THE GE AISYS ANAESTHETIC MACHINE

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1 THE GE AISYS ANAESTHETIC MACHINE All essential components of the anaesthetic machine are shown in the diagram below. Each major component will be explained in detail.

2 The Gas Inlet Module In the diagram below, on machines fitted with all three reserve cylinders, each medical gas has a cylinder connection and primary pressure regulator, shown on the left, marked cylinder supplies. Pipeline gas inlets are shown on the right. The gas inlet manifolds, one for each gas, use non-return valves to direct the highest pressure supply into the anaesthetic machine. The cylinder regulators are set to a lower pressure than the pipeline supply to prevent gas being drawn from the cylinders if they are left open when the anaesthetic machine is connected to pipeline supply. Each medical gas has two electronic pressure transducers, one to monitor cylinder pressure and one to monitor pipeline supply pressure. The pressure displays, configured in units appropriate to location, are allocated to a space on the Aisys front panel for easy observation during machine testing and use. Note: When the anaesthetic machine is operating from pipeline supplies, all reserve gas cylinders must be turned off firmly to prevent gas escape through small leaks. This is important for patient safety as closed gas cylinders will retain contents, ready for immediate use in an emergency. Reserve cylinders connect to pin indexed yoke assemblies of the type pictured below. Each yoke assembly has an integrated primary regulator. The component on the right is the electronic pressure transducer and associated wiring, used to monitor cylinder contents. 1

3 Notes on Proportional Valves and Servo Systems The descriptive text makes frequent reference to proportional valves and servo systems as they are central to the operation of the Aisys anaesthetic machine. Proportional Valves: Shown on the left is a cross-section view of a solenoid operated proportional valve. The valve plunger is drawn away from the valve seat by a magnetic field created by electrical current flow in the solenoid coil which is wound around the body of the unit. The force on the valve plunger is balanced by the return spring which allows the valve to open in a manner proportional to the current flowing in the solenoid coil. Flow from the inlet to the outlet is controlled by the needle on the valve plunger adjusting the opening in the valve seat. Proportional valves progressively open in a controlled manner in response to drive current as shown below. Servo Systems: The term servo is derived from the word servomechanism and only applies where feedback or error-correction signals help control mechanical position, speed or other parameters. Servo systems in the Aisys anaesthetic machine use electronic sensing and feedback to measure and control gas flows. Software allows the control systems to be precisely calibrated during manufacture or routine preventative maintenance. As an example of servo control, a system using a proportional valve to set gas flow is shown below. The key features are a power supply, the control system, a proportional valve and a flow sensor placed in the output gas stream to feed a signal to the control system. Feedback from a sensor, as shown, is the basis for all servo control systems. 2

4 The Electronic Gas Mixer The electronic gas mixer is an autonomous device operating in response to commands from the anaesthesia control system. The unit allows oxygen to be blended with air or nitrous oxide allowing the relative mixture of gases and combined flow to be set very precisely. Once the gas blend is selected, the oxygen concentration and total gas flow to the patient circuit are adjusted. The function of the electronic gas mixer is continuously monitored internally during operation. When oxygen and nitrous oxide are in use, an anti-hypoxic guard, set in the control software, ensures the oxygen concentration at the gas mixer output cannot be reduced below 25%. The diagram below indicates gas connections to the electronic mixer. Air, nitrous oxide and oxygen connections are supplied from the associated gas inlet manifold. The alternate oxygen path and its activation are described later in this document. Front panel controls for oxygen concentration and combined flow and are shown. Virtual flow meters provide indication of individual gas flows, suitable for easy recognition at a long distance if required. Equal flows of N2O and O2 match the 50% O2 concentration as indicated. Shown below is the electronic gas delivery module. 3

