2015 HSC Section 1 Book of Articles

in children. 8 Interestingly, in cases of low suspicion of FBA, some authors support the cost-effectiveness of an initial flexible fiberoptic bronchoscopy before going straight to a rigid bronchoscopy. In one study, for exam- ple, data showed that $1,400 was saved per patient by initially resorting to flexible bronchoscopy. These patients were spared general anesthesia as well; flexible bronchoscopy requires premedication with intrarectal midazolam and can be performed through a facial mask under continuous anesthetic inhalation. 13 General guidelines suggest that findings of asphyxia, a radio-opaque foreign body on chest X-ray, or unilater- ally decreased breath sounds normally warrant an initial rigid bronchoscopy. In other cases, a flexible bronchoscopy can be attempted first. 14 Rhigini et al. presented a “decisional algorithm” to perform a flexible bronchoscopy when patients present with vague symptoms, do not have obvious pulmonary abnormalities on physical examina- tion, and do not show concerning radiographic findings. 13 Martinot et al. performed a cost analysis study that showed both decreased procedural charges ($1,100 rigid bronchoscopy versus $287 flexible bronchoscopy), hospital stay charges, and days of hospitalization when children suspected of having an FB had undergone a flexible bron- choscopy instead of a rigid bronchoscopy first. 14 Rhigini et al. noted that among their eight patients who did not have a foreign body detected on rigid bron- choscopy, five would have been spared the procedure (and general anesthesia) if their decisional algorithm had been followed and flexible bronchoscopies were per- formed initially. 13 Perhaps relating patient symptoms to studies analyzing the rates of identifying a foreign body versus the number of procedures done will help guide the healthcare provider into performing the appropriate procedures based on the probability of a true FBA. However, although some contend flexible bronchos- copy to be a safe and cost-saving diagnostic procedure, there is the risk of FB dislodgement at the time of evalu- ation. This necessitates that use of flexible bronchoscopy be performed by a senior pediatrician near an operating room in the presence of an otorhinolaryngologist. If an FB is found, rigid bronchoscopy most often needs to be performed anyway; the success of object extraction with flexible bronchoscopy is widely variable and ranges from 10% to 90%. 15 At this time, despite increased costs and need for general anesthesia, rigid bronchoscopy still remains the first technique of choice for pediatric airway foreign body extraction. 15 The potential consequences of nonlethal airway obstruction secondary to bronchial FBA events are vari- able, ranging from temporary sequelae to permanent anoxic brain damage or even death. Pulmonary compli- cations include persistent cough, pneumonia, emphy- sema, and bronchial stenosis 16 ; these can persist for months to years. Looking forward, it may be important to investigate the types of complications that our patients may have experienced and stratify them accord- ing to incidence and costs incurred. Additionally, it may be helpful to analyze the data further to know what other procedures (tracheostomy, other surgeries) may have been performed secondary to these complications.

primarily pediatric hospitals, whereas our study ana- lyzed data from a wider selection of hospitals in the United States. Therefore, these data should be viewed as complementary. Bronchial FBA contributes to nonlethal events that can cause significant medical morbidity and produce a considerable socioeconomic burden. For purposes of com- parison with respect to hospital charges, a pediatric intensive care unit admission for an intubated patient in status asthmaticus who suffers a complication is $117,184, and average length of intensive care unit stay is 10 days. 6 Pediatric firearm-related injuries show an average inpatient admission charge of $70,164, whereas the total annual charges for the entire United States is $371 million. 7 Thus, although the charges for foreign body aspiration-related admissions are relatively small on an individual patient basis in comparison to those of other acute pediatric conditions, they remain significant. Studies also reveal that up to 20% of children who suffer FBA can be misdiagnosed and treated incorrectly for more than a month before the correct diagnosis is made. 8,9 When patients present with vague symptoms, and chest radiographs are normal in the first hours to weeks following an event, 10 a diagnosis of a FBA may not even be considered initially by the healthcare profes- sional. Children whose symptoms subside soon after an FBA event may have several visits to a healthcare pro- vider and be given several medical therapies before being referred for specialty care. 11 Missing such a diag- nosis can lead to long-term pulmonary complications such as bronchiectasis, pulmonary abscesses, and irre- versible damage of the lung parenchyma—all of which can ultimately require treatment with surgical resec- tion. 8,12 Thus, total healthcare costs related to the workup and treatment of these more chronic conditions have yet to be clearly defined. Generally, a witnessed choking episode prior to the onset of symptoms has been positively associated with the presence of a true FBA event. Additionally, the pres- ence of a choking event remains important when consid- ering FBA in patients who present with pulmonary symptoms weeks to months after a remote choking epi- sode; an endoscopy can prove to be therapeutic even months after the event. 1 In our study, nearly half of the patients underwent an immediate rigid bronchoscopy for diagnosis and/or therapeutic interventions. Approxi- mately 40% of those patients had a foreign body removed. Our reported negative bronchoscopy rate of approximately 60% is higher than the reported range in the literature of 11% to 46%. 13 Data from the NIS encompasses a wider range of bronchoscopy outcomes because they account for rates across a wider selection of hospitals across the United States and do not selec- tively reflect those among pediatric otolaryngology sub- specialty centers. Academic medical centers reporting lower negative rates may have received referrals from outside hospitals for evaluation of possible airway for- eign bodies, perhaps leading to increased positive findings. Rigid bronchoscopy is considered the safest and most preferred method of airway foreign body removal

Laryngoscope 00: Month 2014

Kim et al.: Cost of Foreign Body Aspiration in Children

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