Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Barking cough and nasal congestion 
Treatment:  Inpatient admission 

The inpatient admission was not medically necessary.

The patient is a female child with medical history significant for later preterm birth at 37 weeks' gestation who presented to the ED with two-day history of barking cough and an acute episode of gasping for air.  She was one set behind on vaccines.  She had no fevers and was eating at baseline. 

Vital signs included temperature 37.6, heart rate 136, and respiratory rate 40.  Physical examination was significant for no distress, moist mucous membranes, clear lungs with no wheezing or retractions but intermittent stridor at rest with barking cough, and non-focal neurologic exam.  She was treated with racemic epinephrine and enteral Decadron and observed for about an hour.  She was no longer stridulous at that time.  With reassessment after another hour, she was sleeping comfortably.  An hour after that, she became stridulous while sleeping with increased work of breathing.  She was given a second racemic epinephrine treatment.  Two hours later, she was asleep with no auditory stridor, but inspiratory stridor on auscultation.  A viral panel was ordered.  After a period of about six hours, she continued to have inspiratory stridor at rest, so she was admitted to the pediatric floor for further care.  

Admission orders included racemic epinephrine as needed, regular diet, and continuous pulse oximetry.  She did well, with no need for additional racemic epinephrine.  She was monitored for eight hours following the last dose with no return of distress.  She was able to tolerate a regular diet and remained hemodynamically stable.  She was discharged later that day.  Viral panel returned later with parainfluenza type I.

Croup, or laryngotracheobronchitis, is a viral infection of the glottis and subglottic regions and is the most common form of acute upper respiratory obstruction.  Typically, patients start with upper respiratory tract infection symptoms, with runny nose, sore throat, cough, and low-grade fever.  The "barking" cough then develops, including hoarseness and inspiratory stridor.  Low grade fever may persist and may spike to 104.  Symptoms are classically worse at night and persist for the better part of a week.  Agitation worsens the symptoms.  

The mainstay of treatment of croup is airway management, with most children managed safely at home.  For moderate to severe croup, racemic epinephrine may help to reduce laryngeal mucosal edema.  Indication for administration is typically stridor at rest, hypoxia, respiratory distress, and impending need for intubation.  Corticosteroids reduce edema through anti-inflammatory action.  Oral steroids are beneficial even for mild cases of croup to shorten duration.  Antibiotics are typically unnecessary for viral croup.  For patients treated with racemic epinephrine, there is typically a period of observation after administration to monitor for recurrence of stridor at rest.  

This young child presented to the ED with signs and symptoms consistent with viral croup.  She was treated appropriately in the ED with Decadron and racemic epinephrine, monitored after for return of symptoms.  She was in the ED for about six hours, and because of persistent inspiratory stridor, was admitted for further monitoring.  Once admitted, she remained hemodynamically stable with resolution of stridor without further racemic epinephrine.  While it was appropriate to continue monitoring her for return of symptoms, she was overall hemodynamically stable with no evidence of sepsis or impending respiratory failure.  She did not require acute inpatient admission and could have been safely managed at a lower level of care.