After the onset of the disease, there was no fever, hemoptysis, chest tightness, chest pain, palpitation, pharyngeal foreign body sensation, and there was no significant weight loss, and recently there was difficulty in falling asleep at night. Appetite and bowel movement were normal. He was clear, no shortness of breath, no cyanosis, normal respiratory movements, rough breath sounds in both upper lungs, a few sputum sounds in both lower lungs, and weak breath sounds in the right lower lung. Outpatient chest radiograph showed right lung atelectasis, right pneumonia, and a small amount of right pleural effusion. Post-admission CT/MRI showed a main tracheal mass with about 80% obstruction of the main trachea and a narrow tumor base. Fiberoptic bronchoscopy: a mass of about 1 cm was seen in the lower part of the trachea, blocking the trachea almost completely, with a smooth surface, clear vascular network, and a small piece of vesicular erosion (Figure 4). The biopsy was sent to pathology and cytology; the pathologic findings showed adenoid cystic carcinoma of the trachea; cytology showed inflammatory changes and no cancer cells were found. Pulmonary function tests: forceful lung volume (FVC): 3.11L, one-second forceful expiratory volume (FEV1)/FVC: 61%, three-second forceful expiratory volume (FEV3)/FVC: 99%, suggesting mild to moderate obstructive ventilatory dysfunction. The patient’s individualized anesthesia management plan was formulated: (1) the patient was placed in the left lateral position, and the resection of adenoid cystic carcinoma of the main trachea was performed under general anesthesia, with tracheal sleeve resection of the cancerous segment, and end-to-end anastomosis of the main trachea; (2) fiberoptic bronchoscopy-guided tracheal intubation was performed, with the tip of the tube resting on the upper part of the mass; (3) the mass was resected as soon as possible after the chest was opened, and the original catheter was sent to the left main bronchus for anesthesia for one-lung ventilation, and if necessary, the right main If necessary, the right main bronchus was incised in the operating field, and a tracheal tube was inserted for jet ventilation; (4) After airway reconstruction, the catheter was withdrawn above the anastomosis, and bilungual ventilation was resumed until the end of the operation, and the tracheal tube was withdrawn after the patient was fully awake. (5) Adequate postoperative analgesia was provided, and the patient was kept in the chin-chest position to minimize tension on the tracheal anastomosis. The next day surgical anesthesia was performed as planned. Anesthesia implementation: surface anesthesia, 1% dicaine spray throat; 2% lidocaine 2ml endotracheal injection after cricothyroid membrane puncture; fiberoptic bronchial guided tracheal intubation, the tip of the tube stayed above the mass; the trocar was inflated to an intracapsular pressure of 40 cm H2O (1 cm H2O=0.098 kPa); connected to the anesthesia machine with capacitated breathing, VT 550 ml, the airway pressure of 23 cm H2O, good ventilation. The airway pressure was 23 cm H2O at VT 550 ml, and ventilation was good. Intravenous midazolam 5 mg, isoproterenol 100 mg, fentanyl 0.2 mg, and vecuronium bromide 4 mg were injected, and the chest was opened in the left lateral position. Intravenous infusion of remifentanil 0.08-0.10 μg・kg-1・min-1, isoproterenol 80-100 μg・kg-1・min-1, and intermittent intravenous vecuronium bromide 0.2-0.4 mg were used to maintain anesthesia. The intraoperative time from chest opening to tumor resection was 35 min, and after tumor resection, a tracheal tube was delivered into the distal trachea. Because the angle of the left bronchus was too large, the tracheal tube could not be sent into the left main bronchus as planned. Although it was estimated in the preoperative discussion, it was more difficult to carry out the operation than expected, and it was forced to send the tube into the right main bronchus temporarily, and the right one-lung ventilation lasted 15 min. Because the patient was lying on the left side and the right side of the chest was opened, the ventilation and blood flow ratio was out of order due to the effect of gravity as well as the surgical interference, and the oxygen saturation was only 85% at the lowest point. The left lung was freed from the root as soon as possible, and after complete exposure of the bulge, the surgeon and anesthesiologist cooperated to feed the tracheal tube into the left main bronchus, with an intracannula pressure of 30 cm H2O. After the left lung was ventilated in a single lung and oxygen saturation was normalized, the stump of the main trachea was surgically trimmed, and the end-to-side anastomosis of the main trachea was carried out. After completion of the tracheal anastomosis and tissue embedding, the catheter was pushed above the anastomosis and bilateral ventilation was resumed, during which the left lung was ventilated for 50 min. Pressurized ventilation was performed to confirm that there was no anastomotic leakage, and the operation was completed by stopping the bleeding and washing out, clearing lymph nodes, and ending the