MACMAN

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Clinical Question

In the patients admitted to Intensive care unit requiring intubation, does video laryngoscopy improve the first pass orotracheal intubation in comparison to direct laryngoscopy ?

Bottom Line

Video Laryngoscopy with McGrathMAC© did not improve the first pass intubation frequency in comparison to direct laryngoscopy.

Major Points

Orortracheal intubations in intensive care unit are more likely to have complications due to sicker patient population in comparison to controlled intubations in operative room. Use of video laryngoscope has been advertised with improved first pass success rate. MACMAN trial compared video and direct laryngoscope with similar blades in a randomized clinical trial and noted no significant difference (67.7% vs 70.3%; p=0.60). This applied to novice operators as well (84.4% v/s 83.2%; p=0.76). Although it didn't show any difference in total, mild or moderate complications, post-hoc analysis demonstrated a higher risk (9.5% v/s 2.8%, p=0.01) of severe life threatening complications with use of video laryngoscope. Median time required for intubation was similar (3 minutes) for both.

Guidelines

Design

  • Multicenter, institutionally sponsored, nonblinded, open-label, 2 parallel-group, randomized

clinical trial.

  • N = 371
    • Video Laryngoscope (n=186)
    • Direct Laryngoscope (n=185)
  • Setting: 7 Intensive care units in France
  • Enrollment: May 2015 to January 2016
  • Mean follow-up: 28 days
  • Analysis: Intention-to-treat
  • Primary outcome: Proportion of successful first pass intubation
  • Secondary outcome: Time to successful intubation, mild to moderate complications, severe life threatening complications.

Population

Inclusion Criteria

  • Intensive care unit admission
  • Need for endotracheal intubation

Exclusion Criteria

  • Contraindication to orotracheal intubation
  • Insufficient time to include and randomize the patient
  • Age younger than 18 years
  • Pregnant or breastfeeding women
  • Correctional facility inmate
  • Patient under guardianship
  • Lack of health insurance
  • Refusal by patient or next of kin
  • Previous enrollment in a trial (including this study) with intubation as the primary end point

Baseline Characteristics

Interventions

Outcomes

Primary Outcomes

Secondary Outcomes

Subgroup Analysis

Adverse Events

Criticisms

Funding

Further Reading