Prevention and Management of

Airway Fire
Alex Chan Shing-Chau
Anyon Chan
 Definition
• surgical fire that occurs in a patient’s airway
and may or may not include a fire in the
attached breathing circuit.
OR fire

Surgical fire

Airway fire
 Incidence
• 50-200 OR fire per year in US
 Consequences
• Burns
• Inhalational Injuries (edema, bronchospasm)
• Airway Obstruction
• Infection
• Disfigurement and Psychological Trauma
• Death
• Prolonged Hospitalisation
• Delay or Cancellation of OT
• Liability
 The Fire Triad

Oxidiser

Fuel Ignition
 Oxidiser
• Oxygen
• Nitrous oxide
 Fuel
• Endotracheal tube
• Gauze/sponge
• Solutions containing volatile substances
(alcohol, ether, acetone)
• Flexible endoscope
• Suction catheter
• GI gas
 Ignition
• Diathermy
• Laser
• Argon beam coagulator
• Heated probe
 High risk procedure
• Ignition source in proximity to an oxidiser-
enriched atmosphere
• Example:
- Adenotonsillectomy
- Removal of laryngeal papillomas
- Tracheostomy
- Others (cataract/burr hole/H&N lesion
removal)
 Prevention - General
• Recognition of high risk procedure
• Close communication among anaesthetists,
surgeons and OT nurses
• Preparation of equipment for managing
airway fire
• Easily visible protocol in OT room
• Regular OR fire drill/simulation training
 Prevention - Oxidiser
• Oxygen concentration reduced to minimum to
avoid hypoxia
• Avoid N2O
• Others (proper drape configuration,
scavenging with suction, flooding surgical field
with CO2)
 Prevention - Fuel
• Use cuffed tube
• Use laser resistant tracheal tube
• Fill balloon with saline (tinted with methylene
blue) instead of air
• Use moistened gauze or sponge
Laser-resistant ET tube
 Prevention - Ignition
• Avoid diathermy (or use bipolar)
• Use laser with lowest energy and shortest
duration if possible
 Recognising airway fire
• Flame or flash
• Unusual sound
• Odour
• Smoke
 Management
• Halt the procedure immediately
• Remove ET tube (caveat) and gauze/sponge
• Stop the delivery of all gases
• Disconnect ventilator from the patient
• Pour saline into the airway
• Use CO2 fire extinguisher if first attempt
unsuccessful
 After fire out…
• Reestablish ventilation by mask, avoiding
supplemental oxygen and nitrous oxide
• Extinguish and examine the tracheal tube to assess
whether fragments were left in the airway
• Consider bronchoscopy to look for tracheal tube
fragments, assess injury and remove residual debris
• Assess the patient’s status and devise a plan for
ongoing care (ICU, supportive therapy,
tracheostomy)
 Take home message
• Airway fire is potentially deadly complication
• Preventive measures do not guarantee fires
will not occur, so be prepared
• Remember the fire triad
• Simple means to extinguish fire should be
immediately on hand
• Keep FiO2 to minimum and avoid N2O
• Removing the ET tube is the rule of thumb
 References
• 1. Apfelbaum JL et al, Practice Advisory for the
Prevention and Management of Operating Room
fires (An Updated Report by the American Society
of Anesthesiologists Task Force on Operating
Room Fires). Chicago: Lippincott Williams &
Wilkins. Anesthesiology 2013; 118:271-90
• 2. Abdelmalak B, Doyle DJ. Anesthesia for
Otolaryngologic Surgery. New York: Cambridge
University Press; 2013. 107-11