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{{Aspiration pneumonia}}
{{Aspiration pneumonia}}
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==Overview==
==Overview==
There are different approaches for different classes of aspiration pneumonia. [[Pneumonitis]] and [[Infection|bacterial infection]] require [[Antibiotic|antibiotic therapy]], while [[foreign body]] aspiration and mechanical [[obstruction]] may need invasive interventions. [[Chemical pneumonitis]] must be treated supportively. Immediate clearing of the [[respiratory tract]] from aspirated material and fluid by [[suction]] must be the first step if the diagnosis of aspiration is definite. Pharmacologic medical therapy for aspiration pneumonia includes [[Antibiotic|antibiotics]] such as [[Ampicillin-Sulbactam|ampicillin-sulbactam]], [[Amoxicillin-Clavulanate|amoxicillin-clavulanate]], or [[clindamycin]] for 7 days. Alternative regimens include combination of [[metronidazole]] with [[Penicillin G benzathine|penicillin G]], [[amoxicillin]], [[ceftriaxone]], or [[Cefotaxime sodium|cefotaxime]]. [[Positive pressure ventilation]] with 100% [[oxygen]] to support [[Lung|pulmonary]] function is sometimes required.
==Medical Therapy==
==Medical Therapy==
* Management of patients with swallowing dysfunction is highly individualized based on the cause of the dysfunction.
*There are different pharmacologic approaches for different classes of aspiration pneumonia. [[Pneumonitis]] and [[Infection|bacterial infection]] require [[Antibiotic|antibiotic therapy]], while [[foreign body]] aspiration and mechanical [[obstruction]] may need invasive interventions.<ref name="DiBardinoWunderink2015">{{cite journal|last1=DiBardino|first1=David M.|last2=Wunderink|first2=Richard G.|title=Aspiration pneumonia: A review of modern trends|journal=Journal of Critical Care|volume=30|issue=1|year=2015|pages=40–48|issn=08839441|doi=10.1016/j.jcrc.2014.07.011}}</ref><ref name="HuLee2015">{{cite journal|last1=Hu|first1=Xiaowen|last2=Lee|first2=Joyce S.|last3=Pianosi|first3=Paolo T.|last4=Ryu|first4=Jay H.|title=Aspiration-Related Pulmonary Syndromes|journal=Chest|volume=147|issue=3|year=2015|pages=815–823|issn=00123692|doi=10.1378/chest.14-1049}}</ref><ref name="Marik20012">{{cite journal|last1=Marik|first1=Paul E.|title=Aspiration Pneumonitis and Aspiration Pneumonia|journal=New England Journal of Medicine|volume=344|issue=9|year=2001|pages=665–671|issn=0028-4793|doi=10.1056/NEJM200103013440908}}</ref><ref name="pmid19857224">{{cite journal| author=Japanese Respiratory Society| title=Aspiration pneumonia. | journal=Respirology | year= 2009 | volume= 14 Suppl 2 | issue=  | pages= S59-64 | pmid=19857224 | doi=10.1111/j.1440-1843.2009.01578.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19857224  }}</ref><ref name="pmid23052002">{{cite journal| author=Almirall J, Cabré M, Clavé P| title=Complications of oropharyngeal dysphagia: aspiration pneumonia. | journal=Nestle Nutr Inst Workshop Ser | year= 2012 | volume= 72 | issue=  | pages= 67-76 | pmid=23052002 | doi=10.1159/000339989 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23052002  }}</ref><ref name="pmid9925081">{{cite journal| author=Marik PE, Careau P| title=The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study. | journal=Chest | year= 1999 | volume= 115 | issue= 1 | pages= 178-83 | pmid=9925081 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9925081  }}</ref>
* Total parenteral nutrition or nasogastric tube feeding may be necessary to safely meet caloric requirements when the patient's swallowing dysfunction is secondary to a transient disease, such as a critical illness.
*[[Chemical pneumonitis]] must be treated supportively. Immediate clearing the [[respiratory tract]] from aspirated material and fluid by [[suction]] must be the first step if the diagnosis of aspiration is definite.
'''Feeding decisions'''
*Pharmacologic medical therapy for aspiration pneumonia includes [[Antibiotic|antibiotics]] such as [[Ampicillin-Sulbactam|ampicillin-sulbactam]], [[Amoxicillin-Clavulanate|amoxicillin-clavulanate]], or [[clindamycin]] for 7 days.  
* The goals of therapy are safe and efficient nutrition that preserves stable respiratory function and appropriate growth.
*Alternative regimens include combination of [[metronidazole]] with [[Penicillin G benzathine|penicillin G]], [[amoxicillin]], [[ceftriaxone]], or [[Cefotaxime sodium|cefotaxime]].
* Oral feeding, while always desirable, is not always the most reasonable goal for patients with severe swallowing dysfunction because the risks of oral feeding may outweigh the psychosocial benefits to the patient and family [6,37,38].
*[[Positive pressure ventilation]] with 100% [[oxygen]] to support [[Lung|pulmonary]] function is sometimes required.
* On the other hand, for some patients with severe static encephalopathy or global delays, the family may choose to maintain oral feeds for pleasure despite the known risks of aspiration and pulmonary injury. These considerations require a clear and detailed discussion of goals and risks between the family and clinicians [39].
===Aspiration pneumonia===
'''Techniques to enhance oral feeding'''
* In children with functional abnormalities, treatment is often led by speech and occupational therapists that specialize in swallowing. The specialist selects specific techniques to improve swallowing function based on individual patient characteristics:
* In infants, change in the flow of liquids may significantly improve swallowing. These changes can be made by changing to a slow flow nipple.
* Other feeding techniques include changes in the infant or child's position and posture during feeding, modification of bolus size, and alterations of consistency, shape, texture, and temperature of food. These techniques should be selected based on the result of the videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) (image 1) [3,40].
* In children with delayed maturation, swallowing function may improve over time. In the interim, the techniques outlined above are used to support adequate nutrition and avoid aspiration. The type of feeding is then gradually advanced as the infant or child matures. Advances in feeding may be directed by repeat swallowing evaluation, including clinical assessment of feeding, with or without VFSS or FEES.
'''Gastrostomy feeds'''
 
