Although the incidence of tracheostomy tube (TT) displacement is as less as 1.5% it can be a life threatening emergency especially when it occurs within 72 hours of formation of stoma. It is very important to rapidly secure the airway and reposition the TT. Complications can be reduced if the guide to facilitate recannulation of trachea is done under direct vision.

A 73 year oldmorbidly obese female with type 2 respiratory failure secondary to obstructive sleep apnea was tracheostomised for weaning from ventilator support. 18 hours later she started desaturating and measured tidal volumes were very less. As the patient could vocalize clearly, displacement of the tube was suspected and was posted for tube change in OT. Attempts to railroad TT over suction catheter failed twice. A strong suspicion of pushing it into a false passage was made in view of inadequate length of the tube. Stoma occluded and oxygenation maintained with bag and mask. There was an urgent need for the establishment of definite airway. 6.0mmID PVC COETT passed through the tracheostomy stoma,position confirmed by capnograph and FOB. It was necessary to ensure the adequate length of the tube inside the trachea by FOB through another port so orotracheal intubation was planned and sevoflurane administered through the same tube. Trachea intubated orally by direct laryngoscopy using 6.5mmID PVC COETT with simultaneous removal of the tube through the tracheostomy stoma over bougie1. FOB passed through the orotracheal tube and a long TT railroaded over bougie1 and adequate length inside the trachea confirmed. Orotracheal tube removed over bougie2. FOB passed through the TT and final position confirmed and then bougie2 was removed.