MACMAN - Poor First-Pass Success

Short Attention Span Summary

Why such poor 1st-pass success in MACMAN?
Intubation is hard, even if you're experienced.  It's harder in a critically ill patient.  Video laryngoscopy (VL) vs. direct laryngoscopy (DL) should make it easier, since it provides better visualization.  But it didn't in this RCT from France.  First-pass success was 68% for VL (using the McGrath Mac Videolaryngoscope) vs. 70% for DL, statistically the same. And there was a trend toward more life-threatening complications in the VL group.  It took them 3 minutes to get the airway in both VL and DL groups.  Over 80% of intubators were "non-experts," i.e. residents.  Also, they did not allow them to use a stylet in the tube for the first pass, which seems like a really bad idea to me.

Success was far lower in this trial than the ED first-pass success rate of 83-86%, also performed 80% of the time by EM residents.  See this article by Ron Walls and colleagues in 2015.  A recent ED-based RCT found a nearly 90% first-pass success with a trend favoring VL, though not significant; and duration of the intubation was only 60 seconds for both VL and DL.

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I think what this study proved is that these ICU residents were not adequately trained to intubate with either VL or DL - with only 2 of 3 attempts successful on the first try, taking three minutes!  What were they doing in there!?  Untrained residents have trouble getting the airway, and every year of EM training leads to greater first pass success.  The first-pass success in this trial was terrible for both methods, doesn't represent the ED success rates we routinely see, and won't change my practice.

Finally, there is a comprehensive new Cochrane Review comparing VL and DL and commentary on EMCrit.  The guest author on EMCrit notes, "the major determinant of success and failure is not the device but rather the hands" using it.


Abstract

JAMA. 2017 Jan 24. doi: 10.1001/jama.2016.20603. [Epub ahead of print]

Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial.

Lascarrou JB1, Boisrame-Helms J2, Bailly A1, Le Thuaut A3, Kamel T4, Mercier E5, Ricard JD6, Lemiale V7, Colin G1, Mira JP8, Meziani F2, Messika J6, Dequin PF5, Boulain T4, Azoulay E7, Champigneulle B8, Reignier J9; Clinical Research in Intensive Care and Sepsis (CRICS) Group.

Author information:

1Medical-Surgical Intensive Care Unit, District Hospital Centre, La Roche-sur-Yon, France.

2Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France3EA 7293, Fédération de Médecine Translationnelle de Strasbourg, Faculté de Médecine, Université de Strasbourg, Strasbourg, France.

3Clinical Research Unit, District Hospital Centre, La Roche-sur-Yon, France5Delegation a la Recherche Clinique et a l'Innovation-CHU Hotel Dieu, Nantes, France.

4Medical Intensive Care Unit, Regional Hospital Centre, Orleans, France.

5Medical Intensive Care Unit, University Hospital Centre, Tours, France.

6AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, F-92700, Colombes, France9INSERM, IAME 1137, Sorbonne Paris Cité, F-75018, Paris, France.

7APHP Hôpital Saint Louis, Service de Réanimation Médicale, Paris, France.

8Medical Intensive Care Unit, Cochin University Hospital Centre, Paris, France.

9Medical Intensive Care Unit, University Hospital Centre, Nantes, France13EA 3826, Clinical and Experimental Treatments for Infections, University of Medicine, Nantes, France.

Abstract

Importance:

In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopy may decrease this risk by improving glottis visualization.

Objective:

To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients.

Design, Setting, and Participants:

Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up.

Interventions:

Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia.

Main Outcomes and Measures:

The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications.

Results:

Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, -2.5% [95% CI, -11.9% to 6.9%]; P = .60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, -6.3% to 8.6%]; P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; P = .95). Video laryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, -2.7% to 10.4%]; P = .25). In post hoc analysis, video laryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, -2.3% [95% CI, -7.4% to 2.8%]; P = .37).

Conclusions and Relevance:

Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels.

Trial Registration:

clinicaltrials.gov Identifier: NCT02413723.

PMID: 28118659 [PubMed - as supplied by publisher]

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