Percutaneous gastrostomy tube placement should be considered for patients who are unable to safely consume enough calories by mouth. Some patients will require gastrostomy tubes to meet part or all of their nutritional needs. Oral-motor and swallowing therapy should be continued in patients in whom swallowing function is expected to improve, and gastrostomy tubes may be removed when no longer necessary.
 
Parents may initially be reluctant to have a gastrostomy tube placed because of concerns about losing pleasure of eating, discomfort, or cosmesis. The importance of preventing pulmonary aspiration, long-term benefits of improved nutrition, and reversibility of this procedure should be emphasized. In addition, gastrostomy tubes can be useful for administering medication and fluid, when needed.
 
General considerations about gastrostomy placement and enteral feeding are discussed in a separate topic review.
 
'''Management of gastroesophageal reflux'''
 
'''Aspiration Pneumonia'''
 
Antibiotic therapy is unequivocally indicated in patients
 
with aspiration pneumonia. The choice of antibiotics
 
should depend on the setting in which the
 
aspiration occurs as well as the patient’s general health
 
(Table 2). However, antibiotic agents with activity
 
against gram-negative organisms, such as third-generation
 
cephalosporins, fluoroquinolones, and piperacillin,
 
are usually required. Penicillin and clindamycin,
 
which are often called the standard antibiotic agents
 
for aspiration pneumonia, are inadequate for most patients
 
with aspiration pneumonia.78 Antibiotic agents
 
with specific anaerobic activity are not routinely warranted
 
and may be indicated only in patients with severe
 
periodontal disease, putrid sputum, or evidence
 
of necrotizing pneumonia or lung abscess on radiographs
 
of the chest.78,79
 
'''Aspiration Pneumonitis'''
 
