Abstract
Endoscopic percutaneous dilational tracheostomy (PDT) has come to be used widely in intensive care units. PDT is simple to perform and is reported to be as safe as surgical tracheostomy, but changing of the tracheostomy tube after PDT may be difficult. Here, we report a case whose tracheostomy tube was misplaced in the anterior mediastinum during a tube change after PDT. This case demonstrates the potential danger of changing the tube in the post-operative period. The surgical method and PDT are shown to differ with regard to the dimensions of the tracheostomy orifice and the passage from the orifice to the trachea. Additionally, we propose solutions for tube misplacement after PDT.
