LMA Supreme™vs i-gel™- a comparison of insertion success in novices

Learning curve of i-gel insertion in novices using a cumulative sum analysis

The i-gel, a popular second-generation supraglottic airway device, has been used in a variety of airway management situations, including as an alternative to tracheal intubation for general anesthesia, rescue in difficult airway settings, and out-of-hospital cardiac arrest resuscitation. We aimed to investigate the number of experiences needed to achieve a rapid, highly successful first attempt i-gel insertion in novices with a cumulative sum analysis. We also looked at how learning affected success rates, insertion time, and bleeding and reflex (limb movement, frowning face, or coughing) incidences. This prospective observational study included 15 novice residents from March 2017 to February 2018 in a tertiary teaching hospital. Finally, 13 residents with 35 [30-42] (median [interquartile range]) cases of i-gel insertion were analyzed. The cumulative sum analysis showed that 11 of 13 participants had an acceptable failure rate after 15 [8-20] cases. With increasing experience, success rate (P = 0.004), insertion time (P < 0.001), and incidence of bleeding (P = 0.006) all improved. However, the incidence of reflex did not change (P = 0.43). Based on our results, we suggest that 20 cases are preferable for novices to develop skills in using the i-gel in airway management.

I-Gel ve laringeal mask airway-supreme’in klinik performans yönünden karşılaştırılması: prospektif çalışma

Amaç: Çalışmamızda; genel anestezi altında ürolojik cerrahi girişim planlanan hastalarda, ikinci jenerasyon supraglottik havayolu gereçlerinden I-gel ve LMA-Supreme’in (Laringeal Mask Airway- Supreme) klinik performans ve postoperatif faringolaringeal komplikasyonlar açısından karşılaştırılmasını amaçladık. Gereç ve Yöntem: Hastane etik kurul onayı (19-8.1T/53) ve hasta yazılı onamı alındıktan sonra, genel anestezi altında elektif ürolojik cerrahi planlanan, 18-65 yaş arası, ASA (The American Society of Anesthesiologists) skoru I-II olan, 120 hasta prospektif olarak çalışmamıza dahil edildi. Hastalar randomize olarak I-gel (n=60) ve LMA-Supreme (n=60) olarak iki gruba ayrıldı. İki grup; supraglottik havayolu gereci yerleştirme kolaylığı, yerleştirme süresi, ilk yerleştirmede başarı oranı, deneme sayısı, gastrik tüp yerleştirme kolaylığı, orofaringeal kaçak basıncı, intraoperatif ve postoperatif komplikasyonlar açısından karşılaştırıldı. Bulgular: Supraglottik havayolu gereci yerleştirme süresi I-gel grubunda anlamlı olarak daha kısa bulundu (p: 0,039). Tüm ölçüm zamanlarında, orofaringeal kaçak basıncı ‘mükemmel’ olan hasta sayısı I-gel grubunda daha yüksekti (p&lt;0,05). Gastrik tüp yerleştirme, LMA-Supreme grubunda anlamlı olarak daha kolay bulundu (p: 0,029). Postoperatif 12. saat boğaz ağrısı (p: 0,049) ve ses kısıklığı (p:0,046) LMA-Supreme grubunda daha fazla görüldü. LMA-Supreme ve I-gel; yerleştirme kolaylığı, ilk yerleştirmede başarı oranı, deneme sayısı ve intraoperatif komplikasyonlar açısından benzer özelliklere sahipti. Sonuç: I-gel’de yerleştirme süresinin daha kısa, orofaringeal kaçağın ve postoperatif komplikasyonların daha az olması LMA-Supreme’e göre tercih nedeni olabilir.

Evaluation of four supraglottic devices used by paramedical staff for securing airway in simulated emergency airway management

Background

Prehospital emergency airway management challenges every paramedic. Emergencies evacuated from difficult areas by armed forces need airway maintenance throughout evacuation. Effective use of supraglottic airway (SGA) devices during prehospital transfer is life saving. This study compared use of four commonly available SGAs by Armed Forces paramedics in simulated emergency situations.

Methods

This prospective observational study conducted in a tertiary care institution, included 58 volunteer paramedics. They were trained on manikins before the study in basic airway skills and insertion of the four SGA devices under study viz. Classic laryngeal mask airway (cLMA), laryngeal tube (LT), I-gel, and Combitube. SGA device insertions were performed on 474 patients scheduled for short elective surgical procedures under general anesthesia. All volunteers inserted and assessed the four SGA devices equal number of times in different patients. Overall success rate, time for successful insertion, first attempt success rate, number of attempts for successful insertion, oro-pharyngeal leak pressures, ease of insertion, durability of device, and complications were recorded.

Results

Differences among the four groups were statistically significant in all parameters. Intergroup comparison revealed that both I-gel and LT were comparable to each other, however superior to cLMA and Combitube in all outcome measures except ease of insertion and durability of device where I-gel was better and oro-pharyngeal seal pressures where Combitube was better.

Conclusion

Considering all parameters, I-gel proved superior with minimal complications compared with other SGA devices tested. I-gel may be recommended for emergency airway rescue use in patients by military paramedics.

