Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.

One of the most common questions I hear from patients immediately prior to their surgical anesthetic is, “Will I have a breathing tube down my throat during anesthesia?”

The answer is: “It depends.”

placing anesthesia breathing tube

Let’s answer this question for some common surgeries:

KNEE ARTHROSCOPY: Common knee arthroscopy procedures are meniscectomies and anterior cruciate ligament reconstructions. Anesthetic options include general anesthesia, regional anesthesia, or local anesthesia. Most knee arthroscopies are performed under a general anesthetic, in which the anesthesiologist injects propofol into your intravenous line to make you fall asleep. After you’re asleep, the most common airway tube used for knee arthroscopy is a laryngeal mask airway (LMA). The LMA in inserted into your mouth, behind your tongue and past your uvula, to a depth just superior to your voice box. The majority of patients will breath on their own during surgery. The LMA keeps you from snoring or having significant obstruction of your airway passages. In select patients, including very obese patients, an endotracheal tube (ETT) will be inserted instead of an LMA. The ETT requires the anesthesiologist to look directly into your voice box and insert the tube through and past your vocal cords. With either the LMA or the ETT, you’ll be asleep and will have no awareness of the airway tube except for a sore throat after surgery. A lesser number of knee arthroscopies are performed under a regional anesthetic which does not require a breathing tube. The regional anesthetic options include a blockade of the femoral nerve located in your groin or numbing the entire lower half of your body with a spinal or epidural anesthetic injected into your low back. A small number of knee arthroscopies are done with local anesthesia injected into your knee joint, in combination with intravenous sedative medications into your IV. Why are most knee arthroscopies performed with general anesthesia, which typically requires an airway tube? Because in an anesthesiologist’s hands, an airway tube is a common intervention with an acceptable risk profile. A light general anesthetic is a simpler anesthetic than a femoral nerve block, a spinal, or an epidural anesthetic.

Laryngeal Mask Airway (LMA)

Endotracheal Tube (ETT)

NOSE AND THROAT SURGERIES SUCH AS TONSILLECTOMY AND RHINOPLASTY: Almost all nose and throat surgeries require an airway tube, so anesthetic gases and oxygen can be ventilated in and out through your windpipe safely during the time the surgeon is working on these breathing passages.

ABDOMINAL SURGERIES, INCLUDING LAPAROSCOPY: Almost all intra-abdominal surgeries require an airway tube to guarantee adequate ventilation of anesthetic gases and oxygen in and out of your lungs while the surgeon works inside your abdomen.

CHEST SURGERIES AND OPEN HEART SURGERIES: Almost all intra-thoracic surgeries require an airway tube to guarantee adequate ventilation of anesthetic gases and oxygen in and out of your lungs while the surgeon works inside your chest.

TOTAL KNEE REPLACEMENT AND TOTAL HIP REPLACEMENT: The majority of total knee and hip replacement surgeries are performed using spinal, epidural and/or nerve block anesthesia anesthesia to block pain to the lower half of the body. The anesthesiologist often chooses to supplement the regional anesthesia with intravenous sedation, or supplement with a general anesthetic which requires an airway tube. Why add sedation or general anesthesia to the regional block anesthesia? It’s simple: most patients have zero interest in being awake while they listen to the surgeon saw through their knee joint or hammer their new total hip into place.

CATARACT SURGERY: Cataract surgery is usually performed using numbing local anesthetic eye drop medications. Patients are wake or mildly sedated, and no airway tube is used.

COLONOSCOPY OR STOMACH ENDOSCOPY: These procedures are performed under intravenous sedation and almost never require an airway tube.

HAND OR FOOT SURGERIES: The anesthesiologist will choose the simplest anesthetic that suffices. Sometimes the choice is local anesthesia, with or without intravenous sedation. Sometimes the choice will be a regional nerve block to numb the extremity, with or without intravenous sedation. Many times the choice will be a general anesthetic, often with an airway tube. An LMA is used more frequently than an ETT.

CESAREAN SECTION: The preferred anesthetic is a spinal or epidural block which leaves the mother awake and alert to bond with her newborn immediately after childbirth. If the Cesarean section is an urgent emergency performed because of maternal bleeding or fetal distress, and there is inadequate time to insert a spinal or epidural local anesthetic into the mother’s lower back, a general anesthetic will be performed. An ETT is always used.

PEDIATRIC SURGERIES: Tonsillectomies are a common procedure and require a breathing tube as described above. Placement of pressure ventilation tubes into a child’s ears requires general anesthetic gases to be delivered via facemask only, and no airway tube is required. Almost all pediatric surgeries require general anesthesia. Infants, toddlers, and children need to be unconscious during surgery, for emotional reasons, because their parents are not present. The majority of pediatric general anesthetics require an airway tube.

CONCLUSIONS: The safe placement of airway tubes for multiple of types of surgeries, in patients varying from newborns to 100-year-olds, is one of the reasons physician anesthesiologists train for many years.

Prior to surgery, some patients are alarmed at the notion of such a breathing tube invading their body. They fear they’ll be awake during the placement of the breathing tube, or that they’ll choke on the breathing tube.

Be reassured that almost every breathing tube is placed after your unconsciousness is assured, and breathing tubes are removed prior to your return to consciousness. A sore throat afterward is common, but be reassured this is a minor complaint that will clear in a few days.

If you have any questions, be sure to discuss them with your own physician anesthesiologist when you meet him or her prior to your surgical procedure.

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.



Clinical Case for Discussion:   A 44-year-old man is scheduled for a knee arthroscopy.  He takes Prilosec for Gastro Esophageal Reflux Disease (GERD).  He is six feet tall, weighs 70 kg, and refuses regional anesthesia.   Regarding airway management for general anesthesia, you may choose a Laryngeal Mask Airway (LMA) or an endotracheal tube.  What do you do?

Discussion:   The symptoms of esophageal reflux and heartburn are exceedingly common in our society.  For years the histamine-2 blockers such as cimetidine and ranitidine were among the top money-making prescription drugs in America, before they became the over-the-counter bestsellers they are today.  Open any weekly magazine such as Newsweek or Sports Illustrated and you may find full page ads for Nexium and Protonix today.   People hurt, and they want these pills.

This is relevant in an anesthesia practice because a large percentage of patients will answer “yes” to the question of heartburn or GERD in a pre-operative questionnaire.   Thus GERD goes on their chart as a diagnosis.  How important is this?  Are they an ASA I or an ASA II, based on GERD?  Do they need endotracheal intubation for general anesthesia to prevent the dreaded complication of pulmonary aspiration of gastric contents?

Miller’s Anesthesia, a leading textbook, says,”The incidence of aspiration of gastric contents is infrequent in fasted elective surgical patients. Despite improvements in several surrogate measures, insufficient evidence exists of clinical benefit (i.e., a reduction in morbidity or mortality from aspiration) to recommend the routine use of antacids, metoclopramide, H 2 -receptor antagonists, or proton pump inhibitors before elective ambulatory surgery. Patients who are receiving these medications chronically should take them before surgery. Patients who regularly suffer from significant acid reflux in the fasted state will also benefit from the head-up tilt position during induction of anesthesia.” (Smith I. Ambulatory(Outpatient)Anesthesia, Miller’s Anesthesia.10e,Chapter 89.2015; 2612-2645)

The same textbook says, “Many ambulatory surgical patients can be managed with an LMA, which results in a significantly less frequent incidence of sore throat, hoarseness, coughing, and laryngospasm compared to inserting a tracheal tube. The LMA can occasionally cause pressure trauma to a variety of cranial nerves, in particular the recurrent laryngeal nerve, whereas hoarseness and vocal cord injuries are common after the use of endotracheal intubation during short-term anesthesia. The LMA is relatively easy to insert with patients in the prone position, 230 making it a simple way of managing procedures such as pilonidal sinus repair or surgery to the short saphenous vein.”

In 2010 I submitted the Clinical Case above to the twenty-plus attending anesthesiologists in private practice in Palo Alto who are members of the Palo Alto Medical Foundation/Sutter or the Associated Anesthesiologists Medical Group. What follows is a consensus of what the majority do, every day, in operating rooms in the heart of Silicon Valley:

If the patient had GERD which was well-treated on medication, and had no symptoms at present, my colleagues said they would use an LMA for airway management, rather than intubate the patient’s trachea. If the patient had active symptoms of GE reflux that were not under control or had gastric paresis, then they would use an endotracheal tube following cricoid pressure.

One could be dogmatic and say this:  If a patient has GERD, then intubate the trachea with a rapid sequence intubation each time, or you run the risk of aspiration pneumonitis. However, no data exist to support this practice. There is no prospective, randomized trial that documents an endotracheal tube is more safe than an LMA in an NPO GERD patient for routine outpatient minor surgery.

The ProSeal LMA has a larger cuff, and a drain tube inside the cuff, which allows the insertion of a gastric tube to drain the stomach.  There is a case report in which an anesthetized patient with a ProSeal regurgitated 25 ml of brown fluid into the drain tube.  The conclusion was that the ProSeal protected the airway by allowing the regurgitated fluid to pass up the drainage tube without leaking into the glottis.  (Evans NR, Can J Anaesth. 2002 Apr;49(4);413-6).   The ProSeal may have a role in the GERD patient population, but to date there is little data to compare it to a classic LMA in this setting.

No physician anesthesiologist would use an LMA in a patient who was not NPO. No one would use an LMA in a patient for emergency surgery, or for a patient with a bowel obstruction. No one, or very few, would use an LMA in a patient who was morbidly obese, or a patient who was having a laparoscopy.

But for a routine outpatient surgery on an NPO patient with controlled GERD, most anesthesia professionals feel safe using an LMA rather than an endotracheal tube. There are anesthesiologists — well trained graduates of the Stanford anesthesia residency program — who use an LMA in this situation. The good news is that the prevalence of clinically important aspiration in otherwise healthy NPO patients is negligible.  I believe that is why most of my colleagues choose the LMA in this case.


Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.


In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:


Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: