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Airway ®re due to diathermy during tracheostomy
S. A. Rogers,1* K. G. Mills2 and Z. Tufail31 Specialist Registrar, 2 Consultant, Department of Anaesthesia and Intensive Care, and 3 Specialist Registrar,
Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Liverpool, UK
We describe a case of airway ®re in an 83-year-old, critically ill patient. The ®re occurred during a
surgical tracheostomy under general anaesthesia, following ignition of the tracheal tube by
diathermy. After debridement of the burnt tissue and treatment with intravenous antibiotics and
glucocorticoids, the patient's respiratory function worsened initially. The patient eventually
recovered without long-term sequelae and was discharged from the intensive care unit. The
circumstances of this and other similar incidents are reviewed, as are the suggested methods for
preventing this frightening occurrence.
Keywords Airway ®re: tracheostomy; diathermy.
* Present address: Department of Anaesthesia and Intensive Care,
University Hospital Aintree, Lower Lane, Liverpool L9 7AL, UK.
Accepted: 2 November 1999
Fires in the operating theatre are seen as mostly of
On the afternoon of the operation, he was transferred
historical interest, dating back to the era of ether and
from the intensive care unit (ICU) to the main operating
cyclopropane anaesthesia. Recent interest in airway ®res
theatre. The patient was ventilated with iso¯urane in 100%
has mostly centred on the use of lasers in laryngeal surgery.
oxygen using the circle system of a Drager Cato anaes-
However, ®res caused by diathermy ignition of tracheal
thetic machine (Drager Medizintechnik GmbH, Lubeck,
tubes are still occasionally reported and may well be under-
Germany), and was monitored with electrocardiogram,
reported. These incidents have led to both morbidity and
pulse oximeter, invasive arterial blood pressure, end tidal
mortality; therefore, anaesthetic and surgical techniques
carbon dioxide and anaesthetic gas concentrations. The
should be modi®ed to reduce their incidence and severity.
surgeon performed a standard collar incision and dissected
down to the trachea with scissors, securing haemostasis
with coagulating bipolar diathermy. The isthmus of the
thyroid did not require division. The surgeon informed
An 83-year-old, male intensive care patient was listed for
the anaesthetist that he would open the trachea using the
a surgical tracheostomy. He had undergone coronary
diathermy, and the anaesthetist partially withdrew the
artery bypass grafting of four vessels 7 days previously,
tracheal tube. As the trachea was opened with the dia-
and had remained intubated (with an 8.5-mm internal
thermy in coagulation mode, there was a loud noise and
diameter Mallinckrodt PVC oral tracheal tube) and venti-
¯ames rushed out of the tracheal stoma during the
lated because of respiratory failure and a stroke. He
inspiratory phase of ventilation. The circuit was immedi-
required 70% oxygen with 2.5 cmH2O positive end-
ately disconnected from the tracheal tube and the ®re was
expiratory pressure (PEEP), as well as epinephrine and
rapidly extinguished with saline. The tracheal tube was
dopamine infusions. He had also developed acute renal
removed and an 8-mm Portex tracheostomy tube was
inserted into the trachea without dif®culty. The patient did
not become hypoxaemic or suffer any systemic distur-
After the ®rst 48 h, the patient's condition improved and
bance. A small area of burnt subcutaneous tissue around
he was discharged from the ICU to a general ward 26 days
the stoma was debrided. No muscle or deeper burn could
later with the tracheostomy tube in place. The patient was
be seen. Examination of the tracheal tube showed that
uneventfully decannulated a few days later and was trans-
it had been ignited and extensively burnt (Fig. 1) around
ferred to his local hospital for further care 14 days after his
the cuff. Although it was quite deformed, it had remained
discharge from the ICU. He eventually took his own
discharge 100 days after the airway ®re. At a follow-up
A bronchoscopy via the new tracheostomy was per-
cardiac surgery clinic 2 weeks later he was in good health.
formed. A possible small area of super®cial burn was
observed on the posterio-lateral surface of the trachea,
but no other burns or signs of inhalational injury were
seen. On direct laryngoscopy, no oral or laryngeal burns
Surgical tracheostomy is a commonly performed opera-
were seen. After consultation with a senior thoracic
tion that is undertaken by a number of surgical specialties
surgeon, dexamethasone 4 mg was given intravenously.
