Learning objectives 

• Recognize an airway fire
• Management of an airway fire

Definition and mechanisms

• An airway fire is defined as a fire occurring in a patient’s airway
• May or may not include a fire in the attached breathing circuit
• All airway fires require three components known as the “fire triad”:
  • Oxidizers oxygen and nitrous oxide
  • Ignition source: electrosurgical devices, lasers, heated probes, burrs and drills, fiberoptic scopes, and defibrillator paddles or pads
  • Fuel: tracheal tubes, sponges, drapes, gauzes, alcohol-containing solutions, oxygen masks, nasal cannulae, the patient’s hair, dressings,  gowns, gloves, or packaging materials

Prevention

• Determine if the procedure is high-risk
• Agree upon a team plan and team roles for preventing and managing a fire
• Notify the surgeon of the presence of or an increase in an oxidizer-enriched atmosphere
• Before an ignition source is activated:
  • Announce the intended use of an ignition source
  • Reduce the oxygen concentration to a minimum needed to avoid hypoxia 
  • Stop the use of nitrous oxide
• Avoid using ignition sources near oxidize-enriched environments
• Configure the drapes to avoid oxidizer pooling or accumulation
• Allow flammable skin-prepping solutions to completely dry
• Sponges and gauzes should be moistened if used near ignition sources
• Airway laser procedures: use laser-resistant cuffed tubes and fill the cuff with saline tinted with methylene blue to identify a cuff puncture by the laser

Management

Keep in mind

The following supplies should be immediately available in the operating room:

• Several containers of sterile saline
• A CO2 fire extinguisher
• Replacement tracheal tubes, guides, facemasks
• Rigid laryngoscope blades including a rigid fiberoptic laryngoscope
• Replacement airway breathing circuits and lines
• Replacement drapes, sponges

Suggested reading

• Cowles CE Jr, Culp WC Jr. Prevention of and response to surgical fires. BJA Educ. 2019;19(8):261-266.
• Akhtar N, Ansar F, Baig MS, Abbas A. Airway fires during surgery: Management and prevention. J Anaesthesiol Clin Pharmacol. 2016;Jan-Mar;32(1):109-11.
• Apfelbaum JL, Caplan RA, Barker SJ, 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. Anesthesiology. 2013;118(2):271-290.

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