Treatment algorithm

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 of gastric contents

1st line – immediate positional drainage

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ACUTE
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pneumonitis due to aspiration of gastric contents
1st line – 

immediate positional drainage

Patients with recent suspected or witnessed aspiration of gastric contents should, whenever possible, be immediately placed semi-prone and tilted to a 30° head-down position. This positions the larynx at a higher level than the oropharynx and allows the gastric content to drain externally.

Plus – oropharyngeal suctioning

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ACUTE
|
pneumonitis due to aspiration of gastric contents
Plus – 

oropharyngeal suctioning

Treatment recommended for ALL patients in selected patient group

The oropharynx should be suctioned gently, taking care to avoid initiating a gag reflex that may worsen aspiration.[2]

Consider – endotracheal intubation + nasogastric tube

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ACUTE
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pneumonitis due to aspiration of gastric contents
Consider – 

endotracheal intubation + nasogastric tube

Treatment recommended for SOME patients in selected patient group

Once the oropharynx has been suctioned, if the patient is deemed to be at risk of further aspiration, is unable to protect their own airway (regurgitation, poor cough reflex), or shows signs of respiratory failure (tachypnea, dyspnea, confusion, cyanosis), their airway should be secured by endotracheal intubation via rapid sequence induction with cricoid pressure.[62][63]​ Once the airway is secured, a nasogastric tube should be inserted to empty the stomach, and where possible the patient can be tilted to a 45° head-up position to help prevent further aspiration.

Consider – bronchoscopy + endotracheal suctioning

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ACUTE
|
pneumonitis due to aspiration of gastric contents
Consider – 

bronchoscopy + endotracheal suctioning

Treatment recommended for SOME patients in selected patient group

If a substantial amount of gastric content (>20-25 mL in an adult) is likely to have been aspirated, prompt (within a few hours) bronchoscopy and suctioning can remove aspirated gastric fluid and solid material from the central airways, thereby helping reduce inflammatory reaction, prevent lung collapse, and lessen risk of subsequent infection.[98]

A volume of gastric aspirate >0.3 mL per kilogram of body weight (i.e., 20-25 mL in adults) with a pH <2.5 is believed necessary for the development of aspiration pneumonitis, although aspiration of particulate food matter can cause severe pulmonary damage, even if the pH of the aspirate is above 2.5.[2][99]​ Animal studies have shown a biphasic pattern to injury, with an initial peak at 1-2 hours after aspiration (direct burn effects) and a second peak at 4-6 hours (related to neutrophil infiltration).[1][2]​​

Consider – antibiotics

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ACUTE
|
pneumonitis due to aspiration of gastric contents
Consider – 

antibiotics

Treatment recommended for SOME patients in selected patient group

Gastric aspirate is sterile under normal conditions due to the low pH, so bacterial infection does not have an important role in the early stages of acute lung injury in most cases.[2] Consequently, immediate routine antibiotic therapy is not recommended for aspiration pneumonitis.[2] Even if a patient has fever, leukocytosis, or pulmonary infiltrates, immediate use of antibiotics may be unnecessary as this may select resistant organisms in an uncomplicated case of chemical pneumonitis.

The empiric use of antibiotics should, however, be considered depending on the clinical situation (e.g., severe respiratory involvement; severe preexisting lung pathology such as advanced COPD or interstitial lung disease; immunocompromise, including corticosteroid or immunomodulator use, post-transplant immunosuppression, chemotherapy, neutropenia; poor dentition; or the development of lung abscess, necrotizing pneumonia, or empyema).[100]​ In practice, antibiotics should be initiated based on clinical concern and if the patient is not responding to supportive care.

Culture and sensitivities of samples obtained via bronchoscopy with bronchoalveolar lavage or protected brush specimens, thoracentesis, or blood taken for culture should guide antimicrobial management.[101]​ Empiric therapy with broad-spectrum antibiotics is recommended if the pneumonitis does not resolve 48 hours after aspiration.[2][102]​ Antibiotics should be stopped if concern for infection drops and narrowed quickly if a specific pathogen is identified. See Aspiration pneumonia, Community-acquired pneumonia, and Hospital-acquired pneumonia.

Computed tomography (CT) imaging can identify related pathologies indicating a need for antibiotic therapy (e.g., empyema, abscess, necrosis). See Lung abscess, Empyema, Pleural effusion, and Sepsis in adults.

In the context of small bowel obstruction, where there is a high risk of bacterial translocation, bacterial contamination of gastric juice, and sepsis, the initiation of antibiotics should be considered up front.[2]​ See Small bowel obstruction and Sepsis in adults.

Local microbiology, resistance patterns, and risks for anaerobic infection should be considered when choosing the antibiotic regimen.

Consider – positive-pressure ventilation

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ACUTE
|
pneumonitis due to aspiration of gastric contents
Consider – 

positive-pressure ventilation

Treatment recommended for SOME patients in selected patient group

Positive-pressure ventilation with positive end-expiratory pressure can be used in patients who are intubated for airway protection or respiratory failure. However, positive pressure ventilation without a secure endotracheal tube should generally be considered contraindicated in patients with known or suspected aspiration causing respiratory failure. Positive pressure helps to prevent atelectasis and improve the ventilation-perfusion ratio in patients who have aspirated gastric content.[37] However, it is essential that endotracheal suctioning, and if needed, post-intubation bronchoscopy, is performed before positive-pressure ventilation is employed, to avoid forcing aspirated material deeper into the lungs.[35][37]​ 

Mechanical ventilatory support should follow lung-protective strategies as per acute respiratory distress syndrome guidelines. See Acute respiratory distress syndrome.

Respiratory cultures should be obtained from patients on mechanical ventilation, and antibiotics should be initiated immediately because of a high risk of developing ventilator-associated pneumonia.[1]​ See Hospital-acquired pneumonia.

pneumonitis due to aspiration of barium

1st line – immediate positional drainage

Back
ACUTE
|
pneumonitis due to aspiration of barium
1st line – 

immediate positional drainage

Patients with recent suspected or witnessed aspiration of barium should, whenever possible, be immediately placed semi-prone and tilted to a 30° head-down position. This positions the larynx at a higher level than the oropharynx and allows the gastric content to drain externally.

Plus – bronchoscopy + endotracheal suctioning

Back
ACUTE
|
pneumonitis due to aspiration of barium
Plus – 

bronchoscopy + endotracheal suctioning

Treatment recommended for ALL patients in selected patient group

Bronchoscopy with suctioning, if considered, should be performed immediately post-aspiration to remove any residual barium from the airway and reduce hypoxemia. Care should be taken to minimize potential spread of barium to unaffected areas from washing or lavage techniques.

Infants, older adult patients, and those of any age with significant symptoms should be admitted for observation if not already hospitalized.

There is no evidence for routinely prescribing antibiotics after barium aspiration, but antibiotics for possible pneumonia are usually considered if infiltrates do not resolve 48 hours after aspiration.[70]

See Aspiration pneumonia.

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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

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