Blind intubation via an i-gel® in the prone patient: Some concerns

It was useful to note from van Dijck and colleagues’ recent study of intubation in the prone position that the success rate of i-gel® (Intersurgical Ltd, Wokingham, Berkshire, UK) insertion in the prone position is high. ¹ However, three things cause us concern about the study design:

This study was designed to achieve a 70% success rate of intubation in the prone position—thereby subjecting 30% of participants to five airway manipulations (i-gel insertion, three intubation attempts via the i-gel in the prone position and finally an intubation attempt in the supine position). Intubation in the prone position is by definition a difficult intubation; as evidenced by the NAP4 study, repeated airway interventions cause airway trauma—and frequently turn difficult intubations into can’t intubate, can’t oxygenate (CICO) situations. ²

We see no existing manikin design of this study—we question why it was carried out with live patients, when the safer and likely just as informative option of using high fidelity manikins or cadavers was available to the authors.

The authors claim to be investigating a low resource solution to unintended extubation in the prone position. The specialised endotracheal tube used in this study (VivaSight-SL single-lumen tube; Ambu A/S, Ballerup, Denmark) is not widely used. The option of utilising an endotracheal tube guided by a fibreoptic bronchoscope (FOB) for all protocol attempts would have been a more ethically defensible study protocol. FOBs are generally available within seconds in the modern operating theatre, and allow for intubation under visual guidance that is likely to cause less airway trauma than blind intubation—a fact noted by the authors themselves.

‘First do no harm’ is our universal first principle—this intention appears to have been lost in the design of this study. We do commend the authors on their conclusion that blind intubation via an i-gel in the prone position is not recommended.