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Pictorial Essay

The Many Faces of Pulmonary Aspiration

Edith M. Marom1, H. Page McAdams, Jeremy J. Erasmus, Philip C. Goodman

A spiration of foreign
the tracheobronchial
material
tree and
into Radiographic
nary opacities
findings
in patients
of dependent
with known
pulmo-
risk fac-
distribution
[2]. Aspiration
of acid caused
of gastric
by violent
acid was
coughing
described
lungs produces a variety of clini- tors for aspiration suggest the diagnosis. initially as a complication of pregnancy but can
cal and pathologic syndromes that depend on However, diagnosis can be difficult because the also be seen in the setting of trauma, alcoholic
the nature and amount of material and on the patient may not have known risk factors and stupor, cerebrovascula accident, general anes-
chronicity of the process. Aspiration of small because the radiographic manifestations can be thesia for emergency surgery, seizure, or car-
amounts of gastric or oral secretions occurs nonspecific or can mimic those of other condi- diac arrest. The chest radiograph reveals
in up to 45% of the healthy population and is tions such as lung cancer, tuberculosis, pulmo- bilateral, symmetric heterogenous or homo-
usually not clinically significant [1]. How- nary metastases, and hydrostatic pulmonary geneous opacities that progress to diffuse
ever, aspiration of large amounts of gastric edema. In this essay, we will show the spec- opacification and to acute respiratory dis-
acid, partially digested food, infectious mate- trem ofradiologic manifestations of aspiration. tress syndrome in severe cases (Fig. I).
rial, foreign bodies, water, or mineral oil can
have serious consequences. Risk factors for Gastric Acid Aspiration (Mendelson’s Aspiration of Partially Digested Food
significant aspiration include debilitation, Syndrome) Aspiration of partially digested food usually
neurologic abnormalities affecting swallow- Acute, massive aspiration of gastric acid results in small, localized pulmonary abnor-
ing and coughing, general anesthesia in non- with a pH of less than 2.5 results in severe alve- malities in dependent portions of lung. Diffuse
fasting patients, and abnormalities of the ola damage, edema, hemorrhage, and pulmo- abnormalities are uncommon because gastric
esophagus such as tracheoesophageal fistula, nary necrosis. The process is generally diffuse, acid is generally neutralized by food. In supine
esophageal stenosis, and achalasia. bilateral, and symmetric because of widespread patients, the material is most commonly aspi-

Fig. 1.-Massive gastric acid aspiration in 30-year-old woman with long history of chronic ethanol and IV drug abuse who was unconscious at presentation.
A, Posteroanterior chest radiograph obtained at presentation to emergency department shows bibasilar heterogeneous pulmonary opacities.
B, Anteroposterior chest radiograph obtained 8 hr afterA shows progression to bilateral, symmetric pulmonary opacification. Patient subsequently developed mild acute
respiratory distress syndrome but survived after prolonged hospital course.

Received April 3, 1998; accepted after revision May 13, 1998.

‘All authors: Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710. Address correspondence to H. P. McAdams.

AJR 1999;172:121-128 0361-803X/99/1721-121 © American Roentgen Ray Society

AJR:172, January 1999 121

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Marom et al.

Fig. 2.-Aspiration of partially digested food in 31-year-old man with esophageal stricture 5 years after radiation therapy for mediastinal Hodgkin’s disease. Patient devel-
oped cough and dyspnea immediately after choking episode.
A, Posteroanterior chest radiograph shows paramediastinal fibrosis and hilar elevation compatible with previous radiation therapy. New heterogeneous opacity can be
seen in left lower lobe.
B, Posteroanterior chest radiograph obtained 2 days after A shows complete clearing of left lower lobe opacities.

rated into the posterior segments of the upper radiograph after the event, and resolution is pneumonitis known as lentil aspiration pneu-
lobes or into the superior and posterior basal commonly observed within 24-48 hr as muco- monia [4, 5]. This condition is typically seen
segments of the lower lobes. ciliary action and coughing clear the airways in debilitated nursing home patients who
As a result, heterogeneous opacities on (Fig. 2). Persistent opacities for more than 4-5 may be asymptomatic or who may present
chest radiographs usually represent small areas days suggest superimposed infection [3]. with progressive respiratory difficulties. Len-
of atelectasis caused by distal airway obstruc- Aspiration of partially digested vegetable til aspiration pneumonia usually manifests
tion by aspirated material [1]. Radiographic particles such as legumes (peas, lentils, or on chest radiographs with small nodular or
findings are frequently seen on the first chest beans) can cause a form of granulomatous reticulonodular opacities (Fig. 3). Large nod-
ules that mimic metastatic disease are occa-
sionally seen. Because the vegetables are
commonly pureed and can be easily dissemi-
nated throughout the lung after aspiration,
the opacities are usually diffuse in distribu-
tion and not confined to dependent portions
of lung. On high-resolution CT, lentil aspira-
tion pneumonia manifests with branching lin-
ear and centrilobular nodular opacities
(creating a “tree-in-bud” appearance) (Fig. 4).

