Bullard Laryngoscope Research Articles

Airway devices in paediatric anaesthesia.

Airway devices were first used in children since 1940 and thereafter an increasingly large number of paediatric airway devices have come into our armamentarium. To control and protect the airway in children during anaesthesia, in intensive care unit or in emergency department either tracheal intubation is performed under direct or indirect visualization of vocal cords with the help of laryngoscopes or video-laryngoscopes respectively or it can be done blindly or by using special instruments such as fiberoptic laryngoscope, lighted stylet or Bullard laryngoscope to name a few. Airway also can be maintained with the help of Laryngeal mask airways, oropharyngeal and nasopharyngeal airways. Updating our information and knowledge regarding these developments is pivotal to our practice of paediatric anaesthesia. With a thorough search of books, MEDLINE, MEDNET, clinical trials.gov.in, this article aims at focusing and understanding a brief basis of paediatric devices and their use.

Successful management of difficult airway in children with the use of adult fibreoptic bronchoscope.

Airway management in children has always been challenging. Various airway devices are used for successful airway management. Fibre optic bronchoscopy is considered as a standard technique in an anticipated difficult airway. Intubating laryngeal mask airway (ILMA), bullard laryngoscope, lighted stylet, glidescope and video laryngoscope are all used to aid intubation. Adult fibreoptic bronchoscope as an aid to intubation in children has been used. We describe successful management of difficult airway in children, using adult fibreoptic bronchoscope as an aid to tracheal intubation.

English

INTRODUCTION: Anaesthesiologists will be facing difficult intubating conditions, anticipated or unanticipated, quite frequently, whenever they anaesthetize patients with faciomaxillary injuries, temporo mandibular joint ankylosis, obesity, pregnancy, congenital air-way abnormalities, etc. A large number of aids are available now for intubating in such difficult situations and a lot of techniques have been described in literature for giving anaesthesia for such patients.(1) Use of Bullard laryngoscope in difficult air-way situation was described by Dullenkopf et al 2003,(2) Lighted Wand by Agro et al 2004,(3) Shikani flexible seeing stylet by Agro et al 2005(4) Blind nasal intubation, L M A, Fiber optic laryngoscope by Levitan et al1999.(5) Glydoscope by Lim et al 2005(6). In this case report, we have given one more alternate solution for this problem.

Perioperative consideration of general anesthesia for acromegalic patients.

Perioperative consideration of general anesthesia for acromegalic patients.

Ventilation with a view and usefulness of Airtraq laryngoscope

Editor, We read with interest the observational controlled study by Legrand et al.1 comparing a modified Macintosh blade with Airtraq and Bullard laryngoscopes published in the Journal. As the study so beautifully shows, intubation success is low in the very difficult airway scenario with the Airtraq laryngoscope (20% for beginners and 50% for experts). The study shows a much better valuation for Bullard laryngoscope (87 and 97% intubation success in beginners and experts, respectively). We wish to point out that the 0.1 to 0.3% failed intubation rate2 quoted in the study actually raises serious doubt as to the power of the study. Observational studies for medical equipment have to take into consideration what failure rate for the equipment is acceptable. In this study with one failure in 60 practitioners, the failure rate of conventional laryngoscopy in the manikin was 1.6% for a moderately difficult airway. For Airtraq and Bullard laryngoscopes, to attain a failure rate equal to or less than this in this scenario, the study would require more than 250 cases before the question can be answered with satisfaction.3 Thus, the apparent 100% success rate with Airtraq and Bullard laryngoscopes in scenario A (moderate difficult intubation) cannot be taken seriously as it will need at least 250 cases before a failure is noted if we are looking at a failure rate of less than 1.6%. There are no data on failure rates in scenario B (very difficult airway) except on manikins. With the high failure rates observed with Airtraq and Bullard laryngoscopes and the gravity of the situation, it might be worthwhile instead to find out how fibreoptic intubation would perform in this situation. We would also like to point out that there are some more practical issues faced in such scenarios that need to be considered before we conclude as to the usefulness of either of these devices in the very difficult airway situation. The most important issue if one cannot intubate as in any difficult airway scenario is if one can manually ventilate the patient to maintain oxygenation! This is the fact that might make or break the situation. Previously, it had been shown that the endotracheal tube loaded on an Airtraq can be used as a conduit to flush oxygen as a method to avoid fogging.4 We wish to point out that the patient can be ventilated as well via the endotracheal tube loaded on an Airtraq laryngoscope as done by us successfully in three anticipated difficult intubation situations (which were not a difficult to ventilate situation through facemask though). Thus, Airtraq may continue to be a very useful airway adjunct unlike the impression given in the study. This new method of ventilating the patient while waiting for optimising the patient and equipment to deal with the difficult intubation does, however, need further evaluation. Acknowledgements Assistance with the study: none declared. Financial support and sponsorship: none declared. Conflicts of interest: none declared. Comment from the editor: Dr Legrand and colleagues did not wish to reply to this letter.

