Get a SALT, he’s aspirating!

Get a SALT, he’s aspirating! 3136 3136 Sandra Robinson

Does it matter if a person aspirates? Yes. And No. Well, sometimes. It depends. It’s a bit complicated…


Firstly, what is aspiration?

One of the ways that Speech and Language Therapists measure aspiration is by using the Penetration-Aspiration Scale (PAS). It looks like this.

So it’s basically a 6, 7 or 8 on the PAS.

So it’s not just food and drink that can be aspirated?


Here are some surprising stats for you:

  • Did you know that just under 50% of people without dysphagia aspirate their saliva all night?!
  • And in one study, 28.0% to 35.7% of asymptomatic healthy older adults had intermittent trace aspiration of liquids during flexible endoscopic evaluation of swallowing.
  • The pneumonia incidence in some of the most vulnerable adults is just 11-20%.

So, if you’re aspirating but not getting pneumonia, does that mean aspiration doesn’t always lead to pneumonia? And you can aspirate without dysphagia? And what else can you aspirate?

Lots of questions.

What else can you aspirate?

Even without dysphagia, it’s possible to aspirate;

  • food
  • drink
  • saliva
  • sputum
  • vomit
  • blood
  • acid (reflux)
  • objects (kids like swallowing small toys!)
Aspiration Pneumonia

When the aspirated material lands on the lungs, it can cause pneumonia. There are two types of aspiration pneumonia.

DAP – Dysphagia-related Aspiration Pnuemonia

This happens because of oropharyngeal dysphagia (a swallow problem in the mouth or throat). It needs the following;

  • A pathogen in solid or liquid matter
  • Travels down by gravity to its destination
  • It’s not airborne, nor is it an inhaled pathogen
  • It can occur anywhere in the lungs

NDAP – Non dysphagia-related Aspiration Pneumonia

This is oesophago-gastric aspiration. It’s because of reflux or vomiting.

Does aspiration cause pneumonia?

No, not necessarily.

It is generally regarded as needing THREE things to result in pneumonia.

Dr John Ashford calls this the Three Pillars.

As you can see, it often takes more than simply aspirating food or drink particles for it to become an aspiration pneumonia.

Oral health is a big deal in PREVENTING aspiration pneumonia as well as treating underlying health conditions and dysphagia.

We recommend our friends over at Knowledge Oral Healthcare for further training on mouth care. Makes such a difference!

Predicting Aspiration Pneumonia

In Langmore’s study, she found that, “Documented aspiration of food or liquid on an instrumental swallow study were not significant predictors of pneumonia.” So what is?

The study authors created a model of significant predictors that are positioned where they are thought to impact colonization and aspiration that can lead to pneumonia.


It takes a few things to result in aspiration pneumonia. But aspiration alone isn’t the issue.

To prevent the people you care for from getting aspiration pneumonia, it takes;

  • regular and thorough mouth care
  • optimised treatment of underlying health conditions
  • swallow therapy for greater efficiency of the swallow if dysphagia is present (this reduces the likelihood of aspiration and is preferable to compensatory measures alone – like texture modified food and drink)
  1. Ashford, J.R., 2005. Pneumonia: Factors Beyond Aspiration. Perspect Swal Swal Dis (Dysph) 14, 10–16. https://doi.org/10.1044/sasd14.1.10
  2. Bock JM, Varadarajan V, Brawley MC, Blumin JH. 2017. Evaluation of the natural history of patients who aspirate. Laryngoscope. Dec;127 Suppl 8(Suppl 8):S1-S10
  3. Huxley EJ, Viroslav J, Gray WR, Pierce AK. Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med. 1978 Apr;64(4):564-8. doi: 10.1016/0002-9343(78)90574-0. PMID: 645722.
  4. 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, 69–81. https://doi.org/10.1007/PL00009559
  5. Logemann Jeri A., Gensler Gary, Robbins JoAnne, Lindblad Anne S., Brandt Diane, Hind Jacqueline A., Kosek Steven, Dikeman Karen, Kazandjian Marta, Gramigna Gary D., Lundy Donna, McGarvey-Toler Susan, Miller Gardner Patricia J., 2008. A Randomized Study of Three Interventions for Aspiration of Thin Liquids in Patients With Dementia or Parkinson’s Disease. Journal of Speech, Language, and Hearing Research 51, 173–183. https://doi.org/10.1044/1092-4388(2008/013)
  6. O’Keeffe, S.T., 2018. Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatr 18, 167. https://doi.org/10.1186/s12877-018-0839-7
  7. Rosenbek, J.C., Robbins, J.A., Roecker, E.B., Coyle, J.L., Wood, J.L., 1996. A penetration-aspiration scale. Dysphagia 11, 93–98. https://doi.org/10.1007/BF00417897
  8. Todd, J.T., Stuart, A., Lintzenich, C.R., Wallin, J., Grace-Martin, K., Butler, S.G., 2013. Stability of aspiration status in healthy adults. Ann Otol Rhinol Laryngol 122, 289–293. https://doi.org/10.1177/000348941312200501

I’m not drinking that, it’s wallpaper paste

I’m not drinking that, it’s wallpaper paste 1516 894 Sandra Robinson
What’s up with thickeners?

