SLPs are trained to scrutinize every swallow during FEES studies. We meticulously document airway protection and residue scores, and we make diet recommendations based on bolus trials. Focusing on just the food and drink trials alone could leave out a critical piece of the pneumonia prediction puzzle.

Enter the New Zealand Secretion Scale (NZSS)—and the research that proves quantifying secretions matters!

The Eye-Opening Research

A landmark 2018 study by Miles and colleagues followed 180 patients across 264 FEES examinations and uncovered some startling findings. While 36% of patients aspirated food or liquids (with 67% doing so silently), an additional 33% silently aspirated their own secretions.

But here’s where it gets really interesting: 11% of patients who developed pneumonia had elevated secretion scores (NZSS >4) but didn’t aspirate during food or liquid trials. They were at risk— but traditional penetration-aspiration scoring with boluses alone didn’t capture it.

Why NZSS Changes the Game

Unlike traditional secretion scales that only measure location and amount, the NZSS adds a third critical component: response. Can the patient spontaneously cough, throat clear, or swallow to manage their secretions? Or are they pooling secretions with no sensory response?

Perhaps most importantly, this research reminds us that NPO status doesn’t equal safety. Patients who are NPO can still develop aspiration pneumonia from saliva alone. If we’re not assessing and documenting secretion management, we’re missing a significant risk factor.

Putting It Into Practice

So what do we do with a high NZSS score? The researchers acknowledge this is where we need more evidence, but clinical reasoning suggests that we identify the underlying deficit and act accordingly:

  • Sensory issues? Consider cold/sour stimulation, ice chips, or other sensory enhancement
  • Motor weakness? Implement strengthening exercises and strategies to increase swallowing efficiency
  • In many cases, patients could benefit from a combined approach

The Bottom Line

For thorough risk assessment, it’s best practice to incorporate objective secretion ratings into FEES reports. Patheous Health has the NZSS built into our standard FEES templates and we’re happy to discuss risks and management strategies for pooled secretions!

References:

Miles, A., Hunting, A., McFarlane, M., Caddy, D., & Scott, S. (2018). Predictive Value of the New Zealand Secretion Scale (NZSS) for Pneumonia. Dysphagia, 33(1), 115–122. https://doi.org/10.1007/s00455-017-9841-z