Ken-ichi Muramatsu.¹, Youichi Yanagawa^1,

We report a case of a tracheal tube exchanger container as a bronchial foreign body in a 75-year-old woman suffered multiple injuries. She needed tracheal intubation and mechanical ventilation for repeated operations and intensive care. On day 2, she showed hypoxia. A physician on duty exchanged the tracheal tube using a tracheal tube exchanger (TTE) with containers consisting of an upper and lower potion. After exchanging the tracheal tube, the upper container remained in right bronchus. From days 3 to 9, she underwent daily chest X-ray, and multiple physicians checked the chest X-ray images each time. However, no one noticed the residual upper container in the right bronchus. She was extubated on day 8. After transportation for skin graft, she expectorated the upper container spontaneously. As a preventive measure to avoid the occurrence of iatrogenic accidents, our hospital decided to sterilize the TTE without containers.

external cylinder, tracheal tube exchanger, bronchial foreign body, adult, iatrogenic accident