The Bullard Laryngoscope for Emergency Airway
Management in a Morbidly Obese Parturient
Aaron I. Cohn, MD, Robert T. Hart, MD, Scott R. McGraw, MD, and Norman H. Blass, MD
Department of Anesthesiology, The University of Texas Medical Branch, Galveston, Texas
he optimal management of a morbidly obese with thiopental, 400 mg IV. Vecuronium, 4 mg, was admin-
parturient who presents for cesarean section be- istered IV for muscle relaxation, and anesthesia was main-
cause of fetal distress poses a dilemma for the tained with isoflurane, nitrous oxide, and oxygen. Glottic
visualization was subsequently attempted under general an-
anesthesiologist. When such a patient has clinical fea- esthesia using a Macintosh 4 blade; however, only a grade III
tures suggesting difficult endotracheal intubation or a laryngoscopic view by the Cormack and Lehane classifica-
history of difficult intubation, cautious airway man- tion (3) could be obtained.
agement is warranted since 41% of maternal anes- Forty minutes after anesthetic induction, a 3600-g female
thetic deaths are caused by difficulty with tracheal infant was delivered breech via classic cesarean section.
intubation (1). However, rapid anesthetic induction is Apgar scores were 3 at 1 min and 5 at 5 min. The infant’s
vital so that the distressed fetus may be delivered trachea was intubated, and she was transported to the neo-
natal intensive care unit. The mother’s trachea was extu-
bated at the conclusion of surgery after neostigmine reversal
of neuromuscular blockade and return of consciousness and
protective airway reflexes. The maternal postoperative
Case Report course was remarkable only for hypertension. Both mother
and infant were discharged from the hospital on the fourth
A morbidly obese, 240 kg, 160 cm, 31-yr-old female (gravida postoperative day.
2, para 1) presented for cesarean section due to fetal distress.
Fetal heart rate by scalp electrode revealed persistent decel-
erations to 80 to 90 bpm.
The patient had been hypertensive during her previous Discussion
pregnancy and had suffered from restrictive pulmonary dis-
ease since 1991 owing to her obesity. She had dyspnea on The only large study of anesthetic outcome in mor-
exertion and two-pillow orthopnea. Her prior cesarean sec- bidly obese parturients showed that these patients
tion had been performed under general anesthesia. Awake were significantly more likely to require emergent
endotracheal intubation had been difficult and was success- cesarean section (4). In another study, it was 11.3 times
ful on the second attempt, despite inadequate visualization more likely that a parturient with a Mallampati class
with a Macintosh 4 blade, with the use of a gum-elastic IV airway would be difficult to manage than one with
bougie. The patient weighed 202 kg at that time. At the
current presentation, the patient had a Mallampati class IV a Mallampati class I airway (5). In a study of obstetric
airway, verified by two observers, and a thyromental dis- anesthesia mortality in Michigan, failure to secure a
tance of two finger-breadths. patent airway was identified as the predominant
In the operating room, after placement of routine moni- cause of anesthesia-related maternal death since 1980
tors, glycopyrrolate, 0.2 mg, fentanyl, 50 pg, and midazo- (6). In the 15 maternal deaths related to anesthesia in
lam, 1 mg, were administered intravenously (IV). Topical that study, 11 occurred with cesarean section, obesity
anesthesia was administered to the upper airway with 10%
was identified as a risk factor in 12, and emergent
lidocaine spray and 5% lidocaine ointment applied to the
inferior and posterior surfaces of an oral airway, as previ- nature was identified as a risk factor in 12. Our patient
ously described (2). An adult Bullard laryngoscope with had all of these risk factors, as well as a history of
blade extender was inserted in the oropharynx and rotated difficult intubation when she was 38 kg lighter. Con-
around the tongue until the handle was vertical. The vocal sequently, a carefully reasoned approach to airway
cords were easily visualized, a 7.0-mm cuffed endotracheal management in these circumstances was crucial.
tube was placed through the vocal cords using the Bullard
Although regional anesthesia was a possibility in
intubating stylet, and anesthesia was induced expeditiously
our case, rapid placement of a spinal block may have
been difficult due to the patient’s morbid obesity.
