Prevention of aspiration is particularly important for those patients at risk. Treatment of illicit drug use and alcohol addiction will significantly decrease the individual patient's chance of intoxication and subsequent aspiration. Feeding in an upright position will decrease the risk of aspiration in patients with dysphagia, on tube feedings through nasogastric or orogastric tubes, or with gastrostomy or jejunostomy tubes. Increasing the gastric pH by the use of antacids (four times a day) or proton pump inhibitors (omeprazole 20 mg/d orally) will decrease the pulmonary damage from silent serial aspirators. 10
Prokinetic agents that increase lower esophageal sphincter tone and stimulate gastric emptying are useful in treating gastroesophageal reflux disease and would be useful in preventing aspiration in patients at risk. These agents include bethanecol 25 mg qid, metoclopramide 10 mg before meals and at bedtime, and cisapride 10 mg before meals and at bedtime. These agents are useful in gastroesophageal reflux disease, but they have some troublesome side effects. The side effects of bethanecol are related to its cholinergic effects: abdominal cramps, salivation, urination, and blurred vision. Cisapride has been reported to cause Q-T interval prolongation and ventricular dysrhythmias, including torsade de pointes, in patients receiving other medication (e.g., ketoconazole and other antifungals). In addition to the desirable antiemetic central nervous system effects of metoclopramide, there are also undesirable effects: mild anxiety, nervousness, insomnia, depression, confusion, disorientation, and hallucinations. other troublesome side effects of metoclopramide include the extrapyramidal effects of tremor; akathisia; tardive dyskinesia, a Parkinson-like syndrome; gynecomastia; and reversible amenorrhea.8
For patients who have experienced an acute, symptomatic aspiration, immediate removal of any airway obstruction and rapid assessment of ventilation is needed. Hypoxia should be corrected by oxygenation, ventilation, and intubation if necessary. Aerosolized bronchodilators are useful for aspiration-induced bronchospasm. For patients in shock, aggressive intravenous (IV) fluid administration and, if appropriate, vasopressors are used.
Healthy patients who aspirate but who are not hypoxic and have no infiltrate on x-ray may be observed for development of signs of infection and may not require antibiotic treatment. Elderly or chronically ill patients who present with signs and symptoms of infection should have antibiotic therapy instituted. In general, appropriate cultures of blood, urine, and sputum (if available) should be obtained in the emergency department, and antibiotic therapy should be initiated. Anaerobes predominate in aspiration pneumonia, and antibiotics that are proven effective include clindamycin 450 to 900 mg IV every 8 h, cefoxitin 2.0g IV every 8 h, ticarcillin-clavulanate 3.1 g IV every 6 h, or piperacillin-tazobactam 3.375 g IV every 6 h.
Bronchoscopy may be indicated for patients who aspirate large objects that move into the distal airways. Patients with viscous materials or tenacious secretions may require direct bronchoalveolar lavage for removal. Patients who develop copious hemoptysis may require bronchoscopy for both diagnosis and treatment.
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