To the Editor:
In their recently published paper, Dr. Cooper and colleagues  allude to the value of clinician innovation in evaluating technologic advancements (the Bullard laryngoscope) in defining both the value and the optimum manner of utilizing these new technologies. Patience and persistent practice are necessary to learn new skills or modify preexistent skills to accommodate technologic advances. In their paper Cooper et al. provide some useful tips to enhance the performance of the Bullard scope. I have used the Bullard scope over the last several years and have also made a number of modifications which may both steepen the slope and increase the area under the learning curve for novice users. These modifications are sufficiently different from those proposed by Cooper et al. to warrant mention.
I have found, as did Cooper et al., that the dedicated intubating stylet facilitates intubation with the Bullard scope. However, I reduced the terminal angulation of the stylet (to 15 degrees), as I found that the endotracheal tube (ETT) was often directed tangentially across the glottis rather than into it. With the decreased terminal angulation, the ETT is positioned more centrally in the glottis and rarely is the right arytenoid cartilage an obstruction to tube passage, as was reported by Cooper et al. I do not project the stylet through the Murphy eye of the ETT, as suggested by Cooper et al., but rather leave it contained within the ETT and position the ETT distally on the stylet. The tube and stylet are held, as described by Cooper et al., against the undersurface of the blade and provide little increase in the overall dimensions of the instrument even with the tube so distally oriented. Continuous oxygen insufflation through the suction/insufflation port as described by Cooper et al. (I use 6-8 L/min flow) serves to maintain patient oxygen saturation (useful as one begins to ascend the learning curve), maintains the viewpiece clear of secretions, and also either prevents or clears fogging of the laryngoscope once it is introduced into the pharynx. I experienced some initial difficulties using the oxygen tubing in the manner diagrammed by Cooper et al. as the tubing tended to readily dislodge. I modified the end of the tubing by cutting it off flush and inserting one end of a double-male Luer-Lok device into the cut end. The other end is attached to the Luer-Lok of the Bullard suction port and a neat and secure contact is obtained Figure 1. After one has achieved a degree of skill with the Bullard scope, teaching the skill to others is very much facilitated by the use of an operative video camera Figure 2. Virtually all cameras used for scope/camera procedures and surgeries (laparoscopic, cystoscopic, and arthroscopic) in our institution have worked exceedingly well with the Bullard scope. Videotaping the intubation process and reviewing it later has been a useful process to enhance the skills of both the teacher and students. I have made it a point to use the video Bullard when providing anesthetic care to most patients presenting for camera/scope surgeries. The camera and video screens are already present in the room and little additional effort is required beyond the Bullard setup.
I hope that the suggestions offered are found to be useful by those readers now gaining experience with the Bullard laryngoscope.
Edward T. Crosby, MD, FRCPC
Department of Anaesthesia, University of Ottawa, Ottawa General Hospital, Ottawa, Ontario, Canada K1H 8L6
© 1995 International Anesthesia Research Society
1. Cooper SD, Benumof JL, Ozaki GT. Evaluation of the Bullard laryngoscope using the new intubating stylet: comparison with conventional laryngoscope. Anesth Analg 1994;79:965-70.