Difficult AirwayLeHeR-VLNCT07902973
LeHeR Maneuver vs Sniffing Position During Video Laryngoscopy in Predicted Difficult Airway
An observational study of Difficult Airway and Difficult Intubation, run by Sakarya University.
Trial summary
The left head rotation (LeHeR) maneuver, in which the head of the supine patient is rotated 45° to the left, is a simple, equipment-free technique proposed to improve the laryngeal view. Read more about this study
- Who is it for?
- Ages 18 to 70 years
- Conditions the study is for
- Difficult Airway, Difficult Intubation, Video Laryngoscopy
- What is being tested?
- Video laryngoscopy in the sniffing position and Left Head Rotation (LeHeR) maneuver
- Type of treatment
- Surgery or procedure
- How many people
- 40 participants
- Where
- No sites listed yet
- Study dates
- 1 Dec 2026to 1 Dec 2027
- Phase
- Observational
- Are there results?
- Not yet: the study is under way
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 to 70 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Study population: Adult patients aged 18-70 years with ASA physical status I-III and a modified El-Ganzouri Risk Index score above 4 who are scheduled for elective surgery under general anesthesia with video laryngoscopy-guided oral endotracheal intubation in the operating rooms of Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital (Cekmekoy State Hospital campus), Istanbul, Turkiye. Consecutive eligible patients will be screened, and those with a POGO score below 100% in the sniffing position will be included.
Who may be able to join
- Age 18-70 years
- Scheduled for elective surgery under general anesthesia with video laryngoscopy-guided oral endotracheal intubation
- Modified El-Ganzouri Risk Index (EGRI) score above 4
- ASA physical status I-III
- Written informed consent
Who cannot join
- Limited mouth opening (less than 3 fingerbreadths)
- Cervical instability, cervical fixation, active cervical pathology, or previous cervical surgery
- High aspiration risk (full stomach, gastroesophageal reflux, hiatal hernia, ileus, pregnancy)
- Neck/oropharyngeal mass, facial trauma, or pathology distorting anterior neck anatomy
- Emergency surgery
- POGO score of 100% in the sniffing position
Trial locations and contacts
No sites are listed yet. Contact the study team or a site near you to ask about taking part.
About this study
Official title: Comparison of Glottic View Between the Sniffing Position and the Left Head Rotation (LeHeR) Maneuver During Video Laryngoscopy in Patients With Predicted Difficult Airway: A Prospective, Observational, Self-Controlled Study
The left head rotation (LeHeR) maneuver, in which the head of the supine patient is rotated 45° to the left, is a simple, equipment-free technique proposed to improve the laryngeal view. Studies using the Percentage of Glottic Opening (POGO) score during video laryngoscopy have reported improvement with LeHeR, but evidence is limited and the maneuver has not been systematically evaluated in patients with a predicted difficult airway. This prospective, observational, self-controlled study aims to compare the POGO score obtained in the sniffing position with that obtained in the 45° LeHeR position in the same adult patients with a modified El-Ganzouri Risk Index (EGRI) score above 4 undergoing elective surgery under general anesthesia with video laryngoscopy. Ease of intubation, number and duration of attempts, need for adjuvant maneuvers, hemodynamic changes, and airway trauma will also be recorded.
Read the detailed description
This single-center, prospective, observational, self-controlled study will be conducted in the operating rooms of the Cekmekoy State Hospital campus of Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital in accordance with the Declaration of Helsinki. Written informed consent will be obtained from all participants. No randomization, blinding, investigational drug, or device is involved. In institutional routine practice, video laryngoscopy is used as standard and the LeHeR maneuver is performed in patients with a modified EGRI score above 4; investigators will not interfere with the anesthesiologist's practice at any stage.
Preoperatively, the EGRI score (mouth opening, thyromental distance, Mallampati class, neck movement, ability to prognath, body weight, history of difficult intubation) will be calculated. After standard monitoring, routine induction of anesthesia and neuromuscular blockade (2 minutes), video laryngoscopy will be performed in the sniffing position with an appropriately sized video laryngoscope blade (e.g., C-MAC Macintosh or D-blade), and the best glottic view will be graded with the POGO score. Patients with a POGO score of 100% will not be studied further. In patients with a POGO score below 100%, the blade will be withdrawn, propofol titrated if needed to maintain anesthetic depth, the head rotated 45° to the left while supine (LeHeR), and video laryngoscopy repeated with POGO grading. Blade type and size will be recorded. If intubation is not achieved in the LeHeR position, routine difficult-airway maneuvers (BURP, external laryngeal manipulation, cuff inflation/deflation, bougie/stylet, return to the sniffing position) will be used and recorded.
