Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wheezing and cough
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a female child with family history of asthma and medical history of eczema and wheezing that presented to the ED with wheezing and cough. The parent described the wheezing as mild and constant, improving with albuterol at home, associated with recent upper respiratory infection (URI) symptoms of rhinorrhea and cough. There was no fever, rash, or sputum production. The cough was described as dry, starting about four days prior and worsening. 

Vital signs included temperature 37.2, heart rate 130, respiratory rate 30 with 100% saturation, and blood pressure 92/52. Examination was significant for no distress, regular heart rate and rhythm, moist mucous membranes, diffuse expiratory wheezing heard best posteriorly, and non-focal neurologic exam. She was treated with three DuoNebs with improvement in wheezing, able to roar like a dinosaur. Reassessment thirty minutes later revealed persistent but improved wheezing and tachypnea. She was treated with additional albuterol with consideration for magnesium. Three hours later, work of breathing and respiratory rate were both improved, but her saturation in room air was down to 90-91%. She was treated with nebulized saline with improvement to 93%. Chest x-ray was obtained, as well as rapid respiratory syncytial virus (RSV) / influenza. 

The decision was made to admit because of hypoxia, with diagnosis of bronchiolitis versus URI with asthma exacerbation. Additional treatments prior to admission included dexamethasone. Rapid RSV/influenza testing was negative. Laboratory evaluation prior to admission included venous blood gas indicative of metabolic acidosis, metabolic panel with metabolic acidosis (CO2 19) and mild increase in transaminase (AST), and complete blood count (CBC) with mild thrombocytosis (platelets 453K). The formal chest x-ray interpretation included central peribronchial thickening which may indicated viral infection versus reactive airway disease, with no acute infiltrate or edema. Admission orders included intravenous (IV) fluids at half-maintenance, regular diet, albuterol every three hours, prednisolone, analgesic/anti-pyretics as needed, and Pulmonary consultation. She improved over the course of her hospital stay, and was deemed stable for discharge to continue albuterol every six hours and apply hydrocortisone to the eczema. 

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 female child with strong family history of atopy including multiple relatives with asthma, and personal history of wheezing and RSV bronchiolitis, presented to the ED for evaluation of wheezing after insufficient improvement at home with albuterol administration. She was aggressively treated in the ED and observed for a number of hours. She was ultimately admitted for ongoing management of hypoxia and bronchospasm, having failed both outpatient and observation care. Based on the documentation provided, current standards of care, and related literature, acute inpatient admission and hospitalization were medically necessary and appropriate in this case.