Aspiration pneumonia

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – antibiotic therapy

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1st line –

antibiotic therapy

If the patient is having an acute aspiration event, see Acute aspiration.

Start empirical antibiotics.

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.[76] Similarly, no additional anaerobic antibiotic coverage is warranted for patients with dysphagia or aspiration associated with stroke.[77]
Seek advice from a microbiologist on selection of antibiotic treatment and consider local and ward-based resistance data. Follow your local protocol.

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][60]

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.

Plus – agree an escalation plan and setting of care

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Plus –

agree an escalation plan and setting of care

Treatment recommended for ALL patients in selected patient group

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]

This should include:[71][74]
- 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]

Plus – supportive care

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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]

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]

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.

Plus – management of dysphagia

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Plus –

management of dysphagia

Treatment recommended for ALL patients in selected patient group

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]

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.[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 underlying 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.[73]

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Aspiration pneumonia

Treatment algorithm

all patients

antibiotic therapy

Practical tip

agree an escalation plan and setting of care

supportive care

management of dysphagia

Practical tip