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Etiology and clinical outcome in dogs with aspiration pneumonia: 88 Cases

(2004-2006)

Article  in  Journal of the American Veterinary Medical Association · January 2009

DOI: 10.2460/javma.233.11.1748 · Source: PubMed

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 Etiology and clinical outcome
SMALL ANIMALS

in dogs with aspiration pneumonia:

88 cases (2004–2006)
David A. Kogan, bs; Lynelle R. Johnson, dvm, phd, dacvim; Beverly K. Sturges, dvm, dacvim;
Karl E. Jandrey, dvm, dacvecc; Rachel E. Pollard, dvm, phd, dacvr

Objective—To evaluate the number and types of underlying disorders detected in dogs
with aspiration pneumonia and determine the survival rate among affected dogs.
Design—Retrospective case series.
Animals—88 dogs with aspiration pneumonia.
Procedures—Medical records were reviewed to identify disease processes that could re-
sult in aspiration pneumonia. To assess outcome (ie, survival to discharge from the hos-
pital or nonsurvival), dogs were grouped by the type and number of underlying disease
processes. Duration of hospitalization and radiographic severity of disease were evaluated
with regard to case outcome.
Results—As the cause of aspiration pneumonia, a single underlying disorder was identified
in 60 of the 88 dogs; 2 or more diseases were identified in the remaining dogs. Esopha-
geal disease (n = 35), vomiting (34), neurologic disorders (24), laryngeal disease (16), and
postanesthetic aspiration (12) were identified most commonly. Overall, 68 dogs survived
to discharge from the hospital (survival rate, 77%). Survival rates were comparable among
dogs regardless of the underlying cause of aspiration pneumonia. Radiographic severity of
disease and duration of hospitalization did not influence survival.
Conclusions and Clinical Relevance—Among these study dogs, aspiration pneumonia
was associated with a high survival rate. The presence of more than 1 underlying disease
associated with aspiration pneumonia did not adversely impact survival rate. Interestingly,
radiographic severity of disease and duration of hospitalization were not associated with
overall survival rate. (J Am Vet Med Assoc 2008;233:1748–1755)

A spiration pneumonia is a common clinical diag-

nosis in dogs, and underlying disorders associated
with this disorder include vomiting, laryngeal disease or
surgery, megaesophagus or esophageal dysfunction, and
decreased level of consciousness.1–8 Aspiration pneumo-
nia results from inhalation of oropharyngeal or gastro-
intestinal contents into the respiratory tract, which trig-
gers chemical, bacteriologic, and immunologic damage
to the airways9–11 and can progress to acute respiratory
distress syndrome.12 Early clinical recognition of aspira-
tion pneumonia allows appropriate treatment of both the
airway injury and the underlying disease process that
lead to aspiration, thereby preventing additional damage
to the lower portion of the respiratory tract through re-
peated aspiration.
Aspiration pneumonia is clinically identified
through the development of respiratory tract signs and
radiographically detectable infiltrates in a person or
From the Veterinary Medical Teaching Hospital (Kogan), and the
Departments of Veterinary Medicine and Epidemiology (Johnson)
and Surgical and Radiological Sciences (Sturges, Jandrey, Pollard),
School of Veterinary Medicine, University of California, Davis, CA
95616. Dr. Kogan’s present address is Veterinary Medical and Surgi-
cal Group, 2199 Sperry Ave, Ventura, CA 93003.
Supported in part by the S.T.A.R. (Students Training in Advanced Re-
search) program, School of Veterinary Medicine, University of Cali-
fornia, Davis, and the Bailey Wrigley Fund.
Address correspondence to Dr. Johnson.
animal at risk. To the authors’ knowledge, definitive
diagnosis of aspiration pneumonia via evaluation of
biochemical markers such as pepsin in bronchoalveolar
lavage fluid has not been described in the veterinary
medical literature; therefore, identification of underly-
ing disorders associated with aspiration is essential to
limit the development of aspiration pneumonia in hos-
pitalized patients and to provide preventive advice for
owners of dogs that have certain diseases.
Despite the common occurrence of this disease
syndrome, little information is available on the relative
incidence of underlying diseases and rate of survival in
affected dogs. The purpose of the study reported here
was to evaluate the number and types of underlying
disorders detected in dogs with aspiration pneumonia
and determine the survival rate among affected dogs.
In humans, the mortality rate associated with multi-
lobar lung disease is higher than that associated with in-
volvement of a single lung lobe13; thus, a secondary goal
of the study was to establish the relationship between ra-
diographic severity of disease and outcome. We hypoth-
esized that dogs with multiple underlying disorders
associated with aspiration pneumonia or radiographic
evidence of more extensive pulmonary infiltrates would
be hospitalized for a longer period and have a decreased
survival rate, compared with dogs with a single caus-
ative disorder or less extensive pulmonary infiltrates. It
was envisaged that results of the study would provide

