CHAPTER 13

LOW COST EQUIPMENT

Outline:

The EMO vaporiser

The Oxford inflating bellows

The Ruben valve, Ambu E valve, paedivalve

The Oxford miniature vaporiser

Oxygen concentrator

Ventilators:
Manley multivent
Glostavent

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THE EPSTEIN MACKINTOSH OXFORD (EMO) VAPORISER

GENERAL DESCRIPTION
The EMO vaporiser is a calibrated, draw-over vaporiser which will
accurately deliver a pre-set concentration of ether in room air. Additional
oxygen can be added if required. The easiest way to describe the EMO
vaporiser is to consider it in three sections.

Fig 13.1 The EMO Vaporiser and cross section

The lower section consists of an ether vaporising chamber surrounded both

inside and outside by a water chamber which acts as a buffer against
changes in temperature of the surrounding air. A tap at the bottom of the
water reservoir is used for filling or draining the chamber. At the entrance to
the ether chamber there is a special closing device. This closes the chamber
when the indicator is in the transit position. Also incorporated in the closing
device is an air inlet relief valve which enables air to enter the inhaler if the
main inlet becomes blocked.
The outlet of the ether vaporising chamber is controlled by a thermo-
compensating valve. This regulates the volume of ether vapour leaving the
vaporising chamber and ensures that the concentration of ether reaching the
patient is constant, independent of the temperature of the liquid ether.

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To summarise, the lower part of the vaporiser consists of the following:
• An ether vaporising chamber.
• A water jacket both inside and outside the ether vaporiser.
• At the entrance to the ether vaporiser an inlet closing device.
• At the exit from the ether vaporising chamber a thermo–compensating
valve.

The middle section of the EMO consists of a central chamber just above the
water compartment already described. This has two entry ports.
• One entry port (a) conducts the gases which have bypassed the ether
vaporising chamber.
• The second entry port (b) conducts gases which have passed through
the ether vaporiser and picked up ether vapour.
These gases then mix and leave the central chamber through the main outlet
of the EMO.
In the transit position the entry port (b) is completely closed and (a) is
completely open. As the concentration of ether is increased, then (b)
progressively opens and (a) progressively closes. Thus more and more of the
gas passing through the EMO machine is made to pass through the ether
vaporising chamber so with each movement of the indicator more ether
vapour is delivered to the patient.

The upper section of the EMO consists of a scale and a concentration

pointer. Concentration shown by the indicator is kept constant because of the
action of the thermocompensator and to a lesser extent the action of the
water jacket.
The concentration is kept constant for a range of respiratory frequencies and
tidal volumes. This is achieved by the design of the apparatus: the volume of
the chambers and the flow directed by the bell mouthed and other orifices.
The chambers are large and have a minimal resistance.
The ether level indicator at the left front consists of a float riding on the
liquid ether inside the vaporising chamber and indicates the degree of filling
of the ether chambers. The ether filler and the temperature compensator are
also in the upper section of the vaporiser.

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FEATURES OF THE EMO

• The concentration delivered by the EMO is constant over the 15-30°C

temperature range despite the temperature of the liquid ether. This is
achieved by an efficient thermocompensator. The active element is a
sealed capsule containing ether. As the temperature of the ether falls,
more air passes through the ether chamber.
It also adjusts to changes in barometric pressure.

Fig 13.2 Shows the effect of immobilising the thermocompensator

• The concentration of ether is constant at different minute volumes

in draw-over mode as shown below in Fig 13.3

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• Introduction of oxygen to the EMO circuit via a T-Piece

Fig 13.4 Introduction of Oxygen to the EMO with a T–piece

Fig 13.5 The concentration of inspired oxygen

The concentration will depend on:
− The oxygen added to the system.
− The patient's minute volume.
− The volume of the reservoir tubing. One metre (450ml) is the
ideal length, delivering 30-40% FiO2 with 1L/min O2 flow.
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INSTRUCTIONS FOR USING THE EMO

Check the water compartment

Mark I every three months (serial numbers 1 – 2859)
Marks II - V every year
When filling the water compartment:
• Move the control lever to the transit position.
• Turn the EMO upside down and unscrew the water filler plug.
• Pour in 1200 ml of water at room temperature.

Fill with Ether

• Turn the control to zero (rather than to the transit position), so that the
air can escape.
• To fill the vaporiser on a Mark I model, lift out the filler and rotate it.
For Mark II-V models press the filler down.
• 150 ml will soak the wicks. A further 300 ml are needed to fill the
chamber. Do not overfill.

