Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma
Treatment:  Inpatient admission

The proposed treatment, inpatient admission, was not medically necessary.

The patient is an unvaccinated male child with medical history of bronchiolitis and mild intermittent asthma, who was taken to the ED via EMS for evaluation of wheezing, cold symptoms, cough, and increased work of breathing that had begun the day prior.  He was receiving albuterol every two to three hours at home with minimal improvement.  He was initially taken to urgent care, where his oxygen saturation was 92% in room air.  He was treated with two doses of albuterol before being sent to the ED. 

Vital signs included heart rate 156, respiratory rate 40, temperature 38.4, and 96% saturation in room air.  Examination was significant for respiratory distress, nasal discharge, moist mucous membranes, red bulging right tympanic membrane, tachycardia, tachypnea, wheezing, intercostal and subcostal retractions, decreased air entry worse on the right, and non-focal neurologic exam.  He was treated with three DuoNebs, Decadron (not given), and ibuprofen.  Laboratory evaluation revealed normal white blood cell (WBC) count (11.2K) with left shift (86%), and blood cultures were sent.  Chest x-ray was informally read as having an infiltrate for formal reading later noted no acute disease.  He was treated with ceftriaxone for possible pneumonia prior to admission to the pediatric floor.  Admission orders included regular diet, albuterol every three hours, prednisolone, Tylenol as needed for fevers, ceftriaxone, and follow-up blood culture.  The following day, the patient had improved sufficiently to wean albuterol to every four hours.  He was subsequently deemed stable for discharge.

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 asthma presented to the ED after failed management at home. He was treated aggressively but remained symptomatic. In addition, there was concern for clinical pneumonia in an unvaccinated child. He was hemodynamically stable, with no oxygen requirement, no impending respiratory failure, no dehydration with ongoing fluid losses, and no evidence of sepsis. While it was reasonable and appropriate to continue monitoring him while administering breathing treatments every three hours and treating the clinical pneumonia, he did not require acute inpatient admission and could have been safely managed at lower level of care (eg, observation).