i-gel: A Game-Changer in Fiberoptic Intubation

The i-gel supraglottic airway device has become one of the most widely studied conduits for fiberoptic-guided tracheal intubation, offering a reliable channel from the mouth to the vocal cords through which a bronchoscope and endotracheal tube can be passed. Its soft, gel-like cuff requires no inflation, and its wide internal bore gives the fiberoptic scope a relatively clear path toward the glottis. Across dozens of randomized trials, the i-gel has performed on par with or better than purpose-built intubating airway devices, and it does so at a lower per-unit cost than many of them.

Why the Design Works for Fiberoptic Intubation

The i-gel was not originally designed as an intubation conduit. It was built as a second-generation supraglottic airway for ventilation, with a non-inflatable thermoplastic elastomer cuff that molds to the patient’s pharyngeal anatomy as it warms. That same design, however, gives it several features that happen to make fiberoptic intubation easier. The cuff seats itself over the laryngeal inlet without requiring the user to fine-tune inflation pressures, and the broad, elliptical airway tube creates a generous channel for scope passage.

When clinicians pass a fiberoptic bronchoscope through the i-gel, the view of the vocal cords tends to be good. One randomized trial comparing the i-gel to the classic laryngeal mask airway found that fiberoptic view scores were significantly better with the i-gel.¹ That alignment matters: if the scope tip enters the airway tube and immediately faces the glottic opening, the operator spends less time hunting for landmarks and more time threading the endotracheal tube into the trachea.

Head-to-Head With Purpose-Built Intubating Devices

The devices most often compared with the i-gel for fiberoptic-guided intubation are the intubating laryngeal mask airway (ILMA, also called the LMA Fastrach), the LMA Protector, the Ambu AuraGain, and the air-Q. The recurring finding across trials is that the i-gel matches or rivals these devices even though most of them were specifically engineered for intubation.

In a trial of 160 patients with predicted difficult airways, fiberoptic-guided intubation succeeded on the first attempt in 96% of cases with the i-gel, compared to 90% with the ILMA. The difference was not statistically significant, but the i-gel group used a standard, inexpensive PVC tracheal tube rather than a proprietary one.² A separate prospective randomized study reached a similar conclusion, finding no significant difference in total intubation time or ease of intubation between the i-gel and the LMA Fastrach, and suggested the i-gel may be a reliable, cost-effective alternative.³

Against the LMA Protector, a randomized trial comparing fiberoptic intubation success found no significant difference between the two, and a separate comparison found comparable tracheal intubation success rates with no meaningful gap in glottic view or ease of tube passage.⁴ In a manikin crossover trial, total fiberoptic intubation time through the i-gel was about 42 seconds, compared to 56 seconds for both the AuraGain and the iLTS-D.⁵

Difficult Airways and Uncooperative Patients

Fiberoptic intubation through a supraglottic airway earns its keep most clearly in patients whose anatomy or medical conditions make direct laryngoscopy risky or impossible. The i-gel has been reported successful in patients with genetic syndromes, intellectual disability, and predicted difficult airways who could not cooperate with standard techniques. In one early case series, two uncooperative adults with learning disabilities and complex dental needs were intubated fiberoptically through the i-gel on the first attempt without complications, after the device established a patent airway immediately following induction.⁶

A larger prospective study enrolled patients with predicted difficult airways and placed the i-gel while they were still awake and breathing on their own. Every patient was successfully intubated. Average insertion time for the i-gel was about 38 seconds, and the subsequent fiberoptic intubation took roughly 37 seconds. No serious adverse events or airway trauma occurred.⁷ Those numbers are worth pausing on: under a minute and a half from device insertion to secured airway in patients whose anatomy made conventional intubation look dicey.

Awake Insertion and Spontaneous Breathing

One of the i-gel’s practical advantages is that it can be placed while a patient is still breathing spontaneously, before full general anesthesia. This avoids the dreaded “cannot intubate, cannot ventilate” scenario, because the i-gel secures ventilation first. Once the device is seated and the patient is oxygenating comfortably, the bronchoscope is passed through at a controlled pace.

