Tracheostomy is one of the most frequent procedures performed in the intensive care unit (ICU), with over 100,000 performed annually in the United States.1 First described by Ciaglia in 1985,2 percutaneous dilatational tracheostomy (PDT) has become the standard of care for tracheostomy placement performed at the bedside. The addition of video bronchoscopy during PDT, which allows for direct visualization during tracheal cannulation and dilation, has further increased the safety of the procedure.3 Despite this, accidental extubation remains a rare but feared complication of PDT, with reported occurrence rates of 0.1–3.3%.4–6 Typically, the tip of the endotracheal tube (ETT) is withdrawn into the subglottic space at the commencement of the procedure. Maintaining airway access via the guidewire is especially critical in patients where emergent orotracheal re-intubation may be difficult e.g. high body-mass-index (BMI), small inter-incisor gap, presence of cervical spine external fixator, history of difficult intubations.