5 The gas delivery module is factory assembled and calibrated. On-board software is aligned to work with the anaesthesia control system. Software download, operating parameters, supervisory monitoring and alarms are transferred via serial data communication links. All gas connections accept hose of a unique diameter, assigned to a particular medical gas. This design feature limits the opportunity for inappropriate connection during equipment service or component exchange. The drawings below indicate the symbols used for gas delivery module components and a concept diagram shows where they are located. Central to gas delivery are solenoid operated proportional valves, referred to below as flow control valves. Each flow control valve, (solenoid operated proportional valve), is an element in a servo system which measures and controls an individual gas flow. As show above on the right, the mixed gas output is the addition of two flow streams, oxygen on the left and nitrous oxide or air on the right. Hot wire anemometers, placed in each gas stream, use the physical properties of a heated wire filament. If the heated wire filament is cooled by a passing stream of gas, more electrical current will be required to keep its resistance constant. The measurement system, designed to maintain constant resistance of the wire filament, accurately relates electrical supply current to gas flow. Signals from the hot wire anemometers provide feedback to the servo control system. The servo control system software precisely sets the proportional valve in each gas stream to maintain accurate output flow and oxygen concentration. 4

6 As accurate gas delivery is essential to machine performance and patient safety, independent measurement of gas flow is provided to continually monitor output. This is achieved by a pneumotach, monitoring the pressure drop across a pneumatic resistance, in line with each hot wire anemometer. The diagram below explains how three pressure transducers are configured to provide a pneuomotach output for each of the two gas streams. Looking at the top half of the diagram. The hot wire anemometer F 1 directly monitors Flow 1. Flow 1 can also be determined by the pressure difference across the pneumatic resistance R 1 using pressure transducers P 1 and P 3. The same system is repeated in the lower half of the diagram with Flow 2 determined by the pressure difference across the pneumatic resistance R 2 using pressure transducers P 2 and P 3. Flow 3 is simply the addition of the individual flows. Component placement in the flow monitoring systems for each gas stream is clarified by looking at half of the concept drawing, as shown. For each gas stream, should a deviation occur between the hot wire anemometer directed flow control system and the pneumotach based flow measurement system, the gas delivery module will immediately report an error, suspend operation and automatically deliver gas via the Alternate O 2 Inlet. When operating, Alternate O 2 delivery bypasses the flow control system, as shown. 5

7 The Alternate O2 Delivery System As described earlier, the Alternate O 2 supply is a safety system and the delivery path is via the electronic gas mixer. The oxygen sources and the delivery system for the Alternate O 2 supply are shown below. With reference to the diagram above, Alternate O 2 delivery requires either pipeline supply or a reserve oxygen cylinder to be connected and the System Switch to be in the ON position. The O 2 Flush Regulator provides a constant delivery pressure covering the difference between pipeline supply and reserve cylinder delivery pressure. The Alternate O 2 delivery system is triggered automatically in three ways: Electronic gas mixer malfunction, (system reacts within 500 milliseconds). LCD screen malfunction, (loss of controls and indicators). No power, (mains and battery supply failure). When operating, the Alternate O 2 Control flowmeter can be adjusted from Litres/Minute providing oxygen flow control to the patient circuit. Depending on the level of system failure in the anaesthetic machine, prompts may allow volatile agent delivery to continue with 100% oxygen. Note: Manual activation of Alternate O 2 delivery is available by pressing the ON/OFF button located above the flow control knob, however, there should never be the need to do this when the machine is operating normally. 6

8 The Electronic Vaporizer or Evap The Evap is an electronically controlled subsystem which operates autonomously in response to inputs from the Aisys anaesthesia control system. Control software inputs are, required output agent concentration, gas flow data obtained from the electronic gas mixer, anaesthetic agent type and cassette temperature. Using this data, the control software calculates and accurately controls the ratio of gas flow through the vaporizing chamber and gas bypass paths. At a fundamental level, Evap operation can be seen as identical to that of an earlier generation mechanical vaporizer, however, it has the unique ability to deliver Sevoflurane, Isoflurane and Desflurane with the same hardware platform. Agent Boiling Points: Sevoflurane Isoflurane Desflurane 58.6 Deg.C Deg.C 23.5 Deg.C. Shown below are two views of the complete Evap assembly. The image on the left shows the Aisys front panel mounted holster into which the vaporizer cassette is inserted. The image on the right is a rear view of the unit. The GE Aladin vaporizer cassettes, one of which is shown below, are essentially the same. The only differences relate to agent identification, the agent specific filling systems used and special provision for extended accuracy of temperature measurement, if required. The vaporizer cassette is basically a removable volatile agent reservoir and vaporizing chamber. 7

