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Airway fire: extensive literature review and practice recommendations

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Airway fire: extensive literature review and practice recommendations

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Content Running head: AIRWAY FIRE

Airway Fire: Extensive Literature Review and Practice Recommendations

by

Justin M. Santa Ana

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2020

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The following manuscript was contributed to in equal parts by Timothy J. Bowman, Maria N.
Marshall, and Justin M. Santa Ana

AIRWAY FIRE iii
Dedication
We would like to dedicate this work to all the healthcare professionals (CRNAs, RNs,
surgeons, anesthesiologists, and OR technicians) and patients who have witnessed, participated
in, or suffered from a surgical or airway fire. We hope our work inspires current and future
providers in the operating room to become knowledgeable in the prevention and management of
airway fire, with the goal of providing patients a safe surgical experience.

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Acknowledgements
We would like to thank the faculty of the Program of Nurse Anesthesia for their
continuous support and providing an opportunity for us to grow individually and professionally.
To our advisors, Dr. Griffis and Dr. Bamgbose, thank you for your guidance and constant
encouragement; your dedication ensured our success. To our program director, Dr. Gold, thank
you for all you have done for us and our entire class. We are humbled to be the first graduating
Doctor of Nursing Anesthesia Practice class of not only USC but the entire state of California.
To all our nurse anesthetist and anesthesiologist preceptors, thank you for your time and patience
and for molding us into amazing anesthesia providers. To our awesome DNAP classmates of
2020: WE DID IT!
To our parents, family, friends, and significant others, thank you for putting up with us
and always being there. We know this has not been easy for all of you, especially with our
constant mood swings, exhaustion, and lack of presence. We love you and appreciate everything
you have done for us.

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Table of Contents
Dedication ...................................................................................................................................... iii

Acknowledgements ........................................................................................................................ iv

List of Tables ................................................................................................................................. vi

List of Figures ............................................................................................................................... vii

Abstract ........................................................................................................................................ viii

Chapter 1: Overview ....................................................................................................................... 1
Clinical Significance ................................................................................................................... 1
Specific Aims .............................................................................................................................. 4
Background ................................................................................................................................. 4

Chapter 2: Literature Review .......................................................................................................... 7
Identification of High Fire-risk Surgeries ................................................................................... 7
Oxidizers ..................................................................................................................................... 8
Ignition ...................................................................................................................................... 16
Fuel ............................................................................................................................................ 18
Interactions of Laser Ignition Sources with Fuels ..................................................................... 19
Management .............................................................................................................................. 23

Chapter 3: Methods ....................................................................................................................... 27

Chapter 4: Discussion ................................................................................................................... 28
Prevention .................................................................................................................................. 28
Management .............................................................................................................................. 30

Chapter 5: Conclusion ................................................................................................................... 33

References ..................................................................................................................................... 34

Appendix A: Practice Recommendations ..................................................................................... 43
Prevention of Airway Fire ......................................................................................................... 43
Management of Airway Fire ..................................................................................................... 44

Appendix B: Practice Recommendations Chart ........................................................................... 47

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List of Tables
Table 1. Historical surgical and airway fire advisories ................................................................. 49

AIRWAY FIRE vii
List of Figures
Figure 1: Christiana Fire Risk Assessment Tool ............................................................................ 7

AIRWAY FIRE viii
Abstract
A significant adverse, although preventable, event that anesthesia providers must be
prepared for is airway fire. Initiation of an airway fire requires the three essential components of
a fire triad: oxidizer, ignition source, and fuel. Procedures with the highest risk of airway fire are
those in which the three components of the fire triad come into proximity, specifically
otolaryngological surgeries. Despite the availability of various practice recommendations
detailing the prevention and management of surgical fires, in general, current literature lacks
practice recommendations specific to airway fire. This extensive literature review examines the
incidence of airway fire and synthesizes currently available evidence into succinct practice
recommendations outlining airway fire risk assessment as well as the prevention and
management of airway fires to enhance the safety margin of anesthetic care of patients
undergoing procedures at high risk for airway fire.

