Chapter 14

Hazards of Anesthesia Machines and

Breathing Systems
Al though enormous st ri des have been made i n i mproving t he safet y of anesthesi a
apparatus, probl ems conti nue t o be report ed. Studies show t hat human error i s
more f requent than equi pment f ai l ure (1,2, 3, 4,5,6, 7,8,9,10,11).
Thi s chapt er wi l l exami ne hazards of anesthesi a machines and breathi ng systems
f rom the perspecti ve of thei r ef fect on t he pat i ent . Many exampl es are given, but
t hese shoul d not be considered a complete l isti ng of al l possi bl e dangers. Many
hazards invol ve ol der apparatus that may have been modi f ied and is no l onger sol d
or serviced by the manuf acturer. A di scussion of anesthesi a machi ne obsol escence
i s found in Chapter 5.
Hypoxia
Hypoxic Inspired Gas Mixture
Incorrect Gas Suppl ied
Piping System
The wrong gas may be suppli ed to t he central oxygen suppl y
(12,13,14, 15, 16,17,18, 19). Crossovers bet ween oxygen and other gases may occur
i n the pi pi ng system (20,21,22, 23). During or f oll owi ng const ructi on or repai r, a
pi pel i ne may be f i l led wi t h ai r or ni trogen rat her t han oxygen (24, 25).
A gas mi xer, anesthesi a machi ne, or venti l at or may al l ow a crossover and
contaminate one pipel i ne gas wi t h the contents of the other
(26,27,28, 29, 30,31,32, 33,34). I f the oxygen pressure is l ower than t he ot her gas,
t hat gas may enter t he oxygen pi pel i ne.
I nsi de the operat ing room, i ncorrect outl ets may be i nstal led
(35,36,37, 38, 39,40,41, 42). A termi nal uni t may accept an i ncorrect connect or
(43,44,45, 46, 47,48). An i ncorrect connector may be pl aced on a hose
(49,50,51, 52, 53,54,55) or the pi peli ne i nl et of t he anesthesi a machine (40). I t may
be possi bl e to at tach an oxygen tubi ng or hose to the out let f rom an ai r f l owmet er
(56,57,58, 59).
I f i t i s suspected that the pi pel i ne oxygen system i s del i veri ng l ess than 100%
oxygen, i t is i mportant to open an oxygen cyl i nder AND to di sconnect the oxygen
pi pel i ne hose. If the pi peli ne hose is not di sconnected, gas f rom the pi pi ng system
wi l l sti l l be del i vered. If t he cause of a l ow oxygen concent rati on is not obvious and
t he si tuati on i s not correct ed by di sconnecti ng the oxygen pi pel i ne hose and
openi ng an oxygen cyl i nder, t he pat i ent shoul d be venti lated wi t h room ai r by usi ng
a manual resusci tat i on bag (Chapter 10).
Cylinders
I t i s possi bl e f or a cyl inder l abel ed oxygen to contai n another gas
(60,61,62, 63, 64,65). A cyl i nder may be pai nted a color ot her t han t hat normal l y
used for a part i cul ar gas. Care should be taken when usi ng cyl i nders i n other
count ri es, because four di ff erent col ors (green, whi t e, blue, and bl ack) are used
around the worl d f or oxygen (66). I n a cyl i nder contai ni ng a mixture of t wo gases,
i ncompl ete mixing may resul t in a hypoxi c mixture bei ng del i vered (67,68). Such a
cyl i nder may requi re 45 mi nut es of rotati ng bef ore mixi ng i s compl ete.
Despi te al most uni versal use of the Pi n Index Safety System, reports of i ncorrect
cyl i nders being connected to yokes conti nue t o appear
(69,70,71, 72, 73,74,75, 76,77,78,79,80,81,82). An i ncorrect yoke bl ock may be
i nsert ed (83,84). A pi n may become unscrewed f rom the yoke (85).
Crossovers in the Anesthesia Machine
Crossovers bet ween oxygen and other gases can occur i nside t he anesthesi a
machi ne and are especial l y li kel y i f the machi ne pi pi ng has been al tered (49,86).
Hypoxic Mixture Set
Flow Control Valve Malfunction
A f l ow control valve mal f uncti on may resul t i n more or l ess gas bei ng del i vered. If
t he oxygen fl ow control valve is damaged and the f l ow i s decreased, hypoxia can
resul t (87,88,89). If the f low cont rol val ve f or another gas mal funct ions in such a
way t hat excessi ve gas i s del ivered, hypoxia coul d also resul t .
Incorrect Flowmeter Setting
Some ol der anesthesi a machi nes do not have a mi ni mum oxygen rati o devi ce that
prevents the user f rom diali ng a hypoxi c f resh gas mi xture. On t hese machines, a
hypoxi c mixture can be caused by partl y or f ul l y cl osing the oxygen f low control
valve, whi l e all owi ng the ni t rous oxi de f low t o cont inue (90,91,92,93). Absence of a
mi nimum oxygen rat io device is one of the cri t eri a f or machi ne obsol escence
(Chapter 5). Unf ortunatel y, many anesthesia machines in service sti l l lack this
device (94). There may be problems wi t h t he mi ni mum oxygen rat io device
(95,96,97, 98, 99,100,101,102,103,104,105), or t he machi ne may have addi t ional
gases that are not i ncorporated i nt o the mi ni mum oxygen rati o devi ce.
Oxygen f l ow can be i nadvertent l y l owered (or the f l ow of another gas i ncreased) i f
t he f l ow control knob is i nadvertentl y rotated by an i tem on t he surface bel ow (106)
or by a hose or wi re al l owed t o drape around i t . Wi th some f l owmeters, in and out
movement of the f l ow cont rol val ve can change the f low signif i cant l y (107).
Someone hel pi ng to move the machi ne coul d grab a f l ow cont rol valve knob and
change t he f l ow (Fi g. 14.1). Most new machi nes have a guard over or around t he
f low control valves to prevent thi s probl em.
The abil i ty to del iver 100% ni trous oxi de was found i n an anesthesi a machi ne where
t he tubing to the common gas outl et became ki nked (108,109). In t hi s case,
P. 406

t he ni trous oxide regul ator was set at a higher pressure t han t he oxygen regul at or,
whi ch caused ni t rous oxi de to pref erent ial l y pass t hrough the tubi ng.

View Figure

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.

Incorrect Flowmeter Reading
On some ol der machi nes, the f l owmet er i ndi cat or can di sappear f rom vi ew at t he
t op of t he tube when the fl ow of gas exceeds the maxi mum scal e cal ibrati on. Such
a fl owmeter i s very si mi l ar i n appearance to one wi th the i ndicator resti ng at t he
bot tom. I f the f l owmet er carri es a gas other than oxygen, a hypoxic mi xture may
resul t .
I f an ai r fl owmeter i s present on a machi ne, di al i ng ai r i nstead of oxygen can resul t
i n a hypoxic mi xture (110). To prevent this, most modern anesthesi a machi nes do
not al l ow admi ni st rati on of ai r and ni t rous oxi de wi thout addi ti onal oxygen fl ow.
Inaccurate Flowmeter
Causes of f l owmeter i naccuracy i ncl ude di rt , grease, or oil on the i ndi cat or or tube;
a st uck or damaged i ndicator; mi sal i gnment of the tube; st at ic electri ci t y; i mproper
cali brati on; the stop at the top of t he tube fal l i ng down onto the i ndicator (Fi g.
14.2); and t ransposi ti on of i ndi cator, scal e, or t ube (111, 112,113, 114, 115,116,117).
Oxygen Lost to Atmosphere
I f there i s a l eak at the t op of the oxygen f l owmet er tube, oxygen wi l l be
pref erenti al l y l ost, even i f the oxygen fl owmet er i s downstream of t he ot her
f lowmeters (118,119,120,121, 122, 123). The posi t ion of the i ndi cator may not be
af fected. Of ten, the def ect cannot be seen unti l t he tube is disassembled.
Ot her l eaks i n the anesthesi a machi ne can resul t i n hypoxi a, t he magni t ude of
whi ch wi l l depend on the si ze of the l eak and i ts locat ion
(121, 122,124,125, 126, 127,128, 129). I t i s i mportant to use a yoke plug i n any yoke
not cont ai ni ng a
P. 407

cyl i nder so that gas wi l l not l eak out of the yoke i f the f l ow cont rol valve to t hat
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 Entrai nment
I f the pressure in t he breathi ng system fal l s bel ow atmospheri c, ai r may be drawn
i nto t he system through a leak or di sconnect i on. Subatmospheri c pressure may be
caused by t he pat i ent 's i nspi ratory eff ort ; suct ion appl ied t o an ent eric tube
i nadvert ent l y placed i n the t racheobronchi al t ree or to the worki ng channel of a
f iberscope i n the ai rway; a probl em wi th a cl osed scavengi ng system i nterf ace; a
venti l ator wi th a hanging bel l ows; a pi ston venti lat or; or a si destream gas anal yzer
wi th a l ow f resh gas f low (130,131,132, 133, 134,135,136,137). Ai r can enter the
breat hi ng system i f the venti l at or bell ows i s i mproperl y connected or has a hol e
(138, 139,140,141, 142, 143,144) or the f resh gas f l ow i s di rected t o the wrong ci rcui t
(145).
I n many cases, ai r entrai nment i s mani f ested by a decrease i n anesthet ic agent as
wel l as oxygen concent rat i ons (135,146).
Hypoventilation
Causes
Insuffici ent Gas in the Breathing System
Low Inflow
Pipeline Problems
Loss of pi pel i ne oxygen pressure was discussed in Chapter 2. Causes i ncl ude
damage during construct ion, debri s in the l i ne f ol l owi ng i nstal l ati on, unannounced
system shutdown, pressure regul ator mal f uncti on, central suppl y system
mal f unct ion, a di srupted l i ne bet ween the central suppl y and t he pi pi ng system,
compressor f ai l ure resul t ing f rom an el ectrical storm, f i res, and a closed i sol at ion
valve (51, 147,148,149,150,151,152,153,154,155,156,157,158,159). A stati on outl et
may become bl ocked or not accept a qui ck connector (159, 160).
A hose may devel op a l eak, become blocked, or devel op a ki nk that obstructs gas
f low (152, 161,162,163,164,165,166,167). The anest hesia machi ne may rol l over a
hose, occl udi ng gas f low (164). The check val ve at t he pi pel i ne inl et of the
anesthesi a machine may mal f uncti on (168), or t he f i l t er may become clogged,
reducing gas f l ow (169).
I f pi ped oxygen pressure i s l ost , an oxygen cyl i nder should be opened and the
pi pel i ne hose disconnected f rom the wal l t o prevent f l ow f rom the cyl i nder i nto the
pi pel i ne. To mi ni mi ze oxygen use, a gas-powered venti l ator should be turned OFF
(thi s i s not necessary i f an el ectricall y powered piston vent i l ator i s bei ng used),
manual or spontaneous vent il ati on i nsti tuted, and t he f resh gas f l ow l owered as
much as possibl e.
I f opening an oxygen cyl i nder does not repressuri ze the anest hesi a machine, then
t here i s a probl em i n the machi ne' s hi gh or i nt ermediate pressure system or the
cyl i nder is empty or not properl y connected (164). A resusci tati on bag shoul d be
used to venti l ate the pat i ent unti l another machine can be obtai ned.

