Aspiration pneumonia and pneumonitis: Clinical sciences

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Aspiration pneumonia and pneumonitis: Clinical sciences

Focused chief complaint

Abdominal pain

Approach to biliary colic: Clinical sciences
Approach to periumbilical and lower abdominal pain: Clinical sciences
Approach to pneumoperitoneum and peritonitis (perforated viscus): Clinical sciences
Approach to postoperative abdominal pain: Clinical sciences
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Abdominal aortic aneurysm: Clinical sciences
Acute coronary syndrome: Clinical sciences
Acute mesenteric ischemia: Clinical sciences
Acute pancreatitis: Clinical sciences
Adnexal torsion: Clinical sciences
Alcohol-induced hepatitis: Clinical sciences
Aortic dissection: Clinical sciences
Appendicitis: Clinical sciences
Approach to ascites: Clinical sciences
Cholecystitis: Clinical sciences
Choledocholithiasis and cholangitis: Clinical sciences
Chronic mesenteric ischemia: Clinical sciences
Chronic pancreatitis: Clinical sciences
Colonic volvulus: Clinical sciences
Community-acquired pneumonia: Clinical sciences
Diverticulitis: Clinical sciences
Ectopic pregnancy: Clinical sciences
Endometriosis: Clinical sciences
Gastritis: Clinical sciences
Gastroesophageal reflux disease: Clinical sciences
Hepatitis A and E: Clinical sciences
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Herpes zoster infection (shingles): Clinical sciences
Ileus: Clinical sciences
Infectious gastroenteritis: Clinical sciences
Inflammatory bowel disease (Crohn disease): Clinical sciences
Inflammatory bowel disease (ulcerative colitis): Clinical sciences
Inguinal hernias: Clinical sciences
Intra-abdominal abscess: Clinical sciences
Irritable bowel syndrome: Clinical sciences
Ischemic colitis: Clinical sciences
Large bowel obstruction: Clinical sciences
Lower urinary tract infection: Clinical sciences
Malaria: Clinical sciences
Nephrolithiasis: Clinical sciences
Paraesophageal and hiatal hernia: Clinical sciences
Peptic ulcer disease: Clinical sciences
Pulmonary embolism: Clinical sciences
Pyelonephritis: Clinical sciences
Rectus sheath hematoma: Clinical sciences
Retroperitoneal hematoma: Clinical sciences
Sickle cell disease: Clinical sciences
Small bowel obstruction: Clinical sciences
Spontaneous bacterial peritonitis: Clinical sciences
Testicular torsion (pediatrics): Clinical sciences

Altered mental status

Approach to altered mental status: Clinical sciences
Acute stroke (ischemic or hemorrhagic) or TIA: Clinical sciences
Alcohol withdrawal: Clinical sciences
Approach to encephalitis: Clinical sciences
Approach to epilepsy: Clinical sciences
Approach to hypercalcemia: Clinical sciences
Approach to hypernatremia: Clinical sciences
Approach to hypocalcemia: Clinical sciences
Approach to hypoglycemia: Clinical sciences
Approach to hyponatremia: Clinical sciences
Approach to hypothyroidism: Clinical sciences
Approach to increased intracranial pressure: Clinical sciences
Approach to mood disorders: Clinical sciences
Approach to schizophrenia spectrum and other psychotic disorders: Clinical sciences
Approach to shock: Clinical sciences
Approach to traumatic brain injury: Clinical sciences
Aspiration pneumonia and pneumonitis: Clinical sciences
Community-acquired pneumonia: Clinical sciences
Delirium: Clinical sciences
Diabetic ketoacidosis: Clinical sciences
Hepatic encephalopathy: Clinical sciences
Hospital-acquired and ventilator-associated pneumonia: Clinical sciences
Hyperosmolar hyperglycemic state: Clinical sciences
Hypothermia: Clinical sciences
Hypovolemic shock: Clinical sciences
Lower urinary tract infection: Clinical sciences
Meningitis and brain abscess: Clinical sciences
Opioid intoxication and overdose: Clinical sciences
Opioid withdrawal syndrome: Clinical sciences
Pyelonephritis: Clinical sciences
Subarachnoid hemorrhage: Clinical sciences
Substance use disorder: Clinical sciences
Uremic encephalopathy: Clinical sciences

