Airway fires are an uncommon but real and devastating complication of trach
eostomy, One such fire in a 31-year-old man is described. Surgical fires ar
e discussed, and 15 reported cases of tracheostomy fire are reviewed. A tra
cheostomy protocol, adopted by our department and designed to avoid this li
fe-threatening complication, is described. Surgeons and anaesthetists invol
ved in tracheostomy must understand the fire hazard and how to avoid it.