The upper airway should be suctioned after a witnessed
 
aspiration of gastric contents. Endotracheal intubation
 
should be considered for patients who are
 
unable to protect their airway (for example, those with
 
a decreased level of consciousness). Although it is
 
common practice, the prophylactic use of antibiotics
 
in patients in whom aspiration is suspected or witnessed
 
is not recommended. Similarly, the use of antibiotics
 
shortly after aspiration in patients in whom
 
a fever, leukocytosis, or a pulmonary infiltrate develops
 
is discouraged, since the antibiotic may select
 
for more resistant organisms in patients with an uncomplicated
 
chemical pneumonitis. However, empirical
 
antibiotic therapy is appropriate for patients who
 
aspirate gastric contents and who have small-bowel
 
obstruction or other conditions associated with colonization
 
of the gastric contents. Antibiotic therapy
 
should be considered for patients with aspiration
 
pneumonitis that fails to resolve within 48 hours after
 
aspiration. Empirical therapy with broad-spectrum
 
agents is recommended (Table 2); antibiotics with
 
anaerobic activity are not routinely required. Sampling
 
of the lower respiratory tract (with a protected
 
specimen brush or by bronchoalveolar lavage) and
 
quantitative culture in intubated patients may allow
 
targeted antibiotic therapy and, in patients with negative
 
cultures, the discontinuation of antibiotics.
 
81,82
 
Corticosteroids have been used for decades in the
 
management of aspiration pneumonitis.
 
83
 
However,
 
there are limited data on the role of these agents. In
 
a prospective, placebo-controlled study, Sukumaran
 
and colleagues found that radiographically evident
 
lung injury improved more quickly in the patients given
 
corticosteroids than in those given placebo; however,
 
the patients given corticosteroids had a longer
 
stay in the intensive care unit, and there were no significant
 
differences between the two groups in the
 
incidence of complications or the outcome.
 
84,85
 
In a
 
case–control study, Wolfe and colleagues found that
 
pneumonia due to gram-negative bacteria was more
 
frequent after aspiration among patients treated with
 
corticosteroids than among those who were not.
 
86
 
Similarly, studies in animals have failed to demonstrate
 
a beneficial effect of corticosteroids on pulmonary
 
function, lung injury, alveolar–capillary permeability,
 
or outcome after acid aspiration.
 
87,88 Furthermore,


given the failure of two multicenter, randomized,
* '''1 Chemical pneumonitis'''
** 1.1 '''Adult'''
*** Preferred regimen (1): [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 1.5-3 g IV q6h for 7 days
*** Preferred regimen (2): [[Amoxicillin-Clavulanate|Amoxicillin-clavulanate]] 875 mg PO q12h for 7 days
*** Preferred regimen (3): High molecular weight colloids IV
*** Alternative regimen (1): [[Clindamycin]] 600 mg IV q8h (for [[Penicillin allergy|penicillin allergic]] patients) for 7 days
*** Alternative regimen (2): [[Metronidazole]] 500 mg PO or IV q8h <u>'''AND'''</u> [[Penicillin G benzathine|penicillin G]] 1-2 million units IV q4-6h for 7 days
*** Alternative regimen (3): [[Metronidazole]] 500 mg PO or IV q8h <u>'''AND'''</u> [[amoxicillin]] 500 mg PO q8h for 7 days
*** Alternative regimen (4): [[Metronidazole]] 500 mg PO or IV q8h <u>'''AND'''</u> [[ceftriaxone]] 1-2 g IV qd for 7 days
*** Alternative regimen (5): [[Metronidazole]] 500 mg PO or IV q8h <u>'''AND'''</u> [[Cefotaxime sodium|cefotaxime]] 1-2 g IV q8h for 7 days
::'''Note (1):''' Immediate clearing of the [[respiratory tract]] from aspirated material and fluid by suction must be the first step if the diagnosis of aspiration is definite.


controlled trials to demonstrate a benefit of high-dose
::'''Note (2):''' [[Positive pressure ventilation]] with 100% [[oxygen]] to support [[Lung|pulmonary]] function is sometimes required.


