When a difficult airway is anticipated, securing it before induction may be the safest approach. Awake tracheostomy is one rare option that anesthesia teams should consider for selected patients—not simply as a rescue procedure, but as part of a deliberate airway plan.

Tracheal intubation is common and usually safe, but familiarity can create a false sense of security. Failed intubation and emergency surgical airway procedures can have life-threatening consequences. A case shared by one of my colleagues illustrates why careful airway assessment and planning matter.

Case: Awake Tracheostomy in Dissecting Aortic Aneurysm

An 80-year-old woman was diagnosed in the emergency department with a dissecting ascending aortic aneurysm. Alerted to her imminent arrival, the anesthesia team prepared the operating room for a major vascular case, including vasodilator and vasopressor infusions and invasive monitoring.

On arrival in the operating room, the patient was hypertensive at 180/105 and weak, but alert. Pulse was 90. There was a significant difference in blood pressure between both arms. The attending anesthesiologist and resident applied monitors, placed an arterial line in the right arm. They connected vasoactive infusions for later use.

The attending immediately recognized signs of a difficult airway: limited mouth opening, a recessed chin, and a Mallampati class IV view.

After discussing the plan with the patient and operating room team, the attending topicalized the airway. She administered remifentanil and midazolam to permit a brief laryngoscopic assessment. Videolaryngoscopy was not available. She chose those agents because they were short acting and easily reversible. During a quick look, neither the resident nor the attending could obtain a view of the vocal cords.

The attending then asked the surgeon to perform an awake, sedated tracheostomy. She was concerned that prolonged attempts at awake intubation would delay the operation, increase physiologic stress, and cause coughing — potentially precipitating rupture of the dissecting aneurysm.

Awake Tracheostomy Performed Before Induction

The surgeon performed the tracheostomy, and the anesthesia team confirmed end-tidal CO₂ before inducing general anesthesia.

Gradual Induction and Assisted Breathing

With the airway secured, the team focused on avoiding abrupt blood-pressure changes. They were concerned about both worsening hypertension and also about potential hypotension during induction in this patient with an aortic dissection. Rather than performing rapid sequence induction, they induced anesthesia gradually with sevoflurane, titrating it upward while closely monitoring blood pressure through the arterial line.

During this gradual induction, the team maintained spontaneous breathing with assistance, aiming to avoid potential instability from an abrupt transition to positive-pressure ventilation.

Surgery and Outcome

Once the patient was asleep, paralyzed, and receiving mechanical ventilation, the surgeon proceeded with the operation. After the surgical incision, the team placed an internal jugular central venous line. The patient tolerated induction well and survived.

The Lesson: Choose the Awake Strategy Deliberately

In this case, the attending anesthesiologist judged awake tracheostomy to be safer than awake fiberoptic-assisted intubation. Time was critical, and she feared that prolonged airway manipulation could create physiologic stress and precipitate aneurysm rupture. This was a case-specific judgment, NOT a universal preference for tracheostomy.

The broader lesson is to consider awake airway management before induction when a difficult airway is anticipated. The goal is to secure the airway while preserving spontaneous breathing and, where relevant, cardiovascular stability.

When to Consider Awake Airway Management

Awake intubation can be comfortable, even with minimal sedation, when the patient is properly prepared. With appropriate training and practice, fiberoptic-assisted intubation can secure the airway efficiently while preserving spontaneous breathing. You can read more about criteria for awake intubation here:

Anticipated Difficult Intubation: Should I Intubate The Patient Awake?

Consider awake intubation or another awake airway strategy as a primary approach when the patient.

• has a history of difficult intubation or ventilation;
• may be difficult to ventilate;
• may not tolerate induction agents or apnea;
• may risk neurologic injury with head or neck manipulation; or
• needs to maintain spontaneous breathing until the airway is secured.

Patient cooperation is a separate planning consideration: assess whether the patient can participate in awake airway preparation.

When Awake Tracheostomy May Be the Safer Choice

Factors that may favor awake tracheostomy include:

• severe upper-airway obstruction;
• failed or impossible intubation or ventilation;
• a high risk of cardiovascular or airway collapse under sedation; or
• a need to preserve spontaneous breathing until the airway is secured. [9, 10]

Do Not Let Familiarity Replace Planning

Providers may hesitate to choose awake intubation because of concerns about patient discomfort or limited experience. Production pressure to avoid delaying the operation, or concern about the surgeon’s reaction can also influence choices. These pressures are real, but they should not replace deliberate consideration of the awake option. If another approach is safer, the team should make that decision consciously.

The takeaway: when a difficult airway is anticipated, consider the awake options before induction—not only after an intubation attempt has failed.

May the Force Be With You.

Christine E. Whitten MD, author:

Anyone Can Intubate: A Step-by-Step Guide, 5th Edition
Pediatric Airway Management: A Step-by-Step Guide
Basic Airway Management: A Step-by-Step Guide

Additional Reading

• Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation in adults. Anaesthesia. 2020;75(4):509–528.
• Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–848.