Treatment of aspiration in intensive care unit patients.

BACKGROUND: Aspiration is a common event, but the clinical consequences are variable. The primary determinants are the nature of the aspirated material and the host response to it. The purpose of this paper is to present treatment algorithms that should be employed in critically ill patients who experience aspiration.

METHODS: Expert review of the available literature was done to provide background information to support the logic of 3 treatment algorithms: (1) treatment of acute aspiration pneumonitis; (2) pulmonary care for acute aspiration; and (3) treatment of aspiration pneumonia.

RESULTS: The discussion of aspirations is separated into 2 clinical scenarios: (1) aspiration pneumonitis (sterile inflammation) versus (2) aspiration pneumonia (an infectious process). Aspiration pneumonitis should be treated by aggressive pulmonary care to enhance lung volume and clear secretions. Intubation should be used selectively. Early corticosteroids and prophylactic antibiotics are not indicated. Treatment of aspiration pneumonia requires diligent surveillance for the clinical signs of pneumonia. Treatment decisions are based on 3 factors: (1) clinical diagnostic certainly (definite versus probable), (2) time of onset [early (< 5 days) versus late (> or = 5 days)], and (3) host factors (high risk versus low risk). There is no ideal antibiotic regimen. Unit-specific resistance patterns and known frequency pathogens should direct broad spectrum empiric therapy. Invasive diagnostic techniques (such as bronchoalveolar lavage) should be used when the diagnosis is not certain. Antibiotic coverage should be narrowed once sputum culture results become available.

CONCLUSIONS: Aspiration is common in critically ill patients and should be aggressively treated by these treatment algorithms.