What is the treatment for Respiratory Syncytial Virus (RSV) bronchiolitis?

Treatment of RSV Bronchiolitis

The treatment of RSV bronchiolitis is primarily supportive care focused on maintaining adequate oxygenation and hydration, while avoiding unnecessary medications including bronchodilators, corticosteroids, ribavirin, and antibiotics in most cases. 1

Core Supportive Management

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90% in previously healthy infants 1
• Maintain SpO2 at or above 90% with adequate supplemental oxygen 1
• Discontinue oxygen when SpO2 remains at or above 90%, the infant feeds well, and has minimal respiratory distress 1
• Continuous pulse oximetry monitoring is not routinely needed as the child's clinical course improves 1
• Infants with hemodynamically significant heart or lung disease and premature infants require close monitoring during oxygen weaning 1

Hydration and Nutrition Support

• Assess hydration status and ability to take fluids orally as a strong recommendation 1
• Provide intravenous or nasogastric fluids for infants unable to maintain adequate oral hydration 2, 3
• Monitor feeding ability and nutritional status throughout the illness 2, 3

Medications NOT Recommended for Routine Use

Bronchodilators

• Bronchodilators should NOT be used routinely in bronchiolitis management 1
• A carefully monitored trial of α-adrenergic or β-adrenergic medication is an option only if there is documented positive clinical response using objective evaluation 1
• Continue bronchodilators only if objective clinical improvement is demonstrated during the trial 1

Corticosteroids

• Corticosteroid medications should NOT be used routinely in bronchiolitis management 1
• This recommendation applies despite some studies showing marginal benefit, as the evidence remains insufficient to support routine use 1

Antiviral Therapy (Ribavirin)

• Ribavirin should NOT be used routinely in children with bronchiolitis 1
• Ribavirin may be considered only in highly selected situations involving documented RSV with severe disease or high-risk patients (immunocompromised or hemodynamically significant cardiopulmonary disease) 1, 4
• The drug has marginal benefit, cumbersome delivery requirements, potential health risks for caregivers, and high cost 1
• FDA labeling indicates ribavirin is for hospitalized infants with severe lower respiratory tract RSV infections, but treatment should be initiated early in the disease course 4

Antibacterial Therapy

• Antibiotics should only be used when specific indications of coexisting bacterial infection are present 1
• Serious bacterial infections occur in only 0-12% of bronchiolitis cases, most commonly urinary tract infections rather than bacteremia or meningitis 1
• When bacterial infection is documented, treat it the same as in the absence of bronchiolitis 1

Chest Physiotherapy

• Chest physiotherapy should NOT be used routinely in bronchiolitis management 1

Diagnostic Approach

Clinical Diagnosis

• Diagnose bronchiolitis based on history and physical examination without routine laboratory or radiologic studies 1
• RSV testing may be useful for cohorting hospitalized patients to prevent nosocomial spread, but is not required for diagnosis 1, 5
• Assess risk factors for severe disease: age <12 weeks, prematurity, underlying cardiopulmonary disease, or immunodeficiency 1

Prevention Strategies

Infection Control in Healthcare Settings

• Hand decontamination is the most important step in preventing nosocomial RSV spread 1
• Decontaminate hands before and after direct patient contact, after touching objects near the patient, and after removing gloves 1
• Alcohol-based hand rubs are preferred over antimicrobial soap 1
• Use gloves and gowns for direct patient contact 1
• Educate personnel and family members on hand hygiene practices 1
• Programs implementing strict hand hygiene and cohorting reduce nosocomial RSV transmission by 39-50% 1

Immunoprophylaxis with Palivizumab

• Administer palivizumab prophylaxis to infants born before 29 weeks' gestation who are <12 months at RSV season start 6
• Infants and children <12 months with chronic lung disease should receive prophylaxis 6
• Children ≤12 months with hemodynamically significant congenital heart disease may benefit from prophylaxis 6, 7
• Dosing: 15 mg/kg intramuscularly every 30 days for 5 monthly doses, typically November through March 1, 6, 7
• Palivizumab reduces RSV hospitalization by 45-55% in high-risk infants 7

Family Education

• Infants should not be exposed to passive smoking 1
• Tobacco smoke exposure increases bronchiolitis risk with an odds ratio of 2.51 for hospitalization 1
• Breastfeeding is recommended to decrease lower respiratory tract disease risk 1
• Educate families on standard precautions including hand hygiene and avoiding contact with sick individuals 3

Critical Pitfalls to Avoid

• Do not use palivizumab for treatment of established RSV infection—it is only for prevention 6
• Do not continue bronchodilators without documented objective clinical improvement 1
• Do not order routine chest radiographs or viral testing for diagnosis 1
• Do not prescribe antibiotics without specific evidence of bacterial co-infection 1
• Do not use ribavirin routinely due to minimal benefit, toxicity, and high cost 1, 4

Expected Clinical Course

• Most infants recover with supportive care alone 8, 2, 9
• Symptoms typically last 2-3 weeks, with parents often seeking care in multiple settings during this period 1
• Initial upper respiratory symptoms (fever, rhinorrhea, congestion) occur after 4-6 days incubation, followed by lower respiratory symptoms (cough, wheezing, increased respiratory effort) 2, 3