The change in POGO score will be compared with the paired t-test or Wilcoxon signed-rank test (p<0.05). Based on published POGO data, a 20% mean improvement in POGO score was considered clinically meaningful (Cohen's d approximately 0.62, assuming a within-subject correlation of 0.5). Allowing for data loss, 40 patients will be enrolled.
- Being tested
- Video laryngoscopy in the sniffing position, Left Head Rotation (LeHeR) maneuver
- Keywords
- LeHeR maneuver, left head rotation, sniffing position, POGO score, El-Ganzouri Risk Index, video laryngoscopy, C-MAC, Fremantle score
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Video laryngoscopy in the sniffing positionProcedure or surgery
After induction of general anesthesia and neuromuscular blockade (2 minutes), video laryngoscopy is performed with an appropriately sized video laryngoscope blade (e.g., C-MAC Macintosh or D-blade) with the head in the standard sniffing position. The best glottic view is graded using the Percentage of Glottic Opening (POGO) score. Patients with a POGO score of 100% are not studied further.
Left Head Rotation (LeHeR) maneuverProcedure or surgery
In patients with a POGO score below 100% in the sniffing position, the blade is withdrawn, propofol is titrated if needed to maintain anesthetic depth, the patient's head is rotated 45° to the left while supine, and video laryngoscopy is repeated. The glottic view is graded again using the POGO score and intubation is attempted in this position. If unsuccessful, routine difficult-airway maneuvers (BURP, external laryngeal manipulation, cuff inflation/deflation, bougie/stylet, return to the sniffing position) are used.
| Study group | Role | What they receive |
|---|---|---|
| Sniffing Position Followed by LeHeR Maneuver (Video Laryngoscopy) | Adult patients (18-70 years, ASA I-III) with a modified El-Ganzouri Risk Index score above 4 undergoing elective surgery under general anesthesia with video laryngoscopy, in whom the POGO score in the sniffing position is below 100%. Each patient undergoes video laryngoscopy first in the sniffing position and then with 45° left head rotation (LeHeR), serving as their own control. Receives: Procedure: Video laryngoscopy in the sniffing position; Procedure: Left Head Rotation (LeHeR) maneuver |
What is being measured
The primary outcome is the main question the study is designed to answer.
Percentage of Glottic Opening (POGO) Score in the Sniffing Position Versus the LeHeR Position
Percentage (0-100%) of the glottic opening visible from the anterior commissure to the interarytenoid notch during video laryngoscopy; higher values indicate a better view. Each patient is assessed first in the sniffing position and then after 45° left head rotation (LeHeR), and the paired scores are compared within the same patient.
Measured: During video laryngoscopy, approximately 2-10 minutes after induction of general anesthesia
Secondary outcomes (8)
Fremantle Score
Three-part score describing video laryngoscopic intubation: view (full / partial / none), ease (1 = easy, 2 = modified, requiring adjuvant maneuvers or devices, 3 = failed), and device (video laryngoscope type and blade size).
Measured: During endotracheal intubation, from first laryngoscopy until confirmed tracheal intubation
Number of Intubation Attempts
Total number of laryngoscopy attempts required for successful endotracheal intubation.
Measured: During endotracheal intubation, from first laryngoscopy until confirmed tracheal intubation
Intubation Time
Time in seconds from passage of the video laryngoscope blade between the lips to the appearance of the first end-tidal carbon dioxide waveform on capnography.
Measured: During endotracheal intubation, from first laryngoscopy until confirmed tracheal intubation
Number of Participants Requiring Adjuvant Maneuvers or Devices
Number of participants requiring BURP, external laryngeal manipulation, stylet or bougie, cuff inflation/deflation, or return of the head to the sniffing position to achieve intubation.
Measured: During endotracheal intubation, from first laryngoscopy until confirmed tracheal intubation
Number of Participants With Airway Trauma
Number of participants with signs of airway trauma, defined as blood on the video laryngoscope blade or endotracheal tube, or lip, dental or oropharyngeal mucosal injury.
Measured: From first laryngoscopy until 5 minutes after intubation
Heart Rate
Heart rate (beats/min)
Measured: Baseline (before induction), after induction, and at 1, 3 and 5 minutes after intubation
Mean arterial pressure
Mean arterial pressure (mmHg)
Measured: Baseline (before induction), after induction, and at 1, 3, 5 and 10 minutes after intubation
Peripheral Oxygen Saturation
Peripheral Oxygen Saturation (sPO2)
Measured: Baseline (before induction), after induction, and at 1, 3, 5 and 10 minutes after intubation
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted29 Oct 2026
- Study start1 Dec 2026 (estimated)
- Primary completion1 Aug 2027 (estimated)
- Study completion1 Dec 2027 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for Difficult AirwayStudies of the same condition, open and under way.
- More trials run by Sakarya UniversityThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Observational
- Observational model
- Cohort
- Time perspective
- Prospective
- Enrolment
- 40 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Sakarya University
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, halil kızılışık, Sehit Prof. Dr. Ilhan Varank Sancaktepe Training and Research Hospital
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT07902973
- Sponsor's protocol ID
- SEAH-EK-2026-527
- Acronym
- LeHeR-VL
- Status last verified
- Oct 2026
- First submitted
- 22 Oct 2026
- Last updated
- 29 Oct 2026
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Study at a glance
From the registry record, last updated by the sponsor on 29 Oct 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Comparison of Glottic View Between the Sniffing Position and the Left Head Rotation (LeHeR) Maneuver During Video Laryngoscopy in Patients With Predicted Difficult Airway: A Prospective, Observational, Self-Controlled Study
- ClinicalTrials.gov ID
- NCT07902973
- Acronym / sponsor ID
- LeHeR-VL / SEAH-EK-2026-527
- Keywords
- LeHeR maneuver, left head rotation, sniffing position, POGO score, El-Ganzouri Risk Index, video laryngoscopy, C-MAC, Fremantle score
- Study type
- Observational
- Recruitment status
- Not yet recruiting
- Enrolment
- 40 participants (estimated)
- Lead sponsor
- Sakarya UniversityUniversity, hospital or other
- Study start
- 1 Dec 2026 (estimated)
- Primary completion
- 1 Aug 2027 (estimated)
- Study completion
- 1 Dec 2027 (estimated)
- First posted
- 29 Oct 2026 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The left head rotation (LeHeR) maneuver, in which the head of the supine patient is rotated 45° to the left, is a simple, equipment-free technique proposed to improve the laryngeal view. Studies using the Percentage of Glottic Opening (POGO) score during video laryngoscopy have reported improvement with LeHeR, but evidence is limited and the maneuver has not been systematically evaluated in patients with a predicted difficult airway. This prospective, observational, self-controlled study aims to compare the POGO score obtained in the sniffing position with that obtained in the 45° LeHeR position in the same adult patients with a modified El-Ganzouri Risk Index (EGRI) score above 4 undergoing elective surgery under general anesthesia with video laryngoscopy. Ease of intubation, number and duration of attempts, need for adjuvant maneuvers, hemodynamic changes, and airway trauma will also be recorded.
Detailed description
This single-center, prospective, observational, self-controlled study will be conducted in the operating rooms of the Cekmekoy State Hospital campus of Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital in accordance with the Declaration of Helsinki. Written informed consent will be obtained from all participants. No randomization, blinding, investigational drug, or device is involved. In institutional routine practice, video laryngoscopy is used as standard and the LeHeR maneuver is performed in patients with a modified EGRI score above 4; investigators will not interfere with the anesthesiologist's practice at any stage.
Preoperatively, the EGRI score (mouth opening, thyromental distance, Mallampati class, neck movement, ability to prognath, body weight, history of difficult intubation) will be calculated. After standard monitoring, routine induction of anesthesia and neuromuscular blockade (2 minutes), video laryngoscopy will be performed in the sniffing position with an appropriately sized video laryngoscope blade (e.g., C-MAC Macintosh or D-blade), and the best glottic view will be graded with the POGO score. Patients with a POGO score of 100% will not be studied further. In patients with a POGO score below 100%, the blade will be withdrawn, propofol titrated if needed to maintain anesthetic depth, the head rotated 45° to the left while supine (LeHeR), and video laryngoscopy repeated with POGO grading. Blade type and size will be recorded. If intubation is not achieved in the LeHeR position, routine difficult-airway maneuvers (BURP, external laryngeal manipulation, cuff inflation/deflation, bougie/stylet, return to the sniffing position) will be used and recorded.
The change in POGO score will be compared with the paired t-test or Wilcoxon signed-rank test (p<0.05). Based on published POGO data, a 20% mean improvement in POGO score was considered clinically meaningful (Cohen's d approximately 0.62, assuming a within-subject correlation of 0.5). Allowing for data loss, 40 patients will be enrolled.
Study design
- Observational model
- Cohort
- Time perspective
- Prospective
- Number of arms
- 1
| Arm | Type | Receives |
|---|---|---|
| Sniffing Position Followed by LeHeR Maneuver (Video Laryngoscopy) | – | Procedure: Video laryngoscopy in the sniffing position, Procedure: Left Head Rotation (LeHeR) maneuverAdult patients (18-70 years, ASA I-III) with a modified El-Ganzouri Risk Index score above 4 undergoing elective surgery under general anesthesia with video laryngoscopy, in whom the POGO score in the sniffing position is below 100%. Each patient undergoes video laryngoscopy first in the sniffing position and then with 45° left head rotation (LeHeR), serving as their own control. |
Who may qualify
- Ages
- 18 to 70 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
- Study population
- Adult patients aged 18-70 years with ASA physical status I-III and a modified El-Ganzouri Risk Index score above 4 who are scheduled for elective surgery under general anesthesia with video laryngoscopy-guided oral endotracheal intubation in the operating rooms of Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital (Cekmekoy State Hospital campus), Istanbul, Turkiye. Consecutive eligible patients will be screened, and those with a POGO score below 100% in the sniffing position will be included.
