Aspiration pneumonia and pneumonitis: Clinical sciences

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.