Impact of left head rotation (LeHeR) maneuver on glottic view during direct laryngoscopy: An observational study

Left head rotation (LeHeR) maneuver improves the glottic view in patients with difficult airway. We aimed to assess whether rotating the head to the left side to 45° improved Cormack-Lehane (CL) glottic view during direct laryngoscopy compared to the classic sniffing position. Ease of intubation in the LeHeR position, number of attempts, time taken for intubation, and hemodynamic changes were also assessed.

This prospective, observational study was performed in 130 surgical patients aged 18-70 years, of American Society of Anesthesiologists Physical Status 1 and 2. Patients with CL grade 1 on initial direct laryngoscopy and those with restricted mouth opening were excluded. Following induction and neuromuscular blockade, direct laryngoscopy was initially attempted with the patient's head in sniffing position and CL grade was documented. Then, the head of the patient was rotated 45° to the left side, glottic view was graded, and the trachea was intubated.

Of the patients, 76.9% showed improvement in CL grade in the LeHeR position. Significantly higher percentage of patients had CL grade 1-2B in the LeHeR position compared to that in sniffing position (95.38% vs. 73.8%). Intubation was performed in the LeHeR position in 73.8%, 26.2% patients were intubated in a supine position, and 20% required bougie for intubation. Mean heart rate remained comparable with baseline values throughout the study period. Compared to baseline values, mean blood pressure values were significantly lower.

LeHeR to 45° improved the glottic view during direct laryngoscopy compared to the classic sniffing position. Intubation was easy with good first-attempt success without desaturation or adverse hemodynamic effects.