9 In overall concept, unidirectional input flow to the Evap system is similar to a mechanical vaporizer with a portion of the gas mixture passed, at a controlled rate, through the cassette vaporizing chamber where the volatile liquid anesthetic is evaporated. The directions of the bypass flow (green) and cassette flow (red) are indicated in the diagram below. Evap Components Cassette identification allows the Evap control software to select the matching lookup table relating saturated vapor pressure and temperature for the volatile agent being used. The Aladin cassette being used is identified by detecting small magnets placed in the body of the assembly. The cassette temperature sensor contacts a metal rod which is in intimate contact with the liquid agent. Accurate temperature measurement is central to the calculation of saturated vapor pressure inside the body of the Aladin cassette. 8

10 The cassette interface connectors are a row of gold plated electrical contacts which connect to internal electronic sensors to report fluid level to the Evap control system and Aisys machine display. Depending on the agent being used, the interface connectors allow the Aladin cassette to be fitted with enhanced temperature sensing facilities to more accurately report temperature of the liquid agent. The input flow is reported to the Evap software from the electronically controlled gas delivery system. The back pressure valve provides a regulated pressure increase on the input to the Evap. This pressure increase selectively drives input gas flow through the vaporizer cassette. 9

11 The inflow check valve prevents uncontrolled gaseous agent escape on the upstream side of the backpressure valve. This is an important component if the cassette pressure has risen to a point where it is sufficient to open the backpressure valve when first inserted into the Evap assembly. Agent type and cassette temperature are used to determine saturated vapor pressure. With known input gas flow, the cassette inflow measurement system and cassette flow control valve work together as a servo control system to continuously adjust the gas flow splitting ratio. By this means, the control software sets a precise concentration of Sevoflurane or Isoflurane at the output. A pressure transducer monitors cassette pressure. 10

12 Due to Desflurane having a boiling point of 23.5 Deg.C., depending on ambient temperature the saturated vapor pressure in the Aladin cassette may be high enough not to require an inflow of carrier gas. If this is the case, the outflow measurement and cassette flow control valve work together as a servo control system to directly blend Desflurane gas and carrier gas to the required concentration. It is important to note the Aladin cassette is not heated. Depending on the rate of evaporation, liquid Desflurane may be cooled to a point where its vapor pressure matches or drops below the pressure of the Evap output gas stream. The Evap control system can respond to low Desflurane vapor pressure and admit an inflow of fresh gas to the vaporizer cassette to control output concentration in the same manner as it does for the higher boiling point agents, Sevoflurane and Isoflurane. This is the key to the Evap being able to accurately deliver Sevoflurane, Isoflurane and Desflurane from the same hardware platform. The ability to accurately measure cassette inflow and outflow provides additional input to the Evap control software. The dual flow measurements allow hardware self-checks during the Aisys machine automatic test routines, run at start-up and continuous comparison of Evap gas flows during operation. 11

