Prediction of aspiration pneumonia development in at-risk patients is vital for implementation of appropriate interventions to reduce morbidity and mortality. Unfortunately, studies utilizing a comprehensive approach to risk assessment are still lacking. The objective of this study was to analyze the clinical features and videofluoroscopic swallowing study (VFSS) findings that predict aspiration pneumonia in patients with suspected dysphagia.Medical records of 916 patients who underwent VFSS between September 2014 and June 2018 were retrospectively analyzed. Patients were divided into either a pneumonia group or a non-pneumonia group based on diagnosis of aspiration pneumonia. Clinical information and VFSS findings were evaluated.One hundred seven patients (11.7%) were classified as having pneumonia. Multivariate analysis indicated that aspiration during the 2- cubic centimeter thick-liquid trial of VFSS (odds ratio [OR] = 3.23, 95% confidence interval [CI]: 1.93-5.41), smoking history (OR = 2.63, 95% CI: 1.53-4.53), underweight status (OR = 2.27, 95% CI: 1.31-3.94), abnormal pharyngeal delay time (OR = 1.60, 95% CI: 1.01-2.53), and a Penetration-Aspiration Scale level of 8 (OR = 3.73, 95% CI: 2.11-6.59) were significantly associated with aspiration pneumonia development. Integrated together, these factors were used to develop a predictive model for development of aspiration pneumonia (DAP), with a sensitivity of 82%, specificity of 56%, and an area under the receiver operating characteristic curve of 0.73.The best predictors for DAP included videofluoroscopic findings of aspiration during a 2-cubic centimeter thick-liquid trial, prolonged pharyngeal delay time, a Penetration-Aspiration Scale level of 8, history of smoking, and underweight status. These 5 proposed determinants and the associated DAP score are relatively simple to assess and may constitute a clinical screening tool that can readily identify and improve the management of patients at risk for aspiration pneumonia.