|Year : 2016 | Volume
| Issue : 3 | Page : 138-142
The advantages of i-gel mask for tube exchange in asthmatic pediatric patients during emergence from general anesthesia
Eslam N Nada, Gehan F Ezz
Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Egypt
|Date of Submission||11-Feb-2016|
|Date of Acceptance||11-Jul-2016|
|Date of Web Publication||4-Nov-2016|
Eslam N Nada
Mohafza Street, El Hedaya Tower, El Sharkia, Zagazig, 44519
Source of Support: None, Conflict of Interest: None
A prospective randomized study was carried out to study the advantages of tube exchange with intersurgical gel (i-gel) during recovery stage in asthmatic children.
Patients and methods
A total of 40 ASA II patients aged between 3 and 12 years suffering from bronchial asthma, excluding patients with difficult airway, were divided into two groups of 20 patients each. After completion of surgery, the tube was left in group I till awakening, whereas in group II the i-gel mask was used for tube exchange during recovery and before discontinuation of anesthesia.
There was a significant difference between both groups regarding hemodynamics and incidence of complications in favor of the i-gel group.
Recovery with i-gel mask in asthmatic children is more smooth and less stressful than recovery with endotracheal tube, as well as with less complications.
Keywords: bronchial asthma, i-gel, pediatric anesthesia, tube exchange
|How to cite this article:|
Nada EN, Ezz GF. The advantages of i-gel mask for tube exchange in asthmatic pediatric patients during emergence from general anesthesia. Res Opin Anesth Intensive Care 2016;3:138-42
|How to cite this URL:|
Nada EN, Ezz GF. The advantages of i-gel mask for tube exchange in asthmatic pediatric patients during emergence from general anesthesia. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2020 Jun 4];3:138-42. Available from: http://www.roaic.eg.net/text.asp?2016/3/3/138/193405
| Introduction|| |
Bronchial asthma is a major public health problem with increasing prevalence and severity worldwide. Bronchial hyperactivity associated with asthma is an important risk factor of perioperative bronchospasm, a potentially life-threatening condition in anesthesia, especially in pediatric anesthesia. This bronchospasm can be provoked by laryngoscopy, tracheal intubation, airway suctioning, cold inspired gas, and tracheal extubation ,,.
Complications are more common during endotracheal extubation than during intubation, such as coughing, bucking, or hemodynamic changes.
Bronchospasm represents a life-threatening complication that needs accurate attention during the entire perioperative period. Therefore, many maneuvers are undertaken to reduce these complications, such as deep extubation or by using hemostabilizing drugs .
Another safe maneuver is to replace the endotracheal tube (ETT) with i-gel before emergence from anesthesia. I-gel is one of the second-generation supraglottic airway devices. It is a truly anatomical, noninflatable device, which is made of a soft, gel-like, and transparent medical-grade thermoplastic elastomer with an esophageal vent. It is designed to conform anatomically the perilaryngeal and hypopharyngeal structures obviating the need for an inflatable cuff .
Many comparative studies have showed that the i-gel mask is superior to other supraglottic airway devices in being easier to insert with shorter insertion time ,, and superior in providing high leak pressure, less nausea and vomiting, less airway trauma, and less incidence of sore throat ,,,.
The aim of this study was to evaluate the advantages of tube exchange with intersurgical gel (i-gel) during recovery stage in asthmatic children.
| Patients and methods|| |
After obtaining approval from the hospital ethics committee, written informed consent was obtained from parents or guardians of the patients. A total of 40 ASA II asthmatic children, aged between 3 and 12 years, and with 10–35 kg body weight were selected for elective surgery in Zagazig University Hospital. Patients with predicted difficult airway were excluded from the study.
These patients were randomly divided into two groups of 20 patients using closed envelops.
Group I: An ETT was used for anesthesia from the start of operation till recovery of patients and awakening.
Group II: An i-gel supraglottic airway device was used for exchange of ETT in the recovery stage.
Patients were preoxygenated for 3 min with 100% oxygen; propofol 2 mg/kg, fentanyl 1 μg/kg, and esmeron 1 mg/kg were administered at induction. An ETT of suitable size for age and weight was inserted.
Anesthesia was maintained with O2-isoflurane and with intermittent positive pressure ventilation and complete muscle relaxation with esmeron with top-up doses 0.3 mg/kg.
After conclusion of surgery, suction of secretions was performed. In group I (n=20), the ETT was retained until complete awakening and recovery of patients. In group II (n=20), an i-gel supraglottic airway device of suitable size for age and weight was replaced with ETT (i-gel/ETT exchange).
In group II, the ease of i-gel insertion was recorded. Anesthesia was discontinued, and neuromuscular blocker reversal was performed using 0.05 mg/kg neostigmine and atropine of 0.04 mg/1 mg neostigmine.
Ventilation was assisted until regain of spontaneous respiration and adequate tidal volume, confirmed clinically with capnography.
In group I, removal of ETT was performed after the patient gained consciousness. Similarly, in group II, the i-gel was removed the patient gained consciousness. In both groups, all patients were monitored from the start of operation until recovery with ECG, pulse oximeter, noninvasive blood pressure monitor, and capnography.
