Management of Swallowing Difficulties in Adults who are at risk of Aspiration

Who is this document for?

This document is for people who have been identified to have swallowing difficulties and there is a risk of aspiration when eating and drinking.

What is aspiration?

The term ‘aspiration’ relates to when food or drink ‘goes down the wrong way’, i.e. into the airway (toward the lungs) instead of into the food pipe/oesophagus (toward the stomach).

In the normal swallow, your body naturally protects your airway to ensure that food and drink pass down into the food pipe. However, sometimes a swallowing problem (dysphagia) can mean that food or drink can enter the airway before, during or after swallowing. This can also happen with saliva in some cases.

A cough can help you to clear the airway again. However, many people with swallowing difficulties may have a weak cough, or may not trigger a cough at all, so the food or drink will pass down toward the lungs.

What are the risks associated with aspiration?

Aspiration of food, drink or saliva into the lungs can lead to chest infections including aspiration pneumonia, which in severe cases can lead to death.

These risks are higher for people who are dependent on others to feed them and provide them with mouth care, those that are bed or chair bound, those with poor dentition, smokers and those who are tube fed whilst still eating food normally. These patients are more likely to develop pneumonia after an aspiration event as they are less likely to fight off an infection.

What about choking?

Choking relates to food or drink becoming lodged in the throat or airway, restricting breathing. People who have problems with chewing and controlling food and drink in their mouth may be at increased risk of this.

Can anything be done to reduce the risks of aspiration and choking?

This depends on the type of swallowing problem. A speech and language therapist is specially trained to assess the risk of aspiration and/or choking and manage swallowing problems. They can advise as to whether there are any food or drink consistencies which are safe to swallow and what should be avoided. Specific guidelines regarding feeding and other ways to help may also be appropriate.

You may choose not to follow the speech and language therapist’s advice and decide to eat and drink textures that are outside your recommendations with an accepted risk of aspiration and/or choking.

What if there are no safe food or drink textures?

If food and drink is not safe for you to swallow, a decision needs to be made about whether or not to continue to have food or drink by mouth. In this case, there are a number of possible options:

1) Continue eating and drinking

If you do not want a feeding tube, if a feeding tube cannot be placed, or is not likely to be of benefit, you may continue to eat and drink by mouth, even though there is a high risk of aspiration and/or choking. This option is often appropriate for individuals for whom eating and drinking is important for their quality of life. Speech and language therapists can offer advice on the safest food and drink textures and dieticians can make suggestions as to how to improve nutrition. This is occasionally referred to by healthcare professionals as ‘risk feeding’ or ‘comfort feeding’.

2) Nil by mouth with tube feeding

You will stop having any food or drink by mouth. A feeding tube will usually be inserted directly into the stomach or via the nose, through which you will receive all your nutrition and hydration. This aims to minimise aspiration risk but may not eliminate all risk, as you can remain at risk of aspirating on saliva and any refluxed feed from the stomach. There is evidence that having a PEG increases the risk of aspiration and mortality for some people such as in those with advanced dementia. These risks will be explained by your doctor and speech and language therapist.

3) ‘Tastes for pleasure’

Sometimes a feeding tube will be placed but you will choose to continue having small amounts of food and/or drink by mouth for comfort or enjoyment. The risk of aspiration is not eliminated with ‘tastes for pleasure’ but may be reduced. Your speech and language therapist can advise on what consistencies are safest.

4) Temporary tube feeding

Sometimes a feeding tube will be placed for a short time whilst options are discussed and decisions made, as improving nutrition and hydration may help to improve your condition and swallow function. There will usually be a time limit on this, and if there is no improvement, the tube may be removed or placed permanently following the decision making process set out below.

How is a decision made?

This decision is usually made by you, together with your family or significant others, and relevant medical professionals, such as your doctor, speech and language therapist, dietitian and nurse. Your wishes are key to this decision.

Your doctor will be able to advise on whether an alternative form of feeding is appropriate and the risks and benefits associated with this. They may also refer to the feeding issues multidisciplinary team, where a group of doctors, speech and language therapists, dieticians and specialist nurses will discuss whether a feeding tube would be appropriate for you and make recommendations based on this.

A patient’s capacity to make a decision

In some cases, you may have difficulty making this decision independently if you have problems understanding, retaining, or weighing up the information, or if you are unable to express a decision. Examples include individuals who may be very drowsy or unresponsive, individuals with dementia, brain injury, severe communication problems or mental health disorders.

In these cases, a Mental Capacity Assessment will be carried out. A speech and language therapist can support your communication during capacity assessment if required. Your doctor will also seek advice from your next of kin, family or advocate, in order to take into account what your wishes may be in these circumstances. The doctor in charge of your care is responsible for making a decision about your treatment unless you have a Lasting Power of Attorney or a valid advanced decision to refuse treatment.

Documenting and reviewing the decision

The medical team will document discussions and decisions that have been made. Further discussions may be held regarding future management options. Any decision made will be open to review, for example, when/if there is any significant change in the patient’s medical status.

If you have been given this leaflet and have any questions or queries, please discuss these with the medical team overseeing the patient’s care.