Aspiration pneumonia and pneumonitis: Difference between revisions
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**Accounts for up to 20% of community-acquired pneumonia in elderly, majority of nursing home-acquired pneumonia | **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- | ***Hospital acquired: [[Pseudomonas]], [[gram-negative]]s | ||
==Clinical Features== | ==Clinical Features== | ||
*Aspiration pneumonia | *Aspiration pneumonia | ||
**Fever | **[[Fever]] | ||
**Dyspnea | **[[Dyspnea]] | ||
**Productive cough | **Productive [[cough]] | ||
**Tachypnea | **[[Tachypnea]] | ||
**Tachycardia | **[[Tachycardia | ||
**Altered mental status | **[[Altered mental status]] | ||
*Aspiration pneumonitis | *Aspiration pneumonitis | ||
**Cough | **[[Cough]] | ||
**Tachypnea | **[[Tachypnea]] | ||
**Bloody sputum | **Bloody sputum | ||
**Respiratory distress | **[[Respiratory distress]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 45: | Line 45: | ||
*Aspiration pneumonitis | *Aspiration pneumonitis | ||
**Suction upper airway if aspiration is witnessed | **Suction upper airway if aspiration is witnessed | ||
**Antibiotics | **[[Antibiotics]] | ||
***Only recommended if symptoms persist >48hr | ***Only recommended if symptoms persist >48hr | ||
**** | ****[[Levofloxacin]]/[[moxifloxacin]] or [[clindamycin]] or [[amoxicillin-clavulanate]] | ||
*Aspiration pneumonia | *Aspiration pneumonia | ||
**Community-acquired | **Community-acquired | ||
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***[[Ampicillin-sulbactam]] + clindamycin '''OR''' | ***[[Ampicillin-sulbactam]] + clindamycin '''OR''' | ||
***[[Cefepime]] + clindamycin '''OR''' | ***[[Cefepime]] + clindamycin '''OR''' | ||
***Levofloxacin + clindamycin | ***[[Levofloxacin]] + clindamycin | ||
==Disposition== | ==Disposition== | ||
Revision as of 15:33, 11 October 2019
Background
- Difficult to predict which patients with pneumonitis will go on to develop pneumonia
- 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
- 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
- Community acquired: Pneumococcus, staph, H flu, enterobacter
- Hospital acquired: Pseudomonas, gram-negatives
Clinical Features
- Aspiration pneumonia
- Fever
- Dyspnea
- Productive cough
- Tachypnea
- [[Tachycardia
- Altered mental status
- Aspiration pneumonitis
- Cough
- Tachypnea
- Bloody sputum
- Respiratory distress
Differential Diagnosis
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
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
Management
- Aspiration pneumonitis
- Suction upper airway if aspiration is witnessed
- Antibiotics
- Only recommended if symptoms persist >48hr
- Aspiration pneumonia
- Community-acquired
- Health care-associated or periodontal disease or alcoholism
- Ceftriaxone + clindamycin OR
- Piperacillin-tazobactam + clindamycin OR
- Ampicillin-sulbactam + clindamycin OR
- Cefepime + clindamycin OR
- Levofloxacin + clindamycin
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