There is a significant risk for aspiration of secretions & reflux with tube feedings, which increases the risk of pneumonia.

Evidence across disciplines is clear: aspiration occurs with tube feedings. 

Insight Swallow’s SLP endoscopists often consider which aspiration risk is greater—a PO diet or an NPO tube feeding. We get a lot of questions as to why and how we evaluate these risks.

Real case example from last week: 

NPO patient with significant secretions. Upon insertion of FEES scope, secretions are observed in the laryngeal vestibule and below the vocal folds (aspirated!).

Before PO trials, the patient is aspirating secretions. 

During the imaging study:

  • PO trials of nectar thick and pureed consistencies are penetrated to level of vocal folds– 1x of 5 trials enter the airway. Patient does not cough. ** SLP cues patient to cough volitionally and subglottic material is ejected. 
  • Thin liquids in large consecutive sips result in aspiration without cough. Small sips swallowed 100% of 8 trials WNL—no residue, no penetration, no aspiration. 
  • Moist and bite-size solid swallows result in laryngeal penetration, no aspiration. Min-Mod pharyngeal retention which easily clears with liquid rinse. 

Recommended diet: Thin liquids & IDDSI 5 (NDD2) only with use of compensatory strategies and thorough oral hygiene. 


  • Patient is cognitively able to remember to use strategies- cough after each bite, alternate liquids and solids.  
  • Patient able to independently complete oral cares & self-feed. 
  • Patient already aspirating secretions with tube-feeding alone. 
  • Patient is cognitively able & motivated to use compensatory strategies and remind caregivers to assist with oral hygiene. 
  • Patient has excellent bed mobility and is walking over 150 ft with physical therapy as opposed to poor posture with severe immobility.

At times, a peg tube is medically necessary. It is ultimately a medical decision between the physician and the patient. We are not saying a patient shouldn’t have a feeding tube—this is not our decision to make. But as SLPs and informed clinical practitioners, we do have a responsibility to educate based on facts and assess risk within our scope of care. 

It IS our responsibility to share information based on the swallow imaging findings and research evidence—for the patient, family and medical team’s consideration. 

It IS within our scope to assess the aspiration risk and predictors of aspiration pneumonia and to provide this information to the medical team.

Resource Statements

1. “In our study, tube feeding was significantly associated with aspiration pneumonia, which is consistent with the findings of others [19,28,31–34,38,40]. Because our patients were usually not taking any food or liquid by mouth, aspiration presumably occurred with secretions. (Langmore Predictor study Feeding/Mode of Nutritional Intake, Dysphagia Journal, Susan E. Langmore, PhD,1,2 Margaret S. Terpenning, MD,1,3 Anthony Schork, PhD,4 Yinmiao Chen, MS,4 Joseph T. Murray, MA,1 Dennis Lopatin, PhD,5 and Walter J. Loesche, DMD, PhD).

2. “Individuals with PEG tubes are likely to encounter negative outcomes such as aspiration of reflux, pneumonia, malnutrition, site infections, GI bleeds, etc.”  (Decreasing Use of Percutaneous Endoscopic Gastrostomy Tube Feeding in Japan, Komiya et al, 2018).

3. “Frequent episodes of gastroesophageal reflux and aspiration of gastric contents, which increased when the infusion rate was speeded up for nutritional replacement. Gastric retention also occurred at the higher infusion rate. Thus, percutaneous gastrostomy may not decrease the frequency of aspiration in patients at risk.”  (Aspiration after percutaneous gastrostomy, M J Cole, J T Smith, C Molnar, E A Shaffer).

4. “Higher rates of aspiration pneumonia were found in tube-fed patients than non tube-fed patients (rates ranged from 58 to 67% versus 14 to 17% for tube-fed and non tube-fed, respectively). Where tubes were placed primarily for nutritional support, several patients developed aspiration pneumonia for the first time (rates ranged from 7 to 29%) and many with a history of aspiration continued to aspirate (rates ranged from 11 to 62%).” (Use of tube feeding to prevent aspiration pneumonia, TE Finucane and JP Bynum. Review published: 1996).

Additional Sources: 

  •  Enteral nutrition as a risk factor for nosocomial pneumonia.Pingleton SK:  Eur J Clin Microbiol Infect Dis 8:51–55, 1989
  • Tube feedings in elderly patients: indications, benefits, and complications.Ciocon JO, Silverstone FA, Graver LM, Foley CJ:  Arch Int Med 148:105–108, 1993
  • Long-term enteral feeding of aged demented nursing home patients. Peck A, Cohen C, Mulvihill MN: . J Am Geriatr Soc 38:1195–1198, 1990
  • Tube feeding-related pneumonias. Pritchard V:  J Gerontol Nurs 14(7):32–36, 1988 37. Cole MJ, Smith JT, Molnar C, Shaffer EA: 
  • Tube feeding and lethal aspiration in neurological patients: a review of 720 autopsy cases.Olivares L, Segovia A, Revuelta R:  Stroke 5:654–657, 1974 41. Sartori S, Trevisani L, Tassinari D, Nielsen I, Gilli G, Donati D, Malacarne P: 
  • Aspiration after percutaneous gastrostomy. J Clin Gastroenterol 9(1):90–95, 1987 38. Hassett JM, Sunby C, Flint LM:
  • No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surg Gyncol Obstet 167:383–388, 1988
  • Prevention of aspiration pneumonia during long term feeding by percutaneous endoscopic gastrostomy: might cisapride play any role? Support Care Cancer 2:188–190, 1994
  • AGS (American Geriactric Society —