Massachusetts Department of Developmental Services Risk Management 

Subject:	Dysphagia  and  Aspiration

What is it?
Dysphagia is a word that describes any problem a person may have with swallowing. Swallowing problems can lead to aspiration. Aspiration is a word that means food or fluids that should go into the stomach go into the lungs instead. Usually when this happens the person will cough in order to clear the food or fluid out of their lungs. Sometimes, however, the person does not cough at all. This is what is known as a “silent aspiration.” There are several ways to tell if someone has dysphagia or aspiration problems. 
Common signs of dysphagia and/or aspiration are:
•	Coughing before or after swallowing
•	Much drooling, especially during meals
•	Pocketing food inside the cheek
•	Choking on certain foods, for example white bread
•	Nose running or sneezing during dining
•	Trouble chewing
•	Trouble swallowing certain types of fluids
•	Trouble swallowing certain types of food
•	Taking a very long time to finish a meal
•	Getting tired during the meal
•	Refusals to eat certain foods or finish a meal
•	A complaint of feeling like something is caught in the throat
•	A gurgly voice during or after eating or drinking
•	Much throat clearing after a meal
•	Repeated episodes of choking, frequent colds, pneumonias or “allergies”
•	Unexplained weight loss
•	Unexplained fevers that come and go
•	Coughing when lying flat or sitting up quickly from a reclined position

Conditions that may lead to dysphagia and/or aspiration:
•	Aging
•	Poor dental alignment or missing teeth
•	Seizures
•	Decreased level of awareness
•	Fatigue
•	Some medication side effects that weaken ability to swallow
•	Poor muscle function as in cerebral palsy
•	Poor eating habits described as stuffing, or rapid eating
•	Some medical conditions 
•	Poor positioning or posture while eating

What risk does it present?
Frequent aspiration can cause damage to the lungs and even death from pneumonias or choking if it is not treated. It can often lead to long term chronic breathing problems like asthma and chronic obstruction pulmonary disease (COPD).

How is it managed?
Call 911 if the person is:  
•	Blue, can’t talk or make a sound or is not breathing 	(Attempt Heimlich Maneuver)
•	Having difficulty breathing
•	Looks very ill 

If you think there might be a problem with swallowing:
•	Document what you see
•	Tell other staff what you see
•	Tell the nurse or your supervisor what you see
•	Offer foods that the person seems to tolerate better
•	Stop the meal if the symptoms worsen and report it to the nurse or your supervisor according to your agency’s policy
•	Have the person eat at a slow pace
•	Tell the doctor what you see 

The person’s doctor will order the tests that they think will be best for each person. They may include chest x-rays, a swallow study. A feeding plan  including directions on consistency of food ( see below)  and positioning while eating may be developed as a result of the tests. The doctor may even recommend placement of a gastrostomy tube (G-Tube).

Where and to whom do these recommendations and protocols apply?

•	This protocol applies to any individual supported by the Department of Developmental Services 

•	Information regarding the individual’s status relative to this issue is to be handled in the same manner as any medical information according to HIPAA regulations.

Where can I find additional help?
•	DDS – Health and Wellness Promotion: www.mass.gov/dds

DESIRED FOOD TEXTURES AND DESCRIPTIONS

PUREE
The food texture is pureed.  It is smooth, moist, pudding-like and contains no lumps.  All food items should drop off the spoon in globs when the spoon is tilted.  They should not run off in a steady stream, nor be pasty or sticky.
GROUND
The food texture consists of small pieces of each food item up to the size of an apple seed.  Dry food items, should be moistened by puree or sauce to bind items together.
CHOPPED
The food texture consists of food items chopped to pea size (1/4”).  Each food item is soft or cooked until soft.  Each food item is recognizable for what it is.
REGULAR
The food texture consists of meat*, vegetable*, and dessert served restaurant style.  Green salads should be cut into bite-sized pieces.  Individual items in the salad should be no larger than a grape.  *In bite size pieces in ½ inch cubes.

YEAST BASED and GLUTEN-FREE BREAD:
Chopped Diets:	May have yeast based, muffins, cakes, cookies, pie with individual modifications as needed.
Ground Diets:	No sandwiches.  No yeast based breads.  May have cake, muffins, cookies broken down in milk.
Pureed Diets:	Pureed bread or cakes, muffins, pie and cookies.
Gluten-Free:	A yeast free bread (much like a biscuit) which breaks down easily and does not stick to the roof of the mouth as yeast based breads can.  This type of bread is available via medical order following Occupation/Speech Therapy evaluation.