My latest podcast guest has a take on aspiration, pneumonia and risk feeding that apparently caused quite a stir when his paper came out in 2021.

The guest is Dr Shaun O'Keeffe, a geriatrician who published a critique of the Royal College of Physicians' guidance on risk feeding. When I interviewed him for the podcast, he seemed surprised I'd asked him on and alluded to some backlash he'd received from the SLP community at the time the article was published.

So what exactly did Shaun say that caused a stir?

He was challenging two assumptions that sit at the centre of a lot of dysphagia practice: that aspiration of thin fluids will lead to pneumonia, and that thickened fluids will prevent it. So he went to the research.

The relationship between aspiration and pneumonia is not straightforward. Aspiration is not synonymous with pneumonia. Pneumonia is caused by pathogenic microorganisms in a vulnerable host. Dysphagia is just one of many risk factors that might lead to pneumonia, but it's not even the strongest risk factor, I might add. Multiple research studies have found no convincing evidence that texture modification or thickened fluids prevent pneumonia. In some cases, the interventions themselves carry risk.

Some responses from the SLP community at the time reportedly reflected a sentiment along the lines of: “But what would he know? He’s not a speech pathologist.”

And I understand this, we're protective of our scope. We also know more than anyone else about the physiology of swallowing, even doctors.

But let's think about this. Medical school is a minimum of five to six years, followed by internship, residency, and for a geriatrician like Shaun, further specialist training adding another five or more years. By the time a geriatrician is practising independently, they have spent the better part of a decade studying and treating the exact things we're debating: infection, immune response, frailty, pneumonia, end of life, and doing so in the same older, medically complex patients we're writing risk feeding plans for.

When the discussion moves beyond swallowing physiology into infection, frailty, mortality and medical outcomes, geriatricians are bringing a level of expertise we shouldn't dismiss.

Does this mean dysphagia doesn't matter?

No, and I honestly don't think that's Shaun's argument. Risk is real and dysphagia matters. What I think he's saying is that we owe our patients accurate, balanced information, and that current practice in many settings is driven more by professional anxiety and defensive medicine than by evidence.

After the episode aired, a listener reached out and said:

"It's a humbling listen for sure, but I feel like I've spiralled into a 'what's the point of any of this?' downfall. Did you feel like this?"

Honestly... yes, I did. And I think for a while I overcorrected  and became too blasé about risk but I hope that these days I've landed somewhere more balanced.

So where do I sit today?

These days, I rarely feel the need to initiate a formal EDAR process solely because an adult chooses thin fluids over thickened fluids, particularly in community settings where the person is otherwise medically stable. In clearer cases of choking risk, yes, I think an EDAR (Eating & Drinking with Acknowledged Risk) process is often warranted. But for the aspiration-pneumonia question specifically, it seems the evidence doesn't support the level of documentation and restriction that has become standard in many settings.

Might there be more risk in someone consuming thin fluids? Yes, absolutely. But what I think should follow is a conversation, one that covers the benefits and the risks, after which a patient makes an informed choice about their own care. Without the need to sign, counter sign, convene an MDT, document the meeting, document who attended, and document that everyone agreed the documentation was sufficient and so now Margaret can have her cup of tea.

What I think we haven't done well in the past is judge aspiration risk on a person's individual situation. We've treated all cases of aspiration the same regardless of the client's history, health condition or even despite the amount and frequency of aspiration. 

We also need to keep in mind that while it can be true that small amounts of aspiration may not significantly affect one person, it's also true that thickened fluids can be helpful for some individuals by improving comfort, reducing distressing symptoms, and supporting safer and more efficient intake of fluids.

The point is we need to make an individualised risk assessment and provide personalised, rather than blanket recommendations.

I don't know about you but when I completed my training I had a real fear of aspiration. In fact, another SLP reached out to me after listening to the podcast and said this:

"Honestly it's been life changing! I had a client pass away... he was frail and no longer ambulant. Sleeping most of the time. And I blamed myself for killing him because he died of aspiration pneumonia. And I stressed and had guilt about it for years."

This example perfectly illustrates one of the points that Shaun is trying to make: we do not currently have strong evidence that our interventions reliably prevent pneumonia, and quite frankly putting this burden upon ourselves is only going to cause a lot of unnecessary guilt and anxiety, which is likely going to result in making recommendations from a place of fear.

So where I sit today is that I think pneumonia risk for someone who is elderly, frail and in hospital acutely unwell, is completely different to someone who is in their 50s, with a lifelong chronic condition who is mobile and generally in good health.

I've spent most of my career in community-based settings, and if I look back, I think there is a lot of overly restrictive and fear-based practice that is dominating dysphagia care in a population of adults that are not acutely unwell. 

Therefore, I think it's something we really need to think about a lot more. I understand it's not a quick fix and clinicians are working within systems that are highly risk-averse and medico-legally conscious, which is inevitably going to influence practice. But I do think these are conversations our profession needs to be willing to have.

Want to hear the full conversation?

Head over to the Dysphagia Research Bites Podcast, Episode 6: Risk Feeding, Informed Consent & Prandial Aspiration with Dr Shaun O'Keeffe.

References:

O'Keeffe, S. T., Murray, A., Leslie, P., Collins, L., Lazenby-Paterson, T., Mccurtin, A., Mulkerrin, S., & Smith, A. (2021). Aspiration, risk and risk feeding: A critique of the Royal College of Physicians guidance on care of people with eating and drinking difficulties. Advances in Communication and Swallowing, 24(1), 63-72. https://doi.org/10.3233/ACS-210031