How to apply iGel?: A Step-by-Step Guide for Medical Professionals

Studies show the iGel® supraglottic airway has a first-pass success rate as high as 83-93% in prehospital settings [1.7.2, 1.7.4]. This guide explains how to apply iGel® effectively, from patient preparation to confirming placement.

Quick Summary

A detailed walkthrough of the iGel® supraglottic airway device insertion process. Covers patient preparation, correct sizing based on weight, the step-by-step application technique, and methods for confirming proper placement.

Key Points

• Sizing is Crucial: iGel® size selection is based on the patient's ideal body weight, which is critical for a proper seal [1.3.1, 1.3.2].

• Lubricate, Don't Overdo: Use a thin layer of water-based lubricant on the cuff, ensuring no bolus obstructs the airway opening [1.2.5].

• Technique Matters: Insert by gliding along the hard palate with a gentle, continuous push until firm resistance is met [1.9.5].

• Confirm with Capnography: While chest rise and auscultation are key, waveform capnography is the gold standard for confirming placement [1.2.6, 1.4.1].

• Faster Than LMA: The iGel® is generally faster and easier to insert than a traditional LMA because it has no inflatable cuff [1.5.1, 1.5.5].

• Troubleshoot Leaks: Air leaks are often due to malposition or over-ventilation; adjust the device or ventilation technique before re-attempting with a different size [1.8.5].

• Know Contraindications: Do not use in patients with a gag reflex, known airway obstruction, or recent caustic ingestion [1.6.1, 1.6.3].

The iGel® is a second-generation, single-use supraglottic airway device (SAD) made from a soft, gel-like thermoplastic elastomer [1.5.1]. Unlike traditional laryngeal mask airways (LMAs), it does not have an inflatable cuff, which simplifies and speeds up the insertion process [1.5.1]. Its anatomically designed shape creates a seal around the laryngeal inlet [1.9.5]. This guide provides a comprehensive overview for medical professionals on how to apply iGel®.

Indications and Contraindications

Before any procedure, it's critical to assess the patient for suitability.

Indications

• Need for an advanced airway in an unconscious, apneic patient who lacks a protective gag reflex [1.6.1, 1.6.6].
• Use in cardiac arrest protocols [1.6.2].
• As a primary airway device in anesthesia for certain procedures [1.5.5].
• When endotracheal intubation (ETI) is unsuccessful after two attempts or is not advised [1.6.2, 1.6.6].

Contraindications

• Patients with an intact gag reflex [1.6.3].
• Known airway obstruction from a foreign body or pathology [1.6.1].
• Significant trauma to the oropharynx, neck, or trachea [1.6.1].
• Patients who have ingested caustic substances [1.6.3].
• Limited mouth opening (trismus) [1.6.4].

Step-by-Step iGel® Application

Proper technique is crucial for successful placement and patient safety. Proficient users can often insert the device in under five seconds [1.2.2].

1. Preparation

• Select the Correct Size: Sizing is based on the patient's ideal body weight [1.4.1]. Always consult the manufacturer's guide, but general sizes are:
  • Size 5 (Orange): Large Adult (90+ kg / 200+ lbs) [1.3.3]
  • Size 4 (Green): Medium Adult (50-90 kg / 110-200 lbs) [1.3.3]
  • Size 3 (Yellow): Small Adult (30-60 kg / 65-130 lbs) [1.3.3]
  • Pediatric sizes are also available for infants and children [1.3.2].
• Inspect the Device: Remove the iGel® from its protective cradle and inspect it for damage or obstructions [1.9.1].
• Lubrication: Apply a thin layer of a water-based lubricant to the back, front, and sides of the soft cuff [1.2.5]. Avoid leaving a bolus of lubricant in the bowl of the device [1.2.5].
• Patient Positioning: Position the patient in the 'sniffing' position (head extended, neck flexed) unless contraindicated by suspected spinal injury, in which case a neutral position with in-line stabilization should be maintained [1.2.6, 1.9.4].
• Pre-oxygenate: If possible, pre-oxygenate the patient with a bag-valve mask (BVM) [1.2.6].

2. Insertion Technique

1. Grasp the Device: Hold the iGel® firmly along the integral bite block [1.9.4].
2. Open the Mouth: Gently press down on the patient's chin to open the mouth. It is not necessary to insert fingers into the mouth [1.2.2].
3. Introduce the Tip: Insert the soft tip of the device into the mouth, aiming towards the hard palate [1.2.6].
4. Advance the Device: Glide the device downwards and backwards along the hard palate with a continuous, gentle push until a definitive resistance is felt [1.9.5]. This resistance indicates the tip has seated in the upper esophageal opening [1.9.5].
5. Confirm Position: The incisors should be resting on the integral bite block [1.9.5]. For adult sizes 3, 4, and 5, a black horizontal line on the bite block should align with the teeth [1.2.1, 1.4.6].

3. Confirmation of Placement

Successful placement must be confirmed immediately.

