Aspiration pneumonia

Contents of this page:

Illustrations
Alternative names
Definition
Causes, incidence, and risk
factors
Symptoms

Signs and tests

Treatment
Expectations (prognosis)
Complications
Calling your health care
provider

Prevention

Illustrations

Pneumococci Bronchoscopy Lungs

organism
Alternative names

Respiratory
system

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Anaerobic pneumonia; Aspiration of vomitus; Necrotizing pneumonia

Definition

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Aspiration pneumonia is an inflammation of the lungs and bronchial tubes caused by inhaling
foreign material (usually food, drink, vomit, or secretions from the mouth) into the lungs. This may
progress to form a collection of pus in the lungs (lung abscess).
Causes, incidence, and risk factors

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Aspiration of foreign material (often the stomach contents) into the lung can be a result of
disorders that affect normal swallowing, disorders of the esophagus (esophageal stricture,
gastroesophageal reflux), or decreased or absent gag reflex in unconscious or semi-conscious
individuals. Old age, dental problems, use of sedative drugs, anesthesia, coma, and excessive
alcohol consumption are also causal or contributing factors. The response of the lungs depends
upon the characteristics and amount of the aspirated substance. The more acidic the material,
the greater the degree of lung injury, although this may not necessarily lead to pneumonia.
The injured lungs may become infected with multiple species of anaerobic bacteria or aerobic
bacteria. A collection of pus may form in the lung. A protective membrane may form around the
abscess.
Symptoms

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Fever
Fatigue

Cough:
o With foul-smelling sputum
o With sputum containing pus or blood
o With greenish sputum
Chest pain
Shortness of breath
Bluish discoloration of the skin caused by lack of oxygen
Rapid pulse (heart rate)
Wheezing

Additional symptoms that may be associated with this disease:

Sweating, excessive
Swallowing difficulty
Breath odor
Signs and tests

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Physical examination may reveal crackling sounds in the lungs.

These tests also help diagnose this condition:

Chest x-ray
Sputum culture
CBC
Blood culture
Bronchoscopy
Swallowing studies

Treatment

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Hospitalization may be required for management of the illness. Treatment measures vary
depending on the severity of the pneumonia. Antibiotics, which treat the organisms in the
environment, may be given. Patients may receive special antibiotics to treat organisms that may
live in the mouth.
The types of organisms present depend on the health of the patient and where they live (private
residence, chronic nursing facility, for instance).
Patients may need to have their swallowing function assessed. If there is difficulty with proper
swallowing, other methods of feeding the patient may be necessary.
Expectations (prognosis)

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The outcome depends on the severity of the pneumonia, the type of organism, the extent of lung
involvement. If acute respiratory failure develops, the patient may have a prolonged illness or die.
Complications

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Spread of infection to the blood stream (bacteremia)

Spread of infection to other areas of the body

Low blood pressure

Shock
Acute respiratory distress syndrome
Pneumonia with lung abscess

Calling your health care provider

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Call your health care provider, go to the emergency room, or call the local emergency number
(such as 911) if shortness of breath, wheezing, chills, fever, or chest pain occur.
Prevention

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Awareness of the risk of aspiration

Avoid behaviors which may lead to aspiration

http://www.nlm.nih.gov/medlineplus/ency/article/000121.htm
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Pneumonia, Aspiration
Last Updated: April 7, 2005

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Synonyms and related keywords:

Mendelson syndrome, pneumonitis, altered
level of consciousness, abnormal
swallowing reflexes, acute respiratory
distress syndrome, acute respiratory failure,
bacterial pneumonitis, chemical
pneumonitis, community-acquired aspiration
pneumonia, Staphylococcus aureus,
nosocomial infection, empyema, stress
dyspnea, rest dyspnea, cyanosis, putrid
expectoration, tachypnea, tachycardia,
bradycardia, crackles, bronchial rales,
pleural effusion, egophony, cerebrovascular
accident, intracranial mass lesions, sepsis,
meningitis
AUTHOR
INFORMATION

Section 1 of 11

Author Information
Introduction
Clinical
Differentials
Workup
Treatment
Medication
Follow-up
Miscellaneous
Pictures
Bibliography

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images.

