Bimanual Laryngoscopy


Laryngoscopist reaches around with the right hand, manipulating the larynx while directly observing the effect on laryngeal view.	After the view is optimized, an assistant maintains pressure at this location, freeing the laryngoscopist’s right hand to place the tube. Bimanual technique is much more effective than backward, upward, rightward pressure (BURP), or cricoid pressure, applied by an assistant.

Bimanual laryngoscopy is the single most practical and effective airway management technique for facilitating intubation during laryngoscopy. It can be applied in seconds. It can transform a “difficult airway” or “difficult intubation” (poor view, intubation failure, repeat attempts) to a well-visualized larynx and first-pass intubation success. It is useful for both adult and pediatric intubation. In rapid sequence intubation, where patients often have very short safe apnea times, it can permit successful intubation on first laryngoscopy, without the need for a round of bagging and reinsertion of the laryngoscope.

Laryngeal exposure and successful intubation with laryngoscopy depends on subtle interactions between the tip of the laryngoscope and the epiglottis. Straight blades elevate the epiglottis directly, but the effectiveness of a curved blade entirely depends upon how the tip of the blade interacts with the vallecula. Pressure on the underlying hyoepiglottic ligament causes the epiglottis to lift upward. Manipulation of the larynx externally, specifically bimanual laryngoscopy by the operator, effectively drives the tip of the blade into proper position, optimizing the mechanics of indirect epiglottis elevation. Bimanual laryngoscopy also works through a second mechanism, by moving the larynx downward (posteriorly), into the operator’s line of sight. This benefit applies to both curved and straight blades.

Bimanual laryngoscopy transforms a poor laryngeal view


Initial view demonstrates posterior cartilages and interarytenoid notch.	With bimanual laryngoscopy, the glottic opening and true vocal cords are well seen.

Bimanual laryngoscopy has been part of the procedure of laryngoscopy since the first reported indirect laryngoscopy by Czermack in 1865. External neck pressure was subsequently done using mechanical devices by the early laryngeal surgeons (Brunnings, Killians, etc.) during the period of ether anesthesia, and it is a vital component of modern phonomicrosurgery.

Steven Zeitels, MD, a prominent laryngeal surgeon at Massachusetts General Hospital, has written a wonderful review of the history of laryngoscopy and the role of "external counterpressure": "External counterpressure" and "internal distention" for optimal laryngoscopic exposure of the anterior glottal commissure. Ann Otol Rhinol Laryngol. 1994 Sep;103(9):669-75.

Conceptually, tip of the curved blade functions as a key being inserted into the lock of the vallecula. Bimanual laryngoscopy serves to fully insert the key all the way into the lock, allowing turning of the lock (elevating the epiglottis), and “opening” the larynx. In some cases bimanual larynoscopy may be best at the cricoid cartilage, or even the hyoid bone, although Benumof found that optimal manipulation was at the thyroid in almost 90% of cases. Benumof JL, Cooper SD. Quantitative improvement in laryngoscopic view by optimal external laryngeal manipulation. J Clin Anesth. 1996 Mar;8(2):136-40. The operator need not be concerned about the exact position of their right hand. There is instantaneous visual feedback about the effectiveness of epiglottis elevation, and it is easy to move the right hand slightly up or down on the patient’s neck to optimize the view.

The most critical aspect of bimanual laryngoscopy is the direct operator connection between external neck manipulation and the immediately observed effect on laryngeal view. Cricoid pressure and Backward Upward Rightward Pressure (BURP) involve an assistant applying pressure to the neck. Minor changes in blade tip position, or force vector and direction, can significantly alter exposure and epiglottis control during laryngoscopy. Bimanual laryngoscopy–by the operator, as opposed to an assistant–is the most effective means of optimizing laryngeal view and facilitating tracheal intubation. About 10% of the time it is helpful for an assistant to maintain pressure at this location when the operator uses their right hand to pass the trachea tube. It is fast and simple to do this, either by initially starting with an assistant’s hand on the neck and directing it to the proper position, or by handing off pressure at the right location, as needed. Verbal communication between operator and assistant is required and the assistant should understand beforehand what the technique is accomplishing.

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Bimanual Laryngoscopy

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