Intubation is necessary.
State the patient-specific need for a tracheal tube, the available alternatives and why this route is appropriate now.
EXHIBIT 434 · MEMBER GALLERY
The
Rescue
From a working supraglottic airway
to a tracheal tube.
The i-gel is ventilating the patient. Now the scope gives you a path into the trachea—and the tube follows over it.
Adult i-gel 3 / 4 / 5 · Direct scope-guided technique
Local visual draft · Clinical and equipment review pending
The Rescue
Captioned introduction · 0:52
THE PROCEDURAL ARC Decide → Prepare → Navigate → Deliver → Verify
Adult i-gel equipment table ↗THE MECHANISM
Keep the route.
Change the airway.
The i-gel is already ventilating the patient. Its airway channel now provides a route toward the larynx.
-
THE CONDUIT
i-gel
Provides the working supraglottic airway and the path for the scope.
-
THE GUIDE
Scope
Passes through the airway channel, across the vocal folds and into the trachea.
-
THE DESTINATION
Tube
Slides over the scope. Its own position and ventilation must then be verified.
Explain each device’s job before following the procedure. This is a relationship diagram, not an anatomical drawing.
PAC interpretive design, 2026 · Local clinical review draftPause hereWhat must remain dependable while the tube is being placed? The team’s ability to oxygenate—and its plan to restore ventilation if the attempt stops.
On the reading table Intersurgical · adult i-gel product information ↗ Sood et al. · direct fiberoptic intubation through i-gel ↗
THE DECISION
Does the airway need
to change now?
A functioning SGA creates time to make a decision. It does not, by itself, create an indication to intubate.
The platform is stable.
Adequate oxygenation, a well-functioning i-gel, a trained operator and an assistant support the attempt. Obtain experienced help.
1
A deliberate rescue attempt
DAS 2025 advises considering one scope-guided intubation attempt through the SGA in this selected, stable rescue setting. An unsuccessful attempt calls for reassessment of the airway strategy.
Say why conversion is necessary before discussing how to perform it.
PAC interpretive design, 2026 · Local clinical review draftContext changes the decision. In perioperative rescue, waking the patient is the default when proceeding is not essential. A well-functioning prehospital SGA generally should not be exchanged in the field simply because it is an SGA.
On the reading table DAS 2025 · unanticipated difficult intubation ↗ NAEMSP · supraglottic airways in prehospital care ↗
PRESERVE THE PLATFORM
Protect the ventilation
you already have.
Before introducing the scope, identify how oxygenation will be maintained and how ventilation will be restored.
- Confirm the baseline
- Review the capnogram, oxygen saturation, chest movement and leak. Stabilize the i-gel and optimize the patient before starting.
- Name the circuit plan
- Scope and tube insertion can obstruct the airway channel or require circuit disconnection. Continued ventilation is not guaranteed; adapters and connections must be compatible.
- Prepare the rescue
- Have suction, oxygen delivery and backup airway equipment ready. Agree who watches physiology, who calls stop and how the team returns to ventilation.
Speak the ventilation handoff aloud. A working SGA is an asset to preserve.
PAC interpretive design, 2026 · Local clinical review draftPause here“If we lose the view or ventilation, who stops the attempt—and what is our first recovery action?”
On the reading table DAS 2025 · unanticipated difficult intubation ↗ Sood et al. · direct fiberoptic intubation through i-gel ↗
THE EQUIPMENT EXHIBIT
A diameter limit
is only the first check.
Start with the adult i-gel already in place. Match the complete scope–tube–conduit system before the attempt.
STANDARD ADULT i-gel
Know the ceiling.
Maximum endotracheal tube internal diameter listed by Intersurgical for scope-guided intubation.
| i-gel size | Maximum ETT ID |
|---|---|
| 3 | 6.0 mm |
| 4 | 7.0 mm |
| 5 | 8.0 mm |
These are manufacturer-listed maxima, not prescribed tube sizes or proof of compatibility. Check the exact device and current local-market instructions. Do not transfer this table to pediatric devices or other i-gel variants.
Read the relevant row, then explain what the table cannot tell you.