Nasotracheal intubation by combined use of a Bullard™ laryngoscope and a cuff inflation technique in a patient with a severely restricted mouth opening

To the Editor, The Bullard laryngoscope (Circon ACMI, Stamford, CT, USA) is an anatomically shaped rigid fibreoptic laryngoscope that has been used for more than two decades. One of its unique characteristics is a very thin blade that requires only a 6-mm mouth opening for insertion. We report a case in which nasotracheal intubation was performed by combined use of a Bullard laryngoscope and a cuff inflation technique in a patient with a severely restricted mouth opening. The patient provided written informed consent for publication of this case. A 66-yr-old male patient, 157 cm tall and weighing 45.5 kg, was scheduled for keratoplasty. The size of his mouth opening was only about 9.5 mm because of previous radiation therapy for maxillary sinus cancer; thus, nasotracheal intubation was planned for airway management. The Bullard laryngoscope was selected for this procedure instead of a fibrescope because with the fibrescope, the tracheal tube is advanced in a blind manner and this may cause airway trauma; arytenoid cartilage dislocation or vocal cord trauma. General anesthesia was induced with fentanyl 150 lg and propofol 30 mg. Bag and mask ventilation was performed successfully, and then rocuronium 40 mg and remifentanil 0.3 lg kg min were administered. Even after neuromuscular blockade, no additional mouth opening was obtained. A 7.5-mm internal diameter tracheal tube was inserted nasally, and the Bullard laryngoscope was inserted orally to lift the epiglottis directly. A laryngeal view was easily obtained through the eyepiece of the Bullard laryngoscope, and then the tracheal tube was advanced carefully into the field of view. Before the laryngeal inlet was reached, the tracheal tube cuff was inflated to lift the tube tip and direct it towards the vocal cords. The cuff was then deflated to pass through the vocal cords. The tracheal tube was successfully inserted into the trachea, and general anesthesia was maintained throughout the operation without any complications. Also, no complications were encountered during postanesthesia rounds. In the past several years, anatomically shaped indirect laryngoscopes with a tracheal tube guide channel, such as the Pentax Airway Scope (HOYA, Tokyo, Japan) and the Airtraq (Prodol Meditec SA, Vizcaya, Spain), have become very popular and have been reported to be useful in airway management. Although several studies have shown that the Airway Scope and Airtraq are more useful than the Bullard laryngoscope for orotracheal intubation and even for nasotracheal intubation, these laryngoscopes have a bulky blade configuration because the tube channel is thicker than the tube diameter (Figure). Even the version of the Airtraq designed for nasotracheal intubation, which is devoid of a tube guide channel, requires an 18-mm mouth opening for insertion; therefore, in our case, the thinner blade of the Bullard laryngoscope was adequate to obtain a laryngeal view. The alternative approaches we could have considered in our case include a fibreoptic bronchoscopic intubation or a lightwandguided technique through the nostril. However, both techniques involve tracheal tube advancement in a blind manner, which may cause trauma, particularly to the arytenoid cartilage or vocal cords. A Bullard laryngoscope-assisted nasotracheal intubation can be a useful approach in patients with a severely restricted mouth opening because it provides a good laryngeal view and continuous observation of tube insertion throughout the procedure. A. Tampo, MD, PhD (&) A. Suzuki, MD, PhD M. Matsumoto, MD H. Iwasaki, MD, PhD Asahikawa Medical University, Asahikawa, Hokkaido, Japan e-mail: atampo1031@gmail.com

