Airway complications and aspiration

Why airway management matters

The fastest pathway to catastrophic harm during general anaesthesia or deep sedation is failure to oxygenate/ventilate. Modern monitoring (pulse oximetry and capnography) and standardized algorithms have made these events rarer, but not impossible.

Difficult airway: key failure modes

• Inadequate mask ventilation or supraglottic airway performance
• Failed or delayed intubation (including unrecognized oesophageal intubation)
• “Fixation error” and delayed transition to a rescue pathway
• Delayed recognition of deterioration (capnography is critical)

Structured responses: DAS and Vortex

Multiple bodies publish difficult airway guidance. In the UK, the Difficult Airway Society (DAS) provides widely adopted guidelines for unanticipated difficult intubation.

The Vortex Approach frames airway rescue around three non-surgical “lifelines” (mask, supraglottic airway, endotracheal tube). If “best effort” at all three fails, a CICO event is declared and neck rescue / emergency front-of-neck access (eFONA) is initiated.

CICO and FONA (front-of-neck access)

In a true “cannot intubate, cannot oxygenate” scenario, time is critical. DAS guidance has recommended a scalpel–bougie–tube technique for eFONA (surgical cricothyrotomy).

Aspiration: what it is

Aspiration is inhalation of stomach contents into the airway/lungs. It can cause chemical pneumonitis, infection, respiratory failure, and in rare cases death. Aspiration risk rises when protective airway reflexes are reduced (GA and deep sedation) and the stomach is not empty.

Major aspiration risk factors

• Emergency surgery (unknown fasting, bowel obstruction/ileus)
• Pregnancy; severe reflux; known gastroparesis (e.g., diabetes)
• Obesity and obstructive sleep apnea (airway obstruction risk during sedation)
• Opioids and some drugs that delay gastric emptying
• Upper GI endoscopy and procedures with insufflation

Fasting and GLP‑1 agonists (Ozempic/Wegovy/semaglutide etc.)

GLP‑1 receptor agonists can slow gastric emptying and are associated with GI symptoms and retained gastric contents in some patients. Guidance has evolved: newer multi‑society recommendations emphasize assessing individual risk and that many low-risk elective patients can continue GLP‑1 therapy, while higher-risk situations may require modifications or delay.

What clinicians do if aspiration risk is high

• Delay elective procedures when safe to do so
• Use “full stomach” precautions (e.g., rapid sequence induction with cuffed tube)
• Positioning, suction readiness, and postoperative observation
• Consider point-of-care gastric ultrasound in some settings (availability varies)