The anal yzer does no t giv e artifac tual results in the presenc e of aeros ol propell ants that are us ed to adminis ter bronch odila to rs (1 42).

Fast Response Time

These ana lyzers c an meas ure insp ired and ex pired lev els of halogenated a gents .

Figure 22.20 Piezoelectric analyzer. A: One vibrating crystal is coated with lipid, and the other is uncoated. By comparing the vibration frequencies of the crystals, the level of anesthetic agent in the gas being analyzed can be measured. B: Piezoelectric crystals. (Courtesy of Biochemical International, Inc.)

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P .702

View Figure

Figure 22.21 Colorometric carbon dioxide detectors. A color code around the outside provides a reference. A: Adult size. The device is supplied with caps that must be removed before use. (Reprinted by permission of Nellcor Puritan Bennett, Inc., Pleasanton, CA.) B: Adult and pediatric versions. The paper strip must be removed to activate the device.

No Need for Scavenging

Bec ause the agents a re not altered, the gas remov ed can be retu rned to the breathi ng s ys tem.

Short Warm-up Time

The wa rm-up period is s ho rter than wi th an i nfrared analyz er.

Compact
These uni ts a re smal l .

Disadvantages Only One Gas Measured

This ana ly zer c anno t measu re ox ygen , CO 2 , n itrogen, o r ni trous ox ide.

No Agent Discrimination
This dev ic e cannot disc rimina te be tween agents . T he use r mus t tel l the moni tor whi c h ag ent is being meas ured. If the wrong agent is selec ted , the read in g c an be i n e rror by as muc h as 118% (162).

Inaccuracy with Water Vapor

W ater wi ll c aus e e rrors wi th the pi ezoelec tric moni to r. In one case, the lines to the pump we re rev ers ed so that wa ter v apo r was remov ed af ter i ts pas sage rather than before (165). This caus ed erroneous l y high re adings .

Chemical Carbon Dioxide Detection

A chemica l (c olori metric ) de tec to r (Fi g. 2 2.2 1) co nsis ts of a pH-sens itiv e indic ator enclosed in a hous ing (3,166,167,168,1 69). W hen the ind ica to r is ex pos ed to ca rbonic ac id that is forme d as a p roduc t of the reac tion between CO 2 and water i t becomes more ac idic and c hanges c olo r. Du ri ng inspi ra tion, the c olo r returns to i ts res ting s tate unles s i t is used wi th a breathing sys tem that a llows rebreathing. The inlet and outlet ports are 15 mm, so the d ev ice c an be p laced between patient and the breathing s ys tem or resusci ta tion bag . W ith the Map leson F s ys tem (Chapter 8), i t may be plac ed between the expi rato ry l imb and the bag (170). Pediatric v e rsions a re av ailab le (Fig . 22.21B).

Technology Hygroscopic
The hygroscopic CO 2 detec tor conta ins h ygrosc opic fi lter p aper that is i mpregnated wi th a colorless bas e and an indicator that c hanges color as a func tion of pH . The f il te r pape r is v is ible th rough a cl ear wi ndow. The co lor c hart on the dome was desig ned to be read u nder f luorescent l ight. A n aux iliary color c hart that is inc luded i n e ach package should be c onsul ted if o ther l igh ti ng is encountered. A purple o r mauv e (A ) c olo r indicates a low CO 2 (<0.5%) l ev el . A beige (B ) color i ndica tes a mode rate lev el (0.5% to 2%). A yellow c olor P .703 (C) in dic ates a high lev el (>2%) (1 71,172 ). The mean minimum concentra ti on of CO 2 ne eded to pro duce a c olor c hange is 0.54%, wi th a range f ro m 0.25% to 0.60 % (169). The hygroscopic CO 2 detec tor's us efu l lif e ma y las t from a few minutes to sev eral hours , depending on the humidity of the gas b eing moni tored (173). Reduci ng the rela tiv e humi di ty of exh aled gases b y us ing an HME to trap mois ture b efo re i t reaches the dev ice prol ongs the detec tor's useful l ife.

Hydrophobic
A hydrophobic indicator in a c olo rimetric dev ice shows a color c hange f rom bl ue to green to yel lo w whe n ex posed to CO 2 (173 ,174). Liquid wate r may cause the d ev ice to not f unc tion pro perly . If the dev ice is al lowed to d ry , it wil l re cov er i ts ac tiv i ty . It has a fas ter response time , performs bette r at hi gh respi rato ry f requenc ies , and is l ess affected by humidi ty than the hygros copic mode l (173,174).

Use

A chemica l CO 2 detec tor is us eful fo r c onf i rming suc ces sfu l trac heal intuba tion whe n a c apnome ter is no t av ai lable. It is usef ul for intubations that are perfo rmed out of the hospital , i n the emergenc y department, or on the wards (175,176 ,177,178). It can be us ed to determin e the pos iti on of the Combi tube (1 79) (Chapter 21 ). It c an b e used du ri ng an in tubation i n a hype rba ric chamb er (180). A manu al resus c i tator ma y hav e a bui l t-in c olo ri metric CO 2 detec tor (181,182 ). Bec ause i t is dis pos able, i t may be es pec iall y useful to conf i rm tracheal intubation i n p atien ts wi th res pi rato ry diseas es s uch as sev ere acute res pi ratory s ynd rome (S ARS ) (183).

Advantages

The dev ice is eas y to us e. Its pe rf ormance is n ot affec ted by ni trous ox ide o r anes thetic v apors . Its small s iz e, portabi li ty, and lack of need for a po wer sou rc e allow it to be us ed in loca tions whe re us e of a CO 2 moni tor is no t pos sible . The c os t is lo w c ompared wi th other methods of CO 2 analysis . S tudi es show the dev ic e to be ac curate i n di agnosi ng esophageal intubation (166,167 ,168,171,176,177,178,182,184 ,185,186,187 ,188,189,190 ,191,192,19 3).

The dev ice can s erv e to ev alua te resus ci tati on or as a prognos tic indicator of succes sful short-term resusci ta ti on af te r the trachea l tube has been correc tl y positioned (186,188,194).

It offers min imal res is tance to flo w. It is al ways ready fo r use, does no t requi re c lean in g, and minimizes th e ris k of tra nsmission of infec tion. Carbon mon oxide does not inte rf ere wi th the c hemic al CO 2 detecto rs (127).

Disadvantages

It may take s ev eral breaths before c onc lus io ns can be drawn about the trac heal tube loc ati on to av oid errors caus ed by fals e-posi tiv e resu lts , as disc ussed bel ow. It is us ual ly rec ommende d to wai t s ix breaths before making a determination .

False -negativ e res ults may be se en with v ery lo w tid al v olumes and lo w e ndtida l CO 2 concen trati ons , such as i n c ases of c ompromised l ung pe rfusi on

(190,192 ). Du ring cardi opulmona ry res us ci tation, a posi tiv e tes t i ndicates that the tracheal tube is in the ai rwa y, bu t a negativ e resul t (s ugges ting es opha geal placemen t) requi res an al ternate method of c onf irming trache al tube pos ition. If th ere is li ttle or no c i rc ul ation to the lung , CO 2 wi ll n ot be av ailab le for the detec tor to v erif y correc t trac heal tub e p lac ement. Fa ilure to i nflate the trachea l tube cuff may cause equiv oca l col or c hang e (167 ). Other methods to determine trachea l tube pos i tion a re discussed i n Chap ter 19.

Drugs i nstil led in the trachea or gas tric c ontents can ca use i rrev ers ible dama ge to the dev ice (195 ,196). False -posi tiv e resul ts c an occ ur if the re is CO 2 in the s tomach (from i nges ted ca rbonated bev e rages or an tac ids or mask v entilatio n) (197,198,199,200). The disp la y ma y ini tial l y turn color and onl y s lowly rev e rt to its origi na l color.

Diff ic ul ty in dis tingu is hing col or ch anges has been repo rted (197). It ma y be diff icul t to dete rmine whether a s ubtle co lo r change is d ue to the patient's l ow end-ti dal CO 2 or a mis plac ed tracheal tu be.

The re is no ala rm or CO 2 wav eform. This dev ic e may not be c os t e ffec tiv e for routine use whe n c ompared wi th us e of a c apnometer (2 01). Its cos t-effec tive ness may be g rea ter with a s mall numb er of appl ic ations (20 2).

A i rf lo w o bs truc tion f rom a manufac turing defec t has been reported (203). This dev ic e is s emiqu antitativ e and can not giv e accurate me asuremen t of CO 2 . For this reason, i ts applicatio n is limi te d to trach eal tube pos i tion v e rification.

Refractometry
In an o ptical inte rf erence refrac tometer (in te rferomete r), one po rtio n of a split l ight beam passes through a c hamber into which th e s ampl e gas has been asp irated, whi l e the other p ortion pass es th rou gh an identic al c hamber c ontaining ai r (204,205 ,206,207). Bec ause v apor s lows the v eloc ity of l ight, the porti on pass in g through the v apo r chamb er is delayed . The beams are then recombine d to fo rm an i nte rference pa ttern that c ons is ts of dark and light bands . The posi tion of thes e bands , o bserv ed through an e yepiec e agains t a s cale s upe ri mpos ed on the pattern, yi el ds the v apo r concentra ti on. In P .704

order to use this d ev ice, one mus t know the ref rac tiv i ty number of the gas bei ng analy zed. Refrac tiv i ty is a nonl inear func tion of the partial pressure of the gas . This i nstrument is used pri ma ri ly for v aporizer ca li brati on . It c annot be us ed to meas ure v apor lev els of halogenated agents in a typic al anes thetic gas mix ture of ox ygen an d nitrous ox ide becaus e of i ts sens i tiv i ty to ni trous ox ide (208 ).

Gas Measurement Oxygen

The s tandards fo r basic anes thesia moni to ring of the A meric an Soci ety of Anes thes iologis ts (A SA ) and A meric an Ass oc iation of Nurs e A nes thetis ts (AA NA ) s tate tha t the c oncentration of ox ygen in the pa tient breath ing s ys tem shal l be meas ured by an ox ygen ana ly zer wi th a low ox ygen conc entra tion alarm in use. The us e of more than on e dev ice to monitor ox ygen is des irabl e.

Standard Requirements
Inte rna tional and U.S . s tandards o n res piratory gas moni to rs an aly zers was publish ed in 2004 and 2005 (209,2 10). The followi ng requi rements are in those s tandards .

Ox ygen re adings s hal l be wi thin 2.5% of the ac tual lev el. This accu rac y shall be maintained for a t leas t 6 hours of conti nuous use. The high and low ox ygen lev el al arms mus t be at leas t medium pri ority. A high-prio ri ty alarm is requi red f or an insp ired oxy gen co ncen tration be lo w 18%. Alarm pri oritiz ation is discussed in Chapter 26.

It shall n ot be poss ible to s et the l ow ox ygen al arm l imi t below 18%.

An ox ygen analy zer with an ala rm that can b e s et below 18% is dange rous (211).

Technology
Ox ygen l ev els may be meas ure d by us ing elec trochemical or pa rama gnetic tec hnology. In mos t c ases , elec troche mica l ana lys is p rov ides onl y mean conc en trations . P aramag netic technol ogy has a s uff iciently rapid res pons e ti me to meas ure b oth insp ired and end-tidal lev els . It ma y be des i rabl e to meas ure the i nspi red ox ygen wi th non -i ntubated, spon tan eous ly breathing patients . This is possible with a div erting dev ice such as a paramagn etic analy zer but not with an

elec troche mic al moni tor. E nd-tidal oxygen can be meas ured during jet v entilation (212).

Applications of Oxygen Analysis Detecting Hypoxic or Hyperoxic Mixtures

The f irs t l ine of defense agains t hypoxemi a i s to av oid a hyp oxic inspi red g as mix tu re. A n ox ygen moni to r prov ides an earl ie r warn ing of inadequate ox ygen than pulse oxime try. In a s tud y of 2000 c ri tic al inc iden ts , 1% we re fi rs t de tec ted b y the ox ygen mon itor (213). Hyp oxia is disc uss ed in Cha pte r 14. Ox ygen ana lysis c an also hel p prev ent probl ems res ul ting from hype rox ygenation, such as patient mov ement duri ng su rge ry , awarenes s , damage to the lungs an d eyes , and fi res . Fi res a re disc usse d i n detail i n Chapter 32 .

Detecting Disconnections and Leaks

Disconnec tion of the tubing to an ox ygen mas k may be detec ted by us in g a div erting ox ygen a nalyze r (2 14). An ox ygen mon itor ca n detec t disc onnec tions in the breath ing s ys tem (215,216 ,217). Howev e r, ox ygen moni toring cannot be depended on for this purpose (218,219). W hether or not the ox ygen l ev el falls at the point be ing moni tored depends on s ev eral fac tors , including the type of breathing sys tem in us e, pos iti on of the s ensor, si te of dis connec tion, al arm se t poi nts , i f the patient is breathi ng sponta neous l y o r v en ti la tion is c ontro lled, and the typ e of v en ti la tor in us e. If ox ygen is the driv ing g as and there is no ph ys ical barri er betwee n the driv in g ox ygen from the v enti lator and the breathin g s ystem gas , a dis con nec tion at the common gas outlet wil l resul t in a risi ng percentage of ox ygen (220). Disconnec tions are discussed i n Chapter 1 4. W ith a si des tream anal yze r, a dec re ase i n ins pi red and expi red oxygen may res ul t f rom a leak in the sampl ing sys tem (221).

Detecting Hypoventilation
Normally , the diffe rence between insp ired and ex pi red ox ygen is 4% to 5%. A differenc e of more than 5% af ter a s teady s tate has been reac hed is a s ensi tiv e i ndicator of hypov enti la tion (222,223,224 ). Hy pov entilation is discussed in detai l in Chapte r 14.

Other
End -tid al ox ygen has been us ed to measure the ad equacy of preox ygenation (225,226 ,227,228,229).

Kno wing the ex pired ox ygen c oncentratio n a llows an es timate o f the patien t's ox ygen c onsu mp tion and c an aid in the diagnos ing mal ignan t hyperthermia. Ox ygen cons ump tion can be es timated from the diffe rence between the inspi red and ex hal ed ox ygen concen trati ons (230 ,231). The c oncentration of ni trous ox id e c an be es timated f rom the concentration of ox ygen . End -tid al ox ygen has been us ed to de tec t air embo lism. W hen a s ign if ic ant amount of air e nte rs the P .705 v ascular bed, there is an i nc reas e in end -tid al ox ygen and a dec reas e in the differenc e between inspi ra tory and end-ti dal ox ygen c onc entrations (232).

Carbon Dioxide Analysis

ASA guide lines f or basic anes thetic moni tori ng s tate that wh en a trache al tube or supraglo ttic airway dev ic e is ins erted, i ts c orrec t posi tioning mus t be v e rified by i dentifying CO 2 in the expi red gas . Continual end -tid al CO 2 analys is shal l be performed u nti l the dev ic e is remov ed or the pa tient is transfe rred to a pos toperativ e c are loca tion. In 2005 , an aud ib le al arm was added to the mon itoring s tandard (233). A court c ase has held that a reaso nabl y pruden t hea lth care fac ili ty wou ld suppl y a CO 2 monitor to a pa tient unde rgoing general an es thes ia (234). S ome s tates hav e mand ated the us e of CO 2 moni tors (158). Carbon di ox ide anal ys is prov ides a means for asses si ng metabol ism, c i rc ul ation , and v entilation and c an de tec t many equipment- and pa tient-rel ated probl ems tha t other mo nitors ei the r fai l to detec t o r detec t so s lowl y that patient sa fety may be co mp romised. A c losed c lai ms analys is foun d tha t c apnography p lus pulse ox imetry could pote ntial l y p rev ent 93% of av oida ble a nes thetic mish aps (235). In one s tudy, 10% of intraoperativ e p rob lems we re i niti ally diagnosed by CO 2 mo ni toring (236). In anoth er s tudy , end-tida l CO 2 was us eful in c onfirming 58% of al ready sus pec ted anes thes ia-re lated c ri tical inc idents and was the initia l detec tor of 27% (237). In yet anoth er s tudy , it was es tima ted that a c apno me te r used on i ts o wn woul d hav e detec ted 55% of c ri tic al inc iden ts i f they had been all owe d to ev olv e and 43% would hav e been de tec te d befo re an y p otential org an damage (238 ). Ca rbon dioxide moni tori ng de tec ts ac ute c omplete a irway obs truc tion and ex tubation more rapidl y than pulse ox imetry o r v i ta l s ign moni to ri ng (2 39). In major tra uma v ic tims , usi ng

capnog rap hy to guide prehospi tal v enti lation resul ted in less hypov entilatio n on hospi tal admiss ion (240,241 ). The resp iratory c yc le (i .e., insp iration v s. ex piration) is def ined in terms of CO 2 meas urement, so end -tidal v alues for other gas es dep end on CO 2 meas urement.

Terminology
Capnometry is the measurement of CO 2 i n a g as mix ture, and a c apno mete r is the dev ic e tha t perfo rms the measu remen t and disp lays the read ings in nume ri cal form. Capnography is the rec ord in g of CO 2 concentra tion v ersus ti me, whi l e a capnog rap h is the machine that generates the wav eform. The c apnogram is the ac tual wav eform (242). It may be poss ible to c onnec t a capn ometer to a nother pati ent monitor and/or rec order to gene rate a wav eform. W av eforms are av ai lab le on all mod ern ph ys iol ogic moni to rs .

The Capnometer Standards Requirements

An inte rna tional and a U.S . s tanda rd on c apnome ters hav e been pub lished (209,210 ). They con tain the fol lowi ng spec ifi cations .

The CO 2 reading s hal l be wi th in 12 % of the ac tual v alue or 4 mm Hg (0 .53 kPa ), wh ic hev e r is greater, ov e r th e full range of the capnome ter. The man ufac ture r mus t dis c lose any i nterferenc e c aused by ethanol , ac etone, methane, he lium, tetraf luoroethane , and dic hl orodif luo rome thane as wel l as c ommonl y used halogena ted anes thetic agents .

The c apno me te r mus t hav e a high CO 2 al arm fo r both ins pi red and exha led CO 2 . An al arm for l ow e xha led CO 2 is requi red .

Technology
Methods to measu re CO 2 lev els i nclude inf rared and c hemical c olori metric analys is . A wid e v ariety of disp la y f ormats a re av ailab le on CO 2 monitors . The CO 2 l ev el may be reported as eithe r parti al pres sure o r v olumes perc ent and ma y be dis played continuous l y or as the peak (no rmal ly e nd-tidal ) v a lue . Other parameters such as respi ra to ry ra te and I:E ratio may be disp lay ed. Porta bl e, battery -op era ted CO 2 monitoring d ev ices a re av ailabl e (243,244 ,245,246,247,248,249,250) (Fi gure 22.12). These are us ef ul in emerg ency

medicine an d patien t trans port (Fig. 22.12). A t leas t one has been reported to not giv e co rrec t v alues during reb rea thing (251). MRI-c ompatible infrared CO 2 moni to rs are av ai lable. Many c apnomete rs are inc lu ded in mu ltipurp ose phys iologic moni tors wi th other parameters suc h as blood pressure, pulse ox imetry, and analys is of other gases . The CO 2 wav ef orm may be on e of sev era l on a display.

Atmospheric Pressure Effects

A tmosph eric press ure can inf luenc e C O 2 rea dings (111,112,252 ,253,254,255 ). Some ins truments inc orpora te a barometer to c ompe nsate fo r c hanges i n atmospheric press ure . Oth ers requ ire the us er to ente r th e a tmos pheric p res sure manu al ly. S ti ll others do not c orrec t for a tmos pheric p res sure. The c apnomete r s tandards (209,210) requi re that the man ufac ture r discl ose the qua nti tativ e effec ts of barometric p res sure on c apnometer perf ormanc e in the i nstruc tions for us e.

Sidestream Analyzers
W hen a s ides tream infrared rep orts res ul ts in v olumes pe rce nt, the atmospheric press ure at meas u rement ti me mus t be k nown to c orrec tly c ompu te the CO 2 v al ue . P .706

TABLE 22.1 Capnography and Capnometry with Altered Carbon Dioxide Productiona Waveform on End-tidal Inspiratory Capnograph Carbon Carbon Dioxide Dioxide Absorption of CO2 from peritoneal cavity Injection of sodium bicarbonate Pain, anxiety, shivering Normal 0 End-tidal to Arterial Gradient Normal

Normal

Normal

Normal

Normal

Increased muscle tone (as from muscle relaxant reversal) Convulsions

Normal

Normal

Normal

Normal

Hyperthermia Hypothermia

Normal Normal

0 0

Normal Normal

Increased depth of anesthesia (in relation to surgical stimulus) Use of muscle relaxants

Normal

Normal

May see curare cleft Normal

Normal

Increased transport of CO2 to the lungs (restoration of peripheral circulation after it has been impaired, e.g., after release of a tourniquet)
a

Normal

Normal end-tidal CO2 is 38 torr (5%). Inspired CO2 is normally 0. The arterial to endtidal gradient is normally less than 5 torr.

For exampl e: FetCO 2 = parti al p res sure (atmospheric pres sure - wate r v apor pressu re) 100 A t 760 mm Hg atmospheric press ure and a CO 2 l ev el of 3 8 mm Hg, FetCO 2 = 38(760 - 4 7) 100 = 5% If the a tmos pheric p res sure is reduc ed to 50 0 mm Hg, FetCO 2 = 38(500 - 4 7) 100 = 8%

If a correc tion for atmospheric pressu re is not mad e, the capn ometer wi ll rea d erro neously h igh v olumes perc en t at i nc reas ed al ti tude. Other options a re to ca li brate at alti tude with a gas th at has a k nown CO 2 conc en tration or to set the dev ic e to read partial p res sure.

Mainstream Infrared Analyzers

Mai ns tre am inf ra red ins truments are ca librated from s eal ed gas c ells of k nown partial pressu re. These ins truments wil l report meas urements in units of pa rtial press ure c orrec tl y (252 ). If s uch an anal yzer reports res ults in v olu mes percent, the atmospheric press ure at measu rement ti me mus t be k nown .

Clinical Significance of Capnometry

Carbon di ox ide is produc ed in the body tissues , conv eyed by the ci rculatory s ys tem to the lungs , exc reted by the lungs , and remov ed b y the breathing s ys te m. The refore, c hanges in respi red CO 2 may refl ec t a lterations in metabol ism, c i rc ulation , res pi ration, o r the breathing s ystem. Tables 22 .1 to 22.4 lis t so me sourc es of c hanges in CO 2 l ev els .

TABLE 22.2 Capnographic and Capnometric Alterations as a Result of Circulatory Changes Waveform on End-tidal Inspiratory Capnograph Carbon Carbon Dioxide Dioxide Decreased transport of CO2 to the lungs (impaired peripheral circulation) Decreased transport of CO2 through the lungs (pulmonary embolus, either air or thrombus; surgical manipulations) Normal 0 End-tidal to Arterial Gradient Normal

Normal

Elevated

Increased patient dead space

Normal

Elevated

P .707

TABLE 22.3 Capnometry and Capnography with Respiratory Problems Waveform on Capnograph End-tidal Carbon Dioxide Inspiratory Carbon Dioxide 0 End-tidal to Alveolar Gradient

Disconnection

Absent

Apneic patient, stopped ventilator Hyperventilation

Absent

Normal

Normal

Hypoventilation, mild to moderate

Normal

Normal

Upper airway obstruction Rebreathing, e.g., (under drapes)

Abnormala

Elevated

Baseline elevated

Normal

Esophageal intubation
a

Absent

See Figure 18.34.

Metabolism
Moni tori ng CO 2 eli mina tion giv es an ind ica tion of the pati ent's metabolic ra te (256). An inc reas e or dec reas e in end -tidal CO 2 is a rel iable indic ato r of metabolism onl y i n mechan ic ally v entil ated s ubjec ts . For s pontaneousl y breathing patien ts , PetCO 2 may no t inc rease wi th i nc reas ed metabol ism becaus e of co mpens ato ry hyperv enti lation by th e patien t (257,258).

Tab le 22 .1 l is ts some me tabolic c auses of inc reased or dec reas ed CO 2 exc retion. These inc lude inc reased tempe rature, s hiv eri ng , conv uls ions , excessiv e ca tec holamine produc tion or adminis tra tion (2 59), blood or b ic arbonate adminis tra tion (260), re lease of an arterial c lamp o r tou rniqu et (261,262 ,263,264,265), and p are nte ral hypera li mentation (266 ). Carbon diox id e produc ti on fal ls wi th dec reased tempe rature a nd inc reased mus cl e rel axa tion. Inc rease d exhaled CO 2 c an res ul t from CO 2 us ed to inflate the peri toneal c av i ty during la paroscopy (267,268,269 ,270,271,272 ), the pleural c av i ty du ri ng thorascopy (273,274 ), a joint duri ng arthrosc opy (275), or to inc rease v isua li zation fo r endosc opic v ein harv est (276).

TABLE 22.4 Capnographic and Capnometric Alterations with Equipment Problem Waveform on End-tidal Inspiratory End-tidal to Capnograph Carbon Carbon Arterial Gradient Dioxide Dioxide Baseline Elevated Normal

Increased apparatus dead space

Rebreathing with circle system: faulty or exhausted absorbent, bypassed absorber (may be masked by high fresh gas flow) Rebreathing with Mapleson system (inadequate fresh gas flow, misassembly, problem with inner tube of Bain system) Rebreathing due to malfunctioning nonrebreathing valve

Baseline Elevated See Figure 18.35 Baseline Elevated See Figure 18.35 Baseline Elevated See Figure 18.35

Normal

Decreased

Decreased

Obstruction to expiration in the breathing system

See Figure 18.34 Absent See Figure 18.39 See Figure 18.41 See Figure 18.42

Decreased

Blockage of sampling line Leakage in sampling line

0 0 Increased

Low sampling rate with diverting device

Increased

Too high a sampling rate with diverting device

Increased

Inadequate seal around tracheal tube

See Figure 18.44

Increased

P .708

Mal ig nant hype rthermia is a hypermetabol ic s ta te wi th a mass iv e inc rease in CO 2 produc ti on. The inc rease oc curs early , before the ris e in temperatu re. E arl y detec tion of this synd rome is one of the mos t impo rtant reas ons for routine ly moni tori ng CO 2 (236,277 ). Capnome try can be us ed to moni tor the effec tiv eness of trea tmen t.

Circulation
Tab le 22 .2 l is ts some of th e c irculatory c han ges that affec t ex haled CO 2 . A dec reas e i n end-tidal CO 2 is seen with a dec reas e in ca rdiac ou tpu t if v entilati on

remains c ons tant (278,279 ,280,2 81,282). End -tidal CO 2 inc reas es wi th i nc reased ca rdiac ou tpu t (283). In addi tion to reduc ed ca rdiac ou tpu t, reduced blood flo w to the l ungs can res ul t f rom s urgical manipulations of the heart or thorac ic v es sels (2 84), a dis sec ting aortic an eurys m compres s ing a pulmonary artery (285 ), we dging of a pulmon ary arte ry c a the ter, and pulmonary embol is m (th rombus , tumor, gas , fa t, marro w, or amniotic fl uid ) (286,287,288 ,28 9,290,291 ,29 2,293,294,295). If the embol i zed gas is CO 2 , the end-tidal CO 2 wil l i ni tial ly i nc reas e a nd th en dec reas e (296,297 ,298,299,300,301). A lthough not as s ensi tiv e as the Doppler for detec ting ai r embo lism, CO 2 monitoring is less subjectiv e, is unaffec te d by elec tros urgery apparatus , and c an be used in major ear, nose, and throat (E NT) c ases for wh ic h the Doppler me thod is not appl icabl e. Capnome try may not b e s uff iciently s ensi tiv e to detec t fat and ma rrow mi c roemb oli (30 2). Durin g res usci tation , exh aled C O 2 is a better guide to the effec tiv enes s of resus ci tati on measu res than the elec trocardi ogram (E CG), pulse, o r blood press ure (303,304 ,305,306,307,308,309,310,311 ,312). The capnometer is not s usc eptible to the mec hanical artif ac ts that are associ ated with ches t comp res si on, and ches t co mp res sions do no t hav e to be inte rrupted to as ses s c irc ul ation. Th e c ol orimetric CO 2 de tec ti on dev ic e has also been shown to be an eff ec tiv e moni tor during resus ci tati on. Ho wev er, i f high-dos e epinephri ne or bicarbonate is use d, end -tid al CO 2 is not a good res usc itation indica tor (313 ,314,315,316 ,317,318). End -tid al CO 2 lev els may be of use in p redic ting the outcome of resusci ta tion (186,304 ,307,310,319,320,321,322,323 ,324,325,326 ,327,328,329 ,330,331,332) and the res ol uti on of a p ulmonary e mbolus (333).

Respiration
Carbon di ox ide monitorin g g iv es information about the rate , frequ enc y , and de pth of respi ra tion. It c an be used to ev alua te the patie nt's abi l ity to breathe sp ontaneo usl y as wel l as the effec t of bronchodil ator or nitric ox ide treatment or a ltered v entilation parameters . It al lo ws contro l of v entil ation with fewe r bl ood gas d ete rminatio ns. End -tid al analysis is no ninv as iv e, av ail able on a breath-by-b rea th bas is , and no t af fec ted by hyperv entilation that is induced by drawi ng an arteri al bl ood s ample. Tab le 22 .3 l is ts some resp iratory c auses of i nc reased and dec reased end -tidal CO 2 . A capnometer can warn of esophageal i ntubatio n, apnea, ex tubation, disc onnec tion , v enti lato r malfunc tion , a change in c ompl iance or res is tanc e, ai rwa y obs truc tion , poor mask f it, or a leak in g tracheal tube cuff .

A depe ndable means to de termine when a trach eal tube has been c o rrec tly positioned in the tracheobronchial tree obv iousl y is of g rea t v alue. Es ophagea l i ntu bation has been a l ead ing c ause of death and ce reb ral damage in the p ast. A disc ussi on of ways to detect i nadv erten t eso phag eal plac ement is found in Chapter 19. Carb on diox ide moni to ring is usuall y cons idered the mos t reli abl e method. Carbon di ox ide measurement to detec t esophageal plac ement has some drawbacks and li mitations , so i ts us e as th e onl y means of c orrec t tube placemen t s hould be s trongl y discou rag ed. Abs enc e of c i rc ul ati on , s ev ere bronc hos pasm, equipment malfunc tion, and appl ic ation of c rico id press ure oc c luding the tracheal tube tip can resul t i n fai lure to detec t CO 2 (334 ,33 5,336,337 ,338,3 39,340,34 1,342,343,34 4). The analy zer may be in a cali bra ti on mode whe n the tube is p laced. W ith esophageal intubation, s mall wav eforms may be trans ie ntl y seen as a res ult of CO 2 that has entered the s tomac h during mas k v enti la tion or f rom carbonated bev erages or medications (197,199,345 ,346,3 47,348). This co ul d g iv e the i mpress ion that the tu be is co rrec tly p lac ed in the trac hea. Ho wev e r, rapidl y dimin is hing c onc entra tions and abnormal wav eforms wi l l usuall y differentia te es opha geal from trachea l i ntubation (345 ,34 9,350). A cas e has been repo rted where a norma l capnogram was presen t desp ite an es opha geal intuba tion (351). There was a cuf fed oro pharyngeal airway i n p lac e, and the patient wa s b rea th ing s pontane ous ly. C arbon dioxide from the trac hea was thoug ht to hav e gotten unde r the c uff ed ai rway and forc ed down the esophagus , whe re i t was asp irated from the trac heal tube. Inflating the trachea l tube cuff i nte rrupted the wav eform. W hi le es ophageal intubation wi ll lik el y be de tec ted by usi ng end-tidal CO 2 , there is no gu ara ntee that the tube is in the trachea. Ca rbon d ioxide can be se nsed f rom a trac heal tube tha t is posi tioned a bov e the voc al c ords (352 ). A div erting CO 2 moni tor can be used to monitor res piratory rate and exha led CO 2 in unintuba ted patien ts who are breath in g s pontaneous ly (50,51,52,53,54,55,67,72,78,89 ,90 ,353,354,355 ,356,3 57,358,35 9). A pnea , ai rway obs truc tion, o r dis connec tion of the ox ygen sou rce may be detec ted. If v entil ati on of the breathing s pace unde r th e s urgic al drapes is inade quate, rebreathing wi ll oc cur an d may be detec ted by a ris ing i nspired CO 2 lev el (52,354 ,360). Capnometry has been us ed to help de termin e the pos i ti on of a do uble-l umen tube (361,362 ). Methods to determine p roper doubl e-lumen tube plac ement a re disc ussed in Chap te r 20. Co rrec t plac ement can be checked b y examining the

wav efo rm from each l ung du ring clamping and unc lampi ng procedu res . Howev er, that method P .709 i s les s rel iable than o ther methods that a re us ed for this purpos e (363 ,364,365). Durin g independent lun g v entilation, c apnog rap hy c an be used to d ete rmine the proper setti ngs for v entilation of eac h l ung (366 ). Capnograph y can be us ed to detec t tracheobronc hial injury du ring thoracos copic procedures (274). Carbon di ox ide monitorin g c an serv e as a warning of ac c idental bronc hial i ntu bation. This may resul t in a trans ient fall or ri se in end-ti dal CO 2 (367 ,3 68,369). Carbon di ox ide monitorin g c an be useful during we aning from arti fic ial v entilation (370,371 ,372,373,374,375,376,377). However, end -tid al CO 2 mon itori ng al one ma y not be a rel iabl e too l during weaning wi tho ut kn owi ng the arterial -E T CO 2 gradient. This is d is cus sed in mo re detail l ate r in this chap ter. Carbon di ox ide monitorin g c an as s is t wi th the decis ion to prov ide v enti latory support (378). It prov ides a means to meas ure the sev erity of bronc hospasm (37 9,380).

Equipment Function
A pro bl em wi th the breathing sys tem ca n c aus e an ins pired CO 2 lev el greater than ze ro. E xamples of s uch problems are lis ted in Table 22.4 and inc lude leaks , faulty or exhaus ted abso rbe nt, channel ing, a bypass ed abso rbe r, i nc reas ed dead s pac e, l ow fres h gas f low to a Mapleson s ys tem, a defec t in the inner tube of a Ba in s ys tem, acc id ental adminis tra ti on of CO 2 , and a defec tiv e non reb rea th ing v alv e (381,382 ,383,384,385,386,387,388). Inc ompetent unidi rec tio nal v alv es are an inh ere nt danger of the c irc le s ys tem. An i ncompete nt ex piratory v alv e allo ws rev ers e f low of gas that c ontai ns CO 2 from the ex piratory l imb duri ng the inspi ra tory phas e, resul ting in an elev a ted baseli ne on the capn ogram (389 ) (Fi g. 22.30). If the inspi rato ry v alv e is incompetent, CO 2 wil l enter the inspi rato ry l imb du ring exhala tion. During the nex t ins pi ration, CO 2 wi l l be rebreathed. This wi l l c ause the pla teau on the c apnog ram to be length ened and a dec reas e i n the s teep ness of the ins piratory d owns lope (Fig. 22 .32 ) (390). An i nc reas e in the b asel ine may not b e seen . A s pi rog ram that plots CO 2 agains t v olume (Fig. 22.22) wil l i llus trate the inspi ra tory v alv e leak by a dec reas ed downs lope on the inspi ra tory si de of the lo op (391).

Carbon di ox ide anal ys is can be us ed to de tec t a disconnec ted ox ygen tubi ng to a mask ov er the face during loc al or region al anes thes ia (355). If the ox ygen s ource becomes de tac hed, the re wi ll be a ri se in CO 2 because of rebreathing. Rarel y a phantom CO 2 wav e may be noted d espi te a dis connec tion. One case was reporte d wh en the g as sample l ine f ro m the CO 2 moni to r was connec ted to the breathi ng s ys tem jus t ups trea m of the ex pi ratory uni di rec tional v alv e (392). Duri ng i nspi rati on , the ins piratory unid irec tional v alv e opened, allowi ng f res h g as plus th e gas (con taini ng CO 2 ) from the monitor to pass to the pa ti ent, whe re i t was detec ted during ins pi ra tion. T his p roblem does not oc cur i f the gas is ei the r di rec ted to the sc av engi ng s ys tem or return ed to the bre ath in g s ys tem downs tream of the ex piratory v alv e. In another c ase , squ are wav e capnographic trac ings were observ ed af te r a patien t was disco nnec te d from a v enti lator th at ha d not bee n turned OFF (39 3). The gas analy zer aspi ra ted CO 2 f ro m the exp iratory tubing, generating a series of dimin is hing trac ings o n the c apnograph.

Figure 22.22 A spirogram that plots CO2 against volume will illustrate the inspiratory valve leak by a decreased downslope on the inspiratory side of the loop better than a capnogram. (Redrawn from Breen PH, Jacobsen P. Carbon dioxide spirogram [but not capnogram] detects leaking inspiratory valve in a circle circuit. Anesth Analg 1997;85:13721376 [Fulltext Link] [CrossRef] [Medline Link] .)

View Figure

Other Uses
A div erting capnometer c an be us ed to loc aliz e the si te of leaks in CO 2 insufflatio n equipment (394), diagnose a tracheoes oph ageal or bronc hoes ophageal fis tula (395,396 ), guide b lind intubatio n (397 ,398,399,400 ,40 1,402,403 ,404,405), determine when the ti p of an exc hange c atheter or f iberscop e is in the trac hea

(406,407 ), or confi rm tha t the needle or ca th ete r is posi tioned in the trachea duri ng a P .710 c ric othyrotomy or percutaneous di lata tiona l tracheos tomy (Chapter 2 1) (408,409 ,410). Carbon di ox ide anal ys is may be use d to ass ess the pos ition of an enteric tube (411,412 ,413,414,415,416,417,418,419 ,420,421,422 ,423). If the tube is placed into the trachea, CO 2 wi l l be detec ted at the f ree end. If CO 2 is not detec ted , the tube is l ik ely in the esophagus . If an enteric tube pas ses into the trac hea in an intuba te d pati ent, the capnograph wi ll s how a downs lo pi ng alv eolar plateau (424).

Correlation between Arterial and End-tidal Carbon Dioxide Levels

Numerous s tud ies hav e shown th at the correlation between arte ri al and end-ti dal CO 2 tens ions in c hi ldren and adu lts withou t cardiorespi ra to ry dys fu nc tion is good enough to warrant routine moni toring (4,110,2 71,425,432 ). E nd-ti dal CO 2 is us ually l ower than PaCO 2 by 2 to 5 to rr (433). The grad ien t may be less or ev en neg ativ e i f the func tional residua l capac i ty is re duced, as in pre gnant or obese patients (428,434 ,435) and is reduced wi th rebreathing (436). Tab les 2 2.1 through 22 .4 show s ome con ditions wi th al tered end-tidal to arterial gradients . P redic tion o f PaCO 2 f rom end-tidal CO 2 alon e is unrel ia bl e i n some pa tients and may be po ten ti al ly dele terious i n s ome patie nt subgroups . A s tu dy of neurosurgical pati ents found that end -tidal CO 2 did not accu ratel y reflec t c hanges in the arteri al CO 2 tens ion (437), al though in heal thy patients during elec tiv e neu ros urgic al procedures , the PaCO 2 -P e tCO 2 diffe rence rema ins s table ov er time (430). Trans cutaneous CO 2 moni to ri ng has been fo und to be mo re acc ura te i n ev aluating CO 2 l ev els du ri ng one-lung v enti lation (438,439 ), i n obes e patie nts (440), du ri ng neurosurgic al proc edures i n adul ts (441), an d i n older c hil dren (442,443). The relations hi p between arte ri al and end-tidal CO 2 tensi on may be cons tant or v a ry, sometimes in different d irections , both wi thin and between pati ents (444). A l though there usuall y is a linear rel ati ons hi p b etween end -tidal an d a rterial CO 2 , the gradient may be u nexpec tedl y la rge or ev en ne gativ e (445,446 ,447,448,449,450). E nd-tidal CO 2 cannot replac e the meas u rement of PaCO 2 in the intens iv e c are uni t or emergenc y room, al though i t is usef ul for trendin g or sc reening (430 ,45 0,451,452 ,453).

Problems with Sampling

Acc urate measurement of end -tidal CO 2 is espec ially di fficul t wi th high v enti lato ry f requenc ies (16). In s mal l patients , sa mp li ng at the pa tient end of the tracheal tube resul ts i n a c loser approx imation to arteria l CO 2 than sampling at the breathi ng s ys tem end (22 ,23 ,24 ,25,26). W hi le plac ing th e gas s ampl ing line on the mac hine s ide of an H ME may av oi d c ontamination and water l oggi ng of the s amp le , this may resul t i n erroneous v al ues and poo r wav ef orms (45 4,455,456). One sourc e of samp li ng error is a leak at the inte rf ace be twee n the pa ti ent a nd th e equipment. P oor mask fi t, us ing an uncuffed trachea l tube or a tube with a defec tiv e cuff , or a loose c onnec tion or leak i n the s ampl ing catheter may ca use erro neously l ow end-ti dal CO 2 readings (106). The co rrel ation be twee n arterial and end -tidal CO 2 tens ions is better duri ng v enti la ti on wi th a supraglottic dev ic e than a face mask (457 ). The correlatio n c an be imp rov ed by samp ling at the pa tient end of the supraglo ttic dev ice (3 0). W ith unintubated , spo ntaneous ly b rea thing pa ti ents , p oor c o rrelation be twee n endtida l and arteri al CO 2 is as soc iated wi th partial ai rway obs truc tion, high res piratory rates , low ti dal v olumes , ox ygen del iv ery through the i psi la teral n asal c annula, and mouth breathing (68 ,93 ,458). Resul ts may be improv ed by is olating ins uffla ted ox ygen f rom ex haled gas es , observ ing the wav eform f or normal c onf ig ura ti on, a nd dec reas ing the oxygen flow rate (5 3,459). W hen a s ides tream capnometer is used wi th a Map les on s ys tem, exha led gas may be dil uted b y fresh gas during the la tter po rtion of exp iration if the expi rato ry f low rate is less than the s ampl ing f low rate of the c apnometer. T his wi l l c ause th e endtida l CO 2 reading to b e lowe red ev en if the alv eola r phase of the capnogram is flat or has a smal l pos itiv e sl ope. The amoun t th at the end-ti da l CO 2 is l owered wi ll depend on s ev eral f ac tors , inc ludi ng whe the r spo ntaneous or con trol led v entil ation i s used , the type of v entila tor and breathin g c ircu it, the fresh gas fl ow, the sampli ng rate , and the ex pi rato ry f lo w rate (22,460 ,46 1). Maneuv ers to obtain a Pe tCO 2 reading that is c loser to the P aCO 2 wi th Maples on sys tems incl ude using lo wer f res h g as fl ows , ex tend in g the time of expi ra tory flow, a dding dead s pace b etwe en the breathing s ys tem and gas s ampl in g point, a nd using a c i rc uit tha t automatical ly i nte rrupts the f resh gas flo w af ter i nspi ra tion or p rev ents mixi ng of exha led and f res h g ases (460 ,462). A q uic k method of ch ecking to see whether the Pe tCO 2 is arti fac tual ly l ow is to tempora ri ly dis connec t the fres h g as supply (463 ). If there is

an ab rup t ri se in P etCO 2 when th e d il uting effec t of the fresh gas is re mov ed, then the fi rs t breaths th at follow wi ll g iv e a better measure of the true P etCO 2 . Durin g high-f requency v en til ation, P etCO 2 is a poo r index of P aCO 2 (88). In order to meas ure the end-ti dal CO 2 , the high-frequenc y v entil ation s hould be in te rrupted to i mpos e a few s l ow bre aths (83 ,87 ,88 ,464,465,466 ).

Disturbances in the Ventilation:Perfusion Ratio

W hen there is v entil ati on -pe rfusi on mis matching, the rela tions hi p betwe en end-tidal and a rteri al tens ions of CO 2 is dis turbed. Cli nic al c ondi tions tha t can al ter the v olume an d/or dis tributio n of pulmona ry bl ood flo w i nc lud e pulmonary embolis m, pulmonary artery s tenos is or P .711 oc c lusi on, reduced ca rdiac ou tpu t, pulmo nary h ypo tensi on, hy pov olemia, and ce rtain h eart lesions (4 33,467,468,4 69,470,471 ,4 72). The end-ti dal to arterial CO 2 gradient inc reases as v enous admix tu re (ri ght to left shunt) occ urs . This can be caus ed b y a telec tas is , bronch ia l in tu bation , or c e rtain heart c ondi tions . Th e eff ect is less dramatic than that caus ed by an inc rease in dead spac e, bu t when the v enous admix ture i s l arg e (as i n c yanotic con geni tal heart d is ease ), i ts c ontri bution can be c onsiderabl e (425,469,473 ,474). Changes in body pos i tion, s uch as the l ate ral or prone pos ition, may c aus e an i nc reas e in the P a/Pe tCO 2 g rad ient (4 75,476). Patients with pulmonary dis eas e hav e an unev en d is tributi on of v entil ati on and, to a l ess er ex tent, blood fl ow. This leads to an inc reased gradien t (4 33,477,478 ,479). S ince posi tiv e end -ex pi ratory pressure (PEE P ) may dec rease the g rad ie nt (480,482 ), the arteri al-end -tid al CO 2 gradien t c an be a us efu l tool f or optimiz ing PEE P (377,482 ). A pati ent wh o has a gra die nt that narrows whi l e PE EP is gradua ll y i nc reas ed may hav e a wi dened gradie nt whe n the op timal lev el has be en exc eeded.

Capnometer Problems
If there is a leak o r break in the sa mp li ng lin e o r its connec tions , air wil l be added to the sa mple , and the end-tidal CO 2 readi ng wi ll b e l owe r th an the ac tual v alue (483,484 ,485) (F ig. 22.37). A n obs truc ted samp li ng cathe ter c an cause th e capnog ram to be dampened and cause fa lse ly high i nspired and falsel y lo w en dex pired CO 2 v alues (48 6). An occ luded sampl ing or ex haus t line ca n result i n no CO 2 be ing detec ted (34 4,487). An internal leak in the anal yzer c an resu lt i n arti fac tual ly h igh v alues (488).

Other probl ems that may resu lt in an inacc ura te P etCO 2 reading inc lude inc reas ed sa mpling tube resis tance , cha nges in atmosphe ric pressu re, improper c al ib ration, drif t, si gnal noise, s el ec tiv ity, p res sure eff ec ts from the s ampling s ys tem or patient env ironment, wate r v apor, and fo reign su bstanc es (252). W i th s ome anal yz ers , the gas used f or zeroing is obta ined from room ai r. If CO 2 -c ontain ing gas enters the ze roing sa mple , there wi ll be fals ely low CO 2 re adi ngs wi th a normal -l ook ing wav efo rm (48 9).

Other
A s ignificant disc repa ncy be twee n PaCO 2 and Pe tCO 2 may occur in patients tak ing ac eta zolamide, wh ic h dela ys the c onv ers io n o f HCO 3 - to CO 2 , caus in g a dec rease i n e nd-ti dal CO 2 (490). Gas so lu bil i ty changes with tempera ture, s o the arte ri al to end-tidal gradi ent may i nc reas e wi th h ypothe rmia u nl ess the P aCO 2 i s correc ted for hypothermia (491). Inadv ertent addi tion of CO 2 to the inspi red g as from a CO 2 las er may c ause elev ated readings (492).

Capnography
Mos t CO 2 moni to rs inc lude a wav efo rm. W av efo rms can be d is played on an os c illosc ope or p ri nted on pape r (112,242,493,49 4). S low s peeds c an be us ed to show t rends . Fas ter s peeds are us ed for exami ni ng indiv idual wav eforms . Exa mina tion of the wav efo rm wil l of ten explain readi ngs that appear inaccu rate. If the capn ometer reads sev eral peaks pe r bre ath o r breaths tha t do not hav e a plateau, the resp irato ry rate and peak CO 2 readings wil l be inac curate . The wav ef orm should be ex amined s ys tematic all y f or hei ght, f re quenc y, rhythm, basel in e, and s hape . Hei ght depends on the e nd-ti dal CO 2 . Frequenc y depends on the res pi ratory rate. The baseli ne is no rmal l y zero. An el ev ated basel ine (Fig. 22 .30) can resu lt f ro m deliberate adminis tration of CO 2 , rebreathi ng, exhaus ted abso rbent, a c ontaminated sa mple c ell , or an inc ompetent ex pi rato ry unidi rec tional v alv e. The basel ine may or may no t be elev ated wi th an i ncompetent i nsp iratory unid irec tional v alv e. The s hape of the no rmal wav ef orm is ill us trated in Fig . 22.23. Only one shape (top hat or si ne wav e) is c ons ide red no rmal . Phase I (ins pi ratory base li ne) begins at E and is normal ly ze ro, refl ec ting ins pired gas, whi ch is norma ll y dev oid of CO 2 . Phase II (ex piratory ups trok e) begins at B and continu es to C. Th is rapi d S -s hape d ups wi ng rep res ents the tra nsi tion f rom gas from the dead sp ace that does not partic ipa te in gas exc hange and alv eo lar gas th at contains CO 2 .

Phase III begins at C and con ti nues to jus t before D. As gas c oming almos t en ti rely f rom alv eoli is exh al ed, a pl ateau is norma lly see n. If a pla te au is no t seen, the maxi mum v alue ob tai ned may n ot be equiv al ent to the end-tidal lev el and the co rrela tion betwee n a rteri al and end -tidal CO 2 i s not l ikel y to be good. Th e s lo pe of this p hase is inc re ased b y v entilati on-perfus ion a bnormal ities in the lung (49 5) as wel l as ex te rna l fac tors s uch as a ki nked tracheal tube. The v ery las t portion of Ph ase III, id entif ied by D, is referred to as the end-ti dal point. The CO 2 lev el he re is n ormall y at i ts max imum. In normal i ndiv idua ls , th is is 5% to 5.5%, or 35 to 40 torr. The angle between Phas es II and III is c al led the (tak eoff, elev ation) angle (496). Normally , it is between 1 00 and 110 d egrees . It is dec reas ed wi th obs truc tiv e lung disease, as the de ad space v ol ume takes longe r to be ex haled. The s lope of P hase III d epends on the l ung 's v entilation-perfusion s tatus . A irway obs truc ti on and PEE P caus e an inc reas ed slope and a larg er angle (379,380,49 6). Other fac tors that af fec t the angle are the P .712 capnometer's response time , s weep s pee d, and the respi ra tory c yc le time (242).

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Figure 22.23 Normal carbon dioxide waveform. EA (Phase I) is the latter part of inspiration, during which the CO2 level remains at zero. BC (Phase II) represents the emptying of connecting airways and the beginning of the emptying of alveoli. As exhalation continues, gas from alveoli in regions with relatively short conducting airways appears and mixes with dead space gas from regions with relatively long conducting airways, resulting in an increasing CO2 level. CD (Phase III) shows the alveolar plateau. Because of uneven emptying of alveoli, the slope continues to rise gently. Point D shows the best approximation of alveolar CO2 (end of expiration, beginning of inspiration). In DE (Phase IV), as the patient inhales, CO2-free gas enters the patient's airway, and the CO2 level abruptly falls to zero. Characteristics of the normal capnogram include (a) rapid increase from B to C, (b) nearly horizontal plateau between C and D, (c) rapid decrease from D to E to zero, and (d) a zero baseline (EA AB). A good alveolar plateau greatly increases the chances that the end-tidal reading is a reliable estimate of the alveolar level.

The angle between the end of Phas e III and the desce nding limb of the capnogram i s cal le d the angle. Norma ll y, i t is approx imatel y 90 degrees . The an gle wi l l be i nc reas ed with reb rea thi ng . A nother p oss ible c ause of an inc reased angl e is a prolonged res pons e time c ompared wi th the res piratory c yc le time, partic ul arly i n ch il dren (242). The ang le wi ll be dec reas ed if the slope o f Phas e III is i nc reased.

Figure 22.24 Low end-tidal CO2 with a good alveolar plateau may be the result of hyperventilation or an increase in dead space ventilation. Comparison of PetCO2 with PaCO2 is necessary to distinguish these two conditions.
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P .713

Figure 22.25 Elevated end-tidal CO2 with good alveolar plateau may be caused by hypoventilation or increased CO2 delivery to the lungs.

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In P hase IV , the patie nt inhales . Norma ll y, CO 2 fal ls abruptl y to z ero and remains at z ero unti l the nex t exh ala tion. A numbe r of si tuations c an cause unus ual wav eforms . So me a re sho wn in Figures 22.24 to 22.42. Th ere is an In ternet webs i te d ev oted to capnography (http://www.c apnography .c om). If there is a leak in the sampl e li ne du ri ng pos itiv e-p res sure v enti lation or at the pati ent c onnec tion , the c apno gra m wi l l hav e a brief peak at the end of the plateau (106,221 ,502,504,505,509,510,511,512 ,513) (Fig . 22.34). If there is a leak in a sa mpling lin e that runs through the l umen of the exp iratory l i mb , th e base line wi ll be elev ate d, fals el y i nd ic ating rebreathing (514).

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Figure 22.26 Curare cleft or notch, which is seen during spontaneous ventilation. The capnogram on the left shows the notch. As the muscle relaxant is reversed, the curve becomes normal in shape. The cleft is in the last third of the plateau and is caused by a lack of synchronous action between the intercostal muscles and the diaphragm, most commonly caused by inadequate muscle relaxant reversal. The depth of the cleft is proportional to the degree of muscle paralysis. The position of the cleft is fairly constant on the same patient but is not necessarily present with every breath. The notch also is seen in patients with cervical transverse lesions, flail chest, hiccups, and pneumothorax and when a patient tries to breathe during mechanical ventilation.

Patients who are pa rtia ll y paral yzed wi th musc le relax ants may make respi ra tory ef fo rts anytime during the res pi ratory c yc le wi th c ontrolled v enti lation (Fig. 2 2.27). If the p ati en t is s pontaneous ly breathing and the depress io n occu rs i n the late r third of the wav eform, i t is referred to as a c ura re cl ef t (515) (Fi g. 22.26). P .714

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Figure 22.27 Spontaneous respiratory efforts during mechanical ventilation. The capnogram shows small breaths at various places during expiration and inspiration. Causes include maladjusted ventilator (hypoventilation), inadequate muscle paralysis, severe hypoxia, or the patient waking up. The end-tidal CO2 may rise slightly because of increasing metabolism of the contracting respiratory muscles. This pattern may also be caused by pressure on the patient's chest or ventilator malfunction.

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Figure 22.28 Cardiogenic oscillations appear as small, regular, toothlike humps at the end of the expiratory phase. They may be single or multiple, and the heights may vary considerably. They are believed to be due to the heart beating against the lungs. A number of factors contribute to the appearance of cardiogenic oscillations, including negative intrathoracic pressure, a low respiratory rate, diminution in the vital capacity:heart size ratio, a low inspiratory:expiratory ratio, low tidal volumes, and muscular relaxation (268,269,497). In many cases, adjustment of the ventilator rate, flow, or tidal volume will remove this pattern from the screen. Other times, however, it cannot be corrected. Cardiogenic oscillations are the rule rather than the exception in pediatric patients because of the relative size of the infant's heart and thorax. Capnograms from patients with severe emphysema tend not to register cardiogenic oscillations. Less sophisticated capnometers may count each oscillation as a breath, displaying a respiratory rate higher than actual. Cardiogenic oscillations may result from the positions of the components in the breathing system in relation to the sampling site. Placing the sampling site on the patient side of an HME may remove the oscillations (454,498) The addition of low level positive end-expiratory pressure can also be used to eliminate these oscillations (499).

A capnogram with two peaks (b iphasic ) ma y b e caus ed by uni late ral conditions that caus e uni latera l hyp ov en tila ti on or high ai rway re s is ta nce, single lun g transplantation, bronch ia l in tubation , or severe k yph osc olios is (516,517 ,518,519,520).

Volatile Anesthetic Agents

Meas uri ng c once ntrations of v olati le anes thetic g ases is common p rac tice. In s ome countries (but no t the Un ited S tates a t the time of this writi ng), agent moni to ring is a s tanda rd of c are (122 ). The anes thesia wo rks ta tion s tanda rd (524) requires that the work s tation be prov ided with a d ev ice to mon itor the c oncentration of anes the tic v apor in the insp iratory gas . An anes thetic agent mon itor may be a s tand-a lone dev ice or part of a mul tiparameter monitor.

Standard Requirements
Inte rna tional and U.S . s tandards f or a nes thetic gas moni tors are av ailabl e (209,210 ). The followi ng are prov isions o f both s tanda rds .

For halogenated anes the tic gas es , the difference be twe en the mea n anes thetic gas reading and the a nes the tic gas lev el shal l b e wi thin 0.2 % v ol % + 15 % of the anes thetic gas lev el .

A high conc entra ti on alarm is mandatory. A l ow c oncentration ala rm is opti onal .

Measurement Techniques
The v ola ti le anes thetic agen ts can b e me asured by us ing inf ra red analysis , refrac tometry , or piez oelec tric analys is . W hen an agent is used f or wh ic h an analy zer i s not P .715 programmed, i t may be p ossible to ap pl y a c onv e rs ion f ac tor s o that the analy zer may be us ed to monitor that a gent (525 ,526).

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Figure 22.29 Prolonged expiratory upstroke. The left curve shows a normal waveform. The other three curves show progressive slanting and prolongation of the expiratory upstroke. As expiration is progressively prolonged, inspiration may start before expiration is complete so that the end-tidal PCO2 reading is decreased. This is indicative of obstruction to gas flow caused by a partially obstructed tracheal tube or obstruction in the patient's airways (chronic obstructive lung disease, bronchospasm, or upper-airway obstruction).

Significance Vaporizer Function and Contents

An adv antage of moni tori ng potent agents is the abi lity to as ses s v apori zer ac curac y. It is recommended that v aporizer output be v erified twi ce a yea r as wel l as at any time a v apo ri zer is disc onnec te d from the anes thes ia machine and then reins tall ed (208). W hen a v aporize r is s uspec ted of malfunc tio n, i t can be easi ly checke d by plac ing the e nd of the s ampl ing catheter i n th e f resh gas f lo w. Agent-s pec ific ana lyz ers c an detec t an incorrec t agen t, and non-agent-spec ific analy zers wil l us ual ly P .716 ex hib it unus ual readi ngs when an agent erro r is made (129 ,130).

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Figure 22.30 The baseline is elevated, and the waveform is normal in shape. This may be caused by an incompetent expiratory valve or exhausted absorbent in the circle system; insufficient fresh gas flow to a Mapleson system; problems with the inner tube of a Bain system; deliberate addition of CO2 to the fresh gas; or in some cases, an incompetent inspiratory valve. It may also be the result of rebreathing under drapes in a spontaneously breathing patient who is not intubated.

Figure 22.31 Return to spontaneous ventilation. The first breath is typically of small volume. Subsequent breaths show progressively higher peaks with gradual resumption of a normal waveform.
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Anes thetic agent mon itoring wi l l alert the us er whe n a v aporizer has b ecome emp ty or is tu rned OF F, when i t is inadv e rtently i n the ON pos iti on, or when a v apo ri zer not in us e is al lowin g significan t amoun ts of v apor to leak into the fres h gas li ne (527). The dif fe rence between the v apori zer setting and the meas ured ins pired conc en tration of the agent puzzles man y clinici ans . The re is usual l y a diffe rence between the two v alues , with th e ins pired co ncen tration be ing lowe r at the beginning of a cas e and higher a t the end. T his d is c repanc y res ults from the ti me needed to equi librate the c oncen tration i n th e relativ ely large v olume of gas in the

breathi ng s ys tem as wel l as by agent uptake by the patient. If low f res h gas flows are us ed , the time needed f or equi li bration wi l l be lo nger. If the v olati le a nes the tic agent is reac ting wi th d esicca ted abs orben t (Chapter 9), th e d iffe renc e wil l be i nc reas ed.

Figure 22.32 Incompetent inspiratory unidirectional valve. The waveform shows a prolonged plateau and a slanting inspiratory downstroke. The inspiratory phase is shortened, and the baseline may or may not reach zero, depending on the fresh gas flow. A similar pattern may be seen with suction applied to a chest tube.
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Information on Uptake and Elimination

Moni tori ng v ola tile an es thetic a gents prov ides inf ormation on uptake a nd el imina tion. The diff ere nce be tween ins pi red and expi re d l ev els p rov id es a measure of patien t s aturation .

Teaching
Anes thetic agent mon itoring c an be used to demons trate the relati onship between agent co ncentration i n the f resh gas li ne and that in the breathing s ys te m. This makes agen t moni to ri ng use ful for teaching lo w-f l ow a nes thes ia .

Figure 22.33 Irregular plateau and/or baseline may result from displacement of the tracheal tube into the upper larynx or lower pharynx with intermittent ventilation of the stomach and lungs or from pressure on the chest, which causes small volumes of gas to move in and out of the lungs.
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P .717

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Figure 22.34 A leak in the sampling line during positivepressure ventilation will result in an upswing at the end of Phase III (71,500,501,502). A plateau of long duration is followed by a peak of brief duration. The height of the plateau is inversely proportional to the size of the leak. The brief peak is caused by the next inspiration, when positive pressure transiently pushes undiluted end-tidal gas through the sampling line. If the patient is breathing spontaneously a falsely low end-tidal carbon dioxide reading may be seen, owing to air entrainment, but no terminal hump is seen. An upswing at the end of Phase III may also be seen in obese and pregnant patients (242,503,504,505).

Information on Anesthetic Depth

Kno wledge of v ola til e agent c onc entrati ons may prov ide ev ide nce that the patient who i s paral yzed is nei th er awak e nor gros sly ov erdose d, may pe rmi t more rapid awa kening of the pa tient, and may a id in the di agnos is of de la yed emergence. A wareness due to a low c oncentration of inh ala ti ona l agent may be av oided (5 28).

Meas uri ng c once ntrations of v olati le anes thetic a gents may help to av oid c ardiac arres ts due to ov erdos age. This is partic ul arly a problem in ped ia tric pa tients (5 29).

Figure 22.35 If the compliance, airway resistance, or ventilation-perfusion ratios in one lung differ substantially from the other lung, a biphasic expiratory plateaus may be seen (506). This type of capnogram has been reported in a patient with severe kyphoscoliosis (507) and following single-lung transplantation (508).
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These dev ic es are not true moni tors of anes th etic dep th, as the c ondi tion of the pati ent d epends on many other things bes ides the inhal ed anes thetic agent conc en tration . A nes th etic agent moni toring shoul d not be regarded as a replacement f or other means of measurin g a nes thetic depth but as an addi ti onal sourc e o f informatio n. A s tudy of a nes theti zed pa tients found th at predic tion of arte ri al lev els f rom end -tidal co ncen trations was diff ic ul t (530). Agen t moni to ri ng has not been s hown to res ul t in an improv ement in intraoperativ e hemodynamic s tabi l ity or ea rl y rec ov ery wi th ei ther high or l ow to tal gas flows (531 ,532,533).

Detecting Contaminants
Con taminan ts in the ni trous oxi de sup ply we re detec ted wi th an a gent mo ni tor that i ndicated the presenc e of a v olatile agent when n o v apori zer wa s turned ON (534). An age nt moni tor i ndic ated a warnin g tha t a foreign agent was present whe n a defec tiv e temperature -compens ation dev ice in a v apori ze r released diethyl e the r i nto the v apori zing ch amber and the ins pired gas (141 ).

Information for the Electronic Record System

W ith the expec ted inc reas e in au toma ted reco rd keepi ng, the abi l ity to automatic al l y add informatio n s uch as the concentra tion of v olatil e agent to the record is i mportant (C hapter 28 ). P .718

Figure 22.36 Too low a sampling rate with a sidestream capnometer will result in a low peak and, often, elevation of the baseline. Erroneous values for both inspired and endtidal CO2 will be reported.
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Figure 22.37 Contamination of expired sample by fresh gas or ambient air may be caused by placing the sampling site too near the fresh gas inlet, a leak, or too high a sampling flow rate. A: A large leak is indicated by the progressive decrease in the plateau. B: Here, the contamination is of lesser magnitude and a dropoff occurs at the end of the plateau.
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P .719

Figure 22.38 A sudden drop of end-tidal CO2 to zero is usually caused by an acute event relating to the airway, such as extubation, esophageal intubation, complete breathing system disconnection, ventilator malfunction, or a totally obstructed tracheal tube. It may also be the result of a plugged gas sampling tube.
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Detecting Disconnections
If a dis connec tion occu rs be twee n the CO 2 s ens ing s i te and the b rea thing s ys tem whi l e the pa tient is sponta neous l y breathing, th e a gent conc entra tion may drop whi l e the end-tidal CO 2 l ev el wi ll be u nchanged (535 ).

Nitrous Oxide
Technology
Ni trous ox id e c an be meas ured direc tl y onl y b y inf rared technology . There are a nd i nte rna ti ona l and U.S . s tandards cov ering th e requ iremen ts (209,210 ). W hen ox ygen an d nitrous ox ide are used toge the r, the ni trous ox ide c onc entration can be approxima ted by the ox ygen anal yzer.

Figure 22.39 The causes of a sudden drop of end-tidal CO2 to a low but nonzero value include a poorly fitting tracheal tube or mask, a leak or partial disconnection in the breathing system, and a partial obstruction of a tracheal tube.

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Figure 22.40 Events that cause an exponential decrease in end-tidal CO2 include sudden hypotension owing to massive blood loss or obstruction of a major blood vessel, circulatory arrest with continued pulmonary ventilation, and pulmonary embolism (air, clot, thrombus, or marrow).

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Significance
Analys is of ni trous ox id e wi l l s ho w wh ether the flowmeters are f unc ti oning properly . A t the end of a c ase , wash out of nitrous ox ide wi ll av oi d diffus ion hypox ia.

Nitrogen
Prev ious ly , ni trogen c oul d be me asured by us ing Raman sca ttering or mass spec trome try. A t the time of this wri ti ng , both of these tech nologies were no longer av ailab le for c l inic al us e. Th is cons titutes a loss fo r the c linici an bec ause there are adv antages to moni tori ng ni trogen. These adv antages a re discussed (pp. 721722)

i n h opes that in the future some technology wil l b e dev eloped tha t wil l a llow th is moni tori ng.

Verifying Adequate Denitr ogenation

An i mportan t use of n itro gen moni toring is to ens ure a dequ ate deni trogenation before induc tion. This is especiall y a concern with pediatri c patients , i n patien ts wi th l ung disease, a nd in pa ti ents wi th a red uced func ti ona l resi dual c apacity P .720 (e.g ., obes i ty o r pregnanc y) as well as durin g a rapid sequenc e i nduc tion.

Figure 22.41 Small air embolus with resolution.

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Figure 22.42 Release of a tourniquet or unclamping of a major vessel may result in a sudden increase in end-tidal CO2 that gradually returns to normal.

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Detecting Venous Air Emboli

A ris e i n exhaled ni trogen may in dicate that air from s ome source has entere d the breathi ng s ys tem (536). Ni trogen monitoring c an prov ide information that is helpf ul i n d is tinguis hin g a ir embol i f rom other ev ents tha t cause re duced CO 2 elimination.

Monitoring Breathing System and Anesthesia Machine Integrit y

Normally du ring general anes thesi a, the level of ni trogen in the b rea th ing s ys tem drops rapidl y at fi rs t an d then more s lowl y. A s low dro p o r a ri se may be ca used by room air e nteri ng thro ugh a leak , disc onnection , poo rl y fi tti ng mask, an uncuffed or l eak ing trac hea l tu be, or a c hang e i n v aporize rs (537,538 ). A leak in the samp li ng s ys tem c an c aus e n itro gen to be d etec ted. To de termi ne if this is occ urri ng, pure ox ygen f rom the anes th esia machine should be sampled. If the moni tor c ontinues to show ni troge n, ai r i s leaki ng in to the sampli ng li ne.

Detecting Nitrogen Accumulation

Des pite high initial gas f lows , nitro gen can buil t up in the breathing sys tem d uring l ow-f l ow anes thes ia. This can c ause a s ignif ic ant dec rease in the lev els of ox ygen, ni trous ox ide, an d v ol atile agen ts .

References
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[Med li ne Link ] 512. Martin M, Zupan J . Unus ual end-ti dal CO 2 wav eform. A nes th esiology 1987;66:712713. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 513. Ras sam S , Hal l JE , Mecklenburgh J . The do ubl e tai ls -up capn ograph. Anaes thes ia 2004;59:1034 1035. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 514. Sch wann N, Maguire D, S mi th C. A cas e of arti fac tual rebreathi ng. J Cl in Anes th 1 997;9:589590. [Cross Ref] [Med li ne Link ] 515. B issi nge r U, Len z G. Capnogra phic detec tion of diaph ragm mov ements (c u rare cl efts ) duri ng complete v ecu ron ium neuro muscular block of the adduc tor poll ic is mus cle. Anes th Analg 1993;77:13031304. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 516. S riniv asa V , Kodali BS , Hartigan P M. Ev olv ing capnograms af te r si ngle lun g transplant. Anes th An al g 2004;98:1504. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 517. W ill iams EL , Jel lis h W S, Modic a PA , et a l. Capnog rap hy in a pa ti ent a fter s ingle lung trans plantation . A nes thesiology 1991;74:621622. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 518. Nichols K P , Be numof J L. B iphasic c arbon dioxi de ex c re tion wav efo rm from a pati ent wi th s ev ere k yphos col ios is . Anes thes iol ogy 1989;71:986987. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

519. B joraker DG. A irway management in the operating room. In: Grav ens tein JS , Jaff e MB , Paulus DA , e ds . Ca pnog raphy: c linical aspects . Cambri dge, MA : Cambridge Univ ersi ty P res s , 2004:3944 . 520. Gilbe rt D, Benumof J L. B iphas ic carbon di oxide eli mination wav efo rm with righ t mai ns tem b ronchial i ntuba ti on. A nes th A nal g 1989 ;6 9:8298 32. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 521. Bhende M. Capnography i n the pediatri c emergenc y department. Pediatr E merg Care 1999;15:64 69. [Cross Ref] [Med li ne Link ] 522. Frakes MA . Measuri ng end-ti da l carbon di ox ide : cl in ic al applica tions and us efulness . Cri t Care Nurs 2001;21:2335. [Med li ne Link ] 523. W ard KR, Yeal y DM. End-tidal carbon diox ide monitoring in emergency medicine. Part 2: c l inical appl ic ations . Acad E merg Med 19 98;5:637646. [Med li ne Link ] 524. A meric an Soc iety fo r Tes ti ng and Materi als . S tandard s peci fic ation for partic ula r requi rements for anes thes ia works tatio ns and thei r c omp onen ts (AS TM F 1850-00). W est Conshohock en, PA : Author, 2000 . 525. Tsu i B , Jo ll y D, Cl anac han A . Es ti matio n of des fl urane concentration us ing i sof lu rane c hannel in optic al i nf rared analy zer. Can J A naes th 1999;46:192 195 . [Med li ne Link ] 526. Gyermek L. Can the ol d v apor moni tors meas ure new v apo r anes thetics ? J Cl in A nes th 1997;9:171172 . 527. Fou nd P , Forres t AP . V aporiz er lev el obs truc tion detec ted by anes th etic v apor analys is . Anes th A nal g 1999;88:46 9. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 528. Osbo rne GA , Webb RK , Runc ima n W B. T he Aus tralian Inc iden t Moni to ring S tudy. Patien t awareness during anaes thes ia: an a nal ysis of 2000 inci dent repo rts . Anaes th Intens Ca re 1993;21:653654. [Med li ne Link ]

529. Morray J P , Geidusc hek J M, Ramamoorthy C. A nes thes ia-related cardiac arres t i n c hi ld ren . A nes thes iology 2000;93:614. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 530. Frei FJ , Zbinden A M, T homso n D A , et al . Is the e nd-tidal parti al press ure of i sof lu rane a good predic tor of i ts a rteri al parti al pres sure? B r J A naes th 1991;66:331339. 531. K lein KW , W ang JK , Liu J , et al. A nes the tic gas moni toring do es not improv e hemo dynamic s tab ility or recov ery times . An es thes iolog y 1 993;79:A449. 532. Liu J , Kl ei n K W, Gri ffin J D, et al . Does moni tori ng end-tidal is of lurane conc en tration improv e ti tration during g eneral a nes thes ia . J Cli n Anes th 1995;7:186191. [Cross Ref] [Med li ne Link ] 533. W ang J , Liu J , White PF, et a l. Effec ts of end-ti dal g as moni to ring and flow rates o n hemodynamic s tabi li ty and recov e ry prof il es . Anesth Anal g 1994;79:538 544. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 534. Joh nson E B . Detec tion of con taminated ni trous oxi de. A nes thes iolog y 1987;66:257. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 535. Kennedy RR, F rench RA . A breathing c ircui t disc onnec tion detec te d by anes thetic agent monitoring. Can J Anes th 2 001;48:847849 . 536. Rus sell GB , Graybeal J M. The sens i tivi ty of Raman spectrometry for detection of air e mbol is m in dogs . Anes th Analg 19 94;78:S372 . 537. Lan ier WL . In traope rativ e ai r entrainme nt wi th Ohi o Modulus anes thes ia machine. A nes thes iology 1986;64:266 268 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

538. Pennant J H. Sudden inc rease in end-tidal ni trogen d ue to changi ng v apori ze rs . Anes th An al g 1995; 81:13051306. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] P .727

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. Ad vantages of a nondiverting mo nitor include A . Quick response time B . W ater is less likely to caus e p rob lems C. Sc av engi ng of gases is not necess ary D. A s tandard ca li brati ng gas can be us ed V iew A ns we r2. Disa dvantages o f a nondiverting monitor include A . Only CO 2 and ox yg en can be meas ured by th is method B . B lood o n the c u rette wi l l cause acc urac y problems C. The s ens or can be damaged b y mishandli ng D. It cannot be used on pa tients who do not hav e a trac heal tub e i n place V iew A ns we r3. P ossible sampling sites for a diverting monitor include A . A n HME B . Th e base or ins ide of th e nos e C. An el bow adaptor D. The d is tal end of a tracheal tube V iew A ns we r4. If the samplin g flow rate of a diverting monitor is too low , A . Th e delay time and rise time wi l l be dec reased B . Th e peak readings o n the c apnog ram wi ll b e l owe red C. The b aseline on the capnogram wi l l be dep res sed

D. The p la teau on the capnog ram wi ll b e absent V iew A ns we r5. Advantages o f a d ive rting gas mon itor inclu de A . Ca librati on and zero ing a re us ual ly au toma tic B . Th e patien t con nec ti on is us ual l y d is posa bl e C. Remo te moni toring is poss ible i n the MRI s uite D. Lo w d ead space V iew A ns we r6. Disa dvantages o f a divertin g ga s mo nitor include A . Dead spac e in the bre ath ing s ys tem is inc reas ed B . Gases from the monitor mus t be retu rne d to the b rea thing s ys tem o r scav enged C. W arm-up is usu all y prolonged D. The d el ay ti me is prolong ed V iew A ns we r7. Advantages o f infra red monito rs inclu de A . Th ey do not need to be k ept o n s tandby B . Response time is f as t enough to meas ure bo th ins pirato ry an d end-tidal v alues C. Units are s ma ll and ligh twei gh t D. Pe ri odic cal ibra tion wi th a s tanda rd gas is suffici en t V iew A ns we r8. Disa dvantages o f infra red gas analysis include A . W ater v apor wi l l cause in terference B . It is diff icu lt to add ne w a gents C. Helium caus es arti fac tu al ly low CO 2 v al ues D. Sa mp led gases must be sc av enged af te r analys is and cann ot be ad ded to the breathi ng s ys tem V iew A ns we r9. Wh ich of the fo llow ing d efinitions is co rrect? A . De lay time is the time to ac hiev e 10% of a s tep change in reading at the gas moni tor B . Th e parti al press ure of a gas is the press ure that a gas in a gas mix ture wo uld ex ert i f i t alone oc cup ied the v ol ume of the mix ture at the s ame tempe rature C. Rise time is the time requi red for a c hang e f rom 10 % to 9 0% of the total c hange i n a gas v alue wi th a c hange in c onc entration at the sampl ing s i te D. The s ampling site is the locati on from whic h gas is d iv erted for meas ure ment in a div erting moni tor or the location of the sens or i n a nondiv e rting mon itor V iew A ns we r10 . Conce rning microstream techn ology, A . It util i zes lase r-based tec hnology B . It prov ides a rapid res pons e time C. Readings are not affec ted by high concentrations of ox ygen or anes thetic g ases D. The a irway adaptor has two channels , e ach f acing a diff ere nt di rec tion

V iew A ns we r

Chapter 23 Airway Volumes, Flows, and Pressures

P .729

Definitions

Compl ianc e: Ratio of a c han ge in v olume to a c hang e in press ure . It is a meas ure of dis tensi bi li ty and is usuall y express ed in mill ili ters pe r cen ti mete r of wa te r (mL/cm H 2 O). Compli ance co mmonl y refers to the lungs and ches t wal l . B re ath ing s ys tem components , espec ia lly breathin g tub es and the reserv oi r ba g, also hav e compl iance .

Exp iratory Flow Rate: Ra te at wh ic h gas is exhal ed by the patient ex presse d as v olu me p er uni t of time. Exp iratory Flow Ti me: Time between the beginning and end of expi ratory flow (Fig . 23.1). Exp iratory Pause Ti me: Ti me from the end of exp iratory f lo w to th e s tart of i nspi rato ry flow (Fig . 23.1). Exp iratory Phase Ti me: Ti me between the start of exp iratory flow a nd th e s tart of ins piratory f lo w. It is the s um of the exp iratory f lo w a nd expi rato ry pause times (Fig . 23.1).

Ins pi rato ry Flow Time : Perio d between th e b eginning and end of inspi rato ry f low (Fig . 23.1). Ins pi rato ry Pause Ti me : That porti on of the i nspi ra to ry phase ti me during whi c h the lu ngs are hel d inf late d a t a fixed pres sure o r v olume (i .e., the time of z ero flo w (Fi g. 23 .1). It is also c alled the inspi ra tory hold, infla tion hold, and insp iratory platea u.

Ins pi rato ry Phase Ti me : Ti me b etween the s ta rt of ins pi ratory flow and the beginning of ex piratory fl ow (Fi g. 23 .1). It is the sum of the i nspi rato ry f low and ins piratory pause times . The insp iratory p ause time :i nsp iratory phase time (T I P :T I ) may be expressed as a p erc entage .

Ins pi rato ry :Exp iratory Phase Ti me Ratio (I:E ratio): Rati o of the ins piratory phase time to the exp iratory ph ase time. For ex ampl e, an I:E ratio of 1:2 means tha t th e ins piratory phase time is one thi rd of the v enti la to ry cyc le time.

Ins pi rato ry Flow Rate: Rate at whi ch gas fl ows in to the patie nt ex pressed as v olume pe r uni t of time. Minute V olu me: Sum of al l ti dal v olumes wit hin 1 minu te. Peak P res sure: Max imum press ure du ri ng th e i ns piratory p has e time (Fig. 23.1). P lateau P ressu re: Res ting airway press ure du ring the ins pi ratory paus e. The re is usua ll y a loweri ng of airway pressure f rom peak pressure when there is an inspi rato ry pause (F ig. 23.1). Thi s l owe r pressu re is c al led the plateau press ure .

Pos itive End-ex piratory P ress ure (P EEP ): Pos itiv e pressure in the ai rway a t the end of exhalation. Res is tance: Ra tio of the c hange in driv ing pre ssure to the cha nge in flow rate . It is co mmonly express ed as cen ti mete rs of wate r per l i ter per second (c m H 2 O/L /s econd).

Ti dal Volume: Volume of gas entering o r leav ing the p ati en t during the i nspi rato ry or expi ra tory phase time, respectiv ely . Ven ti la to ry (Respi ra tory ) Ra te or F requenc y: Number of resp iratory c yc les per uni t ti me, usuall y per minute. W ork o f B re athing: Ene rgy expended by the patient and /o r v enti lator to mov e gas in and ou t of the lungs (1). It i s expres sed as the rati o of work to v olume mov ed, co mmonl y as joules per l iter. It inc lu des bo th th e work needed to ov erc ome the elas tic and flo w-res is tiv e forces of the bo th res pi rato ry s ystem and a pparatus .

Figure 23.1 Flow, volume, and pressure curves from a ventilator that produces a rectangular inspiratory flow wave. A: This represents controlled ventilation with no inspiratory pause. The end-inspiratory pressure will equal the peak pressure. B: With an inspiratory pause, there is a decrease from peak pressure to a lower plateau pressure. C: This illustrates the effect of continuing fresh gas flow during inspiration. The inspired volume increases, and the peak pressure falls, then rises.

View Figure

P .730

General Considerations The Ventilatory (Respiratory) Cycle

A i rwa y p res sure with con troll ed v entilatio n is sho wn in Figure 23.1. The re is a ri se i n p res sure with no preced ing negativ e pressure. A fas t ris e to peak pressure sugges ts too high a fl ow. Th e peak press ure wi l l inc rease if tidal v olume, i nspi rato ry flow rate , or res is tanc e i nc reas es or c ompl ia nce dec reases . A dec reas e i n p eak press ure may resu lt f ro m a leak , s pon tan eous ins piratory effort by the pati ent, a dec rease in res is tanc e, or an inc reas e in compliance. Fi gure 23.1B shows the respi ra tory c ycle wi th an ins piratory paus e . If the pa use is l ong eno ugh, a p la teau p res sure wil l oc cur a t the end of i nspi ration . The pl ateau press ure is usually preceded by a hi gher peak press ure . P .731 P lateau press ure depends on ti dal v ol ume and the total s tatic compl iance bu t is i ndependent of resis tanc e (2).

Compliance and Resistance

In the pas t, compliance and res is tance measu rements du ring anes thesi a were diff icul t and inv olv ed bulk y apparatus . Th ey can now be meas ured acc ura tel y on a real -time bas is with relativ el y c ompac t equ ipment.

Compliance
Compl ianc e me asurement may be dyn amic or s ta tic . Dy namic compl iance is ca lc ula ted b y d iv idi ng the difference i n v ol ume by the difference i n p res sure at two points during the v entilatory c yc le. Th is is not a true measure of total comp li anc e, becaus e the ai rway pressure inc ludes the press ure ne eded to ov ercome resis tance (3). S tatic co mpli ance is ca lc ul ated b y usi ng the e nd-ins pi ratory occ lus ion p res sure (4,5 ) (Fi g. 23.22). Condi tions of zero gas flo w a re ac hiev ed by employ ing an i nspi rato ry ho ld or occ luding the expi rato ry po rt long enough to allow ai rwa y press ure to reach a cons tan t v alue . This pressure, c ommonl y te rmed pl ateau press ure , represents the elas tic recoil of the tota l respi ra tory s ys te m at e ndi nflation v ol ume. S tatic Complianc e = Tidal v olume/P lateau pre ssu re - P os itiv e end-exp iratory press ure (PEEP ) In adul ts , normal total s tatic c ompliance is 3 5 to 100 mL/cm H 2 O. In childre n, normal s tatic compl iance is greater than 15 mL/cm H 2 O (6). Total c ompliance reflec ts the elas tic prope rties of the lun gs , thorax , abdo men, an d the breathing s ys tem. Us ing mus cle relaxa nts wi l l i nc rease c hes t wall c ompl iance but wil l no t affec t lung complianc e, so in paral yzed pa tients , c hanges in c ompliance reflec t mainly al tera tions i n lung compl iance .

Resistance
W hen gas f lows th rough a tube, energy is los t. This is ref lec te d b y a dec rease in press ure . The press ure drop can be express ed as the p roduc t of resis ta nce and f low rate . For a giv en ti dal v olume, a high res is tance may be ov erc ome by us ing a l ower f lo w f or a l onge r ti me or a higher driv ing press ure . During c ontrol led v enti lation , if the re is an inc reas e in ai rway re sis tance, the pres sure neede d to deliv er a giv en ti dal v olume wil l i nc reas e. This can usuall y be supplied by the v enti lato r or the person s queez in g the reserv oi r bag s o tha t ins pi ra tory flow i s not af fec ted. Becaus e exhalation is passiv e, expi rato ry flow depends o n the el as tic and resis tiv e f orces of the lungs and the res is tanc e in the expi rato ry limb of the breathi ng s ys tem and air way dev ic e.

Total res is tance, wh ich may d iffe r during ins piration a nd exp iration , is d ete rmined predomina ntl y by the res is tance of the patient's ai rway, the trac heal tube, and the breathi ng s ys tem. Dec reas ed airway ca liber from b ronchoc ons tric ti on, s ec retions , tumor, edema , a foreign bod y, or airway c losu re is associ ated wi th i nc reased resis tance . Tracheal tube res istance depends p rimari l y on its in ternal diameter. Parti al tub e obs truc tion by s ec reti ons , ki nk ing , or other p roblems wil l cause i nc reas ed res is tance. B reathing s ys te m resis tanc e is affec te d by the l eng th an d i nte rna l diameter of i ts c omponents and is inc reased by s harp bends and cons tric tio ns . Total airway res is tance c an be es tima ted by us ing the dif fe rence between peak and plateau press ures , whi ch is normall y 2 to 5 cm H 2 O. If there is an inc reas e i n resis tance , a higher p eak press ure wi ll be nec essa ry to p roduce the same flow. P lateau press ure, howev er, depends onl y on c ompliance and wi ll not be affec ted by resis tance . Theref ore, if the ins piratory f low a nd tidal v olume remain c ons tant but resis tance inc reas es , there wil l be a greater d iffe rence between the peak and plateau press ures .

Measured Gas Composition

The c ompos ition of th e gas bei ng meas ured wil l affec t the acc urac y of f lo wmeas uri ng dev ices (7,8 ). Differenc es in d ens i ty and v iscosity of the gas es c an i nduc e an error i n flow meas u rement. The compos i tion of c arri er gas has a g rea ter i mpac t on v iscos ity than v ol atile anes th etic agents , whe reas dens i ty is more i nflue nced by v olati le agent c onc entrations (9). For accu rac y, the flow-meas uring dev ic e should be as soc iated wi th a gas monitor that c an make corre c tions to gas f low c aus ed by changes i n gas c ompos i tion . If a gas s uch as x enon that is not meas ured is p res ent, f low meas urements may be i nacc urate (8).

Respiratory Volume and Flow Measurement

A res pi rome ter (sp irometer, v entilati on or respi ra to ry meter or mon itor, v enti lometer, v olume measu ring dev ic e, f low monitor, res pi ratory fl owmeter) is a dev ic e tha t meas ures the v olume of gas pas s ing durin g a p eriod of time through a l ocation in a f low pa thwa y (10 ). Moni tori ng respi rato ry v olumes and flows ca n aid in detec ting bre ath ing s ys tem obs truc tions, dis connec tions, apnea, leaks , v en ti la tor fai lure , and high or l ow v olumes in spontaneousl y breath ing patien ts as wel l as i n thos e whose v enti la tion i s contro ll ed. Some can de tec t rev ersed f low, an in dic ation of an incompe ten t

unidi rec tional v alv e or a leak . A disc repancy be twe en ex pi red and inspi red tidal v olume s houl d sugges t a leak . P .732 A dec rease in tidal v olume as soc iated wi th the tracheal tube mi grating i nto a bronc hus may be de tec ted (11). Al though there a re other wa ys of d etec ting thes e problems , such as observ ing ches t wal l mov ements , monitoring b rea th so unds , capnometry, and airway press u re moni toring , the use of a v olume monitor prov ides additi onal pro tec tion. One s tudy fo und that for detec ting and c las sify ing breathing s ys tem faul ts , a v olume moni tor was be tter than ai rwa y pressure or ca rbo n d iox ide moni tori ng (12). In 1999, the Americ an Soc iety of Anesthes iologis ts (AS A ) s tron gly encourage d qual itativ e moni tori ng of the v olume of ex pi red gas . Th e anes thes ia work s tatio n s tandard requi res a dev ic e to moni tor the patient's exhaled tidal or minute v olume or both (13). Res piratory v olume moni tori ng may fa il to detec t some problems . W i th ai rway oc c lusi on, there may be enough flow duri ng ex pi ration resul ting f ro m compression of gas withi n the b rea thing sys tem d uring inspi rati on to prev ent the respi rometer alarm f rom being ac tiv ated . If the sensor is attached to the pati ent's trache al tube or s upraglottic ai rway dev ice, a disc onnec tion betwe en the s enso r and the breathi ng s ys tem wi ll not be de tec ted if the pati ent is spontaneousl y b rea thing . If the sens or is in the exha la tion s ide of the breathing s ys tem, the disc onnec tion wi l l be de tec ted. It is possi ble to hav e fai rly no rmal fl ow with esophageal intubation. A high-v olume alarm may be us eful to de tect unantic ipa ted inc reas es in tidal v olume (14). This may be due to imprope r venti la tor setti ngs or inc reased gas fl ow i nto the breathing s ys tem duri ng inspi ration, resu lting from a hole i n the v entil ator bellows , an inc reased insp iratory :ex pi ratory (I:E ) ratio , or f rom th e flowmeters (if there is no f res h g as fl ow compensa tion or decoupling ). During pressu re c on trol v enti lation , a dec reas e in complianc e wil l resul t in an inc re ased tid al v olu me. Ol der respirometers we re s tri c tly mechanic al dev ic es . Ne wer respi rometers co nv ert f low i nto a n e lec tronic si gna l th at is processed and displayed. E lec tronic proces s ing enhanc es al arm capabi li ty. A larm limi ts s hould be set as clos e as poss ible to the displayed ti dal or minute v olume withou t pro duci ng an un acc eptable inc id ence o f fals e-pos i tiv e a larms (15 ).

Equipment
Ventilator Bellows Scale

Ven ti la to rs that are used in anes th esia are disc uss ed in Cha pte r 12. If the v enti lato r has a bel lows , the re is us ual l y a s cale on th e bel lows hous ing . This scale can p rov id e a rough es timate of tida l v olume de liv ered i nto the breathi ng s ys tem but is no t an acc ura te es ti mate of th e v olume deliv ere d to the patien t bec ause of was ted v entil ation s eco ndary to gas c ompress ion and dis tens ion of co mponents o f the breathing s ys tem. If the fres h gas f low a dds to the tidal v olume du ring i nspi rati on (s ee Chapte r 12), th is ad ded v olume wi ll not be represe nted on this sc ale.

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Figure 23.2 Wright respirometers. A: This small instrument can be handheld or inserted into the breathing system. It has two dials: a large peripheral one and a smaller one on the upper part of the main dial. The small dial indicates volumes up to 1 L and the large dial up to 100 L. Note the reset button on the side. B: This version has three dials. The top small dial reads up to 1 L, the large dial indicates volumes up to 100 L, and the bottom small dial reads up to 10,000 L. Note the on-off control and the directional flow arrow. (Courtesy of Ferraris Medical, Inc.)

Wright Respirometers Description

Ty pic al W righ t res pi rome ters are s hown i n F igure 23 .2. They are s upp li ed wi th adaptors to fac il i tate connec ti on to a mask , ai rwa y d ev ice, or breathing sys tem. The re is an ON-OFF control in the form of a s li di ng s tud and a sp ri ng-lo aded rese t button to se t the h ands o f the s cales to zero . An infant v e rs ion that c an measu re v olumes d own to 15 mL is av ai labl e (Fi g. 23 .3 ). Its dead s pac e is 15 mL. A n e lec tronic v ers ion is als o av ail abl e (15). The internal c ons truc ti on is shown i n Fi gure 2 3.4 . Gas entering through the outer cas ing is di rec ted through a s eries of tangential s lots enclos ed in a c y li ndrical housi ng and s trikes a v ane, c aus ing i t to rotate. The v ane is c onnec ted by a mechanical gear s ys tem to the hands on the dial s o that a reading corresponding to the v olume of gas pass ing through the dev ic e is regis tered.

Evaluation
Mos t s tudies hav e found tha t the W right respi romete r ov er-reads at high flows a nd under-reads at low f lows (16,17,18 ). Puls atil e f lows c an c ause ad ditional ov erreading. It wi l l giv e s lightly hi ghe r readings wi th mi x tu res of ni trous ox ide an d ox ygen than for ai r and wi l l s lightl y ov e r-read in the presenc e of x enon (8 ). P .733

Figure 23.3 Infant version of Wright respirometer. The outer scale goes up to 500 mL, and the inner scale goes up to 5 L. (Courtesy of Ferraris Medical, Inc.)

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Adv antages of the W right respi romete r inc lude its s mall s ize a nd li ght weight. Its l ow dead space makes it s ui table for us e betwe en the patien t and the bre ath ing s ys tem. The main disadv antage is that i t has no alarms . It is s omewha t di ffic ul t to read and does not giv e respiratory rate. A cl ock is necessary to de termine minu te v olume . It does not read bidi rec ti onal f low. Mai ntenanc e c an be expens iv e. Many ins truments that are in us e are inac curate because of po or mechanical cond ition. Its po rtabili ty can resu lt in inacc urac y due to pock et di rt and a high incidenc e of damag e f rom being dropped. Guards that are des igned to reduc e damage from p hys ic al abuse are av ai lable. It needs to be c lea ned and dis infec ted be twe en patien ts .

Spiromed Description

The S piromed is an elec tron ic respi rometer th at is des igned for use wi th North A meric an Drager breathing s ys te ms (19,20 ). As gas flows through the monitor, i t forc es a pai r of rotors to coun ter-rotate (Fig. 23 .5). A ttached to the ax le of one of the rotors is a four-pronged armature with a smal l magne t at the tip of eac h prong. As ex hal ed gas flo ws through the se nsor, the rotor and arma ture spin in un is on. Located at approxi ma tel y the 12 and 7 o'c lock pos i tions are two tra ns is tors that turn ON in the presence of a magnetic fiel d. A s the armature that c arri es the magn ets rotates , the trans is tors are turned ON and OFF. Thes e paired pulses are transmitted through the senso r cable to the i nte rface panel and then to th e processor.

Figure 23.4 Internal construction of Wright respirometer. Gas entering the casing is directed through a series of tangential slots and strikes the vane in the center, causing it to rotate.

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Figure 23.5 Spiromed. (See text for details.)

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The number of pai red puls es is related to the v olume of gas tha t pas ses through the sens or ov er time. T he to tal number of pulse pairs coun ted during eac h ex hal ation de te rmines the tidal v olume. The speed a t whi ch the exhaled gas flows through the sens or determines the d ura tion of each pulse pa ir. Rapid gas flo w caus es the ro tors and armature to spin quick ly, and s ho rter pulses are produced as the trans istors rap id ly c ycle. W ith sl ower g as flow, l onger puls es are produc ed . The processor anal yzes the p uls e lengths and displays the i nformation as th e exhaled wav efo rm. S ix ty seconds of c ontin uous d ata is requi red for the in itia l displ ay of the respi ra to ry rate , and the displaye d read ing is recalcul ated af ter each ex hal ation. For an ex hal ation to be coun te d as a v ali d b rea th, the proces sor mus t cou nt at leas t 80 mL. A ll exhaled gas v olumes , rega rdles s of s ize, are counted and inc luded in ca lc ula ting the minu te v olume . The sensor in the brea th ing s ys tem is sh own in Fi gure 23.6. The S piromed se nsor rec ognizes the di rec tion of gas fl ow by monitoring the phase rela tions hip betwe en the pulses i n each pu lse pair. W hen the gas f lo ws forwa rd, the pulse from one transis to r leads the pulse from the o the r trans duce r bec ause of the arma ture's rotational direc tion. If gas flows in the wro ng direc tion, the order P .734 of the pu lses is rev ersed a nd the proc esso r rec ogn izes this as rev erse f low. If t wo cons ec utiv e puls e pai rs are in rev erse order, a rev erse flow al arm is generated.

Figure 23.6 Spiromed in place in breathing system.

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Evaluation
This i nstrument is progra mme d to meas ure tidal v olumes equal to or g rea ter tha n 150 mL. If the tida l v olume is les s than 150 mL, the ins trumen t wi ll a uto matica ll y add two or more c ons ecutiv e tidal v olumes and reduce the rec orded frequenc y ac cordingl y. The mi nute-v olume display remains correc t. The accurac y o f ti dal v olume meas ureme nt i s reported as 0 .04 L, minu te v olume as 1 0% of rea di ng or 0.1 L, and resp iratory rate as 8% of readi ng or 1 breath/minu te.

D-Lite Gas Sampler and Flow Sensor Description

The f lo w s ens o r (Fig. 23.7) fo r this dev ice is a modif ied F leisc h pneumo tac h with a t wo-s id ed P itot tube (21,22,23,24). The Fleisc h p neumo tac h meas ures f lo w by meas uri ng the pressu re differenc e ac ross a flow re s is to r (c apillary tub e) in a tube. The P i tot tube uses two se nsing tu bes to make a d iffe ren ti al p res sure meas urement. One tu be faces the di rec tion of flo w (to tal pressu re), and the other fac es the oppos i te di rec tion to meas ure the s tatic press ure . The differenc e in press ure be twe en the total press ure and s ta tic pressu re is the dy namic pressure, whi c h is pro porti ona l to the square of gas flow. The s enso r body (Fig. 23 .8) c onsis ts of a s traight tube wi th a c ombined 15-mm female/2 2-mm male connec tor on the patient end a nd a 15-mm male connec tor on the mac hi ne end. Two s mal l hollow press ure tubes perforate the si de of the tube

and ex te nd in to the lu men. Eac h makes a 90-de gre e turn ins ide the lumen so that the end of one tube fac es the b rea thing system and th e o the r end f aces the patient. A gas sampling po rt is als o presen t. A doubl e-lumen tube c onduc ts the flow s i gna l as a press ure differenc e to the pressure sensor i ns ide the moni to r. The s enso r is plac ed between the breathing s ys tem and the patient. A f il ter or h eat and mois ture exchange r may be placed on e ither s ide of th e sens or. If pl ac ed between the pa ti ent a nd the s enso r, mucus and humid ity wil l be prev ented from enterin g the gas sampli ng tube. If the s ensor is plac ed between the pati ent and the heat and mois ture exchange r, a highe r c ompl ianc e wi l l be obs erv ed than if i t is place d between the heat and mois tu re ex changer an d the Y-piec e (25).

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Figure 23.7 D-Lite flow sensor and gas sampler. The patient end has a 15-mm internal and 22-mm outside diameter connector to fit a mask or tracheal tube connector. The other end has a 15-mm outside diameter connector. Because the pressure tubes point in opposite directions, gas flows can be measured during both inspiration and exhalation. Note that one pressure tube is larger than the other to avoid misconnection of the tubings. There is a gas sampling port on the opposite site of the sensor.

P .735

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Figure 23.8 Sensor for D-Lite flow sensor and gas sampler A: The gas sample port is at the top. Note that the pressure line attachments utilize male and female connectors. B: Attachment for pressure tubings.

Durin g ins pi ration, gas mov es f rom the bre ath in g s ys tem towa rd the patient. The press ure in the hollow tube fac ing the breathing sys tem and the press ure i n th e tube th at faces a way from the di rec tio n of gas f lo w a re meas ured. Si nce the press ure tubi ngs face in opposi te di rec tions, s imilar measu remen ts ca n be made during exhala tion, when the g as fl ow i s rev ers ed. In the moni tor (Fig . 23.9), conc entra tions of carbon dioxi de, oxyg en, and anes th etic agents a re determin ed. The moni tor u ti lizes the gas c ompos i tion data to P .736 co mpens ate for changes due to de nsi ty a nd v iscos ity (7 ). A correc tion fac tor mus t be ap plied if heli um is i n the res pi ra to ry mix tu re (26). From the deriv ed flows (flow rate , peak f low) and meas ured pressu res (end-ex piratory, plateau, mi ni mum, an d maxi mum), th e ins pi ratory and ex piratory tid al and mi nute v ol umes , comp li anc e, and resis tanc e are ca lc ula te d and displayed, and f lo w-v olu me a nd pressu re-v ol ume l oops are displ ayed. Inspi red and ex pired gas c onc entrations are als o d is pl ayed .

Figure 23.9 The monitor utilizes the gas composition data to compensate for changes due to density and viscosity. From the derived flows and measured pressures, the inspiratory and expiratory tidal and minute volumes, compliance, and resistance are calculated and displayed, and flow-volume and pressure-volume loops are displayed. Inspired and expired gas concentrations are also displayed.

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A larms inc lude a h igh PEE P alarm wi th a defa ult v al ue of 10 c m H 2 O. High p res sure and low ins pi ra tory pressu re alarms h av e defau lt s ettings of 40 and 0 cm H 2 O. The re are high and lo w e xpi ra tory minute vo lu me a larms as wel l as mes sages for l eak , dis con nec tion, and obs truc tion .

Calibration
The s enso r needs to be ca li brated a t leas t ev ery 6 months (27 ). One indica tion that ca li brati on needs to be performed is an open or ov ers hoo t pressu re- and fl owv olume loop (Figs . 23 .61 a nd 23.62). The op era tion manua l should b e c ons ulted for the compl ete procedu re. It s hould be perfo rmed wi th the equ ipment i n the configuration tha t wil l be used wi th the nex t patient. A cces sories , s uch as heat and mois ture exchangers , plac ed prox imal to the s enso r wil l no t af fec t cali bra tion. Howev er, if the c li nic ian wis hes to p lace an acc ess ory on the dis tal end of the sens or, then the uni t s hould be c al ibrated wi th this in pl ace. A different si ze of trac heal tube o r the o mis sion of the connec tor could affec t the ca li brati on v alue and resul t i n inc orrec t v olume meas ure ments .

Evaluation
The D-Li te is used to measu re flows in ra nges co mmon for adul ts and c hi ld ren down to 3 k g. Res is tance to f low i s 0.5 c m H 2 O at 30 L/mi nute. Its v ol ume is 9.5 mL. Ti dal v olumes of 150 to 2000 mL and minute v olu mes of 2.5 to 30 L/min ute c an be meas ured. Th e pedi -l i te sensor c an measu re tidal v ol umes in the range from 15 to

300 mL. The range of meas urement for a irway press ure is -20 to +80 cm H 2 O. The range of f low rates is -100 to +100 L/minute. It ov e r-reads when xenon is used (8). Regula r v isual inspec tion and wa ter remov al is req ui red for troublefree performance. If us ed fo r ex tended periods with heav y humidification, c ondensed water may occlude the pressu re sens ing or gas s ampl ing tubes . Th e p res sure and sa mple line tubings shou ld be on the upper s ide of the s ensor. The D-Li te sensor has a si mple a nd rob us t c ons truc tion, l igh t wei ght, low d ead spac e, and no mov ing pa rts . It is not pos ition dependen t and al lows bi di rec tiona l gas fl ow measuremen t. Sma ll amounts of muc us and water d roplets do not affec t the measu reme nts . Onl y one adapto r is needed for respi rometry and gas sampli ng. It can be us ed with both c i rc le and Map leson breathing s ys tems . Another impo rtant adv antage is the abil i ty to moni tor flow-v ol ume and press ure -v olu me loops.

Figure 23.10 Novometrics sidestream sensor.

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Novometrics Sidestream Sensor

The Nov ometrics s ides tream sensor (Fi g. 23 .10 ) c ombines me asuremen t of f lo w, press ure , and ca rbo n d ioxi de. Flow i s d ete rmined f rom a differential pressure meas urement ac ross a fixed orifice wi th a spl i t obs truc tion to one si de of the op tical wi ndow us ed for mains tream ca rbon diox id e measuremen t. The sens or has a de ad spac e of les s than 0 .8 mL, mak ing i t us eful for th e neonate (28).

Heated W ire Anemometer

In the heated-wi re a nemometer (th erma l diss ipation dev ice ) (Fi gs . 23.11, 2 3.12), gas fl ows around a th in wi re (usuall y platinu m or a p latinum al loy ) that is heated to

a c ons tant temperature (10). Heat is diss ip ate d wh en gas f lo ws pas t this wire. T he greater the v olume of gas flowi ng pas t per u ni t ti me, the more heat wi l l be diss ipa ted . The cu rrent lev el is usual ly lo w so that the ou ts ide of the s ens o r does not beco me heated.

Figure 23.11 Heated wire anemometer.

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P .737

Figure 23.12 Heated wire anemometer. One wire is for measuring flow, and one is for reference.

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The hot-wi re s ensor tends to be more accu rate at low fl ow rates . S ince it is i nsens i tiv e to f low d irec tion, two heated wi res a re nee ded to dete rmi ne th e f low di rec tion . The heat dissipa ted by the sec ond wi re i s determined wh en the re is no gas fl ow (e.g., during inh ala tion in the ex halation s ide of the breathing s ys tem). It under-reads in the pres ence of x eno n and sl ightl y ov e r-reads wi th ni trous ox id e (8).

Ultrasonic Flow Sensor

An ul tras ound s ensor (Fi gs . 23.13, 23 .14 , 23.15) me asures the influence of gas f low on the trans mis s ion ti mes of puls es between two c ry s tals . Sen ding and receiv ing transduc ers a re us ed to trans mit s ignals through the f lo w. The s ignal trav els fas ter when mov ing wi th the flow s tream rath er than aga ins t the flow s tream. The dif fe rence between the two trans miss ion ti mes is used to calcul ate th e f low rate . The f lo w s ens o r has no mov ing parts , is eas y to c lean , is autoc lav able, and i ts ac curac y is independent of gas c ompos ition. The fl ow measuremen t ran ge is 0 to 120 L /mi nute. The accurac y is s pecified as 1 0% o r 15 mL, whic hev er is greater. Res is tance is l ess than 2 cm H 2 O at a f lo w of 60 L/minute.

Variable Orifice Flow Sensor

The v ariable orif ic e flow s ensor is used wi th the Ohmeda 7900 se ries v en tila tors (Chapter 12 ) and the ci rcl e s ystem. S ens ors a t both c onnec tio ns to the carbon diox ide absorber a re use d to meas ure insp iratory an d expi ra tory flows . These sens ors can be us ed to generate p res sure- and f low-v olume loo ps. T he 7900 v enti lato r util izes the information f ro m these s enso rs to a llow it to del iv er accurate tida l v olumes .

Construction
Eac h sens or (F igs . 23.16 , 23.17) uses the pri nc iple of p res sure d rop ac ross an orifice. A plas tic fl ap that opens wi th i nc reas ing f lo ws is pl aced ac ross the di rec tion of gas flow. T wo s ens ors and a transduc er P .738 i nsi de the anes thes ia machine meas ure press ure p rox imal and dis tal to the f la p. Volume is calcul ated from these flows . The sens or o n the i nspirato ry s ide is connec ted to a p res sure s ens or s o that b rea thi ng s ys tem p res sure is measured. The inf orma tion is used by the v enti la tor to compensa te for changes in fres h gas f low.

Figure 23.13 Ultrasonic flow sensor in breathing system.

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Figure 23.14 Inside of ultrasonic flow sensor.

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Use
Before use, the tubes s houl d be c hecked to make ce rtain that the y a re cl ear. The press ure lines sho uld poin t up, and th ere s houl d be no k inks , c racks , or othe r problems . The us e of fi lters is recommen ded to p rotec t the s enso rs f rom contamina ti on. Calibratio n b y us ing a menu on the v entil ator is recommended on a wee k ly bas is .

Figure 23.15 Diagram of ultrasonic flow sensor.

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P .739

Figure 23.16 Variable orifice sensor. Gas flow causes the Milar flap to bend. There is a pressure drop across the flap. A transducer inside the ventilator converts the pressure drop into a flow.

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Accuracy
The s enso r c an meas ure f lows from 1 to 120 L/minute. The re are no res piratory rate l imi ts . The ins trument wi l l re ad hi gh with x enon and ni trous ox ide (8). S ince bo th inspi red and ex haled v olumes are meas ured , the v entilator c an make adjus tmen ts s o that c han ges i n f resh gas flo w d o not affec t the del iv ered v olumes .

S ince the sensors are loca ted at the absorber, th ey cannot c ompens ate for gas co mp res sion or ex pans io n i n the breath ing s ys tem. This is a s mall error un less v ery co mpliant breathing tubes are us ed or the breathin g s ystem con tains a large v olume of gas .

Evaluation
The main adv antage of this dev ic e is that i t al lo ws the v entilator to automatica ll y co mpens ate for changes in f res h gas flow. Disa dv an ta ges incl ude the need for two sens ors and f il te rs . A b reak in one of the pres sure l ines can c aus e a l eak i n the breathi ng s ys tem P .740 (29). The sensor i tself may be the source of a leak (30,31,32,33). The s enso rs are sens i tiv e to humidity (34,35).

Figure 23.17 A: Variable orifice sensor. Tubings are attached on either side of the flap. B: Tubings from the sensors attached to the anesthesia machine. It is important that they are attached to the proper connection.

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Fixed Orifice Flow Sensor

This dev ic e cons is ts of a res tric tor and two press ure senso rs , o ne on ei ther si de of the res tric to r. A zeroing v alv e c ompens ates for pressure sensor drift.

Respirometer Position in the Breathing System

Fi gure 23.18 sho ws poss ib le locati ons for a res pi rome ter in the c irc le s ys tem. From the s tandpoin t of ac curac y , the mos t desirable locati on is be twe en the breathing s ys tem and the pa tient (pos ition C). In this loca tion, read in gs are not affec ted b y breathi ng s ys tem leaks , expans ion of bre ath in g s ys tem components , o r gas

co mp res sion. B oth i nspired and ex pired v olu mes can be meas ured. Pl acing the sens or a t th is si te wil l inc reas e the dead s pac e, and wa ter c ondensa tion may be a problem. Th is pos i ti on may resul t in i nc reased l ik eli hood of damage, dis connec tion, or tra cheal tube k ink ing. A disadv antage of pos i ti on C is that if a disc onnec tion oc curs between the sensor and the breathing s ys tem during spon taneous v entilatio n, the spi ro metry meas urements wil l no t be af fec ted. If the s enso r is l oca ted a t pos ition B , the disc onnec ti on wi ll be detec ted by the change in v olume. A common prac tice is to locate the respi rometer in the ex halation l imb ups tream or downs trea m of the unidirec tional v alv e (posi ti ons A and B ). An adv antage of these positions is tha t if the res pi rometer can s ense rev erse f lo w, a malfunc tioning unidi rec tional v alv e can be detec ted . If a d is connec tion that prev ents exhaled gases from pas sing down the exhalati on tu bing occu rs , the resp irometer wi ll not sens e a gas flo w, and an apnea mess age an d a larm wil l be ac tiv ated. A respi ro mete r in this loc ation wi l l usuall y read acc ura tely duri ng spon taneous respi ra tion, but du ri ng con trol led res piration, i t wil l us ual ly g iv e e rroneo usl y high readings P .741 (36,37). This is du e to ex pans ion of components of the breathing s ys tem and gas co mp res sion. If a v en til ato r with a hang ing b ellows is used, a res pi rome ter i n this position may s til l indicate flow when a disc onnec ti on oc curs (38 ).

Figure 23.18 Possible sites for a respirometer in the circle system. (See text for details.) PEEP, positive end-expiratory pressure; APL, adjustable pressure limiting.

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If the resp irometer is located down s tream of the abs orber (posi tion E ), the v olume of gas meas ured wi l l be dec reased by the amount of c arbon dioxi de abs orbed in the absorber. Ano the r pos sible loca tion fo r th e res pirometer is on the ins piratory s id e of the s ys tem (pos ition D ). In this location, the respi rome ter wil l disp lay e rroneousl y high readings , as gas that does no t inflate the pa tient's lun gs wil l also pass th rough it. Durin g contro ll ed v enti lation , a dis con nec tion may not be detec ted. It is c ommon to loca te press ure -f low s ensors at bo th pos i ti ons B and D. This allows both th e ins pi ratory and exhalation v olumes and pressu res to be meas ured. This prov ides the info rmati on to produc e a f low-v olume or press ure -v olu me loop . Sensors in both these posi tions are used wi th the Datex -Ohmeda 7900 v enti lato r to co mpens ate for changes in tidal v ol ume due to fresh gas flow or l eaks . W hen one o f these dev ic es is used in a Map leson sys tem wi th an adul t patient, it shoul d be placed be tween the pa tient c onnec tion port and the patien t. In smal le r pati ents , i t shoul d be placed in the ex pi ratory li mb to av oid an inc reas e in dead spac e (1 1,15).

Airway Pressure Monitoring

A i rwa y p res sure moni tors (v entilator or res piratory monitors or alarms ; press ure alarms ; press ure alarm s ys tems ; anes thes ia, patient, or breathing c i rc ui t moni to rs ; v enti lato r moni to ri ng alarms ; breathing gas i nte rruption moni tors ; d isc onnec t moni tors ; breathing pressure moni to rs ) are us ed to warn of high- or l ow-p res sure condi tions i n the b rea thing sys tem (39,40). Hi gh- o r low-press ure c ondi ti ons in the breath in g s ys tem hav e been a ma jo r caus e of anes thesia mortali ty and morb id ity. A dev ic e tha t res ponds to press ure c hanges wi th in the breath in g s ys tem and prov ides wa rning of a probl em is s trongl y recommen ded. Othe r parameters s uch as ex haled carbon di ox id e and exha le d v olumes ma y remain rela tiv el y normal i n the p res ence of dang erousl y abno rmal ai rwa y pressures . Con tinuous airway pres sure monitoring is now the norm in both the opera ting ro om and in c ritic al c are areas . It is a s impl e and noninv asiv e technique tha t hel ps i n as sess ing the pa ti ent's mechanic al and s pontane ous v enti lation and determining the presenc e of PEE P . P .742

Figure 23.19 Virtual pressure gauge on anesthesia machine display. This can be displayed on demand.

View Figure

Equipment
An ai rwa y pressure moni to r may be frees tan di ng or i ncorporated in to a v en tila to r or an an esthes ia machine. Mos t of these dev ices are inexpens iv e, robus t, eas y to use , and rel ia ble . The y ma y be powered ei th er from the ma in el ec trica l sys tem wi th battery backup o r by a batte ry wi th ba ttery tes t capabi li ty . Mos t new anes thes ia machines h av e a buil t-in da ta sc ree n wh ere informa tion i ncl uding ai rway pre ssure is av ai la ble . Usuall y, the re wi ll be an airway press ure v e rsus ti me wav ef orm displayed on th is s c re en. A v i rtual elec tron ic press ure gauge may be disp layed on the moni tor s c reen (F ig. 23.19). Many mac hines in use are s till e quipped wi th a mec hanica l pressu re gauge on th e abso rber. Th is do es not al low e lec tronic recording or the data to be i nte gra ted wi th o the r parameters to al low c ompl iance c alc ula tions . A larms were not assoc ia ted wi th thes e manometers , so they ha d to be repeatedl y sc anned b y the anes thes ia prov ider.

Alarms
Mos t pressure alarms hav e an aud io pause (delay, mute, s ilenc ing) control that wil l delay the aud ib le s ignal fo r some or a ll functi ons . This pause sho uld not prev ent the v isual s ignal f rom func ti oning. Some units ' aud ib le alarms can be c omp le tel y turned OFF (41 ). Other features on some dev ices incl ude auto ma tic ac tiv ation wh en

a pressu re is detec ted, the abil ity to de tec t i mpending ba ttery f ai lure , and protec tio n f rom ac cidental inac tiv ation or power f ai lure (4 2,43). Some airway press ure mon itors hav e the abi li ty to display press ure wav eforms .

Low Peak Inspirator y Pressure

A lo w pe ak inspi ra tory pressu re (minimum ai rway pres sure, low air way press ure , v enti lation failure, apnea , c yc ling, pressure fa ilure, disc onnec t, v enti lator disc onnec t, minimum v enti la tory, v entilatio n p res sure, thres hold press ure , lo wpress ure , peak a irway, fai l -to-c yc le, low press ure, lo w c i rc ui t press ure ) alarm is ac tiv ated i f the p res sure detec ted does not ex ceed a pres e t min imum wi thi n a fixed time. Bas ic mon itoring s tan dards ado pted b y the ASA and the A meric an Ass oci ation of Nurse Anes thetis ts (A A NA ) s tate that when v en ti lation is controlled by a mec hanical v enti lato r, there sha ll be a means of de tec ting disc onnec tion of bre ath ing s ys tem co mponen ts in conti nuous use. S uch an al arm has been recommended by other respons ible bodies around the world (44). The l ow peak insp iratory pres sure alarm i s one of the means to fu lfil l this requiremen t. Ho wev e r, the pressu re moni tor is n ot fool pro of . Under certain c i rc ums tances , i t may f ail to de tec t anes thetic ci rc ui t disc onnec ti ons . P ressu re moni toring wi ll fail to detec t a disc onnec tion that occu rs during s pontaneous v entil ation (45 ). The airway pressu re mus t exc eed a thres hol d v alue (l i mi t) to prev ent an alarm. If this li mit is not reac hed ov er a perio d of ti me, usual ly around 15 seconds , the alarm i s ac tiv ated. The thresho ld needs to b e s et at a v alue s l igh tl y below th e peak ai rwa y pressure. This v alue v aries , depending on the c linic al s i tuatio n. The l imi t may be se t manua lly or au to ma ticall y aro und a v alue s li ghtly l ower than the peak press ure de termined by sev eral s uccessiv e breaths . W hen the pe ak ai rway press ure becomes higher or l ower, the th res hold may be automatic al ly al tered o r there ma y be a means to mov e the thresho ld c los er to the new peak pressure (Fig. 23.20 ). On so me machines , the re wi ll be a v is ual i nformationa l signa l th at the limit i s set too lo w. The low peak p res sure ala rm is enabl ed when the v en til ato r is turned ON. It is i nac tiv e when the v en tila tor is no t bei ng use d. Conditions that c an caus e a l ow peak p ressure alarm inc lude a disco nnec tion or maj or leak in the breathing s ys tem; an obs truc tion ups tream of the p res sure sens or; i nadequate fresh gas flow (di sc onnec tion of the f resh gas l ine, an inte rna l mach in e obs truc tion, o r los s or reduc ti on of pi pe li ne press ure ); the bag /v entil ator s el ec tor

P .743 v alv e in th e bag pos ition; a leak ing trac heal tube c uf f; ex tu bation; a faulty, poorly se t, o r unconnec ted v entil ator; fai lure of the g as or po wer s uppl y to the v enti lator; a malfunc tioning sc av enging s ys tem; inc reas ed c ompl iance ; re duced res is tanc e; and a s uc tion dev ic e mis tak enl y placed wi th in the gas f low pa thwa y (46 ,47 ). Low press ure alarms are of li ttle o r no use du ri ng s pontaneous breath in g wh en the press ure in the s ys tem does no t rise and f all ap prec ia bl y (45).

Figure 23.20 The pressure (top waveform) exceeds the threshold (dotted line) by a small amount. At the bottom is a touch control marked AUTO PRESSURE THRESHOLD. If the threshold is too high or too low, it can be altered by using the control or by touching the threshold on the screen and moving it to the desired location.
View Figure

The alarm threshold s hould be set jus t bel ow th e mini mum peak press ure expec ted during ins pi ra tion (4 1,42,48,49). This peak pres sure wi l l v ary not onl y from patient to patien t but als o duri ng a giv en case. Of ten, the th res hold is se t lo wer i n an attempt to p rev ent false-pos itiv e ala rms . If the alarm limi t is set too low, a fa ls e negativ e may occur (50 ,51 ,52 ). It has been sugges ted that a pres sure threshold of l ess than 8 to 10 c m H 2 O is unac ceptab le (53). On mos t mode rn de liv ery sys tems , the ci rcu it p res sure wav eform a nd the low-pre ssu re alarm threshol d can be displayed, mak ing i t eas y fo r the operato r to ad jus t the thres hold p roperl y (Fig . 23.2). On some moni tors , an adv is ory s ignal wi l l be ac tiv ated if the thresho ld is set a c ertain amo unt be lo w the peak p res sure. So me u nits automatically s et the threshol d bas ed on the p res sure sens ed during p rev io us breaths . Th ere may b e a manu al threshold reset c ontro l. P roblems wi th these moni tors hav e bee n repo rted. A disc onnec tion or leak ma y not be de tec ted if the alarm is not s wi tc hed ON (5 4) or the th res hold is se t to o low. A

fals e-negativ e con di tion may occ ur if th e end-exp irato ry press ure is abov e the threshol d pressu re. Othe r con ditions that may produce a pressu re hi gh enough to ex ceed the th res hold when a disconnec tion occ urs i nc lude the breathi ng s ys tem connec tor's obstruc tion by a pi l lo w, s heet, or s urgical dra pe; a hi gh-res is tance co mponen t suc h as a heat a nd mois tu re exc hanger, capnometer cuv ette, or humidifier; ai r entrain ment i nto the breathi ng s ys te m (espec ial ly wi th a v en ti lato r bellows des cen ding during ex pi rati on); partial ex tubatio n; compress ion of an empty v enti lato r bel lows ; a nd a Mapleson sys tem wi th a high resis tanc e (55,56,57,58 ,59 ). If a v enti lator that uses a ram of oxy gen to produce inspi ra ti on is used wi th a Tpiece s ys tem, a disco nnec tion at the commo n gas outlet may not be detec ted due to the hi gh resis tance of the f resh gas tubi ng (60). T hos e dev ices op era ti ng on batteri es wi ll not a larm if the batte ri es fail . It i s essential tha t the a larm b e c hec ked before use by mak ing a disc onnec tion at the pa tient c onn ector whi l e the v enti lator i s cyc li ng (Ch apter 33) (50 ). Unfortu natel y, s tudies s how tha t this tes t is not performed routinel y or correc tly (48). It i s importan t tha t ano the r means of detec ting a disconnec tion (s uch as a capnograph o r v ol ume or flo w mon itor) be us ed.

Sustained Elevated Pressure

A sus tai ned (con tinuous , c ontinuing) press ure mon itor ac tiv ates an alarm if the press ure does not fall be low a certain lev el during part of the respi ratory c yc le. Mos t are al ways enabled . S ome incorporate a v alv e tha t ope ns to reliev e the press ure af ter a certain time. Sev era l mechanisms can produce a sus tained e lev ated pressure: acc iden tal ac tiv ation of the ox ygen fl us h v alv e; occ lus ion or obs truc tion of the ex piratory l imb; an i mproperly ad jus te d adjus tabl e pressu re li mi ting (A PL) v alv e ; occ lusion of the sc av engi ng s ys tem; a malf unc tioning v en tila to r; or a malfunc ti oning or inco rrec tly se t P EEP v alv e (42,43,55).

High Pressure
A high-pressure al arm is ac tiv ated if the pressu re ex ceeds a c ertain li mit. On so me dev ic es , the threshol d P .744 i s fix ed (usua ll y 50 to 80 c m H 2 O); o n o the rs , it is adjus table (41). Some i ns trume nts automatica lly s et the alarm thresho ld at a s et amount abov e the av erage peak pres sure for s ev eral p rev io us breaths . Mos t of thes e a la rms are

al ways enabl ed. There shou ld be no dela y on the high -press ure a larm. Some anes thes ia deliv ery sys tems are fi tted wi th pres sure-l imi ting v alv es that v ent gas f rom the b rea th ing s ys tem when a high pressure is detec ted (41 ). Pos s ible c auses of high press ure i nclude air way obs truc tion, reduc ed compl iance , i nc reas ed res is tance, ox ygen fl ush ac tiv ation durin g the i nspi rato ry phase, a punc tured v entilator be ll ows , occ lus ion o r obs truc tion of the expi ra to ry l imb of the breathi ng s ys tem, sc av enge r malfunc tion , or the patient c oughi ng or s trai ning (42,61). Ev en in the p res ence of complete obs truc tion , th is al arm wi l l not b e ac tiv ated i f the peak inspi rato ry press ure do es not reac h the s et l imi t (49). High co mpliance, low res is tanc e, leaks , low i ns pira to ry fl ow rates , high respi ra tory ra tes , l ow I:E ratios , low ti dal v olumes, and lo w f resh gas f lo ws c an al l dec rease the peak i nspi rato ry press ure s o that the re is no ala rm c ond ition (2,62). Duri ng pressure control v entilatio n, the inspi ra tory ai rway p res sure is prese t and thus cannot ac t as a warni ng of trac heal tube occlus ion (63).

Subambient Pressure
A subambi ent (s ubatmos phe ric ) press ure alarm is ac tiv ated by a pressu re that f al ls below atmosp heric press ure by a prede termi ned amount. S ubatmosp heric press ure can be g enerated by a patient atte mpting to inh al e agai nst a c oll apsed reserv oi r bag o r inc re ased res is tanc e; a block ed ins pi ratory limb (du ring the v entilator's ex piratory phase ); a malf unc tioning ac tiv e cl osed s cav enging s ys te m; suc tion applied to a nasogas tric tube plac ed in the tra cheo bronchial tree or to the work ing channe l of an endos cope passed into the air way; a si des tream gas a nal yze r; or the refil ling of a hanging bel lows v en tila tor bel lo ws (14,42 ,49 ,64 ,65 ,66).

Monitoring Site
The loca ti on where pressu re is sens ed wil l affec t i ts usefulness . Figure 23.21 shows pos s ible s i tes . Idea ll y, the s i te s hould be c lose to the patient's airway (pos i tion C). Many disp osab le breathing s yste ms hav e a smal l po rt a t the Y-piec e that c an s erv e as the connec tion s ite fo r tub in g that transmi ts the press ure to a moni tori ng dev ice (57 ). P ress ures during b oth ins piration and exha la tion can be meas ured at this s ite. The D-Li te and Nov ome tric s s ens ors disc uss ed earli er in this chapter P .745 are plac ed at this s i te . P ressure- a nd flow-v olume loops can a ls o b e generated from press ures sens ed at this s ite. W hil e p lacemen t between the patie nt and the

breathi ng s ys tem is bes t f rom this s tandpoin t, i n prac tic e i t may pres ent problems wi th de ad spac e, disc onnec tions , trac heal tube kinki ng, a nd water bui ldup i n the pi lot line . The l in es mus t be c onnec ted for ev ery c as e.

Figure 23.21 Possible sites for monitoring airway pressure in the circle system. (See text for details.) PEEP, positive end-expiratory pressure; APL, adjustable pressure limiting.

