Paediatric anaesthetic breathing systems

The closed circuit and the low flow systems

A breathing system is defined as an assembly of components, which delivers gases from the anesthesia machine to the patients’ airways. When the components are arranged as a circle, it is termed a circle system. The flow of exhaled gases is unidirectional in the system. The system contains a component (absorber), which absorbs exhaled carbon dioxide and it is not necessary to give high fresh gas flows as in Mapleson systems. When the adjustable pressure limiting (APL) valve is closed and all the exhaled gases without carbon dioxide are returned to the patient, the system becomes a totally closed one. Such a circle system can be used with flows as low as 250 to 500 mL and clinically can be termed as low-flow systems. The components of the circle system can be arranged in different ways with adherence to basic rules: (1) Unidirectional valve must be present between the reservoir bag and the patient on both inspiratory and expiratory sides; (2) fresh gas must not enter the system between the expiratory unidirectional valve and the patient; and (3) the APL valve must not be placed between the patient and the inspiratory unidirectional valve. The functional analysis is explained in detail. During the function, the arrangement of components is significant only at higher fresh gas flows. With the introduction of low resistance valves, improved soda lime canisters and low dead space connectors, the use of less complicated pediatric circle systems is gaining popularity to anesthetize children. There are bidirectional flow systems with carbon dioxide absorption. The Waters to and fro system, a classic example of bidirectional flow systems with a canister to absorb carbon dioxide, is valveless and portable. It was widely used in the past and now is only of historical importance.

Mathematical model and minimal measurement system for optimal control of heated humidifiers in neonatal ventilation

The control of thermo-hygrometric conditions of gas delivered in neonatal mechanical ventilation appears to be a particularly difficult task, mainly due to the vast number of parameters to be monitored and the control strategies of heated humidifiers to be adopted. In the present paper, we describe the heat and fluid exchange occurring in a heated humidifier in mathematical terms; we analyze the sensitivity of the relative humidity of outlet gas as a function of thermo-hygrometric and fluid-dynamic parameters of delivered gas; we propose a control strategy that will enable the stability of outlet gas thermo-hygrometric conditions. The mathematical model is represented by a hyper-surface containing the functional relations between the input variables, which must be measured, and the output variables, which have to remain constant. Model sensitivity analysis shows that heated humidifier efficacy and stability of outlet gas thermo-hygrometric conditions are principally influenced by four parameters: liquid surface temperature, gas flow rate, inlet gas temperature and inlet gas relative humidity. The theoretical model has been experimentally validated in typical working conditions of neonatal applications. The control strategy has been implemented by a minimal measurement system composed of three thermometers, a humidity sensor, and a flow rate sensor, and based on the theoretical model. Outlet relative humidity, contained in the range 90+/-4% and 94+/-4%, corresponding with temperature variations in the range 28+/-2 degrees C and 38+/-2 degrees C respectively, has been obtained in the whole flow rate range typical of neonatal ventilation from 1 to 10 L/min. We conclude that in order to obtain the stability of the thermo-hygrometric conditions of the delivered gas mixture: (a) a control strategy with a more complex measurement system must be implemented (i.e. providing more input variables); (b) and the gas may also need to be pre-warmed before entering the humidifying chamber.

An adult system versus a Bain system: comparative ability to deliver minute ventilation to an infant lung model with pressure-limited ventilation

We compared the efficacy of an adult circle system versus a Bain system to deliver minute ventilation (V(E)) to an infant test lung model using pressure-limited ventilation. To simulate a wide variety of potential infant clinical states, V(E) was measured with two compliances: at peak inspiratory pressures (PIP) of 20, 30, 40, and 50 cm H2O and at respiratory rates (RR) of 20, 30, 40, and 50 breaths/min. Each measurement was made three times, and their average was used for analysis. Data were analyzed using the multiple regression technique. In both normal and low-compliance lung models, V(E) was nearly identical between adult circle and Bain systems (P = 0.67 for normal compliance model, P = 0.89 for low-compliance model). V(E) positively correlated with RR (P < 0.001), PIP (P < 0.001), and lung compliance (P < 0.001). Very high PIP or RR were required to deliver V(E) to the low-compliance lung model. The adult circle system is equivalent to the Bain system in its ability to ventilate an infant test lung over a wide range of RR, PIP, and two compliances during pressure-limited ventilation. V(E) is dependent of PIP, RR, and lung compliance. With low-compliance lungs, both systems require a high PIP. We conclude that both anesthetic systems deliver ventilation over a wide range of respiratory variables during pressure-limited ventilation in infants.

IMPLICATIONS

We obtained results from this infant test lung study that indicate that either an adult circle breathing system or the Bain system can reliably deliver ventilation over a wide range of respiratory variables during pressure-limited ventilation in infants.

[Pros or cons of accessory anesthetic circuits. I. Arguments for their use]

In addition to the circle breathing system, which represents the main circuit of the anaesthetic machine, the use of an accessory breathing system (ABS), either a partial rebreathing system according to Mapleson's classification, or a system including a non-rebreathing valve, is appropriate for the anaesthetic management of many patients, depending on their physical status, age, indication and duration of surgery. The same safety rules, namely full checking procedure before use of the system and monitoring of inhaled gases and end-tidal CO2 must be applied as for the main circle system. Potential complications resulting from non compliance with these rules cannot be considered valuable reasons for denying the use of breathing systems that have safely been used for decades in millions of patients.

The effect of circuit compliance on delivered ventilation with use of an adult circle system for time cycled volume controlled ventilation using an infant lung model

This in vitro study examined the effect of circuit compliance on delivered ventilation (VE) using a time-cycled, volume controlled circle system in an infant lung model. A Bio-Tek ventilator tester set to simulate normal and abnormal lung compliance measured VE delivered by the Narkomed 2B system. Circle circuits of varied compliance (2.75, 1.22 and 0.73 microliters.cm H2O-1) were tested. Tidal volume was adjusted to peak inflation pressures (PIP) of 20, 30, 40, and 50 cm H2O with three circuits, two lung compliances, and four different size tracheal tubes (TT) (2.5, 3.5, 4, 4.5 mm ID). Data were analysed using the multiple regression technique. Delivered VE was directly related to PIP and lung compliance. Delivered VE was not affected by the choice of circuit. TT size had minimal effects on VE when lung compliance was low; TT size was a more important factor when test lung compliance was normal. Extrapolating this data to the clinical setting, adequate ventilation of infants can be achieved with an adult circle system if an appropriate PIP is chosen, regardless of the compliance of the circuit used. Infants with poor lung compliance may require very high PIP for adequate ventilation.