The Difficult Airway in Adult Critical Care

Gavin G. Lavery, MD, FCARSCI, MB, BCh, BAO; Brian V. McCloskey, MB, BCh, FRCA, FFARCSI, MRCP


Crit Care Med. 2008;36(7):2163-2173. 

In This Article

Bimanual Laryngoscopy

Backward pressure on the cricoid cartilage, or the BURP maneuver (backward, upward, and rightward pressure), applied by an assistant may improve the view of the larynx at direct laryngoscopy.[90,91] The benefit of BURP may be enhanced further by combining it with mandibular advancement (often helpful in fiberoptic intubation).[92] However, cricoid pressure and BURP, when performed by a blinded assistant, has also been shown to impair laryngeal visualization on approximately 30% of occasions.[93,94,95] External laryngeal manipulation (also termed bimanual laryngoscopy) involves a cricoid pressure- or BURP-type maneuver performed initially by the laryngoscopist (Fig. 2) and then maintained by an assistant. It has been shown to improve the view at direct laryngoscopy.[91,96] Direct comparison has shown that external laryngeal manipulation (bimanual laryngoscopy) is superior to BURP in improving laryngeal visualization, whereas cricoid pressure is the least effective technique.[93]

Bimanual laryngoscopy. Arrows demonstrate use of one hand to control the laryngoscope and the other to apply cricoid pressure or a backward, upward, and rightward pressure (BURP)-type maneuver. Reproduced with permission from Accessed May 29, 2008.


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