Self-Assembled Modified Macintosh Videolaryngoscope Versus McGrath Macintosh (MAC®) Videolaryngoscope: Which is Better?
Phase: NA
Conditions: Airway Management
Sponsor: Indonesia University

Date: December 14th 2020 
 
Self-Assembled Modified Macintosh Video laryngoscope versus McGrath 
MAC® Video laryngoscope: Which is Better? 
 
Budiani Christina, Raden Besthadi Sukmono, Sidharta Kusuma Manggala 
Department of Anesthesiology and Intensive Care 
Faculty of Medicine, Universitas Indonesia–RSUPN dr. Cipto Mangunkusumo 
Jalan Diponegoro No. 71, Jakarta, 10430, Indonesia 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Date: December 14th 2020 
Background 
Endotracheal intubation, the gold standard in definitive airway management, is a procedure for 
inserting an endotracheal tube (ET tube) with the help of a laryngoscope. A study showed that 
94% of intubation done by skilled operators would be successful in 1 to 2 attempts. In contrast, 
non-skilled operators had only 82% first-attempt success rate with 13.2% requiring 3 or more 
attempts, and 10.3% taking over 10 minutes.1, 2 One of the biggest upgrades in the recent decade 
to improve this success rate is the addition of video camera to a laryngoscope, reintroducing 
the device as a Video laryngoscope (VL). McGrath MAC ® laryngoscope is one of the most 
widely used commercial video laryngoscopes that utilize a modified Macintosh blade, with a 
video camera and a light source attached at the end of the blade. The image is displayed in the 
liquid-crystal display (LCD) monitor mounted on the handle of the blade. 3,4 
 
VL has been shown to improve visualization of the larynx.5,6,7,8  However, several studies 
showed that intubation time with McGrath MAC ®  is the same or even longer compared to 
conventional macintosh blades.7-10 Insertion of ET tube through the vocal cords is also more 
difficult even though it is clearly visualized because the ET tube is in contact with the anterior 
tracheal wall, and therefore a stylet is needed to bend the tip of the ETT to an angle > 
35º.3,10,11  McGrath's blades are also less effective than the wider sized Macintosh blades to 
displace the tongue and expanding the area for visualization of the larynx and  ET tube 
insertion10 
 
Despite the advantages of video laryngoscope, the expensive price becomes a problem, 
especially in developing countries.6,12 As an alternative, we modified a classic Macintosh 
laryngoscope by attaching a flexible fiber optic-like camera to its blade.  We compared the 
intubation time, success first attempt rate, laryngeal visualization, complications, and user 
satisfaction between this self-assembled video laryngoscope and McGrath MAC ®. 
 
Research Methods 
This is an experimental single-blinded randomized clinical trial conducted in the operating 
room for elective surgery at the dr. Cipto Mangunkusumo Hospital, a tertiary national referral 
hospital in Jakarta, Indonesia from June to August 2020. The sample size of 62 patients was 
calculated using numerical hypothesis testing formula for two unpaired populations with an 

Date: December 14th 2020 
additional 10% of presumed sample dropout. Ethical clearance was obtained from Universitas 
Indonesia Ethical Board Committee. 
 
All adult patients (18-65 years old), ASA I-II, with Body Mass Index (BMI) of 18 – 30 kg/m2 
scheduled for elective surgical procedures under general anaesthesia were included. All 
subjects provided written consent. We exclude patients with a difficult airway, pregnancy, 
cardiac condition, and neuromuscular disease. 
 
The self-assembled modified Macintosh video laryngoscope (SAM-VL) used in this study was 
constructed from a portable video camera with a Wi-fi connection (Wi-fi Endoscope Video 
Camera model YPC99) attached to a no. 4 Macintosh Laryngoscope blade (Riester no.7040). 
The video signal is transmitted to an Android-based mobile phone (Android version 7.0). The 
portable 2 megapixels video camera is 8 mm in diameter with 8 LED lights for adjustable 
lighting level and 3 meters cable length. Video resolution output is 640x480 pixels (VGA) and 
1280x720 pixels (HD). The camera has a 70º visual angle with a focal length of 4– 6cm and is 
water-resistant. The camera was taped to the Macintosh blade at a distance of 5 cm from the 
distal end of the blade, using transparent waterproof Leukofix ® tape. After installation, the 
camera was oriented on a flat plane to set the desired image.  The video images are then viewed 
on the mobile phone screen using the Y-camera app (downloadable for free in Google Play 
Store for Android). The total cost for this camera device assembly was Rp260.000 (roughly 20 
USD), excluding the Android phone. After intubation, the camera is removed from the 
Macintosh blade and the camera tip that enters the patient's oral cavity is flushed with running 
water and washed with soap for at least two minutes, using a soft bristle brush to remove any 
soil if needed. After drying, the camera is wiped with a 70% alcohol swab before the next 
procedure. 
 