Laryngeal Mask Airway Supreme vs. the Spritztube tracheal cannula in anaesthetised adult patients: A randomised controlled trial

BACKGROUND

The Spritztube is a new supraglottic airway device combining the ability to allow extraglottic ventilation of the lungs with the opportunity to perform fibreoptic-assisted intubation.

OBJECTIVES

To compare the Spritztube tracheal cannula with the Laryngeal Mask Airway Supreme (LMA-S) in anaesthetised adult patients.

DESIGN

A single-centre, randomised controlled study.

SETTING

Tertiary hospital.

PATIENTS

Mechanically ventilated patients undergoing elective surgery in the supine position under general anaesthesia were included. Main exclusion criteria were a history of, or predicted, difficult airway management according to SIAARTI guidelines and absence of written informed consent.

INTERVENTIONS

Patients received the LMA-S or Spritztube tracheal cannula to facilitate ventilation of the lungs.

MAIN OUTCOME MEASURES

Successful placement (primary outcome), time required for insertion, number of attempts, subjective assessment of ease of insertion, safety and incidence of complications were recorded.

RESULTS

One hundred and sixty seven patients were allocated to the LMA-S or Spritztube group, respectively, a total of 334 patients. In the LMA-S group, the device insertion failed in nine patients, compared with none in the Spritztube group (P = 0.002). Spritztube insertion was easy in 100% of cases compared with 94.6% of the cases in the LMA-S group (P = 0.03). The number of attempts was significantly higher with the LMA-S compared with the Spritztube (P = 0.0007), whereas the insertion times were comparable (P = 0.06). Except for the incidence of blood-staining, which was higher in the LMA-S group (P = 0.01), the number of complications was comparable in the two groups.

CONCLUSION

The Spritztube was as effective as the LMA-S in maintaining the airway with all patients being successfully ventilated without difficulty. The success rate of achieving a patent airway was comparable between the groups, with a similar occurrence of complications.

TRIAL REGISTRATION

NCT03443219.

Endosonographic evaluation of the mediastinum through the i-gel O2 supraglottic airway device

INTRODUCTION

Endobronchial ultrasound (EBUS) is an endoscopic diagnostic procedure combining flexible fibrobronchoscopy with ultrasound techniques; it allows transbronchial needle aspiration biopsy for the diagnosis and staging of mediastinal masses. We present our preliminary experience with the use of the i-gel O₂ supraglottic airway device for management of EBUS procedures.

METHODS

An observational study on 39 patients who underwent EBUS under general anesthesia was performed. Airways were managed with i-gel O₂ by anesthesiologists unfamiliar with it. Data collected included patient characteristics, i-gel O₂ positioning, mechanical ventilation, procedure, and complications occurring during and after the EBUS.

RESULTS

The i-gel airway was successfully positioned during the first attempt in 34/39 cases (87.2%). No failed positioning was recorded. The EBUS scope easily passed through the i-gel in all patients and in 14 (35.6%) cases it was also inserted through the esophagus allowing the examination or fine needle aspiration of paraesophageal lymph nodes. In one case, during the EBUS procedure, the i-gel was dislocated but easily put in place again. During EBUS, air leakages were significant in 2 cases (5.1%) and minimal in 14 cases (35.9%). A brief self-solved laryngospasm and a bronchospasm during bronchoscopy were recorded. After recovery, no patients had dysphagia; mild odynophagia and pharyngodinia were referred by 2 (5.1%) and 12 (30.1%) patients, respectively.

CONCLUSIONS

The i-gel O₂ airway is easy to position and manage even for anesthesiologists unfamiliar with it. This supraglottic airway device is suitable for a complete endosonographic evaluation of the mediastinum.

A Comparison between the i-gel® and air-Q® Supraglottic Airway Devices Used for the Patients Undergoing General Anesthesia with Muscle Relaxation

OBJECTIVES

The aim of the present study was to compare two supraglottic airway (SGA) devices (i.e., the i-gel® © Intersurgical Ltd and air-Q® (Reusable) Cookgas company) in terms of the insertion time, amount of leak during ventilation with maximum positive pressure, and postoperative complications in patients referring to Modarres Hospital in Tehran.

METHOD

The present double-blind clinical trial was performed on 60 patients undergoing elective surgeries that required general anesthesia with muscle relaxation. Patients were randomly assigned to either i-gel® (n = 30) or Air-Q® (n = 30) groups.

RESULTS

The mean age, body mass index, duration of surgery, duration of anesthesia, and gender ratio were not significantly different between the two groups. Mean ± SD values of the SGA devices' insertion time (in seconds) in the air-Q® and i-gel® groups were 4.87 ± 1.6 and 6.80 ± 1.2, respectively (P < 0.001). The mean OLP in the Air-Q® group was significantly higher than that of the i-gel® group (35.9 ± 9.6 versus 24.8 ± 3.7, p < 0.001). The frequency of complications occurred after the supraglottic airway insertion was higher in the i-gel® group. However, only in terms of sore throat, the difference between the two groups was statistically significant: 6 (20%) had sore throat (P = 0.024) in the i-gel groups, but in in the Air-Q® groups no one had this side effect after surgery.

