Patients admitted to intensive care units (ICU) frequently need respiratory help. Tracheal intubation is perhaps of the most successive technique acted in ICU. It very well might be related with hazardous difficulties in dependent upon one portion of the cases, a definitive entanglement being heart failure connected with intubation in 2.7% of the cases[1]. Troublesome intubation, characterized by multiple intubation endeavors, is related with dangerous inconveniences. To forestall & restrict the occurrence of complexities connected with intubation, intubation calculations have been created, & risk factors for troublesome intubation in ICU[2].

Troublesome intubation is characterized as at least three laryngoscopic attempts to place the endotracheal tube into the windpipe or as enduring over 10 minutes utilizing regular laryngoscopy. Expecting troublesome intubation is a difficult issue; & as it is as of now settled that the intricacies of intubation are higher when intubation is troublesome, the MACOCHA score has been created & validated[3]. The score is gotten from seven parts in three spaces; patient variables (Mallampati score III or IV, obstructive rest apnea condition, diminished versatility of cervical spine, restricted mouth opening) pathology related factors (extreme lethargies, serious hypoxemia) & administrator related factor(non-anaesthesiologist score) [4].

The larynx is a cartilaginous fragment of the respiratory lot situated in the foremost part of the neck. The essential capability of the larynx in people & different vertebrates is to safeguard the lower respiratory lot from suctioning food into the windpipe while relaxing. It likewise contains the vocal ropes & works as a voice box for delivering sounds, i.e., phonation.

The larynx is a cartilaginous skeleton, a few tendons, & muscles that move & balance out it & a mucous layer. The laryngeal skeleton has nine cartilages: the thyroid cartilage, cricoid cartilage, epiglottis, arytenoid cartilages, corniculate cartilages, & cuneiform cartilages. The first three are unpaired cartilages, & the latter three are paired cartilages [5-7].

All patients screened eligible were invited to participate in the study. Recruitment of participants was initiated after explaining the procedure & obtaining informed consent from the patients (or their legal representatives). The recruited study participants were randomized in a 1:1:1 ratio into one of the three study groups through computer generated random allocation sequence. Recruitment will be continued till there were 100 study participants in each of the study groups.

After written consent for intubation, patient prepared for intubation with supine position. Afterthat, 100% fio2 has been administered with the help of either NIV, AMBU bag or face mask,IV fentanyl ( 1-2mcg/kg) has been used for analgesia followed by short acting depolarising or non depolarising such as inj.succinylcholine (2mg/kg) or inj. Rocuronium (0.9mg/kg) followed by bag mask ventilation with AMBU bag or NIV PC(pressure control) for 10 to 15 seconds & then laryngoscope was inserted in to the mouth & vocal cords were visualised & then endotracheal tube with stylet was inserted through the vocal cords, stylet was removed & cuff was inflated with the help cuff manometer & bilateral air entry was checked with the help of stethoscope & tube was fixed at angle of mouth.

Preparation of Patients:

1. A written informed consent in the study was obtained from each of 100 patients.
2. All procedures were performed according to standard guidelines.
3. After standard monitoring - electrocardiogram (ECG), non-invasive blood pressure (NIBP) & peripheral oxygen saturation (SpO2) were established.

Inclusion criteria:

1. All patients admitted to the ICU of Ramkrishna Care Hospital, Raipur requiring mechanical ventilation through an endotracheal tube.
2. Age of the patient more than 18 years.

Exclusion criteria:

1. Patients or legal attendant not giving informed written consent for participation in the study
2. Pregnancy
3. Following a cardiac arrest.
4. Urgency of intubation precludes safe performance of study procedures.
5. Operator feels an approach to intubation other than use of a bougie or use of an endotracheal tube with stylet would be best for the care of the patient.
6. Operator feels use of a bougie is required for the care of the patient.
7. Operator feels use of an endotracheal tube with stylet is required or contraindicated for the care of the patient.

Photo 1: Endotracheal tube no 8

Photo 2: Stylet

Table 1: Distribution of study participants according to gender (N=300)

The proportion of males in the ETI group, SAI group & BAI group were 66%, 53% & 61% respectively with no statistically significant differences noted (p=0.166).

Table 2: Comparison of BMI of study participants among the study groups (N=300)

The mean BMI were also comparable among the three study groups.

Table 3: Distribution of study participants according to first-pass intubation success rate in the three study groups (N=300)

Table 4: Pairwise comparison of first-pass intubation success rates in the three study groups (N=300)

The first-pass intubation success rates were 63% in the ETI group, 80% in the SAI group & 76% in the BAI group; & these differences were statistically significant (p=0.018).  Upon conducting pairwise analysis, it was observed that the first-pass intubation success rate of SAI group was significantly higher than that of the ETI group (p=0.008).  Similarly, the first-pass intubation success rate of BAI group was significantly higher than that of the ETI group (p=0.045).  However, the first-pass intubation success rate of SAI group was comparable with that of the BAI group (p=0.494).

