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Functions of Anesthesia Reservoir Bag in a Breathing System

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Functions of Anesthesia Reservoir Bag in a Breathing System Professional article Zdrav Vestn | May – June 2017 | Volume 86 Metabolic and hormonal disorders id PROFESSIONAL ARTICLE Functions of anesthesia reservoir bag in a breathing system Miljenko Križmarić Abstract Faculty of Medicine, This article addresses the different functions of anaesthesia reservoir bag in a circle anesthesia University of Maribor, breathing system. A main purpose of the contribution was to explain complex interaction between Maribor the reservoir bag and fresh gas flow during mechanical ventilation. The anesthesia reservoir bag is a collapsible gas container which is an essential component of most anesthesia breathing system. Correspondence: The anesthesia reservoir bag permits manual ventilation and acts as a visual or tactile indicator of Miljenko Križmarić, e: miljenko.krizmaric@ spontaneous breathing. The bag was excluded from traditional breathing system when the mechani- um.si cal ventilator was in use. Discrepancies between the set and actual tidal volume can occur. However, on some anaesthesia workstation systems, such as the Dräger Primus, the reservoir bag is an integral Key words: part of the breathing system during mechanical ventilation, where it serves as a reservoir for oxygen anesthesia breathing and anaesthetic gases. In mechanically ventilated patients, gases enter the reservoir bag from the systems; circle fresh gas flow during inspiratory phase, when the decoupling valve closes. The safe administration anesthesia breathing of general anaesthesia requires understanding of the technological advances in highly sophisticated systems; anesthesia reservoir bag; fresh gas anaesthetic equipment. decoupling Cite as: Cite as: Zdrav Vestn. 2017; 86:226–35. Zdrav Vestn. 2017; 86:226–35. Received: 14. 9. 2016 Accepted: 5. 3. 2017 1. Introduction The anaesthesia reservoir bag is an The reservoir bag is most often placed important component in most breath- between the expiratory valve and CO2 ing systems used in anaesthesia. Figure absorber. Such a configuration allows 1 presents a traditional or classical circle for the dust from absorbent beads to be anaesthesia breathing system that com- pushed into the inspiratory limb during prises 7 different components: manual or mechanical ventilation (3). • inflow of fresh gases, As seen in Figure 1, the inflow of • inspiratory and expiratory unidirec- fresh gases at inspiratory phase is di- tional valve; rected to the patient through the inspi- • an inspiratory and expiratory corru- ratory valve, the inspiratory limb (tube) gated tubes (limbs) and the Y-piece. Expired air containing • Y-piece; carbon dioxide (CO2) flows through • adjustable pressure-limiting valve the expiratory limb through the expi- • CO2 absorber with absorbent; ratory valve and fills the reservoir bag. • reservoir bag (1-2). When the pressure in the bag increases Functions of anesthesia reservoir bag in a breathing system on line edition METABOLIC AND HORMONAL DISORDERS Figure 1: Traditional dotok svežih plinov anaesthesia breathing (Fresh gas flow) system. absorber CO2 ven�lator (Ven�lator) inspiracijska zaklopka (CO2 absorber) (Inspiratory valve) inspiracijski krak nastavek Y (Inspiratory limb) (Y connect) preklopnik (Bag/ven�lator selector switch) ekspiracijski krak bolnik (Ekspiratory limb) (Pa�ent) dihalni balon (Reservoir bag) ekspiracijska zaklopka (Ekspiratory valve) razbremenilni ven�l (Adjustable pressure-limi�ng valve) above the value set on the pressure- the tube is attached with greater force limiting valve, the respiratory gases and thus less likely to slip off. are released from the breathing system ISO 5362 is the international ISO stan- through this pressure-limiting valve dard that defines the characteristics of into the scavenging system. On expira- anaesthetic reservoir bags ISO 5362:2006 tion, the respiratory gases fill the reser- – Anaesthetic reservoir bags) (7). In ac- voir bag, and on inspiration these gases cordance with this standard, the maxi- return to the patient from the reservoir mum permissible gas leakage in reser- bag, thereby passing through the CO2 voir bags of original nominal volume of absorber, which absorbs carbon diox- 1 l is 10 ml/min. In reservoir bags with a ide (CO2). The valves direct the circular volume of more than 1 l, the maximum one-way flow of respiratory gases (4). permissible gas leakage is 25 ml/min. In contrast to the presented traditional The leakage is measured at a pressure of Circle-breathing system, different man- 3 ± 0.3 kPa. Reservoirs can be made of ufacturers may have individual compo- natural rubber and contain latex (often nents placed differently. reusable) or are made of latex-free mate- The disadvantage of the circular rials and are disposable (the note that the breathing system is in a large number of reservoir is latex-free should be indicat- different components