- Email: [email protected]
Acute pediatric tracheitis: Distinguishing the disease by tracheostomy status
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Acute pediatric tracheitis: Distinguishing the disease by tracheostomy status☆
T
Jonathan S. Nia, Jocelyn Kohnb, Udayan K. Shahc,d,e,∗, Jessica R. Levia,b a
Boston University School of Medicine, 72 E. Concord St., Boston, MA, 02118, USA Department of Otolaryngology–Head and Neck Surgery, Boston Medical Center, 820 Harrison Ave., FGH Building 4th Floor, Boston, MA, 02118, USA c Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Rd., Wilmington, DE, 19803, USA d Department of Otolaryngology-Head & Neck Surgery, 130 S 9th St, Philadelphia, PA, 19107, USA e Department of Pediatrics, Thomas Jefferson University, 130 S 9th St, Philadelphia, PA, 19107, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Pediatric Tracheitis Resource utilization Tracheostomy Obstruction
Objectives: Tracheitis is an upper airway infection that often presents in patients with tracheostomies and can potentially cause airway obstruction. This study aims to use a nationwide database to identify a large cohort of pediatric patients admitted with tracheitis to elucidate the management and resource utilization associated with the disease both with and without tracheostomies. Methods: The Kids’ Inpatient Database (KID) 2012 was used to identify 2394 weighted discharges with acute tracheitis, with or without obstruction, as the primary diagnosis. Data on prior tracheostomy status, demographics, hospital characteristics, management, and resource utilization were obtained. Two groups of interest, based on presence of prior tracheostomy, were studied. Linear regression was performed to determine independent predictors of total charges. Results: The mean age was 5.52 years (SD: 5.54), mean length of stay (LOS) was 6.37 days (SD: 10.18), and mean total charges were $60,996.61 (SD: 107,798.41). Patients with prior tracheostomy had lower rates of endoscopy and endotracheal intubation than patients without (p < 0.0005). There was no significant difference in LOS (p = 0.076) or total charges (p = 0.210) between the groups based on prior tracheostomy status. Conclusion: Pediatric tracheitis should be differentiated on the basis of tracheostomy status. We propose that tracheitis diagnosis codes should be distinguished by the presence of tracheostomy as “open” and the absence of tracheostomy as “closed.”
1. Introduction Bacterial tracheitis was initially reported by Jones et al. and was described as an obstructive upper airway infection with some characteristics common to both croup and epiglottitis [1]. However, advances in the prevention of epiglottitis and treatment of croup have left tracheitis, in many cases, as the most dangerous upper airway infection [2]. Often following an upper respiratory infection, the clinical presentation of tracheitis includes acute onset of fever, stridor, and respiratory distress [3]. An important consideration in the diagnosis and treatment of tracheitis is the presence of prior tracheostomy, which may substantially impact a patient's hospital course. Management of tracheitis includes debridement by laryngoscopy or bronchoscopy, antibiotics, and, if necessary, intubation and ventilation. According to the literature, intubation is often indicated, with reported rates as high as
91% [4]. However, the literature on tracheitis remains limited. As such, study of a large cohort of pediatric patients may provide greater insight into how the disease is managed in the inpatient setting. The yearly incidence of bacterial tracheitis is estimated to be 0.1 per 100,000 children [4]. In addition, tracheitis may be viral in etiology. The rarity of this condition makes it difficult to study. We aimed to use a nationwide database to identify a relatively large population of admissions with tracheitis, regardless of etiology, to further elucidate patient demographics as well as trends in management and resource utilization. 2. Materials and methods Institutional Review Board approval was not required as a nationwide database was used. The Kids’ Inpatient Database (KID), Healthcare
☆ ∗
Work conducted: Boston University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, MA. Corresponding author. Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA. E-mail addresses: [email protected] (J.S. Ni), [email protected] (J. Kohn), [email protected] (U.K. Shah), [email protected] (J.R. Levi).
https://doi.org/10.1016/j.ijporl.2019.109800 Received 12 September 2019; Received in revised form 25 November 2019; Accepted 25 November 2019 Available online 29 November 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
31.21, 31.29), enteral infusion or nutrition (96.6), and mechanical ventilation (96.71, 96.72) were identified using ICD-9-CM procedure codes. Independent samples t-test was performed to determine if there were any statistically significant differences in length of stay (LOS) or total charges between two groups. Levene's test for equality of variances was performed, and in instances where the assumption of homogeneity of variances was violated, Welch t-test was performed. Chi-square test for homogeneity was performed to determine if there were any statistically significant differences in rates of procedures between two groups. Fisher's exact test was used to determine differences in proportions in instances where expected frequencies were insufficiently sized to perform Chi-square test for homogeneity. Variables suspected to contribute to total charges were identified. These variables included age, sex, race, region, income quartile for patients' Zip codes, emergency department (ED) services, elective admission, treatment at children's hospital, LOS, laryngoscopy and other tracheoscopy, bronchoscopy, endotracheal intubation, prior tracheostomy, obstruction status, and discharge status. Simple linear regression was performed for each individual variable of interest. Variables with individual simple linear regression models that demonstrated significance (p < 0.05) were incorporated into a multiple linear regression model to determine independent predictors of increased and decreased charges.
Table 1 Demographic information. Acute Tracheitis without Prior Tracheostomy (n = 592)
Acute Tracheitis with Prior Tracheostomy (n = 1865)
Mean age in yrs (SD), 5.93 (5.33), 0-20 5.40 (5.59), 0-20 range in yrs Sex (%) Male 312 (58.9) 1135 (60.8) Female 217 (41.1) 730 (39.2) Race (%) White 271 (58.6) 742 (43.3) Black 72 (15.6) 395 (23.0) Hispanic 88 (19.1) 428 (25.0) Asian or Pacific -a 44 (2.5) Islander 27 (1.6) Native American -a Other 23 (5.1) 79 (4.6) Median household income quartiles by Zip code, $ (%) 1 $1 - $38,999 148 (28.3) 554 (30.0) 2 $39,000 - $47,999 155 (29.7) 545 (29.5) 3 $48,000 - $62,999 106 (20.2) 444 (24.0) 4 $63,000+ 114 (21.8) 304 (16.5) Payer (%) Medicare -a -a Medicaid 273 (51.5) 1368 (73.6) Private including 220 (41.5) 383 (20.6) HMO -a Self-pay -a No charge -a -a Other 26 (4.8) 98 (5.3)
3. Results A total of 2394 weighted discharges were identified. The mean age was 5.52 years (SD: 5.54) and 1446 (60.4%) of patients were male. The most common race was white (46.5%). The most common median household income quartile by Zip code was the first quartile, which made up 29.6% of the total population. The most common payer was Medicaid (68.7%). Individual demographic information for each of the four groups is shown in Table 1. Overall, an average of 1.33 procedures per patient was performed.
Abbreviation: HMO, health maintenance organization. a The Healthcare Cost and Utilization Project Data Use Agreement prohibits reporting of 10 or fewer observations [5].
Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality provides estimated costs of nationwide inpatient stays for patients under the age of 21 years [5]. Many data partners contribute to the HCUP [6]. KID 2012, the most recent version of the database, details nationwide discharges in the year 2012 alone, and was used in this study. Weighted discharges were used and will also be referred to as patients in this study. The International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) code for acute tracheitis without mention of obstruction (464.10) and acute tracheitis with obstruction (464.11) were used to identify admissions with either of these two conditions as primary diagnoses. Patients with prior tracheostomy were identified if any of the following ICD-9-CM diagnosis codes were present as secondary diagnoses: tracheostomy status (V44.0), attention to tracheostomy (V55.0), tracheostomy complication NOS (519.00), infection of tracheostomy (519.01), mechanical complication of tracheostomy (519.02), or other tracheostomy complications (519.09). Procedures of interest performed during the admission, including laryngoscopy and other tracheoscopy (31.42), bronchoscopy (33.21, 33.22, 33.23), endotracheal intubation (96.04), tracheostomy (31.1,
3.1. Procedures: no prior tracheostomy vs. prior tracheostomy A total of 529 patients did not have a tracheostomy prior to admission and 1865 patients did have a tracheostomy prior to admission. Comparing these two groups, there were significant differences in rates of laryngoscopy (and other tracheoscopy) (p < 0.0005), bronchoscopy (p < 0.0005), endotracheal intubation (p < 0.0005), and enteral nutrition (p < 0.0005) and no significant differences in mechanical ventilation for less than 96 h (p = 0.566) or 96 or more hours (p = 0.110) (Table 2). 3.2. Admission characteristics, hospital burden, and resource utilization Admission characteristics for each of the two groups are shown in Table 3. For the entire population, the most common hospital regions were the South (33.3%) and the Midwest (27.7%); 50.4% of patients
Table 2 Procedures.
Procedures (%) Laryngoscopy and other tracheoscopy Bronchoscopy Endotracheal intubation Tracheostomy (during admission) Continuous invasive mechanical ventilation < 96 consecutive hours Continuous invasive mechanical ventilation for ≥ 96 consecutive hours Enteral infusion of concentrated nutritional substances a
Acute Tracheitis without Prior Tracheostomy (n = 592)
Acute Tracheitis with Prior Tracheostomy (n = 1865)
77 (14.6) 60 (11.3) 56 (10.5) -a 115 (21.8) 91 (17.3)
36 (1.9) 59 (3.2) 29 (1.5) -a 383 (20.6) 379 (20.3)
66 (12.5)
411 (22.0)
The Healthcare Cost and Utilization Project Data Use Agreement prohibits reporting of 10 or fewer observations [5]. 2
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
regression determining independent predictors of increased or decreased charges. Variables that did not demonstrate significance on simple linear regression in any of the two groups were excluded from Table 5. In the group without prior tracheostomy, independent predictors of increased charges included Hispanic race (p = 0.045); care in the West (p = 0.030); LOS (p < 0.001); and discharge to skilled nursing, intermediate care, and other facilities (p = 0.014) and there were no identified independent predictors of decreased charges. In the group with prior tracheostomy, independent predictors of increased charges included admission to a children's hospital (p < 0.001); LOS (p < 0.001); performance of a bronchoscopy during admission (p = 0.001); and discharge to skilled nursing, intermediate care, and other facilities (p = 0.016). Independent predictors of decreased charges included care in the Midwest (p < 0.001) and South (p < 0.024).
Table 3 Admission characteristics.
Non-elective admission (%) Elective admission (%) Admission month (%) January February March April May June July August September October November December Hospital region (%) Northeast Midwest South West Children's hospital (%) No Yes ED services (%) Does not meet HCUP ED criteria ED revenue code on record Positive ED charge ED CPT code on record Admission source of ED State-defined ED record; no ED charges available Length of stay in days: mean (SD), range Total charges in $: mean (SD), range Discharge status (%) Routine Transfer to short-term hospital Skilled nursing facility, intermediate care, and other facilities) Home health care Against medical advice Died in hospital Discharged alive, destination unknown
Acute Tracheitis without Prior Tracheostomy (n = 592)
Acute Tracheitis with Prior Tracheostomy (n = 1865)
494 (93.6) 34 (6.4)
1801 (96.8) 60 (3.2)
59 35 51 38 51 32 28 27 45 53 52 56
190 191 171 146 133 108 132 141 166 151 173 163
(10.2) (10.2) (9.1) (7.8) (7.1) (5.8) (7.1) (7.5) (8.9) (8.1) (9.3) (8.7)
88 (16.7) 162 (30.6) 162 (30.6) 117 (22.2)
345 500 636 383
(18.5) (26.8) (34.1) (20.6)
284 (53.7) 245 (46.3)
904 (48.5) 961 (51.5)
193 (36.6)
486 (26.0)
202 (38.1)
746 (40.0)
59 (11.1) -a 75 (14.3) -a
306 (16.4) -a 328 (17.6) -a
7.22 (13.16), 0-140
6.13 (9.14), 0–128days
67408.31 (140862.69), 1654-1534131
59185.07 (96395.51), 1208-1823213
415 (78.4) 16 (3.0)
1269 (68.1) 36 (1.9)
30 (5.7)
167 (8.9)
65 (12.3) -a -a -a
387 (20.8) -a -a -a
(11.1) (6.6) (9.7) (7.1) (9.7) (6.1) (5.4) (5.2) (8.6) (10.1) (9.8) (10.6)
4. Discussion The management of tracheitis is seldom reported in the literature. The diagnosis of tracheitis is often confused with other obstructive airway conditions with similar presentations, such as epiglottitis and croup. The only definitive way to diagnose tracheitis is through direct visualization on bronchoscopy. However, the true rates of diagnostic procedures and airway management in tracheitis have been difficult to determine due to the rarity of the disease as well as variations in clinical practice. Bacterial tracheitis has been shown to vary in its presentation and, subsequently, in how it is diagnosed and managed [7]. While some advocate for the liberal use of laryngoscopy and bronchoscopy due to the risks associated with delayed or inaccurate diagnosis [8], others argue that direct visualization is not always indicated and the decision to perform bronchoscopy is dependent on several factors, including the degree of airway obstruction, concern for epiglottitis, and the age of the patient [9]. Rates of endoscopy for tracheitis vary in the literature. In some studies, all patients undergo endoscopy [8,10], while in another study, only a proportion (83%) underwent endoscopy [2]. In our study, only 4.7% of patients underwent laryngoscopy and other tracheoscopy and 5.0% of patients underwent bronchoscopy. These rates are notably lower than those previously reported. In the literature, rates of intubation in the management of tracheitis have ranged from 21% to 91% [4,11]. In this study, the overall rate of endotracheal intubation was 3.5%, which is, to our knowledge, the lowest reported rate of intubation for a large cohort of patients with tracheitis in the literature. The most likely explanation for this remarkably low rate is that 77.9% of patients in our study had a prior tracheostomy and, as expected, patients with an established airway were less likely to require an intubation. Another explanation for the lower intubation rates could involve other patient characteristics. Salamone et al. identified a subset of patients with bacterial tracheitis who have demonstrated less severe presentations and lower rates of intubation. These patients exhibited a unique set of characteristics: older age (mean: 7.9 years), less severe systemic illness, and stronger response to treatment [10]. However, in our study, there was no statistically significant difference in age between patients who underwent endotracheal intubation (mean: 4.93 years; SD: 5.41) and patients who did not (mean: 5.54 years; SD: 5.54) (p = 0.321). In summary, the wide variation in management data between the literature and our study is likely due to a multitude of factors, including differences in baseline patient characteristics, disease severity, and treatment approach.
