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.
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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)
- Adults 60 years and older: RSV vaccine is recommended
- Pregnant individuals (32–36 weeks gestation, September–January):
- 1 dose of maternal RSV vaccine to provide passive immunity to the infant
- If maternal vaccination occurs ≥ 14 days before delivery, the infant does not require monoclonal antibody prophylaxis
Monoclonal Antibody Prophylaxis for Infants and Young Children
Nirsevimab (Beyfortus) – First-line RSV Immunoprophylaxis
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- All infants <8 months born during or entering their first RSV season should receive 1 dose of nirsevimab
- Infants and children 8–19 months at increased risk for severe RSV should receive 1 dose of nirsevimab before their second RSV season
Palivizumab (Synagis) – Only if Nirsevimab is Unavailable
- Reserved for high-risk infants, but nirsevimab is preferred over palivizumab when available
- Indications for palivizumab prophylaxis:
- Infants born at ≤28 weeks, 6 days gestation and <12 months at the start of RSV season
- Infants <12 months with chronic lung disease (CLD) of prematurity
- Infants ≤12 months with hemodynamically significant congenital heart disease (CHD)
- Infants and children <24 months with CLD of prematurity requiring medical therapy (e.g., oxygen, bronchodilators, diuretics, or chronic steroids) within 6 months of RSV season
- Additional Considerations for Palivizumab Use (AAP Recommendations)
- Infants <12 months with congenital airway abnormality or neuromuscular disorder that impairs secretion clearance
- Infants <12 months with cystic fibrosis and CLD/nutritional compromise
- Children <24 months with cystic fibrosis and severe lung disease or weight-for-length <10th percentile
- Infants and children <24 months who are profoundly immunocompromised
- Infants and children <24 months undergoing cardiac transplantation during RSV season
 Osmosis |
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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 and 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. RSV causes most cases of bronchiolitis.
Play Video + QuizRespiratory Syncytial Virus (RSV) Interventions
The management of caring for a child with RSV includes providing supplemental oxygen, maintaining fluid intake and nutrition, maintaining the airway, and administering 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. |
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References: Merck Manual · UpToDate