View Figure

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.

Cylinder Problems
A cyl i nder may be empty at del i very or af ter use. The cyl i nder val ve may be
i noperable, or t he valve out l et may be bl ocked (170,171,172,173).
Bef ore a cyl inder can be used, i t must be correct l y i nstal l ed on the machi ne. Of ten,
t he most i nexperi enced person in t he operat i ng room i s tol d, wi t hout suf f i ci ent
i nst ructi ons, to repl ace an empty cyl i nder. He or she may f ai l to crack the valve;
i nstal l the cyl i nder wi t hout a washer, wi th a damaged washer, or wi th t wo washers;
f ai l to remove the dust protecti on cap (Fi g. 14.3); or f ai l t o check t hat the cyl inder
i s ful l . Anot her error i s to penet rate the safety rel i ef val ve on the cyl inder valve wi t h
t he retai ni ng screw on the yoke (174). I t is somet imes possi bl e to spot an
i ncorrect l y pl aced cyl i nder simpl y by l ooking at i t . An i mproperl y i nst al led cyl inder
may hang at an angle i nstead of paral lel to t he machi ne and perpendi cular to the
f loor (Fi g. 14.4).
The f act that a f ul l cyl i nder i s present on an anesthesi a machi ne does not mean
t hat there wi l l be oxygen avai labl e when needed. Fi rst , there must be a means of
openi ng the cyl i nder. A good pract ice i s to chai n a handl e to each machine so that
i t wi l l al ways be there when needed.
A cyl i nder may be empty, and t here may not be another one avai l abl e to repl ace i t.
Thi s shoul d be determi ned duri ng the preuse checkout (Chapt er 33). The amount of
oxygen that needs to be in t he cyl i nder depends on the cl i ni cal si tuati on. If t here is
a si ngl e yoke f or oxygen on the machi ne and the cyl inder i s to be t he
P. 408

pri mary source of oxygen f or the anestheti c, t he cyl i nder needs to be ful l and the
number of addi ti onal cyl i nders i mmedi atel y avai lable needs t o be determi ned (175).
I f the pipel i ne i s to be t he pri mary oxygen supply, the oxygen cyl i nder i s the backup
f or this source. I n thi s case, i t i s l i kel y that a quart er- to hal f -f ul l cyl i nder i s
adequate. The anesthesi a provi der must be wat chf ul of the cyl i nder pressure gauge
when checki ng or usi ng t he cyl i nder as the pri mary oxygen source to determine how
much oxygen remai ns i n the cyl inder.

View Figure

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.

Anesthesi a machi nes have a number of ways that warn the anesthesi a provi der that
t he oxygen cyl i nder has become exhausted. Many anesthesi a provi ders do not
recogni ze when this occurs and f urt hermore do not know how to react to the
probl em (176). Thi s has been att ri buted i n part to t he f act that anest hesi a
t echnicians usual l y mai ntain t he cyl i nders on the machi ne and t hat many
anesthesi a provi ders do not have experience wi th changi ng cyli nders. Thi s slows
t hei r react ion duri ng an emergency si tuat ion.
Machine Problems
Obstruction
Obstruct ion t o gas f low i n the anesthesia machi ne may be caused by probl ems i n
t he oxygen fl ush val ve, f l ow cont rol val ve, yoke, or vapori zer connecti ons
(117, 177,178,179, 180, 181,182, 183, 184).
Leaks
I f the check val ve in t he pi pel ine i nl et of the anesthesia machi ne fail s, gas may fl ow
i nto t he room (i f the pipel i ne hose is di sconnected) or i nto the pipi ng system (i f the
hose is connected) (185,186,187). Gas can be l ost through a broken f l owmet er tube
or an open f low control valve wi t h an opening to at mosphere upst ream of t he
f lowmeter (121).
Leaks can occur i n the machi ne pi pi ng (188, 189); at a l oose or def ect ive vapori zer
connecti on
(190, 191,192,193, 194, 195,196, 197, 198,199, 200,201,202,203,204,205,206); a
l oose, def ect i ve, or absent vapori zer f i l l er cap or drai n screw (207, 208, 209) (Fi g.
14.5); or a defect in t he vapori zer i tself (210). Vapori zer l eaks do not mani f est
t hemselves unt i l the vapori zer i s t urned ON. These can be
P. 409

di scovered i f the vapori zer i s turned ON duri ng the checkout process (Chapter 33).
Some machines are desi gned so that when a vapori zer i s removed, a mani f old cap
must be pl aced where t he vapori zer was si tuated. Fai l ure to do so wi l l resul t i n a
maj or l eak. The pressure rel ief devi ce on t he machine may vent f resh gas i f
downst ream resi stance causes the pressure t o ri se (211, 212).

View Figure

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.

Gas Supply Switched OFF
The mai n ON-OFF swi t ch on the machi ne may be acci dental l y turned to t he OFF
posi t i on (213,214,215,216,217). Some machines have a t wo-posi t ion swi t ch to t urn
i t ON. One posi t i on pl aces t he machi ne i n st andby, whi ch enabl es onl y the
el ect rical porti on of the machi ne, whi l e the ot her act ivates both the el ectrical and
pneumat ic port i ons of t he machine. If i t i s not not iced that the swi t ch i s in t he
standby posi t ion, f resh gas wi l l not be deli vered. Newer machi nes have a simple
swi t ch that enabl es al l functi ons.
Problems with the Fresh Gas Supply
The f resh gas hose can be detached, occl uded, devel op a leak, or be at tached to
t he wrong posi t ion
(131, 150,172,218, 219, 220,221, 222, 223,224, 225,226,227,228,229,230,231). The
i nner t ube of the Bain or Lack system, whi ch carri es t he f resh gas f l ow, can become
obstruct ed (232, 233,234).
Whi le most anesthesi a machi nes have one f resh gas outl et t hat suppl i es gas to the
breat hi ng (usual l y ci rcl e) system, some have a second out l et t hat can be used wi t h
ot her t ypes of breathi ng systems. A hazard of t hi s desi gn i s that gas may f l ow
t hrough the auxi l i ary outl et when i t i s not i nt ended to be i n use (235). Havi ng an
i nterl ock to cl ose t his secondary out let is one sol uti on t o thi s probl em (236).
Excessive Outflow
Breathing System Leaks
Most breathing syst em leaks are too smal l to be of cl i ni cal si gni f i cance, but some
are large enough t hat the pat i ent cannot be adequatel y vent i lated, especi al l y i f low
f resh gas fl ows are used. Leaks al so cause pol l uti on of operat ing room ai r (Chapt er
13).
A common l ocati on f or leaks i n the ci rcl e system is t he absorber. I f the canisters do
not f i t together properl y, a l arge l eak can resul t (237, 238,239, 240, 241,242, 243). A
canister may become disengaged f rom the absorber (150,244,245,246). Leaks have
been report ed i n humidif i ers, respi ratory vol ume meters, breat hing tubes, elbow
adapt ers, bags, temperat ure probe si tes, connectors f or respi ratory gas anal yzers
or pressure moni tors, bag/vent i l ator sel ector valves, f i l ters, heat and moi st ure
exchangers (HMEs), oxygen anal yzer adaptors, adjust abl e pressure li mi ti ng (APL)
valves, the reservoi r bag mount, and Y-pieces
(150, 247,248,249, 250, 251,252, 253, 254,255, 256,257,258,259,260,261,262,263,264,
265,266,267,268,269,270,271,272,273,274,275,276,277,278,279,280,281,282,283,2
84,285,286,287, 288,289, 290, 291,292, 293, 294,295,296) (Fi g. 14.6). The cap f or t he
gas sampl ing l i ne to a si destream gas anal yzer att achment may become l ost
(297, 298). A heated humidif i er may mel t a hol e in a breat hi ng tube
(299, 300,301,302).
The APL val ve may fai l t o cl ose (303, 304,305,306,307,308). Thi s l eak may not be
easi l y f ound, because t he exhausted gas wi l l fl ow i nto the scavenging system. The
t ransfer tubi ng may need to be removed f rom the APL val ve to detect the probl em
(308, 309). Most present bag/venti l ator sel ector valves cause t he APL valve to be
excluded f rom the system when swi t ched to the automati c mode or when the
venti l ator is turned ON. Wi th ol der machi nes where the APL val ve i s not excl uded,
t he user may forget to cl ose i t when swi t chi ng to automat ic vent il ati on.

