We read the case report by Sulaiman and Charters [1] with interest and would like to make a few comments. To justify their decision to use awake fibreoptic intubation, they claim that the patient was at risk of being in a ‘can’t intubate, can't ventilate' situation. However, the information they give is insufficient to justify such a conclusion. The patient was conscious and extremely co-operative. He was spitting blood but was haemodynamically stable. Airway assessment showed him to have a short bull neck but the external appearance was unchanged. No comment is made about mouth opening, although it was obviously adequate to allow inspection of the oral cavity. Also, they have omitted the information about the airway management and grade of laryngoscopy during the first anaesthetic, which has to be taken into account. Any patient with oropharyngeal haemorrhage is unlikely to be a good candidate for fibreoptic intubation due to the possibility of blood obscuring the view. The use of a local anaesthetic can start or increase bleeding by causing coughing and straining, as illustrated by this case. Furthermore, the local anaesthetic is unlikely to be effective in the presence of blood. If there was a risk of ‘can’t intubate, can't ventilate', then the safest option would have been a tracheostomy under local anaesthetic, which a conscious and co-operative patient would have tolerated. The use of topical anaesthesia is not completely free from side-effects. It is not uncommon to see a patient cough or strain following the administration of local anaesthetic spray or drops into the nostrils or oropharynx. We had a patient with Ludwig's angina who was severely dyspnoeic and was planned for an awake fibreoptic intubation. Following the use of local anaesthetic spray into the oropharynx he had a bout of feeble coughing and then developed complete airway obstruction. His oxygen saturation dropped to less than 90%. Fortunately, fibreoptic intubation was then successfully performed without delay, preventing further deterioration. Perhaps in cases such as these, nebulised lidocaine might be a safer option. During the last 10 years, the use of awake fibreoptic intubation has increased considerably. It is a relatively easy skill to learn and makes an anticipated difficult intubation scenario safer than before. It is possible that because of its availability, trainees are deciding to perform awake intubation in patients with only a small risk of difficulty. It may be that the trainees are missing out on doing a thorough pre-operative assessment of the airway and also depriving themselves of the mastering another very valuable skill – performing a difficult intubation under direct laryngoscopy. In a patient with a known or anticipated compromised airway the management plan must take into consideration the history of previous anaesthetics. It is true that this patient's anatomy will have been considerably altered by the surgery, but a history of previous straightforward direct laryngoscopy may have resulted in this option being included in the contingency planning at an earlier stage in the case.