title: A case of death caused by tracheal tube aspiration.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Alireza
authors.initials: A
authors.lastname: Mirkheshti
authors.affiliation: Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Morteza
authors.initials: M
authors.lastname: Jabbary Moghadam
authors.affiliation: Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Mohamad Shahab
authors.initials: MS
authors.lastname: Kalantar
authors.affiliation: Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Dariush
authors.initials: D
authors.lastname: Abtahi
authors.affiliation: Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Elham
authors.initials: E
authors.lastname: Memary
keywords: Airway Management; Endotracheal Intubation Complications; Endotracheal Intubation Mortality