Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 3 4 2017 10 28 400 402 EN Parviz Amri Maleh Clinical Research Development Unit of Rouhani Hospital,Babol University of Medical Sciences, Mazandaran, Iran Fatemeh Damavandi Clinical Research Development Unit of Rouhani HospitalBabol University of Medical Sciences, Mazandaran, Iran Fatemeh Heidarnia Clinical Research Development Unit of Rouhani HospitalBabol University of Medical Sciences, Mazandaran, Iran 2017 05 01 2017 06 25 A 72-year-old woman who was a candidate for percutaneous dilatational tracheostomy (PDT) using the Ciaglia Blue Rhino single dilator was examined. After dilation, a stoma was created on the guide wire, but the dilator could hardly pass through and pulled in the endotracheal tube with it. Bronchoscopy was therefore performed. The guide wire that was inside the Murphy eye of the endotracheal tube was then removed. So the dilator and guide wire was removed. The endotracheal tube was pulled back slightly and the tracheostomy tube was inserted once again. Fiberoptic bronchoscopy is recommended in cases of a problematic anatomy or when the PDT tube placement is suspicious. https://aacc.tums.ac.ir/index.php/aacc/article/view/121 https://aacc.tums.ac.ir/index.php/aacc/article/download/121/301