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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 40-45

I-gel versus Air-Q for airway maintenance during general anaesthesia with controlled ventilation in paediatrics


Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Date of Submission22-Apr-2016
Date of Acceptance22-Oct-2016
Date of Web Publication22-Mar-2017

Correspondence Address:
Mahmoud A. F Seoudi
Fayrozahsmouha Building 5 Appartment 809 EL Naklwelhandasa Street, Alexandria, 21311
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2356-9115.202695

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  Abstract 

Background
In the last few years, a number of supraglottic airway devices have been introduced in the clinical practice of airway management, trying to offer a simple and effective alternative to the endotracheal intubation. These devices are designed to overcome the disadvantages of endotracheal intubation such as soft tissue injury and exaggerated haemodynamic response.
Purpose
The aim of the present study was to compare between the I-gel and the Air-Q intubating laryngeal airway as alternative supraglottic airway devices during general anaesthesia with controlled ventilation in paediatrics.
Patients and methods
Sixty ASA grade I and II children, aged 3–6 years, and scheduled to undergo elective surgery under general anaesthesia with controlled ventilation in supine position were randomly categorized into two equal groups (30 patients each): group I, in which the I-gel was used to maintain a patent airway during anaesthesia; and group II, in which Air-Q intubating laryngeal airway was used to maintain a patent airway during anaesthesia. After induction of anaesthesia and muscle relaxation, we measured ease of insertion, time and number of trials to successful insertion, airway sealing pressure, fibrescopic view of the glottis, maintenance success, haemodynamic responses, airway interventional requirements and any other complications.
Conclusion
This study showed that both supraglottic airway devices are suitable for positive pressure ventilation with high success rates in children undergoing elective surgeries. It was found that the I-gel has a shorter time of insertion and a higher airway sealing pressure, whereas Air-Q has a better fibrescopic view of the glottis.

Keywords: Air-Q intubating laryngeal airway, endotracheal intubation, I-gel, supraglottic airway devices


How to cite this article:
Ammar RA, El-gamal NA, Al-rahmany HK, Seoudi MF. I-gel versus Air-Q for airway maintenance during general anaesthesia with controlled ventilation in paediatrics. Res Opin Anesth Intensive Care 2017;4:40-5

How to cite this URL:
Ammar RA, El-gamal NA, Al-rahmany HK, Seoudi MF. I-gel versus Air-Q for airway maintenance during general anaesthesia with controlled ventilation in paediatrics. Res Opin Anesth Intensive Care [serial online] 2017 [cited 2020 May 31];4:40-5. Available from: http://www.roaic.eg.net/text.asp?2017/4/1/40/202695


  Introduction Top


General anaesthesia using the endotracheal tube is today the form of general anaesthesia most often applied. It used in more than 80% of the total cases in hospitals with different surgical specialties. However, in the last few years, a number of supraglottic airway devices have been introduced in the clinical practice of the airway management, trying to offer a simple and effective alternative to the endotracheal intubation [1].

The advantages of supraglottic devices include avoidance of laryngoscopy, less invasion to the respiratory tract, better tolerance by patients, increased ease of placement, improved haemodynamic stability in emergence, less coughing, less sore throat, hands-free airway and easier placement by inexperienced personal [2].

I-gel is a single-use supraglottic airway device (Intersurgical Ltd, Wokingham, Berkshire, UK, with an anatomically designed mask made of a gel-like thermoplastic elastomer. It has features designed to separate the gastrointestinal and respiratory tracts and allows a gastric tube to be passed into the stomach [3].

Air-Q intubating laryngeal airway (Cook Gas LLC, Mercury Medical, Clearwater, Florida, USA is a supraglottic airway device that is used as a primary airway and as an aid for intubation in situations of anticipated or unanticipated difficult airways. The special features of Air-Q intubating laryngeal airway make it superior to the classical Laryngeal mask airway (LMA). Therefore, it has the potential to overcome the limitations of the classical LMA [4].


  Aim of the work Top


The aim of the present study was to compare between the I-gel and the Air-Q intubating laryngeal airway as alternative supraglottic airway devices during general anaesthesia with controlled ventilation in paediatrics.


  Patients and methods Top


The present study was carried out in Alexandria University Hospitals on 60 patients of ASA grade I and II, aged 3–6 years, and scheduled to undergo elective surgery under general anaesthesia with controlled ventilation in supine position without head and neck manipulation.

