Fatal inhalation injury caused by airway fire during tracheostomy.
ABSTRACT A 45-year-old man needed emergency tracheostomy and cranioplasty. He was intubated with a cuffed oral polyvinylchloride endotracheal tube and ventilated with 100% oxygen before tracheal incision. During opening of the trachea using diathermy, a popping sound was heard and flames originating from the tracheal incision were observed. The endotracheal tube was charred and its lumen had melted. Immediately after the incident, bronchofibroscopic examination revealed inhalation injury. After remaining for 8 weeks in hospital, the patient was transferred to a health care centre, where he was found dead in his bed.
- Anesthesia and analgesia 11/2013; 117(5):1042-4. · 3.42 Impact Factor
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ABSTRACT: An estimated 650 fires occur in the surgical environment annually in the U.S.; a figure which may be severely underreported. Any fire in the surgical environment can have devastating implications for patient safety and is clearly an occupational risk to healthcare personnel. Literature searches of the PubMed and Rockwell Laser Industries Laser Accident Databases were performed in order to (1) identify factors and sources affecting the risk of fire in the medical environment, namely, oxidizers, ignition sources, and fuels, and (2) to identify areas of future research for prevention. All papers relevant to the flammability of commonly used medical supplies when subjected to laser radiation, including clinical case reports and publicly available incident data, were identified, reviewed, and summarized. There are numerous materials that are ubiquitous within the medical setting that can ignite when accidentally contacted with laser radiation, including gauze, drapes, sponges, adhesive tapes, and gowns, skin preparatory solutions and ointments, and endotracheal tubes. Future research is warranted to determine the dependence of the ignition potential of the various fuels on laser type and operational parameters. The purpose of this analysis is to summarize and present all of the seminal published literature pertaining to medical laser-related fires and their prevention in order to understand the contributing factors and extent to which these hazards exist, to inform the medical laser community about these hazards, and to prioritize future areas of occupational health and safety research.Journal of Laser Applications 05/2012; 24(3). · 1.34 Impact Factor
- SEMERGEN - Medicina de Familia 01/2003; 29(1):40–43.
Acta Anaesthesiol Scand 2007; 51: 509–513
Printed in Singapore. All rights reserved
# 2007 The Authors
Journal compilation # 2007 Acta Anaesthesiol Scand
ACTA ANAESTHESIOLOGICA SCANDINAVICA
Fatal inhalation injury caused by airway fire
M. NISKANEN1, S. PURHONEN2, V. KOLJONEN3, A. RONKAINEN4and E. HIRVONEN2
1Department of Anaesthesiology and Intensive Care, ENT Hospital, Helsinki University Hospital, Helsinki,2Department of Anaesthesiology
and Intensive Care, Kuopio University Hospital, Kuopio,3Department of Plastic Surgery, Helsinki University Hospital, Helsinki
4Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland
A 45-year-old man needed emergency tracheostomy and cra-
nioplasty. He was intubated with a cuffed oral polyvinylchloride
endotracheal tube and ventilated with 100% oxygen before
tracheal incision. During opening of the trachea using dia-
thermy, a popping sound was heard and flames originating
from the tracheal incision were observed. The endotracheal tube
was charred and its lumen had melted. Immediately after the
incident, bronchofibroscopic examination revealed inhalation
injury. After remaining for 8 weeks in hospital, the patient was
transferred to a health care centre, where he was found dead in
Accepted for publication 15 January 2007
Key words: airway fire; burns; complications; inhalation
# 2007 The Authors
Journal compilation # 2007 Acta Anaesthesiol Scand
reports of airway fires caused by ignition of the
endotracheal tube during tracheostomy. We present
a case report of an electrocautery-ignited fire of the
endotracheal tube that resulted in a patient’s death.