CONCLUSION

It was concluded that the Air-Q® supraglottic airway was placed faster and easier with fewer complications than the i-gel in general anesthesia with muscle relaxation. The frequency of the occurrence of all three complications, cough, sore throat, and blood, on the cuff (6 (20%) was higher in the i-gel group than that in the air-Q® group (cough3 (10%), sore throat 0 (0%), and blood on the cuff 3 (10%) (P < 0.05).

Comparison of the clinical performance of airway management with the i-gel® and laryngeal mask airway SupremeTM in geriatric patients: a prospective and randomized study

Background

Geriatric patients are susceptible to respiratory and hemodynamic adverse events during endotracheal intubation and extubation due to anatomic and physiological changes with aging. Supraglottic airway devices (SADs) provide reduced airway morbidity and increased hemodynamic stability in adults. However, studies that have compared the clinical performance of SADs in geriatric patients are limited. Therefore, we evaluated the clinical performance of airway management with i-gel^® and laryngeal mask airway Supreme (LMA Supreme^TM) in geriatric patients.

Methods

The subjects were American Society of Anesthesiologists physical status classification I–III geriatric (65–85 years) patients who underwent elective surgery with general anesthesia and were randomly allocated into the i-gel^® group and the LMA Supreme^TM group. We compared the time for successful insertion on a first attempt as a primary outcome, and the secondary outcomes were success rate, ease of insertion, maneuver for successful ventilation, oropharyngeal leak pressure, gastric insufflation, fiberoptic view grades, ventilator problems, and adverse events.

Results

Insertion time was significantly shorter for the i-gel^® than the LMA Supreme^TM (21.4 ± 6.8 vs. 29.3 ± 9.9 s; P = 0.011). The i-gel^® was also easier to insert than the LMA Supreme^TM (P = 0.014). Gastric insufflation was less frequent with the i-gel^® than the LMA Supreme^TM (0% vs. 31.3%; P = 0.013). Other measurements were comparable between groups.

Conclusions

Both devices can be safely applied to geriatric patients with similar success rates and oropharyngeal leak pressures. However, inserting the i-gel^® was faster and easier compared to the LMA Supreme^TM in geriatric patients.

A comparative evaluation of ProSeal laryngeal mask airway, I-gel and Supreme laryngeal mask airway in adult patients undergoing elective surgery: A randomised trial

Background and Aims

Second-generation supraglottic airway devices are widely used in current anaesthesia practice. This randomised study was undertaken to evaluate and compare laryngeal mask airway: ProSeal laryngeal mask airway (PLMA), Supreme laryngeal mask airway (SLMA) and I-gel.

Methods

Eighty-four adult patients undergoing elective surgery were randomly allocated to three groups: group P (PLMA), group I (I-gel) and group S (SLMA) of 28 patients each. Insertion times, number of insertion attempts, haemodynamic response to insertion, ease of insertion of airway device and gastric tube, oropharyngeal leak pressure (OLP) and pharyngolaryngeal morbidity were assessed. The primary outcome measure was the OLP after successful device insertion. Statistical analysis was performed using Statistical Package for the Social Sciences version 18.0 software using Chi-squared/Fisher's exact test (categorical data) and analysis of variance (continuous data) tests. P < 0.05 was considered statistically significant.

Results

The demographic profile of patients was comparable. OLP measured after insertion, 30 minutes later and at the end of surgery differed significantly between the three groups (P < 0.001). The mean OLP was 32.64 ± 4.14 cm·H₂O in group P and 29.79 ± 3.70 cm·H₂O in group S. In group I, the mean OLP after insertion was 26.71 ± 3.45 cm H₂O, which increased to 27.36 ± 3.22 cm H₂O at 30 minutes and to 27.50 ± 3.24 cm H₂O towards the end of surgery. However, these increases were not statistically significant (P = 0.641). Device insertion time was longest for group P (P = 0.001) and gastric tube insertion time was longest for group I (P = 0.001). Haemodynamic response to insertion and pharyngolaryngeal morbidity were similar with all three devices.

Conclusion

PLMA provides better sealing pressure but takes longer to insert. I-gel and SLMA have similar sealing pressures. I-gel insertion time is quicker.

Comparison of oropharyngeal leak pressure of air-Q™, i-gel™, and laryngeal mask airway supreme™ in adult patients during general anesthesia: A randomized controlled trial

Study Objective:

Various randomized controlled trials and a meta-analysis have compared i-gel™ and laryngeal mask airway Supreme™ (LMA-S™) in adult patients and found that both the devices provided equivalent oropharyngeal leak pressure (OLP). However, no randomized controlled trial has compared air-Q™ with i-gel™ and LMA-S™ in adult patient. Hence, we designed this study to compare air-Q™ with LMA-S™ and i-gel™ in adult patients.