Comparison of Bullard and Airtraq laryngoscopes with conventional laryngoscopy in a manikin study of simulated difficult intubation

When airway management is difficult, various measures can be taken to facilitate tracheal intubation. The Bullard and Airtraq laryngoscopes were developed for this purpose. We hypothesised that the Bullard and Airtraq laryngoscopes would perform better than a conventional laryngoscope in the management of a simulated difficult airway. We also hypothesised that the indirect laryngoscopes would perform comparably. In a randomised controlled study, 60 anaesthetists (30 with no or little experience and 30 with broader experience in the use of the Bullard laryngoscope, referred to as beginners and experts, respectively) performed three successive intubation attempts using conventional, Bullard and Airtraq laryngoscopes in two simulated difficult airway scenarios: neck immobilisation (scenario A) and neck immobilisation with additional tongue oedema (scenario B). The primary endpoint was overall intubation success rate. Secondary endpoints were time required for successful intubation, the amount of dental stress exerted during laryngoscopy and satisfaction with each airway device. In scenario A, intubation success rates were 97-100% with all devices. In scenario B, all participants failed to intubate the trachea using the conventional laryngoscope. When using the Bullard laryngoscope, intubation success rates of 87-97% did not differ significantly (P > 0.05) from those during scenario A and between groups (beginners vs. experts). In contrast, when using the Airtraq laryngoscope, the overall intubation success rate was significantly lower (P < 0.05) compared with scenario A and compared with use of the Bullard laryngoscope, and differed between beginners and experts (20 and 50%, respectively). In cases of successful intubation, intubation times were comparable between devices and groups. Intubation times were longer during scenario B. Dental stress was always lower (P < 0.05) during use of the Bullard and Airtraq laryngoscopes compared with the conventional laryngoscope, lowest (P < 0.05) during use of the Bullard laryngoscope and (with the exception of use of the conventional laryngoscope by the experts) higher during scenario B than during scenario A. In scenario A, participants preferred both video laryngoscopes to the conventional laryngoscope. In a moderately difficult airway scenario, all laryngoscopes performed equally well. However, in a more difficult airway scenario, the Bullard and Airtraq laryngoscopes performed better than the conventional laryngoscope, with the Bullard device performing better than the Airtraq. This may be in part related to differing prior experiences of operators with the respective airway devices.

Prospective model‐based comparison of different laryngoscopes for difficult intubation in infants

