Prevention of airway fires during tracheostomy is preferable. Comment on: Simulation training results in performance retention for the management of airway fires: A prospective observational study

Eidelman Pozin et al. describe simulation training for the management of airway fires. In their scenario, a ventilated patient with a high oxygen requirement requires a surgical tracheostomy. ¹ A fire ensues when the surgeon uses diathermy in the trachea in the presence of a FiO₂ of 0.6.

Training to manage airway fires is important, but it is preferable to prevent them. The risk of airway fire during tracheostomy can be minimised by a simple change in technique: advancing the tracheal tube (with cuff inflated) into the distal trachea prior to tracheotomy.^2,3 The surgeon can then incise the proximal trachea without damaging the tracheal tube cuff.

Once the fenestration has been formed, the tracheal tube can be withdrawn under direct vision of the surgeon until the tip is proximal to the fenestration. The tracheostomy tube can then be inserted.

This technique has several advantages. Diathermy use is safer because the trachea proximal to the cuff is exposed to room air. The patient can be maintained on a higher FiO₂ and positive end-expiratory pressure throughout, allowing better support for oxygenation. Finally, no airway leak or aerosol generation occurs.

Teaching this technique as part of the simulation programme could help prevent airway fires.