Recommendations
Key Recommendations
Monitor oxygen saturation, pulse, blood pressure, and temperature regularly so that any deterioration can be identified and escalated quickly.
Start empirical antibiotics as soon as possible, taking into consideration local microbiology guidance, where the patient was when symptoms began, recent antibiotic exposure, and recent microbiology results if available, to treat the infection and prevent development of complications such as empyema and lung abscess formation.[3]
Continue antibiotics for at least 5 days and tailor them once the culture sensitivity results are known.[3]
Although acute illness is uncommon in aspiration pneumonia, think ‘Could this be sepsis?’ based on acute deterioration in an adult patient in whom there is clinical evidence or strong suspicion of infection.[48][49][50] See Sepsis in adults.
Use a systematic approach, alongside your clinical judgement, for assessment; urgently consult a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis.[48][50][51][52]
Refer to local guidelines for the recommended approach at your institution for assessment and management of the patient with suspected sepsis.
During the COVID-19 pandemic, for patients with suspected or confirmed COVID-19 pneumonia, see Coronavirus disease 2019 (COVID-19).
Consider all patients with cough and fever or suggestive symptoms to have COVID-19 until proven otherwise. Pneumonia due to COVID-19 is not covered in this topic.
Consider other interventions:
Monitor controlled oxygen therapy. An upper SpO2 limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.
Give thromboprophylaxis unless contraindicated.
Agree an escalation plan with the patient and deciding on setting of care.[71]
Correct any underlying problems that precipitated the aspiration.
Ensure adequate hydration and nutrition.
Manage dysphagia.
Organise a swallowing assessment if dysphagia is a concern.[72][73] Discuss keeping the patient ‘nil by mouth’ with a senior colleague or speech and language therapist if the initial swallowing assessment indicates dysphagia.[72] See Assessment of dysphagia.
Agree an escalation plan with the patient and/or their family/carers as early as possible. Aspiration pneumonia may indicate a terminal event of a chronic progressive illness.[8]
Resuscitation status (i.e., ‘Do Not Attempt Cardiopulmonary Resuscitation’ [DNACPR] decision)
Ceiling of care (e.g., suitability for intubation or intensive care admission).
Escalation plans should take account of advanced care planning, including legally binding advanced directives.[71]
Decide on setting of care based on clinical presentation and escalation plan; there are no established criteria to determine hospital admission or level of care.
Consider admission to an intensive care unit if the patient requires intubation, is hypotensive, or has altered mental status.
In practice, some doctors use the CURB-65 score to assess the severity of symptoms and signs of aspiration pneumonia. [ CURB-65 pneumonia severity score Opens in new window ] This score is recommended by the National Institute for Health and Care Excellence and the British Thoracic Society for people with community-acquired pneumonia; there is no validated tool available to assess severity in aspiration pneumonia.[75]
Start empirical antibiotics to treat the infection and prevent complications such as empyema and lung abscess formation.
Empirical treatment for aspiration pneumonia is the same as that for non-aspiration pneumonia (community-acquired, hospital-acquired, or ventilator-associated), unless the patient has anaerobic pleuropulmonary syndrome (a later presentation of cavitary pneumonia or empyema associated with prior loss of consciousness and poor dental hygiene). See Community-acquired pneumonia (non COVID-19) and Hospital-acquired pneumonia (non-COVID-19).
Empirical treatment for aspiration pneumonia does not require coverage for anaerobic organisms.[3][76] Similarly, no additional anaerobic antibiotic coverage is warranted for patients with dysphagia or aspiration associated with stroke.[77]
However, consider anaerobic cover when patients with aspiration pneumonia are at high risk of anaerobic infection (e.g., those with obvious dental/periodontal disease or putrid sputum production, or when lung abscess/empyema is suspected).[3]
Seek advice from a microbiologist on selection of antibiotic treatment and consider local and ward-based resistance data. Follow your local protocol, taking into consideration local microbiology guidance, where the patient was when symptoms began, recent antibiotic exposure, and recent microbiology results if available.
Practical tip
Think 'Could this be sepsis?' based on acute deterioration in an adult patient in whom there is clinical evidence or strong suspicion of infection.[48][49][50] See Sepsis in adults.