Aspiration of Infectious Material

Aspiration of anaerobic and of facultative
aerobic bacteria from the oropharynx can
cause pneumonia, lung abscess, or empy-
ema. Patients with poor oral hygiene and
Fig. 3.-Lentil aspiration pneumonia those with advanced periodontal disease are
in 84-year-old asymptomatic, de-
at particular risk for development of infec-
mented woman. Posteroanterior
chest radiograph shows scattered, tion after aspiration. In nonhospitalized pa-
poorly defined pulmonary nodules up tients, the normal flora of the oropharynx are
to 10 mm in diameterthroughout both
low-virulence commensal organisms, such as
lungs. Transbronchial biopsy con-
firmed lentil aspiration pneumonia. Actino,nvces israelii, and a variety of anaero-
(Reprinted with permission from [51) bic bacteria, such as Bacteroides and Pep-

122 AJR:172, January 1999

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Pulmonary Aspiration

tostreptococcus species. Aspiration of A. ous fistula is a rare complication ofA. israelii on chest radiographs until 24-72 hr after the as-
israelii clinically manifests with productive aspiration [2, 3]. piration event. II untreated, the opacity may be-
cough and fever. Chest radiographs usually The clinical and radiologic manifestations of come more homogeneous and necrotic over the
show a homogeneous opacity simulating anaerobic bacterial aspiration are highly van- course ofa week (Fig. 6). In some patients, if the
typical lobar pneumonia. In untreated pa- able. In some patients, aspiration results in inoculum of organisms is small and host de-
tients with late-stage cases, pleural thicken- anaerobic pneumonia that initially manifests on fenses are good, aspiration of anaerobic bacteria
ing or fluid, periostitis of adjacent ribs, and chest radiographs as a heterogeneous opacity in can result in focal lung abscess. These patients
soft-tissue swelling of the chest wall can be dependent portions of lung. In patients,
many typically present between 1 and 2 months after
observed (Fig. 5). Bronchopleural-cutane- however, these opacities may not become visible the aspiration event with low-grade fever, night

. l__

Fig. 4.-Lentil aspiration pneumonia in 54-year-old man with esophageal stricture. Fig. 5.-Actinomycosis in 36-year-old woman who presented with 2-month history
High-resolution CT scan (1.5-mm collimation, lung window) through lower lungs of cough, chest pain, low-grade fever, and night sweats. On admission, she was
shows diffuse, 1-mm centrilobular nodules and branching opacities (tree-in-bud found to have poor oral hygiene and advanced periodontal disease. Chest CT scan
pattern). Transbronchial biopsy confirmed lentil aspiration pneumonia. (Reprinted (mediastinal window) shows invasion of anterior chest wall with subpectoral fluid
with permission from [5]) collection (arrow). Needle aspiration confirmed actinomycosis.

A B

Fig. 6.-Anaerobic pneumonia in 55-year-old man with distal esophageal carcinoma who presented with low-grade fever, cough productive of foul-smelling sputum, and
elevated WBC.
A and B, Posteroanterior and lateral chest radiographs show homogeneous consolidation in left lower lobe with multiple air-fluid levels consistent with necrosis and cay-
itation. Incidental note is made of calcified lymph nodes in right paratracheal region.

AJR:172, January 1999 123

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pass distally after aspiration and cause bron-

chial obstruction. These foreign bodies tend to
lodge in the right or left main bronchus with
equal frequency [3]. Aspirated teeth or bridge-
work are a significant cause of bronchial ob-
struction after major trauma or traumatic
intubation (Fig. 8). On chest radiographs, for-
eign body aspiration manifests with air-trap-
ping, atelectasis, or pneumonia distal to the
obstruction (Fig. 9). Migratory opacities can be
seen that are caused by the movement of the in-
haled foreign object from one lobe to another
[6]. Chest radiographs show a radiopaque for-
eign body in 5-1 5% of the cases [3]. A rare but
radiographically dramatic type of aspiration in-
volves sand or gravel that is aspirated during
surfing accidents, drownings, or motor vehicle
collisions. In this setting, the sand or gravel (if
aspirated in large enough quantities) can pro-
duce a pathognomonic sand or gravel bron-
chogram on radiography (Fig. 10).

