From Aspiration Detection to Prevention: A Proposed Risk Stratification Framework and Radiographer-Led Aspiration Risk Management in Barium-Based Fluoroscopic Swallowing Examinations

Abstract Background: Aspiration during barium-based fluoroscopic swallowing examinations is an uncommon but potentially serious patient-safety event, particularly in patients with chronic or progressive dysphagia and previously documented aspiration. Current clinical practice does not provide a widely adopted imaging-specific framework for systematically stratifying the risk of aspiration before contrast administration. Case Presentation: The framework was informed by a longitudinal case of a 74-year-old man with progressive chronic dysphagia who underwent three fluoroscopic swallowing examinations between 2021 and 2026, with aspiration documented during each episode.During the third examination in 2026, extensive barium aspiration into the right tracheobronchial tree occurred immediately after swallowing. The event was promptly recognized by the radiographer/radiologic technologist*, further contrast administration was discontinued, and the patient was closely monitored. Despite the extensive radiographic appearance of aspiration, no clinical respiratory deterioration was observed during 72 hours of follow-up. Risk Stratification Framework: The longitudinal clinical course was used to identify potentially relevant pre-examination risk factors and to develop a provisional aspiration risk stratification framework. The proposed framework incorporates previous documented aspiration, chronic dysphagia, neurological disease, previous aspiration pneumonia, suspected structural abnormalities, advanced age, cognitive impairment, impaired cough reflex, and recurrent fluoroscopic examinations. A provisional weighted scoring system categorizes patients into low-, moderate-, and high-risk groups and is intended to support individualized examination planning rather than replace clinical judgment.