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What is safe swallowing?

Safe swallowing involves the efficient, timely and coordinated transport of food, fluid and saliva from the mouth through the throat to the stomach. During safe swallowing the chances of choking should be very small.

What is meant by “unsafe swallowing”?

When a swallowing problem is present (known as dysphagia) there may be a high risk of food, fluid and saliva entering the trachea (windpipe) or lungs. This is known as aspiration. It can be an uncomfortable feeling for a person to experience and is likely to cause them to cough. However, sometimes a person may be unaware that it is happening, and they do not cough, this is called silent aspiration. Aspiration can be dangerous because it can cause pneumonia (an infection in the lungs) which can be fatal for some people. The cause may be anatomical (e.g. after surgery), neurological (e.g. due to an illness such as Parkinson's Disease, stroke or dementia), due to the aging process or due to an acute illness or infection.

Signs and symptoms

Signs of dysphagia include, but are not limited to:

  • Coughing or choking when eating or drinking
  • Gurgly or wet voice after swallowing
  • Excessive throat clearing
  • Weight loss because eating is difficult or unpleasant
  • Frequent chest infections.

How is unsafe swallowing managed?

A swallowing assessment by a Speech and Language Therapist (SLT) is advised.

Swallowing difficulties can be managed in several ways: 

  • Adjusting the texture of food and thickness of fluids
  • Postural changes and training in swallowing techniques that reduce the risk of aspiration during eating and drinking
  • Being ‘nil by mouth’
  • Tube feeding.

Eating and drinking with acknowledged risks

The term ‘eating and drinking with acknowledged risks’ means that a person is eating and drinking with a known risk of aspiration and aspiration pneumonia, i.e. a person is eating and drinking with a risk of food/drink entering the windpipe to the lungs. 

When might this plan be appropriate?

This is decided by a team with the person’s views (where possible) taken in to account, on a case by case basis. Some examples are: 

  • An adult with the mental capacity to choose to continue eating and drinking, accepting the risk of swallowing-related health complications. Some people are not prepared to give up the comfort that comes from the taste and texture of food and fluids even when eating and drinking results in coughing/choking episodes and aspiration. 
  • Where a person does not have the mental capacity to make the decision, allowing a person to continue eating and drinking, especially if they gain enjoyment from this, may be preferable to a feeding tube and staying "nil by mouth".
  • Situations where alternative feeding (e.g. a NG tube or a PEG tube) is not thought in a person's best interests, for example someone with advanced dementia for whom a PEG tube would not improve life expectancy or quality of life.

Practical factors to consider include:

  • Underlying medical condition and likely prognosis/life expectancy
  • Quality of life
  • The person's wishes
  • The person's best interests when someone does not have capacity.

The implications of ‘eating and drinking with acknowledged risks’

  • Medical implications such as the likelihood of developing aspiration pneumonia, experiencing weight loss and choking is high.
  • There should be clear parameters discussed with the person / carers / GP regarding ongoing treatment of these complications including appropriateness of admission to hospital. 

Advice

Before eating / drinking, check the following:

  • Is the person alert enough for eating and drinking?
  • Is the person comfortably supported in as upright a position as possible for eating and drinking in either bed or chair?
  • Is the environment suitable for eating and drinking, i.e. calm and free from distractions?
  • If appropriate, has the correct food/fluid consistency for safer eating and drinking been provided?
  • Has the correct equipment for eating and drinking been provided? 
  • Does the person wish to eat and drink at that time? - It may not be appropriate to push oral intake in a way that would not support their enjoyment.

Tips for Assisted Feeding

  • Tell the person it is a mealtime and you are going to assist them
  • Ensure they can see the food approaching
  • Offering smaller mouthfuls is safer than offering large mouthfuls
  • Give reminders about the food/drink throughout the meal
  • Maintain eye contact
  • Be patient and give sufficient time. Do not rush mealtimes
  • Make sure the person has swallowed before offering the next mouthful
  • Be comfortable with silence to avoid them needing to answer questions with a mouthful.

If any of the following occur, then WAIT...

  • Coughing
  • Excessive throat clearing
  • Wet/gurgly voice
  • The person starts to sound chesty or becomes short of breath.

and then offer food / fluid a little later.

General advice

  • Encourage small amounts of the correct texture of food and drinks frequently throughout the day
  • Maintain regular mouth care (such as brushing teeth, rinsing mouth with mouthwash, etc.).

Contact us

If you have any queries relating to this information, please contact the Speech and language therapy service.

About this information

Service:
Speech and language therapy

Reference:
VV/016

Approval date:
8 December 2023

Review date:
1 December 2026

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Important note 

This page provides general information only. It is developed by clinical staff and is reviewed regularly every 3 years for accuracy. For personal advice about your health, or if you have any concerns, please speak to your doctor.