Gotta Love the BURP

[docB]

Seems like lately I've run into several semi tricky airways. I get good results with the BURP manuver but I don't hear it talked about much. I find it useful. BURP stands for Backward Upward Rightward Pressure. If you stick the blade in and can't see what you want try reaching up with your right hand and doing your own cricoid pressure in a back up right direction. Often you'll see the cords pop into view. You can then tell an assistant to hold the cricoid pressure right there. If if they do it wrong you'll know where the target is and you can often adjust your blade for a view or sneak the tube in with a partial view. Give it a shot.

Airway is one of the biggest differences between being a resident and an attending. When you're a resident and things get a little sticky someone usually shoulders you out of the way and drops the tube. When you're on your own and you can't get a tube you look up and all you have are the RT and several nurses staring at you. It's that moment when you want every extra option available in your bag of tricks.

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[The White Coat Investor]

Seems like lately I've run into several semi tricky airways. I get good results with the BURP manuver but I don't hear it talked about much. I find it useful. BURP stands for Backward Upward Rightward Pressure. If you stick the blade in and can't see what you want try reaching up with your right hand and doing your own cricoid pressure in a back up right direction. Often you'll see the cords pop into view. You can then tell an assistant to hold the cricoid pressure right there. If if they do it wrong you'll know where the target is and you can often adjust your blade for a view or sneak the tube in with a partial view. Give it a shot.

Airway is one of the biggest differences between being a resident and an attending. When you're a resident and things get a little sticky someone usually shoulders you out of the way and drops the tube. When you're on your own and you can't get a tube you look up and all you have are the RT and several nurses staring at you. It's that moment when you want every extra option available in your bag of tricks.

I recall reading a study recently that the BURP didn't work. But hey, what are you going to hurt?

 

[Apollyon]

I recall reading a study recently that the BURP didn't work. But hey, what are you going to hurt?

I agree - when it's "go to" like an airway, I'll settle for anecdote, and, in cases like that, "nothing succeeds like success"!

I still - totally, completely, and abjectly - love the "Grandview" blade, and have to make sure I have a gum bougie around.

 

[mikecwru]

I recall reading a study recently that the BURP didn't work. But hey, what are you going to hurt?

Well, what docB is describing is technically bimanual laryngoscopy. If I remember the study, traditional BURP (a second person holding backwards, upwards, rightwards) doesn't help much, but bimanual does a lot. Traditional cricoid pressure (Sellick) doesn't help at all and can make laryngoscopy more difficult. I believe Levitan did this study.

mike

 

[EMT2RN2MD]

Hey docb,

What about sticking one's non dominant hand in the oral cavity with the index and middle fingers on either side of the epiglottis. Then, one can pass the ett b/t the finger tips and right through the cords. I've only watched this performed twice. Both, were difficult airways not secured after laryngoscopy attempts. I did it once in a pinch. (no batteries in the scope) It is a really fast method.

As for the BURP, I have never seen it used. Intresting reading, though. Thanks.

 

[Apollyon]

Hey docb,

What about sticking one's non dominant hand in the oral cavity with the index and middle fingers on either side of the epiglottis. Then, one can pass the ett b/t the finger tips and right through the cords. I've only watched this performed twice. Both, were difficult airways not secured after laryngoscopy attempts. I did it once in a pinch. (no batteries in the scope) It is a really fast method.

As for the BURP, I have never seen it used. Intresting reading, though. Thanks.

You're describing "digital intubation", which, it seems, everyone knows, but virtually no one (since you've seen it twice, and done it once) has ever done.

 

[EMT2RN2MD]

I wonder why? It was simple and quick.

 

[12R34Y]

there was a study about bimanual intubation (right hand manipulating the external neck to make better view while left hand has laryngoscope) in the Annals of EM a few months ago and it was good.


However, in the study and the way I was taught the BURP technique is manipulation of the thyroid cartilage and NOT the cricoid.

That's the way the anesthesiologists at my place do bimanual intubation.

I love airway tricks and I love the bougie!

 

[Hayduke]

I wonder why? .

traumatic?
messy?
by definition-blind
committing 2 digits to a cavity line with sharp bits of calcium that can really hurt during that seizure nobody saw coming.

That said, as a medic I did participate in one digital intubation. It worked well. While the pt. was unsalvageable, her organs were. It was a kitchen sink maneuver.

 

[BKN]

Well, what docB is describing is technically bimanual laryngoscopy. If I remember the study, traditional BURP (a second person holding backwards, upwards, rightwards) doesn't help much, but bimanual does a lot. Traditional cricoid pressure (Sellick) doesn't help at all and can make laryngoscopy more difficult. I believe Levitan did this study.

mike

I do a combination of them both that seems to work most of the time. I have an assistant grab the larynx, and I put my right hand on his. I then move his hand and the patients larynx to the position that gives me the best view. Then I tell him to hold it there, I get the tube and put it in.

But I think 5 years from now we'll all be doing videolaryngoscopy for most of our tubes. Much easier and hardly ever a miss. Granted we get most of them reasonably easily now, but for an airway a no error rate is going to be the standard.

 

[a_ditchdoc]

You're describing "digital intubation", which, it seems, everyone knows, but virtually no one (since you've seen it twice, and done it once) has ever done.

I've tried it a few times as a last ditch effort. As much as it works well on manequins, I wasn't nearly as impressed with it on patients . You can't do it with a patient in a collar and, if you have big hands, it is difficult to position them to the epiglottis. If you have nothing better to try, and have small fingers, it might be worth a try...

That is, if you are not afraid of seizures...

