TY - JOUR
AU - FRACS, Michael J. Muller, MBBS, MMed Sci,
AB - Abstract The objectives of this study were 1) to establish clinical profiles of dysphagic and nondysphagic individuals following thermal burn injury and 2) to provide a clinical profile of the progression and outcome of dysphagia resolution by hospital discharge for a dysphagic cohort. A total of 438 consecutively admitted patients with thermal burns were included. All patients underwent a clinical swallowing examination. Medical parameters regarding burn presentation and its treatment and speech-language pathology specific variables from admission to discharge were collected for each participant. Dysphagia was identified in 49 patients via clinical assessment, and their course of recovery was followed up until the point of dysphagia resolution or discharge. No significant difference was observed between the dysphagic and nondysphagic groups in age, gender, and injury etiology. However, the dysphagic cohort was significantly different from the nondysphagic group in all variables pertaining to injury presentation and medical management. Individuals with dysphagia took significantly longer to start, and maintain, oral intake and required nonoral supplementation for three and a half times longer than those who were nondysphagic. Length of speech-language pathology intervention averaged 1 month for the dysphagics and increased with dysphagia severity. Return to normal fluid consistencies occurred in >75% of dysphagic individuals by week 7 after injury, although resumption of normal diet textures was more protracted, with 75% resuming normal oral intake by week 9. Dysphagia had resolved in 50% of the cohort by week 6, and by hospital discharge, 85% of the dysphagic individuals had resumed normal oral intake of thin fluids and a general diet. This is the first large prospective cohort study to establish clinical profiles of dysphagic and nondysphagic cohorts and document the nature of dysphagia and patterns of recovery within the thermal burn population. These current data will assist the allocation and planning of speech-language pathology services and provide baseline data on the course of dysphagia resolution in the adult thermal burn population. Dysphagia (swallowing impairment) has long been recognized as a potential negative consequence of thermal burn injury1,–8; yet, to date, there has been minimal investigation into the nature and recovery patterns of dysphagia in the thermal burn population. Single case reports7,9,10 and retrospective cohort studies within the literature to date11,–13 highlight that the rehabilitation of dysphagia and return to oral intake in this population can be variable, with long-term swallowing dysfunction a possible outcome for a small percentage. However, the current absence of prospective, large cohort studies means that the natural history relating to the nature and resolution of dysphagia following burn injury is currently not well understood. In addition, the literature available on patterns of recovery has largely focused on subsets of patients, such as only those referred to speech-language pathology (SLP)11,–13 or only those with severe burns,7,9,10 and hence does not encompass the whole of this clinical population. As such, the nature, severity, and course of recovery of the swallowing impairment after thermal burn have yet to be systematically reported. In the absence of relevant evidence, speech-language pathologists working in burn care settings have had limited data regarding expected patterns of resolution and achievable outcomes or rates of recovery for dysphagia in this population. Such data are necessary to guide assessment and treatment planning and to facilitate evidence-based prognostic insight. It is important for clinicians and patients and their families to receive accurate information and advice regarding prognosis and the natural history of their swallowing deficit to assist in the goal setting process.14 Thus, this study aims to remedy the current knowledge deficit regarding the natural history of dysphagia following thermal burn injury by 1) establishing the clinical profiles of both dysphagic and nondysphagic individuals following thermal burn injury through a prospective cohort study of admission and initial treatment characteristics and 2) providing a clinical profile of the progression and outcome of dysphagia resolution by hospital discharge. These baseline data will assist clinicians with the prioritization of patient treatment and aid realistic goal setting for dysphagia treatment that maximizes patient rehabilitation. It will also establish an early evidence base for the natural history of dysphagia in this population and may inform future development of clinical management pathways. METHODS Participant Population Participants included 438 adults (348 males and 90 females), ranging in age from 13 to 90 years (M = 38.32, SD = 17.40) with thermal burn injury (ie, caused by exposure to extreme temperature—hot or cold), with or without inhalation injury, who presented for management at a statewide, tertiary centre for adult burn care in Brisbane, Australia, over a 24-month period (August 2007–July 2009). The mean TBSA affected was 10.46% (SD = 11.75, range = 0.5–67.5). The most affected areas (from greatest