Pulmonary Aspiration:

Prevention and Treatment

Daniel Smith, SRNA
Oregon Health Science University
It is pleasant to recall past troubles.
-Cicero
Case report
58 year old female
Hx: laryngeal CA status post partial
laryngectomy, well controlled GERD on
PPI, HTN (well controlled), BMI 34. New
onset of dysphagia -> new laryngeal mass
Presents to outpatient surgery center for
direct laryngoscopy and laryngeal biopsy
and possible LASER excision of larngeal
mass.
Previous anesthetic record reveals a
difficult DL, but easy glidescope intubation.
How would secure this airway?
Standard induction?
Awake fiber optic?
Asleep fiber optic?
RSI?
Our plan:
Preop medications: Pepcid IV and PO
bicitrate. Midazolam 2 mg
Preoxygenate
Induce with fentanyl, propofol and sux
Apply cricoid pressure
Intubate with glidescope in a head up
position.


Opening the mouth reveals clear
liquid rising in the oral pharynx!
How would you proceed?

Objectives:
Incidence/risk factors of aspiration
Review current NPO guidelines
Discuss risk factors for aspiration
Prophylactic pharmacotherapy
Alternative airway management strategies
Cricoid pressure effective?
Treatment of aspiration
Incidence of Pulmonary Aspiration
during General Anesthesia
Overall incidence is 1:2000-3000.
2

Emergency surgery has an incidence of
1:600-800.
Incidence of aspiration during regional
anesthesia < 1:30,000.



Kalinowski CPH, Kirsch JR. Strategies for prophylaxis and treatment for
aspiration. Best Pract Res Clin Anaesthesiol. 2004;18(4):719737.

Top 10 Factors Associated with
Aspiration (from the AIM Study)
Emergency procedures
Inadequate depth of anesthesia
Abdominal pathology
Obesity
Opioid medication
Neurological deficit
Lithotomy position
Difficult intubation/airway
Reflux
Hiatal hernia



Kluger MT, Short TG. Aspiration during anaesthesia: a review of 133 cases from
the Australian Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia.
1999;54(1):1926.

ASA Fasting Guidelines
Ingested Material Minimum Fasting Time
Clear Liquids 2 Hours
Breast Milk 4 Hours
Infant Formula 6 Hours
Light Meal (toast w/out
butter)
6 Hours
Fried, fatty foods, meat,
etc.
8 Hours
Practice guidelines for preoperative fasting and the use of pharmacologic agents to
reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective
procedures: an updated report by the American Society of Anesthesiologists Committee
on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495511.

Conditions Associated
with Reduced Gastric
Emptying
Trauma
Pregnancy
Diabetes
Renal failure

Kalinowski CPH, Kirsch JR. Strategies for
prophylaxis and treatment for aspiration. Best
Pract Res Clin Anaesthesiol. 2004;18(4):719
737.

Pharmacotherapy
Non-particulate antacid
H2-receptor antagonists
Proton Pump Inhibitors
Prokinetic Agents
Kalinowski CPH, Kirsch JR. Strategies for
prophylaxis and treatment for aspiration. Best Pract
Res Clin Anaesthesiol. 2004;18(4):719737.

Airway Management
Standard Induction
Regional
Rapid Sequence
Intubation
Cricoid pressure
Awake Fiber Optic
Intubation
Regional Anesthesia
Reduced risk of aspiration.
Preferred form of anesthesia for C-section
in most situations.
Not appropriate for all patients or
procedures.
Time constraints.

Awake Fiber Optic Intubation
Seems to have a low risk of
aspiration.
Requires patient cooperation.
Requires time to localize the
airway.
Ovaasapian has reported on 123
awake fiber optic intubations in
high-risk patients with zero
incidence of aspiration.

Ovassapian A, Krejcie TC, Yelich SJ, Dykes MHM. Awake Fibreoptic Intubation in
the Patient at High Risk of Aspiration. Br. J. Anaesth. 1989;62(1):1316.

Free Resource
Airwayondemand.org -> More information -> Free
Resources
Rapid Sequence Induction
Pre-oxgenate (denitrogenate)
Cricoid pressure
Avoidance of mask ventilation
When to modify?
Verify mask ventilation prior to administering
NMBA?
Titrate your induction drugs?


Ehrenfeld JM, Cassedy EA, Forbes VE, Mercaldo ND, Sandberg WS. Modified Rapid
Sequence Induction and Intubation: A Survey of United States Current Practice. Anesth
Analg. 2012;115(1):95101.

Broomhead RH, Marks RJ, Ayton P. Confirmation of the ability to ventilate by facemask
before administration of neuromuscular blocker: a non-instrumental piece of information? Br.
J. Anaesth. 2010;104(3):313317.
Cricoid pressure
temporary occlusion of of
the upper end of the
esophagus by backward
pressure of the cricoid ring
against the bodies of the
vertebrae
Prevent gastric regurgitation
Prevent gastric inflation
Salem MR, Sellick BA, Elam JO. The Historical Background of Cricoid
Pressure in Anesthesia and Resuscitation. Anesth Analg. 1974;53(2):230232.
Is cricoid pressure effective?
Case reports exist of regurgitation during
application of cricoid pressure.
Numerous studies demonstrate inconsistent
application of cricoid pressure.
Recent radiological studies suggest that
cricoid pressure may in fact cause lateral
deviation of the esophagus instead of
occlusion.
Ellis DY, Harris T, Zideman D. Cricoid Pressure in Emergency Department Rapid Sequence
Tracheal Intubations: A Risk-Benefit Analysis. Annals of Emergency Medicine. 2007;50(6):653
665.

Lateral deviation of the esophagus
Boet S, Duttchen K, Chan J, et al. Cricoid Pressure Provides Incomplete Esophageal Occlusion
Associated with Lateral Deviation: A Magnetic Resonance Imaging Study. The Journal of Emergency
Medicine. 2012;42(5):606611.

Management of Aspiration
Immediate management:
Head down and to the side
Clear the airway
Secure the airway
Suction the airway through the ETT
Oxygenate and ventilate
Bronchoscopic exam
Give consideration to cancelation of the case

Kalinowski CPH, Kirsch JR. Strategies for prophylaxis and treatment for
aspiration. Best Pract Res Clin Anaesthesiol. 2004;18(4):719737.

Management of Aspiration
Bronchodilator therapy as needed
PEEP
PACU evaluation for minimum of 2 hours.
Patients who are asymptomatic 2 hours post-
op have low risk of developing symptoms
Patients who require mechanical ventilation
for >48 hours have high mortality rate.


Kalinowski CPH, Kirsch JR. Strategies for prophylaxis and treatment for
aspiration. Best Pract Res Clin Anaesthesiol. 2004;18(4):719737.

Thanks!