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PurposeIt is unknown if direct epiglottis lifting or conversion to hyperangulated videolaryngoscopes, or even direct epiglottis lifting with hyperangulated videolaryngoscopes, may optimize glottis visualization in situations where Macintosh videolaryngoscopy turns out to be more difficult than expected. This study aims to determine if the percentage of glottic opening (POGO) improvement achieved by direct epiglottis lifting is non-inferior to the one accomplished by a conversion to hyperangulated videolaryngoscopy in these situations.MethodsOne or more optimization techniques were applied in 129 difficult Macintosh videolaryngoscopy cases in this secondary analysis of a prospective observational study. Stored videos were reviewed by at least three independent observers who assessed the POGO and six glottis view grades. A linear mixed regression and a linear regression model were fitted. Estimated marginal means were used to analyze differences between optimization maneuvers.ResultsIn this study, 163 optimization maneuvers (77 direct epiglottis lifting, 57 hyperangulated videolaryngoscopy and 29 direct epiglottis lifting with a hyperangulated videolaryngoscope) were applied exclusively or sequentially. Vocal cords were not visible in 91.5% of the cases with Macintosh videolaryngoscopy, 24.7% with direct epiglottis lifting, 36.8% with hyperangulated videolaryngoscopy and 0% with direct lifting with a hyperangulated videolaryngoscope. Conversion to direct epiglottis lifting improved POGO (mean + 49.7%; 95% confidence interval [CI] 41.4 to 58.0; p