13 The scavenging valve is operated under software control to vent excess cassette pressure during the Aisys machine start-up and self-test cycles. The output of the scavenger valve is connected directly to the Aisys machine exhaust gas scavenging system. The cassette inflow and cassette outflow valves allow the Aladin cassette to be completely isolated from the Aisys machine fresh gas supply system when the Evap is not in use or the machine is switched off. The valves are closed until power is applied by the Evap control system, allowing the Aisys machine to stand idle for extended periods. In addition, the valves allow the Aisys machine to be operated safely with no volatile agent added to the fresh gas stream. Once the valves are closed, there is no requirement to remove the Aladin cassette from the unit. The liquid flow prevention valve is a ball float safety device designed to seal the cassette outlet path if liquid agent escapes from the Aladin cassette. The valve would only be called into operation if an overfilled Aladin cassette is installed in the Evap assembly or agent is added to the cassette during machine operation, both being actions going against manufacturer s recommendations on safe operation of the Aisys machine. If the liquid flow prevention valve was to operate and the cassette outflow stop, the resultant gas flow anomaly would be detected immediately, causing the Evap system to shut down. 12

14 The Auxiliary O 2 Flowmeter and O 2 Flush Button The Auxiliary O 2 Flowmeter provides manually controlled oxygen flow from 0-10 Litres/Minute. A fixed orifice in the O 2 Flush Button valve assembly ensures oxygen flow can be delivered to the patient circuit in the range Litres/Minute. The oxygen supply path for both the Auxiliary O 2 Flowmeter and O 2 Flush Button is shown below and both require either pipeline supply or a reserve oxygen cylinder to be connected. In addition, the Auxiliary O 2 Flowmeter and O 2 Flush Button operate independently of the machine ON/OFF switch. The O 2 Flush Regulator provides a constant delivery pressure covering the difference between pipeline supply and reserve cylinder delivery pressure. The Advanced Breathing System (ABS) The ABS is an integrated circle breathing system and ventilator bellows assembly which can easily be removed and disassembled for cleaning. Patient gas, supplied by the Electronic Gas Mixer and Evap. systems or the O 2 Flush Button, is input the ABS circle breathing system. The Drive Gas connection to the oxygen supply is shown as it powers the ABS ventilator drive system. 13

15 The schematic diagram of the ABS, shown below, identifies components in the integrated circle breathing system and ventilator bellows assembly. Fresh gas, shown on the lower left, can be directed to the ABS or Auxiliary Common Gas Outlet (ACGO) via the Circle/ACGO Selector Switch. When the ACGO is in use, a small bleed flow of gas is admitted to the O 2 Port on the circle. The O 2 Port is a socket for an electrochemical oxygen sensor which may be installed in the ABS. This sensor is a mandatory requirement in North America where the GE Aisys is manufactured, however, oxygen sensors are not normally installed in machines used in Australia and New Zealand as we rely on side stream gas monitoring, proximal to the patient airway. The Patient Circuit Pressure Sensor provides accurate pressure display and feedback to the ventilator when the circle breathing system is in use, however, pressure indication when the ACGO is selected is misleading due to the bleed flow of gas into the ABS. In addition to the problem of ineffective pressure monitoring, the ACGO has the ability to produce pressures up to 350cmH 2 O at high gas flows. As a result, patient safety is enhanced by the addition of an in-line pressure relief device to which an independent pressure monitor and alarm may be added. The -10cmH 2 O Relief Valve is a safety device to allow room air to enter the circle breathing system if pressure was to become negative for any reason. It is a weighted check valve designed to cover the unlikely event a patient provides independent inspiratory effort co-incident with low gas volume in the circle breathing system. The Absorber Canister is designed to remain in the circle breathing system until the soda lime reaches the end of its life, as indicated by an increase in inspired CO 2 concentration. To facilitate this, the ABS features isolating valves and a quick release canister exchange system to allow the Absorber Canister to be replaced mid-case, if needed. The Fresh Gas Inlet to the ABS is placed between the absorber canister and the INSP. check valve so the flow of gas directed toward the patient on inspiration is a mixture of enriched fresh gas from the machine and scrubbed gas returned from the Bag or Ventilator Bellows via the Absorber Canister. When bag ventilation is selected by the Bag/Vent Switch, the Bag and the Adjustable Pressure Limit (APL) valve are connected to the breathing circle. Waste gas exiting the circle breathing system via the APL valve is directed to the scavenge system for safe removal from the operating theatre. When the ventilator is selected by the Bag/Vent Switch, the Bag and APL valve are disconnected from the circle breathing system and the ventilator takes total control of patient inspiration and expiration. In addition, the ventilator controls the release of waste gas. Waste gas exiting the circle breathing system via the ventilator and ventilator drive gas, displaced from the bellows canister, are directed to the scavenge system for safe removal from the operating theatre. 14

