Review article| Volume 210, 107178, April 2023

Clinical use of Macklin-like radiological sign (Macklin effect): A systematic review

Published:February 27, 2023DOI:


      • Macklin is a radiological sign consisting in air dissecting peribronchial sheaths.
      • Macklin sign is often detected on chest CT scan in patients with barotrauma.
      • Link between Macklin and barotrauma is described in various ways in literature.
      • Recent studies proposed Macklin as an accurate predictor of barotrauma.
      • Macklin could identify patient at risk for barotrauma, to try to prevent it.



      Recent studies suggested that Macklin sign is a predictor of barotrauma in patients with acute respiratory distress syndrome (ARDS). We performed a systematic review to further characterize the clinical role of Macklin.


      PubMed, Scopus, Cochrane Central Register and Embase were searched for studies reporting data on Macklin. Studies without data on chest CT, pediatric studies, non-human and cadaver studies, case reports and series including <5 patients were excluded. The primary objective was to assess the number of patients with Macklin sign and barotrauma. Secondary objectives were: occurrence of Macklin in different populations, clinical use of Macklin, prognostic impact of Macklin.


      Seven studies enrolling 979 patients were included. Macklin was present in 4–22% of COVID-19 patients. It was associated with barotrauma in 124/138 (89.8%) of cases. Macklin sign preceded barotrauma in 65/69 cases (94.2%) 3–8 days in advance. Four studies used Macklin as pathophysiological explanation for barotrauma, two studies as a predictor of barotrauma and one as a decision-making tool. Two studies suggested that Macklin is a strong predictor of barotrauma in ARDS patients and one study used Macklin sign to candidate high-risk ARDS patients to awake extracorporeal membrane oxygenation (ECMO). A possible correlation between Macklin and worse prognosis was suggested in two studies on COVID-19 and blunt chest trauma.


      Increasing evidence suggests that Macklin sign anticipate barotrauma in patients with ARDS and there are initial reports on use of Macklin as a decision-making tool. Further studies investigating the role of Macklin sign in ARDS are justified.

      Graphical abstract


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