eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Respiratory Syncytial Virus (RSV) Infection: Treatment & Medication
Updated: Jul 27, 2009
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Treatment
Medical Care
- Supportive care is the mainstay of therapy for respiratory syncytial virus (RSV) infection. If the child can take in fluids by mouth and tolerate room air, outpatient management, with close physician contact as needed, is reasonable, especially in the absence of significant underlying risk factors. Although bronchodilators have been used, no convincing data as to their efficacy in this setting exist.
- For children who require hospitalization for RSV infection, supportive therapy is still the mainstay of care. Supportive care may include administration of supplemental oxygen (guided by respiratory rates, work of breathing, oxygen saturation, and arterial blood gases, as indicated), mechanical ventilation, and fluid replacement, as necessary. Additionally, bronchodilator therapy with beta-agonists frequently is used, although data on their benefit in this condition are conflicting. At least a subset of patients with RSV-related lower respiratory tract (LRT) infection appears to benefit from such therapy, and a trial with monitoring for effect on respiratory rate, pulse, and oxygenation may be reasonable. Alpha agonists (eg, vaporized epinephrine) have also been used during acute bronchiolitis episodes, although, again, available data do not clearly demonstrate efficacy.
- In 1986, the US Food and Drug Administration (FDA) licensed ribavirin, a broad-spectrum antiviral agent in vitro, for the aerosolized treatment of children with severe RSV disease. The recommended dose is 6 g of drug in 300 mL of distilled water via a small-particle aerosol generator (SPAG unit) over 12-20 hours per day for 3-7 days based on clinical response. Subsequent studies have suggested equivalent efficacy with a higher concentration of drug (6 g/100 mL distilled water) given over three 2-hour periods per day. The use of ribavirin has been limited because of its high acquisition cost and lack of demonstrated benefit in decreasing hospitalization or mortality.
- Secondary toxicity to health care workers from exposure to aerosolized drug was a theoretical concern in the past, although such risk is unproved. For these reasons, ribavirin primarily is reserved for patients with significant underlying risk factors and severe acute RSV disease. Several reports suggest that older children and adults with symptomatic RSV infection after bone marrow transplantation may benefit from ribavirin therapy. If preliminary studies suggesting a long-term benefit (see Complications) are confirmed, broader indications for ribavirin therapy may become a consideration.
Consultations
The primary caretaker, on an outpatient basis, manages most cases of RSV. Even in the hospitalized child with RSV disease, consultation with a subspecialist generally is not necessary.
- Pediatric intensivist: Consultation with an intensivist is advised if the child requires mechanical ventilation or, even before intubation, if the child has marked respiratory distress and a high supplemental oxygen requirement. An intensivist may also be of assistance if difficult issues in fluid management (eg, congenital heart disease, bronchopulmonary dysplasia) occur in which assessment of hydration status and optimal fluid management may be complex.
- Pediatric infectious disease specialist: An infectious diseases evaluation may be indicated if ribavirin therapy is being considered or if the viral origin of the infant's acute respiratory illness is uncertain. Infectious disease specialists often also play a role in addressing epidemiological concerns regarding patient isolation, nosocomial transmission,10 and infection control.
- Pediatric pulmonologist: A pediatric pulmonologist may be consulted if the infant has underlying lung disease (eg, bronchopulmonary dysplasia)11 in conjunction with the acute RSV infection or to assist in decisions regarding bronchodilator therapy.
Diet
- Most infants who are hospitalized with RSV infection are unable to tolerate milk or feedings well and frequently vomit or spit up.
- A brief course of intravenous fluids is generally administered in this setting, with resumption of normal feeding as the child recovers typically over 2-3 days.
Medication
Medications to treat respiratory syncytial virus (RSV) include the antiviral drug ribavirin, which can be used in severe high-risk cases and bronchodilators. Efficacy of bronchodilators or racemic epinephrine in treating RSV disease still has not been proven. If these agents are given, attempts to measure response to therapy should be documented. If benefit to these treatments is not demonstrated, they should be discontinued. Although corticosteroids are administered at times to patients with this condition, clinical data do not support the use of corticosteroids in the treatment of typical RSV bronchiolitis.
Antiviral agents
Antiviral therapy for severe RSV disease is indicated in high-risk patients. Treatment must be promptly initiated at the onset of the infection to effectively inhibit the replicating virus.
Ribavirin (Virazole)
Analog of the nucleic acid guanosine. Ribavirin inhibits viral replication by an unknown mechanism.