View Figure

The more dis tant the meas u rement s i te is from the patien t, the l ess us efu l it is as an es timate of ai rway p res s ure (2,67). B reathing sys tem resis tance and co mpliance, leak s , obs truc tions , and other mechan ic al fac tors may c ause the meas ured pressure to be qu ite diff ere nt f rom the pressure in the pati ent's ai rway (56). Freque ntly, the mon itoring s ite is i n the breathi ng s ys tem (pos itions A , B , and D). An oc clus ion in the breathin g sys tem wil l c ause a low-pre ssure s tate dis tal to the obs truc tion and a high-pressu re s tate p rox imal to i t, s o certain ty pes of pro blems may be misse d (57). If PEEP is us ed, i t wi l l not be indic ated on a p res sure moni tor l ocated at posi ti on B . P osi tions A and D are frequentl y use d to moni tor pressu re during ins pi ra tion and ex halation. These locatio ns may be use d to prov ide press ures for p res sure-v olume loops . In the pas t, the senso r was someti mes located in the v en til ato r (posi tion E ). This is unsatis fac to ry bec aus e under c ertain c i rc ums tances , suff ic ient bac k pressure to i nhibi t the minimum pressure alarm may be genera ted a t the b ellows ev en when there is a disconnec tion (5 5,56). P lac ing the s ensi ng poi nt i n the v entilator may also resul t in fai lure to detect an inc orrec tl y set bag/v entilator s elec tor v alv e .

Spirometry Loops

A loop is a graphic represen tation of the dynamic relations hip between two v a ri ables (p res sure and v olume or f low and v olume) during bo th insp irati on and ex hal ation (6,23,68). The flow, v olume, a nd pressu re curv es i l lus trated in Figure 23.1 are the bases of s pi rometry l oo ps . P ress ure- and flow-v ol ume loops a re av ailable on ce rtain p hysiologic moni tors as an op tion. Late r-gene ration anes th esia machines and mos t ph ysiologic moni tors now offer these l oops , us ually as an op ti on. The authors bel iev e that the i nfo rmati on prov ided j ustif ies the ex tra cos t.

Illustrative Loops
The Pressure-volume Loop
The pres sure-v olume (co mpli ance) l oop sh ows v ol ume on the v ertica l ax is and ai rwa y pressure on th e hori zonta l ax is (F ig . 23.22). W ith c on trolled v entilation, the press ure in the b rea thi ng s ys tem inc reas es during ins pi ration. A t the same ti me, the i nspi red v olume of gas inc re ases . The tidal v olume is the poin t on the v ertical ax is that c orresp onds to the highes t poin t on th e loo p. The peak pressu re is the hi ghes t v alue on the hori zontal axis . The s hape of the i nspiratory phase is determi ned by the type of respi ra tion being monitored.

View Figure

Figure 23.22 Pressure-volume loop. The pressure-volume relationship reflects pulmonary and tracheal tube mechanics. During controlled ventilation, a line drawn from the zero point through the point of end inspiration represents the compliance, which is determined by dividing the tidal volume by the pressure at end inspiration. With good compliance, that line forms an angle of 45 degrees or less with the volume scale. A loop that becomes more horizontal indicates a decrease in compliance.

A line drawn from the z ero po in t th rough the po in t of en d i ns pi ratio n during control led v entil ati on (Fig. 23.2 2) represents the compl ianc e . W ith good co mpliance, that li ne fo rms an angle of 45 degrees or les s with the v olume s cal e. A l oop that becomes more horizontal i ndica tes a dec rease in c ompliance.

The portion of the loo p repres enting exhalation s ta rts at the point of highest v ol ume and mov es down ward toward zero. The a rea ins ide the lo op is related to the work of breathi ng (1 ,69 ).

The Flow-volume Loop

The f lo w-v olume (resis tance ) lo op (Fig. 23.2 3) has v olume on the ho ri zon tal axis and f low o n the v e rtic al ax is . The ze ro point f or v olume is to the righ t on the hori zontal axis , co rres pondi ng to func tional re si dual c apacity. Duri ng inspi rati on , f low rate i nc reas es (plotted down ward ). Th e i ns piratory fl ow dro ps to ze ro as i nspi rati on ends . The tidal v ol ume is reached at the point wh ere flo w returns to zero and the l oop c ross es th e hori zonta l ax is . The s hape of this p art of th e l oop depends on the mechanism of respi ration (e.g., v o lume controll ed, pres sure c ontrolled, manu al , or sp ontaneo us ). P .746

Figure 23.23 Flow-volume loops with controlled ventilation.

View Figure

Exh alati on is rep res ented by th e part of the loop abov e the ho ri zon tal ax is . The shape of this porti on of the loop is dete rmi ned by the rate of passiv e l ung deflation, whi c h is in turn de termi ned by el as tic rec oil of the lu ng and ches t wal l and by th e total fl ow re s is tance offered by the bronc hial tree , ai rway dev ice tube, expi ratory l imb of the breathing s ys te m, and any addi tiona l equ ipment. W i th a no rmal loo p, the f low rate du ring exhalation i nc reas es rapidly at the beginning, quic kl y reac hes a peak , then sl ows and gra dual ly returns to ze ro.

Fi gure 23.24 sho ws another wa y of i llus trating a flow-v olume loop that is used b y so me manuf acture rs . The zero point is at the ju nc tion of the horizontal wi th the v e rtic al ax is . Inhalation is abov e the ho ri zon tal axis , and exha lation is b elo w. Fl owv olume loops i llus trated in this chap te r empl oy th e representation us ed by pulmonolo gis ts . This loop may be presen ted i n other way s , bu t the basic loop is the sa me .

Figure 23.24 Alternative method of displaying flowvolume loops. (See text for details.)

View Figure

Representative Normal Loops

Loops th at are ill ustrated in this chapte r do not c ome from ac tual patien ts bu t are s tyl ized to il lus trate c ertai n aspec ts of respira tory mech anics. T hey are based o n ac tual loops as muc h as poss ible. The reader s hould not expec t to s ee an exac t reproduc tion of thes e loo ps when moni tori ng a patient. Clinica l conditions and v enti lato r func tion a re rarely s tra ig htforward a nd usuall y inc lude a numbe r of fac tors . The l oop represen ts a compos i te of mechanic al and phys io log ic fac tors . As famil iari ty with the loops inc reases , the us er c an pro gress to the finer details of i nte rpretation .

Volume-controlled Ventilation with No Inspiratory Pause Pressure-volume Loop

The pres sure-v olume loop for v olume-c ontro lled v entilati on wi th no insp iratory pause is s hown i n Figure 23 .22 . It begi ns at z ero v olume and nea r or at zero press ure . During i nsp iratio n, both pressu re and v olume inc rease, s o the loop mov es up an d to the right. A t the end of i ns piratio n, both peak p res sure and tida l v olume

are attained . The end of inspi ration re presents a fall i n pressu re that oc curs before ex hal ation c an begin. T he loo p returns down ward and towa rd th e lef t to i ts original s tarti ng pos ition.

Flow-volume Loop
The f lo w-v olume loop s een wi th v olume -c ontrol l ed v enti la tion wi th a cons ta nt f low generato r is s hown in Fi gu re 23.23. The fl ow quick ly ris es to a lev el tha t is cons tant, produc ing a fla t inspi ra tory portion . A t the end of insp iration, the flow drops rapidl y to zero. T he tidal v olume is reac hed as the loop c rosses the v olume l ine. As ex hal ation begins , there is a rapi d ascent to a peak . Flow then dec reases , and the loop falls smoothl y toward ze ro flow and v olume. The angle a t th e top of the l oop is narrow.

Controlled Ventilation with Positive End-expiratory Pressure Pressure-volume Loop

The addi tion of PE EP c auses the s tarti ng po int of the pressure-v olume loop to s hif t to the righ t by the amount of PEEP that is appl ied (F ig. 23.25). PEE P may cause an i nc reas e in compli anc e a nd is represente d b y the loop becomi ng more v ertical wi th a dec rease in peak pressu re. If the loop te nds more to the ri ght, PE EP may not be benef ic ial and may need to be wi thd rawn. The loop disp la y makes i t eas y to detec t inadv e rtent PEE P . This may be due to the PEE P v alv e hav ing bee n i nadv erte ntl y turn ed ON, a parti al obs truc ti on in the breathi ng s ys tem, a malf unc tioning ex halation un id irec tional v alv e, fai lu re of the positiv e-pressu re re lief in the s cav engi ng inte rface , or an inco rrec tly s et APL v alv e. P .747

Figure 23.25 With PEEP, the loop is shifted to the right. PEEP, positive end-expiratory pressure.

View Figure

Flow-volume Loop
The f lo w-v olume loop wi th P EEP during c ontrol l ed v enti la tion wi th a cons ta nt f low v enti lato r is s hown i n F igu re 23 .26 . PEEP wil l d ec rease the exp iratory driv ing press ure , produc ing lower flows duri ng exha la tion so that the loop appe ars f latter (4).

Controlled Ventilation with an Inspiratory Pause Pressure-volume Loop

Fi gure 23.27 sho ws the press ure-v olu me loo p duri ng co ntrol led v entilati on with an i nspi rato ry pause. A fter the peak p res sure is reached, the v enti la to r paus es fo r a short ti me wi th the lungs i nfla ted. During this paus e, the pressu re in the breathing s ys tem drops to a pla te au lev el , usu all y 2 to 5 cm H 2 O lower than peak pressu re. Fres h gas enteri ng the breathing s ys tem from the anes thesia mach in e wi thout fresh gas decou pl ing (Chap ter 12) wi ll inc re ase th e ins pi red v olume. During exhalation, the pressure and v olume wi l l drop in the exp ec ted manne r.

Flow-volume Loop
The f lo w-v olume loop s een wi th an insp iratory pause is shown in Fig ure 23.2 8. The re is a d rop i n flow near the en d of inspira ti on wi th a s mall inc reas e in tida l v olume du ri ng the paus e resu lting from f resh gas f lo win g into the b rea thing s ys tem i f th ere is no fresh gas decoupl in g. This pattern sh ould not be c onfuse d wi th a spontaneous breath d uring c ontrol le d v enti lation (Fig. 2 3.60). The inc rease i n

v olume du e to fres h gas flow is s traight, from ri ght to left, and s tays near the ze ro f low l in e. Exhalation is s imi lar to the loop wi thout an i nspiratory pause .

Figure 23.26 PEEP produces a decrease in expiratory flow. PEEP, positive end-expiratory pressure.

View Figure

P .748

Figure 23.27 During an inspiratory pause, it is common for the airway pressure to decline 2 to 5 cm H2O. The lower pressure is called the plateau pressure. If the ventilator does not block fresh gas flow during inspiration (fresh gas decoupling) there will be an increase in tidal volume during the inspiratory pause.

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Pressure-controlled Ventilation

P ress ure-co ntrol led v entil ation diff ers f rom v olume -c ontrol led res pi ration in that the i nspi rato ry flow i s not c ons tant. P ress ure -co ntrol led v entilati on is d isc uss ed in Chapte r 12.

Pressure-volume Loop
The pres sure-v olume loop is shown in Figure 23.29. The loop is wi der than that seen with v ol ume-con trolled v entilatio n and s tarts off wi th a greater pressu re rise than v olume inc reas e. As inspi ration proce eds , v olume ris es fas ter than wi th v olume -co ntrol led v entilation.

Flow-volume Loop
The pres sure-c ontro ll ed mode of v entilation has an ac celerating-decelera ti ng i nspi rato ry flow prof ile in c ontras t to the cons tant insp iratory flo w s een wi th v ol ume control led v entil ati on (Fig. 23.3 0). The exhala tion part of the loop is s imi lar to that wi th v o lume -c ontrol led v entila ti on.

Figure 23.28 The blip near the end of inspiration represents the increase in tidal volume during the inspiratory pause due to fresh gas continuing to flow into the breathing system. This will not be seen if the ventilator has fresh gas decoupling.

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Figure 23.29 Pressure-volume loop with pressurecontrolled ventilation. Pressure rises rapidly to the set pressure during inspiration.

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Spontaneous Respiration without Positive End-expiratory Pressure Pressure-volume Loop

W ith s pontaneous res piration and no PE EP , the press ure -v olu me loo p (Fig. 23 .31 ) s tarts ou t at ze ro press ure and v olume. Du ri ng inspi ra tion ai rwa y, press ure is negativ e, so the lo op mov es i n a c lock wi se di rec tion. A t the end of i ns pi ration, the press ure returns to zero. A t this point, the loop c rosses the tidal v ol ume point on the ord inate . During ex halation, ai rwa y pressure bec omes pos itiv e, and the loop mov es to the ri ght. A t the same time , the v ol ume d rops . A t the end of exhala ti on, the pressure and v olume return to zero. The s hape of the l oop is s til l double conv ex , but i ts s lope is d iffe ren t from tha t seen wi th c ontro ll ed v en ti lation. Compl ianc e c anno t be c alcu lated f rom this loop because the insp iratory p res sure is negativ e. The area of the loop represents the work of bre ath ing.

Flow-volume Loop
The f lo w-v olume loop wi th s pon taneous resp iration is shown i n Figure 2 3.32. The f low rate du ring ins pi ration v a ries more than wi th mec han ica l v en ti lation. Peak flo w oc curs near the middl e of inspi ra tion. A t the e nd of i nspiration , flow bec omes zero, and the l oop c ross es th e hori zonta l li ne at a v olume corres pond ing to the tidal v olume . The f low du ri ng exhala tion is s imi lar to that found in other forms of respi ra tion.

Figure 23.30 Flow-volume loop with pressure-controlled ventilation. Flow is rapid at the beginning of inspiration, then decreases.

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Figure 23.31 With spontaneous ventilation, the shape of the loop is double convex, but the slope is different from that seen with controlled ventilation. PEEP, positive endexpiratory pressure.

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Spontaneous Respiration with Positive End-expiratory Pressure Pressure-volume Loop

If P EEP is appl ied duri ng spontaneous v en tila tion, the press ure-v olume l oop wi l l s tart out a t the P EE P v alue and mov e to the l ef t (F ig. 23.33). Inspi ra tion cannot begin un ti l the pressu re has become ne gativ e. A t this point, the tid al v olume i nc reas es rap id ly. During ex halation, pressure i nc reas es rap id ly , and the loop mov es toward the right and down ward to the po in t of origin . The loop has a rec tangu lar s hape. The larger i nternal area of the loop indicates the inc reased work of b rea thing .

Flow-volume Loop
The c orrespondi ng f lo w-v o lume loop du ri ng spo ntaneous res pi ration with PEEP is shown in Figure 23.34. B oth the ins pi ra tory and ex hal ation p ortions of the l oop are f lattened . The ex hal ati on po rtio n is more rounded than when PE E P is not p res ent. This configuratio n is s imilar to th e l oop demons trating a f ix ed ins pi ratory and ex piratory obs truc tion (Fig . 23.52).

Face Mask Positive-pressure Ventilation Pressure-volume Loop

The basic shape of th e p res sure-v olume loop is s till doub le co nv ex (Fig. 23.35 ). The insp iratory portion of the loop is more rounded. If there is a si gnific ant leak around the mask , an open loop ma y be seen .

Flow-volume Loop
The f lo w-v olume loop wi th mask v en ti lation (Fig . 23.36) is more rounded duri ng both inspi ra ti on and exhal ation than that seen wi th intubation. Th is c an v ary with the way in wh ic h the anes thesia prov ider s quee zes the bag.

Intermittent Mandator y Ventilation

Inte rmi ttent mandatory v enti lation produc es a c ombinati on of loops representing both spo ntaneous and con trol led b rea ths .

Figure 23.32 With spontaneous ventilation, the flow rate during inspiration varies more than with mechanical ventilation. Inspiration and exhalation tend to mirror each other. Tidal volume during spontaneous ventilation is usually lower than with controlled ventilation.
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Figure 23.33 With spontaneous ventilation and positive end-expiratory pressure, the loop is shifted leftward and becomes rectangular. PEEP, positive end-expiratory pressure.

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Pressure-volume Loop
The pres sure-v olume loop (Fig. 23 .37) s hows both a s pontaneous breath (s olid line ) and a co ntrol led breath (das hed line ). Mos t moni to rs wi ll display these loops cons ec utiv ely and not on the same sc reen as il lus trated un less one of the loops has been prev ious l y sav ed.

Flow-volume Loop
The f lo w-v olume loop (Fig. 23 .38 ) sho ws a s pontaneous breath (s olid line ) and a control led b rea th (dash ed li ne). Each has the c harac teris tics of the no rmal loop for this type of res pi rati on.

Patient-triggered Ventilation
If the v entilator is in a tri ggering mode (p res sure support v entil ation), a spontaneous breath wi l l be nec ess ary to in itia te a pos itiv e-pressure res pi ration. The pres sure-v olume loop wil l s tart out negativ el y, but as the v enti la tor is eng aged , the loop beco mes rap idly posi tiv e fo r P .752 the duration of ins pi rati on (Fig. 23.39). The exh ala ti on portion of the loop wi l l be s imilar to that found in controlled v entil ation . The f low-v o lume loop as soc iated wi th press ure s upport v entilation is sho wn in Figure 23.40.

Figure 23.34 PEEP during spontaneous respiration results in lower flows during both inspiration and exhalation. PEEP, positive end-expiratory pressure.

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Figure 23.35 With mask ventilation, the pressure rises more slowly during inspiration. During expiration, the absence of the tracheal tube decreases resistance to flow and volume and pressure drops rapidly. The shape of the upstroke will vary.

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Spontaneous-assisted Ventilation
If the s pontaneous ly breathi ng patient is not p roduci ng a s atis fac to ry tidal v ol ume, respi ra tion is often manually as sis te d. Fi gure 23.41 sho ws one of the configurations of the press ure -v olume l oop that ma y be s een . As th e patien t initia tes the v enti lation , there wi ll fi rs t be a nega tiv e press ure . As th e bag is s quee zed, p res sure and tidal v olu me inc rease.

Loops Representative of Patient Factors

Vari ations f ro m a normal l oop c an be c aused by an yth in g that affec ts the way gas mov es pas t the s enso r durin g i ns piratio n o r exp iration . This may be a patie nt fac tor, a c ircui t v ariabl e, o r a v enti lator v ariable.

Changes in Compliance Pressure-volume Loop

A major adv antage of p res sure-v ol ume lo ops is the ir ab il i ty to detec t c hanges in co mpliance. If the lun gs or c hes t wa ll become s ti ffer, i nc reased p res sure wil l be necess ary to del iv er the same tida l v olume . This caus es the pressure-v olume loop to be P .753 displac ed c lock wis e (Fi g. 23 .42 ). If PE EP is introduc ed, there ma y or may not be an

i nc reas e in compli anc e (Fig. 23 .43 ). If PEEP does not inc reas e compl iance or makes the s ituation wors e, this c an be determined b y subs equent l oops .

Figure 23.36 Mask ventilation. The inspiratory flow is more variable when ventilation is manually controlled than when a ventilator is used. During exhalation, the lower resistance due to the absence of a tracheal tube results in higher flow.
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Figure 23.37 Pressure-volume loop with intermittent mandatory ventilation.

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Flow-volume Loop
Dec reases i n compl iance wi ll affec t the f low-v ol ume loop (Fig. 23 .4 4). F low wi ll be i nc reas ed during exhalation, wi th a highe r peak and a s teeper s lope. Dec reases i n compl iance can res ult from i na dequ ate mus cl e relax a ti on; a ir embo lism; d is eas es and tumo rs that inv ade la rge a reas of th e l ung o r al ter i ts dis tens ibi lity; narc otics ; bronchial in tubation ; bronchocons tric tion ; pneumothorax;

reduc tion pneumopl as ty; l ateral decubi tus , li tho tomy , or Trendele nburg pos itio ns ; ex ternal pressure on th e c hes t or abdomen; abdo mina l re trac tors o r pac king; abdominal enla rge ment; c urv ature of th e spi ne; obes i ty; prone pos i tion; press uri za tion in the peri toneal c av i ty d uring laparosc opic surgery; or adul t respi ra to ry dis tres s synd rome (A RDS ) (6,6 8,70,71,72,73,74,75,76,77,78,79 ,80 ). Dec reases i n compl iance can be found durin g parti al co ronary bypas s . The loop retu rns to the preby pas s s ta te af te r the b ypas s is disc ontinued. Complianc e is l ower i n c hi ldren than in adul ts (Fig. 23 .45) (8 0). Fac to rs that i nc reas e c ompl iance i nclude PEE P , emphysema , and res ol ution of the fac tors that dec reas e c ompl ianc e. S ince cha nges in compli ance often occ ur graduall y, the y may not be recog ni zed unles s the c hange is la rge . It is us eful, therefo re, to s tore a loop f rom the begi nning of a c as e for c omp arison.

Figure 23.38 Flow-volume loop with intermittent mandatory ventilation.

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Figure 23.39 Patient-triggered ventilation. As the patient takes a spontaneous breath, the loop becomes positive for the duration of inspiration.

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Changes in Resistance
An inc reas e i n res is ta nce may be caus ed by tra cheal tube obs truc tion (ki nking , disl odg ment, or s ec re tions ), b ronchoc ons tric tion, airway c ol laps e f rom loss of elas tic rec oil or by obs truc ti on in a large airway c aused b y s ec retions , blood, fore ign body, neopl as m, inflammation, or using a trachea l tube that is too s ma ll . W hi le mi ld bronc hos pasm causes on ly s l ight c hanges in the flow-v ol ume loop, as it i nc reas es the re wi ll be changes in both the i nspi rato ry and exhalation porti ons . W ith s ev ere expi ratory res is tance, expi ra tory flow may s top abruptl y before the nex t mechanical inflation . The effec ts of treatment for b ronchos pas m can be assessed by observ ing the loop after trea tmen t.

Pressure-volume Loop
Durin g contro ll ed v enti lation , inc re ased res is tanc e me ans that high er inspi ra to ry press ures wil l be requi red to del iv er a giv en f low. Ti dal v ol ume may be reduce d. As shown in Figure 23.46 (s ol id line), the press ure -v olume loop is shif ted to the right and d ownward with a large internal area. The pressu re falls rapid ly af ter inspi ra ti on i s complete. The loop may be open if there is air trapping . Wi th s pontan eous v enti lation , the ins piratory l i mb is displ ac ed leftward (Fi g. 23.47 ).

Figure 23.40 Pressure support ventilation.

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Figure 23.41 Spontaneous-assisted ventilation. As the patient begins to inspire, a negative pressure is seen. Then the bag is squeezed and the pressure becomes positive. The shape of the inspiratory portion will depend on how the bag is squeezed.

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Flow-volume Loop
If res is tance is inc reased, the f lo w-v olume loop wi l l s ho w d ec rease d f low througho ut ex hal ati on (4,21) (Fig . 23.48). As resis tance inc reas es fu rther (Fig. 23.49 ), there wil l be c hanges in bo th the inspi ratory and ex halation po rtions , and

the tidal v olume may be dec reased. Wi th s ev ere exp iratory res is tanc e, ex piratory f low may s top ab rup tl y before the nex t mech anical inflati on.

Chronic Obstructive Lung Disease

E mph ysema is c harac terized by a progress iv e loss of el as tic tis sue in the lung. These patients hav e no problem with in fl atin g the lungs b ut mus t work to exha le . Durin g mec han ic al v enti lation , patients with airflow obs truc ti on may dev elop i nadv ertent PEE P (au to-PEEP , occult or in trinsic PEEP , dy namic hype rinf lation, a ir trappin g) if there is not enough time for c ompl ete P .756 ex hal ation (81,82,83,84,85). The exhal ed vo lu me wi l l be less than the ins pi red v olume .

Figure 23.42 Low compliance causes the loop to be moved closer to the horizontal axis. High compliance causes the loop to move closer to the vertical axis. The dotted line shows normal compliance. The solid line shows decreased compliance.

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Figure 23.43 The dotted line represents decreased compliance. With the addition of PEEP, the loop is moved to the left, and the increased compliance results in a more normal-looking loop. If the loop does not improve with PEEP, the PEEP may not be beneficial and may need to be removed. PEEP, positive end-expiratory pressure.

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Pressure-volume Loop
The pres sure-v olume loop seen wi th this conditio n is sh own in Figure 23.50. A t the beginning of inspi rati on, the pres sure rises s lowl y. Durin g exha lation, the press ure drops wi th li ttle c hange in v olume until the e nd of ex hal ation . A n open loop may be s een.

Flow-volume Loop
The c orrespondi ng f lo w-v o lume loop is s hown i n Fi gure 23.51. Duri ng expi ration , there is a sev ere reduc tion in fl ow. Th e l oop may b e open if th e patien t does not hav e suffici ent time to ex hale c ompl etely . In terrupted expi rato ry f low may su gges t the presenc e of intri nsic PEE P (au to-PEEP ). Patients with obs truc tiv e a irway disease may not c omplete a ful l exhalation prio r to the s tart of the n ex t i nhala tion, res ulting in pe rs is tent posi tiv e p res sure. Th is wi ll be i ndicated by the abs ence of a p eriod of zero f low b efo re the nex t inh al ati on (Fig . 23.63 ).

Airway Obstruction
Fl ow-v olume loops may be he lpful in identi fyi ng ai rway obs truc tions (86,8 7,88). The i nspi rato ry l imb of the loop P .757 i s useful in di agnos ing ex tra tho rac ic ai r way obs truc tio n, an d the ex piratory l imb is sens i tiv e to intra thoracic obs truc tion (87,89). W hen th e c ross -s ec ti onal area of th e

ai rwa y is dec reased to a c ri tical lev el , c harac teris tic patterns of flo w occ ur with spontaneous v en ti la tion. Typical l y, the fl ow ra te wi ll pla teau. Th e v alue of the fl ow rate at this plateau wi ll depen d on the c ros s-s ec tional a rea of the flo w-l imi ting segment i n the airway.

Figure 23.44 The dotted line represents decreased compliance. Flow is greater at the beginning of exhalation due to the increased pressure.

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Figure 23.45 Pressure-volume loop in pediatric patient.

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W ith a fixed intrathorac ic or thorac ic obs truc tion and sp ontaneous v en tila ti on (F ig . 23.52 ), bo th the inspi ra tory and ex pi ratory limbs of the flow-v olume cu rv e are f lattened (86,87,90). A v ariable ex trathoracic obs truc tion (Fig. 2 3.5 3) wi ll affec t ins pi ration as th e negativ e p res sure caus es the obs truc ti on to inc rease. Du ri ng exh al ati on, posi tiv e

press ure in the a irway wi ll k eep the trach ea open at the si te of the les ion, leav ing the expi rato ry c u rv e unaffec ted (87). A v ariable intra tho rac ic obs truc tion (F ig. 23.54) wi l l sho w a normal ins piratory cu rv e as the negativ e intratho rac ic press ure wi l l keep the ai rway open . During ex piration, the in trathoracic pressure bec omes pos itiv e P .758 and thus dec reases the ai rway diameter so that the exp iratory flo w i s reduce d.

Figure 23.46 With an increase in resistance, a higher pressure is needed to deliver the same volume (solid curve). Tidal volume may be reduced.

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Figure 23.47 Spontaneous respiration with increased resistance. The normal loop is shown with dotted lines. With increased resistance, greater pressure (more negative during inspiration, more positive during exhalation) will be needed to move the same volume of gas.

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Restrictive Disease
The inc reas e in elas tic rec oil with res tric tive defec ts inc reas es the force driv in g ex piratory f low. Thus , the fl ow-v olume l oop us ual ly shows a hi gh expi rato ry flow as soc iated wi th a s teep descending limb (Fig. 23.5 5).

Secretions
Sec retions in the trac heal tube wil l ca use a sawtoo th pattern in the press ure- and f low-v o lume loops (83,91 ) (Fi gs . 23.56, 23.5 7).

Pediatric Patients
Pediatric pa ti ents requi re a diff erent sc ale for p res sure- and f low-v ol ume loops . S mal l pa tients requi re re la tiv ely hi gh ai rwa y p res sures bec aus e of the s mall diameter of the trachea l tube. An ex ample is found in Figure 23.45.

Spontaneous Breathing during Controlled Ventilation

It is possible for a nonpa ralyzed patient to b rea the s pontaneous l y duri ng controlled v enti lation . This can oc cur at any time during the resp iratory c yc le. The spontaneous breath usual l y has a lo wer i nspi rato ry flow than the mecha nical breath.

Figure 23.48 Flow-volume loop with increased resistance. The dotted line represents the curve with normal resistance. With increased resistance, there is diminished expiratory flow. The convex configuration of the expiratory limb reflects uneven lung emptying.

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Figure 23.49 With a severe increase in resistance, the ventilator cannot fully compensate, and inspiratory flow will be diminished. Tidal volume may be decreased. Expiratory flow is also severely decreased. The dotted line represents the normal curve.

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Pressure-volume Loop
Fi gure 23.58 sho ws a p res sure-v olume loop with a s pontaneous breath durin g ex hal ation . As the s pontan eous breath occ urs , the p ressure dro ps below th e ex pec ted lev el whi le the v ol ume ris es above the us ual cu rv e. As the s pon taneous breath is ex haled, the press ure inc reases brie fl y and the v olume drops rapidly . The remainder of the loop follo ws the expec ted s hape . Fi gure 23.59 sho ws a s eries of pressure-v olume loops wi th the sol id li ne (loop 1) represen ting a normal l oop produc ed wi th mech anical v entilati on. Loops 2 and 3 show the pa tient b rea thi ng agains t the v entil ato r. The loop mov es toward the negativ e s ide of th e p res sure axis and then cha nges to pos i tiv e. The pres sures generate d a re qui te h igh and the tidal v olume is dec reased s inc e the pa tient is ex hal in g duri ng insp iration .

Flow-volume Loop
Fi gure 23.60 dep ic ts a flow-v olume loop wi th a spontaneous b rea th ne ar the end of i nspi rati on . There is a su dden i nc reas e i n inspi ra to ry fl ow and v olu me. As the breath is ex haled, the flo w and v olume move toward z ero .

Figure 23.50 With severe COPD, resistance during expiration is greatly increased. The patient may have difficulty exhaling completely before the next inspiration, producing an open loop. COPD, chronic obstructive pulmonary disease.

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Figure 23.51 With severe COPD, expiratory flow is severely reduced. COPD, chronic obstructive pulmonary disease.

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Figure 23.52 Flow-volume loop with fixed intra- or extrathoracic obstruction.

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Figure 23.53 A variable obstruction located outside the thorax will cause a plateau during inspiration. The expiratory portion of the curve is close to normal. The dotted line shows a normal loop.

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Figure 23.54 With a variable intrathoracic obstruction (such as a tumor in the trachea or a mediastinal mass), inspiratory flow may be relatively normal, but during expiration, flow rises to a plateau instead of the usual rise to and descent from peak flow. The dotted line shows a normal loop.

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Figure 23.55 With a restrictive defect, the increase in elastic recoil is associated with higher expiratory flows. As the process becomes more severe and lung volumes are decreased, the flow-volume curve becomes tall and narrow. The dotted line shows a normal loop.
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Figure 23.56 Pressure-volume loop with secretions in the tracheal tube.

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Figure 23.57 Flow-volume loop with secretions in the tracheal tube.

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Open Loop
A loop should retu rn to i ts s ta rting poi nt at the end of the resp iratory c ycl e. An open l oop (F ig . 23.61) has a gap between the end and s ta rting points , in dicatin g that the ex hal ed v olume is les s than the inhal ed v olu me . W hi le the pressure-v ol ume loop appears to c los e, i t ac tual ly returns to ze ro press ure along the v ertic al ax is rather

than at the s tarting point. The amount of gas loss can b e read betwe en zero and the return point of the loop. An ope n loop means that more gas has p ass ed the s enso r during ins piration than retu rns du ring exhalation . Mos t often, this is becaus e of a leak dis tal to the s ensor. Inc orrec t ca li brati on s houl d also be c onsi dered. A n op en loop is of ten s een wi th mask anes thes ia , an unc uffed trac heal tube, or a s upraglottic ai rway dev ice. A double-l umen tube may impos e s uffic ient res istanc e to resul t i n the lungs not co mple tel y emptyi ng, ev en in patients wi th n ormal ai rway s (22 ,92 ). Leaks of te n occur after l ung reduc tion or o the r thoracic s urgery (93). The ex tent of the leak and changes in the v olume of gas los t can be tracked wi th the flow-v ol ume l oop. An ope n loop ma y be due to inco mple te ex halation c ause d b y chronic obs truc tiv e pulmonary disease (COPD), i nc reased res ista nce caused b y a pparatus , a tens ion pneumothorax , lung retrac ti on, or a fl ap-v alv e obs truc tion in a large ai rway or a double-l umen tube (94).

Overshoot Loop
An ov ers hoot loop ind ica tes that the exhal ed v olume is greate r than the ins pired v olume . This usually indic ates P .763 that the moni to r nee ds to be rec al ibra ted . It can also resul t if pressu re on the thorax c auses some of the func ti ona l residual v olume to be added to the tida l v olume .

Figure 23.58 This spontaneous breath occurs during expiration.

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Figure 23.59 Loop 1 represents the normal loop. Loop 2 shows a spontaneous breath during inspiration. The pressure drops, and the volume increases briefly. There is a decrease in compliance caused by an increase in tension in the chest wall muscles. In loop 3, the patient inhales at the beginning of the respiratory cycle, so the loop moves to the left of the vertical axis. There is a further decrease in compliance.

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Pressure-volume Loop
The pres sure-v olume ov ershoot loop (Fig . 23.62) c an appe ar as a normal loop , but the begi nning poin t is to the rig ht of the endpoi nt. The differenc e between the beginning and end point is the amo unt o f exc ess gas that is ex hal ed.

Flow-volume Loop
On the ov ersho ot f low-v o lume loop (Fig . 23.63), the endp oin t is to th e right of the ze ro v olume po int. The d is tance to the ri ght rep res ents the ex ces s gas that has been exha led.

Intrinsic Positive End-expiratory Pressure and Air Trapping

Intri nsic (au to, occu lt) PEEP (PEE Pi ) res ul ts f rom a difference be twee n the ac tual ex piratory ti me and the P .764 ex piratory ti me required fo r c omplete exhala tion of the tida l v olume so that s ome ai r is trapped in the lun gs (Fig. 2 3.63). It may be generated by a v ery short ex piratory ti me and/or s low exp iration due to hi gh resis tance or a bnormal ly high co mpliance. A i r trapping is lik el y to occ ur in p atien ts wi th ai rflow li mitation, inv e rse rati o v en ti la tion, or when us in g a h igh res pirato ry rate .

Figure 23.60 The spontaneous breath occurs near the end of inspiration. The thin, dotted line represents the normal loop. Instead of returning to zero at the end of inspiration, the flow increases. There is a small increase in volume as well.

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Figure 23.61 There is a leak, so exhaled volume is approximately 150 mL less than the inhaled volume. This produces open pressure-volume and flow-volume loops.
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Loops Representing Equipment Problems

Tubing Misconnection
Some older sens ors had a l ong and a short nipple des ign ed to c onnec t to the sho rt and long l umens of th e p res sure tubin g, respec tiv ely . It was poss ib le to c onnec t the tubi ngs long to lon g and short to short. If thi s were done, the moni tor would s ense ex hal ation as inha la tion and v ice v ers a. The loops would be dra wn back ward an d upsid e down (F ig. 23.64). It would tak e two re spi ra tory c yc les to produc e a full l oop, and the moni tor wo uld be u nable to c ompute the c ompliance. E x tremely hi gh PEE P v alues would be rec orded. Ne wer s ensors wi th male a nd fe male c onnec tions make tubi ng misconnec ti ons less l ik el y (Fig. 23 .8 ).

Disconnection between the Sensor and the Breathing System

If there is a d is conn ec tion between the spi ro me try s ens or an d the breathing s ys tem, there wi l l be no flow P .765 through the sens or during mechanical v entilatio n and a loo p wil l no t be gene rated (Fig . 23.65).

Figure 23.62 The exhaled volume exceeds the inhaled volume, producing an overshoot loop.

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Figure 23.63 Intrinsic positive end-expiratory pressure and air trapping. The gap in the flow-volume loop indicates that there was still expiratory flow when the next inspiration commenced. PEEP, positive end-expiratory pressure.
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If the p ati en t bre athes spontaneous l y with a d is connec tion between the sens or and the breathing s ys tem, loops s een wi th s pontaneous respi ra tion wi ll b e generated. If a c i rc le breathing s ys te m also conta ins a f lo w s enso r mounted on the exhala tion s ide near the abso rbe r, this sens or wi ll not indicate flow duri ng spon tan eous v enti lation and wil l help to loc ali ze the disco nnec tion.

Leak between the Sensor and the Breathing System Pressure-volume Loop

If there is a leak o r partial d is conn ec tion bet ween the s ens or and the breathing s ys tem, s ome gas wil l be los t. The pres sure-v ol ume loop (Fig. 23 .66 ) wi ll b e norma l i n s hape b ut wi ll s how a dec rease in tidal vo lume and a dec rease in peak a irway press ure . This differs f rom the leak ass oc iated with the open l oop in that the i nhaled v olume is dec reased as a resul t of the l eak , but the amount of gas exha led i s equal to the amoun t of gas inhaled.

Flow-volume Loop
The f lo w-v olume loop d uring a partial dis con nec ti on (Fig. 23.66) wi ll s how a dec reas ed tidal v olu me a nd a dec reas e in peak expi ra tory flow. The lo op wil l no t be open because both ins pi red and exhaled ti dal v olumes wi ll be the same.

Figure 23.64 Misconnection of the tubings will cause the loop to be drawn backward and upside down.

View Figure

P .766

Figure 23.65 A disconnection between the sensor and the breathing system will result in no flow through the sensor.

View Figure

Disconnection between the Sensor and the Patient

W ith a disconnec tion between the sensor an d the pa tient, du ri ng con trolled v enti lation there wil l be flo w du ring i nspi ration bu t not exhalation (Fi g. 23 .67 ). T he press ure -v olu me loop wi l l s ho w a high tida l v olume bu t almos t no pres sure. S ince there wi l l be no retu rn gas f low, there wi l l be only half of a p res sure- or f low-v ol ume l oop.

Bronchial Intubation
B ronch ia l in tubation c an occu r any time a trachea l tube is in pl ace. It is th e most f requentl y occu rring probl em le adi ng to h ypox ia (95). If this hap pens , the co mpliance dec reas es and the pressu re needed to deliv e r a s et tidal v olume rises (21,96,97). B ronc hi al intubation is dis cus sed in Ch apter 19 . It i s mos t likely to oc cur wi th a change in the patient's pos i tion. If a s udden change occu rs in the press ure -v olu me loop at this time, bronc hi al i ntuba tion s hould be s uspec ted. W ithdrawi ng the tracheal tube s l ightly wi l l re medy the p rob le m an d wi l l be demo nstra ted wi th the nex t loop. P res sure-v olume loops may be among the bes t way s of detec ting this probl em.

Pressure-volume Loop
The pres sure-v olume loop wil l show a d ec rease in c ompl iance wi th a rightwa rd and downward s hift and a h igh peak press ure (Fi g. 23.68, s ol id l ine).

View Figure

Figure 23.66 With a leak between the sensor and the breathing system, the loop will have a normal shape but the tidal volume, peak pressure, and expiratory flows will be decreased. The dotted line represents the normal loop, and the solid line represents the loop with a leak.

P .767

Figure 23.67 A disconnection distal to the sensor will result in flow during inspiration but none during exhalation.
View Figure

Flow-volume Loop
The f lo w-v olume loop assoc ia te d wi th b ronchial intubation is s hown i n F igu re 23 .69 (s ol id l ine). The inc rease in peak pres sure wil l i nc rease the peak flow during ex hal ation .

Double-lumen Bronchial Tube Problem

Double -l umen bronc hial tubes are of ten pl ac ed inc orrec tly or may be displaced during patient pos iti oning or s urge ry (6,21,22,98,99,100). Con ti nuous spi rometric moni tori ng can help to detect the probl em. B as el ine fl ow-v olume and press ure v olume loops s hould be es tablishe d and recorded for eac h patien t whi le in the supin e pos i tion du ring two-l ung v entilation to al low c omparis on with la ter loops .

Pressure-volume Loop
W hen one-l ung v entilatio n is beg un, the press ure -v olu me loop s hould s how a s light sh if t of the s lope to the right, ref lec ting decreased c ompl iance (98,99,100). W i th su rgical handling of the nondependent lung, c ompliance may dec rease further (100). If a doub le-lumen tube is plac ed too deepl y, there wil l appea r to be a dec rease in co mpliance (Fig. 23.7 0). Tidal v olume may be dec rease d. Incomp lete lung emptying wi ll res ult in an open lo op (22 ). The loops shown i n Figure 2 3.71 resu lted f rom the ti p of the bronc hi al lumen i mpin gi ng on the wa ll of the bronc hus . Loop 1 (soli d li ne) is th e normal loop. In loop 3 (dotted l ine), the tube tip has i mpinged on the wal l of the bronc hus . P ressure rises rap idl y wi th l ittle inc rease in v ol ume unti l suffici en t pressu re has been P .768

P .769 ex erted to mov e the tip a way from the wal l . A t this point, the v olume rises rapidly . The re wi ll be an inc rease in peak press ure and/or a dec reas e in co mpli ance. If there is a bal l-v alv e ac tion , during exhalation the pres sure wil l dec rease ra pi dly wi th l ittle ch ange i n v olume until the pres sure i n th e b ronchial tube has fall en suff ic ientl y to allow exhala ti on.

Figure 23.68 Bronchial intubation (solid loop) will result in a decrease in compliance.

View Figure

Figure 23.69 Bronchial intubation. The solid loop shows an increase in expiratory flow, especially during the early part of expiration.

View Figure

Figure 23.70 The dotted line represents the loop when the double-lumen tube is correctly positioned. If the bronchial lumen is inserted too deeply, a severe reduction in compliance and tidal volume will be seen.

View Figure

Figure 23.71 Impingement of the end of the tube on the bronchial wall has created a ball-valve obstruction. The pressure rises rapidly with little increase in volume until the pressure is sufficient to overcome the obstruction. The volume then increases, and the pressure drops. If the pressure drops low enough, there will again be obstruction to flow, creating another notch on the upswing of the loop.
View Figure

Flow-volume Loop
The f lo w-v olume loop d uring prope r doub le-l umen tu be placement wi ll show a s lightly dec reased expi ra tory flow ra te. If the tube is p lac ed to o deepl y into the bronc hus , the l oop wi ll show di min is hed i nspi rato ry and expi ratory flows . If there is a ball -v a lv e obs truc tion to the tip of the double-lume n tub e, th e flow-v olume loop wi ll be irregular (F ig. 23.72). The f lo w-v olume loop that would be gene rated if there we re a disconnec tion of on e l imb of a double-lume n tub e o r a leak ing bro nchi al c uff is s hown i n Figu re 23 .73

(s ol id l ine). The inspi ra tory porti on is normal. Because much of the insp ired tida l v olume is los t through the leak , the loop is open. In addi tio n, th ere wi l l be dec reas ed f lo w d uri ng ex halation .

Figure 23.72 The loop represents repeated ball-valve obstruction to flow during both inspiration and expiration.

View Figure

P .770

Figure 23.73 With a leak in the bronchial cuff or a disconnection of one limb (solid loop), there will be an open loop, with the inhaled volume exceeding the exhaled volume. Exhaled flows will be decreased.

View Figure

Esophageal Intubation

W ith esophageal intubation, the press ure -v o lu me loop wi l l usuall y sho w a dec rease i n c ompliance (Fig . 23.74, solid l in e), although comp lianc e ma y be inc reased or normal (21). Gas that ente rs the s tomach an d is not returned wi ll c reate an open l oop. The flow-v olume loop wi ll be dis to rted and show s mall inspi ratory and ex piratory v olumes, often wi th an open lo op.

Obstructed Tube
A nearl y c ompletel y o bs truc ted trache al tube or an inc orrec tl y p laced sup rag lo ttic ai rwa y dev ice wi ll res ul t in a press ure -v o lume l oop that shows a high press ure wi th l ittl e or no tid al v olu me (Fig. 23 .75 ). This is us uall y a s ignal tha t the dev ice should be remov ed and reins erted.

Advantages of Loop Technology

P ress ure- and flow-v ol ume loops p rov ide the c l inic ia n with real-ti me inf ormation . The re are many probl ems th at can occur unex pec tedl y duri ng a case (e.g., k inked trac heal tube, disc onnec tion , migration of a tracheal tube i nto a bronc hus ). W i thout l oops , these problems mi ght no t be recogn iz ed promptl y and c orrec tiv e actio n may be de layed. W hi le many of the probl ems th at oc cur du ring respi ra tion c ould be determined by watchi ng P .771 press ure , tidal v olume, a nd flow moni to rs , lo op tec hnolog y offers a g rap hic represen tati on tha t inte gra tes that i nformation , mak ing changes more obv ious .

Figure 23.74 The loops associated with esophageal intubation may vary greatly. Compliance may be increased, decreased, or normal.
View Figure

Figure 23.75 With a nearly obstructed tube, there will be a high pressure with little volume.

View Figure

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82. Patel H, Yang K L. Va ri abili ty of i ntrins ic posi tiv e e nd-expi rato ry press ure in pati ents rec eiv ing mec hanic al v eni tlation. Crit Ca re Med 1995;23:10741079 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 83. Anonymous . Patient s pi rometry. Cli nic al interpre ta ti on in c ri tical care. Hels ink i, Fi nl and: Datex Ohmeda. 84. Bardoc zk y GI, d' Hol lande r AA , Cap pello M, et al. Interru pted expi ra tory fl ow on automatic al l y c ons truc ted fl ow-v olume cu rves ma y determi ne the presenc e of i ntri nsic posi tiv e e nd-exp irato ry press ure d uri ng one -lung v entilation. Anes th Analg 1998;86:880884. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 85. Duec k R, Coope r S , K apelansk i D, et a l. A pi lot s tudy of expi rato ry f low l imi ta tion and lung v olume reduc tion s u rge ry . Ches t 1999 ;16:1 7621771. [Cross Ref] [Med li ne Link ] 86. Pul le ri ts J , Holzman R. A nes th esia fo r patie nts wi th medias tinal mass es . Can J Anaes th 1989 ;36 :681688. [Med li ne Link ] 87. P insonneaul t C, Forti er J , Donati F. Tracheal resec tion and rec ons truc tion. Can J Anaes th 1999;46:439455. [Med li ne Link ] 88. Weis sman C. Flow-v olume re la tions hip b etwe en spon ta neous b rea thing through endotrac heal tub es. Cri t Care Med 1992;20:615620 . [Cross Ref] [Med li ne Link ] 89. Dahlberg CGW, Hales CA . Pulmona ry func tion tes ts to ev al ua te the airway . In : Roberts JT, ed. Clinic al managemen t of the ai rway . P hiladelphia: W B Saunders , 1994: 5662. 90. B rodsk y J B . B ronchosco pic p roc edures for central a irway obs truc tion. J Cardi othorac Vasc A nes th 2003;17 :638646. [Cross Ref] [Med li ne Link ]

91. Jubran A , Tobin MJ . Use of f low-v olume curv es i n detec ting s ec retions in v enti lato r-dependen t pati ents . A m J Respi r Crit Ca re Med 19 94;150:766769 . [Med li ne Link ] 92. Yoko ta K , To ri umi T, Sari A , et al . Au to-pos itiv e end-exp iratory p res sure during one-lung v entilatio n usi ng a doubl e-lumen endobronchial tube. A nes th A nalg 1996;82:1007101 0. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 93. Robinson RJS . The use of s ide-s tream s pi rometry to ass ess ai r l eak du ring and af te r lu ng v olume reduc tion surgery. Anes thes iology 1999;91:571573 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 94. B reen PH, S erin a E R, Bark er SJ . Exhale d fl ow moni tori ng can detec t bronch ial f lap -v alv e obs truc tion in a mechanic al lung model. A nes th A nalg 1995;81:292 296. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 95. Coope r J . ICPA MM meeting rev iew of safety i ncludes n ew worl dwi de expans ion . J Cl in Moni t 1997;13:205210 . 96. Campos C, Nagui b SS , Chu ang A Z, e t al . Endobronchial intuba tion c auses an i mmediate inc reas e in pe ak in fl ation pres sure i n ped iatric pa ti ents . A nes th A nalg 1999;88:268270. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 97. Mahajan A , W ald S H, Sc hro eder R, et al. Detec tion of endobronc hia l i ntubation i n infants and ch ildren usi ng sp irometry . A nes thesi ology 2002;9 6:A 1268 . 98. S imo n B A , Hurford WE , Alfi ll e PH, et al. A n a id in the d iag nosis of mal pos itioned doubl e-lumen tubes . A nes thes iol ogy 1992;76:862863 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

99. Bardoc zk y GI, Lev a rlet M, En gelman E , et al. Continuous spi rometry for detec tion of double-lu men endobronchial tube d isplacemen t. B r J An aes th 1993;70: 499502. [Cross Ref] [Med li ne Link ] 100. Iwasak a H , Itah K , Mi yak awa H, et al . Continu ous moni tori ng of v entil atory mechanics du ri ng one-l ung v enti lati on . J Clin Moni t 1996;12:161164. [Cross Ref] [Med li ne Link ] P .773

Questions
For the fol low ing ques tions , s elec t the co rrec t answer 1. No rmal s tatic co mp liance in an adult is A . 15 mL/cm H 2 O B . 35 to 100 mL/c m H 2 O C. 20 to 35 mL/c m H 2 O D. 35 to 50 mL/c m H 2 O E . 75 to 125 mL/c m H 2 O V iew A ns we r2. For greatest accuracy, the gas flow sensor should be placed A . In the i nspiratory li mb a t the absorber B . B e twe en the insp iratory l imb an d the Y-pi ece C. Be twee n the Y-pi ece an d the patient D. Be twee n the Y-pi ece an d the ex piratory li mb E . On the abs orber on the exha lation s ide V iew A ns we r3. The pre ferred site for monito ring a irw ay pressure is A . A t the v entil ator B . In the i nspiratory li mb a t the c anis ter C. A t the connec tion between the pa tient and the b rea thing s ys tem D. On the expi rato ry l imb at the ca nis te r E . A t the bag mount c onnec tion V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t

i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

4. Wha t does the diffe rence between the peak and plate au pre ssure measure? A . P lateau press ure B . To tal ai rway res is tanc e C. Comp lianc e D. Insp iratory flo w E . Res is tance in the breathing s ys te m V iew A ns we r5. Use of muscle relaxants A . May c ause the c omp lianc e of th e lungs to inc reas e B . May c ause the c omp lianc e of th e ches t wal l to inc reas e C. May c ause a dec rease in res istanc e D. May resu lt in a dec reas e in pl ateau press ure V iew A ns we r6. A rise in peak airw ay press ure may occ ur as a result of A . A n inc reas e in tida l v olume B . A n inc reas e in inspi rato ry flow rate C. An inc reas e in res is tance D. An inc reas e in c omp lianc e V iew A ns we r7. Wi th inadvertent bronch ial intuba tion, A . Th ere wi l l be a dec reas e in co mpli ance B . Th e pressure-v olume loop wil l b e s hifted to the ri ght and down ward C. The p eak press ure wi l l be inc rease d D. The f low-v olume loop wil l s how an inc rease in peak ex piratory f low V iew A ns we r8. Inc reased res istance to bre athing durin g controlled re spiratio n can be overcome by A . A dding or inc reas ing PEEP B . Inc reas in g the driv ing p res sure C. Inc reas ing the inspi red ox yg en D. Dec re asing inspi ra tory flow V iew A ns we r9. Tota l res is tance during inspiratio n a nd expiratio n is influenc ed by A . Th e patien t's ai rwa y B . Th e exha lation porti on of the breathing sys tem

C. The s iz e and cha rac te ris tics of the trache al tube D. The a mount of PEEP added to the breathing s ys tem V iew A ns we r10 . Means to dete ct a leak aro und a trachea l tube include A . A i rway press u re moni tors B . Respi ratory breath s ound monitoring C. Respi ratory v olume meas urement D. Capnograph y V iew A ns we r11 . Respiratory volume mo nitoring may fa il to detect A . Oc c lusi on of the ai rwa y B . A disconnec tion duri ng spon taneous b rea thi ng C. Es ophageal intubati on D. Apnea V iew A ns we r12 . Whic h factors are compon ents o f total co mp liance ? A . E las tic properties of the lungs B . E las tic properties of the thorax C. E las tic properti es of the abdomen D. E las tic properti es of the breathi ng s ys tem V iew A ns we r13 . Conditions that ca n b e d ete cte d b y u sing a minimum pressu re alarm include A . A n unc onnec ted v en ti lato r B . A major l eak in the breathi ng s ys tem C. A malfunc tioning s c av enging s ys tem D. An inc reas e in res is tance V iew A ns we r14 . T he min imum airw ay pressure alarm should be set A . A t the lowes t setti ng B . A t different s ettings during a case C. Greater than 6 c m H 2 O D. S li ghtly l ess than the peak p res sure during i nspiratio n V iew A ns we r15 . Conditions that may preven t activation of the minimum pressu re alarm w ith a d isc onnec tion inc lud e A . Obs truc tion of a breathing sys tem connec tor B . P a rtia l ex tuba tion C. High res is tanc e of compo nents of the bre athing s ys tem D. A i r en trained in to the breathin g s ys tem V iew A ns we r16 . A s ustained pressure may be caused by A . Oc c lusi on of the scav eng ing s ys tem

B . Ac tiv ation of the ox ygen flus h v alv e C. Impro per adjus tment of the APL v alv e D. Oc clus ion of the inspi ra tory limb of the breathin g s ystem V iew A ns we r17 . An excessively h igh pressu re in the breath ing sy stem may be caused by A . Th e patien t cou ghing or s training B . Us e o f the oxygen flus h du ri ng the ins pi ratory phas e of the v entil ator c yc le C. A punc tured v entilator be ll ows D. Inc reas ed c ompl ianc e V iew A ns we rP .774

18. S ubambient p ressure in the breathin g s ystem may be ca used by A . A nas ogas tric tube p lac ed in the trachea and attached to suc tion B . A block ed ex piratory l imb C. Insp iration wi th a n empty res e rv oir bag D. Refi lli ng of a v en ti lato r with a s tanding bel lows wi th l ow f resh gas flo ws V iew A ns we r19 . On a press ure -volume lo op, A . Th e farthes t poin t to the ri gh t on th e hori zontal axis represents the ti dal v ol ume B . Th e slope of the ins pi ra tory porti on is determined b y the resis tance C. The h ig hes t poi nt on the curv e represents th e peak press ure D. The c urv e can s lope to the right or lef t duri ng inspi ration V iew A ns we r20 . Conce rning a flow -volu me loop, A . Th e porti on below th e hori zonta l line represents insp iration usin g the represen tati on us ed b y p ul monol ogis ts B . Th e porti on abov e the h ori zon tal line represen ts the pass iv e def lation as determined by the e las tic recoi l of the lungs a nd ches t wal l i n the representa tion us ed by pul monologis ts C. The tidal v olume is that poin t where the loop c ros ses the horizontal l in e D. This loop is known as a c ompl iance lo op V iew A ns we r21 . If a double-lumen tu be is placed too deeply, A . Th e pressure-v olume loop wil l b e s hifted to the ri ght and down ward B . Th ere wi l l be a dec reas e in co mpli ance C. An ov ers hoot loop may res ul t D. Resis ta nce wi ll inc reas e V iew A ns we r22 . P oss ible caus es of inadve rtent PEEP include

A . P a rtia l obs truc tio n of the breath ing s ys tem B . Malfunc tioni ng scav enging dev ice C. Obs truc tiv e ai rway d isease D. A i rf low obs truc tion V iew A ns we r23 . P oss ible caus es of an ope n loop include A . Improper c al ibration o f the monitor B . A n unc uffed trac heal tube C. A leak dis tal to the s ensor D. Tens ion pneumothorax V iew A ns we r24 . Decreases in compliance may be caused by A . Inad equa te musc le relaxation B . B ronc hi al intubatio n C. Obes i ty D. Rev erse Trendel enburg pos i ti on V iew A ns we r25 . With restrictive lung disease, A . P eak exp iratory f lo w wi l l be inc reased B . Th e flow-v olume loop may bec ome tall an d narrow C. The f low-v olume loop may hav e a rela tivel y normal s hape bu t may appear smal ler i n all dime nsions D. Resis ta nce is inc reased V iew A ns we r

Chapter 24 Pulse Oximetry

P .776

Introduction
Pulse ox imetry, s ometimes called th e fi fth vi tal si gn, is a noninv asiv e method of meas uri ng hemoglobi n saturation (S pO 2 ) by us ing a li ght s ignal trans mi tted thro ugh tis sue. A low S pO 2 can p rov ide warni ng of hypox emia before other s igns s uc h as c yanos is or a c hang e i n hea rt rate a re obs erv ed. Until the 1 980s , non inv asiv e ox imeters , k nown as ear oxi mete rs , were l arge, ex pens iv e, and c umbersome. They requi red arte ri al ization by hea t or chemic al trea tmen t, and the ir u tili ty was li mi ted by difficul ties i n differentia ting l igh t absorbanc e of arterial bl ood f rom that of v enous blood and tis sues . Tec hnical adv ances , inc luding l igh t-emi tting d io des (LEDs ), min ia turized photo detec tors , and mic roproces sors , allowed the c reatio n of a new gene ration of ox imeters , whi ch we re smal ler, l es s expe nsiv e, and eas ier to us e. These differentia te the abs orp ti on of l ight by the pulsa ti le arteri al c omponent f ro m the s tatic c omponents , so they are cal led puls e ox i meters . A puls e ox imeter may be a s tand -alone d ev ice or inc orpora ted into another dev ice such as a multiparameter moni tori ng s ys tem. A rel ativ el y n ew dev elop ment is a co mbined pulse ox imetry and transc utaneo us carbon dioxi de tens ion ear sens or (1,2 ,3,4). The A me rican Soc ie ty of A nes thes iologis ts (A SA ) and A me ric an As soc iation of Nurse Anes thetis ts hav e made ass essment of oxygenation a s tandard for i ntraop era tiv e and pos toperativ e mo ni toring. In 2005 , an audibl e alarm for th e pulse ox imeter wa s added to the AS A monitoring s tandard (5). In ternati onal s tandards for safe prac tic e endo rse d b y the W orld Federati on of Soc ieties o f Anes thesi ol ogis ts highl y recommen d c ontin uous use of a qua nti tativ e mon itor of oxygenati on such as pulse oxime try (6). In s ome s tates , the use of pulse ox imetry i s mandatory. A s tudy of c losed cl ai ms of anes thetic -rela ted ma lprac tice cas es determine d tha t a co mbination of pulse oxi metry and c apno gra phy could hav e prev en ted 93% of av oid able mis haps (7). One s tudy determine d tha t pulse ox imetry p rov ide d the firs t warni ng of an inc ide nt i n 27% of si tua tions (8). The number of u nantic ipated

i nte nsiv e ca re uni t ad mis sions dec reased afte r th e i ntroduc tion of the pulse ox imetry (9).

Operating Principles
The puls e ox imete r es ti ma tes S pO 2 from the dif ferential abs orption of red and i nfrared li gh t in tis sue (10,11,12,13,14,15,16). The two wav e lengths al low differentia ti on of reduced hemoglobin and ox yhemog lob in . Reduced hemoglobin absorbs more light in the red band than ox yhemo globi n (Fig. 24 .1 ). Ox yhemog lobin absorbs more light in the inf rared band. The p uls e oxi meter computes the ratio between these two s ignals a nd relates this ratio to the arte rial ox ygen s atu rati on, us ing an e mpirical a lgo ri thm. Pulse ox imeters disc riminate between arterial b lood and other c ompone nts b y determin ing the change in transmi tted l ight caus ed by the f low of a rterial blood. T he ox imeter puls es the red an d i nf ra red LE Ds ON and OFF s ev eral hundred times pe r second . The rapid s ampl ing rate allows reco gni ti on of the peak and trou gh of eac h pulse wav e. A t the trough, the l igh t is tra nsmi tted through a v as cul ar bed that contains ma inl y capill ary a nd v enous blood as wel l as i nterv ening tis sue. A t th e peak , i t sh ines through all this plus arteri al blood . A photodi ode c ollec ts the transmitted li ght and conv erts i t into elec tric al si gnals . The emi tted s ignals a re then amplified, process ed, and dis pl ayed o n the moni tor. Oxime ters hav e a p hase wi th both LE Ds OFF to allow detec tion of and c ompensatio n for ex traneous light. Light readings duri ng the OFF period are sub trac ted from the nex t s eque nce. Frac tio nal ox ygen satura tion (% HbO 2 ) is the ra tio of ox yhemoglo bi n to the s um of al l he moglobin s pec ies p res ent, whe the r avai lable for rev ers ible binding to ox yg en or not (1 7). Func ti ona l ox ygen saturatio n (SaO 2 ) is defined as the ratio of ox yhemoglo bi n to al l fu nc tional h emoglobi ns . Thes e mus t be de termined by us ing an P .777 i n v itro oxime ter. Fo r patie nts wi th low dys hemog lobin l ev els , the d iffe rence between f rac tional and func tional sa turation i s v ery s mal l . Howev er, when dyshemoglo bi n l ev els a re elev ated , th e two v alues c an v ary gre atly, and pulse ox imeter readings ma y not ag ree wi th e ither the true f rac tional or f unc tiona l sa turatio n v alues (18).

Figure 24.1 Absorbance of light as a function of wavelength. The extinction coefficient is a measure of the tendency of a substance to absorb light. At the red wavelengths (650 to 750 nm), reduced hemoglobin absorbs more light than does oxyhemoglobin. In the infrared region (900 to 1000 nm), the reverse is true.

View Figure

Transmission Pulse Oximetry

The mos t commo n type of pulse oximeter is th e transmissi on ox imeter. W ith th is tec hnology, a l ight be am is transmitted through a v ascula r bed and is detected on the opposi te si de of that bed.

Reflectance Pulse Oximetry

Ref lec tanc e oxime try rel ies on ligh t th at is ref lec ted (backsc attered) to determin e ox ygen s atu ration. The p robe h as both an LE D and a pho todiode (Fig. 24.16). Trans miss io n pulse ox imetry probes a re not accu rate when us ed in the manner of reflec tanc e oxi metry (19). Ref lec tion orig in ates f rom nonho mogene ity in the optical path, tha t is , at the in terfac es be twe en mate ri als with diff ere nt refl ec tiv e i ndices . The tis sue mus t be wel l perf used to obtain a s trong si gnal . Heating the meas urement s ite and app ly ing p res sure ma y be helpful (20,21). The re are a number of limi tations of ref lec ta nce ox imetry. The probe d esign must el imina te l igh t th at is pass ed di rec tl y to the probe or is sca ttered in the outer su rface of the sk in . The si gna ls are weak er th an th ose found in transmiss ion ox imetry , so the photodi ode a rea ne eds to b e as la rge as possible. If the probe is l ocated ov er an arte ry or a v ein , th e read ing may b e a rtif ac tua lly lo w (22,23). Vas ocons tric tion c an cause ov eres ti mation of the ox ygen s atu rati on (23).

Physiology

Effic ient oxygen trans port rel ies on the ability of hemog lobin to rev ers ib ly l oad and unload ox yg en. The relatio nship between ox yge n tens io n and ox ygen binding is seen in the ox yhemoglob in diss oc iation c urv e (Fig. 24 .2), whi ch plots the hemo globi n ox ygen saturation agains t the ox ygen tens ion. The si gmoid s hape of the curv e is essen tial for phys iologic trans port. As oxyg en is take n up in the lun gs , the blood is nearly f ul ly sa turated ov e r a large range of tens io ns . Du ring pas sage through the P .778 s ys temic c api ll aries , a la rge amount of ox ygen is releas ed with a rel ativ el y s mal l drop in tens ion. This al lo ws oxygen to be rel ease d a t suf fic ien tl y high conc en trations to prov ide an ade quate gradi ent for di ffusion into the c el ls .

Figure 24.2 The oxyhemoglobin dissociation curve. Hemoglobin saturation is plotted as a function of oxygen tension.

View Figure

The s hape of the ox yhemoglobin d is soc iation c urv e l imi ts the deg ree of desatura tion that ca n be tolerated. Be tween 9 0% and 100% s aturation , the p artial press ure of oxygen in arterial b lood (PaO 2 ) wi ll b e 60 torr or a bov e . Below 90% sa turatio n, the curv e bec omes s teeper, and smal l drops in s atura tion co rrespond to l arge d rops in ox ygen pa rtial pressu re. If a problem dev elo ps , there may not be much wa rni ng be fore the ox ygen lev el becomes dangerous ly l ow. No rmal satura ti on wi ll dec reas e as alti tude abov e s ea lev el inc reases (24).

Equipment Probes

The probe (s ensor, trans duc er) is the part tha t comes in c on tac t wi th the patient. It contains one or more LEDs (photodiodes ) th at emi t l ight at s pec if ic wav el engths and a photodetec tor (photoc ell , transducer). The LEDs prov ide monochromatic l ight. This means that they emi t a c ons tant wa v elength th rou ghou t th eir life , so th ey nev er need rec al ib ration. LEDs c aus e relativ ely l ittle heating an d a re so i nexp ens iv e that the y ma y be used in a d is posa bl e p robe. The light, partial ly absorbed and modula ted as i t passes throug h the tis sue, is co nv erted into an elec tronic signal b y the photodetec tor. Fi gures 24.3 to 24 .11 s how s ev eral ty pes of p rob es . P robes may be re usab le or disposable. They hav e th e s ame accu rac y (25 ,26,27,2 8). A disposab le probe is us ual ly attached b y us ing adhes iv e. Reusa ble p rob es eithe r cl ip on or a re attached by us in g adhes iv e o r Velc ro. Dispos able pro bes may be easier to use, but reusable probes a re more economic al as l ong as pers onne l are c areful not to damage the reusable probe (26,29,30,31 ). S elf -adhes ive (band, wrap) probes a re less suscep tible to motion a rtifac t and are les s likel y to c ome off if the patient mov es than th ose that c lip on. Ho wev er, they are usua ll y not as wel l shielded f rom ambient l ight as c l ip-on p rob es . A ttac hing reusable p rob es by us ing an adhes iv e o r Velco wrap may improv e thei r s tab ility. P robes li ned wi th s oft mate rial may be assoc ia ted wi th f ewer motion artifac ts (32). Some probes a re av ailab le in different s i zes . If a p rob e is too large f or the patient, so me of the l ight ou tp ut from the LE D c an reach the photoce ll without pass ing through tiss ue, and fals ely high SpO 2 readin gs wil l b e p rod uced (33,34). The photocel l may not al ign wi th the probe, and re adings wi ll not b e poss ible. Loss of reusable p robes can be reduc ed by making i t diff icul t to s eparate the probe f rom the c abl e (31 ). A ttaching the probe to the oxi meter case when no t in us e wil l reduc e damage and make it eas y to find (3 5). P .779

Figure 24.3 Disposable flexible probe. This can be placed on a variety of sites, including the finger, ear, cheek, tongue, toe, penis, hypothenar or thenar eminence, palm, foot, and wrist. (Picture courtesy of Masimo Corporation, Irvine, CA.)

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To reduc e c ontamination, a glov e, the finger of a glov e, or other c ov ering may be us ed eithe r ov er the ap pl ica tion si te o r ov er the probe (36,37,38). Mi tts are av ailab le to s hield a mb ient l ight (F ig. 24.12).

Cable
The probe is connec ted to the ox imeter b y a n elec trical c able. Ca bles from d iffe ren t manufac tu rers are not inte rchange able.

Console
Many d iffe ren t consoles are av ai la bl e (Figs . 2 4.13,24.14,24.15). Mos t oxi mete rs that are us ed in th e operating room are part o f a phys io logic mon itor. Mos t s tandalone un its are l ine operated but wil l work on batte ri es , making them us eful duri ng transport. Some oxi meters a re hand-held (Fi gs . 2 4.14, 24.15 ). A mic roc omputer mon itors and c on trols s ig nal lev els , perfo rms the calculations , i mple ments s ignal v al id ity schemes , ac tiv ates ala rms and mes sages , and monitors i ts own c ircui try to wa rn of mal func tions . A v ari ety of mess ages ma y be prov ided to i nfo rm the o perato r of i ts P .780 func ti onal s ta tus (13). The panel usual ly displays pe rce nt sa turation, pu ls e rate, and a larm l imits . Mos t uni ts hav e a bright display , al lo wing them to be s een in a wel l -l ig hted room.

Figure 24.4 Disposable flexible probe in place on a finger. (Reprinted by permission of Nellcor Puritan Bennett Inc., Pleasanton, CA.)

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Figure 24.5 Reusable probe. This is most commonly used on a finger or toe. In infants, this type of probe can be placed on part of the hand or foot. These probes offer good shielding from ambient light. (Picture courtesy of Masimo Corporation, Irvine, CA.)

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Figure 24.6 Reusable finger probe in place. (Reprinted by permission of Nellcor Puritan Bennett Inc., Pleasanton, CA.)

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The disp la yed v alues for S pO 2 and pu ls e rate are us ual ly we igh ted av erages . Some ox imeters allow the av eraging pe ri od to be adjusted. A mode that av erages ov er a l onge r period of ti me may work better if there is muc h p rob e mo tion (39). Chang es i n p ulse rate or sa tu ration wil l be reflec ted more ra pidly if the av eraging is done ov er a s horter period of time. Pulse amp li tude may be represented by a signa l indicator. Othe r uni ts use a graphic that indica tes pu ls e amplitude and ma y p rov ide a pl ethysmographic wav efo rm. Mos t ins trumen ts prov ide an audib le tone whose pi tch c hanges with th e s atura tion. In this way, the opera tor can be made awa re of c hanges in S p O 2 withou t lo oking at the ox imeter. B y usi ng a v ariab le tone pu lse ox ime ter, an es thes ia prov iders recognized an episode of ox ygen des aturation more quickl y than th ose us ing one wi th a fixed tone (40). The re is us uall y a me ans to c ontrol the v olume of the audible s igna l. A larms a re commo nly p rov ided for l ow and h igh pu ls e rates and low and high sa turatio n. Many units P .781 generate an alarm wh en the p robe is not pro perly applied to the pa tient o r if for so me o the r reason the si gnal is i nade quate. A S A s tandards fo r Basic A nes th etic Moni tori ng requi re that the v a riable pi tc h puls e tone a nd lo w thresho ld alarm be audible (41).

Figure 24.7 Disposable nasal probe in place. The clip from a disposable oxygen mask may be used to improve contact and to hold the probe in place. (Reprinted by permission of Nellcor Puritan Bennett, Inc., Pleasanton, CA.)

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Figure 24.8 Reusable probe designed for use on the ear. This may be used on other locations, including the cheek. (Picture courtesy of Masimo Corporation, Irvine, CA.)

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Figure 24.9 Reusable probe on the ear. (Reprinted by permission of Nellcor Puritan Bennett, Inc., Pleasanton, CA.)

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Mos t pulse ox imeters offer trend data. Inte rfac es for hard copy recording and data mana gemen t s ys tems are usually av ailable.

Figure 24.10 Disposable wraparound probe on the foot. (Reprinted by permission of Nellcor Puritan Bennett, Inc., Pleasanton, CA.)

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Figure 24.11 Disposable wraparound probe on the toe. (Reprinted by permission of Nellcor Puritan Bennett, Inc., Pleasanton, CA.)

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Oximeter Standards
The international and U.S . s tandards are quite s imil ar (42,43). Among the prov isions a re th e foll owi ng:

The re mus t be a means to l imit the du ration of con tinuous ope ration at temperatures abov e 41C. The accurac y mus t be s tated ov e r the range o f 70% to 10 0% Sp O 2 . If the manufac tu rer c la ims ac curac y be lo w 65 %, the accuracy mus t be s tated ov e r the addi tional range .

If the manuf ac ture r c laims accu rac y d uring moti on, this and the tes t methods us ed to es tab lis h i t mus t be dis cl osed in the i ns truc tions fo r use. If the manuf ac ture r c laims accu rac y d uring condi tions of lo w p erfus ion , th is and the tes t methods used to es tablis h it mus t be disc los ed in the i ns truc ti ons for use.

The re mus t be an in dicatio n wh en the Sp O 2 or pulse rate data is not c urren t. If the p ulse oxi meter i s p rov ided with any ph ys iologic alarm, i t mus t be prov ided wi th a n a la rm s ys tem that moni tors for equipment faul ts , and there mus t be an alarm fo r lo w S p O 2 tha t is not less than 85% SpO 2 in the manufac tu rer-c onf igure d a la rm preset. An al arm for high SpO 2 is optional .

An indic ation of s igna l inadequac y mus t be prov ided if the S pO 2 or pulse rate v alue dis played is potentiall y incorrec t.

P .782

Figure 24.12 Special mitts are available to shield pulse oximeter probes from ambient light.

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If a v ariable pi tch audi tory s ignal is prov ided to ind ica te the puls e si gna l, the pi tc h change shall follo w the SpO 2 read ing (i.e., as the SpO 2 reading lowers , the pi tch s hal l also be l owered).

Use Sites
Finger
The probe is mos t c ommonly attached ov er the finge rtip (Figs . 24 .4, 24.6). The failure rate is les s , and accuracy is better when the probe is p lac ed on the finge r than on the earlobe (44 ,45 ,46 ). The f in ger is re lativ ely s ensitiv e to s ympathetic s ys tem v asocons tric tion (47,48). If there is poo r ci rcu la tion, a f inger b loc k , digital pulp space infi l tration , or a v asodi lato r may imp rov e performanc e (48,49,50,51 ,52 ,53 ,5 4). V igo rousl y rubbing the finge rtip may temporaril y imp rov e c irculation to the area (50).

If there is dark fi ngernai l polish or s ynthetic fingernails , the probe sho uld be oriente d so tha t it trans mi ts li ght f rom one si de of the fi nge r to the other (55). Some c lear ac ryl ic na ils do not aff ec t pulse ox imeter readings (56). A disadv antage of p laci ng a p robe o n an extremi ty is that de tec tion of desaturatio n and resa turation is s lower than when probes are plac ed more c entrall y (48,57,58,59,60,61,62,63,64). Res pons e time ma y be quicke r when the probe is place d on the thumb (62). Motion a rtifac ts are les s frequent whe n the probe is pl aced on on e of the larger f ing ers (32). The l ittle f inger may be us eful i f th e patien t is particularl y l arg e (65). The probe may be placed ov e r a fi nge r tha t has a bu rn (66). The probe s houl d not be on the index f inger during recov ery. As a patient awa kens , the patie nt of ten wil l wan t to rub his o r her eye, us ual ly wi th the index fi nger. If the ox imeter probe is on that finger, th e c ornea can be sc ratched. In general , the arm opp osi te f rom that on which the blood press ure c uff is ap plied or i n whic h an arterial ca the ter has been ins erted s hould be used . The puls e ox imeter is sometimes in teg rated wi th the noninv asiv e bl ood pres sure monitor s o that the pulse ox imeter wi l l not ala rm durin g the inflation c yc le if placed on the sa me a rm as the blood p res sure cuff. Ins erti on of a radia l artery catheter is co mmonl y fol lowed by a trans ient P .783 dec reas e i n b lood flow and loss of an adequ ate s ignal f or a pulse ox ime ter if the probe is on a fi nger of that hand (67 ). Ho wev er, pe rformance is unaffec te d if puls e ox imeter readings are made on the arm in which an arteri al ca nnula is pres ent (68). Occ asi ona lly, poor f unc ti on may occ ur wi th probe attachmen t to the same ex tremi ty as the in trav enous i nfus ion, due to loca l hyp othermia and v asocons tric tion.

Figure 24.13 The console may be a freestanding unit. (Reprinted by permission of Nellcor Puritan Bennett, Inc., Pleasanton, CA.)

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Figure 24.14 Small handheld, battery-operated pulse oximeters are often used, especially during patient transport. This unit is in its recharger. (Picture courtesy of Masimo Corporation, Irvine, CA.)

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The posi ti on of the arm may a ffec t the reading. In mos t patien ts , the Sp O 2 fa lls af te r the monitored arm is raised (69). It may also fall wh en the a rm is lowered (70).

Toe
The toe is an alternate s ite when the finger i s not av ailable or the s igna l from th e f ing er is uns a tisf ac tory. Detec ti on of desatura ti on or resa turatio n wil l not be as rapid as with more centrall y placed probes (63). The de la y in detec tion of hypoxemia may be up to 1 to 2 minu tes (64,71). The toe may prov ide a more

reliable si gna l in p ati ents who hav e had an epidu ral block (7 2). A n inc rease in pulse amp li tude from the toe may be a s ign of a succes sful bloc k (73).

Figure 24.15 Combined pulse oximeter and carbon dioxide monitor. (Reprinted by permission of Nellcor Puritan Bennett, Inc., Pleasanton, CA.)

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Nose
The nose is usual l y a c onv enient loca ti on. Nasal probes respond more rapidly to changes in saturation than probes placed on ex tremiti es . T he bri dge (Fi g. 24 .7), the wi ngs of the nos trils , and the nasa l sep tu m hav e been us ed (74,7 5,76). The nos e c lip f rom a disposab le ox ygen f ace mas k c an be attached to the ou ter s urfac e of a f lex ib le probe to make it fi t snugl y ov er the bridge (7 7). Acc urac y at this s i te is controv ersi al . It has been reco mme nded under c ondi tions such as hypothermia, h ypotens ion, an d i nfus ion of v asocons tric to r dru gs . In hypothermic pa ti ents , the nas al se ptum wa s a more re li able si te than the finge r (74,76). Howev er, some s tudies hav e found tha t nas al probes often giv e gross ly erro neous results and hav e a higher fai lu re ra te than other s ites under c ondi tions of poor perfusi on (78 ,79 ). If the p ati en t is plac ed in the Trendelenberg p osi tion , v enous conges ti on may occ ur around the nos e, caus ing the puls e oxi meter to dis play arti ficial ly l ow saturati ons (80,81).

Ear
An ear probe (Fi gs . 24.8, 24 .9) ma y be held in plac e by a pl as tic semic i rc ula r dev ic e hung aroun d the ea r.

P .784 S tabi li zi ng dev ices such as headbands or around -the-ear l oops may be useful . Us ing a c lip may improv e the qual i ty of the s ignal (82). The earlobe sho ul d be mass aged for 30 to 45 s ec onds wi th a lc ohol o r v as odi la tor or E MLA c ream can be applied for 30 minutes prior to probe app lica tion to inc reas e perfus ion (83). An ear probe c an be partic ula rl y usef ul when there is fi nge r motion . Response time i s fas ter with an ear probe than wi th a finger probe (48,58,62,64,84,85). Under condi tions of poor perfus ion , s ome ea r probes pe rf orm better than fi nge r probes (78). The ear is rela tiv el y immune to v asoc ons tric tiv e effec ts of the s ympathetic s ys tem (47). The ampli tu de of ea r pleth ysmog raphy wi ll res pond mainl y to changes i n p ulse pressu re. E ar probes may g iv e more erron eous readings tha n f inger p rob es i n p atien ts wi th tri cus pid inc ompetenc e (86). A s teep hea d down pos ition may res ul t i n e rroneous readings (87). A n ear ox ime ter ma y be c ombined wi th a transcutaneous ca rbon diox ide sens or (4,88).

Tongue
A tongue probe can be made by pl acing a mal leable aluminu m s trip behin d the probe to allow i t to bend around the tongue (8 9,9 0). A disposable probe wrapp ed around the tip of the tongue in th e s agi ttal p la ne may also be used (91). Ref lec tanc e puls e ox imetry has be en use d o n the s uperior surfac e of the tongue. The mou th should be c losed . Gl oss al pulse ox ime try has been s hown to be accu rate (91). This s ite may be es pecial l y usef ul in patients wh o hav e bu rns ov er a large perc entage of thei r body su rface (90,91). Desa turation and resatura tion is detec ted by a probe at the tongue quick er than one on the f inger or toe (63). A lingu al probe is more res is tant to s igna l in terfe rence from el ec tros urgery than probes p laced on peripheral s ites but may be diffic ult to maintai n in place du ring emergence (8 9,90). Tongue quiv ering ma y mimic tac hyc a rdia. Other proble ms a re v enous c onges ti on f rom a head do wn pos i tion and excess oral s ec re tions . The probe mus t be pos itio ned af te r trac heal intubati on or i nsertion of a s upraglottic ai rwa y. It c an be eas i ly dislodged.

Cheek
A pro be with a meta l s trip back ing can be used to hol d a dispos abl e probe around the cheek or l ips (92,93). A cl ip -on probe wi th a cov er ov er the part of the probe on the bucc al s urface c an als o be used (94,95,96,97). Th is method of use is n ot

recommen ded by the manufac turer (98,99). P robes s peci al ly designed f or this s ite are commerci al ly av ai lab le . Buc cal p uls e oxi metry is mo re ac curate than fin ger pu ls e ox imetry (93,100). P robes at this loc ation d etec t inc reas es and dec reases in saturation more quickl y than f ing er or toe probes (63). Buc cal oxi metry has been found to be ef fec tiv e during hypothermia, dec reas ed c ardiac output, inc reas ed s ys temic v as cular res is tanc e, and o the r lo w puls e p res sure s tates . This site is us eful in pa tients who hav e burns (101). Disadv antages inc lude diffic ult placemen t, poor ac cep tance by awak e pati ents , and arti fac ts du ri ng ai rway ma neuv ers .

Esophagus
This probe us es refl ec tanc e oximetry. Th e esop hagus, a core organ, is bette r perfus ed than the ex tremities d uring s tates of poor pe riphe ral perfus ion and may therefo re prov ide a more c ons is tent, reliable s ourc e for pulse ox imetry wi th hemo dynamic ins tabi lity (1 02,103,104 ,10 5,106,107 ,10 8). It reflec ts c hanges in arte ri al s a tu ration mo re qu ic kly than pe ri phe ral sites such as the finge r. Th is s i te may be us eful for pati ents who hav e ex te nsiv e burns , on whom conv entional p robes wou ld be difficul t to plac e (109,110). Acc urate pl ac ement of the esophagea l probe requi res p rac tice by the us e r (10 7). Ach iev emen t of a re liable s ignal may be a pro blem (104 ).

Forehead
A flat ref lec tance puls e oxime ter sens or can b e used on the forehead (8 2,111,112) (Figs . 24.16 , 24.17). It should be pl ac ed just abov e the eyeb row so that i t is cente red s lightly lateral of the i ris (113). The s ensor s ite s hou ld be c leaned wi th alcoh ol before app lyi ng the sensor to help secu re the adhes iv e. P ress ure on the probe f rom a headband or pressure dressi ng may improv e the s ignal (21,82). This si te is us uall y easil y ac cess ible. The fo reh ead is les s affec ted by v asocons tric tion from c ol d o r poor P .785 perfus ion than the ear or finger (114,115). Changes in sa turatio n c an be detec ted more rapidl y at the fo rehead than at the fing er (48,116). Howev er, pool ing of v enous bloo d due to co mpromised return to th e heart may caus e lo w s atu rati on readings i n sup ine pa tients (81). It s hould not be us ed if th e patien t is in the Trende le nburg posi tio n. The re are us uall y few motion arti fac ts when the f ore head is us ed (117,118).

Figure 24.16 Reflectance pulse oximeter probe. The light source and sensor are situated next to each other. (Picture courtesy of Masimo Corporation, Irvine, CA.)

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Figure 24.17 Reflectance pulse oximeter on the forehead. Note the headband securing it in place. (Picture courtesy of Masimo Corporation, Irvine, CA.)

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Other
Pha ryn geal pulse oxi metry by us ing a pulse ox imeter attac hed to a laryngeal mas k may be us eful in p ati en ts wi th po or peripheral p erf usion (119,120 ). Fl exible probes (Fig . 24.3) may wo rk th rough the p al m, foo t, p enis , ank le, lower ca lf , or ev en th e arm in infants (27 ,12 1,122) (Fi g. 24.10 ). Pulse ox imetry ma y be used to moni tor fetal ox ygenatio n duri ng labo r by attac hing a reflec tanc e pulse oxi metry probe to the pres enting pa rt (20,23,123,124). A

disadv antag e is that the pro be has to be placed bl indl y and may be pos iti oned ov er a s ubcutaneous v ein or artery , whi ch wi ll affec t the reli ab il ity of the readi ngs (23).

Fixation
P roper p robe placemen t is c ruc ial fo r good pe rformance. A malpos i tioned p rob e c an resul t i n false -pos i tiv e and false-nega tiv e alarms . P robes c an be total l y o r parti ally disl odg ed withou t this be ing noticed. Adhesiv e probes may s tay o n better than c lip-on probes . It may b e benef ici al to tape probes i n place whe n they wi l l be inacc essi bl e during surgery, but it is i mportan t to av oid c ompress ion of the f inger or oth er part. W rapp ing the l imb l ightl y wi th ga uze may help to fix the probe in position . Another method is to s lip the cut f ing er of a glov e ov er the probe (125). The probe s hould be protec ted from b ri ght l ight (F ig. 24.12).

Stabilizing the Signal

The s earch that the puls e oxi meter goes through when a pro be is i ni tial ly appl ied (or dis lodged) i ncl udes s equential tria ls of v arious intens ities of l ig ht i n an effort to f ind a si gnal s trong enough to transmi t th rou gh the tis sue bu t not s o s trong that the detec tion s ys te m is saturated (12). Onc e a puls e is found , there is usua ll y a del ay of a few more s econds whi le SpO 2 v al ues for s ev eral pulses are av eraged. Appearance of a s atis fac tory wav efo rm is an indicati on th at the readings are reliable. Comparis on of the pulse rate s hown by the oxi meter and that b y an elec trocardiograph moni tor is a ls o an ind ic ati on that s atu rati on rea di ngs are reliable. A disc repanc y b etween the rates is f requentl y an indication of probe mal pos ition or malfunc tion . A dis c repancy can also oc cur duri ng ce rtain dys rh ythmias .

Reusing Disposable Probes

Bec ause d is pos able probes are cos tly , many i ns titutions reuse them (126,127 ,128,129,130,131,132,133,134 ). A lthoug h c onc erns about this hav e been rais ed (135,136), sev eral s tudies s how tha t th e fai lure rate of rep roc ess ed probes i s equal to or l es s tha n that of new probes , and the ac curacy is not aff ec ted (132,133 ,134,137).

Testing
Dev ic es that can be used to tes t puls e oxi meters a re av ailable (138). Some al lo w the tes te r to s e t th e p lethysmograph ic wav eform at different ampl itudes a nd to tes t the acc uracy of the heart rate as we ll as the Sp O 2 .

Applications Monitoring Oxygenation

Anesthetizing Ar eas
Ox ygen des atura ti on can oc cur a t any time during anes thes ia , regardless of the ski ll and experienc e of the anes thes ia prov ider. Des atura tion greater than 10% P .786 oc curs in up to 5 3% of anes theti ze d patien ts (139,140 ,141,142). Pedi atric pati ents are es peci all y at ri sk (121,143,144 ,14 5,146,147). Mos t sev ere desaturations occur during in duc tion or emergence. Du ring mainte nanc e, desaturati ons a re milde r but more freque nt (148). S tudies hav e s hown that a reduc tion i n the number of hypoxemic ev ents occu rred when puls e oxime try was use d (144 ,149). The inc idenc e of myocardial isc hemia wa s als o dec reas ed (1 50). Pulse ox imetry ma y hel p to detec t ina dv ertent bronc hial i ntubati on (8,151 ,152,153). This method is not al ways reli able, pa rtic ula rl y if an elev ated inspi red ox yg en conc en tration is being used (12 ,15 4). The abs ence of desa turatio n does no t rule out bronchial intuba tion (155). Methods to detec t b ronchial intubation are d isc uss ed i n Chapter 19 . Oxi metry is useful in mana ging one-lu ng anes thesi a to hel p ass ess the ef fec tiv enes s of meas ures tak en to i nc rease the ox ygen sa turatio n (156) Chap ter 20). Oxi metry is useful for p ati ents undergoing regional an d moni tored care anes th esia (157,158 ). Of ten, the si gns of h ypox ia are confus ed with re s tles snes s from an i nadequate block . Ins tead of su ppl ying ox ygen and as sis ting resp iration , add itional sedation is prov ided , whi ch compo unds the problem. W i th ox imetry , the patien t's ox ygenation s tatus ca n be assessed an d me asures taken to improv e S p O 2 . Pulse ox imetry ma y be useful to confi rm corre c t trac heal tube placemen t when a func ti onal carbon dioxi de moni tor is not av ai lab le (159). If oxy gen saturation ris es af te r in tubation , correc t tube pl acement is likel y. Howev e r, a pu ls e oximete r should not be rel ied on fo r th is pu rpose because preox ygenation may dela y the onset of desatura tion beyond the ti me when es ophageal intuba tion would be cons idered l ik ely . Other probl ems that c an c aus e a d rop in oxy gen saturation i nclude fat embolis m, amniotic fl uid embolis m, pulmonary edema , breathi ng s ys tem disco nnec tions and

l eaks , as piration, trac heal tube o bs truc tion, hypoxic gas mix tu re, ox yg en del iv ery failure, hypov entilation, anaphylax is , bronch ospasm, pneumothorax , ma lignant hyperthe rmi a, and p ul monary embol ism (8,160,161 ,16 2,163,164 ,165,166,167 ,168). Causes of h ypox ia relate d to equ ipment are dis cus sed in Chapter 14 .

Postanesthesia Care Unit

The recov ery room is another loc ation whe re des atura tion is c ommon (141,169 ,170,171,172,173,174,175,176 ,177). Routine oxygen adminis tration to recov eri ng pa ti ents may not be n ecessary when pa ti ents are monitored with pulse ox imetry (178 ). B efore leav ing the rec ov ery ro om, a trial of breathi ng room a ir wh il e moni tori ng ox ygen s atu ration may prov ide an in dication of the n eed to c ontin ue ox ygen be yond the pos tanes thes ia ca re un it (P ACU) or to re ta in the patient in the unit for a longe r ti me (179).

Transport
Unrecogni zed ox ygen desaturation may oc cur whil e the patien t is b eing transp orted between the opera ti ng room and the PAC U and b etween that unit and other areas (180,181 ,182,183,184,185,186,187,188 ,189). P ulse ox imetry is inclu ded on mos t transport moni tors , and po rtabl e pulse oximeters are av ailable.

Other Intrahospital Areas

Patients frequentl y experi ence hypoxic episodes in the pos topera tiv e peri od after l eav ing the PA CU (190,191,192 ,193,1 94). Pulse ox imetry c an detec t thes e episodes and a id in deci di ng when ox ygen therapy s houl d be disco nti nued. Teleme tric puls e ox imetry monitoring may be a c os t-effec tiv e me thod of max imizing qual i ty of c are whe n used to mo nitor patien ts on a gen era l care floor (195 ). Pulse ox imetry is us eful fo r moni to ring patie nts i n the intens iv e c are unit (19 6). It may be he lpful during we aning from artif ic ial v enti lation (197,19 8). Pulse ox imetry has been us ed du ri ng cardiopul mona ry resus ci tati on (199,200,201 ). Bec ause of artifac ts and lag times , i t is mo re useful in prima ry res pi rato ry arres t than in c ard iac a rres t. It is us eful in assessing ox ygena tion during newbo rn resus ci tati on (20 3). Ano the r area where pulse ox imetry has p rov ed useful is the emergenc y depa rtment (204,205 ,206). Ref lec tanc e puls e ox imete rs c an b e useful for asses si ng fetal s ta tus during l abor and d eliv e ry by ap pl ying a forehead p robe (207).

Pulse ox imetry is us eful in i den tify ing wh ic h p atien ts wi th tonic -c lonic sei zures are at ri sk of hypoxic ce reb ral brain dama ge (20 8).

Out-of-hospital Use
Pulse ox imetry is us eful in the prehos pi tal setting, inc luding when transporti ng pati ents by hel icopter or ambul anc e (209 ,210,211,212 ,213,214,215 ,216).

Controlling Oxygen Administration

Pulse ox imetry allows the lo wes t s afe ox yge n fl ow and concen tration c ompatible wi th s afe lev els of a rterial ox yg enation to be adminis tered. Keeping th e ox ygen conc en tration and flow low wi ll hel p to dec re ase the ri sk of a fire (Chapte r 32).

Monitoring Peripheral Circulation

Pulse ox imetry c an detec t arm pos itio ns that co mpromise c i rculatio n (217 ). The pulse oxime ter tha t is attached to a to e c an hel p to warn of dec reased pe rfus ion at the foo t in patients i n the l ithotomy pos iti on (218). Howev e r, i t c annot rel iabl y detec t inadequate perfus io n (219 ,220). Moni tori ng ox ygen s atu ration during s houl de r arthrosc opy has been recommend ed as a tes t for P .787 brach ial artery c ompress ion (221 ). Ho wev er, an ad equa te pulse s ignal may be present wi th brac hial pl exus c ompress ion (222). Patients with limb frac tures may hav e c ompromis ed c i rc ula ti on dis tal to the f rac ture. P uls e oxi metry may serv e as a us efu l gui de to b lood fl ow to that area (223,224 ,225). Howev e r, i t may no t be helpful in warn ing that a c ompartment s yndrome is dev eloping, bec ause dimin ution of the arterial p uls e dis ta l to the co mpartment is a late s ign (226). Patients who unde rgo med ias tinos cop y a re at ri sk fo r brachi ocephal ic artery and aortic arc h comp res s ion between the medias tinosc ope an d the s ternum. A rte rial co mp res sion may be detec ted by measurin g p ulse wav e ampli tu de on a pulse ox imeter (227,228). Pulse ox imetry ma y be used to ev aluate the effec t of a s ympathetic block as i ndicated by an i nc reas e in peri pheral blood f low (22 9,230). It ma y be useful d uring and after angiogra phy to detec t inadequa te blood f lo w (231).

Pulse ox imetry ma y be used to determine the bes t s i te of amputation or a rterial bypass s urg ery (232). It has been used to moni to r rei mplanted or rev ascul arized digi ts (233,234,235). Pulse ox imetry c an be used to meas ure pa lmar col la teral c irculation (236,237 ,238,239,240,241,242,243,244 ). Ho wev e r, i ts usef ulness for this has been dispu ted (245 ,24 6). There is a re port of radial artery oc cl usion that was detec ted by pulse oxime try (247). It has prov ed us efu l in ev aluating a pain ful hand af ter c reation of an arte riov enous f is tula (248). A s imil ar tes t of the c oll ateral ci rculation may be pe rformed on the foot b y us ing pulse ox imetry (237).

Determining Systolic Blood Pressure

A puls e ox imeter c an be used to determi ne the sys tol ic blood pressu re (249,250 ,251,252,253,254,255,256). The blood pressure cuff is a pplie d to the same arm as the pulse ox ime ter. Th e c uff is inf lated slowl y, a nd the p res sure at the point at wh ic h the wav eform is los t is no ted . It als o c an be determin ed by inflatin g the cuff we ll pas t the s ys tolic press ure and looking for the onset of a s ignal as the cuff i s def lated . One s tudy f ound that the bes t agreement wi th K orotkoff sounds and noninv asiv e blood p res sure equipmen t occ urred whe n the av era ge of bl ood press ures es timated at the dis appearance and re appearance of the wav eform was tak en as the s ys tolic pressu re (257). In pedi atric patien ts , bl ood press ure determined by th is method wa s f oun d to be more accu rate than tha t determine d b y an au toma tic noninv asiv e blood press ure monitor (258). Pulse ox imetry has been us ed for pati ents with pulseless d is eases of the ex tremities to monitor sa turation and s ys to lic blood press ure (259).

Locating Arteries
W hen the ax il lary artery c annot be palpated, i t may be located by pl ac ing a pu ls e ox imeter on a finger on that s id e and pressing i n the ax il la u nti l the pulse wav e disap pears (2 60,261,262 ). Pu ls e ox imetry has also been used to locate the f emoral and d ors alis pedis a rteri es by us ing a puls e ox imeter app lied to a toe (231,263 ,264).

Avoiding Hyperoxemia
In p rema ture neonates , adminis tration of oxygen may be ass oc iated with dev el opmen t of reti nopathy and other pathol ogic conditions . P uls e ox imetry can aid i n ti trating insp ired ox ygen by de tec ting hyperoxemi a (2 65,266,267 ,2 68,269). It is

recommen ded that the high SpO 2 al arm be s et at 95% o r lo wer fo r th is pu rpos e (269,270 ,271).

Monitoring Vascular Volume and Sympathetic Tone

If the p ulse oxi meter beg ins s kippi ng bea ts or performing i ntermi tten tl y, the caus e could be h ypov olemia (272). A corre lation between pu ls e wav ef orm ampli tu de v a ri ation du ring pos itiv e-pressure v enti la tion and hypov olemia has been reported (272,273 ,274,275,276). If brief interruption of v entil ati on caus es the wav ef orm to retu rn to normal or more c ons tan t fu nctio n, a tri al of f luid therapy may be war ra nted. One of the mos t useful and commonly ov erlooked plethys mographic featu res is wav efo rm ampl itude (277). Ampl i tude changes ca n be c onc ealed by the auto-g ain func ti on found on mos t pulse oximeters . W hen the auto-g ain is tu rned OFF, c e rtain observ atio ns can be made. The plethys mograph s igna l ampl i tude is di rec tl y proportional to the v ascular dis tens ibili ty over a wi de range of c ard iac outp ut. Durin g anes thes ia, the unga ine d pulse ox imeter s ignal may be us ed to de termine the ex tent of atten uation of th e s ympathe tic res pons e to s timuli . Ano the r imp ortant fea ture of the wav eform is the dic ro tic notch (277). The notch tends to desc end toward the basel ine during inc reas ing v asod il ation and gets highe r with v as oc ons tric tion .

Other Uses
Other s i tuations where ox imetry may be us efu l inc lude high-frequency jet v enti lation and determining the effec tiv eness of therapeu tic bronchosc opy. It can be co mbined with measu rement of mixed v enous oxyh emogl obin saturation to es tima te ox ygen c onsu mp tion (278,279 ). Pulse ox imetry has been us ed to gauge pulmonary b lood fl ow in infants a nd ch il dren with cyanotic congen ital h eart lesions (280,281). P .788

Pulse ox imetry c an giv e warni ng of flui d ex trav as ation (282).

Advantages Accuracy
Pulse ox imetry is ac curate , and ac curacy do es not c hang e with ti me. Nume rous s tudies hav e sho wn that the diffe rence between sa turatio n determi ned by puls e

ox imetry a nd arterial bl ood gas a nal ys is is c linical ly ins ig nifican t abov e an SpO 2 of 70% (13,14,26,28,46,57,60,121 ,156,267,283 ,284,285,286 ,287,2 88,289,290,291,292,293 , 294,2 95,296,297 ,298,299,300 ). Mos t manufac turers cl aim that erro rs are less than 3 % at s atu rations abov e 70% (243). This accu rac y s hou ld be s uff ici ent f or mos t c linic al pu rposes , exc ept poss ibl y neonatal hyperox ia. Changes in acc uracy are negligible ov er tempe ratures enc ountered in c linical use (301). Pulse ox imetry is ac curate in patie nts wi th d ys rhythmias , p rov id ed tha t th e S pO 2 is s table and the pl eth ysmo gra m is noise-free and has reasona ble ampli tude (302). The S p O 2 may be corre c t ev en if the pulse rate is not.

Independence from Gases and Vapors

Pulse ox imetry readings are n ot affec ted by anes thetic gas es or v apors .

Fast Response Time

Pulse ox imetry has a fas t response ti me, espec ia ll y compa red wi th tra nsc uta neous meas urements (156).

Noninvasive
Pulse ox imetry is non inv asiv e , which al lo ws it to be us ed as a routi ne moni tor. It is readi l y accepted b y awake pa tients , s o it c an be appli ed before induc tio n of anes thes ia. The bleedi ng, arterial ins uffic ienc y, emboli za tion, and in fec ti on so me times se en after a rterial punc ture are av oided. Temporary elev ation of the PaO 2 i nduced by p ain and apprehens ion is av oided.

Continuous Measurements
Saturation , puls e rate , and blood f lo w a re con ti nuous l y moni to red . Dev elop in g trends c an be de tec ted a nd remedial ac tion tak en before sev e re hypoxia ens ues.

Separate Respiratory and Circulatory Variables

Con tinuous ly moni toring the q uality of the peripheral puls e may b e helpful in determin ing wh ether a hyp otens iv e pati ent h as good c ardiac output. If blood press ure is lo w and puls e signal s trength is high, the patient is probabl y v asodi lated but pe rfus ing ade quatel y. If, howev er, both blood pressu re and pu ls e s trength are low, pe rfus ion may be i nadequate. Perfus ion is indica ted by the pulse s ignal s tre ngth, and ox ygenation is indicated by sa turatio n. Unl ike trans -cu taneous monitorin g, the v al ues disp layed do not require i nte rpretation . Mos t oxi mete rs wi ll signal if the fl ow i s n ot ad equa te to p rov id e a

sa turatio n v alue. Th is is helpful in determining a trul y low sa turation v alue as oppose d to one ca used by low fl ow.

Convenience
The probe is si mple a nd fas t to a ppl y. Si te p rep ara ti on is minimal . A rte rial iz ati on of the sk in is not usuall y not necess ary, ex cept when the e arlob e is the moni tori ng s i te. No cal ibra ti on or c hanging of elec trolyte or membrane is requi red . A v ariety of different p robes are av ailable for d iffe ren t si te app lic a ti ons .

Fast Start Time

The re is minimal dela y in ob tai ni ng the ox yg en saturation . Readout typicall y begins wi th in a fe w be ats after applica tion of the probe. This is a dis tinct adv antage ov er transcutaneous monitoring , whi ch requi res a prolonged warm-up ti me.

Tone Modulation
Changes in pulse tone wi th v aryi ng saturatio n a ll ow th e user to be conti nuousl y updated on SpO 2 wi th out tak ing his or he r eyes off the patient. Tone mod ul ati on al lows a muc h quick er recogn iti on of hypox ic episo des than does a f ix ed tone (40 ). Mos t anes thes ia prov iders c an detec t the direc tion (but not the magni tude) of a change in s atura tion by l is tenin g to the c han ge in pi tc h of a puls e ox imeter tone (303).

User-friendliness
Mos t ins trumen ts are user-f ri endly . Min imal trai ning is requi red to l earn to ope rate the ins trumen t.

Light Weight and Compactness

The c onso le can be made lightwei ght and compac t. This fac i li ta tes use during transport. Hand-held pulse ox imeters are avai lable . Ox yg en saturation monitoring is av ailab le in nearly al l p hysiologic moni tors . P .789

Probe Variety
The wi de v a riety of probe confi gurations confers bro ad cl in ic al applica bil i ty to all types of patients , inc luding prete rm infan ts . The abil ity to us e v arious v asc ular

beds off ers adv antages f rom the s ta ndpoin t of ac ces s duri ng su rge ry an d av oids dis turbing the su rgica l fi el d.

No Heating Required
Hea ting the s k in is no t requi red . The probe can usual ly be left in pl ace for ex tended periods wi th out ris k of therma l inju ry.

Battery Operated
Mos t s tand-alone uni ts and those incorporated in to transport mon itors c an be operated on ba tteries .

Economy
The use of pulse ox ime try can s av e money by l imiting ox yg en adminis tratio n to s i tuations where i t is reall y nee ded and b y d ec reas ing the number of blood g as analyses (178,194 ,304,305,306 ). It may be cos t-effec tiv e to moni to r c erta in patients at high risk for transf er to the intens iv e c are un it (307). T he use of monitors with superior artifac t fil tering abi li ty ma y res ult in c ost s av ings (308,309,310).

Limitations and Disadvantages Failure to Determine the Oxygen Saturation

The re is a s mall but d efi ni te i nci dence of failu re wi th pu ls e ox ime try (140,311 ,312,313,314,315). F ac tors that are reported to c on tribute to higher f ai lure rates inc lude ASA phys ic al s tatus 3, 4, or 5 patients ; young and elderl y patien ts ; orthoped ic , v as cular, and cardi ac su rge ry; elec tros urgery us e; hypothermia ; hypotens ion ; hypertens io n; duratio n of in traope rativ e procedure ; c hronic renal failure; low hematoc ri t; and motion (140,312 ,313,314,316 ,317,318,319 ). The ac tual failure rate v aries with the monitor (320 ). A puls e ox imeter may zero ou t, me aning that i t displays 00 for the SpO 2 and pulse rates v alues whe n i t fai ls to produce a meas urement or it might dis play ______ fo r the v alues (321). S ome pu ls e ox imete rs blank the display or g iv e a mes sag e s uch as Low Qual ity S ignal or Inadequate S ignal . Othe rs freeze the disp la y.

Poor Function with Poor Perfusion

Pulse ox imeters requi re ade quate pulsations to dis tingu ish l ight abs orbed f rom arte ri al bl ood f ro m v enous b loo d and tiss ue li ght (32 2). Readi ngs may be u nreliable or unav ail abl e if the re is los s or diminution of the pe ripheral pulse (prox imal blood press ure c uff inf lati on, ex ternal pres sure, impro per pos i tioning, hypo tensi on,

hypothermia, Raynaud's phenomenon, ca rdiopu lmonary bypas s , l ow c ardiac output, hypov olemia, peripheral v as cul ar dise ase, a V als alv a maneuv er s uch as seen in l aboring patients or in those wi th i nfus ion of v asoac tiv e d rugs (78,140,251 ,287,319,322 ,323,3 24,325,326,3 27,328,329 ,330,331,332 ,33 3). Methods to imp rov e the s ignal inc lude ap plying v asodil ati ng c ream, performing s ympathetic and dig ital n erv e blocks, admini s te ring i ntra-arteria l v as odi la tors , and warmin g c ool ex tremi ties (49,51,52,83,334 ,3 35,336,337 ). Th e use of a probe on a better perfused si te s uch as the cheek , tongue, nasal septum, o r esop hagus ma y be helpful . Imp rov ed si gna l tec hno logy by newe r pulse oxi meters c an imp rov e performance during low-perfus ion conditions (320,330 ,338,339,340 ,341).

Difficulty in Detecting High Oxygen Partial Pressures

A t P a O 2 v alues abov e 90 mm Hg, small c hanges in s atu ration are as soc iated wi th rela tiv el y large c hang es in Pa O 2 . Th us , i t has l imited abil ity to distinguish high but safe l ev els of a rteri al oxygen from excessivel y elev ated lev els (342).

Delayed Hypoxic Event Detection

W hi le the pulse ox imeter response time is gene ral l y fas t, there may be a si gnifica nt delay betwe en a change in alv eola r oxy gen te nsion and a ch ange i n the oxime ter reading. It is pos s ible for arte ri al ox ygen to re ach dangerous l ev els before the pulse oxime ter ala rm is ac tiv ated (343). Setting the lo w S p O 2 alarm th res hold highe r wil l dec rease the delay. Delayed res pons e c an be re la ted to pro be locatio n (62,85). Des atu rati on is detec ted earl ier when the probe is p laced more c entrall y. Lag time wil l be inc reas ed wi th po or perfusi on (251,344,345 ). Ve nous obs truc tion, peri phera l v as ocons tric tion, co ld, and motion a rtifac ts wi ll c aus e i nc reases in the time to d etec t hy pox emia (32,325,327 ). The algo ri th ms that are us ed to prev ent false al arms may inc reas e the delay in detec ting hypoxic ev ents (346). A pulse ox imeter may resp ond to a nois y or weak s igna l by s impl y hol di ng on to an old v alue (321). Inc reas ing the ti me ov e r whic h the pulse s ignals are av erage d als o inc reases the del ay time.

Erratic Performance with Dysrhythmias

Irregular heart rhy th ms c an caus e the puls e ox imete r to pe rf orm erratical ly (347 ). Durin g aortic balloon pulsation, the augmentation of dias to lic pressu re ex ceeds P .790

that of s ys tol ic pressure. This leads to a double - or tri pl e-p eaked a rterial pressure wav efo rm that confuses the pulse oxi meter, so it ma y not prov ide a readi ng (348,349 ). P uls e oxi me try works in pa tients who hav e h ad an aorto myoplas ty (105).

Inaccuracy
Different Hemoglobins
Mos t pulse ox imeters a re des igned to detect only two s pec ies of hemo gobin: reduc ed and ox ygenate d. W hol e blood of te n c ontains other moieties such as ca rbox yhe moglobi n, s ulfhemoglobin, an d me themoglobin. Th is dis turbs th e absorbanc e ratio of the wav elengths us ed to de termine ox ygen s aturation (350).

Methemoglobin
Normally less than 1% of the to tal hemoglob in , methemogl obin (me tHb) is an ox ida tion produc t of h emogl obin th at forms a rev ersi bl e c omplex wi th ox ygen and i mpai rs the unloading of oxy gen to tis sues (351 ,3 52). Methemoglobine mi a can be congen ital (353) or acq ui red . Drugs caus ing me the moglobi nemia inc lude ni trobe nzene (354), benzocai ne (355,356 ), pri loc ai ne (357,358,359 ), and daps one (352,360 ,361). Me themoglobi n abs orbs li ght e qual ly a t th e red and inf ra red wav elengths that are use d b y mos t pu ls e oxi me ters . W hen c ompa red wi th func tional sa turatio n, mos t pulse ox imeters giv e falsely l ow read ings fo r saturati ons abov e 85% and falsel y hi gh v alues f or s atu rati ons bel ow 85% (351,362,363 ,364,365,366 ). The disc repanc y between SpO 2 and func tion al sa turation inc reases as the lev el of metHb inc re ases and func tional he moglobin satura ti on dec reas es (351). W ith trea tmen t of the methemoglobinemia, the Sp O 2 readings bec ome more ac curate (357,358 ,361,365). If there are confl ic ting resul ts b etwe en the p uls e oxi meter and arte ri al blood gas analys is , methemoglobinemia s hould be sus pec ted , and the diagnos is s hould be confi rme d by multi wav elen gth c o-ox ime try. The s tandard bl ood gas an al ys is is no t capable of de tec ting an d me asurin g me tHb (367). A new pulse ox imeter c apab le of measuri ng metHb as we ll as carboxy hemog lobin is now av ai lable (Fig . 24.18).

Carboxyhemoglobin
Carbox yhemoglobin (HbCO, COHb ), formed when he moglobin is ex posed to carbon monox ide (CO), has an absorption s pec trum s imila r to that of ox yhemoglob in , so mos t pulse ox imeters wil l ov er-re ad S pO 2 by the percen tage of carbox yhemoglobin

present (1 8,368,369 ,37 0,371,372,37 3,374,375). In one s tudy, the puls e oxi mete r reading did not go belo w 9 6% wi th c arbox yhemoglob in l ev els as hi gh as 44 % (376). In v itro CO-ox imetry ca n me asure the perc entages o f other moieties by us ing more than two wav eleng ths .

Figure 24.18 Pulse oximetercarbon monoxide monitor.

View Figure

An inc reas e i n HbCO may occ ur during las er s u rge ry in the ai rway, bu t the lev els are not high enough to keep pu ls e oximetry from rel iabl y es tima ting saturation (377). Carbon monoxide produc tion in as soc ia tion wi th dry carbon di oxide absorbent is discussed in Chap ter 9. Pulse ox imeters that differentia te betwee n ox yh emoglobi n and ca rbox yhemoglobin and that can meas ure c arboxyhemogl obin are now av ai lable (Fi g. 24.18).

Fetal Hemoglobin
Mos t s tudies sho w that f etal he moglobin (Hb F) does not appe ar to aff ec t the ac curac y of pulse ox imetry to a c linicall y important degree (378 ,379,380,381 ,383), al th ough v ery high lev els may ca use i t to read sl ightly low (3 82).

Hemoglobin S
The use of pulse ox ime try in the patie nt wi th s ick le cell dis ease is c on trov ers ial . Sev era l inv es tigators hav e conc luded that pulse ox imetry is inacc urate in thes e pati ents , wh ic h mak es i t unreliable for de tec ting seri ous hy poxemia (383,384,38 5).

Other s tudies hav e found i t to be s uff ici ently ac curate to be useful (386,387 ,388,389,390).

Sulfhemoglobin
Sulfhemogl ob inemia may be c aus ed b y dru gs suc h as me toc lo pra mide , phenace tin, dapson e, P .791 and s ulfon amides (391). Sulfhe moglobin c auses the pulse oxi meter to d is pl ay arti fac tual ly l ow oxy gen sa turation.

Other Hemoglobinopathies
Hemoglobin K oln is associated with artifac tu all y low o xygen s atura ti on as measured by the pulse ox imeter (392 ,393). Hemoglobin Hamme rs mi th a nd Hemogl ob in M (Mi l wa ukee ) affec t pulse ox imeter reading so muc h that ox imetry is not us efu l (3 94,395,396 ). Hemoglobin -H disease wil l c ause the pulse ox imeter to indic ate a high er s aturation than is ac tual ly present (397). A patient wi th hemogl obin Cons tan t Springs and alpha-thalass aemi a 2 in whi ch pulse oxime try readings were c ons is ten tl y lo w has been reported (398 ). Heinz Bod y hemol ytic anemia c auses the puls e ox imete r to read low (399 ).

Bilirubinemia
Sev ere hyperbili rubinemi a c an cause an artifac tual elev ation of me tHb an d ca rbox yhe moglobi n when us ing i n v itro oximetry but does no t affec t pulse ox imetry readings (283,378,4 00,401,402,403).

Low Saturations
Pulse ox imetry becomes les s accu rate at low ox ygen s aturations (10,26,57,58,61,84,284 ,285,288,291 ,293,294,297,298,306,404,405 ,406,407,408 ,40 9,410 ,411,412,413,414). T his inaccurac y is greater in patien ts wi th da rk sk in (415). It should be used wi th ca uti on in patien ts wi th c yano tic heart disease (410,411 ,416). Me asuri ng PaO 2 or S aO 2 at low s aturations is recommen ded fo r i mportan t c linic al dec is ions .

Malpositioned Probe
Oxi meters wi th p robes that are not applied we ll v ary g rea tl y in thei r behav ior, dependi ng on both the ac tual S pO 2 and the manufac tu rer and model of th e oxi mete r (70,417,418 ,419,420,421 ,422). If the probe i s not prope rl y posi tioned, i t may al low

the light from the emi tter to the d etec to r to only graze the tiss ue ins tead of pass ing through i t. Th is pe numbra effec t reduces the s ignal-to -no is e ratio and ma y res ult in spuri ous S p O 2 v alues in the low 90s in normal pa tients . If the patie nt is h ypox ic , the ox imeter may ov e res timate the true v alue (41 8,423). In one case , the p robe was co mple tel y una ttach ed but c ontinued to p rov ide a pparently accurate readings . Cl oser examination of the wav eform rev eal ed an unus ual p attern (424). To av oid the probl ems of probe posi tion, the posi ti on sho ul d be c hec ked frequently and inac ces si ble loca tions av oi ded. The use of too l arge or too s mall a probe may resul t i n inaccu rate rea di ngs (33,34,300). Long fingernai ls can c ause inacc ura te positioning (425).

Venous Pulsations
Pulse ox imeter des ign ass umes that the pulsa ti le c omponents of ligh t abs orbance are due to a rterial b lo od. P rominent pulsatio ns of v enous b loo d may lead to underes timation of the SpO 2 (70,426,427 ,428,429,429A ). P uls e rate determi na tion may be co rrec t. The erro r may be worse when probes are us ed on th e head (86,87) but less when the probe is plac ed on the fi nger. In patien ts wi th low s ys temic v ascular res is tanc e, the pulse ox imeter may u nder-read the s aturation , pos si bly becaus e the ox imeter is sensing pulsati le ve nous f lo w (430). Hi gh ai rway p res sures during artif ici al v entilation may c ause phasic v enous conges tion, whic h ma y be in terpreted b y the ox ime ter as a pulse wav e (431). In so me c ases , it may be nec essa ry to turn the v entil ator OFF to obta in a correc t reading.

Mixing Probes
SpO 2 me asuremen ts may no t be acc ura te if one manufac tu rer's p robe is us ed with a different manufac ture r's ins trumen t (432,433).

Severe Anemia
The puls e ox imete r may ov e res timate S pO 2 , es pec iall y at low s aturations , i n pati ents with sev ere an emia (434,43 5,436,437). Howev er, i t is ac curate for n onhypoxic S aO 2 v alues in thes e p atien ts (438).

Skin Pigmentation
A l though s ome earl ier s tudies hav e sho wn that pulse oximeter readings were s lightly hi gh in patients wi th dark sk in (286,439,4 40), newe r s tudies hav e s hown that pigmenta ti on does not mak e a s ign ific ant diffe rence in puls e ox imete r acc urac y

(26,441,442 ). Spuri ous readings were reported in a patient wi th oc ul ocu tan eous albinism who was taking a h erbal remedy (443).

Dyes
Certain dyes inc luding methylene blue, indoc yanine green, l ymphazu ri n (isos ulfan blue), indigo carmine, ni trobenze ne, and patent blue whe n injec ted i ntrav enous l y, i ntra-arteria ll y, into the l ymph atics , intrade rmal l y, or i nto the uterin e c av i ty c an resul t i n dec reas es in Sp O 2 withou t ac tual dec reas ed saturation (354,360 ,444,445,446,447,448,449,450 ,451,452,453 ,454). In v i tro oxi metry may also be affec ted by dyes (360 ,445,455,456 ,457). Usual l y, the in te rference las ts onl y a fe w mi nutes but may persis t muc h longer, ev en hours , whe n lymph atics a re i njec ted (451,452). The reac tion of the pulse ox imeter to exogenous dyes h as been used as a means of confi rming intrav asc ula r catheter plac ement. The d ye is i nj ec ted into the c atheter, and the pulse ox ime ter is obs erv ed (458). The pu lse ox ime ter ma y be usef ul to es timate c ard iac output by the dye di lution method (459 ). P .792

Fi nge rprin ti ng ink wil l c ause a l ow satura ti on readi ng (460). Henna , a s tain used by so me Middl e Eas tern women on the fi nge rs and toes , can ca use a low s atura tion reading (461). Chi ld ren wh o hav e bee n finger painting wi th b lue pa in ts may ex hibit l ow S pO 2 readi ngs (462).

Optical Interference
S tray li ght or li ght f l ic kering a t frequ enc ies s imilar to the freque ncies of the LE Ds , i ncl uding s unligh t, f luorescent l ig hts , ope rating roo m lights , infrared heating lamps , i nfrared radiant warmers , l ight s ou rc es for various scop es, x enon l amps , bi li ru bi n l ights , pho totherapy , or s urgical i maging instrumen ts , can enter the pho todetec tor and resu lt i n inacc ura te or e rratic re adings (14,332,463 ,464,465,466 ,467,4 68,469,470,4 71,472,473 ,474). Hav ing probes o n two adjac ent f ingers can cause an abnorma l trac e (475 ). One clue that optica l in terference is occurring is incons is tency betwee n the pulse rate on the pulse ox imeter and tha t on other mon itors (350). A lthough excess iv e ambien t light usua lly prev en ts the ox imeter f rom track ing the puls e , it c an resul t in apparently no rmal but inac curate measurements in s ome ins tances (470).

Oxi meters v ary s ignif icantl y in thei r sus cepti bil i ty to optic al i nte rference (326,466 ). Some manufac tu rers try to mini miz e the effec t of s tray l igh t by tak ing in termi ttent readings wh en both of the LEDs in the probe are turned OFF and then s ubtrac ting these backg round rea dings from measu reme nts taken b y the photodetec tor wh en ei th er LED is turned ON. Sens i tiv i ty to l igh t may be inc rease d with reduced pu ls e ampli tude. The re are a number of ways to minimize th e e ffec ts of op tical interfe rence. These i ncl ude s election of the c orrec t p robe for the pa tient and use, applying the probe s o that the detec tor is ac ros s f rom the LE Ds , making certain the probe re mains properl y pos i tion ed, a nd shielding the probe f rom l ight an d o the r nearby probes (Fig . 24.12). Extra neous light c an be elimi nated by c ov ering the probe wi th an opaque material suc h as a s urg ic al towel , gauze, f inger c ot, blanke t, alcohol wi pe packet, or o the r foil s hield (59,127 ,476). Thi s may also help to s tabil ize the probe. A ll l igh t may not be adequately s hi el ded by a s impl e c ov ering (463,470).

Nail Polish and Coverings

Some sh ades o f bro wn, blac k , blue, and green (b ut not red or purple ) nai l po lish may cause s ignif ic antly lower s atura ti on readings (477,478 ,479). Synthetic n ai ls may i nterfere wi th pulse ox imetry readings . The pres ence of onyc homyc osis , a ye ll owi sh gray color c ause d b y fungus , can caus e fa ls el y low S pO 2 read ings (48 0). Di rt u nder the na il c an also cause diff ic ul ty i n o bta in ing rel iable readings (481). A l though there is on e repo rt of dried bl ood o n a f inger that c aused errone ous low sa turatio n read ings (48 2), other autho rs hav e found tha t dried b lood does no t affec t pulse oxime ter accu rac y (483,484). Patie nts rece iv ing docetaxe l may hav e disc olo red f ingernai ls that caus e l owe r saturati on readi ngs (485 ). In mos t cases , this problem can be ov erc ome (wi th out remov ing the pol ish or the s ynth etic na il ) by turn ing the probe 90 degre es so that i t trans mits light from one s ide of the finger to the other s id e (55,481).

Electrical Interference
E lec trica l in terfere nce from an elec trosurgical u nit c an caus e the oxi mete r to giv e an i ncorrec t puls e c oun t (us ual ly b y coun ting ex tra beats ) or to fals ely regis ter a dec reas e i n ox ygen satura tion (4 86). This problem ma y be inc re ased in patients wi th wea k pulse s ignals (13). Manuf ac turers h av e made s ign if icant p rog res s in reduc ing thei r i nstru ments ' s ens i tiv i ty to el ec trica l in terferenc e (1 3,207,243,32 6). Some mon itors d is pla y a n otic e wh en s ignifican t in terference is p res ent. Some f ree ze the S p O 2 display duri ng suc h i nterferenc e, whic h may giv e a fals e sens e of

security. Addi tional s teps to mi ni miz e e lec tri cal i nterferenc e inc lude locating the elec trosurgery groundi ng plate as cl ose to, and the ox imeter probe as f ar f ro m, th e su rgical fi el d as pos s ible ; routing the c able from the p robe to the oximete r away f rom the elec tros urgery ap paratus ; ke eping the pulse oximeter probe and c ons ole as f ar as possi bl e from the su rgical s i te and the elec trosurgery grounding plate and tabl e; an d operati ng the uni t in a rapi d response mode. The elec trosurgic al apparatus and pulse ox imeter s hould not be p lu gged i nto the same power c ircui t (486).

Motion Ar tifacts
Motion o f the p robe can cause an arti fac t that the pulse ox ime ter is unable to differentia te f rom normal a rteri al pulsations . Mo ti on artifac t c reates both fa ls epositiv e (false alarm) and fa ls e-negativ e (mi ssed h ypox emia) errors (32,4 87). Changi ng alarm th res holds to reduce one of these errors wil l of ten inc rease th e i nci dence of the other type of e rror (488). Motion is us ual ly no t a problem du ri ng genera l anes thesi a, b ut i f the patien t is sh iv ering, has a condition suc h as P ark inson's dis ease, o r is mov in g about o r being transported, motion artifac ts can be s ignifican t (489,490). Ev oked poten tial moni tors and nerv e s timulators c an produc e mo tion artifac ts if the pulse ox imeter probe is on the s ame ex tremi ty (491 ,492,493,494 ,495). Moti on arti fac ts hav e be en caus ed by p ati ents tapping thei r fi nge rs whi l e u nder regional anes thes ia (4 96). The oxime ter's abi li ty to deal with motion artifac t depends on the c orrel ation with the onse t of the motion a nd the s tart of monitoring. If the mo tion prec edes th e onset of moni tori ng, there is a greater dec re ment in performanc e (497,498). In the 1990s , pulse ox imeter manufac tu rers bega n to make design improv ements , and the newer genera tion P .793 i ns trume nts hav e i mprov ed abi l ity to f il ter motio n a rtif ac ts (320,321 ,338,341,488,497,498,499,500 ,501,502,503 ,504,505). In a ddi ti on to reduc ing alarms , the use of these ins truments has res ul ted in less need for arte ri al blood gas meas u remen ts and f as ter weaning f rom high c oncentra tions of ox yg en (309). The y a re als o as soci ated wi th a s ho rter l oss of s ignal when placed d istal to a blood pres sure c uff or tourniquet (506 ). Lengthening the av eragi ng time wi ll inc rease the likel ihood that e nough true pulses wi ll be detec ted to rejec t motion artifac ts (15,507 ) but may dela y detec tion of

hypoxemia. Mos t puls e oxi mete rs al low the us er to s elec t on e of sev eral timeav eragin g modes . Motion a rtifac ts can usual ly be rec ogni ze d b y false or e rratic pu lse rate d is pl ays or dis torted pl ethys mographic wav efo rms . Inc reased pulse ampli tu de indicates mov ement b ut not necessari ly arti fac tual S pO 2 re adi ngs (487,508 ). Motion a rtifac ts may be dec reased by appl yi ng the p robe to a less ac tiv e si te. Fl exible probes that a re taped i n p lace are less s usc eptible to motion arti fac ts than are c lip-on probes (13,15). La rge r finge rs may be less susceptible to motio n artifac t (32).

Pressure on the Probe

P ress ure on the probe may res ul t in i naccurate SpO 2 re adings wi th out affec ting pulse rate dete rmi nation (42 9).

Hyperemia
If a limb bec omes hype remic af te r blo od flow i s interrup ted , the ox ygen satura tion shown by the pulse ox imetry may be arti f ic ia lly lo w (509). A pulse ox imeter plac ed near the s ite of bloo d transfus ion may show trans ien t dec reases in oxygen sa turatio n wi th rapi d blood i nfusi on (510).

Probe Damage
A damaged pulse ox imeter probe c an caus e the ox yge n s atu ration to be high er than the ac tual v alue (511,512). The us e of a cl eani ng ag ent that is not rec ommended by the manufac turer on a reusa ble probe c an res ul t in damage to the probe, prev enting i ts reuse (513).