Randomization was done with tables and then presented in a closed envelope when the patient 
arrived at the operating room to determine the intervention group: (1) the Self-Assembled 
Modified Macintosh Video laryngoscope (SAM-VL) group or (2) the McGrath MAC ® video 
laryngoscope (McGrath) group. The laryngoscopist is the one who opened the envelope. A 
research assistant helped to prepare the laryngoscope according to the randomization results. 
 
Anaesthesia monitoring was conducted following ASA standard and included ECG, non-
invasive blood pressure, pulse oximeter, etCO2, and temperature. Initial hemodynamic status 

Date: December 14th 2020 
of the patient before induction including systolic, diastolic, mean arterial pressure, pulse, and 
peripheral oxygen saturation was noted. 
 
Anaesthesia was co-induced intravenously with fentanyl 2 µg/kg, propofol 2 mg/kg, and 
rocuronium 0.6 mg/kg. Medications were titrated to effect. Subjects were given positive 
pressure mask ventilation with 80% oxygen for 3 minutes. Hemodynamic status was recorded 
three times: (1) pre-induction, (2) at 3 minutes after co-induction medications were given, and 
(3) after tracheal intubation in confirmed. 
 
The intubation time “A” recording began when the tip of the laryngoscope blade passed 
through the incisors until the operator was able to achieve the best visualization of the 
glottis. The “B” intubation time recording began when the operator received visualization of 
the glottis and ended after the ET tube was confirmed to enter the trachea. Intubation time “B” 
consists of two components, insertion of the ETT into the vocal cords and connecting the 
breathing circuit so that the etCO2 wave appeared on the monitor. When inserting the ET tubes, 
all operators were assisted with a stylet.  To minimize the delay in connecting the circuit, one 
assistant was present to help the operator. 
 
Intubation was done using ET tube No.7.5 for men and No.7 for women with the help of a 
stylet. Subjects underwent laryngoscopy and intubation with either McGrath MAC ® video 
laryngoscope or SAM-VL according to randomization. During visualization of the glottis, the 
operator mentioned the POGO (Percentage of Glottic Opening) score visualized, with a scale 
ranging from 0–100%. Successful intubation was confirmed by capnography tracing. The 
SAM-VL can record both photo and video formats. McGrath MAC ® screen can only be used 
for visualization, but the image cannot be recorded. Thus, a smartphone video camera is used 
to record images from the McGrath MAC ® screen. 
 
One attempt to intubate was noted if the ET tube was successfully placed into the trachea on 
the first attempt. If the laryngoscope blade was removed from the mouth and then reinserted, 
consequently the researcher noted the number of intubation attempts. If the intubation attempt 
was unsuccessful 3 times and/or the intubation time exceeds 120 seconds, the subject was 
dropped out.  
 

Date: December 14th 2020 
If during the procedure an emergency or desaturation of ≤90% occurred, it would be managed 
following ALS algorithms and the subject was dropped out from the study. Any complication 
throughout the procedure was noted. This study also includes a survey to evaluate the operator's 
subjective experience using three questionnaires in Likert scale format. The items evaluated 
are ease in blade insertion, device maneuverability, glottis visualization, and overall 
satisfaction rating.  
 
The 
results 
were 
calculated 
using 
the 
Statistical 
Package 
for 
Social 
Scientists (SPSS) 24. Analysis of the duration of intubation (numerical data) was done with an 
unpaired t-test for data with normal distribution, and Mann-Whitney if the distribution was not 
normal. The results were considered significant if the p-value was < 0.05. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Date: December 14th 2020 
INFORMED CONSENT 
 
I, dr. Raden Besthadi Sukmono, SpAn-KAR from the Department of Anesthesiology and 
Intensive Therapy FKUI / RSCM will conduct a study entitled Comparison of Endotracheal 
Intubation Time Using a Macintosh Laryngoscope Modified with the McGrath 
MAC ® Video Laryngoscope on Adult Population 
 
I will provide information to you about this research and invite you to be part of this research. 
You can participate in this research by signing this form. If you agree to participate in this 
research, you can back away from this research. You also have the right to receive the latest 
information from us about the treatments being tested, if any. If you refuse to participate or 
withdraw from this research, this decision will not affect the relationship between you with me 
and will have no impact on the applicable services in this hospital. If you do not understand 
each statement in this form, you can ask to me 
 
1. Research purposes 
Comparing the insertion time of the airway tube into the airway using the modified 
Macintosh laryngoscope with McGrath video laryngoscope in the adult population. 
 
