Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

Bronchiolitis is an inflammatory process that affects predominantly small airways. Acute bronchiolitis is a clinical diagnosis given to the following constellation of signs and symptoms: viral upper respiratory prodrome followed by increased respiratory effort, wheezing, diffuse bilateral crackles, generally affecting infants less than 12-24 months of age. The most common causative agent is respiratory syncytial virus, but other viruses can cause bronchiolitis as well, including adenovirus, rhinovirus, influenza, enterovirus, parainfluenza, and human metapneumovirus. Non-viral causes include mycoplasma, chlamydia, fungi, and mycobacteria. Bronchiolitis typically starts in the upper airways and spreads to the lower airways within a few days, resulting in inflammation, edema, mucous production, and bronchospasm. Infants with bronchiolitis usually present with tachypnea, tachycardia, and prolonged expiratory phase. High fever is uncommon. Young infants may experience episodes of apnea. 

The likelihood of inpatient apnea (for infants hospitalized with bronchiolitis) is associated with several risk factors: corrected age less than 2 weeks and 2-8 weeks compared to more than 6 months; birth weight less than 2.3 kg compared with more than 3.2 kg; caretaker report of previous apnea during the current bronchiolitis episode; preadmission respiratory rate less than 30 or greater than 7; and preadmission room air saturation less than 90% in room air. Apnea risk is similar for all major respiratory viruses (eg RSV, influenza, adenovirus, human metapneumovirus).

A conservative approach to management is generally appropriate, particularly for the very young in whom apnea must be a consideration. Treatment is generally supportive, including hydration, supplemental oxygen, and assisted ventilation when necessary (CPAP [continuous positive airway pressure], high flow nasal cannula oxygen, mechanical ventilation). The current recommendation is not to use bronchodilator medications including epinephrine and albuterol because studies have failed to show sustained benefit. Hypertonic saline may be considered to facilitate mucociliary clearance. There is no place for corticosteroid administration because the evidence has shown no benefit when used alone and only tentative benefit when used in conjunction with bronchodilators. Use of supplemental oxygen is at the clinician's discretion, particularly if oxygen saturation as measured by pulse oximetry is greater than 90%. There is no evidence to suggest that application of supplemental oxygen for saturation above 90% adds any benefit and may in fact prolong hospital stay. For this reason, continuous pulse oximetry is not considered standard. Antibacterial agents should only be used if there is a concomitant bacterial infection. Finally, hydration via enteral feedings and/or IV fluids is necessary.

This term female infant presented to the ED with signs and symptoms consistent with bronchiolitis. She had no fevers, was mildly irritable, with mild retractions, and no oxygen requirement. Because of her age and her living situation (in a shelter) and her family history (both parents had asthma), it was not unreasonable to monitor her for a period of time. However, she was hemodynamically stable, without significant respiratory distress, with no signs of sepsis. She did not require acute inpatient management and could have been safely managed at a lower level of care.