Materials and Methods:

A total of 75 adult patients of the American Society of Anesthesiologists physical status I/II of both sexes, between 18 and 60 years, were included in this prospective randomized controlled trial conducted in a tertiary care center. Randomization of patients was done in three equal groups according to the insertion of supraglottic airway device by a computer-generated random number sequence: group air-Q™ (n = 25), group i-gel™ (n = 25), and group LMA-S™ (n = 25). Primary outcome of this study was OLP. We also recorded time for successful placement of device, ease of device insertion, number of attempts to insert device, and ease of gastric tube insertion along with postoperative complications.

Results:

The mean ± standard deviation OLP of air-Q™, i-gel™, and LMA-S™ was 26.13 ± 4.957 cm, 23.75 ± 5.439 cm, and 24.80 ± 4.78 cm H₂O (P = 0.279). The first insertion success rate for air-Q™, i-gel™, and LMA-S™ was 80%, 76%, and 92%, respectively (P = 0.353). The insertion time of air-Q™, i-gel™, and LMA-S™ was 20.6 ± 4.4, 14.8 ± 5.4, and 15.2 ± 4.7 s, respectively (P = 0.000). Time taken for air-Q™ insertion was significantly higher than time taken for i-gel™ (mean difference 5.8 s, P < 0.0001) and LMA-S™ (mean difference 5.4 s, P = 0.0001) insertion. Postoperative complications were similar with all three devices.

Conclusions:

We concluded that air-Q™, i-gel™, and LMA-S™ were equally efficacious in terms of routine airway management in adult patients with normal airway anatomy.

Comparison of the clinical performance of i-gel, LMA Supreme and LMA ProSeal in elective surgery

INTRODUCTION

The LMA Supreme™, i-gel® and LMA ProSeal™ are second-generation supraglottic airway devices. We tested the hypothesis that these devices differ in performance when used for spontaneous ventilation during anaesthesia.

METHODS

150 patients who underwent general anaesthesia for elective surgery were randomly allocated into three groups. Data was collected on oropharyngeal leak pressures, ease and duration of device insertion, ease of gastric tube insertion, and airway safety.

RESULTS

Leak pressure, our primary outcome measure, was found to be higher for the i-gel than the Supreme and ProSeal (mean ± standard error of the mean: 27.31 ± 0.92 cmH2O, 23.60 ± 0.70 cmH2O and 24.44 ± 0.70 cmH2O, respectively; p = 0.003). Devices were inserted on the first attempt for 90%, 82% and 72% of patients in the i-gel, Supreme and ProSeal groups, respectively (p = 0.105); mean device placement times were 23.58 seconds, 25.10 seconds and 26.34 seconds, respectively (p = 0.477). Gastric tubes were inserted on the first attempt in 100% of patients in the Supreme group, and 94% of patients in the i-gel and ProSeal groups (p = 0.100). There was blood staining on removal in 9 (18%) patients in each of the Supreme and ProSeal groups, with none in the i-gel group (p = 0.007). The incidence of postoperative sore throat, dysphagia and hoarseness was lowest for the i-gel.

CONCLUSION

The three devices were comparable in terms of ease and duration of placement, but the i-gel had higher initial oropharyngeal leak pressure and lower airway morbidity compared with the ProSeal and Supreme.

Comparison of the i-gel and other supraglottic airways in adult manikin studies: Systematic review and meta-analysis

BACKGROUND

The i-gel has a gel-like cuff composed of thermoplastic elastomer that does not require cuff inflation. As the elimination of cuff inflation may shorten insertion time, the i-gel might be a useful tool in emergency situations requiring prompt airway care. This systematic review and meta-analysis of previous adult manikin studies for inexperienced personnel was performed to compare the i-gel with other supraglottic airways.

METHODS

We searched PubMed, the Cochrane Library, and EMBASE for eligible randomized controlled trials (RCTs) published before June 2015, including with a crossover design, using the following search terms: "i-gel," "igel," "simulation," "manikin," "manikins," "mannequin," and "mannequins." The primary outcomes of this review were device insertion time and the first-attempt success rate of insertion.

RESULTS

A total of 14 RCTs were included. At the initial assessment without difficult circumstances, the i-gel had a significantly shorter insertion time than the LMA Classic, LMA Fastrach, LMA Proseal, LMA Unique, laryngeal tube, Combitube, and EasyTube. However, a faster insertion time of the i-gel was not observed in comparisons with the LMA Supreme, aura-i, and air-Q. In addition, the i-gel did not show the better results for the insertion success rate when compared to other devices.

CONCLUSION

The findings of this meta-analysis indicated that inexperienced volunteers placed the i-gel more rapidly than other supraglottic airways with the exception of the LMA Supreme, aura-i, and air-Q in manikin studies. However, the quicker insertion time is clinically not relevant. The unapparent advantage regarding the insertion success rate and the inherent limitations of the simulation setting indicated that additional evidence is necessary to confirm these advantages of the i-gel in an emergency setting.

Comparison of I-gel with Classic Laryngeal Mask Airway Regarding the Ease of Use and Clinical Performance

OBJECTIVE

I-gel is a new supraglottic airway device without an inflatable cuff. We aimed to compare I-gel and the classic laryngeal mask airway (LMA) regarding the ease of use and clinical performance in Turkish population.

