Gastric Tubes and Airway Management in Patients at Risk of Aspiration

Abstract

Rapid sequence induction and intubation (RSII) and awake tracheal intubation are commonly used anesthetic techniques in patients at risk of pulmonary aspiration of gastric or esophageal contents. Some of these patients may have a gastric tube (GT) placed preoperatively. Currently, there are no guidelines regarding which patient should have a GT placed before anesthetic induction. Furthermore, clinicians are not in agreement as to whether to keep a GT in situ, or to partially or completely withdraw it before anesthetic induction. In this review we provide a historical perspective of the use of GTs during anesthetic induction in patients at risk of pulmonary aspiration. Before the introduction of cricoid pressure (CP) in 1961, various techniques were used including RSII combined with a head-up tilt. Sellick initially recommended the withdrawal of the GT before anesthetic induction. He hypothesized that a GT increases the risk of regurgitation and interferes with the compression of the upper esophagus during CP. He later modified his view and emphasized the safety of CP in the presence of a GT. Despite subsequent studies supporting the effectiveness of CP in occluding the esophagus around a GT, Sellick's early view has been perpetuated by investigators who recommend partial or complete withdrawal of the GT. On the basis of available information, we have formulated an algorithm for airway management in patients at risk of aspiration of gastric or esophageal contents. The approach in an individual patient depends on: the procedure; type and severity of the underlying pathology; state of consciousness; likelihood of difficult airway; whether or not the GT is in place; contraindications to the use of RSII or CP. The algorithm calls for the preanesthetic use of a large-bore GT to remove undigested food particles and awake intubation in patients with achalasia, and emptying the pouch by external pressure and avoidance of a GT in patients with Zenker diverticulum. It also stipulates that in patients with gastric distension without predictable airway difficulties, a clinical and imaging assessment will determine the need for a GT and in severe cases an attempt to insert a GT should be made. In the latter cases, the success of placement will indicate whether to use RSII or awake intubation. The GT should not be withdrawn and should be connected to suction during induction. Airway management and the use of GTs in the surgical correction of certain gastrointestinal anomalies in infants and children are discussed.

An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts

“…Our data suggest an association between increasing nasogastric tube popularity in this context with decreasing national income. Reasons why this very affordable intervention, which is often considered a standard of care, might be omitted in clinical practice in higher income countries warrants further investigation .…”

Erythromycin for Gastric Emptying in Patients Undergoing General Anesthesia for Emergency Surgery

“…Clearly, a patient with an entirely empty stomach cannot regurgitate and aspirate through the trachea. Stomach drainage with a gastric tube 17 does not guarantee complete emptying. Also, preoperative insertion of a gastric tube in a nonsedated patient is not without hazards 18 and is only recommended in patients with bowel obstruction.…”

Anaesthesia and orphan disease: airway and anaesthetic management in Huntington’s disease

“…HD is characterised by involuntary choreatic movements, associated with respiratory compromise, oropharyngeal dysphagia, orobuccolingual dyskinesia and a loss of facial, truncal and limb motor control 5. Despite preoperative fasting, the abnormal oesophageal and gastric motility due to bulbar dysfunction and the presence of a small feeding NGT may not guarantee that the stomach will be completely empty following NGT suction 6. Bedside gastric ultrasonography is an emerging technique to assess residual gastric volume and guide anaesthetic management.…”