A case of death caused by tracheal tube aspiration

Abstract

Introduction: Airway management, especially outside the operating room, needs meticulous observation in order to avoid certain risks, such as; endotracheal tube (ETT) disloca-tion, esophageal intubation, and unwanted extubation. ETT or tracheostomy dislocation is responsible for one-half of death or brain damage cases in the ICU. Despite appropri-ate fixation of an ETT, the previously mentioned compli-cations can still occur. A broken ETT and consequent airway obstruction may lead to lethal complications. Case Presentation: We report a case of death caused by tracheal tube aspiration, where it was located distal to the vocal cords, with a part of it entering the right bronchus and the mediastinum, after tearing the right bronchus. Discussion: The vigilance and experience of medical personnel in the ICU, appropriate IV sedation, and using a bite block are the best ways to prevent mortality caused by aspiration of an ETT in all intubated patients. © 2014, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM).