Aspiration Pneumonia

Risk Factors for Aspiration

Debilitation
History of Dysphagia
Intubation: of any duration
- Swallowing difficulties exist in 50% of intubated patients for up to 1 week after
- No clinical factors reliably predict if patient will aspirate
Muscle Weakness
Older Age
Oral/Nasal Enteral Feeding Tubes
Tracheostomy (see Tracheostomy, [[Tracheostomy]])

Bilateral Vocal Fold Immobility (BVFI) (see Bilateral Vocal Fold Immobility, [[Bilateral Vocal Fold Immobility]]): of any etiology
Cervical Spine Surgery

Esophageal Motility Disorder
- Esophageal Achalasia (see Esophageal Achalasia, [[Esophageal Achalasia]])
  - Scleroderma (see Scleroderma, [[Scleroderma]])
- Esophageal Stricture (see Esophageal Stricture, [[Esophageal Stricture]])
- Gastroesophageal Reflux Disease (GERD) (see Gastroesophageal Reflux Disease, [[Gastroesophageal Reflux Disease]])
- Mixed Connective Tissue Disease (MCTD) (see Mixed Connective Tissue Disease, [[Mixed Connective Tissue Disease]])

Obtundation/Coma with Inability to Protect Airway (see Obtundation-Coma, [[Obtundation-Coma]])
- Intoxication
- Withdrawal
- Sedative
- General Anesthesia (see General Anesthesia, [[General Anesthesia]])
Neuromuscular Swallowing Dysfunction
- Intracerebral Hemorrhage (Hemorrhagic Cerebrovascular Accident) (see Intracerebral Hemorrhage, [[Intracerebral Hemorrhage]])
- Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]])
- Myasthenia Gravis (see Myasthenia Gravis, [[Myasthenia Gravis]])
- Polydermatomyositis (see Polydermatomyositis, [[Polydermatomyositis]])
- Subarachnoid Hemorrhage (SAH) (see Subarachnoid Hemorrhage, [[Subarachnoid Hemorrhage]])

Ankylosing Spondylitis (see Ankylosing Spondylitis, [[Ankylosing Spondylitis]])
Near Drowning (see Near Drowning, [[Near Drowning]])

Assessment of Swallowing Function
- Bedside Swallowing Evaluation: relatively insensitive for evidence of aspiration in patients with tracheostomy, since up to 77% of aspiration was silent [MEDLINE] [MEDLINE]
- Gag Reflex: does not predict adequacy of swallowing function (as gag reflex uses different muscles than swallowing and many patients without gag can swallow normally)
- Modified Barium Swallow: best test
Sputum Gram Stain/Culture and Sensitivity
CXR/Chest CT Patterns
- Alveolar Infiltrate: often located in dependent lung region (particularly RLL-superior segment)
- Bibasilar Fibrosis: may be seen in cases of chronic aspiration

Acute Lung Injury-ARDS (see Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])
Cryptogenic Organizing Pneumonia (see Cryptogenic Organizing Pneumonia, [[Cryptogenic Organizing Pneumonia]])
Interstitial Pulmonary Fibrosis (see Interstitial Lung Disease-Etiology, [[Interstitial Lung Disease-Etiology]])
Lung Abscess (see Lung Abscess, [[Lung Abscess]])
Necrotizing Pneumonia/Pulmonary Gangrene (Necrotizing Pneumonia and Pulmonary Gangrene, [[Necrotizing Pneumonia and Pulmonary Gangrene]])
Parapneumonic Pleural Effusion (see Pleural Effusion-Parapneumonic, [[Pleural Effusion-Parapneumonic]])
Pneumonia (see Pneumonia, [[Pneumonia]])

NPO
Nasogastric Feeding
Gastrostomy Tube Placement
Cuffed Tracheostomy
Laryngeal-Tracheal Separation/Laryngectomy: last resort treatment
- Allows PO intake, but speaking is not possible
- Proven effective and beneficial to improve mood and clinical outcome

Antibiotics (per Infectious Disease Society of America/ISDA Recommendations): second agent for anaerobic coverage may be unnecessary, as Gatifloxacin/Moxifloxacin have adequate anaerobic coverage
- Newer Generation Fluoroquinolone (Levofloxacin/Gatifloxacin/Moxifloxacin) (see Fluoroquinolones, [[Fluoroquinolones]]) + Piperacillin/Tazobactam (Zosyn) (see Piperacillin-Tazobactam, [[Piperacillin-Tazobactam]])
- Newer Generation Fluoroquinolone (Levofloxacin/Gatifloxacin/Moxifloxacin) (see Fluoroquinolones, [[Fluoroquinolones]]) + Ampicillin/Sulbactam (Unasyn) (see Ampicillin-Sulbactam, [[Ampicillin-Sulbactam]])
- Newer Generation Fluoroquinolone (Levofloxacin/Gatifloxacin/Moxifloxacin) (see Fluoroquinolones, [[Fluoroquinolones]]) + Metronidazole (Flagyl) (see Metronidazole, [[Metronidazole]])
- Newer Generation Fluoroquinolone (Levofloxacin/Gatifloxacin/Moxifloxacin) (see Fluoroquinolones, [[Fluoroquinolones]]) + Clindamycin (see Clindamycin, [[Clindamycin]])

Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest. 1994 Feb;105(2):563-6 [MEDLINE]
Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest. 1996 Jan;109(1):167-72 [MEDLINE]
Satisfaction of patients treated surgically for intractable aspiration. Chest. 1999 Nov;116(5):1251-6 [MEDLINE]