ANAESTHETIC

INSTRUMENTS
Presented By :
Dr. ANAS ABU LABAN
 MAPELSON BREATHING CIRCUIT
*** Magill ( A ) :
• Length of corrugated tube is 110 cm, with diameter of 22 mm
• Efficient for spontaneous breathing, with fresh gas flow FGF Equal to alveolar
minute ventilation MV ( 70 ml/kg/min ), preventing the rebreathing
• Not suitable for controlled ventilation, requiring FGF 3 times MV
• Not suitable for children less than 25 kg weight, due to high dead space

*** Lack ( coaxial A ) :

• Length of corrugated tube is 180 cm
• The fresh gas flows through the outside tube, with diameter of 30 mm
• The exhaled gases flow through the inside tube, with diameter of 14 mm
• APL valve and Reservoir Bag, both at machine end
*** Mapelson ( B ) and ( C ) :
• B has corrugated tube, but C has not
• Both are not efficient for spontaneous ventilation, requiring FGF 2 times MV
• B is more efficient for controlled ventilation than A

*** Bain ( coaxial D ) :

• Length of corrugated tube is 180 cm, but can reach 270 cm in Dental or
Ophthalmic surgery, and 540 cm in MRI scanning
• The fresh gas flows through the inside tube, with diameter of 14 mm
• The exhaled gases flow through the outside tube, with diameter of 30 mm
• APL valve and Reservoir Bag, both at machine end
• Not efficient for spontaneous ventilation, requiring FGF 2 times MV
• Suitable for controlled ventilation, with FGF equal to MV
• Having a disadvantage of unnoticed Kinking of inner tube
*** Ayre's T-Piece ( E ) and Jackson Rees ( F ) :
• Valveless systems, used in children less than 25 kg
• F has Reservoir Bag far from the patient, but E has not
• APL valve can be added at end of the bag of F system
• Can be used for both spontaneous and controlled ventilation, requiring a high
FGF 2 to 3 times MV, with a minimal flow of 4 L/m
• Scavenging is allowed only in F system
 BREATHING CIRCLE
• It is called ADE system
• Used for spontaneous and controlled ventilation in all ages
• FGF should be 70 ml/kg in adults , and should be more than 3 L/m in children
• The internal diameter of bore tubes is 15 mm

• Components :
1. Fresh Gas Flow 2. Inspiratory Valve 3. Inspiratory Breathing Tube
4. Y – Connector 5. Expiratory Tube 6. Expiratory Valve
7. APL valve 8. Reservoir Bag 9. Soda Lime Canister
 ENDOTRACHEAL TUBE
• The plastic disposable tube is made of Polyvinyl Chloride PVC
• It has Radio-opaque line, to be visible on X-ray, due to metallic material
• It has Black Depth Marker located 3 cm proximal to the cuff
• Left-Facing Bevel improves the view of vocal cords
• Murphy Eye enable ventilation if bevel become occluded
• IT abbreviation means Implantation Tested
• Cuff can be either High Pressure - Low Volume or Low Pressure - High Volume

• The narrowest point in adult’s airway is the Glottis, so cuffed tube is used
• The narrowest point in child’s airway is the Cricoid Cartilage, so un-cuffed tube is used,
with small leak at pressure of 15 cmH2O is desirable

• Patient tolerate nasal tube better, but if possible, avoid that in childs less than 8 years
 ARMOURED & OXFORED TUBE
• Oxford Tube is a non-kinkable L-shaped tube
• Used in head and neck surgery
• The Bevel is oval in shape, and faces posteriorly
• Introducing Stylet is used to aid the insertion
• The distance between the bevel and the curve is fixed

