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Overview of Aspiration Pneumonia

Aspiration is defined as the inhalation of either oropharyngeal or gastric contents into the lower airways; that is, the act of taking foreign material into the lungs. This can cause a number of syndromes determined by the quantity and nature of the aspirated material, the frequency of aspiration, and the host factors that predispose the patient to aspiration and modify the response.[1] Three types of material cause 3 different pneumonic syndromes. Aspiration of gastric acid causes chemical pneumonia, which has also been called aspiration pneumonitis (Mendelson's syndrome) although the former is an infectious process and the latter is a chemical injury, and both are managed differently.[1] Aspiration of bacteria from oral and pharyngeal areas causes bacterial pneumonia, and aspiration of oil (eg, mineral oil or vegetable oil) causes exogenous lipoid pneumonia, a rare form of pneumonia. In addition, aspiration of a foreign body may cause an acute respiratory emergency and, in some cases, may predispose the patient to bacterial pneumonia. Aspiration pneumonia, according to common usage, includes both chemical and bacterial pneumonia, although the pathophysiology, clinical presentation, treatment, and complications of each entity are different.[2] For patient education information, see eMedicine's Pneumonia Center and Procedures Center, as well as Chemical Pneumonia, Bacterial Pneumonia and Bronchoscopy. For more information, see the following:

Mycoplasma Pneumonia Bacterial Pneumonia Viral Pneumonia Imaging Pneumocystis Carinii Pneumonia Community-Acquired Pneumonia Nosocomial Pneumonia Ventilator-Associated Pneumonia Pneumocystis (carinii) jiroveci Pneumonia Fungal Pneumonia Pneumonia, Immunocompromised Nursing Home Acquired Pneumonia Chlamydial Pneumonias Lymphocytic Interstitial Pneumonia Imaging Typical Bacterial Pneumonia Imaging Atypical Bacterial Pneumonia Imaging Viral Pneumonia

The images below depict aspiration pneumonia in 2 different patients.

Aspiration pneumonia in an 84-year-old man in generally good health who had fever and cough. This posteroanterior radiograph demonstrates a left lower lobe

opacity. Chest radiograph of a patient with aspiration pneumonia of the left lung after a benzodiazepine overdose. The patient was probably positioned to the left at the moment of aspiration

Predisposing Conditions for Aspiration Pneumonia


Almost all patients who develop aspiration pneumonia have one or more of the predisposing conditions listed below. Although all the listed conditions predispose the patient to chemical pneumonia, conditions that alter consciousness and periodontal disease specifically predispose the patient to bacterial pneumonia. Conditions associated with altered or reduced consciousness, including any condition that reduces a patient's gag reflex, ability to maintain an airway, or both, increases the risk of aspiration pneumonia or pneumonitis. Such conditions are as follows:

Alcoholism Drug overdose Seizures Stroke Head trauma General anesthesia Intracranial mass lesion

Esophageal conditions associated with aspiration pneumonia include the following:

Dysphagia: Oropharyngeal dysphagia has been found in the majority of elderly patients (mean age, 84 y).[3]

Esophageal strictures Esophageal neoplasm Esophageal diverticula Tracheoesophageal fistula Gastroesophageal reflux disease

Neurologic disorders also predispose to aspiration pneumonia, such as the following:


Multiple sclerosis Dementia Parkinson disease Myasthenia gravis Pseudobulbar palsy

Aspiration pneumonia is also associated with the following mechanical conditions:


Nasogastric tube Endotracheal intubation Tracheostomy Upper gastrointestinal endoscopy Bronchoscopy Gastrostomy or postpyloric feeding tubes

Other types of associated conditions are as follows:


Protracted vomiting Prolonged recumbency General deconditioning and debility Critical illness

Pathophysiology of Aspiration Pneumonia


In aspiration pneumonia, an infiltrate develops in a patient at increased risk of oropharyngeal aspiration. This occurs when a patient inhales material from the oropharynx that is colonized by upper airway flora. The risk of aspiration is indirectly related to the level of consciousness of the patient (ie, decreasing Glasgow Coma Scale [GCS] score is related with increased risk of aspiration).[4] Aspiration of small amounts of material from the buccal cavity, particularly during sleep, is not an uncommon event. No disease ensues in healthy persons, because the aspirated material is cleared by mucociliary action and alveolar macrophages. The nature of the aspirated material, volume of the aspirated material, and state of the host defenses are 3 important determinants of the extent and severity of aspiration pneumonia.