Difficult intubation in infants is uncommon but may be a challenge for the anesthesiologist. Many optical-assisted techniques are available to ease endotracheal placement of tube but have not been systemically evaluated for pediatric practice. The study was performed to compare conventional pediatric Macintosh - with different optical laryngoscopes in difficult endotracheal intubation in infants. We hypothesized that inexperienced anesthetists would perform more successful with optical devices and that differences between the devices would be found. In this randomized controlled study, 30 anesthesia residents performed endotracheal intubation in an infant model of difficult airway presenting with airway obstruction and neck immobilization. Primary endpoints were intubation success rate and intubation time. Beyond that glottis view, dental trauma and difficulty of technique were evaluated and measured by a study observer. Macintosh, Airtraq(®), Storz DCI(®) -, and Gyrus Infant Bullard(®) laryngoscopes were used in random order. After standardized briefing every resident had three attempts of at most 120 s with every device to place a 3-mm tube into the trachea. Glottis view and difficulty of technique were rated by the residents using classification of Cormack/Lehane and Visual Analogue Scale (VAS; 0 = easy to 10 = very difficult). Success rate was 41% with conventional Macintosh, 43% with Airtraq(®), 62% with Storz DCI(®), and 100% with Bullard(®) laryngoscopes. Median time from passing the lips to first ventilation was 67 s (Storz DCI(®) laryngoscope), 54 s (Macintosh laryngoscope), 45 s (Airtraq(®) laryngoscope), and 21 s (Bullard(®) laryngoscope), respectively. Dental trauma did not occur with Bullard(®) laryngoscope and was frequent with Storz DCI(®) laryngoscope (39%) and Macintosh laryngoscope (42%). Glottis view was best with Bullard(®) laryngoscope (Grade 1 in 100%) and worst with Macintosh laryngoscope (Grade 1 in 2%). Difficulty of technique was rated with a VAS score of 2 (Bullard(®) laryngoscope), 4.5 (Storz DCI(®) laryngoscope) and 6 (Airtraq(®) - and Macintosh laryngoscopes). Inexperienced anesthetists have higher success rates and shorter intubation times with optical-assisted laryngoscopes compared with conventional Macintosh laryngoscope. Gyrus Infant Bullard(®) laryngoscope significantly undertakes best success rate and shortest intubation time with mildest impact to maxillary dents and easiest technique. Our findings support the hypothesis that optical laryngoscopes can be used successfully by inexperienced anesthetists in simulated difficult pediatric airway conditions.

Quest for an Ideal Intubating Device

Quest for an Ideal Intubating Device

Videolaryngoscopes

Videolaryngoscopes

Evolving role of video laryngoscopy for airway management in the emergency department

Evolving role of video laryngoscopy for airway management in the emergency department

Endotracheal intubation with Airtraq® optical laryngoscope in the pediatric patients

Pediatric AnesthesiaVolume 21, Issue 6 p. 703-704 CORRESPONDENCE Endotracheal intubation with Airtraq® optical laryngoscope in the pediatric patients Fu Shan Xue, Fu Shan Xue Department of Anesthesiology, Xinxiang Medical College, Xinxiang, Henan, China Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorHe Ping Liu, He Ping Liu Department of Anesthesiology, Xinxiang Medical College, Xinxiang, Henan, ChinaSearch for more papers by this authorXu Liao, Xu Liao Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorYu Jing Yuan, Yu Jing Yuan Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorJian Hua Liu, Jian Hua Liu Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this author Fu Shan Xue, Fu Shan Xue Department of Anesthesiology, Xinxiang Medical College, Xinxiang, Henan, China Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorHe Ping Liu, He Ping Liu Department of Anesthesiology, Xinxiang Medical College, Xinxiang, Henan, ChinaSearch for more papers by this authorXu Liao, Xu Liao Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorYu Jing Yuan, Yu Jing Yuan Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this authorJian Hua Liu, Jian Hua Liu Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaEmail: fruitxue@yahoo.com.cnSearch for more papers by this author First published: 25 April 2011 https://doi.org/10.1111/j.1460-9592.2011.03568.xCitations: 8Read the full textAboutRelatedInformationPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessClose modalShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume21, Issue6June 2011Pages 703-704 RelatedInformation RecommendedAwake tracheal intubation using the Airtraq® laryngoscope: a case seriesV. K. DIMITRIOU, I. D. ZOGOGIANNIS, D. G. LIOTIRI, Acta Anaesthesiologica ScandinavicaComparison of Bullard laryngoscope and short‐handled Macintosh laryngoscope for orotracheal intubation in pediatric patients with simulated restriction of cervical spine movementsANITHA NILESHWAR MD, FRCA, VISHAL GARG MD, Pediatric AnesthesiaPerformance of the Airtraq™ laryngoscope after failed conventional tracheal intubation: a case seriesE. MALIN, J. de MONTBLANC, Y. YNINEB, E. MARRET, F. BONNET, Acta Anaesthesiologica ScandinavicaThe use of nasotracheal Airtraq® laryngoscope with reinforced endotracheal tube: our experienceFabio Ferrari, Giuliano Marchetti, Sergio Giuseppe Picardo, Pediatric Anesthesia

