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‘BURP’ (1) WORSENS GLOTTIC VIEW WHEN APPLIED TO THE CRICOID CARTILAGE

Department of Anesthesiology and Pain Medicine, 3B2.32 Walter C. Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, T6G 2B7. Department of Anesthesia, Misericordia Community Hospital, 16940-87 Avenue, Edmonton, Alberta, T5R 4H5.

INTRODUCTION

Previous studies have shown that the ‘BURP’ maneuver improved glottic view, when applied to the thyroid cartilage. (1) We hypothesized that backward, upward and rightward pressure on the cricoid cartilage would combine benefits of both ‘BURP’ and Sellick's maneuver (2), improving glottic view and offer potential protection against passive regurgitation.

METHODS

We analyzed glottic view data from 40 adults undergoing elective surgery, in this prospective, randomized, double blind and crossover study. Patients at risk for regurgitation or with difficult airways were excluded. Patients were induced with fentanyl, propofol and rocuronium. In a random sequence for each case, and blinded by a sheet to the laryngoscopist, an anesthetic technician applied 30 newtons of direct, ‘BURP’, or no pressure to the patients cricoid cartilage. A separate laryngscopy was conducted for each maneuver and the views were graded as being good (part of the glottis seen), poor (the arytenoids were seen) and no view (only the epiglottis was seen). After the third maneuver the airway was secured with an endotracheal tube. The same anesthetic technician applied the pressures and the same laryngoscopist assessed the glottic views through the study. Views were recorded and blinding was maintained until the conclusion of the study. Differences were analyzed using the Wilcoxon Signed Rank test.

RESULTS

The hypothesis was rejected and 12/40 (30%) of the patients having ‘BURP’ applied to the cricoid cartilage showed a worse view (p=0.007), while only 2/40 (5%) showed an improved view. Direct cricoid pressure made the view worse in 5/40 (12.5%) of the patients, which was not statistically significant (p=0.279) and only 1/40 (2.5%) showed an improved view. No difference was seen in 26/40 (65%) of the patients.

DISCUSSION

The'BURP' maneuver worsens glottic view when applied to the cricoid cartilage. There would be no benefit in routinely applying ‘BURP’ to the cricoid cartilage, during rapid sequence inductions. Second, proper application of cricoid pressure is important to prevent an obstructed view of the glottis. Finally, there may be situations where cricoid pressure could be removed to get a better view.

REFERENCES

1 Can J Anesth. 40: 279-82.

2 Lancet. ii: 404-406.

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