Aspiration of Water
Aspiration of water during a near-drowning
event often results in serious pulmonary dys-
Fig. 7.-Anaerobic lung abscess in function. There is no significant difference in ei-
50-year-old man who presented with
night sweats, low-grade fever, and 9-
ther the radiologic features or the clinical course
kg weight loss over previous month. of the aspiration of fresh water or the aspiration
Patient had undergone tooth extrac- of salt water resulting from a near-drowning
tion 2 months before admission.
event In both environments, chemical and or-
A, Coned-down view of posteroante-
nor chest radiograph shows 3.5-cm, ganic contaminants in the aspirated water are
well-marginated mass projecting thought to cause acute lung injury and perme-
over right upper lung. ability edema. Affected patients are typically
B, Chest CT scan (mediastinal win-
quite dyspneic at presentation and may suc-
dow, coned to right lung) shows that
mass is smoothly marginated and cumb to progressive respiratory failure and
has low-attenuation center and en- acute respiratory distress syndrome. Initial chest
hancing wall.
radiographs usually show scattered pulmonary
C,Coned-down view of posteroante-
nor chest radiograph obtained 2 opacities that progress to diffuse lung opacifica-
weeks after A shows cavitation in tion over the next several days [2] (Fig. I I).
right upper lobe. Atthis point, patient
began to expectorate foul-smelling
sputum, and diagnosis of anaerobic
lung abscess was confirmed. Aspiration of Mineral Oil
Aspiration of mineral oil is a frequent cause
of exogenous lipoid pneumonia. Aspiration of
sweats, and weight loss. At this point, the chest nonhospitalized patients, the clinical course for large volumes of oil can result in diffuse ho-
radiograph shows a large well-marginated lung hospitalized patients with infectious aspirate is mogeneous pulmonary opacities. These pa-
mass with or without cavitation (Fig. 7). Aspira- often more dramatic with development of mul- tients are usually quite ill at presentation and
tion of anaerobic bacteria may also manifest tifocal bronchopneumonia that occasionally may succumb to progressive respiratory fail-
with empyema and bronchopleural fistula. Af- progresses to diffuse pulmonary opacification ure. Fortunately, this form of mineral oil aspi-
fected patients typically present between I and 2 and acute respiratory distress syndrome. ration is quite rare. More commonly, patients
months after the aspiration event with fever and aspirate small volumes of oil on a chronic ba-
pleuritic chest pain. On chest radiographs, the sis. In this setting, small volumes of mineral
pleural fluid collections are frequently large and Foreign Body Aspiration oil may be aspirated either by chronic use of
loculated and may contain an air-fluid level that Foreign body aspiration is more common in oil-based nose drops or during ingestion of
is mdicative ofbronchopleural fistula (Fig. 8). children than adults. The clinical and radiologic mineral oil used to treat chronic constipation.
The oropharynx of hospitalized patients is manifestations of foreign body aspiration de- Such patients are typically either asymptom-
frequently colonized with more virulent organ- pend on the size of the aspirated material. Aspi- atic or present with nonspecific complaints of
isms, such as Staphylococcus aureus and gram- ration of large foreign bodies or food particles cough or dyspnea. Several radiographic pat-
negative bacteria (e.g., Pseudomonas aerugi- can obstruct the trachea and result in immediate terns have been described, including multifo-
nosa). Although the immediate radiographic asphyxiation and death. Small foreign bodies or cal scattered consolidation, chronic segmental
findings after aspiration are similar to those of food particles, such as nuts, apples, or hot dogs, or lobar consolidation, and focal masslike

124 AJR:172, January 1999

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Fig. 8.-Anaerobic empyema in 53-year-old woman who presented with 1-month history of chest pain, low-grade fever, and night sweats. Patient reported that bridgework
had been missing for 3 months before admission.
A and B. Posteroanterior and lateral chest radiographs show large, loculated hydropneumothorax within right hemithorax consistent with bronchopleural fistula. Radiopaque for-
eign body (arrows) within bronchus intermedius proved to be patient’s missing bridge. Aspiration of pleural fluid revealed frank pus is compatible with anaerobic empyema.

