A Case Study of Aspiration: What would you do?

With help from Dr. James L. Coyle, PhD, CCC-SLP, BCS-S, ASHA Fellow

The call came in two days after the modified barium swallow study (MBSS).

Meet Edwin, a 73-year-old gentleman admitted for a hip fracture after a fall. Prior to this, he led an active lifestyle, volunteered, helped raise his grandchildren, and enjoyed attending baseball games at the local university. His daughter described him as forgetful at times, but overall independent. He had a history of COPD, but no episodes of exacerbation and no history of pneumonia. 

Two days ago, he was found to be coughing at the hospital bedside. This prompted an MBSS, which in turn led to a recommendation for NPO secondary to silent aspiration (trace amounts).  Now, Edwin, who is otherwise alert and loves his evening sherry, is distraught, dehydrated, and asking every nurse why he's being "starved."

Now, it’s your turn. You didn’t do the MBSS, but your colleague asked you to help manage the case. Your job is to determine the clinical significance of the patient’s aspiration risk and decide if he’s indeed facing a feeding tube, or if you can somehow safely get him eating and drinking again. The stakes are high. Are you up for the challenge?

When it comes to aspiration, how much is too much? After all, research confirms that even healthy people experience microaspiration. But at what point is the line crossed from harmless to harmful? The answer is governed by a couple of important factors. But before we get into that, let’s take the sharp edges off of aspiration and discuss how it’s not only expected, but even a healthy part of a functioning pulmonary system…

The Antifragile Lung

“Antifragile” is a term introduced to the world by Nassim Taleb in his popular book by the same title. The premise is simple and can be summed up with a phrase you’ve probably heard before: What doesn’t kill you makes you stronger. In many cases (but not all), the human body operates on the principle of antifragility—a little stress helps it function effectively.

Let’s put this concept into context. We exercise to get stronger, right? Weightlifting, for example, actually adds “stress” to the system. This process creates microtears in our muscle fibers. During recovery, the body repairs these, making muscles grow stronger and larger over time. So, a little bit of a seemingly bad thing can be… a good thing.

But there’s a flip side to this equation. A seemingly good thing can also be a bad thing. Think about sunlight. A moderate amount is crucial for Vitamin D and immune function (the "good thing"), but too much can lead to sunburn and skin cancer (the “bad thing”).

The lungs are similar…

The lungs need a routine, minimal challenge to stay sharp (Think about doing cardio at the gym). This concept can be applied to the microbiota of the lungs. Microaspiration is normal for healthy individuals, especially during sleep, and actually seeds the lungs with low-level microbes, thereby maintaining immunological function by keeping immune cells primed and ready to respond when needed. 

This 2024 article is a valuable resource for learning more about this topic. Authors Marrella, Nicchiotti, and Cassani explain that a healthy lung is “a transient settlement of bacteria continuously inhaled and eliminated.” It accomplishes the maintenance of a healthy pulmonary system through “a continuous dialog between commensal bacteria and resident epithelial and immune cells that support the lung homeostasis.” In other words, aspiration is not something that should be feared, absolutely, but should instead be accepted as a normal part of a healthy system.

However, keep in mind that aspiration, as a seemingly harmless and even helpful event, is limited to very small amounts of aspiration (less than 0.2 mL in this study) of non-injurious material and in an otherwise healthy individual. Aspirating large quantities of anything or even small amounts of something harmful (e.g., pathogenic microbes) can cause issues even in healthy individuals. But it’s unhealthy people who we really need to be watching closely. Speaking of, let’s go back to Edwin…

A Second Look

You’re able to get a hold of the MBSS recording, and you notice something that wasn’t in the report. He only had aspiration once out of nine trials with thin liquids. He had mild residue on all other consistencies and similar quantities and frequencies of aspiration on thickened liquids. Furthermore, an oral hold strategy and slow pacing appeared to improve his tolerance of thin liquids, resulting in no aspiration or penetration. This was the smoking gun?