View Figure

Figure 14.6 Parts of the breathing system may have holes in
them when they are received from the manufacturer.

A leak may occur i n a vent il ator (310,311) or i n i ts attachment t o the breat hi ng
system (312,313,314). If the pi l ot l ine becomes disconnect ed or ki nked during
expi rat ion, t he spi l l val ve ruptures or becomes stuck i n the open posi t i on, or t he
exhaust val ve mal funct ions, gas can be l ost (315,316, 317, 318,319). A l arge leak
wi l l occur if the bag/venti l at or swi t ch i s pl aced i n the venti l ator posi t ion wi t h no
connecti on to the venti l ator (320).
A def ect i ve nonrebreathi ng valve or mi sassembly of a manual resusci tator can
resul t i n part or al l of t he gas vol ume l eavi ng the bag during i nspi rat ion and
escapi ng to atmosphere (321, 322, 323).
Most l eaks can be detected by the preuse check. Many report ed l eaks i nvolve
equipment that was added af ter t he checkout was perf ormed (287,324). I t i s
i mportant that al l equi pment that i s t o be used duri ng a case be i n pl ace bef ore the
preuse checkout i s perf ormed. Checki ng is di scussed in more det ai l in Chapter 33.
Leaks may occur duri ng an anesthetic (252). Such a l eak may be evi dent by a l ow
expi red volume or an i ncrease i n end-ti dal carbon di oxi de. Wi t h a standing bel l ows
venti l ator, t he bel l ows may not return to i ts f ul l y expanded posi ti on (325), and t here
may be a change i n t he vent i l ator sound. An ai rway pressure moni t or
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may al arm wi th a l eak but cannot be rel ied on, especi al ly i f t he leak is not l arge or
t he al arm li mi t is set l ow (258,326).
When a l eak i s suspected, a systematic search of t he anesthesi a machi ne and
breat hi ng system shoul d be made, f ol lowi ng t he route of gas t ravel . It may be
easier to detect a leak if gloves are not worn (279). A l eak can someti mes be
l ocated by pl acing alcohol on the hands and moving the hands over components
whi l e gas f l ow i s occurri ng. The l eaki ng gas evaporates t he al cohol and cool s the
ski n.
Disconnections
A di sconnect i on is an unintended separati on of components (327). Disconnect ions
i n breathing ci rcui ts are among the most common t ype of preventabl e anestheti c
mi shap i nvolving equi pment (1,2,11,238,328,329). Most breathi ng syst em
connectors are sl i p fi t ti ngs that rel y on f ricti on to hol d them together. They wi l l
come apart if suf fi ci ent t ension i s appli ed. If t he connecti on is under a drape, this
wi l l make i t di f f icul t to spot t he disconnect i on (329,330).
Di sconnecti ons can occur anywhere i n the breathing syst em. The most common si te
i s bet ween the breathing syst em and tracheal tube connector or HME (1,331,332).
Di sconnecti ons are of ten associ ated wi th a t hi rd party i nterf eri ng wi t h the breat hi ng
system and wi t h surgery on the head and neck (238).
Di sconnecti ons can be made l ess f requent by maki ng secure connecti ons.
Connectors wi t h l ugs or other f eat ures that make them easy to gri p may be easi er
t o t i ghten. Push and t wi st (wrung) connecti ons are much st ronger t han those made
wi th a st raight push (333). Metal -t o-met al or pl asti c-to-pl ast i c j oi nts are stronger
t han metal -t o-pl asti c j oints (334).
Ant i disconnect devi ces f or breathi ng system components have been descri bed
(327, 335,336). Locking connectors use a mechanical means to ensure that the
connectors do not separate under any f orce that is common during use. Many
bel i eve t hat t hey shoul d not be used at t he connecti on bet ween t he t racheal tube
connector and the breathing syst em, reasoni ng that i t i s safer f or such a uni on to
come apart under tensi on than f or the t racheal tube to be pul l ed out of t he pat ient
(337). I t may be necessary t o make a disconnecti on rapidl y at t hi s poi nt f or
sucti oning or to reli eve a hi gh pressure i n the breathi ng syst em. Latching
connectors are si mi l ar but are desi gned t o break away wi th a cert ain
di sconnecti on f orce (327). Adhesive tape i s somet i mes used to prevent
di sconnecti ons. Unf ortunatel y, tape can prevent the di sconnect i on f rom bei ng seen,
i nhi bi t reconnect ion, and cause an obst ructi on (327).
The anesthesi a workstat i on st andard (338) requi res that the workstati on be
provi ded wi t h an alarm that is acti vated i n the event of a compl et e di sconnect i on i n
t he breathi ng system. Al arms consi dered to compl y wi th t hi s requi rement include a
l ow ai r way pressure alarm, a l ow exhal ed carbon dioxide alarm, and a l ow vol ume
al arm. These devi ces are di scussed i n Chapters 22 and 23. Wi th spontaneous
breat hi ng, no movement of t he reservoi r bag wi l l be seen i f a di sconnecti on occurs
(339).
Negati ve Pressure Applied to the Breathing System
I f the ai r i nl et valve of a cl osed scavengi ng i nterf ace or t he openi ng to atmosphere
of an open i nterf ace becomes blocked or t he i nterf ace i s omi t ted, a subatmospheri c
pressure may be t ransmi tt ed across an open APL valve to the breathi ng system
(339, 340,341,342, 343, 344).
I f sucti on i s appl ied t o the worki ng channel of a f iberscope passed int o the ai rway
or t o an enteric t ube t hat has ent ered the t rachea rather than the esophagus,
respi ratory gases wi l l be removed rapidl y f rom the l ungs and breat hi ng system
(132, 345,346,347).
Improper APL Valve Adjustment
When manual l y cont rol l ed or assisted vent il at i on is used, gas is vented f rom the
system duri ng i nspi rati on (unl ess a cl osed system techni que i s used). Part of the
gas displ aced f rom the bag goes to the pat ient, and the rest is di scharged f rom the
breat hi ng system. The person squeezing the bag may f i nd i t dif f icul t to est i mate
how much gas is enteri ng the pat i ent and how much i s escapi ng t o atmosphere.
Hypoventi l ati on can occur i f too much gas escapes t hrough the val ve.
Blocked I nspiratory and/ or Expiratory Pathway
A parti al or compl ete bl ock i n t he breathi ng system can resul t i n hypoventi l ati on. In
most cases, the probl em can be det ected bef ore the case has begun by havi ng the
anesthesi a provi der or the pati ent breathe through the syst em (348). Lack of
obstruct i on to breathi ng, a sati sf actory capnogram, and reservoi r bag movement
shoul d be seen. It i s i mportant that al l equipment t hat i s pl anned to be used for the
case is i n pl ace i n t he system when the preuse checki ng is perf ormed, as added
equipment may cause an obst ructi on (349,350,351,352).
Causes of breathi ng syst em obst ructi on i ncl ude manuf acturi ng def ects; forei gn
bodies (e.g. , caps, pl ast i c wraps, t ape); mi sconnect i ons; bl ood; secret ions; or other
probl ems
(260, 267,297,349, 350, 351,352, 353, 354,355, 356,357,358,359,360,361,362,363,364,
365,366,367,368,369,370,371,372,373,374,375,376,377,378,379,380,381,382,383,3
84,385,386,387, 388,389, 390, 391,392, 393, 394,395,396,397, 398,399, 400, 401,402, 40
3, 404,405,406, 407, 408,409,410). Obstruction can resul t i f the seal s on a
di sposabl e absorbent package are not removed, f rom occlusi ons in the hol es i n the
t op and bot t om panel s, or f rom compacted absorbent (150,411,412,413,414,415)
(Fi g. 14.7).
A posi t ive end-expi ratory pressure (PEEP) val ve may stick i n the cl osed posi t i on
(351, 383,410). Connecti ng a fl ow-di recti on-sensi ti ve component such as a PEEP
valve or humi di fi er i n reverse wi l l resul t i n l i tt l e or no f l ow (416,417,418). I f the
bag/vent i l at or selector val ve i s l ef t i n the wr ong posi ti on when automati c venti l ati on
i s i ni t iat ed, compl ete obst ructi on t o gas f low wi l l resul t. An HME or f i l t er can
become obstructed (332,419,420,421,422,423).
Breat hi ng tubes can become obstructed f rom ki nki ng or t wi st i ng (424) (Fi g. 14.8),
as can the reservoi r bag neck
P. 411

(425, 426) (Fi g. 14.9). A heated humidif i er may cause the tubi ng to mel t and become
obstruct ed (427) (Fi g. 14.10).

View Figure

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.

Venti lator Problems
Hypoventi l ati on secondary t o vent i l ator problems i s di scussed i n Chapter 12.
Causes i ncl ude cycl i ng f ai lure, leaks of dri vi ng or breathi ng system gas,
i nappropri at e set ti ngs, and t he venti lator bei ng turned OFF. If an anesthesi a
machi ne i s turned OFF and then turned ON again, the vent i l ator may def aul t to
sett ings that are dif f erent f rom those ori ginal l y set (428).

View Figure

Figure 14.8 Kinking of a breathing tube.

