•Our patient was a 5-month old ex-34-week male weighing 3.7kg, who presented for tracheostomy placement

•Shortly after birth, he had a 3-month stay in the NICU

•Past medical history of mosaic trisomy 14, laryngomalacia, chronic lung disease with baseline SpO2 87%, hypotonia, PFO and failure to thrive requiring a G-tube

•Admitted to PICU for acute respiratory failure 2/2 viral bronchiolitis

•Required nightly CPAP and daytime nasal cannula, supplemented with nebulizers

•Given his dysmorphic facial features, ENT was consulted and performed direct laryngoscopy and rigid bronchoscopy with an anterior commissure laryngoscope

•Findings notable for micrognathia, retrognathia, nasal stenosis, laryngomalacia, and omega-shaped epiglottis with a grade 2-3 view of vocal cords

•Consented for tracheostomy with consideration for future supraglottoplasty

•Pt arrived in OR on room air in no distress with a 24g IV in the L hand

•He was placed on standard ASA monitors, including EKG, BP cuff on the R arm, and pulse oximetry on the L foot, with a backup pulse oximeter on the contralateral foot

•Due to the tenuous airway, the anesthesia and ENT teams jointly agreed on an awake intubation to minimize the risk of respiratory compromise

•After preoxygenation, anesthesia team proceeded with the awake intubation with a size 3.5 oral rae tube using a CMAC and a MAC #0 video laryngoscopy blade, revealing a transient view of the arytenoids and a grade I view of the vocal cords

•Upon attempts to pass the tube through the cords, Pt frequently coughed and subsequently desaturated, and he subsequently improved when the tube was withdrawn

•Because he was unable to tolerate awake intubation, the decision was made to fully induce the patient for optimal conditions using 5mg propofol and 3mg rocuronium

•Patient was intubated successfully by the surgeon via rigid telescope with an anterior commissure laryngoscope

•Placement was confirmed with end-tidal CO2, and the tube was secured at a depth of 11cm.

•Surgical anesthesia was maintained with an additional 10mg propofol, 5mcg fentanyl, and 1% sevoflurane

•During placement of the size 3.5 Shiley tracheostomy tube, the anesthesia team withdrew the oral rae tube until slightly above the vocal cords

•The endotracheal tube was subsequently removed after successful placement of the tracheostomy tube

•Due to the high incidence of craniofacial abnormalities in patients with trisomy 14, the anesthesia and surgical teams must expect to manage associated difficult airways

•Careful history must also be taken to elucidate any congenital cardiac abnormalities