PAC table from Intersurgical’s published i-gel size guide; source linked below · Local clinical review draft
Enlarge ↗
Find the airway connection and distinguish it from the separate gastric channel.
Intersurgical · standard i-gel · Original image and device key ↗Read the numbered device key
- 15 mm airway connector
- Gastric-channel entry
- Device size and weight markings
- Adult positioning mark
- Gastric passage
- Built-in bite protection
- Stabilizing body
- Epiglottic support
- Cuff without inflation
- Gastric-channel outlet
The connector measurement is not the airway channel’s internal diameter.
Enlarge ↗
A 7 mm internal-diameter tube in a size 4 i-gel. Identify the distal cuff and the proximal tube that remains available to control.
Sharma, Rogers & Popat · Anaesthesia, 2007 · Figure 2 · Source ↗LOOK CLOSELYTube internal diameter, tube outer diameter and conduit bore are different measurements. This historical photograph illustrates their relationship; the current device instructions govern fit.
Scope inside tube
Verify scope outer diameter, ETT internal diameter, lubrication and free movement using the exact models.
Tube beyond conduit
Confirm usable tube length permits a tracheal cuff and tip position while enough proximal tube remains controllable.
A workable endpoint
Check connectors, pilot line, circuit and the intended i-gel retention or removal plan. A maximum-diameter match does not settle these.
Rehearse fit with a matching spare or training set. Do not remove a functioning i-gel just to perform a bench check.
On the reading table Intersurgical · i-gel adult size guide ↗ Intersurgical · adult i-gel product information ↗
PREPARATION & HANDS
Load the tube.
Assign the handoff.
Prepare the assembly before entering the patient. Each device needs a named owner while another device moves.
-
Check the equipment.
Verify the scope image, tip control and suction; check the tube and cuff according to their instructions. Prepare appropriate lubrication and the circuit connection.
-
Preload the tube on the scope.
Use the verified combination with the tube cuff deflated. Keep the distal scope available for navigation and the tube controlled until the tracheal view is established.
-
Separate the jobs.
The scope operator controls the view and depth. An assistant stabilizes the i-gel and manages the circuit. Name who advances the tube and who monitors physiology; share the screen.
-
Brief the endpoint.
Agree how tube position will be confirmed and how the i-gel will be managed. Patient preparation, anesthesia and rescue choices belong to the responsible clinical team.
Rehearse the handoff with the actual equipment. Do not discover an incompatible connector during conversion.
PAC interpretive design, 2026 · Local clinical review draft
Enlarge ↗
a i-gel — the assembly studied hereb LMA Protector — comparison device
Follow assembly a from scope handle to tube to i-gel. Identify what will advance and what must remain controlled during the handoff.
Mendonca et al. · Anaesthesia, 2019 · Figure 1, shown in full · Source ↗On the reading table Sood et al. · direct fiberoptic intubation through i-gel ↗ DAS 2025 · unanticipated difficult intubation ↗
SCOPE PASSAGE
Find the larynx.
Then establish the tracheal view.
Enter through the i-gel’s airway channel. Advance the scope under vision; its separate gastric channel is not the intubation route.
-
At the outlet
Identify the laryngeal opening. If tissue or secretions obscure it, stop advancing, clear the view and reassess alignment with the assistant.
-
Across the folds
Guide the scope through the visible glottic opening. Keep movement controlled and the image interpretable.
-
Inside the trachea
Identify tracheal rings and the carina. Maintain a controlled tracheal position without driving the tip against the airway or into a main bronchus.
Enlarge ↗
b Standard i-gel · endoscopic viewc / right Standard i-gel · outletd / lower Standard i-gel · cross-section
In panel b, arytenoids are visible before upward scope-tip flexion; the vocal folds are not yet exposed. Compare that view with the standard i-gel outlet and cross-section. The other panels show i-gel Plus.
Chaki et al. · Scientific Reports, 2023 · Figure 2, unmodified · Source ↗ · CC BY 4.0 ↗On the reading table Intersurgical · adult i-gel product information ↗ Sood et al. · direct fiberoptic intubation through i-gel ↗
TUBE DELIVERY
The scope is through.