METHODS

Fifty American Society of Anesthesiologists (ASA) I-II patients were randomly allocated into two groups: Group I-gel and Group LMA. Insertion time and success in first attempt were recorded. Peak, plato and mean airway pressures, EtCO2, airway compliance and leak volume were periodically recorded during the operation. The presence of blood on device removal and postoperative sore throat were also assessed.

RESULTS

The device insertion time in Group I-gel was shorter than that in Group LMA (21.00±4.15 vs. 30.40±12.17 s, p=0.001). The success rate in first attempt, peak, plato and mean airway pressures, EtCO2 and airway compliance did not differ between the groups. The leak volume was lower in Group I-gel 5 and 45 min after insertion (p=0.041 and p=0.027). The presence of blood on device removal and postoperative sore throat were similar in both groups.

CONCLUSION

I-gel may be a more advantageous supraglottic airway device compared with LMA.

Visual recognition of anatomical structures in a circulated and in a non-circulated airway

INTRODUCTION

Pre-hospital airway management is complex and complications occur frequently. Guidelines advice using waveform capnography to confirm correct tube position, but in the emergency setting this is not universally available. Continuous visualization of the airway with a video tube (VivaSight SL™) could serve as an alternative confirmation method, provided that airway structures are properly recognized. With this study we wanted to investigate whether airway management practitioners were able to recognize anatomical structures both in a circulated and in a non-circulated airway.

METHODS

Ten staff anesthetists, ten trainee anesthetists and ten paramedics were asked to examine four pictures of a circulated airway, obtained in a healthy patient and four pictures of a non-circulated airway, obtained in a human cadaver. Correct recognition of the tube position in the airway was scored.

RESULTS

Anatomic structures in the circulated airway were more often recognized than in the non-circulated airway, 90% vs. 43% respectively (P<.001). Overall, anesthetists performed better than paramedics (P=.009), but also when only pictures of the non-circulated model were taken into account (P=.007). The majority of participants and all staff anesthetists correctly recognized the vocal cords in both the circulated and non-circulated airway.

CONCLUSIONS

Pictures of a circulated airway were more often recognized than of a non-circulated airway and personnel with a daily routine in airway management performed better than personnel with less frequent exposure. Future research should determine whether continuous visualization of the airway with a video tube could reduce the number of misplaced tracheal tubes in pre-hospital airway management.

Assessment of suitability of i-gel and laryngeal mask airway-supreme for controlled ventilation in anesthetized paralyzed patients: A prospective randomized trial

CONTEXT

Laryngeal mask airway supreme (LMA-S) has an inflatable cuff while i-gel has a noninflatable cuff made of thermoplastic elastomer.

AIMS

To study the efficacy of ventilation and the laryngeal seal pressures (LSPs) with either device. Our secondary objectives were to compare the ease of insertion, adequacy of positioning the device, hemodynamic response to device insertion, and any postoperative oropharyngeal morbidity.

SETTINGS AND DESIGN

A prospective, randomized, single-blinded study at Teaching Medical School in South India.

MATERIALS AND METHODS

Forty-two patients posted for surgery under general anesthesia were randomly divided into two groups - LMA-S and i-gel. After a standardized premedication and anesthesia induction sequence, the supra-glottic devices were introduced. Ease of insertion was assessed from the number of attempts taken to insert, insertion time, and any maneuvers required to insert the device. Position of the device was assessed by the ease of gastric catheter placement and the fibreoptic grading of laryngeal visualization. Efficacy of ventilation was determined from the LSP, peak inspiratory pressure (PIP), and end-tidal carbon dioxide (EtCO2)values. Any postoperative oropharyngeal morbidity was also recorded.

STATISTICAL ANALYSIS

Descriptive analysis was reported as a mean and standard deviation, median, and range of continuous variables. Demographics were analyzed using a unpaired t-test for parametric data and Chi-square test for nonparametric data. Respiratory and hemodynamic data was analyzed using one-way ANOVA to find statistical difference within and between the two groups.

RESULTS

LMA-S was successfully inserted in 95% of patients and i-gel in 85.5% of patients. There was a significant difference (P = 0.021) in the LSPs between the two groups (18.15 cmH2O in LMA-S and 21.28 cmH2O in the i-gel group). There was no significant difference in the PIPs, leak fraction, and the EtCO2values.

CONCLUSION

Both devices are suitable for positive pressure ventilation (PPV) in anesthetized paralyzed patients. However, i-gel gives a better laryngeal seal when compared to LMA-S and may be chosen preferentially for PPV.

Comparison of the I-gel laryngeal mask airway with the LMA-supreme for airway management in patients undergoing elective lumbar vertebral surgery

BACKGROUND

The single-use supreme-laryngeal mask airway (LMA) [corrected] has been reported to be suitable for airway management in the prone position. However, there are a limited number of cases using the I-gel in the prone position. In this study, we compared the clinical use of the 2 devices in adult patients undergoing elective lumbar vertebral surgery in the prone position.

