AIRWAY FIRE PROTOCOL

If an airway fire or explosion occurs, the surgeon and anesthesiologist must act quickly, decisively, and in a coordinated fashion. This may not be easy after an explosion, because the event may be so traumatic as to incapacitate the operating room staff temporarily. Clear communication and emergency practice (at least a mental drill of the emergency procedure) are key to managing such a crisis. Schramm and colleagues^[104] provided a useful review of the ensuing pathologic features and suggested emergency management.

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, despite reflexive training to the contrary, stop ventilation. Temporarily disconnecting the breathing circuit from the anesthesia machine may be useful. These maneuvers remove the flame and the retained heat in the tube and stop the flow of oxygenenriched gas. The flaming material should be extinguished in a bucket of water, which should always be available during laser surgery. Ventilation with 100% oxygen should then be provided by mask, and anesthesia should be continued.

Direct laryngoscopy and rigid (Venturi-ventilating) bronchoscopy should then be performed to survey damage and to remove debris. If the fire was of the "interior blowtorch" type, gentle bronchial lavage may be indicated, followed by fiberoptic assessment of the more distal airways. If any airway damage is apparent, the patient should be reintubated. Fortunately, small fires involving only the exterior of the tube may not cause appreciable damage. If the damage is severe, a low tracheotomy may be indicated.

The pattern of damage in interior fires tends to be worst in the upper airway and diminishes as the surgeon approaches and passes the carina. The patient's oropharynx and face should be assessed, and a chest radiograph should be obtained. Pulmonary damage due to heat or smoke inhalation, or both, may necessitate prolonged intubation and mechanical ventilation. A brief course of high-dose steroids may be helpful.^{[105] [106]}

Lasers provide a useful tool in the surgical armamentarium, one for which anesthesiologists must with increasing frequency prepare their patients and themselves. Although some of the potential threats posed by clinical lasers are unique, most are extensions of the risks posed by the previous generation of surgical tools. As with most potentially dangerous procedures, the risks of laser use can be minimized by common sense and preconsidered contingency plans.