[Dysphagia] Pneumonitis vs pneumonia

[eripley at yahoo.com (Irene Campbell-Taylor)]

It is disturbing to see the increase in the figures for diagnosis of aspiration pneumonia which is, in fact, one of the most difficult diagnoses to make. The following, while older references are important as they illustrate a vitally important point i.e. that aspiration pneumonitis is often missed as it is of short duration in those who recover but the secondary bacterial pneumonia is mistakenly identified as the primary event:


Pulmonary aspiration of gastric contents. Am Rev Respir Dis. 1976 Dec;114(6):1129-36.
Bynum LJ, Pierce AK.
A retrospective analysis of 50 patients who had been observed to aspirate gastric contents was performed to define better the course of patients with this syndrome. The patients invariably had a disturbance of consciousness, most commonly due to sedative drug overdose or general anesthesia. The onset of clinical signs occurred prompty after aspiration and tended to be similar in all patients, irrespective of their subsequent course or outcome. These findings usually included fever, tachypnea, diffuse rales, and serious hypoxemia. Cough, cyanosis, wheezing, and apnea were each seen in approximately one third of the cases. Apnea, shock, and early severe hypoxemia were particularly ominous events. Initial roentgenograms revealed diffuse or localized alveolar infiltrates, which progressed during the next 24 to 36 hours. Subsequent clinical courses followed 3 patterns: 12 per cent of the patients died shortly after aspiration; 62 per cent had rapid clinical and radiologic improvement,
 with clearing, on average, within 4.5 days; 26 per cent demonstrated rapid improvement, but then had clinical and radiographic progression associated with recovery of bacterial pathogens from the sputum and a fatal outcome in more than 60 per cent. Treatment from the outset by adrenocortical steroids or antimicrobial agents had no demonstrable effect on the outcome. The clinical features of aspiration of gastric contents are characteristic and distinguish it from other forms of aspiration-related lung disease.


Aspiration pneumonia. Clin Chest Med. 1991 Jun;12(2):269-84.
DePaso WJ.
The clinical presentation and course of chemical pneumonitis after inhalation of gastric contents ranges from mild and self-limited to severe and life-threatening, depending on the nature of the aspirate and the underlying condition of the host. In the absence of witnessed inhalation of vomit, diagnosis is difficult and requires a high index of suspicion in a patient who has risk factors for aspiration. In the absence of an obvious predisposition, the abrupt onset of a self-limited illness characterized by dyspnea, cyanosis, and low-grade fever associated with diffuse rales, hypoxemia, and alveolar infiltrates in dependent lobes should suggest aspiration. Treatment consists of supportive care with high-flow oxygen and volume replacement. Bacteria usually play no role in the initial lung injury, and antibiotics should be withheld until there is evidence of superinfection. Prophylactic corticosteroids should not be used. Preventive measures should be employed in patients at high risk
 for aspiration of stomach contents. Patients with unexplained chronic respiratory syndromes should be evaluated for gastric regurgitation and aspiration.

 



Dr I Campbell-Taylor
Clinical Neuroscientist
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