Preventing airway fires during tracheostomy

European annals of otorhinolaryngology, head and neck diseases, 2014

Twenty-five cases of airway fire during tracheostomy have been reported in the literature. The authors describe a case observed in their centre 3 years ago, discuss the causes and preventive management and propose guidelines for prevention of this complication. A 66-year-old woman was intubated and ventilated with 100% oxygen during general anaesthesia for tracheostomy. On opening the trachea by monopolar diathermy, the oxygen present in the endotracheal tube caught fire, inducing combustion of the tube spreading to the lower airways. This airway fire was responsible for severe acute respiratory failure and the formation of multiple laryngotracheal stenoses. Combustion of the endotracheal tube due to ignition of anaesthetic gases induced by the heat generated by diathermy is responsible for airway fire. These various phenomena are discussed. Prevention is based on safety measures and coordination of surgical and anaesthetic teams.

Chang Gung Medical Journal, 2005

Some surgeries, a tracheostomy and oral surgeries in particular, have a higher risk of fire. Often it can occur when leaking flammable gas contacts an ignition heat source. Fire during a tracheostomy can sometimes be seen to produce different degrees of insult to the patient. The essential components of a fire, i.e., the fuel source, ignition, and an oxidizer, can be avoided or blocked in order to prevent fires from occurring. Herein, we discuss a fire during a tracheotomy, and ways to avoid its occurrence, and how to stop once it gets started. This case demonstrates 2 important points regarding tracheostomies. First, extreme caution should be exercised when cautery is used in an approximately 100% oxygen gaseous condition, and second, immediate extubation is not absolutely necessary if a fire breaks out during a tracheostomy. The procedures which can be taken when facing this type of emergency are also considered and discussed.

ANZ Journal of Surgery, 2006

We report a case of airway fire during surgical tracheotomy using diathermy for the incision into the trachea. A literature review of airway fire during tracheotomy was carried out, and the management of airway fire is discussed. Recommendations are made to prevent this adverse outcome.

Ear, Nose & Throat Journal, 2002

Electrosurgery in the presence of volatile anesthetic gases has been associated with operating-room fires. We report a case in which an operating-room fire occurred while an intubated patient underwent electrosurgical tracheostomy. The fire in this case was caused by a combination of an oxygen-rich environment, a polyvinyl chloride tube, and heat generated by an electrosurgical unit. We also discuss factors that increase the risk of this type of fire and the management steps that should be undertaken in the event that such afire occurs, and we briefly review the literature on this subject.

Acta Anaesthesiologica Scandinavica, 2007

A 45-year-old man needed emergency tracheostomy and cranioplasty. He was intubated with a cuffed oral polyvinylchloride endotracheal tube and ventilated with 100% oxygen before tracheal incision. During opening of the trachea using diathermy, a popping sound was heard and flames originating from the tracheal incision were observed. The endotracheal tube was charred and its lumen had melted. Immediately after the incident, bronchofibroscopic examination revealed inhalation injury. After remaining for 8 weeks in hospital, the patient was transferred to a health care centre, where he was found dead in his bed.

International Journal of Pediatric Otorhinolaryngology, 2011

Airway fires are a well-described and potentially devastating complication of oropharyngeal surgery. However, the actual factors required to ignite the fire have never been well-delineated in the medical literature. In this study, we used a mechanical model to assess the oxygen parameters necessary to cause an oropharyngeal fire.An electrosurgical unit (Bovie) was grounded to a whole raw chicken and a 6.0 endotracheal tube (ETT) was inserted into the cranial end of the degutted central cavity. Oxygen (O2) was then titrated through the ETT tube at varying concentrations, with flow rates varying from 10 to 15 L/min. Electrocautery (at a setting of 15 W) was performed on tissue in the central cavity of the chicken near the ETT. All trials were repeated twice to ensure accuracy. Positive test results were quantified by the time required to obtain ignition of any part of the mechanical setup and time required to produce a sustained flame. A test was considered negative if no ignition could be obtained after four minutes of direct electrocautery.At an O2 concentration of 100% and a flow rate of 15 L/min, ignition with a sustained flame was obtained between 15 and 30 s after initiation of electrocautery. At 100% O2 at 10 L/min, ignition was obtained at 70 s with immediate sustained flame. At an O2 concentration of 60%, ignition occurred at 25 s and sustained fire after 60 s. At an O2 concentration of 50% ignition with a sustained flame occurred between 128 and 184 s. At an O2 concentration of 45%, neither ignition nor sustained flames could be obtained in any trial.Operating room fires remain a genuine danger when performing oropharyngeal surgery where electrocautery is performed in an oxygen-enriched environment. In our study, higher O2 flow rates with higher FiO2 correlated with quicker ignition in the chicken cavity. A fire was easily obtained when using 100% O2; as the O2 concentration decreases, longer exposure to electrocautery is required for ignition. Below 50% O2 we were unable to obtain ignition. Our study is the first to examine the relative risk of ignition and sustained fire in a mechanical model of oropharyngeal surgery. Decreasing the fraction of inspired O2 (FiO2) to less than 50% may substantially decrease the risk of airway fire during oropharyngeal surgery.