These infrequent episodes of trace aspiration were what initiated the unraveling of this patient’s diet, quality of life, and hopes for discharge home. Let’s look at some of the risk factors that may have supported the initial decision for NPO status…

Now, it’s your turn again. What risk factors can you identify from Edwin’s case, and what would you need to see in order to justify the decision to maintain NPO status (if any)? Think about it before moving on.

Take a minute to think through this before moving on! 

Ok, back to Edwin. Perhaps you noticed that Edwin had recently undergone hip surgery, which likely limited his mobility; however, he otherwise appeared to be in good health. He was 73 and had a history of mild COPD, but hadn’t had an episode of pneumonia in recent memory. Further, he presented with a mild cognitive deficit, but was generally awake, alert, and able to follow instructions for safety during meals.

Knowing what you know now, what would be your clinical decision? Would you:

A.Keep him NPO and recommend consideration for a feeding tube

B.Let him start eating his baseline diet of regular solids and thin liquids again

C.Recommend a modified diet

D.Recommend a repeat MBSS

Take another minute to decide. There’s no rush. What do you think would be best based on what you know about Edwin?

Let’s do the “math.” The trace aspiration was infrequent. He had a few risk factors, like COPD and decreased mobility, but he also had strengths like intact cognition and a stable respiratory history. 

Additionally, I’d be curious to know why he was sent for the MBSS. Coughing at the bedside isn’t exactly a surprising finding in a patient with COPD (chronic cough is common). I would ask if the coughing occurs immediately after swallowing, generally during meals, or if it is a more general occurrence throughout the day, without a significant increase in frequency during meals or with oral intake (PO). If it were just a general cough that occurred throughout the entire day without a significant increase in frequency during meals, the presence of a cough is not an indication of dysphagia. Without an indication of dysphagia, he may have had no business even having an MBSS to begin with.

Further, modified diets and NPO status are a double-edged sword. In some ways, they reduce the risk of aspiration pneumonia, but in other ways, they increase it– remember, you can’t eliminate the risk of aspirating secretions (which is actually one of the most dangerous things to aspirate, especially in a mouth that hasn’t been cleaned). Further, the risk of aspirating thickened liquids is lower physiologically, but may be higher pathologically, likely because it’s difficult to clear from the lungs once aspirated (compared to thinner consistencies). 

In Edwin’s case, the infrequent episodes of trace aspiration probably aren’t going to tip the scales and send him spiraling down toward a road of recurrent aspiration pneumonia. It’s unlikely to cause him respiratory problems anytime soon, especially if he employs slow pacing and an oral hold strategy, which seemed to help during the MBSS. So, treating this seemingly benign aspiration with an “NPO” status is a treatment that is not only unnecessary, but may cause worse effects than the disorder itself.

So we can rule out option ‘a.’ Other than that, you can probably justify any of the other options. In that sense, there’s really no right answer to the question above, but if you’re asking me? I’d choose ‘b.’ After talking to the team and if they were agreeable, we’d start him on regular solids and thin liquids after training on the effective compensatory strategies. 

Of course, we’d monitor closely and encourage the whole team to do the same, changing course and reassessing via MBSS if needed. This is another important point to note. No decision is ever set in stone. Knowing this allows us to use our best judgment to initiate a diet and make necessary changes if we do encounter a respiratory event. 

What did you learn?

The notion that aspiration could be part of a healthy system is not permission to dismiss every aspiration event. Instead, the objective is to see aspiration through fresh eyes, away from the fear-based, knee-jerk reaction we’ve all learned from spending years in a system that pretends the lungs are two fragile, sterile sacks that can’t handle a little bit of aspiration or bacteria. 

Next time you see it, don’t react immediately. Remember what you’ve learned here. Not all aspiration is created equal, and they will mean vastly different things depending on who is doing the aspiration. So what do we do? We take a step back, examine the risk factors, and distinguish between physiological entry and true pathological risk. This kind of comprehensive review and thoughtful reasoning is what will ultimately help us get our patients home safely.