Welcome, RSV!

Johns Hopkins Module

November 5th, 2012

Question 1
It is January and you are seeing a healthy 2 week old child for
a well visit. His 3 year old sister currently has a cold. You
consider that the sister might have RSV and discuss the
possibility that the infant may contract the illness. Which one
of the following is true concerning the presentation of RSV in
infants?
a. Infants with RSV rarely have significant cough; vomiting
and apneic episodes are the predominate symptoms.
b. Infants with RSV often present with vomiting and diarrhea
long before developing URI symptoms.
c. Sudden onset of central apnea is an indication for RSV
testing in young infants.
d. RSV infection is often asymptomatic in full term newborns.

Answer 1
It is January and you are seeing a healthy 2 week old child for
a well visit. His 3 year old sister currently has a cold. You
consider that the sister might have RSV and discuss the
possibility that the infant may contract the illness. Which one
of the following is true concerning the presentation of RSV in
infants?
a. Infants with RSV rarely have significant cough; vomiting
and apneic episodes are the predominate symptoms.
b. Infants with RSV often present with vomiting and diarrhea
long before developing URI symptoms.
c. Sudden onset of central apnea is an indication for
RSV testing in young infants.
d. RSV infection is often asymptomatic in full term newborns.

Presentation
Common cold symptoms: cough, fever, and rhinorrhea, however
in infancy, 1/3 of cases spread to lower respiratory tract
In infants: peribronchiolar infiltrate of lymphocytes, proliferation
of bronchiolar epithelium, and small airway obstruction due to
mucus and sloughed epithelial cells. The small airway
obstruction can lead to air trapping and atelectasis with
subsequent V/Q mismatch and hypoxemia, with relatively little
smooth muscle constriction. The result is a clinical presentation
called bronchiolitis.
Lung exam can consist of rhonchi, wheezing, and crackles or
lungs may be clear but patient exhibits increased WOB, cough,
and tachypnea
Lung exam changes FREQUENTLY; wheezing one minute,
rhonchi the next

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Diagnosis
Not ALL bronchiolitis is RSV and not all RSV is bronchiolitis Bronchiolitis can
also be caused by parainfluenza, influenza, and human metapneumovirus.
Diagnosis is CLINICAL
Chest x-ray is NOT required for diagnosis and is NOT necessary for
diagnosis, but if obtained, chest x-ray may reveal hyperinflation,
peribronchial thickening, and increased interstitial markings. Atelectasis in
the right upper or middle lobe is common and may appear as consolidation.
Laboratory confirmation of RSV is most commonly accomplished by rapid
diagnostic assays, which test a nasopharyngeal washing and use either
indirect fluorescent antibody (IFA) testing or enzyme immunoassay (EIA).
The sensitivity of the rapid antigen test is in the 80% to 90% range.
Specificity estimates have been reported to be 77%-100% for both IFA and
EIA.
PCR offers high sensitivity and specificity but is limited by expense,
laboratory variation, and prolonged shedding in some children that cause
the test to be positive up to four weeks after acute infection.

Question 2
You have just admitted a 3 month old child with a 4 day history of
rhinorrhea, three days fever, and two days of increasing cough. On
exam he has a temperature of 38.2C and a respiratory rate of 50,
and a SaO2 of 91% on room air. He has moderate intercostal and
subcostal retractions and diffuse wheezing. The emergency room
staff gave acetaminophen to the child and two 2.5 mg Albuterol
nebulized treatments, spaced 20 minutes apart, with no change in
exam or oxygenation clearly documented. What is the BEST plan?
a. Place the child on continuous nebulized
b. Give the child oxygen and IV fluids only and discontinue
Albuterol
c. Increase the amount of Albuterol to 5.0 mg and give by
nebulizer every four hours
d. Give the child 1 mg/kg of Solumedrol and oxygen and
discontinue Albuterol

