Pulmonary aspiration of gastric contents in the perioperative phase is associated with increased postoperative morbidity and mortality. For the management of aspiration, differentiation between acid-associated aspiration pneumonitis and aspiration pneumonia as a consequence of a secondary bacterial contamination is of crucial importance. The incidence of aspiration in elective surgery is 1 per 2000-3000 anaesthesias in adults. In children, it is slightly more common with 1 per 1200-2600 anaesthesias. In the context of emergency anaesthesias the incidence of aspiration is three to four times higher. The risk particularly increases with recent ingestion of solid food or fluids, with older patients, with pregnant women, and with consciousness-reduced patients. Besides giving a review of the pathophysiology, incidence, and the risk factors of aspiration, this article places emphasis on the practical management of this anaesthesia-associated complication. Cricoid pressure, as a non-evidence-based but clinically wide-spread method in the context of the prophylaxis of aspiration, is discussed critically. The main part deals with strategies to structure the management of aspiration by use of scientific concepts based on medical crisis management. For this, an algorithm based on current scientific investigations is presented.