---

{}

---

Background

• Definition: inhalation of gastric contents into the lung via passive regurgitation or active vomiting
• Common patients:
  • “Full stomach”: Not NPO, bowel obstruction, pregnant, gastroparesis, intoxicated
  • Incompetent LES: hiatal hernia, previous esophageal/gastric surgery, obese
  • Can’t protect airway: ↓ LOC, residual NMB, neurologic disease

Considerations

• Signs/symptoms: Severe hypoxemia, ↑ peak insp. pressure, bronchospasm, ↑ tracheal/oropharyngeal secretions, chest retractions, dyspnea, coughing, laryngospasm, pulmonary edema
• ↑ morbidity/mortality: pneumonia, ARDS, sepsis, barotrauma
• CXR: infiltrates and atelectasis, but can be unremarkable

Risk Factors for Aspiration

Strategies for Reducing Aspiration Risk

Extubation

• Awake after return of airway reflexes
• Position (lateral, head down, or upright)

Guidelines to Reduce the Risk of Aspiration

1. Ensure experienced anaesthesia assistance is available at all times.
2. Intubate all emergency cases.
3. Apply appropriate cricoid pressure with all inductions using neuromuscular blocking agents.
4. Intubate or seriously consider intubation in the following scenarios:
   • Delayed gastric emptying (e.g., pregnancy, opioids, diabetes mellitus, renal failure)
   • Increased intra-abdominal pressure (e.g., obesity, ascites, masses)
5. Extubate high-risk cases awake and on their side. Extubate all others on their side.

Complications

• Obstruction (Particle-related)
• Pneumonitis (Inflammation – Acid-related)
• Infection (Bacterial)

Management of Aspiration

Immediate Management

Further Management of Pulmonary Aspiration

Summary of Recommendations from NAP4 on Aspiration

1. Patient Assessment
   • All patients must be assessed for aspiration risk before surgery, especially urgent and emergency cases. In cases of doubt, assume the higher risk.
2. Airway Management Strategies
   • Strategies should align with the identified risk.
3. Equipment and Skills
   • Equipment and skills to detect and manage regurgitation and aspiration should be available at all times.
4. Rapid Sequence Induction
   • Remains the standard technique for airway protection.
5. Cricoid Pressure Application
   • Those applying cricoid pressure should be trained in its application and practice it regularly.
6. Use of Supra-glottic Airways
   • When tracheal intubation is not indicated, but a small increase in aspiration risk exists, consider using second-generation supra-glottic airways.
7. Aspiration Reduction at Emergence
   • Employ strategies to reduce aspiration risk if the patient is at risk.
8. Blood Clot Aspiration Awareness
   • Anaesthetists should be aware of the prevention, detection, and management of blood clot aspiration.
9. Capnography and Blood Near Airway
   • Take active measures when a flat capnography trace occurs after blood has been near the airway.

Links

• Anaesthesia emergencies
• Paediatric emergencies

References:

1. Robinson, M. J. and Davidson, A. H. (2014). Aspiration under anaesthesia: risk assessment and decision-making. Continuing Education in Anaesthesia Critical Care &Amp; Pain, 14(4), 171-175. https://doi.org/10.1093/bjaceaccp/mkt053
2. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/

Summaries:

---

Copyright
© 2025 Francois Uys. All Rights Reserved.

id: “56c2e808-c5ad-45a0-8c00-38cf20e494c8”