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Chapter 1: Overview
Airway fire is a potentially devastating, yet preventable, anesthetic complication
providers must be prepared to manage. Various respected organizations associated with nursing,
anesthesia, surgery, otolaryngology, and healthcare quality have established recommendations
regarding the prevention and management of surgical and airway fires. However, the available
recommendations are largely centered around surgical fires and not well developed with regards
to airway fire prevention and management. The continued prevalence of airway fire, a
preventable event, despite the availability of several recommendations indicates a need for a
standardized, evidence-based policy specifically addressing causative factors, prevention
methods, and the appropriate steps to take in the event of an airway fire. This literature review
will address airway fire prevention and management; the evidence will be synthesized into
practice recommendations to enhance the safety margin of patients undergoing procedures at
high risk for airway fire.
Clinical Significance
Surgical fire (airway or non-airway related) is a relatively rare event. According to data
from various publications, out of the combined 50 million inpatient and outpatient surgeries
performed annually, the number of reported surgical fires, which includes airway fires, ranges
from 50 to 650 per year, with 20 to 30 resulting in severe patient injury and 1 to 2 resulting in
death (Akhtar, Ansar, Baig, & Abbas, 2016; Association of periOperative Registered Nurses
[AORN], 2006; Bruley, 2004; Cowles, 2017; the Joint Commission [JC], 2015; Mehta,
Bhananker, Posner, & Domino, 2013; Remz et al., 2013; Rinder, 2008; Roy & Smith, 2019;
Ward, 2017). A more exact estimate of surgical or airway fire incidence is difficult to define
because the United States has neither a federal decree mandating the report of surgical fires nor a
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centralized database tracking these events (Kaye, Kolinsky, & Urman, 2014). Only a minority of
states require the reporting of surgical fires and most surgical or airway fire cases are reported
only when significant patient harm or fatality has occurred (Rinder, 2008).
An airway fire has the potential to cause severe injury to the mucosa of the upper and
lower tracheobronchial tree, lungs, and surrounding tissue. These airway injuries can lead to
infection, fluid and electrolyte imbalances, heat loss, life-threatening airway obstruction,
inhalational injury, and pulmonary infiltration from toxins released by burning materials, such as
the plastic endotracheal tube [ETT] (Ward, 2017). Additionally, airway fires can result in
superficial burns, disfigurement, and death (U.S. Food and Drug Administration [FDA], 2018).
The surviving patient may require acute treatment in the intensive care unit (ICU) and surgeries
to treat burn injuries and revise scar tissue (Conway, Federico, Stewart, & Campbell, 2011).
Additional injuries, prolonged hospitalization, and lost time from work cause the patient
unnecessary anxiety, stress, and economic burden (Cowles, 2017; Pollock, 2004).
The result of an airway fire has severe legal and economic consequences for the
anesthesia provider as well as the surgical team and facility (Conway et al., 2011). A patient in
Washington state received $30 million as a result of severe airway fire injuries and the
anesthesiologist, surgeon, and hospital each paid multimillion-dollar sums (Cowles, 2017).
According to Mehta et al. (2013), patients received payments in 78% of surgical fire claims
between 1985 and 2009 with a median payout of $120,166. Anesthesia care was judged as
substandard in 51% of these claims. In fact, research by Yardley & Donaldson (2010) shows
17% of anesthesia malpractice claims are related to surgical fire.
In response to the continued prevalence and potentially devastating effects of surgical and
airway fires, several organizations have published recommendations regarding fire prevention
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and management strategies (summarized in the table found in Appendix A). The earliest
recommendations available in the literature were published by the Emergency Care Research
Institute (ECRI) in 1979, which discussed the fire risk associated with high oxygen (O2)
concentrations during head and neck surgery and how to minimize these hazards. In 1996, the
National Fire Protection Association enacted healthcare facility code 99, a set of requirements
based on risk of injury to patients, staff, and/or visitors in healthcare facilities which minimizes
the hazards of surgical fire and details the steps to take should one occur. In 2003, the Joint
Commission (JC), formerly the Joint Commission on Accreditation of Healthcare Organizations,
not only published a sentinel event alert addressing the need for vigilance and the prevention of
surgical fires, but also announced surgical fire prevention as a national patient safety goal (JC,
2003).
The first recommendations specific to airway fire were released by the Pennsylvania
Patient Safety Reporting System (PA-PSRS) in 2007 and discuss the causative mechanisms of
airway fire and how to prevent and manage this event. The following year, the American Society
of Anesthesiologists (ASA) Task Force on Operating Room (OR) Fires issued a practice
advisory, with an update in 2013, providing evidence for surgical and airway fire prevention and
management strategies. In 2010, the Anesthesia Patient Safety Foundation (APSF) released an
18-minute video regarding fire safety in the OR and a Fire Prevention Algorithm outlining OR
fire prevention strategies. The U.S. Food and Drug Administration (FDA), partnering with the JC
and the American College of Surgeons (ACS), launched a patient safety initiative in 2011 which
updated the definition of surgical fire - “fire, flame, or unanticipated smoke, heat, or flashes
occurring during an episode of patient care” - and marked surgical fire as a sentinel event, even if
the fire is extinguished without harm to the patient (JC, 2015). The initiative emphasized surgical
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fire prevention and encouraged providers to report all surgical fires to the JC and to MedWatch,
the FDA safety information and adverse event reporting program. While surgical fires are not
subject to mandatory reporting, the JC sentinel event policy requires a comprehensive systematic
analysis be conducted in all instances of fire to determine how the event happened and what can
be done to prevent recurrence (JC, 2015). Roy and Smith (2019) recommend reporting surgical
and airway fires not only to the JC and FDA, but also the ECRI and state agencies to raise
awareness of the danger of these fires and help prevent future occurrences.
Specific Aims
Despite the existence of various practice recommendations outlining airway fire
prevention and management, many healthcare institutions have yet to formally adopt them into
department policy. As a result, this preventable yet devastating adverse event continues to occur.
Therefore, the specific aims of this paper are to:
1. Investigate the current reported incidence of airway fire during anesthesia care.
2. Review and synthesize current literature regarding airway fire as related to anesthesia
care.
3. Provide current practice recommendations for preventing and managing airway fires.
Background
As defined by the ASA Task Force on OR fires, an OR fire is a blaze, or destructive
burning, that occurs on or near a patient in a surgical suite, while a surgical fire is a type of OR
fire that occurs in or on the patient (Apfelbaum et al., 2013). An airway fire is a type of surgical
fire occurring within a patient’s airway, airway device, or breathing circuit (Ward, 2017).
Fire, defined as “the initiation and continuance of combustion, is a complex set of
chemical reactions resulting in the rapid oxidation of a fuel producing heat, light, and a variety of
AIRWAY FIRE 5
chemical by-products” (Day et al., 2018). Initiation of a fire requires 3 components - oxidizer,
ignition or heat source, and fuel – making up the fire triad, also known as the fire triangle
(Yardley & Donaldson, 2010). Fuel is any substance that can undergo combustion. An oxidizer
acquires electrons from reducing agents (fuel molecules) to oxidize them; the most common
oxidizer is O2. Heat refers to the minimum energy source necessary to sufficiently increase
oxidation-reduction reaction rates, release fuel vapors, and cause ignition (Nyalis, 2009).
Historically, the risk of OR, and thus airway, fires was much higher because the more
commonly administered volatile anesthetic gases, such as ether and cyclopropane, were highly
flammable. In 1941, the American Association of Anesthesiologists, which later became the
ASA, reported a series of 230 anesthetic-associated fires and explosions in the OR. During this
era, prevention of OR and airway fires was considered the responsibility of anesthesia providers
because they managed the highly flammable anesthetic gases. While the replacement with less
flammable anesthetic gases in the 1970s reduced the likelihood of OR and airway fires, this
change also provided a false sense of security as the risk of fire was not completely eradicated
(Yardley & Donaldson, 2010). Case reports from the early 1990s revealed a lack of fire
education resulting in patient mortality (ECRI, 1994; Stouffer, 1992).
Although airway fires are rare, advancements in surgical practice over the past few
decades and increasing utilization of electrocautery units (ECUs) and surgical lasers, especially
in otolaryngological surgeries, continues to pose airway fire risk (Yardley & Donaldson, 2010).
As described above, an airway fire requires the presence of the 3 essential elements of the fire
triad - oxidizer, ignition source, and fuel - which are in proximity during otolaryngological
procedures (Roy & Smith, 2019). In a survey of 349 otolaryngologists conducted by Smith and
Roy (2011), 88 respondents (25%) reported having experienced a surgical fire during their
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career, 69% of which involved the airway. Similarly, in a systematic review by Day, Rivera,
Farlow, Gourin, & Nussenbaum (2018), airway fires were reported in 72% of the 87
otolaryngological cases reviewed. In both studies, the authors identified endoscopic
laryngotracheal or oropharyngeal procedures and tracheostomies as the most common
procedures where airway fire occurred. Otolaryngological procedures are high fire-risk surgeries
because the simultaneous presence of all three fire elements is unavoidable (Ward, 2017). A
high-fire risk surgery involves the use of an ignition source (ECU or laser) in the presence of an
oxidizer-enriched atmosphere (OEA), which is defined as an O2 concentration > 21% or any
combination of O2 and N2O (Apfelbaum et al., 2013; ECRI, 1992).
The components of the fire triad are interdependent and thus, fire risk can be eliminated
when one of them is removed. Each member of the OR team - nurse, anesthesia provider, and
surgeon - typically supplies one component of the fire triad. The anesthesia provider manages
oxidizers, the surgeon controls the ignition source, and the nurse supplies the fuel. Since the
anesthesia provider and surgeon must share the airway during otolaryngological procedures,
heightened vigilance is necessary to prevent an airway fire (Matioc, 2018; Pollock, 2004). Day et
al. (2018) found the most common oxidizer, ignition, and fuel source responsible for initiating
airway fires in otolaryngological procedures were O2 (99% of cases), ECUs and carbon dioxide
(CO2) lasers (94% of cases), and ETTs (49% of cases), respectively. As the airway expert,
anesthesia providers have an increased responsibility in managing all elements of the fire triad;
consequently, they are often tasked with identifying high-fire risk procedures, minimizing fire
risk, and directing airway fire management should one occur (Ward, 2017).
AIRWAY FIRE 7
Chapter 2: Literature Review
Identification of High Fire-risk Surgeries
A fire risk assessment tool, such as the Christiana Fire Risk Assessment Tool (Figure 1)
and Silverstein Fire Risk Assessment Score, can be used during time out in the preoperative
holding area or in the OR to help stratify the risk level of a fire event based on the type of
surgery and the materials to be used during the procedure (Roy & Smith, 2019).
Figure 1
Christiana Fire Risk Assessment Tool

Note: This is a section of a form from Christiana Care Health Services. (n.d). Universal Protocol and Fire Risk
Assessment - Bedside Procedure. Retrieved December 10, 2019 from
https://christianacare.org/documents/firesafety/Universal%20Protocol%2DFire%20Risk%20Assessment%2
0%20Bedside%20Procedure%20%2D%20firesafety.pdf

