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• W2071784410 abstract "Editor, Among the various supraglottic airway devices (SADs) used routinely in clinical practice for airway management, the I-Gel (Intersurgical Ltd, Fontenay sous Bois, France) has been recently demonstrated to have a better fit to the hypopharyngeal and perilaryngeal structures.1,2 The I-Gel is a single-use, latex-free SAD, which includes a noninflatable cuff, an integral bite block and a gastric drain tube.3 Studies performed in children demonstrate a relatively lower success rate of insertion at first attempt4 and a tendency towards a systematic upward displacement after insertion.5 Therefore, we designed this observational study in order to elucidate the intimate mechanisms responsible for this displacement by performing a fibreoptic assessment of the positioning of the I-Gel following insertion. After approval by our institutional ethics committee (Angers, no. 2010/10, 20 April 2010) and parental informed consent, 73 consecutive children (under 35 kg) requiring general anaesthesia with the need for SAD were included in the study. All children received midazolam (0.3 mg kg−1) 30 min prior to induction of anaesthesia, which was performed with sevoflurane. The choice of maintenance anaesthetics (sevoflurane or propofol) and method of perioperative pain control (sufentanil, alfentanil or regional anaesthesia) was left to the discretion of each anaesthesiologist. Muscle relaxants were not administered, although ketamine was allowed as an adjuvant to the analgesia management. Once a stable, adequate depth of anaesthesia was achieved (loss of eyelash reflex, no response to jaw thrust), the I-Gel was inserted in the sniffing position by an anaesthesiologist or a nurse anaesthetist trained in I-Gel use. The I-Gel size was chosen to fit the child's weight (size 1 to 2.5) in accordance with the manufacturer's instruction. Following insertion, assessment of the presence of airway leak was achieved under spontaneous ventilation mode by setting fresh gas flow to 3 l min−1 and the pressure release valve to 30 cm H2O. A leak heard at a pressure below 30 cm H2O led to replacement of the airway device by a larger one. Thereafter, an endoscope (Pentax Life Care, Argenteuil, France; FB 10 V, 3.6 mm external diameter) was inserted up to the distal tip of the I-Gel airway to assess its position in relation to the larynx. The evaluation of the correct position was accomplished using the fibreoptic score suggested by Cook and Cranshaw6 (Fig. 1), which is characterised by three grades: view I (I, ideal positioning) for an I-Gel centred on the larynx and allowing a clear view of the whole laryngeal structure (grade 1)6 view L (L, low positioning) where the I-Gel is positioned too low by reference to the ideal view I, and allowing a view of the posterior pharynx with a pulled down epiglottis (grade 2)6 view H (H, high positioning) for an I-Gel positioned too high by reference to view I, and with the epiglottis being the only visible structure (grade 3)6 FigureIn the hypothesis of misplacement detected during fibreoptic evaluation, we proceeded to a replacement of the I-Gel even in the presence of effective ventilation. We then confirmed the correct positioning by repeating the fibreoptic evaluation. Seventy-three children (ASA I or II) were included [sex ratio: 62 boys/11 girls; median age (interquartile range, IQR): 3 years (6 to 60 months), mean weight of 14.5 kg ± 8, mean duration of surgery: 46 min ± 16]. In the present study, the I-Gel was always inserted at the first attempt. Patients were ventilated in pressure controlled mode (VT ≥6 ml kg−1, EtCO2 30 to 35 mmHg). Median end-tidal peak (IQR) and airway leak pressure were 13 (12 to 15) cm H2O and 24 (20 to 27) cm H2O, respectively. Median difference (IQR) between peak and leak pressures was 11 (9 to 14) cm H2O. The main clinical and endoscopic findings are summarised in Table 1. The fibreoptic evaluation revealed that 85% (n = 62) of the I-Gel offered an ‘ideal’ view of the larynx (view I). This ‘ideal’ view was slightly deviated from the middle mostly rightward in 22% of the cases, particularly in children younger than 4 years of age (n = 10). Suboptimal positioning of SAD (view H or view L) after initial placement or after repositioning for leaks was seen in 10 children (14%), but it never precluded effective controlled ventilation. The arytenoids were not or badly visible (view H) in two cases (3%). The epiglottis was partially pulled down (view L) in eight cases (11%), including two cases in whom epiglottis was folded without impeding breathing. Finally, the view of the vocal cords revealed a fully open positioning in 72% of the cases (n = 51), partially closed vocal cords in 7% (n = 5) and were mobile in the remaining 21% of the cases (n = 15).Table 1: Distribution of endoscopic views at first insertion, according to I-Gel sizeThe present observational study confirms the good tolerance and clinical efficacy of the I-Gel in children with a wide age range. Fibreoptic assessment revealed that suboptimal positioning did not impede ventilation. Moreover, in the situation in which suboptimal positioning was deemed to justify I-Gel replacement or repositioning, an ideal placement could not be guaranteed. Therefore, we can declare that despite a wide variability in the anatomical laryngeal placement of the I-Gel, this airway device appears to provide well tolerated and efficient ventilation when used for airway management in children. Acknowledgements Assistance with the article: none declared. Financial support and sponsorship: This work was supported by the Department of Anaesthesiology, CHU d’Angers, Angers, France. Conflicts of interest: none declared." @default.
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• W2071784410 date "2013-07-01" @default.
• W2071784410 modified "2023-10-06" @default.
• W2071784410 title "Fibreoptic assessment of laryngeal positioning of the paediatric supraglottic airway device I-Gel" @default.
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• W2071784410 doi "https://doi.org/10.1097/eja.0b013e32835f9969" @default.
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