1748 Scientific Reports JAVMA, Vol 233, No. 11, December 1, 2008
clinically useful prognostic information for dogs with
aspiration pneumonia.
Materials and Methods
Case selection—Medical records of dogs dated
January 1, 2004, to January 1, 2006, at the Veterinary
Medical Teaching Hospital of the University of Cali-
fornia, Davis, were searched to identify dogs with a
clinical diagnosis of aspiration pneumonia. This time
frame was chosen to generate a sufficient number of
cases for evaluation from the period prior to transition
from conventional film screen radiography to digital
radiography. This was specifically done so as to elimi-
nate any confounding variability caused by differing
imaging techniques. Dogs were included in the study if
aspiration pneumonia was listed in the medical record
under the record field for the final clinical diagnoses
and radiographic images illustrating pulmonary infil-
trates were available for review. Cases with other forms
of pneumonia were not evaluated.
Medical records review—Medical records were
examined by 2 of the authors (DAK, LRJ), and clini-
cal information was abstracted. At the discretion of the
primary care clinician, diagnostic tests to identify the
underlying causes of aspiration were performed as clin-
ically indicated on the basis of the history and physi-
cal examination findings. Historical features, clinico-
pathologic findings, and results of diagnostic tests were
reviewed by a board-certified internist (LRJ) to verify
the diagnosis by use of criteria (variably documented in
individual records) as follows: witnessed or suspected
regurgitation or vomiting episodes followed by acute
onset of respiratory difficulty, cough, or tachypnea;
physical examination findings consistent with lower
respiratory tract disease or radiographic detection of
pulmonary infiltrates in a dog at risk for aspiration;
and identification of systemic disorders or interven-
tions potentially associated with aspiration, including
anesthesia, esophageal dysfunction, laryngeal disease,
gastrointestinal tract disease, and decreased conscious-
ness in dogs with clinical or radiographic evidence of
pneumonia. Medical records and radiographic reports
were also scrutinized for comments that reflected clini-
cal suspicion of an aspiration event and clinical or clini-
copathologic evidence of hypoxemia. Records were also
reviewed to identify all potential syndromes that could
contribute to an aspiration event.
Assessments were performed to elucidate gastro-
intestinal and extragastrointestinal causes of vomiting;
these included serum biochemical analyses and abdom-
inal ultrasonography to assess intestinal function, ab-
dominal radiography (with and without administration
of contrast medium) to identify gastrointestinal struc-
tural abnormalities and motility disorders, and histo-
logic examination of gastrointestinal biopsy samples to
identify inflammatory or infectious disease. Additional
evaluations included urinalysis, renal and hepatic ultra-
sonography, and assessment of canine pancreatic-like
immunoreactivity. Disorders associated with regurgi-
tation or dysphagia were investigated via cervical and
thoracic radiography and videofluoroscopy (after ad-
ministration of liquid or barium-soaked kibble to as-
JAVMA, Vol 233, No. 11, December 1, 2008 Scientific Reports 1749
sess esophageal motility) where indicated. Underlying
SMALL ANIMALS
causes for megaesophagus were identified via serum
anti-acetylcholine receptor antibody detection, assess-
ment of blood lead concentration, ACTH stimulation
test (detection of hypoadrenocorticism), and endos-
copy. Dogs with focal (esophageal) myasthenia gra-
vis were considered to have only esophageal disease,
whereas those with esophageal disease and lower motor
neuron signs were considered to have both esophageal
and neurologic disease. Disorders of laryngeal structure
or function were diagnosed via direct observation of
the larynx while dogs were in a light plane of anesthe-
sia. Dogs that had had arytenoid lateralization surgery
performed > 2 months prior to evaluation for aspiration
pneumonia at the hospital were placed in the same group
as dogs with other laryngeal disease. Prolonged recum-
bency because of neurologic or neuromuscular disease
and seizures or obtundation associated with neurologic
disorders were recorded as potential causes of aspiration.
Dogs that developed aspiration pneumonia in an imme-
diate perioperative period were assigned decreased level
of consciousness as an underlying cause for aspiration.
All additional historical information and diagnostic test
results were examined to detect any other disease pro-
cess that could result in development of aspiration pneu-
monia. Dogs were assigned to categories with regard to
the type of disease identified and were also classified by
the number of different underlying etiologies.
Thoracic radiographs that were obtained soon after
the aspiration event were reviewed by a board-certified
radiologist (REP); however, the exact timing (in hours)
of radiography in relation to a potential aspiration event
could not be determined. Thoracic radiographs (2-, 3-,
and 4-view sets) obtained for each dog were evaluated
for the type and severity of pulmonary infiltrates. The
radiologist was unaware of the history, clinical course
of disease, or outcome for each case. A score was as-
signed on the basis of the severity (relative opacity) of
interstitial and alveolar infiltrates. The scoring system
applied for an interstitial pattern was as follows: 1 =
mild, 2 = moderate, and 3 = severe. The scoring sys-
tem applied for an alveolar infiltrate was as follows: 4
= mild, 5 = moderate, and 6 = severe. To generate an
overall radiographic assessment of the extent of lung
involvement, the score was multiplied by the number
of apparently affected lung regions to provide a sub-
jective radiographic severity score, with higher num-
bers reflecting more extensive pulmonary involvement
(Figure 1). This methodology has not been established
as a rigorous determination of disease severity for as-
piration pneumonia, but it was considered clinically
relevant for the purposes of the study. For the purposes
of the study, lung regions were defined on the basis of
the lobar branching pattern in dogs14; because the left
cranial lung lobe in dogs is comprised of cranial and
caudal segments (and each was considered indepen-
dently), the location of infiltrates was described as left
cranial-cranial segment, left cranial-caudal segment,
or left caudal, right cranial, right middle, accessory, or
right caudal lobe.
Dogs with aspiration pneumonia were examined by
multiple services throughout the hospital, including the
emergency, internal medicine, neurology, and surgical ser-
SMALL ANIMALS

