Percutaneous dilational tracheostomy Malposition leading to delayed weaning

Abstract

We report a patient in whom delayed weaning from ventilatory support was caused by the malposition of a percutaneous dilational tracheostomy tube. A fold of mucosa, identified at tracheoscopy, was found to be the limiting factor, and the situation was resolved by removal of the tracheostomy and reintubation. We believe that the case supports the routine use of a bronchoscope to check the position of the tracheostomy tube.