A comparison of McGrath MAC® and standard direct laryngoscopy in simulated immobilized cervical spine pediatric intubation: a manikin study

Marcin Madziala, Jacek Smereka, Marek Dabrowski, Steve Leung, Kurt Ruetzler, Lukasz Szarpak, Marcin Madziala, Jacek Smereka, Marek Dabrowski, Steve Leung, Kurt Ruetzler, Lukasz Szarpak

Abstract

Emergency airway management in children is generally considered to be challenging, and endotracheal intubation requires a high level of personal skills and experience. Immobilization of the cervical spine is indicated in all patients with the risk of any cervical spine injury but significantly aggravates endotracheal intubation. The best airway device in this setting has not been established yet, although the use of videolaryngoscopes is generally promising. Seventy-five moderately experienced paramedics of the Emergency Medical Service of Poland performed endotracheal intubations in a pediatric manikin in three airway scenarios: (A) normal airway, (B) manual in-line cervical immobilization, and (C) cervical immobilization using a Patriot cervical extrication collar and using two airway techniques: (1) McGrath videolaryngoscope and (2) Macintosh blade in a randomized sequence. First-attempt intubation success rate, time to intubation, glottis visualization, and subjective ease of intubation were investigated in this study. Intubation of difficult airways, including manual in-line and cervical collar immobilization, using the McGrath was significantly faster, with a higher first-attempt intubation success rate, better glottic visualization, and ease of intubation, compared to Macintosh-guided intubation. In the normal airway, both airway techniques performed equal.

Conclusion: Our manikin study indicates that the McGrath may be a reasonable first intubation technique option for endotracheal intubation in difficult pediatric emergencies. Further clinical studies are therefore indicated. What is known : • Airway management in pediatrics is challenging and requires a high level of skills and experience. Cervical immobilization is indicated in all patients with any risk of cervical spine injury, but it significantly aggravates endotracheal intubation in these patients. Videolaryngoscopes have been reported to ease intubation and provide better airway visualization in the regular clinical setting. What is new: • The McGrath is an easy-to-use and clinically often used videolaryngoscope, but it has never been investigated in pediatrics with an immobilized cervical spine. In the normal airway, the McGrath provided better airway visualization compared to Macintosh laryngoscopy. However, better visualization did not lead to decreased time to intubation and a higher success rate of the first intubation attempt. In difficult airways, the McGrath provided better airway visualization and this led to faster intubation, a higher first-attempt intubation success rate, and better ease of intubation compared to Macintosh-guided intubation.

Keywords: Airway management; Cervical immobilization; Manikin study; Pediatric endotracheal intubation; Videolaryngoscopy.

Conflict of interest statement

Funding

None.

Conflict of interests

The authors declare that they have no conflict of interest.

Ethical approval

Approval was granted by the Institutional Review Board of the Polish Society of Disaster Medicine (approval no.: 11/12/2016/IRB).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Source of support

No sources of financial and material support to be declared.

Figures

Fig. 1
Fig. 1
Intubation scenarios used in the study. a Scenario A—normal airway. b Scenario B—manual in-line cervical spine immobilization. c Scenario C—cervical immobilization using a standard Patriot cervical extrication collar
Fig. 2
Fig. 2
Laryngoscopes used for this study were a the standard Macintosh #2 laryngoscope and b the McGrath MAC laryngoscope
Fig. 3
Fig. 3
Flowchart of design and recruitment of participants according to the CONSORT statement
Fig. 4
Fig. 4
Median time (in seconds) required for endotracheal intubation with the two laryngoscopes in research scenarios

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