tulAnesthesia

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has anyone actually seen this happen, or know of someone that this has happened to?

you pull it out first, right?
 

Gern Blansten

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I have not seen it personally, but, yes, it has occurred before with devastating results. Pull the tube. Another rare occurrence that you should have a plan in place for.
 

Noyac

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Some books and experts (?) say that you turn the gas (mostly O2 ) off b/4 pulling the tube. With O2 flowing the end of the tube acts like a blow torch and scalds everything in its path. I'm not sure how I would react if I saw a fire in the ETT but I wouldn't be surprised if I just pulled the sucker immediately.

I would hope that I would disconnect the circuit first then pull the tube all in one swoop. This would accomplish both.
 

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Noyac said:
Some books and experts (?) say that you turn the gas (mostly O2 ) off b/4 pulling the tube. With O2 flowing the end of the tube acts like a blow torch and scalds everything in its path. I'm not sure how I would react if I saw a fire in the ETT but I wouldn't be surprised if I just pulled the sucker immediately.

I would hope that I would disconnect the circuit first then pull the tube all in one swoop. This would accomplish both.
Yank it - the fire's already there. And yank means yank - don't carefully withdraw the tube - get it out.

And hopefully one wouldn't have 100% O2 flowing anyway. There shouldn't be a "blowtorch" effect at near-room-air O2 levels.
 

rn29306

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Ever seen PVC burn? It turns molten and then drips (while still on fire) like lava down into the lungs. Then it hardens in the resp tract.

Your cuff will burst first, you loose PPV capability.

I've always heard to yank it immediately.
 

dogbone65

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Noyac said:
Some books and experts (?) say that you turn the gas (mostly O2 ) off b/4 pulling the tube. With O2 flowing the end of the tube acts like a blow torch and scalds everything in its path. I'm not sure how I would react if I saw a fire in the ETT but I wouldn't be surprised if I just pulled the sucker immediately.

I saw it happen once in the cath lab. I just happened to be walking by and it DID look like a blowtorch coming of the dude's mouth. Scary $hit!
 

Mapleson D

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I was going to ask whether you're supposed to pop the valve off to deflate the cuff or just yank the balloon through the cords, but I guess according to RN29 that might be a moot point . . .
 

proman

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dogbone65 said:
I saw it happen once in the cath lab. I just happened to be walking by and it DID look like a blowtorch coming of the dude's mouth. Scary $hit!

Curious what the ignition source was in a cath lab?
 

meddog1

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Whiile simultaneously yanking the tube, disconnect the ETT from the circuit to prevent an OR torch from flying around. Irrigate and suction the oropharynx and then get a mask and bag-up the PT. Re-intubate when safe to do so and get a PCXR in the OR ASAP. I would run an ABG and get a baseline CO level as well. Do a bronchoscopy to see if there is any obvious gross damage. Of course, have the surgeons hold or perhaps even cancel the case, depending on your clinical findings.

Just my opinion. :idea:
 

bubalus

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The online miller has an impressive picture of the ETT blowtorch. Flame shooting out about the length of the ETT tube. I've heard both--pull it immediately or stop the fire then pull. I think in the end, you do several things at once. As for what the people wanted on the boards last Saturday, I've got no idea. I've seen the after effects of an airway fire. Not pretty.
 

meddog1

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bubalus said:
The online miller has an impressive picture of the ETT blowtorch. Flame shooting out about the length of the ETT tube. I've heard both--pull it immediately or stop the fire then pull. I think in the end, you do several things at once. As for what the people wanted on the boards last Saturday, I've got no idea. I've seen the after effects of an airway fire. Not pretty.
Bubalus, was there a lot of pulmonary involvement like post-op ARDS (or worse), or did the fire stay isolated to the ETT?
 

VolatileAgent

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sequence is thus:

1.) fire out.
2.) tube out.
3.) bag/reintubate.
4.) change pants (i.e. yours).
5.) pray.
6.) everything else you do after a (suspected) airway burn.

any questions/disagreement/best way to accomplish this sequence, we can discuss.
 

SleepIsGood

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bubalus said:
The online miller has an impressive picture of the ETT blowtorch. Flame shooting out about the length of the ETT tube. I've heard both--pull it immediately or stop the fire then pull. I think in the end, you do several things at once. As for what the people wanted on the boards last Saturday, I've got no idea. I've seen the after effects of an airway fire. Not pretty.
if it's not against copyright infringement or anythign could you post the pic on here?
 

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VolatileAgent said:
sequence is thus:

1.) fire out.
2.) tube out.
3.) bag/reintubate.
4.) change pants (i.e. yours).
5.) pray.
6.) everything else you do after a (suspected) airway burn.

any questions/disagreement/best way to accomplish this sequence, we can discuss.
I disagree, tube out first. It is the problem. Your sequence would suggest that if the fire won't go out the tube stays in???
 

