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Aspiration Pneumonia
Aspiration pneumonia results from inhalation of stomach contents or secretions of the oropharynx, leading to
lower respiratory tract infection. In many healthy adults, very small quantities of aspiration occur frequently but the
normal defence mechanisms (cough, lung cilia) remove the material with no ill effects. However, aspiration may
cause:

Chemical pneumonitis: chemical irritation of the lungs, which may progress to acute respiratory
distress syndrome and/or bacterial infection. Acute aspiration of gastric contents into the lungs can
produce an extremely severe and sometimes fatal illness. This has been termed Mendelson's
syndrome and can complicate anaesthesia, particularly during pregnancy.
Obstruction: large volumes of aspirated material may lead to obstruction of the respiratory tract.
Bacterial infection: infection of the lower airways may lead to empyema, lung abscess, acute
respiratory failure and acute lung injury. Persistent aspiration pneumonia is often due to anaerobes and
it may progress to lung abscess or even bronchiectasis.

The usual site for an aspiration pneumonia is the apical and posterior segments of the lower lobe of the right lung.
If the patient is supine then the aspirated material may also enter the posterior segment of the upper lobes.

Epidemiology
It is common. One study of elderly patients implicated aspiration pneumonia in 10% or cases of
community-acquired pneumonia [1] .
Aspiration pneumonia is relatively common in hospital and usually involves infection with multiple
bacteria, including anaerobes.
It is more common in men, young children and the elderly.

Pathogens
Pathogens of community-acquired aspiration pneumonia are often the normal flora of the oropharynx, including:

Streptococcus pneumoniae.
Staphylococcus aureus.
Haemophilus influenzae.
Anaerobes - eg, Peptostreptococcus, Fusobacterium and Prevotella spp.
'Streptococcus milleri' group.
Klebsiella pneumoniae - increasingly seen in those with a history of alcohol misuse.

Pathogens of nosocomial aspiration pneumonia include [2] :

Oral anaerobes - as above.

Gram-positive cocci - eg, Peptostreptococcus spp., Peptococcus spp.
Gram-negative bacilli - eg, enterobacteria (Klebsiella pneumoniae, Escherichia coli, Enterobacter
spp.), Pseudomonas aeruginosa.
Meticillin-resistant S. aureus (MRSA).
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Risk factors for aspiration pneumonia [3]

In the absence of a tracheo-oesophageal fistula, significant aspiration usually occurs only during periods of
impaired consciousness, with reflux oesophagitis with an oesophageal stricture, or in bulbar palsy. The following
are considered to be independent risk factors for aspiration pneumonia:

Impaired consciousness: drug or alcohol misuse, general anaesthesia, seizures, sedation, acute
stroke, central nervous system lesions, head injury.
Poor mobility, nil by mouth status, increasing age, chronic obstructive pulmonary disease (COPD),
male gender and increasing number of medications [3] .
Swallowing disorders: oesophageal stricture, dysphagia, stroke, bulbar palsy, pharyngeal disease (eg,
malignancy), neuromuscular disorders (eg, multiple sclerosis).
Other: tracheo-oesophageal fistula, ventilator-associated pneumonia, periodontal disease, gastro-
oesophageal reflux [4] , post-gastrectomy, tracheostomy.

Nasogastric tube feeding is considered to be less of a risk than it used to be, due to modern nursing techniques
(eg, avoiding feeding patients in the supine position) [5] .

Presentation
Nonspecific symptoms - eg, fever, headache, nausea, vomiting, anorexia, myalgia, weight loss.
Cough.
Dyspnoea.
Pleuritic chest pain.
Purulent sputum.
Signs may include tachycardia, tachypnoea, decreased breath sounds and dullness to percussion
over areas of consolidation, pleural friction rub.
Severe infection may lead to hypoxia and septic shock.

Differential diagnosis
Other causes of respiratory distress, including:

Other causes of pneumonia.

