The clinical picture can vary very widely from subclinical aspiration to a fulminant picture with rapid death. In clinically apparent cases of aspiration, 12 per cent die within hours, 62 per cent have a rapid improvement over 4 to 5 days, and 26 per cent show an initial improvement but then deteriorate both clinically and radiographically; many, but not all, of these patients have evidence of bacterial superinfection. In patients under anesthesia, where the aspiration of gastric contents was diagnosed by the presence of bilious secretions or particulate matter in the tracheobronchial tree, 64 per cent of survivors did not develop any significant respiratory sequelae. The mortality in the 10 per cent requiring mechanical ventilation for more than 24 h was 50 per cent. Diagnosis is clear with a witnessed aspiration, but otherwise is made by having a high index of suspicion in the correct clinical setting with prompt onset of tachypnea and in many cases cough and wheeze. There may be fever and diffuse rales, and patients can be cyanotic; severe cases will be shocked or even apneic. Hypoxemia is usual, and there are often associated radiological changes on chest radiography. However, there are no characteristic radiological features, although bilateral lower-zone changes are probably the most common finding. Bronchoscopy has a useful place in both diagnosis and therapy.
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