Comparative study of sniffing versus ramp position for teaching andlearning endotracheal intubation in novice Anaesthesiology residents

-  After obtaining ethics committee approval and written and informed consent, patients undergoing elective surgery under general anaesthesia (except obstetric patients) will be recruited for the study.

-   Participants (novice residents) will be classified into two random groups by ask them to pick a chit randomly. There will be two chits, one naming GROUP -S “SNIFF POSITION†and other naming GROUP -R “RAMP POSITIONâ€.  Once the residents are allotted a particular group, he/she will continue to perform intubation in allotted position only.

-  The position for intubation will be given according to the group to which the resident belongs.

-  Pre anaesthetic check-up would be carried out for all the participants day prior to surgery.

-  On arrival to operating room, routine monitoring, that includes pulse oximetry, electrocardiography, non-invasive blood pressure measurement and manual blood pressure will be attached and base line parameters will be noted.

-  The position will be given according to the allotted category.

-  The sniffing position will be given by using gel head-ring under occiput.

-  The ramp position will be given by using gel bolster under the shoulder of the patient to get external auditory meatus and sternal notch in linear alignment and confirmed by using spirit level ruler.

-  All the participants will be pre medicated with inj glycopyrolate 0.005-0.01 mg/kg, inj. Midazolam 0.1-0.2 mg/kg iv, inj fentanyl 1-2 mcg/kg iv, inj lignocaine (2%, preservative free) 3cc iv

-  Pre oxygenation will be done with 100% oxygen for 3 minutes delivered via close circuit. The induction of anaesthesia will be done with propofol (2-2.5 mg/kg) and muscle relaxation achieved with inj succinylcholine (1- 1.5 mg/kg).

-  After achieving adequate muscle relaxation, laryngoscopy will be performed with Macintosh laryngoscope blade no 3 for female and blade no 4 male. Novice resident will be asked about the glottic view that has been obtained by him/her at first attempt by showing them the Cormack-Lehane Classification chart. They will be asked to indicate the Cormack-Lehane grade 1 or 2 on the charts of the diagram shown to them. If inability to achieve grade1 or 2 , external laryngeal manuver will be apllied and again glottic view will be reviewed ,endotracheal tube will only be inserted  after acheiving grade 1 or 2 otherwise senior will take over . Total time will be given of 30 seconds to the novice resident for placement of the endotracheal tube. after that, the senior resident will take over the procedure.

-  The time duration will be noted from insertion of the laryngoscope into the oral cavity till attainment of 5-7 successive square wave formation on capnograpghy.