Detection
Vi gi l ance ai ds used to det ect hypoventi l ati on i ncl ude ai rway pressure, respi ratory
volume, and carbon dioxi de moni tors. These are di scussed i n Chapt ers 22 and 23.
An oxygen anal yzer may detect some disconnecti ons (238, 429, 430) but should not
be rel i ed on, because i t i s ef f ecti ve i n onl y a l imi ted set of ci rcumstances. The l ow
t emperat ure al arm on a heated humi dif i er may si gnal l oss of gas f l ow i n t he
breat hi ng system (238). Because any singl e moni tori ng modal i t y may f ai l to det ect
a probl em, i t is advi sable t o use more than one (428,431, 432, 433).
As stat ed previ ousl y, obst ruct ions in t he breathing system are best detected by
breat hi ng through the system bef ore i t i s used but af ter al l components that wi l l be
used are i n pl ace. The checkout procedure i s di scussed i n Chapter 33.
Response to Hypoventilation
When hypovent i l at ion occurs during mechani cal vent il at ion, the f i rst st ep shoul d be
t o swi t ch to manual vent i lat i on (434,435,436,437). The anesthesi a provi der can
t hen determine whether or not breathi ng system resi stance and compl i ance i s
normal and if t here is adequate gas in t he breathing syst em. I f manual venti l at ion
can be used to vent il ate the pati ent sat isfactori l y, t he problem probabl y l i es wi th
t he vent i lator or venti lator ci rcui t . If the probl em cannot be diagnosed or correct ed
quickly, manual venti l ati on can be cont i nued or a backup anest hesi a machi ne
brought i n.
I f manual venti lati on shows obstruct ion to venti lati on, the next st ep i s to at tach a
resusci tati on bag to t he ai rway devi ce (mask, tracheal t ube, or supraglott ic devi ce).
I f i t remai ns di f fi cul t t o venti lat e the pat ient, t he probl em is probabl y wi t h t he ai rway
device or wi th t he pat ient. Compl icati ons rel at ed to supraglott ic ai rways and
t racheal tubes are discussed i n Chapt ers 17 and 19.
I f manual venti lati on shows that there i s gas f low i nt o the breat hi ng system, but i t i s
not adequate to venti l ate t he pati ent properl y, t he f resh gas fl ow should be
i ncreased. I f increasi ng the f resh f low does not all ow adequate venti l ati on, a
resusci tati on bag shoul d be used.
I f adequate vent i l ati on can be achi eved by usi ng a resusci t ati on bag, the tubi ng to
t he bag shoul d be connected to t he anesthesi a machi ne outl et , if possible. Inspi red
gas moni t oring shoul d be conti nued, i f possi bl e. Thi s wi l l determi ne if the
resusci tati on bag i s bei ng suppl i ed f rom the anesthesi a machi ne or room ai r. I f the
resusci tati on bag cannot be connected to the machi ne outl et or there i s no f l ow
f rom the anesthesi a machi ne, a source of oxygen shoul d be connected to t he
P. 412

resusci tati on bag and anesthesia mai ntai ned by usi ng i nt ravenous agents.

View Figure

Figure 14.9 Twisting has caused this bag to become
obstructed. Many bags have a guard in the neck to prevent
this.

Af ter adequate vent il ati on and anesthesi a level have been est abl i shed, the cause of
t he probl em can be invest i gated. A second knowl edgeabl e person shoul d be sought
and seri ous consi derat i on given to bri ngi ng i n a second anesthesi a machi ne, i f this
has not al ready been done. Even i f the probl em can be found, i t may not be
possi bl e t o correct i t qui ckl y.

View Figure

Figure 14.10 Contact with a heated humidifier can cause a
breathing tube to melt and become obstructed.

Hypercapnia
Hypoventilation
Hypercapni a can be t he resul t of hypoventi l at i on, which was discussed previ ousl y.
I nspi red carbon di oxi de wi l l be zero if hypoventi l at i on is t he sol e cause of
hypercarbi a. Other causes of hypercapni a ment ioned bel ow are associ ated wi t h an
i ncreased inspi red carbon dioxi de concent rati on.
Inadvertent Carbon Dioxide Administration
A f ew anesthesia machines are equi pped wi t h a carbon di oxi de cyl i nder and
f lowmeter (438). Thi s f l owmet er may be acci dental l y t urned ON but not not iced,
especi al l y when the i ndicator is at the top of t he tube (439). An apparent l y OFF
f lowmeter may leak carbon di oxi de i nt o the breat hi ng system (440).
I n one report ed case, a ni t rous oxi de hose was connected to the carbon di oxide
stat ion outl et (441). A cyl i nder may be mistakenl y f i l l ed wi t h carbon di oxi de (65).
Rebreathing without Carbon Dioxide Removal
Absorbent Failure or Bypassed Absorbent
I t i s i mportant to watch f or t he appearance of carbon di oxi de i n the i nspi red gas.
The small er cani sters on some new machi nes have a short er l if e span than t he
l arger ones on ol der machines. Hypercarbi a can occur i f channel i ng al l ows gases to
bypass t he absorbent (150,442).
Bypassed Absorber
An absorber bypass al l ows some or al l of the exhaled gases to bypass the
absorbent . Uni nt ent ional activati on
P. 413

of t hi s bypass can l ead t o hypercarbi a. The absorber may be def ecti ve so that gas
f low i s not di rected through the absorbent (443). Most new anest hesi a breat hi ng
systems that have smal l absorbers al l ow the cani ster(s) t o be changed wi thout t he
breat hi ng system i ntegri t y bei ng interrupt ed. I t i s possi bl e that t he anesthesi a
provi der may not noti ce that a cani ster i s l oose or missi ng. Some anesthesia
provi ders i ntenti onall y remove the cani ster t o al l ow carbon dioxi de to i ncrease i n
t he breathi ng system at the end of a case. This may not be noti ced by the next
anesthesi a provi der.

View Figure

Figure 14.11 Damaged unidirectional valve leaflet.

Unidirecti onal Val ve Problems
Correct movement of gases in a ci rcl e syst em depends on properl y f uncti oni ng
uni di rect ional valves. If t hey do not cl ose properl y, rebreat hi ng wi l l occur. The di sc
may become di spl aced, wet , st i cky, or damaged so t hat i t wi l l not seat properl y
(150, 444,445,446, 447, 448,449, 450, 451,452, 453,454,455,456,457,458,459) (Fi g.
14.11). The disc may not be repl aced af t er removal f or cl eaning or servi ci ng. The
cage hol di ng the disc may become di sl odged (460,461).
Uni di recti onal valve problems can be di scovered preoperat ivel y duri ng t he
breat hi ng system checkout (Chapt er 33). Probl ems wi th t he uni di rect ional valves
may be i ndi cat ed by a respi rometer i ndi cat ing reversed fl ow (Chapter 23), a ri se i n
t he i nspi red carbon di oxi de above zero (Chapter 22) or a capnogram wi th a sl anti ng
downst roke (Fi g. 22.32). Pressure-vol ume loops (Chapter 23) may al so i ndi cate t hi s
probl em.

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 Nonrebreathi ng Valves
I mproperl y assembl ed or sti cky nonrebreathi ng val ves can resul t in part i al or t otal
rebreat hi ng. This i s discussed more f ul l y i n Chapter 9.
Inadequate Fresh Gas Flow to a Mapleson System
I n systems wi thout carbon dioxi de absorpti on, a l ow f resh gas f l ow can resul t i n
dangerous rebreathi ng (Chapt er 8). Report ed causes incl ude t he f resh gas f l ow
bei ng set too low; a l eak or obstructi on i n the machi ne, common gas outl et , f resh
gas suppl y l ine, or a vapori zer; or an empt y cyl i nder (263,462,463,464,465).
Problems with Coaxial Systems
I n Mapleson systems in whi ch the f resh gases are del i vered to t he di stal end of the
system by an i nner tube, rebreathi ng wi l l occur i f the i nner t ube i s avulsed,
damaged, ki nked, or omi tt ed; has a leak at t he machine end; or does not extend to
t he pat ient port (233,466,467,468,469,470,471,472,473,474,475,476) (Fig. 14. 12).
I f the i nner tube of a coaxi al ci rcle system is di spl aced or devel ops a l eak, an
i ncrease i n inspi red carbon di oxi de wi l l be seen, as previ ousl y exhal ed gas wi l l be
rei nhal ed wi thout carbon dioxi de havi ng been removed (477).
Excessive Dead Space
An i ncrease i n dead space wi l l i ncrease rebreathi ng. This i ncrease i s especi al l y
i mportant in smal l pati ents (478). An HME is pl aced bet ween the pat ient port and
t he breathi ng system. These come i n a variety of si zes, and if a l arge one i s used
on a pati ent wi t h a small t i dal vol ume, dangerous rebreathi ng may occur (479).
Of ten, a connect or i s added between the pat i ent port of t he breathi ng system and
t he pat ient to move the breathi ng system away f rom the surgi cal fi el d
P. 414

(Fi g. 14.13). These increase dead space and must be used wi th caut ion.

View Figure

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.

