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.
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.
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.
1. Eichorn JHA burning issue: preventing patient fires in the operating room. Anesthesiology. 2013; 119: 749–751.
2. Shin YD, Lim SW, Bae JH, Yim KH, Sim JH, Kwon EJWire-reinforced endotracheal tube fire during tracheostomy—a case report. Korean J Anesthesiol. 2012;63:157–160.
3. Kim MS, Lee JH, Lee DH, Lee YU, Jung TEElectrocautery-ignited surgical field fire caused by a high oxygen level during tracheostomy. Korean J Thorac Cardiovasc Surg. 2014;47:491–493.
4. Sheridan RLFire-related inhalation injury. N Engl J Med. 2016;375:464–469.
5. Akhtar N, Ansar F, Baig MS, Abbas AAirway fires during surgery: management and prevention. J Anaesthesiol Clin Pharmacol. 2016;32:109–111.
6. Rogers SA, Mills KG, Tufail ZAirway fire due to diathermy during tracheostomy in an intensive care patient. Anaesthesia. 2001;56:441–443.
7. Cooper AElectrocautery safety and OR fire prevention. OR Connection. 3:17–21.
8. Gorphe P, Sarfati B, Janot F, et alAirway fire during tracheostomy. Eur Ann Otorhinolaryngol Head Neck Dis. 2014;131:197–199.
9. Stein E, Subramaniam BPBLD 23 Burning Issues—cautery, skin prep, and airway fires. Society of Cardiovascular Anesthesiologists Annual Meeting, 2011, Savannah, Georgia.
10. Ng JM, Hartigan PMAirway fire during tracheostomy: should we extubate? Anesthesiology. 2003;98:1303.
12. Apfelbaum JL, Caplan RA, Barker SJ, et alAmerican Society of Anesthesiologists Task Force on Operating Room Fires. 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. Anesthesiology. 2013;118:271–290.
13. ECRI. A clinician’s guide to surgical fires: how they occur, how to prevent them, how to put them out. Health Devices. 2003;32:5–24.
14. Chee WK, Benumof JLAirway fire during tracheostomy: extubation may be contraindicated. Anesthesiology. 1998;89:1576–1578.
15. Rogers ML, Nickalls RW, Brackenbury ET, Salama FD, Beattie MG, Perks AGAirway fire during tracheostomy: prevention strategies for surgeons and anaesthetists. Ann R Coll Surg Engl. 2001;83:376–380.
16. Kashefi NS, Nathan JI, Dissanaike SDoes a nebulized heparin/N-acetylcysteine protocol improve outcomes in adult smoke inhalation? Plast Reconstr Surg Glob Open. 2014;2:e165.
© 2018 International Anesthesia Research Society
17. Remz M, Luria I, Gravenstein M, et alPrevention of airway fires: do not overlook the expired oxygen concentration. Anesth Analg. 2013;117:1172–1176.