Reverse technique for I-gel supraglottic airway insertion

Sir,

The I-gel^™ (Intersurgical Ltd, Wokingham, UK) is a single-use extraglottic airway device with a non-inflatable cuff and an esophageal vent.[¹] The device is used for maintaining the patency of airway during cardiopulmonary resuscitation for short surgical procedures and as a conduit for endotracheal tube insertion in difficult airway. I-gel has been compared with other extraglottic airway devices for ease of insertion. Most airway training manikin studies report a high success rate of >95%, even by inexperienced personnel.[¹²] When I-gel was used for airway management in adult patients, a first time success rate of 86% has been reported.[³] Authors required 53 manipulations in 26 patients to achieve a clear airway. A problem of tongue folding during I-gel placement has been reported, though the patient had adequate mouth opening and full set of dentition.[⁴]

We successfully used the reverse insertion technique for I-gel airway in a 30-year-old woman, scheduled for hysteroscopic dilatation and curettage. The technique has been previously described for the insertion of Guedel's airway and classic Laryngeal Mask Airway (LMA).[⁵] Our patient received an induction dose of propofol, and I-gel was initially inserted orally using the standard insertion technique. However, the device could not be positioned properly due to repeated tongue folding. A reverse insertion technique, as reported for classic LMA, was then tried. The I-gel was inserted with concavity facing toward the hard palate. On reaching oropharynx, the device was rotated 180° and placed in its final position to facilitate positive pressure ventilation. This method is easy to use, atraumatic, and may be used for I-gel insertion if first attempt by classic technique fails.