False Alarms
A high percentage of pulse ox imetry alarms are s purious or triv ial (489,503 ,505,514,515,516,517). A rtifac t-induc ed ala rms oc cur i n two way s . W hen an artif ac t is mis taken fo r a pulse, i t c an c orrup t th e me asuremen t and res ul t in an alarm. W hen an artifac t obscures the pulse, it c an res ul t in a l oss -of -pulse al arm. False alarms are mos t common ly c aus ed b y mo tion artifac t bu t are als o associa ted wi th po or s ignal qua li ty , probe dis pl ac ement, ex ternal p res sure, an d interfe rence. False alarms are a more s ignifican t probl em o uts ide the op era ti ng room becaus e pati ents are c ommonl y mov ing, they a re of te n poorly pe rfused , and there are many sourc es of el ec tronic and optical i nterferenc e. False alarms do not represe nt a di rec t danger to the patient but may encou rage the ca re prov ider to take inappropriate ac tions s uch as disabli ng the alarm, s etting th e

l imi ts to inappropria te v alues , or lowe ri ng the ala rm v olume. Mi si nterp retation of alarms c an res ul t in failu re to treat hypoxemia or unnec ess ary treatment. Some f alse al arms can b e av oided b y s imp le meas ures such as putti ng th e p robe on a diff erent ex tremi ty than the automated blood press ure c uff and in a l ocation whe re i t is un lik el y to be affec ted by ex te rna l pressu re. Newe r pulse ox imeters tha t are d esi gned to reduc e motio n-related arti fac ts c an s ignif ic antly reduc e the inc idence of f alse alarms (320,497 ,498,499,503,518,519,520,521 ,522,523,524 ,525,526). Howev er, some of these hav e sho wn les s rel iabi li ty i n i dentif ying hypox ic episodes and b rad ycardi a than older models (346). Delaying the time between de tecting l ow S pO 2 and alarm ac tiv a ti on, us ing a longer av eragin g time, and s etting the low S pO 2 alarm l imit lowe r c an reduc e the number of false alarms (311 ,517,527,528 ,529) but may inc re ase the lag time befo re detec ting hypoxemia. W i th s ome pulse oxi meters , tu rning OFF the lo w pu ls e rate alarm prev ents a la rming when the blood pressu re cuff is inflated (13). S ynchroni zing the pulse oxi meter wi th the el ec troc ardiogram (ECG) moni tor can l ess en artifac ts (32,39). Howev er, the ox ime ter ma y s ync hroni ze with ECG artifac ts generate d b y mo ti on or s hiv ering , resul ti ng i n e rroneous readings (13). Furthermo re, with this s ys tem, the pulse rate displayed by the ox ime ter wil l necess ari ly be equa l to the pulse rate s hown by the ECG monitor, so equal ity of the pulse rates cannot be us ed as an indication tha t th e d is played sa turation data a re v ali d.

Failure to Detect Impaired Circulation

The pres ence of a p ulse oxi meter si gna l and a normal reading does not necessari ly i mply that tissue p erfus ion is adequate. Some puls e oximete rs s how pulses despi te i nadequate tiss ue perfus ion (251 ,327) or even when n o pulse is pres ent (200,530 ,531,532). A mbient l ight may p rod uce a fa ls e s ignal (471). Pulse ox imetry is not rel iable in diagn osi ng i mp ai red pe rfus ion wi th i nc reas ed i ntrac ompartmen tal pressu res (533,534).

Discrepancies between Readings from Different Monitors

A disc repancy in readings between diff erent b ran ds of ox ime ters on the s ame pati ent a t the s ame ti me is no t unc ommon (17 ,270,535,536 ,537,538). The re is a ls o v a ri ation in

P .794 the time tha t it tak es v arious moni tors to detec t resa turation (539 ).

Failure to Detect Hypoventilation

Hypov enti lation and h ypercarbi a may occ ur wi tho ut a dec rease in he moglobin ox ygen s atu ration, es pec ial ly if the patient is receiv ing supple mental ox ygen (540,541 ,542). Pulse oxi metry c annot be relied on to detec t leaks , dis connec tions (543), or esophagea l in tubation (544). Methods to detec t esophageal intubation a re disc ussed in Chap te r 19.

Problems with Sound Recognition

The re is cons iderable v ariation in the v olume and aud io s pec tru m of av ailabl e pulse ox imeters between models and ev en wi th in mode ls (545). Some c li nic ians hav e trouble detecting changes in the pi tch o f the s ound emi tted by p uls e oxi mete rs as the saturation c hanges (303 ,546). The re is wide v ariatio n i n the pitch f requenc y of di fferent puls e oxi meters (547). Thus , in loc ations where d ifferent pulse ox imeters are encounte red , the pote ntial for con fusion ex is ts .

Lack of User Knowledge

Pulse ox imetry is of ten us ed by pe rso nnel whos e k nowl edge of it is l imi ted. Phys ici ans , nurses , and others who use the ins trumen t of ten do not kno w the bas ic princi ples and make s eri ous e rrors in interpreti ng readi ngs (548 ,549,550,551 ).

Interference with Other Monitors

E lec tromagne tic in terfe renc e from the pu ls e ox imete r powe r s upp ly may c ause arti fac ts and fa ls e readin gs on certa in thorac ic impedance moni tors (5 52). If a pulse ox imeter probe is placed in front of c ertain plasma dis play touc h sc reens , a normal -appearing wav eform and 100% saturation is displayed (553 ).

Patient Complications Corneal Abrasions

Patients rec ov ering from g eneral anes thes ia f re quen tl y rub thei r ey es . If there is a pulse oxime ter on the index f inger, a cornea l abras ion may resul t (65,554 ,555). A f ing er other than the i ndex f in ger may be a more appropriate l oca ti on fo r th e p rob e during rec ov e ry (556).

Pressure and Ischemic Injuries

Inju ri es ranging from pers istent numbnes s to ische mic injury at the s ite on which a probe was plac ed hav e b een reported (557,558 ,559,560,561,562,563,564,565 ,566,567,568 ). Loss of the s ignal may oc cur (569). These ri sks a re i nc reas ed by pro lo nged probe applica tion, compromised perfus ion of the ex tremity, and tight appl ic ation of th e p robe. Frequent ex amin ati on of the s i te and mov ing the p rob e to diff erent s ites wi ll reduce the lik el ihood of i njury . Patients wi th l arge finge rs sh ould not hav e a c i rc umferenti al probe plac ed on the finge r. If the pulse ox imeter readi ng appears to be weak , the s i te sh ould be checke d for i nc reased press ure .

Burns
Inju ri es ranging from reddened areas to third-degree bu rns under p uls e oxi mete r probes hav e been reported (562,570 ,571,572,573,574,575,576,577 ,578,579,580 ,581). Consi de ring the mil lions of long-term applica tions , the inc id ence of these burns is quite low (43). Burns ca n res ult f rom incompatib il ity betwee n the probe f rom one manufac ture r with the pulse oximeter of another (575 ,578). A n umber o f pulse ox imeter probes hav e connec tors that fit d iffe ren t pulse ox imeters, bu t th e p robes are not c ompatibl e. T he us e of a damaged probe c an resul t i n a b urn (570,577 ). A pu ls e ox ime ter probe may prov ide an al ternate pa thway for elec tros urg ic al cu rrents (582). Burns that are ass ociated with hyp othermia hav e been reporte d (579 ). Bu rns hav e been rep orted when a pu ls e oxi me te r was used duri ng photo dynamic therapy (583,584 ). To av oid thes e injuries , f requent ins pection of the probe s i te and s ite ro tation are recommen ded (585). W hen a probe is placed on a fi nge r or toe, the l igh t s ou rc e shoul d be placed on the nai l rather than on the pulp (576). A glov e c an be pl aced on the fi nge r to protec t i t f rom therma l i nju ry wi th out affec ting the ac curac y of the i ns trume nt (36). If the pu ls e oxi me te r dis play freezes , the ca use should be i nv es tigated . Onl y the probes reco mmende d b y the ox imeter ma nufac ture r sho uld be us ed (578). Burns that are ass ociated with pulse ox imetry d uri ng magnetic reson ance imaging (MR I) as a resul t of ind uced s k in c urrent beneath looped c ables ac ting as an tennae hav e been reported (586,587,588). The MRI e nv i ronment is discussed in Chap ter 30. During MRI, the dange r of bu rns c an be reduc ed b y the fol lowi ng measures :

A ll poten tial conduc to rs sh ould be chec ked before use to ens ure that there is no f ray ed insulatio n, expos ed wi res , or other hazards . A ll unn ecessary conduc tiv e mate ri als such as unused s urfac e coils s hould be remov ed f rom the MRI s ys te m bo re before patie nt moni toring is ini tiated. P .795

The probe s houl d be placed as far f rom the ima gi ng s i te as possible. Cab les , leads , or wi re s f rom mon itoring d evi ces should be pos itio ned so that no l oops a re fo rmed . A b rai d sho ul d be made of the slack po rtio n of wires . If pos sible , no potenti al c onduc tors should touc h the pa tient a t more than one loc ation. A thick layer of thermal insu lation s hould be p lac ed between any wires or cables and the patien t's sk in. Moni tori ng dev ices that do no t app ear to be operating p roperl y sho ul d be remov ed f rom the patient.

Electric Shock
An el ec trica l shock related to dia the rmy has b een reported (589 ). In this case, there we re bare wi res i n the pu ls e ox imete r probe.

Carbon Monoxide Monitoring

Carbon mon oxide can ac cumulate in the breathing s ys tem from v ario us sourc es , i ncl uding the reac tion be twe en anes thetic agents and des icc ate d abso rbe nt. This is disc ussed in detai l i n Chapter 9. It is diff ic ul t to de termine if CO is present in the i nspi red gases when the patient is anesthe tized . In 2005, a c ombinatio n pulse CO-oxime ter capable o f measu ring ca rbox yhe moglobi n (S pCO) bec ame av ai labl e (Fig. 24 .18 ). The same sensor is us ed for measuring both SpCO and SpO 2 . It ala rms wi th CO c onc entra tions between 5 % and 50%. The ins tru ment uti li zes an e ight- wav e length s ens or to dis tinguish between oxygenated bl ood, deox ygenated blood, and blood c on taining CO. It can a lso measure metHb .

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544. McS hane AJ , Ma rtin JL . P reoxy genati on and pu ls e ox ime try may delay detec tion of esophagea l in tub ation . J Nat Med As soc 1987;79:987,991 -992. [Med li ne Link ] 545. Chan dra D, Tess ler MJ , Ushe r J . Audio s pec trum and sound p res sure lev els v a ry betwee n pulse oximeters . Can J Anes th 2006;53:263 2. 546. Sch ulte GT, Bl ock FE . Can people h ear the pi tc h c hange o n a v ari ab le-pi tc h pulse oxime ter? J Clin Moni t 199 2;8:1 982 00. 547. Santamore DC, Cl eav er TG. Th e s ounds of sa turation. J Clin Moni t 2004;18:8992. 548. K ruger PS , Longden PJ . A s tud y of a hos pital s ta ff 's k nowl edge of pulse ox imetry . A naes th Intens Ca re 1997;5 :38 41. [Med li ne Link ] 549. S toneh am MD, S av ille GM, W ilson IH. Kno wledge about pu lse ox ime try among medical and nu rs ing s taff. Lanc et 1994;344:13391342. [Cross Ref] [Med li ne Link ] 550. Rodri guez IR, Koti n N, Lowen thal D, et a l. A s tud y of ped iatric hous e s taff's knowl edge of pulse ox imetry. Pedi atrics 199 4;93:810813. [Med li ne Link ] 551. B i lg in H, Ku tlay O, Dev herogl u D, et al. K nowle dge about pu ls e oximetry amon g res idents and nurses . B r J Anaes th 1 998;80:A148. 552. Anonymous . Pulse ox imeters . Techno l Anes th 1993;14:67 . 553. Linds ay DR. False comfort f rom a pulse ox imeter. Anes th Analg 1999;88:1428 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 554. B rock -Utne J G, Botz G, Jaffe RA . Perio perativ e co rneal ab ras ions . Anes thes iology 1992;77:221 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 555. Bal l DR. A pu lse ox ime try probe haza rd. Anes th Analg 1995;80:1251 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

556. Metz S . Av oid ru bber f ingers . A nes th Anal g 1996 ;82:217. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 557. Bethun e DW , Ba liga N. Sk in injury wi th a pu ls e ox imete r. B r J A naes th 1992;69:665. [Cross Ref] [Med li ne Link ] 558. Dona hue PJ , Emery S . Digi tal sensory loss wi thout puls e oxime ter malfunc tion. Anes th Analg 1995;81:1312. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 559. Gates RE , Ki nsella SB , Moo rthy SS . Se nsory loss of the dis tal phalanx and pulse oxime ter probe. An es th A nal g 1995;80 :855. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 560. Rubin MM, Ford HC, Sadoff RS . Dig ital i njury from a pu ls e ox imete r pro be. J Oral Max il lo fac Su rg 1991;49:301302. [Med li ne Link ] 561. Berge KH, Lanier W L, Scanlon PD. Ischemic digi ta l skin nec ros is . A co mplica tion of the reusable Nel lcor puls e ox imete r probe. A nes th A nalg 1988;67:712713. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 562. Bannis ter J , Sco tt DH T. The rmal injury assoc iated with pulse ox imetry . Anaes thes ia 1988;43:424 425. [Cross Ref] [Med li ne Link ] 563. Cheme ll o PD, Nelson SR, Wo lford L M. Fi nger i nj ury res ulting from pulse ox imeter probe during orthogna thic surgery. Oral Su rg Oral Med Ora l P athol 1990;69:161163. [Cross Ref] [Med li ne Link ]

564. S togne r SW , Owens MW , Bethge BA . Cuta neous nec rosis and puls e oxi metry. Cutis 1991;48:235238. [Med li ne Link ] 565. Cl ark M, Lav ies NG. Sens ory los s of the dis tal pha lanx c aus ed by pulse ox imeter probe. Anaes thesi a 1997;5 2:508509. [Fu ll tex t Link ] [Med li ne Link ] 566. W ill e J , B raams R, v a Haren W H, et a l. P uls e oxi mete r-in duced digital injury: f requenc y rate and pos sible c aus ativ e fac tors . Crit Ca re Med 200 0;28:3555 3557. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 567. Goodman E , Johnson PA . A pote nti al haza rd wi th nondispos abl e pulse ox imeter probes . A nes th A nalg 1999 ;89 :261. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 568. Ghai B , Rupa l S , Mad an R. Toe gangrene in an infant s ubs equent to use of pulse oxime ter for s hort duration. A nes th An alg 2005;100 :60 2. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 569. Urq uhart C, Be ll G. Ear probe pu ls e oxi mete rs and n eonates . Anaes thesia 2005;60:294. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 570. S loan TB . Finger i nj ury by an ox ygen satura ti on moni tor probe. A nes thes iolo gy 1988;68:936938. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 571. Poler S M, W alke r SS , K ibel bek MJ , et al . Cutaneous injuri es as soc iated wi th pulse oxime ters . J Cl in Monit 1992 ;8:185186 . 572. A lexander R, Lev ison A . Burns from a puls e oxi mete r. Cl in Intens Care 1991;2:188.

573. Miyasaka K , Ohata J . Bu rn, erosion, an d sun tan wi th the us e of pulse ox imetry i n infan ts . Anes thes iology 1987;67:1008 100 9. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 574. Sobel DB . Bu rning of a neonate due to a pulse ox imeter: a rterial saturation moni tori ng. Pedi atrics 19 92;89:154155. [Med li ne Link ] 575. Murphy K G, S ecund a J A , Roc koff MA . Sev ere burns f rom a pu lse ox ime ter. Anes thes iology 1990;73:350352 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 576. Pette rs en B , Kongsgaa rd U, Aune H. Sk in in jury in an infant with pulse ox imetry . B r J Anaes th 1992 ;69 :204205. [Cross Ref] [Med li ne Link ] 577. Mil ls GH, Ralph SJ. Bu rns due to puls e oxi me try. Anaesthes ia 1992;47:276 277. [Cross Ref] [Med li ne Link ] 578. Anonymous . Mis matc hed pu ls e ox imete r probes . Technol An es th 1996;16(11):12. 579. Pandy CK , Rani A , S riv as tav a K , et al . Thermal injury wi th p ulse ox imeter probe i n hypo the rmic patie nt. P uls e oxi meter probe burn in hypothermia . Can J Anes th 1 999;46:908909 . 580. Greenha lgh DG, Lawl ess MB , Chew B B , et al . Temperatu re threshol d fo r burn i njury : an ox imeter safety s tudy . J Burn Ca re Rehabil 200 4;25:411415. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 581. A l i A , Subbaramai ah MT, O'Donohoe B. Ref lec tanc e puls e oxi meter as soc iated burn in a c ritical l y il l pati ent. Anaes thes ia 2005;60:1249 1250 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

P .802

582. Anonymous . Dev ice related bu rns . Technol Anes th 1993;14:16 . 583. Farber NE , McNeel y J , R osne r D. Sk in burn associ ated with puls e oxi metry during perioperativ e ph otodynamic therapy . A nes thes iology 1996;84:983985. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 584. Radu A , Zellwe ger M, Grosj ean P , e t al . Pulse ox imeter as a ca use of s k in burn during photody namic the rapy. End osc opy 1999;31:831 833. [Cross Ref] [Med li ne Link ] 585. W oehick H, Herrmann D, Kaslo w O. S afe us e of pulse ox ime try during v e rteporphi n thera py. Anes th Analg 2003 ;96:1 77178. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 586. Bas hein G, S yrov y G. Bu rns as soc iated wi th puls e oxi metry during magnetic resonance imagi ng. A nes thes io logy 1991 ;75:3 82383. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 587. Shellock FG, S limp GL. Sev ere burn of the f inger ca used b y using a puls e ox imeter duri ng MR imaging . A m J Roentgenol 1989;153:1105 . [Med li ne Link ] 588. Kanal E , S hell oc k FG. B urns ass ociated with c linic al MR examinations . Rad iolog y 1990;175:585. [Med li ne Link ] 589. W akel ing HG. Diathermy f re quency s hock from fau lty pulse ox imeter probe . Anaes thes ia 1995;50:749. [Cross Ref] [Med li ne Link ] P .803

Questions
For the fol low ing ques tion, s elec t the c orrec t ans wer 1. In w hic h w a velength does re duce d hemoglobin absorb more light? A . Th e purple band B . Th e red ba nd C. The inf ra red band D. The n ear i nf rared ba nd E . Th e blue band V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

2. Ca use(s) of b urns associated w ith pulse oxime ters probes inc lude(s ): A . Hypothermia B . Incompatible probe an d puls e ox imeter C. Photodynamic therapy D. Vo ltage su rges V iew A ns we r3. Frac tional o xygen saturation is A . Th e ratio of ox yhemogl ob in to all the func tional hemo-globi ns B . Clos e to func tional ox ygen s atura tion in p ati ents wi th l ow lev els of dyshemoglo bi ns C. Determined by in v itro ox imetry D. The ratio of ox yhemoglob in to the sum of a ll the he mo-glob in prese nt V iew A ns we r4. E ffects o n pulse oximeter readings of a methemoglobin level h igh er than 1% include A . Th e dis c repanc y between Sp O 2 and func tional s aturati on inc reases as the lev el of me tHb inc reas es and f unc ti onal h emogl obin saturation d ec reases B . No rmal ly , there is less than 1% me the moglobin in the bl ood C. Sa turatio n read ings may be fa ls ely low fo r readings abov e 85% D. S inc e methe moglobi n has the same abs orp ti on coeff ic ie nt in the red and infrared bands , there wi ll be n o d ifferenc e i n the pulse ox ime ter read ings

V iew A ns we r5. Wh ich of the fo llow ing d o no t affect puls e o xime ter re adings significantly? A . Hyperbili rubinemia B . He moglobin S C. Hemo gl obi n F D. Sev ere anemia V iew A ns we r6. Wh en using a finger probe, A . Response time is qu ic ker if the probe is p lac ed on the thumb B . Inse rtio n of a rad ial artery catheter i mprov es puls ation C. The p robe can be place d s ideways to avo id dark fingernail pol is h D. Smal ler f ingers c aus e fewer mo tion artifac ts V iew A ns we r7. P ulse oxime try can be used to A . De tec t brachial a rtery c ompress ion du ri ng s houlder arthroscop y B . Mon itor c irculation to reimplanted or revascu lari zed digi ts C. Determine the bes t si te for arterial b ypas s surgery D. Ev aluate a s ympathetic b lock V iew A ns we r8. Factors reported to c ontribute to h igher fa ilure rate s w ith pulse oximetry inclu de A . P h ysical s tatus 3 , 4, or 5; young and elde rl y patien ts B . Orth oped ic , v as cular, and cardi ac su rge ry C. Hypertensi on D. Lo w h ematoc rit V iew A ns we r9. Measure(s) to improve the periphera l pulsatio n include A . A pplic a ti on of v asod il ating c ream B . Digi ta l nerv e block s C. Ad mi nis tra tion of intra-arte rial v asodilators D. S ympathetic bloc k V iew A ns we r10 . Reflec tance pulse oxime try d iffe rs from transmissio n pulse oximetry in w hich w ays ? A . Th e reflec tion o ri gi nates from homoge neity i n the optica l path B . Th e reflec tance ox ime try rel ies on bac ksca ttered light to determin e the ox ygen sa turatio n C. The tissue does not need to be wel l perfused to obta in a s tro ng s ignal D. If the probe is ov er an arte ry or v ei n, the readin g may be arti ficial ly l ow V iew A ns we r11 . Conce rning the nose as a mo nitoring site for pulse oximetry,

A . Nasal p rob es are s lower to res pond than finge r pro bes B . Nasal p rob es hav e a high er failure rate than other s i tes during pe ri ods of hypothermia C. The T rendelenberg position imp rov es th e accurac y of pulse ox imeters rea di ngs D. The n asal probe is recommended wh en vasoc ons tric to r drugs are inf used V iew A ns we r12 . Whic h of the follow ing sta temen ts abo ut ear probes a re true? A . Response time is f as ter than wi th a f inger probe B . Tricusp id inc ompetence may c ause erro neous readings C. The e ar is rel ativ el y immune to v asoconstri c tiv e effec ts of the s ympa the tic s ys tem D. The a mplitude of e ar plethys mo gra phy do es not resp ond to c hanges in puls e press ure V iew A ns we r13 . P rob lems w ith the tong ue as a loca tion for pulse oximetry inclu de A . To ngue quiv ering can mi mic tac hyc ardia B . Ex ces s iv e sec retions C. Venous c onges tion wi th the Tre nden berg posi tion D. Dec re ased resis tanc e to elec trosurgic al s ignal interference V iew A ns we r14 . S ituatio ns w here buccal pulse oxime try ma y b e prefe rable are A . Low p ulse pressure s tates B . Inc reas ed s ys temic v ascular res is tanc e C. Hypothermia D. Dec re ased c ardiac output V iew A ns we rP .804

15. Advan tages of using pulse oximetry inc lud e A . Us ual ly accurate in patients with dys rhy thmi as B . A n indica tion of the adequac y o f perfus ion C. Readings are not affec ted by anes thetic gases and v apors D. Ac curate readings to an SpO 2 of 50% V iew A ns we r16 . What factors cause delayed de tec tion of hyp oxemia b y a pulse oximeter? A . P e ripheral loc ati on of the pu ls e ox imetry sens or

B . P e ripheral v asocons tric tion C. Poor perfusion D. Dec re ased time ov er which the puls e signals are av eraged V iew A ns we r17 . Conce rning carbon monox ide an d pu lse ox imetry , A . Th e abso rption spec trum of carbox yhe moglobin is s imilar to that of ox yhemoglo bi n B . Th e pulse ox imeters does not read below 9 4% wh en carbox yhemo globi n is present C. Pu ls e ox ime ters that ca n d ifferentiate oxyhemoglobi n and c arbox yhemoglobin are av ai lable D. S tandard puls e oxi mete rs can wa rn that CO is p res ent b ut cannot q uanti tate it. V iew A ns we r18 . Whic h hemoglobin (s) d oes(do) no t affect the pulse oximeters ? A . He moglobin H B . S ulfhemoglobin C. Hemo gl obi n S D. Fe tal hemog lobin V iew A ns we r19 . Causes of pro be position pro ble ms include A . To o smal l a probe B . Long fi ngernails C. Too large a probe D. The p enumb ra effec t V iew A ns we r20 . Conce rning pulse oximete r ina ccuracy resulting from ve nous pulsatio ns, A . Th e pulse ox imeter un deres timates the SpO 2 B . V enous puls ations are more pro minent in the f inger than in the head C. The p ulse oxi meter re ads v enous puls ations as if they we re arte ri al pu ls ations D. High sys temic v ascular res is tance pro motes v enous puls ati ons V iew A ns we r21 . Conditions in wh ich the pulse oximete rs reads high S pO 2 va lues include A . V enous puls ations B . Ce rtain intrav enous dyes C. Sk in pigmen tation D. Sev ere anemia V iew A ns we r22 . Whic h dye(s) affec t the pu lse ox imeters? A . Indoc yanine g ree n

B . Is os ulfan blue C. Pa ten t blue D. Indigo ca rmine V iew A ns we r23 . Optical interference to puls e oxime try can come from w hich source(s)? A . B i l irubi n ligh ts B . X enon l igh ts C. Inf rared hea ting l amps D. Sunligh t V iew A ns we r24 . What colors o f nail polish interfere w ith pu lse oximeters ? A . B rown B . Green C. B lac k D. Red V iew A ns we r25 . What other su bstances be sides nail polis h interfere w ith pulse oximeters ? A . Onyc hromyc osis B . Di rt unde r the f ingernai l C. S ynth etic na ils D. Dried b lo od V iew A ns we r26 . What are some of th e motion a rtifacts that may a ffect pulse oximeters ? A . E lec trosurgery B . Ne rv e s timulato rs C. Su rgical mov ements D. Ev oked pote ntial mo ni tors V iew A ns we r27 . Causes of fa lse alarm(s) include A . P oor signa l quali ty B . P robe disp lacement C. Ex ternal pressu re D. Moti on arti fac t V iew A ns we r28 . What are the common ca uses of p ressure and ischemic inju ries related to pulse oximetry probes? A . P rolonged probe applic ation B . Tigh t appl ication of the probe

C. Comp romise d perfus ion under the probe D. P robes hel d on b y a c li p V iew A ns we r

Chapter 25 Neuromuscular Transmission Monitoring

Musc le relaxan ts are empl oyed in anes th esia to prov ide mus cle relaxa ti on and /or abolish pa tient mov emen t. Numerous s tudi es hav e documented enormous v a riation i n p atien ts ' responses to muscl e rel ax ants . Disease s tates and perioperativ e medica tions c an als o modi fy the res ponses of thes e medicatio ns (1). The depth of neuromuscu lar block (NMB ) shou ld be monitored when musc le relaxan ts are used to av oid drug ov erdos age or un derdos age and res idua l NMB duri ng recov ery (2,3 ,4,5,6,7).

Equipment
Moni tori ng the magni tude of NMB is acco mplish ed by deliv ering an e lec tric al s timu lus n ear a pe ripheral mo tor n erv e and ev alu ati ng the ev oked response of the musc le (s ) innerv ated by that nerv e .

Stimulator
Sev era l s timu lators are s hown i n Figu re 25.1. Des i rab le features include co mpac tnes s, l ight wei ght, and P .806 s impl ic ity. Mos t are battery-operated wi th a means to check th e battery s ta tus . Moun ting brack ets for securing the dev ice are des i rab le . A s ti mul ator may be in a modu le in a mu ltip ara mete r moni to r. The a bi li ty to del iv er inf ormation to an automated record (Chapter 28) s hou ld be co nsidered when c hoos ing a s ti mula tor.

View Figure

Figure 25.1 Neuromuscular stimulators. A: This simple device has only two patterns of stimulation: tetanus and single twitch. The delivered current cannot be varied and is not displayed. Note the metal ball electrodes. (Courtesy of Professional Instruments, a subsidiary of Life Tech, Inc.) B: This unit has three modes of stimulation: single stimulus (twitch), tetanus, and TOF. The current is varied by using a rheostat at the side, but there is no display of the current being delivered. C: This unit has four patterns of stimulation: single twitch (available at 0.1 and 1 Hz), TOF (which can be repeated automatically every 12 seconds), 50-Hz tetanus, and DBS. It also is capable of delivering the stimulus pattern for obtaining a PTC. The selected current is displayed in the window. Failure to deliver this current will cause a mark to be displayed to the right of the word ERROR. Note that the connections for the lead wires are of different colors. D: This unit has three modes of stimulation: single stimulus (which can be delivered at 0.1, 1, or 2 Hz), tetanus (which is available at a frequency of 50 to 100 Hz), and TOF. Stimulus current is varied by using a rheostat at the side. The delivered current is displayed in a window, to the left of which is an indicator that lights when a stimulus is being delivered. A battery status check button is present.

Current
Current, not v oltage , is the determining f ac tor i n nerv e s timulati on. B ecaus e sk in resis tance may c hange, onl y a s timulator that automatica ll y adjus ts i ts ou tpu t to mai ntain a c ons tant d irec t c urren t c an ens ure unc hanging s timu la tion wi th changes i n s ki n res is tance. W iping the P .807 sk in wi th alc ohol wi l l re mov e insulatin g s kin oils and l ower the resis tanc e. The f orce of mus cle c ontrac ti on is proporti onal to the numbe r of ac tiv ated mus cle f ibers . If a motor nerv e is s timulated wi th s uff icient cu rrent, al l of the musc le f ibers suppl ie d b y tha t nerv e wi ll c ontrac t. The curre nt requi red for this is ca lled the maxi mal curren t. In the c linical setting, s ti mul i of g rea ter tha n max imal (s upramax imal ) i ntensi ty a re us ed to ens ure that maxi mal s ti mu la tion is d el iv e red if resis tance inc reas es . In the ma jori ty of patien ts , a curren t of 30 mi lli amperes (mA )

wi ll pro duce a supra maxi mal response when the ulnar n erv e is s timu la ted (8). When the pos terio r ti bi al nerv e is s timulated , higher c urrents are neede d (9). A supra maxi mal cu rrent is gen era ll y 2.5 to 3 ti mes hi gher tha n the l owes t c urren t capable of elic i ti ng an ev oked response (thresh ol d c urrent) (10). Higher c urrents may be needed in patients wi th edema (1 1,1 2) or d iabetes (13 ). Muc h lower cu rrents (5 to 8 mA ) are needed when needle elec trodes are us ed (14). A curre nt display is usef ul in al erting the user to the possibi lity of a disco nnec tion, broken l ead, weak battery, or p oorly c onducti ng el ec trodes , bec ause thes e problems wi ll c aus e the cu rrent to be reduced . Some s timu la tors hav e an a la rm to warn when the selec ted cu rrent is not b eing del iv ered. A submax imal cu rrent may be better f or awake patients o r fo r those recov e ring f rom anes thes ia, because patient disc omfo rt i nc reases wi th the in tensi ty of the s timu la ting current (15,16,17,18). Use of a s ubmax imal curren t may res ul t in mo re reliable detec ti on of res idual NMB when v isual or tac ti le moni tori ng is used (19). A submax imal c urrent is no t rel iable for gene ral N MB mon itoring .

Frequency
The f re quenc y of s ti muli is us ual ly express ed in Hertz (Hz), whi ch is c ycles /second . One Hz is one cyc le / s ec ond, and 0.1 Hz is equal to 1 s ti mulus ev e ry 10 s econds . W ith a nondepol arizing b lock , inc reas ed s timulus f requency wi ll s horten the ons et time and prol ong the duration of ac tion (20 ,21 ).

Waveform
The s timul us wav eform s houl d be rec tangu lar (s quare wav e) and monophasic . B iphasic wav es may produce repetitiv e s ti mulatio n, which c an lead to underes timation of the depth of NMB presen t.

Duration
The duration should b e 300 s or l ess (20). If the du rati on of the pulse is ov er 0 .5 ms ec , a sec ond ac tion potenti al may be trigge red .

Stimulation Patterns Single Twitch

S ingle-twi tc h (T 1 ) s timu li a re us ual ly de liv ered at a f requency of 0.1 or 1 Hz. A f requenc y greate r than ev ery 10 sec onds is ass oc iated with a progressiv el y dimin is hed response and c ould res ult in ov ere s ti mating the NMB . The c ontrol res pons e s treng th is noted (Fig. 2 5.2A ). T he s tren gths of s ubsequent t witc hes are then co mpared with the c ontrol and exp res sed as a pe rce ntage of the

control (s ingl e-puls e or -twi tc h depres s ion, T 1 %, T1%, T 1 :T c ). W i th both a nondepo la ri zing and a depolari zing block , th ere wi l l be progressiv e depress ion of the res pons e as the bloc k dev elops . A dec re ase i n tempe rature wil l also ca use a reduc ed res pons e (22 ,23 ,24 ,2 5,26). The s ing le s ti mulus is us efu l in es tabl is hing a s upramax imal s timul us and for i dentifying when conditions satisfac tory for intubation hav e been ach iev ed. It can be us ed (i n conjunc ti on wi th a tetanic s ti mulus ) to moni to r deep lev els of NMB (th e pos t-tetanic c ount, disc ussed bel ow). The re are sev e ral disadv antages assoc ia ted wi th us ing s ingl e twi tc h. The re ne eds to be a c ontrol . It cannot dis tinguis h be twe en a depolariz ing and nondepo lari zing block . Mos t impo rtantly , the res pons e's return to c ontrol lev el does no t gua ran tee that ful l recov ery f rom NMB has oc curred .

Train-of-four
Train-of-fou r (TOF , T 4 , T 4 /T 1 ) c ons is ts of f our single p ulses of equal intens ity deliv ered at i nterv als of 0.5 seconds (2 Hz ) (F ig. 25.2B) (27). TOF s hou ld no t be repeated more frequentl y than ev e ry 10 to 12 s econds (4). Ma ny modern s timu la tors do not a ll ow th e T OF to be re peated more often. Use of TOF ev ery 10 seconds wil l resul t in a s horte r onse t ti me fo r NMB than if i t is used ev ery 20 seconds (21,28 ). W ith the control response (befo re any rel axan t has been giv en), all four res ponses are the s ame. The pattern seen wi th a depol ari zing bl ock dif fe rs f rom that of a nondepo la ri zing bl ock (Fig . 25.2B ). W ith a parti al de pol arizi ng bloc k , there is an equal de pression of a ll fou r twi tc hes . Wi th a n ondepolari zing bl oc k, there is progress iv e depress ion of height wi th each t witc h (fade). A s the bloc k is dee pene d, the fou rth twi tc h wil l be eli mina te d fi rs t, then the thi rd, and s o on (Fig. 25 .3). Counting the numbe r of twitc hes (trai n-of -four-c ount o r TOFC) pe rmi ts qu antitativ e as sess ment of a nondepolariz ing bloc k. W i th recov ery or rev ers al of a nondepo la ri zing bl ock , the TOFC inc reas es unti l there are fo ur responses , th en fade dec reases . The tra in-of -four ratio (T r , T 4 ra ti o, T 4 :T 1 , T r %, TR%, TOF rati o, T OFR) is the rati o of the ampl i tude of the fou rth res pons e to th at of the f irs t, exp res sed as a percentage or a frac ti on. It prov ides an es timati on of the degree of n onde polari zing NMB . In the absence of nondepola ri zing block , th e T OFR is app rox imatel y 1 (100%). The deeper the block , the lowe r th e T OFR (Fig. 25 .3). S ince de terminin g

the TOFR requires that four twi tc hes be present, it c anno t be used to moni to r a deep block . P .808

View Figure

Figure 25.2 Patterns of stimulation and response. A: Single-stimulus stimulation at 1 Hz (1 stimulus/second). The height of the control twitches are noted. With either a depolarizing or a nondepolarizing block, twitch height is decreased. B: Train-of-four stimulation. Four successive single stimuli are delivered with 0.5-second intervals. With a nondepolarizing block, there will be progressive depression of the response with each stimulus (fade). With a depolarizing block, the responses will be depressed equally. C, D: Double-burst stimulation. Three stimuli are delivered at 50 Hz, followed 0.75 seconds later by two or three similar stimuli. There will be depression of the response to the second burst with a nondepolarizing block. Note the increased height of the response to the first burst compared with that seen with TOF stimulation. TW, time weight TOF, train of four; DBS, double-burst stimulation.

View Figure

Figure 25.3 Onset and progressive deepening of nondepolarizing block using train-of-four stimulation. When there is no NMB present, all four responses are equal. With onset of the block, there is progressive depression of twitch height with each twitch (fade). As the block progresses, the last twitch is lost and the TOFC is less than 4. TOFR, train-of-four ratio; TOFC, train-of-four count.

P .809

Acc urate as ses sment of th e T OFR ma y not requi re a su pramax imal s timulus (15 ). Tes ting at 10 mA abov e the lowes t c urrent a t whi ch four responses c an be el ici ted may prov ide v alues tha t are c ons is ten t with th ose of s upramax imal tes ti ng (29). The TOF pa ttern has sev era l adv antages . It is a more s ens itiv e ind ic ato r of res idua l NMB than the s ing le twitc h. A c ontrol is no t nec essa ry. It c an dis tinguish between a depolari zing and a no ndepolari zing block an d is of v alue in de tec ting and follo wing the dev elo pment of a phas e II bloc k fol lowi ng s ucc in ylcholi ne adminis tration. The main disadv antage of TOF is i ts poor performance at bo th ex tremes of NMB , deep relax ation or near co mpl ete recov ery (4,30,31,32,33,34,35 ). Tac til e or v isual observ atio n of the T OFR is of l i ttle v alue abov e a ratio of 0.4 0.5 .

Tetanus
Tetanus is a rapidly repeated (e.g., 50, 100 or ev en 200 Hz) s ti mulus . In the absenc e o f NMB , this c aus es s us tai ned c ontrac tion of the s timula ted mus c les . W i th a dep ola ri zing block , th e response wi l l be dep res sed i n ampl itude bu t sus tained. W ith a nondepol arizing b lock , the response i s depress ed in ampl i tu de and th e contrac tion is no t sus ta ined (fade or dec rement). W i th prof ound NMB , the re is no respons e. Fade af te r 50 Hz te tan ic s ti mula tion is a more sensitiv e index of N MB than s ingle twi tc h but not s uffic ie ntl y sensi tiv e to be used f or ass ess ing adequate recov ery (36). S tudies diff er on the signif icance of fade after 100 Hz (36,37). The mos t commo nly us ed frequ enc y is 50 Hz, b ecause i t s tres ses the neuromuscu lar junc tion to the s ame ex tent as a max imal v oluntary effort. F ade may not be s een a t lo wer f req uenc ies wh en a sig nifican t nondepol arizing block is present. Use of 100 Hz a llows more s ens itiv ity i n ev aluating res idual pa ral ys is (37) and is more us eful i n moni toring profound NMB (38). The duration of the te tanic s timulus is importa nt bec aus e i t affec ts fade. The s tandard du ration is 5 seconds . Te tan ic s timula ti on shoul d not be repea ted more of ten than ev ery 2 minutes (39,40). Some newe r s timulators li mit how frequently i t can be us ed. Pos t-te tan ic faci l itation (potenti ati on, P TF) is a temp orary inc rease in res pons e to s timu la tion fo ll owi ng a te tan ic s ti mulus . It is s een wi th a nondepo lari zing, bu t not a depolari zing, block (3 9,41). It i s maxi mal a t around 3 s ec onds a nd las ts u p to 2 minutes . W hen the NMB is so prof ound that there is n o res ponse to si ngle twi tc h o r TOF s timu la tion, i t may be p ossible to es timate N MB by us in g the pos t-tetanic c ount (P TC) (4 2). This is pe rforme d b y adminis te ri ng a tetanic s timulus of 50 Hz fo r 5

seconds . Af te r a 3 -s ec ond pause , s ingle-twi tc h s timul i are appl ied at 1 Hz, and the numb er of (pos t-te tan ic ) res ponses is c ounted . The numb er of twi tch es elic ited i nc reas es as the d epth of NMB dec reas es . T he ti me to app earanc e o f the fi rs t t witc h i n a TOF is inv ersely related to the number of pos t-tetanic twi tc hes present (43,44,45,46,47,48,49). An ev en deep er bl ock c an be moni to red by c ounting the numb er of res pons es fol lowi ng 100-Hz te tanus (38). A s ignificant disadv antage of tetan ic s timula tion is that it is v ery painful a nd should be av oided in the c onsci ous patien t.

Double-burst Stimulation
Double -bu rs t s timulatio n (DBS , mi ni te tanus ) c onsis ts of two s hort s equences of 50 Hz teta nic s timul i sep ara ted by 750 msec . The two mos t c ommonly used are DBS 3 , 3 and DBS 3 , 2 . DB S 3 , 3 cons is ts of th ree 0.2-msec impulses at 50 Hz, f ol lowed 750 ms ec later by an iden tical burs t (Fig . 25.2C). DB S 3 , 2 c ons is ts of three impuls es followe d by two s uch imp uls es 750 msec later (Fi g. 25.2D). Ano the r permuta tion of DBS is DB S 3 , 3 80-40, whic h is thre e s ti muli at 80 Hz follo wed 750 msec later by three s ti muli at 40 Hz . A modified DBS c onsi s ti ng of fi rs t two s timuli of 0.3 ms duratio n at 50 Hz and then two s ti muli of 0 .2 ms duration a t 50 Hz has also been us ed (50 ). The primary us e of DBS has been to de tec t re si dual NMB . S tudies sho w that fade (res pons e to the s econd burs t wea ker than that to the f i rs t) i s mo re readi l y d etec ted wi th DB S than TOF us ing v isual or tac ti le moni toring (19,30,31,32,33,51,52). It also has been us ed for i ntra operativ e assessmen t of NMB (53). DB S a nd TOF hav e a c los e relationship ov er a wi de range of NMB (4,54,55). A nother us e of DBS is to as sess d eep block , s ince the fi rs t twitc h in d ouble burs t c an be detected at deeper block lev els than the fi rs t twitch i n T OF (53,56,57,58). DBS causes more dis comf ort to the awak e p ati en t than TOF s ti mulation but less than te tanic s ti mulation (16). It c an be use d at s ubmaxi mal c urrents . This c auses l ess disc omfo rt i n the a wake patient and, i n mos t c ases , is more re liable than tes tin g wi th s upramax imal s timul i (10). DBS sho ul d not be repea ted at interv als of less than 12 s econ ds (3 2). Ca ution shoul d be used wh en s wi tch ing between dou ble -bu rs t and TOF s timu lation (59 ). Up to 92 s eco nds may be requi red before the responses are s ta bi li zed .

Electrodes

S timulati on is ac hiev ed by p lac ing two elec tro des al ong a ne rv e and pass ing a cu rrent through them. S ti mu la tion c an be c arri ed out ei ther tra nscu tan eous ly using su rface el ectrodes or perc utaneous l y with need le elec trodes .

Types Surface Electr odes

Surface (g el, patch, pad) elec trodes hav e adhesiv e su rround ing a ge lled foam pad i n c ontac t with a me tal disc with a knob for attachmen t to the el ec trica l lead. Th ey are rea dil y av ailab le, easi l y appli ed, P .810 disposable, self-adh ering, and c omfortable . The el ec trodes can be those usu all y us ed to moni tor the elec troc ardiographic trac ing. The elec trode-s kin res is tance dec reas es wi th a l arge conduc ting a rea , as do sk in bu rns an d pain. Howev er, a l arge c onduc ting a rea may mak e i t dif ficul t to obtain s upramax imal s timul ation a nd may s ti mula te mul tipl e nerv es , so it may be bette r to us e pedi atric elec trodes . The bes t res ul ts a re obtained if the skin is prope rl y c leans ed and rubbed wi th a n abras iv e (20). The re are elec trodes spec ia ll y des igned fo r peripheral ne rv e sti mulation. Thes e hav e a d iffe ren t th ic knes s than elec troc ard iog ram (E CG) elec trodes and ch emic al buffers to main ta in sk in su rface pH.

Metal Electrodes
Some s timula tors are s uppl ied wi th two metal bal ls or pla tes s paced about 1 inc h apart, whi ch attach di rec tl y to the s timu lator (Fi g. 25.1A ). These are c onv eni ent to us e but may no t mak e good contac t. Bu rns hav e been repo rted with their use (60).

Needle Electrodes
Needle elec trodes may be useful wh en supramax ima l s timulation cann ot be ac hiev ed by us ing s urfac e e lec trodes . Th is us ual ly occurs when the ski n is thic ken ed, c old , or edematous and in obes e, hy pothyroid, diabe tic , o r renal fai lure pati ents (20 ,61 ). Additio nal c ompl ic ations (broken needl es , infec ti on, burns , and nerv e damag e) are as soc iated wi th thei r use . Needle elec trodes ca rry a g rea ter ri sk of di rec t muscle s timu la tion than surface elec trodes (6 2).

Polarity

S timulators produce a di rec t c u rrent b y us ing one neg ativ e and one pos itiv e elec trode. T he pol arity of the outle t soc kets should be i ndic ated on the s timulator. Us ually, the posi tiv e elec trode is red, and th e negativ e is bl ac k. Max imal effec t is ac hiev ed when the negativ e elec trode is placed di rec tly ov er the mos t s uperfic ial part of the ne rv e b ein g s ti mulated (63 ). The posi tiv e e lec trode shoul d be pl aced along the cou rs e of the n erv e, us ual ly proximal l y to av oid di rec t mus c le s timulation . If the p ola ri ty is unk nown, the c onnec tions c an be rev ersed to dete rmi ne whic h arra ngemen t ev okes the greater response.

Methods for Evaluating Evoked Responses Visual

V isua l ass ess ment can be used to c oun t the n umber of res ponses pres en t wi th a TOF s timulus , to dete rmine the P TC, and to detec t the presenc e of f ade wi th TOF or DB S . Pos ttetanic fac ilitation can also be as sess ed. S tudies hav e sho wn tha t it is diff icul t to dete rmine the T OFR accu rately or to c ompare a s in gl e-twi tc h heig ht to i ts control v is ual ly (30,64,65,66 ). V isuall y recogn iz in g fade wi th TOF s timulation may be easi er wi th submax imal c urrents (30). V is ually as ses sing fade with 100-Hz tetanic s ti mulation appears to be fai rl y acc ura te whe n ev aluati ng res idual pa ral ys is (38). For v is ual assessmen t, the obs erv er sh ould be at an angle of 90 deg rees to the motion (10).

Tactile
Tac til e ev aluation is ac compl ished b y p lacing the ev al uator's f ing ertips ligh tl y ov er the musc le to be s timul ated and feeling the s trength of con trac tion (Fig. 25 .4). It is more s ens itiv e than v is ual monitoring for assessi ng NMB using TOF (33 ). It c an be us ed to ev aluate the prese nce or abs ence of respo nses and/or fade with train-offour, double bu rs t, an d tetanic stimu lation. The P TC c an be determined. If th ere is a response to all f our s ti muli wi th TOF s timu lation, the TOFR can b e es timated. Howev er, it is difficul t for ev en trai ned obs erv ers to detec t TOF fade manual ly unles s the TOF ratio is b el ow 4 0% (31,32,33,34 ,67 ,68 ,69 ,7 0,71,72,7 3). Detec ting fade tac tilel y is so mewhat easi er wi th DB S bu t cannot b e depended on to detec t resi dual paral ysis (31 ,32 ,3 3,50,72,74). Detec tion is bette r when the ev alua to r uses the domi nant hand of the pa ti ent (67).

Figure 25.4 For tactile evaluation of thumb adduction, the hand is supine and a slight preload is applied. (Picture courtesy of Biometer.)

View Figure

P .811

Mechanomyography
The mec hanomyogram (MMG) uti li zes a forc e-d is pl aceme nt trans duc er, s uch as a s train ga uge, a ttach ed to a fing er or o the r part of the bod y that can be res trai ned by a prel oad and wi l l mov e when s timul ated. The transducer c onv erts th e contrac ti le forc e into an el ectri cal s ignal , wh ic h is ampl ified and display ed on a moni tor sc ree n o r rec orded on a chart. Singl e-twi tc h h eight, res pons e to teta nic s timu la tion, and the T 4 ratio c an be acc ura tel y meas ured by using an MMG (75). Us ing the MMG en tai ls a n umber of diff ic ul ties . These dev ices are cumbe rs ome and diff icul t to s et up for s table and ac curate me asuremen ts (76). P ro per transduc er orienta ti on, isometric cond itions , and appl icatio n of a s table p reload a re requi red (77). Maintenanc e of musc le temperature wi th in l imi ts is i mportan t for accu rate resul ts . Mec hanomyography is ra rel y used c li nical l y but is regarded as the gol d s tandard for sc ientif ic meas urement of neu romus cular resp onse (5,78).

Acceleromyography
W ith acc el ero myography (A CG, A MG), a th in pi ezoelec tric trans duce r or a smal l alumi num rod wi th e lec trodes on both s id es is f ix ed to the mov ing part (79,80) (Fi g. 25.5). W hen the part mov es, a v ol tage which is p rop ortional to the acc ele ration of the mov ing part is generated. This me tho d requ ires unres tric ted mov ement of th e

musc le being s timul ated. An elas tic pre load can be applied to return the mov ing part to its original posi tion . A CG can be us ed to as ses s N MB at the ha nd with th e pati en t's arm tucked a t the s ide as long as the th umb c an mov e f reel y. A pro tec tiv e dev ice can be us ed to al low thumb motion whi le protec ting the hand and fo rea rm (81 ). Mos t s tudies sho w a fairl y c lose relati onsh ip be twe en TOFRs meas ure d b y A CG and the MMG (29,80,82,83 ,84 ,85 ,86 ,8 7,88,8 9,90,91) or elec tromyography (E MG) (75,85,92,93), al th ough the resul ts are not interchangeab le. S ome s tudies sho w poor c orre la tion (94,95). In awak e patien ts , th e results are affec ted by ex tra mov ements to whi ch the thumb ma y be subjec ted , leadi ng to poor repea tab ili ty (96). Acc elerometry is eas y and c onv enient to use, relativ e inexpens iv e, and can be i nte rface d wi th a c omputer. It d oes no t requi re a pre load. It giv es more acc ura te resul ts than v is ual or tac ti le ev aluation (68 ,92 ).

Kinemyography
K inemyography (K MG) util iz es a bend ing s enso r th at is placed be tween the thumb and forefinger (F ig. 25.6). The core of the sensor is a piezoelec tric material (97). Mov ement is determined by the c hange in shape of the mate rial wh en it is ben t by adduc tor poll icis muscle c ontrac tion. W hen the piezoe lec tric ma terial changes shape, the elec tric al ch arg e in th e ma terial i s redis tribu ted , and this lea ds to an elec tron flow to ba lanc e the c harges . This flow is measured as a potential c hange that is proporti ona l to the amount of d is tortion . The hand need no t be immob ili zed s inc e the pos ition and di rec tion of the thumb do no t affec t the meas uremen t as long as the th umb is able to mov e freel y. This dev ice is in a module that can be P .812 added to a mul tipu rpose moni tor (Fig. 25.7 ). The res ults of the neu romuscul ar tes tin g a re displayed on the monitor s c reen. Th is technol ogy can meas ure TOF, double b urs t, and s ingle twi tc h.

View Figure

Figure 25.5 Accelerography. The piezoelectric wafer is attached to the moving part-in this case, the thumb. When the thumb moves, an electrical signal proportional to the acceleration is produced. The monitor allows determination of single-twitch depression, TOF count or ratio and/or the PTC. Responses can be displayed by using the printer. (Courtesy of Biometer International A/S.)

Figure 25.6 Sensor for kinemyography. The sensor is secured with tape.

View Figure

K MG has been c ompa red wi th mec hanomyography (98,99 ). There was a gre ement as to the time to i ntuba ti on and recov ery, bu t K MG lagged behind the MMG i n determin ing recov ery from NMB .

Piezoelectric Film
This method us es a dis pos able p ie zoel ec tric f il m (100 ). T his is plac ed s o tha t it spans a mov able joint (101). Musc le mov ement f rom ev oked s timulation bends the f il m a nd gene rates a v ol tage that is proportiona l to the amount of b ending. It has

been used on the thumb, f if th digit, and the great toe (101,102). It can be us ed with the patie nt's hands tucked a t his o r her s id es . This method is not as accurate as mec hanomyography or E MG but ma y predic t recov ery of the TOF R better than v isual or tac ti le ev aluation (100 ,103,104,105 ).

Electromyography
E lec tromyograph y (E MG) is the proc ess of reco rding the el ec trical ac tiv ity of a musc le (106,10 7). W hen a mo tor nerv e is s ti mula ted , a biphas ic ac tion potential is generate d i n eac h of the muscle cel ls i t s uppl ies , unless some degree of NMB ex is ts . The sum of a nu mber of thes e actio n p otentials can be s ensed by using elec trodes pl ac ed ov er the mus cle being s timul ated. F iv e e lec trodes a re us ed. Two s timu la ting elec trodes are placed ov er the nerv e to be s timula ted. Three elec trodes , t wo rec eiv in g (sensi ng, reco rdi ng) and one ground, are used f or recording. The bes t s igna l is usual l y obtai ned by placi ng the ac tiv e rec eiv ing elec trode ov er the bel l y of the musc le wi th the ind ifferent (reference ) elec trode ov er the tendon inse rtion site. The ground elec trode, whose func tion is to dec reas e s ti mula tion artifac ts , is placed between the s timula ting and rec ording elec tro des . Bes t res ults wi ll be s een when the elec trodes hav e b een in c ontac t with the s k in f or at leas t 15 minutes (c ure time ) before calib rati on. Ca reful s kin p repara tion wi ll help to giv e good resu lts (20). Mov ement a rtifac t can be mi nimi ze d b y f ixation o r by app ly ing a cons tant p reload to the musc le bei ng recorded (108,109). E MG of the larynx c an be acc ompl is hed by us ing either a s pecial ized trac heal tub e wi th i nco rpo rated wi re el ec trodes or a s uperfici al elec trode attache d c irc ul arly around the tube and plac ed between the v oc al co rds (110). The ev oked E MG si gna l is fi ltered, rec tified, a mpli fied , and then displayed and/or recorded at a much s lower s peed . Measu rements may be made of peak -to-peak ampli tude of the majo r deflec tion . The su m of the amp li tudes of the major posi tiv e and n egativ e deflec ti ons , or the area under th e curv e (integrated E MG), c an be meas ured (78 ,111). An E MG machine (F ig . 25.8) au toma ticall y d etermines the sup ramaxi ma l s timu lus , es tablishes a c ontro l P .813 respons e, s ti mulates at a se lec ted interv al , meas ures the res ponse, and c omp ares i t wi th th e c ontrol. A v ailable features include an alarm to warn whe n the si ng le pulse resp onse ex ceeds a chos en v alue and a prin ter to prov ide a permanen t

record. Mos t hav e ala rms fo r func tioning errors , loose c onnec tions , i nc reas ed ski n resis tance , abs ence of supramax imal s timulatio n, an d the l ik e. Mos t show the E MG wav efo rm and automatically a dj us t the gain so that i t occ upi es the ful l s cale.

Figure 25.7 The TOF count and ratio are shown on the monitor. The scale at the bottom shows the frequency of stimulation (every 20 seconds) and how much time has elapsed since the last stimulus. This information comes from a Kinemyograph.
View Figure

Figure 25.8 Electromyography monitor. The T1%, TOFR, and TOFC can be measured and are displayed in the boxes to the right of the printer. Responses can be recorded by using the printer. A T1% high alarm is present. TOF stimulation is performed automatically every 20 seconds. (Courtesy of Datex Medical Instrumentation, Inc.)
View Figure

W ith a nondepol arizing NMB , the action po ten ti al amp li tude is dec reased, and there i s fad e wi th T OF. Freque ntl y, the amp li tude does not retu rn to 100% of c on trol wi th recov ery , al though the TOFR wil l eq ual approxi mately 1 00%. Diff erent h and positions may af fec t the res ul ts (112). A numbe r of s tudies c omparing E MG and MMG hav e been pub lished (86,113,114 ,115,116,117 ,118,1 19,120,121,1 22,123,124 ). W i th a non depo la ri zing

block , a fa irly go od corre lation is us ual ly s een, altho ugh the two tec hn iqu es do not giv e identical inf orma tion. Wi th a depolariz ing bloc k , the relationsh ip is more co mplex , an d s tudies show con tradictory res ults (125). The TOFR determined by E MG may be less affec ted b y changes in tempe rature than wi th the MMG (123). The neuromusc ula r trace does not a lwa ys recov e r to the lev el of the i ni tial ca li brati on v alue. The recov ery ti mes of mus cle rel axants c an be acc uratel y determined if meas uremen ts are ref erenc ed to the new bas eline (126). The loss of supra maxi mal s ti mula tion is p artl y res pons ible fo r the o bserv ed c hanges in the ev oked elec tromyog ram during anes thesi a (127). E MG has sev eral adv antages ov er mechan omyog raphy. Less i mmo bi lization is requi red. It does not requi re bu lk y apparatus nea r the muscl e being moni to red . The hand and arm do no t need to be ex tended or pu t on a board (78 ,128). It c an be us ed to moni tor musc les not av ai lab le to the MMG suc h as the diaph ragm and the l ary ngea l musc les (20,12 9,130,131,132 ,133,134,135 ). It can be us ed to assess motor ne rv e bloc k ind uced b y regional anesthesia (1 36). The re are dis adv antages to E MG. It is se nsitiv e to elec trical i nterferenc e. Th e respons e may v a ry ac cording to th e musc le use d. The equipment is exp ensiv e and tak es s ome ti me and effort to set up . Sk in preparation and elec trode placement mus t be done espec iall y c aref ull y. S ince the s ite is no t immob il i zed, c hanges i n the rela tiv e pos ition of the rec ordin g e lec trodes caus e v ariation in E MG response. Tempera ture plays an i mportan t role i n the respons e ampl i tu de with ampl itude i nc reas ing wi th dec reas ing mus cl e tempe rature (20).

Phonomyography
Phonomyography (acous tic myog raphy or moni toring ) rel ies on the fac t that whe n a musc le c ontrac ts , lo w-f re quenc y s oun ds are e mitted. These aco us tic wav es propagate to the s ki n, ge nerating wav es that ca n be rec orded by a s mall piezo el ec tric mic rophone . The P .814 s igna l ampli tude has been s hown to b e proporti onal to the degree of muscle contrac tion. This method has been us ed to meas ure resp onses in the hand mus cles when the mic rophone is tigh tl y sec ured to th e the nar mas s to moni to r the adduc tor pollic is musc le , or to the groov e between the fi rs t and second metac arpel bone to moni tor the fi rs t dorsal inteross eus mus c le (137,138,1 39,140,141,1 42). The corrugator

superc ili i musc le c an be moni to red by plac in g the mic rophon e abov e the medi al portion of the e yebrow (1 42,143,144 ,145). The musc les of the larynx c an be moni tored by placi ng th e s enso r in the v es tibul ar f ol d jus t l ate ral to the v oc al co rds (110,146 ,147). S tudi es comparing ph onomy ography , A CG, and mechan omyog raphy by us ing hand and c orruga tor supe rc il ii muscles sh ow s ome agreemen t, althou gh the results are not in terchangea ble (99,140 ,14 1,143,144 ,14 5,146). The phonomyogram is eas y to us e and can be us ed on a numbe r of different musc les . It prov ides a s tabl e bas eline wi th r elativ ely few dis tu rbances f ro m arti fac ts (145). Data c an be transferred to an a utomated a nes thes ia reco rd. S ince this me thod moni tors lo w f requenc y sounds , artifac ts are poss ib le. Vess el pulsa tions c an caus e smal l wav es in the bas eli ne . E lec tros urgery units may cause i nte rference . The mic rophone ma y c ome off th e s ki n.

Choice of Monitoring Site

The s ite of s timu la tion s hould be a way from the s urg ic al field. If v isual or tac tile moni tori ng is to be us ed, the locati on mus t be acces si ble to the anes thes ia prov ider. If a musc le in a n a rm or l eg is us ed, the bl ood press ure s hould be meas ured on a dif fe ren t ex tre mity. An arteriov enous s hunt does no t con traindicate that arm bei ng us ed to moni to r NMB (148). If the patien t has an upper-motorneuron les ion , a nerv e in an aff ec ted (pare tic ) ex tremi ty should not be us ed, becaus e i t may falsely s ho w res is tanc e to nondepolari zi ng drugs (14 9,150). If possible, the nerv e s timulator e lec trodes s houl d be pl aced o n a d iffe ren t ex tremity f rom the puls e oxi meter probe to av oid arti fac ts (151,15 2,153).

Ulnar Nerve
The ulna r nerv e is mos t co mmo nly used, and the adduc to r pol licis (thumb ) musc le i s mos t co mmonly moni tored. Because th is mus cle is on the s ide of the arm oppos i te the si te of s timul ation, there is l ittle di rec t musc le s ti mula tion. Howev e r, resi dual NMB may be eas ier to detec t tac ti le ly by us ing the index f inger (71). The ulna r nerv e can be s timulated a t the elb ow, wris t, o r hand (Figs . 25 .9, 25.10). S timulati on at the wri s t wi l l produc e thu mb a dduc tion and fin ger flexi on. S timula ti on at the el bow produces hand adduc ti on as wel l . If an MMG or e lec tromyogra m is us ed for measuring the res ponse , the s timulatin g e lec trodes s hould be placed at the wri s t to li mit hand moti on.

Figure 25.9 Placement of electrodes for ulnar nerve stimulation. A: The electrodes are placed along the ulnar aspect of the distal forearm. B: The electrodes are placed over the sulcus of the medial epicondyle of the humerus.

View Figure

A t the wris t, the two elec trodes s hould be place d a long the med ial aspec t of the dis tal forearm, approx imately 2 c m prox imal to the proximal wri s t sk in c rease wi th the nega tiv e elec trode dis tal (18) (Fig . 25.9A). The re, the ulnar nerv e is superfic ial . A l te rna tel y, the posi tiv e el ectro de may be pl aced on the dorsa l si de of the wri s t (Fig . 25.10). A t the el bow, the elec trodes sh ould be placed ov er the sulcus of the medial epicondyle of th e humerus (Fig. 25.9B ). Caution mus t be ex erc is ed to ensure that the el ec trodes do not ca use ulnar nerv e compress io n (154 ). The elec trodes may also be p lac ed on the hand wi th the nega tiv e elec trode on the palm between the base of the th umb and the s eco nd finge r and the posi tiv e e lec trode i n the same pos ition on th e dors al si de of the hand (15 5).

Figure 25.10 Alternate placement of electrodes for ulnar nerve stimulation. The negative electrode is placed along the ulnar aspect of the ventral side of the wrist. The positive electrode is placed on the dorsal side.

View Figure

P .815

Figure 25.11 Sites for electrodes for electromyography monitoring with ulnar nerve stimulation and recording from the dorsal interosseous muscle. The active receiving electrode is placed in the web between the index finger and the thumb and the reference electrode, at the base of the second finger. Ref, reference electrode; AR, active receiving electrode; G, grounding electrode; N, negativestimulating electrode; P, positive-stimulating electrode.

View Figure

W hen E MG moni to ring is used, the recordi ng el ec tro des can be p laced ov e r th e hypothena r, thenar, o r dorsal inteross eous mus cle. The e lec tric al resis tanc e of the

palm skin may v ary bec ause of s weat p roduc tion and may be i nc reas ed in manu al work ers (156). The dors um of the han d is less aff ec ted than the palm in both respec ts , so the dorsal inteross eous mus cle ma y be p referre d. To record the reac tion of the dorsal i nterosseous mus cle , th e ac tiv e rece iv in g e lec trode is placed i n the web be twe en the index fi nger and the thumb and the othe r elec trod e a t the base of the sec ond fing er (F ig. 25.11). Surfac e elec trodes are s imple to f ix here , easy to maintain in pos ition, an d s el dom are dis turbed by hand mov ements (157 ). For the hypothenar E MG, both elec trodes are placed on the palmar s ide ov er the hypothena r eminenc e o r th e ac tiv e elec trode is placed on the hypoth enar eminence and the other belo w the sec ond l ine on the rin g f inger o r at the bas e o f the dors um of the f if th finger (Fi g. 25.12) (15 8,159). If the thena r musc le E MG is recorded , elec trodes are placed on the th enar emin ence and the prox imal p halanx of the middl e or index f inger or the latera l s ide of the bas e of th e thumb (Fi g. 25.13). Abduc tion of the thu mb wi th a co ns tant p retensio n wil l bring the mus cl es clos er to the skin and minimize mov ement (14,109).

Figure 25.12 Placement of electrodes for electromyography monitoring from the hypothenar eminence. The active electrode is placed over the hypothenar eminence. The reference electrode may be placed more distally on the hypothenar eminence, below the second line on the ring finger or at the base of the fifth finger as shown. Ref, reference electrode; AR, active receiving electrode; G, grounding electrode; N, negative-stimulating electrode; P, positive-stimulating electrode.

View Figure

For tac tile asses sment, the thumb should be he ld in s ligh t abduc tion and the observ er's f ingertips pl aced ov er the dis tal phalanx in the di rec tion of mov ement (160) (Fi g. 25.4). P reloadi ng the thu mb wi th a rubber band ma y i mprov e v isual

as sess ment (161 ). It s hould be n oted tha t th e adduc to r pol lic is is s ometimes suppl ie d b y the median n erv e (162 ). W hen mon itori ng the adduc tor pol l ic is mus cl e, i t is i mporta nt to real i ze th at the onset an d duration of NMB at the l arynx and the diaphragm are shorte r than at the peripheral muscl es (7 8,131,132 ,163,164).

Median Nerve
The med ia n nerv e is l arg er than the u ln ar but les s supe rfic ia l (165). It c an be s timu la ted at the wris t by pl acing the elec tro des medi al to where the e lec trodes wou ld be plac ed for u lnar nerv e s timu la tion or at the elbo w ad jacent to th e brachial arte ry. This res ults in thumb adduc ti on. The E MG si gnal can be monitored from the thena r muscles . P .816

Figure 25.13 Placement of electrodes for monitoring the electromyogram from the thenar eminence. The active receiving electrode is placed over the thenar eminence. The reference electrode may be placed as shown here or at the proximal phalanx of the middle or index finger. Ref, reference electrode; AR, active receiving electrode; G, grounding electrode; N, negative-stimulating electrode; P, positive-stimulating electrode.

View Figure

Tibial Nerve
To s timu la te the ti bi al ne rv e at the p opliteal fos sa, two s timulating el ec trodes are place d along the lateral s ide of the po pli teal f oss a. The g as trocnemius musc le is s timu la ted . This is us uall y monitored by the E MG wi th the se nsing elec trodes ov e r

the la teral head of the gas trocnemius muscle (166). The use of this musc le may caus e signif ic ant l eg mov ement, whi ch may dis trac t the s urg eon (78).

Posterior Tibial Nerve

To s timu la te the pos terio r ti bi al ne rv e, elec tro des are placed behind the med ial mal eolus an d ante rior to the Ac hill es tendon at the ank le (Fig. 25 .14). S ti mulation caus es plan tar flex ion of the foot and big toe. A CG ca n be used at this si te (9,167,168,169 ). If E MG moni tori ng is us ed, the receiv ing elec trodes are pl aced on the flexo r hal lucis brev is on the pl antar s urfac e of th e foot or on the intermetata rsa l musc les with the reference el ectro de on the big toe (F ig. 25.15). The pos teri or tibia l nerv e s i te offers ma ny adv antages . It is es pec ially useful in ch il dren, wh en it is diff icul t to find room on the arm bec aus e of other mon itors o r i nv as iv e lines , and when the hand is inac cess ible or for o the r reasons s uch as ampu tati on, burns , i nfec tion , or head and neck procedures (170 ).

Figure 25.14 Placement of electrodes for stimulating the posterior tibial nerve. The negative electrode is placed behind the medial malleolus, anterior to the Achilles tendon. The positive electrode is placed just proximal to the negative electrode. Stimulation causes plantar flexion of the great toe.
View Figure

Compa red wi th the ul nar nerv e, the pos terior ti bi al nerv e dis plays a lag ti me with a s lowe r onse t of relax ati on (169,171,172). Mos t s tudies sho w l i ttle di fferenc e in the time to recov ery from the ne uro muscu lar relaxa tion (170,171 ,172,173,174,175). T he probabil i ty of tac tile detec tion of fade in response to TOF or DB S is less at the great toe than at the thumb (73 ).

Peroneal Nerve
To s timu la te the peronea l (lateral pop li teal ) nerv e, elec trodes are plac ed on the l ate ral aspec t of the k nee (Fig. 25.16). It ma y be nec essary to try different pos i tions

to achiev e the bes t response (17 6,177). S timul ation caus es dors iflex ion of the foot. Compa red wi th the ul nar nerv e, the peroneal nerv e sh ows a s lower onset of relaxation and the muscles sh ow g rea ter res is tance to NMB (177).

Figure 25.15 Electromyography monitoring using the posterior tibial nerve. The active receiving electrode is placed over the flexor hallucis brevis and the reference electrode, on the big toe. Ref, reference electrode; AR, active receiving electrode; G, grounding electrode; N, negative-stimulating electrode; P, positive-stimulating electrode.
View Figure

P .817

Figure 25.16 Electrode placement for stimulating the peroneal (lateral popliteal) nerve. The electrodes are placed lateral to the neck of the fibula. Stimulation causes dorsiflexion of the foot.

View Figure

Muscular Branch of the Femoral Nerve

The mus cular branch of the femo ral nerv e can be s timula ted and mov ement in the v astus medialis mus c le ev aluated. This musc le can be us ed to moni tor neuromuscu lar func tion in the prone patient. W hen c ompared wi th the adduc to r poll ic is mus cle, the onse t of NMB and recovery were qu ic ker (178).

Facial Nerve
The f aci al nerv e, which enerv ates the muscles around the eye , is one of the eas ier musc les to s timu late and observ e. It is mos t us eful for detec ti ng th e onse t of

relaxation in the muscl es in the jaw, l arynx , and diaph ragm (179). ACG c an be us ed wi th the facial nerv e (180,181 ,182,183). Sev era l diff erent e lec trode c onfigu rations hav e been us ed fo r s timulating the f acial nerv e:

The negativ e elec trode is placed j us t anterior to the inf erio r part of the ear l obe, and the o ther elec trode is pl ac ed jus t pos te rior or i nferior to the lobe (Fig . 25.17). S timulation at this s ite wil l mak e i t more like ly that mus c le contrac tions are the resu lt of nerv e s timu lati on rather than d irec t muscl e s timu la tion.

One elec trode is p laced l ate ral to and below the late ral c anthus of the e ye, and the other elec trode is placed an teri or to the earl obe (1 84) or 2 c m latera l to and abov e the lateral can thus . Th is plac ement ma y result i n di rec t mus c le s timu la tion. If one o f these c onfigu rations is us ed, low c u rrents (2030 mA ) shoul d be used (110).

Figure 25.17 Electrode placement for stimulating the facial nerve. The negative electrode is placed anterior to the earlobe. The positive electrode is placed posterior or inferior to the earlobe.

View Figure

The c orruga ted s uperc i li i mus cle s hould be obs erv ed (185). W ith A CG, the transduc er sh ould be placed i n the mi ddle of the supe rc il ia ry arc h (182). The f aci al muscl es are rel ativ el y res is tan t to NMB drugs (180,186). Therefore, mana ging NMB b y s timul ating the fac ial ne rv e wi l l re sul t in g rea ter relaxa tion than f rom s timulati ng a l imb nerv e if equiv al ent res pons es are used. The faci al ne rv e

shoul d not be us ed to as ses s rec ov ery from NMB because the responses may s how co mple te recov ery wh ile s ignifican t NMB is s till p res ent (182 ,183,184,187 ,188,1 89).

Mandibular Nerve
The man di bular nerv e , a bra nch of the tri geminal , s uppl ies the mas seter musc le . It can be s timulated by pl aci ng th e nega tiv e elec trode anterior and inferi or to the zy gomatic a rc h and by plac ing the p osi tiv e elec trode on the fo rehead. S timulation caus es the jaw to c lose . The ons et of N MB in this musc le is fas te r than in the hand musc les (19 0,191). In ad ul ts , this musc le is more sens i tiv e to both depolariz in g and nondepo la ri zing drugs than the hand musc les (19 0,192). In ch il dren, the sens i tiv i ty may be equal (191 ).

Spinal Accessory Nerve

The s pin al ac ces sory nerv e c an be s ti mula ted b y p lac ing the elec trodes ov er the depression between the ra mus of the mandible and the mas toid p roc ess / s ternoc leidomas toid mus cl e (193 ). S timula tion causes the s ternomas toid and trapezius musc les to con trac t. P .818 This can c aus e s houlder and thorax mov emen t with trans mis sion to the abdomen (194).

Recurrent Laryngeal Nerve

The recu rrent larynge al ne rv e i nne rv a tes mos t of the i ntrins ic musc les of the larynx (110). It c an be s ti mula ted perc uta neous l y b y using two e lec trodes between the notch be twe en the thyroid and th e c rico id ca rtil ages (110,195). The response can be meas ured by plac ing the tracheal tube cuff be twe en the v ocal cords and meas uri ng pres sure c hanges wi thi n the c uff (195) or b y using phonomyog raphy with the mic rophone plac ed in the v es ti bular fold l ateral to the v ocal c ords (14 6). E MG i n the larynx c an be accomplishe d by us ing a s peciali zed tracheal tube wi th i ncorporated wi re elec trodes (1 96) o r an elec trode attach ed to the tube and pl aced between the v ocal c ords (130).

Use Before Induction

P rior to anes thes ia induc tion, the s ti mu la tor s hould be c onnec ted to elec trodes that are posi tioned ov e r the s elec ted nerv e. If EMG moni to ring is to be us ed, the receiv ing elec trodes sh ould be placed at leas t 15 minutes before induc tio n. E lec trode s i tes s hould be dry and free of excessiv e hai r or s car ti ssue or other l esi ons . The sk in sh ould be tho rou ghly c leans ed by us ing a so lv ent suc h as alcoh ol, then comp letel y dried a nd rubbed bris k l y wi th a gauze pad u ntil a s light redness is v isible. The elec trodes s houl d be ch ecked to v erify that the gel is mois t. It is importan t to av oid s pre ading the g el or ov erla pping adhes iv e whi le pl ac in g the el ec trodes . A gel bridge between the el ec tro des can s hort-c i rcu it them and lead to poor s ti mulation . Af ter the leads a re attached to the e lec trode , a piece of tape shoul d be placed ov er the leads to p rev ent mov ement. It is good prac tic e to c reate a loo p to prev en t elec trode displ acement (Fig. 25.18 ).

Induction
Durin g induc tion, the neuromus cul ar s timula to r can be us ed to de termine the ons et time of NMB , detec t unusu al s ensi tiv i ty to re lax ants , and determi ne whe the r or not the patie nt is s ufficiently relaxe d for trac hea l in tu bation . Af ter induc tion of anes thesi a but befo re adminis tering a ny musc le re laxants , the s timu la tor s hou ld be turned ON and set to del iv er s ing le-twitc h s timu li a t 0.1 Hz . Apply ing s ti mulation more frequentl y wi ll make it appear as if the ti me of ons et of NMB is shorter (197 ,198,199). The ou tpu t of the s timu lator s hould be inc reased unti l the res pons e does no t inc rease wi th i nc reas ing c urrent, then inc reas ed 10% to 20%. If max imal s timulation is no t achiev ed with a curren t of 50 to 70 mA , the elec trodes should be checked for prope r placement. If max imal s timul ation s til l cannot b e achiev ed, ne edle elec trod es should be used. Special needle elec trodes are av ai lable c ommerc ia ll y, but ordi nary injec tion needles can be us ed. They should b e short and thin. The needles shoul d be pl aced subc utane ous ly. Ins erti ng them deeper may produce di rec t mus cle exci tation an d/o r caus e damage to the nerv e. The angle of inse rtion s houl d be parallel to the nerv e . The re sh ould be at leas t a few c en timeters be twe en the needles . They sh ould be f ix ed in pl ace wi th tape . The lead should be attac hed to the sha ft of the n eedle unles s the needle has a metal hub. Correc t E MG elec trode placemen t should be v erified by observ ing the qual i ty of the ev oked wav eform, whic h should app rox ima te a si ne wav e . The ga in co ntrol s hould be ad jus te d s o tha t th e wav eform oc cupi es the fu ll s cal e.

Intubation
Complete relax ation of the j aw, l aryngeal an d pharyng eal mus cles , a nd diaphragm i s needed for excellent intuba ting condi ti ons and to re duce the risk of trauma. It shoul d be k ept in mind tha t the res pons e to in tubation is a func tion of both musc ul ar block and the lev el of anes thes ia . It P .819 i s poss ible to intuba te a patient wi th l ess -than-co mp le te paral ys is if a suffici ent depth of anes thes ia is presen t (2 00).

Figure 25.18 Electrodes in place. Creating loops and securing the wires with tape will decrease the likelihood that the wires will be pulled off the electrodes.

View Figure

The onset of NMB wil l be f as ter i n centra ll y located musc les s uch as the diaph ragm, facial, l aryng eal , and jaw musc les than pe riphe ral musc les such as the adduc tor poll icis (110 ,190,201,202 ,203,204,205 ,206,2 07,208,20 9,210). The diaphragm, eye mus cl es , and mos t laryngeal mus cles are mo re resis tant to nondepo la ri zing re lax ants tha n are pe ri pheral muscles (211,212 ). Th e d iaphragm is resis tant to s ucc in ylchol ine, thou gh th e l aryngeal mus cles are s ensi tiv e to it. The mass eter musc le is relativ el y sens itiv e to bo th nondepola ri zi ng and depolari zing relaxants (192,213). It of ten reac ts wi th i nc reas ed tone ins te ad of re laxatio n to succi nylch oline , partic ul arly in chil dren. Moni tori ng the res ponse of the eye mus cles wil l refl ec t the ti me of ons et and the l ev el of NMB at the ai rway mus cul ature mo re c lose ly than moni tori ng pe ri pheral musc les , whi ch wi l l unde res ti mate the rate of onse t of NMB in the ai rwa y

musc ul ature an d may ov eres tima te the degree of b lock (163,179 ,202,214,215,216,217,218). If the f acial nerv e c annot be us ed, a pe ri phe ral nerv e wil l suff ice in mos t cas es . In the majo ri ty of patients , disappearanc e of th e adduc to r pol lic is response is as soc iated wi th good to ex cel lent i ntubating c ondi tions . If the elec tromy ographic respons es are being moni tored, moni tori ng at the hy pothena r emi nenc e ma y be prefera ble (157 ). W hatev e r nerv e is used, it is recommended th at si ngle twitc h at 0.1 Hz be us ed and that the cl in ic ian wa it unti l a response is barely perc eptib le before attempting l ary ngos cop y and in tubation . More rapid s timul ation ma y acce le rate the o nset of block a t the s timul ated s ite (198,199). Double b urs t has be en used as a n i nd ic ato r of optimal c ond itions fo r tracheal intubation (219). The resp onse to s ti mulation wi l l us ual ly disa ppea r for a v ariab le peri od of time, then appear and inc rease progress iv ely to ful l recov ery. A dd itional relaxants s hould not be giv en unti l th ere is ev idence of s ome rec ov ery to mak e s ure that the pa tient does not hav e an abnorma l response. Ho wev er, i t is not nec ess ary to wai t fo r co mple te recov ery befo re giv ing additio nal relaxan ts .

Electroconvulsive Therapy
A common erro r in elec troco nv uls iv e therapy is deliv ering the el ectric al s ti mulus prematurely (220). It is rec ommended that a s ingle s timul us be appli ed at 1 Hz to the pos terio r ti bi al nerv e (221 ). W hen there is c omplete abol ition of respo nse, the elec troconv uls iv e th era py should be a pplied.

Maintenance
Durin g ma in tenance , th e s ti mulator can be used to ti trate the re laxant dosa ge to the needs of the ope rativ e procedure so bo th un der- and ov erdos age a re av oided. Too deep an NMB may mak e it d iffic ult to rev erse the relaxant at the terminati on of the anes thetic . Unde rdosage may resu lt in inadequate relax a ti on or undes irabl e patie nt mov ement. In a s tudy of cl osed c laims aga ins t anes thesiologis ts , e ye in juries cons tituted 3% of cl ai ms (222 ). P atient movemen t during anes thes ia wa s the mechanism of injury in 30% of those cas es . P eriph era l nerv e sti mula tors were not us ed in an y patien ts who made c laims for mov ement under anes thes ia . The degree of NMB required du ring a surgical p roc edure depends on many fac tors , i ncl uding the type of su rge ry, the an es thetic tec hnique, and the depth of anes thes ia. It is impo rtant to prev en t coo li ng of the moni toring si te to av oid

i mpai red nerv e c onduc tion o r inc reased sk in res is tanc e, whi ch may resul t i n ov eres timation of the degree of NMB (26,223,224). It is important to c orrelate the reac tion to ne rv e s timulation wi th the patient's c linic al c ondi tion bec ause the re may be a disc repanc y be tween the degree of relaxation of th e mo ni tored musc les a nd that of the musc les at the s ite of s urgery . If the s urgeon bel iev es that relax ation is inadequate, the anes thes ia p rov ider shoul d conf i rm tha t th e depth of anes thesi a is s uff icient an d the de gre e of NMB is adequate. It s hould be confi rmed that the s ti mu la tor is work ing properly . If it does not display the deliv ere d c urrent, elec trodes may be plac ed on the user's a rm and a l ow c urren t used to confi rm proper func tion. TOF is c ommonl y regarded as the mos t useful pa ttern f or mon itoring NMB during mai ntenance. S upramax imal c u rrents are tra ditionall y us ed . A s ubmax imal c urrent may be us ed, b ut this is con trov ersial (15,18,19,30 ,10 4,225,226). Th e goal f or mos t cases in whic h abdominal musc le relaxation i s requi red s houl d be to maintain at l eas t one response to TOF s timula tion i n a pe riphe ral nerv e (227,228). If no respons e is p res ent, f urther admin is tration of relax ants is no t indic ated. If two respons es are presen t, abdominal relax ation may be ad equa te us ing balanced anes thes ia (229). P resenc e of three twi tc hes is usual ly associ ated with adeq uate relaxation if a v olatile anes thetic agent is us ed. Deeper l ev els of NMB may b e requi red f or upper a bdomi nal or c hes t s urgery or if diaphragmatic pa ralys is is needed. If the fac ial mus cles are used, a t leas t one twi tc h sho uld be added to the mentioned recommendations . Musc le relaxan ts are someti mes adminis te red i n cas es suc h as eye surgery or l ase r su rge ry on the v oc al co rds to guarantee that mov ement d oes not occ ur. T o ens ure total diaphragma tic paral ysis , the NMB shou ld be so intens e that the re is no respons e to pos t-tetanic P .820 s timu la tion (i .e., the PTC is 0) (2 30,231). One ap pro ach is to giv e a bolus of a short-a c ting mus cle relaxa nt when the P TC i s 1 (232 ). A l ternativ ely, the twi tch respons e at a res is tant musc le such as the orbicularis oc ul i may be moni tored and a dos e o f relax ant g iv en as soon as the re is a ny res ponse.

Recovery and Reversal

A t the end of a p roc edure, a s timulato r allows the anes thesia prov ider to determi ne whe the r or not the b loc k is rev ers ibl e and adjus t the d ose of rev e rsa l agent, if

requi red, to the pa tient's requ irements (233). Numerous s tudi es hav e sho wn tha t so me pati ents enterin g the pos ta nes thes ia c are unit hav e an unacc eptabl e lev el of block (69,234,235 ,236,237,238 ,239,2 40,241,242,2 43,244,245 ,246,247,248 ,24 9,250,251 ,2 52,25 3). A ne rv e s ti mulato r may detec t res idual NMB , wh ic h c ould lead to l ifethreatening c ompl ications (74 ,254,255,256 ,257,258). W hen relaxation is no long er requi red , adminis trati on of NMB drugs should b e disc ontinued. A s recov ery progresses , the res pons es to TOF wi ll progressiv el y appear, th en fade wil l disappea r. The ease of rev ers ing a nondep olari zing block is i nv ersely rela ted to the d egree of block a t th e ti me of rev ersal (6,259). If the f irs t t witc h (T 1 ) is pres ent, i t can be estimated how qu ic k ly the bl ock c an be rev ersed. The time depends on the relaxan t that has b een used. Rec ov ery is g ov erned by the se nsi tiv i ty of th e musc le and ra te that the drug disap pears from the p las ma. It is bes t to use a peripheral mus cle to moni to r recov ery , bec ause i ts c omplete recov ery would indic ate that res idual mus cular wea knes s contribu ti ng to problems wi th ai rway patenc y or res pi ra tion is u nlike ly (110,188 ,202,205,260,261,262). The probabil i ty of detectin g fade by us ing the i ndex finger is greater than if the thumb or g rea t toe is use d (71,73 ). In the pas t, many inv es tigators thought that a T OFR of 0.7 was adequate (4,263 ). Howev er, a normal response to h ypox emia , protec tion f rom pulmon ary co mplica tions , and absenc e of heav iness of the eyel ids , v isual dis turbanc es , diff icul ty s wal lowing , or pa ti ent a nxiety ma y require a higher ratio (4,264,265,266 ,267,268,269 ,27 0,271,272 ,27 3). Mos t inv estiga tors now re commend that the TOFR at the adduc tor pol l ic is be a t leas t 90% measured by mechanomyography befo re ex tub ation (248,266 ,275,276). This is p robabl y mos t reliably ac compl ished by usi ng A CG and achiev ing a TOF R at leas t 90 % of the basel in e (68,91,92 ,254,257,277,278,2 79,280). If E MG monitoring is being us ed, resi dual anes thetic ef fec ts usual l y p rev ent the retu rn of T 1 to the preanes the tic refe rence lev el , but the TOF R shoul d exc eed 90% (281). Res idual NMB cannot be relia bl y detec ted by us ing TOF s timu la tion if v isual and/or tac tile moni to ri ng is used (19). Detec tio n ma y be s omewha t better when us in g DB S (30,31,52,282). B oth may be more rel iabl e a t detec ting fade at lower c urrents (19 ). Cl in ic al c riteria i n an awak e pati en t hav e been used to asc ertain whether the retu rn of musc le s trength is adequate. These inc lude the abili ty to (a ) open the eyes for 5 seconds and not experi ence diplopia, (b) s us tain tongue protrus ion , (c ) sus tai n head lift for a t le as t 5 s econds , (d) s us tain hand grip, (e) s us tain leg l ifting in

ch il dren, (f) c ough effec tiv ely, an d (g) s wallow. A more sens itiv e tes t may be the abil ity to resis t remov ing a tongue bla de from c le nched tee th (268). Cl inical c riteria i n a n as leep pa tient i nc lude an adequate tidal v olume and an inspi ra tory fo rc e o f at l eas t 25 cm H 2 O nega tiv e pressu re. S ubjec ti ng the p atient to ne gativ e ins piratory press ure c an c aus e pul monary edema . Thes e c li nica l c riteria do no t exc lude c linic al ly s ignif ic ant res idual pa ral ys is (248,272 ,283).

Postoperative Period
Ev en if a ne rv e s timul ato r has no t been us ed durin g an operatio n, i t can be us ed pos toperativ ely . If the pa ti ent is not full y anes the tized , it is preferable to use less than sup ramaxi ma l s timu lation (1 5,29,284). This dec reases the discomf ort as soc iated wi th s ti mu la tion and may improve the v is ual assessmen t acc urac y (30).

Long-term Muscle Relaxant Infusions

Long-term muscle relax ants i nfus ions a re so metimes us ed in c ri tical care a reas . NMB moni to ri ng should be used to av oid overdos age (285,286 ,287,288,289,290,291,292). A numbe r of fac tors unique to the c ritical c are se ttin g affec t the response to NMB drugs (12,286 ). P rolonged paralys is is so me times se en despite moni to ring (293,294).

Nerve Location
A perip heral ne rv e s ti mula to r may be used to locate nerv es f or regional b lock (2 95). The c urrent needed is far below that ne eded for moni tori ng NMB . S timula to rs wi th different c urrent outputs for both f unc ti ons a re av ailable (2 96,297).

Hazards Burns
Burns hav e been reported when usi ng a s timula tor with me tal ball el ectrodes (298). Needle elec trodes may be associated with loc al tis sue bu rns f rom elec trosurgical units because they prov ide goo d contac t wit h mini mal res is tance for ex i t of high f requenc y curren t ov er a s mal l are a of sk in (299). S ev ere bu rns resu lting in permane nt loss of hand f unc tion caused by a nerv e s timu la tor h av e be en reported (300). P .821

Nerve Damage

The pres sure of an el ec trode on a nerv e can resul t in palsy (154). Thumb pares thesi as were repo rted in pa tients whos e muscular func tion was mon itored by us ing an MMG (3 01). Nerv e damage c an res ul t from intraneural p lacemen t of a needle e lec trode .

Complications Associated with Needle Electrodes

Compl ications ass ociated wi th needle e lec trodes i nc lude inf ec tion, b le edi ng, and pain.

Pain
Patient disc omfo rt wi l l be reduc ed by us ing l ower c urrents and av oiding tetanic or double-burs t s timu lation when the patie nt is not ful ly anes thetized (16,18).

Electrical Interference
The use of a nerv e s timu la tor ma y c aus e c hanges in the E CG tracing or i nterfere wi th an impl anted pac emaker (302,303,304,305).

Incorrect Information
W ith s ome s timula tors , when th e batteries are l ow, on ly three pulses are genera ted during TOF s timulatio n (306 ). T his c oul d lea d to incorrec t i nte rpretation of th e degree of NMB . A potentiall y confus in g user i nterfac e on a n euromusc ular trans mis si on module has been rep orted (307). The mod ule prov ided a bar graph v isua l indication of th e fou r respons es to TOF s ti mul ation. Howev er, if the res ponses we re greater than 120% of the control respons e, the ba r graph rep res entations were c hopped off . As a res ul t, al l four t wi tc hes cou ld appear to be of the same heigh t when the TOF rati o was below 100%.

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Questions
For the fol low ing ques tions , s elec t the co rrec t answer 1. T he w aveform fo r stimulation shou ld be

A . B iphas ic B . Rounde d C. Monophasic D. S loping E . No tch ed V iew A ns we r2. The tw itc h freq uency for the T OF s timula tion is A . 1 Hz f or 1 sec ond B . 2 Hz f or 2 sec onds C. 2 Hz for 1 sec ond D. 1 Hz for 2 sec onds E . 3 Hz f or 2 sec onds V iew A ns we r3. The time interval betw een T OF stimulatio ns should be at least A . 4 seconds B . 8 seconds C. 12 s econds D. 20 s econds E . 22 s econds V iew A ns we r4. The frequency of single-tw itch stimulation should not exceed A . 0.01 Hz B . 0.1 Hz C. 1 Hz D. 1.5 Hz E . 10 Hz V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

5. T OF s timulation A . Can be used if onl y one twitc h is pres ent B . Can be used to determine rev ers ibili ty f ro m NMB

C. Can b e mo nitored by A CG D. Shoul d be performed onc e ev ery 5 seconds V iew A ns we r6. S upramaxinal stimu latio n refers to the A . V oltage us ed to s ti mula te the nerv e B . Cu rrent us ed to s timul ate a nerv e C. Vo ltage abov e that nec es sary for maxima l s timu lation D. Current hi gher th an th at needed for max imal s timu-lation V iew A ns we r7. S ing le-tw itch s timula tion A . Cannot dis tinguis h betwe en depola ri zing and nondepola ri zing bl ock s B . Is useful for i de ntif ying satis fac to ry c ondi ti ons for i ntubation C. Is not useful f or as sess ing rec ov ery from NMB D. Is not useful to determi ne supramaxi mal s timu lus V iew A ns we r8. Factors affe cting the T OFR include A . Th e nature of the NMB (depol arizing o r nondepol arizing) B . Depth of the NMB C. The n erv e being moni to red D. An upper-motor-neuro n l es io n V iew A ns we r9. Advantages o f T OF stimulation in clu de A . It is mo re sens i tiv e than the singl e twi tc h B . It can d etec t a phas e II block C. It can d is tinguish be twe en depo lari zing and nondepola ri zi ng blocks D. It i s eas y to detect fade wi th v isual or tac tile methods V iew A ns we r10 . DBS A . Cons is ts of two s hort te tanic s timul i sep ara ted by 750 ms B . Is primaril y used to determine resi dual NMB C. Is more s ensi tiv e than TOF s ti mu la tion fo r determi ni ng f ade D. Causes less disc omfort than TOF s ti mulati on V iew A ns we r11 . With tetanic s timula tion, A . If no relaxants are present, there wi l l be a c on trac tion fol lowed by relaxatio n of the s timulated musc les B . If there is a depo la ri zing block , the re wi ll be a s us tained co ntrac tion of lower magn itude C. P rofound bloc k wil l show musc le mov eme nt af te r 10 sec onds of s timulatio n D. If a nondepolariz in g b lock is p res ent, there wi l l be a nons us tained c ontrac ti on of the musc le

V iew A ns we r12 . For teta nic stimu latio n, 50 Hz is mos t often use d bec ause A . It is mo re phys iologic B . If the freque ncy is greate r than 50 Hz, the fade wil l be les s p ronounc ed C. If the frequenc y is les s than 50 Hz, the fa de wil l be more pronounced D. It s tresses the neu romuscul ar junc ti on simi lar to a v ol untary eff ort V iew A ns we r13 . P ost-tetanic facilitation A . Is max imal in 3 s econds and las ts for up to 2 minutes B . Is temp ora ry C. Is used to determine the depth of bloc k in profoundly relaxed pa tients . D. Oc curs with depolari zing blocks V iew A ns we r14 . ACG A . Utili zes a pi ezoelec tric sensor that p roduces a n e lec tronic signa l proporti onal to the amoun t of mov ement B . Is useful in pati ents whos e ex tremi ti es are tuc ked C. Requi res a preload D. Can b e i nterfac ed with a c ompu ter V iew A ns we r15 . T he electromyo graph A . Cannot be used to moni tor the diaph ragm B . Measures a biphas ic ac tion in each mus cle s timulated C. Cannot be used wi th mus cles that can not b e used wi th the MMG D. Us es s timul ating elec trod es placed in a s imil ar fashion as other monitoring tec hnologies V iew A ns we r16 . T he facial nerve A . Is relativ el y res is tan t to mus cl e relax ants B . Can be used wi th ACG C. May s how c omplete rec ov e ry when s ignifi cant N MB s ti ll exis ts D. Is usef ul in determin ing the re laxatio n of th e j aw and di aphragm V iew A ns we rP .827

17. During in duction of anesthes ia, A . Th e s ti mulator shoul d be appl ied prior to induc ti on B . Th e fac ia l nerv e is mos t us efu l fo r determining the ti me for intuba tion C. Supra maxi mal s timula tion should be d etermi ned af ter induc tion but befo re the adminis tra tion of relaxan t

D. To de termi ne optimal time of intubation, a nerv e should be s timulated at 1 Hz V iew A ns we r18 . T he PTC A . Is the n umber of res ponses af te r appl ication of a te tan ic s timulus of 50 Hz for 3 seconds B . Is painful f or the patient C. Is di rec tl y pro portiona l to the deg ree of neuromus cular block p res ent D. Is usef ul for asses sing deep NMB V iew A ns we r19 . Needle electrodes A . May b e useful wh en the s k in is cold B . A re useful with hype rthyroid p atien ts C. Carry a ris k of di rec t mus cle s ti mulation D. Shoul d be ins erted pe rpendicular to the n erv e to be s timulated V iew A ns we r20 . Clinical c riteria usefu l to determine the adequacy of re cove ry from NMB include A . A i nspi rato ry forc e o f at leas t -2 0 c m H 2 O pres sure B . S us tained hand gri p C. Sus ta in ed head l if t for 10 seconds D. Adequa te tida l v olume V iew A ns we r21 . Conce rning recovery from NMB, A . Mon itoring the adduc tor poll icis is prefe rable to moni tori ng the orbicul aris ocul i B . DBS is less sens itiv e than TOF moni tori ng C. Recov ery is fas ter in the diaphragm than in adduc tor p oll icis D. Adequa te cl inic al recov ery has occ urred whe n the TOFR is abov e 0 .7 V iew A ns we r22 . Conce rning DBS , A . It cons is ts of two b urs ts of 100 Hz te tanus B . Th e two burs ts are s eparated by 750 ms C. Is not useful in moni tori ng profound NMB D. The DBS ratio has s imi lar properti es to the TOF R V iew A ns we r

Chapter 26 Alarm Devices

The purposes of an al arm are to trans fer informati on , enhanc e v igi lanc e , and warn of a po tential o r ac tual abno rmal o r unus ual condition (1,2,3,4 ). It i s essential tha t there be a means of al erting pe rsonnel to a cha nge or po te nti al c hange in equipment func ti on or the patie nt, for the re wi ll alwa ys be occ as ions wh en operator v igi la nce wi ll be lo were d o r atten tion reduce d while perfo rmi ng other task s . The number of alarms in anes the ti zing areas has inc reased greatly . To add f urther confusi on, alarm s ounds ma y come from sources o the r than from anes thes ia apparatus , inc luding elec trosurgic al equipment, lase rs , heari ng aids, and beepe rs (5,6 ,7). The J oi nt Commiss ion on the Acc redi tation of Heal thcare Organ iz ati ons h as made i t a goal to i mprov e the eff ec tiv eness of alarm s ys tems (8 ,9).

Standards
An inte rna tional s tanda rd for al arm sys tems was publ ishe d in 2003 (10).

Terminology (10)

A larm Con dition Delay : T ime from th e occurrence of a tri ggeri ng ev ent to whe n the al arm s ys tem d ete rmines that a n a la rm cond ition ex is ts . A larm S ignal Generatio n Delay : Time from the onset of an alarm con di tion to the gene ration of i ts al arm s ignals . A larm Li mit: Th res hol d used by an ala rm sys tem to de termine an alarm condi tion. A larm Off: S tate of indefi nite duratio n i n which an alarm s ys tem o r part of an alarm s ys tem does not gene rate alarm si gna ls . A larm P aused: S tate of li mi ted duration in which the a larm s ys tem or pa rt of the alarm s ys tem does not g enerate alarm signals . A larm P reset: Se t of s tored con fi guration p ara me ters , inc ludin g s elec tion of algori thms and ini tial v alues f or us e. A larm Res et: Operato r ac tion tha t causes the c ess ation of an alarm s ignal fo r whi c h no as soc iated alarm c ondi tion cu rrently exis ts . A larm S ettings : A larm s ys tem c onf igura tion, i nc lud ing but no t li mited to ala rm l imi ts , the charac teris tics of any al arm signa l inac tiv ation s tates , and the v alues of v ariabl es or pa rame ters that de termin e the func tion of the alarm s ys tem.

A larm S ignal: Si gnal genera te d b y the alarm s ys tem to indicate the pres ence of an a la rm c ond ition. A larm Sys te m: Parts of med ic al elec tric al eq uipment that detec t alarm condi tions and, as a ppropriate, g enerate ala rm s ignals . Audio Off: S tate of i ndef ini te duration in whi ch the ala rm s ys tem or pa rt of the alarm s ys tem does not g enerate an a udito ry alarm s ignal. Audio Paus ed: S ta te of l imited duration i n which the a la rm s ys tem or pa rt of the alarm s ys tem does not g enerate an a udito ry alarm s ignal. Defaul t Al arm P res e t: A larm pres et that c an be ac tiv ated by the a larm s ystem wi th out opera tor ac tio n. False -negativ e A larm Condi ti on : A bsence of a n a la rm condition when a v ali d tri ggeri ng ev en t has oc curred. P .829

False -posi tive A larm Cond iti on: P resenc e of a n a la rm condition when no v ali d trig gering ev ent has occ urred . Hi gh P ri ority : Indica tes that immediate ope rator resp onse is requi red . Info rmation Signal : Any s ign al that is not an a la rm s ignal o r a reminde r s igna l. E x amples inc lude the tone of the pulse ox imeter or elec trocardiograph, the wav eform of the elec trocardi ograph, and the heart rate numeric .

Intell igent A larm S ys tem: A larm s ys tem that makes logical dec isi ons based on moni tored informati on wi th out operato r in terv en ti on. Intelligent alarm s ys tem methodologi es inc lude analys is of trends , limi t c omparis ons , data redundanc y, data fusi on, rules , fuzz y logic c ontrol lers , and neura l networks .

Latching A larm S ignal: A la rm si gnal that continues to be gene rated af te r its tri ggeri ng ev en t no l onge r ex is ts until s topped by delibe rate operator ac ti on. Low P rio ri ty : Indicates th at ope rator a ware ness is re qui red . Medium P riority : Ind ic ates that pro mpt ope rator resp onse is re qui red . Reminde r Sig nal : Periodic s ignal that reminds the ope rator that the al arm s ys tem is in an a larm s ignal inac tiv ation s tate .

Inhi bi t, s ilenc e, an d s uspend hav e been us ed in pas t terminol ogy for a larms . Unfortun ately , different meanings were attri bu ted to these te rms . For this reas on, these terms wi l l not be used .

Alarm Prioritization
A ll alarms a re not equa ll y imp ortant. The i nforma ti on that an alarm c onv eys may represen t an emergenc y, the potenti al f or an emergency, o r just an unusua l condi tion. P ri oritiz ed alarms help to diff erenti ate life -threatening s i tu ati ons f rom those that a re less urgen t. A larm c ondi tions pri orities are s hown in T able 2 6.1. It may be possible to inc rease the prio ri ty of an ala rm, but the priority c annot be dec reas ed . A high-priority al arm i ndicates a condition th at requi res i mmedi ate ac tio n. Ex ampl es i ncl ude as ys tol e, v entric ul ar f ib ri llation, ca rdiac s uppo rt dev ice (i ntra-aortic balloon pump , c ardiopulmonary by pas s mac hi ne) failu re, hig h a irway press ure , ex treme hypoxemia, and sus tained high-energy radia tion beam. Medium priori ty i mplies a po ten tially dangerous s ituati on tha t requi res a prompt respons e. Exampl es i nclude man y cardiac arrhythmias , high o r lo w b lood p res sure, apnea (u nless prolonged o r ass oci ated with ex tre me h ypox ia ), mi ld hy pox emia , and high or l ow partial p res sure of c a rbon d iox id e (pCO 2 ). A lo w pri ori ty a la rm ind ic ates tha t onl y ope rator awa reness is req ui red . Examples i ncl ude failure of an i nfusi on pump for maintenance in trav enous f lu ids and failure o f an en teral f eed ing pump. The objec t of p rioritization is to minimize dis trac tion f rom less important al arms during an emergenc y. It has b een s ugges ted that only the al arm s ound co rres ponding to the mos t urgent of the prev ail ing alarm conditi ons should be annunc iated; al l other s ounds s hould be temporari ly audio paus ed (2 ). Onc e the mos t urgent alarm c ondi tio n is resolv ed, the s ound c orres pondi ng to the P .830 nex t highes t prio ri ty c ondi tion wo uld then be ini tiated. Th is priori ty interlock should be l imi ted to aud ib le annunc iati on; lower pri ority v isual s ignals need not be suppresse d bec ause they are rel ativ ely u nobtrus iv e.

TABLE 26.1 Alarm Condition Priorities

Potential Result of Failure to Response to the Cause of Alarm Condition Death or irreversible injury Reversible injury

Immediateb

Onset of Potential Harma Promptc

Delayedd

HIGH PRIORITY

HIGH PRIORITY

MEDIUM PRIORITY

HIGH PRIORITY MEDIUM PRIORITY

MEDIUM PRIORITY LOW PRIORITY

LOW PRIORITY

Minor injury or discomfort

LOW PRIORITY or no alarm signal

An information signal may be used to indicate the potential for delayed minor injury or discomfort a Onset of potential harm refers to when an injury occurs and not to when it is manifested. b Having the potential for the event to developed within a period of time not usually sufficient for manual corrective action. c Having the potential for the event to develop within a period of time that is usually sufficient for manual corrective action. d Having the potential for the event to develop within an unspecified time that is greater than that given under prompt. From International Standards Organization. Medical electrical equipment-Part 18: general requirements for safety. Collateral standard: general requirements, tests and guidelines for alarm systems in medical electrical equipment and in medical electrical systems (ISO-IEC 60601-1-8). Geneva, Switzerland: Author, 2003.

Audible Signals
The primary pu rpose of audi tory alarm s igna ls is to ge t the operato r's atten ti on. In additi on, they should help the opera to r to identify the onse t of alarm c ondi tio ns , the urgency of the requi red opera tor res pons e a nd th e l oc ation of the dev ice gene rating alarm s ign als . An aud ib le s ignal wi ll a ttrac t atte ntion f as ter and mo re reli ab ly than one that is v isual (11). Ideal ly , it s hould do this in a timel y, non-s tartl ing, and non-i rritating

fas hion (12). Unfortuna tely, the qual ities tha t c ause sounds to attrac t atten tion als o tend to mak e the m i ntrus iv e o r s tartl ing . S ome are so unpleasant that the res ponse may be to inappropria tel y disable or deac tivate the alarm s ystem. The re are a number of av ailabl e optio ns in a larm s ound technology , includi ng v a ri ations in pattern , pi tc h, tone, f requency, a nd loudness . The international ala rm s tandard s pec if ies the cha rac te ris tic s of aud itory a la rm s ignals (10 ). One problem ass oci ated with alarm sounds i s tha t c l in ic ians ma y not hear them. Bac kground n ois e and other alarms can i nterf ere wi th hearing an a udibl e ala rm s igna l (13). If an a udibl e s ignal is allo wed to c ontinue to sou nd, othe r audi bl e s igna ls may not be notic ed (14,15). An anes th esia prov ider wi th a hea ri ng defic i t may hav e diffic ul ty determin ing the sou rc e of a sound. One s tudy f ound that many anes thes iologis ts hav e an abno rmal audiogram and that 7% had on e o r more al arm i nte nsi ties belo w the detec tabil ity th res hold (1 6). A udi ble a larms should be a djus ted so that the si gna l wi ll be perc eiv ed des pi te background noise. Onc e an a udible s ignal h as been p erc eiv ed, the nex t s tep is to identif y i ts orig in. This is impo rtant because many moni tors are not in the c li nic ian's i mme di ate f ie ld of v ie w, and the operator c annot alwa ys tu rn around to v iew them. Many anes thesi a prov iders hav e trouble identif ying aud ible alarms (13,17,18,19 ). Inab il ity to i den tify an alarm may dela y or prev en t the appropria te remedi al ac ti on (15,20). Af ter an audi bl e si gnal has succeeded i n c apturing attention, aud io paus ing (mu ting, silencing) wi ll prov ide time to co rrec t the si tuation . The continuous presenc e of an audi bl e s ignal c an degrade task p erf ormance and impa ir de tec tion of new ala rm conditions and the abil ity to dis tinguish between exis ting an d new alarm co ndi ti ons . The v isual co mponent of the alarm indicator a nd ass oc iated func ti ons should s ta y ac tiv ated unti l the c ondi tion that tri gge red the al arm is co rrec ted. If another alarm condi tion oc curs whil e an al arm is audio paused, the additi onal ala rm shou ld hav e both audi bl e and v isual indications . Mos t manufac turers p rov ide a means of audi o p ausi ng. The ti me v ari es with the i ns trume nt an d c an sometimes be v aried. Some mon itors i nd ic ate elapsed time. The alarm s tandard requires th at there be a v is ual indica tion that an y a la rm s ignal has been inac tiv ated (10). Some alarms can be turned to A UDIO OF F (defeated, dis abled) for an u nl imi ted time. The v olume of s ome al arms c an b e dec reas ed to a point wh ere the audible s igna l cannot be h eard (21). Us ing AUDIO OFF o r lo w v olume is dan gerous , as ei th er ca n l ead to a fals e -negativ e a la rm.

Visual Signals
V isua l s ignals hel p the operator l ocate the e quipment where res pons e o r awarenes s i s needed and identif y the s pec ific a la rm c onditio n. The ir p rinc ipa l dra wbac k is that they can g o unrecogn iz ed fo r a much lo nger ti me than au di ble s ignals (22). In a s i tuation wh ere the in div idual res pons ible fo r re ac ting to an al arm is required to us e his or he r v ision for oth er tasks , a v isual message may go unnoticed. It may not be possible f or the indiv idual to turn and look at th e source of the al arm (e.g ., during l ary ngos cop y). Graphic al s ymbols for ala rm s ys tems f ro m the in ternational s tandard are shown i n Figure 26.1 (10). Tab le 26 .2 s hows the c olor and f lashing requi rements for a larm ind ic ato r lights or graphica l s imulation of indic ato r ligh ts in the internationa l s tandard (10). The al arm s tandard also requi res th at the presenc e of an alarm condi tion an d i ts p riority be co rrec tly pe rc eiv ed from a dis tance of 4 m and be legi ble f rom at leas t 1 m f rom the operator's pos i tion .

Alarm Organization
Alarm mess ages s ometimes a rriv e i n an uno rga ni zed pattern . The s ingle, i ntegrated display is des ign ed to ai d alarm identification. Th us , anes thes ia pe rso nnel need to l ook in only one pl ace to identif y p rob lems . P .831

P .832 A disadv antage of this is that a c rowd ed display may be di fficul t to read during a c ris is . It may not be p ossible to i ntegrate all mon itors into a s ingl e dis pl ay.

TABLE 26.2 Characteristics of Alarm Indicator Lights

Alarm Category HIGH PRIORITY MEDIUM PRIORITY

Indicator Color Red Yellow

Flashing Frequency 1.4 Hz to 2.8 Hz 0.4 Hz to 0.8 Hz

LOW PRIORITY

Cyan or yellow

Constant

Figure 26.1 Graphic symbols for alarm systems. (From ISO IEC 60601-1-8, Medical electrical equipmentPart 1-8: general requirements for safetycollateral standard general requirements, tests and guidelines for alarm systems in medical electrical equipment and in medical electrical systems, 2003 ).

View Figure

Alarm Limits
An al arm l imi t (set poin t, threshold v alue, thre shold, s etti ng) may be nonadjus table , ope rator-ad jus table , or an algo rith mic all y determined c ri terion (12). The

alarm s tandard requires th at if an ope rator-adjustable a la rm limit is prov ided , the l imi t s hall be indic ated continuous l y o r by ope rator ac ti on so that i t c an be determined if the se t v al ues a re app rop riate f or the pati ent a nd procedu re (10) (Figs . 26.2, 26.3). Defaul t al arm l imi ts can be se t by th e ma nufac turer, the health care fac ili ty , or the operator. Those set b y the manufac ture r may be def aul t v alues or may be brack eted around the v alue of a monitored v ariable a t a point in time, recen t v alues of a moni tored v ariab le , or a current c ontrol s etti ng (10 ). Mo s t moni tors al low the operator to al ter the default settings . Rea lis tic alarm l imits need to be set. W ide li mits res ul t in fewer f alse alarms b ut i nc reas e the risk of mis s ing a true ala rm (go od spec if ici ty bu t poor s ens itiv ity) (12). W ith pressu re and v olume ala rms during arti fic ial v entilatio n, a lo w s etting may resul t i n a partial disc onnec tion or s mal l leak being missed . Cons tric ti ons i n the breathi ng s ys tem that inc reas e res is tance can cause the ai rway pres sure to remain abov e a lo w al arm s et po int althou gh a total d is connec tion would p robabl y not be missed (23). Ens uring that an a la rm is ac tiv ated before a d ange rous cond ition has occ urred wi th out c reating frequ ent spuri ous ala rms re qui res intel lige nce on the part of bo th the alarm s ys tem and the ope rator. Some ope rators set l imits to ex tremes unl ikel y to be e ncountered c li nical ly. The farthe r th res hol ds are from normal v alues , the greater the probab ility that a dan gerous condi tion wi ll occu r withou t ac tiv atin g the alarm. Others s impl y use the limi ts se t by th e las t person wh o used the dev ice. Others k eep the th res holds c lose to the man ufac ture r-preset l imi ts . It is good prac tic e to rec ord ala rm li mits on the anes thes ia reco rd. This prov ides ev ide nce that the alarms we re ac tiv ated. It may also i nc reas e the op era tor's awa reness of the alarms and/or mak e i t more likely that appropri ate v alues wi l l be us ed. It is poss ible that the set a la rm limits may be recorded i n the elec tronic record.

False Alarms
Ac tual al arm malfunc tions are rare (24,25). The anes thes ia prov ider c an reduc e the numb er of false-pos itiv e and fals e-negativ e alarms b y c arefull y preparing the pati ent interfac e, securel y a ttach in g p robes, s elec ting monitors with arti fac t rejec tion c apab il ities , us ing wider li mi ts , incre as ing the ala rm s ignal gene ration delay , and tailoring the alarms to the patie nt or o peration (25,26,27,28,29). Pos itioning the puls e ox imeter probe away fro m el ec trosurgery

P .833 wi res may a ls o help, as may loca ti ng th e e lec trosu rge ry groun ding pad fa r away f rom the puls e oxi meter probe and e lec troca rdiog ram elec trodes (30).

Figure 26.2 Alarms limits are displayed continuously to the right of the values for the parameters. (Picture courtesy of Draeger Medical, Inc.)

View Figure

Figure 26.3 The complete set of alarm values is displayed. To display the alarm limits menu, the alarm limits soft key (1) is pressed. The menu (2) lists the parameters, their current measured values (larger numbers), and the current low and high alarm limits. The alarm limits also appear on the curves as dashed lines (3). (Picture courtesy of Draeger Medical, Inc.)

View Figure

False-positive Alarms
Many a larms are s purious . Onl y a smal l number i ndicate ac tual risk (31,32,33,34,35,36,37,38,39,40 ).

An al arm ac tiv ated wi th out prope r cause req ui res time and effort to c heck the ac tual c ondi tions . This wil l res ul t in less atten ti on to o the r tas ks and may l ead to an i napp rop riate ac tion . False-pos itiv e alarms are a s ourc e of i rri tation and dis trac tion and a re a th rea t to pa tient c are , bec ause the anes thesi a prov ider becomes i nc reas ing ly l ik el y to ignore the s ign als , lower the alarm v olume , tu rn OFF the enti re al arm s ys tem, us e the A UDIO OFF or A UDIO PAUS E wi th out look ing for the caus e, or s et the alarm li mi ts at such ex tremes tha t the ala rm s ys tem is effec tiv el y disab le d (12,41,42 ,43 ,44 ,45 ). F als e-posi tive al arms may frighten patie nts an d rela tiv es . False -posi tiv e al arms a re a fac t of life. While there are s trategi es for minimi zing them, they cannot be entirely eli mi nated. False -posi tiv e al arms ma y b e c aus ed by alarm malfunc tion, artifac ts , ex traneo us sounds be in g mis take n for a larm s ignals , an d inappropria te s et points . The s tart-up s equence on equipment c an p rev ent false-pos itiv e ala rms . Medical equipment that automatica ll y enables the alarm s ys tem when a patie nt is connec ted to the equip ment wh en a v al id phys iologic si gnal is f irs t de tec te d, or through a n admi t new patient func tion activ ated by the operator wi l l dec rease the number of such al arms . False alarms may be reduced b y c hangin g ala rm li mits at c ertain times, s inc e c linic al ranges v ary during different phas es of anes thes ia (46). For ex ample, the high hea rt rate a la rm li mit migh t be set higher du ri ng intubatio n than duri ng mai ntenance. The A LARM PA USE D s ta te c an b e used to av oid nuisance al arm signals before performing an ac ti on th at is likel y to c ause an a larm c ondi tio n (10,38). Ex amples of such ac tions are intenti onal breathing s ys tem dis connec tion to perf orm ai rway suc tion ing , opening a transducer to ai r for zero c al ib ration, intubation, an d tryin g to res tore s pontaneous breathing at the end of a c ase. Moni tors wi th a rtifac t rejec tion suc h as pulse oxi meters wi th mo tion-re sis tant algori thms c an dec reas e the P .834 numb er of false-pos itiv e al arms (47,48,49,50). Fi ltering in the alg ori thm that is moni tori ng for an alarm condi tion of ten caus es alarm condi ti on del ay (10). For i ns tanc e, a hea rt rate mon itor c an av erage the R-R interv al f or sev eral heartbea ts . An abrupt c hange in R-R i nterv als wil l no t immedia tel y ca use an alarm condi tion, becaus e i t wi l l take s ev era l consecu tiv e heartbea ts for the calculated hea rt rate to

ex ceed the alarm limi t. S ome elec troc ard iogra m moni tors hav e automatic lea d s wi tching so that monitoring c an conti nue ev en if one or two e lec trodes come OFF. This can d ec rease false-pos itiv e ala rms . False alarms can be reduc ed by in tegrating moni to rs (38,51). An example is s ynchroni zi ng the pulse ox imeter an d noni nv asiv e blood press ure monitor. If the ox imeter probe is on the same arm as the bl ood press ure c uff , no alarm wi l l sound i f no pulse is detec ted when the c uff is infl ated. An other exa mple is the pulse ox imeter and elec troc ard io gra m (ECG). SpO 2 v alues a re rejec ted u nl ess the pulse rate measured on the ox ime te r matc hes that o n the ECG.

False-negative Alarms
If an alarm s ys te m fails to generate a s ignal wh en it s hou ld (false negativ e), the pati ent's s afe ty may be threatened . A n alarm c ondi tion may be re jec ted o r mis sed becaus e o f spu ri ous i nforma tion produc ed by th e patien t, the patient-equipment i nte rface , other equipment, or the equ ipment i ts elf . Ano the r caus e is the alarm being turn ed OFF. Su bsequent users may not be aware that i t has been tu rned OFF. Automatic enabl ing is p res ent on man y newer moni tors . Once a moni tore d para mete r is s ense d, the alarm bec omes ac tiv e. This el imina tes the probl em of fo rge tting to turn an alarm ON or no t being awa re that an alarm has been turn ed OFF by a prev ious use r. Ap pro priate appl ication of reminder s igna ls s houl d reduce the chance th at the al arm s ys tem is uni ntentio nally lef t in an alarm s ign al inac tiv atio n s ta te (10). Speaker fail ure , setting the audible v olume too low, and s e tting the alarm l imi ts too wi del y may also cause fa lse -negativ e ala rms (52). False -negativ e ala rms may be reduc ed by not s etting the li mits too wi de ly, us ing the AUDIO PA USE rather than the A UDIO OFF s tate , and ch eck ing alarm s ys tems at regu la r interv als to detec t problems suc h as a fau lty loudspeake r or l ow audible v olume that c an resul t in a n audi bl e s ignal n ot being he ard .

Intelligent Alarm Systems

An inte ll igent (s mart, expe rt) alarm s ys tem may do one or more of the fol lowi ng wi th out opera tor interv en tion: d ete rmine an alarm co ndi ti on on the bas is of time , wei ghtings , multiple v ari ables , or other adva nced proc ess ing; gene rate alarm s igna ls for t wo or more a larm c onditio ns of equal p ri ori ty; change the prev ious ly as s igned prio ri ty o r rel ativ e prioriti zation of a particular a larm c ondi tion; ch ange the alarm s ign al generation de lay o r alarm c onditi on del ay; chan ge the c harac teris tics of the generated a la rm s ignals (e.g., to indica te a cha nge in u rgenc y ); prov ide the

operator wi th a l is t of c ondi tions tha t could hav e trig gered the a larm(s ); a nd present i nfo rmati on tha t is helpfu l in deal ing wi th the c ondi tion that tri gge red the al arm (36,46,53,54,55,56,57,58,59,60 ). S mart alarms c an reduce the numbe r of f alse al arms by d isc riminating be twe en arti fac ts and trul y threatening c ondi tions . Human resp ons e times are l ong er and hav e greate r v ariabili ty wi th c onv entional alarms than intel ligent alarms (61).

Alarm Condition Logging

Many modern mon itors and life-s upportin g equi pmen t are equi pped wi th alarm condi tion logging. Logg ing c an be used to determi ne the cause of a trans ie nt alarm condi tion, for q uality ass urance pu rpos es, to s tudy c ri tical incidents , a nd to determine when an al arm condi tion oc curred . The log shou ld incl ude the v alue of the v aria ble that c aus ed the alarm c ondi tion, the ala rm limi ts , and th e ala rm s tatus (ON, A udio Paus ed, Paused , Audio Off , etc ). This i nfo rmatio n can then be made av ailab le if a problem occurs .

References
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17. Fin le y GA , Cohen AJ . Perc eiv ed u rge ncy and the anaes thetis t: res pons es to co mmon operating room moni to r alarms . Can J A naes th 19 91;38:958 964 . [Med li ne Link ] 18. Griff i th RL, Rac iot B M. A surv e y of practic ing a nes thes io logis ts on audi tory alarms in the operating room. In: He dley-Wh yte J , ed. Opera ting room and in tensiv e ca re alarms a nd information transf er (S TP 1152 ). Ph il ade lph ia : Ameri can S ociety for Tes ting and Materials , 1992 :10 18. 19. Loeb RG, J ones BR, Leon ard RA , e t al . Rec ogni tion ac curacy of curren t operati ng room alarms . An es th Anal g 1992 ;75 :49950 5. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 20. Andrzejows k i J , Freeman R. Oxygen failure a la rms on mode rn anaes thetic machines . A naes thesia 2002;57:931 932 . [Fu ll tex t Link ] [Med li ne Link ] 21. Anonymous . Cri tica l alarms : patients as ri sk . Tech nol Anes th 1996;16 (10 ):1 6. 22. Morri s RW , Montano S R. Res pons e times to v isual and a udi to ry al arms duri ng anaes thes ia . Anaes th Intens Care 1996 ;24 :682684. [Med li ne Link ] 23. Anonymous . Mini -set v entil ator alarms can be lethal . Technol A nes th 1999;20:12. 24. Anonymous . Why ala rm-rel ated probl ems reall y happen. Tech nol Anes th 2002;23:18. 25. Wats on MO, Sanders on P M, Russ el l W J. Ta iloring rev eals informa tion requi rements : the cas e o f ana es thes ia alarms . In te rac t Comput 2004 ;16 :271293. [Cross Ref] 26. Anonymous . Delay c i rc uit ma y reduc e pulse ox ime try false al arms . B iomed Saf e S tand 1992;22:162 163. 27. Anonymous . Noise pollu ti on in the op era ting room f ro m monitor al arms . Techno l Anes th 1 993;13(10):3 .

