Many difficult tracheal intubations are unanticipated and can have catastrophic consequences. The patient’s position before intubation is of great importance in increasing the success rate of tracheal intubation. The sniffing position is the most widely accepted position for tracheal intubation.  Lee et al studied the effects of 25 degrees of bed elevation to the supine position and found better laryngeal visualization. Other researchers also showed the effectiveness of bed-up-head–elevated (BUHE) position in endotracheal intubation (ETI) with increased success rates of tracheal intubation, decreased airway complications, reduced need for airway adjuncts, decreased time to endotracheal intubation, and prolonged safe apnea time for intubation. Over the last many years, there has been increasing in the use of video-assisted laryngoscopy (VAL) devices. Literature had showed that VAL is associated with better laryngeal exposure and an increased success rate of endotracheal intubation. ^10,11 The higher cost associated with VAL, especially in developing countries limits its use in patients undergoing endotracheal intubations in a low-resource setting.

Currently, to our knowledge, no literature is there that compared laryngoscopy in the BUHE position with conventional C-MAC laryngoscopy. We wish to perform a noninferiority trial comparing between Macintosh laryngoscopy in the BUHE position and laryngoscopy via conventional C-MAC laryngoscopy in the supine position. Our primary objective is to determine whether laryngeal exposure in the BUHE position Macintosh laryngoscopy is non-inferior to conventional C-MAC laryngoscopy. We hypothesize that Macintosh laryngoscopy in the BUHE position provides noninferior laryngeal exposure when compared to conventional C-MAC laryngoscopy in the supine position, within the bounds of the predefined margin of noninferiority set at −15%.