Airway emergency during anaesthesia using a metered-dose inhaler

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We wish to report a recent critical incident that resulted in a 5-mm fragment from the Luer lock connector of a 50-ml syringe entering the bronchus of a patient during anaesthesia.

This incident occurred during the management of persistent bronchospasm following a suspected anaphylactic reaction. Current guidelines from the Association of Anaesthetists of Great Britain and Ireland [1] advocate the use of salbutamol, either intravenously or via a metered-dose inhaler, in such circumstances. However, as no proprietary adaptor exists, the use of an inhaler device requires an improvised means of connecting and discharging the inhaler into the patient’s breathing system. One such technique that is widely known amongst anaesthetists and operating department practitioners in our institution, and that has recently been highlighted in this journal [2], involves placing the inhaler in the barrel of a 50-ml Luer lock syringe, inserting the end of syringe/inhaler assembly directly into the proximal end of the patient’s artificial airway, and discharging the inhaler by means of gentle pressure applied directly to the plunger. When we performed this technique using a 50-ml Becton Dickinson Plastipak™ syringe (Becton Dickinson, Oxford, UK), a cracking sound was heard emanating from the syringe/inhaler assembly, and immediate examination demonstrated the presence of fracture lines on the syringe barrel and a 5-mm fragment missing from the Luer lock connector (Fig. 1). Careful examination with a fibreoptic bronchoscope confirmed the presence of the syringe fragment in the patient’s left lower lobe bronchus. This foreign body was subsequently retrieved by means of rigid bronchoscopy, following which the patient made an uneventful recovery.

Figure 1.

 50-ml Luer lock syringe demonstrating fracture lines on barrel and 5-mm fragment retrieved from the patient’s bronchus.

We have been unable to find any similar case reports in the literature and could not replicate the pattern of damage during bench testing of a further 20 syringe/inhaler assemblies. To avoid replication of this rare but potentially serious critical incident, we suggest that the delivery of drugs using metered-dose inhalers in the barrel of a 50-ml Luer lock syringe would be more safely performed with the use of a T-piece connector or the attachment of a short length of fine-bore tubing to the end of the syringe that can be fed down the airway, thereby avoiding direct application of the syringe/inhaler assembly to the proximal end of a patient’s artificial airway.

No external funding and no competing interests declared. Published with the written consent of the patient’s parents.

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