Intubation of a critically ill patient is a procedure leading to risks for the patient and nerves for the doctor. The attempt by Godet et al. to provide a scientific basis to the choices of intubation material in these procedures is commendable [1]. However, the association between the size of the Macintosh blade and first attempt success in this study is rightly deemed to be an association. The current study seems an insufficient base for a choice on the size of Macintosh blade. The study documents little to the reasons why operators chose a certain size of blade. If a blade 4 is the default and a blade 3 is only chosen upon judgment of the airway, this could also lead to the same association. The supplementary data seem to imply that within the group of operators intubating with a blade 4, the proportion of relative less-experienced operators (non-anesthesiology residents) is far greater than in the blade 3 group, which could be a serious confounder. Furthermore, the choice of blade size does not seem to be based on size of the patient with only one centimeter difference in median height. Our colleagues have previously performed a randomized controlled trial showing that wearing size 5 clogs resulted in better emergency response times than size 12 clogs, without regard to the size of the feet of the people wearing the clogs [2]. It seems plausible that clogs fitted to size would result in better walking and Macintosh blades chosen to best fit the oropharynx of the patient would result in better intubations. Unfortunately, unlike in feet we do not have measurements which have been shown to predict which blade size best fits the patient’s oropharynx. The authors suggest that this is a hypothesis generating study which should be investigated in a randomized clinical trial. It will probably be more helpful to study which Macintosh blade fits better in which oropharynx than to randomly assign blade size to patients. A randomized controlled trial without regard for size is dangerously close to the clog size trial performed by our colleagues. Therefore, in the end, size does matter, but the right fit might matter even more.
References
Godet T, De Jong A, Garin C, Guerin R, Rieu B, Borao L et al (2022) Impact of Macintosh blade size on endotracheal intubation success in intensive care units: a retrospective multicenter observational MacSize-ICU study. Intensive Care Med 48(9):1176–1184. https://doi.org/10.1007/s00134-022-06832-9
Elbers PWG, de Grooth HJ, Girbes ARJ (2020) The effect of small versus large clog size on emergency response time: A randomized controlled trial. J Crit Care 60:116–119. https://doi.org/10.1016/j.jcrc.2020.07.028
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Geboers, D.G.P.J., Gigengack, R.K. & Zijlstra, G.J. Size does matter. Intensive Care Med 49, 266 (2023). https://doi.org/10.1007/s00134-022-06931-7
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DOI: https://doi.org/10.1007/s00134-022-06931-7