Based on a number of real cases seen in a community hospital

“Robert” was silently aspirating thin liquid after an acute stroke. Mildly and moderately thick liquid wasn’t much better with deep penetration and laryngeal residue. This, of course, was concerning. I spoke to him at length about the risks of aspiration, pneumonia, and respiratory decline. Robert was a smart guy. He verbalized an understanding of the risks and clearly stated his goal in the form of a sentence: “I’ll die before I drink that sludge.” The conversation and decision were well-documented and the patient proceeded to eat and drink whatever he wanted until he was discharged home. I was sad to see him go; certain he would return back soon with aspiration pneumonia.

Two months later

The patient was readmitted to the hospital. My heart dropped. Maybe I should have been more strict with my recommendations or at least made a better case to the patient during our discussions. It has only been two months and this poor guy barely had time to enjoy his life outside of the hospital. Before looking at the chart, I decided to say hello in person and make sure he is ready for the evaluation. I walk into the room. He looks pretty good, sitting upright and watching TV. The first thing I say is,

“I’m so sorry. I was afraid this would happen. I really didn’t want you to have to come into the hospital again.”

“I know,” Robert said. “But, shit happens.”

I nod my head in acknowledgment and ask him if he’s open to another swallow evaluation and if so, I tell him I just need a few minutes to look over his chart. He looks at me confused.

“Another swallow evaluation? I understand doing that after a stroke, but you guys do this after hip surgery too?”

Turns out, Robert was admitted after a fall and a broken hip (Not aspiration pneumonia). In fact he had been eating, drinking, and (probably) aspirating for two whole months and his lungs have been clean as a whistle. This type of case sounds surprising to us, but it really shouldn’t be. Especially in patients with relatively few risk factors for aspiration pneumonia. 

So, how do we know who is at risk and who isn’t? What are the risk factors and how do they help us make clinical decisions?

Below is a list of the risk factors for aspiration pneumonia as identified by the research.

Risk Factors for Aspiration Pneumonia

(Feinberg et al., 1996; Fukuba et al., 2020; Herzig et al., 2009; Kaneoka et al., 2017; Kollmeier & Keenaghan, 2022; Laheij, 2004; Langmore, et al., 1998; Langmore et al., 2002; Leder et al., 2013; Manabe et al., 2015; Marik, 2001; Nativ-Zeltzer et al., 2021; Taylor et al., 2013)

Aspiration is universal

Aspiration is common even in healthy people (Mandell & Niderman, 2019). What’s not so common is to aspirate something harmful that we can’t clear out or fight off. Because our bodies are so extraordinary, you need more than just aspiration to create pneumonia. You need multiple levels of defense to break down. Three to be exact. Is aspiration necessary? Yes. Is it sufficient? No.

Aspiration of harmful contents

As you can see from the chart above, these risk factors are separated into 3 distinct risk categories. The human body has complex, multi-layered defense mechanisms to protect itself against these risks. The SLP typically is familiar with the first category: Aspiration. We have oropharyngeal protective mechanisms that function to improve the extent and timeliness of airway closure. When healthy, these mechanisms seamlessly divert the bolus around the airway. Of course, it’s not only about if the patient is aspirating, but is also about what is being aspirated. Clean water will have a much different effect on the lungs than, say, soda, bacteria-ridden secretions, or reflux. Oh, yes, and speaking of reflux, we can’t forget about retrograde aspiration of gastric contents with vomit or gastro-esophageal reflux disease.

Pulmonary clearance

Let’s say the first level of defense fails. The patient has a neurological disease and her ability to protect her airway during the swallow begins to decline. If the lungs remain healthy, they don’t respond to aspiration like two defenseless water balloons. They are hard-wired for protection with a variety of automatic responses such as coughing, mucociliary clearance, and pulmonary absorption of external contents into the bloodstream. “Come at me,” they say (Especially the right one). “I’m ready to clear out and absorb whatever you got.” 

