Following a recent case of pulmonary aspiration of gastric contents, we seek guidance on the timing of inflation of the tracheal tube cuff, and the best method of assessing adequate seal, following awake fibreoptic intubation in patients at risk of aspiration. Our patient had severe gastric distension that we were unable to decompress; despite several attempts, we were unable to pass a gastric tube. Faced with an unknown airway, we performed an uncomplicated awake fibreoptic intubation. Due to the aspiration risk, we inflated the cuff before general anaesthesia, using a syringe, with manual palpation of the pilot balloon. As we induced general anaesthesia, a large quantity of fluid flowed from the stomach, some of which passed beyond the cuff to soil the airway. We added more air to the cuff to improve the seal, and carried out airway suctioning, but the patient required a 7-day ICU stay postoperatively. We are unaware of any advice about the optimal timing of cuff inflation in patients at risk of aspiration following awake fibreoptic intubation. Inflating the cuff before induction of general anaesthesia risks a stimulatory physiological response that could cause harm, e.g. in trauma, head injury or ischaemic heart disease. Waiting until after induction risks missing any cuff damage incurred on insertion, and risks aspiration in the event of regurgitation. Application of cricoid pressure may provide some protection against aspiration, but may deform the trachea [1] leading to a reduction in cuff pressure on its removal and inadequate seal with a risk of aspiration. The NAP4 project [2] (in which this case was included) recommends that ‘once placed a tracheal tube offers the highest protection against aspiration’, but does not comment on how best to confirm adequacy of the cuff’s seal. One could ask the patient to breathe against a partially closed adjustable pressure-limiting valve and assess for a leak, but we feel this may be poorly tolerated and unreliable. A manometer could be used to assess the pressure, but we could find no clear target value in the literature. An inflated cuff may also cause discomfort. In our experience, the cuff should only be inflated immediately before induction of anaesthesia. Awake fibreoptic intubation has been described as a suitable technique for patients at high risk of aspiration [3] and appears in some algorithms designed for use in situations where aspiration is a possibility [4]. We would be grateful for the expert opinions of anaesthetists with experience in using this technique to manage patients at high risk of aspiration as to when the cuff should be inflated and, if inflated before general anaesthesia, whether the adequacy of the seal can safely be tested.