What is the preferred airway management technique, Supraglottic Airway (SGA) device or Endotracheal Intubation (ETI), in adults at risk of aspiration?

SGA vs ETI for Aspiration Risk in Adults

In adults at risk of aspiration, endotracheal intubation (ETI) remains the preferred definitive airway when performed by experienced operators, as it provides the most secure airway with best protection against aspiration, though second-generation supraglottic airways (SGAs) are acceptable alternatives when ETI expertise is limited or as rescue devices after failed intubation. 1, 2

Primary Airway Strategy Based on Clinical Context

For Elective/Controlled Settings with Aspiration Risk

• ETI is the gold standard when aspiration protection is the primary concern, as it provides complete isolation of the airway from the gastrointestinal tract 2, 3
• However, recent high-quality evidence shows second-generation SGAs significantly reduce major airway complications (RR 0.41,95% CI 0.23-0.71) compared to ETI, with no clinically relevant difference in regurgitation or pulmonary aspiration rates in abdominopelvic surgery 3
• This 2025 meta-analysis of 5,110 patients challenges traditional assumptions about SGA aspiration risk in controlled settings 3

For Emergency/Rescue Airway Situations

• Second-generation SGAs should be immediately available and are the preferred initial rescue device after failed intubation in critically ill patients, even those with high aspiration risk 1
• SGAs provide "some protection from aspiration" through higher oropharyngeal seal pressures and separation of gastrointestinal/respiratory tracts via esophageal drain tubes 1
• The British Journal of Anaesthesia guidelines explicitly state successful SGA rescue has been reported in ICU patients with both difficult intubation AND high aspiration risk 1

Algorithm for Device Selection

Step 1: Assess Operator Skill Level

• If ETI success rate >90%: Either ETI or second-generation SGA is acceptable, with equivalent survival and neurological outcomes 2, 4
• If ETI success rate <70%: Prefer second-generation SGA, which demonstrates superior survival to discharge (RR 1.34) and neurologically favorable survival (RR 1.42) 2

Step 2: Consider Clinical Setting

• Cardiac arrest: SGAs can be inserted without interrupting chest compressions, unlike ETI which requires direct visualization and compression pauses 2, 4
• Failed intubation scenario: Use second-generation SGA as Plan B rescue device, allowing one optimal attempt before considering front-of-neck access 1, 5
• Critically ill patients: Second-generation SGAs with high seal pressures (i-gel, ProSeal LMA) enable ventilation with PEEP in poorly compliant lungs 1, 5

Step 3: Device-Specific Requirements

• Only second-generation SGAs should be used in high-risk scenarios (those with esophageal drain tubes and higher seal pressures) 1
• First-generation SGAs are inadequate for aspiration-risk patients due to lower seal pressures and increased gastric inflation risk 1

Critical Performance Factors

For ETI to Maintain Superiority:

• Requires frequent experience and retraining (Class 1 recommendation) 2
• Must achieve first-pass success to avoid complications from multiple attempts 1
• Demands waveform capnography confirmation (Class I, LOE A) 2

For SGA to Provide Adequate Protection:

• Use devices with oropharyngeal seal pressure >30 cm H₂O (ProSeal LMA has highest, followed by LMA Supreme and i-gel) 1
• Ensure proper placement without excessive attempts (maximum one optimal attempt in rescue scenarios) 1, 5
• Maintain adequate training despite lower skill requirements than ETI 1

Evidence Reconciliation: The Aspiration Paradox

The traditional view that SGAs provide inferior aspiration protection is being challenged by recent evidence:

• The 2025 meta-analysis found no clinically relevant difference in regurgitation or pulmonary aspiration between second-generation SGAs and ETI in 5,110 patients undergoing abdominopelvic surgery 3
• A 2023 cadaver study showed pulmonary aspiration occurred in 20% of SGA procedures vs 50% of bag-mask ventilation, with SGAs also reducing intragastric pressure 6
• British guidelines acknowledge successful SGA use specifically in high aspiration risk ICU patients 1

However, ETI still provides "best protection" theoretically through complete tracheal isolation 2, making it preferred when:

• Operator has high ETI proficiency (>90% success rate) 2
• Time permits careful intubation without compromising other resuscitation efforts 1
• Patient requires prolonged mechanical ventilation 1

Common Pitfalls to Avoid

• Never use first-generation SGAs in aspiration-risk patients—they lack adequate seal pressure and aspiration protection features 1
• Avoid multiple ETI attempts in emergency settings, as failed attempts worsen outcomes; transition to second-generation SGA after one optimal attempt 1, 2
• Don't assume all SGAs are equivalent—the ProSeal LMA has superior seal pressure compared to other devices 1
• Avoid prolonged intubation attempts that interrupt chest compressions in cardiac arrest, as this worsens survival 4
• Don't neglect confirmation—always use waveform capnography for ETI and clinical assessment for SGA placement 2, 5

Quality of Recovery Considerations

Beyond aspiration protection, second-generation SGAs significantly improve patient-centered outcomes compared to ETI:

• Lower postoperative sore throat (RR 0.52) 3
• Reduced hoarseness (RR 0.32) 3
• Less coughing at emergence (RR 0.17) 3
• Decreased postoperative nausea/vomiting (RR 0.64) 3

These quality-of-life benefits, combined with equivalent aspiration safety in controlled settings, support expanding second-generation SGA use beyond traditional indications 3