Don't BURP the Baby?

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External laryngeal manipulation (ELM) was associated with reduced first-pass success in critically ill children requiring emergent intubation.  But it could have simply been a marker of a more difficult airway, not the cause.

Why does this matter?
ELM is taught as a technique to improve glottic view.  Moving the glottis backward, upward, with rightward pressure (BURP) is generally the correct way to improve glottic view.  ELM is the laryngoscopist moving the thyroid cartilage any direction he/she wants to make the view better. How effective is this in children?

Don't BURP the baby?
This was a retrospective review of 7825 emergency intubations in 35 PICUs.  They found first-pass success was 58% with ELM vs 68% without.  This association held with propensity matching.  Overall, that's pretty awful first pass success no matter how you look at it.  With this retrospective approach, there is no way to know if use of ELM was simply a marker of a more difficult airway, not the cause of a more difficult view.  It suggests that ELM may not be beneficial, and certainly suggests that it might not be best to start by using it.  But if you can't see the cords, for goodness sake, move the thyroid cartilage around to see if that helps.

Source
Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children.  Pediatr Crit Care Med. 2017 Nov 14. doi: 10.1097/PCC.0000000000001373. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.

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