Randomised comparative evaluation of midline approach and right molar approach for time for successful oral endotracheal intubation with flexible fiberoptic bronchoscope

In GROUP A, the patient’s table will be lowered to the minimum height . A pillow will be retained

under the occiput. After 4 minutes of neuromuscular blockade, a experienced anaesthesiologist will

position themselves at the head end of the patient to conduct fiberoptic bronchoscopy.

The fiberoptic bronchoscope will be held in the experienced anaesthesiologist’s left hand, while the

scope sheath will be grasped between the index finger and thumb of the right hand. The mouth will

be slightly opened using the ring finger of the right hand. Lingual traction maneuvers will be

performed with the assistance of a trained assistant, who will place a gauze over the tongue and

retract it manually.

The fiberoptic bronchoscope will be gradually inserted into the oral cavity using a midline approach

toward the glottis, maintaining the scope in a midline position. The time from the removal of the face

mask to the first view of the glottis (T1) will be recorded. As the scope tip approaches the epiglottis,

the glottis view will be assessed and graded according to the POGO score

In GROUP B , the table height will be minimized, while a pillow remains positioned under the occiput.

Following a 4-minute period of neuromuscular blockade, a experienced anaesthesiologist will stand

at the head end of the patient to conduct fiberoptic bronchoscopy.

The fiberoptic bronchoscope will be held in the anaesthesiologist’s left hand, with the scope sheath

gripped between the index finger and thumb of the right hand. The mouth will be slightly opened

using the ring finger of the right hand. Cheek pull maneuvers will be executed with the assistance of

an assistant, who will place a J shaped stylet in the right cheek and retract it manually.

The fiberoptic bronchoscope will be inserted gradually into the oral cavity at the right molar

approach toward the glottis, keeping the tip of scope above right molar and advance scope along or

just near the right margin of tongue in the right molar approach. The time from the removal of the

face mask (To) to the first view of the glottis (T1) will be noted. As the scope tip nears the epiglottis,

the glottis view will be assessed and graded according to the POGO score.

After T2, in both groups, the tip of the fiberoptic bronchoscope will be advanced beyond the

glottis into the trachea. Upon nearing the bifurcation of the trachea, visualization of the

carina will be confirmed, and further advancement will be halted. The endotracheal tube will

be rail loaded over the fiberoptic bronchoscope, ensuring the tube tip is positioned in the

mid-trachea. Subsequently, the fiberoptic bronchoscope will be removed, and the cuff of the

endotracheal tube will be adequately inflated. Anaesthesia circuit will be connected

immediately to ETT connector followed by controlled mode of mechanical ventilation

with tidal volume around 250-300 ml and frequency 20/min. Time taken for

appearance of end tidal carbon dioxide (EtCO2) on the capnograph will be noted (T2)

and total intubation time will be calculated (T3=T1+T2) The endotracheal tube will be

secured in place with tape. Fibre-scopy will be performed to assess and note any

injury to the oropharynx & larynx. Surgery will be proceeded as per the requirement

of Patient.

● In both the groups attempt will be abandoned if oxygen saturation falls below 97

percent or time taken for single attempt exceeds 3 minutes.

A maximum of three attempts will be taken for successful intubation. If unsuccessful

then subsequent alternative airway management technique such as laryngeal mask

airway, video-laryngoscopy or direct laryngoscopy will be performed to secure

definitive patent airway as per Difficult Airway guidelines.