Immune status

Maybe this patient with neurological disease is also a smoker with COPD and her lungs aren’t what they used to be. Our immune system is still around and typically does a tremendous job of cleaning up any mess that may occur when all other systems are dragging. It’s sort of like the final safety parachute that deploys after our plane’s engine broke and wings fell off. As soon as a potential infection may be mulling about, our white blood cells (i.e. macrophages) and cytokines team up to destroy any harmful bacteria before it has a chance to create a home. 

Total system failure 

Of course this patient with a neurological disease and COPD may also have some immunodeficiencies. Maybe she is elderly, highly dependent, and with a slew of medical comorbidities, making her more susceptible to pulmonary infection. This would be a total system failure, increasing the overall risk of aspiration pneumonia. Of course, this doesn’t mean she shouldn’t eat or drink. There may be ways we can manage that risk. For example, we could provide her compensatory strategies and exercises for her airway protection, respiratory treatments to manage her pulmonary limitations, physical therapy to get her up and moving around, occupational therapy to get her feeding herself again, and medications to improve her medical stability. The fight never ends. 

Wrapping it up

All in all, it’s the full picture we want to look at from top to bottom (And bottom to top in the case of reflux). Acknowledging and sorting out the risk factors forces us to look not only at if the patient is aspirating, but what that aspiration means for the patient. Then, it’s for us to figure out what we can do to minimize risk and avoid the impossible goal of eliminating it completely (With draconian measures that often cause more harm than good). If a tree falls in the forest and nobody is there to hear it, does it make a sound? No? Then if a patient is silently aspirating and no issues ever arise from it, is it worth treating? Probably not. Especially if the treatment causes potential harm as in the case of modified consistencies and their link to dehydration, malnutrition, poor quality of life, and reduced bioavailability of medication (Chicero, 2013; McCurtin et al, 2018; Vucea et al., 2018). An understanding of how well-equipped the body is to shield, clear out, and fight off potential aspiration is the first step toward understanding what the risk looks like when these systems begin to fail. And if they do? We will be right there as another safety net to help the patient get back on track.

The above case is based off a compilation of experiences and does not represent a specific case or individual. “Robert” is a fictitious name.

Looking for a presenter? George specializes in dysphagia management in patients with medical complexity. Some topics he has presented on include trach/vent management, critical thinking and decision making, and aspiration pneumonia risk management.​ Please feel free to contact him for more details:

Follow him on Instagram @DysphagiaDude

Check out his website:


Cichero, J. A. Y. (2013). Thickening agents used for dysphagia management: Effect on bioavailability of water, medication and feelings of satiety. Nutrition Journal12(1). 

Feinberg, M. J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia, 11(2), 104-109. doi:10.1007/bf00417899

Fukuba, N., Nishida, M., Hayashi, M., Furukawa, N., Ishitobi, H., Nagaoka, M., Takahashi, Y., Fukuhara, H., Yuki, M., Komazawa, Y., Sato, S., & Shizuku, T. (2020). The relationship between polypharmacy and hospital-stay duration: A retrospective study. Cureus. 

Gleeson, K., Eggli, D. F., Maxwell, S.L. (1997). Quantitative aspiration during sleep in normal subjects. Chest, 111(5), 1266-72.

Herzig, S. J. (2009). Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA, 301(20), 2120. 

Kaneoka, A., Pisegna, J. M., Inokuchi, H., Ueha, R., Goto, T., Nito, T., Stepp, C. E., LaValley, M. P., Haga, N., & Langmore, S. E. (2017). Relationship between laryngeal sensory deficits, aspiration, and pneumonia in patients with dysphagia. Dysphagia, 33(2), 192–199. 

Kollmeier, B. R. & Keenaghan, M. (2022). Aspiration risk. StatPearls Publishing. NBK470169. 29262188

Laheij, R. J. F. (2004). Risk of community-acquired pneumonia and use of gastric acid–suppressive drugs. JAMA, 292(16), 1955. 

Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298–307.

Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13(2), 69–81.

