6/7 he has an aspiration event that caused respiratory arrest. During intubation “abundant emetic content in the vocal cord...
6/7 he has an aspiration event that caused respiratory arrest. During intubation “abundant emetic content in the vocal cord with clear evidence of aspiration”. After resuscitation pt underwent Bronchoscopy that also removed emetic material from lungs. Antibiotics were immediately started. Post procedure xray - “Worsening alveolar opacities may be related to worsening pulmonary edema and/or infiltrate”.
Next xray performed 6/9 “Suspect pulmonary edema and pleural effusions although superimposed infectious infiltrate not excluded.”
Antibiotics were d/c 6/9 due to BAL was negative.
We did capture the aspiration/aspiration pna – however he did not have an xray that showed pneumonitis. Can you help clarify please?
In order to capture the Aspriation/Aspiration Pneumonia hospital event, the patient must have inhaled gastric contents or other materials and had a new radiological finding of pneumonitis which requires treatment within 48 hours. Pneumonitis describes inflammation of the lung tissues without the presence of an infection; however pneumonia is sometimes considered a pneumonitis by some providers since the infection causes inflammation.
Based on the documentation provided, I would capture the aspiration/aspiration pneumonia event. I would personally consider the pulmonary edema and pleural effusions a form of pneumonitis or inflammation. Therefore the patient met all three components of the definition (inhalation, pneumonitis and treatment within 48 hours).