corticosteroids in patients with the acute respiratory
:::'''Note (3):''' The use of [[glucocorticoids]] for aspiration pneumonia is controversial.
* '''2 Bacterial infection'''
** 2.1 '''Adult'''
*** Preferred regimen (1):[[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 1.5-3 g IV q6h for 7 days
*** Preferred regimen (2): [[Amoxicillin-Clavulanate|Amoxicillin-clavulanate]] 875 mg PO q12h for 7 days
*** Alternative regimen (1): [[Clindamycin]] 600 mg IV q8h (for [[Penicillin allergy|penicillin allergic]] patients) for 7 days
*** Alternative regimen (2): [[Metronidazole]] 500 mg PO or IV q8h '''AND''' [[Penicillin G benzathine|penicillin G]] 1-2 million units IV q4-6h for 7 days
*** Alternative regimen (3): [[Metronidazole]] 500 mg PO or IV q8h '''AND''' [[amoxicillin]] 500 mg PO q8h for 7 days
*** Alternative regimen (4): [[Metronidazole]] 500 mg PO or IV q8h '''AND''' [[ceftriaxone]] 1-2 g IV qd for 7 days
*** Alternative regimen (5): [[Metronidazole]] 500 mg PO or IV q8h '''AND''' [[Cefotaxime sodium|cefotaxime]] 1-2 g IV q8h for 7 days
***
'''For pneumonia medical therapy, click [[Pneumonia medical therapy|here]].'''


distress syndrome, the administration of corticosteroids
'''For lung abscess medical therapy, click [[Lung abscess medical therapy|here]].'''


cannot be recommended.89,90
'''For pleural empyema medical therapy, click [[Pleural empyema medical therapy|here]].'''


==References==
==References==

Latest revision as of 23:32, 29 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Overview

There are different approaches for different classes of aspiration pneumonia. Pneumonitis and bacterial infection require antibiotic therapy, while foreign body aspiration and mechanical obstruction may need invasive interventions. Chemical pneumonitis must be treated supportively. Immediate clearing of the respiratory tract from aspirated material and fluid by suction must be the first step if the diagnosis of aspiration is definite. Pharmacologic medical therapy for aspiration pneumonia includes antibiotics such as ampicillin-sulbactam, amoxicillin-clavulanate, or clindamycin for 7 days. Alternative regimens include combination of metronidazole with penicillin G, amoxicillin, ceftriaxone, or cefotaxime. Positive pressure ventilation with 100% oxygen to support pulmonary function is sometimes required.

Medical Therapy

Aspiration pneumonia

Note (1): Immediate clearing of the respiratory tract from aspirated material and fluid by suction must be the first step if the diagnosis of aspiration is definite.
Note (2): Positive pressure ventilation with 100% oxygen to support pulmonary function is sometimes required.
Note (3): The use of glucocorticoids for aspiration pneumonia is controversial.

For pneumonia medical therapy, click here.

For lung abscess medical therapy, click here.

For pleural empyema medical therapy, click here.

References

  1. ↑ DiBardino, David M.; Wunderink, Richard G. (2015). "Aspiration pneumonia: A review of modern trends". Journal of Critical Care. 30 (1): 40–48. doi:10.1016/j.jcrc.2014.07.011. ISSN 0883-9441.
  2. ↑ Hu, Xiaowen; Lee, Joyce S.; Pianosi, Paolo T.; Ryu, Jay H. (2015). "Aspiration-Related Pulmonary Syndromes". Chest. 147 (3): 815–823. doi:10.1378/chest.14-1049. ISSN 0012-3692.
  3. ↑ Marik, Paul E. (2001). "Aspiration Pneumonitis and Aspiration Pneumonia". New England Journal of Medicine. 344 (9): 665–671. doi:10.1056/NEJM200103013440908. ISSN 0028-4793.
  4. ↑ Japanese Respiratory Society (2009). "Aspiration pneumonia". Respirology. 14 Suppl 2: S59–64. doi:10.1111/j.1440-1843.2009.01578.x. PMID 19857224.
  5. ↑ Almirall J, Cabré M, Clavé P (2012). "Complications of oropharyngeal dysphagia: aspiration pneumonia". Nestle Nutr Inst Workshop Ser. 72: 67–76. doi:10.1159/000339989. PMID 23052002.
  6. ↑ Marik PE, Careau P (1999). "The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study". Chest. 115 (1): 178–83. PMID 9925081.

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