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 .
1 ) showed a lesion suspicious for tracheal stenosis , but it 's formal decipher by radiologist was no active lung lesion .
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 .
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
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 .
2 ) 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 .
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 .
the operation time was 1 hour 40 minutes and the time under anesthesia time was 3 hours .
after neuromuscular recovery was demonstrated , the patient was awakened , and the i - gel was removed .
many anesthesiologists use a narrow endotracheal tube . however , with this method , there is an associated risk of failed intubation .
the procedure can also lead to complications such as tracheal mucosal trauma , perforation or bleeding . in some patients with tracheal stenosis
, airway control might be achieved by the use of an endotracheal tube positioned above the stenosis .
if the stenotic segment is in the proximal trachea , however , proper fixation of the tube is difficult .
trauma , neoplasm , inflammation , wegener 's granulomatosis and prolonged endotracheal intubation are the causes of the tracheal stenosis . in the case
radiography can be very useful , but chest radiographs can also appear normal in patients with tracheal stenosis .
sads have advantages such as easy insertion and high effectiveness in securing a difficult airway .
the i - gel is a single - use non - inflatable supraglottic airway device which is launched throughout the uk in january 2007 .
it is composed of styrene ethylene butadiene styrene , which is soft and covers the larynx without cuff inflation .
the seal pressure improves over time due to the thermoplastic properties of the gel cuff which may form a more efficient seal around the larynx after warming to body temperature .
when correctly inserted , the tip of the i - gel will be located in the upper esophageal opening .
it is designed to achieve a mirror of the supraglottic anatomy ( pharynx and larynx ) and the noninflatable cuff is semirigid .
donaldson and michalek   reported a successful use of i - gel for subglottic stenosis patient who was undergoing laparoscopic cholecystectomy .
the i - gel has an integral bite block and may decrease rotation within the oropharynx .
suggested that the anatomic position of the i - gel does not vary with head and neck position and that ventilation with the i - gel can be effectively performed with the head and neck in the extended or rotated position . in this report , we have presented a case of failed intubation in a patient with subglottic stenosis successfully managed with the i - gel. we suggest that the i - gel is a suitable choice in situations in which endotracheal tube insertion is difficult or has failed .
 the airway management of patients with subglottic stenosis poses many challenges for the anesthesiologists . 
 many anesthesiologists use a narrow endotracheal tube for airway control . 
 this , however , can lead to complications such as tracheal mucosal trauma , tracheal perforation or bleeding . 
 the asa difficult airway algorithm recommends the use of supraglottic airway devices in a failed intubation / ventilation scenario . in this report , we present a case of failed intubation in a patient with subglottic stenosis successfully managed during an i - gel supraglottic airway device . 
 the device provided a good seal , and allowed for controlled mechanical ventilation with acceptable peak pressures while the patient was in the beach - chair position . 
Case Report
Discussion