Sedation Strategy Influences Aspiration Risk After PEG : Frontline Gastroenterol | May 2026

Introduction

Percutaneous Endoscopic Gastrostomy is widely performed for long-term enteral nutritional support in patients with neurological disease, dysphagia and chronic debilitating illness. Aspiration pneumonia remains one of the most important early complications following PEG insertion and contributes substantially to post-procedural morbidity and mortality. However, the influence of sedation and local anaesthesia practices on aspiration risk has remained poorly defined at a population level.

Problem Statement

Considerable variation exists in endoscopic sedation and throat anaesthesia practices during PEG insertion across institutions. Whether specific sedation approaches independently increase post-PEG aspiration pneumonia risk has not previously been evaluated in a large real-world multicentre cohort.

Summary

This large retrospective population-based study analyzed more than 33,000 adult patients undergoing PEG insertion across England between 2016 and 2021. Investigators integrated Hospital Episode Statistics with National Endoscopy Database provider-level sedation practices to evaluate associations between procedural anaesthesia strategies and aspiration pneumonia occurring within seven days of PEG placement.

Substantial variation in sedation practice was observed across providers. Nearly half predominantly used combined midazolam-opioid sedation, while others favored midazolam alone, local anaesthetic throat spray or propofol/general anaesthesia approaches. Stroke represented the most common indication for PEG insertion and was associated with the highest baseline aspiration risk compared with other clinical indications.

The strongest associations with post-PEG aspiration pneumonia were observed among providers predominantly using propofol/general anaesthesia and those combining midazolam with local anaesthetic throat spray. In contrast, aspiration risk was substantially lower among providers using midazolam alone or combined with opioids without routine throat spray. These findings suggest that suppression of protective airway reflexes may play a central role in aspiration pathogenesis during PEG procedures.

The association with local anaesthetic throat spray is particularly notable because topical pharyngeal anaesthesia may impair laryngeal sensation and cough reflexes in already vulnerable dysphagic patients. Similarly, deeper sedation with propofol or general anaesthesia likely further compromises airway protection and swallowing coordination during and immediately after PEG insertion.

Additional procedural and patient-level risk factors included low provider procedural volume, advanced age and emergency hospital admission. Providers performing fewer than 23 PEG procedures annually demonstrated higher aspiration rates, suggesting an important volume-outcome relationship and potential benefit of procedural centralization or enhanced training pathways.

Clinically, the findings challenge routine use of aggressive sedation strategies during PEG insertion, particularly in frail neurological populations already predisposed to aspiration. The data support more individualized sedation approaches balancing patient comfort with preservation of airway protective reflexes.

Overall, this large national study demonstrates that sedation and local anaesthesia practices substantially influence aspiration pneumonia risk following PEG insertion. The findings have important implications for endoscopy sedation protocols and suggest that minimizing deep sedation and cautious use of local anaesthetic throat spray may improve procedural safety in high-risk PEG populations.