Management Protocol for Airway Fire During Surgery
When an airway fire occurs, immediately remove the tracheal tube, stop all airway gases, remove burning materials from the airway, and pour saline or water into the patient's airway—all as fast as possible without waiting for sequential completion of tasks. 1
Immediate Recognition and Response
Early Warning Signs
Halt the procedure immediately if you detect any of the following: 1
- Unusual sounds ("pop, snap, or foomp")
- Unusual odors
- Unexpected smoke or heat
- Discoloration of drapes or breathing circuit
- Unexpected flash or flame
- Unexpected patient movement or complaint
Fire Confirmation Actions
When fire is definitely present, announce "FIRE" immediately, halt the procedure, and initiate fire management tasks without delay. 1
Airway Fire Protocol (Execute as Fast as Possible)
The ASA Task Force emphasizes that team members should not wait for each other to complete tasks sequentially—speed is critical to prevent the "blowtorch effect" where continued gas flow through a burning tube spreads fire and causes additional burns. 1
Four Critical Steps for Airway Fire:
Remove the tracheal tube immediately 1
Stop the flow of all airway gases (disconnect breathing circuit at Y-piece or inspiratory limb) 1
Remove all flammable and burning materials from the airway 1
Pour saline or water into the patient's airway to extinguish residual embers and cool tissues 1, 2
Post-Extinguishment Management
If Fire is Successfully Extinguished:
Ventilation: 1
- Reestablish ventilation by mask
- Avoid supplemental oxygen and nitrous oxide if possible to prevent reignition
- Extinguish and examine the removed tracheal tube to assess whether fragments remain in the airway
- Perform bronchoscopy (preferably rigid) to:
- Look for tracheal tube fragments
- Assess extent of thermal injury
- Remove residual debris
Ongoing Monitoring: 2
- Monitor for progressive airway edema (can develop over hours)
- Assess for signs of smoke inhalation: soot on face, dysphonia, dyspnea, wheezing, blackish sputum
- Monitor oxygen saturation continuously
If Fire Persists After Initial Attempts:
- Use a carbon dioxide fire extinguisher in, on, or around the patient 1
- If fire continues despite CO2 extinguisher, activate emergency evacuation protocols 1
Critical Pitfalls to Avoid
The "Sequential Delay" Trap: The most dangerous error is waiting for team members to complete tasks in order. The ASA Task Force found that 71% of consultants prefer predetermined sequences, but emphasizes that team members must act immediately without waiting, as delays can allow the blowtorch effect to cause catastrophic injury. 1
Delayed Intubation After Fire: Do not delay reintubation if the patient develops severe hypoxia, hypercapnia, altered mental status, or signs of airway obstruction after the fire is extinguished. 2
Inadequate Airway Inspection: Failure to perform bronchoscopy risks leaving tube fragments in the airway or missing the extent of thermal injury. 1, 2
Premature Oxygen Reintroduction: Restarting high-flow oxygen too quickly can reignite smoldering materials—use room air or minimal oxygen when reestablishing ventilation. 1
Prevention Through Team Preparation
Pre-procedure planning is essential: 1
- Participate in periodic OR fire drills with the entire team
- During the surgical pause, assess if a high-risk situation exists (head/neck surgery, open oxygen delivery, use of electrocautery or laser)
- Assign each team member a specific fire management task in advance
- Ensure all team members understand they must act immediately without waiting for others
High-risk situations requiring heightened vigilance: 1, 3, 4
- Laser surgery of the airway
- Electrocautery during pharyngeal surgery or tracheostomy
- Open oxygen delivery systems (create oxidizer-enriched atmosphere)
- Head and neck procedures where all three elements of the fire triad are present (fuel, oxidizer, ignition source)