Safety of anesthesia machines has been enhanced significantly over the last two decades. While advanced technologies played an important role in their safety, our understanding of the inner workings of the anesthesia machine and establishing clear guidelines for standard machine checkout procedures are an integral part of their safe use in patient care. The scenario revolves around a misassembled bellows housing (enclosure) and is intended for diverse learners ranging from anesthesia technicians to advanced anesthesia residents and nurse anesthetists. In this scenario, the bellows housing is improperly seated to create a leak around the bellows. This will lead to failure of mechanical ventilation while manual ventilation remains intact. Upon switching to mechanical ventilation, the learner will notice the collapsed ventilator bellows followed by low airway pressure and low tidal volume alarms will sound. While the goal is to find the fault and correct it quickly, this is not the only learning objective. If the learner is unable to find the fault, he/she will need to explore alternative solutions (eg, calling for help, replacing the anesthesia machine, or canceling the surgery).

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