to least involved) were the upper limbs, lower limbs, head and neck, and trunk. Participants included had no history of existing neurological or structural impairment that could influence swallowing behavior or a previous history of swallowing disorders, as determined by medical chart review, multidisciplinary discussion, and patient report. The biographical details of the entire participant cohort were found to be representative of both Australian- and worldwide-reported burn patient populations in respect to age and gender distribution, injury etiology, percent TBSA affected, and location of injury.15,–22 A study of dysphagia incidence and predictors for dysphagia risk has used the same participant cohort in a previous report23 and further participant details can be found there. The current study received ethical clearance from the Royal Brisbane and Women's Hospital and the University of Queensland ethics committees. Permission for participant inclusion was sought from the individual, the participant's next of kin or power of attorney, or the parents or guardian if aged younger than 18 years. Procedure Medical parameters known regarding the burn presentation and its treatment from admission to discharge were collected for each participant. Parameters collected included gender, injury etiology, and dichotomous variables such as presence of head and neck burns, presence of inhalation injury, need for intensive care unit (ICU) admission, need for intubation, and need for ventilation. In addition, data were collected related to length of hospital stay, length of ICU stay, length of stay in the burn unit, duration of intubation, duration of ventilation, time to conversion of endotracheal tube (ETT) to tracheostomy, and duration of tracheostomy. SLP-specific variables relating to safe oral intake as determined from clinical swallow examination (CSE) were recorded for all individuals. These included days to initiation of oral feeding from admission (DIOF), days to total oral feeding (no supplementation) from admission (DTOF), days between DIOF and DTOF (DI-TOF), number of days to achieve a normal diet after admission, and the total supplemental feeding period (days) and total period of SLP intervention (days) between admission and discharge. For the purposes of the current research only, all eligible participants underwent a CSE. Dysphagia status was evaluated, using CSE alone, by a speech pathologist experienced in managing patients after burn injury. Instrumental assessment of swallow (using either videofluoroscopy or fiberoptic endoscopic evaluation of swallowing) was not used to confirm or refute dysphagia presence in this study. The initial CSE was conducted during the acute phase of recovery, directly following determination of medical stability and suitability for oral intake by the medical officer in charge. Medical stability, for this study, was defined as the patient having a stable respiratory system, the ability to tolerate an upright position for at least 10 minutes, and the ability to maintain a sufficient level of alertness to tolerate swallowing evaluation. The initial CSE took approximately 20 minutes to complete and consisted of a patient interview, general observation, a perceptual evaluation of vocal quality, an oral motor examination encompassing both visual examination of the oromusculature and cranial nerve examination, observation of ability to handle secretions, performance on dry (saliva) swallows, and a series of oral intake trials, if deemed appropriate. Considerations for conducting a CSE with burned individuals, as outlined by Rumbach et al,8 were followed, with each assessment requiring some variation depending on patient presentation. All participants subsequently diagnosed with dysphagia then underwent a CSE conducted by a speech-language pathologist twice weekly (minimum) until the point of dysphagia resolution or discharge home or to another facility. Those participants without dysphagia (n = 389) were continued on a high energy and high protein diet, and their involvement in the research project was discontinued at this point. For the purpose of large group analysis of dysphagia resolution, only the dysphagia status at the first weekly assessment was used for each individual unless resolution was achieved within the week. It is important to note that treatment was individually prescribed and was consistent with what are considered traditional dysphagia management and rehabilitation techniques used with the burn population as outlined by Rumbach et al.8 Frequency of treatment was determined by patient need, as per normal clinical practice at our facility, and no maximum numbers of treatment sessions were prescribed. Each treatment session lasted for approximately 20 to 30 minutes. Individuals who were tracheostomized were able to use speaking valves if medically appropriate (airway patency confirmed via respiratory physician or an ENT). Treatment ended when dysphagia resolved or the treatment goals were reached (see information on outcome measures). Oral motor function was assessed using a cranial nerve assessment before oral intake trials. Presence of edema and scar and contracture formation at the time of initial CSE was noted. Patient suitability for oral intake trials was determined by