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The scale ranges from 0 (very low risk) to 3 (high risk), with a score of 2 indicating low fire-risk
that has the possibility of turning into a high fire-risk. A point is allotted for each of the
following: surgical site above the xiphoid, open O2 source or increased supplemental O2 use, and
use of an ignition source such as an ECU or surgical laser (ECRI, 2009). While fire risk
assessment tools exist, to date none have been validated. The ASA Task Force on OR fires found
insufficient literature to support the efficacy of preoperative assessment of surgical fire risk and
discussion of a fire response strategy in reducing the incidence or severity of a surgical or airway
fire (Apfelbaum et al., 2013). However, in the most recent analysis performed by Bruley et al.
(2018), the PA-PSRS found a decrease in surgical fire occurrence from 10 to 5.6 fires per year
from 2012 to 2016 – a 44% reduction. Additionally, the authors found a decrease in surgical fire
prevalence from 0.83 to 0.24 per 100,000 OR procedures from 2004 to 2016, representing a
statistically significant (p < 0.001) reduction in surgical fires of 71%. The authors attributed this
reduction to the efforts of the PA-PSRS and other aforementioned medical organizations, which
includes the implementation of fire-risk assessment tools.
Oxidizers
The main oxidizers of airway fire are O2 and nitrous oxide (N2O). O2 is the most common
oxidizing agent and has been found to be involved in 95% of all electrocautery fires (Mehta et
al., 2013). Day et al. (2018) reviewed 64 general anesthesia cases to assess the surgical fire risk
associated with each element of the fire triad, of which 39 used O2 alone. Thirty-six of the cases
reported using a fraction of inspired O2 (FiO2) between 30% and 100%, 27 of which (75%) used
an FiO2 of 100%, and 97% of which used an FiO2 > 30%. N2O alone is not considered an
oxidizer, but can decompose when heated, releasing O2 and increasing the ambient O2
concentration (Kaye et al., 2014).
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Flammability is defined as the ability of a fuel to sustain a flame in a given atmosphere
(Wolf & Simpson, 1987). In a quasi-experimental study, Simpson, Wolf, Rosen, Respi, and
Schiff (1991) examined the flammability of ETTs made of 3 different materials - polyvinyl
chloride (PVC), silicone (Si), and red rubber (RR) - in various mixtures consisting of O2 alone,
N2O alone, and a mixture of O2 and N2O, diluted in nitrogen (N2), to determine the minimum O2
and N2O concentrations required to support a candle-like flame using a laser ignition source. The
authors found N2O alone and a mixture of O2 and N2O supported the flammability of all 3 types
of ETTs regardless of the ignition source. Additionally, the study found that none of the ETT
materials supported combustion in O2 concentrations < 25% and the most important factor in
avoiding combustion of any given ETT was the concentration and combination of oxidizers.
Anesthesia providers control anesthetic gases and thus are primarily responsible for
managing airway fire oxidizers. Supplemental O2 or N2O administered via a closed or semi-
closed breathing circuit is often delivered at high concentrations, creating an OEA within the
breathing apparatus and the patient’s airway and increasing the risk of fire and intensity of
combustion (Kaye et al., 2014). Roy and Smith (2011) conducted a study using an animal model
to measure the minimum concentration of O2 required to ignite and support an airway fire using
a monopolar ECU. O2 was titrated through a 6.0 millimeter (mm) PVC ETT at varying
concentrations (40%, 45%, 50%, 60%, and 100%) and flow rates (10 to 15 liters per minute
[L/min]). The monopolar ECU was placed in the cavity near the ETT tip and cauterized at 15
watts (W). With 100% FiO2 flowing at 15 L/min, the ECU immediately created a high fire-risk
environment and ignition occurred within 15 seconds. Decreasing the O2 flow rate and FiO2
increased the time to ignition; no ignition occurred with an FiO2 of 45% and 40%. The authors
stated the major disadvantage of the study was placing the ETT tip into a cavity, in which O2
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flowed freely, instead of into a narrow tube (such as the trachea), which would allow for
retrograde O2 flow from the larynx back into the oral cavity. The authors concluded using an
FiO2 < 50% likely eliminates the risk of airway fire during analogous oropharyngeal surgery
when using a monopolar ECU at 15 W. Therefore, the authors recommend administering the
lowest FiO2 possible to safely maintain patient physiologic stability.
In another study performed by Roy and Smith (2015a), the authors developed a
mechanical model using a mannequin to assess the combustion of the 5.0 XoMed Laser Shield®
laser safe tube (LST) under varying concentrations of FiO2 at a flow rate of 6 L/min. The
protected, metal-reinforced shaft of the LST can prevent fire formation in an OEA, but the
unprotected distal tip of the LST may still ignite when struck by an ignition source. The authors
intentionally perforated the cuff of the LST using a laser in O2 concentrations of 100%, 40%,
29%, and 21%. Immediate ignition of a sustained flame occurred at an FiO2 of 100%. With an
FiO2 of 40%, it took approximately 2 seconds to develop a sustained flame. In both trials,
significant damage was noted in the airway of the mannequin. With an FiO2 of 29%, a visible
flame was reported but not sustained and with no blow torch effect. The flame melted the plastic,
but no significant damage was noted within the airway. With an FiO2 of 21%, no flame was
created after cuff perforation. In conclusion, the authors recommend avoiding inadvertent cuff
perforation and minimizing FiO2 to allow adequate time to recognize an airway fire should one
occur.
Mattucci and Milatana (2003) designed a prospective study of 25 pediatric patients
undergoing tonsillectomy and/or adenoidectomy to evaluate airway fire risk when using an
uncuffed ETT with an ECU by measuring O2 and N2O concentrations at the tonsillar fossa. The
authors selected the appropriately sized uncuffed ETT, ranging from 4.5 to 6.5 mm, based on
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either the patient’s age (tube size = [age +16]/4) or the patient’s weight, depending on the
anesthesia provider’s clinical evaluation. After induction and intubation, anesthesia was
maintained with 2% to 3% sevoflurane and O2 or N2O flowing at 2 L/min. FiO2 and FiN2O were
measured within the anesthesia circuit. Air leak pressures were determined by auscultation over
the trachea as the pressure was increased using the adjustable pressure-limiting valve. The FiO2
delivered to the participants ranged from 31% to 61% and FiN2O ranged from 37% to 62%.
Although not reported or statistically evaluated by the authors, the raw data showed 46% of
participants (n=14) had O2 concentrations > 30% within the tonsillar fossa. In the 10 cases (40%)
with air leak pressures ≥ 12 centimeters of water (cmH2O), O2 concentrations measured at the
tonsillar fossa did not exceed 30%, while air leak pressures < 12 cmH2O (n=15, 60%) resulted in
O2 concentrations of 22% to 57%. No airway fires occurred during this study; the authors
concluded that using an ECU appears to be safe in oropharynx and hypopharynx procedures
when patients are intubated with appropriately sized uncuffed ETTs and airway leak pressures >
12 cmH2O, in effect minimizing the O2 and N2O concentrations at the surgical site.
Conversely, in a case study reported by Akhtar, Ansar, Baig and Abass (2016), an airway
fire occurred during a routine adenotonsillectomy in an 8-year-old male. The anesthesia provider
reportedly intubated the patient using an uncuffed 5.5 mm PVC ETT. A leak around the ETT in
the oropharynx was noticed, but a throat pack was inserted to reduce the leak and the surgery
continued. The patient was spontaneously breathing a mixture of O2 and N2O (50:50) at 3 L/min
each. The surgery was uneventful until a spark occurred when the surgeon used a bipolar ECU to
cauterize a small bleed at the base of the right tonsil, causing the ETT to catch fire. Normal
saline was poured on the fire and the ETT was immediately removed. After suctioning the
oropharynx, the anesthesia provider re-intubated the patient, who recovered and was discharged
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the next day. The authors concluded that the leak created by the uncuffed ETT, despite the
placement of the throat pack, contributed to airway fire development by increasing the O2
concentration within the oropharynx. Therefore, they recommend using cuffed ETTs whenever
possible during oropharyngeal procedures to prevent accumulation of O2 in the surgical site.
Similarly, in a case study by Kaddoum, Chidiac, Zestos and Ahmed (2005), ECU-
induced fires occurred during two adenotonsillectomies. In the first case, a 7-year-old male was
induced by inhalation of O2, N2O, and sevoflurane. After the insertion of an intravenous (IV)
line, the patient received fentanyl 75 micrograms (mcg) and propofol 40 milligrams (mg). An
uncuffed 6.0 mm oral Ring, Adair, and Ewlyn (RAE) ETT was inserted and no leak was noted at
the time. A leak developed after repositioning the patient, but the anesthesia provider continued
administering 100% FiO2 to facilitate return of spontaneous ventilation and minimize the leak.
Within seconds of monopolar ECU use, a loud “pop” was heard, and a flame was seen on the
tonsillar tissue. The ECU was removed, supplemental O2 was discontinued, and the fire was
extinguished immediately. After a careful airway examination, no excessive damage was noted
and the ETT was found to be intact. Regardless, the ETT was replaced with a 5.5 mm cuffed oral
RAE ETT, and the surgery continued uneventfully. In the second case, a 5-year-old male was
induced by inhalation of O2, N2O, and halothane. After placement of an IV line, the patient
received fentanyl 25 mcg. The anesthesia provider inserted a 4.5 mm uncuffed oral RAE ETT
and maintained anesthesia using O2, N2O and sevoflurane. A leak around the ETT was noted and
the ventilator bellows required an increased fresh gas flow (FGF) to maintain appropriate tidal
volumes. Immediately after the use of a monopolar ECU, a loud ‘bang” was heard, and a flame
was noted to be coming from the patient’s mouth. Upon inspection, the ECU tip had some
charring, but no apparent damage to the patient was noted. Although the ETT was found to be
AIRWAY FIRE 13
intact, it was replaced with a 5.0 mm uncuffed oral RAE ETT. A wet pack was inserted into the
back of the throat to minimize the leak and the surgery continued with no other complications. In
all 3 cases, an ECU was used in the setting of an OEA within the oropharynx, created by a leak
from the uncuffed ETT, with the patient’s tonsillar tissue and/or ETT fueling the fire.
In a study performed by Raman et al. (2012), the authors found cuffed ETTs reduce
OEAs within the oropharynx more significantly than uncuffed ETTs. In this study, pediatric
participants undergoing adenoidectomy, tonsillectomy, or adenotonsillectomy were divided into
4 cohorts: cuffed ETT with spontaneous ventilation (SV) [n= 40]; cuffed ETT with positive
pressure ventilation (PPV) [n=78], uncuffed ETT with SV (n=38), and uncuffed ETT with PPV
(n=44). The type of ETT and mode of ventilation were selected at the discretion of the anesthesia
provider. After induction of general anesthesia, FiO2 was set to 100% and a mouth gag was
placed, followed by a small-bore catheter within the oropharynx connected to a standard
anesthesia gas monitoring device. Within each group, the O2 and anesthetic gas concentrations
(sevoflurane and isoflurane) were measured for 5 breaths, after which the FiO2 was reduced to
25-30% before proceeding with the procedure. Within the cuffed ETT groups (SV and PPV), the
oropharyngeal concentration of O2 did not exceed 21%. Within the uncuffed ETT groups, the
mean O2 concentration was found to be 65% with SV and 71% with PPV. Also, within the
uncuffed ETT and PPV group, when an air leak was detected at < 10 cmH2O, the mean
oropharyngeal concentration of O2 was 83% ± 23% (n=6). When a leak occurred at ≥ 10 cmH2O,
the mean oropharyngeal concentration of O2 was 63 ± 24% (n=76). The O2 concentration was
measured to be 63 ± 21% (n=59) with an air leak < 15 cmH2O and 49 ± 26% with an air leak ≥
15 cmH2O.
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Remz et al. (2013) evaluated circuit response times to reach a fraction of expired O2
(FeO2) < 30% from a starting FiO2 of 100% and 60% after reducing the FiO2 to 21%. They used
varying initial FiO2 concentrations with different FGFs and circuit volumes to assess the changes
in FiO2 and FeO2 over time. The purpose of the study was to investigate the time and conditions
required to reduce an initially high FiO2 to < 30% within the breathing circuit, the recommended
O2 concentration when using an ignition source to avoid a fire (ECRI, 2009). Starting from an
FiO2 of 60% at delivered at 5 L/min, the median times to achieve an FiO2 and FeO2 < 30% with
the extended circuit were 35 and 104 seconds, respectively. When starting from an FiO2 of 60%
delivered at 2 L/min, the median times required to achieve an FiO2 and FeO2 < 30% with the
extended circuit configuration were 303 and 255 seconds, respectively. The primary factors
decreasing the time required to achieve an FiO2 and FeO2 < 30% were a shortened circuit
configuration (p = 0.006) and higher FGF rates (p < 0.0001). Depending on the circuit length,
FGF rate, and starting circuit O2 concentration, the authors concluded the time for FiO2 and FeO2
in the circuit to decrease to < 30% ranged from 1 to 5 minutes. The authors recommend setting
up an audible alarm for when FiO2 and FeO2 rise above 30% and documenting when the FeO2
falls below 30% prior to the use of an ECU or surgical laser within the airway.