IRES in the upper airway are rare, but potentially
devastating, incidents. There have been several
A 45-year-old man with a mild mental handicap and
epilepsy was referred to the Department of Neuro-
surgery, Kuopio University Hospital, Kuopio, Fin-
land for an operation for closure of cerebrospinal
fluid leakage. He had been operated on for a menin-
geoma 6 years earlier and had a ventriculo-peritoneal
shunt. He had suffered from cerebrospinal fluid
leakage problems and had experienced pneumoen-
cephalic episodes with symptoms of increased
intracranial pressure. Elective cranioplasty and tra-
cheostomy were planned. Tracheostomy was antici-
pated to prevent the pneumoencephalic episodes.
During the hospital stay, the patient’s condition
deteriorated and the scheduled operation was
changed to an emergency intervention.
Thepatient wastransferredto theoperating theatre
for open tracheostomy and cranioplasty. He weighed
77 kg and was 180 cm in height. He was positioned
supine with maximal neck extension. His blood
pressure was 140/105 mmHg on arrival at the
operating theatre. General anaesthesia was induced
with thiopentone 350 mg and fentanyl 100 mg, and
cis-atracurium 8 mg was given for muscle relaxation.
The patient was intubated with a cuffed oral poly-
vinylchloride (PVC) endotracheal tube number 8.
The lungs were ventilated with an oxygen–nitrous
oxide (1 : 2) and sevoflurane mixture. The operation
area was prepared with 80% alcohol solution and
draped in the usual manner. The neurosurgeon used
electrocautery, except for the transverse skin incision.
Before tracheal incision, the administration of nitrous
oxide was stopped and the lungs were ventilated
with 100% oxygen for 12 min. When the surgeon was
opening the trachea using diathermy, a loud popping
sound was heard and flames originating from the
tracheal incision were observed. The flames were
extinguished with wet saline towels. After this inci-
dent, it was impossible to ventilate the patient
through the endotracheal tube and it was removed.
The tube was charred and its lumen had melted
(Fig. 1). A size 8 tracheostomy tube was inserted
without any difficulties and ventilation was contin-
ued with air and 8 cmH2O positive end-expiratory
pressure (PEEP). The patient remained haemody-
namically stable. He was given phenylephrine 0.5
mg intravenously and, after the incident, the systolic
blood pressure increased to 120 mmHg.
The cranioplasty was cancelled. Bronchofibro-
scopic examination was performed immediately,
revealing vesicles in the mucosa of the mouth and
pharynx, but the vocal cords were intact. The mucosa
of the lower airway, including the main bronchi, was
covered with black dust. Hydrocortisone and vanco-
mycin therapies were initiated. No problems with
gas exchange were noticed. He was transferred to the
intensive care unit (ICU) for mechanical ventilation.
On the first post-operative day, the chest X-ray
revealed bilateral infiltrates. The patient was weaned
from mechanical ventilation on the second post-
operative day. However, mechanical ventilation
was started again on the fourth post-operative day
because of progressive hypoxaemia. The respiratory
infection was treated with a combination of tobra-
mycin and levofloxacin.
After a 13-day stay in the ICU, the patient was
discharged to the neurosurgical ward. On the 22nd
post-operative day, he still had secretions from his
airways and the treatment was continued in the
otolaryngological ward. After 5 weeks, bronchofibro-
scopy revealed that the lumen of the trachea and
bronchi was open but covered with secretions. At
that time, the patient had dyspnoea, and inspiratory
and expiratory stridors were heard during ausculta-
tion. The thoracic X-ray was normal.
After an 8-week stay in the university hospital, the
patient was transferred to the ward of the health care
centre. He was still dependent on the tracheostomy
and the airway hadto be kept open with suctions and
lavage. He was receiving prednisolone and ipra-
tropium chloride–salbutamol therapy. On the first
morning after the hospital discharge, he was found
dead in his bed.
The autopsy showed that the airways were filled
with pus and part of the bronchi was abnormally
thin. The immediate cause of death was given as
infection of the respiratory tract, and the principal
cause of death was given as burn injury in the airway.
event in the literature. It can be dangerous not only to
the patient, but also to the operation room staff (1).
Preventative measures to avoid this accident should
be taken whenever a tracheostomy is planned. Some
authors recommend that, in patients who need more
than 35–40% oxygen, electrocauterization should be
avoided (2, 3). Percutaneous dilatational tracheosto-
mies have become popular amongst anaesthetists
and surgeons during the past 10 years. This is a result
of the minimal access and simplicity of the operation,
as well as the low rate of immediate and late com-
plications (4–6). This article describes a case of airway
fire during conventional tracheostomy, which ulti-
mately led to the death of the patient. Although an
airway fire during tracheostomy is potentially fatal,
only two previously reported cases have resulted in
patient death (Table 1) (1–3, 7–22).
Thecriteriafor inhalationinjuryare airway oedema,
inflammation, mucosal necrosis and the presence of
soot and charring in the airways, as demonstrated by
bronchofibroscopic examination (23). The first bron-
chofibroscopic examination of our patient revealed
vesicle formation and charring in the major and
terminal airways, which resulted in a diagnosis of
ination showed that the trachea and bronchi were
open, but covered with secretions. The ciliary transport
this is considered to be part of the reason for airway
obstruction and the accumulation of secretions.
The autopsy performed on our patient revealed
cast formation in the peripheral lungs. The casts
consist of fibrin, neutrophils, mucus and epithelial
cell debris (25), and this material may occlude the
lumen of the airway and may promote atelectasis,
pneumonia and barotraumas (26). Failure to clear
casts can be fatal, especially if the cast obstructs the
main bronchi, as described by Nakae et al. (27).
Fig. 1. Removed endotracheal tube, connector and filter. The
endotracheal tube had burned to charcoal black and the tip had
melted, occluding the lumen.
M. Niskanen et al.
Review of the previous literature on airway fires occurring during tracheostomy.
Reference Pre-operative conditionBurns Degree BronchoscopySurvival
Bowdle et al. (1)Biopsy for 3 ? 3-cm mass
of the left neck, peri-operatively
of the airway
Cardiac catheterization and
coronary angiography, COPD
Steroid-dependent nephritis, acute
pancreatitis, pneumonia, ARDS
2nd degree No burns in the airwayAlive
Le Clair et al. (7)3rd tracheal ringSuperficial Not mentionedAlive
Bailey et al. (8)Trachea Superficial Thermal injury to the posterior
mid-trachea involving 3 cm
area, 50% circumference
No evidence of burns
Oral cavity and larynx normal,
anterior trachea charred,
Oedematous hypopharynx, thermal
inhalation injury to the carina level
Mandych et al. (9)
Aly et al. (10)
Inoperable lingual carcinoma
Motor vehicle accident; closed head injury,
pneumothorax, fractured pelvis, comatose
Lew et al. (11) One-week history of breathing difficulties,
left lobe staphylococcal pneumonia,
deteriorating respiratory status
14 days of streptococcal pneumonia,
progressive respiratory failure
Guillan–Barre ´ syndrome
ARDS after laparotomy for sigmoid
Multitrauma, 14 days on
2 weeks earlier traumatic
35 days earlier emergency
craniotomy for closed head injury
Deep Death after 13 days
Marsh and Riley (12)Skin Localized
No apparent damage further
down to the trachea and bronchi
No laryngeal damage
No burns in the airway
Wilson et al. (13)
Michels et al. (14)
Comberg et al. (15)Trachea Superficial One pale spot in the tracheaAlive
Lim et al. (16)NoneNo evidence of burns
in the lower airways
No distal airway burn, and
minimal burns to the proximal
aspect of the tracheostomy site
Trachea and bronchi normal
Trachea and bronchi normal
Thompson et al. (3)
Thompson et al. (3)
4-year-old male, head injury
14-year-old male, Duchennes’
dystrophy, respiratory distress
Parkinson’s disease, 2-week
history of fatigue, shortness
Respiratory failure, morbid obesity,
Coronary artery bypass,
7 days before
Thompson et al. (3)
Baur and Butler (18)
No lumenal burns
Deep burns larynx, trachea,
Died immediately 2nd–3rd degree
Rogers ML et al. (19)None No visible airway damage Alive
Rogers SA et al. (20)None Possible small superficial
burns in the postero-lateral
Few soot particles distal to
the tracheostomy, no burns
or airway edema
Circumferential tracheal burns
to the level of carina,
with spotty burns extending into
the upper main bronchi
Swollen larynx, thermal injury in distal
trachea and carina, swollen bronchi
14 days after
perforated oesophagus carcinoma
Respiratory failure, diabetes,
ischaemic heart disease, obesity
Varcoe et al. (22)
Anterior neck2nd–3rd degree
Wu et al. (2) Progressive respiratory failure,
lung cancer, obesity
ARDS, acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease.
Airway fire during tracheostomy
Before a fire can be ignited, three elements are
needed to be present simultaneously: a source of
heat, an ample oxygen concentration and a source of
fuel. In the present case, these were electrocautery,
100% oxygen and the PVC endotracheal tube. In
addition, the materials used to prepare the patient for
operation may be flammable, such as alcohol-based
skin antiseptics (28).
The cutting mode of the electrocautery device
generates high tip temperatures (up to 910 8C or
1500 8F) (1), a temperature high enough to ignite
a fire (3). Bipolar diathermy is recommended by
some authors as being a safer option (8, 10) but,
in an oxygen-rich environment, sparking at the
electrode–tissue interface can also cause fire (16).
The PVC endotracheal tube acted as a fuel, i.e. the
carbon source, for ignition of the fire. Wolf and
Simpson (29) have investigated the flammability of
PVC endotracheal tubes in a 50% N2O–50% O2
environment. These set-ups resulted in a rapid,
uncontrollable combustion that consumed the endo-
tracheal tube. PVC tubes melt at relatively low
temperatures and vaporize at high temperatures,
producing toxic gases. PVC is first degraded, fol-
lowed by the production of hydrogen chloride.
In Table 2, we present our recommendations for the
prevention and management of this type of injury.
1. Bowdle TA, Glenn M, Colston H et al. Fire following use of
electrocautery during emergency percutaneous transtracheal
ventilation. Anesthesiology 1987; 66: 697–8.
2. Wu CC, Shen CH, Ho WM. Endotracheal tube fire induced by
electrocautery during tracheostomy–a case report.Acta Anaes-
thesiol Sin 2002; 40: 209–13.
3. Thompson JW, Colin W, Snowden T et al. Fire in the
operating room during tracheostomy. South Med J 1998; 91:
4. Flaatten H, Gjerde S, Heimdal JH et al. The effect of
tracheostomy on outcome in intensive care unit patients. Acta
Anaesthesiol Scand 2006; 50: 92–8.
5. Anon JM, Escuela MP, Gomez V et al. Percutaneous trache-
ostomy: Ciaglia Blue Rhino versus Griggs’ Guide Wire
Dilating Forceps. A prospective randomized trial. Acta Anaes-
thesiol Scand 2004; 48: 451–6.
6. Holdgaard HO, Pedersen J, Jensen RH et al. Percutaneous
dilatational tracheostomy versus conventional surgical tra-
cheostomy. A clinical randomised study. Acta Anaesthesiol
Scand 1998; 42: 545–50.
7. Le Clair J, Gartner S, Halma G Endotracheal tube cuff ignited
by electrocautery during tracheostomy. Aana J 1990; 58:
8. Bailey MK, Bromley HR, Allison JG et al. Electrocautery-
induced airway fire during tracheostomy. Anesth Analg 1990;
9. Mandych A, Mickelson S, Amis R. Operating room fire. Arch
Otolaryngol Head Neck Surg 1990; 116: 1452.
10. Aly A, McIlwain M, Duncavage JA. Electrosurgery-induced
endotracheal tube ignition during tracheotomy. Ann Otol
Rhinol Laryngol 1991; 100: 31–3.