Check the temperature compensator indicator

This consists of a rod, a black band and a red band surmounted by a cap.
• If the black band shows it means that the EMO is at the correct
operating temperature.
• If the red band shows it means that the apparatus is too hot. This may
happen if room temperature is above 32o C. It may be cooled by filling
the water compartment with water below room temperature or by
forcing the ether to evaporate.
• If the black band is not visible then the apparatus is too cold. Put it in a
warm room for some time or refill the water jacket with water at 25°C.

OTHER EQUIPMENT USED WITH THE EMO

THE OXFORD INFLATING BELLOWS (OIB)

This consists of two main components:

• Spring loaded bellows.
• Two one-way flap valves.
A tap at the base of the bellows enables oxygen to be added. (This is used
only during resuscitation).
A magnet is used to immobilise the distal flap valve when a non-rebreathing
valve, e.g. a Ruben or Ambu E valve is used.
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Magnet used to immobilise
distal flap valve when used
with
non–rebreathing valve

Fig 13.6 Oxford inflating bellows with magnet in position

THE RUBEN VALVE

This is a non-rebreathing valve, which means that the patient inspires only
from the inhaler and expires into the atmosphere. This is brought about by
the to-and-fro movement of the bobbin.
These valves can stick. Always have a spare valve available. The valves are
sterilised by chemical means: 5% chlorhexidine (Hibitane) for 5 minutes.
It is important to ensure the valve is dry before use.

Fig 13.7 Ruben Valve

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THE AMBU ANAESTHETIC VALVE

The Ambu E valve with 2 flaps is a non-rebreathing valve. This means that
the expired carbon dioxide is not rebreathed. It can be used for both
spontaneous and controlled ventilation. The Ambu valve is like the Ruben
valve except that the bobbin is replaced by 2 yellow silicone rubber flaps.
The valve can be dismantled easily for cleaning and sterilisation.
The Ambu E valve comes in 2 models: the anaesthetic model (2 flaps ) for
both spontaneous and controlled ventilation and the resuscitation model
used for IPPV. This has only 1 flap, is not a non-rebreathing valve and is not
suitable for anaesthetic use.

Fig 13.8 Ambu Anaesthetic Valve

Paedivalve
This is the paediatric version of the Ambu E valve which can be used for
children under 15 kg. It can be used for spontaneous and controlled
ventilation.

SETTING UP THE APPARATUS:

Apparatus here means the EMO, the OMV, the OIB and a non–rebreathing
valve.
It is possible to combine the vaporisers, bellows, valves and other
components in a variety of ways.
Principles
• If more than one vaporiser is to be incorporated in the circuit then the
more volatile agents must be placed further from the patient. If this is
not done, the less volatile agent will condense as the vapour passes
through the second vaporiser. The EMO must therefore always be
placed further from the patient than the OMV.
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• Position the bellows (or the inflating bag) between the vaporiser and
the patient.
• Introduce the oxygen at the vaporiser inlet via a T piece and 1 metre
reservoir tube (i.e. further from the patient).
• When you are using a non-rebreathing (inflating) valve such as the
Ruben valve, always use the horseshoe magnet with the OIB. It must be
used to immobilise the valve closer to the patient.
• Before using the set-up, always check that the flow of air is in the right
direction i.e. towards the patient.
The difficulty of monitoring respiration in spontaneously breathing patients
can be overcome by a simple and inexpensive method. Attach a rubber glove
to the expiratory limb of the uni-directional (non-rebreathing) valve and cut
a small hole in one finger to allow the expired gases to escape. This can then
be attached to the scavenging system if desired. Respiratory excursion can
be monitored by observing the movements of a piece of cotton attached to
the end of the reservoir tube, observing movements of the uni-directional
valve and listening to the chest with a stethoscope.

Fig 13.9 Methods of monitoring spontaneous respiration

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 Standard set up using the EMO, O1B and non–rebreathing valve.

Fig 13.10 OIB and non–rebreathing valve

Fig 13.11 EMO, OIB and non–rebreathing valve

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THE OXFORD MINIATURE VAPORISER:

The OMV was designed by Macintosh and Epstein. It delivers fairly

accurate concentrations of halothane, trilene, enflurane, isoflurane and
sevoflurane within defined limits. It was originally designed to assist
induction of anaesthesia with the EMO. The OMV is then plugged into the
outlet of the EMO. Small variations occur in the delivered concentration
depending on the temperature and the duration of use. There is no increase
in concentration with positive pressure. The scale ranges from 0 to 4. A
special filling device is incorporated. The filler must be pressed down fully
(or unscrewed) to open the filling port and the liquid flows into the
vaporising chamber. The liquid level is visible in the glass window. The
vaporiser should be turned off before refilling to avoid air being drawn in
which would cause an increase in the concentration. The unused anaesthetic
can be poured back into the bottle. Only 3 to 4 ml are retained in the wick.
When combined with a non-rebreathing valve and a means for inflating the
lungs, the OMV (50ml capacity model) can also be used as a draw-over
vaporiser on its own. This set up is suitable for relaxant or spontaneous
breathing techniques. Adequate anaesthesia must then be given by the IV
route. The carrying gas is room air supplemented with oxygen.

