Bullard Laryngoscopy

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  • Oral endotracheal intubation in patients with the following:
    • Unstable cervical disease
      • Trauma
      • Congenital atlanto-occipital instability—for example, some patients with Down syndrome
    • Limited or no neck mobility
      • Spondylosis
      • Cervical fusions
    • Small oral aperture
      • Roger Bullard invented it for use on a Pierre Robin patient.
    • Airway features suggesting difficult intubation or difficult glottic visualization by normal laryngoscope
  • Double-lumen to single-lumen exchange
    • Post-thoracic surgery
    • Traumatic

All contraindications to direct laryngoscopy are relative. In life-threatening, emergency situations, direct laryngoscopy to facilitate endotracheal intubation may provide the only expedient means to a life-saving, secured airway.

In the controlled or elective settings, the following contraindications should be considered:

  • Relative contraindications
    • Significant preexisting uncontrolled oropharyngeal bleeding
    • Significant oral or laryngeal trauma
    • Known difficult mask ventilation
    • Awake patients
      • There are a few case reports of awake intubations, but awake intubation is not a standard practice.
    • Operator inexperience (first time use of a Bullard scope in a known difficult airway)—there is a significant learning curve with Bullard scope.
  • Standard monitors, including blood pressure cuff, pulse oximeter, ECG
  • Face mask and ventilation apparatus with oxygen supply
  • Capnograph or colorimetric carbon dioxide detector
  • Suction device and Yankauer type suction tip
  • Oral airways of assorted sizes
  • Bullard laryngoscope, battery handle, and stylet
  • Lubricant, such as Surgilube or 2% lidocaine jelly
  • Tape or device to secure the endotracheal tube in place
  • Appropriately sized endotracheal tube
    • Parker endotracheal tubes (with a soft, flexible tip) are helpful with Bullard laryngoscopy.

The overall goal of direct laryngoscopy is to visualize the glottic opening between the vocal cords for placement of an endotracheal tube. The ease with which this goal is accomplished is dependent on anatomic variations of the relevant anatomy, including the mouth, oropharynx, posterior pharynx, and larynx.


The size of the mouth opening, size and distribution of teeth, and size of the tongue play important roles in ease of laryngoscopy and intubation.


The oropharynx includes the structures of the upper airway from the soft palate to the level of the hyoid bone. The oropharynx opens anteriorly into the mouth, is bounded laterally by the two palantine arches and tonsils, and includes the posterior tongue. The laryngopharynx includes the epiglottis and larynx, which in turn comprise the vocal folds and vocal cords; the thyroid, cricoid, and arytenoid cartilages; and the intrinsic muscle of the larynx. The larynx begins where the upper airway divides to form the laryngeal inlet and the upper esophagus. The epiglottis is a cartilaginous flap attached to the posterior tongue, which forms a protective flap between the trachea and the upper esophagus. During swallowing, the hyoid bone is elevated, pulling the larynx upward and folding the epiglottis downward over the laryngeal inlet, diverting material into the upper esophagus.

Many major nerves contribute to pharyngeal and laryngeal function. Pharyngeal function is governed by cranial nerves IX, X (pharyngeal plexus), and XI (pharyngeal branch), which control elevation and shortening of the pharynx, alterations in palate position, the size of the pharyngeal lumen, and bolus transport of food in the esophagus. Motor innervation of the larynx is via the external and recurrent laryngeal branches of cranial nerve X. In addition, the facial nerve (7th cranial nerve) and cervical spinal nerves (C1-3) contribute to motor function of the upper airway via actions of the mylohyoid muscle on the hyoid bone to pull the larynx up and the infrahyoid muscles, which pull the larynx down. Mandibular action during phonation is also controlled by the mandibular branch of the trigeminal nerve. Sensory innervation of the larynx is via the internal laryngeal branch of the vagus nerve (cranial nerve X) above the vocal folds and the recurrent laryngeal branch of the vagus nerve below the vocal folds.

Important internal landmarks involved in laryngoscopy and intubation include the epiglottis, the vallecula, the intrinsic cartilages of the larynx (arytenoids, thyroid, cricoid), the true and false vocal cords, and the hyoid bone.

External Anatomic Features

The external anatomy of the larynx is also important in airway management. Operators should be able to identify the external landmarks of the mental protuberance of the mandible, thyroid cartilage, hyoid bone, and cricoid cartilage. Anatomic features of direct relevance to laryngoscopy include extent of mouth opening, extent of jaw subluxation, ability to flex and extend the neck, neck circumference, tongue size and protrusion, ability to visualize the uvula or soft palate with mouth opened and tongue protruded in the sitting posting without phonation (Mallampati score), mandibular size, mento-hyoid distance, thyromental distance, and protuberant dentition. The sensitivity and specificity of any of these measures to predict limited view on direct laryngoscopy is limited. Taken together, limitations of movement, low Mallampati score, and short anatomic distances may warrant alternative strategies to endotracheal intubation. Each of these aspects has been studied extensively in conjunction with radiologic investigations of airway anatomy in awake and unconscious patients. The reader is encouraged to consult the considerable literature on the subject for a more thorough discussion.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • After placement of the endotracheal tube, the cuff should be inflated with the minimum volume of air to prevent a leak at the peak pressures required for effective ventilation (usually less than 30 cm H2O).
  • Check tube position by auscultating the chest and monitoring an in-line capnography or colorimetry device while administering several slow breaths.   Rapid, large tidal volume ventilation may increase aspiration risk if the tube is malpositioned in the esophagus. If these procedures indicate incorrect placement of the endotracheal tube, the tube should be promptly removed with suction available and mask ventilation resumed.
  • Once proper placement has been determined, position of the endotracheal tube at the incisors should be noted and tube secured with adhesive tape. The dental guard should be removed and teeth and mouth inspected for injury.
Clinical Pearls: In persons of average height (173 ± 4 cm for men; 162 ± 3 cm for women), securing the endotracheal tube at 23 cm and 21 cm at the teeth or gums, respectively, has been shown to reliably avoid endobronchial intubation, even with flexion of the neck.
  • Common
    • Bleeding or trauma from scope
    • Tachycardia
    • Hypertension
    • Dental injury
    • Difficulty removing endotracheal tube off of rigid metal stylet
      • This is made easier with Parker tube
  • Infrequent
    • Inability to visualize larynx
      • More common with initial uses due to learning curve
      • Usually due to placement of scope in vallecula instead of larynx
    • Inability to place endotracheal tube despite adequate visualization
    • Hypoxia
    • Endobronchial intubation
    • Accidental esophageal intubation when removing stylet
      • Tube comes out of trachea and is pushed into esophagus
  • Serious, rare complications
    • Soft tissue perforation from rigid metal stylet
    • Major bleeding
    • Airway edema
    • Vocal cord paralysis
    • Laryngospasm
    • Bronchospasm
    • Elevated intracranial pressure
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