Thread by @EM_RESUS

External Laryngeal Manipulation

1. Move the Laryngeal Prominence (Adam's Apple) around with your free hand until your view is optimized

2. Have an assistant hold it there while you pass the tube

It’s amazing how much this can improve your view!

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The reason External Laryngeal Manipulation (ELM) is so effective is that it allows real-time visual feedback to the intubator who finds the precise direction and force required on the thyroid cartilage to optimize their laryngeal view!

2/x

ELM not only provides enhanced laryngeal visualization, but it also brings the larynx into a more posterior position, effectively flattening the angle of the secondary curve, and decreasing the angle the endotracheal tube must travel. This makes it easier to pass the tube!

3/x

ELM has evolved from the original technique known as “BURP”, which was introduced in the early 1990’s. BURP stands for Backwards, Rightwards, Upward, Pressure. This technique called for an assistant to blindly manipulate the thyroid cartilage in the above directions.

4/x

The problem with BURP is that the direction and force that will optimize an intubator's view is dependent on many factors and is highly variable! So while BURP *may* improve your laryngeal view, there is also a good chance that it will worsen it!

5/x

Ok let’s talk Cricoid Pressure. It was first described in 1961 by a British Anesthesiologist, Brian Sellick (AKA Sellick Maneuver). This theoretical technique hoped to “decrease aspiration” by pinning the esophagus between the Cricoid Cartilage and a cervical vertebral body.

6/x

It's important to understand that Cricoid Pressure is NOT a maneuver intended to improve the intubator's view. In fact, not only have studies failed to show it’s efficacy in decreasing aspiration, but there is actually evidence that it is likely to *worsen* laryngeal view!

7/x

So in summary use External Laryngeal Manipulation (ELM) during endotracheal intubation. It’s a much more sophisticated version of BURP that can greatly improve your laryngeal view and facilitate tube delivery. And one more thing: Cricoid Pressure is all but dead!

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