Accepted for publication May 23, 1995. Regional anesthesia may require emergent airway
Address correspondence and reprint requests to Aaron I. Cohn,
MD, Department of Anesthesiology, The University of Texas Med- control under dangerous conditions for various rea-
ical Branch, Galveston, TX 77555-0591. sons. Regional anesthesia may have been suboptimal
01995 by the International Anesthesia Research Society
872 Anesth Analg 1995;81:872-3 0003-2999/95/$5.00
ANESTH ANALG CASE REPORTS 873
dard battery handle, it was easily carried from the
attending anesthesiologist’s office up a flight of stairs
to the delivery suite. Also available for backup was a
“difficult airway” kit, which included laryngeal mask
airways, a gum-elastic bougie, and equipment for jet
ventilation, retrograde intubation, and cricothyroid-
otomy. The blind placement of an introducer stylet
behind the epiglottis, as practiced in our patient’s 1991
intubation, was advocated by Cormack and Lehane (3)
for management of difficult intubations with grade III
laryngoscopic views in obstetric patients. Goldberg et
al. (8) found a 25% incidence of esophageal intubation
when this technique was performed as a teaching
airway exercise in patients with normal airways.
These authors concluded that the risks of esophageal
intubation should be considered before the blind
technique is performed. Because we actually viewed
the larynx, we were able to intubate our patient’s
trachea more confidently and rapidly with the Bullard
The adult Bullard laryngoscope has been advocated
for difficult intubation in several circumstances
(2,9,10), including temporomandibular joint immobil-
ity, cervical spine injury or immobility, and microg-
nathia. In some cases in our experience, intubation
with the Bullard may be easily achieved even after
failed attempts by many operators using the fiberoptic
bronchoscope (2). It seems that the Bullard laryngo-
scope may have a role in managing the difficult air-
way in obstetrical anesthesia as well.
1. King TA, Adams Al’. Failed tracheal intubation. Br J Anaesth
Figure 1. The Bullard laryngoscope ready for use. Attached to the 2. Cohn AI, McGraw SR, King WH. Awake intubation of the adult
end of this blade is a plastic extender that we use routinely to lift the trachea using the Bullard laryngoscope. Can J Anaesth 1995;42:
epiglottis of larger patients. Attached to the back of this blade is the 246-8.
Bullard intubating stylet with an endotracheal tube. Once the glottis 3. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics.
is visualized through the eyepiece, the endotracheal tube is pushed Anaesthesia 1984;39:1105-11.
from the stylet through the glottis. This Bullard laryngoscope blade 4. Hood DD, Dewan DM. Anesthetic and obstetric outcome in
is attached to a standard laryngoscope battery handle (top). The morbidly obese parturients. Anesthesiology 1993;79:1210-8.
whole apparatus can be easily carried by one person. 5. Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk anal-
ysis of factors associated with difficult intubation in obstetric
anesthesia. Anesthesiology 1992;77:67-73.
also because of the patient’s restrictive lung disease 6. Endler GC, Mariona FG, Sokol RJ, Stephenson LB. Anesthesia-
related mortality in Michigan 1972 to 1984. Am J Obstet Gynecol
and orthopnea. 1988;159:187-93.
Because the trachea of our patient appeared difficult 7. Malan TP, Johnson MD. The difficult airway in obstetric
to intubate and was difficult to intubate on a previous anesthesia: techniques for airway management and the role of
occasion, awake intubation under topical anesthesia regional anesthesia. J Clin Anesth 1988;1:104-11.
8. Goldberg JS, Bernard AC, Marks RJ, Sladen RN. Simulation
and light sedation was performed before general an- technique for difficult intubation: teaching tool or new hazard?
esthetic induction. Flexible fiberoptic bronchoscopy in J Clin Anesth 1990;2:21-6.
morbidly obese parturients has been previously de- 9. Gorback MS. Management of the challenging airway with the
Bullard laryngoscope. J Clin Anesth 1991;3:473-7.
scribed (7). A fiberoptic bronchoscope was not imme- 10. Shigematsu T, Miyazawa N, Kobayashi M, et al. Nasal intuba-
diately available for our patient; thus, we chose the tion with Bullard laryngoscope: a useful approach for difficult
Bullard laryngoscope (Figure). Because it uses a stan- airways. Anesth Analg 1994;79:132-5.