Chemical pneumonia

Chemical pneumonia, also known as aspiration pneumonitis and Mendelson syndrome, is due to the parenchymal inflammatory reaction caused by a large volume of gastric contents independent of infection. In fact, aspiration of a massive amount of gastric contents can produce acute respiratory distress within 1 hour. This disease occurs in people with altered levels of consciousness resulting from seizures, cerebrovascular accident (CVA), central nervous system (CNS) mass lesions, drug intoxication or overdose, and head trauma. The acidity of gastric contents results in chemical burns to the tracheobronchial tree involved in the aspiration. If the pH of the aspirated fluid is less than 2.5 and the volume of aspirate is greater than 0.3 mL/kg of body weight (20-25 mL in adults), it has a greater potential for causing chemical pneumonia. The initial chemical burn is followed by an inflammatory cellular reaction fueled by the release of potent cytokines, particularly tumor necrosis factor (TNF)alpha and interleukin (IL)8.

Bacterial pneumonia
Bacterial pneumonia most commonly occurs in individuals with chronically impaired airway defense mechanisms, such as gag reflex, coughing, ciliary movement, and immune mechanisms, all of which aid in removing infectious material from the lower airways. This syndrome caused by aspiration can occur in the community or in the hospital (ie, nosocomial). In both situations, anaerobic organisms alone or in combination with aerobic and/or microaerophilic organisms play a role. In anaerobic pneumonia, the pathogenesis is related to the large volume of aspirated anaerobes (eg, as in persons with poor dentition, poor oral care, and periodontal disease) and to host factors (eg, as in alcoholism) that suppress cough, mucociliary clearance, and phagocytic efficiency, both of which increase the bacterial burden of oropharyngeal secretions. Nosocomial bacterial pneumonia caused by aspiration is common, and the major pathogens involved are hospital-acquired florae through oropharyngeal colonization (eg, enteric gramnegative bacteria, staphylococci). Selection and colonization of gram-negative organisms in the oropharynx, sedation, and intubation of the patient's airways are important pathogenetic factors in nosocomial pneumonia. Because of the relative sterility of normal gastric contents, bacteria do not play an important role in the early stages of the disease. This does not hold true in patients with gastroparesis or small-bowel obstruction or in those using antacids (proton pump inhibitors [PPIs], H2-receptor antagonists). Regardless of the bacterial load of the inoculum, bacterial superinfection may occur after the initial chemical injury.

Causative microorganisms
Initial bacteriologic studies into the causative organisms revealed the anaerobic species to be the predominant pathogens in community-acquired aspiration pneumonia. However, subsequent studies revealed that Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Enterobacteriaceae are the most common organisms.[1] In fact, in 2 studies of patients with acute, witnessed aspiration with protective specimen brush sampling and anaerobic culturing, no anaerobes were isolated.[5, 6] However, hospital-acquired aspiration pneumonia is often caused by

gram-negative organisms including Pseudomonas aeruginosa, particularly in intubated patients.[7] These studies demonstrated a limited role of anaerobic pathogens in both the community and nosocomial variants of the disease.

Epidemiology of Aspiration Pneumonia


A reliable estimate of incidence of chemical pneumonia is not available. Few studies have been designed that distinguish between aspiration pneumonia and aspiration pneumonitis. Several studies suggest that 5-15% of the 4.5 million cases of community-acquired pneumonia (CAP) result from aspiration pneumonia.[1] Nosocomial bacterial pneumonia is the second most likely cause of nosocomial infections, second only to urinary tract infection, and it is the leading cause of death from hospital-acquired infections. Approximately 10% of patients who are hospitalized after drug overdoses will have an aspiration pneumonitis. Nosocomial bacterial pneumonia caused by aspiration is much more frequent in adults than in children, and males are more commonly affected than females. Predisposing factors (see Predisposing Conditions for Aspiration Pneumonia)are more common among elderly people; therefore, this population is more prone to develop aspiration pneumonia.[8] Comparative studies of bacterial pneumonia in patients from the community with those in a continuing care facility have shown a 3-fold increase of this disease in residents of the continuing care facilities (the majority of them had neurologic disease with dysphagia).[9]

