Bronchodilators don't help bronchiolitis

Autumn brings the start of another
Respiratory Syncytial Virus (RSV) season in the U.S., a virus that can
cause bronchiolitis in younger children. The wheezing - and sometimes
decreased oxygen saturation - of bronchiolitis can be scary for parents
and physicians alike; since bronchodilators like albuterol help many
older kids and adults with wheezing, it seems intuitive that they would
help bronchiolitis as well. The November 1 issue of AFP discusses
a Cochrane update, however, demonstrating that bronchodilators don't
improve outcomes in most kids aged less than 2 years with bronchiolitis.

The Cochrane reviewers found
that, in children less than 24 months old with bronchiolitis who were
wheezing for the first time, bronchodilators didn't improve oxygen
saturation, didn't keep children in the Emergency Department from
getting admitted to the hospital, and didn't reduce the length of stay
in children already admitted to the hospital. Unfortunately,
bronchodilators also caused harm; children who received them were more
likely to have tachycardia and decreased oxygen saturation.

It can be frustrating to see child suffering with bronchiolitis and not be able to offer treatment with a medication, but a recent AFP article on RSV infection reinforces
that no studied pharmaceutical interventions have demonstrated a
meaningful impact on patient-oriented outcomes. Hydration and
supplemental oxygen remain the treatments of choice for the more than 90,000 children admitted with bronchiolitis in the U.S. every year; fewer children are being admitted in recent years than in the past, but the children who are being admitted are more likely to have high-risk conditions and require mechanical ventilation.

3
of the 5 Choosing Wisely recommendations from the Society of Hospital
Medicine - Pediatric Hospital Medicine relate to bronchiolitis and/or respiratory tract infections in young children:

1. Don't order chest radiographs in children with uncomplicated asthma or bronchiolitis.
2. Don't routinely use bronchodilators in children with bronchiolitis.
3. Don't use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.

Pediatrics just published a clinical practice guideline on bronchiolitis that reinforces those points. 


If you'd like to read more, there's an AFP By Topic on Upper Respiratory Tract Infections that includes this risk stratification point-of-care guide for treatment of infants with bronchiolitis. You can follow RSV infection rates specific to your region of the U.S. at this CDC website. 

Will this Cochrane review change how you treat young children with bronchiolitis?

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Nurturing the next generation of diverse family physicians

Since joining my current practice two years ago, I've noticed that I
care for a disproportionate number of immigrants of Chinese and other
Asian descent compared to my colleagues. Although both of my parents
were born in Taiwan, I don't speak Mandarin or have special expertise on
medical conditions common in Asian Americans. Nonetheless, Asian
patients seem more comfortable with me anyway. Similarly, U.S. health
workforce analyses show that underrepresented minority physicians
(Black, Latino, and Native American) are more likely to provide primary care to medically underserved populations.



A recent Robert Graham Center Policy One-Pager
examined the racial diversity of family medicine resident physicians
from 1990 through 2012. It compared the proportion of residents of a
particular race with the proportion of the U.S. population of the same
race. The White and Native American resident to population ratio was
close to 1:1, but Blacks and Latinos were present in family medicine
residency programs at only 50 to 75 percent of their proportions in the
population. (Asian residents have always been overrepresented compared
to the population, with a current ratio of 5.1 to 1.) The good news is
that family physicians are diversifying; the bad news is that Black and
Latino physicians still have a long way to go to "catch up" to their
numbers in the population. This means that many Blacks and Latinos will
receive primary care from physicians of different races, which isn't
automatically a bad thing. But it begs the question of why this
situation exists in the first place...



Too many Black and Latino Americans grow up in desperately poor and
crime-ridden neighborhoods with substandard public schools, and for
decades resources have been poured into programs designed to give these
students opportunities for educational success, from Head Start to Fairfax, Virginia's Young Scholars. It's still a rough and treacherous road, as Ron Suskind illustrated in the bestseller A Hope in the Unseen,
about Cedric Jennings, an African American from Washington, DC who
overcame a heartbreaking upbringing (his father was repeatedly
incarcerated for dealing drugs and he and his mother were evicted from
multiple homes for falling behind on rent payments) and dysfunctional
schools to be admitted to Brown University. But if communities can give
these kids enough K-12 support to get them accepted to four-year
colleges, then a good number of them should go on to become doctors,
right?



It's not that simple. In the New York Times Magazine article "Who Gets to Graduate?,"
Paul Tough delved deeply into the problem of college dropouts at the
University of Texas at Austin, a respected public university that offers
automatic admission to any Texas resident who graduates in the top 7
percent of his or her high school class. He followed Vanessa Brewer, an
African American woman raised in a single-parent home who aspired to
become a nurse anesthetist. Vanessa experienced a crisis of confidence
after failing her first statistics test, and wondered: "Am I supposed to
be here? Am I good enough?" Wrote Tough:


There are thousands of students like Vanessa at the University of
Texas, and millions like her throughout the country — high-achieving
students from low-income families who want desperately to earn a
four-year degree but who run into trouble along the way. Many are
derailed before they ever set foot on a campus, tripped up by
complicated financial-aid forms or held back by the powerful tug of
family obligations. ... Many are overwhelmed by expenses or take on too
many loans. And some do what Vanessa was on the verge of doing: They get
to a good college and encounter what should be a minor obstacle, and
they freak out. They don’t want to ask for help, or they don’t know how.
Things spiral, and before they know it, they’re back at home,
resentful, demoralized and in debt.

The bottom line on
national statistics on college graduation rates is that "rich kids
graduate; poor and working-class kids don't." And surprisingly,
graduation rates have little relationship to natural ability and much
more to do with confidence, rooted in one's socioeconomic background.

A case in point: I failed my first anatomy exam in medical school. It
felt terrible to see my score near the bottom of the class, but as the
son of a pharmacist and a computer scientist with two Master's degrees,
and the grandson of a neurologist and related to a long line of doctors,
I pulled myself together and eventually earned a passing grade. Had
this sort of setback happened to a student who was the first in his
family to finish college, it could easily have led to that student
leaving medical school entirely.

A U.T. program called the University Leadership Network (ULN) not only
confirmed that a lack of confidence related to humble upbringing puts
students at the highest risk of dropping out, but successfully tested an
brief online intervention that measurably improved their odds of
completing at least 12 credits during their first semester and staying
on track to graduate in four years. Tough summarized ULN's
straightforward strategy: "Select the students who are least likely to
do well, but in all your communications with them, convey the idea that
you have selected them for this special program not because you fear
they will fail, but because you are confident they can succeed." The
payoff for replicating this program at universities across the nation,
Tough suggested, could be immense:

Beyond the economic
opportunities for the students themselves, there is the broader cost of
letting so many promising students drop out, of losing so much valuable
human capital. ... Most well-off students now do very well in college,
and most middle- and low-income students struggle to complete a degree.
... These two trends are clearly intertwined. And it is hard to imagine
that the nation can regain its global competitiveness, or improve its
level of economic mobility, without reversing them. ... A big part of
the solution lies at colleges like the University of Texas at Austin,
selective but not superelite, that are able to take large numbers
of highly motivated working-class teenagers and give them the tools
they need to become successful professionals. The U.T. experiment
reminds us that that process isn’t easy; it never has been. But it also
reminds us that it is possible.

Becoming a family physician isn't easy. But America's need for the next
generation of diverse family physicians has never been greater, and
Tough's article has convinced me that nurturing them is possible.

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