Figure 1—Dorsoventral radiographic views of the thorax of 2 dogs with aspiration pneumonia. For each dog, a score was assigned on
the basis of the severity (relative opacity) of interstitial and alveolar infiltrates. An interstitial pattern was scored as 1 (mild), 2 (moderate),
and 3 (severe) and an alveolar infiltrate was scored as 4 (mild), 5 (moderate), and 6 (severe). The score was multiplied by the number of
apparently affected lung regions to provide a subjective radiographic severity score, with higher numbers reflecting more extensive pul-
monary involvement. Because the left cranial lung lobe in dogs is comprised of cranial and caudal segments (and each was considered
independently), the location of infiltrates is described as left cranial-cranial segment, left cranial-caudal segment, or left caudal, right
cranial, right middle, accessory, or right caudal lobe. A—In this dog, a severe alveolar infiltrate (score 6) is identified in the right cranial
lung lobe. The subjective radiographic severity score for this dog is 6. B—In this dog, a severe alveolar infiltrate (score 6) is identified in
the left cranial-cranial segment, left cranial-caudal segment, and left caudal lobe (3 affected regions). The subjective radiographic severity
score for this dog is 18.

vices. Some dogs had aspiration pneumonia at the time of
admission to the hospital, whereas others developed aspi-
ration pneumonia during hospitalization. For analysis of
specific variables, dogs were initially stratified as discharged
from the hospital, hospitalized (regular ward or intensive
care unit), or died or were euthanatized at the time of ex-
amination. For any dog that was admitted to the hospital,
the number of days that it remained in an intensive care
unit and duration of hospitalization were recorded.
Statistical analysis—Data are presented as mean ±
SD, and median values and ranges are reported where ap-
propriate. Via χ2 analysis,a survival rates were compared
between dogs with interstitial and alveolar infiltrates and
between dogs with involvement of 1 and > 1 lung region.
For some analyses, dogs were grouped into those that
were or were not admitted to the hospital. Radiographic
severity score was compared between these 2 groups,
and for hospitalized patients, the radiographic score was
compared between those that survived to discharge from
the hospital and nonsurvivors. Days spent in an inten-
sive care unit and duration of hospitalization were com-
pared between dogs that survived and those that died or
were euthanized on initial examination or during hospi-
talization. All analyses were performed by use of a Mann-
Whitney U test for nonparametric data.a
For comparison of outcome, dogs were also grouped
according to the number of underlying disease processes
identified. Among dogs that had 1, 2, or 3 underlying
disease processes associated with aspiration pneumo-
nia, duration of hospitalization, days spent in an inten-
sive care unit, radiographic severity of lung infiltrates,
and outcome were compared by use of a Kruskal-Wallis
comparison for categorical data.a Survival rates were also
compared among dogs with specific predisposing con-
ditions for aspiration pneumonia, including neurologic
disorders, laryngeal disease, esophageal dysfunction, and
postanesthetic aspiration by use of a χ2 analysis.a For all
analyses, significance was set at a value of P < 0.05.
Results
Search of the electronic medical database yielded
medical records of 105 dogs for which aspiration pneu-