16 When Bag ventilation is selected, the active ABS components are highlighted in the diagrams below. The red arrows indicate gas flow during the phases of operation. INSPIRATION EXHALATION When the Ventilator is being used, the active ABS components are highlighted in the diagrams below. The red arrows indicate gas flow during the phases of operation. INSPIRATION EXHALATION 15

17 The Ventilator in Detail The Aisys ventilator is reliant on precise measurement of patient airway pressure and inspired volume delivery. Pressure is measured on the inspiratory leg of the circle breathing system by the Patient Circuit Pressure Sensor. Flow measurement in the Aisys is achieved by variable orifice flow sensors placed in the INSP. and EXP. limbs of the circle breathing system. Small hoses on each flow sensor connect to a differential pressure transducer, as shown below. Pictured below, is the removable flow sensor assembly. The 22mm tapered ends of the INSP. and EXP. flow sensors provide the patient circuit connections. The variable orifice design allows the flow sensor to provide reliable output over a large measurement range without impeding gas flow. When each sensor is manufactured, data relating gas flow to differential pressure is mapped into a memory chip built into each unit. Gold plated contact pins on the flow sensor assembly connect to the ventilator control system allowing the data to be read and used to accurately correlate differential pressure and flow. Gas flow data is integrated to report volume. Inspired volume is determined by integrating the gas flow measured by the INSP. Flow Sensor. Expired volume is determined by integrating the gas flow measured by the EXP. Flow Sensor. Accurate measurement of pressure and flow allow the patient circuit compliance to be measured during the system self-test. In addition, correlation of inspired and expired flow is used to detect patient circuit leaks during ventilator operation. 16

18 Ventilator Drive The ventilator drive system uses the components, shown below, to control drive gas flow and pressure admitted to the ABS Bellows Housing, more commonly referred to as the bellows canister. Oxygen supplied at 400kPa feeds the Precision Pressure Regulator to provide a constant pressure input to the Electrically Operated Proportional Flow Control Valve. The Controlled Output is connected to the Pressure Sensor with the Pneumatic Resistance providing a contained volume and a drive gas leak, via a small orifice, to assist with pressure control. Depending on the ventilator mode and phase of operation, the Control System acts to accurately deliver drive pressure and flow to the ABS bellows canister. During annual calibration the ventilator drive system has the ability to map the output pressure characteristic of the ventilator drive system when stalled. This is achieved by fitting a stopper, shown in the diagram below. The Control System automatically provides Valve Drive output and monitors the Pressure Sensor input. 17

19 Calibration of the ventilator drive system is continued using a calibration orifice with a known pressure versus flow relationship. This is fitted to allow the ventilator drive system to map the output flow characteristic of the ventilator drive system. The Control System automatically provides Valve Drive output and monitors the Pressure Sensor input. As described, the ventilator Pressure Sensor is used to calibrate the Control System during routine machine service. During ventilator operation, the Pressure Sensor is used to correlate canister drive pressure with Patient Circuit Pressure, measured in the circle breathing system. This pressure correlation provides instant warnings and alarm indication in the event of a ventilator system malfunction. 18