• Ventilate: Attach a BVM and ventilate, observing for equal bilateral chest rise [1.4.5].
• Auscultation: Listen for clear breath sounds over both lungs (mid-axillary) and the absence of sounds over the stomach (epigastrium) [1.4.1, 1.4.6].
• Capnography: The gold standard for confirming placement is continuous waveform capnography to monitor end-tidal CO2 (EtCO2) [1.2.6, 1.4.1].
• Other Signs: Look for improvement in skin color and rising SpO2 levels [1.4.1].

4. Securing the Device

Once placement is confirmed, secure the iGel® using the provided strap attached to the hook ring or by taping it from maxilla to maxilla [1.2.6, 1.9.5]. Ensure the strap is not too tight [1.9.5].

Comparison: iGel® vs. LMA

The iGel® and traditional Laryngeal Mask Airways (LMAs) are both SADs but have key differences.

Feature	iGel®	Traditional LMA (e.g., LMA Classic®)
Cuff	Non-inflatable, made of thermoplastic elastomer [1.5.1]	Inflatable silicone or PVC cuff [1.5.1]
Insertion Time	Significantly faster; no cuff inflation required [1.5.1, 1.5.5]	Slower; requires time for cuff inflation and pressure check [1.5.1]
Ease of Insertion	Generally considered easier with a higher first-pass success rate [1.5.3, 1.5.1]	Can be more complex, with potential for the cuff to fold over [1.5.3]
Airway Seal	Provides an effective seal that can improve as it warms to body temperature [1.5.3]	Seal pressure can be higher but may cause more tissue compression [1.5.3, 1.5.2]
Gastric Access	Includes a dedicated gastric channel for drainage or decompression [1.6.5]	Not present in all models (e.g., LMA Classic®); available in others (e.g., LMA ProSeal®) [1.5.3]
Trauma/Sore Throat	Lower incidence of sore throat and mucosal injury [1.5.3, 1.5.2]	Higher incidence of sore throat, potentially due to cuff pressure [1.5.3, 1.5.4]

Troubleshooting and Complications

• Air Leak: If an air leak occurs, it may be due to malposition or over-ventilation. Try to gently advance or pull back the device to reseat it [1.8.5]. Ensure ventilations are slow and gentle [1.8.5]. If the leak persists, consider removing the device and reinserting a larger size [1.8.5].
• Failure to Insert: If early resistance is met, a jaw thrust maneuver or slight rotation of the device may help [1.2.6]. Do not use excessive force. No more than three insertion attempts should be made [1.9.5].
• Complications: Potential complications include laryngospasm, trauma to the airway structures, and gastric regurgitation or aspiration [1.8.5]. The presence of a gag reflex returning requires immediate removal of the device [1.4.1].

Conclusion

The iGel® is an effective and rapidly deployable supraglottic airway device. Its cuffless design and high first-pass success rate make it a valuable tool in both emergency medicine and anesthesia [1.5.1, 1.7.4]. Proper training on sizing, insertion technique, and confirmation methods is essential for its safe and effective use. When applied correctly, the iGel® provides a secure airway, facilitates ventilation, and is associated with fewer complications like sore throat compared to some other SADs [1.5.3].

For more detailed information, consult the manufacturer's official documentation.

Official i-gel® User Guide by Intersurgical

Frequently Asked Questions

What is the main advantage of the iGel® over a cuffed laryngeal mask airway (LMA)?

The main advantage is its non-inflatable cuff made of a soft, gel-like material. This design allows for faster and often easier insertion because it eliminates the need for cuff inflation and pressure monitoring [1.5.1, 1.5.3].

How do you choose the right size iGel®?

The correct size is determined by the patient's ideal body weight. Sizes range from 1 for neonates (2-5 kg) up to size 5 for large adults (90+ kg) [1.3.2, 1.3.3]. However, clinical assessment of the patient's anatomy is also recommended [1.3.1].

What is the best way to confirm iGel® placement?

The most reliable method is to use continuous waveform capnography (EtCO2) [1.2.6]. This should be combined with clinical signs like observing bilateral chest rise, auscultating for breath sounds over the lungs, and confirming the absence of air sounds over the stomach [1.4.1].

What should you do if you notice an air leak after inserting an iGel®?

First, ensure you are not over-ventilating with the BVM. If the leak persists, try adjusting the device by gently advancing or retracting it. If that fails, the device may be the wrong size, and you may need to remove it and reinsert a larger size [1.8.5].

Can you insert anything into the iGel's gastric channel?

Yes, the gastric channel is designed to allow the insertion of a suction catheter or nasogastric tube to decompress the stomach and reduce the risk of aspiration [1.2.6, 1.4.5]. The appropriate size of the catheter depends on the iGel® size [1.3.3].

In what position should the patient be for iGel® insertion?

The recommended position is the 'sniffing position,' with the head extended and neck flexed [1.9.4]. If a cervical spine injury is suspected, maintain the head in a neutral, in-line position [1.2.6].

When is iGel® use contraindicated?

Contraindications include patients with an intact gag reflex, known airway obstruction (e.g., foreign body, mass), significant airway trauma, or after ingestion of a caustic substance [1.6.1, 1.6.3, 1.6.4].