Objective <p>The incidence of Emergency Department (ED) awake intubation is unexpectedly low despite evidence that awake intubation improves patient outcomes. We sought to identify barriers and facilitators to awake intubation by emergency physicians in patients with predictors of a difficult airway.</p> Methods <p>We conducted a qualitative study using semi-structured interviews at two Canadian EDs with different rates of awake intubation. The interview template was created using the Theoretical Domains Framework (TDF). Interviews were conducted, and transcribed verbatim. Two researchers then coded utterances into TDF domains, generated belief statements, and identified salient statements and domains.</p> Results <p>Nineteen physicians were interviewed. There was a marked difference in comfort with awake intubation between the two sites. Both sites agreed training in awake intubation is important for ED physicians. Rarity of the procedure (<i>Environmental context and resources</i>) and lack of training (<i>Skills</i>) were identified as barriers, while engagement in skill maintenance was a facilitator (<i>Skills</i>). Local expertise was markedly different between sites and was identified as a facilitator (<i>Social influences</i>). Support from the interdisciplinary team was identified as a facilitator (<i>Social influences</i>). There was marked divergence between sites in anesthesiology involvement for the management of difficult airways in the ED (<i>Social or professional roles and identity</i>).</p> Conclusions <p>This study identified barriers and facilitators to the use of awake intubation by ED physicians. These barriers and facilitators must be addressed when designing interventions to increase the uptake of awake intubation in the ED. Future studies should aim to translate these factors into practical interventions.</p>