20 Shown on the preceding page are the additional components which connect to the ventilator drive system. The bellows is located inside the canister. The scavenger connection directs gas from the ventilator drive system and exhaust from the circle breathing system to the scavenger assembly for safe disposal outside the operating theatre. Two components, the 110cmH 2 O Overpressure Valve and the Free Breathing Valve are included for patient safety in case of a drive system malfunction and have no part in routine operation of the ventilator. The 110cmH 2 O Overpressure Valve would open in case excessive drive pressure was applied to the canister. The Free Breathing Valve allows room air to enter the canister to equalise pressure inside the canister if a patient is capable of independent inspiratory effort. If the Free Breathing Valve was not present and the patient provided inspiratory effort, the bellows would freeze in the canister, inspiratory flow would stop and pulmonary pressure would become negative. The gas flow from the ventilator drive system is applied to the Drive Gas Check Valve and Exhalation Valve. The Drive Gas Check Valve is a weighted unidirectional valve which provides a 3.5cmH 2 O increase in pressure on the inlet side of the unit. The small pressure increase across the Drive Gas Check Valve provides a pressure bias necessary to close the Exhalation Valve when gas flows toward the ventilator canister. The Exhalation Valve operates on a 3.5cmH 2 O differential pressure using the area ratio between the drive diaphragm and valve seat to seal the canister when drive is applied. The Bellows Pressure Relief Valve is supported on a soft rubber diaphragm and has three functions: The first function is due to the 1.5cmH 2 O bias pressure necessary for gas to push past the valve in order to escape toward the Scavenger Connection. The 1.5cmH 2 O bias pressure ensures the bellows inflates fully inside the canister before the Bellows Pressure Relief Valve will open. The second function is due to the diaphragm coupling pressure from the canister to hold the Bellows Pressure Relief Valve against its seat when the canister is pressurised. The third function is a due to pressure from the canister, coupled via the diaphragm, acting on the Bellows Pressure Relief Valve to partially occlude the circle breathing system exhaust. This function allows the Bellows Pressure Relief Valve to directly control patient circuit pressure. The ventilator drive system cannot operate in isolation as the Inspiratory Flow Sensor and Patient Circuit Pressure Sensor provide feedback. How sensor feedback is applied via the ventilator control system algorithms in volume and pressure delivery modes is the key to ventilator accuracy. Ventilator Operation - Volume Controlled Ventilation - VCV The diagrams which follow describe the phases of volume controlled ventilator operation. The diagram showing the ventilator at the end of inspiration shows the Inspiratory Flow Sensor providing feedback to the ventilator control system. This feedback is applied indirectly to each delivered breath and can only be understood by following the path from initial switch on. When the ventilator is switched on, data stored in the Electrically Operated Proportional Flow Control Valve calibration table is the basis for ventilator control. Using this data, the ventilator control algorithm calculates and delivers a drive flow based on the Tidal Volume, Respiratory Rate and Fresh Gas Flow settings. As a result, the required Tidal Volume is not met perfectly on the first delivered breath. Accurate volume delivery is achieved over time by the ventilator control algorithm continuously comparing the target volume to the measured volume, determined by the Inspiratory Flow Sensor, on a breath by breath basis. By this means, the drive flow and duration are adjusted, as needed, to gradually correct any errors in volume delivery on an on-going basis. The indirect nature of the Inspiratory Flow Sensor feedback and operation of the ventilator control algorithm result in a servo control system which acts very slowly to track and perfect inspired volume delivery. This ensures volume controlled ventilator operation is stable and not easily disturbed by short term transient effects. 19

21 The ventilator is shown above with the bellows full of gas captured during patient exhalation. The 1.5cmH 2 O bias pressure, applied by the Bellows Pressure Relief Valve, is holding the bellows against the top of the canister. This is the start point for the cycle of operation. Patient inspiration, shown above, occurs by drive gas entering the canister pushing gas from the bellows which is then conducted to the patient via the absorber and inspiratory limb of the patient circuit. The drive gas entering the canister is controlled by the Valve Drive applied to the Proportional Flow Control Valve. The Exhalation Valve and Bellows Pressure Relief Valve are closed during this phase of ventilator operation. 20