In June 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommended: "As a general policy, use air or Fio 2 at Յ30% for open delivery (consistent with patient needs)" to prevent surgical fires. One way to interpret JCAHO's recommendation is that 100% O 2 should not be indiscriminately used, and anesthesia providers should have the ability, consistent with patient needs and their clinical judgment, to deliver sub-100% O 2 with nasal cannulae. An auxiliary O 2 flowmeter has a barbed outlet connector that offers a convenient means to connect a cannula to an anesthesia machine and is routinely used for open delivery of 100% O 2 . The auxiliary O 2 flowmeter provides only 100% O 2 and thus does not allow titration of the O 2 concentration to patient needs and may increase the risk of surgical fires. This report clarifies the JCAHO recommendation and describes different means of addressing it that are based primarily on using the anesthesia machine to blend a sub-100% O 2 gas mixture and delivering it via a nasal cannula. The options presented depend on the model and manufacturer of the anesthesia machine and allow delivery via nasal cannula of O 2 concentrations that range from 21% to 100%.

Proceedings of Singapore Healthcare, 2015

Introduction: The fire triangle comprises the ignition source, fuel and oxidizer which is necessary for the initiation of fire. Most surgical fires occur in an oxygen-enriched environment. We report a case of surgical fire in ambient air where an alcohol-based antiseptic was involved. Case report: A 20-year-old male diagnosed with left pleural empyema and respiratory failure, requiring emergent intubation and respiratory support, was brought into the operating theatre for decortication of the left lung. Shortly after induction, the patient desaturated despite 100% oxygen and lung recruitment manoeuvres. The surgical team decided to insert a chest tube emergently to drain the empyema to improve respiratory function. A non-functioning drainage catheter that was in situ was removed and placed on the operating table beside the patient. Skin was prepared using chlorhexidine gluconate 0.5% w/v in methylated spirit solution and iodine. Soon after, cotton drapes were used to cover the patient. After the initial incision for chest tube insertion, electrocautery was introduced. Smoke and a smell of something burning was immediately noted by the surgical team. The drapes were removed and the drainage catheter with a burnt tip was discovered beside the patient. The patient suffered second degree burns to his chest wall. Conclusion: Although it is more common for surgical fires to occur in an oxygen-enriched environment, this case highlights that without adequate precautions they can also occur in ambient air. Recognition that standard anaesthetic and surgical equipment can act as sources of fuel and vigilance for the circumstances that complete the fire triangle are key to the prevention of surgical fires.

Korean Journal of Anesthesiology, 2012

Every operation could have a fire emergency, especially in the case of a tracheostomy. When a flammable gas meets a source of heat, the danger of fire is remarkable. A tracheal tube filled with a high concentration of oxygen is also a great risk factor for fire. Intra-tracheal tube fire is a rare, yet critical emergency with catastrophic consequences. Thus, numerous precautions are taken during a tracheostomy like, use of a special tube to prevent laser damage, ballooning of the tube with normal saline instead of air, and dilution of FiO 2 with helium or nitrogen. Since the first recorded cases on tube fires, most of the fires were initiated in the balloon and the tip. In the present case report, however, we came across a fire incidence, which originated from the wire. (Korean J Anesthesiol 2012; 63: 157-160)

American Journal of Thoracic and Cardiovascular Surgery 2017, 2017

The electric scalpel operates on high values of electric current and tension, which leads to spark formation, exposing the staff to risks. Combustion depends on three elements: fuel, oxidant and ignition. The fuel is represented by the endotracheal tube (ET), composed by a material named polyvinyl chloride (PVC). The oxidant is represented by the oxygen. The ignition occurs when the electric scalpel, laser or diathermic loop are activated. The anesthesiologist plays a crucial role in the prevention and management of crises in the operating room.