Ethics approval: This work is a consensus statement based on expert opinion. It does not involve research on human participants, identifiable human data, or human tissue. According to Swiss national regulations (Human Research Act) such consensus or guideline projects do not fall within the scope of the law on human research and therefore do not require submission to an ethics committee. Consequently, no ethical approval was necessary.

As no individual data or participants were involved, informed consent to participate was not applicable.

The study was conducted in accordance with the principles of the Declaration of Helsinki.

We would like to thank Suzanne Reuss Lübcke (Secretary general SSAPM) for her support with data acquisition and processing.

MGF is supported by a research grant from Foundation Kardio Baden, Switzerland.

None

None declared

SSAPM Swiss Society for Anaesthesiology and Perioperative Medicine

RSI Rapid Sequence Induction

mRSI Modified/Controlled Rapid Sequence Induction

FRC Functional Residual Capacity

EtO₂ End-tidal oxygen concentration

EtCO₂ End-tidal carbondioxid concentration

IV Intravenous

PEEP Positive end-expiratory pressure

SD Standard Deviation

SOP Standard Operating Procedure

GLP-1 agonist Glucagon-like peptide-1 agonist

The perioperative management of patients at risk of pulmonary aspiration varies widely, includes several controversial aspects, and is not regulated by official guidelines. The objective of this study was to achieve peer and expert consensus in the management of patients at risk of aspiration, thereby developing guidance in Switzerland. Controversial aspects to be clarified by expert consensus were previously identified by a broad national survey.

A structured, three-phase national consensus process was conducted in Switzerland. First, the interprofessional SAFE Survey identified areas of agreement and controversy in the practice of perioperative management of patients at risk of pulmonary aspiration. Second, these recommendations were electronically reviewed, accepted, modified, or rejected by the heads of all anaesthesia departments accredited for postgraduate training in Switzerland. Third, the consolidated recommendations were presented to and formally endorsed by the Board of the Swiss Society of Anaesthesiology and Perioperative Medicine (SSAPM).

A total of 42 out of 52 heads of anaesthesia departments contributed to the process, resulting in a response rate of 80.8%. Consensus was reached in 17 out of 21 statements (80.9%) that had been previously identified as controversial. Based on the collective consensus and these findings, a national recommendation for the management of patients at risk of pulmonary aspiration was developed.

The resulting national recommendations, endorsed by the official society of anaesthesiology in Switzerland, aim to standardize and improve care for this vulnerable patient group, providing a foundation for consistent clinical practice across Switzerland and other countries.

The modern understanding and clinical practice of Rapid Sequence Induction (RSI) varies widely and includes many country and clinic specific differences as demonstrated by international surveys conducted by Klucka et al.[1] and Zdravkovic et al.[2] We recently conducted a comprehensive interprofessional survey in Switzerland in collaboration with the Swiss Society for Anaesthesia and Perioperative Medicine (SSAPM) and the Swiss Patient Safety Foundation (SPSA). The ‘SAFE survey’ revealed a broad consensus (> 80% agreement) across the perioperative process and among professionals with varying experience levels, particularly regarding the indication for and performance of traditional rapid sequence induction (RSI). Nevertheless, several major areas of controversy were identified, not only concerning the RSI technique itself, but also the weighting of risk factors, clinical decision-making, and the use and interpretation of technical adjuncts. [3] Despite widespread global efforts toward standardization, many components of RSI including the procedure as a whole lack robust evidence proving their effectiveness in reducing the incidence of pulmonary aspiration.[4] This evidence gap, combined with variability in training, economical burdens or financial constraints, divergent standard operating procedures (SOP)/institutional protocols, and a heterogeneous patient population, contributes to considerable inconsistency in the clinical management of patients at risk for pulmonary aspiration.

For example, even where robust evidence exists such as video laryngoscopy reducing the number of intubation attempts in both elective[5] and emergency settings[6] as well as lowering the risk of failed intubation[7] practical implementation remains reluctant. The SAFE survey revealed that only 76% of respondents considered video laryngoscopy an essential component of high-quality RSI. Similarly, risk stratification tools such as gastric ultrasound - despite their demonstrated impact on clinical decision-making[8, 9] and endorsements by international societies[10], particularly in the context of GLP-1 agonist use - are still not widely adopted in clinical practice. The heterogeneous handling of a vulnerable patient group and the gap between evidence and clinical practice leads to uncertainty in everyday clinical practice. A recently published survey from the UK demonstrates the desire for increased guidance for rapid sequence induction.[11] The heterogeneity of clinical management of patients at risk of aspiration also means that there is a lack of urgently needed large and national international studies to evaluate the effectiveness of RSI and may also be a factor in why the incidence and mortality following pulmonary aspiration has barely improved in the last decades.[12]

