Eur J Anaesthesiol 2015; 32:521526

ORIGINAL ARTICLE

Comparing charcoal and zeolite reflection filters for

volatile anaesthetics
A laboratory evaluation
Louise W. Sturesson, Jan O. Frennstrom, Marcella Ilardi and Peter Reinstrup
BACKGROUND A modified heat-moisture exchanger that
incorporates a reflecting filter for use with partial rebreathing
of exhaled volatile anaesthetics has been commercially available since the 1990s. The main advantages of the device are
efficient delivery of inhaled sedation to intensive care patients
and reduced anaesthetic consumption during anaesthesia.
However, elevated arterial CO2 values have been observed
with an anaesthetic conserving device compared with a
conventional heat and moisture exchanger, despite compensation for larger apparatus dead space.
OBJECTIVE The objective of this study is to thoroughly
explore the properties of two reflecting materials (charcoal
and zeolites).
DESIGN A controlled, prospective, observational laboratory
study.
SETTING Lund University Hospital, Sweden, from December 2011 to December 2012.
PARTICIPANTS None.
INTERVENTIONS Three filters, with identical volumes, were
compared using different volatile anaesthetics at different
conditions of temperature and moisture. The filtering
materials were charcoal or zeolite. Glass spheres were used
as an inert control.

MAIN OUTCOME MEASURES Consumption of volatile

anaesthetics using different reflecting materials in filters at
different conditions regarding temperature and moisture.
CO2 reflection by the filtering materials: glass spheres,
charcoal or zeolite.
RESULTS Isoflurane consumption in an open system was
60.8 g h
1. The isoflurane consumption in dry, warm air was
39.8 g h
1 with glass spheres. Changing to charcoal and
zeolite had a profound effect on isoflurane consumption,
11.8 and 10.7 g h
1, respectively. Heating and humidifying
the air as well as the addition of N2O created only minor
changes in consumption. The percentage of isoflurane conserved by the charcoal filter was independent of the isoflurane concentration (0.5 to 4.5%). Reflection of sevoflurane,
desflurane and halothane by the charcoal filter was similar to
reflection of isoflurane. Both charcoal and zeolite filters had
CO2 reflecting properties and end-tidal CO2 increased by 3
to 3.7% compared with glass spheres. This increase was
attenuated to 1 to 1.4% when the air was heated and
humidified, and isoflurane was added.
CONCLUSION Charcoal and zeolite possess gas-reflecting
properties, which can be used to conserve volatile anaesthetics. They also reflect CO2. The degree of CO2 reflection
was reduced by heating and humidifying the air.
Published online 9 November 2014

Introduction
Inclusion of various filters in the anaesthetic circuit has
been a common practice worldwide for years. Filters have
been developed to reduce bacterial contamination and
maintain a warm and humid environment for the airway.
The rationale for using filters with antimicrobial properties
as well as for providing heat and moisture homeostasis has
been established by thorough investigation.14 Inclusion

of a filter in a partial rebreathing anaesthetic circuit reduces

consumption of volatile anaesthetics. The principle was
originally described by Thomasson et al.5 in 1989 using
zeolite as the filter material. In 1998, the first report on
the use of charcoal was published.6 In the late 1990s, a
filter with reflecting properties, an anaesthetic conserving device (ACD), was developed to reduce volatile

From the Department of Anaesthesiology and Intensive Care, Skane University Hospital Lund, Lund, Sweden
Correspondence to Peter Reinstrup, MD, PhD, Department of Anaesthesiology and Intensive Care, Skane University Hospital Lund, SE-221 85 Lund, Sweden
Tel: +46 46 174223; fax: +46 46 176050; e-mail: peter.reinstrup@med.lu.se
0265-0215 Copyright 2015 European Society of Anaesthesiology. All rights reserved.

