To the Editor: In a double-blind randomized controlled clinical trial comparing dexmedetomidine and remifentanil sedation for awake fiberoptic nasotracheal intubation, Hu et al. [1] showed that both drugs were effective. Moreover, compared with remifentanil, dexmedetomidine produced better endoscopy scores, lower incidence of recall, greater patient satisfaction, and fewer hemodynamic effects. They should be applauded for their efforts to provide useful evidence regarding dexmedetomidine and remifentanil sedation for awake airway management. However, in preparing the patient for awake intubation, the optimal sedation regimen would provide comfort and sedation as well as prevention from negative recall of the procedure. Furthermore, it should ensure good airway reflex suppression under sufficient spontaneous ventilation, hemodynamic stability, and adequate intubating conditions [2]. Based on the findings of this study, we are not sure that some of above targets have been well achieved. First, coughing during awake intubation occurred in 50 % of patients in the dexmedetomidine group and 15 % of patients in the remifentanil group, respectively. It is generally believed that during awake intubation, coughing is frequently reported as one of the most distressing symptoms and described as an undesirable feature [3]. Second, 30–40 % of patients in the dexmedetomidine group and 65–70 % of patients in the remifentanil group had recall for airway procedure events. Such high incidences of recall would put patients at a risk of postoperative psychological morbidity, such as anxiety, depression, posttraumatic stress disorder, cognitive impairment, etc. A main limitation of this study design is the use of a single agent to provide sedation. Actually, none of the drugs currently in use can meet all criteria of the optimal sedation regimen for awake intubation, although many of them have some of the desirable characteristics. For example, opioids can provide analgesia and help blunt airway reflexes, but use of opioids alone fails to provide amnesia [4]. Benzodiazepines have no analgesic effect, but are useful for providing good amnesia, even if the procedure itself appears to be painful. Thus, it is generally recommended that an optimal sedation regimen for awake intubation requires the use of a combination of sedatives, analgesics, and antipsychotic agents [4]. For example, midazolam and propofol, are common agents used for sedation, often with an opioid drug such as fentanyl or remifentanil. It must be pointed out that in a review of four studies, including 443 cases of awake intubation, even if various combinations of sedatives and analgesics are utilized, 17 % of patients still have partial recall and 6 % have recall with unpleasant memories [4]. Dexmedetomidine is a highly selective a2-agonist with anxiolysis and some analgesia without respiratory depression. An answer to this letter to the editor is available at doi:10.1007/s00540-013-1561-4.