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.
  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.
  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.
  6. O’Keeffe, S.T., 2018. Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatr 18, 167.
  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.
  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.

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.

This blog was first published on the Dysphagia Kitchen website.

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.