The use of supraglottic I-gel airway

as a conduit for fiberoptic guided

and blind intubation in children
Thesis submitted for partial fulfillment of Doctorate degree in
Anesthesiology & Intensive care
 
By
 Amr Galal EL-Sherbeny
Cairo University
Review of literature
Airway complications are feared by anaesthetists:
They may occur under elective conditions.

They require immediate management to avoid severe hypoxic sequelae.


They also represent one third of claims in adult patients and in pediatrics, they are the most
common causes of morbidity and mortality.

Pediatrics are not small adults.

So that:
A Detailed knowledge of the normal pediatric airway is so important.
 Supraglottic Airway Devices(SADs)
They are designed to maintain a clear airway while sitting
above and creating a seal around the larynx.

 They may be used:

 In elective surgeries.
 In failed tracheal intubation.
 In emergencies e.g.CPR.
 As a conduit for tracheal intubation.
:Classification of SADs
 First generation e.g. LMA Classic
LMA unique
LMA Fastrach

 Second generation e.g. I-gel

LMA Proseal
LMA Supreme
Air-Q
Ambu Aura-I &Ambu AuraGain
 Third generation SADs:
E.g The Baska mask
I-gel
Fiberoptic Bronchscopy
Aim of the work
 Aim of the work
 To compare between the use of I-gel as a conduit for
.blind intubation &fiberoptic guided intubation in children

 We also aim to validate the use of I-gel as a conduit for

blind intubation in absence of fiberoptic or lack of
experience of its use.
PATIENTS AND METHODS
 :Exclusion criteria :Inclusion criteria

Known difficulty of intubation

PATIENTS :- A randomized, controlled study was conducted at Children Hospital of Cairo University hospitals after research ethics approval , 88 children scheduled for elective were enrolled in the study . patients were assigned in one of the two groups,(blind and control group).

ASA physical status(I-II)

Emergency surgeries Age: 2-6 years

Risk of aspiration e.g. full stomach

Respiratory tract infections

Mangement of anesthesia
Children were premedicated with midazolam(0.5mg/kg)-1
.and atropine(0.1mg/kg)
Non invasive monitoring was applied. -2
3-Induction of anesthesia either inhalational(sevoflurane
.+O2 or intravenous
After deepening of anesthesia;fentanyl(2ug/kg) &– 4
atracurium(0.5mg/kg) are given
.Appropriate-sized supraglottic I-gel was inserted -5
Adequate ventilation was confirmed by capnography and-6
.adequate chest expansion
. I-gel was secured-7
 Blind group(B)
An appropriate-sized E.T.T was
.introduced through I-gel blindly
Only smooth intubation without force is
allowed.
Only one attempt of blind intubation was After insertion of E.T.T & confrmation
allowed.
Control group(C)
A pediatric fiberscope was
primed with an appropriate-sized
.E.T.T
The fiberscope was introduced
through I-gel and guide tracheal
.intubation
of the position,the fiberscope was
.removed
:In both groups
 A second person was present to stabilize the I-gel in
the set position to prevent unintentional movement
during the intubation procedure & removal of I-gel.
 E.T.T insertion was confirmed by capnography,
fiberscope, bilateral chest auscultation ,after
connecting the breathing circuit.
 I-gel was withdrwan with the aid of a stylet(stabilizer)
in a continous push-pull movement.
 Outcomes
Primary outcome Secondary outcome
The success rate of first attempt The success rate of I-gel insertio-1
intubation. Number of trials of I-gel-2
.insertion
.Time taken for I-gel insertion-3
.Time taken for E.T.T insertion-4
Adverse events during insertion-5
and removal of I-gel e.g.
.aspiration ,laryngospasm
postoperative dysphagia,sore-6
throat and hoarseness of voice
Results
Statistical analysis
Statistical package for social science (SPSS) software Microsoft-1
Windows was used for data analysis
Data distribution was assessed for normality using Kolmogorov-Smirnov-2
test and was presented as mean (standard deviation) , median
.(interquartile range) and percentage
Comparison of the means of the study groups using student t-test or-3
.Mann Whitney test
Comparison of the categorical data using chi square(x2)test or fisher-4
.exact test
;In all stastistical tests
.The level of significance will be fixed at the 5%level
.A probability (P value)>0.05…………no significant difference
.0.05…………significant difference< )P value(
:Demographic and clinical data of studied cases

Both groups were comparable with

regard to:
demographic data.
Type of operations.
Success rate of intubation
*There was statistically difference between the two groups(P <0.001)
  Blind group control group Relative risk
)n=44( )B( )n=44( )C(
Intubation )57 -29( 43% )91-100( 100% )0.6 -0.3( 0.43
success
p e r c e n ta g e o f in t u b a t io n s u c c e s s

Intubation success
100%
90%
80%
70%
60%
Intubation success
50%
40%
30%
20%
10%
0%
Blind group Control group
Time to I-gel & E.T.T insertion
Blind group(B) Control group(C) P value

Time to I-gel insertion 12±2.2 12.1±2.1 0.7

Time to E.T.T insertion 41.1±9.6 29±8.5 0.001<

 :Finally
I-gel insertion was easy with only single
trial in all groups and there wasn’t any
recorded complications occurred with I-gel
.insertion and ETT insertion
 
 
DISCUSSION
I-gel has been used as a conduit for tracheal
intubation with of fiberoptic bronchscope in
several studies e.g. Shimizu M. et al in their
study
(Fiberoptic-guided tracheal intubation
through I-gel supraglottic airway)
e.g. Julian A. et al in their study
(Fiberoptic-guided intubation after insertion of the
I-gel airway device in spontaneously breathing
patients with difficult airway predicted)
But limited studies regarding blind intubation in
pediatrics.
 In this study , we found that the blind
intubation through I-gel is considered inferior
to fiberoptic guided intubation through I-gel
in children aged 2-6 years regarding the
success rate (43%&100&respectively) and
time of E.T.T insertion (41 sec.&24
sec.respectively).
I-gel insertion was easy(~12 sec.)with only
single trial with no recorded complications.
 Like our study [with] Unlike our study[against

Like our study, Sameer et al had Bharat et al had reached a 75% at first
reported that I-gel is an inferior device attempt blind intubation through I-
for blind intubation in comparison gel.investigated a stroke volume variation-
with the LMA Fastrach in age group(18- .guided protocol in brain surgeries
. 60) with a success rate of 66% Geeta et al had reached a 95% at first
Pavel et al reported that blind attempt blind intubation through I-gel
intubation through I-gel showed a low
success rate,While fiberoptic
intubation through both ILMA&I-gel
is a highly successful technique
Sastre et al reached a success rate
of 40%for blind intubation through I-
.gel in adults
Aya et al reported that I-gel is a good
conduit for fiberoptic guided
.intubation in pediatrics
Jagannathan et al concluded that I-gel
is a good conduit for fiberoptic guided
. intubation in children
Conclusion
 Our study is considered a step in the management of difficult airways especially

in pediatrics ,Although Blind intubation through I-gel in pediatrics obtained a

poor success rate, our study introduce that idea which may be applicable with

other devices and in different age groups.

 I-gel is considered a perfect conduit for fiberoptic guided endotracheal

intubation in that age group and the application of fiberoscope through I-gel

makes a good access to the vocal cords with no need for excessive manipulations

which makes it a practical technique in the hands of anesthesiologists

especially unexperienced.


Recommendations
We recommend in the further studies
to be applied on difficult airways to
assess the success rate in these cases
and to use different SADs in pediatric
population and assessing their success
rate as a conduit for endotracheal
intubation.
THANK YOU