The tube still has to follow.
A clear path for the scope does not guarantee easy passage of the larger tube.
Keep the scope stable.
Maintain tracheal access and depth while the assistant prevents i-gel displacement.
Slide the tube gently.
Advance the preloaded tube over the scope through the i-gel. Coordinate the movement; do not push the scope deeper with the tube.
Resistance is information.
Stop pushing. Withdraw the tube enough to release impingement while preserving scope position, then reassess the view and alignment. Do not force passage.
Tell your assistant what should stay still while you advance the tube.
PAC interpretive design, 2026 · Local clinical review draftWhy not prescribe one corrective rotation?
Tube bevel, flexibility and device geometry affect impingement. Studies describe corrective maneuvers, but a single direction is not a universal solution for every tube. Reassess the actual combination and preserve oxygenation; do not turn difficulty into repeated forceful advancement.
In one elective trial, i-gel tube impingement occurred despite high intubation success. Those selected anesthetized patients do not establish rescue-airway success rates.
Watch the transition through an existing i-gel. Track the scope position, tube movement and the hands controlling the conduit.
Dr. Munish Goyal · MedStar Emergency Physicians · 2021 · Used with permission · Original video on YouTube ↗ (opens in a new tab)On the reading table Mendonca et al. · scope-guided intubation through i-gel ↗ Bhardwaj et al. · tube passage through i-gel ↗
CONFIRMATION
Verify the tube.
Not just the scope.
The scope can be in the trachea while the tube remains above the vocal folds.
Where is the tube?
Confirm the tube itself is tracheal, with appropriate tip depth relative to the carina and the cuff beyond the vocal folds. Use controlled scope withdrawal to inspect position; avoid moving the tube during scope removal.
What comes through it?
Inflate the ETT cuff appropriately, connect the breathing circuit to the ETT and obtain sustained exhaled CO₂ on waveform capnography. Assess ventilation, tube depth and fixation.
The capnogram looks good. What is still unproven?
A trace obtained through the i-gel before conversion says nothing about the new tube. Even exhaled CO₂ through a tube does not establish appropriate depth or prove its cuff is below the vocal folds. Pair waveform evidence with direct assessment of tube position.
Explain what visual confirmation and waveform capnography each establish—and what neither establishes alone.
PAC interpretive design, 2026 · Local clinical review draftNo sustained exhaled CO₂ after tube connection? Treat the tube as unconfirmed. Act immediately to exclude esophageal placement and restore oxygenation using the emergency airway plan; chest rise alone is insufficient.
On the reading table PUMA · preventing unrecognized esophageal intubation ↗ PUMA authors · CO₂ detection and tube position ↗
WHEN THE TRANSITION STOPS
Protect the patient.
Reassess the route.
Choose a problem below and state the recovery action before opening the explanation.
01 I cannot obtain a usable view.
Stop advancing. Clear secretions and reassess i-gel alignment and oxygenation. If the view remains unusable, abandon the attempt and restore effective SGA ventilation where possible.
02 The scope passes, but the tube will not.
Release resistance and reassess. Do not force the tube or allow it to drive the scope into the distal airway. If passage is not achieved within the agreed attempt, withdraw the assembly as appropriate and return to the oxygenation plan.
03 Oxygenation or ventilation deteriorates.
Stop the intubation attempt and prioritize rescue oxygenation. Restore SGA ventilation if possible; if it fails, move promptly through the emergency airway plan and call for help.
04 I cannot confirm the tube.
Do not secure an uncertain tube and move on. Resolve position immediately while maintaining oxygenation. Repeat direct assessment and waveform evaluation; follow the unconfirmed-tube rescue pathway when necessary.
These are discussion prompts for trained teams, not a patient-specific decision engine.
PAC interpretive design, 2026 · Local clinical review draftOn the reading table DAS 2025 · unanticipated difficult intubation ↗ PUMA · preventing unrecognized esophageal intubation ↗
THE REMAINING DEVICE
The tube is confirmed.
What happens to the i-gel?