information derived from the medical history and performance data related to oral motor functioning and pharyngeal and laryngeal control. Dietary consistencies trialed were consistent with the Australian standards for texture-modified food and fluids24 and included smooth puree, minced and moist, soft and normal food consistencies as well as extremely thick (level 900), moderately thick (level 400), mildly thick (level 150), and thin (regular) fluids. All participants were trialed with the food/fluids considered to be least normal first (ie, extremely thick fluids and puree diet), with progression toward normal dietary consistencies and textures (ie, thin fluids and general diet) if appropriate. Suitability for progression to the next food or fluid texture/consistency was based on a) the safety of food/fluid intake and b) the efficiency of food/fluid intake. Safe food and fluid consistencies were determined to be those for which the patient demonstrated no clinical signs of penetration/aspiration or discomfort (ie, coughing, throat clearing, wet voice, increased respiratory rate, etc) and were able to be managed with efficiency. The efficiency of oral intake was determined by the amount of external facilitation/prompting required and/or the duration and extent of oral motor labor demonstrated by the patient in consuming the various food/fluid presented. This protocol was also consistent for all subsequent CSEs. Outcome Measures Three outcome measures related to return to normal oral intake, ie, functional recovery to premorbid level, were recorded at the initial assessment and for each subsequent reassessment. These included dysphagia severity and the food and the fluid consistencies safely managed at each assessment. Food and fluid consistencies were defined as per Australian standards.24 Dysphagia severity was rated using a purpose-built dysphagia severity rating scale (Table 1). A purpose-built severity scale was required for this study, as existing dysphagia severity scales typically include the need for nutritional supplementation as an indicator of severe dysphagia. As prolonged nutritional supplementation is required for metabolic reasons after burn injury and is independent of the presence of dysphagia, a severity scale that did not incorporate nonoral feeding as part of the severity criteria was required. The scale used in the current study consisted of three severity levels based on ability to manage various dietary consistencies. This scale and its descriptors are presented in Table 1. Table 1. Burn Specific Dysphagia Severity Rating scale (based on levels of oral intake restriction) View Large Table 1. Burn Specific Dysphagia Severity Rating scale (based on levels of oral intake restriction) View Large RESULTS Information relating to admission and treatment characteristics and participants' performance on CSE was entered into a Microsoft Excel program. To establish differences between the dysphagic and nondysphagic cohorts, the data were coded by the presence of dysphagia and analyzed using inferential statistics with Stata software (version 10.0, 2007). Characteristics of the Dysphagic and Nondysphagic Patient Populations Statistical comparisons between the dysphagic (n = 49) and nondysphagic (n = 389) groups were conducted using t-tests and x2 tests. A stringent alpha of P < .01 was adopted because of the multiplicity of tests.25,26 Independent group comparisons on biographical and injury presentation parameters, presented in Table 2, revealed no statistical difference in age (P = .06), gender (P = .438), or injury etiology (P = .135) across the two groups. A statistically significant difference (P = < .01) was found between the two groups with respect to the proportion of patients with head and neck burns and with inhalation injury, which were both higher in the dysphagic cohort (Table 2). Percentage TBSA was also significantly greater (P = < .01) in the dysphagic cohort, with the average burn size four times greater in those with dysphagia (Table 2). Table 2. Biographical details and information regarding initial injury presentation for dysphagic (n = 49) and nondysphagic cohorts (n = 389) View Large Table 2. Biographical details and information regarding initial injury presentation for dysphagic (n = 49) and nondysphagic cohorts (n = 389) View Large All parameters relating to length of stay and treatment periods are presented in Table 3. A significant difference was found between the two groups for duration of ETT intubation and the period of ventilator support required, with the dysphagic cohort requiring intubation and ventilation for five to six times longer than members in the nondysphagic group. Of those with dysphagia, tracheostomy insertion was performed on eight participants to support ongoing medical management in individuals slow to wean or who had sustained injuries that necessitated facial reconstruction or repair at an average of 16 days after-ETT insertion. Tracheotomy procedure was 50% surgical and 50% percutaneous, with no complications after procedure arising for any of the participants. Decannulation occurred on average 48 days (SD = 34.74, range = 7–101 days) after tracheostomy insertion. Of these eight participants, all were dysphagic before and after decannulation. The mean number of days for