A while back, I was reviewing submissions for the ASHA conference session on Complex Cases in Adult Dysphagia, and something Dr. James Coyle said during the session hit me like a ton of pudding thick liquids:

We need to stop casually labeling patients as “aspiration risks.”

Because once that label makes its way into a medical chart, it sticks—and it follows that patient across settings, providers, and treatment decisions. But what does “aspiration risk” even mean?

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What Is an “Aspiration Risk?”

According to Wikipedia (yes, I went there), pulmonary aspiration is “the entry of material (such as pharyngeal secretions, food or drink, or stomach contents) from the oropharynx or gastrointestinal tract into the larynx and lower respiratory tract.”

When we write “aspiration risk” in a patient’s chart, it’s typically shorthand for: “this person has dysphagia and may aspirate food, liquids, or secretions.” But what’s the actual risk? And more importantly, is the presence of aspiration the most important predictor of pneumonia?

Let’s look at the evidence.

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What the Research Says

📌 Martino et al. (2005)

• Found a high incidence of dysphagia and aspiration post-stroke.
• Noted that silent aspiration is surprisingly common.
• Showed that pneumonia risk is proportional to aspiration severity, but not exclusive to it.

Martino, R., et al. (2005). Stroke, 36(12), 2756-2763.

📌 DeLegge (2001)

Identified other major risk factors beyond dysphagia:

• Neurologic dysfunction
• Decreased consciousness
• Advancing age
• GERD
• Tube feeding

DeLegge, M. H. (2001). JPEN, 26(6 Suppl), S19–24.

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🐣 Chicken or the Egg?

Dr. Coyle explored this question beautifully in his article “A Dilemma in Dysphagia Management: Is Aspiration Pneumonia the Chicken or the Egg?”

He argues that:

“Aspiration contributes to dysphagia-related pneumonia—but it’s just one of many risk factors, and sometimes not even the most important one.”

Let that sink in.

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The Langmore Game-Changer

In what might be the most cited article in our profession, Dr. Susan Langmore (1998) dropped a truth bomb:

Top risk factors for aspiration pneumonia:

• Dependence for feeding
• Poor oral care
• Multiple comorbidities
• Smoking
• Tube feeding
• Decayed teeth
• Polypharmacy

Notice something missing?
👉 Dysphagia wasn’t even on the list.

Langmore, S. E., et al. (1998). Dysphagia, 13(2), 69–81.

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The “NPO but Eating Anyway” Dilemma

We’ve all had that patient.

Instrumental shows aspiration across the board. The patient is deemed unsafe for oral intake, but they refuse NPO orders. They eat. They drink. We cringe. We wait for the inevitable pneumonia…

…except it never comes.

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SNF Setting: Another Layer of Complexity

Langmore and colleagues (2002) looked at aspiration pneumonia in nursing home residents and found that risk explodes when the following factors stack up:

• Feeding dependence
• Suctioning
• Mechanical diets
• COPD, CHF
• Bedbound status
• Delirium
• UTI
• Lots of meds
• AND dysphagia

Langmore, S. E., et al. (2002). Dysphagia, 17(4), 298–307.

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Cognitive Status Matters, Too

According to Leder, Suiter, & Warner (2009), patients who couldn’t answer basic orientation questions or follow single-step commands had:

• 57% greater risk of liquid aspiration
• 48% greater risk of puree aspiration
• 69% greater chance of being deemed unsafe for any oral intake

Leder, S. B., et al. (2009). Dysphagia, 24(3), 290–295.

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Wait, Even Healthy Adults Aspirate?

Yep.

Marik (2001) noted that half of all healthy adults aspirate small amounts of secretions while sleeping. Yet most of them never get pneumonia.

Marik, P. E. (2001). NEJM, 344(9), 665–671.

So what’s the difference?

Pneumonia risk rises when:

• Oral health is poor
• Neutrophils are busy fighting other infections
• The person can’t clear aspirated material
• There’s bacterial colonization in the oropharynx

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Final Thoughts: Think Before You Label

Aspiration does not equal pneumonia.
Dysphagia does not equal aspiration.
Being labeled an “aspiration risk” does not mean that patient should automatically be NPO.

When we slap on that label, we may unknowingly change the trajectory of care for that patient—sometimes unnecessarily, and sometimes even harmfully.

So the next time you’re tempted to default to “aspiration risk” in the chart, ask yourself:

Aren’t we all an aspiration risk?

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References

Martino, R., Foley, N., Bhogal, S., Diamant, N., Speechley, M., & Teasell, R. (2005). Dysphagia after stroke incidence, diagnosis, and pulmonary complications. stroke, 36(12), 2756-2763

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.

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.

Leder, S. B., Suiter, D. M., & Warner, H. L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia, 24(3), 290-295.Aspiration Pneumonia

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