Equipment 8-378 - I-Gel Airway

CMH EMS & MIH Protocols

Scope of Practice:

• Emergency Medical Technician
• Advanced Emergency Medical Technician
• Registered Nurse
• Paramedic

Indications:

• Patients who are unable to maintain their own airway (i.e. GCS less than 8).

Contraindications:

• Conscious/semi-conscious patient.
• Trismus, limited mouth opening, pharyngo-perilaryngeal abscess, trauma, or mass.
• Do not use the gastric channel if:
• There is an excessive air leak through the gastric channel.
• There are osophageal varices or evidence of upper gastro-intestinal bleed.
• In cases of osophageal trauma.
• There is a history of upper gastro-intestinal surgery.
• The patient has bleeding/clotting abnormalities.
• Nasogastric tube insertion in the presence of inadequate levels of anaesthesia can lead to coughing, bucking, excessive salivation, retching, laryngospasm or breath holding.

Precautions:

• Do not allow peak airway pressure of ventilation to exceed 40cm H2O.
• Do not use excessive force to insert the device or nasogastric tube.
• Must be lubricated according to the instructions for use.
• The patient should always be in the ‘sniffing the morning air’ position prior to insertion with the assistant helping to open the patient’s mouth, unless head/neck movements are considered inadvisable or are contraindicated.
• The leading edge of the i-gel’s tip must follow the curvature of the patient’s hard palate upon insertion.
• If there is a failure to achieve complete insertion after utilising the standard insertion technique and a jaw thrust, deep rotation or triple manoeuvre has also failed, then the device should be inserted under direct vision by laryngoscopy or one size smaller device should be used.
• After insertion, i-gel should be taped down from maxilla-to-maxilla.
• Excessive air leak during manual ventilation is primarily due to either sub-optimal depth of anaesthesia or sub-optimal depth of i-gel insertion.
• Particular care should be taken with patients who have an ASA or Mallampati score of III and above, or who have fragile and vulnerable dental work, in accordance with recognised airway management practices and techniques.
• As with all supraglottic airways, it is important to ensure the correct size of device is used, lubrication is optimal, the device is inserted and positioned correctly and regularly checked intraoperatively in order to reduce the potential for nerve damage, tongue numbness, cyanosis and other potential complications.
• No attempt should be made to use i-gel as a conduit for intubation without fibre optic guidance.
• The i-gel is supplied in a protective cradle or cage pack to ensure the device is retained in the correct flexion prior to use and also acts as a base for lubrication. The i-gel must always be separated from the cradle or cage pack prior to insertion. The cradle and cage pack are not introducers and must never be inserted into the patient’s mouth.
• : Do not apply excessive force on the device during insertion. It is not necessary to insert fingers or thumbs into the patient’s mouth during the process of inserting the device. If there is early resistance during insertion, a ‘jaw thrust’, ‘Insertion with deep rotation’ (Figure 24) or triple maneouvre is recommended.
• In order to avoid the possibility of the device moving up out of position prior to being secured in place, it is essential that as soon as insertion has been successfully completed, the i-gel is held in the correct position until and whilst the device is secured in place.

Procedure:

• Pre-use check and preparation:
• Select the appropriate size i-gel by assessing the patient’s anatomy.
• Inspect the packaging and ensure it is not damaged prior to opening.
• Inspect the device carefully, check the airway is patent and confirm there are no foreign bodies or a BOLUS of lubricant obstructing the distal opening of the airway or gastric channel.
• Open the i-gel package and on a flat surface take out the protective cradle containing the device.
• Place a small bolus of a water-based lubricant, such as K-Y Jelly, onto the middle of the smooth surface of the cradle in preparation for lubrication. Do not use silicone based lubricants.
• Grasp the i-gel along the integral bite block and lubricate the back, sides and front of the cuff with a thin layer of lubricant.
• Place the i-gel back into the cradle in preparation for insertion.
• Insertion:
• A proficient user can achieve insertion of the i-gel in less than five seconds.
• Grasp the lubricated i-gel firmly along the integral bite block. Position the device so that the i-gel cuff outlet is facing towards the chin of the patient.
• The patient should be in the ‘sniffing the morning air’ position with head extended and neck flexed. The chin should be gently pressed down before proceeding to insert the i-gel.
• Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate.
• Glide the device downwards and backwards along the hard palate with a continuous but gentle push until a definitive resistance is felt.
• At this point the tip of the airway should be located into the upper osophageal opening and the cuff should be located against the laryngeal framework. The incisors should be resting on the integral bite-block.
• I-gel should be taped down from ‘maxilla to maxilla’.
• If required, an appropriate size nasogastric tube may be passed down the gastric channel.
• Gastric channel use:
• Select the appropriate size of nasogastric (NG) tube.
• If regurgitation is anticipated, then it is recommended that a nasogastric tube is passed through the gastric channel of the i-gel into the patient’s stomach and the stomach emptied. The nasogastric tube can be left in situ.
• Removal:
• Once consciousness is regained and protective reflexes such as coughing and swallowing have returned, gently suction around the airway device in the pharynx and hypopharynx.
• Once the patient is awake or easily arousable with vocal commands, the i-gel can safely be removed by asking the patient to open his/her mouth wide, and replaced with an MC (medium concentration oxygen) mask.
• DO NOT attempt to forcibly remove the device if the patient is biting on it. Wait until the patient, on vocal command, has fully opened their mouth or opens their mouth spontaneously.

Size selection:

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