1750 Scientific Reports JAVMA, Vol 233, No. 11, December 1, 2008
monia was listed as a final clinical diagnosis. Two cases bency, and 7 dogs had a seizure disorder (1 dog had
were excluded because review of the medical records concurrent myasthenia gravis). Four of 7 dogs with sei-

failed to identify supportive clinical evidence for as-
piration pneumonia, and 15 cases were excluded be-
cause of the lack of radiographs for review. Medical
records for the remaining 88 dogs were comprehen-
sively reviewed.
Clinical, clinicopathologic, and radiographic find-
ings in the dogs included in the present study have
been reported elsewhere.15 Among the 88 dogs, a single
underlying disease process associated with aspiration
pneumonia was identified in 60 (68%); 2 disease asso-
ciations were identified in 23 (26%) dogs, and 3 disease
associations were identified in 5 (6%) dogs. The most
common underlying disorders included esophageal dis-
ease or dysfunction (n = 35), vomiting (34), neurologic
disorders (24), laryngeal disease (16), and postanes-
thetic aspiration (12).
In the 35 dogs with esophageal disease, the cause
was determined as megaesophagus (n = 25) or esopha-
geal motility disorders (6) or hiatal hernia (1); causes
of regurgitation were unidentified in the remaining 3
dogs. Megaesophagus was considered idiopathic in 13
of the 25 dogs and was associated with diffuse myas-
thenia gravis (n = 9), focal myasthenia gravis (2), or
persistent right aortic arch (1) in the remaining dogs.
Esophageal dysmotility was idiopathic in 3 dogs and
caused by cricopharyngeal achalasia in 2 dogs and oro-
pharyngeal dysphagia in 1 dog.
In the 34 dogs that had vomiting, the condition
was related to primary inflammatory, functional, or
neoplastic gastrointestinal tract disease in 8, toxins or
foreign bodies in 8, renal disease in 5, pancreatic dis-
ease in 4, and liver disease in 2; causes were unidenti-
fied in 7 dogs.
In the 24 dogs with neurologic disorders, muscle
weakness associated with generalized myasthenia gravis
was identified in 9 dogs, all of which had megaesopha-
gus; 8 dogs had spinal cord disease resulting in recum-
SMALL ANIMALS
zures were receiving antiseizure medication long term.
In dogs with spinal cord disease, the diagnoses includ-
ed intervertebral disk disease in 5 dogs, meningomyeli-
tis encephalitis (determined via magnetic resonance or
computed tomographic imaging and CSF analysis) in 2
dogs, and degenerative myelopathy in 1 dog.
Laryngeal disease was reported for 16 dogs, among
which laryngeal paralysis was the most common diag-
nosis (n = 14). Arytenoid lateralization had been per-
formed 2 months to 3 years prior to development of
aspiration pneumonia in 6 dogs and within 24 hours
in 3 dogs. Uncorrected laryngeal paralysis was reported
for 3 dogs, and a laryngeal foreign body and previous
laryngectomy were each reported for 1 dog.
Overall, 68 of 88 (77%) dogs survived the episode
of aspiration pneumonia and were discharged from the
hospital. Survival rates did not differ among dogs with
aspiration pneumonia associated with esophageal, la-
ryngeal, gastrointestinal, or neurologic disease process-
es or postanesthetic aspiration (Table 1).
In 60 dogs in which a single disorder was identi-
fied, the most common finding was esophageal disease
(n = 23 [38%]), followed by vomiting (20 [33%]), neu-
rologic disease (7 [12%]), laryngeal disease (6 [10%]),
and postanesthetic aspiration (4 [7%]; Table 2). Twen-
ty-three of 88 (26%) dogs had 2 underlying disorders.
The combination of esophageal and neurologic dis-
ease was most common (7/23 [30%]); those dogs had
generalized weakness and megaesophagus secondary
to diffuse myasthenia gravis. Neurologic disease was
identified in an additional 7 dogs that had 2 underlying
disease processes associated with aspiration pneumonia
(4 dogs with concurrent vomiting and 3 dogs with as-
piration pneumonia that developed as a postanesthetic
complication). In the remaining 9 dogs, various combi-
nations of disease processes were identified. In 5 dogs
with 3 identified disease associations, laryngeal disease

Table 1—Diseases identified in dogs with aspiration pneumonia and survival rates
among affected dogs. More than 1 disease process were defined in some dogs.