Patients were randomly allocated into two equal groups (30 patients each using the closed envelope method:

Group I, in which the I-gel was used to maintain a patent airway during anaesthesia.

Group II, in which the Air-Q intubating laryngeal airway was used to maintain a patent airway during anaesthesia.

After obtaining approval of the local Ethical Committee and once all patients had signed an informed written consent, all patients were assessed preoperatively by proper history taking and clinical examination, proper airway assessment by using COPUR scale [5] (which includes assessment of chin-size opening, opening of the mouth, previous intubation or obstructive sleep apnea, uvula and range of neck movement and routine laboratory investigations. All patients were premedicated with chloral hydrate 25–50 mg/kg orally 30 min before induction of anaesthesia.

On arrival to the operating room, patients were connected to the standard monitoring, including ECG, noninvasive arterial blood pressure and pulse oximeter. For all patients an intravenous access was established (22–24-G cannula. After preoxygenation with 100% oxygen for 3 min, induction of anaesthesia was carried out by intravenous administration of fentanyl 1 μg/kg, propofol 3 mg/kg (10 mg lignocaine 1% was added to each 100 mg propofol and atracurium (0.5 mg/kg. Ventilation was provided through a face mask with 100% oxygen and 1.2% isoflurane for 2–3 min. Once an adequate depth of anaesthesia was achieved (no eye lash reflex and no response to jaw thrust, the selected airway device was inserted.

Measurements

  1. Insertion criteria: These included ease of insertion, time to successful insertion of the airway device, number of attempts to successful insertion, airway sealing pressure and fibrescopic view of the glottis using the Brimacombe score (4: only vocal cords seen; 3: vocal cord plus posterior epiglottis; 2: vocal cords plus anterior epiglottis; 1: vocal cords not seen [6].
  2. Maintenance success: Adequacy of ventilation was assessed by end-tidal carbon dioxide (mmHg, expiratory tidal volume (ml and peak airway pressure (cmH2O. These were recorded every 15 min of ventilation with the device.
  3. Airway interventional requirements during maintenance: Adjustment of head and neck position, jaw thrust and reinsertion or changing the device were carried out if needed. Any of these interventions was recorded.
  4. Haemodynamic measurements: The hemodynamic measurements included pulse (beats/min, mean arterial blood pressure (mmHg and peripheral oxygen saturation (SpO2%. These haemodynamic parameters were measured continuously and recorded before the induction of anaesthesia, after induction of anaesthesia and before insertion of the airway device, just after insertion of the airway device, 5 min after insertion of the airway device and 10 min after insertion of the airway device.
  5. Complications: Complications included traces of blood after removal of the device, laryngeal spasm, cough, hoarse cry and sore throat. Any of these complications was recorded as yes or no.


Statistical analysis

Data were tested for normal distribution, and analysis was carried out using the independent t-test for two independent groups, the paired t-test for paired samples, and х2 and Fisher’s exact tests for qualitative data.

Results were presented in the form of range, percentage (%, arithmetic mean (х2 and SD. The P-value of less than 0.05 was considered statistically significant.


  Results Top


Regarding ease of insertion, the insertion of the I-gel was easy in 28 patients (93.3% and difficult in two (6.7%, whereas that of the Air-Q was easy in 27 patients (90% and difficult in three (10%. On comparing the two groups, there were no statistically significant differences as regards ease of insertion (P=1.000 ([Figure 1]).
Figure 1 Comparison between the two studied groups according to ease of insertion.

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Time to successful insertion of the I-gel ranged from 12 to 17 s with a mean of 13.87±1.53 s, whereas that of the Air-Q ranged from 14 to 21 s with a mean of 16.33±2.02 s. On comparing the two groups, there were statistically significant differences between the I-gel and the Air-Q as regards time to successful insertion. The insertion of the I-gel was faster than that of the Air-Q (P<0.001 ([Figure 2]).
Figure 2 Comparison between the two studied groups according to time to successful insertion.