Adult
Reconstitute 6 g in 300 mL of distilled water to a concentration of 20 mg/mL
Administer as aerosol for 12-20 h/d for 3-7 d based on clinical response
Alternatively, 6 g in 100 mL of distilled water aerosol in 2-h pulses tid has been suggested as equally effective in small studies
Pediatric
Administer as in adults
Decreases zidovudine effect when administered concurrently
Documented hypersensitivity; pregnancy; women who may become pregnant during drug course
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution with mechanical ventilation; pay strict attention to minimization of drug precipitation, which may interfere with ventilator function and cause increased pulmonary pressures; affected parts include heated wire tubing, filters in the expiratory limb of the ventilator circuit, and water column pressure release valves
Ribavirin has demonstrated teratogenic effects in rodents and rabbits; the amount of drug that one would be exposed to in caring for a child receiving aerosolized ribavirin is likely to be minimal, and teratogenesis has not been reported in offspring of mothers exposed to aerosolized ribavirin during pregnancy; however, avoiding unnecessary exposure to the drug is advisable (this can be accomplished by turning off the SPAG unit administering the drug for 5-10 min before prolonged patient contact, use of a ribavirin scavenger device, and administration in a room with adequate ventilation)
Bronchodilators
These act to decrease muscle tone in the small and large airways in the lungs, thereby increasing ventilation. Beta2-adrenergic and alpha-adrenergic agents frequently are used (via inhalation) in an attempt to treat the bronchospasm observed in bronchiolitis.
Albuterol (AccuNeb, Proventil)
As a selective beta2-agonist, this agent produces bronchial smooth muscle relaxation. Efficacy in older children with reactive airway disease is well established, but the benefits in acute bronchiolitis are less well established. Available in inhalation and PO preparations.
Adult
Not applicable in adults
Pediatric
Acute bronchiolitis: 0.01-0.05 mL/kg inhaled (via nebulization of 5 mg/mL of solution) q4-6h
Outpatient: 2-4 mg/dose PO (syrup) tid/qid sometimes is used in young children
Beta-blockers may block pulmonary effects and induce severe bronchospasm; possible potentiation of effects on vascular system with concomitant MAOIs and tricyclic antidepressants; possible decreased digoxin levels; possible worsening of hypokalemia if coadministered with non–potassium-sparing diuretics
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders
Racemic epinephrine (microNefrin, Nephron, S-2)
This drug is 1-1.125% of epinephrine base solution given by aerosol. Recent studies suggest it may be superior to beta2-agonists in RSV LRTI.
Adult
Not applicable in adults
Pediatric
Bronchiolitis: 0.1 mL/kg/dose (diluted with 0.9% NaCl to final volume of 3 mL) inhaled via nebulizer q3-4h
Coadministration with of beta-blocking and alpha-blocking agents may result in hypertension; coadministration with halogenated inhalational anesthetics may result in ventricular arrhythmias
Documented hypersensitivity; cardiac arrhythmias; angle-closure glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for tachycardia and hypertension
Antiviral immunoglobulins
Specific immunoglobulin products with anti-RSV activity have been developed for the prophylaxis of high-risk patients against RSV infection.
Palivizumab (Synagis)
A humanized monoclonal antibody directed against the F (fusion) protein of RSV. Administered monthly through the RSV season, it has been demonstrated to decrease the chances of RSV hospitalization in premature babies who are at increased risk for severe RSV-related illness.
Adult
Not applicable; not approved for adults
Pediatric
15 mg/kg/dose IM every mo through RSV season (typically November through April in the northern hemisphere)
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Thrombocytopenia or coagulation disorder, as with any IM injection
More on Respiratory Syncytial Virus (RSV) Infection |
| Overview: Respiratory Syncytial Virus (RSV) Infection |
| Differential Diagnoses & Workup: Respiratory Syncytial Virus (RSV) Infection |
 Treatment & Medication: Respiratory Syncytial Virus (RSV) Infection |
| Follow-up: Respiratory Syncytial Virus (RSV) Infection |
| Multimedia: Respiratory Syncytial Virus (RSV) Infection |
| References |
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Further Reading
Keywords
respiratory syncytial virus infection, RSV, bronchiolitis, viral pneumonia, lower respiratory tract infection, LRT infection, upper respiratory tract infection, URT infection, chimpanzee coryza agent, Rs virus, asthma, otitis media, bone marrow transplantation, chronic lung disease of infancy, bronchopulmonary dysplasia, congenital heart disease, reactive airway disease, prematurity, severe combined immunodeficiency, SCID, atelectasis, pneumonitis, treatment, diagnosis
