Know RSV medications: Here is what’s new
There are several advances in medications for respiratory syncytial virus (RSV) that ED nurses should be aware of. Here are updates on research that may impact your clinical practice:
• Steroids.
The use of steroids has been well-studied, but there is no evidence of benefits for routine use in children with RSV under a year old, particularly with a first-time episode, says Carol Ledwith, MD, FAAP, an attending physician in the ED at the Children’s Hospital ED in Denver.
"Some kids come in on albuterol syrup and steroids, when neither of those medications is helping them," she notes. "This is a disease that needs to run its course."
Consider steroids in some cases
However, if the physician strongly suspects the child has reactive airway disease, such as in a child with a history of more than one episode of wheezing, who has demonstrated an excellent response to ß2-agonist medication, steroids should be considered, Ledwith adds.
• Racemic epinephrine.
Racemic epinephrine has been found to be more effective than albuterol in RSV patients, notes Jennifer Dearman, RN, BN, charge nurse at the pediatric ED at Loma Linda (CA) University Medical Center and Children’s Hospital.1
"Be aware that albuterol is not the only option with these kids," Dearman emphasizes. "A trial of racemic epinephrine is worthwhile if a child isn’t responding to albuterol."
However, benefits of racemic epinephrine are limited in the ED, since the treatment can’t be continued at home. "We don’t currently use that as standard care for bronchiolitics in the ED," says Ledwith. "There is not much benefit to giving a trial of racemic; because even if they get better, they would not use it on an outpatient basis. This would be an excellent study for future directions of care."
• Prophylaxis.
There are two medications that are now approved by the Food and Drug Administration for prophylaxis with children considered at risk, notes Dearman. Respigam (respiratory syncytial virus immune globulin intravenous) manufactured by MedImmune in Gaithersburg, MD, is IV and given monthly throughout the RSV season, and palivizumab is an intramuscular monoclonal antibody that is also given monthly throughout the season, she says.
Both medications reduced hospitalization for RSV patients by 55% and decreased length of stay for RSV patients who were admitted, notes Dearman. "Days in the hospital decreased by 42%, and intensive care unit requirement was reduced by 57%," she says. "Also, oxygen requirement of patients decreased by 40%."2,3
When taking a history, find out whether the child has been immunized for RSV, Dearman advises. "If they have been given one of those medications, one would expect that their course of illness would be better than if they had not received the medication."
At Cook Children’s Medical Center in Fort Worth, TX, Respigam and Synagis (palivizumab), also manufactured by MedImmune, are given once a month during RSV season, from November through April, says Maggie Huey, RN, BSN, MHA, medical director of emergency services. "For high-risk children, such as premature and low birth-weight babies, it’s believed that this prevents contraction of RSV," she reports.
• Heliox.
Heliox is a mixture of helium and oxygen used to nebulize medications and has been effective in treating severe cases.4 "This is an area we are currently investigating in our ED — as there is little research — and we have had great success with asthmatics and heliox," says Dearman.
• Ribavirin.
Recent studies do not support the use of Ribavirin (virazole), manufactured by ICN Pharmaceuticals in Costa Mesa, CA, according to Dearman. The Elk Grove Village, IL-based American Academy of Pediatrics (AAP) modified its recommendation for its use in 1996, she says. "The recent reports do not indicate that it decreases the length of stay in the ICU or hospital."
The drug is extremely expensive and has significant risks to patients and health care workers, she notes.5
The initial guidelines from the AAP recommended that ribavirin should be used to treat RSV, says Dearman. "Unfortunately, the early studies that this was based on did not evaluate ribavirin in severely ill kids on ventilators. Those studies also didn’t show significant differences in lengths of stay in the hospital or ICU."6,7,8
Dearman says there have been recent studies that demonstrated ribavirin is not effective in lessening the severity of the RSV course.9,10
"Based on those studies and the cost of ribavirin, the AAP now states that ribavirin may be considered,’ stating that its use is based on the clinical situation," she adds.
The AAP also states that more studies are necessary to determine conclusively if it is useful, Dearman notes. "There are likely still smaller hospitals that continue to use ribavirin."
References
1. Klassen TP, Menon K, Sutcliffe T. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. J Pediatr 1995; 126:1,004-1,007.
2. American Academy of Pediatrics Policy Statement. Prevention of respiratory syncytial virus infections: Indications for the use of palivizumab and update on the use of RSV-IGIV. Pediatrics 1998;102:1,211-1,216.
3. American Academy of Pediatrics Policy Statement. Respiratory syncytial virus immune globulin intravenous indication for use (RE 9718). Pediatrics 1997; 99:645-650.
4. DeNicola G. Bronchiolitis. Jacksonville Medicine 1998; 49:394-398.
5. American Academy of Pediatrics Policy Statement. Reassessment of the indications for ribavirin therapy in respiratory syncytial virus infections. Pediatrics 1996; 97:137-140.
6. Wheeler JG, Wofford J, Turner RB. Historical cohort evaluation of ribavirin efficacy in respiratory syncytial virus infection. Pediatr Infect Dis J 1993; 12:209-213.
7. Meert KL, Sarnaik AP, Gelmini MJ, et al. Aerosolized ribavirin in mechanically ventilated children with respiratory syncytial virus lower respiratory tract disease: A prospective double blind randomized trial. Crit Care Med 1994; 22:566-572.
8. Law BJ, Wang EE, Stephens D. Ribavirin does not reduce hospital stay (LOS) in patients with respiratory syncytial virus lower respiratory tract infection. Pediatr Res 1995; 37:110A.
9. Moler FW, Steinhart CM, Ohmit SE, et al. Effectiveness of ribavirin in otherwise well infants with respiratory syncytial virus-associated respiratory failure. J Pediatr 1996; 128:422-428.
10. Law BJ, Wang EE, Stephens D. Ribavirin does not reduce hospital stay in patients with respiratory syncytial virus lower respiratory tract infection. Pediatr Res 1995; 37:110A.
For more information on medications used for respiratory syncytial virus, contact:
• Maggie Huey, RN, BSN, MHA, Emergency Services, Cook Children’s Medical Center, 801 Seventh Ave., Fort Worth, TX 76104. Telephone: (817) 885-4092. Fax: (817) 870-7499. E-mail: [email protected].
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