Preserved Spontaneous Ventilation for Tracheostomy in a Severely Agitated Patient With Bilateral Vocal Cord Paralysis: A Case Report

Bilateral vocal cord paralysis is a potentially life-threatening condition, and when an agitated patient refuses awake airway management for an emergent procedure, balancing spontaneous ventilation with adequate sedation is essential.This report presents a 31-year-old male with alcohol use disorder who presented with progressive stridor and dyspnea due to bilateral vocal cord paralysis and posterior glottic stenosis.An awake tracheostomy was initially planned but was not feasible due to severe agitation and refusal to cooperate.Instead, the patient underwent inhalational induction with incremental sevoflurane, supplemented by midazolam, dexmedetomidine, and ketamine, while maintaining spontaneous ventilation.Rocuronium was administered only after tracheostomy placement and was reversed with sugammadex.Postoperative bilateral pneumothoraces and pneumomediastinum were managed conservatively.He was ultimately weaned to a tracheostomy collar with preserved voicing.This case suggests that a carefully titrated inhalational induction that preserves spontaneous ventilation may be a feasible, individualized alternative when awake tracheostomy is not possible in agitated patients with critical airway obstruction.