Airway Fire During Left Pneumonectomy: A Case Report

Abstract Background. Intraoperative airway fire is extremely rare yet potentially fatal, and an oxygen-filled tracheal tube is a major risk factor. Fire during pneumonectomy—in which the airway is simultaneously the operative field, the sole ventilatory route, and the conduit for combustion—is uniquely hazardous. We describe such a case and analyze its mechanism, management, and prevention. Case presentation. A 70-year-old man with hypertension, type 2 diabetes mellitus, and a long history of smoking underwent thoracoscopic resection of a centrally located left-lower-lobe squamous cell carcinoma. During left pneumonectomy, while the left main bronchus was being divided with monopolar electrosurgery, sudden flame and smoke indicated combustion of the double-lumen tube, which was judged nonventilatable and urgently changed to a single-lumen tube. Before chest closure, bronchoscopy showed red, edematous mucosa with diffuse black carbonized deposits over the carina and both main bronchi; four intraoperative lavage passes were performed, and three further passes were carried out intermittently while the patient remained intubated in the intensive care unit. He was extubated on the first postoperative day, developed transient atrial fibrillation on the second, and was discharged on the seventh. Histopathology confirmed keratinizing squamous cell carcinoma (pT4N2M0, stage IIIB). Conclusions. Recognition of the fuel–oxidizer–ignition triad, and preventive measures adopted before and during bronchial division, are essential. Once a fire occurs, immediate cessation of oxygen, rapid re-establishment of a ventilatable airway, aggressive bronchoscopic saline lavage, glucocorticoid pulse therapy, and supportive postoperative care together supported a favorable outcome; at follow-up the patient had completed five cycles of chemotherapy, with intermittent cough and sputum production and hoarseness attributed to unilateral vocal cord paralysis, but remained able to carry out the activities of daily living without clinically significant laryngotracheal stenosis.