No. of No. (%) of

Disease category Underlying disease process dogs affected survivors
Esophageal disease (n = 35) Megaesophagus 25 27 (77)
Motility disorder 6
Hiatal hernia 1
Unknown 3

Vomiting (n = 34) Primary gastrointestinal disease 8 25 (74)

Toxin or foreign body 8
Renal disease 5
Pancreatic disease 4
Liver disease 2
Unknown 7

Neurologic disease (n = 24) Generalized myasthenia gravis 9 15 (62)
Seizures 7*
Spinal cord disease 8

Laryngeal disease (n = 16) Laryngeal paralysis 14 12 (75)
Previous debarking surgery 1
Laryngeal foreign body 1

Postanesthetic aspiration (n = 12) 12 10 (83)

*One dog had concurrent myasthenia gravis.

JAVMA, Vol 233, No. 11, December 1, 2008 Scientific Reports 1751
 Table 2—Survival rates (%) and radiographic scores in dogs with 1, 2, and 3 underlying disease pro-
cesses associated with aspiration pneumonia.
SMALL ANIMALS

No. of Mean Range of

disease No. of No. of radiographic radiographic
processes Disease or disease combination dogs survivors score* scores
1 Esophageal disease 23 19 7 2–14
Vomiting 20 17 7 4–20
Neurologic disease 7 5 8 1–24
Laryngeal disease 6 5 5 3–8
Postanesthetic complication 4 10 10 1–20
Overall 60 50 ND ND

2 Esophageal and neurologic disease 7 6 5 2–10
Vomiting and neurologic disease 4 2 7 2–15
Vomiting and laryngeal disease 3 1 7 2–10
Neurologic disease after anesthesia 3 1 9 6–10
Laryngeal disease after anesthesia 2 2 7 4–10
Esophageal disease and vomiting 2 1 15 12–18
Esophageal and laryngeal disease 1 1 5 NA
Vomiting after anesthesia 1 1 5 NA
Overall 23 15 ND ND

3 Laryngeal disease and vomiting after anesthesia 2 2 7 3–16
Laryngeal, esophageal, and neurologic diseases 1 0 2 NA
Laryngeal and neurologic diseases and vomiting 1 1 12 NA
Neurologic and esophageal diseases and vomiting 1 0 4 NA
Overall 5 3 ND ND

*Actual value presented if 1 dog in subgroup.

NA = Not applicable. ND = Not done.

