Asthma
Inpatient hospital stay

This pediatric patient has with obesity, persistent asthma, allergic rhinitis, and obstructive sleep apnea and presented to the emergency department with wheezing and shortness of breath. Patient was well until 2 days prior to admission when they developed a cough, congestion, and wheezing. The patient had a poor response to albuterol at home at that time and was brought to the primary doctor's office. In the office patient was noted to be febrile with a temperature of 101°F, and had biphasic wheezing. Patient received 3 albuterol/Atrovent nebulized treatments as well as oral corticosteroids. However after the treatments the oxygen saturation dropped to 93% on room air, and patient was transferred to the emergency department for further care. In the emergency department patient was noted to be tachycardic and tachypneic. The physical examination was significant for persistent wheezing. Patient received continuous albuterol, magnesium sulfate, and two boluses of normal saline. Laboratory values including a venous blood gas were obtained. A respiratory virus panel was also sent. The symptoms continued despite this treatment, and patient was admitted to the pediatric intensive care unit for acute respiratory failure secondary to status asthmaticus. In the intensive care unit patient was initially treated with albuterol every hour, Atrovent every 6 hours, and corticosteroids. Patient was also receiving maintenance intravenous fluids. The pulmonology team was consulted and recommended starting Symbicort as well as Singulair and cetirizine. The health plan's determination of medical necessity is overturned in whole. The decision making at the time of admission for this patient was consistent with the patient's young age, the presence of status asthmaticus that persisted despite appropriate and intensive treatment, and the need for ongoing intensive treatment with very frequent bronchodilator administration and close monitoring for potential deterioration of clinical status. In the emergency department patient continued to have significant wheeze and abnormal laboratory values. Patient received additional bronchodilators, intravenous fluids, and magnesium sulfate at that time, and the decision was made to admit to the intensive care unit. In the intensive care unit the patient initially required albuterol therapy every hour while also receiving intravenous fluids and continuous cardiorespiratory monitoring. This frequency of therapy requires intensive care in an inpatient setting.