The formation of an OEA outside of the airway can occur when supplemental O2 is
administered via nasal cannula or face mask during monitored anesthesia care (MAC) cases
involving the head, face, and/or neck resulting in a surgical fire (ECRI, 2009). According to the
ECRI (2009), 44% of surgical fires occur around the head and face. Additionally, Mehta et al.
(2013) found that out of the 103 surgical fires reported in the ASA Closed Claims Database
between 1985 and 2009, 78 (76%) occurred during MAC, 99% of which used supplemental O2.
In the Day et al. (2018) review, 13 of the 21 reported MAC cases used O2 flows ranging from 0
AIRWAY FIRE 15
to 10 L/min. The O2 flow was > 2 L/min in 11 cases (85%), ≥ 4 L/min in 5 (38%), and ≥ 6 L/min
in 2 (15%). Laboratory studies evaluating surgical material flammability, especially surgical
drapes, in the setting of increased O2 concentrations have demonstrated a decreased time to fuel
ignition, increased total burn time, and increased speed of fire propagation (Goldberg, 2006;
Wolf, Sidebotham, Lazard & Charchaflieh, 2004; Culp, Kimbrough & Luna, 2013). While
surgical fires involving the head, face, and neck during MAC cases may occur, currently there
are no reported airway fires during MAC cases in the literature.
Barnes and Frantz (2000) measured O2 concentrations in the microenvironment beneath
the surgical drapes of healthy patients undergoing MAC procedures with supplemental O2
administered via nasal cannula at flow rates varying from 0 to 4 L/min. The authors evaluated
the efficacy of using a scavenger system beneath the drapes to prevent O2 accumulation. The
system was described as follows: “one end of suction tubing was inserted through a hole and
secured in the bottom of a 4 ounce (oz) specimen cup, while the other end of the tubing was
connected to high continuous wall suction (170 - 190 mmHg [millimeters of mercury]). The
specimen cup was then secured to the subject's chest below the surgical drapes with the open end
under the subject's chin” (Barnes & Frantz, 2000, p. 158). Without a scavenger system, O2
concentrations underneath the drapes decreased from 21% to 19% in the absence of
supplemental O2. When supplemental O2 was administered, the O2 concentration beneath the
drapes was directly proportional to the O2 flow rate. At O2 flow rates of 2 and 4 L/min, the O2
concentration beneath the drapes was 30.8% and 44.6%, respectively. When a scavenger system
was utilized, the O2 concentration dropped to 25.8% with a flow rate of 2 L/min and to 34% with
a flow rate of 4 L/min. The study demonstrated commonly utilized O2 flow rates increase the risk
of surgical fire by creating O2 concentrations at or above the OEA threshold underneath the
AIRWAY FIRE 16
surgical drapes. In conclusion, the authors recommend minimizing the supplemental O2 flow rate
or using a scavenger system to prevent O2 accumulation beneath the drapes.
Ignition
An ignition results from the production of a spark or from a concentrated heat source. In
the OR, heat sources include defibrillators, ECUs, heated probes, drills and burs, argon beam
coagulators, fiber optic light sources, and cables, and lasers used with the free beam method or
with contact tips or fibers. These heat sources produce temperatures ranging from several
hundred to a few thousand degrees Fahrenheit, enough to ignite most fuels, especially within an
OEA (ECRI, 1992). According to Smith and Roy (2011), the primary sources of ignition are
ECUs and lasers. In their survey of 100 otolaryngologists who have experienced an OR fire, 96%
of the fires occurring during endoscopic airway and laryngeal procedures were ignited by a laser,
81% of which were ignited by a CO2 laser, and 55% were fueled by the ETT. Monopolar ECUs
ignited 100% of fires during oropharyngeal surgery (n=24) and 100% of fires during
tracheostomy (n=18); the ETT fueled 38% (n=9) and 39% (n=7), respectively. In a review by
Day et al. (2018) of 87 otolaryngological surgical fires, 65 involved the airway. The ignition
sources included the following: 69% ECUs (n=45), 23% CO2 lasers (n=15), 0.6% other lasers
(n=4), and 1 unidentified. 66% of the airway fires (n=43) were fueled by the ETT. Although the
surgeon is primarily responsible for surgical instruments that may cause ignition, the anesthesia
provider must be knowledgeable of the various ignition sources and which ones will be used
during the procedure (Kaye et al., 2014).
Electrocautery units emit a radiofrequency current which produces heat, coagulating
blood and tissues to produce hemostasis. The ECU has 2 modes: coagulation and cutting. The
cutting mode produces a more intense heat than the coagulation mode, causing water within cells
AIRWAY FIRE 17
to explode into steam at the cautery tip. A fire from an ECU can be caused by heating the
material to ignition temperature or producing a spark to cause combustion (Bowdle, Glenn,
Colston & Eisele, 1987). According to Pollock (2004), it takes 451 °F (232.8 °C) to ignite paper;
the temperature of an ECU can reach 1500 °F (815.6 °C).
CO2 lasers produce a non-ionizing invisible radiation beam containing energy capable of
vaporizing biological tissue. The beam penetrates only the initial 200 micrometers of tissue and
produces a precise, clean incision with little surface bleeding or damage to surrounding tissue.
Surgical lasers are the second most cited ignition source in surgical fires (Day et al., 2018; ECRI,
2009). The heat generated within the tissues it targets depends on several variables including
power density, distance from laser tip, time of irritation, and wave setting. While the laser energy
focus is precise, misdirected beams can lead to perforation of ETT cuffs and ignition of ETTs or
biological tissues (Wilder-Smith, Arrastia, Liaw, & Berns, 1995).
In a study by Roy and Smith (2010), the authors compared the fire risk from an ECU
(Bovie) with a bipolar radiofrequency (RF) ablation wand (Coblator) using an animal model to
simulate oropharyngeal surgery. The ECU was set to 15 W and the bipolar RF ablation device
was utilized in various settings (ablate: 9W, 7W, 5W, and 3W; coagulate: 5W and 3W). 100%
FiO2 was administered at 10 L/min in all trials. The ECU ignited the ETT with an immediate
sustained fire occurring in 50 seconds. The bipolar RF ablation did not ignite or produce a
sustained fire in any of the trails. According to the authors, a bipolar RF plasma ablation removes
tissue through the generation of ionized sodium molecules in a plasma field using high-
frequency energy to ablate and coagulate soft tissues in a low temperature environment (40
o
–
70
o
C). This is significant because the temperature generated by the ablation mode is not high
enough to serve as an ignition source for fuels found within the airway. The authors
AIRWAY FIRE 18
demonstrated using an ECU will produce a fire quickly (< 1 minute) in an OEA; whereas, the
bipolar RF ablation wand does not create a spark thereby removing the ignition arm of the fire
triad and reducing the fire risk in high fire-risk surgeries.
Stuermer, Ayachi, Gostian, Beutner and Hüttenbrink (2013) investigated and quantified
the factors contributing to airway fire in laryngeal laser surgery. They tested variable levels of
CO2 laser strength (2, 4, 6, and 8 W) in five different O2 concentrations (30, 40, 50, 70, and 95%)
with and without smoke exhaustion on animal fat, muscle, and cartilage using a mechanical
model. The aim was to determine the time until ignition at different O2 concentrations in
different mediums. The conditions simulated during this experiment were intended to replicate
laryngeal tissues during exposure to CO2 laser with use of high frequency jet ventilation (HFJV).
The authors determined fat burned the fastest, followed by cartilage and muscle. Increasing laser
energy or O2 concentration reduced the time to ignition of any tissue. Raising O2 by 10%
increased the risk for ignition more than increasing the laser strength by 2 W. When using 50%
O2 and laser energy ≥ 6 W, tissue inflammation - defined as a “single flame which extinguished
as soon as laser irradiation stopped” - occurred in less than 5 seconds (Stuermer et al., 2013).
When using ≤ 50% O2, an irradiation interval of 5 seconds can be used safely in preventing
ignition or sustained flame, given that a smoke exhaust is used. The authors recommend when
using laser during HFJV, O2 concentration should never exceed 50%.
Fuel
Fuel sources within the OR may include: patient hair, gastrointestinal tract gases, prepping
agents such as degreasers (ether and acetone), aerosol adhesives, alcohol, and tinctures, linens,
personal protective equipment, dressing materials, tape (cloth, plastic, and paper), ointments,
alternative airway devices, breathing circuits, scavenging tubes, suction catheters, and pledgets
AIRWAY FIRE 19
(ECRI, 1992). In the OR, the circulating nurse is primarily responsible for monitoring
combustible material (Kaye et al., 2014). For the prevention and management of an airway fire,
the responsibility is shifted to the anesthesia provider. In the review by Day et al. (2018), out of
the 85 cases reporting a fuel source, the most common was the ETT (n=42, 49%), followed by
gauze (n=12, 14%), surgical drapes (n=8, 9%), and O2 tubing (n=5, 6%). Moreover, the patient
was considered to be a fuel source in all cases (n=85, 100%), but only 12 cases (14%) identified
the patient as being the only fuel source. In the same study, among the 17 cases reporting the
type of ETT, 4 (24%) utilized a plastic ETT (PVC, portex, and vinyl plastic), 7 (41%) utilized
plastic ETTs wrapped in aluminum or metal, and 3 (18%) utilized RR ETTs, 2 of which were at
least partially wrapped in aluminum, 1 (6%) utilized a “metal-sheathed” laser resistant ETT, and
1 (6%) utilized a Xomed Laser Shield® ETT. The anesthesia provider must choose the most
appropriate ETT based on the type of ignition source the surgeon will be using.
Interactions of Laser Ignition Sources with Fuels
The use of a laser requires additional management strategies to prevent an airway fire as
compared to use of an ECU. An early method of making ETTs more resistant to laser ignition
involved wrapping the ETT with reflective foil. This technique is rarely used today with the
advent of LSTs and the increased liability incurred by the provider in wrapping the ETT (Miller
et al., 2015). Currently, there are 4 commercially available LSTs: the Medtronic Laser-Shield
II®, the Sheridan Laser-Trach®, and the Covidien Laser Oral/Nasal Tracheal Tube Dual Cuffed
(Laser-Flex®), all designed to be used with CO2 lasers and KTP lasers. The Rusch Lasertubus
tube® can be used with all laser types (Miller et al., 2015). Roy and Smith (2015b) designed a
study to assess the ability of CO2 lasers and radiofrequency ablation (RFA) devices to ignite a
non-reinforced PVC ETT or an aluminum and fluoroplastic wrapped LST at varying O2
AIRWAY FIRE 20
concentrations in a mechanical model of airway surgery. When a CO2 laser is fired directly at a
non-reinforced ETT at a setting of 5 W, ignition was observed at O2 concentrations of 21% and
26%, and ignition with an immediate sustained flame was observed at O2 concentrations of 44%,
53%, and 60%. Using the same settings, a reinforced LST did not ignite or exhibit a sustained
flame at any O2 concentration when a CO2 laser was directly fired at the body of the LST for 2
minutes. The CO2 laser was also directed to the distal tip, which is not metallically reinforced, of
the reinforced LST resulting in ignition and sustained flame at the same O2 concentrations as the
non-reinforced ETT. Using an O2 concentration of 60%, the authors varied the wattage of the
CO2 laser to test the reinforced LST body’s penetrability. Even at high wattage, the CO2 laser
was unable to penetrate the reinforced LST, but the reinforced tape on the tube can be removed,
damaging the LST. Finally, the RFA was used in both the coagulation and ablate settings against
the non-reinforced ETT and the reinforced LST. No penetration, ignition, or sustained flame was
recorded in either ETT, but the outer layer of the non-reinforced ETT and the outer layer of tape
on the reinforced LST were removed by the RFA. The study demonstrated using a reinforced
LST is useful in preventing fires at varying O2 concentrations and CO2 laser settings.
In a study by Sosis and Dillion (1991) using a mechanical model, a comparison of ETT
cuffs filled with air (n=5) versus saline (n=5) exposed to a CO2 laser showed no statistical
difference in the time to cuff perforation, but showed a statistically significant difference in the
time to cuff deflation. The time for deflation of the air-filled cuff was 2.59 ± 1.97 seconds
compared to 104.6 ± 67.5 seconds with the saline-filled cuff. This study shows while filling a
cuff with saline does not provide added protection from perforation by a CO2 laser, it does allow
the surgeon a greater amount of time to identify the perforation. Pandit, Chambers, and O’Mally
(1997) conducted an in vitro study of the laser-resistant properties of the reinforced laryngeal
AIRWAY FIRE 21
mask airway (RLMA) against a potassium titanyl phosphate (KTP) laser. Within this study
design, power density (watts/mm
2
), power at the source (watts), distance (millimeters) of the
RLMA from the laser source, points of laser contact on the RLMA, the effect on RLMA based
on time exposed to KTP laser, the effect of RLMA exposure to KTP laser in an OEA, and time
to perforation of air-filled versus saline-filled cuffs were tested. The air-filled cuff was the most
vulnerable area of the RLMA, with perforation occurring at lower power densities and time
exposure to KTP laser. The air-filled cuffs did not ignite at the power densities (1.22, 0.37, 0.13,
and 0.10 W/mm
2
) or time exposures (20 and 60 seconds) tested. The RLMA with a saline-filled
cuff (n=7) had increased resistance to perforation by KTP laser (5-11 seconds at 1.22 W/mm
2

