Aspiration Pneumonitis and Pneumonia
Aspiration pneumonitis and pneumonia are caused by inhaling toxic substances, usually gastric contents, into the lungs. Chemical pneumonitis, bacterial pneumonia, or airway obstruction can occur. Symptoms include cough and dyspnea. Diagnosis is based on clinical presentation and chest x-ray findings. Treatment and prognosis differ by aspirated substance.
(See also Overview of Pneumonia.)
Aspiration can cause lung inflammation (chemical pneumonitis), infection (bacterial pneumonia or lung abscess), or airway obstruction. However, most episodes of aspiration cause minor symptoms or pneumonitis rather than infection or obstruction, and some patients aspirate with no sequelae. Drowning may also cause inflammation of the lungs and is discussed elsewhere.
Risk factors for aspiration include
Impaired cognition or level of consciousness
Impaired swallowing (such as occurs after some strokes or other neurologic diseases)
GI devices and procedures (eg, nasogastric tube placement)
Respiratory devices and procedures (eg, endotracheal tube placement)
Gastroesophageal reflux disease
Multiple substances are directly toxic to the lungs or stimulate an inflammatory response when aspirated; gastric acid is the most common such aspirated substance, but others include petroleum products (particularly of low viscosity, such as petroleum jelly) and laxative oils (such as mineral, castor, and paraffin oil), all of which cause lipoid pneumonia. Aspirated gasoline and kerosene also cause a chemical pneumonitis (see Hydrocarbon Poisoning).
Gastric contents cause damage mainly due to gastric acid, although food and other ingested material (eg, activated charcoal as in treatment of overdose) are injurious in quantity. Gastric acid causes a chemical burn of the airways and lungs, leading to rapid bronchoconstriction, atelectasis, edema, and alveolar hemorrhage. This syndrome may resolve spontaneously, usually within a few days, or may progress to acute respiratory distress syndrome. Sometimes bacterial superinfection occurs.
Oil or petroleum jelly aspiration causes exogenous lipoid pneumonia, which is characterized histologically by chronic granulomatous inflammation with fibrosis.
Healthy people commonly aspirate small amounts of oral secretions, but normal defense mechanisms usually clear the inoculum without sequelae. Aspiration of larger amounts, or aspiration in a patient with impaired pulmonary defenses, often causes pneumonia and/or a lung abscess. Elderly patients tend to aspirate because of conditions associated with aging that alter consciousness, such as sedative use and disorders (eg, neurologic disorders, weakness). Empyema (see Etiology) also occasionally complicates aspiration.
Gram-negative enteric pathogens and oral anaerobes are the most frequent cause of aspiration pneumonia.
Symptoms and signs include
Chemical pneumonitis caused by gastric contents causes acute dyspnea with cough that is sometimes productive of pink frothy sputum, tachypnea, tachycardia, fever, diffuse crackles, and wheezing. When oil or petroleum jelly is aspirated, pneumonitis may be asymptomatic and detected incidentally on chest x-ray or may manifest with low-grade fever, gradual weight loss, and crackles.
For aspiration pneumonia, chest x-ray shows an infiltrate, frequently but not exclusively, in the dependent lung segments, ie, the superior or posterior basal segments of a lower lobe or the posterior segment of an upper lobe. For aspiration-related lung abscess, chest x-ray may show a cavitary lesion. Contrast-enhanced CT is more sensitive and specific for lung abscess and will show a round lesion filled with fluid or with an air-fluid level. In patients with oil or petroleum jelly aspiration, chest x-ray findings vary; consolidation, cavitation, interstitial or nodular infiltrates, pleural effusion, and other changes may be slowly progressive.
Signs of ongoing aspiration may include frequent throat clearing or a wet-sounding cough after eating. Sometimes no signs are present, and ongoing aspiration is only diagnosed via modified barium esophagography done to rule out an underlying swallowing disorder.
Treatment is supportive, often involving supplemental oxygen and mechanical ventilation. Antibiotics (a beta-lactam/beta-lactamase inhibitor or clindamycin) often are given to patients with witnessed or known gastric aspiration because of the difficulty in excluding bacterial infection as a contributing or primary factor; however, if no infiltrate develops after 48 to 72 h, antibiotics can be stopped.
Potentially causative toxic substances should be avoided. Anecdotal reports suggest systemic corticosteroids may be beneficial in patients with oil or petroleum jelly aspiration.
For aspiration pneumonia, Infectious Diseases Society of America (IDSA) guidelines recommend a beta-lactam/beta-lactamase inhibitor, clindamycin, or a carbapenem. Some examples include clindamycin 600 mg IV q 8 h (followed by 300 mg po qid) and amoxicillin/clavulanate 875 mg IV q 12 h. Duration of treatment is usually 1 to 2 wk (see also Infectious Diseases Society of America Clinical Guideline on Community-Acquired Pneumonia).
Treatment of lung abscess is with antibiotics and sometimes percutaneous or surgical drainage.
Strategies to prevent aspiration are important to care and overall clinical outcome. For patients with decreased level of consciousness, avoidance of oral feeding and oral drugs and elevation of the head of the bed to > 30 degrees may help. Sedating drugs should be stopped. Patients with dysphagia (due to stroke or other neurologic conditions) may require diets with specialized textures to reduce the risk of aspiration. A speech pathologist may be able to train patients in specific strategies (chin tuck, etc.) to reduce the risk of aspiration. For patients with severe dysphagia, a percutaneous gastrostomy or jejunostomy tube is often used, although it is not clear whether this strategy truly reduces the risk of aspiration.
Optimization of oral hygiene and regular care by a dentist may help prevent development of pneumonia or abscess in patients who repeatedly aspirate.
Patients with aspiration pneumonitis and aspiration pneumonia should be tested for an underlying swallowing disorder.
Aspiration pneumonia should be treated with antibiotics; treatment of aspiration pneumonitis is primarily supportive.
Secondary prevention of aspiration using various measures is a key component of care for affected patients.