operation. The operation time was 3 h 10 min. Postoperatively, intravenous analgesia, chin-chest position, and ventilator support therapy were performed for 3 h. The endotracheal tube was removed after the patient was awake and cooperative. The actual size of the surgically resected tumor was 2.7 cm×2.0 cm×1.8 cm (Figure 5). Pathological results showed that the adenoid cystic carcinoma had invaded the whole trachea, and there were 6 lymph nodes, all of which were chronic inflammation; no carcinoma was seen at the cut edge of the trachea at both ends. Considering that the cancer had invaded all layers of the trachea, one course of intensive radiotherapy was performed after surgery. Fiberoptic bronchoscopy showed that the surgical incision suture remained in the trachea at a distance of 1.5 cm from the rudimentary process, and the surrounding mucous membranes were flushed, with smooth lumen, and the mucous membranes of the bronchus of both lungs did not have any abnormality. The bronchial mucosa of both lungs did not show any abnormality. The patient was discharged from the hospital 25 days after surgery. Discussion: Patients with adenoid cystic carcinoma of trachea were asymptomatic or only had mild dyspnea in early stage. If the tumor occupies more than 75% of the tracheal lumen, symptoms of obstruction may appear, but the symptoms are not specific. Cough, sputum and intermittent blood in sputum may be the initial clinical manifestations, which are common to most diseases and thus easily lead to misdiagnosis. CT scan is the first choice of examination for early detection of this disease, which can more accurately reflect the location of primary tracheal cancer and the degree of airway obstruction. CT scan is the first choice for early detection of the disease, which can reflect the location of primary tracheal cancer and the degree of airway obstruction more accurately. Early diagnosis and aggressive surgical resection are extremely important to the prognosis. The key of anesthesia for tracheal surgery lies in the management of the airway, which must ensure a smooth airway and good ventilation and oxygenation, and at the same time, it is also necessary to provide an open surgical field for the surgery, so as to avoid interfering with the surgical operation, so the design of individualized anesthesia plan is very important. The experience and lessons learned in this case are: (1) The patient’s tracheal obstruction should be fully evaluated preoperatively, and the patient should be encouraged to take breathing exercises, anti-inflammatory treatment, and individualized anesthesia plan should be established for each surgical patient with tracheal tumor. Endoscopy played a very important role in this patient. Preoperative examination confirmed the tumor location and the degree of tracheal obstruction, which laid the foundation for the anesthesiologist to evaluate the intubation location and the size of the selected tube. (2) More importantly, we chose to perform awake tracheal intubation under the guidance of fiberoptic bronchoscopy to prevent the adverse effects of inotropes. The intubation process should be fully surface anesthesia, laryngeal spray and cricothyroid puncture medication; to reduce the possible cardiovascular reaction or tracheal spasm induced during the guidance of bronchoscopy; (3) close cooperation with the surgeon, ready to adjust the position of the catheter, the pressure of the sleeve and the ventilation mode; the left lateral position of the left main bronchial intubation is difficult, must be fully prepared and ready to take contingency measures. (4) Close monitoring of vital signs throughout the process; (5) Prolonging the postoperative respiratory support time, removing the endotracheal tube after the patient is fully awake and cooperative, and preventing the removal process from leading to patient agitation; (6) Adequate postoperative analgesia, and maintaining the chin-thorax position is an important measure for postoperative healing. (7) After the patient recovered, fiberoptic tracheoscopy was still used to confirm the complete healing of the anastomosis, which provided a clinical basis for the complete healing in this case. In summary, tracheal adenoid cystic carcinoma has an insidious onset and is often misdiagnosed as tracheitis or pneumonia in the outpatient clinic and remains untreated, and it is often not diagnosed until respiratory distress occurs; therefore, CT/MRI and fiberoptic tracheoscopy are particularly important for the diagnosis of this type of disease. Once the diagnosis is confirmed, surgical treatment is the first choice, and the anesthesiologist should work with the endoscopist and surgeon to formulate a surgical and anesthetic plan before surgery. Intraoperative airway management is particularly important, and a variety of feasible ventilation management plans need to be formulated, and the anesthesiologist must be skilled in the ventilation management and evaluation techniques, and must readily adjust the ventilation management methods. The success of this case lies in accurate assessment, careful preparation, close multidisciplinary cooperation, and flexibility.