LAUSR

© BMJ Publishing Group Limited 2022. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION Reported causes of an airway foreign body (AFB) from anaesthesia airway equipment include endotracheal tube (ETT) fragments, laryngoscope lightbulbs and shearing of fragments from double lumen tubes and bougies. AFBs from a dislodged fragment of a bronchoscope dualaxis swivel adapter are potentially lifethreatening. Such adapters are commonly used during the airway procedures where the adapter allows access of a bronchoscope to the airway while maintaining ventilation and oxygenation without disconnection from the ventilator circuit. We report a rare case where a fragment from an airway swivel adapter dislodged into the patient’s airway during an endobronchial ultrasound (EBUS). A woman in her 50s presented for an urgent EBUS to investigate the cause of a large left hilar mass causing extrinsic compression of the left main bronchus. To facilitate the procedure, a double swivel elbow adapter with port, manufactured by Southern Cross Medical, New South Wales, Australia, was attached distally to the patient’s ETT and proximally to the ventilation circuit. The connector port has a fenestrated plastic membrane (inner diameter 12.8 mm) that allows the passage of the bronchoscope, without compromising the air seal for ventilation (figure 1). As the Fujifilm EB530 ultrasound bronchoscope (outer diameter 6.7 mm) was passed through the swivel adapter, a fragment of the plastic membrane dislodged into the patient’s trachea. Fortunately, the AFB was visualised in the distal trachea, approximately 22 mm proximal to the carina (figure 2) and the bronchoscopist was able to retrieve the fragment without incident (video 1). Fragmentation of the plastic membrane may be explained by the factors related to the swivel connector itself, the bronchoscope or the proceduralist. A defect in the dualaxis swivel adapter may be due to an isolated manufacturing defect in the plastic membrane, or that the integrity of the membrane was compromised by incorrect storage or handling. In the present case, we postulate that the reason for the defect in the dualaxis swivel adapter was because the EBUS had a larger outer diameter compared with a standard bronchoscope, so it is likely that the rotational and linear forces of the EBUS damaged the membrane. The proceduralist’s level of experience may also have played a role in the amount of stress placed on the plastic membrane during the EBUS insertion. Although early recognition of the AFB and an appropriate response by the bronchoscopist ensured a good outcome for this patient, the potential consequences of the fragmented swivel connector were serious. In retrieving the AFB, the procedure duration was extended and further instrumentation within the airway was required, both of which increased the risk of airway trauma, hypoxia and respiratory compromise. Furthermore,