Dysphagia following thermal burn injury: Clinical risk factors, anatomical and physiological characteristics and road to resolution and recovery

Anna Rumbach (2011). Dysphagia following thermal burn injury: Clinical risk factors, anatomical and physiological characteristics and road to resolution and recovery PhD Thesis, School of Health and Rehabilitation Sciences, The University of Queensland.

       
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s4056099_phd_abstract.pdf s4056099_phd_abstract.pdf application/pdf 11.96KB 8
s4056099_phd_finalthesis.pdf s4056099_phd_finalthesis.pdf application/pdf 27.16MB 76
Author Anna Rumbach
Thesis Title Dysphagia following thermal burn injury: Clinical risk factors, anatomical and physiological characteristics and road to resolution and recovery
School, Centre or Institute School of Health and Rehabilitation Sciences
Institution The University of Queensland
Publication date 2011-08
Thesis type PhD Thesis
Total pages 367
Total colour pages 4
Total black and white pages 363
Subjects 11 Medical and Health Sciences
Abstract/Summary Over the last two decades, burn injury mortality rate has been decreasing and patient morbidity have been improving due to significant improvements in both medical and surgical techniques and the adoption of a multidisciplinary team approach to care. The role of the speech-language pathologist as a member of the multidisciplinary burn care team is relatively new, and as such, the professional knowledge base is yet to be fully established. Many authors, at an anecdotal level, have proposed moderate to severe dysphagia to be a common sequela following thermal burn injury, whilst others note it to be a consistent and prominent dysfunction associated with this population. Even so, authors continue to recognise that a systematic research base to support the incidence and anticipated severity of dysphagic symptoms in this population is minimally represented. Furthermore, it is not possible to determine exactly who is at risk for dysphagia post burn or what we can expect regarding prognosis, which limits optimal care for this population. The current series of investigations aimed to address this current lack of clinical evidence through a systematic program of research that was prospective in nature and had sufficient participant numbers to enable informed data analysis for incidence, determination of dysphagia risk and patterns of dysphagia resolution. Additionally, utilisation of small cohort and individual case study designs allowed insight into the heterogeneity of the burn population, the nature of the dysphagia, and justifies the need for speech pathology involvement. A total of 438 adults who were admitted to a specialised burn centre for treatment of a thermal burn injury during a 24-month period participated in this research. Patients admitted for other burn types (i.e., chemical, electrical), those who were to receive only palliative management and those with existing neurological or structural impairment that could influence swallowing behaviour, or a prior history of a swallowing disorder were excluded. Participants underwent a clinical swallow examination (CSE) by a speech-language pathologist experienced in managing burn patients directly following determination of medical stability and suitability for oral intake by a medical officer. Individuals were subsequently diagnosed with dysphagia (n = 49) or normal swallow function (n = 389). In addition to dysphagia status, parameters relating to the burn presentation and medical treatment received from admission to discharge were collected for each participant. Those with dysphagia then received weekly repeated CSE’s and traditional dysphagia therapy and contracture management up until the point of dysphagia resolution or discharge from the burns unit. Dysphagia severity and variables relating to the recovery of safe oral intake as determined from CSE were also recorded for all individuals. For a small subset of individuals with dysphagia (n = 19), for whom instrumental examination of swallow function using fiberoptic endoscopic evaluation of swallowing (FEES) was deemed clinically appropriate were assessed to objectively examine the physiological characteristics associated with dysphagia post burn. Results revealed the incidence of dysphagia in the admitted cohort of 11.18%. In addition a core set of parameters (known within the first 24 hours post injury) were identified to have high levels of strong sensitivity and specificity for detection of dysphagia risk. These included, in isolation or in combination, with the consideration of increasing age: total body surface area burnt greater than or equal to 18%, head and neck burns, need for escharotomy, inhalation injury, need for intensive care admission and need for mechanical ventilation. Analysis of the clinical recovery of the dysphagic cohort highlighted the heterogeneity of the sample, however group patterns revealed the potential for the majority of patients (50% by week 6 and 75% by week 9 post burn) to return to normal oral intake, with only a small proportion having unresolved dysphagia still at discharge. Investigation into the nature of the dysphagia via CSE and FEES revealed generalised oromotor weakness in the majority of the cohort, with functional deficits of the oral phase reserved for the few individuals with severe dysphagia and orofacial contractures. Observable physiological deficits on FEES that were identified as being prominent across the cohort included: laryngotracheal pathology, decreased ability to manage secretions, delayed swallow initiation, decreased laryngopharyngeal sensation, diffuse pharyngeal residue and a high risk of silent aspiration. These deficits and their remediation were detailed further through two detailed case studies of individuals with severe swallowing impairment after thermal burn injury. These cases, followed from admission to hospital discharge highlight challenges for both the patient and the treating speech-language pathologist and emphasise benefits of working within an interdisciplinary and multidisciplinary team. The current series of investigations mark the first large prospective cohort investigation of dysphagia in the thermal burn population. Continued research to firmly establish the validity and reliability of the criteria set for dysphagia risk, with the goal of developing evidence-based guidelines for referral to speech-language pathology was recognised as an imperative direction for future research. The need for ongoing investigation of swallow function via instrumental means has been highlighted due to the multifaceted nature of dysphagia and the propensity for silent aspiration in this population. Furthermore, the need for ongoing evaluation, development and expansion of traditional dysphagia treatment practices in this population was emphasised.
Keyword dysphagia
burn
speech-language pathology
incidence
microstomia
contracture
oropharynx
rehabilitation
risk
Recovery
Additional Notes Pages of PDF that are colour: 45, 153, 155, 197 Pages of PDF that are landscape: 61, 102, 146, 149, 150, 169, 174, 175, 182, 210, 217

 
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Created: Tue, 18 Oct 2011, 13:12:18 EST by Ms Anna Rumbach on behalf of Library - Information Access Service