In group I, pre-extubation systolic blood pressure (SBP) was measured, and then immediately after removal of ETT (within 1 min before and after extubation). In addition, heart rate (HR) was monitored before and after extubation.
In group II, SBP at the time of tube exchange with i-gel was recorded with HR (immediately before and after exchange). SBP and HR were monitored continuously from time of i gel insertion to time of complete recovery from anesthesia ,with recording their readings within 1 minute before and 1 minute after i gel removal.
Any episode of complications including spasm, coughing, bucking, and need for reintubation was recorded in both groups during recovery.
The primary outcome of the present study was the difference in hemodynamic stability between the two groups, and the secondary outcome was the incidence of complications in both groups.
A sample size of 15 patients was needed in each group to achieve 80% power to detect 50% difference in hemodynamic stability between both groups. Twenty patients were included per group to replace any dropouts and to increase the power of secondary outcomes.
Dropouts included surgical complications, unstable hemodynamics, or failure of i-gel insertion.
Collected data were analyzed using a database software program (version 14.0; SPSS Inc., Chicago, Illinois, USA). Data are expressed as mean±SD or as number and percentage. χ2-Test and paired t-test were performed. P value less than 0.05 was considered to be statistically significant.
| Results|| |
There were no statistically significant differences between patients regarding age (P=0.7) and sex (P=0.196). All patients were ASA II ([Table 1]).
In addition, there was no significant difference in time of operation between the two groups (P=1).
In group I, there was a significant difference in HR (P=0.0001) immediately before and after extubation, and the same was observed for SBP (P=0.0001) ([Table 2]).
|Table 2: Comparison between heart rate and systolic blood pressure before and after extubation during awakening in group I|
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In group II, there was a nonsignificant difference in HR (P=0.682) immediately before and after i-gel insertion, and the same was observed for SBP (P=0.535) ([Table 3]).
|Table 3: Comparison of heart rate and systolic blood pressure at the time of exchange in group II (i-gel insertion)|
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In group II, there were significant differences in both HR (P=0.005) and SBP (P=0.01) before and after removal of i-gel, but these changes were lesser than that seen in group I for HR and SBP ([Table 4]).
|Table 4: Comparison between heart rate and systolic blood pressure before and after i-gel removal on awakening in|
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Considering comparison of HR and SBP between the two groups, there were no significant differences between both groups neither in HR (P=0.632) nor in SBP (P=0.14) before airway device removal (ETT in group I or i-gel in group II) ([Table 5]).
|Table 5: Comparison of heart rate and systolic blood pressure before tube/i-gel removal on awakening between both groups|
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There were significant differences between the two groups in HR (P=0.0001) and SBP (P=0.001) immediately after ETT in group I and i-gel in group II ([Table 6]).
|Table 6: Comparison of heart rate and systolic blood pressure after tube/i-gel removal on awakening between both groups|
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The success rate for i-gel insertion in group II was 100% from the first attempt.
Considering complications (cough and spasm) and the need for reintubation, we noticed the following ([Table 7]):
- There was a significant difference between the two groups in the incidence of complications (cough and spasm) (P=0.025).
- The incidence of spasm alone showed a significant difference between the two groups (P=0.037). Despite the fact that the incidence of need for reintubation was nonsignificant between both groups (P=0.29), the need for reintubation was higher in group I.
- The incidence of cough showed a nonsignificant difference between both groups (P=0.465) with higher incidence in group I.
|Table 7: Comparison of complications (cough/spasm) and need for reintubation between both groups|
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| Discussion|| |
Childrenwith bronchial asthma are more likely to develop several complications during anesthesia, the most significant one being bronchospasm, which is recognized by bilateral expiratory wheezes, prolonged expiration, active expiration with increased expiratory efforts, increased airway pressure, rising end-tidal CO2, and possibly hypoxemia .
Supraglottic airway devices have several advantages including lower incidence of sore throat , less hemodynamic changes during induction and maintenance of anesthesia , and better oxygenation during emergence .
I-gel is one of the second-generation supraglottic airway devices that is truly anatomical and noninflatable, made up of a soft, gel-like, and transparent medical-grade thermoplastic elastomer with an esophageal vent .
In our study, with the use of i-gel mask in group II, we found that insertion of i-gel was easy, and the success rate of insertion from the first attempt was 100%. This is in agreement with Chauhan et al.  and Theiler et al.  who found that i-gel airway provides an easy and rapid insertion technique with lower postoperative complications and adverse effects.
We exchanged the ETT with i-gel in group II after completion of surgery and before discontinuation of anesthesia with no obvious hemodynamic changes due to deep extubation and deep i-gel insertion.
In group I, there was a significant difference in SBP and HR before and after extubation, which is in agreement with the study of Asai et al. ; Singh et al.  and Shajar et al.  who demonstrated that extubation is associated with significant hemodynamic changes that can be reduced by drugs or deep extubation.
