Safety measure

• Airway fire


  A fire that occurs within a patient's airway or involves an insitu airway device or contiguous breathing circuit
• Operating-room fires (airway- or non-airway-related) are rare events
• Fires in the airway have become less common due to the discontinuation of the older, more flammable anesthetic agents (ether and cyclopropane), but they have the potential for devastating patient morbidity and mortality, despite their fleeting nature
• Fire triad


  • An ignition source
  • An oxidizer
  • A fuel source
• Ignition sources


  • Electrocautery
  • Lasers
  • Static electricity
  • Heated probes
  • Drills and burrs
  • Argon beam coagulators
  • Fiberoptic light sources and cables
  • Defibrillator pads and paddles
• Oxidizer


  The use of supplemental oxygen or nitrous oxide in anesthetic gases delivered via closed or semi-closed breathing circuits creates an oxidizer-enriched environment within patients' airways and breathing apparatus
• Fuel sources


  • Endotracheal tubes
  • Surgical drapes
  • Alternative airway devices
  • Breathing circuits
  • Scavenging tubes
  • Suction catheters
  • Wound drains
  • Surgical packs
  • Dressings
  • Pledgets
  • Sponges
  • Gauze
• The formation of a surgical tracheostomy is one example of a high-risk procedure, whereby the surgical field becomes oxidizer-enriched as soon as the tracheal aperture is created
• Laser airway and vocal cord surgeries are also especially hazardous as there is an ignition source (the laser), an oxygen-enriched environment (the air–oxygen mixture delivered to the patient) and a fuel (the endotracheal tube or breathing circuit)
• Injuries from airway fires


  • Infection
  • Loss of fluid and electrolytes
  • Heat loss (related to the surface-area of the affected tissues)
  • Life-threatening airway obstruction
  • Severe inhalational injuries and widespread pulmonary infiltration from the toxins released by burning materials (especially plastics)
• Patient prognosis following an airway fire is guarded and is dependent upon the extent of the fire and the injuries incurred
• Prevention of airway fires

  The key is prevention rather than management
• Preventing airway fires


  1. Remove ignition sources

  2. Avoid oxidizer-enriched environments

  3. Remove potential fuels
• Measures to remove ignition sources

  • Secure light source cables before activation
  • Place electrical equipment in standby mode when not in use or being disconnected
  • Avoid electrocautery where possible, use lowest effective voltage, avoid cutting diathermy mode, prefer bipolar over monopolar, avoid when making tracheal incision for tracheostomy, avoid when fractional-inspired oxygen levels are above 50%, operate by a single person
  • Use surgical lasers at lowest clinically effective power density and pulse duration, keep active tip visible and away from bronchoscopes/endotracheal tubes before activation, deactivate before removal, place in sheath when not in use, use non-reflective surgical instruments and surfaces
• Measures to avoid oxidizer-enriched environments

  • Avoid nitrous oxide
  • Use lowest possible fractional-inspired oxygen concentration, discontinue supplemental oxygen at least one minute before using electrocautery or laser, scavenge gases in oropharynx, flood surgical field with carbon dioxide
  • Use cuffed endotracheal tubes, inflate cuffs to lowest possible volume to reduce leakage, ensure adequate cuff pressure to eliminate oxygen leakage, avoid cuff puncture
  • Use specially designed adherent incise drapes or open drape arrangement to isolate incision site, deliver air separately to wash out oxygen buildup under drapes
• Measures to remove potential fuels

  • Prefer patient breathing spontaneously in room air or use alternative ventilation strategies
  • Use endotracheal tubes made of polyvinyl chloride (PVC) over rubber or silicone, use specially designed laser-resistant tubes
  • Soak up any pooled or spilled flammable agents, allow alcohol-based skin prep to dry fully, apply water-soluble gels to facial/head hair, moisten surgical pledgets/sponges/gauze/packs with water/saline, keep wound drains/packs/dressings/suction catheters/breathing circuits/nasal cannula/scavenging tubes away from surgical field
• Managing airway fires


  1. Maintain vigilance, recognize early signs

  2. Immediate coordinated response - surgeon stops procedure, anesthetist stops airflow, extinguish fire with saline/water, remove burnt debris, re-establish airway, use CO2 extinguisher if fire remains active, evacuate theatre if unsafe