Comparison of Modified between-the-Fingers Grip and Conventional Pen-holding Grip for Endotracheal Tube Handling during Orotracheal Intubation: A Randomised Clinical Trial

Introduction: Correct handling of the Endotracheal Tube (ETT) is essential for successful tracheal intubation. The “betweenthe-fingers grip” allows real-time manipulation of ETT curvature during insertion, potentially improving alignment with the laryngeal inlet compared to conventional pen-holding grip. Aim: To compare the efficacy of between-the-fingers grip with conventional pen-holding grip for endotracheal intubation regarding first-pass success rates, requirement for Backward Upward Rightward Pressure (BURP) manoeuvre, and procedural efficiency. Materials and Methods: The randomised single centre clinical study was conducted at a tertiary care academic hospital from September 2024 to February 2025. One hundred adult patients (18-60 years) undergoing elective surgery under general anaesthesia were randomised to group C (conventional penholding grip, n=50) and group M (modified between-the-fingers grip, n=50). A single experienced anaesthesiologist performed all intubations using direct laryngoscopy. Parameters studied included first-pass success rate, BURP requirement, intubation time, and haemodynamic changes (heart rate, mean arterial pressure). Data were analysed using Statistical package for Social Sciences (SPSS) version 23. Categorical variables were compared using Fisher’s-exact test, continuous variables using independent t-tests. Statistical significance was set at p<0.05. Results: Demographic characteristics were similar with mean age 32.6±9.8 vs 30.9±8.2 years, 50% vs 48% males, and comparable airway assessments between group C and group M respectively. First-attempt intubation success was equivalent between groups (98.0% vs 98.0%, p>0.05). BURP requirement was significantly reduced in the modified grip group (4.0% vs 24.0%, p<0.001), representing 20% absolute risk reduction. Mean intubation time was shorter with modified grip (12.7±5.1 vs 16.5±7.1 seconds, p<0.01). Haemodynamic parameters remained stable and comparable between the groups. Conclusion: The between-the-fingers grip demonstrates equivalent first-pass success to conventional technique while significantly reducing BURP requirements by 20% and intubation time by 23%. This technique offers clinical advantages particularly when skilled assistance is limited.