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Background and Aims Regional anaesthesia is frequently the preferred anaesthetic technique in cases of predicted difficult airway, as it avoids approaching the patient’s airway. However, choosing the best technique frequently becomes a challenge for some surgeries.

Methods The authors describe the case of a 76-year-old patient undergoing a bilateral breast reduction surgery. She had a history of severe subglotic tracheal stenosis, which required multiple tracheal surgeries.

Results On the preoperative anaesthesia consultation the patient denied respiratory symptoms, no other predictors of difficult airway were identified and otorhinolaryngology observation did not contraindicate the surgery. Nevertheless, a 4.0mm internal diameter cuffed endotracheal tube was used in previous surgeries and a neck CT scan confirmed a 10x10mm subglotic tracheal stenosis; hence, an epidural anaesthesia with moderate sedation was the choice for the anaesthetic technique. On the day of surgery a thoracic catheter was placed at T5-T6 level and 0,4% ropivacaine and sufentanil were administered with a resulting sensory block from T1 to T8. A combination of ketamine and dexmedetomidine was used for sedation. The procedure was uneventful, with no respiratory adverse events.

Conclusions Thoracic epidural anaesthesia can avoid the need to manage the airway in cases similar to the one described. However it is not free of complications, including respiratory muscle paralysis with respiratory depression. Therefore, the level of surgical anaesthesia should be carefully tapered. Accompanied procedural sedation should also be regarded cautiously, as the need to maintain airway reflexes and spontaneous breathing is essential.