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Q1: Start with the syndrome, not the antibiotic
Examiner: “A patient aspirates. How do you distinguish pneumonitis from pneumonia?”[1][3]
Candidate: Aspiration pneumonitis is primarily chemical lung injury, usually after a witnessed macroaspiration with abrupt respiratory illness. Aspiration pneumonia is infection in a host with impaired swallowing or airway protection; the event is often unwitnessed. Fever, leukocytosis, infiltrates, foul sputum, and dependent distribution can support the assessment but none creates a precise boundary. The syndromes overlap, and there is no reliable 48-hour test.[1][3]
Branch — “Do you give antibiotics immediately?”[1][2]
- In a convincing, uncomplicated chemical pneumonitis: stabilise and observe without routine prophylactic antibiotics.
- In clinically suspected bacterial pneumonia or sepsis: start empiric antibiotics promptly.
- If uncertain: reassess trajectory, obtain indicated cultures and imaging, and avoid both reflex antibiotics forever and premature withholding in a sick patient.[1][2]
Q2: Instability and intubation
Examiner: “The patient is drowsy, cannot handle secretions, is tiring, and remains hypoxaemic. What do you do?”[1]
Candidate: I call for senior airway and critical-care help, use an ABC approach, position the patient, suction visible oropharyngeal material, give oxygen, establish monitoring and IV access, and prepare for intubation. Failure to protect the airway, worsening ventilation, severe work of breathing, or refractory hypoxaemia are physiology-based reasons to secure the airway; I would not wait for an antibiotic or a repeat radiograph.[1]
Branch — “What if shock is present?”[2][4]
Treat this as a resuscitation emergency: obtain cultures if they do not delay care, start appropriate antibiotics when infection is suspected, give haemodynamic support using the local sepsis pathway, and seek critical-care review.[2][4]
Q3: Particulate aspiration and bronchoscopy
Examiner: “The aspiration contained food particles, and one lobe has collapsed. Does bronchoscopy help?”[1]
Candidate: Yes. Urgent bronchoscopy is indicated when solid aspirate is causing central or lobar obstruction, persistent atelectasis, or impaired ventilation. It permits removal and airway inspection. Bronchoscopy does not wash away diffuse acid already distributed through the distal lung, so it is not routine treatment for uncomplicated chemical pneumonitis.[1]
Branch — “Would you perform a blind finger sweep?”[1]
No. I remove only visible, accessible material with appropriate airway technique and suction; blind manipulation may push material distally or injure the airway.[1]
Q4: Community treatment and the anaerobe trap
Examiner: “A dysphagic patient has community-onset aspiration pneumonia. What is your antibiotic plan?”[2][3]
Candidate: I use the current local CAP regimen, choosing route and agent from severity, allergy, organ function, recent exposure, ability to absorb, and local resistance. I do not automatically add clindamycin or metronidazole. Modern microbiology does not support routine anaerobic treatment for uncomplicated aspiration pneumonia.[2][3]
Branch — “When is extra anaerobic activity appropriate?”[2][3]
When there is lung abscess, empyema, or necrotising infection. Those complications also demand CT, microbiology, and source-control review; antibiotics alone may not be sufficient.[2][3]
Branch — “How long do you treat?”[2]
There is no universal 7–14-day “aspiration” course. Uncomplicated CAP is treated to clinical stability with the guideline minimum course; complications, unusual pathogens, inadequate source control, or immunocompromise may need longer specialist-directed therapy.[2]
Q5: Nursing home versus true HAP/VAP
Examiner: “The patient came from a nursing home. Should you prescribe a carbapenem plus MRSA cover?”[2]
Candidate: Not for residence alone. The HCAP category is retired. A nursing-home resident with community-onset pneumonia is managed by CAP severity and locally validated MRSA or Pseudomonas risk—particularly prior isolation and relevant recent hospitalisation with IV antibiotics—not by postcode.[2]
Branch — “Now the patient develops pneumonia while ventilated in ICU. What changes?”[4]
That is a true VAP setting. I obtain an appropriate respiratory culture, use the ICU antibiogram and patient-specific factors such as prior IV antibiotics and prior colonisation to decide antipseudomonal or MRSA coverage, then de-escalate when microbiology and response allow. The aspiration label does not replace HAP/VAP guidance.[4]
Q6: Abscess, empyema, and source control
Examiner: “The patient remains septic; CT shows cavitation and a loculated pleural collection. Talk me through the next steps.”[1][3]
Candidate: I repeat physiological assessment, obtain blood and respiratory microbiology, sample the pleural collection under imaging, and involve respiratory medicine, interventional radiology, and thoracic surgery early. Cavitating infection requires reliable anaerobic-active therapy and assessment for obstruction or malignancy. Pleural infection requires drainage; persistent loculation or failure may need further intrapleural or surgical source control according to the pleural team.[1][3]
Branch — “At what abscess size must you drain?”[1]
There is no safe single size rule for every patient. Drainage or surgery depends on clinical failure, obstruction, bleeding, rupture risk, anatomy, procedural access, and multidisciplinary judgement. Duration is guided by clinical and radiological response, not an automatic number of weeks.[1]
Q7: Treatment failure and procalcitonin
Examiner: “The patient is worse despite treatment. Give me a structured failure review.”[1][2][4]
- Is there new airway, respiratory, or haemodynamic instability?
