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

<b>Purpose:</b> 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.<b>Method:</b> Consecutive inpatients (<i>N</i> = 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.<b>Results: </b>There was a high incidence of accumulated secretions, with 77% of inpatients having elevated NZSS (<i>Mdn</i> = 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.<b>Conclusions: </b>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.<b>Supplemental Material S1.</b> Subgroup regression analysis: Patient Outcomes – FEES findings.<b>Supplemental Material S2. </b>Subgroup regression analyses: NZSS score outcomes - physiological measures across diagnostic groups and acuity (ICU, intubation, tracheostomy).Hunting, A., Steffanoni, B., Jacques, A., &amp; Miles, A. (2023). Accumulated secretions and associated aerodigestive function in patients with dysphagia. <i>American Journal of Speech-Language Pathology, 32</i>(6), 2691–2701. https://doi.org/10.1044/2023_AJSLP-23-00118

研究目的：咽喉分泌物蓄积与吞咽困难（dysphagia）、误吸（aspiration）及不良健康结局密切相关。尽管咽喉分泌物评估领域已有诸多进展，但学界对其潜在病理生理机制的认知仍较为有限。明确分泌物蓄积相关的病理生理学机制，可为制定个体化、靶向性治疗路径提供依据。本研究旨在明确大型急诊收治病例队列中咽喉分泌物蓄积的患病率，并探索分泌物蓄积与呼吸消化道功能之间的关联。
研究方法：连续纳入经言语语言病理学家（speech-language pathologist）评估后疑似吞咽困难、接受吞咽功能柔性内镜检查（flexible endoscopic evaluation of swallow, FEES）的住院患者共222例，最终完成250次标准化FEES检查（其中222例为首次检查，28例为复查）；纳入病例中43%为神经系统疾病患者，22%为神经外科疾病患者，20%为重症监护患者，15%为其他疾病患者。本次检查方案涵盖：采用新西兰分泌物量表（New Zealand Secretion Scale, NZSS）进行分泌物评估、咽部挤压试验（pharyngeal squeeze maneuver）、喉运动与感觉功能评估、误吸渗透量表（Penetration-Aspiration Scale）以及耶鲁咽部残留物严重程度评定量表（Yale Pharyngeal Residue Severity Rating Scale）。内镜检查过程中采集患者的清咽冲动评分，同时记录咳嗽峰值呼气流速、吞咽频率数据，以及患者出院时的临床结局指标。
研究结果：咽喉分泌物蓄积发生率较高：77%的患者NZSS评分升高（中位数Mdn=3，分值范围0~7），37%的患者存在喉部分泌物蓄积。分泌物蓄积与吞咽频率降低、喉内收反射减弱、咽部挤压试验异常及峰值呼气流速降低显著相关。NZSS评分还与吞咽功能评估指标（误吸渗透量表、耶鲁咽部残留物严重程度评定量表）及患者临床结局（如出院时的饮食建议、住院期间的肺炎发生情况）显著相关。
研究结论：本大型研究为感觉与运动功能受损均与分泌物蓄积及误吸风险相关这一结论提供了实证支持。进一步探索分泌物蓄积的关键生理机制，可为制定分泌物管理方案的干预靶点提供原理验证标志物。
补充材料S1：亚组回归分析——患者结局与FEES检查结果。
补充材料S2：亚组回归分析——NZSS评分结局：不同诊断组别与病情严重程度（重症监护病房、气管插管、气管切开术）的生理指标关联。
参考文献：Hunting, A., Steffanoni, B., Jacques, A., & Miles, A. (2023). 吞咽困难患者的分泌物蓄积及其相关呼吸消化道功能. 《美国言语语言病理学期刊》, 32(6), 2691–2701. https://doi.org/10.1044/2023_AJSLP-23-00118