Monitoring for disconnection: ventilators with bellows rising on expiration can deliver tidal volumes after disconnection.

Anesthesia ventilators with bellows that rise on expiration (standing bellows) are favored over ventilators with bellows that descend during expiration (hanging bellows). Standing bellows will not rise if there is a disconnection, and thus they facilitate detection of disconnections. Yet, during a disconnection of ventilators with standing bellows, mechanical inspiration compresses the empty bellows beyond its resting position; with expiration the elastic bellows recoils and aspirates up to 140 ml, depending upon the fresh gas flow. Tidal volumes recorded after disconnection ranged from 50 to 140 ml (mean, 112.2 +/- 9.22 [SD]) at adult settings and from 55 to 90 ml (mean, 69.8 +/- 4.28 [SD]) at pediatric settings. Thus, spirometers that measure tidal volume (VT) in the expiratory limb of the breathing system may falsely indicate an expiratory VT after a disconnection of the breathing system at the Y-piece or the endotracheal tube. Existing low-pressure alarms and capnography alarms provide redundant warning of disconnection, however, should the ventilator continue to deliver small VTs after a disconnection.