Presentation of Aspiration Pneumonia


The clinical presentation of both aspiration pneumonia and pneumonitis ranges from mildly ill and ambulating to critically ill, with signs and symptoms of septic shock and/or respiratory failure. Host factors and chronic conditions that result in a decreased ability to protect one's airway include a previous cerebrovascular accident (CVA), a history of esophageal diseases including achalasia[10] or esophageal web, being a nursing home patient, and being chronically fed by feeding tube (nasogastric [NG] tube or gastric tube). Physical examination findings vary depending on the severity of the disease, presence of complications, and host factors. Patients with aspiration pneumonitis secondary to seizure, head trauma, or drug overdose should be inspected for signs related to these processes. In addition to exhibiting signs associated with the underlying disease that led to their aspiration, patients with aspiration pneumonia or pneumonitis may demonstrate the following:

Fever or hypothermia Tachypnea Tachycardia Decreased breath sounds Dullness to percussion over areas of consolidation

Rales Egophony and pectoriloquy Decreased breath sounds Pleural friction rub Altered mental status Hypoxemia Hypotension (in septic shock)

Chemical pneumonia
Patients with chemical pneumonia may present with an acute onset or abrupt development of symptoms within a few minutes to 2 hours of the aspiration event, as well as respiratory distress and rapid breathing, audible wheezing, and cough with pink or frothy sputum. Findings on physical examination may include tachypnea, tachycardia, fever, rales, wheezing, and possibly cyanosis.

Bacterial pneumonia
The presentation of bacterial aspiration pneumonia is similar to that of community-acquired pneumonia (CAP) and may include nonspecific symptoms including headache, nausea/vomiting, anorexia, weight loss. The onset of illness may be subacute or insidious, with the symptoms manifesting in days to weeks when anaerobic organisms are the pathogens. The patient may also describe the following:

Cough with purulent sputum Fever or chills Malaise, myalgias Absence of rigors Shortness of breath, dyspnea on exertion Pleuritic chest pain Putrid expectoration (a clue to anaerobic bacterial pneumonia)

In hospital acquired aspiration pneumonia, the symptoms of cough and shortness of breath of may be more acute in onset than in CAP when aerobic organisms are the pathogens; fever and rigors may be present. Patients brought in after witnessed large-volume vomitus and subsequent aspiration pneumonitis will have a history consistent with an acute change in mental status, which may include seizure, alcohol abuse, drug overdose, and/or head trauma. On physical examination, findings may include periodontal disease (primarily noted as gingivitis), bad breath, fever, bronchial breath sounds and rales over a consolidated posterior area, and possibly clubbing of the fingers.

Diagnosis in Aspiration Pneumonia

Clinicians must consider the diagnosis of aspiration pneumonia when a patient presents with risk factors and radiographic evidence of an infiltrate suggestive of aspiration pneumonia (see Predisposing Conditions for Aspiration Pneumonia). The location of the infiltrate on chest radiograph depends on the position of the patient when the aspiration occurred. The laboratory studies obtained should be guided by the patients clinical presentation (see Presentation of Aspiration Pneumonia). Patients with signs or symptoms of sepsis or septic shock require further laboratory testing than those with uncomplicated aspiration syndromes.

Differentials
When evaluating a patient with suspected aspiration pneumonia, also consider necrotizing pneumonia, bronchopleural fistula, lung carcinoma, lung abscess, mycoses, and hypersensitivity pneumonitis. In children, consider bronchiolitis, croup or laryngotracheobronchitis, epiglottitis, asthma, reactive airway disease, respiratory distress syndrome, and foreign bodies. In addition, assess for the following conditions:

Acute respiratory distress syndrome Tuberculosis Altitude illness - Pulmonary syndromes Bronchitis Chronic obstructive pulmonary disease and emphysema Adult epiglottitis Pneumonia, empyema and abscess Pneumonia, Immunocompromised Mycoplasma pneumonia Viral pneumonia Septic shock

Arterial Blood Gas and Mixed Venous Gas Analysis


Arterial blood gas (ABG) analysis is used to assess oxygenation and pH status and adds information to guiding oxygen supplementation. The results demonstrate acute hypoxemia in patients with chemical pneumonia and normal to low partial pressure of carbon dioxide with respiratory alkalosis. The lactate level (often included with blood gases) can be used as an early marker of severe sepsis or septic shock. A mixed venous gas measurement should be obtained in any patient in whom septic shock is suspected. Decreased mixed venous oxygen saturation is a marker for septic shock.