28. Ahlborn V , Bohnhors t B , P e ter CS , et al. Fa ls e a la rms in the neonatal i ntens iv e ca re uni t: c ompa rison be twe en 3 modular moni toring s ys tems . Ac ta P aediatr 2000;89:571576. [Cross Ref] [Med li ne Link ] 29. Seagull FJ , S anderson P M. A nes thes ia alarms in co ntex t: an obs erv ation al s tudy . Hum Fac tors 2001 ;43 :6678. [Cross Ref] [Med li ne Link ] 30. B lock FE , De tko GJ . Min imi zing in terference and false alarms f rom elec trocau tery in the Nellc or N-100 pulse ox ime ter. J Clin Moni t 1986;2:203 205. [Cross Ref] [Med li ne Link ] 31. Kosk i E MJ , Makiv irta A , S ukuv aara T, et a l. Frequenc y and rel iabi lity of alarms i n the moni toring of cardiac pos toperativ e patients . Int J Clin Moni t Comput 1990;7: 129133. [Cross Ref] [Med li ne Link ] 32. Scha af C, Bl ock FE . Ev al ua tion of alarm s ounds in the operating room. J Cl in Moni t 19 89;5:300301. 33. O'Ca rrol l TM. Surv ey of al arms i n an intensiv e the rap y uni t. A naes thes ia 1986;41:742744. [Cross Ref] [Med li ne Link ] 34. Kes tin IG, Mi ller B R, Lock hart CH. Aud itory a la rms duri ng anes thesia moni tori ng. Anes thes iology 1988;69:1 06109. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 35. Lawl ess ST . Cry ing wo lf : fa ls e ala rms in a pediatric i ntens iv e c are u nit. Crit Care Med 1994 ;22 :98 198 5. [Cross Ref] [Med li ne Link ] 36. Ts ien CL, Fackler J C. Poor p rog nosis f or exis ting moni to rs in the inte nsiv e c a re unit. Cri t Care Med 199 7;25:614619. [Fu ll tex t Link ]

[Cross Ref] [Med li ne Link ] 37. Chambrin M-C, Rav aux P , Calv elo -A ros D, et al. Mu ltic entric s tudy of moni tori ng alarms in the adul t i ntens iv e ca re uni t (ICU): a des c riptiv e anal ys is . Intens iv e Care Med 1999 ;25 :13601 366. [Cross Ref] [Med li ne Link ] 38. B lock FE , Sc haaf C. Audi tory alarms durin g anes thes ia mon itoring wi th an i nte gra ted monitoring s ys tem. Int J Cl in Mon it Comput 1996;13:8184. [Med li ne Link ] 39. Wikl ung L M, Hok B , S tahl K , et al . Pos t anes thes ia moni to ri ng rev isi ted : f requenc y of true an d false alarms f rom di fferent moni toring dev ices . J Cl in Anes th 1994;6: 182188 . 40. Yasu moto M, S akuragi T , Maru ta S , et al. Ac tiv ation of apnea alarm b y a su rgical theater l igh t during ophthal mological surgery. An es th A nal g 1997;85 :1414 1415. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 41. Mc In ty re JW R. E rgonomic s . An aes thetists ' us e of aud itory a larms in the opera ti ng room. In t J Cli n Moni t Comput 198 5;2 :4755. [Med li ne Link ] 42. Anonymous . Cri tica l alarms : patients a t ri sk . Tec hnol A nes th 1987 ;7 (10 ):16. 43. Geddes LA . Some ex ampl es of ha zards i n the ope rati ng room. J Clin Eng 1999;24:175186. 44. Lofsk y AS . TURN Y OUR A LARMS ON! APS F News lett 20042005;19(4):43 . 45. Norton RN. S i lenc ed ala rm res ul ts i n ne ar-mis s. APS F News lett 2005;20:42. 46. Myl rea K C, Orr JA , Wes tensk ow D R. In teg ration of moni tori ng f or intell igent alarms in anes thesia: neural ne tworks c an the y help? J Cli n Moni t 1993;9:3137 . 47. Miyasak a K . Pulse ox imetry i n the manageme nt of c hi ldren in the P ICU. Anes th Analg 20 02;94:S44S46. [Med li ne Link ] 48. Ahlborn V , Bohnhors t B , P e ter CS , et al. Fa ls e a la rms in the neonatal i ntens iv e ca re uni t: c ompa rison be twe en 3 modular moni toring s ys tems . Ac ta P aediatr 2000;89:571576. [Cross Ref]

[Med li ne Link ] 49. Hay W W, Rodden DJ , Col lins S M, e t al . Relia bi li ty of conv entional and new pulse oxime try in neonatal p atients . J P e rinatol 2002;22:360366. [Cross Ref] [Med li ne Link ] 50. Malv iy a S , Reynolds P I, Voepe l-Lewi s T, et a l. False alarms an d s ens itiv ity of conv en tiona l puls e ox imetry v ers us the Maxi mo SE T technol ogy i n the pediatri c pos tanes thesia c are un it. Anes th Analg 2 000;90:13361340. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 51. Nav abi MJ , W att RC, Ha meroff S R, et al. Integra ted mon itoring c an detec t c ritical ev ents and improv e alarm ac curac y . J Clin E ng 1991;16:2 95306. [Med li ne Link ] 52. Anonymous . Nel lc or-Various pulse ox imeters : audio a larm failure. Heal th Dev ic es Ale rts 2004 ;28 :5 6. 53. Anonymous . Ala rms i n the opera ting ro om. Can J Anaes th 1 991;38:951. [Med li ne Link ] 54. Fuku i Y, Mas uzawa T. Knowl ege -based app roach to i ntelligen t alarms . J Clin Moni t 19 89;5:211216. [Cross Ref] [Med li ne Link ] 55. Pan PH. Fa ls e alarms dis tri butio n i n i ntraopera tiv e pulse ox ime try. Anes thes iology 1992;77:A 494 . [Fu ll tex t Link ] [Cross Ref] 56. Farrell RM, Orr J A , K uck K , et al. Diffe ren ti al features fo r a neutra l network based anes thes ia al arm sys tem. B io med Sc ienc es 1992 ;28:99104. 57. Orr J A , W es tens kow DR. A bre ath ing c ircui t alarm s ys tem base d on neural networks . J Clin Moni t 1994;10:1 011 09. [Med li ne Link ] 58. Watt RC, Maslana ES , My lrea KC. Al arms and anes th esia c hall enges in the desig n of intell igent s ys tems for pati ent mon itoring . IEE E En g Me d B iol Mag 1993;(Dec ):3441. [Cross Ref]

59. Oberli C , Urzua J , Sae z C, et al . An ex pert s ys tem for moni tor alarm i nte gra ti on. J Cl in Moni t 1999;15:2 935 . 60. Imhoff M, K uhls S . Al arm algorithms in c ri tica l care moni to ring. Anes th Analg 2006;102:152515 37. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 61. Westensk ow DR, Orr J A , S imon FH, et a l. Intelligen t alarms reduce anes thes iologis t's res pons e time to c ritic al faul ts . Anes th esiology 1992;77:1074 1079. [Med li ne Link ] P .836

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. P urposes of an alarm include A . W arni ng of a poten tial or ac tual abnormal or unus ual c ondi tion B . Getting a ttentio n C. Trans fe rring inf orma tion D. Trans ferring legal responsi bil i ty f rom the manuf ac turer to the us er V iew A ns we r2. P roblems ass ociate d w ith de termining the s ource of an alarm include A . Th e hearing of th e anes thes ia p rov ider B . Diffic ul ty in recogn iz ing tone pa tterns C. Noise lev els in the o perating room D. Audib le s ignals that do not s ound continu ousl y V iew A ns we r3. V isual signals A . Giv e less spec ific i nfo rmation tha n audi bl e s ignals

B . May g o unrecogniz ed for a longer pe ri od of time than aud ib le s ignals C. Us e c ontinuous l ights for mo re c ruc ial i nforma ti on D. Requi re the anes thesi a p rov ider to b e l ook ing at the moni tor ins tead of the pati ent V iew A ns we r4. Causes of false-positive alarms include A . Ac tiv ation by an i napp rop riate dev ice B . Ex traneous sounds that s ound l ik e an ala rm s ignal C. A larm malf unc tion D. W idel y set l imits V iew A ns we r5. Means to reduce the incidence of the fa lse -pos itive a larms include A . A l tering al arm l imi ts d uring the procedure B . S y nchronizing monitors C. Delay in g the time between detec tion of an al arm condi tion and al arm ac tiv a tion D. Dec re asing the av eraging time V iew A ns we r6. Concerning ala rm p rioritiza tion, w hich of the follow ing are true? A . Low-p ri ori ty v is ual s ignals need no t be suppressed B . W i th mul tiple al arm c ondi tions , al l alarms wi l l be annunci ated C. A ll al arms are no t equ all y importan t D. A larm pri ori ties may be inc reased or decreased. V iew A ns we r7. The purpose(s) of a la rm s ign als include(s) A . Gaini ng attention B . No tify ing the ope rator of the a la rm urg enc y C. Identify ing the ons et of an ala rm condition D. Identify ing the dev ic e tha t prov ides the al arm V iew A ns we r8. The characteristics o f a false-nega tive alarm inc lude A . A u toma tic enabling B . Th e ala rm may be tu rned OF F C. Narrow a larm li mit range D. Failure to genera te a signal when there is a th rea t to pa tient s afety V iew A ns we r9. Wh ich are some of th e func tions tha t a smart a la rm may perfo rm? A . De termin in g the alarm condi tion on the bas is of mu lti ple v ariabl es B . Changing the alarm s ignal gene rati on delay C. P resenting a lis t of condi tions that ma y hav e generated the alarm

D. Changing the ala rm pri ority V iew A ns we r10 . Ala rm condition lo gging A . S hould inc lude th e v al ue of the v ariable that caus ed the alarm c ondi tion B . Can help to determi ne the cause of transi ent al arm c ondi tions C. Is usef ul for qual ity ass urance D. Can d ete rmine when an al arm c ondi tion occurre d V iew A ns we r

Chapter 27 Noninvasive Blood Pressure Monitors

Introduction
Freque nt blood pres sure determi nations duri ng anes thesi a a id drug titration and f luid mana gement and prov ide warni ng of co ndi ti ons that could affec t pati ent s afe ty (1,2 ). There are a numbe r of dev ic es that au toma tical ly me asure blood press ure noninv asiv ely (indirec tl y). The origina l automated dev ic es were s tand-alone moni tors . Now, the maj ority of bl ood pres sure monitors for operating room us e are i ncorporated in to a phys iologic mo ni tor o r anes thes ia works tation .

Intermittent Blood Pressure Monitors

Inte rmi ttent noninv asiv e measu rement of b lo od pressure requi res a dis tens ib le c uff or b lad der enc losed in an unyieldi ng cov er. The cu ff is inflated, and bl ood flow through the underl ying artery is obs truc ted . The cu ff is then def la ted in a c ontrolled mann er, caus in g the press ure appl ied to the artery to dec reas e. Puls a ti ons are detec ted , and the resul ts are displaye d o r recorded as blood pres sure. Mos t dev ic es also display pu ls e rate.

Standards
An Americ an s tanda rd on automated sp hygmomanometers was pub lis hed in 2002 (3). It s tates that bl ood P .838 press ure measurements determined b y the dev ice mus t b e equiv alen t to those obtained by a tra ine d obse rv e r us ing the ausc ul tatory me thod or by di rect moni tori ng us ing an intra -arte rial c ath ete r within the li mits of the s tanda rd. An inte rna tional s tanda rd was publis hed in 1999 (4 ). It l imi ts the max imum cuff press ure ob tainable duri ng normal use to 30 0 mm Hg fo r equipmen t s peci fi ed fo r adults and 150 mm Hg fo r equipmen t s pecified fo r neonates. In addi tion , means mus t be present to prev ent the cuff from remaini ng inf lated for l ong peri ods of time .

Operating Principles
The majority of automated n oninv asiv e moni to rs employ os ci ll ometry (5,6). T he cuf f i s infl ated abov e the point where p res sure osci l la tions are presen t. As the cuf f is defl ated, press ure puls ations (os ci llations ) c aus ed b y mov emen t of the arterial wal l are trans mi tted to the c uff . The magni tude of these os c illatio ns inc re ases to a

maxi mum, then dec reases (Fig. 27 .1). The monitor measures these os ci ll ations . Af ter the de te rminatio n is comp lete, the remaining air in the cuff is rapidl y ex haus ted . Durin g the firs t c ycle, the cuff is inflated to a predetermined pressure th at is held cons tant wh il e the monitor tri es to detec t osc illations . If si gn ific ant p ulsatio ns are s till p res ent, th e cuff is i nf la ted furthe r. W he n fi rs t turned ON, mos t automatic blood press ure mon itors s top inf la tion at 1 60 to rr or l es s (7). On pediatri c uni ts , a lo wer press ure is used. If the i ni tial c uff pressu re i s g rea ter than n eces sary to de termine s ys tolic press ure , the mon itor may dec rease this pressure durin g the nex t c ycl e. If the initial pressu re is too l ow, the moni to r wi ll inc rease it d uring the nex t c yc le . W hen no os c illatio ns are detec ted, the pressu re in the cuff is dec reas ed in a s tepwi se or li nea r manne r (Fi g. 27.1 ). Non inv asiv e blood pres sure (NIBP ) moni tors rel y on measuremen t, extrapo la tions . and c linical ly tes ted algo ri thms to arriv e at v alues fo r mean, s ys tol ic , and dias tol ic press ures (6,7,8). The point of max imum ampl itude co rres ponds to the mean press ure (5,9,10,1 1). S ys tol ic an d dias tolic blood press ures are then ca lc ula te d f rom the inc reas ing and dec re asi ng magni tude of the os c il lations acco rdi ng to an empi ric all y deriv ed al gorithm. These algori thms are proprietary and v ary from manufac tu rer to manufac turer a nd sometimes from dev ice to dev ice (10). Consequently , diff erent dev ices do no t al ways yi el d the s ame pressu res (12). W ith osc ill ometry, accu rate bladde r pl aceme nt is not neces sary, and the risk that the cuff bladder wi ll become dis lodged is minimal . Thes e moni tors do not requ ire a l ow-n oise env i ronmen t, are not s ens itiv e to elec trosurgical interferenc e, and wo rk wel l whe n the re is p eriph era l v as ocons tric tion . Venous engorgement has li ttle effec t on ac curacy (7). Thes e monitors can re jec t mos t artifac ts c aused b y patien t mov ement o r ex ternal interf erenc e, bas ed on ana lysis o f the s hape of the os c illometric puls e wav efo rm and the timing of the osci llome tric puls es (5 ).

Figure 27.1 A, B: Sequence of oscillometric blood pressure determination. Cuff deflation may be linear (A) or in steps (B). Pressure oscillations increase in magnitude, then decrease. The oscillations are analyzed to determine systolic, mean, and diastolic pressures. (Reprinted with permission from Nellcor Puritan Bennett, Pleasanton, CA.)

View Figure

Equipment
These moni to rs us e elec trici ty, either line or ba ttery, as the powe r source . Many units are equipped wi th a c onnec tion fo r a pri nter or data man agement s ys tem. Some ca n d is pl ay trends . Many manufac ture rs offe r diff ere nt models for differents ize pa tients .

Inflatable Cuff
Cuffs c ome in different s izes . Disposable an d l atex -f ree cuffs are av ai la ble. Some hav e an antimic robial agent P .839 on the c uff fabric to hel p p rev ent bac teri al gro wth and mi ldew. S o me c uffs are c ol or coded by s i ze. The inte rna tional s tanda rd re qui res that cuf fs are mark ed wi th an i ndication of the li mb ci rcumferenc e for wh ic h they a re app rop riate (4).

Pressure Tubing(s)
One or two tu bings serv e as a means to i nflate the c uff and sens e the p res sure wi th in the c uff. A Y-piece near th e c uff can be us ed to mix s ingle- and two-hose s ys tems (13 ). B lood p res sure tub ings shou ld no t hav e L uer c onnec tions , bec ause

these may allow a p res s ure tube to be connec ted to another dev ice such as an i ntrav enous l ine (14 ).

Cuff Inflation and Deflation Mechanism

The c uff inf lation mec hanis m cons is ts of a pump and a reserv oi r that holds a quantity of ai r that c an be quick l y rele ased into the c uff . A bleed v alv e deflates the cuff . The speed and manner of def la tion v ary from manufac turer to manufac turer. Some adjus t the rate as a func tion of pressu re.

Sensing Mechanism
A pressu re trans duc er detec ts the pressure in the cuff and trans duces i t into an elec tric al current that c an be meas ured . The press ure -s ens ing mec hanis m is bu il t i nto the cuf f i n mos t mon itors . A n autoz ero v alv e tha t periodic ally opens the transduc er to a tmos phere, automatica lly es tabl ishing zero pressu re, ma y be present (7 ).

Timing Circuitry
The timi ng ci rcui try reg ul ates the f requenc y of blood pres sure dete rminations . Mos t i ns trume nts a ls o a llow manua l cyc ling . Mos t o ffer a sho rt-term au toma tic (S TA T) mode that allows a numb er of dete rmi nations to be made in quick s uccession.

Control Circuitry
The c ontrol c i rc uitry de termi nes such parameters as the maxi mum pressu re in the cuff , artifact rejec tion , elec trosurgical interferenc e s upp res si on, deflation rate, an d automatic cutoff. Th e ov erpressu re s wi tc h may be set d ifferentl y fo r adul t and pedia tric models . Some mac hines hav e a utomatic c uff deflation when the c ycl e time ex ceeds a p redete rmined l imi t.

Alarms
Moni tors v ary ac cording to whic h pa rame ter(s ) wi ll tri gger an alarm. Some moni to rs automatic al l y s et alarms aro und the ini tial values . Some hav e def aul t alarm limi ts that c an be changed by the operator. Some moni to rs ac tiv ate an alarm when they are unab le to dete rmi ne the b lood pressu re.

Accuracy
Factors Affecting Blood Pressure Determinations Cuff/Arm Relationship

Acc urate bl ood p res sure measuremen t dep ends on the relationsh ip be twe en arm c i rc umference and c uff width (1 0). T ypicall y, a c uff that is too s mall fo r the p atien t's arm c ircumference wi ll ov eres timate blood pres sure, wh ereas a cuff that is too l arge wil l underes timate blood press ure (10,15,16). It is important that different s izes c uffs are readil y av ail able. If a suff ic ie ntl y large c uff is no t av ailabl e, i t may be poss ible to pl ace a cu ff more dis tall y on the li mb. Current rec ommendations are that a cu ff 's wi dth should be approx imately 40% to 5 0% of th e c ircumference (125% to 150% of the diamete r) o f the l imb on wh ic h i t is used a t th e li mb's midpo in t (17,18,19). Cuff le ngth has little effec t as l ong as the bladde r enc i rc les at least 50% of the arm's c i rcumference (17). In the pas t, it wa s the prac tice in pediatric p atien ts to use a c uff that was two th irds to three fourths of the upper arm leng th . This res ul ted in unde res timation o f blood press ure (20). Ano the r mis leading c riteri on f or de termin ing p rop er c uff s ize is a label s uch as i nfa nt, child , pediatric , smal l adu lt, adult, an d l arge adult. These te rms are open to i nte rpretation b y the us er and c an lead to inapp rop riate c uff s elec tion (20 ).

Site
The s ite where the cuff is pl aced wi l l affec t the measu red press ure. As the s ite mov es more pe ripheral ly , the s ys tolic pressure tends to i nc reas e and dias tol ic press ure to dec reas e (21 ). Inc reas ed v as cul ar tone may resul t in an inc re ase in pulse pres sure. Vas cular dis ease and p eriphe ral v as ocons tric tion may c ause reduc ed pressures at dis ta l locatio ns . The f orearm or wri s t may be us ed when the upper arm is inaccessi ble and/or a s tandard blood p res sure cuff does n ot f it (22,23,24 ,25 ). The ank le may als o be us ed (26 ,27 ). The mean and dias tol ic pressures meas ured at the ank le are co mparable with those measu red in the a rm but the sys tolic pressu re is higher. A poor c orre la tion was f ound be twee n blood pre ssu res meas ures on th e arm and ca lf of wo men who were u ndergoi ng cesarean sec tion (28).

Arm Position
If the c uff and the patient's hea rt a re not a t th e s ame lev el , a correc tion mus t be made . For e ach 10 c m of v e rtic al he ig ht, 7.5 mm Hg (for ev e ry i nch 1.80 mm Hg ) abov e or belo w the hea rt l ev el s hould b e added to or s ub trac ted f rom the p res sures meas ured (21 ).

Arrhythmias

The osci ll ometric techn iq ue is v ulnerable to error i n patients wi th a rrhythmias (29,30,31,32). P .840

Improper Calibration and Maintenance

S tudi es performed wi th i ns truments in c ommon use hav e shown p rob lems wi th ca li brati on , main tenanc e, and accurac y (10). E rrors in the algorithm may occ ur (33,34).

Correlation with Other Methods of Blood Pressure Determination

Many feel tha t the s ta ndard of c omp arison s hou ld be the pressu re meas ure d di rec tly in an artery, mos t c ommon ly the radia l. Ho wev e r, indi rec t press ure readings wi ll nev e r exac tl y match inv asiv e pres sures . On e reas on is that s imu ltaneous meas urements often cannot be made. Another reason is that di rec t and ind irec t moni tors meas ure different physical p rop erti es . The di rec t meth od measu res both the sys tol ic and dias tol ic pres sures and c alc ula tes the mean . Osc i llometry meas ures the mean a nd calcu lates the s ys tol ic and dias tolic p res sures . Many s tud ies hav e co mpared pressures ob tained wi th NIB P moni to rs wi th thos e obtained di rec tly (16,35,36,37,38 ,39 ,40 ,41 ,4 2,43,44,4 5,46,47,48,49,50,51,52). In general, correlatio n of di rec tly meas ure d b lo od pressu res wi th indi rec tly measured blood pres sures is bes t in normal hea lthy pa tients and l eas t accu rate at the ex tremes of b lood pressure. A l thoug h e rrors c an occ ur in either d irec tio n, os c illometric dev ic es tend to ov e res timate low press ures and underes ti mate hi gh press ures . The S TA T mode does n ot denig rate v alues a nd is subjec t to the s ame v a ri ations as measu rements tak en u nder norma l ci rc umstanc es (53 ). Mos t s tudies hav e c onc lud ed th at an NIB P monitor is not s uffic iently accurate if v asoac tiv e drugs are being admi nis tered or i n c ri tica ll y ill pa tients al though i t may be us efu l fo r trending p urposes . Another pro blem is that wi th mode rate to sev ere hypotens ion , the auto mated machi ne of ten c ycles repeatedly before indic ating a failure to meas ure (2).

Proper Use
If pos sible , the c uff should no t be app li ed to the limb in whic h an intrav enous i nfus ion is plac ed bec ause infus ion of f lu ids a nd drugs wi ll b e s lo wed or bloc ked

and the i nc reased pressure may cause bl ood to f lo w retrog rade into the inf usi on se t tubi ng or ex trav asatio n (7). Chec k v alv es in the intrav enous tub in g between th e f luid bag and the pa ti ent usuall y prev ent back fl ow in to the tubin g. A s imple method to av oid, or at leas t reduce, this problem is to route the infus ion tubing und er or through the blood pressu re cuff (54). Oth er means to prev ent this probl em hav e been sugges ted (55,5 6,57). In s ome c ases , it may be poss ib le to place the c uf f dis tal to the inf usion si te . If used o n the arm, th e c uff should be p lac ed as high as possi bl e, an d the i nfl ati on tubes s houl d exi t proxi mally (58,59). If th e u pper a rm is v ery large or conic al ly shaped , it ma y be better to meas ure bloo d p res sure at ano ther location such as the ankle , th igh, or f orearm. The cuff should not b e appl ie d ov er a su perfic ial nerv e, bony prominence, or j oin t. Padding shou ld be plac ed around the sk in unde r the c uff to prev ent sk in c reas in g, petec hiae, blis teri ng, nerv e damag e, and p roblems f rom res idual c leani ng materials (60). P rior to apply ing the cuff , all res idual air should be ex pelled. The c uff should be applied snugl y enou gh to al low onl y one finge r to be s lippe d under i t. Too tight a cuff may c aus e disc omfort a nd v enous dis tentio n. Too loos e a c uff ma y caus e fals el y elev ated readings and ma y p rev ent the moni tor f rom determini ng the blood press ure . The c uff s houl d be pl aced a nd sev era l infl ations made whi le the patient is awa ke to elic i t complaints . Nothing should be allowe d to press agains t the c uff during meas u rements . B lood press ure measurements should be ma de no more f requen tl y than c li nical l y necess ary . In one s tudy, i t was s hown that excep t when rapid c hanges i n b lood press ure are antic ip ated, a one - or two-mi nute cyc le time off ers no adv an tage ov er a fiv e -minute c ycle ti me, but the shorter ti me may inc rease the complication rate (61). The c uff site and ex tremi ty shoul d be inspec ted pe ri odicall y during p rol onged applica tions . It is good prac tice is to oc cas ionall y s wi tch the c uff to ano ther s i te , if possible.

Complications
Damage to Underl ying Tissues
Petec hiae, erythema, edema, thrombophlebiti s , and skin av uls ion at the c uff s ite hav e been reported (62 ,63 ,64 ,65,6 6,67,68,69). P redis pos ing fac tors to the dev el opmen t of pe tec hi al hemo rrhages inclu de patients tak ing an ti -inf lammato ry

drugs , s tero ids , or an ticoagul ants and pa ti ents with th in or redundan t sk in (70). Petec hia of ten occ ur under fo lds in the cuff. W rappi ng the space unde r the c uff with co tton may av oid these p rob lems .

Neuropathies
Neu ropath ies of the median, ul nar, an d radial n erv es hav e been reported fol lowi ng us e of an automatic NIBP moni to r (5 8,5 9,69,7 1,72). A ll res olv ed spontaneous ly. Locating the cuff c los e to the axi lla and awa y from the el bow wi ll help to prev en t radial ne rv e injury . Exc ess iv e mov ement makes i t diff icul t for th e dev ice to determine p res sures , so it wil l c ycle more of ten , pos sibly to hi gher p res sures . This can c ontri bute to ne rv e injuries .

Compartment S yndrome
Cas es of c ompartmen t s yn dro me assoc ia ted wi th p rolonged use hav e been repo rted (73,74,75). In on e case , the pati en t had hyperac tiv ity and tremo r. In another c ase , P .841 the blood pressu re was labi le, c ausi ng the monitor to c yc le l ong er and wi th high er press ures tha n usual . In a thi rd c as e, the cuff was appl ied ac ross the antecubital fossa .

Mechanical Problems
Fail ure of an NIBP monitor is not unc ommon and ma y be associ ated with serious morbidity or mortali ty (2,76). A c ommon problem is a l eak ing cuff , hos e, or connec tor (7,76,77).

Artifacts
Osc il lometric dev ices a re se nsi tiv e to both intri nsic and ex trins ic motions (79). Intri nsic motion artif ac ts are caused b y movemen ts suc h as del iberate patient motion, sh iv eri ng, tremors , co nv ulsions , restles sness , o r v igorous sk in preparatio n (79,80). Ex trins ic motio n a rtif ac ts are c aus ed by ac tions th at compress the c uff, such as bumping by pers onne l or equipment (7) or massagin g the arm wh ere the blood pres sure c uff is loca ted (81). S ynchroni zation with the e lec troca rdiogram c an reduc e a rtif ac ts (8 2). B lood press ure readings were reporte d in a patient whe re the cuff was under the pati ent's head (8 3). It is surmis ed that hea d mov emen ts caused enough motion in the cuff to p roduc e the artifac tua l readings . In another case, a c uff b ecame

unfas ten ed, but the bladder remaine d between the a rm and the tho rax (84). It was s till a ble to detec t osci llati ons an d d is pla yed a fic ti tious press ure.

Air Embolism
If the li ne us ed to in flate the cuff is con nec ted to a n intrav enous l ine , a serious ai r embo lus c an res ul t (8 5).

Advantages
Automaticity
A major adv antage of NIBP dev ic es is that they c an determine press ures regularl y and f requen tl y on an automatic bas is . Du ri ng bus y times , this is v e ry he lpful , sav ing time and allowi ng c l in ic ians to perf orm other task s . Automatic dev ices elimin ate mos t of the factors that c aus e e rrors wh en blood press ures are de termined manua ll y, s uch as v ari able concentrati on, reac tion times , hearing ac uity, a mbient no is e, con fusion of aud itory and v isua l cues , v a riable defl ation rates , backg round noise, v ariab le interp retation o f sounds , preferenc e for ce rtain d igi ts , and b ias due to knowl edge of prev ious readi ngs . They may e li minate so me of the mis trus t that some ind iv iduals h av e when o the rs measure the bl ood press ure manual ly .

Simplicity
Automatic NIBP moni tors are si mple to use. They do no t requi re ex tensiv e training to s et up or ma in tain.

Noninvasiveness
In c omparison wi th di rec t meas urements , NIBP moni tors are les s expensiv e, s impler, and av oid the risk s (ischemic damage, emboli) assoc iate d wi th d irec t tec hniques .

Reliability
NIBP monitors are rel iable dev ices that generally do n ot requi re a lot of mai ntenance or ex perienc e a lo t of do wnti me.

Usefulness
Some NIBP dev ices wil l work in c e rtain patien ts (such as thos e with obes ity or sc leros is an d infants ), i n wh om an accu rate pressu re can not be o bta ined manua ll y. The y wil l read acc urately through bulky d res si ngs (86). Pulse rates be twe en 40 and 200 b eats per minute usua ll y do not h inder readings (78).

Versatility

Osc il lometric blood pressu re meas urements can be made on a v ariety of si tes .

Monitor Integration
NIBP monitors c an be i ntegrated with oth er moni tors . This in teg rati on may allow the numb er of false alarms to be reduced. For exampl e, i t may be p oss ible to s et the pulse oxime ter so tha t it does not alarm for a c erta in pe ri od of time af te r the NIBP cuff is inflated.

Disadvantages
Unsuitable Situations
W hi le non-c ontinuous bloo d p res sure moni tori ng is he lpful in es tab lish ing trends , i t i s unsu itabl e fo r detec ting rapid ch anges in blood press ure (87). If rap id ch anges are antic ipa ted, a con tinuous meth od should be us ed.

Patient Discomfort
Patient disc omfo rt is of ten assoc ia ted wi th a prolonged cyc le time. Cyc le time wil l be prol onged with a large cuff , hype rtens iv e p ati en ts , poor peri phera l ci rc ula tion, a l eak in the mon itor, low bl ood p res sure, dysrh ythmias , or mo tion artifacts .

Clinical Limitations
Automated bl ood pres sure d ev ices do n ot work wel l with ex treme heart ra tes and press ures . In ex treme co ndi ti ons , ev en me an pressu re may not be meas u rable . S tudi es i nv olv ing ambu lance and helico pte r trans port hav e s hown that thes e moni tors are not as rel iable as needed (8 8,8 9,90).

Noncontinuous Measurements
Af ter a b lood pressure meas ure ment has b een made , the v alue is us ual ly d is pla yed unti l the next me asuremen t. P .842 Mos t moni tors giv e s ome indica tion of the age of the disp layed v al ue. S ome c linic ians do not s et the blood press ure mon itor to automatic un ti l af te r in duc tion is co mple te. On occasion, there is a prolonged pe riod unti l th e automatic mode is us ed (91 ,92 ). Du ri ng th is time , the o riginal b lood p res sure wil l be disp la yed.

Continuous Noninvasive Blood Pressure Instruments

Con tinuous or nea r-con tinuous blo od pressu re moni tori ng is des i rable in pati ents wi th c a rdi ac or c erebrov as cul ar dise ase, in c ritically i ll patients , and in s urgical procedures in whi ch pe riods of hemodynamic ins tabi li ty a re antic ipated.

Vasotrac
The V asotrac c ons is ts of a wris t module and a moni tor/dis pl ay c onnec ted b y a cable (93). The sensor is pl ac ed ov er the radial artery at the wris t. A press ure sens ing mech anism a ppl ies v ariable pres sure d irec tl y abov e the arte ry. The counterp res sure in the artery produces a p res sure wav eform. Anal ys is of the wav efo rm is us ed to c alc ulate the s ys to lic , d ias to lic , and mean arteri al press ures. B lood press ure measurements , pulse rate, a nd an arteria l wav efo rm dis pl ay are updated sev e ral times a minute an d dis pl ayed on a moni tor. It is av ail abl e in a handhel d v ers ion. W hen the Vas o trac was co mpared with di rec t arterial press ure , good c orrelation was found (93,94,95,96,97 ,98 ). It was found to be acc ura te whe n delibe rate hypotens ion was used (98,99). Howev er, i n l iv e r trans plantation pa tients , the Vas otrac was n ot suff ic ien tl y acc ura te to s ubs ti tu te for di rec t arterial blood press ure mon itoring (100 ). B lood press ure c an be detec ted down to 40 mm Hg an d up to 240 mm Hg. It is ac curate wi th a rrhythmias . Th e V asotrac s ys tem is s usc eptibl e to patient arm mov ement, but the wav eform can alert the caregiv er to artifac ts . A l though the V aso trac does not prov ide c ontinu ous blood pres sure me asuremen t, i t prov ides much more f requent measu remen ts (3 to 4 times per mi nu te) than the i nte rmi ttent me thod. This may dec re ase the need f or intra-arterial ca nnulatio n.

T-Line Tensymeter
The T-Line Tens ymeter u ti li zes a rterial ton ometry, in whi ch a peri pheral artery is s lightly c ompressed and the p uls e wav e is sens ed by a transduce r placed ov er i t. It cons is ts of th ree parts : A disposable wris t spl in t, a disposab le radi al artery sens or, and a reus able b rac elet. The patie nt's heigh t and wei gh t mus t be e nte red into the moni tor. Fi rs t, the wris t res traint is applied. The radial pulse is p alpated and marked. T he sens or is aligned ov er the point of max imum pu ls ation . Then , the b rac elet is connec ted ov er this . The d ev ice then automatic al ly and c ontinuous ly de te rmines the point of maxi mum pulsation and ex erts s l ight press ure on the artery. Once th e opti mum s ite is loca ted , the s ys tem does a dynamic pressure sea rc h to determine the mean arteri al press ure . The pulsa tion is conv erted into a disp layed wav eform, and s ys tolic and dias tolic blood press ures are computed by us ing the wav eform, the pati ent's body mass index , and a n algori thm. This prov ides continuous , beat-to-beat NIBP measuremen ts .

This dev ic e requires l ess time to s et up than inv asiv e arteria l catheter plac ement and av oids the risks as soc iated wi th an invas iv e arterial c athe ter. One s tudy found that the blood press ures agreed c lose ly wi th s imul taneous pressures meas ured i nv as iv el y f rom a co ntralateral ra dial arte ry (1 01).

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64. White W B . The Rumpe l-Lee de s ign ass oc iated with a noni nv asiv e ambul atory blood pres sure monitor. JA MA 1985;253:172 4. [Cross Ref] [Med li ne Link ] 65. de Silv a P HDP , Mos tafa S M. Assessmen t of the Din amap 845 . Anaes thes ia 1985;40:817. [Cross Ref] [Med li ne Link ] 66. Nic hol ls BJ , Ryan DW . Pe tec hial ras hes and automatic blood pressure meas urements . An aes thes ia 1986;41:88. [Cross Ref] [Med li ne Link ] 67. Showman A , Betts EK . Ha zard of automatic n oninv asiv e blood pressu re moni tori ng. Anes thes iology 1981;55:7 17718. [Med li ne Link ] 68. Saul L , Smi th J , Mo ok W . The safety of au toma tic v ersus manual bl ood p res sure cuffs for patien ts receiv ing thro mbol ytic therapy. A merica n J Crit Care 1998;7:192 196. 69. Kampen P M. Co mplica tion of a no n-inv as iv e blood press ure c uff during prone positioning. Can J A nes th 2006 ;53:1 06. 70. Ramsey M III. A utomatic os ci ll ometric NIB P v ers us manual aus cul ta to ry blood press ure in the PA CU. J Cli n Moni t 199 4;10:136 139. [Med li ne Link ] 71. Tol ln er U, B ec hi nger D , Pohland t F. Rad ia l nerv e palsy in a p rema ture infan t followi ng long term meas urement of blood pre ssu re. J Ped 1980;96 :921922. [Cross Ref] [Med li ne Link ] 72. Lin C-C, Ja wan B , de Vi lla MV H, et al. B lood pressure cuff co mpression i nju ry of the radial ne rv e. J Cli n Anes th 20 01;13:306308. [Cross Ref] [Med li ne Link ] 73. Cel oria G, Daws on JA , Te res D. C ompartmen t syndrome i n a patient moni tored wi th an au toma ted bloo d p res sure cuff. J Cli n Moni t 1987 ;3:13914 1. [Cross Ref] [Med li ne Link ]

74. V idal P , S ykes PJ , O'S haughnes sy M, et a l. Co mpartment s yndrome af ter use of an au toma tic arterial pressu re moni toring dev ic e. B r J An aes th 1993;71:9 02904. [Cross Ref] [Med li ne Link ] 75. Sutin K M, Longak er MT, W ah lander S , et al . Acu te biceps c ompa rtment s yndrome assoc iated with the us e of a non inv asiv e blood p res sure monitor. Anesth Analg 19 96;83:13451346. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 76. Webb RK , Rus sel l W J, Kl epper I, et al . Eq uipment fai lu re: an anal ys is of 2000 i nci den t reports . A naes th Intens Care 1991;21:67 367 7. 77. Gallac her B , Cov eler L . Failu re of a noni nv as iv e automated blo od pressu re moni tor to d etec t the blood press ure af te r re posi tioning of the patien t's arm. A nes th Analg 19 97;85:1178 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 78. Amoore JN, Geak e WB , Scott HT. T he effec ts of pulse rate, a rtif ac t and pulse s trength on osci llometric non-inv asiv e blood p res sure measuremen ts . J Clin E ng 1998;23:103109. 79. de Courc y J G. A rtefac tual hypote nsion f rom s hiv ering . Anaes thesi a 1989;44:787788. [Cross Ref] [Med li ne Link ] 80. Das PA . A rtefac tual hypertension from rhy thmic fi nge r tappi ng. A naes thesi a 1994;49:262263. [Med li ne Link ] 81. Healzer J M, Pearl RG. Husband-i nduc ed hypotens ion . Anes thes iology 1995;82:323. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 82. Van Horn RN, Kahlke RJ , Tayl or LA , et al . Non inv asiv e blood p res sure performance: a reproduc ib le method for qu antif ying motion a rtif act toleranc e in os c illometry . Biomed Ins trum Tec hnol 2001;35:395414 .

[Med li ne Link ] 83. Ehlers KC, Grabenbauer SA . E rroneous blood press ure measurements with a noninv asiv e blood p res sure moni tor. A nes thes iology 1991;74:967 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 84. B lue D, Hannallah M. An un usua l cause of an erroneous noninv asiv e blood press ure reading . Anes thes iol ogy 1993;78:11961197. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 85. Anonymous . Acute care phys iolog ic mon itoring s ys tems. T echnol Anes th 2 002; 22:14 . 86. Bainbridge LC, Si mmons HM, E lliot D. The us e o f automatic b lood p res sure moni tors in the burned patient. B r J Plas t Surg 1990;43:3 22324. [Cross Ref] [Med li ne Link ] 87. Derrick JL, B assin DJ . S ampl ing interv al s to record sev e re hy potens iv e and hyox ic episod es in an es thetis ed patients . J Cl in Moni t Comput 1998;14:347 351. [Cross Ref] [Med li ne Link ] 88. Low RB . Ac curacy of b lo od pressure measu rements made aboa rd hel icopters . Ann Emerg Med 198 8;17:604612. [Cross Ref] [Med li ne Link ] 89. Runc ie CJ , Reev e W G, Reidy J , et al . Blood press ure measurement during transport. A c omparis on of di rec t and osci l lo tonometric rea di ngs i n c ri ticall y il l pati ents . A naes thes ia 1990;45:659 665 . [Cross Ref] [Med li ne Link ] 90. Morl ey AP . P rehospi tal moni toring of trauma pati ents : ex perience of a helicop ter emergency medic al se rv ice . B r J Anaes th 1996;76 :726730. [Med li ne Link ] 91. Salgar V , Hartmannsgruber MW B , S i lv erman DG, et al. Fals e rel iance on old non-inv asiv e blood press ure (NIB P ) rea dings : h uman error o r fa ulty des ign? J Clin Moni t Comp ut 20 00;16:50.

92. Mole J R, Riley RH. D isp la y time of noninv asiv e blood p res sure d ata. A naes th Intens Care 2005;33:69069 1. [Med li ne Link ] 93. Belani K , Ozaki M, Hyns on J , et al. A n ew n oninv asiv e meth od to meas ure blood pres sure. Res ults of a mul ticente r tri al. Anes thes io logy 1999 ;91:6 866 92. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 94. Belani K G, Buck ley J J , Poliac MO. Acc ura cy of radial a rtery blood p res sure determination wi th the V as otrac . Can J Anaes th 1999;46:488496. [Med li ne Link ] 95. Beebe D, Os tanni y I, Komandu ri V , et al. Con tinual non-inv as iv e b lood pressure moni tori ng wi th the Vaso trac : expe rienc e i n th e mo rbidl y obes e. Anes thes iology 1998;89:A565. 96. Thomas SH , Wi ns or GR, P ang PS , et al. Us e of a radia l artery comp res si on dev ic e for noninv asiv e, n ear-continuous bl ood press ure monitoring i n the E D. A m J E merg Med 2004 ;22 :47 447 8. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 97. Cua CL, Thomas K , Zu rak owsk i D, et al. A co mparis on of the Vaso trac with i nv as iv e arterial bl ood press ure moni tori ng in c hi ld ren af ter pedia tric ca rdi ac su rge ry. Anes th Analg 200 5;100:12891294. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 98. Mc Cann ME , Hil l D, Thomas KC, et al. A c omparis on of radi al artery blood press ure de termination betwe en the V asotrac dev ice and inv asiv e arterial blood press ure mon itoring in adol es cents undergoi ng scol iosis surgery. A nes th A nalg 2005;101:978985 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 99. Hartmann T, Sos taric M, Grabne r C, et a l. As ses sment o f Vas otrac blood press ure mon itor du ri ng del iberate hypotens ion. A nes th esiology 2001;95:A329 .

100. Fi ndlay J Y, Gali B , K eegan MT, et a l. V as otrac arteria l blood press ure and di rec t arte ri al blood p res sure moni tori ng durin g liv er transplan tation. Anes th Analg 2006;102:690693 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 101. Jan el le GM, Grav ens tein N. A n accurac y ev aluation of the T-Line Tens y me te r (c ontinuous noni nv asiv e bl ood pressu re managemen t dev ice ) v ersus c onv enti onal i nv as iv e rad ial artery moni tori ng in su rgica l patients . A nes th A nalg 2006;102 : 484 490. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] P .844

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i s D is correc t i f A , B , C, and D a re co rrec t.

1. Du ring the measurement cyc le to de termin e the blood pressure, A . Th e point of maxi mum amp li tude is c onsidered the s ys tol ic pressure B . S ys tolic and d ias to lic pressu res may be es timated by i dentifying the region whe re ampli tudes of os ci llations inc rease an d dec rease rapidl y C. The d ias tolic pressu re is the po in t where osc il la tions cease D. Mean p res sure is de termi ned and the s ys tol ic and di as tolic p res sures are ca lc ula ted V iew A ns we r2. Wh ich statements rega rding accu racy o f noninvas ive blood pressure monitors a re correc t? A . S inc e mos t us e osc il lome tric technology, the re is c lose agreement between different i ns truments

B . P lac ement of the c uff ov er the arte ry is impo rtant C. Pa tient mov emen t causes a great deal of a rtifac t to an os ci ll ometric techn ique D. The p osi tion of the c uff in re la tion to the hea rt is important V iew A ns we r3. Accuracy of the automatic blood pressure mo nitor may be affe cted by A . E lec trosurgical interfe rence B . V enous engorgemen t C. Pe ri pheral v asocons tric ti on D. Cuff s ize V iew A ns we r4. Wh ich factors cha rac teriz e the re la tionship betw een th e siz e of the cuff and th e s iz e o f the arm? A . Unders ized cuffs g iv e falsely l ow readings B . Th e cuff wid th sh ould be 125% to 150% of the diame ter of the limb on whi ch it is us ed C. Ov ers ized c uffs giv e falsel y high rea di ngs D. The c uff length has li ttl e effec t on acc urac y V iew A ns we r5. Factors that ca n a ffect the determination of b loo d pressu re by the auscultatory metho d include A . Ra te of c uff def la tion B . Ra te of c uff infl ation C. Hearing ac uity D. S tandard iz ed conc ept o f sys tolic and dias tol ic end points V iew A ns we r6. Wh ich techniques c onstitute p rope r cuff pla cement? A . Th e cuff should be p lac ed tigh tly on the li mb B . A l oose ly appl ied c uff wil l us ual ly c ause falsel y elev ated readings C. The c uff s hould be k ept on the same arm ev en du ri ng lo ng proced ures D. The li mb s hould be wrapped wi th p adding whe re the cuf f is to be pl aced V iew A ns we r7. Patients at risk for deve lop ing pe tec hia e include A . Th ose on an ticoa gulants B . Th ose tak ing s teroids C. Those taking nons te roi da l anti-i nfl ammatory drugs D. Those wi th redundant s kin V iew A ns we r8. Contrib uting causes of a compa rtme nt syndrome include A . P rolonged use B . Hyperac tiv e patien t C. Lo w p lac ement of the cuff

D. S tabl e blood press ures V iew A ns we r

Chapter 28 Data Management Systems

P rogress i n moni toring ins trumen tation has l argely outpaced methods used to record and manage the expanding body of cl inica l data (1). W hi le man y a nes thes ia departments continue to use the tradi ti onal method of rec ording inf orma tion manu al ly, elec tron ic da ta managemen t s ys te ms a re gaining i n popularity. The Anes thes ia P atient S afety Foundation and the Soc iety for Technolog y in Anes thes ia hav e endo rs ed computeriz ed anes th esia rec ords (2,3,4).

Definitions
Anes thes ia In formation Sy stem (A IS or A IMS ): A s ys tem that manages inf ormation througho ut the periopera tiv e pe riod. Applications: Computer programs , usuall y of a si milar type. Analog Da ta: Continuous da ta that c an, wi th in l imi ts , as sume any v alue. An analo g co mputer cannot handle al phanumeric da ta (l ette rs and numbers ) bu t can proc ess wav efo rms . A nalog is the op posi te of di gital. A rti fac t: Data that is no t a true rep res entation of a c ond ition. Automated A nes thesia Reco rd K eeper (AA RK ): Dev ice that c ollec ts , displays , and records i ntraopera tiv e data from a v ariety of mon itors and other s ources . P .846

Cl osed A rchitec ture o r Sys tem: Equipment d esigned to work o nl y with accesso ri es made by one c ompany. Database: A co llec tion of da ta, often in s torage for l ater ac cess . Data Management S ys tem: S ys te m that reco rds da ta rela ting to the patient's c are througho ut the periopera tiv e pe riod and integra tes with other medic al data s ys tems to gain o r share data. Dec is ion Support: Any method that takes inpu t i nfo rmatio n about a c linical si tua tion and p rod uces i nferences that can as sis t prac titi oners in dec isi on maki ng. Di gi tal : A way of s to ri ng information us ing numbe rs . Digi tal is the oppos ite of analog. Edi ting : The process of c hang ing a recorded v alu e, comment, anno tation, or ev en t af te r it has been made part of the record. Fi le : A collection of inf ormation in a format designed f or co mputer use .

Fi leserver (S erver): The mas ter c omputer i nto wh ic h all the other c omputers on a network are c onnec ted. The f i les erv er s tores programs, p roc esses and s tores data i n a data base , and runs the network o perating sys tem. Hardware: Th e phys ic al parts of a compu ter. Ex amples inc lude the p rinter, sc reen, ke yboa rd, and elec tronic c omponents . Input Dev ice: A means to manual ly en ter data o r c ontrol a compute r. Ex amples i ncl ude a ke yboa rd, mo use, track ball, l ight p en, ba r code s canner, touch sc reen , v oic e recogni tion dev ic e, and p en pad . Inte rface : The c ommon b ound ary b etwe en compu ters , between c omp ute rs and thei r peripheral dev ices , or be tween two peri pheral d ev ices . Local A rea Network (LA N): A network tha t is limi ted to a local area s uch as a department. A LAN c an be i ntegrated into a la rge r network . Dev ic es connec ted by a network are referred to as modules . Mac ro: A tool used to automate task s or proced ures withi n a program. Ex amples are pre typed notes or c heck -off boxes . Network : A group of c omputers c onnec ted together. Open A rc hi tec ture: The practice of mak in g the des ign and c ompute r engineering or programs pub lic knowledge. Operatin g Sys tem: Sof tware that c ontro ls ho w a co mputer perfo rms i ts func tions . Output Dev ice: A dev ice tha t pres en ts informati on from a c omputer s ys tem to a us er fo r v iewi ng or s torage. Examples inc lude p rinters , sc reens , floppy disks , and tape driv es . Peri pheral : A general term for an y of the dev ices b y whic h a c omputer g athers i ts i nput and dissemina tes i ts outp ut. Software : P ro grams that control the hardware and determi ne the fu nc tions performed b y a c omputer.

Elements of the Data Management System

A typic al anes thes ia da ta managemen t s ys tem is s hown i n Fig ure 28 .1. The data mana gemen t s ys tem c onsis ts o f one or mo re c entral fi les erv ers and a network connec ting the components . E ach compu te r rec eiv es data and sends i t to the se rv e r. In a p roperl y des igned s ys te m, if an ind iv idual c omputer f ai ls , it wil l not disab le the entire s ys te m bu t wil l affec t o nly thos e func ti ons that the partic ular co mputer was pe rforming. A data manage ment s ys tem ma y be c losed or open . A c losed sys tem helps to ensure that all compo nents work tog ether and a ll ows the ins ti tution to deal with a

s ingle v endor. A c losed s ys tem ma y not wor k wel l wi th componen ts f rom other manufac tu rers . B ecause of the great v a riety o f sou rc es used to capture data, c los ed s ys tems are not f re quen tl y used. In an o pen s ys tem, componen ts f rom v arious v endors are us ed. This e nables each department to c hoose the bes t dev ic es for its needs while s til l all owi ng the i nfo rmati on to be ac ces sed by other s ys tems . Ins ti tu ti ons s elec ting a n open s ys tem mus t mak e certain that new c omponents wil l i nterfac e with their n etwo rk . A data manage ment s ys tem ma y be centralized o r dis tri buted. If the data are c opi ed i nto a central repos i tory (s erv er), the s ys tem is centra li zed . If the da ta res ides at or near the point of c are , the s ys tem is dis tri bu ted . Ev en in th e d is tributed s ys tem, a network con nec tion is nec es sary to s tore the data af ter it has been c ollec ted . The dis tributed s ys tem may be mo re reliable than the c entral i zed s ys tem because it of fe rs redundanc y (5). Exp anding a dis tributed sys tem is s traightfo rwa rd, a s it us ual ly requi res si mply adding ano the r compu ter or peripheral dev ice to the network and updating the s ys te m's software.

Fileserver
The f iles erv er processes and s tores data and pro grams in a databas e and runs the network operating s ys tem. T here may be o ne or more fileserv ers , depending o n the s ize of the s ys tem.

Input Sources
Electronic Anesthesia Record
The elec tronic anes th esia rec ord c ollec ts informati on from v arious sources , processes the data, p res ents sel ec ted v alues and trends on a s c reen (F ig. 28.2), and transpo rts data to other parts of the sys te m. It may perform addi tiona l func tions such as in tegra ting in formation and al arms . A c hoice of d is pla y confi gurati on on the sc reen is us ual ly av ailab le . The elec tronic anes thes ia reco rd computer and da ta sc reen ma y be mounted on P .847

P .848 the anes thes ia machine, a c art, the fl oor, or the ce il ing. Some are an inte gra l part of the anes thesia work s tation.

View Figure

Figure 28.1 Typical anesthesia information management system. Workstations and peripheral devices are physically connected to each other and to the fileserver by wires or cables to form a LAN. Part of the network operating system resides in the fileserver and part at each user workstation. Applications software that runs the AARKs may reside in the fileserver but are executed in the AARKs. An AARK can be located in other places beside the operating room. AARK, automated anesthesia record keeper; PACU, postanesthesia care unit.

Figure 28.2 Electronic anesthesia record with device for reading the label on the syringe and plunger movement to record the amount of drug administered. (Picture courtesy of DocuSys, Inc.)

View Figure

The elec tronic record mus t prov ide a means to enter da ta that c anno t be transfe rred automatic al ly (5,6,7 ,8,9). Handheld compu ters offer a c onv enient way to enter data a t the b edsi de (10). A ll in put devi ces mus t be eas y to cl ean to av oid c ross inf ec tion. A s ealed , pl astic -c ov ered ke yboa rd may be the mos t appropriate so lution. Manu al en try s hou ld be as e asy as poss ible. If it is difficul t or tak es a l ot of ti me, the rec ord wi l l of ten be inc omplete or inc orrec t. Mac ros that enter routine i nfo rmati on or us er prefe rences i nto the record make data entry easi er and reduce the information that mus t be en tered manual ly .

Bec ause i t is not al way s poss ib le to ente r al l info rmation at the time i t occurred, there needs to be a means to a dd it after the fac t an d to in dicate when i t took place . Av ailabl e sys tems h andle bac k dating dif ferentl y. A common method is to al low the timi ng of an e ntry in the pas t with an i ndication of when the entry wa s made . In o rde r to prope rl y identif y the respons ible c lin ic ian , there mus t be a way of ending a record with an elec tron ic signatu re.

Inputs from Other Components of the Data Management System

Input f rom o the r compu ters or se rv ers al lows th e e lec tronic anes thes ia record to ac qui re info rmation from o th er areas of the fac i li ty and to i ntegrate i t i nto the data mana gemen t s ys tem. Demographic info rmati on from the ad mitting department and pre- an d pos tope rativ e data may be entered i nto the reco rd. There may be connec tions to elec tron ic l ib raries , the pha rmac y, or the Inte rne t. W irel ess technol ogy is being used mo re f req uently (11). S ince radio frequenc y may i nte rfere wi th medic al dev ices such as infusi on pumps or pace makers , inf rared is the mos t useful means of transmis si on (12). W i re less technolog y fac il i tates us ing smal l c omputers for c ollec ti ng da ta (s uch as preopera tiv e as ses sment) from si tes awa y f rom the ope rating room. This data can s ubsequently be entered i nto the co mputer network (13 ). A wi rel es s n etwork is rel ativ el y inex pens iv e, e asy to ins ta ll , and e asi ly expanded.

Printer
If a printed (hard ) copy o f the anes thes ia record or other information that c anno t be obtained f rom the compu ter network is des ired, a dev ice c apable of prin ting both graphics a nd tex t wi ll b e neede d. Frequently , th e p ri nting is perfo rmed i n a loc ation such as the pos tanes thes ia care uni t (PA CU) or an off ice . An i mportan t c ons idera tion is whether the printed record is ge nerated as data becomes av ai lable or a t the c ompl etion o f th e c ase, or both. If the rec ord c an onl y be prin ted a t the end of the cas e, data could be los t if the data manag ement s ystem malfunc tions . F requent b ack -up wi ll li mit the loss . W ith a real -ti me copy , the rec ord can be remov ed from the printe r and co mple ted by hand if the auto mate d s ys tem fails (14).

Records

Preanesthesia
The data man agemen t s ys te m has been found to be eff ic ient and effec tiv e fo r preoperativ e ev aluation (15,16,17). P atient-co mple ted ques tio nnai res can be performed e lec tronica lly (18 ). This c ould be completed and submitted th rou gh the Inte rne t from the pa tient's home (19) or f rom a phys ici an's office. Based on this i nfo rmati on, pa ti ents who do no t present pro blems tha t requi re a preoperativ e v isi t can be s eparated from th ose wi th c omp licated medic al his tori es . P reanes thes ia cons ul tati on us ing telemedicine technol ogy of fe rs the chance to reduc e trav el cos ts and to id entif y patie nts wi th p rob lems s o tha t addi tional wo rk up o r consul ta tions can be p erf ormed without delay ing the surgery (2 0). This d ata c an allow the c linic ian to determine wh ic h patien ts are at ri sk a nd require more tes ting and perhaps inc re ased inv asiv e moni to ri ng (21,2 2). P atien ts who wou ld benefit f rom anti bi otic prophy laxis c an be identif ied (23 ). W i th good preoperativ e data, an as soc iation between the preanes thesi a ev aluati on and perioperativ e inc idents c an be ev aluated. P reope rativ e informatio n c an be obtai ned f rom the heal th c are fac il ity's or phys ici an's offic e rec ords . This is usual ly i n the form of a his tory and phys ical o r progress no tes . In addi tion, labora tory res ults a nd rad iolog y inf ormation sh ould be av ailab le. Wh il e laborato ry informati on may be acc epted by the data management s ys tem, in fo rmation tha t is in tex t s tyle, s uch as the his to ry and p hys ica l, may not l end i ts elf to automatic c apture b y the da ta mana gemen t s ys tem and may n eed to be en tered into the s ys tem man ually .

Intraoperative
Patient Variables
The bulk of entries during surgery are ob jectiv e pa ti ent v ariab les (bl ood pres sure, heart rate, ox ygen s atu ration, insp ired and ex hal ed carbon d iox ide c onc entrations , ox ygen an d anes the tic agen t concentrations , cen tral and arterial pressu res , blood gases , mixed v enous oxygen saturati on , in trac rani al p res sure, c a rdiac ou tpu t, tidal and minute v olumes , respi ra tory rate, c ompliance, res is tanc e, tempe rature, elec trocardiogram, tourniquet times , el ec troenc ephalogram, urine ou tpu t, P .849 neuromuscu lar transmiss ion da ta ). Mos t of this data c an be automatical ly transfe rred from the mon itors to the intraoperativ e rec ord .

S ys te ms edit automatic al ly captu red pa tient v ariab les differentl y. S ome wil l no t permi t edi ti ng and requ ire a note to exp lain an artifac t. There may be mac ros that ex pla in c ommon arti fac ts . Oth ers requi re the ope rator to approv e v ariab les befo re they are rec orded, offer a win dow of time for ed iting, or mak e the v ari ables ed itabl e at any time. One of th e adv an tag es of editing may be algorithms to help rejec t arti fac ts .

Workstation and Monitor Information

Much of the inf orma tion that is gene rated by mon itors and the a nes thes ia mac hine, v aporizers , v en tila tors , and ass oci ated equipmen t [f resh gas f lo w, v ap ori ze r setting, co mpos i tion of res pi ratory gas es, breathing s ys tem press ures , tidal and mi nute v olumes with c ontrolled v enti lation , respi ratory rate, ins piratory:expi ra tory (I:E ) rati o, b rea thing s ys tem p res sures and f lo ws , end-ti dal c once ntrations , wh eth er alarms a re ON or OFF and thei r settings , drugs admin is tered by i nfus ion pumps ] can be transf erred au to ma ticall y to a data management s ys tem total ly o r in pa rt. W ith s ome anes thes ia mach in es , gas flows and v apori zer s e ttings can be transfe rred.

Information from the Anesthesia Provider

Some inf ormation, inc lud in g observ ations an d s ome interv en tions , is av ai lable only f rom the anes thesia c are prov ide r. Th is includes pre - and pos to perativ e d iagnoses ; premedica tiontype, amount, time giv en, and effec ts ; opera tion(s ) performed; position of trac heal tube; diffic ul ties encou nte red wi th i ntuba tion; heart and lung sounds ; ech ocardi ography inf orma tion; patie nt appearance (e.g., pal e, f lushed , s we aty , wri nk led); p ati en t pos itio n; es timated blood loss ; u ri ne output; the type of breathi ng s ys tem; s pec ia l safety precauti ons ; and checks of equipmen t. The s ite, s ize, and type of intrav enous catheter(s ) and the typ e, amount, and time of f lu id adminis tra tion need to be noted. Routine p roc edures such as pos itioni ng, padding press ure poin ts , and eye c are need to be i nc luded. Special proce dures suc h as plac ing a central o r arterial line or a regi ona l block shoul d be rec orded wi th i nfo rmati on on how it was perfo rmed an d any problems that occ urred . Ev ents that need to be entered (a lo ng with the time ) incl ude surgery s tart and s top, tournique t i nflation and re le ase, clamping and unc lamp in g of major v es sels , a nd ca rdiopu lmonary b ypas s beginning an d end. In many c ases , this i nfo rmation can be i ncorporated in to mac ros that c an be eas il y entered in to the rec ord . Thes e entri es shoul d alwa ys be time s tamped by the s ys tem.

Mos t neuromus cular s ti mula tors (Chapter 25 ) depend on the anes thesia p rov ide r to as sess the response, s o manual entry wi ll be requi red . Howev er, some ins truments both s timu late and as ses s the res ponse. Thes e c an be in te rfaced to automatic da ta recordi ng. The reco rd should c ontai n the dosages and ti mes of a ll me dicatio ns admi nis tere d. Vari ous methods hav e bee n used to a t leas t p artially automate thes e en tries . The medica tion can be s elec ted from a menu and its dos age en tered. Labels ca rrying the drug names and bar c ode c an be attac hed to s yrin ges (24). The anes thes ia prov ider can sc an the labe l to the automatic b ar co de reader. It is als o pos s ible to automatic al l y dete rmi ne th e a mount of drug adminis tered f rom a pref ille d s yringe (Fig . 28.2).

Information Transfer
An i mportan t adv antage of the data management s ys tem is i ts abil i ty to impo rt data f rom and ex port data to other c omputer s ys tems i n the hea lth c are fac il i ty . Thes e i ncl ude the laborato ry , radiolog y, bus iness offic e, and c ri tical care. Laborato ry i nfo rmation such as hemoglobin, b lo od gases , cl otti ng v alu es, and elec troly tes a re of ten needed d uring the cou rse of an anes th etic . If the data mana gemen t s ys tem is c onnec ted to the laborato ry , information s houl d be quick ly av ailab le. Tes t res ults should be ente red on the record immediatel y af ter the da ta becomes av ai lable . The time that the res ul ts arriv e sh ould be rec orded as wel l . If the informa ti on on a blood co nta iner can b e s canned, this can be transf erred to the rec ord . If the da ta managemen t s ys tem i s interfaced to the blood bank , the i nfo rmati on on the c ontainer ca n be chec ked to determi ne if the b loo d is being adminis tered to the correc t patient. P ic ture arch iv ing an d c ommunica tion s ys tems (PA CS ) that allow ac quis i tion, s torage, and re triev al of digital i mag es can be i ncluded in the inf ormation s ys tem (25). Thus , an eso phag eal echoc ard io gra ph obtained i n the ope rating room c an be v iewe d b y c li nic ians in other areas of the fac il ity.

Postanesthesia
The pos tanes thes ia rec ord can be cons id ere d a c ontinuation of the intraoperativ e record but usual l y with a d iffe ren t fo rmat. Preope rativ e patient i nfo rmation and the record made during the intraoperativ e pe riod mus t be immed iatel y av ailable to the PA CU. Data is ex trac ted f rom moni to rs i n the s ame manner as during a nes thes ia . It is i mportan t th at moni tors us ed in the PA CU be able to c ommunicate with th e data

mana gemen t s ys tem. Drugs , laboratory resu lts , a nd inc idents are rec o rded, along wi th us er notes . Patie nt consc ious nes s , pa in lev els , and other i nforma tion requi red by regul atory agenc ies shou ld be pa rt of the pos tanes thes ia rec ord . Qual ity as surance c an be conduc ted from the pos tanes thes ia rec ord (26). P .850

Uses for Data Management Systems

Info rmation from a da ta man agemen t s ys tem c an b e used by the anes thesi a department and others for a v ariety of task s. S peci al s oftware mo dules may be needed for some of these.

Anesthesia Record Generation

An anes thesi a info rmatio n s ys tem can prov ide a timel y and ac curate rec o rd of pati ent c are through the entire perio perative pe riod.

Research
Bec ause a large v ol ume and v a riety of info rmation can be co llec ted and s earc hed by proce dure, pa ti ent c harac teris tics , dru gs us ed , and other paramete rs , an anes thes ia info rmation manage ment s ys tem d atabas e c an be v ery useful for c li nic al resea rch (22,27,28,29,30,31 ,32 ). S tudi es hav e sho wn tha t manua l records f requentl y a re not suffici ently accu rate fo r res earch purpos es (29,33,34,35,36,37,38). La rge retros pec tiv e s tudi es are d ifficult to hand le man ually and may reflec t the bi as of the rev ie wer. E lec tronic data management makes i t easie r to c ollec t and ana lyze th e v ariables b ei ng s tudied. An Internet webs ite can be us ed for data c ol lec tion for mul ticente r res earch projec ts (39 ). Af te r the datab ase has been es tabl ished, the effec ts of a change in some as pec t of c are c an be s tudied . A nec essa ry f ac tor to b e able to exa mine da ta f rom diff erent ins ti tu tions is a s tandard anes thes ia lex icon . This is being dev eloped by usi ng S NOME D (s ys temi zed nomenclature of medici ne) as a b ase (40,41,42,43).

Education
In a traini ng program, an au toma ted reco rd can be us ed to rev iew and refine the trai nee 's s ki lls . Si nc e trainees are req uired to k eep a log of thei r c ases , the data mana gemen t s ys tem c an be u tili zed to fu rnish that informati on and track eac h trai nee 's experience (44).

As departments ins titute v arious prac tice guidelines , the av ailabi lity of these on l ine may i mprov e and si mpl ify thei r implementa tion. Compl iance with th ese guide li nes can als o be determined .

Billing
Info rmation necessary fo r bill ing inc ludes pa tient c harac teris tics , case -spec ific data, a nd concurrenc y (the number of a nes thetics superv is ed at on e time). A da ta mana gemen t s ys tem c an be used to ass ign the proper bi lling codes (45). P roper data can i nc reas e bil labl e diagnoses , help the fac il ity inc rease re imbu rs ement, and dec reas e the ti me between the ev en t and pa yment (15). If the reco rd is inc omplete o r does not co nfo rm to Heal th Care Fi nance Admi nis tration rules , the bil l may be d is all owe d o r red uced . Ev en wo rse , the i ns titution ma y be accused of a nd fined for fra udul ent bill in g. A pro gra m can be set up to improv e documen tati on by cal ling a ttentio n to requi red entri es .

Administrative Functions
S ince al l the fu nctio ns in an operating room env i ronment are i nterrelated, i t makes sens e that they sh ould be in teg rated into the data management s ys tem. These i ncl ude pa tient track ing , nursi ng, radiology , schedul ing, room util ization , c lean ing , i ns trume nt ca re and p referenc es , transport, and the like. If a probl em dev elops , i t is i mportan t to de termine what occurre d a nd to dev elop a s trategy to prev ent its reocc urrenc e. An integra te d data manageme nt sys tem may he lp wi th this . The data man agemen t s ys te m can p rov id e inf ormation on uti li zati on of faci l ities , personnel , equipment, and suppl ies . It may be us ed to fac i li tate s cheduli ng (46,47). Surgical delays ca n be anal yz ed and the pro blems c orrec ted . The inf orma tion management s ys tem can be used to obtain summa ries of an anes thes ia prov ider's o r a group's practice pa tterns , for ex ample, the numbe r of cases of a pa rtic ular ty pe done in a giv en peri od of time. In a gro up prac tic e, ques tions often aris e as to ho w the work is div ided , ti me off, c all , and number of nights and hours wo rke d. The inf orma tion management s ys tem can be us ed to track these ev ents .

Quality Assurance
Data gathered elec tronic ally is rel ativ el y eas y to anal yz e for qual ity ass uranc e purposes . Wi th manual c harti ng, the re may be a cons iderabl e def ic it i n documenti ng adv ers e ev ents (27,48,49,50,51,52,53,54,55,56). W hen an inc ide nt oc curs , the relationsh ips to drugs or proc edures may be determined more

ac curate ly f rom the data manage ment s ys tem than f rom the wri tten reco rd. In one reporte d c ase, it would not hav e been possible to de termine the cause of a c ri tical i nci den t from the manual reco rd, b ut the data management s ys tem ind ic ate d the sourc e o f the p rob lem (57). A reg is try of anes thes ia-re lated probl ems ca n be c ompi led (58,59 ,60 ,61 ). Ev ents such as mal ignant h yperthermi a, s uspec ted la tex allergy, a typic al ps eudochol ines terase , and diff icul t i ntubatio n that woul d be of importance to subs equent anes thes ia p rov iders c an be sent to a data bank that ins ti tu tions and anes thes ia personnel c an acc ess elec tronical ly. P .851

Advantages Accuracy, Completeness, and Legibility

The accurac y , comp leteness , and legibili ty of hand wri tten records of ten leav e much to be d esi red (6,29,33,34,35,36 ,62 ,63 ,64 ). T here is a bias to ward recording more normal v al ues (37,38,65,66). S tudi es show that a h ig h number of errors are made wh en blood gas anal ysis resul ts a re telephon ed to the operating room (6 7). E lec tron ic transfe r of l abo ratory i nfo rmati on should be more acc ura te. Cl in ic ians are no t al ways ab le to make ti mely notations in the wri tten rec ord whi le respondi ng to eme rgenci es , and their me mori es are not c ompletely reliable wh en recordi ng data after an inc ident. The resul t i s often an inc omp le te record during periods of s ignificant and rapid c hanges when i nc reas ed phys ic al and pharmac ologic manipulations occu r. W i th elec tronic data transfer, re cording wil l continue d uring these times . New v iews of data a re av ail able wi th elec tronic rec ords (25). Data that wou ld be sp read among many pages or repo rts in a paper record can be formatted to a si ngle page or moni tor sc reen , al lo win g the cl inic ia n to rev iew l ongitudinal information a t a glanc e.

Decreased Paper Use

Dec reased paper us e is a goal of da ta mana gemen t s ys tems . It is possi ble tha t in the future a paper p rintout wi l l be unneces sary, as i t wi ll be pos sible to cal l up al l records f rom th e e lec tronic database.

Accessibility
Anes thes ia prov iders need ac ces s to prev ious anes thetic reco rds , es peci al ly if there wa s an adv e rs e reac tion, d ifficu lt intuba ti on, unex pla ined problem, or naus ea and v omiting. In the p as t, th is neces s itated hav in g s omeone loc ate the old chart. This can b e time c onsuming and may not b e p ossible durin g ev ening or nightti me hours . Many ol d charts a re s tored at an off -s i te loc ation . If the record is s tored elec tronically , i t should be read ily av ail abl e at an y time a t al l locations where ac cess is nee ded. In th e future, i t may be pos s ible to trans fer rec ords between i ns titutions by usi ng the In ternet or other s ecure means .

Integrating Monitored Variables and Alarms

The operating room is an inf ormation-in tensiv e location wi th d ata p rov ided by a heteroge neous mix of inde pendent dev ices . It ma y b e diff icult to compare v a ri ables and d ete rmine the rel ationship between them. A data management s ys tem may make i t eas ier to pres ent da ta in a format that al lows ra pid a nd accu rate recognition of dev eloping patterns and examina ti on of the re la tions hip betwe en v a ri ous interv entions and responses . Ano the r problem in th e operating room is that s ev e ral dif ferent alarms often occ ur s imul ta neous ly . This may resul t in confusi on as to the s ource and s ignif ic ance of the alarms . An integ rated sys tem c an gene rate more s pecific and d esc ri ptiv e alarm mess ages . Ideal ly, all al arms woul d be displ ayed on o ne central panel desi gned for maxi mal v is ib il i ty and read abili ty, and the alarms o n the prima ry moni tors c ould be turned OFF. Th is wou ld aid in rec ogni zi ng what c ondi tion (s ) require atten tion. The elec tronic data s ys tem coul d th en analyze the da ta an d s ugges t diag noses and, possibl y, trea tmen ts . S ee Sma rt A larms i n Chapter 26 .

Legal Protection for Anesthesia Providers

Ev e ry an es thetic reco rd has the potential to become a legal doc ument (68,69,70,71,72,73,74). No cas e wil l come to tri al or s ettlement without a d eta il ed analys is of the anes thes ia and perio perative c a re records . Manual rec ords often l ack i nformation that c ou ld be es sen tial if legal ac tion occu rred. Inc omp le te or i llegi bl e medical rec ords c re ate the imp res si on that care was ca reless , sup erf ici al, or s ubs tandardev en if, i n truth, i t was good. Clear, co mple te, and ti mely anes thes ia records wi ll a lmos t al ways he lp to defend a c as e that was properly mana ged, although it wil l no t help with one that wa s poorly ha ndl ed.

A data manage ment s ys tem can faci li tate documen ting protec tiv e ac tiv i ties b y presenti ng the cl in ici an wi th a ch eckl is t of relev ant safe ty i tems . Data manage ment s ys tems can be us ed to determine p opulation-base d normal limi ts for v i ta l signs during anes thesi a (75 ). These may play a ro le in profes si onal li abi l ity cas es . The med ic olegal s ig nificance of the data ma nage ment s ys tem has yet to be determined, as there hav e not been a l arge numbe r of l ega l procee dings in wh ic h they were inv olv ed. One la rge s u rv ey determined that the re were n o reported cas es i n whic h the da ta managemen t sys tem hinde red the defens e p roc ess (76). Howev er, s inc e then , a c ase h as been reported where a data transmission fa il ure was not noticed, and the pla in tiff 's attorney sugges ted that the absenc e of data was ev ide nce that the s tand ard of c are wa s not met (77).

Beneficial Effects on the Anesthesia Provider's Time

S tudi es hav e shown that 20% of to tal anes thesia ti me is used for manual documentation (78 ). S tudies also hav e shown tha t charting time is modes tl y less wi th a data management s ys tem (6 3,79,80). P .852

Automated Therapy
E lec tronic data i nforma tion offe rs the potentia l fo r information integration . Info rmation s uch as b lo od pressure, p uls e rate, and neuromus cular bloc kade could then be allo wed to c ontrol the adminis tra ti on of v olatil e and in trav enous drugs and agents (81).

Decision Support Capability

The data man agemen t s ys te m should be able to ac cess v ari ous s ourc es of i nfo rmati on. Thes e can inc lude the pharmacy fo r information a bout d rugs and thei r i nte rac tion wi th other me dic ations as wel l as ca lc ula tions a nd drug c os ts . Other sourc es cou ld inc lude tex tbooks and j ournals . The s peed, breadth, and cons is tenc y of a c omputer decis ion support s ys tem far exceed those of ev en the mos t dedicated and expert c l inic ia n.

Problems Artifacts

A common conce rn wi th data management sys tems is tha t arti fac ts wi l l be us ed agains t the anes thes ia prov ider i f there is an untoward occ urrenc e (82,83,84,85,86,87). A rti fac ts may be c aus ed by mechanical o r el ec trical dis turbanc es (e.g., ex ternal pressure on the b lo od pressure cuff ; elec tros urg ic al i nte rference on the E CG, ox yge n mon itor, or pu ls e ox imete r; malposition, ambient l ight, o r motion on the pulse ox ime ter s ens or; li ne flus hing or samp li ng on i nv as iv e press ure lines ; a nd a plugged gas sampli ng li ne). Ano the r sou rce of artifac ts is l ogging erro rs by the anes thes ia prov ider. Unfortun ately , arti fac t recognition is n ot an ex ac t s c ience . Notes tha t are made to ex pla in an artifac t ma y be retrospec tiv e and i n error. Of ten , the data man agement s ys tem mak es it diff ic ult to dis tin guish an arti fac t f ro m a true v alue (82,88). A rti fac ts c an be reduce d b y us ing moni to rs wi th res is tanc e to in terf ere nce and arti fac t rejec tion c apabil i ty . A nother me thod i s to u ti lize the data compa rison or arti fac t rejec tion c apabil i ties of the da ta management s ys tem. For example, hea rt rate is common ly measured by s ev eral different mon itors . The c omputer c oul d co mpare thes e measuremen ts an d rej ect one that does not match the others . W hen an erro neous v al ue is not fil te red , manua l notes can b e used to explain the ques tionabl e reading. Many artifac ts ca n be address ed by using prewritte n notes f rom a lis t of common c auses of artifac ts (e.g., saturation of p eriph era l oxygen (S pO 2 ) aff ected by el ec trosurgery). Inc omp lete data entry can occu r with elec tro nic reco rds , esp ecial ly wh en the y rel y on f ree tex t entri es or i t is time c onsumin g a nd diff ic ult to en ter c oded ev ents (89).

Physical Layout
Con tempora ry ope rating rooms a re of te n c ro wded, so the bulk o f the elec tronic data s ys tem may c aus e problems . Carefu l consideration s hould be giv en to wh ere the s ys tem and the neces sary cabl es are placed . It s hould be in a l oca tion that is ergonomic ally practical b ut does not interf ere with oth er equ ipment. In on e c ase , the data management c omputer sh if te d i n i ts moun t and co mpressed the trans fe r tubi ng between the adj us tab le press ure limiting (AP L) v alv e and the scav enging i nte rface , blocking gas flow.

Interfacing
All of the dev ic es th at are connec ted to the data management s ys tem mus t b e able to c ommunicate wi th that s ys tem. An inte rfac ing dev ic e is needed to perform this func ti on. It is important that if a moni tor fails to func tion, another mo nitor c an be attached to the s ystem withou t hav ing to reb oot or rec onf igu re the s ys tem.

Inte rf aci ng some equi pment to the d ata management s ys tem c an be diffic ul t. Some dev ic es mus t be modified, and unless this is done correc tl y, the y may be ren dered unsafe. A lso, the warra nty ma y become v oid . A c us tomi zed i nterface may mak e it diff icul t to exchange moni tors .

Adverse Effects on Operator Vigilance

Ano the r worry about the data management s ys tems is that the c linician wil l no t lo ok at the moni tors s inc e the re is no need to rec ord the v alues s hown on them (90 ). The reas oning is that the process of en te ring data on the reco rd causes the anes thes ia prov ider to mentally absorb and ev alu ate that informa ti on (91). S tu dies hav e fou nd that v igila nce is not adv ersel y affec ted b y using a data manage ment s ys tem (79,80,92).

User Attitude and Acceptance

Us e r atti tude c an make o r break a sys tem. A n anes thes ia prov ide r who finds co mputers intimidating or who has the pe rce pti on that a utomated reco rds inv ite l aws uits may be reluc tan t to i nv es t the ti me and energy neces sary to learn to use an i nformation sys tem. S ince the data man agemen t sys tem is continual l y bei ng i mprov ed, the re wi ll b e f requent upg rades , wh ic h c an be a source of i rri ta tion and confusi on. For a s ys tem to be s ucces sful , it needs to be use r-frie ndl y and dep endable . Inv olv ing the us ers in c hoos ing a nd conf igurin g the sys tem wi l l help to wi n s upport. A team to carry ou t data manag ement s ys tem implemen tation should be p ut together p rior to its in troduc tion (5 3). P .853 Detai led educ ation i n both the reasons for the c onv e rsi on an d the ac tua l s ys te m operati on wil l be neces sary. The introduc tion me thod wil l affec t ac cep tance. Ex perience su gges ts that in mos t cases , it is bes t is to make a quick , cl ean break wi th the old s ys tem and requi re all prov iders to us e the ne w o ne (93 ). Af ter the s ys tem has been in us e for an ex tended peri od, us er ac ceptance is us ually h igh , prov ided that there are n ot f requent ma lfunc tions (94,95).

Security
Sec uri ty conc erns hav e bec ome v ery imp ortant for all medical rec ords . The re needs to be a means to guard a gains t unauthori zed pers onnel maki ng entries or gaining

ac cess to the s ys tem as wel l as a means of identifying person nel wh o log on to the s ys tem.

Confidentiality
Info rmation c an be transfe rred between ins ti tutions by way o f th e Internet (8,70,96,97). A major p roble m in elec tron ic medical record transfer is protec ting pati ent p riv ac y (98). Th e s ys tem mus t prov ide tools to s afeguard data confidentiality yet make i t eas il y retri ev able for selec ted use rs . The anes thesia record wil l be us ed by other anes thes ia and heal th c are prov ide rs , inc luding adminis tra tors , nurs es, technic ians , pharmac ists , bi l li ng pe rso nnel , pharmac y, a nd peer rev iew p ers onnel. A ll of thes e i ndiv iduals need certain info rmation but no t necess ari ly all the informa ti on in the record. It may be adv antageous to mak e the record av ai lable in different formats tha t incl ude onl y th e i nformation ne eded for spec ific purpos es .

Training
Implementing a da ta managemen t sys tem re qui res an ini tial inv estment of time fo r us er education. Inadequate training c an lead to resis tanc e to usi ng the sys tem. A n i nadequatel y prepared prov ider c an caus e rec ords to be inacc ura te , los t, or unusab le. Training ca nnot be hit or miss . A ll prov ide rs mus t rec eiv e adequate i ns truc ti on before us ing the data management s ys tem. This can b e d ifficult, es pecial l y i f there are prov ide rs who work onl y occ as iona ll y at the fac ili ty . Af ter users are tra in ed on the data man agement s ys tem, the c ompl iance lev el needs to be monitored and the cause of any d ec reased compli ance de termined. Criteria for determini ng us er co mpliance hav e been dev eloped (99). A d ec reas e in co mpliance can s ignif y tha t the user is unwi l ling to perf orm wi th in s e t c riteria or that there is a problem in the s ys tem that ca n be correc ted .

Mechanical Problems
The operating room can be a hos ti le env i ron ment for c omputers . Damag e ma y be caus ed by o the r equi pmen t or us er ab use. Cleanliness can be a probl em. B loody glov es may be used to make entries . Liqui ds may find thei r way i nto the mouse or ke yboa rd. The s ys tem shou ld not be affec ted by power f luc tuatio ns , a browno ut, or a blacko ut. P rev entiv e meas ures inc lude an uninterrupti ble p ower s uppl y (UP S ) and a line condi tione r to prev ent v oltage f luc tuations .

P roblems are i nherent i n any compu te r s ys tem. There wil l be times wh en i nfo rmati on is slow i n c omi ng or the compu ter is down. Look ing up information may be too ti me cons uming in emergency s i tu ations . If th e s erv er whe re al l the data ev entual ly ends up is not func tioning, the da ta needs to be retain ed in the bedside co mputer unti l the s erv er is abl e to receiv e that informa ti on. Info rmation in the data manage ment s ys tem needs to be bac ked up at f requen t i nte rv als and s to red in a manner tha t wil l e nsure tha t it wil l no t be los t. There needs to be a means to reco rd data if the computer f ails .

Inability to Deal with Certain Information

No dev ic es are av ai la bl e for qu antif yi ng or measuring phys iolog ic s igns s uch as pupil lary s ize and reac tiv i ty, s weating , or blood los s . This type of informa tion nee ds to be manual l y entered into the c omputer.

Difficulty Adapting to Special Situations

In the opera ting ro om, the e qui pment is l oca ted in one or t wo locatio ns. T his means that c onnec ti ons b etween moni to rs an d the data mana gement s ys tem and be twe en the data management s ystem and the n etwork do no t need to be al te red f requentl y. W hen anes thes ia is adminis te red in a remote are a, the moni to rs in that locatio n may no t be abl e to interf ace wi th the data management s ys tem. This wi l l necess itate tak ing the enti re anes thesi a mach ine wi th i ts monitors and data mana gemen t s ys tem to the l ocation. S inc e a c onnec tion to the se rv e r may not be av ailab le in these are as , the i nfo rmation wil l ne ed to be s tored in the c omp ute r until i t can be c onnec te d to the n etwork and the inf orma tion down loaded for s torage and prin ting. Wi re less commun ic ation f rom th e moni tors in the locati on where the procedures occ ur may ov e rc ome some probl ems . E lec troconv uls iv e thera py poses another p roblem for the data management s ys tem (100). In this si tua tion, s ev e ral patien ts ca n be lined up an d anes thes ia adminis tered in a ra pi d ma nner. This is us ual ly performed in a ps ych iatry s ui te or PA CU. T he to tal ti me per pa tient is onl y several minutes , a nd an anes thesi a machine is us ual ly no t used. To us e a da ta mana gemen t P .854 s ys tem for thes e c as es , moni tors wou ld need to be c onnec ted a nd discon nec ted ev ery few minu tes and th e rec o rd res tarted and d emographic info rmation added for each patie nt. A ll of this wo uld greatly ex tend the time required to perform this procedure.

Lack of Information Standardization

It is important that da ta f rom other s ites be i nte gra ted . Horiz ontal integration shoul d i ncl ude c onnec tions betwe en the a reas such as the pha rmac y, laboratory, an d radiology. If thes e a reas use a different forma t, i t may no t be eas y to add this i nfo rmati on elec tron ic all y.

Long-term Manufacturer Stability

Some ea rl y hardware and sof tware prov ide rs went out of bus iness , s o the ir s ys tems that ha d been ins tal led became obs olete. As the technolog y matu res an d beco mes more popul ar, i t is expec ted that the companies that maintain the s ys tems wi ll become more s table , and this p rob lem wi ll d iminish. A v endor's long-term v iab il i ty shoul d be c ons idered wh en purchas ing a s ys tem.

Financial Considerations
The drugs and equipmen t used in anes thesia c on trib ute to the c os t of the anes thetic . The ab il ity to track drugs and monitoring p roc edures al lo ws the ir c os t and eff ec tiv eness to be as ses sed. The data management s ys tem c an be us ed to determine the ef fec t of a d rug or moni tor on ov eral l outc ome and cos ts and wh ether an ex pens iv e d rug c ould be rep lac ed by one of less cos t withou t a dec rease in the quali ty of care (72 ).

Costs
The ini tial c os t of a data management s ys tem is high and de pends on the number of operati ng rooms , wha t equ ipment and inf rastruc ture is al ready in place, the wi ri ng requi rements and abi lity of ex is ti ng moni to rs , and other equipment to inte rfac e wi th the sys tem. The re are cos ts inv olv ed i n trai ni ng users and s upport pe rs onnel . Th ese wi ll be repeated each time th ere is a rev isi on in the program and each time a new user o r se rv ice pe rs on is added. Af ter purchas e and ins tallation, ongoing cos ts inc lude hard ware and s of tware mai ntenance, upgrades , and s upport perso nnel . Other cos ts to be cons idered i ncl ude paper, printer c artri dges , p ref illed syri nges , and ad ding bar co des . There mus t be technical bac kup av ail able to s olv e proble ms and to k eep th e s ystem func ti onal . If the s ys tem is difficul t to operate, mis takes may res ult in los t bi l li ngs .

Savings

Data management s ys tems may reduc e l os ses f rom cha rges not capture d and i nacc urate c oding or time bill ing (1 01,102). The c os ts of different techniques can be co mpared. Af te r eac h c ase, the an es thes ia prov ide r can be presented with the cos ts of drugs and other items used. These can then be ex amined to de termine if they were trul y nec es sary and if other less c os tly on es c ou ld be us ed (1 03). Sav ings c an be ac hiev ed by reduc ing las t-minute dela ys and s urgery cancel lations ; i mprov ed s taffing; better inv entory c ontrol ; and reduc tio ns in ad minis tra tiv e and ov erhead cos ts s uch as bil ling, medic al reco rds , quali ty as suranc e, and c omplia nce wi th the J oi nt Commiss ion o n A cc redi ta tion of He althc are Organi za tions and other regulatory b odies . Sav ings c an be ac hiev ed if data management s ys tems aid anes thes ia prov iders and i ns titutions in profess io nal l iabi li ty l i tigati on. One insu rance company offe red a disc ount for us ing data management s ys tems (71 ). So me p rob le ms that res ult in l aws uits , s uch as injec ting the wrong drug, may be av oi ded. If cen tral trending and al arm func tions are assumed by the a utomated rec ord s ys tem, it may be pos s ib le to use moni tors wi th out thes e fea tures and that cos t les s than th e top -of -the-l ine models (104). W hether d ata management s ys tems wil l be cos t effec tiv e remains to be demo nstra ted . W hile s ome c enters hav e re ported s av ings (105), i t is dif ficul t to document tha t data manag ement s ystems sav e enough to jus tify the high ini tial and mai ntenance cos ts . In s ummary, the data management s ys tem offers many adv antages as we ll as a numb er of d is adv antages . Some ins ti tutions hav e us ed one for a time and then s topped bec aus e the work of supporti ng i t was too demand in g o r the s ys tem was f lawed (10 6). S ys tems presen tl y av ailable are s till elementary in re lation to thei r poten tial , but they a re bec oming more po werf ul and eas ier to us e . Many of the poten tial f eatures discussed in this ch apter are theore tical , whi le many of the poten tial f eatures discus sed hav e yet to be i mp le mented. Despi te the fact that there are li ttl e hard data to support the s uperio ri ty of data manage ment s ys tems , i t seems l ik ely that in the future, mos t medical rec ords wil l be c omputeri ze d and in teg rated i nto a fac ili ty-wide data managemen t s ys tem.

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69. Gibbs RF. The p res ent and future medicolegal impo rtanc e of record k eepi ng in anes thes ia and intensiv e c are: the c ase for automati on. J Cl in Mon it 1989;5:251 255. [Cross Ref] [Med li ne Link ] 70. K roll DA . The legal i mplic ations of c omputeri zed anes thes ia rec o rds : an admi tted ly bias ed rev ie w. S em A nes th 1991;10:3035. 71. Scho ens tadt DA . Compu teri zed anes thes ia records : an ins ura nce company's perspec tiv e. Sem Anes th 1991;10:4147. 72. Thys D. The role of informa ti on s ys tems in anes thesia (AS A Refreshe r Course #165). Park Ridge, IL: ASA , 1998. 73. Zei tl in GL . Automated rec ords do not reduce anes thes ia li abil ity. AS A News lett 1995;59(6):2123. 74. Zei tl in G. A uto mate d rec ords do n ot reduc e anes thesi a l iabi li ty. Am J Anes thes iol 1997;24:27227 3. 75. Dex ter F, P enning DH, L ubarsky DA , et al . Use of an automated anes thesi a i nfo rmati on s ys tem to dete rmi ne referenc e li mits for v i tal s igns during cesa rea n sec tion . J Cli n Moni t 199 8;14:491498. 76. Fel dman J M. Do anes thes ia information s ys tems inc reas e malp rac tice ex posu re? Res ul ts of a s urv ey. A nes th Analg 200 4;99:840843. [Fu ll tex t Link ] [Cross Ref] 77. V igoda MM, Lubars k y DA . Fa il ure to recogn iz e l os s of incoming data whi le us ing an a uto mated anes thesia reco rd keepi ng s ys tem i nc reased medical l iabi li ty ex posu re. Anesthes io logy 2005 ;103:A 1204 . 78. Anonymous . Ov erv iew of anes thesia data management s ys tems . Technol Anes th 2 005;25:28 . 79. A ll ard J , Dzwo nc z yk R, Yab lok D, et al . Effec t of a uto matic record k eep ing on v igi la nce and reco rd keeping time. B r J A naes th 199 5;74:619626. [Cross Ref] [Med li ne Link ] 80. Wein ger MB , He rndon OW, Gaba DM. The effec t of elec tron ic reco rd keeping and transes ophageal echocardiography o n task d is trib ution, work lo ad and v igilance during c ardiac anes th esia. Anes thes iol og y 1 997;87:144155. [Fu ll tex t Link ] [Cross Ref]

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87. Hoare SW, Beatty P C. A utomatic artifact i den tifica ti on in anaes thesia patien t record keepin g: a c ompari son o f tec hniques. Med E ng l Phys 2 000;22:54 7553. 88. Lagasse R. Se lf -repo rtin g c an be a rel iable means of tracki ng adv erse perioperativ e ev ents . A nes thesio lo gy 1997 ;87 :722723. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 89. Drisco ll WD, Pete rf re und RA , Columbia MA . Data entry into an elec tronic anes thes ia record: an obs erv atio nal s tudy of record completeness . Anes thes iolog y 2005;103:A 827 . 90. Noel T A II. Computeriz ed anes thes ia rec ords may be dange rous . Anes thes iology 1986;64:300 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

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Questions
For the fol low ing ques tion, s elec t the c orrec t ans wer 1. Which of the follow ing de finitions is incorrec t? A . A nalog data is co nti nuous data that can , wi thi n limi ts , ass ume any v alue . B . Clos ed arc hi tec ture refers to eq uipment d esigned to work o nly wi th accessori es made by one c ompany. C. Analo g is a way of s to ri ng information usi ng numbe rs .

D. Pe ri pheral is a gene ral term for a ny of the dev ic es by which a compu ter gathers i ts i nput and des si mina tes i ts output. E . A mac ro is a tool used to automate task s or procedures within a p rog ram. V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i f D is correc t i f A , B , C, and D a re co rrec t.

2. Us es of a data manage ment sys tem in anesthesia inc lud e A . E ducation B . Quali ty assu rance C. Researc h D. B il ling V iew A ns we r3. P roven benefits of automated rec ords include A . Legal p rotec ti on fo r th e anes thes ia prov ide r B . Fina ncial s av ings C. Major b enef icial effec t on the anes thes ia prov ider's time D. Ac curacy V iew A ns we r

Chapter 29 Temperature Monitoring

Indications for Temperature Monitoring
Numerous s tud ies hav e shown th at s ignif ic ant temperature c hanges routinel y oc cur i n a nes the ti zed pa tients (1 ,2,3). The moni tori ng gu id elines of th e A me rican Soci ety of A nes thes iologis ts s tate tha t Ev ery p atien t rec eiv ing anes th esia s hall hav e temperature mon itored when c li nic al ly si gn ific ant c hang es in body temperatu re are i nte nded , antic ipated or sus pec ted . The S tandards fo r Nurse Anes thesi a P rac tice s tate tha t one mus t mon itor body temp era tu re con ti nuo usl y on all ped iatric patients receiv ing general anes thesi a and, when indicated, on all other pa ti ents (3A ). Tempera ture moni to ri ng sho uld be performed whenev er large v olumes of cold bl ood and/o r in trav enous flui ds are adminis tere d, whe n the patient is del iberately c ool ed and/o r warme d, for ped ia tric s u rge ry of s ubs tan ti al duration, and in hy pothermic or py rex ial patients o r those wi th a s us pec ted or k nown temperature regulatory problem suc h as ma li gna nt hyperthe rmi a. Major s urgic al proc edures , es pec ial l y those inv olv ing body cav ities , s hould be cons idered a s trong indica ti on fo r temperature mon itoring .

Standards
A U.S . s ta ndard fo r el ectronic thermometers , not inc luding inf ra red thermometers , was pu bl is hed in 2000 (4 ). Ce ls ius d isp la y the rmometers mus t be graduated in i nte rv als of not g rea ter than 0 .1C, whi l e thermometers us ing a Fahrenheit dis pl ay mus t be graduated in interv als of no t greater than 0.2F. The maxi mum error for an i ndiv idual reading is s hown in Table 2 9.1 . The re is als o a U.S . s tandard f or inf rared thermometers (5). This spec if ication does not presc ribe a method for de te rminin g clinica l acc urac y. P .859

TABLE 29.1 Maximum Error for Electronic Thermometers

Temperature Celsius Scale Less than 35.8C

Maximum Error

0.3F

35.8C to less than 37.0C 37.0C to 39.0C

0.2F 0.1F

39.0C to 41.0C Greater than 41.0C

0.2F 0.3F

Fahrenheit Scale Less than 96.4C 0.5F

96.4C to 98.0C 98.0C to 102.0C 102.0C to 106.0C

0.3F 0.2F 0.3F

Greater than 106.0C (From ASTM 15111200, 2000).

0.5F

Technologies

A v arie ty of tec hnologi es are av ailable to measure tempe rature. None is su itabl e fo r al l si tuations . Man y dev ices s imply display the temperatu re. Thes e a re less than opti mal, because a hi gh or l ow te mpera ture may go unnotice d for s ome ti me. Mos t mode rn dev ic es hav e ala rms that ca n be set i f the tempera ture exc eeds h igh or low l imi ts . Tempe rature-moni tori ng capabili ty is av ailable on mos t phys iolog ic moni tors us ed in the operatin g room and periope rative areas . F requentl y, they hav e the abil ity to measure temp era ture at two diff ere nt si tes (Fig. 29 .1 ). These dev ic es us ual ly hav e the abili ty to trend the tempera ture and to transf er tempe rature i nfo rmati on to an elec tronic rec ord . The re are a number of s tand-alone dev ices , both mechanic al and c hemical . Those s tand -al one dev ices that a re battery -po were d shou ld hav e a me ans to indica te whe n battery power is l ow. Trend i ndicators are av ai la ble on s ome of thes e i ns trume nts .

Thermistor
A thermistor is composed of a metal (i.e., manganes e, nick el, cobalt, i ron , or zinc ) ox ide s intered in to a wi re or fuse d i nto a rod or bead (6,7 ). Th ere mus t be a s ourc e of c urrent and a means to meas u re that c u rrent. Res is tance of the meta l oxi de i nc reas es as the tempe rature dec reas es and v ice v e rs a s o the resis tance c an be conv erte d to a te mpera tu re. A dv antages of thermis tors incl ude s mall s ize , rapid respons e time, c ontinuous read ings , and s ens itiv ity to s ma ll chan ges i n temperature . They are fa irly inex pens iv e. P robes c an be in terchangeabl e and disposable.

Figure 29.1 Monitor with capability for monitoring temperature at two sites and alarms. (Courtesy of Fisher Paykel Healthcare.)

View Figure

Thermocouple
A thermoc oupl e cons is ts of an elec trica l c i rc uit tha t has two diss imilar metals wel ded toge the r at thei r ends (6,8). One of the two metal j unc tions remai ns at a cons tant tempe rature. The othe r is ex pos ed to the area being measu red , pro duc ing a v ol tage diff erence that is meas ured and conv erted to a tempera ture rea di ng. Adv antages of thermocouples i nclude accu rac y, small s iz e, rapid res pons e time, continuous readi ngs , s tabi li ty, and p robe interchan geabil i ty. The materi als are i nexp ens iv e , so the probes c an be ma de dispos able.

Platinum Wire
The elec tric al res is tanc e of plati num wi re v a ri es almos t l inearl y with temperature. B y employ ing a n ex tremel y smal l d iame ter wi re, rapid the rmal e quilibration is possible. Res is tance is measured in a manner si mi lar to a th ermis tor. Thes e thermomete rs are acc ura te and giv e c ontinuous readings . P robes c an be made i nte rc hangeabl e. If a probe with a the rmoc ouple, thermis to r, or pla tinum wi re is to be use d i ns ide the body, i t mus t hav e P .860 an ou ter s heath. T he end of the probe designed to be ins erted i nto the pa tient is seale d and the elec trical c onnec tion made a t the o ther end . The co nnec tion nee ds to be k ept d ry. If i t bec omes we t, erro neous readin gs can resul t (9,10,11).

View Figure

Figure 29.2 The flexible adhesive-backed strip of this liquid crystal temperature monitor has a black background. To use, the covering over the adhesive is removed, and the monitor is placed on the skin.

Liquid Crystal
Certain organ ic co mpounds in thermal transformati on from a s olid to a l iq ui d s ta te pass through an in termediate phas e that exhibi ts a nis otropic (optic ally ac tiv e) properties (12,13). The term l iquid c rys ta l is us ed to desc ribe this state. W hen l ig ht sh ines on suc h a materia l, c rys tals sc atter s ome of the light, produc ing irid esc ent co lors . T he li quid c rys tals are encapsulated so tha t the colors form letters and numb ers . A liquid c rys tal tempe rature moni tor is sh own in Figure 29.2. It cons is ts of a fl exible adhes iv e back ing wi th plas tic -encas ed liquid c rys tals on a bl ack backgroun d that prev ents ref lec tion of the transmitted li ght and enhances the c olo r res ol ution . The cov ering ov er the adhes iv e is remov ed, and the disc o r s tri p is placed on the sk in . The l iquid c rys tal thermo mete r is av ai lable in two f orms : one disp lays the s k in temperature di rec tly ; th e o the r has a bui l t-in c orrec ti on fac to r (offs et) so that the temperature dis play ed es timates c ore tempe rature (7,13). Liquid c rys tal thermometers a re s afe, conv enient, noninv asiv e , eas y to app ly and read, d is posable, non irri tating, and i nexpens iv e . They giv e f as t, continuous readings and inv olv e no elec tronic c ircui try. They ca n be appl ied before induc ti on of anes thesia and are easi ly transferred to the rec ov ery area wi th the patient. Disadv antages of l iqu id c rys tal the rmometers include the n eed for s ub jec tiv e observ er interp retatio n and the i nabil i ty to interface with a rec ording s ys tem. They are les s acc ura te than other dev ices. Extreme ambien t temperatu re, humi dity, and ai r mov ement c an caus e inaccu rac y (13). Other disa dv anta ges incl ude dif ficul ties

wi th ad hesi on secondary to ski n sec reti ons , allergic reactions to adhes iv e bac king, i nacc urac y, and imp rec is io n (14,15). The y are capable of meas uring tempe rature only on the skin. If lef t in the sun for an ex tended peri od, a n e rror i ndicating hyperthe rmi a can be produc ed. If the dev ice is frozen, all the numbe rs can be v isible at onc e (13 ). Inf rared hea ting lamps may cause erroneous ly el ev ated readings (12). The re is a report of a l iqui d cry s tal thermo mete r th at gav e a falsel y high temperature (16).

Infrared
An infrared thermome ter is an el ec tronic instrumen t that meas ures a portion of the i nfrared radia tion from surfaces wi th in i ts fie ld of v ie w (17,18,19). El ec tro magne tic radiation is emitted by an objec t in propo rtio n to its te mperatu re. Because the probe is placed in the ou ter part of the ear c anal and usually has a relativ ely wi de v iew ang le, it detec ts inf ra red emiss io ns from parts of b oth the ear c anal wal l and tympan ic membrane an d computes an av erage or highes t temperature. The displayed v al ue may be the ac tual temperature (un adjus ted, c al ib ration mode) o r wi th an offset to es tima te temperature at another s ite base d on selec ted s tudy sa mples (s i te equiv alent mode) (5,7,17,20). The ins trument has an otoscopel ik e pro be (Fi g. 29.3 ). Disposable probe c ov ers are us ed for hygiene and to prev ent cerumen bu ildup . The probe should be pl aced ca reful ly but fi rmly as far as possible in to the ear c anal , ai ming towa rd th e tympan ic membrane . The probe wi ndo w s hould be c lean and s hiny, and a n ew probe cov er s hould be use d eac h time.

Figure 29.3 The infrared thermometer's probe is inserted into the external ear canal.

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P .861

Patients tolerate inf ra red thermometry wel l (18). Beca use i t does not co ntac t an y su rface, the re shoul d be no trauma ass oc iated wi th i ts us e. Meas urements are rapid. This technology is often use d i n the pos tanes thesia c are uni t and othe r c ritical c are a reas . The re are a number of problems with infrare d the rmometry. Poo r pene tration , i mproper ai mi ng, and obs truc tions such as c urv atures of the e ar c anal c an res ul t in s ignif ic antly l ower tempe ratures . Meas uremen ts are intermittent. This dev ice is generall y not useful for monitoring i n the operating room.

Mercury-glass
These thermo me te rs are not us eful for in traopera tiv e anesthes ia, as they hav e a l ong equ il ibra ti on period (us ual ly 3 to 5 mi nutes ) and cannot be read wi th out bein g remov ed f rom the moni to ri ng s i te . In the fu ture, they wi l l be banned to reduc e mercury contamination in the env i ronmen t. If a new the rmome ter is us ed on each patient, there is a was te-disposal p rob lem. If the the rmome ter is reuse d, i t mus t be c leaned an d s te ri li zed. If a thermometer is broken, the merc ury v aporizes and ca n present a h eal th hazard.

Thermal Compartments

A l though arbi trary, i t is s omewha t useful to div ide the body i nto two th erma l co mpartments : the co re that i ncludes the deep, v ital internal o rgans and a she ll of peripheral tissue that s erv es as insulation for the co re.

Core
Core tempera ture is unif orm and high compared wi th the res t of the bod y. It normal ly v ari es be twe en 35.7C and 37.8 C (21 ,22 ,23 ). W hen s ig nifican t changes i n b ody he at are ex pec ted, c o re temperatures s hould be moni tored. S i tes d iffe r in how we ll they ref lec t c o re temperature . The diff erenc e may depend on the rate of temperature c hange. A s i te that ref lec ts c ore temperature ac curatel y whe n tempe rature change is sl ow may fail to reflec t rap id c hanges .

Periphery
Normally , thermoregula tory v as ocons tric tion mai ntains a tempera tu re gradient between the co re and pe riphe ry (s hell ) of 2C to 4C. Regi ona l tempera tu re v a ri ations ex is t i n the peri phe ry. The corre la tion between temperatures measu red at diffe ren t bod y s ites de pends on sev e ral fac tors , inc luding the s tabi l ity of the body tempera ture and whe the r or no t there hav e been recent c old or wa rm challen ges . Sk in a nd ax il lary te mperatu res are us uall y co nsidered she ll temperatures .

Monitoring Sites
Bod y tempe rature can be moni tored a t a numbe r of s i tes . The temp erature can v a ry cons iderabl y in different parts of the body at an y time. Fac to rs influencing temperature at any giv en si te inc lude the tis sue 's he at produc tion, the temperature and rate of blood f low thro ugh the area, the amoun t of insulation from the env ironment, and ex ternal inf luenc es on the s ite (24). The bes t s ite for tempe rature moni toring depends on the purpose of the meas urement, duration of the s urg ic al proce dure, the surgical s ite, the anes thes ia tec hnique, and av ail able equi pment. Cons iderations s hou ld inc lude ac curacy , speed, c onv enienc e, acc ess , safety, pa tient acce ptabi li ty , and c os t-ef fec tiv enes s . Abs olute ac curac y is usuall y not necessa ry, but measurements mus t be c lose enough to detec t temperature c hanges th at may i nfl uence treatment decis ions . It may be he lpful to moni tor two s ites . The difference be twe en core and a seco nd s i te can p rov id e i nd irect i nforma tion on bl ood f lo w (s l ow c hange = poor blood flow) and i s helpful in guarding agains t an ov ershoot du ring warming o r c ooli ng.

S tudi es comparing temperature measurement among diff erent s ites are often confusi ng. Man y try to re late peripheral s ites to c ore temperature and use di fferent s i tes as th e s tandard for core tempe rature.

Pulmonary Artery
Pulmona ry arte ry temperature can be measu red in patients wh o hav e a S wan-Ganz ca the ter with a thermis to r in plac e. It is thou ght by many to be the bes t method of meas uri ng c ore body tempera ture (25,26). Pulmona ry arte ry temperature generally co rrela tes we ll with intrath ecal and j ugular bulb temperatures , ev en with rapid cool ing and rewa rming (27 ,2 8). P oor co rrelation wi th brai n tempera ture was found duri ng profound hypothermia (29). Pulmona ry arte ry readings a re not reliabl e d uring thoracotomy or c ardiopulmonary bypass wh en the re is no flow throug h the he art and lu ngs an d ma y be direc tl y af fec ted by the c ard io plegia used duri ng cool ing.

Esophagus
Eso phag eal tempe rature measuremen t can be ac compl ishe d b y us ing a si mp le probe, an esophageal s tethos cope wi th thermis to r (Fi g. 29.4 ), o r a gas tric tu be with the tempera ture sensor s ome dis tance from th e end of the tube (Fig. 29 .5 ). P .862

Figure 29.4 Esophageal stethoscope and temperature probe.

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Tempera tures in the es ophagus may v a ry up to 4C, depending on the temperature probe l ocation withi n th e esophagus (7). The esophageal tempe rature shou ld be meas ured with the s enso r located in the lo wer thi rd or fourth of the es ophagus (30). A t this depth, the esophagus lies be twe en the heart and the desc ending ao rta. P lac ing the sens or in this pos ition wil l minimi ze (but not c omp le tel y el iminate) the ef fec t of res pired gas es (31). When the s enso r is part of an eso phag eal s tethos cope , the idea l dep th of p lacemen t is 12 to 16 cm dis tal to the point of maxi mum hea rt sounds (32). If th e p rob e is place d h igher in the es ophagus , th e reading wi ll be lower (3 0,32,33,34). If the probe is placed in the s tomac h, i t may record tempera tures highe r than core, refl ec ting liv e r metabolis m. In addi tion, the respons e time to temperature c hang es is s low wi th the probe in the s tomac h. The probe is mos t accu rately pl aced by usin g an elec troc ard io gra phic lead bui lt into the probe (35 ,36). T he pos i tiv e lead is attached to the probe , and the negativ e lead i s attac hed to the ri ght s hou lder. A bi phas ic P wav e in dic ates tha t the p robe tip is at the mi datri al lev el. In adul ts , the ide al position is approx imately 38 to 42 cm bel ow the ce ntral inc is ors (32) or a t leas t 24 c m belo w the lary nx (30 ). Fo r nas al insertion , the f ol lowi ng formulas c an be used (37): L (c m) = 0 .228 (s tandi ng height) - 0.194 or L (c m) = 0 .479 (si tti ng hei ght) - 4.44 whe re L is the length from the opening to the nares .

Figure 29.5 Gastric tube with temperature probe. This also functions as an esophageal stethoscope.

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P .863

In c hi ldren, the idea l dis tance in c entimete rs below the cornicul ate c arti la ges is approxima ted b y the foll owi ng formu la (38): 10 + (2 age i n yea rs )/3 c m A temp era ture probe c an be i ns erted into the esophagus through the drain tube of a P roSeal la ryngeal mask . The optimal locatio n for the temperature probe is 15 to 20 cm dis tal to the drai n tub e (39). Eso phag eal tempe rature is cons idered c ore te mpera ture by many i nv estiga to rs . Tempera tures meas ured in this loc ation have s hown good agreeme nt wi th pulmonary artery temperature (28,40,41,42,43,44 ,45 ). Du ring rapid wa rmi ng or cooling , esophageal temperature s hows l ess lag time th an tha t meas ured a t mos t other s ites (46), al though some s tud ies f oun d tha t bladde r temp era ture sho wed a c los er app rox imation to pu lmonary a rtery temperature than the eso phageal temperature (47,48). B ra in temperature may b e adequ ate ly ref lec ted b y esophageal temperature du ri ng mild, b ut no t profound, h ypothermia (29). Patients hav ing ac tiv e or pass iv e ai rway humidification hav e s li ghtl y h igher es opha geal tempe ratures (31,34). Con traindications to us e of an es ophageal p rob e inc lude procedu res on the f ace, oral c av i ty , nos e, ai rwa y, or esophagus and patients wh o hav e es opha geal disorders . It is poorly tolerate d b y awake pati ents . Correc t p lacemen t may be diff icul t, and probes may b ecome displac ed. Es ophageal te mpera tu res are unrel iable during thorac ic surgery. Co nti nuous gas tric s uc tioning wil l ca use a dec reas e i n esophagea l temperatu re (49). When an eso phag eal p robe is us ed with the patie nt in the si tting or prone pos i ti on, ora l s ec retions can track down to the connec tion between the probe and mon itor c able. This ca n l ead to incorrec t readings (9).

Nasopharynx
The temperature of the n asopharynx is measu red wi th a s ensor tha t is in contac t wi th the pos terio r nas opha ryngeal wal l pos terio r to the sof t palate. This loc ation shoul d place it c lose to the hypothal amus . A l though s ome s tudies show a good c orrelation of nas opharyngeal tempe rature with co re te mperatu re (29,46,50,51,52), other s tudies hav e f ound the c orre lation less sa tisfac tory (53,54,55 ).

An adv antage of this s i te is that is i t us ually e asi ly acces si bl e duri ng su rge ry. Readin gs taken wi th a probe in this pos ition a re normally not affec ted by the temperature of ins pi red gases un les s the re i s a leak a round the tracheal tube (53,56). This si te is not useful for pa tients who are awak e . E pis tax is may fo ll ow pro be i nsertion (57). Nasopharyn geal tempe rature is no t affec ted b y c ontinuous suc tion ing through a gas tric tube (49).

Urinary Bladder
Urina ry bladder temperature mon itoring invo lv es inserti ng an i ndwel l ing u rinary ca the ter with a thermis to r or thermocou ple n ear the patient end (Fi g. 29 .6). Urina ry bladder temperature us ual ly c orrelates wel l wi th those measured by nasoph aryngea l, p ulmonary artery, an d esophageal s ensors (20,28,45,47,48,51,58,59,60) P .864 but may la g behi nd during rapid warmin g o r cooling (2 9,43,46,50,61,62). The co rrela tion wi ll be inc reased wi th a high ra te of u ri ne flow.

Figure 29.6 Urinary catheter with temperature sensor near the patient end.

View Figure

Urina ry bladder temperature mon itoring c an be used both du ri ng and af ter s urgery. It may be espec ially us eful in the pa tient with ex tens iv e burns (63). It s hould no t be us ed during geni touri nary procedures (64).

Rectum

E lec tronic rectal the rmometers may hav e two measu rement modes : dwe ll o r moni tor. In the dwel l mode , the tempe rature is displ ayed conti nuousl y. The d wel l mode requi res a minimum of 2 to 3 minutes to reac h a s table temperature . The predic tiv e mode esti ma tes the temperature on the bas is of the c urv e of temperatu re rise . This mode requi res only 30 seco nds . A c omparis on of the meas urements o f the two modes yielded s imilar v alues during s te ady-s tate c onditio ns and mild temperature flux . Disposable probe cov ers c an be used to avo id c ross c ontamination . P robes sh ould be i nserted to at leas t 8 cm in adults and 3 cm in c hildren (65). The dep th of i nsertion c an be mark ed on the p robe. It s ho uld be c heck ed fo r placement af te r the pati ent is mov ed. The probe s hould be sec ure ly tape d to the p ati en t's buttocks , and the lead wire s hou ld be secured to a ga rment or s heet to av oid probe displace ment. Rec tal tempera ture is inf luenced b y heat-p roduci ng flora, the te mperatu re of the blood return ing f ro m the le gs , and ins ulation by feces . Rec ta l te mpera tu re is us ual ly s omewhat higher than that me asured at more c en tral si tes during s teadys tate cond itions (51,66,67,6 8,69,70,71). The rec tum is not a v asc ula r area, and the l ag ti me may be prolo nged wi th s hif ting tempe rature (26,52,55 ,72 ,73 ). The rec tum is us ual ly acces sible and moni to ri ng re lativ ely noninv asiv e. Rec tal temperature is not inf luenced b y ambient tempe rature. It is generally dis l iked by pati ents as unc omfo rtable, by hospi tal perso nnel as cumbe rsome, and b y b oth as aes thetica ll y objec ti onable . P robes are p rone to ex trusi on during rec ov ery from anes thes ia. Other dis adv antages are the relativ e inacces sibili ty d uring su rge ry and the risk of bac teri al contamination. Con traindications inc lude gynec ologic and urologic procedu res . Bowe l perfo ration is a ri sk (74). A pararec tal abs ces s and pneumope ri toneum hav e b een reported wi th i ts use (75,76).

Tympanic Membrane
Two di fferent tec hnologi es utili ze the ear. One uses a p robe tha t contac ts the tympan ic membrane , and the other measures infrared radiation.

Contact
The anatomic al pos i ti on of the ty mpanic membrane is deep wi th in the sku ll a nd separated f rom the inte rna l carotid arte ry by only the narro w ai r-f il l ed c left of the middl e ear an d a thi n s hel l of bone, mak ing it an attrac tiv e s ite fo r tempera ture meas urements . The tympa nic membra ne and the hypo thalamus share a common blood s uppl y, s o me asuring tempera ture at this s ite may re fl ect the rmal inf ormation at the prima ry si te of thermoregula ti on (17).

Tempera ture can be measured by inserting a thermis tor or the rmoc ouple probe in to the ex ternal audi tory c anal un ti l i t con tac ts the tympanic membrane. Because of the danger of perfo rating the memb rane, c linic ia ns tend not to place the p robe far enough i nto the canal . If i t does not touch th e memb rane, the readi ngs wi ll not be ac curate . In the awak e patien t, i t s hould be inserted until the patient feels the thermocou ple touc h the tympanic membrane ; app rop ri ate plac ement is confi rmed whe n the patient eas ily d etec ts a gentle ru bbing of the attached wi re (77). The l ower a nte ri or quarter of the memb rane s hould be use d (78 ). Af te r th e p robe is i nserted, the aural c anal should be oc cluded wi th c otton wool and cov ered ex ternal l y to prev en t ai r mov ement f rom coo ling the probe (79,8 0). Con tac t ty mpanic membrane probes a re shown in Fi gure 29.7. The s ens or is enclosed in sof t foam. It usuall y has a wi dened segment, p iece of foam, or a feather or barb to hold it in pl ace af ter ins erti on . After i nse rtion, the reading s hou ld s tabi l iz e quickl y. If i t does not, the probe s houl d be s lowl y adv anced unti l the reading s tabi lizes . Numerous s tud ies hav e shown a good co rrel ation be twe en tymp anic membrane temperature and tempe rature measu red in the es ophagus , pulmonary artery, o r urinary bladder (31,71,78,79,80,81 ,82 ,83 ,84 ,85). T emperature may be less ac curate duri ng rapid c hanges (29,40,79). Head pos i ti on can c aus e as ymmetric c hanges in the tympanic tempera tures (86). Upon assuming a late ral pos i tion , the tempe rature on the lower s ide inc reas es whi l e that on the u pper s ide dec reas es. Adv antages of ty mpanic membrane temperature moni tori ng inc lude c leanliness and conv enience. It is tol erated by c onsci ous pati en ts , mak ing it useful for pos toperativ e mon itoring . The s i te is readi ly acces s ible d uring mos t surgical procedures . Compl ications hav e been reported. Ooz ing fro m the ear, trauma to the ex te rna l auditory c ana l wi th s ubseq uent ex ternal otiti s , an d perforation of the memb ran e hav e been reported (81 ,87 ,88 ). These c omplica ti ons occurre d befo re the adv ent of f lex ib le co tton-tipped pro bes that are less trauma tic (7). Rec ommende d me thods to av oid tra uma inc lu de otoscopic ins pec ti on of the can al and drum before ins erti on, s topping ins ertion as s oon as res is tance is fel t, and placemen t in a wake patients to as sess d is comf ort. Care shou ld be take n that the P .865 probe is not pushed i nto the c anal when the head is mov ed .

Figure 29.7 Tympanic membrane temperature probes.

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Con traindications inc lude any ear abn ormality that would p rev ent c orrec t place ment, a sku ll f rac ture that passes through the os seous meatus , and perfora tion of the tympanic membrane.

Figure 29.8 Disposable probe for measuring skin temperature.

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Infrared
Infrared ear thermometry (infrared emis sion detec tion thermometry , infrared tympan ic membrane thermometry , infrared tympanic the rmometry ) i s p erformed by i nserting an o tos cope like probe into the ex ternal ear c anal (19). The tip is usu al ly cov ered by a dispos abl e cov e r. The dev ice de tec ts the amount of inf rared heat

emi tted. The wi de angle is too large to measu re only the tympanic membrane, s o it also reads the temperatu re of the ear cana l. S ince thes e thermometers a re known to give temperatures l owe r th an core temperatures , s ome man ufac ture rs prov ide of fs ets to es timate the te mperatu re at other s ites (89). Thes e offsets v ary fo r diff erent brands (17,26 ,90 ,91 ). A tug o n the ea r to s tra ighten the canal wh ile tak ing a reading wa s found by s ome i nv es tigators to i mprov e corre lati on with c ore temp era tures (92,93,94,95,96). Other s tudies di d not fi nd th at an ear tug is hel pful (20,69). The dev ice should be inse rted wi th a gen tle back and forth mo ti on, a nd fi rm but gentle p res sure s hou ld be ap plied to s eal the c anal f rom amb ien t ai r (9 4). Many s tud ies hav e co mpared temp era tures obtained b y inf ra red ea r th ermome ters to tempe ratures obtai ned f rom other s ites (19,25,41,42,44,52,58,66,69,70 ,83 ,90 ,91,93,9 7,98,99,100,101 ,102,103,104 ,105,1 06 ,107,108 ,109,110,111 ,112,113,114,11 5,116,117,118 ,1 19,120,121 ,122,123). The co rrela tions v ary f ro m ex cellent to poor. The re is c ons ide rab le v a riation amo ng different i ns truments and wi th different users of the same ins trument (20,109,114 ,120). A diffe rence of 1.6C be twe en the two ears has been repo rted (114). Readin gs are aff ec ted by the ambient tempe rature (124 ,125). If the face is coole d, there wil l be a dec rease in the reading (1 26). Acute otitis med ia wi ll not i nflue nce the reading unless there is suppuratio n, in wh ic h P .866 case the reading wi l l be s lightl y i nc reas ed (98 ,10 2,117,127). Adv antages of infrared temp era ture moni tori ng inc lude speed and reduc ed potentia l for c ross c ontamination . It is non inv asiv e, requi res no c lothing remov al , and is wel l tole rated by c onsc ious patients . The si te is us ual ly readi l y accessible. The e ase wi th whi ch the meas urements c an be obtained has made these the the rmometers of choic e in many p re- a nd pos topera tiv e uni ts. B ec aus e the readings are in termi ttent and s ubjec t to suc h v ariab il i ty, this technology is not rec ommended for i ntraop era tiv e us e.

Skin
Sk in te mperatu re c an b e me asured by us in g a l iquid c ry s ta l dev ic e o r flat d is c o r ti p of a lead c ontain in g a thermocou pl e o r thermis tor (6) (F ig. 29.8). Some skin probes hav e a s pec ial back in g to attac h to the body and ma te rial to ins ulate the sens or

f rom ambient conditio ns . An o paque d res si ng and/or tape ov er the sens or may dec reas e the effec t of env ironmenta l fac tors . Sk in te mperatu re is mos t commonl y measu red at the forehead , bec ause this si te has a fai rl y good bl ood f low, an d there is not much underly in g fat. The back , c hes t, anterio r abdominal wal l , finge rs , toes , and the an tec ubi ta l space ins ide the elbo w hav e also been us ed. The c orrel ation be twe en sk in temp era ture and co re temperature is controv ersi al . Sk in surface temperatu re is typic all y 2C to 4C less than co re temperatu re. Some manufac tu rers bui ld in an offs et to c ompensate for this differenc e (128). In s ome s tudies , sk in temperatu re has been found to c orrel ate well with core tempera ture (129,130 ). Ho wev er, mos t inv estigations hav e f ound tha t sk in temp era tu re does not ac curate ly reflec t core te mpera ture, and there may no t be a relationship betwee n a change in sk in and co re temperatu re (2 9,31,61,78,108,131,132,133). Moni tori ng sk in temperature c arries few ris ks . The s ite is e asi ly acces si bl e. The mai n disadv antage is tha t ski n te mperatu re i s a poor es ti mate of core body temperature and ma y giv e e rroneous info rmatio n (16). Sk in temperature readings are affec ted by a mbient temperature, skin surface warmi ng dev ices , intraope rativ e changes in cardiac outpu t, an d regional v asoc ons tric ti on (13 4,135,136,137). T he us efulness of s k in tempe rature mo ni toring as a sc reening dev ice for malignant hyperthe rmi a is l imi te d, as c utaneous v asocons tric ti on may oc cur wi th this s yndrome (138). Sk in te mperatu re may be us ed to ev aluate the qu ali ty of a regional bloc k. A rise in sk in temperature is an in dic ation that the bloc k is succes sful . Another use is in mic rosurgery. An inc reas e in sk in temperatu re may indicate that bl ood f lo w to tha t area has inc reas ed.

Axilla
To meas ure ax ill ary tempe rature, a mercury-g lass thermome ter or a probe with a thermocou ple o r the rmis tor is posi tioned over the ax il lary artery and the arm adduc ted (31). Signific ant diff ere nces hav e been found between mercury and elec tronic ax illary tempera tures (68,111). Tempera ture should no t be meas ured on the same side where a bl ood pressu re cuff is on the upper arm. Equi li brati on may tak e as long as 10 to 15 minu tes (72,138 ). A l though a few s tudies found satis fac to ry co rrel ati on wi th more central s i tes (133,139 ,140,141,142), mos t s tudies sho w p oor c o rrelation (20,25,29,45,51,58,68,69,98,11 5,116,129,14 3,144,145,146 ,147,148,149 ).

Ax il la ry temperature measurements are easy to take a nd are no t obj ec tionab le to the patie nt or nurs ing s taf f . The s i te is usuall y ac cess ib le. Howev er, i t is not cons idered acc ura te or reliable in adu lts . It i s used mos t frequently on i nfants and ch il dren because the patient's small s ize a nd gre ater surface v as culature mak e a rela tiv el y uniform te mperatu re (17,31). Readings a re i nfluenced by c ontac t with the probe, ski n perfus ion, ex posu re to the env ironme nt, skin warmi ng dev ices , and prox imity of the probe to the ax ill ary arte ry (20,26,56,148 ).

Mouth
Sublingual temperature is measu red by p lacing a p robe in one of the pocke ts on ei th er s ide of the f renulum of the tongue (15 1). The patie nt's mouth s hould b e c los ed and enough time allo wed fo r the read ing to be acc ura te. This a rea c ontains smal l muscul ar a rteri es that respond to masti ca tion or ho t or co ld l iquids by ex pand ing or c ontrac ting . Corre lation with te mperatu res measured at more c entral si tes v aries s omewha t but i n g eneral is fairl y s atisfac tory (2 0,58,77,113,115 ,151,152,153). Sublingual temperatures are wel l tolera ted b y patien ts . Readi ngs a re not aff ec ted by the presence or absenc e of teeth , in tubation , admi nis tration of ox ygen , a nasogas tric tube on c ontinuous s uc tio n, or the temperature of i ns pi red gases (145,150 ,154). Subl in gual tempera ture may be inacc ura te if th e pati en t is a mouth breather o r has tachy pne a (155 ). W arm and cold ambient tempe ratures hav e a smal l eff ec t on o ral temp era tures (124,125 ).

Trachea
Tempera tures in the trac hea c an b e me asured by us ing a trachea l tube with th e temperature s ensor in the c uff. S tud ies d iffe r in ho w we ll tempe ratures meas ured a t this s ite correlate with those at o the r si tes (156 ,1 57,158,159 ). P .867

Inguinal Area
The ingu inal area has be en us ed to meas u re temperature (45,72,160). Th e l eg is f irs t abducted and the femoral pulse de te rmi ned. T he sensor is placed j us t lateral to the f emoral arte ry, and the leg is adduc ted to c reate a s eal . A s ignificant drawback to this s ite is the time re qui re d to reach equ ilibri um.

Hypopharynx

A thermoc oupl e can be a ttached to the cuff of a supraglottic d ev ice to measure temperature in the hy pop harynx (1 61,162). Tempera tu res measured in this loc ation hav e correlated wel l wi th thos e a t other s i tes .

Hazards of Thermometry Damage to the Monitoring Site

Ty mpanic membrane and rec tal pe rf oration and trauma to the nose , ex ternal auditory c ana l, rec tum, and esop hagus have been reported (74,75,76,81,87,88,163 ,164). P robes can hav e sha rp edges th at could p res ent a hazard to the pati en t (165).

Burns
Burns ca n occur at the measu remen t si te if the probe ac ts as a gro und fo r the elec trosurgical apparatus (166,167,168). No ins ula ti on can c ompletely bloc k rad io f requenc y curren ts , and if there is no other sa tisfac tory return p ath , the c urrent can burn th rough insul ation (169 ). Us ing a ba ttery -o pera ted dev ice is no guarantee of elec tric al safety, b ecause the c has s is may b e g rounded through a metal support. Tempera ture probes should be ex amined befo re us e to detec t damage to the i nsulation. Es ophageal burns may be av oide d by inserti ng th e p robe v ia a sma ll trac heal tube (170 ). T he probe may be pul led back i nto the tube du ring periods of maxi mal elec trical ac tiv ity.

Incorrect Information
A faulty probe c an c ause an inco rrec t tempe rature to be displ ay ed (171,172 ,173,174). Sec retions or f lu ids in th e c onnec tion b etwe en the p rob e and reading i ns trument c an resu lt in fals el y e levated readings (9,10). If the batte ry i n a battery -po wered dev ice is depleted, the unit ma y s top f unc tioning or giv e i nc orrec t i nfo rmati on (6). Us ing jack s tha t fi t the rec eptacle but hav e intern al el ec tro nics i ncompatible with th e mo ni tor c an giv e fa ls e read in gs .

Probe Contamination
Reusable temperatu re probes may be a s ourc e of bac te ri al or v i ral pathogens ev en i f protec tiv e c ov ers are us ed (6 ,175).

Faulty Probes
Af ter a p robe is remov ed f rom i ts packaging, i t shoul d be i ns pec ted. A part o f the sheath o n a p robe c ould break off and be as pi rated.

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Questions

For the fol low ing ques tions , answer

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i f D is correc t i f A , B , C, and D a re co rrec t.

