Is there an optimal place for holding the tracheal tube during intubation? A proof-of-concept randomised clinical trial.

Background: The optimal way to hold an endotracheal tube (ETT) during intubation has not been studied. In this randomised clinical trial, we examined the effect of site-holding the ETT in two different positions on time and ease of intubation by anaesthesia trainees.
Methods: A single-centre, randomised trial of intubations of stable patients with uncomplicated airways was conducted from 15 September 2019 to 31 May 2021 in the All India Institute of Medical Sciences, Bhubaneswar, India. A previous pilot study performed in the unit determined the comparator positions for the ETT and the sample size for a 20% difference for the primary outcome of mean time to intubation (TTI). Patients were randomised at the time of the intubation; anaesthesia trainees held the ETT at 19 or 24 cm according to the patient's assignment. Video recordings of intubations were independently reviewed by two assessors blinded to the assignment. Secondary outcomes were intubation success, ease of intubation and complications. Intention-to-treat and per-protocol analyses were performed.
Results: 360 adults were randomised (180/arm) and intubated by 19 trainees. In intention-to-treat analysis, there was no significant difference in TTI. Sixteen times, trainees assigned to hold the ETT at 24 cm moved their grip distally (closer to the cuff) during the procedure. In a per-protocol analysis, TTI for those whose grip remained at 24 cm was shorter than those holding at 19 cm: 6.6 (SD 3.0) vs 7.6 (SD 4.2) s (95% CI for the difference 0.2 to 1.7 s), p=0.01. In both intention-to-treat and per-protocol analyses, there was no difference in first-pass success or ease of intubation between techniques. Eight patients assigned to 19 cm group and four assigned to 24 cm developed sore throats.
Conclusion: In stable patients with uncomplicated airways, there was no significant difference in TTI based on the site at which trainees were assigned to hold the ETT. However, the shorter TTI at 24 cm in per-protocol analysis and fewer sore throat observed suggest this practice change warrants further investigation.
Trial Registration Number: CTRI/ 2019/09/021201.
Competing Interests: Competing interests: None declared.
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