Answer 2
You have just admitted a 3 month old child with a 4 day history of
rhinorrhea, three days fever, and two days of increasing cough. On
exam he has a temperature of 38.2C and a respiratory rate of 50,
and a SaO2 of 91% on room air. He has moderate intercostal and
subcostal retractions and diffuse wheezing. The emergency room
staff gave acetaminophen to the child and two 2.5 mg Albuterol
nebulized treatments, spaced 20 minutes apart, with no change in
exam or oxygenation clearly documented. What is the BEST plan?
a. Place the child on continuous nebulized
b. Give the child oxygen and IV fluids only and discontinue
Albuterol
c. Increase the amount of Albuterol to 5.0 mg and give by
nebulizer every four hours
d. Give the child 1 mg/kg of Solumedrol and oxygen and
discontinue Albuterol

Treatment
Supportive Care!
Oxygen (NC or HFNC), IV fluids (NPO
if tachypneic)
Suctioningalthough there is not
good evidence for deep suctioning

Other Treatments
Bronchodilators-A Cochrane review did show some benefit in average
clinical score of wheezing, but no overall improvement in
oxygenation, hospitalization rate, or hospitalization duration was
seen.
Usual practice at CNMC-try albuterol, if doesnt help, do not continue
Higher risk population?

Racemic epinephrine-A single dose of nebulized racemic epinephrine

may be considered for ill children who have not responded to
albuterol, but it should be discontinued if no benefit is demonstrated.
Because of the short duration of action, potential adverse effects,
and unknown long-term side effects, racemic epinephrine is generally
not given in the clinic or office setting.
Hypertonic saline- Meta-analysis suggests that nebulized 3% saline
may significantly reduce the length of hospital stay among infants
hospitalized for non-severe acute bronchiolitis and improve the
clinical severity score in both outpatient and inpatient populations.

Other treatments
Steroids-Not currently recommended
(very mixed results from several
studies); may be indicated in more
severe illness
Chest PT-no good evidence to
support for bronchiolitis
Antibiotics-serious bacterial infection
is rare with bronchiolitis (<3%)

Question 3
Synagis (palivizumab) is recommended for all the
following children EXCEPT
a. A 19 month old ex-28 week preemie using
nighttime oxygen
b. A 4 month old child with a hemodynamically
insignificant ventricular septal defect
c. A 7 month old ex-27 week preemie with no
oxygen requirement
d. A 2 month old 34 week preemie born in August
who required intubation for 2 days, is currently in
day care, and has 3 and 7 year old siblings

Synagis (palivizumab) is recommended for all the

following children EXCEPT
a. A 19 month old ex-28 week preemie using
nighttime oxygen
b. A 4 month old child with a hemodynamically
insignificant ventricular septal defect
c. A 7 month old ex-27 week preemie with no
oxygen requirement
d. A 2 month old 34 week preemie born in August
who required intubation for 2 days, is currently in
day care, and has 3 and 7 year old siblings

Synagis
lessens RSV disease severity but
does not prevent RSV infection
Aimed at those that RSV hits hardest
premature, CLD, congenital heart
disease
Why cant we give it to everyone?
each injection costs well over $1000

Who gets Synagis?

For the following infants born
premature, five monthly doses of
palivizumab are recommended
between November and March:
Infants born 28 weeks gestation, and are
12 months or younger at start of RSV
season
Infants born at 29 weeks, 0 days through
31 weeks, 6 days gestation and are 6
months or younger at start of RSV season

Who gets Synagis?

For the following infants born premature, UP
TO THREE MONTHLY doses of palivizumab
are recommended between November and
March:
Infants who are 32 weeks, 0 days through 34
weeks, 6 days AND who are:
Born during OR are less than three months at the
start of RSV season, AND
Have one of two risk factors:
(a) child care
(b) sibling < 5 years

Who gets Synagis?

For the following infants with chronic
lung disease, five monthly doses of
palivizumab are recommended between
November and March:
Infants < 24 months with chronic
lung disease who required medical
therapy (supplemental oxygen,
steroids, diuretic or bronchodilator)
within 6 months at start of RSV season

Who get Synagis?

For the following infants with congenital heart
disease, five monthly doses of palivizumab
are recommended between November and March:
Infants < 24 months at start of season with
hemodynamically significant congenital heart
disease, particularly:
Receiving medication to control congestive
heart failure
Moderate to severe pulmonary hypertension
Cyanotic heart disease

Who gets Synagis?