22 Shown above, the bellows volume has been reduced and the ventilator control system has terminated gas flow into the canister. The Drive Gas Check Valve is closed, the Exhalation Valve is free to open and the Bellows Pressure Relief Valve is closed ready to allow the bellows to capture returned gas. During inspiration the Inspiratory Flow Sensor has been measuring delivered volume providing input to the ventilator control algorithm. Shown above, the bellows is now capturing gas from the circle breathing system in response to patient exhalation. The Drive Gas Check Valve remains closed, the Exhalation Valve is open allowing waste drive gas to be pushed from the canister toward the scavenger as the bellows inflates. The 1.5cmH 2 O bias pressure, applied by the Bellows Pressure Relief Valve, ensures the bellows rises toward the top of the canister. 21

23 Shown above, the bellows has now captured the maximum volume of gas from the circle breathing system and no more waste drive gas is being pushed from the canister via the Exhalation Valve. The Drive Gas Check Valve remains closed, and the Bellows Pressure Relief Valve is allowing waste gas to escape from the circle breathing system, as shown. This is the last phase of the volume control ventilation cycle which will now repeat. Note: Flow compensation is an important feature of the ventilator when operating in a volume delivery mode and is best understood by carefully examining the diagram on the left which shows gas flow in the ABS during patient inspiration. Gas flow toward the patient during inspiration is the sum of gas returned from the bellows, on the left of the diagram, and fresh gas entering the circle breathing system, on the right of the diagram. The two gas streams meet and are conducted toward the patient via the inspiratory flow sensor, which in turn provides feedback to the ventilator control system. By this means, the gas returned from the bellows compensates for the fresh gas flow entering the circle breathing system during patient inspiration. At low fresh gas flow, the ventilator bellows will have maximum movement. The ventilator bellows movement will progressively reduce as fresh gas flow is increased. The ability to measure inspired flow in the patient circuit is the key to accurate volume delivery irrespective of fresh gas flow entering the circle breathing system. 22

24 Ventilator Operation - Pressure Controlled Ventilation - PCV The ventilator is shown above with the bellows full of gas captured during patient exhalation. The 1.5cmH 2 O bias pressure, applied by the Bellows Pressure Relief Valve, is holding the bellows against the top of the canister. In common with volume controlled ventilation, this is the start point for the cycle of operation. Shown above, patient inspiration occurs by drive gas entering the canister pushing gas from the bellows which is then conducted to the patient via the absorber and inspiratory limb of the patient circuit. The drive gas entering the canister is controlled by the Valve Drive applied to the Proportional Flow Control valve. The Exhalation Valve and Bellows Pressure Relief Valve are closed during this phase of ventilator operation and feedback from the Patient Circuit Pressure Sensor will be used by the Control System to terminate patient inspiration. 23

25 Shown above, when the required inspiratory pressure has been achieved, the ventilator drive gas flow into the canister will cease. The Drive Gas Check Valve and the Exhalation Valve are held closed by the Valve Drive applied to the Proportional Flow Control Valve. The leak from the Pneumatic Resistance is allowing the Control System to maintain a constant pressure within the canister. Under these conditions, pressure applied via the Bellows Pressure Relief Valve diaphragm is partially occluding the circle breathing system exhaust to maintain Peak Inspiratory Pressure (PIP). Shown above, the bellows is capturing gas from the circle breathing system in response to patient exhalation. The Drive Gas Check Valve remains closed, however, the Exhalation Valve is partially occluding waste drive gas escape from the canister toward the scavenger as the bellows inflates. The canister pressure applied to the Bellows Pressure Relief Valve ensures the bellows rises toward the top of the canister. The Valve Drive applied to the Proportional Flow Control Valve is reduced allowing the drive gas leak from the Pneumatic Resistance to maintain a constant pressure within the canister. 24

