A randomized controlled trial comparing conventional versus reverse insertion techniques for i-gel supraglottic airway placement

• Author Details:   
• Thongam Sheityabala Devi
• Saswati Das
• Ayesha Pattnaik
• Shreyasi Mallick ^*

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Background and Aims: Supraglottic airway (SGA) devices are pivotal for airway management and can serve as effective conduits for tracheal intubation. The i-gel® is a commonly used second-generation SGA. While its conventional insertion technique is well-established, a 'reverse' technique has been proposed to potentially improve performance. This randomized controlled trial aimed to compare the conventional versus the reverse i-gel insertion technique with respect to first-attempt placement success and the efficacy of subsequent blind tracheal intubation.

Materials and Methods: Eighty adult patients (aged 18–60 years, American Society of Anesthesiologists physical status I/II) undergoing elective surgeries under general anesthesia were enrolled. They were randomly allocated into two groups (n=40 each): Group C (Conventional i-gel insertion) and Group R (Reverse i-gel insertion). Following correct device placement, blind tracheal intubation through the i-gel was attempted. The primary outcomes were the first-attempt success rate for both i-gel placement and blind tracheal intubation. Secondary outcomes included total insertion and intubation times, number of attempts required, oropharyngeal leak pressure (OLP), and the incidence of postoperative airway complications (sore throat, hoarseness).

Results: The reverse insertion technique (Group R) demonstrated statistically significant superiority across several metrics. It yielded a significantly higher first-attempt insertion success rate (97.5% vs. 72.5%; p = 0.002), a markedly shorter mean insertion time (4.72 ± 1.17 s vs. 11.22 ± 2.21 s; p = 0.001), and a higher OLP (34.25 ± 2.42 cmH₂O vs. 28.07 ± 3.68 cmH₂O; p = 0.003) compared to the conventional technique. Furthermore, Group R also showed a greater first-attempt success rate for blind tracheal intubation (32.5% vs. 12.5%; p = 0.005) and a faster mean intubation time (17.97 ± 3.69 s vs. 22.77 ± 9.46 s; p = 0.014). The incidence of postoperative airway complications was low and comparable between both groups.

Conclusion: The reverse technique for i-gel insertion is demonstrably superior to the conventional method. It offers a higher first-attempt success rate, faster and more reliable device placement, a better seal, and improved efficacy for blind tracheal intubation, without increasing postoperative morbidity. It should be considered a valuable alternative in clinical airway management.