1. Dysphagia Outcomes in Thermal Burn Injury
Sarah Wallace
Speech and Language Therapist (SLT)
Wythenshawe Hospital, Manchester

2. Project background
Increase in referrals to SLT from the Burns Unit, in particular ICU, requesting swallowing assessments (18 referrals last year)
Paucity of research into dysphagia recovery and eventual outcome in burns patients
(2 studies: Ward et al 2001, Brisbane. Du Bose et al 2005, Florida)
Burns is developing as an area of specialism within SLT profession

3. Project aims
To provide data on the characteristics of burns patients with dysphagia
To determine the duration of dysphagia and factors influencing swallow recovery
To determine any indicators for early referral by burns team

4. Method
Retrospective review of burns patients referred to SLT over 4 yr period
41 patients (28m 13f)
Age range 16-91yrs (mean 48yrs)
No previous history of dysphagia
All underwent bedside swallowing assessment by SLT with critical care skills
Further assessment as needed until discharge from unit or swallow recovery
6 had FEES (Fibreoptic Endoscopic Evaluation of Swallowing)

5. Aspiration on FEES

6. General findings 38/41showed signs of dysphagia
Range of burn injury 2-74% (mean 29%)
26 patients (68%) had burns to head/neck/face
27 patients (71%) had inhalation injury, 21 both
Ventilation
34 (89%) required ventilation via ETT
29 (76%) had a tracheostomy for between 7-90 days (mean 26 days)

7. Findings - Aspiration pneumonia
Pre SLT referral, medics documented 21 patients had aspiration pneumonia
Recurred in only 1 patient following SLT input (silent aspirator detected on FEES)
Average age of patients with aspiration pneumonia was 53, 21yrs older than those without

8. Findings – Swallow recovery
Range 3–104 days from admission to commencing oral feeding (mean 27)
Tracheostomised patients took on average 32 days, 18 longer than those without
Ventilated patients took 29 days, 2 weeks longer than non-ventilated
Burn severity >50% took 33 days, 1 week longer than patients with lesser burns
Head/neck/facial burn took 32 days, 1 week longer than those without
4 patients with all 4 factors averaged 29 days (12 days without)

9. Findings –Tracheostomy status
Patients were reassessed for safety of oral feeding at various stages of the tracheostomy weaning process. Commencement of oral feeding was as follows:
18 patients on achieving cuff deflation
1 on downsizing to minitrache
6 following decannulation
2 fed cuff inflated (1 non-compliant,1 assessed by FEES)
Remaining 2 died

10. Other findings Laryngeal oedema seen on all FEES
18 patients (44%) recommended NBM initially
12 (29%) needed modified diet/thickened fluids
Patients recommended normal diet and fluids increased from 3 to 25 by SLT discharge
The only patients not to achieve normal feeding had either died or been transferred out of the unit
Each patient needed between 1-23 SLT assessments (mean 7)

11. Conclusions
Aspiration pneumonia rates can be reduced by SLT management of dysphagia (early referral can help facilitate ventilator weaning)
Swallow recovery takes longer if:
tracheostomised/ventilated
head/neck/facial burn
burn severity higher
Most tracheostomised patients are not safe for oral feeding until cuff deflation or decannulation
Dysphagia is often severe initially but should eventually fully recover

12. Recommendations
Involvement of SLT in the acute management of burns patients can be beneficial (SLT needs competencies in critical care)
SLTs working with burns need to develop links, training and a burns competency framework
More research needed:
Prospective study identifying incidence of dysphagia and aspiration in burns using FEES
Survey of SLT input in burns units in UK

13. References
Ward E., Uriarte M., Conroy A.L., (2001) Duration of dysphagic symproms and swallowing outcomes after thermal burn injury. Journal of Burn Care & Rehabilitation 22,
DuBose C.M., Groher M.G., Mann G.C., Mozingo D.W., (2005) Pattern of dysphagia recovery after thermal burn injury. Journal of Burn Car & Rehabilitation 26,
Edelman D.A., Sheehy-Deardoff D.A., (2008) Bedside assessment of swallowing is predictive of an abnormal Barium Swallow examination. Journal of Burn Care & Research 29(1):89-96

14. Aspiration of excess secretions