BREATHING SYSTEMS

74. Breathing systems

A question on breathing systems often starts with the examiner showing photographs of different types of systems,
asking you to identify them and explain how they function.
There are three main objectives when using a breathing system:
> To supply O2 to the patient
> To allow removal of CO2 from the system and avoid rebreathing
> To supply anaesthetic gases to the patient
There are several classification systems, but the most commonly used (and examined) is the Mapleson classification
system (Professor Bill Mapleson worked in Cardiff and classified the breathing systems in 1954).

Describe the movement of gas The respiratory cycle comprises three phases: inspiration, expiration and the
within each system. expiratory pause.
> During inspiration, gas is drawn in from the equipment.
> In quiet breathing, the average 70 kg patient’s tidal volume is
approximately 500 mL. At 20 breaths per minute, their minute volume
(MV) would be 10 L/min. In order to avoid rebreathing, the fresh gas flow
rate would have to exceed the patient’s MV. This would result in very high
volumes of gas needing to be delivered. This is wasteful and requires high
flow rates that would be uncomfortable for the patient.
> With maximum effort, the average 70 kg patient can draw in
approximately 5 L of gas over about 2 seconds. Again, unless flow rates
were extremely high the patient would entrain air.
> To overcome these problems, reservoir bags have been added to the
breathing systems.
> During deep inspiration the patient can draw oxygen and gases from
these as well as from the fresh gas flow.
> At the beginning of expiration, gas expired is from the anatomical dead
space, so it does not contain CO2 and is not depleted of O2. This gas is
fit to be inhaled again.
> As expiration continues, alveolar gas is exhaled next, this contains CO2
and is O2 deplete. It is desirable to rid the system of this gas before the
next inspiration.
> Adjustable pressure-relieving (APL) valves have been added to some
circuits to vent waste gases and overcome the problem of rebreathing.

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 02 PHYSICS
Mapleson A (Magill)

FGF

Patient
Reservoir
Bag

FGF
Mapleson B (not used)

Reservoir
Bag

Mapleson C FGF
(Used on ITU - Waters' circuit) Patient

Reservoir
Bag

Mapleson D Patient FGF

Reservoir
Bag

Mapleson E FGF Patient

(Ayre's T-Piece)

Patient

Mapleson F = E + Open Bag FGF

(Jackson-Rees modification)

Reservoir
Bag

Patient

Fig. 74.1  Diagrammatic respresentation of Mapleson classification of breathing systems

Mapleson A (non-co-axial ‘Magill’ system)

Spontaneous ventilation
When describing breathing systems always start with the statement, ‘The
patient has just exhaled, the equipment is full of fresh gas and I put the mask
over the patient’s face. At the perfect flow rate ...’
> The patient inhales fresh gas, from the supply and from the reservoir bag,
which deflates proportionally.
> The patient exhales and the dead space volume is expelled into the
breathing system, passing down the tubing and fills the reservoir bag
again. In addition, the fresh gas flow will also contribute to filling the bag.

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 BREATHING SYSTEMS
> After the dead space gas, the alveolar gas is exhaled. At this stage the
reservoir bag is already filled and so the pressure in the system begins
to rise. Because of this, the alveolar gas is vented through the APL valve
and lost from the system, so avoiding rebreathing.
> If the fresh gas flow is too low, the bag will not be filled solely by dead
space gas. Some alveolar gas will be able to enter the bag, and the
patient will rebreathe.
> If the fresh gas flow is too high, the fresh gas flow will fill the bag to a
degree and dead space gas will be vented along with alveolar gas. While
this avoids rebreathing, it is wasteful and inefficient.
Controlled ventilation
> The anaesthetist squeezes the bag, forcing gas into the patient. Some
gas, however, will be vented from the expiratory valve near the patient.
At the end of inspiration, the reservoir bag will not be full.
> During exhalation, dead space and alveolar gas will move down to fill the
reservoir bag.
Unless the gas flows are high, 2.5 × MV, rebreathing will occur.
The Mapleson A is:
> Efficient in spontaneous ventilation (70 mL/kg/min)
> Inefficient for controlled ventilation (2.5 × MV).
Mapleson A (co-axial version ‘Lack’ system)
Co-axial means there is an inner tube surrounded by an outer one.