Fig 13.12 Oxford Miniature Vaporiser in section and front view

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OMV vaporisers can be coupled together to use 2 volatile agents
simultaneously, e.g.. halothane upstream (for its anaesthetic properties) then
trilene (for its analgesic properties).

Fig 13.13 OMVs in series

The OMV is suitable for draw-over paediatric use (under 15 kg), provided
three important steps are taken. Use paediatric bellows or self–inflating bag
instead of the adult size on the OIB, use the paedivalve instead of the adult
non-rebreathing valve and use tubing of a smaller diameter. Alternatively,
oxygen at 4–6L/min can convert the OMV vaporiser into a plenum device
for use with the Ayre’s T– piece.

Fig 13.14 Paediatric set–up using paediatric self–inflating bag

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THE OXYGEN CONCENTRATOR
This machine concentrates oxygen from atmospheric air. Atmospheric air
consists of approximately 80% nitrogen and 20% oxygen. An oxygen
concentrator separates these two components. Zeolite granules are used to
selectively adsorb nitrogen from compressed air.

Fig 13.15 Simplified diagram of an oxygen concentrator

Atmospheric air is drawn into the oxygen concentrator. It is filtered and

raised to a pressure of 20psi (1.5kg/cm2) by an air compressor. Two canisters
filled with zeolite granules are used alternately to adsorb nitrogen. The
compressed air passes through the first canister, the nitrogen is adsorbed and
the oxygen is made available to the patient. After about 20-30 seconds the
compressed air is diverted into the second canister where the same thing
happens.
While the second canister is being used, the first canister rests. The pressure
is reduced to zero, the zeolite is regenerated and the nitrogen that was
adsorbed is released into the atmosphere. By using the two canisters
alternately a continuous supply of oxygen is maintained.

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 Fig 13.16 An Oxygen Concentrator

Oxygen concentrators have an output of up to 5 L/min with an oxygen

concentration of 95%.
The World Health Organisation lists tested models which meet the
recommended Performance Standard and details can be obtained from
WHO, 1211 Geneva 27, Switzerland. They can be powered by the mains
and if this fails by a small generator. Warning lights indicate a fall in oxygen
concentration below 85%.
The oxygen concentrator provides an adequate supply of oxygen to be used
with the EMO or OMV and also the Ambu bag in the case of the ketamine
relaxant technique. It is also useful in resuscitation with IPPV and in
supplementing inspired oxygen by mask or nasal catheter. Routine
maintenance consists of changing the filter at regular intervals as specified
by the manufacturers. The output of the oxygen concentrator must be
regularly analysed using an oxygen analyser.

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VENTILATORS

Manley Multivent
This is a versatile ventilator designed mainly to meet the needs of
developing countries and is one of the less expensive makes. In practical
terms, it is a mechanised OIB with a control panel. There are 2 types
available, standard and ether compatible.
It has an on/off switch and 3 other controls, one each for tidal volume,
respiratory rate and inspiratory: expiratory ratio.
Standard settings for a normal adult are indicated by colour coding and there
is a low-pressure alarm system. The ventilator is powered by an oxygen
cylinder or compressed air at 20psi (1.5kg/cm2) from a modified oxygen
concentrator (a De Vilbiss model is currently produced). If the oxygen
cylinder runs out, or there is a power failure it can be used as a hand
ventilator.
If the drive gas is supplied by an oxygen cylinder, the gas can be recycled
into the breathing circuit to give approximately 34% inspiratory oxygen
concentration.
A rechargeable battery operates the electronic circuits and if it is kept fully
charged it will function for 150 hours. The weight on the arm compressing
the bellows ensures complete emptying with each compression. Tidal
volumes can be set to accommodate child as well as adult patients.

GLOSTAVENT
The Glostavent is the name describing the Manley Multivent mounted on a
trolley, which has on the lower shelf a modified oxygen concentrator,
incorporating an inbuilt oxygen analyser. This is capable of producing
compressed air at 20psi (1.5kg/cm2), to power the ventilator as well as
producing oxygen to entrain into a draw-over system.

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 Fig 13.17 The Glostavent
(Manley Multivent with O2 concentrator mounted on trolley)

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