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Questions

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A 56-year-old man is brought to the emergency department after being found intoxicated from alcohol. EMS reports that the patient was found covered in vomit lying on the sidewalk. There is no evidence of injury or trauma. The patient is observed for several hours in the emergency department and is reassessed at the bedside when clinically sober. Temperature is 37.0°C (98.6°F), pulse is 84/min, blood pressure is 123/83 mmHg, and oxygen saturation is 99% on room air. The patient is well-appearing, in no acute distress, and has no symptoms at this time. The patient has a normal dental examination. Pulmonary auscultation demonstrates faint rales over the right lung base. A chest radiograph is obtained and demonstrates right lower lobe infiltrates. Which of the following is the next best step in management?  

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Aspiration pneumonia and pneumonitis refer to lung inflammation that typically occurs in individuals with impaired swallowing function or decreased level of consciousness. Aspiration pneumonia occurs when a person aspirates oropharyngeal content colonized by pathogenic bacteria, most commonly Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae.

On the other hand, aspiration pneumonitis occurs when a patient aspirates a large volume of sterile acidic gastric content that causes lung inflammation.

Now, if you suspect aspiration pneumonia or pneumonitis, you should first perform an ABCDE assessment to determine whether your patient is unstable or stable. If the patient is unstable, stabilize the airway, breathing, and circulation.

This often requires bronchoscopy and suctioning of the aspirated content to prevent asphyxia. In some cases, you might need to consider intubation and mechanical ventilation.

Next, obtain IV access and, if the patient is hypotensive, start IV fluids for volume resuscitation. Finally, put your patient on continuous vital sign monitoring, such as pulse oximetry, blood pressure, and heart rate.

Alright, now, let’s go back to the ABCDE assessment and talk about stable individuals. Start by obtaining focused history and physical, as well as chest X-ray, which can all help you differentiate aspiration pneumonia from pneumonitis.

First, let’s start with aspiration pneumonia.

In patients suspected with aspiration pneumonia, history reveals a gradual onset of symptoms that typically include pleuritic chest pain, shortness of breath, and fever.

Most of the time, the aspiration is not witnessed, since pneumonia is usually associated with microaspirations due to impaired swallowing function, such as dysphagia.

Additionally, history might reveal neurologic conditions that can also affect swallowing, such as stroke, seizures, or a period of decreased consciousness, like sedation or intoxication.

On the flip side, physical exam findings usually include elevated body temperature, labored breathing, tachypnea, and tachycardia. On auscultation, you might hear crackles and decreased breath sounds due to pulmonary edema.

Finally, chest X-ray might reveal infiltrates in gravity-dependent lung parts. If the patient was upright, the chest X-ray might show infiltrates in basal segments of the lower lobes. On the other hand, if they were in a supine position, the chest X-ray can reveal infiltrates in the superior segments of the lower lobe and posterior segments of the upper lobe. At this point, you can diagnose aspiration pneumonia.

Next, you should assess the site where the aspiration occurred. If aspiration occurred in a community setting, assess the patient's dental health to determine adequate treatment. Individuals with normal dental health can be treated with ampicillin-sulbactam, respiratory fluoroquinolones, or carbapenems only.

On the other hand, if the patient presents with poor dental health, such as necrotizing gingivitis, combine one of the previous antibiotics with clindamycin,

Now, let's go back and take a look at individuals that aspirated in a hospital or nursing home. In this case, first, you need to assess risk factors for multidrug resistant, or MDR, pathogens, which include the use of IV antibiotics in the last 90 days and a hospital stay of 5 or more days.

Sources

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  3. "Utilizing Procalcitonin in a Clinical Setting to Help Differentiate between Aspiration Pneumonia and Aspiration Pneumonitis. 4153418." SSRN
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  11. "The diagnosis of aspiration pneumonia in older persons: a systematic review. 1‐10." European Geriatric Medicine (2022)
  12. "Clinical utility of the 3‐ounce water swallow test. 23(3), 244‐250." Dysphagia (2008)
  13. "A paradigm shift in the diagnosis of aspiration pneumonia in older adults. 11(17), 5214." Journal of Clinical Medicine (2022)
  14. "Development and implementation of an aspiration pneumonia cause investigation algorithm" The Clinical Respiratory Journal (2022)