Adjustable
Pressure-relieving
Valve

Fresh Gas Flow

Patient
Reservoir
Bag

Fig. 74.2  Co-axial Mapleson A

The Lack is a version of the Mapleson A, which was designed to move the
pressure release valve away from the patient and so make it less awkward
and bulky to use. The fresh gas flows down the outside tubing, and gas is
vented via the inner tubing. The reservoir bag is in the inspiratory limb, while
the pressure release valve is in the expiratory limb. The gas flows required in
the system are the same as for the standard A. The Lack is bulkier than the
Bain (see next page) because the inner tube has to have a sufficiently large
diameter to minimise expiratory resistance.
Mapleson B and C
These are essentially the same, but the C has shorter tubing. The B is not
used. The C is used for transfer, or ‘bagging’ patients on ICU. This system
needs high gas flows to prevent rebreathing (2.5 × MV for spontaneous and
controlled ventilation).
The Mapleson C is colloquially referred to as a ‘Waters’ circuit’, though
strictly this is inaccurate as a true Waters’ circuit would include a canister
of soda lime to absorb CO2 and prevent rebreathing. These are not
manufactured any more.

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 02 PHYSICS
Mapleson D (non-co-axial system)
Spontaneous ventilation
The patient has just exhaled, the equipment is full of fresh gas and I put the
mask over the patient’s face. At the perfect flow rate:
> The patient inhales fresh gas, from the supply and from the reservoir bag,
which deflates proportionally
> The patient exhales and the dead space volume is expelled into the
breathing system. The fresh gas flow and the exhaled dead space gas
mix and both pass down the tubing to fill the reservoir bag
> After the dead space gas, the alveolar gas is exhaled. At this stage the
reservoir bag is already filled and so the pressure in the system begins
to rise. Because of this, the alveolar gas is vented through the pressure
release valve and lost from the system so avoiding rebreathing
> During the expiratory pause, fresh gas continues to push exhaled alveolar
gas down towards the reservoir bag (as the pressure release valve is
further away than in the A) and rebreathing will occur at gas flows of
< 2.5 × MV.
Controlled ventilation
> The patient exhales and a mixture of fresh gas and dead space gas
enters the bag, as described above.
> The anaesthetist squeezes the bag and fresh gas from the distal tubing
is forced into the patient and a variable amount of gas from the reservoir
enters the patient. Following this, the pressure in the system rises
(according to the patient’s lung compliance) and further gas gets vented
from the expiratory valve.
The Mapleson D is:
> Inefficient for spontaneous ventilation (2.5 × MV)
> Efficient for controlled ventilation (70 mL/kg/min).
Mapleson D (co-axial ‘Bain’ system)

Fresh Gas Flow

Reservoir Patient
Bag

Fig. 74.3  Co-axial Mapleson D

In this circuit the fresh gas flows down the inner tubing, and exhaled gas
enters the outer tubing. Both the reservoir bag and APL valve are in the
expiratory limb. The Bain is equally efficient for controlled or spontaneous
ventilation.
During controlled ventilation at a flow rate of 70 mL/kg/min, the patient will
in fact be rebreathing. However, because we tend to over-ventilate our
patients, their end tidal CO2 will not actually rise despite the fact they are
rebreathing. If we managed not to over-ventilate, we would actually see a
rising ETCO2 as evidence of this. To truly avoid rebreathing during controlled
ventilation in the Bain circuit, we would need to use 2.5 × MV, the same flow
rate as is necessary to avoid it in spontaneous ventilation.

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 BREATHING SYSTEMS

Mapleson E
This is also called the Ayre’s T-piece after the man who invented it.
It has no valves or reservoir bag and so is a very low resistance system. This
makes it suitable for use in paediatrics.
Mapleson F
This is an E with the ‘Jackson–Rees modification’: an open-ended reservoir
bag connected to the end of the tubing. This allows for the application of
CPAP and controlled ventilation.
In both E and F, fresh gas flows of 2.5 × MV are required to prevent
rebreathing.

Table 74.1  Volume of fresh gas flow required to prevent rebreathing during spontaneous and
controlled ventilation using the Mapleson breathing systems

Mapleson classification Spontaneous ventilation Controlled ventilation

A 70 mL/kg/min 2.5 × MV
B 2.5 × MV 2.5 × MV
C 2.5 × MV 2.5 × MV
D 2.5 × MV 70 mL/kg/min
E 2.5 × MV 2.5 × MV
< 20 kg 2.5 × MV (minimum 3 L/min) 1000 mL + 100 mL/kg/min

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