Evaluation of the Bullard, GlideScope, Viewmax, and Macintosh laryngoscopes using a cadaver model to simulate the difficult airway

Study Objective To assess the performance and cervical (C)-spine movement associated with laryngoscopy using the Bullard laryngoscope (BL), GlideScope videolaryngoscope (GVL), Viewmax, and Macintosh laryngoscopes during conditions of a) unrestricted and b) restricted C-spine and temporomandibular joint (TMJ) mobility. Design Prospective, controlled, randomized, crossover study. Setting University teaching hospital. Subjects 21 cadavers with intact C-spine anatomy. Interventions Each cadaver underwent to total of 8 intubation attempts to complete the intubation protocol using all four devices under unrestricted and restricted C-spine and TMJ mobility. Measurements Laryngoscopic view was graded using the modified Cormack-Lehane system. Time to best laryngoscopic view and total time to intubation were recorded. C-spine movement was measured between McGregor's line and each vertebra from radiographs taken at baseline and at best laryngoscopic view. Main Results During both intubating conditions, the BL achieved the highest number of modified Cormack-Lehane grade 1 and 2A laryngoscopic views as compared to the other three devices ( P < 0.05) and had fewer intubation failures than the Viewmax or Macintosh laryngoscopes ( P < 0.05). The GVL had superior laryngoscopic performance as compared to the Viewmax and Macintosh laryngoscopes ( P < 0.05) and had fewer intubation failures than those two devices ( P < 0.05). All devices except the Macintosh laryngoscope in restricted mobility achieved median times to intubation in less than 30 seconds. For both conditions, BL showed the least total absolute movement between Occiput/C1 and C3/C4 of all the devices (all P < 0.05). Most of the difference was seen at C1/C2. Conclusions In cadavers with unrestricted and restricted C-spine mobility, the BL provided superior laryngoscopic views, comparable intubating times, and less C-spine movement than the GVL, Viewmax, or Macintosh laryngoscopes.

Comparison of Bullard laryngoscope and short-handled Macintosh laryngoscope for orotracheal intubation in pediatric patients with simulated restriction of cervical spine movements

To compare time to intubation, time to optimal laryngoscopy, best laryngeal view, and success rate of intubation with pediatric Bullard laryngoscope and short-handled Macintosh laryngoscope in children being intubated with neck stabilization. Securing airway of a patient with restricted cervical spine movement has been a challenge faced by anaesthesiologists around the world. Macintosh laryngoscope with manual inline stabilization is most commonly used. Bullard laryngoscope is also useful in this situation as minimal neck movement occurs with its use. Forty patients, ASA I or II, aged 2-10 years, were enrolled in this prospective, controlled, and randomized study. Patients were randomly allocated to one of two groups: Group MB (first laryngoscopy using short-handled Macintosh laryngoscope followed by pediatric Bullard laryngoscope) and Group BM (first laryngoscopy using pediatric Bullard laryngoscope followed by short-handled Macintosh laryngoscope) with manual inline stabilization after induction of anesthesia and paralysis. Trachea was intubated orally using the second equipment. Laryngeal view when obtained was always Grade 1 with Bullard laryngoscope (38/38) when compared to Macintosh laryngoscope [Grade 1 (10/40)]. The mean time to laryngoscopy (and intubation) was shorter with Macintosh laryngoscope [15.53 s (38.15 s)] than Bullard laryngoscope [35.21 s (75.71 s)], respectively. Success rate of intubation was higher with Macintosh laryngoscope (100%) when compared to Bullard laryngoscope (70%). Laryngoscopy and intubation is faster using a short-handled Macintosh laryngoscope with a higher success rate compared to pediatric Bullard laryngoscope in pediatric patients when manual inline stabilization is applied.