. It is also frequently required in critically ill patients.
The operation was completed without further problems
Although large retrospective studies suggest that the mor-
and the patient was transferred back to the ICU. Over the
bidity and mortality of the operation have been decreasing
next 48 h, his oxygen requirement increased to 100%. He
for some years , there are still many short- and long-
required neuromuscular blocking agents to facilitate ven-
tilation and he developed copious secretions from his
Ignition of the tracheal tube by diathermy (or electro-
lungs. After discussion, no further doses of dexamethasone
cautery, electrosurgery) during surgical tracheostomy is
were given. A further bronchoscopy showed normal
reported occasionally [2±7]. Its incidence is impossible to
trachea and bronchi and no signi®cant thermal injury.
determine , but, even though it is rare, laryngotracheal
burns following such a ®re may have contributed to a
The classical triad needed for a ®re or explosion (fuel,
energy and oxidising sources) are all present during surgi-
cal tracheostomy. Possible fuel sources include the tracheal
tube (usually made of PVC), charred tissue, suture mate-
rial, drapes and antiseptic alcohol solutions [2, 4, 9, 10].
Diathermy delivers an energy source that generates tip
temperatures in excess of 910 8C (1500 8F)  using an
alternating sine wave current at frequencies between
20 000 and 50 000 Hz. The cutting mode is continuous,
whereas coagulation is intermittent [4, 5, 11]. The oxidis-
ing sources are both oxygen and nitrous oxide; the latter
being a powerful oxidising agent in its own right .
In many of the reported cases, there are several common
factors. Many occurred in intensive care patients [2±7]
with complex needs, such as high oxygen requirements
and poor tolerance of periods of apnoea and loss of PEEP.
These patients have an increased incidence of mortality
and morbidity in larger studies of surgical tracheostomy
[1, 13]. High oxygen requirements [3, 5, 6], routine pre-
oxygenation prior to changing the tracheal tubes [2, 4, 7]
and supplementary nitrous oxide  were the usual
oxidising sources. In several cases [4, 6, 7], including the
one reported here and the case that resulted in a fatality ,
the tracheal incision was intentionally made using the
diathermy, either in the cutting or coagulation mode.
However, in other cases [2, 3], the tracheal incision was
made with a scalpel and the tracheal tube was ignited by
Figure 1 The 8.5-mm internal diameter Mallinckrodt PVC oral
the diathermy while securing haemostasis. In most of the
tracheal tube that was ignited at the cuff and extensively burnt.
cases [2±7], ignition was started by cuff de¯ation causing a
high ¯ow leak of oxygen-enriched gas into the surgical
assessment of respiratory function on the ICU [4, 7].
®eld, or in the case of oral ®res, a retrograde leak of oxygen
However, diathermy use can be avoided completely by
into the oral and pharyngeal cavities.
percutaneous dilational tracheostomy, a technique with a
In the case reported here, failure to withdraw the
tracheal tube suf®ciently and opening the trachea with
the diathermy were probably the most important factors.
Previous authors have made various recommendations
regarding the prevention of such ®res, which can be
1 Zeitouni AG, Kost KM. Tracheostomy: a retrospective
grouped into anaesthetic and surgical considerations.
review of 281 cases. Journal of Otolaryngology 1994; 23:
Anaesthetic considerations include keeping the inspired
oxygen concentration just high enough to allow satisfac-
2 Lim HJ, Miller GM, Rainbird A. Airway ®re during
tory arterial oxygen saturation, which may be dif®cult
elective tracheostomy. Anaesthesia and Intensive Care 1997;
in intensive care patients. However, some authors still
recommend the routine use of high oxygen concentrations
3 Bailey MK, Bromley HR, Allison JG, Conroy JM,
. Combining oxygen with a non-¯ammable carrier gas,
Krzyzaniak W. Electrocautery-induced airway ®re during
such as nitrogen or helium, has also been recommended
tracheostomy. Anesthesia and Analgesia 1990; 71: 702±4.