• Armoured Tube has thick wall, containing Spiral of metal wire or nylon
• Used in head and neck surgery
• Introducing Stylet is used to aid the insertion
• It is not possible to cut the tube, so increasing the risk of bronchial intubation
• Two Black Markers are present proximal to the bevel
 RAE TRACHEAL TUBE
• RAE means Ring, Adair, & Elwyn
• It is a Preformed tube, can fit the mouth or nose without kinking
• Due to preformed shape, it carries a high risk of bronchial intubation
• It has a bend located just as the tube emerges
• It can be either North or South Facing
• The Cuffed RAE tube has one Murphy Eye, whereas The Uncuffed version has
two Murphy Eyes
• It can be temporarily straightened to insert a suction catheter
 LASER RESISTANCE TUBE
• It is used in Laser surgery on the larynx or trachea
• It can withstand the effect of carbon dioxide and KTP laser beam
• Reflected beams from the tube are defocused
• It has a flexible stainless steel body
• The cuff is filled with Saline instead of air
• Some designs have two cuffs, because the upper cuff may be damaged by laser
 TRACHEOSTOMY SET
• The curved plastic tube is inserted through 2nd, 3rd, 4th tracheal cartilage rings
• An introducer is used for insertion
• Wings attached to the proximal part to fix it in place with ribbon or suture
• The proximal end has 15 mm connector
• The tip is cut-square rather than beveled

• Indications :
1. Long term intermittent positive pressure ventilation
2. Upper airway obstruction
3. Impaired pharyngeal or laryngeal reflexes after head injury
4. To facilitate weaning from mechanical ventilator
 DOUBLE LUMEN ENDOBRONCHIAL TUBE
• It is used for One-Lung Ventilation during Thoracic surgery
• Mallinckrodt Bronchocath Tube has two separate colour-coded lumens, each
with its own Pilot Balloon, Cuff, and Bevel
• There are two curves, the standard anterior to fit into oropharyngeal tracheal
airway, and the second curve, either to right or left, to fit into the bronchus
• The proximal end is connected to Y-shaped catheter mount of 15 mm
• French Scale means the External Diameter in Millimeter multiplied by 3

• The Right DLT has an Eye in the bronchial cuff to facilitate ventilation of right
upper lobe, because the distance between carina and right upper lobe is 2.5 cm
• The Left DLT has No Eye in the bronchial cuff, because the distance between
carina and right upper lobe is 5 cm
• The position of the tube should be checked by auscultation after intubation and
after positioning, while it is preferred to use fibreoptic bronchoscope of 4.0 mm

• It is desirable to use Left DLT in most surgical procedures

• Right DLT is recommended to be used only in cases of:

1. Left Intrabronchial Mass 2. Descending Thoracic Aortic Aneurysm
3. Left Pneumonectomy 4. Left side Lung Transplantation

• The usual insertion depth to the corner of the mouth in a patient 170 cm tall is
around 29 cm
• During One-Lung ventilation, the unoxygenated blood from upper lung is mixed
with oxygenated blood from ventilated dependent lower lung, so leading to
wide A-a Gradient and increasing the Shunt by 30%
• Blood flow to the non-ventilated upper lung is decreased by Hypoxic Pulmonary
Vasoconstriction HPV and by surgical compression of the upper lung

• Factors that inhibit HPV and worsening the shunt :

1. Very high or low pulmonary artery pressure 2. Hypo-capnia
3. Very high or low mixed venous PO2 4. Vasodilators
5. B agonist and Ca channel Blockers 6. Inhalational Anesthetics

• Factors that decrease blood flow to the ventilated lung :

1. High PEEP 2. Low FiO2 3. Inadequate Expiratory Time
 ENDOBRONCHIAL BLOCKER
• It is used in One-Lung ventilation
• The Blocker Catheter is 9 FG and 78 cm length, having a distal cuff, with a Guide
Loop emerges from its tip
• This blocker is passed through standard single-lumen tracheal tube, and
advanced toward the desired main bronchus under direct visualization via a
fiberoptic bronchoscope
• After cuff inflation, ventilation of other lung is maintained through tracheal tube
 OROPHARYNGEAL AIRWAY
• It is called Guedel airways
• It is inserted through the mouth into the oropharynx
• The Body is flattened antero-posteriorly and curved laterally
• The Bite Portion is straight and fit between teeth
• The Flange at the oral end prevents it from falling back
• It allows a suction catheter to pass through the air channel

• If inserted in a patient having good pharyngeal reflexes, the Gag reflex

stimulation will lead to vomiting
 NASOPHARYNGEAL AIRWAY
• It is inserted through the nose into the nasopharynx
• The distal end is just above the epiglottis
• The Body is rounded and curved
• The Bevel is Left Facing
• The Flange is present on proximal end
• It allows a suction catheter to pass through the air channel

• It is better tolerated by semi-awake patient than the oral airway

 LARYNGEAL MASK AIRWAY
• It is a Supra-glottic Airway Device, with a proximal end of 15 mm
• An Elliptical Cuff is inflated via a Pilot Balloon
• The cuff lies over the larynx

• It has a wide internal diameter to reduce the flow resistance :

2’’ = 7mm ..….. 3’’ = 10mm ….... 4’’ = 10mm ….... 5’’ = 11.5mm

• It can be used up to 40 times

• It does not protect against the aspiration of gastric contents

• Should remain in place until regaining airway reflexes and coughing
 REINFORCED & PROSEAL LMA
• Reinforced LMA is used in head and neck surgery
• It is flexible , and has stainless steel wire spiral in the wall
• It has a smaller internal diameter and longer length, leading to higher resistance

• Proseal LMA It has a Double Lumen

• One lumen leads to the cuff for ventilation
• Second lumen ends at distal point of the cuff, as a Drain Tube, to allow passage of
oro-garstic tube through esophageal sphincter
 INTUBATING & i-GEL LMA
• Intubating LMA facilitates tracheal intubation
• Tracheal tube is blindly inserted through LMA toward the vocal cords

• i-GEL LMA has a soft, gel-like, non-inflatable cuff

• Made from a medical grade thermoplastic elastomer
• Designed to provide an anatomical impression fit over the laryngeal inlet
 KING LARYNGEAL TUBE
• A tube with small esophageal balloon and larger hypopharyngeal balloon
• It has a single Pilot Balloon, inflating both proximal and distal cuffs
• The proximal cuff stabilize the tube and seals the oropharynx
• The distal cuff prevent the entry into esophagus
• There are two Ventilation Outlets in front of the larynx, to maintain ventilation,
and allow passage of fiberoptic bronchoscope
• It has a Radio-opaque Line
 ESOPHAGEAL TRACHEAL COMBITUBE
• Two fused tubes, each with 15mm connector on its proximal end
• The longer blue tube has an occluded distal tip, that forces gas to exit through a
series of side perforations
• The shorter clear tube has an open tip, without side perforations
• It has two cuffs, the proximal 100 ml and distal 15 ml, both should be fully
inflated after insertion

• It is blindly inserted through the mouth, and advanced until the two black rings
on the shaft lie between upper and lower teeth

• The distal lumen usually comes to lie in the esophagus in 95% of times, so that
ventilation through blue side perforations pass to the larynx
 CATHETER MOUNT
• It is a Flexible Link between the breathing system tubing and tracheal tube,
face mask, laryngeal mask, or tracheostomy tube
• The length varies from 45 to 170 mm
• The distal end is connected to 15 mm tracheal tube or 22 mm mask
• The proximal end has 22 mm connector to breathing system

• It contributes to additional Dead Space

 LARYNGOSCOPE
• The Handle houses the power source
• The Blade can be either curved or straight

• The straight blade is used for neonates and infants, to left the epiglottis

• The curved blade push the tongue to the left and advanced to the vallecular

• The Left-sided Macintosh blade is used in right-sided facial deformity

• The Polio blade of 120’ is used to overcome large breast tissue

 DIFFERENT BLADES
(A) Miller blades (large, adult, infant, premature)

(B) Macintosh blades (large, adult, child, baby)

(C) Macintosh polio blade

(D) Soper blades (adult, child, baby)

(E) left-handed Macintosh blade

(F) Wisconsin blades (large, adult, child, baby, neonate)

(G) Robertshaw’s blades (infant, neonatal)

(H) Seward blades (child, baby)

(I) Oxford infant blade

 FACE MASK
• It is made of silicon, rubber, or transparent plastic
• The Body rests on air-filled Cuff
• The Proximal Orifice has 22 mm inlet connection to the angle piece
• The Angle Piece has 90’ bend with 22 mm end
• The Retaining Hooks are used for stabilization