DOI:10.1097/EJA.0000000000000177

Copyright European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

522 Sturesson et al.

anaesthetic agent consumption during anaesthesia.57 In

the ACD system, volatile anaesthetic agents are delivered
on the patient side of the filter. The working principle of
the filters is the same as that of a heat and moisture
exchanger (HME). During expiration, the volatile gases
are adsorbed onto the filter material. During the subsequent inspiration, volatile anaesthetics are displaced
from the filter back into the gas stream, reducing the need
to replenish with additional vapour.

lung model (2-l ISO antistatic ventilation bag;

SH, Kernen, Germany) with a Fisher & Paykel
RU
MR 450 humidifier (Fisher & Paykel, Auckland,
New Zealand) interposed in the inspiratory limb. The
volatile anaesthetic gas inlet system was connected to
the low-pressure gas inlet port of the ventilator. This
open set-up was used to check the validity of the
system when compared with calculated values as
described by Perhag et al.7

The efficacy of inhaled sedation using the ACD during

anaesthesia8,9 and in the ICU10 has been established.
Inclusion of a filter in the airway increases the dead space
and thereby rebreathing of CO2. However, higher arterial
CO2 values in patients have been observed during the use
of the ACD despite compensation for larger internal dead
space.11 What actually happens when different filters for
reducing volatile anaesthetics consumption, reflectors,
are used, and when conditions of use vary, has not been
well studied.

In the main experiments, the following equipment

(Fig. 1) was connected in a serial manner after the
Y-piece (Y): molecular sieve-reflector (R), side-stream
Hewlett-Packard Agent Monitor M1025B [McPeak HB
1993; Hewlett-Packard, Palo Alto, CA, USA (M)] measuring volatile anaesthetics as well as CO2 and N2O with
photo-acoustic spectroscopy, humidifier (H) controlled
by a temperature probe (T), T-piece for volatile anaesthetic gas inlet system (F) and a CO2 inlet system which,
through a thin plastic tube, ended in the lowest part of the
ventilation bag used as a test lung (L).

The aim of this study was to explore the reflecting properties of filters with charcoal and zeolite filters looking firstly
at their volatile anaesthetic conserving effect, and secondly
at their CO2 reflection. The reflecting materials in the
filters were evaluated following exposure to varying combinations of dry, humid, cold and heated gases, both with
and without isoflurane. In addition, the reflecting properties of charcoal- and zeolite-containing filters were tested
for commonly used volatile anaesthetics.

The volatile gas inlet system (G) consisted of a precision

flow meter (F) (administering atmospheric air), and a
TEC 1 vaporiser (Ohmeda, Little Chalfont, Bucks., UK)
(V) modified to deliver near-saturated vapour of anaesthetic agent. The vaporiser was placed on an electronic
scale (G 1200, Ohaus, New Jersey, USA). A magnetic
valve controlled by the ventilator allowed the anaesthetic
gases to be injected only during inspiration.
Dead space consisted of tubing (7 ml), reflector (60 ml)
and humidifier (85 ml). Dead space of the humidifier was
kept as low as possible.

Materials and methods

Experimental set-up

A Servo Ventilator 900C (Siemens-Elema, Solna,

Sweden) was used in all experiments. In the baseline
experiments, the Y-piece was connected directly to the

The filters were custom built by emptying Siemens

HME filters (Servo humidifier 152; Siemens-Elema) of

Fig. 1

Exp
irat
ion
ServoVentilator 900 C

Y
irat
Insp

H
T

ion

G
Test
lung

MV

CO2
bottle

Atm air

Scale

Experimental set-up. A Servo Ventilator, tubes to the Y-piece (Y), reflector material tested (R), gas monitor (M), humidifier (H), connected to the test
lung (L). CO2 from a bottle was fed to the test lung. The volatile gas inlet system (G) consisted of a precision flow meter (F), a magnetic valve (MV)
and a vaporiser (V) placed on a scale.

Eur J Anaesthesiol 2015; 32:521526

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Reflecting filters for volatile anaesthetics

their contents and refilling them with 60 ml of glass

spheres (control), zeolite or charcoal.
Glass spheres filter

The filter was filled with glass spheres with a diameter of

1 mm.
Charcoal filter

The adsorption material was granulated charcoal derived

from burned coconut shells.
Zeolite filter

The adsorption material consisted of ultrastable

zeolite Y (US-Y) pellets with a diameter of 1 mm, a
synthetically prepared material using Al2O3 as the
binder. Ultrastable zeolites represent a group of crystalline microporous silicates built by corner-sharing
[SiO4]4--tetrahedral molecules forming a framework
structure characterised by the presence of cavities and
channels. Zeolite represents a unique framework, the
FAU (Faujasite) structure type, in three dimensions
connecting into micro-void cages [O(II)-cages] within
the structure.12

