Quantitative improvement in laryngoscopic view by optimal external laryngeal manipulation

Summary Fifty female patients were studied to compare the view of the larynx at direct laryngoscopy under general anaesthesia with and without cricoid pressure applied. We also compared the view using the standard technique of cricoid pressure with that using cricoid pressure in an upward and backward direction and further investigated whether these views were improved with a firm foam rubber neck support. The order in which the types of cricoid pressure were applied was randomised and also blinded with a drape over the neck. Cricoid pressure was simulated on weighing scales after each case and a mean force of 3.2 kg was applied. The majority of views at laryngoscopy (95%) were grade 1, with too few grade 2 and 3 views for statistical comparison. Both types of cricoid pressure applied without neck support were more likely to give a better view than no cricoid pressure (p < 0.01) and cricoid pressure in an upward and backward direction was more likely to give a better view at laryngoscopy than the standard technique (p < 0.01). Neck support during the standard technique of cricoid pressure did not improve the view of the larynx at laryngoscopy. Cricoid pressure is likely to improve the view at laryngoscopy which may be further improved by applying it in an upward and backward direction.

The effect of cricoid pressure and neck support on the view at laryngoscopy

The displacement of the larynx in the three specific directions (a) posteriorly against the cervical vertebrae, (b) superiorly as possible, and (c) slightly laterally to the right have been reported and named the “BURP” maneuver. We evaluated the efficacy of the BURP maneuver in improving visualization of the larynx. Six hundred thirty patients without obvious malformation of the head and neck participated in this study. We divided the degree of visualization of the larynx using laryngoscopy into five grades and compared the visualization of the larynx using the BURP maneuver with that of laryngoscopy with and without simple laryngeal pressure (“Back”). The maneuver of Back and BURP significantly improved the laryngoscopic visualization from initial inspection. The BURP maneuver also significantly improved the visualization compared with the Back maneuver. We concluded that the BURP maneuver improved the visualization of the larynx more easily than simple back pressure on the larynx. (Anesth Analg 1997;84:419-21)

The Efficacy of the "BURP" Maneuver During a Difficult Laryngoscopy

Background: Previous studies have suggested that the incidence of difficult intubation in acromegalic patients is higher than in normal patients. However, these studies were retrospective and did not include preoperative assessment of the airways. The aims of this study were to determine the incidence of difficult intubation and to assess the usefulness of preoperative tests in predicting difficult laryngoscopy. Methods: One hundred twenty-eight consenting acromegalic patients requiring general anesthesia and tracheal intubation were studied. Preoperatively, Mallampati classification, thyromental distance, and head and neck movement were determined in each patient. After induction of anesthesia and muscle paralysis, laryngoscopic grade was assessed during direct laryngoscopy; Cormack and Lehane grade III or IV were classified as difficult. The association of individual airway assessment with laryngeal view was evaluated using the Fisher exact test. Predictors of difficult laryngoscopy were evaluated by calculating their sensitivity and specificity. Results: Laryngoscopy was difficult (grade III) in 33 of 128 patients (26%). Application of external laryngeal pressure improved laryngeal visualization to grade II in 20 of these 33 patients. In the remaining 13 patients (10%), intubation was difficult (more than two attempts, blade change, use of gumelastic bougie). Mallampati classes 3 and 4 were significantly related to laryngoscopy grade III (Fisher exact test, P 5 0.001). Conclusions: The incidence of difficult laryngoscopy and intubation in acromegalic patients is higher than in normal patients. Preoperative Mallampati scores of 3 and 4 were of value in predicting difficult laryngoscopy. Nevertheless, even this test

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Difficult intubation in acromegalic patients: incidence and predictability.

MANAGEMENT of anesthesia for the patient with acromegaly requires careful attention to changes in the upper airway. Several case reports have documented the airway difficulties associated with acromegaly'-' and recommended specific management, ranging from awake fiberoptic intubation to routine tracheostomy in selected patients.*-" However, there are only few data available regarding the incidence of difficult intubation in acromegalic patients. Two published retrospective series documented an incidence of 12 and 30 per 100 patients, respecti~ely,'~~ but neither reported clinical signs for estimating the likelihood of difficult intubation in these patients. Among many criteria tested as potential predictors for difficult intubation, three simple and easy-to-perform examinations- the modified Mallampati classification, measurement of the thyromental distance, and head and neck movement- have proven to predict a difficult airway with an acceptable accuracy.'-'' We hypothesized that using these tests to assess typical acromegalic airway alterations such as enlargement of the tongue, hypertrophy of soft tissue, and mandibular prognathism may help to identify acromegalic patients at risk of a difficult airway. Therefore, we undertook this prospective study to ascertain the incidence of difficult laryngoscopy and intubation and to assess the usefulness of easy-to-perform preoperative tests.

micult Intubation in Acromegalic Patients Incidence and Predictability

The laryngeal lift: a method to facilitate endotracheal intubation.

The Role Of Silent Nociceptors In Inflammatory Knee Pain

Study Objective: To assess the efficacy of the “laryngeal lift” maneuver in improving laryngoscopic visualization to facilitate endotracheal intubation. Design: Blinded study Setting: Operating room at Meridia Huron Hospital. Patients: 305 patients receiving general anesthesia for elective surgery requiring intubation. (Five patients were eliminated from the study because we elected to intubate these patients awake and sedated.) Interventions: Following induction of anesthesia and paralysis with muscle relaxants, laryngoscopic views of each patient were evaluated by the laryngoscopist before and after the laryngeal lift was performed by an anesthesiologist assisting the lalyngoscopist. Each patient served as his or her own control group. The anesthesiologist was blinded to the results obtained by the laryngoscopist. All Grade I laryigoscopic views were eliminated (198 patients). Five patients were eliminated on the basis of obesity or atlantoaxial subluxation. The laryngeal lift was performed on the remaining IO2 patients, representing Grade II to Grade V lqngoscopic views. Measurements and Main Results: A modification of the original classification of Ealyngoscopic views b Cormack and Lehane was used: Grade I = full view of glottis; Grade II = only posterior commissure visible; Grade III = arytenoids visible; Grade IV = epiglottis visible; Grade V = no glottic structure visible. In 98 of 102 cases (96%), the maneuver improved visualization by at least 1 grade. There was no evidence of change in the 4 remaining cases. Conclusions: The laryngeal lift should be part of the anesthesiologists’ armamentarium in helping the laryngoscopist who is faced with Grao!es II, III, IV, and V lalyngoscopic views to enhance visualization of the larynx and thus facilitate endotracheal intubation.

The Laryngeal Lift: A to Facilitate Endotracheal Intubation

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The laryngeal lift: a method to facilitate endotracheal intubation.

The Role Of Silent Nociceptors In Inflammatory Knee Pain

The Laryngeal Lift: A to Facilitate Endotracheal Intubation