Successful use of the I-gel supraglottic airway as a conduit for blind pre-hospital intubation during resuscitation

Abstract

We report on a medical emergency, which was handled at dusk in the forecourt of a neighbouring rehabilitation clinic. A 58-year-old male patient, who had undergone a triple CABG-operation 11 days before, collapsed and fell on his face. Primarily, he suffered from ventricular fibrillation. Despite problematic conditions for intubation (position of the patient, lighting conditions, and intraoral bleeding), an I-gel supraglottic airway (I-gel), size 4, was easily placed without having to cease thorax compression in the neutral position. Ventilation with adequate thoracic excursion was possible without any leakage of air. Following successful defibrillation, an endotracheal tube, size 7 (Rüsch Company, Kernen, Germany) was placed without difficulty to achieve complete and successful airway management. This was done whilst bleeding persisted. During transport in the ambulance, the I-gel was left in situ in order to stabilise the tube. The I-gel was removed on the intensive care unit during endotracheal tube exchange using a COOK airway exchange catheter. The patient received an automatic implantable cardioverter-defibrillator and was discharged 2 weeks later. He sustained no neurological damage (Fig. 1). The pre-hospital use of supraglottic airways devices (SADs) is recommended as an alternative to endotracheal intubation (ETI) when managing difficult airways and when inadequately practised users attempt airway management.1Nolan J.P. Soar J. Airway techniques and ventilation strategies.Curr Opin Crit Care. 2008; 14: 279-286Crossref PubMed Scopus (56) Google Scholar However, it is still unclear which SAD is best suited for airway management during resuscitation. The advantages of the I-gel (quick insertion, high sealing pressure, high rate of success) and its safe clinical use render it interesting for potential pre-hospital use.1Nolan J.P. Soar J. Airway techniques and ventilation strategies.Curr Opin Crit Care. 2008; 14: 279-286Crossref PubMed Scopus (56) Google Scholar, 2Gabbott D.A. Beringer R. The iGel supraglottic airway: a potential role for resuscitation?.Resuscitation. 2007; 73: 161-162Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar So far, there have been few case reports that assessed the pre-hospital use of the I-gel. Leakage of air due to exceeding the airway leak pressure was reported as a problem.3Thomas M. Benger J. Pre-hospital resuscitation using the iGEL.Resuscitation. 2009; 80: 1437Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar In our case, however, ventilation was performed without difficulty. Generally, SADs should allow secondary ETI. In a comparative investigation, where applying a neck collar simulated a difficult airway, there was a better fibre optic view of the glottis when using the I-gel.4Theiler L.G. Kleine-Brueggeney M. Kaiser D. et al.Crossover comparison of the laryngeal mask supreme and the I-gel in simulated difficult airway scenario.Anesthesiology. 2009; 111: 55-62Crossref PubMed Scopus (123) Google Scholar Another investigation studied blind intubation on an airway management trainer. When using the I-gel, the rate of success was only between 47% and 64%. The relatively straight shaft of the I-gel was considered as a potential cause since it does not actively aid the tube passing anteriorly when exiting the I-gel.5Michalek P. Donaldson W. Graham C. Hinds J.D. A comparison of the I-gel supraglottic airway as a conduit for tracheal intubation with the intubation laryngeal mask airway: a manikin study.Resuscitation. 2010; 81: 74-77Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar In general, the I-gel should not be used for blind intubation. However, if ETI is required in a pre-hospital setting where no fibre optic equipment is available, blind intubation through the I-gel could still be considered. Further clinical investigations should determine if the use of different types of endotracheal tubes could enhance the rate of success when performing blind intubation via the I-gel in an emergency situation. Neither author has a conflict of interest to declare.