• The dead space may reach 200 ml in adults

• Positive pressure ventilation through face mask should be limited to 20 cmH2O

to avoid stomach inflation
 GOLDMAN NASAL INHALER
• It is used in dental chair anesthesia

• The Inflatable Cuff is fit to the face

• The APL valve located at proximal end
• The mask is connected to Tubing for FGF
 SIMPLE OXYGEN MASK
• It is a type of Variable Performance Devices
• Its performance varies between patients and from breath to breath

• Component : 1. Plastic Body 2. Port connected to supply 3. Elastic Band

• A minimum oxygen flow of 5 L/m is applied to limit the rebreathing

• FiO2 is determined by:

1. Oxygen Flow Rate 2. Pattern of Ventilation 3. Size of Reservoir
4. Maximum Inspiratory Flow Rate 5. How well the mask fits the face
• During normal tidal ventilation, the peak inspiratory flow rate is 20 L/m, which is
higher than the oxygen supplied to the patient and the oxygen contained in the
body of the mask. So some ambient Air is inhaled through the holes on both
sides to meet the demands. Thus diluting the fresh oxygen supply

• During the expiratory pause, the fresh oxygen supplied helps in venting the
exhaled gases through the side holes

• The Body of the mask acts as a reservoir, and filled with fresh oxygen supply,
and is available for next inspiration

• The body of the mask leads to an apparatus dead space of 100 ml, so the
rebreathing of carbon dioxide makes a problem for tired patients
 PARTIAL & NON REBREATHING MASK
• Adding a 700 ml Bag to the face mask will act as an extra reservoir. So will be
called Partial-rebreathing or Non-rebreathing Masks

• In Partial-rebreather, without any valve, a part of the expired tidal volume

refills the bag.

• In Non-rebreather, the flap-type valves between the bag and mask and a valve
at exhalation ports will prevent the rebreathing of CO2

• A minimum flow of oxygen is 10 – 15 L/m is applied

 NASAL CANNULA
• It is a type of Variable Performance Devices
• It is better tolerated than face mask for long-term therapy
• Composed of two Prongs that protrude 1 cm into the nostrils

• FiO2 is determined by :
1. Oxygen Flow Rate 2. Tidal Volume 3. Inspiratory Flow
4. Respiratory Rate 5. Volume of Nasopharynx

• Mouth breathing causes inspiratory air flow, so this produce Venturi Effect in the
posterior pharynx entraining oxygen from the nose

• FiO2 = ( 4 * Flow Rate ) + 0.21

 VENTURI MASK
• It is a type of Fixed Performance Devices or HAFOE
• Composed of Plastic Body with side holes, and proximal Venturi Device
• It delivers a fixed concentration of O2, specially for Hypoxic-Driven pts ( COPD )

• As Bernoulli states that the sum of kinetic and potential energy remains constant
at all points of gas or liquid Flow , so , at a specific constriction , the Kinetic
Energy ( Velocity ) increases and the Potential Energy ( Pressure ) decreases

• At a constriction, the Velocity of gas increases distal to the orifice, and the
Negative Pressure causes Ambient Air to be entrained and mixed with O2 flow

• FiO2 is dependent on the degree of Air Entrainment ( inverse proportion )

 SPINAL NEEDLE
• The length varies from 5 to 15 cm, but 10 cm is most commonly used
• It has a proximal transparent Hub
• A Stylet is used to prevent a core of tissue to occlude the lumen
• The 25 G and smaller needles are used with introducer

• The Sharp cutting traumatic Bevel is seen in Quincke needle

• The Blunt pencil-point Bevel with side hole is seen in Whitacer & Sprotte needle

• The Blunt needles decrease the incidence of PDPH

 EPIDURAL NEEDLE
• It is called Tuohy needle
• It is 10 cm in length, with a shaft of 8 cm ( 1 cm markings )
• It has a Blunt Bevel, with a curve of 20’ at the tip
• A Stylet is used to prevent a core of tissue to occlude the lumen
• Commonly used gauges are 16 G or 18 G