MATERIALS AND METHODS

Two hundred and sixty-four consecutive patients scheduled for lumbar surgery in the prone position were randomized to receive either the I-gel or the LMA [corrected] for airway management. All I-gels and LMAs [corrected] were inserted in the supine position by experienced anesthesiologists using standard techniques. Time and number of attempts needed for insertion, quality of ventilation, airway peak pressure, airway seal pressure, fiberoptic view, and complications were compared between the 2 groups.

RESULTS

No differences were observed in insertion time between groups. The I-gel required significantly more attempts at insertion (P<0.001). Airway seal pressure was lower in prone than in supine position in both groups (P<0.001). The I-gels provided a higher airway seal pressure ([28.4±5.4] vs. [24.8±4.6] cm H2O; P<0.001) in the prone position. There was no difference observed in fiberoptic view of the vocal cords between the 2 groups. The complication rate was low and was similar between the groups. There was little fluid in the mask of both the I-gel and the LMA [corrected] and the pH value was 6.8±0.7 versus 6.6±0.9, respectively.

CONCLUSIONS

The I-gel laryngeal mask airway can also be used safely in airway management of patients undergoing lumbar surgery in the prone position as well as the LMA [corrected].

Complications Associated with the Use of Supraglottic Airway Devices in Perioperative Medicine

Supraglottic airway devices are routinely used for airway maintenance in elective surgical procedures where aspiration is not a significant risk and also as rescue devices in difficult airway management. Some devices now have features mitigating risk of aspiration, such as drain tubes or compartments to manage regurgitated content. Despite this, the use of these device may be associated with various complications including aspiration. This review highlights the types and incidence of these complications. They include regurgitation and aspiration of gastric contents, compression of vascular structures, trauma, and nerve injury. The incidence of such complications is quite low, but as some carry with them a significant degree of morbidity the need to follow manufacturers' advice is underlined. The incidence of gastric content aspiration associated with the devices is estimated to be as low as 0.02% with perioperative regurgitation being significantly higher but underreported. Other serious, but extremely rare, complications include pharyngeal rupture, pneumomediastinum, mediastinitis, or arytenoid dislocation. Mild short-lasting adverse effects of the devices have significantly higher incidence than serious complications and involve postoperative sore throat, dysphagia, pain on swallowing, or hoarseness. Devices may have deleterious effect on cervical mucosa or vasculature depending on their cuff volume and pressure.

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

Comparison of five 2nd-generation supraglottic airway devices for airway management performed by novice military operators

OBJECTIVES

Five different second-generation supraglottic airway devices, ProSeal LMA, Supreme LMA, i-gel, SLIPA, and Laryngeal Tube Suction-D, were studied. Operators were inexperienced users with a military background, combat lifesavers, nurses, and physicians.

METHODS

This was a prospective, randomized, single-blinded study. Devices were inserted in the operating room in low light conditions after induction of general anesthesia. Primary outcome was successful insertion on the first attempt while secondary aims were insertion time, number of attempts, oropharyngeal seal pressure, ease of insertion, fibre optic position of device, efficacy of ventilation, and intraoperative trauma or regurgitation of gastric contents.

RESULTS

In total, 505 patients were studied. First-attempt insertion success rate was higher in the Supreme LMA (96%), i-gel (87.9%), and ProSeal LMA (85.9%) groups than in the Laryngeal Tube Suction-D (80.6%) and SLIPA (69.4%) groups. Insertion time was shortest in the Supreme LMA (70.4 ± 32.5 s) and i-gel (74.4 ± 41.1 s) groups (p < 0.001). Oropharyngeal seal pressures were higher in the Laryngeal Tube Suction-D and ProSeal LMA groups than in other three devices.

CONCLUSIONS

Most study parameters for the Supreme LMA and i-gel were found to be superior to the other three tested supraglottic airway devices when inserted by novice military operators.

Comparison of i-gel® and LMA Supreme® during laparoscopic cholecystectomy

Background

In laparoscopic surgical procedures, many clinicians recommend supraglottic airway devices as good alternatives to intubation. We compared the i-gel® (i-gel) and LMA Supreme® (Supreme Laryngeal Mask Airway, SLMA) airway devices during laparoscopic cholecystectomy regarding sealing pressure and respiratory parameters before, during, and after pneumoperitoneum.

Methods

Following Institutional Review Board approval and written informed consent, 93 patients were randomly allocated into the i-gel (n = 47) or SLMA group (n = 46). Insertion time, number of insertion attempts, and fiberoptic view of glottis were recorded. Oropharyngeal leak pressure (OLP), the use of airway manipulation, peak inspiratory pressure, lung compliance, and hemodynamic parameters were measured before, during, and after pneumoperitoneum.

Results

There were no significant differences between the two groups regarding demographic data, insertion time, fiberoptic view of glottis, and the use of airway manipulation. The gastric tube insertion time was longer in the i-gel group (20.4 ± 3.9 s) than in the SLMA group (16.7 ± 1.6 s) (P < 0.001). All devices were inserted on the first attempt, excluding one case in each group. Peak inspiratory pressure, lung compliance, and OLP changed following carbon dioxide pneumoperitoneum in each group, but there were no significant differences between the groups.

