Malleable Stylet Research Articles

Successful endotracheal intubation for difficult airway using a protruding malleable stylet

Successful endotracheal intubation for difficult airway using a protruding malleable stylet

Comparison between gum elastic bougie and malleable stylet as aids to intubation during application of cricoid pressure: a prospective randomised controlled study

Background: Rapid sequence intubation with application of cricoid pressure is widely practiced in all emergency situations to prevent aspiration of gastric contents. Stylet or gum elastic bougie is used as intubation aid for rapidly securing the airway. Aim: To compare gum elastic bougie and malleable stylet as aids for endotracheal intubation during application of cricoid pressure. Results: Endotracheal intubation was successful in the first attempt in all of the 60 patients enrolled in the study. Time taken for laryngoscopy and intubation was clinically similar in both the groups of patients. However, in the stylet group, successful ET intubation was achieved in about 7 sec less when compared to the bougie group (p< 0.05). Ease of intubation as compared using the Visual Analogue Scale (VAS) Score was similar in both groups. Laryngeal view improved in 22 patients of 60 patients (36.66%) after application of cricoid pressure, while it remained the same as before in 22. Overall, the grade remained the same or improved after cricoid pressure in 73.3% of patients. The laryngeal view worsened in 16 patients (27.7%). Conclusion: Gum elastic bougie and stylet are equally effective intubation aids during rapid sequence intubation. Intubation aided by bougie takes more time than that of a stylet, even though it is clinically trivial. Cricoid pressure does not affect the laryngoscopic visualisation of glottis in majority of patients

Randomized, Active-Controlled, Parallel-Group Clinical Study Assessing the Efficacy and Safety of FKScope® for Nasotracheal Intubation in Patients Scheduled for Oral and Maxillofacial Surgery Under General Anesthesia.

Most of the reports showed that videolaryngoscopy has better outcomes than direct laryngoscopy for nasotracheal intubation. The FKScope® comprises a semirigid and malleable stylet with a terminal camera and has been used to facilitate orotracheal intubation. However, its efficacy and safety for nasotracheal intubation remain unknown. This study compared FKScope® with Macintosh direct laryngoscopy for nasotracheal intubation. Sixty-four patients scheduled for oral and maxillofacial surgery requiring nasotracheal intubation were enrolled and randomly assigned to FKScope® (n = 32) or Macintosh group (n = 32). The primary outcome was time to successful intubation during the first attempt. Secondary outcomes included modified nasal intubation difficulty scale (MNIDS) scores; percentage of glottic opening (POGO); immediate postintubation side effects such as mucosal bleeding, dental injury, and lip lacerations; and postoperative side effects including nasal pain, sore throat, hoarseness, dysphagia, and dyspnea. The rates of successful first-attempt intubation were 87.5% and 90.6% in the FKScope® and Macintosh group, respectively (P = 0.69). Mean (± standard deviation) total intubation time was 68.7 ± 34.8 s in the FKScope® group compared with 61.5 ± 21.9 s in the Macintosh group (P = 0.35), despite a higher POGO for the FKScope® group (77 ± 27 vs. 41 ± 31, P ＜ 0.01). The MNIDS scores of the FKScope® group were significantly lower (0.8 ± 1.0 vs. 2.8 ± 1.4, P ＜ 0.01). The groups did not differ significantly regarding most postoperative side effects, although the FKScope® group had fewer lip lacerations (P = 0.04). The use of FKScope® improves the view of the glottic opening and is safe for nasotracheal intubation with normal airways. However, secretions and blood can obstruct the camera, and therefore, to select the patient carefully is necessary.

Predictors of difficult intubation when using a videolaryngoscope with an intermediate-angled blade during the first attempt: a prospective observational study.

The curvature of a videolaryngoscope blade has been diversified from the standard macintosh-type to the hyperacute-angle-type, resulting in different performances. We aimed to determine the intubation success rate and identify predictors of difficult intubation when using an intermediate-angled videolaryngoscope in the first attempt of intubation under routine anaesthesia settings. We enrolled 808 patients between 19 and 79years of age, scheduled for elective surgeries under general anaesthesia with orotracheal intubation from July 2017 to November 2018; patients who were candidates for awake intubation were excluded. We obtained patient demographic data and performed airway evaluation before induction of anaesthesia for elective surgeries. We used the UEScope for tracheal intubation with a hockey stick-shaped malleable stylet. The intubation time was defined as the total duration from the entry of the blade into the oropharynx to the detection of first end-tidal carbon dioxide capnogram; this duration was recorded along with the number of intubation attempts. Difficult intubation was defined as either > 60s duration for tracheal intubation, or > 1 intubation attempt. The use of the UEScope demonstrated a 99.4% success rate for intubation; however, increased difficulties were observed in patients who were male, obese, had a short thyromental distance, limited mouth opening, and high upper-lip-bite test class. Despite the high intubation success rate using an intermediate-angled videolaryngoscope, we recommend preparing backup plans, considering the increased difficulty in patients with certain preoperative features.Clinical trial number and registry URL: Clinical Trials.gov Identifier: NCT03215823 (Date of registration: 12 July).

Comparison of the efficacy of a bougie and stylet in patients with endotracheal intubation: A meta-analysis of randomized controlled trials

Endotracheal intubation (ETI) is a common procedure in the emergency department, one in which fist-attempt success is vital to preventing peri-intubation adverse events. Endotracheal intubation is often performed with assistance from either a flexible bougie or malleable stylet placed into the endotracheal tube. A recent article in the Journal of the American Medical Association found that the bougie had a higher first-attempt success rate. This meta-analysis took this recent study and compared it to other randomized controlled trials evaluating first-attempt success, intubation duration, and safety of using a bougie versus using a stylet.

Effect of embryo transfer difficulty on live birth rates studied in vitrified-warmed euploid blastocyst transfers.

The aim of this study was to investigate the relationship between the different manoeuvres employed or degrees of difficulty during embryo transfer and live birth rate (LBR) in frozen euploid (blastocyst) embryo transfer (FEET). A retrospective, observational study of women undergoing FEET was performed. If the catheter encountered any resistance in its passage through the cervix, a stepwise approach was used. Easy embryo transfer was defined as a direct embryo transfer or use of the outer sheath of the catheter. Difficult embryo transfer was defined as when the process required the use of a Wallace Malleable Stylet (Smiths Medical International Ltd., UK) without or with additional instrumentation such as a tenaculum or uterine sound. The analysis involved 370 FEET. LBR was significantly lower in difficult FEET procedures compared with easy ones (54.5% versus 40.5%, P = 0.026) but significance was lost after adjustment for confounders. Use of the outer sheath use did not affect LBR. Although LBR was significantly lower when the stylet, without or with a tenaculum, was required (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.34-0.93; P < 0.05), no statistically significant reduction was observed after adjustment for confounders (OR 0.81, 95% CI 0.45-1.47). No significant reduction in LBR was observed after adjustment for confounders between difficult and easy FEET, or when use of stylet without or with a tenaculum was required for embryo transfer. The lack of significance may be due to factors such as the sample size or the use of array comparative genomic hybridization analysis. Further studies are needed to confirm these results.

Simulação de manejo de via aérea difícil para residentes: estudo comparativo prospectivo

