A 50 percent or greater savings in oxygen usage and aesthetic benefits leading to increased compliance are reasons for increasing use of the transtracheal catheter for administration of home supplemental oxygen. Minor complications of the procedure are common and include catheter dislodgement, bronchospasm, subcutaneous emphysema, bleeding at the catheter site, as well as hemoptysis and wound infections. Rare complications include retroflexion of the catheter into the upper trachea from coughing, and fracture of the catheter with loss in the trachea. New, improved catheters and detailed descriptions for operator use may reduce the frequency of these complications. This report describes a potentially serious complication of a transtracheal catheter system which resulted despite appropriate use and care of the catheter.