Answer:

Awake patients capable of airway protection should be placed in the upright or recovery position and encouraged to cough. However, clinicians may need to suction or rescue the airway if the patient has impaired protective airway reflexes. Supplemental oxygen should be administered for hypoxemia. Clinicians should avoid noninvasive ventilation because of the risk of gastric insufflation unless there is no further risk of additional vomiting. There is no evidence supporting lavage with saline or sodium bicarbonate. Gastric acid is rapidly neutralized by the physiologic response. When possible, the stomach should be emptied with a nasogastric tube. A chest radiograph should be ordered. In select circumstances, a bronchoscopy may be necessary for airway clearance and evaluation especially if airway obstruction is suspected. Bronchoscopy can provide quantitative lower respiratory tract cultures from bronchoalveolar lavage or protected brushings. These techniques can distinguish aspiration pneumonitis from pneumonia.

Although some animal studies support the use of corticosteroids in aspiration pneumonitis, there is no evidence of benefit in human studies. Moreover, the literature does not support the routine use of antibiotics immediately after aspiration. A retrospective cohort study reviewing 200 patients divided into groups that received supportive care versus antimicrobials did not show any clinical benefit when looking at mortality or need for transfer to an intensive care unit. Patients, however, should be followed closely to identify the development of a secondary infection. If the clinicians diagnose aspiration pneumonia, they should choose antibiotics that provide coverage against oral flora including gram-negative coverage for patients with nosocomial colonization. This may include extended spectrum lactamases inhibitors such as piperacillin-tazobactam.