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  • Image not available. Because insufflation avoids any direct patient contact, there is no rebreathing of exhaled gases if the flow is high enough. Ventilation cannot be controlled with this technique, however, and the inspired gas contains unpredictable amounts of entrained atmospheric air.
  • Image not available. Long breathing tubes with high compliance increase the difference between the volume of gas delivered to a circuit by a reservoir bag or ventilator and the volume actually delivered to the patient.
  • Image not available. The adjustable pressure-limiting (APL) valve should be fully open during spontaneous ventilation so that circuit pressure remains negligible throughout inspiration and expiration.
  • Image not available. Because a fresh gas flow equal to minute ventilation is sufficient to prevent rebreathing, the Mapleson A design is the most efficient Mapleson circuit for spontaneous ventilation.
  • Image not available. The Mapleson D circuit is efficient during controlled ventilation, because fresh gas flow forces alveolar air away from the patient and toward the APL valve.
  • Image not available. The drier the soda lime, the more likely it will absorb and degrade volatile anesthetics.
  • Image not available. Malfunction of either unidirectional valve in a circle system may allow rebreathing of carbon dioxide, resulting in hypercapnia.
  • Image not available. With an absorber, the circle system prevents rebreathing of carbon dioxide at fresh gas flows that are considered low (fresh gas flow ≤ 1 L) or even fresh gas flows equal to the uptake of anesthetic gases and oxygen by the patient and the circuit itself (closed-system anesthesia).
  • Image not available. Because of the unidirectional valves, apparatus dead space in a circle system is limited to the area distal to the point of inspiratory and expiratory gas mixing at the Y-piece. Unlike Mapleson circuits, the circle system tube length does not directly affect dead space.
  • Image not available. The fraction of inspired oxygen (Fio2) delivered by a resuscitator breathing system to the patient is directly proportional to the oxygen concentration and flow rate of the gas mixture supplied to the resuscitator (usually 100% oxygen) and inversely proportional to the minute ventilation delivered to the patient.


Breathing systems provide the final conduit for the delivery of anesthetic gases to the patient. Breathing circuits link a patient to an anesthesia machine (Figure 3-1). Many different circuit designs have been developed, each with varying degrees of efficiency, convenience, and complexity. This chapter reviews the most important breathing systems: insufflation, draw-over, Mapleson circuits, the circle system, and resuscitation systems.

Figure 3-1
Graphic Jump Location

The relationship between the patient, the breathing system, and the anesthesia machine.


Most classifications of breathing systems artificially consolidate functional characteristics (eg, the extent of rebreathing) with physical characteristics (eg, the presence of unidirectional valves). Because these seemingly contradictory classifications (eg, open, closed, semiopen, semiclosed) often tend to confuse rather than aid understanding, they are avoided in this discussion.


The term insufflation usually denotes the blowing of anesthetic gases across a patient’s face. Although insufflation is categorized as a breathing system, it is perhaps better considered a technique that avoids ...

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