[2, 3]. Other manoeuvres include: positioning the tracheal
4 Aly A, McIlwain M, Duncavage J. Electrosurgery-induced
cuff either just above the carina or above the operative site,
endotracheal tube ignition during tracheotomy. Annals of
Otology, Rhinology and Laryngology 1991; 100: 31±3.
®lling the tracheal cuff with saline and packing uncuffed
5 Lew EO, Mittleman RE, Murray D. Endotracheal tube
tracheal tubes. Controversy also exists as to which type of
ignition by electrocautery during tracheostomy: case report
tracheal tube material is best, with PVC being described as
with autopsy ®ndings. Journal of Forensic Science 1991; 36:
both suitable  and unsuitable . The newer generation
of laser-resistant tubes may be the best solution , but
6 Marsh B, Riley RH. Double-lumen tube ®re during
this would entail an additional tube change in critically
tracheostomy. Anesthesiology 1992; 76: 480±1.
7 Le Clair J, Gartner S, Halma G. Endotracheal cuff ignited
Surgical considerations include: opening the trachea
by electrocautery during tracheostomy. Journal of the
with a scalpel blade, using a suction catheter to remove
American Association of Nurse Anesthetists 1990; 58: 259±61.
oxygen and smoke from the operative ®eld, and fashioning
8 Sosis MB, Braverman B. Prevention of cautery-induced
the tracheostomy in stages if there is a large gas leak. Use of
airway ®res with special endotracheal tubes. Anesthesia and
¯ame-retardant drapes, swabs and sutures may also be
9 Thompson JW, Colin W, Snowden T, Hengesteg A,
helpful, but these are often either expensive or unavailable.
Stocks RMS, Watson SP. Fire in the operating room
The most important factor is preventing the diathermy
during tracheostomy. Southern Medical Journal 1998; 91:
from coming into contact with both a fuel and an oxidis-
ing source. This is best achieved by avoiding diathermy
10 Brechtelsbauer PB, Carrol WR, Baker S. Intraoperative ®re
altogether. If diathermy is required, recommendations
with electrocautery. Otolaryngology ± Head and Neck Surgery
include disconnecting the breathing circuit prior to dia-
thermy use, covering visible portions of the tracheal tube
11 Hazard Report. Electrosurgical airway ®res still a hot topic.
with saline-soaked pledglets and using bipolar diathermy
in the coagulation mode at the lowest effective power
12 Macdonald AG. A short history of ®res and explosions
level. The bipolar mode will minimise current leakage to
caused by anaesthetic agents. British Journal of Anaesthesia
13 Wease GL, Frikker M, Villalba M, Glover J. Bedside
Practice ®re drills may be of bene®t [4, 9], but the most
tracheostomy in the intensive care unit. Archives of Surgery
important point is that the surgeon and the anaesthetist
must work together via good communication. In the event
14 Hill BB, Zweng TN, Maley RH, Charash WE,
of a ®re, it is important to assess the entire airway with
Toursarkissian B, Kearney PA. Percutaneous dilatational
both bronchoscopy and laryngoscopy. Treatment of airway
tracheostomy: report of 356 cases. The Journal of Trauma:
®res involves antibiotics, dexamethasone and regular
Injury, Infection, and Critical Care 1996; 40: 238±43.
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Primary Tracheomalacia T h o m a s H . Cogbill, M . D . , Frederick A . M o o r e , M . D . , Frank J . A c c u r s o , M . D . , a n d J o h n R. Lilly, M . D . ABSTRACT Tracheomalacia is a rare congenital malformation of the tracheobronchial cartilages in cheomalacia have been seen at our institution which the supporting cartilaginous rings permit ex-over the past four years. The clinical sym