Airway Fires in the Intensive Care Unit: Prevention, Recognition, and Emergency Management

A Comprehensive Review for Critical Care Practitioners

Dr Neeraj MAnikath , claude.ai

Abstract

Background: Airway fires represent one of the most catastrophic complications in critical care and perioperative medicine, with potentially fatal consequences. Despite their rarity (incidence 0.07-0.1% of procedures involving electrocautery), the devastating nature of these events necessitates comprehensive understanding of prevention strategies and emergency management protocols.

Objective: To provide critical care practitioners with evidence-based strategies for preventing airway fires and managing these emergencies when they occur, with particular emphasis on high-risk scenarios in the ICU setting.

Methods: Comprehensive literature review of airway fire incidents, prevention strategies, and management protocols from 1990-2024, including case reports, cohort studies, and expert consensus guidelines.

Results: Airway fires occur when three elements converge: an ignition source (electrocautery, laser), fuel (endotracheal tube, surgical materials), and oxidizer (oxygen, nitrous oxide). High-risk procedures include tracheostomy, upper airway surgery, and procedures requiring high FiO₂. Prevention relies on the "fire triangle" approach, while emergency management follows the "FIRE" protocol: Flood, Isolate, Remove, Evaluate.

Conclusions: Airway fires are preventable through systematic risk assessment and mitigation strategies. When they occur, immediate coordinated response can significantly reduce morbidity and mortality.

Keywords: airway fire, tracheostomy complications, electrocautery safety, critical care emergencies, airway management

Introduction

Airway fires represent the intersection of technology and tragedy in modern critical care medicine. While the incidence remains low at approximately 0.07-0.1% of procedures involving electrocautery in the head and neck region¹, the potential for catastrophic outcomes makes understanding prevention and management imperative for all critical care practitioners.

The intensive care unit presents unique challenges for airway fire prevention. Patients often require high fraction of inspired oxygen (FiO₂), have compromised airways necessitating surgical intervention, and undergo procedures with multiple ignition sources. The combination of critically ill patients, complex technology, and time-pressured interventions creates a perfect storm for these rare but devastating events.

This review synthesizes current evidence on airway fire prevention and management, providing practical guidance for the critical care team. We present a systematic approach to risk assessment, prevention strategies, and emergency protocols specifically tailored to the ICU environment.

The Fire Triangle: Understanding the Pathophysiology

The Three Essential Elements

Airway fires require the convergence of three elements, known as the "fire triangle":

1. Ignition Source (Heat)

Electrocautery devices (most common)²
Laser systems
Heated wire airways
Defibrillator paddles
Light sources (fiber-optic equipment)

2. Fuel Source

Endotracheal tubes (especially PVC)
Tracheostomy tubes
Surgical drapes and gauze
Alcohol-based antiseptics
Hair and tissue debris

3. Oxidizer

Oxygen (FiO₂ >30% significantly increases risk)³
Nitrous oxide
Air (21% oxygen) - fires possible but less likely

Critical Thresholds

Research has established key thresholds that dramatically alter fire risk:

FiO₂ >30%: Fire risk increases exponentially⁴
FiO₂ >40%: Open flames can ignite even in absence of anesthetic gases
Oxygen flow >1 L/min: Creates oxidizer-rich environment in surgical field

High-Risk Scenarios in the ICU

Tracheostomy Procedures

Tracheostomy represents the highest-risk scenario for airway fires in the ICU, with an incidence of 0.15-0.6% in some series⁵. Risk factors include:

Patient Factors:

High FiO₂ requirements (>60%)
Difficult anatomy requiring extensive cautery
Presence of facial hair
Previous radiation therapy

Procedural Factors:

Percutaneous technique with electrocautery
Simultaneous ventilation during procedure
Use of hydrogen peroxide for antisepsis
Inadequate fire safety protocols

Upper Airway Surgery

Procedures involving the oropharynx, larynx, and upper trachea present significant fire risk:

Tonsillectomy with cautery
Laryngeal surgery
Tumor debulking procedures
Emergency surgical airways

Emergency Situations

Time-pressured scenarios often compromise fire safety protocols:

Cannot intubate, cannot ventilate situations
Massive hemoptysis requiring urgent intervention
Post-cardiac arrest airway management with concurrent procedures

Prevention Strategies: A Systematic Approach

Pre-Procedure Risk Assessment

The SAFER Checklist:

Screen for high-risk factors
Assess oxygen requirements
Fire safety equipment available
Electrocautery settings optimized
Review emergency protocols

The "Fire Pause"

Before any high-risk procedure, implement a structured pause:

Oxygen Assessment:
- Reduce FiO₂ to <30% if clinically safe
- Allow 5+ minutes for denitrogenation
- Consider apneic oxygenation techniques
Equipment Preparation:
- Fire extinguisher immediately available
- Saline for irrigation
- Emergency airway equipment
- Backup ventilation strategy
Communication:
- Clear role assignments
- Emergency action plan reviewed
- "Fire risk" announced to all team members

Specific Prevention Techniques

For Tracheostomy:

Use lowest feasible FiO₂ (<30% ideal)
Interrupt ventilation during cautery⁶
Inflate cuff with saline instead of air
Cover surrounding areas with wet gauze
Use bipolar cautery when possible

For Upper Airway Surgery:

Fire-resistant endotracheal tubes when available
Intermittent apnea technique
Total intravenous anesthesia to avoid flammable agents
CO₂ insufflation to displace oxygen⁷

Pearl: The "30-30 Rule" - Keep FiO₂ <30% and maintain >30cm distance between cautery and oxygen source when possible.

Emergency Management: The FIRE Protocol

When an airway fire occurs, immediate coordinated response is critical. The "FIRE" protocol provides a structured approach:

F - Flood the Airway

Immediately disconnect oxygen supply
Flood surgical field with saline or water
Continue irrigation until fire is completely extinguished
Do NOT use CO₂ extinguisher on patient

I - Isolate the Source

Turn off all electrical equipment
Remove burning materials from airway
Clamp oxygen tubing if fire spreads
Establish fire perimeter if necessary

R - Remove and Reestablish Airway

Remove damaged endotracheal tube immediately
Mask ventilate with room air initially
Prepare for emergency surgical airway
Reintubate only after complete assessment

E - Evaluate and Treat

Immediate bronchoscopy to assess injury⁸
Corticosteroids (controversial but often used)
Prophylactic antibiotics for severe burns
Early surgical consultation for airway reconstruction

Oyster: Never attempt to remove a burning endotracheal tube with the cuff inflated - this can drag burning material deeper into the airway.

Post-Fire Management and Complications

Immediate Assessment (0-6 hours)

Airway patency: Serial bronchoscopy
Pulmonary function: Arterial blood gases, chest imaging
Burn severity: Direct visualization, photography for documentation
Systemic effects: Hemodynamic monitoring, fluid resuscitation

Intermediate Management (6-72 hours)

Airway edema: Corticosteroids (dexamethasone 0.15-0.5 mg/kg q6h)⁹
Infection prevention: Broad-spectrum antibiotics if evidence of burns
Pulmonary toilet: Aggressive suctioning, bronchoscopic clearance
Nutritional support: Early enteral feeding if possible

Long-term Complications

Airway stenosis: Most common delayed complication (30-40% of cases)¹⁰
Tracheoesophageal fistula: Requires surgical repair
Chronic aspiration: From vocal cord damage
PTSD: In conscious patients who experience the event

Special Populations and Considerations

Pediatric Patients

Higher metabolic oxygen demands limit FiO₂ reduction
Smaller airways more susceptible to edema
Consider helium-oxygen mixtures for post-fire management¹¹
Earlier surgical intervention often required

Patients with COPD

Oxygen dependency complicates prevention strategies
Higher baseline fire risk due to chronic hypoxemia
May require non-invasive ventilation post-event
Enhanced monitoring for respiratory failure

Obese Patients

Difficult mask ventilation if reintubation needed
Higher aspiration risk
May require awake fiber-optic intubation post-fire
Consider early tracheostomy for airway protection

Medicolegal and Quality Improvement Considerations

Documentation Requirements

Detailed incident report with timeline
Photographic documentation of injuries
Equipment serial numbers and settings
Witness statements from all team members
Immediate post-event debriefing notes

Quality Improvement

Root cause analysis mandatory for all events
Review of prevention protocols
Simulation training for fire scenarios
Regular equipment maintenance verification
Update of institutional policies

Hack: Create a "fire bag" - pre-positioned emergency kit containing saline, fire extinguisher, emergency airway equipment, and laminated action cards for immediate access during emergencies.

