Airway Fire

[SleepIsGood]

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Ok so I was debating this with someone the other day.

IF you start smelling smoke or see an airway fire...what would you do?

The question for the boards usually I've heard asks, "what's the best next step?" You are always torn between two options as the FIRST step...1)pull the tube 2) stop the FGF

I've always read stop the FGF flow then extubate. A friend of mine that recently went to a review coarse stated that the ABA wants you to answer extubate first.

Obviously in real life, these things are done semi simultaneously. However, it makes sense to turn of the FGF FIRST so that you dont have a blow torch effect. Apparently the ABA doesnt agree with this.

What are people's thoughts???

 

[coprolalia]

Pull the tube. You won't get a blowtorch. Burning plastic in the airway is a bad thing.

-copro

 

[cchoukal]

I'm not sure what the boards answer is, but shutting off the FGF will not prevent an additional breath being given, and it is the next breath that will basically blow flames into the patientss lungs in the event of an airway fire. This is particularly true with newer piston-drive ventilators that don't rely on FGF to fill the bellows in order to provide a breath.

My opinion is the best next step is to disconnect the airway circuit from the machine first (preferably the inspiratory limb first). This way, you have a few seconds to undrape the patient's face (these are usually ENT cases where the face is covered and might not even be near you) and consider your next step (probably extubation). I didn't come up with this plan myself, of course, but of all the things I've heard, this approach makes the most sense to me.

 

[Planktonmd]

ok So I Was Debating This With Someone The Other Day.

If You Start Smelling Smoke Or See An Airway Fire...what Would You Do?

The Question For The Boards Usually I've Heard Asks, "what's The Best Next Step?" You Are Always Torn Between Two Options As The First Step...1)pull The Tube 2) Stop The Fgf

I've Always Read Stop The Fgf Flow Then Extubate. A Friend Of Mine That Recently Went To A Review Coarse Stated That The Aba Wants You To Answer Extubate First.

Obviously In Real Life, These Things Are Done Semi Simultaneously. However, It Makes Sense To Turn Of The Fgf First So That You Dont Have A Blow Torch Effect. Apparently The Aba Doesnt Agree With This.

What Are People's Thoughts???

Pull The Tube Out!

 

[DrBrown]

On the exam I would answer pull the tube. In real life I would disconnect the tube from the circuit at the elbow in the milisecond before I pulled it out of the patients airway.

 

[SleepIsGood]

I'm not sure what the boards answer is, but shutting off the FGF will not prevent an additional breath being given, and it is the next breath that will basically blow flames into the patientss lungs in the event of an airway fire. This is particularly true with newer piston-drive ventilators that don't rely on FGF to fill the bellows in order to provide a breath.

My opinion is the best next step is to disconnect the airway circuit from the machine first (preferably the inspiratory limb first). This way, you have a few seconds to undrape the patient's face (these are usually ENT cases where the face is covered and might not even be near you) and consider your next step (probably extubation). I didn't come up with this plan myself, of course, but of all the things I've heard, this approach makes the most sense to me.

Never heard of this approach. Makes great sense since it's practical.

Since it's July...I'm just thinking in an exam mode.

 

[deleted126335]

.

 

[cchoukal]

yeah, I think pulling the tube is probably the board answer, but in my (admitedly brief) experience, for most of these cases, the circuit-machine junction is closer and more accessible to me than the ETT-patient junction. A few extra seconds of burning plastic in the airway is a pretty raw deal, but, on the other hand, the few seconds it would take to yank the ETT might allow that next breath, which would be far worse.

 

[Planktonmd]

yeah, I think pulling the tube is probably the board answer, but in my (admitedly brief) experience, for most of these cases, the circuit-machine junction is closer and more accessible to me than the ETT-patient junction. A few extra seconds of burning plastic in the airway is a pretty raw deal, but, on the other hand, the few seconds it would take to yank the ETT might allow that next breath, which would be far worse.

I am not sure I understand the logic behind wanting to do other things before removing the burning plastic out of the airway.

 

[cchoukal]

the logic as I see it is that the real goal is preventing the next breath from scorching the lungs and killing the patient. In other words, as harmful as burning plastic in the airway is, having the ventilator deliver a breath with burning plastic in the airway would be far worse. Many times, the single fastest way to prevent that is to extubate the patient as quickly as possible. Some times, however, disconnecting the circuit at the machine will be faster. At our institution, many ENT cases (the highest likelihood for an airway fire) are done at 90 or even 180 degrees from the anesthesiologist and anesthesia machine. The inspiratory limb of the machine is literally inches from my hand during most of the case; the ETT may be feet away.