Laryngospasm

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VolatileAgent said:
sequence is thus:

1.) fire out.
2.) tube out.
3.) bag/reintubate.
4.) change pants (i.e. yours).
5.) pray.
6.) everything else you do after a (suspected) airway burn.

any questions/disagreement/best way to accomplish this sequence, we can discuss.
Tube out first, it is the source of the fire. I wouldnt give that answer during oral boards, unless i was looking for a return trip.
 

bubalus

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The post-fire airways looked horrible--scorched and charred. Very bad.

I'm still not convinced whether you put out the fire or pull the tube first. I've asked several anesthesiologists I respect and heard both answers. I think the important thing is to get the fire out and get the tube out then reintubate and bronch to evaulate damage. If you pull the tube first, you risk blowtorching the airway as you pull the tube. On the other hand, the ETT is the fuel and will burn the airways and leave ash and molten plastic behind. I do think it is important to disconnect the circuit before pulling the tube since that will decrease the flow of oxidizer and shorten the flame.

One of the problems with ETT fires is that you may actually get 2 flames, an intraluminal that travels toward the flow of oxidizer vaporizing volatile combustible products from the tube, and a secondary flame at the downstream end of the tube which ignites those products and shoots them out like a blowtorch.

You can see a picture of the ETT on fire at ETT fire. rn2936, the cuff is still inflated in that picture. It's also inflated in the Miller picture. I don't know whether the cuff stays inflated in vivo or not.

This is a little different from the picture in Miller. The Miller picture has an oxygen line entering the tube, so the flame is longer, more like a blowtorch.
 

meddog1

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bubalus said:
The post-fire airways looked horrible--scorched and charred. Very bad.

I'm still not convinced whether you put out the fire or pull the tube first. I've asked several anesthesiologists I respect and heard both answers. I think the important thing is to get the fire out and get the tube out then reintubate and bronch to evaulate damage. If you pull the tube first, you risk blowtorching the airway as you pull the tube. On the other hand, the ETT is the fuel and will burn the airways and leave ash and molten plastic behind. I do think it is important to disconnect the circuit before pulling the tube since that will decrease the flow of oxidizer and shorten the flame.

One of the problems with ETT fires is that you may actually get 2 flames, an intraluminal that travels toward the flow of oxidizer vaporizing volatile combustible products from the tube, and a secondary flame at the downstream end of the tube which ignites those products and shoots them out like a blowtorch.

You can see a picture of the ETT on fire at ETT fire. rn2936, the cuff is still inflated in that picture. It's also inflated in the Miller picture. I don't know whether the cuff stays inflated in vivo or not.

This is a little different from the picture in Miller. The Miller picture has an oxygen line entering the tube, so the flame is longer, more like a blowtorch.
Dude, that's brutal! :eek:
 

Noyac

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bubalus said:
ETT fire. rn2936, the cuff is still inflated in that picture. It's also inflated in the Miller picture. I don't know whether the cuff stays inflated in vivo or not. .

Generally, the cuff will burst in vivo. This is usually before the fire when the laser hits it. It is recommended that the cuff be filled with saline and methaline blue dye so as to detect a ruptured cuff before a fire occurs.

The other way a fire occurs is when 02 leaks around a wrinkle in the cuff. You can minimize this by lubing the cuff with a jelly before insertion in attempts to form a better seal.

Like I said earlier. Disconnect the circuit while pulling the ETT.
 

Noyac

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ericL said:
I'm just a paramedic, premed, who happened to be exploring and wandered in here, but I had a question: what would be the ignition source for thes fires?

Lasers and bovies.
 

bubalus

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Laser hits the cuff and bursts it. Now you've got exposure to an oxygen-enriched atmosphere. A Bovie can do the same thing, especially if it's set on light saber power. The tube itself is the fuel. Other things can serve as fuel including pledgets, laps, etc. Kids are something else to consider because many people use uncuffed tubes in them, so there will be a leak at a certain pressure, and that can also lead to an oxygen-enriched atmosphere where you've got a source of ignition. Dessicated tissue can burn, but it usually can't support combustion long enough to cause severe damage like other fuels can.
 

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Laryngospasm said:
Tube out first, it is the source of the fire. I wouldnt give that answer during oral boards, unless i was looking for a return trip.
"In conclusion, it seems prudent to specify the circumstances in which the ETT should be removed immediately after the occurrence of airway fire. It is necessary to consider the benefits and the risks involved in removing the ETTs in patients with potentially difficult airways. Because the most common cause of anesthesia-related morbidity and mortality is hypoventilation and hypoxemia from difficult airway management [19] and a severe and extensive burn injury seems unlikely with airway fire during tracheostomy, further critical review of the airway fire management protocol is warranted."

link

like i said, put the fire out first.
 

