[Dysphagia] "Aspiration tolerance"

[HAL9600 at aol.com (HAL9600 at aol.com)]

Is this a meaningful concept to those on the listserv, and, if so, how is  it 
evaluated clinically?
SLP's involvement is to evaluate the integrity of the swallow and thus  
determine causes of unsafe swallow and to minimize those to allow a person to  eat 
and drink. However, especially in the case of someone who is NPO due to  a 
severe loss of motor integrity from a stroke or TBI, we confront a decision  
regarding when to start and how aggressively to proceed with individuals who may  
seem no worse on clinical and instrumental exam than others with whom we  
work.  The difference, however, is that these same individuals are  virtually or 
literally immobile due to paralysis or severe paresis, were  sometimes in 
prolonged coma and in compromised cognitive state, and  sometimes have a h/o or URI 
even while on NPO.  The same individual may be  progressing in terms of 
mobility so that we can be guardedly optimistic that the  immobility is temporary 
rather than permanent.
 
In our thought process we try to take into account that even normals  
aspirate but tolerate it.  We understand the major risk is aspiration of  infected 
secretions from poor oral hygiene.  But in the scenario I  describe, would you 
opt to wait a bit, work on other motor competencies, provide  as much cognitive 
rehabilitation as possible, until, hopefully, this person can  move about a 
bit and is more resistant to URI as a result?  Are there other  factors than 
immobility that put the individual with otherwise adequate  respiratory function 
at risk and that would cause you to wait, and, if so, how  are these 
evaluated objectively?