Related Articles

Altitude Illness Pulmonary Syndromes

Asthma
Bronchitis

Author Information Introduction Clinical Differentials Workup Treatment

Medication Follow-up Miscellaneous Pictures Bibliography

Author: Philippe Le Conte, MD, PhD,

Consulting Staff, Department of Emergency
Medicine, University Hospital of Nantes in
France
Editor(s): Dana A Stearns, MD, Assistant
Director of Undergraduate Education, Assistant,
Department of Emergency Medicine,
Massachusetts General Hospital; Francisco
Talavera, PharmD, PhD, Senior Pharmacy
Editor, eMedicine; Paul Blackburn, DO,
Program Director, Department of Emergency
Medicine, Maricopa Medical Center; Assistant
Professor, Department of Surgery, University of
Arizona; John Halamka, MD, Chief Information
Officer, CareGroup Healthcare System,
Assistant Professor of Medicine, Department of
Emergency Medicine, Beth Israel Deaconess
Medical Center; Assistant Professor of
Medicine, Harvard Medical School; and Robert
E O'Connor, MD, MPH, Director of Education
and Research, Department of Emergency
Medicine, Christiana Care Health System;
Professor of Emergency Medicine, Thomas
Jefferson University

Chronic Obstructive
Pulmonary Disease and
Emphysema
Epiglottitis, Adult
Foreign Bodies, Trachea
Pediatrics, Bacteremia
and Sepsis
Pediatrics, Bronchiolitis
Pediatrics, Croup or
Laryngotracheobronchitis
Pediatrics, Epiglottitis
Pediatrics, Pneumonia
Pediatrics, Reactive
Airway Disease
Pediatrics, Respiratory
Distress Syndrome

Disclosure

Pneumonia, Bacterial

INTRODUCTION

Section 2 of 11

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Medication Follow-up Miscellaneous Pictures Bibliography

Background: Aspiration pneumonia frequently is

seen in emergency medicine. Its primary cause is
impaired airway protection, which occurs in
patients with an altered level of consciousness
and/or abnormal swallowing reflexes. The risk is

Pneumonia, Empyema
and Abscess
Pneumonia,
Immunocompromised
Pneumonia, Mycoplasma
Pneumonia, Viral

extremely high in any patient with an altered

mental status. Therefore, the clinician must
consider the condition as a coincident risk in the
presence of drug ingestion, infection, metabolic
and/or endocrine derangements, acute stroke
and/or CNS mass lesions, or head trauma.
The extent and severity of the condition often
depends on the volume and acidity of the
inoculum. Aspiration of a massive amount of
gastric contents can produce acute respiratory
distress occur within 1 hour. Mechanical
obstruction of the airways may occur after
aspiration of fluid or particulate matter.
Tracheobronchial suction may be indicated for
acute respiratory failure. However, most
frequently, the size of the inoculum is small, and
the course of the illness more insidious. Bacterial
pneumonitis often is caused by oropharyngeal
flora, but gram-negative bacilli and other
nosocomial pathogens must be considered in
nursing home residents or those recently
hospitalized.
Pathophysiology: Aspiration of gastric liquid may
result in a chemical pneumonitis (Mendelson
syndrome). Particulate matter or thick fluid may
cause bronchial obstruction and ventilationperfusion mismatch. Bacterial pneumonitis in this
setting may be caused by a wide variety of
pathogens ranging from preexisting oropharyngeal
flora to nosocomial pathogens.
Community-acquired aspiration pneumonia often
is associated with anaerobic bacteria alone (4558%) or aerobic species (41-46%). However, in
hospital-acquired infections, gram-negative bacilli
and Staphylococcus aureus resistant to betalactam and/or methicillin are most common.
The clinician must consider nosocomial infection if
the patient is from a nursing home or has been
hospitalized recently.

Shock, Septic

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Pneumonia
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Chemical
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Overview
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Symptoms
Chemical
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Treatment

Frequency:

In the US: Community-acquired cases

number 1200 per 100,000 people per year.
Nosocomial cases number 800 per 100,000
hospital admissions per year.

Internationally: Aspiration pneumonia is

considered a common disease, but no
statistics are available.

Mortality/Morbidity:

The 5% mortality rate increases to 20% in

the presence of empyema. The mortality
rate with Mendelson syndrome (severe
chemical pneumonitis) is 70%.

