Airway Fire in Laser Surgery: A Team Protocol

Why the airway is a high-risk site

A fire needs an ignition source, fuel and an oxidiser. In laryngeal and tracheal laser surgery all three share a narrow space: the laser is the ignition source, the endotracheal tube, swabs and drapes are fuel, and oxygen, sometimes enriched, is the oxidiser. A standard polyvinyl chloride tube can ignite if the beam strikes it, and the burning plastic can feed a flame inside the airway.

The risk cannot be reduced to zero, so the strategy is to remove or isolate each element and to rehearse the response. Many hospitals formalise this with a fire risk assessment performed at the surgical time-out.

Laser safe endotracheal tube: selection and use

A laser safe endotracheal tube is designed to resist a specific laser type and wavelength. The word specific matters: a tube validated for one laser is not automatically suitable for another, so read the tube manufacturer's labelling and match it to the laser in the room, for example a 10,600 nm CO2 laser such as the A.R.C. C-Las.

Cuffs are often the most vulnerable part. Anaesthesia teams commonly fill the cuff with saline, sometimes tinted so that a leak is visible, and protect it with wet pledgets. Verify the cuff position relative to the surgical site and have a spare tube ready.

Oxygen, nitrous oxide and ventilation strategy

Use the lowest inspired oxygen concentration that is clinically acceptable and avoid nitrous oxide, which supports combustion. Ventilation techniques vary, including intermittent apnoea, jet ventilation and tubeless approaches; the choice belongs to the anaesthetist and surgeon according to the case and local protocol.

Agree beforehand who communicates with whom. The surgeon should announce when the laser is about to be activated, and the anaesthetist should confirm oxygen concentration and readiness. See also our overview of laser laryngeal surgery.

• Lowest clinically acceptable FiO2, confirmed aloud before activation.
• No nitrous oxide in the breathing circuit during laser use.
• Laser-safe tube matched to the laser and wavelength.
• Saline-filled cuff and wet protection around it.

Fuel control, drapes and equipment

Keep drapes and swabs wet near the field, count them, and keep a bowl of saline and a syringe within reach. Use moistened cotton patties to protect tissue and the cuff. Remove or cover other flammable materials, including alcohol-based skin preparations and gels, and let them dry fully before draping.

Equipment is part of the system: set the laser to standby when not in use, use a footswitch only under the surgeon's control, and use smoke evacuation near the field. Wavelength-appropriate eyewear and warning signs support the wider safety programme described in our medical laser safety guide.

If a fire occurs, and training

The widely taught response is to stop the laser, disconnect the breathing circuit and oxygen source, remove the tube, flood the airway with saline, then re-establish ventilation and assess the injury. Your hospital protocol defines roles and sequence, and the team should rehearse it with simulation at least periodically.

Beckfinity supports departments with product information and training coordination for A.R.C. lasers. Request a quote or consultation, and confirm current requirements for laser safety and device registration with the relevant UAE authorities.