Aspiration pneumonia and pneumonitis

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Background

  • Difficult to predict which pts with pneumonitis will go on to develop PNA
  • Aspiration pneumonitis
    • Inflammatory chemical injury of tracheobronchial tree and pulmonary parenchyma
      • Due to inhalation of regurgitated sterile gastric contents
        • Must aspirate at least 20-30mL of gastric contents with pH <2.5
      • Can lead to aspiration PNA d/t pulmonary defense mechanism injury
  • Aspiration pneumonia
    • Alveolar space infection d/t inhalation of pathogenic material from oropharynx
      • Increased in pts w/ periodontal dz, chronic colonization of upper airways, PPI/H2 meds
    • Accounts for up to 20% of CAP in elderly, majority of nursing home-acquired PNA
    • Microbiology
      • Community acquired: Pneumococcus, staph, H flu, enterobacter
      • Hospital acquired: Pseudomonas, gram-negatives

Clinical Features

  • Aspiration pneumonitis
    • Cough, tachypnea, bloody sputum, respiratory distress
  • Aspiration PNA
    • Fever, dyspnea, productive cough, Tachypnea, tachycardia, AMS

Differential Diagnosis

Acute dyspnea

Emergent

Non-Emergent

Diagnosis

Work-Up

  • CXR
    • Unilateral focal or patchy consolidations in dependent lung segments
    • Right lower lobe is most common area; bilateral patterns can also be seen
    • Lower lobe infiltrate when aspiration occurs in upright position
    • Upper lobe infiltrate when aspiration occurs in recumbent position

Management

  • Aspiration pneumonitis
    • Suction upper airway if aspiration is witnessed
    • Abx
      • Only recommended if symptoms persist >48hr
        • Levo/moxifloxacin or clindamycin or amoxicillin-clavulanate
  • Aspiration pneumonia
    • Community-acquired
      • Moxifloxacin or clinda or amoxicillin-clavulanate
    • Health care-associated or periodontal disease or alcoholism
      • Ceftriaxone + clindamycin OR
      • Piperacillin-tazobactam + clindamycin OR
      • Ampicillin-sulbactam + clindamycin OR
      • Cefepime + clindamycin OR
      • Levofloxacin + clindamycin

Disposition

  • Healthy person
    • Observe for 1hr; if asymptomatic discharge
    • If mild-moderate symptoms develop and persist >48hr treat with antibiotics
  • Chronically ill or nursing home pt
    • Consider ED obs unit versus short admission for observation +/- prophylactic abx
  • Admit all pts w/ aspiration PNA

See Also

Pneumonia (Main)

References