A prospective observational study specifically assessed this approach in patients with anticipated difficult airways. After topical anesthesia to the oropharynx and light sedation, the i-gel was inserted in spontaneous ventilation. Oxygen saturation remained stable throughout the procedure, and all patients were successfully intubated. The researchers concluded that inserting the i-gel in a spontaneously breathing patient effectively eliminates the ventilation-failure risk, giving the team a secure bridge to definitive intubation.⁸

The Aintree Catheter Technique

A standard adult endotracheal tube (typically 7.0 mm or larger) fits through the i-gel’s airway channel, but the fit can be tight, and the tube tip sometimes catches on the device’s distal aperture. One workaround is the Aintree intubation catheter, a hollow bougie that can be loaded onto a pediatric fiberoptic bronchoscope. The scope-and-catheter assembly is threaded through the i-gel, through the vocal cords, and into the trachea. The i-gel and scope are then removed, leaving the Aintree catheter in place as a rail over which a full-sized endotracheal tube is slid into position.

Case reports have described this technique working smoothly when the i-gel was already in place as a rescue airway. The authors of one such report concluded that the i-gel can serve not only as a substitute when intubation fails but also as a reliable conduit for subsequent fiberoptic intubation via the Aintree catheter.⁹ A randomized trial comparing the i-gel and LMA Protector as conduits for Aintree catheter-guided fiberoptic intubation found the i-gel had a lower complication rate and more stable hemodynamics, leading the authors to suggest it may be preferable for this technique.¹⁰

Choosing the Right Endotracheal Tube

The type of endotracheal tube threaded through the i-gel matters more than you might expect. A study comparing three tube types found that a standard PVC tube achieved the highest first-attempt success rate (68%) and required the least time for intubation through the i-gel, compared to a flexible reinforced tube and a purpose-built ILMA tube. The overall success rate with the PVC tube was about 88%, while the other tube types trailed behind.¹¹ This is somewhat counterintuitive: you might guess that a soft, flexible tube would navigate the curves more easily, but the stiffer PVC tube holds its shape and follows the fiberoptic scope’s path more predictably. The practical takeaway is that reaching for a standard tube when using the i-gel as a conduit is often the best choice.

Tube size also deserves attention. The internal diameter of the i-gel’s airway channel limits how large a tube you can pass. A size 3 i-gel (suitable for a 30–60 kg patient) accommodates a 6.0 mm cuffed tube comfortably, but a 7.0 mm tube will be a tighter squeeze. Sizing up the i-gel by one size can help if a larger tube is needed, though that trades off against cuff fit in the pharynx.

Cervical Spine Immobilization

Trauma patients in a cervical collar present one of the trickiest intubation scenarios. The collar limits mouth opening and prevents the head-tilt maneuver that normally opens the airway for laryngoscopy. Fiberoptic intubation through a supraglottic airway sidesteps much of this problem because neither the i-gel insertion nor the scope passage requires significant neck movement.

A trial comparing the i-gel and the ILMA as conduits for fiberoptic intubation in patients with simulated cervical spine immobilization found first-attempt success rates of about 99% for the i-gel group and 95% for the ILMA group. The difference was not statistically significant, but both devices performed well enough that the authors considered them comparably effective in this setting.¹² For trauma teams, having an i-gel on the airway cart means one device can handle both ventilation and fiberoptic-guided intubation without removing the collar or manipulating the neck.

Pediatric Fiberoptic Intubation

Children pose their own challenges: smaller airways, less tolerance for apnea, and anatomy that changes with age. The i-gel comes in sizes as small as size 1 (for neonates 2–5 kg), and the pediatric literature on its use as a fiberoptic conduit is growing. A randomized trial comparing the i-gel and the air-Q in children found no significant difference in median time to successful intubation (about 56 seconds for the i-gel versus 63 seconds for the air-Q), and success rates and airway leak pressures were similar between devices.¹³

A manikin study focused specifically on the learning curve for pediatric fiberoptic intubation through supraglottic airways found that all 30 participants reached proficiency within 8 to 25 practice attempts, and the overall success rate was about 93%. Procedure time dropped sharply after just the second trial, suggesting the skill is learnable without a huge number of repetitions.¹⁴ That said, the bottleneck step was advancing the endotracheal tube past the vocal cords after the scope was in the trachea, which accounted for roughly half of total procedure time and the vast majority of failures. Practicing that specific step seems to matter most.