Experimental procedure
All experiments started with a 30-min equilibration
period. Initial measurements were made with the glass
spheres configuration. Ventilation was set at 9.0 l min
1,
frequency to 15 min
1, inspiratory time at 33% and pause
time at 0%. The CO2 flow to the lung model (L) was set to
produce an end-tidal concentration of 4% and this flow of
CO2 was kept constant.
When a volatile anaesthetic was used, the flow through
the vaporiser was adjusted to produce and maintain
the desired end-tidal concentration throughout the
experimental period (1 h). The different tests reported
below were performed by substituting the glass
spheres filter with either a charcoal or a zeolite filter.
Weight changes in the vaporiser were recorded every
5 min.
CO2 reflection was monitored by the changes in end-tidal
CO2 in the majority of experiments. In a parallel series of
experiments, end-tidal CO2 was kept constant at 4% by
adjusting the tidal volume of the ventilator to maintain
constant end-tidal CO2.
The experiments were carried out with different configurations to evaluate:
(1) CO2 reflection in warm and dry, cold and dry and
warm and moist air in turn, without any volatile
anaesthetic. Warm, cold and moist air was produced
by having the reservoir of the humidifier (H) empty
with the middle part of the reservoir removed, filled
with ice or with warm water, respectively.
(2) CO2 and 1.5% isoflurane reflection in warm, dry and
in warm, moist air.

523

(3) The CO2 and 1.5% isoflurane reflection in warm, dry

and warm, moist 70% N2O in O2 mixture delivered
by the ventilator. In the following experiments, only
the glass spheres and charcoal filter were used.
(4) The reflection of increasing concentrations of isoflurane.
(5) The reflection of 1.5% isoflurane, halothane, sevoflurane and desflurane.
(6) The reflection of one MAC isoflurane, halothane,
sevoflurane and desflurane.
(7) The effect of isoflurane delivered only during
inspiration or continuously.

Calculations of measurement errors

The results of the consumed volatile anaesthetics,
expressed in grams per hour, can differ from the exact
values due to measurement errors in the balance, the gas
analyser and/or inaccuracy in the delivered volume from
the ventilator. According to manufacturers specifications, the measurement errors of the balance, gas analyser
and ventilator are 2%, 5% and 5%, respectively,
giving a combined measurement error of 7%.

Results
Isoflurane consumption in an open system using 1.5%
isoflurane concentration

In this study, before inserting the different filters, the

validity of the laboratory assembly was tested in an open
system, in which isoflurane consumption was measured
as 60.8 g h
1 corresponding to a calculated value of
58.9 g h
1.
The impact of an inspiratory-guided versus continuous
delivery of isoflurane on the effectiveness of the charcoal
filter

In all experiments, volatile anaesthetics were delivered

exclusively during inspiration. The isoflurane consumption in warm dry air with glass spheres and charcoal filter
was 39.8 and 11.8 g h
1, respectively. Bypassing the
valve, resulting in a continuous delivery of isoflurane,
did not change the consumption (39.6 and 11.5 g h
1,
respectively).
Consumption of isoflurane using glass spheres, charcoal
and zeolite filter

Changing from glass spheres to the charcoal or zeolite

filter had profound effects on the isoflurane consumption.
Warming and humidifying the air as well as adding N2O
had only minor effects on isoflurane consumption
(Table 1).
Reflection properties of the charcoal filter at different
isoflurane concentrations

The isoflurane reflection using the charcoal filter was

independent of isoflurane concentration from 0.5 to 4.5%
(Table 2).

Eur J Anaesthesiol 2015; 32:521526

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524 Sturesson et al.