1. Ad vantages of thermis tors inc lude A . S ma ll s ize B . Interc hangeable and dis posab le probes C. Continuous readings D. Rapid respons e time V iew A ns we r2. Wi th the pla tinum wire thermomete r A . Cu rrent f lo ws in propo rtion to th e tempe rature d iffe rence B . Rapid thermal equilibration is poss ib le becaus e of the smal l diameter of the wi re C. Two wi re s of different me tals are weld ed together at their ends D. Resis ta nce of the wi re v a ri es wi th temperatu re V iew A ns we r3. Advantages o f the liq uid crystal thermome ters inc lud e A . Fas t co ntinuous readings B . Inf rared lamps do not interfe re wi th thei r re adings C. They can be applied p ri or to induc tion D. Ac curacy ev en at the ex tremes of ambien t tempera tu re V iew A ns we r4. Advantages o f infra red temperature monitors include A . Th ey do not contac t the ea rdrum di rec tl y B . To le rated wel l by pa tients C. Rapid measurement D. Continuous meas ureme nt V iew A ns we r5. The accu racy o f axillary temperature determinations is influenc ed by A . P rox imi ty to the ax ill ary artery B . P e rf usion of the sk in C. Sk in contac t wi th the probe D. Pa tient age V iew A ns we r6. Factors influencin g the temp era ture read ing in the nas opha rynx include

A . Te mperatu re of the i nspi red gases B . Leak in the trac heal tube c uff C. Gas tric s uc tion D. Temperatu re in the hypothalamus V iew A ns we r7. For correc t use of the esop hagea l te mp era ture mo nitor, A . Th e sens or shoul d be loc ated in the lo wer third to lower f ourth of the esophagus B . S tomac h placemen t of the probe wi ll p rov ide tempe ratures lo wer than core C. The p robe should be pl ac ed 12 to 16 cm dis tal to the po int of max imum hea rt sounds D. Temperatu re of the respi red g ases is not a fac tor i n th e l owe r th ird of the es opha gus V iew A ns we r8. Factors that ca n c ause esophag eal temperatu res to be unreliab le include A . A i rway humidification B . Th orac ic surgery C. Continuous gas tric s uctio n D. Pa tient i n th e sitting pos i tion V iew A ns we r9. Wh en using the ty mpanic me mb rane to me asure tempera ture, A . Th e probe does no t hav e to ac tual ly c ontac t the memb rane B . P e rf ora ti on of the membrane ca n occu r C. Readings wi ll be s table if the probe is in c lose prox imi ty to the memb ran e D. The p robe should hav e a means to hold it i n place V iew A ns we r10 . Factors that w ill cause inco rrect re adings from an infrare d ear th ermometer include A . Ce rumen B . A mb ien t ai r temperatu re C. Otitis media wi th s uppu ration D. Otitis media wi thout s upp ura ti on V iew A ns we r11 . Factors a ffecting the tempe rature mea sured in th e re ctu m include A . Cys toscopy B . P e ri to neal lav age C. Rec ta l con ten ts D. Colon pa thology V iew A ns we r

Chapter 30 Equipment for the Magnetic Resonance Imaging Environment

P .872

Magn etic reson ance imaging1 (MRI) i s a noninv asiv e diagnos tic procedure tha t can produce supe rior i mages wi thout us ing io nizing radiation. MRI s tudies a re no t painful but do requi re p atient immob ili ty. Pati en ts who are unab le to hold s til l of ten requi re s edation or genera l anes thes ia. Med ic all y uns table patients s uch as th ose f rom in tens iv e care may nee d s cann ing. A more rec en t dev el opment is the use of MRI to guide and moni tor inte rv entional procedures (1 ,2,3,4,5,6 ). MRI-g uided procedures may resul t in s maller i nc is ions as wel l as more accu rate local ization and tissue retriev al . Admi nis tering anes thes ia in the MRI un it poses a number of tec hnical diffic ulties . Kno wledge of this env i ronment as wel l as i ts ris ks and problems are essential for safe anes thesi a prac tic e. The p rac tice gui de lines f or anes thesia c are and moni tori ng dev el oped b y the Americ an Soc iety of An esthes iolog is ts and the A meric an Ass ociation of Nurs e Anes the tis ts apply to the MRI env ironment jus t as i n other parts of the hea lth care fac ili ty (8). In some s tates, these guidel ines are codif ied in to law (9).

Definitions
A dev ice is considered to be MR safe if i t prese nts no addi tion al risk to the patient or operato r. The presenc e of suc h a d ev ice may affec t the quali ty of the diag nos tic i nfo rmati on when i t is p lac ed in the MR env iro nment (10,11,12 ,13 ,14 ). A dev ice is MR c ompatible if i t is MR safe, its use in the MR env i ro nment does no t s ignif ic antly affec t i maging quali ty, an d there is no s ig nificant eff ec t on its operati ons . A dev ice may be MR compa tible o r saf e fo r certai n MR env i ronments but not o the rs . Theref ore , usi ng the terms MR c ompatib le and MR sa fe wi thout spec ifica tion of the MR env i ronment to whi ch the d ev ice was tes ted should b e av oid ed. The term MR env ironment is used to desc ribe the a rea wi th in the 5-gaus s l ine a rou nd the s cann er (the pe ri mete r around an MR sca nner wi thi n wh ic h the s tatic magnet field is hi gher than 5 gauss ).

Basic Principles

The re is a s tatic magnetic field i ns id e the MRI sc anne r bore (7,13,15,16,17,18,19,20,21,22,23). Onc e the magnetic fiel d is es tabl is hed, it is us ual ly no t tu rne d OF F. If the mag net is deac tiv ate d, i t can take up to 9 6 hours to rees tabl ish the magnetic f ield. The un it of meas urement of ma gnetic f ield s trength i s the Tes la. A fi el d of 1 Tesla is roughl y 10,000 times the magne tic fi el d at the earth's s urf ac e. One Tes la equals 10,000 ga uss. The s trength of a ma gnet is quantif ied in the mi dd le of the magnet. Howev er, the f ie ld ex tends beyond the margins of the magne t (the fringe field), dec reasi ng in s trength with dis tance f rom the bore. A tomic nuc lei wi th an o dd numbe r of protons and/o r neutrons hav e a s pin that produces a weak loca l magne tic field. In the a bsence of a s trong magne tic field, these nuc lei are ran doml y aligned. A s trong magnetic field c aus es approx imatel y half of them to rotate and al ig n para ll el to th is ap pl ied f ie ld (the low-energy, or ground, s tate). T he rema in ing nuc lei ali gn agai ns t the appl ied f ield (th e highenergy, or exci ted, s tate). Res onance des c ri bes the process of induc in g a c hange in ene rgy s tates of the nucle i caused by absorption of a s pec if ic radio frequenc y (RF) radi ation . A dding energy wi th a s hort, c ontrol led burs t of RF e nergy c auses so me low-energy (parall el ) sp ins to ju mp to the exci te d (anti -pa ral lel ) energy lev el . Immediately after the RF p ulse, the nuc le i ro tate bac k i nto al ignment wi th the s tatic magnetic field. As they re tu rn to thei r orig inal orienta ti on, energy is rel eas ed. A receiv er coi l detec ts this we ak elec tric al s ignal and ampl ifies i t fo r process ing a nd ev entual image formati on. Re laxation rates v ary fo r spec if ic b ody tis sues , al lo win g d iffe ren tiation of body s truc tures .

Facility Design
A member of th e anes thes ia departmen t sho ul d be inv olv ed i n p lanning the MRI uni t (24,25). An anes thes ia induc tion room that adjoins the sc anni ng area is us eful . The anes thetic c an be in itia ted at this location, wh ere ferromagnetic objec ts c an be safel y us ed. The anes thetized pati ent c an th en be mov ed into the sc anni ng area. Cons ideration s hould be giv en to plac ing a pos tanes thesi a c are room nea r the MRI unit. W av e gu id es , s pec ial l y d esigned c ondu its in the wal ls , c an be used to pass pi pes , cables , duc ts , tubi ngs , and elec trica l wi res through the wal l whi le maintai ni ng RF sh ielding (26,27) (Fi g. 30.1). They a re commonly p lac ed lo w i n th e room at the farthes t point f ro m the magne t and RF coils.

Fl uoresc ent l ighting emits RF energy th at inte rferes with imagin g (21). Therefore, i ncan des cent l ightin g a t a lo w wattage is used. Is ola ted e lec tric al po wer i s used to reduc e the probl em of l eakage curre nts (10). It is important that there are an adequate numb er of elec tric al plugs a t conveni en t locations for portab le mon itors and o the r equipment. The re are fou r bas ic op tions for l ocati ng moni to ri ng and other equi pment tha t is us ed to adminis ter an es thes ia or s edati on and the pers on attending the mo nitors and p ati ent: P .873

Figure 30.1 Wave guides are used to pass cables, tubings, sires, and the like through the wall while maintaining radio frequency shielding.

View Figure

Both th e mo nitors and the attend ant a re ins ide the magnet room. This allows di rec t obs erv atio n of the patien t. The attendant c an both see an d hear the moni tors , but the attendan t is s ubjec t to pos si bl e hazards (loud sounds , magn etic f orc es , and poss ibly trac e anes the tic gas es or hypox ia). It may be necess ary for the attendant to be in the room when there is an inabi lity to see the patient, partic ula rl y if the patient has entered the s cann er headfi rs t and/o r the patient is a chil d (28 ).

The mon itors are ins ide the room wi th the attendant outs ide. The p atien t and moni tors c an be v iewed through a win dow or by us ing a telev ision came ra. Light-e mitti ng diode (LE D) d isp la ys are us ual ly eas ier to read from a

dis tanc e than l iqui d c rys tal displays (21). Remo te aus cul tation us ing spec ial ly des igned eq ui pment c an be use d to moni to r heart an d res piratory sounds (29). A drawback is that moni tor sou nds an d a la rm s ignals may not be he ard wel l b y the attendan t.

The thi rd op tion is to hav e the moni tors ou ts ide a nd the attendant ins ide the room. Mos t equipmen t c an be k ept ou ts ide the sc anne r roo m wi th c ables and such run ni ng through wav e guides (30,31). The a ttendant c an obse rv e the moni tor through a win dow or a te lev is ion screen but cannot hea r moni to r and alarm so unds we ll .

The las t option is to hav e both the monitors and the attend ant o uts id e the room. The a ttendant ca n s ee the monitors and can h ear the al arms and sounds bu t cannot obs erv e the patient wel l.

If the a ttendant is outs ide the room, he may fai l to detec t dange rous s ituations in a timel y mann er (32). There is a report of a patient d ying during an MRI p roc edure whe n the pneumatic ally-driv en v enti la tor ran ou t of ox ygen (33). MRI auditory alarm s igna ls need to be muc h louder than those used i n the ope rating room due to the s ignif ic ant s canner noise .

Problems
It is important to note that s ome dev ic es tha t are s ta ted to be MR compatib le hav e l imi ta tions or res tric tions to the ir use in the MR e nv i ronment, and if they are not us ed in ac cordanc e with these res tric tions /limitations , they c an pose the s ame types of haza rds as dev ices that are no t MR c ompatible (14,34).

Ferromagnetic Materials
A ll materials can be c las sified as ei ther pa ramagnetic o r di amagnetic (7,15,16,17,18,21,22,27,35,36,37,38,39,40 ,41 ,42 ). Pa ramagnetic ma terials a re wea k ly a ttrac ted and di amagnetic materi als are we ak l y repel led b y magnetic fi el ds . Ferro magne tism is an ex treme fo rm of paramagnetis m ex hibited by a small g rou p of materials that are powerf ull y attrac ted to ma gnetic f ields . Fe rromagnetism is s hown by dev ices co nta in ing i ron, i ron ox id e, i ron -containing a lloys , nickel, and cobalt (43). Depending on the configuration of the magnetic f ie ld and the shape and mas s of the objec t and i ts posi tion wi thin the magnetic field, these f orces ca n result i n rota tiona l (torque) and/or translati ona l (a ttrac tiv e ) motion of the objec t.

Ferromagnetic Materials External to the Patient

The attrac tiv e forc e exerted on a ferromagnetic o bj ect depends on the dis tance between the objec t and the cen ter of the ma gnet, the mass an d geometry of the objec t, the s tre ngth of the magnet, and fac tors that modif y the f ie ld co nfi gu ration such as magne tic shielding. The attrac tiv e forc e i nc reases rapi dl y as one nea rs the magne t and ca n be s ev e ral times that of the earth's grav i ta tiona l field by th e time i t reac hes the c enter of the magn et. When free, ferro magnetic objec ts can mov e toward the magnet c enter wi th dangerous s peed (miss i le or pro jec til e effec t). Th is can resu lt in equ ipment dama ge as wel l as se rious injury to patients a nd/or workers trying to res train the equipment or trapped b etween the e quipment and the magnet (14 ,44 ,45 ). S inc e the magn et is continuousl y ON, it c an attrac t ferromagnetic dev ices ev en when n o i magi ng is occurri ng . In ad dition, P .874 s ignif ic ant mas ses of ferromagne tic mate ri al i n proxi mi ty to the magne t c an dis turb the homog enei ty of the s ta tic magnetic field, resul ting in dis torted ima ges . Ferro magne tic parts may wo rk l oose ov er time, so precauti ons shoul d be tak en during produc t desi gn to prev ent the incl usion of compo nents that could be pulled l oose and attrac ted to the magne t bore (10 ). Remov able equ ipment cov ers should us e c aptiv e hardware (e.g., sc rews and fas tene rs ). The re are hund reds of fe rromagnetic obj ec ts that mus t be kep t out of the MRI roo m. These inc lude personal i tems (watches , sc is sors , k eys , paper c lips , nai l cl ippers , hairpins , c alc ulato rs , identif ic ation badges , c igarette l ighte rs , s teel -tipped/hee led shoes , pens , je wel ry, c lipb oards , pagers , c ell phones , f irearms , e tc .); patient i tems (s trap buc k les , s afety pi ns , je wel ry, zi ppers, metal g own fas te ners , co ntrac eptiv e diaph ragms , cos metic s c ontaining metall ic p articl es (s uch as eye makeup ), s k in s taples , s uperf ic ia l metallic sutures , RF tagging brace lets , me tall ic handc uffs or ankle c uffs , e tc .), and medical dev ic es (s tan dard gas c yli nders , hemos tats , needles , v ia ls , s te th oscopes , ches t tube s tands , in trav enous po les , s tre tc hers , whe elc hai rs , mobi le s tands , c arts , anes thesi a machines , v apo ri zers , mo nitors , defi bri lla tors , s andb ags , trac tion weights , etc .) as wel l as mop buckets , v acuum c lean ers , laund ry c arts , ch airs , ladders , l ight fix tures , f loor buffers , an d parts of a fork lift (12 ,38 ,39,4 0,46,47,48,49,50,51). Non-l ithi um b atteries are s tro ngl y magn etic . The pres ence or absence of ferromagnetism i n a giv en obj ec t depends on a number of fac tors , i ncluding i ts c ompos ition and manufac ture. S ome objec ts tha t are

ferromagnetic may s ti ll be safe because thei r mass is too s mall for the forc es i nv olv ed to be s ignif ic ant and/o r bec aus e they are fi rml y anc hored in posi tion at a safe dis tanc e f ro m the sca nner. One method is to anchor a ll dev ices that hav e ferrous material to a mov able c ei ling pendant s ys tem with a predetermine d l imited range of mo tion (2 4). Ev en wi th a reduc ed ferro us load, s ome delic ate ins truments are s til l f erromagn etic and s ubj ec t to to rque tha t can c ause se ri ous dama ge. The refore, al l equipment that is no t re qui red s hould be remov ed f rom the s ite. Equipme nt may be posi tioned a way from the mag net, in a room adjacent to the MRI room with tub ings and wi res us ed to c onnect to the pa tient. The s afe dis tanc e from the center of the magnet depends on fi el d strength and shielding. It is usuall y cons idered to be g rea ter than the 5-gaus s line (1 2). Equipment containing ferromagnetic co mponents s houl d not be a llowe d pas t the 5-gaus s line unles s i t has been lab el ed MR s afe for that s pec ific MR env i ronment. A ll persons entering the scan room mus t be ri gorous ly sc reened f or inte rnal and ex ternal ferro magne tic mate ri al . P romine nt warni ng s igns shoul d be pos ted . MRI cente rs sh ould keep regis ters of common ly us ed dev ices and whether the y are safe to b ring in to the magne t ro om. The us e of metal de tec tors in MR env ironments may help, but is not recommended b y the A meric an Col lege of Rad io logy (49). Nonambulatory p atients should be brought into the MR uni t by us in g a n onmagn etic whe elc hai r or wh eeled s tretch er and transpo rt equipment c heck ed fo r magne tic objec ts (12). Materials considered safe in the MRI sca nner sui te inc lude aluminum, brass , nick el , plas tic , titanium, c oppe r, bery ll ium, s i lv er, and gold (43,52). Certai n types of s tainless s teels are cons id ered s afe, but oth ers are s tron gl y a ttrac ted in the magn etic f ield (1 1,38). Battery -po were d equipment s hou ld be tes ted at i ts i ntended locatio n and max imum f ield s trength to ens ure that there is n o s ignific ant attrac tion . A magnet can be us ed to tes t equi pmen t going into the MRI room (53 ). Mos t ins titutions hav e a c a rdiac pacemak er ri ng magn et, and this c an be use d. Ferro magne tic sc reening does not ev aluate th e potential for RF-related patien t i njury (53). Nonf erromagnetic me tals (e .g., alumi num or c opper) that wo uld y ield a negativ e magnetic s c reen c an absorb RF e nergy, resu lting in MR image a rtifac t or thermal i nju ry to the pa tient.

Implanted or Inserted Ferromagnetic Objects

Ferro magne tic objec ts wi thi n the patien t are s ubjec t to fo rces tha t try to bri ng them i nto alignmen t wi th the magnetic fi el d. The ex tent of injury wil l be affec ted by th e magn etic f ield s trength, f erromagn etis m of the objec t, the objec t's geometry and orienta ti on, the l oca tion of the objec t in s i tu, and the length of time the objec t has been ind wel li ng (fi bros is or granulation tissu e c an serv e to s tab il i ze the o bjec t). The re are documented cas es of death an d bli ndness resul ting f rom MR imagin g of pati ents with fe rromagne tic in trace reb ral aneurys m c li ps , c ardiac pace makers , an d c linic al ly oc cul t metal lic in traoc ula r (3 9,54,5 5,56). MRI is c ontraind ica ted for a pati ent wi th s hrapnel loc ated in a biologically sens itiv e area. It cou ld mov e a nd i njure the patie nt (10). People i n c ertai n occ upati ons , such as s heet me tal work ers , are at ri sk of hav ing magnetic f ragments in thei r bod ies and in many c ases a re not awa re of thei r presence (39). Now tha t MR imaging is a f i rml y es tabl is hed diagnos tic modality, efforts are b ei ng made to us e magnetical ly c ompatible subs titutes fo r prev iousl y util i zed f erromagnetic implants (39 ). Fo r ex amp le , mos t new ce reb ral aneu rys m c lips are made of no nfe rrous material (52 ). The Fo od and Drug Admi nis tration (FDA ) requires th at MR imagers be labeled to i ndicate that the dev ice is contrain dic ated fo r patients wh o h av e elec trica l, magn etic , or mechanical impl ants bec aus e the ene rgies produced by MRI s ys tems may i nterfere wi th the opera tion of thes e dev ices (57). The c omposi tio n of the dev ic e and i ts magn itude of magnetic def lec ti on s hould be determi ned befo re these pati ents are s canned. Th ese P .875 dev ic es inc lude pacemak ers , c ardi ov erter-def ibri l lators , elec tromechanical infus ion pumps , coc hlear impl ants , n euros timu lators, bone-gro wth s timula to rs , dental i mpla nts , bul lets , magn etic s phinc ters , magne tic s toma plugs , magnetic oc ul ar i mpla nts , tiss ue exp ande rs wi th magnetic pos ts , and magnetic pros the tic appl iances (57). P roblems ma y als o occu r with magne tic objec ts that are attac hed to the pati ent's body (e .g ., body pi erc ing) (12).

Equipment Malfunction
Magn etic inte rf erence can caus e c omputer o r osc il lo metric images to be dis torted (7,21,27,58,59). Dev ices wi th rech arg eable batteri es may s wi tch off and blank thei r sc reens . MRI interferenc e als o caus es trans fo rmers to bec ome saturated and burn out. RF puls es are also capable of induc ing elec tric al eddy c urrents and short

c i rc ui ting el ectri cal equ ipment. The magne tic field may cause damage o r erase data on magnetic media such as digi tal tap es or f loppy disks . Equipme nt may c onta in pumps , e lec tric motors , elec tronic ci rc uitry , or a nalog gauges that a re affec te d b y the magnetic f ie ld (10). The magnets in motors may become s aturated. This ca n res ult in l ack or s lo win g of moto r ope ration or i nc reas ed operating c urrent, whi ch co ul d u lti ma tel y burn th e mo tor out. The re are two general methods to solv e this p rob lem: loc ate the equip ment ou t of the magne tic field or make the equipme nt co mpatible wi th th e magnetic fields . One way to make equipme nt MRI c ompatib le is to s hiel d moni to rs and c ables f rom RF curre nts . Cables c an be wrapped wi th a th in laye r of aluminum fo il , and s mall copper boxes c an be used to hous e elec trical equipmen t. Us ing appropriate RF f il te rs in the magnet s hie lding and iso la ted fil tered a lternatin g-c urrent power c i rc ui ts may pe rmi t effec tiv e mon itoring (58). Moni tors s peci al l y d esigned f or use in the MRI uni t c ombine low f erromagnetic content, s hielding, an d f ilters to min imi ze magnetic f ield inte rference . Thes e dev ic es may hav e some limi tations to their use in the uni t. It is imp ortant tha t pri or to use, manuf ac ture r dec laration a nd/or cl ea rance by a rec ogni zed body such as the FDA demons trates MR c ompatibil i ty .

Image Degradation
Equipme nt can degrade the qual i ty of imag ing i n two way s (7,10,17,27 ,30 ,58 ,60 ). Fi rs t, ferrous me ta l in mon itors and other eq ui pment c an cause dis tu rbanc es in the magn etic f ield. S econ d, the equipmen t may genera te s ignals that interfere with th e MRI s ign als . Any RF en erg y withi n the ba ndwi dth of the rece iv er, inc luding s tray radiation f ro m outside RF sou rc es , is amplif ied. So urc es of RF noise incl ude elec trical mac hi nery, motors , c omp uter hardware, disp la ys , telev is ion trans mitters , beeper-pa ging s ys tems , two- way rad ios , comme rc ial rad io s tatio ns , and oth er elec tric al equ ip ment. It is c ommon prac tic e, therefo re, to enc lose the s cann in g a rea in an RF s hield. Nonconduc tiv e dev ices c an s afel y be pas sed th rough the s hield , but wires that transgress the shi el d can ac t as aeria ls and feed n ois e from the ex ternal env ironment into the examin ati on area. T his c an be ov e rco me b y fi ltering wi res th at run in and out of the sh ield. Care mus t be taken to match f il ters to spec if ic moni tors . To prev ent RF in terferenc e from degrading the MR image , appropriate measures to prov ide sh ielding, such as hous ing the display in a RF-tigh t enc losure o r locatin g

the uni t outsi de the room, s hou ld be used. In ei ther cas e, the con nec tions between the display uni t and the pa ti ent s hould pas s through f i lters tha t attenuate f requenc ies a round th e i maging f requenc y. A ll elec tric all y c onduc tiv e materi al tha t i s not requi red shou ld be remov ed f rom the MRI s ys tem bore . The dis tance from the magnetic co re nec ess ary to prev ent RF interferenc e v aries wi th the s trength of the magnet. Sev era l meters be twe en the sc ann er and other equipment are us uall y nec ess ary . This dis tance c an make it diff ic ult to read and i nte rac t wi th the equi pmen t. Long spl iced lin es and tubings may disc onnec t, imp ose high res is tanc e , or become obs tructed. Ano the r solution is to adjus t the frequenc y of the nois e source so that i t is outs ide the MRI-rec eiv er s ys tem band width. This c an of ten be ac comp lished by adjus ting the block that controls the operation of the mic roproces sor in the monitor. Onc e the ex amination has s ta rted, the pos iti on of the moni to ring equipment s hould not be c hanged, because repos itio ni ng of a la rge metal lic mas s ma y degrade magn etic f ield homogeneity.

Burns
Apply ing i ntermi tten t RF fields to metal lic objec ts wi th in the imaging a rea c an caus e hea ti ng and resu lt i n burns (7 ,1 0,16,2 6,48,57,59,61,62,63,64,65,66). Equipme nt of p rimary c onc e rn is tha t whic h may be pos itioned di rec tly i n the RF transmis si on field. Th is incl udes elec troc ard io gra m (ECG) elec trodes and leads , pulse pick up and pu ls e ox imetry sensors and c ables , halo dev ic es , and surfac e co ils as wel l as metal lic componen ts , connec tors , and s urface c oils . Thes e c an prov ide a path fo r curren t flow th rough the p ati en t or along the cab le sh ie ld to ground. If this current is not li mi ted, p atient burns c an resul t at the loca tion of equipment or at bod y parts located nex t to a n i ns uff iciently ins ulated RF shi el d. Other dev ices that uti li ze a wi re s uc h as th ermod ilution S wan-Ganz ca the ters or epidu ral c atheters c an also sub jec t the patie nt to elec tric s hock s or dan gerous heating (43). Burns may also oc cur f rom co ntac t wi th the scanner bore. Hi gh duty c yc le sequences ca use hea t to bu il d up P .876 on the ins ide of the bore. Burns can b e minimized by us ing the fo llowi ng meas ures :

E lec trica ll y-con duc tiv e leads should b e replac ed with nonconduc tin g paths (e.g ., fiberoptic cable o r plas tic tubi ng) o r hi gh-res is tance paths (e.g ., c arbon E CG leads ).

E lec trica ll y-con duc tiv e mate rial (ECG leads, c abl es , e tc .) that mus t remai n wi th in the MR s ys tem bore s hould be pos itio ned to p rev ent c ross po ints . A c ross poin t is wh ere a ca ble c ros ses anoth er c ab le , loops ac ros s i tself, or touches ei the r the p ati en t or s ides o f the ma gnetic bore more th an once . W hen the patient is mov ed , wires may coil a nd fo rm a l oop, s o i t is important to c hec k a ll wires eac h time the patient is mov ed.

Cab les a nd sens ors s houl d be k ep t away f ro m the bore (e.g., by plac ing a pulse oxime ter sens or on the patie nt's toe when the head is bei ng ex amined).

A ll s ensors , wi res , an d c ables shoul d be c hec ked to e nsu re that the el ec trical i nsulation around them is intac t. A s mall towel s hould be placed be twee n the pati ent a nd the wi res or cab le to av oid con tac t wi th the skin.

A ll unn ecessary conduc tiv e mate ri als such as unused wires , l eads , s enso rs , cables , and s urfac e c oi ls shoul d be remov ed f rom th e MRI env i ronment. A ll elec trica ll y-conduc tiv e mate rial that must remai n i n th e MR sys tem b ore shoul d be k ept from direc tly c ontac ting the pa ti ent by pl acing thermal and/or elec tric al insulatio n (inc luding ai r) between the cond uc tiv e ma terial and the pati ent. W ires shoul d not c ross me tall ic pros theses .

Cab les s houl d be pos iti oned s o that they exi t as c lose as possi bl e to the cente r of the patie nt tabl e of the MR s ys tem (63). It is a lso important to av oid cable c ontac t wi th the sk in or the MRI s cann er.

Consci ous pa ti ents sho ul d be ins truc ted to c all out if they ex perience uncomfortabl e hea t lev els so that the procedu re c an b e i mmedi atel y disc ontinued.

Any mon itor that d oes no t appear to b e operati ng prope rl y during the MR procedure s hould be remov ed . A cold c ompres s /ic e pack sho ul d be placed along sk in s tap les , superfic ial metallic sutures , and le ad attac hment s ites , if this can be safely ac complished (49).

Hypothermia

Hypoth ermi a can be a probl em, es pec ial l y with s mal l children (27 ). Ai r is often c i rc ulated ov er the pa tient duri ng the ima gin g s equ ence . Cov e ri ng th e pati en t, warmin g f luids , and us ing non -elec tric al hea ting pads and humidified i nspi red gas es can help to prev ent hypo th ermi a (52 ). He ating blankets and radia nt lights c anno t be us ed beca use they i nte rfere wi th i maging .

Other Patient Problems

Loud sounds in the MR e nv i ronment ma y o bsc ure c ries for hel p from a pa tient i n dis tress (9). The patien t s hould be giv en a s quee ze bal l to s oun d a dis tress signa l, but this is of limi ted us efulness in th e s edated pa tient. A major problem f or anes thes ia pe rs onnel is the relativ e in acc essibi lity of the pati ent. This c reates problems with moni to ring, airway mana gemen t, intrav enous ac cess , pati ent v isual iz ati on, and moni tor application. Pa tients c an only be di rec tly observ ed from ei the r end of the tunne l and can onl y be ex tricated by sl iding them out.

Specific Equipment
A numbe r of dev ices spec ial ly des igned to b e used in the MRI unit are av ai la ble . It i s impo rtant to demons trate MR co mpatib ility by preus e tes ting, ma nufac turer decla ration, and/or c learanc e by a rec ogni zed bo dy s uc h as the FDA . For d ev ices that do not carry s uch c redentials , i t is adv isable to consul t the manufac turer or biomed ic al personnel with expe rtis e i n MRI before introduc ing them in to the MRI room. It is i mporta nt to read all of th e i ns truc tions acc ompanying a p iec e of equipment, bec ause s ome equipment may be MR s afe or compa tible onl y if i ns tal led a ce rtai n dis tance from th e magnet (67). MR is an ev olv ing tec hnol og y, and s pec if ic ati ons and perfo rmanc e c harac teris tics of s pec ific MR s ys tems c ontinual ly c hange. P roduc ts s hould be tes te d under s imulated or ac tual use condi tions . Bec ause upgrades to the MR s ys tem to achiev e highe r perfo rmanc e lev els ma y aff ec t the c harac teris tics of the equ ipment, yes te rda y's dev ice tes ts may not be s uf fic ient to ens ure the s afety and ef fec tiv enes s of a dev ice wi th toda y's MR sy s tem (10). Sinc e new eq uipment is continuall y being introd uced , it is on ly possible to make ge neral iza tions about whi c h eq uipment is MRI c omp ati bl e. It is rec ommended tha t equipmen t intended for us e wi thi n the magn et room be c learly labeled wi th the maxi mum fi el d l ev el wi th in whi c h i t c an opera te effec tiv ely (10).

Moni tors wi th mul tiple func tions dec rease the amount of equip ment that mus t be transported, dec re asing the ri sk of equipment damage and injury to the personnel respons ible f or tra nspo rt. Any equipment that has an al arm s hould hav e a v isu al al arm s ignal , bec ause auditory s ignals may not be heard (5).

Anesthesia Machines
S tanda rd anes thetic mac hines con ta in v a rying amounts of fe rromagnetic subs tanc es and elec tronically c ontrol led components , making them unsui table f or us e in P .877 prox imity to an MRI magnet (68 ,69 ). Non-MRI c ompatible a nes thes ia mac hines hav e been us ed wi thout probl ems by ke eping them 20 to 30 feet awa y f rom the core of the magnet (26). Some anes thes ia prac titioners hav e us ed long tubings fe d into the scanning room f ro m an anes thesi a mach in e p laced outs ide the scan ni ng room or a s tandard anes thes ia mac hine bol te d to th e wa ll (31 ,52 ). Re placing ferromagnetic co mponents (e.g., s upport s truc tures , c as tors , c y li nde rs , and parts of c ylinde r s upports ) with nonf erromagnetic materia ls an d aluminum c ylinders c an make an anes thes ia mac hi ne MRI compatible. A fe w o unces of magn etic material may prov e negl igible. MRI-c ompatible anes thes ia mac hines are av ail able (Fig. 30.2). A luminum c yl in ders hav e been av ai lable for s ome time. Unfo rtunatel y, confusi on abou t c yli nder c ompos iti on can aris e (70 ).

Vaporizers
Mos t s tandard v aporize rs perf orm acc ura tely whe n used in the sc anni ng room (36,68,69,71). Howev er, a portable v aporizer may be dangerous du e to ferromagnetis m (51).

Anesthesia Breathing Systems

A numbe r of breathi ng s ys tems hav e been used s uccessful ly in the MRI env ironment. Thes e inc lude the c i rc le a nd Mapleson s ys tems (2 0,35,52,58,72,73). Long corrugated or fresh g as tub in g wi l l be requi red if the anes thes ia machine is remote f rom the patient. Fortunate ly , mos t c omponents of ci rc le breathing sys tems us ed tod ay are nonmetallic .

Figure 30.2 MRI-compatible anesthesia machine. (Picture courtesy of Ohmeda.)

View Figure

P .878

Anesthesia Ventilators
S tanda rd anes thesia v en til ato rs us ual ly c ontain ferromagnetic materia ls , pumps , elec tric motors , and a nal og gaug es that c an b e aff ec ted by the magne tic fi el d unles s spec if ically adapted fo r the MRI. These may not func tion prope rl y in a magn etic f ield or may d egrade the image. A remote v en ti lato r in the con trol room wi th c i rcui t tubing fed i nto the sc ann ing room c an be us ed, o r an incompa tible v enti lato r can be attached to the wall (31 ,52 ). Speciall y engineered MRI-compa tible v enti lators (bo th an es thes ia and c ri tical care) that hav e no el ec tro nic c omponents are av ai lab le (27,35,74,75,76,77). Fl uidic v enti lato rs work wel l i n the MRI env i ronment (75). Cur-rently av ai lab le MRIco mpatible anes thesia machines a re eq uip ped wi th v entil ators . An MR-c ompatible positiv e end -ex piratory p res sure (PEEP ) dev ice is av ailabl e (78).

Pulse Oximetry
Mos t of the early pu ls e ox imete rs were both susc eptible to interferenc e from the RF pulses and a sourc e of interfe rence to the MRI s ignal (10 ,15,1 7,21,79,80). Burns hav e been reported at both the s ens or s i te and along th e c able

(17,22,61,62,81,82). Heav y insulation and shielding c an be us ed to isolate the moni tor signa l (17,2 1). The moni to r should b e p lac ed as far from the magnet as possible. Components , i nc luding the probe , with a low f erromag netic c ontent are us eful , as is minimi zing the numbe r of elec trica l connec tions and c omputer c hips within the moni tor. Mos t c onsoles h av e fil te rs in the circ ui try and some models hav e fil te rs i n the cable to help elimin ate ex traneous s igna ls . Thes e help to separa te the s ignal f rom bac kground nois e (21). A conv enient method to eli mi na te ferromagn etic wi re i s to us e a fiber-optic c abl e (79,83). If a s tandard f erromagnetic c abl e is used, i t s hould be wra pped wi th alumi num or co pper foi l to s hield the metal and d ec reas e RF interferenc e (22,80,84). A v arie ty of MRI-compatible s ens ors , cables, and co nsoles a re av ailable. The sens or c an be shielded to prev ent noise from reachi ng th e MR s ys tem. The digi ts can be p rotec ted wi th c lear plas tic c ov erings (27). The s enso r s hould be plac ed as fa r from the s can si te as p ossible. This may requi re that i t be plac ed on th e foo t or hea d, depend ing on the area to be i mage d. The c abl e should be ex tended in a s traight line away from th e patien t. The length of the cable should a llow th e oxi mete r to be far enough f rom th e ma gnet to prev ent i mage deg radation .

Respiratory Gas Monitoring

The re are a number of di fferent technologi es to meas ure res pi ratory gases . The y are dis cus sed in Chapter 22 . Mains trea m c apnome try s ys tems ca use image i nte rference . The sens or requires shielding f rom RF rad iation. Sides tream moni tors may be us ed during i maging as l ong as the moni tori ng dev ice is ou ts ide the magn etic f ield (1 9,58,85). Multiple len gths of tubing may be con nec ted to a llow th e moni tor to b e outs id e the mag netic f ie ld. The ex tra l eng th of tubing be twe en the pati ent a nd the mon itor may d egrade the c apnogram and dec reas e the ac curac y of the end-tidal readi ng, es pec iall y with s mal l pa ti ents (22 ). Ho wev e r, ev en if end-tidal meas urements are no t acc ura te, the tre nds and resp iratory pa ttern ma y s ti l l giv e us eful info rmatio n. If enough tu bi ngs are c onnec ted together, th e res is tanc e can become s o high that the alarm fo r bl ocked tubing is ac tiv ated (83). MRI-c ompatibl e mul tigas monitors are av ai lable . This tec hno logy c an be combined wi th other modal ities suc h as pulse ox imetry , elec troc ardiography, and non inv asiv e

blood pres sure monitorin g (52). Such equipmen t can be posi ti oned either i ns ide o r outside the magne t ro om. Che mica l detec tors (Chapter 22) tha t change c olor i n the p res enc e of carbon diox ide are made of plas tic and co ntain no metal parts . They mus t be placed c los e to the pa tient and may be diff ic ul t to see. Th ey are qu al itativ e dev ices and are on ly generall y quanti tativ e . This makes them more s ui ted for c heck ing tracheal tube place ment than for l ong cas es. Elec troc hemi cal ox ygen anal yze rs are usua lly s afe for use i n the MRI s ui te as long as they are outside th e ma gnetic f ield (20,22).

Noninvasive Blood Pressure Monitors

Automated bl ood pres sure monitors are disc uss ed in Chapte r 27. T he MRI does n ot af fec t monitors that use the osci l lometric me thod as long as the elec tronic uni t is ei th er sh ielded o r wel l away f ro m the magne t c ore (18 ,19 ,20,2 6,27,36,85,86,87,88). It may be nec ess ary to use ex tended tubings . Ferrous c onnections on the c uff shoul d be replac ed wi th plas tic ones (83). Manu al sp hygmomanometers hav e b een ada pted f or use during MRI by rep lacing all ferromagnetic co mponents wi th b ras s , aluminum, o r plas tic piec es (36 ). A pl astic s tethos cope c an be used to moni tor Koro tk off s ounds . Th e ma gnetic f ield ma y af fec t the acc uracy of anal og gaug es since the mov eme nt mec hanism in so me gauges us es a smal l magn et and a co il for o perati on . B lo od pressu re can be moni tored outside the sc ann er by l engthen in g the tubing c onnec ted to the c uff (89). Ul traso nic Doppl er units hav e been used to moni to r sys tolic blood pressu re (89,90).

Invasive Blood Pressure Monitors

Mos t intrav as cul ar l ines are nonmagnetic an d a re no t affec ted by the magn etic f ield (36). Direc t pressure readings c an b e obtain ed if the l ead f rom the p res sure P .879 transduc er is pass ed th rou gh a RF f il ter or p osi tioned a way from the magnet (30,58). Fiber-op tic MRI-compa ti ble transducers are av ai lable (18,91).

Electrocardiographic Monitors
The E CG ca n c ause patient burns and i mage deg rad ati on as we ll as function i nacc urate ly in the MRI e nv i ron ment (15,17,21,27,35 ,52 ,58 ). S T -se gment moni tori ng is imposs ibl e in the presence of the magne tic field us ing current tec hnology (92).

The amo unt o f RF interfe rence tha t is c oupled i nto the leads c an be c ontroll ed by appropriate design meas ures (e.g., by se lec ti ng appropri ate ma te ri als for the ECG l eads and by fi l tering the amp lifi er c ircui try i nput) (10). S pec ial MRI-compa tible elec trocardiographic leads may be c ons tructed by us ing hi gh-res is tance c onduc to rs that minimize induced RF currents (23). A numbe r of measures wil l mini miz e eff ec ts (7,21 ,27 ,35 ,5 8,93). Non-ferro magnetic fas teners , e lec trodes , leads , and c ables are av ai lable. A filter c an reduce artifac ts i n mos t l eads (68,94). Goo d s kin p repara tion is important to optimi ze the E CG s igna l. The skin should b e s hav ed and cleansed wi th alc ohol before th e e lec trodes are plac ed (15). For bes t resul ts , the sk in should be d ried or l ig htly ab raded (27 ). E lec trodes sh ould be placed as c los e to the center of the magnet as poss ible becaus e the RF powe r is c hang ing leas t at this point. The limb el ectro des should be as c los e togeth er as possi bl e and in the same plan e. Us ing ches t leads , V 5 and V 6 mi ni mizes artifac ts (95). Li quid c rys tal sc reens do not undergo dis torti on as do ca thode ray tubes (58 ). The relativ e len gth of ECG leads ma y be c ri tic al i n prev enti ng gradient-ind uced a rtifac t; therefo re, many manu fac turers adv ise ag ains t modif yi ng E CG l eads supp li ed wi th MR sys tems (58). Telemetry ma y soun d appea ling bec aus e i t reduc es the wirin g and cabl es needed , but it ma y interfere wi th th e RF used f or ima gi ng. Th is i nterference is not s een wi th ul trahigh f requenc y uni ts . Thes e tel emetry u ni ts are limited to QRS co mpl ex detec tion (27,88).

Temperature Monitors
S tanda rd thermis tor tempe rature p rob es can dis tort the magnetic f ield, c aus ing l ocali zed image dis torti on if placed ne ar the a rea of in teres t (96 ). They could also caus e a localiz ed concentrati on of RF po wer that wo uld result i n inc reased h eating. S mal l wi re probes hav e be en used in th e MRI without exc ess iv e heating (96). A l though temperature probes with fi l tered cables a re av ailab le, the y carry the same risk s of s ignal inte rf erence and b urns as oth er elec tronic moni tors (9 7,98). A bu rn as soc iated wi th temperature mon itoring us in g a p rob e s pec iall y desi gne d for use during MRI has been reported (98). A b urn may be c aused by in adv e rtent formation of a c able loop d uring pa tient mov emen t. Fl uoroptic tempe rature pro bes th at contain material that has tempe raturedependent op tical properti es are n ot affec ted by high magne tic fi el d s trength and RF pulses and are theref ore more sui ta bl e for use in the MRI env ironmen t (96). These probes are more expensiv e and more f ragi le than wi re thermis tors .

Liquid c rys tal tempe rature s trips work we ll in the MRI roo m bu t may not b e eas y to observ e (15 ).

Laryngoscopes
The s tandard laryng oscope (Chapter 18) is no t fe rromagne tic but c an undergo a degree of to rque in a magne tic field (58). P las tic laryngosc opes are av ail able, b ut mos t batteries are magnetic . One s oluti on is to modify the hand le to operate f rom a non-battery-b ased power s ource (36 ,52 ). A remote f iberoptic l ight so urc e c an be us ed. MRI-c ompatible l aryngoscopes are avai lable. Mos t are po were d by li th ium batteri es . A paper- or p las tic -cov ere d l i th ium battery can be used wi th a plas tic l ary ngos cop e (17,18,19,58 ,99 ). If an MRI-c omp ati bl e la ryn gosc ope is not av ai lable , anes th esi a can be induc ed and the ai rway i ntubated ou ts ide the magne t room using a c onv entional l aryngoscope before the patient is mov ed in to the scanner (19). If inadv ertent ex tu bation occurs whi l e the pa tient is in the sc anne r, an MRI-s afe l aryngoscope wil l be ne eded .

Tracheal Tubes
Trac heal tubes (Chap te r 19) are mos t c ommonl y made of p ol yv inyl c hl oride and a re safe to us e in the MRI env ironment. There a re reports of signal interfe rence from the sprin g i n th e c uff inflation c heck v alv e (60 ,100,101). A trac heal tube wi th a wi re sp iral c annot be used in the MRI room (3 5,102). Connec tors shou ld be plas tic .

Supraglottic Airway Devices

The laryngeal mas k (Chapte r 17) is sui table for the MRI env i ron ment. It a llows the l ight lev el of anes thesi a that is poss ib le, as the re are no painf ul s timuli inv olv ed in the MRI proces s . Bec aus e s ome la ryngeal inf lation v alv es mask s c ontai n me tall ic material , i t may be necess ary to remov e th e v alv e and knot the pilot tub e (103 ). Special lary ngeal mask a irways (LMAs ) wi th v alv es that do not co nta in f errous material are av ailab le (104). If the L MA -Flex ibl e or LMA -P roSeal is us ed, the metal co il p roduces a l arge black hole in the image in the area surrounding the airway as wel l as dete ri ora tion of the i mage fu rther out (105). P .880

The LMA may no t be sui table if magnetic resonanc e spec trosc opy is p erf ormed becaus e the resonance of s ome s i lico ne-c ontai ni ng materi als compromises i nte rpretation of the s cans (106 ).

Other su pragl ottic dev ices a re for th e mos t pa rt mad e of pol yv iny l chloride or s il ic one, wh ic h does no t caus e problems wit h the MRI. The re are no reports of problems at the time of this wri ti ng .

Other
MRI-s afe and -comp atible suc tion regul ators and nonmetallic preco rdial s tethos copes a re av ail ab le and s houl d be used. Some inf usion pumps n eed to be loc ated a way from the mag net o r shielded or they may pe rform inacc ura tel y (17,36). MRI-saf e infus io n pumps are av ai lable. Ex tensio n tubing may be required. T here is a report of a patient-control led analges ia dev ice that ma lfunc tioned a fter ex pos u re to the magnetic f ield (107,108). Some inf usion pumps func ti on co rrec tly in the MRI env i ronment (52,109 ,110,111). It is possible to moni tor intrac ran ial pressure in this s etti ng by us in g a nonfe rromagne tic sub dural bo lt o r plas tic cath ete r and a fibe roptic cabl e (21,53,112,113 ). E lec troenc ephalog raphy and ev oked po ten tial monitoring, both of wh ic h use long conduc ting wi res , wil l requ ire tec hnologica l adv anc es before they c an be used in magn etic f ields (92).

Personnel Hazards
It is no t pos s ible a t th is time to dete rmine wi tho ut ques tion if there a re hazards to personnel who work in the MRI env i ro nment. Th is is largel y due to the relativ ely short ti me for wh ic h this method of i maging has been in ex is tence and the fact that this wo rk is occas ional for mos t prac ti tione rs . Futu re ep ide miologic ev id ence may or may not demons tra te harmfu l effec ts of lo ng-term expos ure . Female s taff sho uld cons ider av oiding th is area during the firs t 3 mon ths of a p regnanc y.

Noise
Noise is due to v ibratio n of the s wi tch ed gra di ent c oils and is enhanc ed wi th h igher s trength gradient coils , s horter gra die nt duty c ycles , and fas ter pulse repetitio n f requenc ies i n th e ma gnet (114). T he trend toward upgraded i maging sys tems and s tronger magnets would sug ges t tha t noise l ev els are likel y to inc reas e (31 ). No is e l ev els up to 106 4 dec ibe ls wi th a n av erage around 92 d eci bels hav e b een demo nstra ted (31). These are po ten tially damaging lev els , a nd care mus t be taken to reduce these lev els of expos ure as much as pos si ble . Ear plugs shou ld be cons idered, a lthough the y may interfe re wi th heari ng aud itory ala rm si gnals (43,5 2).

Exposure to the Magnetic Field

W ith the inc reased us e o f MRI and magnets of i nc reasing s trength, anes thes ia prov iders are experienc ing inc reas ed exposure to s tatic magnetic f ie lds wi thin MRI units . Th e s ta tic magne tic field ex tends b eyond the confines of th e ma gnet. The s trength of this f ri nge field de pends on the magnet c onf ig ura tion and sh ie ldi ng . It dec reas es rapi dl y as the dis tance from the magnet i nc reas es . T he biologic effec t of s tatic magnetic f ie lds is a con trov ers ial topic (38). There are no de mons tra ted oncoge nic o r teratoge nic e ffec ts (52 ). It wou ld se em p rudent to tak e reasona ble precauti ons agai ns t repe ti tiv e and av oidable ex pos ure to intens e magnetic fields . Risks i ncl ude dange r from unres trained ferromagnetic objec ts a nd from mov ement or malf unc tion of MR-incompa tible impl ants wi thi n their bodi es (31).

Trace Anesthetic Gases

Trac e an es thetic gases and the ir ris ks to anes thes ia pe rs onnel are disc uss ed in Chapte r 13. Sc av enging s ys tems and good v entilation wi th f re quen t ai r exc hang es are not al ways av ail able in the MRI uni t (31). S ome breathi ng s ys tems suc h as the Maples on s ys tems (Chapter 8 ) are often use d for pedi atrics , and many of thes e are not scav enged.

Hypoxia
If liquid heli um that surrounds the sup erc onduc ting so lenoid in the magnet esc apes , i t is possi bl e that a hyp oxic env i ronment may be c reated (31 ). Ox ygen s enso rs can be plac ed in the cei li ng to warn of this problem.
1

Mo s t ph ys ici ans refe r to this typ e of imaging as MRI, wh ile mos t p hys ic is ts refer to

i t as nuc le ar magnetic res onanc e (NMR) (7). B oth are accepte d terms and refer to the same techn ology.

References
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Questions
For the fol low ing ques tion, s elec t the c orrec t ans wer 1. T he dis tance from the center of the magne t tha t is usually cons ide red to b e safe fo r ferromag netic objects is A . Th e 2-gauss l ine B . Th e 3-gauss l ine C. The 4 -gauss l ine D. The 5 -gauss l ine E . B e yond the 5-gaus s line V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i f D is correc t i f A , B , C, and D a re co rrec t.

2. Which fa cto rs determine th e a ttrac tive force on a ferro ma gnetic objec t in the MRI unit? A . Th e s treng th of the magnet B . Th e mass and geometry of the ob jec t C. Magnetic s hie ld ing D. The d is tance of the obj ec t from the ou ter field of the ma gnet V iew A ns we r3. Wh ich of the fo llow ing a re cons ide red to be safe in the MRI scanner? A . A luminum B . B e ryll iu m C. Gold and s ilv er

D. A ll types of s tai nless s teel V iew A ns we r4. Wh ich metals can cause a ne gative magnetic screen and abs orb radio freq uency energ y that can result in an MRI artifac t or th ermal inju ry to the patient? A . A luminum B . Gold C. Copper D. S ilv er V iew A ns we r5. S ources of ra dio freq uency no ise that can degrade the MRI image in clu de A . Co mme rci al rad io s tations B . B eepers C. Motors D. Liqu id c rys tal d is pl ays V iew A ns we r6. Wh ich items may cause a burn from rad io frequency fields? A . E CG elec trodes B . E pidural catheters C. Pu ls e ox ime try cables D. S wa n-Ganz catheters V iew A ns we r7. Me tho ds to keep pediatric patients from develo ping hypothe rmia in the MRI u nit include A . W arm f luids B . Radia nt lights C. Cov ering the patient D. E lec tric al hea ting pads V iew A ns we r

Chapter 31 Temperature Control Equipment

Physiologic Temperature Control
Numerous s tud ies hav e shown th at s ignif ic ant temperature c hanges routinel y oc cur i n a nes the ti zed pa tients (1 ). Inadv erten t hyp othermia is b y far the mos t common dis turbanc e. W ithou t spec ific in terv en tions , up to 9 0% of patients e nte ri ng th e pos tanes thesia c are un it (PA CU) may be h ypothe rmic (2). A n exc eptio n may be pati ents unde rgo ing magnetic resonanc e imaging (MRI) i n whom th e abso rption of radio f requenc y radiation may pa rtia lly offse t hea t loss. P .885

In the unanes the ti zed pa tient, v asoc ons tric ti on main tains a temperature gradi en t between the co re and pe riphe ry of 2 C to 4C. Core body temperature is normal ly mai ntained wi thin a narrow range of 37 0.2C. W hen c ore body temperature go es out of this range, physiologic mecha nis ms are i ni ti ated to rees tablish the norm. Anes thes ia al ters th e res pons e threshold , al lo wing the bod y to ex perience greater v a ri ations in temperature before it attempts to rees tab lis h a 37C c ore temperature . Res pons es to al tere d tempe ratures are les s effec tiv e under anes thesi a. Hypoth ermi a und er anes thesi a usuall y foll ows a charac te ris tic p attern (1,3,4). Core body tempera ture usuall y dec re ases 0.5C to 1.5C durin g the firs t hour (5,6 ,7) as v asodi lata ti on caus es redis tri bution of bo dy heat from the c ore to the periphery. W arming pe ri phe ral tissues before induc tion of anes thes ia (prewarming) dec reases the central-to -pe riphe ral tempera ture gradient, thereby minimi zing the redis tri bution of heat f rom the core to the periphery and reduci ng the ini tial dec rease in co re temperature (8,9 ,10,11,1 2,13,14,15,16,17,18,19). This redis tribution c anno t be prev ented by intraope rativ e ski n surface warmi ng (14). Af ter the f irs t hour, core tempera ture ty pic ally dec reases at a s lower rate as the body's heat los s exceeds the meta bolic h eat produc tion . This is follo wed by a thermal plateau during whi ch core temp era ture no longer s ignifican tl y dec reas es . A t this time , hea t loss equ ilib rates wi th heat produc ti on and v asocons tric tion cons trains metabolic hea t to the core c ompa rtment wh il e all owi ng pe ri pheral tissues to c ontinue to co ol . Patients wi th n europathi es hav e mo re sev ere h ypothermi a than other patien ts , poss ib ly becaus e the onset of v as ocons tric tion is del ayed (20 ). A

plateau may nev er be reac hed when regiona l anes thes ia bl ocks v asoc ons tric tion (1). In pos tanes thetic pati ents , v asoc ons tric tion dec reases re warmi ng rates . Fo r this reason, patients shou ld be warmed duri ng surgery rather than a llowed to cool and then be pos toperativ ely res cued . W armin g ma y be accele rated by us ing c ertain drugs (21,22) o r with a sympa the tic block (23).

Etiologies of Heat Loss

Mos t heat is los t v ia the ski n surface. This los s is ro ughl y proportion al to the sk in to-env i ronment tempe rature g rad ient and the bod y surfac e area in con tac t wi th a l ower temperature env i ronment. Ped iatric pa tients hav e a high s u rf ace area to body mass ratio and thus tend to cool more qu ic kl y than adul ts bu t also re warm more quick ly (24).

Radiation
Rad iation is the maj or hea t loss mechanism, ac counting for 65% to 70 % of the body's heat los s (6). This is the loss of electromagnetic energ y through inf ra red rays f rom th e wa rm body to colder o bjec ts in the roo m that do not co ntac t the body. Rad ian t hea t loss is a func tion of the difference in tempera ture between the patient and o bjec ts in the operating room (OR) and th eir h eat e miss iv ity (3 ). It i s unaffec ted by ai r temperature , ai r mov ement, or the dis ta nce betwee n the su rf aces .

Convection
The s ec ond ma jor mechanis m of heat los s is conv ec tion. This is the trans fer of hea t to an a ir c urrent. The magni tude of conv ec tiv e hea t exc hang e is de termin ed by the temperature gradient between the body a nd the ai r as we ll as the v eloc i ty of the ai r. Surgical drapes prev en t conv ec tiv e hea t loss during s urgery. Mos t of the heat los t by this mechanis m oc curs when bod y surfaces are exposed prio r to s u rgica l draping.

Conduction
The thi rd heat loss mechanism is co nduc tion. Heat is los t through di rec t c ontac t between the pa ti ent a nd colder o bj ec ts such as the opera ting table , line ns , s urgic al i ns trume nts and skin preparation , irriga ti on, a nd in trav enous (IV ) f luids (25 ,26 ). The heat flo w i s proporti onal to the temperatu re diff erenc e b etween the two bod ies . The rmal ins ulation be twe en the s urf aces wil l reduc e heat tra nsfer. We tness i nc reas es conduc tiv e heat los s (6). Relativ el y l i ttle heat is los t to objec ts such as

the OR table pad, but h eat los t when col d preparatory a nd irri gation s ol utions and IV f lu ids a re us ed can reduc e body temperature s ign if ic antly .

Evaporation
The f ourth heat loss mec hanism is ev apo rati on. Ev aporation l os ses oc cur f ro m the sk in, res pi ratory trac t, open s urgic al wounds , pneu moperitoneum, or we t to wel s and drapes that are i n direc t c ontac t with th e p atien t's body.

Other Factors
A numbe r of fac tors d ete rmine the s ev e ri ty of hypo the rmi a. The longer the s urgical procedure, the greate r th e d rop in temp era ture. Th e site of s urgery is another cons ideration , si nce large cav i ties a re subjec t to cons iderable heat l oss f rom ev aporation, whether open or l aparoscopic tech niques are used (27,28,29,30,31,32,33,34,35,36 ). Ad minis terin g large quanti ties of c oo l IV or i rrig ation fluids wi l l fu rther c hill the patient. Ex tremes of age , cac hex ia, female sex , and low bod y mass are assoc ia ted wi th i nadv ertent hypothermia.

Problems Associated with Hypothermia

Hypoth ermi a is a po ten tial c ause of adv e rs e p ati en t outcomes and may be as soc iated wi th l ife-threaten ing c omplic ati ons (37,38). Mos t c ompl ications are i ni ti ated intraope rativ ely, al though they a re genera ll y manifes ted P .886 or detec ted in the rec ov e ry peri od. Th e c ons equences of hypo the rmia wil l de pend on the s i ze and co ndi ti on of the pa tient. Smal l pa tients or those i n weak ened condi tions wi l l be more s usc eptible to the negativ e eff ec ts . Maintai ni ng patient's temperature dec reases p os toperativ e mo rtal ity and improv es ou tco me (39,40,41,42,43).

Metabolic Changes
Adv ers e me ta bolic c hanges inc lude a lef tward s hif t of the ox yhemogl obin diss oci ation c urv e, ac cumulation of metaboli c p roduc ts , and exac erbation of lac tic ac idos is (44 ,45 ,46 ). Hemogl obin satura ti on may be hi ghe r wi th warming (47). Babies of mothers ac tiv ely wa rmed during ces arean del iv ery hav e a higher umbil ic al v ein pH (48).

Shivering and Thermal Discomfort

Hypoth ermi a is assoc ia ted wi th pos toperativ e shiv ering, whic h is often i ntense and uncontro ll abl e. It ca uses patien t discomf ort; i nc reased metabol ic demand and

ca rdiorespirato ry work ; i nc reas ed intraoc ular and i ntrac ran ia l pressu res ; and i nte rferes with moni to ring, espec ia lly pulse ox imetry . W ound pain may be aggrav ated by shiv e ring. Ma ny patie nts reca lled shiv e ri ng and a feel ing o f in tense co ld as the mos t d is tress ing memo ry of their anes thetic manageme nt, ev en af ter rela tiv el y sho rt p roc edures . Some patients repo rt the disco mfort f rom shiv e ri ng and the cold sens ation wo rse than the s urgical p ai n (49,50). Sk in temperatu re is of equal importa nce wi th co re te mperatu re in d etermining therma l comfort (51 ).

Increased Recovery Time and Length of Stay

Mos t s tudies hav e s hown that intrao perative h ypothermia c auses s lo wer awa k ening and long er time in the recov ery room (ev en when temperature is not a d is charge c riterion). Hypothermia ma y c aus e pos toperativ e confus ion (52). Higher pos tanes thesia s cores, earl ier ex tubation, and sho rter PACU times a re ass oci ated wi th no rmothermia (53,54,55,56,57,58,59 ,60 ,61 ,6 2,63,64,6 5). Mild hypo the rmia does not prol ong recov ery in pedia tric pa ti ents hav ing pe riphe ral surgery (66 ). Mai ntaining normo the rmi a may s horten hosp ital ization (45).

Impaired Drug Tolerance

Drug dis tribution is al tered, dru g me tabol is m is dec reas ed, and the behav ior of anes thetic drugs is al te red . This often results in highe r blood c oncentrations and prolonged dura ti on of ac tion (44,67,68,69).

Hypovolemia
Hypoth ermi a can lead to fluid s hifts from the v ascular to the ex trac el lular s pac e and a re lativ e hypov olemia. Fo r ev e ry deg ree c entigrade of hypo th ermi a, 2.5% of the i ntrav ascula r v ol ume may be l os t (6). Cold-induced di ures is can oc cur, add ing to the problem. As th e patien t re warms , v as odi la tation may occ ur and more fl ui ds wi ll need to be giv en to acc ommodate the l os s. Patients with hypo the rmia hav e s ignif ic antly greater f luid and transf us ion requi rements (41 ,43,5 2). Peri pheral v asoc ons tric ti on can mak e i t more diffic ult to i nsert pe ri pheral v enous ca the ters . A c tiv e l ocal warming fac il itates IV ca the ter ins erti on (70).

Cardiovascular System Effects

Hypoth ermi a enh ances s ympathe tic ac tiv ity. Ca techol amine c oncentra tions may rise (71). Periphera l v as oconstri c tion, whic h reflec ts the body 's eff ort to conserv e hea t, can resu lt in inc rease d b lood pressu re and ca rdiac wo rk load and elec trocardiographic ch anges (65,72,73). Risks i nc lude c ardiac dys rhythmias , dec reas ed c ontrac til i ty, myoc a rdial isc hemia and i nfa rc tion, a nd cardiac arres t

(74,75,76). Hypo the rmi a can resul t in inc reased adv erse hemod ynamic ev ents and i nc reas ed req uiremen ts f or v asoac tiv e drugs (41,77). Normothermia is assoc ia ted wi th a re duction in the incidenc e of pos toperativ e morbid c ardiac ev en ts in p atien ts wi th k nown ri sk fac tors f or c oronary artery d is ease (46,65,74,76,78 ). Howev er, the ef fec ts a re modes t in relativ ely y oung , genera ll y heal thy pati ents (55). Rap idl y re warming pa tients with profound hy pothermia can res ult in s hock due to redis tribution of bl ood to the pe ri phery as tiss ues v asodi late.

Effects on Coagulation
Hypoth ermi a inhibits platele t func tion and ac tiv ation o f the c oagu la ti on cas cad e (79). It ma y be associated with inc reased blood loss and higher tra nsf usion requi rements (41,53 ,58 ,80 ,8 1,82,83,8 4,85,86,87).

Reduced Resistance to Infection

Ev en mil d hypo the rmia ma y delay hea li ng and predispose pa tients to wound and other i nfec tions (45,88,89,90,91,92). W arming may prev ent pos toperativ e wo und i nfec tion (93). Maintain in g normo the rmia ma y attenuate p rotein breakdo wn after su rge ry (9 4).

Interference with Monitoring

The rmoregu latory v as ocons tric tion dec reases c utaneous blood flow and may i nte rfere wi th pulse oxi metry and o the r fo rms of mon itoring (95,96).

Increased Costs
Hypoth ermic patients hav e prolonged s ta ys i n the inte nsiv e ca re uni t an d heal th ca re fac i li ty (41,87). Hea rt s urgery pa tients hav e s horte r durations of v enti lato ry support wi th no rmothermia . A reduc tion in cos ts may resul t f rom ac tiv e warming (53,97).

Other
Cold agglutinins may be fo und in assoc ia ti on wi th i nfec tion . Vasc ular obs truc tion and ev en gangrene may resul t (98). Cool in g ma y c aus e a dec rease in urine outpu t (99). The agreement of c entral and peri pheral v enous P .887 press ures deteriorates at lower temperatures (100). Inc reas ed pa in and anx iety may be as soc iated wi th hypothermia (101).

Warming Devices

Standards
Two U.S . s tand ards on warmi ng dev ic es were publ is hed in 2002: one f or c i rc ula ti ng l iquid and forced -ai r pa tient tempe rature manage ment dev ices (102) and one for f luid warmers (103 ). The f ol lo win g a re in the s tandard f or c i rc ul ating l iquid and fo rce d a ir dev ices :

For forc ed -ai r dev ices , the max imum c ontact su rface temperature shal l not ex ceed 48 C, and the av erage con tac t surface temperatu re shall not exceed 46C during no rmal cond itions .

For c irc ulati ng liquid dev ic es, the co ntac t su rface temperature shal l not ex ceed 43 C, and the av erage con tac t surface temperatu re shall not exceed 42C during no rmal cond itions .

The f lu id warmi ng s tandard re qui res that the dev ice does not hea t the f luid abov e 44C unde r normal condi tions .

Warming Methods
It is generally ac cepted that no s ingle techni que alone is supe rior i n combating hypothermia. The bes t resul ts are likely to b e achiev ed by combi ning methods . The cos ts , risk s , and b enef i ts of warmi ng s hould b e s pec ific al ly cons idered fo r eac h pati ent, fac toring i n preex is ting med ic al c ondi tions and the s urg ic al procedure.

Forced-air Warming Devices

Forc ed-air wa rmi ng dev ices (conv ec tiv e warmin g dev ices , warm ai r bl owe rs ) entrain ambien t ai r through a mic robi al f il ter. The air is wa rmed us ing a n e lec tric h eater thermos tatica ll y con trol led , and then blown through a hos e that is connec ted to an i nflatabl e patient c ov er (Fig. 31 .1). Some dev ices moni tor the temp era ture setting wi th in the warmi ng un it. S ome newer uni ts monitor the temperature at the end of the ai r deliv ery hos e (1 04). Mos t offer a se lec tion of tempe ratures (F ig. 31.2). A v arie ty of c ov e rs , both dis posable a nd reusabl e, are av ailab le . They hav e a se ri es of holes tha t al low the warm, fi ltered ai r to pass th rough. Another des ign us es a fab ric tha t al lo ws the he ated air to fil ter throug h the en ti re pa ti ent s ide. The s hape of the cov er v aries (Figs . 31 .1, 31.3,31.4,31.5 ). A number of pediatric blank ets a re av ailab le. A U-shaped tu bular blanket that enc i rc les the pa ti ent ma y be us efu l in s ituati ons such as cardiac surgery, wh ere muc h of the body cannot be cov ered. Ho wev er, i t is l es s effec tiv e th an a b la nket p laced ov er the body (13,22,105,106 ). It is poss ible to c ut s ome c ov ers and s eal the edg es of the cut to

f it the patient (107 ,108). Pati en t and hea lth care prov ider go wns that can be connec ted P .888 to a forced-ai r uni t are av ai lable. Sl eev es for warming an a rm to faci li tate IV ca the ter ins ertion are av ai lable.

Figure 31.1 Forced air-warming device with low body blanket. (Picture courtesy of Arizant Healthcare, Eden Prairie, MN.)

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Figure 31.2 Control unit on a forced air device. A selection of temperatures is provided.

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Figure 31.3 Warming blanket for a small patient. Note the plastic cover over the child. (Picture courtesy of Arizant Healthcare, Eden Prairie, MN.)

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P lac ing a blank et or s heet ov er the warming b lanket wil l res ul t in i nc reas ed heat transfe r (1 09). Lower body warmi ng is sl ightly more effec tiv e than upper body warmin g (110 ,111,112). Unde rbody blank ets al low eas y acces s to the patient (113). Howev er, they are p robabl y onl y us eful for v ery s ma ll patients . A numbe r of ins titutions hav e used thes e units wi thout the warmi ng blank et by plac ing the hos e e ither under the su rgic al drapes or between c otton bl anke ts (free hosin g) (114,115 ,11 6). Free hosi ng may resul t in heated ai r bl owi ng direc tl y onto only a s mall area of the patient's s kin and caus e burns (117,118). The ref ore, this prac tice is no t recommended.

Figure 31.4 Over-the-body warming blanket with an area in center removed to allow surgical access. (Picture courtesy of Arizant Healthcare, Eden Prairie, MN.)

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Numerous s tud ies hav e shown th at forc ed-ai r warmi ng is effec tiv e in maintai ni ng or i nc reas ing the pati ent's (includi ng both ma te rna l and baby) temperature , dec reasing the incidenc e of shiv ering and i nc reas ing thermal co mfort (31,48,55,58,59,62,105 ,110,119,120 ,121,122,123,124,125,126,127 ,128,129,130 ,13 1,132 ,133,134,135,136,137,138,139). It P .889 work s wel l ev en when the av ail able ski n surfac e area to be warmed is res tric ted , as oc curs during orthopedic , major v ascul ar, or abdominal o perations (9,109 ). Fo rc edai r warmin g is of ten used in c onj unc tion wi th other wa rmi ng methods (140).

Figure 31.5 Cardiac access blanket. This provided localized warming to the legs while allowing access to both legs.

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A l though forc ed-ai r warming is often eff ec tiv e in ra is ing p eriphe ral temp era ture, co re te mperatu re may no t rise (47,141,142 ,143,1 44,145,14 6,147). This may be becaus e o f limi ted heat transfer between thermal c ompartments in v as ocons tric ted pati ents . In the pa tient with a neurax ial b loc k , the v as odi lation may aid in heat transfe r from the pe riphe ral to the core tissu es . Mos t s tudies hav e found forced -ai r warmin g supe rior to older-s tyl e liqui d-c i rcu lating mattress es , wa rmed or unwarmed blanke ts , rad iant heat l amps , inhala tion rewarming , pas siv e insulation , elec tric blank ets , negativ e-press ure wa rmi ng dev ic es , o r warming IV fl ui ds (14,19,22,46,47,57,109 ,127,128,139 ,144,145,147,148,149,150,151 ,152,153,154 ,15 5,156 ,157,158,159,160,161,162,163,1 64,165,166 ,167,168,169 ,170,171,172,173,1 74 ,175,176 ,177,178,179 ,180,181,182). Newer li qu id-c i rc ul ati ng dev ices and resis tiv e heating dev ic es may be as or mo re efficient than f orced -ai r warmin g dev ices (85,137,138 ,183,184,185 ,186,1 87,188). Some s tud ies h av e found that wa rmi ng IV f luids wa s as eff ec tiv e as forc ed-air warmi ng in ma intaining normothermia (189,190 ). Forc ed-air wa rmers are us ual ly s afe wh en pro perly us ed. There a re a fe w reports o f burns (191,192 ,193,194,195 ,19 6,197,198 ,19 9). Care shoul d be exerc ised that the hose does not come in contac t with th e patien t's ski n and that the exi t v ents are positioned away from the pa tient and the s urg ic al f ie ld. Spec ial care s houl d be tak en to av oid con tac t wi th ischemic areas (i.e., dis tal to a v asc ula r cl amp).

Forc ed-air wa rmi ng is si mple, s afe , effec tive , and inexpens iv e. The v a riety of pati ent c ov ers makes i t adaptable to man y d iffe ren t si tuations . Mos t nurs ing personnel and fa mil y members prefer this method to radiant heat. Force d-a ir warmin g p rov ides more c alo ries /cos t than other mod al ities (47,97,200,201 ,202,203). Fiberoptic laryngoscopes c an b e warmed befo re use wi th a fo rce d-air warmi ng dev ic e (204 ). W arming these dev ices wil l prev ent fogging whe n the dev ic e is inse rted in to the mouth for i ntubation. It can be used to warm the operating tabl e bef ore the pa tient is transfe rred to i t by plac ing the hos e under a s heet. It c an also be us ed for c ool ing (205 ,206). Another use is to rel iev e c laus troph obia (207). A c oiled tubing c an be pl ac ed ins ide the hose from a forc ed ai r hea ti ng dev ic e to hea t IV f lu id (F ig . 31.14). Howev er, this is effec tiv e onl y at low f luid flow. A disadv antage is tha t its el ec tric powe r re qui reme nts mak e it unsui tabl e for f iel d us e (208 ). It is s omewh at cumbers ome to transfer or se t up in a c omputed tomography (CT) s canner (1 90). It mus t be remov ed f rom the patient to expose cov ered areas . A nother disadv an tag e is that man y s ys tems do no t permit the conc urrent us e of mul tipl e b lank ets (i .e., upper and lower body) wi thout using two separate forced-ai r uni ts .

Figure 31.6 Liquid-circulating device. The patient contact part can be wrapped around various parts of the body. (Picture courtesy of Gaymar Industries, Inc.)

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Liquid-circulating Devices
A liquid-c i rc ul ating dev ic e cons is ts of a h eating/c ooling uni t and patient c ontac t dev ic e (mattress , pad , bl anke t, o r wra p) th at i s connec ted to the hea ti ng/coo le r uni t by hoses (Fig . 31.6). Heated/coo le d l iquid ci rcu la tes through the patie nt contact

dev ic e and then bac k to the h eating/c ool ing ele ment. Some machines can su ppl y more tha n one patie nt contac t dev ice. Other dev ices may be attached to th e l iqui d-c i rc ulati ng uni t (2 09). IV f lu ids c an be heate d b y us ing a wate r mattress pad a pplie d to the tubi ng c los e to the patien t (210). A pad ca n be placed ei ther ov er or under the patient bu t is s afe r and more effec tiv e whe n placed ov e r the P .890 pati ent (154 ,211) (Fig . 31.7). Direc t patien t con tac t wi th the pad surface s hould be av oid ed. Folds and c reases in the pad shoul d b e av oided . These uni ts may predispos e patients to burns, s o skin in teg rity mus t be as sess ed frequently (212,213 ,214).

Figure 31.7 The pad from a liquid-circulating device may be placed over the patient. (Picture courtesy of Augustine Biomedical.)

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Figure 31.8 Liquid-circulating device. The patient contact part adheres to the body surface. (Picture courtesy of Kimberly-Clark.)

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Some ne wer l iquid -c i rcul ating s ys tems use a disposab le thin pa d tha t adh eres di rec tly to the sk in and is made of a ma teri al that fac il itates heat cond uc tion towa rd the patie nt. Diffe ren t sha pes and s izes are av ai lable , al lo wing a ttachment to v a ri ous bo dy surfaces (183,186 ,215) (F igs . 31.8, 3 1.9). Mos t i ncorporate a mic roproces sor that c ontrols the flow and temperature and a pa tient tempera ture sens or s o tha t the li quid tempera ture c an be ad jus ted to mai ntain the des ired pati ent tempe rature. One s ys tem operates under nega tiv e press ure s o that i f the pad is cut or punc tu red , ai r wi ll b e p ul led i nto the s ys tem rather than water s pill ing out (104). Ol der-s tyle li qu id-c i rc ul ati ng units are l ess effec tiv e tha n forc ed -ai r heating (14,154,163 ,164,165,166 ,167,1 81,216,217,2 18). The newer-s tyle uni ts may be more ef fec tiv e than forc ed-ai r heating, because th ey c an cov er a larger su rface area (65,78,85,104,183,184,185,219 ,220,221,222 ).

Figure 31.9 Close-up of liquid-circulating device. The backing is removed, revealing the sticky side of the pad that is attached to the patient.

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The olde r-s tyle mattres ses are heav y and cumbers ome. It is d ifficult to mai nta in good contac t with th e s tiff mattress and to cov e r a large s u rf ace area (15). T hei r us e c an lead to bu rns , espec ially ov er press ure poin ts whe re the patient c on tac ts the blanke t (109,212,213 ,214,2 23,224,225). P lac ing them abov e the patien t may dec reas e the likeli hood of burns . Ca re shoul d b e tak en that the tub ing does not co me into contac t with th e patien t.

Passive Coverings
Apply ing passiv e i nsulation can dec rease he at l oss f rom conv ection, radiation, conduc tion, and ev aporation . Cotton bl ankets , su rgica l drapes , to wels and sheets , plas tic shee ti ng, p las tic bags , an d s pec iall y designed ref lec tiv e c ompos ites (the rmal d rapes , s pac e b lankets , ref lec tiv e blankets , metalli zed plas tic sheets o r sheets , he ad cov e rings , blank ets , soc ks , l eg gings , e tc .) are among the materials that hav e been used (226,227 ,228,2 29,230,231,2 32) (Fi g. 31.10). The re are minimal c l in ic al differenc es among the v arious cov erings (228,233 ,234,235,236,237). W arming the c ov ers or addin g addi tional l ayers of i nsulation further reduc es heat loss onl y s lig htl y and has not been fo und to be of benef it in prev en ting shiv e ri ng (238,239). These cov ers p rov ide a trans ient s ense of warmth . Cov e ring as much s urface area as possible is more impo rtant than the ty pe of c ov ering or s peci fic area cov ered. Cos t and conv enience sho ul d be ma jor fac tors whe n c hoos ing among cov ers . The c os ts of l aunderi ng and replac ing c otton blank ets mus t be taken into account. The re are n o publ is hed reports of patient i njury c aused by warmed hospi tal bl ank ets (240 ).

Pas s iv e insulation wi l l re duce c uta neous heat los s but wi ll not maintai n normothermia (6,22,127,158,159,177,218,230 ,231,241,242 ,243,244,245 ,246,247,248,249). Apply ing wa rmed co tton blanke ts to the pa tient has been a traditional ri tual in the PA CU, but is ineff ec tiv e (2 50). Howev er, plac ing a c otton P .891 blank et ov er the patie nt as soon as pos sible af ter the patie nt has ente red the OR wi ll red uce initial he at loss and resu lt in a hi gher b ody temperature whe n the pati ent e nte rs the PACU (231).

Figure 31.10 Thermal head covering.

View Figure

Ins ulated cov erings hav e been found to be less effec tiv e tha n forced -ai r warming for cons erv ing bod y tempe rature (22,47,57,127,128,149,150,151 ,152,153,155 ,158,159,160 ,161,172,251). W armed blank ets we re found to be inferio r to radiant h eat in prev en ting shiv e ri ng (248). Pas s iv e cov ers are conv eni en t, easy to us e, l i ghtwei ght, and no t s ubjec t to elec tric al or mec hanica l failures . There is no burn haz ard . Howev er, the y ma y i nhibi t acc ess to the pa tient. Mos t of them are combus tible a nd should be us ed wi th caution when a s ource of igni tion is present (252) (s ee Fi res in Chapter 32).

Resistive Heating
Res is tiv e elec tric al hea ting dev ic es gene rate hea t by pas s ing lo w-v o ltage cu rrent through semico nduc tiv e wi res o r carbon-fibe r fab ric . No da nger res ults from

penetrating the f abric . The sys tem c ontin ues to operate normal l y beca use the cu rrent s impl y flows through ad jac ent fabric. The wa rmi ng bl anke t or mattress is thermosta tical ly c ontroll ed by a c omputer to mai ntain the contac t su rf ace at the se t tempera tu re. This s ys tem c an hea t sev eral f ields independently . B lank e ts and mattres ses are av ailabl e in a large number of configurations th at can be used i n v arious combinations to inc rease the heating su rface. They c an be cl eane d and disinfec te d after us e. Res is tiv e hea ting has b een found to b e as or more effec tiv e than mos t other tec hnologies , inc lud in g forc ed-ai r warming (9,57,85,101,109,137,1 38,208,253,2 54,255,256 ,257). A repo rted adv antage is c os t sav ing compa red wi th f orced-ai r warming (57,254,255). It i s also qui eter than forc ed ai r. Resis tiv e heating dev ices may be es pec iall y hel pfu l fo r field treatment of hypothermia (101,208 ). Howev er, sev ere thermal injuries hav e been reported wi th an elec tric al warming ma ttres s (258). A f ire may res ul t if an elec tric bl anke t is fold ed and wi re s a re broke n.

Radiant Heaters
Rad ian t warmers us e s pec ial incand esc ent bulbs o r heated su rfaces to gen era te i nfrared ene rgy . The radiant he ater c an be a s impl e lamp on a po rtable s tand or a more elaborate panel (145 ). The latter comes as a portable uni t or ma y be c ei ling moun ted o n tracks (6,259,260 ). The radiant dev ice is most effec tiv e when i t heats areas hi gh in a rteri ov enous anas tomoses s uch as the fo rehead, nose , ears , hands , and feet (261). These c an di late in res pons e to l ocal heati ng and anesthesia and allow a pplied heat e nergy to be transferred di rec tl y to the c ore. Rad ian t warming c an be used on expos ed areas of the patient's s kin during ca the ter placemen t, s k in p repara ti on, and during the su rgical procedure , when feasible (6). It may be es pec ial ly useful in the PAC U (260). The heat s hould s hi ne on the patient's ba re sk in or at mos t through a thin s heet. If placed too c lose to the sk in, burns can res ul t. The sk in su rf ace mus t be ass ess ed frequentl y to detec t ea rl y s igns of burns . S k in expos ure may resu lt in coo ling by conv ec tion c u rrents , so i t is i mportan t to eli mina te draf ts i n the env i ronment. Rad ian t hea t c an prov ide fas ter rewarming a nd reduced s hiv ering (6,248,259,262 ,263,264,265 ,26 6). It is more effec tiv e in small infants bec ause of thei r re lativ el y la rge body surface area. Rad ia nt hea ti ng has been found to be les s ef fec tiv e than forc ed-ai r warmi ng bu t sup erior to el ec tric , wa rmed , or reflec tiv e

blank ets (145 ,149,154,178 ,180,2 48,260,267,2 68). It d ec reas es heat los s before sk in was hi ng but inc reas es i t during wa shing (269). Rad ian t hea t lamps enab le the medical and nurs ing s taff to hav e an unobs truc ted v iew of and access to the patient. There are n o d is posa bles and no pati ent c ontac t. Howev er, the equipment is bulk y a nd somewhat cu mbersome. Expos ure of th e adul t pati ent may be unac ceptable to the patient and fami ly memb ers (145 ). It may ca use burns or hyperthermia if use d for l ong pe ri ods of time, if the radian t heat source is c los e to the patien t's sk in, o r if there is a probl em with the s k in-tempe rature meas urement s ens o r (21 4,270). B ec ause radiant warmers inc rease ev aporativ e heat loss , they ma y inc rease fluid requi reme nts (271). Patients with poor periphera l c i rc ulation may be more di ffic ul t to he at. It is nec essa ry to adjus t the hea te r-sk in dis tanc e if the ope rating tab le P .892 i s raised o r lowere d. Radi an t warme rs may interf ere with imag ing if us ed in an MRI unit (272 ).

Heating and Humidifying Inspired or Insufflated Gases

Ev aporativ e heat l oss f ro m the ai rway c an be prev ented by us ing warm, h umid if ied gases (inh ala ti on re warmi ng ). Dev ic es fo r hea ti ng and humidif yi ng inspi red gas es are dis cus sed in Chapter 11 . Min imal heat transfer occurs with this method , whi ch ca rries the risk of thermal in juries . Some s tudi es hav e found that he ating insp ired gas es is of minimal v alue in rewarming , ev en wh en used in conjunc tion wi th o the r warming mod ali ties (14,163,259 ,273,274). Other s tudies found that heated humidifica tion s ys te ms c an reduc e the inc idence of s hiv ering and resu lt i n a more rapid return to normothermia (263,275 ). A i rway heating and humidifica tion may be more effec tiv e in infants and ch il dren than in adu lts (2 76,277,278 ), but cu taneous wa rming is far more effec tiv e (279). Hea ting and hu midif ying gases used for pe ri toneal i ns uff lation c an prev ent the heat l oss as soc iated wi th this p roc edure (280).

Heat and Moisture Exchangers

Hea t and mois ture excha ngers (HMEs ) are d isc uss ed in Cha pter 11. T hey prov ide ef fic ient humidification and work almos t as we ll as heated humidifiers to prev ent respi ra to ry hea t loss but cos t les s and prov ide fi l tration. Howev er, th e a mount of

heat preserv ed by this method is s mall (281,282). Heat cons erv ation by a ll av ailab le HMEs is comparable (38).

Low Fresh Gas Flows

Us ing l ow fresh gas f lows re duces h eat los s through the ai rwa ys (282). Howev er, s tudies indicate th at us ing low-fl ow anes thes ia is ineffec tiv e in mainta in ing i ntraop era tiv e no rmothermia (158).

Fluid Warming
Fl ui d warmers are used to warm blood produc ts , IV soluti ons , irri gation s ol utions , and ins uff lating gases (283,284 ). Si nc e thes e fluids are usuall y well below body temperature , exposure to them can be a s ignificant so urc e of hea t loss when large v olumes are us ed. Mos t fl ui d warmers hav e a temp era ture display and an alarm to alert th e operato r if the heater te mperatu re or temperature of th e fl uid is too high. Some alarm if the heater tempe rature falls b elo w a thresho ld. Manufac tu rers wil l p rov ide informa ti on about the maxi mum f low rate tha t is p ossible for th e parti cul ar s ys tem. This flow rate wi l l not neces saril y prov ide flui d at b ody temperature . If there is a disc rep ancy , the manuf ac turer wi ll a ls o p rov ide the f lo w rate that wi l l prov ide fluid warmed to bod y tempera ture. Mos t uni ts are des igned fo r use wi th de dicated dispos abl e sets . So me o f these s ets are us ed in conjunc ti on wi th a s tandard bloo d o r IV adminis tra tion set and ex tensi on tubing, whi l e o the rs inc lude a Y-set as well as a patien t l ine . Some offer a numbe r of different dis pos abl e sets des igned for s pec if ic appl ic ations . Diff erences among these s e ts i nclude the gauge and length of the tubing, the numb er of bag spik es , and the pres ence of a bl ood f il ter and /or degas sing mechanism. Fl ui d warming can p rev ent the hea t loss caused by infus ion of c old f lu ids but generall y cannot tra nsfer enough heat to p rev ent h ypothermia o r res to re normothermia ex pedi tious l y unless ex traco rpo real re warmi ng is used (14,27,30,156,157,162,189,210 ,274,285,286 ,287,288,289 ,290,291,292,293,2 94,295 ,296). W arming l iquids improv es the f lo w through the adminis tration s et b y lowe ri ng the v iscos ity (297,298). No cl ear guidel ines abou t when thes e d ev ices s hould be used exis t. Drawb ack s i ncl ude the expense and the time ne eded to asse mble the appara tus . It is generally agreed that warmi ng shoul d be performed during massiv e and/o r rap id transfusi on, i n p atien ts wi th co ld aggl utinins , and fo r exc hange transfusi ons i n th e neonate , but i ts us e f or routine procedu res is con trov ersial . V ariables that sh ould b e cons idered

i ncl ude the ra te of infus ion, the total v olume to be used , the tempe rature of the f luid to be inf used, and o the r patient warmin g tec hniques that are in us e (2 83,299).

Factors Determining the Fluid Temperature at the Patient

Temperature Controller Set Point
Inc reas ing the set tempe rature of the warme r res ul ts i n a h igher ou tlet and dis tal f luid temperatu re. The fluid may or may no t re ach the set poin t, depending on the ef fic ienc y with whi ch hea t is transf erred by the warme r and the speed tha t the f luid trans i ts the warme r.

Starting Fluid Temperature

Fl ui ds maintained at co ld temperatures s uch as b lood wil l requi re more heat to warm them th an fluids s tored at room tempera ture or i n warmi ng cabinets .

Fluid Flow Rate

Fl ui ds lose hea t whi le hanging and whi le fl owi ng to the patient. The hea t loss us ual ly inc reas es as the rate of i nfus ion s lows (300,301 ,302,303,304,305,306,307,308 ,309,310,311 ,312). This is es pecial ly i mportan t in pediatric p atien ts whe re f low ra tes a re us ual ly relativ ely l ow. Howev er, i f th e fl ow is v e ry ra pi d, i t may exc eed the abi li ty of th e fl ui d wa rmer to hea t it adequatel y.

Length of Tubing between the Warmer and Patient

Keeping the tubi ng between the warmer an d the pati ent as s hort as poss ible wil l reduc e heat l oss (200 ,27 9,302,306,31 3,314,315,316,3 17). Heating the tubi ng may prev ent hea t l oss . Placing the tubing under a warming bl anket wi l l hel p to maintain f luid temperatu re.

Methods of Fluid Warming

Preuse Warming
Fl ui ds other than blood p roduc ts can be warmed in an OR c ab inet (316,318). A maxi mum temperatu re of 43C is rec ommended (319 ); s ome manuf ac turers recommen d l owe r te mpera tu res . This method P .893 can be us ed to heat s al ine that is subsequently mixed wi th red bl ood c ells (320,321 ). Dex trose -c ontain ing s ol uti ons s houl d not be heated bec aus e the

dex trose wi l l be al te red by heat. Containers should be marked wi th the date th at they were placed in the warmer. A uni t of blood or bag of IV fluid may be imme rse d i n a bowl of warm water b efo re adminis tra tion (44,3 22). Howev er, this is s lo w a nd assoc iate d with tec hnical problems (3 23). The ba th water mus t not ente r th e b lood or IV so lu tion. P lac ing the unit betwe en two ho t pac ks may resul t in overheati ng (32 4). W hol e bags of blood and blood c ompon ents hav e be en warmed by plac ing them in a mic ro wav e ov en. This prac tice was abandoned bec ause the nonunifo rm dis tribution of energy and the fini te depth of pene tration resu lted in hot s po ts and ov erheating (325,326 ,327,328,329). More rec ently , a mic rowav e dev ice s pec if ic all y des ig ned fo r thawi ng fresh f rozen plas ma and warmi ng pac ked red blood cells has bec ome av ailab le (330). During heating, the produc ts are rotated withi n the dev ice. S yringes that c ontai n f lui d c an be warmed by us ing a ci rc ula ting water mattres s o r forc ed-ai r warme r (323). S mall er s yringes warm more rap idly than la rge ones . A c irc le s ys tem ma y be c re ated to al lo w the f luid in the hea ted tubing to ac t as a reserv oi r f rom whi ch f luid can be wi thdrawn in to s y ri nges (331 ). P rewarming b lood or fluids is inexpens iv e and conv enie nt. It is mos t eff ectiv e with rapid transf usion . A t s lower fl ow rates or if tra nsfus ion is d el ayed , the f luid c ools rapidl y (301 ). Insu la ting the fl ui d c ontainer or tubing wi l l re duce heat loss (300). W armed IV fl ui d bags o r pl as tic co ntainers of irri gati on solutions should no t be applied to the pa tient's s k in either as warming or pos i ti on ing dev ices , bec ause this has been as soci ated wi th burns and is ineffec tiv e (38,214,332 ).

In-line Warming
In-l i ne warmi ng dev ices hea t fluid as i t pass es from the s ource (a s olu ti on bag or i nfus ion dev ice ) to the patient. The warmer may be mou nted on a s tandard inf usi on pole, attached to a ded ic ate d pole s ys tem, o r frees tanding. A spec ial disposable adminis tra tion set is us ual ly used, but at leas t one unit warms the fluid in conv en tiona l IV tubing. So me d ev ices h av e a means for c ontroll ing i nfus ion rate and may d is play the inf used v olu me in real time. Some al low the operator to s et the temperature . Some hav e a means to ad minis ter a bo lus of fluid. Des irable qual i ti es i nclude a l ow pri ming v ol ume, large heat transf er a rea , lo w press ure drop, and the abili ty to heat eff ici ently at all flow rates (323,333 ).

Advantages of In-line Warmers

The y can generall y be used with red bl ood c ells , whol e blood, o r IV or i rrig ation fluids . Onc e the warmer is s et up, new f luid bags can be co nnec ted at once . Entry p orts mus t be punc tured before warming, so warmed blood cannot be mis takenly retu rned to the blood bank for i ssue to other pa tients (4 4).

S tudi es show that plas tic ize r does not leach i nto heated IV tubing (2 10). One drawback is that mos t dev ices ca n be used for onl y one l ine at a time (44 ). Loss of body heat can be minimi zed b y warmi ng th e fluid f lowi ng to one IV s ite whi le keepi ng v eins open at other av aila bl e s ites . Multi pl e heating d ev ices c ould be used for mul tiple IV infus ions .

Types of In-line Warmers

Dry Heat
In a dry hea t exc hanger, the fluid passes through a tubing, c asse tte, or bag th at is place d around or wi th in a hea ted bloc k or plate(s ) (3 08,334) (Fi g. 31 .11 ). It may also be he ated b y a magnetic induc tion heater (335,336 ) (Fi g. 31.1 2). Inf ra red l amps can a ls o be used to heat the IV fluid (284). S ome ca n be placed in an x -ray cassette on c ertain OR tabl es . S tudi es differ on the effec tiv eness o f dry heat wa rmers at hi gh f low rate s (284,312 ,334,337,338,339,340,341). Newe r models may perform bette r than older ones . Becaus e the f luid is usua lly fo rc ed through long , cons tric ted plas tic tubes o r channe ls , high res is tanc e may limi t th e f low rate (297,340). Curren t leak age has been rep orted wi th some units (342,343,344,3 45). Ov erheating with burni ng of the plas tic dis pos abl e tub ing has been reported (336).

Micr owave
A l though bu lk mic rowav e wa rmi ng dev ices were ab ando ned s ome time ag o, recen t s tudies s how tha t in -l in e mic rowav e blood warming is not assoc ia ted wi th s ignif ic ant damage to b lood (298,3 26,346,347 ,348,349,350 ,351,352,353 ). One i n-l ine mic rowav e warmer empl oys a dispos able ca rtri dge that c ontains a short l ength of IV tubi ng co il ed around a plas tic bobb in . Tempe rature monitoring is ca rried out by mic ro wav e radiometry , whi ch measu res the temperature wi th in the l umen of the tubing withou t di rec t c on tac t wi th the fluid (350,436). The amount of mic ro wav e po wer i s then auto matica ll y adjus ted un ti l the me asu red temperature matches the target temperature .

Mi c ro wav e warmin g uni ts prov ide rapi d heating and acc ura te temperature c ontrol (298,346 ).

Water Immersion
W ater bath uni ts wa rm a fluid as it passes through a bag or coi ls of tubing i mme rs ed in he ated wate r (35 4). One or more IV ex tens ion s ets c an be used in place of the c oil or bag (355 ). Mos t water ba th warmers mon itor and dis play onl y the water bath te mpera tu re (44). Some uni ts agitate the water to improv e heat transfe r. If this is done, i t is important that injec tion ports no t bec ome contaminated and that the connec ti ons a re sec ure. S tudi es show that these dev ic es are ineffic ien t at hi gh f low rate s (312,334,356). Some units take a long time to warm the water, s o the y mus t be turned ON so me time prior to use . P .894

Figure 31.11 A: Dry heat warmer. A disposable cassette through which fluid flows is placed inside the device. B: Disposable cassette.

View Figure

Hazards associ ated with wate r baths incl ude leaking co ils , blockage, hemolys is resul ting f rom ov erheatin g, leaka ge curren ts , and septice mia secondary to contamina ti on of the water that may ente r th e IV tu bing (357,358 ,359,360,361,362,363,364,365 ). T he long tubing may offer a hi gh resis tance that c ould limit flow. A l arge p riming v olume may be needed.

This type of dev ice is i mprac tic al f or f ie ld or a mbulance use. It may re qui re more mai ntenance than other types of fluid warme rs (299). B lood or IV f luid c an leak in to the water bath solution.

Countercurr ent Heat Exchangers

Counte rcu rrent heat ex changers us e a cou nterc urrent f low of hea ted wa ter with a tube con taining the IV f luid ins ide (4 4,283,284,334 ,339,366,367 ,368). S in gle channe l and mul tich anne l counte rc urrent heat exchangers are av ailable (353 ) (Fi g. 31.13 ).

Figure 31.12 Disposable set from a magnetic induction heater.

View Figure

Mos t flui d warmers that us e c oun terc urrent tec hnology hea t more eff ec tiv el y than other fl uid wa rmers (28 4,305,307,30 8,309,333,33 4,339,366,369 ), s o the y ma y be appropriate for s ituations whe re ra pid v ol ume res usci tati on is necessa ry (3 35). Howev er, their effec tiv eness may dec reas e as f lo w rate i nc reas es (306). Conti nual counterc urrent warmi ng of f luids in the tu bin g l eading to the patien t dec reases the l oss of heat dis tal to the warme r. Th e res is tance to f low may be lower tha n wi th water ba th warmers (305 ).

Other
IV tubing c an be p laced ins ide the tub ing betwe en the patien t and a conv ectiv e warmin g d ev ice (156,299 ,37 0,371). One fo rc ed-air uni t manuf ac turer offers a spec ial disposable co il with IV tubing to be plac ed ins ide the hose that goes from the warmi ng un it to th e b lanket (Fi g. 31 .14 ). A f olded water mattress pa d can be applied to the tubing c lose to the pa tient (210 ). The use of i ns ula tion s lows heat

l oss f rom tubing but is of limi ted effec tiv eness (210,315 ,369). A ll of th ese warming methods res ult in re duced access to the tubi ng for dru g injec ti on.

Negative-pressure Warming Devices

This dev ic e (Fig. 31 .1 5) consis ts of a the rmal exch ange c hamber tha t prov ides negativ e p res sure when ai r is exhaus ted from the ch amber (175 ,37 2). A s eal around wh ere the wri s t enters the cha mber ensures nega tiv e P .895 press ure . Heat is suppl ie d b y a n elec trical warmi ng dev ic e.

Figure 31.13 Countercurrent heat exchangers. Different arrangements can be used for IV fluid and warming fluid flow.

View Figure

The theo ry behind this dev ice is th at peri pheral v asoc ons tric ti on can hi nder the ef fec tiv enes s of warming therapies appli ed to the sk in . If the su bcutan eous v ascular s truc ture of th e hand of a hypothermic indiv idual can be dilated by us ing subatmos pheric press ure appli ed to the sk in , a the rmal link between the sk in an d the body c ore would be c rea ted , al lowing tra nsfer of a ppl ie d heat to the c ore . Some s tudi es i ndica te that this ma y be a usef ul technique fo r rewarmi ng hypothermic indiv idua ls (373,374 ,375). Othe r s tudies hav e f ai led to f ind an y s ignif ic ant benef its (175,176,377,378,379).

Esophageal W arming Devices

This dev ic e cons is ts of a disposab le doubl e-lumen esophageal tube and a bas e uni t wi th water h eater, c irc ul ati ng pump, and moni to r/alarm module (3 80,381). S terile dis til led water i s h eated and then ci rc ulated through the es opha geal tube. This dev ic e is ex pens iv e a nd somewhat invas iv e. Mos t s tudies hav e found it to be of l imited effec tiv eness (131,266,3 82,383).

Cryogen Packs
Hot-c ol d c ryogen packs hav e been us ed to tre at local i zed areas of the bo dy. Ma ny burns hav e occ urred wi th thei r use .

Hot-water Containers
P las tic c ontainers of i rriga ti on or IV fluid a re f requentl y k ept i n warmers or ov ens near ORs , s ometimes a t qui te el ev ate d temp era tures (2 11). It may be temp ting to try to wa rm patients b y p osi tioning thes e c ontai ners in areas of high b lood flow such as the axi ll a. Th is prac tice, howev er, i s both ineffec tiv e and dange rous . The l ack of effic acy resu lts because the surface area inv olv ed is s mall (3 8). The danger i s tha t burns may resul t f rom high local tissue temperatures (214).

Figure 31.14 Disposable fluid-warming coil that fits inside the hose of a forced-air warmer.

View Figure

P .896

Figure 31.15 Negative-pressure warming device. The seal around the wrist is not shown. (Picture courtesy of Dynatherm Medical, Inc.)

View Figure

Increased Operating Room Temperature

Inc reas ing amb ien t te mperatu re in the OR, es pec ial l y whi le the patient is being prepped and draped f or s u rge ry, wil l dec rease the loss of body heat by reduci ng the radiation and c onv ection g radients (384). Th e room can be c ooled af ter the pa tient i s draped, and other mea ns of temperature control a re ini tiated. The tempe rature can be raised again d uring emergence from anes thes ia when the surgery is f inished (385). S ys tems a re av ailable that wi ll keep s urg ical pers onnel c ool rega rdl es s of the tempera ture of the ro om.

Endovascular Devices
Con tinuous arteriov enous re warmi ng uses percutaneous l y placed femoral arterial and v enous catheters and the patient's own blood pressu re to c reate an arte ri ov enous fis tul a that div e rts a porti on of the cardiac output through a he parinbonded he at ex changer (43). The hea t exc hanger cons is ts of an i nner c hambe r through whi ch hot wate r is p umped and a n o ute r c hamber through which the pati ent's blood flows i n a co untercurren t di rec tion. Thes e d ev ices c an inc re ase core temperature by 1.5C to 2.5C per h our (386). Cen tral v enous heat ex change catheters are disc uss ed unde r the Cooling Dev ic es sec tion . Thes e catheters c an also be use d for heating. W hile they are highly ef fec tiv e , they are h ighly i nv asiv e and ex pens iv e.

Lavage
Peri ton eal , bladde r, o r gas tric lav age with warme d l iquids ca n be performed.

Cost-effectiveness
The inf lu ence of warming on pe ri operativ e cos ts depends on the patient's c ondi tion , su rgical procedure , and ins titutio nal fac tors rel ated to c os t accounting (59). Av oid ing the neg ativ e effec ts assoc iated with the c old patient may red uce ex pens es . B lood los s and trans fus ion requirements , ti me to ex tuba ti on, the need fo r drugs , and the numbe r of blank ets and the leng th of s ta y in the PA CU ma y be reduc ed (53 ,59 ,155,387,388 ). Th e normo thermic patient is mo re he modynamic all y s table, requ irin g l es s intens iv e nursi ng care. In looking at the diff erent methods of prov idi ng warmth to pa ti ents , i t was determined that the old s tyle of wa ter ma ttress and insulating c ov e rs hav e th e l owes t return on a c os t b asis ; IV fl ui d warmers were mo re effec tiv e bu t not as ec onomical as fo rced-a ir wa rmers (47 ,200,201,202 ). E lec tric bl ankets ma y be more cos t-effec tiv e than f orc ed-ai r dev ices (57 ). If the bla nke ts are reusable, the reproces si ng cos ts mus t be c ons idered.

Hazards
Softened Tracheal Tubes
Hea t suppli ed by a conv ec tiv e warming d ev ice has been shown to soften a pol yv iny l ch lori de tracheal tube (389,390 ). This may mak e the tube more likely to k ink and possibl y obs truc t (391).

Infection
The possi bi l ity of bac te rial diss emination f ro m forc ed-ai r dev ices has caused some to be u ncomf ortable wi th thei r us e. E nv ironmenta l con taminati on of the in tens iv e ca re uni t (ICU) is wel l known. Ho wev er, s tudies indica te that there is no inc reas ed risk assoc ia ted wi th forc ed-ai r warmin g d ev ices (392). A l l forc ed-ai r uni ts inc lude f il te rs that remov e b acteria from the heated ai r. Recommend ati ons to av oid this problem include using a fi l ter in the hose , changing the f i lter regularly , using on ly manufac tu rer-rec ommended b lankets , s teri lizi ng the d etacha ble hose, and not reus ing cov erle ts (393,394 ,395). A water bath can ac t as a sou rc e of infec ti on (358,396,39 7,398). IV i njec tion p orts and tubi ng connec tions s houl d be k ep t out of the wate r (44 ). The wate r shou ld be disc arded after use and the res erv oi r cl eane d and disinfec ted. If a leak dev elops in a counterc urrent f luid wa rmi ng s ys tem, uns teril e water may be i nfused into the pati ent (399 ). To av oid this problem, a le ak check should alway s be

performed b efo re connec ting the li ne of the warming s et to the patient. S ince the press ure in the IV line may P .897 be highe r th an tha t in the water chamber, blood or fluid ma y enter the wate r bath.

Sedation
Patients under regional anes thes ia hav e al tered therma l percep ti on and behav ioral respons es that ma y coun ter the ac ti on of s edativ e drugs . W armin g may rev ers e this ef fec t wi th resul tant s edation (15 5,299,400).

Burns
A rep ort from the Americ an Ass oc iation of Anes thes iologis ts (AS A ) c losed-cl ai ms datab ase showed 54 pati ent bu rns out of 3000 tota l c laims (214 ). E igh tee n burns were c aus ed by bags or bottles that h ad bee n heated and pl aced nex t o r c los e to the patie nt's sk in. Othe r cas es of this type h av e been reported (401,402). Of the eight burns from elec trically -powered warmi ng eq uip ment, fiv e resul ted from c i rc ulating -water mattres ses . Othe r burns resul te d f rom a warmin g light a nd a heate d humidif ier tu bi ng. In onl y one cas e was the heatin g dev ice f ound to b e defec tiv e. There are reports of burns wi th fo rc ed-air warmi ng (191,192 ,193,194,195,196,197), ra diant war mers in infants (403), and resis tiv e warmin g ma ttresses (258,404). Unfo rtunately, b urns a re not usua ll y recogn iz ed unti l af te r s urgery has been compl eted. A common pa tient fac tor in many burns is poo r cutane ous blood f lo w. In juries are us ual ly mos t sev ere in areas ov e rl yi ng bon y p romi nences . The risk of tiss ue injury i s further i nc reased when hea t or press ure is combined with chemical irri tation such as that p roduced by many sk in-c leaning so lutions , espec ially those c ontain ing i odine (3 8). Age is an other fac tor. The elderly often hav e thin, delica te sk in that is es pecial l y s usc eptib le to i nj ury. Th e s kin on n ewborn patients has a reduced thic kness compared wi th a dul ts . This di minishes protec ti on agains t ex te rnal noxio us ev ents (402 ). Pa tients with is chemic tis sue or thos e wh o undergo procedures inv olv ing c ardiopulmonary by pas s a re lik ely to be at i nc reas ed risk of thermal i nju ry . Heatin g dev ices s houl d not be used dis tal to a tou rni quet or arteri al c lamp or duri ng ca rdiopu lmonary b ypas s . W hen a warmin g dev ice is used for a patient wi th compromised c ircu lation, the pati ent's s k in c ondi tio n s hould be moni tored f requen tl y and the uni t's maxi mum se ttin g not us ed (19 2,211,405). Cons tant v igi lance mus t be ex erc is ed to ens ure

that po rtions of he ati ng dev ices no t meant for d irec t patien t con tac t, s uch as tubing for a water bl ank et or the hos e of a fo rc ed-a ir ma ttres s , do no t c ome i n contac t with the patie nt (211). Solution and blank e t-warming cabinet temperature s houl d be l imi ted to 43C (319 ,40 6). W hen a burn occ urs , th e pattern of the lesion c an help to iden tify the cause (407). If a warming dev ic e has been used an d the l esi on confo rms to that d ev ice's edges but no other area of the sk in is inv olv ed, the n i t is likely that the warming d ev ice caus ed the lesion.

Increased Transcutaneous Medication Uptake

An inc reas e i n trans dermal drug uptake may occur when the s ki n is heated (408,409 ). Fo r th is reason, transdermal med ic ation s hould be applied in a location that wi l l not be warmed or s hou ld be disc ontinued during heating (410).

Hemol ysis
B lood may hemoly ze if ov erhea ted (44,324 ,336,345,359 ). Al terati ons in red ce ll i nte gri ty do not oc cur bel ow a temperature of 46C, and f rank hemol ys is does not oc cur un ti l 48 C (411,4 12). Pac ked re d b lood c el ls remaining s tationary wi thi n mic ro wav e or c ountercurre nt hea ting c artri dges ma y s how ev idence of hemol ys is (353). If water from a f luid-wa rmi ng sys tem l eaks into blood, hemol ys is may resul t (399).

Current Leakage
Liquid bath and dry heat exchange rs mus t be wel l grounded. Th ey can leak elec tric al current into the flui d path (44).

Air Embolism
A hazard wi th fluid warmers is the poss ib il ity of infusi ng ai r i nto the patiente ither as a res ul t of b ubbles c reated as the flui d is wa rmed (outgass ing), air entrained through an infus ion s ys tem, o r by del iv ering a ir c ontained in the f luid sou rc e (283,299 ,413,414,415,416,417,418,419 ,420,421,422 ,423,424,425 ,426,427,428,42 9) . The dange r is greates t with the use of pres sure infuse rs ; when fluids are infus ed by a pump ; and when rapi d, h igh-v olume f lui d a dmin is tration is nec essa ry. Solutio n manufac turers typica ll y put 5 0 to 75 mL of ai r into each s ol ution container (299,421 ). Th is s hould be remov ed f rom the container and the tubing c hecked for bubbles before the s tart of an infus ion. Parti all y emptied fl ui d bags should not b e reattac hed to the IV s ys tem (427,4 28).

Many s ys tems prov ide a warnin g feature to alert th e operato r to ai r i n the IV line, and traps that co ll ec t bubbles in th e f luid are incorporated into many disposab le se ts . If the trap is ins talled ups ide down, a ir may be transmi tted to the pa tient (430). Many of these traps c anno t be eas il y v ented ; onc e the trap becomes full, a ir may be de liv ered to the pa tient. S ome gas -e liminating dev ices us e a mic roporous membrane that a ll ows the gas to escape withou t any us er i nte rv ention (431 ). Ano the r des ign uses a mechanism that s tops th e flui d f low when ai r is detec ted (432,433 ,434). Some s ys tems al low fl uid c ontai ni ng ai r to be reci rc ula ted to th e reserv oi r chamber (310 ). Ho wev er, no gas -e liminating dev ice can rel iably remov e l arge a mounts of ai r. Automatic ai r de tec ti on dev ic es may fail (335,413 ,421,435,436). P .898

Interference with Bispectral Index Monitoring

Falsely el ev ated bis pec tral index v alues hav e been re ported in patients rec eiv ing forc ed-ai r warmi ng aroun d the hea d (437). T emporary interrup tion of the warm ai r f low may be requi red to ge t acc ura te readings .

Pressurized Infiltration
The use of a fluid-warmi ng s ys tem that pressuri zes the fluid can resul t i n ex trav as ation of fluid. A compartment s ynd rome could occur (438).

Cooling Devices
Patients may require c oo ling fo r a v arie ty of reas ons , includi ng treatment of mal ignant hype rthermia and poss ible c erebral p rotec tiv e effec ts du ring neu rolog ic or c ard iac s urgery o r fol lowi ng head tra uma or cardiac arres t.

Chilled Intravenous Fluids

Hypoth ermi a can be i nduced by rapid inf us ion of chi ll ed f lu ids o r IV f luids at room temperature (440,441 ,4 42,443). One l iter of c rys talloid at ambien t temperatu re or one u nit of refrig era ted blood adminis te red through a peripheral si te reduces mean body tempera ture by app rox imatel y 0.25C in adul ts (444 ). A dmin isterin g the fluid central ly wi l l dec rease core tempera ture more rapidly (442). This me thod is res tric ted by the v ol ume tha t can be admin is tered wi tho ut ov erl oadin g the ca rdiov ascular s ys tem but ma y help to c omp ensa te for antici pated diuresis and hel p

to ma intai n cerebral pe rfusi on press ure . It is less effec tiv e than immers io n in ice water (206).

Circulating Water Units

Newe r c i rcu la ting water un its hav e be en fo und to b e eff ec tiv e for c ontro ll ing fev er i n n eurol ogic patie nts (445,446). Ol de r uni ts we re less effec tiv e (447).

Forced-air Cooling
Coo li ng can be performed by usi ng a fo rc ed-a ir u ni t. This needs to be c ombined wi th other me thods to ac hiev e ef fec tiv e c ooling (206 ,448). Als o, mos t uni ts hav e no feedb ack co ntrol . Pers onal ai r-condi tioni ng s ys tems tha t attac h to the medical a ir l ine a re av ailabl e.

Immersion in Ice Water

Coo li ng by co nduc tion may be less effici en t than us ing fo rc ed air and is more like ly to interfere with patient c a re (449,450 ).

Central Venous Heat Exchange Catheters

Dev ic es are av ailable that hav e he at transfe r elements that can be ins erted i nto the central v enous s ys tem (4 51,452,453 ,45 4). Patien t te mperatu re is regu la ted through a c lose d-loop c ontroll er. Thes e d ev ices c an lo wer c ore temperatu re rapidly (455 ). The ir i nv asiv eness is a d rawb ack i n terms of ease of applica tion and ris k of co mplica tions . The time l ag before c ool ing c an be in itiate d is a potential drawback .

Lavage
Peri ton eal , bladde r, o r gas tric lav age with ic ed s ol utions can be pe rf ormed. Peri ton eal l av age is inv asiv e, a nd bladde r lav age prov ides mi ni mal c ooling.

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437. Hemmerling TM, F ortier JD. F als el y inc reased bis pec tral index v alues in a se ri es of pa ti ents undergoin g cardiac s urgery usi ng fo rced-a ir warmi ng therapy of the head . A nes th A na lg 2002;95:322323. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 438. W illsey D, P e terfreund R. Compartme nt s yndrome of the uppe r arm af te r press uri ze d i nfil tration of intrav enous f luid. J Cl in A nes th 1997;9:428430. [Cross Ref] [Med li ne Link ] 439. Lus combe M, A ndrz ej owsk i J C. Cl inic al ap pl ic ations of induc ed h ypo the rmia. Con tinuing Education in A naes thesia, Cri tical Care & Pain 2006 ;6:2327. [Cross Ref] 440. Baranov D, Bumgardne r J , S mi th DS , et al . Rapid i nfusi on of chil led IV so lutions f or mode rate hyp othermia. Anes thes iolog y 1998;89 :A 316. 441. Bernard SA , Buis t MD, Monteiro O, et al . Induced hypothermia us ing large v olume , ic e-c old intrav enous fluid in c omatose surv iv ors of ou t-of -hospi ta l cardiac arres t: a p rel imina ry report. Resus ci tati on 2003 ;5 6:913. [Cross Ref] [Med li ne Link ] 442. Rajek A , Greif R, Ses sl er DI, et al . Core c ool ing by central v enous infus ion of i ce-cold (4 and 20C) fluid. A nes thes iology 2 000;93 :629637. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 443. Baumg ardner J E , Baranov D, S mith DS , et al . The effec tiv eness of rapidly i nfused intrav enous fl ui ds for induc ing mode rate hypothermia in neurosurgical pati ents . A nes th A nalg 1999 ;89 :16 3169. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 444. W erlhof V . Hotli ne f lu id warming fai ls to mainta in no rmothermia . Anes thes iology 1996;84:15201521. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

445. Maye r SA , Kowals ki RG, P res ci utti M, et al. Clinical tria l of a nov el s urface cooling s ys tem for fev e r con trol in neuroc riti cal c are patients . Cri t Care Med 2004;32:2508251 5. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 446. Carhuapoma JR, Gup ta K , Co plin W M, et al . Treatment of refrac tory fev er in the neurosc iences intens iv e c are un it using a nov el, wa ter-c ircu lating cool ing dev ic e. J Neu ros urg A nes thesiol 2003 ;15 :31 331 8. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 447. O'Donne ll J M, Axel rod P , Fishe r C, et al . Us e a nd effec tiv eness of hypothermia bl ank ets for febrile pati ents in the in tens iv e care uni t. Cl in Infec t Dis 1997;24:1208121 3. [Med li ne Link ] 448. Maye r SA , Commichau C , Scarmeas N, e t al . Clinical tria l of an a ir-c i rculatin g cooling bl anket f or f ev er c ontrol i n c ri tic all y il l neuro logic patients . Neurology 2001;56:292298. [Fu ll tex t Link ] [Med li ne Link ] 449. Cre echan TA , Voll man K M, K rav utske M. Co mparis on of coo li ng by co nv ecti on to c ooling by conduc tion for the trea tmen t of f ev er in the c ri tic al ly i ll me dical p ati en t population . Cri t Care Med 1999 ;27 :A32. [Fu ll tex t Link ] [Cross Ref] 450. The ard MA , Tempelhoff R, Crowde r CM, et al . Conv ec tion v ers us c onduction cooling for induc tion of mi ld h ypothermia duri ng ne urov asc ul ar procedures in adults . J Ne uro Anes th 1997;9:250 255 . 451. Sch mu tzhand E , E ngel hardt K , B eer R, e t al . Saf ety and efficac y of a nov el i ntrav ascula r c ooli ng dev ice to control bo dy tempera ture in ne uro lo gic intens iv e ca re pati ents : a prospec tiv e p il ot s tudy. Crit Ca re Med 2002;30:24812482. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

452. A l -Senani F M, Graffagni no C, Grotta JC, e t al . A prospec tiv e, mu lticenter pil ot s tudy to ev alua te the feasibili ty and s afety of usi ng the Cool Gard s ys tem and Ic y ca the ter fol lowi ng cardi ac arres t. Resusc itation 2004;62:143150. [Cross Ref] [Med li ne Link ] 453. Les lie K , W il l iams D, Irv ine K , et a l. Peth idine an d s kin warmi ng to p rev ent sh iv ering duri ng endov as cular cooling . Anaes th Intens Care 2004 ;32 :362367. [Med li ne Link ] 454. Inderbi tzen B , Yon S , Lashe ras J , et al. S afety and perf ormance of a nov el i ntrav ascula r c atheter f or induc tion and reve rsa l of hy pothermia i n a p orc ine model . Neu ros urgery 2002;50:364 370 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 455. Kel ler E , Imhof H-G, Gass er S , e t al . Endov asc ular c ooli ng wi th he at ex change ca the ters : a ne w method to induce and main tai n hypothermia. Intens iv e Ca re Med 2003;29:939943. [Med li ne Link ] P .905

Questions
For the fol low ing ques tions , s elec t the co rrec t answer 1. Wha t is the normal core bo dy tempe rature? A . 38C 0.2 C B . 38C 1C C. 37 C 0.6 C D. 37 C 0.2 C E . 37C 0.6 C V iew A ns we r2. How muc h d oes core b ody te mp era ture n ormally d ecrease durin g the firs t hour after the be gin nin g of surgery w ithout using measures to re duce he at loss? A . 0.5C to 2C B . 0.5C to 1.5C C. 0.5C to 1C

D. 1C to 1.5C E . 1C to 2C V iew A ns we r3. Wh at is the majo r mechan ism of hea t lo ss during ane sthesia? A . Ev aporation B . Conduc tion C. Conv ec tion D. Radia tion E . S i te of surgery V iew A ns we r4. Wh at percent o f the intrava scular vo lume may be lo st to the extrace llular space during each degre e o f hypo thermia ? A . 1.85 % B . 2% C. 2.5% D. 2.75% E . 3% V iew A ns we r5. Wh at is the hig hest temperature abo ve w hic h a ltera tions in red cell integ rity occ ur? A . 44C B . 45C C. 46 C D. 47 C E . 48C V iew A ns we r6. How muc h d oes a liter o f cry sta lloid a t ambient tempera ture or one unit of refrigera ted blood infus ed through a periphera l site re duce the mean body temperatu re? A . 1C B . 15C C. 0.2C D. 0.25C E . 0.3C V iew A ns we r7. Wh ich factors determine the tempe rature of a flu id as it enters the vein? A . Th e temperature set poin t on the warming dev ic e B . S tarting temperature of the i nfusate C. Rate of fluid f lo w

D. Le ngth of the tub in g between th e patien t and the warme r V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i f D is correc t i f A , B , C, and D a re co rrec t.

8. Which con ditio ns prevent an eq uilib ratio n b etw een heat loss and he at production during surgery ? A . Th orac ic surgery B . P e ripheral neuropathies C. Intra-abd ominal su rge ry D. Regional a nes thetic blocks V iew A ns we r9. Wh ich factor(s) determine the seve rity of hy poth ermia? A . Length of the surgical p roc edure B . A mount of c ool fl ui ds C. S i te of s urgery D. Sex V iew A ns we r10 . Whic h metabo lic changes occur a s a result of hypothe rmia? A . S hif t of the ox yhemo globi n d is soci ation curv e to the ri ght B . Lower umb ilic al pH in babies whose moth ers we re warmed C. Highe r hemog lobin s atu rati on D. Ac cumulation of metabolic pro duc ts V iew A ns we r11 . Whic h problems are associated w ith shivering in the pos tope rative period? A . Inc reas ed metabolic d emand B . Inc reas ed cardiov ascular wo rk C. Inc reas ed in traocu la r pressu re D. Dec re ased intrac ran ial pressu re V iew A ns we r12 . Whic h patient(s) are most s usce ptible to burns fro m hea ting devices? A . Th ose wi th poor cu taneous blood fl ow B . Diabe tics

C. The e ld erl y D. Inf ants V iew A ns we r13 . What are the ca rdiovascular effec ts of hypothermia? A . Dec reased need fo r v as oac tiv e dru gs B . Ca rdiac dys rhythmias C. Inc reas ed c ontrac til i ty D. Inc reas ed c atech olamine p roduc tion V iew A ns we r14 . T he most e ffective w ay (s) to utiliz e a w ater heating pad include A . P lac ing the hea ting pad ov er the patient B . P lac ing the hea ting pad un der the patient C. Us ing a thin pad attac hed to the patient D. Heating af te r the patien t is in pl ace V iew A ns we r15 . E ffective use of passive coverin gs inc ludes A . Cov ering as much of the bod y s urfac e as poss ib le B . A pplying in the PA CU to re warm the patie nt C. P lac ing a warm b lanket ov er the pati ent as s oon as he en ters the operating room D. Us ing ref lec tiv e cov erings V iew A ns we rP .906

16. Advan tages of rad ian t heat lamps include A . Dec reased heat l oss f ro m the skin durin g wa shing B . Unobs tructed acc ess to the patient C. Dec re ased f lu id requi rements D. Mos t effec tiv e in are as of arte ri ov enous anas tomos es suc h as the f ore head , hands , a nd feet V iew A ns we r17 . In dication(s) for fluid w armin g include A . P a tients with cold agg lutinins B . Ex change trans fus ion in neo nates C. Rapid infus ion D. Res to ring normothermia af te r s urgery V iew A ns we r

Chapter 32 Operating Room Fires and Personnel Injuries Related to Sources of Ignition
P .908

A l though flammable a nes thetics hav e dis appeared from operating rooms , perioperativ e fi res c ontin ue to oc cur. They c an hav e dev as tating consequences , prec ipi ta te legal ac tion, and take a great psyc hological to ll on ev eryone inv olv ed. The y us ua ll y come as a comple te su rpris e to the s taff (1,2,3,4 ). Mos t operatin g room fi res are o f li ttle cons equence and a re not rep orted, maki ng the ac tual inc idence difficul t to determine (2,5 ,6). App rox imatel y 10% to 20 % of reporte d fi res resu lt in serious pati ent injury (7,8). Fuels presen t in the ope ratin g room inc lu de plas tic s tha t produc e dense blac k smoke when ignited. The s moke may conta in toxi ns and may h in der s afe ev acua tion of the patient and s taff f rom the room. Sud den igni tion can p res ent s econdary pro blems (9). It can c ause a s tartle reflex , caus ing the su rgeon's hand to je rk and po tentially c ut i nto u nin tended tis sue or s et other a reas of the s urgical s ite on fi re .

The Fire Triangle

For a f i re to occur, there mus t be thre e fac tors (f ire tri angle or tri ad) p res ent: an i gni tion s ourc e, a fu el , and an ox id ize r to support c ombus ti on together in the prope r proportions and und er the ri ght c ondi tio ns (Fi g. 32.1 ).

Figure 32.1 Three things are necessary for a fire to occur: an ignition source, fuel, and an oxidizer.

View Figure

Ignition Source
The re are a number of ig ni tion sou rces in the operating room. Mos t are unde r th e su rgeon's control.

Lasers
The ac ro nym laser (li ght ampl ific ation b y s timul ated emis sion of radiation ) def ines the proces s b y whic h a f orm of energy is conv erted i nto l ight energ y (10,11,12,13,14,15,16). The term can als o ref er to the dev ice tha t produc es the l ight or to the l ight i ts elf. Lasers us e a col ima ted , coherent, monoc hro ma tic , i ntens e beam of elec tromagnetic radiation to cut, c oagulate, or v aporize tissu e. The rate that the lase r energy is deliv ered is ca ll ed powe r and is measu red in watts . The wattage is e qual to the amoun t of energ y, meas ured in joul es, d iv id ed by the duration of ex posure measured in s eco nds . Lase r power dens ity is the amoun t of power d is tribu ted wi thin an a rea an d is indicated in wa tts per s quare centimete r.

Components of a Laser System

The basic compo nents of a laser s ys tem are two parallel mirrors enc ompas sing the l aser me di um a nd a power s ourc e (Fig. 3 2.2). In add ition, there may be an aiming beam f or de liv ering laser energ y tha t is o uts ide the v isible ran ge.

Laser Medium

The med iu m (head ) hol ds the subs tance ene rgi zed to produc e l as er ligh t. The medium, wh ic h ma y be a s olid, li quid, o r gas , determines the wav elength of the emi tted radiation . The laser is named for the material used as the medium.

Power Source
The power (pumping, pump, exc i ta tion) s ource supplies energy to the laser med ium to c rea te the light. W hen the powe r sou rce is ac tiv ated, energy is absorbed by elec trons of the atoms in the laser medium, whi c h are e lev ated to energ y lev els abov e th ei r ground s tate. The y then deca y to lo wer en erg y lev els a nd emit photons that are not in phase with one an other and trav el i n all di rec tions .

Optical Ca vity
The optical (resonator) c av i ty p rov ides th e e nv i ronment in whi ch the las er medi um i s conf ined. E nergy releas ed from the mediu m trav els in al l di rec tions . Mi rrors a re us ed to reflec t and inc rease the ene rgy of emis si on. On e of the mi rrors is no t 100 % reflec tiv e and all ows a s mall portion of the li ght to escape.

Light Guide
A light guide (deliv ery s ys tem) di rec ts the laser b eam to the surgical s ite (Fig. 32.3). Fiber-optic bundles are a conv enien t flex ible condui t for some wav el engths . Other lase rs utili ze a hol lo w tube wi th mi rrors aligned to refl ec t the beam f rom i ts sourc e through the f ocus in g l ens .

Aiming Beam
W ith c erta in las e rs , it is nec ess ary to use a lo w-po wered v is ib le beam as a marke r. This is us ua ll y a helium-neon gas las er. It pas ses th rough the s ame optic al pa th as the laser beam. P .909

Figure 32.2 Components of a laser.

View Figure

Laser Types
Ty pes of med ic al lase rs c ommonly used in s urgery a re sho wn in Table 32 .1.

Laser Hazards
Lasers c an cause s ignificant damage to op era ti ng room pers onne l (inc lud in g the anes thes ia prov ider) and the patient. Haza rds inv olv ing las ers i nclude f ires , atmospheric contamination, eye damage, organ o r v ess el pe rforation, and embo lism (10). Fig ure 32.4 s hows a s ign used to warn p ers onne l th at a laser is i n use.

Figure 32.3 This is a schematic representation of a CO2 laser guide as might be found in either an operating microscope or a handheld wand. The guide consists of hollow tubes with hinged, aligned mirrors that reflect the beam from its source through the focusing lens.

View Figure

A rec urrent problem wi th l as ers is that they may be ac tiv ated when not in use (22,23). Often, a foot s witch ac c identally activ a tes the laser. The las er may be in a position where this is n ot no ticed for some ti me . W hen the las er is not ac tuall y i n us e, i t s hould be p lac ed in the STAND-B Y mode. A fi re may resu lt wh en a las er beam hits a fuel or the laser f iber bec omes dama ged. Ign ition can be al mos t ins tan taneous . W hi le mos t igniti on sou rces mus t be i n contact with a ma terial to c aus e ign itio n, a laser c an s upp ly heat to a fuel f rom a few c entimeters to sev era l meters away, s o i t c an ignite mate ri al c los e to the tip, at some d is tance from the tip , or un der sev eral laye rs of o the r mate rial . A su rface drape can be penetrated b y the lase r but not igni te . Mate ri als unde r the drape may then igni te an d burn wi thout being notic ed for sev e ral minu tes (24). The l aser beam can be ref lec te d f rom a metal su rface , c ausing a burn or ign iting material in a remote l oca tion.

Laser Risk Classification

A c lass if ic ation sys tem ref lec ting lase r ri sk to the pa tient and pers onnel has been dev el oped (25,26,27). The higher the c lass , the more s tri ngen t th e p rotec tion needed. P .910

TABLE 32.1 Commonly Used Lasers and Associated Personnel Hazards Laser Medium CO2 Features Potential Hazards to the Eye Injury to the eye will be confined to the cornea. There is no risk to the retina. Since the laser is absorbed by plastic and glass, ordinary eyeglasses with sideguards can be used for eye protection. Special Considerations

Readily absorbed by all biologic materials, independent of pigmentation. Tissue destruction is proportional to its water content. Produces a very superficial tissue effect.

Fires involving both tracheal tubes and supraglottic devices have been reported with this laser.