The Swiss Society for Anaesthesiology and Perioperative Medicine (SSAPM) and the Swiss Patient Safety Foundation (SPSA) together with the Swiss Society of Nursing in Anaesthesia (SIGA) aimed to undertake a multi-step, consensus-driven initiative to develop basic guidance and practical recommendations for the perioperative management of patients at risk for pulmonary aspiration. Building on the controversies identified in the SAFE survey, the aim was to formulate recommendations that integrate diverse perspectives but provide a clear basis for clinical guidance. These recommendations are intended to support clinical decision-making, streamline training programs, and ultimately enhance patient safety in anaesthesia care.

The Swiss Society of Anaesthesiology and Perioperative Medicine (SSAPM), the Foundation for Patient Safety in Anaesthesia (SPSA) and the Swiss Society or Nursing in Anaesthesia (SIGA) jointly launched this structured, three-step, consensus-driven initiative. Draft recommendations were developed by society representatives based on areas of consensus and controversy identified through the interprofessional SAFE Survey.[3]

An invitation to electronically evaluate the draft recommendations (using the Forms Office platform, Google Inc., Mountain View, CA, USA) was sent personally to all heads of anaesthesia departments accredited for postgraduate training in Switzerland (expert panel). The size of the anaesthesiology departments and the extent of their academic involvement were classified according to the Swiss Medical Board.[13] Participants were asked to either accept or reject each recommendation. In cases of rejection, respondents were required to provide a rationale and/or propose a modified version. Depending on the response pattern and the extent of suggested modifications, additional consensus rounds were planned to achieve final agreement if required. The survey remained open from 8 May to 7 July 2025. Midway through this period, non-respondents received a written or telephone reminder.

The consolidated results and corresponding recommendations were subsequently presented to the SSAPM Board, which unanimously approved and formally endorsed the final version.

No patient data were collected. All other data were collected anonymously. In accordance with Swiss and international standards, the local ethics committee granted a waiver for the study. Therefore, consent for data analysis and publication was not mandated.

The complete questionnaire is shown in Appendix 1. The questionnaire was only available in English. The questionnaire consisted of 24 recommendations.

The data set has been checked for completeness and a plausibility. Due to the mandatory completion of all questions, no missing data were recorded.

The main data presentation includes descriptive statistics. Descriptive statistics were used to describe participants’ baseline characteristics and responses to each question. Continuous variables are expressed as mean ± standard deviation. Categorical variables are presented as absolute frequencies. We defined consensus at ≥80% agreement. Data analysis was performed using SPSS Statistics 19™ (IBM, Ehningen, Germany).

During the study period 42 of 52 heads of anaesthesia departments accredited for postgraduate training in Switzerland completed the questionary (response rate 80.8%). Among the participating institutions, 8 (19%) were categorized as A1, 11 (26%) as A2 (large institutions), 18 (43%) as B, and 5 (12%) as C (medium to small institutions). The respondents had a mean of 24.0 years of experience in anaesthesiology. Overall, there was a high level of agreement with the proposed recommendations, with consensus achieved for 17 of 21 statements (80.9%). For the remaining controversial items, opinions diverged widely, and no meaningful proposals for modification were submitted; therefore, no further consensus round was conducted.

Regarding pre-operative gastric ultrasound, 81% of respondents recommended its use in cases of unclear fasting status, emergency surgery, patients receiving GLP-1 agonists and presenting with gastrointestinal symptoms. Additionally, 81% agreed that sonographic confirmation of an empty stomach justifies the omission of rapid sequence induction (RSI) after individual risk-benefit assessment. The panel expressed strong agreement on the importance of implementing a standard operating procedure (SOP) to guide the management of patients at risk of aspiration. 95% agreed that all departments should implement SOP covering risk stratification, anaesthetic management, and pulmonary aspiration management (see Fig. 1).

Based on this study, we were able to create a peer community and expert-approved consensus regarding the management of patients at risk of aspiration and to derive national guidance. The survey’s high response rate underlines the importance and the professional community’s determination to harmonize the assessment and management of patients with risk factors for pulmonary aspiration. Similarly, our guidance endorsed by the national professional anaesthesiologic society cover an unmet need for standardization, with 95% of respondents agreeing that all institutions should have standard operating procedures (SOPs) for this matter.

