Tracheal foreign body following tube change during percutaneous dilational tracheostomy: a cautionary tale.

Although studies have shown percutaneous dilational tracheostomy to be a safe and cost-effective alternative to conventional surgical tracheostomy, there are inherent risks and complications. We report an incident occurring during percutaneous dilational tracheostomy using the Portex technique, in which a significant cuff leak occurring on insertion of the tracheostomy tube necessitated an immediate tube change. During this latter procedure, using a fresh Portex kit and guidewire, the guidewire introducer became dislodged from the guidewire assembly and inadvertently impacted in the trachea. Routine bronchoscopy identified the hazard and the foreign body was successfully removed via the bronchoscope with no adverse sequelae.