# Anyone using i-gel airway device in BLS pre-hospital setting?



## Talonrazor (Feb 13, 2012)

My agency is looking into the i-gel supraglottic airway device right now. I was wondering if anyone has any experience using these devices as a BLS agency in the field? They look fantastic and easy to use. How do they compare to other airway adjuncts?


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## NomadicMedic (Feb 13, 2012)

Are they approved for use by your state/region? 

Do you currently use combi-tubes or Kings?


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## Talonrazor (Feb 13, 2012)

A number of BLS agencies use them currently. It depends on the expanded scope. We do not use King LTs or Combi-tubes currently but the i-gel doesn't carry the risk of crush trauma due to non-inflatable cuffs. We are sending info sheets to our medical director to see what he thinks. I was just wondering if people are using them in the field where you guys work and if you like them.


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## NomadicMedic (Feb 14, 2012)

I'd not seen nor heard of them until you mentioned them. (and we're pretty progressive over here) I'm curious why you feel you "need" these when you're not cleared for any other SGA, like a combi or King, and you have ALS available to respond to an incident where a pt may need an advanced airway. Why not focus on GREAT compressions and getting a shock in quickly, instead of messing about with an SGA. 

And FYI, the big issue with the inflatable cuff isn't "crush trauma", it's a measurable decrease in cerebral perfusion, from the cuff compressing the vessels. There is a great study that made mention of it at the NAEMSP conference. 

If you're really curious about them, why not check with one of the number of BLS agencies that you're aware of that use them.


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## systemet (Feb 15, 2012)

n7lxi said:


> And FYI, the big issue with the inflatable cuff isn't "crush trauma", it's a measurable decrease in cerebral perfusion, from the cuff compressing the vessels. There is a great study that made mention of it at the NAEMSP conference.



Really?  That seems strange.


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## NomadicMedic (Feb 15, 2012)

systemet said:


> Really?  That seems strange.



Why is that strange?


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## systemet (Feb 15, 2012)

n7lxi said:


> Why is that strange?



I'm just trying to picture how enough force is being transmitted to the vascular structures from the cuff in the pharynx to affect cerebral perfusion.  You may well be correct.  I did a quick look on Pubmed and couldn't find anything, but I didn't spend a lot of time.


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## NomadicMedic (Feb 15, 2012)

Yeah. I'll find the study and post it up. There was a comparison between a King, a combi and an ETT.


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## systemet (Feb 15, 2012)

n7lxi said:


> Yeah. I'll find the study and post it up. There was a comparison between a King, a combi and an ETT.



Cool, thanks!


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## NYMedic828 (Feb 15, 2012)

systemet said:


> Really?  That seems strange.













Those balloons don't seem a bit bigger than the average object entering the pharynx? It has to press against the walls to create a seal. The problem is every patient is different but we use a relative size for the majority of them. For one patient it may be a perfect fit, for another it may tear the lining of the esophagus or compress surrounding vessels. When dealing with cerebral perfusion, even a slight decrease is of significant importance.

Most agencies don't carry various sizes of secondary airways (to my knowledge)

At work I only have ET tubes of all sizes, and one size combitube.


The I-gel is really just an improvised LMA. The difference being an LMA has an inflatable cuff, and the I-gel "conforms" to the pharynx and is non-inflatable.


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## STXmedic (Feb 15, 2012)

LOL!! Compressing arterioles and venuoles around the pharynx is not going to affect cerebral pressure 

Yes, people vary in size, but not everybody gets 90cc of air forced into that balloon. If you're trying to cram air in there, you're doing it wrong.


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## Handsome Robb (Feb 15, 2012)

Seems like you need someone with perfect anatomy for it to work properly. First time I have ever heard of it. 

How many suprglottic airways do we need?


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## NomadicMedic (Feb 15, 2012)

n7lxi said:


> Yeah. I'll find the study and post it up. There was a comparison between a King, a combi and an ETT.