where malfunc- ed on the packaging). The force that the tions can occur (5). These occur due to reservoir is required to withstand during incorrectly connected connection sites, the linear load testing of the reservoir leakage of gas, obstruction of the tube, neck is 40 ± 4 N (7). The tolerances for cracks in the filters, or because the tube the nominal volume range within ± 15 %. may accidentally slip off the coupling. Connection to the breathing system is When connecting the tube, it is neces- made by means of two connectors with sary to keep in mind that the tube should internal diameters of 15 mm (15F, female be pushed and rotated (the manufac- conical fitting) and 22 mm (22F, female turer in the user manual talks about the conical fitting). The material of the res- “push and twist” procedure). In this case ervoir must be antistatic (i.e. not prone on line edition Zdrav Vestn | May – June 2017 | Volume 86 PROFESSIONAL ARTICLE ration function is then taken over by a mechanical ventilator. 2. Reservoir bag and spontaneous breathing The most important function of a reservoir bag during patient’s sponta- neous breathing is the collection of re- spiratory gases. In the patient’s inspira- tion of 500 ml of gas for 1 second, a high average flow of 30 l/min (0.5 l × 60 s) is generated; the maximum values in the middle of inspiration are higher by Figure 2: Breathing to static electricity buildup) and should 30–40 % (12). The inflow of fresh gases reservoir bags of different volumes and not slip when held in hands. The material does not allow for such high flows, so couplings (Intersurgical should also not be permeable to inspira- the gasses must be collected in a respi- Ltd). tion anaesthetics and should not absorb ratory reservoir bag. During spontane- or adsorb them. The upper part of the ous breathing, the patient inhales fresh reservoir with the coupling is called the respiratory gases along with gases from “neck” and the opposite part is the “tail”. the reservoir bag, which are devoid of The tail, which is a tubular extension of CO2 as they pass through the CO2 ab- the reservoir, must be at least 2 cm long. sorber and the inspiratory valve, with When open (i.e. open tail), it functions the expiratory limb being closed via the as a relief mechanism in the linear Ma- expiratory one-way valve. During expi- pleson F breathing system. The reservoir ration, the reservoir bag is filled with ex- bag has an ellipsoid shape, which facili- haled air and the inflow of fresh gases as tates grip (7). the inspiratory valve is closed (Figure 1). Reservoir bags intended for paediat- When the reservoir bag is filled up to its ric use generally have a nominal volune nominal volume, the excess gases are re- of 0.5 or 1 litre (Figure 2, three lower res- leased through the adjustable pressure- ervoir bags), and for adults a volume of 2 limiting valve. In this case, the pressure or 3 l (two upper reservoir bags in Figure limiting outflow valve in the Dräger 2). The lower two reservoir bags in Fig- Primus anaesthesia workstation is in ure 2 have couplings with a standardised the position marked “Spont” (fully open internal diameter of 15 mm (15F) while valve). other reservoir bags have a standardised During spontaneous breathing, the internal diameter of 22 mm (22F). reservoir bag is a visual monitor; it is In the traditional circle breathing sys- slightly deflated on inspiration and re- tem, a reservoir bag has a function only filled on expiration. The reservoir bag is in spontaneous breathing or in manual also a tactile monitor, as its soft structure positive pressure ventilation. During enables us to feel its filling or emptying mechanical ventilation, it is excluded by touch (23). from the breathing system by bag/ven- The monitoring of spontaneous tilator selector switch (Figure 1) and in breathing depends on several factors: the this mode it has no function. The respi- shape of the reservoir bag, its size, the Functions of anesthesia reservoir bag in a breathing system on line edition METABOLIC AND HORMONAL DISORDERS to that of spontaneous breathing. In as- sisted ventilation, the onset of inspirato- ry phase can be determined by tactile or visual monitoring of the reservoir bag. 4. Safety pressure The reservoir bag has a safety function which protects the patient’s lung from barotrauma. It is the most flexible part of the breathing system. During gas filling, it is the reservoir bag that first shows evi- dence of filling. When the pressure limit- ing outflow valve is closed, the reservoir Figure 3: A protective level of inflation, the flow of fresh gases, bag is filled beyond the nominal volume, cage on the inside of the 22F coupling. and the patient’s respiratory capacity. but nevertheless it must maintain a safe- The accurate assessment of the pa- ty pressure within the limits below 60 cm tient’s respiratory volume cannot be H2O (7). Laplace’s law shows the correla- done simply by observing the reservoir tion between the tension on the surface bag (8).
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