Abbreviations: CPT, current procedural terminology; ED, emergency department. a The Healthcare Cost and Utilization Project (HCUP) Data Use Agreement prohibits reporting of 10 or fewer observations [5].
were treated at children's hospitals. There was a significant difference in rates of ED services between patients with and without prior tracheostomies. Among all patients, the mean LOS was 6.37 days (SD: 10.18) and the mean total charges was $60,996.61 (SD: 107,798.41). Data on LOS and total charges for both of the groups are detailed in Table 3. There was no statistically significant difference in LOS (p = 0.076) or total charges (p = 0.210) between the groups with or without a prior tracheostomy.
4.1. Differences by prior tracheostomy status 3.3. Independent predictors of resource utilization A total of 77.9% of patients in this study had a prior tracheostomy. This high frequency may be due to bacterial colonization of the tracheobronchial tree, which has been shown to create potential for
Table 4 details the simple linear regression for variables of interest in regard to hospital charges. Table 5 details the multiple linear 3
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
Table 4 Simple linear regression for individual variables of interest. Variable
Age Sex Male Female Race White Black Hispanic Asian or Pacific Islander Native American Other Region Northeast Midwest South West Median household income quartiles by Zip code 1 $1 - $38,999 2 $39,000 - $47,999 3 $48,000 - $62,999 4 $63,000+ Children's hospital No Yes ED services No Yes Elective admission No Yes Length of stay Laryngoscopy and other tracheoscopy No Yes Bronchoscopy No Yes Prior tracheostomy No Yes Obstruction No Yes Endotracheal intubation No Yes Discharge status Routine Transfer to short-term hospital Other transfers (skilled nursing facility, intermediate care, and other facilities) Home health care Against medical advice Died in hospital Discharged alive, destination unknown
Acute Tracheitis without Prior Tracheostomy
Acute Tracheitis with Prior Tracheostomy
Difference in total charges: mean, standard error ($)
p-value
Difference in total charges: mean, standard error ($)
p-value
−1924.95 (1157.50)
.097 .783
628.93 (399.55)
.116 .353
Reference −3455.61 (12542.94)
.783 < .001
Reference −1384.32 (17887.31) 68492.58 (16250.54) -a -a 67578.02 (28981.76)
.938 < .001
.020 .014
Reference −44537.76 (18574.16) −54584.57 (18510.90) −19818.02 (19806.57)
.017 .003 .317 .004
Reference 23172.94 (15973.09) −21560.34 (17714.53) −36265.79 (17256.06)
.147 .224 .036 .096
Reference 20561.80 (12327.10)
.096 .234
Reference 15264.90 (12810.36)
.234 .368
Reference −22556.55 (25020.97) 9805.26 (183.39)
.368
Reference 4259.59 (4588.89) Reference −854.17 (5833.41) 538.10 (5689.24) 17648.55 (14941.63) 51546.04 (18735.72) −6542.35 (11324.82) Reference −26885.12 (6703.46) −9025.80 (6393.48) 9143.68 (7131.21) Reference 4139.51 (5784.16) 938.71 (6124.03) 7604.61 (6866.97) Reference 12595.33 (4473.41) Reference −3511.72 (5114.04) Reference 7942.69 (12639.93) 8905.47 (129.80)
.943 Reference 1246.47 (17375.92)
.943 .649
Reference 8814.91 (19341.02) – – –
.649 – – – .792
Reference −6681.96 (25374.47)
.792 .004
Reference 57855.40 (19809.73)
.004 < .001
Reference 87303.52 (32020.96) 125232.98 (23476.54)
.007 < .001
17644.76 (16611.76) -a -a -a
.289
Reference 7947.56 (16196.37) Reference 89066.79 (12563.01) – – –
.353 .090 .884 .925 .238 .006 .564 < .001 < .001 .158 .200 .684 .474 .878 .268 .005 .005 .492 .492 .530 .530 < .001 .624 .624 < .001 < .001 -
.133 Reference 24922.62 (16581.89) Reference 2987.76 (18157.93) Reference 53056.04 (16096.94) 32711.97 (7852.59) −8962.53 (5532.51) -a -a -a
.133 .869 .869 < .001 .001 < .001 .105
Abbreviation: ED, emergency department. a sample size ≤10.
for tracheitis in patients with a tracheostomy. This would eliminate the need, in many cases, for an operative bronchoscopy. In addition, the therapeutic benefit of laryngoscopy and bronchoscopy is not typically necessary in patients with prior tracheostomy as suctioning can be performed directly through the tracheostomy.
infection [12,13]. Patients with tracheostomies are at greater risk of aspiration with oral intake, which could explain why this group of patients had higher rates of enteral nutrition. Furthermore, pediatric patients with tracheostomies are likely to have had complicated medical histories that initially necessitated a tracheostomy and may likewise have necessitated non-oral mechanisms of feeding. One explanation for lower rates of diagnostic visualization in patients with prior tracheostomies could be that the presence of a tracheostomy alone may have elevated clinical suspicion for tracheitis enough that confirmation on endoscopy was deemed unnecessary. Even more likely is that flexible fiberoptic endoscopy can be performed at the bedside to evaluate
4.2. Resource utilization Median household income quartile by Zip code did not significantly impact charges in either of the groups. Length of stay was, unsurprisingly, an independent predictor of increased charges for both groups of 4
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
Table 5 Multiple linear regression identifying independent predictors of total charges. Variable
Race White Black Hispanic Asian or Pacific Islander Native American Other Region Northeast Midwest South West Median household income quartiles by Zip code 1 $1 - $38,999 2 $39,000 - $47,999 3 $48,000 - $62,999 4 $63,000+ Children's hospital No Yes Length of stay Laryngoscopy and other tracheoscopy No Yes Bronchoscopy No Yes Endotracheal intubation No Yes Discharge status Routine Transfer to short-term hospital Other transfers (skilled nursing facility, intermediate care, and other facilities) Home health care Against medical advice Died in hospital Discharged alive, destination unknown a b
Acute Tracheitis without Prior Tracheostomy
Acute Tracheitis with Prior Tracheostomy
Change in total charges: mean, standard error ($)
Change in total charges: mean, standard error ($)
p-value
p-value
-b Reference 3307.28 (7645.47) 14612.82 (7255.87) -a -a 1758.07 (13002.00)
.666 .045
.892
Reference −4534.24 (7992.11) −1431.68 (7953.22) 18881.82 (8665.16)
.571 .857 .030
Reference −4882.24 (6586.09) 4875.45 (7053.59) −3861.52 (7183.36) -b
Reference −24305.33 (3571.76) −7562.54 (3341.33) 4838.78 (3908.17) -b
< .001 .024 .216
Reference 11535.40 (2524.88) 8813.47 (129.92) -b
< .001 < .001
.459 .490 .591
9591.29 (220.29) -b
.000
-b
Reference 1238.42 (8096.58)
.878
Reference 22275.65 (6651.90) -b -b -b
Reference 20141.68 (15156.39) 28060.84 (11347.92)
.184 .014
Reference 3343.79 (8476.67) 10255.58 (4256.59)
−7163.98 -a -a -a
.342
1227.44 (3013.99) -a -a -a
.001
.693 .016 .684
sample size ≤ 10. indicates variable that did not demonstrate significance on simple linear regression.
