More Tips for Users of the Bullard[trade mark sign] Laryngoscope

To the Editor: Habibi et al. [1] described two cases in which the Bullard[trade mark sign] laryngoscope (BL; Circon Corporation, Stamford, CT) blade extender became dislodged in the oropharynx. The first case highlights a common problem, in which inexperienced users attach the blade extender incompletely. A good preuse test is to try to remove the blade extender manually after it "clicks" into place. As suggested in the BL instruction manual, if incompletely attached, it comes off easily. If correctly and completely attached [2], it requires >20 Ib of force to dislodge the BL using the removing tool. In the second case, Habibi et al. [1] claim that an "experienced" BL user had difficulty removing the scope from the mouth and dislodged the extension piece. From the case description, it seems likely that the BL was incompletely rotated around the tongue and was trapped in the submandibular area. This could account for their inability to visualize the glottis and is another common mistake by inexperienced users. We disagree with Habibi et al.'s suggestion that the manufacturer extend the BL blade. In its current design, the BL accommodates a wide range of ages and airway anatomies. Cooper et al. [3] showed that, without the extension piece, the epiglottis could not be retracted in only 2 of 60 adults, not 2 of 50, as Habibi et al. [1] incorrectly stated. We have shown that the adult BL can be used in patients as young as 1 yr of age [4]. Lengthening the BL to accommodate a small number of patients would likely reduce its effectiveness in small adults, patients with reduced thyromental distance, and children. The authors' suggestion that the oropharynx be routinely suctioned under direct laryngoscopy to look for foreign bodies is unnecessarily invasive. A simpler alternative would be to account for items placed in the oropharynx before extubation. Contrary to Habibi et al. [1], we find the BL ideal when there is limited jaw mobility. Our combined clinical experience of several hundred cases of this type without complications forms the basis for our conclusions. Even in the cases presented by Habibi et al. [1], neither patient suffered a long-term adverse outcome. Our advice to any potential user of the BL is: 1) familiarize yourself with the equipment, including the instruction manual, before using it on patients; and 2) do not rely on the scope for managing a difficult airway before mastering the technique in normal airways. These tips would have probably avoided the problems encountered by Habibi et al. [1]. Steven M. Dunn, MD Department of Anesthesiology; Baystate Medical Center; Tufts University Medical School; Springfield, MA 01199 G. Brent Shulman, MD Department of Anesthesiology; Marshfield Clinic; Marshfield, WI 54449 Aaron I.