Lecture
Patient will present as → a 5-month-old infant with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C, and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Nasal flaring, use of accessory muscles, and subcostal and intercostal retractions are noted. Expiratory wheezes and a cough are present.
To watch this and all of Joe-Gilboy PA-C's spectacular video lessons you must be a member. Members can log in here or join now.
RSV is the most common cause of lower respiratory tract infections in children worldwide. Virtually all children contract it by the age of three.
- It's the leading cause of pneumonia and bronchiolitis in infants. It may play a major role in the pathogenesis of asthma bronchiolitis
Distinct symptoms of RSV bronchiolitis include:
- Rhinorrhea
- Wheezing and coughing can persist for several months
- Low-grade fever
- Nasal flaring and retractions
- Nail Bed cyanosis
Nasopharyngeal secretions RSV antigen test
- CXR can show hyperinflation, peribronchial thickening, and/or diffuse interstitial infiltrates
Chest X-ray of an infant with respiratory syncytial virus bronchiolitis demonstrating lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions.
Treatment is supportive with nasal suctioning, humidifier use, hydration, and antipyretics
- Patients with hурохеmiа should receive supplemental οxygen by nasal cannula, face mask, or hood
- Variable thresholds are used for starting oxygen therapy in infants with bronchiolitis, most commonly SpO2 <90 to <92 percent
- Bronchodilators (e.g., albuterol via nebulizer) may be trialed but are not routinely recommended
- Systemic steroids are not recommended, except in cases of RSV-associated bronchial reactivity or pre-existing asthma
- Symptoms typically peak at days 3-5 and resolve within 7-10 days
- Indications for hospitalization include moderate tachypnea with feeding difficulties, visible retractions, and oxygen desaturation
Vaccination (view current CDC guidelines)
- Approved for individuals 60 years and older
- 1 dose of maternal RSV vaccine during weeks 32 through 36 of pregnancy, administered September through January
- To prevent severe RSV disease in infants, the CDC recommends either maternal RSV vaccination or infant immunization with RSV monoclonal antibodies. Most infants will not need both
Infants and young children
- 1 dose of nirsevimab for all infants younger than 8 months born during or entering their first RSV season
- 1 dose of Nirsevimab for infants and children 8–19 months old who are at increased risk for severe RSV disease and entering their second RSV season
Palivizumab (Synagis) prophylaxis
- Infants born at ≤ 28 weeks 6 days gestational age and <12 months at the start of RSV season
- Infants < 12 months of age with chronic lung disease (CLD) of prematurity
- Infants ≤ 12 months of age with hemodynamically significant CHD
- Infants and children < 24 months of age with CLD of prematurity necessitating medical therapy (eg, supplemental oxygen, bronchodilator, diuretic, or chronic steroid therapy) within 6 months prior to the beginning of RSV season
AAP also suggests that palivizumab prophylaxis may be considered in the following circumstances:
- Infants < 12 months of age with congenital airway abnormality or neuromuscular disorder that decreases the ability to manage airway secretions
- Infants < 12 months of age with cystic fibrosis with clinical evidence of CLD and/or nutritional compromise
- Children < 24 months with cystic fibrosis with severe lung disease (previous hospitalization for pulmonary exacerbation in the first year of life or abnormalities on chest radiography or chest computed tomography that persist when stable) or weight for length less than the 10th percentile
- Infants and children < 24 months who are profoundly immunocompromised
- Infants and children < 24 months undergoing cardiac transplantation during RSV season
 Osmosis |
|
 |
RSV, or respiratory syncytial virus, is a viral infection that infects upper airway epithelial cells, leading to copious secretions, coughing, sneezing, and wheezing in patients. It primarily affects infants and young children with a peak incidence between 2 to 7 months of age. It affects more males than female infants; occurs less frequently in breastfed infants; and has a peak incidence during winter and spring. Most cases of bronchiolitis are caused by RSV.
Play Video + QuizRespiratory Syncytial Virus (RSV) Interventions
The management of caring for a child with RSV is providing supplemental oxygen, maintaining fluid intake and nutrition, airway maintenance, and administration of medications.
Question 1 |
antibiotics Hint: Antibiotics are utilized to treat bacterial, not viral, illnesses. | |
hospitalization | |
inhaled corticosteroids Hint: Inhaled glucocorticoids (budesonide, fluticasone, dexamethasone) have not been beneficial in reducing symptom duration or readmission rates | |
Racemic epinephrine Hint: Racemic epinephrine is not indicated in the treatment of bronchiolitis. |
Question 2 |
pulse oximetry of 94% on room air Hint: A pulse oximetry reading of 94% on room air is equivalent to a PaO2 of approximately 80 mm Hg which indicates the child is not in severe respiratory distress. | |
children between 4-6 months of age Hint: Children less than 2 months of age require hospitalization. | |
moderate tachypnea with feeding difficulties | |
hyperinflation and interstitial infiltrates on chest x-ray Hint: Hyperinflation and interstitial infiltrates on chest x-ray are frequently seen with acute bronchiolitis and by themselves are not an indication for hospitalization. |
Question 3 |
Prednisolone Hint: Corticosteroids are not indicated for the treatment of previously healthy infants with bronchiolitis. | |
Oxygen | |
Ceftriaxone (Rocephin) Hint: Antibiotics are not indicated in the treatment of bronchiolitis unless there is a secondary bacterial infection. | |
Palivizumab (Synagis) Hint: Palivizumab is used only for prevention of RSV infection. |
Question 4 |
Chest X-ray Hint: May be used to rule out pneumonia but is not necessary for the initial diagnosis of bronchiolitis. | |
Nasopharyngeal swab for viral PCR | |
Complete blood count (CBC) Hint: Not specific for diagnosing bronchiolitis and typically shows nonspecific findings. | |
Pulmonary function tests Hint: Not feasible or practical in infants with acute respiratory distress. | |
Blood culture Hint: Indicated if there is a suspicion of bacterial sepsis, not for uncomplicated bronchiolitis. |
|
List |
References: Merck Manual · UpToDate