Appeal type: Medical necessity
Decision: Upheld

Diagnosis - Asthma
Treatment - Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male child with medical history significant for reactive airway disease with previous admission for wheezing. He was taken to the emergency department (ED) for two-day history of labored breathing and shortness of breath not relieved by nebulized albuterol. 

Vital signs included temperature 37, heart rate 161, respiratory rate 32, and 96% saturation in room air. Examination was significant for distress with intercostal and suprasternal retractions, intermittently crying and then sleepy, tachypnea, wheezing, benign abdomen, tachycardia, and non-focal neurologic exam. Rapid influenza and respiratory syncytial virus (RSV) testing were negative. He was treated with three DuoNebs, dexamethasone, intravenous (IV) fluids, and magnesium, followed by four hours of continuous albuterol. He improved such that he was able to tolerate treatments every two hours but could not be weaned further. He was admitted for further management of asthma exacerbation with status asthmaticus. 

The patient did well overnight with no acute events. He was able to tolerate weaning to every three hours by the morning, with plans to wean further during the day. He was tolerating a regular diet and enteral steroids. He was able to tolerate transition to every four hours by the morning of day #2. At this time, the patient was deemed stable for discharge to home, to complete a five-day course of steroids and begin a course of azithromycin for presumed community acquired pneumonia. 

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 child with history of reactive airway disease presented to the ED with wheezing and increased work of breathing consistent with an asthma exacerbation. He was treated aggressively in the ED, but continued to be symptomatic, so was admitted with the additional diagnosis of status asthmaticus. Over his two-day hospital stay, he responded well to treatment. He remained hemodynamically stable, with no oxygen requirement, able to take adequate food and fluids by mouth. While it was reasonable and appropriate to provide ongoing respiratory treatments in the hospital, he did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.