Aspiration mgmt: LMA

The patient should be placed in the head-down position, oxygen 100% administered, anesthesia deepened, suctioning performed and the severity of the regurgitation/aspiration event assessed fibreoptically. The decision about whether to intubate the trachea or continue with the LMA will depend on how well the LMA is functioning, the severity of the regurgitation/aspiration event and the anticipated risk of further regurgitation/aspiration. Removal of the LMA may result in further regurgitation and consideration should be given to intubating the patient fibreoptically via the LMA. Consideration should also be given to passing a gastric tube, but this may also provoke further regurgitation.

Updated definition 2020:

• GI Risks: known or suspected full stomach, hiatal hernia, GERD, bowel obstruction, known or risk factors for delayed gastric emptying.
• Airway Risks: poor lung compliance, high airway resistance, glottic or subglottic obstruction, small mouth opening (<1.5cm).
• Signs of Aspiration? What Now!?
  • Increase FiO₂
  • Deepen anesthetic
  • Place the patient in head-down position
  • Suction/NGT
  • +/- Intubation
  • Assess severity and potentially remove particulate matter with fiberoptic bronchoscopy
  • PEEP
  • +/- Bronchodilators if bronchospasm has been induced or is suspected.
• Should you intubate!? The decision to intubate may be appealing in order to secure the airway and allow for more advanced ventilation. While it may prevent aspiration of additional gastric contents, any contents that have already been aspirated may be introduced further into the airway. Ultimately, this decision should be made based on careful clinical assessment of patient and situation. If the decision to intubate is made, consider adding PEEP ton improve oxygenation by opening distal airways. Delivering PEEP through an unprotected airway could increase the risk for further aspiration.
• Outcomes: Most patients that aspirate will be asymptomatic. Of those who develop symptoms, non-invasive or invasive ventilation may be temporarily required, and mortality is ~10%. Longer duration of ventilation is associated w/ higher mortality.
• What NOT to do…
  • Bronchial lavage. May flush aspirate further into the lungs.
  • Empiric antibiotics. Has been shown to increase the risk of developing ventilator acquired pneumonia.
  • Empiric corticosteroids. Has been shown to increase mortality in critically ill patients.