The use of thickeners is a compensatory measure. They’re for pulmonary safety rather than swallow rehabilitation.

Most thickeners are now gum-based rather than starch-based. Why? Well, the starch-based thickeners aren’t amylase resistant. This meant that if a person with dysphagia held the thickened drink in their mouth for longer than usual, the enzyme amylase produced in the saliva, would break down the starch and… make the drink thinner!

I’ve often wondered if some people with dysphagia ended up on really thick drinks because they were ‘holding’ and by the time they swallowed it, it was about right. Ugh.

The gum-based thickeners solved that problem. And they look slightly better given that they’re clear.

Some of the prescribed thickeners you may have come across include;

and not on prescription;

When mixing up a prescribed thickened drink, always follow the instructions on the tin. Not to do so means that you could place the person with dysphagia at risk of chest infections or pneumonia, or dehydration if they continue to refuse the thickener as it’s not mixed right.

Prescribed gum-based thickeners should be mixed like this;

  • note the IDDSI Level recommended by the speech and language therapist and how many scoops per how many mls this is
  • place the number of flat scoops into the dry shaker / cup / glass first
  • if you are making a hot drink, don’t use a shaker, and do make up the drink as normal in a cup or mug
  • pour the drink onto the powder
  • if it’s a cold, still drink, then shake or if it’s any other drink or you have no shaker, stir with a small whisk, fork or spoon
  • stir for as long as the thickener instructions tell you to and making sure it’s all dissolved
  • leave the drink to complete thickening for as long as the thickener instructions tell you to – many people miss this out and serve immediately

For Slõ drinks, you simply add the sachet to the drink and stir. Done!

Carry out regular IDDSI audits to see if the drinks are being thickened correctly using the IDDSI audit sheets.

If the drink is an incorrect consistency or has lumps of powder still in it that won’t dissolve – throw it away and start again!

For anyone with dysphagia, enjoying their drinks is important for quality of life. By simply following instructions and not making assumptions about how to do it, you’ll significantly improve the drinks and heighten the person with dysphagia’s enjoyment of those drinks.

I had the pleasure of hosting a webinar recently during which Dr Ben Hanson gave his presentation on why thickening drinks can be so tricky.

Head over to Viscgo and sign up to watch the recorded webinar.


Dying for a meal

Dying for a meal 4225 2814 Sandra Robinson
Choking is a serious risk for people with dysphagia

I read the saddest news story this week.

An inquest jury has found that Tony Wilkinson, a disabled man with dysphagia, who choked to death in 2018, was ‘unlawfully killed’.

He choked to death because his support workers did not follow the speech and language therapist’s swallow recommendations of mashed food (this was before IDDSI) and thickened drinks.
Choking can happen to any of us. And it especially increases with age as this U.S. study found. Just look at that graph!

It’s also interesting to note the percentage distribution of associated causes of death for accidental suffocation by condition in over 65s.

People with learning disabilities such as Tony are at significant risk of choking.

The incidence of fatal choking incidents of people with learning disability is almost 100 times greater than in the general population1.

There were 605 reports of choking-related incidents involving adults with learning disabilities over a 3 year period in the UK2.
– 58% took place at mealtimes

and when looking at where they took place;

  • 41% in care homes
  • 58% in inpatient settings
  • 1 % outside either setting

42% of 674 adult service-users with learning disability had one or more choking episodes3.

There was a significantly greater occurrence of choking among people with;

  • more severe learning disability
  • with Down syndrome
  • people who had an incomplete dentition or
  • were taking a greater number of psychotropic drugs

It’s really important that the speech and language therapist swallow recommendations are followed, that the dysphagia care plan is up to date, and that every single person who supports someone with dysphagia is aware of the recommendations.

The old National Patient Safety Agency produced excellent guidance especially for supporting people with learning disability. It can be found here.

The full story on Tony Wilkinson can be found here.

How to help someone who is choking can be found here.

Our training gives you the theory and practical support you need to ensure that none of the people in your care ever choke to death because the swallow recommendations and their rationale were not fully understood.

Ask us about our training here.

  1. Dupont A, Mortensen PB. (1998) Avoidable death in a cohort of severely mentally retarded. In: Fraser W, editor. Key issues in mental retardation research. London and New York: Routledge.
  2. Hampshire safeguarding Adults Board. (2012) Reducing the risk of choking for people with a learning disability. A Multi-agency review in Hampshire. Hampshire County Council Adult Services Department, UK.
  3. Thacker, A. et al. (2008) Indicators of choking risk in adults with learning disabilities: A questionnaire survey and interview study, Disability and Rehabilitation, 30:15, 1131-1138, DOI: 10.1080/09638280701461625

Kramarow, E., Warner, M., & Chen, L. H. (2014). Food-related choking deaths among the elderly. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention, 20(3), 200–203. https://doi.org/10.1136/injuryprev-2013-040795

This blog was first published on the Dysphagia Kitchen website.

A game-changer for people with dysphagia

A game-changer for people with dysphagia 1920 1080 Sandra Robinson
This product is amazing for people with dysphagia.
I worked with a man, who hadn’t had a taste of tea IN OVER A YEAR.
Until now.
If anyone knows how many people are living ‘nil by mouth’ (NBM) because of profound dysphagia in the UK, please share because so many of them could benefit from this.
Are you one of them?
Are you a speech and language therapist, who knows people who would love to taste drinks again?
Many people with dysphagia, despite therapy, are either at too much risk of choking or pneumonia on liquids or do not like thickener in their drinks, that they remain NBM.
Imagine watching everyone else around the table drink and you can’t.
Imagine having such a dry mouth you can’t move your tongue.
Imagine wanting to raise a glass and toast the bride and groom at your daughter’s wedding but you can’t join in taking a sip of champagne.
Imagine never tasting anything nice again. Toothpaste, if you’re lucky.
Some people choose to take the risk of drinking, others cannot. Either because they do not have the mental capacity to choose for themselves or the risk is simply too high physically.
Sometimes the Frazier Free Water Protocol is an option. But not for everyone. And it’s water only.
People with dysphagia often want to drink before they can eat. This is because their mouths feel so awful.
And it can also benefit people being cared for at the end of their life.
This innovation is a game-changer for many.
You could even take it down the pub.
Well, the man who enjoyed the tea last week is enjoying red wine next week!
See how to help someone with dysphagia savour flavour again.
You’ll massively improve their quality of life.
All in one place, here’s my what’s great about this product:
– It helps people enjoy the tastes of their favourite drinks again with very little risk (swallow assessment recommended)
– It helps people’s mouths feel better
– It helps to moisten the mouth so some therapies are easier to carry out, for example, the Masako
– It can form part of sensory assessment and therapy
– It provides relief and enjoyment for people at the end of their lives, who have no appetite but may enjoy the taste
– It works with any drink – including alcohol (when appropriate)
– It’s relatively easy to carry around and can be taken out of the home
– It means someone with dysphagia can enjoy the taste of drinks whilst others drink
– It’s good value
– The powder is suitable for vegans and is free from gluten and lactose
Check out the video, let me know what you think!
(I have no affiliation with the company. I just think the product is ace.)

Have you tried it? What do you think?

Will you be trying it with your patients if you haven’t yet?

Let me know!

Dysphagia and malnutrition

Dysphagia and malnutrition 854 572 Sandra Robinson

Written by Caroline Hill, Dietitian and owner of Caroline Hill Nutrition, providing private consultations and nutrition consultancy services.

As the result of swallowing difficulties, it is highly likely that a person’s eating and drinking is affected. The degree to which their eating and drinking is affected will vary on an individual basis. One of the major consequences of dysphagia not being identified and/or not being managed appropriately is malnutrition.

Malnutrition is the result of an imbalance of the energy, protein and other important nutrients in the body resulting in the following:

  • loss of muscle mass
  • weight loss
  • reduced ability to fight infection
  • increased risk of falls
  • impaired wound healing

Malnutrition is a severe complication of dysphagia and studies suggest up to 50% individual with dysphagia are at risk of malnutrition and 16% are malnourished (1).

Why does malnutrition occur in people with dysphagia?

There are numerous reasons why a person with dysphagia becomes malnourished or is at increased risk of malnutrition.

