Which way does an i-gel go in?

October 11, 2025 •

4 min read

Studies show the i-gel supraglottic airway can have a first-pass success rate of over 82% in out-of-hospital settings [1.6.1]. Knowing the answer to 'Which way does an i-gel go in?' is crucial for leveraging its efficiency in emergency and anesthetic scenarios.

Quick Summary

The i-gel is inserted downwards and backwards along the hard palate. This guide details the step-by-step technique, sizing, and confirmation methods for proper placement of this supraglottic airway device.

Key Points

Direction: The i-gel is inserted downwards and backwards, following the curve of the hard palate [1.2.5].
Cuff: It uses a non-inflatable, gel-like cuff that anatomically seals the laryngeal inlet [1.5.1].
Sizing: Correct size selection is critical and is based on the patient's ideal body weight [1.9.3].
Confirmation: Placement must be confirmed with bilateral breath sounds, chest rise, and waveform capnography (ETCO2) [1.2.3].
Speed: The i-gel is designed for rapid insertion, often achievable in less than 5 seconds by trained providers [1.3.1].
Key Feature: An integrated gastric channel allows for passive drainage or active suctioning of stomach contents [1.2.1].
Contraindications: Do not use in patients with an intact gag reflex, trismus, or known esophageal disease [1.4.5].

Understanding the i-gel Supraglottic Airway

The i-gel is a single-use, second-generation supraglottic airway device (SAD) used in anesthesia and emergency medicine to manage a patient's airway [1.4.3, 1.5.6]. Unlike traditional laryngeal mask airways (LMAs), the i-gel features a non-inflatable cuff made from a soft, gel-like thermoplastic elastomer [1.5.1, 1.5.6]. This material is designed to create an anatomical seal over the laryngeal framework without the need for cuff inflation, potentially reducing insertion time and minimizing tissue compression trauma [1.5.1, 1.5.4]. The device also includes an integrated bite block to prevent occlusion from the patient's teeth and a gastric channel that allows for the passage of a nasogastric tube to manage gastric contents [1.2.1, 1.2.5]. Its use is indicated for apneic, unconscious patients who lack a gag reflex and require an advanced airway [1.2.3].

Indications and Contraindications

Indications for i-gel use primarily involve the need for an advanced airway in an unresponsive patient without a gag reflex, especially in cases of cardiac arrest or when endotracheal intubation is unsuccessful or not feasible [1.2.3, 1.4.3].

Contraindications are critical to observe for patient safety. An i-gel should not be used in patients who:

Have an intact gag reflex [1.4.2].
Suffer from trismus (limited mouth opening) [1.4.5].
Have known esophageal disease or trauma [1.4.2].
Have ingested a caustic substance [1.4.5].
Have obstructions, masses, or significant trauma within the airway (larynx/pharynx) [1.2.3].

Step-by-Step Insertion Guide: Which Way Does an I-gel Go In?

Correct insertion is a smooth, continuous motion that follows the natural anatomy of the oropharynx. Proficient users can often achieve placement in under five seconds [1.3.1].

1. Preparation:

Select the Correct Size: Sizing is based on the patient's ideal body weight [1.7.5, 1.9.3]. Sizing is color-coded for quick identification. For example, a small adult (30-60kg) typically requires a size 3 (yellow), a medium adult (50-90kg) a size 4 (green), and a large adult (90kg+) a size 5 (orange) [1.9.1].
Position the Patient: The ideal position is the "sniffing position" (head extended, neck flexed), though insertion in a neutral position is possible for suspected spinal injuries [1.2.3, 1.4.3].
Pre-oxygenate: Ventilate the patient with a bag-valve-mask (BVM) to increase oxygen reserves [1.2.3, 1.8.1].
Prepare the Device: Remove the i-gel from its protective cradle. Apply a small amount of water-based lubricant to the back, sides, and front of the soft cuff tip [1.2.3]. Ensure no lubricant blocks the airway opening [1.2.3].

2. Insertion:

Orient the Device: Grasp the i-gel firmly along the integral bite block. The cuff outlet must be facing towards the patient's chin [1.2.2].
Open the Mouth: Gently press down on the patient's chin. It is not necessary to place fingers inside the patient's mouth [1.2.2, 1.2.5].
Introduce and Advance: Introduce the soft tip into the mouth, directing it towards the hard palate [1.2.3]. Glide the device downwards and backwards along the hard palate with a continuous, gentle push [1.2.5]. The device is designed to follow the natural curve of the pharynx.
Feel for Resistance: Continue advancing the i-gel until a definitive resistance is felt [1.2.5]. This indicates the tip has seated in the upper esophageal opening. Do not use excessive force [1.2.5].

