Knill’s Backward, Upward and Rightward Pressure May Need Modification as Jain’s Backward, Upward and Rightward Pressure

Backward, upward and rightward pressure (BURP) technique devised by Knill[1] needs modification as per Amit Jain. Herein, we highlight problems with Knill’s BURP which may get resolved with Jain’s BURP. Knill’s BURP utilises the use of longitudinally/sagittally aligned thumb-index-middle fingers [Figure 1a] to move thyroid cartilage for improving glottic view. However, healthcare providers, whether intubating patients’ tracheas themselves or supporting those who are intubating patients’ tracheas, may often hold, press and move cricoid cartilage inadvertently rather than holding, pressing and moving thyroid cartilage. Therein, Knill’s BURP becomes Sellick manoeuvre with glottic view and tracheal intubation becoming difficult[2] because Sellick manoeuvre has been only indicated for occluding post-cricoid hypopharynx to prevent gastroesophageal contents regurgitating and soiling airways.[3] Alternately, thyroid cartilage fused anteriorly and separated posteriorly being less stiff as compared to the stiffer complete ring-like cricoid cartilage,[4] Sellick manoeuvre styled pressure applied on thyroid cartilage can force its two anteriorly fused hyaline cartilages to come closer posteriorly thus worsening glottic view and making tracheal intubation difficult. Therefore, Jain’s BURP may come to the rescue by simply modifying the three-digit technique into single-digit technique wherein the horizontally/transversely aligned index finger [Figure 1b] allows movement of glottic view into a more centralised position without glottis getting narrowed by being compressed under the counteracting forces of thumb and middle finger. The abovementioned differences in glottic views with Knill’s BURP versus with Jain’s BURP may be clinically reproducible and scientifically validated by reviewing and comparing laryngoscopy images saved and stored during videolaryngoscopy. Therefore, to address the reproducibility of clinically acceptable glottic view with Jain’s BURP especially in emergent and unanticipated difficult airways, further testing before validation may be warranted.Figure 1: Thumb-index-middle fingers used for Knill’s backward, upward and rightward pressure (BURP) technique (a) versus Index finger alone used for Jain’s BURP technique (b)Authors' contributions All authors have contributed equally. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.