The Basics of RSV

Respiratory syncytial virus (RSV) is a single-stranded RNA virus that is transmitted by respiratory droplets. It is highly transmissible and individuals can become infected if droplets land in their eyes, nose or mouth, or by touching an infected surface and then touching their face, or through direct contact such as kissing an infected individual. 

RSV Pathophysiology

RSV targets ciliated epithelial cells of the respiratory tract, causing acute respiratory illness with symptoms that resemble the common cold. However, this doesn’t mean that RSV is to be taken lightly. In fact, illness can be quite severe and have lasting effects, especially when young children or neonates are affected. Studies show that 90% of children are infected with RSV during their first two years of life, though it can affect older children and adults as well.

The virus triggers an inflammatory response that causes: 

• Obstruction of the small airway with mucus and cellular debris
• Airway edema
• Decreased lung compliance
• Decreased mucus clearance

Anytime you have issues involving the airway, they are going to be compounded in young children due to anatomical differences in the airway. Namely, the airway is smaller in diameter but it is also shorter, which allows pathogens to more easily enter the deeper areas of the respiratory tract. This is likely why RSV often causes bronchiolitis in children, which is an infection of the lower respiratory tract that can cause small airway obstruction.

RSV can also cause asthma or COPD exacerbations and secondary infections such as bronchitis or pneumonia. And, since the body does not create long-term immunity to RSV, reinfections are possible and can be frequent. 

Let’s go through the basics of RSV using the Straight A Nursing LATTE method.

If you’re new to the LATTE method, it’s a great framework for organizing the most important information you need to know for nursing school (and on the job!).

L: How does the patient LOOK?

RSV usually causes an upper respiratory illness with a wide range of symptoms such as:

• Headache, fever and muscle aches
• Cough and sore throat
• Runny nose, congestion, sneezing
• Conjunctivitis and/or ear infection
• Vomiting, diarrhea, loss of appetite

In children under two years of age or high-risk patients, RSV may cause a lower respiratory tract infection, which can lead to severe complications such as viral pneumonia and/or acute respiratory failure. In addition to the above symptoms, an infection of the lower respiratory tract could also include: 

• Rhonchi, wheezing, crackles, diminished breath sounds
• Tachypnea and increased WOB (look for accessory muscle use)
• Periods of apnea

Your very young patients, namely infants, may show signs of irritability, decreased levels of activity and may even have difficulty breathing. When RSV is severe, infants can display cyanosis of the mouth, lip, or fingernails as well as other ominous respiratory signs such as nasal flaring, tachypnea and shallow breathing. Always take respiratory distress in children very, very seriously. You can read more about it here.

A: How do you ASSESS the patient?

Your key assessments with RSV are going to be related to the patient’s respiratory status. 

• Measure oxygen saturation via pulse oximetry or arterial blood gas
• Assess for signs of hypoxia such as restlessness, confusion, cyanosis
• Auscultate the patient’s lung sounds. Listen for wheezes, crackles, stridor, rhonchi, etc. 
• Assess respiratory rate, depth, pattern and wob. Nasal flaring, intercostal or substernal retractions, and grunting are incredibly serious and must be addressed immediately.
• Assess the patient’s cough. This includes the cough characteristics such as dry, wet, productive, nonproductive, weak, effective, etc…. If the patient is producing sputum, you’ll want to assess that as well (quantity, color, odor, and consistency).

General assessments related to infection include:

• Monitor urine output, which can decrease significantly in severe infection or sepsis. For infants, this typically involves weighing wet diapers. At home, parents can count the number of wet diapers.
• Assess for decreased nutritional intake as RSV often causes a lack of appetite.
• Assess for signs of dehydration, especially if the patient is vomiting, has diarrhea, or decreased oral intake. Signs of dehydration include poor skin turgor, hypotension with tachycardia, and, in infants, sunken fontanelles and decreased tear production.
• Of course, monitor the patient’s temperature to assess for fever. 
• Observe the patient for outward signs of infection such as enlarged lymph nodes, and purulent discharge from the eyes or nose.
• Assess the patient for pain related to coughing or respiratory inflammation.

T: What TESTS will be ordered?

In healthy infants and children, lab tests for RSV may not always be done simply because the result wouldn’t change the course of treatment. However, in immunocompromised patients or in situations where the clinician does need to identify the specific virus in order to plan care, then antigen, PCR or viral culture testing may be conducted. 

• Rapid antigen detection test (RADT) is fast and highly sensitive and specific in children, but false negatives can occur in adults. Additionally, antibody therapy can alter results.
• Polymerase-chain-reaction-based testing (PCR) is the preferred method due to high sensitivity and can be used in patients who have already received RSV antibody therapy.
• A viral culture looks at a sample of respiratory secretions to identify the virus. These tests are slower to result and may take from 4 days to 2 weeks.
• Chest x-ray may be utilized in cases of RSV-induced bronchiolitis.
• CT scan may be conducted to diagnose respiratory complications such as pneumonia or bronchiolitis.

T: What TREATMENTS will be provided?

Most of the time, RSV  can be treated at home with supportive care unless the patient has respiratory distress or needs oxygen therapy. This includes:

• Nasal suctioning as needed and nasal saline drops for lubrication
• Hydration
• Rest
• Medication for fever and pain such as acetaminophen. Note that children under 16 years of age should not take aspirin due to the risk for developing Reye syndrome (some sources say 12 years of age).

