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

RSV Treatment

RSV treatment is primarily supportive care—maintain hydration, provide supplemental oxygen if saturation falls below 90%, and avoid routine use of bronchodilators, corticosteroids, or antibiotics unless bacterial co-infection is documented. 1, 2

Core Treatment Principles

Supportive Care (Mainstay of Treatment)

• Hydration and nutrition support are essential; assess fluid intake regularly and provide nasogastric or intravenous fluids if oral intake is inadequate 1, 2, 3
• Oxygen supplementation should be initiated when oxygen saturation persistently falls below 90% in previously healthy infants (some sources suggest 90-92% threshold) 1, 2, 3
• Fever and pain management with acetaminophen or ibuprofen as needed 1
• Nasal saline irrigation may provide symptomatic relief in adults with upper respiratory symptoms 1

What NOT to Use (Critical to Avoid)

• Do NOT use corticosteroids routinely—they provide no benefit in bronchiolitis 1
• Do NOT use bronchodilators routinely—discontinue if no documented clinical improvement 1
• Do NOT use antibiotics unless there is specific evidence of bacterial co-infection 1, 2, 3
• Do NOT use palivizumab for treatment—it has zero therapeutic benefit for established RSV infection and is only approved for prevention in high-risk infants 1, 2
• Do NOT use ribavirin routinely in children with bronchiolitis 1

Respiratory Support Escalation

Oxygen Delivery Methods

• High-flow nasal oxygen (HFNO) may be considered in selected patients with hypoxemic respiratory failure, but only in monitored settings with personnel experienced in intubation 1, 4
• Non-invasive ventilation (NIV) is NOT recommended due to high failure rates and risk of aerosol generation 1
• Early intubation and mechanical ventilation should be considered if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 1

Indications for ICU Transfer

• Failure to maintain oxygen saturation >92% despite FiO2 >60% 1
• Shock or severe respiratory distress with rising PaCO2 (>6.5 kPa) 1
• Severe respiratory distress requiring mechanical ventilation 1

Special Populations Requiring Different Management

Immunocompromised Patients & Hematopoietic Stem Cell Transplant Recipients

• Aerosolized ribavirin is the primary treatment option for RSV lower respiratory tract infection in these high-risk patients 1, 5
• Oral ribavirin may be an effective alternative that can reduce progression to lower respiratory tract infection and mortality 1
• Systemic ribavirin (oral or intravenous) can be used for patients unable to take oral medication 1
• Combination therapy with intravenous immunoglobulin or anti-RSV-enriched antibody preparations may be considered 1
• RSV infection should be documented by rapid diagnostic method before or during the first 24 hours of treatment 1, 5

Mechanically Ventilated Infants

• Ribavirin may be considered in mechanically ventilated infants with documented severe RSV infection, though this should only be undertaken by physicians familiar with this mode of administration 1, 5
• Treatment with aerosolized ribavirin in mechanically ventilated patients significantly decreased duration of mechanical ventilation (4.9 vs. 9.9 days) and supplemental oxygen requirements (8.7 vs. 13.5 days) in controlled trials 5
• Intensive monitoring is required: endotracheal tube suctioning every 1-2 hours, hourly recording of airway pressure and ventilatory rate, and arterial blood gas monitoring every 2-6 hours 5

Hospitalization Criteria

• Severe respiratory distress with retractions or accessory muscle use 2, 3
• Inability to maintain adequate hydration or feeding 2
• Oxygen saturation <90% despite supplemental oxygen 2
• High-risk patients: prematurity, chronic lung disease, congenital heart disease, immunocompromised status, or profound lymphopenia 2

Monitoring Requirements

• Mental status should be monitored and recorded as part of vital signs 1
• Continuous SpO2 monitoring is not routinely needed as clinical course improves 1
• Close monitoring during oxygen weaning is required for infants with hemodynamically significant heart or lung disease and premature infants 1

Infection Control (Essential to Prevent Nosocomial Spread)

• Hand hygiene is the single most important measure to prevent transmission—perform before and after patient contact, after contact with objects near the patient, and after removing gloves 1, 2
• Alcohol-based rubs are preferred if hands are not visibly soiled 1
• Wear gowns for direct patient contact 1
• Use gloves with frequent changes to avoid spreading organisms 1
• Educate personnel and family members about hand sanitation and prevention measures 1
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1

Common Clinical Pitfalls

• Overusing antibiotics without evidence of bacterial co-infection 1
• Continuing bronchodilator therapy without documented clinical improvement 1
• Using palivizumab to treat established infection (it only works for prevention) 1, 2
• Inadequate infection control measures leading to nosocomial transmission 1