Complications include acute respiratory

failure and/or reactive airways caused by
bronchiolar constriction and acute
respiratory distress syndrome.

Empyema can occur in cases of

inadequate antibiotic treatment.

Sex: Aspiration pneumonia is more common in

males than in females.
Age: Aspiration pneumonia is more common in
extremely young or old patients.

CLINICAL

Section 3 of 11

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Medication Follow-up Miscellaneous Pictures Bibliography

History: History-taking may reveal the following

findings:

Sudden onset of coughing and shortness of

breath associated with eating, drinking, or

regurgitation

Altered mental status

Stress dyspnea, rest dyspnea, cyanosis

Putrid expectoration

Fever

Chest pain (pleuritic)

Abdominal pain

Anorexia

Weight loss

Physical: Findings at physical examination may

include the following:

Fever

Tachypnea, tachycardia, bradycardia

Cyanosis

Crackles and bronchial rales (most

common on the right, but also may be
present on the left or bilaterally)

Percussion dullness over the ipsilateral

hemithorax in the presence of a pleural
effusion and/or empyema

Altered mental status

Egophony

Decreased breath sounds

Pleural friction rub

Causes: Conditions that may reduce a patient's

gag reflex and/or ability to maintain an airway

include aspiration as a coincident risk.

Drug and/or alcohol ingestion (includes

drugs used for general anesthesia or
conscious sedation)

CNS trauma, cerebrovascular accident,

intracranial mass lesions

Sepsis or meningitis

Isolated alteration of the swallowing reflex

associated with pharyngeal disease

DIFFERENTIALS

Section 4 of 11

Author Information Introduction Clinical Differentials Workup Treatment

Medication Follow-up Miscellaneous Pictures Bibliography

Altitude Illness - Pulmonary Syndromes

Asthma
Bronchitis
Chronic Obstructive Pulmonary Disease and
Emphysema
Epiglottitis, Adult
Foreign Bodies, Trachea
Pediatrics, Bacteremia and Sepsis
Pediatrics, Bronchiolitis
Pediatrics, Croup or Laryngotracheobronchitis
Pediatrics, Epiglottitis
Pediatrics, Pneumonia
Pediatrics, Reactive Airway Disease
Pediatrics, Respiratory Distress Syndrome
Pneumonia, Bacterial
Pneumonia, Empyema and Abscess
Pneumonia, Immunocompromised
Pneumonia, Mycoplasma
Pneumonia, Viral
Shock, Septic
Other Problems to be Considered:
Hypersensitivity pneumonitis

WORKUP

Section 5 of 11

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Bibliography

Lab Studies:

ABG analysis
o

Ventilation-perfusion mismatch and bronchiolar constriction and/or

reactive airways are common in severe cases.

As a guide to acute intervention with oxygen, bronchodilator therapy,

continuous positive airway pressure ventilation, or intubation, ABG
levels are considered in the presence of hypoxia to determine the
extent of hypercarbia and acidosis.

CBC analysis
o

Determine the baseline hematocrit level and platelet count.

A differential test should be ordered, with the leukocyte count, to

assess for a left shift and/or "bandemia."

Determine serum electrolytes, BUN, and creatinine levels to guide

intravenous fluid therapy, especially in patients with a history of poor oral
intake or recurrent episodes of emesis.

Blood cultures may be used in baseline screening for potential bacteremia.

Sputum culture and Gram staining can be used to screen for pathogenic
infection and to guide appropriate antimicrobial therapy.

Imaging Studies:

Chest radiography
o

The right middle and/or lower lobe are the most common sites of
infiltration. However, left and bilobar processes are possible,
depending on the amount of aspirate and the body position during
aspiration.

Empyema should be ruled out in the presence of pleural effusion.

Procedures:

Protected brush or protected bronchial sample - Used to guide initial

antibiotic therapy in nosocomial aspiration pneumonia, but not necessary in
community-acquired pneumonia

Bronchoscopy

Thoracentesis

TREATMENT

Section 6 of 11

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Bibliography

Prehospital Care:

Oxygen supplementation as needed

Continuous pulse oximetry

Cardiac monitoring

Intravenous catheterization

Tracheal intubation may be necessary in patients with a poor gag reflex,

altered mental status, or persistent hypoxia.