was most common. Laryngeal disease was detected in 2

dogs that vomited in the postanesthetic period and in
2 dogs with concurrent neurologic disease and either
esophageal disease or vomiting. An additional dog with
neurologic and esophageal disease developed aspira-
tion pneumonia after a vomiting episode. There was no
identifiable difference (P = 0.30) in survival rates among
dogs with 1, 2, or 3 causes of aspiration pneumonia.
Eleven of 88 (12%) dogs were discharged from the
hospital on the day of examination. Seven were treat-
ed with a β-lactam antimicrobial, 2 were treated with
a β-lactam antimicrobial combined with enrofloxacin,
and 1 was treated with enrofloxacin alone. The remain-
ing dog received no antimicrobial treatment because
the aspiration pneumonia was considered to be mild.
Two of the 11 dogs were euthanatized within 30 days
because of continual aspiration, 1 dog was lost to fol-
low-up, and the remaining 8 dogs were known to have
survived from 6 to 810 days. The remaining 77 of 88
(88%) dogs were hospitalized; 57 (74%) dogs survived
to discharge from the hospital, and the remaining 20
(26%) dogs died (n = 2) or were euthanatized (18) dur-
ing hospitalization. Reasons for euthanasia included a
poor prognosis associated with concurrent neoplasia (n
= 9), complex medical conditions (3), sepsis (2), the
need for ventilator therapy (2), refractory regurgitation
(1), or meningomyelitis (1). The role of aspiration in-
jury in failure to survive could not be fully determined.
However, necropsies were performed in 14 of 20 dogs
and revealed evidence of aspiration pneumonia in 11;
in the remaining 3 dogs, pulmonary congestion, metas-
tasis, or fibrosis was evident.
Duration of hospitalization did not differ (P = 0.76)
between the group of dogs that survived (mean ± SD,
5.0 ± 4.5 days; range, 1 to 23 days) and those that died
or were euthanatized (5.4 ± 4.5 days; range, 1 to 19
days). In dogs that were admitted to the hospital, there
Figure 2—Distribution of subjective radiographic severity scores
in 88 dogs with aspiration pneumonia.
was no significant (P = 0.10) difference in the mean
number of days spent in the intensive care unit for those
that survived (2.0 ± 0.3 days) or did not survive (3.2 ±
0.7 days). Comparison of data for dogs with 1, 2, or 3
underlying diseases processes associated for aspiration
pneumonia revealed no significant (P = 0.53) difference
in mean number of days spent in the intensive care unit
or duration of hospitalization.
Survival rates did not differ between dogs with in-
filtration of 1 and > 1 lung region (P = 0.58) or between
dogs with interstitial and alveolar infiltrates (P = 0.65).
Scores for the severity of infiltrates determined via as-
sessment of thoracic radiograph views ranged from 1 (a
mild interstitial infiltrate in 1 lung region) to 24 (severe
alveolar infiltrates affecting 4 lung regions). A bimodal
distribution of severity (centered on scores of 4 and 10)
was evident (Figure 2). There was no significant differ-
ence in the radiographic score between dogs that were
or were not hospitalized (ie, discharged immediately af-
ter initial examination). The mean radiographic severi-
ty of infiltration in dogs that were hospitalized and later
discharged was 7.3 ± 5.0 (range, 1 to 24); this value
did not differ significantly (P = 0.57) from that of dogs
that died or were euthanatized during hospitalization