 

[mikecwru]

I do a combination of them both that seems to work most of the time. I have an assistant grab the larynx, and I put my right hand on his. I then move his hand and the patients larynx to the position that gives me the best view. Then I tell him to hold it there, I get the tube and put it in.

But I think 5 years from now we'll all be doing videolaryngoscopy for most of our tubes. Much easier and hardly ever a miss. Granted we get most of them reasonably easily now, but for an airway a no error rate is going to be the standard.

Yes, I think most medical airways will move this way. A camera doesn't help a whole lot in a bloody trauma. I haven't used a trach light personally but they look nice. The intubating LMAs have too many pieces for me. I like using the boogie.

mike

 

[BKN]

I've tried it a few times as a last ditch effort. As much as it works well on manequins, I wasn't nearly as impressed with it on patients . You can't do it with a patient in a collar and, if you have big hands, it is difficult to position them to the epiglottis. If you have nothing better to try, and have small fingers, it might be worth a try...

That is, if you are not afraid of seizures...

Well, years ago I got called to the unit for a patient in an iron lung who needed to be intubated. Turns out that the rigid head rest & the cylinder made it impossible to get the scope in the mouth since the handle kept hitting the frame of the lung in any position at any angle. Since I had paralyzed the patient without knowing this, I was real happy that my first try with blind manual intubation went well.

Oh yeah, and I had used sux in this patient who had upper motor neuron disease. So next thing his pressure dropped. After I thought about it I checked the K. Had gone from 4 to 9.5. Got him through that as well.

4 am and half asleep is a real bad time to need do a code on a problem you've never seen before.

 

[Apollyon]

I like using the boogie.

Is that with a finger in the nasopharynx instead of the oropharynx?

 

[mikecwru]

Is that with a finger in the nasopharynx instead of the oropharynx?

what? is it spelled bougie?


you know what helps you duke grads intubate? an anesthesiologist... j/k

mike

 

[The White Coat Investor]

But I think 5 years from now we'll all be doing videolaryngoscopy for most of our tubes. Much easier and hardly ever a miss. d.

Go Go Glidescope! Did you notice the price recently went up from 7K to 10K?

 

[The White Coat Investor]

A camera doesn't help a whole lot in a bloody trauma.
mike

Video (not fiberoptic) works great even in a bloody airway. I have done dozens of trauma airways using the glidescope and never lost my view due to blood.

I think the boogie is what the attending does while you intubate (similar to digital nasal intubation)

 

[mikecwru]

Video (not fiberoptic) works great even in a bloody airway. I have done dozens of trauma airways using the glidescope and never lost my view due to blood.

I think the boogie is what the attending does while you intubate (similar to digital nasal intubation)

I still am not completely sold on the glidescope as a difficult airway tool. I always thought of it more as a teaching "here is what you should look for" type deal. I do have limited experience with it, so I should bow to you guys who have used it a lot, though.

On our helicopter they carry boogies (?bougies?) and the crich rate is fairly low.

mike

 

[docB]

One thing I love about BURP and bougies is that they are low tech and don't have any moving parts, lights, monitors, batteries, etc. to fail on you. The more high tech the device the more ofetn it will wind up sitting on the table like a paperweight while you continue to stuggle because of a failed light source or whatever. Anyone who has ever intubated with a burnt laryngoscope bulb and a flashlight in their mouth will agree.

 

[bartleby]

The Murphy's Law quotient on all of the electronic scopes is high. If you know how to handle an unsexy conventional laryngoscope, it's Green Eggs and Ham (...in a boat, with a goat, in the rain, on a train, etc.). "The Glidescope's in the shop... sorry!" doesn't cut it.

Particularly given the cost of the Glidescope and devices like it, the market penetration is never going to be 100%. Devices like the Airtraq (battery powered disposable laryngoscope handle with integrated fiberoptics) require no major capital expenditure to get into your airway cart but are not going to be used routinely due to their cost per device.

The dirty secret of the Glidescope is that it gets your eyes "around the bend" but you still have to be relatively proficient at handling the tube itself and actually maneuvering it through the cords.

It's like ultrasound guided central line placement. Yes, ultrasound may help facilitate central line placement in a more timely and safer fashion. But you'd damn well better know how to put in a central line based on landmarks alone as many, if not most, community hospitals still lack even rudimentary ultrasound in the ED.

 

[The White Coat Investor]

The dirty secret of the Glidescope is that it gets your eyes "around the bend" but you still have to be relatively proficient at handling the tube itself and actually maneuvering it through the cords.
.

You are correct, the intubation is more difficult, but getting the view is cake.

 

[ERMudPhud]

We have all kinds of toys in our difficult airways cart but I have to admit that as time goes on my difficult airway kit has become, "take a deep breath and try harder"

 

[roja]

The bougie is a life saver. Just last week I had a total nightmare airway. A piece of my soul and the bougie are all that saved teh dude.

I love bimanual, in fact, I scold my residents if they don't use it... In essence, my philosophy is good technique (position, good sweep, etc) and if you need it, apply your own pressure, then get someone to hold it for you. if you need to, put your hand back on thiers. Your driving and can see so move that baby around. 🙂

 

[The White Coat Investor]

A piece of my soul and 🙂

I'm starting to wonder how much more of my soul I can barter away and still have enough left to stay out of hell.

 

[docB]

I'm starting to wonder how much more of my soul I can barter away and still have enough left to stay out of hell.

We've all spent too many Saturday nights in the pit so don't worry about it. Barter away and I'll see you there.

 

[roja]

Yeah. I am already going there so you know, whats one more little piece to save a guys life? even if it is just to go out and do more crack and thus get the wierdest angioedema I have every fracking seen.


Besides, doesn't selling a piece of your soul to save someones life put you overall in the positive? hmmmm