Table 1

Effect of temperature, humidity and N2O on isoflurane consumption with different reflecting filters
N2O
Temp (-C)
Humidity
Isoflurane

CO2 3.8%

CO2 4.0%
CO2 4.0%

Glass
Charcoal
Zeolite
Charcoal
Zeolite

No
17
No
Consum Insp
39.5
11.5
11.1
13.5
13.2

0.1
1.1
1.1
1.1
1.1

MV
9.0
9.0
9.0
10.8
10.8

No
33
No
Consum Insp
39.8
11.8
10.7
13.9
13.6

0.1
1.1
1.1
1.1
1.1

MV
9.0
9.0
9.0
11.0
10.4

No
33
Yes
Consum Insp
40.6
13.9
12.1
16.4
14.1

0.1
1.0
1.0
0.9
1.0

MV
9.0
9.0
9.0
10.2
10.3

70%
33
No
Consum Insp
38.3
11.3
10.7
13.5
11.7

0.1
1.1
1.1
1.0
1.1

MV
9.0
9.0
9.0
10.8
10.8

70%
33
Yes
Consum Insp
39.4
10.9
11.5
12.3
13.2

0.1
1.0
1.1
1.0
1.0

MV
9.0
9.0
9.0
10.1
10.3

The effect of N2O, temperature and humidity on the isoflurane consumption with a 60 ml filter filled with glass spheres, charcoal or zeolite. The effect is expressed during
constant minute ventilation (MV, 9.0 l min-1) and respiratory rate (RR 15 min-1) and when MV is changed to keep end-tidal CO2 constant at 4.0%. The consumption
(Consum) is expressed in g h-1.

Halothane, isoflurane, sevoflurane and

desflurane consumption
Reflection properties of the charcoal filter with a
concentration of 1.5% of halothane, isoflurane,
sevoflurane and desflurane and at MAC 0.5 and 1.0,
respectively

These different, commonly used, volatile anaesthetics

were reflected similarly by the charcoal filter, shown by
similar conservation (Tables 3 and 4).

CO2 reflection
Compared with the glass spheres filter, the charcoal and
zeolite filters increased end-tidal CO2 by 3.0% and 3.7%,
respectively, in cold (17.2oC) air. To keep end-tidal CO2
constant at 4%, the minute volume had to be increased
from 9.0 to 13.0 l min
1 and from 9.0 to 13.2 l min
1,
respectively. CO2 reflection was reduced, when the air
was heated, humidified and when isoflurane was added.
No further reduction was noted when 70% N2O in
oxygen was used.
In the clinical simulation, with volatile anaesthetics in
warm humid air, end-tidal CO2 increased by 1.0% for the
charcoal and 1.4% for the zeolite filter. In order to keep
CO2 constant, the minute volume had to be increased
from 9.0 to 10.1 l min
1 and from 9.0 to 10.4 l min
1 for
charcoal and zeolite filter, respectively.
The CO2 reflection data are presented in Table 5.

Discussion
The present study demonstrates similar reflection properties of charcoal and zeolite filters on volatile anaesthetics, with approximately 70% conservation of volatile
anaesthetics compared with the glass spheres filter. Charcoal and zeolite filters also displayed CO2 reflection
properties that were reduced when the air was warmed
The hourly consumption in grams of isoflurane at 33-C, dry
air and different concentrations with a glass spheres and a charcoal
filter

Table 2

Isoflurane concentration
Glass spheres
Charcoal: dry
% change

0.5
13.8
3.6
74

1.15
30.2
8.5
72

1.5
39.5
10.6
73

3
85.6
26.8
69

4.5
158.4
43.0
73

and humidified to physiological values. The CO2 reflection was further attenuated when isoflurane was added,
resulting in a final 1% increase in end-tidal CO2 compared with the glass spheres filter.

Isoflurane reflection
The open system, in which isoflurane was delivered
through the ventilator guided by the anaesthetic agent
monitor, was used to address the combined accuracy of
the delivered volume by the ventilator, the measured
concentration of volatile anaesthetic and the scales apparatus. The actual consumption of the open system corresponded to the calculated values, indicating accuracy of
these instruments.
In the filtering system, the volatile anaesthetic was
delivered on the patient side of the filter and solely
during the inspiratory phase. This was made possible
by a magnetic valve controlled by the ventilator. Inspiratory delivery of volatile anaesthetic reduces consumption
compared with the open system.5,6 However, with a
charcoal filter in use, bypassing the valve did not affect
the consumption. Thus, a filter with no magnetic valve
will be just as effective at volatile anaesthetic sparing as a
system with a magnetic valve, but the present experiments were still performed using this device.
Both charcoal and zeolite had marked reflecting properties when combined with isoflurane in accordance with
previous studies, reducing the need for adding isoflurane
to the system by almost 75% at 1.5% end-tidal isoflurane,
compared with a glass spheres filter.57 Increasing the
temperature from 17oC to 33oC did not change this
1
Table 3 The hourly consumption (g h ) of 1.5% isoflurane (Iso),
sevoflurane (Sevo), desflurane (Des) and halothane (Halo) using
glass bead or charcoal filter in dry and moist air