• The Epidural Catheter is 90 cm in length

• It is transparent, and made of nylon or Teflon
• The 16 G version has ED of 1 mm and ID of 0.55 mm
• The distal end has three side ports, with a closed rounded tip
 COMBINED SPINAL EPIDURAL SET
• 26 G spinal needle of about 12 cm length
• 16 G Tuohy needle of about 10 cm length
 CENTRAL VENOUS CATHETER
• The catheter is positioned in the superior vena cava at the entrance of right atrium
• The most common method of insertion is Seldinger Technique
• CVP pressure should be measured during End Expiration ( normal= 1-7 mmHg )

• The catheter is has two or three lumens of 16 G or 18 G

• It is made of Polyurethane
• To reduce the risk of Infection, it is antiseptic-coated with ( chlorhexidine - silver -
sulfadiazine ), or it is antibiotic-coated with ( minocycline - rifampin )

• Indications : 1. Monitoring of CVP 2. Administration of fluid in shock

3. Infusion of TPN 4. Aspiration of Air Emboli
5. Insertion of Transcutaneous Pacing Leads
• Internal Jugular Vein :
1. Central Approach:
find 1cm above the apex of head of SCM and clavicle > 60’to skin, towards ipsilateral nipple (blood obtained within 3cm)
2. Posterior Approach:
find 2-3 finger above clavicle along posterior border of SCM, direct needle towards jugular notch (blood obtained within 5cm)
3. Anterior approach:
identify the carotid and mid point of medial SCM border, aim toward ipsilateral nipple

• Subclavian Vein :
1. Subclavian Approach:
find 1 cm inferior to the junction of middle and medial third of the clavicle, and advance the needle toward suprasternal notch
2. Supraclavicular Approach:
find 1 cm lateral to the lateral border of clavicular head of SCM, and 1 cm superior to clavicle, and advance the needle toward
contralateral nipple

• Femoral Vein :
1. Approach:
slight external rotation of hip, palpate pulse, 1 cm medial to arterial pulsation, and advance the needle with 45’ in a cephallad
 ARTERIAL LINE
• Component :
1. An indwelling Teflon cannula 22G is used
2. A column of bubble-free heparinized saline at a pressure of 300 mmHg
3. Transducer, Amplifier, Oscilloscope, and Diaphragm

• It can estimate Blood Pressure, Myocardial Contractility, [Link], & stroke Volume

• The natural frequency of the monitoring system is :

1. Directly related to the catheter diameter
2. Inversely related to the Square root of the System Compliance
3. Inversely related to the Square root of the Length of the Tubing
4. Inversely related to the Square root of the Density of the Fluid
• DAMPING is caused of dissipation of stored energy
• Optimal Damping = 0.64

• The addition of tubing, stopcocks, soft transducer, and air in the line, all
Decrease the Frequency of the system, leading to Over-Damping, and so
Underestimate the Systolic BP but Normal Mean BP

• The transducer should be positioned at the level of Right Atrium

( raising or lowering that level will give error readings by 7.5 mmHg for 10 cm )

• The Site of choice for insertion is Radial Artery ( after performing Allen’s Test) ,
because it is more superficial than Ulnar artery and having good collaterals
 PULSE OXIMETRY
• It consists of a Probe with two LEDs and a Photodetector

• The two Light Emitting Diodes LEDs produce beams at red (660 nm) and
infrared (940 nm) frequencies, in a rate of 30 times per second

• Oxygen Saturation is estimated by measuring the transmission of light through

a pulsatile vascular bed, based on Lambert-Beer Law

• It gives readings every 10-20 seconds

• The response time of desaturation is longer with finger probe (60 seconds)
whereas in ear probe it is shorter (15 seconds)
• Oxy-hemoglobin absorb infrared light (940 nm) and Deoxy-hemoglobin absorb
red light (660 nm), while both are equal in absorption at (805 nm)

• Arterial Pulsations can be identified by Plethysmography

• Sources of Error Readings :

1. Met-Hb 2. CO poisoning 3. Methylene Blue 4. Blue Nail varnish
5. Hypothermia 6. Low Perfusion 7. Sensor Malposition 8. Severe Anemia

