CLINICAL ANAESTHESIA

Anaesthetic breathing Learning objectives

systems After reading this article, you should be able to:
C Outline an anaesthetic breathing system

Andrew Donnelly C Describe the key elements of an anaesthetic breathing system

C Illustrate the Mapleson classification system with adaptations

Stuart Dolling
C Discuss the advantages and disadvantages of each system

Abstract
A breathing system is a series of components that allows the delivery
of oxygen and other anaesthetic gases to the patient as well as aiding

A reservoir bag (RB) of distensible material of a size
in the removal of carbon dioxide. There are key elements that feature in
adequate for the patient’s peak inspiratory flow rate (0.5, 1
all anaesthetic breathing systems with numerous classification sys-
and 2 litre sizes commonly available). It allows collection
tems used. The layout of individual breathing systems determines
of fresh gas flow during expiration and minimizes the
their clinical application and use. All of the above will be discussed
amount of FGF required to prevent rebreathing.
further in this article as well as a brief summary of the use of carbon

A carbon dioxide (CO2) absorber if a rebreathing system is
dioxide absorbers and their function.
used.
Keywords Carbon dioxide absorbers; circle system; Mapleson; non-
Corrugated tubing to connect all of the above components.
rebreathing systems; rebreathing systems

Royal College of Anaesthetist CPD Matrix: 1A03, 1C02

Rebreathing
The respiratory cycle consists of three phases: inspiration, expi-
ration and the expiratory pause. Rebreathing occurs when an
Features of a breathing system inspired tidal volume breath contains the CO2 and reduced ox-
An ideal anaesthetic breathing system should have the following ygen content from the previous exhaled breath e it can be
properties: quantified as an increase in the ratio of dead space (comprising

safe, compact, lightweight and durable parts of the upper respiratory tract not involved in gaseous ex-

easy to clean and disinfect or, if disposable, have minimal change and equating to 2 ml/kg, as well as areas of the lung that
environmental impact are ventilated but not perfused) to tidal volume.1

suited to spontaneous and controlled ventilation in all Factors influencing the degree of rebreathing include:
sizes and ages
design of the system

allow the effective removal of exhaled gas with no
FGF rate which is the prime determinant
rebreathing.
patient’s respiratory rate
All anaesthetic breathing systems consist of similar key ele-
duration of the end-expiratory pause
ments but may be configured differently. The key elements of all
ventilation pattern used: spontaneous ventilation (SV) or
anaesthetic breathing systems are: controlled ventilation (CV).

A fresh gas flow (FGF) supply. Rebreathing in a circuit can be eliminated by using fresh gas

Connection to patient comprising an inspiratory and flow rates that are high enough to flush out and remove exhaled
expiratory limb. Although tubing length will vary within alveolar gas from the system and incorporating a CO2 absorbing
each system, the diameter is of a standard size (22 mm for component (e.g. soda lime) within a circle system.
adult and 18 mm for paediatric systems).

An expiration port or valve such as the adjustable pressure
limiting (APL) valve. This allows a variable pressure Classification of a breathing system
within the anaesthetic system using a one-way, spring- There are several ways anaesthetic breathing systems can be
loaded valve in order to safely vent waste gases. The classified. Historical nomenclature includes:
minimum pressure required to open the valve is 1 cmH2O
open system which uses solely atmospheric FGF
and a safety mechanism exists to prevent pressure
semi-open system using FGF from atmosphere and other
exceeding 60 cmH2O. sources

semi-closed system which is closed to the atmosphere. The
FGF is greater than uptake with excess scavenged
Andrew Donnelly MB ChB MRCP FRCA is a Consultant Anaesthetist at
closed system which is closed to the atmosphere with FGF
Salford Royal NHS Foundation Trust Hospital, Salford, UK. Conflicts equivalent to uptake and CO2 removed.
of interest: none declared. A more modern alternative classification, the Conway classi-
Stuart Dolling MBBS FRCA is a Consultant Anaesthetist at Salford fication,2 incorporates the rebreathing potential of a system and
Royal NHS Foundation Trust Hospital, Salford, UK. Conflicts of is shown in Table 1. We will discuss these in more detail using
interest: none declared. this classification.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 23:1 24 Ó 2021 Published by Elsevier Ltd.
 CLINICAL ANAESTHESIA

