Bimanual laryngoscopy: A videographic study of external laryngeal manipulation by novice intubators

Study objective: We perform a videographic analysis of external laryngeal manipulation (ELM) by novice intubators using a direct laryngoscopic imaging system and a validated means of assessing laryngeal view (percentage of glottic opening [POGO] score). Methods: Nine first-year emergency medicine residents performed a total of 484 laryngoscopies during a 1-year study period, of which 271 were videotaped. Of this convenience sample, cases were included in the study if the initial laryngeal view had a POGO score of less than 50% and the quality of video imaging permitted POGO scoring before and after application of ELM. Results: Seventy-two cases met the study criteria. Initial POGO scores equaled 0% in 30 cases, less than 20% in 20 cases, and 20% to 50% in 22 cases. ELM improved the POGO scores in all cases (95% confidence interval [CI] 96% to 100%) by an average of 57% (SD 23.7; 95% CI 40% to 75%). Among those with an initial POGO score equal to 0%, the mean improvement was 61% (SD 36.3; 95% CI 48% to 74%). For those with an initial POGO score of less than 20%, the mean improvement was 63% (SD 19.5; 95% CI 54% to 71%), and for those with an initial POGO score of 20% to 50%, the mean improvement was 47% (SD 16.0; 95% CI 40% to 55%). Conclusion: ELM is a simple and very effective technique for improving laryngeal view during laryngoscopy by novice intubators. [Levitan RM, Mickler T, Hollander JE. Bimanual laryngoscopy: a videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med. July 2002;40:30-37.]