Insights on the efficacy of between-the-fingers versus pen-holding grip for endotracheal intubation: A commentary on a recently published study

Dear Editor, We read with great interest the study ‘To compare the efficacy of the between-the-fingers grip with the conventional pen-holding grip to hold an endotracheal tube for intubation: A randomised controlled trial’ by Thakur et al.[1] We congratulate the authors on addressing this long overdue topic, highlighting the efficacy of the unconventional grip in holding an endotracheal tube (ETT)—a technique frequently passed down through teachings of seasoned anaesthesiologists. However, based on our experience, we have observed that utilising the middle finger as the fulcrum, rather than the ring finger, provides superior control in directing ETT towards the glottic inlet. Studies indicate that the middle finger contributes the most to grip strength,[2,3] which supports our practical approach of engaging the middle, ring and little fingers together, as opposed to relying solely on the ring and little fingers. In addition, we observed that the range of motion in the distal part of ETT (the portion that enters the glottis) is greater when using the middle finger as the fulcrum compared to the ring finger [Figure 1]. We believe that holding an ETT between the middle and index fingers, with index and thumb fingers on top may be better suited for novice anaesthesiologists, left-handed individuals or situations where the ring and little fingers may be weaker in comparison to the radial digits.Figure 1: Comparison showing that using the middle finger as a fulcrum provides superior control in directing the endotracheal tube towards the glottic inletFinancial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.