of a one-way valve that prevents rebreathing by preventing

The Conway classification of anaesthetic breathing mixing of fresh and expired gas. The bag is self-inflating so that
systems when piped or cylinder gas is unavailable, room air is
Breathing systems without CO2 Breathing systems with CO2 entrained. This makes it a valuable back-up or emergency
absorbers absorbers alternative. It is, however, bulky and unable to provide hu-
midification or heat conservation without an additional heat
Unidirectional flow: Unidirectional flow: and moisture exchanger, and requires a high FGF to deliver
C Circle system without absorber C Circle system with absorber higher oxygen concentrations.
C Non-rebreathing systems
(AmbuÒ bag) Bidirectional flow
Bidirectional flow: Bidirectional flow: Mapleson Classification (Table 2): In 1954 Mapleson described
C Mapleson AeF C To-and-fro system five different rebreathing circuits, collectively known as the
C Humphrey ADE Mapleson systems.3 Organized from letters A to E, each system’s
C Enclosed Afferent function and classification is determined by the positioning of its
Reservoir various components. The FGF requirements for each system vary
and are determined by which form of ventilation is utilized:
Table 1 spontaneous or controlled. The Mapleson circuits are described
below and the advantages and disadvantages of each are sum-
Breathing systems without a CO2 absorber
marized in Table 3.
Unidirectional flow
Non-rebreathing systems (e.g. the AmbuÒ bag) are mainly Mapleson A: This is the most efficient system for SV, as warm
associated with patient resuscitation. The AmbuÒ bag consists and humidified exhaled dead-space gas is reused. It is inefficient

The Mapleson classification

System Diagram Spontaneous ventilation Controlled ventilation

Mapleson A 1  minute volume (MV) 2.5  MV

Lack/Magill 70 ml/kg/min

Mapleson B 2.5  MV 2.5  MV

Mapleson C 2.5  MV 2.5  MV

Water’s Circuit

Mapleson D 2e3  MV 1  MV
Bain 70 ml/kg/min

Mapleson E 2  MV 1  MV
Ayres T-piece 70 ml/kg/min or minimum
3 litres/min

Mapleson F As Mapleson E As Mapleson E

Table 2

ANAESTHESIA AND INTENSIVE CARE MEDICINE 23:1 25 Ó 2021 Published by Elsevier Ltd.
 CLINICAL ANAESTHESIA

Advantages and disadvantages of Mapleson systems

System Advantages Disadvantages

Mapleson A Efficient during SV Inefficient during CV

APL positioned close to patient so difficult to operate
Mapleson B Inefficient during SV and CV
Mapleson C Compact and lightweight Inefficient during SV and CV
Mapleson D Efficient during SV Inefficient during SV
APL position distal to patient
Inspiration limb length can vary e useful for use in
MRI suite
Mapleson E Low resistance: useful in paediatric setting Difficult to scavenge waste gases
Needs high FGF
Mapleson F Low resistance: useful in paediatric setting Difficult to scavenge waste gases
RB allows ventilation Needs high FGF

Table 3

for IPPV as wastefully high FGFs are needed to prevent connecting the rest of the system to the reservoir bag and is
rebreathing. highly inefficient, so much so that it is deemed to be impractical

Spontaneous ventilation: for clinical use for either SV or CV. The Mapleson C (often
 Inspiration: the patient inhales fresh gas and partially referred to as a ‘Water’s circuit without absorber’) is used in
empties the reservoir bag (RB). resuscitation situations and for short patient transfers.
 Expiration: the patient begins to exhale, first anatomical
dead space gas then alveolar gas, down the tubing to- Mapleson D: FGF is introduced at the patient end of the system
wards the RB. As the bag fills, the pressure within the with the heavy components, namely the APL valve and RB, sited
system opens the APL valve to vent the exhaled gases away from the patient. It is mostly used in the coaxial form
which are by now mainly alveolar.2 known as the ‘Bain’ system. The Bain system consists of narrow
 During the expiratory pause the FGF flushes the inner tubing that delivers FGF directly to the patient, who will
remaining alveolar gas away from the patient and out of then exhale down the outer corrugated tubing to the reservoir
the APL valve. If the FGF matches the alveolar ventila- bag and APL valve. Disconnection of the inner tubing can result
tion (VA) then just as much gas flows into the system as in an increased dead space which causes massive rebreathing.
is exhaled, leaving only fresh and humidified dead space Therefore, one must to perform ‘Pethick’s test’ before use to
gas in the circuit. assess for a disconnection. The inner tube of the Bain circuit is