I f a disconnect i on occurs i n a cl osed space, such as under a pl asti c drape over the
f ace duri ng spontaneous breathi ng, exhaled gas contai ni ng carbon di oxide can
accumul ate in t hat space and the i nspi red carbon di oxide l evel wi l l ri se (339).
Hypercarbia i s best det ected usi ng capnometry. I nspi red carbon di oxi de wi l l be zero
i f a ci rcl e system wi th properl y f uncti oning absorbent and unidi rect ional val ves i s
used and hypoventi l ati on i s the sol e cause of the hypercarbi a. I f the hypercarbi a is
not caused by added carbon di oxide and is t he resul t of hypovent i l at ion, i ncreasi ng
t he minute volume wi l l reduce the carbon di oxide i n the breathi ng system. If the
carbon dioxi de absorbent or a unidi recti onal val ve is not worki ng properl y,
i ncreasi ng the f resh gas fl ow wi l l l ower the carbon dioxi de level s i n the ci rcl e
system. Hypercarbi a when usi ng a Mapleson system i s usual l y t he resul t of l ow
f resh gas fl ow, so i ncreasi ng the f resh gas f l ow wi l l l ower t he inspi red carbon
di oxi de l evel . Chapters 8 and 9 discuss the Mapl eson systems and ci rcl e systems.
Chapter 22 of fers a ful l er di scussi on of carbon di oxi de moni tori ng.
Hyperventilation
A hol e or t ear i n the vent i l at or bel l ows can cause i nadvertent hypervent i l at i on
(138, 139,480). Thi s can be det ected by an i ncreased oxygen concentrat ion, if
oxygen i s the dri vi ng gas (or a decreased concentrati on i f ai r i s used); i ncreased
venti l ati on as i ndi cated by a spi rometer; or decreased end-t i dal carbon di oxi de.
These moni tors are di scussed i n Chapters 22 and 23.
Excessive Airway Pressure
I n addi ti on t o i nterferi ng wi t h venti lati on, a high pressure can cause barotrauma
and adverse ef fects on the cardi ovascular system. Neurol ogi c changes and
ot orrhagi a have been report ed (481,482). A hyperi nf lated l ung may i nt erf ere wi t h
surgery (483).
Modifying Factors
The rat e and extent of the pressure ri se are i mport ant and wi l l be af f ect ed by a
number of f actors, i ncl uding t he reservoi r bag; the vol ume and compl i ance of the
system; the f resh gas f low; and use of a cuf f ed or uncuf fed t racheal tube, f ace
mask, or supragl ot ti c ai rway devi ce.
The pressure i n the breathing system is normal l y l i mi t ed to 50 cm H
2
O by the
reservoi r bag. Non-l atex bags may al l ow sl ightl y hi gher pressures (484). When an
automati c vent i l ator i s i n use, the bel l ows buf fers i ncreases in pressure. I f the bag
or bel l ows i s excluded f rom the system, thi s buf feri ng capaci ty i s removed and
dangerousl y hi gh pressures may be reached rapi dl y if there is coi nci dental
obstruct i on to t he out fl ow of gases f rom, or hi gh i nfl ow i nto, the syst em. Bag
excl usi on is most commonly caused by an obst ructed expi ratory l imb upst ream of
t he bag. The bag may become obstructed at i t s neck (485) (Fi g. 14.9).
Unf ortunatel y, an anest hesi a provi der who f i nds a reservoi r bag t hat i s not f i l l ed
may i ncorrect ly assume t hat t here is a l eak i n the syst em and operate t he oxygen
f lush in an at tempt to compensate (486). The hi gh gas f l ow f rom the oxygen fl ush
can rai se the pressure in the breat hi ng system to dangerous l evels very rapi dl y
when t he bag i s excluded.
Protective Devices
The anesthesi a workstat i on st andard requi res t hat there be a device t o l i mi t the
pressure i n the breathi ng system t o 125 cm H
2
O (338). These devi ces may
mal f unct ion (487). I n addi ti on, there must be a means to conti nuousl y displ ay the
pressure i n the breathi ng system and a pressure moni tor that acti vates a high
pri ori ty al arm when the pressure i n the breathing syst em exceeds the operat or-
adj ustable l i mi t f or hi gh pressure.
Some of the newer venti l ators have pressure-control l ed venti l at ion i n whi ch peak
ai rway pressure is l ower than when vol ume control venti l at ion i s used. Some of
t hese vent i l ators automati cal l y swi tch f rom t he i nspi ratory to t he expi rat ory phase
when t he peak pressure threshol d is exceeded (488).
Another factor that can reduce the ai rway pressure rise i s an uncuf f ed t racheal tube
or a t racheal tube i n whi ch t he cuf f i s not i nf lated to a high pressure. Adj usti ng cuf f
pressure to 34 cm H
2
O or l ess wi l l all ow i t to act as a saf et y val ve for excessive
pressure i n the ai rway. The use
P. 415

of a mask or supragl ott ic ai rway device wi l l al so provi de a means of pressure rel i ef .
Aut omat i c disconnect ion of breat hi ng system components cannot be rel i ed on to
provi de pressure rel i ef , because the pressures requi red f or di sconnecti on are f ar in
excess of those that cause l ung i nj ury (334).
Causes of Excessive Airway Pressure
High Infl ow
I f the oxygen f l ush valve sti cks i n the ON posi ti on, 35 to 75 L/minute of oxygen wi l l
be del ivered. Oxygen f l ush valves on newer machi nes are desi gned to close
automati cal l y but can f ai l (489, 490,491). It i s possi ble f or personnel to acci dental l y
actuate some oxygen f l ush valves. Ot her equi pment may cause the f l ush valve to
st i ck in t he ON posi ti on (492,493,494,495). I f the oxygen f l ush valve i s act i vated
duri ng inspi rati on when a mechani cal vent i lat or i s bei ng used, a l arge vol ume of
gas wi l l be added to the i nspi red ti dal vol ume, resul ti ng i n a greatl y i ncreased
pressure wi th cert ai n breathi ng system conf i gurati ons (496,497). A vent i l ator
control val ve can mal functi on, resul ti ng i n a constant f l ow of dri vi ng gas (498).
Low Outfl ow
Obstruction in the Expiratory Limb
As noted previ ousl y, excludi ng the bag f rom t he breat hi ng system resul ts i n l oss of
buff eri ng capaci t y. Thus, breathi ng system obst ructi on i n the expi rat ory l i mb i s
part icularl y hazardous if i t occurs upstream of t he reservoi r bag. The expi rat ory
pathway can be obstructed by f oreign bodi es (i ncluding ampul es, coi ns, plasti c
wraps, discs, t ape, and caps) (361,499,500,501,502), water (503), or equipment
defects or mi sassembl y
(383, 410,497,504, 505, 506,507, 508, 509,510, 511,512,513,514,515,516,517,518). A
PEEP valve may sti ck or be pl aced backward (383,410,519,520,521,522,523).
The expi rat ory li mb of a T-pi ece system can become obst ructed by the user' s
f inger, ki nki ng, external compressi on, mi sassembl y, or adhesi ve tape
(524, 525,526).
I f a pedi at ri c breat hi ng system wi t h an adapter that has t he f resh gas inlet
prot ruding near t he end i s used wi th a l ow dead space t racheal tube connector,
t he f resh gas suppl y tube may cl osel y approxi mate or even press agai nst t he end of
t he connector, causing parti al or compl ete obst ruct ion of the exhal at ion pathway
(527, 528,529). The same probl em has been report ed wi th a bronchoscope (530).
Obstruction at the Ventilator
I f the venti l at or spi l l valve becomes stuck, the pressure i n the breathi ng syst em wi l l
ri se (317,531,532,533,534). The exi t of dri vi ng gas f rom the bel lows housing may
be bl ocked (535).
Obstruction at the Adjustable Pressure-Limiting Valve
APL valve omissi on, mal funct ion, or bl ockage may occur
(485, 486,536,537, 538, 539,540, 541). The user may f ai l to open the val ve when
swi t chi ng f rom automatic t o spontaneous vent i l at ion i f t he APL valve i s not
automati cal l y excl uded f rom t he breat hi ng system duri ng mechanical vent i l at ion and
automati cal l y i ncl uded duri ng manual or spontaneous venti lati on. Wi th some APL
valves, subambi ent pressure f rom an act i ve scavengi ng system wi l l cause the val ve
t o close, prevent ing excess gas f rom l eavi ng t he breathing system
(542, 543,544,545).
Obstruction in the Scavenging System
The scavengi ng system i s essent ial l y an extension of the breathi ng system. If
mal f unct ions in t he scavengi ng system occur, t he pressure i n the breathi ng system
may be af f ected. Obstructi on in t he transfer tubi ng between the APL valve i n the
breat hi ng system or between the spi l l valve i n the venti lator and the i nterface can
prevent gas f rom l eaving the breat hi ng system (544, 545, 546,547,548,549,550,551).
The t ransf er t ubi ng may be connected t o an i ncorrect si te (552,553,554).
I f the pressure rel i ef valve i n a closed acti ve scavengi ng int erf ace (Chapter 13)
f ai l s to open, sustai ned posi ti ve pressure i n the breat hi ng system can resul t . In one
reported case, a val ve i ntended f or negati ve pressure rel ief rather than one f or
posi t i ve pressure reli ef was acci dental l y i nst al l ed (555).
Problems with Nonrebreathing Valves in Resuscitators
A sudden hi gh inf l ow of gas or a qui ck squeeze or bump on t he sel f -refi l l i ng bag of
a resusci tator may generate suff i ci ent pressure t o l ock the nonrebreat hi ng val ve i n
t he i nspi rat ory posi t ion (556). Conti nui ng i nf low wi l l cause a ri se in pressure.
I ncorrect nonrebreathing valve assembl y or mal f unct ion may resul t i n obstruct ion to
exhal ati on (557, 558,559, 560).
Misconnected Oxygen Tubi ng
Mi sconnecti on of oxygen t ubi ng di rect l y to an indwel l i ng t racheal or tracheostomy
t ube or supragl ott i c ai rway devi ce wi t hout provi si on for vent i ng has occurred, of ten
wi th di sastrous resul ts (561,562,563,564,565, 566, 567,568, 569) (Fi g. 14.14).
Another cause of i ncreased pressure is connection to a T-pi ece wi t h a closed
expi ratory l i mb (570).
Unintentional Positi ve End-expiratory Pressure
An external PEEP val ve may remai n i n the ci rcui t and not be removed, or an
i ntegral PEEP val ve may be l ef t i n t he ON posi t ion at the end of a case and not
noti ced by the next user (523,571) (Fi g. 14.15). Wi th ol der breathi ng systems, t he
ai rway pressure gauge is l ocated on the absorber si de of t he uni di rect ional valves,
and PEEP cannot be observed on the gauge (483,523,572). Newer breathi ng
systems measure the pressure on the pati ent si de of t he uni di recti onal valve.
I nadvertent PEEP may be caused by wat er t hat i s condensed in t he tubi ng
connecti ng the venti lat or t o the
P. 416

breat hi ng system (573) or an inadequate openi ng i n the bag of a Mapl eson F
system (574).

View Figure

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.