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As regards number of attempts to successful insertion, in group I, the I-gel was inserted successfully in the first attempt in 28 patients (93.33% and in the second attempt in two patients (6.667%. Whereas in group II, the Air-Q was inserted successfully in the first attempt in 27 patients (90% and in the second attempt in three patients (10%. No patients in the two groups required a third attempt of insertion to establish a successful airway or encountered a failure of insertion. There were no statistically significant differences between the two groups as regards number of attempts to successful insertion (P=0.647 ([Figure 3]).
Figure 3 Comparison between the two studied groups according to number of trials to successful insertion.

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As regards airway sealing pressure, in group I (I-gel, it ranged from 18 to 27 cmH2O with a mean of 23.20±2.16 cmH2O, whereas in group II (Air-Q it ranged from 15 to 23 cmH2O with a mean of 19±2 cmH2O. On comparing the two groups, the I-gel had a statistically significant higher airway sealing pressure than did the Air-Q (P<0.001 ([Figure 4]).
Figure 4 Comparison between the two studied groups according to airway sealing pressure.

Click here to view


On comparing fibrescopic visualization of the glottis, in group I (I-gel, the Brimacombe score ranged from 2 to 4 with a mean of 3.10±0.55, whereas in group II (Air-Q it ranged from 3 to 4 with a mean of 3.57±0.50. On comparing the two groups, the Air-Q had a statistically significant higher Brimacombe score than did the I-gel, indicating better fibrescopic visualization of the glottis (P=0.002 ([Figure 5]).
Figure 5 Comparison between the two studied groups according to Brimacombe score.

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Regarding ETCO2, tidal volume and peak airway pressure, there were no statistically significant differences between the two groups at different times.

Regarding intraoperative airway interventional requirements, in the I-gel group there were minor airway interventions in five patients (16.7%, whereas in the Air-Q group there were minor airway interventions in six patients (20%. There were no statistically significant differences between the two groups regarding the number of intraoperative airway interventional requirements (P=0.739 ([Figure 6]).
Figure 6 Comparison between the two studied groups according to airway interventional requirements.

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Regarding haemodynamic changes, comparison between the two studied groups revealed nonsignificant statistical differences as regards heart rate, mean arterial blood pressure and peripheral oxygen saturation at different times.

Regarding complications, in group I (I-gel, complications were encountered in four patients (13.3%, bleeding from the soft tissues and the presence of blood on the airway device on removal were encountered in three patients and laryngospasm was encountered in one patient only. In group II (Air-Q, complications were encountered in three patients (10%, bleeding from the soft tissues and the presence of blood on the airway device on removal were encountered in one patient only and laryngospasm was encountered in two patients. On comparing the two groups, there were no statistically significant differences regarding the occurrence of complications (P=1.000 ([Figure 7]).
Figure 7 Comparison between the two studied groups according to complications.

Click here to view



  Discussion Top


The present study demonstrated that both airway devices have a high easy insertion success rate in the first attempt.

In agreement with the findings of the present study, Abukawa et al. [7] showed a high first attempt insertion success rate (94% on using paediatric I-gel in an observational study on 70 children undergoing elective surgeries.

Our findings are also in line with those of Jagannathan et al. [8], who demonstrated a very high insertion success rate (99% in an observational study using the Air-Q in 421 paediatric patients.

Regarding time to successful insertion of the airway devices, group I (I-gel showed a significantly shorter insertion time with a mean value of 13.87±1.53 s compared with group II (Air-Q with a mean value of 16.33±2.02 s.

In agreement with the present study, Sanket et al. [9] demonstrated a faster time to insertion of I-gel (14±5 s compared with LMA on 163 children undergoing elective surgeries.

This is in agreement with Beringer et al. [10], who evaluated the paediatric I-gel in 120 children with a time to successful insertion of 14 s.

In contrast, Jagannathan et al. [11] found that the median time to insertion for the Air-Q was 16.7 s, which was shorter than for the I-gel (19.6 s in a randomized comparison between the I-gel and the Air-Q supraglottic airways in 96 children.

As regards airway sealing pressure, the I-gel group showed a significantly higher airway sealing pressure with a mean value of 23.20±2.16 cmH2O compared with the Air-Q group with a mean value of 19±2 cmH2O.

The success of the I-gel in the achievement of high airway sealing pressure was also demonstrated by Saran et al. [12] who compared the I-gel versus LMA proseal in paediatric patients under controlled ventilation. The median airway sealing pressure obtained for I-gel was 23.13±5.22 cmH2O, which is nearly similar to that achieved in our study. Hence, paediatric I-gel can provide a safety margin in terms of airway leak pressure for ventilating small children undergoing general anaesthesia.