1752 Scientific Reports JAVMA, Vol 233, No. 11, December 1, 2008
(mean, 6.6 ± 4.4; range, 1 to 15). The 3 dogs with the
most severe radiographic scores (18, 20, and 24, respec-
tively) all survived to discharge from the hospital.
Antimicrobial treatment was not given to 4 of 77
dogs; these dogs were admitted to the hospital but were
euthanatized prior to drug administration. Airway sam-
pling was performed in 4 of the 88 dogs. The most com-
mon antimicrobial treatment administered was a β-lac-
tam antimicrobial combined with enrofloxacin (50/73
[68%] dogs); of the dogs treated with this drug combina-
tion, 39 survived to discharge from the hospital and 11
did not. Two dogs received metronidazole in addition to
this combination. Among the 73 dogs receiving antimi-
crobial treatment, a β-lactam derivative alone was given
to 20 (27%), enrofloxacin alone was given to 2 (3%), and
amikacin was given to 1 (1%). Nebulization with sterile
saline (0.9% NaCl) solution followed by coupage was
performed in 30 of 57 (53%) dogs that survived to dis-
charge from the hospital and in 9 of 20 (45%) dogs that
did not survive. No specific treatment could be associ-
ated with survival or duration of hospitalization.
Discussion
In the present study, the specific underlying dis-
ease processes in dogs with aspiration pneumonia were
determined and the survival rates associated with the
detection of 1 or more of these diseases were evalu-
ated. Vomiting, esophageal dysfunction, neurologic
disease, laryngeal disorders, and postanesthetic aspira-
tion were detected (in decreasing order of frequency)
in the dogs included in this study. Overall survival rate
in these dogs was high, and contrary to our hypothesis,
the severity of pulmonary infiltrates (determined radio-
graphically) and the presence of more than 1 disease
process associated with aspiration pneumonia did not
negatively impact outcome.
Among the 88 dogs included in our study, aspira-
tion pneumonia was most commonly associated with ei-
ther esophageal dysfunction or vomiting in the absence
of additional identifiable disease processes. In a recent
study16 in humans, 23% (41/180) of patients that died
from medically managed gastroesophageal reflux disease
developed aspiration pneumonia, indicating the serious
health threat of gastrointestinal dysfunction. The sever-
ity or chronicity of vomiting in the dogs included in the
present study could not be accurately assessed because
of the retrospective nature of the investigation; however,
no specific entries in the medical record detailed copi-
ous regurgitation or vomiting. It is possible that the dogs
may have had subclinical or transient concurrent laryn-
geal dysfunction that allowed aspiration or that the vol-
ume of fluid vomited may have overwhelmed laryngeal
capacity. The competence of the larynx was not assessed
in all dogs, although none had historical or physical ex-
amination findings suggestive of laryngeal dysfunction.
Subclinical dysphagia resulting in silent aspiration (ie,
aspiration that occurs without any signs of swallowing
difficulty) has been reported as a contributor to pneumo-
nia in humans with a variety of disorders17 and may play
a role in veterinary patients also.
Megaesophagus can result in aspiration pneumo-
nia because of chronic, recurrent, or massive regurgita-
JAVMA, Vol 233, No. 11, December 1, 2008 Scientific Reports 1753
tion or from excessive pooling of secretions in the oro-
SMALL ANIMALS
pharynx with overflow into the respiratory tract. In the
dogs with aspiration pneumonia in the present study,
megaesophagus was related to myasthenia gravis in 11
dogs, of which 9 had generalized weakness and 2 had
focal myasthenia involving only the swallowing appa-
ratus. In a clinical study18 of acquired myasthenia gra-
vis, generalized muscle weakness was reported in 64%
(16/25) of affected dogs, and the combination of sys-
temic weakness and esophageal dysmotility likely con-
tributed to development of aspiration pneumonia in the
current study. Mortality rates of 48% to 60% have been
reported for dogs with focal, generalized, or acute ful-
minant myasthenia gravis, and death is often associated
with aspiration pneumonia.1,18 However, in the current
study, only 3 of 9 affected dogs failed to survive.
Generalized weakness from myasthenia gravis was
the most commonly identified neurologic disorder in
the dogs of the present study; however, recumbency
associated with spinal cord disease was also common.
Muscle weakness and deconditioning from thoraco-
lumbar disease may have increased the likelihood of an
aspiration event. Seizure disorders were identified in
7 dogs with aspiration pneumonia, and 3 dogs had no
other underlying disorder that could result in aspira-
tion pneumonia. In contrast, humans with epilepsy that
are otherwise healthy rarely develop aspiration pneu-
monia.5 Use of phenobarbital for seizure control could
play a role in development of aspiration pneumonia if
excessive sedation was present or if liver dysfunction
resulted in vomiting; these conditions were not identi-
fied in dogs of our study.
Aspiration pneumonia developed in an immediate
perioperative period in 12 dogs and in most instances
(8 dogs) was associated with the presence of an addi-
tional risk factor for aspiration. Aspiration pneumonia
following anesthesia is uncommon in people, although
the rate in children or during emergency surgeries is
higher than that in adults; many affected humans have
additional diseases that could contribute to the phe-
nomenon of aspiration.7,19,20 The prevalence of aspira-
tion pneumonia following anesthesia has not been fully
examined in veterinary medicine to our knowledge, al-
though the risk is well known clinically. Monitoring of
pH at the lower esophageal sphincter during anesthesia
has revealed gastroesophageal reflux in approximately
17% (47/270) of dogs,21 indicating the risk for esopha-
geal irritation and subsequent regurgitation that could
lead to aspiration injury.
Aspiration pneumonia has been reported as a com-
mon complication of laryngeal surgery in dogs.2,22 This
likely results from a combination of reduced laryngeal
sensation and deficient motor responses, as well as an-
esthetic-induced depression of reflexes including the
gastroesophageal reflex. Surgical technique, experience,