The patient may present with non-specific or non-localised symptoms (e.g., acutely unwell with a normal temperature) or there may be severe signs with evidence of multi-organ dysfunction and shock.[48][49][50]
Remember that sepsis represents the severe, life-threatening end of infection.[59]
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[48][49][51][60] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[52]
Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns).
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[52]
In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[50]
Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
At risk of neutropenic sepsis.
Continue antibiotics for at least 5 days in a patient who responds promptly and longer if highly resistant pathogens such as Pseudomonas aeruginosa are isolated, or if the patient does not improve.
Tailor antibiotic treatment once the culture sensitivity results are known.
Risk of a resistant organism is proportional to the number of prior infections and previous exposure to antibiotics. Patients who live in an environment where many different types of antibiotics may have been used (e.g., nursing homes) are also at higher risk for resistant organisms.[11]
More info: Antibiotics
Patients who aspirate with an endotracheal tube or who have been hospitalised for more than 48 hours may be colonised with nosocomial organisms and require coverage for pathogens common in hospital-acquired or ventilator-associated pneumonia, such as gram-negative rods and Staphylococcus aureus.[78]
While older guidelines recommended extending empirical coverage based on the prevalence of drug-resistant pathogens in the healthcare setting, more recent guidelines have omitted mention of healthcare-associated pneumonia, based on the finding that healthcare-associated pneumonia does not accurately identify drug-resistant pathogens.[21][79]
The British Thoracic Society advises that a balance must be found between providing sufficient cover for the polymicrobial nature of aspiration pneumonia and the risk of broad-spectrum antibiotics promoting antimicrobial resistance or infections such as Clostridium difficile.[3] Though cephalosporins have been shown to be effective for aspiration pneumonia, their adverse ecological effects mean their use has been de-emphasised in the UK. Co-amoxiclav has been identified as a suitable empirical antibiotic, pending sensitivities, taking the above into consideration. To a large extent, the therapy of aspiration pneumonia has to be individualised depending on host factors, risk factors for multidrug-resistant pathogens, institutional antibiotic formularies, and severity of encountered pneumonia.
Assess oxygen requirements. Monitor controlled oxygen therapy. An upper SpO2 limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.
Evidence suggests that liberal use of supplemental oxygen (target SpO2 >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[69]
A lower target SpO2 of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[70]
Evidence: Target oxygen saturation in acutely ill adults
Too much supplemental oxygen increases mortality.
Evidence from a large systematic review and meta-analysis supports conservative/controlled oxygen therapy versus liberal oxygen therapy in acutely ill adults who are not at risk of hypercapnia.
Guidelines differ in their recommendations on target oxygen saturation in acutely unwell adults who are receiving supplemental oxygen.
The British Thoracic Society (BTS) guideline recommends a target SpO2 range of 94% to 98% for patients not at risk of hypercapnia, whereas the 2022 Thoracic Society of Australia and New Zealand (TSANZ) guideline recommends 92% to 96%.[70][80]
The Global Initiative For Asthma (GINA) guidelines recommend a target SpO2 range of 93% to 96% in the context of acute asthma exacerbations.[81]
One systematic review including a meta-analysis of data from 25 randomised controlled trials published in 2018 found that in adults with acute illness, liberal oxygen therapy (broadly equivalent to a target saturation >96%) is associated with higher mortality than conservative oxygen therapy (broadly equivalent to a target saturation ≤96%).[69] In-hospital mortality was 11 per 1000 higher for the liberal oxygen therapy group versus the conservative therapy group (95% CI 2 to 22 per 1000 more). Mortality at 30 days was also higher in the group who had received liberal oxygen (relative risk 1.14, 95% CI 1.01 to 1.29). The trials included adults with sepsis, critical illness, stroke, trauma, myocardial infarction, or cardiac arrest, and patients who had emergency surgery. Studies that were limited to people with chronic respiratory illness or psychiatric illness, or patients on extracorporeal life support, receiving hyperbaric oxygen therapy, or having elective surgery, were all excluded from the review.