The high degree of agreement within this consensus process shows that many aspects of aspiration risk management within the professional community are largely undisputed. There is broad consensus on the main aspects of perioperative management of this vulnerable patient group. In contrast, some points remain controversial. Despite robust evidence supporting the use of video laryngoscopy in reducing failed intubation[7] and improving first-pass success rates[5, 6], our findings show that only 57% of respondents rated its use as mandatory for RSI. This discrepancy raises questions about the barriers to implementation. The surveyed experts concern was primarily that they would be forced to use video laryngoscopy and would lose the ability to perform conventional laryngoscopy safely (educational aspects). Another concern was the cost-effectiveness of video laryngoscopy, as many patients do not present with potential “difficult to intubate” conditions. As a result, the original statement was adapted as such that conventional laryngoscopy remained an option, but that video laryngoscopy must be readily available, which was in line with the experts’ opinion.

A similarly cautious adoption was observed for apnoeic oxygenation strategies such as nasal high-flow. Most respondents favoured etO₂-guided preoxygenation with a tight facemask and did not consider nasal high-flow to be a suitable alternative. The experts’ most frequently mentioned concerns were the inability to measure the effectiveness of preoxygenation, practicability issues and potential contraindications (e.g. restricted nasal breathing). This in spite of the fact that, although literature remains inconclusive, there is growing evidence that the two procedures are at least equivalent and the proven ability to safely prolong apnoea time.[14, 15]

Preoperative gastric ultrasound was endorsed by 81% of respondents, particularly in the context of emergency surgery, unclear fasting status and GLP-1 agonist therapy. This reflects a growing awareness of the relevance of delayed gastric emptying in certain patient groups. However, barriers such as the need for structured operator training, time constraints, and limited access to ultrasound devices may still inhibit broader adoption. These findings echo global trends: while the theoretical utility of point-of-care gastric assessment is high, its practical integration into workflows remains inconsistent.[16]

The relatively high acceptance (88%) of modified or controlled RSI techniques in the adult patient population underscores the need for flexibility in real-world clinical settings - especially in scenarios involving hypoxia risk or hemodynamic instability. Interestingly, while 86% endorsed positive pressure ventilation during modified RSI, only 36% agreed with a flat supine position. This suggests that most respondents are aware of the associated benefits of this position, namely a more effective preoxygenation[17] and an increased functional residual capacity (FRC)[18]. Regarding the preparation and practice of mRSI, a high level of consistency with conventional RSI could be observed, with exception of the use of positive pressure ventilation prior to intubation. The majority of respondents believed that moderate positive pressure ventilation does not significantly increase the risk of regurgitation and is particularly beneficial in patients at risk of hypoxia. These results the need for less rigid RSI approaches after individual risk benefit assessment. Of note, from a scientific point of view, many questions regarding the efficacy of modified/controlled rapid sequence induction (mRSI) remain unanswered.[12]

The main strength of our consensus process was the multi-step design, integrating both peer opinions as well as expert recommendations, which were thereafter endorsed by the national professional society. The development of national guidance, as exemplified by the present initiative, has the potential to facilitate the alignment of practice, in addition to the harmonisation of curriculum development and quality assurance initiatives. Furthermore, consensus-based recommendations have been shown to facilitate the adoption of safe, modern practices in smaller or resource-constrained institutions, thereby relieving them of the burden of independently developing evidence reviews or protocols.

However, we are aware of several limitations. Overall, our modified consensus process might be prone to substantial bias: First, the survey targeted department heads of accredited teaching hospitals, potentially excluding the views of individual experts, private hospitals, outpatient anaesthesia institutions or smaller non-teaching institutions. Second, while the response rate was high, the binary nature of the voting format (yes/no) may have limited nuanced responses. Finally, our findings reflect expert consensus, not direct clinical outcome data, which limits the ability to infer effectiveness from agreement alone.

In conclusion, the results of this initiative provide a valuable foundation for a standardized practice for the perioperative management of patients at risk of aspiration in Switzerland, thereby meeting an unaddressed need. Despite the fact that a high level of consensus was reached for the majority of aspects, there remains a certain reluctance to adopt never techniques. Therefore, further evidence remains urgently needed to investigate the true impact of different RSI strategies on aspiration rates, morbidity, and mortality. Likewise, follow-up work should examine the implementation and impact of these new national recommendations, including their influence on training, adherence, and patient outcomes.