each hospitalization period (ICU and burn unit) and total duration of inpatient treatment was significantly higher for those who presented with dysphagia (Table 3). Individuals within the dysphagic cohort required on average a stay in ICU approximately 12 days longer than the nondysphagic group and stayed >30 days longer in the burn unit. Overall length of hospital stay was almost five times higher for the dysphagic group compared with the nondysphagics. Table 3. Hospitalization and treatment periods after thermal burn injury for dysphagic (n = 49) and nondysphagic cohorts (n = 389) View Large Table 3. Hospitalization and treatment periods after thermal burn injury for dysphagic (n = 49) and nondysphagic cohorts (n = 389) View Large Across all parameters relating to referral, assessment, and commencing oral intake, the dysphagic cohort took significantly longer to achieve each milestone than the nondysphagics (Table 4). Specifically, initial dysphagia assessment occurred significantly earlier for nondysphagic patients at around the second or third day after admission compared with the dysphagic cohort who had their initial assessment on average 2 weeks after admission (Table 4). Further analysis of the dysphagic cohort revealed that the initial assessment was initiated within the first 2 weeks after admission for 63% of all dysphagic subjects, with an additional 24% of subjects being seen initially by SLP in weeks 3 and 4 after admission. The remaining six dysphagic subjects were not medically appropriate for initial swallowing assessment until 5 to 8 weeks after injury. On initial assessment, all dysphagic subjects were weaned from ventilation but approximately 16% had a tracheostomy in situ and 97% were receiving supplementary feeding via nasogastric tube (NGT) at the time of initial SLP assessment. After initial assessment, not all individuals were appropriate to commence oral intake; therefore, average DIOF for the dysphagic population occurred at a mean of 19 days compared with 1 day for the nondysphagic population, because those individuals who were nondysphagic were often placed on a diet at admission, before the initial SLP visit (Table 4). Within the dysphagic cohort, 12% (n = 6) still had a tracheostomy in situ when they commenced oral intake. Table 4. Speech-language pathology and nutrition information for dysphagic (n = 49) and nondysphagic cohorts (n = 389) View Large Table 4. Speech-language pathology and nutrition information for dysphagic (n = 49) and nondysphagic cohorts (n = 389) View Large Feeding via orogastric or NGT, either for alternative or supplemental means, was used for 98% (n = 48) of dysphagics and was prolonged over an average period of 34.23 days (Table 4). Only 5% (n = 20) of the nondysphagic received supplemental feeding via NGT for an average duration of 9.55 days (Table 4). Figure 1 indicates the proportion of patients in each group receiving supplementary feeding over time. This shows that >75% of dysphagic individuals ceased supplementary feeding 7 weeks after hospital admission, with the majority of individuals ceasing supplementation between weeks 2 and 4. Three participants (6%) were discharged receiving ongoing nutrition support via percutaneous endoscopic gastrostomy (n = 1) or NGT (n = 2) in conjunction with some oral intake, thus did not reach DTOF. The remaining 46 dysphagic individuals reached DTOF (ie, without supplementation) approximately 5 weeks after admission (Table 4). Those dysphagics who progressed to maintaining adequate nutritional requirements via oral intake alone during their hospital admission did so on average 14.8 days after initiating oral intake (ie, DI-TOF) (Table 4). Regarding the duration of overall SLP intervention, the data revealed that nondysphagic patients in this study typically received a single visit from the SLP on hospital admission, were placed on a general (high energy and high protein) diet and thin fluids (±supplementation as prescribed by the dietician), and received no further SLP intervention. In comparison, the dysphagic cohort on average received a month of SLP intervention, with one patient having up to 5 months of inpatient management (Table 4). Figure 1. View largeDownload slide Cessation of supplementary feeding over time for dysphagic and nondysphagic subjects after thermal burn. A, admission. Figure 1. View largeDownload slide Cessation of supplementary feeding over time for dysphagic and nondysphagic subjects after thermal burn. A, admission. Resolution of and Recovery from Dysphagia After Burn In the dysphagic cohort, severity of dysphagia at initial assessment was 41% severe, 31% moderate, and 28% mild (Table 5). Those with mild dysphagia presented with oral stage deficits alone, whereas individuals rated as having moderate or severe dysphagia (71%) presented with deficits in both the oral and pharyngeal stages of the swallow. Within the dysphagic group, length of SLP intervention naturally increased with dysphagia severity, with patients diagnosed as having severe dysphagia requiring over three times the length of management of those who presented with mild dysphagia at initial assessment (Table 5). Table 5. Breakdown of dysphagia presentation, severity, and associated length of SLP treatment View Large Table 5. Breakdown of dysphagia