Background and objectivesProcedural simulation training for difficult airway management offers acquisition opportunities. The hypothesis was that 3 hours of procedural simulation training for difficult airway management improves: acquisition, behavior, and patient outcomes as reported 6 months later. MethodsThis prospective comparative study took place in two medical universities. Second‐year residents of anesthesiology and intensive care from one region participated in 3h procedural simulation (intervention group). No intervention was scheduled for their peers from the other region (control). Prior to simulation and 6 months later, residents filled‐out the same self‐assessment form collecting experience with different devices. The control group filled‐out the same forms simultaneously. The primary endpoint was the frequency of use of each difficult airway management device within groups at 6 months. Secondary endpoints included modifications of knowledge, skills, and patient outcomes with each device at 6 months. Intervention cost assessment was provided. Results44 residents were included in the intervention group and 16 in the control group. No significant difference was observed for the primary endpoint. In the intervention group, improvement of knowledge and skills was observed at 6 months for each device, and improvement of patient outcomes was observed with the use of malleable intubation stylet and Eschmann introducer. No such improvement was observed in the control group. Estimated intervention cost was 406€ per resident. ConclusionsA 3h procedural simulation training for difficult airway management did not improve the frequency of use of devices at 6 months by residents. However, other positive effects suggest exploring the best ratio of time/acquisition efficiency with difficult airway management simulation. ClinicalTrials.gov IdentifierNCT02470195.

Simulation of difficult airway management for residents: prospective comparative study

Background and objectivesProcedural simulation training for difficult airway management offers acquisition opportunities. The hypothesis was that 3 hours of procedural simulation training for difficult airway management improves: acquisition, behavior, and patient outcomes as reported 6 months later. MethodsThis prospective comparative study took place in two medical universities. Second-year residents of anesthesiology and intensive care from one region participated in 3h procedural simulation (intervention group). No intervention was scheduled for their peers from the other region (control). Prior to simulation and 6 months later, residents filled-out the same self-assessment form collecting experience with different devices. The control group filled-out the same forms simultaneously. The primary endpoint was the frequency of use of each difficult airway management device within groups at 6 months. Secondary endpoints included modifications of knowledge, skills, and patient outcomes with each device at 6 months. Intervention cost assessment was provided. Results44 residents were included in the intervention group and 16 in the control group. No significant difference was observed for the primary endpoint. In the intervention group, improvement of knowledge and skills was observed at 6 months for each device, and improvement of patient outcomes was observed with the use of malleable intubation stylet and Eschmann introducer. No such improvement was observed in the control group. Estimated intervention cost was 406€ per resident. ConclusionsA 3h procedural simulation training for difficult airway management did not improve the frequency of use of devices at 6 months by residents. However, other positive effects suggest exploring the best ratio of time/acquisition efficiency with difficult airway management simulation. ClinicalTrials.gov IdentifierNCT02470195.

Study of role of malleable stylet vs gum elastic bougie in facilitation of tracheal intubation with and without use of cricoid pressure

Study of role of malleable stylet vs gum elastic bougie in facilitation of tracheal intubation with and without use of cricoid pressure

Breakage of stylet inside endotracheal tube following intubation

A 52-year-old lady was scheduled for hemithyroidectomy for right colloid goitre. After the preanesthetic check-up, she was classified as an American society of anesthesiologists (ASA) physical status I. Her baseline vitals parameters were within normal limits. After receiving premedication, she was induced and intubated with a 7.0 mm ID flexometallic endotracheal tube (ETT) preloaded with a malleable aluminium stylet. Shortly afterwards, while fixing the ETT, the size of the stylet was noticed to be shorter than initial length. Immediately, ETT was removed and replaced with a new one. The broken piece of stylet was found inside the removed ETT.

Qualifying the difficulty of embryo transfer with a visual analogue scale and assessing its impact on IVF outcomes

The aim of this study was to determine whether a continuous visual analogue scale (VAS) is a reliable tool to grade embryo transfer (ET) difficulty when assessing IVF outcomes. No standardized grading system exists for reporting ET ‘difficulty’ which is typically recorded in descriptive terms. Clinicians performing 188 fresh single ETs between November 2014 and May 2016 also recorded a VAS score (0–100). Embryo transfers were stratified into three levels of ET ‘difficulty': (A) ‘easy’ – no resistance; (B) ‘medium’ – resistance overcome by advancing the catheter’s outer sheath; and (C) ‘difficult’ – a malleable stylet was required to overcome resistance; and these compared to the VAS scores. Clinical pregnancy and live birth rates were the primary outcomes. VAS scores were categorized into four incremental groupings according to the 25th, 50th and 75th percentiles (Groups 1–4) for analysis. No significant relationship (p > 0.05) was seen in clinical pregnancy or live birth rates in either the standard difficulty or the VAS groupings. The median VAS scores in Groups A–C increased as difficulty increased, but the interquartile ranges overlap with wide clinician variation, suggesting the VAS is not itself a reliable enough tool to record ET difficulty in isolation.

