Laser initiated endotracheal tube explosion

A 62-year-old male with a diagnosis of subglottic and tracheal stenosis resulting from a prolonged intubation was scheduled for a laser bronchoscopy and placement of a silicon T-shaped tube. His history was significant for two myocardial infarctions, an episode of congestive heart failure and exertional angina. A 6 mm polyvinyl chloride endotracheal tube, wrapped with aluminum tape, was placed in an existing tracheostomy stoma. During the course of the procedure, a sudden bright flash occurred followed by an explosive noise and black smoke rising in the anesthesia circuit and from the patient's mouth. The endotracheal tube was removed and the patient was treated for first and second degree burns in the supraglottic area and base of the tongue. In laser surgery of the airway, special care should be given to reducing the flammability of the inspired gases which can be best accomplished by the mixture of helium with oxygen. Helium acts to retard ignition of polyvinyl chloride tubes in concentrations of 60% or greater. The external surface of the tube can also be protected with the application of a metallic tape affixed in a spiral fashion. Finally, a protocol for the management and treatment of this emergency should be adopted and rehearsed.