Bronchiolitis.
Croup.
Epiglottitis.
Foreign body in respiratory tract.
Asthma.
Cardiovascular disease.

Investigations
Blood count: neutrophil leukocytosis.
Electrolytes and renal function: dehydration, electrolyte imbalance.
Blood culture.
Blood gases.
Culture of sputum:
In patients with bacterial aspiration pneumonia, this may show organisms normally resident
in the pharynx.

CXR:
Right, middle and lower lung lobes are the most common sites.
Aspiration when upright may cause bilateral lower lung infiltrates.
Right upper lobe often shows consolidation in those with a history of alcohol misuse who
aspirate in the prone position.
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Lung CT is only very occasionally required.

Specimens obtained from bronchoscopy may help to guide choice of antibiotic treatment [4] .

Management [4]
Mechanical obstruction: removal of the object, normally by bronchoscopy.
Tracheal suction if seen early.
Intubation with positive pressure ventilation may be required.
Bacterial infection of lower airways (the choice of antibiotics will be influenced by any recent previous
antibiotic treatment, microbiology culture results and the patient's condition):
Initial empirical antibiotic therapy while awaiting culture results.
Antimicrobial therapy should be based on the patient's characteristics, the setting in which
aspiration occurred, the severity of pneumonia, and available information regarding local
pathogens and resistance patterns [6] .
Community-acquired aspiration pneumonia is often initially treated with co-amoxiclav.
Metronidazole may need to be added if there is evidence of complications - eg, lung
abscess. See separate Pneumonia article for indications for hospital admission [2] .
Hospital-acquired aspiration pneumonia: a suitable combination in patients who have
already recently been treated with antibiotics is piperacillin with tazobactam.

The role of steroids is uncertain and not of proven benefit.

Supportive therapy with fluid management, bronchodilators and physiotherapy may help.
Referral to speech and language therapists.

Complications
Untreated, bacterial aspiration pneumonia may progress to lung abscess or bronchiectasis.
Acute respiratory distress.

Prognosis
This depends on the underlying cause, general well-being of the patient, presence of complications, speed of
diagnosis and effective treatment.

Prevention
Keep the head of the bed at a 30 angle: this reduces the risk or aspiration pneumonia in those at risk.
Nasogastric feeding for at-risk patients - eg, poor gag reflex, dysphagia.

Further reading & references

Lanspa MJ, Peyrani P, Wiemken T, et al; Characteristics associated with clinician diagnosis of aspiration pneumonia: a
descriptive study of afflicted patients and their outcomes. J Hosp Med. 2015 Feb;10(2):90-6. doi: 10.1002/jhm.2280. Epub
2014 Nov 1.

1. Simonetti AF, Viasus D, Garcia-Vidal C, et al; Management of community-acquired pneumonia in older adults. Ther Adv
Infect Dis. 2014 Feb;2(1):3-16. doi: 10.1177/2049936113518041.
2. Kwong JC, Howden BP, Charles PG; New aspirations: the debate on aspiration pneumonia treatment guidelines. Med J
Aust. 2011 Oct 3;195(7):380-1.
3. Hibberd J, Fraser J, Chapman C, et al; Can we use influencing factors to predict aspiration pneumonia in the United
Kingdom? Multidiscip Respir Med. 2013 Jun 11;8(1):39.
4. Raghavendran K, Nemzek J, Napolitano LM, et al; Aspiration-induced lung injury. Crit Care Med. 2011 Apr;39(4):818-26. doi:
10.1097/CCM.0b013e31820a856b.
5. Blumenstein I, Shastri YM, Stein J; Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol.
2014 Jul 14;20(26):8505-24. doi: 10.3748/wjg.v20.i26.8505.
6. Acute aspiration; BMJ Best Practice, 2016
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Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no
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Author: Peer Reviewer:

Dr Laurence Knott Prof Cathy Jackson
Document ID: Last Checked: Next Review:
2625 (v26) 30/11/2016 29/11/2021

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