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VolatileAgent said:
"In conclusion, it seems prudent to specify the circumstances in which the ETT should be removed immediately after the occurrence of airway fire. It is necessary to consider the benefits and the risks involved in removing the ETTs in patients with potentially difficult airways. Because the most common cause of anesthesia-related morbidity and mortality is hypoventilation and hypoxemia from difficult airway management [19] and a severe and extensive burn injury seems unlikely with airway fire during tracheostomy, further critical review of the airway fire management protocol is warranted."

link

like i said, put the fire out first.
You seem to have defined the rule with the exeption, interesting tactic. While in some specialized situations such as tracheostomy pulling the tube may be incorrect, both Miller et al and Niels Jensen Big blue say to pull the tube first. Miller says specifically to remove the source of the fire and extinguish it in a bucket of water. Since both of these sources are very knowlegeable, and board examiners I will go with them. I guess well agree to disagree.
 

Noyac

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Laryngospasm said:
You seem to have defined the rule with the exeption, interesting tactic. While in some specialized situations such as tracheostomy pulling the tube may be incorrect, both Miller et al and Niels Jensen Big blue say to pull the tube first. Miller says specifically to remove the source of the fire and extinguish it in a bucket of water. Since both of these sources are very knowlegeable, and board examiners I will go with them. I guess well agree to disagree.

You just referenced Jensen's BIG BLUE. :eek:

I read it. It helped me get through boards but it is filled with misinformation. Board examiners HATE it (probably because it works).

In my book "Noyac's Everyday Practice of Anesthesia" disconnect the circuit as you pull the tube. It takes no time.
 

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This just blows my mind. I have never heard of it, but I hope it's a rare freaky occurence. How many of you have actually seen this in your practice? I can't imagine having good sense to do anything productive for a few seconds at least if I saw a fire coming out of my patients ETT.
 

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"Fire in the ET tube!"

Makes me think of the anesthesia equivalent of "Fire in the hole!"
 

VolatileAgent

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i think the whole point is that this has not been extensively studied. the "best practice" guidelines have only been cobbled together from case reports.

the bottom line is that, in examination ex post facto of patients who've had this happen to them, there seems to be generally little evidence of extensive airway burn if the problem is identified and corrected early - whether or not the tube is pulled.

it is clear, and i think we'd all agree, that you should stop ventilation (i.e., the "blow torch effect") immediately. what to do next is clearly controversial. it seems prudent, to me, to put the fire out first. if your first reaction is to yank the tube, you may not get it back in. then what will you do? it seems logically that you run a much greater risk of failing your "A" in the ABCs if you pull the tube out right away, especially if it was tricky getting it in there in the first place (which is not an uncommon scenario in a patient who is likely to be undergoing laser surgery in that area - e.g., laryngeal tumor, etc.).

several authors have suggested that we revisit this "standard practice" of pulling the tube. unfortunately, you can't prospectively study this in people. perhaps some enterprising resident or medical student has access to a few pigs, and through a nice study we could put this discussion to rest once and for good.

in the meantime, i'm going to extinguish (if it ever happens) before i pull. this will be agreed upon - and has been in the past when i've done such cases - with the ent surgeons before the case starts. of course, careful planning and equipment choice should hopefully preclude this complication from happening at all.
 

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VolatileAgent said:
i think the whole point is that this has not been extensively studied. the "best practice" guidelines have only been cobbled together from case reports.

i've been trying to put together a RCT for this problem but i get stopped by the institutional review board everytime with pesky details about how i'll create a fire in the ET tubes of the test subjects. something about ethics, they say.
 

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Yeah, I was always trained to use a lower FiO2 in those potentially dangerous ENT cases. I would keep it as close to atmospheric as possible and put a little PEEP on to help keep the O2 moving across. Whatever you do, keep N20 out of the mixture.
 

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Trisomy13 said:
i've been trying to put together a RCT for this problem but i get stopped by the institutional review board everytime with pesky details about how i'll create a fire in the ET tubes of the test subjects. something about ethics, they say.
did you read my whole post, or were you just being sarcastic for sarcasm's sake?
 

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VolatileAgent said:
did you read my whole post, or were you just being sarcastic for sarcasm's sake?

the latter. it's research humor! only for those who find humor in study design.
 

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You seem to have defined the rule with the exeption, interesting tactic. While in some specialized situations such as tracheostomy pulling the tube may be incorrect, both Miller et al and Niels Jensen Big blue say to pull the tube first. Miller says specifically to remove the source of the fire and extinguish it in a bucket of water. Since both of these sources are very knowlegeable, and board examiners I will go with them. I guess well agree to disagree.
Just read the newest edition of miller a couple of weeks ago. it says to disconnect and then pull out (although in all practicality you'll probably be doing a maneuver more similar to what Noy has been saying - doing both at the same time). From what i understand this is a new change to miller over previous editions b/c of the realization of the blow torch effect - i.e you'll be blow torching their airway as your pulling out the flaming tube :eek: