Potential for barotrauma or hypoventilation with the Dräger AV-E ventilator

The system pressure relief valve of the Dräger AV-E anesthesia ventilator is powered by connecting tubing from the ventilator. In this case, the tubing became kinked when the anesthesia machine was moved. This resulted in an iatrogenically induced valve malfunction and increasing minimum and peak pressures in the patient circuit. A laboratory study was performed to evaluate the effects of kinking the connecting tubing. The potential for producing barotrauma or hypoventilation with this design of ventilator is discussed. Repositioning the anesthesia machine after a satisfactory check may precipitate a hazardous situation. An anesthesia machine should be checked out in the final position in which it is to be used.