benign presentations, such as with a viral etiology. Prior tracheostomy also did not impact charges, regardless of obstruction status even though theoretically, having a prior tracheostomy should facilitate care and subsequently lead to lesser resource utilization.
patients. Hospital region also played a role in the majority of the groups, with the West region predicting increased charges in the group without prior tracheostomy and the South and Midwest regions predicting decreased charges in the group with prior tracheostomy. It is unclear why these regional trends do not apply to every group, but more research into potential charge-increasing or charge-reducing strategies employed in these regions is necessary. Admission to children's hospitals and discharge to skilled nursing, intermediate care, and other facilities predicted increased charges in the group with prior tracheostomy. Theoretically, children's hospitals should be more adept at treating pediatric tracheitis, but this does not seem to necessarily translate to more optimal utilization of resources. It is also possible that non-children's hospitals are underutilizing resources in the appropriate treatment of tracheitis. Having laryngoscopy and other tracheoscopy or endotracheal intubation did not significantly impact charges in either of the two groups, but performance of bronchoscopy did significantly increase charges in the group with prior tracheostomy. While the actual performance of these procedures would certainly incur charges, this may be offset by improved diagnostic accuracy and provide for more optimal and resource-effective treatment. The very low rates of procedures in this study may suggest that providers may be more conservative than necessary when ordering procedures for tracheitis, especially for more
4.3. Limitations There were several limitations present in this study. One limitation is imposed by the diagnostic uncertainty of tracheitis. It is possible that patients with more mild presentations were documented as having acute tracheitis without obstruction, but were actually presenting with a different disease process altogether. The low rates of direct visualization to definitively distinguish between diseases only increase the likelihood of misdiagnosis. In addition, the ICD-9-CM codes for acute tracheitis do not specify whether or not the infection was bacterial or viral. It is possible that a substantial number of cases of viral tracheitis were included, which may have led to the overall milder presentation of tracheitis found in our study. Another limitation is the possibility that mechanical ventilation, while performed, was not used subsequently in the airway support of the patient with tracheitis, but rather was responsible for the infection itself [14]. The temporal relationship is unable to be determined from this database, but patients who developed ventilator-associated tracheobronchitis may potentially comprise a 5
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
agencies in the public, commercial, or not-for-profit sectors.
subset of patients diagnosed with acute tracheitis in this study. It is important to note that this database only studies tracheitis in an inpatient setting. Pediatric patients with tracheitis who are discharged from the ED or managed as outpatients in clinic are not accounted for in the database. Coding errors within this database are a possibility. The HCUP Data Use Agreement prohibits reporting on sample sizes of 10 or fewer (1-10) patients [5]. In addition, statistical data regarding groups ≤10 were excluded due to small sample size. As the KID does not detail patient-level data, it is possible that some patients had multiple admissions and were counted multiple times in the database. The latest version of the KID (2012) was used. In 2012, fee-for-service (FFS) payments were commonly used by children's hospitals, a trend that has since changed. Thus, this data may be more representative of charge data for hospitals using an FFS payment plan as opposed to more recent data that would likely more frequently involve diagnosis-related groupbased payment plans.
Declaration of competing interest None. References [1] R. Jones, J.I. Santos, J.C. Overall Jr., Bacterial tracheitis, JAMA 242 (1979) 721–726. [2] A. Hopkins, T. Lahiri, R. Salerno, B. Heath, Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis, Pediatrics 118 (2006) 1418–1421. [3] B.W. Donnelly, J.A. McMillan, L.B. Weiner, Bacterial tracheitis: report of eight new cases and review, Rev. Infect. Dis. 12 (1990) 729–735. [4] M. Tebruegge, A. Pantazidou, K. Thorburn, A. Riordan, J. Round, C. De Munter, et al., Bacterial tracheitis: a multi-centre perspective, Scand. J. Infect. Dis. 41 (2009) 548–557, https://doi.org/10.1080/00365540902913478. [5] HCUP Kids’ Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, Rockville, MD, 2012http:// www.hcup-us.ahrq.gov/kidoverview.jsp , Accessed date: 3 June 2018. [6] Publishing with HCUP Data, Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, Rockville, MD, 2018www.hcup-us. ahrq.gov/db/hcupdatapartners.jsp , Accessed date: 3 June 2018. [7] A.D. Miranda, T.A. Valdez, K.D. Pereira, Bacterial tracheitis: a varied entity, Pediatr. Emerg. Care 27 (2011) 950–953, https://doi.org/10.1097/PEC. 0b013e3182309d45. [8] H.E. Eckel, B. Widemann, M. Damm, B. Roth, Airway endoscopy in the diagnosis and treatment of bacterial tracheitis in children, Int. J. Pediatr. Otorhinolaryngol. 27 (1993) 147–157. [9] B. Al-Mutairi, V. Kirk, Bacterial tracheitis in children: approach to diagnosis and treatment, Paediatr. Child Health 9 (2004) 25–30. [10] F.N. Salamone, D.B. Bobbitt, C.M. Myer, M.J. Rutter, J.H. Greinwald Jr., Bacterial tracheitis reexamined: is there a less severe manifestation? Otolaryngol. Head Neck Surg. 131 (2004) 871–876. [11] Y.L. Huang, C.C. Peng, N.C. Chiu, K.S. Lee, H.Y. Hung, H.A. Kao, et al., Bacterial tracheitis in pediatrics: 12 year experience at a medical center in Taiwan, Pediatr. Int. 51 (2009) 110–113, https://doi.org/10.1111/j.1442-200X.2008.02669.x. [12] I. Brook, Bacterial colonization, tracheobronchitis, and pneumonia following tracheostomy and long-term intubation in pediatric patients, Chest 76 (1979) 420–424. [13] M.S. Niederman, R.D. Ferranti, A. Zeigler, W.W. Merrill, H.Y. Reynolds, Respiratory infection complicating long-term tracheostomy. The implication of persistent gramnegative tracheobronchial colonization, Chest 85 (1984) 39–44. [14] S. Nseir, C. Di Pompeo, P. Pronnier, S. Beague, T. Onimus, F. Saulnier, et al., Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome, Eur. Respir. J. 20 (2002) 1483–1489.