26 Shown above, the bellows has captured the maximum volume of gas from the circle breathing system and no more waste drive gas is being pushed from the canister via the Exhalation Valve. At this point, constant pressure within the canister is applied to the Bellows Pressure Relief Valve diaphragm. As a result, the Bellows Pressure Relief Valve is partially occluding the circle breathing system to maintain Positive End Expiratory Pressure (PEEP). This is the last phase of the pressure control ventilation cycle which will now repeat. Concluding Comments on Ventilator Operation Pure VCV and PCV operation represent both ends of the ventilation spectrum and all the Aisys ventilator modes are variations on, or blends of, VCV and PCV operation. As described, the ventilator control system algorithms use precise inspiratory flow and circuit pressure measurement for feedback. Signals from the flow transducers are also used for synchronized triggering, allowing the Aisys ventilator capabilities to match those of an advanced ICU ventilator. Adult and paediatric patients require a change of circuit, the compliance of which is determined during the automated machine self-test. Having access to circuit compliance, measured with the same flow and pressure transducers used for ventilator control, allows the ventilator to accurately target patient volume delivery. The flow transducer in the expiratory limb of the patient circuit is used to report and display exhaled tidal and minute volumes. The expiratory flow transducer provides a breath-by-breath check on ventilator performance acting as a patient circuit leak detector and patient circuit disconnection monitor. 25

27 The Scavenger The scavenger is an open interface design. The schematic diagram, shown above, shows machine exhaust entering on the left and exiting via the fitting on the right. The diagram, shown on the right, indicates how the assembly fits together on the Aisys machine. Key components are: The Air Brake, part of the Scavenging Receiver. The 2.2 Litre reservoir, shown on the right and named the Overflow Container. The Relief Valve which prevents sub-ambient pressure being applied to the machine exhaust. The Signal Orifice and Flow Gauge which provide visual indication of scavenger flow. 26

28 Notes on Liquids From the explanations so far, the Aisys design is heavily dependent on electronics for all control and patient safety systems. As a result, the unit is more sensitive to fluid spills than earlier generation equipment designs which were based on simple mechanical and pneumatic components. Shown below are some examples of fluid spills. None resulted in equipment failure, however, as is evident, this is by sheer luck alone. A slightly larger saline spill would have pooled and dripped down onto the gas mixer assembly. Evidence of a saline spill into the ventilator control system. Severe corrosion on the frame of the ventilator, the result of a saline spill. This caused a screw to bind requiring significant effort to release. The affected stainless steel screw fortunately released after sitting in an aluminium housing with prolonged exposure to saline liquid. It is not a good look when you have to use a hammer on an $80,000 machine to release frozen components. 27

29 Conclusion The Aisys anaesthetic machine is a further example of technological developments based on electronic control and modular construction. Electronic control in the aviation industry is referred to as fly-by-wire technology. The automotive industry refers to modular construction as platform technology. The main driver for electronic control in the aviation and automotive industries is fuel efficiency, an exact corollary for the reduced volatile agent consumption offered by electronically controlled anaesthetic machines. Keeping the hardware as simple as possible allows maximum flexibility in software development. As a result, most design changes in the Aisys so far are the result of software enhancements. Since delivery at JHH in 2007, there have been five software revisions, the latest being Version 8.01, which along with simple hardware modification, enables Et Agent and EtO 2 control. Et control, referred to as Cruise Control, is an excellent example of the Aisys designers using modular construction and software enhancement to great effect. The downside of electronically controlled equipment is fragility due to its dependence on extremely reliable and stable electrical and gas supplies and an enhanced level of user care. These requirements, coupled with regular maintenance and calibration, mark this this equipment as a First World solution, unsuitable for use in the Real World. Prepared By: Steven Threlfo Senior Technical Officer - Departments of Anaesthetics and Intensive Care Level 3, John Hunter Hospital Postal Address: Locked Bag 1, Hunter Region Mail Centre 2310 Direct Extension: Workshop Phone: steven.threlfo@hnehealth.nsw.gov.au Date: 17 th January 2014 References: GE Healthcare Explore! Aisys CD-ROM and book, 2006 The Biomedical Engineering Handbook, Ed. Joseph D. Bronzino, IEEE Press, 1995 Equipment for Anaesthesia and Intensive Care, W.J. Russell, 1983 Anaesthetic Equipment - Physical principles and Maintenance, C.S. Ward,

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