The Bullard Laryngoscope for Emergency Airway Management in a

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					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
1995;Sl 872-3

                                                                                                 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.