Aspiration: When Food or Liquid Goes Down the Wrong Way

What happens when you aspirate

When you swallow, the epiglottis (a flap of tissue) and the vocal cords close over the airway, so food and drink pass into the esophagus. If timing or muscle control fails, material slips past the vocal cords into the trachea (windpipe). The normal protective response is a forceful cough to clear it.

Doctors separate two related terms:

• Penetration: material enters the voice box but stays above the vocal cords.
• Aspiration: material passes below the vocal cords toward the lungs.

Signs and symptoms of aspiration

During or soon after eating and drinking:

• coughing, choking or throat clearing
• a wet, gurgly or hoarse voice
• watery eyes or a red face
• feeling short of breath or breathing faster
• food or liquid coming out of the nose
• pocketing food in the cheeks or needing several swallows per mouthful

Over days to weeks:

• repeated chest infections or pneumonia
• low-grade fevers
• weight loss and dehydration from eating and drinking less
• a long-term cough or wheeze

Silent aspiration

In silent aspiration, material enters the airway without any cough or visible sign, because sensation or reflexes are impaired. It is very common after stroke and in advanced dementia, Parkinson's disease and head and neck cancer treatment. It often comes to light only after recurrent pneumonia, and is diagnosed by a swallowing study.

Who is at risk of aspiration?

Complications of aspiration

Aspiration pneumonia

Aspiration pneumonia is a type of pneumonia, a lung infection caused by bacteria from the mouth and throat carried into the lungs. It develops over a day to several days, with fever, cough, breathlessness and sometimes foul-smelling sputum. It often affects the lower right lung, because of the angle of the airway. Older adults may simply become confused or drowsy.

Chemical pneumonitis

Inhaling acidic stomach contents can burn the lungs within hours, causing sudden breathlessness, wheezing and low oxygen. This is chemical pneumonitis, and it happens most often during anesthesia, seizures or heavy intoxication.

Airway blockage

A large piece of food or an object can block the airway, which is choking and an emergency. Smaller objects, such as peanuts in toddlers, can lodge in a bronchus and cause a persistent cough, wheeze or repeated pneumonia in one area. See foreign body aspiration.

How aspiration is diagnosed

1. Bedside swallow screen: a nurse or speech-language pathologist watches you swallow small amounts of water and food, checking for coughing, voice change and oxygen drops.
2. Videofluoroscopic swallow study (modified barium swallow): you swallow foods mixed with barium while X-ray video records exactly where they go. It shows silent aspiration.
3. Fiberoptic endoscopic evaluation of swallowing (FEES): a thin camera through the nose watches the throat during swallowing.
4. Chest X-ray or CT: for pneumonia or an inhaled object.
5. Bronchoscopy: to remove an inhaled object or take samples.

Treatment and prevention

Swallowing therapy

A speech-language pathologist (speech and language therapist) is the key specialist. They may recommend:

• exercises to strengthen swallowing muscles
• techniques such as tucking the chin when swallowing, or swallowing twice
• modified textures: thickened liquids and soft, minced or pureed foods, following the IDDSI framework
• avoiding mixed textures such as cereal with milk or soup with chunks

Safe eating habits

• Sit fully upright (90 degrees) to eat and stay upright for 30 to 60 minutes afterward.
• Take small bites and sips, and eat slowly without distractions.
• Do not talk with food in your mouth.
• Avoid eating when drowsy or after sedating medicines or alcohol.
• Keep the mouth clean: brush teeth and dentures twice daily. Good oral care reduces pneumonia risk in care homes.

Reflux and medical measures

Treat reflux, raise the head of the bed, and avoid late meals. People with severe swallowing problems may need a feeding tube, though tubes do not eliminate aspiration of saliva or reflux. Aspiration pneumonia is treated with antibiotics. Chemical pneumonitis is treated with oxygen and support, and antibiotics only if infection develops.

Frequently asked questions

What are the signs of aspiration?

Coughing, choking or throat clearing during or after eating, a wet or gurgly voice, watery eyes, shortness of breath and repeated chest infections are common signs. Some people aspirate silently with no cough at all, which is common after a stroke. A swallowing study can confirm it.

What happens if you aspirate food into your lungs?

A small amount usually triggers coughing that clears it with no harm. If material reaches the lungs, especially repeatedly or with mouth bacteria or stomach acid, it can cause aspiration pneumonia or chemical pneumonitis over hours to days. Watch for fever, cough and breathlessness.

How long after aspiration does pneumonia develop?

Chemical pneumonitis from stomach acid can cause breathing trouble within 1 to 2 hours. Bacterial aspiration pneumonia usually appears over 1 to 3 days, with fever, cough and breathlessness. Seek care if these develop after a known aspiration episode.

What is silent aspiration?

Silent aspiration is when food, liquid or saliva enters the airway without causing a cough or other visible reaction, because the throat's sensation or reflexes are impaired. It is common after stroke and in neurological diseases, and is found with a videofluoroscopic swallow study or endoscopic swallow test.

Is aspirating water dangerous?

Usually not, in a healthy person who coughs it out. Repeated aspiration of liquids in someone with swallowing problems can lead to pneumonia, which is why thickened drinks may be recommended. Good mouth hygiene reduces the risk, as the bacteria carried in matter more than the water itself.