These days, everybody is coughing. The resurgence of COVID, RSV, and flu has overwhelmed emergency rooms and hospitals this early winter. But not all coughs are viral. If you recently visited a family member for the holidays and noticed a persistent cough after dinner, you may have witnessed not a viral illness but what’s known as an aspiration event.

As primary care providers, we frequently take care of people who are at high risk for these aspiration events or have already aspirated and find themselves hospitalized for weeks at a time. Increasing public awareness of more subtle aspiration, or “micro-choking,” may get people the help they need before complications arise.

Aspiration is choking, but not the choking that most people are familiar with. People may remember Mrs. Doubtfire, played by Robin Williams, performing the Heimlich maneuver while reassuring the choking victim, “Hold on, dear! Help is on the way!” Every First Aid course – and nearly every movie – teaches us how to recognize signs of choking: the gasping, the clutching of the neck, the panicked silence, and the look of fear as persons realize they cannot breathe.

Fewer people are familiar with the chronic, subtle aspiration events, effectively “micro-choking.” This type of aspiration can lead to prolonged stays in the hospital, recurrent pneumonia, and, in some cases, requiring a breathing tube on life support. The deadliest consequence of aspiration is aspiration pneumonia, a bacterial infection of the lungs, which kills approximately 18,000 people a year.

Aspiration occurs when tiny particles of food, liquids, or saliva enter the airway instead of the stomach: when something goes down the wrong pipe. It can sometimes be as dramatic as choking, but more often, aspiration presents as a persistent cough.

What’s causing the micro-choking is important, too, as this will help determine what to do next.

A primary care doctor usually refers someone with possible aspiration to a speech-language pathologist, an expert in evaluating and providing recommendations on reducing the risk of aspiration. Speech-language pathologists observe people eating and drinking to see what triggers micro-choking. Sometimes, speech-language pathologists will perform specific tests to directly observe swallowing function, such as with a small camera. Once they determine the cause of aspiration, these specialists can provide specific exercises, adjustments to diet, and, depending on the cause, additional recommendations to prevent aspiration and potential complications.

Common risk factors for aspiration include any condition that causes difficulty swallowing (or dysphagia), as well as alcohol use and heartburn. In fact, one in five healthy adults over the age of 50 (and two in five elderly people) experience some sort of difficulty swallowing. Having any sort of difficulty swallowing dramatically increases the risk of developing aspiration pneumonia. People with the highest risk of complications from micro-choking include those with dementia, stroke, and seizures.

To be sure, not all coughs are due to aspiration. The common cold, flu, and other viruses often cause coughing. Additionally, chronic lung diseases, such as asthma and emphysema, cause people to cough and feel short of breath. People who have pneumonia, which is typically due to a bacterial infection in the lungs, will typically have fever and coughing. However, aspiration pneumonia is common enough – according to a 2019 review in the New England Journal of Medicine, 15 percent of all pneumonia are estimated to be aspiration-related – that it is clear that recognizing aspiration before it causes pneumonia and other complications is worthwhile.

That’s why the timing is good for all of us to consider whether a cough might be caused by micro-choking or aspiration. Increased awareness and early recognition of aspiration can help people receive the treatment needed to prevent potential complications, keeping them healthy and out of the hospital.

The West Haven VA Center of Education in Interprofessional Primary Care includes Deanna Blansky, MD, Edward Chen, MD, Sanjana Garimella, MD, Rose Gedeon, MD, Elizabeth Hammond, NP, Tiffany Hu, MD, Natalie Kolba, MD, Daniel Lee, MD, Abigail Marriott, MD, Johnathan Yao, MD, MPH, Lucia You, MD, and Anna Reisman, MD.