I-gel vs Fastrach: Which SGD is better for intubation?

In a systematic review and meta-analysis comparing the I-gel and Fastrach supraglottic airway devices (SGDs) when used in adult patients requiring intubation, the latter edges out the former in terms of success rate for first-pass intubation. However, intubation success rate was better when a flexible scope was used through the I-gel.

This analysis comprising 14 randomized controlled trials (n=1,340) favoured the Fastrach over the I-gel in terms of first-pass success rate (risk ratio [RR], 0.81, 95 percent confidence interval [CI], 0.67–0.98; p=0.03). [Anesth Analg 2025;140:243-251]

However, on subgroup analysis, the I-gel achieved a better first-pass success rate for tracheal intubation than Fastrach due to the former’s flexible scope-guided intubation (RR, 1.05, 95 percent CI, 1.01–1.11; p=0.03).

“Although this shows only a slight superiority, it is well supported by … studies that showed homogeneity (I²=0 percent). In our opinion, [this supports the potential of] I-gel as a substitute for Fastrach for flexible scope-guided intubation through an SGD,” the researchers said.

Flexible scope-guided intubation has been proven to increase successful intubations and decrease intubation times in patients with anticipated difficult airways. [Anesthesiology 2022;136:31-81] British and Canadian guidelines also highlight higher first-attempt success rates when using flexible-scope guidance for intubation via SGD. [Br J Anaesth 2015;115:827-848, Can J Anaesth 2021;68:1373-1404]

“These guidelines recommend that flexible scope-guided intubation through an intubating SGD is preferable when the device is placed to rescue oxygenation,” said the researchers.

Other outcomes

There were no significant between-group differences in terms of overall intubation success rates (RR, 0.92, 99 percent CI, 0.82–1.04; p=0.08) and time (weighted mean difference [WMD], -1.03 s, 99 percent CI, -4.75 to 2.69; p=0.48), as well as providers’ device insertion time (WMD, -6.48 s, 99 percent CI, -13.23 to 0.27; p=0.01).

There were also similar incidences of complications such as sore throat (RR, 1.01, 99 percent CI, 0.65–1.57; p=0.95) and presence of blood post-SGD removal (RR, 0.89, 99 percent CI, 0.42–1.86; p=0.68).

I-gel a suitable substitute for Fastrach?

Fastrach and I-gel are among the few intubating SGDs that allow direct endotracheal tube passage without an intermediate tool. [Br J Anaesth 1997;79:699-703; Anaesthesia 2007;62:419-420]

Fastrach is the first commercially available intubating SGD that has been extensively investigated. [Can J Anaesth 2010;57:588-601] The I-gel, although mainly used during the maintenance of anaesthesia, is a newer device that can also be used as an intubating SGD and has even replaced Fastrach in some facilities, the researchers noted.

“However, there is uncertainty regarding the comparison between these devices in terms of efficacy for intubation and ventilation, and safety in an airway rescue situation,” they said.

In the current analysis, the Fastrach showed better clinical performance than the I-gel as reflected by the intubation success rate at the first attempt. Nonetheless, with the latter’s advantage over the former for flexible scope-guided intubation, the researchers opined that the I-gel could be a suitable substitute for Fastrach as an intubating SGD.

However, they noted that the slight superiority of the I-gel over Fastrach should be interpreted with caution, given the lack of statistical correction for multiple primary outcomes.

“Nevertheless, even if this is a false-positive result, the conclusion that the I-gel has at least the same efficacy as Fastrach for this outcome would still be true. More studies are needed to confirm this is an accurate finding,” the researchers concluded.