Emergency Department Care:

Continued oxygen supplementation as needed

Cardiac monitoring

Intravenous catheterization

Endotracheal intubation is indicated for patients with a poor gag reflex,

altered mental status, or persistent hypoxia despite noninvasive measures
(including high-flow oxygen, continuous positive airway pressure ventilation).
Positive end expiratory pressure may be used in cases of
bronchoconstriction and refractory hypoxemia.

Consider tracheobronchial suction or tracheobronchoscopy to remove

particulates or plugs.

Use empiric antimicrobial therapy with coverage adequate for the given
clinical scenario (eg, community-acquired or nosocomial infection).

Administer intravenous hydration with electrolyte supplementation as

needed.

Consultations:

Consult a pulmonary and/or critical care specialist in severe cases of

respiratory failure that require ventilatory support.

Consult an infectious disease specialist for advice about proper antibiotic

therapy when the patient is at risk for nosocomial, highly resistant microbial
infections.

MEDICATION

Section 7 of 11

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In the case of community-acquired aspiration pneumonia, empiric therapy must

cover anaerobic and streptococcal species. Patients at risk for nosocomial
pneumonia must be covered for anaerobic species, gram-negative bacilli (eg,
Pseudomonas aeruginosa), and methicillin-resistant S aureus until sputum
culture results are available to guide therapy. Corticosteroids are not indicated
but may be considered for use in adjunctive therapy for coincident reactive
airways or bronchoconstriction.

Drug Category: Antibiotics -- Empiric antimicrobial therapy must be

comprehensive and should cover all likely pathogens in the context of the clinical
setting.

Drug Name

Amoxicillin and clavulanate (Augmentin) -- Drug

combination that extends the antibiotic spectrum of
this penicillin to include bacteria normally resistant to
beta-lactam antibiotics; indicated for skin and skin
structure infections caused by beta-lactamaseproducing strains of S aureus.

Adult Dose

1 g IV q8h

Pediatric Dose
Contraindications
Interactions

50-80 mg/kg/d in 3 IV injections

Documented hypersensitivity
Coadministration with warfarin or heparin increases
risk of bleeding

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Give for a minimum of 10 d to eliminate organism and

prevent sequelae (eg, endocarditis, rheumatic fever);

after treatment, obtain cultures to confirm eradication
of streptococci

Drug Name

Clindamycin (Cleocin) -- Lincosamide for treatment of

serious skin and soft tissue staphylococcal infections.
Also effective against aerobic and anaerobic
streptococci (except enterococci). Inhibits bacterial
growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes and causing RNA-dependent
protein synthesis to arrest.

Adult Dose

600 mg IV q6-8h; dilute 300 mg in 50 mL of saline;

duration of perfusion must be >10 min

Pediatric Dose
Contraindications

15-40 mg/kg in 3-4 IV perfusions

Documented hypersensitivity; regional enteritis;
ulcerative colitis; hepatic impairment; antibioticassociated colitis

Interactions

Increases duration of neuromuscular blockade,

induced by tubocurarine and pancuronium;
erythromycin may antagonize effects; antidiarrheals
may delay absorption

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in severe hepatic dysfunction; no

adjustment necessary in renal insufficiency;
associated with severe and possibly fatal colitis

Drug Name

Ceftazidime (Fortaz, Ceptaz) -- Third-generation

cephalosporin with broad-spectrum gram-negative
activity; lower efficacy against gram-positive
organisms; higher efficacy against resistant
organisms; arrests bacterial growth by binding to 1 or
more penicillin-binding proteins.

Adult Dose

500 mg to 2 g IV/IM q8-12h

Pediatric Dose
Contraindications

1-4 weeks: 30 mg/kg IV/IM q12h

1 month to 12 years: 30-50 mg/kg/dose IV/IM q8h; not
to exceed 6 g/d
Documented hypersensitivity

Interactions

Nephrotoxicity may increase with aminoglycosides,

furosemide, and ethacrynic acid; probenecid may
increase ceftazidime levels

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in renal impairment

Drug Name

Amikacin (Amikin) -- For gram-negative bacterial

coverage of infections resistant to gentamicin and
tobramycin; effective against Pseudomonas
aeruginosa. Irreversibly binds to 30S subunit of
bacterial ribosomes and blocks recognition step in
protein synthesis.