In contrast, Jagannathan et al. [11] in their comparative study between the I-gel and the Air-Q in children found no significant differences between both devices as regards airway sealing pressure. Also, they found that the success rate of intubation through device was not statistically significant among patients of the two groups.

As regards fibrescopic view of the glottis, the Air-Q showed better visualization of the glottis with a higher Brimacombe score than did the I-gel.

A good visualization of the glottis on using the Air-Q was also proved by Darlong et al. [13] in their study comparing the Air-Q with flexible laryngeal mask airway in anaesthetized and paralyzed infants and children.

These findings are in line with those of Whyte et al. [14]; they succeeded in obtaining good fibreoptic visualization of the vocal cords in 102 patients in their observational study on the Air-Q in 110 infants and children.

Moreover, the I-gel served as a good conduit for fibreoptic intubation (to a lesser extent than did Air-Q by providing good visualization of the glottis in most cases. This was demonstrated by Fukuhara et al. [15] who found that the fibreoptic views were significantly better with the I-gel than with the laryngeal mask airway proseal in their study on 134 paediatric patients.

Regarding adequacy of ventilation, measured in terms of end-tidal carbon dioxide, expiratory tidal volume, and peak airway pressure, no statistically significant differences between the two groups were found. Therefore, both I-gel and Air-Q are considered suitable devices for controlled ventilation for paediatric patients undergoing short surgical procedures who are not at risk for aspiration.

This was in agreement with Saran et al. [12] who in their comparative study between the I-gel and the LMA proseal in paediatrics under controlled ventilation reported that the I-gel provided adequate ventilation with low peak airway pressure and high sealing pressure.

Similarly, adequacy of ventilation was also demonstrated by Whyte et al. [14] in their study of usability and performance characteristics of the paediatric Air-Q intubating laryngeal airway on 110 children undergoing elective surgeries. They reported excellent ventilation in 98% of their patients.

In terms of intraoperative airway interventional requirements, only few cases in both groups required minor interventions such as adjustment of head and neck position or jaw thrust.

Similar results proving the stability of the I-gel device were obtained by Beringer et al. [10] in their evaluation of the paediatric I-gel airway during anaesthesia in 120 children where only 11 of them (9.1% required airway manipulations during maintenance of anaesthesia.

There were no statistically significant differences between the two groups regarding haemodynamic parameters. Both devices proved to offer only a very minor stress response.

Similarly, the minimal effects of the I-gel on haemodynamics were demonstrated by Lee et al. [16] who compared the I-gel with classic LMA in 63 children undergoing elective surgeries.

The haemodynamic stability on using paediatric Air-Q was also evident in the study conducted by Jagannathan et al. [17], who found no significant changes in heart rate and blood pressure following insertion of the Air-Q and LMA unique in 50 children.

As regards complications, in group I (I-gel, complications were seen in four patients (13.3%. Two patients experienced sore throat and traces of blood were observed during I-gel removal in another two patients. Whereas in group II (Air-Q, complications were encountered in three patients (10%. Two patients experienced sore throat and one patient suffered hoarse cry after Air-Q removal during emergency. There were no statistically significant differences between both groups as regards the occurrence of complications.

The low morbidity on using the paediatric I-gel was also reported by Gasteiger et al. [18] in their randomized study between size 2 I-gel and LMA proseal in ventilated children. Blood staining of the I-gel after removal was reported in only two of 26 cases.

Similarly, Darlong et al. [13] conducted a comparison of performance and efficacy of the Air-Q intubating laryngeal airway and flexible laryngeal mask airway in 50 children undergoing ophthalmic elective surgeries. They reported not noticing any complications in the form of blood staining over the device, cough, laryngospasm, vomiting, desaturation and sore throat.