Table 5: Distribution of study participants according to incidence of complications in the three study groups (N=300)

In terms of peri-intubation complications, severe hypoxemia was observed to more frequent in the ETI group (34%) as compared to the SAI group (10%) & BAI group (9%); & this difference was statistically significant (p<0.001).

Although less common, esophageal intubation was also reported to be significantly higher in the ETI group (8%) when compared to the SAI group (1%) & BAI group (1%) (p=0.006).

However, the incidences of cardiac arrest & cardiovascular collapse were comparable across the three study groups (p>0.05).

Traditional endotracheal intubation (ETI) utilizing direct laryngoscopy is a psychomotor expertise which requires critical experience to dominate, yet quiet & situational qualities might add further troubles to accomplishing effective ETI[8]. Patient factors frequently refered to as reasons for a troublesome intubation incorporate conspicuous overbite, restricted mouth opening, limitation of neck movement, weight, short neck, liquids or unfamiliar material in the aviation route, & front place of the larynx, however sporadically patients without any of these rules are as yet observed to be challenging to intubate by ETI. The MACOCHA score was used in the review to anticipate the gamble of troublesome intubation[9]. The MACOCHA score enjoys the benefit of being comprised with effectively recognizable & clinically appropriate factors. Moreover, the things utilized in the MACOCHA score are near those recognized in the working room & remember risk factors firmly connected with troublesome intubation for different examinations acted in anesthesiology. In the current review, in the ETI bunch, 59% patients had a score of 0-3, which showed generally safe of troublesome intubation; 28% had a score between 4-7 demonstrating moderate gamble; while the excess 13% were surveyed to have high gamble of troublesome intubation with MACOCHA score between 8-12. In the SAI bunch, the extent of patients with okay, moderate gamble & high gamble of troublesome intubation were 52%, 30% & 18% separately. In the BAI bunch, the extent of patients with okay, moderate gamble & high gamble of troublesome intubation were 57%, 29% & 14% respectively[10-12]. Generally speaking, the dispersion of patients across the MACOCHA score classes were tantamount among the three review gatherings.

The most broadly involved technique for tracheal intubation in fundamentally sick patients includes utilizing an endotracheal tube alone. It is fundamental to guarantee better first-pass intubation progress to diminish peri-intubation entanglements & work on quiet results. Trouble in either envisioning the glottic opening or conveyance of the tracheal cylinder to the laryngeal gulf might influence first pass achievement. Different gadgets & devices like video-laryngoscopes, stylets, & tracheal cylinder speakers (bougies) have been proposed to further develop first pass achievement. In the current review the first-pass intubation achievement rate was 63% in the ETI bunch, & 80% in the SAI bunch & 76% in the BAI bunch; with a general first-pass intubation achievement pace of 73%. Pairwise examination uncovered that the first-pass intubation achievement paces of SAI gathering & BAI bunch was essentially higher than that of the ETI bunch; notwithstanding, the first-pass intubation achievement pace of SAI bunch was tantamount with that of the BAI group[13]. In the INTUBE concentrate on which included 2964 patients, intubation assistants were utilized in 35.6% of the cases; with the review revealed a general first-pass intubation achievement paces of 79.8% 8 which is reliable with our review finding. The BOUGIE preliminary revealed the first-pass intubation achievement pace of 80.4% in the bougie bunch & 83% in the stylet bunch. In the concentrate by Driver B et al. first-pass achievement was more noteworthy with than without bougie use (95% versus 86% separately). 21 Even the STYLETO preliminary revealed 78.2% first-endeavor intubation achievement rate in the tracheal cylinder + stylet bunch against 71.5% in the tracheal cylinder alone group[14]. Subsequently, our review discoveries substantiate with perceptions detailed in earlier examinations as well as help the organic believability of a superior first-endeavor intubation achievement rates in quite a while going through intubation with the help of assistants (stylet & bougie) when contrasted with the utilization endotracheal tube alone.

The overall incidence of peri-intubation complicationswas significantly higher in the ETI group than the BAI group & SAI group. The findings from the present study emphasizes that, every effort must be pursued to guide the tracheal tube between the vocal cords while minimizing time & injury. The early use of tracheal tube introducers & stylets may be advocated in airway management guidelines, supported by adequate training & proper knowledge of specific characteristics, indications, techniques & complications in order to maximize first-pass intubation success.

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