Supportive Care Only for RSV in 2023– Can We Do Better?

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Dr. Soni: 
Hello, everyone. Thank you for joining. My name is Priya Soni. I'm a Pediatric Infectious Disease Specialist at Cedars Sinai Medical Center, as well as David Geffen School of Medicine at UCLA in Los Angeles. Today we're going to be talking about Supportive Care Only for RSV in 2022 – Can We Do Better? 

So currently, with RSV, the major cause of bronchiolitis in children less than 2 years old, treatment options are very limited to supportive measures only. And we know that there are very well-defined risk factors for severe illness. However, the measures that we have currently in place are mainly focused towards supportive measures and prevention, in order to prevent children from sort of developing horrible complications from this terrible virus. 

So in terms of clinical management, there is a long list of evidence-based measures that have been sort of tried and tested. But currently supplemental oxygen and some of the other supportive care measures, including hydration, are really the ones that we have the most clear evidence for. There are a list of ineffective measures, including previously known trials for ribavirin, as well as immunoglobulins specific for RSV which had been used in in the past. 

So the key takeaway here is that the strategies, like I said, have been focused on prevention and prophylaxis, and the prophylaxis mainly in form of a monoclonal antibody administration of palivizumab during the RSV season. 

Other measures including nebulized epinephrine therapy has not been known to decrease the length of stay in these infants. Chest physiotherapy as well as inhaled bronchodilators are generally not recommended. And of course, this is a virus we're dealing with, so antibiotics are not recommended. 

So to focus specifically on supportive measures, we're going to be talking about respiratory support, nasal suctioning, and fluid management. 

Respiratory support really is to maintain oxygen saturations in these infants above 90 to 92% on room air. We are able to provide high-flow nasal cannula as a form of oxygen, as well as CPAP, or continuous positive airway pressure. And the goal is to really reduce work of breathing in these infants, improve the gas exchange, and to avoid endotracheal intubation in these infants, which really can happen sometimes, but with these early measures, we many times prevent the need for endotracheal intubation. However, if there are signs of impending respiratory failure in these children, including retractions that are marked, poor response to stimulation, including weak cry, fatiguing out, as well as our lab findings of a venous blood gas or to arterial blood gas showing hypercapnia, these signs do sort of point to the need for a higher level of care with endotracheal intubation. 

Nasal suctioning is also extremely effective in helping these infants get through this virus. As we know, the airways in these infants are extremely small and so providing that manual nasal suctioning, and teaching parents and caregivers proper sectioning techniques for these infants is extremely necessary. We often use normal saline drops in order to help break up those secretions before the suctioning is provided, generally, every 3 to 4 hours, especially before the infant is feeding. 

And lastly, fluid management. So fluids are an extremely important part of the pillars of supportive care in these infants because they're losing insensible losses due to tachypnea and respiratory distress. And they're having decreased intake because of these reasons as well. So I.V. fluid administration really is important in getting these infants better sooner and will help to decrease the length of stay overall. In addition, you know, fluids are helpful because while these infants are on oxygen, you know, they are not able to feed, some may not tolerate OG tube feeds, and may be at risk for aspiration. 

So with that, that concludes our mainstays of supportive measures for treatment of RSV for infants. And thank you all for joining and watching it.

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