• Fetal Hb, Bilirubin, & Dark Skin, all do not cause significant errors
 CAPNOGRAPHY
• End-Tidal CO2 is less than Alveolar CO2 because it is diluted with alveolar dead
space gas, while the Alveolar CO2 is less than Arterial CO2 due to shunt

• CO2 absorbs the infrared radiation at (430 nm), based upon Beer-Lambert Law

• in the above diagram, the End-Tidal CO2 is read at the point marked as (D)

• Sampling can be done either by Sidestream Chamber or Mainstream Chamber

• Mainstream : 1. faster 2. risk of sensor damage 3. heavy weight on the tube
• Sidestream : 1. slower 2. risk of disconnection 3. risk of gas leak

• Special Filter should be used, because N2O can also absorb the infrared light
• Increased ETCO2 : 1. Hypoventilation 2. Malignant Hyperthermia 3. Sepsis
• Decreased ETCO2: 1. Hyperventilation 2. Pulmonary Embolism 3. Low BP
• No ETCO2 : 1. Esophageal Intubation 2. Circuit Disconnection
 BISPECTRAL INDEX
• It monitors : 1. Electrical Activity in brain 2. Level of Sedation
3. Awareness under anesthesia 4. Titration of Hypnosis

• It contains a Forehead Sensor with Four numbered Electrodes and a Smart Chip
* Number 1 … at the center of forehead, 5 cm above the nose
* Number 4 … just above and adjacent to the eyebrow
* Number 2 … between number 1 and number 4
* Number 3 … on either temple between corner of eye and the hairline

• BIS can not be used to monitor hypnosis during Ketamine anesthesia

• Sedative effect of 70% Nitrous Oxide do not affect BIS
 ELECTROENCEPHALOGRAPHY
• EEG is composed of 16-25 electrodes attached to the scalp

• The brain cells communicate via electrical impulses and are active all the time
even when the patient is asleep

• EEG activity occurs mostly at frequencies between 0.5-30 Hz

• Waves normally range from 1-500 micro-volt in Amplitude

• EEG Waves : Beta ..… 13 - 30 Hz ….. ( in concentrating individuals )

Alpha ….. 8 - 13 Hz ……. ( in resting adults with closed eyes )
Theta .….. 4 - 8 Hz …….. ( in sleeping individuals )
Delta ..….. 0.5 - 4 Hz ….. ( in brain injury and anesthesia )
 PERIPHERAL NERVE STIMULATOR
• It delivers a current of ( 15-50 mA ) to a pair of ECG silver-chloride pads or
subcutaneous needles placed over a peripheral motor nerve

• The negative electrode is positioned over the most superficial part of the nerve,
while the positive electrode along the proximal course of the nerve

• The most commonly monitored sites are :

1. Ulnar Nerve stimulation of Adductor Pollicis Muscle
2. Facial Nerve stimulation of Orbicularis Muscle

• The duration of stimulus is less than 0.2 ms ( < 200 micro-seconds )

• All stimuli are having Equal current, with a Square-Wave Pattern
• Single Twitch :
* Frequency ( 0.1 - 1 Hz ) * Increasing block results in decreased evoked response

• Tetanic Stimulation :
* Frequency ( 50 - 100 Hz ) * sustained contraction for 5 seconds is adequate for reversal

• Train-of –Four :
* Four twitches of ( 2 Hz ) each applied over ( 0.2 ms ) with a gap of ( 500 ms )
* On Fading : Disappearance of 4th then 3rd then 2nd then 1st
* 4th … 75% block , 3rd … 80% block , 2nd … 90% block
* Clinical relaxation usually requires 75-90 % neuromuscular blockade
* On recovery : Appearance of 1st then 2nd then 3rd then 4th
* Reversal is easier if 2nd twitch is visible

• Double Burst Stimulation :

* Two variations of tetany * less painful * most accurate
* Two Short bursts of ( 50 Hz ) with interval of ( 750 ms )
* Each burst compromise of two to three impulses lasting for ( 0.2 ms )