considerations as are settings in which the aspiration occurs Aspiration pneumonias developing outside the hospital generally involve aerobes and are adequately treated with ampicillin with or without sulbactam, or clindamycin Nosocomial infections following aspiration require broader aerobic and anaerobic coverage Ampicillin/sulbactam is used most commonly, although regimens such as clindamycin and gentamicin have also been described In neurologically impaired children, with either aspiration or tracheostomy-associated pneumonia, antibiotics effective against penicillin-resistant anaerobic bacteria and P aeruginosa have been shown to produce superior clinical and microbiologic responses The use of corticosteroids in the treatment of aspiration pneumonia is controversial Because experimental evidence indicates no more than minimal benefit and because the concomitant immune suppression may contribute the development of secondary bacterial pneumonia, their administration is not usually indicated in the ED Clinical Indications for Discharge or Admission Children with significant aspiration pneumonia, diagnosed either by clinical suspicion or radiograph, require admission to the hospital, particularly if there is associated hypoxia or respiratory distress BRONCHOPULMONARY DYSPLASIA CLINICAL PEARLS AND PITFALLS Diagnosis is usually established prior to presentation to the ED Management involves supportive measures, including supplemental oxygen, assurance of adequate hydration, and often bronchodilators Current Evidence BPD is a chronic respiratory disease, usually occurring in premature infants BPD is a clinical diagnosis, requiring supplemental oxygen at a prescribed postconceptual or chronologic age, with associated radiographic findings The definition continues to evolve, and therefore specifics of the diagnostic parameters have changed over time The etiology of BPD is thought to be multifactorial While newer data suggest a genetic predisposition, previously defined risk factors include prematurity, relatively long duration of supplemental oxygen therapy after birth, need for positive-pressure ventilation (and various ventilation strategies), and inadequate nutrition The disease process is thought to begin after inflammation and injury to the lung, with resultant arrest of alveolar septation and impaired microvascular development This occurs most commonly in infants with hyaline membrane disease or other acute perinatal lung disease Infants with apnea, congenital heart disease, or other illnesses requiring prolonged ventilation in the first weeks of life are also at risk Utilization of improved ventilation strategies, as well as antenatal glucocorticoids, surfactant, and improvement in nutrition, has improved outcomes in children with BPD In the emergency setting, patients with BPD may present with acute exacerbations of their chronic lung disease Furthermore, BPD is a risk factor for increased severity of other respiratory illnesses Goals of Treatment Treatment of BPD exacerbations involves supportive care with focused attention on the need for supplemental oxygenation and ventilation support, as well as the hydration status Bronchodilators, inhaled corticosteroids (ICSs), and diuretics may also be helpful Clinical Considerations Clinical Recognition BPD should be suspected among premature infants, as well as in children previously requiring either assisted ventilation and/or prolonged supplemental oxygen therapy Emergency providers most often will evaluate children with BPD when their underlying disease is worsened by intercurrent acute respiratory infections More than 50% of infants with BPD require admission for respiratory illness within a year of their diagnosis Of particular importance is respiratory syncytial virus (RSV) infection, which typically causes bronchiolitis with fever, tachypnea, crackles, and wheezing Patients with BPD who develop RSV bronchiolitis are prone to more severe courses, including higher rates of ICU admission, need for mechanical ventilation, and mortality Triage Children with BPD exacerbations may present with significant distress and may require prompt evaluation and treatment Initial Assessment/H&P Signs and symptoms of BPD exacerbations vary based on severity of the underlying disease; therefore, recognizing interim worsening of disease requires an understanding of baseline examination findings and pulmonary function Children with BPD are often tachypneic at baseline, with some degree of retractions that worsen with even mild respiratory or febrile illnesses Findings on auscultation including crackles, wheezes, or decreased breath sounds may be present at baseline and worsened with exacerbations or acute illness Infants with BPD may have a history of failure to thrive, often resulting from concomitant nutritional issues, or from increased energy expenditure secondary to chronic increased work of breathing CXRs ( Fig 99.2 ) often demonstrate varying amounts of hyperinflation; several patterns occur, including cystic areas with signs of fibrosis, which are often confused with congenital lobar emphysema or severe CF Comparison with prior CXRs is important to distinguish old changes from new infiltrates Management Management of children with BPD and intercurrent respiratory illnesses is primarily limited to supportive care If the exacerbation is mild, outpatient therapy may be indicated with frequent follow-up every to days However, for infants with moderate to severe BPD at baseline, even mild deterioration may herald early respiratory failure Ensuring hydration by oral or IV routes, and, when necessary, providing supplemental oxygen or assisted ventilation for hypoxemia or hypercarbia with respiratory acidosis are the mainstays of therapy FIGURE 99.2 Bronchopulmonary dysplasia This 2-month-old child was treated with mechanical ventilation during the first days of life for hyaline membrane disease The chest film shows generalized overaeration and coarse nodularity with multiple cyst-like areas throughout both lung fields Pulse oximetry is important to assess for hypoxemia ETCO2 measurement through noninvasive means or PCO2 measurement with arterial, venous, or capillary blood gas analysis is indicated when signs and symptoms predict hypercapnia or when cyanosis, respiratory distress, or deterioration from baseline cannot be easily reversed A CXR may provide additional information; however, given baseline abnormalities, these often need to be compared with prior films Bronchodilators, ICSs, and diuretics may also be helpful Most children with BPD have had trials of β-agonist therapy Although the use of MDIs for βagonists is effective in older infants with asthma, the evidence for their use in young infants with BPD is less well defined Although most acute episodes are from viral infection, antibiotic therapy should be considered when the risk of bacterial infection appears higher Prevention of BPD exacerbations is challenging Although routine viral illnesses may not be avoidable, RSV and influenza are the leading preventable causes of rehospitalization in patients with BPD Monoclonal antibody against RSV (palivizumab, Synagis) is used to help prevent or lessen disease secondary to RSV Such immunoprophylaxis is recommended for children less than year of age who: (i) were born prior to 29 weeks’ gestation, (ii) were born