Rigid indirect laryngoscopy and optical stylets

Indirect laryngoscopy, in the form of flexible fibreoscopy, is the established ‘gold standard’ for the management of the predicted difficult airway. Rigid indirect laryngoscopy (RIL) is not new. The Bullard laryngoscope, for example, has been used by a small number of airway enthusiasts for around 20 yr. The practice of RIL has markedly increased in recent years, with availability and use of devices appearing to be greater than any robust evidence of their efficacy. 3 In light of this relative lack of evidence, direct laryngoscopy (DL) remains the technique most taught and practised for the management of the unpredicted difficult intubation (DI). This is despite a 1 in 75 failure rate. In time, it may be that RIL will ‘fill the gap’ between DL and flexible fibreoscopy and perhaps even replace one or both of them. These new devices use modern technology to look around the anatomical ‘corners’ of the upper airway to provide a view of the glottis, the visual axis being closer to 608, rather than the direct line of sight of MacIntosh laryngoscopy. In general, devices are categorized in relation to the method of image transmission back to the viewfinder. For some, this is based on reflection, involving prisms, mirrors, or most commonly, fibreoptics. In others, digital images are transmitted electronically from a distal tip video camera back to a monitor screen. However, the classification outlined below is based on the method of passing the tracheal tube (TT) through the glottis.

Parker Flex-Tip Tube® facilitates intubation when the Pentax-AWS® fails to reach the larynx

To the Editor: Pentax-AWS Airway Scope (AWS: Hoya, Tokyo), a new rigid, indirect videolaryngoscope with integrated tube guidance, has been successfully used in patients with both normal and difficult airways. In some case, however, the blade tip cannot be advanced beneath the epiglottis, even after multiple attempts [1], and the intubation frequently fails due to blade configuration [2]. Several authors proposed the use of tube introducer (elastic bougie) to solve the problem [3]. We propose the use of the Parker Flex-Tip Tube to facilitate intubation under this situation. Preoperative airway assessment of a 61-year-old man scheduled for general anesthesia indicated a risk of difficult intubation because of relatively small mandible, his thyromental distance being 4 cm. Since the patient did not have risk factors of difficult mask ventilation, he was anesthetized with propofol and rocuronium. After complete paralysis was confirmed with the peripheral nerve stimulator, laryngoscopy was performed with a Macintosh no. 4 blade, but only the epiglottis was visualized, and it was graded as Cormack‐Lehane grade 3b. We next used the AWS for the second intubation attempt. However, the tip was not able to be advanced beneath the epiglottis but inserted into the vallecula. The epiglottis was indirectly elevated, and the laryngeal exposure was approximately 80% of the glottic opening. We tried to insert the standard bevel tube (Phycon Tube, Fuji System, 7.5 mm ID, 10 mm OD) set in the channel, but the tube tip impinged onto the epiglottis, and intubation failed. Next, we used the Parker Flex-Tip Tube (Kobayashi Medical, 7.5 mm ID, 10 mm OD), and the tube was inserted smoothly into the glottis without trapping on the arytenoids. The Parker Flex-Tip Tube has a tapered, curved tip and has been shown to facilitate intubation with the Bullard laryngoscope [4] and fiberoptic bronchoscope [5]. The advantage of using the Parker tube in combination with the AWS has not been well evaluated. Figure 1 shows the two tubes, with the same outer diameter as those used in this case, protruding from the channel. We can see more space from the blade tip to the Parker tube than with the standard tube. It seems that this space allows the Parker tube to be advanced without impinging upon the epiglottis, and the tapered, curved tip glides on the posterior surface of the epiglottis to lead the

