Pulmonary aspiration - NYSORA

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Pulmonary aspiration

Learning objectives

  • Identification of patients at risk for pulmonary aspiration
  • Reducing the risk of pulmonary aspiration
  • Management of pulmonary aspiration


  • The inhalation of oropharyngeal or gastric contents into the larynx and the respiratory tract
  • Aspiration accounts for more deaths than failure to intubate or ventilate 
  • May lead to chemical pneumonitis, bacterial pneumonia, or acute respiratory distress syndrome

Signs and symptoms

  • Symptoms can range from none to respiratory failure and subsequent cardiac arrest in a massive aspiration event

Risk Factors

Patient factorsFull stomach
Emergency surgery
Inadequate fasting time
Gastrointestinal obstruction
Delayed gastric emptyingSystemic diseases, including diabetes mellitus and Chronic kidney disease
Recent Trauma
Increased intracranial pressure
Previous gastrointestinal surgery
Pregnancy (including active labor)
Incompetent lower oesophageal sphincterHiatus hernia
Recurrent regurgitation
Previous upper gastrointestinal surgery
Esophageal diseasesPrevious gastrointestinal surgery
Morbid Obesity
Surgical factorsUpper gastrointestinal surgery
Lithotomy or head down position
Anesthetic factorsLight anesthesia
Supra-glottic airways
Positive pressure ventilation
Length of surgery > 2 h
Difficult airway
Device factorsFirst-generation supra-glottic airway devices


Reducing gastric volumePreoperative fasting
Nasogastric aspiration
Prokinetic premedication
Avoidance of general anestheticsRegional anesthesia
Reducing pH of gastric contentsAntacids
H2 histamine antagonists
Proton pump inhibitors
Airway protectionTracheal intubation
Second-generation supraglottic airway devices
Prevent regurgitationCricoid pressure
Rapid sequence induction
ExtubationAwake after return of airway reflexes
Position (lateral, head down or upright)


  • Anesthesiologists should have a low index of suspicion for aspiration
  • Emergency anesthesia on its own is an important risk factor for aspiration
  • Management is supportive
  • The trachea should be suctioned after securing a safe airway, ideally before positive pressure ventilation to prevent the distal displacement of aspirated material
  • Antibiotics should only be used if pneumonia develops, early antibiotics may lead to the selection of virulent bacteria including pseudomonas
  • There is no evidence that using steroids either reduces mortality or improves outcome

Suggested reading

  • Michael Robinson, MB ChB FRCA, Andrew Davidson, MA MBBS FRCA FFICM, Aspiration under anaesthesia: risk assessment and decision-making, Continuing Education in Anaesthesia Critical Care & Pain, Volume 14, Issue 4, August 2014, Pages 171–175.
  • Asai T. Editorial II: Who is at increased risk of pulmonary aspiration?. Br J Anaesth. 2004;93(4):497-500.

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