A Cormack-Lehane grade 3 view is obtained at direct laryngoscopy. The MOST effective single manoeuvre to improve the laryngoscopic view to grade 1 or 2 is:

• A Increasing the head-extension from neutral to maximum sniffing position
• B Withdrawing the laryngoscope blade by 2 cm and re-advancing
• C Asking the patient to phonate to bring the vocal cords into view
• D Applying backward, upward, rightward pressure (BURP) on the thyroid cartilage ✓

Explanation

Backward, upward, rightward pressure (BURP) on the thyroid cartilage displaces the larynx posteriorly (improving posterior wall visibility), superiorly (reducing vertical distance from the examiner's eye), and to the right (aligning with the laryngoscopist's line of sight). This single manoeuvre applied by an assistant improves Cormack-Lehane grade in the majority of difficult views. It is distinct from simple cricoid pressure (Sellick's), which is applied posteriorly only to prevent regurgitation. The sniffing position optimises the three-axis alignment before laryngoscopy but has less impact once a grade 3 view is already present.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.