Basic Metabolic Panel


Serum electrolyte, blood urea nitrogen (BUN), and creatinine levels can be used to assess fluid status and the need for intravenous hydration. This is especially important in patients who present with fever, vomiting, or diarrhea who may have significant fluid loss.

Serum BUN and creatinine levels can also be used to assess renal function in order to appropriately dose antibiotics. In addition, these values can be used to assess end-organ damage in patients who present with sepsis or septic shock.

CBC With Differential


The complete blood cell (CBC) count may reveal an elevated white blood cell (WBC) count, increased neutrophils, anemia, and thrombocytosis in patients with bacterial pneumonia caused by anaerobic bacteria. Elevated WBC count and increased neutrophils may also be present in patients with chemical pneumonia.

Sputum Gram Stain, Microscopy, and Culture


Although sputum culture and Gram stain are generally not helpful in the initial diagnosis or treatment, sputum Gram stain and microscopy reveal a multitude of bacteria (eg, cocci, bacilli, coccobacillary forms, spirochetes, fusiforms) in patients with bacterial pneumonia caused by anaerobic bacteria. In nosocomial bacterial pneumonia, sputum culture may be helpful in detecting gram-negative bacteria. Findings on sputum culture may not isolate organisms, because the major pathogens are anaerobes.

Blood Cultures
Use blood cultures as a baseline screening for bacteremia. In uncomplicated pneumonia (no signs of sepsis or septic shock), blood cultures have a low yield and are not necessary for the initial management and treatment.

Chest Radiography
Radiographic evidence of aspiration pneumonia depends on the position of the patient when the aspiration occurred.[11] The right middle and lower lung lobes are the most common sites of infiltrate formation due to the larger caliber and more vertical orientation of the right mainstem bronchus.[11] Patients who aspirate while standing can have bilateral lower lung lobe infiltrates. Patients lying in the left lateral decubitus position are more likely to have left-sided infiltrates (see the following image). The right upper lobe is a common area of consolidation in alcoholics who aspirate in the prone position.

Chest radiograph of a patient with aspiration pneumonia of the left lung after a benzodiazepine overdose. The patient was probably positioned to the left at the moment of aspiration The presence of pleural effusion may indicate the need to perform thoracentesis to rule out empyema.

Chemical pneumonia
Chest radiographic findings in patients with chemical pneumonia are characterized by the presence of infiltrates, predominantly the alveolar type, in one or both lower lobes, or diffuse simulation of the appearance of pulmonary edema. Volume loss in any lobar area suggests obstruction (eg, by aspirated food particles or other foreign bodies) in the bronchus.

Bacterial pneumonia
Chest radiographic findings in patients with anaerobic bacterial pneumonia typically demonstrate an infiltrate with or without cavitation in one of the dependent segments of the lungs (ie, posterior segments of the upper lobes, superior segments of the lower lobes). Lucency within the infiltrate suggests a necrotizing pneumonia. Air-fluid levels within a circumscribed infiltrate (density) indicate a lung abscess or a bronchopleural fistula. Costophrenic angle blunting and the presence of a meniscus are signs of a parapneumonic pleural effusion. More images in patients with aspiration pneumonia are provided below.

Aspiration pneumonia in an 84-year-old man in generally good health who had fever and cough. This posteroanterior radiograph demonstrates a left lower lobe

opacity. pneumonia

confirms

the

Lateral radiograph in an 84-year-old patient with aspiration location of the abnormality in the left lower lobe.

Chest radiograph of a patient with massive aspiration pneumonia of the right lung.

Ultrasonography
Ultrasonography is helpful when confirming and locating pleural effusions.

CT Scanning
Computed tomography (CT) scan of the chest is not needed in all cases of suspected aspiration pneumonia. This imaging modality may be helpful in further characterizing pleural effusions or empyema, such detecting necrosis within infiltrates, cavities, and loculated pleural effusions. CT scanning provides a better definition of the affected areas and is used to differentiate pulmonary abnormalities from pleural abnormalities.