Other medications used to treat RSV are antivirals and antibiotics. Monoclonal antibodies are used to prevent disease in high risk individuals. 

• The antiviral medication (ribavirin) can be administered orally or nebulized. It should be avoided in individuals who are pregnant or who have a pregnant partner. Additionally, pregnancy should be prevented for at least six months after taking ribavirin. The nebulized form can cause bronchoconstriction, so it is used very cautiously in patients with COPD and asthma. Some other adverse effects of ribavirin include depression, hemolytic anemia, blurred vision, photosensitivity and pruritus. All patients taking ribavirin should be monitored for suicidal and homicidal ideation.The American Academy of Pediatrics recommends only using ribavirin in severe cases due to the high risk of toxicity to health care providers.
• Antibiotics may be used if there is a bacterial infection also present such as bacterial pneumonia or otitis media. Antibiotics are never used to treat the RSV itself, as RSV is a viral illness.
• Monoclonal antibodies may be used in those who are at high risk as a way to prevent infection. You may see this referred to as passive immune prophylaxis. Palivizumab is a monoclonal antibody that reduces the ability of the virus to fuse with cell membranes, thereby preventing disease. It is administered monthly during RSV season, which can vary slightly but is typically Fall, Winter and Spring in the US. Recommendations vary based on risk factor, but in general, those who are at highest risk for RSV are children less than 12 months of age who have prematurity of 29 weeks gestation or less, children/infants with chronic lung issues related to prematurity (such as bronchopulmonary dysplasia), children with neuromuscular disorders, and children with congenital heart disease. 

General nursing interventions include: 

• Provide oxygen as ordered to maintain adequate oxygen levels. In severe cases, CPAP or mechanical ventilation may be necessary. Humidified oxygen is generally provided to avoid drying out secretions.
• Maintain a patent airway, suction as needed. Infants should have nasal secretions removed before feeding and sleeping. Older children and adults should have HOB elevated to help maintain airway patency.
• Encourage PO fluids and consider administering fluids via IV or NG tube if the patient is unable to consume adequate fluids. Popsicles are a great way to get children to take in fluid, especially if they have a fever. Supplements such as pedialyte may be used to also replace electrolytes.
• Initiate droplet precautions with a private room (if the patient must share a room, then the other patient(s) must also have RSV) 

E: How do you EDUCATE the patient/family?

Much of your teaching about RSV will be focused on prevention and limiting spread of disease:

• Teach the importance of basic hygiene (especially for parents of young and/or premature children). This includes hand hygiene, avoiding touching the face, covering coughs and sneezes, and disinfecting high-use surfaces. Sick individuals should not share utensils, towels, cups or any other personal items with others.
• Teach the importance of staying home when sick and avoiding contact with infants/compromised adults if possible.
• Teach patients/parents that RSV usually occurs during fall, winter and spring months in the northern hemisphere. In tropical climates RSV is usually aligned with the rainy season.

Other key teachings include:

• Teach parents how to use a bulb syringe to suction the nares before feeding and bedtime. 
• Instruct parents to avoid cough suppressant medications, as coughing is an effective way to remove secretions from the lungs and airway. 
• Ensure individuals understand limits on acetaminophen and to avoid aspirin use in children. 
• Teach the parents to seek emergency care if the child has difficulty breathing or is cyanotic.
• Teach parents to call the MD if the child shows signs of ear infection, has a high respiratory rate (this will vary based on the age of the child), fever over 101-degrees F, persistent cough for more than 2 days, wheezing, listlessness, or confusion.

I hope this helps you take care of patients with RSV (whether it’s in person, in sim lab or on an exam.)  You’ve got this!

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References:

Barr, F. E., & Barney, G. S. (2021a, July 1). Uptodate. Respiratory Syncytial Virus Infection: Clinical Features and Diagnosis. https://www.uptodate.com/contents/respiratory- syncytial-virus-infection-clinical-features-and- diagnosis?search=rsv&source=search_result&selectedTitle=1~150&usage_type=default &display_rank=1

Barr, F. E., & Barney, G. S. (2021b, November 16). Uptodate. Respiratory Syncytial Virus Infection: Treatment. https://www.uptodate.com/contents/respiratory-syncytial-virus- infection- treatment?search=rsv&source=search_result&selectedTitle=2~150&usage_type=default &display_rank=2

CDC. (2020, December 18). Learn about respiratory syncytial virus infection (RSV). Respiratory Syncytial Virus Infection (RSV). https://www.cdc.gov/rsv/index.html

Perry, S. E., & Olshansky, E. F. (2018). Maternal child nursing care (Sixth edition). Elsevier.

Piedra, P. A., & Stark, A. R. (2021, October 7). Uptodate. Patient Education: Bronchiolitis and RSV in Infants and Children (Beyond the Basics). https://www.uptodate.com/contents/bronchiolitis-and-rsv-in-infants-and-children-beyond- the-basics?search=rsv&topicRef=5994&source=see_link

Respiratory syncytial virus (RSV). (2021, November 9). https://www.lung.org/lung-health- diseases/lung-disease-lookup/rsv

Schweitzer, J. W., & Justice, N. A. (2021). Respiratory syncytial virus infection. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK459215/