Conclusions

Both the i-gel and SLMA airway devices can be comparably used in patients who undergo laparoscopic cholecystectomy, and they offer similar performance including OLP.

Randomized comparison of the i-gel(TM) with the LMA Supreme (TM) in anesthetized adult patients

BACKGROUND

The LMA Supreme(TM) (LMA-S) and i-gel(TM) are two of the most commonly used supraglottic airway devices (SADs) with an inbuilt drain channel. These devices are particularly indicated for performing certain procedures accompanied by high peak airway pressure, such as laparoscopy. This study compared the devices regarding efficacy, safety, ease of use and incidence of adverse events, focusing on the postoperative rate of sore throat, dysphagia or dysphonia and development with time, in patients undergoing laparoscopic cholecystectomy procedures under general anesthesia.

METHODS

This was a prospective, randomized, controlled clinical study including 140 patients randomized into 2 groups undergoing elective laparoscopic cholecystectomy to use either i-gel or LMA-S. After the general anesthesia procedure, the speed of insertion, success rates, ease of insertion of the drain tube, leak pressure and tidal volume achieved by the devices were evaluated. The postoperative oropharyngeal discomfort (POPD) during the period of stay of the patients in the recovery room was also recorded.

RESULTS

The mean leak pressure was comparable between the two groups (i-gel 28.18 ± 3.90 cmH2O and LMA-S 27.50 ± 4 cmH2O, p = 0.09), as well as maximum expiratory tidal volume provided (i-gel 559.60 ± 45.25 ml and LMA-S 548.95 ± 56.18 ml, p = 0.12). Insertion times were lower for the i-gel (10 ± 1.62 s) compared with the LMA-S (11.31 ± 2.85 s, p = 0.008). Insertion success rate at the first attempt was higher for the LMA-S (95 % compared with i-gel 79 %, p = 0.007). Drain tubes were easier to insert in the LMA-S group (p < 0.001). No differences were found between groups relating to intraoperative complications. Frequency of coughing and visible blood on removal of the device were low and comparable in both groups (p = 0.860 and p = 0.623, respectively). There were no differences relating to the incidence of sore throat, dysphagia or hoarseness at 10 min postoperatively between groups (p = 0.088). The i-gel group complained about a higher sore throat score at 2 h postoperatively (p = 0.009), specifically patients receiving i-gel suffered more from sore throats with 0.24 more points on the visual analog scale (VAS) than patients from the LMA-S group. The i-gel group also reported a lower POPD drop during the first 2 h (p < 0.001).

CONCLUSION

No differences were found between i-gel and LMA-S regarding leak pressure in the groups of anesthetized patients undergoing laparoscopic cholecystectomy. The LMA-S was easier to insert than the i-gel (based on its better first time success rate) and this device showed better ease of drain tube insertion, although the i-gel was quicker to insert than the LMA-S. The i-gel resulted in higher sore throat scores at 2 h postoperatively and lower POPD reduction during the 2 h period studied in the recovery room was reported.

Application of the LMA-Supreme™ and i-gel™ laryngeal masks during pelvic operations in adults

OBJECTIVE

The aim of this study was to evaluate the practical application and safety of the i-gel and LMA-Supreme laryngeal masks for airway management during pelvic operations in adults.

METHODS

Ninety patients undergoing general anesthesia for elective pelvic operations (ASA Grades I-II) were randomly divided into two groups, the i-gel group and the Supreme group. The laryngeal mask was inserted after induction, and the relevant examination grading indexes were recorded.

RESULTS

The Supreme group required less time for laryngeal mask insertion and gastric tube indwelling time. Gastric tube indwelling was easier, compared with those in the i-gel group (p = 0.03), but the i-gel group had fewer complications (p = 0.03). There were no significant differences in the degree of difficulty in insertion, airway sealing pressure, PETCO2, Ppeak, and laryngeal mask alignment accuracy between the two groups (p > 0.05). There was no statistically significant difference in fibrobronchoscopy grading between the two groups (p > 0.05).

CONCLUSION

The i-gel and LMA-Supreme laryngeal masks are safe and effective for airway management in patients during pelvic operations.

Comparison of the proseal, supreme, and i-gel SAD in gynecological laparoscopic surgeries

We compared proseal, supreme, and i-gel supraglottic airway devices in terms of oropharyngeal leak pressures and airway morbidities in gynecological laparoscopic surgeries. One hundred and five patients undergoing elective surgery were subjected to general anesthesia after which they were randomly distributed into three groups. Although the oropharyngeal leak pressure was lower in the i-gel group initially (mean ± standard deviation; 23.9 ± 2.4, 24.9 ± 2.9, and 20.9 ± 3.5, resp.), it was higher than the proseal group and supreme group at 30 min of surgery after the trendelenburg position (25.0 ± 2.3, 25.0 ± 1.9, and 28.3 ± 2.3, resp.) and at the 60 min of surgery (24.2 ± 2.1, 24.8 ± 2.2, and 29.5 ± 1.1, resp.). The time to apply the supraglottic airway devices was shorter in the i-gel group (12.2 (1.2), 12.9 (1.0), and 6.7 (1.2), resp., P = 0.001). There was no difference between the groups in terms of their fiber optic imaging levels. pH was measured at the anterior and posterior surfaces of the pharyngeal region after the supraglottic airway devices were removed; the lowest pH values were 5 in all groups. We concluded that initial oropharyngeal leak pressures obtained by i-gel were lower than proseal and supreme, but increased oropharyngeal leak pressures over time, ease of placement, and lower airway morbidity are favorable for i-gel.