Bronchoscopy
Bronchoscopy is indicated in patients with chemical pneumonia only when aspiration of a foreign body or food material is suspected. Bronchoscopy with protected brush and a protected catheter are used to retrieve pathogens in bacterial pneumonia and may be helpful in guiding antibiotic therapy. This procedure is useful when ruling out the presence of an obstructing neoplasm in anaerobic bacterial pneumonia with lung abscess; however, bronchoscopy is not useful in the treatment of community-acquired aspiration pneumonia.

Pulmonary Artery Catheterization

Pulmonary artery catheter placement may be needed to differentiate cardiac from noncardiac pulmonary edema caused by chemical pneumonia and for appropriate fluid management.

Thoracentesis
Thoracentesis, also known as pleural fluid aspiration, is a diagnostic and therapeutic procedure in which fluid (or air) is removed from between the pleura and chest wall. Analysis of the specimen can help determine the underlying cause of the pleural effusion as well as relieve any symptoms from excess build up of fluid. A chest x-ray should be obtained both before and after this procedure to detect possible complications from the thoracentesis.

Mechanical Ventilation
Mechanical ventilation is needed in severe cases of chemical pneumonia that cause acute respiratory distress syndrome (ARDS).

Chest Tube Placement


Placement of a chest tube can be used to drain large empyema.

Prehospital Management of Aspiration Pneumonia


Prehospital care should focus on stabilizing the patient's airway, breathing, and circulation. In patients found with signs of gastric aspiration (ie, vomitus) suctioning of the upper airway may remove a significant amount of aspirate or potential aspirate. Intubation should be considered in any patient who is unable to protect his or her airway. The ability of paramedics to provide this intervention depends on the level of their training. [12] In addition, emergency medical technicians (EMTs) trained in intubation may choose to intubate patients with poor gag reflex before aspiration. Other measures include the following:

Oxygen supplementation Cardiac monitoring and pulse oximetry Intravenous (IV) catheter placement and IV fluids, as indicated

Emergency Department Management


Emergency department care should start with stabilizing the patient's airway, breathing, and circulation. Oropharyngeal/tracheal suctioning may be indicated to further remove aspirate. Reassess the need for intubation on a frequent basis depending on the patients oxygenation, the patient's mental status, signs of increased work of breathing, or impending respiratory failure.

Continue supplemental oxygenation as needed, as well as continue cardiac monitoring and pulse oximetry and provide continued supportive care with intravenous fluids and electrolyte replacement.

Inpatient Management
Patients with aspiration pneumonia, both chemical pneumonia (chemical pneumonia) and bacterial pneumonia (bacterial pneumonia), need inpatient care for several reasons, including the acuity of illness, host factors, and the uncertain course and prognosis of aspiration pneumonia.[13] Admit patients with severe hemodynamic compromise and/or persistent respiratory distress to the intensive care unit (ICU). Intubated and ventilated patients must be transferred to a hospital with an ICU, as well as patients with signs or symptoms indicating severe sepsis or septic shock. If the patient's respiratory status is stabilized, admit the patient to a general-care floor.

Complications
Complications of chemical pneumonia include acute respiratory failure, acute respiratory distress syndrome (ARDS),[14] and nosocomial bacterial pneumonia. Complications of bacterial pneumonia include parapneumonic effusion, empyema, lung abscess, and superinfection; bronchopleural fistula is also a complication. Aspiration pneumonitis can rapidly progress to respiratory failure.

Consultations
Consultation with the following specialists may be warranted:

Pulmonologist For bronchoscopy when obstruction is suspected in patients with chemical pneumonia or in ruling out a neoplasm in bacterial pneumonia cases Intensivist (critical care) For severe chemical pneumonia if hypoxemia is severe and ventilatory support is anticipated[15, 16] Thoracic surgeon For anaerobic bacterial pneumonia with complications (eg, closed tube drainage of an empyema, open tube drainage, and decortication). In general, there is no role for surgical care, except in such cases with complications. Infectious disease specialist For advice about proper antibiotic therapy Speech and language therapist For a comprehensive swallowing evaluation in patients with stroke or other risk factors for aspiration. These therapists can perform the bedside swallowing evaluation and, if abnormalities are found, can teach the patient compensatory strategies with soft or pureed foods.

Overview of Antimicrobial Therapy

Antibiotics are always indicated for aspiration pneumonia; however, for aspiration pneumonitis, early presumptive antibiotics (ie, prophylactic) are not recommended. This practice is believed to lead to the selection of more resistant organisms.[17] In addition, those patients with recent aspiration, fever, and leukocytosis should not be treated even in the presence of a pulmonary infiltrate due to the risk of development of resistant organisms. The following situations call for the use of antibiotics in managing pneumonitis:

Administer antibiotics if the pneumonitis fails to resolve within 48 hours. Patients with small-bowel obstruction, particularly of the lower region, should receive antibiotics (bacteria may colonize the gastric contents). Antibiotics should be considered for patients on antacids due to the potential for gastric colonization.

Antibiotic choice
In patients without a toxic appearance, the antibiotic chosen should cover typical communityacquired pathogens. Ceftriaxone plus azithromycin, levofloxacin, or moxifloxacin are appropriate choices. In patients with a toxic appearance or who were recently hospitalized, although communityacquired pathogens are still the most common, gram-negative bacteria including Pseudomonas aeruginosa and Klebsiella pneumoniae as well as methicillin-resistant Staphylococcus aureus (MRSA) must be covered. Piperacillin/tazobactam or imipenem/cilastatin plus vancomycin would be appropriate. Add clindamycin for purulent sputum.

Management of Chemical Pneumonia


Treatment of individuals with chemical pneumonia should include maintenance of the airways and clearance of secretions with tracheal suctioning, oxygen supplementation, mechanical ventilation if the patient is unable to maintain adequate oxygenation, early use of positive end-expiratory pressure (PEEP), and administration of intravenous (IV) fluids. Routine use of corticosteroids is not recommended, because supporting studies, both animal and human, are not convincing of a favorable benefit-to-risk ratio. Early prophylactic (before evidence of a bacterial pneumonia) use of antibiotics, although widely practiced, is not backed by evidence. Choosing antibiotics based on organisms cultured from sputum, tracheal aspirates, or aspirate obtained through a protected catheter by bronchoscopy rather than empirically is more appropriate. However, because the chemically injured bronchi and lungs are very susceptible to bacterial infection, it is reasonable to use antimicrobial agents based on the probability of the bacteria, the severity of the pneumonia, patient-related risk factors (eg, malnutrition, comorbid illnesses), intervention-related factors (eg, previous use of antibiotics, corticosteroids, cytotoxic agents, endotracheal tube), and the duration of hospitalization. The usual coverage is for gram-negative bacteria and anaerobes. As examples, dual treatment involving a carefully chosen second-generation cephalosporin or nonpseudomonal third-generation cephalosporin and clindamycin, aztreonam, or fluoroquinolones

is appropriate in many cases. However, in severe pneumonia occurring many days after initiation of mechanical ventilation, the probability of resistant organisms, including Pseudomonas aeruginosa, Acinetobacter species, and methicillin-resistant S aureus (MRSA) is increased, and, therefore, antibiotic treatment should be broader and aggressive. The choices of antimicrobial agents include ciprofloxacin, quinolones, aminoglycoside with antipseudomonal penicillin, ceftazidime, imipenem, and vancomycin.

Management of Bacterial Pneumonia


Antibiotics are the mainstay of treatment. The choice of antibiotics and duration of treatment depend on the clinical setting in which the aspiration occurred (community vs nosocomial) and on the suspected or proven causative organisms. Antibiotic agents with activity against gram-negative organisms as well as gram-positive organisms are usually required. In community-acquired bacterial pneumonia, the most common causative organisms are indigenous oral flora. These are predominantly anaerobes (eg, Bacteroides species, Fusobacterium species, Peptostreptococcus species) and streptococci. Microbiologic evidence indicates that empiric coverage of anaerobes is not indicated, unless the patient presents with putrid sputum, severe oropharyngeal disease, or evidence of lung abscess or necrotizing pneumonia on chest radiographs or computed tomography scans. Clindamycin is the antibiotic of choice in community-acquired bacterial pneumonia. Alternative agents to clindamycin include amoxicillin with clavulanate (Augmentin) and metronidazole (Flagyl). Metronidazole used alone is not recommended because of a high failure rate. Similarly, macrolides, cephalosporins, and fluoroquinolones are additional alternative antibiotics that are not recommended as first-line agents, because they are not well studied. In nosocomial bacterial pneumonia (ie, aspiration in the hospital), in addition to the usual oral flora pathogens such as Staphylococcus aureus, Escherichia coli, Klebsiella species, Enterobacter species, and Pseudomonas species may be involved. Ventilator-associated pneumonia may require broader antibiotic coverage.[15, 16]