The Learning Curve for Novices

One of the strongest arguments for the i-gel in fiberoptic intubation is how quickly new users pick it up. In a manikin study comparing the i-gel to the Aura-i, novices achieved significantly faster insertion times with the i-gel, both at initial training (about 12 seconds versus 22 seconds) and at a 90-day follow-up reassessment (about 15 seconds versus 29 seconds). Participants also rated the i-gel as significantly easier to manipulate.¹⁵ A separate randomized study that tested participants with no prior experience in the technique found that most succeeded at fiberoptic intubation through the i-gel despite their lack of background, leading the authors to describe the technique as genuinely “low skill.”¹⁶

Skill retention is worth flagging because it cut both ways. The manikin study that tested novices at 90 days found that times increased compared to initial training for both the i-gel and the Aura-i, though the i-gel still held an advantage.¹⁵ If you learn the technique and then go months without using it, expect some rust. Periodic refresher practice on a manikin appears worthwhile.

Severely Obese Patients

Obesity makes both mask ventilation and direct laryngoscopy harder. Excess soft tissue in the pharynx, a shorter thyromental distance, and reduced functional residual capacity all conspire against the airway team. A prospective randomized trial compared fiberoptic intubation through the i-gel and the AuraGain in severely obese patients (average BMI around 39). Mean intubation time was virtually identical: about 54 seconds for the i-gel and 56 seconds for the AuraGain, with no significant differences in any other parameter measured.¹⁷ The finding that the i-gel performed just as well in this population is reassuring, since these are exactly the patients in whom you most want a backup plan if laryngoscopy fails.

Prehospital and Emergency Settings

Fiberoptic intubation through an i-gel is primarily a controlled operating-room technique, but the i-gel itself has a growing presence in prehospital and emergency airway management. During the COVID-19 pandemic, some EMS systems transitioned to supraglottic airways (including the i-gel) as their primary advanced airway device to reduce aerosol generation during intubation. A study comparing this approach to standard endotracheal intubation by paramedics found dramatically different first-pass success rates: 96% for the supraglottic airway group versus 68% for direct intubation. Placement was also faster, averaging about 6 minutes for the supraglottic airway versus nearly 10 minutes for intubation.¹⁸

In a simulation study of intubation during active chest compressions, a setting where glottic visualization is often impossible, blind intubation through the i-gel was actually faster than fiberoptic-guided intubation through the same device (about 15–18 seconds versus 27–29 seconds). Both approaches succeeded, but the researchers noted that in the chaos of active CPR, the simplicity of blind passage through the i-gel may trump the precision of the bronchoscope.¹⁹ The broader point: the i-gel can serve as a bridge. Place it fast to secure ventilation, and if definitive intubation is needed later, pass a scope through it at that point.

The i-gel Plus Redesign

The original i-gel was not optimized for intubation, and tube passage sometimes hung up at the distal end of the airway channel. The manufacturer responded with the i-gel Plus, which incorporates a ramp at the airway tube orifice designed to redirect the fiberscope and endotracheal tube toward the vocal cords more reliably.²⁰ The intent is to reduce the time spent searching for the glottic opening and to smooth the tube’s passage from the device into the trachea. Early data suggest the redesign achieves this, with quicker visualization of the vocal cords and faster tube advancement compared to the standard i-gel. For clinicians who already favor the i-gel as a fiberoptic conduit, the Plus version addresses what was arguably the device’s main ergonomic shortcoming.

Cost and the Practicality Argument

Part of the i-gel’s appeal is that it is a single-use, relatively inexpensive device that does not require a dedicated intubating laryngeal mask or proprietary endotracheal tube. The ILMA, by comparison, typically requires its own specially shaped silicone tube, adding cost and inventory complexity. When a standard PVC endotracheal tube works well through the i-gel, the consumable cost per intubation drops further.

A large randomized trial in out-of-hospital cardiac arrest (the AIRWAYS-2 study) compared overall costs between i-gel and tracheal intubation as primary airway strategies. Total costs per patient at six months were similar, at roughly £3,570 for the i-gel group and £3,413 for the intubation group, but the differences were small and surrounded by wide uncertainty.²¹ That study was not specifically about fiberoptic intubation, but it illustrates a broader point: the i-gel does not add meaningful cost to airway management, and when it doubles as a fiberoptic conduit, you get two functions from one device already sitting on the cart.