Adult Dose

15 mg/kg/d in 2 IV perfusions of 30-min duration; use

the patient's IBW for dose calculation

Pediatric Dose
Contraindications

Administer as in adults
Documented hypersensitivity

Interactions

Coadministration with other aminoglycosides,

penicillins, cephalosporins, and amphotericin B
increases nephrotoxicity; enhances effects of
neuromuscular blocking agents; causes respiratory
depression; irreversible hearing loss may occur with
coadministration of loop diuretics

Pregnancy

C - Safety for use during pregnancy has not been

established.

Precautions

Not intended for long-term therapy; caution in renal

failure (not receiving dialysis), hypocalcemia,
myasthenia gravis, and conditions that depress
neuromuscular transmission

Drug Name

Vancomycin (Vancocin) -- Potent antibiotic against

gram-positive organisms and active against
Enterococcus species. Useful in the treatment of
septicemia and skin structure infections. Indicated for
use in patients who cannot receive or who have
infections that fail to respond to penicillins and
cephalosporins or infections with resistant
staphylococci. For abdominal penetrating injuries, it is
combined with an agent active against enteric flora
and/or anaerobes. Used with gentamicin for
prophylaxis in penicillin allergic patients who are
allergic to penicillin and undergoing GI or
genitourinary procedures.
To avoid toxicity, assay vancomycin trough levels after
third dose drawn 0.5 h prior to next dose; use CrCl
value to adjust dose in patients with renal impairment.

Adult Dose

500 mg to 2 g/d IV divided tid/qid for 7-10 d

Pediatric Dose
Contraindications
Interactions

40 mg/kg/d IV divided tid/qid for 7-10 d

Documented hypersensitivity
Erythema, histaminelike flushing and anaphylactic

reactions may occur when administered with

anesthetic agents; taken concurrently with
aminoglycosides, risk of nephrotoxicity may increase
above that with aminoglycoside monotherapy; effects
in neuromuscular blockade may be enhanced with
coadministration of nondepolarizing muscle relaxants
Pregnancy

Precautions

C - Safety for use during pregnancy has not been

established.
Caution in renal failure, neutropenia; red man
syndrome is caused by too-rapid IV infusion (dose
given over a few minutes) but is rare when dose is
given over 2 hours, PO, or IP; red man syndrome is
not an allergic reaction

FOLLOW-UP

Section 8 of 11

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Further Inpatient Care:

Admit patients with severe hemodynamic compromise and/or persistent

respiratory distress to the ICU.

Admit the patient to a general-care floor if the patient's respiratory status is

stabilized.

Transfer:

Intubated and ventilated patients must be transferred to a hospital with an

ICU.

Deterrence/Prevention:

Keep the head of the bed at a 30 angle. Patients with dysphagia and/or a
poor gag reflex should not be fed orally; feeding through a nasogastric or
gastric tube may be required.

Complications:

Acute respiratory failure

Acute respiratory distress syndrome

Empyema

Pulmonary abscess

Superinfection

Prognosis:

The mortality rate of massive aspiration and/or Mendelson syndrome

approaches 70%.

The mortality rate for aspiration pneumonitis complicated by empyema is

approximately 20%.

The mortality for uncomplicated pneumonitis is approximately 5%.

Patient Education:

For excellent patient education resources, visit eMedicine's Pneumonia

Center. Also, see eMedicine's patient education article Chemical
Pneumonia.

MISCELLANEOUS

Section 9 of 11

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Medical/Legal Pitfalls:

The airway must always be stabilized in patients with an abnormal gag

reflex or altered mental status.

PICTURES

Section 10 of 11

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Bibliography

Caption: Picture 1. Chest radiograph of a patient with aspiration pneumonia of the

left lung after a benzodiazepine overdose - The patient was probably positioned to
the left at the moment of aspiration.
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Picture Type: X-RAY

Caption: Picture 2. Chest radiograph of a patient with massive aspiration
pneumonia of the right lung
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Picture Type: X-RAY
http://www.emedicine.com/EMERG/topic464.htm

Aspiration pneumonia

Overview
Symptoms
Treatment
Prevention

Definition:
Aspiration pneumonia is an inflammation of the lungs and bronchial tubes caused
by inhaling foreign material (usually food, drink, vomit , or secretions from the
mouth) into the lungs. This may progress to form a collection of pus in the lungs
(lung abscess).