Key inclusion criteria (5 listed)
- Age 18-70 years
- Scheduled for elective surgery under general anesthesia with video laryngoscopy-guided oral endotracheal intubation
- Modified El-Ganzouri Risk Index (EGRI) score above 4
- ASA physical status I-III
- Written informed consent
Key exclusion criteria (6 listed)
- Limited mouth opening (less than 3 fingerbreadths)
- Cervical instability, cervical fixation, active cervical pathology, or previous cervical surgery
- High aspiration risk (full stomach, gastroesophageal reflux, hiatal hernia, ileus, pregnancy)
- Neck/oropharyngeal mass, facial trauma, or pathology distorting anterior neck anatomy
- Emergency surgery
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Video laryngoscopy in the sniffing positionAfter induction of general anesthesia and neuromuscular blockade (2 minutes), video laryngoscopy is performed with an appropriately sized video laryngoscope blade (e.g., C-MAC Macintosh or D-blade) with the head in the standard sniffing position. The best glottic view is graded using the Percentage of Glottic Opening (POGO) score. Patients with a POGO score of 100% are not studied further. | Procedure or surgery | Sniffing Position Followed by LeHeR Maneuver (Video Laryngoscopy) |
| Left Head Rotation (LeHeR) maneuverIn patients with a POGO score below 100% in the sniffing position, the blade is withdrawn, propofol is titrated if needed to maintain anesthetic depth, the patient's head is rotated 45° to the left while supine, and video laryngoscopy is repeated. The glottic view is graded again using the POGO score and intubation is attempted in this position. If unsuccessful, routine difficult-airway maneuvers (BURP, external laryngeal manipulation, cuff inflation/deflation, bougie/stylet, return to the sniffing position) are used. | Procedure or surgery | Sniffing Position Followed by LeHeR Maneuver (Video Laryngoscopy) |
Primary outcome
Percentage of Glottic Opening (POGO) Score in the Sniffing Position Versus the LeHeR Position
Time frame: During video laryngoscopy, approximately 2-10 minutes after induction of general anesthesia
Percentage (0-100%) of the glottic opening visible from the anterior commissure to the interarytenoid notch during video laryngoscopy; higher values indicate a better view. Each patient is assessed first in the sniffing position and then after 45° left head rotation (LeHeR), and the paired scores are compared within the same patient.
8 secondary outcomes
Fremantle Score
Time frame: During endotracheal intubation, from first laryngoscopy until confirmed tracheal intubation
Number of Intubation Attempts
Time frame: During endotracheal intubation, from first laryngoscopy until confirmed tracheal intubation
Intubation Time
Time frame: During endotracheal intubation, from first laryngoscopy until confirmed tracheal intubation
Number of Participants Requiring Adjuvant Maneuvers or Devices
Time frame: During endotracheal intubation, from first laryngoscopy until confirmed tracheal intubation
Number of Participants With Airway Trauma
Time frame: From first laryngoscopy until 5 minutes after intubation
Heart Rate
Time frame: Baseline (before induction), after induction, and at 1, 3 and 5 minutes after intubation
Mean arterial pressure
Time frame: Baseline (before induction), after induction, and at 1, 3, 5 and 10 minutes after intubation
Peripheral Oxygen Saturation
Time frame: Baseline (before induction), after induction, and at 1, 3, 5 and 10 minutes after intubation
Results and safety
This study is still under way. Results are not available in the source record yet.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 29 Oct 2026.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part.
Questions about this trial
What is this clinical trial studying?
An observational study of Difficult Airway and Difficult Intubation, run by Sakarya University.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 5 inclusion and 6 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: opening soon, as of the sponsor's last update on 29 Oct 2026. Status can change between updates, so confirm with the study contact before making plans.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
This study is still under way. Results are not available in the source record yet.
How can a doctor refer a patient or contact the research team?
Contact Halil Kızılışık (+905372601101, halilkizilisik07@gmail.com), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Percentage of Glottic Opening (POGO) Score in the Sniffing Position Versus the LeHeR Position (time frame: During video laryngoscopy, approximately 2-10 minutes after induction of general anesthesia). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 29 Oct 2026.