What is the treatment for aspiration?

Treatment of Aspiration

Simple aspiration is recommended as first line treatment for aspiration requiring intervention, with subsequent steps depending on the type and severity of aspiration. 1

Types of Aspiration and Initial Management

Aspiration of Gastric Contents/Vomit

1. Immediate actions:

   • Position patient head down in right lateral position to drain vomit from airway 2
   • Perform oropharyngeal suction to clear the airway 2
   • Laryngoscopy to clear the airway if needed 2
   • Bronchoscopy if solid material is causing obstruction 2
   • Endotracheal intubation if liquid aspiration is severe 2

2. Oxygen therapy:

   • Administer high-flow oxygen (10 L/min) to increase the pressure gradient between pleural capillaries and pleural cavity 1
   • This can increase the rate of reabsorption of aspirated material by up to four-fold 1

3. Ventilatory support:

   • Initiate artificial ventilation if PO2 is low 2
   • For patients requiring mechanical ventilation, use lung-protective strategies with low tidal volumes and low plateau pressures 3

Pneumothorax from Aspiration

1. Assessment based on severity:

   • For small pneumothoraces (<1 cm) with minimal symptoms: observation may be sufficient 1
   • For symptomatic pneumothoraces: active intervention required 1

2. Therapeutic aspiration:

   • Use a scalp vein needle (19 or 21 gauge) for aspiration 1
   • For primary pneumothoraces: simple aspiration is first-line treatment 1
   • For secondary pneumothoraces: aspiration is recommended only for small (<2 cm) pneumothoraces in minimally breathless patients under 50 years 1

3. Chest tube placement:

   • If aspiration fails, proceed to chest drain insertion 1
   • Patients with secondary pneumothoraces treated successfully with aspiration should be observed for at least 24 hours 1

Specific Considerations by Aspiration Type

Chemical Pneumonitis

1. Assessment:

   • Measure pH of gastric contents, blood gases, and acid-base values 2
   • Monitor vital signs including pulse, blood pressure, and central venous pressure 2

2. Treatment:

   • Correct acidosis if present 2
   • Consider aminophylline if bronchospasm is severe 2
   • Administer plasma or plasma substitute for hypotension and hypovolaemia 2

Aspiration Pneumonia

1. Antibiotic therapy:

   • Antibiotics are indicated only in patients with confirmed aspiration pneumonia 3
   • Not recommended for prophylaxis after witnessed aspiration without signs of infection

2. Supportive care:

   • Maintain adequate oxygenation
   • Provide respiratory support as needed

Important Caveats and Pitfalls

1. Steroids are not proven effective:

   • Despite common practice, steroids have not been proven to improve outcomes or reduce mortality in aspiration cases 3

2. Avoid unnecessary antibiotics:

   • Antibiotics should be reserved for confirmed infectious pneumonia, not chemical pneumonitis 3

3. Recognize risk factors:

   • Highest risk in patients with decreased consciousness, compromised airway defenses, dysphagia, gastroesophageal reflux, and recurrent vomiting 4
   • Increased incidence in obstetric and pediatric anesthesia 3

4. Prevention is critical:

   • Proper fasting protocols before procedures
   • Rapid sequence induction for high-risk patients 3
   • Early identification and management of dysphagia, especially in children 5

5. Diagnostic challenges:

   • Aspiration is often unsuspected and undiagnosed 4
   • Clinical symptoms can be nonspecific, requiring high index of suspicion 5

The treatment approach should follow a stepwise progression, starting with the least invasive interventions (aspiration and supportive care) and advancing to more invasive measures (chest tube placement, mechanical ventilation) as needed based on clinical response.