Treatment
Treatment varies, depending on the severity of the pneumonia. Some patients may require hospitalization. Antibiotics may
be administered, with patients receiving special antibiotics that specifically treat organisms that live in the mouth. The types of organisms present depend on the patient’s health and location (private residence or chronic nursing facility, for instance). The antibiotics of choice should be tailored to the setting in which the aspiration occurred (community vs. nosocomial); however, antibiotic agents with activity against gram-negative organisms as well as gram-positive organisms is usually required.
Patients may need to have their swallowing function assessed. If they have trouble swallowing, patients may need to use other feeding methods.
Prehospital Care
Prehospital care should focus on stabilizing the patient’s airway, breathing, and circulation.
- In patients found with signs of gastric aspiration (i.e., 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 their level of training. In addition, EMTs trained in intubation may choose to intubate patients with poor gag reflex prior to aspiration.
- Oxygen supplementation.
- Cardiac monitoring and pulse oximetry.
- Intravenous catheter placement and intravenous fluids as indicated.
Emergency Department Care
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 oxygenation, patient’s mental status, signs of increased work of breathing, or impending respiratory failure.
- Continue supplemental oxygenation as needed.
- Continue cardiac monitoring and pulse oximetry.
- Provide continued supportive care with intravenous fluids and electrolyte replacement.
- Antibiotic therapy:
- Aspiration pneumonia: Always indicated
- Aspiration pneumonitis:
- Prophylactic antibiotics are not recommended in most cases.
- 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.
- When to use antibiotics: (1) Pneumonitis fails to resolve within 48 hours. (2) Patients with small bowel obstruction – lower bacteria may colonize gastric contents. (3) Antibiotics should be considered for patients on antacids due to the potential for gastric colonization.
- Corticosteroids
- 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 requiring vasoactive substances to maintain blood pressure should receive stress-dose steroids.
Consultations
A pulmonary/critical care specialist may be consulted in severe cases of respiratory failure requiring ventilatory support. An infectious disease specialist may advise regarding proper antibiotic therapy.
Complications
Complications of aspiration pneumonia include:
- Spread of infection to the bloodstream (bacteremia)
- Spread of infection to other areas of the body
- Low blood pressure
- Shock
- Acute respiratory distress syndrome
- Pneumonia with lung abscess
Prognosis
The outcome depends on the severity of the pneumonia, the type of organism and the extent of lung involvement. If acute respiratory failure develops, the patient may have a prolonged illness or die.
Prevention
Aspiration pneumonia is a potentially preventable illness, requiring attention to the small details of patient care. Elevation
of the head of the bed, using gravity to prevent reflux and aspiration of gastric contents, is an important safety measure. High-risk patients should be fed in the sitting position and not placed supine until 1 to 2 hours after meals. Dental prophylaxis and good oral hygiene are also important. Nonrestorable teeth are a nidus for pathogenic bacilli and should be extracted.
Feeding tubes should be managed properly. The position of oral feeding tubes should be monitored, because they can easily become displaced over time. The position of small-bore nasogastric tubes should be confirmed by radiography after reinsertion or repositioning. The residual volume of tube feedings in the stomach should be monitored, and tube feedings should be held if the residual volume exceeds 50 mL. There is no evidence that prophylactic antibiotic therapy after a recognized episode of aspiration prevents the subsequent development of bacterial pneumonia; rather, it may select for resistant organisms.
Summary
Gross aspiration of liquid or particulate matter into the lung can result in severe hypoxemia, pulmonary infiltrates in dependent lung regions, fever, and leukocytosis. The initial lung injury is primarily due to inflammatory mediators rather than infection. The responsible bacterial pathogens differ between community-acquired and nosocomial aspiration pneumonia.Many aspiration pneumonias are mixed aerobic-anaerobic infections. Enteric gram-negative bacilli and S aureus are more common in nosocomial aspiration pneumonia.
Current treatment guidelines support initial empirical antibiotic therapy in patients with severe aspiration pneumonia pending culture results. Appropriate initial treatment improves outcome. Antimicrobial therapy for aspiration pneumonia is often empirical, and should be based on patient characteristics, the setting in which aspiration occurred, the severity of the pneumonia, and available information regarding local pathogens and resistance patterns.