Use of the i-gel™ supraglottic airway device in a patient with subglottic stenosis -a case report-
A 50-year-old male (182.9 cm, 78.5 kg) was scheduled for arthroscopic debridement of the left shoulder. The patient had a history of old pulmonary tuberculosis and TB pleurisy (20 years ago) and had no previous surgeries. His Mallampati class was 2 and he had been NPO for more than 8 hours. He had a bull neck with limited neck extension. His thyromental distance was 6 cm and mouth opening was 4 cm.\nChest X-ray () showed a lesion suspicious for tracheal stenosis, but it's formal decipher by radiologist was no active lung lesion. He had no upper airway narrowing symptom and no history of endotracheal intubation. So, no further evaluation of airway have been done before surgery. In the operating room, electrocardiogram (lead II), pulse oximetry, non-invasive blood pressure, end-tidal carbon dioxide concentration (ETCO2) and bispectral index were monitored. Intravenous glycopyrrolate 0.2 mg was given as premedication. Following 3 minutes of preoxygenation, general anesthesia was induced with lidocaine 60 mg, propofol 120 mg, rocuronium 60 mg and remifentanil 0.5-1.0 mcg/kg/min. On direct laryngoscopy, Cormack and Lehane score was grade 4. We tried to insert a 7.5 mm reinforced endotracheal tube with a stylet, but this procedure failed. We then attempted to perform a blind intubation by inserting a 6.5 mm reinforced endotracheal tube with a stylet by another anesthesiologist, but we felt resistance under the vocal cords. We decided to try intubation with Optiscope PM 201™ (Video assisted system, Kyung Won medical, Seoul, Korea), but this attempt failed because a 6.0 mm reinforced endotracheal tube stopped at subglottic level. Therefore, an alternative airway device was considered. The i-gel™ (Intersurgical Ltd., Wokingham, Berkshire, UK) supraglottic airway device () was chosen, and the device was inserted without difficulty on the first attempt. It was inserted blindly, until mild resistance was felt, as recommended by the manufacturer. Dexamethasone 5 mg was injected intravenously to prevent airway edema. Subglottic stenosis of the trachea was revealed by fiberoptic bronchoscopy. The patient's lungs were ventilated with a tidal volume of 650 ml at a rate of 12 breaths per minute. The i-gel™ provided a good seal, and allowed for controlled mechanical ventilation with acceptable peak pressures (12-15 mmHg) while the patient was in the beach-chair position.\nThe operation time was 1 hour 40 minutes and the time under anesthesia time was 3 hours. There was no leakage from the i-gel™ airway throughout the procedure. After neuromuscular recovery was demonstrated, the patient was awakened, and the i-gel™ was removed. He was discharged without significant complications on 11th postoperative day.