Diagnosis: Asthma
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

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) Unfortunately, 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 male child with no personal or family history of asthma presented to the ED in significant respiratory distress that persisted after three DuoNebs, two one-hour rounds of continuous albuterol, steroids, and magnesium. He was diagnosed with status asthmaticus after having no atopic history and no prior wheezing episodes. He was not safe for discharge home, and not appropriate for outpatient management. He required the frequent evaluations, family asthma education, and medication manipulations only available in a hospital setting, specifically an ICU setting. Once he no longer required treatments every hour and was tolerating every two hour treatments, he was stepped down to the pediatric floor, where his treatments and education continued until he was deemed stable for discharge. Acute inpatient admission and management was medically necessary and appropriate. He could not have been safely managed at a lower level of care.