  Conclusion Top


The I-gel was found to have a shorter time of insertion and a higher airway sealing pressure, whereas the Air-Q was shown to have a better fibrescopic view of the glottis. No significant differences were found between the two devices regarding ease of insertion, number of attempts to successful insertion, airway interventional requirements during maintenance, haemodynamic changes or complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Amathieu R, Combes X, Abdi W, Housseini LE, Rezzoug A, Dinca A et al. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrach: a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology 2011; 114:25–33.  Back to cited text no. 1
    
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Calder I. Cervical spine disease and anaesthesia. Anaesth Intensive Care Med 2005; 6:181–183.  Back to cited text no. 2
    
3.
Gal TJ Airway management. In: Miller RD, editor. Textbook of anesthesia. 6th ed. Philadelphia: Elsevier; 2005. 1617–1652.  Back to cited text no. 3
    
4.
Brimacombe J. A proposed classification system for extraglottic airway devices. Anesthesiology 2004; 101:559.  Back to cited text no. 4
    
5.
Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology 2009; 110:891–897.  Back to cited text no. 5
    
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Keller C, Brimacombe J, Puhringer F. A fibreoptic scoring system to assess the position of laryngeal mask airway devices. Interobserver variability and a comparison between the standard, flexible and intubating laryngeal mask airways. AINS 2000; 35:692–694.  Back to cited text no. 6
    
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Abukawa Y, Hiroki K, Ozaki M. Initial experience of the i-gel supraglottic airway by the residents in pediatric patients. J Anaeth 2012; 26:357–361.  Back to cited text no. 7
    
8.
Jagannathan N, Sohn LE, Mankoo R, Langen KE, Roth AG, Hall SC. Prospective evaluation of the self‐pressurized air‐Q intubating laryngeal airway in children. Paed Anaesth 2011; 21:673–680.  Back to cited text no. 8
    
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Sanket B, Ramavakoda CY, Nishtala MR, Ravishankar CK, Ganigara A. Comparison of second-generation supraglottic airway devices (i-gel versus LMA ProSeal during elective surgery in children. AANA J 2015; 83:275.  Back to cited text no. 9
    
10.
Beringer RM, Kelly F, Cook TM, Nolan J, Hardy R, Simpson T, White MC. A cohort evaluation of the paediatric i‐gel™ airway during anaesthesia in 120 children. Anaesthesia 2011; 66:1121–1126.  Back to cited text no. 10
    
11.
Jagannathan N, Sohn L, Ramsey M, Huang A, Sawardekar A, Sequera-Ramos L et al. A randomized comparison between the i-gel™ and the air-Q™ supraglottic airways when used by anesthesiology trainees as conduits for tracheal intubation in children. Can J Anaesth 2015; 62:587–594.  Back to cited text no. 11
    
12.
Saran S, Mishra SK, Badhe AS, Vasudevan A, Elakkumanan LB, Mishra G. Comparison of i-gel supraglottic airway and LMA-ProSeal™ in pediatric patients under controlled ventilation. J Anaesthesiol Clin Pharm 2014; 30:195.  Back to cited text no. 12
    
13.
Darlong V, Biyani G, Pandey R, Baidya DK, Punj J. Comparison of performance and efficacy of air‐Q intubating laryngeal airway and flexible laryngeal mask airway in anesthetized and paralyzed infants and children. Paed Anaesth 2014; 24:1066–1071.  Back to cited text no. 13
    
14.
Whyte SD, Cooke E, Malherbe S. Usability and performance characteristics of the pediatric air-Q® intubating laryngeal airway. Can J Anaesth 2013; 60:557–563.  Back to cited text no. 14
    
15.
Fukuhara A, Okutani R, Oda Y. A randomized comparison of the i-gel and the ProSeal laryngeal mask airway in pediatric patients: performance and fiberoptic findings. J Anaesth 2013; 27:1–6.  Back to cited text no. 15
    
16.
Lee JH, Cho HS, Shin WJ, Yang HS. A comparison of supraglottic airway i-gel™ vs. classic laryngeal mask airway in small children. Korean J Anaesthesiol 2014; 66:127–130.  Back to cited text no. 16
    
17.
Jagannathan N, Sohn LE, Mankoo R, Langen KE, Mandler T. A randomized crossover comparison between the Laryngeal Mask Airway‐Unique™ and the air‐Q Intubating Laryngeal Airway in children. Paed Anaesth 2012; 22:161–167.  Back to cited text no. 17
    
18.
Gasteiger L, Brimacombe J, Oswald E, Perkhofer D, Tonin A, Keller C, Tiefenthaler W. LMA ProSealTM vs. i‐GelTM in ventilated children: a randomised, crossover study using the size 2 mask. Acta Anaesthesiol Scand 2012; 56:1321–1324.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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Introduction
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Patients and methods
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