and postoperative management probably also have a
role in development of aspiration injury. Aspiration
pneumonia in dogs has been reported less frequently
when arytenoid lateralization is performed by a single
surgeon.23 In human medicine, laryngeal dysfunction
or surgery is variably reported as a contributor to as-
piration pneumonia. Vocal fold immobility contributes
to aspiration after esophagectomy, although 40% (8/21)
 of patients with normal vocal fold function may also
SMALL ANIMALS
aspirate.24 Humans that undergo vocal fold surgery25,26
rarely develop aspiration pneumonia as a complication.
In the present study, 6 dogs with laryngeal paralysis de-
veloped aspiration pneumonia 2 months to 3 years after
surgery; such a delayed occurrence has been previously
reported.2 Although some dogs had additional under-
lying diseases associated with aspiration, 6 dogs with
laryngeal disease (4 with laryngeal paralysis) did not
have additional identifiable disorders, suggesting that
laryngeal dysfunction alone may predispose to aspira-
tion pneumonia, perhaps as a result of silent aspiration.
However, full neurologic work assessments were not
performed in all dogs of our study, and it is possible that
generalized neuromuscular disease was not detected.27
Some findings in the present study were unexpect-
ed. First, radiographic evidence of disease severity was
not related to duration of hospitalization or with over-
all survival rate. Similarly, a recent evaluation of radio-
graphic findings in dogs with pulmonary blastomycosis
failed to identify an association between a weighted
index of radiographic severity and survival,28 indicat-
ing that prognosis for survival should not be based on
radiographic evidence of disease. The scoring scheme
used in the present study has not been used previously.
It was deliberately simplistic for ease of clinical applica-
tion and would not be suitable for evaluation and com-
parison of cases with other disease processes. For ex-
ample, a dog with a moderate diffuse interstitial pattern
associated with chronic bronchitis would generate a
relatively high radiographic severity score (2 X 7 = 14),
but that disease process is obviously not comparable to
aspiration pneumonia. It is possible that the timing of
radiographic view acquisition in relation to disease made
it impossible to detect differences. Radiographic views
obtained soon after the aspiration event were scored for
severity; however, the number of hours that elapsed af-
ter the aspiration event prior to radiography could not
be accurately assessed. Dogs with radiographically evi-
dent interstitial infiltrates may have been in the early
stages of the disease or have already progressed into the
recovery phase. Progressive changes in infiltrates could
not be evaluated because of variation in the number and
timing of additional radiographic evaluations. Thus, re-
sults may have been influenced by a time delay between
the generation of radiographic views and the onset or
zenith of aspiration pneumonia. It is also possible that
radiographic evidence of pulmonary involvement did
not correlate with duration of hospitalization or out-
come because radiographic changes lag behind clinical
changes in physiologic processes or function. It was
not possible to determine whether the dogs’ conditions
were improving or destabilizing or whether aspiration
pneumonia or pneumonitis was present at the time that
radiography was performed.
Two other unexpected findings were that survival
rate and duration of hospitalization did not differ be-
tween dogs that had 1 or had > 1 underlying disease
identified and that the specific disease that was associ-
ated with aspiration did not impact duration of hospi-
talization or survival rate in this population of dogs.
Despite the fact that many dogs had a disorder that
could be associated with persistent or chronic aspira-
1754 Scientific Reports JAVMA, Vol 233, No. 11, December 1, 2008
tion (eg, laryngeal disease and megaesophagus), there
was no difference in duration of hospitalization or out-
come, compared with dogs that had aspiration pneu-
monia associated with gastrointestinal tract conditions
or postanesthetic aspiration, which are typically revers-
ible. This lack of influence of underlying disease on du-
ration of hospitalization or survival might explain the
high survival rate among dogs in the present study.
Results of our study indicated that multiple diseases
are associated with aspiration pneumonia in dogs; how-
ever, limitations of the study should be considered. As a
retrospective study, diagnostic testing was not standard-
ized and multiple clinicians were involved in many cas-
es. Invasive tests were only performed if a disorder was
considered likely to be present in a given dog and if that
dog’s condition was stable. For example, laryngoscopy
was performed only in dogs with evidence of laryngeal
dysfunction, including inspiratory respiratory distress,
voice change, exercise intolerance, or stridor. Dogs with
subclinical disease may not have been identified. In dogs
that developed postanesthetic aspiration, specific tests
for esophageal or gastrointestinal dysfunction were not
performed, and it could not be determined whether a
primary disorder such as esophagitis was present or if
decreased consciousness was solely responsible for aspi-
ration. Necropsy data were unavailable for most dogs in
the study, and the role of aspiration pneumonia in death
of dogs could not be accurately estimated with available
information.
The data obtained in the present study provide im-
portant information regarding the number and type of
underlying diseases that may be associated with aspira-
tion pneumonia in dogs and expected outcome. Con-
trary to our hypothesis, dogs with multiple underlying
diseases associated with aspiration pneumonia or dogs
with more extensive radiographic evidence of pulmo-
nary involvement did not have prolonged hospitaliza-
tion or decreased survival rates. Importantly, findings
of our study suggest that among dogs with multiple dis-
orders that could result in aspiration pneumonia, the
outcome is generally favorable with an overall survival
rate of 77%.
a. GraphPad Prism, version 5.0, GraphPad Software Inc, San Di-
ego, Calif.
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