Motion of a Cadaver Model of Cervical Injury During Endotracheal Intubation With a Bullard Laryngoscope or a Macintosh Blade With and Without In-line Stabilization

Endotracheal intubation in patients with potential cervical injury is a common dilemma in trauma. Although direct laryngoscopy (DL) with manual in-line stabilization (MILS) is a standard technique there is little data on the effect of MILS on cervical motion. Likewise there is little data available regarding alternative airway techniques in this setting. This study compared intubations with and without MILS in a cadaver model of cervical instability. We also used this model to compare intubations using DL with a Macintosh blade versus a Bullard laryngoscope (BL). Complete C4-C5 disarticulations were surgically created in 10 fresh human cadavers. The cadavers were then intubated in a random order with either BL or DL with and without MILS. The motion at the unstable interspace was measured for subluxation, angulation, and distraction. MILS did not significantly affect maximal motion of this model in any of the three measures using either DL or BL. There were no clinically significant differences in maximal median motion in any of the three measures when comparing the two blades. However, there was significantly more variance in the subluxation caused by DL than by BL. We were unable to demonstrate any significant effect of MILS on the motion of an unstable cervical spine in this cadaver model. The BL appears to be a viable alternative to DL in the setting of an unstable lower cervical spine.

A simple fibreoptic assisted laryngoscope for paediatric difficult intubation: a manikin study

The fibreoptic assisted laryngoscope is a new airway device. We compared the fibreoptic assisted laryngoscope with the Bullard laryngoscope, Macintosh laryngoscope and fibreoptic bronchoscope in a manikin with a simulated Cormack and Lehane Grade 4 laryngoscopic view. Eighteen anaesthetists intubated the manikin's trachea using these devices and the success rate of intubation was measured. They were then asked to rate the subjective difficulty of intubation. The success rate (95% confidence interval) was 100% (94.6-100) with the fibreoptic assisted laryngoscope, 88.9% (80.5-97.3) using the Bullard laryngoscope, 37.0% (24.1-49.9) with the Macintosh laryngoscope, and 22.2% (11.1-33.3) using the fibreoptic bronchoscope. Tracheal intubation using the fibreoptic assisted laryngoscope or Bullard laryngoscope is easier than that using the Macintosh laryngoscope or fibreoptic bronchoscope by subjective difficulty score. All of the intubations were successful with the fibreoptic assisted laryngoscope without practice. These results suggest that fibreoptic assisted laryngoscope may be a useful tool for paediatric difficult intubation.

Cardiovascular responses to tracheal intubation with the Airway Scope (Pentax-AWS)

The recommended laryngoscopy technique with the AWS involves using the blade tip to elevate the epiglottis directly. This procedure is very similar to that used with the Bullard laryngoscope (BuLS; Gyrus ACMI, Southborough, MA, USA). Araki et al. [2] demonstrated that there were no signifi cant differences in cardiovascular responses after intubation between the BuLS and the McL in 30 patients without airway problems. The Airtraq laryngoscope (ATQ; Prodol, Vizcaya, Spain) is another device similar to the AWS, but the view of the glottis can be optimized either by lifting the epiglottis directly, as with the AWS or BuLS, or indirectly by tensioning the hyoepiglottic ligament after the blade tip is positioned in the vallecula. Maharaj et al. [3] demonstrated that increases in HR were less when intubation was achieved with the ATQ than with the McL. Both the AWS and the ATQ provide a view of the glottis from behind the dorsum of the tongue, and therefore both devices probably require less lifting force than that required during direct laryngoscopy. It is unlikely that the technique of epiglottis elevation could cause this different result, (i.e., ATQ, but AWS attenuates cardiovascular responses), because the McL blade tip is alCardiovascular responses to tracheal intubation with the Airway Scope (Pentax-AWS)

Atlas of Airway Management: Techniques and Tools.

Atlas of Airway Management: Techniques and Tools.