Intermittent positive pressure ventilation: occluded at the patient end using the end of a 2 ml syringe
 Inspiration: with the APL valve closed the bag is plunger. If the tube is connected, this causes back pressure on the
squeezed generating an inspiratory breath which FGF and the flowmeter bobbin will dip. Alternatively, rapid
partially empties the bag. flushing of FGF through an intact system leads to a venturi effect,
 Expiration: the subsequent expiratory breath fills the RB causing the reservoir bag to collapse.
and tubing with both dead space and alveolar gas. If this Mapleson D systems are most efficient when used during IPPV
is not flushed out with a high FGF rebreathing of exhaled and will lead to rebreathing during SV.
CO2 will occur.
Spontaneous ventilation:
A modification of the Mapleson A system is called the ‘Lack’  Inspiration: the patient takes a breath from the fresh gas
system. The Lack system uses an additional length of tubing, which has filled the outer corrugated tubing and reser-
thereby moving the APL valve further from the patient and to- voir bag.
wards the RB. This runs either parallel to, or more commonly,  Expiration: exhaled gases, mixed with the continuous
inside the original corrugated tubing (co-axial) and eliminates FGF, travel down the corrugated tubing towards the
the inconvenience of the APL sitting at the patient end. The FGF reservoir bag and APL valve. Once pressure within the
travels via the outer tube and the exhaled gas through the inner system is high enough, the APL valve opens and vents
tube. There is a large amount of dead space present at the patient exhaled gases.
end, so the Mapleson A is not suitable for patients under 30 kg in  The expiratory pause allows the FGF to flush out the
weight.4 exhaled gas and fill the corrugated tubing with any
excess vented. High FGFs are required to prevent
Mapleson B and C: These require a very high FGF to prevent rebreathing.
rebreathing. The potential for mixing inspiratory and expiratory
Intermittent positive pressure ventilation:
gases is due to the close proximity of the APL valve to the fresh  Inspiration: the RB is squeezed, forcing its contents and
gas port. The ‘B’ circuit has a length of corrugated tubing all fresh gas distal to it into the patient.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 23:1 26 Ó 2021 Published by Elsevier Ltd.
 CLINICAL ANAESTHESIA

 Expiration: exhaled gases, mixed with the continuous ventilation of alveolar gas. During SV there is no pressure within
FGF, travel down the corrugated tubing towards the the container and the APL valve remains fully open as for a
reservoir bag and APL valve. Once pressure within the Mapleson A. FGF requirements are the same for each mode of
system is high enough, the APL valve opens and vents ventilation, namely 70e100 ml/kg/min.
exhaled gases.
 Factors affecting rebreathing (e.g. minute ventilation and Breathing systems with CO2 absorber
inspiratory flow rate) are controlled by the anaesthetist,
Carbon dioxide absorbers
allowing a lower FGF. This is consequently a more effi-
For a system to be efficient, the removal of CO2 from the exhaled
cient system, requiring FGF of only 70 ml/kg/min, equal
gas is an essential process. The chemical reaction between CO2
to VA.
and either soda lime [94% Ca(OH)2, 5% NaOH, 1% KOH] or
Baralyme [80% Ca(OH)2, 20% Ba(OH)2] and a dye indicator
Mapleson E: Introduced in 1937 as the Ayre’s T-piece, this
allows CO2 to be safely and efficiently removed. This is an
functions much like a Mapleson D, has minimal dead space, no
exothermic reaction, with water as a by-product, and warms and
valves and generates very little resistance to breathing. This
humidifies the system. Soda lime is presented as dyed granules,
makes it ideal for paediatric anaesthesia in children weighing less
size 4e8 mesh, with small amounts (0.2%) of silica to prevent
than 20 kg. The open-ended corrugated tubing acts as an inspi-
disintegration of the granules. The dye changes the colour of the
ratory reservoir and consequently must have a length that ex-
granules once they have become exhausted. NaOH and KOH act
ceeds the tidal volume of the patient. During expiration the
as catalysts and are regenerated at the expense of the Ca(OH)2:4
tubing fills with dead space and alveolar gas which is then
flushed out by the FGF; the absence of an expiratory pause in 1: CO2 þ 2NaOH/Na2 CO3 þ H2 O þ Heat
small infants means that some rebreathing is inevitable at modest
FGF. The FGF is ultimately the sole determinant of whether 2: Na2 CO3 þ CaðOHÞ2 /2NaOH þ CaCO3
rebreathing occurs and directly influences the oxygen concen-
tration of inspired gas. Therefore if the FGF is not equal to the To prevent channelling of gases via a settling process, and
inspiratory flow rate air will be entrained creating a dilutional consequent inefficiency, the canisters are used in the upright
effect. position.

