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Predictive Value of the New Zealand Secretion Scale (NZSS) for Pneumonia


Accumulated pharyngo-laryngeal secretions have been associated with aspiration and pneumonia. While traditional secretion scales evaluate location and amount, the eight-point New Zealand Secretion Scale (NZSS) uniquely encompasses a responsiveness subcomponent. This prospective observational study investigated the predictive value of NZSS for aspiration and pneumonia. Consecutive inpatients (N:180) referred for flexible endoscopic evaluation of swallowing (FEES) were recruited (neurological 49%, critical care 31%, structural 15%, other 5% etiologies). Mean age was 63 years (range 18–95 years, S.D. 18). A standardized protocol was completed on 264 FEES (180 first FEES, 84 repeat FEES). Penetration-aspiration scale (PAS) (ICC = .89) and NZSS (ICC = .91) were independently scored by two raters. Aspiration of food and/or fluids occurred in 36% of FEES; 24% silently. Median NZSS was 3 (range 0–7); with silent aspiration of secretions in 33% of FEES. There was a significant correlation between NZSS and PAS (R = .37, p < .001). Incidence of pneumonia during admission was 46% and was significantly associated with PAS (p < .001), NZSS (p < .001), age (p < .001), and tracheostomy (p < .001). Of those who developed pneumonia, 33% had both high PAS (>5) and high NZSS (>4). Eleven percent of those who developed pneumonia had an elevated NZSS (>4) in the absence of aspiration (PAS < 6). This large study reports the significant relationship between accumulated secretions, airway responsiveness, and pneumonia. This comprehensive scale is a useful tool when carrying out endoscopic evaluation and has the potential to predict pneumonia in patients irrespective of their aspiration status.

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  1. 1.

    Smith-Hammond C, Goldstein L, Zajac D, Gray L, Davenport P, Bolser D. Assessment of aspiration risk in stroke patients with quantification of voluntary cough. Neurology. 2001;56(4):502–6.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Pikus L, Levine M, Yang Y, et al. Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia. Am J Roentgenol. 2003;180:1613–6.

    Article  Google Scholar 

  3. 3.

    Nakagawa T, Sekizawa K, Arai H, Kikuchi R, Katsuhiro M, Hidetada S. High incidence of pneumonia in elderly patients with basal ganglia infarction. Arch Intern Med. 1997;157(3):321–4.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Murray J, Langmore S, Ginsberg S, Dostie A. The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia. 1996;11:99–103.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Ota K, Saitoh E, Baba M, Sonoda S. The secretion severity rating scale: a potentially useful tool for management of acute-phase fasting stroke patients. J Stroke Cerebrovasc Dis. 2011;20(3):183–7.

    Article  PubMed  Google Scholar 

  6. 6.

    Donzelli J, Wesling M, Brady S, Craney M. Predictive value of accumulated oropharyngeal secretions for aspiration during video nasal endoscopic evaluation of the swallow. Ann Otol Rhinol Laryngol. 2003;112:469–75.

    Article  PubMed  Google Scholar 

  7. 7.

    Link DT, Willging JP, Cotton RT, Miller CK, Rudolph CD. Pediatric laryngopharyngeal sensory testing during flexible endoscopic evaluation of swallowing: feasible and correlative. Ann Otol Rhinol Laryngol. 2000;109(10):899–905.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Takahashi N, Kikutani T, Tamura F, Groher M, Kuboki T. Videoendoscopic assessment of swallowing function to predict the future incidence of pneumonia of the elderly. J Oral Rehabil. 2012;39:429–37.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Rosenbek J, Robbins J, Roecker E, Coyle J, Wood J. A penetration-aspiration scale. Dysphagia. 1996;11:93–8.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Mann G, Hankey G, Cameron D. Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovasc Disord. 2000;10:380–6.

    CAS  Article  Google Scholar 

  11. 11.

    Cichero JAY, Lam P, Steele CM, et al. Development of international terminology and definitions for texture-modified foods and thickened fluids used in dysphagia management: The IDDSI framework. Dysphagia. 2016;32(2):293–314.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Preiksaitis H, Mills C. Coordination of breathing and swallowing: effects of bolus consistency and presentation in normal adults. J Appl Physiol. 1996;81:1707–14.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Leder S, Cohn S, Moller B. Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia. 1998;13:208–12.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Leder S, Sasaki C, Burrell M. Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia. 1998;13:19–21.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Hafner G, Neuhuber A, Hirtenfelder S, Schmedler B, Eckel H. Fiberoptic endoscopic evaluation of swallowing in intensive care unit patients. Eur Arch Otorhinolaryngol. 2008;265:441–6.

    Article  PubMed  Google Scholar 

  16. 16.

    Westendorp W, Nederkoorn P, Vermeij J, Dijkgraaf M, van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMJ Neurol. 2011;11(110):1–7.

    Google Scholar 

  17. 17.

    Leder SB, Ross DA. Confirmation of no causal relationship between tracheostomy and aspiration status: a direct replication study. Dysphagia. 2010;25:35–9.

    Article  PubMed  Google Scholar 

  18. 18.

    Daly E, Miles A, Scott S, Gillham M. Finding the red flags: Swallowing difficulties after cardiac surgery in patients with prolonged intubation. J Crit Care. 2016;31(1):119–24.

    Article  PubMed  Google Scholar 

  19. 19.

    Langdon P, Lee A, Binns C. High incidence of respiratory infections in ‘nil by mouth’ tube-fed acute ischemic stroke patients. Neuroepidemiology. 2009;32:107–13.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Sellars C, Bowie L, Bagg J, et al. Risk factors for chest infection in acute stroke: a prospective cohort study. Stroke. 2007;38:2284–91.

    Article  PubMed  Google Scholar 

  21. 21.

    Dziewas R, Ritter M, Schilling M, et al. Pneumonia in acute stroke patients fed by nasogastric tube. J Neurol Neurosurg Psychiatry. 2004;75(6):852–6.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Butler S, Stuart A, Markley L, Rees C. Penetration and aspiration in healthy older adults as assessed during endoscopic evaluation of swallowing. Ann Otol Rhinol Laryngol. 2009;118(3):190–8.

    Article  PubMed  Google Scholar 

  23. 23.

    Bax L, McFarlane M, Green E, Miles A. SLT-led FEES services: functional outcomes for patients following stroke. J StrokeCerebrovasc Dis. 2014;23(3):195–200.

    Article  Google Scholar 

  24. 24.

    Altman K, Yu G, Schaefer S. Consequence of dysphagia in the hospitalized patient. Arch Otolaryngol Head Neck Surg. 2010;136(8):784–9.

    Article  PubMed  Google Scholar 

  25. 25.

    Finlayson O, Kapral M, Hall R, Asllani E, Selchen D, Saposnik G. Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology. 2011;77:1338–45.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Wirth R, Dziewas R, Beck AM, et al. Oropharyngeal dysphagia in older persons—from pathophysiology to adequate intervention: a review and summary of an international expert meeting. Clin Interv Aging. 2016;11:189–93.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Smith CH, Logemann JA, Coleangelo LA, Rademaker AW, Pauloski BR. Incidence and patient characteristics associated with silent aspiration in the acute care setting. Dysphagia. 1999;14(1):1–7.

    CAS  Article  PubMed  Google Scholar 

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Thank you to the allied health staff for support with participant recruitment: Emma Wackrow, Naomi McLellan, Kelly Davis and Irene Kumar.

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Correspondence to Anna Miles.

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Miles, A., Hunting, A., McFarlane, M. et al. Predictive Value of the New Zealand Secretion Scale (NZSS) for Pneumonia. Dysphagia 33, 115–122 (2018).

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  • Dysphagia
  • Deglutition
  • FEES
  • Endoscopy
  • Secretions
  • Airway responsiveness
  • Silent aspiration