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Severe central airway obstruction presents major challenges during bronchoscopic airway interventions. General anaesthesia with neuromuscular blockade using rigid bronchoscopy and positive-pressure ventilation is a commonly used technique for tracheal stent placement in many centres. However, patient-specific anatomical and physiological factors may occasionally influence anaesthetic planning. We report the case of an elderly woman with metastatic thyroid carcinoma who presented with progressive dyspnoea and stridor due to critical extrinsic tracheal compression. Following multidisciplinary discussion, an alternative anaesthetic strategy was adopted in this patient to preserve spontaneous ventilation while maintaining procedural conditions for flexible bronchoscopic stent placement. Regional airway anaesthesia combined with titrated sedation enabled successful stent deployment, with transient desaturation and immediate symptomatic improvement. This case illustrates an individualised anaesthetic approach in a specific clinical context and highlights the importance of tailoring airway management strategies to patient characteristics, procedural requirements and institutional expertise.