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Case Reports

Two Tips for Users of Bullard[trade mark sign] Intubating Laryngoscope

Habibi, Ali MD; Bushell, Erin MD; Jaffe, Richard A. MD, PhD; Giffard, Rona G. MD, PhD; Brock-Utne, John G. MD, PhD

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doi: 10.1213/00000539-199811000-00044
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The Bullard[trade mark sign] Intubating Laryngoscope (Circon Corporation, Stamford, CT) was introduced into anesthesia practice for use in patients with normal airways and in cases in which a difficult endotracheal intubation is anticipated. It is designed to allow insertion of an endotracheal tube without extending the patient's neck and head or widely opening the mouth. We report two cases in which the Bullard[trade mark sign] scope was used and the serious clinical concerns that arose. Based on our experience, we recommend that all Bullard[trade mark sign] users carefully review the instruction manual and be aware of the potential complications associated with its use.

Case 1

A 73-yr-old, 91-kg, 180-cm man, ASA physical status III, with severe cervical spondylosis and right upper extremity spasticity was scheduled for posterior laminectomy at C7-T1. The patient had a history of hypertension and asthma.

Physical examination revealed a Mallampati class II airway with thyromental distance of 3 fingerbreadths and marked decrease of neck mobility. After the administration of midazolam 2 mg IV, anesthesia was induced with thiopental 425 mg, followed by succinylcholine 120 mg IV. A remifentanil infusion (0.15 [micro sign]g [center dot] kg-1 [center dot] min-1) was then started. The ventilation was difficult via a mask; therefore, direct laryngoscopy was attempted with a Macintosh 3 blade, and an 8-mm endotracheal tube was inserted on the first attempt with visualization of only the posterior arytenoids. The Bullard[trade mark sign] Intubating Laryngoscope with the blade extender tip was used to confirm tube position and to view the airway. After the tube position was confirmed, the Bullard[trade mark sign] Intubating Laryngoscope was removed, the endotracheal tube was taped into position, the patient was positioned prone, and the surgery proceeded uneventfully. At the end of the 2.5-h procedure, the patient was returned to the supine position and awakened. Once he was responsive, the trachea was extubated, and the patient was transferred to the recovery room. Initial recovery was uneventful, except that the nurses noted partial airway obstruction while the patient was sleeping. The patient was released from the postanesthesia care unit and sent to the ward after 3 h 15 min. Seventy-five minutes later, the patient complained of tightness around the throat and had audible wheezing. His respiratory rate was 12-14 breaths/min, and O2 saturation was 98% with 2 L of supplemental oxygen delivered via a nasal cannula. The patient was treated with an albuterol nebulizer with moderate improvement. One hundred fifty minutes later, the patient began to cough violently and subsequently coughed up the blade extender tip from the Bullard[trade mark sign] Intubating Laryngoscope. The tip had apparently become detached from the laryngoscope and been inadvertently left in the oropharynx. Fortunately, there were no further sequelae, and the patient was discharged on Hospital Day 5.

Case 2

A 40-yr-old, 130-kg, 190-cm man, ASA physical status II, with a left parietal region arteriovenous malformation (AVM), was scheduled for craniotomy for resection of the AVM. One month before surgery, the patient had undergone a glue embolization with a 30% decrease in the size of the AVM. The patient was receiving phenytoin for seizure prophylaxis.

The physical examination revealed a Mallampati class II airway, thyromental distance of 3.5 fingerbreadths, full range of motion of the neck, and a full set of teeth but a very small mouth opening (<2 cm) with a narrow mandible. After the patient received midazolam 2 mg IV, anesthesia was induced with fentanyl 750 [micro sign]g, pancuronium 1 mg, and thiopental 650 mg. After confirming adequate mask ventilation, succinylcholine 150 mg was administered for muscle relaxation. A well lubricated 8-mm endotracheal tube was inserted onto the Bullard[trade mark sign] scope standard stylet. The disposable blade extender tip made for the Bullard[trade mark sign] scope blade was securely attached to the distal end of the blade. Because of the patient's abnormal airway anatomy, the insertion of the Bullard[trade mark sign] scope was more difficult than usual. An adequate view of the vocal cords could not be obtained initially or with repositioning of the blade and the patient's head. Oxygen saturation began to decrease. The Bullard[trade mark sign] Intubating Laryngoscope was removed from the mouth with difficulty and, to our dismay, we noticed that the blade extender tip was no longer attached. The patient was ventilated via a mask, which promptly restored normal oxygenation. A direct laryngoscopy with a Macintosh 4 blade was performed, revealing bloody secretions, and the vocal cords could not be visualized. A gum-elastic bougie was placed blindly into the trachea, and a 8-mm endotracheal tube was placed safely over the bougie. Subsequent mechanical ventilation was uneventful.

We then turned our attention to locating the missing Bullard[trade mark sign] blade extender tip. Direct laryngoscopy was performed, but the tip could not be found. Digital exploration of the oropharynx revealed that the tip was trapped in the left subglossal area among the tongue medially, the mandible laterally, and the genioglossus inferiorly. Because of the tip's unique shape and smooth contours, it was quite difficult to retrieve, but the tip was successfully removed with a Magill's forceps. The craniotomy and resection of the AVM were completed successfully. On emergence, while the patient was breathing spontaneously, a gum-elastic bougie was inserted through the endotracheal tube, and the endotracheal tube was removed [1]. After assessing that the patient could maintain his airway without difficulty, the bougie was removed. The patient was transferred to the surgical intensive care unit for observation. He complained of a sore throat and was evaluated by the otorhinolaryngology service. They found moderate pharyngeal edema with a small, nonexpanding hematoma located at the aryepiglottic fold. The patient was transferred to a neurosurgical ward 24 h later and was discharged home after 3 days.

Discussion

The Bullard[trade mark sign] Intubating Laryngoscope was introduced into anesthesia practice for use in cases in which a difficult endotracheal intubation is anticipated [2]. It is designed to allow insertion of an endotracheal tube without extending the patient's neck and head [3,4] or widely opening the mouth and is also used in patients with normal airway anatomy. The Bullard[trade mark sign] Intubating Laryngoscope and its components are shown in Figure 1, Figure 2, and Figure 3. Initially, it was sold without the tip extender [2]. However, in a study comparing Bullard[trade mark sign] and conventional laryngoscopy, intubation failed with the Bullard[trade mark sign] in 2 of 50 patients. The authors cited the inability to retract the epiglottis as the reason for failure in these two cases and suggested that a tip extender may be advantageous in these cases [2]. According to the Bullard[trade mark sign] Intubating Laryngoscope's manufacturer, the purpose of the tip extender is to facilitate lifting of the epiglottis when the patient's anatomy necessitates a longer blade.

Figure 1
Figure 1:
Bullard[trade mark sign] Intubating Laryngoscope (modified with permission from Circon Corporation, Stamford, CT).
Figure 2
Figure 2:
The blade extender tip is attached to the distal end of the laryngoscope, where it snaps into place. Removal of the extender tip requires either a significant force at the location of the arrows or a blade extender remover tool (used with permission from Circon Corporation, Stamford, CT).
Figure 3
Figure 3:
Blade extender removal tool (used with permission from Circon Corporation, Stamford, CT).

In the first case, an inexperienced user may have failed to confirm the secure placement of the tip as explained in the instruction manual. More importantly, he or she failed to recognize that the tip was missing after the laryngoscopy. Regardless of the cause of the tip detachment, the postanesthesia care unit course and postoperative event leading to the coughing up of the tip could have been avoided if part of the extubation routine, the suctioning of the oropharynx, had been performed under direct laryngoscopy. Suctioning of the oropharynx under direct vision provides an opportunity to detect and remove foreign objects such as throat packs, blood clots, and the occasional Bullard[trade mark sign] tip extender.

This first case was presented at a departmental conference immediately after its occurrence. The proper handling of the Bullard[trade mark sign] extender tip was demonstrated and discussed. The second case occurred 1 wk after this meeting and involved anesthesiologists experienced in the use of the Bullard[trade mark sign] Intubating Laryngoscope and the blade extender tip. In this latter case, the patient had an abnormal anatomy (narrow mandible and maxilla). We believe that during removal of the Bullard[trade mark sign] Intubating Laryngoscope, the patient's molar teeth acted as a blade extender tip remover. The force applied to remove the blade was equal to the force needed to remove the extender tip. In this case, the loss of the tip was immediately recognized but was removed only after considerable difficulty. Should there be difficulty in removing the Bullard[trade mark sign] Intubating Laryngoscope from the mouth, it is imperative to reposition it and/or the patient's head to ensure that the blade and tip are removed intact. It may be useful to add a radiopaque marker to the tip or, even better, to extend the metal blade so that there is no need for a removable tip. Based on our experience, we do not agree with Midttun et al [5]., who recommend the use of the Bullard[trade mark sign] in patients with limited jaw mobility. We suggest caution in these cases.

To our knowledge, there has not been any previous report of complications attributed to the Bullard[trade mark sign] extender tip. We believe that in our first case, human error played the major role. In the second case, the mechanism by which the extender tip fits onto the Bullard[trade mark sign] blade may not be sufficient to hold the tip in certain circumstances. Hence, we have two tips for the users of the Bullard[trade mark sign] Intubating Laryngoscope: 1) read the instructions and verify proper tip attachment and 2) exercise caution when using it in patients with abnormal airway anatomy by verifying that the tip is still attached when the scope is removed scope. We recommend that the users of the Bullard[trade mark sign] Intubating Laryngoscope be aware of the potential for these problems when using the extender tip.

REFERENCES

1. Robles B, Hester J, Brock-Utne JG. Remember the gum-elastic bougie at extubation. J Clin Anesth 1993;5:329-31.
2. Cooper SD, Benumof JL, Ozaki GT. Evaluation of the Bullard laryngoscope using the new intubating stylet: comparison with conventional laryngoscopy. Anesth Analg 1994;79:965-70.
3. Hastings RH, Vigil AC, Hanna R, et al. Cervical spine movement during laryngoscopy with the Bullard, Macintosh and Miller laryngoscopes. Anesthesiology 1995;82:859-69.
4. Cohn AI, Zornow MH. Awake endotracheal intubation in patients with cervical spine disease: a comparison of the Bullard laryngoscope and the fiberoptic bronchoscope. Anesth Analg 1995;81:1283-6.
5. Midttun M, Lerkholm Hansen C, Jensen K, et al. The Bullard laryngoscope: reports of two cases of difficult intubation. Acta Anaesthesiol Scand 1994;38:300-2.
© 1998 International Anesthesia Research Society