Comparison of three types of intubation stylets for tracheal intubation with a McGrath MAC® video laryngoscope by novice intubators in simulated cervical immobilisation: A randomised crossover manikin study

Introduction: Tracheal intubation using video laryngoscopes has been a better approach for trauma patients requiring cervical immobilisation. The aim of this study was to compare the time to successful intubation by novice intubators using three types of intubation stylets with the new McGrath MAC video laryngoscope in a manikin model. Methods: This was a randomised crossover manikin study. The participants performed tracheal intubations using three intubation stylets (arcuate shape malleable stylet, McGrath MAC-shaped malleable stylet and McGrath MAC-shaped rigid stylet) in a difficult airway model with cervical immobilisation. The order of the stylets was randomised. The primary outcome was the time to successful intubation. The secondary outcomes were the overall success rates, incidence of dental trauma and ease of intubation. All intubation attempts were assessed by trained assistants. The data were analysed using a multilevel model followed by Tukey’s post hoc test. Results: A total of 68 nurses participated in this study. The time to successful intubation of the McGrath MAC-shaped malleable stylet was significantly shorter than that of the arcuate shape malleable stylet (24.5 (18.0–51.0) s vs 31.5 (21.0–89.0) s, p = 0.005). The overall success rate of the McGrath MAC-shaped malleable stylet was also higher than that of the arcuate shape malleable stylet ( p = 0.047). The participants indicated that intubation was easier using the McGrath MAC-shaped malleable stylet compared with the other stylets. Conclusion: The McGrath MAC-shaped malleable stylet, when used by novice intubators, may be an optimal stylet shape for tracheal intubation using the McGrath MAC in cervical immobilisation.

The Extent of Mechanical Esophageal Deviation to Avoid Esophageal HeatingDuring Catheter Ablation ofAtrialFibrillation.

This study sought to determine the extent of lateral esophageal displacement required during mechanical esophageal deviation (MED) and to eliminate luminal esophageal temperature elevation (LETElev) during pulmonary vein(PV) isolation. MED is a conceptually attractive strategy of minimizing esophageal injury while allowing uninterrupted energy delivery along the posterior left atrium during PV isolation. MED was performed using a malleable metal stylet within a plastic tube placed within the esophagus. Barium was instilled to characterize the trailing esophageal edge. For each MED attempt, the MEDEffective, defined as the distancefrom the trailing esophageal edge-to-ablation line, was correlated to occurrences of LETElev. In 114 consecutive patients/221 PV pairs undergoing MED (age 62.1 ± 11 years, 75% men, 62%/38% paroxysmal/persistent AF), esophageal stretching invariably occurred such that the esophageal edge trailed behind the plastic tube. MEDEffective distances of 0 mm to 10 mm, 10 mm to 15 mm, 15 mm to 20 mm or >20 mm were achieved in 60 (27.1%), 64 (29%), 48 (21.7%), and 49 (22.2%) attempts, respectively. Overall, LET elevation >38°C occurred in 81of 221 (36.7%) PV pairs. The incidence of LETElev among the 4 groups was 73.3%, 35.9%, 25%, and 4.1%, respectively. MEDEffective distances were 9.1 ± 6.5 mm and 18 ± 7.6 mm in patients with and without LETElev, respectively (p<0.0001). Three patients (2.6%) experienced clinically significant MED-related trauma, albeit only with a stiffer stylet. Mechanical esophageal deviation >20 mm from the PV ablation line prevents significant esophageal heating during PV isolation, but this level of displacement was difficult to safely achieve with this off-the-shelf mechanical stylet approach.

