Recently on my ED shifts, there were several especially challenging endotracheal intubation scenarios.

  • A patient with thick frothy sputum constantly oozing out her trachea such that we couldn’t see the vocal cords– no matter how much suction we used. Imagine the Diet Coke and Mentos backyard experiment. I’m not kidding.
  • A 300+ pound agitated trauma patient with almost no neck, who eventually was found to have an epidural and subdural hemorrhage.
  • A COPD patient who was increasingly lethargic, hypoxic, and hypercarbic (pCO2>115), who I knew would start desaturating quickly as soon as rapid-sequence induction drugs were given.

The difficult airway can be one of the most stressful things to deal with as an emergency physician. For this reason, I wanted to review a maneuver called Bimanual Laryngoscopy. This involves using both of your hands during the direct laryngoscopy. I wrote about this trick of the trade in 2007 ACEP News but it is a timeless pearl.

Direct posterior cricoid pressure does not consistently provide an optimal view of the vocal cords. It is controversial whether the BURP maneuver (back-upward-rightward pressure) applied to the cricoid cartilage improves or worsens visualization. A 2006 study by Levitan et al. suggests that the bimanual laryngoscopy technique is superior to simple cricoid pressure and the BURP maneuver.

What is bimanual laryngoscopy?

It involves operator-directed manipulation of the cricoid cartilage using his or her right hand while manipulating the laryngoscope with the left hand. Upon visualization of the vocal cords, the assistant takes over the job of external laryngeal manipulation as the operator uses the right hand to insert the endotracheal tube.

Bimanual laryngoscopy
(R= right hand of intubator, L = left hand of intubator)

As an alternative, to minimize laryngeal movement during the hand-off exchange, the operator can actually use the right hand to directly manipulate the assistant’s hand, which is grasping the cricoid cartilage. When the vocal cords are seen, the assistant’s hand remains still and maintains constant laryngeal pressure, while the operator inserts the endotracheal tube.

Alterative approach to bimanual laryngoscopy:
Manuevering the cricoid cartilage by repositioning the assistant’s hand
(R= right hand of intubator, L = left hand of intubator)

 These photos were taken on shift using medical student and paramedic student “volunteers”. If you are rotating in the ED with me, imagine all the fun photo ops that you too can be “volunteered” for! Don’t worry, only the laryngoscope handle was used in these staged photos (no blade). Looks fairly real though, right?

Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD