|Year : 2016 | Volume
| Issue : 3 | Page : 143-150
Fiberoptic assessment of air-Q, i-gel, and ProSeal position during laparoscopic cholycystectomy
Ragab M Khattab1, Magdy A Mansour2, Ihab I Moharram2, Rana Abo-Alsoud El-Din Abo-Alsoud2
1 Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Medical Research Institute, University of Alexandria, Alexandria, Egypt
2 Department of Anaesthesia, Medical Research Institute, University of Alexandria, Alexandria, Egypt
|Date of Submission||18-Mar-2016|
|Date of Acceptance||23-Jun-2016|
|Date of Web Publication||4-Nov-2016|
Rana Abo-Alsoud El-Din Abo-Alsoud
313 Taksim Elkoda, Smouha, Sidi Gaber, Alexandria
Source of Support: None, Conflict of Interest: None
The cuffed tracheal tube was considered the gold standard in laparoscopic surgeries but it has many disadvantages. Several studies have reported the successful safe use of the supraglottic airway devices in patients undergoing laparoscopic surgery.
Aim of the work
This study was carried out to compare the fitting of i-gel, air-Q, and ProSeal supraglottic airway devices during laparoscopic cholycystectomy before and after pneumoperitoneum using a fiberoptic bronchoscope.
Patients and methods
This study was conducted on 60 adult patients undergoing elective laparoscopic cholycystectomy. Patients were selected for airway management with either i-gel (Intersurgical LTD, Wokingham, Berkshire, UK) (group I), air-Q (Cookags LLC, Mercury Medical, Clearwater, FL, USA) (group II), or ProSeal (Intavent Orthofix, Maidenhead, UK) (group III) using the closed envelop method. They were divided into three equal groups (20 patients in each group). Fiberoptic assessment was carried out before and after pneumoperitoneum in the supine position.
There was no significant difference in fiberoptic grading between the three groups before insufflation, but after insufflation the fiberoptic grading of air-Q and proseal laryngeal mask airway (PLMA) was significantly better than that of i-gel (P=0.014 and 0.028, respectively). As regards leak volume, there was no significant difference between the three groups before insufflation. However, there was a significantly greater leak with i-gel in comparison with air-Q and PLMA (P=0.040 and 0.010, respectively) after insufflation. There was no significant difference in number of attempts to insertion on comparing the three groups. As regards intraoperative airway intervention, less intervention was observed with i-gel and PLMA in comparison with air-Q (P=0.017 and 0.027, respectively). With regard to airway sealing quality, there was better sealing with air-Q and PLMA in comparison with i-gel (P=0.018 and 0.047, respectively). There was significantly greater complication with air-Q in comparison with both i-gel and ProSeal (P=0.013 and 0.038, respectively).
Keywords: air-Q, fiberoptic, i-gel, laparoscopic cholycystectomy, ProSeal
|How to cite this article:|
Khattab RM, Mansour MA, Moharram II, El-Din Abo-Alsoud RA. Fiberoptic assessment of air-Q, i-gel, and ProSeal position during laparoscopic cholycystectomy. Res Opin Anesth Intensive Care 2016;3:143-50
|How to cite this URL:|
Khattab RM, Mansour MA, Moharram II, El-Din Abo-Alsoud RA. Fiberoptic assessment of air-Q, i-gel, and ProSeal position during laparoscopic cholycystectomy. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2020 Jun 4];3:143-50. Available from: http://www.roaic.eg.net/text.asp?2016/3/3/143/193407
| Introduction|| |
Laparoscopic surgery aims to minimize trauma of the interventional process but still achieve a satisfactory therapeutic result. Laparoscopic cholecystectomy procedure offers several advantages such as a reduction in stress response, postoperative pain, postoperative wound infection rate, intraoperative bleeding, impairment of respiratory function, pulmonary complications, short recovery time, cosmetic appearance, and hospital stay ,,.
The use of supraglottic airway devices (SADs) under conditions of elevated intra-abdominal pressure requires an excellent airway seal to divide the respiratory and alimentary tracts in a reliable manner due to the potential risk for regurgitation ,. Endotracheal intubation was regarded as the gold standard in the management of the airway during laparoscopic surgery. However, the gold lost its glitter in the light limitations such as failed tracheal intubation, the ‘can’t intubate, can’t ventilate’ situation, patient refusal of advised awake fiberoptic-assisted intubation, airway problems following extubation, and dental damage ,. Current practice has shown an increased usage of SADs in low-risk elective laparoscopic surgery in view of less airway trauma , better hemodynamic changes during insertion, maintenance of anesthesia ,, and better oxygenation during emergence .
The use of fiberoptic bronchoscopy [Figure 1] to facilitate endotracheal intubation is the gold standard in cases with difficult airways. It consists of a bundle of flexible glass fibers able to coherently transmit an image ,.
|Figure 1: (a) Components of fiberoptic bronchoscope. 1, Eye piece; 2, diopter ring for focusing; 3, control lever; 4, working channel port; 5, body; 6, insertion cord; 7, light source; and 8, suction valve and port. (b) Fiberoptic bronchoscope. 1, Eye piece; 2, diopter ring for focusing; 3, control lever; 4, working channel port; 7, light source; 8, suction valve and port.|
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The i-gel airway [Figure 2] is a supraglottic airway management device made of thermoplastic elastomer, which is soft, gel-like, and transparent. It was designed to create a noninflating anatomical seal of the pharyngeal, laryngeal, and perilaryngeal structures while avoiding the compression trauma that can occur with inflatable SADs ,. The i-gel has evolved as a device that accurately positions itself over the laryngeal framework, providing a reliable perilaryngeal seal, and therefore no cuff inflation is necessary . Its advantages include easier insertion, minimal risk for tissue compression, and stability after insertion. An integrated gastric channel can provide an early indication of regurgitation, facilitates venting of gas from the stomach, and allows for the passing of a nasogastric tube to empty the stomach contents .
PLMA [Figure 3] has a dorsal cuff, in addition to the peripheral cuff of LMA, which pushes the mask anterior to provide a better seal around the glottic aperture and permits high airway pressures without leak. The drain tube parallel to the ventilation tube permits drainage of passively regurgitated gastric fluid away from the airway and serves as a passage for gastric tube .
|Figure 3: (a) The ProSeal laryngeal mask airway. (b) The ProSeal laryngeal mask airway.|
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The air-Q [Figure 4] is a new SAD intended for use as a primary airway and an aid for tracheal intubation in situations of anticipated or unanticipated difficult airways. Its design includes a large airway tube inner diameter, a short airway tube length, and a tethered, removable standard 15 mm circuit adapter. These features enable direct insertion of larger tracheal tubes up to 7.5 and 8.5 mm inner diameters for air-Q sizes 3.5 and 4.5, respectively ,.
| Patients and methods|| |
After obtaining an approval from the local Ethics Committee and informed consent from patients, the research was carried out on 60 adult patients admitted to the Medical Research Institute, University of Alexandria, and scheduled for elective laparoscopic cholycystectomy (This sample size is according to the recommendation of the Department of Statistics, Medical Research Institute, University of Alexandria.).
- American Society of Anesthesiologists physical status: class I and II.
- Mallampati class I or II.
- Mouth opening: more than 3 cm.
- Thyromental distance: more than 6 cm.
- Sternomental distance more than 13 cm.
- Sore throat.
- Gastroesophageal reflux disease.
- Pulmonary disease.
- Dysphonia and dysphagia.
- Previous history of difficult intubation.
- Stiffness or limited mobility of the neck or cervical spine disease.
- BMI greater than 35 kg/m2.
Patients were selected for airway management with either i-gel (group I), air-Q (group II), or ProSeal (group III) using the closed envelop method; they were divided into three equal groups (20 patients in each group).
All patients were premedicated with ondansetron 4 mg, ranitidine 50 mg, and midazolam intravenously 10 min before surgery. Preoxygenation was maintained with 100% oxygen. Anesthesia was induced with fentanyl 1–2 μg/kg, propofol 2–2.5 mg/kg, and cisatracurium 0.15 mg/kg intravenously, and then insertion of the airway device was attempted. In group I, i-gel was inserted, in group II air-Q was inserted, and in group III ProSeal was inserted. The position of supraglottic airways was confirmed with fiberoptic bronchoscope to asses grading. Gastric tube was lubricated and inserted down the gastric drainage port.
Ventilation parameters were set at a tidal volume of 6–8 ml/kg and respiratory rate was adjusted to maintain end-tidal CO2 (35–45 mmHg). Fresh gas flow was adjusted at 3 l/min. Inspiratory-to-expiratory ratio was 1 : 2. The position of the supraglottic airway was reassessed with a fiberoptic bronchoscope again after pneumoperitonium and any change in the grading of position was recorded.
Anesthesia was maintained at minimum alveolar concentration 1.0–2.0 with isoflurane in 100% oxygen. Peritoneal insufflation pressure was preset and maintained at 15 mmHg. Head-up and lateral tilt was provided at the surgeon’s request. Supplementary fentanyl and cisatracurium were given as required.
At the end of the surgery, anesthesia was shut off and residual blockade was reversed with atropine and neostigmine. Once the patient was awake or easily arousable with vocal commands, the SAD was safely removed by asking the patient to open his/her mouth wide, and replaced with a facemask.
Hemodynamic measurements (including the heart rate, the ECG changes, and the mean arterial blood pressure), fiberoptic assessment and grading of fitting of supraglottic device (before and after pneumoperitonium), insertion measurements (including number of insertion attempts and intraoperative airway intervention), operative duration, ventilation (end-tidal CO2, SPO2, leak volume, and airway sealing quality), and complications of their use were recorded and statistically analyzed.
| Results|| |
A total of 60 adult patients scheduled for elective laparoscopic cholycystectomy were included in the study. There was no significant difference as regards demographic data, operative time, and vital signs between the three groups [Table 1],[Table 2],[Table 3]. As regards fiberoptic grading, there was no significant difference between the three groups before insufflation; however, after insufflation, we found that fiberoptic grading of air-Q was significantly better than that of i-gel (P=0.014). Moreover, fiberoptic grading of ProSeal was significantly better than that of i-gel (P=0. 028) after insufflations [Table 4]. As regards leak volume, there was no significant difference between the three groups before insufflation. However, there was a significantly greater leak with i-gel in comparison with air-Q (P=0.040) after insufflation. Moreover, we found a greater leak with i-gel on comparison with ProSeal (P=0.010) after insufflation [Table 4]. There was no significant difference in number of attempts to insertion on comparing the three groups [Table 5]. As regards intraoperative airway intervention, less intervention was observed with i-gel on comparison with air-Q (P=0.017). Moreover, there was a significant difference between ProSeal and air-Q (P=0.027) in favor of ProSeal [Table 5]. According to airway sealing quality, there was better sealing with air-Q in comparison with i-gel (P=0.018). Moreover, better sealing was observed with ProSeal in comparison with i-gel (P=0.047) [Table 5]. There was a significantly higher incidence of complication with air-Q in comparison with both i-gel and ProSeal (P=0.013 and 0.038, respectively) [Table 5].
|Table 2: Comparison between the three studied groups according to heart rate and mean arterial blood pressure|
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|Table 3: Comparison between the three studied groups according to peripheral oxygen saturation and end-tidal CO2|
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|Table 4: Comparison between the three studied groups according to fiberoptic grading and leak volume|
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|Table 5: Comparison between the three studied groups according to number of attempts, airway intervention, airway sealing quality, and complications|
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| Discussion|| |
The use of SADs under conditions of elevated intra-abdominal pressure requires an excellent airway seal to divide the respiratory and alimentary tracts in a reliable manner due to the potential risk for regurgitation ,. Current practice has shown an increased usage of SADs in low-risk elective laparoscopic surgery in view of less airway trauma , better hemodynamic changes during insertion, and maintenance of anesthesia , and better oxygenation during emergence .
In the present study, we found that there were no significant differences on comparing the three groups together as regards successful insertion of SADs on first attempt. However, there was a significant airway intervention with the air-Q group (76.9%) on comparing with i-gel and ProSeal groups (P=0.017 and 0.027, respectively).
Similar to the present study, Neoh and Choy  compared the success rate of tracheal intubation using the air-Q laryngeal mask airway and that using the LMA Fastrach (Teleflex Medical Europe Ltd. Athlone Co. Westmeath, Ireland), and concluded that intubation using the air-Q laryngeal mask airway required more attempts at external cricoid manipulation to facilitate its insertion (P=0.009). Moreover, Bhandari et al.  evaluated the i-gel and air-Q for ventilation in anesthetized and paralysed patients and found that the mean insertion time in first attempt for i-gel (25.85±1.7 s) was significantly lower than that for air-Q (26.73±1.51 s) (P=0.012).
In the present study, there were no significant differences in fiberoptic grading between the three groups before insufflation, but after insufflation there was better grading with ProSeal and air-Q compared with i-gel (P=0.014 and 0.028, respectively).
In agreement with the study, Kim et al. , who compared the i-gel with the air-Q self pressurizing (SP) in children undergoing general anesthesia, found better fiberoptic view with the air-Q SP group compared with the i-gel group at all measurement points: at initial assessment, 10 min after initial assessment, and at completion of surgery (P=0.031, 0.047, and 0.022, respectively).
In the present study, there was better airway sealing quality in both the ProSeal and air-Q groups compared with the i-gel group (P=0.018 and 0.047, respectively). Moreover, there was less leak volume with ProSeal and air-Q compared with the i-gel (P=0.040 and 0.10, respectively).
In agreement with the present study, Chauhan et al. , who compared the i-gel and PLMA, found that the mean airway sealing pressure in the PLMA group (29.55±3.53 cmH2O) was significantly higher than that in the i-gel group (26.73±2.52 cmH2O; P=0.001). Moreover, Kim et al.  conducted a study to compare the i-gel and the air-Q SP in children and found that the air-Q SP group had better fiberoptic views compared with the i-gel group at all measurement points (initial assessment, 10 min after initial assessment, and at completion of surgery).
In this study, 45% of cases in the air-Q group suffered from sore throat and cough, which was significantly higher than that in both the i-gel and ProSeal groups. This may be because the cuff of the air-Q is made of harder and stiffer plastic material, when compared with the softer silicone cuff of the ProSeal .
In agreement with the present study, Galgon et al.  conducted a study to compare air-Q and PLMA in adults undergoing general anesthesia, and found that the incidence of postoperative sore throat was higher with the air-Q (46 vs. 38%, P=0.03), as well as pain on swallowing (30% in air-Q vs. 5% in PLMA, P=0.01).
Similar to this study, Asai and Liu  used the i-gel in 20 adults who were breathing spontaneously under general anesthesia, and found that no airway complications occurred during the anesthesia and no blood was detected on the device after removal in all patients. Moreover, Bashandy and Boules  studied the hemodynamic stress responses to tracheal intubation using air-Q and direct laryngoscopy and found that sore throat was more frequent in the air-Q group than in the direct laryngoscopy (DLS) group (6/30 vs. 0/30; P<0.05).
| Conclusion|| |
- The new SADs are an effective alternative to exercise tolerance test in patients undergoing laparoscopic cholecystectomy.
- The ProSeal and air-Q are associated with better fiberoptic grading and airway sealing quality compared with i-gel.
- The incidence of postoperative airway complications of the correctly inserted proper size of the i-gel and PLMA was lower than that of the air-Q.
- SADs could be used in laparoscopic surgeries.
- More studies with larger numbers of patients need to be carried out to confirm the findings.
Financial support and sponsorship
Nil.Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]