and no perforation after 60 seconds at 0.37 W/mm
2
) as compared to that with an air-filled cuff
(n=5), which was perforated after 1-3 seconds at 1.22 W/mm
2
and after 6 seconds at 0.37
W/mm
2
.
Moistened gauze and pledgets have also been shown to protect the ETT cuff and shaft
from exposure to lasers (Ahmed et al., 2010; Sosis, 1995). Ahmed et al. (2010) measured the
time of laser penetration through various surgical materials: dry and wet gauze swabs, dry and
wet neurosurgical patties, surgical gloves, paper drapes, dry and wet cloth drape, and the wall
and cuff of a PVC ETT. The authors used a Sigmacon Acupulse Lumenis CO2® laser for up to
180 seconds in the continuous wave and super pulse modes focused in a 2 mm diameter at power
levels of 2 to 12 W increasing in 2 W increments and with beam angulations of 45º and 90º. Each
material was tested 3 times and the mean was calculated at each 2 W increment. Unprotected
ETT cuffs and shafts, as well as dry gauze, were penetrated in < 1 second at the lowest 2 W
power level in both laser settings, while moistened gauze was not penetrated at any power level
or setting within the 180 seconds of laser exposure. The authors make the point that while in
AIRWAY FIRE 22
vitro gauze dries quickly and thus must be kept moistened, in vivo gauze dries slower due to
surgical bleeding and saliva production.
In another study evaluating the protective quality of moistened pledgets against CO2
laser, Sosis (1995) demonstrated moistened pledgets maintained integrity of the ETT cuff. In this
study, 12 PVC ETTs were divided evenly into 2 groups and each ETT was placed inside a 100
mL glass graduated cylinder with a 2.5 cm internal diameter. The ETT cuffs were then each
filled with 20 mL of air to seal the cylinder. With use of an anesthesia circle system delivering
O2 at 5 L/min, the system pressure was maintained at 20 cmH2O using the adjustable pressure-
limiting valve. The ETT cuffs of the control group were left unprotected, while the ETT cuffs of
the experimental group were covered completely by 3 saline-soaked pledgets (Mercocel®). Both
groups were exposed to a Cooper model 500 Z CO2 laser with a 0.66 mm beam diameter at 40 W
set in the continuous mode. In the control group, all 6 unprotected cuffs ignited in < 1 second and
filled the cylinder with smoke and fire. In the experimental group, none of protected cuffs were
ignited within 60 seconds of laser use. The author concluded moistened gauze may be utilized
when the surgical field is supraglottic; however, when the surgical field is subglottic, moistened
pledgets may be placed above the tracheal cuff (Sosis, 1995). The pledgets serve a second
function in creating a barrier to oxidizer leakage around the ETT, uncuffed or cuffed. However,
it is important to prevent the gauze from dehydrating during the procedure, as this will transform
the gauze from a protective measure to an additional fuel source (Ahmed et al., 2010; Sosis,
1995).
In a Roy and Smith (2015a) study, the authors tested the traditional methods of fire
prevention by inflating the cuff of an LST with saline and using wet pledgets to protect the ETT
from laser strikes. Following the LST manufacturer’s instructions for use, the authors placed the
AIRWAY FIRE 23
cuff distal to the vocal folds into the airway. Using a LEI Ultra MD CO2 Surgical Laser® in
continuous mode at 5 W, an immediate sustained flame on perforation of the cuff was reported in
100% FiO2 (n=2). With regards to filling the cuff with saline and blue dye, the cuff itself became
the initial flammable substrate that burned at 100% FiO2. Lastly, the saline-soaked pledget did
not offer significant protection from cuff perforation. The authors postulated the laser either
struck an area of the cuff where the pledget was not present or penetrated the pledget, causing
cuff perforation. Additionally, the pledget could have become an additional fuel source if
allowed to dehydrate. The authors concluded, not all reinforced ETTs are safe; the cuff and distal
end of the ETT are not reinforced and can quickly result in a fire. More distal placement of the
cuff within the trachea may minimize the risk of laser contact and accidental perforation and
saline-soaked pledgets placed over the cuff may provide some minimal amount of protection.
Management
Recognizing signs of airway fire early is paramount, which according to Kaye et al.
(2014) may include any of the following: a flash or flame, unusual sounds (e.g. “pop” or “snap”)
or odors, unexpected smoke, heat, movement of surgical drapes, or patient movement or
discomfort, and discoloration of the drapes or breathing circuit. Once an airway fire is
confirmed, the authors recommend the following steps: stop surgery and announce the fire,
extubate to avoid thermal injury, stop all gas flow, pour saline or sterile water into the airway,
remove any burning or flammable materials from the airway, then mask ventilate the patient with
room air until reintubation can be performed. The authors suggest leaving the ETT in patients
with a difficult airway to avoid losing airway access. Akhtar et al. (2016) recommend similar
measures should be taken to extinguish an airway fire: immediately announce the fire and stop
AIRWAY FIRE 24
the surgery, especially the usage of a laser or ECU, disconnect the O2 supply with or without
extubation, depending on the difficulty of the patient’s airway, followed by saline lavage.
In the event of an airway fire, the ASA Task Force on OR fires recommend anesthesia
providers immediately announce the fire and stop the procedure (Apfelbaum et al., 2013). The
following steps should then be performed in order as fast as possible: extubate the patient, stop
all gas flow, remove all flammable and burning material from the airway, then pour saline or
water into the airway. After the airway fire is extinguished, the ASA Task Force recommends
reestablishing ventilation by mask without O2 and N2O, if possible. It is recommended the ETT
be extinguished and examined for potential fragments left in the airway. Rigid bronchoscopy is
recommended to assess injury and look for and remove ETT fragments and residual debris. The
ASA Task Force recommends patient assessment and development of a plan of care as the final
step in airway fire management.
The first step in airway fire management recommended by the PA-PSRS (2007) is to stop
all gas flow by disconnecting the breathing circuit, followed by extubation to minimize thermal
and chemical damage to the airway and avoid repeat ETT ignition. The PA-PSRS also
recommends removing any ETT fragments remaining in the airway, extinguishing the fire, and
saving the ETT and other involved materials for later examination. The final recommended step
is to reestablish the airway and resume ventilation with room air until the fire is completely
extinguished, at which point the patient should be ventilated with 100% FiO2. The PA-PSRS
suggests providers examine the airway to assess the extent of damage and to treat the patient
accordingly, removing soot and particles in the airway with lavage and suction when necessary.
Kaye et al. (2015) report the most fundamental, yet frequently overlooked, factor in
preparation, prevention, and management of an airway fire is communication amongst members
AIRWAY FIRE 25
of the OR team. According to the AORN (2006), a deficiency in communication is associated
with an increased risk of sentinel events and medical errors. Moreover, Bruely (2004) concluded
that problems in communication were the root cause of more than 60% of sentinel events
reported to the JC. Specifically, OR fires occurred when the surgical and anesthesia team failed
to ask about or identify the FiO2 before deployment of an ignition source, resulting in a fire. In
the case of an airway fire, communication is the first course of action once the signs of a fire
have been established (Kaye et al., 2014).
In the event of an airway fire, prior ECRI recommendations were to stop gas flows before
removing the ETT (ECRI, 1992). However, more recent recommendations from the ECRI
suggest removing the ETT first, followed by stopping FGF, lavaging the airway with saline or
sterile water, and then caring for the patient (ECRI, 2009). The last recommended step involves
reestablishing the airway and resuming ventilation with room air until all materials are
extinguished, at which point the patient should be ventilated with 100% FiO2 and the airway
should be assessed to determine the extent of damage and plan treatment accordingly.
A study by Remz et al. (2013) determined FeO2 can lag behind FiO2 and still be > 30% in
the breathing circuit. The authors deduced FeO2 is higher than FiO2 during reduction in FiO2
because the O2 reservoir contained within the patient’s FRC contributes to FeO2. This O2
reservoir is exhaled back into the upper respiratory tract at a higher concentration than the
concentration inspired during this period, resulting in a potentially higher FeO2 at the site of
airway fire if the ETT is not removed immediately.
If inhalation injury is suspected, Akhtar et al. (2016) indicate oxygenation, ventilation,
and hemodynamic stabilization as the top priorities of care. Aggressive pulmonary toileting can
minimize short-term morbidity related to sloughing mucosa and mucous plugging. Inhaled
AIRWAY FIRE 26
bronchodilators reduce bronchospasm risk while air humidification relieves excessive drying and
mucous plugging. Antibiotics and corticosteroids have not been shown to improve survival rates
and thus are not recommended (Akhtar et al., 2016). Admission to the ICU or burn unit with or
without re-intubation may be necessary depending on the extent of airway injury. It is also
recommended to save all involved materials and devices for later investigation and follow local
regulatory reporting requirements and institutional protocol (PA-PSRS, 2007; Pollock, 2004).

