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Perioperative Management of an Airway Fire

A Case Report

Salaria, Osman Nawazish, MD; Suthar, Rekha, MD; Abdelfattah, Sarah, MD; Hoyos, Jason, DO

doi: 10.1213/XAA.0000000000000620
Case Reports: Case Report

Accidental fire can occur with upper airway injury and can be fatal if inappropriately managed. Effective communication between the anesthetic and the surgical teams can reduce the risk of such an adverse event. Understanding the interaction between fuel, oxidizer, and ignition source in an airway fire may also reduce the incidence. The literature on upper airway thermal injury has focused on prevention and intraoperative management, but few studies have described postburn management. In this report, we describe the intraoperative occurrence of an airway fire during a surgical tracheostomy and subsequent patient management.

From the Miami Beach Anesthesiology Associates, Inc, Department of Anesthesiology, Mount Sinai Medical Center, Miami, Florida.

Accepted for publication June 27, 2017.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Osman Nawazish Salaria, MD, Department of Anesthesiology, Mt Sinai Medical Center of Florida, 1035 West Ave, PH08, Miami Beach, FL 33139. Address e-mail to

An airway fire can result in major injury to the patient. Operations using lasers in the airway, tracheostomies, and procedures involving the head, neck, and face1 may all place the patient at higher risk of an airway fire.2 Fires occurring during tracheostomy are often associated with significant morbidity and mortality.3 In particular, patients undergoing tracheostomy often require a high FIO2 and may be ventilator dependent, both major risk factors for airway fire.

After an airway fire, extinguishing the fire, reestablishing the airway, stabilizing cardiorespiratory function, and appropriate thermal injury management are key issues. Frequent bronchoscopies maybe performed to assess the severity of airway burns and response to healing. Bronchodilators, corticosteroids, and antibiotics may also be given to improve lung function but are not recommended by current guidelines.4

In this case report, we describe an airway fire occurring during elective tracheostomy and the postfire management of the patient.

Written consent was obtained from the patient’s family regarding the inclusion of the patient’s hospital course in this case report. All patient identification data have been removed including name, date of birth, and medical record number.

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A 79-year-old Caucasian man was admitted to the hospital for dyspnea due to severe aortic valve stenosis. The patient had a medical history of obesity, chronic obstructive pulmonary disease, congestive heart failure, obstructive sleep apnea, and atrial fibrillation. After evaluation and assessment, the patient underwent an endoluminal minimally invasive mitral valve repair, aortic valve replacement, and MAZE procedure. His postoperative course was complicated by respiratory failure requiring multiple reintubations and frequent bronchoscopy for thick airway secretions and atelectasis. Due to several failed extubations and prolonged ventilator dependence, an elective tracheostomy was performed on postoperative day 14.

Prior to tracheostomy, the patient was intubated with a size 8 polyvinyl chloride endotracheal tube (ETT) receiving assist control mechanical ventilation at an FIO2 of 40% and a pH of 7.50, PO2 of 110 mm Hg, and PCO2 of 44 mm Hg on arterial blood gas measurement. Bedside telemetry revealed atrial fibrillation with a rate of 68 bpm. Induction of anesthesia was performed with 30 mL propofol and 20 mL rocuronium, and 2% sevoflurane was used for maintenance. During the initial dissection, monopolar electrocautery was utilized and the patient was placed on 40% FIO2 to maintain an SaO2 of 99%. After tracheal exposure, electrocautery was discontinued, and FIO2 was increased to 100% to preoxygenate prior to tracheal incision. The trachea was then incised above the ETT cuff, the patient was manually ventilated, and the ETT was then partially withdrawn until the tip was just above the tracheal incision.

The surgeon then began to use monopolar electrocautery. Immediately, the operative field ignited, and a 3-cm flame arose from the tracheal incision site. The surgical field was flooded with normal saline, the ETT was removed, and FIO2 was decreased to room air levels. The upper airway was then also flooded with sterile saline. The surgeon then reintubated the patient via the tracheal incision using a 7.0-cm ETT. Once the patient was stabilized and the fire extinguished, the FIO2 was increased to 100% and the tracheostomy was completed. Fiberoptic bronchoscopy performed immediately after the tracheostomy revealed edematous, red, and inflamed mucosa in the right upper lobe and middle lobe bronchus. GlideScope visualization of the supraglottic area also revealed mild edema and red, inflamed mucosa. The patient was transferred back to the intensive care unit. Postoperative chest computed tomography revealed bilateral patchy, nodular air space opacities, and ground glass opacities with right perihilar bronchial thickening. Repeat fiberoptic bronchoscopy demonstrated blackened tracheal mucosa distal to the tracheal tube. The right upper lobe was heavily charred (all 3 segments); however, all segments were patent. The left main stem bronchus was patent with mild charring.

The patient was started on inhaled heparin every 8 hours, N-acetylcysteine, and albuterol. Daily bronchoscopy demonstrated a healing tracheal mucosa with persistent mucous impaction that was removed by lavage. Respiratory cultures were obtained, and broad-spectrum antibiotics were begun on postoperative day 3 after purulent secretions were observed in the left upper lobe. Although cultures did not reveal bacterial growth, antibiotics were continued due to the presence of injured tracheal epithelium, which placed the patient at increased risk for infection. Because of persistent atrial fibrillation, a heparin drip was begun and Lasix every 8 hours was started for chronic systolic heart failure, increased secretions, and an increased alveolar-arterial PaO2 gradient. Due to a low platelet count and positive heparin-induced thrombocytopenia (HIT) panel, intravenous heparin was switched to argatroban on postoperative day 6. Hematology consultation recommended that inhaled heparin be discontinued because systemic absorption could be an HIT trigger (Figures 1–5).

