Long-term Survival after Endobronchial Fire during Treatment of Severe Malignant Airway Obstruction: DiscussionLaser phototherapy has been shown to be effective with acceptable risks in the management of malignant and benign obstructing airway lesions. The concomitant use of radiation therapy after LPT for malignant lesions improves the quality of life and survival, which may exceed one year. At initial treatment, our patient had a Karnofsky score of 10 percent, indicating an extremely poor prognosis with a high likelihood of early mortality. As a result of the endobronchial fire, there was initial worsening of the airway obstruction and her hospital stay was lengthened by a few days. Combined LPT and radiation therapy enabled her to survive nearly 23 months with improvement of her Karnofsky score and no long-term morbidity due to the fire.

Major complications occurring during LPT include bronchial perforation, hemorrhage, esophageal fistula, hypoxemia, anesthetic complications, endobronchial fire,- and death. Careful case selection and meticulous technique can reduce these complications. Patients with severe malignant airway obstruction frequently have significant underlying cardiac, pulmonary, or other diseases which can cause instability, significantly complicate their management, and require rapid therapeutic intervention. In these patients, intensive monitoring is necessary during LPT. Continuous communication among members of the operating team during LPT regarding changes in condition or therapy is imperative, since serious consequences can occur when these elements fail to operate effectively.
Several points deserve discussion concerning potential fire during LPT. First, several authors have suggested using a rigid metal bronchoscope (RB) during LPT since it contains no flammable materials. However, endobronchial fire is rarely seen during LPT utilizing the FOB. Some problems associated with the rigid bronchoscope include lack of familiarity in technique, potential damage to upper airway, limited access to lower airways, inability to use local anesthesia, difficulty in using inhalation agents, and frequently, prolonged recovery time after narcotic anesthesia. Second, TCFs employ high airflow to assist in local cooling of treated tissue, but NTCFs lack this feature. Thus, higher local tissue temperatures may occur during treatment with NCTFs and could increase the likelihood of fire. Third, laser fires may occur at any oxygen concentration. This risk increases as the oxygen concentration increases and becomes very high above FIo2 0.5. Not infrequently, brief self-limited flash fires occur after tissue has carbonized. Fortunately, extensive fire rarely results.