Is Every Pneumonia Aspiration Pneumonia?
There are two camps on this one. Some believe that since any and all pneumonia requires an outside pathogen to be sucked into the airway then all pulmonary infections should be considered aspiration pneumonia. I believe that this is short-sighted and defeats the purpose of what we are trying to do with pneumonia diagnosis and management. It is true that aspiration pneumonia is hard to diagnose, and can be difficult to differentiate from other types of pneumonia. However, claiming they are all the same only muddies the water further by oversimplifying the issue. Let’s get to the bottom of this issue and figure out why a specific and identifiable diagnosis with key criteria for aspiration pneumonia really matters.
Arguing that all pneumonia is aspiration pneumonia is like arguing that no matter what country you visit in Europe, you’re still in the same place. Yes, technically you’d be in the European Union in most cases, but if you’re going to Germany in search of The Louvre, you’re going to be disappointed. Differences are important and, in the case of pneumonia, knowing these differences could mean life or death. An accurate diagnosis must precede an accurate and appropriate treatment plan. There are obvious and important differences to acknowledge when it comes to a pneumonia caused by aspiration (e.g. secondary to dysphagia or vomiting) vs pneumonia from an airborne virus that is breathed in. Knowing these differences helps us identify key risk factors that can be investigated and managed to lower the risk profile and improve the patient’s opportunity for a successful recovery.
So it’s obvious which camp I belong to here. The answer is no, every pneumonia is not aspiration pneumonia. Now that we got that out of the way, we can focus our attention on making a correct general diagnosis of pneumonia (presence of infection, changes in respiratory status, and abnormal chest imaging) and then a correct aspiration pneumonia diagnosis (presence of all previously mentioned criteria for a general diagnosis of pneumonia AND the presence of gravity dependent abnormality on chest imaging, oral bacteria in the lungs, and signs or risks of dysphagia and/or reflux/vomiting). Reflux/vomiting is often associated with aspiration pneumonitis, an inflammation of the airways without infection, but may result in full on aspiration pneumonia if the pH of the gastric contents is high enough and no longer sterile (say, from the use of proton pump inhibitors).
Making the differential diagnosis is the first step toward making sure it doesn’t happen again. This allows us to accurately identify the cause so we can create an effective plan of care. ALL of this is to treat a specific, identifiable condition so we can develop a research-based approach to address that condition, ultimately, to care for the patient. It’s not technical terms and medical jargon that matters here, but the patient who comes first. That’s what matters most.
To read more on assessing the range of risk factors for aspiration pneumonia, see my blog with Dr. James Coyle and Doreen Benson here.
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