5. Conclusion There is a paucity of literature on the management and resource utilization of pediatric tracheitis, specifically with respect to tracheostomy status. This study found that overall rates of endoscopy and endotracheal intubation in this population may be lower than previously reported. In addition, rates of endoscopy and endotracheal intubation are significantly lower in pediatric patients with a prior tracheostomy compared with patients without. Interestingly, there was no significant difference in resource utilization, as measured by total hospital charges and LOS, between the two groups. Our findings highlight the differences in the management of tracheitis based on prior tracheostomy status. There are existing ICD-9-CM and ICD-10 codes for tracheitis that specify obstruction status; accordingly, we propose additional diagnosis codes differentiating tracheitis based on prior tracheostomy status by considering tracheitis as “open” in the presence of a tracheostomy and “closed” in the absence of a tracheostomy. A broader review studying these two groups of tracheitis, including the “open” versus “closed” designation, in both the inpatient and outpatient setting, is necessary to further elucidate differences in disease course, management, and resource utilization. Funding This research did not receive any specific grant from funding
6
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Acute pediatric tracheitis: Distinguishing the disease by tracheostomy status☆
T
Jonathan S. Nia, Jocelyn Kohnb, Udayan K. Shahc,d,e,∗, Jessica R. Levia,b a
Boston University School of Medicine, 72 E. Concord St., Boston, MA, 02118, USA Department of Otolaryngology–Head and Neck Surgery, Boston Medical Center, 820 Harrison Ave., FGH Building 4th Floor, Boston, MA, 02118, USA c Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Rd., Wilmington, DE, 19803, USA d Department of Otolaryngology-Head & Neck Surgery, 130 S 9th St, Philadelphia, PA, 19107, USA e Department of Pediatrics, Thomas Jefferson University, 130 S 9th St, Philadelphia, PA, 19107, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Pediatric Tracheitis Resource utilization Tracheostomy Obstruction
Objectives: Tracheitis is an upper airway infection that often presents in patients with tracheostomies and can potentially cause airway obstruction. This study aims to use a nationwide database to identify a large cohort of pediatric patients admitted with tracheitis to elucidate the management and resource utilization associated with the disease both with and without tracheostomies. Methods: The Kids’ Inpatient Database (KID) 2012 was used to identify 2394 weighted discharges with acute tracheitis, with or without obstruction, as the primary diagnosis. Data on prior tracheostomy status, demographics, hospital characteristics, management, and resource utilization were obtained. Two groups of interest, based on presence of prior tracheostomy, were studied. Linear regression was performed to determine independent predictors of total charges. Results: The mean age was 5.52 years (SD: 5.54), mean length of stay (LOS) was 6.37 days (SD: 10.18), and mean total charges were $60,996.61 (SD: 107,798.41). Patients with prior tracheostomy had lower rates of endoscopy and endotracheal intubation than patients without (p < 0.0005). There was no significant difference in LOS (p = 0.076) or total charges (p = 0.210) between the groups based on prior tracheostomy status. Conclusion: Pediatric tracheitis should be differentiated on the basis of tracheostomy status. We propose that tracheitis diagnosis codes should be distinguished by the presence of tracheostomy as “open” and the absence of tracheostomy as “closed.”
1. Introduction Bacterial tracheitis was initially reported by Jones et al. and was described as an obstructive upper airway infection with some characteristics common to both croup and epiglottitis [1]. However, advances in the prevention of epiglottitis and treatment of croup have left tracheitis, in many cases, as the most dangerous upper airway infection [2]. Often following an upper respiratory infection, the clinical presentation of tracheitis includes acute onset of fever, stridor, and respiratory distress [3]. An important consideration in the diagnosis and treatment of tracheitis is the presence of prior tracheostomy, which may substantially impact a patient's hospital course. Management of tracheitis includes debridement by laryngoscopy or bronchoscopy, antibiotics, and, if necessary, intubation and ventilation. According to the literature, intubation is often indicated, with reported rates as high as
91% [4]. However, the literature on tracheitis remains limited. As such, study of a large cohort of pediatric patients may provide greater insight into how the disease is managed in the inpatient setting. The yearly incidence of bacterial tracheitis is estimated to be 0.1 per 100,000 children [4]. In addition, tracheitis may be viral in etiology. The rarity of this condition makes it difficult to study. We aimed to use a nationwide database to identify a relatively large population of admissions with tracheitis, regardless of etiology, to further elucidate patient demographics as well as trends in management and resource utilization. 2. Materials and methods Institutional Review Board approval was not required as a nationwide database was used. The Kids’ Inpatient Database (KID), Healthcare
☆ ∗
Work conducted: Boston University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, MA. Corresponding author. Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA. E-mail addresses: [email protected] (J.S. Ni), [email protected] (J. Kohn), [email protected] (U.K. Shah), [email protected] (J.R. Levi).
https://doi.org/10.1016/j.ijporl.2019.109800 Received 12 September 2019; Received in revised form 25 November 2019; Accepted 25 November 2019 Available online 29 November 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
31.21, 31.29), enteral infusion or nutrition (96.6), and mechanical ventilation (96.71, 96.72) were identified using ICD-9-CM procedure codes. Independent samples t-test was performed to determine if there were any statistically significant differences in length of stay (LOS) or total charges between two groups. Levene's test for equality of variances was performed, and in instances where the assumption of homogeneity of variances was violated, Welch t-test was performed. Chi-square test for homogeneity was performed to determine if there were any statistically significant differences in rates of procedures between two groups. Fisher's exact test was used to determine differences in proportions in instances where expected frequencies were insufficiently sized to perform Chi-square test for homogeneity. Variables suspected to contribute to total charges were identified. These variables included age, sex, race, region, income quartile for patients' Zip codes, emergency department (ED) services, elective admission, treatment at children's hospital, LOS, laryngoscopy and other tracheoscopy, bronchoscopy, endotracheal intubation, prior tracheostomy, obstruction status, and discharge status. Simple linear regression was performed for each individual variable of interest. Variables with individual simple linear regression models that demonstrated significance (p < 0.05) were incorporated into a multiple linear regression model to determine independent predictors of increased and decreased charges.
Table 1 Demographic information. Acute Tracheitis without Prior Tracheostomy (n = 592)
Acute Tracheitis with Prior Tracheostomy (n = 1865)
Mean age in yrs (SD), 5.93 (5.33), 0-20 5.40 (5.59), 0-20 range in yrs Sex (%) Male 312 (58.9) 1135 (60.8) Female 217 (41.1) 730 (39.2) Race (%) White 271 (58.6) 742 (43.3) Black 72 (15.6) 395 (23.0) Hispanic 88 (19.1) 428 (25.0) Asian or Pacific -a 44 (2.5) Islander 27 (1.6) Native American -a Other 23 (5.1) 79 (4.6) Median household income quartiles by Zip code, $ (%) 1 $1 - $38,999 148 (28.3) 554 (30.0) 2 $39,000 - $47,999 155 (29.7) 545 (29.5) 3 $48,000 - $62,999 106 (20.2) 444 (24.0) 4 $63,000+ 114 (21.8) 304 (16.5) Payer (%) Medicare -a -a Medicaid 273 (51.5) 1368 (73.6) Private including 220 (41.5) 383 (20.6) HMO -a Self-pay -a No charge -a -a Other 26 (4.8) 98 (5.3)
3. Results A total of 2394 weighted discharges were identified. The mean age was 5.52 years (SD: 5.54) and 1446 (60.4%) of patients were male. The most common race was white (46.5%). The most common median household income quartile by Zip code was the first quartile, which made up 29.6% of the total population. The most common payer was Medicaid (68.7%). Individual demographic information for each of the four groups is shown in Table 1. Overall, an average of 1.33 procedures per patient was performed.
Abbreviation: HMO, health maintenance organization. a The Healthcare Cost and Utilization Project Data Use Agreement prohibits reporting of 10 or fewer observations [5].
Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality provides estimated costs of nationwide inpatient stays for patients under the age of 21 years [5]. Many data partners contribute to the HCUP [6]. KID 2012, the most recent version of the database, details nationwide discharges in the year 2012 alone, and was used in this study. Weighted discharges were used and will also be referred to as patients in this study. The International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) code for acute tracheitis without mention of obstruction (464.10) and acute tracheitis with obstruction (464.11) were used to identify admissions with either of these two conditions as primary diagnoses. Patients with prior tracheostomy were identified if any of the following ICD-9-CM diagnosis codes were present as secondary diagnoses: tracheostomy status (V44.0), attention to tracheostomy (V55.0), tracheostomy complication NOS (519.00), infection of tracheostomy (519.01), mechanical complication of tracheostomy (519.02), or other tracheostomy complications (519.09). Procedures of interest performed during the admission, including laryngoscopy and other tracheoscopy (31.42), bronchoscopy (33.21, 33.22, 33.23), endotracheal intubation (96.04), tracheostomy (31.1,
3.1. Procedures: no prior tracheostomy vs. prior tracheostomy A total of 529 patients did not have a tracheostomy prior to admission and 1865 patients did have a tracheostomy prior to admission. Comparing these two groups, there were significant differences in rates of laryngoscopy (and other tracheoscopy) (p < 0.0005), bronchoscopy (p < 0.0005), endotracheal intubation (p < 0.0005), and enteral nutrition (p < 0.0005) and no significant differences in mechanical ventilation for less than 96 h (p = 0.566) or 96 or more hours (p = 0.110) (Table 2). 3.2. Admission characteristics, hospital burden, and resource utilization Admission characteristics for each of the two groups are shown in Table 3. For the entire population, the most common hospital regions were the South (33.3%) and the Midwest (27.7%); 50.4% of patients
Table 2 Procedures.
Procedures (%) Laryngoscopy and other tracheoscopy Bronchoscopy Endotracheal intubation Tracheostomy (during admission) Continuous invasive mechanical ventilation < 96 consecutive hours Continuous invasive mechanical ventilation for ≥ 96 consecutive hours Enteral infusion of concentrated nutritional substances a
Acute Tracheitis without Prior Tracheostomy (n = 592)
Acute Tracheitis with Prior Tracheostomy (n = 1865)
77 (14.6) 60 (11.3) 56 (10.5) -a 115 (21.8) 91 (17.3)
36 (1.9) 59 (3.2) 29 (1.5) -a 383 (20.6) 379 (20.3)
66 (12.5)
411 (22.0)
The Healthcare Cost and Utilization Project Data Use Agreement prohibits reporting of 10 or fewer observations [5]. 2
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
regression determining independent predictors of increased or decreased charges. Variables that did not demonstrate significance on simple linear regression in any of the two groups were excluded from Table 5. In the group without prior tracheostomy, independent predictors of increased charges included Hispanic race (p = 0.045); care in the West (p = 0.030); LOS (p < 0.001); and discharge to skilled nursing, intermediate care, and other facilities (p = 0.014) and there were no identified independent predictors of decreased charges. In the group with prior tracheostomy, independent predictors of increased charges included admission to a children's hospital (p < 0.001); LOS (p < 0.001); performance of a bronchoscopy during admission (p = 0.001); and discharge to skilled nursing, intermediate care, and other facilities (p = 0.016). Independent predictors of decreased charges included care in the Midwest (p < 0.001) and South (p < 0.024).
Table 3 Admission characteristics.
Non-elective admission (%) Elective admission (%) Admission month (%) January February March April May June July August September October November December Hospital region (%) Northeast Midwest South West Children's hospital (%) No Yes ED services (%) Does not meet HCUP ED criteria ED revenue code on record Positive ED charge ED CPT code on record Admission source of ED State-defined ED record; no ED charges available Length of stay in days: mean (SD), range Total charges in $: mean (SD), range Discharge status (%) Routine Transfer to short-term hospital Skilled nursing facility, intermediate care, and other facilities) Home health care Against medical advice Died in hospital Discharged alive, destination unknown
Acute Tracheitis without Prior Tracheostomy (n = 592)
Acute Tracheitis with Prior Tracheostomy (n = 1865)
494 (93.6) 34 (6.4)
1801 (96.8) 60 (3.2)
59 35 51 38 51 32 28 27 45 53 52 56
190 191 171 146 133 108 132 141 166 151 173 163
(10.2) (10.2) (9.1) (7.8) (7.1) (5.8) (7.1) (7.5) (8.9) (8.1) (9.3) (8.7)
88 (16.7) 162 (30.6) 162 (30.6) 117 (22.2)
345 500 636 383
(18.5) (26.8) (34.1) (20.6)
284 (53.7) 245 (46.3)
904 (48.5) 961 (51.5)
193 (36.6)
486 (26.0)
202 (38.1)
746 (40.0)
59 (11.1) -a 75 (14.3) -a
306 (16.4) -a 328 (17.6) -a
7.22 (13.16), 0-140
6.13 (9.14), 0–128days
67408.31 (140862.69), 1654-1534131
59185.07 (96395.51), 1208-1823213
415 (78.4) 16 (3.0)
1269 (68.1) 36 (1.9)
30 (5.7)
167 (8.9)
65 (12.3) -a -a -a
387 (20.8) -a -a -a
(11.1) (6.6) (9.7) (7.1) (9.7) (6.1) (5.4) (5.2) (8.6) (10.1) (9.8) (10.6)
4. Discussion The management of tracheitis is seldom reported in the literature. The diagnosis of tracheitis is often confused with other obstructive airway conditions with similar presentations, such as epiglottitis and croup. The only definitive way to diagnose tracheitis is through direct visualization on bronchoscopy. However, the true rates of diagnostic procedures and airway management in tracheitis have been difficult to determine due to the rarity of the disease as well as variations in clinical practice. Bacterial tracheitis has been shown to vary in its presentation and, subsequently, in how it is diagnosed and managed [7]. While some advocate for the liberal use of laryngoscopy and bronchoscopy due to the risks associated with delayed or inaccurate diagnosis [8], others argue that direct visualization is not always indicated and the decision to perform bronchoscopy is dependent on several factors, including the degree of airway obstruction, concern for epiglottitis, and the age of the patient [9]. Rates of endoscopy for tracheitis vary in the literature. In some studies, all patients undergo endoscopy [8,10], while in another study, only a proportion (83%) underwent endoscopy [2]. In our study, only 4.7% of patients underwent laryngoscopy and other tracheoscopy and 5.0% of patients underwent bronchoscopy. These rates are notably lower than those previously reported. In the literature, rates of intubation in the management of tracheitis have ranged from 21% to 91% [4,11]. In this study, the overall rate of endotracheal intubation was 3.5%, which is, to our knowledge, the lowest reported rate of intubation for a large cohort of patients with tracheitis in the literature. The most likely explanation for this remarkably low rate is that 77.9% of patients in our study had a prior tracheostomy and, as expected, patients with an established airway were less likely to require an intubation. Another explanation for the lower intubation rates could involve other patient characteristics. Salamone et al. identified a subset of patients with bacterial tracheitis who have demonstrated less severe presentations and lower rates of intubation. These patients exhibited a unique set of characteristics: older age (mean: 7.9 years), less severe systemic illness, and stronger response to treatment [10]. However, in our study, there was no statistically significant difference in age between patients who underwent endotracheal intubation (mean: 4.93 years; SD: 5.41) and patients who did not (mean: 5.54 years; SD: 5.54) (p = 0.321). In summary, the wide variation in management data between the literature and our study is likely due to a multitude of factors, including differences in baseline patient characteristics, disease severity, and treatment approach.