These reasons may include:

  • inadequate food and fluid intake following changes to the recommended consistency of food and fluid that is safe to consume as advised by a speech and language therapist
  • inadequate provision of nutritious texture modified food and fluid
  • taking longer to eat a meal therefore a person may lose interest, or the meal goes cold therefore the meal becomes unappetising
What role does a dietitian play in helping people with dysphagia?
Following diagnosis of dysphagia, it is important that a dietitian works closely with speech and language therapists to ensure any nutritional concerns are addressed. As discussed earlier there may be numerous reasons why a person with dysphagia may become nutritionally compromised and identifying these reasons will be key to improving someone’s nutritional intake.
1. Texture modified diets and fluids
Management strategies for dysphagia can include texture modification of diet and fluids. The IDDSI framework is a globally developed standardised set of terminology to describe texture modified foods and thickened liquids (2).
Depending on the recommendations set out by the speech and language therapist, the degree of nutritional support required will vary. For some individuals they may be able to manage for example 80% of their nutritional intake from texture modified diet but require oral nutritional supplements to provide the deficit. When considering the use of oral nutritional supplements there are several things a dietitian will need to consider:
  • does the person need their drinks thickened?
  • does the person like milk?
  • is the person able to make a drink or do they need a ready to drink version?
Dependent on these factors will determine the type and format of oral nutritional supplement recommended. It may be appropriate to consider a pre-thickened oral nutritional supplement if the person requires thickened fluids as these products offer a safe solution to ensure that the recommended thickened fluid consistency is received.
Before or alongside the use of oral nutritional supplements, food fortification is usually recommended and is a way of improving the nutritional value of food and can be used in texture modified diets.
For example:
  • Using cream or whole milk instead of water to puree the food
  • Add butter or cheese into food before preparing to the correct consistency e.g. mashed potato
  • Add cream or custard to fruit before it is pureed.
In addition to addressing nutritional concerns, dietitians will also look at the hydration status of an individual. It is common for people with dysphagia to have inadequate fluid intake which can lead to dehydration.
The major consequences of dehydration include:
  • Low blood pressure
  • Urinary tract infections
  • Constipation
  • Confusion
  • Dizziness
Maintaining adequate hydration in people with dysphagia can be challenging due to a number of reasons.
Thickened fluids are commonly used as part of texture modification strategies to reduce the risk of aspiration. However, it is important that the extent to which the fluid is thickened is balanced alongside risk of dehydration, compliance with thickened fluids and the safety aspect for a safe swallow. This is where collaboration between dietitians and speech and language therapist is essential to ensure the risk of dehydration is minimised whilst also managing the risk of aspiration.
Strategies to reduce the risk of dehydration in people with dysphagia could include the following:
  • Offered flavoured thickened drinks rather than thickened plain water
  • The use of gum-based thickeners over starch-based thickeners may be preferable to improve the visual appeal and palatability of the thickened drink
  • Pre-thickened drinks may play a role particularly if the person also requires nutritional supplementation
2. Provision of safe and nutritious food and drink
Dysphagia management is everyone’s responsibility and once a plan has been outlined about how to manage dysphagia, it is important all key individuals are involved in the plan. Once recommendations are in place for a texture modified diet, it is important that those who prepare and serve the food and drink are aware of these recommendations.
Texture modified foods can be self-prepared or ready meals can be purchased. When preparing homemade texture modified it is important that the preparation of the food is in line with the IDDSI framework descriptors for the recommended level advised by the speech and language therapist.
Due to the overlap between dysphagia and malnutrition, it is important that speech and language therapists and dietitians work together. The role of the dietitian in dysphagia management is to ensure adequate nutrition and hydration, particularly when texture modified food and diet recommendations are in place. This will help to improve a person’s nutritional status, aid recovery and improve quality of life.
1. Tagliaferri S, Lauretani F, Pelá G, Meschi T, Maggio M. The risk of dysphagia is associated with malnutrition and poor functional outcomes in a large population of outpatient older individuals. Clinical Nutrition [Internet]. 2019;38(6):2684–9.
2. Cichero JAY, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, et al. Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia [Internet]. 2016/12/02. 2017 Apr;32(2):293–314.

Thickener or water?

Thickener or water? 2000 675 Sandra Robinson

Recommending thickened drinks is a common practice by speech and language therapists / speech pathologists when supporting people with dysphagia.

I recently used this video to stimulate debate amongst caregivers. Opinions vary!

What role does thickener play in dysphagia management now and is this changing? How do our patients / clients feel about it? What do caregivers and relatives think of it? What more can industry do to support patients / clients and health care professionals?

Let me know your thoughts whether you’re someone with dysphagia, a health care professional, or relative.