Airway fire
Stem
A 46-year-old woman, 70 kg, is having CO2 laser excision of laryngeal papillomas under general anesthesia. She is intubated with a laser-resistant tube whose cuff is filled with saline tinted with methylene blue, and you are ventilating with 30% oxygen in air. Forty minutes in, the surgeon shouts that there is a flame at the tip of the tube, and you see smoke in the circuit.
Question
What do you do, right now and over the next hour?
Ideal answer
HeadlineAirway fire. I announce it and at once pull the tube and stop all airway gases, while the surgeon removes sponges and any burning material and we pour saline in.1
- Not out on the first attempt: CO2 extinguisher; if it still persists, we activate the alarm, evacuate, close the door and shut off the room's gas supply.1
- Mask ventilation once it is out, avoiding supplemental oxygen and nitrous oxide if her saturation allows, because both support combustion and the fire can reignite.
- Inspect the tube, then bronchoscopy, preferably rigid, to look for missing tube fragments, assess the injury and remove debris.1
- Reintubate under direct vision, smaller tube if swollen, and plan for the ICU, serial airway examinations and ventilation as needed.
- Treat it as an adverse event, reported as local regulations require and disclosed to her.1
Breaking down the answer
- Simultaneous, not sequential — the advisory says team members perform their preassigned tasks immediately without waiting for each other; saying "at once" shows command of the algorithm.1
- Tube out and gas off together — the burning tube in an oxygen stream acts as a blowtorch; pulling it and disconnecting the circuit take away fuel and oxidizer. Saline cools tissue and puts out embers.
- Name the fire triad in prevention — oxidizer, ignition source and fuel; for laser airway surgery I keep oxygen at the minimum that avoids hypoxia, avoid nitrous oxide, and wait a few minutes after lowering the oxygen before the laser fires.1
- Prepare the tube — a laser-resistant tube matched to the laser wavelength, cuff filled with saline and an indicator dye such as methylene blue so a punctured cuff shows itself; a cuffed tube when clinically appropriate.1
- Open versus sealed delivery — under sedation for head and neck surgery, open delivery is limited to 30% oxygen or less; a patient who needs more gets a supraglottic airway or tracheal tube.2
- Why look inside — bronchoscopy grades the burn; this is the adaptability step examiners grade, because the injury dictates whether she wakes up today or stays intubated.
Follow-up question
The fire is out and she is mask-ventilated on room air, but her saturation falls to 84% and mask ventilation is getting harder. Rigid bronchoscopy shows soot and swelling in the trachea. What now?
Follow-up answer
HeadlineHypoxemia from thermal and chemical airway injury with evolving edema; I say it aloud so the team shifts from fire control to airway rescue.
The ignition source is off and the fire is out, so I now give 100% oxygen. I secure the airway immediately while it is still possible: the surgeon ventilates through the rigid bronchoscope while debris is cleared, then I intubate with a smaller tube under direct vision rather than waiting for the swelling to close the glottis.1 She stays intubated and sedated on lung-protective settings and goes to the ICU for repeat bronchoscopy before any extubation attempt; I reassess gas exchange, the chest radiograph and the airway daily with ENT.
Pitfalls that cost points
- Stopping to reduce the oxygen or call for help before pulling the tube.
- Reintubating and ventilating with high oxygen before the fire is confirmed out.
- Filling a laser-tube cuff with air.
Rapid-fire
Q: What are the three elements of the fire triad? A: An oxidizer, an ignition source and a fuel.1
Q: What counts as an oxidizer-enriched atmosphere? A: Any oxygen concentration above room air or any concentration of nitrous oxide.1
Q: How long do you wait after lowering oxygen before the laser fires? A: A few minutes; the algorithm gives 1–3 minutes as an example.1
Q: What are early warning signs of a fire? A: An unexpected flash, flame, smoke or heat, a pop or snap, an odd smell, or discoloration of drapes or the breathing circuit.1
Q: How should the surgeon use electrosurgery near the trachea? A: The anesthesiologist advises against entering the trachea with an electrosurgical unit.1
Numbers to know
| Item | Value |
|---|---|
| Wait after reducing oxygen or stopping nitrous oxide | 1–3 min (example)1 |
| Open oxygen delivery limit near an ignition source | ≤30%2 |
| Laser-tube cuff fill | Saline with methylene blue1 |
| Fire not out on first attempt | CO2 extinguisher1 |
Links
- Electrical safety, electrocautery and lasers, Tracheostomy, laser surgery and jet ventilation, Anticipated difficult airway and the ASA algorithm, Procedural sedation and office-based anesthesia
- Atlas: Monitor atlas: other perioperative and peripartum events
- ASA Practice Advisory for the Prevention and Management of Operating Room Fires (2013); APSF OR fire prevention algorithm
Sources
- 1.Practice Advisory for the Prevention and Management of Operating Room Fires · ASA, 2013 · asahq.orgAnesthesiology 2013;118(2); OR fires algorithm and Appendix 1 summary statements.
- 2.Assessing Fire Risk in Surgery: Why Limit Open Oxygen Delivery to 30%? · APSF, 2025 · apsf.orgBruley and Feldman, APSF Newsletter, February 2025.
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.