CURRENT Essentials of Critical Care.pdf

Chapter 8 Respiratory Failure 95■■■Aspiration Pneumonitis & PneumoniaEssentials of Diagnosis• Aspiration pneumonitis: chemical irritation (food, gastric acid)plus inflammation; may be witnessed; symptoms and chest radiographchanges 2–5 hours after event; aspiration of gastriccontents from impaired consciousness, loss of gag reflex, enteralfeeding, impaired gastric motility, endotracheal intubation,supine positioning• Aspiration pneumonia: aspiration of bacteria from oropharynxor stomach; usually unwitnessed; increased with periodontal infection,alcoholism, impaired consciousness; increased in criticallyill (altered bacterial flora, impaired swallowing, endotrachealintubation, advanced age)Differential Diagnosis• Community-acquired pneumonia, tuberculosis, fungal pneumonia• Ventilator-associated pneumonia• Pulmonary edemaTreatment• Treat respiratory failure due to acute lung injury• Keep airway clear by suctioning; may need endotracheal intubationif severe• Antibiotics not needed in pneumonitis unless high risk of bacterialcolonization of stomach (small bowel obstruction, inhibitionof gastric acid production) or fever, abnormal chest radiograph,respiratory failure 48 hours after suspected aspiration;corticosteroids contraindicated• Aspiration pneumonia: Antibiotics indicated; if hospitalized 72 hours, treat as community-acquired pneumonia (ceftriaxoneor levofloxacin); hospitalized 72 hours or resident in longtermcare facility, treat Gram-negative bacilli includingPseudomonas; high likelihood of anaerobic or mixed infection(alcoholism, periodontal disease), levofloxacin or ceftriaxoneplus clindamycin or metronidazole■ PearlRoutine elevation of head of bed to 30–45 degrees decreases risk ofaspiration and ventilator-associated pneumonia by as much as 60%over first 7 days.ReferenceMarik PE: Aspiration pneumonitis and aspiration pneumonia. N Engl J Med2001;344:665. [PMID: 11228282]