Abbreviations: CPT, current procedural terminology; ED, emergency department. a The Healthcare Cost and Utilization Project (HCUP) Data Use Agreement prohibits reporting of 10 or fewer observations [5].
were treated at children's hospitals. There was a significant difference in rates of ED services between patients with and without prior tracheostomies. Among all patients, the mean LOS was 6.37 days (SD: 10.18) and the mean total charges was $60,996.61 (SD: 107,798.41). Data on LOS and total charges for both of the groups are detailed in Table 3. There was no statistically significant difference in LOS (p = 0.076) or total charges (p = 0.210) between the groups with or without a prior tracheostomy.
4.1. Differences by prior tracheostomy status 3.3. Independent predictors of resource utilization A total of 77.9% of patients in this study had a prior tracheostomy. This high frequency may be due to bacterial colonization of the tracheobronchial tree, which has been shown to create potential for
Table 4 details the simple linear regression for variables of interest in regard to hospital charges. Table 5 details the multiple linear 3
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
Table 4 Simple linear regression for individual variables of interest. Variable
Age Sex Male Female Race White Black Hispanic Asian or Pacific Islander Native American Other Region Northeast Midwest South West Median household income quartiles by Zip code 1 $1 - $38,999 2 $39,000 - $47,999 3 $48,000 - $62,999 4 $63,000+ Children's hospital No Yes ED services No Yes Elective admission No Yes Length of stay Laryngoscopy and other tracheoscopy No Yes Bronchoscopy No Yes Prior tracheostomy No Yes Obstruction No Yes Endotracheal intubation No Yes Discharge status Routine Transfer to short-term hospital Other transfers (skilled nursing facility, intermediate care, and other facilities) Home health care Against medical advice Died in hospital Discharged alive, destination unknown
Acute Tracheitis without Prior Tracheostomy
Acute Tracheitis with Prior Tracheostomy
Difference in total charges: mean, standard error ($)
p-value
Difference in total charges: mean, standard error ($)
p-value
−1924.95 (1157.50)
.097 .783
628.93 (399.55)
.116 .353
Reference −3455.61 (12542.94)
.783 < .001
Reference −1384.32 (17887.31) 68492.58 (16250.54) -a -a 67578.02 (28981.76)
.938 < .001
.020 .014
Reference −44537.76 (18574.16) −54584.57 (18510.90) −19818.02 (19806.57)
.017 .003 .317 .004
Reference 23172.94 (15973.09) −21560.34 (17714.53) −36265.79 (17256.06)
.147 .224 .036 .096
Reference 20561.80 (12327.10)
.096 .234
Reference 15264.90 (12810.36)
.234 .368
Reference −22556.55 (25020.97) 9805.26 (183.39)
.368
Reference 4259.59 (4588.89) Reference −854.17 (5833.41) 538.10 (5689.24) 17648.55 (14941.63) 51546.04 (18735.72) −6542.35 (11324.82) Reference −26885.12 (6703.46) −9025.80 (6393.48) 9143.68 (7131.21) Reference 4139.51 (5784.16) 938.71 (6124.03) 7604.61 (6866.97) Reference 12595.33 (4473.41) Reference −3511.72 (5114.04) Reference 7942.69 (12639.93) 8905.47 (129.80)
.943 Reference 1246.47 (17375.92)
.943 .649
Reference 8814.91 (19341.02) – – –
.649 – – – .792
Reference −6681.96 (25374.47)
.792 .004
Reference 57855.40 (19809.73)
.004 < .001
Reference 87303.52 (32020.96) 125232.98 (23476.54)
.007 < .001
17644.76 (16611.76) -a -a -a
.289
Reference 7947.56 (16196.37) Reference 89066.79 (12563.01) – – –
.353 .090 .884 .925 .238 .006 .564 < .001 < .001 .158 .200 .684 .474 .878 .268 .005 .005 .492 .492 .530 .530 < .001 .624 .624 < .001 < .001 -
.133 Reference 24922.62 (16581.89) Reference 2987.76 (18157.93) Reference 53056.04 (16096.94) 32711.97 (7852.59) −8962.53 (5532.51) -a -a -a
.133 .869 .869 < .001 .001 < .001 .105
Abbreviation: ED, emergency department. a sample size ≤10.
for tracheitis in patients with a tracheostomy. This would eliminate the need, in many cases, for an operative bronchoscopy. In addition, the therapeutic benefit of laryngoscopy and bronchoscopy is not typically necessary in patients with prior tracheostomy as suctioning can be performed directly through the tracheostomy.
infection [12,13]. Patients with tracheostomies are at greater risk of aspiration with oral intake, which could explain why this group of patients had higher rates of enteral nutrition. Furthermore, pediatric patients with tracheostomies are likely to have had complicated medical histories that initially necessitated a tracheostomy and may likewise have necessitated non-oral mechanisms of feeding. One explanation for lower rates of diagnostic visualization in patients with prior tracheostomies could be that the presence of a tracheostomy alone may have elevated clinical suspicion for tracheitis enough that confirmation on endoscopy was deemed unnecessary. Even more likely is that flexible fiberoptic endoscopy can be performed at the bedside to evaluate
4.2. Resource utilization Median household income quartile by Zip code did not significantly impact charges in either of the groups. Length of stay was, unsurprisingly, an independent predictor of increased charges for both groups of 4
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
Table 5 Multiple linear regression identifying independent predictors of total charges. Variable
Race White Black Hispanic Asian or Pacific Islander Native American Other Region Northeast Midwest South West Median household income quartiles by Zip code 1 $1 - $38,999 2 $39,000 - $47,999 3 $48,000 - $62,999 4 $63,000+ Children's hospital No Yes Length of stay Laryngoscopy and other tracheoscopy No Yes Bronchoscopy No Yes Endotracheal intubation No Yes Discharge status Routine Transfer to short-term hospital Other transfers (skilled nursing facility, intermediate care, and other facilities) Home health care Against medical advice Died in hospital Discharged alive, destination unknown a b
Acute Tracheitis without Prior Tracheostomy
Acute Tracheitis with Prior Tracheostomy
Change in total charges: mean, standard error ($)
Change in total charges: mean, standard error ($)
p-value
p-value
-b Reference 3307.28 (7645.47) 14612.82 (7255.87) -a -a 1758.07 (13002.00)
.666 .045
.892
Reference −4534.24 (7992.11) −1431.68 (7953.22) 18881.82 (8665.16)
.571 .857 .030
Reference −4882.24 (6586.09) 4875.45 (7053.59) −3861.52 (7183.36) -b
Reference −24305.33 (3571.76) −7562.54 (3341.33) 4838.78 (3908.17) -b
< .001 .024 .216
Reference 11535.40 (2524.88) 8813.47 (129.92) -b
< .001 < .001
.459 .490 .591
9591.29 (220.29) -b
.000
-b
Reference 1238.42 (8096.58)
.878
Reference 22275.65 (6651.90) -b -b -b
Reference 20141.68 (15156.39) 28060.84 (11347.92)
.184 .014
Reference 3343.79 (8476.67) 10255.58 (4256.59)
−7163.98 -a -a -a
.342
1227.44 (3013.99) -a -a -a
.001
.693 .016 .684
sample size ≤ 10. indicates variable that did not demonstrate significance on simple linear regression.