- Was the syndrome or diagnosis wrong—chemical pneumonitis, obstruction, oedema, embolism, haemorrhage, organising pneumonia, or ARDS?
- Is there abscess, necrosis, empyema, collapse, or tumour requiring CT or source control?
- Do I need new cultures, pleural sampling, or BAL?
- Was acquisition, resistance risk, dose adjustment, absorption, adherence, or de-escalation handled correctly?
- Is the patient continuing to aspirate because the swallow or feeding plan has failed?[1][2][4]
Branch — “Procalcitonin is low. Can you call this pneumonitis and stop?”[2]
No. Procalcitonin does not reliably discriminate pneumonitis from aspiration pneumonia, and the ATS/IDSA guideline advises against withholding initial antibiotics in clinically suspected, radiographically confirmed CAP on the basis of a low value. It may be one piece of serial stewardship, never the diagnosis by itself.[2]
Q8: ARDS branch
Examiner: “Bilateral opacities and escalating oxygen needs develop after macroaspiration. What complication concerns you?”[1]
Candidate: Aspiration-related ARDS. I exclude hydrostatic oedema and other causes while escalating critical-care support. Management is supportive and includes lung-protective ventilation and treatment of the precipitant. Steroids and antibiotics are not automatic merely because chemical aspiration occurred; antibiotics are for suspected infection.[1]
Branch — “What must you not miss before calling it diffuse ARDS?”[1]
A central particulate obstruction, lobar collapse, pneumothorax, pleural collection, fluid overload, and an alternative infective or cardiopulmonary diagnosis.[1]
Q9: Dysphagia, stroke, and feeding
Examiner: “The patient coughs with water but has an intact gag. Can they eat?”[1]
Candidate: Not unsupervised. The gag reflex does not establish swallow safety. I withhold unsafe oral intake and oral medication, arrange a structured swallow assessment, and provide an interim hydration, medication, and nutrition plan. VFSS or FEES is used when the bedside assessment is abnormal or uncertain.[1]
Branch — “Should every dysphagic stroke patient receive early PEG?”[5]
No. The FOOD trial applies to acute stroke and did not support routine early PEG over NG feeding. NG is generally used initially when enteral feeding is required, with reassessment and a multidisciplinary longer-term decision. The trial must not be extrapolated to dementia.[5]
Branch — “The patient instead has severe dementia. What do you tell the family?”[6]
Use dementia-specific evidence and goals of care. The Cochrane review found no eligible randomised trials and very low-certainty observational evidence; it found no evidence of improved survival or quality of life and a signal for pressure-ulcer harm. A tube does not eliminate aspiration of saliva or reflux. Discuss careful assisted oral feeding where feasible, burdens, comfort, and the person’s wishes rather than using the FOOD stroke trial.[6]
Q10: Immunocompromise and safe regional boundaries
Examiner: “How does your answer change after transplantation, neutropenia, or major immunosuppression?”[1][2]
Candidate: I lower the threshold for urgent specialist and critical-care input, broaden the differential to opportunistic and non-infectious disease, obtain targeted microbiology early, and use CT and BAL when appropriate. Empiric therapy depends on immune defect, prophylaxis, prior isolates, recent antimicrobials, organ function, severity, and the local pathway—not a universal aspiration combination. A low procalcitonin does not safely exclude infection.[1][2]
Branch — “Give one globally safe prescribing statement.”[2][4]
Use the current national or institutional CAP or HAP/VAP guideline and local antibiogram; adjust for allergy and organ function. Do not prescribe fixed doses from memory across regions, do not equate nursing-home residence with HAP, and do not add routine anaerobic therapy without abscess, empyema, or necrosis.[2][4]
Branch — “What must be true before discharge, and what safety net do you give?”[1][2]
Respiratory and haemodynamic status, oxygen need, and mental state must be stable for the destination; hydration, medication, nutrition, and swallowing must have a safe deliverable plan; caregivers must understand feeding position, oral care, and medicines; and pending cultures, imaging, and swallow review must have named follow-up. I give written return triggers for worsening breathlessness or oxygenation, recurrent choking or aspiration, fever, confusion, inability to maintain intake, or failure to improve. Unstable physiology, uncertain airway protection, unsafe nutrition, unavailable support, obstruction, empyema, abscess, or unresolved treatment failure requires admission or escalation.[1][2]
References6ShowHide
- [1]Košutova P, Mikolka P. Aspiration syndromes and associated lung injury: incidence, pathophysiology and management. Physiol Res, 2021.PMID 35199544
- [2]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med, 2019.PMID 31573350
- [3]DiBardino DM, Wunderink RG. Aspiration pneumonia: a review of modern trends. J Crit Care, 2015.PMID 25129577
- [4]Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis, 2016.PMID 27418577
- [5]Dennis MS, Lewis SC, Warlow C. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet, 2005.PMID 15733717
- [6]Davies N, Barrado-Martín Y, Vickerstaff V, et al. Enteral tube feeding for people with severe dementia. Cochrane Database Syst Rev, 2021.PMID 34387363