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Endotracheal intubation is indicated if airway reflexes are acutely
compromised or for severe cases with impending respiratory failure. Children
with impaired baseline pulmonary function may require significant supportive
care after aspiration.
The suspicion of aspiration should be confirmed with a CXR. Some children
who aspirate may have relatively normal radiographs early in the course but
significant symptomatology and findings. Conversely, radiographs may be
significantly abnormal in the face of minimal clinical symptoms in patients with
aspiration of hydrocarbon or other volatile agents (further discussed in Chapter
102 Toxicologic Emergencies ).
The decision to initiate antibiotic therapy is challenging which reflects the
difficulty in distinguishing aspiration pneumonitis and aspiration pneumonia.
Infection plays little role in the initial pulmonary complications after aspiration,
that is, aspiration pneumonitis. However, pathogenic bacteria from the
oropharynx may accompany foreign material, resulting in direct inoculation of
lung tissue. Alternatively, following acid aspiration, the injured lung becomes
vulnerable to secondary bacterial infections which may occur in up to half of
these cases. There is no strong data to suggest that prophylactic antibiotic therapy
will prevent subsequent infection in a patient with chemical pneumonitis.
Moreover, fever, purulent sputum, leukocytosis, and pulmonary infiltrates may
result from chemical inflammation alone, furthering the difficulty distinguishing
between aspiration pneumonitis and aspiration pneumonia. A reasonable initial
approach is to defer antibiotic treatment in favor of careful observation in a wellappearing child and empirically treat only those with tenuous respiratory status or
compelling clinical evidence of infection, or significant medical history which
may complicate their clinical course. In practice, many of the children at risk for
aspiration pneumonia are also medically complex and benefit may often outweigh
risk with empiric treatment with these patient populations.
For those who develop infection, two distinct patterns are possible. A localized
necrotizing bacterial pneumonia, abscess, or empyema may result from a heavily
infected aspirate. Although opinions vary, anaerobic organisms, either alone or as
polymicrobial infection with aerobes, are likely etiologies in such cases. The

second pattern of infection is that which follows large aspirates, usually of acidic
contents. Aerobic rather than anaerobic organisms predominate in this case;
gram-negative organisms, such as Pseudomonas aeruginosa, and gram-positive
organisms, such as Staphylococci , may be isolated.
The choice of antibiotics can be guided by the clinical setting and the results of
properly obtained specimens for culture. Size and type of aspirate are