Aspiration pneumonia and pneumonitis: Difference between revisions

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==Background==
==Background==
*Difficult to predict which pts with pneumonitis will go on to develop PNA
*Difficult to predict which patients with pneumonitis will go on to develop pneumonia, aspiration alone does not cause pneumonia
*Witnessed aspiration key to distinguishing between the two
*Aspiration pneumonitis
*Aspiration pneumonitis
**Inflammatory chemical injury of tracheobronchial tree and pulmonary parenchyma
**Inflammatory chemical injury of tracheobronchial tree and pulmonary parenchyma
***Due to inhalation of regurgitated sterile gastric contents
**Due to inhalation of regurgitated sterile gastric contents
****Must aspirate at least 20-30mL of gastric contents with pH <2.5
**Must aspirate at least 20-30mL of gastric contents with pH <2.5
***Can lead to aspiration PNA d/t pulmonary defense mechanism injury
**Can lead to aspiration pneumonia due to pulmonary defense mechanism injury
*Aspiration pneumonia
*Aspiration pneumonia
**Alveolar space infection d/t inhalation of pathogenic material from oropharynx
**Alveolar space infection secondary to inhalation of pathogenic material from oropharynx
***Increased in pts w/ periodontal dz, chronic colonization of upper airways, PPI/H2 meds
**Result of a complex interplay of the aspirated material, aspirated volume, pH, patient physiology and pulmonary defense mechanisms
**Accounts for up to 20% of CAP in elderly, majority of nursing home-acquired PNA
**Increased in patients with periodontal disease, chronic colonization of upper airways, or taking PPI/H2-blockers
**Accounts for up to 20% of community-acquired pneumonia in elderly, majority of nursing home-acquired pneumonia
**Microbiology
**Microbiology
***Community acquired: Pneumococcus, staph, H flu, enterobacter
***Community acquired: [[Pneumococcus]], [[staph]], [[H flu]], [[enterobacter]]
***Hospital acquired: Pseudomonas, gram-negatives
***Hospital acquired: [[Pseudomonas]], [[gram-negative]]s


==Diagnosis==
==Risk factors==
*Advanced age
*Altered level of consciousness
*Anatomic abnormality of upper airway
*[[Dementia]]
*Esophageal disorders
*Gastroesophageal reflux
*Neuromuscular disease
*Poor oral hygiene
*Prior history of aspiration
*Prolonged supine position
*Retained gastric material
*Tube feedings
 
==Clinical Features==
*Aspiration pneumonia
**[[Fever]]
**[[Dyspnea]]
**Productive [[cough]]
**[[Tachypnea]]
**[[Tachycardia
**[[Altered mental status]]
*Aspiration pneumonitis
*Aspiration pneumonitis
**Cough, tachypnea, bloody sputum, respiratory distress
**[[Cough]]
*Aspiration PNA
**Bronchospasm
**Fever, dyspnea, productive cough, Tachypnea, tachycardia, AMS
**[[Tachypnea]]
**CXR
**Bloody sputum
***Unilateral focal or patchy consolidations in dependent lung segments
**Low-grade fever
****Right lower lobe is most common area; bilateral patterns can also be seen
**[[Respiratory distress]]
 
==Differential Diagnosis==
{{SOB DDX}}


==Work-Up==
==Evaluation==
*CXR
===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
*[[CT]]
**Increased sensitivity, specificity, and overall accuracy compared to CXR
**Reasonable to obtain even if CXR negative if clinical suspicion is high
**Aspiration is a risk factor for pulmonary abscess formation


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


==Disposition==
==Disposition==
*Healthy person
*Admit all patients with aspiration pneumonia
**Observe for 1hr; if asymptomatic discharge
*For aspiration pneumonitis, consider discharge if:
**If mild-moderate symptoms develop and persist >48hr treat with antibiotics
**Otherwise healthy and non-toxic
*Chronically ill or nursing home pt
**Give outpatient antibiotics if symptomatic for >48hrs
**Consider ED obs unit versus short admission for observation +/- prophylactic abx
*For aspiration pneumonitis, consider admission for:
*Admit all pts w/ aspiration PNA
**Chronically ill or immunocompromised
**Nursing home patient
 
==See Also==
==See Also==
[[Pneumonia (Main)]]
*[[Pneumonia (Main)]]


==Source==
==References==
Tintinalli
<References/>


[[Category:ID]]
[[Category:ID]]
[[Category:Pulm]]
[[Category:Pulmonary]]

Revision as of 07:16, 15 January 2021

Background

  • Difficult to predict which patients with pneumonitis will go on to develop pneumonia, aspiration alone does not cause pneumonia
  • Witnessed aspiration key to distinguishing between the two
  • 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 pneumonia due to pulmonary defense mechanism injury
  • Aspiration pneumonia
    • Alveolar space infection secondary to inhalation of pathogenic material from oropharynx
    • Result of a complex interplay of the aspirated material, aspirated volume, pH, patient physiology and pulmonary defense mechanisms
    • Increased in patients with periodontal disease, chronic colonization of upper airways, or taking PPI/H2-blockers
    • Accounts for up to 20% of community-acquired pneumonia in elderly, majority of nursing home-acquired pneumonia
    • Microbiology

Risk factors

  • Advanced age
  • Altered level of consciousness
  • Anatomic abnormality of upper airway
  • Dementia
  • Esophageal disorders
  • Gastroesophageal reflux
  • Neuromuscular disease
  • Poor oral hygiene
  • Prior history of aspiration
  • Prolonged supine position
  • Retained gastric material
  • Tube feedings

Clinical Features

Differential Diagnosis

Acute dyspnea

Emergent

Non-Emergent

Evaluation

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
  • CT
    • Increased sensitivity, specificity, and overall accuracy compared to CXR
    • Reasonable to obtain even if CXR negative if clinical suspicion is high
    • Aspiration is a risk factor for pulmonary abscess formation

Management

Disposition

  • Admit all patients with aspiration pneumonia
  • For aspiration pneumonitis, consider discharge if:
    • Otherwise healthy and non-toxic
    • Give outpatient antibiotics if symptomatic for >48hrs
  • For aspiration pneumonitis, consider admission for:
    • Chronically ill or immunocompromised
    • Nursing home patient

See Also

References