2015 HSC Section 1 Book of Articles

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.

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.

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,

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.

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.

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%.

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

in children.

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.

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.

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.

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.

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.

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%.

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.

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

; 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.

Laryngoscope 00: Month 2014

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