2. Participation in research 
Overall, this research will run for 3 months. If you decide to participate in this research, 
you will be asked to participate in the event when you will undergo surgery under general 
anesthesia. This research will involve you in one period, namely when going to undergo 
general anesthesia. 
 
3. Reasons of recruitment 
You were chosen for this study because it meets the criteria for adults aged 18–65 years, 
with the condition of the body does not have severe disease or complication in anesthesia 
and has a mass index body 18.5–30 kg / m 2 
 
4. Research procedure 
• One day before surgery, during the pre-anesthesia visit, you will be interviewed by the 
doctor to be asked and recorded. Basic data: Name, record number medical, place of 
birth date, age, weight, height, address, telephone number, medical history, history of 
drug use, history of allergies, diagnosis, surgery, and history of previous anesthesia. 

Date: December 14th 2020 
• The night before the study, you were asked to fast 6 hours before the operation and 
were allowed to drink plain water 2 hours before surgery. 
• On the day of the surgery, you will be received by the operating room officer at 
RSUPNCM. 
• After entering the operating room, you will be sedated using the usual anesthesia 
technique practiced in the operating room. Then the type of assistive device to insert 
the breathing tube into the airway will be selected according to the options listed in the 
closed envelope. The patient will be supervised by trained personnel during anesthesia 
and surgery. 
• The assessment and recording of your condition will be carried out at the beginning 
anesthesia by the research team. What will be assessed is the time it takes to enter the 
breath tube of each device used. 
 
5. Risks, side effects, and their management 
The device for inserting the airway into the airway is widely used and does not provide 
significant side effects but sometimes minor mucosa of the lips and mouth injuries can 
occur in some people. During the research, you are supervised by trained personnel. When 
an emergency condition happens, then you will be managed according to the basic life 
support algorithm.  
 
6. Benefits 
The time of breath tube insertion into the airway can be shorter 
 
7. Compensation 
You will not get any reward for participating in this research 
 
8. Financing 
Research funding will be fully borne by the researcher 
 
9. Confidentiality 
All data and original research files will be stored in the department's research cabinet 
which will be locked and only accessible for audit purposes. The patient's ID will be saved 
in the initial format. Presentation research results in scientific meetings/conferences and 

Date: December 14th 2020 
publications in scientific journals will not include the name of subjects. However, 
representatives from sponsors, ethical committees, and national regulatory bodies will 
have access to research data for verification. 
 
10. Obligations of research subjects 
As research subjects, you are obliged to follow the research rules or guidelines as written 
above. If anything is not clear, you can ask the research team. 
 
11. Right to refuse and resign 
You do not have to participate in this research if you don't want to. You must understand 
that even if you agree to participate, you have the right to withdraw from this research. If 
you refuse to participate or withdraw from the study, the decision will not affect your 
relationship with me, and it will not have an impact on the standard of service that applies 
at this hospital. I will allow you at the end of this explanation to consider the decisions to 
be taken. 
 
12. Additional Information 
You are allowed to ask all the things that are not yet clear in this research. If at any time 
there are side effects or need further explanation, You can contact R. Besthadi Sukmono, 
MD in the Department of Anesthesiology and Intensive Therapy FKUI / RSUPN Dr. 
Cipto Mangunkusumo, Jakarta 
 
 
  
 
 
 
 
 
 
 
 
 
 

Date: December 14th 2020 
RESEARCH PARTICIPATION AGREEMENT SHEET 
  
  
All these explanations have been presented to me and all my questions have been answered 
by doctor. I understand that if I need an explanation, I can ask the doctor 
  
  
Certificate of Approval (Consent) 
  
I have read all the descriptions about 
this research. I've been given the 
opportunity to asked and all my questions 
have been answered clearly. I am willing to 
participate in this research study voluntarily 
 
____________________________ 
Subject / guardian name 
  
____________________________ 
Signs hand participants study 
  
Date _________________________ 
day / month / year 
  
I confirm that the participants have 
given the opportunity to ask about 
research, and all questions have been 
answered correctly. I confirm that 
consent has been granted voluntarily. 
 
____________________________ 
Name of researcher / approval requester 
   
____________________________ 
The signature of 
the researcher / approval request 
  
Date _________________________ 
day / month / year 
 
Researcher Information: 
Main Researcher 
: R. Besthadi Sukmono, MD 
                                      Jalan Pangeran Diponegoro No.71, Central Jakarta                         
Researcher  
 
: Budiani Christina, MD                            
                                      Jalan Pangeran Diponegoro No.71, Central Jakarta  
KEPK FKUI-RSCM : Jalan Salemba 6, Central Jakarta, 10430