 

[Planktonmd]

the logic as I see it is that the real goal is preventing the next breath from scorching the lungs and killing the patient. In other words, as harmful as burning plastic in the airway is, having the ventilator deliver a breath with burning plastic in the airway would be far worse. Many times, the single fastest way to prevent that is to extubate the patient as quickly as possible. Some times, however, disconnecting the circuit at the machine will be faster. At our institution, many ENT cases (the highest likelihood for an airway fire) are done at 90 or even 180 degrees from the anesthesiologist and anesthesia machine. The inspiratory limb of the machine is literally inches from my hand during most of the case; the ETT may be feet away.

Tell whomever is close to the airway to pull the tube out.

 

[Gern Blansten]

the logic as I see it is that the real goal is preventing the next breath from scorching the lungs and the patient. In other words, as harmful as burning plastic in the airway is, having the ventilator deliver a breath with burning plastic in the airway would be far worse. Many times, the single fastest way to prevent that is to extubate the patient as quickly as possible. Some times, however, disconnecting the circuit at the machine will be faster. At our institution, many ENT cases (the highest likelihood for an airway fire) are done at 90 or even 180 degrees from the anesthesiologist and anesthesia machine. The inspiratory limb of the machine is literally inches from my hand during most of the case; the ETT may be feet away.

Laser airway cases seem to be the most likely culprit. I don't allow the patient's airway out of my reach if we are doing a laser case. I agree with everyone else...pull the tube ASAP.

 

[IctalSmile]

Pardon my ignorance, but how does an Airway fire get started in the first place???

 

[bubalus]

This was on the boards the past 2 years. 2 years ago, the question wasn't written very well. Last year, it was much better, and there was a clear answer so you didn't have to go through the mental masturbation of "Do I pull the tube first or shut off the flow first?"

I've seen several pictures of the blowtorch effect, and I believe it. If you've got the online Miller, there's a picture of an ETT blowtorch. There may be one in the hardcopy too. Very scary. My answer is to disconnect the circuit at the ETT as you're pulling it. After that, they need their airway resecured and they need bronched.

How do fires start? You need fuel, an ingition source, and an oxidizing agent. We provide the oxidizing agent (O2 or N2O which will support combustion). We can also provide the fuel with the ETT, though dessicated tissue can also be a fuel source. The surgeon provides the ignition source. Something like a misdirected laser or a Bovie on light saber setting is all it takes to have a very bad outcome. From closed claims, airway fires are costly and pay 100% of the time, so if you have one, get ready to write the check.

 

[IctalSmile]

The surgeon provides the ignition source. Something like a misdirected laser or a Bovie on light saber setting is all it takes to have a very bad outcome. From closed claims, airway fires are costly and pay 100% of the time, so if you have one, get ready to write the check.

Isn't the ventilation a closed system? how would the laser come in contact with the "fumes" etc? Do you have to be doing an ENT type surgery?

Im on my first anesthesia rotation, just trying to understand... thanks in advance.

 

[bubalus]

Cuffless tube in peds case. Laser hit on the cuff which pops it. Peri-cuff leaks. Lots of possibilities. Most of the cases have been ENT types of surgery--things in the mouth to the airways, trachs, etc.

 

[Ender]

Ok so I was debating this with someone the other day.

IF you start smelling smoke or see an airway fire...what would you do?

The question for the boards usually I've heard asks, "what's the best next step?" You are always torn between two options as the FIRST step...1)pull the tube 2) stop the FGF

I've always read stop the FGF flow then extubate. A friend of mine that recently went to a review coarse stated that the ABA wants you to answer extubate first.

Obviously in real life, these things are done semi simultaneously. However, it makes sense to turn of the FGF FIRST so that you dont have a blow torch effect. Apparently the ABA doesnt agree with this.

What are people's thoughts???

Is anyone sure of what to do? Any final word according to the ABA?

