What NPs Need to Know About Treating RSV

Cold and flu season if definitely here! In addition to the seasonal flu, respiratory syncytial virus (commonly referred to as RSV) is another prevalent and highly contagious virus that can affect patients of all ages through the fall and spring months. Nurse practitioners can expect to see these patients in their practices this season. In most older children and adults who are generally healthy, RSV causes mild, cold-like symptoms which typically resolve on their own within a few weeks. But for some patients, RSV can be serious and in some cases, life threatening.

Generally the concerns associated with RSV are focused on the pediatric population, and rightfully so as it affects more than half of all infants before their first birthday and is the leading cause of hospitalization of young children; but the virus can also be especially dangerous for geriatric patients. In fact, it’s estimated that RSV accounts for 170,000 hospitalizations and 10,000 deaths per year in patients over the age of 65 and is responsible for 17 out of 1,000 deaths of nursing home residents per year.

Regardless of age, the disease has the potential to create complications for any patient. Here’s what nurse practitioners need to know when diagnosing and treating RSV.

The Risk Factors and Importance of Diagnosing

It’s important that as a clinician, you properly diagnose RSV and interview patients or the parent of your patient to assess the risk factors for the disease, as this greatly impacts what your next steps should be in regards to the right treatment plan. Lower respiratory infections like bronchiolitis and pneumonia are commonly caused by the virus, and are a concern for high risk patients; and most deaths associated with RSV occur in infants who have certain risk factors in addition to the virus.

Pediatric patients at high risk for developing severe complications from the virus include those who are either under the age of one, are premature infants, have chronic lung or heart disease, or suppressed immune systems and/or neuromuscular disorders. In older children and adults (particularly adults age 65 and older), high risk patients also include those with chronic lung or heart disease, or with weakened immune systems. RSV can also lead to exacerbation of serious conditions such as asthma, COPD and congestive heart failure.

How to Diagnose the Virus

The American Academy of Pediatrics recommends that clinical judgment is a reasonable way to diagnose RSV; but the CDC states that clinical symptoms of RSV are nonspecific and can overlap with other viral respiratory infections as well as some bacterial infections. As such, clinical lab tests can be helpful in confirming RSV, especially if the patient is at high risk for developing further complications.

The CDC recommends that both rRT-PCR and antigen detection tests are effective methods for diagnosing the illness in infants and young children. Antigen sensitivity ranges from 80 - 90% but antigen detection tests are not sensitive for older children and adults because these patients may have lower viral loads in their respiratory specimens; so providers should only use highly sensitive rRT-PCR assays in this age group, which are now commercially available for RSV. It is possible to have a false negative, which is why you should also be aware of the symptoms and the timeline of RSV, as well as what the viral activity has been in the community.

Within two to eight days from the time a patient is exposed, they may start to experience decreased appetite and a runny nose. Because these symptoms in children under two can be attributed to any number of things, the initial onset may go unnoticed by parents of pediatric patients. After one to three days from the time these initial symptoms appear, a patient with RSV may start to develop any of the following symptoms, though in stages and not all at once.

  • Cough (may be producing yellow, green or gray mucus)

  • Fever

  • Irritability

  • Lethargy or sluggishness

  • Runny nose

  • Sneezing

  • Wheezing

  • Difficulty breathing; breathing that is faster than normal; using chest muscles to breathe in a way that seems labored

In some cases, the patient’s symptoms may be more severe resulting in:

  • Signs of dehydration such as sunken fontanels and no tear production when crying

  • Coughing up thick mucus

  • Thick nasal discharge that makes it hard for the patient to breathe

Treatment Options

Most cases of RSV resolve on their own and symptoms can be managed at home with supportive care like managing fever with acetaminophen or ibuprofen, clearing nasal passages, and preventing dehydration. Treatment of RSV with prescriptions for inhalers such as albuterol and epinephrine is debatable. While clinical trials vary in response, none support their use in infants with RSV and the studies did not find a significant difference in such drugs versus placebo in older patients.  

Patients who are either younger than six months of age or over the age of 65, are at a high risk for developing a more severe illness, or who are having trouble breathing and/or are dehydrated may need to be hospitalized for supportive care. In the most severe cases, patients may need to be provided with supplemental oxygen or intubation.

Currently there is no specific treatment for RSV though researchers have been working to develop antivirals.

Have you treated patients with RSV this winter?