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). 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.
Crit Care Med. 2008;36(7):2163-2173. © 2008 Lippincott Williams & Wilkins
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