AIRWAY FIRE 27
Chapter 3: Methods
A search of the databases PubMed, Scopus, and Web of Science with the keywords
“airway,” “fire,” “prevention,” “management,” and “protocol” was performed. The initial search
yielded 536 articles. Inclusion criteria consisted of: (1) articles written in English, (2) articles
published after the year 2000, and (3) the abstract or title mentioned airway fire prevention,
management, or protocol. Some articles did not meet all inclusion criteria requirements but were
added to exemplify progression of evidence to current practice standards. Exclusion criteria
included: (1) the abstract did not address airway fires and (2) the article was not available to be
reviewed via electronic format. Sources from PubMed, Scopus, and Web of Science were added
to Mendeley and duplicate articles were excluded. After duplicate articles and those meeting
exclusion criteria were removed, 58 articles remained. Using the snowballing technique, an
additional 12 sources met inclusion criteria and were included in the review.

AIRWAY FIRE 28
Chapter 4: Discussion
Prevention
As previously noted, the ECRI, ASA, AORN, FDA, APSF, and JC have all stated a fire
in the OR is preventable; each entity released recommendations regarding fire prevention and
management. Although many of these recommendations were intended for OR fires in general,
some mention the prevention and management of or concepts applicable to airway fire.
To prevent an airway fire, the ASA Task Force on OR fires recommends the anesthesia
provider take a proactive role in identifying high fire-risk situations (Apfelbaum et al., 2013).
The authors suggest anesthesia providers participate in identifying high fire-risk surgeries and
actively engage with other OR team members in discussing and implementing risk reduction
strategies and management plans. Recent recommendations from the ECRI, AORN, APSF, and
ASA suggest using a fire risk assessment tool during surgical time out (ECRI, 2009; Watson,
2010; APSF, 2010; Apfelbaum et al., 2013). As none of the fire risk assessment tools have been
validated to date, we recommend the use of the Christiana Fire Risk Assessment Tool for its ease
of use and integration within the surgical time out.
To reduce the risk of fire, we agree with the recommendations from the ASA, APSF,
AORN, ECRI, FDA, and JC to minimize the delivered FiO2 to as low as clinically possible when
an ignition source is close to an OEA. Ideally, this would mean achieving a FeO2 ≤ 30% before
the use of a surgical laser and maintaining FeO2 ≤ 50% if using an ECU within the oropharynx.
There is conflicting evidence regarding the use of saline-soaked pledgets to protect ETT
cuffs from laser strikes. If an LST or unprotected ETT is used, the anesthesia provider should ask
the surgeon to place 3 saline-soaked pledgets superior to the ETT cuff before proceeding with
the use of a surgical laser. While there is no study assessing the best position of the ETT cuff to
AIRWAY FIRE 29
protect from laser strike, Roy and Smith (2015b) found an increased risk of cuff perforation
when located just distal to the vocal cords; as such, we recommend the ETT cuff be placed
within the distal trachea, as opposed to the usual placement of the cuff in the proximal trachea.
This maneuver distances the ETT cuff from the operative area and reduces the risk of laser
strike; although, when placing the ETT cuff distally, care must be taken not to intubate the right
bronchus.
According to Raman et al. (2012), it is routine practice in anesthesia to use uncuffed
ETTs in children under 6-8 years old. However, studies suggest uncuffed ETTs allow
supplemental O2 to escape from the lower airway into the upper airway, placing the patient at
risk for airway fire should an ignition source be introduced during procedures of the oropharynx
and hypopharynx (Mattuci & Militana, 2003; Raman et al., 2012). Therefore, we recommend
utilizing cuffed ETTs during electrocautery procedures of the oropharynx and hypopharynx in
children, when appropriate, to reduce the risk of airway fire. If an uncuffed ETT is indicated, we
recommend maintaining leak pressure above 12 cmH2O with an appropriately sized ETT to
minimize the escape of O2 into the operative field.
Before permitting the surgeon to activate ignition sources within the airway, FeO2 should
be allowed to fall to ≤ 30%. It takes 163 seconds to achieve an FeO2 < 30% after decreasing FiO2
from 100% to 21% with O2 delivered at 5 L/min through an extended breathing circuit; this lag
period can be shortened by increasing FGF or shorting the breathing circuit (Remz et al, 2013).
During tracheotomy, ECU use should be avoided after the trachea has been opened and
when entering the trachea. A number of case reports within the literature demonstrate the
dangers of airway fire using an ECU when performing tracheostomy, as such a situation
combines all 3 elements of the fire triad, increasing the risk for airway fire (Bailey, Bromley,
AIRWAY FIRE 30
Allison, Conroy, & Krzyzaniak, 1990; Barker & Polson, 2001; Baur & Butler, 1999; Bowdle et
al., 1987; Chee & Benumof, 1998; Ho et al., 2007; Lew, Mittleman, & Murray, 1991; Niskanen,
Purhonen, Koljonen, Ronkainen, & Hirvonen, 2007). If an ECU is deemed necessary by the
surgeon, CO2 delivered at 10 L/min should be aimed at the diathermy tip in a caudal direction
when the ECU in use (Ho et al., 2007).
Management
Due to the ethical issues inherent in case control studies evaluating methods of airway
fire management, the available literature lacks prospective experimental studies comparing
interventions for managing airway fire on a human study sample. Current research regarding the
management of airway fire consists of retrospective case reports offering expert opinion coupled
with integration of scientific foundations.
While many recommendations indicate immediate extubation is a necessary step in
airway fire management, some authors suggest the decision to extubate should be made on a case
by case basis. Leaving the ETT in place may be warranted to avoid losing a secure airway if
difficulty reestablishing the airway is expected due to edema or a history of difficult intubation
(Akhtar et al., 2016; DeMaria et al., 2011; Kaye et al., 2014; Salaria et al., 2018). However, if the
ETT is left in place, heat generated by the smoldering ETT can continue to injure surrounding
tissue while smoke and gases produced by the fire and burning ETT can cause chemical burns or
toxic reactions (ECRI, 1992; Kaye et al., 2014; PA-PSRS, 2007; Salaria et al., 2018).
Additionally, a study by Remz et al. (2013) demonstrated that airway fire can reignite as a result
of residual FeO2 if the ETT is not removed immediately.
Another controversial decision in the management of airway fire is which intervention
should be carried out first: stopping all anesthetic gas flow to the patient by disconnecting the
AIRWAY FIRE 31
breathing circuit and/or turning off the gas supply, removing the ETT, or pouring sterile water or
saline down the airway. The earliest recommendation available in the literature is to first stop gas
flow by disconnecting the breathing circuit (Boyd, 1969). Burgess & LeJeune (1979) suggested
removing the ETT first; whereas, other authors have recommended extubating the patient should
occur simultaneously with stopping gas flow (Cowles, 2017; PA-PSRS, 2007; Roy & Smith,
2019; Schramm et al., 1981; Yardley & Donaldson, 2010). The ECRI has recommended
stopping gas flow first and then extubating the patient (ECRI, 1992; ECRI 2006; ECRI, 2009).
Airway lavage was added as the third step in the latest ECRI recommendations and remains a
recommendation published by other authors (ECRI, 2009; Cowles, 2017; Roy & Smith, 2019;
Yardley & Donaldson, 2010). DeMaria et al. (2011) recommended stopping all gas flow and
disconnecting the breathing circuit, followed by pouring saline or water into the patient’s airway,
and then removing the ETT. Several more recent recommendations, including those published by
the ASA Task Force on OR fires, indicate extubation as the first step, followed by cessation of
gas flow and then airway lavage with sterile water or saline (Apfelbaum et al., 2013; Kaye et al.,
2014; Ward, 2017).
Roy and Smith (2015) established a mechanical model using an airway mannequin to
evaluate airway fire formation under various conditions of laryngeal airway laser surgery.
According to the study, previous literature recommended extubation prior to lavage; however,
the Laser Shield Tube® manufacturer recommends pouring saline into the airway immediately
prior to extubation. The results from the study showed neither maneuver was particularly
effective once a sustained flame was created, both resulting in severe, almost indistinguishable
damage to the models. Roy and Smith concluded that the best way to prevent damage is
AIRWAY FIRE 32
immediate recognition of ETT cuff perforation with subsequent extubation and airway lavage
before a sustained flame can be created.