Transfer of airway skills from manikin training to patient: success of ventilation with facemask or LMA-Supreme(TM) by medical students

During emergency care, the ability to ventilate the patient's lungs is a crucial skill. Supraglottic airway devices have an established role in emergency care, and manikin trials have shown that placement is easy even for inexperienced users. However, there is current discussion as to what extent these results can be transferred to patients. We studied the transfer of skills learnt on a manikin to the clinical situation in novice medical students during their anaesthesia rotation. They were required to ventilate the lungs of a manikin using a facemask and then position a supraglottic airway device (LMA-Supreme™) and ventilate the lungs. This process was then repeated on anaesthetised patients, with standard ventilator settings to assess adequacy of ventilation. Sixty-three students participated in the manikin study. The success rate for ventilating the lungs was 100% for both devices, but the mean (SD) time to achieve successful ventilation was 27.8 (24.4) s with the facemask compared with 38.6 (22.0) s with the LMA-Supreme (p = 0.008). Fifty-one of the students progressed to the second part of the study. In anaesthetised patients, the success rate for ventilating the lungs was lower for the facemask, 27/41 (66%) compared with the LMA-Supreme 37/41 (90%, p = 0.006). For 26 students who succeeded with both devices, the tidal volume was lower using the facemask, 431 (192) ml compared with the LMA-Supreme 751 (221) ml (p = 0.001), but the time to successful ventilation did not differ, 60.0 (26.2) s vs 57.3 (26.6) s (p = 0.71). We conclude that the results obtained in manikin studies cannot be transferred directly to the clinical situation and that guidelines should take this into account. Based on our findings, a supraglottic airway device may be preferable to a facemask as the first choice for inexperienced emergency caregivers.

A comparison of the performance of the I-gel™ vs. the LMA-S™during anesthesia: a meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Conflicting results were found between the I-gel™ and the LMA-Supreme™ during anesthesia, so we conducted a meta-analysis of randomized controlled trials (RCTs) to compare the effectiveness and safety of the I-gel™ vs. the LMA-Supreme™during anesthesia.

METHODS

A comprehensive search was conducted using Pubmed, EMbase, ISI Web of Knowledge, the Cochrane Library, China Journal Full-text Database, Chinese Biomedical Database, Chinese Scientific Journals Full-text Database, CMA Digital Periodicals, and Google scholar to find RCTs that compare the LMA-S™ with the i-gel™during anesthesia. Two reviewers independently selected trials, extracted data, and assessed the methodological qualities and evidence levels. Data were analyzed by RevMan 5.0 and comprehensive meta-analysis software.

RESULTS

Ten RCTs were included. There were no significant differences in oropharyngeal leak pressures (mean difference [MD] 0.72, 95% confidence interval [CI] -1.10 2.53), device placement time (MD -1.3, 95%CI -4.07 1.44), first attempt insertion success (risk ratio [RR] 1.01, 95% CI 0.9 1.14), grade 3 and 4 fiberoptic view (RR 0.89, 95%CI 0.65 1.21), and blood on removal (RR 0.62, 95%CI 0.32 1.22) between the i-gel™ and the LMA-Supreme™, respectively. However, the LMA-Supreme™was associated with easier gastric tube insertion (RR 1.17, 95%CI 1.07 1.29), and more sore throat (RR 2.56, 95%CI 1.60 4.12) than the i-gel™ group.

CONCLUSIONS

The LMA-Supreme™ and i-gel™ were similarly successful and rapidly inserted. However, the LMA-Supreme™ was shown to be easier for gastric tube insertion and associated with more sore throat compared with the i-gel™.

Optimal bent length of lightwand for intubation in adults: a randomized, prospective, comparative study

OBJECTIVE

To evaluate the effect on intubation success of different bent lengths of a lightwand (a malleable illuminating stylet used for intubation), based on the patient's thyroid prominence-to-mandibular angle distance (TMD), thyroid prominence-to-incisor distance (TID) and gender.

METHODS

This prospective, randomized, blinded study included patients undergoing elective surgery. In group A, the bent length was determined based on the patient's gender. In groups B and C, the bent length was calculated according to the patient's TMD or TID, respectively. Intubation success rate, time required for intubation, haemodynamics and complications postintubation were documented.

RESULTS

A total of 246 patients were recruited and randomly assigned to one of the study groups. There were no significant differences in number of intubation attempts and success rate among the three groups. The mean time required for intubation was significantly shorter in group A than in the other groups. There were no major complications in any group.

CONCLUSIONS

Gender-determined bent length was more suitable for lightwand-guided intubation than TID or TMD. For most patients, the optimal bent length was in the range of 6.0-6.9 cm.