Original contribution
A comparison of the bullard laryngoscope versus the flexible fiberoptic bronchoscope during intubation in patients afforded inline stabilization

Presented in part at the annual meeting of the International Anesthesia Research Society, Honolulu, HI, March 11–15, 2000.
https://doi.org/10.1016/S0952-8180(01)00241-0Get rights and content

Abstract

Study Objective: To compare the Bullard laryngoscope (BL) with the flexible fiberoptic bronchoscope (FFB) in a cervical spine injury model, using inline stabilization.

Design: Randomized clinical trial.

Setting: Main operating room of a tertiary care hospital.

Patients: 50 adult, ASA physical status I, II, and III patients undergoing an elective general anesthetic.

Interventions: Each patient’s trachea was intubated with both techniques. Cricoid pressure was applied to half of the study patients.

Measurements: The time for laryngoscopic view and the time to intubation were recorded for each technique. The effects of cricoid pressure on laryngoscopic view and intubation time were determined.

Main results: The times for laryngoscopy and intubation were longer in the FFB group than in the BL group (p < 0.004). There was a significantly lower success rate of laryngoscopy view in the FFB group in the presence of cricoid pressure (15 of 25 patients, or 60%) than either of the BL groups or the FFB no-cricoid pressure group.

Conclusions: The BL is more reliable, quicker, and more resistant to the effects of cricoid pressure than is the FFB.

Introduction

Airway management in patients with suspected cervical spine injury remains a challenge for the anesthesiologist. Most often the airway is secured in trauma patients through direct laryngoscopy. However, the act of direct laryngoscopy results in the movement of the cervical spine,1 which may worsen a preexisting injury. In an attempt to reduce motion of the cervical spine that occurs during airway management, the application of inline stabilization is recommended.1 This procedure has been shown to minimize the degree of cervical spine extension,2 and it is safe in patients with these injuries.3, 4 Alternative techniques further reduce the degree of cervical spine motion, when compared with direct laryngoscopy, and thus provide an additional measure of safety in preventing aggravation of a preexisting injury. The Bullard laryngoscope (BL) has been shown to result in less cervical spine extension when compared to direct laryngoscopy, but it can take longer than direct laryngoscopy to intubate patients’ tracheas.5 The flexible fiberoptic bronchoscope (FFB) should also be considered in the management of patients who are predisposed to cervical spine injury. However, to date, no study has prospectively evaluated this comparison in anesthetized patients. Thus, we have undertaken a study to compare the BL with the FFB with respect to time to intubate and the quality of the laryngeal view in patients undergoing inline stabilization.

Section snippets

Materials and methods

After Institutional Review Board approval from the Marshfield Clinic, Marshfield, WI, and the Baystate Medical Center, Springfield, MA, 50 adult, ASA physical status I, II, and III patients, who were scheduled for surgical procedure requiring general anesthesia and endotracheal intubation, were enrolled in the study. Exclusion criteria included underlying cervical spine pathology, indications for rapid-sequence induction, or an awake intubation. The 50 participants were divided into two groups

Results

The two groups (those who had cricoid pressure and those who did not) had similar demographic data (Table 1). Because each patient served as his or her own control, comparison within each group was unnecessary.

In the group undergoing intubations without cricoid pressure, both techniques successfully intubated the patient in every case. In one case, the BL’s extension piece was needed to obtain an adequate view. The time for this intubation included the time to decide if the extension piece was

Discussion

This study shows that in anesthetized patients who are undergoing inline stabilization, the BL is faster than the FFB in obtaining a view of the larynx and in intubating patients. Our BL times reflect closely those of other reports. The majority of the patients (70%) with standard BL are intubated within 30 seconds.6 Watts et al.5 compared BL intubation times with and without cricoid pressure and inline stabilization, and they found that BL intubations without inline stabilization took 26 ± 10

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