AIRWAY FIRE 33
Chapter 5: Conclusion
Although rare, airway fires can result in devastating consequences for the patient, OR
personnel, and institution. Despite multiple efforts from various organizations to educate
members of the OR team about fire safety and prevention, this adverse yet preventable clinical
event persists, especially during high fire-risk procedures where an ignition source comes in
contact with an OEA in or near the airway. While primarily responsible for the oxidizer,
anesthesia providers must have a firm understanding of all elements of the fire triad and how
each contributes to an airway fire. In collaboration with other OR team members, identification
of high fire-risk situations and a thorough discussion of the preventative and management
strategies is essential to mitigate the potential risk and damages of an airway fire. According to
Bruley et al. (2018), these educational and prevention efforts have shown promise in decreasing
the rate of surgical fires in Pennsylvania hospitals. An updated set of practice recommendations
has been created based on the extensive literature review completed (Appendix A). Adoption of
these recommendations into standard practice can be an addition to the continuing efforts of
providing a safe surgical experience for patients by equipping anesthesia providers with airway
fire reduction and management strategies.
AIRWAY FIRE 34
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AIRWAY FIRE 43
Appendix A: Practice Recommendations
Prevention of Airway Fire
1. During the surgical timeout, use the Christiana Fire Risk Assessment Tool (see Appendix
B) and document fire risk in patient chart (Roy & Smith, 2019).
2. Discuss airway fire prevention and management plan with OR team in high fire-risk
procedures (Apfelbaum et al., 2013; AORN, 2006).
3. Minimize or avoid oxidizer-enriched atmosphere (OEA) near ignition source/surgical site
I. Use FiO2 < 30%; < 50% if patient is O2-dependent (ECRI, 2009; Roy & Smith,
2011; Stuermer et al., 2013).
II. Use a cuffed ETT, placing the cuff distally in the trachea without intubating the
bronchus. Have surgeon place 3 saline-soaked pledgets superior to the ETT cuff
before using surgical laser (Ahmed et al., 2010; Mattucci & Militana, 2003;
Raman et al., 2012; Roy & Smith, 2015b).
III. If uncuffed ETT is utilized, have surgeon pack saline-soaked
gauze/pledgets/sponges in the oropharynx and choose appropriate ETT size to
maintain leak pressure > 12 cmH2O (Mattucci & Militana, 2003; Raman et al.,
2012; Roy & Smith, 2015a).
IV. Scavenge oropharynx with metal suction (ECRI, 2009).
V. Prior to utilization of ignition source, communicate with surgeon, reduce FiO2 <
30% and wait 1-3 minutes, document, and notify surgeon when FiO2 and FeO2 <
30% (Remz et al., 2013).
AIRWAY FIRE 44
VI. Surgeon should be advised against using ECUs to enter the trachea and after
trachea has been opened (Bailey et al., 1990; Barker & Polson, 2001; Baur &
Butler, 1999; Bowdle et al., 1987; Chee & Benumof, 1998; Ho et al., 2007; Lew
et al., 1991; Niskanen et al., 2007).
VII. If an ECU is used to enter the trachea, have surgeon direct CO2 at 10 L/min to the
ECU tip in a caudal direction (Ho et al., 2007).
4. For laser surgery, use a laser-safe tube (LST): Xomed Laser shield II®, Mallinkrodt
Laser Flex tube®, Rusch Lasertubus® (Roy & Smith, 2015a; Ahmed et al., 2010).
5. Equipment and materials for managing a fire should be readily available (AORN, 2005)
Management of Airway Fire
1. Recognize the early signs of fire: unexpected flash, flame, smoke, or heat, unusual
sounds (“pop,” “snap,” “foomp”) or odors, unexpected drape or patient movement,
discoloration of surgical drapes or the breathing circuit, or patient complaint (Apfelbaum
et al., 2013; Kaye et al., 2014; Ward, 2017).
2. Announce fire, halt the procedure, and ensure the ignition source is removed (Apfelbaum
et al., 2013; Kaye et al., 2014; Roy & Smith, 2019; Ward, 2017).
3. Remove the ETT, unless the patient has a known difficult airway, and have another team
member extinguish it (Akhtar et al., 2016; Apfelbaum et al., 2013; Burgess & LeJeune,
1979; Chee & Benumof, 1998; Cowles, 2017; DeMaria et al., 2011; ECRI, 1992; ECRI,
2006; ECRI, 2009; Kaye et al., 2014; Pollock, 2004; PA-PSRS, 2007; Roy & Smith,
2019; Salaria et al., 2018; Schramm et al., 1981; Sosis, 1990; Ward, 2017; Yardley &
Donaldson, 2010).
AIRWAY FIRE 45
4. Stop all gas flow to the airway and disconnect the patient from the breathing circuit
(Akhtar et al., 2016; Apfelbaum et al., 2013; Boyd, 1969; Cowles, 2017; DeMaria et al.,
2011; ECRI, 1992; ECRI, 2006; ECRI, 2009; Kaye et al., 2014; Pollock, 2004; PA-
PSRS, 2007; Roy & Smith, 2019; Schramm et al., 1981; Sosis, 1990; Ward, 2017;
Yardley & Donaldson, 2010).
5. Pour sterile saline or water into the airway (Akhtar et al., 2016; Apfelbaum et al., 2013;
Cowles, 2017; DeMaria et al., 2011; ECRI, 2009; Kaye et al., 2014; Roy & Smith 2019;
Ward, 2017; Yardley & Donaldson, 2010).
6. Care for the patient
I. Hand ventilate the patient with bag and mask using room air, then switch to 100%
FiO2 once all sources contributing to fire or reignition are eliminated from the
airway (Apfelbaum et al., 2013; Cowles, 2017; ECRI, 2006; ECRI, 2009; Pollock,
2004; Kaye et al., 2014; PA-PSRS, 2007; Ward, 2017; Yardley & Donaldson,
2010).
II. Examine the airway to assess the extent of the damage (Apfelbaum et al., 2013;
Cowles, 2017; Day et al., 2018; DeMaria et al., 2011; ECRI, 2006; ECRI, 2009;
Kaye et al., 2014; Pollock, 2004; PA-PSRS, 2007; Schramm et al., 1981; Sosis,
1990; Ward, 2017; Yardley & Donaldson, 2010).
III. Perform laryngoscopy to assess upper airway for melted ETT fragments and soft
tissue swelling.
AIRWAY FIRE 46
IV. Perform bronchoscopy (preferably rigid) of the lower airway to remove foreign
body fragments, wash out particulate matter with lavage, and assess the degree of
edema, ulceration, and necrosis.
V. Prognosticate the need for mechanical ventilation.
a. If necessary, reintubate and place on mechanical ventilation.
Tracheostomy may be required if reintubation proves difficult (Burgess &
LeJeune, 1979; Day et al., 2018; DeMaria et al., 2011; Kaye et al., 2014;
Pollock, 2004; PA-PSRS, 2007; Schramm et al., 1981; Sosis, 1990;
Yardley & Donaldson, 2010).
b. Consider ICU admission for delayed airway edema (Day et al., 2018;
DeMaria et al., 2011; Ward, 2017).
7. Save all the involved materials and equipment for later investigation, document, and
report the airway fire event to the local fire department, state department of health, JC,
FDA, and ECRI (ECRI, 1992; ECRI, 2006; ECRI, 2009; Pollock, 2004; PA-PSRS, 2007;
Ward, 2017).

