What oxygen saturation (SpO₂) target should be maintained in patients with respiratory syncytial virus infection, including specific thresholds for infants, children, adults, and those with cardiac or pulmonary comorbidities?

SpO₂ Targets in RSV Infection

For infants and children with RSV bronchiolitis, maintain oxygen saturation above 90%, and for adults with RSV infection without risk factors for hypercapnic respiratory failure, target SpO₂ of 94-98%. 1, 2

Infants and Children with RSV Bronchiolitis

Primary Target

• Maintain SpO₂ >90% as the threshold for supplemental oxygen therapy 1, 2
• This represents the standard of care endorsed by the American Academy of Pediatrics for RSV bronchiolitis management 1

Clinical Context

• Continuous pulse oximetry monitoring is no longer required once the child is stable 1
• Decreased initial oxygen saturation (<90%) is associated with prolonged hospitalization (5.3 vs 3.2 days) and increased oxygen requirements 3
• Infants younger than 6 weeks require closer monitoring as they experience longer hospitalizations and more severe courses 3

Oxygen Delivery Approach

• Use supplemental oxygen only when SpO₂ falls below 90% 1, 2
• Treatment is primarily supportive; bronchodilators, epinephrine, corticosteroids, and hypertonic saline are not recommended 1, 2

Adults with RSV Infection

Without Comorbidities

• Target SpO₂ 94-98% for adults without risk factors for hypercapnic respiratory failure 4
• Start with nasal cannulae at 2-6 L/min or simple face mask at 5-10 L/min 4
• If SpO₂ <85%, initiate therapy with reservoir mask at 15 L/min 4

With Cardiac or Pulmonary Comorbidities

COPD or Risk of Hypercapnic Respiratory Failure:

• Target SpO₂ 88-92% pending arterial blood gas results 4
• Risk factors include: severe/moderate COPD (especially with previous respiratory failure or long-term oxygen), severe chest wall/spinal disease, neuromuscular disease, severe obesity, cystic fibrosis, or bronchiectasis 4
• Start with 24-28% oxygen or 1-2 L/min nasal oxygen 4
• Adjust to 94-98% if PaCO₂ is normal on blood gas analysis (unless history of previous hypercapnic respiratory failure requiring NIV/IMV) 4
• Recheck blood gases after 30-60 minutes 4

Interstitial Lung Disease:

• Target SpO₂ 88-92% as the initial conservative target for acute exacerbations 5
• Obtain arterial blood gas immediately upon presentation to establish baseline PaO₂, PaCO₂, and pH 5
• Monitor for clinical deterioration requiring escalation within 1-2 hours 5

Critical Monitoring Parameters

For All Patients

• Measure respiratory rate and heart rate carefully, as tachypnea and tachycardia are more common than visible cyanosis in hypoxemic patients 4
• Obtain blood gases to confirm adequate oxygenation and exclude respiratory acidosis 4

Warning Signs Requiring Escalation

• pH <7.35 with PaCO₂ >6.0 kPa indicates respiratory acidosis requiring immediate senior review and consideration of NIV or invasive ventilation 4
• Continuously monitor respiratory rate, work of breathing, and mental status as indicators of treatment failure 5

Common Pitfalls to Avoid

• Do not assume normal SpO₂ excludes serious pathology, as pulse oximetry can be normal despite abnormal pH, elevated PaCO₂, or severe anemia 5
• Avoid sudden oxygen withdrawal; titrate down gradually to prevent rebound hypoxemia 5
• Do not over-oxygenate patients with COPD or other hypercapnic risk factors, as this may worsen CO₂ retention 4
• For infants with RSV, avoid unnecessary interventions such as bronchodilators, antibiotics, or chest physiotherapy, as these are not beneficial 1, 2