NdYAG

Can be transmitted through fiberoptic fibers. Poorly absorbed by water but well absorbed by pigmented tissue (11).

Retinal damage can occur. Opaque green eyewear or eyewear with clear lenses with a special coating should be worn.

Because it is taken up by pigment, colored markings on tracheal tubes are more likely to be damaged than clear portions (12). Blood or mucus on or in the tracheal tube makes the tube less resistant to the laser beam. Fires have been reported from an NdYAG laser passed through the channel of a flexible bronchoscope (17,18). The rigid bronchoscope is recommended for use with this laser, although the flexible scope may be needed to treat hard-to-reach areas (19).

KTP

Passes through clear substances but is absorbed by hemoglobin and other pigments (11,20,22).

Retinal damage may occur. Special eyewear with red filter should be worn.

Argon

Beam is selectively absorbed by red, orange, and yellow pigment and strongly absorbed by hemoglobin and

Retinal damage may occur. Special opaque orange goggles/eyewear should be worn.

melanin. Fiberoptic bundles can be used to transmit the laser beam.

From Klarr P. Laser complications. In: Atlee J, ed. Complications in Anesthesia. Philadelphia: WB Saunders, 1999:588590.

Class 1 Lasers
Lasers that are totall y enclosed or that emit ex treme ly low output fall into c las s 1. These are s afe to v iew.

Class 2 Lasers
Low-ris k l as ers are in c las s 2. Their ri sk is approxi mate ly eq uiv alent to s taring at the sun or o the r bri gh t li ghts that can c aus e c entra l re tinal injury. These are not hazardous unless someo ne ov e rco mes their n atura l av ersion response to b ri ght l ight.

Class 3 Lasers
Cl ass 3 l asers ope rate at a powe r lev el a bov e 1 mW . This is a hazard ev en if v iewe d o nly momenta ri ly . Cl ass 3 lasers are s ubdiv ided into a and b s ubc las ses . The 3a s ubc las s cons is ts of las ers in the 1 to 5 mw powe r ra nge. These lase rs pos e a moderate ocular h azard. Clas s 3 b inc lu des lasers that emi t between 5 and 500 mW of output power. Ev en momenta ry v iewi ng of thes e lasers is potenti al ly hazardous to the ey e. They may also be a haza rd to s kin. P .911

Figure 32.4 Note that the laser class is on the sign.

View Figure

Class 4 Lasers
Any c ontinuous wav e las er wi th a power output abov e 500 mW is in c lass 4 . Thes e l asers pos e s erious ski n, eye, and fi re hazards . Igni tion risk is re lated to a number of fac to rs bes id e the las e r c lassif ic ation . Class 3b an d 4 lase rs are cons idered to be igni ti on hazards . The igni tio n risk of other c las ses of las ers wi ll depend on how they are foc us ed , th e time of exp osure, and the ox idizers and fuels tha t are p res ent. Metal ins truments can bec ome ov e rheated with pro longed laser use and co ul d caus e a burn (28 ).

Electrosurgery Unit
E lec trosurgery (radio frequenc y) appa ratus i s s o wid ely used that there is of ten co mplacenc y abou t readi ng the i ns tructio n manual or followi ng safe prac tic es (29,30). Elec tros urg ery u nits are the mos t common i gni ti on so urc e in su rgica l fi res (6). T he ins truc ti on manua l should b e s tudie d at the beginning of a tra ining program and rev iewe d peri odica ll y. A brief s et of ope rating instruc tions s hould be readi ly av ailab le on the ins trumen t (31).

Terminology
The v ocabulary c oncerning el ectrosurgery is somewhat confusi ng (32). This c hapte r wi ll def ine e lec trosu rge ry dev ic es as thos e that emplo y a h ig h-f requenc y (radi o f requenc y) el ec tric cu rrent pass ing thro ugh tiss ues to c ut, coa gulate, or prov ide a blend of c utti ng and c oagu lation. El ec troc aute ry utili zes a hea ted wi re o r blade,

us ual ly at the end of a probe fo r coagulation . Mos t elec troca ute ry dev ices are battery -opera ted.

Physics
The re are three modes av ai lable on modern elec tros urgery dev ices .

Cutting Mode
The c utti ng mode uses a c ontinuous s ine wav e. He ating is rap id and p rod uces h igh temperatures that expl ode c el ls that c ome in c ontac t wi th the elec trode. This produces a cut in the tissue.

Coagulation Mode
The c oagu lation mode features s hort burs ts of a damp ened s ine wav e. Less heat is produced s ince the curre nt is not c ontinuous . Tis sue des iccation occ urs , and the ends of bl ood v essels are thermall y seal ed .

Blend Mode
The blend (cut-c oag ulati on) mode empl oys a wav efo rm and v oltage be twee n tha t of the cutting and c oagu la tion c yc le . The rela tiv e amou nt of c utting or co agulation depends on the lengths of the bu rs ts of v oltage. Sev era l blend se ttin gs may be av ailab le on an elec trosurgical uni t (33).

Types
Monopolar
W ith monopolar (u nipolar) electros urg ery un its , e lec trons f lo w f ro m the genera tor to the ac tiv e elec trode and throug h the pa tient to the dis pers iv e (return , inac tiv e) elec trode, s ometimes inc orrec tl y c alled the grounding pad (Fig. 32.5). The curren t dispe rs es from high d ensi ty at th e tip of the ac tiv e elec trode to a l owe r dens ity v ia the lo wes t i mpedance pa thway tha t it can find .

Generator
The elec tric ally po were d generator (power u ni t) c rea tes a radi o frequenc y cu rrent that passes through the ac tiv e el ec tro de. Th e effec t on tissue depe nds on the cu rrent intensi ty, the type of cu rrent e mp lo yed, the du ration of ex posu re to the cu rrent, th e hand piece us ed, and the dis pers iv e electrode (34). Coagulation requi res longer c ontac t wi th the probe than cuttin g. As elec trica l ene rgy is appl ied to the tis sue, c har forms . S ince ch ar has h ig her i mpedance, more cu rrent d iss ip ates di rec tly to the dispers iv e elec trode an d the ef fec t is reduced (34).

Active Electrode

The ac tiv e el ec trode has a handle and is c onnec ted to the gene rator b y a f lex ible wi re. It d irec ts curre nt flow to the su rgical si te. The ti p of the ac tiv e el ectrode may be a blade, spatula, b all , lanc et, loop, forc eps , need le po int, or suc tion tip. It may be disposab le or reus able. The ti p P .912 configuration determines i ts abili ty to desicc ate tissue . A n eedle-ti p elec trode conc en trates more po wer on tis sue c on tac t than does a paddle or ba ll -s haped elec trode (3 4). A t a giv en elec trode v ol tage, the paddle-s haped tip p res ents a highe r powe r at the edge than on the fl at porti on. The elec trode may be ac tiv a ted by a han d contro l or foot s witch. The con trol may also be used to s witc h f rom one mode to another.

Figure 32.5 Monopolar electrosurgery unit.

View Figure

Dispersive Electrode
The disp ers iv e (inac tiv e, return ) el ec tro de (grounding or ground el ec trode, pla te, or pad) c ol lec ts the c urrent from the pati ent and returns it to the gene rator to co mple te the c i rcu it. The l arge contac t s urface of the pad prov ides low i mpedance. Mos t pads pres ently i n use are prejel led. Re usab le metal p lates us ed in c onj unc tion wi th c onduc tiv e ge l are rarely used today . Wi th s ome el ec trosurgery uni ts , two dispe rs iv e e lec trodes s houl d be us ed (35 ).

Safety System

Mode rn elec trosurgical uni ts posses s a return e lec trode (contac t quali ty ) moni to ring s ys tem. This ens ures tha t the p atient is connec ted to the return e lec trode (34,36). Current flowi ng to the ac tiv e elec trode is me asured and c ompared with curre nt retu rning f rom the d is pers iv e elec trode. If th e c urren ts are not ba lanced , th e uni t is deac tiv ated. A more rece nt i nnov ation is ac tiv e elec trode monitoring (AE M) (37,38,39,40). This c on tinuousl y moni tors th e elec trical c ircui t and automatic all y shuts down the generator and s ounds an ala rm if d ange rous e lec trical leakage oc curs . Newe r generators can s ense dramatic c hanges in tis sue impeda nce or temperature c hanges at the return elec trode (33,41). Some modern el ec trosurgery machines are e quipped wi th spl i t pads (42). The uni t wi ll not func ti on unl es s both halv es of the pad are i n con tac t wi th the patient.

Bipolar
The bipo lar elec tros urg ery u nit is co mpose d o f a gene rator and two elec trodes l ocated wi th in mill ime ters of each other. The energ y f low is be tween the two elec trodes , and no cu rrent f lows through the pa tient's body . This al lows the ene rgy to be loc al ized mo re precise ly. The c urrent densi ty in the tissues surrounding th e ac tiv e elec trode is s ubs tantiall y l ess than that for monopolar elec trodes , and deeper ti ssue laye rs are preserv ed wi th l ower v ol tag e and powe r req uiremen ts . This type of e lec trosu rge ry un it c an coagul ate even when the tip is i mmersed i n b lood. B ipolar units cannot be us ed fo r cutting . B ipolar elec trodes a re produc ed in a v a riety o f configuratio ns: hooks , spa tulas , sc is sors , forc eps , and needles (29 ,43). Of ten, thes e dev ices a re batte ry -op era ted . The re are rep orts that the ON-OFF s wi tc h on one of these dev ices did not al ways deac tiv ate the dev ic e wh en it was set asi de (44 ,45 ). T he hot tip c ould then s et drapes on f i re. A t le as t one dev ice c ould be ac tiv ated by another dev ice's wi re les s remote-c ontrol uni t or by f luoresce nt room l ights (46 ).

Hazards Associated with Electrosurgery

Mi shaps with the elec trosu rge ry uni t of ten inv olv e faul ty re tu rn elec trodes , imprope r elec trode placement, or al te rna te low-impedanc e outlets . Ins uff ic ient co ntac t wi th the dispersiv e pad c an res ul t in pa tient burns and/or bu rns to others who are i n contac t wi th the patient. Among the lo w-i mpedance al te rna tiv es a re elec trocardiogram (E CG) mon itoring elec trodes , temperature probes , urinary ca the ters , me tall ic pa rts of s u rgica l ta bles , heating pads , and ox imeters (47). About 68% of repo rted surgical fi res inv olv e e lec tros urgical equ ip ment (48). Fires as soc iated wi th the el ec tros urg ery u nit are of ten ass oc iated with an oxidi zer-

enriched atmos phere. W hen the el ec trosurgery uni t is used, heat v apo ri zes tis sue or expels tiss ue embers from the tip. In room ai r, ti ssue v apors do not igni te, and embe rs are quick ly ex ti nguished. In an ox idizer-e nriched atmosphe re, the v apors can ignite into a bri ef f lame, an d embers c an fl y sev eral inches and burn until they are cons umed. A f la re of ev olv ed gases can d irec tl y ignite any co nv enient fuel . The elec tric al wi res as soc ia ted wi th the elec trosurgery elec trode ma y d ev elop a s hort c i rc ui t, wh ic h c ould res ul t in a fire (49 ). Durin g laparoscopic s urgery , burns that are sometimes fatal can occ ur ou tsi de the su rgeon's v iew when us ing an elec trosurgery uni t (14,29,33,38,40,50,51,52). These are us ua ll y caused by insu lation fai lure, di rec t co upling, or c apac itiv e coup li ng. If a def ec t occurs in the ac tiv e el ec tro de's ins ulation , curre nt can flow through the defec t. Defec ts c an res ul t from imprope r handling or damage to b oth reus able and disposable elec trodes . A number of dev ices are av ai lable to detec t ins ula tion defec ts (33,40,51). Ac tiv e elec trod e mo nitoring continuously monitors the el ec tric al c i rc ui t and au toma tic al l y shuts down the gene rator and sounds an alarm if dangerous el ec tric al l eakage occ urs (37,38,39,40). Capac i ta tiv e coupling occurs when the elec tro surgic al c urrent induces s tray cu rrents on other nea rby c onduc tors . It c an occ ur ev en throug h intac t insulation . It oc curs as a res ult of the ac tiv e e lec trode c ontac ting o r coming i nto v ery c los e prox imity to a non-i ns ula te d metal ins trument (such as a laparosco pe) in the su rgical fi el d. If th e elec trical ly -e nergiz ed la parosc ope has been placed through a metal c annula, the cu rrent wi l l s impl y flow to the patient's abd ominal wal l . Howev er, i f th e l aparoscop e has been placed th rough a nonc onduc tiv e c annu la, the c urrent cannot f low to the abdo mi na l wal l. In th is c ase, any piece of bowel o r other internal tis sue touch ing the laparosc ope can be burn ed. Capac i tativ e c oupling is al ways present and c anno t be to tal l y eli mi nated.

Argon Beam Coagulator

The argon b eam (enhanc ed) c oagulator (ABC) i s solely a c oagu la ting ins trument. Rad io f req uenc y monopo la r c urren t is d elive red through a flow of ioni ze d argon gas . P .913 The f lo w i s al te red as the powe r is c hanged. The ti p does no t touch the tissue. If the tip is greater than 1 c m from the tis sue su rface , only a gentle s tream of argon wi ll fl ow. W hen the ti p is 1 c m or l es s f rom the tiss ue surface, the ac tiv e mode

oc curs . If the nozz le tip gl ows red, the tip is too cl os e to the tissue or the po wer se ttin g is too hig h.

Fiber-optic Illumination System

A fiber-optic illumi nation s ys tem cons is ts of a l ight s ourc e and l ig ht-trans mitti ng cable . The cable is con nec ted to a n endoscope o r headli gh t. Th e term c old l ight, us ed to desc ribe l ight f ro m a fibe r-optic sourc e, is inc orrec tly ass umed by many to mean that heat is not generated. A c tual ly co ld l ight refe rs to l ight i n whic h the amou nt of inf ra red radiatio n has been reduced (5 3). Thes e li ght s ources ca n prov ide sev eral hundred watts of v is ible, infra red , and ul trav iolet li ght. A l th ough so me of these wav ele ngths can be f il tered o ut, the power i s ty pic al ly focused i nto a f ibe r-optic c able of smal l d iame ter tha t c an deliv er a h igh -po wer dens i ty . A numbe r of f ires hav e been igni ted when th e unprotec ted end of the fibe r-optic cable wa s allowe d to res t on a drape (6 ,49 ,5 3,54,55,5 6,57). The c able en d c an reta in a signi fica nt amount of heat a fter be ing d isc onnec ted from the l ight s ourc e.

Defibrillator
W hen a def ibri l la tor i s ac tiv ated, a s park ma y be gene rated if insufficient force is applied to the paddles ; if the paddle pad is too smal l; if paddles are appli ed ov e r an i rregul ar s urfac e o r bony p romi nence or near an E CG elec trod e; when ins uffic ient, ex cess o r the wrong ki nd of gel is used; or if there is ano the r c onduc tiv e medium between the paddles (6 ,58 ,59 ). If disposable def ibri l la tion pads a re us ed to i nc reas e e lec tric al c onduc tion be twee n the paddle and the patien t, an arc can occu r i f th e s urfac e of the paddle is n ot comple tely on the pad, if the pad is smal ler than the padd le, if there is a fold in the pad, o r if the pa d is dry.

Pressure Regulators
W hen gas is al lowed to f lo w f ro m a high-pressu re to a l ow-pre ssu re cha mber, recompres s ion c an cause a rap id ris e i n temperatu re. Ma te ri als that cannot wi th s tand both 100% oxy gen and hi gh temperatures wil l i gni te . This haz ard is as soc iated mos tl y with alumin um ox ygen regula tors (60,61,62,6 3,64,65,66,67,68). Ano the r caus e of heat in a pres sure regu la tor is partic le impac t f rom c ontaminants . Tef lon tape, c hips f rom s eal materials , or hy drocarbon c onta minants ma y be present (6 9).

Surgical Lights
Surgical lights can be a so urc e of igni tion. If the li ght does n ot hav e the prope r mechanism to diss ipa te inf rared radia tion or i f that mec hanism f ails , the pa ti ent o r

personnel env i ronment can be exposed to energy lev els high en ough to c aus e burns or f i res (70,71). The heat f rom a s urgi cal l ight c an con tac t and rupture a hos e f rom the medical gas pi pel in e s ys tem (72 ).

Electrical Faults
An el ec trica l fi re c an occ ur i n a ny env ironmen t where the re is elec tric al equipment. A short c i rc ui t c an occur in an anes thesi a mach ine (73,74,75). In one reported case, a short circu it in a laryngosc ope wi th a rechargeable handle c aused flames to shoot f rom the charging end of the handle (76 ). E lec tric al arc ing in s urg ic al booms has been reported to cause fi res (77,78 ).

Other Ignition Sources

Other reported sources of ig nition in opera ting ro om f i res i ncl ude resec tosco pes , heat lamps , heated probes , pneu matic tourniquets , de nta l and orthopedic burs an d dril ls , he ated-wi re b rea th ing tubes , and h umid if ie rs (1,79,8 0,81,82,83,84).

Fuels
Fue ls ab ound i n the operating room. A fuel is anythi ng that can burn, inc luding mos t things tha t come in c ontac t with patients as we ll as the pa tients themselv es.

Tracheal Tubes
The ris k and cha rac te ris tic s of a trach eal tube fire wil l depend on the ty pe of tube us ed. In mos t c ases , ig ni tion requi res the tube to be penetra ted (85). The f ire begins on the ins ide rim of the pene tration a rea and then s pre ads both wi th and agains t the fl ow of ox id iz ing gas .

Polyvinyl Chloride Tubes

Pol yv inyl ch lori de (PV C) tubes are c ombus tible in an ox idi ze r-enric hed atmosphere wi th a carbon d iox ide (CO 2 ) l as er. Once igni ted and pene trated, a PV C tube can sus ta in a torc hlike fla me. PVC tubes wi th out mark ings are re lativ el y res is ta nt to the Nd-YA G laser, but ma rk ings i nc reas e the ris k (86 ). If there is bl ood, mucus , or sa liv a on the tube, the risk of fi re is inc reased. The inju ri es ass oci ated wi th PV C tube fi res are more s ev ere than wi th other types of tubes (87,88).

Red Rubber Tubes

Red rubbe r tubes are c ombus ti bl e with the CO 2 , potas si um titan yl phosph ate (KTP ), and Nd -YA G l asers (86,87,8 8,89,90). A major p rob le m is the inabil ity to s ee through the tube. S hould an intraluminal fi re dev elop, it may g o undetec ted for a l onge r period of ti me th an with other tubes .

Damage to the trac heobronc hial tree af te r an in traluminal fire may be less s ev ere wi th a re d rubber tube than a PV C tube (87). Red rubbe r tubes are les s likel y to soften, d efo rm, or fragmen t if ignited than are o the r tubes . A nother adv antage is that they c an be quickl y P .914 remov ed f rom the patient (91). The high press ure in the c uff c aus es it to defl ate more quickl y than is poss ible with a low-press ure cuff .

Silicone Tubes
A s ilicone tube is more res istant to pe netrati on by a CO 2 laser than other tubes (87). If ign ited, a s i lic one tube rapidly becomes a bri ttle as h tha t c rumbles eas il y and may be aspi ra ted , ra is ing the pos si bil i ty of future pro blems with s ilic os is (87,90,92,93). Howev er, the ac ute injuries are l ess sev ere tha n with red rubbe r and PV C tu bes (88).

Laser-resistant Tubes
A numbe r of ready -to-use laser-res istant tub es and tube wra ps are av ai la bl e and are desc ribed i n Chapter 1 9. The y should meet the requi rements of Inte rna tional S tanda rds Organ ization (IS O) 1 4408 (93). It i s i mportan t to remember tha t laserresis tant does not me an laser-proof . Las er-resis tant tubes can igni te, especial ly i f manufac tu rer's warni ngs , prec autions , or direc tions fo r use are not follo wed. If a l aser tub e is used with a las er other than that for wh ic h i t was d esigned o r a f lammable part s uch as the cuf f is exposed, it wi l l catch f ire (92 ,9 4). Laser-res is tan t tubes are us uall y not res is tan t to othe r heat s ources s uch as an el ec trocau tery penci l.

Supraglottic Airway Devices

The relativ e resis tanc e o f sup rag lottic ai rway dev ices depends on thei r co mpos i tion . Thos e dev ices tha t are made of s i lico ne rub ber s uch as the LMA Cl ass ic , LMA -F lexible , and LMA -P roS eal are s ign if ic antly more res is tant to the CO 2 l aser tha n a re PV C tracheal tubes (95 ). Man y dis pos able s upragl ottic dev ic es are made of PV C and are p rob ably as sus ceptibl e to fi res as trach eal tubes of the s ame co mpos i tion .

Surgical Products
Surgical drapes , towe ls , and dress ings are co mmon fue ls for op era ti ng room fi res . Of ten , th e d rape is igni te d f rom another fire (24 ). W hi le many dra pes are res is tan t

to ignition in room a ir, the ox idi zer-en riched a tmos phere that is often present may caus e them to burn with v igor (49,96,97,98,99,10 0,101,102,103,104). Disposable drapes may be pa rtic ularl y diff icul t to deal wi th d uring a fi re because they are wate r repellen t. A ddi ti on of wa ter ma y ev en s p read the f lame. Las erresis tant drapes are av ai lab le . S ome s yn theti c drapes wi l l mel t away f rom the las er rather th an igni te (1 03). The re are numerous reports of surgical s ponges , gauze p ads , and s wabs being i gni te d (49,105 ,106,107,108 ,10 9,110,111 ,11 2,113). W et sponges ma y be used to protec t a trac heal tube from a lase r beam. Howev e r, if they are allowe d to dry out, they bec ome flammable.

Adhesive Substances
Adhesiv e tape can be the fuel f or a fi re (114 ). Co ll odi on and b enzo in are f lammable .

Skin Preparatory Solutions

Fl ammable v olatile organic so lutions are often us ed to prepare the s k in pri or to su rge ry. If the liqu id or v apor is contacted by an igni ti on sou rce , a fl ame c an resu lt (1,101,115,116 ,117,118,119 ,12 0,121). A lcohol-bas ed solutions are espec ia ll y f lammable . They c an also in fi ltrate and pool u nder the drapes . W hen this happens , they are slo w to dissipate. A lcohol -b ased f ires hav e a flame tha t is d ifficult to see . Of ten , th e result of the flame is the fi rs t thin g notic ed.

Intestinal Gases
Gas es that acc umulate i n the bowel (es pecial ly h ydrogen , hyd rog en sulfide , and methane ) c an be the fuel for a fi re o r exp los ion if an elec trosu rge ry uni t is used to open the bo wel (105). P roper bowel preparati on may prev ent this (122 ). Suffic ient ox ygen to s upport combus tion is normall y not present in intes tina l gas . Howev er, ni trous ox ide may diff use into the intestinal l umen, c rea ting a flammable mix tu re.

Oxygen Cannulas
Ox ygen c annul as are ma de of plas tic that can burn . They c arry 100% oxy gen. If touched by a hot e lec trosu rge ry probe or a lase r beam, the y b urn readil y. Ev en if not di rec tl y contac ted , the a rea around them may be s o ox ygen-ric h that a smal l spark c an turn in to a burning ember tha t can igni te the cannul a.

Lubricants and Ointments

Petro le um-based ointments th at are used in an ox idizer-en ric hed a tmos phere wi ll i gni te whe n enough heat is present to c ause v aporization (105,123,124). W ate rbased lubric ants wi l l not burn a nd can be us ed to coat ha ir to make i t fi re -resis tant.

Body Hair
Bod y hai r, i ncluding e yelas hes , mous taches, and b eards can be inv olv ed in a fi re (105,106 ,125,126). Coating the hair with a wa ter-based lubricant wil l dec re ase the risk . Surface fl ame propagation occurs where the re are fine surface fibe rs of fabric o r body hai r (1 27). In the presence of an ox id ize r, thes e fine fibe rs can be igni ted. Of ten , th e s kin o r und erl yi ng fabric is not bu rne d. The s urfac e fi re races in the di rec tion of the ox ygen s ource, where the ox ygen suppl y tubing may be ignited (58).

Other Combustible Substances

A numbe r of artic les us ed in or near the pati ent c an serv e as the flammable material . Th ese incl ude (but are not l imited to ) ox ygen tubi ngs , endoscop es , s moke ev acua tor hos es, es ophageal s te thosco pes , breath ing tubes , reserv oi r bags , e ye patches , s ten ts , mask s , nas ogas tric tubes , en teric feeding tubes , rubber and plas tic nasoph aryngea l ai rwa ys , c ov ers , paper p rod uc ts, blood p res sure c uffs , aeroso l adhes iv es , tourniq uets , glov es, s tethoscope tubi ng , th roa t pack s, eggc rate f oam P .915 mattress es , bandages , s tocki nettes , d res sings , pil lows , glue, gown s , s traps , c aps and h oods , rubber elec tros u rgica l uni t probe s heaths , s hoe cov ers , loca l anes thetic sp ray , and organic gas f rom a nec ro tic tumo r (106,116 ,128,129,130,131,132,133,134 ,135,136,137 ). A lcohol-bas ed hand s ani ti ze rs (g els , f oams , and li qu ids ) are h ighly f lammable (138). The y shou ld be s tored in a cabinet that is des igned fo r fl ammable materi als . Howev er, a s tudy pub lished in 200 3 fou nd no fi res attri bu tab le to hand sanitizers , and the National Fire P rotec ti on Ass oc iation no w a ll ows alcohol -bas ed hand saniti zer d ispens ers in corri dors and other p ublic a reas, prov ided c ertain res tric tions are observ ed (139). If a dis penser is mounted i n a hall way , th e c orri dor mus t be at leas t 6 fee t wid e. The dispense r can proj ec t up to 6 inches f ro m the wal l and mus t be ins tal led abov e ha ndrai l hei ght.

Oxidizers

W ith an ox idi ze r-enriched atmosphere , a fi re igni tes eas ier, burns more v igorousl y, sp reads more rapidl y, an d is more d ifficu lt to ex ti nguish . The oxi di ze rs of g rea tes t i nte res t are oxygen and ni trous oxide. Ni trous oxid e supp orts combus tion and in the process releases the energy of i ts formation, prov iding inc rease d heat. Thus , any mix tu re of ox ygen and ni trous ox ide wil l support co mbus tio n. A i r wi ll a ls o s uppo rt co mbus tion, becaus e it c ontains oxy gen. Bec ause ox ygen is heav ier than ai r, i t c ollec ts in low-l yi ng areas , inc lud ing d rape folds . Some materia ls such as drapes a nd towels absorb oxy gen and reta in i t fo r so me time (1,127). Ten ting drapes wi l l al low ox ygen to dra in off toward the f loor and b e d il uted by ai r c i rc ulation.

Common Scenarios Airway Fires

Durin g airway su rge ry, all of the th ree necess ary c omponents are i n clos e prox imity: a c ombus tible subs tance (tra chea l tube, gauze , etc .), an igni tion s ourc e (las er or e lec trosu rge ry ap paratus ), and gas to s upport combus tion (ox ygen wi th or wi th out ni trous oxi de). An ai rway f i re is parti cul arl y se rious becaus e a c onside rab le amou nt of heat is genera ted i n a s mal l area, and the smok e and gases f rom suc h f ires can be b lown deep in to the patient's l ungs .

Using Electrosurger y during Tracheostomy

Many a irway fi res hav e occurred whil e us ing the elec trosurgery uni t durin g trac heos tomy (9,105,128,130 ,140,141,142 ,14 3,144,145 ,14 6,147,148,149,150,151,152 ,153,154). Of ten , th e patien t is being giv en 100% ox ygen i n antic ipa tion of interrupted v enti lation and/o r bec aus e of the underly ing c li nical cond ition. If the tracheal tube or c uff is contac ted, an ox idizer wi ll be released. Cu rrently , there is no tracheal tube th at is safe for use wi th el ec tros urgical d ev ices or elec troc autery , al though so me a re more resis tant to igni tion than others (155).

Using Electrosurger y in the Mouth

Us ing elec trosurgery in the oral cav i ty may resul t i n a f i re (6,156,157,158 ,159,160,161 ,16 2). The trach eal tube is of ten the fuel , but o the r i tems s uch as sponges or pati ent tis sue may be i nv olv ed. Of te n, wet g auze is used i n the throat to c atch s ec retions or to pro tect th e trache al tube. If there is a l eak around the tube, the ga uze can becomes oxi diz er-en ric hed and dry ou t more quick ly .

Laser-induced Tracheal Tube Fires

The l ikelih ood that a l aser wil l co ntac t the trach eal tube du ri ng ai rwa y p roc edures i s high (163 ). Cuff ed tubes are more lik el y to be contac ted than nonc uffed tubes . The tube may be expos ed to ei ther the di rec t or reflec ted las e r beam. Fla ming tis sue in c lose prox imity to the tube ma y caus e it to ignite (164). In addi tion to loc al da mage in the l arynx , injury c an occ ur to the lower a ir way and the parenc hymal tissue in th e lung . The produc ts of combus tion may b e b lo wn i nto the lungs . The c uff is the mos t v ulnerable part of the tracheal tube . It c anno t be wra pped , and l aser-res is tan t tubes do not hav e lase r-res is tan t cuffs . W et c otton sponges a re of ten used around the tube to protec t the c uff f rom the l aser beam. If these dry out, they can b ecome fuel f or a fire (16 5). Tape that is us ed to sec ure the tube ca n igni te. Durin g lowe r ai rway s urg ery us ing a las er, the cable may be pass ed through the i nsi de of a trac heal tube. The tracheal tube sho ul d be placed jus t belo w the v oc al co rds s o that the tip is as fa r away f rom the operativ e s ite as pos sible.

Other Head and Neck Fires

Head and neck f i res c an occu r during loc al anes thes ia proce dures when elec trosurgery appa ratus is used (6,49,56,126,16 6,167,168,169 ,170,171,172 ,173). Of ten , ox ygen is being adminis te red , and i t may diffus e into the s urg ic al area. An y f lammable i tem in the v ic ini ty can c atch f ire.

Fires Involving Pressure Regulators

W hi le no t a freque nt oc currence, a f ire in a re gulator ca n be d is as trous (174). These fi res may res ul t from adiabatic compress ion o r partic le ignition in whi ch debris is b lown f rom the c yl inder into th e regulator wi th s uffic ient energy to cause i gni tion. Imprope r pressu re regul ator ass embl y may als o cause a f i re. P .916

Regula tors wi th alumi num compo nents are more like ly to burn than othe r regulators . The Food and Drug Adminis tration (FDA ) and the National Ins ti tute f or Occ upati onal Safe ty an d Heal th (NIOS H) now rec ommend that aluminum re gulators be repl aced wi th o nes wi th brass c omponents (64,66). A numbe r of al uminum ox ygen regulators hav e be en rec alled (67).

Intraperitoneal Fires
Sev era l ex plos ions hav e been reported during l apa ros copy wh en nitrous ox ide wa s us ed as th e i ns uff lating gas (122,175,176,177 ). Ni trous oxi de in the inspi red g ases wi ll diffuse into the peritoneal c av i ty and ma y reach a high enough c onc entration to support combus tion (178,179). Fires hav e al so resul ted f ro m i nflating the p eri tonea l cav ity wi th an ox ygen -CO 2 mix ture ins tead of pure CO 2 (180,181). The P in Index Safety S ys tem (Chapter 1) wi l l not p rev ent this error, bec ause the in dex ho les f or tanks wi th 1 00% C O 2 are the same as for an y tank wi th g rea te r than 7% CO 2 .

Fires during Defibrillation

Ox ygen is alwa ys used duri ng resus ci tati on, a nd the s ource is of ten disconnec ted and p lac ed nea r the h ead (58,182,183). This may allow o x yg en to flow ov er the defi bri lla ti on elec trodes (184). A spark caused by plac ement of the defibril lato r paddle o r elec trode cl ose to an E C G elec trode or poor contac t be tween the pati ent's s k in a nd th e defibril lator paddle or elec trod e ma y ignite hai r or other co mbus tible materials in the area (183,185 ).

Fires in Canisters
Fi res in CO 2 abs orbent c anis ters h av e been reported (186,187 ,188,189,190,191,192,193). These are d is cus sed in more detail i n Ch apter 9.

Personnel Risks Smoke Hazards

Potential ly ha zardous ai rborne contaminan ts are formed from tiss ue v apo rizati on whe n a lase r is us ed. Thes e by -p roduc ts hav e the potential to be mu tagenic , ca rc inogenic , teratogenic , or a v ec tor for v iral infec tio n (10,194). E lec trosu rge ry dev ic es and bone saws also produce v aporized f ragments that hav e the s ame hazards (25 ). Inhali ng potentia ll y hazardous ai rb orn e c ontami nants can be k ept to a minimum by sc av engi ng the s moke. T his wi l l help to give the surgeon a c lea rer v iew o f th e su rgical fi el d and re mov es o ffens iv e and irrita ting odo rs . V arious s moke ev acua to rs are av ai lable (103,1 95). To be mos t effec tive, the ev acua tor nozz le s hould be positioned as c lose as pos si ble to the operativ e f ie ld and b e func tiona l bef ore, during and for 30 seconds after tis sue is v apo ri zed (196).

Person nel masks shoul d be remov ed and disc arded as soon as poss ib le af te r use (196). S tanda rd s urgical masks f il ter ou t parti c les down to abou t 3 mic rons i n diameter. The las er plu me h as partic les as small as 0.31 mic rons . High-eff ic ienc y mask s can f il te r partic les do wn to 0.30 mic rons , bu t the y are difficul t to breath e through and lose thei r efficienc y when wet (10,10 3).

Ocular Injuries
The lase r beam may be di rected ov er some dis tanc e . The area of h azard may not be l imi ted to the immed iate surgical are a and may present risk to o perating room personnel (25). The s urgeon is not hi ghly suscep ti bl e to injury becaus e of the safety dev ic es bui lt into the ins trument. Howev er, if the ins trument is ac c idental ly ac tiv ated, he is ex posed to the same hazards as other pe rso nnel . The eye is es pec iall y v ulnerabl e to injury . Beca use CO 2 l ase r beams are abs orb ed wi th in the fi rs t 200 m of tis sue, the y are a haz ard to the c ornea (1 97). A rgon, KTP , and Nd -YA G l asers are more like ly to caus e d amage to the retina . The ex ten t of dama ge wil l depend on wh ic h part of the reti na is aff ec ted. Pe rman ent v isual loss may res ul t (25). A ll personnel in the are a wh ere a laser is us ed s hould we ar app rop riate p rotec tiv e eyewear. This may inc lude go ggles , fac e s hi elds , spec tacles , or presc ri ption eyewear us ing spec ial materials or refl ec tive c oatings (or a combination of b oth), se lec te d to reduce the potential oc ula r exposure. The s afety e yewea r should be marked ac cordi ng to the wav elength (laser type ) (Fi g. 32.6). It s hould be noted that l aser safety eyewea r is n ot des igned fo r look ing di rec tly at a lase r beam (1 6). The pati ent's eyes should be c losed and c ov e red wi th s aline -soaked gauze or a nonshiny metal s hield . A wake pa tients shoul d we ar goggles spec ific for the lase r being us ed. W indo ws in the room s hould be cov e red and a warni ng si gn plac ed P .917 on the operating room doo r at ey e lev el (Fig. 32.4). Spare eye ware should be av ailab le at a ll entranc es.

Figure 32.6 All laser-protective eyewear should be clearly and permanently labeled.

View Figure

Electrical Shock
Ano the r conc ern is elec tric al shock from the e lec trosu rge ry dev ic e. A c ommon prac tice among s u rgeons is to al lo w a n assis tant to touch the dis ta l end of a forc eps wi th the ac tiv e elec trode f rom the elec trosurgery appa ratus . This ac tion makes the forc eps the ac tiv e elec trode. A glov e may no t offer suffic ient p rotec tion f rom the elec tric al c irc ui t. Holes appear in as many as 15% of g lov es. The re are ways to minimiz e the s hock po tenti al wh ile usi ng elec trosurgery. T he ac tiv e elec trode should be f irmly i n con tac t wi th the forc eps bef ore i t is energized . The pers on holding th e forc eps s houl d try to c ontac t i t in as large an area as possible to spread the concentration of the charge.

Fire Prevention
The bes t wa y to deal with fi res is to prev ent them f rom s tarti ng (127,198). Fi res c an be av oided by not all owi ng the th ree elemen ts of the fire triangle to come toge the r at the sa me time .

Controlling Ignition Sources

One way to reduce fires is to properly use equi pmen t that might ac t as an i gni ti on sourc e. It is important to read ins truc tion manuals and to alter techniques to f i t these ins truc tions .

Lasers

Person nel wh o use las ers should take a certif ied las er cours e (6,23,26,103 ). They shoul d prac tic e thei r techn ique on inanima te ob jec ts and gain expe ri ence a t the hands of an experienced c li nic ian. S pec if ic pe rsonnel should be desi gnated to moni tor and prev ent lase r haz ards . A laser protoc ol should b e dev eloped and fo llowe d. Las ers s hould be tes t f ired onto a s afe surface before us e to ensure tha t the b eams are p roperl y al igned. Lase rs shoul d alwa ys be kept i n the s tand by mode ex cept when needed. The lo wes t power densi ty and s hortes t pu lse dura ti on th at wi ll do the j ob sho ul d be used . The l aser shoul d be ac tiv ated onl y when th e tip is under the surgeon's d irect v is ion. The l ase r shoul d be placed in s ta ndby mod e bef ore remov ing i t from the s urg ic al s i te. Laser f ib ers s hould not be c lipped to drapes b ecause the f ibers may be broken. The l aser fi ber s hould be careful ly passed through an endos cope before in troduc in g the sc ope i nto the pati ent to minimize the ris k of f ibe r damage. Th e fi ber's func tionali ty shoul d be v erif ied before inse rting the endosc ope i nto the pati ent. If a las er c ontac t tip is used , th e tip wil l remai n hot for s ev eral s econds . B l ind entry i nto c av i ties wi th this tip should be av oided (1 99). The risk of tracheal tube igni tion wi ll be lowere d if the laser is ac tiv ated durin g the ex piratory paus e (200 ).

Electrosurgery Unit
The elec trosu rge ry uni t s hould not b e used during trach eos tomy (31,34,50,111,171,201,202,203 ,204). B leeding should not be trea ted wi th elec trosurgery af ter f lammable dressings hav e been appl ied. A bipol ar el ec trosurgery uni t s hould be used wh enev er pos s ible . This wi ll reduce the curren t densi ty in the tis sues s urroundin g the ac tiv e elec trode and mi ni mize the poten tial f or di rec t c oupl ing. B ipolar units work at lower v oltages and are not as soc iated wi th i nsul ati on fai lure . Mono pol ar un its should hav e a means to moni tor the retu rn elec trode or ac tiv e elec trode. Us ing ac tiv e e lec trode mon itoring wi l l min imi ze the risk of s tray elec trosurgical burns (38 ). Before eac h us e, the elec trosurgery uni t and as soc ia ted safety featu res s hould be inspec te d for s igns of damage and tes ted to ens ure that the uni t is func tioning c orrec tl y. If it is not work ing p roperl y or is damag ed, the elec trosurgical apparatus should be immediatel y remov ed f rom serv ice. The uni t shoul d be pro tec ted f ro m sp il ls . Unintenti onal ac tiv ation may oc cur i f f luids ente r the gene rator. The alarm s ys tem s hould be checke d pri or to appl ying the dispers iv e elec trode. T he ac tiv e electrode s houl d hav e a tip that is secure, becaus e a loos e tip may cause a spa rk . P rej el led dispers iv e elec trode pads s hould be checke d for

unif orm gel dis tribution a nd absence of exposed wi res before being applied to the pati ent. Outdated or prev ious ly opened but unused disp ers iv e e lec trode pads shoul d not be us ed, b ecause the g el c an undergo elec trolys is and/or des icca ti on. If a dispers iv e elec trode pad requi ring gel is used , the pad shou ld be c heck ed ca reful ly to identify any dry spo ts on i ts su rface before it is plac ed on the p ati ent. Af ter the pa ti ent has been p osi tion ed, the connec tion between the patient and the unit s hould be es tabl ishe d b y p lac ing the dispers iv e elec trode on a nonhai ry a rea of c lean , dry s k in. The dis pers iv e elec trod e s houl d be the appropria te s ize for a pati ent (i.e., neonate, infant, ped iatric , adult) and nev er be cu t to reduc e its si ze. The disp ers iv e elec trod e s hould be app li ed to c le an, dry skin ov er a large, wel lperfus ed mus cle mass as c lose to the operativ e s i te as prac tica l, av oiding bony prominenc es , s car tis sue , ski n ov e r a me tal pros thesis , o r dis tal to a tourni quet. Exc ess iv e hair s hou ld be remov ed b efore ap ply ing the disp ers iv e e lec trode , becaus e h ai r wil l i nsu late the pad from the p ati ent. Th e pad's entire surface are a shoul d ma in tai n unif orm body c ontac t. The re s hould not be an y ten ting, gaping, o r mois ture under the pad . This wil l interfere with adhesi on to the sk in and dec re ase the contac t surface. The dis pers iv e elec trode P .918 shoul d not be mov ed to another s i te a fter i ni ti al appl ic ation. The s tatus of the dispe rs iv e e lec trode sh ould be chec ked if any tens ion is applied to the co rd or i f the patie nt is reposi ti oned after the pad is appl ied. A use d dis pers iv e el ec tro de shoul d not be reapp li ed. E lec trocardi ographic elec trodes should be placed as far as possible from the operativ e si te to mi ni mi ze the alternate f low o f current through the elec trodes and moni tor to g round. If insulated elec tros urgic al elec trode probes a re requi red, onl y comme rc ial l y av ailab le insulated probes s hould be used (9). Ins ul ating s leev es c ut f rom catheters or o the r mate rials shou ld no t be use d to she athe p robes . The lowes t powe r setti ngs tha t are eff ec tiv e for the su rgical procedure , as determined by the s urgeon in c onjunc tion wi th the manuf ac turer's recomme ndation, shoul d be used . The enti re ci rc ui t sho uld be c heck ed if the operato r req ues ts highe r power settings beca use of ineffec tual res ults . The elec trosu rge ry uni t s hould be ac tiv ated onl y when the ti p is under the su rgeon's direc t v ision and onl y by the person us ing i t. Cords shou ld no t be c lamped with or wound a round any objec ts . The el ec trosurgery probe should be

kept c lean to minimi ze th e risk of adherent tis sue incandes ci ng or flaming. The elec trosurgical penc il s hould be place d in a hols ter whe n i t is not in ac tiv e use. The elec trosurgical uni t sho uld be plac ed in s tan dby mode wh enev er i t is no t in ac tiv e us e. Unneces sary foo t s wi tc hes shoul d be remov ed s o that they are not ac c identally ac tiv ated . Durin g laparoscopic s urgery , all-metal or a ll-p las tic cannulas sh ould b e used and not a h ybrid c annula s ys te m (i.e., a combi na tion of pl as tic and metal c annulas ) (37). E lec tros urgery elec trodes s houl d not be used ins ide metal s uc tio n i rri gators . The elec trosu rgica l uni t sh ould be deac tiv ated before remov ing it f rom the surgical s i te. Ev en after deac tiv ation , the p robe tip ma y retain enough heat for a f ew seconds to mel t plas tic s or igni te some fuels , so it shou ld be placed ins ide a c lean, wel l -i ns ulated holde r or broken off . In addi tion to p rotec ti ng th e tip, this mak es i t more diffic ult to acc identally ac tiv ate the s witch . The tip should be broken, and a safety c ov er s hould be placed ov er the ti p and ac tiv ation s wi tch before the dev ice i s dis carded (205).

Argon-enhanced Coagulation
A ll s afety meas ures o bserv ed for the el ec trosurgical unit shou ld be observ ed for argon-enhanc ed coagulation (31). The elec tro de s hould not be placed in di rec t contac t wi th tis sue. The hand piece should be mov ed away f rom the patient's tiss ue af te r eac h activ ation. The argon gas flo w and the argon c oagu lator s houl d be ac tiv ated si mul taneous ly . The argon gas line s hould b e purg ed of ai r before eac h procedure and by ac tiv ating the s ys tem after mode rate del ays between ac tiv ations .

Fiber-optic Light Sources

A ll c onnec tions should be made before the light s ourc e is ac tiv ated, because the end of the c abl e can ca use a fi re (53). An ac tiv e fiber-o ptic cable s houl d not be place d on fl ammable materi al . The l ig ht sourc e shou ld be turn ed OFF before disc onnec ti ng the cab le. The end of a fiber-optic cabl e can retain a si gnific ant amou nt of heat after be ing disc onnec ted from the l ight s ourc e (206 ). Therefo re, i t is i mportan t to be c areful where one pl aces the end of a f iber-op tic cord.

Heated Humidifiers
Onl y a bre ath ing tube and heatin g ci rcu it l abeled for use with a s pec ific humid if ier shoul d be used (207). Hea ted breathing c i rc ui ts shoul d not be c ov ered wi th s heets , blank ets , towel s , cl othing, o r other material. They should n ot res t on s urfac es s uch as the patient, operating table, blankets , o r medical equipmen t. Ins tead, a boom

arm or tube tree shou ld be us ed to su pport them. A hea ted -wi re breathing ci rc ui t shoul d not be turned ON bef ore flo w has been i ni tiated. If there is no flow (as during c ardiopulmona ry by pass ), the heate r should be turned OFF (208).

Defibrillators
W hen us in g a defi brill ato r, c are should be taken to hold the paddles fi rml y and position them p roperl y. Disposable conduc tiv e pads should be larger than the meta l su rface of the paddl e and be wi thi n their expi ration da te. This wil l prev ent arc ing whe n the paddles are ac tiv a ted (58). E CG el ec trodes should b e appl ied as far as possible f rom the def ibri l lation pads .

Electrical Faults
A ll elec trica l cords should be reg ul arl y inspec ted for c uts a nd nicks i n the i nsulation, f ray ed insulation, an d l oos e conn ec tio ns at the plug or recep tac le ends (209). A l l plugs sh ould be pus hed completely in to the rec eptacl es to p rev ent p rongto-p ron g a rc ing (210).

Managing Fuels
Tracheal Tubes Non-intubation Techniques
S ince the tracheal tube is of ten the fuel for the fi re , anes thetic techn iques th at do not requi re a tracheal tube wi ll el iminate one c omponen t of the fi re tri ad (92). These inc lude apnea, j et v entilation, and s pontaneous breathing.

Apnea
W ith the apneic technique, the patient is v enti lated by us ing a mas k or trac heal tube, a nd these are withdrawn as the laser is used (92,93,211 ). Af ter a period of time, v enti lation is rei ns tated. This is repeated as long as needed to perf orm the su rge ry.

Insufflation
Patients may be al lowe d to spontaneous ly bre ath e a c ombinatio n of oxy gen and anes thetic agents whi le laser procedu res are und ertak en. The gases are adminis tered through a c atheter or hook in the P .919 co rne r of the mouth tha t is wel l out of the way of the las e r beam. T he suc tion channe l of a lary ngos cop e may be used to ins uffl ate ox ygen. Operating room

pollution wi th anes thetic agen ts may be high wi th this tec hnique. Ox idizers s hould be us ed as spa ri ngly as pos s ible s ince the ins uffl ated gas cou ld su pport co mbus tion.

Jet Ventilation
Je t v entila ti on techni ques ei the r v ia a me tal bronc hoscope o r a catheter i nse rted through the c rico thy roid membrane may be us ed (212). A h igh -v eloc i ty jet of oxygen or helium and ox ygen c an be di rec ted into the ai rway abov e or below the glo ttis b y us ing v arious apparatus (2 1,92,93,1 96,213,214). The re has been a fi re repo rted with th is technique (21 5). A n e rrant las er s trike i gni te d the s u rgeon's gl ov e. The res ul tan t burning v apors we re entra ined into th e pati ent's airway. T he patient's mus tac he was also igni ted , and the patie nt suffered fac ial bu rns .

Filling the Cuff with Saline

The c uff is the mos t v ulnerable part of the tracheal tube, regardles s of the tube or cuff materia l. If a l aser beam pene trates an ai r-filled cuff , gas c an le ak in to the operativ e fi el d, a nd if the ox ygen c oncentration is high, the ris k of fi re is great. Fl ui d in a cuf f ac ts as a heat s ink and mak es th e cuff less eas y to perforate (216,217 ). Fi l li ng the tracheal tube c uff wi th a l idoc aine jelly -plus -s aline mix ture no t only prev ents the c uff f rom being igni ted but may plug s ma ll holes in the cuff resul ting f rom a laser h it (218 ). If the c uff is pe rf ora ted, a je t of fluid may ex tingu is h the f ire. If perfo rated, fl ui df il led cuffs reta in thei r shape lo nger than a ir-f il led cuffs . Care mus t be take n to remov e all ai r f rom the cuff, bec ause any remai ni ng ai r wil l s ettl e i n the mos t superior part of the c uff, whic h is the part mos t l ikel y to be h it b y the l aser beam. Additio n of methylene blue or o the r biocomp ati bl e and highl y v isible dye to the sa li ne wi ll help the su rge on to rec ognize a p erforated cuff. S ome surgeons objec t to the addi tion of meth ylene blue bec aus e if the c uff is punc tured, the colo r of the tis sues is al tered, maki ng it diff icu lt to recognize pathol ogy.

Protective Wrappings
The tube c an be cov ered wi th a protec tiv e wrap ping. Th ese are dis cus sed in greater de tai l in Chap ter 19. Meroc el wra p (Las er-Guard T M ) was f ound to be acc eptable for s urg ic al l ev els of CO 2 , K TP , and Nd-YA G l ase rs (219,220,22 1,2 22). Merocel -wrapp ed tubes are not more c ombus ti bl e if the y a re co ated with blo od (223). Reflec ted l ase r beams hav e

not been a probl em with th is wrap (224). Thi s produc t is eas ie r to apply than metallic ta pes (225). A luminum and copper tapes a re effec tiv e for us e with the CO 2 and Nd-Y A G lase rs if the tub e is metic ulous l y wrapped (226 ,22 7,2 28). Howev er, a fi re can occur if the l aser contacts part of the tube that is not wr apped (229,2 30). A wrap ped re d rubber tube does not offer protec tion f rom the K TP laser (86). The adhes iv e back ing or su rface co ati ng of s ome tapes c an b e i gn ited by l aser beams (9 2). The presence of blood on the s urfac e of f oi l-wra pped tubes makes combus ti on more l ik el y to occ ur (223). Tap e-wrapped tubes may unrav el, leav ing porti ons of the tube ex posed. If the wrap pi ng is dislodged, i t could o bs truc t the airway . A wrapp ed tu be may catch f ire (231,2 32). Meta ll ic tapes may reflec t the laser to non ta rge ted areas (224). Spi ral wrappi ngs may c ause the tu be to k ink . Any wrapping ad ds thick nes s to th e trac heal tube, whi ch co ul d be a problem fo r th e s urgeon.

Protecting the Cuff with Wet Covers

As a fu rther p rec autio n, mois t c ottono ids , sp onges , or pledgets can be placed on the cuff (92,233,234 ). Cotton gauz e is a goo d c hoice becaus e i t s tays wet l onge r than other c ov ers and has low ene rgy transmissi on (235). W et gauze wi ll als o protec t the shaft (236 ). Thes e hav e been found to be es peci al ly help ful with the CO 2 l ase r (234). The Nd-YA G, K TP , a nd argon lasers may allow s ome energy to penetrate the pledget and rup ture th e c uff (235). It is important that we t cov e rs be k ept mois t. Las er beam h its may dry them, and if that ha ppens , they lose thei r protec tiv e eff ec t. Further hi ts c an c ause the co ttonoids and/or cuff to ign ite. Al l thes e mus t be retriev ed af ter surgery.

Special Tracheal Tubes

Ready-to-us e las er-re s is tant tubes are discussed i n Chapter 1 9. Las er res istant means tha t th e ma terial ca n wi ths tand l imi te d l as er ene rgy wi th l i ttle o r no damage. The use of a spec ial l aser tube does no t necessa ri ly prev ent a f ire during lase r su rge ry (2 37). Ev en thou gh th e tube is labeled laser-res is tant, the cuff wi ll not be resis tant, and sp ecial p rec autions need to be taken to protec t it. A fi re may oc cur i f the pro tec tiv e wet gauze ov er the cuff dries or i s dis pl aced . No laser-resis tant trache al tube is completel y s afe f ro m all types of lasers under all condi tions . A ll of thes e tubes can be damaged or i gni ted by lasers for whic h they are not intended o r by high laser e nergies (238,2 39). Some are made more co mbus tible by blood (22 3). Tubes s old for us e with las ers s hould indic ate the type of las er fo r whi ch th ey are s ui ted as we ll as the c ondi tions (power, p ower d ens i ty,

spot s i ze, oxygen concentra tion) u nder whic h the tube is safe to us e. S tric t adherence to manuf ac turer's warni ngs and d irec tions is essen tial . If the Nd -YA G laser is us ed through a fiber-optic bro nchoscope pass ed th rough a trac heal tube, i t is b es t to use an unmark ed PV C tube (240 ). The trac heal tube shoul d be placed jus t b el ow the v ocal c ords so tha t the tip is as far awa y from the operativ e si te as poss ible. It s hould be reme mbered tha t the c ov er on the fiberoptic endoscope is plas tic and c an bu rn. Some lase r-res is tan t tubes are mo re resis tant to fi re than conv en ti ona l tracheal tubes wh en c ontac ted by elec trosu rgical instrumen ts (155). P .920

W hen lase r contac t tips are used , th ere is an ev en g rea ter opportuni ty for i gni ti on . The y can get hot enough to melt and burn pl as tic s ev en whe n the las e r is i nac tiv e (241). Double -c uff tubes are no t more resis tant to l eaks that wil l oc cur af ter cuff punc ture but do al low a s ea l to b e maintained if one c uff remains intac t. The secon d c uff is s till v ulnerable to punc ture (239). The re are dis adv antages assoc ia ted wi th l ase r-res is tant tubes . They are more ex pens iv e than PV C an d red rubber tubes . S inc e these tubes are often used f or pati ents who hav e h ad prev ious lary ngeal surgery, the an atomy ma y b e dis to rted, making intubation diff ic ult. S ome las e r-res is ta nt tubes are so s tiff that i t is diffic ult to pass a s tylet or us e wi th a spec ia li ze d l aryng oscope suc h as the Bu ll ard l ary ngos cop e (Chap te r 18). Theref ore , a diff ic ult intub ation may bec ome ev en more challen ging when these tubes are nee ded.

Using Smaller Tracheal Tubes

S mal l -diameter trac hea l tu bes requi re high er power densities fo r ignition than l arge-d iame ter tub es bec aus e the hi gher gas flow c ools s maller tubes mo re quic k ly than larger tubes . A ls o, the smal le r the tracheal tube, the l ess l ik el y i t is to be hi t by an igni tion s ource.

Making the Tracheal Tube Easy to Remove

The tube s hould be fixed s o that it c an be re mov ed rapi dl y, if nec ess ary . If the tube i s to be remov ed , th is shoul d be done i mmediatel y after i gni tion to minimi ze dama ge to the ai rway a nd lu ngs . If the tube conti nues to burn, i t may be v ery

diff icul t to remov e. S ome trac heal tubes break apa rt as the y burn . If the tube is wrapped, the wrapping may break in to pieces tha t could l odge in the airway. Some tubes a re eas ie r to remov e than others (91 ). PV C tubes wi th s al ine-f il led cuffs are more diff ic ult to remov e than red rubber tubes . The f astes t way to defl ate a fluid-filled cuff is to remov e the contents wi th a s yringe rather than cu ttin g the pi lot bal loon. Uncl amping the infl ati on tube on a red rubber tube wi ll res ult in rapid release of the c uff c ontents .

Wetting Fuels
The use of wet towe ls , pack ers , or s pong es around the surgical s ite c an prev ent i gni tion of ma terials n ear the s i te . Gauze or sponges us ed with unc uffed trac heal tubes to mini mize gas leak age in to the pharynx a nd spo nges , gauze, and pledges (and thei r s tri ngs ) used to protec t the trache al tube c uff shoul d be mois tened and not allowe d to dry. Hai r that is near the opera tiv e si te (e.g., eyeb rows , bea rds , and mous taches ) shoul d be made nonfl ammable by c oa ting i t th oro ughl y wi th a water-soluble l ubric ati ng jelly .

Proper Preparation Practices

W ater-bas ed solutions s hould b e used to d econ taminate th e skin prior to surgery whe nev er poss ible . If a lc ohol -c ontai ni ng solutio ns mus t be used, a mi ni mum of th e agent sh ould be used and appl ied like paint, no t in a thick, runn y c oat. The so lu tion shoul d not be applied in a ma nner tha t allows d ri ppi ng, pooli ng, or wic king. If so lution drips away from the s u rgica l s i te , it should be i mmedi ate ly blotted with a gauze spo nge before it c an soak into any absorbent ma te ri al . Any soaked materials shoul d be remov ed. Daubing of p rep pooled on skin (i n the u mb il icus or c ricoid notch ) may be needed. Draping should be delaye d to al lo w the s ol uti on to full y v aporize a nd become d iluted in room ai r. Th is c ould tak e 1 0 minu tes or longer (1,117). Incis e (adhes iv e, occ lus iv e) drapes s houl d be us ed, if pos si bl e, to iso late head and nec k inc is ions from oxygen-enric hed atmospheres and from fl ammable v apors b enea th the drapes (120). If the i ncise material does not adhere to the pati ent, the prep is likely s ti ll wet, and the patien t sho ul d be redraped o nce the prep is f ul ly d ry.

Correct Product Choices

It is important to c ons ide r the fi re potential whe n c hoos ing equipmen t. Th e anes thes ia prov ider s houl d be awa re of the c i rc umstances unde r whi c h a fi re can

oc cur an d s triv e to us e the produc t that wi l l hav e the l owes t fl ammabil ity under condi tions wh ere i t wi ll b e used . Fi re /lase r-res is tan t drapes s houl d be used when exposure to i gni ti on is poss ib le. It i s impo rtant that the drape is tes te d with the type of ignition source that is to be us ed. A s tandard f or tes tin g d rap es usi ng the CO 2 laser has been pu blished (2 42). Laser-res is tant anes thes ia c i rcui t protec tors a nd drapes are av ail able. Thes e are alumi ni zed to deflec t th e l as er bea m. There is s ti ll the poss ibi li ty tha t the beam may be refl ec ted on to a fl ammab le su rface and s ta rt a fire (24 3). The use of a metall ic Y-pi ec e a nd elbow wi ll e nsure tha t trac heal tube c ombus tion wi ll not s p read to the anes thesi a b rea thing s ys tem (244 ).

Other Measures
A numbe r of other meas ures may be be nef ic ial in prev enting a f ire. The tracheal tube sho ul d be withdrawn to ab ov e the s i te of s urg ery d uring trac heotomy. The use of pos i tiv e end-expi ra tory pressu re (P E EP ) may dec rease the risk of a irway fi re i n so me c ases (245 ,246). Nurs ing pers onnel can reduc e the c ombus tible load i n th e room by remov ing dis pos able paper wrap pers and c ov ers b efo re the s ta rt of the case. No t onl y does this reduce the fuel in the room, bu t it a ls o reduces the was te that mus t be disposed as red bag wi th i ts higher dis posal c os ts (2).

Minimizing Oxidizer Concentrations

The f ire risk can be red uced by remov ing or iso la ting the ox idi zer f rom the surgic al area or mi ni mizing i ts c oncentratio n. P .921

Durin g def ibri llatio n, all s ourc es of ox ygen s houl d be c omp le tel y remov ed f rom the area around the patient. Ox ygen s hould be adminis te red only whe n indic ated a nd in no h igh er co ncen tration than is needed (as gu ided by ox ygen saturation mon itoring ). The re are sev e ral ways of supp ly ing a gas with an oxygen concentra tion greater than 21% but les s than 1 00% to the patient. A n ox ygen and an ai r flowme ter can be connec ted by us ing a Y -pi ec e (Fig. 32 .7), or a bl ender ca n be used . If the mac hin e has an a ir f lowmeter, a mix ture of oxy gen in a ir c an be set and del iv ered to co mmon gas outl et (247). If the co mmon gas outl et can be accessed, a nas al cannula can be mated to the ou tl et by us ing a 5 -mm tracheal tube connec tor. If the co mmon gas outl et cannot b e accessed , a ci rc le s ys tem c an b e attac hed to the

machine, the adj us table pressu re limi ti ng (APL) v a lv e c losed, and the selec tor s wi tch s et to BA G. A nas al c annula c an then be attache d to the Y -piece . This arra ngemen t may cause th e c ontinuous p ositiv e press ure alarm to be ac tiv ated. A forc ed-ai r c onv ection machine c an be used to p rov id e a high f lo w o f ai r around the pati ent's head whi le a nasal c annu la deliv ers a low f lo w of 100% ox ygen to the pati ent.

Figure 32.7 Gas from an oxygen flowmeter and an air flowmeter can be connected to produce a gas with an oxygen concentration of less than 100%.

View Figure

If pos sible , the oxygen flow s hould be disc ontin ued f or at leas t 1 minu te before heat-produc ing s urg ic al ins trume nts a re us ed (24 8,249). W hen the heat s ourc e is no l onge r us ed a nd any tis sue embe rs are ex tinguished, ox ygen adminis tra tion can be res ume d. Durin g head and n eck su rge ry, a barri er s ho ul d be es tablis hed between the ox ygen enriched atmos phere bene ath the drapes and the s urgica l fi el d, if poss ible. Th is can often be acc ompl is hed wi th an ad hes ive (incis e, occl usiv e ) drape (2,117). W hen gas is us ed to v enti late the area unde r th e d rapes and prev ent CO 2 ac cumulation, the lo wes t accep tab le co ncentration of ox ygen should be used (250). Forming an open tent wi th the drapes wil l prev ent gas es from collec ting a nd allow ox ygen to dis s ipate (56 ,170). Since ox ygen i s s lightl y heav ier than room ai r as long

as there is s ome wa y for the ox ygen to get in and out of a spac e, i t wi ll tend to flow toward the f loor. A c tiv ely sc av enging the s pac e benea th drapes wi th a s uc tion dev ic e wil l l ower o xygen conc entrations s ign if ic antly (251). Dev ic es that co mb ine ox ygen de liv ery wi th suc tion to prev ent ox yg en bui ldup unde r the d rape h av e been desc ribed (25 2,253). A fan c an b e used to blo w the acc umulated ox ygen away f rom the patie nt. Direc ting the f lo w o f nasa l ox ygen through a nas al ai rway wil l l ower the ox ygen c once ntration a t the s k in (254 ). Hea lth care ins ti tu tions s hould consider pu rchas ing anes thesi a works tations tha t i ncl ude internal pipel ines and f lowmeters f or ai r (248). This makes it eas y to s witc h pati ent v entilatio n benea th the drapes f rom ox ygen to air b efore the use of heatproducin g surgic al ins truments . A n ex ternal flowmeter c an be added to an anes thes ia mach ine if pi ped air is av ailabl e (Fi g. 32.7). Ni trogen, ai r, o r hel ium may b e used to reduce the ins pired ox ygen c oncentration to the lo wes t l ev el that wi ll prov ide acc eptabl e patien t oxygena tion. Nitrous oxide supports c ombus ti on and shoul d not be us ed as the di luent gas (255 ,2 56,257). Helium is a good heat co nduc tor and may offe r a s ligh t pro tec tiv e eff ect wi th the CO 2 bu t not the K TP laser (258,259). The use of hel ium may dec rease the resis tance of the gases passing through the trache al tube (2 60,261). P .922

Ni trogen ins uff lation can s ignifican tl y reduce the inc idence of laser-i nduced trac heal tube c uff fi res (262). T his c an be acc ompl is hed by attaching a catheter cov ered with a las er-res is tant wrap to the trac heal tub e. Ni trogen is then insufflated through the catheter. This tec hnique shoul d be unde rtaken wi th c aution, as a hypoxic mix tu re may pos sibl y be adminis te red . A l though us ing lowe r inspi red oxygen conc entrations wi ll red uce the ri sk of igni tion , i t wi ll n ot tota lly prev en t it. If there is a s igni fic an t leak aro und the tracheal tube cuff , the anes thesi a p rov ider may fi ll the res erv oi r bag by pushing the ox yg en flush . This wi ll res ult in an elev ated ox yg en conc entra tion. A more appropria te response wou ld be to inc rease the f resh gas f lo w wh il e main ta ining the s ame ins pi red oxy gen conc en tration or to re pl ace the tracheal tube. W hen elec trosurgery is used in the oral c av ity , th e use of a cu ffed trach eal tube wi l l minimi ze the ox idi zer l ev el . Leak s aro und the tube ma y res ult in f ires (1 61,263). If an uncuf fed tube mus t be used, an oc clus ive pha ry ngeal pac k mois tened with a nonflammab le l iquid wi l l reduc e the gas f low i nto the oral c av i ty (264). Insuff la ting

the mouth with gases s uch as h elium, CO 2 , or n itrogen wi ll reduce th e ox idiz er conc en tration . The oroph arynx can be sc ave nged wi th s eparate s uc tio n. Pneumatic po wer tools shou ld be opera ted wi th n itro gen or ai r. Infl atable tourniq uets should be infla ted wi th ai r or nitrogen bu t not oxygen o r ni trous ox id e (56,79,265). Ni trous ox ide s hould not be used for i nsuff la ting the abdomi nal cav ity during la paroscopy (266,267,268 ).

Preventing Pressure Regulator Fires

Fi res in regul ators c an be minimi zed by no t al lo win g them to become contamina ted wi th oi l , grease , or other c ombus tibl e ma te ri als o r c leaned with a fl ammable agen t such as alcohol (122,269 ). B efore a regula tor is fitted to a c yl inder, partic les sh ould be cleared f rom the c ylin der ou tlet b y remov ing the protec tiv e c ap or seal an d s lowl y and briefl y ope ning (c racking) the valv e wi th the port poi nted away f rom the user and any othe r persons . A cyl inder v alv e should al ways be opened sl owly to al low h eat to be dissipated as the gas is rec ompressed. Cons ideration s hould be giv en to rep lac ing alu minu m regulators with those made f rom brass . Rul es for handling c ylinders a re discussed in Chap ter 1.

Fire Plan
Eac h heal th c are fac il ity should formu late a plan for deal ing quickl y wi th an operati ng room f ire (1 ,6,56,58,127,1 71,202,206 ,2 40,270,271 ,27 2,273,274 ). Su rgica l teams sho ul d be train ed in and p rac tice dril ls for keeping minor f i res f rom ge tting out of co ntrol and manag ing f ires that do get out of c ontrol . The y s hould know the l ocation and prope r use of a larm b oxes , gas s hut-o ff v alv es , and fi re ex ti nguis hers . Ev acuati on procedures s hould be rev iewed pe riodicall y. It is important to i mmedi ately c al l f or hel p, d ecide who is going to f ight the fi re , whe n i t wi ll be appropriate to leav e the room, and how to c are f or the patient du ring the fi re . Burning material o n o r in the patient of ten can be ex ti ngu is hed effec tiv ely an d safel y by hand or wi th a nonfl ammable li qu id (e .g ., s ali ne f rom a bas in on the sc rub tabl e) or we t c loth. W ith laser s urgery in the a irway, a t leas t two s yringes f il led with sodiu m c hlo ride sho uld a lwa ys be av ailable to ex ti ngu is h the f ire (275). Larger areas ca n be s mothered with a bla nket or wet towe l. Fi re b lank ets are not recommen ded (8 ,2 76). If the drape is wate r-re s is tant, wate r poured on i t wi ll be i neffec tiv e (277). The f ire wi ll burn on the unders ide. The only effec tiv e tec hni que i s to pul l the burning materials from the pa tient.

Fi res tha t inv olv e elec trica l components are bes t handled by disc onnec ting the dev ic e from i ts elec tric power s uppl y and remov ing the dev ic e f rom the room. The f lo w o f ox ygen, n itro us ox ide, or ai r to a ny inv olv ed eq uipment s hould be turned OFF, if this c an be acc ompl is hed wi thout injury to personnel or the patient. Mos t patie nts c an tol erate s hort periods of ox ygen depriv ation . The pati ent s hould be v enti lated with ai r and intrav enous agents use d to mainta in anes thesi a unti l all possible s ources of fi re or reigni tion are sup pressed . It ma y be necessa ry to c lose the ox ygen and ni trous ox ide shut-off v alv es to the affec ted ro om (58,278 ,279). Cyl inder v alv es shoul d be c losed an d all c yli nders remov ed from the a rea . If suppl emental ox ygen is necess ary to ox ygena te the patient, the pa ti ent should be mov ed to the neares t are a wh ere ox yge n c an be saf el y us ed (56). If an ai rway f i re occ urs , the breath in g s ys tem s hou ld be disc onnec ted from the trac heal tube to s top gas f lo w. If this s i te is not eas i ly acces sible o r the operato r may be bu rned in the process o f disconnec ti ng the tube , the b rea thing s ys tem c an be disc onnec ted at the abso rbe r (280). The trachea l tube sho uld no t be undul y s ecu red s o that i t c an be remov ed quick ly . A l though i mmediate remov al of the trac heal tube and protec tiv e dev ices is usua ll y recommen ded wi th an ai rway fi re , th is may no t al ways be the bes t c ou rse of ac tio n (148,281 ). The risk :ben efi t ratio of ex tubatio n needs to be cons idere d. A s tyl et or ai rwa y exch ange c ath ete r c an be us ed to s ubs ti tute a new tube the bu rned tube for. If the d ecis ion to remov e the tube has been made, s al in e-f i ll ed cuffs on plas tic tubes c an be defla ted fas ter by aspi ra ting th e fl ui d than by c utting th e p il ot tube (91). W i th red rubbe r tub es , unc lamping the pilot tube is fas tes t. P .923

The airway s hould be re-es tabl ished and the pa tient v entil ated wi th ai r unti l it is ce rtain that nothing remains bu rning . Then , 100 % ox ygen should be adminis tered. A search for f ragments tha t rema in in the trac hea and asses sment of damage to the l ary nx and trac heobronc hi al tre e shou ld be made.

Extinguishing a Fire
A l though mos t operating roo ms hav e a sprink ler sys tem, sprinkl ers a re frequently not eff ec tiv e wi th ope rating room f ires (206). This is becaus e the s prink le rs are rare ly located ov er the operating room table a nd are heat ac tiv ated . Operati ng room f ires tend to giv e off a lot of s moke and tox ic produc ts bu t not n eces sarily eno ugh

heat to i mmedi ately ac tiv ate the sprinklers . The refore, i t is important the all operati ng room pers onnel are fami liar wi th fi re ex ti nguishers .

Location
Strategic all y placed portable fi re ex tinguishers are a n i mportant pa rt of any f ire protec tio n p rog ram (1 ,282,283). The y shou ld be located in cons picuous , readi l y ac cess ib le loca tions that a re k no wn by al l operatin g room s taff (F ig. 32.8). Hands -on experi enc e with fi re ex ti ngu is hers i s es sential to a f ire safety educ ation program (284). S etting up real fi res in a park ing lot and p rov iding prac tice wi th ex tinguis hers c an hav e v al uable payoffs during an ac tual fi re.

Use
Us e of any f ire ex tinguisher can be recall ed by the ac ronym, pass . P ul l the p in. Aim the horn o r nozzle a t th e base of the f ire. Squeeze the tri gger o r handle wh il e holding the ex tinguishe r upright. S weep the ex tin guishe r from s ide to side, c ov e ri ng the area of the fi re. Ins tructions are found on the f ire ex tinguish er (F ig. 32.9). The pin and hose are s hown i n F igu res 32.1 0 and 32.11.

Choice of Extinguisher
The c hoic e of ex tingu is her s hould be bas ed on the p red ic ted f ire risk for that l ocation (282,285,286 ). Fi res are c las sified ac cording to thei r fu el. Clas s A f i res i ncl ude s ma ll masses of ordinary c ombus tibl es-c lo th, pape r, and mos t plas tics . Fi res inv olv ing flammable liqu ids o r gre ase are in c las s B . E lec tric al ly energized f ires are c lass C. Two s tand ard s ets of fi re c las s labels exis t: a tradi tional le ttering s ys tem and a newer u niv ers al pictograph s ys tem tha t does not requi re the use r to be famil iar wi th the alphabet fire c lass cod es (F ig. 32.9).

Figure 32.8 Fire extinguishers should be in conspicuous locations, well known to all operating room staff.

View Figure

Halogenated Agents
Haloge nated ex tinguishing agents are li quids th at upon dis cha rge under relativ ely high press ure s u rround a fire with a combination of v apor and l iquid droplets (mis t). Haloge nated agents are ideal ly s ui ted for fig hti ng f ires inv olv ing el ec tronic equipment and fi res in areas where elec trical or elec tronic equi pmen t is nearb y. Halon was the agent of c hoice fo r ope rating roo m fires fo r many ye ars (202). It has the abi li ty to penetrate burning ma teri al and to s mother and c ool the c hemical reac tion of the fi re . W hil e usual ly marked for c lass B and C f ires , i t is also effec tiv e agains t cl as s A fires f ound i n the opera ting room. Unfortunately , bec ause of env ironmental concerns , halon ex tinguishe rs are no longer av ai la ble . If present in an op era ting room, they may be us ed but c annot be rec harged. The National Fi re P rotec tion As soc iati on requi res that nonrecha rgeable P .924

P .925 ex tinguis hers be remov ed from s erv ice 12 years from the date of manufac ture

(287). In res ponse to the prohibi tions on the use of ha lon , a numbe r of ex tinguis hing agents hav e been dev eloped to rep lac e it (282 ,288,289) (Fi g. 32 .12 ).

Figure 32.9 The instructions for using the fire extinguisher are printed on the extinguisher.

View Figure

Figure 32.10 The pin that needs to be pulled to activate the extinguisher is in the handle at the top of the extinguisher. The hose is normally attached to the side of the extinguisher. This figure also shows the pressure gauge, which indicates that the extinguisher is usable, and the monthly checkout list, which shows that the extinguisher has been checked, the extinguisher and hose is undamaged, and the pressure is in the use range.

View Figure

Figure 32.11 Close-up of pin and pressure gauge at top of extinguisher.

View Figure

Figure 32.12 There are several substitutes for halon available.

View Figure

Carbon Dioxide
CO 2 ex tinguis hers e mit a fog of CO 2 gas with liquid and s olid partic les that rapidl y v aporize to cool and smothe r a f i re. A lthough the y carry a B and C ratin g, they c an be us ed to ex tinguis h s mall class A fi res . CO 2 f ire ex tinguis he rs are heav ie r and bulk ier than halo n-typ e dev ices . CO 2 ex tinguishers do no t leav e a resi due but do emi t l iquid and s ol id c omponents that rap idly v ap ori ze . This causes rapid c ool ing

that might c aus e f re ezing i f it c omes into c ontac t wi th exposed sk in or internal organs (283 ,290).

Water
P ress uri zed -wa ter ex ting uishers are c hiefl y ef fec tiv e agains t c las s A f ires . They are more diffic ult to use than CO 2 and halon-ty pe ex tinguishe rs . T o put ou t fi res on water-repel lant d rapes , a f inger mus t be placed ov er the noz zle to pro duc e a fine sp ray . A s tream or splash of water c oul d fan the fi re (1). A non-magne tic water mis t ex tinguis her is av ai lable for use in the MRI unit mag net room.

Figure 32.13 All operating room personnel must know where the fire alarm is located. The instructions for activating it are printed on the fire alarm.

View Figure

If the f i re s tarts to g et out of co ntrol , the fi re al arm (Fig . 32.13) should be so unded, and the f ire department s hould be notif ied to giv e firef igh ters ample ti me to respond (1). F iref igh te rs would ra the r find that a sma ll f i re has b een extinguished than s ee smok e billowi ng out of a bui ld ingespecially in a health c are faci li ty . The patient and s taff sho uld be ev acuated if the fi re and s mok e a re ex cess iv e (210). In s ome s i tua tions , howev er, it ma y be more hazardous to mov e the patient than to a ttempt to ex tinguish or c ontain the fi re. The attendi ng ph ys ici an mus t determine whic h would present the l ess er hazard . The doors s hould be c losed to con tain the smoke an d isola te the fi re . Wet s heets o r towel s can be s tuffed u nder the do ors to red uce the s pread of s moke f rom th e room. W hatev e r s teps are necessary should be tak en to protect or ev ac uate patie nts i n adjac ent a reas.

Af ter the f ire, inv olv ed materi als and dev ic es sho ul d remain in pl ac e for the fire department inv estigators . Notes should b e made as soon as poss ible af te r the f ire and a n i nc ident report co mp le ted . P .926

References
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244. Sos is M, B rav e rman B , Iv ankov ic h A D. Meta l anes thes ia c i rcu it c omponents s top l aser f i res . Anes thes iology 1991;75:A 396. [Fu ll tex t Link ] [Cross Ref] 245. Anonymous . Inc rease d P EEP lev els ma y reduce laser-i nduc ed trac heal tube f ire risks . Bi omed Saf e S tand 1993;23 :12 3. 246. Pas hayan A G, San Giov anni C, Dav is LE . Pos i tiv e end-exp irato ry press ure l owers the ris k of las er-i nduced po lyv inylchloride tracheal-tu be fi res . Anes thes iology 1993;79:8387. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 247. Lamp otang S , Grav ens te in N, P aulus DA , et al. Re duc ing the inci denc e of su rgical fi res : su pplying nas al ca nnulae wi th s ub-100% O 2 gas mix tu res f rom anes thes ia mach ines . A nes th A nalg 2005 ;10 1:14071412 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 248. Anonymous . Reduc ing the risk of f ires during head an d neck su rge ry . Technol Anes th 2 002;22:12 . 249. Lowry RK , Noone RB . Fi res and burns during plas tic su rge ry . Ann P las t Su rg 2001;46:7276. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 250. Greco RJ , Gonzalez R, J ohns on P , et a l. P o tential d ange rs of oxygen suppl ementation duri ng fac ial s urgery . Pl as t Recons tr Su rg 1995;95:978 984. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 251. Barnes A M, Frantz RA . Do ox ygen -en riche d a tmos pheres ex is t beneath su rgical drapes and c ontri bute to f ire potentia l i n the operating room? AANA J 2000;68:153161. 252. Ramanathan S , Capan L, Cha lon J , et al . Mi ni env i ronmental c ontro l unde r the drapes duri ng opera tions on the eyes of consc ious p ati en ts . A nes thes iology 1978;48:286288.

[Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 253. Ri nder CS , Dabu-Bon doc S , S algar V . A dev ic e to reduc e O 2 ac cumulation and reduc e fi re hazard duri ng MAC anes thesi a. Anes thes iology 2 005;103 :A804. 254. Borkows k i RG, Meneghetti C, Morgan MM, e t al . A c omparison of methods for deliv ering suppleme nta l ox ygen du ri ng plas tic s urgery . Anes th esiology 2005;103:A 841 . 255. Sos is M. Ni trous ox ide is contraindicated i n endoscop ic s urgery . Can J Anaes th 1987 ;34 :539. [Med li ne Link ] 256. Sos is M. Ni trous ox ide s hou ld no t be used duri ng laser endoscop ic su rge ry . Anes th An al g 1987;66:10541055. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 257. Shapiro JD, E l -B az NM. N 2 O has no p lace during o rop haryngeal and l ary ngotrache al procedures . A nes thes iolog y 1 987;66:447448. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 258. S impson J I, Sc hiff GA , W olf GL. The effect of h el ium on end otrac heal tube f lammabili ty . Anes thesi ol ogy 1990;7 3:538540. [Full tex t Link ] [Cross Ref] [Med li ne Link ] 259. A lhaddad S , B renne r J . Hel ium and lower ox ygen co ncentrations do not prolong trac heal tube ign ition ti me d uring po tas sium ti tan yl ph osophate las er us e. Anes thes iology 1994;80:936938 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 260. Rampi l IJ . He li um and gas flo w. A nes th Analg 1993;76:S 453 . 261. E isenk raft J B , Bark er SJ . Hel ium and g as fl ow. A nes th Analg 1993;76:4 52 453. [Med li ne Link ]

262. Sos is MB . Ev aluatio n of a tec hnique of nitrogen insuff lation to dec re ase plas tic endo trache al tube c uff f lammabi li ty d uring c a rbon d iox ide las er su rge ry. J Cl in A nes th 1993;5:468470 . [Cross Ref] [Med li ne Link ] 263. Pas hayan A G, Grav ens tein JS . Ai rway fi res during s urgery wi th the ca rbo n diox ide las e r. A nes thes iology 1989;71:478. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 264. Sommer RM. P rev enting e ndotracheal tube fi re duri ng phary ngeal surgery. Anes thes iology 1987;66:439 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 265. Inappropri ate us e of ox ygen to inf late o r power me dical dev ices . Heal th Dev ic es 1983 ;3:3. 266. Coral l IM, E li as JA , S trunin L. La paroscopy explos io n wi th n itro us ox ide. B r Med J 1975;1 :288. [Med li ne Link ] 267. Robins on JF, Thomps on JF, W ood AW . L aparosc opy ex pl osion with ni trous ox ide . B r Med J 197 5;3 :7 647 65. [Med li ne Link ] 268. Robins on JS , Thompson J M, W ood AW. Laparoscopy explos io n hazards wi th ni trous ox ide. B r Med J 1975;4:760 761. [Med li ne Link ] 269. MDA S N 2 000(07), Medical gas c ylinders : ri sk of f i re. MDA Adv erse Inci dent Cen ter, aic@ medica l-dev ices .gov .uk /sn 2000 (07 ).htm 270. Moxon MA , Reading ME , W ard MB . Fi re in the opera ting theatre. Ev ac uatio n pre-planning may s av e liv es . A naes thesi a 1986;4 1:543546. [Cross Ref] [Med li ne Link ] 271. W es ton CJ . The operating thea tre's on fi re . Heal th S e rv Mana ge 1988;84(3):2023. [Med li ne Link ]

272. Fen nell M. A multi disc iplinary approach to intraoperativ e fi re safety. A ORN J 1995;62:636637. [Cross Ref] [Med li ne Link ] 273. V idor K , P ute rba ugh S , W ill is C. Fire saf ety trai ning: a program f or the operati ng room. A ORN J 1989;49 :10451049. [Cross Ref] [Med li ne Link ] 274. Anonymous . Rec ogni zing and ex tingu is hing medical g as fi res . Health Dev ices A lerts 2003;27:5. 275. Lierz P , Heinatz A , Gus torff B . Management o f in tratrac heal fi re du ri ng laser su rge ry. Anes th Analg 200 2;93:502. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 276. Anonymous . Fi re blank ets in th e OR? T echn ol Anes th 2000;20:3. 277. B runer J MR. Fi re in the ope rating room. ASA News lett 199 0;54:2225. 278. Anonymous . Res ponding to fi res in areas of ox ygen use. Heal th Dev ic es 1994;23:306309. [Med li ne Link ] 279. Anonymous . Rec ogni zing and ex tingu is hing medical g as fi res . Health Dev ices A lerts 2003;27(A14):5. 280. Debo er GE . Endotrac heal tube fi res . Can Ana es th Soc J 1993 ;40:10031004 . 281. W olf G, S idebo tha m GW . E ndotrac heal tube f i re: c omments on the a dv isab il i ty of not ex tubating . Anes thes iology 1999;91:888. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 282. National F ire P rotec tion Ass oc iation . NFPA gui de to portable fi re ex tinguis hers . Qui ncy , MA : A uthor, 2003. 283. Anonymous . Talk to the spec ialis t. Techno l Anes th 19 96;17(4):34. 284. Fi nnegan J . S taff education c an prev en t OR f i res . Toda ys OR Nurs e 1994;16(3):2426. [Med li ne Link ] 285. National F ire P rotec tion Ass oc iation . Sta ndard fo r portab le f ire ex tinguishe rs (NFPA 10), 2002 ed. www.nfpacatal og.org. Quinc y, MA : Au tho r, 2002.

286. National F ire P rotec tion Ass oc iation . Sta ndard fo r portab le f ire ex tinguishe rs (NFPA 10), 2002 ed. Qui ncy , MA : NFPA , 2002. 287. Anonymous . 10 ques tions abou t NFPA 10. W ha t you mi ght wa nt to k now about mai ntaining and using po rtabl e fi re ex ti ngu is hers . NFPA J 200 1;95:26, 92 . 288. Frees tone A . Finding a halon alternativ e. NFP A J 2002;96:6873. 289. Gibson J . Fin ding a halon alternativ e. NFP A J 2002;96:18, 20. 290. Anonymous . Selec ting fi re ex tinguis hers for the opera ting ro om. Hea lth Dev ic es 1996 ;25:261, 263. P .929

Questions
For the fol low ing ques tions , s elec t the co rrec t answer 1. T he perc entage of operatin g room fires that result in patient injury is A . 10% to 20% B . 20% to 30% C. 30 % to 40% D. 40 % to 50% E . 50% to 75% V iew A ns we r2. Wh ich of the fo llow ing is most co mmon ly involved in ope ratin g room fires ? A . Lasers B . E lec trosurgery equipme nt C. A rgon beam c oagula tors D. Fiber-optic illumi nation s ys tems E . Defibril la tors V iew A ns we r3. Wh ich type of trac heal tube w ill cause the most severe dama ge to the tracheob ronc hia l tree if it catche s fire? A . Red rubber B . S i l ic one C. Laser resis tant D. PV C V iew A ns we r4. In order to filte r out potentia l airborne contaminants, the surgical mask mus t be able to filter pa rticles of w h ich size? A . 30 mic rons

B . 3 mic ro ns C. 0.3 mic rons D. 0. 03 mic rons E . 0.00 3 mic rons V iew A ns we r5. We t cotton gauze w ill prote ct th e s haft and cuff of a tu be bes t w ith w hic h lase r? A . A rgon B . K TP C. Nd-YA G D. CO 2 V iew A ns we r6. A clear, unmarked PVC tube is rela tively resistant to be use d w ith w hich laser? A . A rgon B . K TP C. Nd-YA G D. CO 2 V iew A ns we rFo r the followin g questions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i f D is correc t i f A , B , C, and D a re co rrec t.

7. T he fac tors necessary to sta rt a fire include A . Igni tion s ource B . Fu el C. Ox idi ze rs D. Lasers V iew A ns we r8. The characteristics o f laser ligh t inc lude A . Coherenc y B . Mon ochromatic i ty C. Coll ima ted D. Ul trav iol en t V iew A ns we r9. Wh ich factors determine the ignition risk w ith a laser? A . Laser me dium being used

B . Ho w the laser is focus ed C. Class of laser D. Ex posu re time V iew A ns we r10 . Common errors w hen u sin g e lec trosurgical equ ipmen t include A . Improper p lac ement of dispe rs iv e elec trode B . Insuff ic ient dispe rs iv e elec trode co ntac t C. Faulty re tu rn elec trode D. Insu lating the patien t from the op era ti ng ro om table V iew A ns we r11 . Measu res to minimize the risk of a tracheal tube fire from a laser inc lude A . Fil ling the cuf f wi th s aline B . Mi ni miz ing the las er p ower d ens i ty and duration C. Us ing a lase r-res is tan t tu be D. Us ing low ox ygen conc en trations in the ins pi red gas V iew A ns we r12 . Conce rning la ser-induce d tra cheal tub e fires A . Th e tub e ma y be contac ted by a reflec ted lase r beam B . Th e cuff is l ase r-re sis ta nt C. Cotton s ponges that p rotec t the c uff ma y dry ou t D. Us e of an unc uffed tube inc reases the ris k V iew A ns we r13 . Whic h lase r(s) is (are) lik ely to d amage the retina ? A . K TP B . Nd -YA G C. A rgon D. CO 2 V iew A ns we r14 . Whic h lase r(s) is (are) lik ely to d amage only the corne a? A . K TP B . Nd -YA G C. A rgon D. CO 2 V iew A ns we r

Chapter 33 Equipment Checkout and Maintenance

P .932

A checkou t procedure is analogous to the prefli ght c heck f or ai rline pilo ts an d is i nte nded to determine whe the r equipme nt is p res ent, func ti oni ng properly , and ready f or us e. Fail ure to chec k equipmen t properly is a fac to r in man y c ri tical i nci den ts (1,2 ,3,4,5,6,7 ,8,9,10,11,12). P roperl y c hec king equi pmen t can reduc e equipment-rela ted mo rbidi ty and mo rtal ity, improv e prev entiv e maintenance, and educate the anes thes ia prov ide r abou t equipment (1,9 ,13 ,14 ,1 5,16,17). Defec ts may be f ound ev en jus t af ter prev en tiv e maintenance has been perfo rmed (18). Fail ure to perform a p rop er check before use is c ommon (4,19,20,21,22,23,24,25,26,27). Many anes thes ia prov ide rs are unable to iden tify i nte ntional ly c reated f aul ts (28,29,30,31,32,33). W ith i ntens iv e training, performance imp rov es, but hi gh rates o f completi on are not ac hiev ed (34). Us e r manua ls that a re prov ided by anes thes ia mac hine manuf ac turers h av e detail ed di rec ti ons for check ing . Thes e shou ld be read c arefully . Unfortuna te ly, these proc edures are often ov e rl y compl icated. W hen a p roc edure tak es too lo ng to perform, i t is often ab ridged o r sk ippe d a ltoge the r. The Fo od and Drug Admi nis tration (FDA ), worki ng with re presentativ es of the anes thes ia commu nity and indus try, dev elop ed a p reuse checkou t proced ure , whi ch was pu bl is hed in 1986 (35). Unfo rtunatel y, this lis t wa s too compl ica ted for mos t us ers , and a s impl if ied, more user-f rien dl y v ers io n was publ ished i n 1993 . This is shown in Ta ble 33.1 . The new v e rs ion retain ed or added c hecks of c ompon ents tha t fail more f requentl y than o thers an d that c an quick ly injure the patient wh en the y fail (36 ). Components that f ai l inf req uently a nd tha t do not immed iatel y je opardize the patie nt when they d o ma lf unc ti on were n ot i ncl uded in the 1993 v e rs ion bu t mus t s til l be c hecked during routine p rev entiv e main tenanc e. Chec k lis ts hav e been publish ed in other c oun tries (16,17,37,38 ,39 ). This chapter is c ons truc ted along the line of the 1993 FDA c hec kout p roc edu re. One of the defic ienc ies o f the 1993 FDA checkou t was that wh il e it s aid to c heck a ce rtain i tem, it did n ot ex pla in ho w. Many c li nicians dev is ed their o wn methods to f il l that v oid but in f ac t were no t correc tly ch eck ing c ertai n items . W e hav e recommen ded a numbe r of tes t me thods to ov erc ome th is de fic ienc y. W hen an

al te rna te tes t me thod is giv en, an attemp t wil l b e made to point out the adv antages and d efic ienc ies of that method . S ince anes thes ia mac hin es from differe nt manufac tu rers and different models from the same manufac tu rer v ary , the user s hould s tudy the manufac turer's s ugges te d check ing procedures and inco rpo rate s pecifi c points into this generic checko ut. Parts of the c heck out p roc edure des c ri bed in this c hapter wi ll not appl y to mach ines wi th an el ec tronic chec kou t. Th e user mus t de termine whic h parts are chec ked automatic al l y and add thos e that a re not c ov e red . The FDA check out is des igned fo r work s tations with a c irc le s ys tem, v entilator, capnog rap h, ox ygen an aly zer, respi ra tory volume meter, and ai rwa y pressure moni tor. Clinicians who us e equipmen t that does not c onform to this conf igurati on may need to modif y the procedure to acc ommoda te differenc es . Fo r exa mp le , if a Maples on s ys tem is to be used, the checking proc edure s houl d incl ude this . Such modific ati ons s hould hav e appropria te peer rev i ew. The manufac ture r's us er manual shoul d be c ons ul ted for s peci al p roc edures . A copy of th e c hec kout p roc edu re s hould b e k ept i n, on, or near the anes thes ia machine. A rec ord that the check lis t wa s used should be made and k ept. A p rinted check lis t may pres ent a more o rgani zed and s ys tematic approach than if th e anes thes ia prov ider uses a mental c heck lis t and may resul t in i mprov ed f aul t detec tion (9 ,33 ). A pic torial chec kou t may be eas ier to read and f ol low than a typewri tten list (5). E lec tronic c hec klis ts hav e been dev el oped (40,41). Unlike the e lec tronic checko ut (s ee bel ow), thes e on ly lis t what the anes thes ia prov ider should do . An elec tron ic check lis t may be more ex tens iv e than a paper c heck lis t.

Electronic Checking
Many of the n ewer anes thes ia mac hin es prov ide an elec tronic c hec king procedu re (Fig . 33.1). W hen the machine P .933

P .934 i s turned ON, i t remin ds the user to s tart the c heck out. B efore an e lec tronic checko ut is performed, a ll c ompo nents that are to be used for the anes thetic s houl d be i n place. If the breathing tub ing is to be ex tended , it s hou ld be ex tended to the

desired length prior to beg innin g the c heck out. During the checking procedure, the machine ma y p romp t the anes thesia p rov ider to mak e certain adj us tments such as opening or c los ing the adj us tab le press ure -limi ting (APL) v alv e, oc c luding the Ypiece , or ad jus ting the gas flo ws .

TABLE 33.1 Anesthesia Apparatus Checkout Recommendations, 1993 This checkout, or a reasonable equivalent, should be conducted before administration of anesthesia. These recommendations are only valid for an anesthesia system that conforms to current and relevant standards and includes an ascending bellows ventilator and at least the following monitors: capnograph, pulse oximeter, oxygen analyzer, respiratory volume monitor (spirometer), and breathing system pressure monitor with high- and low-pressure alarms. Emergency Ventilation Equipment *1. Verify that backup ventilation equipment is available and functioning. High-pressure System *2. Check the oxygen cylinder supply. a. Open the oxygen cylinder, and verify that it is at least half full (about 1000 psig). b. Close the cylinder. *3. Check the central pipeline supplies. Check that the hoses are connected and pipeline gauges read about 50 psig. Low-pressure System *4. Check the initial status of the low-pressure system. a. Close the flow control valves and turn vaporizers OFF. b. Check the fill level and tighten vaporizers' filler caps. *5. Perform a leak check of the machine's low-pressure system. a. b. c. d. e. f. Verify that the machine master switch and flow control valves are OFF. Attach a suction bulb to the common (fresh) gas outlet. Squeeze the bulb repeatedly until fully collapsed. Verify that the bulb stays fully collapsed for at least 10 seconds. Open one vaporizer at a time, and repeat parts c and d above. Remove the suction bulb, and reconnect the fresh gas hose.

*6. Turn the machine master switch ON as well as all other necessary electrical equipment *7. Test the flowmeters.

a. Adjust the flow of all gases through their full range, checking for smooth operation of floats and undamaged flow tubes. b. Attempt to create a hypoxic oxygennitrous oxide mixture, and verify correct changes in flow and/or alarm. Scavenging System *8. Adjust and check the scavenging system. a. Ensure proper connections between the scavenging system and both the APL (pop-off) valve and ventilator relief spill valve. b. Adjust the waste gas vacuum flow, if possible. c. Fully open the APL valve and occlude the Y-piece. d. With minimum oxygen flow, allow the scavenger reservoir bag to collapse completely, and verify that the absorber pressure gauge reads about zero. e. With the oxygen flush activated, allow the scavenger reservoir bag to distend fully and then verify that the absorber pressure gauge reads <10 cm H2O. Breathing System *9. Calibrate the oxygen monitor. a. b. c. d. Ensure that the monitor reads 21% in room air. Verify that the low oxygen alarm is enabled and functioning. Reinstall the sensor in the circuit, and flush the breathing system with oxygen. Verify that the monitor now reads greater than 90%.

10. Check the initial status of the breathing system. a. b. c. d. Set the selector switch to Bag mode. Check that the breathing circuit is complete, undamaged, and unobstructed. Verify that the carbon dioxide absorbent is adequate. Install the breathing circuit accessory equipment (e.g., humidifier, PEEP valve) that is to be used during the case.

11. Perform a leak check of the breathing system. a. b. c. d. e. Set all gas flows to zero (or minimum). Close the APL (pop-off) valve, and occlude the Y-piece. Pressurize the breathing system to about 30 cm H2O with an oxygen flush. Ensure that the pressure remains fixed for at least 10 seconds. Open the APL (pop-off) valve, and ensure that the pressure decreases.

Manual and Automatic Ventilation Systems 12. Test the ventilator systems and unidirectional valves. a. b. c. d. e. f. g. h. i. j. k. l. m. Place a second breathing bag on the Y-piece. Set the appropriate ventilator parameters for the next patient. Switch to the automatic ventilation (Ventilator) mode. Turn the ventilator ON, and fill the bellows and breathing bag with and oxygen flush. Set the oxygen flow to minimum and other gas flows to zero. Verify that during inspiration, the bellows delivers appropriate tidal volume and that during expiration, the bellows fills completely. Set the fresh gas flow to about 5 L/minute. Verify that the ventilator bellows and simulated lungs fill and empty appropriately without sustained pressure at end expiration. Check for proper action of the unidirectional valves. Exercise the breathing circuit accessories to ensure proper function. Turn the ventilator OFF, and switch to manual ventilation (Bag/APL) mode. Ventilate manually and assure inflation and deflation of artificial lungs and appropriate feel of system resistance and compliance. Remove the second breathing bag from the Y-piece.

Monitors 13. Check, calibrate, and/or set alarm limits of all monitors. Capnometer Pulse oximeter Oxygen analyzer Respiratory volume monitor (spirometer) Pressure monitor with high and low airway alarms Final position 14. Check the final status of the machine. a. b. c. d. e. f. Vaporizers OFF. APL valve open. Selector switch to Bag. All flowmeters to zero. Patient suction level adequate. Breathing system ready to use.

*If an anesthesia provider uses the same machine in successive cases, these steps do not need to be repeated or may be abbreviated after the initial checkout.

These el ec tro nic c heck in g p roc edures tes t the elec tronic as wel l as so me mechanical components of the anes th esia machi ne . In ad dition, they may ga ther i nfo rmati on abou t breathing s ys tem resis ta nce and P .935 co mpliance and leaks . They ma y a ls o remind the us er to check fu nc tio ns tha t are not included in the au toma tic chec kou t.

Figure 33.1 Electronic checkout procedure on a newer model anesthesia machine.

View Figure

Mos t mac hines hav e a mechanism to li mi t or sk ip the elec tronic c heck out. This is mean t fo r emergenc y situa tions . Many c li nic ians routinel y by pass the c heckout (42,43,44). This is not good p rac tice . The elec tronic c hec k ma y p rov ide a more co mp rehens iv e c heck than mos t people perform and ma y detec t some p rob le ms that probably woul d not hav e been foun d o the rwi se. If a n anesthes ia mac hi ne has been hel d in a ready-to -us e s ta te f or emergencies , i t sh ould be turned OFF at leas t dail y and res tarted wi th a new c heckout procedure. W hether a full el ec tro nic c hec k has been c arri ed out o r bypassed is automatical ly recorded in the mac hine's c ompu ter and can be ac ces sed. If a problem should oc cur, fa ilure to use the checkout may be cited as ev idence of s ubs tandard ca re. A pro bl em wi th e lec tronic checkouts is th at so me anes thes ia prov ide rs feel that the elec tronic chec k is all that is needed. This is not true. The user ma nual should be cons idered as the fi nal authority on what tas ks need to be performed on each machine. S ince thes e elec tronic checkouts differ among manufac tu rers and different mo dels f rom the s ame manuf ac turer and s ince they are s ubj ec t to change, it is not feasib le to dis cuss d eta ils of thes e in a tex t suc h as th is . The Commi ttee on Equ ipment and Fac il i ties of the A meric an Soc iety of Anes thes iologis ts in c onjunc tion wi th manufac tu rers , the A meric an Association of Nurs e Anes thetis ts , an d the Americ an Soc ie ty of A nes thes ia Technolo gis ts and Techn ic ians is work ing to c rea te a new checko ut procedure that wil l i nc lude anes thes ia mac hines wi th elec tronic chec kouts (45). Anes thes ia p rov iders s hould follow th is process cl osely.

Daily Checks before Beginning Anesthesia Emergency Ventilation Equipment

Resuscitation Bag
Tho ugh rare, certa in malfunc tions can rende r the anes thes ia mac hi ne ino perativ e (36,46,47). S ometimes , the problem c anno t be diagn osed or quick l y correc te d. In this s ituation, a manu al resus c i tator (Chap te r 10) wi l l allow the us er to prov ide positiv e-pressu re v en til ati on whi l e the problem is c orrec ted or the mach ine replaced . The patient port sho uld be occluded a nd the bag squeezed (Fig. 33.2). P ressu re shoul d bui ld up rapidl y to a point a t whi ch th e bag can no longe r be comp res sed. If there is a pressu re-li mi ting dev ic e, i t can be c heck ed by con nec ting a pressure

mano mete r between the patient po rt and the bag, us ing a T-fi tti ng. If there is an ov errid e mec hanis m on the pressu re-limi ti ng dev ice, this should be ch eck ed. The resusc i ta tor should be ins pec ted fo r s igns of we ar s uch as c racks o r tea rs . A reserv oi r ba g s hould be pl aced ov er the pati ent port (Fi g. 33 .3). Squeez ing the resus ci tati on bag shoul d c aus e the reserv oir bag to inflate. Af te r the rese rv oir bag i s full y inf lated a nd th e resusci tati on bag h as been release d, the res erv oi r bag shoul d def late eas ily. T his tes ts both the ins piratory and exhala tion paths for patenc y. To check that the bag refil l v alv e o pens , the b ag should be s queez ed, then the pati ent p ort occluded, then the bag re leased . The ba g s hould re -ex pand rapidl y. If the resusci ta to r has a cl osed rese rv oir, i ts func ti on can be c heck ed by perfo rming sev eral compress ion-re lease c yc les with no ox ygen flow i nto the reserv oi r. T he reserv oi r shoul d def la te, but the resusc itatio n bag should c ontinue to exp and. This checks that the ai r inlet v alv e func tions wi th a n empty rese rv oir.

Oxygen Source
A source of ox ygen to co nnec t to the res uscitation bag s hould be av ai lable. An ox ygen f lo wmete r attac hed to the pipel ine outle t (F ig. 33.4) or the cou rtesy f lowme ter on the anes thes ia mac hine (Chapte r 5) wi ll prov i de a s ource of ox yge n.

Difficult Airway Equipment

If there is any indication tha t the patien t's ai rway o r tracheal intubation wil l be diff icul t, the difficul t ai rway cart should be in the roo m. Emergenc y a irway dev ic es are dis cus sed in Chapter 21 . W hatev er dev ice ex pec ted to b e used needs to b e present and i n work ing ord er.

Suction
The adequac y of s uc tio n c an be checke d b y plac ing the end of the s uc ti on tu bing on the unde rs ide of the thumb (Fig . 33.5). Wi th the hand at wais t height, the tubing P .936 shoul d s ta y attached witho ut sup port. A rigid s uction ca the te r (Yankau er) s hould be i mmediate ly av ai lable .

Figure 33.2 Squeezing the resuscitation bag with the patient port occluded.

View Figure

Gas Supply
Cylinder Pressure
Ox ygen c y linde rs shoul d be chec ked f or corre c t mounting . If there is a da te-ex pired l abel on a c ylinder i t should be chec ked (48,49). Yokes should be sc anned to make ce rtain that any yok e not c ontainin g a c yl ind er is f i tted wi th a yok e (bl ank ing) plug (Chapter 5). A ll tags sh ould ind ic ate full or in use. Before proceeding furthe r, a ll f low c ontro l valv es s houl d be c lose d by turning them co mple tel y cl ock wis e. Ex cess iv e torque sh ould be av oided. Opening a c yl ind er or connec ting a pipel ine hose when a f lo w c ontrol v alv e P .937 i s open may c ause the indic ator to s hoot up to the top of the tube and be damaged, s tuck a t the top, or not notic ed.

Figure 33.3 The resuscitation bag is further checked by placing a reservoir bag over the patient port. Squeezing the resuscitation bag should cause the reservoir bag to inflate. The reservoir bag should then deflate easily when it is squeezed.

View Figure

Figure 33.4 A flowmeter that is separate from the anesthesia machine can provide a source of oxygen in an emergency.

View Figure

The pres sure in an ox ygen c ylinder is c heck ed by turn ing the v alv e s lowl y counterc lock wi se whi l e o bserv ing the related press ure gauge (F ig. 33.6). If a hiss ing s ound oc curs , the cyl inder shou ld be tig htened in the yoke. If tigh tening the c ylinde r fa ils to s top the sound, the washer sho ul d be c hec ked f or damage. If the hiss ing s ound pe rs is ts , the c y li nde r should be repl aced. The c ylinder(s ) s hould c on tain suffic ien t gas that in th e ev ent of a problem with the pipel ine s upply , lif e support c an be maintain ed until the pipe line problem can be co rrec ted or more c yl inders obtained. Ho w l ow a pressu re is accep table wi l l depend

on whe the r addi tional c yl inders a re re adily av ai lable , how l ow a f res h gas flo w c an be us ed, wh ether mechanical v enti lation is neces sary, and what type of v entilator is present. Some v enti la tors use ox ygen to driv e the bel lows . Others use ai r or a mix tu re of a ir and oxy gen as the driv ing gas. A pis ton v entilator wi l l not requ ire any ox ygen to driv e i t. A f ul l E c ylinder wi l l c ontain about 625 L of ox ygen with a press ure of around 200 0 ps ig. One full c yl inder wil l l as t less than 3.5 hou rs at a f low of 3 L /minute.

Figure 33.5 Check of suction. The strength of the vacuum is tested by determining that the weight of the suction tubing can be supported at waist height by the seal between the tubing and the underside of a finger. If the vacuum is unsatisfactory, the tubing will not remain in contact with the finger.

View Figure

The FDA check lis t reco mme nds that the c y linde r be at l eas t half fu ll (ab out 1,000 ps ig). If there are two c ylinders and one is c ompl etely ful l, a lowe r press ure in the second c ylind er may be ac ceptable. The authors bel iev e that 500 psig in an oxy gen c ylinde r is adequa te , prov ided c ylinde rs wi ll n ot be the primary ox ygen sup pl y (i .e., there is a pipeline s upply) and th e anes thesi a p rov ider is a ware of the s teps needed to c ons erv e ox ygen. Venti lato rs that us e ox ygen as the driv ing gas must be turned OFF and manual v entil ation us ed. Ev en if the re is onl y one c yl inder and it is only 25% full , i t woul d del iv er oxygen at 1 L/minu te f or ov e r 2 hours . E mp ty or n earempty c ylinde rs should b e l abele d as empty and replaced wi th f ul l c yli nders (s ee Chapte r 1). Anes thes ia machine c y li nders are frequ ently check ed and re pl aced by anes thes ia tec hnic ians or other o perati ng perso nnel . If anes thes ia prov iders are no t ac cus tomed to chec k ing and replac ing cy linde rs , the y wil l not reac t efficien tl y and ef fec tiv ely in the ev ent of an ox ygen suppl y failure (50).

It has be en sugges ted that merel y chec ki ng a c yl inder for adequa te press ure is not enough (38,51). The check v alv e that prev ents c yli nder gas from being used when the pipel ine is con nec ted may s tick , p rev enting flow from the c y li nde r if the pi pe li ne i s not in use. To chec k this v alv e, the pipeline hoses sh ould be dis connected and f low at the f lo wmete rs demo ns tra ted af ter th e c yl inder P .938 i s opened. This wi ll also tes t the non-re turn v alv es in th e p ipeline hose in let (see Chapte r 5). Ox ygen should not leak back through the disconnec ted pipe line hos e (52).

Figure 33.6 Top row: Pipeline pressure gauges. Bottom row: Cylinder pressure gauges.

View Figure

The 1993 FDA rec ommendations do not men tion checki ng c y linde rs c onta ining gases other than ox ygen, bec aus e thes e are no t ess ential fo r life s uppo rt. If it is planned to us e one of thes e gas es , i t is reass uring to know that c ylinder suppl ies are av ai lable on the mac hine. As disc uss ed in Cha pter 1, the con tents of a n itrous ox ide c ylinder are not reflec ted b y the press ure u nless al l of the l iqu id has ev aporated and the c yli nder is nea rl y empty. The p res sure gauge wi l l con tinue to read 745 ps ig un ti l all the liqu id has v apori zed. If the pressu re is les s than 600 ps ig, the ni trous ox ide cyl inder is ne arl y empty and sh ould p rob abl y be replaced. Af ter the pres sures are c heck ed, a ll c yl inder v alv es s hould be c losed, unless there i s no pipeline s uppl y fo r that gas . During use, there wil l be p res sure fl uctuations in the mac hi ne and the pipel ine hos es , es pec ial ly when a v en tila tor is in use. As the v enti lato r c yc les , there wil l be a trans ient dec rease in p res sure in the machine. If

the pressure fa lls below th at s uppl ied by the regul ator for the c yl inder, gas c an flow f rom the c ylinder i f the c ylinder v alv e is open. Th is gas los s wil l at s ome point deple te the c yl inder c ontents , and the re wi ll n ot be an eme rge ncy su ppl y av ail able. W hen piped g ases are not going to be us ed, there should be one ful l or n early ful l c ylinde r of each gas to be used and the v alv e on one c yl inder shou ld be fully open af te r the p res sure is checked.

Pipeline Pressure
Some ins titutions disco nnec t the p ip eline hoses f rom the machine at nigh t to allow the anes thes ia machine to be mov ed for c leaning an d reduce gas loss f rom leak s . If this is the c ase , th e hoses need to be reconnec ted to the pipe li ne s ys tem. Fi ttings shoul d hold fi rml y, no leak s shou ld be audible , and the hoses shou ld be arra nged to prev ent oc clusion. The pipel ine pres sure i nd ica to rs (F ig . 33.6) shoul d read 3 45 to 380 k Pa (50 to 55 ps ig). As disc ussed in Chap te r 5, a pipel ine pressure gaug e wil l regis ter onl y pipel ine press ure if i t is posi ti oned ups tream of th e c heck v alv e at the pi peline inlet, as requi red by the A merican Soc ie ty for Tes ting and Materia ls (AS TM) works tation s tandard (53). If it is l ocated downs tream of the check v alv e, as i t is o n s ome ol der machines , the press ure regis tered wil l refl ec t the p res sure i n th e machine, but no t necess ari ly tha t in the pipel ine (54 ).

Low-pressure System
The low pressu re s ys tem is discus sed in Chapter 5 and d iagra mme d i n Figure 5 .1 .

Vaporizers
The low-pressu re s ys te m check is begun b y chec king the l iquid lev el in each v aporizer, addi ng more if needed . Filler caps and drain v alv es s houl d be tight. Vapori ze rs should be chec ked to make certa in that they are not tilted and ca nnot be l if ted from thei r moun tings .

Leaks
Leaks i n the low-p res s ure part of the anes th esia machine can c aus e h ypox ia or pati ent a ware ness (55,56). P rofound hy percarbia c an occ ur if a Mapl eson s ys tem is i n use (5 7). Selec ting an app rop ri ate leak c hec k c an be con fus ing, becaus e s ome anes th esia machines hav e a c heck v alv e either at the common gas outlet o r jus t do wns tre am of the v apo ri zers . This c heck v alv e prev ents gas that is P .939

under pos itiv e pressu re i n the breathing syste m f rom f lowi ng back in to the machi ne and through a leak .

Figure 33.7 The suction bulb is attached to the common gas outlet and squeezed until it is collapsed. It should remain collapsed for at least 10 seconds. Following this, each vaporizer in turn should be turned ON and the maneuver repeated.

View Figure

The mi ni mum ma ndatory ox ygen flow on mos t machines may dec rease the abi li ty to detec t smal l leak s (58). The leak tes t should be pe rf ormed without the basal f low. To el imina te this minimum mandatory fl ow, the mach ine needs to be turned OFF . Irres pec tiv e of whi ch tes t is used , th e tes t shou ld be repea ted wi th each v aporize r turned ON to its min imum setting . If this is n ot done, the machi ne wi ll pas s the tes t for l eaks , but a leak assoc ia ted wi th the v ap ori ze r or i ts mounting wi ll not be found (59).

Negative Pressure Test

The negativ e pressure tes t us es a suc ti on bulb to c reate a negativ e pressu re i n the machine (55,60). The b ulb is attac hed to a tubi ng wi th a 15-mm a daptor, whi ch wi ll f it the anes thes ia mach ine c ommon gas ou tlet on the other end (Fi g. 3 3.7 ). This dev ic e is av ai lab le co mmerc ial l y or can be c ons truc ted by tak ing a sphygmo manometer b ulb , rev ers ing the ai r i nlet v alv e in the bulb, and c onnec ting one e nd of a sho rt tubi ng to the bu lb and the other to a 15-mm trac heal tube adaptor. W hen rev ers ed, the v alv e wi l l pul l ai r f rom th e mac hi ne si de of the bulb. A l te rna tel y, the dev ice can be cons truc ted from the bul b pump of a d is posa ble i ntrav enous b lood admi nis tration s et (61). To perf orm the tes t, a ll fl owmeters are tu rne d OF F. If the re is a mi ni mum mand ato ry ox ygen f low, the entire machine mus t be tu rned OFF . Squeezing the

bulb unti l it is remai ns col lapsed c reates a n egativ e pressu re in the machine. If the bulb re mains col lapsed for 10 s ec onds , there is n o s ig nificant leak present. If there i s a leak , the bul b wil l inflate. This tes t shou ld be repea ted wi th e ach v apori ze r turned ON. The suc tion bu lb is the n remov ed and the fresh gas hose rec onnec ted . This neg ativ e p res sure l eak tes t wil l wo rk f or al l makes and models of machines , whe the r there is a c hec k v alv e or no t (55 ). Fo r th is reason, i t is s ometimes c al led the universal leak tes t. It differentiates between breathing sys tem leaks a nd leaks i n the mac hine. S tudies comparing this with other l eak tes ts found that i t was the only one that ide ntif ie d a ll l eaks and was the mos t sens itiv e at find ing s mall leaks (55,56). Unfortun ately , it is no t pos sible to use this tes t on some new an es thesia mach ines becaus e the common gas outl et is not ac ces sible to the us er. A n unintention al continuous gas f lo w wi l l re sul t in a false-pos itiv e tes t (56).

Positive Pressure Test

W hen pe rf ormi ng a pos itiv e pressure le ak tes t, c are mus t be take n that the press ure does not i nc reas e beyond th e presc rib ed li mits . T here is l ittle room for co mp res sion in the mach ine tubing, and no bag to buffe r pressu re inc reases . It is possible tha t the p res sure c ould inc rease to a poin t where a fl owmeter or o the r part of the mac hine c ould be damaged.

Pressure Gauge Test

A pressu re gauge (the gauge from a s tandard s phygmomano mete r wil l do ) is attached to the c ommon gas ou tl et (Fig. 33.8), and a flow c o ntrol v alv e is s lowl y opened un ti l the pressure on the g auge reac hes 30 cm H 2 O (22 mm Hg) (57,62). The f lo w i s then lo were d until that pressure is s teady. The flow rate on the f lowme ter is then equal to the leak rate i n th e machine at that p res sure. It s hould be l ess than 50 mL/min ute . This tes t ca nnot be performed if the re is a mi ni mum mand ato ry flo w, bec ause thes e f lows are usual l y around 200 mL/minute .

Fresh Gas Line Occlus ion Test

W ith this tes t, a flow of 50 mL/minute is se t on the oxygen flowmeter an d the f res h gas l ine k inked . The indicator in the f lowmeter tube P .940 shoul d mov e down ward . An adv antage of this tes t is that it c an be perfo rmed du ring a c as e (55). This test c anno t be perfo rmed if there is a minimum manda to ry fl ow, becaus e these flows are usuall y around 20 0 mL /minute.

Figure 33.8 A pressure gauge from a blood pressure cuff is attached to the delivery hose from the machine. Sufficient flow is established on a flowmeter to maintain a pressure of 22 mm Hg on the pressure gauge. The flow that is required to maintain that pressure should be less than 50 mL/minute.

View Figure

Combination Breathing System and Machine Leak Tests

The f ol lo win g tes ts can b e used to c heck f or l eak s in the breath in g s ys tem and parts o f the machine down s tream of the check v alv es .

Retrograde Fill Test

The A PL v alv e is clos ed and the patie nt port oc c luded . The mas ter c ontrol s wi tc h needs to be turned ON. The oxygen flush or a high f lo w f ro m the flowmeter is use d to fi ll the reserv oi r bag. As the bag beg ins to dis tend, the press ure o n the mano mete r in the breathi ng s ys tem is o bserv ed . As the p res sure s tarts to ris e, the f low on the flowmeter is adj us ted s o that a p res sure of 30 cm H 2 O is maintained i n the breathing s ys tem. If this pres sure is ov ers hot, the A P L v alv e should be o pened briefly. The flow necessa ry to maintain a s te ady press ure should be no greater than 350 mL/minute. The p res sure shou ld be rele ased b y opening the APL v alv e rath er than remov ing the occlus ion f rom the patient port at the Y-pi ece. The adv antages of this tes t are that i t c an be perfo rmed quick ly wi thout accessory equipment and tha t it c hec ks the b rea thing s ys tem as well as the low-pressu re parts o f the machine i n thos e mo dels that do not hav e a ch eck v alv e (63). It also al lows the c ontinuous ai r way pressu re alarm to be chec ked. Dis adv antages are tha t i t is relativ ely i nsens i tiv e to smal l leaks , and i t does n ot loca li ze the source of the l eak between the breathing s ys te m an d the mac hine.

Squeeze Bulb Test

W ith the machine mas ter s witch and f lo w c ontrol v alv es turned OFF, the Y-piece is oc c luded an d the APL v alv e c losed. A s uc tio n bulb wi th a 22 -mm c onnec tor is attached to the rese rv oir bag mount a nd squ eezed repeatedl y until the breathing s ys tem pres sure gauge reads 5 0 c m H 2 O. The ga uge is obs erv ed. If a d rop in press ure f rom 50 to 30 cm H 2 O tak es 30 s ec onds or longer, th e leak rate is ac ceptable.

In-use Tes t
Durin g use, a l eak in th e mac hi ne or breathing sys tem can be quan tified by l owerin g the f res h gas flow as low as pos s ib le (64). If the v entilator bell ows or reserv oi r ba g c ontin ues to f i ll , the le ak rate is l es s than the fres h gas flow. W hen a l eak is s uspec ted, a s ys tematic se arc h of the anes thes ia machine and breathi ng s ys tem s hould be made, followin g the route of gas trav el . A leak can so me times be located by plac ing alc ohol on the ha nds and mov ing the hands ov er co mponen ts whi le gas flow i s occu rring. The leak ing gas ev apora tes the alcohol and c ools the s kin. W hen the machi ne leak tes t is c omp le te, res idual v apors shou ld be f lushed ou t of the mac hi ne by turnin g ON an ox ygen f low a t 1 L/mi nute fo r 1 minu te wi th all v aporizers OFF (63). There should be no n oti ceable odor i n the gas c oming f rom the common gas outlet. Us ing the oxy gen f lus h c ontro l wi ll not f lush v apo rs ou t of the mac hi ne, because i ts f lo w en te rs the fresh gas f low d owns tream from the v aporizers .

Turn the Machine's Master Switch and All Other Necessar y Equipment ON
To conti nue the checko ut, the mac hi ne master s wi tch needs to be turned ON to enable the pneumatic s and el ec tro nics . The machine sh ould be all owe d to comp lete i ts own diag nos tic c hec ks and an y a utomated c hec king procedu re. Any elec trica l equipment to be us ed du ring the anes the tic sho uld be turned ON at this ti me wi th the exc eption of a d iv erting gas moni tor, whic h should be turned ON after the breathi ng s ys tem is chec ked for l eaks .

Flowmeter
Eac h fl owmeter shoul d be examined wi th the flow c o ntrol v alv e c losed to make ce rtain the indicator is at the zero pos i tion (or at mi ni mum fl ow if the mac hine is so equipped). Eac h flow c ontro l v alv e s houl d be s lowl y open ed and c losed whil e observ ing the indica tor. The f loat sh ould mov e smoo thl y and respond to s ma ll flow

P .941 control v alv e adj us tments . If the indic ator is a rotameter or ba ll , i t s hould rotate f ree ly . An indic ato r that mov es erratic al ly or f ai ls to return to ze ro may be display ing e rroneous flow ra tes , and the machine s hould be taken out of serv ice unti l the proble m is c orrec ted. An atte mpt should b e ma de to c reate a hypox ic mix ture b y adj us ting the ni trous ox ide flo w u p o r the ox ygen fl ow down whi l e b oth ni trous oxide and ox ygen a re f lowing . Turning the n itrous ox ide fl ow up sh ould caus e the ox ygen f lo w to inc rease. S imilar resu lts should oc cur i f a high ni trous ox ide flow is present and the ox ygen f low i s adjus ted down ward. S ome anes thes ia mach ines wil l no t al ter the ox ygen f low bu t wil l l i mi t the ni trous ox ide f low. If th e machine has a ni trous ox ide : oxy gen rati o alarm, i t s hould be ac tiv ated.

Adjustable Pressure-limiting Valve and Scavenging System

The A PL v alv e and v en ti lato r should be c onnec ted to the scav enging s ys tem i nte rface . If a n ac tiv e d is posa l s ys tem is being used, the flow s hould be adjus ted.

Adjustable Pressure-limiting Valve

The s cav enging s ys te m an d A PL v alv e are c heck ed by cl osi ng the APL v alv e, oc c luding the patien t port, and fil ling the s ys tem by us ing the oxygen flus h s o tha t the breathing s ys tem pressu re gauge reads 50 cm H 2 O. The A PL v alv e is then opened. There should be a gradua l l oss of p res sure from the s ys tem. This es tablishes proper APL func tion and transfer tubing patenc y. If the s cav engi ng s ys tem interf ac e has a res erv oi r bag, it s hould inflate when the AP L v alv e is opened an d then defl ate (65 ). If the p res sure is rele ased by remov ing the oc c lusi on at the patient po rt, th e A PL v alv e a nd scav enging s ys tem patency wi l l not be chec ked. In add ition, this c ould caus e a c loud of a bsorben t dus t to en ter the breathing s ys te m (66,67).

Scavenging System Closed System

Air Intake Valve (Negative Pressure Relie f)
W ith minimal or no flow f rom the anes thesi a machine, the AP L v alv e s hould be f ull y opened an d the patient port occ luded. Sc avenging suc tion shou ld be turned ON. If

there is a bag at the sc av enging in terface, it sh ould collapse . The reserv oi r bag i n the breathing s ys tem may also col lapse . A t this p oin t, the breathing sys tem press ure gauge s hould indic ate a press ure of 0 to -2 c m H 2 O.

Positive Pressure Relief

To tes t the pos itiv e pressu re re lief v alv e on the s cav enging inte rface, the A PL v alv e i s full y opened and th e b rea thing s ys tem patien t port oc c luded. The oxygen f lus h is ac tiv ated. The breathing s ys tem pressu re i ndicator sh oul d read les s than 1 0 cm H 2 O. An al te rna te tes t c an be us ed. The v acuum f low to the sc av engi ng s ys tem is turned OFF and the AP L v alv e ful ly opened . The reserv oi r bag a nd th e s cav enging sys tem bags are ful ly i nflated by us ing the ox ygen fl ush. A flo w of 2 L /minute is then s e t on the ox ygen fl owmeter. The pres sure gauge in the b reathing s ys tem s hould re ad not more tha n 3 c m H 2 O.

Open System
Open s cav engi ng s ys tems d o not hav e v alves that need to be c hec ked , as the s ys tem is open to atmosphe re. The flow i ndi cator on the scav enging interfac e shoul d be c hec ked to make c ertain that the flow i s adequate.

Breathing System
Oxygen Monitor Calibration
Not a ll ox ygen anal yzers requ ire a d ail y ca libration c heck . The ins truc tion manu al shoul d be c ons ul ted to determi ne wha t procedures a re needed and how o ften th ey shoul d be c arri ed out. If daily c al ibration is requi red, the sens or sh ould be remov ed from th e b rea thi ng s ys tem and mov ed wel l away from sources of gas that might c hange the amb ien t ox ygen c once ntration. It s hou ld be c ali brated to 21 % and the low o x ygen ala rm checke d by setting i t abov e 21%. Th e s ens or s hould then be p lac ed sec ure ly i n its moun t in the breathing s ys tem and the breathing sys tem flus hed wi th ox ygen . This shoul d res ult in a reading of ov er 90 %.

Initial Breathing System Status

The breathing s ys tem s houl d be inspec ted to determine that no parts are damage d or miss ing and tha t al l acc ess ory equipment [e.g., humidifier, heat and mois ture ex changer, fi l ter, pos itiv e end -ex pi ratory p res sure (PEE P ) v alv e] for the propos ed anes thetic are in plac e. A ll c onnec tions s hould be made s ecure b y push and twis t. If a div erting gas mon itor is to be us ed, the sampling line s houl d be checked for

k ink s o r occ lus ion and c onnected to the breathi ng s ys tem, but the moni to r should not be tu rned ON at this ti me. Trans parent b rea thi ng tubes s houl d be c hecked f or fore ign bodies (68). T he bag-v enti lato r selec tor s witch sh ould be in the bag position. The pressure gauge s hou ld read zero. If the abso rbe r is detac hab le, it shoul d be c hec ked to make s ure tha t the a ttach ment is sec ure . The absorben t c ol or s hould be noted. If there is any c ol or ch ange , the absorben t shoul d be dis carded an d replac ed with fresh absorben t. If there is a dual -chamber absorber, both c hambers s hould be cha nged at the same ti me. If the mac hine is rare ly us ed or i f it has been s itting wi th g as flowi ng th rough it for a n undetermin ed time, the absorbent shou ld be ch ange d ev en if there is no color c hange, un les s an absorbent that does n ot cause P .942 formati on of c a rbon monox ide is bei ng us ed. The effec ts of des iccated absorbent are dis cus sed in Chapter 9. Accumu la ted absorbent dus t and water s hould be remov ed f rom the abs orber dus t cup , tak ing care n ot to s pi ll either.