Detection
When an automati c venti lator is used, i t i s essenti al that the chest wal l moti on,
defl ecti ons on the breathing system pressure gauge, t idal and mi nute vol umes
regi stered on a respi romet er, and breath sounds be caref ul l y moni tored. Observing
t he ai rway pressure wavef orm, if avai l abl e, can detect some probl ems. Pressure-
volume l oops (Chapter 23) are al so usef ul . The vent il ator may change sound wi th
stacked breaths. A conti nuing or high ai rway pressure al arm may alert t he operat or
t o t hi s hazard. The capnograph (Chapter 22) may show an ascendi ng l i mb wi th a
prol onged ri se ti me and no pl at eau.
Obstruct ions to the breathing system can be detected by perf ormi ng a t horough
anesthesi a machine
P. 417

and breathi ng system check, i ncl udi ng having someone breathe through the system
pri or to use (383). The procedure f or preuse checking i s di scussed i n Chapter 33.

View Figure

Figure 14.15 A: PEEP valve with 0 PEEP. B: Same valve
with PEEP. Note the similarity in appearance.

Response
I f there i s a pressure bui ldup i n the system, a disconnect ion should be made
I MMEDIATELY at the tracheal tube connector (575). Ti me spent l ooking f or t he
cause of t he probl em may resul t in ever-i ncreasi ng pressure.
Venti lati on shoul d be cont i nued by using a resusci tati on bag unti l the probl em i s
di agnosed and corrected.
Inhalation of Foreign Substances
A f orei gn body i n the breathing system can of fer more risk than obst ructi on. In
some cases, i t coul d migrate into the pat ient ' s respi ratory t ract (576,577).
Absorbent Dust
I nhal i ng absorbent dust can cause bronchospasm, laryngospasm, cough, decreased
compl i ance, and burns to the pat ient' s f ace (578, 579). This can be avoi ded by usi ng
a fi l ter at t he pat ient port, rel easi ng breathing syst em pressure at t he APL val ve
when checki ng for l eaks, tapping each canister to remove dust bef ore i t i s put i nto
t he absorber, and not overf i l l i ng canisters (581,582).
Medical Gases Contaminants
Report ed contami nants i n medi cal gases i nclude wat er, oi l , hydrocarbons, hi gher
oxides of ni trogen, and metal l ic f ragments
(35,53,170,582,583,584,585,586,587,588,589,590,591). Bacteri a may be found,
especi al l y i n compressed ai r (592,593,594,595).
Parts of Breathing System Components
Part of a breat hi ng system component may break and become detached. Report ed
cases have invol ved parts of the sampl i ng si te f or an aspi rat ing respi ratory gas
moni tor, an APL val ve, an oxygen sensor, and HMEs
(297, 388,596,597, 598, 599,600, 601, 602,603). Some manuf acturers plate the i nside
surf aces of components wi th materi al s that may f l ake of f (604,605).
Other Foreign Bodies
A number of ot her f orei gn bodi es have been f ound in breathi ng systems
(377, 378,379,381, 396, 400,499, 500, 501,502, 577,606,607,608,609). Of ten, t hese
enter duri ng cl eaning.
Carbon Monoxide
Dry absorbents containing sodi um or potassi um hydroxi de can resul t i n carbon
monoxi de format ion when
P. 418

exposed t o vol at il e anest het ic agents. This i s discussed i n detail in Chapter 9.
Anesthetic Agent Overdose
An anest het ic agent overdose can resul t in severe cardiovascul ar depressi on.
Chapter 6 off ers a more complete di scussi on of overdose caused by vapori zer
mal f unct ion.
Tipped Vaporizer
I f a vapori zer charged wi th l i quid i s ti pped or agi tated, a very hi gh concent rati on
may be deli vered when the vapori zer is turned ON (610). Some newer vapori zers
have a t ravel set ti ng that i sol at es the vapori zi ng chamber f rom the rest of t he
vapori zer when t he vapori zer is removed f rom t he anesthesi a machine.
Vaporizer or Nitrous Oxide Inadvertently Turned ON
Previ ous vapori zer sett ings by a col l eague or servi ce techni ci an can resul t i n the
vapori zer control di al bei ng l ef t i n the ON posi t i on (611,612,613). Someone helpi ng
t o move the machi ne may grasp a control di al , i nadvert ent l y turni ng i t ON.
I nadvertent admi ni strat ion of ni trous oxide may occur if gas f rom the mai n
f lowmeters i s used t o suppl y suppl ementary oxygen (614).
Incorrect Agent in the Vaporizer
I f an agent i s i ncorrect l y placed i n a vapori zer desi gned f or an agent wi th a l ower
vapor pressure and/ or a hi gher mi ni mum alveol ar concentrat ion (MAC) val ue, a
hazardously hi gh concentrat ion may be del i vered (615,616,617,618). An exampl e i s
pl aci ng i sof l urane or hal ot hane i n a vapori zer desi gned f or enf l urane.
Improper Vaporizer Installation
I f a vapori zer not desi gned t o be exposed to hi gh gas fl ows i s placed i n t he f resh
gas suppl y tube bet ween the anesthesi a machi ne and t he breathi ng system, there
wi l l be a higher-t han-usual f l ow of gas t hrough the vapori zer when the oxygen f l ush
i s act ivated (619). Some vapori zers del iver a consi derabl y higher-t han-expected
vapor output i f connected so t hat gas f l ow i s reversed, al though some wi l l del i ver a
normal concent rat i on (620,621).
Overfilled Vaporizer
Most vapori zers are now desi gned so that they cannot be overf i ll ed. Many agent-
speci f i c fi l li ng devices prevent overf il l ing by connect ing t he ai r i ntake in t he bot tl e
t o t he i nsi de of the vapori zi ng chamber. Thi s saf et y feature can of t en be overridden
by sl i ght l y unscrewi ng the bot tl e adapter and turni ng the concent rati on di al ON
duri ng fi l li ng (622, 623, 624). A drai n has been added t o some fi l li ng devi ces t o help
prevent overf i l l i ng.
Vaporizer Interlock System Failure
I f the vapori zer i nterl ock system fai l s, i t i s possible to t urn on more than one
vapori zer at a t i me (625, 626).
An agent moni tor (Chapt er 22) wi l l measure the concentrati on of vol ati l e agent i n
t he breathi ng system. When an overdose of anestheti c agent i s suspected, t he
pati ent shoul d be di sconnected f rom t he breat hi ng system and venti l ated by usi ng a
resusci tati on bag and gas f rom a source other t han the anesthesi a machi ne out l et.
Inadequate Anesthetic Agent Delivery
I nadequat e anestheti c agent del i very can cause seri ous morbi di ty and resul t i n
pati ent awareness duri ng the surgi cal procedure (627,628,629,630).
Decreased Nitrous Oxide Flow
Pi pel i ne ni t rous oxi de may be l ost as a resul t of l eaks, a f rozen regul ator, i mproper
mai ntenance, depl et ion of the syst em supply, and del i berat e tamperi ng wi t h the
equipment (51,631,632,633). Cyl i nder suppl i es al so can f ail . An obst ructi on or l eak
i n the anesthesia machine may cause decreased ni t rous oxi de f low (634). Another
potenti al probl em is i nadvertentl y usi ng ai r i nst ead of ni t rous oxi de (635).
Unexpectedly High Oxygen Concentration
I f a connecti on between the ni t rous oxi de and oxygen sources occurs in t he
pi pel i ne system, a mi xer, or t he anesthesi a machi ne, and t he oxygen pressure i s
hi gher than that of ni t rous oxi de, oxygen wi l l f low i nt o the ni trous oxi de l i ne
(636, 637).
Acci dent al acti vati on of t he oxygen f l ush may occur (490, 493, 638,639,640, 641).
Repeatedl y usi ng the oxygen f l ush t o keep the reservoi r bag f i l l ed can l ead t o
pati ent awareness (491,642,643). Damage to the oxygen f l ush valve can cause i t to
l eak oxygen i nto t he f resh gas (644).
On some el ectroni c machi nes, a machi ne probl em wi l l cause i t t o swi t ch i nto a saf e
mode where onl y oxygen is del ivered (645).
Air Entrainment
As di scussed earl i er i n thi s chapter, ai r entrai nment can cause di luti on of i nhaled
anesthet ic agents.
P. 419


