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Objective To examine the association between local anaesthetic throat spray and sedation practice and aspiration pneumonia following percutaneous endoscopic gastrostomy (PEG) insertion.Methods A retrospective cohort study of adults undergoing PEG, identified from Hospital Episode Statistics between January 2016 and December 2021, and their 7-day post-PEG aspiration pneumonia rate at provider level. The National Endoscopy Database provided contemporaneous throat spray and sedation data during PEG at provider level. Logistic regression analysis examined associations with post-PEG aspiration pneumonia.Results 33 357 patients were analysed (59.8% male; age median 67 (IQR 56–77) years). 47% of providers predominantly used Midazolam and opioid, 19% Midazolam only, and 23% local anaesthetic throat spray with or without other sedation. Stroke was the main PEG indication (33%). Compared with stroke, all other indications were inversely associated with aspiration pneumonia. The strongest association with aspiration pneumonia was in providers predominantly using general anaesthetic/propofol (OR 4.83, 95% CI 2.66 to 8.79, p<0.001) and Midazolam and local anaesthetic throat spray (OR 4.52 (2.71–7.53), p<0.001). The association was much weaker with providers predominantly using Midazolam only (1.61 (1.02–2.56), p=0.042) or Midazolam with opioid (1.82 (1.20–2.75), p=0.004). Other associated factors included: fewer PEGs per provider ≤23 per annum (1.19 (1.05–1.36), p=0.009), emergency admission 15% vs 3% (4.29 (3.81–4.83), p<0.001) and increasing age >79 years (1.86 (1.61–2.15), p<0.001).Conclusions The strongest association with aspiration pneumonia was in providers who predominantly used propofol/general anaesthesia and midazolam with local anaesthetic throat spray for PEG insertion.