AIRWAY FIRE 47
Appendix B: Practice Recommendations Chart

PRACTICE RECOMMENDATIONS FOR AIRWAY FIRE

PREVENTION
Use Christiana Fire Risk Assessment Tool during timeout; document fire risk in patient chart.
Minimize or avoid oxidizer-enriched atmosphere (OEA); use FiO2 < 30%; < 50% if patient is
O2- dependent.

Use a cuffed ETT; have surgeon place 3 saline-soaked pledgets superior to the ETT cuff
before using surgical laser.
If uncuffed ETT is utilized, have surgeon pack saline-soaked gauze/pledgets/sponges in the
oropharynx and choose appropriate ETT size to maintain leak pressure > 12 cm H2O.
For laser surgery, use a laser-safe tube (LST): Xomed Laser shield II®, Mallinkrodt Laser
Flex tube®, Rusch Lasertubus®.
Prior to utilization of ignition source, communicate with surgeon, reduce FiO2 < 30% and wait
1-3 minutes, document, and notify surgeon when FiO2 and FeO2 < 30%.
Advise against using ECUs to enter the trachea and after trachea has been opened.

Advise to direct CO2 at 10 L/min to the ECU tip in a caudal direction if ECU used.

AIRWAY FIRE 48

MANAGEMENT
RECOGNIZE
v Flash, flame, smoke, heat, sounds, odors
v Unexpected drape or patient movement
v Discoloration of drapes or circuit
v Patient complaint
ANNOUNCE
v Halt procedure
Remove ignition source
REMOVE ETT
v Unless known difficult airway
v Have another team member extinguish
STOP FGF
v Disconnect patient from circuit
LAVAGE
v Pour sterile saline or water into airway

CARE
v Hand ventilate using room air → 100%
v Laryngoscopy of upper airway
v Bronchoscopy of lower airway
v Prognosticate need for mechanical
ventilation
SAVE & REPORT
v Save involved material and equipment for investigation
v Report event to local fire department, state department of health, JC, FDA, and ECRI
AIRWAY FIRE 49
Table 1. Historical surgical and airway fire advisories
Year Organization Advisory Summary
1979 ECRI “Fires during surgery of the
head and neck area”
Discusses the fire hazards associated
with high O2 concentrations during
head & neck surgeries; makes
recommendations for minimizing
these hazards
1992 ECRI “The patient is on fire! A
surgical fires primer”
Discusses surgical fire prevention:
control each aspect of the fire
triangle, develop a surgical fire plan,
and manage surgical fires
1996 National Fire
Protection
Association
“Standard for health care
facilities” healthcare facility
code 99
Set of requirements based on the risk
of injury to patients, staff, and/or
visitors in health care facilities that
minimize the hazards of surgical fire;
details steps to take in the event of a
fire, including notification of the fire
department
1998 AORN “Recommendation practices
for electrosurgery”
Discuss safety standards that all
perioperative personnel should
follow to minimize risks to both
AIRWAY FIRE 50
“Recommendation practices
for laser safety in practice
settings”
patients and staff during the use of
ECUs and lasers
2003 ECRI “A clinician’s guide to
surgical fires: How they
occur, how to prevent them,
how to put them out,”
including the cognitive aid
“Only you can prevent
surgical fires: Surgical team
communication is essential”
Surgical fire prevention and
management recommendations based
on the organization's > 25 years of
research and publications on surgical
fires; accepted by The National
Guideline Clearinghouse as a
national guideline
JC & ECRI “Sentinel event alert” Describes surgical fire risk, noting
the importance of prevention and
education
Army
Medical
Command
“Fires associated with the
performance of surgical
procedures”
Provides policy recommendations to
reduce surgical fire risk in any
healthcare setting
JC 2005 National Patient Safety
Goal: “Surgical fire
prevention”
How to reduce surgical fire risk in
ambulatory & office-based surgery;
specifies education for all surgical
staff on how to control heat sources
AIRWAY FIRE 51
and manage fuels; establishes
guidelines to minimize O2
concentrations under surgical drapes
2005 AORN “Fire prevention in the
operating room”
Recommends reducing fire risk be
multidisciplinary and involve staff
education and risk reduction
strategies
2006 ECRI Patient safety initiative:
“Surgical fire safety”
Describes surgical fire causes and
preventive measures for healthcare
personnel; reviews how staff should
respond to a surgical fire
Christiana
Care Health
System
“Christiana Surgical Fire Risk
Assessment Tool”
Tool incorporated into the Universal
Protocol process to enhance
communication among team
members & prevent surgical fire
2007 PA-PSRS “Airway fires during surgery” Discusses mechanisms of airway
fires, how to reduce the likelihood of
airway fires, and how to fight airway
fires
2008 ASA “Practice advisory for
prevention and management
Details existing evidence for
prevention and management of OR
AIRWAY FIRE 52
of operating room fires: A
report by the American
Society of Anesthesiologists
Task Force on Operating
Room Fires”
fires, including an airway fire
algorithm
2009 ECRI “New clinical guide to
surgical fire prevention.
Patients can catch fire: Here’s
how to keep them safer”
Includes practice recommendations
for O2 delivery designed to reduce
the likelihood of surgical fires
2010 APSF “OR fire safety video” Outlines OR fire prevention and
management strategies for all OR
personnel
2011 FDA, JC,
ACS
“Preventing surgical fires
initiative”
Establishes surgical fire prevention as
an annual priority, encouraging
providers to report surgical fire
events
2012 APSF “OR fire prevention
algorithm”
Outlines process for OR fire
prevention
2015 JC “Monitoring fires to improve
patient safety” sentinel event
policy
Encourages OR staff to investigate
and take action whenever an OR fire
occurs
AIRWAY FIRE 53
AORN “Fire safety tool kit” Offers tools to help perioperative
personnel prevent surgical fires, plan
effective response strategies, and
develop department-specific
evidence-based policies and
procedures to protect patients and
personnel
2018 FDA “Recommendations to reduce
surgical fires and related
patient injury” safety
communication
Reminds health care professionals of
factors that increase the risk of
surgical fires and recommends
prevention practices, including the
safe use of medical devices and
surgical products

Abstract (if available)

Abstract A significant adverse, although preventable, event that anesthesia providers must be prepared for is airway fire. Initiation of an airway fire requires the three essential components of a fire triad: oxidizer, ignition source, and fuel. Procedures with the highest risk of airway fire are those in which the three components of the fire triad come into proximity, specifically otolaryngological surgeries. Despite the availability of various practice recommendations detailing the prevention and management of surgical fires, in general, current literature lacks practice recommendations specific to airway fire. This extensive literature review examines the incidence of airway fire and synthesizes currently available evidence into succinct practice recommendations outlining airway fire risk assessment as well as the prevention and management of airway fires to enhance the safety margin of anesthetic care of patients undergoing procedures at high risk for airway fire.

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Asset Metadata

Creator Santa Ana, Justin Michael (author)

Core Title Airway fire: extensive literature review and practice recommendations

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Publication Date 04/24/2020

Defense Date 05/15/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag airway fire,Management,OAI-PMH Harvest,practice recommendations,Prevention,surgical fire

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Bamgbose, Elizabeth (committee chair), Darna, Jeffrey (committee member), Gold, Michele (committee member)

Creator Email jsantaan@gmail.com,jsantaan@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-290778

Unique identifier UC11673472

Identifier etd-SantaAnaJu-8314.pdf (filename),usctheses-c89-290778 (legacy record id)

Legacy Identifier etd-SantaAnaJu-8314.pdf

Dmrecord 290778

Document Type Capstone project

Rights Santa Ana, Justin Michael

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA