To the Editor:--The Bullard laryngoscope, because of its rigid, anatomically shaped blade and fiberoptic light source, is used in patients in whom the trachea is difficult to intubate. Multiple techniques for intubating the trachea with a Bullard laryngoscope are described in the literature. [1–5]We find that the following technique is simpler, faster, and allows jet ventilation or insufflation of oxygen through a catheter, if required.
Our technique uses a 70-cm 8 F catheter and a two-part intubation catheter (Cook Critical Care, Bloomington, IN);Figure 1). These catheters have an easily removable Rapi-fit adapter (with luer lock and 15-mm connector), which allows jet ventilation or Oxygen2administration to the patient during the procedure. The tongue surface of a Bullard laryngoscope is well lubricated and introduced into the oral cavity in the midline position, while the head and neck remain in neutral position. The laryngoscope blade is passed over the tongue into the posterior pharynx and elevated against the dorsal surface of the tongue, allowing the blade to be positioned in front of the epiglottis and exposing the glottis. The 8 F catheter is passed through the channel, which exists next to the light source, and directed into the trachea under fiberoptic visualization (Figure 2(A)). Slight adjustment of the blade may be required to guide the catheter into the glottis. The Bullard laryngoscope is then carefully removed, while maintaining the catheter in the trachea.
The distal segment of the two-part intubation catheter is then passed carefully over the 8 F catheter into the trachea, and the second proximal segment is threaded onto the distal segment (Figure 2(B)). With the use of a two-part intubation catheter, kinking and impingement at the aryepiglottic fold by the 8 F catheter are less likely to occur than if an endotracheal tube were passed directly over the 8 F catheter. The endotracheal tube can then be passed over the two-part intubating catheter and into the trachea (Figure 2(C)). In pediatric patients, a 50-cm long 8 F catheter is used, and the endotracheal tube is directly inserted over the catheter without any difficulty.
There are several advantages to this technique: 1) the ability to maintain the head and neck in a neutral position and with much less manipulation of the airway than when a dedicated stylet is used; 2) the ease and rapidity of establishing access to the trachea with the 8 F catheter; 3) the ability to oxygenate and jet ventilate through the lumen of that catheter, if needed; 4) the passage of a two-part intubating catheter (for endotracheal tubes greater or equal to 7.0 mm) over the 8 F catheter is less likely to kink the 8 F catheter than an endotracheal tube is; and 5) the relatively atraumatic nature of these steps. We have had excellent success with this technique, and find that it takes approximately 30 s. We hope that others find it as useful.
Vijayalakshmi U. Patil, MD; Associate Professor of Anesthesiology, Carlos J. Lopez, III, MD; Assistant Professor of Anesthesiology, David J. Romano, MD; Assistant Professor, SUNY Health Science Center at Syracuse, Department of Anesthesiology, 750 E. Adams Street, Syracuse, New York 13210.
(Accepted for publication May 2, 1996.)