Respiratory Syncytial Virus (RSV)
As we have moved forward with the holidays, our minds have focused on family, relaxation, and preventing burnout by resetting. However, in medicine, there is no rest from disease and even in the winter months, we see clinics, urgent cares, ERs, and primary care offices become flooded with acute illnesses. Last month’s article was focused on croup and as we are moving forward into the colder month of December we start to see more RSV.
As a student and a previous EMT, I always struggled with children. Our EMT instructor told us that children tend to compensate for a long time, and then suddenly crash; meaning the child who seems fine in one minute, can become an emergent case the next. This has always stuck with me and I remain cautious and guarded when it comes to evaluating ill pediatric patients.
If you need a refresher on croup and some of the PANCE Pearls associated with it, please see my previous article. Today, we will focus on everything RSV. RSV is an RNA virus that is responsible for upper and lower respiratory tract infections in all ages, but it notoriously impacts infants and children (McKeen, 2016). RSV is so common that it is estimated that almost 100% of children by the age of two have been impacted.
- RSV is the number one cause of bronchiolitis in children
- Leads to over 100,000 hospitalizations per year
- The peak incidence is the winter months, classically between December and March.
The pathophysiology of RSV involves:
- inflammation of the small airways (bronchiolitis)
- an inflammatory response
- airway edema and subsequent air trapping
- a rise in mucus production
- bronchospasms (McKeen, 2016).
The result is lower and upper airway inflammation causing the characteristic symptoms.
Risk factors for RSV include:
- young age during RSV season
- low socioeconomic status
- attending daycare
- Family exposure
Prevention of RSV includes hand washing with alcohol based soap/rub, avoiding smoking exposure and keeping RSV infected children away from healthy. This usually involves keeping them out of daycare, where outbreaks tend to spread very rapidly.
The history often includes a potential recent exposure however, this is not necessary in some cases.
Parents may complain that their child has a history of:
- worsening cough
- decreased feedings in the newborn/neonate
- increased breathing
A history of prematurity should clue us in to a possible RSV case. Social history and birth history are very important to assess for smoking exposure or prematurity as well as a documented immunization status.
The physical exam is important and as a clinician my goal is to identify the children that I am worried about who need immediate care, versus those who are stable in the office or urgent care setting.
- A general impression of the child’s breathing should be performed as the door opens and parents start to give the history.
In some cases, we may need to jump right to the physical exam/intervention if the child is truly very ill.
Vital signs are important to identify respiratory distress. Temperature, pulse, respiration, pulse oximetry are all extremely important and enable the clinician to start with a disposition.
An EENT exam should look for comorbid infection such as otitis media and also generally address the hydration status of the patient. Important indications of their hydration status include:
- Checking mucous membranes
- skin turgor
- Capillary refill
In the ED setting, repeat examinations over time can allow for the detection of subtle changes in exam, or look for improvements as interventions are taken.
Obviously, the most important part of the examination for a child with suspected RSV is the pulmonary exam. As discussed above, the clinician should immediately determine whether there is respiratory distress present upon walking into the exam room in order to identify children that need for evaluation immediately. A good measure of distress is also how clingy the child is to parent, especially for older children. The presence or absence of intercostal, infraclavicular, and abdominal retractions should also be assessed, as well as the overall respiratory rate. A list of “normal” respiratory rates based on age is attached for review.
The diagnosis is largely clinical. In the correct setting and symptomology present, RSV can be a vastly clinical diagnosis. Lab work is commonly done in the ED setting and a WBC count can be normal or elevated (McKeen, 2016).
There are nasal swabs available for RSV detection, but this is not necessary routinely, as it typically does not change patient management. An x-ray of the chest can be performed to rule out infiltrate/pneumonia and may show lobar consolidation or hyperinflation (McKeen 2016).
The vast majority of patients diagnosed with RSV are treated supportively. Hydration status should be assessed and if the patient is significantly dry, an IV can provide fluid replenishment. PO fluid challenges are options for stable patients. Oxygen should be given to patients with hypoxemia on exam. Intubation may be required for the child with respiratory distress. Nebulized epinephrine may be required and this can improve symptoms.
According to McKeen (2016), there is no evidence to support the use of glucocorticoids. Antibiotics can be used if there is suspicion for comorbid bacterial infection.
Luckily the prognosis for RSV does tend to be good, many infants and children do recover in about a week’s time. They should be held out from daycare during this period. I hope that today’s review of RSV has been helpful for both clinicians and students alike.
EMRAP (2019). Table image on normal vital signs for children. Date of access 6 December 2019.
McKeen E.C. (2016). Respiratory Syncytial Virus Infection. Wolters Kluwer.
This article or blog post should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast or blog.