Fig. 9.-Foreign body aspiration in 19-year-old woman who presented

with signs and symptoms of chronic pneumonia.
A, Coned-down view of posteroanterior chest radiograph shows con-
solidation within left lower lobe.
B, Chest CT scan (lung window) confirms consolidation of left lower
lobe and mild volume loss.
C,Chest CT scan (lung window) shows left hilar mass with high-attenuation
linear opacity in distal left main bronchus (arrow). At surgery, aspirated
thread with exuberant granulomatous response was found.
 Marom et al.
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Fig. 1O.-f3ravel bronchogram in 20-year-old man admit- Fig. 11.-Aspiration ofwater in 23-year-old man who experienced near-drowning event from driving his car into a lake.
ted to emergency room after being thrown from motorcy- A. Anteroposterior chest radiograph shows bilateral, with right being greater than left, homogeneous and heter-
cle. Coned-down view ofirontal chest radiograph shows ogeneous parenchymal opacities that are compatible with near-drowning event. Patient clinically developed
multiple pebbles within left main, left upper lobe, and left acute respiratory distress syndrome.
lower lobe bronchi (arrows). B, Posteroanterior chest radiograph on discharge 1 month after A shows scattered reticular opacities compati-
ble with residual fibrosis.

Fig. 12.-Lipoid pneumonia in 45-year-old woman with chronic constipation and cough.
A, Posteroanterior chest radiograph shows volume loss in left hemithorax and poorly defined masslike opacity in left lower lobe. Heterogeneous opacities are also seen
in right lower lobe.
B, Chest CT scan (mediastinal window) shows low-attenuation consolidation within left lower lobe. Cursor readings were between -30 and -50 H, which is compatible with
aspirated mineral oil.

opacities (paraffinoma) that radiologically Recurrent Aspiration monia, pulmonary fibrosis, and occasionally
mimic lung cancer [2. 7] (Figs. 12 and 13). CT Patients with hiatal hernia, gastroesoph- total lung destruction (Fig. 14).
can be useful for diagnosis by showing fat-at- ageal reflux, esophageal stricture or malig-
tenuation regions within the pulmonary opaci- nancy, esophagorespiratory fistula, laryngeal
ties. High-resolution CT scans may show a dysfunction, and stroke may aspirate small Summary
crazy-paving appearance with scattered quantities of acid, food, or lipid on a recurrent The clinical and radiologic manifestations
ground-glass opacities and superimposed basis. In many cases, affected patients are ci- of aspiration are truly protean. The diagnosis is
thickening of interlobular septa [8]. Chronic ther asymptomatic or have nonspecific symp- straightforward in patients with known risk
mineral oil aspiration can result in pulmonary toms such as cough, wheezing, and dyspnea. factors and new radiographic findings in de-
fibrosis with traction bronchiectasis and hon- If unrecognized and untreated, recurrent aspi- pendent portions of lung. However, diagnosis
eycombing (Fig. 13). ration can result in chronic or recurrent pneu- is difficult in patients without known risk fac-

126 AJR:172, January 1999

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Pulmonary Aspiration

Fig. 13.-Lipoid pneumonia in 75-year-old man with chronic constipation and progressive dyspnea.
A, Posteroanterior chest radiograph shows left lower lobe consolidation and heterogeneous opacities within right lung. Air is noted within proximal esophagus (arrow).
B, High-resolution chest CT scan (1-mm collimation, lung window) shows fibrosis with honeycomb cystformation involving left lower lobe and a focal region in right upper
lobe. Note moderate subcarinal adenopathy (arrowhead).
C,Chest CT scan (10-mm collimation, mediastinal windows) show diffuse low-attenuation material within left lower lobe consolidation. Cursor readings ranged from -20
to -50 H, which is compatible with aspirated mineral oil.
D, Posteroanterior chest radiograph after barium esophagram shows barium aspiration into fibrotic and consolidated regions of lung. Surgical clips are seen in aor-
topulmonary window (arrows) from performing Chamberlain procedure. Lymph node biopsy revealed only mineral oil-laden macrophages; there was no evidence of
malignancy.

AJR:172, January 1999 127

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Marom et al.

Fig. 14.-Bronchoesophageal fistula and end-stage left lung fibrosis in 37-year-old man with history of recurrent pneumonia in left lung.
A, Posteroanterior chest radiograph shows end-stage pulmonary fibrosis involving left lung with multiple air-containing cystic spaces in left upper lobe. Note air within
proximal esophagus (arrow).
B, Coned-down view of posteroanterior chest radiograph after barium esophagram shows contrast material in proximal left main bronchus (arrows), suggesting broncho-
esophageal fistula. At bronchoscopy, congenital bronchoesophageal fistula was found.

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2382-2413 monary infiltrates secondary to aspirated foreign
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3. Armstrong P, Wilson AG, Dee P, Hansell DM. body (letter). JAMA 1978:240:2469
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128 AJR:172, January 1999

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