Acute aspiration

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

pneumonitis due to aspiration

1st line – immediate positional drainage

Plus – oropharyngeal suctioning

Consider – oxygen

Consider – endotracheal intubation + nasogastric tube

Consider – positive-pressure ventilation

Consider – antibiotics

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Consider –

antibiotics

Additional treatment recommended for SOME patients in selected patient group

Do not give immediate antibiotic therapy routinely if the patient has aspiration pneumonitis, even if they have associated fever, leukocytosis, or pulmonary infiltrates.[2]

For patients who have aspirated gastric contents, note that gastric aspirate is sterile under normal conditions due to the low pH, so bacterial infection does not tend to occur in the early stages of acute lung injury.[2]
Immediate use of antibiotics may select resistant organisms in uncomplicated chemical pneumonitis.

However, always give antibiotics if the patient is receiving mechanical ventilation; they are at high risk of developing ventilator-associated pneumonia. In addition, consider antibiotics if the patient has any of the following:

Gastroparesis (often seen in critically ill patients)
Small bowel obstruction
Possible colonisation of the stomach (e.g., patients taking proton-pump inhibitors, H2 antagonists, or antacids, where the stomach pH is less acidic)
Aspiration pneumonitis that does not resolve within 48 hours. See Non-resolving pneumonitis after 48 hours below.

Check your local protocol for choice of antibiotic, and always obtain respiratory cultures before starting antibiotics.

Stop or modify the antibiotics within 72 hours based on the culture results.[1]

Consider – bronchoscopy

Consider – observation

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.[50][51] See Assessment of dysphagia.

An initial screen of swallowing function should be completed by an appropriately trained healthcare professional.[52][53] Screening questions that may be used are:[54]
- 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.
In addition, organise a specialist swallowing assessment (e.g., by a speech and language therapist).[50][52] See Screening.
Give food, fluids, and medication in a form that is appropriate for your patient once they have had a swallowing assessment.[50][52]
- Consider alternative feeding strategies if the patient is unable to take adequate food, fluids, and medication orally.[52] 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.[52]
- Ensure the patient is screened for malnutrition and dehydration and involve a dietician to optimise the patient’s nutritional needs.[52]
- 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.[51] This strategy is also known as ‘risk feeding’.[70]
- Practical tip
  Be aware that thickened fluids can alter the pharmacokinetics of the patient’s medication by reducing the bioavailability.[71] 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.[50]

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.[52]

ONGOING

non-resolving pneumonitis after 48 hours

1st line – antibiotics

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1st line –

antibiotics

Suspect aspiration pneumonia if the patient has non-resolving pneumonitis 48 hours after a confirmed or probable aspiration event.

Clinical features of aspiration pneumonia include cough, breathlessness, fever, and persistent leukocytosis.
Order a repeat chest x-ray if you suspect aspiration pneumonia clinically; confirm the diagnosis if infiltrates are present >48 hours after a confirmed or suspected aspiration event.
Pneumonia can also occur due to tissue damage secondary to pneumonitis rather than due directly to the aspiration event.

Start empirical antibiotics to treat the infection and prevent complications such as empyema and lung abscess formation.

Always send a sputum sample for Gram stain and culture where possible before starting antibiotics.
Empirical antibiotic 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 and Hospital-acquired pneumonia (non-COVID-19).
Empirical treatment for aspiration pneumonia does not require coverage for anaerobic organisms.[72] Similarly, no additional anaerobic antibiotic coverage is warranted for patients with dysphagia or aspiration associated with stroke.[73]
Most patients with aspiration pneumonia are treated initially with intravenous antibiotics.
Seek advice from a microbiologist on selection of antibiotic treatment and consider local and ward-based resistance data. Follow your local protocol.

Patients with aspiration pneumonia will need additional further management. See our topic Aspiration pneumonia.

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Acute aspiration

Treatment algorithm

pneumonitis due to aspiration

immediate positional drainage

oropharyngeal suctioning

oxygen

endotracheal intubation + nasogastric tube

positive-pressure ventilation

antibiotics

bronchoscopy

observation

management of dysphagia

Practical tip

non-resolving pneumonitis after 48 hours

antibiotics