Aspiration pneumonia and pneumonitis: Clinical sciences

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Introduction0:00–0:37

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.

Unstable patient0:37–1:16

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.

Stable patient1:16–1:32

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.

Aspiration pneumonia1:32–2:48

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.

Aspiration pneumonia - treatment - community2:48–3:17

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.

Aspiration pneumonia - treatment - hospital/nursing home3:17–4:21

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.
If your patient has no MDR risk factors, treat them the same way you would treat individuals with community-acquired aspiration pneumonia.
In other words, give them ampicillin-sulbactam, respiratory fluoroquinolones, or carbapenems. But, keep in mind that sometimes you might need to add clindamycin too, especially if there's necrotizing pneumonia or lung abscess.
However, individuals that present with MDR risk factors require treatment with pseudomonas coverage, such as piperacillin-tazobactam, cefepime, respiratory fluoroquinolones, or carbapenem; in combination with an aminoglycoside or colistin.
Additionally, if there’s a positive finding of nasal colonization by MRSA, add anti-MRSA coverage, such as vancomycin or linezolid.
Now that we are done with aspiration pneumonia, let’s switch our focus to aspiration pneumonitis. These individuals can be asymptomatic or develop sudden symptoms of pleuritic chest pain, shortness of breath, fever, and dry cough.

Aspiration pneumonitis4:21–5:32

In contrast to aspiration pneumonia, there’s usually a positive history of witnessed aspiration that’s typically large in volume and associated with impaired consciousness.
Moreover, you should think of aspiration pneumonitis when there’s a history of general anesthesia, alcohol use, or medications that can result in a depressed level of consciousness, such as opioids and benzodiazepines.
Physical exam findings are similar to ones seen in individuals with aspiration pneumonia, like elevated body temperature, labored breathing, tachypnea, and tachycardia, as well as low oxygen saturation indicating hypoxemia.
Also, on auscultation, you might hear crackles and decreased breath sounds. Finally, chest X-ray might reveal infiltrates in gravity-dependent lung parts.
At this point, you can diagnose aspiration pneumonitis.Now, if the patient is asymptomatic, you should observe them and withhold antibiotics.

Aspiration pneumonitis - treatment5:32–5:32

Aspiration pneumonitis - treatment5:32–6:01

But, if they do develop severe clinical manifestations, such as acute respiratory distress syndrome, start antibiotics based on their dental health and MDR risk factors!
Now, here’s a high-yield fact to keep in mind. In early aspiration pneumonia and pneumonitis, chest X-ray findings can be normal, so consider ordering a CT scan, which is the gold standard for diagnosing these conditions.All right, as a quick recap… If you suspect aspiration pneumonia or pneumonitis, first, you should perform an ABCDE assessment to determine whether your patient is unstable or stable.

Review6:01–7:45

Unstable individuals usually require bronchoscopy and suctioning of the aspirated content, but in severe cases, you might need to consider intubation and mechanical ventilation.
On the other hand, when approaching a stable patient, you should first obtain a focused history and physical examination and order a chest X-ray.
In patients with aspiration pneumonia, first, you need to 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 should be treated with ampicillin-sulbactam, respiratory fluoroquinolones, or carbapenems.
Individuals with poor dental health require additional coverage with clindamycin. On the flip side, in individuals that aspirated in a hospital or nursing home, you should first assess risk factors for MDR pathogens.
Patients with no MDR risk factors should be treated the same way as you would treat individuals with community-acquired aspiration pneumonia.
If needed, add clindamycin. On the other hand individuals with MDR risk factors require treatment with pseudomonas coverage like piperacillin tazobactam cefepime respiratory fluoroquinolones or carbapenem in combination with aminoglycoside or colistin Additionally if needed add MRSA coverage with vancomycin or linezolid Finally individuals with aspiration pneumonitis should be observed if they are asymptomatic However if they develop signs of acute respiratory distress syndrome start antibiotics based on their