Bimanual Visualized ELM

The following is a great example from Ricardo Urtubia showing how effective laryngeal manipulation can be in exposing the larynx. Note that in this case, once ELM is taken off, the laryngeal view is lost. This may be because the patient was not optimally positioned first with head elevation and ear to sternal notch positioning. Often, as mentioned above, ELM will seat the blade tip optimally within the valleculae to engage the hyoepiglottic ligament and lift the epiglottis indirectly and allow a good view without the need to continue to maintain ELM.

[Update 2016-08-10] Ricardo further points out his opinion that ELM stabilizes the laryngeal complex to assist tube delivery into the trachea and thus should be maintained by an assistant.

On further thinking, this makes sense to train one’s assistant to practice this and do it routinely especially for those cases where ELM must be maintained for optimal laryngeal exposure and may be helpful for a difficult tube delivery (small spaces, larger ETT, hyperangulated indirect (“video laryngoscopic” or VL) approach etc).

The only downside of maintained ELM is when it is applied blindly (usually under direct laryngoscopy only (DL) circumstances), the exposure may become suboptimal or too much pressure is used and hampers tube delivery. VL/DL combination and trained/briefed assistants can avoid this issue.


4 thoughts on “Bimanual Visualized ELM

  1. Thank you Yen! Actually, I filmed this video about 10 years ago and surely the patient was not ear-to-sternal notch positioned.
    I would like to comment that I think ELM should always be maintained during the intubation process because ELM also stabilizes the larynx, keeping it in place just at the moment during which the TT passes in front of our line of sight. Being the larynx a mobile structure, this could give the best chance of first pass intubation without trauma, allowing the tube entering the trachea and avoiding unnoticed esophageal intubation.
    All the best to you!


    1. Thanks Ricardo. I will add that to the collected wisdom on this page. This sounds like a good idea although I have not tried it specifically for this. RT’s holding ELM for me usually comment that they can feel the tube pass. Not sure how accurate that is but it reassures me. It would be interesting to see what other opinions on this are.

      In my tracheal tube or bougie deliveries I always aim to have the tip visualized to ride over the interarytenoid notch in order to assure that the tube or bougie is heading into the trachea before the rest of the tube blocks the line of sight. Having ELM stabilization of the laryngeal complex makes sense to improve this but I have not always found that to be necessary for successful tube delivery. This depends on making sure my assistant is prepped to assist me in this and that is probably a good thing to incorporate into my practice anyways! I have found occasionally that the blind assisted ELM is too aggressive after I have removed my hand from guiding their hand and have to ask them to back off.

      I think it is also potentially useful to do this if one has difficulties with tube delivery: stabilizing the laryngeal complex may help tube passage.

      Thanks for your thoughts on this. Great topic for discussion!


      1. Thanks to you, Yen! I hope this discussion may help others to improve safety in tracheal intubation. I am convinced that this technique with ELM made by the operator and maintained by an assistant, should be implemented to improve the chance of first pass intubation, especially in the critically ill patient, and also in our routine healthy patients (!). I think this is a good strategy (free, without harm) to avoid more than 2 attempts, which is related to increased morbility. Maybe an expert like you is always successful, but a young doctor, an emergency physician or an intensivist, may need a more structured procedure to assure success. That’s what I teach to my students, so they have a model leading to success, which includes position, preoxygenation, continuous oxygenation, laryngoscopy with maintained ELM and full confirmation of intubation. Receive my best regards!


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