Secretions and aerodigestive function (Hunting et al., 2023)

Purpose: Accumulated pharyngo-laryngeal secretions are associated with dysphagia, aspiration, and poor health outcomes. Despite ongoing developments in the evaluation of pharyngo-laryngeal secretions, understanding of the underlying mechanisms is limited. Pathophysiology associated with accumulated secretions is needed to guide tailored, targeted treatment pathways. This study reports the prevalence of accumulated pharyngo-laryngeal secretions in a large acute care caseload and explores the relationship between secretions and aerodigestive function.Method: Consecutive inpatients (N = 222) referred for flexible endoscopic evaluation of swallow (FEES) with suspected dysphagia following assessment by a speech-language pathologist were recruited (43% neurological, 22% neurosurgical, 20% critical care, 15% other), and 250 standardized FEES were completed (222 first FEES, 28 repeat FEES). The assessment protocol included secretion assessment using the New Zealand Secretion Scale (NZSS), pharyngeal squeeze maneuver, laryngeal motor and sensory assessment, Penetration-Aspiration Scale, and Yale Pharyngeal Residue Severity Rating Scale. Urge-to-clear ratings were collected during endoscopy. Cough peak expiratory flow and swallow frequency measures were also collected, as well as clinical outcomes at time of discharge.Results: There was a high incidence of accumulated secretions, with 77% of inpatients having elevated NZSS (Mdn = 3, range: 0–7) and 37% with pooled laryngeal secretions. Accumulated secretions were associated with reduced swallow frequency, reduced laryngeal adductor reflex, impaired pharyngeal squeeze maneuver, and peak expiratory flow. NZSS scores also correlated with swallow measures (Penetration-Aspiration Scale and Yale Pharyngeal Residue Severity Rating Scale) and patient outcomes including diet recommendations at discharge and pneumonia during admission.Conclusions: This large study contributes to evidence associating both sensory and motor impairments with secretion accumulation and aspiration risk. Further exploration of the key physiological mechanisms contributing to accumulated secretions will serve as markers to provide proof of principle for targets for secretion management protocols.Supplemental Material S1. Subgroup regression analysis: Patient Outcomes – FEES findings.Supplemental Material S2. Subgroup regression analyses: NZSS score outcomes - physiological measures across diagnostic groups and acuity (ICU, intubation, tracheostomy).Hunting, A., Steffanoni, B., Jacques, A., & Miles, A. (2023). Accumulated secretions and associated aerodigestive function in patients with dysphagia. American Journal of Speech-Language Pathology, 32(6), 2691–2701. https://doi.org/10.1044/2023_AJSLP-23-00118

目的：咽喉部分泌物的累积与吞咽困难、误吸以及不良的健康预后相关。尽管在评估咽喉部分泌物方面持续取得进展，但对潜在机制的理解仍显不足。针对累积分泌物的病理生理学研究对于指导定制化的治疗路径至关重要。本研究报告了在大量急性护理病例中咽喉部分泌物累积的流行情况，并探讨了分泌物与呼吸道消化功能之间的关系。
方法：连续入院的病人（N = 222）被招募进行可弯曲内窥镜吞咽评估（FEES），疑似吞咽困难，在言语治疗师评估后，其中43%为神经性病例，22%为神经外科病例，20%为重症监护病例，15%为其他病例，共完成了250项标准化的FEES（222项首次FEES，28项重复FEES）。评估方案包括使用新西兰分泌物量表（NZSS）进行分泌物评估、咽部挤压动作、喉部运动和感觉评估、穿透-误吸量表以及耶鲁咽部残留严重程度评分量表。在内窥镜检查期间收集了急迫清除评分。还收集了咳嗽峰值呼气流量和吞咽频率的测量值，以及出院时的临床结果。
结果：累积分泌物的发生率较高，77%的住院病人NZSS评分升高（中位数 = 3，范围：0–7），37%存在喉部分泌物积聚。累积分泌物与吞咽频率降低、喉部括约肌反射减弱、咽部挤压动作受损和峰值呼气流量降低相关。NZSS评分还与吞咽测量值（穿透-误吸量表和耶鲁咽部残留严重程度评分量表）以及患者的预后相关，包括出院时的饮食建议和入院期间的肺炎。
结论：这项大型研究为证据提供了贡献，将感觉和运动障碍与分泌物累积和误吸风险联系起来。进一步探索导致分泌物累积的关键生理机制，将作为分泌管理方案靶点的原理证明的标志。
补充材料S1. 亚组回归分析：患者预后 – FEES发现。
补充材料S2. 亚组回归分析：NZSS评分结果 - 各诊断组和严重程度（ICU、插管、气管切开）的生理指标。
Hunting, A., Steffanoni, B., Jacques, A., & Miles, A. (2023). 吞咽困难患者中的累积分泌物及其相关的呼吸道消化功能。美国言语-语言病理学杂志，32(6)，2691–2701. https://doi.org/10.1044/2023_AJSLP-23-00118