presentation, severity, and associated length of SLP treatment View Large Mapping of dysphagia resolution by severity for the dysphagic cohort during the course of their hospital admission is shown in Figure 2. Dysphagia resolution (of both oral and pharyngeal deficits) was observed to progress most rapidly in the 6 weeks postadmission. By week 6, 50% of the cases resolved and by week 9, 75% of individuals had resolved. By discharge, dysphagia had resolved in 86% (n = 42) of participants, 10% (n = 5) had mild dysphagia, and 4% (n = 2) continued to present with moderate impairment of swallow function. Figure 2. View largeDownload slide Ranking of dysphagia severity during progression toward dysphagia resolution and hospital discharge for 49 dysphagic subjects after thermal burn injury. Figure 2. View largeDownload slide Ranking of dysphagia severity during progression toward dysphagia resolution and hospital discharge for 49 dysphagic subjects after thermal burn injury. At initial assessment, 11 participants were unsuitable to commence any oral intake and remained nil by mouth, whereas another 16% were commenced on small amounts of thickened fluids with supervision and were unable to manage any food consistencies/textures at that time. The remaining 61% of subjects were able to safely tolerate oral intake trials of both food and fluid. Following initial assessment, the clinical progression across fluid and food consistencies during recovery and return to oral intake is represented in Figures 3 (fluid consistencies) and 4 (food textures). Analysis of the weekly patterns revealed that safe management of thin fluids occurred in >50% of individuals between weeks 4 and 5 postinjury (Figure 3). By week 7, greater than 75% of dysphagic individuals had successfully returned to thin fluids. The majority of participants (96%) had achieved thin fluid diet status by week 12. By discharge, 97% of the group was safely managing thin fluids. Only one patient continued to present with aspiration on thin fluids by discharge. Figure 3. View largeDownload slide Return to normal fluid consistencies over time for 49 subjects with dysphagia after thermal burn. Figure 3. View largeDownload slide Return to normal fluid consistencies over time for 49 subjects with dysphagia after thermal burn. Figure 4. View largeDownload slide Return to normal food consistencies over time for 49 subjects with dysphagia after thermal burn. Figure 4. View largeDownload slide Return to normal food consistencies over time for 49 subjects with dysphagia after thermal burn. In comparison, progression toward normal food textures was not as expeditious, with persisting oral phase difficulties being apparent within the cohort (Figure 4). Although 57% of dysphagics had begun consumption of food by week 3 postinjury, the majority (49%) were on modified diet textures. It was not until week 6 that >50% of individuals achieved a general diet. Although return to normal food textures was somewhat prompter for those with less severe burn injuries, consumption of modified texture diets continued, with the number of participants progressing toward normal food textures increasing gradually up until week 16 postadmission. By discharge, all dysphagic subjects were able to safely ingest an oral diet consistency/texture. However, seven patients continued to require texture modification. Three required a soft diet because of poor dentition, whereas a further two had mild tightness at the oral commissures and preferred soft texture diets for ease of chewing and to limit discomfort/fatigue throughout the course of a meal. One participant required a minced diet because of a combination of poor dentition, fatigue, and orofacial tightness, all impacting on the oral stage of the swallow. One patient was discharged on a pureed diet owing to severe orofacial contractures that limited mouth opening and ability to adequately masticate and manipulate food for safe consumption. Three of these individuals received ongoing intensive dysphagia management postdischarge. DISCUSSION Clinical presentation within the thermal burn population is complex, as is the nature of patient recovery. The current data highlight that SLP management for those with dysphagia can be protracted, extending for many weeks postinjury. Although most clinical gains will be found to occur in the period between the second and sixth weeks postinjury, almost one third of patients can be expected to require ongoing management beyond this period. In addition, chronic dysphagia will be a reality for a small proportion, with 15% of the current cohort requiring ongoing dysphagia management and SLP follow-up at discharge, largely because of oral stage deficits caused by severe orofacial contractures. The current study has established the first set of prospective cohort data, providing both clinical profiles of dysphagic and nondysphagic groups and information regarding the natural course of dysphagia recovery in the thermal burn population. This information will aid patients and service providers alike in planning for rehabilitation. This study established that there are significant differences in injury presentation and subsequent management requirements for those who present with dysphagia from those who have intact swallow function following