Leder, S. B., Suiter, D. M., Murray, J., & Rademaker, A. W. (2013). Can an oral mechanism examination contribute to the assessment of odds of aspiration? Dysphagia, 28(3), 370-374. doi:10.1007/s00455-012-9442-9

Manabe, T., Teramoto, S., Tamiya, N., Okochi, J., & Hizawa, N. (2015). Risk Factors for aspiration pneumonia in older adults. PLOS ONE, 10(10), e0140060. 

Mandell, L. A., & Niederman, M. S. (2019). Aspiration pneumonia. New England Journal of Medicine380(7), 651–663. 

Marik, P. E. (2001). Aspiration pneumonitis and aspiration pneumonia. New England Journal of Medicine, 344(9), 665–671.

Matthay, M. A., Zemans, R. L., Zimmerman, G. A., Arabi, Y. M., Beitler, J. R., Mercat, A., Herridge, M., Randolph, A. G., & Calfee, C. S. (2019). Acute respiratory distress syndrome. Nature Reviews Disease Primers, 5(1). 

McCurtin, A., Healy, C., Kelly, L., Murphy, F., Ryan, J., & Walsh, J. (2017). Plugging the patient evidence gap: What patients with swallowing disorders post‐stroke say about thickened liquids*. International Journal of Language & Communication Disorders53(1), 30–39. 

Nativ‐Zeltzer, N., Nachalon, Y., Kaufman, M. W., Seeni, I. C., Bastea, S., Aulakh, S. S., Makkiyah, S., Wilson, M. D., Evangelista, L., Kuhn, M. A., Sahin, M., & Belafsky, P. C. (2021). Predictors of aspiration pneumonia and mortality in patients with dysphagia. The Laryngoscope, 132(6), 1172–1176.  

Taylor, J. K., Fleming, G. B., Singanayagam, A., Hill, A. T., & Chalmers, J. D. (2013). Risk factors for aspiration in community-acquired pneumonia: Analysis of a hospitalized UK cohort. The American Journal of Medicine, 126(11), 995–1001. 

Vucea, V., Keller, H. H., Morrison, J. M., Duizer, L. M., Duncan, A. M., Carrier, N., Lengyel, C. O., Slaughter, S. E., & Steele, C. M. (2018). Modified texture food use is associated with malnutrition in long term care: An analysis of making the most of mealtimes (M3) project. The Journal of Nutrition, Health & Aging22(8), 916–922. 

Previous articleSwallowing with a Trach and Vent in the ICU: Part Two
Next article Swallowing with a Trach and Vent in the ICU: Part Three
George Barnes MS, CCC-SLP, BCS-S has developed an expertise in dysphagia with a focus on diagnostics in the medically complex population through his dedication to a variety of medical settings. He is co-founder of FEESible Swallow Solutions, a mobile speech pathology company dedicated to improving patient access to high-quality dysphagia services. George has a track record of supporting the field of speech pathology by paying his knowledge forward to other professionals via graduate-level education, clinical fellowship and student supervision, the Student to Empowered Professional (STEP) mentorship program, The Medical SLP Collective mentorship service, ASHA special interest groups, peer review for ASHA course material, the SIG13 Dysphagia Editorial Committee, the NJSHA Dysphagia Subcommittee, and participation in various interdisciplinary teams and committees in the hospital setting. He has earned multiple ASHA ACE Awards and leads his field through education and training in dysphagia management. George pioneers innovative research and clinical techniques aimed to improve efficiency and accuracy in dysphagia management. He is currently building a risk assessment calculation tool for aspiration pneumonia. With a passion for food and a deep appreciation for the joy and connection it gives to our lives, he has dedicated his life to helping others enjoy this simple, but deep-rooted pleasure. Affiliations: FEESible Swallow Solutions LLC. Looking for a presenter? George specializes in dysphagia management in patients with medical complexity. Some topics he has presented on include trach/vent management, critical thinking and decision making, and aspiration pneumonia risk management.