To the Editor:

Medical device complications remain a major source of morbidity, especially device-acquired infections. However, many other sources of patient harm related to device insertion also exist. We describe the case of a 6-year-old male undergoing bronchoscopy through a 4.5 oral RAE endotracheal tube (ETT) found to have a partially obstructing retained Murphy eye remnant. During bronchoscopy, a clear foreign body was seen within the ETT lumen. The ETT was removed with bronchoscopic visualization. The object was the retained Murphy eye cutout (see ESM picture). The case was completed without further issues and no patient harm occurred. Per protocol, a safety incident report was filed. The lot number was identified and all anesthesia providers were notified immediately of the potential risks.

This case highlights a potential injury secondary to production flaws in a pediatric ETT. This has been previously reported in adult ETTs but not pediatric RAE ETTs, used in high volumes for ENT procedures in children [1, 2]. Fortunately, this was recognized prior to dislodgement. The remnant was large enough (0.6 cm × 0.4 cm) to obstruct pediatric bronchial branches. Unrecognized airway foreign bodies may be difficult to diagnose and have lethal complications. In our case, the foreign object was recognized while still within the lumen of the ETT. Nonetheless, our findings highlight the need to examine all medical devices prior to insertion, because sometimes Murphy’s law (anything that can go wrong will go wrong) applies to Murphy eyes.