Dysphagia outcomes in patients with burn injury

1
Dysphagia outcomes in patients with burn injury

• Sarah Wallace
• University Hospital of South Manchester,
  Wythenshawe

2
Background

• Dysphagia is a reported complication of
  inhalation injury in burns patients (Muehlberger
  et al 1998)
• Secondary causes suggested include intubation,
  sepsis, tracheostomy, critical illness and
  orofacial scarring
• Burns patients have elevated metabolic rates and
  increased nutrition / hydration requirements
• Achieving optimum nutrition is critical for
  healing and successful outcomes

3
Previous studies

• Paucity of research into dysphagia and swallow
  recovery following burns
• 2 retrospective studies (30 and 28 patients)
  found associations between burn severity,
  protracted ventilation / tracheostomy and
  dysphagia
• (Ward et al 2001, McKinnon DuBose et al 2005)
• No UK studies to date

4
Study aims

• To gather data on the characteristics of our
  burns patients with dysphagia
• To determine the duration of dysphagia and
  factors influencing swallow recovery
• To suggest indicators for early referral

5
Method

• Retrospective review of dysphagia referrals from
  burns unit / burns ICU over 4 years
• Data gathered
• medical history
• burn cause, severity and facial involvement
• inhalation injury
• ventilation and tracheostomy requirements
• aspiration pneumonia events
• days to oral feeding
• initial and final feeding recommendations
• Bedside swallowing assessments performed by SLT
  with critical care skills
• 9 FEES performed

6
Patient data

• 41 patients (28 m 13 f) age range 16-91yrs (mean
  48yrs)
• 38 (93) showed signs of dysphagia requiring
  further assessment
• Burn severity
• 2-74 TBSA (mean burn severity 29)
• half sustained gt25 burns
• 26 patients (63) had facial and neck burns
• 27 (66) diagnosed with inhalation injury
• 7 patients died

7
Co-morbidities
8
Cause of burn injury
9
Ventilation tracheostomy requirements

• Ventilation
• 36 (88) mechanically ventilated via ETT
• Of 26 with facial/neck burns, 25 were ventilated
• All 27 with inhalation injury were ventilated
• 4 ventilated patients had neither facial burn nor
  inhalation injury (2 scalded, 1 electrocuted, 1
  flame burn to trunk)
• Tracheostomy
• 29 (71) required a tracheostomy
• Duration tracheostomised 7-90 days (mean 33 days)

10
Aspiration pneumonia

• Before referral to SLT, aspiration pneumonia was
  diagnosed in 21 patients
• Following SLT intervention, aspiration pneumonia
  recurred in 1 patient (silent aspirator on FEES)
• Aspiration pneumonia is associated with older
  patients
• mean age 53yrs
• mean age 32yrs for asymptomatic patients

11
Days from hospital admission to commencing safe
oral feeding

• Overall range 3104 days (mean 27days)

12
Initial and final feeding recommendations
13
FEES findings

• 9 FEES performed
• all had inhalation injury and tracheostomy
• all exhibited laryngeal trauma (oedema, mucosal
  sloughing)
• excess secretions common
• penetration and aspiration on 5 FEES
• FEES is very useful in burns but tolerance of
  scoping is an issue

14
FEES images
Normal larynx
15
Conclusions

• Dysphagia is often severe in the acute phase but
  swallow function should fully recover
• Patients require on-going artificial feeding
• Expect slower swallow recovery in ventilated,
  tracheostomised patients with facial or severe
  burns
• Early referral of these patients to SLT can
  facilitate safe introduction of oral feeding and
  may reduce aspiration pneumonia

16
Recommendations

• Develop guidelines, competency framework and
  links for SLTs working with burns
• Further research
• prospective study identifying predictors of
  dysphagia and aspiration in all burns admissions

17
References

• McKinnon DuBose C.M, Groher M, Carnaby Mann G,
  Mozingo DW. J of Burn Care Rehab 2005 26233-37
• Muehlberger T, Kunar D, Munster A, Couch M.
  Efficacy of fibreoptic laryngoscopy in the
  diagnosis of inhalation injuries. Arch
  Otolaryngol Head Neck Surg 1998 1241003-7
• Ward EC, Uriarte M, Conroy B. Duration of
  dysphagic symptoms and swallowing outcomes after
  thermal burn injury. J of Burn Care Rehab 2001
  22441-45
• sarah.wallace_at_uhsm.nhs.uk