Treatment of RSV in Adults with Asthma
Treat RSV in adults with asthma by managing the asthma exacerbation itself with standard therapy—systemic corticosteroids, bronchodilators, and oxygen—while providing supportive care for the viral infection, as RSV acts as a trigger rather than a treatment target. 1
Primary Treatment Strategy
The management approach focuses on two parallel pathways: treating the asthma exacerbation and providing supportive care for RSV, since no FDA-approved antiviral exists for RSV in adults 2, 3.
Immediate Asthma Exacerbation Management
Bronchodilator therapy:
- Administer albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses 1
- Both delivery methods are equally effective when properly administered 1
Systemic corticosteroids (critical component):
- Start immediately with prednisolone 40-60 mg orally, or IV hydrocortisone 200 mg if unable to take oral medication 1
- This addresses the underlying inflammatory pathology that beta-agonists cannot impact 1
- Continue for 5-10 days after discharge 1
- Short courses up to two weeks do not require tapering and can be stopped from full dosage 1
Adjunctive anticholinergic therapy:
- Add ipratropium bromide 0.5 mg via nebulizer (or 8 puffs via MDI) every 20 minutes for 3 doses, then as needed 1
- This reduces hospitalizations, particularly in severe airflow obstruction 1
Oxygen Support
- Administer oxygen via nasal cannula or mask to maintain SpO₂ >90% (>95% in pregnant patients or those with heart disease) 1
- Escalate to high-flow nasal oxygen in monitored settings if standard supplementation inadequate 2
Supportive Care for RSV
Since RSV treatment is primarily supportive with no specific antivirals approved for adults 2:
- Ensure adequate hydration and fluid intake 2
- Use analgesics (acetaminophen or ibuprofen) for fever and pain 2
- Consider nasal saline irrigation for upper respiratory symptoms 2
Critical Clinical Context
Why this approach matters: Adults with asthma have 7-8 times greater risk of RSV-associated hospitalization compared to those without asthma 4, 1. In hospitalized adults with RSV, 49.5% of asthma patients experienced disease exacerbation 4, and asthma exacerbations were more common with RSV than influenza (OR = 1.5) 4.
Discharge Criteria
Do not discharge until:
- PEF reaches ≥70% of predicted or personal best 1
- Symptoms are minimal or absent 1
- Oxygen saturation is stable on room air 1
- Observe for 30-60 minutes after last bronchodilator dose to ensure stability 1
Provide written asthma action plan, review inhaler technique, and ensure patients continue or initiate inhaled corticosteroids at discharge 1.
What NOT to Do (Critical Pitfalls)
Do NOT use ribavirin unless the patient is severely immunocompromised (e.g., transplant recipient, hematologic malignancy) 2, 3. Ribavirin is FDA-approved only for hospitalized infants with severe RSV 3, and its use in immunocompetent adults is not supported.
Do NOT use palivizumab for treatment of established RSV infection—it has no therapeutic benefit in active infection and is only approved for prevention in high-risk infants 2
Do NOT withhold or delay corticosteroids thinking they might worsen viral infection—they are essential for treating the asthma exacerbation component 1
Do NOT use antibiotics empirically—only use when specific bacterial co-infection is documented 2
Prevention for Future Seasons
RSV vaccination is now recommended for adults with asthma according to local immunization schedules 4, 1. The vaccine shows 82.6% efficacy against RSV-associated lower respiratory tract disease in adults ≥60 years 1. Administer between September and November before RSV season 2, 5.