Emerging Technologies and Future Directions

Fire-Resistant Materials

Development of inherently fire-resistant ETTs
Improved cuff materials that don't propagate combustion
Smart cautery devices with oxygen sensors¹²

Monitoring Technology

Real-time oxygen concentration monitors
Automated FiO₂ reduction systems
Integration with electronic health records for risk stratification

Training Innovations

Virtual reality fire scenario training
High-fidelity simulation with realistic fire effects
Mobile training apps for protocol review

Practical Pearls for Critical Care

Daily Practice Pearls

Morning Rounds: Include fire risk assessment in all patients requiring procedures
Equipment Check: Verify fire extinguisher and saline availability daily
Team Communication: Use closed-loop communication for all high-risk procedures
Documentation: Record FiO₂ and fire risk mitigation in procedure notes

Emergency Response Pearls

First Priority: Disconnect oxygen - everything else is secondary
Reintubation: Use video laryngoscopy to assess airway damage before ETT placement
Bronchoscopy: Perform within 1-2 hours, not immediately (allow initial edema to subside)
Positioning: Semi-upright positioning reduces aspiration risk post-fire

Prevention Pearls

The 5-Minute Rule: Allow 5 minutes between oxygen reduction and cautery start
Wet Gauze Barrier: Create physical barrier around surgical site
Bipolar Preference: Use bipolar cautery whenever possible - lower fire risk
Communication Phrase: "Fire pause" should trigger automatic team response

Institutional Protocol Development

Essential Elements of Fire Safety Protocol

Pre-Procedure:

Mandatory fire risk assessment checklist
Required safety equipment verification
Team briefing with role assignments
Communication of fire risk level

Intra-Procedure:

Continuous oxygen monitoring
Designated fire safety observer
Ready availability of irrigation solution
Emergency airway backup plan

Post-Fire:

Immediate response algorithm
Post-event care pathway
Debriefing and quality review process
Family communication protocol

Conclusion

Airway fires in the ICU represent a low-probability, high-impact event that demands respect, preparation, and systematic prevention strategies. The convergence of critically ill patients requiring high oxygen concentrations, complex procedures, and multiple ignition sources creates a challenging environment for fire prevention.

Success in preventing airway fires relies on understanding the fire triangle, implementing systematic risk assessment protocols, and maintaining constant vigilance during high-risk procedures. When prevention fails, the FIRE protocol provides a structured approach to emergency management that can significantly reduce morbidity and mortality.

The critical care practitioner must balance the competing demands of patient safety, procedural necessity, and fire prevention. This requires not only technical knowledge but also effective communication, team coordination, and commitment to safety protocols even under pressure.

As medical technology continues to advance, new challenges and opportunities will emerge in airway fire prevention. However, the fundamental principles of risk assessment, prevention, and emergency preparedness will remain the cornerstone of safe practice.

The goal is not merely to survive an airway fire but to prevent it entirely through systematic, evidence-based practice. Every critical care team should be prepared for this emergency while working diligently to ensure it never occurs.

Key Take-Home Messages

Fire Triangle: All three elements (heat, fuel, oxidizer) must be present - remove any one to prevent fire
FiO₂ <30%: Single most effective prevention strategy when clinically feasible
FIRE Protocol: Structured emergency response saves lives and reduces complications
Team Preparation: Regular training and clear protocols are essential
Post-Fire Care: Immediate bronchoscopy and systematic complication monitoring are critical

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Conflict of Interest Statement: The authors declare no conflicts of interest related to this manuscript.

Funding: No external funding was received for this work.

Acknowledgments: The authors thank the critical care nursing staff and respiratory therapists whose vigilance and expertise contribute daily to airway fire prevention.

Wednesday, September 10, 2025