Synopsis
Separate sterile chemical aspiration pneumonitis from bacterial aspiration pneumonia, stabilise acute lung injury, treat infection proportionately, and reduce recurrence through swallowing, oral-care and person-centred feeding decisions.
- Aspiration pneumonitis is an acute chemical injury, often after witnessed large-volume gastric aspiration in a person with reduced consciousness; aspiration pneumonia is infection after aspiration of bacteria-rich secretions.
- The distinction is temporal and clinical, not established by procalcitonin: pneumonitis can improve over 24–48 hours with support, whereas persistent or later fever and deterioration suggest secondary infection.
- Assess swallowing impairment, consciousness, neurological disease, frailty, reflux, dentition, sedative medicines, feeding dependence and the patient's baseline communication and goals.
Key red flags
Abrupt cough, wheeze, hypoxaemia and bilateral or dependent infiltrates within hours of a witnessed large gastric aspiration, usually during reduced consciousness, anaesthesia or vomiting.
Investigation priorities
Distinguish abrupt chemical aspiration from infective microaspiration and identify recurrence risks.
Management branches
Abrupt respiratory deterioration during vomiting, feeding, anaesthesia or reduced consciousness.
- Call for airway help, position safely, suction visible oral or tracheal material, provide target-based oxygen and support ventilation; bronchoscopy is considered for persistent large particulate obstruction, not routine lavage.
- Assess severity with observations and gas exchange, obtain imaging when stable, and treat bronchospasm or shock through the appropriate acute pathway.
Key medicines
Co-amoxiclav for aspiration pneumoniaA typical community oral regimen is 500/125 mg three times daily for 5 days; use the locally approved IV regimen when severe or swallowing is unsafe.
Alternative in immediate penicillin allergySelect a fluoroquinolone, macrolide, tetracycline or other local alternative at its current BNF dose after microbiology and patient-specific review.