An upper SpO2 limit of 96% is therefore reasonable when administering supplemental oxygen to patients with acute illness who are not at risk of hypercapnia. However, a higher target may be appropriate for some specific conditions (e.g., pneumothorax, carbon monoxide poisoning, cluster headache, or sickle cell crisis).[82]
In 2019 the BTS reviewed its guidance in response to this systematic review and meta-analysis and decided an interim update was not required.[70]
The committee noted that the systematic review supported the use of controlled oxygen therapy to a target.
While the systematic review showed an association between higher oxygen saturations and higher mortality, the BTS committee felt the review was not definitive on what the optimal target range should be. The suggested range of 94% to 96% in the review was based on the lower 95% confidence interval and the median baseline SpO2 from the liberal oxygen groups, along with the earlier 2015 TSANZ guideline recommendation.
Subsequently, experience during the COVID-19 pandemic has also made clinicians more aware of the feasibility of permissive hypoxaemia.[83]
Management of oxygen therapy in patients in intensive care is specialised and informed by further evidence (not covered in this summary) that is more specific to this setting.[84][85][86]
Give thromboprophylaxis, unless contraindicated. Patients with aspiration pneumonia are at increased risk of venous thromboembolism and should receive subcutaneous low molecular weight heparin or a suitable alternative.[3]
Assess hydration and nutrition, and manage as appropriate. Normalise fluid balance and discuss strategies for adequate nutrition involving speech and language therapists and dieticians.[3]
More info: Respiratory physiotherapy
In most cases, there is no evidence to show benefit of respiratory physiotherapy in aspiration pneumonia and British Thoracic Society guidelines suggest that patients with aspiration pneumonia should not routinely be treated with airway clearance techniques (ACTs).[3][87]
However, when there is clinical evidence of secretions or radiological evidence of atelectasis, and in patients with respiratory muscle weakness or pneumonia secondary to stroke, physiotherapy such as ACTs have shown to be of benefit.[88] Once they have been initiated, ACTs should continue until the patient is free of secretions and atelectasis.
Manage hypotension, acute respiratory distress syndrome, and shock as appropriate. See Shock and Acute respiratory distress syndrome.
Ensure the patient’s airways are well suctioned for those with an endotracheal tube or tracheostomy.
Correct any reversible underlying problems that precipitated the aspiration.
Involve the multidisciplinary team early for any patient with suspected dysphagia and organise a swallowing assessment. Always involve the patient and/or carer in decision-making where possible.[72][89] See Assessment of dysphagia.
An initial screen of swallowing function should be completed by an appropriately trained healthcare professional.[73] Screening questions that may be used are:[90]
Do you cough and choke when you eat and drink?
Does it take you longer to eat your meals than it used to?
Have you changed the type of food that you eat?
Does your voice change after eating/drinking?
Discuss keeping the patient ‘nil by mouth’ with a senior colleague or speech and language therapist if the initial swallowing assessment indicates dysphagia.[72]
In addition, organise a specialist swallowing assessment (e.g., by a speech and language therapist).[72][73] For more information, see Screening.
Give food, fluids, and medication in a form that is appropriate for your patient once they have had a swallowing assessment.[72][73]
Consider alternative feeding strategies if the patient is unable to take adequate food, fluids, and medication orally.[73] Tube feeding (e.g., nasogastric tube, gastrostomy, or nasal bridle tube) may be appropriate to provide temporary nutritional support for patients with non-progressive causes of dysphagia such as stroke.[72][73]
Ensure the patient is screened for malnutrition and dehydration and involve a dietician to optimise the patient’s nutritional needs.[72][73]
Discuss feeding strategies carefully with the patient and/or family because the risk of aspiration may be outweighed by the patient’s quality-of-life needs, especially in progressive disease. It may be preferable for the patient to eat and drink (while accepting it is unsafe) rather than using a modified diet, feeding tube, or ‘nil by mouth’ regimens.[72] This strategy is also known as ‘risk feeding’.[91]
Practical tip
Be aware that thickened fluids can alter the pharmacokinetics of the patient’s medication by reducing the bioavailability.[92] Seek advice from a senior colleague or pharmacist.
Other management strategies include swallowing rehabilitation, education, careful positioning when feeding, and referral to an oral hygienist/dentist.[72]
If a patient does not have a known cause for their dysphagia (e.g., not known oropharyngeal dysphagia), organise urgent referral for upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for upper gastrointestinal cancer.[72]
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