Corticosteroid Management
Historically corticosteroids have been used in the treatment of aspiration pneumonitis, but randomized control studies have been unable to demonstrate a benefit to using high-dose corticosteroids. Patients with septic shock that requires vasoactive substances to maintain blood pressure should receive stress-dose steroids.

Postdischarge Management
Patients who recover from chemical pneumonia generally do not require additional outpatient care, except for adherence to measures to prevent further aspiration episodes.

Unlike chemical pneumonia, anaerobic bacterial infections require prolonged antibiotic treatment; therefore, outpatient treatment is necessary. Patients can be discharged from the hospital after clinical improvement and stability (eg, no fever, no leucocytosis, resolution of hypoxemia) and radiographic improvement (eg, decreased infiltrate or cavity size, no pleural effusion). In cases with lung abscess, oral antibiotic therapy (ie, clindamycin) is continued for several weeks for treating, although the exact duration of treatment has not been determined.

Prevention of Aspiration Pneumonia


Position patients with altered consciousness in a semirecumbent position with the head of the bed at a 30-45 angle. This reduces the risk of aspiration leading to pneumonia.[12] For patients with known swallowing dysfunction (eg, dysphagia and/or a poor gag reflex), helpful compensatory techniques to reduce aspiration include a soft diet reducing the bite size, keeping the chin tucked and the head turned, and repeated swallowing. However, although body positioning and changing the consistency of food are reasonable steps, their efficacy has not been proven in controlled trials.[18, 19] In addition, feeding through a nasogastric or gastric tube may be required. Use of nonparticulate antacids and histamine 2 (H2) blockers to reduce gastric acidity has been a common practice; however, this is very questionable, because gastric acid suppression and consequent loss of the acid barrier to bacteria is associated with a higher rate of pneumonia. Use antiemetics to reduce lower esophageal sphincter pressure. Before starting enteral tube feeding, confirm the tip location radiographically. Check residual gastric volume regularly. For those on bolus tube, feeding residual should not exceed 150 mL before the next bolus feed. Avoid oversedating patients.

Prognosis of Aspiration Pneumonia


The prognosis of both chemical pneumonia and bacterial pneumonia is dependent on underlying diseases, complications, and host status. The mortality associated with aspiration pneumonia mimics that of community-acquired pneumonia: approximately 1% in the outpatient setting and up to 25% in those requiring hospitalization. This mortality range depends on complications of the disease. In Mendelson's original series in 1946, Mendelson described 61 obstetric patients who aspirated gastric acid during anesthesia, all of whom had a complete clinical recovery within 24-36 hours. [20] In subsequent studies, which have included older sicker patients, chemical pneumonia has a reported mortality rate of 30-62%, because chemical pneumonia often leads to acute respiratory distress syndrome (ARDS). The mortality rate for severe chemical pneumonitis (Mendelson syndrome) can be up to 70%.

If bacterial pneumonia is not treated early, it can lead to development of complications, including lung abscess and bronchopleural fistula in comparison to community-acquired pneumonia. Nosocomial pneumonia is associated with a longer period of hospitalization and increased mortality rates. The mortality rate for aspiration pneumonitis complicated by empyema is approximately 20%; the mortality for uncomplicated pneumonitis is approximately 5%. An animal model study demonstrated that mice with aspiration pneumonitis were more susceptible to subsequent respiratory infection with certain pathogens.[21]

Special Considerations
The following may be medicolegal pitfalls:

Not recognizing or not weighing the risk for aspiration based on predisposing conditions Feeding patients at high risk for aspiration Resumption of feeding after intubation without assessing patient's ability to swallow and gastric motility Delay in diagnosis of anaerobic lung abscess because of subacute presentation Misdiagnosis of anaerobic lung abscess (mistaken for lung carcinoma or tuberculosis)