thermal burn injury. Nondysphagics presented with less severe injuries that required fewer days or no time in critical care, thus allowing resumption of oral intake to be expeditious and the need for and duration of supplementary feeding being significantly less. In the current study, the DIOF for the majority of nondysphagics was before the initial SLP assessment (0.08 ± 0.59 vs 2. ± 2.89 days) as dysphagia risk was calculated as low, using a dysphagia screener administered by trained nursing staff on admission. Factors that increase dysphagia risk after thermal burn have been established23 and should be incorporated into admission screening tools in burn centers to aid in correct identification of the small subset of patients at high risk of dysphagia who require specialized SLP assessment and management. The dysphagic subgroup in this study received initial contact with SLP within 2 weeks of hospital admission, a time period approximately four times longer than that for those who were classified as nondysphagic. The delay between admission and the commencement of SLP intervention observed in the present burns group, similar to the dysphagic burns populations retrospectively studied before it,11,–13 is a reflection of severity of burn injury and associated protracted periods of medical instability. The initial stage of acute burn management focuses on achieving medical and ventilatory stability,27,28 and during this period, patients often undergo repeated debridement and grafting procedures. Furthermore, a high percentage of inhalation injury and/or large TBSA affected that necessitated mechanical ventilation via ETT and, in some cases, the need for a tracheostomy was evident in the current dysphagic cohort. Consequently, fluctuating medical states within the first weeks of admission are not always conducive to early commencement of dysphagia assessment, treatment, and rehabilitation.7,10,13,23 The results of this study revealed a mean duration of 18 days until DIOF in the dysphagic cohort. When comparing the current study with those of Edelman et al11 and McKinnon DuBose et al,12 it is striking that mean days to SLP consultation and DIOF in their studies were three times greater than that required for the current sample. Some part of this finding could be attributed to differences in international healthcare settings, with variation in practice policies regarding patient accessibility. Indeed, when comparing the current data with those from Ward et al,13 which was conducted in the same facility as the current study, it reported durations only 1.5 times longer than the current study (initial assessment, M = 20 days; DIOF, M = 30 days). Other factors that could account for the relatively shorter duration to initial assessment and oral feeding in the current cohort may also be the overall severity of the injuries of the participants. In the earlier studies, the patient populations had larger %TBSA than the current cohort,11,–13 and thus along with this greater injury severity comes longer dependence on mechanical ventilation, intubation, and longer delays to initiation of feeding. Finally, changes in medical practice and availability of SLP services may also be a factor. Particularly in the study by Ward et al,13 their data reflect practice of almost a decade before the current research, and at the time, SLP services were one quarter of the dedicated service that now exists in that setting. Hence, it is possible that the advancements made in medical management procedures and the increased role of SLP in burn care management over the last decade may also have contributed to the early commencement of oral intake observed in the current cohort. DTOF in the dysphagic group was not achieved until a mean of 33 days postinjury. This period was 17 days shorter than that data reported a decade ago by Ward et al.13 It is important to note that need for supplemental feeding in this population is exclusive of aspiration risk and ultimate duration of supplementary feeding may or may not be solely dependent on the severity of the burn injury and the hypermetabolic response. Therefore, the difference seen with supplementary feeding durations between the current study and the one conducted at the same centre by Ward et al13 may be attributable to larger TBSA injuries being seen in the cohort of Ward et al.13 The current findings revealed that 50% of the cohort had resolved by week 6 and >75% by week 9. During this period, the recovery curve for dysphagia was observed to be steepest for the first 6 weeks postburn. These data provide important insights into patterns of service demand, highlighting the need to prioritize patients at dysphagia risk after thermal burn for early assessment of dysphagia, followed by continual monitoring and intervention for at least 2 to 3 months postinjury. Duration of SLP management was also observed to increase considerably with severity. Thus, considering that >70% of the dysphagic group presented with moderate to severe dysphagia at the initial time of assessment, lengthy periods of SLP intervention can be anticipated for most patients. Diagnostic management and dysphagia rehabilitation in the acute period (especially in ICU) is often hindered by the complexity created by fluctuating medical states and need