Here are hot tips for management of RSV
Respiratory syncytial virus (RSV) is highly contagious and causes significant morbidity and mortality in very young children, notes Jennifer Dearman, RN, BN, charge nurse at the pediatric ED at Loma Linda (CA) University Medical Center and Children’s Hospital.
"It is the most common isolated pathogen in patients hospitalized with bronchiolitis," she adds.
Children at high risk of complications are premature infants and children under two with chronic lung disease, says Dearman. Eighteen to twenty percent of infants who are in the hospital with bronchiolitis will develop apnea, she reports.1
Here are some tips to consider when managing RSV in the ED:
• Consider that infants under 2 months old may have apnea.
Those patients may be sicker than other children with RSV because of the apnea, says Carol Ledwith, MD, FAAP, an attending physician in the ED at the Children’s Hospital ED in Denver. "But that doesn’t mean you have to admit every child under two months of age that you think has bronchiolitis," she cautions. "You don’t have to admit them all, but be aware that there is a higher risk of apnea."
Take a thorough history to ensure the child is not having problems associated with apnea, Ledwith advises. A longer period of observation in the ED may be necessary.
• Suction the child’s nose.
One of most the most helpful interventions you can do for children with RSV is deep nasal suctioning, stresses Ledwith. "It is amazing what that local therapy of getting congestion eased can do for those kids," she says. "In my opinion, it probably helps more patients than nebulizers. Their nasal passages get so clogged, and it’s one of our main reasons for admissions." Deep suctioning can’t be done at home, and the congestion may prevent a child from being able to feed.
• Send children home with nebulizer treatments.
If a child with RSV gets better after a nebulizer treatment in the ED, set the patient up with a home nebulizer machine, advises Ledwith. "It is preposterous to give them a nebulizer treatment, make them better, but then send them home on albuterol syrup, just because it is easier," she says. "That it is not appropriate therapy."
About 30% of children will get better from nebulizer treatments; about 30% will get worse; and the remainder will show no effect, Ledwith notes.
• Start babies on IVs after interventions.
When babies are feeding poorly, they may be hypoxic and congested. "But if you suction them out and put them on some oxygen, a lot of them will start feeding great. So they really don’t need to have an IV put in first," says Ledwith.
Evaluate the baby’s hydration status after you control their respiratory status with these two interventions, she recommends.
• Document the child’s pulse oximetry.
"It has been well studied that the ability of physicians and nurses to accurately predict pulse oximetry levels is poor," notes Ledwith.2
"Obviously, the patient’s respiratory rate and behavior are valuable pieces of information, but oxygen saturation may be the single best predictor of severe disease," she stresses. "It is a cheap, easy, noninvasive test, and should be documented on the chart."
However, don’t assume a child is fine just because the oxygen saturation level is good, cautions Ledwith. "If the child looks great, the pulse oximetry will support that assessment."
• Warn caregivers that the child may get worse.
Families need good follow-up instructions to inform them about what to expect. (See home instruction sheet, inserted in this issue.)
"RSV is a frustrating illness for all of us," Ledwith says. "There is not a medication that will make it go away, and the medications we do have only help a minority of kids."
Caregivers need to understand that if they brought the child in on day one or two of the illness, the child will probably get worse. "Let them know that if the child stops feeding or starts getting irritable, they need to come back in," says Ledwith. "The natural progression of RSV is to get worse before it gets better."
• Instruct family members not to smoke.
Babies that are exposed to smoke will have longer courses of RSV, says Ledwith. "If the caregiver insists they don’t smoke around the baby, that is hogwash," she emphasizes. "They need to not smoke anywhere at all in the house or the car, because it makes the wheezing worse."
References
1. American Academy of Pediatrics Policy Statement. Reassessment of the indications for ribavirin therapy in respiratory syncytial virus infections. Pediatrics 1996; 97:137-140.
2. Shaw K. The outpatient assessment of infants with bronchiolitis. Am J Dis Child 1991; 145:151-155.
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