I just read this in Barash:

"...if an endotracheal tube is on fire, disconnecting the anesthetic circuit from the tube, or disconnecting the inspiratory limb of the circuit, will usually result in the fire immediately going out. It is not recommended to remove a burning endotracheal tube because this may cause even greater harm to the patient. Once the fire is extinguished, the endotracheal tube can be safely removed, the airway inspected via bronchoscopy, and the patient's trachea reintubated."

Assuming this is the correct answer (I hope it is), how would you manage the airway after pulling the tube? Mask ventilate, then asleep fiberoptic (this seems like it could take a long time just to get the equipment in the room)? Thanks for your input guys.

Ender

 

[Ender]

Is anyone sure of what to do? Any final word according to the ABA?

I just read this in Barash:

"...if an endotracheal tube is on fire, disconnecting the anesthetic circuit from the tube, or disconnecting the inspiratory limb of the circuit, will usually result in the fire immediately going out. It is not recommended to remove a burning endotracheal tube because this may cause even greater harm to the patient. Once the fire is extinguished, the endotracheal tube can be safely removed, the airway inspected via bronchoscopy, and the patient's trachea reintubated."

Assuming this is the correct answer (I hope it is), how would you manage the airway after pulling the tube? Mask ventilate, then asleep fiberoptic (this seems like it could take a long time just to get the equipment in the room)? Thanks for your input guys.

Ender

Anyone?.....Anyone?....

 

[huktonfonix]

It shouldnt take very long to get a fiberoptic scope with a standard or portable lightsource into the room. It may take a bit if you want the video screen and equipment. If time is an issue you may want to just reintubate and fiberoptic when you get the scope and pull back the tube over the scope if you need more visualization.

 

[dfk]

remember too that edema from this example occurs rather quickly.
i'm not sure you have time to call the FOB equipment in.
ILMA/ETT would be my way to go.
ventilation/re-intubation is key before the edema sets in, IMO.

 

[DrN2O]

Per ENT: antibiotics and steroid ASAP.

 

[CerebralEdema]

Is anyone sure of what to do? Any final word according to the ABA?

I just read this in Barash:

"...if an endotracheal tube is on fire, disconnecting the anesthetic circuit from the tube, or disconnecting the inspiratory limb of the circuit, will usually result in the fire immediately going out. It is not recommended to remove a burning endotracheal tube because this may cause even greater harm to the patient. Once the fire is extinguished, the endotracheal tube can be safely removed, the airway inspected via bronchoscopy, and the patient's trachea reintubated."

Assuming this is the correct answer (I hope it is), how would you manage the airway after pulling the tube? Mask ventilate, then asleep fiberoptic (this seems like it could take a long time just to get the equipment in the room)? Thanks for your input guys.

Ender

Miller (6th edition, pp 2584-2585) says something a bit different and follows along the lines of what Plankton was stating...

"A surgeon who detects an endotracheal or other source of airway fire should as quickly as possible remove the source and simultaneously inform the anesthesiologist who should immediately stop ventilation. Disconnected the breathing circuit may be useful. These maneuvers remove the flame and the retained heat in the tube and stop the flow of oxygen enriched gas."

It then goes on to say to provide 100% O2 via mask and resecure the airway... DL and Rigid bronch to assess damage and remove debris (sometimes flaming) .... bronchial lavage as needed.... Brief, High-dose steroids... prolonged intubation.... etc.

Antibiotics may have a role but still not clear... Low tracheostomy as needed for upper airway fires ... Follow with CXRAYs, ABGs, and possibly carboxyhemoglobin levels if fire was persistent.

- Edema

 

[Ender]

Miller (6th edition, pp 2584-2585) says something a bit different and follows along the lines of what Plankton was stating...

"A surgeon who detects an endotracheal or other source of airway fire should as quickly as possible remove the source and simultaneously inform the anesthesiologist who should immediately stop ventilation. Disconnected the breathing circuit may be useful. These maneuvers remove the flame and the retained heat in the tube and stop the flow of oxygen enriched gas."

It then goes on to say to provide 100% O2 via mask and resecure the airway... DL and Rigid bronch to assess damage and remove debris (sometimes flaming) .... bronchial lavage as needed.... Brief, High-dose steroids... prolonged intubation.... etc.

Antibiotics may have a role but still not clear... Low tracheostomy as needed for upper airway fires ... Follow with CXRAYs, ABGs, and possibly carboxyhemoglobin levels if fire was persistent.

- Edema

Good info guys, thanks.

Ender