From BURP to BILP: backwards internal laryngeal pressure

A burns patient whose tracheal tube was accidentally dislodged and ended up placed in the oesophagus on day 2 of his ICU stay continued to spontaneously ventilate and maintain saturations on a midazolam infusion. The oesophageal tube was left in during laryngoscopy (after propofol but no muscle relaxant due to anticipated difficult airway) which revealed a cormack-lehane grade 3 view. The operator’s hand which was holding a bougie rested on the oesophageal tube, which displaced it backwards. This resulted in backwards displacement of the larynx and improved the glottic view to 2b, facilitating intubation.
The discovery of this ‘backwards internal laryngeal pressure’ manoeuvre led the authors to make the recommendation that during difficult intubation an inadvertently placed oesophageal tube should be left in place to allow a BILP manouevre, but removed if it impedes the passage of the tracheal tube.
I love anything that might improve success rates of critical procedures and this one could conceivably come in handy. I can just see Minh Le Cong inventing a transoesophageal posterior laryngal retractor for under 50 bucks…
The use of “Internal Laryngeal Pressure” to improve the laryngeal view following inadvertent oesophageal intubation in a patient with difficult airway
Anaesth Intensive Care. 2012 Jul;40(4):736-7

4 thoughts on “From BURP to BILP: backwards internal laryngeal pressure”

  1. Liz – worth a try if the oesophagus has been intubated and you can’t get a good enough view of the larynx to pass a bougie.

  2. yeah it is an interesting case report for sure!
    problem is if oesophageal intubation during RSI and critical hypoxia, its hard to rescue oxygenate with BVM when an ETT is still down.
    But I am sure there is a way to make this discovery useful! stay tuned!
    thanks Cliff!,

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