for ventilation and intubation, thus protracting recovery time. During this period, dysphagia management is typically approached conservatively and continual patient monitoring is required, usually on a daily basis. Return to oral intake must be considered for this particular clinical population from two domains: resolution of aspiration risk and orofacial burn wound healing. In particularly complex cases, oropharyngeal dysphagia management has been reported to continue for numerous months during inpatient stays and posthospital discharge, with the prospect of long-term supplementary feeding.7,8,10,–13,29 Previous single case studies7,10 have alluded to the ongoing oral stage deficits being solely attributable to the persistence of oral scars and contractures. These cases also highlight comparatively earlier resolution of pharyngeal stage dysphagia (ie, the elimination of aspiration risk) to oral stage deficits. This is also evidenced in the current study, with a discrepancy noted between return to safe intake of fluids vs foods, largely because of persistent oral stage deficits limiting safe management of normal food textures. In the presence of orofacial scarring and contractures, individuals frequently present with poor lip seal, microstomia, and restricted facial movement7,10,12,30,–32 that limit ability for safe and successful oral intake. Although some degree of oral intake can usually be introduced successfully and safely for patients with orofacial contractures, deficits remain that require further intensive rehabilitation, and such deficits may prevent the return to normal dietary textures by hospital discharge.7,10 In the current cohort, seven individuals were unable to resume normal food textures by discharge because of oral stage deficits. This study has established that resolution of swallowing impairment and return to oral intake can be quite protracted with a small proportion of individuals continuing to be dysphagic in the long term. In the current cohort, dysphagia resolved in >75% of patients by week 9 postinjury and 85% had resolved by discharge. This is not unlike the findings from the retrospective study by Ward et al,13 conducted in the same centre nearly a decade before. However, reports from the United States11,12 differ, with their cohorts exhibiting much lower rates of dysphagia resolution by discharge (39.3–45%) despite having relatively comparable length of hospital stay (range = 44–85 days) to the current cohort (M = days). Reasons for this difference cannot be explained by the current data. CONCLUSION This study has provided the first step toward achieving a systematic, prospective evidence base regarding the impact of dysphagia on return to oral intake in adult patients after thermal burn injury. Those who presented with dysphagia in the current cohort had increased severity of injury and need for critical care admission, creating a multifaceted platform for dysphagia presentation. Overall, the data confirm that dysphagia recovery is protracted over months postinjury and SLP management is often very lengthy, particularly for those with more severe dysphagia. However, recovery can be anticipated for >50% of patients by week 6 and 75% by week 9. Only about 15% will continue to have dysphagia by discharge, largely due to the presence of orofacial contractures. The current data will assist clinicians to determine probable prognoses for swallowing recovery and resolution postburn injury. The data will also enable service providers to better estimate the ongoing demand for clinical resources and help optimize appropriate timing and resource allocation of SLP services with this population. Future research is needed to define the causal relationships between the initial presentation of the injury and resolution of dysphagia to further enhance prognostic decision-making and refine service delivery models. Supported by funding from the Royal Brisbane and Women’s Hospital (RBWH) Foundation. ACKNOWLEDGMENTS We thank funding support for this study from the Royal Brisbane and Women's Hospital Foundation. We also thank the assistance of the Royal Brisbane and Women's Hospital Professor Stuart Pegg Adult Burns Unit in the recruitment of participants for this study. Finally, we wish to thank the participants of this study for their patience, determination, willingness to help teach others, and the generous gift of their time. REFERENCES 1. Bartlett RM, Niccole M, Tavis MJ, Allyn PA, Furnas DW. Acute management of the upper airway in facial burns and smoke inhalation. Arch Surg. 1976;111:744–9. 2. Clark WRRylah LTA. Inhalation injury. Critical care of the burned patient. 1992 Wiltshire Cambridge University Press. 3. Gaissert HA, Lofgren RH, Grillo HC. Upper airway compromise after inhalation injury: complex strictures of the larynx and trachea and their management. Ann Surg. 1993;218:672–8. 4. 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TI - Clinical Progression and Outcome of Dysphagia Following Thermal Burn Injury: A Prospective Cohort Study
JO - Journal of Burn Care & Research
DO - 10.1097/BCR.0b013e3182356143
DA - 2012-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/clinical-progression-and-outcome-of-dysphagia-following-thermal-burn-ZuAms5H07m
SP - 336
EP - 346
VL - 33
IS - 3
DP - DeepDyve
ER -