3. Confirmation and Securing:

Check Placement: For adult sizes, the horizontal line on the bite block should be aligned with the patient's incisors [1.7.4]. For pediatric sizes, insertion continues until resistance is met [1.2.3].
Confirm Ventilation: Attach a BVM and ventilate. Confirm successful placement by observing equal chest rise, auscultating for bilateral breath sounds, and noting the absence of epigastric sounds [1.8.1]. The gold standard for confirmation is monitoring for a continuous waveform with end-tidal capnography (ETCO2) [1.2.3].
Secure the Device: Once placement is confirmed, secure the i-gel using the provided support strap attached to the hook ring or with tape from maxilla to maxilla [1.2.5].

Troubleshooting Common Issues

Air Leak: If an air leak is heard, it may be due to malposition or over-ventilation. Try adjusting the device by advancing or pulling it back slightly, or attempt re-insertion, potentially with a larger size. Ensure ventilations are slow and gentle [1.7.3].
Resistance During Insertion: If early resistance is met, a gentle jaw thrust or a slight rotation of the device may help overcome it [1.2.3]. Ensure the patient is adequately sedated and relaxed.
Gag Reflex Returns: If the patient's reflexes return, immediately turn them onto their side, remove the device, and be prepared to suction the airway [1.8.1].

Comparison: i-gel vs. Laryngeal Mask Airway (LMA)


Feature	i-gel	Traditional LMA (e.g., LMA Classic)
Cuff	Non-inflatable, made of a soft thermoplastic elastomer [1.5.1].	Inflatable, typically made of silicone [1.5.6].
Insertion Time	Generally faster; studies show mean insertion times of ~16-30 seconds [1.5.1, 1.5.2].	Generally slower due to the need for cuff inflation/deflation; studies show mean times of ~26-41 seconds [1.5.1, 1.5.2].
First-Attempt Success	Often higher; some studies report a 100% first-attempt success rate [1.5.1].	High, but may be slightly lower; one study reported an 84% first-attempt success rate [1.5.1].
Seal Pressure	Provides an effective seal sufficient for positive pressure ventilation [1.5.2]. Some LMAs may provide a higher seal pressure [1.5.2, 1.5.4].
Postoperative Sore Throat	Often results in a lower incidence of sore throat due to the non-inflatable cuff [1.5.2].	Higher incidence of sore throat may be associated with cuff pressure on tissues [1.5.2].
Gastric Access	Integrated gastric channel is a standard feature [1.2.1].	Varies by model; some, like the LMA ProSeal, have a drainage tube, while others do not [1.5.6].

Conclusion

The i-gel is an innovative supraglottic airway that simplifies and expedites airway management. The correct insertion technique involves guiding the device downwards and backwards along the hard palate until it naturally seats over the laryngeal opening. Its non-inflatable cuff and high first-pass success rate make it a valuable and efficient alternative to traditional LMAs in both pre-hospital and hospital settings. Successful use hinges on proper sizing, adequate lubrication, correct insertion trajectory, and diligent confirmation of placement.

For more information from the manufacturer, visit Intersurgical's i-gel page. [1.9.4]

Frequently Asked Questions

An i-gel is a type of supraglottic airway device (SAD) used to keep a patient's airway open during anesthesia or resuscitation. It features a unique, soft, non-inflatable cuff that creates a seal over the top of the larynx [1.5.1, 1.5.6].

The i-gel size is chosen based on the patient's ideal body weight. For example, a size 4 (green) is for patients weighing 50-90 kg, while a size 3 (yellow) is for those 30-60 kg [1.9.1].

No, the i-gel has a non-inflatable cuff made of a thermoplastic elastomer. It is designed to conform to the patient's anatomy as it warms to body temperature to create a seal [1.5.1, 1.5.6].

The i-gel is generally faster and easier to insert than a traditional LMA because it does not require cuff inflation. Studies have also shown it may result in a lower incidence of postoperative sore throat [1.5.1, 1.5.2].

Proper placement is confirmed by observing equal chest rise and fall, listening for clear breath sounds over both lungs, and using waveform capnography to detect continuous end-tidal CO2 (ETCO2) [1.2.3, 1.8.1].

Contraindications include the presence of a gag reflex, limited mouth opening (trismus), suspected ingestion of caustic substances, and trauma or masses in the pharynx or larynx [1.4.5, 1.2.3].

If you encounter early resistance, you can try applying a gentle jaw thrust or slightly rotating the device. Do not apply excessive force. If resistance persists, you may need to reconsider the device size or patient positioning [1.2.3, 1.7.4].