Figure 33.9 Test for leaks in the breathing system. With all gas flows set to zero or minimum, the APL valve is closed and the patient port occluded. The reservoir bag is filled by using the oxygen flush until a pressure of 30 cm H2O is shown on the gauge. With no additional gas flow, the pressure should remain at this level for at least 10 seconds.
View Figure

Leaks in the Circle Breathing System

If le aks in the c i rc le s ys tem were c heck ed fo r prev ious ly in c ombination wi th machine leaks , this tes t does not need to be pe rformed. To ini ti ate the breathing s ys tem l eak tes t, all gas f lows should be at zero. The A P L v alv e s houl d be c lose d and the patien t port occ luded. The breathing s ys tem sho uld be press uri zed to 30 cm H 2 O by us ing the ox ygen flus h (Fig. 33 .9 ). If there is no

l eak , the pres sure wi l l re main near this l ev el for at leas t 10 sec onds . The AP L v alv e i s the n opened. The p res sure s hould dec rease. The leak c an be quan tifi ed by adjus ting the ox ygen f lowme te r to maintain a press ure of 30 cm H 2 O in the bre ath ing s ys tem (wi th the Y-piece occ luded and the AP L v alv e c los ed). The b rea thi ng s ys tem s tandard requ ires that this does no t ex ceed 30 0 mL /minute (69 ).

Leak in a Mapleson Breathing System

A Mapleso n b rea thing sys tem s hould be connec ted to the f res h gas so urc e with the AP L v alv e c los ed. Wi th the patient port occluded, the s ys tem s hould be pressuri zed us ing the oxygen f lush. If there is no l eak , the sys tem wi l l re tain th e pressure fo r at l eas t 10 sec onds . The press ure sh ould be released by opening the A PL v alv e. The leak rate c an be quantif ied b y a ttac hing a man ometer to the patient po rt a nd determin ing the f low ne eded to s us tain a c ertai n pressu re (70).

Bain System Inner Tube

The integrity of the Bain breathing s ys tem in ner tube (C hapter 8) is es senti al to av oid exces siv e dead s pace . P rofound re bre ath ing and hype rc arb ia c an occur if the i nner tube has a hol e, is detac hed a t the machine end , or do es not ex tend to the pati ent e nd of the outer tubi ng. For th is reas on, i t is esse nti al tha t this is tes ted .

Inspection
The B ain s ystem s hould fi rs t be inspec ted to de termin e if the cen te r tub e is properl y conn ec ted to the abs orber end of the tube . The inner tube mus t also be connec ted near the patient end. A ny retrac tion or disc onnec tion f rom ei th er end shoul d caus e the s ys tem to be rejec ted.

Inner Tube Occlusion Test

NOTE : If the s ys tem has s ide h oles or s lots at the patient end of the inne r tu bing, this tes t w il l no t work (75,76 ). To perf orm th is tes t, a 2 L/mi nute fl ow i s s et on on e of the flowmeters (26,71,72,73,74). The plunger f rom a s mall s y ringe or a f inger is inserted into the pati ent e nd of the outer tube, occ luding the inner tube (Fig . 33.10). The f lowmeter i ndicator s houl d fa ll . P .943

Figure 33.10 Bain system inner tube test. The plunger from a small syringe is inserted into the patient end of the system over the end of the inner fresh gas delivery tubing. The flowmeter indicator should drop.

View Figure

A v aria tion of this procedu re is to attac h a manometer to the end of the inner tube and d ete rmine the f low needed to caus e a sus tained p res sure (70).

Oxygen Flush Test

To perf orm th is tes t, the res erv oi r bag is fi lled (77). The pati ent p ort mus t be op en to a tmos phere. The ox ygen fl us h v alv e on th e machine is ac tiv a ted . The high gas f low thro ugh the inner tube wi ll p roduce a Venturi effec t, whi ch lo wers the press ure i n the larger ou ter tube. If the re are no pro blems with the i nne r tu be, the bag shoul d def late. If the bag does not deflate or i nfl ates , the inne r tube shou ld be checke d. This tes t may fail to detec t maj or faul ts that can be de tec ted b y the inner tube occ lusi on tes t (7 4,78,79,80).

Lack System Inner Tube

To tes t the integri ty o f the inner l imb of the Lac k s ys tem, a trachea l tube can be i nserted into th e i nner tube at the patient en d (81,82 ). B lowi ng down the trac heal tube wi th the APL v alv e c losed wil l produce bag mov ement if there is leak age between the inner and outer l imbs . An al te rna tiv e method is to occ lude both the inne r and outer l i mbs with th e A PL v alv e ful ly open (82). There should be no gas escape when ap ply ing p res sure to the reserv oi r ba g. If the inne r limb is d efec tiv e , gas wi l l flow th rou gh the AP L v alv e, and the bag wi l l c ol laps e . A third tes t is to insert a trache al tube into the i nner tube at the pa tient end (83). The c uff is inflated to obs truc t the open ing b etwe en the o ute r and i nner tub es . W i th

the APL v alv e full y open, the reserv oi r bag shoul d be fi l led us in g the ox ygen flush. Squeezing the bag sh ould caus e the flo wmete r indic ator to d rop , but n o gas should be rele ased through the AP L v alv e . S till another tes t uses a pressu re manomete r and inflating bulb (62 ). A 7-mm nas al ai rwa y tha t is c onnec ted to the bulb and manome ter is inserted into the inner tube wi th the APL v alv e c los ed. The inf lating bu lb is used to pressuri ze the i nne r tube to 30 cm H 2 O. There should be minima l dec line in pressure ov er 30 sec onds . The A PL v alv e is then opened. T he pressure sho uld fal l i mmedi ate ly .

Coaxial Circle System

Hyperc arb ia related to a faulty coaxi al c i rc le s ys tem has been repo rted (84 ). T his can be d etec ted by hav in g the anes thesi a prov i der o r patient breathe th rou gh th e s ys tem wi th the APL v alv e open and observ i ng the c apnogra ph. If there is a connec tion between the two l i mbs , the capnograph basel ine wil l be elev ated.

Smell Test
Some au tho rs recommend tha t the anes thes ia prov ide r smel l the gas f rom the pati ent p ort with a 3 L/mi nute fl ow of ox ygen s e t on the f lowmeters . No odo r i ndicates that a v aporiz er is not l eaki ng or l ef t ON (85 ).

Manual and Automatic Ventilation Systems

A sec ond reserv oi r bag s houl d be pl aced o n the pa ti ent p ort (Fi g. 33 .11). T he ox ygen f lo wmete r should be s et at the mi nimum f lo w or 300 cc /minute i f there is no minimum f lo w. The bag-v entilator se lec to r swi tc h s hould be in the bag pos i tion. As the res erv oi r bag on the bag moun t in the breathing s ys tem is s quee zed , the bag on the patie nt port sh ould inflate (Fi g. 33 .11 ). The bag on th e patien t port sh ould then be squeez ed. The res erv oi r bag on the bag moun t s hould inf la te. S ys tem res is tanc e and c ompl ia nce shoul d be ev al uated du ri ng th is tes t. This is usef ul to detec t i nadv ertent PEE P or an obs truc ti on in the sys tem (86,87). Ven ti la to r parameters appropri ate fo r the pati ent s hou ld be se t and the bagv enti lato r selec tor s witch pl ac ed in the v entila tor mode. The ox ygen flowmeter shoul d be s et a t the mini mum f low or 300 cc /min if there is no mi ni mun flow. The bellows and res e rv oir bag on the p ati en t port s hould be f i ll ed by us ing the oxy gen f lus h and the v enti lator turned ON. The bag on the patien t port sho ul d i nf la te and defl ate (Fig. 33 .12 ). Th e appropria te tida l volume shoul d be deliv ere d and the bellows fil l comple tel y duri ng ex pi ration . If use of the PEEP v alv e is antic ip ated, i t shoul d be adjus ted to d iffe ren t v alues and the breathing sys tem pres sure g auge

observ ed to v erify c orrec t perfo rmanc e. Th e b ag sho uld be remov ed from the pati ent p ort and the v entilator al lowed to c ontin ue c yc ling (88). The l ow a irway press ure and tidal o r min ute v olu me a larms sho uld annunc ia te af te r an app rop riate delay . P .944

Figure 33.11 Test of manual ventilation system. A reservoir bag is placed on the patient port. The bag-ventilator switch is turned to the bag position. As the reservoir bag in the breathing system is squeezed, the bag on the port should inflate. Squeezing the bag on the patient port should cause the reservoir bag in the breathing system to inflate.
View Figure

View Figure

Figure 33.12 Test of ventilator. A reservoir bag is placed on the patient port. The oxygen flowmeter is set for a flow of 300 mL/minute. Ventilator parameters that are appropriate for the next patient are set. The bag-ventilator selector switch should be in the ventilator position. The bellows and reservoir bag are filled, and the ventilator is turned on. The bellows should move freely and fill completely as the ventilator cycles. The unidirectional valves should be observed to make certain that the discs open properly.

P .945

W ith the v entilator s ti ll c yc li ng, the pa ti ent p ort shou ld be oc cl uded and the be ll ows f il led us ing the ox yg en flush . The breathing s ys tem press ure s hould rise no highe r than th at se t on th e h igh p res sure s afety relief pressu re dev ic e. The h igh p res sure alarm sh ould sound. To check f or a leak in an up ri ght bel lo ws , the bello ws should be oc cluded , the pati ent p ort occluded, and the f lowme te rs turned OFF. A l te rna tel y, the bagv enti lato r selec tor s witch c an be set to bag. The bell ows should s tay inf la ted . If i t falls , the re is a leak . To check f or a leak in a v entilato r with a hanging bellows (Fi g. 33.13 ), al l f lowme ters should be turned OFF or to the minimum f low and th e v entilator turned ON. W hen the bel lows is ful ly c ontrac te d, the patient port is occluded (or the bagv enti lato r selec tor s witch is put in th e bag pos i tion) and the v en tila to r s wi tched OFF. The bel lows s hould remain contrac ted at the top o f the hous ing. If i t ex pands downward, a leak is p res ent. A nother way of pe rf ormi ng this tes t is to occlude the pati ent p ort (or put the bag-v en ti la to r selec tor s witch in the bag p osi tion) with the v enti lato r tu rned OFF and lo wer the bel lo ws s to p. The bellows s houl d not expan d downward.

Figure 33.13 Test for leak in ventilator with hanging bellows. The flowmeters should be turned off or at minimum flow. The APL valve is closed and the ventilator turned on. When the bellows is fully contracted against the head of the bellows assembly, the patient port is occluded (or the bag-ventilator selector switch is put in the bag position), and the ventilator is turned off. The bellows should remain at the top of the housing for at least 10 seconds.

View Figure

Unidirectional Valve Tests

The FDA check lis t does not spec if y how the uni di rec tional v alv es a re to b e c hec ked (89). Many prac titi oners feel that wa tch ing the i nhalation v alv e disc ris e duri ng i nhalation and th e exha lation v alv e rise during ex halation whi le the v entilator is c ycl ing is an adequate check . Th is v erifies that the y open but not that they c lose co mple tel y. Durin g use, inc ompetent unidi rec tional v alves c an be detec ted by an insp ired ca rbon d ioxide greate r than zero when us ing a capnograph (Chapter 22). Some respi ro mete rs can detec t rev ersed fl ow. Unidi rec tion al v alv es may be checked by s ev eral me thods .

Breathing Method
W ith the A P L v alv e cl osed, the ins pi ratory limb of the breath ing s ys tem is de tac hed f rom the absorber and occ luded. Weari ng a mask , the tes ter tries to breath through the Y-piec e (Fig. 33 .1 4A ). It s hould be pos si ble to exhale f re ely b ut not inhale. Nex t, the ex halati on tube is detached and occ luded. T he tes te r shou ld be ab le to i nhale but not ex hale (Fig. 33.1 4B).

Valve Tester
This method util i zes a dev ic e cons is ting of a bu lb wi th a 22-mm f emale fi tting that can a ttach to the insp iratory and exha lation ports (90,91). To tes t the inspi ra tory v alv e, the compress ed bulb is attache d to th e i ns pi ratory p ort. It sho ul d i mmediate ly rei nflate. W he n the bulb is c ompress ed, i t s hould meet f irm res istanc e (Fig . 33.15A ). To check the expi rato ry v a lv e, the tes ter is attached wi th the bulb i nflated. It s houl d be poss ible to s queez e the bulb, a nd it shou ld remain deflated (Fig . 33.15B ).

Pressure Decline Method

To check the v alv es b y this method, a n ex tra reserv oi r is p laced on the inspi ratory port (92,93,94). The other bag re mains on the bag mo unt. The f res h gas f low i s s et to a minimum a nd the AP L v alv e is c los ed. The c irc le s ys tem is p ressuriz ed to 30 cm H 2 O by us ing the ox ygen flush. If the bag on the bag moun t remains i nfla ted, the expi rato ry v alv e is competent. Nex t, the AP L v alv e is opened. If the rese rv oir bag o n the ins pi rato ry po rt does not deflate, the inspi rato ry v alv e is compete nt. P .946

Figure 33.14 Checks for incompetent unidirectional valves. A: The inspiratory limb is detached and occluded. The tester tries to breathe through the Y-piece. It should be possible to exhale freely but not inhale. B: The exhalation tubing is detached and occluded. The tester should be able to inhale from the Y-piece but not exhale.

View Figure

Final Configuration and Obstruction Check

A t this point, bre athing s ys tem acc esso ry eq uipment (e.g., P EEP v alv e, h eated humidifier) should be in pl ace and turned ON. Obs truc ti ons in the breathi ng s ys tem can be d etec ted by hav in g the patient b rea the 10 0% oxygen through a mas k, prov ided a tight mask f it is ac hiev ed (95,96). This can also be d one by the anes thes ia prov ider we ari ng a mask (Fig. 33 .16 ) (97 ). The res erv oi r bag should i nflate and deflate, and the breathing sys tem pressu re indic ator s hould sho w no PEE P . Negativ e pressu re wi ll rev eal an obstruc tion in the inspi rato ry l imb ; pos i tiv e press ure wi l l rev eal an obs truc tion in th e expi ra tory limb (98 ). W hil e this is being done, the capnogram shou ld be ch eck ed to make c ertain tha t a normal wav efo rm appears . P .947

View Figure

Figure 33.15 Checking the inspiratory unidirectional valve. The bulb should be compressed (A) and then attached to the inspiratory port. It should inflate. Then, it should not be possible to compress the bulb. B: Testing the expiratory unidirectional valve. The bulb should compress easily and remain compressed.

Monitors and Controls

A ll moni tors s houl d be tu rned ON (36). A la rms sh ould b e tes ted b y s imu lating alarm condi tions , and ap pro priate limits should be set. The f in al s tatus of a ll c ontrols sh ould be chec ked before the machine is p ut in use. This i ncludes hav ing all f low c ontrol v alv es c los ed, al l f lo wmete rs indicating zero f low, al l v apori zers tu rned OFF, the bag-v en ti lato r s wi tc h s et to B A G, the P EEP v alv e OFF, and the A PL v alv e open. Th e brea th ing s ys tem s hou ld be ready to use wi th al l c omponents c onnec ted by using a pus h and twi s t mo ti on. The scav eng ing s ys tem v acuum s hould be ON.

Subsequent Checks on the Same Machine on the Same Day

If a tho rough chec k is pe rformed b efore the fi rs t cas e of the day, a les s c ompl ete procedure c an be use d befo re s ubseq uent cases . Th ose s teps are indicated in P .948 Tab le 33 .1 by an as te risk (*). The tes ts s o ma rke d ma y not be repeated o r may be abbrev ia ted if the machi ne is used b y the sa me a nes thes ia prov ide r fo r suc cess iv e cases on the same day .

Figure 33.16 Breathing system patency can be confirmed by inhaling and exhaling through the patient port.

View Figure

It is important for th e breathing s ys tem to be c hecked before the nex t c as e begi ns (47). One of the mos t c ommon al te rations made be tween cases is changing of the ca rbon d ioxide abso rbent. The abs orb er may not be c losed prope rl y. This may caus e a la rge leak and inabili ty to v entila te.

Procedure at the End of the Case

A t the conclus ion of a c ase, f lowmeters , v ap ori ze rs , and s uc tion should be turned OFF. Mo ni tors th at would need rec alibration i f turned OFF shou ld be l ef t ON o r put i n a s tandby mode . The absorbent s hou ld be c hecked for s igns of ex haus ti on and change d if i ndic ated (Chapter 9 ).

Other Machine and Breathing System Checks

W hi le the FDA c heckou t recommendations a re adequate fo r dail y use, o the r parts may need to be check ed either dai ly or as the need aris es. This is espec ial ly true af te r the machine has be en al tered or s erv ic ed.

Oxygen Pressure Failure Alarm

Mos t anes thes ia machi nes are equ ipp ed with an ox ygen press ure fai lu re alarm, whi c h is ac tiv ated if there is no o r low ox ygen p res sure i n the machine. To tes t this alarm, the ox ygen pip el ine hose is d is connec ted and all ox ygen c ylinders c losed. Any pres sure remai ni ng in the mac hine s hould be bled off by us ing the ox ygen f lus h. Th e a la rm should sound. This s tep was not incl ude d in the FDA chec kout recommen dations , because is olated fai lure of this comp onen t wil l no t in ju re a

pati ent (36). The As soc iation of A naes thetists of Grea t B ri tain and Irel and recommen d tha t this alarm is tes ted on a we ekl y basis (39).

Leaks at the Yoke

If a cyl inder is not p roperl y ti gh ten ed in a yoke, there wil l be a gas leak when the c ylinde r is turned ON. A la rge leak wi l l be qui te apparent b y the s ound. A s mall le ak wi ll not be heard b ut cou ld c ause si gn ific ant g as loss. To c heck for a leak at the yoke, after the cyl inder p res sures hav e been c hecked a nd th e v alv es cl os ed, the c ylinde r pressu re indicators s hould be observ ed for 2 to 5 minutes , wi th no f low o n the flowmeters . A drop of more than 5 0 psi g i nd ica tes s ig nifican t leakag e. If the re i s a minimum mandatory ox ygen fl ow, the mach in e mus t be turn ed OFF. The minimum f lo w wi l l mask any l eaks in the hi gh-pressu re sys tem.

Oxygen Failure Safety Valve

The oxygen f ai lure safety v alv e was i nc luded as a rou tine tes t in th e f i rs t edi ti on of the FDA chec kout but wa s not made part o f th e l ater v ers ion because it rarel y fai ls , and there are man y oth er methods of detec ti ng oxygen pressu re f ailure (36 ). Th is tes t c an be perfo rmed by us ing either the pipel ines or c ylinders as the gas source. A c yli nder of eac h g as on the machine is turned ON whi le the pipel ine hoses a re disc onnec ted. Flows of 2 L/minute a re es tab lished on the f lo wmete rs for eac h gas . The oxygen c ylinder is then turned OFF . As the ox yge n p res sure fal ls, the flows of al l other gases except ai r in s ome machines , as indicated by thei r fl owme ters , shoul d dec reas e in proporti on to the dec rease in oxygen flow and ev entual ly s hut OFF. Res toring the oxy gen press ure sh ould caus e the indic a tors to retu rn to thei r prev ious p osi tions . To perf orm the tes t by us ing pi peli ne gas es , a ll c yl inder v alv es should be c los ed and the f low c ontrol v alv es ope ned un til the c yl in der p res sure i ndic ato rs regis ter ze ro. The pi peline h oses a re con nec ted and f lows es tabl ishe d on all flowmeters . The oxygen hose is the n d is conn ected. The indic ators of the anes thetic gas f lowme ters should fal l j us t befo re the oxy gen in dicator.

Spare Components
Ex tra c ompon ents of the bre ath ing s ys tem shou ld be i mmedi ate ly av ailable (99). These inc lude an additional dis pos able s ys tem or i ndiv idual components of reusable s ys tems (Y-piece , tubings , bag).

Electrical System

Tes ts of the elec tric al s ys tem v ary wi th the different mak es and models of machines . Mos t hav e a means to tes t the reserv e ba ttery. In a ddi ti on, the re is us ual ly an i ndica ti on that the machi ne is work in g on the ba ttery power. To check this , the machi ne is d is connec ted from the mains power. The battery power i ndicator s houl d be il luminated. Man y electronic mach ines wil l hav e an indicator of the batte ry cha rge (s ee Chapter 5).

Vaporizer Exclusion System

Mos t anes thes ia machi nes hav e a mecha nism to al low on ly on e v aporizer to be turned ON at a ti me (Chap te r 6). To tes t the v apori zer ex cl usion sys tem, one v aporizer s hould be turned ON and an attempt made to turn eac h of the o the r v aporizers ON, one at a time. P .949

Other Equipment Tracheal Tubes

App rop riate tracheal tubes of the s i zes useful for the pati ent s houl d be re ady for us e. Lumen patency s hould be checked . W ith c lear tubes , s imple observ a ti on wi ll suff ic e. W ith other tubes , i t is nec es sary to l ook in both ends or i nse rt a s tylet. The cuff s hould be held in fl ated fo r at leas t 1 minute to v erify that the re are no leaks. The c uff shou ld i nfl ate ev enly and not s tick to the tube wal l or dec rease the s ize of the lume n. One l arger and one smal le r th an the tracheal tube that is intended fo r us e s hould be readi ly av ailable.

Rigid Laryngoscopes
Laryngosc ope malfunc tio n is a frequ ent problem. A t leas t two handles s hould be present, eac h fitted with the type of blade th at the user antic ipa tes wi l l be bes t fo r the patie nt. The ligh ts sh ould be chec ked for ade quate in tens i ty . B la des of o ther s izes and s hapes s hould b e immediatel y avai lable and ch ecked for p rop er func tion.

Accessory Intubation Equipment

A s tylet and bougie shou ld be i mmediatel y av ai lable. If a rap id s equence intubation i s planned , the s tylet should be fitted to the tracheal tube . An intubating forc eps shoul d be immed iately av ailabl e. If a diff icult i ntubatio n is anticipated, s peci al ized

equipment for difficul t intubation desc ribed in Chapters 18 and 21 shoul d be in the operati ng room and chec ked for c omp le teness , defec ts , and proper as sembl y.

Masks and Airways

An as sortmen t of mas ks and ai rways in a v ari ety of s izes s hould be readi ly av ailab le.

Other Equipment
Special equipment that is requi red for pa rtic ular cases , such as ex te nsion pipel ine hoses , ex tension breathing hos es, patien t warming equipment, and i nfus ion dev ic es , s hould be present and c heck ed before us e.

Procedures at the End of the Day

Foll owi ng the las t cas e, the pipeline h oses s houl d be disconnec ted at the wa ll o r ce il in g (no t at the bac k of the machine) and coi led ov er the mac hine. If the hoses are dis con nec ted at the back of the machine , they wil l c ontinue to be press uri zed, and g as may be los t i nto the room throug h leaks. If a flow c on trol v alv e is op en and the pipel ine s uppl y is c onnec ted, dry gas c an desicc ate the abs orbent, promoting the formatio n of carbon monox ide (Chapter 9). Cyl inder v alv es shoul d be c losed . Eac h fl ow control v alv e s hould be opened unti l th e c yl inder and p ip eline press ure gauges read zero, then c los ed. If the fl ow con trol v alv e is left open , res to ration of the gas su pply may forc ibly raise the indicator to the top of the tube, c aus ing dama ge. Vapori ze rs should be fi ll ed at the co ncl usion of the da y a fter mos t ope rating room personnel hav e v acated the room. This wil l dec reas e personnel exposure to anes thetic agents .

Checking New or Modified Equipment

Eac h new anes thes ia machine, v entil ator, or other complex piece of equi pmen t shoul d be c hec ked f or proper func tion ing befo re being pu t in to us e. This is bes t performed b y a manufac ture r's rep res entativ e, who may giv e in-serv ice ins truc tions . A doc ument c erti fying that the equ ip ment has been c heck ed for p roper as sembl y and func ti on shoul d be obtain ed and kept. A manual that c onta ins asse mb ly an d ins tallation i ns truc tio ns , maintena nce requi rements , check ing proc edures , a nd instruc tions for us e is su pplied wi th each piece of equipmen t. This mus t be read c areful ly an d rev iewe d peri od ic all y. A c opy shoul d be k ept in the centra l equ ipment f il es and wi th the equip ment i ts elf.

Preventive Maintenance
Many i tems in an anes thes ia mach ine and venti la tor deteri orate wi th ti me and use. P rev entiv e maintenance is d esigned to antic ipate predic table failures and replace wea kened c omponents before they fail. In some cases , an improv ed part has become av ail abl e and can be subs ti tu ted. The rec ommended f requenc y of prev entiv e maintenanc e (us uall y ev ery 4 to 6 months ) is determined by the manufac tu rer and wil l b e s tated i n the opera tor's ins truc tion manua l. P roper p rev entiv e main tenance has been s hown to be effec tiv e in prev enti ng equipment fai lu re (100). One s tudy de termin ed th at an ade quatel y mainta in ed anes thes ia mach ine that was 10 yea rs old had no more fai lures tha n new ma chines . Lack of a prev en tiv e maintenance program may l ead to an unac cep tab ly high rate of b reakdowns , premature replac ement of major equipment, and unnecessary ri sk s. The re are a number of ways that e qui pment can be se rv ic ed. P .950

Equipment Manufacturer Service Contract

W ith a serv ice con tract, the manufac turer's se rv ice represen tativ e comes to the health care fac ili ty . Different lev els of s erv ic e a re av ailable. The cos t wi ll d epend on the numbe r of pa rts cov e red , th e f requenc y of the v isi ts , and the nec essa ry respons e time.

Independent Service Company

Indep ende nt companies that are not assoc ia ted wi th a pa rtic ular manufac turer may perform s erv ice on c e rtai n equipment on a c ontrac tual bas is . It may be difficul t fo r the anes thes ia prov ider to dete rmine the qual ific ations of an independent s erv ic e prov ider. Some manufac ture rs certif y indepe ndent prov iders to serv ice thei r equipment. To bec ome certified , the y mus t s atisfac toril y comp lete the same cours es as the company's own s erv ice tec hnici ans . It may not be poss ibl e fo r an i ndependent c omp any to p rocure manufac turer-approv ed parts unles s the s erv ic e tec hnic ian has been c ertif ied by the manufac turer. A lternatel y, the fac ili ty may be able to p urc hase parts from the manufac ture r. Laws e nac ted in at leas t one s tate (New J ersey ) re qui re that the c reden tials of eac h se rv ic ing pe rs on a re app rov ed by the machine manufac tu rer o r determined b y the

phys ici an di rec to r of the anes thes ia department to be equiv alen t to the c reden tials of the manufac tu rer's s erv ic e person (101).

In-house Biomedical Services

In-house biomedic al se rv ices may be a satis fac to ry opti on for much equipme nt, es pecial l y i n ins titutions where the re are a large numbe r of s imilar machines . B iomedica l technic ians c an attend courses and become c ertified to s erv ic e s pec if ic equipment. Often, a c ombination of an outside se rv ice agenc y a nd in-house biomed ic al serv ices is used. Th e in-hous e biomedical tec hnici ans do i nterme dia te checks a nd res pond to immed iate problems between s erv ic es from the ou ts ide se rv ice agency (102 ). Adv antages of in -ho use biomed ic al maintenance incl ude minimal res pons e ti me and the abi li ty to obs erv e pro blems whil e the equipmen t is in us e. The serv ice intens i ty f rom outs ide sou rc es and down ti me f or equi pment c an be reduced. The biomedic al tec hnic ians c an as s is t wi th c l inic al educa tion, p rov id e l iaison between users and manufac tu rers , help wi th equipment s el ec tio n, an d k eep ab reas t of mo dificatio ns and s erv ic e bulleti ns is sue d b y manuf ac turers . The ques tion of liab il i ty ex posu re mus t be addres sed when c onsidering in -house se rv ice (103). If a pro blem oc curs as a res ul t of the ac tions of a bi omedic al tec hnic ian , the fac il ity wi ll l ikel y hav e l iabi lity.

Record Keeping
Rec ord k eepi ng on equip ment has frequently been neglec ted i n the pas t. Often, i t is as sumed that the serv ice represen tativ e who does periodic prev entiv e maintena nce wi ll tak e care of th is task . Expe rienc e does not supp ort this ass umption. Rec ord keepi ng is i mporta nt for sev eral reasons .

It prov ides proof that an effort has been made to keep the equi pme nt i n proper work in g o rde r. Th is c ould hav e medico legal o r Joint Co mmiss ion for Acc reditation of Heal thcare Orga ni zatio ns (J CAHO) signi fica nce. The s tate of New J e rse y requires that reco rds be mai ntained of all serv ice and mai ntenance pe rf ormed o n a ll anes thesi a machines , v enti la tors , and v aporizers . The record mus t inc lude machi ne id entif ication, serv ic ing age nt, work performed, and date of the work . The mai ntenance mus t conf orm to tha t requi red by the mac hine manufac turer. The serv ic ing agent's c redentials

mus t be determined to be equ iv alent to the c redenti als of the manufac turer's se rv ice agents . New York has s imi la r requi remen ts (101). JCAH O requi res tha t an equ ipment managemen t program des igned to ass ess and c ontrol the c linical phys ic al risk s of equipment f or trea tmen t, c are , and pati ent monitoring b e i n place . W ri tten c riteria mus t inc lude the charac te ris tic s of equ ip ment func tion, maintenance, and inc ident his to ry (101).

It prov ides a means o f c ommun ic ation wi th the serv ice represen tative. Rep res entativ es freque ntl y co me in the late afternoon o r ev enin g, af te r anes thes ia personnel h av e left. If there is no wri tten reco rd of probl ems that hav e occ urred wi th the equipmen t, the serv ice represen tativ e may not perform the indic ated repair(s ).

It prov ides a complete, u p-to-date rec ord for each pi ece of equipment. If one piece of equipmen t malfunc tions more f requentl y than o the rs , cons idera tion shoul d be giv en to replac ing i t.

It prov ides a w ri tten reco rd that maintenance by a serv ice representativ e was performe d a nd shows what was done. Se rv ice represe nta tiv es may p res ent only a bill for s erv ic e and parts and no rec ord of what was ac tual ly done to whi c h mac hin e.

It prov ides a check on the s erv ice rendered by the repres entative . After equipment is serv iced , it s hould perfo rm wel l. If a mach ine dev elops a problem soon after se rv ic ing or if there is an inc reas ed frequenc y of repairs that c an be traced to a c hange in se rv ice representa tiv es , one may wi s h to ques tion that rep res entativ e 's ab il i ti es .

W ith pi eces o f equ ipment such as vapori ze rs th at ne ed to be se nt to the manu fac tu rer periodic ally fo r serv ici ng or ox yge n analy ze rs that need to have ce rtain P .951

co mponen ts replaced a t in te rva ls , rec ords serve to remind the us er w hen the equip ment needs to be servic ed or a co mponen t replaced . After a v aporizer i s serv iced, i t may be held in reserv e before b eing put into use. This wo uld

ex tend the time before s erv icing would be due. This can be noted on the fo rm by recording the time when a v apo ri zer is receiv ed f ro m the manufac turer and wh en it is ac tuall y put into serv ic e on a machine.

Rec ording e quipment p roble ms may be useful for i mprov ing qua li ty by analy zi ng c ausativ e fac tors and su gges ting preven ta tive s trateg ies (104 ).

A rec ord s houl d be k ep t fo r eac h p iec e of co mp lex equi pment suc h as an anes thes ia mach ine, v en til ato r, v aporizer, or moni tor. This s houl d i ncl ude i dentification information ; date of pu rc hase; ins truc ti ons for serv ic ing; and the name , add res s , and telephone number of the s erv ice represen tativ e. If a probl em wi th the equipment aris es , the date, p roblem, and c orrec tiv e ac tion s hould be recorded . W hen routine se rv ic ing is performed, this should be noted, along wi th any problems or parts rep laced. Each entry s hou ld be s igne d by the pers on mak ing the entry. La ws rec ently enac ted in at least one s ta te s ti pulate that rec ords mus t be kept for eac h machine, i nc lu ding the na me of the s erv ic e person, work pe rforme d, and d ate the work was perfo rmed. The amoun t of time ne eded to retain these records v aries with th e heal th c are fac il ity's pol ic ies . Certainly, the reco rds ne ed to be kept beyond the s tatu te of li mitations for poss ib le l itigation i n the s tate where the equi pmen t is loc ated (105 ).

Accident Investigation
Any time a patient has an unexpl ai ned problem, eq uipment malf unc tion or misuse shoul d be s uspec ted and the appara tus not use d agai n until this has been disprov ed (10 6,107,108,10 9,110). W hen there has been an injury to a patient, th e heal th ca re fac ili ty saf ety off ic er (o r risk manager) shoul d be c ontac ted at once to s upe rv ise inv estiga ti on of the i nci den t. An es tablish ed pro tocol s hould be fo llowe d s o that al l imp ortant areas are cov ered s ys tema ticall y. A l l indiv iduals i nv olv ed in the inc ident s houl d doc ument thei r obs erv ations s oon af te r th e ev ent, wh il e detai ls are s ti l l f res h in thei r minds . This should be a s impl e s tatement of fac ts , wi tho ut judgments a bout c aus ali ty or respons ibi li ty . The f ol lo win g ques tions need to be as ked:

W hat was the date an d ti me of the p rob lem? In wh at area di d the problem occ ur? W hat monitors were b eing used?

W hat were the s et a la rm limits? W hat was the firs t ind ica tion that there was a pro blem? A t wh at time di d this occ ur? W ho fi rs t no ted the probl em? W hat c hanges attracted attention? W ere any alarms ac tiv ate d? W hat s igns or s ymptoms did the patient ex hi bit? Had there been any rec ent mod ific ations to the elec trical s ys tem or gas pipel ines in tha t are a? W as any th ing al tered shortl y before the inc iden t? W as this the fi rs t c ase perfo rmed in tha t are a tha t day? W ere there any problems du ring prev ious cases pe rformed in that area on that da y or the prev ious day? W ere there any unus ual occ urrenc es in o the r areas on that da y or the prev ious d ay? Had an y equi pmen t been mov ed in to that area rec en tl y? W ere there any problems noted in the room where it wa s p rev ious l y used? W hat p reus e checks were made of the anesthesia equ ipment? W ho las t f il led the v apori zers on the anes thes ia mac hine? If a v apo rizer wa s rec ently attache d to the machi ne, were preca uti ons tak en to p rev ent l iquid from being s pi lled into the outflow trac t? Af ter the ini ti al i ndic a ti on of a problem, wh at was the sequenc e of ev ents that oc curred?

An i mportan t s tep inv olv es cons truc tion of a ti me l ine, on wh ic h all ev ents are lis ted i n c hronol ogic al order (81). This wil l he lp to sort out ev ents and may lead to i dentification of miss ing data. Numerous photographs s hould be taken of the area from v arious angles , wi th al l equipment s i tuated where it was at the time of the inc ident. Eac h p iece of equipment s houl d be photog raphed sep ara tel y. Af ter pic tu res hav e been tak en, al l s uppl ies and equipment as soc iated wi th the case should be s av ed and seques tere d i n a sec ure loca tion and l abe led DO NOT DISTURB . Settings s hould not be c hanged. Re lev ant identif yi ng information s uch as the manuf ac turer and lot and/or se ri al numbers s hou ld be recorded . If af ter a ll this has been acc ompl is hed i t appears possi ble that the equipmen t may be i mplic a ted in causi ng the problem, a thorough ins pec ti on of the equipmen t by an uninv olv ed third party i n the pres ence of the primary anes thes ia pe rs onnel ,

i nsuranc e c arri er, heal th c are f aci l ity safety officer, patient represen ta tiv e, o r equipment manufac ture rs should be c ond ucted. The inv estigation s houl d cons is t of an i n-d epth examinati on of the equipment s imilar to the c heck ing p roc edu res desc ribed earlier i n this chapter. V aporizers s houl d be c alibrated and checked to determine if v apor is del iv ered in the OFF pos ition. An analys is s hou ld be made of the P .952 v aporizers ' con ten ts , if nec essary. Foll owi ng the inv estigation, a re port s hou ld be made that details al l f ac ts , an al yses , and co nclus ions . If a problem wi th the equ ipment is fou nd, an a ttempt s hould be made to rec ons truc t the acc ident if this c an be done wi th out danger to anyone, and the equi pmen t shoul d agai n be locke d up until any li tiga ti on is s ettled. If the inv estigatio n rev eals no problems , the equipment c an be re turned to serv ice with th e c ons ent of all parties . The S afe Medica l Dev ices Ac t of 1990 require s me dic al dev ice use r fac ili ties to report i nc idents that reas onabl y sugges t there is a p rob abili ty tha t a medical dev ice has c aus ed or con trib uted to th e death, s eri ous injury, or s eri ous i l lness of a pati ent (87). The report is due as so on as pos s ible bu t no late r than 10 work in g days after the us er faci li ty bec omes aware of the inc ide nt.

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80. Peters en WC . Bain c ircu it. Can Ana esth S oc J 1978 ;25 :532. [Med li ne Link ] 81. Beaupri e IG, Clark A G, K ei th IC, Spe nce D, E ng P . P re -us e tes ti ng of c oaxi al c i rc ui ts : the peri ls o f Pethick . Can J A naes th 199 0;37:S 103. [Med li ne Link ] 82. Furs t B , Laff ey DA . An a lternate tes t for the Lack s ys te m. Anaes thes ia 1984;39:834. [Cross Ref] 83. Marti n L VH, McKeown DW . A n alternativ e tes t fo r th e Lack s ys tem. Anaes thes ia 1985;40:8081. [Cross Ref] 84. Normandal e JP , Found P . Check ing the Lac k bre ath ing s ys tem. Anaes thes ia 1994;49:735. [Cross Ref] [Med li ne Link ] 84A . Jell is h W S , Nolan T , K le inman B . Hype rc apnia related to a faul ty adul t coax ial breathing c ircui t. A nes th A na lg 2001;93:973974. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 85. S treets C, Dav ies P . Should we perfo rm a s niff tes t? A naes thesi a 2000;5 5:509 10. 86. James RH. Check ing the ex piratory l imb o f ana es thetic breathi ng s ys tems . Anaes thes ia 1994;49:646 647. [Med li ne Link ]

87. Carter J A . Chec k ing ana es thetic eq ui pment and the expert group on bl oc ked anaes thetic tub ing (E GBA T). Anaes thes ia 2004;5 9:105107. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 88. Campbe ll RM, Sheikh A , Cross e MM. A s tudy of th e i nc orrec t us e of v entilator disc onnec ti on alarms . A naes thes ia 19 96;51:369 370. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 89. Dzwonc zyk D, Dahl MR, S teinhause r R. A defec tiv e u ni direc tional dome v alv e was no t discov ered during norma l tes ting . J Clin Eng 1991;16:485 490. [Med li ne Link ] 90. Eappen S , Corn S B . The anes thesi a mach ine v alv e tes te r: A new dev ice and method for ev aluati ng the comp etenc e of u nid irec tional anes the tic v alv es . J Clin Moni t 19 96;12:305309 . [Cross Ref] [Med li ne Link ] 91. Corn SB . A method a nd appa ratus f or tes ting the anes thes ia mach ine c irc ui t unidi rec tional v alv es. J Cl in A nes th 1996 ;6 :261262. [Cross Ref] [Med li ne Link ] 92. Weig el W A , Murray W B. De tec ti ng unidirec tional v alv e incompe tence by the modified p res sure decl ine method. Anes th Anal g 2005 ;100:17231727 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 93. Weig el W A , Murray W B. A ne w ap proach to tes ting unidi rec tional v alv es in anes thes ia c i rc le s ys tems . Anes thes iolog y 2 002;96:A572. 94. K itaga wa H, S ai Y, Nosak a S , Amaka ta Y. A new l eak tes t for s peci fying malfunc tions in the exh al ati on and inhala ti on c heck v alv e . Anes th Ana lg 1994;78:611. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

95. Oly mpio MA , S toner J . T igh t mask f it could hav e p rev ented a irway o bs truc tion . Anes thes iology 1992;77:822825 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 96. Dunn S M, Mus hlin PS . Food and Drug Admi nis tration guidel ines fo r machine checko ut ne ed modificati on. A nes th A nalg 1997 ;84 :468469. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 97. Katz J . Tips fo r pre-fligh ti ng you r anes th esia work s tation . Outpatien t Surgery Maga zine 2001 ;11 :4149 . 98. Grundy E M, Bennett EJ , B rennan T. Obs truc ted anes thetic c i rc ui ts . Anes thesiol Rev 19 76;3:35366. 99. Sanc hi O. B reathing s ys te m malfunc tion a nd th e ex tra c ircui t. A naes thes ia 2003;58:1131113 2. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 100. Holley HS , Carrol l J S . A nes thes ia equipmen t malfunction . Anaes thes ia 1985;40: 6265. [Cross Ref] [Med li ne Link ] 101. Anonymous . Laws , re qui rements a nd recommendations rega rdi ng med ic olegal i mplica tions and main ten ance o f anes thes ia equipmen t from Ohmeda Exc el Anes thes ia S ys tem Operation and Main tenanc e Manual , 1992. 102. Dex ter F , Coffi n S , W oodward J . Performanc e of anes thesia machines ' dev ic es that are not part of the Food and Drug Adminis trati on's daily c heck out. J Cl in Moni t 1997;13:171179. [Cross Ref] [Med li ne Link ] 103. W elch JP . Cl inic al engineerin g in anesthesia. Me d Ins trum 1985;3:109112. [Med li ne Link ] 104. Fas ting S , Gisv old SE . Equi pment problems during an aes thes iaare the y a quali ty p roblem? B r J A naes th 200 2;89:825 831.

105. Anonymous . Retaining medical e quipment rec ords. Techno l Anes th 2000;21:1 7. 106. A rms trong J N, Dav ies J M. A s ys tematic method for the inv es tigation of anaes thetic inc idents . Can J Anaes th 1991 ;38 :10 331 035. [Med li ne Link ] 107. Eagle CJ , Dav ies J M, Reason J . Acc iden t analys is of la rge -sc al e tec hnol ogical disas te rs applied to a n anaes thetic comp lication. Can J An aes th 199 2;39: 118 122. [Med li ne Link ] 108. Coop er JB , Cul len DJ , E ic hho rn J H, Ph ili ps JH, Ho lz man RS . Adminis trativ e guidelines for res ponse to a n adv e rse anes thes ia ev ent. J Cli n Anes th 19 93;5:79 84. [Cross Ref] [Med li ne Link ] 109. Fors el l RD. The cl in ic al engineer's role i n inc ident i nv estigation . Bi omed Ins t Tec h 1993 ;27 :378383. 110. Lee RB . Repl y to gui de li nes an d tec hniques for the i nv es ti gation of an es thetic ac c idents . J Clin An es th 1994 ;6:171 172 . [Cross Ref] [Med li ne Link ] P .954

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i f D is correc t i f A , B , C, and D a re co rrec t.

1. Wha t actions a re re quired by the Safe Med ica l Devices Act? A . P robl ems whic h mus t be reported i nclude d eath of a patient B . Reporting is done by the cl inici an who experienced the problem C. Se ri ous injury resu lting f rom equi pment mus t be reported

D. Inc iden ts mus t be reported wi th in 20 wo rk ing da ys V iew A ns we r2. If there is a los s o f pipeline oxygen, w h ich steps sh ould be taken to conserve oxygen from the cylin der? A . Disc ontinue usi ng ni trous ox id e B . Us e a ir and in trav enous agents C. Disc ontinue us ing a pis ton v entil ator D. Us e a low ox ygen fl ow V iew A ns we r3. Wh ich are important points to remembe r w hen chec kin g the gas cylin ders? A . Th e pressure in the oxy gen c y li nde r shou ld be at leas t 50 0 ps ig B . Th e cyl inder v alv e shou ld remain open to s uppl y gas if the pipeline f ai ls C. The v alv e is turned counterc loc k wi se to o pen the c yl in der D. The p res sure in the ni trous ox ide c yl inder refl ec ts c ontents in the c ylinder V iew A ns we r4. How c an the low -press ure syste m in a ll a nesthesia mach ines b e c heck ed for leaks? A . P osi tiv e press ure f rom the breath ing s ys tem tes t B . E lapsed time pressu re tes t C. Fresh gas li ne oc c lusi on test D. A negativ e pres sure tes t V iew A ns we r5. Wh at actio ns should be tak en if a piece of e quipment is sus pected to ha ve caused harm to a patie nt? A . Documen t the c ircums tances s u rrounding the time the pro blem f irs t occurred B . De termin e if s imi la r problems occ urred in o the r operatin g rooms at the s ame time C. Isolate the equipment until the probl em can be inv es tigated D. Hav e the c ompany s erv ic e repres entative s e rv ic e the equ ip ment V iew A ns we r6. Concerning calibration of the oxy gen analyze r A . It should read 2 1% wh en the s enso r is ex pos ed to ro om a ir B . Th e sens or shoul d fi rs t be remov ed f rom th e b rea thi ng s ys tem C. Repeated oxygen f lus hing with the s ens or i n the breathing sys tem shoul d c aus e the anal yzer to read ov er 90% D. A ll ox ygen anal yze rs need to be calibrate d dai ly V iew A ns we r7. Concerning tes ting the inner tube on th e Ba in Sys tem. A . Th e inner tube can be occ luded wi th a plunger B . If there a re holes in the inne r tu be at the patient end , the inn er tube occ lus ion tes t wi l l not work

C. The b ag sho uld be open to atmos phere when the oxygen flus h is us ed D. us ing the ox ygen f lush should c aus e the bag to in fl ate if the tubin g is intac t V iew A ns we r8. Leaks in the ve ntila tor bellow s and trans fer tubing can be detected by w hich of th e follow ing tests ? A . Is ol ating these parts wi th the bag -v enti lator selec tor s wi tch B . V e rify ing that a hangi ng bellows remains ful l y contrac ted af ter the bag-v entilator s wi tch is pu t in the bag pos i ti on. C. Us ing a minimum f lo w f ro m the ox ygen flowme ter and obs erv ing the bel lows retu rn to the full y inflated pos ition D. Obs erv in g the ex curs ion of the bel lows during ins piration V iew A ns we r9. How s hould the unidirec tional valves be chec ked? A . Observ ing the motion of the leaflet as the v entil ator c yc les B . Oc c luding the ins piratory tubing an d not being able to inh al e through the ex piratory tube C. Remov ing the v alv e le afl et to inspec t fo r damage to the lea fl et or its s eat D. Oc clu di ng the expi ratory tub ing and not b eing able to exh al e through the i nspi rato ry tube V iew A ns we r

Chapter 34 Cleaning and Sterilization

P .956

A ll anes thesi a prac titi oners should be c once rne d with the c lea nliness of thei r equipment, both to prev ent s pread of in fec tion betwee n pati en ts an d to ens ure that they themselv es do not c ontrac t an infec tion . Nosoc omial i nfec tions con ti nue to be a s ignificant drai n on human and economic resou rces , producing suffe ri ng and highe r heal th c are c os ts . Infec tio n c ontro l has become an importan t focus of the Jo int Commis sion on Acc redi tation of Heal thcare Organizati ons (J CAH O).

Definitions (1,2,3)

Anti mic robial : A chemica l or materia l cap able of des troying or inhibi tin g the growth o f mic roo rganisms . Antiseptic : A chemica l germic ide that has antimic rob ial ac tiv ity and that c an be safel y applied to l iv ing tiss ue. An tisep tics are regula ted as d rugs . Ase psis : A sc heme or proc ess that prev ents c ontac t with mic roorgan is ms . Bac teria: Mic roscopic unic el lular o rganisms. Bac terici de: A c hemic al ag ent or compou nd th at ki l ls bac te ri a. Bac terios tat: An agen t that wi ll prev ent bac terial gro wth bu t does not necess ari ly k i ll the bac te ria. Bac te ri os tatic ac tion is rev ers ib le; when the agent is remov ed, the bac teria wil l resume n ormal gro wth .

B ioburden (Bi oload, Mic robial Load): The nu mber an d types of v iab le organis ms c ontaminating an objec t. The level of biobu rde n is re lated to the anato mic s i te wh ere the dev ic e wa s us ed .

B iological Indic ato r: A s teril iz ation -proc ess moni tori ng dev ice cons is ting of a s tandard iz ed, v iab le population of mic roorganis ms (us ual ly bac terial s pores ) that are kno wn to be res is tant to the mode of s teri lization be ing monitored. Subsequ ent g rowth or f ai lure of the mic roo rganis ms to grow unde r sui table condi tions i ndica tes wh ether or not condi ti ons were adequate to ac hiev e s teril i ty.

Ceil ing Va lue: Conc entra tion of an airborne con taminan t abov e whic h a person s hould not be exposed ev en momentaril y.

Che mica l In dic ator (chemical moni tor, s terili zer c ontrol, c hemical c ontro l devic e, s terili zatio n-p roc ess mon itoring d evi ce): A s teri l iza ti on-proces s moni tori ng dev ice desi gned to respo nd with a c harac teris tic and v is ible chemic al or phys ic al change to o ne or more parameters of a s te ri li zation process .

Che mica l In tegra tor: Che mica l indicator that reac ts to a v ari ety of s teril i zation paramete rs . Che mos teri l izer (c hemical s te ri lant): Chemic al us ed for the pu rpose of des troying al l f orms of mic rob iolog ic al l if e, inc lud ing bac terial s pores . The sa me c hemical used for sho rter ex pos ure pe ri ods and/o r at a l ower conc en tration may be used f or dis infec tion . P .957

Cl eaning : Remov al of forei gn mate ri al f ro m an i tem. Con tamination: S tate of ac tua ll y or po ten ti al ly hav ing been in contac t with mic roorganisms . Critic al Ite m: Item tha t pene trates th e s kin o r mucous membranes or is in contac t wi th no rmal l y s te ri le areas of th e body. Dec ontamination : A process that rend ers c ontaminated inani mate i tems s afe for handl ing by pers onne l who are not wea ri ng protec tiv e a ttire (i .e ., reasonabl y free of the probab ili ty of transmitti ng infec tion) (2,3,4). Dec ontamination c an ran ge from s imple cl eaning to s teri lization .

Dis infec tant: Chemic al germic ide formu la ted to be used on inanima te objec ts . Dis infec tion : P roces s capa ble of des troying mos t mic roorganisms bu t, as ordinaril y us ed, not bac teria l spo res . A dis infec tant is usual l y a c hemical agent, but s ome proces ses (s uch as pas teuriz ation ) are dis inf ec ti ng. The Cen ters fo r Dis ease Control and P rev ention (CDC) has adop ted a c las sif ication tha t inc ludes three lev els of dis infec tion.

Hi gh-level Dis infec tion: A procedure that k ill s all org anisms wi th the ex cepti on of bac te ri al s pores and ce rtain s pec ies , suc h as the Creutzfeldt-

Jakob prio n. Mos t high-l ev el disinf ec tants can produce s teri lizati on wi th suff ic ient con tac t time.

Inte rmed iate-level Dis infec tion: A procedure that k il ls v ege tativ e bac teria, i ncl uding Myc obac terium tube rcu los is , mos t fungi , and v i ruses bu t not bac te rial s pores (5).

Low -l evel Dis in fec tion: A proc edure tha t k ills mos t v egetativ e bac teria (but not M. tuberculosis ), some fungi , and v irus es but no s pores (5 ).

Disposable: Intended for use on one pa tient d uring a si ngle procedure . Fun gic ide: An agent or proc ess that k il ls fun gi . Germic ide: A n agent that destroys mic roorganis ms . Mechanical Moni tor (physical moni tor, phys ical ind ic ator): S teri l izer co mponen t that gauges and rec ords time, temperature, humidi ty, or press ure during a s te ri liza tion c ycle .

Nonc ri tic al Item: A n i tem that does no t ordin aril y touch the p ati en t or only touches in tac t sk in but not muc ous membranes (5). Nos ocomial : P ertaining to a heal th c are fac ili ty. A nos oc omial i nfec tion is one acqui red in a hea lth care fac ili ty. Permis si bl e E xpos ure Li mi t (PE L): The ti me- weig hted av erage max imum conc en tration of an ai r contaminan t to whi ch a worker c an be exp osed ac cording to Occ upational S afe ty an d He al th Adminis trati on (OSHA ) s tandards .

P rions : P roteinaceous infectious agents wi th no as soc iated nuc le ic ac ids . P roces si ng: A l l of the s teps performed to mak e a c ontaminated dev ice ready for pati ent us e. Pse udoinfec tion: A pos itiv e cul tu re wi th out c linical infec tion. Py roge ns : S ubs tanc es th at can p roduce f ever. Rep roc essi ng : Decontamina ti on and repackaging of a dev ice that h as been us ed for its intended purpos e a nd is l abe led f or s ing le us e (6). Res teri li zati on: S terili zation of an unopened (i .e., i nner wrap s ti ll intac t, and therefore , th e dev ice is presumably unus ed) s teri le dev ice or an unused wrapped s te ri le dev ice that is pas t the ex piration date.

Reusable: Intende d for repeated use ei ther on the s ame or diffe ren t patients , wi th ap pro priate rep roc ess ing be twe en uses . Sanitization : P roces s of reducing the numbe r of mic robial co ntamin ants to a rela tiv el y safe lev el . In general , sa nitation is us ed for nonc ri tic al surfaces or

for app lications i n whic h s tronger mic ro bi al agents ma y caus e dev ice materials to dete riora te (4).

Sanitizer: A l ow-lev el d is infec tan t. Semic ritical Ite m: A dev ice that is in tended to c ome in c ontac t wi th muc ous membranes o r in tac t sk in bu t wil l no t normal ly co me into contac t with s teri l e tis sues .

Sho rt-term Ex posure Li mit (STEL ): A 15-min ute time -we igh ted av erage ex posu re that s hould not b e excee ded at any ti me during a wo rk day . Spo re: The normal res tin g s tage in the life c ycle of ce rtain bac teria . Spo rici de: A n agent that k ills spo res . S tanda rd P recau ti ons : Pol ic ies promu lg ated b y the Cente rs f or Diseas e Con trol an d P rev ention (CDC) in 1996 that inc lud e univ ersal p rec autions , ai rborne p rec autions , d rople t precautions , and con tac t precautions . S tanda rd precauti ons appl y to all pa tients , rega rdl es s o f their diagnos is o r known o r presu med inf ec ti on s tatus .

S teril ant/Dis infec tant: Te rm appl ied by the E nv i ronmental P rotectio n A genc y (E PA ) to a ge rmicide that is c apab le of s te rili za ti on or high -l ev el disi nfec tion . S teril e/S teri li ty : S tate of being free f rom al l l iv ing mic roorganisms . In prac tice, s teril i ty is usually des c ribe d in terms of the s terili ty as suranc e l ev el .

S teril ity Ass urance Lev el (SAL): P robabi l ity th at mic roorganisms wi ll s urv iv e af te r a terminal s teril i zation p roc ess . Before a man ufac tu rer can label a produc t as s terile, i t mus t hav e a s teril i ty as suranc e lev el of 10 - 6 , wh ich means tha t th e poss ibil ity that mic roorganisms hav e s urv iv ed on the i tem ex is ts but is no greater than 1 10 - 6 or 1 in 1,000,000.

S teril ization : P roces s c apable of remov in g o r des troying al l v iable fo rms of mic robial l ife, i ncludi ng bac terial s pores , to an acc eptable s teri l ity ass urance l ev el . P .958

Termi nal S teril i zation: S teri l ization proc ess th at is carri ed out after an i tem has been placed in i ts f inal pac kaging .

Thres hold Limi t Value Ceil in g: Concentra tion of an a ir c ontamin ant to which i t is beli ev ed that nea rl y al l workers ma y be repeatedl y exposed da y after day wi thout adv e rse effec t.

Ti me-weig hted Average (TW A ): Integration of all the c onc entrations of a chemic al to whic h a wo rk er has been exp osed du ri ng a s ampl ing perio d, reporte d as an av erage .

Trans miss io n-b ased P reca uti ons : Rec ommenda tions b y the CDC fo r patients wi th k nown or suspec ted infec tion or colon iz ation wi th hi gh ly transmissible o r epidemiolog ic ally i mportan t pathoge ns that can be trans mi tted by ai rborne or droplet tra nsmission or b y c ontac t with dry s ki n o r c ontaminated su rfaces .

Tub erc uloc ide: A n a gent or proces s tha t k ills tu berc le baci l li . Universa l P recautions : Recommendations made by the CDC tha t heal th care work ers cons ider blood a nd certain bod y flui ds to be po tential ly i nfec tious f or bloodborne pathogens and us e pro tec tiv e barriers and workplac e p rac tices to reduc e the risk of exp osure. In 1996 , univ ersal precau tions were i ncorporated in to s tandard p rec autions , wh ich expanded the cov e rag e to any body fluid tha t may c on tain con tag io us mic roo rganis ms .

Vegeta tive: Ac tiv e g rowth phas e of a mic roorganis m. V i rucid e: Agent that inac tiv ates v iruses . V i rus : Sub mic ros copic , n once ll ul ar pa rtic le co mposed of a pro tein shell and a nucle ic ac id c ore , and, in c omp lex typ es , a su rround in g env elope. In b road terms , v i rus es are e ither l ipophil ic (env eloped ) or hy dro philic (naked ) (7 ).

Role of the Federal Government and Professional Associations

The E PA regis ters and reg ul ates c hemic al germici des (8,9). It requires manufac tu rers to tes t formul ati ons of c hemica l germic ides fo r mic robici da l potenc y (eff icacy ), s tabil i ty , and tox ici ty . It a ls o a pprov es s teri lization dev ices. The Fo od and Drug Admi nis tration (FDA ) regulates med ical dev ic es and c onsi ders l iquid c hemic al germicides us ed to reprocess medical ins truments as ac cess ories to medical dev ic es . The FDA requ ires that the manuf ac turer of a dev ice marketed as reusable prov ide the use r wi th ade quate instruc tions for c lean in g and disi nfec ting or s teri li zing th e item. In 1993, the FDA and E P A s igned a memora ndum of u nders tandi ng that s tates that the agenci es wil l div ide the premark et cl ea rance of ge rmic ides s o that the FDA

wou ld c lear li qui d che mica l s teril ants and the EPA would reg is ter general -purp ose disi nfec tants bef ore ma rke ting (9A ). OS HA regulates occ upational expos ure to chemical disinf ec tants and s teril izers . The CDC does not ap prov e, regu la te, or test ge rmic ides or s terili zers . Ra the r, i t recommen ds broad s trategies to prev ent trans miss ion o f infec tions in the h eal th ca re env ironment. P rac tic es and procedures to reprocess reusable dev ic es hav e been pu blished by sev eral profess ion al organ iz ations , inc luding the A merica n S oc iety of Anes thes iologis ts (A SA ), the A meric an Assoc iation of Nurs e A nes thetis ts (AA NA ), and the Ass oci ation of Operating Ro om Nu rses (A ORN) (2,10,11).

Resistance of Microorganisms to Disinfection and Sterilization

Mi c roorganisms can be c ategoriz ed in to groups accordi ng to thei r innate res is tance to a s pec trum of phys ic al processes o r chemica l germic idal agents . Figure 34.1 shows a gene ral desc ending order of mic rob ial res is tance lev els . Resis tance to disi nfec tion and s teri lization is not e quiv alent to resis tance to antibiotics . Fo r ex ample, antibiotic -resis tant s trains of s taphy lococ c i do no t appe ar to be mo re resis tant to c hemica l germic ides than nonres istant bac teria (8).

Cleaning
The f irs t and mos t important s tep in deconta mina tion is thorough c leaning (12,13,14). In s ome c ases , cl eanin g ma y be suffic ient to render an i tem s ui tab le for reuse . If an a rtic le is not c lean, retained salts a nd organic soi l could inac tiv ate chemic al ge rmicides or p rotec t mic roorgan is ms d uring the dis infection or s teril i zation p roc ess . Ev en if the item is rende red s terile, res idu es may in terfere wi th the dev ice 's func ti on or c ause a reac tion in a pati ent. It is important to p rev ent blood or other bo dy fluids f rom drying on dev ices . Enz ymatic foam sprays that prev ent d ry ing , break down b loo d and prote in, and i nhibi t bac terial growth a re av ail ab le. Flushing l umens wi th en zymatic cl eaner wil l break up debris . Items th at can be immersed s hould b e soak ed in water p lus an enzyme presoak with or wi thout de tergen t fo r at leas t 3 minutes (15). S tain less s teel or other metal dev ices s hould not be soak ed in s aline or s odi um hypochlorite so lutions , becaus e the c hl oride ions i n these two s ubs tances wi ll caus e the metal to co rrode (13). A c los ed c on taine r shou ld be us ed to mov e contaminated dev ic es to the deco ntamination area.

P .959

Figure 34.1 Descending order of resistance of organisms.

View Figure

Cl eaning s hould be perfo rmed in a des ignated l oca tion that is sepa rate from other parts o f the fac il ity to mi ni mize i nadv ertent pe rsonnel exposure or exposure of other i tems to c onta minants . The area sh oul d be res tric ted to authorized person nel as muc h as poss ible. It s houl d be away f rom traffic , patients , and c lean-i tem s torage. The floors , walls , c ei li ng, and work surfac e shou ld be made o f non-porous materials that wi ll not s uppo rt the growth o f mold . These s urfac es should be was hed frequently . The area sh ould h av e ad equa te ligh ting wi th no shadowe d or dark areas . The floo r should be desi gned to prev ent s lipping bu t be eas y to c lean . Horizontal wo rk su rfaces s houl d be c leaned and dis infec ted dai ly . Fluid s pi lls shoul d be c leaned up q uick l y to prev ent sl ips and falls . If the spil le d ma terial was contamina ted wi th b lood, the spil l area s hou ld be treated after i t has been c leaned up wi th a tuberculoc ida l germic ide. The heating , v enti la tion, and ai r-c onditioning s ys te ms s hould be des ig ned to minimi ze sp reading contaminan ts to adjacen t s paces . The ai r pressu re wi thi n the decontami nation s pac e s houl d be neg ativ e relativ e to the s urrounding spac es so that ai r does not f low out of the area. There should be a min imum of 6 to 10 total ai r ex chan ges eac h hour wi th 100% fresh air. A ir f rom this area s houl d be ex haus ted to the outs id e wi thout rec irculatio n o r to a fi l te red pa rtial rec ircu lati ng s ys tem.

The area should be div ided in to di rty and clean a reas . Signs s howi ng where di rty equipment is to be plac ed s hou ld be prominen tl y displayed . S inks should be bi g enough to c ontain large ins truments , and there shou ld be en ough s ink s to ac commoda te co ncurre nt soak ing, washing, and ri ns ing . S inks should hav e attached c ounters or adj ac ent work s urfaces on wh ich to place soi led and c lean i tems s eparatel y. Hand-wa shing faci li ti es s houl d be conv enientl y loc ated in or n ear the deco ntamination area. P ers onnel s hould we ar a full c omplement of protec tiv e atti re (hai r c ov erin g, f lui d-res is tant mask , ey ewear, waterproof gown o r apron, appropriate glov es , and waterproof shoes or boots wi th n ons kid s oles ) (13,16). Person nel s hould be careful not to i njure thems elv es wi th co ntamina ted i ns trume nts . Eac h dev ice manufac tu rer's ins truc tions sho ul d be c ons ulted to determi ne th e appropriate cleaning methods and agen ts to remov e s oil wi tho ut damaging the dev ic e. Ta pe should be remov ed and adh esiv e res idue disso lv ed by us ing an appropriate solv ent. P .960

The nex t s tep is disass embly (i f not done at the sourc e). An ini tia l water ri ns e o r soak ing wi th a spec ia li ze d p roduc t (e.g., a p rotein-dis solv ing so lution) c an prev ent blood c oagulation on th e dev ice and remove gros s debris . The water temperature shoul d not ex ceed 45C, because hi gher tempera tures cause prote inaceous soil to coagulate (17 ). A n al ternativ e is to us e a s pra y-o n p rec leaner to help disso lv e the so il (12). Af ter the equipment h as soaked long enough to loos en organic matter, i t should be thorough ly sc rubbed i nside and ou t. P artic ul ar atte nti on sh ould be paid to l umens , c rev ices , co rne rs , groov es , and k nurled or tex tured surf aces . It is importan t to hav e a v ariety of brushes (18). B rushes and other c leaning impl emen ts should be disposable or s hould be c leaned and s teril ized or undergo high-lev el disi nfec tion at l eas t daily . Imme rsi ble dev ic es cleane d under wate r to prev ent ae ros oliza ti on of mic roorganisms . A c loth soaked i n dete rgent and wa ter can be us ed to c lean i tems that c annot be immersed. Detergents should be low s uds ing and ri ns e off wi thout l eav ing a residue. Dete rgent resi dues c an le ad to s tai ni ng and may i nterfere with the ac tion of some chemical d is infec tan ts (13).

Cl eaning may be accomplishe d ma nual l y, mec hanical l y, or by a c ombination of both. Using mechanic al eq ui pment may inc rease produc tiv i ty, improv e c leaning ef fec tiv enes s , and off er greater protec tion for the worker. A v arie ty of washing mac hin es are av ai lable (12,19). The y are highly au toma ted , us ual ly wi th mic roproces sor c ontrol. W as her-s teril i zers are des igned to wash, ri nse , and then s team s teril i ze items (4,13). W asher-d econ taminators /dis infec to rs us e hot water i n the range of 60C to 95C. They a re des igned to wa sh, rinse, and dry the sa me i tems as a washe r-s teri l ize r but c an proces s items th at wou ld be de teriora ted by the high tempera tu re us ed in s team s teril izati on . Some equipment that has join ts , c rev ices , lu mens , and other ha rd-to -reach a reas can be treated in an ul tras onic cl eaning s ystem after gross s oil has been remov ed. In an u ltrasonic c lean er, high-f reque ncy so und wav es pass ing through a so lv ent produce submic rosc opic bubb les . These bub bles c ol la pse on thems elv es, generating tiny s hock wav es that k nock debris off su rfaces . A detergent is of ten added to the ul trasonic l iqui d. The wa ter may be heated. Ultrasonic clean ing tank s are av ai lable in a v ari ety of s i zes an d c onf ig ura tions . The equ ipment to be c leaned i s placed in a baske t or tray and in to the ultrason ic tank for a preset period of timeus ually 3 to 6 minutes . Ultrasonic cleaning monitors are av ailable (20). Some manufac tu rers of de licate ins truments , inc luding la ryngos copes , recommend tha t they not be subjec ted to ul tras on ic c leaning because the proces s ma y l oosen fi ne sc rews a nd adv e rs ely aff ec t a li gnment (21). Af ter c leani ng, ri nsing should be performed to remov e s oil and residual detergent and to k eep i t f rom res ettl ing on the equipment. Lu mens and c hann els s hould be wel l f lushed du ring eac h ri nse. Inadequate rinsi ng can cause i rritation and burns in pati ents (22 ). So me i tems (such as those un dergoing pl asma s teril i zation) sho ul d be rins ed wi th alcohol or d is ti lled or demin era li ze d wa ter. The c lea ned i tem shoul d be tho roughl y dried. Ev en if an i tem is to und erg o no further p roc ess ing, drying is important bec aus e a hu mid env ironment may encourage the growth of certain organis ms . If a liqui d c hemical agen t is to be used , water on the equ ip ment wi ll dilute the agent and make i t less effec tiv e. If wate r droplets remain on equip ment that is to be g as steri lized, ethy lene ox ide (E O) wil l diss olv e in the wate r and form ethylene gl yc ol , whi ch is both tox ic and dif ficul t to remov e. Most i tems may be towe l- o r ai r-dried . A ir-d ry ing c abinets and hot-air ov ens are av ai lable (Fig. 34 .2 ). If an i tem is to und ergo E O s teril i zation, unheated ai r s hould be used .

Af ter c leani ng, each i tem s hould be inspec ted to v erify c lean li nes s and tes ted for func ti onal i ty (23). All acc ess ible surfaces sh ould be examined u nder normal l ighting. S wab tes ts f or d etec ting res idual prote in on su rfaces a re av ailable. Disas sembled dev ic es mus t be reassembled to perform func tion ali ty tes ting. A fter func ti onal i ty is v erified, so me d ev ices mus t aga in be disassemb led to ens ure that the s teri lant can contac t all the s urf ac es .

Disinfection and Sterilization Methods Pasteurization

W ith pas teu ri zation (ho t water dis inf ec tion), the eq ui pment is imme rsed in water at an elev ate d tempe rature (bu t below 100C) for a s pec if ied time. Th e time and temperature v a ry. A typica l sequenc e is 30 minutes at a temperature of 70C . Con tac t ti me is i nv ers ely related to temperature , tha t is , for equ iv alent mic robial k il l, a longer exp osure ti me is requ ired when the temp era ture is reduced. CDC guidelines refer to p as teurization as a hi gh-l ev el dis infec tion proc ess, althou gh so me feel it is inte rmedi ate-lev el (13,24). Pas teuri zing mach ines come in diffe ren t s izes (Fig. 34.3). Many also was h the equipment. They a re s impl e to lo ad and op era te. Spec ial dry ers that a re equ ipped wi th f il te rs are av ailabl e. Pas teuri zation has been used f or breathing tubes , res erv oi r bags , trac heal tubes , fac e mask s , ai rways , la ryngosc ope blades , s tyl ets , bi te blocks, Y-p iec es , elbows , adaptors , and v enti lator bellows . A major adv antage of p as teurization is that the lower te mperatu re is les s damagi ng to equipment than the hi ghe r te mperatu res emp loyed during autocl av ing . There are no tox ic fumes or res idues . It is si mpl e, P .961 i nexp ens iv e , and rel iab le . This tec hnology ma y res ult in c onsi derable sav ings co mpared with throwi ng equ ipment awa y. Th e ma in dis adv antage is th at the treated equipment is wet an d mus t s ti ll be dri ed and packaged, d uring whi ch time i t may again bec ome c onta mina ted . The heat may dama ge some materials .

Figure 34.2 Forced-air drying cabin for equipment. (Picture courtesy of Olympic Medical.)

View Figure

Steam Sterilization
Steam s teril ization (autoc lav ing) util izes saturate d s team under p res sure (19,25,26,27,28,29). It is the mos t widely us ed and inex pens iv e o f the s teri li zation tec hniques . A t s ea lev el , water bo ils at 100C. W hen it is boi led withi n a c los ed v essel at i nc reas ed pressure, the temperature at whic h it b oils and that of the s te am i t forms wi ll exceed 100C. The inc rease in temperature depends on the pres sure withi n the chamber. P ressu re per se has little or no s teri li zi ng ef fec t. It is th e mo is t heat a t a su itable tempera tu re, as reg ula ted b y the press ure in the c hambe r, that b ri ngs about s teril i zatio n. Inc reas ing the temperatu re dramatic all y reduc es the time ne eded to achiev e s teril i zation. The minimum time for s terili zation by s team a t 121 C is 15 mi nutes . If the tempera ture is 126C, the time is reduce d to 10 min utes . P .962 It is 3.5 minutes at 134C and only a few s econ ds at 150C.

Figure 34.3 Pasteurization machine. (Picture courtesy of Olympic Medical.)

View Figure

Inc reas ing the temperatu re dramatic all y reduc es the time ne eded to achiev e s teril i zation. The minimum time for s terili zation by s team a t 121 C is 15 mi n. If the temperature is 126C, the time is reduc ed to 10 min. It is 3 .5 mi n a t 134C and only a fe w s econds at 15 0C. Autoc lav in g is effec tiv e becaus e the s team transfers he at to ma terials rapi dl y on contac t. Mic rob ial des truc tion wi l l be mos t eff ectiv e at loca tions wh ere sa turated s team can c ontac t the mic roorganisms . A t locatio ns inaccessi ble to s team penetration (as mi ght occu r with complex dev ices , imprope rl y pack aged i tems or i ncorrec t load co nfi gu rati ons ), s ome mic robial d es truc tion may oc cur, but d ry he at i s not as eff ic ient at s teri li zing as saturated s team. Equipme nt to be s te ri li zed is cl ean ed, and then may be pack aged i n a ma teri al easil y penetrated by s team. A fter s teril i zatio n, the pack aging material prev ents recon tamination during s ubs equent handl ing and s to rage. P .963

Autoclave Design
A s team s te ri li ze r can range f rom a smal l , manuall y-operated table top s teri li zer to a l arge, co mputer-con trolled , floo r-loading model (26 ,28 ,29 ,30 ,31). S teril i zers are desc ribed by the method o f ai r remov al , temperature and the time the chamb er is held at the spec ified temperature (e.g ., v acu um, 130 C, 4 minutes ) (28).

The c hamber (press ure v essel) is where materi als to be s terili zed are plac ed and through whi ch s team is c irc ul ated. It mus t be c ons truc ted to withs tand the high press ures required to b ring the s team up to th e tempe ratures requi red and fi tted wi th a saf ety v alv e to p rev ent dev el opment of excessiv e press ure . Chambe r s ize v a ri es from less than 1.5 c ubic fee t in s ma ll tabletop s terili zers to more than 7 0 cubic feet in large f loor-l oad ing mod els (28). The j ack et is the p ortion surrou nding the chamber. It f unc tions to ma in tai n the tempe rature in the cha mber. The s terili zer may be equipped with one or two doors . Doors may be hinged or s lidin g and are o pene d and cl osed manual ly o r by powe r (el ec tric , pneumatic or hydraulic ). Items are pl aced on a s helf in the c hamber, and the door c losed and secured. A i r mus t b e dis placed f ro m the chamber. Thi s is ca lled the cond itioning or hea t-up phase (F igu re 34 .4). Its length v aries , depending on the load. In the grav i tydisplac ement type of s teri lizer the inc oming s team dis places the ai r th rough a port or d rain in or near the bottom of the c hambe r. The s te rili ze r chamber drain remai ns open until the temperature i n the d rai n is the s ame as the temperature of the s team enterin g the c hamber, i ndicating tha t the a ir h as bee n remov ed. The p re-v acuum s teril i zer depends on one or more pressu re and v acuum ex cursi ons to remov e a ir. The s team-f lush pressu re-pulse s teril i zer us es a repeated seq uenc e of a s team f lus h and a pressu re pulse . No v acuum is re qui re d. A pre -v acuu m or s tea m-f lush press ure -pu ls e s te ri lizer res ul ts in s horte r cyc les because ai r is remov ed mo re rapidl y. In the grav i ty-dis plac emen t ty pe of s teril izer, th e inc oming s team d is places the ai r through a port or drain in or n ear the bottom of the c hamber. The s terili zer P .964 chamber d rain remains open unti l th e tempera ture in the dra in is the s ame as the temperature of the s tea m en terin g the c hamber, indicating tha t the air h as bee n remov ed . The pre-v acuum s te ri li ze r depends on one o r more pres sure a nd v ac uum ex cursi ons to remov e a ir. The s team-flus h pre ssure-pulse s terilizer us es a repeated sequence of a s team flus h and a p res sure pulse (F ig. 34.4). No v acuum is requi red . A prev ac uum or s team-fl ush pres sure-pulse s teri l izer res ul ts in shorter c ycles becaus e the ai r is remov ed more rapidly.

View Figure

Figure 34.4 Typical steam sterilization cycle. Conditioning phase (A); sterilization phase (B); exhaust phase (C); dry phase (D). (Redrawn from a figure in Young JH. Steam sterilization: scientific principles. In: Reichert M, Young JH, eds. Sterilization Technology for the Health Care Facility. 2nd ed. Gaithersburg, MD: Aspen Publishers, Inc., 1997:124133 .)

As s team enters the c hamber, i t enters the load to be s te ri li zed and giv es up i ts l ate nt he at. Once the intend ed te mperatu re i s reac hed, the s teri li zation time is se t. This is c al led the ex posu re or s teri li zati on phas e. B y conv en tion, s te rili za tion c ycles in heal th c are s ettings hav e be en s tanda rdi zed a t a few temperature-time rela tions hips (29 ). The lowes t temperature for a s teril i zer is 121C (250 F). Cyc les may also be programmed at 132C (270F), 134C (275F), or 1 45C (285F), dependi ng on the s terilizer. In general, wrap ped items should be s teri l ized for 30 minutes and un wrapped i tems for 20 mi nutes at 121C (32). Af ter the s teril i zation phas e, i tems mus t be dried b efo re being remov ed from the s teril i zer. This is c all ed the pos tex pos ure (exha us t, dry ) phase and co nsis ts of ex haus ting the chamber to atmosphere fol lowed by c i rc ul ating f iltered air throug h the chamber or by d rawi ng a deep v acuum (27). S ome tabletop autocl av es require that the doo r be c racked, bu t newer mo dels may allow c los ed-door d ry ing (33,34). Fl ash s teril ization allows i tems to be s team s teri l ized fo r immed iate use (35,36). The i te ms to be processed are usuall y unwrapped. T he time and temperatu re wi ll depend on the s teril izer and the c onfiguratio n of the loa d. The processe d i tems are transfe rred immedia tel y f rom the autoc lav e to the po int of us e, us ually the s teri le f ield in an ongoing s u rgica l proced ure .

Problems with Steam Sterilization Problems with the Steam

S team qual i ty or s atura tion refers to the percen tage of liqu id in s te am. Curre nt s tandards call fo r a s team qual ity greater than 97% (l es s than 3 % l iq uid wa ter). Vari ations in s team pressu re may affec t the ti me needed to attain the proper temperature and tempe rature uniformi ty wi th in the chamb er. Clogged f il te rs , poorly engineered piping, or excessiv e dema nds on the s team supp ly may ca use press ure v a ri ations . S team is s atu rated when i t has the prope r bal anc e of press ure and temperature . If the press ure is too h ig h, th e s te am wi l l change to l iqui d, c aus ing packs to become wet; i f the pressure is too l ow, the s team wil l be superheated. Superheated s team is l ess ab le to transfer its h eat e nergy to the cooler i tems being s teril i zed than saturated s team and wil l i nterf ere with achiev ing a un iform temperature in the c hamber.

Air in the Autoclave Chamber

The pres ence of air in the chamber wi ll i mpa ir s terili zati on. A i r c onduc ts heat poo rl y and retards s team p enetra tion. The autocl av e ev ac uates much of the ai r at the beginning of the cyc le (F ig . 34.4). All of the air does no t hav e to be remov ed, but al l su rf aces requ irin g s te ri liza ti on mus t be expos ed to adequate mois ture (27). Improper s teril izer load ing and incorrec tl y prepared indiv idual pack ages c an affec t the abi li ty of th e s te ri lize r to remov e ai r f rom the load (37). Many autocl av es hav e a bui lt-in v acuum leak tes t (37). S uch s teril izers are c apab le of runn ing a spec ial c yc le that pauses when the max imum v ac uum is achiev ed. For others , the efficac y of the ai r remov al p roc ess can be tes ted b y a Bo wie -Dick tes t. This is run wi th a s ingl e tes t pack in the cha mber. This shou ld be run eac h d ay before the firs t s te ri li za tion c yc le (20,38). Ai r detec tion dev ices ma y be added to the s teri l ize r pl umbing and c ontrol s ys tem.

Equipment Malfunction
Exa mples of equip ment malfunc tion inclu de out-o f-cal ib rati on temp era tu re or press ure gauges and controllers , inco rrec t s team s uppl y pressu re, fau lty or mal adjus ted c ontrol v alv es , leaks , clogged v ent l ines or drain sc reens , faul ty v acuum pumps , defec tiv e s team traps , and malf unc tioning c yc le se quenc e control le rs .

Personnel Errors
Person nel e rrors i ncl ude ina dequate c lea ning, i nco rrec t pack preparation o r packaging methods , and poor load ing tec hni ques (39). Items in the s teril i zer mus t be pos itioned s o that air c annot be trapped. Items should no t be c rowded o r s tuffed

i nto the autoc lav e. Crowdi ng may inte rfere wi th b oth ai r el imin ati on and d ryi ng . If the shap e of an i tem woul d allo w wa ter to col lec t in any pa rt, th at i tem s hould be positioned on i ts s id e o r ups ide do wn so that th e wate r can run out. If wate r can pool, the n a ir c ould be trapped agai ns t the s urface .

Steam Sterilization Monitoring

S teril ization v alidati on is achiev ed b y us ing a c ombinati on of mec hanic al , c hemical , and b iolog ic al indicators (19,40 ). Us ing thes e in concert wi ll g iv e the greates t possible c onfidenc e that items are s teri le .

Mechanical Indicators
Mechanical moni tors indicate time, temperature , and press ure (37). Mos t autoc lav es prov ide a permanen t record o f th ese pa rameters . The tempe rature in a f loor-lo ading s teril izer is typic all y meas ured in the chamber drain p iping . In s ma ll tabl etop s te ri li ze rs whe re the s team is genera ted wi thin the cha mber, th e temperature is us uall y meas ured in the c hambe r. So me tabl etop s teril i zers do not hav e a rec order. W i th P .965 these , it is i mportan t to mon itor ph ys ical c onditions duri ng the c yc le (39 ).

Figure 34.5 Autoclave tape is an example of an external process indicator. The exposed tape is at top.

View Figure

Chemical Indicators
Che mica l indicators a re div ided i nto f iv e c lass es (41 ,42 ,43,44). The higher the c las s , the more sens i tiv e the indicator.

Cl ass 1 i ndicators a re i nternal and ex te rnal proces s ind ic ato rs . Thes e inform the us er th at the item has be en exposed to the s teril i zation p roc ess . The mos t c ommon ex ample o f an ex ternal p roc ess i ndica tor is autoc lav e tape (Fig. 34 .5). Mos t ta pes do no t res pond to al l the paramete rs of s te ri li za tion but do offer v isual proof tha t the pack h as been through the proces s . Inte rna l process indic ators us ual l y exhibi t a co lor chan ge from white to blac k . Like au toc lav e ta pe, they hav e limi ted sens i tiv i ty to the pa rameters of s teril ization b ut do i ndicate exposure to s team. Cl ass 2 i ndicators relate to the B owi e-Dick tes t for v acuum s team s terili zers . They do no t determine i f the s te ri li za tion parameters hav e been met but onl y ass ess v acuum pump efficiency and de tec t the p res enc e of ai r leaks an d/o r gases in the s team. The in dic ator is p lac ed in a pack of towel s (handmade or purchased ) on th e f ron t bottom shelf ov er the drain and a 3.5- to 4 -mi nute c yc le is run. Many new s teril i zers a re equip ped wi th l eak tes t c yc les , so these indicators d o not need to be us ed. Cl ass 3 i ndicators a re si ngle parameter. A n exa mp le is the tempe rature tube that contains a c hemical that me lts and someti mes ch anges c olor whe n the appropri ate temperature is attained . Thes e ind ic ato rs are helpful in determining if the appropriate temperature was ac hiev ed in the c ente r of large pack s . Fals e -posi tiv e resul ts hav e been reported (43). Cl ass 4 i ndicators res pond to o ne or more steri l iza tion parameters . They con tai n an i nk th at changes c olor when expos ed to the correc t c omb in ati on of s te ri li za ti on parameters . Cl ass 5 i ndicators a re also known as integra ting indicators o r in teg rators . They respond to al l pa rame ters of s terili zation over a sp ecified range of tempera tures . False -posi tiv e and f als e-negativ e resul ts hav e been reported (41). Che mica l indicators c an detec t fail ures o r errors in packa ging, pack dens ity, l oading, insuffici ent humidif ication, inadequate expos ure ti me at the s elec ted temperature , or s terili zer mal func tion. An important adv antage is tha t th ey c an be read as soon as the packs hav e bee n opened. Ano ther adv antage is tha t th ey are so inex pens iv e that one can be used i n ev ery pack . The CDC and a ll major U.S . o rga ni zations tha t issue s teril ization-related s tanda rds or guid el ines adv ocate tha t a chemical indicator be attached to ev ery pac kage that goes through a s terili zation cyc le and wi thi n e ach pac kage to be s teril ized in wha t i s expec ted to be the mos t diffic ul t-to-s te ri lize loca tion. The re are both U.S . (45,46,47) and inte rna tional (48 ,49,50,5 1,52,53) s tandards for chemic al indicators .

Biological Indicators
B iological ind ic ato rs are s tandardized preparati ons of s pores (typica lly s tri ps or ampo ules ) that a re place d in th e mos t dif ficul t-to-s te ri li ze loc a ti on(s ) i n the l oad (37,43). Alternativ el y, a biological ind ic ato r th at is enc los ed in a commerc ial tes t pack can be us ed. The ind ic ato rs are exposed to the s teril i zation c yc le, retriev ed, i ncub ated, and examined for mic robial growth. A pos i tiv e b io log ic al indicator i s i ndicativ e of a pos sible s teri li zation proces s f ai lure . Commerc ial mail-i n b iolog ic al moni tori ng se rv ices eliminate the ne ed for on-si te i ncubati on . One type of b io log ic al indicator c ontai ns a rapi d detec ti on s ys tem that is bas ed on the in terac tion of an en zyme in the bac te ri al s pore wi th a s ubs tra te in the growth medium. F luo res cence occ urs whe n the v iab le bi ol ogical in dic ator is ex pos ed to ul trav iol et light. This type of i ndicator c an be read in 3 hou rs wi th a wrapped i te m or i n 1 hour with an unwrapped i tem. It may be parti cularl y usef ul in the operating or a mbulato ry se ttin g where p roduc ts are often s te ri lized unwrapped in a grav ity displac ement s te rili ze r (43 ,54 ). The main problem with bio logic al i ndica tors is the ti me needed fo r incuba ti on. B iological moni tors s hould b e used at leas t onc e a we ek but p ref erabl y dai l y a nd af te r major re pai rs to the s terili zer (37,43). The re are both U.S . (55,56,57,58,59 ) and inte rna ti ona l (60,6 1,62,63) s tand ards for biological indic ators .

Advantages and Disadvantages of Autoclaving

S team autoc lav ing c an ki ll a ll bac teria, v i rus es , a nd spores . Adv antages inc lude speed, g ood penetrati on, ec onomy , eas e of use , abs ence of tox ic produc ts o r resi dues , and reliab il i ty. The material c an be prepac kaged and kep t s teri le until us ed. It pos es no harm to P .966 the env i ronment. A major adv antage is that at leas t one au toclav e is av ai la bl e i n ev ery modern opera ti ng theater. The princ ipal dis adv antage of autoc lav ing is that many pieces of equipme nt are dama ged if subjec ted to s team. Au toc lav ing can cause blunted c utting edges , metal su rface co rrosion, a nd sho rtened l ife of elec tronic components . F ib er-optic l ary ngos cop e b lades sho w a dec re ase i n light transmission wi th repeate d autoc lav ing (64 ).

Dry Heat Sterilization

Dry h eat is used for i tems tha t might be damaged by mois t heat (65,66,67). W hile s low, this technique p enetra tes we ll and does not co rrode metal and s harp i ns trume nts (68). It is useful for nonaqueous liquids or semiso li ds such as talc , gl yc erin, o ils , petrol eum jell y, wa xes , and powd ers . Ti mes and temperatures frequentl y us ed for dry he at s teril i zation a re 170 C fo r 60 minutes , 1 60C for 120 minutes , and 150 C fo r 150 minutes (32 ,6 8). S ome of the newer dry heat s teri lizers can attain tempe ratures up to 210C (65). Conv ec tion h ot ai r s terili zers improv e heat transfe r by us ing forced ai r. These units hav e co mpara tiv ely fas t c ycle ti mes . The re are both U.S . and in ternational s tandards for biological ind ic ato rs for dry heat s teril ization proc esses (69 ).

Chemical Disinfection and Sterilization

Che mica l (c ol d) dis infec tio n/s teri lizati on involv es immers ing an item i n a solutio n that c ontains a d is infec tan t (3 ). Th is method is esp ecial ly us eful f or hea t-sens itiv e equipment. It c an be acc ompl is hed by au toma ted equipment, whi ch typical l y prov ides a c yc le of c lean ing , ri ns ing , dis infec tion, ri ns ing , and so metimes drying.

Regulation and Labeling

The E PA regulates formulations and labe li ng of c hemical germic ides (70). The l abel ing mus t p rov ide c ertai n information , inc luding precau tiona ry s tatements , di rec tions for use, the requi red c ontac t ti me, recommended us e tempe rature, us e pattern , us e l ife, and s he lf life. The EP A also req ui res that the label show the abil ity of the che mic al agent to des troy c ertain organisms such as M. tuberc ul os is . It is imperativ e that the us er s tric tl y fol lows th e d irec tions prov ided by the manufac tu rer. The FDA cl ea rs l iquid c hemical s teri lants . The cu rrent l is ting of c leared li quid chemic al s teril an ts and the time-te mperatu re c laims for s te ri li za tion and high-l ev el disi nfec tion c an be acc ess ed at http ://www.f da.gov /cd rh/ode/g erml ab.html.

Factors Influencing Chemical Disinfection Concentration of the Chemical

In general , hi ghe r conc entra ti ons of the ac tiv e ingredi ents inc re ase the disi nfec tant's b ac teric ida l abi lity. An ex ception is the alcoh ols . Howev er, ex tremely high concen trations i nc rease the potential for damage bo th to inanima te ob jec ts and to the s k in a nd mucous membranes of p ers onne l. For bes t resul ts , produc ts shoul d be used ac cording to the manuf ac turer's recommendations .

W ater l eft on equipmen t wil l d ilute the c hemic al and render i t less effec tiv e. Dilution can become s ign if ic ant with frequent reuse and c an re duce the concentra ti on to a l ev el tha t is too low to be effec tiv e . For this reason, equi pmen t sho uld be d ried before unde rgo ing c hemical d is infec tion or s teri li zation. In some cas es , the tec hnique (manual or automatic ) ma y determine ho w f as t the co ncen tration fal ls (71).

Temper ature
Hi gher temperatures us ual ly inc reas e the effec tiv enes s of che mic al agents . Spec ial dev ic es are av ai labl e for heating s ome chemica l solutions . Too high a tempe rature may cause the ac tiv e ing redie nts to ev apora te or degrade. The la bel s hould te ll whi c h temperature s hould be used.

Evaporation and Light Deactivation

If the s olution is in an uncov ered c ontainer, ev apora tion ca n occur. Us ual ly , ev aporation is not as serio us as di lu tion. Ho wev e r, i f the chemica l agen t is mo re v olati le than the diluent, loss by ev aporation c an be v ery impo rtant. Chlorine produc ts are espec ial ly s usceptible to ev aporation and deac tiv ation from exp osure to l ight.

Bioburden
In general , the hig her the lev el of mic ro bial con tamina ti on, the l onge r the expos ure to the ch emic al ge rmici de nec essa ry before the enti re mic robial population is k illed . Thus , i te ms s hould be sc rupulous l y cl eaned. Liqui d agents v ary wi del y in their ef fec tiv enes s agai ns t v arious types of mic roorganis ms . Table 34.1 shows the capabil ities of s ome c ommonly used agents.

pH
The relativ e ac id ity or alkali ni ty of dis infec ta nts c an inf luenc e the bioc ida l ac tiv ity . An inc reas e i n pH ten ds to dec re ase the efficac y of phe nols , i odi ne, and hypochlori tes . In c ontras t, i t wi l l imp rov e the an timic robial ac tiv ity of glutaraldehy de and q uaternary ammonium c ompounds . S olu bl e c alc iu m or ma gnes ium in the wa ter suppl y can reac t wi th deterg ents to fo rm insoluble precipi tates , whic h ten d to neutral ize s ome dis in-fec tan ts (4).

Characteristics of the Item to Be Disinfected

A dis infec tant so lu tion wi ll be effec tiv e onl y if i t c an c ontac t al l surfaces (inner an d outer) of the i tem to be d is infec ted (72). Unev en or po rous s urfac es res is t che mic al disi nfec tion. Ai r

P .967 entrapment can prev ent con tac t between the l iquid and parts of the dev ic e.

TABLE 34.1 Capabilities of Disinfecting Agentsa,b Disinfectant GramPositive Bacteria + GramNegative Bacteria Tubercle Soores Virusus Fungi Bacillus

Quaternary ammonium compounds Alcohols Glutaraldehydes

+ +

+ +

+ +

Hydrogen peroxidebased compounds

Formaldehyde and other agents

Phenolic compounds Chlorine

a

+ +

+ +

0 -

From Chatbum RL. Decontamination of respiratory care equipment what can be done, what should be done. Respir Care 1989:34:98; and Berry AJ. Infection control in anesthesia. Anesth Clin North AM 1989;7:967981.
b

+, good; , fair, 0, little or none.

Use Pattern, Use Life, and Storage Life

The produc t label s hould b e exami ned f or info rmation on the us e pattern, us e life, and s torage l ife. Use patte rn refers to ho w man y times the solution c an be used . Us e l if e commonly appl ies b ut is not l imi ted to disinf ec tant p roduc ts th at applies , but is no t limi ted to, requi re mix ing of two in gre di ents for ac tiv ation. Once a disi nfec tant s olution is mix ed, there wil l be a l imi te d peri od of ti me d uring whi ch the ac tiv ated so lution may be used. The c ontain er sh ould be mark ed with th e date the so lution was prepared and the date it expi res . The s to rage li fe is the time pe riod af te r whi ch the u nused and/or unac tiv ated pro duc t is no l onge r deemed effec tiv e.

Time
The time requi red for diff erent chemic al agents to function eff ec tiv el y v aries from seconds to hou rs and wi l l depend on the fac to rs j us t men ti one d. Some mic roorganisms are k ill ed fas te r than others . Contac t time may make the difference between s te ri li za tion and hi gh-l ev el dis infecti on . For high -lev el dis infec tion , a minimum co ntac t time of 20 to 30 minutes is recommended (3). A lowe r lev el of disi nfec tion c an be ach iev ed in l es s time. Le av ing dev ic es in the disi nfec tant too l ong can make it h ard er to rinse off th e c hemical (22 ).

Safe Practices
Des ignated areas fo r chemica l disinfec tion s houl d be s tron gl y encouraged (2,5 ,73 ,74 ,75,76,7 7,78,79,80,81). Id eally , th e a rea us ed fo r c leaning should be separate f rom the spac e where the chemic al is used. B oth of thes e s paces s hould be separate f rom pa ti ent p roc edure and pe rsonnel supp ort areas . Traffic should b e l imi ted to trai ned pe rso nnel . Che mica l dis infec tants shou ld be us ed in an a rea that is la rge enough to ens ure adequate v apor diluti on wi th an ai r ex change ra te not les s than 10/hour. The f resh ai r i nle t should be p lac ed ac ros s the room from the local exhaus t v entilation. Local exhaus t v entil ati on (ei the r a duc tl ess s ys tem or a duc ted fu me h ood) s houl d be i ns talled to c ap ture chemical v apors . A duc ted fume hood sh ould be conn ec ted to a no n-rec irculatin g exhaus t sys tem that goes to the ou ts ide a tmos phere at a l ocation away f rom people and ai r in tak e duc ts . Se lf -c ontained (duc tless ) fume hoods (F ig. 34.6) enc aps ula te the s oaking container and hav e a blowe r tha t draws fumes away f rom the operator and d el iv e rs them to a s ys tem that c hemicall y i nac tiv ates the germic ide and returns c lean fil te red ai r to the room. This el imina tes the need to ins tall a duc t. The emp lo yer s houl d prov ide training to eac h employee wh o h andles ge rmic ides and v erif y tha t each e mp lo yee has rece iv ed and unders tood the required trai ni ng.

Automated process ing equ ip ment c an reduce exposure to ge rmici des . Hoods desig ned f or automatic was hi ng mach ines are av ai lable. Person nel s hould wear appropria te protec tiv e equipment desi gned to protect the sk in, eyes (goggles or fu ll fac e shields ), and c lothi ng from splas hes when us in g chemic al ge rmicide solutions . Imperv i ous glov es and gowns shou ld be wo rn. T he us er sho ul d double glov e and/o r change si ngle gl ov es f requen tly. P rotec tiv e c lothing s hould be remov ed quick ly if it becomes s atura ted and should be l aundered before reuse . There should be ready access to means to decontaminate the eyes a nd ski n in the ev ent of c ontac t with the so lu tion. Durin g preparation an d ac tiv a ti on of germicide sol utions , ev ery effort s hould be made to minimi ze splas hin g, sp il ling , and pe rsonnel exposure. The c hemical s houl d be kept in a c los ed con taine r with a ti ght-f i tting l id. A gi tation and s plashing should be av oided when the solution is poured. S afety nozzles c an be used to P .968 reduc e the ex posu re to v apors c reated when pouri ng so lutions .

Figure 34.6 Glutaraldehyde user station. Fumes are drawn away from the operator and into a filter, where they are neutralized.

View Figure

If it is nec ess ary to trans port an ac tiv ated solutio n, a method of tra nspo rtation that wi ll mi nimi ze the potential for s pills and the poss ib ili ty of pers onne l expos ure to the so lution or v apor should be selec ted . Transpo rting s ol uti ons in con taine rs s uch as tray s or buc kets shou ld be av oided. The dis inf ectan t solutio n s hould be s tored in a tigh tl y cl osed c ontainer i n a we ll v enti lated area. Containers that minimi ze the s urfac e area shou ld be us ed. The lid

shoul d be k ept on the c ontain er at a ll ti mes exc ept wh en items are p laced i nto or remov ed f rom the solutio n. Items s hould be immers ed in the c hemic al solution gently , taking care to dis turb and a gitate the s urface as l i ttle as poss ible. W hen the so lu tion mus t be manual l y i rrig ate d o r fl us hed th rough in ternal channels or l umens , care should be taken to av oid s plashi ng. The s yri nge should b e c arefull y fil led wi th the solution and securely a ttac hed to the c han nel openi ng or a ll -c hannel i rrigator and the solutio n pushed s lowl y. Items s hould be gentl y remov ed from the s ol ution and rinsed thoroughly in c lean or s terile water. Rins e wate r sho uld be dis carded promptly , not reus ed. Se mic ri tical i tems s hould be rins ed with s teri le wa ter to prev ent organisms that ma y be in tap water f ro m co ntamina ting them. Al te rna tel y, the i tems ma y b e rinsed fi rs t with tap water an d then wi th a lc ohol . Disca rding a che mic al so lution inv olv es hi gh ris k of employee exposure. The so lution s hould be d isc arded, along with copious amounts of c old wa ter i nto a drain connec ted to a s ani ta ry s e wer. Chemical germic ide so lutions sh ould not be disc arded into sep tic s ys tems . A spi ll c on tainmen t response team s hould be c reated and be respons ible for dev el oping and ex ecu ting procedures for c hemical spi lls . If there is a c hemic al that can be us ed to neutra lize th e germici de and reduc e ambi ent v apor lev els in sp ill s i tuations, i t s hould be readily av ail able. S mal l sp ills and dropl ets c an be abs orb ed and neu tral ized by usi ng spec ial mats that are highl y abso rbent and treated with th e neutral i zi ng chemic al. Al tern ately , they can b e wi ped u p quickl y with a sponge, towel , or mop tha t has be en neutral ized with an app rop riate c hemic al agent and then wip ed up. T he sponge, towel , or mop s houl d be thoroughly ri ns ed with la rge amounts of water an d the water di sc arded th rough the drain. Larger spi lls are bes t treated by usi ng chemic al s pil l ki ts tha t inc lude an app rov ed deac tiv ato r/neutrali ze r to pour ov er the s pi ll. P ersonnel s houl d wear s ui table protec tiv e a ttire. T he spill shou ld be c ontained and ne utral ized or co ntained and co ll ec ted f or disposal . Af ter the so lu tion is remov ed, the area where the solu tion was c oll ec ted s hould be thoroughly ri ns ed. The c leanup tools should be rinsed wi th a la rge amount of water and the water disc ard ed down the dra in. To ensure a s afe work env ironmen t and es tablish co mpli ance with rec ommend ed l imi ts and guidel ines on occ upa ti onal exposure to germicides , s ev e ral air s ampl ing and mon itorin g tec hni ques c an be used. S ampl ing should be c onduc te d in all areas

whe re work ers migh t be exposed to v apo r. Mo nitoring s hould be co nduc ted du ring normal use and whenev er there is a major change in protoco l, wo rk place v enti lation , cas e loa d, or major repa ir to washers or oth er automated eq uipment. Special attention should be giv en to periods o f ti me when ai rb orne conc entrati ons of v apor migh t be particu larl y high (e.g., when the work er is pouring the s pent so lution down the dra in or p ourin g f resh solution into a container). Mo ni toring shoul d be docu mented and records maintain ed. Exp osure c an be dete rmi ned by us ing a sampling pu mp to pul l a known quan ti ty of ai r through a tube containing an abs orbent med ium. This is an aly zed l ater by P .969 an i ndus trial laboratory . A pass iv e monitorin g badge c an be worn b y pers onnel. The germic ide v apo r is c onv erted in to a s table deriv ativ e and anal yzed.

Monitoring Chemical Disinfection

S tanda rd bi ol ogic al pre parations a re av ailab le on ly for s terili zation p roc ess es and cannot b e appl ied to dis infec tio n. The only wa y to ass ess the le thali ty o f disi nfec tion is to use th e d irec t-assay s te ri lity tes t of the finished p roduc t (4). This tes t is diff ic ul t and time c onsuming, renders the tes ted objec t unus abl e until it is subs equentl y rec lea ned and decon taminated, and is relativ ely ins ensi tiv e in its abil ity to de tec t low-l ev el contamina ti on. Bec ause d is infec tion procedures c annot be ef fec tiv ely mon itored biologic al ly , th ey mus t be moni to red ph ys ical l y. Rec ords indic ating ex pos ure time , tempera ture, and press ure (if appl ic able) s hould be mai nta ined.

Agents
No che mic al germic ide is su itabl e fo r all purpos es . A numb er of fac tors shou ld be cons idered in s elec ting o ne, inc luding the deg ree of mic robial d eath needed; the nature and composi ti on of the i te m be ing tre ated; whe the r th e i tem is c ritical , se mic ri tical , or n onc ri tical ; and the cos t, s afety, and ease of use. A n tisep tics are not appropriate for disi nfec ting ina ni ma te su rfaces o r obj ec ts .

Glutaraldehyde
Gl uta ralde hyde -based solutions hav e been wi del y used because of thei r ex cellent germic idal prope rties , ac tiv i ty i n th e p res ence of organic matter, noncorros iv enes s wi th mos t equipment, and lack of c oagulation with pro teinaceous mate rial (3,5 ,8,68,70 ,82 ,83 ,84 ). Gl utaraldehyde has an ex tens iv e shelf l ife. It may be us ed

as long as 30 days af te r ac tiv ation , prov ided in-use di lu tion and organ ic s tress are properl y contro ll ed. Gl uta ralde hyde is effec tiv e aga ins t bac te ri a, f ungi , a nd v i rus es at room temperature . High-l ev el disi nfec tion requires 20 to 3 0 minu tes (85,86,87,88). It is also sp orici dal , prov ided adequate time is al lotted. Th ree to 10 hours are requ ired for s teril ization . El ev ati ng the tempe rature c an sho rten these times (89). The manufac tu rer's ins truc tions should a lwa ys be c onsul ted. Di lu tion of ten occurs during use, and it is importan t to ens ure tha t equipment is disi nfec ted wi th an ac ceptable c oncentration of agent. Glutaraldehyde conc en tration tes t s trips tha t are d ip ped in to the solutio n to determine the ac tiv e conc en tration are av ailabl e. P roblems wi th thes e s trips hav e been reported (90). It i s general l y recommended that 1% to 1.5 % glutarald ehyde be the minimum conc en tration f or high-lev el dis infec tion (88). S olution c oncentratio n s hould be moni tored a t leas t o nce ev ery da y and a log k ept of eac h tes t (81 ). A wid e v ariety of brand -name p rod ucts is av ai lable . They d iffe r pri maril y i n the conc en tration of glu ta raldeh yde and a ddi tives . Mos t aqueous solutions are acidic and mus t be ac tiv ated (ma de alkal ine) to become sporic idal (Fi g. 34.7 ). A cid glutara ld ehydes are av ailable and do not require ac tiv ation , but s ome s tudies hav e shown th em to hav e less mic robi ocidal ac tivity than alkaline preparations (88). The pH needs to be be twe en 7.5 and 8.5 to be sporici dal (5).

Figure 34.7 Glutaraldehyde. The small container contains the activator, which must be added to the contents of the large container.

View Figure

Gl uta ralde hyde s olu tions ev aporate at room temperature. Ex posu re to glutara ld ehyde c an resul t in a v a riety of re ac tions in h eal th ca re work ers , inc lud ing headac hes ; skin, eye, and mucous memb ran e i rri ta ti on; a nd as thmal ik e symptoms (91,92,93,94). Sal iv ary gla nd enl argement attri bu ted to oro pharyngeal air ways i nadequatel y rinse d after ex pos ure to glu taraldeh yde has been reported (95). These s ymptoms a re us ually temporary and subs ide when the indiv id ual l eav es th e area of ex posu re but may be exacerbated with re peated con tac t. If i t co ntac ts the eyes , there ma y be corneal injury. Unfortunatel y, so me ins ti tu tions hav e use d glutara ld ehyde inappropriatel y to dis inf ect floors , wal ls , and linen (96). Duc tl ess fume hoods are av ai lable f or gl utaraldehyde (Fig. 34.6 ). A neu tralizer shoul d be added to the s olution when i t is time fo r dis pos al. This wil l el imina te P .970 the v apo rs that a re c reated when disp osing of the solution. In s ome local i ties , i t is i llega l to pu t un-neu tralized glu ta raldeh yde i nto the sewage s ys tem. Gl uta ralde hyde -neutral izing abs o rbent mats can be pl aced u nder and around ba ths and wa shers to absorb and neu tral ize s pi lls.

Orthophthalaldehyde
Orthophthalaldehyde (OPA or Ci dex OP A ) can ac hiev e hi gh-lev el d is infec tion at room tempe rature after a 12 -minute ex posure and af ter a s horter ti me a t an elev ated tempe rature (30,97 ,98 ,99 ). It is s poric id al wi th prolonged exposure (100). It is often us ed in an automatic e ndos cope p roc ess ing s ys tem, which reduc es th e process ing time to 5 minutes (3 0). It is nonc orros iv e. Tes t s tri ps to measure the minimum effec tiv e c onc entrati on are av ai lab le and shou ld be empl oyed pri or to each use. Some local ities requi re that OPA be neu tral ized before d is posal. Neu tralize rs that c hange c olor wi th deactiv ati on are av ail able. OPA has a number of a dv an tages compared wi th g lu taraldeh yde. These incl ude fas ter dis infec tio n, minimal odo r, no need fo r ac tiv ation o r mix ing , and no OS HA v apor l imi t. It c an be disca rded through the drain. It is effec tiv e in th e presenc e of organic so il . W hi le s ign if ic antly more expens iv e pe r gal lon tha n g lu taraldehyde, i t may be more economic al at high-v olume centers (10 1). W hi le s ide effec ts and hazards are l ess wi th OPA than wi th glutara ldehyde, ey e contac t may c ause s tinging, exces s tea ri ng, and rednes s . It s tains pro tei ns (inc lu ding unprotec ted sk in), and repe ated c ontac t may c aus e d erma ti tis . Les ions of the skin, l ips , mou th, and es ophag us hav e b een reported fol lowin g prolon ged us e of

a trans esophageal ec hoc ard iog rap h p robe tha t may hav e b een i mproperly processed wi th this agen t (1 02).

Quaternary Ammonium Compounds

Quaternary ammonium compounds (quats ) a re low-lev el dis infec tants (5 ). Th ey are bac te ric idal , fungicidal , and v iruci da l at room tempera ture wi thi n 10 minutes but hav e not demons trate d s poric idal effec ts . If a s pore is c oated with a quaternary ammonium co mpound , it wil l no t dev elo p into a v ege tativ e cell as l ong as the germic ide remains , but if the coa ting is remov ed, the spore can germinate. These co mpounds are more effec tiv e aga ins t gram-p os i tiv e than gram-negativ e bac teria. Quats i nac tiv ate the hu man immunodefic ienc y v i rus (HIV ) bu t some do no t i nac tiv ate the hepatitis v irus . They are ineffec tiv e aga ins t M. tuberculos is or hydrophi lic v i ruses (2 ,8 7). Earl y generation q uats were affec ted by factors s uch as ha rd water, soap , anionic resi dues , and protei naceous soils . They were inac tiv ate d b y organic ma teri als (e.g., co rk , cotton , and ga uze pa ds ). S ome, e ither us ed in ins uffici ent c oncentrations or i n s olutions deteri orated by age or deac tiv ated by the presenc e of organic soi l , not only f ailed to k ill s ome mic robes but ac tual ly supported the ir growth (8). Newe r ones are mixed wi th v ari ous s ubstanc es to p rod uce s ynergis tic antimic robial and detergen t ac tiv ities whi le maintai ni ng the ha rd water, protein, and anionic tol era nce necess ary in env ironmen tal dis infec tants . They a re qu ick ac ting , re lativ el y nontox ic , and n oncaus tic and do not produce nox io us fumes . They are us eful f or c leaning as wel l as dis inf ec ti on.

Phenolic Compounds
Phenol ic c ompoun ds (p heno lics , phenols ) are deriv ed f rom c arbolic ac id (pheno l), one of the oldes t ge rmic ides (2,5 ,8,87). They are s ometimes c ombined wi th detergen ts to form de te rge nt germic ides . They are good bac te ri cides an d a re ac tiv e agains t fungi . They are ac tiv e in the p res ence of organic ma tter an d soap . Phenols are v ery s table and rema in ac tiv e af te r mild heating and prolonge d d rying . W hen mois ture is app li ed to a su rface that h as been prev iousl y treated with a phenolic co mpound , it can redisso lv e the che mic al so that i t again b ecomes bac teric idal. Phenol ic s remain ac tiv e in c ontac t wi th o rga nic s oi l and for this reas on are often the disinfec tants of cho ic e wh en deal ing with gross organic conta mina tion in general housek eeping. Mos t phenolics hav e a bad odor and are irri tating to sk in. They are absorbed by rubber and may damage the s kin o r mucous membra nes that they co ntac t. They a re

diff icul t to ri nse from mos t materials , and res idua l dis infec tant may c ause tis sue i rritation o r hyperbil irubi nemia in neona tes . Phenols are c ons idered i nte rmediate- to low-l ev e l disi nfec tants . Mos t phe nolic detergen ts are tub erc uloc idal , f ungici dal , an d bac teric idal when used as di rec ted. Certain v i ruses , inc luding those as soci ated wi th wi des pre ad common respi rato ry i llnes ses , are resis tant to these co mpounds. The pheno lics are not s poric idal ex cept at or abov e 100C. They are used mainl y on env ironmen tal surfaces and for nonc ritic al dev ices .

Alcohols
W ithin heal th c are faci l ities , a lc ohol usuall y refers to ei ther ethyl or is opropyl alcoh ol , both of whic h are wate r-solubl e compounds tha t are interme di ate - or l owl ev el disinfec ta nts (3). The alc ohols a re best us ed at c oncen trations of 70% to 90 % by v olu me. B oth are effec tiv e a gains t most v i ruses , inc luding th ose for hepatitis B (HBV ) and A IDS (or HIV ). The CDC recommends expos ure to 70% ethano l fo r 15 minutes to inac tiv ate HBV , bu t 1 minu te sh ould be adequate f or HIV . A lco hols display high ac tiv i ty a gains t g ram-negativ e bac teria, fung i, and M. tu berc ul osis but cannot inac tiv ate bac te ri al s pores . Isop ropyl alcohol c anno t k i ll certain hyd rophilic v i ruses . A lcohols h av e a c leans in g ac tion , but wipi ng a surface wi th an alc ohol s olu tion may not main tain a 1-minu te co ntac t time betwee n the s u rf ace to be dis infec te d and the so lution (11 ). They are inac tiv a ted b y p rotein but n ot by so ap. It is not nec es sary to rins e items soaked in a lc ohol , becaus e it evapo rates rapidl y. For this reas on , an alcoh ol flush cyc le is used i n some automati c process in g P .971 machines . The fl ush cyc le ma y be useful to disi nfec t the cha nnels of f lex ible f iberoptic endoscopes . A fter hi gh-lev el dis infec tion wi th a che mic al germic ide and a tap water rin se, a lcohol c an re mov e minor water c ontaminants . Its speed of ev apo ration promotes rapid d rying in the ch anne ls . A lcohols are often us ed to cl ean the ex ternal su rfaces of fi beroptic cables and s copes. An i mportan t use of a lc ohol is i n hand rubs (103). These reduce the bac teria c ount on ha nds more rapidl y th an antimic robial s oaps o r detergents . The A ssoc ia tion fo r P rofess ionals in Infec tion Control and E pidemio logy (AP IC) guide lines urge us e of an alcohol -based rub bef ore an d after pa ti ent c ontac t and af te r any possible

contac t wi th body fluids and s ubs tanc es , mucous memb ranes , b rok en ski n, o r contamina ted objec ts . A lcohol and agents c on taining alcohol mus t not be a ll owed to get into anes thesi a gas s ampl ing l ines , as th is can lea d to incorre c t resul ts wh en measu ri ng anes thetic agents (104 ). A lco hols c an damage th e l ens mounts on ins truments and tend to s we ll a nd harden rubbe r and c ertain plas tics wi th repea ted us e (2). A lcoh ols a re f lammable , s o care must be tak en not to use them in the presence of a hea t sou rce that c ould ignite the v apor. A lcoh ol so lutions shoul d be s to red i n spec ia l flammab le materials cabinets (Fig. 34.12 ).

Iodine Compounds
An iodop hor is a c ombinati on of i odine and a s olubil izing agent or ca rrier with the resul ting c omplex prov idi ng a s ustai ned-re le ase reserv oi r of iod ine and rel eas ing f ree iodi ne in a queo us sol ution (2,3,5,8 ). Iodophors are b ac teric ida l, v iruc idal , and tuberc ul oc idal but ma y require prolonged c ontac t time to ki ll c ertai n fu ngi and bac te rial s pores . S ome i odophors do not kil l M. tube rc ulos is (87). Iodop hors a re us ed princ ipa ll y as antiseptics but are capable of intermedia te - and l ow-l ev el disi nfec tion. Iodophors formulated as antis eptic s are no t s ui table f or disi nfec ting medical ins truments or env ironmenta l surfaces (8). Some iodophors are uns table in the p res enc e of hard wate r, heat, and organ ic soil , bu t mos t a re reliabl e general-purpos e dis infec ta nts i f us ed in c oncen trations rec ommende d by the manufac tu rer. Some metal lic i ns truments may become co rroded if they are routinel y disi nfec ted wi th iodop hors ; non meta llic i tems are s eldom damaged but may be s tained or d is col ored.

Peracetic Acid
Perace tic (perox yac etic ) acid is bac te ric idal, f ungici dal , v i ruc idal , and s poric id al at l ow temperatures (3 ,5 ,68 ,105,106,107,10 8,1 09,110). It re ma ins effec tiv e in the presenc e of o rganic materia l. It may be effec tiv e agai ns t prions (111 ). An important adv antage is that i ts dec ompos iti on produc ts (acetic acid , water, ox ygen, and hydrogen peroxide ) are no t harmfu l. It ca n c orrode c oppe r, bras s , bronze, plain s teel , and galv ani zed i ron, bu t th ese effec ts c an be reduced b y addi tiv es and pH modific ati ons (88). A concentra ted s olu ti on can c aus e e ye and sk in damage, but i t has no OS HA ex pos ure l imi t. S teris 20 is a pate nted produc t tha t has been dev eloped spec ifical l y for S teris processors . T he ac tiv e ing redient is a c once ntrate of 35% perac e tic acid pl us co rros ion and degra dation inhibi tors that a re c onta ined in a sealed, s ingle-use

container. It sh oul d be used only i n a S teris process ing s ys tem. It is not i ntended for open-pan techniques . A S te ris s ys tem is s hown i n Figure 34 .8. Equipmen t to be s terili zed mus t be c lean but need no t be dry. Th e equi pment is pl ace d in a special tray , whic h is then P .972 place d in the process or. The s teril iz er has a v ariety of trays , co ntainers , and adaptors to accommodate v ario us medical dev ices . Eac h tray has holes for fluid entry a nd drainage and is des ign ed so that there is a con tinuous flow of s teril an t on ex posed s urfac es and thro ugh inte rna l channels of i ns truments .

View Figure

Figure 34.8 The Steris system A: Items to be sterilized are cleaned, then placed in a tray. The tray is then placed in the sterilizer. B: After the lid is closed and the processing cycle is started, the processor automatically opens the sterilant concentrate and mixes it with filtered water. The use dilution of the sterilant enters the tray, covering the instruments, and is circulated for 12 minutes. It is then drained from the chamber, and the chamber and tray are rinsed four times with sterile water. Next, sterile air is pumped into the chamber to displace the rinse water. A printout is provided, confirming that the sterilization parameters were met.

Figure 34.9 The sealed package of sterilant is placed in the processor, and the lid is punctured before the lid is closed.

View Figure

Af ter the tra y is pos iti oned i n the S teris proc esso r, a se al ed pack age of s te ri lant conc en trate is placed i n the s te ri li ze r (Fi g. 3 4.9 ). The li d is c los ed and the process ing c ycle s tarted. Duri ng the c ycle, the lid is s ealed. The proces sor automatic al l y opens the s terilant c onc entrate and mix es i t wi th a c on trolled v olume of fi ltered s teri le wa ter heated to b etwe en 50C and 56C . The di lu ted s teri lan t enters the tra y, cov ering the ins truments , an d is c i rc ulated f or 12 minutes . It is th en drained f rom the c hambe r, a nd the ins truments and chamber are ri nsed fou r ti mes wi th s terile water. Then, s teri le air i s pumped into th e c hambe r to disp lac e the rinse water. The c ycl e tak es from 20 to 45 minutes , d epen ding o n the i ni tial tempe rature of the water and how ex tens iv ely the local wate r s up ply mus t be fil te red . After the c ycle is comp le te, the un it f lushes the di luted s te rilant and ri nse water di rec tly into a drain . The tray c an be trans ported di rec tly to a s te ri le f ie ld . The S teris proc esso r moni to rs and maintains th e parameters neces sary to ens ure s terile proces sing. It wi ll s top the c ycl e i f a process error i s detec ted . A t the end of each cyc le, a p ri ntout c onf irming that the s teril i zation parameters were met is prov ided . Spore s tri ps can b e used as biologica l moni to rs . Thes e g o through the s teril i zer and a re then re triev ed for cul turing . The S teris s ys tem p rov id es a quick method of dis inf ec ti ng a wid e v ariety of heatsens i tiv e immers ib le ins trume nts , incl uding f ibe rsc opes (112 ,11 3) (Fig . 34.10). The S teris sys tem has been found to be effec tive in s te ri li zing the lumens of endosc opes wh en organic s oi l and s alt were pres ent (114).

Figure 34.10 Endoscope in Steris processor. Note the tubings that are connected to the channels.

View Figure

The S teris s ys tem is less da maging to delicate ins trumen ts than s team s teri liz ation and is comp ati bl e with a wid e v ariety of materials , inc lu ding plas tic s , rubber, and mos t heat-s ens itiv e items . It is impo rtant that the absenc e of long-te rm effec ts on the dev ices being s teri l iz ed by the S teris s ys tem are conf irmed with the ins trument manufac tu rer. Polymers , g lasses , coa tings , adhes iv es , and sealants tha t are typicall y used in medical dev ices are compati ble with th e p roc ess . Untrea ted metals such as copper, brass , s ilv e r, aluminum, and iron are s ubjec t to ox id ation . A luminum anod ized c oating c an bec ome dull . The S teris s ys tem is es peci al ly usef ul f or i te ms requ iring a quic k turnaround time. It i s fas ter than s te ri li za tion wi th E O or glutara ldehyde and can be us ed on wet or dry i tems . No s teri lant di lution is nec essa ry , and pers onnel a re no t exposed to a ny tox ic chemica ls . Cons equen tl y, i t c an be located in the operating roo m suite. The s i te requ irements are a tap water su pply, a drain, and elec tric ity. It l eav es no resi due. W rapp ing is not necessary. This sys te m does hav e s ome dis adv antages. Unlik e some automated processors , the S te ris machine has n o c leaning c yc le . Cos ts per c yc le are g rea ter tha n if glutara ld ehyde is us ed (115). On ly i tems tha t c an be totall y i mme rsed c an be s teril i zed, and only a smal l number of i ns truments can be processe d i n a c yc le. The tray s cann ot be us ed for ex tended s to rag e, so process ing mus t be cons is tent wi th jus t-in -time deliv ery .

Chlorine Compounds

Sev era l chlorine compounds are av ai lable fo r use as disinfec tants , inc ludin g sodiu m an d calcium h ypoc hl ori te (househo ld bl each), chlorin e d iox ide, and ch loramine T (3,5,116). The h ypoc hlori tes are P .973 the mos t wi del y us ed. They are inex pens iv e and fas t ac ti ng. They are av ail able in both liqu id (s odium hypochlorite) and s ol id (calci um hypochlorite) form. Rela tiv el y l ow c onc entrations of s odi um hypochl orite (50 pp m) exhi bi t rapi d ac tiv ity agains t v egetativ e bac teria. One hundred ppm is effec tiv e agains t mos t fungi. Ma ny v i ruses are inac tiv ated a t c oncentra tions of 200 ppm, with HIV bei ng susce pti bl e at conc en trations as lo w as 5 0 ppm. HBV exh ibi ts ma rk ed inac tiv ati on at 500 ppm. Concentra ti ons of 1,000 ppm are c ons ide red adequa te to ac hiev e high -l ev el disi nfec tion. A 1:5 to 1:10 di lution wil l des troy the agent of Creutzfeldt-J akob disease (CJ D) af ter an expos ure ti me of 1 hour (11 7).

TABLE 34.2 Preparation of Household Bleach for Disinfectionaa Desired Chlorine Concentration 5,000 ppm1,000 ppm 500 ppm Dilution for use within 24 hours Dilution for use for 1 to 30 days
a

100 ppm 1:500 1:250

1:10 1:5

1:50 1:25

1:100 1:50

Starting with 5.25% NaOCl, which contains 50,000 ppm of free chlorine.

Tab le 34 .2 s hows the d ilution of 5.25% NaOCl (hous ehold bl eac h) needed to ac hiev e the desi re d c hl orine concen tration . Solutio ns that wi ll b e used for ex tended periods (1 to 30 days ) sh ould h av e an ini tial c oncentration twi c e as high as ac tuall y desired and s hould be s tored in an op aque container. Chlorin e s ol utions a re not often us ed for ins trument dis infec tion bu t hav e b een us ed wid ely in env ironmen tal disinfec ti on . Current OS HA regu la tions cons ider di lutions of 1:10 to 1:100 chlo rine to be ac cep tab le f or us e wi th b lood s pi lls . Othe r

us es inc lude spo t dis infection of coun tertops and f loors and deco ntamin ati on of resus ci tati on maniki ns. Hi ghc hlori ne co mpound c onc entrations are c orros iv e as well as irri tating to personnel , and thei r us e s hou ld be limi ted to s i tu ations in whic h there a re unusuall y high concen trations of mic roo rga nisms (8). Their use is l imited by thei r co rros iv eness, inac tiv ati on by organ ic matter, a nd relativ e ins tabili ty . The y ma y l eav e a residue and a re i rritating to th e s ki n, ey es , an d res piratory trac t. Chlorin e d ioxide is us ed in a gas eous p hase (118). It is not s tored but is genera ted at the po int of use . A dv antages are that i t le av es l i ttle res idue and is nonozo ne deple ting. D isadv antages inv olv e materia l incompa tibi li ty.

Hydrogen Peroxide
Hyd rogen peroxi de is an effec tiv e bac tericide, fungic ide, v i ruc ide, and s poric ide (2,3 ,5,119 ,120). It is comme rci al ly av ai lable i n sev era l different c once ntrations . It is not inac tiv ated b y organic matter. There are n o res tric ti ons on disposal . It rapidly l oses effec tiv eness when ex posed to hea t and l ig ht and requ ires careful s torage . It can damage rubbe r and plas tic and may corro de c opper, zi nc , a nd brass . It is an i rritant to the sk in and eyes . A 7.5% s ol ution ac hiev es high -l ev el disinfec ti on in 30 minutes . A n effec tiv e low-l ev el dis infec tant, 3% hydrogen pe rox ide is useful fo r work surfaces . Hydrogen pe rox ide is us ed for plasma s teri l iz ati on (see bel ow).

Ozone
Ozone s teri l ize rs us e ox ygen, wa ter, and e lec tric ity to produce ozone (121,122 ,123). The gas is humidified and dispers ed in to a s teril ization chamber. A s teril i zation c yc le incl udes three s tages : ai r ev ac uation, followe d by ai r and ozone mix tu re admiss io n; an ex posu re s tage ; and a s tage of v acuum-drying and o zone remov al . Af ter the c yc le, the ozone pas ses through a c atalytic c onv e rter that changes i t back to ox yge n. Ozone s teri l iza ti on is good for mos t goods that need low-tempera ture s teri lizati on . It is no t app rov ed fo r flex ibl e scopes and reac tiv e metals s uch as c oppe r and brass . It is c ompatib le wi th mos t ano diz ed aluminum s te ri li za tion con tai ne rs and all p las tic containers . It is uns ui table for dev ic es th at contain na tural gum rubber produc ts , so me p las tics , and some metals suc h as brass and copper. Acc ording to the ma nufac turer, o zone c an steri l ize s ingle s tai nless s teel lumens wi th an ins ide diameter of 2 mm and no long er than 250 mm, lumens wi th an i ns ide diameter of 3 mm or l arger and no lon ger than 47 0 mm, and those wi th an insi de diameter of 4 mm and no longer th an 600 mm (121,1 22).

The proc ess is env i ronmental ly f riendly and produces no tox ic res iduals . It requ ires no v ent or d rain and us es onl y ox ygen, electri c i ty, and a li ttle water. T he s teril izer can be trans ported eas il y. N o exhaus t gas v entilation duc t is requi red in a room that is adequatel y v enti lated. The treated ob jec ts are dry. No ri ns ing or degassing i s required. While s ignificantl y sl ower than g as pl asma, this proces s is less ex pens iv e.