Mapleson F: Mapleson described five systems in his classifica- Bidirectional flow

tion but the Jackson Rees modification of the Mapleson E has led To-and-fro breathing system: No longer widely used, this system
to an unofficial sixth. It is mainly used in paediatric anaesthesia. initiated the development of the circle system. It consists of a
An open-ended valve-less bag is attached to the expiratory limb Mapleson C system with a horizontal soda lime canister positioned
of a Mapleson D allowing the application of continuous positive between the RB and APL valve. The canister serves to warm and
airway pressure or hand ventilation while also providing a visual humidify the gases, but it is cumbersome and inefficient as the
indicator of respiration. As with the Bain system, the reservoir granules nearest the patient are exhausted first, thus increasing
bag can be replaced by a mechanical ventilator. dead space with channelling likely as the canister is horizontal.4

Humphrey ADE Circuit: In 1938 Dr David Humphrey invented Unidirectional flow

this single system that incorporates both the Mapleson A and D The circle system (Figure 1): By using soda lime to absorb the
systems and allows the user to alternate between them by the patient’s exhaled CO2, this system allows the exhaled gases,
turn of a lever. The lever is moved upwards for SV and flow is including the volatile agent, to be re-circulated. Lower flows are
directed through the RB and the APL valve, functioning like a
Mapleson A. When IPPV is required the lever is moved down and
the flow bypasses the RB and is instead directed though the
ventilator, becoming a Mapleson D. If no ventilator is connected
and the tubing is left open ended, then the system works as an
Ayres T-piece (the ‘E’ of ADE).2 The gas is then conducted to and
from the patient via the inspiratory and expiratory limbs of
anaesthetic tubing. The system is suitable for adult and paedi-
atric use owing to its low resistance.

Enclosed afferent reservoir system (EAR): This system

(described by Miller and Miller in 1988) was designed to work
efficiently for both SV and IPPV.5 It performs as a Mapleson A,
but has the reservoir bag and APL valve within a non-distensible
container. A piece of corrugated tubing and a further reservoir
bag is connected to this container and this second bag is
squeezed during hand ventilation, forcing air into the container
and compressing the enclosed reservoir bag to deliver a breath.
The APL valve is opened during passive expiration to allow Figure 1

ANAESTHESIA AND INTENSIVE CARE MEDICINE 23:1 27 Ó 2021 Published by Elsevier Ltd.
 CLINICAL ANAESTHESIA

possible making this system more efficient and less polluting, as inadequate anaesthesia as the concentration of the volatile
well as warming and humidifying inspired gases. Gas analysers anaesthetic will be dependent on the patient’s inspiratory flow
are essential at low flows to ensure adequate volatile and oxygen rate. VOC allows the required volatile concentration to be ach-
are administered and that rebreathing does not occur via absor- ieved by adjusting the vaporizer; the maximum volatile con-
bent exhaustion. The system consists of: centration can never be greater than that set. A

two one-way valves

a reservoir bag

APL valve REFERENCES

a soda lime cannister 1 Milner Q. Anaesthetic breathing systems. Update Anaesth 1997; 7:

a Y-piece patient connector 145e50.

a source of FGF. 2 Conway CM. Anaesthetic breathing systems. Br J Anaesth 1985;
The positioning of the vaporizer can either be outside the 57: 649e57.
circle (VOC), e.g. on the anaesthetic machine backbar, or inside 3 Mapleson W. The elimination of rebreathing in various semi-closed
the circle (VIC). In order for a VIC to work, the vaporizer must anaesthetic systems. Br J Anaesth 1954; 26: 323.
have an extremely low internal resistance to allow easy passage 4 Al-Shaikh B, Stacey S. Essentials of anaesthetic equipment. 3rd
of the gas.4 There is also an increased risk of high volatile con- edn. Philadelphia: Churchill, Livingstone Elsevier, 2007.
centrations owing to vapour containing gas to-and-froing 5 Miller DM, Miller JC. Enclosed afferent reservoir breathing systems.
through the vaporizer, so inspired anaesthetic gas monitoring Description and clinical evaluation. Br J Anaesth 1988; 60:
is essential. In a spontaneously breathing patient, VIC can lead to 469e675.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 23:1 28 Ó 2021 Published by Elsevier Ltd.