RSV (Respiratory Syncytial Virus) - More Than Just a Cold

NotReady4PrimeTime, RN

RSV. Those three little letters are enough to strike terror in the hearts of PICU nurses everywhere. It's like a bad penny, turning up without fail every autumn; by mid-winter, virtually every PICU in the northern hemisphere has admitted at least one case. Some years are much worse than others and, at least in my part of the world, 2017 is shaping up to be one humdinger. What's the big deal with this bug, anyway?

Respiratory syncytial virus is the leading cause of lower respiratory tract infection in infants and small children in the world. Most children will have had at least one bout of it before their second birthday. For children older than 4 and for adults, it's little more than a nasty cold, but for those people with tiny airways, it may cause severe bronchiolitis and pneumonia.

A syncytium is, at its most basic, a multi-nucleated giant cell, often resulting from the fusion of several uni-nucleated cells. This virus, in creating syncytiae, essentially becomes self-replicating by transferring its fusion proteins to the surface of the host cell, which then allows the host cell to fuse with other cells around it. This single-stranded negative-sense RNA virus is medium-sized and has a lipoprotein coat; it was first isolated in chimpanzees in 1956, the same year it appeared in a human infant for the first time. In the last decade, reverse transcription polymerase chain reactive (RT-PCR) assays have transformed the diagnosis of RSV and allows for rapid isolation of the patient and appropriate treatment.

RSV has an incubation period of 2-8 days, but typically takes only 4-6 days to present. It spreads easily by direct contact, remaining viable for 30 minutes or more on hands and up to 5 hours on hard surfaces. Active infection typically lasts 2-8 days, but effects may last up to 3 weeks. Infants present with cough, wheeze, tachypnea, retractions, poor feeding and perhaps cyanosis; fever is low-grade when present but very young infants may be hypothermic and experience intermittent apneas. Sepsis from concomitant bacterial pneumonia can be life-threatening. Based on the American Association of Pediatricians' Bronchiolitis Algorithm sicker infants will be admitted. Those requiring more than a little supplemental oxygen and fluid will be admitted to the PICU. Children who were born prematurely, those with chronic pulmonary disease or cardiac compromise and those with immune system dysfunction are at higher risk for severe disease.

On physical exam, the PICU-admitted child appears ill, with all the usual manifestations of increased work of breathing. They are often dehydrated and require aggressive fluid resuscitation. Chest auscultation reveals coarse crackles and wheezes throughout, with a gurgly, bubbly sounding cough. Secretions tend to be moderately thick, frothy and clear. Moderate-to-severe respiratory distress is accompanied by tracheal tug, head-bobbing, nasal flaring, intercostal, subcostal and substernal retractions and cyanosis. Inflammation and secretions reduce the luminal diameter of the bronchioles and cause atelectasis throughout the chest. If high-flow nasal oxygen is insufficient to maintain pulse oximetry at least 90%, the child will require intubation and mechanical ventilation. These are the infants you do not want to turn your back on... they tend to wake up with a bang, stimulate their vagus nerve with both coughing and ETT movement, desaturate and drop their heart rates to

For those children falling in the premature/pulmonary/cardiac/immunosuppressed category, immune globulin prophylaxis has shown to prevent infection or reduce the severity of illness. Palivizumab (RespiGam or Synagis) given IM once monthly for the typical duration of RSV "season" is prescribed for these children:

Those under 24 months with hemodynamically-significant congenital heart disease or have chronic lung disease and are off oxygen and/or medications for less than 6 months at the start of RSV season
Infants born at
Infants born at 29-32 weeks gestation who are less than 6 months old at the beginning of the season, again with prophylaxis continuing to the end of the season and not when the child is 6 months old
Infants born at 32-35 weeks who are less than 3 months old at the beginning of the season and who either attend day care or have at least one sibling or other child under the age of 5 living in the same home who does

These prescribed guidelines exclude older children who are immunosuppressed following organ transplantation or treatment of malignancy. This omission may have dire consequences, particularly in a child who becomes ill with more than one virus concurrently. While overall mortality for RSV in children is only about 1%, these children are at high risk of such severe disease as to need extracorporeal life support; they are the sickest of the sick and at dramatically increased risk for death, regardless of age.

Long-term complications of RSV bronchiolitis in infants aren't common. Some children will go on to develop reactive airway disease but evidence of its association with a past RSV infection is weak. The combination of RSV and respiratory adenovirus has a higher rate of complications which can include bronchiolitis obliterans. Most children recover completely.

RSV is SO much more than just a cold. Treat it with the respect it demands!

Wuzzie · Jan 19, 2017

Great article! 'Tis the season! Having transported hundreds and hundreds of these babies one thing I might add for those of you in smaller ED's and pediatric units. If the baby is going to go south it's going to happen on Day 5-7. Most often on Day 5 (we actually had stats to support this which I no longer have access to). So the caveat is to really monitor them at all times but in particular starting day 5 and if they are having even minor apneic episodes know that they are more than likely going to need intubation and transport to a tertiary pediatric facility. Do not wait until they completely decompensate as these kiddos are particularly difficult to ventilate.

NotReady4PrimeTime, RN · Jan 19, 2017

Great points, Wuzzie. My perspective is the PICU one, so they're already bad when we get them. Thanks for your contribution.

jrbl77, RN · Jan 21, 2017

Thanks for the article. I'm a long time med surg nurse and have heard the initials RSV, but didn't know much about it. My 15 month old grandson has it now and your information helped me have a good understanding of what is happening. He is at home, but myself and the other grandparents have been caring for him since he can't go to day care. Grandchildren are wonderful even when they are sick!

NotReady4PrimeTime, RN · Jan 21, 2017

I hope your little man recovers quickly. Just remember... wash your hands, wash your hands, wash your hands!

Allie_A&EMommie · Jan 23, 2017

Great article!!! If you don't mind, where did you find your information? I'm a PN student and currently gathering my information on this topic for my research paper. I'm looking for facts that I can use to educate and not seem boring. Thank you

NotReady4PrimeTime, RN · Jan 23, 2017

Presenting facts doesn't have to be boring! It's all in how you frame them. I use Medscape, Medline, the CDC website and eMedicine as authoritative and reliable sources.

RSV (Respiratory Syncytial Virus) - More Than Just a Cold

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