On the other hand, in group II, there was also a significant difference between HR and SBP before and after removal of the i-gel, but it was less significant compared with group I.
This is because the supraglottic devices as we mentioned before have lower incidence of hemodynamic changes compared with the ETT .This comparison became very obvious when comparing SBP and HR between groups I and II after removal of the tube and i-gel, respectively, as it showed a significant difference in hemodynamics between both groups.
Considering complications at recovery in the form of cough or spasm, of which some needed reintubation, significant differences were observed between both groups with lower incidence in group II.
The incidence of spasm alone showed a significant difference between the two groups with more incidence in group I, but the incidence of cough alone showed a nonsignificant difference between the two groups, although it was higher in group I.
The same held for the incidence of reintubation, which showed a nonsignificant difference between the two groups, but with higher incidence in group I.
At the end, although the ETT is the gold standard for airway maintenance, it is associated with many complications during both intubation and extubation, including trauma, hemodynamic instability, airway spasm, sore throat, esophageal intubation, and hypoxia ,.
Therefore, the laryngeal mass airway was introduced as an acceptable alternative to ETT in selected cases because of its ease of insertion and less hemodynamic instability ,,; however, there are still problems with its use, including incorrect placement, sore throat, risk of aspiration, air leak, and laryngospasm .
These problems are minimal with i-gel because it is anatomically designed with a noninflatable cuff and with an esophageal vent, reducing the risk of gastric distension and aspiration; in addition, it has a lower incidence of nausea and vomiting, sore throat, and airway trauma ,,.
We recommend the use of i-gel mask for tube exchange in asthmatic pediatric patients during emergence from general anesthesia for better hemodynamic stability and less complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hepner DL, Castells MC. Anaphylaxis during the perioperative period. Anaesth Analg 2003; 97:1381–1395.
Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth 1998; 80:767–775.
Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J Anaesth 2009; 103: Suppl 1:57–65.
Richez B, Saltel L, Banchereau F, Torrielli R, Cros AM A new single use supraglottic airway device with a noninflatable cuff and an esophageal vent: an observational study of the i-gel. Anesth Analg 2008; 106:1137–1139.
Chauhan G, Nayar P, Seth A, Gupta K, Panwar M, Agrawal N. Comparison of clinical performance of the i-gel with LMA proseal. J Anaesth Clin Pharmacol 2013; 29:56–60.
Theiler L, Gutzmann M, Kleine-Brueggeney M, Urwyler N, Kaempfen B, Greif R i-gel™ supraglottic airway in clinical practice: a prospective observational multicentre study. Br J Anaesth 2012; 109:990–995.
Weber U, Oguz R, Portura LA, Kimberger O, Kober A, Tschernko E. Comparison of the i-gel and the LMA unique laryngeal mask airway in patients with mild to moderate obesity during elective short-term surgery. Anesthesia 2011; 66:481–487.
Heuer JF, Stiller M, Rathgeber J, Eich C, Züchner K, Bauer M, Timmermann A Evaluation of the new supraglottic airway devices Ambu AuraOnce and Intersurgical i-gel. Positioning, sealing, patient comfort and airway morbidity. Anaesthesist 2009; 58:813–820.
Siddiqui AS, Ahmed J, Siddiqui SZ, Haider S, Raza SA New single use supraglottic airway device with non-inflatable cuff and gastric tube channel. J Coll Physicians Surg Pak. 2012; 22:419–423.
Roberts G, Newsom D, Gomez K, Raffles A, Saglani S, Begent J et al.
, North West Thames Asthma Study Group Intravenous salbutamol bolus compared with an aminophylline infusion in children with severe asthma: a randomised controlled trial. Thorax 2003; 58:306–310.
Higgins PP, Chung F, Mezei G. Postoperative sore throat after ambulatory surgery. Br J Anaesth 2002; 88:582–584.
Dyer RA, Liewellyn RL, James MF. Total IV anaesthesia with propofol and the laryngeal mask for orthopaedic surgery. Br J Anaesth 1995; 74:123–128.
Webster AC, Morley-Forster PK, Dain S, Ganapathy S, Ruby R, Au A, Cook MJ Anaesthesia for adenotonsillectomy: a comparison between tracheal intubation and the armoured laryngeal mask airway. Can J Anaesth 1993; 40:1171–1177.
Singh H, Vichitvejpaisal P, Gaines GY, White PF Comparative effects of lidocaine, esmolol, and nitroglycerin in modifying the hemodynamic response to laryngoscopy and intubation. J Clin Anesth 1995; 7:5–8.
Shajar MA, Thompson JP, Hall AP, Leslie NA, Fox AJ Effect of a remifentanil bolus dose on the cardiovascular response to emergence from anaesthesia and tracheal extubation. Br J Anaesth 1999; 83:654–656.
Souza N, Carvalho WB. Complications of tracheal intubation in pediatrics. Rev Assoc Med Bras 2009; 55:646–650.
Takahata O, Iwasaki H. Problems and complications in airway management by endotracheal intubation and laryngeal mask airway. Masui 2006; 5544–50
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]