It's in the current issue of PEC, in the Abstracts for the 2012 NAEMSP Scientific Assembly.

Prehospital Emergency Care Jan 2012, Vol. 16, No. 1: 152–187.


I don't have access to it at home, but maybe someone here does...


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## systemet (Feb 16, 2012)

n7lxi said:


> It's in the current issue of PEC, in the Abstracts for the 2012 NAEMSP Scientific Assembly.
> 
> Prehospital Emergency Care Jan 2012, Vol. 16, No. 1: 152–187.
> 
> ...



My institutional access doesn't cover it, unfortunately.  I'd be interested in seeing it if someone has a copy.

Thanks for looking it up.


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## NomadicMedic (Feb 16, 2012)

systemet said:


> My institutional access doesn't cover it, unfortunately.  I'd be interested in seeing it if someone has a copy.
> 
> Thanks for looking it up.



I asked one of our education guys to forward it to me. I'll have it in a day or so...


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## Tyler (Feb 22, 2012)

LMAs have been in use by Irish Paramedics (broadly similar to US EMT-Is) for a few years now, but there is a move to i-gels now. They cannot use Combitubes/Combitubes or intubate (only our Advanced Paramedics can).

In the most recent guidelines i-gels have been approved for EMTs (similar to US EMT-Bs) and for EFRs (similar to US EMRs, lower skill set but more ASA, O2 GTN, epi-pen and Salamol assist) operating under the direction of a Fire Service/in association with the State Ambulance service.

Anecdotally - although theres no research on changes in outcome as yet - Many Paramedics prefer them to the LMAs, and also a lot of providers have been happy at their expanded use as its allowed them to go beyond CPR and manual airway maintenance.


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## Talonrazor (Feb 22, 2012)

Tyler said:


> LMAs have been in use by Irish Paramedics (broadly similar to US EMT-Is) for a few years now, but there is a move to i-gels now. They cannot use Combitubes/Combitubes or intubate (only our Advanced Paramedics can).
> 
> In the most recent guidelines i-gels have been approved for EMTs (similar to US EMT-Bs) and for EFRs (similar to US EMRs, lower skill set but more ASA, O2 GTN, epi-pen and Salamol assist) operating under the direction of a Fire Service/in association with the State Ambulance service.
> 
> Anecdotally - although theres no research on changes in outcome as yet - Many Paramedics prefer them to the LMAs, and also a lot of providers have been happy at their expanded use as its allowed them to go beyond CPR and manual airway maintenance.



Interesting! This is a lot of the same reasoning I am hearing from other providers. One local standby agency just had their usage approved and they love it because it is easier and better than an LMA.


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## NomadicMedic (Feb 24, 2012)

Impairment of Carotid Artery Blood Flow by Supraglottic Airway Use in a Swine Model of Cardiac Arrest

Nicolas Segal, Demetris Yannopoulos, Brian D. Mahoney, Ralph J. Frascone, Daniel Zarama, Scott H. McKnite, David G. Chase, University of Minnesota

Introduction. Supraglottic airway devices (SGDs) are often used as an alternative to endotracheal tubes (ETTs) during cardiopulmonary resuscitation (CPR). SGDs can be inserted “blindly” and rapidly, without stopping compressions. These devices utilize pressurized balloons to direct air to the trachea and prevent esophageal insufflation.

Objective. We hypothesized that the use of an SGD would compress the carotid artery and decrease carotid blood flow (CBF) during CPR in pigs.

Methods. Ventricular fibrillation was induced in nine female pigs (32 ± 1 kg) anesthetized with isoflurane followed by 4 minutes without compressions. CPR was then performed continuously for three 6-minute epochs. During each epoch, an ETT was used for the first 3 minutes, followed by 3 minutes of each SGD (King LTS-D, LMA Flexible, or Combitube) in a random order. The primary endpoint was mean CBF (mL/min). Statistical comparisons among the four airway devices were performed by Wilcoxon rank test. Postmortem carotid arteriographies were performed with the SGDs in place.

