Background <p>Percutaneous dilatational tracheostomy (PDT) is a widely performed procedure in intensive care units (ICUs) for patients requiring prolonged mechanical ventilation. Although generally safe, PDT carries risks of complications, some of which may be life-threatening. Foreign body aspiration is a well-known concern, but the iatrogenic migration of procedural components, such as a tracheostomy needle sheath, has received little attention.</p> Case presentation <p>We report the case of a male patient with intracerebral hemorrhage (ICH) who underwent a percutaneous dilatational tracheostomy. During the procedure, the sheath of the tracheostomy needle became dislodged and migrated into the tracheobronchial tree. Urgent intervention was required to prevent further complications. Bronchoscopy was promptly performed at the bedside, revealing the foreign body in the right main bronchus. Initial retrieval attempts using biopsy forceps were unsuccessful due to the sheath’s positioning. The sheath was eventually maneuvered into the endotracheal tube (ETT) and extracted in a coordinated manner with the simultaneous removal of the ETT and forceps. The tracheostomy tube was then successfully placed under bronchoscopic guidance, and the patient remained stable without further complications.</p> Conclusion <p>This case highlights a rare and potentially life-threatening complication of PDT, emphasizing the essential role of bronchoscopy in managing intraprocedural complications. It underscores the importance of procedural expertise and vigilance in ICU settings.</p>