Effect of Laryngoscope Blade Size on First Pass Success of Tracheal Intubation in Critically Ill Adults

Kevin R Landefeld, Seiji Koike, Ran Ran, Matthew W Semler, Christopher Barnes, Susan B Stempek, David R Janz, Todd W Rice, Derek W Russell, Wesley H Self, Derek Vonderhaar, Jason R West, Jonathan D Casey, Akram Khan, Kevin R Landefeld, Seiji Koike, Ran Ran, Matthew W Semler, Christopher Barnes, Susan B Stempek, David R Janz, Todd W Rice, Derek W Russell, Wesley H Self, Derek Vonderhaar, Jason R West, Jonathan D Casey, Akram Khan

Abstract

Tracheal intubation (TI) is a common procedure in critical care, often performed with a Macintosh curved blade used for direct laryngoscopy (DL). Minimal evidence informs the choice between Macintosh blade sizes during TI. We hypothesized that Macintosh 4 blade would have higher first-attempt success than Macintosh 3 blade during DL.

Design: Retrospective analysis using a propensity score and inverse probability weighting of data from six prior multicenter randomized trials.

Setting and participants: Adult patients who underwent nonelective TI at participating emergency departments and ICUs. We compared the first-pass success of TI with DL in subjects intubated with a size 4 Macintosh blade on the first TI attempt to subjects with a size 3 Macintosh blade on the first TI attempt.

Main results: Among 979 subjects, 592 (60.5%) had TI using DL with a Macintosh blade, of whom 362 (37%) were intubated with a size 4 blade and 222 (22.7%) with a size 3 blade. We used inverse probability weighting with a propensity score for analyzing data. We found that patients intubated with a size 4 blade had a worse (higher) Cormack-Lehane grade of glottic view than patients intubated with a size 3 blade (adjusted odds ratio [aOR], 1.458; 95% CI, 1.064-2.003; p = 0.02). Patients intubated with a size 4 blade had a lower first pass success than those with a size 3 blade (71.1% vs 81.2%; aOR, 0.566; 95% CI, 0.372-0.850; p = 0.01).

Conclusions and relevance: In critically ill adults undergoing TI using DL with a Macintosh blade, patients intubated using a size 4 blade on first attempt had a worse glottic view and a lower first pass success than patients intubated with a size 3 Macintosh blade. Further prospective studies are needed to examine the optimal approach to selecting laryngoscope blade size during TI of critically ill adults.

Keywords: airway management; critical care; laryngoscopesize; laryngoscopy; mechanical ventilation; tracheal intubation.

Conflict of interest statement

Dr. Khan has received research funding from Eli Lilly, AstraZeneca, Regeneron pharmaceuticals, United Therapeutics, Johnson & Johnson, Dompe Pharmaceuticals, and 4D Medical, as site Principal Investigator for research enrollment, and consulting fees from Dompe Pharmaceuticals for clinical trial design. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.

Figures

Figure 1.
Figure 1.
Flow chart of patient selection. ED = emergency department.
Figure 2.
Figure 2.
Percentage of Cormack-Lehane grade view obtained by Macintosh (Mac) blade on the initial attempt. Mac 4 was associated with a worse view compared with Mac 3. Adjusted odds ratio 1.45 (1.06–2.00) size.
Figure 3.
Figure 3.
Number of attempts by Macintosh (Mac) blade size. Mac 4 associated with lower first pass success and higher number of attempts in comparison to size 3 Mac blade.

References

    1. Casey JD, Janz DR, Russell DW, et al. : Bag-mask ventilation during tracheal intubation of critically ill adults. N Engl J Med 2019; 380:811–821
    1. Russell DW, Casey JD, Gibbs KW, et al. : Effect of fluid bolus administration on cardiovascular collapse among critically ill patients undergoing tracheal intubation: A randomized clinical trial. JAMA 2022; 328:270–279
    1. Russotto V, Myatra SN, Laffey JG, et al. : Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA 2021; 325:1164–1172
    1. Walls R, Murphy M. (Eds): Manual of Emergency Airway Management. Fourth Edition. Philadelphia, PA, Lippincott Williams & Wilkins, 2012
    1. Macintosh RR: A new laryngoscope. Lancet 1943; 1:205
    1. Tripathi M, Pandey M: Short thyromental distance: A predictor of difficult intubation or an indicator for small blade selection?. Anesthesiology 2006; 104:1131–1136
    1. Kim JH, Kim SW, Kim YM, et al. : Effect of the curved blade size on the outcomes of tracheal intubation performed by incoming interns: A randomized controlled manikin study. Medicine (Baltim) 2018; 97:e11984
    1. Kim H, Chang JE, Han SH, et al. : Effect of the Macintosh curved blade size on direct laryngoscopic view in edentulous patients. Am J Emerg Med 2018; 36:120–123
    1. Sakles JC, Chiu S, Mosier J, et al. : The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013; 20:71–78
    1. Janz DR, Semler MW, Lentz RJ, et al. : Randomized trial of video laryngoscopy for endotracheal intubation of critically ill adults. Crit Care Med 2016; 44:1980–1987
    1. Semler MW, Janz DR, Lentz RJ, et al. : Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. Am J Respir Crit Care Med 2016; 193:273–280
    1. Semler MW, Janz DR, Russell DW, et al. : A multicenter, randomized trial of ramped position vs sniffing position during endotracheal intubation of critically ill adults. Chest 2017; 152:712–722
    1. Janz DR, Semler MW, Joffe AM, et al. : A multicenter randomized trial of a checklist for endotracheal intubation of critically ill adults. Chest 2018; 153:816–824
    1. Janz DR, Casey JD, Semler MW, et al. : Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): A randomised controlled trial. Lancet Respir Med 2019; 7:1039–1047
    1. Cormack RS, Lehane J: Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39:1105–1111
    1. Rubin DB: The design versus the analysis of observational studies for causal effects: Parallels with the design of randomized trials. Stat Med 2007; 26:20–36
    1. Knaus WA, Draper EA, Wagner DP, et al. : APACHE II: A severity of disease classification system. Crit Care Med 1985; 13:818–829
    1. King G, Nielsen R: Why propensity scores should not be used for matching. Political Anal 2019; 27:435–454
    1. Therneau TM: A Package for Survival Analysis in R. 2022. Available at: . Accessed January 9, 2022
    1. Rigby RA, Stasinopoulos DM: Generalized additive models for location, scale and shape. J R Stat Soc Ser C (Appl Stat) 2005; 54:507–554
    1. R Core Team: A language and environment for statistical computing. MSOR Connect 2014; 1
    1. Greifer N: Weighting for Covariate Balance in Observational Studies [R package WeightIt version 0.10.2]. 2020. Available at: . Accessed January 9, 2022
    1. Torgo L: Data Mining With R: Learning With Case Studies. Second Edition. Boca Raton, FL, CRC Press, Taylor & Francis Group, 2017
    1. von Elm E, Altman DG, Egger M, et al. : The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Lancet 2007; 370:1453–1457
    1. Godet T, De Jong A, Garin C, et al. : Impact of Macintosh blade size on endotracheal intubation success in intensive care units: A retrospective multicenter observational MacSize-ICU study. Intensive Care Med 2022; 48:1176–1184
    1. De Jong A, Molinari N, Terzi N, et al. : Early identification of patients at risk for difficult intubation in the intensive care unit: Development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med 2013; 187:832–839

Source: PubMed

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