Faulty Vaporizer
Vapori zer l eaks and problems wi th t he mounti ng or i nterl ock devi ce are rel ativel y
common
(630, 646,647,648, 649, 650,651, 652, 653,654, 655,656,657,658,659,660,661,662,663,
664). Such a l eak of ten does not occur unt i l t he vapori zer i s t urned ON. Therefore,
i t is essenti al that the preuse checki ng procedure f or l eaks be perf ormed wi t h the
vapori zers t urned ON (Chapter 33).
Whi le t he overf il l ed vapori zer has usual l y been associ ated wi t h a higher-t han-
expected vapor output, t here is one report ed case where i t was associ ated wi t h no
vapor output (665).
Empty Vaporizer
Another cause of underdosage is a vapori zer that runs empty (627). Cases have
been report ed i n which a l i qui d l evel was visibl e i n the vaporizer si ght glass
al though t he vapori zer was empt y (666). In one report , a f ragment of rubber
obstruct ed the channel f rom t he l ower end of the l i qui d level i ndi cator, showi ng a
l i quid l evel despi te the vapori zer bei ng empt y (667). Some el ectroni c vapori zers wi l l
acti vate an al arm when the l iqui d l evel reaches a cert ai n poi nt.
Incorrect Agent in Vaporizer
I f a vapori zer t hat is desi gned f or use wi t h a hi ghly vol ati le agent i s fi l led wi t h an
agent of low vol ati l i ty, the pat ient wi l l f ai l t o receive the concentrat i on expected
(615, 616). An exampl e is pl acing enfl urane i n a vapori zer t hat i s designed for
i sof lurane.
Incorrect Vaporizer Setting
An i ncorrect vapori zer set t ing can be a cause of anesthet ic underdosage. I t i s
i mportant to check sett ings f requent l y duri ng a case because they can be al tered
wi thout t he operator' s knowl edge. It i s not uncommon to f orget to t urn ON a
vapori zer af ter f i ll i ng i t duri ng use. I f an anest hesi a machine i s turned OFF and
t hen turned ON agai n, the vapori zer sett i ng may def aul t to zero (428).
Anesthetic Agent Breakdown
The reacti on bet ween some desi ccated absorbents and sevofl urane (Chapt er 9) can
be so rapi d and extensi ve that i t is di f f i cul t t o maintai n a sat isfactory i nspi red
concentrati on. If there i s a l arge di screpancy bet ween t he vapori zer set ti ng and t he
agent l evel in t he breat hi ng system, anestheti c breakdown should be consi dered.
Inadvertent Exposure to Volatile Agents
I t i s possi bl e that hal othane-rel at ed hepati ti s or mal i gnant hypert hermia may be
t ri ggered by small amounts of agent present i n a machi ne and breathi ng system
even i f the vapori zers are turned OFF (661,668,669,670,671,672,673,674). When a
pati ent wi t h a hi story or suspi ci on of one of these ent i ti es must be anestheti zed,
t he anesthesi a machi ne shoul d be prepared f or use by removi ng al l vapori zers i f
possi bl e (673). Ot her necessary act i ons i ncl ude changi ng t he absorbent , repl aci ng
t he f resh gas suppl y hose, usi ng new tubings and bag, and f lushi ng wi th a hi gh f l ow
of oxygen for a prol onged ti me (675,676,677,678,679, 680).
Shoul d an epi sode of mali gnant hyperthermi a occur during admi nistrat ion of
anesthesi a and t he depart ment has a machi ne f rom whi ch vapori zers have been
removed and that has been thoroughl y fl ushed of volati l e agents, i t shoul d be
subst i tut ed f or the machi ne in use. A f resh breathi ng system shoul d be used. If the
department does not have such a machine, t he fol l owi ng measures shoul d be taken
t o reduce the i nhaled concent rati on of vol ati l e anesthet ic (675,677):
Change the breathi ng system hoses and bag.
Change the f resh gas suppl y hose.
Change the absorbent.
Use very hi gh oxygen f lows.
I nsert a charcoal f il t er on the i nspi rat ory port of t he absorber.
Avoid using a contaminated vent i l ator.
Remove vapori zers f rom the machi ne if possi bl e.
I nadvertent anestheti c agent exposure can occur i f the anesthesi a machi ne i s used
t o del iver oxygen to a pati ent undergoi ng l ocal or MAC anesthesi a if t he f resh gas
del i very port or t he pat i ent port of the breathi ng syst em i s used t o del i ver oxygen t o
a nasal cannul a. If a vapori zer is i nadvertentl y turned ON, the pati ent may become
deepl y sedated or anestheti zed wi th t he agent (681, 682). These probl ems can be
avoided by usi ng the auxil iary f l owmeter on the anesthesia machi ne, an oxygen
f lowmeter attached to t he pi pel i ne syst em, or a cyl i nder as the oxygen source.
Physical Damage
Ol der anesthesia machines of ten have equipment added to t he top of the machi ne.
Thi s may resul t i n the machi ne becoming t op heavy. If t he equi pment contacts a
ceil ing col umn or other structure, equipment may be knocked onto the f l oor or
personnel . Whi le newer anesthesi a machines have a generall y l ower prof il e and
t end to i ncl ude many of t he moni tori ng devices that are of ten pl aced on the t op of
ol der machi nes, i t is sti l l possibl e to do physi cal damage to the machi ne.
Another hazard to anesthesi a equi pment is t he presence of wi res and tubi ngs on
t he f l oor. These make i t more l i kel y that the machi ne wi l l ti p during movement ,
spewi ng equi pment to the fl oor. Many machi nes come
P. 420

wi th opti onal arms that hol d breathi ng system hoses, t ubi ngs, and wi res of f the
f loor. A number of devi ces have been manuf act ured to move t he i mpedi ments f rom
t he machi ne wheel s (683,684,685, 686) (Fi g. 14.16). The castors on a machi ne can
break, causi ng the anesthesia machine t o ti p over (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
Over the past f ew decades, the number of wi rel ess radi o f requency (RF)
t ransmi t t ers i n medi cal f acil i ti es has i ncreased dramat ical l y (688,689,690,691).
Wi rel ess computer networks, pagi ng syst ems, handhel d radi os, cel l ul ar tel ephones,
and other RF t ransmi t ters, which are sources of el ect romagneti c energy, have
become preval ent in cl i ni cal envi ronments. I n the f uture, i t i s l ikely t hat moni tors
and other devi ces wi l l be connected to the data management system t hrough a
wi rel ess connecti on. These produce el ectromagnetic radi at ion even when the
device is i n standby mode, as they constantl y send si gnals t o the base st ati on.
I t has l ong been recogni zed t hat equi pment that emi ts radi o waves can interf ere
wi th t he operat ion of el ect roni c medical equi pment (el ect romagneti c interference or
EMI ). The extent of the problem i s unknown. Avai l able cl i ni cal data i ndi cate that
seri ous mal f uncti ons are rare (689). Equi pment report ed bei ng af fected incl udes
moni tors, venti l ators, and i nfusion pumps. The ri sk of int erference depends on
t ransmissi on power and f requency, di stance t o the t ransmi tter, and i mmuni ty
(constructi on) of the medi cal device.
The wi de vari et y of RF transmi t ters and medical devices used i n and around heal th
care faci li ti es makes i nteracti ons di f fi cul t t o predict. Areas such as the operati ng
room and cri t ical care areas, whi ch have a high concentrat ion of el ect ronic medical
devices, are most l i kel y t o be aff ected by EMI . Di agnosti c, moni tori ng, and
t herapeuti c equi pment that i s di rect l y att ached to pati ents is part i cul arl y suscepti bl e
t o EMI .
To hel p prevent EMI, newer medi cal devi ces are manuf actured t o enhance thei r
i mmuni ty to, or compat i bi l i ty wi th, ext ernal sources of el ectromagnet ic energy.
Newer cel l phones and newer equi pment off er bett er shi el di ng to mi ti gate or
prevent el ect romechani cal i nterference. Ol der medical equipment i s of more
concern because i t may not have been designed to be i mmune to t he i ncreasi ngl y
compl ex electromagnet ic envi ronment t hat can be f ound i n heal th care f aci l i t ies.
For most RF transmi t ters, the f i el d strengt h decreases wi th di stance. I t fol l ows t hat
i n general , the greater the separat ion bet ween a RF t ransmi tter and a medi cal
device, t he lower t he RF exposure t o the devi ce, and the l ower the potent ial for
EMI .
Caref ul consi derat ion must be gi ven t o wei ghi ng the ri sks and benef i ts of wi rel ess
equipment used i n and around heal t h care facil i ti es to determi ne whether i t can be
used saf el y and ef f ecti vel y. Unl ess each medi cal devi ce i s tested f or i mmuni ty t o
each RF t ransmi tt er, i t is di f f i cul t to identi f y whi ch devi ces may be aff ected by a
part icular transmi t ter and what transmi ssion condi t i ons are l i kel y to cause
i nterf erence.
Si nce t he ti me that cel l ul ar t elephones were i nt roduced, heal th care organi zat i ons
have struggled t o determine a prudent pol i cy for thei r use i n cl i ni cal set ti ngs. Some
f aci li t ies have banned the use of cel lular t el ephones on t hei r premi ses. Others
al l ow t hem to be used f reely, whereas ot hers have banned t hei r use in cert ai n
areas or wi t hi n a cert ai n distance of medical equi pment (688).
Al though appropri ate medi cal devi ce desi gn and test ing f or el ectromagneti c
compat ibi l i t y (EMC) can
P. 421

