Comment on published article: Assessment of awake i-gel™ insertion for fiberoptic-guided intubation in patients with predicted difficult airway: A prospective, observational study.

Madam,

We read with interest the article by Ludeña et al.[1] on “Assessment of awake i-gel™ insertion for fiberoptic-guided intubation in patients with predicted difficult airway: A prospective, observational study.” We appreciate the authors’ efforts in doing the above study. However, we have several concerns and queries regarding the methodology of this study.

We agree with authors that in patients with anticipated difficult airway, awake intubation is the first choice;[2] the awake intubation in such cases is mostly done with airway preparation with local anesthetic instillation and giving recurrent laryngeal nerve block and transtracheal local anesthetics. In this study, patients were given fentanyl, midazolam, and propofol to ease the insertion of i-gel™. Combination of fentanyl, midazolam, and propofol even in such medium doses can easily make patients apneic and also, in many cases, may trigger a laryngospasm with airway instrumentation (i-gel™) in inadequate depth of anesthesia.

Author cited two references[34] and quoted that i-gel™ was used previously in spontaneously breathing patients who are either awake or under light sedation. In fact, in first study, general anesthesia was induced in every patient before placing supraglottic airway device (SAD) (i-gel™ in one group and ProSeal™ laryngeal mask airway in second group) and other reference included management of three cases with i-gel™ for resuscitation and emergency situation for airway obstruction by some form of sedation or alcohol intoxication. Also, use of SAD is not advisable or difficult to pass or may be contraindicated in patients with reduced mouth opening.[5] Use of video laryngoscopes in patients with predicted difficult airway but adequate mouth opening results in higher frequency of successful intubations, and a higher frequency of first attempt intubations (Level A1-B evidence).[5]

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Conflicts of interest

There are no conflicts of interest.