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Liem EB (2006): Bullard Laryngoscope Intubation. Retrieved <insert
date of retrieval here>, from University of Florida Department
of Anesthesiology, Center for Simulation, Advanced Learning and Technology,
Virtual Anesthesia Machine Web site: http://vam.anest.ufl.edu/airwaydevice/bullard/index.html
Keywords: Bullard laryngoscope, Intubation, difficult airway,
Bullard Laryngoscope (ACMI)
See Bullard videos in the video library
The Bullard laryngoscope is one of several different types
of rigid fiberoptic laryngoscopes that are available (1). The rigid
fiberoptic laryngoscopes aids with visualization of the glottic opening
even when there is an inability to align the oral, pharyngeal, and laryngeal
axes. Compared to conventional direct laryngoscopy the rigd fiberoptic
laryngoscopes only require minimal head manipulation and positioning
(3, 4). In addition, the Bullard laryngoscope can be used in patients
with a mouth opening of as little as 6 mm.
The Bullard laryngoscope can assist in both oral and nasal
intubations (5, 6). For nasal intubations, the Bullard laryngoscope
is introduced into the mouth for visualization of the vocal cords but
the ETT is not loaded onto the dedicated stylet. With experience the
Bullard laryngoscope allows for rapid visualization of the larynx and
can be used for rapid sequence intubation. Awake intubation is possible
but requires good patient preparation and considerable skill (2,7).
It can be used in the pediatric population, since a pediatric sized
laryngoscope and stylet are available.
These above mentioned features make the Bullard laryngoscope
a good option for certain scenarios where conventional direct laryngscopy
might prove to be very difficult : patients with anterior larynx, unstable
cervical spine fracture, upper body burns, trauma, patients with TMJ
immobility and micrognathia (e.g. Pierre Robin syndrome).
We will describe the preparation and sequence of events
when using the Bullard laryngoscope with its dedicated stylet for oral
intubation in a patient induced with general anesthesia (8,9).
Reference Article List
The Bullard laryngoscope comes in both an adult and pediatric
size. A stylet should be used to guide the ETT during intubation. This
can be the dedicated unmalleable wire stylet, which has to be attached
to the laryngsocope, or an independent malleable stylet. Alternatively,
there is also a multifunctional stylet available which has the same
shape as the old stylet and attaches in the same way. The multifunctional
stylet is hollow which allows for the passage of an airway catheter,
suctioning under direct vision, or oxygen administration. A fiberoptic
lightsource and the blade/tip extender should be available. The choice
between the adult or pediatric size laryngoscope is a function of both
the height of the patient ( < 5 ft pediatric, > 5ft adult, > 6ft adult
with tip extender), and the minimal size of the ETT that can be fitted
onto the adult stylet. Some find the tip extender useful in patients
as small as 5'4", depending on their mandibular angle to thyroid cartilage
- Place tip/blade extender onto laryngoscope blade - make sure the
tip extender is securely snapped into place (the extender is only
used for the adult bullard).
- Select the appropriate size ETT for the patient. Temporarily remove
the ETT connector when using smaller sizes, as this will facilitate
advancing the ETT over the stylet during intubation. Apply a water-based
lubricant (e.g. Lidocaine jelly, K-Y jelly, Hurricaine spray,) then
insert stylet into ETT until tip extends out of the regular opening.
- When using the unmalleable wire stylet, it should be attached to
the laryngoscope handle. When looking through the optical eyepiece,
the stylet should be seen through the lens but not the ETT. It should
be withdrawn until it is out of view if the ETT is also seen.
- If needed, apply water based lubricant to blade section to facilitate
insertion of the blade.
- Test fiberoptic lightsource and snap onto ETT/stylet/laryngoscope
assembly. A guard for the fiberoptic lightsource can also be used;
snap it into place by depressing the knob located directly behind
the fiberoptic source attachment.
- Make optical element non-wettable by applying silicon oil (this
will have better adherence to the lens than anti-fog solution.)
- Consider giving the patient an anti-sialogogue.
Oral Intubation: A
Step by Step Guide
- Induce patient as if for regular intubation; apply cricoid pressure
if rapid sequence intubation is desired.
- Patient position should be undisturbed or neutral, not "sniffing".
- Position yourself as for regular direct laryngoscopy and position
the scope axis parallel to patient axis pointing caudad (see below
- Introduce the scope tip between the teeth, into the pharynx. Try
to stay as close to midline as possible.
- The ETT is held firmly in the "nook" of the Bullard as the laryngoscope/ETT
assembly is advanced as a single unit into the mouth and pharynx.
- Advance the laryngoscope/ETT assembly over the tongue using the
left hand, sweep to a position perpendicular to the patient axis minimally
distorting the anatomy.
- Elevate the bullard handle straight up, the blade tip should retract
the epiglottis and you should be able to visualize the glottic opening.
It should be noted that this is NOT a passive technique where
the scope is simply advanced into the pharynx for visualization. SUSPENSION
laryngoscopy is required to establish the viewing space necessary
to identify the epiglottis and ultimately the larynx. When performing
the suspension laryngoscopy, the right hand can be placed on the laryngoscope
for stabilization. Alternatively, some prefer to use the right hand
to grab the mandible (thumb in the mouth, fingers on mentum) and elevate
it so that less traction can be applied to the Bullard laryngoscope,
thereby making maneuverability easier
- Advance the ETT over the stylet using the right hand.
- Detach the stylet from the laryngoscope and remove the larygnoscope
in the opposite motion as during intubation.
- Withdraw the stylet and confirm correct position as for regular
Cannot see vocal cords
Usually this means one is not exactly midline.
Because the view through the Bullardscope is less panoramic than
regular intubation, it is harder to correct during laryngoscopy
if you are not entering the mouth perfectly in the midline. Step
back and determine if you are perfectly midline with the laryngoscope.
Feel the trachea / thyroid cartilage to determine the midline again,
then re-advance the laryngoscope.
Another approach would be to elevate the jaw with the right hand
while looking through the eyepiece at the same time. Then attempt
to visualize the vocal cords; the decreased amount of pressure on
the blade will make it easier to maneuver the blade.
Difficulty advancing the ETT with the vocal cords
The laryngoscope is advanced too far and advancement of the stylet
is obstructed by the arytenoids. Usually this means that you are
too close to the larynx. Remember that the viewing lens is to the
side of the ETT; as you advance it off the stylet, it will travel
from its coaxial position to a position directly in line with the
view from the lens. Withdraw the laryngoscope slightly in the horizontal
plane and re-advance the ETT.
Webauthor: E.B. Liem
R. Bullard (inventor of the Bullard Laryngoscope)
Contributors: A.J. Deckinga
Reference Article List
- Bjoraker-DG. The Bullard intubating laryngoscopes.
Anesth Rev 17(5): 64-70, 1990.
- Cohn-AL, Zornow-MH. Awake endotracheal intubation
in patients with cervical spine disease: A comparison of the Bullard
laryngoscope and the fiberoptic bronchoscope. Anesth Analg 81:1283-1286,
- Hastings-RH, Vigil-AC, Hanna-R, Yang-BY, Sartoris-DJ.
Cervical spine movement during laryngoscopy with the Bullard, Macintosh,
and Miller laryngoscopes. Anesthesiology 82:859-869, 1995.
- Watts-ADJ, Gelb-AW, Bach-DB, Pelz-DM. Comparison
of the Bullard and Macintosh laryngoscopes for endotracheal intubation
of patients with a potential cervical spine injury. Anesthesiology
- Shigematsu-T, Miyazawa-N, Kobayashi-M, Yorozu-T,
Toyoda-Y, Morisaki-H. Nasal intubation with Bullard laryngoscope:
A useful approach for difficult airways. Anesth Analg 79:132-135,
- Brown-RE jr, Vollers-JM, Rader-GR, Schmitz-ML.
Nasotracheal intubation in a child with Treacher-Collins syndrome
using the Bullard intubating laryngoscope. J Clin Anesth 5:492-493,
- Cohn-AL, MCGraw-SR, King-WH. Awake intubation
of the adult trachea using the Bullard laryngoscope. Can-J-Anaesth
- Cooper-SD, Benumof-JL, Ozaki-GT. Evaluation
of the Bullard laryngoscope using the new intubating stylet: Comparison
with conventional laryngoscopy. Anesth Analg 79:965-970, 1994.
- Cohn-AI, Isaac-P, Ramakrishnan-U, Harbourne-K.
Bullard laryngoscope: Preliminary experience with the new multifunctional
stylet. J Clin Anesth 10:681-683, 1998.