title: Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy.
abstract: OBJECTIVE
  External cricoid and thyroid cartilage manipulations are commonly taught to facilitate laryngeal view during intubation. We compare the laryngeal views during laryngoscopy with 4 manipulations (no manipulation, cricoid pressure, backward-upward-rightward pressure [BURP], and bimanual laryngoscopy) to determine the method that optimizes laryngeal view.
  
  
  METHODS
  This was a randomized intervention study involving emergency physicians participating in airway training courses from December 2003 to November 2004. Direct laryngoscopies were performed with curved blades on fresh, non-fixed cadavers by using each of the 4 methods. The percentage of glottic opening (POGO), a validated scoring scale, was recorded for each laryngoscopy. Scores for bimanual laryngoscopy were recorded before the assistant applied external pressure.
  
  
  RESULTS
  A total of 1,530 sets of comparative laryngoscopies were performed by 104 participants. One thousand one hundred eighteen of 1,530 sets (73%) had POGO scores less than 100 with no manipulation. Compared to no manipulation, mean POGO scores with bimanual laryngoscopy improved by 25 (95% confidence interval [CI] 23 to 27); mean POGO score improvement with cricoid pressure and BURP were 5 (95% CI 3 to 8) and 4 (95% CI 1 to 7), respectively. POGO scores with bimanual laryngoscopy were higher compared to cricoid pressure (mean difference 20, 95% CI 17 to 22) and BURP (mean difference 21, 95% CI 19 to 24). Among laryngoscopies with no manipulation in which the POGO score greater than 0 (n=1,434), laryngeal view worsened in 60 cases (4%, 95% CI 3% to 5%) with bimanual laryngoscopy, in 409 cases (29%, 95% CI 26% to 31%) with cricoid pressure, and in 504 cases (35%, 95% CI 33% to 38%) with BURP.
  
  
  CONCLUSIONS
  Using a cadaver model, we found pressing on the neck during curved blade laryngoscopy greatly affects laryngeal view. Overall, bimanual laryngoscopy improved the view compared to cricoid pressure, BURP, and no manipulation. Cricoid pressure and BURP frequently worsen laryngoscopy. These data suggest bimanual laryngoscopy should be considered when teaching emergency airway management.
authors.affiliation: Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Levitan
authors.forename: William C
authors.initials: WC
authors.lastname: Kinkle
authors.forename: William J
authors.initials: WJ
authors.lastname: Levin
authors.forename: Worth W
authors.initials: WW
authors.lastname: Everett
mesh_terms: D000488:Allied Health Personnel; D002102:Cadaver; D002983:Clinical Competence; D003413:Cricoid Cartilage; D004635:Emergency Medicine / Q000193:education / Q000379:methods; D006801:Humans; D007396:Internship and Residency; D007828:Laryngoscopy / Q000379:methods*; D010823:Physician Assistants; D011312:Pressure