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Figure 4

Figure 4

Figure 5

Figure 5

In the following week, bronchoscopy revealed more frequent purulent secretions with left lung collapse. Paroxysms of atrial fibrillation with hypotension and new-onset bradycardia became more frequent. Hypotension was managed with multiple intravenous fluid boluses and norepinephrine. Ultimately, the patient developed multiorgan dysfunction of the heart, lungs, and kidneys and passed away.

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An estimated 550 to 650 surgical fires occur among the 65 million surgical cases performed in the United States each year, with many causing serious injury, disfigurement, and death.5 A majority involved head, neck, and upper chest procedures such as tonsillectomy, tracheostomy, and cataract surgery.1,5 In these cases, monitored anesthesia care was used with supplemental oxygen delivered via nasal cannulae or facemask. The accumulation of leaked oxygen under the drapes in these procedures increases the risk of an airway fire. Fires have also occurred during laser surgery of the airway and 1-lung ventilation for lung mass resection cases. These procedures are at particularly high risk because all elements of the airway fire triad: fuel, an oxidizing agent, and an ignition source, were present.

In our case, the fuel source was the ETT. Most commonly used ETTs are made of highly combustible polyvinylchloride, as in our case. The use of such tubes for high-risk surgery is controversial6 because newer laser-resistant, reinforced tubes are less flammable. Oxidizing agents relevant to the anesthesia environment include oxygen and nitrous oxide. Many critically ill patients require a high FIO2 to maintain adequate oxygen saturation. This requirement may often conflict with the need to minimize the risk of fire by using the lowest possible FIO2 consistent with an adequate O2 saturation.2,17 By decreasing the amount of oxidizing agent, a low FIO2 reduces the risk of fire. In our case, the airway fire occurred when the FIO2 was increased to 100% for ETT removal. Although we used an FIO2 of 40% for initial dissection without triggering an airway fire, reports suggest that ETTs can be ignited with FIO2 levels as low as 25%.2,17 Last is the ignition source, which in our case study was the use of monopolar electrocautery. In cases with high fire risk, bipolar rather than monopolar electrocautery devices are preferred to minimize current leakage to surrounding tissues.6,7 Monopolar cautery can generate temperatures as high as 910°C and create sparks leading to a fire.8,7 The cutting action of bipolar cautery generates lower temperatures, less tissue damage, and avoidance of sparks. In our case, the precipitating event was the use of monopolar diathermy to control bleeding in the presence of ventilation with 100% FIO2. Ideally, the anesthesia and surgery teams should discuss with the use of electrocautery for control of bleeding and communicate regarding the FIO2. We used an FIO2 of 40% due to concerns about the patient’s comorbid conditions and medical history.

Although no standard protocol for procedures at high risk of airway fires exists, a compilation of case reports and studies produces several reasonable recommendations: (1) avoidance of oxidizing agents such as nitrous oxide to the lowest level possible; (2) fill the ETT cuff with normal saline; (3) use suction to remove oxygen that leaks from the airway; (4) use low FIO2 oxygen-air and/or helium mixtures to further minimize the presence of oxidizing agents; (5) use bipolar rather than monopolar electrocautery devices if possible to limit current leakage, and use sparingly; (6) communication between the surgical and the anesthetic teams is also important to avoid concurrent use of high FIO2 and cautery.2,3,6,11-13,15 In our case, the use of monopolar cautery in close proximity to the open tracheostomy site resulted in the triggering event that caused the airway fire. Ideally, electrocautery should be avoided or, if needed, bipolar cautery should be used.9

After an airway fire has occurred, the next steps are controversial. The decision to immediately extubate a patient is best made on a case by case basis.10,14 If difficulty reestablishing the airway is expected due to edema or a history of difficult intubation, then leaving the tube in place is reasonable. However, in other cases, the heat and chemical reaction generated by the burning tube in addition to damage to surrounding tissues should lead to prompt extubation.10,14 We immediately extubated our patient and reintubated him with a new ETT. The tracheostomy stoma was intact and provided an easy conduit for reintubation.

Postoperatively, the use of antibiotics and steroids has been suggested, although more recent studies indicate that such strategies are not universally adopted.4,16 We initiated broad-spectrum antibiotics while the patient was in the intensive care unit. Frequent bronchoscopies, which were daily initially and then every 2 to 3 days along with respiratory cultures, were performed. Heat injury to the tracheociliary respiratory lining, airway edema, and mucus secretions can lead to mucus plugging and infection. Although evidence supporting inhalational heparin, N-acetylcysteine, and albuterol are mixed, we initiated all 3 agents. Although some evidence suggests that this therapy decreases lung injury scores and duration of mechanical ventilation,16 it is not universally adopted because clinical benefits are controversial.4 Unfortunately, with the development of a positive antibody panel for HIT, the therapy had to be abandoned.

In conclusion, tracheostomy carries a high risk for airway fire. Continuous awareness, communication, and cooperation by all involved can facilitate prevention of airway fire. Scrupulous attention to inspired oxygen concentration and cautery use are required. Although some guidance for prevention and acute management exist, postoperative management strategies are mostly driven by recommendations from case studies and investigational techniques.

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Name: Osman Nawazish Salaria, MD.

Contribution: This author helped design the study, collect the image, and prepare and edit the manuscript.

Name: Rekha Suthar, MD.

Contribution: This author helped collect the image and design the study.

Name: Sarah Abdelfattah, MD.

Contribution: This author helped obtain patient medical records.

Name: Jason Hoyos, DO.

Contribution: This author helped prepare the manuscript.

This manuscript was handled by: Avery Tung, MD, FCCM.

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