Results. CBF (mean mL/min ± standard deviation) was significantly lower with each SGD (King [168 ± 42], LMA [106 ± 89], and Combitube [99 ± 128]) versus ETT (209 ± 134) (p < 0.05 for each SGD compared with ETT). Arteriograms showed that with each SGD there was compression of the internal and external carotid vessels.

Conclusions. The use of three different SGDs during CPR significantly decreased CBF in a porcine model of cardiac arrest. While limited to pigs, these observations may impact management decisions related to the type and duration of SGD use in humans undergoing CPR.


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## triemal04 (Feb 24, 2012)

Unless the "LMA Flexible" is meant to be an i-gel, that's not quite a rining endorsement for not considering it's use.  Part of the reasoning behind using an i-gel is that it is supposed to seat itself in the esophageus "naturally" without any extra compression of the surrounding tissues.  

I can see overinflation of the combitube, king, or LMA being a problem, although the size of the decrease is surprising.

Can't help but wonder if there would have been a difference if each of the airways choosen was used the entire time instead of being switched for an ET tube each time.

Nice small study, but I wouldn't go so far as to call it difinative proof of anything.


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## Handsome Robb (Feb 24, 2012)

This is a pretty interesting study. 



triemal04 said:


> Can't help but wonder if there would have been a difference if each of the airways choosen was used the entire time instead of being switched for an ET tube each time.





Agreed however you can swap an ETT with a King in <10-15 seconds. Dr. looked at me like I was nuts when I said it during a clinical the other day but I made him a believer.

Bougie down through the main ventilation port on the King, deflate the cuff and pull the King while leaving the bougie in place, drop the ETT over the bougie, inflate the cuff, walla...good tube!!!


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## STXmedic (Feb 24, 2012)

NVRob said:


> Bougie down through the main ventilation port on the King, deflate the cuff and pull the King while leaving the bougie in place, drop the ETT over the bougie, inflate the cuff, walla...good tube!!!


I've never been able to insert the bougie through in an actual patient (no trouble in mannequins or without it being inserted). It always binds up and catches at the distal port. Did you do anything special with the patient?


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## Handsome Robb (Feb 24, 2012)

PoeticInjustice said:


> I've never been able to insert the bougie through in an actual patient (no trouble in mannequins or without it being inserted). It always binds up and catches at the distal port. Did you do anything special with the patient?



I just put a little lube on it and the pt was in a pretty good anatomical position too so I'm sure that helped. To be honest I've only done it once and seen it done a handful of times but I've never seen it get stuck. I could see how that possibility is there though. I


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## rhan101277 (Feb 24, 2012)

NVRob said:


> I just put a little lube on it



That is what she said


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## jjesusfreak01 (Feb 25, 2012)

PoeticInjustice said:


> I've never been able to insert the bougie through in an actual patient (no trouble in mannequins or without it being inserted). It always binds up and catches at the distal port. Did you do anything special with the patient?



Never tried it on a real patient, but the problems when I practiced with the manakins seemed to be: 

1. Stiff anatomy, the king would bend enough that the bougie got caught.

2. Different sizes and models of king airways are shaped a little differently at the distal port. Some work most of the time, some not at all.


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## NomadicMedic (Feb 26, 2012)

triemal04 said:


> Unless the "LMA Flexible" is meant to be an i-gel, that's not quite a rining endorsement for not considering it's use.  Part of the reasoning behind using an i-gel is that it is supposed to seat itself in the esophageus "naturally" without any extra compression of the surrounding tissues.
> 
> I can see overinflation of the combitube, king, or LMA being a problem, although the size of the decrease is surprising.
> 
> ...



Yeah, I certainly wouldn't call it definitive proof, but it certainly is an interesting study. I’ve only seen one other study, done in Japan, which compares ETT to SGA and survival to discharge, with no statistical difference. And how similar is a pig's carotid vascular structure compared to humans?


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