Risk Factors Associated with Aspiration During Rapid Sequence Induction

Background: Aspiration during rapid sequence induction and intubation (RSI) remains a serious emergency department (ED) complication, particularly in critically ill, non-fasted patients with physiological instability and difficult airway conditions. Objective: To determine the frequency of aspiration pneumonia and describe patient- and procedure-related factors observed among adults undergoing RSI in the ED. Methods: A cross-sectional observational study was conducted over four months in the ED of Social Security Hospital, Lahore. Adult patients (≥18 years) undergoing RSI for urgent airway management were enrolled using purposive consecutive sampling. Standardized data were recorded from clinical and procedural documentation, including comorbidities, altered sensorium, intubation attempts, Cormack–Lehane (CL) grade, adjunct use, aspiration markers, and early post-intubation outcomes; aspiration pneumonia was assessed within 48 hours using prespecified clinical and radiographic criteria. Results: Among 87 patients (mean age 51.7 ± 21.3 years; 72.4% male), hypoxia/pulmonary failure was the commonest indication (66.7%). Pre-intubation vomiting occurred in 5.7%, food particles were observed on immediate suction in 10.3%, and in post-intubation contents in 20.7%. First-attempt success was 69.0%, while 31.0% required ≥2 attempts; CL grade III–IV views occurred in 46.0%. Aspiration pneumonia developed in 19.5% within 48 hours. Conclusion: Aspiration pneumonia was frequent following ED RSI in this cohort, occurring alongside substantial airway difficulty and aspiration markers, underscoring the need for rigorous pre-intubation risk assessment