Interactive navigation-guided ophthalmic plastic surgery: navigation enabling of telescopes and their use in endoscopic lacrimal surgeries.

PurposeThe aims of this study were to report the preliminary experience of using telescopes, which were enabled for navigation guidance, and their utility in complex endoscopic lacrimal surgeries.MethodsNavigation enabling of the telescope was achieved by using the AxiEM™ malleable neuronavigation shunt stylet. Image-guided dacryolocalization was performed in five patients using the intraoperative image-guided StealthStation™ system in the electromagnetic mode. The “look ahead” protocol software was used to assist the surgeon in assessing the intraoperative geometric location of the endoscope and what lies ahead in real time. All patients underwent navigation-guided powered endoscopic dacryocystorhinostomy. The utility of uninterrupted navigation guidance throughout the surgery with the endoscope as the navigating tool was noted.ResultsIntraoperative geometric localization of the lacrimal sac and the nasolacrimal duct could be easily deciphered. Constant orientation of the lacrimal drainage system and the peri-lacrimal anatomy was possible without the need for repeated point localizations throughout the surgery. The “look ahead” features could accurately alert the surgeon of anatomical structures that exists at 5, 10 and 15 mm in front of the endoscope. Good securing of the shunt stylet with the telescope was found to be essential for constant and accurate navigation.ConclusionNavigation-enabled endoscopes provide the surgeon with the advantage of sustained stereotactic anatomical awareness at all times during the surgery.

Techniques for Improving Video Laryngoscopy With a Hyperangulated Blade.

Video laryngoscopy (VL) is being employed increasingly for emergency airway management. The original GlideScope advanced video laryngoscope has a hyperangulated blade with a 60-degree curvature intended to improve glottic exposure. This hyperangulated shape usually requires the use of a correspondingly curved stylet, such as the GlideRite stylet, to guide the endotracheal tube to the laryngeal inlet. If a curved stylet is not available, you can bend a malleable stylet to the same degree as the blade you are using. While some studies have shown better first-pass success rates with VL compared with direct laryngoscopy, the technique can be frustrating for users of standard nonvideo nonhyperangulated blades.1-5 A link to the video is given below that highlights three tips/techniques that we have used in our airway course to teach emergency medicine residents how to best use the GlideScope. First, a common error after the GlideScope is placed in the mouth is that the blade is pushed in too deeply. This position can impair placement of the tube, so the GlideScope should be pulled back about 2 cm. This back-up maneuver will create more room to pass the endotracheal tube. Second, the endotracheal tube with stylet should be held at its distal end rather than in the middle of the tube, as is typically done for standard nonvideo laryngoscopic intubations. This technique allows better manipulation and control of the direction of the tip. Then the tip of the endotracheal tube should be advanced into the inlet until it is just visualized on the screen. Third, the equipment should be stabilized by grasping both the endotracheal tube and the GlideScope blade in one hand while watching the GlideScope screen. The endotracheal tube is then advanced into the trachea in a three-step process: Once the endotracheal tube tip is placed in the inlet, 1) the stylet end should be pulled back slightly, 1 or 2 cm, usually with the thumb while 2) simultaneously advancing the tip between the cords. Watch for the tip of the stylet to reach the upper corner of the video screen, then 3) continue to advance the endotracheal tube until its tip passes between the cords. Then completely remove the stylet and secure the tube in place. Video can be accessed at vimeo.com at: https://vimeo.com/164775680?lite=1 Password: password

Comparison of the GlideRite to the conventional malleable stylet for endotracheal intubation by the Macintosh laryngoscope: a simulation study using manikins.