Glass beads dry

Glass beads moist
Charcoal dry
Charcoal moist
% change dry
% change moist

Iso

Sevo

Des

Halo

39.8
40.6
11.8
13.9
70.4
65.8

46.8
48.1
13.6
14.9
70.9
69

39.3
35.9
10.6
12.1
73
66.3

48.4
48.8
14.9
18.4
69.2
62.3

% change dry and moist expressed as the saved percentage using charcoal filter
compared with glass bead.

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525

Reflecting filters for volatile anaesthetics

1
Table 4 The hourly consumption (g h ) of 0.5 and 1 MAC isoflurane (Iso), sevoflurane (Sevo), desflurane (Des) and halothane (Halo) using
glass beads or charcoal filter in dry and moist air

0.5 MAC
Glass beads dry
Glass beads moist
Charcoal dry
Charcoal moist
% change dry
% change moist

1 MAC

Iso

Sevo

Des

Halo

Iso

Sevo

Des

Halo

16.5
16.8
4.3
4.6
74
72.6

34.1
36.2
9.3
10.4
72.7
71.2

62.3
58.9
17.3
20.8
72.2
64.6

21.1
13
2.5
2.8
88.2
78.5

30.2

66.1
64.4
21.6
22.1
67.3
65.7

165.7
162.6
58
62.6
65
60

28.1
28.4
7.1
10.7
74.7
62.3

8.5
72

% change dry and moist expressed as the saved percentage using the charcoal filter compared to glass beads.

reflection. Contrary to this, when the air was humidified,

the raised water content increased the loss of isoflurane
through both filter types. This increase in apparent
permeability in humidified air was also seen with CO2,
indicating that trapped water in the filter material attenuates the adsorbing properties of the filtering material in
general. The zeolite filter was, by volume, somewhat
more effective in reflecting isoflurane, as seen by a lower
hourly consumption in all situations. Considering charcoals ease of availability and the possible carcinogenic
effects of zeolite, the rest of the experiments were
performed using the charcoal filter.13,14

larger concentrations or amounts of volatile anaesthetics.

The binding process in the filter material appears to be
time-dependent so that the higher flow during expiration
of higher tidal volumes allows the volatile anaesthetics to
pass through the filter.

Halothane, isoflurane, sevoflurane and

desflurane reflection
In previous investigations, the properties of the different
filters have been evaluated solely with isoflurane.57,12
Other volatile anaesthetics are similar in chemical composition, and similar effects were seen for reflection of
halothane, sevoflurane and desflurane by charcoal
(Tables 3 and 4).

The amount of reflected isoflurane caused both by zeolite

and charcoal has previously been found to be smaller at
higher tidal volumes.5,6 One would therefore expect that
increasing concentrations of the volatile anaesthetic
would increase the loss through the filter. This was,
however, not the case as seen in Table 2. This might
be due to sufficient amount of binding sites existing on
the reflecting materials in this filter, coping with even
Table 5

CO2 reflection
Rebreathing of CO2 and CO2 retention have been
described but have not been thoroughly investigated.6,15
A charcoal filter used in a 17oC system was found to have
profound CO2 reflecting properties compared with the

