An airway fire occurs within a patient’s airway or respiratory tract during a medical procedure. While uncommon, these events are a serious complication that happens almost exclusively in the operating room. This environment is where the specific elements needed to start a fire can come together in a small, controlled space.
The Fire Triad in the Operating Room
For any fire to start, three elements must be present: an oxidizer, a fuel, and an ignition source. In the operating room, these components of the “fire triad” are often brought into close proximity. The oxidizer is an oxygen-enriched atmosphere created by supplemental gases. While air is about 21% oxygen, medical procedures can require concentrations up to 100%, and nitrous oxide can also act as an oxidizer.
This oxygen-rich environment lowers the ignition temperature for many materials, making them fire hazards. Common fuel sources include the endotracheal tube, surgical sponges, alcohol-based skin prep, and the patient’s own tissues or hair. Many of these materials are not flammable in normal air but become hazardous in high oxygen concentrations.
The final component is an ignition source. During surgery, these are most often electrosurgical tools used for cutting tissue and controlling bleeding. Other potential ignition sources include surgical lasers, heated probes, and high-intensity fiber-optic light sources. When one of these heat sources is activated near a fuel in an oxygen-rich environment, the conditions for a fire are met.
High-Risk Surgical Scenarios
The risk of an airway fire is not uniform across all procedures and is higher when the fire triad elements are concentrated. Surgeries involving the head, neck, face, and upper chest are high-risk because an ignition source is used close to the patient’s airway. Examples of such procedures include tonsillectomies, tracheotomies, and certain oral surgeries.
In these scenarios, an anesthesiologist delivers an oxygen-rich mixture through a breathing tube or mask while a surgeon works nearby with a tool like an electrocautery device. This places the ignition source centimeters away from both a potent oxidizer and a fuel source like the plastic breathing tube.
A leak in the cuff of an endotracheal tube can allow oxygen to escape into the surgical field, increasing the danger. The combination of an open oxygen delivery system, such as a nasal cannula, with surgery above the chest is a common factor. Surgical drapes can also trap these gases, creating a pocket of highly flammable atmosphere at the surgical site.
Prevention and Team Communication
Preventing airway fires relies on the coordinated efforts of the surgical team, including the surgeon, anesthesiologist, and nurses. A primary practice is conducting a fire risk assessment before the procedure to identify and discuss potential hazards.
Carefully managing the oxidizer concentration is an effective strategy. This involves using the lowest oxygen level safe for the patient, ideally below 30%, and discontinuing nitrous oxide when an ignition source is active. The anesthesiologist may also temporarily halt all gas flow before a high-energy tool is used near the airway.
Other preventative measures target the fuel and ignition sources:
- Allowing flammable alcohol-based skin prep solutions to dry completely before placing drapes.
- Keeping sponges and gauze used near the surgical site moist with saline.
- Using specialized laser-resistant endotracheal tubes for certain procedures.
- Filling the cuffs of these tubes with saline to help extinguish a fire if the tube is punctured.
Managing an Active Airway Fire
If an airway fire occurs, surgical teams follow an emergency protocol to minimize harm. The response focuses on dismantling the fire triad as quickly as possible, with steps executed almost simultaneously by the team.
The first action is to stop the flow of all gases to the patient’s airway, which removes the oxidizer. Simultaneously, the burning item, usually the endotracheal tube, must be removed from the airway. These two steps are the foundation of managing the emergency.
After the tube is removed and gas flow is stopped, any remaining fire is extinguished by pouring sterile saline or water into the airway. Once the fire is out, the team’s priority shifts to re-establishing a safe airway. They will then assess the extent of the burn injury and provide respiratory support.