ObjectiveTo compare the effectiveness of the GlideRite stylet with the conventional malleable stylet (CMS) in endotracheal intubation (ETI) by the Macintosh laryngoscope.MethodsThis study is a randomized, crossover, simulation study. Participants performed ETI using both the GlideRite stylet and the CMS in a normal airway model and a tongue edema model (simulated difficult airway resulting in lower percentage of glottic opening [POGO]).ResultsIn both the normal and tongue edema models, all 36 participants successfully performed ETI with the two stylets on the first attempt. In the normal airway model, there was no difference in time required for ETI (TETI) or in ease of handling between the two stylets. In the tongue edema model, the TETI using the CMS increased as the POGO score decreased (POGO score was negatively correlated with TETI for the CMS, Spearman’s rho=-0.518, P=0.001); this difference was not seen with the GlideRite (rho=-0.208, P=0.224). The TETI was shorter with the GlideRite than with the CMS, however, this difference was not statistically significant (15.1 vs. 18.8 seconds, P=0.385). Ease of handling was superior with the GlideRite compared with the CMS (P=0.006).ConclusionPerformance of the GlideRite and the CMS were not different in the normal airway model. However, in the simulated difficult airway model with a low POGO score, the GlideRite performed better than the CMS for direct laryngoscopic intubation.

An observational study of the feasibility of Airtraq guided intubations with Ring Adair Elvin tubes in pediatric population with cleft lip and palate.

Context:The airway management requires refined skills and technical help when associated with cleft lip and palate. Airtraq has improved our airway management skills and has been successfully used for rescue intubation in difficult pediatric airways.Aims:This study was to evaluate the efficacy of Airtraq as the primary intubation device in patients with cleft lip and palate. The study adheres to the STrengthening the Reporting of OBservational Studies Epidemiology Statement.Subjects and Methods:A total of 85 children posted consecutively for lip and palate repair were enrolled. Children were intubated with Ring Adair Elvin (RAE) tube using size 1 and 2 of Airtraq device. The design of Airtraq has an anatomical limitation to hold RAE tubes. The preformed bend of the tube was straightened with a malleable stylet. The intubations were assessed for device manipulations and time taken for glottis visualization and intubation, airway complications such as bleeding, laryngospasm and failed intubations.Statistical Analysis Used:The outcome data were reported as numbers and percentages or range with identified median value, where applicable.Results:The success rate of Airtraq guided intubations was 98.21%. The cumulative insertion times and intubation times were 31.50 ± 12.57 s and 48.04 ± 35.73 s respectively. Airtraq manipulations were applied in 25.45% subjects.Conclusions:The presence of cleft lip or palate did not hamper the insertion of Airtraq. The use of malleable stylet to facilitate the loading of the preformed tube into the guide channel is a simple and efficacious improvisation. Airtraq can be utilized as a primary intubation device in children with orofacial clefts.

