A common lower respiratory tract infection of infants, typically presenting in the winter with cough, wheeze, fever, poor feeding. The cough is characteristically moist and wheezy, there are widespread creps and wheeze with recession, there may be (apparent) hepatomegaly from hyperinflation (but beware the differential diagnosis of cardiac failure developing from undiagnosed cardiac defect). The usual culprit is respiratory syncytial virus, else influenza, coronavirus and Human metapneumovirus (HMPV) can all produce an identical syndrome. Symptoms typically worsen over a few days, plateau for a few days, then resolve over a few days more. Cough and intermittent wheeze may be prolonged for several months.
No difference between patient characteristics of ICU admissions for RSV and controls, ie impossible to predict who may require ICU (Peds 99).
Systematic review of epinephrine (n = 8), [beta]2-agonists (n = 13), corticosteroids (n = 13), and ribavirin (n = 10) found that studies were underpowered and few collected data on useful outcomes eg duration of hospitalization. Neb adrenaline reduced admissions/length of stay in 2 out of 5 RCTs. 7 RCTs of beta agonist nebs, none found reduced length of stay. Out of 4 studies of oral steroids, 1 found reduced length of stay, but 1 found prolonged LOS! No evidence for parenteral. 1 study of inhaled steroids found less asthma at 2 years, but 2 studies found higher rates!Arch Ped & Adol Med Vol 158(2) February 2004 p 127–137, King, Valerie
HMPV is a newly identified relative of RSV. It is probably the second biggest cause of LRTI after RSV. It is seasonal, there is a PCR test. IVIG and Tribavirin are effective in vitro. It produces less pneumonia than RSV and a less severe illness, it can produce croup but less often than paraflu. Found frequently in patients with wheeze – role in asthma needs to be explored. Co-infection with other viruses is common. Reinfection with different strains (of which there are 4) is possible. 100% of the population is seropositive by age 5 yrs, but it reemerges in immunodef and elderly patients. No information yet on how much nosocomial transmission occurs (IIC).
Palivizumab (Synagis) is a monoclonal antibody against RSV. Indicated for preterms esp with BPD, and haemodynamically significant congenital heart disease in first 2yr. It works, but expensive. See Immunity.
RSV not more common in CF but associated with pseud aerug colonization so potential benefit of Synagis?
3% saline nebulized for bronchiolitis shortened hospital stay by 1 day, improved clincal scores esp outpatients cf 0.9% saline. Cochrane, 4 trials, nearly 300 patients.
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