Effect of temperature, humidity, isoflurane and N2O on CO2 reflection

Baseline

Temperature increased

Humidity added

Isoflurane added

Temp C

17

33

33

33

33

Humidity

No

No

Yes

Yes

Yes
1.5%

Isoflurane

1.5%

N2O

ET CO2 Insp CO2

MV

Glass spheres

4.0

0.1

9.0

Charcoal

7.1

2.0

9.0

Zeolite

7.7
2.3
9.0
CO2 -level restored

ET CO2 Insp CO2

MV

4.0

0.2

9.0

6.6

2.1

9.0

5.8
1.1
9.0
CO2 -level restored

ET CO2 Insp CO2

MV

4.0

0.2

9.0

5.2

0.8

9.0

4.8
0.5
9.0
CO2 -level restored

ET CO2 Insp CO2

Nitrous oxide added

70%
MV

3.8

0.2

9.0

4.8

0.5

9.0

4.9
0.6
9.0
CO2 -level restored

ET CO2 Insp CO2

MV

3.8

0.2

9.0

4.9

0.5

9.0

5.1
0.5
9.0
CO2 -level restored

Charcoal

4.0

0.7

13.0

4.0

0.8

12.5

4.0

0.5

10.7

4.0

0.4

10.2

4.0

0.3

10.1

Zeolite

4.0

0.5

13.2

4.0

0.4

11.3

4.0

0.4

9.9

4.0

0.4

10.3

4.0

0.3

10.3

Humidity removed

Humidity removed

Temp C

33

33

Humidity

No

No

Isoflurane

1.5%

1.5%

N2O

ET CO2 Insp CO2

70%
MV

ET CO2 Insp CO2

MV

Glass spheres

3.8

0.2

9.0

3.8

0.2

9.0

Charcoal

5.3

1.1

9.0

5.3

0.8

9.0

Zeolite

5.0
0.6
9.0
CO2 -level restored

5.3
0.6
9.0
CO2 -level restored

Charcoal

4.0

0.7

11.0

4.0

0.5

10.8

Zeolite

4.0

0.4

10.4

4.0

0.4

10.8

Eur J Anaesthesiol 2015; 32:521526

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526 Sturesson et al.

glass spheres filter, resulting in an increase in end-tidal

CO2. Accordingly, in order to keep end-tidal CO2 constant, the tidal volume of 600 ml had to be increased by
266 ml. However, as soon as the filter was warmed to
33oC, which in clinical practice should take less than
10 min, the CO2 reflection was reduced.16,17 Furthermore, when the filter had been humidified by a patients
expired gas over 5 to 10 min, the CO2 increase on the
patient side of the filter was further reduced to 30%.16,17
In such a clinically relevant situation, without volatile
anaesthetics, the CO2 increase was 1.2% for the charcoal
filter and 0.8% for the zeolite. The corresponding
increases in tidal volume necessary to compensate for
this reflection were 233 and 153 ml, respectively. Adding
isoflurane to the dry system caused a considerable
reduction in end-tidal CO2. This increased CO2 permeability was first believed to be caused by a relative
decrease in dead space due to the isoflurane inlet in front
of the reflector. However, the same assembly and flow,
but without isoflurane, only caused a 0.2% CO2 reduction,
suggesting the mechanism to be a higher affinity to
isoflurane and the binding sites in the adsorbing material
than CO2. The CO2 reflection of the filters differed when
the system was humidified. This was shown by a further
reduction of end-tidal CO2 using glass spheres and charcoal filters, but not when using zeolite filters. The binding sites between the two materials must therefore differ
in their reaction to H2O.

Acknowledgements relating to this article

HME filters have also been suspected to reflect CO2, but

this effect has been found to be due solely to the increased
internal dead space of the filter.18 In our investigation, the
internal dead space was the same for the different types of
filters, the increased CO2 being unique to zeolite and
charcoal properties as filter materials.

11

In conclusion, charcoal and zeolite filters with an internal

volume of 60 ml had similar reflection properties on
volatile anaesthetics, with approximately 70% conservation compared with the glass spheres filter. In addition,
they displayed CO2 reflection properties, which were
reduced when the air was warmed and humidified to
physiological values. The CO2 reflection was further attenuated when isoflurane was added, for a total of a 1% in
end-tidal CO2 compared with the glass spheres filter.

Assistance with the study: we wish to thank the late Associate

Professor Olof Werner, MD, PhD, at the Department of Anaesthesiology and Intensive Care, Skane University Hospital Lund for
suggesting the reflector idea and for invaluable discussions throughout the work.
Financial support and sponsorship: none.
Conflict of interest: none.
Presentation: none.

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