For the following infants with congenital
abnormalities of the airway or neuromuscular
disease, five monthly doses of palivizumab are
recommended between November and March:
Infants and young children born with
significant congenital abnormalities of the
airway or neuromuscular disease that
compromises handling of respiratory
secretions, and <12 months at start of RSV
season

Which of the following statements about the

epidemiology and transmission of RSV is true?
a. RSV has become a year-round threat in most
climates; it is no longer a seasonal epidemic except
in the colder regions.
b. Otherwise healthy children infected with RSV shed
virus for 3 weeks on average.
c. Self-inoculation with contaminated secretions
persisting on fomites is an important factor in
nosocomial spread.
d. Animal reservoirs for RSV are an important factor
in patterns of human RSV epidemics.

Which of the following statements about the

epidemiology and transmission of RSV is true?
a. RSV has become a year-round threat in most
climates; it is no longer a seasonal epidemic except in
the colder regions.
b. Otherwise healthy children infected with RSV shed
virus for 3 weeks on average.
c. Self-inoculation with contaminated
secretions persisting on fomites is an important
factor in nosocomial spread.
d. Animal reservoirs for RSV are an important factor
in patterns of human RSV epidemics.

It is November and you are seeing a previously healthy 5

month old child in the office for a follow-up after being
hospitalized for five days for RSV bronchiolitis. The father
asks you if his child can contract RSV again. You tell him
that
a. Yes, and his child is at risk for severe bronchiolitis in the
future because of the severity of the infection that has
just occurred
b. No, because immunity is lifelong
c. Yes, but subsequent infections should be milder
because of immunity from previous infections
d. No, because immunity after RSV lasts for 6-12 months
and by that time his child will be too old to contract RSV

It is November and you are seeing a previously healthy 5

month old child in the office for a follow-up after being
hospitalized for five days for RSV bronchiolitis. The father
asks you if his child can contract RSV again. You tell him
that
a. Yes, and his child is at risk for severe bronchiolitis in
the future because of the severity of the infection that
has just occurred
b. No, because immunity is lifelong
c. Yes, but subsequent infections should be milder
because of immunity from previous infections
d. No, because immunity after RSV lasts for 6-12 months
and by that time his child will be too old to contract RSV

You are seeing a 3 month old child in the hospital with

RSV bronchiolitis. Her respiratory rate is 60, her SaO2
is 89% on room air, and her oral intake has been poor
for the last 24 hours. 1 dose each of racemic
epinephrine and Albuterol were tried in the emergency
room and documented to have no effect. Your
treatment should consist of
a. IV fluids and oxygen only
b. q2 hour Albuterol, IV fluids and oxygen
c. Dexamethasone, IV fluids, and oxygen
d. q1 hr prn racemic epinephrine, dexamethasone, IV
fluids, and oxygen

You are seeing a 3 month old child in the hospital with

RSV bronchiolitis. Her respiratory rate is 60, her SaO2
is 89% on room air, and her oral intake has been poor
for the last 24 hours. 1 dose each of racemic
epinephrine and Albuterol were tried in the emergency
room and documented to have no effect. Your
treatment should consist of
a. IV fluids and oxygen only
b. q2 hour Albuterol, IV fluids and oxygen
c. Dexamethasone, IV fluids, and oxygen
d. q1 hr prn racemic epinephrine, dexamethasone, IV
fluids, and oxygen

All of the following infants are eligible for monthly

Synagis (palivizumab) EXCEPT
a. a 3 month old child with unrepaired Tetralogy of
Fallot on Lasix therapy
b. a 10 month old child, ex 27 week preemie in good
health and no chronic oxygen requirement
c. a 4 month old child, ex 33 week preemie with a 2
year old brother and a stay-at home parent
d. a 20 month old ex 30 week preemie on chronic
Flovent therapy and with one hospital admission for
difficulty breathing 5 months ago, but no oxygen
requirement

All of the following infants are eligible for monthly

Synagis (palivizumab) EXCEPT
a. a 3 month old child with unrepaired Tetralogy of
Fallot on Lasix therapy
b. a 10 month old child, ex 27 week preemie in good
health and no chronic oxygen requirement
c. a 4 month old child, ex 33 week preemie with
a 2 year old brother and a stay-at home parent
d. a 20 month old ex 30 week preemie on chronic
Flovent therapy and with one hospital admission for
difficulty breathing 5 months ago, but no oxygen
requirement