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Three Part Question

[In patients in with a poor laryngoscopic view] is [the BURP technique better than simple cricoid pressure] at [improving laryngoscopic view]?

Clinical Scenario

A 35-year-old man with a severe head injury is brought to the emergency department. He has fallen from a ladder and is leaking CSF from the left ear suggesting a base of skull fracture. He has a GCS of 3 and dilated pupils. There are no other apparent injuries. You decide to intubate him using an RSI technique. Laryngoscopic view is poor despite the use of a McCoy laryngoscope and cricoid pressure. You eventually intubate using a gum-elastic bougie. Your assistant performing cricoid pressure asks during the procedure if you want a BURP. Other bodily functions come to mind! Later your colleague explains that BURP (backwards, upwards, to the right, with pressure) on the thyroid cartilage improves the view. You wonder if in fact it is any better than simple cricoid.

Search Strategy

Medline 1966-11/2003 using the OVID interface.
[{exp laryngoscopy OR laryngoscopy.mp OR exp intubation, intratracheal OR intubation.mp OR intubate$.mp} AND [{(back.mp OR backward$.mp OR posterior.mp) AND pressure.mp} OR BURP.mp]] LIMIT to human AND english.

Search Outcome

80 papers were found of which 3 were relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Benumof JL, 1996, USA	181 elective patients undergoing GA. Back plus cephalad pressure was compared with standard view	Observational study	Improvement of laryngoscopic view	All views improved
			Number of improved views in grade 3 group	All views improved
Takahata O, 1997, Japan	630 patients undergoing routine surgery.BURP was compared with back pressure on the larynx	Observational study	Number of improved views in grade 3 group	357 grade 1 views,261 grade 2 views,12 grade 3 views, 0 grade 4 views. 9 patients with an initial grade 3 Cormack view improved to grade 2 after simple back pressure.	Comparison was with back pressure on thyroid cartiladge rather than on cricoid. Very small number of initial grade 3, and no grade 4 views
			Number of improved views in grade 3 group	All patients with an initial grade 3 Cormack score improved to grade 2 after BURP.
			Number of grade 2 views that improved (to grade 1 or an improved grade 2)	176/261 after back pressure alone. 42/85 further improved with BURP
Vanner RG, 1997, UK	55 elective female patientsstandard view vs. simple cricoid vs. cricoid plus upward pressure	Observational study	Number of improved views with upward pressure vs simple cricoid alone	Better with upward pressure	Only female patients

Comment(s)

Optimising the view at laryngoscopy is an important step in succesfully intubating patients in the emergency department. Although these studies only contain small numbers of true grade 3 patients (and no grade 4) there was a consistent improvement in laryngoscopic view. The BURP technique appears to be an additional step beyond simple backward pressure (which is likely to have a similar effect as cricoid pressure). It should therefore be taught to individuals assisting in RSI in the emergency department.

Clinical Bottom Line

The BURP technique can improve the laryngoscopic view and should be taught to those assisting in anaesthetic procedures.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Benumof JL, Cooper SD. Quantiative improvement in laryngoscopic view by optimal external laryngoscopic manipulation. Anesthesia and Analgesia Journal of Clinical Anaesthesia 1996;8:136-140.
2. Takahata O, Kubota M, Mamiya K et al. The efficacy of the Anesthesia and Analgesia 1997;84:419-421.
3. Vanner RG, Clarke P, Moore WJ et al. The effect of cricoid pressure and neck support on the view at laryngoscopy. Anaesthesia 1997;52:896-900.