- Bimanual laryngoscopy using external laryngeal manipulation (ELM) is the single most practical and effective airway management technique for facilitating intubation during direct laryngoscopy.
- The technique can also be used effectively with video laryngoscopy when using standard geometry (MacIntosh) laryngoscope blades.
- During laryngoscopy, the laryngoscopist reaches around with the right hand, manipulating the larynx while directly observing the effect on laryngeal view.
- the force on the neck is in the opposite direction to the force of lift with the laryngoscope.
- After the view is optimized, an assistant maintains pressure at this location, freeing the laryngoscopist’s right hand to place the tube.
Modified method (recommended based on Hwang et al, 2013)
- An assistant places his/her hand on the patient’s thyroid cartilage
- the laryngoscopist guides the assistant’s hand with his/her right hand to achieve the best laryngeal view and says “keep the pressure and direction.”
- The assistant maintains the pressure on the thyroid cartilage in the same direction and with same force as guided by the laryngoscopist during the tracheal intubation.
- Levitan et al (2002) showed using videographic analysis that external laryngeal manipulation (ELM) by novice intubators using a direct laryngoscopy markedly improved laryngeal views (measured as POGO scores).
- Levitan et al (2006) conducted a randomised controlled trial using a cadaver model and found that when emergency physicians performed direct laryngoscopy, bimanual laryngoscopy improved the view compared to cricoid pressure, BURP (backwards upwards rightwards pressure), and no manipulation. They also found that cricoid pressure and BURP frequently worsen laryngoscopy.
- Hwang et al (2013) performed a randomised controlled trial involving 78 patients and found that modified bimanual laryngoscopy (with the intubator guiding an assistant’s hand to optimise view) was more effective at optimising laryngeal view than conventional bimanual laryngoscopy (intubator performing external laryngoscopy then asking an assistant to “push this way”).
References and Links
- Hwang J, Park S, Huh J, et al. Optimal external laryngeal manipulation: modified bimanual laryngoscopy. Am J Emerg Med. 2013;31(1):32-6. [pubmed] [article]
- Levitan RM, Mickler T, Hollander JE. Bimanual laryngoscopy: a videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med. 2002;40(1):30-7. [pubmed]
- Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Ann Emerg Med. 2006;47(6):548-55. [pubmed]
FOAM and web resources
- ALIEM — Trick of the Trade for Intubation: Two hands are better than one
- Richard Levitan — Bimanual laryngoscopy saves the day in old woman with no teeth (Macintosh blade) (video)
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.