Awake flexible fiberoptic intubation (FFI) is the gold standard for management of anticipated difficult tracheal intubation. The purpose of this study was to compare awake FFI to awake McGrath® video laryngoscope, (MVL), (Aircraft Medical, Edinburgh, Scotland, United Kingdom) intubation in patients with an anticipated difficult intubation. The authors examined the hypothesis that MVL intubation would be faster than FFI. Ninety-three adult patients with anticipated difficult intubation were randomly allocated to awake FFI or awake MVL, patients were given glycopyrrolate, nasal oxygen, topical lidocaine orally, and a transtracheal injection of 100 mg lidocaine. Remifentanil infusion was administered intravenously to a Ramsay sedation score of 2-4. Time to tracheal intubation was recorded by independent assessors. The authors also recorded intubation success on the first attempt, investigators' evaluation of ease of the technique, and patients reported intubation-discomfort evaluated on a visual analog scale. Eighty-four patients were eligible for analysis. Time to tracheal intubation was median [interquartile range, IQR] 80 s [IQR 58-117] with FFI and 62 s [IQR 55-109] with MVL (P = 0.17). Intubation success on the first attempt was 79% versus 71% for FFI and MVL, respectively. The median visual analog scale score for ease of intubation was 2 (IQR 1-4) versus 1 (IQR 1-6) for FFI and MVL, respectively. The median visual analog scale score for patients' assessment of discomfort for both techniques was 2, FFI (IQR 0-3), MVL (IQR 0-4). The authors found no difference in time to tracheal intubation between awake FFI and awake MVL intubation performed by experienced anesthesiologists in patients with anticipated difficult airway.