Awake intubation with a flexible bronchoscope in the emergency department: Expanding the emergency physician's airway toolkit

Background: Awake intubation using a flexible bronchoscope is a well-established technique in the operating room but remains underutilized in the Emergency Department (ED), despite its potential benefits in managing anticipated difficult airways. Case presentation: We describe three cases in which awake fiberoptic intubation was successfully performed in the ED setting. The first involved an elderly woman with caustic ingestion and progressive oropharyngeal edema. The second was a post-thyroidectomy patient presenting with massive cervicothoracic subcutaneous emphysema and suspected tracheal injury. The third case concerned a previously healthy woman with refractory angioedema and severe trismus. In all cases, conventional sedated intubation was deemed high-risk due to potential airway collapse or distortion. Awake intubation allowed for maintenance of spontaneous ventilation, real-time airway navigation, and safe endotracheal tube placement. All patients were successfully intubated and transferred to the Intensive Care Unit. Conclusion: These cases illustrate the feasibility and clinical utility of awake intubation with a flexible bronchoscope in emergency settings. When conventional techniques are contraindicated or unsafe, this approach may provide a life-saving alternative. Increased familiarity with fiberoptic-guided intubation could significantly expand the airway management toolkit of emergency physicians.