Decide the intended endpoint before intubation. Managing the SGA must not undo the airway you just established.
Leave it in place for now.
Selected procedural studies retained the SGA temporarily. Confirm that tube fixation, circuit access and ongoing patient care remain practical. Reassess and document the next plan; this is not evidence for indefinite retention or every transport setting.
Protect the tube during removal.
Use a rehearsed, device-specific method that preserves control of ETT depth, cuff and pilot line. Available tube length and connector design matter. Removal can dislodge a correctly placed tube.
After any manipulation
Recheck depth, ventilation and sustained waveform capnography, then secure the final arrangement.
Describe your endpoint before beginning. No generic removal maneuver has been validated for the station’s unspecified scope and tube.
PAC interpretive design, 2026 · Local clinical review draftThis gallery teaches direct scope-guided intubation. A guide-preserving Aintree conversion is a separate technique in FBI 435 →.
On the reading table Bhardwaj et al. · tube passage through i-gel ↗ PUMA · preventing unrecognized esophageal intubation ↗
IN THE STUDIO · EDUCATOR-SUPPORTED
Rehearse the complete
transition.
On an airway trainer, move from an established i-gel airway to a confirmed tracheal tube while another person protects the ventilation plan.
Gather Adult i-gel training set, airway trainer, compatible scope/display and ETT, lubricant, suction setup, circuit and capnography simulation, plus an assistant and educator.
Start here Identify the i-gel size. Read its ETT limit, then explain why that number alone does not validate the assembly.
Physical station release pending: the educator must approve the exact scope, tube, connections and endpoint method before device passage. Until then, use this as a tabletop briefing.
-
Verify the set.
Do Check the exact devices and their instructions on a spare or training assembly.
Look for Free movement, adequate working length and a feasible cuff, connector and i-gel endpoint plan.
-
Brief and prepare.
Do Establish the simulated baseline, load the tube and assign scope, SGA, tube and monitoring roles.
Look for Each person can state the stop call and the route back to ventilation.
-
Navigate under vision.
Do Use the airway channel, identify the glottis and enter the trachea.
Look for Recognizable landmarks and controlled depth while the i-gel stays stable.
-
Deliver and verify.
Do Advance the tube, assess its position, withdraw the scope with control and connect the circuit.
Look for No forceful passage; tube position and simulated sustained waveform both assessed. A trainer cannot reproduce clinical capnography.
-
Manage the endpoint.
Do Rehearse the educator-approved retention or removal plan, secure the tube and recheck it.
Look for Tube depth stays controlled during the handoff. Repeat once with a loss-of-view or resistance cue and demonstrate recovery.
FINISH LINE
Show it. Explain it.
The educator observes the full sequence, the confirmation explanation and one stop-and-recover response. Completion is rehearsal evidence, not a competence credential.
RESET & RECOVERY
Return to a known start.
Stop if equipment binds or the model is unclear. Return to the relevant gallery room. Reset the trainer and devices according to local cleaning and manufacturer instructions; restore the starting setup and rotate roles.
The reading room
Guidelines define the rescue boundary. Manufacturer information defines device limits. Elective studies help explain technique; they do not predict success in an unstable rescue airway.
Sources, interpretation and limits
- DAS 2025 · unanticipated difficult intubation ↗
- Intersurgical · i-gel adult size guide ↗
- Intersurgical · adult i-gel product information ↗
- Mendonca et al. · scope-guided intubation through i-gel ↗
- Sood et al. · direct fiberoptic intubation through i-gel ↗
- Bhardwaj et al. · tube passage through i-gel ↗
- PUMA · preventing unrecognized esophageal intubation ↗
- PUMA authors · CO₂ detection and tube position ↗
- NAEMSP · supraglottic airways in prehospital care ↗
Reviewed September 16, 2026. The current packaged and local-market device instructions govern the actual equipment. New clinical copy, exact combinations, physical station and forthcoming media require review before release.
EXIT PASSAGE
Keep the route
and verify the result.
A successful conversion preserves oxygenation, delivers the tube under guidance and ends with a confirmed, secure airway.
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