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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