From the Guidelines
Aspiration pneumonitis is a chemical injury to the lungs caused by inhalation of gastric contents, particularly acidic stomach fluid, and treatment begins with immediate airway protection and supplemental oxygen to maintain adequate saturation levels. The management of aspiration pneumonitis involves several key strategies to minimize morbidity, mortality, and improve quality of life.
- Position the patient with the head elevated to prevent further aspiration.
- Antibiotics are not routinely recommended initially as this is primarily a chemical inflammation, not an infection, however, if bacterial infection develops (aspiration pneumonia), broad-spectrum antibiotics like ampicillin-sulbactam 1.5-3g IV every 6 hours or piperacillin-tazobactam 4.5g IV every 6 hours should be started, as recommended by guidelines for the management of adult lower respiratory tract infections 1.
- Corticosteroids are not recommended as they haven't shown benefit.
- Bronchoscopy may be necessary to clear large particulate matter or assess airway damage.
- Prevention strategies include fasting before procedures, proper positioning of at-risk patients, and medication adjustments for those with impaired swallowing, as certain conditions may increase the incidence of dysphagia, aspiration, and pneumonia, such as acute stroke, cervical spinal surgery, and elderly residents of long-term care facilities 1. The severity of pneumonitis depends on the volume and acidity of the aspirated material, with pH below 2.5 causing more severe inflammation, and complications can include acute respiratory distress syndrome, requiring intensive care management with mechanical ventilation and supportive care. It is essential to identify patients at risk of aspiration, such as those with oral-pharyngeal dysphagia, and implement preventive measures to reduce the risk of aspiration pneumonitis, as the mortality rate for aspiration pneumonia can range from 20 to 65% 1. In patients with suspected large-volume aspiration, anaerobes, chemical pneumonitis, or obstruction should be considered, and empiric antibiotic treatment should be guided by the patient's epidemiologic conditions and the likely causative pathogens 1. Overall, the management of aspiration pneumonitis requires a comprehensive approach that includes prevention, early recognition, and prompt treatment to minimize morbidity, mortality, and improve quality of life.
From the Research
Definition and Prevention of Aspiration Pneumonitis
- Aspiration pneumonitis is a spectrum of infectious/noninfectious diseases affecting the lung, with disease manifestation depending on the chemical characteristics, frequency, and volume of inoculum 2.
- Recognizing the factors that predispose patients to aspiration and identifying the patients who are susceptible to aspiration are the first steps in preventing aspiration pneumonitis 3.
- Techniques to avoid or reduce aspiration are important in preventing pneumonia and pneumonitis, including the semi-recumbent position, surveillance of enteral feeding, use of promotility agents, and avoiding excessive sedation 4.
Treatment of Aspiration Pneumonitis
- Aspiration pneumonitis does not require any antimicrobials, whereas aspiration pneumonia has to be treated 4.
- Empiric antimicrobials treatment should be started on clinical suspicion, with the choice of the drug guided by local pathogen epidemiology and clinical features 4.
- Prophylactic antimicrobial therapy for acute aspiration pneumonitis does not offer clinical benefit and may generate antibiotic selective pressures that result in the need for escalation of antibiotic therapy among those who develop aspiration pneumonia 5.
Risk Factors and Diagnosis
- Patients diagnosed with aspiration pneumonia experience greater morbidity and mortality than patients with community-acquired pneumonia 2.
- Risk factors for aspiration include malnutrition, smoking, poor oral hygiene, and dry mouth, which can influence oral colonization and increase the risk for aspiration pneumonia 6.
- A proposed definition of aspiration pneumonia includes the presence of one or more risk factors of oropharyngeal aspiration and one or more risk factors for oral bacterial colonization, which can help unify the diagnostic criteria and provide strategies to prevent oral colonization 6.