How should I manage the cough in a patient with respiratory syncytial virus (RSV)?

Management of Cough in RSV Infection

For RSV-associated cough, provide supportive care only—honey and lemon for patients over 1 year, adequate hydration, and supplemental oxygen if saturations fall below 90%—while avoiding bronchodilators, corticosteroids, antibiotics, and antitussives, as none have proven benefit. 1, 2, 3

Natural Course and Expectations

• RSV bronchiolitis typically begins with 2-4 days of upper respiratory symptoms (fever, rhinorrhea, congestion) followed by lower respiratory tract symptoms including increasing cough, wheezing, and increased respiratory effort 2
• The cough associated with RSV is self-limited and usually resolves within 2-3 weeks without specific treatment 1
• Most RSV cases can be managed as outpatients with supportive care alone 4

First-Line Supportive Management

• Recommend honey and lemon as the initial intervention for cough suppression in patients over 1 year of age, as this provides symptomatic relief through central modulation of the cough reflex and is the simplest, cheapest approach 1, 5
• Ensure adequate hydration with regular fluid intake (approximately 2 liters per day or less) to prevent dehydration, especially when fever is present 1, 5
• Administer nasogastric or intravenous fluids for infants who cannot maintain hydration status with oral intake 2, 3
• Provide supplemental oxygen therapy to maintain oxygen saturation above 90% 2, 3

Positioning and Non-Pharmacologic Measures

• Advise patients to avoid lying flat on their back, as this position makes coughing ineffective and worsens symptoms 1, 5
• Sitting upright increases peak ventilation and reduces airway obstruction 1
• Encourage voluntary cough suppression techniques, which can reduce cough frequency through central modulation 6, 1

What NOT to Use in RSV

• Do not prescribe bronchodilators—they are not recommended as standard practice and provide no proven benefit in RSV bronchiolitis 2, 7, 3
• Do not prescribe epinephrine—it is not useful for RSV management 2, 3
• Do not prescribe corticosteroids—they are generally not useful in RSV infection 2, 3
• Do not prescribe antibiotics—RSV is viral, and antibiotics provide no benefit while promoting resistance 1, 5, 3
• Do not prescribe nebulized hypertonic saline—it is not recommended for RSV bronchiolitis 2, 3
• Do not use codeine or pholcodine—these opiate antitussives have significant adverse side effects without greater efficacy and are not recommended for acute viral cough 6, 1

When to Escalate Care

• Hospitalize infants and children who develop signs of respiratory distress including markedly raised respiratory rate, grunting, intercostal retractions, breathlessness with chest signs, cyanosis, or severe dehydration 8
• Provide mechanical ventilation if respiratory failure develops despite supplemental oxygen 4, 7
• Monitor closely for deterioration in high-risk patients: premature infants, those with chronic lung disease, hemodynamically significant heart disease, immunocompromised status, or neuromuscular conditions 2, 4, 7

Prevention and Prophylaxis

• Educate parents on infection prevention: hand washing, cleaning environmental surfaces, and avoiding contact with sick individuals 2, 7, 3
• Consider palivizumab prophylaxis (monthly intramuscular injections during RSV season, November through April) for high-risk infants: those born before 29 weeks' gestation, infants with chronic lung disease of prematurity, and infants with hemodynamically significant heart disease 2, 7, 3

Common Pitfalls to Avoid

• Do not use antipyretics (paracetamol) solely to reduce body temperature—use them only when fever causes discomfort or is associated with other symptoms 5, 8
• Do not perform routine diagnostic testing including chest radiography or viral testing, as bronchiolitis remains a clinical diagnosis 2, 3
• Do not use continuous pulse oximetry monitoring routinely—intermittent monitoring is sufficient 2
• Recognize that patients are infectious and can transmit RSV even before symptomatic presentation begins and throughout the period of viral shedding 4