11. Lew EO, Mittleman RE, Murray D. Endotracheal tube ignition
by electrocautery during tracheostomy: case report with
autopsy findings. J Forensic Sci 1991; 36: 1586–91.
12. Marsh B, Riley RH. Double-lumen tube fire during tracheos-
tomy. Anesthesiology 1992; 76: 480–1.
13. Wilson PT, Igbaseimokumo U, Martin J. Ignition of the
tracheal tube during tracheostomy. Anaesthesia 1994; 49:
14. Michels AM, Stott S. Explosion of tracheal tube during
tracheostomy. Anaesthesia 1994; 49: 1104.
15. Comberg G, Elfeldt R, Jeckstrom W et al. [Burning endotra-
cheal tube. A complication of tracheotomy using electro-
cautery]. Chirurg 1995; 66: 927–8.
16. Lim HJ, Miller GM, Rainbird A. Airway fire during elective
tracheostomy. Anaesth Intensive Care 1997; 25: 150–2.
17. Chee WK, Benumof JL. Airway fire during tracheostomy:
extubation may be contraindicated. Anesthesiology 1998; 89:
18. Baur DA, Butler RC. Electrocautery-ignited endotracheal
tube fire: case report. Br J Oral Maxillofac Surg 1999; 37:
19. Rogers ML, Nickalls RW, Brackenbury ET et al. Airway fire
during tracheostomy: prevention strategies for surgeons and
anaesthetists. Ann R Coll Surg Engl 2001; 83: 376–80.
20. Rogers SA, Mills KG, Tufail Z. Airway fire due to diathermy
during tracheostomy in an intensive care patient. Anaesthesia
2001; 56: 441–3.
21. Wheatley TJ, Maddern GJ. Airway fire during formation of
tracheostomy. ANZ J Surg 2002; 72: 157–8.
22. Varcoe RL, MacGowan KM, Cass AJ. Airway fire during
tracheostomy. ANZ J Surg 2004; 74: 507–8.
Algorithm for avoidance and management of airway fire.
Do not use an electrosurgical device for tracheal incision
Avoid alcohol-based skin antiseptics
Avoid a high oxygen environment
Fill the intubation tube cuff with saline and place
the cuff as far down in the trachea as possible
Inform the surgeon about the use of a high oxygen fraction
Disconnect the oxygen supply immediately
Extinguish the fire with water or saline
Complete the tracheostomy
Perform bronchoscopy to document the
degree and extent of thermal damage
Consult a plastic surgeon for the management
of skin and airway burns
M. Niskanen et al.
23. Moylan JA, Adib K, Birnbaum M. Fiberoptic bronchoscopy
following thermal injury. Surg Gynecol Obstet 1975; 140: 541–3.
24. Hubbard GB, Langlinais PC, Shimazu Tet al. The morphology
of smoke inhalation injury in sheep. J Trauma 1991; 31: 1477–86.
25. Cox RA, Burke AS, Soejima K et al. Airway obstruction in
sheep with burn and smoke inhalation injuries. Am J Respir
Cell Mol Biol 2003; 29: 295–302.
26. Pruitt BA, Jr., Cioffi WG. Diagnosis and treatment of smoke
inhalation. J Intensive Care Med 1995; 10: 117–27.
27. Nakae H, Tanaka H, Inaba H. Failure to clear casts and
secretions following inhalation injury can be dangerous:
report of a case. Burns 2001; 27: 189–91.
28. Spigelman AD, Swan JR. Skin antiseptics and the risk of
operating theatre fires. ANZ J Surg 2005; 75: 556–8.
29. Wolf GL, Simpson JI. Flammability of endotracheal tubes in
oxygen and nitrous oxide enriched atmosphere. Anesthesiol-
ogy 1987; 67: 236–9.
Department of Anaesthesiology and Intensive Care
Helsinki University Central Hospital
PO Box 220
Airway fire during tracheostomy