Alternative Names:
Anaerobic pneumonia; Aspiration of vomitus; Necrotizing pneumonia

Causes, incidence, and risk factors:

Aspiration of foreign material (often the stomach contents) into the lung can be a
result of disorders that affect normal swallowing, disorders of the esophagus
( esophageal stricture , gastroesophageal reflux ), or decreased or absent gag
reflex in unconscious or semi-conscious individuals. Old age, dental problems,
use of sedative drugs, anesthesia, coma , and excessive alcohol consumption
are also causal or contributing factors. The response of the lungs depends upon
the characteristics and amount of the aspirated substance. The more acidic the
material, the greater the degree of lung injury, although this may not necessarily
lead to pneumonia.

The injured lungs may become infected with multiple species of anaerobic
bacteria or aerobic bacteria . A collection of pus may form in the lung. A
protective membrane may form around the abscess .
http://www.umm.edu/ency/article/000121.htm

Aspiration
Pneumonia

Factoid 2310 - Created:

2001-07-09 13:23:15-04
- Modified: 2002-09-01
20:54:35-04

ACR Codes: 6.-1

Aspiration of a sufficient amount of gastric acid produces a chemical
pneumonitis characterized by acute dyspnea and wheezing with
hypoxemia and infiltrates on chest x-ray in one or both lower lobes.
Clinical findings depend on the extent of endobronchial obstruction
and ranges from acute apnea to persistent cough. Although the
aspiration of oral anaerobes can initially lead to infiltrates, it ultimately
results in putrid sputum, tissue necrosis and pulmonary cavities. In
75% of cases, the clinical course of an anaerobic abscess is indolent
and mimics pulmonary tuberculosis, with cough, shortness of breath,
chills, fevers, night sweats, weight loss, pleuritic chest pain and bloodstreaked sputum for several weeks. Patients with anaerobic abscesses
are usually prone to aspiration of oropharyngeal contents and have
peridontal disease.
Chest x-ray is more sensitive than physical exam for detection of
pulmonary infiltrates. Chest x-ray can confirm the presence and
location of the pulmonary infiltrate, assess the extent of the
pulmonary infection, detect pleural involvement, pulmonary cavitation,
hilar lymphadenopathy and gauge the response of antibiotic therapy.
However, chest x-ray may be normal when the patient is unable to
mount an inflammatory response or is in the early stage of an
infiltrative process. High-resolution CT can improve the accuracy of the
diagnosis of pneumonia, especially when the process involves lung
obscured by the diaphragm, liver, ribs, clavicles or heart.
The anatomic localization of the inflammatory process can have
diagnostic implications. Most pulmonary pathogens produce focal
lesions. A multicentric distribution suggests hematogenous infection.
Heamtogenous pneumonia appears as multiple areas of pulmonary
infiltration that subsequently may cavitate. A diffuse distribution
suggests P. carini, CMV, hantavirus, measles virus or herpes zoster

virus. Pluerisy and hilar nodal enlargement are unusual with PCP and
CMV pneumonia. Oral anaerobes, S. aureus, S. pneumoniae serotype
III, aerobic gram-negative bacilli, M. tuberculosis, and fungi can
produce tissue necrosis and pulmonary cavities. In contrast, H.
influenza, M pneumoniae, viruses and most other serotypes of S
pneumoniae almost never cause cavities. Apical disease, with or
without cavities, suggests reactivation tuberculosis. Anaerobic
abscesses are located in dependent, poorly ventilated, and poorly
draining bronchopulmonary segments and characteristically have airfluid levels, unlike the well-ventilated, well drained upperlobe cavities
caused by M. tuberculosis, an obligate aerobe. Mucor and Aspergillus
invade blood vessels and cause pleural-based, wedge-shaped area of
pulmonary infarction which may subsequently cavitate.
In the patient with an uncomplicated course, chest x-ray need not be
repeated before discharge, since the resolution of infiltrates may take
up to 6 weeks after initial presentation. At times, CT may be especially
helpful in distinguishing different processes: pleural effusion versus
underlying pulmonary consolidation; hilar adenopathy versus
pulmonary mass; and pulmonary abscess versus empyema with an
air-fluid level
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