Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestion, shortness of breath
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is a teen-aged female with medical history significant for intermittent asthma who presented to the ED with one-day history of congestion and shortness of breath. Albuterol provided some relief. Her symptoms worsened overnight with increasing chest tightness. She treated herself with four albuterol treatments with minimal improvement. She had no fevers. 

Vital signs included temperature 37, heart rate 101, respiratory rate 22 with 98% oxygen saturation, and blood pressure 100/58. Examination was significant for diffuse wheezing bilaterally, prolonged expiratory phase, subcostal retractions, and moist oral mucosa. She was given three DuoNebs, three albuterols, magnesium, and Decadron. Because of persistent symptoms with wheezing and chest tightness, she was admitted to the pediatric floor. Admission orders included sequential compression devices for deep vein thrombosis (DVT) prophylaxis, famotidine for gastrointestinal (GI) protection, enteral steroids, albuterol every three hours, and Asthma Education. The patient improved overnight, weaning albuterol to every four hours in the morning. She did well over the course of the day and was deemed stable for discharge that evening. 

Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients...our review findings support the importance of controlling persistent asthma...early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)
 
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

This young woman with intermittent but well-controlled asthma was admitted with acute asthma exacerbation. Despite aggressive management in the ED, she continued to experience chest tightness and wheezing. She was admitted for frequent bronchodilator treatments. Once she was able to wean to a frequency reasonable to do at home with improvement in symptoms, she was discharged home. While she was overall hemodynamically stable, with no evidence of impending respiratory failure, she required frequent bronchodilator treatments and steroids. Pulmonology was consulted for Asthma Education and Asthma Action Plan. This level of care is not possible in the outpatient setting. The hospital admission was medically necessary and appropriate.