reduce potenti al EMI ri sks i n the cli ni cal envi ronment, they cannot ensure t hat a
device wi l l not experi ence problems. Under cert ain ci rcumstances, EMI can st i l l
occur, even i f the device conf orms t o current EMC standards. Theref ore, di rect or
cl ose cont act between the medi cal devi ce and wi rel ess communicati on devices
shoul d be avoi ded. Wi rel ess phones i n publ i c areas do not appear to cause
probl ems (690). Peri odical t est i ng of wi rel ess t ransmi tt i ng devices and medi cal
equipment wi l l be requi red to ensure a saf e envi ronment.
Accident Investigation
Any t i me a pat i ent has an unexpl ai ned probl em, equi pment mal f unct i on or mi suse
shoul d be suspected, and the apparat us shoul d not used agai n unt il thi s has been
di sproved (692,693,694,695,696).
When t here has been a pati ent inj ury, t he heal t h care facil i ty saf et y of f i cer (or ri sk
manager) shoul d be contacted at once to supervi se i nvesti gat i on of the inci dent . An
establ i shed protocol shoul d be desi gned and f ol l owed so that al l i mport ant areas
are systemat i cal l y covered. Al l individual s invol ved i n the i nci dent shoul d document
t hei r observati ons soon af ter the event whi l e detai l s are sti l l f resh in t hei r mi nds.
Thi s shoul d be a simpl e statement of facts, wi thout j udgments about causali t y or
responsi bi li ty.
The f ol lowi ng quest i ons need to be asked:
What was the date and ti me of the problem?
I n what area di d the probl em occur?
What moni tors were being used?
What were t he set alarm l i mi ts?
What was the f i rst i ndicati on t hat t here was a probl em?
At what t i me di d the probl em occur?
Who f i rst noted the probl em?
What changes at tract ed at tenti on? Were any al arms act ivated?
What signs or symptoms did t he pat i ent exhi bi t?
Had t here been any recent modif icati ons to t he elect ri cal system or gas
pi pel i nes i n t hat area?
Was anything al tered shortl y bef ore the i nci dent?
Was t his t he f i rst case performed i n t hat area on that day?
Were t here any probl ems duri ng previ ous cases perf ormed i n that area on
t hat day or on the previ ous day?
Were t here any unusual occurrences i n other areas on that day or on the
previ ous day?
Had any equi pment been moved into that area recentl y? Were t here any
probl ems not ed i n the room where i t was previousl y used?
What preuse anesthesi a equi pment checks were made?
Who l ast f il l ed the vapori zers on the anest hesia machine?
I f a vapori zer was recent l y at t ached to the machi ne, were precauti ons taken
t o prevent l i qui d f rom bei ng spi l l ed i nt o the outf l ow t ract?
Af ter the i ni ti al i ndicati on that a probl em had occurred, what was the
sequence of events?
An i mportant st ep invol ves const ructi on of a t i me l i ne, on whi ch al l events are l i st ed
i n chronol ogi cal order (692). Thi s wi l l hel p t o sort out events and may l ead to
i denti f i cat i on of mi ssi ng data. Trend data f rom moni t ors or a dat a management
system can hel p.
Numerous phot ographs shoul d be taken of the area f rom various angl es, wi th al l
equipment si tuat ed where i t was at t he ti me of the incident . Each piece of
equipment shoul d be phot ographed separatel y.
Af ter pictures have been t aken, al l suppl i es and equipment associated wi th t he
case should be saved and sequest ered i n a secure l ocati on and l abeled DO NOT
DI STURB. Set ti ngs shoul d not be changed. Relevant identi f yi ng informati on such
as t he manuf acturer and lot and/ or seri al numbers should be recorded.
I f af ter all thi s has been done i t appears possi bl e that t he equipment may be
i mpl i cated i n causing the probl em, a t horough i nspect i on of the equi pment by an
uni nvol ved thi rd party i n the presence of the pri mary anesthesia personnel ,
i nsurance carri er, heal th care f aci l i t y saf et y off i cer, pat i ent representati ve, and
equipment manuf acturers shoul d be conduct ed. The invest i gati on shoul d consi st of
an i n-depth exami nati on of t he equi pment si mi l ar t o the checking procedures
descri bed earl i er i n thi s chapter. Vapori zers shoul d be cal i brated and checked t o
determine i f vapor i s del i vered in t he OFF posi t ion. An anal ysi s should be made of
t he vapori zers' contents, i f necessary. Fol l owi ng the i nvesti gati on, a report shoul d
be made, detai l i ng al l f acts, anal yses, and conclusions.
I f a problem wi th t he equipment i s found, an att empt shoul d be made t o reconst ruct
t he acci dent, if t hi s can be done wi t hout danger t o anyone, and the equi pment
shoul d agai n be locked up unti l any li ti gati on i s set tl ed. If t he invest i gat ion reveal s
no probl ems, the equi pment can be returned t o servi ce wi t h the consent of al l
part ies.
Problem Reporting
I n t he Uni ted States, the Cent er for Devi ce and Radi ol ogi cal Heal th (CDRH) of the
Food and Drug Administ rati on (FDA) recei ves postmarket adverse event reports
submi t t ed by manuf acturers, user faci l i ti es, heal th care
P. 422

prof essi onals, and consumers i nvolvi ng deat h, seri ous i nj ury, or i l l ness and product
mal f unct ions (698,699). The FDA analyzes the reports to determi ne the impact on
t he publ i c heal th and makes recommendati ons to manuf act urers, heal th care
prof essi onals, and consumers. MedWatch is t he FDA' s name f or i ts medical
products report i ng program. I t i s a broad program that encompasses both voluntary
and mandatory report ing f or medical product s.
User f aci l i ti es are requi red to report t o the FDA medical devi ce probl ems that have
or may have caused or cont ri buted t o death, seri ous i l lness, or serious injury.
Seri ous i l l ness or injury i s def ined as li f e-t hreateni ng or resul ti ng i n permanent
i mpai rment of a body funct ion or permanent damage to a body st ruct ure or that
necessi tat es i mmedi ate medi cal or surgical i nterventi on to prevent damages to t he
body.
User f aci l i ti es must report a problem no l at er than 10 days af t er becomi ng aware of
i t. Fail ure to report accuratel y and i n a ti mel y manner can l ead to civi l or even
crimi nal penal t i es. Probl ems resul ti ng i n pati ent deaths are to be sent t o the FDA
and to the equi pment manuf acturer. Seri ous i l lness or i nj ury events are report ed to
t he manuf act urer or, i f the manuf act urer is not known, t o the FDA. The
manuf acturer has the responsibi l i t y to i nvest i gate the i nci dent and, i f appropri ate,
report the inci dent t o the FDA. Adverse events, i ncluding those i n whi ch a device
f ai l ed t o performed as i ntended but di d not resul t i n a deat h or seri ous i nj ury may
al so be reported vol untari l y through t he FDA' s MedWatch program.
Report s shal l not be admi t ted i nto evi dence or ot herwi se used i n a civil act ion
unl ess the f aci l i t y or personnel maki ng the report knew that the inf ormati on was
f alse. There are a number of ways t hat the i nf ormati on coul d become avai l abl e,
i ncl udi ng t he Freedom of I nf ormati on Act . It i s theref ore possi bl e that this
i nformati on coul d be avai l able f or a civi l sui t (698).
The user f aci l i t y should set up a protocol f or handl ing adverse i nci dents i n order
t hat they wi l l be properl y report ed in a ti mel y fashi on. Medical personnel need t o
know who (t he heal t h care f aci l i t y saf et y off i cer, ri sk management, biomedi cal
department , or other designated personnel ) shoul d receive the report.
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Questions
For the f ol lowing quest ions, answer
f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
1. Hypercarbia due to an i ncompetent unidi recti onal valve can be
di stinguished from that due to exhausted absorbent by
A. The shape of the carbon di oxi de waveform
B. An i ncrease in i nspi red carbon di oxi de
C. I ncreasing t he f resh gas f l ow
D. Absence of heat in t he absorber
Vi ew Answer2. Causes of air entrai nment i ncl ude
A. Sucti on appl i ed to an nasogastric t ube curl ed in t he esophagus
B. Mal f unct i on of t he interf ace of a cl osed scavengi ng system
C. Use of a mainst ream gas anal yzer
D. A l eak i n t he venti l ator bel l ows
Vi ew Answer3. What course of acti on shoul d be taken if a gas crossover
i n the pi pel ine system i s suspected?
A. Use t he oxygen f lush on the machi ne to purge the crossed gas
B. Di sconnect t he pi pel ine, and open an oxygen cyl i nder
C. Turn up t he f l owmet er f or t he crossed gas, and turn of f the oxygen fl owmeter
D. Use a resusci tati on bag to vent i l ate wi th room ai r
Vi ew Answer4. Color(s) which an oxygen cylinder may be pai nted i nclude
A. Bl ack
B. Whi te
C. Bl ue
D. Green
Vi ew Answer5. Safety mechanism(s) that prevent a hypoxic mi xture bei ng
del i vered because the flowmeters are i ncorrectl y set i nclude
A. The oxygen fai l ure safety valve
B. An oxygen anal yzer
C. The oxygen pressure fai l ure alarm
D. Proport i oning system
Vi ew Answer6. A l ower-than-expected anesthetic level may be caused by
A. Sevof lurane breakdown by desi ccated absorbent
B. A l eak i n a venti l at or bel l ows
C. Vapori zer l eak
D. Ai r f rom a li ght source
Vi ew Answer7. Which measures shoul d be taken i n the event that the
oxygen pipel ine suppl y is lost?
A. Use l ow f resh gas fl ows
B. Open an oxygen cyl i nder
C. Di sconnect the machi ne f rom the cent ral suppl y
D. Turn the piston venti l at or OFF
Vi ew Answer8. A l eak i n the breathing system should be suspected i f
A. The end-ti dal carbon di oxi de begi ns to i ncrease
B. There i s a change in the venti lator sound
C. A standi ng venti l at or bel l ows f ai l s to return t o the t op of i ts housi ng
D. The Fi O
2
decreases during cont rol l ed vent i lati on
Vi ew Answer9. Which si tuati ons would result in a negati ve pressure i n
the breathi ng system?
A. Nasogastri c tube placed i n the t rachea
B. Sucti on appl i ed to a working channel of a f iberscope
C. Mal f uncti on of valves in a cl osed scavengi ng i nterf ace
D. Loss of oxygen pressure to the machi ne.
Vi ew Answer10. An obstructi on in the breathi ng system may cause
A. An i ncrease in the peak breathi ng system pressure
B. Acti vat i on of t he hi gh pressure al arm
C. Hypoventi l at ion
D. Decreased movement of the vent il at or bel l ows
Vi ew Answer11. Which monitors are rel iable detectors of a breathi ng
system di sconnection?
A. Carbon dioxi de
B. Ai rway pressure
C. Respi rometer
D. Oxygen anal yzer
Vi ew Answer12. Causes of carbon di oxi de in the i nspiratory gas incl ude
A. Absorbent bei ng bypassed
B. I nadequate f resh gas fl ow to a ci rcle breathi ng system
C. An i ncompet ent uni di rect ional val ve
D. Excess carbon di oxi de producti on
Vi ew Answer13. Excessi ve ai rway pressure may be caused by
A. Mal f unct i on of t he APL val ve
B. Use of the oxygen f l ush duri ng i nspi rati on wi th cert ai n mechanical venti l at ors
C. Obstructi on in t he scavengi ng system
D. A uni di rect ional PEEP valve placed i n the expi rat ory l i mb
Vi ew Answer14. Anestheti c agent overdosage may be caused by
A. Isof l urane in a hal ot hane vapori zer
B. Reversed f low t hrough a vapori zer
C. Enf l urane i n an i sof l urane vapori zer
D. Overf i l l ed vapori zer
Vi ew Answer