Formaldehyde
Formaldehyde is a highly toxic and f lamma ble gas tha t has been used as a disi nfec tant and a s te ri lant in both a wa ter-b ased s olu tion (f ormal in) and th e gaseous s ta te (5 ). It is nonc orrosiv e and is not inac tiv ated b y organic matter. P .974

A l though forma li n is a high-l ev el dis in fec tant, its uses a re l imi te d b y its pungent odor and fumes, whi ch irri ta te the sk in, eyes , and respi ra tory trac t. Its toxic i ty requi res tha t disinfec ted ma te rials be tho rou ghly ri nsed befo re us e. NIOSH has i ndicated that forma ld ehyde s hould be handl ed as a potent s ensi tizer and probabl e ca rc inogen. K i ts are av ai lab le to abso rb and neutral ize fo rmaldeh yde s pi l ls . S teril ization wi th low- te mpera ture s team and formalde hyde is used in s ome countries (5 ,124).

Advantages and Disadvantages of Chemical Disinfection and Sterilization

Adv antages of liqu id ch emic al disinf ec tion inc lude economy, s peed , and s impl ic ity. This is es peciall y imp ortant in busy endosco py s ui tes beca use i t enables equi pmen t to be us ed sev eral times a da y. It is us eful for eq uipment that does no t requi re s teril i zation but does require high-lev el d is inf ec ti on. Che mica l dis infec tion c anno t be used f or all typ es of equipment. Many dev ices cannot b e s oak ed. P repackaging is not poss ible, and th e equi pmen t wil l be we t. The re is a risk of rec on tami nation durin g s ubs eque nt rins ing, drying, or wrap pin g. W ith mos t a gents , s te ri li ty c annot be gua ran teed. It is mo re exp ensiv e , less ef fec tiv e , and more pro ne to hu man error than s team s teriliz ation . Hi nged i ns trume nts mus t be opened and thos e with s liding or multiple parts dis ass embled. Some so lu tions are irri tati ng to tissu es and hav e unpl eas ant odors . Personnel who handle them mus t tak e precautions to av oid pro lon ged sk in co ntac t or v apo r

i nhalation (92 ). The c hemicals may be abs orbed onto the tre ated items , c aus ing harm to the patien t. A s ignificant disadv antage of cold s teri l ization is the lack of a good method for v ali dation. The eff ic ac y c an be moni tored on ly indi rec tl y, through s urv eying pa tient outcomes , to identif y s ubs equ ent inf ec tions th at can be a ttri buted to expos ure to the reusable dev ic e (125 ). Mos t health c are ins ti tutions hav e an ac tiv e su rv eil lance program in which infec tion c ontrol prac ti tioners s eek to identif y nosocomial i nfec tions.

Gas Sterilization
Characteristics of Ethylene Oxide
E thylene ox ide (E tO, E O) is a c olo rl ess , poisonous gas with a s weet odor (126,127 ,128,129,130,131,132,133,134 ). It i s av ail able in high-press ure tank s and unit-dos e ampules and cartridges . It is fl ammab le in c onc entrations of 3 % or greater. Manufac turers hav e dealt with this haz ard i n two wa ys . E O may be mixed wi th c a rbon dioxide or hyd roc hlorofluoroca rbons (HCFs ). Mi x tures con taining up to 12% E O in these i nert dil uents are nonf lammable b ut re tain thei r s teri l izing abil i ty. A mix ture of E O and ch lo rof luorocarbon (CFC) was us ed in the pas t, but the use of CFCs was banned because of damage to the ozone la yer. HCFs are s imil ar to CFCs but are less damaging to the ozo ne la yer (127,13 5). Thei r use wi l l be elimi nated i n the Uni ted S tates by 2030. E O is s uppl ied mos tly as 1 00% in smal l c ylinders , c artri dges (Fig. 34.11), or ampu les . E qu ipment is des igned for g as con tai nmen t and to mi ni mi ze the ris k of f ire or exp losion (12 6,127,136). A c artri dge is punc tured onl y af ter i t is sec ured in a seale d and locked s te ri li zation chamb er. An ampule is broke n onl y after i t is placed i n a bag with the med ic al dev ice to be s terili zed. Ex pl osion -proof c abinets s hould be us ed for s to ring cartri dges of 100% E O (Fi g. 34.12). E O k ills bac teria, s po res , fungi , an d v iruses. It pene trates in to c rev ices and th rough permeab le bags . It is not degraded by organ ic so il but wi ll not penetra te dried protein materia l.

Preparation for Ethylene Oxide Steriliz ation

It is important to v erif y tha t a dev ice is sui ta bl e for s terili zati on us ing E O. The manufac tu rer's ins truc tions should b e c ons ulted. Some dev ices need to be s teril i zed at a lower tempe rature.

Before pack aging, i tems mus t b e d is assembled, c leaned, d ried, and wra pped. Disas sembly is important to remov e barri ers to free mov eme nt of gas . Caps , plu gs , v alv es, and/or s tyl ets mus t be remov ed. Hollo w-b ore P .975 produc ts s uch as needles and tubes mus t be open at both ends . The wrapp ing mus t be pe rmeab le to E O gas and water v a por and allow proper aera ti on (137).

View Figure

Figure 34.11 Cartridge of EO. The cartridge is punctured only after the sterilizer door is closed and locked and proper conditions are met. There are no external tanks, hoses, or gas source hookups, which are major sources of potential operator exposure to EO.

Figure 34.12 Explosion-proof cabinet for flammable materials.

View Figure

B lood an d o the r prote inaceo us mate rials can ac t as a barri er to E O. If s al t and protein a re presen t in a na rrow l umen , s teri liz ation wi l l not be achi ev ed cons is ten tl y

(114). The ref ore, equip ment mus t be th oroughl y c leansed and rinsed before s teril i zation. Items for gas s te rili za tion mus t be free of water dropl ets . T hey sho ul d be allowe d to dry in ambien t ai r or towel d ri ed. The use of h eated ai r should be av oided bec aus e E O s teri l ization depends on the presence of a dequate (but not ex cess iv e) mois ture . A relativ e humidi ty be twee n 35% and 70% and a te mpera tu re between 18C and 22C throug hout the proc essing and s torage faci l ity are recommended (23,128 ). Dev ic es s hould be s orted ac cordin g to the ste ri li za tion ti me and recommended temperature . Items to b e s teri li zed a re place d i n wi re bas kets , metal s teri li zer carts , or o the r c arri ers tha t do not absorb E O. The s teri li zer ma nufac turer's ins truc ti ons for l oadi ng shoul d be carefull y fo llowed . Items sh ould be loaded loose ly to allow gas to penetrate throug hout the load. Items sho uld be loaded in s uch a fashion that packages wil l not c on tac t the chamb er wal ls o r the operato r's hands when the loa d i s transferred to the a era tor. Some i ns truments are s terili zed in rigid c ontainers that hav e filters on the l id and botto m to allow di ff usion of s te ri lant gas . The re may als o be an additional lid attac hed to the upper l id .

The Sterilization Process Processing Parameters affecting Ethylene Oxide Sterilization

Gas Concentration
As the E O c onc entration inc reases at a g iv en temp era ture and rela tiv e humi di ty, the mic robial inac tiv ati on rate inc reas es up to a ce rtain rang e when it begins to plateau (126). E O conc entrations be twee n 450 and 75 0 mg /L are commonl y us ed in process ing medical produc ts . The solubil ity of E O i n the produc t and the diff usion rate through the pro duc t wil l i nfluence the steri l ant c onc entration. The operating press ure of the E O c yc le wi l l greatly inf luence the gas di ffus ion rate. Pac kag ing may also be c ri tical . Dev ic es that perform con ti nuous E O mo nitoring i n the s teril i zation c hambe r are av ailable .

Temperature
Inc reas ing the temperatu re can dec rease the nec ess ary ex pos ure time. Many s teril i zers p rov id e a s elec tion of te mpera tu res . In he alth care, p roc ess ing c ycl es are commonl y performed betwe en 38C and 60C . Some conduc t s te ri li za tion at room tempe rature. Th is is equall y efficac ious if other fac tors (exp osure time and conc en tration ) are adjus ted.

Relative Humidity
Mois ture hydrates mic robes , mak ing them more s usce ptibl e to d es truc tion by E O. The refore, humidi ty mus t be c ontroll ed in the s tora ge and c lean in g/p roc ess ing a rea and in th e s te ri lizer itself . Mos t E O ch ambers are he ld be tween 40% a nd 80% rela tiv e humi di ty . Des ired humidi ty l ev els are usua ll y acc ompl is hed by l owtemperature s team injec tio n. For tabletop moni tors , it is necess ary to add water to the s teri l ize r.

Exposure T ime
The neces sary s te ri li za tion time wi ll d epend o n the fac tors me nti oned prev iousl y. The time generally ranges between 1.5 and 6 hours in au toma tic s teri l izers . Up to 12 ho urs may be required.

Sterilizers
E O s teri l izers range in s i ze from s mall tableto p to la rge floor-l oading models (126). The basic desi gn inc ludes a p res sure-rated v es sel with a p ort for admitting a ir, a v acuum pump to ev ac uate the chamber g as con ten ts , a j ac ket to heat the v essel, a s team sou rc e to humi dify the chamber and its c ontents , and a me ans to injec t the s terilant. A recent chan ge has bee n to integra te co mputers , mic rop roc ess ors , and software i nto the c ontrol , monitoring , and documen tation of s teril ization p roc ess ing . Anc ill ary equipment s uch as rec i rc ul ati on blowe rs to e quilibrate the ch amber env ironment, exhaus t s ys tems to mi ni mize releas e of s teri l ant into the wo rk env ironment on door ope ning, and a s teri lan t re mov al /rec lama tion sys tem to handl e s terilant emis s ions are commonl y us ed. P .976

Mos t E O s teri li zers are s ophis tic ated uni ts wi th a c hoice of au toma tic c yc les . A sourc e o f E O gas (c yl inder or c artridge) is prov ided, and a s te ri liza ti on c yc le is se lec te d. Af ter the s teril izer c hambe r is tightl y sealed and the c ontrols se t, a typical c ycle i nc ludes th e foll owi ng: (a) warming the c hamber, (b ) ev ac uating air, (c ) i ntroduc ing mois tu re and mai ntaining it for a dwel l period, (d ) in troduc in g the E O, (e) ra is ing the cha mber press ure (in s ome steri l ize rs ), (f) rai si ng the tempe rature (i f requi red), (g) ex pos ure to E O for the ti me re qui red , (h ) releas ing the press ure in the chamber, and (i ) remov ing the E O mix ture (purge c yc le or phas e). S ome s teril i zers p rov id e sev eral s ucc ess iv e p urg e p hases . A s teril izer wi th out a purge c ycle c an re lease a cl oud of E O gas wh en the door is opened. This neces sitates an

ex trac tion hood abov e the door wi th a dedicated exh aus t s ys tem and may ex pos e the operator to E O gas (138 ). T he las t phase is (j) re-es tablishing atmosph eric press ure by introducing f il te red ai r into the chamber. Uni ts that c arry ou t s teril ization at room temperatu re and a mbient humidi ty a re av ailab le. Spec ial v enti lation c abine ts are av ail able fo r ex haus ting the E O from these un its to atmosphere.

Indicators
Three types of indic ators are av ailabl e. F or maxi mum v alue, they s hould be us ed in co mbination .

Physical Indicators
Phys ical mo nitors inc lude s teri lizer co mponen ts that meas ure exposure time, temperature , and humidi ty and/or press ure du ring eac h c ycl e. They sh oul d be ex amined at the begi nn ing , middle, and end of eac h c yc le.

Chemical Indicators
Che mica l indicators c hange color when c ertain conditions nec ess ary f or s teril i zation (te mperatu re, gas conc en tration , and humidi ty) hav e been met (41). Color c hang e v aries wi th the produc t. T hey are av ai lable as tapes , s trips , ca rds , and s heets . T hey may be attached to the p ackaging mate rial or enc los ed in the packages . It is recommended that a c hemical indica tor be used wi th e ach pac kage that undergoes E O s teri liz ati on . In mos t pac kages , the chemical in dic ator is plac ed in the geome tric c enter. In ri gid containeri zed pac kaging s ys tems , the ch emic al i ndicator i s placed in the c orn er (128).

Biological Indicators
A biolo gic al indica tor shou ld be plac ed in the mos t inac ces s ible loca tion i n the s teril i zed load (54,1 39,140,141). T he CDC rec ommends thei r us e a t leas t once a wee k . The y shou ld al way s be used af ter a steri l ize r is ins tal led, af ter any repa irs or modific ati ons a re made to the s terili zer, and any time the re are changes in packaging p roc edures or materia ls or the co mpos i tion of the load. The As soci ati on for th e Adv ancemen t of Med ic al Ins trumenta tion (A A MI) rec ommends that one be us ed with ev ery c yc le in E O s te ri li zers (3 0). P rob le ms wi th thes e indic ato rs hav e been rep orted (142).

Aeration

E O not o nly c omes in c ontac t with the su rfaces of artic les being s teril ized but also penetrates s ome i tems , which then reta in va ryi ng amounts . These i tems need aeratio n (degass ing, des orp tion, off gas ing) to reduce E O to a lev el s afe for bo th personnel and patient us e. Aeration ma y be done passiv el y in a ir (ambient aeratio n) or ac tiv ely in a mechanic al ae rator.

Ambient Aeration
A mbi ent aerati on is sl ower than mec hanical aerati on . The nec ess ary time is highl y v a ri able because of the lack of tempera ture and ai r flow c ontrol . The temperature in the aeration area sh oul d be at leas t 18C. Items that requi re be twe en 8 a nd 12 hours of mechanic al ae ration may req ui re 7 days of ambient aera tion. S ome items tak e betwee n 5 and 6 we eks. A mbi ent aerati on may i nc reas e work er exp osure to E O. If amb ien t aeration is unav oidable (for heat-s ens i tiv e i tems th at cannot wi ths tand the elev ated temperatures of conv enti onal aerato r c ab ine ts or when an aerator is not av ai lable ), meas ures should be taken to min imi ze traffic in the aeratio n a rea a nd to ens ure that pe rs onnel who mus t enter the a rea a re not expos ed to E O at hazardous conc en trations .

Mechanical Aeration
In mechan ic al aerators , a s trea m of fi ltered ai r is d irec ted ov e r the s te ri li ze d i tems . An E O s teri l ize r may be c omb in ed with an aerator so that one c hambe r is used fo r both proces ses .

Factors Affecting Aeration

Device Characteristics
The amo unt o f res id ual E O and the l ength of time ne eded for i t to diss ipate depend on the dev ice bein g s te ri li zed (143 ). Th ic ker o bjec ts a nd wra ps require longer aeratio n times than thi n ones . Unwrapp ed nonporous metal and g lass items do not absorb E O an d requ ire li ttle o r no aeratio n b ut mus t be aerated if wrapped in E Oabsorbent ma teri al. P las tics, rubber, c lo th, pape r, and musl in may absorb s ignifican t quan ti ties . Items that c ons is t of a combi nation of absorbent and nonabso rbe nt materials (e .g., a metal i tem wi th rubbe r parts ) mus t be treated as though they were made enti rel y of absorbent ma teri al. The mos t c ommon materi al tha t retains large amounts of E O is polyv in yl c hlo ride (PV C). Te fl on and ny lon abso rb li ttle E O; howev er, i t is bound

tigh tl y and therefo re requi res a relativ ely long peri od of ti me to elute . W hen the co mpos i tion of a d ev ice is in doubt, it s hould be trea ted as if i t were P V C.

Package Size and Arrangement in the Aerator

A rranging items loose ly i n the ae rator wi l l al lo w f as ter ae ration. P .977

Diluent
Gas mix tures with fluoroca rbo n requ ire a longer ae ration ti me than thos e diluted wi th c a rbon dioxide.

Wrappings
The packaging ma te rial shoul d allow f or eas y gas transfe r.

Temperature
Inc reas ing the temperatu re acc elera tes d esorption. The us ual aera tion temperature i s between 50C and 60C. If these temperatu res wo uld be d amagi ng to a dev ice, aeratio n should be ca rrie d out at room te mperatu re.

Air Flow
Aeratio n is affec te d b y the rate of ai r exc hange a nd th e a ir f low p attern. Inc reas ing ai r ex chan ge beyond a certain point wil l not furth er enhanc e a era tion unles s the temperature is inc reased .

Characteristic s of an Ethylene Oxide Sterilizer

S teril izers that s ubjec t mate ri als to hot gases under elev ated pressu re ca n res ult in highe r lev els of E O in the items s teril i zed.

Intended Use of the Device

W hether the i tem is to be ex ternal to the body , withi n a body cav i ty , in trav as cular, or i mplanted wi ll affec t the ac ceptab le lev el of res idual E O.

T ime
For ma ny yea rs , aerato r manuf acturers p ass ed out inf orma tion detai li ng ae ration times for di fferent items . T his has cha nged, pri maril y bec ause the growi ng mul ti tude of E O-s teril ized dev ic es made i t impossi bl e to ke ep up with al l the changes required. A recommendation tha t aeration s hould be perfo rmed for 12 hours at 50C has ev olv ed (143). Another is 8 hours a t 60C.

Complications of Ethylene Oxide Sterilization

Patient Complications
Compl ications of E O s teril ization that s te m f rom failure to el imina te res idual gas f rom s teri lized items inc lude sk in reac tions and laryngotracheal inflammati on . When blood is exposed to E O-trea te d materia ls , hemolys is c an occu r. S ens i tiza ti on and anaphy lax is f rom ex posu re to p roduc ts tha t are s te ri li zed wi th E O hav e been reporte d. Howev er, the risk of pa tients dev eloping c anc er or s uffering other adv ers e health ef fec ts f rom ex posu re to res idual E O is ne gl igible (14 4). E thylene c hlo rhydrin is f ormed when E O comes i nto contac t with c hl orid e i ons that may be pres ent in prev ious l y -irradia ted PV C i tems . The Ameri can National S tanda rds Insti tute at one ti me rec ommende d that PVC i tems th at hav e been i rradiated nev e r be res te ri lized with E O b ut v ery lo w l ev els of by-produc ts i n i rradiated produc ts treated wi th E O hav e cas t doubt on th is recommen dation and E O s teri l ization of -i rradi ated PVC items may be ac cep tab le if s tric t a ttentio n is paid to a era ti on. P roduc ts s teril i zed us ing E O may inc reas e the risk of la tex s ensi tization (145).

Equipment Alteration
Repeated exposure of some p las tics to E O and heat ma y l each plas tic iz ers and wea ken thei r s truc tural integrity. Rubbe r and s ome pl as tic tracheal tubes ma y soften, k ink mo re eas il y, o r bec ome s tick y. In one c as e, the bal loon on a dispos able es opha geal s te thoscope tha t was s teril i zed wi th E O became detac hed (146 ). Damage to the fl exible s hea th of a flexible e ndos cope has been reported (14 7).

Personnel Complications
Possible Ethylene Oxide Exposure Hazards
The pres ence of gase ous E O in v e ry high co ncen trations is eas ily detec ted because i t is i rri tating to the eyes and mucous membra nes , but odor is not a re liable way to detec t its presence and does not p rov ide adequate warning of h azardous conc en trations . Acu te ex pos u re to s ignif icant lev els of E O usua ll y prov ok es an i rritant respons e . Upper re spi ra tory complaints , e ye irri tati on, head ache , blunting o f tas te o r s mell, a metallic tas te, and c oughing f requentl y occu r. W i th hi gher concentrati ons , nausea, v omi tin g, diarrhea, inc reased fatigabi l ity, memo ry loss , dro ws i ness , weak nes s , di zziness , l ac k of coo rdina ti on, c hes t discomfort, s hortness of b rea th, diffic ulty s wa llowi ng, c ramps , an d c onv uls ions may occ ur (148). Respiratory p ara lysis and peripheral nerv e damage hav e been repo rted af ter massiv e ex posu re. The ons et of

neurolog ic signs and s ymp toms may be dela yed for 6 hours or more af ter expos ure. E O gas is heav ier tha n a ir and can cause as phyx ia tion in enc losed, poo rl y v enti lated, or l ow-l yin g areas . Chronic exposure can aff ec t the eyes (co rne al bu rns , catarac ts , epitheli al k e rati tis ), the central and peri phe ral nerv ous s ys tem, and s ki n (i rritant and al le rgic reac tions ). Res piratory inf ec ti ons , anemia, and impa ired c ogni tiv e func tio n ma y occu r. E O is a recognized mutagen an d c arc inogen and ma y adv ers ely affec t the reproduc tiv e s ys tem.

Occupational Safety and Health Ad ministration Regulations

OS HA regulations limit work er ex posu re to a n 8 -hour ti me- wei ghted av e rag e (TW A ) of 1 pp m wi th a sh ort-term excursi on limi t (S TEL) of 5 ppm (149 ,150,151). In fac i li ties wh ere wo rk e r exposure exce eds thes e lev els , employe rs mus t insti tute ce rtain measures to meet OSHA regulations. Howev er, a fac ili ty is exc used f rom these requi rements if i t c an document that the E O s teri l ization s ys tem employed does not expos e work ers to TW A lev els ab ov e 0.5 ppm during 8 hours o r 5 ppm during 15 min utes time (ac tion lev els ). The pu rpose of ac ti on lev els is to enc ourage E O users to achiev e an ev en lo wer maxi mum exposure lev el . B y demons trati ng co mpliance with the ac ti on lev el, a faci l ity is no t requi red to c onduc t routi ne moni tori ng (other than af ter an equipmen t or f ac ili ty modificati on or mai ntenance), sc heduled e mp lo yee training, o r periodic employee medica l examin ations . OS HA regulations do not iden tify a spec ific moni tori ng sampling technique but d o se t fo rth accu rac y requ iremen ts for s amp ling methods (149 ). There are P .978 t wo b asic approaches to moni toring work place lev els of E O: personnel and env ironmental area moni to ring. Pe rs onnel moni to ri ng incl udes dev ices that c an be af fixe d to employe e l apels to determine opera tor breathing-zon e exposures . A rea moni tori ng incl udes dev ices that rap idl y meas ure E O l ev els presen t at the samp li ng l ocation (Fi g. 34.13). They are used to monito r E O c oncentrations around equipment or in the work place env ironme nt. They are useful to ev aluate the ef fec tiv enes s of eng ine ering changes and can he lp to es timate person nel expos ure . Mos t also serv e as alarm s ys tems for proble ms s uch as leak s or failures in the v enti lation sys tem.

Figure 34.13 Area monitoring device for EO (on ceiling).

View Figure

OS HA requi res employers to prov ide respi ra tory protec tion a nd personal protec tiv e equipment for work suc h as main ten ance , re pai r, o r other ac tiv ities whe re engineering and work p rac tice c ontrols are no t feas ible.

Ethylene Oxide Exposure Sources

The re are eight areas wh ere E O is l ikel y to contac t pe rsonnel : the area in f ron t of the s teri l ize r when the doo r is op ened af ter th e cyc le is c ompl eted, the fres hly s teril i zed goods thems elv es, the aerati on ca bi net, the s te ri li zer, the floor dra in, whe re th e tank and/or ca rtri dge is changed, the s afe ty v alv e, and wh ere the s upply tanks or cartrid ges are s to red .

Recommendations to Reduce Exposure

Unnec es sary use of E O sh ould be av oide d (149 ). It shoul d be res erv ed fo r produc ts that mus t be s teril ized and c anno t wi ths tand other methods of s teril i zation.

The re mus t be s tri c t ad herence to the manufac ture r's ins ta llation and operati ng ins truc ti ons for s teril i zers and aerators . E ac h s teri li zer and aerator mus t hav e regular p rev entiv e main ten anc e to ens ure that malf unc tions , es pecial l y l eaks , a re min imi zed . Reco rds mus t be kept on al l mal func tions and repa irs .

E O c yli nders mus t be s to red in a des igna ted area that mee ts bu ilding codes and OS HA regulations and is out of the wa y of traffic . Cy linders mus t be

chain ed upright to a s olid s truc tu re and the protec tion c ap kept in place wh en not in us e. The s torage area mus t be v en tila ted to prev ent buildup of a s ignif ic ant E O c oncen tration i n the ev ent a c ontainer l eaks .

Cau tion mus t be exercis ed when c hangin g tanks and f il te rs to av oid personnel exposure. P rotec tiv e a ttire (e.g., goggles or a face shield, heav y duty glov es, ful l-body s uits ) mus t be worn. There mus t be c heck or s hutoff v alv es in the lines c lose to the con nec ti on point to li mit the releas e of gas during c yli nder c hanges . A loc al exhaus t hood mus t be ins ta lled near the E O c ylinde r c onnec tion area to cap ture E O releas ed during c hang eov er and l eaks a rou nd li ne co nnec tions . It mus t ex haus t the E O to the ou ts ide or an emiss ion co ntrol s ys tem.

S teril izers and aerato rs mus t be located in we ll -v entilated areas wi th l imi ted ac cess . The room(s ) i n wh ic h the s terili zer a nd aerato r are l oca ted mus t be l arge e nough to ens ure a dequa te E O dilu ti on. The v enti la tion s ys te m mus t be non-rec i rculating , al lo w at leas t ten ai r c hanges pe r hour, and be d esigned so that a ir f lows ov er the s teril i zer door opening to an exhaus t fan, blowe r s ys tem, or emiss ion c ontrol s ys tem. S igns warn ing that h igh l ev els of E O a re possible mus t be pos ted at the entrances . No supplies or u nnec essa ry equipment s houl d be s tore d in th e v ic in ity of s teril i zation/aera tion equ ip ment.

P roduc ts that a re to b e s teri li zed wi th E O mus t be organi zed into f ul l loads , and thos e requiring the s ame s te ri li za tion times should be grouped toge the r. E O s teri l izers , s teri liz er re li ef v alv es, and aerators mus t be v ented to th e outside, an emissi on con trol s ys tem, or a sa ni tary floor dra in. Runni ng v ent l ines in ways tha t woul d re lease E O withi n the bu ilding, allowi ng re -en try of E O-c ontaminated ai r into the bui lding o r re leasing E O n ear pedes trian traffic , i s prohib ited.

An E O s teri l ize r mus t b e c ons truc ted s o that the c yc le c annot be in itia ted o r al lowed to c ontinue unless the doo r is c los ed and sec ured. It mus t not be P .979

possible to open the do or when the chamber i s unde r pressu re or be fo re the pos tev acuation c yc le is compl eted. Loc al ex haus t v enti lation s ys tems mus t be i ns talled to c ap ture E O as close to the sou rc e as poss ibl e and ex haus t i t to the ou tsi de atmosp here.

A combina tion s teri l iz er/aerator wi ll red uce E O exposure ass oc iated with opening the s terili zer door and trans ferri ng goods to an aera tor (128). Exp osure to E O can be av oided by us ing a load ing c art and/or wi re baske ts that c an be mov ed di rec tly i nto the ae rator. Items mus t be lo aded in s uch a mann er that they wi ll not touc h the op era tor's hands wh en th e c art or bas ket i s transferred .

W ith s teri lizers wi thout a purge c yc le, the singl e greates t s ourc e of E O ex posu re oc curs when th e s te ri li ze r door is opened af te r the s teri li zation c ycle is comp le te. Items mus t n ot be l eft in a c lose d s te ri li zer after the c yc le i s complete, as this wil l al low high c onc entrations of E O to bui ld up i n the s teril i zer and be releas ed in to the room wh en the door is fi rs t opened. The chamber d oor s hould be opened 6 inc hes immediately f ol lo win g a c yc le on so me s teri li zers . A door-ope ning dev ice al lows th e operato r to push a button and then wa lk awa y whil e the s te ri li ze r door s lo wly opens . The ope rator shoul d leav e the immediate s teri lizer area for a mi ni mum of 15 minutes after opening the door. The purge c harac teris tics of s ome newer s te ri li zers prev en t E O f rom ac cumulating ins ide the ch amber. These s teri l ize rs sh oul d be unloaded i mmediate ly upon openin g the door, b ecause this is when the E O conc en tration in the c hambe r is l owes t.

S teril ized items mus t be trans ferred rapi dl y to the aerator. Goods should nev er be handled di rec tl y. T ransfer c arts s houl d be us ed to re mov e i tems f rom la rge s teri li zers and glov es and f orc eps for items in s mall s teri lizers . Carts mus t be pul led, rather than pushed , to the aerator s o that pers onnel are not up wind of th e goods . Bas kets mus t be c arried at the s ide and not at the front of the pers on. Items should be pl ac ed in the aerato r wi tho ut del ay . Unaera ted i tems mus t nev er be lef t outs ide the aerato r, wh ere they might contamina te the env i ronmen t or be us ed pre matu rel y.

Porta bl e E O s teril i zers mus t be used onl y i n a wel l -v e ntilated roo m. If a s teril i zer does not h av e a v en ti ng mechanism other than the door o r lid, the health care fac ili ty mus t determine that the v enti lation sys tem effec tiv el y minimi zes e mployee ex posu re to E O. P oss ib le meas ures inc lude usi ng local ex haus t v en ti la tion and adding a c hemical neutra li zation s ys tem or E O absorbent to the s te ri li ze r.

A ll E O-s te ri li zed i tems mus t be aera ted befo re handl ing . A mec han ic al aerator is bes t. If ambient aeration is unav oi dable, the aeration a rea mus t be segregated from general work areas and hav e l imi ted acc ess. It mus t hav e good v enti lation and be at a negativ e pressure wi th re spec t to adjo in ing areas . S to ring sup pl ies in the a rea wh ere ambi en t aeration is prac tic ed shoul d be prohibited.

Person nel and env i ronmen tal moni tori ng mus t be p rac tic ed to ensu re that recommen ded lev els are not ex ceeded (1 52,153,154 ). Checking for l eak s mus t be performed regularly . The moni tori ng f requenc y req uired by OSHA depends on the lev els found in the wo rk env ironme nt. B adges that can be worn by employees are av aila bl e. Ins truments to aid in ins tantaneous leak detec tion and to ale rt pers onnel s hould be ins tal led (Fi g. 34.13).

The s eals on s teri l ize r and ae rator doors mus t be inspec ted for c racks , tears , and foreign s ubs tanc es befo re eac h loa d. Steri l izer and aerator v alv es an d f ittings mus t be i nspec ted regularl y and replace d as necessary. Intake ai r f il te rs f or the res tric ted acces s area mus t be insp ec ted and c leaned regularly .

A limi ted number of E O c artri dges can be s tored in the immedia te v icini ty of the s teri l ize r, p referabl y in a spec ial c abinet (Fi g. 34.12). Eac h fac il i ty in whic h E O is used mus t hav e a wri tten emergenc y plan for dealing wi th E O leaks an d s pills (149). This inc ludes proc edures fo r alerting personnel , av oidin g E O contac t, ev acuati ng unprotec ted person nel , contac ting appropri ate saf ety personn el, and s pecify ing the c riteria for area re-e ntry by unauth ori zed pers onne l.

E mpl oyees who ope rate s teri lizers o r aerators mus t be properly ins truc ted in the haza rds of E O a nd appropriate s afe ty proce dures .

Environmental Problems
Onc e E O is emitted, i t re mains in the ai r wit hou t break ing do wn f or long pe ri ods of time. Peopl e who liv e near fac i lities with s teri l ize rs or a era tors may, the refore, be ex posed to signi fica nt lev els of a irborne E O. S ome s tate and local areas limi t th e amou nt of E O that c an be emi tted in to the ai r (13 5,155). Catal ytic conv erte rs that break E O down i nto c arbon diox ide and wa ter a re av ailab le.

Advantages and Disadvantages of Gas Sterilization

E O s teri l ization is v ery rel iable because the gas pen etrates into c rev ices , na rrow l umens , and regions bloc ked by liquids . It can be used on a wid e v ariety of i tems , i ncl uding those that would be d amaged by heat o r mois tu re. It is the o nl y reliable and p rac tical means for s teril izing many dev ic es that are used today . Damag e to mos t equi pmen t is mi ni mal . Items can be p ackaged before s teri l iza ti on and s tored s terile fo r ex tended periods . P repackag ing e liminates the danger of recon tamination that c an occur d uring rinsing and pac kaging following P .980 co ld s teril i zation and al lows i tems to remain s te ri le du ri ng long-te rm s to rage. A l arge a mount of equ ip ment c an b e s te ri li zed a t one time. E O has a numb er of disadv an tages. F ires and explos ions inv olv ing s teri li zers hav e oc curred . A ma jor dis adv antage is the long total proces sing time req ui red . This may make i t necess ary to hav e mu ltiple se ts of equi pmen t. E O is mo re cos tl y th an mos t other types of s terili zation. Person nel need to be h ighly tra ined and sup erv is ed. Meas ures to reduc e e mplo yee ex posu re and mon itor l ev els of E O mus t be taken . Equipme nt that is to be s terili zed ne eds to b e d ry . Some materials deteriorate after repeated E O s teri liz ati on , es peci al ly at elevated te mperatu res . It cannot be us ed to s teril i ze dev ices tha t hav e petroleum-bas ed lubric an ts in or on them, becaus e E O cannot p ermeate thes e.

Radiation Sterilization
Gamma-ra dia tion us es an el ec tromagnetic wav e produc ed durin g the dis integration of c ertai n radioac tiv e elements . If the dosag e appl ied to a produc t is l arge enough, al l mic ro organisms , inc luding bac terial s po res and v irus es , wi l l be k illed . The re are many adv antages to -rad iation. The p roduc t c an be pac kage d in a wi de v a ri ety of impermeabl e c ontainers before tre atme nt. The pac kage wi ll not interfere wi th the s teri lization process . The treated items remain s te ri le i ndefini tel y unti l the packaging s eal is broken . As there is v i rtually no tempe rature rise durin g treatment, thermolabile materials can be s teri li zed and the rmolabi le p ack agi ng can be us ed. Items may be us ed immediate ly af ter treatment with no risk f rom re tai ned radioac tiv i ty. Gamma ra di ati on is not prac tical for ev eryday use in he al th care fac ili ties . It requi res expe nsiv e equ ip ment and is use d onl y by la rge man ufac tu rers to s teril i ze disposable equipment. Some hea lth care f ac il ities sen d thei r own packs to outs ide fac i li ties f or tre atme nt.

Gas Plasma Sterilization

Gas plas ma is some ti mes des c ri bed as the fourth s tate of matte r, c ons is ting of a c loud of reac tiv e ions , elec trons , and neutra l atomic and molecular p artic les (109,156 ,157,158,159). It is p rod uced by appl yi ng energy to c ertain gas es . Hyd rogen peroxi de v apor is mos t of ten used . The reac tiv e spec ies in the plasma i nte rac t wi th the molecules that are ess entia l fo r the metab olism and reproduc ti on of l iv ing cel ls. Dev ic es to be s terili zed ne ed to be thorough ly cl eaned and dri ed. They can be unwrapped or enclos ed in a nonwov en wrap (137). Ce ll ul osic materi als should n ot be us ed for wrapping, bec aus e the y abso rb th e s te ri lant v apors , reduc ing i ts conc en tration .

Figure 34.14 Gas plasma sterilizer. (Picture courtesy of Sterrad, a division of Johnson & Johnson Company.)

View Figure

The s terili zer (Fi g. 34 .14 ) runs on an automatic c ycle that is c ontro lled by a mic roproces sor. The machine p roduces a pri nto ut for eac h l oad p roc ess ed. If fo r any reas on the p roc ess is outs ide the n orma l li mi ts , the c yc le is i nterrupted and the prin tou t giv es the re ason . The hydrogen pe rox ide is con tained in a sea led disposab le c asse tte (Fig. 34 .15) that is pl aced ins ide the s teri l izer along wi th the items to b e s te ri lized. It is important to read the ins truc tions wi th the s teriliz er, espec ial ly when dev ices wi th s ma ll l umens are processed. Early models could not s te ri li ze dev ices wi th l ong

narrow l umens (160). Later mode ls can s te ri li ze mos t of these dev ices , al tho ugh a l onge r c yc le time may be requi red. Af ter the i te ms to be s teriliz ed are p lac ed in the s teril i zation c hambe r, the doo r is c los ed and the gas i n the c hamber is ev acuated (Fig . 34.16). Mois ture remaining on or i n th e objec ts in the chamber wi ll mak e it diff ic ult to ac hiev e th e recommended v acuum, a nd th e c ycle wil l a bort (23 ,1 59). Fil tered a ir is then in troduced to restore atmospheric press ure . This is the preplas ma (v acuum, preco ndi ti oning ) phas e. P .981

Figure 34.15 Once the hydrogen peroxide cassette has been placed in the sterilizer, it is automatically advanced by the machine.

View Figure

The c hamber is again ev acuated, and a s ma ll v olume of aqueous h ydrogen perox ide is in jec te d f rom a c asse tte. The h ydrogen pe rox id e v apori zes and diffuses around the i tems to be s teri lized for a f ix ed period of time. T his is the diffus ion phase (F ig. 34.16). Then , a low-temperature pl as ma is genera ted b y appl ying ra dio f requenc y energy. T his is the plasma phas e. Duri ng the p las ma phas e, the temperature inc reas es abou t 5C. Af ter the radio frequenc y is turned OFF , the f ree radic als lose thei r high ene rgy and recombi ne to form ox ygen, water v apor, and o the r nontox ic produc ts . W ith s ome s teril i zer mod els , this proc ess is repeated with th e excep tion of the preplasma s tage . After the c ycl e(s ) has been completed, fi ltered ai r is i ntroduced i nto the chamber, displac ing the v apor f rom th e c hambe r and passi ng it through a dev ice spec ial ly des igned to decompose the hyd rog en perox ide. T his is th e v ent phas e. The temperature duri ng the whole c yc le do es not excee d 50C. The cyc le time v a ri es wi th the s te ri li ze r model . Different mo dels hav e different s izes , shap es , numb ers of s helv es , an d number of in jec tion s tages . A c hemic al indicator s houl d be i ncl ude d i n eac h tray and a biological ind ic ato r used a t le as t once a week (54,159). Gas plas ma is an effec tiv e s teril i zation process . It c an be us ed for mos t heat-l abile and mois ture-sens itiv e items wi th the exception of cellulosic ma terials (e.g., cotton , l inens , paper), powde rs , li quids , implan ts , and dev ic es con tai ni ng long, narrow, dead-end lumens . It p rod uces l ess effec t on me tal items than s team s te ri liza tion. It i s compati bl e wi th c eramic s, s i lic a, glass , and a wi de range of pl as tics incl uding polye thylene, poly propyl ene , PVC, s ilicones, and f luorina ted s il ic ones . It can be us ed with a v ariety of h inged and non-h inged ins trumen ts , dev ices with lumens (not dead ende d), elec tric and fiberoptic cables , batte ri es , and rigid endoscopes . It ca n s teril i ze s tain less s teel lumens tha t are 1 mm or la rge r and no l ong er than 125 mm, l umens that a re 2 mm or larger and no lo nger than 2 50 mm, and lumens that a re 3 mm o r la rge r and no longe r than 400 mm (121 ). A gas plas ma s teri li zer is si mple to ope rate. It us es rel ativ el y lo w c oncentratio ns of the s teri l izing ag ent, does not l eav e tox ic res iduals , and has s hort proces sing times . There is no n eed f or aeration o r cool-down time. T he s teri l ized pro duc ts are dry and i mme di ate ly av ailab le f or us e o r c an be s tored fo r la ter use. There is no need for c ool ing or aeration. The re are no emis si ons or tox ic by -produc ts . The prima ry end produc ts of the process a re oxy gen an d wa ter. Lack of worker exposure and env ironmen tal contaminati on are major adv an tages . No person nel o r exhaus t mo nitorin g is needed. Results from monitorin g a round th e s teril i zer hav e sho wn an 8-h our TW A concentra tion of 0 .005 ppm h ydrogen

perox ide (105). The OS HA limi t is 1 ppm. No water so urc e, heating , or ou ts ide v enting is required. Thus , it can be located i n c lose prox imity to the area where the i ns trume nts wi l l be us ed. It can be mov ed around eas i ly . A l though thes e a re l ow-c apac ity s teri l iz ers , th e v olume of produc ts p roc essed per unit of time may be equiv ale nt to that of larg e-c apac ity E O s teri li zers . In c os t co mpariso ns wi th other s teri li zation tec hnologies, plasma s terili zatio n was less ex pens iv e than E O but more ex pens iv e than s team (161,162 ,163). P .982

Figure 34.16 Gas plasma sterilization cycle. (Redrawn from a figure in The future of low-temperature sterilization technology in healthcare. A roundtable discussion, April 28, 1995 .)
View Figure

The s ys tem has a numbe r of disadv antages . These i nclude the smal l s ize of the s teril i zing chamber. Ce ll ul ose materia ls , pape r, l inens , powd ers , liquids , and i mpla nts c anno t be proces sed . Dev ices wi th a dead-end or a lumen 400 mL or l onge r c annot be s teril i zed wi th out a s peci al adaptor. Pene tration is not as g ood as wi th E O (1 64). The s terilization p roc ess is impa ired when protein o r sal t is present (156,165 ,166). Dev ices that a re to b e s te ri lized mus t be able to wi ths tand a v acuum. Items whose desi gn permits the s urfac es to c ollaps e onto eac h other (e.g., bags ) sh ould not be p roc ess ed unl ess s ome means is used to keep the surfaces separated. This process requi res s pec ial s uppl ies (e .g., i ndicators , tra ys , wraps ) that are compatible with th e s ystem. It may also requi re mod if ic ation of some wrapping and s tac k ing techniques .

A Program for Anesthesia Equipment

General Considerations
Those who are conc ern ed with anes thes ia equi pmen t find themse lv es fac ed wi th a di lemma as to how muc h time, effo rt, and mone y shou ld be ex pend ed to prev ent i nfec tion transmission. Wi th inc reased press ure to hold down cos ts , the temptation to do les s may be s tron g. P roponents f or mo re v igorous measures argue as f ollows :

Cas es of c ros s c ontaminatio n c ause d by anes thesi a and res pi ra tory equipment hav e been repo rted (167,168,169 ,170,171,172 ,173,174). The ris k of c ross c ontamin ati on may be greater than is genera ll y bel iev ed. The lack of doc umentation o f many nos ocomial inf ec tions secondary to anes thetic prac tice may re fl ect a long i nc ubatio n period , diff ic ul ty in pinpointing the s ource of i nfec tion, or inadequate f ol low-up (175,176 ,177). Anes thes ia in terferes wi th c il iary and mucous activ ity, an d surgery c an imp ai r the patie nt's abi l ity to c ough and b rea the deepl y, s o patien ts are more l ik el y to dev elop respi rato ry i nfec tions than the no rmal popu lation. An es thes ia ca re prov iders of ten c are for i mmunoc ompromis ed patients , and thes e patien ts may be unable to protect thems elv es aga ins t what were once though t to be harmless organisms or ins ig nifican t inoculums .

A l though there is ge neral agreement that s teril i zation or hi gh-lev el disi nfec tion of equipme nt is essential after use with a patien t hav ing a respi ra to ry or bloodborne i nfec tion , it is imposs ib le to identif y all of these pati ents .

Ev en if the inc idenc e of infec tions res ul ti ng from anes thesi a apparatus is l ow, the c os t of a s ingl e suc h P .983

i nfec tion i n te rms of mortali ty, morbidity, and resource ex penditure is high.

B lood contamination of a nes thesia equipment s urfac es is c ommon (178). V isua l inspec tion is not a reliab le means for d etec ting blood.

Centers for Disease Control and Prevention Guidelines

The CDC has publ is hed guide lines on h ow to prev en t or control n osoc omial i nfec tions based on a c lass ifica ti on of i ns truments and other i tems by the ris k of i nfec tion i nv olv ed (68 ).

Critical Items
These inc lude v as cular and regional bloc k need les and catheters . These items mus t be s terile, because they bear a h igh ris k of i nfec tion if they are contami nated.

Semicritical Items
Semic ritical i tems do not p ierce muc ous membranes . E quipme nt that fal ls i nto this ca tegory i ncludes endoscopes ; laryng osc ope bl ades ; reusable rec tal , nasoph aryngea l, a nd esophageal temperature p rob es ; face mas ks ; o ral and nas al ai rwa ys ; res usci tation bags ; b rea thing tubes and connec tors ; ox ygen mas ks ; es opha geal s te thoscopes ; and trach eal and doub le -l umen tubes . Ide al ly , se mic ri tical items should b e s teri le . Howev er, h igh-l ev el disinfec tion is an ac ceptable s tandard of c are wh en s teril ization is not prac tical .

Noncritical Items
Nonc ri tic al i tems c ome into con tac t wi th i ntac t sk in . Items in this catego ry i nclude s tethos copes (not esop hageal); blood p res sure cuf fs and tubing ; arm boa rds ; pulse ox imeter s enso rs and c ables ; e lec troc ardiog ram (E CG) c ables an d elec trodes ; reusable s k in tempe rature p robes ; tempe rature moni tor c ables ; head s traps ; b lood warmers ; c arbon diox id e absorber asse mblies ; adapto rs f or oxy gen se nsors ; and the ex teriors of the anes thesi a machi ne , v enti la tor, humidif iers , s cav enging s ys tem, resus ci tati on bags , in trav enous f lu id pumps, mon itors , an d equi pment carts . Since i ntac t sk in no rmall y ac ts as an effec tiv e ba rrier to mos t mic roorganis ms , these i tems need onl y cl ean ing follo wed by in termedi ate- or low-l ev el dis infec tion. Some ex perts add another c ategory-env i ronmental su rf aces (8). These include su rfaces that do not ordi naril y come into direc t contac t with th e patien t, b ut i f they do, it is only wi th i ntac t sk in . Thes e surfaces may poten tially co ntribute to secondary c ros s contaminatio n b y heal th c are wo rk e rs or medic al ins truments tha t subs equentl y c ome in to contact wi th pa tients . These s u rf aces c an be further div ided into medic al equipment s urfac es suc h as adjus tment k nobs or handles and housek eepi ng su rfaces s uch as floors , wal ls , and wi ndo ws i lls.

Factors Influencing Cleaning Procedures

No si ngle agent or proc edure is ad equa te for al l purpos es . Fac tors that shou ld be cons idered in the s el ec ti on incl ude the degree of mic robiologic inac tion requ ired fo r

the parti cul ar dev ice, the na ture and ph ysical compos iti on of the dev ic e, and the cos t and e ase of usi ng a particular procedure. Cos ts can be div ided in to di rec t an d i ndi rec t cos ts (179 ). Di rec t cos ts inc lude process ing (cl ean ing , s teril iz ation packaging), purc has ing (in itial pric e, ins tal lation, s hipping), re pai r, replac ement, l abor, and dis posal. Indi rec t c os ts inc lude infec ti on control (empl oyee immuni za tion and e duca tion), l iab il i ty (c ompensation, i nsu rance, and regulato ry complianc e), adminis tra tion (p roc edure wri ting ), and los t rev enu e (processing diffic ul ties , produc t fail ures, and procedure de la ys ). Res pons ib ility fo r anes th esi a equi pmen t dec ontamination s houl d be v es ted in one i ndiv idual who dev is es and adminis ters a c ompre hens iv e progra m. This pers on shoul d be a member of the ins titution's infec tion con trol c ommitte e. An infec tion control p olic y that docu ments p roc edures to prev ent transmissi on of infec ti ous agents to patients and personnel and tha t is a pprov ed by the infec ti on control co mmi ttee s hould be in p lac e for anes thesia (180 ,18 1). It is impera tiv e th at equipment c leaning and disinfec tion o r s teril izati on be pe rforme d b y cons c ientio us , wel l -trai ned indiv idu als wh o unders tand s tandard p rec autio ns . Another fac tor necess ary for a s ucces sful decontamination progra m is s urv ei llance to c heck that tec hniques are adequate . CDC guidel ines do not rec ommend routine c ultures . Cul tures need to be tak en onl y if a problem bec omes ev ident. A track ing s ys tem s hou ld be in place to enable reus able ins trume nts to be traced to an i ndiv idua l patie nt in the ev ent of a c li nical inc ident (e.g., fa il ure of the decontami nation p roc ess or a dev ice bei ng us ed on a patient wi th uns us pec ted CJ D) (181). F urthermore, some anes thetic e quipment (e.g., l aryngea l mask s , gum elas tic boug ies ) should o nly be reprocessed a finite numbe r of times , so this mus t be documen ted .

Filters
S tudi es show that an effec tiv e fil te r at the patie nt port wi ll pro tec t the bre ath ing s ys tem and env i ronment from c ontamination (182 ,183,184,185). A n ad ditional benef it is that i t helps to humidif y the ins pi red gases and lowe rs the humidity that reaches s idestream moni tors . Ho wev er, the ef ficac y of fi l te rs in reduc ing patient c ross inf ec tion is un prov en. The Assoc iation of Anaes thetis ts of Great B ri tai n and Irel and and the A us tral ian and New Zealan d Co ll ege of Anaes thetis ts hav e recommen ded that a fil te r is plac ed at the patie nt po rt f or al l adul t patie nts (186,187 ,188), whil e the ASA c onc lud ed th at there was i ns ufficient c linical outc ome

data to rec ommend routine us e (2). Howev er, when a patie nt wi th a respi ra tory i nfec tion mus t be giv en i nha lational P .984 anes thes ia, a f il ter sh ould be used . Fi lters a re discussed in Chap ter 7. Choosi ng the proper f il ter is tric k y, because the s pecif ic ations a re difficul t to i nterpre t. Fi l ters are more effec tiv e a t prev en ti ng bac terial than v i ra l trans mis si on. It has be en sugges ted that a fil te r is us ed with eac h p atien t and , as a cos t-s av ing meas ure , the anes thes ia c ircui t is reused (189). This does not address outer su rface co ntamina ti on that may oc cur wi th b rea thing c ircui ts that are no t cha nged between p atien ts (190). The de bate abou t us ing f il te rs and reus ing the breathing s ys tem is not resolv ed at this ti me (191 ).

Equipment Choice
Disposable equipment may be for s ingle use or s ingle patient use (181,192 ,193,194,195). S ingle use indicates that the manufac tu rer intends for the i tem to b e used on ly once on an indiv idual p ati en t and then disca rded. S ingle pati ent us e indic ates th at the manufac turer adv is es that the item may be used mo re than onc e on the s ame patien t. Mos t depa rtments hav e s truck a bal anc e bet ween disposable and reus able i tems . This balanc e should be p eriodica lly reassessed in light of ch anging techn ol ogies , cos ts , and wa s te management probl ems . Mos t departmen ts ke ep at leas t some disposable i tems av ai la ble for us e with known i nfec ted cas es . Dis posables ensu re that the patient wi l l al ways receiv e a s teril e or c lean i tem, and there is no need for decontami nation after us e. Among the disadv an tages is the need to k eep a l arge i nv entory and an inc reas e in the was te gene rated by a faci li ty. FDA re gulations requi re manufac turers of new or redes igned med ic al dev ic es l abeled as reus abl e to prov ide wri tten ins truc tions for c leaning, deconta mina tion, and, if appropriate , disi nfec tion or s te rili za tion. A reusa ble dev ice of ten requ ires disas sembl y, c leani ng, dry ing, reass embl y, repac kagi ng, and dis infec tion o r s teril i zation befo re reuse . W hile equipme nt i s being c leaned, i t c annot be used. This may necess itate a larger inv entory . There is a l imi ted life s pan fo r reusabl e equipment. The reprocess ing of disposable eq ui pment is a controv ers ial matter (196,197 ,198,199,200,201,202,203). In an eff ort to reduc e cos ts , s ome heal th c are fac i li ties hav e been or hav e cons ide red reus ing s ingle -us e dev ices (204 ,20 5).

Thi rd-p arty reprocess ors a re av ailable. In some cases , their rep roc ess ing cos ts a re l ower than reproc es sing at the health care fac il ity. The FDA req ui res ins ti tutions that reprocess singl e-use dev ic es to mee t th e s ame regulato ry requi rements as the original manufac tu rer o f the p roduc t (206 ). Th is s hif ts the l iabili ty f or produc t safety and eff ec tiv eness from the manufac turer to the party doing the re process in g (180). The A SA Task Force on Infec ti on Con trol do es not rec ommend reuse of d is posa bl e equipment (207). Mos t of the controv ers y rela ted to reuse of s ing le-us e d ev ices h as conc erned ex pens iv e i tems suc h as c ardiac c atheters . Pulse ox imeter s enso rs hav e been recyc le d (208 ). Successful reprocessi ng of Combitubes h as bee n repo rted (2 09). The heal th c a re faci li ty mus t formulate a pol ic y to ens ure the c lean lines s , ph ysical i nte gri ty, and func ti onali ty of th e dev ice af te r re process ing. It is recommended that an i nterd isc ip li nary c ommi ttee wi th in each ins ti tution be dev eloped to ass ess reques ts to rep roc ess an d reus e any dev ic e lab el ed s ingle us e or disposab le . Both the eff icac y of the reproc ess ing proce dure a nd th e l ikel ihood that the dev ic e wi l l func ti on as in tended af te r reprocess ing must be cons idered (1 97,204,210 ,2 11,212).

Intraoperative Considerations
Anes thes ia prov iders shou ld al way s work f rom a c lean su rf ace. A t the s ta rt of a case, only thos e a rtic les tha t are likel y to be us ed shou ld be plac ed there . Clean and d irty areas need to be establis hed and equipment p lac ed in the proper l oc ation . S ince gl ov es are used duri ng parts of the proce dure where the risk of contac t with blood or body fluid is gre ates t, the y can bec ome con taminated, and this contamina ti on can be transf erred to equi pmen t. An y reusabl e item that is touched wi th a di rty glov e sh oul d be placed in the co ntainer for di rty equipmen t. This ma y contain water wi th d ete rgent to p rev ent s ec retions or bl ood f rom drying (2). Di rty equi pmen t suc h as la ryngosc ope blades can be isolated by wra pping them i n a gl ov e or the packag in g f rom anoth er i tem (213). A t the end of the c ase, the recep tac le for di rty equ ipment shoul d be tak en to the dec ontamination area. Used disposable i tems s hould be discarded in suitabl e contai ners . B lood or o the r bod y f luids on equi pmen t or env i ron mental su rfaces s hould be remov ed wi th wa te r and detergent fol lowed by decontamination usi ng an i nte rmed iate-lev el d is infec tant. A 1:10 to 1 :100 dilution of 5.25% sodium hypochlori te has b een recommended by the CDC for c leaning blood s pi l ls . ASA , AANA , an d CDC gu ide lines s tate th at s y ringes a re si ngle-patient i tems (214 ). Onc e a s y ringe has been c onnec ted to or has been us ed to en ter a patient's

i ntrav enous i nfus ion , the s yringe a nd need le are c ons idered contaminated, because blood may hav e bac ked up into the tubing. S y ringes should no t be us ed to adminis ter med ic ation to mu ltiple pa tients ev en if the needle is cha nged. Unfortun ately , some an es thes ia prov iders re use sy ri nges on mo re than one pa tient (177,215 ,216,217). Mul tidos e s olutions repres ent a potenti al s ource of transmis si bl e b loodbo rne inf ec tions (174,216,218 ,219,220).

The Anesthesia Work Area

The anes thes ia work area is us ual ly the si te wh ere c lea ning and other proc edures are performed unles s the equip ment goes dire c tl y to a ce ntral reproc ess ing area. P .985 P roced ures inc lude disass embl y, c lea ni ng, disi nfec tion, and s te ri li za tion. How much i s done in the an es thes ia work room wil l depend on how muc h can be ca rried out by the operating room or c entral s erv ice depa rtment f or the enti re faci li ty . Ev en if mos t of the proc edures are p erf ormed in anoth er area, i t may be des i rab le to disas sembl e di rty items i n the anes thes ia work room, remov ing gross s oil and rendering them s afe f or handl ing p rior to transp ort. Soi led equipment s hould be transp orted on ded ic ated c arts or mechan ic al conv ey ances tha t are c learl y mark ed to indica te that the items are contaminated. These s hould be p laced i n a designated area fo r ti mely transport to the centra l process ing department or th e reproc essi ng area in the ope rating room. A dedicated so il ed cart l if t f rom the operating room to the c en tral s uppl y depa rtment is recommen ded if they are on d iffe ren t fl oors . The reprocess ing area should hav e ade quate s pac e for the intended p roc edures . It may be desi rab le to h av e a mach ine to wash c onta mina te d i tems . S ink s s houl d be l arge e nough tha t bulk y i tems wi l l fi t into the m and hav e attached c ounters on whi c h so iled and c lean items can be plac ed separatel y. T here s houl d be enough s ink s to acc ommodate c oncurren t soak ing, wa s hing, and ri nsi ng. Rack s for d rying wi ll be needed.

Consideration of Individual Items

The c hoic e of decontamination method wil l depend on a nu mber of fac tors , i ncl uding the nature of the c ontamination ; th e ti me required fo r proces sing; the heat, p res sure, mois ture, an d c hemical tol erance of the i tem; the av ai labi li ty of process ing equ ipment; and the risks assoc ia ted wi th the dec ontamination metho d (181). The man ufac ture r's ins truc ti ons shoul d be s tudied and foll owe d c arefu lly.

Anesthesia Carts
Anes thes ia carts a re use d as a reposi tory fo r equi pmen t and drugs . Containers that hold drugs , s yrin ges , need les , and s uch sho ul d be c leanab le . A ttention sho uld be paid to h ow e quipment is plac ed in the dra wers . For ins tance, a blood p res sure c uff that is used on s ev eral patien ts wi th no a ttempt to decontaminate i t betwee n c ases shoul d not be plac ed in the same drawer as airway s o r mask s tha t are not kep t in s terile c on tainers , b ut the cuff may be pl ac ed in a drawer c ontain ing i tems suc h as suc tion c a thete rs and s yring es tha t are k ept i n disposable wra ppers . Eq uipment that is not k ept s teri le s hould be placed i n dra wers that a re less f requentl y opened, that is , not in the sa me d rawe r as frequ ently us ed drugs . The top s urfac e s hould be c lean ed of v is ible mate rial betwe en c as es and at the conc lus ion of the workda y and disi nfec ted wi th a germic ide (8). A c lean c ov e ri ng shoul d be placed on the top of the cart at the s tart of each cas e. Vertic al surfaces sh ould be cleane d a t the e nd of the work day or if there is obv ious con tamina tion. A t leas t once a month, al l equipment s houl d be remov ed and the drawers and containe rs c lea ned, then wi ped or s pra yed wi th a germic id e.

Gas C ylinders
Gas c y li nders are trans ported to the fac i lity in open truck s and are f requen tl y s tored outs ide. Befo re taking a tank i nto the o perating room sui te , the wrapper, if present, should be remov ed. The c ylind er should be was hed wi th wate r and detergen t and wi ped or s prayed wi th a germic id e. Af te r plac ing the c ylinder on the anes thes ia mach ine, i t s hou ld be c ons idered pa rt of the mac hi ne and treated ac cordingl y.

Anesthesia Machines
The s ame princ iples ap pl y to cleaning anes thes ia mac hin es as to c arts . The top su rface sh ould be supp lied wi th a c lean cover for each cas e. The machine should be cleaned between c ases and at the end of the workday , then sprayed o r wi ped wi th a germic ide. Care shou ld be take n not to get l iquid in the v apori zer f il l ing funne ls . Parti cul ar attention s houl d be paid to f re quen tl y used k nobs . Equipmen t shoul d be remov ed from dra wers and the d rawe rs c leaned and disinf ec ted regul arl y.

Anesthesia Ventilators
The outs ide of the v entil ator should be treated the s ame as the outs ide of an anes thes ia mach ine. Many be ll ows and tubings can be s teriliz ed by us ing E O. A n i mportan t fe atu re of the newer gen era tion of anes thes ia v entil ators is that mos t

parts tha t come into c ontac t wi th resp iratory g ases c an be eas i ly remov ed and s team autoc lav ed (Fig. 34.17). The manufac tu rer's recommendati ons shoul d be followe d.

Unidirectional Valves, the Adjustable Pressure-limiting Valve, and W ater Traps

The outs ide of APL and un idi rec tio nal v alv es sho ul d be c leaned and dis infec ted periodicall y. Unidi rec tional v alv es are us uall y eas il y dis ass embled and c leaned by wi pi ng the d isc , the ins ide of th e p las tic dome , and the v alv e seat wi th alcohol or a detergen t. Some A PL v alv es may be au toc lav ed, and some c an be pasteu ri zed (221). Using glutara ld ehyde on AP L v alv es may c ause s tickines s and inc reas e the opening pressu re (2 22). W ate r traps sh ould be cl eane d and disi nfec ted period ic al ly and wh enev er water i s v isible (223 ).

Absorbers
Carbon di ox ide absorben t is a so mewhat e ffec tiv e fi l ter, and s tud ies s ugges t that pati ents rarel y contaminate it with high lev el s of bac teria (184 ,2 24,225). The P .986 manufac tu rer's ins truc tions should b e c ons ulted wi th respec t to dis ass embl y, c lean in g, and d isi nfec tion. Man y of the newer anes thes ia wo rks ta ti ons hav e absorber as sembl ies th at can be e asi l y d is assembl ed and s team autocl av ed (Fig. 34.18 ). Canis te rs s hould be c leaned wh en the absorbent is changed, wi th pa rtic ular attention to sc reens , as they are susc eptible to obs truc tion . Some can is ters c an be s team autoc lav ed, and some can be s teri li zed using E O. Others c an be disinfec ted by immers io n i n a liquid suc h as gluta ralde hyde .

Figure 34.17 Drager Divan ventilator that is disassembled for steam autoclaving.

View Figure

Newe r abso rbe rs us e one or more dis pos able plas tic recep tac les . These are smal ler than those us ed in olde r abso rbe rs and a re ch ange d more frequently . S inc e they are dis pos abl e, they do no t need to be c leaned. The us er manual s houl d be checke d to determine if the connec tions to the breathing sys tem need regu la r c lean in g.

Reservoir Bag
In many ins ti tutions , reserv oi r ba gs are s uppl ied with th e d is posa bl e b rea thing tubes as p art of a set, so they do no t need c leaning. Reusab le reserv oi r bags shoul d be c leaned and then s te ri li ze d o r sub jec te d to hi gh-lev el dis infec tion. Ba gs can be c leaned manual ly or in an au toma tic washing mac hine. E O can be used to s teril i ze the bag. Ae ration ti mes sho ul d be c arefu ll y obse rv ed and the bag fi lle d and emptied a few times befo re us e . Some bags ma y be pas teuri zed, although th is wi ll resul t i n gradual deterioration . Chemical disinfec tion can be used . The bag mus t be f il led with liquid to remov e a ir pocke ts .

Breathing Tubings
S tudi es hav e shown that c orrug ated tubing is contaminated af te r use, especi all y at the end cl oses t to the pa ti ent. W ater commo nl y c ondens es in the expi ra tory tubi ng. If the tubi ng is lifted up , th is water may run down into the ai rway or the abso rbe r, reserv oi r ba g, or v entilator. Thes e tub es should pe ri odical l y be dra ined away f rom the patie nt and the condens ate d is carded (2 ).

Disposable tu bings are wide ly us ed today. Thes e tubings a re us ual ly s uppl ied c lean but not s teri le. When it is nec ess ary to inc lude the b rea thing tubes in the s te rile f ield, i t is important to make c ertain tha t they are s teri le. The low c os t of disposab le tubings mak es th eir use attrac tiv e, c ons ide ri ng th e c os t and d ifficu lty of c leanin g and disi nfec ting reusa bl e tubings . Reusable breathing tubi ngs shoul d be c leaned and then s te rili ze d o r s ub jec ted to high-lev el d is infec tion (226). The y shou ld be rins ed soon after us e to prev ent drying. Th ey may then be soak ed in a c ontainer that c ontai ns water an d dete rgent. The long le ngth and co rrugations prec lude a brush f rom bei ng effec tiv e in c leaning . Ultrasonic c lea ning can be us ed to remov e debris . A was hing mac hin e ma y be used . After wa shing, the tubi ngs shoul d be tho roughl y dried un less th ey are to unde rgo pas teuriza tion. Special tube dryers are av ai lab le (Fi g. 34.2). Pas teuri zation can be us ed fo r corrug ated tubings . The Y -piec e s hould be remov ed beforeha nd; otherwi s e, a l oos e f i t may res ult. Che mica l dis infec tion c an be carri ed ou t by us ing an au toma tic wash ing mac hi ne or by immers io n i n a liquid agent. It is important tha t the tube be ins erted v ertica ll y, making c ertain tha t it is fil led on the i nside and that the re are no ai r pock ets . One s tudy foun d that mac hine-as sis ted c hemical dis infec tion wi th gl utaraldehyd e was superior to mach ine-assis ted pas teu ri zation for tubings (227).

Y-piece
The Y-piece is contaminated in a high pe rc entage of c ases . It has been pos tulated that a co ntamina ted Y-piec e may hav e caused pa tient-to-patient transmis s ion of hepatitis C v i rus (HCV ) i n one case (169). Dis posable Y-pieces tha t are permane ntl y attached to dis pos able tub ings are c ommonl y used . A reusable Y-piece sho ul d be c leaned and s te ri li zed o r subjec ted to high-lev el disi nfec tion (226). A fter us e, P .987 i t sho uld be remov ed from the c o rrugated tubings and ri nsed . It s houl d then be soak ed in a s oluti on of wate r and de tergen t, then sc rubbed manual ly or p laced in a was hing machine. If c hemical dis infec tion or E O s teri l iz ation is to be us ed, i t should be thorough ly dried. Y-pieces may be p as teuriz ed, immersed in li quid agen ts , or s teril i zed by us ing E O or p las ma s te ri li za tion.

Figure 34.18 A: Absorber assembly that is partly disassembled. B: The APL and unidirectional valves are also disassembled. The assembly can now be steam sterilized.

View Figure

Mapleson S ystems
Af ter use, Mapleson s ys tems should be d is assembled and th e c omponents cl eane d. Metal c omponents c an unde rgo autoclav ing. Rubber and pl as tic p arts can un dergo gas o r pl asma s teril ization or a li quid chemica l agen t may be us ed. In many cas es , disposable tubings are more c os t-ef fec tiv e . The B ain an d Lack co axial c ircui ts p res ent p rob lems wi th c leani ng because of the central tubi ng . It is bes t to us e dis pos abl e circu its .

Adaptors
Adapto rs that a re use d near the pati ent are con taminated in a h igh perc entage of cases . A fter us e, they should be ri nsed and then soak ed in a s oluti on of de tergen t and wa ter. They may be wash ed manuall y or i n a wa shing mach ine . Rubber and plas tic adap tors may be s teri l ized with E O, plas ma s teri lization, or in a liquid such as glutaraldehyde. Metal adaptors ma y be autoclav ed or pas teu ri zed .

Scavenging Equipment
A satis fac to ry method of treating s cav engi ng equ ip ment is to was h the dev ice in a detergen t s ol ution month ly and to c hange the hoses tha t con nec t the dev ice to the breathi ng s ys tem and v entil ator at the same ti me (221 ). Lint ma y accu mula te in the ai r i ntake v alv es o n c los ed sc av engi ng in terfac es . Thes e v alv es shoul d be remov ed and c leaned f req uentl y. P .988

Face Masks
Fac e masks are among the mos t heav il y con taminated pieces of equipment. Bec aus e of their p rox imi ty to the patien t, i nfec tion trans miss io n is a def in ite possibi li ty . For o bv ious ly c ontamin ated cases , disp osab le mask s s hou ld be used. Ase psis sho uld be p rac ticed wh en us ing face mask s . A fac e mask sh oul d not be al lowed to d rop on to the floor o r be exposed to obv ious c ontami nation. Af ter use, the mask sh ould be kept near the patient's h ead or wi th the di rty equipmen t. It shoul d not be al lowed to c ontaminate clean equ ipme nt. Reusable face mask s s hould be cl ean ed th en s te ril ize d or s ub jec ted to high-lev el disi nfec tion. Immediate ly af ter use , th e c onn ec tor s hould b e remov ed and the mask rins ed, then s oaked a nd sc rubbed. It may be c leaned automatic ally in a was hi ng machine. Mask s shou ld al way s be tho rou ghly ri ns ed a nd dri ed . W ith gas s teril i zation, the mask can b e kept s te ri le for l ong pe riods of time. Aeratio n mus t be adequa te; otherwi s e , facia l burns may resul t. Mos t automatic E O s teril i zers employ a v acuum a t leas t once duri ng the s teri li zation c yc le. This v acuum may cause the p neuma tic cus hion on the mas k to be da maged. This can be prev ented by remov ing the plug that s eals the c ushion or b y using a s te rili ze r that does not hav e a v ac uum phas e. S team autoc lav ing is someti mes used for face mas ks . A s wi th E O s terili zation, i t i nv olv es a v acuum phase that wi l l damag e the i nflated c ushi on, s o the plug shoul d be remov ed befo rehand. Pas teurization has been us ed fo r face masks . Liquid c hemic al agents a re of ten used to d is infec t or s teril i ze face masks . Tho rough rins in g is importan t to remov e res idual age nt. Crac ks in the mask c ushion ca n a ll ow l iquid agent to enter the ai rspace. When placed on a pa tient's fac e, the liquid c an be squeez ed out, pos sibl y into the e yes.

Head Straps
Af ter use, head s traps shoul d be s ubjec ted to c le aning wi th a detergent, then soak ed in a dis infec tan t solution or s teriliz ed using E O or plasma s teril ization.

Airways
A i rwa ys sho uld be tre ated as clean obj ec ts and n ot all owed to drop on to the floor. Mos t airway s are no w disp osab le . They s hould be placed i n a sui ta ble c ontai ner.

As soon as pos sible af ter use , re usab le ai rways s hould be ri nsed wi th c old wa te r, then place d in a solutio n of water and de te rgent. They ca n be was hed manual l y o r i n a mac hine. They sho ul d be thoroug hl y ri nsed to remov e res id ual dete rgent. Pas teuri zation, l iqui d c hemical dis infec tion, and E O and pl asma s teril i zation hav e been used for ai rways . Rubbe r airway s ma y be autocl av ed, bu t th is wi ll s horten thei r use ful life .

Rigid Laryngoscopes
Disposable la ryngos copes a re disc ussed in Chap ter 18. E i ther the blade or the blade an d handle may be disposab le (228). Con tamination of rigi d l aryngos cope blades and handles is c ommon, and there are reporte d c ases of c ross i nfec tion a risi ng from c ontami nated la ryngos copes (229,230 ,231,232,233,234,235,236,237 ,238). Laryngosc opes s hould be s tored unde r cl ean c ondi tions . Dis pos able c ov e rs that f it ov er th e handle and /o r blade are av ai lable (239 ,240,2 41) (Fi g. 34 .19 ). Af ter use, the ha ndle and blade are contaminated and s hould not be p laced on a c lean s urf ace . The glov e that the opera to r is wea ri ng may be inv erte d ov er the blade an d handle to p rev ent s pre ading con tami nation (24 2,243). The re is no c ons ens us on what c ons ti tutes adequa te blade o r hand le process ing, and the methods emp lo yed range f rom sup erf ic ial cl ean ing to s teri l ization (24,244,245 ,246). If p ri ons are a l ikel y con tami nan t, d is posable blades shoul d be us ed, if pos s ible (238 ). Af ter use, the ou ts ide of the handle should firs t be wi ped c lean with water and detergen t, then wi th alc ohol . The ba tteries (and bulb c hamber, i f presen t) mus t be remov ed p ri or to d is infec tion or s teril i zation unl ess the hand le is designed to be waterpro of. The batte ries mus t be remov ed i f th e me thod of s teri l ization inc ludes a v acuum c yc le , pressu re, or hea t. Af ter the batteries are remov ed, the handle c an be s teril i zed by us ing s tea m, plas ma, or gas steril i zation. As soon as pos sible af ter use , the bla de should be rinsed, then i mmersed in wate r and a n enzyma tic detergent. It should be washed gently bu t tho rou ghl y by usi ng a soft b rus h, wi th pa rtic ula r atten tion to the area around the bul b or l igh t bundle . Cl eaning is often inadequate (2 4,232,233). Ul traso nic c leaning is usual ly not recommen ded. A fter c leaning, the bl ade sho ul d be ri nsed and dried. B lades ma y be s te ri li zed wi th E O, s team, plas ma, or tre ated with liqui d chemica ls . The re is one reported c ase i n wh ic h tongue s wel l ing wa s thought to be caus ed by a reac tion to glutara ld ehyde that was use d on the laryngoscop e b lade (247). The

S teris sys tem c an be used (248 ). E O is a ppropriate fo r mos t b lades , p rov ided a temperature of 180F a nd pressu re of 8 po unds pe r square inch are not exceeded. No aeratio n is re qui re d. Some blades can be s teril ized by us ing s team. Flash s teril i zation is not rec ommended. Autoc lav in g f iber-op tic bl ades may c ause de trimen ta l effec ts to the f ibers that transfe r li gh t (64 ,249,250). Fi ber-o ptic bl ades s hould not be immersed in cold wate r af te r autoc lav ing , as the fi ber-optic bundles may c rack . P .989

Figure 34.19 Disposable laryngoscope covers. A: Covering for blade only. (Picture courtesy of Blue Ridge Medical, Inc.) B: Covering for both blade and handle.

View Figure

Flexible Endoscopes
Endoscopes are semic ritic al dev ices that c arry a rea l risk that infec tion may be transmitted to pa tients (88,101,108 ,251,252,253 ,254,2 55,256,257,2 58,259,260 ,261,262,263 ,26 4,265,266 ,2 67,26 8,269,270,271,272,273,274 ,275,276,277 ,27 8,279,280,281,282,283,284 ,285,28 6,287 ,288,289,290,291). P seudoinfec tions h av e also been rep orted (283,289 ,292,293,294,295,296,297,298 ,299,300,301 ,302,303,304 ). Onl y endoscopes that are s ubme rs ible sho ul d b e used. Dis posa bl e s uc tion v alv es may he lp to reduce the risk of c ros s infec tion (25 1,266,268). A fi be r-optic endosc ope should be s to red i n a c lean area with the dis tal ti p p rotec ted . A fibersc ope is c omplex , f ragi le, and hea t-sensi tiv e, whic h makes i t diffic ul t to c lean and dis infec t or s terili ze. It may be bes t to hav e i t dec ontaminated in an

endosc opy uni t. P ressu re (i .e., leak ) tes ting s hould be pe rforme d befo re i mme rs ion to av oid cos tl y damage that c an occ ur du ri ng the c leani ng proces s (253). S peci al l eaka ge tes te rs are av ai labl e for this purpos e. If a leak is de tec ted, the endoscope shoul d be remov ed from serv ice and the manufac turer c onsu lted. Immediate ly af ter being remov ed f rom the patie nt, the ex te ri or of the fibers c ope shoul d be wip ed with a d is infec tan t. T he endoscope shou ld no t be s queezed tightly (257). A l l channels should be flush ed with water and /or an enzymatic detergent. It i s impo rtant that the en zymatic s olution is pro perly di luted; otherwi s e, the endosc ope may be dama ged (257). Af ter leak tes ti ng, the f ibers cope s hould be i mme rse d in an enz ymatic d ete rge nt so lution. It is impo rtant to plac e a water-re si s tant c ap ov er the v ideo c onnec to r before subme rs ion (257). A ll c hannels sh oul d be filled wi th the solutio n and allo wed to s oak for the ti me s ta ted on the l abel (us ual ly 2 to 5 minutes ). Th e f iberscope shoul d the n be c le aned . Spec ia l cl eaning dev ices that c an be inserted into the channe ls are av ai lable. Short s trokes should be us ed to graduall y i ntroduce the brush . If s ignificant res is tance is fel t, one should p roc eed f rom the o the r di rec tion rather th an fo rce the brush through a blocke d c han nel . If a c le aning dev ice c anno t be passed eas ily through a cha nnel , the sco pe sho uld be s ent for repai r. The so lution s hould be s uc tioned th rou gh al l cha nnels unti l th ey are f ree of deb ris . Suc tioni ng f lu id and a ir al ternately remov es more de bris from lumens th an suc tion ing only f lu id (101). S peci al k i ts to check fo r bl ood res idue i n the c hannel are av ai lable. Foll owi ng c leaning , the f iberscop e and all of i ts c hannels s hould be thoroughl y rins ed with s teri le wate r or rins ed wi th tap wate r th en alc ohol. Tap wate r ri ns ing that is not f ol lo wed by alcohol rins ing has been li nked to contami nation (281). Endoscopes s hould be hung v ertic al ly to allow any remaining fluid to drain out of the insertion tu be (101). P .990

Foll owi ng c leaning , fiberscopes should be steri l ized or receiv e high-lev el disi nfec tion. Curre nt data sugges t tha t high-lev el dis inf ec tion prov ides the same degree of s afety as s teril ization (88). If the sc ope is totally immers ib le , c hemica l disi nfec tion c an be used. Al l lumens and/or cha nnels must be fi ll ed . Gl uta ralde hyde , hyd rogen peroxi de, a nd OPA are effec tiv e d is infec tan ts (101,120 ,305). After dis infec tio n, the dev ice s houl d be thoroughly ri ns ed with

s terile water, foll owed by 70% alc ohol (298). The S teris s ys tem, us ing s pecial adaptors for the lumens (F ig. 34.10), cons iste ntly s terili zes f ibe rs copes , ev en with protein and s al t i n the narrow l umen (110,11 3,114,309,310 ). Automated endosc ope reproces sors tha t perform d is infec tion and rinsi ng are av ailab le, but s ome hav e been implicated in i nfec tions and pseudoinfec tions (267,269 ,276,277,278,292,293,294,295 ,296,306,307 ,308). All automatic reproces si ng s ys tems hav e fi l tration s ystems (261). It i s imp ortan t tha t th e filters are changed regularly . The sc ope s hould b e a llowed to cool abou t 5 to 7 minutes af te r it has been p roc ess ed (257). Gas s teril i zation ma y als o be used . It is effec tiv e b ut wi ll k eep the fibersc ope out of se rv ice f or a long perio d of ti me. S ome suc ti on v alv es c an be autoc lav ed (266). Mos t fibersc opes hav e lumens that are too n arrow and too long for p lasma s teril i zation.

Stylets
Many believ e that s tyle ts shoul d be k ep t s teri l e because they are plac ed ins ide a s terile trac heal tube . Reus abl e gum elas tic bougies are f requen tl y con taminated (311,312 ,313,314). S te ril e d is posa ble s tylets are av ai lable (315 ), but they may not work as wel l as mul tiple-use ones (31 6). As soon as pos sible af ter use , the s ty le t sho uld be rinsed and then immers ed in water an d dis infec tant. S tylets , d epen ding on the ir c ons tructio n, may be autoc lav ed, gas or plas ma s teri li zed , or trea ted wi th l iqui d chemica ls . Of the li quid chemic al agents , alcohol a nd glu ta raldeh yde are used mos t frequently . Peracetic ac id and h ydrogen pe rox ide c an also be use d. If E O is us ed for s te ri liza ti on, no aeratio n time is requi red unless the s ty le t is i n a pack age.

Tracheal and Double-lumen Tubes and Connectors

A trach eal o r double-lumen tube is plac ed in to an area of the bod y tha t is normal l y s terile. It shoul d be kept free of contamina tion unti l use d. Disposabl e s teri le tubes are av ai lable at such a low c os t that i t us ual ly is not c os t-effec tiv e to us e reus able ones . The tube s hould be kep t in i ts p ackage until just before use, and th e patien t end s houl d not be touched . S tu di es in dic ate that tracheal tubes c an be used f or up to 28 days af ter being op ened bu t not remov ed from the package (317,318,319). Lubrican ts , s tylets , and s uc tion c ath ete rs for us e wi th thes e tub es should be f ree f rom c on tami nation. If poss ible, the tu be should no t touch any part o f the mouth or pharynx durin g ins erti on.

A high percentage of tracheal tubes s how con tamina ti on wi th blood af te r us e (320). If the tube is reusab le, s ec retio ns should be p rev ented from dry in g b y ri nsing and then soak ing in a detergen t sol ution. B efore i mmers ion, the infl ating tube s houl d be plugged. The connec tor and any tape shou ld be remov ed. The tube should then be was hed i nside and ou t, tak ing ca re no t to ca tc h the c uff on any sharp objec t. Trac heal tubes may als o be c leaned in a washing mac hin e. The tube s hould be rinse d thoroughl y, mak ing c ertai n to f lus h the lumen. Thorough dryi ng is i mportant before c hemica l disi nfection or gas s teril ization. Unless the tube i s to be s team autocl av ed or pas teuri ze d, the c onnec tor sh ould be reins erted af te r c lean in g. E O is a popular method for s teril iz in g trache al tubes . The en d of the inf la ting tube shoul d be open . Wi th rep eated gas s teril i zation, ru bber and some plas tic trac heal tubes s often and k ink mo re eas il y. Sp iral l atex trac heal tub es shou ld no t be gas s teril i zed wi th a v ac uum appl ied durin g the s teril i zi ng c yc le, as this can c aus e the l atex layers to separa te. S team s teril ization has b een us ed in the pas t for certain trach eal tubes. Repeated au toc lav ing makes them more l ik ely to k ink and c auses a dec rease in the elas tic i ty of the cu ffs . Sp iral emb edde d tubes are es pec iall y susc eptible to damage f ro m autoc lav ing. Mos t of the newe r trache al tubes that are mad e of plas tic wi l l not wi th s tand the high tempe ratures inv olv ed i n autoc lav ing . Liquid c hemic al disi nfec tion has been us ed for trac heal tubes . Th e i nf lating tube shoul d be c losed du ri ng imme rs ion to p rev ent the so lution from enteri ng the cuff. The tube wi ll frequently f loat and needs to b e held down wi th an obj ec t th at does not dis to rt i t or p rev ent the so lution from reaching all s urfaces . Thoroug h rins ing is necess ary after us e of al l chemic al agents exce pt alcohol. Ps eudomembranous l ary ngi tis has been li nk ed to disinfec ti on of trac heal tubes with glutara ldehyde .

Suction Catheters
Suc tion cathe ters are d is posable dev ices that a re disca rded after us e unl ess us ed i n a c los ed suc ti on s ys tem (Chap ter 3 ). A co ntamina ted s uctio n c atheter that may s till b e needed for a pa ti ent shou ld be rins ed wi th s teril e water and then retu rned to i ts packagin g after us e, no t placed under the mattress of the opera ting room tabl e or d rap ed ov er the ca rbon dioxide abs o rbe r. A t the end of the c ase , it should be disc arded.

Supraglottic Airway Devices

Up to 76% of laryngeal mask ai rwa ys (LMAs) hav e been found to hav e oc cul t bl ood on them after use (320,321,322 ,323). P .991 The re hav e been no c ases of diseas e transferred be twe en patients b y reus e of a s teril i zed LMA reported (324). Disposable sup raglottic ai rway dev ices are av ai lab le (325). The y may be more ec onomical to us e than reus able dev ices wh en th e c os ts of c lea ning a nd s teril i zation a re fac tored along with th e number o f reuses that a dev ice wil l tol era te . The man ufac ture r's di rec tions wi th regard to c lea ni ng and s teril izing s upragl ottic ai rwa y dev ices s hould be consul ted. So aking the reus abl e sup rag lottic ai rway in a di lute (8% to 10%) so lu tion of bica rbonate bef ore c leaning wil l help to d is solv e sec re tions (326). The infla ti on v alv e s houl d not be exposed to a ny fl ui d (327). T he supraglo ttic airway s hould be c leaned in di lute bicarbona te or mi ld d etergent so lution until all v isi ble foreign ma te ri al is remov ed. A pipe -cl eaner type brush shoul d be ins erted through the dis ta l ape rture (s ). S tudi es show tha t c omplete remov al of proteins from an LMA is of ten n ot ac hiev ed (235,321 ,328,329,330 ,331). Ul traso nic c leaning may be more eff ec tiv e than o ther methods of cleaning to remov e proteinac eous materi al from the mos t inaccess ible areas of the mask (321). Supplementary c leaning with potass ium pe rmangana te wi ll s ignifican tl y reduce the amou nt of p rotei n deposi ts (331). The LMA shoul d be ri nsed with wate r and then dried. Autoc lav in g is the onl y rec ommende d me thod of s teril ization f or a reusable LMA . Tempera tures up to 134C (273 F) may be used (326,327 ). Highe r tempera tures can c aus e the tube to become brittle and f ra gment. It may be prefe rab le to use a s teril i zer wi th out a v acuum phase (3 32). As much ai r as poss ible should be remov ed f rom the cuf f shortl y befo re au toc lav ing (333,3 34). Res idual ai r wi ll ex pand in the heat and ma y damage the cuff, v alv e, or pi lo t ball oon (3 35). After s teril i zation, the dev ice should be left in its pac kage u ntil jus t p rior to use (336). Liquid c hemic al agents s hould not be used on an L MA , as they are adsorbed onto the si licone and c an cause phary ngi tis and laryngi tis as we ll as s horten the lif e of the LMA (326,3 37). Gas s teri l ization mus t not be us ed . The man ufac ture r's ins tructions should be cons ul ted f or ins truc tions on cleaning and s teri li zi ng other reus able supragl ottic dev ic es .

Spray Applicators

Mul tidose spray applicators are f requentl y contaminated (275,338). Considerati on shoul d be giv en to us in g d is posa bl e dev ices . If a mu ltidos e applica tor i s us ed, the nozzle shou ld be cl eaned and disi nfec ted afte r use .

Resuscitation Bags
Res usci tation bags hav e been implica ted as the sourc e of c ross infec tio n (339 ). The ir relativ ely low c os t probably mak es the d is pos able ones cos t-effec tiv e. The prima ry s ourc e of con tamination is the v alve . This sho uld be dis assembled and c lean ed and, if p oss ible, dis infec ted o r s te ri li ze d after each use or on a regu lar basis if de dic ated to a s ingle patient. The manufac tu rer's ins truc tions sho uld be followe d.

Blood Pressure Cuffs, Tubing, and Stethoscopes

B lood press ure c uffs are f requen tl y con taminated wi th blood a nd can be a res erv oi r of bac teria (178,340 ). Sp ray ing c uffs wi th a to pic al dis infec tant wil l reduc e the ir bac te rial load (340). P rotec tiv e c ov ers fo r cuf fs a re av ail able (341). The arm c an be wrapped wi th s of t cotto n bef ore the c uff is appl ied to prev ent sk in c ontac t. Reusable c uffs s houl d be c leaned with a detergent a t the end of the day and wh en v isibl y contaminated (2 ). P eri odic dis inf ec tio n o r s teri lizati on is adv isable . Mos t cuffs can be was hed af te r the bladder i s remov ed. A fter drying, the c uff may be subjec ted to gas s te ri li zation or ch emic al dis infec tion. No nfabric c uffs c an be s teril i zed by us ing p las ma s te ri liza tion. The s tethos cop e is a potentia l sou rc e f or tra nsmi tting bac teria (342,343 ,344,345,346,347,348). S ingle-use cov ers a re av ailable (342). S tethosc opes c an be washed with water and wi ped wi th alco hol . Earplugs ca n be c lean ed with an alc ohol-sa turated appl icator.

Pulse Oximeter Probes and Cables

Pulse ox imeter p robes and c abl es are f requentl y contaminated wi th bl ood and organis ms (178,349,3 50). Dis pos abl e probes may be reproces sed for re use by pulse oxime ter manuf ac turers and heal th c are i ns ti tutions . Reproces s ing may be cos t-effec tiv e (349,35 1). Reus able probes and cab les s hould be c leaned at the end of the da y o r when v isi bl y con taminated by wi pi ng with alcohol or the cl ean ing so lution rec ommended by th e ma nufac turer (2 ). Ca bles can be s teril ized by us in g plasma s teril ization.

Temper ature Monitors

Tempera ture sens ors should be c leaned wi th a disinfec tant af te r use (2). S peci al soak s tati ons for rec tal p robes are av ailable. The majority of temperature s enso rs are dis pos able.

Transesophageal Echocardiography Probes

Trans esop hage al ec hoca rdiograph y probes are easi l y damaged (352 ). T hey s hould be cleaned carefully and then s oaked in dis inf ec tant. A soak s tation shown i n Fi gure 34.20. One c ontai ner is fo r the dis infec tant, and the secon d one is us ed fo r the initial ri ns e. Fumes a re drawn away f rom the operator and into a s pec ial filter, whe re th ey are neutral i zed . An automated reproces sor for ul tras ound probes tha t comp letes the disinfec tion and rins e cyc les in less than 8 minutes is av ail ab le. It uses a fresh bottle of a P .992 glutara ld ehyde-bas ed disi nfec tant for eac h c ycle. This is pie rc ed ins ide the reproces sor, av oid ing s plashes and spills . A v apor ma nage ment s ys tem a dsorbs chemic al v apors .

Figure 34.20 Soak station for transesophageal echocardiography probes.

View Figure

A chemica l burn sec ondary to a probe that may not hav e been prope rl y proces sed has been reported (102 ).

Other

Objec ts that do no t c on tac t the patien t but a re co ntac ted by th e anes thes ia prov ider's fingers (the pen used to rec o rd data, the comp uter keyboard, telephone, nerv e s timula to rs , i nfusi on dev ices , etc .) s houl d be co nsi dered sou rces of contamina ti on. A s imple dev ic e for a pen has been d esc ribed (3 53). Computer ke yboa rds c an be cov ered wi th a pl as tic cov er that c an be changed or c lea ned. Adequate lev els of safety fo r medical equipmen t surfaces may be ac hiev ed b y thorough c leaning fol lowed by ap plica tion of a n i ntermedi ate - or l ow-lev el ge rmicide (8). A dequate safe ty lev els for surfaces can be achiev ed by mai nta in ing them in a s tate of c leanlines s by usi ng water an d a dete rge nt or a hospi ta l-gra de disi nfec tant/dete rgent that is des ig ned fo r gene ral hous ek eeping purposes . Onl y whe n there has been a s ignifican t s pi l l of blood o r other po ten tial ly infec tio us bod y f luid should the ad ded use of an in termedi ate-l ev el chemic al dis infec tant be necess ary .

Preventing Occupational Infection

In 1991, OS HA ma ndated univ e rsa l precau tions . Thes e are no w p art of s tanda rd precauti ons . These prec au tions requi re that glov es and o the r barri er protec ti on are us ed when hea lth care pers onnel pe rf orm tasks that ma y res ult in ex posu re to blood an d other bod y fluids , s ec retions , ex cre ti ons , non -i ntac t s kin , or muc ous membranes (2,12,354 ). Fo r patients wi th s pec if ic infec ti ons , a ddi ti onal transmis si on-bas ed precautions are appl ied. Thes e are des igned to reduce the risk of airborne, d rop le t, or c ontac t trans miss ion o f pathogens . Annua l educational programs on the use of p rec autions are requi red for employees. Unfortunately , noncompl ianc e wi th these procedu res is common .

Barriers
App rop riate barri er precau ti ons i ncl ud ing glov es, fl uid -resis tant masks , fac e sh ields , eye protec tion, and gowns or l ab co ats mus t be us ed when co ntac t wi th body fluids , mucous memb ran es , o r broken sk in is poss ible (2,355,356). It is i mportan t to remov e or change these barri ers immediately af ter use and before touching u ncon taminated i tems o r going to a nother pa tient (178 ,216,357). The us e of glov es can reduce need les tick s, pe rc u taneous i nj uries , and s urfac e contamina ti on in the an es thes ia work plac e (358 ). It sho ul d be noted tha t glov e protec tio n is c omp romised wi th e ach ac tiv i ty pe rformed a nd esp ecial ly when adhes iv e tape is torn, unless adhes iv e-spa ri ng mois tu ri zing c ream is us ed (359). The refore, i t is important that h and dis infec tion be performed immedia tel y af te r remov ing glov es. A full -face disp osable plas tic shi el d is bes t for eye p rotec tion.

Gogg les or presc ription gl as ses are les s adequate. It sho uld be note d that the edge of the f ace sh ield cou ld be a sourc e of in ju ry to the patient (360 ).

Hand Hygiene
Anes thes ia personnel c an harbor high bac teri al c ounts on thei r hands (361,362 ,363). Hand hyg iene shou ld be pe rforme d after touc hing blood or other body fluids , s ec retions , ex c retions , mucous membranes , broken s k in , wound dress ings , or contaminated items ; prior to and be twee n patien t con tac ts ; and at any other ti me wh en mic roo rganis ms migh t be trans fe rred to other patien ts , s taff , or env ironments . The us e of glov es d oes no t pre cl ude the need f or prope r hand trea tmen t. If the hands P .993 are v isibly s oiled , hand was hi ng sho uld be p erformed. If there is no v isi bl e soiling, rubbing wi th an alco hol -based gel or so luti on with pers is tent ac tiv i ty is more conv enient and effec tiv e (103 ,364,365,366 ). S ome hand solution manufac turers recommen d a s oap-and -water h and was h after eight to ten cons ecutiv e appl ications to remov e res idual and o rganic c ontami nants . A disadv an tage o f alcoho l-bas ed produc ts is that they are flammable (367). Howev er, a s tud y publ ished in 2003 found no f ires attri butabl e to hand sani tize rs , and the Nati onal Fi re P rotec tion Ass oc iation now allows a lcohol -bas ed ha nd san itizer dispense rs in c orri dors and other publ ic a reas , prov ided c ertai n res tric tions are obs erv ed (3 68). If a disp ense r i s mo unted in a hall way, the c orridor mus t be at leas t 6 fee t wid e. The dispense r can p roj ec t up to 6 inches from the wal l and mus t be ins tal le d abov e handrai l heigh t. Hand wa shing sho uld be performed by fi rs t wetting the sk in, then a dding the s oap or c leans ing agent. Tepid water sh oul d be used . The hands sho ul d be v ig oro usl y rubbed toge the r fo r at leas t 15 sec onds , cov eri ng and g enerating f ri c ti on on all su rfaces , then thoroughl y dried . W hen us ing an a lcohol -bas ed rub, rubbing s houl d be continu ed until the hands are dry . If the hands dry in less than a min ute, more of the waterl ess rub s hould be used . It is i mportan t to mak e c ertain th at th e rub is applied to all parts of the hand. S tudi es show tha t th is is frequentl y not done (369).

Preventing Needlesticks
Percutaneous injury , esp eci al ly a needles tic k with a hol lo w ne edle, is ass oc iated wi th the ri sk of transmi tting bloodborne inf ec tion (37 0,371,372,37 3). Used nee dles shoul d not be recapped, bent, or b rok en by hand o r otherwis e manipulated b y using

any tec hnique that inv olv es di rec ting the poi nt toward any part of the bod y. If i t is necess ary to rec ap needles , a s ingl e-handed techniqu e in whic h the needle is not di rec ted towa rd an unpro tec ted hand or a mec hanical pro tec tiv e dev ice shou ld be us ed (2,374 ). P unc ture-res is tant s harps conta ine rs mus t be av ail able in a ll wo rk l ocations and s hould be l ocated as cl os e as poss ib le to wh ere s harps are us ed (375). Rou tinel y wearing glov es resul ts in a s ignificant re duc tion in needles tick and percu taneous i nj uries (358 ). Dou bl e g lov ing offers inc reased protec tion (376,3 77). Double -glov e s ys tems that us e a c olore d i nn er glov e mak e i t eas ier to d etec t glov e perfora tions (378). Efforts to reduce needles ticks hav e resul ted i n a v arie ty of new prod uc ts (371,379). P rotec tiv e d ev ices s uc h as sh ielded needl es , pro tectiv e lanc ets , and ne edleless i ntrav enous l ine con nec tors c an play an importan t role i n p rev entin g needl es tick s . S traigh t needles tha t are us ed to s utu re c entral v enous access (CVA ) and pulmonary artery (PA ) ca the ters are assoc ia ted wi th f requen t in ju ries . T he CDC recommen ds usi ng cu rv ed, ins trument-he ld su ture needles (380 ).

Emergency Ventilation Devices

W hen resus ci tation is p erformed, mou thpieces , res usc i tation bags , o r other v enti lation dev ices should be us ed as a n a lternativ e to mouth-to-mouth v enti la tion.

Personnel with Cutaneous Lesions

Hea lth care work ers wi th b reaks in the ski n or ex udativ e lesi ons shoul d ref ra in f rom di rec t pa tient c ontac t and from hand ling pati ent c are equipment unless the open area c an be protec ted by a barri er that is impermeabl e to bl ood and body f luids (381). One i nv es ti gation s ugges ted that two patients became i nfec ted with HBV f rom a heal th c are wo rke r with sev ere ex uda tiv e dermatitis on the hands (382).

Specific Disease States Tuberculosis

Outbreaks of multidru g-resis tant TB hav e he igh tened concern abou t nosocomial transmis si on (175,380,383 ,384,385,386 ,387). M. tuberc ulosis is s pread primarily v ia droplet nuc le i. Because of thei r smal l s iz e, dropl et nuc lei remain s uspended in ai r c u rrents and can sp read ov er g rea t dis tances . TB is les s infec tiv e af ter the rap y has begun . Cons ideration s hould be giv en to des igning one opera ti ng room to handle pa tients wi th TB . To prev ent s uspended inf ec ti ous droplets from leav ing the op era ting room,

the ideal opera ting room would h av e an an teroom that has a negativ e pressure between the co rridor and opera ti ng room (383 ). An isolation room is d esi rab le . It s hou ld hav e nega tiv e press ure to the su rround ing rooms , outs ide air exhaus t, an anteroom to ac t as an ai rl ock , and ul trav io let lights to k ill M. tube rc ulosis in infectious d rop le ts (3 83). The c a regiv er in this are a wil l need to hav e adequate s uppl ies readi ly av ai lable s o that it wi l l not be necessa ry to make man y trips into the ma in recov ery area. The CDC has publ is hed guide lines f or preve nting M. tube rcu los is transmission i n health care fac ili ties , inc luding the operating room sui te (383,385 ,38 8). Respi rato ry i sol ation is requi red for al l pers ons sus pec ted o r k nown to hav e activ e pu lmonary TB unti l th e d iagnos is has been ruled out or therapy has been i ni tiated and i t can be de mons tra ted that the indiv idual is no l onger infec tious . The patien t with TB shoul d be placed in a room that has negative ai r pressu re, 1 2 or more air c hanges per hour, and d isc harges ai r di rec tly to the ou ts ide or high-eff ic ienc y pa rtic ulate (HEPA ) f il tration of ai r prior to reci rcu lation. Ul trav io let light can be used as an adjunc t P .994 to v entil ation (38 5,387). A heal th c a re faci lity with an obs tetric al uni t shoul d hav e a TB isol ation room that is p roperl y equ ipped fo r obs tetrica l care. E lec tiv e procedu res s hould be delay ed until the pa ti ent is no longe r infec tious . A pati ent wi th T B wh o is undergoing surgery shou ld be transported to the operating room wearing a su rgical mask (383). Indiv iduals ca ri ng fo r the infec ted pati ent, i ncl uding those tra nspo rting the pa tient, sho ul d we ar respi ra to ry protec tion dev ices that mee t CDC c ri teri a fo r filtration an d f i t (385,387). Radi os tethos copes can be us ed for ausc ul tation (389). S tandard surgic al mas ks are general ly not s uitable. The operating room should hav e an anteroom tha t prov ides some isolation from outside ha ll ways and nega tiv e ai r press ure rela tiv e to the co rridor and other operati ng rooms (390). T raff ic in the room and openi ng and c losi ng doors duri ng su rge ry should be li mited. The patient should be th e las t cas e of the day or shoul d hav e the proc edure performed at a time whe n minimal pe rs onne l are p res ent (214). S igns sh ould be placed on the ope rati ng roo m do ors to minimi ze traffic . Unnec es sary or ov e rs toc ked equip ment s hould be remov ed f rom the roo m. A HEP A f il te r s hould be p lac ed between the breathing s ys tem and the patient (383). During pos tanes thesia recov ery, the patient sh ould be placed i n a p riv ate roo m that me ets the rec ommend ed s ta ndards for TB is ol ation rooms . S ince mos t ins ti tu tions do no t

hav e suc h a n is olati on roo m i n the s urg ic al su ite, an al tern ativ e is to utili ze pos tanes thesia c are un it (PA CU) pers onne l to prov ide pos toperativ e c are in th e operati ng room or in the patient's is ol ation room. Equipme nt that has been us ed fo r a patien t wi th TB s hould be s teri li zed o r unde rgo high-lev el dis infec tion. In genera l, cul turi ng anes thes ia equipmen t fo r the p res ence of tube rc le bac ill i is not indic ated. Throug h the ir partic ip ati on in procedu res that migh t in duce c oughing , anes thesi a prov iders are a t risk of acquiring TB . The CDC recommends period ic tube rcu lin sc reening of al l he alth care workers , wi th retes ting on a regular bas is (385). If a positiv e tes t is rec orded, a ches t radi ograph s hould be obtai ned and chemoprophylaxis ins ti tu te d, if needed.

Bloodborne Pathogens
Hepati tis B v i rus (HBV ), hep ati tis C v i rus (HCV ), an human i mmunod efic iency v i rus (HIV ) c an be trans mitted through blood and other body fluids . Anes thesiolo gis ts hav e an inc reased ris k of dea th f rom HIV an d v iral hepati tis (391). The greates t risk of expos ure is a need les tick i nj ury . Large-gauge, holl ow-bore need les with v is ib le blood an d deep penetration inc re ase the ri sk (380). The ris k of infec tion af te r a percu taneous expos ure to blood carry ing HB V , HCV , and HIV is 10 % to 30%, 2% to 4%, and 0.3 %, res pec tiv el y (1 75). Contami nated mul ti dos e v ials hav e been i mplica ted i n nos ocomial i nfec tions wi th HBV , HC V , and HIV (381 ,392). A b reac h in procedure b y any one pe rs on can pl ace multiple patients at ri sk . Dev ic es c ontami nated wi th bl ood f ro m pa tients infec ted wi th a hepatitis v irus or HIV shoul d be s te ri li ze d o r undergo h igh -lev el dis infec tion (68). HBV can s urv iv e for a long time on inani mate objec ts (7). Fif ty percent of s urfac es f rom whi ch hepati tis B anti gen can be rec overed do not h av e v isible blood contamina ti on. Multiple s tud ies h av e shown tha t anes thes ia prov iders are at ri sk fo r ac qui ri ng HBV . The pri mary s trategy for prev enting HBV i nfec tion is immun ization wi th he patitis B v accine, whic h is recommen ded f or al l anes thes ia pers onnel wh o do no t hav e immuni ty . OS HA regulations require employe rs to p rov ide the hepati tis B v ac cine at no c os t i f occ upational exposure is ex pec ted. HCV is transmi tted by respi rato ry s ec re tions as we ll as blood (1 67). Tra nsfer of HCV from anes thes ia personnel to patien ts and p ati en ts to anes thes ia prov ide rs has occurred (172,3 92,393). Trans mi ttal has been attribu ted to reusi ng need les a nd s y ringes (215 ,381).

HCV infec ti on is a major caus e of c hronic l iv e r disease and hepatocell ula r cancer and p oses a cons iderabl e risk for anes thes ia pers onnel . It is more common in health care work ers than the genera l pop ula tion. A t presen t, there is no v accine av ailab le to p rev ent i nfec tion, ne ither is there eff ec tiv e pos tex posu re prophy lax is . Current rec ommendations from the CDC do not sugg es t that HCV -infec ted hea lth ca re personnel be res tric ted f rom patient c are du ti es as l ong as they f ol low s tric t as eptic techniques an d s tandard precautions (394,395). HIV is re lativ el y uns tab le in the env i ronment and is rapidly inac tiv a ted by a wi de range of c hemical germici des , ev en thos e th at are c lassif ied as l ow l ev el . Th ere is a c as e where HIV was trans mitted f rom a pa tient to an anes thes iologis t (396 ).

Creutzfeldt-Jakob Disease
CJ D is one of a group of neurodeg enerativ e dis orders c ause d by pri ons (111,397 ,398,399,400,401,402). It i s one of a c lass of diseases k nown as transmis si bl e s pongiform enc ephalopathies bec aus e o f the path ol ogic chan ges i n the central nerv ous s ys tem. These dise ases a re ch aracte ri zed by i ncubatio n periods rangi ng f rom months to years a nd fo llowed by a rapidly progressiv e deme nti a. The diseas e is inv ariabl y fatal once c li nical s ymptoms hav e a ppea red . Currentl y, the re are n o k nown trea tmen ts to inh ib it i ts p rog res si on or ou tcome. The re is no ev idence tha t hea lth care work ers are at inc reas ed occ upational risk fo r CJ D. The disc ov e ry that pri ons can lurk in body org ans long before peop le ex hib it s igns of dis ease has the al arming impl ication that multi ple -us e dev ices used on P .995 i nfec ted indiv iduals can transmit the dis ease. The ex tens iv e lymphoreticu lar i nv olv ement that is presen t in CJ D raises the pos si bil i ty that dev ices that c ome in contac t wi th l ymphore ticular tis sues s uch as the tons i ls c ould bec ome c ontami nated (398). It has been rec ommended tha t la ryngosc opes and sup rag lottic dev ices us ed on pa tients with s us pec ted CJD s hould be des troyed (235,244 ,3 99).

TABLE 34.3 Methods of Inactivation of Prionsa

Effective Methods Incineration Prolonged steam sterilization (132C, 1 to 4 hours) Others: 270F for 18 minutes in a prevacuum sterilizer or at 250F for 60 minutes in a gravity sterilizer (402) Sodium hydroxide (1N, 1 hour) Sodium hypochlorite (1:10 solution) Proprietary phenolics Peracetic acid in Steris system (possibly)

Ineffective Methods Glutaraldehyde Formaldehyde Hydrogen peroxide Chlorine dioxide Phenolics Iodophores Alcohols Dry heat Boiling Desiccation Freezing Ultraviolet, ionizing, and microwave radiation Normally recommended autoclave cycles Ethylene oxide Gas plasma

No method has currently been shown to be 100% effective against prions. From Antloga K, Meszaros J, Malchesky PS, et al. Prion disease and medical devices. ASAIO J 2000;46:S69S72.

P rions are no to ri ousl y hardy and demons trate res is tanc e to routine methods of s teril i zation. S tanda rd was hing tec hniques reduce th e c once ntration of prio ns in an ex pone nti al fas hion, bu t 10 to 20 c ycles are required to p rod uce negligible lev els (181). Effec tiv e and i neffec tiv e me th ods of inac tiv ation are s ummari ze d in Tab le 34.3. Dev ices that a re diff icul t or i mpos si ble to cl ean should b e d is carded (403). The Creutzfeldt-Jakob prio n requ ires a unique decontamination procedu re. The preferred treatment of co ntamina ted ins truments after c le ani ng is s tea m s teril i zation f or at leas t 30 minutes at a temperature of 132C (12 1C is i neffec tiv e ). W hen a prev acuum s teril i zer is us ed, 18 minutes at be tween 134C and 138C has been found to be effec tiv e. A l te rna tiv el y, items can be i mmers ed in a 1N sodiu m hydrox ide solutio n for 1 hour at room temperatu re and then s team s teril i zed at 121C for 30 mi nutes (5 ). Nonc ritical patient care i tems or su rfaces ma y be disi nfec ted wi th ei ther bleac h (up to 1 :10 dilution ) or 1N so dium hydrox ide at room

temperature for 15 mi nutes . It may be nec es sary to sac rifice s ome equipmen t af ter us e on a patient at risk o f trans mi tting this d is ease (404,405 ).

Severe Acute Respiratory Syndrome

Sev ere acute res piratory s yndrome (S A RS ) i s a v iral diseas e that is trans mi tted by respi ra to ry dropl ets o r c on tac t (4 06,407,40 8,4 09,410,411 ). Anes thes ia prov iders are at high risk because of f req uent exposure to patients ' res pi rato ry sec re tions . Tradi ti onal precautions ma y not af fo rd adequate protec tion wh en handling SARS pati ents . W henev er p oss ible, patien ts s hould hav e a priv ate, negativ e -pres sure room wi th at l eas t 6 to 12 exc hanges per hour. If this is u nav ail able, they s hould hav e a room wi th a HEPA fi l te r. A NIOS H ap prov ed, f i t-tes ted N-95 or g rea te r res pi rator s hould be used wh en contac t wi th pa tients is n eces sary. Goggles or a face shield, a disposab le gown a nd cap, and doubl e glov es s houl d be worn b y the an esthes ia prov ider and disca rded whe n leav ing the pa tient's room. W hen su rge ry is required, eff orts s hould be made to li mit expos ure to personnel and o the r patients . In a ddi ti on to observ i ng s tandard precauti ons , the anes thes ia prov ider shou ld us e a resp irator. Double gl ov es are recommended. The outer pai r shoul d be remov ed af ter direc t patie nt contac t and befo re touch ing equipment o r furn iture in other areas o f the room. Hands shoul d be washed immediatel y af ter glov es are remov ed.

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358. Ben-Dav id B , Gaitin i L. The routine wearing of glov es: impac t on the f requenc y of needl es tick and p erc utaneous inj ury and on su rf ace contamina tion in the operati ng room. Anes th Analg 19 91;83:623 628. [Med li ne Link ] 359. Cork RC, W ood D, Ev ans B , et al. Leak rate of la tex g lov es af te r tea ri ng adhes iv e tape. A m J Anes th 1995;22:133 137 . 360. Ho A M-H, Lam GC S , Karmak er MK . Potential eye injury due to protec tiv e f ac e sh ields . A nes thes iology 2004;100:201 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 361. Babb J R, B radley CR. The mec hanics of endoscope dis infec tion. J H osp Infec t 1991;18[Suppl A ]:130135 . 362. B jerk e NB . Tes t you r hand hy giene IQ. Outpatien t Surgery Ma gazi ne 2003;4:3844 . 363. Tes sl er MJ , Grill as N, Giosef fini S . Bac teri al c ounts on the ha nds of anes thetis ts and a nes thes ia technicians . A nes th Analg 199 4;78:10301031 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 364. Anonymous . CDC back s hand rubs ov er s oap and water. Outpatien t Surgery Maga zine 2002 ;3:6. 365. Anonymous . Integra ting the n ew CDC h and hygiene guidelines wi th OSHA 's BBP s tand ard . Heal th Dev ic es A lerts 2002;2 6:12. 366. Katz J D. CDC guideline urges phys ici ans to was h thei r hands of a di rty problem. ASA News le tt 2 003;67:21. 367. Maywo rm D. Do alcohol-bas ed hand s ani ti zers pos e a fire hazard? Ou tpa tient Surgery Magaz ine 2003;4:9495. 368. Barlas S . TIA c lea ns up hand-s ani ti ze r controv ers y. NFPA J 2004;98 :36 . 369. W id me r AF, Da ngel M. A lc ohol -based h andrub: ev aluation of tec hn ique and mic robiological eff ic ac y wi th i nternation al infec tion c ontrol profes s ionals . Infec t Con trol Hos p Epidemiol 2004;25:207209. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ]

370. Ros enberg AD, Berns tein DB , B erns tein RL, e t al . Acc identa l needles tic ks : d o anes thes iologis ts prac tic e proper inf ectio n c ontrol precauti ons? A m J Anes th 1995;22:125132. 371. Orens tein R , Reynolds L, Karabaic M, et al. Do p rotec tiv e dev ic es prev ent needles tic k injuries among health c are work ers? A m J Infec t Co ntrol 1995;23:344 351. 372. Perry J . Improv ing yo ur sh arps s afety program. Ou tpa tient S urgery Mag azine 2003;4:9496 . 373. Anonymous . Need les tick p rev entio n: a brief rev iew. Tech nol An esth 2003;24:15. 374. Tai t A R, Tuttle DB . P rev ention of oc cupa ti ona l trans mis sion of human i mmunodeficienc y v irus an d hepati tis B v irus among anes thesi ologis ts : a surv ey of anes thes iology p rac tice. Anes th Analg 1994;7 9:623628. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 375. Anonymous . Saf e dispos al of me dical wa s te s harps . Tec hnol Anes th 1993;14:112 . 376. Anonymous . Doub le -glov ing . Tec hnol A nes th 2002(12);22:35 . 377. Edl ich RF, W ind TC, Hill L G, et al . Resis tance of double-glov e hol e puncture i ndication s ys tems to surgic al needle punc tu re. J Long Term Eff Med Implants 2003;13:8590. [Med li ne Link ] 378. Lee J . How to prev ent i nfec tion f rom health care work ers . Outpatient S urgery Maga zine 2002 ; Spec ia l edi tion :21 24. 379. Hugh es SC, Marti n DE . Tradi tional I.V . catheters : to be o r not to be, that is the ques tion! A SA News lett 2005;69:141 7. 380. Hugh es S . HIV a nd other oc cupa tiona l exp osures : risk managemen t (AS A Ref resher Cours e #531 ). Pa rk Ridge, IL: A uthor, 1998 . 381. Greene E . Hepatitis C outbreak : more than 50 i nfec ted by reused needl es and s y ringes . ASA News lett 20 02;66:2224. 382. Sny dman DR, Hi ndman S H, Wineland MD, et al . Nos ocomial v iral hepatitis B . A c lus ter among s taff wi th s ubs equent transmis si on to pa tients . Ann Intern Med 1976;85:573577. [Med li ne Link ]

383. Peters on GN. CDC s ets guidel ines f or prev enti ng TB transmis si on in heal th ca re fac i li ties . ASA News lett 1995;59:2426. 384. Greene ES , B e rry AJ , Jagger J , et a l. Mu ltic enter s tudy of c on tami nated percu taneous i nj uries in anes thes ia pers onn el . Anes thesiolo gy 1998;89:1362 1372. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 385. Tai t A R. Oc cupationa l transmis sion of tuberc ul os is : imp lications fo r anes thes iologis ts . A nes th A nal g 1997;8 5:444451. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 386. Dec ker MD. OSHA enforcement po lic y for occ upational exposure to tuberc ul os is . Infec t Contro l Hosp Ep idemio l 1993 ;14:6 896 93. [Med li ne Link ] 387. Dav is YM, Mc Cray E , S imone P M. Hospi tal inf ectio n c ontrol prac tices for tuberc ul os is . Clin Ches t Med 1997;18:1933 . [Cross Ref] [Med li ne Link ] 388. Centers for Dis ease Con trol and P rev entio n. Guidel ines f or prev enting the transmis si on of Myc obac te rium tub erc ulos is in hea lth care fac il i ti es . MMW R Morb Morta l W kly Rep 1994;43(RR-13):132. 389. Cand io tti K , Sa ltzman B , Rodri guez YF. Rad ios te thoscopes : a s olution for the problem of auscul tation whi l e wearing protec tiv e gear. Anes thesiology 2005;103:A 811 . 390. Anonymous . Nega tiv el y press uri zed operating rooms . Technol Anes th 2003;23:1. 391. A lexander BH, Check oway H, Nagahama S I, et al. Cause -s pec ific morta li ty risk s of anes thesiologis ts . A nes thes io logy 2000 ;93 :92 293 0. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 392. Ros s RS , Via zov S , Gross T , et al . Trans miss ion o f hepati tis C v i rus f ro m a pati ent to an anes th esiology as sis tant to five patients . N E ngl J Me d 2000;343:185118 54.

[Cross Ref] [Med li ne Link ] 393. Cody S H, Nainan OV , Garfe in RS , e t al . Hepa ti tis C v irus transmission from an anes thes iologis t to a patient. A rc h Intern Me d 2002;162 :34 5350. [Cross Ref] [Med li ne Link ] 394. Berry AJ . Infec tion con trol recommendations ; the ir i mporta nce to the prac tice of anes thesiology. AS A News le tt 2 001;65:15 . 395. Berry AJ . Spreading the word on infec ti on control. ASA Ne ws lett 2002;66:4546 . 396. Bus by J . Th rough the v alley of many shadows . HIV i nfec ted phys ic ia ns . Tex Med 1991;87:3646. [Med li ne Link ] 397. Hal ti a M. Human prion dis eas es . An n Me d 2000;32 :493500. [Med li ne Link ] 398. Collinge J . Variant Creutzfeld t-Jak ob di seas e. Lancet 1999;354 :3173 23. [Cross Ref] [Med li ne Link ] 399. B lunt MC, B urc hett KR. Variant Creutzfeldt-Jakob disease and disposable anaes thetic equipmen tbal anc ing the risk s. B r J An aes th 2003;90:13. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 400. Lowe PR, Engelha rdt T . P rion-rela ted d iseases and anaesthes ia. A naes thesia 2001;56:485. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 401. Farling P , S mi th G. Anaes thes ia for patien ts wi th Creutzfeldt-Jak ob disease. A prac tical guide. Ana es thes ia 2003;58:627629. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 402. Hernandez-P al azon J , Martinez-Lage JF, To rtosa JA , et al . Anaes thetic mana gemen t in pa ti ents sus pec ted of , or a t ri sk of hav ing, Creu tzfel t-J akob disease. B r J A naes th 19 98;80:516518.

[Med li ne Link ] 403. Reiche rt M, S c hul tz J K . CJ D: how to process ins trumen ts . OR Manager 2001;17:2122. [Med li ne Link ] 404. Dombrov s ki A , Popat M, Farme ry A . Fibreop tic equipment and prion dis eas e. Anaes thes ia 2003;58:909 1. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 405. Anonymous . Fi breoptic equipment and prion dise ase. Anaes thes ia 2003;58:482483. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 406. Peng PW H, W ong DT, Bev an D, et al . Inf ec tion c ontro l and anes thes ia: l ess ons learned from the To ron to SARS ou tbreak . Can J Anes th 2003;50:989 997. 407. Chan g K -A , Luk H-N, J awan B , e t al . Modified protec tiv e sui ts for anes thes iologis ts perfo rming tracheal intuba tion fo r sev ere ac ute respiratory s yndrome patie nts i n Tai wan. A nes thes io logy 2004 ;100:16301631 . [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 408. Anonymous . Infec ted: an anes thes iolog is t's persona l battle wi th S ARS . ASA News le tt 2003;67:23 25. 409. S tackhous e RA . S ARS : i ts his tory, i ts c hal lenges . ASA News l ett 2003;67:19 22, 5. 410. Kamming D, Gardam M, Chun g F . Anaes thesi a and SARS . B r J Anaes th 2003;90:715718. [Fu ll tex t Link ] [Cross Ref] [Med li ne Link ] 411. Capu to K M, B y rick R, Ch apman MG, et a l. Intuba ti on of SAR S pa tients : i nfec tion and perspec tiv es of heal thcare work ers . Can J Anes th 2006;53:122129. P .1001

Questions
For the fol low ing ques tions , answe r

i f A , B , and C are c orrec t i f A a nd C a re co rrec t i f B a nd D a re co rrec t i f D is correc t i f A , B , C, and D a re co rrec t.

1. Concerning the th ree levels of disinfection re cognized by the CDC, A . High-l ev el dis infec ti on means tha t bac teri al spores a re k il le d B . S emic ri tical items can be treated with intermedi ate-l ev el dis inf ec tion C. The Creutzfeldt-Jakob v i rus is k il le d with hig h-lev el disi nfec tion D. Intermedia te-l ev el dis infec tion means tha t M. tuberc ul osis is kil led V iew A ns we r2. Advantages o f steam a utoc la ving include A . It is highly effec tiv e B . Items c an be pac kaged beforehand C. It i s i nexpensiv e D. Absenc e of toxic res idues V iew A ns we r3. Factors that affe ct th e e ffectiveness of chemical disinfection inclu de A . Te mperatu re B . Us e p attern C. pH D. Charac te ris tic s of th e item to be disinf ected V iew A ns we r4. E O A . Is flammable in c onc entrati ons exc eeding 5% B . Is not us eful for i tems c ontaining petroleum-bas ed lu bricant C. Is odorless D. Shoul d not be us ed on i tems that a re wet V iew A ns we r5. Clea ning is importa nt as the first s tep be cause A . Re tai ned s al ts and o rga nic s oil can inac tiv ate chemica l germic ides B . Ev en af ter s te ri li za tion residues can c aus e a patient reac ti on C. So il c an protec t mic ro organisms duri ng dis in fec ti on and s te ri li zation

D. Resid ues may interfere with the dev ice fu nc tio n ev en af te r s teri l ization V iew A ns we r6. Concerning the class ific ation of items accord ing to the CDC, A . S emic ri tical items incl ude trac heal tub es B . B lood p res sure cuffs are nonc ri tica l items C. High-lev el dis infec tion is acce ptable f or s emic ri tica l items D. Phenols are usef ul for s emic ri tic al items V iew A ns we r7. Wh ich of the fo llow ing s tatements are co rrect? A . A n an tisep tic can be s afe ly ap plied to liv ing tiss ue B . A disinf ec tant is a germic ide to be use d s olely on inan ima te objec ts C. A san iti zer is a low-l ev el dis infec tant wi th no c laim for tube rc ulocidal ac tiv i ty D. A s terilant/d is infec tan t is a ge rmici de that i s c apable of s te rili za tion or high -l ev el disi nfec tion V iew A ns we r8. The role of the F DA is to A . Requi re new ge rmici des to demons trate 1 0 6 s teril ity B . Regul ate medic al dev ices C. Requi re tes ting of fo rmul ations for mic robici dal potenc y, s tabi lity, and tox ic ity D. Regulate l iqui d c hemical germic ides tha t are us ed to reprocess medical i ns trume nts V iew A ns we r9. The fun ctions of the CDC include A . A pprov ing germic ides B . Regul ating ge rmic ides C. Tes ting ge rmic ides D. Recommend in g b road s trategies to prev ent transmission of infec tions i n the health care env i ronment V iew A ns we r10 . P ractices an d p roce dures to rep roc ess reusable devices have been published by w hich org anization s? A . A me rican Soc ie ty of A nes thes iologis ts B . As soc iation of Ope rati ng Room Nurs es C. American Ass oc iatio n of Nurs e Anes thetis ts D. Cente rs for Diseas e Control and P rev enti on V iew A ns we r11 . Advan tages of pas teu rization include A . No toxic residues or f i lms B . Can be used for prepac kaged items C. Can b e used for trac heal tubes and breathing tubes D. High temperatures c an be us ed

V iew A ns we r12 . Disadvantage(s ) of steam ste riliz atio n include A . A dequa te penetrati on into a pack may not oc cur wi th l arge pac ks B . A l l s pores may not be k il led C. Danger to proces sing personnel D. Ins trument damage V iew A ns we r13 . Glutaraldehyde is effective against w h ich class es of organisms? A . S pores B . V i ruses C. Fungi D. Bac te ri a V iew A ns we r14 . Haza rds of glutara lde hyde ex posure inc lude A . Sk in i rritatio n B . Headac hes C. As thmalike s ympto ms D. Gas troi ntes tinal ups et V iew A ns we r15 . Whic h agent(s) is(are) sporic ida l? A . Quats B . A lco hols C. Phenolics D. OPA V iew A ns we r16 . Disadvantages of liquid chemical dis infectio n include A . P repackaging is not poss ib le B . Lack of g ood method f or v al idatio n C. No gu ara ntee of s teri l ity D. Not eff ec tiv e aga ins t HIV V iew A ns we r17 . Whic h of the follow ing are killed by E O? A . V i ruses B . Fu ngi C. Bac te ri a D. Spores V iew A ns we rP .100 2

18. Wh ich factors are importa nt fo r proper E O s terilization ? A . Ex pos ure time

B . Re lativ e humidi ty C. Gas c once ntration D. Temperatu re V iew A ns we r19 . P atien t complications associated w ith contact w ith E Osteriliz ed items include A . Lary ngotracheal infl ammati on B . A naphy lax is C. Hemo lysis when E O is ex pose d to bl ood D. Cancer V iew A ns we r20 . Advan tages of E O ste rilizatio n include A . Items c an be prepac kaged B . A l arg e amount of equ ipment can be s te ri li zed a t one time C. It can be used for i tems that heat or mo is ture could da mage D. Short p roc ess ing ti me V iew A ns we r21 . Disadvantages of E O ste rilizatio n include A . No t useful for e quipment with smal l l umens B . Danger of fi res and exp los ions in s teri li zers C. Dama ge to s ome v ery s mall equi pmen t D. More cos tl y than other ty pes of s te ri li za tion V iew A ns we r22 . Advan tage to -radiation include A . P roduc t may be prepackaged B . Th ermolabil e equipme nt can be s te ri li zed C. No temperature ris e duri ng s teril i zation D. It i s usef ul f or the av e rage h ospi tal V iew A ns we r23 . Advan tages of plasma steriliza tion inc lude A . No work er exposure or env ironmen tal con tamination B . Lack of toxic resi dues C. Comp ati bl e wi th c eramics , s il ica, glass , a nd many plas tics D. S teril i zed produc ts are immed ia tel y av ailabl e for use V iew A ns we r24 . Appropriate barrie r precautio ns include A . E y e protec tion B . Face s hi el ds C. Fluid-res is tan t mask s D. Gl ov es V iew A ns we r25 . Tech niques that are designed to preve nt need les ticks include

A . W ea ri ng glov es wh en s tarti ng an in trav en ous i nfus ion B . Disposi ng of us ed nee dles in a cen tral loca tion C. Us ing protec tiv e dev ices ov er the ne edle D. Recapp ing needl es as soon as th ey are used by us ing both hands V iew A ns we r26 . Whic h of the follow ing are pa rt of the CDC guidelines for care of a patient w ith TB? A . Th e patien t sho ul d be in a room wi th posi tiv e-press ure v entilation B . Respi ratory is olation is required un ti l TB is ruled out C. Ul trav iol et li ght is not helpfu l D. Pe rsonnel s hou ld wea r spec ia l protec tion dev ices that a re app rov ed by the CDC for fil tratio n and fi t V iew A ns we r27 . Whic h s tatements are true of HIV? A . Th e risk of HIV infec tion af ter a holl ow-bore needle s tick is 0 .3% B . Th e v irus is relativ el y s table in the env i ro nment C. HIV is rela tiv ely uns ta ble i n the env i ro nment a nd is rapidly inac tiv ated b y a wi de range of c hemical germici des D. HIV -c ontaminated dev ices need on ly intermedia te-lev el decontamination V iew A ns we r28 . Whic h s tatements are true of HBV ? A . Th e risk of c ontrac ting HB V af ter a needles tick is 10% to 30% B . Mul tidose v ials hav e no t been found to fac ili tate nosoc omia l infec tions C. Dev ic es con tamina ted wi th b lood with patien ts f rom HBV requi re high-l ev el decontami nation D. HB V su rv iv es onl y a s hort ti me on env ironmen tal s urfac es V iew A ns we r29 . Whic h s tatements concerning CJD are true ? A . S terili zation requ ires s team at 134C to 1 38C B . Lary ngos copes and LMAs that are exposed to an infec ted patient should be disc arded C. The inc ubation perio d c an be months to y ears D. Gl utara ldehyde, formal dehyde , and ph enol ics are not effec tiv e agains t p ri ons V iew A ns we r