benign presentations, such as with a viral etiology. Prior tracheostomy also did not impact charges, regardless of obstruction status even though theoretically, having a prior tracheostomy should facilitate care and subsequently lead to lesser resource utilization.
patients. Hospital region also played a role in the majority of the groups, with the West region predicting increased charges in the group without prior tracheostomy and the South and Midwest regions predicting decreased charges in the group with prior tracheostomy. It is unclear why these regional trends do not apply to every group, but more research into potential charge-increasing or charge-reducing strategies employed in these regions is necessary. Admission to children's hospitals and discharge to skilled nursing, intermediate care, and other facilities predicted increased charges in the group with prior tracheostomy. Theoretically, children's hospitals should be more adept at treating pediatric tracheitis, but this does not seem to necessarily translate to more optimal utilization of resources. It is also possible that non-children's hospitals are underutilizing resources in the appropriate treatment of tracheitis. Having laryngoscopy and other tracheoscopy or endotracheal intubation did not significantly impact charges in either of the two groups, but performance of bronchoscopy did significantly increase charges in the group with prior tracheostomy. While the actual performance of these procedures would certainly incur charges, this may be offset by improved diagnostic accuracy and provide for more optimal and resource-effective treatment. The very low rates of procedures in this study may suggest that providers may be more conservative than necessary when ordering procedures for tracheitis, especially for more
4.3. Limitations There were several limitations present in this study. One limitation is imposed by the diagnostic uncertainty of tracheitis. It is possible that patients with more mild presentations were documented as having acute tracheitis without obstruction, but were actually presenting with a different disease process altogether. The low rates of direct visualization to definitively distinguish between diseases only increase the likelihood of misdiagnosis. In addition, the ICD-9-CM codes for acute tracheitis do not specify whether or not the infection was bacterial or viral. It is possible that a substantial number of cases of viral tracheitis were included, which may have led to the overall milder presentation of tracheitis found in our study. Another limitation is the possibility that mechanical ventilation, while performed, was not used subsequently in the airway support of the patient with tracheitis, but rather was responsible for the infection itself [14]. The temporal relationship is unable to be determined from this database, but patients who developed ventilator-associated tracheobronchitis may potentially comprise a 5
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109800
J.S. Ni, et al.
agencies in the public, commercial, or not-for-profit sectors.
subset of patients diagnosed with acute tracheitis in this study. It is important to note that this database only studies tracheitis in an inpatient setting. Pediatric patients with tracheitis who are discharged from the ED or managed as outpatients in clinic are not accounted for in the database. Coding errors within this database are a possibility. The HCUP Data Use Agreement prohibits reporting on sample sizes of 10 or fewer (1-10) patients [5]. In addition, statistical data regarding groups ≤10 were excluded due to small sample size. As the KID does not detail patient-level data, it is possible that some patients had multiple admissions and were counted multiple times in the database. The latest version of the KID (2012) was used. In 2012, fee-for-service (FFS) payments were commonly used by children's hospitals, a trend that has since changed. Thus, this data may be more representative of charge data for hospitals using an FFS payment plan as opposed to more recent data that would likely more frequently involve diagnosis-related groupbased payment plans.
Declaration of competing interest None. References [1] R. Jones, J.I. Santos, J.C. Overall Jr., Bacterial tracheitis, JAMA 242 (1979) 721–726. [2] A. Hopkins, T. Lahiri, R. Salerno, B. Heath, Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis, Pediatrics 118 (2006) 1418–1421. [3] B.W. Donnelly, J.A. McMillan, L.B. Weiner, Bacterial tracheitis: report of eight new cases and review, Rev. Infect. Dis. 12 (1990) 729–735. [4] M. Tebruegge, A. Pantazidou, K. Thorburn, A. Riordan, J. Round, C. De Munter, et al., Bacterial tracheitis: a multi-centre perspective, Scand. J. Infect. Dis. 41 (2009) 548–557, https://doi.org/10.1080/00365540902913478. [5] HCUP Kids’ Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, Rockville, MD, 2012http:// www.hcup-us.ahrq.gov/kidoverview.jsp , Accessed date: 3 June 2018. [6] Publishing with HCUP Data, Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, Rockville, MD, 2018www.hcup-us. ahrq.gov/db/hcupdatapartners.jsp , Accessed date: 3 June 2018. [7] A.D. Miranda, T.A. Valdez, K.D. Pereira, Bacterial tracheitis: a varied entity, Pediatr. Emerg. Care 27 (2011) 950–953, https://doi.org/10.1097/PEC. 0b013e3182309d45. [8] H.E. Eckel, B. Widemann, M. Damm, B. Roth, Airway endoscopy in the diagnosis and treatment of bacterial tracheitis in children, Int. J. Pediatr. Otorhinolaryngol. 27 (1993) 147–157. [9] B. Al-Mutairi, V. Kirk, Bacterial tracheitis in children: approach to diagnosis and treatment, Paediatr. Child Health 9 (2004) 25–30. [10] F.N. Salamone, D.B. Bobbitt, C.M. Myer, M.J. Rutter, J.H. Greinwald Jr., Bacterial tracheitis reexamined: is there a less severe manifestation? Otolaryngol. Head Neck Surg. 131 (2004) 871–876. [11] Y.L. Huang, C.C. Peng, N.C. Chiu, K.S. Lee, H.Y. Hung, H.A. Kao, et al., Bacterial tracheitis in pediatrics: 12 year experience at a medical center in Taiwan, Pediatr. Int. 51 (2009) 110–113, https://doi.org/10.1111/j.1442-200X.2008.02669.x. [12] I. Brook, Bacterial colonization, tracheobronchitis, and pneumonia following tracheostomy and long-term intubation in pediatric patients, Chest 76 (1979) 420–424. [13] M.S. Niederman, R.D. Ferranti, A. Zeigler, W.W. Merrill, H.Y. Reynolds, Respiratory infection complicating long-term tracheostomy. The implication of persistent gramnegative tracheobronchial colonization, Chest 85 (1984) 39–44. [14] S. Nseir, C. Di Pompeo, P. Pronnier, S. Beague, T. Onimus, F. Saulnier, et al., Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome, Eur. Respir. J. 20 (2002) 1483–1489.
5. Conclusion There is a paucity of literature on the management and resource utilization of pediatric tracheitis, specifically with respect to tracheostomy status. This study found that overall rates of endoscopy and endotracheal intubation in this population may be lower than previously reported. In addition, rates of endoscopy and endotracheal intubation are significantly lower in pediatric patients with a prior tracheostomy compared with patients without. Interestingly, there was no significant difference in resource utilization, as measured by total hospital charges and LOS, between the two groups. Our findings highlight the differences in the management of tracheitis based on prior tracheostomy status. There are existing ICD-9-CM and ICD-10 codes for tracheitis that specify obstruction status; accordingly, we propose additional diagnosis codes differentiating tracheitis based on prior tracheostomy status by considering tracheitis as “open” in the presence of a tracheostomy and “closed” in the absence of a tracheostomy. A broader review studying these two groups of tracheitis, including the “open” versus “closed” designation, in both the inpatient and outpatient setting, is necessary to further elucidate differences in disease course, management, and resource utilization. Funding This research did not receive any specific grant from funding
6