Malleable stylet in difficult intubation: A modified technique

Malleable stylet in difficult intubation: A modified technique

Use of the GlideScope®for double-lumen endobronchial intubation

Dr Russell et al. recently published the results of a randomised controlled trial comparing the GlideScope® with the Macintosh laryngoscope for double-lumen endobronchial intubation 1. We would like to thank our colleagues from Toronto for performing this study, which provides useful information on the use of GlideScope for this purpose, but wish to comment on some aspects of this study compared with a preliminary observational study published in 2012 2. Firstly, the operators were similar in both centres with regard to training with the GlideScope and also with the concomitant use of the GlideScope with double-lumen endobronchial intubation. The ratio of operators to cases was comparable, with 30 operators/80 cases (38%) in Toronto and 17/50 (34%) at our institution. Secondly, the authors reported a 17% failure for first attempt at intubation with the GlideScope, compared with 9% with the Macintosh, stating that these results are similar to those in our study. We indeed reported a failure rate of 26% on the first attempt with the GlideScope in our study, but the time allowed to succeed was 60 s, as opposed to 120 s in Toronto. In Quebec City, our failure rate was 4% at 120 s (unpublished data). Thirdly, Russell et al. reported that three out of 40 cases had cuff rupture with the GlideScope, but none in the Macintosh group. Unfortunately, they did not mention how many subjects had upper teeth. In our study, we had 17/50 (34%) subjects with upper teeth and we had no tracheal cuff ruptures. This occurs frequently in the presence of upper teeth when using a double-lumen endobronchial tube. We described in 1999 a technique to help minimise this problem, simply by inserting the tube in the mouth before the laryngoscope, and we use it successfully with the GlideScope as well 3. Fourthly, the main difference between these two studies is that we used the GlideRite Double-Lumen Tube Stylet (GR-DLT-S) we designed in 2009, in collaboration with Verathon Medical Inc. (Bothell, Washington, USA). This semi-rigid stylet is a safe and effective way to ease the insertion of the double-lumen endobronchial tube with minimal trauma. In Toronto, the original malleable stylet supplied with the double-lumen endobronchial tube was used. The operator shaped it to replicate the curve of the GlideScope or the Macintosh blade's curvature as needed. In our experience, this original aluminium stylet is too malleable and does not maintain its curvature when facing any obstruction in the upper airway. We postulate that the difference in the rate of success at 120 s (96% in our study vs 83% in the Toronto study) might be explained by the use of different stylets, knowing that operators had similar expertise with the GlideScope. We agree with the authors that the GlideScope is not an easy device to use for double-lumen endobronchial intubation, particularly with novices. Our conclusion is that using GlideScope in combination with a double-lumen endobronchial tube requires training. The presence of upper teeth and small mouth opening might add some degree of difficulty but the use of special techniques and facilitating tools, such as the GR-DLT-S, can greatly improve the success rate of intubation. In our teaching institution, we encourage the use of the GlideScope/DLT/GR-DLT-S combination for every case in order to develop our expertise with these devices and to enable us to be more efficient when facing a difficult intubation.

Assessment of Truflex™ articulating stylet versus conventional rigid Portex™ stylet as an intubation guide with the D-blade of C-Mac™ videolaryngoscope during elective tracheal intubation: study protocol for a randomized controlled trial

BackgroundA variety of videolaryngoscopes with angulated blade have been recently introduced into clinical practice. They provide an indirect view of the glottic structures in normal and challenging clinical settings. Despite the very good visualization of the laryngeal structures by these devices, the insertion and advancement of the endotracheal tube may be prolonged and occasionally fail as it does not conform to the enhanced angulation of the blade. To overcome this handicap, it is recommended to use a pre-shaped, styleted tracheal tube during intubation. Unfortunately, these malleable rigid stylets permit only a fixed shape to the advancing endotracheal tube. This may necessitate withdrawal of endotracheal tube-stylet assembly for reshaping, before undertaking a new attempt. This may cause soft tissue injury and hemodynamic disturbance.This single-blinded randomized clinical trial aims to overcome these handicaps using a novel method of dynamically changing the shape of the advancing endotracheal tube by Truflex™ articulating stylet as per need during D-blade C-Mac™ videolaryngoscopy.MethodsOne hundred and fifty four patients between 18 and 60 years of age belonging to either sex undergoing tracheal intubation under uniform general anesthetic technique will be randomly divided into Portex™ malleable stylet group and Truflex™ articulating stylet group. The primary efficacy variable of success/failure between the two groups will be analyzed using the chi square test. For comparison of intubation times and the Intubation Difficulty Score, ANOVA will be used. Primary efficacy endpoint results will be successful or failed tracheal intubation in the first attempt, total intubation time and the intubation difficulty score. Secondary efficacy endpoints will be overall user satisfaction graded from 1 to 10 (1 = very poor, 10 = excellent), Cormack and Lehane’s grading, glotticoscopy time and ETT negotiation time and total number of intubation attempts. Result of safety endpoints will include dental and airway trauma, hemodynamic disturbances, arrhythmias or cardiac arrest.Trial registrationCurrent Controlled Trials ISRCTN57679531; Date of registration 12/02/2013